Preliminary Efficacy of a Cognitive-Behavioral Treatment Program for Anxious Youth with Autism Spectrum Disorders

Anxiety is a commonly occurring psychiatric concern in adolescents with autism spectrum disorders (ASD). This pilot study examined the preliminary efficacy of a manual-based intervention targeting anxiety and social competence in four adolescents with high-functioning ASD. Anxiety and social functioning were assessed at baseline, midpoint, endpoint, and 6 months following treatment. Treatment consisted of cognitive-behavioral therapy, supplemented with parent education and group social skills training. The treatment program was effective in reducing anxiety in three of the four subjects and improving the social skills in all four subjects. Recommendations for the assessment and treatment of anxiety youth with ASD such as use of self-report measures to complement clinician and parent-reports and adaptations to traditional child-based CBT, are offered.     

No Offense Intended: Fear of Negative Evaluation in Adolescents and Adults with Autism Spectrum Disorder

Social anxiety disorder (SAD) is a common comorbidity for individuals with autism spectrum disorder (ASD). The present study examined the cardinal cognitive component of SAD, fear of negative evaluation (FNE), in adolescents and adults with ASD (n = 44; 59 % with social anxiety) and those without ASD (n = 69; 49 % with social anxiety). Group (ASD or non-ASD) significantly moderated the relationship between social disability, as well as social motivation impairment, and FNE, such that there was a stronger positive relationship for the adolescents and adults without ASD. Few differences emerged between those with and without ASD, with respect to specific indicators of FNE. Clinical implications are discussed, including the importance of assessing FNE among individuals with ASD.     

Social Anxiety in Parents of High-Functioning Children with Autism and Asperger Syndrome

We evaluated social anxiety (SA) symptoms in parents of children with autism spectrum disorders (ASDs; N = 131) and community parents (N = 597) using the Social Phobia and Anxiety Inventory (SPAI). SA was significantly more common in ASD than control mothers (15.6 vs. 6.7 %) and more equal between the ASD and control fathers (3.3 vs. 4.8 %). The ASD mothers scored significantly higher than control mothers on all SPAI scales. ASD fathers scored significantly higher than control fathers on the somatic, cognitive, avoidance and agoraphobic symptoms of SA. It is of clinical import to support ASD parents’ well-being as their psychiatric features may contribute greatly to their children’s emotional development and the well-being of the whole family.     

Parents’ State and Trait Anxiety: Relationships with Anxiety Severity and Treatment Response in Adolescents with Autism Spectrum Disorders

Comorbid anxiety is common among children with Autism Spectrum Disorder (ASD), and parents of children with ASD are more likely to have anxiety disorders. This study investigated the relationship between parents’ state and trait anxiety and parent-reported internalizing and externalizing symptoms among adolescents (n = 30) with ASD, as well as the relationship of parents’ anxiety symptoms and adolescent treatment response in the context of a randomized controlled trial. Parental state anxiety correlated with severity of adolescent anxiety, and trait anxiety in parents correlated with parent-reported adolescent internalizing and externalizing symptoms. Also, parents of adolescent treatment responders experienced a decrease in their own trait anxiety. Findings highlight the importance of considering parental anxiety when targeting anxiety among youth with ASD.     

Self-reported social anxiety symptoms and correlates in a clinical (CAP) and a community (Young-HUNT) adolescent sample

Purpose

The frequencies of social anxiety symptoms in a mental health clinical and a community sample of adolescents are compared. Also, we explore if adolescents can be classified in subgroups based on social anxiety symptoms. Associations between social anxiety symptoms and coexisting problems and sociodemographic characteristics are examined.

Methods

Adolescent participants, aged 13–18, in two large Norwegian studies, consisting of a clinical (n = 694, 42.1 % participation rate, 55 % girls, mean age = 15.6) and a community (n = 7,694, 73.1 % participation rate, 51 % girls, mean age = 15.8) sample completed identical self-report questionnaires measuring social anxiety and related variables.

Results

Median sum scores (interquartile range) of social anxiety symptoms were higher among girls than boys and in the clinical [girls = 16 (12–22); boys = 12 (9–16)] compared to the community sample [girls = 12 (9–15); boys = 10 (7–12)] (p < 0.001). Latent profile analysis revealed two classes of adolescents based on social anxiety profiles. Adolescents scoring high on social anxiety symptoms, which ranged from 16 % (boys in community sample) to 40 % (girls in clinical sample), had significantly more coexisting problems than those scoring low. Social anxiety symptoms were associated with academic school problems, bullying, eating problems, acne, and general anxiety and depression in both samples.

Conclusion

Social anxiety symptoms were commonly reported by adolescents, in both clinical and community settings. These symptoms were associated with a broad spectrum of coexisting problems, which can be used to detect adolescents struggling with social anxiety. Adolescent, family, peer, school, and community interventions targeting these associated problems may contribute to prevent and alleviate social anxiety symptoms.     

Intensive Cognitive Behavioral Therapy for Anxiety Disorders in School-aged Children with Autism: A Preliminary Comparison with Treatment-as-Usual

Children with autism spectrum disorders (ASDs) frequently present with a comorbid anxiety disorder that can cause significant functional impairment, particularly at school. An intensive modular cognitive behavioral treatment (CBT) program was delivered to address anxiety, self-regulation, and social engagement in school and in the community. A particular emphasis was placed on increasing generalizability of coping skills and positive social behavior by involving school personnel in the treatment process. Children (7–11 years old) were randomly assigned to an immediate treatment condition (IT) that included 32 sessions of CBT (n = 7) or a 16-week treatment-as-usual (TAU) condition (n = 5). The CBT sessions emphasized behavioral experimentation and emotion regulation training as well as social coaching on increasing positive peer interactions. School observations and consultations were included in the treatment model. Independent evaluators blind to treatment condition conducted structured diagnostic interviews at baseline and post-IT/post-TAU. Post-treatment analyses showed that 71.4 % of the IT group had remitted from their primary anxiety disorder diagnosis as compared with none of the TAU group. In addition, an ANCOVA analysis conducted with baseline anxiety scores included as a covariate revealed a statistically significant difference by treatment group in anxiety severity favoring the IT group at post-treatment. The 32-session CBT program is an intensive approach for children with ASD and moderate-to-severe anxiety disorders that appears to yield a clinically significant impact on anxiety symptoms. The generalizability of coping skills may be enhanced by the inclusion of school-based treatment components due to the consistency of supports this permits across the child’s daily settings.     

Age-related differences in the prevalence and correlates of anxiety in youth with autism spectrum disorders

Age-related differences in the prevalence and correlates of anxiety were cross-sectionally examined in 1316 children and adolescents with autism spectrum disorder (ASD) who presented for initial evaluation at 14 outpatient autism centers around the country and in Canada. The prevalence of clinical and subclinical anxiety as well as the correlates of anxiety were examined in three age groups of children: preschool, school age and adolescents. Findings showed that the prevalence of anxiety in each age group exceeded the prevalence of anxiety in the general population. Adolescents and school age children had the highest prevalence of clinical (40%) and subclinical anxiety (26%), respectively. Higher IQ and less ASD severity were each weakly correlated with more anxiety in preschool and school age children. Affective symptoms were strongly associated with anxiety in each age group. Age specific psychiatric comorbidities were also present. Anxiety was associated with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms in the preschool group, ODD and somatic symptoms in the school age children, and ADHD symptoms in adolescents. These data underscore the need for prevention and treatment of anxiety as well as research examining the characteristics of anxiety in children with ASD using a developmental framework.     

Discriminant and Convergent Validity of the Anxiety Construct in Children with Autism Spectrum Disorders

Despite reports of high anxiety in children with autism spectrum disorders (ASD), there is controversy regarding differential diagnosis of ASD symptoms and anxiety symptoms. This study examined 88 children, aged 7–11 years, with ASD referred for concerns about anxiety. A multitrait-(social anxiety, separation anxiety, overall anxiety severity, and overall ASD severity), multimethod-(diagnostic interviews, parent-, and child-based measures) analysis was conducted. Results from structural equation modeling suggest statistical discrimination between anxiety and ASD severity and convergence among differing reports of two of the anxiety subdomains (separation anxiety and overall anxiety). These findings suggest that anxiety symptoms experienced by children with ASD are separate from ASD symptom severity and may instead reflect anxiety syndromes (e.g., separation anxiety) similar to those that occur in typically developing children.     

Long-Term Effects of CBT on Social Impairment in Adolescents with ASD

Anxiety interventions involving social skills training and CBT for youth with ASD have shown promise, but few studies have examined the effects on social functioning or the maintenance of treatment gains. This study evaluated change in social skills during a randomized controlled trial of CBT and during the 1-year follow-up for 25 adolescents with ASD and anxiety. We examined the effect of pretreatment social anxiety and loneliness on treatment response. Social impairment improved during treatment and continued to improve through the 3-month follow-up. Although adolescents with higher social anxiety had greater pretreatment social impairment, they showed steeper improvement in social skills during treatment. Loneliness was not a significant predictor of change during treatment. CBT targeting social skills and anxiety can lead to long-term improvements in social functioning.     

The Parent-Version of the Spence Children’s Anxiety Scale (SCAS-P) in Chinese and Italian Community Samples: Validation and Cross-Cultural Comparison

The current study aimed to validate the parent-version of the Spence Children’s Anxiety Scale (SCAS-P) among Chinese and Italian community adolescents and to compare adolescents’ anxiety symptoms in these two countries. Chinese (N = 456) and Italian (N = 452) adolescents and their parents participated in the study. Results showed that: (1) the six correlated-factor structure was demonstrated and invariant across countries. (2) The reliability of the total scale was good in both samples, whereas reliabilities of subscales were acceptable and moderate in Chinese and Italian samples, respectively. (3) The SCAS-P showed good convergent and divergent validity. (4) Adolescent–parent agreement was from low to medium while mother–father agreement ranged from medium to high. (5) There were cultural and gender differences in levels of parent-report anxiety symptoms. In conclusion, SCAS-P seems to be a promising parent-report instrument to assess Chinese and Italian adolescents’ anxiety symptoms.     

The Youth Anxiety Measure for DSM-5 (YAM-5): Development and First Psychometric Evidence of a New Scale for Assessing Anxiety Disorders Symptoms of Children and Adolescents

The Youth Anxiety Measure for DSM-5 (YAM-5) is a new self- and parent-report questionnaire to assess anxiety disorder symptoms in children and adolescents in terms of the contemporary classification system. International panels of childhood anxiety researchers and clinicians were used to construct a scale consisting of two parts: part one consists of 28 items and measures the major anxiety disorders including separation anxiety disorder, selective mutism, social anxiety disorder, panic disorder, and generalized anxiety disorder, whereas part two contains 22 items that focus on specific phobias and (given its overlap with situational phobias) agoraphobia. In general, the face validity of the new scale was good; most of its items were successfully linked to the intended anxiety disorders. Notable exceptions were the selective mutism items, which were frequently considered as symptoms of social anxiety disorder, and some specific phobia items especially of the natural environment, situational and other type, that were regularly assigned to an incorrect category. A preliminary investigation of the YAM-5 in non-clinical (N = 132) and clinically referred (N = 64) children and adolescents indicated that the measure was easy to complete by youngsters. In addition, support was found for the psychometric qualities of the measure: that is, the internal consistency was good for both parts, as well as for most of the subscales, the parent–child agreement appeared satisfactory, and there was also evidence for the validity of the scale. The YAM-5 holds promise as a tool for assessing anxiety disorder symptoms in children and adolescents.     

Friendship and Internalizing Symptoms Among Children and Adolescents with ASD

Anxiety and depression are common among children and adolescents with autism spectrum disorders (ASD), highlighting a need to identify factors that protect against these symptoms. Among typically developing children, friendships are protective, and lead to better emotional outcomes. The current study examined a large, well-characterized sample of children and adolescents with ASD to examine the relations among friendship, ASD symptom severity, and anxiety/depression. Rates of anxiety/depression were high in this sample. Greater ASD severity was associated with fewer symptoms of anxiety/depression, lower IQ, and poorer number and/or quality of reciprocal friendships. Surprisingly, children with no or very poor dyadic relationships experienced less anxiety than those with existing, but limited, friendships. Implications and directions for future research are discussed.     

A Replication and Extension of the PEERS Intervention: Examining Effects on Social Skills and Social Anxiety in Adolescents with Autism Spectrum Disorders

This study aimed to evaluate the Program for the Education and Enrichment of Relational Skills (PEERS: Laugeson et al. in J Autism Dev Disord 39(4):596–606, 2009). PEERS focuses on improving friendship quality and social skills among adolescents with higher-functioning ASD. 58 participants aged 11–16 years-old were randomly assigned to either an immediate treatment or waitlist comparison group. Results revealed, in comparison to the waitlist group, that the experimental treatment group significantly improved their knowledge of PEERS concepts and friendship skills, increased in their amount of get-togethers, and decreased in their levels of social anxiety, core autistic symptoms, and problem behaviors from pre-to post-PEERS. This study provides the first independent replication and extension of the empirically-supported PEERS social skills intervention for adolescents with ASD.     

Exploring the nature of anxiety in young adults on the autism spectrum: A qualitative study

BackgroundResearch exploring the nature of anxiety symptoms in autism spectrum disorder (ASD) has thus far focused on children and adolescents, providing evidence for both typical and atypical anxiety symptom presentations associated with ASD. This study builds on previous research by focusing on young adults, and comparing anxiety presentation between individuals with ASD and non-ASD individuals with anxiety disorders. We anticipated that while the non-ASD group would report only typical anxiety symptoms, and the ASD group would report both typical and atypical presentations of anxiety symptoms.MethodTen individuals with ASD and anxiety (M = 21.8 years, SD = 6.76), and 10 individuals with anxiety (M = 24.4 years, SD = 4.17) participated in focus groups. Participants responded to semi-structured interview questions specifically developed using the DSM-5 criteria for each of the anxiety disorders, Illness Anxiety Disorder, and Obsessive-Compulsive Disorder. These questions focused on carefully elucidating experiences of anxiety including DSM-5 anxiety symptomatology and ASD-specific anxiety symptomatology.ResultsThematic analysis revealed a theme structure for the ASD group composed of both DSM-5-related (e.g., social anxiety themes) and ASD-specific anxiety presentations (i.e., related to core ASD symptomatology). In contrast, the non-ASD group described predominantly DSM-5-related anxiety symptomatology.ConclusionsOur findings support the predicted outcome that there are both ASD-specific anxiety and DSM-5-related anxiety symptomatology in young adults with ASD, compared with young adults with anxiety who show only DSM-5 symptomatology. Future research elucidating the relationship between ASD symptomatology and anxiety in ASD, utilising both quantitative and qualitative measures, is crucial to enable a more comprehensive understanding of the nuances of anxiety in ASD. Gaining this knowledge is a crucial step for the development of more accurate and appropriate assessment and treatment tools that can target their specific anxiety experiences.     

Relationship between anxiety, anxiety sensitivity and conduct disorder symptoms in children and adolescents with attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit hyperactivity disorder (ADHD) is often comorbid with anxiety disorders and previous studies observed that anxiety could have an impact on the clinical course of ADHD and comorbid disruptive behavioral disorders (conduct disorders and oppositional-defiant disorders). Anxiety sensitivity (AS) is a different concept from anxiety per se and it is believed to represent the constitutionally based sensitivity of individuals to anxiety and anxiety symptoms. We aimed to assess the associations between anxiety, AS and symptoms of disruptive behavioral disorders (DBD) in a clinical sample of children and adolescents with ADHD. The sample consisted of 274 treatment naive children with ADHD aged 8–17 years. The severity of ADHD symptoms and comorbid DBD were assessed via parent rated Turgay DSM-IV-Based Child and Adolescent Behavioral Disorders Screening and Rating Scale (T-DSM-IV-S), Conners’ Parent Rating Scale (CPRS), and Conners’ Teacher Rating Scale (CTRS). AS and severity of anxiety symptoms of children were evaluated by self-report inventories. The association between anxiety, AS, and DBD was evaluated using structural equation modeling. Analyses revealed that AS social subscale scores negatively predicted symptoms of conduct disorder (CD) reported in T-DSM-IV-S. On the other hand, CD symptoms positively predicted severity of anxiety. No direct relationships were detected between anxiety, AS and oppositional-defiant behavior scores in any scales. These results may suggest a protective effect of AS social area on the development of conduct disorder in the presence of a diagnosis of ADHD, while the presence of symptoms of CD may be a vulnerability factor for the development of anxiety symptoms in children and adolescents with ADHD.     

Profiles and Correlates of Parent–Child Agreement on Social Anxiety Symptoms in Youth with Autism Spectrum Disorder

This study characterized patterns and correlates of parent–youth agreement on social anxiety in youth with and without autism spectrum disorder (ASD). Participants (279 verbally-fluent youth aged 8–16 years, N_ASD?=?144, N_TD?=?135) completed the SASC-R. Youth with ASD exhibited higher social anxiety across informants. While TD youth endorsed higher anxiety than did parents, self- and parent-reports did not differ in youth with ASD. For children with ASD, higher parent–youth agreement was associated with lower lifetime ASD symptoms and higher adaptive skills. For TD youth, agreement on high anxiety was associated with lowest adaptive skills. Demographic factors (age, verbal IQ, gender) did not relate to agreement for either group. In ASD, parent–child agreement on youth anxiety, either high or low, was associated with better outcomes.     

Traditional and Atypical Presentations of Anxiety in Youth with Autism Spectrum Disorder

We assessed anxiety consistent (i.e., “traditional”) and inconsistent (i.e., “atypical”) with diagnostic and statistical manual (DSM) definitions in autism spectrum disorder (ASD). Differential relationships between traditional anxiety, atypical anxiety, child characteristics, anxiety predictors and ASD-symptomology were explored. Fifty-nine participants (7–17 years, M_age = 10.48 years; IQ > 60) with ASD and parents completed semi-structured interviews, self- and parent-reports. Seventeen percent of youth presented with traditional anxiety, 15 % with atypical anxiety, and 31 % with both. Language ability, anxious cognitions and hypersensitivity predicted traditional anxiety, whereas traditional anxiety and ASD symptoms predicted atypical anxiety. Findings suggest youth with ASD express anxiety in ways similar and dissimilar to DSM definitions. Similarities support the presence of comorbid anxiety disorders in ASD. Whether dissimilarities are unique to ASD requires further examination.     

Pilot study of community-based cognitive behavioral group therapy for adolescents with social phobia

OBJECTIVE: A pilot study to evaluate the efficacy of a cognitive-behavioral group therapy program for adolescents with social phobia, simplified both in terms of time and labor intensity from a previously studied program (Social Effectiveness Therapy for Children and Adolescents) to be more appropriate for a community outpatient psychiatric setting. METHOD: Twelve adolescents with social phobia (ages 13-18), diagnosed by DSM-IV criteria and confirmed with Anxiety Disorders Interview Schedule for Children assessment, were randomly assigned to treatment (n=6) and waitlist (n=6) groups. The waitlist group was subsequently treated, and results were included in the data analysis. Assessments, including Anxiety Disorders Interview Schedule for Children interviews and self-report Social Phobia and Anxiety Inventory and Beck Depression Inventory II questionnaires, were performed at baseline and immediately after treatment or waitlist. RESULTS: All subjects completed the treatment program. Compared with the waitlist group, treated subjects showed significantly greater improvement in both examiner-evaluated (Anxiety Disorders Interview Schedule for Children) and self-reported (Social Phobia and Anxiety Inventory) symptoms of social anxiety (effect sizes [d], 1.63 and 0.85, respectively). No significant change was seen in Beck Depression Inventory II scores for treatment or waitlist groups. CONCLUSIONS: This study provides support for the use of simplified cognitive-behavioral interventions for adolescents with social phobia that are practical for community psychiatric settings.     

School-based behavioral treatment for social anxiety disorder in adolescents: results of a pilot study.

OBJECTIVE: To provide preliminary estimates of feasibility and effectiveness for school-based behavioral treatment in adolescents with social anxiety disorder. METHOD: Six adolescents with social anxiety disorder were treated in a 14-session group treatment program conducted at their school. Assessments were conducted at baseline and after treatment. RESULTS: All participants were classified as treatment responders (markedly or moderately improved). Half of the participants did not meet diagnostic criteria for social phobia after treatment. Clinician severity ratings, as measured by the Anxiety Disorders Interview Schedule for Children for DSM-IV: Child Version and the Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA), decreased significantly after intervention, with effect sizes of 2.5 and 1.8, respectively. All LSAS-CA scale scores decreased significantly after treatment. Self-reported social phobia symptoms on the Social Phobia and Anxiety Inventory for Children were not significantly reduced. Fear and avoidance ratings of the 10 most feared situations significantly decreased after treatment, with effect sizes of 1.5 for anxiety and 2.1 for avoidance. CONCLUSIONS: This study provides preliminary support for the promise of school-based behavioral intervention for treating social phobia in adolescents. The school environment may be a rich and innovative setting for implementation of behavioral treatment because this is the setting where adolescents with social phobia endure the most distress.     

Anxiety in children and adolescents with Autism Spectrum Disorders

Anxiety symptoms and disorders are highly prevalent in children and adolescents with Autism Spectrum Disorder (ASD), although they are often unrecognized or misdiagnosed. The purpose of the present review is to (1) provide clinicians with practical information on assessment and diagnosis of co-morbid anxiety in children and adolescents with ASD, (2) summarize and critically examine the literature on anxiety in children and adolescents with ASD, and (3) recommend avenues for future research in this area. A review of the literature yielded several recommendations for the assessment of anxiety in youth with ASD. It was concluded that comprehensive assessments of anxiety in ASD populations should use multiple informants, multimodal assessment techniques, and standardized assessment methods that are appropriate for clinical use in ASD samples. Overall, studies suggest that youth with ASD experience greater levels of anxiety than community populations, similar levels of anxiety to clinically anxious groups, and different patterns of anxiety when compared to other clinical groups. Although existing studies are methodologically fair, their correspondence with clinical recommendations for assessment is poor. Recommendations to improve of the quality of empirical studies and directions for future research are discussed.