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Evidence-Based Practices for Treating Fear & Anxiety in Children & Adolescents with ASD!
Laura B. Turner, Ph.D., BCBA-D!!Presented at the Hudson Valley Regional Center for Autism Spectrum Disorders 3rd Annual Spring Conference – 04/29/2016!
The purpose of this presentation is to provide…!
1. An overview of the prevalence of fear and anxiety in children and adolescents with ASD!
2. An overview of evidence-based approaches for alleviating anxiety in children and adolescents with ASD!
3. Additional readings and resources for you to be able to learn more about these techniques!
Starting with Definitions: Fear and Anxiety!
• It depends on the individual’s cognitive and social-communicative abilities!• Verbalizations (content) & Vocalizations (volume, tone)!• Facial expressions !• Caution: Individuals with ASD can display atypical expression of emotional states, contextually-
incongruous emotional reactions, and unreliable and atypical fearful facial expressions!• Body tenseness!• Approach/avoidance behaviors!• Noncompliance, aggression, self-injury & self-stimulatory behavior!
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How Do we Identify Fear & Anxiety in Individuals with ASD?!
Hagopian & Jennett, 2008
• Issues related to diagnostic overshadowing and symptom overlap!
With those caveats…fears and anxiety disorders are highly prevalent among children & adolescents with ASD!
• Approximately 40% have an anxiety disorder (APA, 2013; Leyfer et al., 2006; Muris et al., 1998; Simonoff et al., 2008; Sukhodolsky et al., 2008) (<20% in general population)!▫ Specific Phobia: 9% - 64% (5-16% of children/adolescents without ASD)!
▫ Social Anxiety Disorder: 8% - 30% (7% of children/adolescents without ASD)!
▫ Generalized Anxiety Disorder: 2% - 23% (<1% of children/adolescents without ASD)!
• Children with ASD have more intense fears than children with other developmental and intellectual disorders (Evans et al., 2005; Rodgers et al., 2011)!
• Atypical presentation of fear (Evans et al., 2005; Gillis et al., 2009; Turner & Romanczyk, 2012)!
▫ More likely to have fears related to medical/dental procedures !▫ Less likely to have fears of dangerous situations and items that could
cause harm !!
Rank! Fear Item! “A lot of fear”!1! Getting Blood Drawn! 64%!2! Getting a Shot! 54%!3! Getting Teeth Cleaned! 36%!4! Making Mistakes! 29%!5! Insects! 29%!6! Finger Prick! 28%!7! The Dark! 16%!8! Doctor Exam! 15%!9! Severe Weather! 15%!10! Meeting Peers! 14%!
Turner & Romanczyk (2012)!
Top 10 Fears Rated by Parents of Children with ASD!
n = 41!
When to seek help?!
• Does the fear/anxiety interfere with the individual’s ability to learn or gain independent skills?!
• Is the fear/anxiety abnormally intense?!• Does the fear/anxiety interfere with everyday activities?!• Are there associated dangerous behaviors?!
Seeking Help: An Evidence-Based Approach to Overcoming Excessive Fear and Anxiety!• Cognitive Behavior Therapy (CBT)!▫ Much empirical support for the effectiveness of CBT for children and adolescents
without ASD (e.g., Kazdin & Weisz, 2003; Kendall, 2000)!
BIACA – Building Confidence
▫ Growing body of support for the effectiveness of CBT for high functioning children and adolescents with ASD (e.g., Reaven et al., 2011; Wood et al., 2015) !� Must match approach to the cognitive, language and social-emotional abilities of the individual!
What is CBT?!
• An approach that merges theory and techniques from behavior and cognitive therapy!▫ Cognitive: Behavior is a function of faulty thinking and irrational
beliefs (Beck, 1972)!
▫ Behavioral: Behavior (including verbal behavior) is a function of the environment (e.g., Skinner, 1938)!
• So, the focus of intervention is on the ! ! ! acquisition of new ways of behaving.!
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• Underlying assumption is that fear/anxiety is learned (e.g., Watson & Raynor, 1920)!
Step 1. Psycho-Education: Recognizing Your Anxiety!
• Evaluating & developing emotional competence!▫ Typically need to spend more
time on this step than with individuals without ASD!
• Identification of idiosyncratic internal cues!▫ How do I know I’m anxious?!
• Identification of idiosyncratic external triggers!▫ What situations make me
anxious?!• Linking behavior, thoughts
and feelings!▫ Self-monitoring!
Step 2. Teaching Alternative Skills!!
Attwood & Scarpa, 2013; McNally Keehn et al., 2013; Reaven et al., 2011; White et al., 2015; Wood et al., 2015 !
▫ Positive self-talk, self-instructions!
• Specific Skills – Coping & Problem Solving!▫ Cognitive Restructuring!
� Challenge irrational beliefs & faulty thinking patterns!
� Increased focus on flexible thinking!
▫ “Worry time”!▫ Relaxation techniques, e.g., !
� Diaphragmatic breathing!� Progressive muscle relaxation!
• Teaching Considerations!▫ Incorporation of concrete language and examples &
visuals!▫ Use prompts and reinforcers!▫ Teach to fluency in a calm state!▫ Program for generalization!
Step 2 Continued. A Relatively New Approach for Individuals with ASD: Acceptance!
Eilers & Hayes, 2015; Dixon, 2014; Hayes et al., 2001, 2012; Hoffman et al., 2016; Pahnke et al., 2014; Spek et al., 2013!
• Focus isn’t on changing private events (i.e., thoughts and feelings); rather, focus is placed on changing the way an individual reacts to those thoughts and feelings. !
• A few components:!▫ Mindfulness – contact with present moment!▫ Defusion of thoughts!
• Acceptance & Commitment Therapy!▫ A form of CBT; based on behavior analytic theory!
Considerations for Conducting Sessions!
• Talking about private events (e.g., thoughts and emotions) can be non-preferred, unpredictable and difficult…!
• Motivation – Make it fun!!▫ Consider motivation to change and to attend sessions!▫ Incorporate reinforcers for participation!▫ Incorporate idiosyncratic interests!!
• Schedule!▫ Inclusion of clear session and activity schedules!▫ Schedules & reminders for CBT homework!
Attwood & Scarpa, 2013; McNally Keehn et al., 2013; Reaven et al., 2011; White et al., 2015; Wood et al., 2015 !
Step 3. Graduated Exposure*!• ALL forms of CBT include this component - Considered the most important! • Effective for lower-functioning children with ASD
*Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) !
• Gradually and systematically place the individual in contact with the feared stimuli(us) ▫ Respondent Extinction: Shape approach responses to break the association between the
conditioned stimulus (e.g., a dog) and the unconditioned stimulus (e.g., loud bark) so the individual can learn a new association ▫ It is important that the feared stimulus not be paired with aversive events (including extreme
anxiety responses) and the individual not be able to escape the situation (i.e., operant extinction) � Consideration: Preventing escape is correlated with more aggression in children with an ASD than
typically developing children (Evans et al., 2005)
Graduated Exposure – Developing a Fear Hierarchy*!
*Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) !
• Following a multi-component and individualized assessment, collaboratively develop a fear hierarchy
� Direct observation; interview with individual and caregivers
• Start with situation that elicits mild anxiety – ensure success with approaching!!▫ Importance of clearly defining responses!
• Provide prompts* (e.g., verbal, visual, model*) to engage in the approach behavior!
• Ensure consistent success before moving on to next step!!▫ Can have individuals rate their anxiety during
contact with stimulus to ensure success!
Graduated Exposure – Using a Fear Hierarchy*!
*Considered evidence-based for the treatment of specific phobia in children with ASD (Jennett & Hagopian, 2008) !
• Provide contingent reinforcement* for approach responses and absence of fear responses!▫ Importance of identifying effective reinforcers!▫ Include goal setting!
Making Exposure Collaborative by Incorporating Choice: An Example!
“I’m afraid you’re going to cut my pinky
toe” !
Important to Include Social Skills Training!
• Particularly important when individual has social phobia!▫ Poor social skills can produce negative outcomes for social
exposures!
Involving Parents…Even though this is the last slide, this is one of the most important parts of CBT!!
• Parent training is important – “Co-therapists”!▫ Continue skills learned in sessions at home (e.g., psycho-education, coping
skills, exposure exercises, contingency management)!▫ Target parenting behavior and the parent-child relationship!!
• Some support for a focus on parent anxiety!▫ Parents of children with ASD have more anxiety (and stress and
depression) than parents without a child with ASD!▫ High parental anxiety is associated with negative ! !
child outcomes!
Creswell et al., (2008); Kuusikko-Gauffun et al., 2013; Reaven & Blakeley-Smith, 2013!
