J Autism Dev Disord (2010) 40:1179–1187
DOI 10.1007/s10803-010-0977-z
ORIGINAL PAPER
Dysfunctional Attitudes and Perfectionism and Their Relationship
to Anxious and Depressive Symptoms in Boys with Autism
Spectrum Disorders
Rebecca Greenaway • Patricia Howlin
Published online: 25 February 2010
Ó Springer Science+Business Media, LLC 2010
Abstract In spite of increasing interest in cognitive
behaviour therapy for emotional disorders in children with
autism spectrum disorders (ASD), little research has
explored the relevance of the cognitive model in this
population. This study explores dysfunctional attitudes and
perfectionism in boys with ASD and the relationship with
anxious and depressive symptoms. Compared to a typically
developing group (n = 42), boys with ASD (n = 41)
endorsed more dysfunctional attitudes and reported higher
emotional symptoms. The relationship between emotional
and cognitive variables was weak in both groups, although
in the ASD group dysfunctional attitudes were significantly
associated with reported obsessive–compulsive symptoms.
Reasons for elevated dysfunctional attitudes in the ASD
group are discussed and the roles of cognitive inflexibility
and social impairments are explored.
Keywords Autism spectrum disorders (ASD)

Anxiety
Depression
Dysfunctional attitudes

Perfectionism
Perseveration
The work reported here was completed by the first author in partial
fulfilment of the requirements for the award of Doctorate in Clinical
Psychology.
R. Greenaway
P. Howlin
Department of Psychology, Institute of Psychiatry,
King’s College London, London, UK
R. Greenaway (&)
The Wolfson Neurodisability Service, Great Ormond Street
Hospital, 10th Floor, Nurses Homes, London WC1N 3JH, UK
e-mail: r.greenaway@ich.ucl.ac.uk
Introduction
There is an increasing literature demonstrating higher
levels of anxious and depressive symptoms in children with
autism spectrum disorders (ASD) compared to typically
developing children (e.g. Farrugia and Hudson 2006;
Meyer et al. 2006) and children with other developmental
or learning disabilities (e.g. Brereton et al. 2006; Gillott
et al. 2001). Severe depression and anxiety are clinically
debilitating disorders that have a substantial impact on
young people (Kessler et al. 1995; Van Ameringen et al.
2003). Anxious and depressive symptoms are also likely to
exacerbate core ASD symptoms such as social withdrawal
and repetitive behaviours (Ghaziuddin et al. 2002). For
example, increased anxiety is thought to amplify social
inappropriateness, repetitive questioning, slowness, ritual-
ized behaviour, aggression, social withdrawal and irrita-
bility (Tantam 2003).
In spite of the high prevalence of anxiety and depression
in individuals with ASD, there has been little research into
interventions for these comorbid disorders (Anderson and
Morris 2006; Ghaziuddin et al. 2002). Cognitive behaviour
therapy (CBT) is recommended by the National Institute
for Health and Clinical Excellence (2005) for the treatment
of depression in young people and there is increasing
evidence of the value of CBT for treating anxiety disorders
in typically developing young people (James et al. 2005).
Whilst there are currently no published studies of CBT for
depression in young people with ASD, there has been a
recent proliferation in studies investigating the effective-
ness of CBT for anxiety in this population (Chalfant et al.
2007; Ooi et al. 2008; Reaven et al. 2009; Sofronoff et al.
2005; White et al. 2009; Wood et al. 2009). These studies
have tended to report significant improvements in anxiety
compared to control groups. However, the extent and
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nature of the cognitive components in these interventions is
not clear. Thus, although most of these studies include
educational (e.g. affect recognition) and behavioural (e.g.
relaxation and exposure) components, the few that do
mention cognitive restructuring do not elaborate further on
how this was carried out, nor do they discuss the cognitions
that were addressed. Furthermore, studies that have
explored factors relating to depression and anxiety in ASD
have tended to focus on social rather than cognitive factors
(e.g. Bellini 2004; Green et al. 2000). Therefore, little
research has explored the relevance of the cognitive model
to anxiety and depression in children with ASD. As a result
there is currently limited theoretical basis for the use of
cognitive techniques in psychological interventions for
comorbid emotional disorders in children with ASD.
In recent years, a small number of studies exploring the
relationship between cognitive variables and depression and
anxiety in children with ASD has been published (Barnhill
and Myles 2001; Farrugia and Hudson 2006; Hedley and
Young 2006; Meyer et al. 2006). For example, Meyer et al.
(2006) investigated social-cognitive factors related to
emotional and behavioural difficulties in young people with
Asperger syndrome. They found parent-reported (but not
self-reported) child anxiety was associated with social
encoding errors and hostile intent attributions. These studies
offer preliminary evidence that cognitive factors may be
important in understanding anxiety and depression in indi-
viduals with ASD and may have significant implications for
successful intervention. However, the focus has tended to
be on social cognition and attributional styles rather than
deeper level dysfunctional beliefs that have formed the core
of Beck’s (1967) cognitive model.
Dysfunctional attitudes are typically excessively rigid
and perfectionistic, for example ‘‘if I do not succeed at
everything I am a complete failure’’. Research with typically
developing young people has found evidence that high
levels of dysfunctional attitudes are a risk factor for sub-
sequent depressive symptoms (e.g. D’Alessandro and Bur-
ton 2006; Lewinsohn et al. 2001). One form of dysfunctional
belief that might be particularly pertinent to individuals with
ASD is clinical perfectionism. In relation to obsessive
compulsive disorder in typically developing individuals,
perfectionism has been defined as ‘‘the tendency to believe
there is a perfect solution to every problem, that doing
something perfectly (i.e. mistake-free) is not only possible,
but also necessary, and that even minor mistakes will have
serious consequences’’ (Obsessive Compulsive Cognitions
Working Group 1997, p. 678). Shafran et al. (2002) offer a
cognitive–behavioural definition of perfectionism ‘‘the
overdependence of self-evaluation on the determined pur-
suit of personally demanding, self-imposed, standards in at
least one highly salient domain, despite adverse conse-
quences’’ (p. 778). Perfectionist beliefs have been found to
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correlate with depression and anxiety in typically develop-
ing children (Hewitt et al. 2002) and can be addressed in
CBT (Antony and Swinson 1998).
To our knowledge, there are no published studies of
dysfunctional attitudes and perfectionism in people with
ASD although anecdotally they are often described as
demonstrating perfectionism (e.g. Bolton et al. 1994). It
has also been suggested that the cognitive inflexibility
often observed in these individuals might cause them to
hold too strongly to non-functional beliefs (Gaus 2007).
Inflexibility has also been linked to perfectionism in the
typical adult literature (e.g. Shafran and Mansell 2001).
Studies exploring the cognitive profile in ASD have often
reported greater cognitive inflexibility (Hill 2004) and
therefore we might expect higher levels of dysfunctional
and perfectionistic attitudes in boys with ASD.
Aims of the Study
The principal aim of this study was to explore whether
dysfunctional and/or perfectionistic attitudes are elevated
in children with ASD compared to typically developing
children and to explore whether these are related to anxious
and depressive symptoms. A secondary aim of the study
was to explore whether dysfunctional and/or perfectionistic
attitudes are related to cognitive inflexibility.
The following hypotheses were explored:
Primary Hypotheses
1. Children with ASD will show higher levels of anxious
and depressive symptoms compared to typically
developing children.
2. Children with ASD will show higher levels of
dysfunctional and perfectionistic beliefs compared to
typically developing children.
3. Dysfunctional attitudes and clinical perfectionism will
be associated with anxious and depressive symptoms
in both groups.
Secondary Hypothesis
4. Cognitive inflexibility will relate to higher levels of
dysfunctional and perfectionistic attitudes.
Methods
Participants
The ASD group consisted of 41 boys aged 11–14 years
(range 11.5–14.8 years; mean 13.2 years). All had an IQ
J Autism Dev Disord (2010) 40:1179–1187
above 80 (range 80–125, mean 100.0) and had previously
received a diagnosis of Asperger syndrome or high-func-
tioning autism from child psychiatrists, psychologists or
paediatricians. To ensure the validity of the initial diag-
nosis, parents of participants in the ASD group completed
the Social Communication Questionnaire (SCQ; Berument
et al. 1999; Rutter et al. 2003). A cut-off of 15 is suggested
as optimal for differentiating pervasive developmental
disorder (PDD) and non-PDD diagnoses (Berument et al.
1999). In the current study SCQ scores in the ASD group
ranged from 18 to 37, with a mean of 25.84. This is similar
to the mean (24.23) reported by Berument et al. for a group
of high-functioning young people with autism.
The control group consisted of 42 typically developing
boys (TD group) group-matched on age (range 11.8–14.4,
mean 13.2 years) and intellectual functioning (Full Scale
IQ on Wechsler Abbreviated Scale of Intelligence range
85–133, mean 103.9). The SCQ was not given to parents of
young people in the TD group because of concerns that the
questions would be inappropriate for typically developing
children of this age and might dissuade parents and their
children from completing the other measures. Boys with
ASD were recruited via special schools as many higher
ability children with a formal diagnosis of ASD in the UK
continue to be educated in specialist provision and educa-
tion in such settings does not imply significant behavioural
or learning difficulties. The typically developing boys were
recruited via mainstream schools. In both groups, teachers
were asked to confirm that all the boys were working
within the average range for their age group and were not
suspected of having any degree of intellectual impairment.
The groups did not differ significantly in age (t = .13,
df = 81, p = .899) or Full Scale IQ (t = -1.70, df = 80,
p = .093).
Measures
Intellectual Ability
All the young people completed the Wechsler Abbreviated
Scale of Intelligence (WASI) (Psychological Corporation
1999; two-subtest version).
Questionnaires
The boys also completed the self-report Spence Children’s
Anxiety Scale (SCAS, Spence 1997), whilst their parents
completed the parent version of this scale (SCAS-P, Nauta
et al. 2004). This yields a total anxiety score, as well as six
subscale scores: generalised anxiety disorder, obsessive
compulsive disorder, specific phobia, panic and agora-
phobia, separation anxiety disorder and social anxiety. The
scale has been previously used with young people with
1181
high-functioning autism and Asperger syndrome (e.g.
Chalfant et al. 2007; Sofronoff et al. 2005). In the current
study, internal consistency for the SCAS was good in both
groups (child-report; ASD, a = .84; TD, a = .92; parent-
report; ASD, a = .93; TD, a = .88). Internal consistency
was lower for the subscale scores, although predominantly
acceptable. The physical injury subscale had especially
poor internal consistency (ASD, a = .18; TD, a = .40),
therefore this subscale score was not entered into statistical
analyses.
The Children’s Depression Inventory (CDI; Kovacs
1992) is one of the most widely used and best-studied self-
report measures of childhood depression and has been used
as a measure of depression in young people with Asperger
syndrome (e.g. Barnhill and Myles 2001; Hedley and
Young 2006). The young people completed the self-report
short-form (CDI-S) and parents completed the parent-ver-
sion (CDI-P; Kovacs 1992). In the present study, coeffi-
cient alpha was acceptable for the CDI-S (ASD, a = .75;
TD, a = .72) and good for the CDI-P (ASD, a = .85; TD,
a = .83).
The Dysfunctional Attitudes Scale for Children (DAS-C,
D’Alessandro and Burton 2006) is an adaptation of the
Dysfunctional Attitude Scale (Weissman and Beck 1978)
and is one of the most extensively used measures of cog-
nitive vulnerability relating to depression. Internal reli-
ability in the current study was good (ASD, a = .90; TD,
a = .85).
The Child and Adolescent Perfectionism Scale (CAPS;
Flett et al. 2000) is a self-report measure of perfectionism
with two subscales: self-oriented perfectionism and
socially-prescribed perfectionism. In the current study,
alpha coefficients indicated good internal reliability (ASD,
a = .82; TD, a = .86).
Cognitive Flexibility
The Wisconsin Card Sorting Test (WCST; Heaton 1981) is
the most extensively used measure of cognitive flexibility
in autism and has been found to be highly reliable over
time in this population (Ozonoff 1995). The shorter Wis-
consin Card Sorting Test (WCST-64; Kongs et al. 2000)
was employed in this study. Participants are instructed to
match a series of 64 cards to a target according to a non-
explicit sorting rule which changes during the course of the
test. The standard score for perseverative errors was the
measure of interest in the current study.
Procedure
Written consent was obtained from all participants and
their parents. Participants completed the assessment in two
30-min sessions at their school; young people in both
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groups completed the WASI and WCST and four ques-
tionnaires (SCAS, CDI-S, DAS-C and CAPS). To control
for reading difficulties, all instructions and questionnaire
items were presented verbally as well as visually. Parents
were posted questionnaire packs containing the SCAS-P
and the CDI-P. Additionally, parents of children in the
ASD group were also asked to complete the SCQ.
Results
Preliminary Analyses
Several of the factors were skewed in distribution and
outliers were present. Non-parametric, two-tailed analyses
were employed and corrections for multiple comparisons
and correlations were made using Hochberg’s Multiple
Test Procedure (Hochberg 1988). Statistical adjustments
were made according to the number of tests per scale and
are denoted by padj in the text. The significance level was
set at p \ .05. Strength of associations were interpreted
according to the criteria of Cohen (1992; r = .10, small;
r = .30, medium; r = .50, large). Unless stated, correla-
tions were not substantially affected by partialling out age
and IQ. There was no significant relationship between
child- and parent-report on the CDI (ASD, rho = .007;
TD, rho = .138) or the SCAS (ASD, rho = .180; TD,
rho = .251), suggesting that each type of report may pro-
vide unique information. Thus scores from both sources
were employed separately in the following analyses.
Primary Hypotheses
Children with ASD will Show Higher Levels of Anxious and
Depressive Symptoms Compared to Typically Developing
Children
The ASD group scored significantly higher than the TD
group on child- and parent-reported SCAS and CDI total
scores, see Table 1. The ASD group also scored signifi-
cantly higher on all SCAS subscale scores, except child-
reported social anxiety (U = 763.0, ns).
Children with ASD will Show Higher Levels of
Dysfunctional and Perfectionistic Beliefs Compared to
Typically Developing Children
The ASD group scored higher than the TD group on the
DAS-C and CAPS although this difference only reached
significance for the former. Further analysis of the sub-
scales from the CAPS indicated that whilst both groups
scored similarly on self-oriented perfectionism, the ASD
group tended to rate themselves higher than the TD group
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on socially-prescribed perfectionism (U = 486.0, padj =
.086, d = .46). However, following Hochberg adjustment,
this difference no longer met significance.
Dysfunctional Attitudes and Clinical Perfectionism will be
Associated with Anxious and Depressive Symptoms in Both
Groups
Correlations between dysfunctional and perfectionistic
attitudes and child-reported anxious and depressive symp-
toms are shown in Table 2. The only significant correlation
in the ASD group was between obsessive compulsive
symptoms and dysfunctional attitudes (rho = .42, df = 39,
padj = .036). When partial correlation was used to control
for age and IQ the strength of the association increased
(rho = .52, df = 37, p = .001). Thus, those children
reporting higher obsessive compulsive symptoms endorsed
more dysfunctional attitudes. There was also a medium-
sized association between measures of obsessive compul-
sive symptoms and perfectionism in the ASD group,
although this no longer met significance following Hoch-
berg adjustment.
In the TD group there were medium-sized correlations
between measures of perfectionism and panic/agoraphobia
and between perfectionism and separation anxiety, but
again these no longer met significance following adjust-
ment for multiple correlations.
Overall, the correlations between emotional and cogni-
tive measures tended to be positive but weak. Dysfunc-
tional attitudes and child-reported depression did not
correlate significantly in either group. Similarly, there were
no significant associations between perfectionism or dys-
functional attitudes and parent-reported anxious and
depressive symptoms.
Secondary Hypothesis
Cognitive Inflexibility will Relate to Higher Levels of
Dysfunctional and Perfectionistic Attitudes
In line with previous research, the ASD group made more
perseverative errors on the WCST than the TD group
(U = 584.5, p = .012, d = -.58). The CAPS, DAS-C and
WCST perseveration standard scores did not violate
assumptions of normality, thus Pearson’s product-moment
correlation was used in these analyses. In the ASD group,
those children who were more perseverative on the WCST
endorsed more perfectionistic beliefs (r = -.403, df = 38,
padj = .020) and dysfunctional attitudes (r = -.327,
df = 39, padj = .037). After controlling for age and IQ
effects, there remained a significant correlation between
perseveration and perfectionism (r = -.320, df = 37, p =
.050), but not between perseveration and dysfunctional
J Autism Dev Disord (2010) 40:1179–1187 1183

Table 1 Group differences on emotional and cognitive measures

ASD group TD group Group difference
Median 25th–75th quartile Median 25th–75th quartile Statistic padj

SCAS child 25.0 20.0–38.0 13.0 10.0–21.0 u = 388 \.001

SCAS parent 31.0 20.0–48.0 9.5 5.0–17.8 u = 167 \.001
CDI-S child 49.0 43.0–53.0 43.0 43.0–49.0 u = 648 =.049
CDI parent 57.0 52.0–66.0 44.0 39.0–49.0 u = 200 \.001
DAS-C 52.0 41.0–66.5 44.5 39.8–54.3 u = 599 =.034
CAPS self 32.5 26.3–36.0 33.0 28.0–37.0 u = 760 =.457
CAPS social 26.0 20.5–29.8 22.5 17.0–28.0 u = 623 =.086
WCST pers 101.0 86.0–116.0 110.0 96.0–135.0 u = 585 =.012
Note: SCAS, Spence Children’s Anxiety Scale, total score (parent and child report shown); CDI-S, Children’s Depression Inventory, short form.
CDI parent, Children’s Depression Inventory, parent form; DAS-C, Dysfunctional Attitudes Scale for Children; CAPS, Child and Adolescent
Perfectionism Scale (self-oriented and socially-prescribed subscale scores shown); WCST pers, Wisconsin Card Sorting Test standard score for
perseverative errors

Table 2 Correlations between dysfunctional attitudes/perfectionism and child-reported anxious and depressive symptoms
ASD group (n = 41) TD group (n = 42)
Dysfunctional attitudes Perfectionism Dysfunctional attitudes Perfectionism

Spearman r
CDI-S .21 .16 .17 -.01
SCAS .21 .12 .09 .24
Obsessive–compulsive .42** .34* .06 .30
Panic/agoraphobia .11 .02 .18 .38*
Social phobia -.07 .01 .26 .05
Separation anxiety .16 .07 .13 .31*
Generalised anxiety .06 -.03 .02 .08
Note: CDI-S, Children’s Depression Inventory, short form; SCAS, Spence Children’s Anxiety Scale
* Significant at the p \ .05 level prior to adjustment
** Significant at the p \ .05 level after Hochberg adjustment

attitudes (r = -.176, df = 37, p = .289). In the typically
developing group perseveration did not correlate sig-
nificantly with perfectionism (r = -.054, df = 40, p =
.736) nor dysfunctional attitudes (r = -.028, df = 40,
p = .860).
Additional Research Question
on the social reciprocal interaction domain of the SCQ and
socially-prescribed perfectionism on the CAPS was
examined. Those children with ASD whose parents rated
them as having more severe social interaction impairments
on the SCQ endorsed more socially-prescribed perfec-
tionistic beliefs (rho = .33, df = 35, p = .050).

Does Higher Socially-Prescribed Perfectionism in ASD Discussion

Relate to Impairments in Reciprocal Social Interaction in
ASD?
It was interesting to find that whilst both groups scored
similarly on self-oriented perfectionism, the ASD group
scored higher than the TD group on socially-prescribed
perfectionism. Therefore, an additional research question
was explored—whether higher socially-prescribed perfec-
tionism in the ASD group might relate to social interaction
impairments in ASD. The relationship between the score
The study aimed to explore dysfunctional attitudes and
perfectionism and their relationship to anxious and
depressive symptoms in boys with ASD. Consistent with
previous research, scores on measures of anxious and
depressive symptoms were higher in the ASD group
compared to the TD group. The ASD group also endorsed
more dysfunctional and socially-prescribed perfectionistic
beliefs than the TD group. In the ASD group, children who
endorsed more dysfunctional attitudes also reported higher

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levels of obsessive–compulsive symptoms. Overall, the
correlations between cognitive distortions and emotional
measures were weak and inconsistent, although there was
no evidence to indicate that the cognitive measures were
more strongly related to anxiety and depression in the TD
group compared to the ASD group.
The ASD group endorsed more dysfunctional attitudes
than the TD group. There was also a greater tendency for
the ASD group to endorse statements indicating that others
set high standards for them, whilst both groups showed
similar levels of self-oriented perfectionism. The evidence
also indicated that cognitive inflexibility was associated
with greater endorsement of these beliefs in the ASD
group. As there is no published research on perfectionism
or dysfunctional attitudes in individuals with ASD, it is
only possible to speculate about these findings. Cognitive
inflexibility might lead to rules being applied in an overly
rigid way by children with ASD, even in the face of con-
tradictory evidence. Thus, cognitive inflexibility might
explain, in part, the higher levels of dysfunctional and
perfectionistic attitudes in the ASD group. Furthermore,
difficulty interpreting social information might lead indi-
viduals with ASD to overestimate others’ expectations.
There was some evidence for this in the present study as a
higher score for impairments in reciprocal social interac-
tion in the ASD group was associated with higher socially-
prescribed perfectionism. A further possibility is that the
pragmatic language deficits that are typically observed in
individuals with ASD (Baron-Cohen 1988), might lead
children to interpret comments about others’ expectations
(e.g. ‘‘I want you to give 110%’’) in an over-literal way.
Pragmatic language skills were not, however, assessed in
the current study.
Thus far, dysfunctional attitudes and clinical perfec-
tionism have been considered to be disadvantageous cog-
nitive styles. However, it is also possible that these traits
have advantages for children with autism, for example, in
simplifying social expectations and offering a framework
for social understanding. Furthermore, it should be ques-
tioned whether these higher scores on measures of dys-
functional attitudes and socially-prescribed perfectionism
actually represent distorted thinking or whether they reflect
the harsh social reality faced by many individuals with
ASD. It could be argued that people do, in fact, set overly
high standards for individuals with ASD who are of normal
or above average IQ, and that the consequences of not
meeting these expectations can be very negative. For
example, many children with ASD are expected to attend
mainstream school, a highly complex and demanding
social environment, and to interact successfully with their
typically developing and socially much more sophisticated
peers. If their attempts at social interaction fail this can
frequently lead to rejection and ridicule (Attwood 1998).
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J Autism Dev Disord (2010) 40:1179–1187
However, whilst some of the items on the scales used relate
to social performance, the majority cover more general
perfectionistic performance standards and rigid ideas about
the world. Thus, it is unlikely that the elevated scores in
dysfunctional attitudes and socially-prescribed perfection-
ism can be ascribed entirely to social failure. Moreover, the
boys with ASD in this study all attended specialist provi-
sion and thus are likely to have been in more ‘‘ASD
friendly’’ and hence less stressful environments than many
other children with this condition.
In contrast to some other studies of typically developing
children (e.g. Lewinsohn et al. 2001), the relationship
between reported emotional symptoms and cognitive dis-
tortions was generally weak. In particular there was no
significant correlation between scores for dysfunctional
attitudes and depression in either group. The only signifi-
cant correlation between child-reported anxiety and dys-
functional attitudes was for the obsessive–compulsive
subscale in the ASD group. Dysfunctional attitudes have
been theoretically linked to depression rather than anxiety
and few studies have examined the relationship between
dysfunctional attitudes and anxiety disorders. Although not
theoretically related, evidence in the typical adult literature
reported a relationship between obsessive compulsive dis-
order (OCD) and dysfunctional attitudes (Vogel et al.
2000). Therefore, it is possible that dysfunctional attitudes
play an important role in OCD in both typical and ASD
populations.
Limitations and Future Research
The weak or absent relationships between emotional and
cognitive factors may be due to a small sample. A study of
dysfunctional attitudes among 94 depressed adolescent
outpatients found that whilst dysfunctional attitudes were
associated with more severe depression, cognitive distor-
tions were not universal across the depressed group
(Marton and Kutcher 1995); thus the association may only
be consistently detected among larger sample sizes. A
further reason why few significant relationships between
cognitive and emotional factors were identified might be
the use of a community rather than a clinic sample. In the
typically developing group there was only a limited range
of depressive symptomatology reported, with the majority
scoring in or below the average range for depressive
symptoms.
There were differences between the special schools
where the young people with ASD were placed and the
mainstream schools from where the typically developing
children were recruited. All but one of the special schools
was independent (although pupils were typically funded by
their LEA) whilst all mainstream schools were state-fun-
ded. The special schools were smaller than the mainstream
J Autism Dev Disord (2010) 40:1179–1187
schools and, unlike the mainstream schools, all but one had
boarding provision. These differences in the schools
attended by the two groups is likely to impact on their day-
to-day lives and the findings, particularly for the ASD
group, might not be replicated in pupils attending less
specialized (and hence less supportive) integrated provi-
sion. The schools were also all in predominantly white
middle-class areas and the study aimed to target a fairly
homogenous sample, which limits the generalisability of
the results.
Detailed diagnostic assessments were not conducted on
the boys in the ASD group; therefore classification was
based on previous diagnoses given by a variety of clinical
teams. The SCQ was, however, used as an additional
screening tool in the ASD group and all scored within the
clinical range for PDD. No ASD assessments were used in
the TD group, so we cannot be sure that any of the boys in
this group did not have an undiagnosed ASD. However,
neither parents nor teachers reported any suspected neu-
rodevelopmental difficulties in the TD group.
A further limitation of the study is the use of typically
developing boys as a comparison group as, by nature of the
condition, development in boys with ASD is likely to fol-
low a different trajectory. A typically developing com-
parison group was chosen because CBT techniques for
emotional disorders in ASD are extrapolated from the
typically developing literature. In future studies in this area
the inclusion of a comparison group with a different neu-
rodevelopmental disorder may provide additional infor-
mation, although, of course, how to select the most
appropriate comparison group remains an issue of debate.
Whilst efforts were made to keep the groups as
homogenous and as closely matched as possible, there
remained variability in IQ scores within each group, with
some participants scoring in the low average and some in
the above average range. Furthermore, the ASD group
contained boys who had been diagnosed with Asperger
syndrome or high-functioning autism. No attempt was
made to explore subgroups within the ASD group owing to
the relatively small group size and because the ASD
diagnoses came from a range of clinical teams. In addition,
it is now increasingly argued that there is insufficient
research evidence reliably to distinguish between these two
(e.g. Sanders 2009).
It is also important to note that the correlational nature
of the study means that causal interpretations cannot be
made; there are no data on the directionality of the rela-
tionship or the influence of other potential variables. Future
studies would benefit from the use of prospective designs
to develop a better understanding of the factors that make
individuals with ASD vulnerable to anxiety and depression.
Finally, the questionnaires used in this study have not
been standardised for use with individuals with ASD.
1185
Children with autism often present with different fears
compared to typically developing children (Howlin 1998)
and there may be overlap between symptoms of depression
and features of ASD (e.g. social withdrawal, impaired sleep
patterns) that might be difficult to tease apart when relying
solely on questionnaire measures. It is also important to
note that children with ASD may have difficulty reporting
their emotions, or fully understanding the concepts mea-
sured by standard questionnaires. The boys with ASD in
the current study appeared to have little difficulty com-
pleting the self-report anxiety and depression measures,
although we have no data on whether their interpretation of
the questions is the same as for typically developing peers.
Future studies may benefit from the use of clinical inter-
views to assess emotional symptoms and the clinical
impact of these.
Strengths of the Study
In spite of these limitations, the study also benefits from
several strengths. Firstly, it is unique in measuring dys-
functional attitudes and perfectionism in relation to
depression and anxiety in children with ASD. Secondly, the
participants comprised a well-defined group of boys with
ASD who were closely matched with the typically devel-
oping comparison group. Diagnoses from school reports
were validated by parental screening questionnaire and
level of intellectual functioning was established by both
teacher report and an IQ test. Finally, a further strength of
the study was the use of both child- and parent-report
emotion measures.
Clinical Implications
This study provides further evidence of higher than normal
levels of anxious and depressive symptoms in a community
sample of children with ASD, with the data supported by
both child- and parent-report. This highlights the necessity
of developing appropriate interventions for anxious and
depressive disorders in ASD populations. There is also a
need to determine the accuracy of standardised measures of
emotional distress in this group and at the very least
research and clinical work with high-functioning children
with ASD should collect both child- and parent-report to
gain a fuller understanding of the individual’s symptoms.
The ASD group tended to show inflated socially-pre-
scribed perfectionism, which in turn was associated with
reported impairments in reciprocal social interaction.
Given the potentially negative impact of perfectionism
on psychopathology (Shafran and Mansell 2001) and
functioning (e.g. procrastination and obsessional slow-
ness), adults may need to exercise caution in the use
of achievement-related comments, which although to
123
1186
typically developing children may be encouraging, by
children with ASD may be interpreted either too rigidly or
literally (e.g. ‘‘you must always do your best’’).
The current study suggests that OCD symptoms in
children with ASD are associated with cognitive distor-
tions. Consequently, this suggests that psychological
interventions for OCD in children with ASD may be more
effective if they tackle these distorted cognitions. There is
also some evidence that perfectionism can interfere with
treatment outcome when treating typical adults with emo-
tional disorders (e.g. Blatt et al. 1998) and hence inter-
ventions that aim to ameliorate dysfunctional and
perfectionistic beliefs may also enhance therapeutic pro-
gress and relapse prevention in children with ASD.
There was no evidence to indicate that cognitive dis-
tortions are less relevant to anxious and depressive symp-
toms in children with ASD than in typically developing
children. However, the weak and inconsistent correlations
in both groups suggest that there are many other important
factors involved and that cognitive distortions may play a
larger role in emotional symptoms for some young people
than others. In clinical practice, detailed assessment and
individualised formulation is important to understand the
factors relevant to the individual. Bolton (2004) suggests
that when conducting CBT with children, a pragmatic
approach should be taken, whereby cognitive distortions
are assessed and if they are present, then they should be a
target for therapy; if not then other approaches should be
taken, regardless of the age of the child.
Finally, there was evidence that cognitive deficits might
underlie cognitive distortions in children with ASD, as
perseveration was related to perfectionism and measures of
reciprocal social interaction skills were related to socially-
prescribed perfectionism in the ASD group. As cognitive
inflexibility and social cognitive deficits also relate to the
core diagnostic triad of ASD, this may suggest that cog-
nitive distortions will be more resistant to change in these
individuals. This indicates that CBT with these individuals
might be more effective if cognitive deficits are also
addressed. For example, interventions may include reha-
bilitation techniques aimed at reducing cognitive inflexi-
bility (e.g. Young and Freyslinger 1995) or improving
social understanding (e.g. Howlin et al. 1999).
Conclusions
To our knowledge, this is the first study to investigate
perfectionism and dysfunctional attitudes in young people
with ASD. The study revealed elevated scores on measures
of anxious and depressive symptoms and cognitive dis-
tortions in children with ASD, indicating that this is an
important area of study. Dysfunctional attitudes were
123
J Autism Dev Disord (2010) 40:1179–1187
related to OCD symptoms in the ASD group and there was
evidence that cognitive inflexibility and social impairments
in ASD might relate to some aspects of distorted beliefs.
Further research is needed to demonstrate the relevance of
cognitive models to the treatment of emotional problems in
young people with ASD and to investigate the active
components of CBT for these individuals.
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