have only been six published randomized controlled trial (RCT) studies of group CBT for youth with ASD and co-occurring anxiety disorders (Chalfant et al., 2007; Murphy et al., 2017; Reaven et al., 2012; Sofronoff et al., 2005; Sung, 2011; and White et al., 2013). As discussed above, two of these utilised a multi-modal approach that additionally targeted social skill improvement.
Group treatment is an economical alternative to individual therapy, which is often expensive for parents and therefore difficult to access. Despite suggestions that the linear format of group therapy limits matching intervention techniques to client characteristics among the general paediatric population (Kerns et al., 2016; Wood et al., 2014), group treatment has shown to be at least as effective as individual treatment (Rapee, 2000). Finally, group treatments provide the opportunity for adolescents to share their experiences and normalise their feelings of isolation. With significant social difficulties the opportunity to practice important social skills in a supportive environment can be highly beneficial, particularly for older adolescents with ASD who
are often wanting social relationships but lack the necessary skills to initiate and maintain them (Reaven 2009).
The majority of group CBT anxiety treatment studies have focused on children with ASD. For example, Sofronoff and colleagues (2005) compared child-only and child + parent CBT groups to a waitlist control. Seventy-one children aged 10-12 years with Asperger’s disorder and parent-reported anxiety (OCD, social phobia, separation anxiety disorder and/or GAD) attended six weekly CBT sessions. Using the “Exploring Feelings” (Attwood, 2004) program specific to anxiety management, these researchers found a significant reduction in anxiety symptoms for both treatment groups in comparison to the waitlist group.
Children in the child + parent group demonstrated greater improvement than the child-only group and these results were mainly observed at the 6-week follow-up on the Spence Child Anxiety Scale—Parent version (SCAS-P; Nauta et al., 2004) and the Social Worries Questionnaire (SWQ-P; Spence, 1995). The vignette used as a measure, “James and the Math Test”, demonstrated significant improvement in the number of strategies children were able to give to cope with anxiety-producing situations. While this study used an experimental design, it lacked blinding procedures. In addition, parents in the child + parent condition may have been more likely to expose their children to, and coach them through, anxiety-provoking situations than parents of children in the child-only condition.
Similar results were found in Chalfant and colleagues’ (2007) study whereby the authors adapted the Cool Kids Program (Lyneham, Abbott, Wignell, & Rapee, 2003) to better suit the needs of children and early adolescents with ASD. This program incorporated graded exposure and emphasised relaxation techniques, visual strategies in the cognitive restructuring component, and included simplification of cognitive restructuring tasks (e.g., listing helpful and unhelpful thoughts). The program was also extended to six months in length (9 weekly and 3 monthly 2-hour sessions). Each week parents attended a concurrent session that included psychoeducation, anxiety coping exercises, exposure planning, parent management training, and relapse prevention. Similar to the protocols used by Sofronoff et al., (2005) and Wood et al., (2009), parents were encouraged to serve in the role of “coach” or “co-therapist”, to support the delivery of interventions. Together, therapists and parents planned exposure tasks and, consistent with best practice in CBT, these were implemented and rehearsed outside of sessions (Albano & Kendall, 2002). Forty- seven children (aged 8-13 years) with ASD and at least one clinical anxiety disorder
were assigned to either the CBT or waitlist condition. Compared to the waitlist group, the treatment group improved on the Revised Children’s Manifest Anxiety Scale (RMAS-P), Spence Children’s Anxiety Scale (SCAS-P), Children’s Automatic Thoughts Scale, and the Strengths and Difficulties Questionnaire (parent report). Upon completion of the program, 71% of the participants, compared to 0% of the waitlist group, no longer met the criteria for an anxiety disorder diagnosis (Chalfant et al., 2007). Unfortunately, long-term treatment gains are not known since follow-up data was not provided. In addition, the study clinicians conducted the post-treatment diagnostic interview, which may have biased the results (Green & Wood, 2013). Instead, independent evaluators blind to the condition of the participants are likely to have produced more objective results.
In 2008, Reaven and colleagues created an original CBT manual targeting anxiety, as opposed to modifying an existing protocol aimed at typically developing children. They incorporated modifications such as systematic reinforcement, visual aids, and predictable routines, embedding special interests into program content, role- play, video modelling and increased parent participation. They later conducted an RCT implementing random assignment and using independent clinical evaluators blind to condition to conduct pre-and-post assessments (Reaven et al., 2012). Using the Facing Your Fears (FYF) protocol (Facing Your Fears: Group Therapy for Managing Anxiety in Children with High-Functioning ASD; Reaven, Blakely-Smith, Nichols, & Hepburn, 2011) they compared group CBT intervention with treatment-as-usual (TAU) among 50 children with ASD aged 7-14 years. Children in the intervention condition attended 12 group CBT sessions to reduce anxiety with clinicians implementing careful pacing of each session, token reinforcement, visual structure, and predictability of routine, along with additional adaptations (e.g., multiple choice worksheets, hands-on activities, video modelling). In addition, a detailed parent curriculum including anxiety psychoeducation, parent coaching to enhance child participation, and “protective” parenting styles was implemented. Children in the treatment group showed greater reductions in clinician severity ratings of their principal anxiety diagnosis at post-intervention, compared with children in the TAU condition. Those in the treatment condition also met diagnostic criteria for significantly fewer overall number of anxiety diagnoses, and as a group, children in the FYF condition were significantly less likely to meet the criteria for GAD than those in the TAU condition. This latter finding is of interest considering previous research has cited challenges with treatment motivation in participants with a sole diagnosis of
GAD (Wood et al., 2009). All participants who received FYF intervention continued to meet criteria for SEP, SOC and SP diagnoses at post-treatment. Although a small sample of respondents, treatment gains appeared to be maintained for the FYF group at 3- and 6-month follow-up. Differences between the two groups at post-treatment may have been compromised given that some control participants continued to engage in treatment outside of study. The study researchers suggest that future studies include functional measures of success such as school attendance, improved social relationships, and quality of life.
The first anxiety RCT to compare CBT to another treatment type for youth with ASD has been conducted by Sung et al. (2011). Here, 70 children (9-16 years; mean age of 11 years) were randomly assigned to either a 16-week CBT or Social Recreational program. The SCAS-C and the CGI-S measures were taken at pre-, post- treatment, and follow-up (3- and 6-months). Significantly lower levels of generalised anxiety and total anxiety symptoms were found for participants in both programs at 6- month follow-up on the SCAS-C. An increase in the percentage of participants rated as ‘‘Normal’’ and ‘‘Borderline’’ for both programs were found on the clinician ratings on the CGI-S. Standard components in both treatments included regular sessions in a structured setting, consistent therapists, social exposure and the use of ASD-friendly strategies, and hence may be integral to anxiety reduction programs for children and adolescents with ASD (Sung et al., 2011). Since parent training was not included this may have impacted on the generalisation of skills to other settings. This study is likely to be the first in an Asian setting therefore providing preliminary evidence for the effectiveness of CBT in an Asian cultural context (Sung et al., 2011).
Despite some methodological concerns, group CBT treatment studies have demonstrated success in reducing anxiety in children with ASD (e.g., Chalfant et al., 2007). However, there is a scarcity of RCTs investigating anxiety reduction in adolescents, particularly older adolescents.
2.4.4 Adolescents/adults with ASD and anxiety. Providing CBT to ASD