Examining Use of CBT Strategies for Anxiety: A Pilot Study with Adolescents with ASD and Intellectual Disability

Background: Cognitive Behavioral Therapy (CBT) has been used to address anxiety symptoms in youth with ASD with promising results (Reaven et al., 2012, 2018; Wood et al., 2009). However, few treatment programs have specifically used CBT to reduce anxiety in individuals with ASD and Intellectual Disability (ID; Rosen et al., 2016). The extent to which individuals with ASD and ID are able to learn and use CBT strategies is unclear, particularly given of the heterogeneity of this population. A pilot intervention assessing the initial feasibility, acceptability and efficacy of CBT for adolescents with ASD, ID, and anxiety was completed (Blakeley-Smith et al., submitted INSAR 2019). The purpose of this study is to evaluate the attainment of CBT skills in a subsample of this study.

Objectives: To determine whether adolescents with ASD, ID, and anxiety are able to develop core skills and strategies from a CBT program for anxiety as documented through individualized Goal Attainment Scaling (GAS; Ruble et al., 2013) and evaluate anxiety and mood in this subsample.

Methods: Seven adolescents (Mage=16.60 years, SD=2.13, range=12-18 years) with ASD, ID, and anxiety participated in a larger pilot study evaluating an adaptation of Facing Your Fears (Reaven et al., 2011), a 14-week group CBT program to treat anxiety. All participants completed treatment and met criteria for ID: Full Scale IQ (M=64.00, SD=9.17; range=54-79) and adaptive behavior scores (M=57.29, SD=20.48) and anxiety based on parent report on either the Screen for Childhood Anxiety and Related Disorders (SCARED; Birmaher et al.,1999) or the Anxiety, Depression, and Mood Scale (ADAMS; Esbensen et al., 2003).

GAS goals and ratings were determined for each participant across 5 treatment domains: somatic management, emotion identification and regulation, cognitive strategies, exposure practice, and behavior management. Ratings were based on a parent interview conducted pre- and post-treatment and direct observation based on recommended GAS procedures (Ruble et al., 2013). Two to five goals per domain were created for each participant with total number of goals ranging from 11-17. See Table 1 for scoring information.

Results: Results from GAS scores indicated variability in use of CBT skills within participants and across subdomains after participating in treatment (See Table 2). In addition, dependent samples t-test indicated significant differences on the ADAMS (pre-treatment=42.00, SD=11.66; post-treatment=26.14, SD=8.61; t(6)=3.87, p=.008), suggesting decreased mood and anxiety symptoms.

Conclusions: GAS scoring showed that all participants made gains in CBT strategy use following participation in modified CBT program for anxiety. Of note, six of the seven participants exhibited ‘expected’ or ‘greater than expected’ use of cognitive strategies. This is noteworthy as cognitive strategies are not well researched or addressed in this underserved population (Rosen et al., 2016). Decreases were also noted in anxiety and mood symptoms, although it is unclear to what extent this reduction is tied to increased strategy use. Further research is needed to examine the active ingredients of treatment and if GAS ratings can best capture teens’ use of these skills. Limitations include a small sample size and lack of independent raters for the GAS scores.