Luxford, S., Hadwin, J. A., & Kovshoff, H. (2017). Evaluating the effectiveness of a school-based cognitive behavioural therapy intervention for anxiety in adolescents diagnosed with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47(12), 3896-3908.

Reviewed by:
Samreen Rizvi, MA, and Robert H. LaRue, PhD, BCBA-D, Graduate School of Applied and Professional Psychology, Rutgers University

Why research this topic?

Autism spectrum disorder (ASD) refers to a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech, and nonverbal communication. In addition to these impairments, research shows that more than half of the individuals on the spectrum also suffer from anxiety disorders. The prevalence rate for anxiety in children with ASD is considerably higher than in those developing typically. Additionally, teachers report anxiety-related issues among the most common presenting problems for young people on the spectrum in school settings.

Further research has found that these difficulties impact social functioning as well as academic performance. Given the prevalence rate and impact of anxiety on school-aged children with ASD, several treatment approaches have received increased scientific attention. One such treatment is Cognitive Behavioral Therapy (CBT), which addresses the behavioral manifestations of anxiety, as well as the underlying negative cognitions associated with them. Due to the increasing use of this treatment, this study sought to evaluate the effectiveness of school-based CBT on symptoms of anxiety, social worry, and social responsiveness in adolescents with ASD.

What did the researchers do?

Following the completion of the screening requirements for the study, 35 students (aged 11-14 years) were recruited from different schools in southeast England. All participants had a previous diagnosis of ASD, had an IQ greater than 70, and were currently experiencing significant symptoms of anxiety on either a teacher-reported school anxiety scale or parent-reported anxiety scale. These scores were used as baseline measures of anxiety. Eighteen participants were randomly assigned through a computer-generated assignment system to the intervention group (Exploring Feelings CBT intervention), while 17 were assigned to a no-intervention (waitlist/control) group. Intervention groups contained four to six participants. Four groups participated in the study over three months, with two groups running simultaneously for six weeks with a six-week follow-up. Participants assigned to the waitlist control group could receive the same intervention delivered through schools once the study was completed. The primary outcome measure for the study was anxiety, while the secondary measures were social responsiveness and attentional control. At the end of the program, symptoms of anxiety were measured, using the same scales from pre-intervention, to evaluate the effectiveness of the CBT intervention. In addition to anxiety symptoms, researchers sought to determine the impact of CBT on other deficits that usually accompany ASD; including, social responsiveness (i.e., ability to display appropriate social behavior), attentional control (i.e., level of distractibility), and attention to threat (i.e., ability to appropriately recognize and respond to threats in social situations).

What did the researchers find?

Following CBT intervention, adolescents with ASD who received CBT showed greater reductions in anxiety symptoms, school anxiety, and social worry, as reported by parents, teachers, and the participants themselves, as compared to those in the waitlist control group. These results were maintained at a six-week follow-up as well. Further, teachers reported marginally increased social responsiveness for the adolescents in the intervention group, which was more evident at the six-week follow-up. However, the intervention’s impact on attentional control and attention to threat was less clear, as both groups showed reduced interference of threat stimuli to achieve task goals.

What are the strengths and limitations of the study?

The results of this study support previous findings that indicate CBT is an effective intervention for reducing symptoms of anxiety and social worry in a community sample of adolescents with ASD, and where positive effects were maintained six weeks following the intervention. Using a wait-list control group increased the soundness of the research design, as well as the validity of the results. The control group (or the no-intervention group) helped ensure that the reduction in anxiety symptoms in the treatment group was due to the CBT intervention and not any other factor. Additionally, using a community sample allowed researchers to highlight that some neurotypical adolescents attending mainstream school experience anxiety as well, and the identification of elevated anxiety symptoms often go unnoticed and untreated.

The effectiveness of using CBT to increase attentional control and improve attention bias to threat has already been established in previous studies (e.g., review by Kreslins et al., 2015). Although parent-reported symptoms in the current study did associate poor attentional control and heightened perception to threat stimuli with their adolescents’ anxiety symptoms, the results of the study did not find any significant links between better attentional control or reduced threat bias and CBT intervention. Both groups showed increased resistance to distraction post-intervention and in follow-up. This might support the proposition that instead of an intervention such as CBT, individualized attention, objective thinking, and a chance to re-appraise anxiety-provoking thoughts might play a role in mood regulation, improving attentional control, and reducing bias to threat stimuli.

Other limitations of this study were also discussed. One limitation appears to be the lack of a control group that would test the effectiveness of CBT relative to other behavioral interventions. Additionally, the study included no formal measurement of treatment integrity (i.e., the quality and efficacy of individual therapists’ treatments). Finally, the researchers and raters for the study were not blinded to condition allocation at post-intervention or follow-up, leading to potential over-reporting of change in anxiety symptoms.

What do the results mean?

Previous research suggests that for school-based interventions to be effective in terms of generalization and maintenance of effect, strategies that promote these qualities need to be incorporated every day at school and at home. However, studies in the past also show that young people on the spectrum show difficulty generalizing learned social skills to contexts outside of the teaching environment. Such findings are consistent with the current study, which found that parents did not report a change in social responsiveness following the intervention. Therefore, for target skills to generalize to other environments, additional training (e.g., teaching new skills in natural settings and using consequences to reinforce new behaviors) is required for both teachers and parents.

Citation for this article:

Rizvi, S., & LaRue, R. H. (2021). Research synopsis: Evaluating the effectiveness of a school-based cognitive behavioural therapy intervention for anxiety in adolescents diagnosed with autism spectrum disorder. Science in Autism Treatment, 18(1).

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