Efficacy and predictors of outcome in parent training interventions for children with conduct problems

Aggressive and disruptive behaviors in childhood are one of the most common reasons for referral to child psychiatric clinics and are predictive of a range of negative health outcomes later in life. The present thesis comprises four studies of parent training (PT) interventions targeting conduct problems (CP) in children aged 3 to 12. The main objectives were to evaluate issues pertaining to short- and long-term effects, dissemination modalities (Internet-based and face-to-face delivery) and predictors of change. Study I was a randomized controlled trial including parents of 104 children who were allocated to either an Internet-based PT program or a waitlist condition. At post-test, intervention families had improved significantly in parent-reported child CP and parenting practices, compared with waitlist families. Between-group effects sizes were in the moderate range for CP reductions, i.e., similar to effects commonly reported in meta-analyses of face-to-face PT programs. Study II concerned prediction of outcome for intervention families in the study-I sample. Results showed that children with elevated levels of callous-unemotional (CU) traits benefitted less from the Internet-based PT program, compared with low-CU children, despite the fact that parents of high-CU children reported increased use of positive/praiseful parenting, as well as decreased use of harsh parenting, following participation in the Internet-based PT program. Study III employed an 18-month follow-up of intervention families (from the study-I sample) showing further improvements of child CP and mostly maintenance of treatment gains in other domains (e.g., hyperactivity and prosocial behaviors). Within the same study, associations between homework compliance and outcomes were investigated. Results indicated that higher parental engagement in homework tasks related to conflict management (ignoring misbehavior and time out) was associated with greater reductions of child CP, compared to less engagement in homework assignments. Study IV compared the effectiveness of four group-based PT programs (Comet, Incredible years, Cope and Connect), including behavioral as well as non-behavioral interventions, at a 2-year follow-up. Participants were parents of 749 children who had been randomly allocated to one of the PT programs. At follow-up, children in all four conditions had improved to a similar extent with regard to child CP, hyperactivity and inattention problems, when controlling for baseline severity and age differences. A comparison of change rates, from baseline to the 2-year follow-up indicated that children in behavioral programs were reported to have more rapid reductions of problems during the course of the intervention, compared with children in the non-behavioral program. During the 2-year follow-up period, however, participants in behavioral programs were mostly characterized by maintenance of previous treatment gains, whereas participants in the non-behavioral program continued to improve. In conclusion, the current thesis provides support for the short- and long-term efficacy of an Internet-based PT program, suggesting that online dissemination of interventions targeting child CP could be an alternative to face-to-face PT. The findings also highlights the predictive role of child CU traits in PT programs, emphasizing the need for different treatment approaches, for the subgroup of children who present with a combination of CP and CU traits. The current thesis also provides support for the long-term effectiveness of four group-based PT programs, when employed in Swedish routine care settings. This finding should be important for future guidelines and recommendations of PT-program implementation

Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders : a single-centre, single-blind, randomised controlled trial

Background: Paediatric anxiety disorders are prevalent and associated with substantial disability and long-term adverse consequences. Only a minority of affected children have access to evidence-based treatment; internet-delivered cognitive behaviour therapy (ICBT) could help increase accessibility but needs further rigorous evaluation. The objective of this trial was to evaluate the clinical efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders. Methods: In this single-blind randomised controlled trial, children 8-12 years with a principal anxiety disorder diagnosis were randomly allocated (1:1) to ICBT or internet-delivered child-directed play (ICDP), an active comparator aimed to improve parent-child relationships and increase child self-esteem without directly targeting anxiety. The study was conducted at a single site within the Stockholm specialist child and adolescent mental health services (CAMHS). Primary endpoint was clinician-rated symptom severity (CSR) of the principal anxiety disorder at post-treatment. All participants were included in the primary analysis (intent-to-treat). Trial registration number: NCT02350257. Findings: Participants (N=131) were recruited between March 2015 and October 2016, mainly via advertisement and referrals from CAMHS, and allocated to ICBT (n=66) or ICDP (n=65). Analyses revealed greater reduction of symptom severity in favour of ICBT (mean difference 0·79, 95% CI 0·42 to 1·16, p=0·002; Cohen’s d=0·77, 95% CI 0·40 to 1·15) and at post-treatment, 48% (n=29) of participants randomised to ICBT no longer fulfilled their principal diagnosis, compared to 15% (n=9) in ICDP (odds ratio 5·41, 95% CI 2·26 to 12·90, p<0·0001). Numbers needed to treat were 3 (95% CI 2·85 to 3·15). Treatment gains were maintained at 3-month follow-up, at which point 70% (n=40) of participants randomised to ICBT no longer met the criteria for their principal anxiety disorder. ICBT resulted in an average societal cost saving of €493·05 (95% CI 477·17 to 508·92) per participant. No severe adverse events were reported. Interpretation: ICBT is a cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care.The Swedish Research Council for Health, Working Life and WelfareStockholm County CouncilAccepte

Selective visual attention to threat in children and adolescents with social anxiety disorder

Background Social anxiety disorder (SAD) is a common and disabling condition that often onsets during early adolescence (median 13 years) [1]. With a lifetime prevalence of about 11% and a substantially increased risk for individuals with SAD to develop subsequent depression, there are good reasons to detect and treat social anxiety early [2]. The best available psychosocial treatment for SAD is cognitive behavioral therapy (CBT) and a generic form of CBT is often used to treat children and adolescents with anxiety disorders such as SAD (e.g., the cool kids program) [3]. But generic CBT does not seem to be as effective for children with SAD as for those with other anxiety disorders [4, 5]. This was for instance shown in the Child Anxiety Multimodal Study (CAMS) where only 40.6% of participants with SAD were in remission after generic CBT, compared to 72% of those with separation anxiety disorder and generalized anxiety disorder [6]. Other forms of CBT, specifically targeting SAD (e.g., social effectiveness therapy for children, SET-C) [7], have been shown to be more effective but are often lengthy and require substantial resources. They have therefore struggled to find their way from research settings to implementation and even when they are used they tend to leave 30-50% of patients with a retained SAD diagnosis after treatment. Conversely, for adults with SAD there are effective treatments where up to 80-85% of particpants are reported to be free from their SAD diagnosis after treatment [e.g., 8]. Through well defined and carefully tested maintenance mechanisms that are targeted in treatment, CBT for adult SAD has attained a level of efficiency superior to many other psychological treatments [9]. However, there are currently no maintenance models for childhood SAD and due to differences in, e.g., cognitive maturation and differences in social contexts between adults and children, adult models of SAD [e.g., 9, 10] cannot be assumed to be directly applicable to children and adolescents. Processes that maintain SAD in childhood are therefore in need of further investigation [11] and one such suggested process is selective attention to threat in the surrounding, i.e., attention bias [12, 13]. Anxious individuals have been shown to be hypervigilant to threat as well as to have a reduced ability to disengage attention from threat, and these atypical ways of directing the gaze are suggested to be implicated in both the development and maintenance of anxiety [14]. Specifically, facilitated attention to threat, as well as impaired disengagement from what is perceived as threatening, are thought to lead to overestimations of danger and likelihood of harm [15]. Another suggested atypical way of reacting to threatening social stimuli is by avoidance. A recent systemativ review concluded that visual avoidance of faces seems to emerge during adolescense for individauls with social anxiety [16]. Avoidance could be an important maintaining mechanism in social anxiety, as it may lead to a deficit of social information that prevents disconfirmation of perceived threats during interaction with others. However, only a limited number of studies have investigated avoidance in youth populations with SAD and further studies are needed. To summarise, previous findings aiming to confirm potentially maintaining mechanism in youth SAD, such as vigilance, impaired disengagement and avoidance have been equivocal, possibly due to variability in sample composition with regard to age and level of social anxiety severity [17], different test paradigms used and generally small sample sizes. In the present study we will attempt to evaluate attention characteristics related to threat in a disorder specific group of children and adolescents (10-17 years) with SAD, using an experimental paradigm that allows simultaneous investigation of vigilance, disengagement and avoidance. In addition to saccadic latency which is commonly studied in visual attention tasks, we plan to examine peak saccade velocity. Peak saccade velocity is linked to arousal, so that invididuals in highly aroused states tend to make saccades of higher velocity [18] (ref.). If SAD is associated with emotional hyperarousal, this could result in saccades of higher peak velocity. On the other hand, reduced peak velocity has been associated with a range of psychiatric and neurological conditions, including depression in adults, meaning that the opposite pattern is also possible. Current status of the project Data has been collected from all participants but no analyses have been conducted at the time of this preregistration. Aim We aim to determine if youth with SAD, relative to non-anxious youth, display selective attention to threatening social stimuli (angry faces), compared to non-threatening social stimuli (happy/neutral faces). Furthermore, we aim to determine if youth with SAD, relative to non-anxious youth, are faster or slower to disengage from threatening social stimuli, compared to non-threatening social stimuli (happy/neutral faces). Hypotheses 1. We hypothesize that youth with SAD, relative to non-anxious controls, will demonstrate a shorter latency to direct their gaze toward peripheral angry faces relative to happy and neutral faces using the gap paradigm. 2. We hypothesize that youth with SAD, relative to non-anxious controls, will demonstrate either shorter or longer latency to disengage from angry faces relative to happy and neutral faces, using the overlap paradigm. Indicating either impaired disengagement from threat or avoidance of threat. 3. We hypothesize that attentional differences between the SAD and non-anxious group postulated in hypotheses 1 and 2 will be more evident in older participants than in younger participants, as suggested by several studies investigating developmental impact on attention in anxious children [19-21]. 4. We hypothesize that individuals with SAD will show atypical peak saccade velocities compared to non-anxious controls. Since previous studies are lacking, this hypothesis is undirected. Participants Children and adolescents (10-17 years) with SAD were recruited from a clinical trial evaluating internet-delivered CBT for SAD. Initially, 107 individuals were invited to participate and of those N=69 accepted and were subsequently included in the eye-tracking study. All participants fullfilled diagnostic criteria for SAD according to the Anxiety Disorder Interview Schedule – child version [22]. Participants in the SAD group were excluded if they had a severe comorbid condition such as psychosis, eating disorder or suicidal ideation, if they had initiated psychotropic medication during the last six weeks, or if they had received CBT within the last 6 months. Participants in the healthy control (HC) group were recuited from a random selection of individuals in the Swedish population register. Initially, 326 families were contacted with information about the study and of those, 153 did not respond and 107 declined participation. Of the 66 families that were interested in participating, 18 were excluded during a screening process (where the MINI International Neuropsychiatric Interview [23] was used) due to the youth having a current or previous psychiatric disorder and 7 were excluded due to difficulties finding a suitable time point for the eye-tracking test, leaving a sample of N=41 participants in the HC group. Experimental task and other measures A modified version of the gap-overlap paradigm was used [24, 25] where participants initially focused on a central visual stimulus when a peripheral stimulus appears that they reorient their gaze to. In gap trials, the central stimulus is extinguished before the peripheral stimulus appears whereas in overlap trials, the central stimulus remains when the peripheral stimulus appears. Latency to orient to peripheral emotional stimulus (angry, happy or neutral faces) in gap trials served as an index of vigilance whereas latency to reorient the gaze from a central emotional stimulus to a peripheral non-social stimulus (an object such as a berry or a house) served as an index of disengagment. Participants completed 60 trials (30 gap trials and 30 overlap trials). Pictures of emotional faces were drawn from the Karolinska Directed Emotional Faces (KDEF) database [26]. Recording and processing of eye-tracking data Eye-tracking data was recorded with a corneal reflection eye-tracker (X3-120 fromTobii) with a sample rate of 120hz. Stimuli were presented on a 17” monitor and a 9-point callibration procedure was applied before the experiement began. Fixations and saccades will be identified using a custom I-VT filter with settings determined based on data quality. Peak saccade velocity will be normalized to saccadic amplitude to account for the fact that saccadic amplitude and velocity are typically closely linked (the “main sequence”). Statistical analyses Data will be analyzed using generalized linear mixed effects models (GLMM) with random intercept for participant. Statistical tests for an effect will be performed by comparing a model including the effect to the most complex model without the effect in question (the null model). For example: a main effect of group can be tested by comparing the full model Y ~ GROUP + (1|ID) to a null model including only the intercept: Y ~1+ (1|ID), where Y is the response variable. Hypothesis 1 will be tested using gap trials, hypothesis 2 by using overlap trials and hypothesis 3 is tested by using both gap and overlap trials. References 1. Kessler, R.C., et al., Lifetime prevalence and age-of-onset distributions of dsm-iv disorders in the national comorbidity survey replication. Archives of General Psychiatry, 2005. 62(6): p. 593-602. 2. Beesdo, K., et al., Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Archives of general psychiatry, 2007. 64(8): p. 903-912. 3. Rapee, R., et al., Cool Kids therapist manual: For the Cool Kids child and adolescent anxiety programs. Sydney, Australia: Centre for Emotional Health, Macquarie University, 2006. 4. Hudson, J.L., et al., Comparing outcomes for children with different anxiety disorders following cognitive behavioural therapy. Behaviour Research and Therapy, 2015. 72: p. 30-37. 5. Waters, A.M., et al., Predicting outcomes for anxious children receiving group cognitive‐behavioural therapy: Does the type of anxiety diagnosis make a difference? Clinical Psychologist, 2018. 22(3): p. 344-354. 6. Ginsburg, G.S., et al., Remission after acute treatment in children and adolescents with anxiety disorders: findings from the CAMS. Journal of consulting and clinical psychology, 2011. 79(6): p. 806. 7. Beidel, D.C., S.M. Turner, and T.L. Morris, Behavioral treatment of childhood social phobia. Journal of consulting and clinical psychology, 2000. 68(6): p. 1072. 8. Clark, D.M., et al., Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of consulting and clinical psychology, 2006. 74(3): p. 568. 9. Clark, D.M. and A. Wells, A cognitive model of social phobia, in Social phobia: Diagnosis, assessment, and treatment. 1995, Guilford Press: New York. p. 69-93. 10. Rapee, R.M. and R.G. Heimberg, A cognitive-behavioral model of anxiety in social phobia. Behaviour research and therapy, 1997. 35(8): p. 741-756. 11. Halldorsson, B. and C. Creswell, Social anxiety in pre-adolescent children: What do we know about maintenance? Behaviour research and therapy, 2017. 99: p. 19-36. 12. Armstrong, T. and B.O. Olatunji, Eye tracking of attention in the affective disorders: A meta-analytic review and synthesis. Clinical psychology review, 2012. 32(8): p. 704-723. 13. Bar-Haim, Y., et al., Threat-related attentional bias in anxious and nonanxious individuals: a meta-analytic study. Psychological Bulletin, 2007. 133(1): p. 1-24. 14. Cisler, J.M. and E.H. Koster, Mechanisms of attentional biases towards threat in anxiety disorders: An integrative review. Clinical psychology review, 2010. 30(2): p. 203-216. 15. In-Albon, T., J. Kossowsky, and S. Schneider, Vigilance and Avoidance of Threat in the Eye Movements of Children with Separation Anxiety Disorder. Journal of Abnormal Child Psychology, 2010. 38(2): p. 225-235. 16. Chen, J., E. van den Bos, and P.M. Westenberg, A systematic review of visual avoidance of faces in socially anxious individuals: Influence of severity, type of social situation, and development. Journal of Anxiety Disorders, 2020. 70: p. 102193. 17. Capriola-Hall, N.N., T.H. Ollendick, and S.W. White, Gaze as an Indicator of Selective Attention in Adolescents with Social Anxiety Disorder. Cognitive Therapy and Research, 2020. 44(1): p. 145-155. 18. Di Stasi, L.L., et al., Saccadic velocity as an arousal index in naturalistic tasks. Neuroscience &amp; Biobehavioral Reviews, 2013. 37(5): p. 968-975. 19. Dudeney, J., L. Sharpe, and C. Hunt, Attentional bias towards threatening stimuli in children with anxiety: A meta-analysis. Clinical Psychology Review, 2015. 40: p. 66-75. 20. Field, A.P. and K.J. Lester, Is There Room for "Development" in Developmental Models of Information Processing Biases to Threat in Children and Adolescents? Clinical Child and Family Psychology Review, 2010. 13(4): p. 315-332. 21. Kindt, M. and M. Van Den Hout, Selective attention and anxiety: A perspective on developmental issues and the causal status. Journal of Psychopathology and Behavioral Assessment, 2001. 23(3): p. 193-202. 22. Albano, A.M. and W.K. Silverman, Anxiety Disorders Interview Schedule for DSM-IV-Child Version: Clinician Manual. 1996: Psychological Corporation. 23. Sheehan, D.V., et al., The Mini- International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM- IV and ICD- 10. Journal of Clinical Psychiatry, 1998. 59(Supplement 20): p. 22-33. 24. Csibra, G., M.H. Johnson, and L.A. Tucker, Attention and oculomotor control: a high-density ERP study of the gap effect. Neuropsychologia, 1997. 35(6): p. 855-65. 25. Kleberg, J.L., et al., Autistic Traits and Symptoms of Social Anxiety Are Differentially Related to Attention to Others' Eyes in Social Anxiety Disorder. Journal of Autism and Developmental Disorders, 2017. 47(12): p. 3814-3821. 26. Lundqvist, D., A. Flykt, and A. Öhman, The Karolinska Directed Emotional Faces-KDEF. 1998: Department of Clinical Neuroscience, Psychology section, Karolinska Institutet, Stockholm, Sweden

Pupil dilation to emotional expressions in adolescent social anxiety disorder is related to treatment outcome

Atypical attention to potential social threats, such as emotional faces, may be one of the core mechanisms underlying social anxiety disorder (SAD). Pupil dilation is an index of locus coreuleus-noradrenergic activity, and closely linked to attention. In the present study, pupil dilation was studied in adolescents with SAD (N = 26; 22 Female) before the onset of a 12-week cognitive behavioral treatment, and in healthy controls (N = 23). Stimuli were faces with angry or happy emotional expressions. Contrary to our hypothesis, the SAD group did not show hyper-responsiveness to angry compared to happy faces. Instead, an atypical time course of the pupil dilation response was found, resulting in an attenuated response during late time stages. Larger pupil dilation amplitude to happy faces before treatment was related to worse treatment response. These results contribute significantly to our understanding of the mechanisms underlying adolescent SAD

An exploratory study of stressors, mental health, insomnia, and pain in cisgender girls, cisgender boys, and transgender and gender diverse (TGD) youth

Introduction: Transgender and gender-diverse (TGD) youth experience more stressors and are therefore at a higher risk of health problems compared with their cisgender peers. The aim of this study was to investigate the prevalence of TGD youth in a general population sample and to explore a wide variety of health-related factors. We investigate differences in stressors and health outcomes between TGD youth and cisgender girls and boys and the influence of stressors and demographic factors on health outcome in the whole group. Methods: Cross-sectional survey data from a Swedish school-based study were used (N = 3,067, M = 17.8 years). Those who had reported their gender identity as “other” or other than their assigned gender (N = 41) were compared with cisgendered girls (n = 1,544) and boys (n = 1,482). Regression models in the whole group explored if demographics and stressors statistically predicted health outcomes. Results: In comparison with cisgender girls and boys, TGD youth (1.3% of the whole sample) reported a higher prevalence of self-harm and pain problems. Both TGD youth and cisgender girls more frequently reported insomnia, social anxiety, depressive symptoms, pain, and stressors compared with cisgender boys. When only demographic variables were entered, but not when stressors were added to the model, being TGD magnified the odds of depressive symptoms, sub-diagnostic social anxiety, and pain problems. Stressors magnified the odds of reporting health problems for the whole group. Conclusion: TGD youth generally reported more stressors, which negatively influence health outcomes. Results are important for professionals who meet TGD youth.

Social attention in children and adolescents with social anxiety

To successfully navigate the social world, we have to attend to complex and quickly shifting information, such as facial expressions and emotional displays. Work in psychology and neuroscience has demonstrated that typically developing children are remarkably apt at doing this. However, many children with social anxiety have a difficulty directing their attention flexibly and adaptively to social events, typically manifested as avoidance of eye contact or hyper-vigilance towards potential social threat (e.g., someone looking angry). This atypical social attention has been suggested to lead to a range of problems. According to theoretical models, atypical social attention is one of the core mechanisms underlying the development of social anxiety disorder (SAD), but it is also seen in other clinical conditions such as autism spectrum disorder (ASD). However, there is a lack of knowledge about these attentional mechanisms in children with SAD, the overlap between conditions, and if they can be affected by psychological treatment. We aim to test the specificity of fundamental social attention mechanisms that have been linked to SAD and their relationship to the outcome of cognitive behavioral therapy (CBT) for youth with SAD. Social attention will be measured with eye-tracking. Youth with SAD will be compared to other groups with clinical conditions related to atypical social attention (youth with ASD, general anxiety and body dysmorphic disorder) and non-anxious controls

Delayed gaze shifts away from others' eyes in children and adolescents with social anxiety disorder

Background: Social anxiety disorder (SAD) is linked to atypical attention to other's eyes. Empirical literature about this phenomenon in childhood and adolescence is scarce. Previous studies in adults have suggested that SAD may be characterized by either rapid avoidance of eye contact, or by impaired shifting of attention away from eyes once eye contact has been established. SAD has also been linked to quick orienting towards eyes, indicating vigilant monitoring of perceived threat. Methods: In the largest eye-tracking study of youth with SAD to date, 10 to 17 year-olds with SAD (n = 88) and healthy controls (n = 62) were primed to look at either the eyes or the mouth of human faces. The latency and likelihood of a first gaze shift from, or to the eyes, was measured. Results: Individuals with SAD were slower to shift their gaze away from the eye region of faces than controls, but did not differ in orienting toward eyes. Limitations: Participants were assessed once after the onset of SAD symptoms, meaning that the longitudinal predictive value of delayed gaze shifts from others' eyes could not be examined. Conclusions: Youth with SAD may be impaired in shifting attention from other's eyes. This could contribute to the experience of eye contact as aversive, and may be a maintaining factor of childhood SAD

Clinical, demographic and theory-derived maintaining factors as moderators of treatment outcome in internet-delivered cognitive behavioural therapy for children and adolescents with social anxiety disorder

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10–17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials

Reduced left visual field bias for faces in adolescents with social anxiety disorder

Introduction: Individuals tend to explore the left side of a face first and for a longer time in comparison to the right side. This left visual field (LVF) bias is suggested to reflect right hemispheric dominance for face processing. Social anxiety disorder (SAD) is associated with maladaptive interpretations of facial expressions, but it is not known whether this is linked to an atypical LVF bias. Previous studies have reported a reduced LVF bias in autism, a condition overlapping with SAD. This pre-registered study examined the LVF bias in adolescents with SAD. Methods: Eye-tracking was used to investigate the ratio of first fixations to the left on upright and inverted face stimuli in 26 adolescents (13-17 years) with SAD and 23 healthy controls primed to look either between the eyes or at the mouth. Results: The SAD group showed a smaller LVF bias and an atypical face inversion effect when primed to look at the eyes. Autistic traits predicted a smaller LVF bias, independently of social anxiety level. Conclusions: Results suggest that SAD is associated with impaired processing of faces at an early stage of visual scanning. The findings contribute to a better understanding of SAD and its overlap with autism