Treating Anxiety Disorders in Children with High Functioning
Autism Spectrum Disorders: A Controlled Trial
Anne Marie Chalfant Æ Æ Ron Rapee Æ Æ Louisa Carroll
? Springer Science+Business Media, LLC 2006
ment for anxiety in 47 children with comorbid anxiety
disorders and High Functioning Autism Spectrum
Disorder (HFA) was evaluated. Treatment involved
12 weekly group sessions and was compared with a
waiting list condition. Changes between pre- and post-
treatment were examined using clinical interviews as
well as child-, parent- and teacher-report measures.
Following treatment, 71.4% of the treated participants
no longer fulfilled diagnostic criteria for an anxiety
disorder. Comparisons between the two conditions
indicated significant reductions in anxiety symptoms as
measured by self-report, parent report and teacher
report. Discussion focuses on the implications for the
use of cognitive behaviour therapy with HFA children,
for theory of mind research and for further research on
the treatment components.
A family-based, cognitive behavioural treat-
Autism Spectrum Disorder ? Anxiety ?
It is frequently noted that children with a High
Functioning Autism SpectrumDisorder (HFA)
experience anxiety, where HFA refers collectively to
those children who have Autistic Disorder, without
intellectual delay, together with those children who
Association, 1994). HFA children have been noted to
experience anxiety across their school life, social life
and family life (Coupland, 2001; Groden, Cautela,
Prince, & Berryman, 1994; Kim, Szatmari, Bryson,
Streiner,& Wilson, 2000;
Merckelbach, Holdrinet, & Meesters, 1998; Tonge,
Brereton, Gray, & Einfeld, 1999). In fact, anxiety
related difficulties are so frequently exhibited in
children with Autism Spectrum Disorders (ASDs) that
DSM-IV highlights anxiety-like responses as a com-
mon, ‘‘associated feature’’ of autism stating that,
‘‘there may be excessive fearfulness in response to
harmless objects’’ (American Psychiatric Association,
1994, p. 68).
Prevalence rates of anxiety symptomatology in
children with HFA support the argument that anxiety
is a core difficulty of many children who suffer with
HFA. Several small studies have reported the preva-
lence of anxiety disorders in ASD children to be
between 47 and 84.1% (Gillot, Furniss, & Walter, 2001;
Muris et al., 1998; Rumsey, Rapoport, & Sceery, 1985).
For example, a study by Muris et al. (1998) found that
of 44 children with HFA and families interviewed,
84.1% of the children met DSM-IV criteria for at least
one anxiety disorder. Furthermore, within the anxious
group, 63.6% met DSM-IV criteria for a specific
phobia (SpP) (Muris et al., 1998). More recently,
Gillot et al. (2001) found that from a sample of 15
children with high-functioning autism, 47% presented
with clinically significant levels of anxiety based on
self-report anxiety scales.
A. M. Chalfant (&)
Annie’s Centre, PO Box 456, Randwick, NSW 2031,
Macquarie University, North Ryde, NSW, Australia
Children’s Hospital at Westmead, Sydney, NSW, Australia
J Autism Dev Disord
Not only is anxiety a frequent difficulty for children
with HFA, but also, there is evidence to suggest that
anxiety difficulties occur more frequently in ASD
children than in other paediatric populations such as
children with severe mental retardation and/or epi-
lepsy (Steffenburg, Gillberg, & Steffenburg, 1996) and
children who have a language disorder (Gillot et al.,
Similarly children with an ASD have also been
found to experience higher rates of anxiety than
Benjamin, Costello, & Warren, 1990; Bird, 1996; Gillot
et al., 2001; Matson & Love, 1990). For example, the
rates of anxiety symptomatology reported for children
with an ASD, i.e. 47–84.1%, are markedly higher than
the lifetime prevalence rates reported for typically
developing children in DSM-IV [1.5–3.5% Panic
Disorder (PD), 3–13% Social Phobia (SP), 3%
Generalised Anxiety Disorder (GAD), 11% SpPs;
American Psychiatric Association, 1994] or other large
epidemiological studies (1% for SP, 1–3.6% for GAD;
Bernstein, Costello, & Warren, 1990; Bowen, Offord,
& Boyle, 1990; Clark, Smith, Neighbors, Skerlec, &
Randall, 1994; Costello et al., 1988; Craske, 1997;
Kashani & Ovraschel, 1988, 1990; Kendall, Krain, &
Treadwell, 1999). Anxiety prevalence rates are also
higher in ASD children than in typically developing
children who suffer with chronic medical conditions
such as asthma (35%) (Vila, Nollet-Clemencon, de
Blic, Mouren-Simeoni, & Scheinmann, 2000).
Despite the strong evidence that anxiety difficulties
occur commonly in children with HFA, resulting in
marked distress to their families, little research has
explored effective treatment options for the anxiety
related difficulties of ASD children. Indeed, a review
of both the psychological and medical literature
between reveals the use of only two forms of inter-
vention to address anxiety in ASD children: psycho-
analytic therapy and pharmacotherapy.
In general, psychoanalytic treatments have focused
on therapist techniques such as exploring the clients
‘‘separation anxiety’’ from the analyst, exploring anx-
iety relating to a disturbance in the primary bond
between the client and the mother and exploring the
client’s ‘‘body anxiety’’ in order to help the client
address the physiological component of their anxiety
response (Braconnier, 1983; Heinemann, 1999; Sch-
teingart, 1989). However, several methodological and
theoretical limitations exist within the psychoanalytic
treatments of anxious ASD individuals including small
sample sizes (e.g. n = 1) and a lack of quantitative
Evidence for the use of medication in the treatment
of anxiety in children with an ASD, also seems to be
limited. Studies have explored medication regimes for
their ability to address the associated features of
anxious ASD individuals rather than to specifically
target primary anxiety difficulties (Brodkin, McDou-
gle, Naylor, Cohen, & Price, 1997; Kalus et al., 1991;
McDougle et al., 1992; Nicolson, Awad, & Sloman,
1998; Tsai, 1999). A further limitation is that most
pharmacological investigations have only involved
adult participants with Autistic Disorder. Moreover,
the effects of medication only appear to last as long
as the medication is being consumed with relapse
occurring once the medication regime is ceased (Tsai,
The limitations of the abovementioned interven-
tions for ASD children indicate that researchers need
to explore whether other forms of anxiety treatment
might be more appropriate for the anxious, ASD
population. In particular, it might be important to
consider other psychotherapeutic interventions that
target the underlying cognitions and behaviours that
maintain the ASD individual’s anxiety, for example,
cognitive behaviour therapy (CBT).
It has been suggested recently that evidence for the
efficacy of CBT in treating childhood anxiety disorders
is now strong enough to warrant CBT being considered
as a ‘‘Probably Efficacious’’ treatment in accordance
with the criteria for ‘‘Empirically Supported Treat-
ment’’ set out by the American Psychological Associ-
(Chambless & Hollon, 1998). Specifically, the findings
for the use of CBT in treating anxiety disorders in
children are considered exemplary in five ways (for
recent reviews of the efficacy of CBT in treating
anxious children see Albano, Chorpita, & Barlow,
2003; Albano & Kendall, 2002; Alfano, Beidel, &
Turner, 2002; Compton, Burns, Egger, & Robertson,
2002; Kashdan & Herbert, 2001; Ollendick & King,
1998; Weisz, Weiss, Han, Granger, & Morton, 1995).
First, research has included cases serious enough to
warrant formal diagnosis of an anxiety disorder and has
employed standardised assessment tools in determin-
ing these diagnoses (Barrett, Dadds, & Rapee, 1996;
Kendall, 1994; Kendall et al., 1997). Second, rando-
mised control trials have indicated clinical significance
of CBT treatments compared with waiting list (WL)
control conditions (e.g. Barrett et al., 1996; Kendall,
1994; Kendall et al., 1997; Rapee, 2000; Silverman
et al., 1999a, b). For example, Kendall (1994) found
that the majority of the 47 children assigned to the
treatment condition with an anxiety disorder diagnosis
J Autism Dev Disord
no longer met criteria for an anxiety disorder post-
treatment. Moreover, a significant group by time
interaction was found with 64% of the treatment
group no longer meeting anxiety disorder criteria
compared to 5% (one client) in the WL control group.
Third, research has indicated that the post-treatment
reductions attained from CBT programs have been
maintained over long, post-treatment follow-up peri-
ods (Barrett, Duffy, Dadds, & Rapee, 2001; Barrett,
Rapee, Dadds, & Ryan, 1996; Kendall, Safford,
Flannery-Schroeder, & Webb, 2004). Specifically,
several recent long-term follow-up studies revealed
that CBT treatment gains were maintained as long as
6 years after treatment (Barrett et al., 2001) or 7 years
after treatment (Kendall et al., 2004). Fourth, the
superiority of CBT as a treatment for anxiety in
children has been demonstrated by independent
research groups in at least two different countries:
the USA (Kendall et al., 1997) and Australia (Barrett
et al., 1996). Fifth, most of the CBT programs
evaluated have employed treatment manuals and,
therefore, have maintained treatment integrity.
Not only has CBT been shown to be effective in
treating anxiety symptoms in children, but also, more
recently, CBT has been found to be effective in
preventing the development of anxiety symptoms in
children (see Barrett & Turner, 2004 for a review). For
example, Barrett and Turner (2001) developed a 12-
session CBT intervention called the ‘‘Friends for
Children’’ program that could be incorporated into
classroom curriculum as a means of preventing anxiety.
They (2001) assessed the efficacy of the preventative
intervention using a sample of 489 primary school aged
children. The intervention was found to reduce the
report of anxiety symptoms (Barrett & Turner, 2001).
Although, CBT has widely demonstrated efficacy
among typically developing, anxious children (without
intellectual delay), there is no published literature
regarding the direct relevance of CBT models to
children with an ASD who have age appropriate
intellectual functioning. When employed, CBT-like
strategies tend to be used indirectly by focusing on
the parents. They are used either to teach the parents
how to manage their own stress and, in turn, cope
more effectively with their child’s anxious behaviours
(Verheij & Van Loon, 1993; Wolf, Noh, Fisman, &
Speechly, 1989) or to teach the parents anxiety-
reducing skills so that they can re-teach the skills to
their child, thereby becoming their child’s own therapist
(Verheij & Van Loon, 1993). There are documented
benefits for including parents in anxiety interventions
for children (Mendlowitz et al., 1999; Shortt, Barrett, &
Fox, 2001). However, failure to include the child as a
direct participant in the intervention might not only
hinder the child’s ability to become independently
aware of their anxiety difficulties but also, the child’s
ability to independently manage their anxiety difficul-
ties (Jackson, 1983; Piacentini & Bergman, 2001).
The paucity of research into CBT as a potential
model for treating anxiety in HFA children may be, in
part, due to suggestions from research that all children
with an ASD have difficulty in identifying emotions
and cognitions both in themselves and in others,
otherwise known as ‘‘Theory of Mind (ToM)’’ impair-
ment (Baron-Cohen, 2001; Baron-Cohen, Leslie, &
Frith, 1985). Based on the ToM hypothesis outlined by
Baron-Cohen et al. (1985), an anxious ASD child
might not be considered an appropriate candidate for a
CBT program because CBT relies on the child’s ability
to infer their own emotional states and thoughts in
order to shift their cognitive style and, in turn, their
anxious behaviour (Beck, 1976; Kendall et al., 1999).
However, while early ToM research suggested ToM
impairments to be specific to children with ASD and
global across all ASD children (Happe ´, 1994a; Holroyd
& Baron-Cohen, 1993; Kleinman, Marciano, & Ault,
2001), more recent literature has highlighted growing
evidence that children with HFA are able to identify
both their own and other’s thoughts (Bauminger &
Kasari, 1999; Bowler, 1992; Buitelaar, van der Wees,
Swaab-Barneveld, & van der Gaag, 1999; Dahlgren,
Sandberg, & Hjelmquist, 2003; Dyck, Ferguson, &
Shochet, 2001; Happe ´, 1995; Yirmiya, Erel, Shaked, &
Solomonica-Levi, 1998). Given the new ToM findings,
it may be plausible to suggest that psychotherapeutic
interventions like CBT be explored as a potential
treatment for anxious HFA children.
Furthermore, CBT might be appropriate for children
between their information processing style and that of
typically developing anxious children. According to
central coherence theory, children with an ASD are
argued to be over-selective in their information process-
ing style, focusing on small details rather than scanning
focus on (e.g. Frith, 1989; Happe ´, 1994a; Happe ´, Brisk-
man, & Frith, 2001; Morgan, Maybery, & Durkin, 2003;
children are argued to have an information processing
bias whereby they selectively attend to threat related
information resulting in the misinterpretation of ambig-
uous situations as threatening because of a failure to
Kendall, 1985; Kendall & Ronan, 1990).
The information processing difficulties of both ASD
and typically developing anxious children have both
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