Parenting Stress as a Correlate of Cognitive Behavior Therapy Responsiveness in Children With Autism Spectrum Disorders and Anxiety

Abstract

Children with autism spectrum disorder (ASD) often show high rates of anxiety, and cognitive behavior therapy (CBT) is recognized as an emerging evidence-based practice. Eighteen children (8–12 years of age, M = 9.5, SD = 1.34; male: n = 15) with ASD and significant anxiety problems participated in a 12-session group “Coping Cat” intervention together with their parents. Statistically significant reductions were noted across measures of parent-reported child anxiety, with 50% of children demonstrating clinically meaningful improvements using the conservative Reliable Change Index. Significant correlations were found between change in parenting stress and change in child anxiety from pre- to post-treatment. These results are applicable to the community service sector, where the Coping Cat program is commonly utilized. Due to the high prevalence of anxiety disorders in children with ASD, further research is needed to advance capacity building to help meet the significant needs of youth with ASD and anxiety.

Keywords

autism spectrum disorder Asperger syndrome anxiety treatment cognitive behavior therapy parenting stress

Children with autism spectrum disorder (ASD) are known to have deficits in sociocommunicative functioning and restricted, repetitive, and stereotyped patterns of behavior (American Psychiatric Association, 2013). Anxiety is among the most commonly associated challenges for children with ASD. Indeed, an estimated 42% to 55% of children with ASD have an anxiety disorder, and 11% to 84% show some level of impairment due to anxiety (White, Oswald, Ollendick, & Scahill, 2009). Anxiety is related to deficits in academic and social functioning (Russell & Sofronoff, 2005), and to significant distress for families (Mills & Wing, 2005). Cognitive behavior therapy (CBT) has long been considered the primary psychotherapeutic intervention for typically developing children with anxiety (Ollendick, King, & Chorpita, 2006), and is quickly becoming the evidence-based treatment of choice for addressing anxiety in youth with ASD (see Lang, Regester, Lauderdale, Ashbaugh, & Haring, 2010, for a recent review).

Efficacious CBT protocols for children with ASD usually demand a high level of parent involvement, both with weekly parent participation in the intervention and planning for parent-mediated exposures outside of group (Moree & Davis, 2010). Across interventions, parents are typically involved as co-therapists with their children, assisting them to complete handouts and materials. Parents are also provided with an opportunity to speak with the therapists without the children present to learn about the function of anxiety and plan intervention strategies. In one such program, Wood and colleagues (2009) added modules focusing on social skills, adaptive skills deficits, special interests, attention and motivation, comorbidities, and school-based problems to the family-based “Building Confidence” CBT program. Significant reductions in anxiety were noted in 64% of children (7–11 years of age) in the treatment group (n = 17), compared with 9% in the waitlist control group (n = 23), according to parent-report. Significant reductions were not found according to child-report. Reaven, Blakeley-Smith, Culhane-Shelburne, and Hepburn (2012) provided 12 sessions of the “Facing Your Fears” group CBT program, including its parent component, to 24 children (7–14 years of age), and compared the results with those of a treatment-as-usual group with 26 children. Children were randomly assigned to the CBT group and treatment-as-usual group. Using the Clinical Global Impressions Scale-Improvement scores, which were completed by independent assessors blind to treatment condition, 10 out of 20 children (50%) in the CBT treatment group showed clinically significant gains, compared with 2 out of 23 children (8.7%) in the comparison group. Recently, McNally, Lincoln, Brown, and Chavira (2013) provided 16 sessions of the “Coping Cat” individual CBT program to 12 children (8–14 years of age), comparing the results with those of a treatment-as-usual group with 12 children. Twelve children were randomized to the CBT condition and 10 children were randomized to the waitlist condition. At post-treatment, 58% of the participants in the CBT group (7 out of 12 children) no longer met diagnostic criteria for their primary anxiety disorder diagnosis according to parent-report, and no changes were found in diagnostic status of participants in the control group.

It is becoming clear that involving parents in group CBT for children with ASD enhances outcomes. Sofronoff, Attwood, and Hinton (2005) compared changes following 6 weeks of CBT with a parent component (n = 25) to a child-only CBT (n = 23) and to a waitlist control condition (n = 23), in children with Asperger Syndrome and anxiety (“Exploring Feelings”; Attwood, 2004b). Children whose parents were involved showed significantly greater decreases in anxiety after treatment than those in the child-only group, according to parent-report, and participants in both treatment groups demonstrated greater improvements than the waitlist control group. More recently, Puleo and Kendall (2011) examined ASD symptoms as predictors of CBT outcomes in typically developing children using either the individual-based (Kendall & Hedtke, 2006) or family-based version of Coping Cat (Howard, Chu, Krain, Marrs-Garcia, & Kendall, 2000). Moderate levels of ASD traits in typically developing children were associated with decreased treatment responsiveness to individual CBT, but not to family CBT, suggesting that family-based CBT may be more effective than individual CBT for children with any symptoms of ASD.

Involving parents in CBT for children with ASD may provide an added benefit for several reasons. From a practical perspective, greater parent involvement increases parents’ ability to help their children with homework outside of sessions, including the prescribed exposures related to specific anxiety-producing situations (Wood et al., 2009). In addition, Reaven and Hepburn (2006) propose that parenting stress and anxiety is associated with child anxiety in children with ASD, and that parental negative affect should be an additional focus of child treatment (Reaven, 2011). In these authors’ model, parental negative affect increases the likelihood that parents will tolerate avoidant behaviors in their child (i.e., parent accommodation), resulting in fewer opportunities for their child to develop alternative coping techniques, and ultimately an increase in child anxiety and parenting stress and anxiety. Although it is hypothesized that a reduction in parenting stress would be correlated with a reduction in child anxiety, this relationship has yet to be explored within the context of providing CBT to children with ASD.

Parenting stress may be a particularly important variable to consider with regard to fostering change in children with ASD through CBT. Parenting stress is operationalized as the stress of the demands of being a parent, and, in the general population, is more related to parenting behaviors and child outcomes than stress caused by the general demands of life events (Deater-Deckard, 1998). Parenting stress levels prior to treatment have been shown to be a significant predictor of parent-reported improvement in child anxiety after a CBT intervention with typically developing children (Crawford & Manassis, 2001). High levels of parenting stress may impede the treatment of anxiety in children by limiting parents’ capacity to support and acknowledge the work required to effect child change (Breinholst, Esbjørn, Reinholdt-Dunne, & Stallard, 2011). Given that parents of children with ASD experience higher levels of parenting stress compared with parents of typically developing children (Murphy et al., 2000), measuring parenting stress within the context of CBT for children with ASD seems particularly important.

We used an adapted version of group Coping Cat (Flannery-Schroeder & Kendall, 2000) with children with ASD who have significant problems with anxiety, assessing both child anxiety and parenting stress. Given the evidence for the effectiveness of CBT for children with ASD and anxiety, we hypothesized that parent- and child-reported symptoms of child anxiety would show statistical and clinically meaningful decreases from pre- to post-treatment. We also hypothesized that parenting stress would be related to changes in child anxiety as reported by parents and children in two ways. First, high parenting stress levels at baseline would be associated with poorer child outcomes following the intervention. Second, change in parenting stress over the course of the intervention would be positively correlated with changes in child anxiety.

Method

Participants

Participants were recruited over a 2-year period (2009–2011) through community-based programs in an urban center and through referrals from clinicians who work with children with high-functioning ASD. Families were made aware of the research project through community presentations on CBT and ASD, and through flyers that described the research project.

To be eligible, youth were required to have a diagnosis of an ASD from a child psychiatrist or psychologist in the community. The diagnosis was verified with the Autism Diagnostic Observation Schedule at screening (ADOS; Lord, Rutter, DiLavore, & Risi, 2002). All children had an estimated IQ above 80 on the Wechsler Abbreviated Scale of Intelligence (Wechsler, 2003), and all showed clinically significant levels of anxiety, exceeding the cutoff score for at least one anxiety disorder on the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1999). Children were excluded if they were currently participating in another psychological intervention for anxiety. None of the children altered medication use over the course of treatment.

Twenty-five families contacted the project coordinator over the 2-year recruitment period, and attended a screening session. Five youth were deemed ineligible to participate: four due to disruptive aggressive behavior and one due to a scheduling conflict. None of the enrolled youth dropped out of the treatment. However, two children were removed from the group sessions for extensive periods of time and provided with individual therapy. One child was removed because his verbal skills were considerably lower than those of the other children in the group (2nd percentile) and he had difficulties with comprehension of the material. The other child was removed as a result of aggressive behavior directed toward other children and the therapists.

Eighteen children with ASD and their parents participated in the study. Children were between 8 and 12 years of age (M = 9.5, SD = 1.34), with the majority being male (n = 15). Full-Scale IQ scores for the children ranged from 94 to 133 (M = 113.24, SD = 11.44). All children met criteria for ASD on the ADOS and had clinically significant levels of anxiety on at least one subscale of the SCARED. Eighteen children (89%) had a diagnosis of Asperger Syndrome. The remaining two participants had been diagnosed as young children with autism (high-functioning), and demonstrated IQ levels and language skills commensurate with the children with Asperger Syndrome.

The majority of the parents who completed the questionnaires were mothers (94.5%), were living with a partner/spouse (89%), and were university educated (72%). The majority of their partners/spouses were also university educated (83.5%). The majority of parents reported household income above US$60,000 (83%).

Measures

ASD diagnostic measure

The Autism Diagnostic Observation Scale (Lord et al., 2002) is a semi-structured observational measure that examines social and communicative behaviors. The ADOS Module 3 was used and takes approximately 30 to 45 min to administer, providing scores for communication and socialization that support the likelihood of an ASD diagnosis. The ADOS has been found to have good test–retest reliability and excellent internal consistency (Lord et al., 2002).

Intellectual functioning

Intelligence was estimated using the Wechsler Abbreviated Scales of Intelligence (WASI; Wechsler, 2003). The two-subset WASI (Vocabulary and Matrix Reasoning) was administered to obtain a general estimate of intellectual functioning. This measure has been shown to have adequate to high test–retest reliability (r = .72–.95) depending on the subtest, and high internal consistency across groups and subtests (Cronbach’s α = .87–.98).

Child anxiety

Many outcome studies of anxiety treatments for children with ASD have utilized parent-report continuous measures to examine change across time (McNally et al., 2013; Ooi et al., 2008; Reaven, 2009; Reaven et al., 2012; Sofronoff et al., 2005). In the current study, parents reported on child levels of anxiety using the Child Behavior Checklist (CBCL) Anxious/Depressed subscale (Achenbach, 2001) and the SCARED (Birmaher et al., 1999).

The CBCL: School Age Version 6–18 is a standardized parent-report questionnaire that assesses current problems exhibited by children. This measure consists of 40 competence items, and 113 items related to behavioral or emotional problems. Good reliability and validity have been established for the CBCL in the general population (Achenbach & Rescorla, 2001). The empirically based problem scales have been shown to have good test–retest reliability (r = .82–.92) depending on the subscale, and high internal consistencies (Cronbach’s α = .78–.97). The CBCL Anxious/Depressed scale includes 13 items that specifically reflect worries, fears, and depressed mood. Each statement is rated on a 3-point scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true). The subscale is reported to have good internal consistency, reliability, and validity (Achenbach & Rescorla, 2001). The CBCL has been used to examine broad mental health problems (Goldstein & Schwebach, 2004), and specific problems such as anxiety (White & Roberson-Nay, 2009) in children with ASD.

The SCARED is a parent-report measure consisting of 40 statements that map on to five types of anxiety experienced by children. Each statement is rated on a 3-point scale (0 = almost never, 1 = sometimes, 2 = often). It provides a total score and subscale scores for Panic Disorder/Somatic Symptoms, Generalized Anxiety Disorder, Separation Anxiety Disorder, and Social Anxiety Disorder. The SCARED has been shown to have good discriminant validity (Birmaher et al., 1997) and concurrent validity (Muris, Merckelbach, van Brakel, Mayer, & van Dongen, 1998). This scale also exhibited adequate to good internal consistency in the current study for the total score (Cronbach’s α = .84) and subscales (Cronbach’s α = .68–.89). It has been used in other studies of CBT for children with ASD, and has been shown to be sensitive to treatment responsiveness (Reaven et al., 2009).

Children self-reported on their feelings of anxiety utilizing the Revised Children’s Manifest Anxiety Scales (RCMAS; Reynolds & Richmond, 1978). The measure consists of 37 items to which the child responds “Yes” or “No,” and has demonstrated good reliability and factorial and construct validity (Reynolds & Richmond, 1985). This measure provides a total score for anxiety and subscale scores for Physiological Symptoms, Worry and Oversensitivity, and Social Concerns/Concentration, and has previously been used to measure self-reported symptoms of anxiety in children with ASD (Chalfant, Rapee, & Carroll, 2007). The overall total score and subscale scores were converted to T-scores based on child age and sex. T-scores greater than 60 on the total score and greater than 13 on the subscales were considered clinically significant.

Parenting stress

Parenting stress was assessed using the Parenting Stress Scale (PSS; Bonds, Gondoli, Sturge-Apple, & Salem, 2002). The PSS was adapted from the Parental Stress Items Scale (PSI; Pearlin & Schooler, 1978), which includes seven items asking parents to indicate how much they experience each of seven distressed feelings about parenting (e.g., “When you think of your experiences as a parent to this child, how [worried/frustrated/tense/etc.] do you feel?”). Parents were provided with a 4-point Likert scale for each item, ranging from not at all (1) to very much (4). The PSS includes four additional items that focus on positive feelings about parenting (e.g., happy, satisfied) that are reverse coded. Scores on the PSS range from 11 to 44, with higher scores indicating greater parenting stress. The PSS has been used successfully to assess parenting stress in mothers of children with ASD (Ekas, Lickenbrock, & Whitman, 2010). Past authors who have used the PSS with all 11 items have reported good internal consistency (Cronbach’s α = .87–.89; Bonds et al., 2002; Ekas et al., 2010).

Intervention Program

The treatment was led by a trained therapist who had completed workshops with Phillip Kendall and had been providing Coping Cat for more than 10 years at a community mental health center. Four groups were staggered over a 2-year period in the fall (September-December) and winter (February-May). Twelve weekly 1.5-hr sessions were provided to each group of five children. All intervention sessions were supervised by a clinical psychologist who compared treatment activities with the prescribed activities in the Coping Cat manual, using the modifications outlined below.

The Coping Cat manualized group program integrates behavioral approaches, such as exposure, relaxation, and role-play, with the social-cognitive information-processing factors that are associated with child anxiety (Kendall, Aschenbrand, & Hudson, 2003). Children are taught to recognize anxious feelings, physiological reactions to anxiety, and their negative thoughts, and to utilize behavioral strategies, such as relaxation, rewards for effort, and modification of self-talk in anxiety-provoking situations (Flannery-Schroeder & Kendall, 2000). The program has been validated with children 8 to 14 years of age, and varies in length, from 12 to 18 sessions, each lasting 1.5 hr. Although the original Coping Cat program is primarily child-focused, parents participate in a supportive role, meeting with therapists regularly to collaborate with them on treatment plans (Podell, Mychailyszyn, Edmunds, Puleo, & Kendall, 2010). The current treatment was modified across each of the weekly Coping Cat modules by increasing parent involvement to weekly meetings, and increasing visual activities, time spent on emotion education and relaxation, and higher client to therapist ratios (Attwood, 2004a; Moree & Davis, 2010; Reaven, 2009, 2011).

Five main adaptations were incorporated across each of the weekly Coping Cat modules:

Concrete visual tactics. In addition to using the Coping Cat workbook, emotions were explored by encouraging comic strip conversations (with thought bubbles) and physical activities (Attwood, 2004b), and incorporated drawing, videotaping, additional written work sheets, and multiple choice lists when appropriate (Reaven, 2009; Reaven et al., 2009).

Affective education and self-regulation. The Coping Cat program includes programming related to learning emotion-related language, as well as the use of a feelings thermometer. This programming was extended into several sessions, allowing children additional time to master the emotion-related language. The Coping Cat sessions related to bodily awareness and self-regulation skills, two valuable components of CBT (Gosch, Flannery-Schroeder, Mauro, & Compton, 2006), were also extended.

Increased support. CBT groups for youth with high-functioning ASD often require higher client to therapist ratios than found in CBT groups for typically developing children (Sofronoff et al., 2005). Although the Coping Cat group intervention traditionally recommends one leader per five children, we elected to provide greater individualized support, with each child paired with a “buddy therapist,” and one group leader trained in the Coping Cat program. Prior to the start of treatment, the buddy therapists participated in one training session and were provided with the Coping Cat manual for review. Buddy therapists were graduate students in the Clinical-Developmental Psychology program at the university, who were interested in receiving training in CBT and ASD. The same buddy therapist partnered with the same child each week, providing consistency for the children and fostering therapeutic alliance and rapport. Buddy therapists assisted in tailoring the weekly content of the intervention to youths’ social limitations and addressed the attention deficits common to ASD by redirecting youth to program tasks (Schatz, Weimer, & Trauner, 2002). Following each session, buddy therapists received group supervision from a clinical psychologist and the lead therapist.

Child-specific interests. Circumscribed, special interests are common in children with ASD, and the present study used these interests to increase motivation and willingness to participate in program activities. The present intervention used the Coping Cat character, but when possible also added figures and themes that capitalized on youth interests, such as a specific videogame character or movie.

Parent involvement. The Coping Cat program typically has three intermittent parent sessions that run separately from the child groups. It was elected instead to have parents attend a weekly semi-structured parent group, run concurrently with the child group. Parents covered the material prescribed by the manualized Coping Cat parent sessions, as well as received education related to bullying at school, working with teachers and principals, friendships, and promoting independence. At the end of each child session, buddy therapists provided immediate feedback about progress in front of the child, allowing parents to be audience members for their child’s successes. Both parents were encouraged to attend; however, for most families only one parent attended each weekly meeting.

Procedure

The study was reviewed and approved by the university’s Research Ethics Board. Families contacted the program coordinator, who then conducted a phone screening and coordinated a full screening for ASD and anxiety. Screenings for group eligibility lasted between 2 and 3 hr, at which time demographic information was collected from parents, and diagnostic and developmental tests were administered, supervised by a clinical psychologist. Graduate students who were not directly involved in the treatment administered the tests. Parents completed the CBCL and SCARED within a period of 2 weeks prior to the start of treatment and within 2 weeks of treatment completion, and children completed the RCMAS with the assistance of a research assistant in the same time frame.

Data Analysis

Change in parent-reported scores of anxiety on the CBCL and SCARED as well as child-reported scores of anxiety on the RCMAS were examined for statistically significant change at the group level, as well as clinically significant change at the individual level. The Jacobson Truax (JT) method is considered a well-established method for examining clinical significance (Jacobson & Truax, 1991), and involves two criteria: (a) the individual’s score should move into the normal range post-treatment or out of the range of dysfunctional scores, by determining a cutoff level, and (b) the magnitude of each individual’s change must be statistically reliable. For the second criterion, the Reliable Change Index (RCI) is calculated to determine the magnitude of change, and involves examining post–pre changes, taking into account the measure’s margin of measurement error (RCI = x₂ – x₁ / Sdiff; Jacobson & Truax, 1991). An individual’s RCI value must exceed 1.96 to demonstrate reliable improvement at post-treatment. By taking into account the magnitude of change in addition to whether the child passes the cutoff score, the JT method is considered a more conservative measure of change than examining change in criteria alone. Participants were classified based on their pattern of meeting the two JT method criteria: “recovered” (i.e., passed the established cutoff point and demonstrated reliable change), “improved” (i.e., failed to pass the established cutoff point but demonstrated reliable change), “unchanged” (i.e., failed to demonstrate reliable change; McGlinchey, Atkins, & Jacobson, 2002), “worsened” (i.e., failed to pass the cutoff but demonstrated reliable change in negative direction; Schauenberg & Strack, 1999) or “deteriorated” (i.e., passed the cutoff and demonstrated reliable change in negative direction).

Results

Data were missing for one child on the parent-reported SCARED at pre-treatment. All children fell in the borderline-clinical range on at least one parent-reported measure of anxiety at baseline. As shown in Table 1, at pre-treatment, 94% (n = 17) of children were in the borderline or clinical range on the CBCL Anxious/Depressed scale, and 82% (n = 14) of children scored in the borderline or clinical range on the SCARED total score. In contrast, only two children endorsed clinically significant symptoms of anxiety on the RCMAS total score or any of its subscales at pre-treatment. Post-treatment, 33% of children moved into non-clinical categories on the CBCL Anxiety/Depressed subscale, 53% moved into non-clinical categories on the SCARED total score, and 50% moved into the non-clinical category on at least one of the SCARED subscales.

Table 1.

Percentage of Children in the Borderline and Clinical Range on Outcome Measures at Pre- and Post-Treatment.

	Pre-treatment			Post-treatment
	Borderline	Clinical	Total	Borderline	Clinical	Total
Measures	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
CBCL
Anxious/Depressed	5 (28)	12 (67)	17 (94)	4 (22)	7 (39)	11 (61)
SCARED
Total Anxiety Disorder Score	5 (29)	9 (53)	14 (82)	0	5 (29)	5 (29)
Panic Disorder/Somatic Symptoms	N/A	3 (18)	3 (18)	N/A	2 (12)	2 (12)
Generalized Anxiety Disorder	N/A	12 (71)	12 (71)	N/A	9 (53)	9 (53)
Separation Anxiety Disorder	N/A	11 (65)	11 (65)	N/A	7 (41)	7 (41)
Social Anxiety Disorder	N/A	8 (47)	8 (47)	N/A	4 (23.5)	4 (23.5)
RCMAS
Total Anxiety Score	N/A	2 (11)	2 (11)	N/A	3 (17)	3 (17)
Physiological Anxiety	N/A	2 (11)	2 (11	N/A	1 (6	1 (6)
Worry/Oversensitivity	N/A	3 (17)	3 (17)	N/A	4 (22)	4 (22)
Social Concerns/Concentration	N/A	4 (22)	4 (22)	N/A	3 (17)	3 (17)

Note. The CBCL and SCARED are parent-reported measures and the RCMAS is a child-report measure. CBCL = Child Behavior Checklist; SCARED = Screen for Child Anxiety and Related Emotional Disorders; RCMAS = Revised Children’s Manifest Anxiety Scales.

Parent- and Child-Reported Statistical Change

The majority of the dependent variable difference scores were non-normally distributed, and the nonparametric Wilcoxon signed-rank test was used instead of the paired-samples t test to test for statistical change. As shown in Table 2, scores on the CBCL Anxious/Depressed scale and SCARED total were significantly lower at post-treatment, with medium effect sizes. This pattern of statistically significant change extended across all the SCARED subscales. In contrast, children did not report any significant differences from pre- to post-treatment on the total score of the RCMAS or its subscales.

Table 2.

Wilcoxon Signed-Rank Test From Pre- to Post-Treatment on Parent- and Child-Reported Measures.

	Pre-treatment	Post-treatment
Variable	M (SD)	M (SD)	T	r
CBCL
Anxious/Depressed	73.83 (10.29)	69.17 (10.34)	27.5*	−.35
SCARED
Total Anxiety Disorder Score	30.47 (8.95)	23.06 (13.47)	24.5**	−.42
Panic Disorder/Somatic Symptoms	4.76 (2.79)	3.33 (3.97)	15.0**	−.44
Generalized Anxiety Disorder	11.06 (3.93)	9.22 (4.15)	26.0*	−.33
Separation Anxiety Disorder	5.88 (3.74)	4.28 (4.49)	24.5*	−.35
Social Anxiety Disorder	7.00 (4.00)	4.83 (4.22)	14.5*	−.41
RCMAS
Total Score	50.17 (9.91)	47.89 (11.31)	40.5	−.13
Physiological Anxiety	8.94 (2.65)	8.72 (2.49)	53.0	−.07
Worry/Oversensitivity	9.72 (2.95)	9.44 (3.45)	51.0	−.09
Social Concerns/Concentration	10.11 (2.59)	9.00 (2.87)	30.0^†	−.29

†

p < .10. *p < .05. **p < .01.

Parent- and Child-Reported Clinically Significant Change Using the RCI

For the CBCL subscale, norms collected by the measure’s authors were averaged across normative samples of boys and girls aged 6 to 18 years (Achenbach & Rescorla, 2001) and were utilized for the calculations to establish the clinical cutoff point (M = 53.88, SD = 5.65). As shown in Table 3, 33% (n = 6) of children were classified as either “recovered” or “improved” on the Anxious/Depressed scale, one child was classified as “worsened,” and one child as “deteriorated.” SCARED total score cutoff values were calculated using a combined mean score (M = 16.51, SD = 11.99) from three normative samples of youth, ages 8 to 18 (Birmaher et al., 1997; Muris, Merckelbach, Ollendick, King, & Bogie, 2002; Wren et al., 2007). On the SCARED total score, 35% (n = 6) of children were classified as “recovered” and one child as “worsened” post-treatment. Overall, 50% of children (n = 9) were classified as recovered or improved on at least one of the parent-reported anxiety measures (CBCL or SCARED Total). Recovered or improved (treatment responsive) children did not differ from children who were non-responsive to treatment in their pre-treatment CBCL or SCARED scores (all p > .10).

Table 3.

JT Method Classifications on CBCL, SCARED, and RCMAS.

	Recovered	Improved	Unchanged	Worsened	Deteriorated
Measure	n (%)	n (%)	n (%)	n (%)	n (%)
CBCL
Anxious/Depressed	3 (16.5)	3 (16.5)	10 (55)	1 (5.5)	1 (5.5)
SCARED
Total Anxiety Disorder Score	6 (35)	0	10 (59)	1 (6)	0
RCMAS
Total Anxiety Score	2 (11)	0	16 (89)	0	0

Note. The CBCL and SCARED are parent-reported measures and the RCMAS is a child-report measure. JT = Jacobson Truax; CBCL = Child Behavior Checklist; SCARED = Screen for Child Anxiety and Related Emotional Disorders; RCMAS = Revised Children’s Manifest Anxiety Scales.

The RCMAS cutoff score was calculated using normative sample means collected by the measure’s authors (M = 50, SD = 10; Reynolds & Richmond, 1978). As shown in Table 3, 11% (n = 2) of children were classified as “recovered” and 89% remained “unchanged” on the RCMAS total score.

Parenting Stress and Child Anxiety

To test the hypothesis that high parenting stress levels at baseline would be associated with less child improvement during the course of the treatment, we conducted an independent-samples t test to compare parenting stress levels pre-treatment between children who were found to be treatment responsive according to the JT method and those who were not. A trend was noted: Those who were classified as treatment non-responsive (n = 9) had parents with higher parenting stress scores pre-treatment (M = 28.22, SD = 5.31) compared with treatment responsive children (M = 23.89, SD = 4.91), t(16) = −1.80, p = .09, Cohen’s d = .95.

We also hypothesized that change in parenting stress would be related to changes in child anxiety. A series of Pearson product–moment correlations partially supported this hypothesis, with change in parenting stress scores being correlated with change in child total SCARED scores, r(17) = .50, p = .04. As shown in Table 4, change in parenting stress scores was correlated with the SCARED General Worries subscale, and there was a trend toward a correlation with the Panic subscale. This relationship was not evident for parenting stress and change in CBCL Anxious/Depressed scores. In terms of changes in child-reported anxiety on the RCMAS, there was a trend indicating that change in parenting stress was correlated to change in RCMAS Worries subscale, r(18) = .46, p = .06, but not with the other subscales of the RCMAS.

Table 4.

Summary of Spearman Correlations Between Change Scores on the PSS, CBCL, and SCARED.

Measure	1	2	3	4	5	6
1. Parent Stress	—
2. CBCL Anxious/Depressed subscale	.09	—
3. SCARED Total	.50*	.53**	—
4. SCARED Panic/Somatic	.47*	.10	.63**	—
5. SCARED General Worries	.55*	.64**	.69**	.38	—
6. SCARED Separation Anxiety	.25	.51*	.77**	.45	.52*	—
7. SCARED Social Avoidance	.09	.35	.79**	.60**	.37	.60**

Note. PSS = Parenting Stress Scale; CBCL = Child Behavior Checklist; SCARED = Screen for Child Anxiety and Related Emotional Disorders.

*p < .05. **p < .01.

Discussion

It is important for researchers to critically examine psychotherapeutic interventions for youth with ASD and anxiety, and to identify the variables that may contribute to treatment success. This pilot study assessed whether parenting stress was associated with changes in child anxiety following participation in a modified version of an evidence-based CBT intervention for youth with ASD. The results indicate that children who were provided with a modified Coping Cat program showed significantly less anxiety over time, according to parent-report. Significant decreases in anxiety were noted overall, as well as in specific types of anxiety (i.e., social anxiety, panic disorder). These results provide additional support to the body of literature that points to CBT as an effective intervention for anxiety with this population (Reaven et al., 2012).

The present study used a conservative assessment of clinically significant change in individual children. We found that 50% of children made positive, meaningful gains over time on at least one of the primary outcome measures, as reported by parents. This rate is similar to improvement rates recorded in group Coping Cat interventions in the general population (Flannery-Schroeder & Kendall, 2000) and in other CBT interventions for youth with ASD (McNally et al., 2013; Reaven et al., 2012). Children themselves, however, did not report significant change in anxiety from pre- to post-treatment, nor had they reported scores in the clinical range prior to treatment. Our findings are similar to those of other studies of anxiety in the ASD population, in that children with known anxiety disorders report lower than expected levels of anxiety on self-report measures than their parents (e.g., White et al., 2009; Wood et al., 2009). Many studies have found that children do not report decreases post-treatment when parents do (Ozsivadjian & Knott, 2011; Reaven et al., 2009; Wood et al., 2009), although this is not always the case (Chalfant et al., 2007; Ooi et al., 2008). Reaven and colleagues (2009) postulate that child self-report may be an indicator of symptom awareness, rather than a measure of treatment outcomes.

We found a significant relationship among change in parenting stress and parent-reported change in child anxiety, based on the parents’ responses to the SCARED only. The SCARED relies on considerably more items than the CBCL Anxiety/Depression subscale, and the potentially increased sensitivity of a more detailed measure may better reflect all changes noted after an intervention. Determining if child change mediates parent change, or vice versa, requires a larger sample size and more detailed assessment of child and parent variables across therapy sessions, rather than simply pre–post analyses. If the link between parenting stress and child anxiety is indeed transactional (Reaven, 2011), then involving parents in child CBT may be most efficacious if clinicians take into account parenting stress. For instance, parents might be involved as co-therapists to actively work with their children, using coaching by the therapist (e.g., Reaven, 2011). Parents may also benefit from their own supports to dealing with parenting stress, including mindfulness-based strategies, which have been shown to positively affect child outcomes (Singh et al., 2007).

We also examined the relationship among parenting stress and changes in child anxiety. There was a trend to suggest that parents of treatment responsive children had less parenting stress pre-intervention compared with parents of non-treatment responsive children. This is particularly relevant given that treatment responsive and non-responsive children did not differ in pre-intervention levels of parent-reported child anxiety. While correlational, this result supports the possibility that as with typically developing children (Crawford & Manassis, 2001), the parenting stress experienced by parents of children with ASD may be an important factor to consider when providing CBT, especially in explaining why some children are not responsive to treatment according to parent-report. Further research is needed to examine how parent factors, including parent anxiety (Crawford & Manassis, 2001), warmth and depression (Liber et al., 2008), and family cohesion (Victor, Bernat, Bernstein, & Layne, 2007), interact with child symptoms to affect the likelihood of successful treatment in ASD populations. Researchers have found that children with ASD who have anxious parents do not have poorer outcomes in treatment, however, children who are treatment responders have parents who report significant decreases in their own anxiety after their child’s treatment (Conner, Maddox, & White, 2013). Research in the typical population has found that maternal anxiety typically hinders child response to treatment (Creswell, Willetts, Murray, Singhal, & Cooper, 2008).

The current exploratory study has several limitations. The study had fewer participants than many outcome studies examining CBT for anxiety in children, and it did not include a control group or random assignment of participants. Therefore, while very similar to existing reports, we cannot determine whether improvements were due to the specific contributions of the intervention or the additional attention and general therapeutic experience provided by any intervention context. The small sample size of this study limits the statistical methods that could be used (e.g., regression tests of moderation), and does not provide enough power to detect small effects. Our study did not include long-term follow-up with participants, and for some children, mastering the strategies of CBT may take additional time and opportunities to practice, and treatment gains may continue after treatment completion (Sofronoff et al., 2005). The results of this study may also not be generalizable to the broader population of children with ASD, such as those with additional comorbidities, significant behavioral problems, or lower levels of functioning. The study would have also benefited from alternative observer report measures of anxiety to assess changes in the functional outcomes of participants.

Tailoring the program to the individual needs of each child with ASD may be difficult within group settings. Providing children with buddy therapists who function as additional support under the supervision of a more advanced therapist, as we did, may not be feasible in agencies where personnel are in short supply. At the same time, it may be possible that agencies can work in conjunction with universities and colleges to attain volunteers, such as psychology graduate students who are looking for practicum and internship experiences, to fulfill the buddy therapist role. The current study also did not control for deviations from Coping Cat programming or increased time spent on weekly modules. Future studies would benefit from a measure of treatment fidelity.

Conclusion

This study was the first to evaluate the group Coping Cat CBT program for children with high-functioning ASD using a conservative index of change. This study should be seen as a first step in highlighting the potential importance of considering parental variables such as parenting stress in the treatment of children with concurrent ASD and anxiety. There continue to be children who are not responsive to treatment, and further research is needed to parse out the treatment methodology that will serve these children best, including how to optimally work with their parents who experience significant parenting stress.

Footnotes

Acknowledgements

Thanks to all the participating families, Linda Brightling and Megan Ames for leading the groups, Jennifer Summers for assistance with measures, and the many graduate students involved in the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a New Investigator Fellowship from the Ontario Mental Health Foundation, the Canadian National Autism Foundation, and the York University Foundation, to the first author (J. Weiss).

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