**11. Computer-Assisted CBT for the treatment of anxiety in youth with ASD and co-occurring anxiety**

Children and adolescents with ASD have unique needs regarding the treatment of their disorder, and in most cases, behavioral analysis interventions were the preferred treatment [75]. The success of behavioral interventions combined for the treatment of ASD, and cognitive behavioral interventions for the treatment of co-occurring anxiety disorders are largely unknown and represent a significant gap in the research. Although it is known that CBT is an effective treatment for use with youth with cooccurring anxiety disorders and ASD, future research needs to determine the efficacy of computer-assisted CBT for the treatment of this population [117, 132–135]. Zabel recently completed a dissertation at Philadelphia College of Osteopathic Medicine, Department of Psychology, investigating the efficacy of CCAL CD Rom for treating anxiety symptoms in children with ASD. The single case study revealed inconsistent results on the overall reduction of anxiety symptoms in the participants diagnosed with ASD. The study utilized a small sample (n = 4) with no control group. According to Zabel [135] the 12-week CCAL intervention was "generally successful in decreasing some symptoms of anxiety for each of the participants" (p. 111). However, results on outcome measures yielded no statistically significant changes in symptom severity and were inconsistent across scales, subscales, and participants. The variability observed across outcome data was attributed to participant heterogeneity and a small sample size. Although quantitative data analysis did not reveal a statistically significant change in the participants' self and parent report outcomes measures, the researcher discussed valued qualitative information obtained during the study. For example, Zabel [135] discussed overall parent-reported satisfaction with the intervention and observed improvement in the participant's ability to approach their fears as they progressed through the intervention. Results from this first-known study on the efficacy of CCAL in treating anxiety in children with ASD offered valuable limitations identified that will benefit researchers wishing to continue examining the potential efficacy of CCAL, an empirically supported intervention program in youth with co-occurring ASD. To date, no known studies investigating the efficacy of CCAL have been conducted utilizing a larger sample size or RCT design.

Most recently, our group [95] reported the results of a crossover design showing the efficacy of a computer-assisted intervention program for youth with ASD who also experience co-occurring anxiety. The computer-assisted cognitive behavior program, CCAL was compared to control intervention, another computer-assisted

program, The Social Express (TSE), that does not employ CBT nor is targeted for the treatment of anxiety. TSE is designed to improve social skills in youth with ASD. Participants had a principal anxiety disorder and a current diagnosis of ASD. Participants received 12 sessions of CCAL or 12 sessions of TSE. Outcome measures were obtained at intake, upon completion of the first intervention of the trial, and upon completion of the second intervention of the trial. CCAL was efficacious for treating anxiety. Participants who completed CCAL demonstrated significant clinical reductions in anxiety when compared to participants who completed TSE. The study obtained an NNT = 2.17 which is comparable or superior to those reported by pharmacological research examining evidence-based approaches to treating pediatric anxiety [136]. While a multi-modal treatment approach has been found most effective in treating anxiety in youth [136], there remains the potential for adverse events with psychopharmacological interventions. A small dropout rate for CCAL, and the intervention required minimal financial support interventions, CCAL and TSE, also both showed some limited improvement in social skills.
