Treating Anxiety in Autistic Children: What Happens When ADHD is Also Present?
Autistic children face higher rates of mental health challenges compared to their non-autistic peers, with anxiety and ADHD being widespread. When these conditions occur together, parents and clinicians often wonder whether standard treatments will still be effective. A new study provides reassuring answers about cognitive behavioural therapy for anxiety in autistic children who also have ADHD.
The Challenge of Multiple Conditions
Mental health conditions rarely occur in isolation, and this is especially true for autistic children. Research shows that approximately 40% to 50% of autistic children have two or more co-occurring mental health conditions, compared to less than 15% of non-autistic children. Anxiety and ADHD represent the most frequent combination, creating complex challenges for families and treatment providers.
When multiple conditions are present, questions naturally arise about treatment effectiveness. Will therapy designed for anxiety work as well when ADHD symptoms like difficulty concentrating and hyperactivity are also present? This study set out to answer that question.
Understanding the Research
Researchers analyzed data from 167 autistic children aged 7 to 13 who participated in anxiety treatment trials. These children received either standard cognitive behavioural therapy, autism-adapted CBT, or treatment as usual. What made this study particularly valuable was its focus on children who had both anxiety and ADHD, which represented 62% of the participants.
The researchers wanted to understand three key questions: whether ADHD would make anxiety treatment less effective, whether treating anxiety might also help ADHD symptoms, and whether improvements in one condition were related to improvements in the other.
The results were encouraging for families dealing with both conditions. ADHD did not predict worse outcomes for anxiety treatment. Children with ADHD responded just as well to cognitive behavioural therapy as those without ADHD, whether they received standard CBT or autism adapted versions.
This finding challenges concerns that ADHD symptoms might interfere with a child's ability to engage with and benefit from anxiety treatment. The structured approach of CBT, which teaches specific coping strategies and employs gradual exposure to fears, appears robust enough to work effectively even when attention and hyperactivity challenges are present.
Unexpected Benefits for ADHD
A surprising finding is that treating anxiety also led to improvements in ADHD severity. When children received CBT for their anxiety, evaluators noticed reductions in ADHD related impairment, though parent reports of ADHD symptoms didn't show the same pattern.
This difference between evaluator and parent perspectives might reflect how CBT helps families manage challenges more effectively, even if core symptoms remain present. The therapy process may equip parents and children with better strategies for navigating ADHD related difficulties, reducing their overall impact on daily functioning.
The Connection Between Conditions
The study revealed a relationship between improvements in anxiety and ADHD. As children's anxiety symptoms decreased through treatment, their ADHD symptoms and severity also tended to improve. This suggests the conditions may influence each other in important ways.
For autistic children, executive functioning difficulties that affect planning, attention, and emotional regulation may represent a common pathway linking anxiety and ADHD. When anxiety treatment helps children develop better coping strategies and emotional regulation skills, these improvements may naturally extend to managing ADHD related challenges.
What This Means for Families
These findings offer hope for families navigating the complexity of multiple conditions. Parents can feel confident that existing CBT programs designed for anxiety are appropriate and effective for their autistic children, even when ADHD is also present. The treatment doesn't become less effective because of ADHD, and it may provide unexpected benefits for attention and hyperactivity concerns.
The research also suggests that addressing anxiety first, rather than trying to treat all conditions simultaneously, can be a reasonable approach. The improvements in ADHD that occurred alongside anxiety treatment indicate that focusing on one condition may create positive ripple effects for others.
Implications for Treatment Planning
For clinicians and families making treatment decisions, this research supports the use of established anxiety treatments without major modifications for ADHD. Both standard CBT and autism adapted versions showed similar effectiveness for children with co-occurring ADHD.
The study participants had anxiety as their primary concern, with ADHD as a secondary condition. For families where ADHD is the main challenge, additional research is needed to understand how these findings might apply.
This research contributes to growing understanding of how mental health conditions interact and respond to treatment. The finding that anxiety treatment can positively impact ADHD symptoms opens questions about the mechanisms behind these improvements.
Future research may help identify which specific aspects of CBT create benefits for ADHD, potentially leading to more targeted and effective treatments. Understanding whether certain ADHD symptoms are more responsive to anxiety treatment could also help personalize treatment approaches.
The study also highlights the importance of considering how conditions interact with one another, rather than viewing them as completely separate challenges. For autistic children, who often face multiple mental health conditions, this interconnected perspective may lead to more effective and efficient treatment strategies.
Ng‐Cordell, E., Storch, E. A., Kendall, P. C., Wood, J. J., Mikami, A. Y., & Kerns, C. M. (2025). Implications of cooccurring ADHD for the cognitive behavioural treatment of anxiety in autistic children. Journal of Child Psychology and Psychiatry.
For now, families can take comfort in knowing that effective anxiety treatment remains available and beneficial for autistic children, regardless of whether ADHD is also present. The therapy process may offer broader benefits than originally expected, helping children develop skills that support their overall wellbeing and functioning across multiple areas of their lives.
Different Ways of Delivering CBT Therapy: What Works Best for Anxiety?
When it comes to treating generalized anxiety disorder, cognitive behavioural therapy (CBT) has long been considered one of the most effective approaches. But as mental health services evolve and technology advances, researchers are asking an important question: Does it matter how this therapy is delivered?
A new study examined data from 52 clinical trials involving over 4,300 people with generalized anxiety disorder to compare three main ways of receiving CBT: traditional one on one sessions with a therapist, group therapy sessions, and remote therapy delivered through digital platforms.
What the Research Revealed
Individual therapy sessions emerged as the most effective format, showing greater results compared to remote therapy, standard care, and waiting lists. This traditional approach appears to maintain its edge in helping people manage their anxiety symptoms.
Group therapy also demonstrated strong effectiveness, particularly when compared to no treatment at all. The researchers found that group sessions produced notably positive results, with effect sizes that were actually larger than individual therapy in some measures, though the direct comparison between individual and group therapy didn't show a significant difference.
Remote therapy, while still beneficial compared to no treatment in some analyses, showed the most mixed results. It did not prove superior to standard care or waiting lists in the main network analysis, though it did show benefits in direct comparisons with waiting lists.
Why These Differences Matter
The effectiveness of individual therapy likely stems from the personalized attention and strong therapeutic relationship that develops between patient and therapist. This one on one connection allows for tailored treatment approaches and immediate feedback, which can be particularly valuable for addressing the complex worry patterns characteristic of generalized anxiety disorder.
Group therapy's strong showing might surprise some people, but it offers unique advantages. Participants can learn from others facing similar challenges, provide mutual support, and practice new skills in a social setting. The group dynamic can create a sense of community and reduce the isolation often felt by those struggling with anxiety.
The more modest results for remote therapy highlight some current limitations of digital mental health approaches. While convenient and accessible, remote therapy may lack some of the interpersonal connection that makes therapy effective. The researchers suggest that future developments might focus on enhancing how therapists establish relationships with patients in digital settings or creating virtual group environments that promote more effective patient interaction.
For people seeking CBT for anxiety, these findings suggest several considerations. Individual therapy remains a gold standard option, particularly for those who can access it readily. However, group therapy emerges as a viable and potentially equally effective alternative that may also be more cost effective and accessible.
The research indicates that group CBT could help address the shortage of mental health services by allowing therapists to work with multiple patients simultaneously while maintaining effectiveness. This could be particularly valuable in areas where mental health professionals are scarce or where cost is a significant barrier to treatment.
Remote therapy, while showing promise, may work best as a supplement to other forms of treatment rather than a complete replacement, at least with current technology and approaches. As digital mental health tools continue to evolve, future versions may prove more effective.
The study involved participants ranging from children to older adults, providing a broad view of CBT effectiveness across age groups. However, the researchers note that responses to different therapy formats may vary among different patient populations, suggesting that personalized approaches to treatment selection could become increasingly important.
The research also underscores the importance of ongoing innovation in mental health service delivery. As demand for mental health services continues to rise, understanding how to deliver effective treatment in various formats becomes increasingly crucial for meeting population needs.
For mental health providers, these findings support maintaining individual therapy as a primary treatment option while considering group therapy as a valuable alternative. The results also suggest that improvements in remote therapy delivery methods could enhance their effectiveness in the future.
This research provides valuable guidance for anyone navigating anxiety treatment options, offering evidence based insights into what approaches are most likely to provide relief from the persistent worry and distress that characterize generalized anxiety disorder.
Liu, S., Xiao, H., Duan, Y., Shi, L., Wang, P., Cao, L., ... & Qiu, C. (2025). CBT treatment delivery formats for generalized anxiety disorder: a systematic review and network meta-analysis of randomized controlled trials. Translational Psychiatry, 15(1), 197.
Taking Therapy Outside: What Happens When Therapists and Patients Walk and Talk in Nature
Most therapy happens in offices, with the therapist and patient sitting across from each other in a controlled, private environment. But what if therapy took place while walking through a forest instead? A recent study from Germany examined the experiences of therapists who transitioned their sessions outdoors, providing valuable insights into this alternative approach to mental health treatment.
Researchers at a German clinic interviewed seven therapists who had conducted sessions both in traditional office settings and while walking through nature with their patients. The outdoor sessions followed a predetermined 50 minute route that started at the clinic, wound through a nearby forest, and returned to more urban areas before ending back at the clinic.
The Appeal of Outdoor Therapy
The idea of combining therapy with nature and movement isn't entirely new. Even Sigmund Freud, often considered the father of modern psychotherapy, conducted some of his training sessions while walking. Today, there's growing interest in what researchers call "ecotherapy" approaches that incorporate natural settings into mental health treatment.
Research shows that psychotherapy, exposure to nature, and mild exercise each provide mental health benefits on their own, particularly for people with depression. The question is whether combining all three elements might create even greater benefits.
What Therapists Discovered Outside
The therapists who participated in the study found several notable advantages to conducting sessions while walking in nature. Many reported feeling a deeper connection with their patients and experiencing a more balanced, less hierarchical relationship. The shared experience of being in a new environment together seemed to enrich their understanding of each other.
Movement itself proved beneficial in multiple ways. Therapists appreciated getting away from sitting for extended periods, and many noticed that conversations seemed to flow more naturally while walking. The reduced eye contact that naturally occurs while walking side by side helped create a more relaxed atmosphere for some patients.
The natural environment also provided rich material for therapy conversations. Therapists found they could draw on their surroundings for metaphors and comparisons that related to their patients' experiences in ways that might not emerge in an office setting.
Perhaps most notably, therapists reported that the outdoor setting had a positive impact on their own mood, which they felt benefited the therapeutic process.
Challenges of the Great Outdoors
Despite these advantages, conducting therapy outside presented real challenges that therapists had to navigate. The most significant issue was the lack of a controlled environment. Unlike the calm, predictable office setting, outdoor sessions involved potential distractions from traffic, other people, weather, and even uneven walking surfaces.
Privacy emerged as another major concern. Public spaces mean the possibility of being overheard during sensitive conversations or having patients encounter people they know. Therapists had to develop strategies for handling these situations, such as pausing conversations when others were nearby or discussing in advance how to handle unexpected encounters.
The therapists also had to pay attention to practical considerations they never faced indoors, such as finding a comfortable walking pace for both people, dealing with weather conditions, and maintaining appropriate physical boundaries when walking side by side rather than sitting across from each other.
Adapting to New Challenges
Interestingly, the therapists found ways to work around most of these challenges. They learned to prioritize their attention moment by moment, sometimes focusing on navigation or safety before returning attention to the patient's words. They developed protocols for protecting privacy and discussed potential scenarios with patients beforehand.
Many of the difficulties seemed related to inexperience with this type of therapy rather than insurmountable obstacles. The therapists suggested that with more practice and proper preparation, many challenges could be minimized.
The Verdict from Practitioners
Despite the challenges they encountered, all seven therapists expressed positive feelings about outdoor therapy and interest in incorporating it into their future practice. They felt that the advantages outweighed the difficulties, and several mentioned wanting to integrate nature more actively into their outdoor sessions rather than simply using it as a backdrop.
The therapists showed a clear preference for the more natural parts of their walking route compared to urban areas, suggesting that the specific outdoor environment matters significantly. They recommended choosing routes that minimize urban distractions and establishing consistent paths rather than varying the route each time.
Practical Considerations for Therapists
For therapists interested in trying outdoor sessions, the study participants offered practical insights. They recommended bringing essential items like cell phones for emergencies, tissues for emotional moments, and water during hot weather. They also emphasized the importance of route planning and advance preparation with patients about potential challenges.
The therapists noted that outdoor therapy felt like meaningful therapeutic work, with patients comfortable enough to discuss deeply personal issues while walking. This suggests that the change in setting doesn't necessarily compromise the therapeutic process, though the specific environment and preparation clearly matter.
Broader Implications
This research adds to growing evidence that alternative therapy settings can be both acceptable and beneficial. As mental health needs continue to rise globally, exploring different approaches to delivering effective therapy becomes increasingly important.
The findings are particularly relevant given growing awareness of how environmental factors affect mental health. Some therapy organizations are recognizing climate change and environmental degradation as significant mental health threats, making approaches that connect people with nature potentially valuable on multiple levels.
This study was designed as a pilot to test the feasibility of conducting larger research on outdoor therapy. The positive experiences of these therapists suggest that such research would be worthwhile and that outdoor therapy could become a valuable option for certain patients and situations.
The researchers plan to conduct larger studies examining not just therapist experiences but also patient outcomes and the quantitative effects of therapy while walking in nature. Future research might also explore how to integrate nature more actively into therapeutic conversations rather than simply using natural settings as a backdrop.
While walk and talk therapy represents just one approach to incorporating nature into mental health treatment, it illustrates how traditional therapeutic practices can be adapted and potentially enhanced. The key seems to be thoughtful implementation that addresses the real challenges while maximizing the unique benefits that natural settings can provide.
For now, the experiences of these German therapists suggest that taking therapy outside can offer meaningful benefits for both practitioners and patients, provided that proper attention is paid to training, preparation, and selecting appropriate outdoor environments. As research in this area continues to develop, outdoor therapy may become a more widely available option for people seeking mental health support.
Pischel, M., Wüster, A. L., Metz, K., Wulf, H., Lahmann, C., & Pfeifer, E. (2025). They Talk the Talk and Walk the Walk: Psychotherapists' Experiences of Psychotherapy While Walking in Nature. Counselling and Psychotherapy Research, 25(3), e70035.
