CBT for Anxiety May Boost Cognition in Kids With Autism

Pam Harrison

May 18, 2015

SALT LAKE CITY — Children with autism spectrum disorder (ASD) and comorbid anxiety show increased attention to faces, especially emotional faces, in comparison with objects following treatment with cognitive-behavioral therapy (CBT), suggesting that CBT may alter cognitive processes in this patient group, preliminary findings indicate.

"We know that in individuals who have anxiety ― although not autism, just an anxiety diagnosis in general ― tend to have an attentional bias, where they are more attentive to information associated with a threat, such as a negative face," Laura Klinger, PhD, associate professor of psychiatry, University of North Carolina, Chapel Hill, and executive director of TEACCH Autism Programs, told Medscape Medical News.

"And we were really encouraged with this pilot study, where the attentional bias in children treated with the intervention looked more like the attentional bias that we saw in typically developed children who did not have an ASD diagnosis or anxiety disorder."

The study was presented here at the International Meeting for Autism Research (IMFAR) 2015.

Increased Attention

Twenty-six children between the ages of 8 and 14 years with ASD and 18 age-matched typically developing children who served as control participants completed a dot-probe task to measure attention bias.

Each trial consisted of presenting an emotional face — either happy or angry — or an object paired with a neutral face to study participants.

Participants were asked to respond to a target probe (an asterisk) that appeared immediately after being shown the two stimuli.

As the authors point out, a faster reaction time to the probe presented along with either one of the emotional faces or an object compared with a neutral face was taken as evidence that the child had either an emotional bias or an object bias.

Of those children with ASD, 12 had comorbid anxiety and were treated with a 14-week CBT intervention called Facing Your Fears.

Facing Your Fears is a large, ongoing trial involving many centers in the United States and Canada designed to evaluate the effectiveness of CBT in youth with ASD and comorbid anxiety, Dr Klinger noted.

Typically developing youth responded more quickly to probes at the location of emotional faces relative to neutral faces (reaction time, 17 ms) and neutral faces over objects (reaction time, 27 ms).

"Both results indicate a bias towards attending to faces, especially emotional faces," the investigators point out.

In contrast, participants with ASD with and without comorbid anxiety showed a preference for objects over neutral faces (reaction time, 17 ms) but no preference for emotional faces over neutral faces (reaction time, 2 ms).

As the study authors point out, the interaction between diagnosis and stimulus type was a large effect: F (1, 42) = 21.90 (P < .001).

After 14 weeks of exposure to CBT, children with ASD had attentional bias scores that were similar to those of typically developing children, including a preference for emotional faces over neutral faces (reaction time, 10 ms) as well as a preference for neutral faces over objects (reaction time, 15 ms).

"We're not looking at something where participants have time to think; it's something that is more automatic, and because it happens much more quickly, we're measuring these automatic attention biases in terms of milliseconds," Dr Klinger explained.

"So while we're talking a very small proportion of seconds in terms of how quickly participants allocate their attention, they are still significant."

Investigators also suggested that the CBT anxiety-focused intervention also altered cognitive functioning.

By way of an example, Dr Klinger described a child who was interested in the way the solar system worked but who decided that if he turned left down a street or corridor or if his parents turned left while driving, it would change the way the solar system moved, and the earth would get out of alignment.

"We worked very hard with this child to change his anxiety around his erroneous cognition that going left would change the way the earth rotated," Dr Klinger observed.

"And by helping him change his cognition, it really made a significant difference in his anxiety."

Dr Klinger and colleagues are now interested in elucidating what it is in CBT that helps change the way in which individuals with autism interact with their lives.

"I think this idea of attentional bias is at least one explanation as to why CBT might be so effective for individuals with ASD and anxiety," Dr Klinger observed.

"Our next steps are to take on a larger, more controlled trial and to test subjects before and after the intervention to see how attentional biases change over time."

"Exciting" Findings

Fred Volkmar, MD, Yale University School of Medicine, New Haven, Connecticut, who is also editor-in-chief of Journal of Autism and Developmental Disorders, told Medscape Medical News that the results of the study by Dr Klinger and colleagues are "exciting" and suggest that a treatment for anxiety increases attention to faces in children with autism.

"Anxiety is one of the most common conditions associated with autism, and the results are of interest both in terms of clinical benefit as well as in demonstrating potential changes in basic cognitive processes involved in autism," Dr Volkmar noted.

"This study joins several others studies that have demonstrated changes in EEG responses to faces and perception of social emotion on functional magnetic resonance imaging, and this growing body of work suggests important plasticity in the brains of children with autism that are potentially amenable through treatment."

The study was funded by a grant from the National Institutes of Health. Dr Klinger and Dr Volkmar report no relevant financial relationships.

International Meeting for Autism Research (IMFAR) Annual Meeting 2015. Abstract 20529. Presented May 14, 2015.

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