Cognitive Behavioral Therapy for Early Adolescents With Autism Spectrum Disorders and Clinical Anxiety: A Randomized, Controlled Trial

doi:10.1016/j.beth.2014.01.002

Behavior Therapy

Volume 46, Issue 1, January 2015, Pages 7-19

https://doi.org/10.1016/j.beth.2014.01.002 Get rights and content

Highlights

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Clinically elevated anxiety is common among adolescents with high functioning autism spectrum disorders.
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A CBT program for youth with ASD outperformed a 4-month waitlist condition.
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The CBT program showed greater improvement in parent-rated autism symptom severity at posttreatment compared to waitlist.
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Comparison to an active treatment condition is a logical next step in evaluating the intervention program.

Abstract

Clinically elevated anxiety is a common, impairing feature of autism spectrum disorders (ASD). A modular CBT program designed for preteens with ASD, Behavioral Interventions for Anxiety in Children with Autism (BIACA; Wood et al., 2009) was enhanced and modified to address the developmental needs of early adolescents with ASD and clinical anxiety. Thirty-three adolescents (11–15 years old) were randomly assigned to 16 sessions of CBT or an equivalent waitlist period. The CBT model emphasized exposure, challenging irrational beliefs, and behavioral supports provided by caregivers, as well as numerous ASD-specific treatment elements. Independent evaluators, parents, and adolescents rated symptom severity at baseline and posttreatment/postwaitlist. In intent-to-treat analyses, the CBT group outperformed the waitlist group on independent evaluators’ ratings of anxiety severity on the Pediatric Anxiety Rating Scale (PARS) and 79% of the CBT group met Clinical Global Impressions–Improvement scale criteria for positive treatment response at posttreatment, as compared to only 28.6% of the waitlist group. Group differences were not found for diagnostic remission or questionnaire measures of anxiety. However, parent-report data indicated that there was a positive treatment effect of CBT on autism symptom severity. The CBT manual under investigation, enhanced for early adolescents with ASD, yielded meaningful treatment effects on the primary outcome measure (PARS), although additional developmental modifications to the manual are likely warranted. Future studies examining this protocol relative to an active control are needed.

Section snippets

Participants

The sample included 33 adolescents, ranging in age from 11 to 15 years (M = 12.3 years, SD = 1.14) and their parents, recruited through two research sites: 17 at the University of South Florida (USF) Rothman Center for Neuropsychiatry (11 males, 6 females) and 16 at the University of California–Los Angeles (UCLA) Center for Autism Research and Treatment (12 males, 4 females). Sample size was determined via power analysis, where an ES of d = 1.0 was assumed for group differences in anxiety reduction,

Results

The intent-to-treat sample size was 33. There were 2 dropouts and 1 protocol violation during the waitlist, and 1 dropout and 2 protocol violations (beginning excluded treatments or changing medication dose) during CBT (see Figure 1). Recruitment began on 9/21/2010 and ended on 6/14/2011; posttreatment assessments were completed on 12/13/2011. Table 1 presents descriptive and diagnostic information for children in the two treatment conditions. Total child DSM-IV diagnoses including ASD, anxiety

Discussion

Early adolescents with clinical anxiety may benefit from developmentally appropriate, individually administered CBT with collateral parent and school support components. A notable characteristic of the participants in this study was their overall level of concurrent psychiatric symptomology as illustrated by meeting criteria for multiple (2 to 7) comorbid diagnoses over and above their ASD diagnosis. In spite of the overall level of clinical challenge posed by concurrent ASD-related

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Autistic adolescents who experience anxiety face unique challenges. Cognitive-behavioural therapy is an evidence-based treatment for anxiety in Autistic children, yet there is less evidence for adaptations of these CBT group interventions for adolescent populations.
This study evaluated the efficacy of the Cool Kids Autism Spectrum Disorder Anxiety program in reducing anxiety in Autistic adolescents. Forty-nine Autistic adolescents with clinically significant anxiety (ages 12–18; IQ > 70) were randomly assigned to the intervention condition or waitlist.
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We reviewed articles published in several databases through October 2022 and relevant reference lists. We used the standardised mean difference (SMD) as the main effect size indicator and focused on SRS metrics from baseline to endpoint. We analysed subgroups, heterogeneity, bias risk, and publication bias.
Our meta-analysis included 214 children from seven randomised controlled trials with nine datasets. Forest plot analysis shows CBT improved social skills in children with autism compared to controls. Subgroup analysis revealed parents' and teachers' SRS scores for children, SRS scores of CBT versus waitlist controls, and those of CBT versus non-waiting-list controls.
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Anxiety disorders (ADs) are common in youth with autism and cognitive-behavioral therapy (CBT) may be less efficacious than among anxious youth without autism. Yet, little is known about which aspects of anxiety are targeted less effectively by CBT in youth with autism.
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CBT for youth with autism yielded significantly better effects than control conditions for frequency of symptoms, intensity of anxiety, avoidance, family interference, and social interference but not for physical symptoms of anxiety. Youth with more pronounced autism traits had poorer outcomes for frequency of symptoms, family interference, and social interference. Compared to anxious youth without autism, youth with autism had poorer outcomes for physical symptoms and family interference.
CBT is efficacious across core aspects of anxiety for youth with autism, but outcomes for anxiety-related interference, particularly for those with more pronounced autism traits, may be poorer than among youth without autism. More work is needed to better understand how anxiety impacts the everyday lives of anxious youth with autism and which interventions and support are needed.
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Individuals with autism spectrum disorder (ASD) often present with cooccurring anxiety disorders. The interaction of ASD and cooccurring anxiety can lead to a complex clinical presentation which may impact accurate assessment and treatment. Though exposure-based cognitive-behavioral therapy (CBT) has shown to be an effective therapy for treating anxiety and obsessive-compulsive disorder in both individuals with and without ASD, it is often necessary to adapt CBT to tailor treatment for individuals with ASD. CBT adaptations for individuals with ASD include creating contingency reward systems, robust inclusion of family in therapy sessions, peer engagement, and a focus on social communication with perspective-taking techniques. A recent but robust literature has shown that CBT adapted for individuals with ASD demonstrates strong efficacy for decreasing both anxiety and nonanxiety-related impairments.

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^☆

This study was supported by a multisite grant awarded to Jeffrey J. Wood, Eric Storch, and Jill Ehrenreich from the National Institute of Child Health and Human Development (HD65270). We are very grateful to the participating families. We also acknowledge the contributions of Lindsay Brauer, P. Jane Mutch, Josh Nadeau, Amy Parks (University of South Florida), Michael Hernandez, Carly Schwartzman and Ilana Seager (University of Miami), and C. Enjey Lin and Kelly Decker (UCLA).

Clinicaltrials.gov trial reference number: NCT01177969. Internet links: http://clinicaltrials.gov/ct2/show/NCT01177969

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Cognitive Behavioral Therapy for Early Adolescents With Autism Spectrum Disorders and Clinical Anxiety: A Randomized, Controlled Trial☆

Highlights

Abstract

Section snippets

Participants

Results

Discussion

Journal of the American Academy of Child & Adolescent Psychiatry

Behaviour Research and Therapy

Evaluation and Program Planning

Biological Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Asperger's syndrome: A guide for parents and professionals

Small-sample degrees of freedom with multiple imputation

Biometrika

Social skill deficits and anxiety in high-functioning adolescents with autism spectrum disorder

Focus on Autism and Other Developmental Disabilities

Testosterone and social behavior

Social Forces

Kurtosis

Treating anxiety disorders in children with high-functioning autism spectrum disorders: A controlled trial

Journal of Autism and Developmental Disorders

Effects of anxiety disorder severity on social functioning in children with autism spectrum disorders

Journal of Developmental and Physical Disabilities

Statistical power analysis for the behavioral sciences

Taxonomy, assessment, and diagnosis of depression during adolescence

Psychological Bulletin

The Social Responsiveness Scale

The handbook of research synthesis and meta-analysis

Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model

Pediatrics

High rates of psychiatric co-morbidity in PDD-NOS

Journal for Autism and Developmental Disorders

Effects of cognitive behavioral therapy on daily living skills in children with high-functioning autism and concurrent anxiety disorders

Journal of Autism and Developmental Disorders

Young adult outcome of autism spectrum disorders

Journal of autism and developmental disorders

Intensive cognitive behavioral therapy for anxiety disorders in school-aged children with autism: A preliminary comparison with treatment-as-usual

School Mental Health

Comparative study of children with ADHD only, autism spectrum disorder + ADHD, and chronic multiple tick disorder + ADHD

Journal of Attention Disorders

Depression in children with autism/pervasive developmental disorders: A case–control family history study

Journal of Autism and Developmental Disorders

Social and psychiatric functioning in adolescents with Asperger syndrome compared with conduct disorder

Journal of Autism and Developmental Disorders

Early Clinical Drug Evaluation Unit (ECDEU) assessment manual for psychopharmacology

Statistical methods for meta-analysis

Reliability of the services assessment for children and adolescents

Psychiatric Services

Assessing change in early intervention programs for children with autism

Journal of Autism and Developmental Disorders

Social anxiety in high-functioning children and adolescents with autism and Asperger syndrome

Journal of Autism and Developmental Disorders