A Pilot Proof-of-Concept Study of Telehealth-Based Trauma-Focused Cognitive Behavioral Therapy for Autistic Youth: Initial Evidence of Efficacy and Acceptability

Abstract

Autistic youth experience disproportionately high rates of child maltreatment and a wide range of other traumatic and stressful events, such as peer victimization. Very little empirical work has evaluated trauma-focused supports for Autistic youth, despite high rates of posttraumatic stress disorder (PTSD) and other trauma-related symptoms. The current study is a pilot proof-of-concept evaluation of telehealth-based trauma-focused cognitive behavioral therapy (TF-CBT) for Autistic youth (N = 17, ages 10–17) and their caregivers. Youth PTSD symptoms significantly declined from the beginning to end of the program across youth self-report, caregiver report, and clinician interview, and effects were maintained at the 1-month follow-up with large effect sizes. Youth self-reported significant declines in anxiety. Caregivers reported significant improvements in all co-occurring youth mental health symptoms and some caregiver-level outcomes. Youth and caregivers rated the program and telehealth delivery favorably overall. Future larger-scale randomized evaluations of TF-CBT for Autistic youth are needed.

Keywords

autism telehealth trauma-focused cognitive behavioral therapy trauma

Introduction

Autism is defined by social communication differences and restricted and/or repetitive behavior criteria (APA, 2022). Autistic youth disproportionately experience a wide range of traumatic and stressful events, such as adverse childhood experiences (e.g., child maltreatment, household or community violence, caregiver divorce, household mental illness and/or substance use; Hartley et al., 2024) and peer victimization (Kerns et al., 2022). Posttraumatic stress disorder (PTSD) is defined by intrusions, trauma-related avoidance, hypervigilance, and negative changes in mood and cognition (APA, 2022). Traumatic stress reactions also include anxiety, depressive symptoms, irritability, and externalizing behavior (Farley et al., 2021).

Autistic youth experience high rates of trauma symptoms after trauma exposure (see Rumball, 2019, for review). For example, Autistic youth self-report significant trauma symptoms on PTSD questionnaires (Hoover & Romero, 2019). Using caregiver report, abuse related to higher levels of PTSD symptoms (e.g., intrusive thoughts, distressing memories) and broader behavioral changes (e.g., loss of interest, irritability, and lethargy) for Autistic youth (Brenner et al., 2018). Therefore, core PTSD and a wider range of behavioral symptoms (e.g., emotion dysregulation, declines in adaptive behavior) are both important domains of traumatic reactions among Autistic youth (Kerns et al., 2023; Mehtar & Mukaddes, 2011).

Autistic youth have very little access to trauma-based supports due to a variety of factors (Kerns et al., 2020). PTSD and trauma-related mental health difficulties may be underdiagnosed among Autistic youth (Brenner et al., 2018), potentially as a result of limited assessment tools for detecting trauma symptoms and/or diagnostic overshadowing (Kildahl et al., 2020). In community mental health settings, autism-focused professionals report lacking training in identifying or treating trauma symptoms, and many agree that there is a lack of effective treatments for trauma for Autistic youth (Kerns et al., 2020). Similarly, a significant proportion of trauma-focused professionals report discomfort in providing trauma-focused therapy, and/or that their work setting limits services, for youth with developmental disabilities such as autism (D’Amico et al., 2022). Thus, there is an urgent need to develop and establish the evidence base for interventions for traumatic stress for Autistic youth and their caregivers.

Trauma-Focused Cognitive Behavioral Therapy

Decades of research show that trauma-focused cognitive behavioral therapy (TF-CBT) is associated with large effect sizes in improving child outcomes after traumatic and stressful events (Bennett et al., 2021; Lewey et al., 2018; Mavranezouli et al., 2020; Thielemann et al., 2022). TF-CBT has been successfully applied to diverse traumatic events including complex trauma (Cohen et al., 2016), and is effective for youth experiencing subclinical levels of traumatic stress and youth with formal PTSD diagnoses (Lewey et al., 2018; Ross et al., 2021). TF-CBT reduces posttraumatic stress and associated symptoms through family-based, cognitive-behavioral, and exposure techniques (Cohen et al., 2016). In its standard form, treatment consists of approximately 12–25 weekly sessions lasting 60–90 minutes facilitating gradual exposure and trauma processing using a combination of child-focused, caregiver-focused, and conjoint child-caregiver components. The treatment components are summarized using the PRACTICE acronym: (1) Psychoeducation and Parenting Skills, (2) Relaxation, (3) Affective modulation, (4) Cognitive coping and processing, (5) Trauma narrative, (6) In-vivo mastery of trauma reminders, (7) Conjoint child-caregiver sessions, and (8) Enhancing safety and development (Cohen et al., 2016). TF-CBT reduces youth PTSD symptoms and broader co-occurring internalizing and externalizing symptoms associated with trauma (Hoogsteder et al., 2022; Thielemann et al., 2022). TF-CBT is also associated with improvements in youth positive outcomes, such as personal resiliency (Deblinger et al., 2017).

Given the dyadic nature of TF-CBT and significant caregiver involvement (Brown et al., 2020), TF-CBT is also associated with improvements in caregiver outcomes such as parenting stress (Gusler et al., 2023). Parenting techniques such as consistency and praise are also supported by TF-CBT (Cohen et al., 2004; Deblinger et al., 2011). TF-CBT may also improve caregiver mental health, including PTSD and mood symptoms (Martin et al., 2019).

Telehealth has the potential to increase access to services, and was critical during the COVID-19 pandemic (Freitag et al., 2022). TF-CBT has been successfully implemented via telehealth for youth, with significant and clinically meaningful pre-post reductions in PTSD and related symptoms following intervention (Stewart et al., 2017, 2020). Youth and caregivers also report high satisfaction with telehealth delivered TF-CBT, and may prefer telehealth over office-based services (Villalobos et al., 2023).

Potential of TF-CBT for Autistic Youth

TF-CBT is a flexible program that can be personalized for youth. The treatment developers have detailed specific ways TF-CBT can be implemented with different populations (Cohen, Mannarino, & Deblinger, 2012), including youth with developmental disabilities such as autism (Grosso, 2012). Several groups have also proposed specific ways TF-CBT can be personalized for Autistic youth (Peterson et al., 2019; Romney & Garcia, 2021; Stack & Lucyshyn, 2019; Supporting Trauma Recovery for Youth with Developmental Disabilities [STYRDD] Center, n.d).

Recommendations for personalizing TF-CBT for Autistic youth generally include broad clinical strategies such as increases in caregiver involvement and using a wide range of teaching strategies to support diverse learning and communication styles. More specifically, the STRYDD Center’s implementation guide details a “matrix” of ways in which each of the core TF-CBT components can be tailored for Autistic youth (Hoover et al., 2024; STRYDD Center, n.d). A recent survey of TF-CBT clinicians found that the majority of respondents had provided TF-CBT for youth with developmental disabilities such as autism using a range of these strategies (D’Amico et al., 2022). Despite calls to consider TF-CBT for Autistic youth and a case study demonstrating its utility (Gerhardt & Smith, 2020), to date there has been no published empirical investigation of the efficacy nor acceptability of TF-CBT for Autistic youth to our knowledge.

Goals of the Current Study

To address the significant gap in the literature regarding trauma-focused interventions for Autistic youth, the current study is a proof-of-concept pilot study of telehealth-based TF-CBT for Autistic youth. Specific goals were to (1) evaluate whether telehealth TF-CBT is effective at reducing PTSD and associated symptoms for Autistic youth (via pre-post analyses), (2) assess whether significant changes are also seen for caregiver-level outcomes (Martin et al., 2019), (3) examine youth and caregiver satisfaction with TF-CBT (Brumley et al., 2021; Lange et al., 2021) and telehealth delivery in particular (Villalobos et al., 2023), and (4) describe clinical strategies used for program delivery. Due to the preliminary small-scale nature of this study, some descriptive information is presented in a generalized form to ensure de-identification, although we acknowledge the limitations of this approach.

Method

Participants

Participants were 17 Autistic youth between the ages of 10 and 17 years (M = 13.76, SD = 2.51) and their caregivers (all of whom were legal guardians for the participating child). The majority (70.6%) of youth participants were boys (17.6% girls, 11.8% non-binary). The average age of their caregivers was 47.94 years (SD = 9.90), and the majority of caregivers were women (94.1%). Regarding race and ethnicity, 41.2% of youth and 23.53% of caregivers had a minoritized racial or ethnic identity, including Latino/a or Hispanic, Black, Biracial or Multiracial, American Indian/Alaska Native, or Other/Not Listed. To fully de-identify this data, we do not report the number of individuals in each individual category (e.g., it is possible that only one participant may have endorsed a particular identity). Please see Table 1 for additional sample characteristics, which were assessed via a family demographics form at intake.

Table 1.

Participant Characteristics.

	Child	Caregiver
Education
12^th grade, GED, and/or trade school	—	11.76%
Some college or Associate’s degree	—	29.42%
Bachelor’s degree	—	35.29%
Master’s degree	—	23.53%
Household income (USD; M, SD)	95,390 (39,411)
Age (years; M, SD)	13.76 (2.51)	47.94 (9.90)
Gender
Girl/Woman	17.6%	94.1%
Boy/Man	70.6%	5.9%
Non-binary	11.8%	—
Race and ethnicity*
White	76.5%	76.5%
Minoritized racial or ethnic identity (including black, latino/a or Hispanic, biracial or multiracial, American Indian/Alaska native, or not listed)	41.2%	23.53%
Child descriptive characteristics M (SD)
Child age of autism diagnosis (years)	5.97 (3.75)
SCQ score	21.35 (8.92)
CARS-2 abbreviated Obs score	17.44 (2.47)
WASI-2 VCI score	96.41 (17.69)
Prior child Co-occurring mental health diagnoses (caregiver-reported; %)
ADHD	70.59%
Intellectual or cognitive delay or disability	11.76%
Learning disorder or disability	23.53%
Speech/language delay or disorder	64.71%
Oppositional defiant disorder	11.76%
Anxiety	70.59%
Depression	35.29%
Posttraumatic stress disorder	17.65%
Other/Not listed	17.65%
Child Co-occurring services (caregiver-reported; %)
Any current psychiatric medication	82.36%
Any current social skill services	35.29%
Any current non-trauma focused counseling	29.41%
Any current speech/language therapy	29.41%
Any current occupational therapy	35.29%

Note. *Percentages for race and ethnicity do not add to 100 if more than one identity was endorsed. The percentage endorsing any minoritized racial or ethnic identity is presented above as a general percentage to ensure de-identification given the small sample size. Additional services endorsed at low frequencies included either ABA, generalized (non-trauma focused) group counseling support, parent training, physical therapy, or “other”. Specific rates for these services are not reported to maintain de-identification.

Following parental consent and permission and child assent, further inclusion criteria required that youth had verbal language and an autism diagnosis. All caregivers provided detailed information about where and when this diagnosis was received (M age of diagnosis = 5.97 years, SD = 3.75). Diagnosis was further confirmed for all participants via brief telehealth-based observation of youth autistic traits using an abbreviated version of the Childhood Autism Rating Scales (CARS-2; Schopler et al., 2010; Sanchez & Constantino, 2020). To further characterize autistic traits, caregivers completed the Social Communication Questionnaire-Lifetime version (Rutter et al., 2003), wherein scores of 12–15 or higher characterize significant autistic traits (Corsello et al., 2007). The average score for this sample was 21.35 (SD = 8.92). To characterize verbal cognitive skills, youth completed the Wechsler Abbreviated Scale of Intelligence-Second Edition Verbal Comprehension Index (WASI-2 VCI, Wechsler, 2011). The average score was 96.41 (SD = 17.69); 29.41% of scores fell in the Borderline or Low Average range, 41.18% in the Average range, and 29.41% in the High Average or Superior ranges.

A previous diagnosis of PTSD was not required to participate, although the presence of significant youth PTSD symptoms was confirmed via a score in the clinically significant/probable PTSD range on the Child and Adolescent Trauma Screen measure (either caregiver reported or self-reported youth score >21; Sachser et al., 2017). Youth could not currently be receiving trauma-focused therapy. Most participants experienced more than one trauma (discussed in general terms for descriptive purposes only to ensure de-identification). Index traumas broadly included (1) abuse or assault (sexual, physical, and/or emotional), (2) family changes such as adoption or other moves/changes in care, (3) broader stressors such as family conflict, serious medical or mental health difficulties of caregiver, and/or death of loved one, (4) peer victimization/bullying, and/or (5) other traumatic/stressful events.

To increase generalizability, youth were not excluded due to co-occurring diagnoses or services (see Table 1, caregiver report). The most frequently reported diagnoses were attention-deficit/hyperactivity disorder (ADHD; 70.59%), anxiety (70.59%), and speech/language delay or disorder (64.71%). The most frequently reported services were psychiatric medication (82.36%), occupational therapy (35.29%), social skill services (35.29%), speech/language therapy (29.41%), or generalized (non-trauma focused) counseling support (29.41%).

Recruitment involved distributing emails and virtual flyers to clinics, listservs, and community groups advertising an opportunity to participate in a research study evaluating the virtual trauma-focused program run via a university psychology research lab. Initially, 30 caregivers signed up and completed the consent and caregiver permission form for the study, followed by a two-part initial assessment visit (first with caregiver-only, second including child). Of those 30, reasons for exclusion and/or incomplete or non-participation were: did not respond to schedule the first assessment (n = 6), did not complete the second assessment with the child (n = 4, due to non-response to scheduling after completion of first assessment, or child not providing assent), and/or other (n = 3; included cases in which child did not want to continue at first or second program visit or did not complete measures), leading to our sample size of 17 who completed the program (14 completed the 1-month follow-up). All procedures received institutional review board (IRB) approval (University of Wyoming IRB Protocol 20220304CM03259; Virginia Tech IRB 19-993). No unexpected or adverse events occurred. Families were compensated with gift cards for their time/measure completion ($20 for each assessment visit, $25 for each program visit, $30 for follow-up).

Procedure

Initial Assessment

Part one of the intake assessment was conducted with the caregiver only, and involved re-review of the consent form with a research staff member, assessment of children’s trauma symptoms via clinical interview, and completion of a range of symptom measures. A separate intake session including the child was then completed, which involved obtaining child assent, brief task-based assessments of autistic traits and cognitive skills as described above, assessment of trauma and mood symptoms via clinical interview, and completion of a range of self-report measures. All assessments took place via HIPAA-secure Zoom. Internal consistencies for the intake measures are presented as Cronbach’s alpha (α).

TF-CBT

Twelve sessions of individually delivered TF-CBT were provided via telehealth (HIPAA-secure Zoom, all participants completed 12 sessions). Sessions were typically held once per week, lasting between 60-90 minutes per session. Session content followed the standard TF-CBT protocol, and included a combination of child, caregiver, and conjoint components. The majority of sessions also included routine outcome monitoring of youth symptoms that served as a check-in each week, wherein a brief subset of youth symptom measures (Child and Adolescent Trauma Screen, Sachser et al., 2017; Short Mood and Feelings Questionnaire, Angold et al., 1995) were administered and reviewed on a regular basis to monitor and discuss progress.

Fidelity

For each session, clinicians self-rated which primary program component was implemented and whether caregivers were involved, using a fidelity checklist based on the TF-CBT Brief PRACTICE Checklist (Deblinger et al., 2008), which has been used in prior TF-CBT research (Jensen et al., 2017; Peters et al., 2021). Checklists were reviewed by the supervisor after each session and discussed in supervision as needed. A random sample (4 of 17) was co-coded to further confirm fidelity (100% agreement for which PRACTICE component was delivered and caregiver involvement, which was expected given the specificity/observability of these components). According to the treatment manual (Cohen et al., 2016), the only program component that is optional is in vivo mastery, as not all youth will present with generalized avoidant behaviors requiring further exposure-based practice. Review of all fidelity checklists confirmed that 16 out of 17 cases (94%) fully addressed all required program components in the expected order (the 1 case rated as not having full fidelity was missing one of the required components as only partially completed). As part of this checklist, clinicians also rated how adaptable they felt each session was for Autistic youth from 0 to 3, which confirmed high adaptability ratings (average session rating 2.92 out of 3, all individual component ratings >2.6). See Supplemental Table S1 for further information.

Implementation Strategies

Supervision routinely focused on the use of implementation strategies for personalizing TF-CBT for Autistic youth (e.g., use of visuals, technology, added caregiver involvement), which were conceptualized as flexible ways of implementing TF-CBT based on individual participant needs (D’Amico et al., 2022). Fidelity to these strategies was not formally rated (techniques may not universally apply for all participants). Instead, a random subsample (20%) of cases was formally rated by two independent coders for the presence of core implementation strategies based on video recordings (based on D’Amico et al., 2022). Co-coding demonstrated interrater agreement, and confirmed strategy use. See Supplemental Table S2, and the Results section for a broader qualitative description of techniques.

Clinicians

Seven clinicians were involved in assessment and/or provision of TF-CBT sessions, including six clinical psychology doctoral students and one clinical psychologist. All clinicians completed a required training sequence including: (1) reading the TF-CBT manual (Cohen et al., 2016), (2) completing online virtual training (12 hours of training via TF-CBT Web 2.0; Medical University of South Carolina, 2017), and (3) reviewing 3-h of webinars on telehealth delivery from the Medical University of South Carolina’s Telehealth Outreach Program (Medical Univ of South Carolina, n.d.). For additional training, the majority of clinicians (6 out of 7) also completed advanced formal training with certified TF-CBT trainers (live training model), which is highly recommended by the treatment developers (Cohen et al., 2016). Clinicians received weekly group and/or individual supervision by a clinical psychologist (who had completed external TF-CBT training provided by certified TF-CBT trainers, and then completed the national certification process themselves). The clinician remained the same for each participant during the study, except for one participant (clinician changed during program due to schedules).

Follow-Up Assessment

At the end of the 12-week program, youth and caregivers re-completed symptom assessments with the same clinician (100% of participants), and provided treatment feedback (17 out of 17 youth, 16 out of 17 caregivers). The symptom assessments were repeated at a 1-month follow-up visit with the same clinician (14 out of 17 youth and caregivers).

Measures

Anxiety Disorders Interview Schedule – Child/Parent Version (ADIS C/P)

The ADIS is a semi-structured clinician interview (Albano & Silverman, 2024; Silverman & Albano, 1996; Kerns et al., 2024); the PTSD module was used for the current study (separately with both youth [self-report, ADIS-C] and caregivers [caregiver report of youth symptoms, ADIS-P]). The ADIS has been used to assess trauma symptoms among Autistic youth (for review, see Hoover, 2015). The primary metric used was the clinician severity rating (CSR) of PTSD symptoms, which ranged from 0 (little or no) to 8 (maximum severity). The ADIS was administered at the initial assessment, end of treatment, and 1-month follow-up by the same clinician. All administrations that were video recorded were co-coded by two raters. When recordings were available, the follow-up assessments were coded by two raters who were not the original clinician. Interrater reliability was achieved for the CSR ratings (intraclass correlations were .79 for youth report, .84 for caregiver report). Final CSR values were computed as the average of two ratings (when video recordings were available for co-coding). If co-coding was not possible due to lack of available recordings (due to technical or logistic difficulties that prevented recording), the original rating from the clinician was used. Thus, these ratings should be interpreted with caution given that the interview was administered by the clinician, but are presented for reference relative to self- and caregiver-rated symptoms.

Child and Adolescent Trauma Screen (CATS)

The CATS is a 20-item questionnaire which measures traumatic symptoms among youth based on DSM-5 criteria for PTSD (Sachser et al., 2017). Items are rated on a 4-point scale from 0 (never) to 3 (almost always) and are summed for a total score range of 0 – 60. Scores of 15 or higher indicate potentially clinically significant/moderate levels of symptoms (Hagen et al., 2019), with 21 or higher indicating probable PTSD according to the CATS Clinical Guide (n.d.). Caregivers reported on their child’s symptoms (α = .80) and youth self-reported on their own symptoms (α = .93).

Co-Occurring Youth Mental Health Measures

Youth depressive symptoms were assessed via the child self-report (α = .88) and caregiver-report (α = .84) versions of the Short Mood and Feelings Questionnaire (SMFQ), a 13-item measure assessing depressive symptoms among youth over the past two weeks (Angold et al., 1995). Youth anxiety symptoms were assessed via the child self-report (α = .94) and caregiver-report (α = .95) versions of the Screen for Anxiety and Related Disorders (Scared; Birmaher et al., 1997). Youth broader internalizing (α = .69) and externalizing (α = .65) concerns were assessed via the 25-item caregiver-report version of the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997).

Youth Resilience

The Brief Resilience Scale (BRS; Smith et al., 2008) is a 6-item measure of trait resilience administered via youth self-report (α = .84) and caregiver-report (α = .71). Items were averaged for an overall score ranging from 1 to 6; higher scores indicate higher resilience. The BRS was used among youth aged 12–17 years as an outcome variable in a study evaluating an expressive writing intervention (Greenbaum & Javdani, 2017). Items were also adapted for an exploratory caregiver report version (caregiver perception of child resilience).

Parenting

The Alabama Parenting Questionnaire-Short Form (APQ-SF; Elgar et al., 2007) is a 9-item self-report measure that examines parenting skills and includes three subscales: positive parenting (α = .94), inconsistent discipline (α = .76), and poor supervision (α = .71). The Parental Stress Scale (PSS; Berry & Jones, 1995) is an 18-item measure which asks parents to endorse general feelings about their parenting role and related stressors (current α = .86).

Caregiver Mental Health

Caregivers completed the Posttraumatic Symptom Checklist for DSM-5 (PCL-5; Weathers et al., 2013), a 20-item self-report measure of their PTSD symptoms (α = .86). Caregiver internalizing symptoms were assessed via the Dysphoria subscale of the Inventory for Depressive and Anxiety Symptoms (IDAS-2; Watson et al., 2012), which assesses generalized depression and anxiety symptoms (α = .84). Caregivers also reported on their own resilience using the BRS (Smith et al., 2008; described above; α = .77).

Beach Center Family Quality of Life Scale (FQOL)

The FQOL scale is a 25-item caregiver-report measure that assesses family quality of life among families of children with disabilities (Hoffman et al., 2006; Park et al., 2003), and has been used among caregivers of Autistic youth (Hsiao, 2018). Caregivers indicated satisfaction across five domains, including Family Interaction (α = .82), Parenting (α = .94), Emotional Well-Being (α = .90), Physical/Material Well-Being (α = .58, not included further), and Disability-Related Support (α = .83).

Treatment Satisfaction and Feedback Measures

Caregivers and youth separately completed a treatment feedback form designed by the research team for the current study. Caregivers completed the treatment feedback form independently (via self-report). For youth, the treatment feedback form was completed as either a self-report or interview-based format. Participants rated how involved they felt they were in the program on a Likert scale from 1 (not at all involved) to 5 (greatly involved). For overall satisfaction, caregivers and youth indicated how much they enjoyed the program, understood the program, felt the program helped, would recommend the program to others, and agreed with the program’s message, on a scale from 1 (not at all) to 5 (greatly). Then, caregivers and youth rated how much each individual component of TF-CBT was easy to understand and helpful, to inform which program components were perceived most positively (Ascienzo et al., 2022; Brumley et al., 2021; Dittmann & Jensen, 2014; Lange et al., 2021). Participants also responded to items asking about their perception of logistic components of the program such as length. Lastly, participants completed an adapted version of the Telehealth Satisfaction Scale (Morgan et al., 2014), which has been used in prior work with children with disabilities (Murphy et al., 2021; current sample α = .929 for youth; α = .907 for caregivers).

Analytic Strategy

Treatment response was assessed via paired samples t-tests (two-tailed) to assess within-person change from the initial assessment (pre-treatment) to the end of treatment, with effect sizes reported as Hedge’s g. Analyses were repeated with the 1-month follow-up data. Treatment feedback is presented descriptively. Given the small pilot nature of the study, descriptive data/results are discussed in general terms to ensure complete de-identification. Data is not complete for all cases; results are presented on available data only (missing data estimation not used given the small n and descriptive analyses).

Results

Changes in Youth Measures

Significant reductions in PTSD symptoms were seen across all measures of PTSD symptoms at the end of treatment and the 1-month follow-up (see Table 2). All effect sizes were large, except for the effect size for youth self-reported PTSD symptoms, which was moderate at the end of treatment (g = .65) and large at the 1-month follow-up (g = .85). Youth self-reported anxiety symptoms significantly decreased at both time points (g = .63 at end of treatment, g = .98 at 1-month follow-up). Youth self-report of depression symptoms and resilience did not significantly change. Caregivers reported significant improvements across all measures of co-occurring youth mental health at both time points, including reductions in depression, anxiety, internalizing, and externalizing, and significantly higher levels of youth resilience (g ranged from .66 to 1.97 across measures).

Table 2.

Pre-post Change Across Youth Outcome Measures.

	Pre-Tx	End Tx	1-Mo post	Pre-treatment to end of treatment (n = 17)		Pre-treatment to 1-Mo post treatment (n = 14)
Variable	M (SD)	M (SD)	M (SD)	t	Hedge’s g	t	Hedge’s g
Youth PTSD symptoms (youth reported)
CATS-youth	19.88 (14.53)	10.71 (13.55)	9.57 (10.69)	2.81*	0.65	3.37**	0.85
ADIS CSR	4.76 (2.09)	2.74 (1.98)	2.50 (2.18)	4.31***	1.00	4.39***	1.10
Youth PTSD symptoms (Caregiver reported)
CATS-caregiver	38.88 (8.11)	14.82 (10.51)	14.50 (9.97)	9.97***	2.30	8.86***	2.23
ADIS CSR	5.78 (1.79)	3.09 (1.84)	2.96 (1.54)	4.89***	1.16	7.42***	1.87
Co-occurring youth mental health (youth reported)
SMFQ (mood)	7.53 (6.00)	5.00 (6.25)	5.00 (5.73)	1.65	0.38	1.68	0.42
Scared (anxiety)	34.15 (17.92)	22.38 (18.07)	18.71 (16.81)	2.42*	0.63	3.90**	0.98
BRS (resilience)	3.13 (0.82)	2.82 (0.80)	3.06 (0.85)	1.46	0.36	0.50	0.13
Co-occurring youth mental health (Caregiver reported)
SMFQ (mood)	12.35 (5.35)	5.12 (4.54)	5.71 (4.20)	8.54***	1.97	4.75***	1.19
Scared (anxiety)	37.12 (18.52)	23.35 (14.99)	19.42 (12.58)	3.91**	0.90	2.45*	0.66
BRS (resilience)	2.22 (0.50)	2.73 (0.59)	3.05 (0.70)	−3.10**	−0.72	−4.31***	−1.08
SDQ internalizing	12.76 (3.72)	9.65 (4.44)	9.08 (3.23)	3.09**	0.71	3.26**	0.85
SDQ externalizing	10.88 (3.05)	8.00 (3.30)	8.00 (2.32)	5.54***	1.28	5.31***	1.34

Note. Significant findings are bolded. M = mean, SD = standard deviation. *p < .05; **p < .01, ***p < .001. All t-tests are two-tailed. CATS = Child and Adolescent Trauma Screen. ADIS CSR = Anxiety Disorders Interview Schedule Clinician Severity Rating. SMFQ = Short Mood and Feelings Questionnaire. SCARED = Screen for Anxiety and Related Disorders. BRS = Brief Resilience Scale. SDQ = Strengths & Difficulties Questionnaire. Missing data included: caregiver ADIS CSR end treatment (n = 1), child SCARED end treatment (n = 4), caregiver SCARED 1-month follow-up (n = 2), SDQ Internalizing end treatment (n = 1), child BRS end treatment (n = 2) and 1-month follow-up (n = 2).

Changes in Caregiver and Family-Level Measures

There were significant reductions in inconsistent parenting at both time points (large effect, g = 1.19 at end of treatment and .98 at 1-month follow-up). There was a significant reduction in poor supervision at the end of treatment (g = .54), though that difference was marginally significant at the 1-month follow-up. No significant changes were seen in positive parenting nor parenting stress. At the end of treatment, caregivers self-reported significantly reduced traumatic stress symptoms (g = .70; though effect was marginally significant at the 1-month follow-up) and significantly higher levels of their own resilience (g = −.51; effect was non-significant at 1-month follow-up). For family quality of life, caregivers reported significantly higher disability-related quality of life at the end of the program (g = −.53; non-significant at 1-month) and parenting-related quality of life at the 1-month follow-up (g = −.56) (Table 3).

Table 3.

Pre-post Change Across Caregiver- and Family-Level Outcome Measures.

	Pre-Tx	End Tx	1-Mo post	Pre-treatment to end of treatment (n = 17)		Pre-treatment to 1-Mo post treatment (n = 14)
Variable	M (SD)	M (SD)	M (SD)	t	Hedge’s g	t	Hedge’s g
Parenting
APQ positive	12.88 (1.86)	12.38 (1.71)	12.86 (1.75)	0.88	0.21	−0.22	−0.06
APQ inconsistent	6.56 (2.37)	4.25 (1.48)	4.36 (1.55)	5.00***	1.19	3.91**	0.98
APQ poor sup	3.81 (1.42)	3.00 (0.00)	3.14 (0.36)	2.28*	0.54	1.93+	0.49
Parenting stress	42.76 (9.50)	40.42 (8.20)	42.07 (7.19)	1.35	0.31	0.20	0.05
Caregiver mental health
PCL trauma sx	19.13 (10.08)	10.69 (8.55)	11.73 (11.61)	2.95*	0.70	2.19+	0.61
IDAS mood sx	18.53 (5.93)	17.00 (5.98)	16.71 (5.61)	0.79	0.18	1.43	0.36
BRS resilience	3.55 (0.51)	3.82 (0.57)	3.57 (0.57)	−2.19*	−0.51	−0.23	−0.06
Family quality of life
Family interaction	22.63 (3.67)	23.19 (3.80)	23.14 (3.30)	−0.76	−0.18	−0.80	−0.20
Parenting	20.94 (5.80)	22.35 (3.00)	23.43 (3.01)	−1.08	−0.25	−2.24*	−0.56
Emo well-being	13.42 (3.89)	13.71 (3.29)	14.57 (2.50)	−0.29	−0.07	−0.74	−0.19
Disability supp	13.50 (3.98)	15.94 (2.79)	14.54 (4.03)	−2.22*	−0.53	−1.19	−0.31

Note. Significant findings are bolded. M = mean, SD = standard deviation. *p < .05; **p < .01, ***p < .001, + p < .10. All t-tests are two-tailed. APQ = Alabama Parenting Questionnaire – Short Form. PCL = Posttraumatic Symptom Checklist for DSM-5. IDAS = Inventory of Depressive and Anxiety Symptoms Second Edition Dysphoria subscale. BRS = Brief Resilience Scale. Missing data included: APQ subscales end of treatment (n = 1), PCL end treatment (n = 1) and 1-month follow-up (n = 3), Quality of life: family interaction end treatment (n = 1), Quality of life: disability support end treatment (n = 1) and 1-month follow-up (n = 1).

Youth and Caregiver Satisfaction

For overall program ratings (see Table 4), all youth ratings were above a 3.5 out of 5 (a rating of 3 corresponded to “moderately” and a rating of 4 corresponded to “very much”) regarding the extent to which they enjoyed, understood, felt helped by, would recommend, agreed with the message, and felt involved in the program. All caregiver-reported ratings for the same items were 4.5 out of 5 or higher. Youth rated the relaxation, affective, and enhancing safety components as easiest to understand (ratings ranged from 3.93–4.27 out of 5) and most helpful (ratings ranged from 4.06–4.24). All other youth ratings were 3.6 out of 5 or higher (except their understanding rating for the in vivo module, rated as a 3.20). Caregivers rated psychoeducation, parenting, and enhancing safety as the easiest to understand (ratings ranged from 4.63–4.75), and the psychoeducation, affective, and conjoint modules as the most helpful (ratings ranged from 4.60–4.67). All other caregiver ratings exceeded 4 (except their understanding rating for the conjoint module, rated as 3.88). Both caregivers and youth also rated high telehealth satisfaction (see Supplemental Table S3 for individual item responses). The majority of youth and caregivers endorsed satisfaction with logistic aspects of the program (e.g., modal response was ‘just right’, see Table 4, and Supplemental Table S4 for item responses).

Table 4.

Ratings of Overall Program, Involvement, Treatment Components, and Telehealth Satisfaction.

	Youth report			Caregiver report
	M (SD)	Med	Mode	M (SD)	Med	Mode
Program ratings (1-not at all, 2-slightly, 3-moderately, 4-very much, 5-greatly)
Enjoyed	3.56 (1.03)	4	4	4.50 (0.63)	5	5
Understood	4.35 (0.86)	5	5	4.50 (0.52)	4.50	4, 5
Feel helped by	3.65 (1.17)	4	3	4.44 (0.73)	5	5
Would recommend	3.82 (1.29)	4	4, 5	4.50 (0.82)	5	5
Agree with message	4.53 (0.51)	5	5	4.63 (0.62)	5	5
How involved	4.12 (0.99)	4	5	4.56 (0.63)	5	5
Program components (1-definitely not easy/helpful, 2-not easy/helpful, 3-neutral, 4-mostly easy/helpful, 5-definitely easy/helpful)
Psychoed – easy to understand	3.73 (1.28)	4	4, 5	4.63 (0.53)*	5	5
Psychoed – helpfulness	4.00 (1.32)	5	5	4.67 (0.49)*	5	5
Parenting – easy to understand	---	---	---	4.75 (0.58)*	5	5
Parenting – helpfulness	---	---	---	4.40 (0.74)	5	5
Relaxation – easy to understand	4.07 (1.03)*	4	5	4.56 (0.51)	5	5
Relaxation – helpfulness	4.24 (0.90)*	4	5	4.47 (0.74)	5	5
Affective – easy to understand	3.93 (0.88)*	4	3	4.56 (0.51)	5	5
Affective – helpfulness	4.18 (0.88)*	4	5	4.60 (0.51)*	5	5
Cognitive – easy to understand	3.87 (1.06)	4	4	4.50 (0.63)	5	5
Cognitive – helpfulness	3.94 (1.09)	4	5	4.53 (0.64)	5	5
Narrative – easy to understand	3.60 (1.24)	3	3	4.38 (0.89)	5	5
Narrative – helpfulness	3.88 (1.32)	4	5	4.53 (0.65)	5	5
In vivo – easy to understand	3.20 (1.42)	3	3, 4	4.13 (1.15)	4.5	5
In vivo – helpfulness	3.62 (1.59)	4	5	4.53 (0.64)	5	5
Conjoint – easy to understand	3.77 (1.24)	4	4	3.88 (1.15)	4	5
Conjoint – helpfulness	3.94 (1.39)	4.50	5	4.60 (0.63)*	5	5
Enhance safety – easy to understand	4.27 (1.22)*	5	5	4.63 (0.50)*	5	5
Enhance safety – helpfulness	4.06 (1.20)*	5	5	4.40 (0.91)	5	5
Telehealth satisfaction scale (M, SD)
Total score (10–40)	32.93 (5.56)			37.50 (3.31)
Feedback on program structure (% rating each component as ‘just right’)	[Youth %]			[Caregiver %]
Program length (12 weeks)	58.8%			50%
Meeting length (60–90 minutes)	70.6%			93.8%
Individual time for child	70.6%			75%
Individual time for Caregiver	82.4%			75%
Conjoint time	70.6%			68.8%
Meeting frequency	100%			87.5%

Note. M = mean, SD = standard deviation, med = median. Highest rated mean values for treatment components are marked with a *. Available n ranged from 13–17 per item for program ratings, components, and telehealth satisfaction. Available n for feedback on program structure was 17 for youth and 16 for caregivers. Please see Supplemental Table S3 for item level ratings on the Telehealth Satisfaction Scale and Supplemental Table S4 for a full breakdown of item responses to the feedback on program structure.

Qualitative Description of Telehealth Treatment Techniques

General strategies for delivering TF-CBT, as well as ways of supporting engagement, executive functioning, and generalization across each specific module have been well detailed in prior work, including via telehealth (D’Amico et al., 2022; Peterson et al., 2019; Romney & Garcia, 2021; Stack & Lucyshyn, 2019; Stewart et al., 2017; STRYDD, n.d). Thus, we briefly describe how these recommendations were implemented in the current study. For general strategies, we were flexible with regard to length of meetings and caregiver involvement, such as by having caregivers join for longer portions of each individual session to provide further support to their child. To support predictability, we had a general order for each session that was followed when possible, including (1) beginning with a brief check-in with both caregiver and child together, (2) having a more detailed individual child check-in (including completion of self-report measures, though this was shortened or removed as needed for any particular meeting as necessary, such as for managing time and/or to support child engagement) followed by child session content, (3) brief conjoint time to review the session with child and caregiver together (e.g., “teach-back” time), and (4) caregiver-only time. We often used visual schedules and/or checklists that were screenshared with the participant. Across all modules, we used a combination of learning materials via screenshare, including PowerPoint slides, gamified ways of practicing coping skills in interactive ways, YouTube videos, books, etc. To support different ways of communicating, we also supported youth if they wanted to respond via Zoom’s chat function instead of verbally in moments where that was preferrable.

For the psychoeducation/parenting, relaxation, affective modulation, and cognitive coping modules, we focused on supporting safety and predictability by letting participants know what to expect in each session and that they could request to stop and/or take a break at any time (including via chat). For psychoeducation, the intersection of autism and trauma was often discussed, including (but not limited to) topics of sensory experiences, masking, differentiating trauma symptoms from other mental health concerns and emotion regulation, chronic trauma experiences, and emotional/communication differences (e.g., alexithymia). Resources designed and/or co-produced with Autistic people were emphasized as they were relevant to these questions. Coping skills were taught via videos, interactive games, and screenshared worksheets and creative activities. We took a flexible approach to enhance youth motivation, including supporting creative activities for relaxation when deep breathing or other relaxation strategies were not preferred, and using teaching examples that related to child interest areas.

Across the trauma narration/processing modules, narrative creation was supported in several ways, including using creativity (e.g., metaphors for different sections of the narrative based on interests, inclusion of pictures/songs, narrative formats aligning with child interests), promoting predictability (such as by providing a checklist of ‘chapters’ within the trauma narrative, helping structure narration with specific questions to get started), and supporting youth to use chat to communicate when preferred. For youth with chronic trauma experiences, framing the narrative within a “life story” approach could be useful. It was also helpful to add structure to the conjoint module, such as including checklists and other visual schedules/supports. Safety planning content often included topics related to the intersection of autism and trauma.

Discussion

This pilot, proof-of-concept evaluation suggests that telehealth-based TF-CBT can be effective and acceptable to Autistic youth and their caregivers, and future research is warranted to evaluate this treatment more rigorously. Our results show significant reductions in youth trauma symptoms and related mental health difficulties that are maintained at a 1-month follow-up and are observed across multiple raters (youth, caregiver, interviewer). Significant improvements were also seen for caregiver-level outcomes. The program and telehealth delivery were highly rated by both youth and caregivers. Clinician adaptability ratings and fidelity were high (94% of cases), similar to prior work (93.4%, Jensen et al., 2017; 85%, Peters et al., 2021).

Changes in Child Outcomes

Youth PTSD symptoms significantly declined across all measures at both time points. Youth self-reported effect sizes were moderate to large (.65 at end of treatment, .85 at 1-month follow-up). Caregiver reported (2.30 – 2.23) and interview rated (1.00 – 1.10 for youth interview, 1.16 to 1.87 for caregiver interview) effect sizes were large at both time points. To contextualize the current effect sizes, a meta-analysis of pre-post within group effect sizes for individually delivered TF-CBT identified an overall effect size for PTSD symptoms of .94 (.85 including high risk of method bias studies), based upon interviewer and/or self-ratings (interview ratings were prioritized; Thielemann et al., 2022). The present interviewer and caregiver-reported effect sizes exceeded these estimates, and youth-reported effect sizes were similar. Regarding co-occurring mental health concerns, youth self-reported significant reductions in anxiety, with a moderate effect size at the end of the program (.63) and a large effect size at the 1-month follow-up (.98). These effect sizes are similar to or larger than the previous meta-analytic estimate (.59) for changes in anxiety post TF-CBT (Thielemann et al., 2022).

There were non-significant changes for youth self-report of depression symptoms and resilience. This may be due to low power and/or low depressive symptoms in this sample, or TF-CBT may support anxiety symptoms more than depressed mood for Autistic youth. The BRS has not yet been used to measure resilience among Autistic youth, and future work may consider other measures (Deblinger et al., 2017). More broadly, resilience may be facilitated by broader supports (e.g., identity, social, or sensory support) for Autistic youth (Heselton et al., 2022).

Caregivers reported significant changes across all measures of youth co-occurring mental health, including large effect sizes for depression (1.97 at end of treatment, 1.19 at 1-month follow-up) and externalizing concerns (1.28 at end of treatment, 1.34 at 1-month follow-up), and moderate-large effect sizes for anxiety (.90 at end of treatment, .66 at 1-month follow-up), resilience (−.72 at end of treatment, −1.08 at 1-month follow-up), and internalizing (.71 at end of treatment, .85 at 1-month follow-up). These effect sizes are larger than prior meta-analytic estimates for changes in anxiety (.59) and depression (.63) post TF-CBT (Thielemann et al., 2022), and for changes in externalizing from a meta-analysis (d = .666) that pooled results for TF-CBT along with Eye Movement Desensitization and Reprocessing therapy (EMDR; Hoogsteder et al., 2022). Thus, caregivers perceived TF-CBT to be helpful to a significant degree for a range of youth traumatic stress symptoms across internalizing and externalizing domains.

Changes in Caregiver Outcomes

Caregivers reported significant reductions in inconsistent parenting that were maintained at the 1-month follow-up with large effect sizes, and temporary reductions in supervision difficulties at the end of the program. Encouragingly, this suggests that TF-CBT also supports consistent caregiving for caregivers of Autistic youth, similar to prior research documenting improvements in parenting behavior in TF-CBT (Cohen et al., 2004; Deblinger et al., 2011). On the quality of life scale, improvements in parenting-related quality of life were observed at the 1-month follow-up, and temporary improvements in disability-related support were reported at the end of the program, supporting that positive changes associated with TF-CBT may also generalize to broader family-level processes. No changes were observed for parenting stress, which should be explored further to clarify which caregiver processes change across TF-CBT. Caregivers reported reductions in their PTSD symptoms and improvements in their resilience at the end of the program. These changes are consistent with prior research showing that TF-CBT can support caregiver mental health (Martin et al., 2019), although effects were not maintained at the 1-month follow-up and no changes were seen for mood symptoms. Future work should consider how to best support caregivers with their own trauma and/or mental health histories.

Treatment Feedback

Feedback data supports that TF-CBT can be an acceptable program to Autistic youth and their caregivers. For overall ratings, average youth ratings were all higher than a 3.56 out of 5 (corresponding to responses of at least moderately-very much), with the highest ratings for agreeing with the message and understanding the program. Average caregiver ratings were all higher than 4.44 out of 5, suggesting that caregivers also perceived the program positively, to an even higher degree than youth. Future research is needed to better understand for whom TF-CBT would be a particularly strong fit, versus when other treatment programs may be preferred. Of the PRACTICE components, youth rated relaxation, affective modulation, and enhancing future safety as most helpful. Prior research with youth similarly shows that skill building for reducing stress is helpful (Dittmann & Jensen, 2014), and that safety is a key theme characterizing youth experience of TF-CBT (Ascienzo et al., 2022). Caregivers rated psychoeducation, affective modulation, and the conjoint modules as most helpful, consistent with caregivers finding information, skill building, and talking about their child’s trauma experiences helpful (Brumley et al., 2021). Lange and colleagues (2021) also described that psychoeducation, parenting, relaxation, and affective modulation are particularly helpful for caregivers. Telehealth delivery was also highly rated, consistent with prior TF-CBT research (Villalobos et al., 2023).

Limitations and Future Directions

The small sample size and lack of comparison group or control condition greatly limits the conclusions that can be drawn, as it is not possible to establish the reason for change observed over the course of this pilot study. Future research with larger and more diverse samples using a randomized design is a critical next step for expanding the evidence base for TF-CBT among Autistic youth. Moreover, our training sequence did not require all clinicians to complete the live, synchronous (e.g., 2-day) training with TF-CBT trainers. Future evaluations of TF-CBT for Autistic youth should expand clinician training protocols according to treatment development recommendations. Some outcome measures used in the study have not yet been rigorously evaluated among Autistic youth. The same interviewer conducted the initial assessment, provided the intervention, and conducted follow-up assessments, which greatly limits the conclusions that can be drawn from interview-rated data. Although steps were taken to minimize the potential bias introduced by this non-independent rater, future research should assess intervention response via independent interview ratings.

Moving forward, it would be particularly useful to compare telehealth to in-person TF-CBT and consider protocols longer than 12 weeks. Future research should consider the inclusion of younger children and transition-age youth, given that TF-CBT has been established as efficacious for both developmental periods among non-autistic youth (McGuire et al., 2021; Peters et al., 2021). Future research should consider TF-CBT for Autistic youth with intellectual disability (Hoover et al., 2024). Although the current study qualitatively described implementation strategies to guide future work, more complete assessment of clinician strategies and how they relate to outcomes is also important. Lastly, clinician training and support is urgently needed to increase the availability of trauma-focused therapies for Autistic youth.

Supplemental Material

Supplemental Material - A Pilot Proof-of-Concept Study of Telehealth-Based Trauma-Focused Cognitive Behavioral Therapy for Autistic Youth: Initial Evidence of Efficacy and Acceptability

Supplemental Material for A Pilot Proof-of-Concept Study of Telehealth-Based Trauma-Focused Cognitive Behavioral Therapy for Autistic Youth: Initial Evidence of Efficacy and Acceptability by Christina G. McDonnell, Theresa Andrzejewski, Saily Gomez Batista, Elizabeth A. DeLucia, Janey Dike, Kaitlyn E. Breitenfeldt, and Alison U. Tassone in Child Maltreatment

Footnotes

Acknowledgments

We are very grateful to the youth and their families who participated in this research study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Organization for Autism Research (Applied Research Grant (C. McDonnell).

ORCID iDs

Christina G. McDonnell

Theresa Andrzejewski

Supplemental Material

Supplemental material for this article is available online.

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