CBT: AN INTERVENTION FOR ANXIETY IN CHILDREN WITH AUTISM

SPECTRUM DISORDER

CBT: An Intervention for Anxiety in Children with Autism Spectrum Disorder

Alicia Marchini
University of Calgary

CBT: AN INTERVENTION FOR ANXIETY IN CHILDREN WITH AUTISM

SPECTRUM DISORDER

CBT: An Intervention for Anxiety in Children with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is characterized by social communication and
interaction impairments that persist across contexts and over time (American Psychiatric
Association [APA], 2013). Repetitive and restrictive patterns of movement, behaviour, or
interests are also distinguishing factors of ASD. These symptoms are identifiable in early
development and cause substantial deficiency in social, occupational, and other forms of
functioning (APA, 2013). According to the Diagnostic and Statistical Manual of Mental
Disorders (DSM-V; APA, 2013), autism spectrum disorder affects 1% of the population
of U.S. and non-U.S. countries. According to a review of literature regarding the
prevalence of anxiety disorders in children and adolescence with ASD, almost 42% meet
the diagnostic criteria for an anxiety disorder and between 11% and 84% demonstrate
impairing anxiety symptoms (White, Oswald, Ollendick, & Scahill, 2009). The difference
of comorbidity among studies may likely be rooted in the variation of sample size,
ascertainment, and type of anxiety measures (Hallett et al., 2013). However, a large
number of studies have corroborated the frequency of the concurrent relationship
between ASD and anxiety. For instance, one particular study that compared anxiety
disorder rates in children with ASD to typically developing children using a parent report
questionnaire found that only 3% of the community sample of 1751 typically developing
children scored above the clinical cutoff for symptoms of anxiety (White et al., 2009). In
contrast, 14% of the sample of 59 children with ASD were above the cutoff for symptoms
of generalized anxiety disorder and 8.5% of the ASD children were above the cutoff for
symptoms of separation anxiety (White et al., 2009). Accordingly, among individuals
with ASD, the most frequently co-occurring anxiety diagnoses are generalized anxiety

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SPECTRUM DISORDER

disorder and separation anxiety disorder, as well as simple phobias, obsessive-compulsive

disorder, and social phobia (White et al., 2009). It is important to note that some anxiety
disorders, such as social phobia and obsessive-compulsive disorder, are not typically
diagnosed in people with spectrum disorders because there is a widespread clinical
agreement that these symptoms are components of ASD (White et al., 2009). Children
with ASD and an anxiety disorder or anxiety symptoms may experience severe distress
and an increase in the severity of ASD symptoms (Hallett et al., 2013). As such, target
behaviour of children with ASD and anxiety means that the target student may exhibit
intensified repetitive and restrictive patterns of movement (e.g., hand flapping, refusal to
enter a particular room), increase in specific interests (e.g., fixation on trains), outbursts
of anger or silliness, heightened preference for rules and rigidity (e.g., adherence to
routine), and increased social interaction impairments (e.g., avoid eye contact; Minahan
& Rappaport, 2013, p. 35).
Several theories regarding the etiology of anxiety in ASD have developed.
Sensory over-responsivity (SOR) has been suggested to be a possible cause of anxiety
disorders in those with ASD (Kerns & Kendall, 2012). It proposes that youth acquire
troubling fears as a result of a heightened sensitivity to specific stimuli (Kerns & Kendall,
2012). However, the strength of this theory is limited, as its examinations employ
common measures of anxiety and SOR by increases in cortisol, over-activation of the
amygdala, and behavioural expressions of stress, which impedes on a discrimination
between the two constructs. Although a study revealed that the anxiety in typically
developing adults was related to SOR and responded to sensory-based treatments,

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SPECTRUM DISORDER

implying that SOR can be a potential cause of anxiety disorders, studies have not yet
provided evidence for this pattern between SOR and ASD (Kerns & Kendall, 2012).
Other theories suggest that characteristics of ASD indirectly increase the risk of
anxiety disorder (Kerns & Kendall, 2012). For instance, limited cognitive abilities can
lead to difficulties understanding and predicting occurrences, as well as understanding
and identifying emotion, which can ultimately cause ambiguity and anxiety (Kerns &
Kendall, 2012). Limbic system dysfunction and behavioural inhibitions are common in
those with anxiety disorders and ASD (Bellini, 2006). It is hypothesized that behavioural
avoidance is associated with lower threshold arousal levels in the amygdala, which cause
more frequent reactions and an overall inhibition after continual adverse incidents
(Bellini, 2006). Physiological arousal and a lack of social skills may be prognostic of
social anxiety in youth with ASD because higher base levels of arousal would likely
cause the youth to avoid and be conditioned by adverse incidents (Bellini, 2006).
Furthermore, in high functioning (IQ >68) children with ASD who are entering the
developmental stage of adolescence, childhood inconsistencies in verbal and nonverbal
IQ (a possible representation for right hemispheric dysfunction) predicted difficulties
with anxiety and mood (Kim, Szatmari, Bryson, Streiner, & Wilson, 2000). Kerns and
Kendall (2012) found that parental involvement is commonly heightened in youth with
ASD and typically developing youth with anxiety disorders (Kerns & Kendall, 2012);
however, a study by Drahota, Wood, Sze, and Van Dyke (2010) discovered that less
parental involvement was related to reduced anxiety and progress in daily living skills in
children with ASD and anxiety disorders who were high functioning (IQ above 70) and
being treated with CBT.

CBT: AN INTERVENTION FOR ANXIETY IN CHILDREN WITH AUTISM

SPECTRUM DISORDER

Rather than the notion that anxiety and ASD have a causal connection to one
another, it can also be suggested that anxiety and ASD commonly co-occur due to a
shared risk factor. For example, both anxiety and ASD have familial comorbidity, as
studies show that parents and relatives of youth with ASD and internalizing problems
often exhibit internalizing disorders as well (Kerns & Kendall, 2012). Genetic loading or
environmental predisposition may be the reason for this comorbidity (Kerns & Kendall,
2012). According to several studies, structural and neurochemical brain disruptions, such
as unusual amygdala volumes and 5HT neurotransmission, may predispose individuals to
anxiety, as well as ASD; however, it is uncertain as to whether these neurological
deviations cause or result from these disorders (Kerns & Kendall, 2012). It is difficult to
distinguish a causal relationship between anxiety and ASD, particularly because many
individuals with ASD have multiple comorbid disorders and anxiety disorders may be
epiphenomenal comorbidities, deriving from other co-occurring disorders. Yet, anxiety
disorders also arise in individuals with ASD who do not have additional comorbid
disorders. Ultimately, there are many hypotheses regarding the etiology of anxiety in
those with ASD and, due to the diversity in the manifestation and prevalence of anxiety in
ASD, there is potentially both causal and covariation models that are pertinent (Kerns &
Kendall, 2012).
There are tenuous treatments that target the behavioural and emotional issues,
such as anxiety, in youth with ASD, such as psychopharmacological treatments and
cognitive behavioural therapy (CBT). CBT has been employed to treat anxiety in those
with ASD (Kerns & Kendall, 2012). Two case studies that used CBT for individuals with
autistic disorder and obsessive-compulsive disorder (OCD), a type of anxiety disorder,

CBT: AN INTERVENTION FOR ANXIETY IN CHILDREN WITH AUTISM

SPECTRUM DISORDER

implemented modified exposure and response prevention, and found a decrease in

symptoms. One of these studies, where the use of visual aids and parent involvement was
accentuated, found a 65% decrease of OCD symptoms in the 7-year-old girl with autism
disorder based on parent and child interview of symptoms using the Childrens YaleBrown Obsessive Compulsive Scale (CY-BOCS; Scahill et al., 1997; White et al., 2009).
In a study by Chalfant, Rapee, and Carrol (2006), 47 school-age children with high
functioning autism or Aspergers Syndrome were assessed using the child version of the
Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Albano & Silverman,
1996). It was discovered that 74% of the sample met one or more anxiety disorder
(Chalfant et al., 2006). In contrast to a wait-list control group, the children who received
a 12-week, group-delivered cognitive-behavioral treatment showed significant reductions
in anxiety symptoms (Chalfant et al., 2006). This intervention, which emphasized
cognitive strategies, such as visual aids, structured homework/worksheets, simplification
of strategies, and exposure to the anxiety trigger, was adapted for the treatment of anxiety
in youth with ASD in Lyneham, Abbott, Wignall, and Rapees (2003) program called,
Cool Kids. The results of the treatment were successful, as these children were better
able to identify their automatic thoughts, which illustrates some theory of mind ability,
and had a significant reduction in automatic thoughts, compared to those in the wait-list
condition (Chalfant et al., 2006). Of the children in the CBT condition, 71.4% no longer
met the criteria for an anxiety disorder, in contrast to 0% of the wait-list condition
(Chalfant et al., 2006). In a study by Sofronoff, Attwood, and Hinton (2005) that
examined the effect of a six-week cognitive-behavioural group intervention for anxiety in
71 children with Aspergers Syndrome, as well as the effect of parent involvement,

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SPECTRUM DISORDER

children were separated into three groups: child-based intervention, child and parent
intervention, or wait-list. Those in the child and parent intervention, where children were
taught strategies to effectively manage and learn about their feelings and parents were
trained in all aspects of intervention, reported fewer symptoms of anxiety than those in
the child-based intervention, according to the Spence Child Anxiety Scale-Parent Report
(SCAS-P; Spence, 1997; Sofronoff et al., 2005). However, both intervention groups
developed more coping strategies after treatment in comparison to those in the wait-list
group (Sofronoff et al., 2005). It is important to note that the reliance on parent-report is a
limitation because the parents who were integrated into the intervention process may
have been more invested in their childs improvement. As such, although this study
provided initial evidence that parent involvement in the intervention process that targets
anxiety in children with ASD can increase success and effectiveness, further research is
necessary.
Due to the literary support for the effectiveness of CBT in treating anxiety in
those with ASD, it may be deemed an appropriate intervention. However, prior to
implementing this intervention, it is imperative to determine the students current
functioning and to measure the target behaviours as they occur in the natural environment
(Upah & Tilly, 2002). In this way, the effects of the intervention can be accurately
examined to determine baseline behaviour and to reevaluate behaviour during and after
treatment to measure the effectiveness of the intervention (Upah & Tilly, 2002). Some
studies suggest engaging in semi-structured or structured diagnostic interviews with the
parent(s) and child, such as the Anxiety Disorder Interview Schedule Child/Parent
(ADIS-C/P; Silverman & Albano, 1996) for the DSM-V, to determine the duration,

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SPECTRUM DISORDER

frequency, latency, topography, and intensity of target behaviours (Drahota et al., 2010;
Chalfant et al., 2006). For example, a case study of a child with OCD symptoms and
autism disorder used a parent and child interview of symptoms using the Childrens YaleBrown Obsessive Compulsive Scale (CY-BOCS; Scahill et al., 1997; White et al., 2009).
Also, one study by Chalfant et al. (2006) of children with high functioning autism or
Aspergers Syndrome were assessed using the child version of the Anxiety Disorders
Interview Schedule for DSM-IV (ADIS-C/P; Albano & Silverman, 1996) and another
study of children with Aspergers Syndrome and anxiety used Spence Child Anxiety
Scale-Parent Report (SCAS-P; Spence, 1997; Sofronoff et al., 2005). As such, the
aforementioned measures can be used as a measurement strategy for anxiety levels in
children with ASD and can be administered by trained and qualified professionals (e.g.,
psychologists) who would also analyze and document the results.
The results of the semi-structured interviews and scales will determine whether a
problem exists, as it would determine whether the child with ASD meets the DSM-V
criteria for anxiety disorders, thus providing problem validation. The results will also
assist in deciphering the reason for the target behaviour or the trigger that instigates it
because such scales and interviews (e.g., ADIS-C/P; Albano & Silverman, 1996) explore
and evaluate the childs reaction to a range of potential anxiety-provoking experiences
and situations, such as being away from a parent or interacting with others (Morris &
March, 2004). Consequently, the anxiety triggers of the child with ASD can be
illuminated through such tests, as well as through direct observation. In this way, the
analysis of the problem can be completed.

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Although each study indicated different time durations for treatment (e.g., 12week treatment, six-week intervention), these durations may have been impacted by time
limitations of the study (e.g., researchers decision to cease study when progress
monitoring indicated that improvement had occurred) or, perhaps, these durations were
the appropriate time limits to address the anxiety problem(s) of the participants with ASD
in the studies. Ultimately, the time duration of the CBT treatment can be individualized,
according to the severity of the target behaviour exhibited by the particular child in
question (e.g., in six weeks, when Maxs father drops him off at his classroom in the
morning, Max will retreat to a corner to rock back and forth only four times before taking
a seat on the carpet in the classroom, and in 12 weeks, Max will no longer perform this
behaviour when his father leaves him in his classroom).
As evidenced by the aforementioned studies, there are various ways to conduct
cognitive behavioural therapy. For instance, modified exposure to the anxiety trigger and
response prevention using visual aids are methods that have been found to effectively
reduce anxiety symptoms in children with ASD (White et al., 2009). In one study, groupdelivered cognitive strategies to identify and control automatic thoughts were explained
simply, using visual aids, and structured homework/worksheets and exposure were
provided (Chalfant et al., 2006). Similarly, another study of cognitive-behavioural group
intervention for anxiety in children with Aspergers Syndrome, children were taught
strategies to effectively manage and learn about their feelings to reduce anxiety
symptoms (Sofronoff et al., 2005). It may be also be helpful to train parents in all aspects
of intervention to have the intervention plan implemented across settings (Sofronoff et
al., 2005; e.g., at the clinic with the psychologist, at school with the school psychologist,

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10

and at home with parents). Considering the CBT techniques used in these studies, a
potential intervention for anxiety in children with ASD may be group-delivered by the
school psychologist who would teach them to identify and control automatic thoughts, as
well as manage and understand their feelings, using visual aids and worksheets. The
school psychologist may also use monitored modified exposure to triggers to coach the
student in managing their anxiety as they experience it. At school, the school
psychologist can administer the most suitable anxiety scales and/or conduct the semistructured interviews to measure and document the childrens anxiety every three weeks
over a 12-week period.
Although the research studies that have been explored do not make mention of a
decision-making plan, such a plan must be instituted to ascertain the childs progress after
each three-week period in order to deem the plan acceptable, inadequate, or in need of
alterations (Upah & Tilly, 2002). This data will likely vary from child to child and should
be visually represented on a graph, as shown in Figure 1 (i.e., dotted line), in order to
provide parents, teachers, and other professionals with a better understanding of the
childs progress (Upah & Tilly, 2002). In instances that the child is progressing
appropriately, those who are invested in the intervention implementation may more likely
maintain participation and adherence to the plan, which is imperative for success (Upah
& Tilly, 2002). Once a projected performance goal is established for the child (e.g., a
score of zero after 12-week intervention on the ADIS-C/P; Albano & Silverman, 1996), a
goal line can be indicated on the graph, stretching from the current performance to the
goal performance, in order to outline desired progress performance. This will provide a
guideline for progress, which will be formatively assessed by the school psychologist to

11

CBT: AN INTERVENTION FOR ANXIETY IN CHILDREN WITH AUTISM

SPECTRUM DISORDER

determine a need for a change or modification of intervention (e.g., longer duration) if

there is a notable discrepancy between the actual performance of the child and the goal
performance (e.g., four consecutive data points are above/below the goal line; Upah &
Tilly, 2002).
Figure 1
Max'sScoreonADIS-C/POver12-WeekCBTProgram
8
7
6

ADIS-C/P

5
4
ADIS-C/P
3
2
1
0
05-Mar

26-Mar

16-Apr

07-May

Date

The integrity of the treatment must be maintained and monitored, as the

intervention plan must be adhered to in order to successfully implement it (Upah & Tilly,
2002). Considering the intervention of CBT, only trained and qualified professionals
(e.g., school psychologist, clinical psychologist) will be responsible for implementing the
intervention plan. Thus, the psychologist must occasionally conduct treatment integrity
checks throughout the duration of intervention to ensure that s/he is fulfilling all
requirements of the plan (e.g., implementing intervention, measuring, documenting, and
analyzing progress, etc.). The psychologist must also observe the way in which the child
utilizes the cognitive strategies to determine whether the child employs the strategies
accurately and appropriately.
When the treatment integrity is confirmed and the intervention plan is completed,
a summative evaluation must occur. Ideally, the child will reach the projected goal

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12

performance and the target behaviour will diminish or cease to occur; however, the child
may not have attained this goal and more intervention time may be required, or a
modification or complete change of intervention may be necessary (Upah & Tilly, 2002).
The psychologist will make this decision, as s/he will reanalyze the problem.
Although the etiology of anxiety in ASD is undetermined, anxiety disorders are
evidently prevalent in children and adolescents with ASD, particularly in those with
higher IQ levels and functioning abilities (Hallett et al., 2013). Within this extant research
on anxiety disorders in individuals with ASD, methodological limitations are common,
and consequently, further studies are necessary to advance our understanding of the
relationship. Given the increasing number of youth with ASD who are in need of
treatment, future treatment research is imperative, particularly to acquire an empirically
based understanding of characteristics related to ASD, such as thoughts, behaviours, and
emotions that may cause anxiety within those with ASD. This will allow for the
successful development and application of anxiety treatments to individuals with ASD.
Also, fundamental constituents of effective treatment, a most effective delivery of
treatment method (e.g. group, individual, parent involvement), and treatments for anxiety
in youth with ASD and cognitive limitation are areas of research that need to be explored
in the future (White et al., 2009).
Clinically, the starting point of evaluating and treating anxiety in children with
ASD should be a detailed assessment that takes into account the symptoms, needs, and
functioning of the individual (Davis, 2011). However, it is important for clinicians to
strive to complete a multi-method, multi-informant assessment (self-, parent-, and
teacher- report measures, as well as a reliable and valid structured diagnostic interview

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13

and rating scale) over a limited period of time, as mixed results can occur if evaluations
are conducted over an extensive period (White et al., 2009). Due to the complex and
variant manifestation and course of anxiety in youth with ASD, it is likely that the anxiety
symptoms of some children are overlooked or mislabeled. For instance, a child with ASD
may not be able to accurately report on his/her symptoms, may deny symptoms (despite
overt expression), and may lack insight into feelings and thoughts of worry. As such, a
comprehensive understanding of the childs cognitive functioning and ASD severity,
including communication and social deficiencies, must be considered for diagnosis
(White et al., 2009). Furthermore, the individual childs learning style, strengths, and
needs must be accommodated for in the treatment of anxiety in youth with ASD.
Individual therapy, as well as interdisciplinary collaboration, may be beneficial. For
example, occupational therapy may be employed to reduce anxiety in children with ASD
who have sensory sensitivities (White et al., 2009). The childs teachers must be educated
on classroom recommendations and accommodations and modifications (e.g., a
structured lunchtime may be implemented to reduce stress for the student with ASD).
Parent education and support, which may include referrals to local parent support groups,
may also be beneficial. Research on CBT as an evidence-based intervention for anxiety in
children with ASD is promising; however, modifications to traditional CBT, such as more
practice and exposure opportunities, the use of visual aids (particularly when teaching),
having structured and predictable therapy sessions, and increasing parent involvement to
encourage skill use outside of treatment environment, is essential (White et al., 2009).
Practitioners working with children with ASD and anxiety should be cognizant of the

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childs social and communication skills when implementing CBT modifications and
should emphasize and build upon the childs strengths as much as possible (Davis, 2011).

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15

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