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Intervention for Anxiety and Problem Behavior in Children with Autism Spectrum Disorder and Intellectual Disability

Abstract

There is little research on the functional assessment and treatment of anxiety and related problem behavior in children with autism spectrum disorder (ASD), particularly those with intellectual and developmental disability (IDD). In a recent study, we evaluated a multimethod strategy for assessing anxiety in children with ASD and IDD (Am J Intellect Dev Disabil 118:419–434, 2013). In the present study, we developed treatments for the anxiety and associated problem behavior in these same children. A multiple baseline design was used to evaluate the effectiveness of a multicomponent intervention package, incorporating individualized strategies from Positive Behavior Support and Cognitive Behavioral Therapy. During intervention, all three participants showed substantial decreases in anxiety and problem behavior and significant increases in respiratory sinus arrhythmia in the situations that had previously been identified as anxiety-provoking.

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Author Contributions

Dr. Lauren Moskowitz conceptualized, designed, and implemented the study, analyzed the behavioral data, drafted the initial manuscript, reviewed and revised the manuscript, and approved the submission of the final manuscript. Dr. Caitlin Walsh was the primary coder of anxious behavior and problem behavior, assisted with conceptualizing the study, reviewed and revised the manuscript, and approved the submission of the final manuscript. Dr. Emile Mulder analyzed the HR and RSA data, carried out the statistical analyses for the physiological data, and drafted the results for the physiological data. Dr. Darlene Magito McLaughlin helped design and conceptualized the study as well as reviewed and revised the manuscript. Dr. Greg Hajcak supervised the physiological data collection and analysis and reviewed the manuscript. The late Dr. Edward G. Carr (Ted Carr) was instrumental in helping to design and conceptualize the study. Dr. Jennifer Zarcone helped to conceptualize the study and analyze the behavioral data as well as played a major role in reviewing and revising several drafts of the manuscript and approving the final manuscript as submitted.

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Correspondence to Lauren J. Moskowitz.

Appendices

Appendix A

See Table 1.

Table 1 Treatment Components For Each Participant

Appendix B

Text of Ben’s Social Story (for Separation)

Everyone feels worried or afraid or anxious sometimes—kids and grownups too. It is okay to feel worried or afraid or anxious sometimes. If a lion is chasing you, it is okay to feel afraid, because your fear will make you run from the lion! There are some things I’m afraid of and some things I am not afraid of. Some other kids are afraid of thunderstorms and lightening. Some kids are afraid of dogs. I am not afraid of thunder and lightning. I am not afraid of dogs. I am a little bit afraid of fireworks. I am very afraid of walking over railroad tracks. I am very afraid of bees. I am very, very afraid when Mom or Dad leave the house and go out without me. I am afraid because I really want to go with them. I really want Mommy and Daddy. But I don’t have to be afraid when Mommy or Daddy leaves the house and I stay with Uncle or Grandma and Poppi or Grandpa. I don’t have to be afraid because Mommy and Daddy will always come back (picture of Mommy and Daddy walking through the front door and hugging Ben). At first, when Mommy and Daddy leave, I will feel scared. Then, after a while longer, I will feel less scared. Then, after a while longer, I won’t be scared anymore. I will see that my anxiety goes down after a while, even when Mommy and Daddy are not home. I don’t have to be afraid. My anxiety will go away. I will see that I am okay, even if Mommy and Daddy are not home. When Mommy and Daddy are not home, here are some things I can do when I feel afraid. When I feel worried or anxious, I can tell myself, “This is just my anxiety talking. I don’t have to be afraid. I am okay. I can beat my anxiety.” When Mommy and Daddy are gone, I can tell myself, “Mommy and Daddy always come home. So I won’t be afraid.” When Mommy and Daddy are gone, I will go do something fun, like play Leapster or Math Desk, or watch a movie, like the Muppet movie. When Mommy and Daddy are gone and I feel afraid, I can breathe nice and slow while I count to ten. This will help me feel calm. So, from now on, when Mommy and Daddy go out, I am going to be brave because I want to fight my anxiety and beat my anxiety. I am going to fight my anxiety and I will win (picture of Kai-Lan saying “We can do it!”). When Mommy and Daddy come home, they will bring me a special prize for being so brave. Mommy and Daddy will be so proud of me for being brave and staying with Uncle or Grandma and Grandpa.

Text of Sam’s Social Story (for Left/Right Turns in Car Ride) Based on Dr. Seuss’ The Foot Book

Left turn, left turn, right turn, right. Turns in the morning, turns at night.

Left turn, left turn, right turn, right. Turns in the morning, turns at night.

Left turn, left turn, right turn, right. Wet turn, dry turn. Low turn, high turn.

Front light, back light. Red light, green light.

Left turn, left turn, right turn, right. How many, many turns can you learn?

Slow turn, quick turn. Trick turn, sick turn.

Up turn, down turn. Here comes the clown turn.

Small turn, big turn. Here comes the pig turn.

When you drive up to the light, you put on the brake. You turn on a street, and on a lake.

How many, many turns you make.

Up in the air turn, over a chair turn. More and more turns. Twenty-four turns.

Here come more and more... and more turns!

Left turn, right turn. Turns, turns, turns. Oh, how many, many turns you learn.

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Moskowitz, L.J., Walsh, C.E., Mulder, E. et al. Intervention for Anxiety and Problem Behavior in Children with Autism Spectrum Disorder and Intellectual Disability. J Autism Dev Disord 47, 3930–3948 (2017). https://doi.org/10.1007/s10803-017-3070-z

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Keywords

  • Autism
  • Anxiety
  • Intellectual disability
  • Applied behavior analysis
  • Positive Behavior Support
  • Cognitive Behavioral Therapy
  • Respiratory sinus arrhythmia