Running head: CBT TREATMENT FOR ASD WITH ANXIETY 1

Cognitive Behavioural Therapy for Children and Adolescents with ASD and Anxiety

Kaitlyn Mullally

Brock University

PSYC 4P79

Dr. Julie Baker

November 20, 2018

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Introduction

Autism Spectrum Disorder (ASD) is prevalent in approximately 1.68% of children (Baio

et al., 2018). Early signs of ASD often appear between the ages of 12 and 24 months, and males

are four times more likely than females to develop it (Baio et al., 2018). The DSM-V states that

ASD criteria includes difficulty in communicating and interacting with others, restricted

interests, and repetitive behaviours, as well as other symptoms that hinder the individual’s ability

to function in various domains such as school or work (Baio et al., 2018). ASD is known as a

spectrum disorder due to the variation in types and severities of symptoms that individuals

experience (Baio et al., 2018). Previously, in the DSM-IV, people would be diagnosed with one

of several separate conditions: Autistic disorder, Asperger’s syndrome, or pervasive

developmental disorder not otherwise specified (PDD-NOS) (Baio et al., 2018). In the current

DSM-V, these disorders have been combined, simply to be referred to as Autism Spectrum

Disorder (Baio et al., 2018). When an individual is diagnosed, immediate treatment is advised so

that learning difficulties can be reduced (National Institute of Mental Health, 2017). It is also

imperative to find a treatment that works for each individual specifically which can take time.

(National Institute of Mental Health, 2017). Because treatment must be custom-built to each

individual, it can include a mix of pharmacological and psychotherapy methods. Medication is

typically suggested as the initial way to deal with ASD symptoms (National Institute of Mental

Health, 2017). It can be a useful tool to decrease symptoms such as aggression and irritability,

hyperactivity and attention problems, repetitive behaviour, anxiety, and depression (National

Institute of Mental Health, 2017).

Individuals with ASD are at a greater risk of experiencing comorbid mental health issues

such as anxiety and depression (Reaven et al., 2011). This anxiety can lead to future psychiatric
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problems, employment issues, and self-medicating coping mechanisms such as substance abuse

in later years (Reaven et al., 2011). CBT has been modified for children and adolescents who

have ASD and has been shown to be effective in various studies. For reference: ‘children’ in this

paper can refer to anyone from infancy to 18 years of age and adolescents/youth will specifically

refer to anyone between the ages of 11-18. Based on a review of the literature, CBT has been

found to be an effective treatment method for youth with ASD and anxiety, showing significant

impacts on the decrease of anxiety symptoms and ASD-specific symptomology.

Differences in Anxiety Symptomology when Comorbid with ASD

To explore whether children with ASD experience ASD-specific symptomology in

addition to the typical anxiety symptoms from the DSM-V, Halim, Richdale, and Uljarevic

(2018) took a sample of 20 individuals; 10 with ASD and anxiety and 10 with only anxiety, and

put them into focus groups accordingly. They measured anxiety symptoms based on semi-

structured interview questions that were developed based on the DSM-V criteria for each of the

anxiety disorders as well as Illness Anxiety Disorder and Obsessive-Compulsive Disorder

(Halim, Richdale, & Uljarevic, 2018). The anxiety-only group predominantly experienced DSM-

V anxiety symptomology (Halim, Richdale, & Uljarevic, 2018). Meanwhile, results showed that

the theme structure of anxiety symptoms for the ASD group included both DSM-V criteria (i.e.

social anxiety) as well as ASD-specific anxiety that was related to the symptomology of the

disorder itself (Halim, Richdale, & Uljarevic, 2018). It is important to explore this relationship

further in order to gain the appropriate assessment and treatment tools to offer those with ASD,

ones that will target their specific anxiety experiences which differ from the experiences of those

without ASD (Halim, Richdale, & Uljarevic, 2018).

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Is the Cognitive Portion of CBT Manageable for Individuals with ASD?

Since CBT is heavily weighted on the identification of maladaptive cognitions, it is

important to make sure that children with ASD are able to understand and report their cognitions.

In order to determine if children with ASD are able to accurately self-report their cognitions,

Ozsivadjian, Hibberd, and Hollocks (2014) contrasted child-reports and parent-reports on an

Anxiety Scale and a Depression Inventory questionnaire (Ozsivadjian, Hibberd, & Hollocks,

2014). They found a congruence between the child-reports and parent-reports on both of these

scales which shows that children with ASD were able to provide accurate self-reports on anxiety

and depressive symptoms (Ozsivadjian, Hibberd, & Hollocks, 2014). Children also tended to

under-report their symptoms in comparison to parent and clinician ratings (Ozsivadjian, Hibberd,

& Hollocks, 2014). However, this result has not been universal throughout all studies observing

this relationship (Ozsivadjian, Hibberd, & Hollocks, 2014). Some studies have found a

discordance between parent and child measures which could be due to certain symptoms of ASD

that make reporting cognitions challenging; specifically, rigid thinking and a lack of ability to

recognize emotion (Ozsivadjian, Hibberd, & Hollocks, 2014). In addition to these findings, it is

up for debate whether or not the cognitive component in CBT is even the greatest factor in

improving the negative symptoms of those with ASD (Ozsivadjian, Hibberd, & Hollocks, 2014).

In another study, CBT was found to be as effective as a Social-Recreational treatment in

reducing ASD symptomology (Ozsivadjian, Hibberd, & Hollocks, 2014). Therefore, contrary to

the belief that the ASD population “...might be less able to access their own thoughts due to

difficulty with introspection and theory of mind.” these results show something different,

especially when negative thoughts are able to be communicated with visual tools (Ozsivadjian,

Hibberd, & Hollocks, 2014). One limitation of Ozsivadjian, Hibberd, and Hollocks’ (2014) study
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is that they only observed the effects of a small sample size. Another limitation would be their

focus on anxiety as a continuous measure whilst not taking diagnoses into account (Ozsivadjian,

Hibberd, & Hollocks, 2014).

Overall Effectiveness of CBT for Treating ASD and Anxiety

To explore the overall effectiveness of cognitive behavioural therapy in children and

adolescents with ASD and comorbid anxiety, several studies will be outlined in the following

section. Reaven et al. (2011) tested 50 children with high-functioning ASD, 47 of which

completed the full duration of the study. Children were split into two groups; one group received

12 weeks of CBT and the other continued treatment as usual (TAU) (Reaven et al., 2011). All of

the children were given structured interviews pre- and post-intervention by clinical evaluators

who were blind to conditions. The results showed significantly better outcomes for children in

the CBT condition (Reaven et al. 2011). 50% of the children in the experimental condition (10

out of 20) experienced clinically significant, positive treatment response while only 8.7% (2 out

of 23) of the TAU group showed improvements (Reaven et al., 2011). Some limitations that

Reaven et al. (2011) discuss in their study is that first of all, they had a relatively small sample

size. In comparison to some of the other literature on CBT for children with ASD and anxiety,

their sample size is quite large but it still is not large enough to be generalizable to a greater

population (Reaven et al., 2011). Another important limitation that they mention is their lack of

an attention control group (Reaven et al., 2011).

Secondly, in another study by Reaven et al. (2012), they tested the efficacy of a specific

CBT treatment called Facing Your Fears which is specifically geared towards adolescent

children with ASD and anxiety. They found that those who received the treatment showed
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significant reduction in anxious symptoms (Reaven et al., 2012). Those who posed fewer anxiety

diagnoses before the intervention were also more likely to experience clinically meaningful

improvement compared to those in the treatment-as-usual (TAU) group (Reaven et al., 2012).

Thirdly, in a randomized control trial by Wood et al. (2014), the Behavioural

Interventions for Anxiety in Children with Autism (BIACA) was used to assess the effectiveness

of CBT (Wood et al., 2014). The BIACA was modified to accommodate specific developmental

needs of early adolescents (Wood et al., 2014). A sample of 33 adolescents between the ages of

11 and 15 was recruited with participants assigned to either a waitlist condition, or a CBT

condition where they would receive 16 weeks of therapy (Wood et al., 2014). In the CBT

condition, exposure was emphasized, as well as challenging irrational beliefs (Wood et al.,

2014). Symptom severity, both at baseline and post-test were measured by the participants, their

parents, and independent evaluators (Wood et al., 2014). Independent evaluators rated anxiety

severity with the Pediatric Anxiety Rating Scale (PARS) and found that the CBT group’s

symptoms were significantly reduced by the end of the 16 sessions (Wood et al., 2014). 79% of

CBT group members were classified as positive treatment responders compared to only 28.6% of

those in the waitlist group (Wood et al., 2014). Parents also reported a positive treatment effect

of the CBT on ASD symptom severity (Wood et al., 2014). Wood et al. (2014) also refer to a

study by Kuusikko et al. (2008) in which it was found that youth with high-functioning ASD, in

comparison to younger children with ASD and typically developing youth, have more

pronounced social anxiety and behavioural avoidance. Their theory is that individuals with ASD

may begin to notice their own social impairment at a young age so by the time they reach

adolescence, their level of self-consciousness and behavioural avoidance are noticeably higher

than that of typically developing youth (Wood et al., 2014). This is an important aspect to take
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into account because getting rid of these avoidance behaviours is imperative to future

relationship development (Wood et al., 2014). In conclusion, Wood et al. (2014) state that it is

crucial for treatment geared toward adolescents with ASD and comorbid anxiety disorders to

include the following components: they must be developmentally appropriate for the specific

age-group, and they must address ASD-specific barriers to the anxiety treatment such as

cognitive restructuring and exposure therapy.

Training Clinicians to Deliver CBT to Individuals with ASD

In order to effectively treat individuals with ASD and anxiety using CBT, therapists must

receive the proper training which many do not have according to Reaven et al. (2018). They

studied whether or not CBT would be more effective if clinicians were provided ASD-specific

training (Reaven et al., 2018). They also wanted to see if the way in which clinicians were taught

ASD-specific CBT would affect the responsiveness of the clients (Reaven et al., 2018). They

split clinicians into three conditions in which they learned about Facing Your Fears therapy, and

then measured their knowledge as well as the responsiveness of their clients (Reaven et al.,

2018). The sample of 34 clinicians (with a combined client sample of 91 children) was divided

into a manual condition, a workshop condition, and a workshop-plus condition (Reaven et al.,

2018). The effectiveness of each condition was measured by implementation of the treatment

(i.e. CBT knowledge, treatment fidelity) and outcomes (i.e. reduction of anxiety measured by the

ADIS-P) (Reaven et al., 2018). Overall, results showed that clinicians in both workshop

conditions significantly increased in their CBT knowledge and all conditions showed good

treatment fidelity (with highest ratings in the workshop conditions) (Reaven et al., 2018). Many

of their clients demonstrated significant reductions in anxiety symptoms and clinicians in all
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conditions could deliver effective Facing Your Fears CBT treatment (Reaven et al., 2018). One

limitation of this study however was that it lacked a no-treatment condition so there was no

group to compare the results to (aside from clients’ baseline anxiety levels) (Reaven et al., 2018).

How Group Therapy and Parental Involvement Play a Role

Another important factor in the effectiveness of CBT treatment for children and

adolescents is the parental role in therapy. Parents of children with ASD are often heavily

involved in the treatment of their child’s disorder so high stress levels of parents can decrease

positive outcomes for their children (Weiss, Viecili, & Bohr, 2015). Weiss, Viecili, & Bohr

(2015) conducted a study on whether parental involvement in CBT correlated with the treatment

responsiveness of their children. They tested a sample of 18 children between the ages of 8 and

12 with ASD as well as significant anxiety problems (Weiss, Viecili, & Bohr, 2015). All

participants took part in a 12-week CBT treatment called Coping Cat, along with their parents

(Weiss, Viecili, & Bohr, 2015). By the end of the 12-week period, they noted a significant

reduction in participants’ anxiety levels, which were measured by parent-report (Weiss, Viecili,

& Bohr, 2015). 50% of the children who participated exhibited clinically meaningful

improvements (measured with the Reliable Change Index) (Weiss, Viecili, & Bohr, 2015). There

was also a significant correlation between parent stress and the change in child anxiety from pre-

to post-treatment (Weiss, Viecili, & Bohr, 2015). Parental involvement in weekly therapy

sessions is highly important to aid the child’s improvement as well as to help initiate any

homework completion or exposures that are required to happen outside of sessions (Weiss,

Viecili, & Bohr, 2015). Parents of children with ASD are sometimes even considered ‘co-

therapists’ as they often help their child’s therapist create the treatment plans (Weiss, Viecili, &
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Bohr, 2015). Within this study there were several other studies mentioned that support the results

of Weiss, Viecili, & Bohr (2015). Sofronoff et al. (2005) tested the role of parent involvement in

anxiety reduction of children with ASD by separating their participants into a child-only

condition, a parent condition and a waitlist condition (Weiss, Viecili, & Bohr, 2015). They

provided 6 weeks of CBT and those whose parents were involved in the therapy with them

showed a significantly greater reduction in anxiety compared to those in the child-only group

(Weiss, Viecili, & Bohr, 2015). They measured this by parent-report without any measures by an

independent evaluator, so results could potentially be biased and/or unreliable (Weiss, Viecili, &

Bohr, 2015). Another study by Puelo & Kendall (2011) looked at ASD symptoms that occurred

in typically developing children and how these symptoms would predict CBT outcomes (Weiss,

Viecili, & Bohr, 2015). Participants either partook in individual- or family-based Coping Cat

(Weiss, Viecili, & Bohr, 2015). They found that moderate levels of ASD symptoms in the

children were associated with a decrease in treatment response but only in the individual-based

condition (Weiss, Viecili, & Bohr, 2015). In the family therapy condition, these symptoms had

no significant impact which suggests that CBT along with family involvement may be more

effective for children with ASD symptoms (Weiss, Viecili, & Bohr, 2015).

Lastly, another study that supports the efficacy of group therapy is one by McGillivray

and Evert (2014). In their study, they also split participants into a waitlist condition and a group

intervention condition to see if group therapy is more effective in decreasing depression and

anxiety in adolescents with ASD (McGillivray & Evert, 2014). Individuals who partook in the

group therapy sessions reported lower depression and stress scores overall compared to those in

the waitlist group and these benefits were maintained at both the 3-month and 9-month follow-

ups (McGillivray & Evert, 2014). However, no significant change was found when looking at
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anxiety symptoms (McGillivray & Evert, 2014). Although anxiety symptoms were not seen to be

reduced in this study, the group therapy still showed some positive effects compared to the

control condition, further suggesting the importance of having others present to support the client

(McGillivray & Evert, 2014).

Effectiveness of CBT Alongside Other Treatment Methods

To observe the effects of CBT in contrast with a different treatment method, Sizoo and

Kuiper (2017) compared the effectiveness of mindfulness based stress reduction (MBSR) and

CBT in individuals with ASD. They wanted to observe whether or not they were equally

effective in reducing anxiety and depression symptoms in adults with ASD (Sizoo & Kuiper,

2017). Although they chose to study adults, their results can still apply to the treatment of

children and adolescents with ASD (Sizoo & Kuiper, 2017). They tested a sample of 59 adults

with ASD, and either an anxiety or depression score above 7 (on the Hospital Anxiety and

Depression Scale) (Sizoo & Kuiper, 2017). 27 partook in CBT treatment and 32 in MBSR

treatment (Sizoo & Kuiper, 2017). Anxiety and depression scores, ASD symptoms, rumination,

and global mood were measured pre-treatment, post-treatment (after 13 weeks), and at a 3-month

follow-up period (Sizoo & Kuiper, 2017). Both treatment methods showed decreases in anxiety

and depressive symptoms post-treatment as well as at the 3-month follow-up (Sizoo & Kuiper,

2017). Similar patterns were observed for the other measures as well such as rumination and

global mood (Sizoo & Kuiper, 2017). Their conclusions showed that MBSR may actually be

preferred over CBT treatment in the case of adults with ASD; especially when irrational beliefs

or positive global mood at baseline are high (Sizoo & Kuiper, 2017).

Another common treatment method for individuals with ASD and anxiety is
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pharmacological treatment. It is common to initially receive pharmacological treatment when

first diagnosed with ASD but this type of treatment does not prove effective for everyone

(National Institute of Mental Health, 2017). Furthermore, it is crucial to look at it in conjunction

with CBT. In a study by Storch et al. (2015), the objective was to estimate the effectiveness of

CBT in treating anxiety disorders in adolescents with ASD and anxiety who were already

receiving pharmacological treatment in the form of antidepressants. They measured a very small

sample of 7 males from ages 12 to 15 with ASD and at least one anxiety disorder, who were non-

responders or partial-responders to serotonin reuptake inhibitor (SRI) treatment (Storch et al.,

2015). All participants received 16 CBT sessions and 4 out of 7 participants were classified as

treatment responders by the end of the sessions, however the ASD symptoms themselves were

not significantly reduced (Storch et al., 2015). All of the participants had been taking SRIs for 12

or more weeks, and were recruited from other studies in which they had been placed in waitlist

conditions (Storch et al., 2015). The anxiety disorders they included in their study were OCD (at

that time OCD was classified by the DSM-IV as an anxiety disorder), generalized anxiety

disorder, separation anxiety disorder, specific phobias, and social phobia, all with clinical

severity ratings greater than 4 (Storch et al., 2015). Anxiety symptoms were measured by the

Pediatric Anxiety Rating Scale (PARS) which has good inter-rater reliability, test-retest

reliability, as well as convergent and divergent validity (Storch et al., 2015). On the PARS, there

were significant improvements seen from the time of pre-treatment to post-treatment (Storch et

al., 2015). Because this study only measured a very small sample size, it does not hold much

power (Storch et al., 2015). The age-range of participants was also very narrow and no females

with ASD were measured (Storch et al., 2015).

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Discussion

The reviewed literature provides much evidence to support the efficacy of CBT in

treating anxiety in children and adolescents with Autism Spectrum Disorders. Since most studies

mentioned here have included relatively small sample sizes, it is crucial that larger scale studies

are completed in the future in so as to gain further knowledge in this area. This will likely

continue to be a challenge however given that the prevalence rate of ASD is only 1.68%, and

there are typically many exclusion criteria in clinical studies so participants are not readily

available (Baio et al., 2018).

One implication for psychotherapy treatment is the knowledge that CBT may have to be

adjusted to accommodate those with high-functioning ASD comorbid with anxiety. This will

inform therapists that they must develop a slightly different CBT method for treating those with

ASD in order for it to be effective. There needs to be more research done in order to find various

working combinations of therapies specific to individuals with ASD. Clinicians must also be

properly trained in how to treat anxiety disorders in those with ASD, especially adolescents since

their programs must be specific to their developmental level as well.

Something else to take into account as well is the lack of research regarding individuals

with lower-functioning ASD and anxiety. For individuals with lower-functioning ASD, verbal

communication may be a challenge so anxiety levels for example could be more difficult for

children and parents to report. In addition, there may simply be less responsiveness to treatment

for those individuals. There needs to be more research done on the CBT methods that have

already shown efficacy for those with high-functioning ASD, and how these methods can be

adjusted to accommodate those elsewhere on the spectrum.

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References

Autism Spectrum Disorder. (2017). Retrieved November 19, 2018, from

https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml

Baio, J., Wiggins, L., Christensen, D., Maenner, M., Daniels, J., & Warren, Z. (2018). Correction

and republication: Prevalence and characteristics of autism spectrum disorder among children

aged 8 years - Autism and developmental disabilities monitoring network, 11 sites, United

States, 2014. Morbidity and Mortality Weekly Report,67(6), 1-23.

doi:10.15585/mmwr.mm6745a7

Halim, A. T., Richdale, A. L., & Uljarević, M. (2018). Exploring the nature of anxiety in young

adults on the autism spectrum: A qualitative study. Research in Autism Spectrum Disorders,55,

25-37. doi:10.1016/j.rasd.2018.07.006

McGillivray, J. A., & Evert, H. T. (2014). Group cognitive behavioural therapy program shows

potential in reducing symptoms of depression and stress among young people with ASD. Journal

of Autism and Developmental Disorders,44(8), 2041-2051. doi:10.1007/s10803-014-2087-9

Ozsivadjian, A., Hibberd, C., & Hollocks, M. J. (2013). Brief report: The use of self-report

measures in young people with autism spectrum disorder to access symptoms of anxiety,

depression and negative thoughts. Journal of Autism and Developmental Disorders,44(4), 969-

974. doi:10.1007/s10803-013-1937-1
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Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2011). Group cognitive

behavior therapy for children with high-functioning autism spectrum disorders and anxiety: A

randomized trial. Journal of Child Psychology and Psychiatry,53(4), 410-419.

doi:10.1111/j.1469-7610.2011.02486.x

Reaven, J., Blakeley-Smith, A., Leuthe, E., Moody, E., & Hepburn, S. (2012). Facing your fears

in adolescence: Cognitive-behavioral therapy for high-functioning autism spectrum disorders and

anxiety. Autism Research and Treatment,2012, 1-13. doi:10.1155/2012/423905

Reaven, J., Moody, E., Klinger, L., Keefer, A., Duncan, A., O’Kelley, S., Blakeley-Smith, A.

(2018). Training clinicians to deliver group CBT to manage anxiety in youth with ASD: Results

of a multisite trial. Journal of Consulting and Clinical Psychology,86(3), 205-217.

doi:10.1037/ccp0000285

Sizoo, B. B., & Kuiper, E. (2017). Cognitive behavioural therapy and mindfulness based stress

reduction may be equally effective in reducing anxiety and depression in adults with autism

spectrum disorders. Research in Developmental Disabilities,64, 47-55.

doi:10.1016/j.ridd.2017.03.004

Storch, E. A., Nadeau, J. M., Rudy, B., Collier, A. B., Arnold, E. B., Lewin, A. B., Murphy, T.

K. (2014). A case series of cognitive-behavioral therapy augmentation of antidepressant

medication for anxiety in children with autism spectrum disorders. Childrens Health Care,44(2),

183-198. doi:10.1080/02739615.2014.906310
CBT TREATMENT FOR ASD WITH ANXIETY 15

Weiss, J. A., Viecili, M. A., & Bohr, Y. (2014). Parenting stress as a correlate of cognitive

behavior therapy responsiveness in children with autism spectrum disorders and anxiety. Focus

on Autism and Other Developmental Disabilities,30(3), 154-164.

doi:10.1177/1088357614547808

Wood, J., Ehrenreich-May, J., Alessandri, M., Fujii, C., Renno, P., Laugeson, E., Storch, E.

(2015). Cognitive behavioral therapy for early adolescents with autism spectrum disorders and

clinical anxiety: A randomized, controlled trial. Behaviour Therapy,46, 7-19.