In all CBT cases, the clinicians thoroughly reviewed current anxiety symptomatology at the outset of treatment and then, in collaboration with the children and their parents, they generated two to three treatment goals. For children starting treatment at the start of the COVID-19 outbreak, treatment goals were determined based on current anxiety symptoms, including those associated with COVID-19 (e.g., worries about family members contracting the virus, fear and avoidance of attending school online). For children who had started treatment prior to the onset of the pandemic, anxiety symptoms were re-evaluated and treatment goals were updated as necessary to address the children’s most salient and current anxiety concerns. For one child, for example, reduction of fear of heights had been one of the main treatment goals prior to COVID-19. This fear interfered with his ability to participate in leisure activities, such as using a slide at the playground or accompanying his family on hikes due to a chance that a trail might go over a bridge. Prior to COVID-19, treatment included a hierarchy of exposures to reduce fear of heights, including walking upstairs in the clinic, visiting a toy store on the second floor of the local mall, and using the largest slide at the local playground. For obvious reasons, most of these exposures could not be implemented during the pandemic. Thus, following the outbreak, the clinician and family shifted the treatment plan to focus on the child’s separation anxiety, which was becoming increasingly prominent and tied to COVID-19 related concerns. To this end, treatment consisted of a hierarchy of exposures: the child’s mother leaving the house for a 5-min errand, then a 30-min errand, and finally working up to a 30-min errand without responding to any of his calls or text messages during that time.
At the beginning of the pandemic, and subsequently as needed, treatment inevitably addressed how the COVID-19 outbreak was affecting a child and the family. This included a conversation with parents about the best way to discuss the pandemic with their children, how much information to provide and how to answer questions and concerns raised by the child. The clinicians encouraged parents to consider their children’s developmental level, including language and cognitive abilities, emotional maturity, level of anxiety surrounding COVID-19, and severity of ASD symptoms in preparation for discussing the pandemic with their children. Parents were advised to provide information using developmentally appropriate language and level of detail (e.g., “there is a virus, like the flu, that some people have, and we are staying away from other people so that we do not get it from them”) and to limit information that was too advanced, practically unnecessary, and/or would needlessly exacerbate anxiety (e.g., details regarding the impact of COVID-19 on the human body). For many families, this included limiting children’s exposure to news and media coverage of the pandemic. Parents were also encouraged to answer their children’s questions and provide information in a clear, developmentally appropriate way in order to help their children better understand and contextualize the changes in their daily lives (e.g., “since a person with the virus can give it to another person by getting their germs into the other person’s nose or mouth, we are going to wear masks when we go outside so no one’s germs get into our nose or mouth”). Lastly, parents were coached to provide reassuring information where possible (e.g., “we are doing our best to stay safe,” “lots of doctors and nurses are working hard to make people with the virus better and to figure out how to get rid of the virus”) to help their children maintain a resilient mindset in the face of uncertainty brought about by the pandemic. As the pandemic unfolded and information about COVID-19 and child behavioral health became available, we compiled the website resources that were helpful to us when working with children with ASD and their families (see Table in the “Supplementary material”).
COVID-19-related anxiety was also addressed by working directly with the child. The goals of this work included reducing anxiety about the virus and helping the child to engage in appropriate safety behaviors. This included adopting a more realistic perspective regarding risks and necessary precautions and limiting engagement in safety-taking behaviors to those consistent with standard medical guidelines. To this end, psychoeducation on COVID-19, including information on mode of transmission, relative levels of risk, and guidelines for prevention from authoritative medical institutions (e.g., Centers for Disease Control and Prevention) was provided and geared to the developmental level of the child. For example, for the child who refused to step out of the house and play in the backyard out of fear of contracting COVID-19, detailed information was provided on how the virus is spread (i.e., via person-to-person contact, transmission of water droplets), complete with illustrative diagrams. The clinician and child reviewed this information several times while also reviewing how this information contrasted with the child’s anxiety-provoking thoughts (e.g., “COVID is in the outside air, and if I step outside, I will catch it”). Next, the clinician helped the child to generate coping statements to remind himself of the newly-learned information and combat his anxious thoughts (e.g., “I cannot catch COVID-19 by simply going outside to play”). Following that, he and the clinician developed a fear hierarchy corresponding to situations involving him stepping outside of his home, ranging from mildly anxiety-provoking situations (e.g., taking one step outside and stepping back inside) to highly anxiety-provoking ones (e.g., going for a 15-min walk in his neighborhood, while wearing a facial mask and maintaining a six-foot distance from others). They also reviewed the fear hierarchy with the child’s mother, who subsequently helped him to carry out the exposure exercises in accordance with the hierarchy.
For children experiencing notable social and/or separation anxiety prior to the onset of COVID-19, treatment took a similar course. This included helping the child to identify thoughts and feelings associated with anxiety, generate and practice coping skills to manage anxiety, create a fear hierarchy, and engage in exposure exercises. In some cases, certain elements of treatment were emphasized over others. For example, for the child with social anxiety and pronounced distress over online learning, ASD-related social communication difficulties made it challenging for her to articulate specific thoughts and feelings associated with her distress. Still, she was able to associate online learning with having an “uncomfortable” feeling in her body, and thus relaxation exercises, such as deep breathing, proved to be a helpful strategy for reducing anxious feelings when they arose. Other key components of treatment included exposure exercises in which the amount of time in the virtual classroom was gradually increased (see “Adapting Exposures” section). Work with the child’s parents focused on helping them calmly respond to their child’s anxiety, as well as to use encouragement, praise, and planned rewards to promote her use of coping skills and engagement in exposures.