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  1. 1. COGNITIVE-BEHAVIORAL GROUP THERAPY FOR ADOLESCENTS WITH HIGH-FUNCTIONING AUTISM SPECTRUM DISORDERS AND ANXIETY: A PILOT STUDY Reaven, J., Zapapas, L., Ridge, K., Hepburn, S., & Blakeley-Smith, A. JFK Partners The University of Colorado at Denver and Health Sciences Center, Department of Psychiatry <ul><li>INTRODUCTION </li></ul><ul><li>Anxiety Symptoms and Autism Spectrum Disorders </li></ul><ul><li>Anxiety disorders are among the most common childhood psychiatric conditions (Compton et al., 2004). </li></ul><ul><li>Children with developmental disabilities are at increased risk for developing anxiety disorders compared with the general population (Lainhart, 1999). </li></ul><ul><li>Children with high-functioning Autism and Asperger Syndrome (ASD) are at greater risk for developing significant anxiety symptoms compared to children with other developmental disabilities (Brereton et al., 2006; Gilliott et al, 2001; Muris et al., 1998). </li></ul><ul><li>Psychosocial Treatment of Anxiety Symptoms in Children with ASD </li></ul><ul><li>Cognitive-behavior therapy (CBT) is effective in reducing anxiety symptoms in typically developing children (Compton et al., 2004). </li></ul><ul><li>Individual and group CBT are equally effective in reducing anxiety symptoms (Manassis et al., 2002; Silverman et al., 1999). </li></ul><ul><li>Studies using CBT to reduce anxiety symptoms in individuals with ASD are rare but promising (Chalfant et al., 2006; Reaven & Hepburn, 2003; Reaven et al., in press; Sofronoff et al., 2005). </li></ul><ul><li>Adolescents with ASD and Anxiety </li></ul><ul><li>None of the treatment studies published to date have specifically targeted adolescents with ASD. </li></ul><ul><li>Only 3% of original articles published in the premier autism journal, JADD , in 2006 involved treatment related studies of adolescents with ASD. </li></ul><ul><li>OBJECTIVES </li></ul><ul><li>To conduct a pilot study to assess the efficacy of an original manualized, group cognitive behavior intervention package designed to reduce anxiety symptoms in adolescents with high-functioning ASD. </li></ul><ul><li>To describe the modifications necessary in the implementation of CBT for adolescents with ASD. </li></ul><ul><li>METHOD </li></ul><ul><li>Participants </li></ul><ul><li>4 adolescents ages 14-17 (and their parents) who met the following criteria: </li></ul><ul><ul><li>Current clinical diagnosis of Autistic Disorder or Asperger Syndrome. </li></ul></ul><ul><ul><li>Clinically significant symptoms of anxiety on the SCARED. </li></ul></ul><ul><ul><li>Verbal IQ of 80 or higher. </li></ul></ul><ul><li>Procedures </li></ul><ul><li>Families participated in pre-, post-evaluation sessions to examine anxiety symptoms </li></ul><ul><li>The intervention protocol was based on an intervention originally developed for children with ASD and anxiety ( Coping Group: Fighting Worry and Facing Fears ; Reaven et al. unpublished treatment manual). </li></ul><ul><li>Modifications to the Face Your Fears manual for use with the adolescents were documented </li></ul><ul><li>Overview of Intervention (Reaven et al., 2005) </li></ul><ul><li>12 weekly 1 ½ hour group therapy sessions, including large group activities, small group activities (parents alone, adolescents alone) and dyadic work (parent/adolescent pairs) </li></ul><ul><li>Adolescent Components </li></ul><ul><li>Increase awareness of the signs and symptoms of anxiety, emphasize the connection between cognitions and physiological responses to anxiety </li></ul><ul><li>Create “tools” to resist symptoms—relaxation and cognitive restructuring </li></ul><ul><li>Establish a fear hierarchy and teach adolescents to “face fears” a little at a time (graded exposure) </li></ul><ul><li>Parent Components </li></ul><ul><li>Psychoeducation for anxiety symptoms including an introduction to CBT </li></ul><ul><li>Encourage parents to ignore excessive anxiety and reward adolescents for “facing fears” </li></ul><ul><li>Parental anxiety and parental protection reviewed (Reaven & Hepburn, 2006) </li></ul><ul><li>Measures </li></ul><ul><li>The SCARED is a 40 item questionnaire for children and adolescents that assesses symptoms of anxiety. There are identical parent and child versions. Items are rated on a 3 point scale. A Total Score of 25 or higher is considered to be clinically significant. </li></ul><ul><li>The CATS is a 40 item questionnaire for children and adolescents that assesses negative self statements. Items are rated on a 5 point scale and summed to created an Internalizing factor and an Externalizing factor. </li></ul><ul><li>RESULTS </li></ul><ul><li>Adolescent Ratings of SCARED: Parent Ratings of SCARED: </li></ul><ul><li>Total Anxiety Total Anxiety </li></ul><ul><li>Adolescent Ratings of CATS: Adolescent Ratings of CATS: </li></ul><ul><li>Internalizing Externalizing </li></ul><ul><li>CONCLUSIONS </li></ul><ul><li>Modifications to traditional CBT protocols are necessary for use with adolescents with ASD and anxiety </li></ul><ul><li>Preliminary findings suggest that group CBT treatment with parent participation may be effective in decreasing anxiety symptoms in adolescents with ASD. </li></ul><ul><li>LIMITATIONS </li></ul><ul><li>Results are based on a small sample of participants </li></ul><ul><li>No follow-up was done except immediate post-treatment measures </li></ul><ul><li>Some participants used the PDAs and others did not; thus, the impact of technology on initial treatment efficacy is hard to determine. </li></ul><ul><li>Parent and adolescent report measures were used as outcome measures, and could be influenced by investment in intervention. </li></ul><ul><li>FUTURE DIRECTIONS </li></ul><ul><li>Further develop the treatment manual for use with adolescents with ASD. </li></ul><ul><li>Establish feasibility and acceptability with a larger sample. </li></ul><ul><li>Expand PDA use to examine the relative impact on the efficacy of the intervention. </li></ul><ul><li>Develop fidelity measures and measurement strategies in preparation for a larger efficacy study </li></ul><ul><li>ACKNOWLEDGEMENTS </li></ul><ul><li>A special thank you to the parents and adolescents who participated in our study. </li></ul><ul><li>Original anxiety manual was created during a study funded by the Organization for Autism Research, the Doug Flutie Foundation, and Cure Autism Now. </li></ul><ul><li>Additional support from the Centers for Disease Control (CDC) – CADDRE and JFK Partners—the University Center of Excellence in Developmental Disabilities (UCEDD) at the University of Colorado at Denver and Health Sciences Center, through the Administration on Developmental Disabilities, Grant # 90DD0561 </li></ul><ul><li>Minna Levine and SymTrend (PDA) </li></ul>Table 3. Examples of application of treatment adaptations for ASD (Hurley, 1998) as applied to the Face Your Fears manual Table 2. Modifications of critical elements of Coping Cat CBT for children and adolescents with ASD Parents remain an essential part of the adolescent group, especially when working on hierarchies and exposure Parents are an essential element of the intervention and participate in all sessions with their child; homework focuses on rehearsal of concepts and practicing facing fears using an exposure hierarchy Involve caregivers Adolescents generated their own relaxation techniques which were filmed as an instructive video; various artistic media were available Activities vary and stimulate learners of various information processing styles; e.g., participants collaborate to make a movie of a child facing his/her fear with the help of a coach Flexible methods Stories and games are eliminated and group brainstorming is used; video and artistic activities remain; group discussion used instead of individual problem-solving Sessions include drawing, drama, story time, and/or photography, and sessions include many games and playful activities Activities Lists are used, but adolescents are encouraged to add their own items; verbal or written examples replace visual images (used with younger population) Concrete, visual stimuli (e.g., multiple choice lists) are used to illustrate concepts; non-language based activities are included in curriculum and can substitute for language-based activities Language Modifications for Adolescents with ASD-Face Your Fears Modifications for Children with ASD-Face Your Fears Suggested Adaptation Types (Hurley, 1998) <ul><li>Included </li></ul><ul><li>Included </li></ul>Self-evaluation and reward <ul><li>Adolescents track their exposure at home using the PDAs or paper equivalents </li></ul><ul><li>Children are assigned homework which was discussed the following week </li></ul>Homework– Show-That-I-Can (S-T-I-C) <ul><li>Included </li></ul><ul><li>Included </li></ul><ul><li>In vivo exposure was heavily emphasized and SUDS measures recorded </li></ul><ul><li>Included </li></ul><ul><li>“ Face Your Fear” movies were created as a group using a shared fear, rather than creating individual videos </li></ul><ul><li>Parents help to develop hierarchies and beginning steps (for exposure) are identified </li></ul><ul><li>Children and parents watch previous “Face Your Fear” movies, depicting children facing their fears in a variety of situations </li></ul><ul><li>Imaginal exposure is not used; role play and in vivo experiences are created. </li></ul><ul><li>Parents are coached on how to create exposure experiences at home. </li></ul><ul><li>Children film “Face Your Fear” episodes to practice exposure </li></ul>Graded exposure tasks using role play, imagery/tage-a-long activities, and in vivo practice <ul><li>Adolescents focused on “calming activities” rather than deep breathing and PMR, then filmed their own model video using techniques they thought their peers would utilize </li></ul><ul><li>Deep breathing and progressive muscle relaxation (PMR) are taught through video modeling </li></ul><ul><li>“ Relaxation” is broadened to include a range of “calming activities” that may be substituted, especially for PMR </li></ul>Relaxation and other somatic management strategies <ul><li>Included </li></ul><ul><li>SUDS were recorded on a personal digital assistant (PDA) or on a paper version; this data was then available for analysis over a time period </li></ul><ul><li>Adolescents chose whether to artistically represent either “worry” or a “helper” and were encouraged to come up with language that was useful to them </li></ul><ul><li>Automatic thoughts are discussed, but emphasis is on coping statements </li></ul><ul><li>With parental support, children identify anxious situations, assign Subjective Units of Distress (SUDS) ratings (using a visual aide), and make a plan to handle anxiety </li></ul><ul><li>Additional content : </li></ul><ul><li>Hands-on art activities were used to “externalize” anxiety (March & Mulle, 1998); “worry” bug identified and “helper” bug created to fight the worry </li></ul><ul><li>Cognitive strategies: </li></ul><ul><li>Cognitive restructuring </li></ul><ul><li>Identification of anxious situations, thoughts, feelings, actions; problem-solving strategies </li></ul>Modifications for Adolescents with ASD-Face Your Fears Modifications for Children with ASD- Face Your Fears (Reaven et al. 2005) Critical Elements-Coping Cat (Kendall, 2000)