J Autism Dev Disord (2013) 43:57–67

DOI 10.1007/s10803-012-1541-9

ORIGINAL PAPER

The Coping Cat Program for Children with Anxiety and Autism
Spectrum Disorder: A Pilot Randomized Controlled Trial
Rebecca H. McNally Keehn • Alan J. Lincoln •

Milton Z. Brown • Denise A. Chavira

Published online: 17 May 2012

Ó Springer Science+Business Media, LLC 2012

Abstract The purpose of this pilot study was to evaluate Introduction

whether a modified version of the Coping Cat program
could be effective in reducing anxiety in children with Since autism was originally described (Kanner 1943),
autism spectrum disorder (ASD). Twenty-two children anxiety has been accepted as an associated feature of the
(ages 8–14; IQ C 70) with ASD and clinically significant disorder. Previous studies have reported that 11–84 % of
anxiety were randomly assigned to 16 sessions of the individuals with autism spectrum disorder (ASD) experi-
Coping Cat program (cognitive-behavioral therapy; CBT) ence clinically significant levels of anxiety, with variables
or a 16-week waitlist. Children in the CBT condition evi- such as specific ASD subtype, level of intellectual ability,
denced significantly larger reductions in anxiety than those degree of social impairment, and method of assessment
in the waitlist. Treatment gains were largely maintained at influencing reported rates (White et al. 2009b). Thus, this
two-month follow-up. Results provide preliminary evi- population experiences higher levels of anxiety than typi-
dence that a modified version of the Coping Cat program cally developing (TD) children (APA 2000). Individuals
may be a feasible and effective program for reducing with ASD may be at a greater risk for developing anxiety
clinically significant levels of anxiety in children with due to inhibited temperament, physiological hyperarousal
high-functioning ASD. (Bellini 2006), and information-processing biases (Happe
and Frith 2006). In addition, it has been proposed that
Keywords Cognitive-behavioral therapy
Autism individuals with ASD are more vulnerable to stress and
spectrum disorder
Anxiety disorders
Randomized anxiety because they often lack an appropriate repertoire of
controlled trial skills to navigate social situations (Bellini 2006) and fail to
develop adaptive coping mechanisms (Gillott and Standen
2007).
R. H. McNally Keehn (&)
A. J. Lincoln
M. Z. Brown Anxiety in children with ASD is associated with per-
California School of Professional Psychology, Alliant vasive consequences including increased maladaptive
International University, 10455 Pomerado Road, San Diego, behavior (Kim et al. 2000), social skills deficits (Bellini
CA 92131, USA
2004), and negative life experiences (Farrugia and Hudson
e-mail: [email protected]
2006). Further, without treatment, anxiety in children with
A. J. Lincoln ASD appears to run a chronic course into adulthood (Far-
Center for Autism Research, Evaluation and Service, San Diego, rugia and Hudson 2006; Gillott and Standen 2007). Despite
CA, USA
the clear need for effective treatments for children with
D. A. Chavira ASD and anxiety, there have been few treatment studies to
Department of Psychiatry, University of California, San Diego, date.
CA, USA Cognitive-behavioral therapy (CBT) has been deemed
the treatment of choice for TD children with anxiety
D. A. Chavira
Child and Adolescent Services Research Center, (Ollendick and King 1998). Kendall and colleagues (1994;
Rady Children’s Hospital, San Diego, CA, USA Kendall et al. 1997) have pioneered the most empirically

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supported (Albano and Kendall 2002) and disseminated the first randomized controlled trial of CBT delivered in an
(Velting et al. 2004) cognitive-behavioral treatment protocol individual format for children with ASD and anxiety.
for TD children with anxiety disorders (i.e., Coping Cat Participants were school aged children with ASD and
Cognitive-Behavioral Therapy for Anxious Youth). The co-occurring diagnoses of separation anxiety disorder,
Coping Cat program has demonstrated efficacy in several social phobia, and/or obsessive compulsive disorder. A
randomized controlled trials across cultures (Barrett et al. standard CBT program was augmented with multiple
1996; Treadwell et al. 1995) and has been shown to be treatment components designed to accommodate or reme-
effective in the maintenance of treatment gains over time diate the social and adaptive skill deficits of children with
(Kendall 1994; Kendall et al. 1997, 2004; Kendall and ASD that could pose barriers to anxiety reduction. This
Southam-Gerow 1996). The Coping Cat program has gar- treatment model incorporated individual treatment, parent
nered the distinction of ‘‘empirically supported’’ (Albano training, and school consultation across 16 sessions. The
and Kendall 2002) and ‘‘probably efficacious’’ (Ollendick authors found that CBT significantly outperformed the
and King 1998) due to the abundance of evidence supporting waitlist group in terms of diagnostic outcome, a clinician
this treatment protocol. Preliminary evidence suggests that rated standardized measure of treatment response, and
this program may be successfully adapted for children with parent measures of anxiety symptoms. Treatment gains
attention deficit/hyperactivity disorder, physical impair- were maintained at three-month follow up.
ments, selective mutism, and comorbid depression (Hudson More recently, White et al. (2009a) conducted an
et al. 2001). To date, there are no studies that have examined additional promising preliminary treatment study targeting
whether the Coping Cat program may be modified to suc- both anxiety and social competence in four adolescents
cessfully reduce anxiety in children with ASD. with ASD. The intervention program, Multi-Component
Some authors (e.g., Chalfant et al. 2007) have hypoth- Integrated Treatment (MCIT; White et al. 2010), is based
esized that the lack of exploration into the effectiveness of on principles of CBT and integrates techniques for social
CBT for children with ASD may be due to the notion that skills development in ASD (e.g., modeling, specific feed-
children with ASD are impaired in their ability to identify back, social reinforcement) and evidenced-based approa-
and understand emotions and cognitions in themselves and ches for the treatment of anxiety (e.g., exposure, cognitive
others (Baron-Cohen et al. 1985). However, since Baron- restructuring, education). The treatment was delivered via
Cohen et al. (1985) first reported on ‘‘Theory of Mind’’ in three separate modalities including individual therapy,
children with ASD, there has been mixed support for the parent education, and group therapy skills practice across
ubiquitous nature of these deficits. For example, chrono- 11 weeks. Three of four participants evidenced a statisti-
logical age and intellectual ability have been found to cally significant reduction in parent reported anxiety
moderate Theory of Mind abilities in children with ASD symptoms and all four experienced improvement in parent
(Bauminger and Kasari 1999; Happe 1995; Yirmiya et al. reported social skills.
1998). Meyer et al. (2006) found that children with ASD Preliminary reports in the literature (e.g., White et al.
are able to report on their own stress and social attributions; 2009a; Wood et al. 2009) provide evidence of promising
further, this relatively spared self and social awareness may preliminary support for the use of CBT to treat anxiety
play a role in the development of psychopathology, symptoms in children with ASD. However, it is unclear
including anxiety. Evidence supporting relatively intact whether these treatments are feasible for managed care
emotion recognition abilities in individuals with age clinical settings due to their multimodal nature, which
appropriate intellectual and verbal abilities suggests that requires integrated clinic, school, and peer-based inter-
CBT may be a plausible and appropriate intervention for ventions. Because children with ASD and their families
this population. most often access psychological services in managed care
A small, growing body of literature has demonstrated settings, it is critical that effective treatments be practical,
preliminary support for the use of CBT to treat anxiety in efficient, and generalizable across these settings. The cen-
children with ASD. Three non-randomized (Ooi et al. tral purpose of this pilot study was to determine whether an
2008; Reaven et al. 2009; White et al. 2009b) and three empirically supported, individually-based cognitive-
randomized (Chalfant et al. 2007; Sofronoff et al. 2005; behavioral treatment could be modified to effectively
Wood et al. 2009) treatment studies have demonstrated reduce anxiety in children with ASD. This is the first
empirical evidence that CBT treatments effectively reduce known empirical study using the Coping Cat program for
anxiety. Two of these studies (Wood et al. 2009; White children with ASD. Extending the existing support for the
et al. 2009a) have employed specific multimodal cognitive- Coping Cat program to those with ASD has clinically
behavioral treatments aimed at targeting the core deficits of significant implications. Because this treatment package
ASD that some authors have proposed may render typical has been widely disseminated and already exists in many
CBT approaches ineffective. Wood et al. (2009) conducted clinicians’ repertoires, if found to be effective, it could be a

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primary resource for use with children with ASD across Anxiety and comorbid (non-ASD) diagnoses were made
many clinical settings. using the ADIS-P (Silverman and Albano 2004), admin-
istered to parents of study participants by trained graduate
student evaluators. The ADIS-P was also employed as the
Method primary measure of outcome. Evaluators were blind to
intervention assignment at all phases of assessment. The
Participants ADIS-P is a structured clinical interview that enables the
assessor to obtain information about past and current
Participants were 22 children, ages 8–14 (M = 11.26; symptomatology, course, etiology, and severity of anxiety
SD = 1.53), diagnosed with ASD and at least one pri- and problem behaviors and to screen out additional disor-
mary anxiety disorder of separation anxiety disorder ders. Parent-reported Interference Ratings C4 (0–8 scale)
(SAD), generalized anxiety disorder (GAD), or social were considered to be indicative of clinically significant
phobia (SP) (see Table 1 for demographic data). Twelve impairment. The ADIS-C/P has sound psychometric
children were randomized to the CBT condition and 10 properties (Silverman et al. 2001) and has shown sensi-
children were randomized to the waitlist (WL) condition. tivity to treatment effects in CBT outcome studies with TD
Sample size was determined a priori by conducting a children (e.g., Kendall et al. 1997). Further, the ADIS-C/P
power analysis using G*Power 3 (Faul et al. 2007). A has demonstrated utility for diagnosing anxiety disorders
large effect size was specified for group differences at and measuring treatment outcome in children with ASD
post-treatment/waitlist based on the recent report of Wood across a number of recent studies (e.g., Chalfant et al.
et al. (2009) in a RCT of CBT for anxiety in children 2007; Wood et al. 2009). ADIS-P evaluators were con-
with ASD. Participants were recruited from several sidered reliable administrators when they met 85 % reli-
sources in the Southern California area including local ability with a trained clinician across three consecutive
agencies and non-profit organizations for children and interviews (coding audiotaped interviews and co-scoring
families affected by ASD. Informed assent and consent during live administrations).
was obtained from all participating children and parents
in accordance with the Alliant International University Parent- and Child-Report Anxiety Measures
Institutional Review Board.
Children were included if they met the following crite- The Spence Children’s Anxiety Scale (SCAS; Spence
ria: (a) diagnosis of ASD based on the Autism Diagnostic 1998) and the parallel parent version (SCAS-P; Nauta et al.
Observation Schedule (ADOS; Lord et al. 2002), Autism 2004) were used as secondary outcome measures. The
Diagnostic Interview- Revised (ADI-R; Rutter et al. 2003), SCAS is a 45-item (4-point Likert scale) self-report ques-
and expert clinical judgment based on DSM-IV criteria, tionnaire designed to assess children’s report of anxiety
(b) diagnosis of SAD, SP, or GAD, made on the basis of and provide information about specific childhood anxiety
the Anxiety Disorders Interview Schedule-Parent Version disorders (Spence 1998). The parent report version of the
(ADIS-P; Silverman and Albano 2004), (c) Full-Scale SCAS is identical to that of the child report except that it
IQ C 70 as confirmed by the Wechsler Abbreviated Scale assesses the parent’s perceptions of the child’s current
of Intelligence (WASI; Wechsler 1999), (d) age 7–14 (no anxiety. The Total Score (sum of the 38 anxiety items)
children age 7 were recruited, thus the age of children in ranges from 0 to 114 with higher scores indicating greater
the study ranged from 8 to 14 years), and (e) English as the levels of anxiety. The SCAS and SCAS-P have positive
primary language. Children receiving additional pharma- psychometric properties (Spence et al. 2003; Nauta et al.
cological and/or psychosocial interventions at the time of 2004) and have been used to measure anxiety symptoms
intake were included (no children received concurrent CBT and treatment outcome with high levels of internal validity
or anxiety-based interventions). and reliability (Sofronoff et al. 2005) in anxious children
with ASD (e.g., Chalfant et al. 2007; Sofronoff et al. 2005).
Measures
Cognitive-Behavioral Intervention
Diagnostic Measures
Children in the CBT condition received a 16-week manu-
The ADOS (Lord et al. 2002) and ADI-R (Rutter et al. alized cognitive-behavioral intervention according to the
2003) were used to confirm ASD diagnoses for study Coping Cat program (Kendall and Hedtke 2006a, b). The
inclusion purposes. The ADOS and ADI-R were adminis- Coping Cat program is designed for children and young
tered to study participants by evaluators who were trained adolescents with SAD, SP, and GAD (Kendall and Hedtke
to research reliability on administration and coding. 2006a). The primary goal of the treatment program is to

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Table 1 Pre-treatment
CBT (n = 12) WL (n = 10) v2 p value
comparability across
n (%) n (%)
demographic, diagnostic, and
intervention usage variables Child gender
Male 12 (100) 9 (90) 1.26 .26
Parent highest education 2.72 .26
High school graduate 4 (33) 1 (10)
College graduate 7 (59) 6 (60)
Graduate degree 1 (8) 3 (30)
Parent marital status 2.06 .26
Single 1 (8) 2 (20)
Married/remarried 11 (92) 7 (70)
Cohabitating 0 (0) 1 (10)
Child ethnicity 3.18 .37
Caucasian 8 (66) 4 (40)
Native/American Indian 0 (0) 0 (0)
Black/African American 0 (0) 0 (0)
Asian/Pacific Islander 0 (0) 0 (0)
Hispanic/Latino 2 (17) 1 (10)
Other/mixed ethnicity 2 (17) 1 (10)
Not reported 0 (0) 4 (40)
ASD diagnosis 1.43 .49
Autism 3 (25) 3 (30)
Asperger syndrome 9 (75) 6 (60)
PDD-NOS 0 (0 1 (10)
Baseline anxiety diagnoses
Separation anxiety disorder 5 (42) 3 (30) .32 .57
Generalized anxiety disorder 11 (92) 7 (70) 1.72 .19
Social phobia 8 (67) 7 (70) .03 .87
Specific phobia 8 (67) 7 (70) .07 .79
Obsessive compulsive disorder 2 (17) 0 (0) 1.83 .18
Baseline comorbid diagnoses
ADHD 8 (67) 8 (80) .49 .47
Oppositional defiant disorder 4 (33 5 (50) .63 .43
Major depressive disorder 1 (8) 0 (0) .87 .35
At post-treatment, 3 of 22 Pharmacological intervention usage
(CBT = 1/12; WL = 2/10) of SSRI 2 (17) 1 (10) .21 .65
children had changed
Anti-psychotic 3 (25) 0 (0) 2.90 .09
medication type and 1 of 22
(CBT = 1/12) of children had Stimulant 0 (0) 4 (40) 5.87 .02*
discontinued psychosocial Psychosocial intervention usage
intervention services received Psychological/behavioral 3 (25) 2 (20) .08 .78
over the course of treatment
School-based 5 (42) 5 (50) .15 .70
* p [ .05

teach children to recognize signs of anxious arousal and to hierarchical sequence of anxiety-provoking situations. Two
let these signs serve as a cue to implement anxiety man- parent-only sessions (i.e., at sessions 4 and 9) are included
agement techniques. The 16 sessions are divided into two to provide psychoeducation on the child’s treatment goals,
content-based parts; sessions one through eight are focused collaborate regarding the parent’s input, impressions, and
on skills training (e.g., affective education, awareness of ideas, and encourage parental cooperation with treatment.
somatic sensations associated with anxiety, cognitive Homework tasks from the Coping Cat workbook are
restructuring, developing a coping plan, and evaluating assigned weekly to reinforce and generalize skills.
performance and administering self-reinforcement) and Several modifications to the Coping Cat program,
sessions nine through 16 are focused on exposure tasks in a judged to remain within treatment fidelity (Kendall and

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Hedtke 2006a), were made in order to accommodate the scheduled. All study related assessment and treatment took
learning style of children with ASD and increase treatment place at Alliant International University. During the intake
success. Previous reports in the literature (e.g., Anderson evaluation, diagnostic and IQ measures and parent- and
and Morris 2006; Reaven 2009) have suggested that spe- child-report measures of anxiety were administered.
cific modifications to traditional CBT techniques may Included participants were block randomized to either
make these interventions more accessible to children and the 16-week CBT intervention or 16-week WL using a
adolescents with ASD. Therefore, the following modifica- stratified randomization procedure. Children were stratified
tions to the Coping Cat program were made: based on age, intellectual ability, and pre-treatment anxiety
severity. All children, regardless of condition, were per-
1. Following each session, 10–15 min were spent on
mitted to receive treatment as usual (i.e., pharmacological
reviewing the content covered, skills learned, and
or psychosocial interventions) concurrent to study partici-
homework assigned with parents in order to increase
pation. The primary author (RMK) delivered all of the
children’s homework compliance and skill gener-
treatment. All participants in the CBT condition completed
alization.
16 sessions, including the seven exposure sessions as pre-
2. Session duration was lengthened to 60–90 min to
scribed in the Coping Cat program manual. Homework
allow more time to thoroughly cover session content at
compliance was calculated for each participant by aver-
a pace appropriate for children with ASD.
aging the percentage of homework completed across all
3. Additional written and visual materials (e.g., written
treatment sessions. Across all participants receiving treat-
schedules, pictorial scale of anxiety) were utilized to
ment, the mean homework compliance score was 66 %.
accommodate children’s visual style of learning.
Anxiety measures were administered within one week of
4. Concrete language was used to accommodate chil-
completion of the 16-week CBT intervention or WL period
dren’s literal and sometimes rigid language and
as well as at two-month follow-up for those in the CBT
thought patterns.
condition. Data were collected on the types of pharmaco-
5. Children’s specific interests and preoccupations were
logical and psychosocial interventions each participant
integrated into the treatment when appropriate in order
received (as well as changes in intervention usage) during
to build rapport, increase understanding of therapeutic
the study (see Table 1). Children initially randomized to
material, and motivate participation.
the WL condition were offered the opportunity to receive
6. Children with attention and concentration difficulties
the CBT treatment following WL completion. Children
were offered frequent sensory input through the use of
were offered $20 for completing the study.
sensory stimulating objects or proactive movement
breaks.
7. For children with motor difficulties, in-session writing
Results
tasks were completed with the help of the therapist or
computer in order to reduce motor burden.
For between-condition (CBT, WL) comparisons, treat-
8. In order to adhere to the stated goals of each session,
ment-completer sample sizes were 12 and 10, respectively.
all components of the treatment were administered to
No participant dropouts occurred during the study, ren-
each child. However, in keeping with a child-centered,
dering intent-to-treat analyses unnecessary (see Fig. 1).
individualized approach, the particular learning style
Recruitment occurred from June to September 2009; post-
of each child was respected. For example, for some
treatment/WL and follow-up assessments were completed
children who had more difficulty with cognitive
by April 2010.
restructuring due to their particular learning profile,
behavioral components of the program were empha-
Pre-treatment Comparability
sized over cognitive components (e.g., more time was
spent on relaxation, role-plays, and exposure tasks than
Pre-treatment group differences were assessed using Chi-
on cognitive restructuring).
square and t tests. There were no statistically significant
9. Reinforcement strategies were enhanced and/or tai-
pre-treatment differences across any of the demographic,
lored to each child individually.
diagnostic, or intervention variables with one exception; a
larger proportion of children in the WL condition were
Procedure using stimulant medications at pre-treatment than those in
the CBT condition (see Table 1). Additionally, no statis-
Within several days of initial parent contact, a phone tically significant pre-treatment differences were found
screen was conducted and an intake evaluation was across the stratification variables (see Table 2).

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Assessed for eligibility (N = 36)

Excluded (n = 14)
-Did not meet inclusion criteria (n = 10)
-Declined to participate (n = 1)

Randomized (N = 22)

Allocated to CBT condition (n = 12) Allocated to WL condition (n = 10)

-Followed CBT protocol (n = 12) -Followed WL protocol (n = 10)
-Drop out (n = 0) -Drop out (n = 0)

Assessed at post-treatment (n = 12) Assessed at post-WL (n = 10)

Analysed (n = 12) Analysed (n = 10)

Fig. 1 Participant flow diagram

Table 2 Pre-treatment comparability across stratification variables was conducted by trained graduate research assistants who
CBT (n = 12) WL (n = 10) t p value had familiarity with the concepts of CBT and the treatment
Mean (SD) Mean (SD) protocol. Coders viewed sessions and simultaneously
completed a checklist according to whether clearly opera-
Child age 11.65 (1.41) 11.02 (1.69) .94 .36
tionalized session goals, as outlined in the Coping Cat
Full scale IQ 108.42 (17.70) 110.40 (17.39) -.26 .76
program manual, were sufficiently addressed. For example,
VIQ 105.83 (17.89) 107.00 (15.71) -.16 .87
goals from Session 2 include: (1) build rapport, (2) review
PIQ 108.58 (16.96) 111.90 (18.62) -.44 .67
homework, (3) introduce concept that different feelings
Anxiety severity 7.00 (1.21) 7.10 (1.10) -.20 .84
have physical sensations, (4) normalize experience of fears
and anxiety, (5) construct fear hierarchy, and (6) assign
homework task. The study therapist adhered to session
ADIS-P Inter-rater Reliability goals at a rate of 95 % (inter-rater reliability among coders
was good; ICC = .88).
ADIS-P diagnostic assessments were audiotaped to assess
for agreement between raters. Fifteen percent of all ADIS-
P assessments (n = 9) were randomly chosen for inter- Treatment Outcome
rater reliability analyses. Agreement among raters for
ADIS-P Interference Ratings across all diagnoses was good Outcome at Post-Treatment/WL
(ICC = .83).
Using ADIS-P primary anxiety diagnosis Interference
Treatment Adherence Ratings at post-treatment/WL as the recovery criterion,
58 % (7 of 12) of children receiving CBT no longer met
In order to evaluate therapist adherence to the Coping Cat criteria for their primary anxiety diagnosis at post-treat-
program session goals, all sessions were videotaped. ment; 100 % (10 of 10) of those in the WL condition
Twelve percent of sessions were randomly selected across continued to meet criteria for the primary anxiety diagnosis
participants and sessions. Coding for treatment adherence at post-WL assessment (v2 (1) = 8.56, p = .003).

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main effect for time, F(1, 20) = 7.22, p = .01, Cohen’s

d = .61, and significant group 9 time interaction, F(1,
20) = 6.31, p = .02, Cohen’s d = 1.17, was found (see
Table 3).
In order to examine changes in total number of comorbid
diagnoses (e.g., anxiety and other psychiatric conditions
based on ADIS-P Interference Ratings), a mixed-model
repeated measures ANOVA with group (CBT, WL) as a
between-subject factor and time (pre-treatment/WL, post-
treatment/WL) as a within-subject factor was conducted
using total number of ADIS-P diagnoses as the dependent
variable. A significant main effect for time, F(1, 20) =
13.80, p = .001, Cohen’s d = .83, and significant group 9
time interaction, F(1, 20) = 29.73, p \ .001, Cohen’s d =
Fig. 2 ADIS-P Interference Ratings for primary anxiety diagnoses 1.22, was found (see Table 3).
across time. Error bars represent standard error of the mean. Bold line
represents ADIS-P clinical cutoff (i.e., interference rating C4 is
considered to be in the clinical range) Outcome at 2-Month Follow-Up

Data from 92 % (11 of 12) of participants who received the

A mixed-model repeated measures ANOVA with group CBT intervention were collected at two-month follow-up.
(CBT, WL) as a between-subject factor and time (pre- Using ADIS-P primary anxiety diagnosis Interference
treatment/WL, post-treatment/WL) as a within-subject Ratings at post-treatment/WL as the recovery criterion,
factor was conducted to assess treatment outcome using 36 % (4 of 11) of participants remained free from meeting
both primary and secondary outcome measures. All effect diagnostic criteria for their primary anxiety diagnosis at
sizes were calculated using G*Power 3 (Faul et al. 2007). 2-month follow-up. One participant relapsed and again met
For ADIS-P primary anxiety diagnosis Interference Rat- criteria for the primary anxiety diagnosis; ten participants
ings, a significant main effect for time, F(1, 20) = 25.94, retained their diagnostic status from post-treatment.
p \ .001, Cohen’s d = 1.15, and significant group 9 time Using only the data from the CBT group, a repeated
interaction, F(1, 20) = 12.53, p \ .01, Cohen’s d = 1.35, measures ANOVA with within-subject factor time (pre-
was found (see Fig. 2; Table 3). treatment, post-treatment, follow-up) was conducted to
For child-report SCAS scores, a non-significant main assess maintenance of treatment gains using both primary
effect for time, F(1, 19) = 2.58, p = .13, Cohen’s d = .40, and secondary outcome measures. For ADIS-P primary
and a marginally significant group 9 time interaction, F(1, anxiety diagnosis Interference Ratings, a significant main
19) = 3.10, p = .09, Cohen’s d = .51, was found (see effect for time was found, F(2, 20) = 16.60, p \ .001,
Table 3). For parent-report SCAS-P scores, a significant Cohen’s d = 1.29 (see Fig. 2; Table 3). Follow up

Table 3 Means and standard

Measure Pre-treatment/WL Post-treatment/WL Follow-up
deviations for outcome
measures CBT WL CBT WL CBT

ADIS-P Interference Rating

M 7.00 7.10 3.67 6.50 4.45
SD 1.21 1.10 2.50 1.18 2.54
ADIS-P comorbid diagnoses
M 4.00 3.70 2.42 4.00 3.00
SD 1.04 1.06 1.38 1.25 1.67
SCAS total score
M 27.08 28.89 26.75 36.11 29.00
ADIS-P Interference Rating
SD 19.75 17.15 20.79 16.46 22.43
refers to primary anxiety
diagnosis; ADIS-P comorbid SCAS-P total score
diagnoses refers to the total M 34.92 32.20 20.08 31.70 21.64
number of comorbid (non-ASD) SD 13.71 16.54 11.34 13.36 9.15
diagnoses based on the ADIS-P

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comparisons show a significant difference between ADIS-P 2007; Wood et al. 2009). In addition, participants in the
Interference Ratings at pre-treatment and follow-up, CBT group demonstrated a greater reduction in total
t(10) = 3.68, p = .004, Cohen’s d = 1.12, and a non-sig- number of psychiatric diagnoses at post-treatment than
nificant difference between ADIS-P Interference Ratings those in the waitlist group, suggesting that the Coping Cat
between post-treatment and follow-up, t(10) = -1.90, program may ameliorate symptoms of co-occurring inter-
p = .09, Cohen’s d = .31. nalizing and externalizing conditions.
For child-report SCAS scores, a non-significant main Cicchetti et al. (2010) recently emphasized that the
effect for time was found, F(2, 20) = .30, p = .74, Cohen’s ultimate test of a new treatment is not whether it has pro-
d = .17 (see Table 3). For parent-report SCAS-P scores, a duced a statistically significant result, but instead whether
significant main effect for time was found, F(2, 20) = 10.85, the result is clinically meaningful (i.e., using measures of
p = .001, Cohen’s d = 1.04 (see Table 3). Follow up effect size and NNT). Large effect sizes for comparisons in
comparisons show a significant difference between SCAS-P reduction of anxious symptoms among children in the
scores at pre-treatment and follow-up, t(10) = 4.57, active treatment versus waitlist were found. Furthermore,
p = .001, Cohen’s d = 1.38, and a non-significant differ- mean ADIS-P Interference Ratings for primary anxiety
ence between SCAS-P scores between post-treatment and disorders in the CBT group, but not the WL group, dropped
follow-up, t(10) = -.87, p = .40, Cohen’s d = .27. below the clinical cutoff at post-treatment. Analysis of
clinical significance examined using NNT suggest that
Clinical Significance approximately two children must be treated in order for one
child to evidence a clinically significant remission in
Number Needed to Treat (NNT) was calculated using anxiety symptoms. These results are promising and com-
return to non-clinical levels for the primary anxiety diag- parable to studies of Coping Cat efficacy for TD children
nosis on the ADIS-P (i.e., ADIS-P interference rating \4) (NNT = 2.8; Walkup et al. 2008).
at post-treatment/WL as the recovery criterion. Results Secondary outcomes based on parent, but not child,
indicate that approximately two children must participate report yielded clinically meaningful reductions in anxiety
in the Coping Cat program in order for one child to return and are in line with those previously reported in the litera-
to non-clinical levels for their primary anxiety diagnosis at ture (e.g., Chalfant et al. 2007). Based on SCAS-P scores,
post-treatment (NNT = 1.72). children receiving CBT evidenced a decrease in anxious
symptomatology at post-treatment. While these results were
not replicated by child version of the SCAS, previous
Discussion studies have brought into question the accuracy of child-
reported symptoms in children with ASD (e.g., Reaven et al.
Given the high rates of co-occurring anxiety disorders in 2009; Sofronoff et al. 2005; Wood et al. 2009). In light of
children with ASD, finding efficacious treatments for this the discrepant findings between parent and child reported
population has been an area of recent interest. This is the symptoms at outcome, it is possible that children in the
first study to evaluate whether a modified version of the current study may not be accurate reporters of their own
Coping Cat program could be effective for reducing anxi- psychiatric symptoms or that the instruments used to mea-
ety in children with ASD. Overall, the results provide sure anxiety may not be reliable or valid in this population.
promising initial evidence that, despite high levels of An alternative hypothesis may be that, although children
anxiety and comorbidity, children with ASD who complete did not experience a significant change in their experience
the 16-week Coping Cat Program experience a larger of anxiety (e.g., as reflected in statistically equivalent self-
reduction in anxiety symptoms than those receiving no reported SCAS scores), they learned coping strategies in
treatment or treatment as usual and these gains are largely order to manage and face their fears in a more adap-
maintained at two-month follow-up. tive manner. This hypothesized skill acquisition could be
Over half (58 %) of all children who participated in related to parents’ perceptions of anxiety reduction in their
CBT treatment demonstrated a remission in clinically- children.
significant anxiety symptoms, no longer meeting diagnostic Although only 36 % of children remained free of their
criteria (based on parent report) for their primary anxiety primary anxiety diagnosis at two-month follow-up, statis-
disorder at post-treatment. This finding is comparable to tical differences in anxiety scores from pre-treatment to
estimates of primary anxiety disorder remission for TD follow-up suggest that treatment gains were maintained.
children completing the Coping Cat program (53–70 %; These results are consistent with those previously reported
Barrett et al. 1996; Kendall 1994; Kendall et al. 1997) and in CBT outcome studies with children with ASD and
to findings from studies of children with ASD completing anxiety (Sofronoff et al. 2005; Wood et al. 2009). Although
alternative CBT interventions (64–71 %; Chalfant et al. treatment gains were largely maintained at follow-up, it

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may be that children with ASD require booster treatment to produce statistically significant and clinically meaning-
sessions to fully maintain skills learned in the initial dose ful results for most measures of outcome, the sample size
of intervention. of the current study is small and thus, statistical results and
effect sizes should be interpreted with caution (Kraemer
et al. 2006). Second, outcome measures used in this study
Clinical Implications
were, in large part, based on parent report. Parents were not
blind to treatment condition and likely had considerable
Results of this pilot study can be taken as a first step in
investment in the success of the treatment (e.g., due to time
providing evidence that a modified version of the Coping
spent, hope that it would help their children, etc.). Parent
Cat program may be a feasible and effective intervention
reported improvements in children’s anxiety could have
package for reducing clinically significant levels of anxiety
been due to perceptions of treatment credibility and
in children with high-functioning ASD. These results have
expectancy for change, increased education about their
clinically significant implications given that: (a) children
child’s anxiety, or facilitation of their child’s engagement
with ASD are at an increased risk for developing co-
in the treatment process (e.g., through completion of
occurring anxiety disorders, (b) little evidence exists for
homework and out of session exposure tasks). Neverthe-
effective treatments for children with ASD and co-occur-
less, parent perception of improved anxiety is clinically
ring psychiatric conditions, and (c) results of this study are
meaningful as this type of perceived change may have
in accordance with a small body of literature providing
significant impact on family quality of life. Additionally,
support for the use of CBT to treat anxiety in children with
relying on measures designed for typical children may
ASD. It appears that the Coping Cat program was accept-
have a significant impact on accurately measuring outcome
able to children with ASD and their families as no dropouts
as previous researchers have suggested that children with
occurred during the treatment phase of the study. Further,
ASD may have a differential pattern and manifestation of
this program appears to be a feasible treatment to modify
anxiety symptoms than typically developing children
and implement for children with ASD and anxiety.
(Gillott et al. 2001). Third, the primary author delivered all
Modifications to the Coping Cat program in the present
of the treatment. There are many challenges in working
study, though considered to be within treatment fidelity
with this highly complex clinical population. It may be that
(Kendall and Hedtke 2006a), included such additions as
the author’s clinical training and experience working with
bolstering the parent-training component, lengthening ses-
children with ASD limits the generalizability of the results
sion duration, utilizing additional visual supports, adjusting
to other treatment providers. It is unclear at this point
language to be more concrete, incorporating children’s
exactly what type of clinical experience is required to
interests into treatment, providing sensory and motor
flexibly modify the treatment and achieve successful
accommodations, emphasizing behavioral over cognitive
outcomes.
aspects of the treatment, and tailoring reinforcement to meet
Although initial results are promising, future research is
individual needs. These modifications are consistent with
needed to replicate and expand upon this pilot study.
many of the recommendations outlined by previous authors
Future research on the efficacy of the Coping Cat program
(Anderson and Morris 2006; Reaven 2009) for accommo-
for children with ASD would benefit from: (a) replication
dating the challenging clinical profile of children with ASD.
with a larger sample size, (b) employing outcome measures
Kendall and colleagues have been very successful in
based on more objective sources instead of relying on
effectively disseminating the Coping Cat program not only
parent and child report, and (c) examining treatment
to research groups internationally, but have also made
response across therapists.
treatment materials available to clinicians in a variety of
settings via resources available for purchase over the Acknowledgment This study was supported by grants awarded to
internet. Availability of treatment and training materials as RMK from the National Foundation for Autism Research and the
well as promising initial evidence make Coping Cat a Autism Society of America—San Diego County Chapter. We would
possible first line treatment for children with ASD and like to thank the children and families who generously participated.
Trial Registry Information: Clinicaltrials.gov database reference
anxiety across a range of clinical settings. number: NCT01187784. Internet link: http://clinicaltrials.gov/ct2/
show/NCT01187784.

Limitations and Future Research

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