Category: Child / Adolescent - Anxiety


Effects of CBT for Anxiety on Neural Mechanisms of Emotion Regulation in Children With Autism

Friday, November 17
12:00 PM - 1:30 PM
Location: Sapphire Ballroom B, Level 4, Sapphire Level

Keywords: Autism Spectrum Disorders | Anxiety | Neuroscience
Presentation Type: Symposium

Introduction: Approximately 40% of children with ASD exhibit clinically significant anxiety. While Cognitive Behavioral Therapy (CBT) is a promising treatment for anxiety in ASD, its neural-systems-level targets are unknown.

Method: We collected fMRI data during an emotion regulation and a face perception task before and after CBT for anxiety in 10 children with ASD complicated by clinically significant anxiety symptoms. Subjects included 7 boys and 3 girls, in the age range from 10 to 12 years with full scale IQ ranging from 79 to 122. CBT was provided using a structured manual that has been modified for children with ASD by increasing parental participation and addressing the role of core ASD symptoms in the experience and expression of anxiety (Wood et al., 2009). Subjects were comprehensively characterized with regard to ASD diagnosis, IQ, adaptive behavior, and comorbid psychopathology. Anxiety symptoms were evaluated before and after treatment using a Pediatric Anxiety Rating Scale (PARS).

Results: There was a significant reduction in the mean PARS total score from 19.1+1.4 at baseline to 8.5+3.0 at endpoint (t=11.6, p<0.001).  A whole-brain fMRI analysis using decrease vs. look-negative contrast of the emotion regulation task revealed increased activation in the emotion regulation circuit including vmPFC, vlPFC, and dlPFC after CBT. We also observed reduction of left amygdala and bilateral insula activation in the look-negative vs. look-neutral contrast (emotional reactivity) after treatment. The magnitude of the effects of CBT on the levels of BOLD activation in the contrasts of interest calculated as the Cohen’s d effect size for the difference in post- to pre-treatment activation divided by the pooled standard deviation ranged from 0.68 to 1.23, indicating moderate to large effect sizes. Although not all changes were statistically significant, all were consistent with increased activation of the prefrontal regions during emotion regulation and decreased amygdala and insula reactivity from pre- to post-treatment with CBT. Using PPI analysis with structurally defined left and right amygdala seeds, we observed increased bilateral amygdala-vmPFC connectivity after CBT with the decrease vs. look-negative contrast of the emotion regulation task, voxel-level threshold Z>1.64, cluster-level p<.05. Consistent with findings on the emotion regulation task (look-negative vs. look-neutral), we observed reduction of amygdala activation during emotional face perception task after CBT.

Discussion: Reduction of anxiety after CBT was paralleled by the enhanced activation in the emotion regulation circuitry consisting of the prefrontal cortex, amygdala, and insular cortex. The results represent one of the very first efforts to examine neural mechanisms of anxiety in ASD and a pioneering effort to utilize an intervention as an experimental probe to understand the neural systems that might be targeted to reduce debilitating anxiety in young people living with ASD. 

Denis G. Sukhodolsky

Associate Professor
Yale Child Study Center, Yale School of Medicine


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Effects of CBT for Anxiety on Neural Mechanisms of Emotion Regulation in Children With Autism

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