Intolerance of Uncertainty Predicts Anxiety Outcomes Following CBT in Youth with ASD – A. Keefer and colleagues (2017)
Background
Anxiety is often a difficulty faced by individuals with ASD, frequently at a level that suggests a need for intervention through therapy and educational supports. Cognitive-behavioral therapy (CBT) is an approach to treatment that looks at how thoughts, feelings, and behaviors are tied together and affect how someone functions. CBT has a strong research base showing effectiveness for reducing anxiety in individuals without ASD. Modified CBT (MCBT) has been used for children with ASD and anxiety, who do not have intellectual disability, to help make therapeutic exercises and activities more concrete and relatable. The reason that MCBT was developed is because individuals with ASD tend to have problems with social perspective-taking and self-reflection that can make standard CBT difficult to understand or use in everyday life. Although MCBT has shown effectiveness, up to 50% of individuals with ASD who receive this type of therapy do not show large improvements after therapy is over. One reason for this might be that individuals who have both ASD and high anxiety also tend to react negatively to and struggle with uncertain or new situations, which is part of the course of therapy and ongoing improvement. The current study looks at whether there is a poorer response to MCBT if an individual shows greater dislike and upset for uncertain or new situations when treatment begins.
Who was involved?
Forty-three children and adolescents ages 8-14 years old with a diagnosis of ASD and an anxiety disorder participated in this study. There were 15 sessions of MCBT. In this study, MCBT included providing children and parents with information about anxiety, behavioral coping strategies, modified ways of altering thought patterns to be more supportive/constructive, and gradually exposing children to situations that provoke anxiety. Levels of dislike of/upset regarding uncertainty, worry, and anxiety were measured both before and after the intervention. Both children and parents provided input about symptoms.
What was the outcome?
As other studies have shown, MCBT was able to help reduce anxiety based on parent report, although the children who participated in the intervention did not report as big of a decrease in anxiety. Difficulty with uncertain or new situations was associated with higher anxiety and worry both before and after MCBT. So, although anxiety was shown to decrease for children and adolescents in the study, children who had a harder time with new or uncertain situations had higher levels of anxiety and worry after treatment. This means that these children might need additional supports, extended treatment, or some other assistance in improving their functioning.
What are the strengths and limitations of the study?
This study helps determine why an existing treatment for ASD and anxiety may be more effective for some children compared to others, which helps to predict how helpful the treatment can be. However, the study did not assess how having a harder time with new or uncertain situations affects the treatment specifically, just that anxiety and worry were not as low as for other children at the end of treatment. The study also focused only on individuals with ASD who have normative intellectual ability, which means that the results cannot be easily applied to children with lower cognitive functioning.
What are the implications?
The results suggest that MCBT can be effective, but that some types of behavioral rigidity (e.g., insistence on sameness) common to ASD might result in less improvement in anxiety symptoms for a subset of children with ASD. Tolerating uncertainty and novelty might require additional training and support beyond what MCBT provides as a current package. This study helps highlight that assessing an individual’s tolerance of uncertainty and novelty is important before and throughout therapy so that modifications and additional supports can be considered for better outcomes.
