Effects of Cognitive Behavioral Therapy on Daily Living Skills in Children with High-Functioning Autism and Concurrent Anxiety Disorders

CBT is a promising treatment for children with autism spectrum disorders (ASD) and focuses, in part, on children’s independence and self-help skills. In a trial of CBT for anxiety in ASD (Wood et al. in J Child Psychol Psychiatry 50:224–234, 2009), children’s daily living skills and related parental intrusiveness were assessed. Forty children with ASD (7–11 years) and their primary caregiver were randomly assigned to an immediate treatment (IT; n = 17) or 3-month waitlist (WL; n = 23) condition. In comparison to WL, IT parents reported increases in children’s total and personal daily living skills, and reduced involvement in their children’s private daily routines. Reductions correlated with reduced anxiety severity. These results provide preliminary evidence that CBT may yield increased independence and daily living skills among children with ASD.     

Assessment of the Prerequisite Skills for Cognitive Behavioral Therapy in Children with and Without Autism Spectrum Disorders

The purpose of this study was to assess the cognitive skills of children with autism spectrum disorders (ASD) thought to be necessary for Cognitive Behavioral Therapy (CBT). Forty children with ASD and forty age-matched typically developing children between the ages of 7-12 years participated. Groups were comparable with regard to nonverbal IQ, but children with ASD had significantly lower verbal IQ. Children completed three CBT-related tasks requiring emotion recognition, discrimination among thoughts, feelings and behaviors, and cognitive mediation. With the exception of the emotion recognition task, children with ASD performed comparably to typically developing children and with a high rate of accuracy.     

Cognitive Behavioural Therapy for Anxiety Disorders in Children and Adolescents: A Meta-Analysis

We conducted a meta-analysis using 20 randomised controlled studies of cognitive behavioural therapy (CBT) for anxiety disorders in children and adolescents. The mean pre-post effect size was d  = 0.94, which was maintained at follow-up. The mean effect size when comparing the CBT and control group was d  = 0.61. Within the CBT group, the mean effect size of university clinics ( d  = 0.77) was larger than that of other clinics ( d  = 0.37). The difference in effect sizes was hardly noticeable when comparing CBT with family or parents and CBT with child only ( d  = 0.03). Further studies are required to examine the effectiveness of family CBT versus child CBT.     

Autism Spectrum Traits in Children with Anxiety Disorders

The aim of this study was to examine ASD traits in children with clinical anxiety in early development, as well as current manifestations. Parents of 42 children with an anxiety disorder (but no known diagnosis of ASD) and 42 typically developing children were interviewed using the Autism Diagnostic Interview (ADI-R). They also completed questionnaires that assessed child anxiety (SCARED-71) and children’s ASD symptoms. Results revealed that children with anxiety disorders had higher scores than typically developing children, for both ASD traits in early development as well as current ASD symptoms. A specific association was found between symptoms of Social Anxiety Disorder and ASD traits early in life. Findings are considered in terms of clinical implications, and limitations are discussed.     

Cognitive Behavioral Therapy for Childhood Anxiety Disorders: a Review of Recent Advances

Purpose of Review

We review recent research validating cognitive behavioral therapy (CBT) as a first-line intervention for childhood anxiety disorders. We also review recent research aimed at enhancing exposure-based CBT components and adapting CBT to work with specific populations.

Recent Findings

Exposure-based CBT is a well-established intervention. Different research groups have found positive evidence to augment CBT by evaluating inhibitory learning principles, the role of parents in child treatment, an individualized case formulation, computer and online forms of CBT, and virtual and augmented reality systems for exposure practice. Specific programs have been developed to meet specific needs of preschoolers, adolescents, and children with comorbid autism spectrum disorder and anxiety.

Summary

Successful adaptations to CBT exist and the field should continue to improve the generalizability, feasibility, and expected benefit of CBT to improve its effectiveness.

     

Overview of Meta-Analyses on Early Intensive Behavioral Intervention for Young Children with Autism Spectrum Disorders

This paper presents an overview of 5 meta-analyses of early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASDs) published in 2009 and 2010. There were many differences between meta-analyses, leading to different estimates of effect and overall conclusions. The weighted mean effect sizes across meta-analyses for IQ and adaptive behavior ranged from g = .38–1.19 and g = .30–1.09, respectively. Four of five meta-analyses concluded EIBI was an effective intervention strategy for many children with ASDs. A discussion highlighting potential confounds and limitations of the meta-analyses leading to these discrepancies and conclusions about the efficacy of EIBI as an intervention for young children with ASDs are provided.     

Parental Involvement in Cognitive Behavior Therapy for Children with Anxiety Disorders: 3-Year Follow-Up

Parental factors have been linked to childhood anxiety, hence, parental involvement in cognitive behavioral therapy (CBT) for anxious children has been examined. However, findings do not consistently show added effects of parent-enhanced CBT, longitudinal investigations are scarce and long-term effects unclear. In the present study, 40 out of 54 families who, 3 years previously, completed one of two types of CBT treatment: with limited or active parental involvement, were assessed using semi-structured diagnostic interviews. Diagnostic status at 3-years follow-up was compared between groups. Changes in diagnostic status across assessment points: posttreatment, 6-month and 3-year follow-up were analyzed within groups. Diagnostic change from 6-month to 3-year follow-up was compared between groups. Intent-to-treat analyses revealed no significant difference in diagnostic status between groups at 3-year follow-up. Nonetheless, children whose parents actively participated in treatment showed significantly more remission from 6-month to 3-year follow-up than children with limited parental participation.     

Effects of Cognitive-Behavioral Therapy on Anxiety in Children with Autism Spectrum Disorders: A Randomized Controlled Trial

We compared the effects of a 16-week Cognitive-Behavioral Therapy (CBT) program and a Social Recreational (SR) program on anxiety in children with Autism Spectrum Disorders (ASD). Seventy children (9–16 years old) were randomly assigned to either of the programs (n _CBT = 36; n _SR = 34). Measures on child’s anxiety using the Spence Child Anxiety Scale—Child (SCAS-C) and the Clinical Global Impression—Severity scale (CGI-S) were administered at pre-, post-treatment, and follow-ups (3- and 6-month). Children in both programs showed significantly lower levels of generalized anxiety and total anxiety symptoms at 6-month follow-up on SCAS-C. Clinician ratings on the CGI-S demonstrated an increase in the percentage of participants rated as “Normal” and “Borderline” for both programs. Findings from the present study suggest factors such as regular sessions in a structured setting, consistent therapists, social exposure and the use of autism-friendly strategies are important components of an effective framework in the management of anxiety in children and adolescents with ASD.     

Brief Report: Effects of Cognitive Behavioral Therapy on Parent-Reported Autism Symptoms in School-Age Children with High-Functioning Autism

This pilot study tested the effect of cognitive behavioral therapy (CBT) on parent-reported autism symptoms. Nineteen children with autism spectrum disorders and an anxiety disorder (7–11 years old) were randomly assigned to 16 sessions of CBT or a waitlist condition. The CBT program emphasized in vivo exposure supported by parent training and school consultation to promote social communication and emotion regulation skills. Parents completed a standardized autism symptom checklist at baseline and posttreatment/postwaitlist and 3-month follow-up assessments. CBT outperformed the waitlist condition at posttreatment/postwaitlist on total parent-reported autism symptoms (Cohen’s d effect size = .77). Treatment gains were maintained at 3-month follow-up. Further investigation of this intervention modality with larger samples and broader outcome measures appears to be indicated.     

Treating Anxiety Disorders in Children with High Functioning Autism Spectrum Disorders: A Controlled Trial

A family-based, cognitive behavioural treatment for anxiety in 47 children with comorbid anxiety disorders and High Functioning Autism Spectrum Disorder (HFA) was evaluated. Treatment involved 12 weekly group sessions and was compared with a waiting list condition. Changes between pre- and post-treatment were examined using clinical interviews as well as child-, parent- and teacher-report measures. Following treatment, 71.4% of the treated participants no longer fulfilled diagnostic criteria for an anxiety disorder. Comparisons between the two conditions indicated significant reductions in anxiety symptoms as measured by self-report, parent report and teacher report. Discussion focuses on the implications for the use of cognitive behaviour therapy with HFA children, for theory of mind research and for further research on the treatment components.     

Group-based Cognitive Behavioural Therapy for Anxiety Disorder in Children with Autism Spectrum Disorder: a feasibility study

Abstract

Purpose: Autism spectrum disorder (ASD) includes core symptoms that affect general and social development. High risk of developing comorbid disorders such as anxiety is prominent. Up to 60% of children with ASD suffer from anxiety disorders which can negatively influence educational, social and general development together with quality of life. This study is the first to investigate the feasibility of the manualised cognitive behavioural therapy (CBT) group programme 'Cool Kids ASD' for anxiety adapted for children with ASD in a general hospital setting.

Methods: Nine children, aged 9–13 years, with ASD and anxiety recruited from a public child psychiatric health clinic were enrolled in the study. Outcome measures were collected from both child and parent pre- and post-treatment and at 3-month follow-up and included scores from a semi-structured anxiety interview, together with questionnaires on anxiety symptoms, life interference, children's automatic thoughts and satisfaction with the programme.

Results: Eight out of nine families found the programme useful and would recommend it to other families in a similar situation. Six families attended all 12 sessions in the programme, two missed one session and one family only managed to attend eight sessions. At follow-up, five children were free of all anxiety diagnoses and a further two out of the nine children no longer met the criteria for their primary anxiety diagnosis.

Conclusions: This study suggests that the transition of the group programme 'Cool Kids ASD' from University Clinics to standard child psychiatric clinical settings is feasible. Further randomised studies are needed to confirm the efficacy of the programme in a larger sample.     

Cognitive Behavioral Therapy for Anxiety Disorders: Outcomes From a Multi-State,Multi-Site Primary Care Practice

BackgroundAnxiety disorders are among the most common mental health conditions. Individuals with anxiety typically seek services in primary, rather than specialty, care. While there is significant evidence supporting the efficacy and effectiveness of cognitive behavioral therapy (CBT) for anxiety disorders, there have been no naturalistic studies reporting anxiety-specific treatment outcomes in primary care.MethodsParticipants (N = 1,589) were recruited from a multi-state, multi-site primary care practice, with 491 participants endorsing moderate to severe anxiety at baseline and engaging in at least one CBT session. Data was drawn from a psychotherapy tracking database.ResultsAmong participants with moderate to severe anxiety who engaged in CBT, a significant decrease in anxiety and depression symptoms was observed over the course of psychotherapy (p < .001, d = 0.57-0.95). Rates of reliable change, response, and remission varied across diagnostic categories. The use of CBT interventions also varied across diagnoses in line with evidence-based treatment recommendations.DiscussionShort-term CBT delivered in primary care is associated with significant improvements in anxiety and depression symptoms among participants with anxiety disorders. These findings support the use of a population-based approach to anxiety disorders treatment and suggest that evidence-based CBT can be implemented in the real-world setting.     

Concurrent Validity of Social Subtype and IQ after Early Intensive Behavioral Intervention in Children with Autism: A Preliminary Investigation

Three subtypes of autism based on social style have been proposed by Wing: active-but-odd, passive, or aloof. Previous research has shown evidence of an association between IQ and Wing subtype in untreated children and adults. Because IQ changes can accompany behavioral treatment, but often only for a subset of children, social subtype may be related to treatment responsiveness. We administered a social subtyping measure, the Wing Subgroups Questionnaire (WSQ), at various points in treatment to younger children than previously studied with autism in early, intensive behavioral intervention (EIBI). Thirty-seven children in EIBI (aged 39–71 months, amount of EIBI 0–44 months) were assessed to determine whether Wing’s three proposed subtypes were found in this sample and whether subtypes were associated with current IQ and change in IQ after a period of EIBI. Results confirmed that all three subtypes were present and correlated with IQ after a period of intervention, as well as with change in IQ. Participants classified as aloof had significantly lower IQ scores and changes in IQ after EIBI than other children. Future studies should extend these findings by examining whether social subtype at pretreatment predicts EIBI outcome.     

Exploring the Manifestations of Anxiety in Children with Autism Spectrum Disorders

This study explores the manifestation and measurement of anxiety symptoms in 415 children with ASDs on a 20-item, parent-rated, DSM-IV referenced anxiety scale. In both high and low-functioning children (IQ above vs. below 70), commonly endorsed items assessed restlessness, tension and sleep difficulties. Items requiring verbal expression of worry by the child were rarely endorsed. Higher anxiety was associated with functional language, IQ above 70 and higher scores on several other behavioral measures. Four underlying factors emerged: Generalized Anxiety, Separation Anxiety, Social Anxiety and Over-arousal. Our findings extend our understanding of anxiety across IQ in ASD and provide guidance for improving anxiety outcome measurement.     

A Preliminary Exploration of the Barriers to Delivering (and Receiving) Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings

Despite the effectiveness of exposure-based cognitive behavioral therapy (CBT) for anxiety disorders, few individuals in need receive this treatment, particularly in community mental health settings serving low-income adults. The present study took a preliminary step to understand these barriers by conducting a series of key informant interviews and focus groups among patients, providers, clinical administrators, and policy makers. Several themes emerged as barriers to the delivery of exposure-based CBT in these settings, including therapist training and compentency issues, logistical issues, and funding stream issues. Clinical implications and future research that can build from these data are discussed.