CBT for Anxiety in Autism Spectrum Disorders (ASD) Professor Jeffrey J. Wood UCLA Department of Education Division of Psychological Studies

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1 CBT for Anxiety in Autism Spectrum Disorders (ASD) Professor Jeffrey J. Wood UCLA Department of Education Division of Psychological Studies

2 Anxiety Defined Anxiety: a mood state of mixed negative emotion and neural arousal that occurs when anticipating a future threat. A normal mood state experienced by everyone at times. Has adaptive (motivational) value. Anxiety disorders: Unrealistic, disabling anxiety associated with personal distress and substantial impairment in social or academic functioning.

3 Anxiety Disorders in ASD Not Anxious Other 35% Social & Separation Anxiety Generalized Anxiety Separation anxiety: fearfulness re: safety of self and loved ones. Associated with avoidance of certain situations (e.g., playdates, school) and dependence or clinginess to adults. Social phobia: associated with shyness, fear of embarrassment, social reticence. Leads to social isolation & few peer friendships. Generalized anxiety: excessive worry about daily events, past & present (e.g., homework, tests, popularity, health ). Associated with tension, irritability, aches/pains, or difficulty sleeping

4 Why so Common in ASD? Why is the prevalence of anxiety so high (35%+) in ASD? Brain mechanism / genetics Neurotypicals Youth w/ ASD Role of the amygdala in both syndromes? % Children Increased rate of mood disorders in parents of children with ASD High levels of stress due to ASD

5 Diagnostic Overshadowing Refers to clinicians tendency to overlook psychological and behavioral syndromes such as anxiety or aggression in children with developmental disabilities like MR or autism (Reiss et al., 1982). 1. Symptoms such as anxiety may be viewed as less important than the primary disability and not addressed Co-occurring symptoms are often misattributed to the primary disability, promoting a fallacious assumption: 1. Treating the primary disability is the only way to reduce anxiety/aggression, etc.

6 Implications & Example Implications: Symptoms of children with ASD may be misclassified and mismanaged if anxiety is not properly diagnosed. E.G.: a child w/ ASD with moderate social skills but high social anxiety may receive traditional social skills training that is unlikely to improve sociability & friendship because it addresses the wrong target problem. s/he may need a treatment that can address anxiety to improve sociability.

7 Example #2 A child w/ ASD with average academic skills who constantly falls behind in class due to perfectionistic work habits, repeated questions, and refusal to try problems s/he is not certain about is likely to be criticized for poor work habits and pushed to focus by the teacher. Interventions such as 1:1 aides are crutches that may fail to address the anxiety causing these behaviors. s/he needs an intervention to reduce perfectionism & increase tolerance of uncertainty.

8 Example #3 A child w/ ASD refuses to attend school or afterschool extra-curriculars (e.g., an art class); or only attends with a parent present may be viewed as having inadequate academic/performance skills to succeed in these settings possibly leading to use of homeschooling and/or avoidance of extracurriculars. Problem: this can overlook the key role of anxiety. s/he may be able to function independently in school and other settings and may simply need an intervention to raise self-efficacy and decrease anxiety.

9 Common Misperceptions about Anxiety High anxiety & unrealistic fears are normal. Children grow out of shyness and anxiety. Anxiety does not interfere significantly with social or school functioning.

10 Actual Impact of Anxiety Anxiety in children with ASD is associated with even greater problems with social adjustment (e.g., approaching others, participating in conversations / friendships) (Bellini, 2004). Anxiety disorders tend to have a long-term course for children and youth (Newman et al., 1996). Significant negative long-term outcomes: School failure, lowered vocational attainment Social isolation & rejection High cost to society/disease burden (WHO top 10)

11 The Challenge The ASD treatment research literature has been marked by few successes. This is a difficult population to intervene with. Cognitive and personality features in ASD (e.g., impaired attention; poor motivation; Koegel & Koegel, 1986) seem to undermine generalization of skills taught in intervention programs. No autism intervention is currently classified as empirically supported, according to the APA (Kazdin & Weisz, 2003).

12 Use of Evidence-Based Treatment Can we adapt the refined evidence-based treatments developed with neurotypical populations (e.g., Kazdin & Weisz, 2003) to address cooccurring problems and syndromes commonly seen in ASD (e.g., anxiety disorders, aggression)? Medication, behavioral parent- and teachertraining, and cognitive-behavioral therapy for children may be good candidates. (Namerow et al., 2003; Sofronoff & Attwood, 2003)

13 How to Intervene? Cognitive behavioral therapy (CBT) is an evidence-based treatment that has been established by the APA as effective for children. But previous studies have excluded children with ASD. Can CBT also address anxiety disorders in ASD? Would a decrease in anxiety improve social and adaptive functioning?

14 How Well Can it Work? Research in Neurotypical Populations: Compared to waiting-list, children with anxiety disorders receiving CBT have extremely high anxiety remission rates Wood et al. Barrett et al Barrett 1998 Family CBT Child CBT Waiting List

15 Effects on Functioning In our recent study of CBT for neurotypical children (Wood et al., under review), we found that: Children s school performance increased & they attended school more regularly Children had more friends & better quality friendships Chidren got along better with family members Children had higher self-esteem

16 Can CBT Work in Autism? We have finished two years of pilot testing CBT in inpatient and outpatient settings at UCLA with school-aged children with ASD and anxiety disorders. A set of adaptations to CBT have been developed to tailor it to the needs of children with ASD (Wood & Drahota, 2005). Initial cases have shown good treatment response.

17 Traditional CBT Approach Phase 1: Understanding anxiety E.G.: (1) Learning bodily cues, (2) recognizing facial expressions, etc. Phase 2: Skills training E.G.: (1) Relaxation, (2) positive self-talk (coaching oneself), (3) self-reward Phase 3: Skills practice (50%+ of sessions) E.G.: Children gradually attempt increasingly challenging feared situations to develop confidence & mastery.

18 Modifications to CBT Adaptations to our original CBT program (Wood, McLeod, & Sigman, 2000) were based on research & clinical experience in working with children with ASD. Examples of adaptations: Expanded emotion education & thought monitoring skills training using visual stimuli Friendship skills for youth (Frankel et al., 1998) Peer buddy and playdate programs at school and home to increase social engagement Social coaching at home and school Independence / self-help skills focus

19 Intervention Parameters 16 weekly outpatient meetings, 90 minutes each 45 minutes with the child 45 minutes with the parents and/or family 2+ school visits & consultations IEP meeting attendance with an aim towards incorporating social coaching, peer buddies, and gamesleading opportunities into child s school program

20 Sample Case Profile 12 year old boy Sam High-functioning autism (verbal but shy), OCD, generalized anxiety d/o Anxiety-related symptoms School refusal Social avoidance (failure to speak in most situations except with those who were very well known due to shyness) Severe compulsive rituals (e.g., showering for one hour each time he defecated).

21 Profile Continued Social functioning No friends in or out of school Ate lunch at table with popular 14-year-old girls (who did not care for his company) and followed them around school ( stalking ) History of awkward playdates in which focus on his immature interests (e.g., Pokemon) played a central & deleterious role Self-help skills Still received assistance choosing clothes & tying shoes

22 CBT Approach with Sam Treatment of anxiety symptoms Graduated return to school using positive self-talk, removal of reinforcers at home, hierarchical increase of time at school, daily reward (earning privileges) Did research on likelihood of contracting disease from sitting on the toilet or not washing hands used to develop realistic thoughts. Began with exposure to wiping hands on counters, doorknobs, etc. without washing. Moved to defecating with brief shower only. Ended with 3-4 days of no showering at all.

23 Modified CBT Components Social interventions home Friendship skills: two basic rules serve as key principles for successful playdates Playdate consultation: helped mother identify children with Asperger s and somewhat younger neurotypical children with similar interests to Sam for playdates; gave mother intensive playdate-structuring advice Social coaching

24 Sam Interventions, Cont d Social interventions school Taught 1:1 aide social coaching, focusing on recess and lunch as key times to prompt him (greetings, questions) Worked with school admin to identify 3 peer buddies (12 year old boys known to be very empathic & kind) to invite him to lunch 2x / week. Trained buddies directly. Provided reinforcers for participating in class and answering teachers questions

25 Sam s Outcomes No diagnosis of OCD or generalized anxiety disorder based on independent evaluator s assessment (e.g., showering ritual terminated; social anxiety decreased) Returned to school full time by session 4 Had numerous successful playdates; made 1 friendship that was clearly reciprocal More class participation no longer mute Stopped eating lunch at girls table; enjoyed time with his peer buddies; showed insight

26 Sample Case Profile #2 7 year-old boy, Jonah High-functioning autism (verbose), OCD, generalized anxiety disorder Anxiety-related symptoms Extreme reactions to academic pressure (frequent crying and refusal during testing and homework due to perfectionism) Jonah s list of things to do 3-4 h. / day Separation anxiety unable to be alone

27 Profile Continued Social functioning Likeable, but no reciprocal friends Previously abandoned peers, set the play agenda, and did not share toys during attempted playdates Walking around aimlessly during recess Self-help skills Relied on mother to perform all activities related to bathing and dressing

28 CBT Approach with Jonah Interventions for anxiety symptoms Paradoxical intervention with perfectionism: intentionally make mistakes in pretend assignments; later, in homework; later, on tests. Learn positive self-talk related to abilities & relative unimportance of perfection. To-do list compulsions: Restricted length of time to be devoted to to-do list per day. Later challenged Jonah to try days, then weeks, without any list whatsoever. Rewarded Jonah for engaging in non-list activities after school. Separation anxiety: developed realistic thoughts about safety; increasing time in rooms alone; sleeping without a night light / door closed.

29 Social Interventions Friendship skills: Capitalized on Jonah s rulegoverned personality to help him master and implement rules of a good host. 3-4 short playdates per week, hosted by Jonah, in which he practiced these skills (and was rewarded for effort) Lunch buddies peer intervention with classmates; they invited him to lunch. Jonah and mother problem-solved in advance on conversation topics, and he was instructed to finish lunch in time to walk to recess with peers and play with them for 5-20 min.

30 Self-Help Skills Jonah had previously demonstrated some ability to engage in most aspects of dressing and bathing low hanging fruit. Had early success in mastering all aspects of each, except for setting water temp. in bath. Capitalized on his desire to be a grown-up (and have his own business ) by pointing out how mature he would be if he did these activities himself. He adopted these terms and rapidly experienced increased selfesteem after mastering the self-help skills.

31 Jonah s Outcomes Like Sam, Jonah did not meet criteria for any anxiety disorder (OCD, GAD) at post-treatment, per the independent evaluator s diagnosis. Had identified 2 peers with whom he enjoyed playing after school. No more break-downs or refusal at school or during homework; flexible Increased pride and self-efficacy

32 Themes in Treatment Anxiety reduction helps youth with ASD improve behavioral regulation and flexibility Anxiety reduction may potentiate improved functioning in school and in peer relationships In the context of traditional CBT, ASD-specific treatment add-on components such as friendship skills training and social coaching can help children capitalize on their reduced anxiety and make progress in areas of social development commonly viewed as core deficits of autism, such as failure to maintain peer relations and reciprocal interactions.

33 To Review Anxiety disorders are a mental health problem with significant implications for children with ASD. At least 1/3 of children with ASD have impairments in social, school, or family functioning that are due to anxiety. Significant progress may be made in the social, academic, and/or adaptive functioning of affected children by reducing anxiety.

34 Next Steps We are currently conducting a full randomized, controlled clinical trial at UCLA in the Departments of Education and Psychiatry: Behavioral Interventions for Anxiety in Children with Autism (BIACA) PI: Jeffrey Wood, Ph.D. [Conducted in collaboration with NIH-UCLA Center for Autism Research and Treatment (CART)]