School-aged children with Autism Spectrum Disorder (ASD) experience significant difficulty with peer interaction (Lord & Bishop, 2010), an important aspect of childhood. Unresolved social skills difficulties lead to continued dysfunction in relationships which influence long term success. Research into the most effective strategies has increased but several questions remain. One approach that appears to help school-aged children is Cognitive Behavior Therapy (CBT) which focuses on changing how a person thinks about specific social situations as well as how they behave. This study evaluated the efficacy of a 15-week CBT-based social skills group intervention for boys aged 10-12 years diagnosed with an Autism Spectrum Disorder. Boys with average or better receptive language skills and IQ attended weekly sessions focused on teaching self-monitoring skills, social perception and affective knowledge, conversation skills, taking another persons perspective, social problem-solving, and friendship management skills. Group size varied from four to six participants. The intervention was based on two intervention programs available in the literature and was manualized. Eight of the fifteen participants were waitlisted (Delayed Treatment group) while the remaining participants began 15 sessions of intervention immediately (Immediate Treatment group). A repeated measures ANOVA was used to compare the Delayed Treatment group to the Immediate Treatment group on pre and post measures of social perception, peer interaction, social knowledge, pragmatic language, social responsiveness and general socialization skills. Compared to the Delayed Treatment group, the Immediate Treatment group showed significant improvements after intervention in social perception, peer interaction, and social knowledge. The Delayed Treatment group was also examined on all measures at three time points: prior to the waitlist time, pre-intervention, and post-intervention. Significant improvements only after intervention were present for peer interaction, social knowledge, and a parent report measure of socialization. The implications of these findings are discussed in relation to a model of social information-processing, the executive functioning theory of autism, and how cognitive behaviour therapy techniques may contribute to social skills intervention for children with ASD. The intervention used in this study shows promise but replication with larger samples is needed. / Rehabilitation Science

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Design-oriented research is an approach to HCI research that frames HCI as a design discipline. One approach to design research is that of critical making, which incorporates critical thinking and practical ‘making’ into the design process whereby ‘making’ is framed as another context of thinking. Cybertherapy is any computationally mediated psychotherapy intervention technique. Contextually, cybertherapy is situated within the field of Psychology and yet it is argued here the area is non-binary by nature and highly relevant to the field of HCI. This study demonstrates the validity of critical making as a design-oriented research approach to the field of cybertherapy design and beyond. Through the immersive demonstration of critical making for cybertherapy innovation design, the design research approach is evaluated and argued to be a beneficial stance towards such non-binary research and development.

Background: The present study was designed to examine prefrontal cortical processes in anxious children that mediate cognitive regulation in response to emotion-eliciting stimuli, and the changes that occur after anxious children participate in a cognitive behavioral therapy treatment program. Methods: Electroencephalographic activity was recorded from clinically anxious children and typically developing children at pre- and post-treatment sessions. Event-related potential components were recorded while children performed a go/no-go task using facial stimuli depicting angry, calm, and happy expressions. Results: At pre-treatment, anxious children had significantly greater posterior P1 and frontal N2 amplitudes than typically developing children, components associated with attention/arousal and cognitive control, respectively. For the anxious group only, there were no differences in neural activation between face (emotion) types or trial (Go vs. No-go) types. Anxious children who did not improve with treatment showed increased cortical activation within the time window of the P1 at pre-treatment relative to comparison and improver children. From pre- to post-treatment, only anxious children who improved with treatment showed increased cortical activation within the time window of the N2. Conclusions: At pre-treatment, anxious children appeared to show increased cortical activation regardless of the emotional content of the stimuli. Anxious children also showed greater medial-frontal activity regardless of task demands and response accuracy. These findings suggest indiscriminate cortical processes that may underlie the hypervigilant regulatory style seen in clinically anxious individuals. Neural activation patterns following treatment suggest that heightened perceptual vigilance, as represented by increased P1 amplitudes for non-improvers, may have prevented these anxious children from learning the treatment strategies, leading to poorer outcomes. Increased cognitive control, as represented by increased N2 amplitudes for improvers, may have enabled these anxious children to implement treatment strategies more effectively, leading to improved treatment outcomes. Hence, P1 activation may serve as a predictor of treatment outcome, while N2 activation may serve as an indicator of treatment-related outcome. These findings point to the cortical processes that maintain maladaptive functioning versus the cortical processes that underlie successful intervention in clinically anxious children.

Background: The present study was designed to examine prefrontal cortical processes in anxious children that mediate cognitive regulation in response to emotion-eliciting stimuli, and the changes that occur after anxious children participate in a cognitive behavioral therapy treatment program. Methods: Electroencephalographic activity was recorded from clinically anxious children and typically developing children at pre- and post-treatment sessions. Event-related potential components were recorded while children performed a go/no-go task using facial stimuli depicting angry, calm, and happy expressions. Results: At pre-treatment, anxious children had significantly greater posterior P1 and frontal N2 amplitudes than typically developing children, components associated with attention/arousal and cognitive control, respectively. For the anxious group only, there were no differences in neural activation between face (emotion) types or trial (Go vs. No-go) types. Anxious children who did not improve with treatment showed increased cortical activation within the time window of the P1 at pre-treatment relative to comparison and improver children. From pre- to post-treatment, only anxious children who improved with treatment showed increased cortical activation within the time window of the N2. Conclusions: At pre-treatment, anxious children appeared to show increased cortical activation regardless of the emotional content of the stimuli. Anxious children also showed greater medial-frontal activity regardless of task demands and response accuracy. These findings suggest indiscriminate cortical processes that may underlie the hypervigilant regulatory style seen in clinically anxious individuals. Neural activation patterns following treatment suggest that heightened perceptual vigilance, as represented by increased P1 amplitudes for non-improvers, may have prevented these anxious children from learning the treatment strategies, leading to poorer outcomes. Increased cognitive control, as represented by increased N2 amplitudes for improvers, may have enabled these anxious children to implement treatment strategies more effectively, leading to improved treatment outcomes. Hence, P1 activation may serve as a predictor of treatment outcome, while N2 activation may serve as an indicator of treatment-related outcome. These findings point to the cortical processes that maintain maladaptive functioning versus the cortical processes that underlie successful intervention in clinically anxious children.

Abstract Co-morbid emotional disturbances are not uncommon in individuals with Asperger syndrome (AS) especially during the tumultuous period of adolescence. The few empirical studies that exist have only examined treatment outcomes for anxiety and anger in individuals with AS during childhood but there are no available treatment studies for adolescents or adults. Therefore, this research project aimed to examine the efficacy of a modified cognitive-behaviour therapy (CBT) program for emotional disturbance in young people with a diagnosis of AS. Firstly, it was important to establish the need for treatment by examining the prevalence and presentation of emotional disturbance in this population. Secondly, an investigation of the role of pessimistic attributional style, negative problem orientation and social competence as risk factors for emotional disturbance helped to determine the suitability of CBT. It was also essential that an existing CBT program was modified to suit the cognitive profile of young people with AS. Finally, the efficacy of a modified CBT program was evaluated in a pilot study and randomised controlled trial. In the first study, 68 young people with existing diagnosis of AS between the ages of 11 and 23 years completed a battery of measures that assessed for AS characteristics, emotional disturbances, risk factors, and cognitive ability. The results of this study indicated that approximately 21%, 20% and 40% of young people reported elevated levels of depression, anxiety, and anger symptoms respectively. Furthermore, approximately 60% of young people reported elevated levels on at least one of the emotional disturbance measures (i.e., depression, anxiety or anger symptoms), while 40% of adolescents reported elevated levels on at least two. Therefore, the study suggests that there is a need to develop evidence-based treatment for young people with AS. In addition, significant associations were found between pessimistic attributional style, negative problem orientation and social competence, and emotional disturbance. Multiple regressions suggested that these risk factors account for approximately 54%, 39% and 25% of variance in depression, anxiety and anger respectively. These results are consistent with the literature for typically developing young people, and thus, cognitive-behaviour therapy typically used to treat mood and anxiety disorders in the general population should be efficacious for the AS population. Furthermore, CBT has been shown to be efficacious in treating anxiety and anger problems in children with AS. Although there are no existing CBT programs targeting depression in young people with AS, there are numerous CBT programs for typically developing young people. One example is the Aussie Optimism Program (AOP), an Australian adaptation of the Penn Prevention program which has a strong evidence-base for treating depression. Based on the AS literature, the program was modified to suit the cognitive profile of young people with AS. These modifications include providing affective education, using visual materials, small groups with high therapist to adolescent ratio, and other modifications to assist learning. Study Two piloted the modified program with three young people with AS. The pilot study provided some evidence that the modified Aussie Optimism reduced symptoms of emotional disturbance, but the sample size was too small to obtain clear results. In addition, observations from the pilot study were used to further modify the CBT program, which enhanced the structure and delivery of the program. The final modified CBT program consisted of six 2-hour sessions teaching young people to identify emotions and discriminate between different levels of emotional intensity; to cope with emotions; to identify and challenge negative thoughts; and to solve problems. Finally, a randomised controlled trial was used in Study Three to examine the efficacy of the modified CBT in treating depression in young people with AS. Given the high co-morbidity of emotional disturbance, the study also tested the efficacy of CBT program in reducing symptoms of anxiety and anger. Forty-four young people with AS were randomly allocated to the intervention (n = 21) or the waitlist control (n = 23). The results of Study Three demonstrated that young people with high levels of depression and anger symptoms initially showed a significant reduction after the intervention, compared with the waitlist control group. Although anxiety levels reduced from time 1 to time 2 for the intervention group, the pattern of results was not statistically significant. Reliable change index (RCI) indicated that young people with high levels of symptoms at Time 1 showed meaningful clinical changes across measures of depression, anxiety and anger (parent and adolescent report) only in the intervention group (42-83%), but not in the waitlist control group (8-12%). Results in Study Three suggest that CBT modified to suit the cognitive profile of AS is efficacious in reducing depression and anger symptoms. Some of the methodological limitations of this study include a small sample size, attrition, participant variability, and a lack of longer-term follow-up. Despite these methodological limitations, these three studies provided strong evidence for the efficacy of CBT in treating emotional disturbance in young people with AS by establishing the need for an intervention, identifying the importance of the risk factors targeted by CBT, and demonstrating the efficacy of a modified CBT in reducing symptoms of emotional disturbance, specifically depression and anger, using a randomised controlled trial.

Doctor of Philosophy (PhD) / The purpose of this thesis was to investigate relationships between treatment knowledge, beliefs and outcome in Panic Disorder and/or Agoraphobia (Panic-Ag). Research from the psychotherapy and medical literature indicates patients’ treatment knowledge and beliefs, specifically acceptance of the treatment rationale (ATR), expectancies of treatment outcome (ETO) and treatment self-efficacy (TSE), are associated with clinical outcomes for a range of disorders. However, methodological limitations surrounding measurement of these constructs have undermined conclusions and/or such relationships have not been investigated in the field of Panic-Ag. Relationships between treatment knowledge, beliefs and outcome in Panic-Ag were examined using a 2 phase procedure. Phase 1 involved developing measures of treatment knowledge, ATR, ETO and TSE using patient and clinician samples. The psychometric properties of these measures were found to be satisfactory. Phase 2 investigated associations between treatment knowledge, beliefs and outcome following cognitive behaviour therapy (CBT) among 41 Panic-Ag participants. Measures were administered at pretreatment and 6-months posttreatment. It was hypothesised that treatment knowledge, ATR, ETO and TSE would be related to outcome, with associations mediated by belief in catastrophic cognitions. Of 4 Panic- Ag outcome measures (panic attack frequency, panic sensation severity, frequency of catastrophic cognitions and agoraphobic avoidance), results indicated improved treatment knowledge was significantly associated with frequency of catastrophic cognitions and agoraphobic avoidance. Posttreatment TSE was significantly associated with panic attack sensation severity, frequency of catastrophic cognitions and agoraphobic avoidance. Contrary to the hypothesis, ATR was not related to outcome. Similar findings concerning TSE and ATR were obtained in an independent sample of 34 Panic-Ag participants. Exploratory analyses found that pretreatment beliefs including outcome expectancies were unrelated to outcome. Mediational analyses revealed relationships between TSE and outcome were partially mediated by belief in catastrophic cognitions while relationships between treatment knowledge and outcome were not. Results are discussed in light of previous research, methodological limitations, clinical implications and future research directions.

The current research project has addressed the issue of the stress and anxiety experienced by Australian senior high school students as they prepare to undertake their final year examinations. Two studies were conducted. The first study looked at the feelings experienced by senior high school students, resources available to them to assist with exam preparation, resources actually accessed, and the strategies used to cope with examinations and associated feelings. Focus group interviews were conducted with 14 Year 11 and 13 Year 12 students from a public senior high school in Perth, Western Australia. Results indicated that students tend to most frequently report using avoidance strategies to cope with preparing and undertaking examinations, supporting previous research findings (e.g., Zeidner, 1996). The second study examined the effectiveness of a group based, cognitive behavioural program purposely designed to teach students strategies for coping specifically with test anxiety and also generalized anxiety symptoms. The program involved seven one-hour weekly sessions implemented with 31 Year 12 students who were undertaking their final year examinations. The program covered education about the nature and causes of stress and anxiety, relaxation training, cognitive restructuring, imaginal exposure and study skills training. The pre- and post-intervention scores on the TAI and RCMAS were analyzed using 2 (group) x 2 (gender) x 3 (symptom severity level) full factorial repeated measures ANOVAS. At pre-intervention, there were no significant differences between the treatment (N=31) and control (N=6), except for RCMAS Worry and Over Sensitivity, whereby the treatment group had a higher mean score, consistent with the greater ratio of female to male participants in the treatment group compared to the control group. At post intervention, the treatment group had reduced scores from preintervention levels for TAI Worry and Emotionality, RCMAS Total Anxiety, Physiological, Worry and Over Sensitivity and the Social Issues and Concentration subscales. In contrast, the post-intervention scores for the control group for these measures had increased from pre-intervention levels. However, there was no significant main effect for Group. Anecdotal program evaluation results from the treatment group students revealed that relaxation training was considered the most helpful aspect of the program. In contrast, at-home practice activities were considered the least helpful. A majority of participating students also reported that they believed the program would help them to manage stress and anxiety associated with examinations and other life stressors. Despite the lack of significant differences between the treatment and control groups in the current study, the pattern of results obtained generally followed that of previous research on the treatment of symptoms for test anxiety (e.g., Wessel & Mersch, 1994) and generalized anxiety (e.g., Kendall, 1994) employing a CBT approach. While the results of the current study may have been limited by the relatively small sample sizes of the treatment and control groups, the short- and longterm benefits of providing training in appropriate coping strategies for test anxiety, such as those involved in cognitive behavioural intervention, are further highlighted.

Despite the growing need for depression prevention programming for university students, few programs exist and those that do are too resource-intensive for broad dissemination. Furthermore, limited research has been conducted on mechanisms of change in CBT-based prevention programs and similar research conducted on CBT for depression demonstrates mixed findings. Therefore, there is a need to incorporate a formal model of health-behaviour change in prevention (and intervention) programs to clarify mechanisms of change and improve outcomes, such as the theory of planned behaviour (TPB). This series of studies developed and tested a formal CBT-TPB “hybrid” model to predict intention to change thinking patterns and a brief depression prevention program for university students and to examine the program’s potential to change the hypothesized constructs in the hybrid model. Results indicated support for the hybrid model, in that TPB factors predict intention to change thinking patterns. In addition, across an open and randomized control trial, my “Start Making a Change” intervention promotes change in TPB factors, as well as improvement in relevant CBT and well-being outcomes. The implication of this work is that brief, easy-to-disseminate, programs, based on a formal model of change, can effectively, at least in the short term, target and change important risk factors for depression onset in university students.

Cognitive behaviour therapy (CBT) is an effective treatment for depression but access is limited. One way of increasing access is to offer CBT via the Internet. In Study I, guided Internet-based CBT was found to have a large effect on depressive symptoms compared to taking part in an online discussion group. Approximately two hours were spent on guiding each patient and the large effect found differs from previous studies that showed smaller effects, probably due to lack of guidance. The intervention had no effect on the participants’ quality of life but significantly decreased their level of anxiety. Internet-based versions of self-report measures can be more practical and efficient than paper versions. However, before implementation, evidence of psychometrical equivalence to the paper versions should be available. This was tested in Studies II and III for the Montgomery-Åsberg Depression Rating Scale – Self-rated (MADRS-S) and the Beck Depression Inventory – Second Edition (BDI-II). When the full scales were investigated, equivalent psychometric properties were found in the two versions of the MADRS-S and BDI-II. However, in the Internet-version of the BDI-II, a lower score was found for the question about suicidality and the difference was statistically significant. Although the difference was small, this indicates that suicidality might be underestimated when using the Internet-based BDI-II. As the long-term prognosis after treatment for depression is poor, in Study IV we investigated the possibility of delivering CBT-based relapse prevention via the Internet. The results revealed that fewer participants in the intervention group experienced a relapse compared to the control group and that the time spent on guiding each participant was approximately 2.5 hours. A trend towards a higher remission rate was found in the CBT group at the six-month follow-up and a reduction of depressive symptoms was associated with a lowered risk of relapse. CBT-based relapse prevention via the Internet can potentially be made available to large numbers of patients, thus improving their prognosis. The Internet increases the possibilities for health care providers in the management of depression.