Cognitive behavioural therapy for anxiety in children and young people on the autism spectrum: a systematic review and meta-analysis
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Background: Anxiety is common in youth on the autism spectrum and cognitive behavioural therapy (CBT) has been adapted to address associated symptoms. The aim of the current systematic review and meta-analysis was to examine the efficacy of CBT for reducing anxiety in autistic youth. Method: Searches of PubMed and Scopus databases were undertaken from January 1990 until December 2020. Studies were included if they consisted of randomised controlled trials (RCTs) using CBT to reduce anxiety in autistic youth. Separate random effects meta-analyses assessed anxiety ratings according to informant (clinician; parent; child), both at end-of-trial and at follow-up. Results: A total of 19 RCTs met our inclusion criteria (833 participants: CBT N = 487; controls N = 346). Random effects meta-analyses revealed a large effect size for clinician rated symptoms (g = 0.88, 95% CI 0.55, 1.12, k = 11), while those for both parent (g = 0.40, 95% CI 0.24, 0.56; k = 18) and child-reported anxiety (g = 0.25, 95% CI 0.06, 0.43; k = 13) were smaller, but significant. These benefits were not however maintained at follow-up. Moderator analyses showed that CBT was more efficacious for younger children (for clinician and parent ratings) and when delivered as individual therapy (for clinician ratings). Using the Cochrane Risk of Bias 2 tool, we found concerns about reporting bias across most trials. Conclusions: The efficacy of CBT for anxiety in autistic youth was supported in the immediate intervention period. However, substantial inconsistency emerged in the magnitude of benefit depending upon who was rating symptoms (clinician, parent or child). Follow-up analyses failed to reveal sustained benefits, though few studies have included this data. It will be important for future trials to address robustness of treatment gains overtime and to further explore inconsistency in efficacy by informant. We also recommend pre-registration of methods by trialists to address concerns with reporting bias.
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Sharma et al. (2021) observed large effect sizes for clinician-rated symptoms but only small ones from autistic individuals themselves, with benefits not sustained at follow-up.
“Sharma et al. (2021) observed large effect sizes for clinician-rated symptoms but only small ones from the autistic individuals themselves, with benefits not sustained at follow-up.”
From Rethinking psychological interventions in autism: Toward a neurodiversity‐affirming approach. (2025) · cites this paper as Sharma et al., 2021
The Discussion (page not provided) reports a large clinician-rated effect and a small self-rated effect, as claimed. It also reports no support for sustained effects at 1–9 months, but that analysis included only parent and child ratings from five trials; the authors caution against a firm conclusion. Saying benefits were not sustained overstates that limited finding. (LLM, conf=0.87)
Experimental — accuracy not yet measuredRecent reviews and meta-analyses suggest that CBT has the potential to be an effective component for addressing anxiety-related symptoms in autistic children.
“Los resultados de recientes revisiones y metaanálisis (Perihan et al., 2019;Sharma et al., 2021) sugieren que los TCC tienen el potencial de ser un componente eficaz para abordar los síntomas relacionados con la ansiedad en niños y niñas autistas.”
From Ansiedad y trastornos del espectro del autismo: notas para la intervención psicoeducativa (2022) · cites this paper as Sharma et al., 2021
Sharma et al. (2021) and Weston et al. (2016) reported higher effect sizes based on clinician evaluations, whereas autistic individuals' self-reports indicated only mild or moderate effects.
“Sharma et al. (2021) and Weston et al. (2016) reported higher effect sizes based on clinician evaluations, whereas autistic individuals' self-reports indicated only mild or moderate effects.”
From Rethinking psychological interventions in autism: Toward a neurodiversity‐affirming approach. (2025) · cites this paper as Sharma et al. (2021)
Clinician-reported outcomes are often prioritised over self-reports from autistic participants.
“clinician-reported outcomes are often prioritised over self-reports from autistic participants.”
From Rethinking psychological interventions in autism: Toward a neurodiversity‐affirming approach. (2025) · cites this paper as Sharma et al. (2021)
The Results compare clinician-rated and child self-rated anxiety outcomes, and the Discussion emphasises their differing effect sizes. Neither section says clinician reports are often prioritised over autistic participants’ self-reports; the paper instead calls for informant differences to be investigated. (LLM, conf=0.74)
Experimental — accuracy not yet measured
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- Authors
- Sharma, S., Hucker, A., Matthews, T., Grohmann, D., & Laws, K. R.
- Affiliations
- University of Hertfordshire (GB)
- Corresponding author
- Sharma, Shivani
- Venue
- BMC Psychology
- Published
- 2021-10-01
- Volume
- 9
- Issue
- 1
- Pages
- 151-151
- ISSN
- 2050-7283 (ISSN-L)
- PMC
- PMC8487131
- OpenAlex
- W3202426903
- Cited by
- 109
- References
- 77
- Citations by year
- 2026: 18 · 2025: 18 · 2024: 54 · 2023: 12 · 2022: 5 · 2021: 2
- FWCI
- 2.70
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Psychology (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- University of Hertfordshire Research Archive (University of Hertfordshire) (acceptedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- University of Hertfordshire Research Archive (University of Hertfordshire) (submittedVersion, cc-by)
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- cognitive behavioral therapy, autism spectrum disorder, anxiety, autistic youth, treatment efficacy, clinician ratings, parent ratings, child self-report, individual psychotherapy, age differences, follow-up maintenance, reporting bias
- MeSH terms
- Adolescent, Anxiety, Anxiety Disorders, Autistic Disorder, Humans, Parents, Cognitive Behavioral Therapy
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