Family Cognitive Behavioral Therapy for Anxiety in Autism Spectrum Disorders

Background:  This paper will discuss the role of anxiety in autism spectrum disorders (ASD), provide a description and rationale behind a novel family-based cognitive behavioral (CBT) treatment that has been developed for anxiety problems in ASD, and present results of an initial study testing this variant of family-based CBT for adolescents with ASD. Anxiety disorders are common among youth with high-functioning autism, Asperger syndrome (AS) and pervasive developmental disorder, not otherwise specified (PDD-NOS), with major anxiety disorders affecting approximately 35% of the population (Green, Gilchrist, Burton, & Cox, 2000; Klin et al., 2005). The relative frequency of anxiety disorders among adolescents with autism spectrum disorders indicates that anxiety could be an important treatment focus for many affected youth.

Objectives:  Adolescents with ASD experience significant impairment in functioning when anxiety is a part of the clinical picture (Attwood, 2003; Bellini, 2004). But, at present, few treatment protocols have been developed for adolescents with comorbid anxiety and ASD. Family-based CBT has been established as a probably efficacious treatment for anxiety disorders in typically developing youth and it has produced large effect sizes in multiple trials (cf. Barmish & Kendall, 2005). This study developed a family CBT program for adolescents with ASD.

Methods:  A standard family-based CBT program for anxiety disorders (Wood et al., 2006) was modified to meet the needs of adolescents with ASD. In two new modules that address social skills deficits, adolescents and parents are taught “friendship skills” (e.g., giving compliments, acting like a “good sport,” becoming a good playdate host, etc.) and parents and other caregivers give children “social coaching” on appropriate entry behavior immediately before they attempt to join activities with others, adapting techniques developed for youth with ADHD (Frankel et al., 1997). Parents are also given intensive training on behavior management and methods for supporting the teen’s exposure therapy homework. Sessions are approximately 90 minutes, with 30-45 minutes with the adolescents, and 45-60 minutes with the parent and/or family. We conducted a randomized controlled trial of this family-based CBT program for comorbid ASD and anxiety disorders. Thirty two adolescents (11-14 years old) were randomly assigned to 16 sessions of family CBT or a 3-month waitlist. Therapists worked with individual families. Independent evaluators blind to treatment condition conducted structured diagnostic interviews and parents and adolescents completed anxiety symptom checklists at baseline and post treatment/post waitlist.

Results:  In intent-to-treat analyses, a statistically significant group difference was found between CBT and waitlist on the Clinical Global Impressions-Improvement scale, with more adolescents in CBT meeting criteria for positive treatment response at post treatment, as compared to adolescents in the waitlist group. CBT also outperformed the waitlist on diagnostic outcomes and self-reports. Treatment gains were maintained at 1-month follow-up.

Conclusions:  The family-based CBT manual employed in this study is one of the first adaptations of an evidence-based treatment for adolescents with autism spectrum disorders. Remission of anxiety disorders appears to be an achievable goal among high-functioning adolescents with autism.