Keywords

Autism spectrum disorders; cognitive-behavioral therapy; anxiety; treatment

CBT for Anxiety in Typically Developing Children

CBT is probably the most effective evidence-based treatment for those with anxiety disorders (Read et al., 2013). CBT typically involves various components that address three areas: distorted cognitions, dysfunctional behaviors (e.g., avoidance), and identification of emotions and physiological symptoms (Chorpita, 2007; Davis and Ollendick, 2005; Kendall, 1992, 1993; Friedberg and McClure, 2015). To address these problematic areas, a stepwise format for CBT has been formulated for neurotypical children. Read et al. (2013) include the following steps in their analysis of CBT: psychoeducation, relaxation training/somatic management, cognitive restructuring, problem solving, exposure tasks, and booster sessions/relapse prevention. The authors mention that additional steps may be necessary based on the client’s specific needs. For example, Kendall (1993) mentions that additional strategies may be necessary when cognitive deficiencies (i.e., the lack of information processing when it would be beneficial as compared to cognitive distortions, which are biases in information processing) are present. Laying out these specific techniques for neurotypical children in the following sections will provide a clearer path from which to examine possible strategies for modification for children with ASD.

Psychoeducation

In many CBT manuals, the clinician begins by informing the client about anxiety and describes the model that maintains the occurrence of anxiety. For children, it is often helpful for the family to be involved in this step. The client can then better understand the environmental triggers, physiological responses, and factors that maintain their problems with anxiety. Furthermore, the client learns to no longer associate anxiety with something that is defective within them, but rather a normal, adaptive response that happens to everyone. Adaptations for young children may include using more concrete language, picture cards, and culturally appropriate metaphors (e.g., fire alarms, brain hiccups). Lastly, additional practice with the important skills of identifying and understanding emotions and establishing connections between thoughts, feelings, and actions can be beneficial for treatment progression, particularly for young children and those with impaired cognitive abilities (Read et al., 2013).

Relaxation and Somatic Management

This stage of treatment often encompasses both breathing exercises and muscle relaxation. The client learns to tense and relax specific muscle groups successively; this promotes awareness of tension that is caused by anxiety and relaxation as a solution for this tension. Deep diaphragmatic breathing is emphasized as well to counteract the quick and shallow breaths that occur with anxious physiological arousal (Read et al., 2013).

Cognitive Restructuring

By this stage, the therapist has usually already addressed the important link between thoughts, feelings, and actions, thus, the client understands that tackling biased “self-talk” (i.e., self-referential thoughts) is one way to address anxiety. The client first begins with identifying thoughts that may contribute to his/her anxious feelings and arousal. Next, the client begins to identify and categorize patterns in his/her biased thinking. The client can then challenge these errors with more accurate, probable, and adaptive responses. This step usually helps the client to reduce feelings of anxiety (Read et al., 2013).

Problem Solving

Many individuals with anxiety may view their distress as uncontrollable and catastrophic in nature. However, this step specifically targets this distortion, as the client is told to view anxiety as a problem that can be solved. The therapist and the client act as a team to brainstorm ideas on decreasing the client’s level of distress. The therapist should continuously encourage the client to come up with many alternatives to solve the problem and systematically “test” their viability in order to achieve the best outcome (Friedberg and McClure, 2015). Children might perceive the problem-solving phase as overwhelming and difficult to understand. In this case, the therapist should use concrete examples (e.g., looking for a lost toy) to more appropriately explain the steps of problem solving (Read et al., 2013).

Exposure

Exposure is an essential component in the treatment of anxiety and is used in approximately 80% of all anxiety treatment models (CBT and other models; Chorpita and Daleiden, 2009). Behavioral avoidance is extremely common, and likely impairing, in those with anxiety disorders (Chorpita and Daleiden, 2009). Exposure is a systematic hierarchical presentation of fearful stimuli that, while mildly distressing, provides the client the opportunity to cope with the feared situation without the ability to avoid or escape. First, the hierarchy is built by the client’s self-reported ratings of feared situations, from the least feared to the most catastrophic (and likely most impairing) fear. For younger children, the parents’ ratings of the child’s fears are typically included in building the hierarchy. During the actual exposure, the client practices and tests his/her coping skills learned in previous sessions. Furthermore, clients are taught to distinguish between their catastrophic perceptions of fear and the facts about the actual threat. In experiencing the exposure, clients learn that their beliefs about the outcome of the situation do not match the actual outcome of the exposure, discovering that they are able to successfully manage their fear and cope with the outcome. The goal is for clients to feel that they are able to successfully deal with distressing or threatening situations (Chorpita and Daleiden, 2009; Read et al., 2013).

Exposures can either be directly experienced in session (in vivo) or imagined (imaginal; in vitro). Imaginal exposures can be used when the situation is difficult to practically simulate in a session (e.g., getting smallpox). The therapist and the client work together to imagine a very vivid, detailed scene of the feared environment or stimulus, possibly while listening to an anxiety-inducing audio tape and/or viewing a group of pictures. Throughout the exposure, the client’s level of distress is measured on a scale of subjective units of distress (SUDS), with 0 representing a state of total relaxation and a rating of 100 being the most fear the person can imagine. For children, a simpler scale of varying degrees of smiling/frowning faces or a numerical scale from 0 to 10 or 0 to 8 (per the Anxiety Disorders Interview Schedule Child/Parent; ADIS-IV-C/P) can be used to evaluate subjective anxiety (Friedberg and McClure, 2015).

Exposures are often repeated to allow the client to build a history of adaptive coping; this allows the client to habituate more quickly to successive exposures. Progress monitoring sheets can be used to track exposures and improve the client’s sense of autonomy and self-efficacy. Exposure tasks can be practiced in multiple settings to encourage generalization of learning and coping. Additionally, exposures typically look different based on the client’s particular fears and symptoms (Peterman et al, 2015).

Treatment of Anxious Children With ASD

ASD represents a cluster of varied characteristics that require careful assessment and treatment considerations. Communication disorders, intellectual disabilities, stereotypy, and mental health comorbidities are common in ASD (Myers and Johnson, 2007). These comorbid concerns may inhibit the individual’s ability to independently complete self-report measures during assessment and understand some of the specific components of CBT during treatment (e.g., cognitive restructuring process). Therefore, modification of the traditional CBT process may be needed to maximize treatment efficacy for anxious children with ASD. Along these lines, commonly used treatments of anxiety for children with ASD include psychosocial interventions, medication, CBT modification (e.g., Coping Cat; Kendall and Hedtke, 2006a,b), and behavioral interventions (e.g., reinforcement for completion of exposure).

Psychosocial interventions usually include social skills training for children with distinct skill deficits (Schohl et al., 2014). Pharmacological interventions typically involve medication management strategies and occasionally other components (e.g., behavioral activation). This combination of approaches can be loosely defined as “treatment as usual” (TAU). Additionally, various studies have applied behavioral techniques (e.g., exposure plus reinforcement) for the treatment of anxiety in the ASD population (Chok et al., 2010; Love et al, 1990; Rapp et al., 2005; Schmidt et al.,2013). In a recent study, Storch et al. (2013) compared TAU (defined as receiving pharmacological and medication management interventions, school counseling, special education services, and social skills training) to a modified version of CBT for anxious youth with ASD. The authors found that a personalized CBT intervention significantly reduced both anxiety symptoms and impairment with generally large effects observed across clinician-rated anxiety outcomes.

Modifying CBT for Children With ASD

An increasingly common option for anxiety treatment for children with ASD is modifying traditional CBT to fit the unique needs of these youth. Adapting CBT to improve outcomes for children with ASD may involve including more social skills and emotion recognition modules, incorporating more parental involvement in treatment (e.g., reviewing session content and homework assignments with parents), incorporating technology to guide clients through coping strategies, increasing use of visual aids (e.g., worksheets, cue cards), and modifying the pacing of treatment (e.g., scheduling more frequent sessions, spending more time reviewing material, including more exposure tasks; Scattone and Mong, 2013). Some characteristics inherent to youth with ASD (e.g., perseveration, restricted interests) can be leveraged to enhance treatment fidelity and outcomes. For example, the restricted interests of youth with ASD can be used both as a reward for session engagement and participation and also as a mechanism to explain the importance of strategies; e.g., a client’s favorite movie character may be used consistently throughout the sessions to demonstrate skills, model appropriate cognitions, and reinforce brave behaviors (Danial and Wood, 2013).

One example of a modified CBT program for youth with comorbid ASD and anxiety is the modified Coping Cat program, a 16-week program which includes the following modifications for children with ASD: more time spent reviewing for skill generalization, additional visual materials (e.g., cue cards, schedules, scales), more concrete language, and increasing behavioral components (e.g., relaxation training, role playing). Furthermore, for children with motor skill difficulties, writing assignments were completed with the help of the therapist or a computer. Large effect sizes were reported for children participating in the modified Coping Cat treatment as compared to waitlist controls; importantly, these gains were maintained at two-month follow-up (McNally Keehn et al., 2013).

Estimated Efficacy of CBT for Children With ASD

Though additional research is warranted, there is initial evidence to support the efficacy of CBT for children with ASD. Sukhodolsky et al. (2013) completed a review of the literature on CBT for children with ASD: although all reporters produced relatively large effect sizes, clinician- and parent-reported improvements in anxiety were slightly larger than child-rated improvements (d = 1.19 for clinician-rated improvements, d = 1.2 for parent-rated improvements, and d = 0.68 for self-reported improvements). Support for CBT applied to youth with ASD and anxiety has also been found across age groups, from preschoolers to adults. Although only a case study, improvements in a preschooler (age 4 years) with comorbid ASD and anxiety were reported and the gains were maintained at a four-month follow-up (Nadeau et al., 2015). Ehrenreich-May et al. (2014) evaluated CBT for adolescents with ASD and found a reduction of clinician-rated and parent-rated anxiety severity. Furthermore, level of impairment and behavioral problems were significantly reduced at post-treatment and maintained at a one-month follow up. Support has also been provided for CBT with adults with ASD and psychiatric comorbidity, including anxiety (Spain et al., 2015).

There is promising evidence for the efficacy of CBT in youth with ASD beyond improvements in anxiety symptomology. Drahota et al. (2011) noted that children with ASD often have difficulty in mastering and consistently applying basic daily living skills, resulting in impairments in functioning and greater dependence on caregivers to accomplish simple tasks. After a 16-week CBT program, participants’ overall anxiety level and anxiety sensitivity significantly decreased. Interestingly, the children’s total and personal daily living skills also improved, and their parents reported more independence and less need for involvement in their child’s daily routine. These findings suggest broad utility for CBT in youth with ASD, as improvements were demonstrated across domains (e.g., anxiety, social skills, adaptive functioning).

High rates of comorbid OCD have been associated with ASD. Russell et al. (2013) investigated the outcome of children receiving CBT versus another active treatment (i.e., anxiety management) for OCD symptoms. Findings suggested that children who received CBT were more responsive to treatment, had slightly better outcomes at the end of treatment, and higher self-reported improvement scores. Last, given that high family accommodation of OCD symptomology has been associated with poorer outcomes, parent-training modifications of CBT for OCD in ASD may facilitate the best outcomes (see Davis et al., 2014 for more disorder-specific recommendations).

Current Research Limitations and Areas for Improvement

The data to date are promising, but, as Danial and Wood (2013) noted, there are some important considerations. For example, many treatment studies evaluating youth with comorbid anxiety and ASD have small sample sizes and rely heavily on parent report. Few studies have investigated associated characteristics for individuals with ASD that may complicate therapy progress (e.g., repetitive behaviors, sensory issues, comorbid disruptive behaviors) as well as characteristics that may increase probability of treatment response (e.g., advanced memory). Also, much of the literature examining the efficacy of CBT with persons with ASD and anxiety fails to assess the level of cognitive change (e.g., theory of mind skills) in addition to the amount of behavioral change (e.g., approach/avoidance in feared situations). More work is needed to examine the course of anxiety in those who also have comorbid ASD (e.g., Davis et al., 2011a). Needed are studies that help to dismantle CBT components to determine which of the varied components of modified CBT is most responsible for treatment outcomes. Additional empirical study is warranted to answer these and related questions that will optimize the efficacy of CBT for anxious youth with ASD.

Suggestions for Specific Modifications of CBT for Children With ASD

Careful assessment of the client before beginning therapy is vital in determining any special considerations and individualized components that may be necessary for successful implementation (Moree and Davis, 2010). For example, clinicians should assess for any sensory issues that may impede treatment (e.g., oversensitivity to material types, bright lights, loud noises) and pay attention to the need for the environment to be arranged so that the client feels comfortable and safe. Additional considerations may include using concrete visual displays and literal language (e.g., limiting use of metaphors or finding one that works and sticking with it) to improve understanding of new concepts for children with ASD, particularly for those with intellectual disability. Social skills training may be necessary for socially anxious individuals to remediate impairing skills deficits (e.g., emotional awareness, perspective taking) that often accompany ASD (White et al., 2010). Therapeutic approaches are best when tailored to the child’s interests in order to increase motivation and rapport (Moree and Davis, 2010). For children with limited communication or intellectual abilities, structured preference assessments can determine potent reinforcers for completion of tasks related to treatment (e.g., exposure tasks, between-session activities; Hagopian et al., 2004). Clinicians report that children with ASD may require a slower pace throughout CBT, which may be attributed to rigidity, general executive dysfunction, or comorbid intellectual disability (Danial and Wood, 2013).

Clinicians may consider using the acronym “PRECISE” as a mnemonic device to recall the modifications needed to effectively conduct CBT with individuals with ASD (Davis et al., 2014). The “P” stands for a collaborative partnership between the client and therapist that capitalizes on the client’s strengths and assists with any difficulties. The collaborative partnership which emphasizes client strengths is particularly important in individuals with ASD, who might have difficulty connecting with others. The “R” stands for right developmental level (e.g., using visual cues, involving the parents along a continuum; Lang et al., 2010). The “E’” stands for empathy, and the “C” stands for creative implementation (e.g., incorporating special or restricted interests). The “I” stands for investigative approach (e.g., the use of behavioral experiments rather than verbal cognitive restructuring) and the “S” stands for self-discovery. Finally, the last “E” stands for enjoyable, which is particularly important for children in order to ensure their cooperation with treatment (Davis et al., 2014).

Due to the amount of time children with ASD spend with their caregivers, involving parents and aides in treatment can be important to a successful treatment response. Caregivers are valued sources of information, who can inform the clinician about the nature of the client’s anxiety (e.g., antecedents, consequences, maintaining factors). Additionally, training the caregivers to conduct between-session activities and exposure tasks may be beneficial in treatment (Davis et al., 2014). For example, Storch et al. (2013) conducted a randomized 16-week trial of CBT, which was modified specifically for children with high-functioning ASD by increasing parental participation. The authors found that parental involvement was important for the completion of exposure tasks at home, which resulted in large treatment success effect sizes. Similarly, anxious youth with higher parent-rated autism spectrum symptoms have been found to respond better to family CBT compared to individual CBT (Puleo and Kendall, 2011), again with family CBT having more at-home exposure tasks. It may be important for parents to complete training for problem behaviors (e.g., how to give consistent rewards and consequences, differential reinforcement) before beginning treatment for anxiety as such work may increase adherence to treatment by addressing problem behaviors which may serve to maintain the child’s anxiety (e.g., facilitating avoidance) or interfere with treatment progress (e.g., refusal to participate; Davis et al., 2014). Finally, some degree of persistent impairment across the lifespan is typical for most individuals with an ASD diagnosis; involving parents in anxiety treatment is ideal for maintaining gains and consistent with the degree of parental involvement across development (Reaven and Blakeley-Smith, 2013).

Lickel et al. (2012) discussed how the assessment of the client’s skill deficits can influence the treatment plan. For example, children with ASD tend to have difficulty with emotional regulation, perspective taking, and self-reflection. CBT for children with these difficulties could include additional components to teach affect discrimination and emotional awareness (Davis et al., 2014). Traditional CBT approaches include tasks such as detective thinking and identifying cognitive distortions; these tasks rely on the skill of cognitive control, the ability to manage internal reactions to distressing stimuli. Cognitive control may be a difficult skill for children with ASD to master. In modifying CBT for youth with ASD, these strategies could be made more concrete (e.g., using worksheets to write down all evidence for and against a thought). Children with ASD may also have difficulty in generating their own coping thoughts. If this is the case, it is recommended that therapists give the client a selection of coping thoughts that may be individualized according to their specific interests (Gross and Thompson, 2007).

According to Rieffe et al. (2011), individuals with ASD may struggle with rumination due to their problems with attentional networks and emotional awareness. For these children with deficits in emotional awareness or with alexithymia (inability to recognize emotions), more time should be spent on modules related to emotion identification and recognition prior to beginning CBT (Moree and Davis, 2010). Furthermore, individuals with ASD may benefit from learning how to address the experience of emotion and to express emotions in socially appropriate ways. Relaxation training and deep breathing are options for emotional regulation that are often part of CBT. A functional behavioral assessment helps to determine the function of specific therapy interfering behaviors (e.g., stereotypy, avoidance), and can thus be useful to address them appropriately (e.g., not allowing the client to escape, receive attention).

Additional Options for Treatment

Group Therapy

CBT may be implemented in a small-group format and studies have found support for the efficacy of group CBT for children with comorbid ASD and anxiety. Reaven et al. (2012) conducted a 12-week randomized trial with 50 youth with high-functioning ASD and anxiety. These children were assigned to either a TAU group (which consisted of either medication to treat anxious symptomology, social skills interventions, school-based anti-bullying programs, individual coping or emotional regulation skills training sessions, or family-focused behavioral interventions) or a CBT intervention designed specifically for youth with ASD. The Facing Your Fears (FYF) intervention involved typical CBT components (e.g., relaxation, deep breathing, graduated exposure, strategies to promote emotion regulation, use of cognitive control) as well as ASD-specific modifications (e.g., increased reinforcement for behavior in group, visual cues such as multiple choice lists, hands-on activities, video modeling). The program also included a separate parent component and curriculum, which involved psychoeducation, coaching skills (e.g., supporting child brave behaviors, participation), and information about how to best parent a child with comorbid anxiety and ASD. Parents in the FYF program discussed the reciprocal relations between parental psychopathology (e.g., anxiety), parenting style (e.g., adaptive versus excessive protection), and the maintenance of anxiety symptoms in children. As children with ASD are prone to challenges with social skills and adaptive communication, “excessively protective” parenting styles are common in caregivers of youth with ASD. Caregivers who fall in the excessively protective category tend to allow their children to avoid anxiety-provoking or uncertain situations, therefore limiting their children’s opportunities to practice adaptive coping skills and contributing to the maintenance of symptoms of anxiety. Participants in the FYF program exhibited significant reductions in anxiety (as compared to the TAU condition), suggesting that the group format may be an effective modification of CBT for youth with ASD (Reaven et al., 2012). However, no studies were found which directly compared the efficacy of group CBT to individual CBT. Additionally, due to the heterogeneity of symptoms associated with ASD, group interventions may not be appropriate for every child with comorbid ASD and anxiety.

Future Directions and Applications

Anxiety disorders can be extremely impairing, particularly in persons with pre-existing challenges (e.g., youth with ASD). van Steensel et al. (2013) compared the societal costs of children with high-functioning ASD and comorbid anxiety disorder(s) to typically-developing control children and neurotypical children with anxiety disorder(s), finding that costs in the comorbid group were 27 times higher than the comparison group and four times higher than the neurotypical anxiety disordered group. The authors concluded that these costs can be significantly decreased with efficacious therapies for anxiety in individuals with ASD. There is increasingly promising evidence for the application of CBT, an evidence-based treatment for many mental health problems in typically-developing individuals of all ages (Sukhodolsky et al., 2013).

Nearly all CBT principles and procedures can be used with individuals with ASD, especially if individualized. ASD severity may be the strongest moderator of response to treatment in individuals with ASD (even above children’s language or overall cognitive abilities). Accordingly, it is important to conduct a thorough intake assessing level of functioning and symptom severity prior to treatment onset (Storch et al., 2015). This assessment can help to determine which modifications may improve likelihood of treatment adherence and success. These modifications typically include greater parent/caregiver involvement, social skills training, coping skills training, more time spent reviewing for skill generalization, additional visual materials (e.g., cue cards, schedules, scales), more concrete language, and increasing behavioral components (e.g., relaxation training, role playing; Scattone and Mong, 2013). However, it is important to apply CBT flexibly for all children with ASD, as one should expect treatment to progress at a slower pace than it would for neurotypical individuals (Storch et al., 2015).

Some youth with ASD may have more difficulty than others in adjusting to treatment. Teaching coping skills may aid progress; these skills may help individuals with ASD cope with discomfort during changes in routine, social interactions, and other fears or worries. Additionally, many children in therapy, who are often involuntarily taken by their parents, often lack motivation for treatment. Therapists can build both rapport and motivation for change by asking the child about the kinds of things they value, what they would like to improve, and how the therapist can help improve quality of life. Difficulties completing homework assignments can also interfere with treatment progress. Children with ASD may have executive functioning deficits which causes disorganization and forgetfulness with assignments. These individuals may benefit from additional support; e.g., homework assignments can be divided into small chunks, instructions can be simplified, additional practice can be built into sessions, and written and visual reminders to complete homework may be provided (Storch et al., 2015).