Evaluating a School-based Cognitive Behavioural Therapy for Anxiety in Adolescents with Autism Spectrum Disorder

Hanna Kovshoff & Julie A. Hadwin

Centre for Innovation in Mental Health

Scottish Autism Research Group (SARG)

2nd March, 2017

Outline of talk

• Anxiety and Autism

• Evaluation of a manualised CBT intervention in a

mainstream school

• Related work- overview of our research programme @ CIMH

Anxiety Disorder

• Anxiety categories include

– Generalised anxiety disorder, Specific phobia, Social anxiety disorder, Separation anxiety disorder

• Core anxiety features

– Physiological change, intrusive worrisome thoughts, behavioural avoidance

• Attentional characteristics

– Lowered attentional control and increased attention to threat

• Poorer Outcomes

– social and educational underachievement

Autism Spectrum Disorder and Anxiety

• High prevalence of co-occurring psychiatric conditions

• Anxiety is one of the primary reasons for mental health referrals (Skokauskas & Gallagher, 2012)

• Anxiety contributes to functional impairment over and above any functional impairment associated with the ASD symptoms– Up to 84% of children with ASD experience some

degree of impairing anxiety (White et al., 2009)

– 42% (Simonoff et al., 2008) – 55% (De Bruin et al., 2007) Anxiety disorder

Anxiety and depression symptoms in adults diagnosed with ASD in adulthood

Male

(N = 60-64)

Female

(N = 23-24)

Total

(N=83-88)

Variable Mea

n

SD

Range

Mean SD

Range

Mean SD

Range

1 2 3 4 5

1.Age

(years)

32.25 13.57

18-74

32.25 11.87

18-57

32.45 13.06

18-74

--

2.Anx 15.06 12.39

0-52

22.38* 16.11

0-60

17.06 13.81 -.18* --

3.Dep 18.22 12.37

0-51

20.50 16.85

0-60

18.84 13.67 -.12 .69** --

4.AQ 34.74 7.14

12-47

37.17 6.77

19-47

35.40 7.09

12-47

.21* .26* .20 --

(Murray, Kovshoff & Hadwin, submitted)

Challenges to Identifying Anxiety in ASD• Diagnostic overshadowing

– Overlapping symptoms – e.g. social phobia, perseverative thinking

• True comorbidity?

– Phenotypically and etiologically identical to anxiety in TD populations?

• ASD specific variant of anxiety?

– Anxiety phenotypically altered by the ASD

– not a manifestation of the ASD

• Specific phenotype/subtype of ASD?

– Differing etiology from those with ASD who do not experience anxiety rather than true comorbidity

(Wood & Gadow, 2010)

Treatment Approaches –Cognitive Behaviour Therapy (CBT)

• The efficacy of CBT for childhood anxiety is well supported in the literature (Cartwright-Hatton et al., 2004)

• Addresses behavioural manifestations of anxiety and underlying maladaptive cognitions

• Efficacy of CBT for children with ASD (with careful adaptations to accommodate unique needs of children with ASD) – Meta-analysis (Sukhodolsky et al 2013) 1.21 for clinician

reported outcomes and 1.19 for parent reported outcomes 0.68 self report

• Effect of CBT on school based samples?

Study Aims – CBT for Anxiety in Mainstream Schools

• CBT intervention group vs a wait-list control group– RCT design

• Primary outcome– Anxiety symptoms across three time-points: pre-intervention,

post-intervention and 6 week follow-up

• Secondary outcomes including– social worry– social responsiveness– attentional control– attention to threat.

• Where possible to gather reports of symptoms/impairment across informants

Participants• Inclusion criteria

- Formal clinical diagnosis of ASD (validated through the SCQ)

- Experiencing clinically significant symptoms of anxiety as measured by elevated scores on either teacher or parent measures

- Verbal and total IQ >70

• 35 participants in total– recruited from four mainstream secondary schools located

within the south-east of England

– 31 boys and 4 girls (Mean age = 13.2, SD = 1.1, range = 11.1 -15.8)

Methodology - Primary

Pre-Assessment Measures:

Social Communication Questionnaire (SCQ; Rutter, Bailey & Lord, 2003)

Weschler Abbreviated Scale of Intelligence – second edition (WASI-II; Weschler, 1999)

Anxiety:

School Anxiety Scale—Teacher Report (SAS-TR; Lyneham, Street, Abbott & Rapee, 2008

Spence Children's Anxiety Scale (SCAS; Spence, 1998

Spence Child Anxiety Scale for Parents (SCAS-P; Spence, 1998)

Methodology - Secondary• Social Responsiveness:

– Social Responsiveness Scale (SRS, Constantino & Gruber, 2002)

– measures the severity of ASD symptoms as they occur in natural social settings

– assesses social awareness, social information processing, capacity for reciprocal social communication, social anxiety/avoidance, and autistic preoccupations and traits

• Social Worry:– Social Worries Questionnaire (SWQ - P; Spence, 1995)– Assesses social anxiety

• Attentional control:– Flanker (Erikson & Schultz, 1979)

• Attention to threat:– Schematic Emotional Face Stroop Task

Attentional (inhibitory) control

• Flanker task

– Time taken to identifythe direction of the target (middle stimulus) as left or right

– Interference effects are evident in incongruent/ incompatible trials

• Conflict score

– Incongruent –congruent trials (higherscores > 0 = more interference/ lessinhibitory control)

Emotional Faces Stroop Task

• Stroop colour matching task

• Threat bias: time taken to colour match angry (versus neutral) faces

– Higher scores > 0 = attentional bias to threat

– We also included happy and fear faces as comparisons

– 6 week programme x 1.5 hour sessions/6 week follow up

– 4-6 participants per group

– Understand the specific feelings of being happy, relaxed and anxious

– ‘Tool Box' of anxiety management strategies

– Reduction in parent-report anxiety and self-report social worry for the intervention group (n = 23) in comparison to the wait-list group (n = 23)

– Our aim – to deliver intervention in the school setting

Design and Recruitment

Attentional control and colour matching at baseline

Emotion

Angry Happy Fear Neutral

Me

an

re

actio

n t

ime

s (

co

lou

r m

atc

h)

600

700

800

900

1000

1100

Condition

Neutral Congruent Incongruent

Me

an

re

actio

n t

ime

650

700

750

800

850

900

950

1000

1050

Associations at baseline between parent, pupil and teacher report variables

Intervention Effects - Anxiety

F(1, 23) = 16.90, p <.001 F(1, 31) = 7.10, p = .012 F(1, 32) = 16.07, p <.001

Results – Secondary Outcomes

• Social Worries/Social Impairment

– self, parent, teacher – no main effect of group

• Attention to threat/Inhibitory control

– Greater interference from angry faces across the sample but no effect of intervention

– No group X time interaction for flanker task

Implications CBT for Anxiety

• Preliminary evidence that a school-based CBT intervention can reduce anxiety symptoms in a community derived sample of adolescents with ASD with elevated levels of anxiety as reported by multiple-informants

• Skills taught were generalised to contexts outside of the intervention setting, with notable effects reported both at school and at home

• Group differences were maintained six weeks post-intervention, both at school and at home

Limitations

• Treatment integrity was not formally measured

• No active control group

• Raters were not blinded to condition allocation at post-intervention or follow-up

• Relatively short follow up

Ongoing Related Research• Understanding the physiological and environmental

correlates of anxiety in adolescents with ASD across the school day (Emma Lee)

• Mapping the Landscape of Fear – Understanding whether/which lessons, time points or geographical locations are anxiety provoking in young people with ASD (Ellie Hayes and Caitlin Murray)

• Understanding the cognitive and psychiatric profile of a clinic based group referred for ASD diagnosis in adulthood (Caitlin Murray & Vicki Russ)

• Social anxiety in girls with ASD (Leanne Pickering)

• Developing a co-constructed parent-delivered CBT intervention for anxious autistic children (with Cathy Cresswell/Fiona Knott @ Reading)

Questions?

Thank Youh.kovshoff@soton.ac.ukj.a.hadwin@soton.ac.uk

References

• Attwood, T. (2004). Exploring Feelings: Anxiety: Cognitive Behaviour Therapy to Manage Anxiety. Future Horizons.

• Bellini, S. (2004). Social skills deficits and anxiety in higher functioning adolescents with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 19 (3), 78-86. doi: 10.1177/10883576040190020201.

• Sofronoff, K., Attwood, T., & Hinton, S. (2005). A randomised controlled trial of a CBT intervention for anxiety in children with Asperger syndrome. Journal of Child Psychology and Psychiatry, 46(11), 1152-1160. doi: 10.1111/j.1469-7610.2005.00411.x.

• Sukhodolsky, D. G., Scahill, L., Gadow, K. D., Arnold, L. E., Aman, M. G., McDougle, C. J., McCracken, J. T., Tierney, E., Williams White, S.,Lecavalier, L., & Vitiello, B. (2008). Parent-rated anxiety symptoms in children with pervasive developmental disorders: Frequency and association with core autism symptoms and cognitive functioning. Journal of Abnormal Child Psychology, 36, 117–128. doi: 10.1007/s10802-007-9165-9.

• Sze, K., & Wood, J. (2007). Cognitive behavioral treatment of comorbid anxiety disorders and social difficulties in children with high-functioning autism: A case report. Journal of Contemporary Psychotherapy, 37, 133–143. doi: 10.1007/s10879-007-9048-y.

• White, S. W., Oswald, D., Ollendick, T., & Scahill, L. (2009). Anxiety in children and adolescents with autism spectrum disorders. Clinical Psychology Review, 29, 216–229. doi: 10.1016/j.cpr.2009.01.003.