CBT for Anxiety and Core Autism Symptoms

CBT for Anxiety in ASD

CBT, an efficacious treatment for numerous child and adult disorders, is currently being used to treat a variety of symptoms associated with ASD. Because anxiety disorders are frequently comorbid in individuals with ASD (Wood and Gadow, 2010), CBT has been adapted for use with youth with ASD. CBT for children with autism and concurrent anxiety commonly consists of basic CBT elements, such as replacing irrational thoughts with rational, adaptive beliefs, and graded exposures to feared situations, alongside various adaptations for children with ASD (e.g., incorporating perseverative interests and visual representations of concepts; Danial and Wood, 2013).

In one waitlist-control RCT, an efficacious CBT program for typically developing youth with anxiety, the Coping Cat program, was modified for use with youth (N = 22; ages 8–14 years) with ASD and anxiety randomly assigned to treatment or waitlist (McNally Keehn et al., 2013). Treatment consisted of 16 weekly 90 minute one-on-one sessions. The major components of the Coping Cat manual are coping techniques, emotion recognition and understanding, cognitive restructuring, self-evaluation, and self-reinforcement. The modified version of the program involved use of participants’ special interest to foster engagement, session content, and homework review at the end of sessions, longer sessions (from 60 to 90 minutes), use of visual aids, breaks, as well as technique and reward individualization. In the waitlist group, all participants continued to meet criteria for their primary anxiety disorder on the Anxiety Disorders Interview Schedule-Parent version (ADIS-P; Silverman and Albano, 1996), while in the treatment group 58% no longer met criteria for their primary anxiety disorder. The principal investigator was the therapist for all cases in the study, which raises questions about whether less experienced therapists would be able to successfully deliver the protocol. Regarding weaknesses, the study utilized a small sample size and one experienced therapist.

A 16-session family-based CBT program, Behavioral Interventions for Anxiety in Children with Autism (BIACA), was developed for children with ASD and clinical anxiety, drawing upon successful elements of both programs for ASD (e.g., pivotal response treatment: Koegel et al., 2005) and anxiety CBT programs for children. In the initial study examining the BIACA program, children ages 7–11 years (N = 40) were randomly assigned to an immediate treatment group or a waitlist control group (Wood et al., 2009). On average, the participants met criteria for four anxiety disorders on the ADIS-IV-C/P at baseline. At posttreatment, over half the children in the treatment group did not meet criteria for an anxiety disorder and parents reported significant reductions in anxiety. Both of these outcome variables showed a significant treatment effect for BIACA compared to waitlist. There were no significant reductions in anxiety at posttreatment according to child report. However, the children in the study reported low overall anxiety levels at baseline and the study used measures that have not been validated for use in children with ASD.

In a second study conducted by the same research group (Fujii et al., 2013), 16 additional sessions were added to the protocol in order to enhance the generalizability of the skills learned to real-life settings. Participants (N = 16, ages 7–11) were randomly assigned to a 32 week treatment condition or a 16-week treatment-as-usual (TAU) condition. The initial 16 weeks were similar to the original BIACA protocol and focused on decreasing anxiety. The second half of the treatment emphasized developing the skills and relationships that would facilitate coping with anxiety in real-life situations. Parents, therapists, and school professionals were trained to be social coaches, helping the participants apply their skills in everyday contexts, such as parks or the schoolyard. Due to numerous missed sessions, four participants were not included in the analyses. At posttreatment, five of the seven children in the BIACA group did not meet criteria for their primary anxiety disorders on the ADIS-IV-C/P, while all participants in TAU continued to meet criteria for an anxiety disorder, a statistically significant difference. While the outcome is promising, the study is limited by its small sample size and the greater number of sessions received by the CBT group.

An independent research group also found BIACA to be efficacious in a recent randomized controlled trial (Storch et al., 2013). Participants (N = 45, ages 7–11) were randomly assigned to receive BIACA for 16 weeks or TAU for 16 weeks. The same BIACA manual was implemented in 60–90 minute weekly sessions, as in prior BIACA trials. At posttreatment, the participants who received BIACA demonstrated significantly greater reductions in anxiety than those who received TAU.

Two recent randomized controlled trials by two independent research groups examined the efficacy of BIACA in treating anxiety in early adolescents with ASD. In one study, participants (N = 33, ages 11–15) were randomized to either an immediate treatment or waitlist group (Wood et al., 2015). The treatment was similar in length (i.e., 16 weekly 90 minute sessions) to that of previous studies. Developmental modifications were made to the BIACA manual, such as fostering independence and age-appropriate social skills. The BIACA group experienced significantly greater reductions in anxiety severity than the waitlist group on the Pediatric Anxiety Rating Scale (PARS; Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002). A significantly greater percentage of the BIACA group qualified as treatment responders (79%) than the waitlist group (28%) on the Clinical Global Impressions-Improvement (CGI-I) scale. Parent report measures also demonstrated decreases in autism symptom severity in the BIACA group. However, no significant differences between groups were found for anxiety disorder diagnoses on the ADIS-IV-C/P.

Another randomized controlled trial conducted by an independent research group examined the efficacy of BIACA for early adolescents with ASD and anxiety (Storch et al., 2015). In this RCT, participants (N = 31, ages 11–16) were randomly assigned to either a 16 week BIACA group or a 16 week TAU group. Participants received the same developmentally modified version of BIACA implemented in Wood and colleagues’ (2015) study. At posttreatment, the BIACA group experienced significantly greater improvements than the TAU group on all clinician-rated anxiety measures (i.e., the PARS, ADIS-IV-C/P, CGI-I) and the measure of autism symptom severity (i.e., the Social Responsiveness Scale). Improvements were maintained at 1-month follow-up for the CBT group.

Since BIACA has demonstrated efficacy in four RCTs from two different research groups (Storch et al., 2013, 2015; Wood et al., 2009, 2015), it meets criteria for probable efficacy and, to the extent that a TAU comparison group is considered an active treatment, also meets criteria as a well-established treatment.

White and colleagues (2013) combined one-on-one therapy, group therapy, and parent education to target both anxiety and social skills in adolescents with ASD. In this randomized controlled trial, participants (N = 30, ages 12–17) were assigned to either CBT or a waitlist control group. Participants received up to 13 one-on-one therapy sessions, seven group therapy sessions, and a parent education component during each individual and group session. Sessions targeted social skills using techniques, such as social reinforcement and modeling. The treatment also targeted anxiety with established techniques, such as cognitive restructuring and exposure. Parents were instructed to promote generalization by practicing exposure tasks in real-life settings. While results showed significant differences between the CBT and control groups on social skills outcomes, there were no significant differences between groups on the anxiety outcome measures. These results suggest that while this particular protocol may be helpful in developing social skills in adolescents with ASD, it may not be an effective treatment for anxiety in this population.

Clinical Features of CBT for Anxiety in Children with ASD

As an efficacious individual CBT treatment for the ASD population, the clinical features of BIACA are described forthwith. BIACA was adapted from the Building Confidence CBT program (Wood et al., 2008), which was developed for general childhood anxiety problems. Both parent and child attend 16 weekly sessions lasting approximately 90 minutes each. The therapist typically spends 30 minutes with the child and 60 minutes with the parent/family. Similar to other childhood anxiety CBT programs, the BIACA manual includes psychoeducation, coping skills training (e.g., emotion recognition, cognitive restructuring), and in vivo exposure (facing feared situations gradually and repeatedly until habituation to the situation occurs). Usually after the first couple sessions, when adequate background information has been gathered and rapport established, the therapist creates a fear hierarchy with the child and/or parent, in which they rate how fearful the child is in certain situations. This hierarchy serves as a guide for the remainder of the treatment sessions. Starting with the least distressing situations, children gradually work their way up the fear hierarchy through in vivo exposures in session with the therapist and practice tasks at home. Children are rewarded for their efforts in session and at home with reward charts and point systems. The BIACA manual includes several parent-training components throughout the course of the treatment, in which parents learn parenting techniques to help their child when he or she is feeling anxious (e.g., using positive reinforcement, reflecting emotions, extinction).

There were numerous enhancements to the original Building Confidence manual to simultaneously address common deficits associated with ASD in conjunction with treating anxiety symptoms. These additions were designed to treat poor social skills, adaptive skills deficits, circumscribed interests and stereotypies, poor attention and motivation, and common comorbidities in ASD (e.g., disruptive behavior disorders). In particular, new modules were added to address difficulties children with ASD have in forming and maintaining peer relationships. These modules focus on teaching key skills needed to make and keep friends, such as being a good play date host. In session, the child and therapist discuss “social rules” to follow during play dates (e.g., letting the friend choose the activity, giving compliments) and key “super friend” behaviors are illustrated through cartoons and role-playing (cf. Frankel and Myatt, 2003). The complimentary parent module reviews tips for ensuring successful play dates (e.g., keeping them short, having the children decide on an activity to do beforehand), as well as, sources of potential friends for their child (e.g., extracurricular activities, clubs). Additionally, in these modules, children are given social coaching by the therapist, parents, and school staff on appropriate ways to play and converse with their peers in different situations. Therapists, parents, and school staff provide social coaching immediately before the social activity as a priming tool to maximize success in the interaction (Koegel et al., 2005). These skills are practiced at the park, on play dates, and at school and are reinforced with a comprehensive reward system that typically includes daily privileges and longer term rewards. Another module that targets social isolation at school focuses on implementing a peer buddy system and mentoring program at school. For this module, the child with ASD can benefit from serving as both the mentee and mentor and it is intended to enhance social acceptance and perspective taking skills (cf. Fulk and King, 2001; King-Sears, 2001; Maheady et al., 2001; Rogers, 2000). Typically, the therapist meets with the school one to two times to teach the intervention techniques to the school staff (e.g., aides, teachers).

The manual also includes modules aimed at increasing the child’s adaptive skills by building independent daily self-help skills (e.g., dressing, showering). Typically two to three skills are identified and broken down into steps to work on at home. In session, the therapist focuses on providing motivation for the child (e.g., “you’re going to be so grown-up!”) and emphasizes to the parent the importance of developing these daily living skills for future independent living. Additionally, children’s circumscribed interests and sterotypies are incorporated throughout treatment. To establish rapport and maximize attention and motivation in session, special interests are employed to teach therapeutic concepts (e.g., emotion regulation) by using the characters in the examples. Special interests are also used as reinforcers to increase motivation and participation during the session. Stereotypies and special interests that are interfering with the child’s success socially (e.g., will only talk about a special interest with peers, engages in hand flapping during recess) are addressed later in treatment through a suppression approach. The therapist works with the child and parent to increase the amount of time per day in which the child refrains from discussing this topic or engaging in the stereotypy (cf. Sze and Wood, 2007). To provide a rationale for the child, the therapist discusses with the child social expectations by illustrating other children’s perspectives through cartoons and role-plays (e.g., these behaviors are fine in private but tend to confuse peers and get in the way of friendship).

There are also modules in the BIACA program that address behavior problems associated with comorbid disruptive behavior disorders by including behavioral goals (e.g., following directions, keeping hands, and feet to self) on the child’s weekly homework chart and providing the parent with strategies for dealing with difficult behaviors (e.g., planned ignoring). These items are also incorporated into the child’s reward system. For example, a child may earn a point for speaking calmly and respectfully each day. School personnel can also be recruited to keep track of daily target behaviors at school through a “school-home” note from which the child also earns points and privileges.

The BIACA manual’s modular format allows therapists to choose modules on a session-by-session basis depending on the child’s most pressing needs and treatment trajectory. Typically, modules focusing on teaching coping skills are delivered early in the intervention with in vivo exposure modules conducted for the remainder of the treatment sessions. The modules addressing ASD-related deficits can be interspersed throughout the treatment, as needed. Usually, adaptive skill deficits and behavior problems are addressed early in treatment, with social skill modules delivered later in treatment (see Sze and Wood, 2007). The manual is flexible and the modular format allows the treatment to be individualized depending on the needs of the child. Despite this flexibility, at least three sessions are spent on basic coping skills and eight on in vivo exposure to ensure adequate doses of CBT for anxiety across cases.

Clinical Examples of CBT for Anxiety in ASD

In the following section, we will provide two brief clinical exemplars of CBT for anxiety in ASD. These case examples illustrate ways in which CBT for anxiety has been adapted for children with ASD using the BIACA protocol, as well as key techniques employed. Key details of the cases have been changed to protect confidentiality.

Case example 1: Jordan. Jordan was a 9-year-old boy who met criteria for ASD as well as social phobia, obsessive compulsive disorder, generalized anxiety disorder, and concurrent ADHD-combined type at intake. Jordan presented as overly shy and would often fail to speak with unknown individuals until he became comfortable with them. Jordan was often anxious in social situations involving peers, stating that he was worried that others would not think he was “cool.” He frequently avoided parties and get-togethers with peers from school due to his fear that the other children would not like him and would think he was weird. Jordan spent half of his school day in a special day class and was excessively worried that other kids would find out that he was in that class and negatively evaluate him. As a result, Jordan would often isolate himself during periods of free play, choosing to sit alone in the library. While in the special day class Jordan would often participate, however in his mainstream classes he would never participate unless compelled by the teacher. Two main goals for Jordan were to increase his participation in his mainstream class as well as to increase his peer interactions during unstructured free-time.

During therapy sessions, Jordan was encouraged, through a structured rewards program, to gradually increase his interactions with new same-aged children, with a similar program focused on increasing interactions with his peers implemented within his classroom by his primary teacher. In addition, Jordan was taught in sessions what it meant to be a “friend” and was encouraged to spend time with his peers both in and out of school. Jordan’s mother encouraged Jordan to go on play dates and hosted several at her home to promote his use of appropriate social skills learned during therapy sessions. Jordan’s teacher was also instrumental in encouraging these behaviors during the school day. With the establishment of a rewards system for all attempts Jordan took during free-time to interact with peers, and additional points earned for participating in class, Jordan was able to slowly increase both of these targeted behaviors. By the end of treatment he was able to approach and interact with unknown peers and sustain interactions with even small groups of children, something that would have paralyzed him with anxiety at the beginning of treatment.

Case example 2: Beth. Beth was a seven-year-old girl diagnosed with ASD as well as generalized anxiety disorder, social phobia, and separation anxiety disorder. A primary area of concern for Beth and her family was her heightened anxiety in social situations with peers and unfamiliar adults. She was concerned about being negatively judged by other people. She worried about joining conversations with peers, anticipating that peers would ignore her or she would embarrass herself. She tended to avoid interacting with peers and directed most of her social overtures to one close friend at school.

A main goal for treatment was to address Beth’s social phobia and concurrently enhance her social-communication skills. Beth’s relationship with her one friend was high in conflict and they isolated themselves from other peers. Despite only positive interactions with other peers (although infrequent), Beth would avoid these interactions due to fear of rejection. In session Beth was taught to change her negative cognitions about approaching and interacting with peers, by instead focusing on the positive interactions she had previously had with her peers. She was also encouraged in session and school to gradually increase her interactions with peers, with a structured rewards program in place for all attempts made to interact with peers both in and outside of school. In addition, concepts about friendship such as the meaning of being a good friend and the qualities Beth preferred in friends were discussed. Further, play dates with other peers in her class were set up to expand Beth’s friendships. Beth learned and practiced play date hosting skills to promote successful get-togethers. As play dates with a variety of girls from her class occurred, Beth became increasingly aware of the poor quality of her friendship with her “close” friend. Eventually, she used this realization and her success in the play dates to develop closer friendships with other girls in her class, increasing her network of friends to play with at school. By the end of treatment Beth was consistently playing with other peers for the majority of time at school and would often engage in play dates with these new friends.

CBT for Core ASD Symptoms

Growing evidence supports the use of individual CBT to address core social functioning deficits in children and adolescents with ASD (e.g., Storch et al., 2013, 2015; Wood et al., 2009, 2015). While CBT for core autism symptoms has been delivered in varying dosages and formats (i.e., one-on-one and group), interventions frequently involve emotion recognition, cognitive restructuring related to social competencies, and in vivo exposure (Danial and Wood, 2013). Several open trials, RCTs, and multiple-baseline design group intervention studies examining CBT for core autism symptoms demonstrate significant improvements in domains such as pro-social behavior, social problem solving, and peer engagement. In two RCTs targeting both anxiety and core autism symptoms (Storch et al., 2013; Wood et al., 2009), individualized CBT including parent and school involvement produced gains in parent-reported autism symptoms that were maintained at 3-month follow-up in one study. In another RCT targeting both anxiety and social skills in adolescents with ASD, youth social skills improved significantly, while anxiety did not (White et al., 2013). Improvements in social awareness, cognition, and communication were also found in a recent RCT comparing CBT with treatment as usual for adolescents with ASD (Storch et al., 2015; also see Wood et al., 2015). The above examples of CBT for anxiety also illustrate how CBT is applied to autism symptoms such as isolation and social skill challenges, and how closely anxiety and social challenges may be interrelated in this population.

Overall, preliminary findings suggest that one-on-one individualized formats may be capable of producing more generalizable, lasting changes than group formats, although further study in this area is warranted (cf. Danial and Wood, 2013). Individualized CBT has been shown to improve core autism symptoms in two RCTs comparing CBT to wait-list control and in two RCTs comparing CBT to treatment as usual; therefore, CBT for core autism symptoms in youth with ASD meets criteria for probable efficacy.

CBT for Externalizing Behavior in Children With ASD

Stepping Stones Triple P—Positive Parenting Program (SSTP) is a specialized form of CBT for parents of children ages 2–16 years with a variety of disabilities that targets child internalizing and externalizing problems by altering parenting style and improving parent mental health (Sanders et al., 2002). It utilizes a tiered, public health approach in which parents begin with less intensive versions of the intervention and move on to more intensive intervention if their needs are not met. The intervention approach consists of five levels: level 1 is delivered via media; level 2 consists of a few group seminars; level 3 is brief and individually delivered; level 4 is a longer course of 10 individual, group, or self-directed sessions; level 5 involves additional modules targeting specific problems (e.g., partner conflict). In a RCT comparing level 3 SSTP to a care as usual control condition, families of children with ASD ages 2–9 in the SSTP group demonstrated improvements in parent-reported child behavior problems, parenting style, parent confidence, parent stress, parent relationship conflict, and parent relationship satisfaction, which were largely maintained at 6-month follow-up (Tellegen and Sanders, 2014). However, significant improvements were not found on observational measures of child behavioral problems and parent aversive behavior (Tellegen and Sanders, 2014). While level 3 SSTP may meet possibly efficacious criteria, further research examining other levels of SSTP and using observational measures will help to determine the efficacy of this approach for families of school-aged youth with ASD.