In children with autism spectrum disorders, 30 to 80% have a comorbid anxiety disorder. Cognitive behavioral therapy is one evidence-based treatment for anxiety, but was hardly studied in autistics. In 2009, Wood et al. carried out a randomized, controlled study of a modified form of family-focused cognitive behavioral therapy in the treatment of anxiety in children with autism spectrum disorders.
The CBT program was expanded to include a module in social skills training, whereby parents and teachers were taught to teach the children social skills, so that in vivo exposure could take place immediately. This was done to optimize generalization from therapy to real life. Children and parents were also trained in adaptive skills. Particularly, parents were motivated to reinforce children’s independence, and children were motivated to learn self-help skills. Lastly, children’s special interests and stereotypies were used in therapy. Firstly, they were used to enhance motivation, such as as rewards, or to enhance comprehension of the therapy, such as by using the special interest as an example. For example, if a child was interested in a particular cartoon character, this character’s thoughts and feelings in fearful situations were discussed. However, later in treatment, children were also taught to suppress their special interests and stereotypies, with the rationale that those interfere with social inclusion.
Beyond these extensions, a standard CBT protocol was followed that helps children identify fear-provoking thoughts and teaches them cognitive restructuring. I missed a module on connecting thought to feeling. As a person who has anxiety, cognitive therapy consistently fails me because I can’t identify the thoughts that lead to anxiety.
Families were randomly assigned to an immediate treatment group and a waiting list condition. Evaluators were blind to group assignment. The treatment was effective as judged by standard measures of clinical outcome. Both global clinical impression as well as the children’s diagnosable anxiety disorders, improved in the immediate treatment group, to the point where half of the treatment group remained anxiety-free for three months post-treatment.
In a further study, Drahota et al. (in press) investigated the effects of this CBT program on the autistic children’s daily living skills. As I said, the original program creators had incorporated training in self-help skills into the CBT program. It seemed this training was particularly motivational, which seems a bit odd to me given that children with autism may have genuine deficits in daily living skills.
The Drahota et al. study starts out, annoyingly, by reinforcing the stereotype that parental over-involvement is the problem for autistics with poor self-help skills. This may’ve been the case in this particular group, but not all autistics with poor daily living skills are spoiled brats.
Children’s daily living skills were assessed using the daily living subscale of the Vineland Adaptive Behavior Scales (VABS). Parental intrusiveness in children’s self-care was also assessed. After the CBT treatment, children’s daily living skills improved and parental over-protection decreased significantly as compared to the waiting list condition. This was correlated with a decrease in anxiety. With regard to daily living skills, however, the improvement was statistically significant, but may not be clinically significant, because the children remained significantly delayed. It is questioned whether a longer or more intensive training program would yield better results or whether autistic children simply hit a developmental wall.
Drahota A, Wood JJ, Sze KM, Van Dyke M (in press), Effects of Cognitive Behavioral Therapy on Daily Living Skills in Children with High-Functioning Autism and Concurrent Anxiety Disorders. Journal of Autism and Developmental Disorders. Published online: May 28, 2010. DOI: 10.1007/s10803-010-1037-4.
Wood JJ, Drahota A, Sze K, Har K, Chiu A, Langer, DA (2009), Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50(3):224-234. DOI: 10.1111/j.1469-7610.2008.01948.x
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