Family Accommodation Hinders Anxiety Treatment in Youths With ASD

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At 16 weeks, both CBT treatments significantly reduced accommodation frequency more than standard treatment, with no significant differences between the CBT treatments.

In youths with autism spectrum disorder (ASD), high family accommodation before treatment was associated with greater anxiety, externalizing behavior, and autism severity, as well as poor outcomes after therapy. Adjunctive cognitive behavioral therapy (CBT) decreased family accommodation, and posttreatment accommodation was highest in nonresponders, according to a study published in the Journal of Clinical Child & Adolescent Psychology.1

Family accommodation consists of methods family members use to reduce children’s distress due to anxiety-provoking stimuli, including reassurance of worries and modification of routines, which may encourage avoidant behavior and conflict with the CBT model of managed approach. In typically developing youth, accommodation is associated with greater functional impairment, symptom severity, and comorbidity. Youth with ASD often experience higher levels of family accommodation for anxiety.2

Hannah E. Frank, PhD of the department of psychology, Temple University, Philadelphia, Pennsylvania, and colleagues recruited children and adolescents (ages 7-13 years) with diagnoses of ASD as assessed by an independent evaluator, significant anxiety defined as a score of 14 or higher on the Pediatric Anxiety Ratings Scale (PARS), and an IQ over 70. The majority of patients were white (76.6%) and male (79.6%).

Patients were randomized to receive either 16 weeks of CBT for anxiety (n=148) or standard treatment (n=19). CBT involved either Coping Cat (n=72) or Behavioral Intervention for Anxiety in Children with Autism (BIACA). Coping Cat consists of 60 minute sessions that treat anxiety through coping plans for anxiety-provoking stimuli. BIACA involves 90 minute sessions focused on the development of anxiety coping and relationship building skills to decrease distress in social settings. Unlike Coping Cat, BIACA may also include focused intervention on family accommodation.

The researchers measured accommodation using the Pediatric Accommodation Scale (PAS), which is divided into 3 subscales that measure accommodation frequency, as well as the impact of accommodation on the parent and child.  They also measured participant behavior, ASD and anxiety symptoms via the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), Clinical Global Impression Scale-I (CGI-I), Multidimensional Anxiety Scale for Children, Parent Version (MASC), Child Behavior Checklist (CBCL), and Social Responsiveness Scale (SRS).  

Higher family accommodation before treatment was significantly associated with greater anxiety severity, externalizing symptoms, and parent reported ASD severity.  Linear regression showed significant associations between PAS subscales with PARS (frequency: β=9.34; parent impact: β=2.80; child impact: β=4.40; all P <.001), CBCL (frequency: β=11.08; P <.001; parent impact: β=2.79; P =.001; child impact: β=3.32; P =.01), and SRS (frequency: β=6.74; P =.001; parent impact: β=2.18; P =.005; child impact: β=3.87; P =.001).

At 16 weeks, both CBT treatments significantly reduced accommodation frequency more than standard treatment, with no significant differences between the CBT treatments (P =.006). Higher pretreatment accommodation was predictive of higher posttreatment anxiety when assessed by a clinician but not by parents. Lower levels of posttreatment accommodation were associated with greater treatment response as assessed by the CGI-I.

Study limitations included an imbalance in the racial and ethnic background of the sample. Patients were generally high functioning and accommodation may influence anxiety differently in lower functioning youths with ASD.

“Clinicians should consider the ways in which accommodation is provided in response to internalizing, externalizing, and ASD symptoms. In many ways, accommodation of anxiety appears to function similarly among youth with and without ASD and should be addressed accordingly in treatment,” the researchers concluded.

Disclosures: A study author reported financial relationships to pharmaceutical sales. See original study for a full list of disclosures.


1.     Frank HE, Kagan ER, Storch EA, et al. Accommodation of anxiety in youth with autism spectrum disorder: results from the TAASD study [published online ahead of print, 2020 Jun 8]. J Clin Child Adolesc Psychol. 2020;1-11.

2.     Storch EA, Zavrou S, Collier AB, et al. Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: Incidence, clinical correlates, and behavioral treatment response. J Anxiety Disord. 2015;34:94-99.