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The OARacle Newsletter

Recent data suggests that 40% of autistic children under the age of 7 have an anxiety disorder. Anxiety can exacerbate autism symptoms, such as worsening sensory over-reactivity and difficulty tolerating change, and contribute to social withdrawal and avoidance. Further, anxiety in young children is associated with a 3.5 times higher risk of anxiety and depression in adulthood. Yet few treatments are available for these children.

OAR-funded researcher Amy Keefer, Ph.D., supervising clinical psychologist at the Hugo W. Moser Research Institute at Kennedy Krieger, Inc. located in Baltimore, Md., led a 2020 OAR-funded research study, “Piloting an Integrated Anxiety Intervention for Preschool Children with Autism Spectrum Disorder.” This is the first study to pilot an intervention for anxiety specifically designed for preschoolers with ASD.

For the study, Dr. Keefer used a program she created, DINO Strategies for Anxiety and Intolerance of Uncertainty Reduction (DINOSAUR), delivered via telehealth. DINOSAUR utilizes cognitive behavioral therapy, modified for young autistic children, and integrates components targeting intolerance of uncertainty and parental accommodation to enhance treatment response.

She recruited 12 autistic children between 3 and 5 years old along with one parent of each child from a larger study at Kennedy Krieger to participate. The research team conducted the telehealth intervention, which consisted of 12 weekly sessions. The first six group sessions were for parents only and included education about anxiety and intolerance of uncertainty. Parents also learned how to teach their children effective coping skills and recognize and reduce reinforcement of triggers that cause anxiety and uncertainty.

Both parents and children attended the next six sessions. In those sessions, parents learned how to systematically expose their child to stimuli related to the child’s fears and to uncertainty during sensory, social, and daily living situations that are often distressing to preschool autistic children. Parents also practiced exposures during sessions so that group leaders could provide coaching. Parents then practiced exposures with their children at home to generalize their skills.

Parents completed weekly ratings of treatment satisfaction, videorecorded their implementation of treatment strategies at weeks 8 and 11, and completed pre- and post-treatment assessments.


Overall findings support DINOSAUR’s feasibility and acceptability. Attrition was low (14.3%) and group attendance was high (96%), indicating high levels of engagement by participating families. Parents also rated the intervention highly on their weekly satisfaction ratings, with an overall median score of 4.3 out of 5, with 5 being “very helpful.” Parents’ qualitative reports also indicated their satisfaction and noted positive changes in their children’s behavior.

Pre- and post-treatment data also suggest the potential of the intervention, as 9 out of 11 participating children experienced a reduction in primary anxiety symptoms and 54% of participants’ overall anxiety symptoms were rated “much” or “very much improved.” Furthermore, results suggest that participants experienced a reduction in intolerance of uncertainty (5 out of 6 children) and parental accommodation (6 out of 6 parents) from pre- to posttreatment. (Data was missing so only data for half of the participants was available.)


In her final report, Dr. Keefer noted the contributions this study makes to the field:

  • Study findings indicate that modified cognitive behavioral therapy can reduce anxiety in young autistic children. This finding, when considered with data indicating a high prevalence of anxiety in young autistic children, supports the need to develop early intervention anxiety treatment models specifically for autistic children. It also indicates the importance of training clinicians, educators, and parents to detect anxiety in young autistic children so they can be treated quickly. Researchers can build upon this study to expand anxiety treatment models to serve autistic children with language and cognitive delays.
  • This study is also the first to demonstrate that delivering cognitive behavioral therapy via telehealth is feasible for children in this age range, adding to the small body of literature supporting telehealth delivery of cognitive behavioral therapy to autistic children. Given the advantages of virtual treatment models — like not needing to drive back and forth to appointments and increased access for families living in rural and under-resourced areas, Dr. Keefer encourages other autism researchers and clinicians to further develop and investigate the efficacy of telehealth cognitive behavioral therapy models for children with anxiety.
  • Study findings support targeting intolerance of uncertainty and parental accommodation in young autistic children and their parents. Given that many autistic children do not experience full remission of their anxiety symptoms following cognitive behavioral therapy, it is important for clinicians and researchers to continue to consider targeting mechanistic and maintaining factors of anxiety as well and to develop and examine treatment strategies to reduce intolerance of uncertainty and parental accommodation.

Dr. Keefer and her research team are using the study’s findings to launch other projects studying anxiety treatment in autistic children.


Sherri Alms is the freelance editor of The OARacle, a role she took on in 2007. She has been a freelance writer and editor for more than 20 years.