COGNITIVE-BEHAVIORAL GROUP TREATMENT FOR ANXIETY SYMPTOMS IN CHILDREN WITH HIGH-FUNCTIONING AUTISM SPECTRUM DISORDERS Judy Reaven and Susan Hepburn Anxiety disorders are among the most common psychiatric conditions that present during childhood and often co-occur with other diagnoses (Compton et al., 2004). Individuals with developmental disabilities are at increased risk for developing anxiety disorders and children with high-functioning autism and Asperger Syndrome are at even greater risk for developing significant anxiety symptoms (Brereton, Tonge & Einfeld, 2006; Lainhart, 1999). The presence of anxiety symptoms can interfere significantly with the child s ability to participate in home, school, and community activities (Russell & Sofronoff, 2005). Additionally, children with significant anxiety symptoms are at risk for serious educational problems, later underemployment, substance abuse, and other psychiatric problems (Velting, Setzer & Albano, 2004). Studies of the effectiveness of treatment for reducing anxiety symptoms in children with ASD have focused primarily on medications such as anxiolytics (Buitelaar, van der Gaag & van der Hoeven, 1998) and serotonergic agents (Aman, Arnold & Armstrong, 2000; Potenza, Holmes, Kanes & McDougle, 1999). Cognitive behavioral therapies are often viewed as the intervention of choice when treating anxiety symptoms in the general population (Compton et al. 2004). By definition, cognitive behavioral therapies (CBT) assume that most of behavior is meaningful and purposeful, and that there is an interaction between thoughts, feelings and behaviors. Thus, CBT for children focuses on understanding that behavior is influenced by cognitions/thoughts and other perceptual experiences, and that by improving coping strategies, affect regulation and problem solving skills, behavior improves (Reinecke, Dattilio & Freeman, 2003). Although there is a vast literature supporting the effectiveness of cognitive-behavioral treatment (CBT) of anxiety symptoms in typically developing children (Compton et al. 2004), studies that have examined the use of CBT for anxiety symptoms in persons with ASD are limited; however, published case studies are promising (Hare, 1997; Reaven & Hepburn, 2003). 1
An additional treatment study implemented a brief group CBT intervention to reduce anxiety symptoms in children with Asperger Syndrome with positive results (Sofronoff, Attwood & Hinton, 2005). The purpose of the present study was to assess the effectiveness of an original, manualized, cognitive-behavioral group treatment with parental involvement, in the reduction of anxiety symptoms in children with high-functioning ASD. The intervention targeted social, separation, and generalized anxiety symptoms (Sep, Soc, and GAD). METHOD Participants Thirty-three children with ASD (Autistic Disorder: n = 15; Pervasive Developmental Disorder: n = 4; Asperger Disorder, n = 14), between the ages of 8 and 14 years, and their mothers (n = 31) or fathers (n = 2) participated in this study. See Table 1 for participant characteristics by treatment condition. Mean age of the children upon entry was 11 years, 10 months, (or 132.20 months with a standard deviation of 22.80 months; and a range of 97 to 177 months). TABLE 1 ABOUT HERE Inclusion and exclusion criteria Inclusion criteria for child participants included: (1) chronological ages between 7 and 14 years, and (2) a diagnosis on the autism spectrum. Participants were also required to have an overall IQ above 70 and be verbally fluent because of the language demands of the treatment protocol. Only children with significant anxiety symptoms were included in the present study. 2
On a first-come, first-serve basis, families were invited to join intervention groups. The first 10 parent-child dyads completed their baseline anxiety assessment and entered active treatment immediately (two groups of 5 families being conducted simultaneously). Twenty-three children were assigned to an age cohort (i.e. young : ages 8-10 years; and older : ages 11-14 years) for the wait-list control group, receiving treatment as usual in their community. Groups were not significantly different on age, IQ or severity of anxiety symptoms. All children in the wait-list condition eventually received the intervention. Measures Pre-Treatment: Qualification Measures Autism Diagnostic Observation Scale (ADOS; Lord et al., 1999) The Social Communication Questionnaire (SCQ; Berument et al.,1999) Wechsler Abbreviated Scales of Intelligence (WASI, PsychCorp, 1999), or Wechsler Intelligence Scales for Children : Version IV (Wechsler et al, 2003 Pre-Treatment: Anxiety Battery Screening for Childhood Anxiety and Related Emotional Disorders (SCARED; Birmharer, et al., 1999) (parent/child versions) Leyton Obsessional Inventory (Berg, Whitaker, Davies, Flament, & Rapoport, 1988) (parent/child versions) Six-month and 12-month follow-up. Six and twelve month follow-up assessments occurred. Treatment Protocol: There are three manuals in the protocol one for parents, one for children, and a set for facilitators. The current treatment protocol involved 12 weekly sessions each lasting 1 ½ hours. Large group time, separate parent and child group meetings, and parent/child dyads comprised the weekly sessions (Reaven, Hepburn, Nichols, Blakeley-Smith, & Dasari, unpublished treatment manual). Many of the concepts that are outlined in these manuals are based on mainstream cognitive-behavioral approaches discussed by well-known researchers (e.g. 3
Albano, Barrett, Dadds, Kendall, March, Silverman, etc.) but have been modified to meet the cognitive, linguistic and social needs of children with ASD. Child Component: The goals of the child component are as follows: 1) Identify anxious symptoms and situations, 2) Make the connection between the body s reaction and cognitive interpretation of the physiological responses, 3) Generate tools to resist anxiety, such as relaxation, helpful thoughts and other cognitive restructuring strategies, 4) Create a stimulus hierarchy rank-ordering of fears in preparation for graded exposure assignments, 5) Complete assignments at home and in-session that include graded exposure tasks, 6) Self-evaluate and deliver self-reinforcement, and 7) Write, direct and star in a series of short films ( Facing your Fears ), depicting children facing fears in a variety of contexts. Parent Component: The parent component includes: 1) Psycho-education of anxiety disorders and introduction to the basic principles of CBT, 2) Identification of the child s specific anxiety symptoms, 3) Identify target behaviors in preparation for graded exposure assignments, 4) Discuss parental anxiety and parenting style, and 5) Discuss the social and communicative challenges inherent in ASD and how these challenges may lead to a protective parenting style (Reaven & Hepburn, 2006). RESULTS Attrition and participation Of the 33 families eventually enrolled in treatment, 31 completed the 12-week course, resulting in a low attrition rate of 6%. Attendance rate was 96%. Parent and Child Ratings on the SCARED A 2 Group (Active Treatment vs. Wait-List) x 2 Time (Pretreatment vs. Post-treatment) repeated measures ANOVA of parent report of symptoms on the SCARED revealed a significant effect for Time, F(1,30) = 24.20, p =.00, and a significant Group X Time interaction effect, F(1,30) = 19.52, p = 00 (see Table 2). Thus, according to parent report, children in the active treatment group experienced a significant decrease in severity of anxiety symptoms over 4
time, whereas children in the waitlist group did not. See Figure A for total SCARED scores and Figure B for domain scores on the SCARED. TABLE 2 ABOUT HERE FIGURES 1 & 2 ABOUT HERE In contrast, when looking at child report on the SCARED, a 2 (Active Treatment vs. Wait- List) x 2 (Pretreatment vs. Post-treatment) repeated measures ANOVA revealed no significant effects for Time F(1,27) =.67, p =.43; no effects for Group F(1,27) = 2.63, p=.12; and no interaction effects: F(1,27) =.02, p =.99. Parent and Child Ratings on the Leyton Obsessional Inventory effects. Neither parent report nor child report of symptoms on the Leyton revealed significant Maintenance of Treatment Effects (6- and 12-month follow-up) At the time of this writing, 6-month follow-up data were available for 9 participants and 12-month follow-up data were available for 4 participants. Although not yet analyzed statistically, the data suggest that the children are reporting decreases in anxiety symptoms at follow-up. Means and standard deviations of parent and child report of symptoms on the SCARED are provided in Table 3. TABLE 3 ABOUT HERE DISCUSSION The results of the present study found that parents reported significant decreases in anxiety symptoms in their children following participation in the manualized cognitive-behavior 5
group therapy intervention. These findings are promising and consistent with the results from other studies that have begun to demonstrate the applicability of CBT strategies for individuals with ASD (Reaven & Hepburn, 2003; Sofronoff et al., 2005). Significant reductions in child selfreport of symptoms were not found at post-treatment. However, in a limited sample of follow-up data, children reported decreases in symptoms later (i.e., at 6- and 12-months) and parents reported maintenance of treatment effects; however, these results have not yet been analyzed statistically. No significant changes from pre to post treatment were noted on the Leyton, a specific measure of OCD symptomatology. The null findings for the Leyton are not surprising considering the hypothesized phenomenological differences between OCD and the cluster of socially mediated anxiety symptoms (Sep, GAD, and Soc) (March & Mulle, 1998; Velting et al., 2004). Limitations/Future Directions: The relatively small number of participants and the lack of a randomly assigned comparison group limit the generalizability of the findings. Further, the current study used only two primary measures to assess anxiety symptoms in the children (parent report and child selfreport). Future studies should include the use of multiple methodologies and reports from multiple sources (King et al., 2005). 6
REFERENCES Aman, M. G., Arnold, L. E., & Armstrong, S. C. (2000). Review of serotonergic agents and perseverative behavior in patients with developmental disabilities. Mental Retardation and Developmental Disabilities Research Review, 5, 279-289. Berg, C., Whitaker, A., Davies, J., Flament, M. & Rapoport, J. (1988). The survey form of the Leyton Obsessional Inventory child version: Norms from an epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 759-763. Berument, S.K., Rutter, M., Lord, C., Pickles, A., & Bailey, A. (1999). Autism screening questionnaire: Diagnostic validity. British Journal of Psychiatry, 175, 444-451. Birmaher, B., Brent, D., Chiapetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED). Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1230 1236. Brereton, A., Tonge, B. & Einfeld, S. (2006). Psychopathlogy in children and adolescents with autism compared to young people with intellectual disability. Journal of Autism and Developmental Disorders, 36, 863-870. Buitelaar, J., Van der Gaag, R., & Van der Hoeven, J. (1998). Buspirone in the management of anxiety and irritability in children with pervasive developmental disorders. Results from an open-label study. Journal of Clinical Psychology, 59, 56-59. Compton, S.N., March, J.S., Brent, D., Albano, A.M., Weersing, R., & Curry, J. (2004). Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: An evidence-based medicine review. Journal of American Academy of Child and Adolescent Psychiatry, 43, 930-959. 7
Hare, D.J. (1997). The use of cognitive-behavioral therapy with people with Asperger syndrome: A case study. Autism, 1, 215-225. King, N., Muris, P., and Ollendick, T. (2005). Childhood fears and phobias: assessment and treatment. Child and Adolescent Mental Health: (p. 50-56). United Kingdom Blackwell Publishing Ltd. 102. Lainhart, J. E. (1999). Psychiatric problems in individuals with autism, their parents and siblings. International Review of Psychiatry, 11, 278-298. Lord, C., Rutter, M., DiLavore, P., & Risi, S. (1999). Autism Diagnostic Observation Schedule WPS Edition. Los Angeles, CA: Western Psychological Services. March, J. & Mulle, K. (1998). OCD in children and adolescents: a cognitive-behavioral treatment manual. New York: The Guilford Press. Potenza, M. N., Holmes, J. P., Kanes, S. J., & McDougle, C. J. (1999). Olanzapine treatment of children, adolescents, and adults with pervasive developmental disorders: An open-label pilot study. Journal of Clinical Psychopharmacology, 19, 37-44. Reaven, J., & Hepburn, S. (2003). Cognitive-behavioral treatment of obsessive-compulsive disorder in a child with Asperger s Syndrome: A case report. Autism: International Journal of Research and Practice, 7, 145-164. Reaven, J., & Hepburn, S. (2006). The parent s role in the treatment of anxiety symptoms in children with autism spectrum disorders. Mental Health Aspects of Developmental Disabilities, 9, 73-80. Reaven, J. Hepburn, S., Nichols, S., Blakeley-Smith, A., & Dasari, M. Coping group: Fighting worry and facing fears: An unpublished treatment manual for children with ASD and anxiety disorder. University of Colorado at Denver and Health Sciences Center, Denver, CO. Reinecke, M., Dattilio, F., & Freeman, A. (2003). Cognitive therapy with children and adolescents, The Guilford Press, New York. 8
Russell, E. & Sofronoff, K. (2004). Anxiety and social worries in children with Asperger syndrome. Australian and New Zealand Journal of Psychiatry, 39, 633-638. Sofronoff, K., Attwood, T. & Hinton, S. (2005). A randomized controlled trial of a CBT intervention for anxiety in children with Asperger syndrome. Journal of Child Psychology and Psychiatry, 46, 1152-1160. Velting, O., Setzer, J, & Albano, A. (2004). Update on and advances in assessment and cognitive-behavioral treatment of anxiety disorders in children and adolescents. Professional Psychology Research and Practice, 35, 42-54. Weschler, D. (1999). Weschler Abbreviated Scale of Intelligence (WASI), Psychological Corporation: San Antonio, Texas. Weschler, D. (2003). Weschler Intelligence Scale for Children Fourth Edition (WISC-IV). Administration and Scoring Manual, Psychological Corporation: San Antonio, Texas. 9
Table 1 Participant characteristics Active Treatment Wait-list Control (n = 10) (n = 23) Demographic variables n % n % Sex Male 7 70 19 82.6 Female 3 30 4 17.4 Ethnicity White 8 80 19 82.6 African-American 1 10 1 4.3 Hispanic 1 10 1 4.3 Other 0 0 2 8.6 Mother s education High school graduate 0 0 2 8.7 Some college 3 30 6 26.1 College graduate 4 40 8 34.8 Post-college 3 30 6 26.1 Missing 0 0 1 4.3 Autism spectrum disorder Autistic disorder 3 30 12 52.2 Pervasive developmental disorder not otherwise 2 20 2 8.7 specified Asperger syndrome 5 50 9 39.1 Primary anxiety diagnosis of child Generalized anxiety 7 70 15 65.2 Separation anxiety 2 20 4 17.3 Social anxiety 1 10 4 17.4 Medications Anti-anxiety or antidepressant 3 30 12 52.2% Other psychotropic medicines 3 30 15 65% Vitamins/supplements 6 60 20 87% Restricted diet 2 20 8 34% 10
Table 2 Means and standard deviations of parent and child report on the SCARED by treatment condition Active Treatment (n =10) Wait-list Control (n = 23) Measure Pre-Tx Post-Tx Pre-Tx Post-wait 1 Parent Report TOTAL SCARED SCORE M (SD) 32.70 (12.21) 19.53 (8.82) 29.35(10.69) 27.33 (8.85) Range 20-54 9-38 7-51 9-52 PANIC SYMPTOMS M (SD) 4.40 (4.2) 2.34 (2.54) 5.91 (4.55) 5.76 (4.44) Range 0-15 0-7 1-18 1-19 GENERALIZED ANXIETY M (SD) 9.94 (2.61) 6.20 (2.86) 9.84 (3.82) 9.14 (3.16) Range 5-13 2-12 3-16 2-17 SEPARATION ANXIETY M (SD) 4.92 (3.87) 2.60 (2.63) 5.13 (4.39) 4.60 (2.81) Range 1-13 0-8 0-16 0-11 SOCIAL ANXIETY M (SD) 9.40 (3.12) 6.80 (2.25) 6.82 (5.32) 6.57 (3.47) Range 5-14 4-12 0-14 0-14 SCHOOL ANXIETY M (SD) 1.80 (2.09) 1.5 (1.95) 2.43 (1.94) 1.27 (1.16) Range 0-7 0-3 0-7 0-3 Child Report TOTAL SCARED SCORE M (SD) 25.67 (9.84) 20.50 (12.69) 26.09 (11.99) 24.85 (16.34) Range 4-34 1-31 3 48 4-64 PANIC SYMPTOMS M (SD) 4.67 (4.72) 3.33 (3.07) 6.04 (3.67) 5.60 (5.94) Range 1-15 0-8 0 15 0-21 GENERALIZED ANXIETY M (SD) 5.33 (4.15) 4.33 (2.50) 6.23 (3.89) 6.45 (6.14) Range 0-14 0-7 0-14 0-16 SEPARATION ANXIETY M (SD) 4 (3.87) 2.83 (2.40) 6.09 (3.09) 5.90 (5.14) Range 0-11 0-6 0-13 0-21 SOCIAL ANXIETY M (SD) 6.89 (3.44) 6.33 (3.72) 7.23 (4.25) 6.50 (4.53) Range 2-13 0-10 1-14 0-14 SCHOOL ANXIETY M (SD) 2.44 (1.87) 2.83 (2.10) 2.05 (1.60).91 (.03) Range 0-5 1-6 0-6 0-2 1 N = 21; 2 families did not participate in post-treatment assessments, citing busy schedules 11
Table 3 SCARED scores for the entire sample before and after treatment, with follow-up at 6 and 12 months Pre Post-tx 6-month follow-up (n = 9) 12-month follow-up (n = 4) (n = 33) (n = 31) Parent Report TOTAL SCARED SCORE M (SD) 30.36 (11.10) 19.68 (8.57) 18.22 (7.56) 17.67 (11.50) Range 7-54 3-38 3-26 6-29 PANIC SYMPTOMS M (SD) 5.45 (4.46) 3.12 (2.92) 3.00 (2.78) 3.0 (2.65) Range 0-18 0-10 0-9 1-6 GENERALIZED ANXIETY M (SD) 9.79 (3.45) 6.12 (2.57) 5.22 (12.17) 5.67 (2.52) Range 3-16 2-13 2-8 3-8 SEPARATION ANXIETY M (SD) 5.06 (4.18) 3.20 (3.07) 3.00 (2.71) 3.33 (3.51) Range 0-16 0-12 0-9 0-7 SOCIAL ANXIETY M (SD) 7.61 (4.94) 5.68 (3.17) 4.89 (2.14) 4.05 (2.65) Range 0-14 0-12 0-7 2-7 SCHOOL ANXIETY M (SD) 2.24 (1.98) 1.36 (1.49) 1.44 (1.92) 1.33 (2.33) Range 0-7 0-5 0-4 0-4 Child Report TOTAL SCARED SCORE M (SD) 24.52 (11.52) 21.41 (12.38) 17.22 (5.85) 14.67 (10.47) Range 3-48 1-49 7-24 3-31 PANIC SYMPTOMS M (SD) 5.64 (3.97) 3.94 (4.39) 3.11 (3.0) 2.67 (3.79) Range 0-15 0-16 1-7 0-7 GENERALIZED ANXIETY M (SD) 5.97 (3.71) 5.41 (3.57) 4.0 (3.0) 4.0 (4.35) Range 0-14 0-13 0-8 1-9 SEPARATION ANXIETY M (SD) 5.48 (3.95) 3.59 (2.89) 2.11 (1.76) 2.33 (4.04) Range 0-13 0-9 0-9 0-7 SOCIAL ANXIETY M (SD) 7.13 (3.98) 6.17 (3.56) 6.17 (3.56) 6.00 (4.58) Range 1-14 0-10 0-10 2-11 SCHOOL ANXIETY M (SD) 2.16 (1.69) 1.58 (1.67) 1.44 (1.13) 2.0 (2.0) Range 0-6 0-4 0-3 0-4 12
Mean score Figure 1 Effects of Treatment on Parent Total Score on SCARED Active Wait-List 35 30 25 20 15 10 5 0 Pre Time Post Figure 2 Pre- and Post-Treatment Parent Report Scores by SCARED Domain (n=33) 12 10 8 6 4 PANIC GAD SEP SOC SCHOOL 2 0 PRE-TX POST-TX 13