Cognitive behavior therapy as a treatment for anxiety and autism
This article was authored by Victor Rivera and Stacy Shaw as part of the 2018 pre-graduate spotlight week.
One of the most pressing concerns in the field of developmental psychopathology, and for parents all over the world, is regarding the need of efficacious interventions for children with autism spectrum disorder (ASD). ASD is a condition characterized by deficits in social communication (e.g., lack of eye contact, understanding of sarcasm, making friends), as well as restrictive and repetitive interests (e.g., hand flapping, being obsessed with only or mostly dinosaurs, fast cars, the solar system, etc.). According to the CDC  out of every 68 children in the United States is diagnosed with ASD. To make matters more challenging, approximately 40 percent of children with autism are comorbid with a diagnosable anxiety disorder, such as specific phobia, OCD, and/or social anxiety disorder  These comorbidities further exacerbate the issues that autism symptoms alone can create in the home and/or in school. Therefore, many ASD youth aren’t just in need of help with the negative aspects of their ASD diagnosis, but also in dealing with various forms of anxiety.
Fortunately, there have been several promising studies that have found benefits of therapy for children who have both ASD and anxiety. In one seminal study  Wood et al., recruited 40 children to test whether using a special type Cognitive Behavior Thearpy (CBT), which had been augmented to support social and adaptive deficits of the autism, could improve treatment outcomes for children with ASD. CBT is a form of psychotherapy that focuses on maladaptive thoughts, beliefs, and attitudes, and it is commonly used to alleviate feelings of anxiety and depression.
In the study, 40 children participants (ages 7-11 years old) from the greater Los Angeles area were recruited and randomly assigned to a treatment condition with the CBT, or a control condition where families were told they were on the waitlist for treatment.
To participate in the study, children had to meet criteria for autism, Asperger Syndrome, or PDD-NOS, as well as criteria for anxiety, separation anxiety disorder (SAD), social phobia, or obsessive-compulsive disorder (OCD); the participants could not change the dosage of their medications (e.g., SSRIs), or start medication in order to be accepted into the trial. The participants’ IQs had to be greater than or equal to 70. They could not be receiving therapy, family therapy, social skills training, or applied behavioral analysis (ABA), while in the study as to avoid treatment confounds. Parents also had to participate for their children to be considered.
The intervention consisted of ASD youth receiving 16 weekly sessions lasting 90 minutes (30 minutes alone with the child, and 60 minutes with the parent/s and child) that used an ASD version of Wood’s and McLeod’s “Building Confidence with CBT Program} . The researchers applied coping skills from this program to work on affect recognition, cognitive restructuring, and principle of exposure. This was then followed by placing the child into “in vivo” situations to help them learn to navigate experiences they find distressing, but will encounter in their lives (e.g., talking to new people). In therapy, children began working on situations they found the least distressing, and once the child became comfortable with a given situation, the therapists would move on to a more difficult situation. Throughout this process, therapists worked with the children on inhibiting behaviors typical of autism, such as restrictive interests (e.g., dinosaurs) and repetitive behaviors (e.g., hand flapping).
The researchers conducted this treatment for 16 weeks for children in the treatment condition, and compared their treatment outcomes to a group of children who had been on a 3-month waitlist for treatment (control condition). Their findings showed that parents of more than 50% of the children who were in the treatment condition reported that their child no longer showed signs of anxiety.
Moreover, 64.3% of children in the treatment condition no longer met criteria for an anxiety disorder, compared to just 9.1% of children in the control condition. When followed up three months later, 80% of the treatment children who no longer showed signs of anxiety after the treatment still did not meet the criteria for an anxiety diagnosis (indicating a long term effect). Furthermore, 78.5 percent of the treatment children saw improvement on the Clinical Global Impressions-Improvement Scale, which measures the severity of mental illness .
Even more promisingly, Wood and his team have been able to replicate these outcomes in follow-up studies [6, 7] showing the efficacy of CBT in treating anxiety in ASD youth and possibly other clinical populations comorbid with anxiety. In order to treat the challenging aspects of ASD, parents, caretakers, and the individuals themselves have to also be able to simultaneously address comorbid psychopathologies, and CBT appears hold great promise toward mitigating anxiety in children with autism.
Victor Rivera is a former UCLA student who received his BA in psychology where he also assisted research in the Cognitive Lab, the Attention-Deficit Hyperactivity Disorder Lab, and the Smooth Sailing Study in UCLA's Department of Psychology. Victor is currently doing research on graduate students and faculty who either have or are looking to start families while in academia and other topics in clinical psychology.
1. Centers for Disease Control. (2014, March 27). CDC estimates 1 in 68 children has been identified with autism spectrum disorder. Retrieved from http://www.cdc.gov/media/releases/2014/p0327-autism-spectrum-disorder.html
2. Van Steensel, F. J. A., Bögels, S. M., & Perrin, S. (2011). Anxiety Disorders in Children and Adolescents with Autistic Spectrum Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 14(3), 302–317. doi:10.1007/s10567-011-0097-0
3. 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 & Psychiatry, 50(3), 224-234.
4. Wood, J.J., & McLeod, B. (2008). Child anxiety disorders: A treatment manual for practitioners. New York: Norton.
5. Busner, J., & Targum, S. D. (2007). The Clinical Global Impressions Scale: Applying a Research Tool in Clinical Practice. Psychiatry (Edgmont), 4(7), 28–37.
6. Wood, J. J., Ehrenreich-May, J., Alessandri, M., Fujii, C., Renno, P., Laugeson, E., ... & Murphy, T. K. (2015). Cognitive behavioral therapy for early adolescents with autism spectrum disorders and clinical anxiety: A randomized, controlled trial. Behavior Therapy, 46(1), 7-19.
7. Ehrenreich-May, J., Storch, E. A., Queen, A. H., Hernandez Rodriguez, J., Ghilain, C. S., Alessandri, M., ... & Fujii, C. (2014). An open trial of cognitive-behavioral therapy for anxiety disorders in adolescents with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 29(3), 145-155.