Anxiety in Adolescents With

Asperger Syndrome: Negative

Thoughts, Behavioral Problems,
and Life Interference
Sylvana Farrugia and Jennifer Hudson

This study examined anxiety symptoms in 29 adolescents with

Asperger syndrome (AS) aged 12 to 16 years, compared to 30
nonclinical (NC) adolescents and 34 adolescents with anxiety
disorders (AD). Comorbidity between anxiety symptoms and
negative thoughts, behavioral problems, and life interference
was also examined. Self- and parental reports revealed
significantly higher levels of anxiety in both the AS group
and the AD group than in the NC group. Negative thoughts,
behavioral problems, and life interference were significantly
higher for the AS group than for the two comparison groups.

sperger syndrome (AS) is one of the five pervasive developmental disorders (PDDs) that share a cluster of
developmental problems in reciprocal social interaction, communication, and stereotyped interests and behaviors
(American Psychiatric Association [APA], 2000). AS is, however, a distinctive subtype of PDD, characterized by social
dysfunction and idiosyncratic interests, without clinically significant delay in language and cognitive development. Diagnosing individuals with AS is complicated. First, there is no
universal agreement on diagnostic criteria (Klin, Volkmar, &
Sparrow, 2000). Second, the term Aspe7ger syndrome is often
used synonymously with high-functioning autism (HFA),
characterizing those who function at the high end of the autistic spectrum disorders (ASD), a term used synonymously with
PDD (Ghaziuddin, 2002).Third, individuals with AS present
with high rates of comorbid disorders, which might delay or
obscure the diagnosis of AS (Sverd, 2003).
Common comorbid problems in the AS population indude emotional disorders such as anxiety and depression
(Ghaziuddin, Weidmer, & Ghaziuddin, 1998; Wing, 1981) as
well as behavioral disorders such as conduct disorder (CD),
oppositional defiant disorder (ODD), and attention-deficit/
hyperactivity disorder (ADHD) (Barnhill et al., 2000; Gillberg, 2002). Anxiety and depressive disorders are conceptual-

ized as "internalizing disorder," while behavior disorders are

considered "externalizing disorders" (Achenbach, 1985). Despite this evidence, most of the studies on comorbidity in AS
have focused mainly on depression, rather than anxiety and behavioral problems, which are the focus of the present study.

Comorbid Anxiety Disorders in

Adolescents With AS
In the PDD population, fears are very common and occur
more frequently than in nondisabled controls (Matson & Love,
1990). Clinically significant anxiety, which differs from fears
on level ofseverity, associated distress, and life interference, has
also been documented. For example, Gillott, Furniss, and Walter (2001) found that children with HFA reported significandy higher anxiety levels than typically developing children;
however, when compared to the clinically anxious population
mean, children with HFA obtained lower anxiety scores. On
the other hand, two studies using structured clinical interviews
found that individuals with PDD met full criteria for at least
one anxiety disorder (Muris & Steerneman, 1998; Rumsey.
Rapoport, & Sceery, 1985).
Clinicians have also observed high levels of anxiety in the
adolescent population (Attwood, 1998; Szatmari, 1991; Tantam, 2000; Wing, 1996). Despite these clinical accounts, as
well as the strong evidence that anxiety disorders are one of
the most common forms of adolescent psychopathology (Donovan & Spence, 2000), research on anxiety in adolescents with
AS is still lacking. However, the few studies that have emerged
in recent years found that both self- and parental reports show
that adolescents with AS have significantly higher levels of
anxiety than adolescents in the general population (Bellini,
2004; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000;
Tonge, Brereton, Gray, & Einfeld, 1999) and adolescents w,ith
CD (Green, Gilchrist, Burton, & Cox, 2000). In addition to

FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES

VOLUME 21, NUMBER 1, SPRING 2006
PAGES 25-35

FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES

26
these high internalizing symptoms, adolescents with AS have
high levels of externalizing problems (Kim et al., 2000). In
fact, levels of conduct and overactivity symptoms are so high
that adolescents with AS are sometimes misdiagnosed as having CD (Green et al., 2000) or ADHD (Attwood, 1998).

Comorbid Behavior Disorders in

Adolescents With AS
In a study by Green and colleagues (2000), adolescents with
AS and their parents reported levels of CD, ODD, and/or
ADHD as high as adolescents with CD, who like adolescents
with AS, show a failure of social adaptation, even though of a
different etiology. Kim and colleagues (2000) also found clinically relevant scores ofPADHD and ODD in 9- to 14-year-old
adolescents with AS; however, based on parental reports, these
adolescents did not reach clinically significantly levels of CD.
Tonge and colleagues (1999) found that the level of behavioral problems in adolescents with AS was higher than that
found in general childhood populations (Rutter, 1989) and
even higher than that found in populations with intellectual
disabilities (Einfeld & Tonge, 1996).
The point illustrated by these studies is that adolescents
with AS present with both emotional and behavioral problems.
But what are the risk factors for these comorbid problems in
adolescents? Apart from the complex interplay between biological, psychological, and environmental factors (Cooper,
2000), cognition has a major role in the development and
maintenance of internalizing and externalizing problems in
clinical and community samples of adolescents (Schniering &
Rapee, 2002, 2004a, 2004b).

Cognitive Factors in Adolescents

With AS
According to IFrith (1991), deficits in cognitive processes also
have a role in the multiple behavioral manifestations exhibited
by adolescents with AS. Individuals with AS have difficulties
in conceptualizing and appreciating the thoughts and feelings
of other people (Ozonoff & Miller, 1995). They are also rigid
in their thinking (Church, Alisanski, &Amanullah, 2000), which
makes them unable to learn from mistakes (Prior & Hoffmann, 1990), to cope with being wrong (Attwood, 1998),
and to change their behavior to meet environmental demands
(Szatmari, Bremner, & Nagy, 1989).
However, to our knowledge, there is no research investigating cognitive biases that may predispose or maintain anxiety and behavioral problems in adolescents with AS. On the
other hand, cognitive factors related to depression have been
investigated by two studies using the same sample of thirtythree 12- to 18-year-olds with AS (Barnhill, 2001; Barnhill &
Myles, 2001). Barnhill found a significant positive relationship

between depressive symptoms and ability attributions for social failure. Barnhill and Myles found that adolescents with AS
have a learned helplessness style, meaning that the more depressive symptoms reported by the adolescents, the more the
adolescents explained negative events by internal, stable, and
global causes. These results are consistent with studies involving clinical and nonclinical adolescents without AS, whose depressive symptoms were strongly predicted by thoughts on
personal failure (Schniering & Rapee, 2002, 2004a, 2004b).
These researchers also found that anxiety symptoms were
strongly predicted by thoughts on social threat, whereas externalizing symptoms were strongly predicted by thoughts on
hostility. Thus, research needs to be conducted to see if the
cognitions of adolescents with AS are also related to specific
internalizing and externalizing problems, which in the general
population have been found to be highly distressing, leading
to significant life interference (Schniering & Rapee, 2002).

Level of Distress and Life Interference in

Adolescents With AS
Adolescents with AS experience difficulties arising from their
core symptoms (Steyn &Le Couteur, 2003). In addition, they
have to deal with the transitional changes of adolescence,
which is a difficult time for many teenagers, but more so for
adolescents with AS, who have major problems with peer
group identification and peer relationships (Green et al., 2000).
In fact, Tantam (1991) asserted that AS may cause the greatest disability in adolescence, when social relationships are the
key to almost every achievement. Even though at times adolescents with AS do not consider themselves to be at risk for
any of these problems (Barnhill et al., 2000), these complexities dearly provide difficulties for them (Groden, Cantela,
Prince, & Berryman, 1994), affecting their overall life adaptation and leading to a highly disabling condition (Tantam,
2000). Thus it is important that adolescents with AS are identified as early as possible and provided with appropriate interventions.

The Present Study

Recent years have witnessed numerous studies on anxiety and
behavior disorders in adolescents, but the presence of these
problems in adolescents with AS has rarely been studied. In
the few studies that have been conducted, individuals with AS
demonstrated high levels of both anxiety and behavioral problems. However, none of these studies examined anxiety and
behavioral problems specifically in adolescents with AS and
used comparison groups to tease apart the specificity or generality of these problems.
It is important to examine anxiety and behavioral symptoms in adolescents with AS because they might represent ad-

VOLUME 21, NUMBER 1, SPRING 2006

27
ditional debilitating problems, which if left untreated might
lead to significant life interference and persist through adulthood. In addition, the potential comorbidity of these two
problems might increase the overall severity of the condition.
This comorbidity of emotional and behavioral problems, as
well as their impact on quality of life, are two other areas that
have not been covered in the studies of adolescents with AS.
In this population there is also a paucity of research on cognition, which in the general population has been found to be a
critical factor in the development and maintenance of both internalizing and externalizing disorders. The reviewed studies
on adolescents with AS were further limited because they
(a) used only one-tailed statistical analysis, thus predicting the
direction of the results, and (b) used either a parent or selfreport, between which there is a demonstrated low level of
agreement (Engel, Rodrigue, & Geften, 1994) that could
skew the results.
In an effort to address these issues, the present study examined anxiety symptoms in adolescents with AS and provided
two comparison groups, a group of individuals with anxiety
disorders (AD) and a group of individuals from the general
population (nonclinical; NC). The relationship betveen anxiety symptoms and negative automatic thoughts, behavioral
problems, and life interference was also examined. The methodology of this study was strengthened by the use of nondirectional two-tailed analyses and information obtained from
both adolescents and parents. The purpose of the present
study was to answer the following questions:
1. Are adolescents diagnosed wvith AS more likely to
experience symptoms of anxiety than adolescents in
the general population? And is the level of anxiety
experienced by adolescents with AS as high as that
experienced by adolescents with AD? It was anticipated
that adolescents with AS and adolescents wvith AD would
both manifest significantly higher levels of anxiety than
the NC group.
2. Do the three diagnostic groups differ significantly on
levels of negative automatic thoughts, behavioral problems, and life interference? Is there a correlation between
any of these three factors and anxiety symptoms? And
are the negative automatic thoughts correlated with the
anxiety and behavioral problems exhibited by adolescents
with AS?
It was expected that due to the equivalent levels of anxiety
symptoms exhibited by adolescents wiith AS and adolescents
with AD, both would exhibit more negative thoughts, behavioral problems, and life interference when compared to the NC
group. It was also anticipated that threat-based thoughts
would correlate with anxiety symptoms, whereas hostility cognitions would correlate wvith behavioral problems in all three
diagnostic groups.

Method
Participants
The sample consisted of 93 adolescents and one of their parents: 29 adolescents with AS, 34 adolescents with AD, and 30
NC adolescents. The 64 (69%) boys and 29 (31%) girls were
between 12 and 16 years of age, with a mean age of 13.8 years.
The AD and NC groups had similar proportions of boys and
girls, but the AS group had a higher boy to girl ratio, which is
consistent with the gender ratio found in the AS population
(AD: 19 boys, 15 girls; NC: 19 boys, 11 girls; AS: 26 boys,
3 girls).
Asperger Group. Adolescents with AS were recruited via
two sources: 20% from local support groups and the remaining 80% via the Autism Association of New South Wales
(NSW). All of the adolescents in this group had been diagnosed with AS by qualified mental health professionals: 31%
by psychiatrists, 28% by clinical psychologists, 21% by child pediatricians and clinical psychologists, 17% by child pediatricians, and one adolescent diagnosed by a clinical psychologist
and a psychiatrist. These adolescents were diagnosed within
the last 8 years in the following settings: private practice (55%);
the Autism Association of NSW (24%); Forestville Autism Australia (10%); and the Child and Family Health Center, Delphis
Anxiety, and Westmead Children's Hospital, with the latter
three settings diagnosing one adolescent each.
Anxious Group. Adolescents from the AD sample presented for assessment and treatment at the Macquarie University Child and Adolescent Anxiety Clinic, Sydney, Australia.
Postgraduate students in clinical psychology, under the supervision of experienced clinical psychologists, interviewed the
adolescents and their parents separately, using the Anxiety Disorders Interview Schedule for DSM-IV Child and Parent Version (ADIS-IV-C/P; Silverman & Albano, 1996). From the
assessed 88 participants, 54 met criteria for another disorder
in addition to anxiety. The present study included the 34 adolescents who only met criteria for anxiety disorders, with diagnosis based on interviews with both parents and adolescents.
The principal diagnosis in the AD group included the following: generalized anxiety disorder (41%), separation anxiety disorder (18%), social phobia (18%), obsessive compulsive disorder
(15%), specific phobia (6%) and panic (3%), with 73% diagnosed with more than one anxiety disorder.
Nonclinical Group. The NC group consisted of adolescents recruited from the community via an advertisement
placed in a local newspaper. To avoid bias, the advertisement
provided a general statement that the study was investigating
factors affecting adolescents. The inclusion criterion was that
these adolescents have never sought treatment from a mental
health professional. These participants were not interviewed

FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES

28
because we did not want to select a diagnosis-free group.
Rather, we wanted to make comparisons with a more normally
distributed nonclinical group. It is recognized, therefore, that
some of these adolescents may have met criteria for some
forms of psychopathology. Since the NC group was the most
difficult to recruit, these participants received monetary compensation.
Measures
Questionnaires. The Children'sAutomaticThoughts Scale
(CATS; Schniering & Rapee, 2002) is a self-report of negative
automatic thoughts in children aged 7-16 years. It consists of
40 items yielding a total score and four cognitive subscales:
(a) Physical Threat, (b) Social Threat, (c) Personal Failure, and
(d) Hostile Intent. The scale effectively discriminates between
nonclinical and clinical anxious, depressed, or behavior disordered children, with a mean total score for the community
group significantly lower than the mean for the anxious group
(mean difference = -25.88), the depressed group (mean difference = -30.52), and the behavior disordered group (mean
difference = -11.85). Internal consistency was also very high
(.95), and test-retest correlation coefficient for the total score
was .76 at 3 months (Schniering & Rapee, 2004a, 2004b).
The present study slightly modified the CATS self-report and
used it as an informant report for the AS group, in addition to
self-report.
The Spence Children'sAnxietyScale (SCAS; Spence, 1998)
is a measure of overall levels of anxiety in children and adolescents. In addition to the total score, it includes six subscales
based on DSM-IV criteria: (a) Panic/Agoraphobia, (b) Social Phobia, (c) Separation Anxiety, (d) Generalized Anxiety,
(e) Obsessive-Compulsiveness, and (f) Fears of Physical Injury,
with the latter closely resembling Specific Phobias in DSM-IV.
The SCAS has been found to have sound psychometric properties, with a convergent validity of .75 and an internal reliability coefficient of .93 and a Guttman split-half reliability of
.92 (Spence, Barrett, & Turner, 2003). The present study used
both the SCAS self-report and parent report, which correlate
well with each other, with parent-child agreement ranging
from .41 to .66 (Nauta et al., 2004).
The Strengths and DifficultiesQuestionnaire(SDQ; Goodman, 1997) is a brief behavioral screening measure consisting
of 25 positive and negative attributes that generates scores for
five subscales: (a) Emotional Symptoms, (b) Conduct Problems, (c) Hyperactivity/Inattention, (d) Peer Relationship Problems, and (e) Prosocial Behavior. The first four subscales are
added to provide a valid total difficulty score with an internal
reliability of.82 (Goodman, 2001). The SDQ reliability is satisfactory, whether judged by internal consistency (mean = .73),
cross-informant correlation (mean = .34), or retest stability up
to 6 months (mean = .62) (Goodman, 2001). In the present
study, adolescents completed the self-report version suitable
for ages 11 to 16, and parents completed the informant-rated

version, which covers the same 25 items, thus increasing comparability of scores obtained from children and parents (Goodman, Meltzer, & Bailey, 2003).
The Life InterferenceMeasure (LIM; Lyneham, Abbott, &
Rapee, 2003) is a new self-report questionnaire consisting of
31 items scored on a scale from 0 to 4, which when added together give a global life interference score. The self-report version was slightly modified and used as an informant report for
the AS group. This measure has not yet been analyzed for psychometric properties; however, an analysis using the data from
the present study showed high internal reliability for both
the adolescents' (alpha = .95) and parents' (alpha = .91) total
score.
Additional Questions. In addition to completing the
four questionnaires (SCAS, SDQ, CATS, LIM), the parents of
adolescents with AS were asked to answer the following six additional questions written by the researchers: (a) In which
clinic/center was your child diagnosed? (b) Which of these
professionals (child pediatrician, clinical psychologist, psychiatrist, other) diagnosed your child? (c) How long ago was your
child diagnosed? (d) Has your child ever been given psychological treatment? If yes, what type of treatment? (e) Has your
child ever been given treatment for anxiety symptoms? If yes,
what type of treatment? (f) Is your child taking any medication? If yes, what type of medication and for what problem?

Procedure
This research was approved by Macquarie University Ethics
Review Committee, the Macquarie University Anxiety Research Unit, and the Education and Research Committee of
the Autism Association of NSW.
In the AD group, parents seeking treatment for their children's anxiety contacted the Child and Adolescent Anxiety
Clinic for an initial assessment. The clinic sent the family the
information/consent form to be signed by parents and adolescents, as well as the four parent questionnaires (SCAS,
CATS, SDQ, LIM) and the two self-questionnaires (SCAS,
SDQ). Participants returned the questionnaires and consent
form at the time of the assessment; postgraduate clinical psychology students interviewed the parents and adolescents separately, using the ADIS-IV-C/P.
In the AS group, an information sheet explaining the nature of the present study was sent to five AS support groups.
The parents of interested participants were asked to contact
the researchers by phone. The self-report and parent report of
the four questionnaires (SCAS, CATS, SDQ, LIM) were sent
to these participants, together with the six additional questions
and the information/consent form. Parents and adolescents
were asked to separately fill in the questionnaires, which would
take approximately a half hour, and return them in the selfaddressed envelope. Recruitment of other adolescents with AS
was completed through the Autism Association of NSW. One

VOn1MF

"21, NUMBER

1, SPRING 2006

29
hundred self-addressed envelopes, each containing the package of questionnaires, additional questions, and information/
consent forms, were given to the principals of four different
schools, situated at Central Coast, South East Sydney, Western Sydney, and North Sydney, who sent the envelopes to the
families of students with AS; participation was voluntary. To
attend these particular schools, the adolescents had to have
been diagnosed with AS by qualified mental health professionals.
To validate the self-report method of this study, rather than
relying only on the answers provided by adolescents Nith AS,
who might have misunderstood the items due to their difficulties with abstract terms, a parent version of each measure
was included, thus increasing our confidence that the results
obtained are reliable.
In the NC group, those interested were asked to contact
the researchers by phone. After ensuring that they had never
sought treatment from mental health professionals, the researchers sent them a self-addressed envelope containing the
SCAS and SDQ parent version and the SCAS, CATS, SDQ,
and LIM self version, together with the information/consent
form. Participants indicated their willingness to participate in
the study by returning the signed consent form, together with
the completed questionnaires, to the researchers. These participants then received monetary compensation for their participation.

Results
PreliminaryAnalyses
Gender. Although the three diagnostic groups differed
significantly with respect to gender, c2(2, N = 93) = 8.94,
p < .05, no significant difference was found between male and
female scores on the administered measures, so gender was not
used as a covariate in later analyses.
Age. The adolescents' age was not significantly different
across the three diagnostic groups, F(2, 90) = .78, p > .05 (AS
group, M = 13.76, SD = 1.27; AD group, M = 13.82, SD =

1.29; NC group, M= 13.90, SD = 1.56). In addition, no significant correlation was found between age and anxiety levels
as measured by the SCAS self-report total score: AS group,
r(29) = .27, p > .05; AD group, r(34) = .07, p > .05, and NC
group, ;(30) = .35, p > .05.

TABLE 1
Correlation Between Adolescent Self-Reports and Parent
Reports in Each Group on All Four Measures
Asperger
(n = 29)

Anxious
(n = 34)

Nonclinical
(n = 30)

SCAS

.697"*

.527**

.433*

CATS

.727**

SDQ

.515**

.566**

.410*

LIM

.688**

Measure

Note. SCAS = Spence Children'sAnxiety Scale (Spence, 1998); CATS =

Children'sAutomatic Thoughts Scale (Schniering & Rapee, 2002); SDQ
Strengths and Difficulties Questionnaire(Goodman, 1997); LIM = Life
Interference Measure (Lyneham, Abbott, & Rapee, 2003). Dashes indicate
that the CATS and LIM measures were not administered to parents of
adolescents in the anxiety disorders and nonclinical groups.
*p < .05. -p < .01.

Correlation Between Adolescent and

Parent Reports
Table 1 shows a significant positive correlation between adolescents' total scores and parents' total scores on all the ad-

ministered questionnaires, in all the three diagnostic groups.

It is important to note that the adolescents with AS and their
parents correlated highly on the total scores of all four measures, thus giving confidence in the AS adolescents' selfreport. Therefore, future analyses comparing the three diagnostic groups will only utilize the adolescent self-reports.

Anxiety as Measured by SCAS

The three diagnostic groups differed significantly on levels of
anxiety as measured by the SCAS total score, F(2, 90) = 10.89,
p < .05. Table 2 shows that both the AS and AD groups scored
significantly higher than the NC group on all the SCAS subscales, except the Fears of Physical Injury subscale, where no
significant difference was found across the three groups, F(2,
90) = 2.78, p > .05. Adolescents with AS scored highest on
symptoms of Obsessive-Compulsiveness, Social Phobia, Generalized Anxiety, Separation Anxiety, Panic/Agoraphobia, and
Fears of Physical Injury, respectively.

Behavioral Difficulties as Measured

by SDO
Analyses
Differences betveen the three diagnostic groups were investigated using one-way analysis of variance (ANOVA). The dependent measures for the analyses included the raw total scores
and subscales of the SCAS, CATS, SDQ, and LIM, both parent and self-report. A Bonferroni correction was used to adjust
for inflation of the Type 1 error rate on follow-up comparisons.

Table 3 shows that adolescents in the three diagnostic groups

scored significantly differently on behavioral difficulties, F(2,
90) = 21.56, p < .05, with the AS group having the highest
level of behavioral problems, followed by the AD and NC
groups, respectivel)y The AS sample also scored significantly
higher than both comparison groups on the Hyperactivity/
Inattention and Peer Relationship Problems subscales. No sig-

FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES

30
TABLE 2
Means and Standard Deviations on Adolescent Self-Reports and Parent Reports for SCAS Measure Across Groups
Nonclinical
(n 30)

Anxious
(n = 34)

Asperger
(n = 29)
M

SD

SD

SD

34.38a
3.79a
7.38a
4.93a

21.54
3.01
4.47
4.92

30.26a
2.59a
4.91a
4.71a

18.45
2.50
4.10
5.03

13.70b
2.20a
1.83b
1.30b

13.75
2.63
2.65
2.47

Social Phobia

6.97,

5.05

6.59a

4.31

3.37b

2.87

Separation Anxiety

5.17a

4.66

4.56a

3.23

1 .8 7

3.36

Generalized Anxiety

6.14a

4.49

6.91 a

3.83

3.13b

Measure
SCAS (Total Score)
Fears of Physical Injury
Obsessive-Compulsiveness
Panic/Agoraphobia

2.78

Note. SCAS = Spence Children'sAnxiety Scale (Spence, 1998). Means with different superscripts differ significantly at p < .05.

TABLE 3
Means and Standard Deviations on Adolescent Self-Reports and Parent Reports for SDQ, CATS,
and LIM Measures Across Groups
Nonclinical
Anxious
Asperger
(n

(n =29)
Measure

SD

(n =30)

34)

SD

SD

18.45a
4.55a
2.76a

5.64
3.04
1.66

13.03b
4.91 a
2.18a

6.06
2.02
1.68

8.93c
1.73b
2.13a

4.74
1.78
1.50

5.93a
5.21,
6.93a

2.02
2.69
1.98

4.00b
1 .9 4 b
6.91a

2.39
2.07
2.25

3 .3 4 b

7.31a

1.97
1.94
2.63

CATS (Total Score)

47.03a

28.21

27.88b

27.43

18 .67b

14.40

Physical Threat
Social Threat

9.76a
12.31 a

7.88
8.89

4 .97 b
7.82ab

7.45
9.61

2.77b
3.67b

3.69
4.42

Personal Failure

10.34a

9.80

6.94a

8.97

2 .4

3b

3.65

14.62a

8.02
25.29

8.15b
24.27b

7.37
20.13

9.80b

6.72
15.70

SDQ (Total Score)

Emotional Symptoms
Conduct Problems
Hyperactivity/Inattention
Peer Relationship Problems
Prosocial Behavior

Hostile Intent
LIM (Total Score)

53.07a

1 .5 3 b

17

.9 0 b

Note. SDQ = Strengths and Difficulties Questionnaire (Goodman, 1997); CATS = Children'sAutomatic Thoughts Scale (Schniering & Rapee, 2002); LIM = Life
Interference Measure (Lyneham, Abbott, & Rapee, 2003). Means with different superscripts differ significantly at p < .05.

nificant difference was found between the three groups on the

Prosocial Behavior, B(2, 90) = .286, p > .05, or the Conduct
Problems subscale, F(2, 90) = 1.39, p > .05.

Negative Automatic Thoughts as

Measured by CATS
The three diagnostic groups differed significantly on negative
automatic thoughts as measured by the CATS total score, F(2,
90) = 10.46, p < .05, and subscales: Physical Threat, F(2,
90) = 8.55, p < .05; Social Threat, F(2, 90) = 8.51, p < .05;
Personal Failure, .F(2, 90) = 7.31, p < .05; and Hostile Intent,
_F(2, 90) = 6.35, p < .05. As shown in Table 3, adolescents

with AS scored significantly higher than both the AD and NC

groups on the CATS total score. Analysis of the CATS subscales revealed that the AS group also scored significantly
higher than the NC group on all the subscales, whereas scores
for the AS and AD groups were equivalent on the Physical
Threat and Hostile Intent subscales.

Life Interference as Measured by LIM

Table 3 also shows a significant difference between the three
diagnostic groups on levels of life interference as measured by
the LIM total score, .F(2, 90) = 24.37, p < .05. Adolescents
with AS scored significantly higher on the LIM total score than
both comparison groups.

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31

CorrelationsBetween the Four Measures

As shown in Table 4, a significant positive correlation was found
between the total scores of all four measures, across the whole
sample. The more negative the automatic thoughts measured
by the CATS, the higher the anxiety levels measured by the
SCAS, the more behavioral problems measured by the SDQ,
and the higher the life interference measured by the LIM.
More specifically, a significant positive correlation was found
between the Social Threat subscale of the CATS and the SCAS
total score, 7(93) = .726, p < .01. That is, the more negative
thoughts of social threat, the higher the adolescents' level
of anxiety symptoms in all the three diagnostic groups: AS,
r(29) = .797, p < .01; AD, r(34) = .608, p < .01; NC, r(30) =
.653, p < .01. Similarly, a significant positive correlation was
found between the Physical Threat subscale of the CATS and
the SCAS total score, r(93) = .752, p < .01, in all three diagnostic groups: AS, r(29) = .839, p < .01; AD, r(34) = .614,
p < .01; NC, r(30) = .809, p < .01. A significant positive correlation was also found between the Hostile Intent subscale of
the CATS and the SDQ behavioral problem score, r(93) =
.481, p < .01; however, this was only the case for the AD
group, r(34) = .602, p < .01, and NC group, r(30) = .428,
p < .05, with no significant correlation found in the AS group,
r(29) = .244, p > .05.

Discussion
The results of the present study support what we anticipated,
that adolescents with AS have high levels of anxiety equivalent
to adolescents with anxiety disorders (AD) and significantly
higher than adolescents in the general population (NC). And
beyond what we originally expected, the positively correlated
negative automatic thoughts, behavioral problems, and life interference were significantly higher for adolescents with AS
than for the comparison groups.
The obtained results support previous research indicating
that individuals with PDD, including adolescents with AS,
have significantly more anxious symptoms than the general
population (Bellini, 2004; Gillott et al., 2001; Green et al.,
2000; Kim et al., 2000; Muris & Steerneman, 1998; Rumsey
et al., 1985; Tonge et al., 1999), and contradict the findings
of Gillott and colleagues (2001), where children with -IFA
obtained lower anxiety scores than the clinically anxious population. As in most of these studies, adolescents with AS in the
present study reported Obsessive-Compulsiveness, Social Phobia, and Generalized Anxiety symptoms as the highest anxiety
symptoms, respectively. Interestingly, these match the highest
anxiety symptoms experienced by the AD group, though not
in the same order. The AS group scored as high as the AD
group and significantly higher than the NC group on every
anxiety subscale of the SCAS except the Fears of Physical
Injury subscale, where no significant difference was found between the three diagnostic groups. This is contrary to the find-

TABLE 4
Correlations Between Total Scores on the Four

Measures Across the Three Groups

Measure

SCAS

SCAS

CATS

SDQ

LIM

.783**

.720**

.694**

.748**

.852**

CATS

.783*

SDQ

.720**

.748**

LIM

.694"

.852**

.770**
.770**

Note. SCAS = Spence Children'sAnxiety Scale (Spence, 1998); CATS Children's Automatic Thoughts Scale (Schniering & Rapee, 2002); SDQ =
Strengths and Difficulties Questionnaire(Goodman, 1997); LIM = Life
Interference Measure (Lyneham, Abbott, & Rapee, 2003). Dashes indicate
that the CATS and UM measures were not administered to parents of
adolescents in the AD and NC groups.
*P < .01.

ings of Matson and Love (1990), who reported that specific

fears in children with autism occur more frequently than in
nondisabled controls. These different results could be due to
the fact that fears of children with autism are different from
the fears of adolescents with AS. Or it may simply be that the
presentation of anxiety changes from childhood to adolescence. In fact, studies with clinically anxious children found
that specific phobia decreases during adolescence (King, 01lendick, & Mattis, 1994).
Apart from these high levels of anxiety, the present study
also found that adolescents with AS have significantly higher
behavioral problems than both the AD and NC groups. These
results, however, could be due to the exclusion of adolescents
from the anxious group who met criteria for any other disorder in addition to anxiety. Nonetheless, these results are consistent with the findings ofprevious studies (Green et al., 2000;
Kim et al., 2000; Tonge et al., 1999) showing that adolescents
with AS present with significantly higher externalizing problems than the general population. Although self- and parental
reports of the present study showed that adolescents with AS
have significantly higher levels of ADHD than both comparison groups, contrary to Green and colleagues (2000), no significant difference was found between the three diagnostic
groups on levels of CD. This is, however, consistent with the
findings of Kim and colleagues (2000), where adolescents with
AS did not reach clinically significant levels of CD.
Notably, the results of the present study indicate that adolescents with AS have clinically significant levels of both anxiety and behavioral problems, which despite their obvious
dissimilarities, have been found to be significantly correlated
with each other. This significant positive correlation between
anxiety and disruptive behaviors has also been found in another
study of adolescents with AS (Kim et al., 2000) and studies
involving adolescents with clinical symptomology (Anderson,
Wifliams, McGee, & Silvia, 1987; Last, Strauss, & Francis,
1987).

FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES

32
Studies in both clinical and community samples have shown
that anxiety, depression, and externalizing problems are related to specific negative automatic thoughts (Schniering &
Rapee, 2002, 2004a, 2004b). This was also found across the
whole sample of the present study, where anxiety symptoms
measured by the SCAS were strongly correlated to thoughts
on social threat and physical threat as measured by the CATS.
The externalizing symptoms measured by the SDQ were also
strongly correlated with hostility cognitions as measured by
the CATS; however, this was only the case for the AD and NC
groups. In the AS group, externalizing problems were not correlated with hostility cognitions, even though these adolescents scored significantly higher than the two comparison
groups on both externalizing problems and thoughts of hostility. Thoughts related to depression could not be examined
because no measure of depression was administered in this
study; however, adolescents with AS scored similarly to the AD
group and significantly higher than the NC group on the
CATS Personal Failure subscale, which is associated with depression. This is consistent with the pessimistic, failure-prone
style of thinking found in adolescents with AS (Barnhill, 2001;
Barnhill & Myles, 2001).
Cognitive factors have also been found to differentiate between children with nonclinical symptomology and children
with clinically significant problems (Schniering & Rapee, 2002,
2004a, 2004b). In the present study, adolescents with AS not
only scored significantly higher than both comparison groups
on negative automatic thoughts as measured by the CATS
total score, but also scored significantly higher than the NC
group on every subscale of the CATS, and significantly higher
than the AD group on the Physical Threat and Hostile Intent
subscales of the CATS. Interestingly, the AD and NC groups
scored similarly to each other on every subscale of the CATS
except for the Personal Failure subscale, which was significantly higher for adolescents with AD. This finding contradicts
the good discriminant validity found between clinically anxious youth and nonclinical youth reported in Schniering and
Rapee (2002, 2004a, 2004b). It would have been of valuable
clinical information to have administered the parent reports of
this measure to the AD and NC groups, to see if the parents'
report would have supported the self-reports.
Internalizing and externalizing problems in clinical and
nonclinical adolescents have been found to be highly distressing and lead to significant interference in important areas of
functioning (Schniering & Rapee, 2002). This was also the
case in the present study, where adolescents with AS revealed
significantly higher levels of life interference than both the AD
and NC groups, which was also significantly correlated with
their high levels of anxiety and behavioral problems.
Interestingly, in the AS group, the self-reported scores of
anxiety, behavioral problems, negative automatic thoughts,
and life interference were correlated significantly with their
parents' report, which was also the case across the whole
sample. This contradicts studies in clinical and nonclinical populations, which have consistently shown poor concordance
between parent and child reports across measures of anxiety

(Engel et al., 1994), with an even weaker correlation for behavioral problems (Rey, Schrader, & Morris-Yates, 1992). Research into children's development found that the accuracy of
self-reports depends on the child's cognitive development, language skills, understanding of emotions, self-awareness, and
perception of others. Adolescents with AS have major problems with all these skills, yet they still correlated highly with
their parents, going against the assertions that adolescents with
AS lack insight into their own problems (Toichi et al., 2000)
or deny the existence of their problems (Barnhill et al., 2000).
Two other studies on adolescents with AS (Bellini, 2004;
Green et al., 2000) have also found that parental reports mirrored the self-reported scores. It is worth noting that the selfand parental reports of both the anxiety measure and problem
behavior measure used in the present study correlate well with
each other (Goodman et al., 2003; Nauta et al., 2004).
So, what could be the possible explanations for the significantly higher anxiety symptoms and behavioral problems in
adolescents with AS, which are supported by both self- and
parental reports? These could simply be reactions to having to
deal with the difficulties arising from their core symptoms.
However, if these are only seen as a direct consequence of the
disorder, appropriate treatment would not be provided, leading to greater severity and impact on life interference. In addition, the cognitive factors acting as potential mediators for
both anxiety and behavioral problems have not been given
enough attention in this population; thus the current available
treatment may not be targeting these cognitions. Another potential explanation could be the peer relationship problems experienced by these adolescents with AS, who on this subscale
of the SDQ scored significantly higher than both the AD and
NC groups. This is consistent with studies reporting major
problems with peer relationships in adolescents with AS (Green
et al., 2000). Studies in the general population have also found
that negative peer interactions may contribute to the emergence of anxiety and behavioral problems (Ginsburg, La Greca,
& Silverman, 1998; La Greca & Lopez, 1998).
Regardless, these complexities are clearly providing difficulties for adolescents with AS. Thus it is important that these
coexisting problems be identified as early as possible and treated.
Anxiety symptoms and related cognitions might be responsive
to cognitive behavior therapy (Hare, 1997; Hare & Paine,
1997), while disruptive behaviors can be modified by educational interventions (Schreibman, 2000), behavioral modification techniques (Buschbacher & Fox, 2003; Myles &
Southwick, 1999), and social skills training (Khouzam, ElGabalawi, Pirwani, & Priest, 2004; I(rasny, Williams, Provencal, & Ozonoff, 2003). Pharmacotherapy has also been used
to treat coexisting conditions in adolescents with AS (Buitelaar & Willemsen-Swinkels, 2000; Gordon, 2000; McDougle,
Price, & Volkmar, 1994).
In the present study, in addition to collecting symptom
data, the parents in the AS group were also asked questions regarding any previous treatments received by the adolescents
with AS. These results are not reported in this paper; nonetheless, they will be briefly discussed. Despite the significantly

VOLUME 21, NUMBER 1, SPRING

ZUVO

33
high scores on symptoms and life interference, only a small
percentage of adolescents with AS have received psychological
treatment, treatment for anxiety symptoms, and/or pharmacological treatment for anxiety symptoms. And those adolescents who did receive treatment did not score lower on any of
the measures when compared to adolescents who did not receive any treatment. These self-reports, however, were contradicted by the parents' report, where a significant difference in
the level of negative automatic thoughts was found between
those adolescents taking anxiety medication and those not taking medication. The parents' report also showed that those
adolescents receiving psychological treatment experienced significantly lower rates of anxiety symptoms than those not receiving psychological treatment. Interestingly, treatment for
anxiety symptoms was the only intervention not reaching significant difference on parental report. However, it is still unclear whether the treated adolescents would have scored much
higher without the treatment, or whether the interventions
were ineffective for this group. Regardless, due to the small
number of adolescents receiving treatment, caution should be
used in generalizing these results.
Hare and Paine (1997) reported that no single therapy
appears to be generally effective with the AS population. In
addition, a recent study by Bellini (2004) filed to show a significant difference between adolescents with AS taking medication for anxious symptoms and those not taking medication
on both self- and parental reports. This lack of positive treatment outcomes could be due to the heterogeneous nature of
AS and the problems it encompasses (Blackshaw, Kinderman,
Hare, & Hatton, 2001) or to the way these individuals view
the client-therapist relationship and their rigid way of interacting with the therapist (Hare, 1997). It could also be due to
the fact that these interventions have not been thoroughly
evaluated for beneficial outcomes in the AS population (Attwood, 1998; Kin et al., 2000); 80% of the psychopharmacological interventions used to treat children have only been
empirically tested on adults (Riddle, Kastelic, & Frosch, 2001).
Adolescents with AS may not be receiving the help they require; thus there is a particular need to develop more appropriate clinical and pharmacological interventions for the AS
population.

candy limits the ability to make generalizations. Sample selection was another limitation. The AS group was informed about
the nature of the study, which might have skewed the sample
toward adolescents already suspected of having anxiety. Another limitation is that no information was collected regarding
comorbid conditions for the adolescents with AS, which might
have underestimated or overestimated the results. Further, the
LIM, unlike the other three highly reliable and valid measures
used in the present study, was developed recently and its psychometric properties have not been thoroughly tested; thus
the LIiM findings are tentative and need to be replicated. In
addition, none of the four administered measures have been
standardized on adolescents with AS, and only the SCAS has
been previously used for research in this population. The modifications of the CATS and LIM self-report to an informantrated measure might have affected analysis and interpretation
of results; however, the items of these two measures have performed as expected, and a significant positive correlation was
found between adolescents' total scores and parents' total
scores on both measures in all the three diagnostic groups. Additionally, due to the abstract language found in these measures, some might question the utility of these self-reports for
the AS sample, especially since no information regarding cognitive functioning of the adolescents with AS was collected;
however, this study found a high correlation between parent
and self-report on all four measures, supporting the reliability
of the results.
Suggestions for Future Research
As this is the first study of its kind, there is need for replication studies that would address methodological and research
design limitations. Larger samples of children from a broader
age range would provide generalizability of results. Selecting
participants who are unaware of the exact purpose of the research would avoid biasing the sample. Apart from self-reports
and informant-rated measures, the additional use ofstructured
diagnostic interviews with both parents and children would
provide means for clinical diagnoses. Applied studies are needed
to provide evidence-based interventions.
Conclusions

Clinical Implications
The results of the present study have clear implications for clinicians assessing and treating adolescents with AS. Adolescents
with AS must be assessed for comorbid anxiety and behavioral
problems, related negative automatic thoughts, and their impact on life interference. The design and implementation of
treatment interventions should address all these factors and be
tailored specifically for adolescents with AS.
Limitations of the Study
This study is not without limitations. The low response rate
and hence small sample size of adolescents with AS signifi-

This study has several unique features: (a) It used both selfand parental reports to investigate anxiety in adolescents with
AS; (b) it provided AD and NC comparison groups; and (c) it
examined the comorbidity between anxiety symptoms and
negative thoughts, behavioral problems, and life interference.
The significant positive correlation between parental and
self-reports of the present study confirms that adolescents xvwith
AS report levels of anxiety equivalent to those of adolescents
with AD and significantly higher anxiety symptoms than adolescents in the general population. Across the whole sample,
anxiety symptoms have been found to be significantly correlated with negative automatic thoughts, behavioral problems,
and life interference, all of which where significantly higher for

FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES

34
adolescents with AS than for the two comparison groups. According to self-reports, treatment did not significantly lower
anxiety symptoms and behavioral problems in adolescents with
AS as compared to adolescents with AS not receiving treatment. In summary, the results of the present study reveal the
need for better assessment, diagnosis, and treatment of comorbid anxiety and behavioral disorders in adolescents with
AS.

ABOUT THE AUTHORS

Sylvana Farrngia,M.Psych (Clinical),graduatedwith a master's in

clinicalpsychology from Macquarie University, Sydney, Australia. Her
current interests include anxiety disorders, and pervasive developmental disorders.JenniferHudson, PhD,is currently a researchfellow and
senior lecturer at Macquarie University, Sydney, Australia. Her research interests include child and adolescent anxiety disorders.Address:
Sylvana Farrugia,Department of Psychology, Macquarie University,
42-48,BurleyRoad, HorsleyPark,Sydney, Australia;e-mail:farrqgiasyl@
yahoo.com

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TITLE: Anxiety in Adolescents With Asperger Syndrome:

Negative Thoughts, Behavioral Problems, and Life
Interference
SOURCE: Focus Autism Other Dev Disabil 21 no1 Spr 2006
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