Monday 13 October 2014

Cognitive-Behavioural Therapy (CBT) for anxiety in autism

I'll readily admit that despite having a tinge of psychology running through my research career, I'm not overly enthused about the impact of the discipline on the autism spectrum down the years. I'm not necessarily just talking about the Freudian effect which set autism research back decades and shamefully added needless worry and stigma to those on the spectrum and their loved ones, but also the grand over-arching psychological theories which seemed, for example, to completely miss the 'heterogeneity' aspect to the condition(s) nor seemingly took into account the importance of comorbidity. Thankfully psychology is trying to make amends for its past sins when it comes to autism as per the article by Happé and colleagues [1] which also featured in a recent special edition of The Psychologist (see here). That being said, old habits still seemingly die hard [2] and 'unifying' generalisations still abound...
"Farewell and adieu to you, fair Spanish ladies"

With all this in mind, I've always been a little hesitant when it comes to the application of psychological therapies to autism. I'm not necessarily talking about the various behavioural/educational interventions [rightly or wrongly] put forward with autism in mind, but more the 'talking therapies' and in particular, the idea that cognitive-behavioural therapy (CBT) might be something to consider for at least some of those on the autism spectrum.

The paper by Danielle Ung and colleagues [3] has kinda restored my faith in how psychology might yet be useful to helping some aspects of daily living for some on the spectrum; specifically with a focus on abating the often crippling effects of comorbidity such as anxiety. Based on their review and meta-analysis, the authors concluded that: "CBT demonstrates robust efficacy in reducing anxiety symptoms in youth with high-functioning ASD [autism spectrum disorder]".

I've talked before on this blog about anxiety and how, for some on the autism spectrum, the effects of anxiety seem to take precedent over and above the effects of autism in a persons day-to-day life. I can't overstate the impact that anxiety can have on a person with autism and how, alongside physiological consequences, there may well be some new triads to look at when it comes to such issues (see here). With all this in mind, anything that can be done to alleviate excessive anxiety from the lives of people with autism should be looked into outside the roads which some might have already travelled. CBT already has some practical use with certain types of anxiety outside of anything directly linked to autism so pairing CBT with anxiety in autism seems like a logical step to take.

The Ung paper is not the first however to report on how CBT might be useful for anxiety comorbid to autism:

  • Sukhodolsky and colleagues [4] similarly meta-analysed the peer-reviewed literature up to 2012 (see here) and found some pretty good effect sizes based on their re-analysis of the cumulative data.
  • Storch and colleagues [5] actually carried out a trial of CBT (versus treatment as usual) with children with autism and "clinically significant anxiety" and suggested that: "CBT adapted for anxious youth with high-functioning ASD demonstrates large effects in reducing anxiety symptoms".
  • Reaven and colleagues [6] concluded similar things based on their group CBT intervention "specifically developed for children with ASD".
  • That being said, the result from Sung and colleagues [7] are also worth mentioning because of their comparison of CBT with a "Social Recreational (SR) program". They reported: "lower levels of generalized anxiety and total anxiety symptoms at 6-month" for both CBT and SR programs and concluded that: "factors such as regular sessions in a structured setting, consistent therapists, social exposure and the use of autism-friendly strategies are important components of an effective framework in the management of anxiety in children and adolescents with ASD". The indication there is that the specific effects of CBT on anxiety in autism may very well turn out not be the whole story as per other activities potentially indicated for some on the autism spectrum (see here).

Psychology still needs to tread carefully when it comes to autism and perhaps hold back from trying to over-psychologise(?) any effect noted from CBT for certain people on the autism spectrum. As per those Sung results, the idea of comparing CBT to interventions outside of just 'treatment as usual' is an area where more investigation needs to be focused so as not to imply that CBT is the be-all-and-end-all for anxiety when present in cases of autism. Further inquiry perhaps also needs to be undertaken into various types of CBT available and whether specific programs [8] might show greater benefits for specific people or groups of people on the spectrum. Also how more physiological measures linked to anxiety, might need to be included in those further investigations to represent something of a more objective measure of effectiveness. All this to make sure that CBT for anxiety in autism does not go the same way as CBT for schizophrenia [9] for example.

Oh, and just before I go, I'm gonna be blogging soon about some of the work on intolerance of uncertainty linked to anxiety in autism as something of a potentially new dimension for looking at the presentation of anxiety in relation to at least some autism.

And now for some (hopefully relaxing) music ... Passenger and Let Her Go.


[1] Happé F. et al. Time to give up on a single explanation for autism. Nat Neurosci. 2006 Oct;9(10):1218-20.

[2] Fletcher-Watson S. et al. Interventions based on the Theory of Mind cognitive model for autism spectrum disorder (ASD). Cochrane Database Syst Rev. 2014 Mar 21;3:CD008785.

[3] Ung D. et al. A Systematic Review and Meta-Analysis of Cognitive-Behavioral Therapy for Anxiety in Youth with High-Functioning Autism Spectrum Disorders. Child Psychiatry Hum Dev. 2014 Sep 23.

[4] Sukhodolsky DG. et al. Cognitive-behavioral therapy for anxiety in children with high-functioning autism: a meta-analysis. Pediatrics. 2013 Nov;132(5):e1341-50.

[5] Storch EA. et al. The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: a randomized, controlled trial. J Am Acad Child Adolesc Psychiatry. 2013 Feb;52(2):132-142.e2.

[6] Reaven J. et al. Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: a randomized trial. J Child Psychol Psychiatry. 2012 Apr;53(4):410-9.

[7] Sung M. et al. Effects of cognitive-behavioral therapy on anxiety in children with autism spectrum disorders: a randomized controlled trial. Child Psychiatry Hum Dev. 2011 Dec;42(6):634-49.

[8] McNally Keehn RH. et al. The Coping Cat program for children with anxiety and autism spectrum disorder: a pilot randomized controlled trial. J Autism Dev Disord. 2013 Jan;43(1):57-67.

[9] Jauhar S. et al. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry. 2014 Jan;204(1):20-9.

---------- Ung D, Selles R, Small BJ, & Storch EA (2014). A Systematic Review and Meta-Analysis of Cognitive-Behavioral Therapy for Anxiety in Youth with High-Functioning Autism Spectrum Disorders. Child psychiatry and human development PMID: 25246292

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