Cognitive Behavioral Therapy for Anxiety in Children with ASD

Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224-234.

Reviewed by: Kathleen Moran, MA, Caldwell College

Why research this topic?

Approximately 30-80% of children diagnosed with autism also experience severe anxiety. For example, they may show intense fears of particular situations accompanied by physiological arousal. Several studies indicate that a modified cognitive behavioral therapy (CBT) treatment may help lessen anxiety symptoms in such children, but these studies have had important limitations such as insufficient assessment of anxiety before and after treatment and an absence of measures of whether therapists implemented the treatment as intended. Additional research, therefore, is needed.

What did the researchers do?

The researchers used an individually focused modified CBT intervention. Children in this study met research criterion for autism spectrum disorder and anxiety disorder based on an independent evaluation, and a verbal IQ above 70. They were split into one of two groups: a treatment group (i.e., one that received intervention) and a control group (i.e., one that did not receive intervention). In the treatment group, training was implemented with children and parents over 16 weeks based on a modified version of the CBT program Building Confidence. Parent training focused on supporting children during interactions while using positive reinforcement and communication skills. For children, the intervention included teaching coping skills in a therapeutic setting and then practicing them in real-life situations. Sessions addressed each child’s specific fear. Specific areas of emphasis included friendship skills, social acceptance, and self-help skills. Friendship skills training consisted of social coaching on appropriate ways to enter interactions and maintain conversation. Social acceptance was addressed by forming “buddy” systems and mentoring programs. Self-help skills focused on using motivating concepts and task analysis to break difficult skills into smaller steps.

What did the researchers find?

Independent evaluators rated children’s anxiety before and after intervention based on structured diagnostic interviews with either the parent or child. The ratings ranged from 0 (no anxiety at all) to 8(very, very much anxiety). Before the study, anxiety levels did not differ significantly between the groups. After intervention, all but one participant in treatment met criterion for a positive treatment response, and most participants were free of anxiety. In contrast, participants in the control group did not show a significant reduction in anxiety.

What are the strengths and limitations of the study?

One strength of the study is that the treatment was designed to be flexible enough to be tailored to a child’s specific needs. Another feature is that training took place within the child’s natural setting helping to promote generalization and maintenance of the skill. A limitation of the study is the inclusion of child report measures. Children with autism may self-report anxiety in a different way from children of typical development.

What do the results mean?

This study offers initial support for the use of a modified CBT program for children with autism and co-morbid anxiety disorders. Intervention was effective in diminishing anxiety as well as promoting generalization and maintenance for newly learned skills. With little research on treating anxiety in children with autism, additional research is needed to determine whether these findings are replicable and to better understand autism related characteristics that may cause or compound anxiety.