School Mental Health

, Volume 5, Issue 1, pp 25–37 | Cite as

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

  • Cori Fujii
  • Patricia Renno
  • Bryce D. McLeod
  • C. Enjey Lin
  • Kelly Decker
  • Kaycie Zielinski
  • Jeffrey J. Wood
Original Paper

Abstract

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.

Keywords

Autism spectrum disorders Anxiety disorders Comorbidity Cognitive behavioral therapy 

References

  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders-text revision (4th ed.). Washington, DC: Task Force.Google Scholar
  2. Ashburner, J., Ziviani, J., & Rodger, S. (2010). Surviving in the mainstream: Capacity of children with autism spectrum disorders to perform academically and regulate their emotions and behavior at school. Research in Autism Spectrum Disorders, 4(1), 18–27.CrossRefGoogle Scholar
  3. Brereton, A. V., Tonge, B. J., & Einfeld, S. L. (2006). Psychopathology in children and adolescents with autism compared to young people with intellectual disability. Journal of Autism and Developmental Disorders, 36(7), 863–870.PubMedCrossRefGoogle Scholar
  4. Centers for Disease Control and Prevention. (2007). Prevalence of autism spectrum disorders—autism and developmental disabilities monitoring network, 14 sites, United States, 2002. Morbidity and Mortality Weekly Report. Surveillance Summaries, 56, 12–28.Google Scholar
  5. Chalfant, A. M., Rapee, R., & Carroll, L. (2007). Treating anxiety disorders in children with high functioning autism spectrum disorders: A controlled trial. Journal of Autism and Developmental Disorders, 37, 1842–1857.PubMedCrossRefGoogle Scholar
  6. Chorpita, B. F., Taylor, A. A., Francis, S. E., Moffitt, C., & Austin, A. A. (2004). Efficacy of modular cognitive behavior therapy for childhood anxiety disorders. Behavior Therapy, 35(2), 263–287.CrossRefGoogle Scholar
  7. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., et al. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The early start Denver model. Pediatrics, 125(1), e17–e23.PubMedCrossRefGoogle Scholar
  8. Drahota, A., Wood, J. J., Sze, K. M., & Van Dyke, M. (2011). Effects of cognitive behavioral therapy on daily living skills in children with high-functioning autism and concurrent anxiety disorders. Journal of Autism and Developmental Disorders, 41(3), 257–265.PubMedCrossRefGoogle Scholar
  9. Estes, A., Rivera, V., Bryan, M., Cali, P., & Dawson, G. (2011). Discrepancies between academic achievement and intellectual ability in higher-functioning school-aged children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 41(8), 1044–1052.PubMedCrossRefGoogle Scholar
  10. Ferraioli, S. J., & Harris, S. L. (2011). Effective educational inclusion of students on the autism spectrum. Journal of Contemporary Psychotherapy, 41(1), 19–28.CrossRefGoogle Scholar
  11. Gadow, K. D., DeVincent, C., & Schneider, J. (2008). Predictors of psychiatric symptoms in children with an autism spectrum disorder. Journal of Autism and Developmental Disorders, 38(9), 1710–1720.PubMedCrossRefGoogle Scholar
  12. Harrower, J. K., & Dunlap, G. (2001). Including children with autism in general education classrooms: A review of effective strategies. Behavior Modification Special Issue: Autism Part 1, 25(5), 762–784.CrossRefGoogle Scholar
  13. Kasari, C., Locke, J., Gulsrud, A., & Rotheram-Fuller, E. (2011). Social networks and friendships at school: Comparing children with and without ASD. Journal of Autism and Developmental Disorders, 41(5), 533–544.PubMedCrossRefGoogle Scholar
  14. Kim, J. A., Szatmari, P., Bryson, S. E., Streiner, D. L., & Wilson, F. J. (2000). The prevalence of anxiety and mood problems among children with autism and Asperger syndrome. Autism, 4(2), 117–132.CrossRefGoogle Scholar
  15. Koegel, L. K., Koegel, R. L., Hurley, C., & Frea, W. D. (1992). Improving social skills and disruptive behavior in children with autism through self-management. Journal of Applied Behavior Analysis, 25(2), 341–353.PubMedCrossRefGoogle Scholar
  16. Koegel, R. L., Koegel, L. K., & McNerney, E. K. (2001). Pivotal areas in intervention for autism. Journal of Clinical Child Psychology, 30(1), 19–32.PubMedCrossRefGoogle Scholar
  17. Koegel, R. L., Koegel, L. K., Vernon, T. W., & Brookman-Frazee, L. I. (2010a). Empirically supported pivotal response treatment for children with autism spectrum disorders. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 327–344). New York, NY, US: Guilford Press.Google Scholar
  18. Koegel, L. K., Singh, A. K., & Koegel, R. L. (2010b). Improving motivation for academics in children with autism. Journal of Autism and Developmental Disorders, 40(9), 1057–1066.PubMedCrossRefGoogle Scholar
  19. Langley, A. K., Bergman, R. L., McCracken, J., & Piacentini, J. C. (2004). Impairment in childhood anxiety disorders: Preliminary examination of the child anxiety impact scale—parent version. Journal of Child and Adolescent Psychopharmacology, 14(1), 105–114.PubMedCrossRefGoogle Scholar
  20. Le Couteur, A., Lord, C., & Rutter, M. (2003). The autism diagnostic interview-revised. Los Angeles: Western Psychological Services.Google Scholar
  21. Lord, C., Rutter, M., DiLavore, P. C., & Risi, S. (2002). Autism diagnostic observation schedule. Los Angeles: Western Psychological Services.Google Scholar
  22. Lovaas, O. I., & Smith, T. (2003). Early and intensive behavioral intervention in autism. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 325–340). New York, NY, US: Guilford Press.Google Scholar
  23. Mayes, S. D., Calhoun, S. L., Murray, M. J., & Zahid, J. (2011). Variables associated with anxiety and depression in children with autism. Journal of Developmental and Physical Disabilities, 23(4), 325–337.CrossRefGoogle Scholar
  24. Mychailyszyn, M. P., Mendez, J. L., & Kendall, P. C. (2010). School functioning in youth with and without anxiety disorders: Comparisons by diagnosis and comorbidity. School Psychology Review, 39(1), 106–121.Google Scholar
  25. Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: A randomized trial. Journal of Child Psychology and Psychiatry, 53(4), 410–419.PubMedCrossRefGoogle Scholar
  26. Rispoli, M. J., O'Reilly, M. F., Sigafoos, J., Lang, R., Kang, S., Lancioni, G., Parker, R. (2011). Effects of presession satiation on challenging behavior and academic engagement for children with autism during classroom instruction. Education and Training in Autism and Developmental Disabilities, 46(4), 607–618.Google Scholar
  27. Shaffer, D., Fisher, P., Dulcan, M. K., & Davies, M. (1996). The NIMH diagnostic interview schedule for children version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA study. Journal of the American Academy of Child and Adolescent Psychiatry, 35(7), 865–877.PubMedCrossRefGoogle Scholar
  28. Silverman, W. K., & Albano, A. M. (1996). The anxiety disorders interview schedule for DSM IV—Child and parent versions. San Antonio, TX: Graywind.Google Scholar
  29. Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37(1), 105–130.PubMedCrossRefGoogle Scholar
  30. Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 921–929.PubMedCrossRefGoogle Scholar
  31. Sofronoff, K., Attwood, T., Hinton, S., & Levin, I. (2007). A randomized controlled trial of a cognitive behavioural intervention for anger management in children diagnosed with Asperger syndrome. Journal of Autism and Developmental Disorders, 37(7), 1203–1214.PubMedCrossRefGoogle Scholar
  32. Sukhodolsky, D. G., Scahill, L., Gadow, K. D., Arnold, L. E., Aman, M. G., McDougle, C. J., et al. (2008). Parent-rated anxiety symptoms in children with pervasive developmental disorders: Frequency and association with core autism symptoms and cognitive functioning. Journal of Abnormal Child Psychology, 36, 117–128.PubMedCrossRefGoogle Scholar
  33. Sung, M., Ooi, Y. P., Goh, T. J., Pathy, P., Fung, D. S. S., Ang, R. P., et al. (2011). Effects of cognitive-behavioral therapy on anxiety in children with autism spectrum disorders: A randomized controlled trial. Child Psychiatry and Human Development, 42(6), 634–649.PubMedCrossRefGoogle Scholar
  34. Sze, K. M., & Wood, J. J. (2008). Enhancing CBT for the treatment of autism spectrum disorders and concurrent anxiety: A case study. Behavioural and Cognitive Psychotherapy, 36, 403–409.CrossRefGoogle Scholar
  35. Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., et al. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. The New England Journal of Medicine, 359(26), 2753–2766.PubMedCrossRefGoogle Scholar
  36. Walsh, M. E., Barrett, J. G., & DePaul, J. (2007). Day-to-day activities of school counselors: Alignment with new directions in the field and the ASCA national model. Professional School Counseling, 10(4), 370–378.Google Scholar
  37. Webster-Stratton, C., & Reid, M. J. (2010). The Incredible Years parents, teachers, and children training series: A multifaceted treatment approach for young children with conduct disorders. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 194–210). New York, NY: Guilford Press.Google Scholar
  38. Weisz, J. R., Sandler, I. N., Durlak, J. A., & Anton, B. S. (2005). Promoting and protecting youth mental health through evidence-based prevention and treatment. American Psychologist, 60(6), 682–684.CrossRefGoogle Scholar
  39. Witwer, A. N., & Lecavalier, L. (2010). Validity of comorbid psychiatric disorders in youngsters with autism spectrum disorders. Journal of Developmental and Physical Disabilities, 22(4), 367–380.CrossRefGoogle Scholar
  40. Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009a). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224–234.PubMedCrossRefGoogle Scholar
  41. Wood, J. J., Drahota, A., Sze, K., Van Dyke, M., Decker, K., Fujii, C., et al. (2009b). Brief report: Effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism. Journal of Autism and Developmental Disorders, 39(11), 1608–1612.PubMedCrossRefGoogle Scholar
  42. Wood, J. J., & Gadow, K. D. (2010). Exploring the nature and function of anxiety in youth with autism spectrum disorders. Clinical Psychology: Science and Practice, 17(4), 281–292.CrossRefGoogle Scholar
  43. Wood, J. J., & McLeod, B. D. (2008). Child anxiety disorders: A treatment manual for practitioners. New York: Norton.Google Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Cori Fujii
    • 1
  • Patricia Renno
    • 1
  • Bryce D. McLeod
    • 2
  • C. Enjey Lin
    • 1
  • Kelly Decker
    • 1
  • Kaycie Zielinski
    • 1
  • Jeffrey J. Wood
    • 1
  1. 1.University of CaliforniaLos AngelesUSA
  2. 2.Virginia Commonwealth UniversityRichmondUSA

Personalised recommendations