Group Cognitive Behavioral Treatment for Anxiety in Adolescents with ASD and Intellectual Disability

Background: Adolescents with ASD and intellectual disability (ID) are an exceedingly underserved population. These teens evidence significant anxiety and behavioral challenges (Helverschous and Martinsen 2011), yet receive limited mental health support. While there is now an emerging body of literature supporting the effectiveness of adapted cognitive behavioral treatment (CBT) for youth with ASD, individuals with ID are typically excluded from these intervention studies. Given that behavioral approaches alone may not adequately address all anxiety symptoms (King, 2005), there has been a call for researchers to examine the use of CBT in an ASD/ID population (Rosen, Connell, & Kerns, 2016).

Objectives: The purpose of the study is to: 1) adapt a group CBT program designed for youth with ASD and anxiety (Facing Your Fears; Reaven et al., 2011) to meet the cognitive and linguistic needs of adolescents with ID, 2) assess initial feasibility and acceptability of the intervention, and 3) examine initial efficacy of the intervention.

Methods: This 14-week family focused intervention includes core CBT components for anxiety (i.e., psychoeducation, somatic management, cognitive strategies, and exposure) with adaptations made to treatment modality, session duration, and content. Content adaptations include: tailored visuals for adolescents with emerging language skills (e.g., single words/phrase speech) and those with verbal fluency, video modelling, adapted cognitive substitutes, and behavior plans. A well characterized sample of 23 adolescents (M = 15.9, range: 12-18) with ASD and ID were included. Participants had a mean Full Scale IQ of 58.3 (SD = 12.1, range: 40-79) and a mean Adaptive Behavior Composite of 57.45 (SD= 13.2, range: 40-79). Anxiety was assessed via parent report on the SCARED (Birmaher et al. 1999) and Anxiety Depression and Mood Scale (ADAMS; Esbensen et al. 2003) and was differentiated from problem behavior via functional assessment (O’Neill et al. 1990). Outcome measures also included parent acceptability (e.g., compilation of likert ratings of all CBT activities and adaptations of support). Dependent t-tests were conducted to examine pre-post differences in child outcomes.

Results: Of the 23 adolescent participants, 19 completed treatment and attended 94% of treatment sessions. Four adolescents withdrew and attended an average of 3 sessions. Parent acceptability ratings average was 4.56 (likert scale 0-5, with 5 indicating extremely satisfied). There was a significant reduction for the total SCARED score from baseline (M= 32.9, SD= 15.8) to post-intervention (M=26.2, SD=12.7) time points; t(18)= 2.25, p = .04. Similarly, there was a significant reduction in scores on the ADAMS from baseline (M= 40.7, SD= 10.7) to post intervention (M=29.9, SD=13.0) time points; t(18)= 4.28, p = .001.

Conclusions: This adapted program is the first group intervention to incorporate a CBT framework to treat anxiety in adolescents with ASD and ID. Results indicate that the group format and content is acceptable and feasible. Preliminary tests of outcomes suggest the intervention may improve teen anxiety and mood concerns, although this finding requires replication with a larger sample size and comparison to a control group. Future directions include further refinement and efficacy testing using a more rigorous methodological design.