Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial

Background: Children with autism spectrum disorders often present with comorbid anxiety disordersthat cause signiﬁcant functional impairment. This study tested a modular cognitive behavioral therapy(CBT) program for children with this proﬁle. A standard CBT program was augmented with multipletreatment components designed to accommodate or remediate the social and adaptive skill deﬁcits ofchildren with ASD that could pose barriers to anxiety reduction. Method: Forty children (7–11 yearsold) were randomly assigned to 16 sessions of CBT or a 3-month waitlist (36 completed treatment orwaitlist). Therapists worked with individual families. The CBT model emphasized behavioral experi-mentation, parent-training, and school consultation. Independent evaluators blind to treatment con-dition conducted structured diagnostic interviews and parents and children completed anxietysymptom checklists at baseline and posttreatment/postwaitlist. Results: In intent-to-treat analyses,78.5% of the CBT group met Clinical Global Impressions-Improvement scale criteria for positivetreatment response at posttreatment, as compared to only 8.7% of the waitlist group. CBT also out-performed the waitlist on diagnostic outcomes and parent reports of child anxiety, but not children’sself-reports. Treatment gains were maintained at 3-month follow-up. Conclusions: The CBT manualemployed in this study is one of the ﬁrst adaptations of an evidence-based treatment for children withautism spectrum disorders. Remission of anxiety disorders appears to be an achievable goal amonghigh-functioning children with autism. Keywords: Cognitive behavioral therapy, autism spectrumdisorders, anxiety disorders, parent-training.Anxiety disorders are common among children withautism spectrum disorders (ASD) and are associatedwith heightened impairment in social functioning(Bellini, 2004; de Bruin, Ferdinand, Meester, de Nijs,& Verheij, 2007), leading investigators to call fortreatments that address anxiety-related symptomsin ASD (e.g., Sofronoff, Attwood, & Hinton, 2005;Volkmar & Klin, 2000). Although probably efﬁca-cious intervention programs have been developed fortypically developing youth with anxiety disorders(e.g., Barrett, Dadds, & Rapee, 1996), the linguistic,cognitive, and social characteristics of ASD (e.g.,Baker, Koegel, & Koegel, 1998) may render standardtreatment approaches less effective for children withASD. This study is a randomized, controlled trialtesting a modiﬁed cognitive behavior therapy (CBT)protocol for children with ASD and comorbid anxietydisorders.Autism, Asperger syndrome, and pervasivedevelopmental disorder not otherwise speciﬁed(PDD-NOS) affect as many as 1 out of 150 children(Centers for Disease Control, 2007), and manyhigher-functioning children with ASD are not dia-gnosed until elementary school or later (Fombonne,2003). These disorders are typiﬁed by severe deﬁcitsin social communication and marked idiosyncraticbehavior. Signiﬁcant impairment in social andschool/occupational functioning is common. Evenwhen compared to other types of childhoodpsychopathology, ASD is particularly severe andlongstanding (Howlin, Goode, Hutton, & Rutter,2004).Comorbid psychological disorders are common inthe ASD population, with anxiety disorders affecting30–80% of the sampled children in multiple studies(deBruinetal.,2007;Klin,Pauls,Schultz,VMuris,Steerneman,Merckelbach,Holdrinet,M Klin et al., 2005; Muris et al.,1998).Diagnosing anxiety disorders among childrenwith ASD may be complicated by children’s com-munication impairments and emotion recognitiondeﬁcits (Leyfer et al., 2006). Furthermore, certainsymptoms of anxiety disorders may appear similar