By Lainett Cuarezma
This issue of NASET’s Autism Spectrum Disorder series was written by Lainett Cuarezma from Florida International University. The paper explores several peer-reviewed articles that report on results from therapy conducted on comorbid anxiety in youth with Autism Spectrum Disorder (ASD). First, the researcher synopsizes the description, characteristics, and etiology of ASD. Then reviews how anxiety affects individuals with ASD. Lastly, the researcher discusses how the intervention, known as cognitive behavioral therapy, can benefit individuals with ASD and anxiety. The researcher has used the results from the articles to give recommendations or suggestions based on these findings.
Abstract
This paper explores several peer-reviewed articles that report on results from therapy conducted on comorbid anxiety in youth with Autism Spectrum Disorder (ASD). First, the researcher synopsizes the description, characteristics, and etiology of ASD. Then reviews how anxiety affects individuals with ASD. Lastly, the researcher discusses how the intervention, known as cognitive behavioral therapy, can benefit individuals with ASD and anxiety. The researcher has used the results from the articles to give recommendations or suggestions based on these findings.
Keywords: autism spectrum disorder, anxiety, cognitive behavioral therapy
Autism Spectrum Disorder (ASD) is known for persistent deficits in social communication and interaction and restricted and repetitive patterns of behaviors, interests, or activities (Autism Spectrum Disorder, n.d.). There is a possible relationship between symptoms found in anxiety and autism that cause behaviors to intensify when found together in an individual. Having a treatment that can address both disorder and symptoms present can benefit these individuals in reducing non-conforming behaviors. In order to gain an understanding of how well a therapy can assist in reducing maladaptive behaviors, the question for investigation is proposed: “Does the use of cognitive-behavioral therapy aid in the treatment of anxiety in students with autism?” The articles chosen in this literature review address the disability, the effects of anxiety and ASD, and cognitive behavioral therapy’s impact on individuals with ASD.
Defining Autism
Autism Spectrum Disorder (ASD) is a developmental disorder rapidly increasing in the United States. Only two decades ago, ASD was considered rare, occurring or detected in about 1 in 1,000 children. Now, the prevalence of ASD is 1 in 88 children (Pennington, et al., 2014, p. 1). Individuals with this disability have significant social, communication, and behavioral challenges. Presently ASD is defined as “a single disorder that includes disorders that were previously considered separate, this includes; autism, Asperger’s syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified” (Mahmood, et al., 2015, p. 1). Although there is no known single cause for autism spectrum disorder, it is largely accepted that abnormalities in brain structure or function cause it.
The characteristics of this disability consists of social interaction impairment, communication impairment, and restricted, repetitive, and stereotyped behaviors/interests. The characteristics are described in three broader areas. The first area is social interaction impairment, lack of peer relationships, lack of social-emotional reciprocity, lack of spontaneous joint attention, uncommon or unsuitable body language, awkward movements and facial expressions, and sensitivity to touch. The second area is communication impairment, impaired development of spoken language, impaired ability to initiate or sustain a conversation, stereotyped and repetitive use of language, strange tone of voice- an unusual rhythm or pitch, literal interpretation of language, and lack of expression. The last area is restricted and repetitive behaviors, fixation on specific topics, resistance to change in routines or environment, preoccupation with parts of objects, awkwardness, strange posture, and unusual repetitive movements (Mahmood, et al., 2015).
Anxiety and Autism
As seen in the description of autism spectrum disorder (ASD), some of these descriptors can almost coincide with those behaviors seen in anxiety disorders or those related. Although anxiety is not a core trait in autism, “anxiety symptoms are common in ASD, and diagnosable anxiety disorders occur in approximately 40 % of children and adolescents with ASD” (Conner et al., 2013, p. 1811). When both disorders are present, a decreased response to treatments and weaker relationships with family and teachers are evident (Conner et al., 2013). ASD impairments may, to some extent, contribute to increased stress due to stance and communication difficulties, limited flexibility, and sensory sensitivities. An increase in stereotypical and challenging behaviors could result as a consequence of efforts to reduce high levels of anxiety-related arousal (Magiati et al., 2016). Anxiety in students with ASD can exacerbate behaviors such as social withdrawal, repetitive behaviors, depression, irrational fears, or aggression to oneself or others. The diagnostic overlap between ASD and specific anxiety symptoms may contribute to the more copious amounts of variance explained in generalized anxiety, panic/agoraphobia, and obsessive-compulsive disorder (OCD) symptoms (Magiati et al., 2016). Therefore, anxiety is examined as an underlying issue to the problems that affect children with ASD.
Cognitive- Behavioral Therapy
The concept sustaining CBT is known as the cognitive model. The core idea of the cognitive model is that dysfunctional thinking leads to increased emotional distress and maladaptive behaviors. The therapy requires an individual to engage in both cognitive and behavioral tasks such as identifying automatic thoughts, cognitive monitoring, identifying links between thoughts, feelings and behaviors, cognitive restructuring and behavioral experimentation in order to manage their mood. The therapy is structured, goal-oriented, and time-limited (Cooney, et al., 2018). Cooney et al. (2018) suggest that an individual must be assessed in four areas before implementing CBT. Those areas are as follows: communication skills, cognitive aptitude, capacity to identify emotions, and capacity to understand cognitive components of the CBT model.
Individuals who received CBT as treatment have demonstrated improvement in social communication and reduction in the severity of autism symptoms (Wood et al., 2014). CBT was associated with improved ASD-specific characteristics and reduced functional impairment. Even three months after receiving treatment, the children in the study maintained gains from the therapy, providing preliminary evidence that CBT effects are relatively durable. However, anxiety diagnosis remains evident in 75% of youth receiving CBT. This is due to difficulties with the generalization of learned intervention strategies or reduced use of treatment skills overtime. Children receiving CBT showed to be treatment responders, revealed more significant improvements, and superior results in comparison to treatment as usual, which can include psychosocial and pharmacological treatments (Storch et al., 2013).
Conclusio
Overall, the results of CBT for youth with ASD and anxiety are promising. The studies have shown a reduction in anxiety and, as a result, improved autism symptoms. As seen in the articles, anxiety is prevalent in those with ASD. Anxiety symptoms and ASD symptoms have overlapped in their characteristics and descriptors. In treating one disorder, a reduction in symptoms is evident within both disorders. The results prove that the conditions are treatable, and behaviors can be diminished. CBT focuses on both cognitive and behavioral therapy which assists an individual to explore a problem presented (what is causing the anxiety), the effects (how does it make the person feel), and how to deal with it (coping strategies).
Most of the research found addresses individuals who fall under the ASD diagnosis with higher or more developed communication abilities. For children with more severe symptomatology or difficulties with language and communication, more extensive modifications would have to take place. The duration of the treatment sessions must also be modified. As for most individuals with ASD, it can be a challenge to remain on one task for an extended period. Scaffolding the therapy can be a great strategy to implement along with CBT. Given that children with ASD have trouble expressing and understanding their emotions, having a concrete idea of such emotions and feelings will assist in the delivery of treatment.
Research has indicated that parents play a critical role in the intervention, especially among those with ASD (Storch et al., 2013). Parent involvement is necessary as they may facilitate acquisition in real-life situations and allow the generalization of skills obtained during treatment. Parents may also ensure that the gains obtained from CBT are prolonged and continuous throughout the child’s life. Having both parent and child receive treatment can assist in the efficacy of the intervention and assist in reduced anxiety. As stated by Conner et al. (2013), parents with anxiety are better identifiers and reporters of their adolescent’s anxiety, given their first-hand experience.
Environmental and social factors must also be considered when addressing anxiety in students with ASD. These aspects may contribute to the prevalence of anxiety symptoms and provoke anxiety in these individuals. Efforts should be made to ensure the correct treatment components are selected to fit the child’s most pressing needs. In doing this, CBT can be personalized to each child. Working inconjunct with teachers, therapists, and parents, can facilitate in pinpointing each child’s area of need and capabilities.
References
Autism Spectrum Disorder. (n.d.). Retrieved from www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
Cooney, P., Tunney, C., & O’Reilly, G. (2018). A systematic review of the evidence regarding cognitive therapy skills that assist cognitive behavioural therapy in adults who have an intellectual disability. Journal of Applied Research in Intellectual Disabilities, 31(1), 23-42. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1111/jar.12365
Conner, C. M., Maddox, B. B., & White, S. W. (2013). Parents’ state and trait anxiety: Relationships with anxiety severity and treatment response in adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(8), 1811-1818. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1007/s10803-012-1728-0
Magiati, I., Ong, C., Lim, X. Y., Tan, J. W., Ong, A. Y. L., Patrycia, F., & Howlin, P. (2016). Anxiety symptoms in young people with autism spectrum disorder attending special schools: Associations with gender, adaptive functioning and autism symptomatology. Autism: The International Journal of Research and Practice, 20(3), 306-320. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1177/1362361315577519
Mahmood, H., Saleemi, M., Riaz, H., Hassan, Y., & Khan, F. (2015). Coping Strategies of Mothers with Asd Children. Professional Medical Journal, 22(11), 1454-1463. doi:10.17957/TPMJ/15.3078
Pennington, M. L., Cullinan, D., & Southern, L. B. (2014). Defining Autism: Variability in State Education Agency Definitions of and Evaluations for Autism Disorders. Autism Research Spectrum & Treatment, 1-8. doi:10.1155/2014/327271
Selles, R. R., Arnold, E. B., Phares, V., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2015). Cognitive-behavioral therapy for anxiety in youth with an autism spectrum disorder: A follow-up study. Autism: The International Journal of Research and Practice, 19(5), 613-621. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1177/1362361314537912
Storch, E. A., Arnold, E. B., Lewin, A. B., Nadeau, J. M., Jones, A. M., De Nadai, A. S., & Murphy, T. K. (2013). The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 52(2), 132-142. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1016/j.jaac.2012.11.007
Wood, J. J., Fujii, C., Renno, P., & Van Dyke, M. (2014). Impact of cognitive behavioral therapy on observed autism symptom severity during school recess: A preliminary randomized, controlled trial. Journal of Autism and Developmental Disorders, 44(9), 2264-2276. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1007/s10803-014-2097-7