The Treatment of Social Phobia in a Young Boy With Asperger's Disorder

Anxiety disorders, including social phobia, occur often in children with autism spectrum disorders (ASD; Gillott, Furniss, & Walter, 2001; Leyfer et al., 2006; Simonoff et al., 2008); however, little is known about the conceptualization and treatment of social phobia in this population. The current study presents the case of “James,” a 6-year-old male with comorbid Asperger's disorder and social phobia. A cognitive-behavioral treatment (CBT) package, including parent training, psychoeducation, graduated exposure, and reinforced practice, was implemented to decrease avoidance behaviors in social settings. Results showed that James's avoidance behaviors were reduced significantly following intervention, suggesting that a CBT approach may be effective in treating social phobia in children with ASD. The significant influence of CBT on decreasing avoidance behavior in comorbid social phobia and ASD highlights the need for continued investigation of adapting CBT for use with children with ASD.     

Cognitive-Behavioral Therapy in the Treatment of Internalizing Disorders in High-Functioning Youth with Autism Spectrum Disorder

Anxiety and depression are often comorbid with Autism Spectrum Disorder (ASD). There is empirical support to suggest that cognitive-behavioral therapy (CBT) is an efficacious treatment for comorbid anxiety disorders in youth with ASD. Modifications to CBT for youths with ASD have been made with emphasis on exposure being a critical component. Few studies have evaluated the efficacy of CBT on symptoms of depression in youths with ASD. Modifications to CBT will be outlined in this review, as will implementation suggestions for the clinician practicing CBT with ASD youth. Limitations of the studies investigating this intervention include small sample sizes, clinician- and parent-report of symptom change but not consistent self-identified change, limited validated tools for assessing change, and lack of long-term follow-up.     

Psychiatric Comorbidity in Children with Autism Spectrum Disorders: A Comparison with Children with ADHD

The present study was conducted with the aim to identify comorbid psychiatric disorders in children with autism spectrum disorders (ASD) (n = 40) and to compare those comorbidity rates to those in children with attention deficit hyperactivity disorder (ADHD) (n = 40). Participants were clinically referred children aged 7–18 years. DSM-IV classifications were used for the primary diagnosis (ASD/ADHD), while comorbid psychiatric disorders were assessed using a structured diagnostic interview, the structured clinical interview for DSM-IV, childhood diagnoses (KID-SCID). Twenty-three children with ASD (57.5 %) had at least one comorbid disorder, whereas 16 children with ADHD (40.0 %) were classified as having at least one comorbid disorder. No group differences were found with respect to this comorbidity rate or for the rate of comorbid externalizing disorders (ODD and/or CD). However, children with ASD had more comorbid internalizing disorders compared to children with ADHD. More specifically, children with ASD had higher rates of anxiety disorders, but not mood disorders. No associations between comorbidity and age or between comorbidity and the intelligence quotient was found. It is important for clinicians to always be aware of, and screen for, comorbidity, and to consider treatment for these comorbid disorders. In addition, research should focus on establishing valid and reliable screening tools as well as effective treatment options for these comorbid disorders.     

Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder

In current classification systems, selective mutism (SM) is included in the broad anxiety disorders category. Indeed, there is abundant evidence showing that anxiety, and social anxiety in particular, is a prominent feature of SM. In this article, we point out that autism spectrum problems in addition to anxiety problems are sometimes also implicated in SM. To build our case, we summarize evidence showing that SM, social anxiety disorder (SAD), and autism spectrum disorder (ASD) are allied clinical conditions and share communalities in the realm of social difficulties. Following this, we address the role of a prototypical class of ASD symptoms, restricted and repetitive behaviors and interests (RRBIs), which are hypothesized to play a special role in the preservation and exacerbation of social difficulties. We then substantiate our point that SM is sometimes more than an anxiety disorder by addressing its special link with ASD in more detail. Finally, we close by noting that the possible involvement of ASD in SM has a number of consequences for clinical practice with regard to its classification, assessment, and treatment of children with SM and highlight a number of directions for future research.

     

高功能孤独症儿童的合作行为

合作行为是一种重要的亲社会行为, 对儿童的社会适应具有重要意义, 而孤独症儿童的典型特征是社会功能存在缺陷, 从而导致合作行为的缺乏。以往研究未能就孤独症儿童在不同合作任务类型中的表现做出区分, 本研究采用经典的囚徒困境博弈和合作性工具任务比较了6~12岁的高功能孤独症儿童和正常发展儿童在不同任务中的合作行为。结果显示高功能孤独症儿童和正常儿童在囚徒困境中的合作行为没有显著差异, 然而, 他们在工具性任务中表现出比正常儿童更低水平的合作行为。这说明高功能孤独症儿童在对认知能力有不同要求的合作任务中的表现不同。     

Anxiety Disorders in Children and Adolescents with Autistic Spectrum Disorders: A Meta-Analysis

There is considerable evidence that children and adolescents with autistic spectrum disorders (ASD) are at increased risk of anxiety and anxiety disorders. However, it is less clear which of the specific DSM-IV anxiety disorders occur most in this population. The present study used meta-analytic techniques to help clarify this issue. A systematic review of the literature identified 31 studies involving 2,121 young people (aged <18 years) with ASD, and where the presence of anxiety disorder was assessed using standardized questionnaires or diagnostic interviews. Across studies, 39.6% of young people with ASD had at least one comorbid DSM-IV anxiety disorder, the most frequent being specific phobia (29.8%) followed by OCD (17.4%) and social anxiety disorder (16.6%). Associations were found between the specific anxiety disorders and ASD subtype, age, IQ, and assessment method (questionnaire versus interview). Implications for the identification and treatment of anxiety in young people with ASD are discussed.     

Cognitive Behavioral Therapy for Social Anxiety Disorder: Predictors of Treatment Outcome in a Quasi-Naturalistic Setting

We examined the outcomes of individual cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) in a sample of 93 adults seeking treatment in a university outpatient clinic specializing in CBT for SAD. Treatment followed the structure of a manual, but number of sessions varied according to client needs. After approximately 20 weeks of therapy, patients’ social anxiety had decreased and their quality of life had increased. Patients with more severe SAD or comorbid major depressive disorder (MDD) at pretreatment demonstrated higher levels of social anxiety averaged across pre- and posttreatment. However, clinician-rated severity of SAD, comorbid MDD, or comorbid generalized anxiety disorder did not predict treatment outcome. Higher pretreatment scores on measures of safety behaviors and cognitive distortions were associated with higher social anxiety averaged across pre- and posttreatment and predicted greater decreases from pre- to posttreatment on multiple social anxiety outcome measures. We found no predictors of change in quality of life. Those with high levels of safety behaviors and distorted cognitions may benefit more from CBT, perhaps due to its emphasis on targeting avoidance through exposure and changing distorted thinking patterns through cognitive restructuring methods. Our study lends support to the body of research suggesting that manualized CBT interventions can be applied flexibly in clinical settings with promising outcomes for patients over a relatively short course of therapy.     

Modified CBT using visualization for Autism Spectrum Disorder (ASD), anxiety and avoidance behavior – a quasi‐experimental open pilot study

In recent studies it has been suggested that Cognitive Behavior Therapy (CBT) is beneficial to people with Autism Spectrum Disorder (ASD) but that the method needs to be modified in relation to their cognitive profile. The aim of this study is to measure the effect of modified CBT, that is, using visualized language throughout the entire session for clients with ASD and anxiety and avoidance behavior. The modification of CBT in this study consists of focusing on CBT protocols for anxiety disorders and depression, while visualizing and systematizing “the invisible” in the conversation, in order for the clients to understand the social, cognitive and emotional context of self and others and how they should interact to avoid misunderstandings. ASD clients may need help to detect the invisible code of social interaction and communication. The level of anxiety and the frequency of target behavior were measured. Four assessments were made, two at the pre‐assessment, and one in mid‐therapy and end of therapy respectively. Generally, results suggest no improvement during pre‐treatment period but a significant improvement during treatment. The values of the clients' psychological, social and occupational ability to function improved on the Global Function Rating scale. The preliminary conclusion of this pilot study indicates that the use of visualized language throughout the CBT therapy sessions is a promising modification of current CBT protocols for individuals with ASD. After manualization, larger studies with randomized controlled study designs can replicate or challenge these results.     

Children’s Perspectives of an Enhanced Cognitive-Behavioral Treatment for Child–Parent Dyads With Anxiety Disorders

Prior research has extensively evaluated the efficacy of cognitive-behavioral therapy (CBT) for child anxiety disorders—however, few studies have investigated anxious children’s perspectives and experiences of participating in CBT. This qualitative study explored children’s acceptability of a newly developed enhanced CBT intervention, designed specifically for the treatment of anxiety disorders in children with a clinically anxious parent. The study also explored children’s perceptions and experiences of individual (child only) and joint observational (child–parent) exposure activities that were key to the intervention. Ten children (age range 6–11, M = 8.5 years) and their mothers (age range 34–45, M = 39.5 years) completed in-depth semistructured interviews to investigate child participants’ anticipated and experiential acceptability of the enhanced CBT intervention. Thematic analysis revealed seven major themes broadly reflecting the acceptability, appropriateness, and perceived benefit of the intervention elements, with particular value credited to exposure tasks and the dyadic nature of the intervention. Findings suggest that future experimental evaluation of the enhanced intervention is warranted. Further, the study highlights that CBT for child anxiety disorders, where exposure work is a feature, is acceptable and perceived to be effective by its intended treatment recipients. Trial prospectively registered, preresults, ANZCTR1261900033410.     

Development of a Cognitive-Behavioral Intervention Program to Treat Anxiety and Social Deficits in Teens with High-Functioning Autism

Anxiety is a common co-occurring problem among young people with autism spectrum disorders (ASD). Characterized by deficits in social interaction, communication problems, and stereotyped behavior and restricted interests, this group of disorders is more prevalent than previously realized. When present, anxiety may compound the social deficits of young people with ASD. Given the additional disability and common co-occurrence of anxiety in ASD, we developed a manual-based cognitive-behavioral treatment program to target anxiety symptoms as well as social skill deficits in adolescents with ASD [Multimodal Anxiety and Social Skills Intervention: MASSI]. In this paper, we describe the foundation, content, and development of MASSI. We also summarize data on treatment feasibility based on a pilot study that implemented the intervention.     

New and Familiar Roles for Clinical Psychologists in the Effective Treatment for Children With an Autism Spectrum Disorder

Alongside the increased prevalence of autism spectrum disorders (ASD), there is a greater likelihood of clinical psychologists having a role in the treatment of children with these disorders. Population heterogeneity with respect to ASD-specific symptomatology, comorbid medical and psychiatric issues, level of cognitive functioning, and presence of adaptive behaviors, all add to the complexity of providing treatment to this population. Consequently, psychologists often find themselves in multiple roles in order to effectively manage treatment for children with ASD and their families. The purpose of this article is to increase awareness of three major roles for clinical psychologists working with this population: assisting families with treatment coordination, identifying and treating comorbid psychopathology, and addressing parental stress.     

A Review of Behavioral Interventions for Anxiety‐Related Behaviors in Lower‐Functioning Individuals with Autism

Anxiety is highly prevalent in persons with autism and affects individuals with higher‐functioning autism (HFA) and lower‐functioning autism (LFA). Although there is emerging support for the efficacy of cognitive‐behavioral therapy (CBT) in treating anxiety in autism, these findings are largely based on HFA samples. Moreover, CBT may be inappropriate for individuals with LFA who may struggle to grasp the cognitive components of the therapy because of their more limited verbal abilities. Behavior analytic interventions may be better suited to treat anxiety in this population; however, the quantity and quality of the extant literature have yet to be reviewed. Toward this end, the extant behavioral intervention literature was reviewed. Seven studies met the inclusion criteria and were evaluated against quality indicators for within‐subject design research. Next, the efficacy of each treatment component was assessed using established criteria for defining empirically supported therapies. Results revealed behavioral interventions to be efficacious, with desensitization and reinforcement emerging as efficacious treatment components, while prompting, modeling, and antianxiety stimuli were established as possibly efficacious. However, given that some of the quality indicators were not met, these results should be interpreted with some caution. Additional research is needed to form a more conclusive evidence base for the treatment of anxiety in individuals with LFA. Copyright © 2016 John Wiley & Sons, Ltd.     

Treatment of Anxiety Disorders With Comorbid Depression: A Survey of Expert CBT Clinicians

Cognitive-behavioral therapy (CBT) is an empirically supported psychological treatment for anxiety disorders. These treatments have primarily been developed to target primary anxiety disorders, despite the fact that these disorders frequently co-occur with a diagnosis of depression. Empirical evidence provides guidance regarding how to treat an individual with a primary anxiety disorder with comorbid depression; however, there is limited data regarding how to translate these findings into clinical practice. Improving our understanding of how CBT is currently being used in practice among experts is integral to learning whether modifications to protocols lead to more or less effective treatments. Accordingly, we surveyed expert CBT clinicians about their assessment and treatment approaches and what challenges they face in formulating and treating mood and anxiety comorbidity. Most experts reported that their assessment includes a semistructured interview and self-report measures to determine breadth and hierarchical ordering of comorbidity severity. Symptom severity, client's goals, temporal onset of disorders, presence of suicide risk, and potential for early treatment success were reported as factors to consider when deciding where to begin treatment. Almost three quarters of experts surveyed indicated that they usually take some type of sequential treatment approach when treating primary anxiety disorders with comorbid depression. The top three reported challenges associated with treating comorbid presentations were client's motivation/energy, hopelessness/pessimism, and ongoing need for risk assessment. Implications for the nature and timing of CBT interventions in “real-world” clinical practice are discussed.     

The Relationship Between Treatment Acceptability and Youth Outcome in Group CBT for Youth with ASD and Anxiety

Anxiety is one of the most common co-occurring diagnoses in youth with autism spectrum disorder (ASD). Cognitive behavior therapy (CBT) is an evidence-based treatment that has been tailored for youth with ASD and anxiety and has shown good efficacy in reducing youth anxiety immediately after treatment. One area that has not been widely studied is acceptability of CBT for anxiety in this population. Acceptability includes beliefs about the potential helpfulness and satisfaction with a given treatment and may be important in understanding treatment outcomes. This study focuses on parent, youth, and clinician acceptability of a well-researched CBT program, Facing Your Fears, for youth with ASD and anxiety. Data was collected as part of a larger multi-site study that compared three different instructional conditions for clinicians learning the intervention. Results indicated that parents rated acceptability as higher for the overall treatment compared to youth. Further, youth and parents rated exposure related sessions as more acceptable than psychoeducation, and higher exposure acceptability ratings were predictive of lower youth anxiety levels post-treatment. Clinicians who received ongoing consultation rated treatment acceptability lower than clinicians in the other training conditions. While some clinicians may be hesitant to implement exposure techniques with this population, findings suggest that it is the technique that parents and youth rated as the most acceptable. Results are discussed in terms of treatment and research implications for youth with ASD and their families.     

Anxiety Levels in Children with Autism Spectrum Disorder: A Meta-Analysis

The aim of the current study was to meta-analytically examine whether anxiety levels in children with autism spectrum disorders (ASD) are elevated. A total of 83 articles were selected from a systematic literature search and were included in the meta-analyses. Results demonstrated that children with ASD had higher anxiety levels compared to typically developing children, and this difference increased with IQ. Youth with ASD also tended to have higher anxiety levels compared to clinically referred children, and this difference increased with age. Children with ASD had higher anxiety levels compared to youth with externalizing or developmental problems, but not when compared to youth with internalizing problems. The study findings highlight the importance of more research in order to fully understand the nature and development of anxiety in children with ASD. More specifically, the results suggest that especially high-functioning adolescents with ASD may be at risk for developing anxiety disorders. Therefore, it seems important to carefully follow and monitor children with ASD transcending to adolescence.     

Relationship Quality as a Moderator of Anxiety in Siblings of Children Diagnosed with Autism Spectrum Disorders or Down Syndrome

The purpose of this study was to examine typically-developing adolescents’ perceived relationship quality with their developmentally-disabled sibling, specifically siblings diagnosed with an autism spectrum disorder (ASD) or Down syndrome (DS). The 119 eleven through seventeen-year-old adolescent participants (M = 13.32, SD = 1.90) completed an online survey that assessed demographics, sibling relationship quality, and anxiety. Results showed that siblings of children with DS have a greater overall sibling relationship quality than do siblings of children with an ASD. Results further indicated that reporting more negative interchanges within the sibling relationship was related to higher levels of anxiety regardless of sibling disability type. Lastly, sibling relationship quality moderated the relation between sibling disability type and anxiety. These findings promote greater understanding of the sibling dynamic in families with children with developmental disabilities and suggest the need for establishing more research and greater clinical evaluation in this area. Furthermore, the current study suggests that therapeutic intervention to address the sibling relationship quality within children diagnosed with ASDs and their typically-developing siblings would be beneficial in order to increase social support within the relationship as well as decrease the amount of negative interchanges within the sibling relationship. Results also suggested that decreasing the amount of negative interchanges within the sibling relationship may decrease the level of anxiety the typically-developing sibling reports.     

Multi-family Psychoeducational Psychotherapy (MF-PEP) for Children with High Functioning Autism Spectrum Disorder

This article describes the development and methodology of a novel psychosocial intervention for children with high functioning autism spectrum disorder (HFASD). Originally developed as an adjunctive treatment for children with mood disorders, Multi-Family Psychoeducational Psychotherapy (MF-PEP) has been adapted for children with ASD (MF-PEP-ASD). Consisting of eight sessions, children with ASD and their parents receive psychoeducation and social support, and learn coping, problem-solving, communication, and symptom-management skills in separate and joint sessions. Core treatment components of MF-PEP-ASD include psychoeducation, social skills treatment, cognitive-behavioral therapy, and parent training and involvement. Preliminary qualitative data from parent and child participants have indicated positive and promising findings. Continued evaluation of this treatment using comprehensive outcome and treatment fidelity measures is warranted.     

Improving Social Skills of Adults With Autism Spectrum Disorder Through Physical Activity,Sports, and Games: A Review of the Literature

Socialization skill deficiencies among adults with autism spectrum disorder (ASD) can lead to depression, anxiety, aggression, and physical health problems. Clinical interventions must treat primary deficiencies and prevent secondary conditions. A treatment model emphasizing the integration of physical activity with social intervention strategies for adults with ASD is proposed.     

Comorbid ADHD: Implications for the Treatment of Anxiety Disorders in Children and Adolescents

Despite high comorbidity rates and potential clinical implications, the influence of co-occurring attention-deficit/hyperactivity disorder (ADHD) on outcomes of cognitive-behavioral treatment (CBT) for anxious youth remains poorly understood. In this qualitative review, the current literature on the influence of comorbid ADHD on CBT of youth with diverse anxiety disorders is explored. Peer-reviewed studies examining ADHD, at the diagnostic and symptom level, received highest priority. In addition, inasmuch as some studies did not isolate the effects of ADHD from other disruptive behavior disorders (DBDs: oppositional defiant disorder, conduct disorders), studies with the three DBDs were explored as well. Ten studies met our specified methodological criteria. Findings are discussed in relation to the following two factors: type of anxiety disorder and measurement of ADHD (diagnostic or symptom level) in these studies. There was evidence that youth with a variety of anxiety disorders and with co-occurring ADHD fared worse than their counterparts without ADHD. Additionally, grouping ADHD with other DBDs tended to obscure the negative impact of ADHD on treatment outcomes. Additional research is needed to delineate the influence of comorbid ADHD specifically on treatment outcomes for the various anxiety disorders. Clinical implications of treating anxious youth with comorbid ADHD are explored.     

Adult Asperger Syndrome and the Utility of Cognitive-Behavioral Therapy

Asperger syndrome (AS) is a developmental disorder that was first recognized in the United States in 1994 with the publication of DSM-IV (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 1994). As a relatively new concept to the United States, both within the professional community and public awareness, the diagnosis has most often applied to children, but there is a large cohort of affected adults who have never been diagnosed or properly treated. Many of these individuals are now seeking treatment for the symptoms of AS and/or comorbid mental health problems (e.g., mood and anxiety disorders). Clinicians are in need of practical and evidence-based interventions to address the problems presented by this growing patient population, but there are few such resources available. This article will present a framework for conceptualizing the mental health needs of adults with AS, using the evidence-based approaches found in the cognitive-behavior therapy (CBT) literature to inform treatment.