With April being World Autism Month it is the month in which autism receives a lot of attention, every day is a new opportunity to learn more about it and how we can support neurodiverse individuals in their mental health journeys. Not only is autism highly prevalent, but many people with this diagnosis also experience anxiety and depression.
There is some recent evidence that traditional therapies such as CBT and iCBT are effective in ameliorating depressive and anxiety symptoms in people with autism. However, we need to better understand how unaltered and tailored programs help this subgroup in order to better cater to their needs in the future. SilverCloud’s programs have the potential to help people diagnosed with autism who also struggle with anxiety or depression, as well as families supporting a child or teen in this situation.
Autism: what is autism, characteristics, prevalence, cost
According to the current classification of psychiatric disorders (DSM-5), the term autism spectrum disorder (ASD) is an umbrella term for a few different previous classifications such as autistic disorder, Asperger's disorder/syndrome, pervasive developmental disorder nor otherwise specified (PDD-NOS) etc. Clinically speaking, ASD is characterized by deficits in social interactions and communication, as well as restricted and repetitive patterns of behavior such as stereotyped or repetitive movements. About 1 in 59 children in the US receives a diagnosis of ASD according to the Centers for Disease Control and Prevention (2018), which is a 15 percent increase since 20121, with males being four times more likely to be affected than females2. In addition to the primary symptoms, research studies have also found that people with ASD are at higher risk of having an intellectual disability1, other psychiatric or medical disorders3,4, and challenging behaviors such as aggression and self-injury5,6. Medical costs, as well as the need for special education services, residential care, or assisted living accommodations lead to high costs associated with a diagnosis of ASD7. Besides the financial burden, there is also an emotional toll on the caregivers of children with ASD, who report higher parenting stress compared to families of typically developing children8.
Anxiety and depression in ASD
Several recent reviews9,10,11 have suggested that anxiety and depression disorders are very common in children, young people, or adults with ASD. Anxiety disorders have a lifetime prevalence rate between 27 and 42% for adults with ASD, and depression has a lifetime prevalence rate between 23 and 37% in the same population10. Moreover, research11 suggests the likelihood of individuals with ASD experiencing depression in their lifetime is 4 times higher than that of typically developing people. The most common anxiety disorders in the ASD population are specific phobia, obsessive-compulsive disorder, and social anxiety, and the prevalence rates may vary based on age, ability level, or severity of the ASD characteristics9. Despite reported challenges in measuring anxiety and depression in ASD and the differences observed in prevalence rates reported, it is fair to say that anxiety and depression are highly prevalent amongst individuals with ASD and should receive more attention.
Does iCBT work for neurodiverse populations?
In terms of treatments for anxiety and depression in ASD, one question is whether interventions such as CBT and iCBT, which are effective in the typically developing population, also work for this subgroup of patients. Recent evidence from a meta-analysis suggests that CBT was efficient in reducing anxiety symptoms in youth with high functioning ASD12, while a separate systematic review13 suggested that web-based interventions can be efficient in reducing condition-specific or comorbid psychological symptoms in children and youth with neurodevelopmental disorders such as ASD. Internet-delivered interventions could therefore be an effective treatment method for this population, which is important given the social challenges specific to a diagnosis of ASD that may make it harder to seek face-to-face, traditional treatment. In addition, similar to the typically developing population, another advantage of the internet-delivered interventions is the provision of access to treatment to those who do not have local resources or do not have the ability to travel to a clinical facility.
With regards to the effectiveness of these therapies in reducing anxiety or depressive symptoms in individuals with ASD, a small number of research studies have focused on adapting existing interventions to better fit the needs of these patients. For example, several randomized-controlled trials (RCTs) have evaluated the effectiveness of adapted CBT and iCBT in reducing anxiety in individuals with high functioning autism14. More recently, there have been attempts to adapt a low-intensity (guided self-help) intervention15 for depression in adults with ASD and an iCBT intervention16 to treat obsessive-compulsive disorder in youth with ASD. Overall, the results from all these studies suggest that adapted interventions are feasible and effective in reducing the psychiatric symptoms in this population.
While altering interventions seems to lead to effective interventions for individuals with ASD, not much work has been done in assessing whether existent interventions may be appropriate as well for this subgroup of patients. Adapting interventions takes time, and they may still not be tailored to everyone’s needs, therefore making use of existing interventions to alleviate psychiatric symptoms in ASD could be useful. There is some limited, recent work suggesting that even unaltered iCBT interventions can be effective for individuals with ASD. For example, a recent RCT17 found that an existent iCBT intervention for anxiety (BRAVE-ONLINE) significantly reduced symptoms, as well as the number of anxiety diagnoses and the clinical severity of the diagnosis in a sample of youth with high functioning ASD. This suggests that while it may not work for everyone with ASD, unaltered iCBT programs may still be useful in ameliorating psychiatric symptoms that individuals with ASD experience.
SilverCloud’s Space from Anxiety and Space from Depression programs could be helpful resources for neurodiverse adults that have comorbid psychiatric disorders. Moreover, with the addition of our Family Suite programs, SilverCloud Health can also now support teenagers with ASD who are struggling with anxiety or depression, as well as parents of children and teens experiencing anxious or depressive symptoms. However, there is also an acknowledgment of the need to further adapt programs, tailoring or adding content that addresses the needs of individuals from neurodiverse groups.
About the author
Catalina Cumpanasoiu has earned her PhD in Personal Health Informatics, a joint program between the Bouvé College of Health Sciences and the Khoury College of Computer Sciences at Northeastern University. She currently works as a Clinical Research Associate at Silvercloud Health. Her background and doctoral work have been in leveraging technologies and wearable physiological devices to better understand human behavior, with a focus on behavioral and clinical applications in the Autism Spectrum Disorders (ASD) field. Coming from a psychology and computer science background with experiences working in different settings, she continues to be passionate about innovative research in the healthcare field.
1. Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., Warren, Z., … Dowling, N. F. (2018). Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR. Surveillance Summaries, 67(6), 1–23. https://doi.org/10.15585/mmwr.ss6706a1
2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
3. Vohra, R., Madhavan, S., & Sambamoorthi, U. (2017). Comorbidity prevalence, healthcare utilization, and expenditures of Medicaid enrolled adults with autism spectrum disorders. Autism, 21(8), 995–1009. https://doi.org/10.1177/1362361316665222
4. Bauman, M. L. (2010). Medical comorbidities in autism: Challenges to diagnosis and treatment. Neurotherapeutics, 7(3), 320–327. https://doi.org/10.1016/j.nurt.2010.06.001
5. Gray, K., Keating, C., Taffe, J., Brereton, A., Einfeld, S., & Tonge, B. (2012). Trajectory of behavior and emotional problems in autism. American Journal on Intellectual and Developmental Disabilities. https://doi.org/10.1352/1944-7588-117-2.121
6. Kanne, S. M., & Mazurek, M. O. (2011). Aggression in children and adolescents with ASD: Prevalence and risk factors. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-010-1118-4
7. Buescher, A. V. S., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). Costs of autism spectrum disorders in the United Kingdom and the United States. JAMA Pediatrics, 168(8), 721–728. https://doi.org/10.1001/jamapediatrics.2014.210
8. Hayes, S. A., & Watson, S. L. (2013). The impact of parenting stress: A meta-analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(3), 629–642. https://doi.org/10.1007/s10803-012-1604-y
9. Kent, R., & Simonoff, E. (2017). Prevalence of anxiety in autism spectrum disorders. Anxiety in children and adolescents with autism spectrum disorder, 5-32.
10. Hollocks, M. J., Lerh, J. W., Magiati, I., Meiser-Stedman, R., & Brugha, T. S. (2019). Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis. Psychological medicine, 49(4), 559-572.
11. Hudson, C. C., Hall, L., & Harkness, K. L. (2019). Prevalence of depressive disorders in individuals with autism spectrum disorder: A meta-analysis. Journal of Abnormal Child Psychology, 47(1), 165-175.
12. Ung, D., Selles, R., Small, B. J., & Storch, E. A. (2015). A systematic review and meta-analysis of cognitive-behavioral therapy for anxiety in youth with high-functioning autism spectrum disorders. Child Psychiatry & Human Development, 46(4), 533-547.
13. Khan, K., Hall, C. L., Davies, E. B., Hollis, C., & Glazebrook, C. (2019). The effectiveness of web-based interventions delivered to children and young people with neurodevelopmental disorders: systematic review and meta-analysis. Journal of medical Internet research, 21(11), e13478
14. Rudy, B. M., Lewin, A. B., & Storch, E. A. (2013). Managing anxiety comorbidity in youth with autism spectrum disorders. Neuropsychiatry, 3(4), 411.
15. Russell, A., Gaunt, D. M., Cooper, K., Barton, S., Horwood, J., Kessler, D., ... & Wiles, N. (2020). The feasibility of low-intensity psychological therapy for depression co-occurring with autism in adults: The Autism Depression Trial (ADEPT)–a pilot randomised controlled trial. Autism, 24(6), 1360-1372.
16. Wickberg, F., Lenhard, F., Aspvall, K., Serlachius, E., Andrén, P., Johansson, F., ... & Mataix-Cols, D. (2022). Feasibility of Internet-delivered cognitive-behavior therapy for obsessive-compulsive disorder in youth with autism spectrum disorder: a clinical benchmark study. Internet Interventions, 100520.
17. Conaughton, R. J., Donovan, C. L., & March, S. (2017). Efficacy of an internet-based CBT program for children with comorbid high functioning autism spectrum disorder and anxiety: a randomised controlled trial. Journal of Affective Disorders, 218, 260-268.