Parents of autistic kids and teens with anxiety disorders or obsessive-compulsive disorder (OCD) often wonder how to make cognitive-behavioral therapy (“CBT”) most effective for their child. While traditional behavioral therapies often aren’t tailored to meet the needs of these young people, research shows that well-adapted CBT can be very effective for autistic youth who also experience anxiety or OCD and related disorders (Landry et al., 2022). Since many autistic youth experience anxiety disorders (20-40%) and OCD (about 9-17%) (Lai et al., 2019; van Steensel et al., 2011), it’s important to adjust CBT to each autistic child’s specific strengths and needs.

So, what is CBT, and how does it work? CBT is considered a well-established, gold-standard treatment for anxiety and OCD. It helps people recognize unhelpful thoughts and action urges and learn more helpful ways to respond to them. Exposure therapy, also known as Exposure and Response Prevention (ERP), is a key part of CBT that involves gradually approaching feared situations without engaging in avoidance or compulsions. Over time, young people learn that feared outcomes are not as bad as they thought and/or that they can handle them. 

With autistic youth, exposures should focus on fears that are out of proportion to real danger and that your child genuinely wants help with.  Exposures should not be used to change their autistic traits, but to help them face fears that truly get in the way of the life they want to live.  This work is done with neurohumility, staying open, flexible, and guided by what works best for your child.

What to Look for in CBT for Autistic Youth

To get the most out of CBT and ERP for your autistic child or teen, it is important to share as much as possible about your child’s strengths, interests, learning style, and sensory needs with their treatment team. This will help the team ensure your child’s care is adapted to their specific needs. Here are a few key things to address when working with your child’s therapist or treatment team:

Care That Builds on Your Child’s Strengths and Interests

Anxiety and OCD often hold kids back from leading the lives they want to live. At InStride, we work as a team to show your child how anxiety or OCD stops them from doing things they care about, like participating in their favorite hobbies, making meaningful friendships, or accomplishing important milestones. This helps build their motivation for treatment.

Many autistic youth have special interests that make them awesome and unique! An effective treatment team will often use these interests as powerful tools in therapy. By using clear language that connects therapy concepts to what your child already loves and understands, providers can make it easier for your child to learn how to notice and name their feelings, thoughts, and behaviors in anxiety-provoking situations. 

You and your child can collaborate with your child’s care team to incorporate their interests into treatment. For example, a provider might:

• Talk about being brave, similar to their favorite superhero or other movie or book character, or otherwise incorporate favorite characters into discussions about emotions, thoughts, and behaviors. Sometimes kids feel less vulnerable when they can talk about a character instead of themselves.
• Have them rate how easy or hard exposures feel based on a metaphor that relates to their interest (e.g., a child who likes space might rate exposures on a scale from a “speck of space dust” all the way to a “big supernova!”).
• Celebrate brave steps with rewards building up to a special event or activity connected to their interest.

Care That Fits with How Your Child Learns

Your child’s provider can work with you, your child, and their educational team (with your permission) to adapt treatment to how they learn best. You can also refer to past evaluations for ideas and data that describe your child’s learning style. The same methods that help your child learn in school can be adapted to help them learn new ways to cope with anxiety and OCD. Many autistic kids are practical, active learners and enjoy hands-on, visual, and interactive activities. Taking action and repeating activities can help their brain build new pathways for responding to anxiety and OCD over time. Your child might benefit from:

• Presenting CBT skills in a variety of ways, such as in writing, with verbal explanations, with picture or video examples, and through interactive activities
• Using clear, direct language and allowing more time to process questions
• Providing a written schedule for treatment sessions, with pictures explaining each part of session and key exposure steps
• Providing extra scaffolding, such as clear instructions or social scripts, to support social or community-based exposures
• Giving written and verbal reminders to practice coping skills that are posted around your home or saved in your phone for when you are on the go
• Incorporating breaks to move or chat in between exposure and skill-building activities in order to reduce fatigue, overwhelm, or restlessness
• Introducing new anxiety-management skills at a slower pace or in small, digestible “chunks” to maximize understanding 
• Breaking long sessions into multiple shorter sessions
• Practicing skills and exposures frequently and repeatedly in session, at home between sessions, in the community, and at school to help deepen learning 

Care that Encourages Flexible Thinking

Anxiety and OCD tend to create fixed “rules” and routines children and teens feel they must follow to reduce their anxiety and discomfort. For autistic kids, this can be amplified, as autism can include strongly preferring routines, disliking unexpected changes, adhering to rules without exceptions, and taking things literally. 

Your child’s treatment plan can include “flexibility exposures” to gently encourage coping with unexpected, unavoidable changes likely to occur in daily life. This might include examples such as playing a card game with modified rules or practicing steps for getting ready for school in a slightly different order than usual. This is often paired with interactive activities that encourage new ways to think about anxiety-provoking situations. We often use a metaphor of imagining your brain as a robot – rigid and inflexible – telling you stories about how things “should” or “must” go versus a human brain that is “bendable” and doesn’t HAVE to follow “robot rules.” We may have children watch a favorite movie and imagine different choices the characters could make or talk about how different characters could perceive a situation. We may generate real-life examples of times when an exception to a rule might be appropriate or necessary. Exposure goals can include specific training in social skills to encourage flexibility in social situations, if that makes sense to incorporate for your child and their goals.

Care That Incorporates Your Child’s Sensory Needs

Autistic children and teens often have unique sensory profiles and experience reduced habituation to sights, sounds, smells, tastes, and textures. For this reason, we encourage and support sensory-soothing activities, such as using a weighted blanket or vest, provided these supports do not interfere with them living the life they want to lead. It’s crucial for your treatment team to recognize and plan accordingly.

The goal of our exposure work is therefore focused on fears that are getting in the way of the life your child wants to live, while simultaneously adjusting the environment to support their sensory needs. We prioritize exposures that fit your child’s goals, such as practicing joining a club so they can participate in an activity they enjoy!

While traditional exposure therapy typically avoids the use of coping skills, autistic children may benefit from incorporating sensory strategies during exposures. Your child’s therapist can help them identify sensory tools and supports that help them stay present. If your child is working with an occupational therapist, you can request and share feedback from them to better understand your child’s sensory needs.

Building Your Child’s Team

You don’t have to do this alone! Helping autistic kids effectively manage anxiety and OCD is best done with a team, including mental health professionals, parents, educators, and other important adults in the child’s life. Your child should feel like an active part of their own care, contributing ideas, making age-appropriate choices about their exposure plans, and feeling they have a voice in the treatment process. Involving parents and caregivers in treatment is another key way to enhance anxiety and OCD treatment for autistic children and youth. Kids benefit when all the adults in their lives respond to anxiety and OCD with consistent language and encouragement based on the child’s strengths, interests, learning style, ways of thinking, and sensory profile.

At InStride, your child’s therapist, coach, and psychiatrist will work with you to ensure everyone is aligned on the best ways to adapt CBT for them. We can also connect with your child’s school and medical providers and review past records so we have clear knowledge of your child to inform how we structure treatment, target skill-building, and develop our exposure plans. 

Supporting an autistic child with anxiety or OCD can feel overwhelming, but you don’t have to do it alone. With the right team and a personalized approach that honors your child’s strengths, interests, and needs, CBT and ERP can lead to meaningful progress in reducing the impact of anxiety and OCD on their life.

REFERENCES

Lai, M. C., Kassee, C., Besney, R., et al. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: A systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 819–829. https://doi.org/10.1016/S2215-0366(19)30289-5

Landry, L.N. et al. (2022). Exposure Therapy for Anxiety and Obsessive-Compulsive Disorders Among Individuals with Autism Spectrum Disorder. In: Smits, J.A.J., Jacquart, J., Abramowitz, J., Arch, J., Margraf, J. (eds) Clinical Guide to Exposure Therapy. Springer, Cham. https://doi.org/10.1007/978-3-031-04927-9_6

van Steensel, F. J., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review, 14(3), 302–317. https://doi.org/10.1007/s10567-011-0097-0