Clarke, C., Hill, V., & Charman, T. (2017). School based cognitive behavioural therapy targeting anxiety in children with autistic spectrum disorder: A quasi-experimental randomised controlled trial incorporating a mixed methods approach. Journal of Autism and Developmental Disorders, 47(12), 3896-3908. https://doi.org/10.1007/s10803-016-2801-x

Reviewed by Amanda Austin, PsyM and Robert H. LaRue, PhD, BCBA-D
Rutgers, The State University of New Jersey

Why research this topic?

Children with autism have a greater risk of developing anxiety disorders as compared to their typically developing peers. In fact, a recent meta-analysis found that 40% of children with autism have a comorbid anxiety disorder (van Steensel et al., 2010). Cognitive behavioral therapy (CBT) represents an evidence-based approach to supporting autistic children with anxiety (Chalfant et al., 2007; White et al., 2009; Wood et al., 2009). However, the existing literature does not provide information regarding mechanisms of change in the treatment of children with autism using CBT for anxiety. In addition, CBT research has been limited to clinic-based settings, rather than schools. Intervention in school settings may have several benefits, such as proximity to the referral concern (high levels of anxiety in school settings), the familiarity and accessibility of the setting, and the social demands that are inherent in the setting, which allow for practice and generalization of skills learned.

What did the researchers do?

Twenty-eight children aged 11 to 14 were identified across six schools for participation in the study. Participants were referred by their schools for having autism and heightened levels of anxiety. Each school had four to six participants, and schools were randomly assigned to either the control or experimental group. Children in the experimental group participated in six 1-hour treatment sessions using the Exploring Feelings: Cognitive Behavioral Therapy to Manage Anxiety protocol (Attwood, 2004). This program is designed for children with autism and covers topics such as identifying anxious thoughts and behaviors, using relaxation strategies and thinking tools, and creating plans for dealing with anxiety-provoking situations. An anxiety scale (Spence Children’s Anxiety Scale; SCAS) and a coping scale (Coping Scale for Children and Youth; CSCY) were administered prior to the start of the intervention, immediately following the intervention, and 6-8 weeks after the conclusion of the intervention. In addition, semi-structured interviews with the children and their parents were also conducted to gain information about the process of skill development and the impact of the strategies learned. Intervention was withheld for the control group until the completion of study. Control participants received the intervention after all intervention data for the experimental group was completed.

What did the researchers find?

The experimenters sought to test two primary hypotheses. The first hypothesis was a test to determine if children with a diagnosis of autism who take part in a school-based CBT program showed lower levels of anxiety than a control group. The researchers found significant differences between the control and experimental groups after the intervention in anxiety symptoms, behavioral avoidance, and problem solving. That is, participants in the experimental group reported fewer anxiety symptoms than those in the control group at the conclusion of the intervention. Parent and child reports confirmed these findings following intervention.

The second question addressed in the current study was whether autistic children taking part in the CBT program demonstrated different coping mechanisms and engaged in fewer avoidance strategies than the control group. The investigators found that children in the experimental group
reported less behavioral avoidance and greater use of problem solving as a coping behavior than the control group. No significant differences were found between groups in their use of cognitive avoidance or assistance seeking as coping behaviors. At six to eight weeks following the completion of the intervention, the intervention effects were maintained and, interestingly, less cognitive avoidance was reported, indicating a delayed treatment effect. Findings from the parent and child interviews were consistent with these outcomes; parents noted that they noticed gradual improvements in positive coping behaviors. Children expressed recognition of the connection between thoughts and behaviors and reflected on their processing of complex emotions.

What are the strengths and limitations of the study?

The study provided promising evidence for the potential effectiveness of a school-based CBT intervention using a variety of measures, including child and parent versions of the Spence Children’s Anxiety Scale, the Coping Scale for Children and Youth and parent/child interviews. One limitation of the study was its sample. All participants were male, and relatively few participants were included. Because the groups were randomized by school, and not within each school, it is possible that some contextual factors may have influenced scores. Another possible limitation was that the children and their parents were aware of which treatment group they were in, allowing for the possibility of rater bias.

What do the results mean?

The results of the study suggest that school-based CBT may be effective in treating anxiety and promoting positive coping behaviors in children with autism. Significant outcomes were achieved immediately following the intervention and were maintained after 6-8 weeks. Reductions in the use of cognitive avoidance were more gradual, only showing significant differences between groups after the follow-up data were collected.

Citation for this article:

Austin, A., & LaRue, R. (2022). Research Synopsis: School based cognitive behavioural therapy targeting anxiety in children with autistic spectrum disorder: A quasi-experimental randomised controlled trial incorporating a mixed methods approach. Science in Autism Treatment, 19(7).

References: ​

Attwood, T. (2004). Exploring feelings: Cognitive behavioural therapy to manage anxiety. Arlington, TX: Future Horizons.

Chalfant, A. M., Rapee, R., & Carroll, L. (2007). Treating anxiety disorders in children with high functioning autism spectrum disorders: A controlled trial. Journal of Autism and Developmental Disorders, 37, 1842-1857.

van Steensel, F. J. A., Bogels, S. M., & Perrin, S. (2010). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child Family Psychology Review, 14, 302-317.

White, S. W., Ollendick, T., Scahill, L., Oswald, D., & Albano, A. M. (2009). Preliminary efficacy of a cognitive-behavioural treatment program for anxious youth with autism spectrum disorder. Journal of Autism and Developmental Disorders, 39, 1652-1662.

Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioural therapy for anxiety in children with autism spectrum disorders: a randomised, controlled trail. Journal of Child Psychology and Psychiatry, 50(3), 224-234.

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