Intervention for Anxiety and Problem Behavior in Children with Autism Spectrum Disorder and Intellectual Disability. L. J. Moskowitz, C. E. Walsh, E. Mulder, D. M. McLaughlin, G. Hajcak, E. G. Carr, & J. R. Zarcone (2017)
Background
Anxiety is a common co-occurring problem in individuals with ASD. Cognitive behavioral therapy (CBT) has the most evidence in reducing anxiety in children without ASD, and modified CBT (e.g., visual supports, more concrete language, greater parental involvement, incorporating special interests) for children with ASD without cognitive impairment has shown promise. However, it is unknown whether children with ASD who also have intellectual and other developmental disabilities (IDD) may benefit. This study examined whether combining modified CBT and positive behavior support strategies would help to reduce both anxiety and related problem behavior in children with ASD and IDD.
Who was involved?
Participants included three school-aged children with ASD ages 6-9 years old and their parents. Children also met criteria for at least one anxiety disorder and had a history of displaying problem behaviors that were more frequent when anxious. These children were also functioning within the low range on intellectual and/or adaptive skills (i.e., standard scores of 70 or lower). In collaboration with parents, the researchers first assessed typical anxiety provoking situations and possible causes for related problem behaviors. Parents were then taught how to use strategies to help their child manage anxiety via modeling, coaching, and problem-solving discussions with the trainers. Modified CBT strategies included learning about anxiety and how it can be managed, identification and alteration of stress-inducing thought patterns using social stories and video modeling, and gradual exposure to feared situations. Many positive behavior support strategies were included such as, increasing predictability, providing choices, incorporating special interests, and reinforcing appropriate “approach” behavior (i.e., toleration of a feared situation/object without significant upset).
What was the outcome?
All 3 children demonstrated large, immediate reductions in anxiety once intervention was introduced. Substantial decreases occurred in both the display of anxious behaviors and problem behaviors as coded by independent raters. Although small amounts of anxiety persisted during treatment, the anxious behaviors were of a much milder variety and rarely resulted in problem behavior.
What are the strengths and limitations of the study?
Strengths: This study incorporated evidence-based procedures from both CBT and applied behavior analysis literatures to create highly individualized interventions for each child. The researchers also collaborated heavily with the families and assessment and treatment occurred within the child’s natural environment. Use of naturalistic settings and parent-driven intervention is helpful for promoting lasting change.
Limitations: Since many intervention components were used at the same time, it is difficult to determine what part or parts of the intervention were actually responsible for the changes. It is possible that only a few of the strategies were necessary to produce the desired changes. In addition, although this study was conducted in naturalistic settings, the researchers did not directly examine whether treatment effects would transfer to other anxiety provoking situations or if the treatment effects would maintain over time.
What are the implications?
This study provides initial support for use of a combined treatment approach to reduce anxiety and related problem behavior in children with ASD and IDD. It highlights that anxiety is a relevant concern in children with ASD and IDD, and that parent training and support contributes to the successful decrease in symptoms. The researchers emphasize that it is important not to dismiss problem behavior as being explained by ASD and IDD diagnoses alone, stating that labeling “anxiety” when it is present helps to better assess maintaining variables for the observed behavior and results in more rapid alleviation of difficulties.
