Cognitive Behavioral Therapy for Anxiety for a Child with Autism Spectrum Disorder and Intellectual Impairment: A Case Study

Background:  

Cognitive behavioral therapy (CBT) is the primary psychosocial therapy for treatment of mood and anxiety disorders in typically developing children. There is emerging literature on interventions for anxiety disorders in children with ASD, with the majority focused on providing modified CBT. Two randomized controlled trials have shown potential for the use of CBT in the treatment of children with ASD who have average to above average intellectual and verbal abilities. However, children with ASD who are higher functioning may be better able to understand the cognitive components of CBT than children with cognitive impairments, and less work has discussed how to address the needs of youth with ASD and intellectual impairment.

Objectives:  

The purpose of the present case study is to describe the use of modifications to The Coping Cat Workbook in the treatment of anxiety of an 8-year-old boy, Chris, with ASD and mild intellectual impairment. The objective of the case study is to provide a description of a number of modifications used to assist Chris in maintaining a relationship with peers with ASD with average IQ within the group intervention, while at the same time learning the Coping Cat material in a way that would help him control his anxiety.

Methods:  

Chris and his family were recruited through a community-based program offered to children with ASD to partake in a CBT program for children aged 8-12. At intake, Chris met clinical cut-off for autism on the ADOS-G and had an estimated Full Scale IQ of 81, with notable difficulties in receptive and expressive language. When anxious, Chris would become verbally and physically aggressive. Due to behavioral difficulties, Chris participated in a modified group therapy that included a substantial individual therapy component. Modifications included the introduction of visual aids as the primary method of treatment delivery, the inclusion of special interests in therapy, physical play activities, and parental involvement. The CBCL and two measures of anxiety (e.g., SCARED, RCMAS-2) were administered pre- and post-treatment to assess treatment effects.

Results:  

Chris’ initial scores for the CBCL internalizing, externalizing, and total problems subscales were within the clinical range. Scores were within the borderline range for anxiety/depressed syndrome scales and within the clinical range on all other syndrome scale scores (excluding somatic complaints). Following treatment, scores for the internalizing, externalizing, and total problems subscales remained in the clinical range. However, scores on the social problems, rule-breaking behaviour, and attention problems decreased, although all other scores either remained the same or increased.

Conclusions:  

In general, many of Chris’ scores seemed to increase over time, although initial levels were already quite elevated. Limitations of the CBT intervention and the need for tailoring supports to meet the cognitive needs of youth with ASD and intellectual impairment are discussed.