High Risk, High Gain: High-Anxiety Adolescents with ASD Make the Most Gains over the Course of Treatment

Background:  Many individuals with ASD are characterized by high social anxiety (White et al., 2009).  Social anxiety curtails initiation of social interaction, and may lead to further disruption of healthy social development. Social anxiety may limit positive outcomes for this population, especially in adolescence, when peer interactions become more heavily emphasized.  Research has shown that social skills treatments are an effective treatment for ASD (Reichow, Steiner, & Volkmar, 2012), and that anxiety can decrease over the course of social skills treatments for ASD (Schohl et al., 2014). However, it is unknown whether adolescents with ASD, who also present with high levels of anxiety, show similar responses to social skills treatment, versus low-anxiety adolescents.

Objectives:  Do treatment outcomes differ in high- and low-anxious adolescents with ASD?

Methods: 106 adolescents (mean/sd age= 13.5/1.5; 91 male; 88% Caucasian) with ASD and their caregivers were recruited. Participants had a verbal IQ > 70 (mean/sd=100/18.5) and diagnoses confirmed with the ADOS-G. A randomized controlled trial (RCT: immediate vs. waitlist control) of the PEERS^® (Laugeson & Frankel, 2010) intervention was conducted. To examine the specific effects of anxiety on treatment outcomes, analyses were conducted with the 30 least anxious adolescents (lowest quartile, less than a score of 13) and the 27 most anxious adolescents (highest quartile, greater than a score of 23) on the Social Anxiety Scale-Adolescent (SADNEW subscale: self-report of fear and anxiety about unfamiliar peers; La Greca & Lopez, 1998). Data at pre- and post-PEERS^® included: (1) the TASSK (adolescent report of PEERS^®social skills knowledge; Laugeson, 2012), (2) the QSQ (adolescent report of social interaction frequency; Laugeson, 2012), and (3) the SRS-Parent Total score (ASD symptoms; Constantino, 2005).

Results: Multivariate ANOVAs indicated time (pre, post) by group (experimental, waitlist control) interactions for both High [F (4, 15) = 7.26, p = .002] and Low [F (4, 16) = 7.83, p = .001] anxiety groups. Follow-up univariate ANOVAs, separately for High and Low anxiety groups, indicated that only one outcome measure, the TASSK, showed a time by group interaction for Low anxious teens, F (1, 19) = 30.70, p = .001.  In contrast, the High anxious teens showed significant time by group interactions for TASSK [F (1, 18) = 19.25, p = .001] and SRS [F (1, 18) = 11.21, p = .004], with QSQ approaching significance, F (1, 18) = 3.82, p= .06. 

Conclusions: Both high- and low-anxious adolescents benefitted from the PEERS intervention, in the form of increased social skills knowledge.  However, highly anxious adolescents showed more widespread improvement in outcomes than less anxious adolescents, specifically showing fewer symptoms of ASD and more social interactions with peers.  These results highlight a unique opportunity and imperative to address social skills and friendships in a sub-group of adolescents with ASD who also have high levels of anxiety.