Cognitive Behavioral Treatment of Anxiety in Children and Adolescents with ASD

*Alan Lincoln, Shamiron Bales, Angela Woolard and Felicia Pryor*

#### **Abstract**

Children and adolescents with a neurodevelopmental disorder experience vulnerabilities and coping deficits that contribute to the likelihood of developing co-occurring anxiety disorders. The development of anxiety disorders, including social anxiety disorder, is very often reported in children and adolescents with autism spectrum disorder (ASD). Cognitive behavior therapy (CBT) has strong evidentiary support both in combination with medication and as a stand-alone treatment for anxiety disorders in general and more specifically for phobic-type anxiety in children, adolescents, and adults. Moreover, specific manualized CBT is an evidentiarily sound method for treating anxiety in children and adolescents with ASD.

**Keywords:** ASD, autism, autism spectrum disorder, anxiety, social anxiety, cognitive behavior therapy, computer facilitated CBT, CBT, cCBT

#### **1. Introduction**

Individuals with autism spectrum disorders (ASD) have increased vulnerability to the development of other co-occurring neuropsychiatric disorders, including both neurodevelopmental disorders such as attention deficit disorder (ADD), intellectual disability, developmental coordination disorder, and learning disability, as well as other neuropsychiatric and medical disorders such as Gilles de la Tourette's disorder, epilepsy, depressive disorders, and anxiety disorders. We use the term co-occurring instead of comorbid, where the latter term suggests some common etiological relationship with ASD. Such potential for comorbidity does seem probable for some of the disorders that do co-occur such as Tourette's syndrome or ADD, presumably due to abnormalities of systems used in the regulation of dopamine, but to date, all that is really known remains hypothetical about such relationships. It is also reasonable to conclude that when a child begins to develop ASD, for which there is overwhelming evidence of neuropathologic, neuropathophysiologic, and substantial genetic influence on etiology, the evident symptoms used to diagnose the disorder are well preceded by the atypical development of the brain. It is also reasonable to conclude that such differences in brain development lead to secondary consequences on various brain functions early in development involving attention, perception, the ability to construct social-communication schemes, and the exercise of effective executive control for goal-oriented behavior. The dysfunction of these secondary consequences then leads to vulnerability in basic learning, the development and ability to engage in reciprocal social relationships, the cognitive flexibility to develop effective adaptations to internal and external stress, increased conflict with the environment, and more unsuccessful efforts to receive positive rewards. Additive vulnerabilities increase the potential for a substantial degree of anxiety in children and adolescents with ASD [1–4]. Specifically, it has been reported that nearly 40% of children and adolescents with a diagnosis of ASD meet clinical criteria for at least one co-morbid anxiety disorder [5], and those with high-functioning ASD experience more anxiety than those with ASD and accompanying intellectual impairment [6, 7].

While it is beyond the scope of this chapter to review the various vulnerabilities or relationship among vulnerabilities of persons with ASD to the potential development of anxiety disorders, there is recent evidence that different patterns of functional connectivity may be associated with persons who have ASD with and without cooccurring anxiety [8]. In a resting state functional magnetic resonance study comparing matched samples of persons with ASD with and without anxiety to non-ASD controls, they reported different patterns of functional connectivity in brain regions previously identified in persons with anxiety disorders [9, 10]. Findings suggest comorbid anxiety in ASD may be associated with disrupted emotion monitoring processes supported by amygdala-dorsal anterior cingulate cortex/medial prefrontal cortical pathways [8] Such findings would be favorable to the idea of a comorbid versus co-occurring relationship between the association of ASD and anxiety. Notwithstanding such evidence of comorbidity, a finding that could eventually lead to interventions related to core etiology, this chapter will focus on current evidencebased behavioral interventions for children and particularly children with ASD.

However, it is also worth discussing the nature of anxiety vis-à-vis the development of anxiety disorders. Anxiety disorders are defined in various ways, but generally through consensus opinion involving experts. These experts agree on various symptoms necessary to meet the criteria for some specific anxiety disorder (e.g., social anxiety disorder, generalized anxiety disorder, separation anxiety disorder, etc.) and once some consensus is reached by a professional association those symptoms along with some other considerations such as the duration of symptoms becomes the diagnosis, at least for some period of time until a new revision is made. Alternative methods employ such criteria in developing questionnaires which, when developed properly, generally have better reliability and validity than the original symptom-based classification. Thus, different types of anxiety can be assessed using psychometric measurements. This is generally required if one was to conduct research about anxiety or assess and measure anxiety in some formal way over time.

However, anxiety can also be considered a dimensional symptom that cuts across many types of psychological conditions that lead to human suffering. People experience anxiety to situational stress, threat, trauma, and uncertainty. Anxiety can be triggered by various medications, substances, medical conditions, and even the onset of other psychiatric symptoms such as hallucinations or delusions. So, the unwanted conditions that lead to anxiety are experienced by most humans from time to time throughout their lifespan. However, it is clear that we evolved as a species to have the potential to experience anxiety not as an evolutionary goal to increase our vulnerability to anxiety disorders but to enhance the potential that we could survive long enough to get our genes in the gene pool. Most psychologists and psychiatrists would, in fact, argue that

*Cognitive Behavioral Treatment of Anxiety in Children and Adolescents with ASD DOI: http://dx.doi.org/10.5772/intechopen.108223*

some anxiety is not only beneficial for survival but that in the right doses can improve motivation and serve as a signal or discriminant stimulus to evoke an adaptive coping response when a person is under such stress or threat. Consequently, our goal in the behavioral treatment of anxiety disorders is to help the individual normalize and better tolerate their response to anxiety, and in particular, to learn more effective coping strategies that lessen the overreliance on avoidant coping and increase the potential for more problem-solving coping and interpersonal problem-solving coping.

#### **2. Prevalence of childhood anxiety disorders**

The Centers for Disease Control reports the prevalence of anxiety disorders among children and adolescents to be 9.4% (https://www.cdc.gov/childrensmentalhealth/ data.html). Mohatt et al. [11] reported that children and adolescents are often diagnosed with separation, generalized, and social anxiety disorders. The chapter sections will detail: (a) anxiety disorders in youth, (b) co-occurring anxiety in youth with ASD, (c) treatment for anxiety in youth populations, (d) CBT for youth with ASD, (e) CBT for youth with ASD and co-occurring anxiety, (f) computerized CBT for the treatment of anxiety, (g) computer-assisted models of treatment for youth, and (h) computerassisted CBT for the treatment of anxiety in youth with ASD and co-occurring anxiety. The final section of the literature review will be the summary and conclusion.

#### **3. Anxiety disorders in youth**

The Diagnostic and Statistical manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Associated [12]) stated that pathological anxiety, across ages, may be described by persistent or extensive degrees of anxiety and avoidance associated with subjective distress or impairment. However, when it comes to children, normal and pathological anxiety can sometimes be hard to distinguish [13]. Oddly, the high rates of symptoms of anxiety disorders in children and adolescents may itself be responsible for this diagnostic difficulty. Because of its commonality within the community, with some portion of anxiety during childhood and adolescence deemed developmentally appropriate, clinicians may pay less attention to the issue and overlook clinically significant symptoms of the disorder [13]. Usually, children manifest various types of fears and anxieties in their normal course of development and these fears and anxieties are difficult to immediately characterize as pathological [14–16]. This makes distress an unreliable and inadequate criterion for establishing that children are experiencing pathological anxiety. This problem forms unique dilemmas when one attempts to distinguish among normal, subclinical, and pathological anxiety states in children. Beesdo et al. [17] claimed that children at younger ages might face problems with communicating cognition, emotions, and avoidance, as well as the associated distress and impairments to their parents, doctors, and diagnostic clinicians. This creates a new host of problems for detecting childhood anxiety disorders.

According to Beesdo et al. [17], it is during childhood and adolescence when anxiety symptoms and syndromes usually first materialize. In fact, childhood and adolescence are considered the core risk phases for individuals to develop anxiety-related illnesses, ranging from mild symptoms to significantly interfering anxiety disorders.

The nature of clinically-significant anxiety disorders as a whole almost guarantees that the individual, regardless of age, will have significant and negative impacts on

their social and personal development, causing marked impairment of family life, academic achievement, and relationships with peers [18–20]. Because of poor social functioning, anxious youth tend to have fewer friends and less social support during childhood and adolescence, and experience victimization in many arenas [19]. Anxiety disorders in childhood and adolescence are not only extremely common but the resultant distress of living with both the symptoms and the functional consequences of the disorder are associated with lifelong psychiatric disturbance [21].

Prevalence of childhood anxiety disorders has been reported between 2.6 and 41.2% [22]. Children and adolescents are most commonly diagnosed with separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and social phobia (SoP) [11]. Childhood anxiety disorders usually persist into adulthood, making children at risk of having psychiatric disorders in the future [17]. Anxiety disorders among children are linked to considerable developmental, psychosocial, and psychopathological complications.
