Escolar Documentos
Profissional Documentos
Cultura Documentos
Cognitive Behavioural Therapy for Children and Adolescents with ASD and Anxiety
Kaitlyn Mullally
Brock University
PSYC 4P79
Introduction
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
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
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
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
CBT TREATMENT FOR ASD WITH ANXIETY 3
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
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
(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
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,
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).
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
CBT TREATMENT FOR ASD WITH ANXIETY 5
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,
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
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
CBT TREATMENT FOR ASD WITH ANXIETY 6
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).
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
CBT TREATMENT FOR ASD WITH ANXIETY 7
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
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
CBT TREATMENT FOR ASD WITH ANXIETY 8
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).
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, &
CBT TREATMENT FOR ASD WITH ANXIETY 9
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
CBT TREATMENT FOR ASD WITH ANXIETY 10
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
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
CBT TREATMENT FOR ASD WITH ANXIETY 11
first diagnosed with ASD but this type of treatment does not prove effective for everyone
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-
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
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
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
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
References
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
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
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
CBT TREATMENT FOR ASD WITH ANXIETY 14
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
doi:10.1111/j.1469-7610.2011.02486.x
Reaven, J., Blakeley-Smith, A., Leuthe, E., Moody, E., & Hepburn, S. (2012). Facing your fears
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
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
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.
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
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