Objective: To date, no one-on-one psychotherapy protocol for elementary and middle school-aged children with autism spectrum disorder (ASD) has been found to be efficacious for treating autism-related symptoms such as failure to initiate social interactions. This study compared modular cognitive behavioral therapy (CBT) with enhanced standard community treatment (ESCT) in terms of impact on the severity of autism-related symptoms. Method: Children with ASD (N = 107; aged 6-13 years) were randomly assigned to a treatment condition (CBT or ESCT). Both treatments provided 32 therapy sessions. The CBT condition utilized a modular design, matching specific evidence-based treatment elements to each child's clinical needs (e.g., social-communication symptoms). The ESCT condition provided social skills training and cognitive behavioral training in a structured and linear group therapy format. The primary outcome measure was independent evaluator ratings of peer engagement during school recess using a structured and validated observation system. Parents also made sessionby-session ratings on personalized autism-related symptom profiles throughout treatment. Results: CBT outperformed ESCT on the primary outcome measure ( p < .001; d = .50; 95% CI [.06, .93]) and the secondary outcome measure ( p = .003; d = .87; 95% CI [.45, 1.27]). Conclusions: The modular one-on-one CBT program evaluated in this study may be beneficial for reducing the severity of autism-related symptoms in some children with ASD. Further research is needed to clarify the extent of the treatment effect and the feasibility of implementation for therapists in the community. Public Health Significance StatementThere is currently no well-established psychotherapy treatment for autism-related symptoms. The present study identified cognitive behavioral therapy as a potential treatment for reducing symptom severity among children with autism spectrum disorder.

Few measures of autism-related symptoms have been established as both psychometrically robust and sensitive to the effects of treatment. In the present study, a personalized measure of autism-related symptoms using the Youth Top Problems (YTP) method (Weisz et al., 2011) was evaluated. Participants included 68 children with diagnoses of autism (ages 6-13 years), and their parents, who were randomized to cognitive behavioral therapy (CBT) or enhanced standard community treatment (ESCT) addressing autism-related symptoms. At pretreatment, parents described their child's top autism-related problems (YTPs) in their own words and rated the severity of these problems on a Likert-type scale. Parents also made daily severity ratings on the child's top three YTPs for 5 days prior to treatment and 5 days following treatment while videorecording their child's behavior at home on each of these days. Trained observers coded these videorecordings, focusing on the same YTPs that the parents rated. Parents also completed standardized checklists of autism-related symptoms and general mental health symptoms. There was evidence of convergent and discriminant validity as well as good test-retest reliability for the YTP measures. YTP severity scores converged with the standardized measure of autism-related symptoms. Parent-reported YTP scores predicted observers' YTP scores at the daily level, and both parent-reported and observers' YTP scores decreased from pre-to post treatment. Observers' ratings of the videorecordings exhibited sensitivity to treatment condition. These applications of the YTP method are promising and may complement standardized symptom checklists for clinical trials focusing on autism-related symptoms.

Autism spectrum disorder (ASD) is heterogeneous and likely entails distinct phenotypes with varying etiologies. Identifying these subgroups may contribute to hypotheses about differential treatment responses. The present study aimed to discern subgroups among children with ASD and anxiety in context of the five-factor model of personality (FFM) and evaluate treatment response differences to two cognitive-behavioral therapy treatments. The present study is a secondary data analysis of children with ASD and anxiety (N=202; ages 7–13; 20.8% female) in a cognitive behavioral therapy (CBT) randomized controlled trial (Wood et al., 2020). Subgroups were identified via latent profile analysis of parent-reported FFM data. Treatment groups included standard-of-practice CBT (CC), designed for children with anxiety, and adapted CBT (BIACA), designed for children with ASD and comorbid anxiety. Five subgroups with distinct profiles were extracted. Analysis of covariance revealed CBT response was contingent on subgroup membership. Two subgroups responded better to BIACA on the primary outcome measure and a third responded better to BIACA on a peer-social adaptation measure, while a fourth subgroup responded better to CC on a school-related adaptation measure. These findings suggest that the FFM may be useful in empirically identifying subgroups of children with ASD, which could inform intervention selection decisions for children with ASD and anxiety.

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