How effective is CBT for anxiety disorders in youth with Autism?
Is CBT for anxiety in youth less effective for youth with autism? If so, how much less so? Cervin and colleagues (2023) pooled data across 5 RCTs in which youth with autism were randomly assigned to either CBT and a control condition (either a wait list [k = 1] or treatment as usual [TAU, k =4]) (N=280 in total, age M = 10.4yo; 21% female). Autism diagnoses were established or confirmed by an independent evaluator using either the ADOS (Autism Diagnostic Observation Schedule) or Childhood Autism Rating Scale. Inclusion criteria for all trials were an IQ > 70 and ability to communicate verbally. Four RCTs used the Behavioural Interventions for Anxiety in Children with Autism (BIACA) protocol involving 16 x weekly 60-90 min sessions; in one of these studies, youth with autism were randomly assigned to either BIACA, Coping Cat or TAU. In one RCT, a family-based protocol emphasizing exposure was used. Results were compared with a sample of youth without autism from another RCT (n=129). Outcomes were measured on the Pediatric Anxiety Rating Scale (PARS).
So how did youth with autism respond to CBT for anxiety? They reported significantly greater decreases than those in control conditions in: frequency and duration of worry and anxiety symptoms, intensity of anxiety, avoidance (home, school, friends, activities), interference with family life, and interference with school performance, everyday interactions and extracurricular activities. The only domain not to evidence significant reductions in response to CBT was frequency, intensity and duration of physical symptoms of anxiety such as stomach aches, dizziness, restlessness and breathing difficulties.
The authors then explored whether severity of Autism traits as measured by scores on the Social Responsiveness Scale (SRS-2) (taken before CBT commenced) predicted response to CBT for anxiety. A smaller sample was available for this exploration (n=183). Higher SRS-2 scores predicted higher post-CBT severity of frequency and duration of worry and anxiety symptoms, interference with family life, and interference with school performance, everyday interactions and extracurricular activities. In contrast, sex did not predict outcome.
Finally, the authors compared the responsiveness of youth with and without autism to CBT for anxiety. Youth with autism had 2.4x more physical symptoms of anxiety and 2.22x more family interference post-CBT but otherwise were no different in their response to CBT for anxiety.
For youth with autism, the differences between receiving control conditions vs CBT were consistent with conventional medium to large effect sizes. The structured CBT programs were clearly better than business as usual. Means at baseline for most domains were in at least the moderate range and following CBT, they were in the mild range.
In addition to the most prevalent anxiety disorders for youth (specific phobias, separation anxiety disorder, social anxiety disorder and generalised anxiety disorder), youth with Autism are more prone than youth without Autism to experience fears and worries about sensory sensitivity, social confusion, circumscribed interests and minor changes in the environment. The main modifications incorporated into CBT for anxiety for youth with Autism include addressing social skill deficits, disruptive behaviours and using special interests to motivate interest in treatment as well as increased parental involvement. The authors speculate that future improvements to CBT for youth with autism with anxiety disorders might be achieved through targeting sensory processing difficulties and addressing a broader range of everyday functioning.
The BIACA Protocol
(Behavioural Interventions for Anxiety in Children with Autism)
BIACA is a modular manualised treatment consisting of 16 x weekly sessions lasting 90 minutes (45 minutes with the child and 45 minutes with the parents). The sequence of modules and number of sessions on each is individually-tailored to each client according to an algorithm (see MEYA below), although these can also be selected by the therapist session-by-session depending on the child’s greatest need (Wood et al., 2017; Wood et al., 2019). There are 4 anxiety coping skills modules. Anxiety is primarily treated through graded exposure. A fear hierarchy is developed which breaks the achievement of treatment goals into increasingly challenging behavioural tasks. Parents are also taught skills to help their child when they feel anxious (e.g., positive reinforcement, reflection emotions and extinction).
BIACA also includes modules specifically to address the needs and challenges of youth with autism. Children are taught skills needed to make and keep friends (playdate hosting, joining peers at play) across several social modules. Children are taught “social rules” to follow during playdate hosting (e.g., letting the friend choose the activity, giving compliments). Parents are taught tips for successful playdates (e.g., keeping them short, having children decide what to do beforehand) and sources of potential friends for their child (e.g., extracurricular activities, clubs). Parents and school staff are taught how to coach the child to play and converse with peers immediately before social activities to give the child the best chance of a successful interaction.
Stereotypies and special interests that interfere with children’s social success are addressed later in treatment via habit reversal training (substituting an incompatible response to triggers of the socially-impeding behaviour). Rationales are given to child clients through cartoons and role-plays that illustrate other children’s perspectives (e.g., these behaviours are fine in private but tend to confuse peers and get in the way of friendship).
Parents (weekly) and school personnel (in two 1-hour consultations across the program) are taught to support children entering or maintaining conversations or play. A peer “buddy” system is implemented during school consultations to enhance social inclusion, in which the child client can benefit from being both the mentor and the mentee. This component aims to increase social acceptance and perspective taking.
BIACA incorporates a charts and points system to reward children for their efforts in session and homework. Coping skills are usually taught first and to ensure an adequate “dose”, at least 8 sessions should focus on in vivo exposure. Adaptive skills deficits and behaviour problems are also addressed early in treatment. Modules addressing autism-related challenges can be interspersed throughout treatment.
The UCLA Modular Evidence-Based Practices for Youth with Autism Spectrum Disorder Project
Clinicians can access the content and treatment algorithm employed in BIACA via the MEYA website: https://meya.ucla.edu/public/
You need to register, but this gives you access to brief video-clip training modules, implementation checklists and client handouts.
Clinician implications
Over 4 RCTs, CBT adapted for children with Autism (with IQs > 70) has reduced worry and anxiety, avoidance, and interference in family, school and social functioning significantly more than treatment as usual.
Children with Autism (with IQs > 70) respond to CBT for anxiety disorders similarly well to children without autism with the exception of severity of physical symptoms and interference in family functioning.
The BIACA approach to CBT for anxiety in youth with Autism should be offered ahead of interventions that have not been evaluated with this population in randomised controlled trials. Clinicians can access free training and resources at: https://meya.ucla.edu/public/
For the original article, go to: https://www.sciencedirect.com/science/article/pii/S1750946723001216?via%3Dihub
REFERENCES
Cervin, M., Storch, E. A., Kendall, P. C., Herrington, J. D., Small, B. J., Wood, J. J., & Kerns, C. M. (2023). Effects of cognitive-behavioral therapy on core aspects of anxiety in anxious youth with autism. Research in Autism Spectrum Disorders, 107, 102221–. https://doi.org/10.1016/j.rasd.2023.102221
Wood, J.J., et al. (2019). Cognitive behavioral treatments for anxiety in children with autism spectrum disorder: A randomized clinical trial. JAMA Psychiatry, 77(5): 474-483. doi:10.1001/jamapsychiatry.2019.4160
Wood, J.J., Klebanoff, S., Renno, P., Fujii, C., & Danial, J. (2017). Individual CBT for anxiety and related symptoms in children with autism spectrum disorders. In C.M.Kerns, P.Renno, E.A.Storch, P.C.Kendall and J.J.Wood (Eds.). Anxiety in Children and Adolescents with Autism Spectrum Disorder. San Diego, CA: Elsevier Academic Press, pp. 123-141. doi:10.1016/B978-0-12-805122-1.00007-7