Cognitive-Behavioral Group Therapy for Children with Autism Spectrum Disorders and Anxiety: The Moderating Influence of Negative Cognitions

Background: Anxiety disorders are relatively common in children with Autism Spectrum Disorders (ASD) (White et al., 2009) and modified Cognitive Behavioral Therapies (CBT) for children with ASD have demonstrated promising results (Chalfant et al., 2007; Reaven et al., 2009). In examining the initial efficacy of modified CBT for youth with ASD and anxiety it is important to examine who may respond best to these interventions.  Multiple variables may determine who best responds to treatment.  Attention to cognitions is a central element of CBT interventions; therefore, pre-treatment levels of negative cognitions may be one such factor that may determine treatment response.  This is an especially interesting variable to consider, given questions raised in the literature about the role of cognitions in intervention programs for children with ASD (e.g., Lang et al., 2010).

Objectives: The current study examined whether pre-treatment negative cognitions moderated the relationship between treatment condition (i.e., Facing Your Fears (FYF) vs. Treatment-as-Usual in the community (TAU)) and outcome (i.e., anxiety symptom improvement) among children with ASD. We hypothesized that youth with relatively high levels of negative cognitions would respond better to active treatment than children presenting with low levels of negative cognitions. 

 Methods: The sample was well-characterized using gold standard measures of autism and anxiety (e.g., ADOS, SCARED, ADIS-P). The current sample of 30 children was a subsample from a larger randomized control trial for the FYF program (Reaven et al., in preparation);  a 12-week manualized group CBT program designed for children ages 8-14 with ASD and anxiety (Reaven et al., in press).  Children were randomized into one of two conditions: TAU (n=13) and FYF Intervention (n =17). No significant differences were found between groups on participant’s age or overall cognitive functioning, and most participants were male (n=29). Negative cognitions were measured using the four subscales of the Children’s Automatic Thoughts Scale (CATS; Schniering & Rapee, 2002): Hostility, Social Threat, Physical Threat, and Personal Failure. Symptom improvement was measured by the Clinical Global Impression Scale - Improvement (CGIS-I; Guy & Bonato, 1970), assigned by an Independent Clinician blind to group assignment.

Results: For each CATS subscale a linear regression analysis was used to assess main and interaction effects of treatment condition and negative cognitions on anxiety symptom change.  The interaction terms for two subscales were significant predictors of anxiety symptom change: Hostility β=-0.62, p<.05 and Social Threat β=-0.52, p<.10, with R² increasing by .17 and .10, respectively. Plots revealed children with relatively high levels of pre-treatment Hostility or Social Threat who received FYF showed better CGIS-I ratings relative to children in the TAU group.  There was no difference in CGIS-I ratings for children with relatively low levels of pre-treatment negative cognitions across groups. 

Conclusions:  For children with ASD and clinical anxiety, pre-treatment levels of certain negative cognitions may be important predictors of who will benefit most from CBT. Limitations include a lack of an attention control group and a limited understanding of the stability of negative cognitions over time.