A Short-Term Group Telehealth Cognitive Behavioral Therapy Intervention for Youth with Autism and Anxiety: A Pilot Study

Abstract

Background:

Children with autism often present with comorbid anxiety disorders. Cognitive behavioral therapy (CBT) is an effective, evidence-based approach to treating anxiety, but information on youth with autism and anxiety is limited. Coping Cat is a 16-week CBT intervention for children with anxiety but its use in a group telehealth format in an urban, predominantly Hispanic population is limited.

Objectives:

(a) To examine the feasibility and preliminary effectiveness of a short-term CBT telehealth group for youth with autism and anxiety disorders in an urban, predominantly Hispanic population and (b) to examine satisfaction with the intervention.

Methods:

Single-arm pilot study that consisted of a 16-week telehealth CBT group therapy was based on a modified Coping Cat curriculum. Youth with autism and anxiety disorders who were on a waitlist for psychotherapy at an urban developmental center were invited to participate. Anxiety was assessed pre- and posttreatment using the Screen for Child Anxiety Related Emotional Disorders, parent and self-report.

Results:

Eighteen children were enrolled; 16 children completed the program. Mean age was 11 ± 2.5 years (8–15 years); 89% males, 61% Hispanic. There was a significant reduction in pre-post intervention in symptoms of overall anxiety (parent: 41.0 ± 18.5 to 31.0 ± 16.3 p ≤ 0.003, self: 25.9 ± 12.8 to 14.1 ± 7.8 p ≤ 0.001), panic disorder (parent: 8.1 ± 7.0 to 4.1 ± 4.2 p = 0.013, self: 5.1 ± 4.8 to 0.8 ± 0.9 p = 0.004), and separation anxiety disorder (parent: 7.5 ± 4.8 to 5.7 ± 4.4 p = 0.041, self: 5.8 ± 3.3 to 3.8 ± 2.4 p = 0.018) as per parent and self-reports. Self-report data also revealed a significant reduction in symptoms of social anxiety disorder (6.5 ± 3.5 to 3.9 ± 2.7 p ≤ 0.001). Parents and children reported satisfaction with the group.

Conclusion:

In this small, predominantly Hispanic population of youth with autism and anxiety disorder, 89% of families were compliant with a group telehealth CBT intervention. Parents and youth reported a significant reduction in anxiety symptoms and program satisfaction. A modified group CBT program via telehealth represents a feasible intervention for youth with autism and anxiety disorders.

Introduction

Children with autism spectrum disorders (ASD) are more likely to experience anxiety disorders compared with neurotypical peers (Bellini, 2004; Gillott et al., 2001). According to a recent report from the Centers for Disease Control and Prevention, 1 in 36 children, 8 years of age, has ASD (Maenner et al., 2023) and about 70% of individuals with ASD have a comorbid diagnosis (American Psychiatric Association, 2013), with high rates of anxiety (Kerns et al., 2014; Valicenti-McDermott et al., 2023). Without proper identification and treatment of anxiety, youth with ASD run the risk of anxiety developing into a chronic condition that can persist into and throughout adulthood (Gotham et al., 2015).

While psychopharmacology, particularly selective serotonin reuptake inhibitors (SSRIs), may be effective in treating anxiety in autism (Thorkelson et al., 2019), trials have indicated high rates of behavioral activation, such as agitation, irritability, aggression, and disinhibition, and diminished tolerability (King et al., 2009). These findings may suggest that individuals with autism may be more vulnerable to side effects compared with their typically developing peers. As a result, current treatment recommendations for anxiety in youth with autism emphasize psychoeducation, care coordination, and modified cognitive behavioral therapy (CBT) (Vasa et al., 2016).

CBT focuses on helping individuals identify their emotions as well as identify and challenge maladaptive thoughts, attitudes, and beliefs. Initially developed for adults, CBT has been adapted for use with children and adolescents through various modifications (Grave and Blissett, 2004). These modifications encompass a range of strategies, including the integration of visual aids and hands-on activities to make concepts more concrete; supplementing verbally presented information with written information; the use of structured, brief, and parent-supported activities; encouragement of flexible thinking; modeling how to handle misunderstandings; agenda setting with clear structure and consistency within and between sessions; incorporation of special interests and talents; a focus on emotion identification in self and others; among others (Attwood and Scarpa, 2013; Beidas et al., 2010).

The Coping Cat program, a 16-week manualized CBT intervention (Kendall and Hedtke, 2006a; Kendall and Hedtke, 2006b) teaches emotion identification, awareness of somatic experiences associated with anxiety, thought identification and cognitive restructuring, development of a coping plan with self-reinforcements, and completion of exposure tasks. While most of the research on CBT efficacy has focused on neurotypical populations, preliminary evidence suggests that modified CBT, including Coping Cat can effectively treat anxiety disorders in youth with developmental disabilities, such as ASD (Chalfant et al., 2007; Kendall 1994, Ooi et al., 2008; Reaven et al., 2009; Sofronoff et al., 2005; Wood et al., 2009; Wood et al., 2020).

Psychotherapy delivered via telehealth has become increasingly prevalent, especially during the COVID-19 pandemic. Studies have indicated that telehealth psychotherapy demonstrates comparable efficacy to traditional in-person therapy, particularly when employing CBT for affective disorders (Fernandez et al., 2021). However, despite its growing use, research on telehealth psychotherapy for children and adolescents, especially those with developmental disabilities, remains limited. This gap in research hinders our understanding of the effectiveness and appropriateness of telehealth interventions for this population, and there is a need to explore the feasibility, acceptability, and effectiveness of telehealth psychotherapy in addressing the unique needs of youth with developmental disabilities (Meininger et al., 2022).

The objectives of this study were to (a) examine the feasibility and preliminary effectiveness of a short-term CBT group intervention (based on the Coping Cat curriculum) via telehealth for youth with ASD and anxiety disorders in an urban, predominantly Hispanic population and (b) to evaluate the satisfaction level of both parents and children regarding their participation in the intervention.

Methods

Participants

Participants were recruited from a psychotherapy waitlist at an urban, multidisciplinary, university-affiliated center, with referrals originating from schools, foster care agencies, parents, and pediatricians. Upon evaluation at our center, patients underwent a comprehensive multidisciplinary assessment involving developmental pediatricians, psychologists, psychiatrists, social workers, and speech and language pathologists. Following assessments, patients deemed appropriate were referred to therapeutic interventions within our center. Patients were required to have autism and anxiety disorder diagnoses. While there was no IQ requirement for participation, patients were required to be verbal, English dominant, and deemed able to participate in a CBT intervention, by evaluating clinicians.

The center predominantly serves urban residents of the Bronx, with a significant representation of Hispanic and African American children. All participants had received a diagnosis of both ASD and anxiety disorder (including generalized anxiety disorder, unspecified anxiety disorder, and specific phobia) confirmed by our multidisciplinary team, in accordance with the Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition (American Psychiatric Association, 2013). Diagnosis of ASD was confirmed with the Childhood Autism Rating Scale—Second Edition (Schopler et al., 2010).

Participants presented with additional comorbid developmental diagnoses including language disorders, specific learning disorders, attention-deficit/hyperactivity disorder (ADHD), intellectual disabilities, and borderline intellectual functioning. Children and adolescents meeting inclusion criteria for both autism and anxiety disorder diagnosis were invited to participate in this CBT for anxiety group. Participants were grouped by age into four groups: three groups for school-age children (ages 8–13; two groups with five patients each, and one group with three patients) and one for adolescents (ages 13–15; with five patients). Eighteen patients initially agreed to participate, with 16 completing the intervention.

Children receiving pharmacological interventions for ADHD and/or anxiety were included in the study. Of the seven patients on medication, three had changes made to their medication during the course of psychotherapy. None of the patients were receiving concurrent CBT.

The study was approved by the organization’s Scientific Review Committee and Institutional Review Board (IRB # 2020-11181). Informed consent and assent were obtained from all participating children and parents in accordance with the IRB.

Measures

The Screen for Child Anxiety Related Emotional Disorders (SCARED), parent and self-report measures, were administered pre- and postintervention (Birmaher et al., 1997). The SCARED assesses anxiety including symptoms of generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, panic disorder, and somatic complaints, as well as school-related anxiety and avoidance. The SCARED was selected for use as a screening tool and progress monitoring measure as all participants had previously undergone comprehensive evaluations that led to diagnoses and it has been shown to have strong psychometric properties when used with youth with high-functioning ASD (Stern et al., 2014). Additionally, the parallel nature of the parent- and self-report versions was important to elicit symptom ratings from both parents as well as youth.

Parent and patient satisfaction ratings were also provided at the end of the intervention. Parents were asked whether their child enjoyed attending the group (agree, neutral, disagree). They were also asked to rate on a 1–10 scale how likely they would be to recommend the group to other parents (1 = never, 5 = somewhat likely, 10 = very likely) as well as their level of satisfaction with the group (1 = not satisfied, 5 = somewhat satisfied, 10 = very satisfied).

Children were asked to provide feedback on their overall experience with the group using a 3-point scale (1 = bad, 2 = not good, but not bad, 3 = good). Additionally, they were asked to rate on a Likert scale (1 = not at all, 2 = a little, 3 = a lot) their feelings toward the following questions/statements: “How much did you like participating in the group?,” “The group was fun,” “The group was hard,” and “I learned from the group.” Visual supports, including sad, neutral, and smiling faces, were provided on the child satisfaction questionnaire. Attendance was also assessed as an indicator of feasibility, given problems with compliance with mental health services (Gould et al., 1985; Wierzbicki & Pekarik, 1993), including among the Hispanic population (Chavira et al., 2014).

Demographics, other developmental diagnoses, medication, and IQ were available for review and collected once the patient started the intervention.

Intervention

Cognitive behavioral intervention

A modified Coping Cat curriculum via telehealth was used for the group. Modifications to the curriculum were made to address the needs of the group members and the telehealth platform while maximizing fidelity to the CBT principles put forth in the curriculum and were developed in advance of delivering the therapy. Groups were run consecutively, between April 2022 and December 2023, with modifications remaining the same throughout each group’s course of treatment. Modifications included the incorporation of short ice breaker and team-building activities at the start of sessions to build rapport, increase comfort level, and improve social relations and interactions among group members. Frequent repetition of information was provided including a review of previously learned concepts at the beginning of the session, along with agenda setting, and a review of session content at the end of each session. The use of visuals was included, including videos, via screen-sharing to make the skills learned concrete and relatable as well as to mitigate the underlying language vulnerabilities the group members presented with. Psychoeducation on anxiety was incorporated throughout most of the sessions to increase group members’ knowledge and awareness of how anxiety can present itself as well as to normalize the experience. Psychoeducation around reading others’ facial expressions and nonverbal cues was included. Finally, an increased emphasis was placed on teaching and practicing CBT skills (e.g., emotion identification, scaling of emotions, the cognitive triangle, challenging negative self-talk) and concrete behavioral strategies (e.g., mindfulness, deep breathing, guided imagery, progressive muscle relaxation). Given that many of the patients presented with cognitive, learning, and language challenges, coupled with the group format and limited parental involvement, a decreased emphasis was placed on exposures to be conducted independently. Additionally, given the developmental challenges the patients presented with, they required more frequent repetition and practice with initial CBT skills, using the majority of this time-limited treatment to master the foundational skills (e.g., emotion identification, thought identification, challenging thoughts, relaxation techniques, mindfulness). Weekly homework was assigned to group members with a review at the beginning of the subsequent sessions. Homework assignments focused on previously learned skills as well as completion of exposures in the second half of the treatment. Information on skills learned throughout the group was provided to parents halfway through the group as well as at the end to increase generalization of skills.

Procedure

A review was conducted by the investigators of all youth on a psychotherapy waitlist at an urban, multidisciplinary, university-affiliated center to confirm inclusion criteria. Families were contacted by phone, and if they agreed to participate, an initial visit was scheduled. During the initial visit, informed consent and assent were obtained, and parent and child report measures of anxiety (SCARED) were administered. All children were permitted to receive treatment as usual (pharmacological and school services). The first author (E.R.) delivered all of the treatment. The intervention consisted of 16 sessions: an initial parent/child session, 13 group sessions, a final parent/child session, and a parent-only session halfway through the group. Eighteen children and adolescents were enrolled in a total of four groups (mean = 11 ± 2.5 years, range = 8–15 years). Sixteen children/adolescents completed the intervention. One child from the child group unenrolled after the first session and one adolescent from the adolescent group never attended any sessions. At the end of the intervention, both the parent and child were asked to fill out a satisfaction questionnaire.

Analyses

Descriptive statistics were used to calculate, describe, and summarize demographic and clinical data, as well as the results of satisfaction questionnaires. A series of paired t-tests were used to assess pre-(T1) and postintervention (T2) anxiety ratings as per parent and self-report, using the SCARED (Birmaher et al., 1997). Analyses were conducted for total scales as well as subscales. Due to changes in pharmacotherapy during the intervention, analyses were conducted on the overall sample and separately after excluding participants whose medication regimen was altered during the study period. Statistical significance was defined as p < 0.05, with two-tailed tests used throughout. All analyses were performed using SPSS software (SPSS, Inc., Chicago, IL).

Results

Sixteen children completed the intervention; 89% of participants who enrolled in the groups were males and 61% were Hispanic (Table 1). In addition to ASD and anxiety disorder, all participants had at least one other developmental diagnosis, with many having multiple diagnoses. The most common additional diagnosis was a language disorder, present in 100% of the participants (Table 1). Group members had a mean Full Scale IQ score of 88 ± 16, as assessed on an individually administered intelligence test (e.g., Wechsler Intelligence Scale for Children—Fifth Edition) (Wechsler, 2014), with a range of 64–124. Seven of the participants were prescribed medication: methylphenidate (n = 3), sertraline (n = 3), clonidine (n = 1), and lisdexamfetamine (n = 1).

Table 1.

Demographics and Diagnoses (N = 18)

Demographics
Mean age (years ± SD, range)	11 years ± 2.5, 8–15 years
Gender boys/girls	89% males, 11% females
IQ (mean FSIQ ± SD, range)	88 ± 16, 64–124
Race
Hispanic	n = 11 (61%)
Diagnoses
Anxiety disorder, unspecified	n = 14 (78%)
Generalized anxiety disorder	n = 3 (17%)
Specific phobia	n = 1 (6%)
Language disorder	n = 18 (100%)
Specific learning disorders	n = 4 (22%)
Attention-deficit/hyperactivity disorder	n = 8 (44%)
Intellectual disability	n = 1 (6%)
Borderline intellectual functioning	n = 1 (6%)
Medication
Sertraline	n = 3 (17%)
Lisdexamfetamine	n = 1 (6%)
Clonidine	n = 1 (6%)
Methylphenidate	n = 3 (17%)

FSIQ, Full Scale IQ; SD, standard deviation.

There was a significant reduction pre-post intervention in symptoms of total anxiety (parent: 41.0 ± 18.5 to 31.0 ± 16.3 p = 0.003, self: 25.9 ± 12.8 to 14.1 ± 7.8 p < 0.001), panic disorder (parent: 8.1 ± 7.0 to 4.1 ± 4.2 p = 0.013, self: 5.1 ± 4.8 to 0.8 ± 0.9 p = 0.004), and separation anxiety disorder (parent: 7.5 ± 4.8 to 5.7 ± 4.4 p = 0.041, self: 5.8 ± 3.3 to 3.8 ± 2.4 p = 0.018) as per parent and self-reports (Table 2). Self-report data also revealed a significant reduction in symptoms of social anxiety disorder (6.5 ± 3.5 to 3.9 ± 2.7 p < 0.001). Out of the seven patients receiving medication, three participants had changes made to their medication during the intervention. One patient underwent an increase in sertraline, one had an increase in sertraline and clonidine, and one had an increase in methylphenidate. Separate analyses excluding these three patients did not alter the results observed in the overall sample, maintaining significant improvements in anxiety symptoms reported by both parents and the participants.

Table 2.

Pre- and Postintervention Means and Standard Deviations of Anxiety Scores

SCARED scale	Parent report (N = 15)			Self-report (N = 15)
SCARED scale	Preintervention mean ± SD	Postintervention mean ± SD	p	Preintervention mean ± SD	Postintervention mean ± SD	p
Anxiety disorder (total)	41.0 ± 18.5	31.0 ± 16.3	0.003 ^*	25.9 ± 12.8	14.1 ± 7.8	<0.001 ^*
Panic disorder/somatic symptoms	8.1 ± 7.0	4.1 ± 4.2	0.013 ^*	5.1 ± 4.8	0.8 ± 0.9	0.004 ^*
Generalized anxiety disorder	11.7 ± 4.8	10.3 ± 5.7	0.068	5.8 ± 4.5	4.1 ± 3.1	0.078
Separation anxiety disorder	7.5 ± 4.8	5.7 ± 4.4	0.041 ^*	5.8 ± 3.3	3.8 ± 2.4	0.018 ^*
Social anxiety disorder	10.0 ± 3.9	8.7 ± 3.8	0.100	6.5 ± 3.5	3.9 ± 2.7	<0.001 ^*
School avoidance	2.9 ± 2.6	2.3 ± 2.1	0.146	2.1 ± 1.5	1.5 ± 1.7	0.106

p < 0.05.

Statistical analysis: paired t-test.

Both the children and parents expressed satisfaction with the group. Children reported finding the group enjoyable (2.8 ± 0.5), fun (2.6 ± 0.5), educational (2.5 ± 0.5), and that they had an overall positive experience (2.8 ± 0.4). Parents reported similar satisfaction. Eighty percent of the parents felt their child enjoyed participating in the group; 20% felt neutral. Additionally, parents reported that they were overall satisfied with the group (9.6 ± 0.8) and that they would recommend it to other parents (9.6 ± 0.9).

Participants demonstrated strong attendance throughout the course of the group. Of the 16 participants who completed the group, 14 (88%) had >80% attendance, 75% (n = 12) had >90% attendance, and 44% (n = 7) had 100% attendance. Of the 18 participants who were enrolled, 89% (n = 16) completed the course of the treatment, with the two who did not complete the treatment, dropping out within the first three sessions.

Discussion

In this small sample of an urban, predominantly Hispanic population of children and adolescents with ASD and anxiety disorders, a group CBT intervention, conducted via telehealth, showed preliminary effectiveness in reducing parent- and self-reported anxiety. In this sample, 89% of families were compliant with a CBT group via telehealth, highlighting the feasibility and acceptability of this delivery method within families in an urban area. Overall, results indicate a significant reduction in overall anxiety, as well as symptoms of panic disorder, separation anxiety disorder, and social anxiety disorder. The findings are comparable to previous CBT studies individually and in-person for children with ASD and anxiety (McNally Keen et al., 2013; Wood et al., 2020). While CBT, an evidenced-based psychotherapy approach, has been shown to address a range of mental health conditions (Hofmann et al., 2012), the research has been more limited in youth with developmental disabilities, particularly in an ethnic minority population, in a group format, and conducted via telehealth.

Despite CBT being an effective treatment for anxiety in Hispanics, this population has been underrepresented in research examining the effectiveness of CBT interventions (Casas et al., 2020). This study works to address the gap, as in our predominantly Hispanic group of children and adolescents, parents and children reported reductions in anxiety as well as satisfaction with this CBT approach. As all participants were English dominant, all sessions took place in English and no additional modifications were made to the curriculum. In this small sample, no significant differences were found between Hispanic and non-Hispanic participants.

Furthermore, the study highlighted the satisfaction reported by both parents and children with the CBT approach delivered via telehealth, underscoring its acceptability and potential benefits for enhancing treatment accessibility and consistency. Telehealth’s flexibility allows for consistent attendance and participation, addressing logistical barriers commonly encountered in in-person interventions. Eighty-nine percent of the participants initially enrolled completed the treatment. Of those who completed the treatment, 88% demonstrated attendance at over 80% of the sessions. This is considerably higher than the 40–60% premature termination rates found for mental health treatment (Gould et al., 1985; Wierzbicki & Pekarik, 1993). While telehealth has been around for many years and has been shown to be an effective treatment modality (Fernandez et al., 2021), the application of specific evidence-based CBT approaches for youth has been minimally researched.

In previous studies using the Coping Cat program (McNally Keen et al., 2013; Wood et al., 2020), the curriculum was implemented in person and individually, as opposed to a group telehealth format. The results from this pilot study suggest that this CBT intervention, conducted via telehealth in a group format, is an effective short-term intervention targeting anxiety symptoms in a minority pediatric population with ASD and anxiety. Implementation via a group format can increase the number of individuals being treated while also providing them with opportunities for social interaction and social skill building.

Limitations of this study include the small sample size, lack of a control group, and possibility for observation bias, given the open nature. However, the reduction of anxiety was measured using parental and child instruments, not the therapist’s observations. The findings underscore the effectiveness of the short-term CBT intervention delivered via telehealth in reducing anxiety symptoms among youth with ASD. The significant improvements across multiple anxiety domains highlight the potential of group CBT as a valuable therapeutic approach in this population. Further research, involving larger sample sizes and incorporating control groups, could address some of the limitations and generalize the effectiveness of group CBT intervention via telehealth. The use of standardized, validated satisfaction measures could also increase the reliability and validity of conclusions drawn regarding patient and participant satisfactions.

Conclusions

CBT has been found to be an efficacious treatment approach to targeting anxiety symptoms in youth with ASD. This study sought to examine the feasibility and preliminary effectiveness of a short-term CBT group intervention via telehealth for youth with ASD and anxiety disorders in an urban, predominantly Hispanic population as well as to examine satisfaction with the intervention. Parents and children reported significant reductions in overall anxiety, as well as symptoms of panic and separation anxiety over the course of the treatment. Additionally, youth reported significant reductions in symptoms of social anxiety. Moreover, parents and youth reported satisfaction with the intervention. Therefore, this pilot study provides preliminary evidence supporting the effectiveness of a short-term, modified CBT protocol delivered through telehealth groups for youth with ASD and anxiety.

Clinical Significance

The results from this study along with previous studies support the use of CBT, with adaptations, in treating anxiety in youth with ASD. Additionally, this study showed the preliminary effectiveness of implementing CBT in a predominantly Hispanic population of youth with ASD in a group setting, conducted via telehealth.

Footnotes

Acknowledgments

The authors wish to express their appreciation for the families who participated in this study along with the colleagues who provided support and referrals throughout the process. The authors also wish to express their sincere appreciation to the Mother Cabrini Health Foundation for their support.

Disclosures

The authors declare no relevant disclosures or conflicts of interest.

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