Considering efficacy and effectiveness trials of cognitive behavioral therapy among youth with autism: A systematic review

Cognitive behavioral therapy is a widely studied and commonly used psychosocial intervention for treating emotional problems in individuals with autism. To date, most studies of cognitive behavioral therapy and autism have focused on efficacy. Effectiveness trials, by contrast, measure whether an intervention produces particular results under “real-world” clinical conditions. We conducted a systematic review of cognitive behavioral therapy interventions targeting affective disorders among youth with autism and (a) classified studies as either efficacy or effectiveness trials and (b) coded how the effectiveness trials reflect the implementation characteristics outlined in the Framework of Dissemination in Health Services Intervention Research. The systematic search yielded 2959 articles, with 33 studies meeting inclusion criteria. Thirteen studies were categorized as effectiveness and 20 as efficacy. We discuss how the effectiveness studies considered elements of the implementation framework and provide recommendations for future studies, including greater consideration and measurement of adoption and sustainability processes, as well as organizational- and system-level outcomes. Results shed light on our understanding of the effectiveness of cognitive behavioral therapy in routine clinical practice, how an implementation framework can be used to guide and improve effectiveness studies, and identify barriers, facilitators, and gaps in the implementation process. Lay abstract Cognitive behavioral therapy is a common treatment for emotional problems in people with autism. Most studies of cognitive behavioral therapy and autism have focused on efficacy, meaning whether a treatment produces results under “ideal” conditions, like a lab or research setting. Effectiveness trials, by contrast, investigate whether a treatment produces results under “real-world” conditions, like a community setting (e.g. hospital, community mental health center, school). There can be challenges in bringing a cognitive behavioral therapy treatment out of a lab or research setting into the community, and the field of implementation science uses frameworks to help guide researchers in this process. In this study, we reviewed efficacy and effectiveness studies of cognitive behavioral therapy treatments for emotional problems (e.g. anxiety, depression) in children and youth with autism. Our search found 2959 articles, with 33 studies meeting our criteria. In total, 13 studies were labelled as effectiveness and 20 as efficacy. We discuss how the effectiveness studies used characteristics of an implementation science framework, such as studying how individuals learn about the treatment, accept or reject it, how it is used in the community over time, and any changes that happened to the individual or the organization (e.g. hospital, school, community mental health center) because of it. Results help us better understand the use of cognitive behavioral therapy in the community, including how a framework can be used to improve effectiveness studies.