Update on the Effectiveness of Psychotherapy for Anxiety Disorders in Children and Adolescents with ASD

Background: Anxiety disorders are prevalent and impairing in children with Autism Spectrum Disorders (ASD). A growing body of research has investigated the efficacy of Cognitive Behavioural Therapy (CBT) as a treatment for anxiety disorders in children with ASD. However, a review is needed to ascertain CBT can yet be considered an efficacious treatment for anxiety in ASD, or if not, what additional studies are needed to reach this standard.

Objectives: The purpose of this review was to: (1) Critically evaluate the current evidence base for the efficacy and effectiveness of CBT for anxiety disorders in children and youth with ASD (ages 7-25) using Chambless & Hollon’s (1998) criteria; and (2) Provide recommendations for future research.

Methods: 20 studies were included in the review. Studies were selected from three existing systematic reviews conducted prior to 2017, along with a more recent search in PsycINFO to identify new findings. Inclusion criteria were: An open or randomized trial design, focus on CBT for anxiety, and focus on children (ages 4 – 18 years) with ASD. Identified studies were then evaluated using Chambless & Hollon’s (1998) criteria, which uses the standards of independent replication, methodological rigor, and representativeness of studies to determine if a treatment should be consider possibly efficacious, probably efficacious, or well-established.

Results: The present review identified 10 CBT programs for anxiety in children with ASD that have been evaluated in open trials (8 studies) or RCTs (12 studies). These programs varied in format (i.e., linear or modular, individual or group) and degree of modification (i.e., adaptation for use with children with ASD). At present, though no treatment program meets well-established criteria, two programs – one individual modular CBT and one group linear CBT – meet probably efficacious criteria, and five programs meet possibly efficacious criteria. Current gaps in the literature include a need for RCTs comparing CBT to alternate treatments, and a need for multi-site replication to verify the efficacy of CBT programs across settings and samples. The seven treatments that met probably or possibly efficacious criteria varied widely in format and degree of modification, suggesting that CBT may be delivered in a flexible manner to suit client, provider and setting needs while still maintaining efficacy. Yet, across our review, only four programs were assessed in community settings and only two met possibly efficacious criteria, suggesting that further research is needed to determine the effectiveness of CBT outside research settings.

Conclusions: Seven of 10 CBT programs, with ranging format (individual, group), parent involvement and degrees of adaptation for ASD, were identified in the present review as probably or possibly efficacious treatments. CBT cannot yet be considered well-established; however, two current studies, designed to compare adapted CBT to standard CBT (R01 HD080098) and adapted CBT to pharmacological intervention (P50 HD093079), are likely to address this gap. Studies illuminating the essential ingredients, implementation and effectiveness of CBT in community settings as well as the long-term impact of treatment are needed.