Autism Spectrum Disorder (ASD) is a neuro-developmental disorder that affects an individuals’ social, communication and behavioral functioning. The current Diagnostic and Statistical Manual of Mental Health Disorders-5th Edition-Text Revision (DSM-5) outlines the current classification system for diagnosing and individualizing a patient’s needs and symptoms on the spectrum (American Psychiatric Association [APA], 2013). The diagnosis of autism is characterized by identifying significant deficits in the areas of: social interactions, communication, restricted and repetitive behaviors. The most recent report from the Centers for Disease Control and Prevention, estimates that now 1 in 68 children (or 14.7 per 1,000 8 year olds) will be identified with ASD and the rate is predicted to steadily increase in the future (CDC, 2014). The increasing number of ASD cases yearly, calls for greater action and improved understanding of the diagnosis and treatment of autism spectrum disorder.
This blog post will provide a review of the current cognitive behavioral therapy (CBT) research on evidence based practices in the treatment of children and adolescents with ASD with co-morbid anxiety. “Children with autism experience a higher rate of co-morbid mental health problems, including anxiety, depression, attention-deficit hyperactivity disorder (ADHD) and disruptive behavior disorders than children with other communication disorders, children with intellectual disability and typically developing children” (Lickel, MacLean Jr., Blakely-Smith & Hepburn, p. 992, 2012). The central focus will be on providing a comparative review of the relevant empirically supported research for these three common CBT approaches with children under the ages of 18 with ASD and anxiety: Cognitive Behavior Therapy, Exposure Therapy and Acceptance and Commitment Therapy.
Cognitive Behavioral Therapy: Current Research in Treatment of Children and Adolescents with Autism Spectrum Disorders with Co-morbid Anxiety
As rates of autism increase, the use of cognitive behavioral therapy for this population has propelled increased research efforts and empirical attention. Many approaches to treating children with autism focus more on the behavioral procedures given some children with autism may present with lower cognitive functioning. “Although CBT typically includes a variety of treatment components, the cognitive skills emphasized during participation in the range of cognitive behavioral procedures include emotion recognition, self-reflection and metacognition (i.e., thinking about thinking), perspective taking, verbal ability, short-and long-term memory, and causal reasoning” (Lickel, et. al., p. 992-993, 2012). To arrive at a diagnosis of autism, children typically present with deficits and challenges in many of these cognitive functioning areas. Emotional identification, emotion recognition and discrimination of feelings can be more difficult for children on the autism spectrum. These skills are core components of CBT and therefore affective skill building may be necessary for this population prior to engaging in CBT interventions. When taking cognitive and verbal abilities into account while making individualized accommodations for skill functioning, children with autism can benefit from cognitive behavioral therapy (Lickel, et. al, 2012). Another central component of CBT is the ability to identify how our thoughts can be related to our feelings and behaviors. When compared to typically developing peers, most children with average cognitive abilities and ASD were able to differentiate and make connections between feelings and their behaviors (Lickel, et. al., 2012). Tailoring and individualizing treatment interventions is important as children with ASD are all unique in their developmental needs.
Children with autism spectrum disorders often present to therapy with comorbid anxiety (Lickel, et. al, 2012). Anxiety is estimated to occur between 42-85% of individuals with ASD (Selles & Storck, 2013). This additional presentation of anxiety may exacerbate and intensify social and behavioral impairments resulting from their ASD diagnosis. Concurrently, as children get older with higher functioning ASD, they may become more distressed and anxious due to the ability to recognize their social deficits when comparing themselves to their typical peers. They may desire to be more social but struggle with successful peer interactions. This may impact their self-esteem and increase anxiety in certain settings and relationships (Selles & Stork, 2013). While much research still needs to be conducted on evidence based treatments of ASD and comorbid anxiety, CBT outshines other approaches for its efficacy, low risk from implementation and long-term maintenance capabilities.
The clinician working with this populations should make additional considerations due to the multiple needs of children with ASD. Characteristics of children with autism can include a literal communicative style, therefore the therapist should tell it like it is in sessions. They can use language the child can relate to, or allow the child to give their input on what to call strategies and tools in sessions (Reaven & Hepburn, 2003). The high functioning autistic child can be very verbal but lack social communication and pragmatic skills. Using language based interventions such as social stories, comic strips and visuals can aid in facilitating cognitive understandings of the emotional and behavioral connections. The child with autism often values their autonomy, therefore the therapist should involve the child in decisions and collaborative planning throughout the sessions (Reaven & Hepburn, 2003). Another characteristic of autism is the individual may have a general lack of social understanding. The therapist can use more direct 1:1 training in the areas of social skills to improve the CBT intervention process. Finally, using the child’s preferences and interests to help motivate and engage them in treatment is essential. Being flexible and often checking in with the child to keep therapy novel and reinforcing will be an important strategy to incorporate in treatment activities.
Although more studies should continue, cognitive behavior therapy for high functioning children with autism, with an IQ over 70, can be effective in treating co-morbid anxiety. In a meta-analysis of several studies using CBT interventions to treat anxiety in children with autism, the research demonstrated that across interventions, flexibility was needed to address and accommodate individual needs (Ho & Stephenson, 2014). Although various co-morbidities can occur with ASD, anxiety is the most often researched mental health disorder regarding CBT and ASD. Adaptations for various components of CBT were needed. For example, one program targeted cognitive restructuring components, but called them thinking tools (Ho & Stephenson, 2014). Many of the behavioral intervention components for children with ASD receiving behavior therapy include practice of skills, homework, visual supports, relaxation training and emotion training. “On the other hand, some often-discussed CBA components such as cognitive restructuring, self-instruction, and problem solving were not commonly documented/reviewed in the studies” (Ho & Stephenson, p. 27, 2014). Some of the CBT intervention programs studied in this meta-analysis were: Coping Cat, Cool Kids, Social Skills Training and Facing your Fears. Group CBT has been shown to be an empirically sound intervention as well (McGillivray & Evert, 2014). Using a quasi-experimental design, a CBT group intervention program was implemented with 54 young adults with aspergers and 56% of the sample reported experiencing anxiety while 50% reported having recurrent depressive episodes (McGillivray & Evert, 2014). The participants in this study underwent 9 sessions using a ‘think well, feel well and be well’ group intervention and upon completion of the program, they reported improved psychological functioning with a reduction in negative thinking (McGillivray & Evert, 2014). The research demonstrates that these programs can be effective but proper individualization is needed and more research is needed on the cognitive considerations when using CBT with children with autism and comorbid anxiety.
Exposure Therapy for Children with Autism and Co-morbid Anxiety
Exposure therapy is a form of cognitive behavioral therapy that includes a step by step process to gradually expose an individual to anxiety provoking stimuli with the goal to improve distress tolerance skills over time. Children with autism spectrum disorders and comorbid anxiety may benefit from exposure based therapy when presenting with extreme fear and anxious responses. If their fears are limiting their overall functioning then exposure therapy can help improve their ability to access learning, interventions and healthy social interactions with others. Exposure therapy includes gradual exposure via a hierarchy of stimuli and response prevention by blocking previous maladaptive behaviors (Lehmkuhl, Storch, Bodfish & Geffken, 2008). When presented with anxiety provoking stimuli, the patients are prevented from completing their typical fear based response whether that be avoidance or compulsions (Selles & Storch, 2013). “Exposure to anxiety provoking stimuli without the maladaptive response results in habituation or reductions in anxiety” (Selles & Storch, p. 408, 2013). In the case of applying CBT exposure based techniques with children, parent involvement is important to improve treatment success (Reaven & Hepburn, 2003). As well, an area of concern when teaching new skills to children with autism is the difficulties in generalizing learned skills across multiple people and settings. The combination of including parents in sessions can also aid in improving generalization skills (Reaven & Hepburn, 2003).
Children with autism spectrum disorders can develop specific fears associated with a variety of activities and settings e.g.: medical visits, school refusals, food refusal and fears associated with aversive sensory stimuli. Rigidity and inflexibility are core features of autism spectrum disorders and can compound the effects of anxiety and specific fears on overall functioning (Koegel, Bharoocha, Ribnick, Ryan & Bucio, 2012). Certain accommodations can be made to improve the effectiveness of exposure therapy and individuals with ASD. Stimulus fading, slow progressions along the exposure heirarchy and reinforcements can improve exposure based techniques (Koegel, et. al., 2012). Again, individualizing the treatment to meet the developmental, communication and cognitive needs of the child with autism is important. Using visuals such as a behavior monitoring chart or visuals of the hierarchy chart can be a helpful accommodation. Mapping, using drawings or other representations to increase cognitive and social awareness about the fear or compulsive response is recommended (Reaven & Hepburn, 2003). The therapist can establish a hierarchy with the child in session, arranging stimuli from least to most distressing. At the same time, introducing a visual fear and worry thermometer to help the child conceptualize the cognitive and affective components of CBT. Allowing the child to give their input, ideas and interests into treatment is a helpful strategy to increase engagement and motivation with the autistic child (Reaven & Hepburn, 2003). As well, collaborating with the parents and child, a list of tools can be developed to help the child ‘beat’ the symptoms of anxiety and fear (Reaven & Hepburn, 2003). Visual strategies, social narratives, comic strips, social stories, taking a break, distraction, reward charts and relaxation strategies are individualized strategies the CBT therapist can utilize to improve exposure therapy interventions with ASD clients.
Acceptance and Commitment Therapy for Children with Autism and Comorbid Anxiety
Acceptance and Commitment Therapy (ACT) is a cognitive behavioral therapy intervention based on principles of behavioral science. It is often used to teach mindfulness and acceptance skills while focusing on behavior change as a catalyst for coping with unwanted thoughts and feelings associated with anxiety. While most of the interventions for children with autism involve the behavioral components of skill acquisition and behavior reduction programs, acceptance and commitment therapies look to improve emotional functioning and psychological flexibility (Dixon, 2014). What ACT attempts to do through mindfulness and acceptance interventions is to teach the child with autism to understand their disability. ACT can help a child become more psychologically flexible through teaching awareness in the moment, not becoming tied to their thoughts, accepting difficult and frustrating situations and finding their values to help them make healthier behavioral choices (Dixon, 2014). There are six interconnected components that make up the foundational pieces of ACT: present moment awareness, values, committed action, self-as-context, defusion and acceptance (Dixon, 2014).
Parents of children with disabilities experience a great deal of additional stress when compared to parents of typical developing children. Using acceptance and commitment therapy with parents can help alleviate parental distress as demonstrated by current research (Jones, Hastings, Totiska, Keane & Rhule, 2014). A research study evaluated the effectiveness of 71 mothers and 39 fathers of children with autism and utilized self-report measures such as the Five Facet Mindfulness Questionnaire (FFMQ) and child measures to identify their own positive and negative psychological well-being (Jones, et. al, 2014). “Psychological acceptance was found to act as a mediator variable for maternal anxiety, depression, and stress, and for paternal depression” (Jones, et. al, p. 171, 2014). Utilizing acceptance and mindfulness strategies was shown to be an effective intervention to navigate child behavior problems and improve parental well-being.
Cognitive Behavior Therapy is the most commonly researched and implemented intervention for those experiencing psychological distress. Cognitive models initially proposed by Ellis and Beck focus on identifying negative thinking, awareness of automatic thoughts and cognitive restructuring. Children and adolescents with autism spectrum disorders experience a high rate of co-morbid anxiety in addition to their social, communication and behavioral deficits. Additional considerations should be to evaluate whether the core symptoms of ASD are causing increased anxiety or is the anxiety a separate condition? Cognitive behavior therapy, both individualized and in group settings, has shown to be beneficial for addressing the psychological needs of children and parents living with ASD. Since all children with autism present with their own set of unique strengths and challenges, careful consideration should be given to individualize treatment programs. The therapist is encouraged to make certain individualized accommodations to interventions to assist the child in engaging and being successful with therapy. Parental involvement is critical for the overall success of therapy programs including parent support for their own psychological distress, modeling of therapy programs at home and working towards generalization of learned replacement skills in multiple settings. Exposure therapy can be highly effective for phobias and irrational fear responses that children may adopt due to their rigid and un-flexible nature and the overstimulation they may receive from environmental stimuli. Acceptance and commitment therapy is showing to be a promising intervention for children with ASD and parents living with children who have ASD. However, given this is an emerging evidence based treatment, much more research needs to be conducted with the child population experiencing co-morbid anxiety with ASD. As the rates of autism diagnosis and identification steadily increase, I identified that more research needs to be conducted in the areas of mindfulness and acceptance therapy interventions. Eventually, children with ASD will grow up and need to be independent and working adults. Giving them the skills now through evidence based interventions and empirically sound practices towards accepting their strengths and limitations while teaching them the tools towards psychological well-being is critical.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Health Disorders (5th ed.). Arlington, VA: American Psychiatry Publishing, Inc.
Centers on Disease Control and Prevention. (2010). Prevalence of autism spectrum disorder among children aged 8 years- Utism and developmental disabilities monitoring network, 11 sites, United States, 2010. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6302.pdf (February 21, 2017).
Dixon, M. (2014). Acceptance and Commitment Therapy for Children with Autism and Emotional Challenges. Carbondale, IL: Shawnee Scientific Press, LLC.
Ho, B., & Stephenson, J. (2014). Cognitive-behavioral approach for children with autism spectrum disorders: a meta-analysis. Journal of Autism and Developmental Disorders, 1, 18-33.
Jones, L., Hastings, R., Totiska, V. Keane, L. & Rhule, N. (2014). Child behavior problems and parental well-being in families of children with autism: the mediating role of mindfulness and acceptance. American Journal on Intellectual and Developmental Disabilities, 119, (2), 171-185.
Koegel, R., Bharoocha, A., Ribnick, C., Ribnick, R., Bucio, M., Fredeen, R. & Koegel, L. (2012). Using individualized reinforcers and hierarchical exposure to increase food flexibility in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 1574-1581.
Lehmkuhl, H., Storch, E., Bodfish, J. & Geffken, G. (2008). Brief report: exposure and response prevention for obsessive compulsive disorder in a 12-year-old with autism. Journal of Autism and Developmental Disorders, 977-981.
Lickel, A., MacLean Jr., W., Blakely-Smith, A. & Hepburn, S. (2012). Assessment of the prerequisite skills for cognitive behavioral therapy in children with and without autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 992-1000.
McGillivray, J.A., Evert, H.T. (2014). Group cognitive behavioural therapy program shows potention in reducing symptoms of depression and stress among young people with ASD. Journal of Autism and Developmental Disorders,44, 2041-2051.
Pahnke, J., Lundgren, T., Hursti, T., Hirvikoski, T. (2014). Outcomes of an acceptance and commitment therapy-cased skills training group for students with high-functioning autism spectrum disorder: A quasi-experimental pilot study. Sage Journals, 18, (8), 851-871.
Reaven, J., & Hepburn, S. (2003). Cognitive-behavioral treatment of obsessive-compulsive disorder in a child with Asperger syndrome. The National Autistic Society, 7, 145-164.
Selles, R., Storch, E. (2013). Translation of anxiety treatment to youth with autism spectrum disorders. Journal of Child and Family Studies, 22, 405-413.