Cognitive Behavioral Treatments for Anxiety in Children With Autism Spectrum Disorder

Abstract

IMPORTANCE Anxiety is common among youth with autism spectrum disorder (ASD), often interfering with adaptive functioning. Psychological therapies are commonly used to treat school-aged youth with ASD; their efficacy has not been established.OBJECTIVE To compare the relative efficacy of 2 cognitive behavioral therapy (CBT) programs and treatment as usual (TAU) to assess treatment outcomes on maladaptive and interfering anxiety in children with ASD. The secondary objectives were to assess treatment outcomes on positive response, ASD symptom severity, and anxiety-associated adaptive functioning. DESIGN, SETTING, AND PARTICIPANTSThis randomized clinical trial began recruitment in April 2014 at 3 universities in US cities. A volunteer sample of children (7-13 years) with ASD and maladaptive and interfering anxiety was randomized to standard-of-practice CBT, CBT adapted for ASD, or TAU. Independent evaluators were blinded to groupings. Data were collected through January 2017 and analyzed from December 2018 to February 2019. INTERVENTIONSThe main features of standard-of-practice CBT were affect recognition, reappraisal, modeling/rehearsal, in vivo exposure tasks, and reinforcement. The CBT intervention adapted for ASD was similar but also addressed social communication and self-regulation challenges with perspective-taking training and behavior-analytic techniques. MAIN OUTCOMES AND MEASURESThe primary outcome measure per a priori hypotheses was the Pediatric Anxiety Rating Scale. Secondary outcomes included treatment response on the Clinical Global Impressions-Improvement scale and checklist measures. RESULTSOf 214 children initially enrolled, 167 were randomized, 145 completed treatment, and 22 discontinued participation. Those who were not randomized failed to meet eligibility criteria (eg, confirmed ASD). There was no significant difference in discontinuation rates across conditions. Randomized children had a mean (SD) age of 9.9 (1.8) years; 34 were female (20.5%). The CBT program adapted for ASD outperformed standard-of-practice CBT (mean [SD] Pediatric Anxiety Rating Scale score, 2.13 [0.91] [95% CI, 1.91-2.36] vs 2.43 [0.70] [95% CI, 2.25-2.62]; P = .04) and TAU (2.93 [0.59] [95% CI,]; P < .001). The CBT adapted for ASD also outperformed standard-of-practice CBT and TAU on parent-reported scales of internalizing symptoms (estimated group mean differences: adapted vs standard-of-practice CBT, −0.

Modified CBT for Social Anxiety and Social Functioning in Young Adults with Autism Spectrum Disorder

“…In line with research demonstrating the bene ts of CBT programs in improving social anxiety [24] and social functioning [32], and studies in children demonstrating improvements in both domains [29], we hypothesised that the CBT group intervention would result in reductions on both the primary measures of social anxiety and social functioning de cits. Given the theoretical understanding of the bidirectional relationship of social anxiety and social functioning, it was hypothesised that an analysis of predictor variables would support this model, and the predictive in uence of demographic factors would provide insight into potential generalisability or limitations of the program.…”

“…The lack of change on mood outcomes across GSSIs for adults with ASD is inconsistent with other literature demonstrating the e cacy of group interventions (especially CBT-based) in improving mental health outcomes for adults with SAD [4,25]. An exception to this was a study that involved adults with ASD (aged [18][19][20][21][22][23][24][25][26][27][28][29] which reported increases in social functioning and signi cant small-to-medium treatment effects on mood upon completion of the intervention [26]. The reduction in mood symptoms was suggested to be due to positive social experiences and the support gained from the group intervention, though it remains unclear why this generalisation effect has not been observed in other group studies with adults [26].…”

“…A recent meta-analysis of 11 studies reported statistically signi cant improvements on clinician and informant-report measures of anxiety in response to CBT interventions [4]. While this meta-analysis only included two studies with adults, additional randomised-controlled trials have demonstrated the positive effects of CBT-based interventions for transdiagnostic anxiety disorders in children and adults with ASD [27][28][29]. Wood et.…”

“…While this meta-analysis only included two studies with adults, additional randomised-controlled trials have demonstrated the positive effects of CBT-based interventions for transdiagnostic anxiety disorders in children and adults with ASD [27][28][29]. Wood et. al (2020) in their RCT with 167 children found signi cant improvements in children on their primary anxiety measure, but also found improvements related to social communication.…”

Parent-led, stepped-care cognitive-behavioral therapy for youth with autism and co-occurring anxiety: study rationale and method

“…Cognitive-behavioral therapy (CBT) has been established as the gold-standard treatment for anxiety disorders among typically developing youth and adults, with similar efficacy among youth with high-functioning autism (HFA). [17][18][19] A recent meta-analysis that included studies published until 2017, comprising 23 studies with 745 participants, supported CBT as an efficacious anxiety-reduction treatment for youth with HFA and anxiety. 20 More recent studies have provided further support for CBT in small samples.…”