Skip to main content
SpringerLink
Log in

Examining the Relationship Between Anxiety Severity and Autism-Related Challenges During Cognitive Behavioral Therapy for Children with Autism

  • Original Paper
  • Published:
Journal of Autism and Developmental Disorders Aims and scope Submit manuscript

Abstract

Purpose: Using data from a randomized clinical trial evaluating cognitive behavioral therapy (CBT) for children with autism and co-occurring anxiety, this study examined the relationship between autism features and anxiety symptoms throughout CBT. Methods: Two multilevel mediation analyses were run which examined the mediating role of changes in anxiety for changes in two core features of autism, (a) repetitive and restrictive behaviors (RRBs) and (b) social communication/interaction impairments, between pre- and post-treatment. Results: Indirect effects between time and autism characteristics were significant for both models, indicating that as anxiety changes, so do RRBs and social communication/interaction as the outcomes respectively. Conclusion: Findings suggest a bidirectional relationship between anxiety and autism features. Implications of these findings are discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Notes

  1. Constrained maximum-likelihood estimation was used because it yields unbiased and consistent estimators for variance coefficients and is less sensitive to outliers compared to maximum likelihood estimation. However, when the models were run using to maximum likelihood estimation (instead of constrained maximum-likelihood estimation), the results stayed identical.

  2. While the authors were interested in a fine-grained examination of the precise subscales analyzed (Social Communication and Restricted Interests and Repetitive Behaviour) rather than the total SRS score (which includes additional Social Awareness, Social Cognition, and Social Motivation subscales), additional analyses indicated that the two subscales examined are highly correlated with the total SRS score (r > .7). The results reported above did not change when the models were run with the total SRS scores.

References

  • Adams, D., Clark, M., & Keen, D. (2019). Using self-report to explore the relationship between anxiety and quality of life in children on the autism spectrum. Autism research: official journal of the International Society for Autism Research, 12(10), 1505–1515. https://doi.org/10.1002/aur.2155

    Article  PubMed  Google Scholar 

  • Akaike, H. (1987). Model selection and Akaike’s Information Criterion (AIC): the general theory and its analytical extensions. Psychometrica, 52(3), 345–370. https://doi.org/10.1007/BF02294361

    Article  Google Scholar 

  • Bal, V. H., Leventhal, B. L., Carter, G., Kim, H., Koh, Y. J., Ha, M., Kwon, H. J., Hong, P., & Kim, Y. S. (2021). Parent-reported suicidal ideation in three Population-Based samples of School-Aged korean Children with Autism Spectrum disorder and autism spectrum screening questionnaire screen positivity. Archives of suicide research: official journal of the International Academy for Suicide Research, 1–18. https://doi.org/10.1080/13811118.2020.1868367. Advance online publication.

  • Baribeau, D. A., Vigod, S., Pullenayegum, E., Kerns, C. M., Mirenda, P., Smith, I. M., & Szatmari, P. (2020). Repetitive behavior severity as an early indicator of risk for elevated anxiety symptoms in autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 59(7), 890–899.

    Article  Google Scholar 

  • Baribeau, D. A., Vigod, S., Pullenayegum, E., Kerns, C. M., Mirenda, P., Smith, I. M., Vaillancourt, T., Volden, J., Waddell, C., Zwaigenbaum, L., Bennett, T., Duku, E., Elsabbagh, M., Georgiades, S., Ungar, W. J., Zaidman Zait, A., & Szatmari, P. (2021). Co-occurring trajectories of anxiety and insistence on sameness behaviour in autism spectrum disorder. The British journal of psychiatry: the journal of mental science, 218(1), 20–27. https://doi.org/10.1192/bjp.2020.127

    Article  PubMed  Google Scholar 

  • Ben-Itzchak, E., Koller, J., & Zachor, D. A. (2020). Characterization and prediction of anxiety in adolescents with Autism Spectrum disorder: a longitudinal study. Journal of abnormal child psychology, 48(9), 1239–1249. https://doi.org/10.1007/s10802-020-00673-0

    Article  PubMed  Google Scholar 

  • Briot, K., Jean, F., Jouni, A., Geoffray, M. M., Ly-Le Moal, M., Umbricht, D., Chatham, C., Murtagh, L., Delorme, R., Bouvard, M., Leboyer, M., & Amestoy, A. (2020). Social anxiety in children and adolescents with Autism Spectrum Disorders contribute to impairments in Social Communication and Social Motivation. Frontiers in psychiatry, 11, 710. https://doi.org/10.3389/fpsyt.2020.00710

    Article  PubMed  PubMed Central  Google Scholar 

  • Caporino, N. E., Brodman, D. M., Kendall, P. C., Albano, A. M., Sherrill, J., Piacentini, J., Sakolsky, D., Birmaher, B., Compton, S. N., Ginsburg, G., Rynn, M., McCracken, J., Gosch, E., Keeton, C., March, J., & Walkup, J. T. (2013). Defining treatment response and remission in child anxiety: signal detection analysis using the pediatric anxiety rating scale. Journal of the American Academy of Child and Adolescent Psychiatry, 52(1), 57–67. https://doi.org/10.1016/j.jaac.2012.10.006

    Article  PubMed  Google Scholar 

  • Capriola-Hall, N. N., McFayden, T., Ollendick, T. H., & White, S. W. (2021). Caution when screening for autism among socially anxious youth. Journal of autism and developmental disorders, 51(5), 1540–1549.

    Article  PubMed  PubMed Central  Google Scholar 

  • Cholemkery, H., Mojica, L., Rohrmann, S., Gensthaler, A., & Freitag, C. M. (2014). Can autism spectrum disorders and social anxiety disorders be differentiated by the social responsiveness scale in children and adolescents? Journal of Autism and Developmental Disorders, 44(5), 1168–1182.

    Article  PubMed  Google Scholar 

  • Chun, J., Bong, G., Han, J. H., Oh, M., & Yoo, H. J. (2021). Validation of Social Responsiveness Scale for Korean Preschool Children with Autism. Psychiatry investigation, 18(9), 831–840. https://doi.org/10.30773/pi.2021.0182

    Article  PubMed  PubMed Central  Google Scholar 

  • Constantino, J. N., & Gruber, C. P. (2005). Social Responsiveness Scale (SRS) Manual. Los Angeles, CA: Western Psychological Services.

    Google Scholar 

  • Duvekot, J., van der Ende, J., Verhulst, F. C., & Greaves-Lord, K. (2018). Examining bidirectional effects between the autism spectrum disorder (ASD) core symptom domains and anxiety in children with ASD. Journal of child psychology and psychiatry and allied disciplines, 59(3), 277–284. https://doi.org/10.1111/jcpp.12829

    Article  PubMed  Google Scholar 

  • Factor, R. S., Moody, C. T., Sung, K. Y., & Laugeson, E. A. (2022). Improving Social Anxiety and Social Responsiveness in Autism Spectrum Disorder through PEERS®, Evidence-Based Practice in Child and Adolescent Mental Health, 7:1, 142–159, https://doi.org/10.1080/23794925.2021.2013138

  • Fombonne, E. (2009). Epidemiology of pervasive developmental disorders. Pediatric research, 65(6), 591–598. https://doi.org/10.1203/PDR.0b013e31819e7203

    Article  PubMed  Google Scholar 

  • Ginsburg, G. S., Keeton, C. P., Drazdowski, T. K., & Riddle, M. A. (2011). The utility of clinicians ratings of anxiety using the Pediatric anxiety rating scale (PARS). Child & Youth Care Forum, 40(2), 93–105. https://doi.org/10.1007/s10566-010-9125-3

    Article  Google Scholar 

  • Gotham, K., Brunwasser, S. M., & Lord, C. (2015). Depressive and anxiety symptom trajectories from school age through young adulthood in samples with autism spectrum disorder and developmental delay. Journal of the American Academy of Child and Adolescent Psychiatry, 54(5), 369–76e3. https://doi.org/10.1016/j.jaac.2015.02.005

    Article  PubMed  PubMed Central  Google Scholar 

  • Hus, V., Bishop, S., Gotham, K., Huerta, M., & Lord, C. (2013). Commentary: Advancing measurement of ASD severity and social competence: a reply to Constantino and Frazier (2013). Journal of child psychology and psychiatry, and allied disciplines, 54(6), 698– 700. https://doi.org/10.1111/jcpp.12065

  • Kenny, D. A., Korchmaros, J. D., & Bolger, N. (2003). Lower level mediation in multilevel models. Psychological methods, 8(2), 115–128. https://doi.org/10.1037/1082-989x.8.2.115

    Article  PubMed  Google Scholar 

  • Kerns, C. M., Kendall, P. C., Berry, L., Souders, M. C., Franklin, M. E., Schultz, R. T., Miller, J., & Herrington, J. (2014). Traditional and atypical presentations of anxiety in youth with autism spectrum disorder. Journal of autism and developmental disorders, 44(11), 2851–2861. https://doi.org/10.1007/s10803-014-2141-7

    Article  PubMed  PubMed Central  Google Scholar 

  • Kerns, C. M., Kendall, P. C., Zickgraf, H., Franklin, M. E., Miller, J., & Herrington, J. (2015a). Not to be overshadowed or overlooked: functional impairments associated with comorbid anxiety disorders in youth with ASD. Behavior therapy, 46(1), 29–39. https://doi.org/10.1016/j.beth.2014.03.005.

    Article  PubMed  Google Scholar 

  • Kerns, C. M., Maddox, B. B., Kendall, P. C., Rump, K., Berry, L., Schultz, R. T., Souders, M. C., Bennett, A., Herrington, J., & Miller, J. (2015). Brief measures of anxiety in non- treatment-seeking youth with autism spectrum disorder. Autism: the international journal of research and practice, 19(8), 969–979. https://doi.org/10.1177/1362361314558465

    Article  PubMed  Google Scholar 

  • Kerns, C. M., Wood, J. J., Kendall, P. C., Renno, P., Crawford, E. A., Mercado, R. J., Fujii, C., Collier, A., Hoff, A., Kagan, E. R., Small, B. J., Lewin, A. B., & Storch, E. A. (2016). The treatment of anxiety in Autism Spectrum disorder (TAASD) study: Rationale, Design and methods. Journal of child and family studies, 25(6), 1889–1902. https://doi.org/10.1007/s10826-016-0372-2

    Article  PubMed  PubMed Central  Google Scholar 

  • Kerns, C. M., Rast, J. E., & Shattuck, P. T. (2020). Prevalence and correlates of caregiver- reported Mental Health Conditions in Youth with Autism Spectrum Disorder in the United States. The Journal of clinical psychiatry, 82(1), 20m13242. https://doi.org/10.4088/JCP.20m13242

    Article  PubMed  Google Scholar 

  • Kerns, C. M., Winder-Patel, B., Iosif, A. M., Nordahl, C. W., Heath, B., Solomon, M., & Amaral, D. G. (2021). Clinically significant anxiety in children with Autism Spectrum Disorder and Varied Intellectual Functioning. Journal of clinical child and adolescent psychology: the official journal for the Society of Clinical Child and Adolescent Psychology American Psychological Association Division, 53(6), 780–795. https://doi.org/10.1080/15374416.2019.1703712

    Article  Google Scholar 

  • MacNeil, B. M., Lopes, V. A., & Minnes, P. M. (2009). Anxiety in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders. 2009;3:1–21. https://doi.org/10.1016/j.rasd.2008.06.001

  • Marker, C. D., Comer, J. S., Abramova, V., & Kendall, P. C. (2013). The reciprocal relationship between alliance and symptom improvement across the treatment of childhood anxiety. Journal of clinical child and adolescent psychology: the official journal for the Society of Clinical Child and Adolescent Psychology American Psychological Association Division, 53(1), 22–33. https://doi.org/10.1080/15374416.2012.723261. 42.

    Article  Google Scholar 

  • Pickard H, Rijsdijk F, Happé F, Mandy W. Are Social and Communication Difficulties a Risk Factor for the Development of Social Anxiety? J Am Acad Child Adolesc Psychiatry. 2017 Apr;56(4):344–351

  • Preacher, K. J., & Selig, J. P. (2012). Advantages of Monte Carlo confidence intervals for Indirect Effects. Communication Methods and Measures, 6:2, 77–98. https://doi.org/10.1080/19312458.2012.679848

    Article  Google Scholar 

  • Raudenbush, S. W. (2001). Comparing personal trajectories and drawing causal inferences from longitudinal data. Annual Review of Psychology, 52, 501–525. https://doi.org/10.1146/annurev.psych.52.1.501

    Article  PubMed  Google Scholar 

  • Research Units on Pediatric Psychopharmacology Anxiety Study Group. (2002). The Pediatric anxiety rating scale (PARS): development and psychometric properties. Journal of the American Academy of Child and Adolescent Psychiatry, 41(9), 1061–1069. https://doi.org/10.1097/00004583-200209000-00006

    Article  Google Scholar 

  • Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 921–929. https://doi.org/10.1097/CHI.0b013e318179964f

    Article  PubMed  Google Scholar 

  • Singer, J. D., Willett, J. B., & Willett, J. B. (2003). Applied longitudinal data analysis: modeling change and event occurrence. Oxford university press.

  • Storch, E. A., Lewin, A. B., Collier, A. B., Arnold, E., De Nadai, A. S., Dane, B. F., Nadeau, J. M., Mutch, P. J., & Murphy, T. K. (2015). A randomized controlled trial of cognitive- behavioral therapy versus treatment as usual for adolescents with autism spectrum disorders and comorbid anxiety. Depression and anxiety, 32(3), 174–181. https://doi.org/10.1002/da.22332

    Article  PubMed  Google Scholar 

  • Storch, E. A., Arnold, E. B., Lewin, A. B., Nadeau, J. M., Jones, A. M., De Nadai, A. S., Mutch, J., Selles, P., Ung, R. R., D., & Murphy, T. K. (2013). The effect of cognitive- behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: a randomized, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 52(2), 132–142e2. https://doi.org/10.1016/j.jaac.2012.11.007

    Article  PubMed  Google Scholar 

  • Storch, E. A., Wood, J. J., Ehrenreich-May, J., Jones, A. M., Park, J. M., Lewin, A. B., & Murphy, T. K. (2012). Convergent and discriminant validity and reliability of the pediatric anxiety rating scale in youth with autism spectrum disorders. Journal of autism and developmental disorders, 42(11), 2374–2382. https://doi.org/10.1007/s10803-012-1489-9

    Article  PubMed  Google Scholar 

  • Sukhodolsky, D. G., Scahill, L., Gadow, K. D., Arnold, L. E., Aman, M. G., McDougle, C. J., McCracken, J. T., Tierney, E., White, W., Lecavalier, S., 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(1), 117–128. https://doi.org/10.1007/s10802-007-9165-9

    Article  PubMed  Google Scholar 

  • Tofighi, D., & MacKinnon, D. P. (2011). RMediation: an R package for mediation analysis confidence intervals. Behavior research methods, 43(3), 692–700. https://doi.org/10.3758/s13428-011-0076-x

    Article  PubMed  PubMed Central  Google Scholar 

  • Van Steensel, F., & Heeman, E. J. (2017). Anxiety levels in children with Autism Spectrum disorder: a Meta-analysis. Journal of child and family studies, 26(7), 1753–1767. https://doi.org/10.1007/s10826-017-0687-7

    Article  PubMed  PubMed Central  Google Scholar 

  • White, S. W., Oswald, D., Ollendick, T., & Scahill, L. (2009). Anxiety in children and adolescents with autism spectrum disorders. Clinical psychology review, 29(3), 216–229. https://doi.org/10.1016/j.cpr.2009.01.003

    Article  PubMed  PubMed Central  Google Scholar 

  • Wood, J. J., Drahota, A., Sze, K., Van Dyke, M., Decker, K., Fujii, C., Bahng, C., Renno, P., Hwang, W. C., & Spiker, M. (2009). Brief report: effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism. Journal of autism and developmental disorders, 39(11), 1608–1612. https://doi.org/10.1007/s10803-009-0791-7

    Article  PubMed  PubMed Central  Google Scholar 

  • Wood, J. J., Kendall, P. C., Wood, K. S., Kerns, C. M., Seltzer, M., Small, B. J., Lewin, A. B., & Storch, E. A. (2020). Cognitive behavioral treatments for anxiety in Children with Autism Spectrum disorder: a Randomized Clinical Trial. JAMA psychiatry, 77(5), 474–483. https://doi.org/10.1001/jamapsychiatry.2019.4160

    Article  PubMed  Google Scholar 

  • Wood, J. J., Sze Wood, K., Chuen Cho, A., Rosenau, K. A., Cornejo Guevara, M., Galán, C., Bazzano, A., Zeldin, A. S., & Hellemann, G. (2021). Modular cognitive behavioral therapy for autism-related symptoms in children: a randomized controlled trial. Journal of consulting and clinical psychology, 89(2), 110–125.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 4-400, Houston, TX 77030, USA

    Madeleine N. Fuselier, Andrew G. Guzick, Wayne K. Goodman & Eric A. Storch

  2. Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA

    Jafar Bakhshaie

  3. Department of Education, University of California, Los Angeles, Los Angeles, CA, USA

    Jeffrey J. Wood

  4. Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, USA

    Jeffrey J. Wood

  5. Department of Psychology, Temple University, Philadelphia, PA, USA

    Philip C. Kendall

  6. Department of Psychology, University of British Columbia, Vancouver, BC, Canada

    Connor M. Kerns

  7. School of Aging Studies, University of South Florida, Tampa, FL, USA

    Brent J. Small

Authors
  1. Madeleine N. Fuselier
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andrew G. Guzick
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jafar Bakhshaie
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jeffrey J. Wood
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Philip C. Kendall
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Connor M. Kerns
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Brent J. Small
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Wayne K. Goodman
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Eric A. Storch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eric A. Storch.

Ethics declarations

Dr. Wood discloses the following relationships: Research support from NIH and the Department of Defense. Dr. Kendall receives royalties from the sales of materials related to the treatment of anxiety disorders in youth. Dr. Kerns receives royalties from Elsevier. In addition, she has received honoraria and consulting fees for training other researchers on the Autism Spectrum Addendum. Dr. Storch discloses the following relationships: consultant for Biohaven Pharmaceuticals and Brainsway; Book royalties from Elsevier, Springer, American Psychological Association, Wiley, Oxford, Kingsley, and Guilford; Stock valued at less than $5000 from NView; Research support from NIH, IOCDF, Ream Foundation, and Texas Higher Education Coordinating Board.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Numbers 1R01HD080096, 1R01HD080098, and P50HD103555 for use of the Clinical and Translational Core facilities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fuselier, M.N., Guzick, A.G., Bakhshaie, J. et al. Examining the Relationship Between Anxiety Severity and Autism-Related Challenges During Cognitive Behavioral Therapy for Children with Autism. J Autism Dev Disord (2023). https://doi.org/10.1007/s10803-023-05912-z

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10803-023-05912-z

Keywords

Search

Navigation