CBT Reduces Anxiety in Children with Autism Spectrum Disorder

family therapy, therapy for child
Both cognitive behavioral therapy conditions achieved a higher rate of positive treatment response than the treatment as usual condition.

Study data published in JAMA Psychiatry support the efficacy of cognitive behavioral therapy (CBT) for reducing anxiety symptoms in children with autism spectrum disorder (ASD).

In a randomized clinical trial, Jeffrey J. Wood, PhD, of the department of psychiatry, University of California, Los Angeles, and colleagues recruited at 3 universities in metropolitan cities in the United States: Los Angeles, California; Tampa, Florida; and Philadelphia, Pennsylvania. A volunteer sample of children ages 7 to 13 years with ASD and maladaptive and interfering anxiety were randomly assigned to (1) standard-of-practice CBT, (2) CBT adapted for ASD, or (3) treatment as usual. Children assigned to standard-of-practice CBT or adapted CBT received 16 weekly sessions led by study therapists. Patients in the treatment as usual arm continued care with their physicians for 4 months, after which they were offered the option of CBT.

The primary outcome was reduction in Pediatric Anxiety Rating Scale (PARS) total score and subscale scores. The PARS was administered by study clinicians at baseline, mid-treatment (week 8), and after treatment (week 16). General linear mixed models were used to assess the impact of each treatment condition on PARS score, and in these models, study site was treated as a random effect and baseline PARS score was included as a covariate. Models were also adjusted for sex, race/ethnicity, household income, parental educational attainment, parental marital status, and estimated IQ. Secondary outcomes included positive treatment response per the Clinical Global Impression-Improvement scale and parent-reported Child Behavior Checklist, Social Responsiveness Scale–2, and Child Anxiety Impact Scale scores.

Overall, 145 children (mean age, 9.9±1.8 years; 20.5% girls) completed treatment, and discontinuation was not significantly associated with treatment condition. Mean PARS score at posttreatment was significantly lower in the adapted CBT condition (2.13±0.91) compared with standard practice CBT (2.43±0.80; P =.04) and treatment as usual (2.93±0.59; P <.001). Both CBT conditions achieved a higher rate of positive treatment response (adapted CBT, 92.4%; standard CBT, 81.0%) than the treatment as usual condition (11.1%; P <.001 for both comparisons).  

The adapted CBT condition outperformed standard practice CBT and treatment as usual on parent-reported scales of internalizing symptoms (P =.01 vs standard CBT; P =.04 vs treatment as usual), ASD-associated social-communication symptoms (P =.04 and P =.01, respectively), and anxiety-associated social functioning (P =.04 and P =.02, respectively). Clinically significant improvement, defined as a >35% reduction in PARS score from baseline, was achieved by 53.0% of the adapted CBT group, compared with 37.9% of the standard CBT group and 0% of the treatment as usual group (P <.001 in 3-condition likelihood ratio test).

These data support the efficacy of CBT for reducing anxiety symptoms in children with ASD. The investigators noted that the relatively homogenous study cohort may impact generalizability; the majority of participants were white and male.

“Although supervision opportunities and expert training are not yet widely accessible, the benefits of CBT appear to justify efforts to disseminate relevant protocols in clinical settings where children with ASD receive services,” the researchers concluded.

Disclosure: A study author declared affiliations with the pharmaceutical industry.

Please see the original reference for a full list of disclosures.


Wood JJ, Kendall PC, Wood KS, et al. Cognitive behavioral treatments for anxiety in children with autism spectrum disorder: a randomized clinical trial. JAMA Psychiatry. 2020;77(5):474-483.