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.     

Parents' perceptions of pharmacological and cognitive-behavioral treatments for childhood anxiety disorders

Cognitive-behavioral therapy (CBT) and pharmacotherapy are the most well-established treatments for childhood anxiety disorders. This study examined how parents (N=71) seeking treatment for their child's anxiety disorder perceive the acceptability, believability, and effectiveness of these treatments. While both treatments were perceived favorably, CBT was rated as more acceptable, believable, and effective in the short- and long-term. Children's treatment history influenced parents' perceptions of pharmacotherapy, with parents of children with no treatment history perceiving medication treatment as less acceptable and believable than parents of children with a history of medication alone or in combination with behavior therapy. No effect of treatment history was found for perceptions of CBT. Significant positive correlations emerged between parents' perceived acceptance and believability for pharmacotherapy and child age and level of dysfunction due to their child's anxiety, respectively. The level of the child's anxiety was not significantly correlated with parents' perceptions of either CBT or pharmacotherapy. Our results suggest that parents of anxious children prefer CBT to medication for the treatment of their child's anxiety disorder. Directions for future research are discussed.     

Parent Training for Childhood Anxiety Disorders: The SPACE Program

Anxiety disorders are the most prevalent disorders of childhood and adolescence. Cognitive behavioral therapy (CBT) for anxiety poses a challenge for clinicians as it requires active client participation, and many children either decline or do not adequately comply with treatment. In addition, even after treatment with CBT, up to 50% of children remain symptomatic, and many still meet diagnostic criteria. Parent-directed clinical work has been advocated as a potential enhancer of treatment outcomes, and exclusively parent-based interventions might replace child treatment when the child is reluctant. However, parent involvement has yet to be shown to significantly improve outcomes, relative to child-only therapy. Studies so far have focused mainly on including parents in children’s therapy, training parents as lay therapists, or teaching parenting skills. Parent training focused on parental behaviors specific to childhood anxiety, such as family accommodation, may be more effective. In this treatment development report we present the theoretical foundation, structure, and strategies of a novel parent-based intervention for childhood anxiety disorders. We will also present the results of an open trial of the treatment, with an emphasis on feasibility, acceptability, and initial outcomes. Participants in the trial were parents of 10 children, aged 9 to 13. Children had declined individual child treatment. Multiple excerpts from the treatment manual are included with the hope of “bringing the treatment to life” and conveying a rich sense of the therapeutic process. Parents participated in 10 weekly sessions. Significant improvement was reported in child anxiety and family accommodation as well as in the child’s motivation for individual treatment. No parents dropped out and satisfaction was high. The SPACE Program (Supportive Parenting for Anxious Childhood Emotions) is a novel, manualized parent-based intervention that is feasible and acceptable and may be effective in improving childhood anxiety.     

Brief Cognitive-Behavioral Therapy for Anxious Youth: Feasibility and Initial Outcomes

We developed and evaluated a brief (8-session) version of cognitive-behavioral therapy (BCBT) for anxiety disorders in youth ages 6 to 13. This report describes the design and development of the BCBT program and intervention materials (therapist treatment manual and child treatment workbook) and an initial evaluation of child treatment outcomes. Twenty-six children who met diagnostic criteria for a principal anxiety diagnosis of separation anxiety disorder, generalized anxiety disorder, and/or social phobia were enrolled. Results suggest that BCBT is a feasible, acceptable, and beneficial treatment for anxious youth. Future research is needed to examine the relative efficacy of BCBT and CBT for child anxiety in a randomized controlled trial.     

Treating Speech Anxiety in Youth: A Randomized Controlled Microtrial Testing the Efficacy of Exposure Only Versus Exposure Combined With Anxiety Management Strategies

CBT for anxious youth usually combines anxiety management strategies (AMS) with exposure, with exposure assumed to be critical for treatment success. To limit therapy time while retaining effectiveness, one might optimize CBT by restricting treatment to necessary components. This study tested whether devoting all sessions to exposure is more effective in reducing speech anxiety in youth than devoting half to AMS including cognitive or relaxation strategies and half to exposure. After a 6-week waitlist period, adolescents with speech anxiety (N = 65; age 12–15; 42 girls) were randomized to a 5-session in-school group-based CBT training consisting of either (1) exposure-only (EXP+EXP) or (2) cognitive strategies followed by exposure (COG+EXP) or (3) relaxation strategies followed by exposure (REL+EXP). Clinical interviews, speech tests, and self-report measures were assessed at pretest, posttest, and follow-up. For all conditions (a) the intervention period resulted in a stronger decline of speech anxiety than waitlist period; (b) there was a large sized reduction of speech anxiety that was maintained at six-week follow-up; (c) there was no meaningful difference in the efficacy of EXP+EXP versus COG+EXP or REL+EXP. These findings suggest that devoting all sessions to exposure is not more effective than combining exposure with AMS. AMS appeared neither necessary for CBT to be effective, nor necessary for youth to tolerate exposure. This indicates that CBT can be optimized by restricting treatment to exposure.     

Mothers and Fathers in Family Cognitive-Behavioral Therapy for Anxious Youth

Cognitive-behavioral therapy (CBT) for anxiety disorders in youth has been evaluated in randomized clinical trials and found to be an efficacious treatment. Studies have investigated the effects of increased parental/family involvement in treatment. In the majority of these studies, however, parental involvement is synonymous with maternal involvement leaving the role of fathers unknown. Studies including parents in treatment have yet to examine the independent contribution of mothers and fathers to child outcome. We examined the relationship between both mother (n = 45) and father (n = 45) attendance and engagement in therapy sessions, maternal and paternal psychopathology, and child (n = 45) treatment outcome when parents were included in a Family CBT program for anxiety-disordered youth. Some indications were found for the notion that greater rates of mother and father attendance in session, as well as higher ratings of mother and father engagement in session, are associated with improved child outcome. Parental psychopathology was not associated with attendance, engagement, or child outcome. Recommendations for future research are offered.     

Parent Accommodation Contemporaneously Mediates the Association Between Youth Irritability and Youth Anxiety Treatment Outcome

Research documents that child and adolescent (youth) irritability and anxiety have high co-occurrence, and anxious-irritable presentations are associated with greater impairment than anxious nonirritable presentations. This study examines the association between irritability and youth anxiety treatment outcome and tests a conceptual model of the associations among youth irritability, parent accommodation, and youth anxiety severity following cognitive behavioral treatment (CBT). Participants were N = 128 clinic-referred youths ages 6 to 17 years (M = 9.76 years; 57% female) who met criteria for primary anxiety disorder diagnoses and completed a 12- to 14-week CBT anxiety protocol. Parent- and youth-report on youth irritability, parent accommodation of their child’s anxiety, and youth anxiety severity were assessed pretreatment and posttreatment. Using parent-report, youth irritability at pretreatment was associated with high parent accommodation of youth anxiety and high youth anxiety severity at posttreatment. The association between irritability and youth anxiety outcome was mediated contemporaneously by parent accommodation at posttreatment. These findings show that parent accommodation of their anxious-irritable children’s anxiety may account for high youth anxiety severity following treatment. Developing strategies to target irritability in anxious youth and/or reduce parent accommodation in the presence of youth irritability represent important directions for future research.     

The Treatment of Anxiety in Autism Spectrum Disorder (TAASD) Study: Rationale,Design and Methods

This paper describes the rationale, design, and methods of the Treatment for Anxiety in Autism Spectrum Disorders study, a three-site randomized controlled trial investigating the relative efficacy of a modular CBT protocol for anxiety in ASD (Behavioral Interventions for Anxiety in Children with Autism) versus standard CBT for pediatric anxiety (the Coping Cat program) and a treatment-as-usual control. The trial is distinct in its scope, its direct comparison of active treatments for anxiety in ASD, and its comprehensive approach to assessing anxiety difficulties in youth with ASD. The trial will evaluate the relative benefits of CBT for children with ASD and investigate potential moderators (ASD severity, anxiety presentation, comorbidity) and mediators of treatment response, essential steps for future dissemination and implementation.     

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.     

Exploring Relationships Between Negative Cognitions and Anxiety Symptoms in Youth With Autism Spectrum Disorder

Although cognitions are central to the conceptualization and treatment of anxiety in typically developing (TD) youth, there is scant research investigating automatic thoughts and their relationship with anxiety in youth with autism spectrum disorder (ASD). We sought to examine the types of automatic thoughts experienced by youth with ASD and co-occurring anxiety as well as the predictive relationship of anxiety to different types of automatic thoughts in 97 children, ages 8-14 years. We also explored the relationship of automatic thoughts and intolerance of uncertainty. Consistent with prior data, there was a strong relationship between anxiety and automatic thoughts pertaining to social and physical threat. Anxiety and IU were independently associated with thoughts pertaining to personal failure which raises the hypothesis that personal failure may serve as a common pathway between anxiety, IU, and depression in ASD youth. These findings highlight the importance of assessing and treating negative cognitions in youth with ASD and anxiety.     

Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms

The purpose of the present study was to examine the potential efficacy, patient acceptability, and feasibility of a novel, cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. Thirty-one adults with ADHD and stable psychopharmacology for ADHD were randomized to CBT plus continued psychopharmacology or continued psychopharmacology alone. Assessments included ADHD severity and associated anxiety and depression rated by an independent evaluator (IE) and by self-report. At the outcome assessment, those who were randomized to CBT had lower IE-rated ADHD symptoms (p < .01) and global severity (p < .002), as well as self-reported ADHD symptoms (p < .0001) than those randomized to continued psychopharmacology alone. Those in the CBT group also had lower IE-rated and self-report anxiety (p's < .04), lower IE-rated depression (p < .01), and a trend to have lower self-reported depression (p = .06). CBT continued to show superiority over continued psychopharmacology alone when statistically controlling levels of depression in analyses of core ADHD symptoms. There were significantly more treatment responders among patients who received CBT (56%) compared to those who did not (13%) (p < .02). These data support the hypothesis that CBT for adults with ADHD with residual symptoms is a feasible, acceptable, and potentially efficacious next-step treatment approach, worthy of further testing.     

Cognitive Behavioral Treatment of Comorbid Anxiety Disorders and Social Difficulties in Children with High-Functioning Autism: A Case Report

A substantial proportion of children with high-functioning autism (HFA) or Asperger syndrome (AS) have one or more comorbid anxiety disorders. Because anxiety disorders exacerbate the social difficulties and other functional impairments caused by an autism spectrum disorder (ASD), there is a need for efficacious treatments to address the clinical needs of youth with this comorbid presentation. This article describes an evidence-based cognitive behavioral therapy (CBT) treatment manual enhanced to address the unique characteristics and clinical needs of children with ASD. A case study is presented in which CBT was utilized in the successful treatment of an 11-year-old girl with HFA. The intervention was effective in reducing anxiety and improving social and adaptive functioning. These findings suggest that an enhanced CBT approach may be a viable intervention for children with comorbid HFA and anxiety disorders that should be further evaluated.     

Emotion-Focused Cognitive-Behavioral Therapy for Youth with Anxiety Disorders: A Randomized Trial

Difficulties with emotion regulation are a core feature of anxiety disorders (ADs) in children and adults. Interventions with a specific focus on emotion regulation are gaining empirical support. Yet, no studies to date have compared the relative efficacy of such interventions to existing evidence-based treatments. Such comparisons are necessary to determine whether emotion-focused treatments might be more effective for youth exhibiting broad emotion-regulation difficulties at pretreatment. This study examined an emotion-focused cognitive-behavioral therapy (ECBT) protocol in comparison to traditional cognitive-behavioral therapy (CBT) in a sample of children with a primary anxiety disorder diagnosis. Moderation analyses examined whether children with higher levels of emotion dysregulation at pretreatment would show greater levels of improvement in ECBT than CBT. Ninety-two youth ages 7 to 12 years (58% male) with a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia were included. Participants were randomly assigned to ECBT or CBT. Results showed that youth in both conditions demonstrated similar improvements in emotion regulation and that pretreatment levels of emotion dysregulation did not moderate treatment outcomes. Additional analyses showed that ECBT and CBT were similarly effective on diagnostic, severity, and improvement measures. Future work is needed to further explore the ways that emotion regulation is related to treatment outcome for anxious youth.     

An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents

Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive–compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.     

Alliance-Outcome Associations in a Community-Based Social Skills Intervention for Youth With Autism Spectrum Disorder

Although the alliance is a consistent predictor of treatment outcomes in psychosocial interventions, few studies have examined this association among youth with autism spectrum disorder (ASD). In particular, youth-therapist alliance has never been examined in social skills interventions (SSIs), a common modality for this population. In this study, thirty-four youth with ASD (M_age = 12.41; 79% male) participated in a community-delivered, group-based SSI in a summer camp format led by eight Head Therapists (M_age = 32.12; 50% male). Early alliance and change in alliance over the course of the treatment were assessed via self- and observer-reported measures. Both self- and observer-rated alliance were associated with positive treatment outcomes as reported by parents (decreased problem behaviors) and other peers in the group (reciprocated friendship and social preference). These results provide the first evidence of the role of the alliance in an SSI for youth with ASD and add to the growing body of literature that demonstrates the importance of assessing and addressing the alliance in treatment for this population.     

Show-That-I-Can (Homework) in Cognitive-Behavioral Therapy for Anxious Youth: Individualizing Homework for Robert

Cognitive-behavioral therapy (CBT) has been reviewed and described as an empirically supported treatment for anxious youth. One component of CBT is the use of out-of-session “Show That I Can” tasks (STIC; i.e., homework tasks). STIC tasks vary in content and are to be completed between sessions. We discuss homework in CBT for Robert, a 13-year-old boy with social anxiety. Robert experienced distressing anxiety participating in and giving presentations at school and was fearful of open-ended questions. Robert had difficulty maintaining conversations with peers and reported being preoccupied with a concern that he would say something “weird” or “stupid.” Robert avoided numerous situations, and his social anxiety affected his grades, social interactions, family, and quality of life. Robert’s initial homework tasks entailed (a) journaling and self-monitoring anxious feelings and thoughts, and (b) practicing relaxation skills. During the second half of treatment, Robert’s STIC assignments were exposure tasks, including (a) opinion discussion assignments, (b) participating in class, and (c) initiating conversations with children at the bus stop. The present discussion focuses on how homework was individualized and presented so that it was palatable and sensitive. Issues regarding out-of-session exposure tasks that elicit sufficient anxiety, resistance to high-level exposure tasks, and parent involvement are explored.     

Acceptability of aversive procedures and medication as treatment alternatives for deviant child behavior

The present investigation evaluated the acceptability of alternative treatments for deviant child behavior. Clinical cases of children who displayed severe behavioral problems at home and at school were described along with three different treatments. The treatments, time-out from reinforcement, locked seclusion, and medication, were rated by psychiatric inpatient children and parents in a 3 × 3 replicated Latin-square design. The investigation also evaluated whether acceptability ratings were influenced by the clinical effectiveness of treatment in altering behavior. Although children and parents did not differ overall in acceptability ratings, they differed in their ranking of different treatments. Children viewed medication as the most acceptable treatment, whereas parents viewed time out as the most acceptable treatment. For both children and parents, treatments described as producing marked effects were rated as more acceptable than treatments producing weaker effects. The results indicated that disturbed children and their parents can readily distinguish the acceptability of alternative treatments. The implications of treatment acceptability for clinical applications of treatment are discussed.Completion of this investigation was facilitated by a Research Scientist Development Award (MH00353) and a grant (MH35408) from the National Institute of Mental Health. The author is grateful for the assistance of the clinical research team of the Child Psychiatric Treatment Service, especially that of Irene Heidish, M.A., who assisted with the data analyses.     

Using a Smartphone App and Clinician Portal to Enhance Brief Cognitive Behavioral Therapy for Childhood Anxiety Disorders

Cognitive behavioral therapy (CBT) is an efficacious treatment for child anxiety disorders, but 40%–50% of youth do not respond fully to treatment, and time commitments for standard CBT can be prohibitive for some families and lead to long waiting lists for trained CBT therapists in the community. SmartCAT 2.0 is an adjunctive mobile health program designed to improve and shorten CBT treatment for anxiety disorders in youth by providing them with the opportunity to practice CBT skills outside of session using an interactive and gamified interface. It consists of an app and an integrated clinician portal connected to the app for secure 2-way communication with the therapist. The goal of the present study was to evaluate SmartCAT 2.0 in an open trial to establish usability, feasibility, acceptability, and preliminary efficacy of brief (8 sessions) CBT combined with SmartCAT. We also explored changes in CBT skills targeted by the app. Participants were 34 youth (ages 9–14) who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder. Results demonstrated strong feasibility and usability of the app/portal and high satisfaction with the intervention. Youth used the app an average of 12 times between each therapy session (M = 5.8 mins per day). At posttreatment, 67% of youth no longer met diagnostic criteria for an anxiety disorder, with this percentage increasing to 86% at 2-month follow-up. Youth showed reduced symptom severity over time across raters and also improved from pre- to posttreatment in CBT skills targeted by the app, demonstrating better emotion identification and thought challenging and reductions in avoidance. Findings support the feasibility of combining brief CBT with SmartCAT. Although not a controlled trial, when benchmarked against the literature, the current findings suggest that SmartCAT may enhance the utility of brief CBT for childhood anxiety disorders.     

Acceptability of a brief computerized intervention targeting anxiety sensitivity

Despite the well-documented efficacy of cognitive behavioral treatments for anxiety disorders, the acceptability of these treatments remains an under-researched area. A better understanding of acceptability could help to improve the initiation of, and engagement in, these effective interventions. Recent research has suggested computerized interventions of anxiety-related risk factors may be one way to improve acceptability and overcome several common barriers to treatment. Considering this, the current study tested the acceptability of a computerized, anxiety sensitivity (AS)-focused treatment among a sample of treatment-seeking community participants and military veterans (N = 58). Results indicated that the majority of participants rated the intervention as acceptable, and that drop-out rate was low (ie 5%). Moreover, higher acceptability scores were associated with older age, veteran status, lower income levels, African-American race, and being separated/divorced. Findings suggest that a computerized AS-focused treatment may be an acceptable treatment method, and may have advantages in acceptability for hard to reach populations.     

Perceptions of the acceptability of parent training among Chinese immigrant parents: contributions of cultural factors and clinical need

Parent training (PT) is well established for reducing child externalizing problems; however, lower rates of engagement in PT among ethnic minority/immigrant families have been found. We assessed PT acceptability among Chinese immigrant parents and explored clinical and cultural factors that may be associated with acceptability. Participants were a community sample of 145 Chinese immigrant parents (84% mothers) between the ages of 32 and 65 years (M=43.3 years, SD=6.2) who had children (84 boys, 59 girls) between the ages of 4 and 17 years (M=10.7 years, SD=3.6). Results suggest that parents found positive reinforcement techniques significantly more acceptable, less problematic, and more likely to be supported by others than punishment-based techniques. Parents who endorsed the Chinese child-rearing value of shaming were less likely to find PT acceptable. Parents who reported greater dysfunction in parent-child interactions rated PT as more acceptable, and families with prior Child Protective Services (CPS) involvement rated PT as less acceptable. However, previous mental health treatment appears to bolster acceptability among parents with prior CPS involvement. Clinical implications for addressing barriers to PT engagement and future research directions are discussed.