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A systematic review of dysfunctional thoughts,

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with autism. Solutions and therapeutic methods

Christine K. Syriopoulou-Delli & Areti-Eirini Filiou

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review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
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A systematic review of dysfunctional
thoughts, feelings and phobias of children
and adolescents with autism. Solutions and
therapeutic methods
Christine K. Syriopoulou-Delli and Areti-Eirini Filiou
Department of Educational and Social Policy, University of Macedonia, Thessaloniki, Greece

Background: Children and adolescents with Autism Spectrum Disorder (ASD) often experience symptoms of
various mental disorders along with the characteristics that define ASD. High rates of several psychiatric dis-
orders have been reported in people with ASD such as anxiety, depression, cognitive problems, emotional
regulation difficulties and related behavioral problems can occur in children of all ages with ASD. There are
many treatment programs that can help autistic persons cope with these symptoms. Cognitive and
Behavioral Therapy (CBT), Information and Communication Technology (ICT) and more are treatment pro-
grams that can help people with autism recognize and manage their symptoms.
Aim: This paper examines through bibliographic sources of the last 15 years the possible mental disorders
that a child or adolescent with ASD may experience, as well as the therapeutic interventions that can help to
manage them.
Methodology: For the present bibliographic research, 15 scientific articles from English journals were used.
The databases from which the scientific articles were found were PubMed, PsycINFO, MEDLINE, and
Google Scholar.
Results: According to the results of various studies, children and adolescents with autism show various
symptoms of psychological disorders such as Anxiety Disorders, Depression and Obsessive-Compulsive
Disorder. The combination of CBT and ICT can help people with autism recognize and manage
their symptoms.
Discussion: The various symptoms of disorders that children and adolescents with autism experience can
have a major impact on their family, their daily life, their schooling, and their future work. It is of the utmost
importance that these children enter into a treatment program in order to better manage and treat their
symptoms. The support of the school is also very important.
KEYWORDS: Adolescents; autism spectrum disorders; child; mental disorders; intervention

1. Introduction addition to that attributed to the underlying symptoms

Autism Spectrum Disorder (ASD) is the most common
developmental disorder, but also the least understood
(Boulter et al., 2014). Children and adolescents with
ASD, along with the characteristics that define ASD,
may present with a variety of cognitive, emotional, and
behavioral problems. These symptoms appear in child-
hood and continue into early adulthood. Mental illness
is common in children and adolescents with ASD,
including Anxiety, Depression, Obsessive Compulsive
Disorder (OCD), and Phobia Problems. These diseases
can worsen the functional impairment of individuals, in
Correspondence to: Christine K. Syriopoulou Delli, Department of
Educational and Social Policy, University of Macedonia, Thessaloniki, 156
Egnatia str. 54636 Thessaloniki, Greece. E-mail: csyriop@uom.edu.gr
of ASD (Boulter et al., 2014; Berkovits et al., 2017;
Brockman et al., 2017). Indicatively, van Steensel et al.
(2011) report that significant psychiatric disorders occur
in 40% of children and adolescents with ASD.
The purpose of this article is to note the main disor-
ders that can occur in a child with autism, as well as
ways to treat them. In addition, it aims to combine two
interventions by Cognitive and Behavioral Therapy
(CBT) and Information and Communication
Technology (ICT). Through ICT intervention, combined
with CBT techniques, the child with autism can better
manage the symptoms of the disorder. Research shows
that ICT is widely used in children with autism and
seems to be a very good way to approach it by

# The British Society of Developmental Disabilities 2022

DOI 10.1080/20473869.2022.2134962 International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0 1
C. K. Syriopoulou-Delli and Areti- Eirini Filiou A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
Solutions and therapeutic methods
specialist educators. Especially the use of robots seems
to be a new and very effective way of intervening in
children with autism. CBT, on the other hand, is widely
used by the psychologicalcommunity. The aim of this
article is to combine both aspects at a theoretical level
with a view to future intervention research.
1.1. Anxiety disorders
1.1.1. Special phobia
Starting from the first year of life, young children show
that they have fears. According to Marks (1969, p. 1),
‘Fear is a normal response to an active or imaginary
threat to higher animals and includes an external behav-
ioral expression, an inner emotion, and accompanying
physiological changes’. In contrast, SP, according to the
American Psychiatric Association (APA) ‘Diagnostic
and Statistical Manual of Mental Disorders (DSM), is
defined as an intense fear or anxiety about a particular
object or condition that lasts for a long time and is the
actual risk posed by the object or situation’ (DSM-5;
APA 2013). SP is characterized by avoidance of the
stimulus, negative emotional reactions to the stimulus
(e.g. crying, violent outbursts, physical aggression),
negative verbal response (e.g. Dogs scare me!),
increased autonomic arousal (e.g. increased heart rate,
blood pressure) and normal stress responses (e.g.
increased circulating cortisol) (Christner, Forrest,
Morley and Weinstein, 2007; Hollon and Beck, 2013;
Maskey et al., Rodgers et al., 2019;).
SP has been documented to be the most common
lifelong diagnosis of DSM-5 in children and adoles-
cents with ASD and it is estimated that 12% of children
and adolescents diagnosed with ASD also receive a co-
diagnosis of SP (Christner, Forrest, Morley and
Weinstein, 2007; Hollon and Beck, 2013; Maskey
et al., 2019; Muskett et al., 2020). Many have different
types of phobias, involving more than one object or
condition, and have specific types of phobias that are
more common in Autistic children.More than 10% of
children with ASD have been reported to have a phobia
of loud noises, which is not common in children with
normal development (TD), and fear of gunshot wounds
and crowds, as well as needle SP.
According to van Steensel et al. (2011) Autistic chil-
dren are generally more frightened than non-
Autistic children.
1.1.2. Social anxiety disorder
Reported rates of social anxiety disorder in children
with ASD range from 11% to 84%. The large variation
is probably due to the application of different instru-
ments, the use of simple interviewers in some studies
and the differences in the study samples, but also the
overlap between the characteristics of ASD and the cri-
teria used to measure stress.
2 International Journal of Developmental Disabilities 2022
Stress symptoms can cause cognitive and behavioral
difficulties and increase the symptoms of ASD. They
also affect the sense of well-being of children and
young people and harm their social and educational
progress (Grondhuis and Aman, 2012). Systematic
reviews of stress in children and adolescents with ASD
show that many of their stereotyped behaviors, such as
hoarseness, twisting, shaking, banging, clapping, and
repetitive questions, increase as children are distressed
or anxious. According to Grondhuis and Aman (2012),
anxiety symptoms can cause acute discomfort in chil-
dren and adolescents with ASD and cause more
extreme behavioral difficulties such as anger, aggres-
sion, and self-harm.
Stress and social anxiety can have a profound impact
on the sociability of people with ASD. People with
ASD often give the initial impression that they prefer to
isolate themselves from social contact, but many of
them want to be somewhat different and that instead of
being isolated, they should be sociable and have many
friendships (Layne et al., 2003; Mayes et al., 2011). It
can be assumed that the social disability associated with
ASD could be stressful, especially for higher function-
ing young people who are aware of their lack of social
skills. Knowing that they face difficulties in social con-
tacts due to the symptoms of ASD, they can become
more anxious and thus become even more isolated. The
symptoms of anxiety, in this situation, come from their
frustrated desire for social contact. In contrast, in many
people with ASD, it is the anxiety symptoms that make
them avoid social situations and contact with others
(Layne et al., 2003; Mayes et al., 2011; Grondhuis and
Aman, 2012; Spain et al., 2018).
According to Mayes and colleagues (2011) social
anxiety can affect the school performance of children
and adolescents with ASD and can be an obstacle to
their successful functioning in the school environment.
Children and adolescents with ASD are at risk for aca-
demic performance and engage in fewer school activ-
ities than expected for children their age (Wood et al.,
2009; Mayes et al., 2011).
1.2. Depression
Many children and adolescents with ASD have symp-
toms that meet the diagnostic criteria for major depres-
sion (Berkovits et al., 2017; Christner, Forrest, Morley
and Weinstein, 2007). It is estimated that 10% meet the
full DSM-5 criteria for major depressive disorder and
an additional 14% meet some of these criteria.
Depression is a common diagnosis, with approximately
2–30% of adolescents with ASD having symptoms that
reflect discomfort or depression (Hill & Furniss, 2006;
Berkovits et al., 2017; Cai et al., 2018).
According to Cai and colleagues (2018), people with
ASD who are depressed can experience a wide range of
symptoms, such as irritability, sadness, aggressive
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 C. K. Syriopoulou-Delli and Areti- Eirini Filiou A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
outbursts, feelings of isolation, interpersonal struggles,
and even suicidal thoughts. Young people with ASD
with depressive symptoms and a history of abuse are
more likely to have suicidal thoughts. People with ASD
may also have trouble sleeping and eating. Adolescents
are more likely to have hypersomnia and have an
increased risk of suicide compared to their predecessors
(Layne et al., 2003). They may also show a lack of
interest in activities and feelings of worthlessness or
guilt, despair and reduced ability to make decisions, as
manifestations of depression. In general, women with
ASD and depression are more likely to experience
changes in appetite and/or weight, increased crying and
feelings of guilt or low self-esteem, while males are
more likely to express depression due to anemia, social
withdrawal and mood swings and energy. (Campbell-
Sills et al., 2006; Cohen and Mendez, 2009). Many
researchers have noticed that depression seems to
increase the symptoms of ASD. Children and adoles-
cents with ASD and depression may experience an
increase in ideological thoughts and behaviors and rit-
uals or, conversely, a complete loss of interest in past
concerns and interests. arousal, stereotypes, and self-
harm may increase with depression (Campbell-Sills
et al., 2006; Cohen and Mendez, 2009; Sukhodolsky,
Smith et al., 2016; Sukhodolsky, Vander Wyk et al.,
2016; Tudor et al., 2016; Hudson et al., 2019).
1.3. Obsessive and compulsive disorder (OCD)
Another DSM-5 disorder in children and adolescents
with ASD is OCD, which was diagnosed in 3–12% of
children with ASD (Boyd et al., 2011). OCD is charac-
terized by disturbing and repetitive thoughts, urges or
images (obsessions) and repetitive behaviors or mental
actions (compulsions) that are extremely disturbing to
them and seriously affect their social, academic and
professional functioning (Boyd et al., 2011; Boyd et al.,
2012; Murray et al., 2015).
Although ASD and OCD are distinct disorders, it is
documented that children with ASD show increased
rates of obsessive-compulsive symptoms (Murray et al.,
2015) and children with OCD often exhibit other fea-
tures of ASD (Vause et al., 2020). Indeed, some
researchers have suggested that ASD is in the OCD
spectrum and have suggested that obsessive-compulsive
symptoms in ASD and OCD may have common neuro-
biological features (Boyd et al., 2012). According to
Murray et al. (2015), repetitive behaviors in ASD usu-
ally overlap with OCD compulsions, and it is often dif-
ficult to distinguish between the phenomenological
characteristics of ASD and those of OCD.
While these two disorders appear to show similar-
ities, they also show qualitative differences in repetitive
behaviors. For example, children and adolescents with
ASD exhibit more stereotyped repetitive behaviors,
such as storing specific objects and touching and hitting
International Journal of Developmental Disabilities
Solutions and therapeutic methods
behaviors, which appear to act as positive reinforce-
ment. Children and adolescents with OCD are more
likely to have recurring annoying and disturbing
thoughts (obsessions) and exhibit repetitive mental and
behavioral rituals (compulsions) such as controlling,
repeating, and counting behaviors that can help reduce
stress and feelings. et al., 2014).
1.4. Cognitive Behavioral therapy (CBT)
This form of psychotherapy focuses on three aspects,
namely thoughts, feelings and behaviors. CBT is
increasingly used for children and adolescents with
ASD who are able to engage in verbal communication
(Christner, Forrest, Morley and Weinstein, 2007; Danial
and Wood, 2013; Greenlee et al., 2016; Brockman
et al., 2017). CBT for children and adolescents with
ASD focuses on both the symptoms of ASD, and add-
itional psychological problems (Mulligan et al., 2014;
Vause et al., 2020), and can help in a number of ways
€ et al., 2016; Uhre et al., 2020; White et al., 2018).
(Ost
First, CBT interventions, such as reassessment and
exposure therapy, are very effective in treating SP
(Hollon and Beck, 2013; Halldorsdottir and Ollendick,
2016). CBT methods are aimed at reducing the fear and
anxiety caused by a particular object, animal or condi-
tion, gradually teaching patients to live with that fear in
a technique called desensitization (Hollon and Beck,
2013; Halldorsdottir and Ollendick, 2016).CBT can
help patients with ASD suffering from anxiety symp-
toms reduce their stress levels (Vause et al., 2020) by
using a variety of methods (White et al., 2018).
Through CBT, individuals can learn skills to modify
their thoughts and beliefs and develop problem-solving
strategies to improve their interaction with others in
effective and appropriate ways, thus promoting self-
regulation (Mulligan et al., 2014; Murray et al., 2015;
Vause et al., 2020).
CBT has also been shown to be effective in treating
children and adolescents with ASD who have symptoms
of OCD (Ost et al., 2016; Uhre et al., 2020). The tech-
nique in this case includes exposure, early response pre-
vention (ERP), extended cognitive elements, social skills
training and integration of the child’s interests, with the
use of visual aids and self-monitoring and increased par-
ental involvement (Neil and Sturmey, 2014).
CBT techniques can also help children and adoles-
cents with ASD who show symptoms of depression
(Hudson et al., 2019; White et al., 2018). The techni-
ques in this case focus on depressive thoughts and
negative emotions. People help identify these thoughts
and feelings, evaluate them, and then replace them with
other thoughts that are more positive, optimistic, and
realistic. CBT also focuses on activation in patients
with depression. Due to depression, children and ado-
lescents may experience reduced activity and tend to do
little or nothing in their daily lives.
2022 VOL. 0 NO. 0 3
C. K. Syriopoulou-Delli and Areti- Eirini Filiou A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
Solutions and therapeutic methods
1.5. Information and
communication technology
Radio, television, video, telephone, interactive white-
board, satellite systems, computers, networks, building
materials, and software used by these media can be con-
sidered ICT. So what can ICT offer for children and
adolescents with ASD? ICT can provide audiovisual
information, with the ability to compose text and audio,
and display color graphics, animation and digital video
projection. One of the advantages is the predictability
of ICT and another advantage is the ability for inter-
active activities. Various ICT devices have micro-
phones, cameras and speakers that are important
elements (Higgins and Boone, 1996).
One type of ICT that offers opportunities for inter-
action is robotics. Robots provide a ‘fun’ activity for
children, which can give them very strong motivation.
According to Dautenhahn (2003), a robot can be used
as a social mediator or as an example of a social agent,
even as a therapeutic partner. Typical examples are the
robot dog, AIBO and the social robot Zeno, with which
children particularly enjoy interaction (Tseng and Do,
2010). Robots are especially suitable for teaching chil-
dren with ASD, due to their predictability and their use
can be very effective.
Many studies report that children with ASD enjoy
the company of a robot. According to Cabibihan and
colleagues (2013), robots can be used to enhance com-
munication, deal with emotions, and maintain social
relationships in children with ASD. Robots can be an
important factor in social interaction and the develop-
ment of social skills for children with ASD. Robots can
contribute to the development of social behavior and
the maintenance of social norms in children with ASD,
providing a model of appropriate behavior that the child
can imitate (Dautenhahn, 2003).
Research shows that ICT intervention is 45% effect-
ive in children and adolescents with ASD. ICT inter-
vention can help children and adolescents with autism
cope with symptoms of anxiety, depression, phobia, and
ocd. Through internet, online programs and the use of
robots it is possible to reduce the symptoms of mental
disorders (Jolstedt et al., 2020).
Especially, ICT intervention can combine with CBT
an offer grate results. CBT is an effective first-line
treatment for anxiety disorders in children but access to
it is limited. Internet CBT (ICBT) is both effective and
cost-effective for young people with anxiety disorders
and has the potential to significantly increase the avail-
ability of treatment (Jolstedt et al., 2020). However, the
long-term effects of ICBT on pediatric anxiety disor-
ders have rarely been studied. To date, only three trials
have investigated whether the benefits of ICBT treat-
ment for pediatric anxiety disorders were retained in
long-term follow-up (Jolstedt et al., 2020). The ICBT
4 International Journal of Developmental Disabilities 2022
protocol is a completely online CBT self-help program
led by therapists (psychiatrists, psychologists) for chil-
dren with anxiety disorders and their caregivers
(Jolstedt et al., 2020). The treatment includes 12 con-
secutive sections that the child must complete together
with one or both parents and 12 separate sections that
are addressed only to the parent. The duration of treat-
ment is 12 weeks and one section must be completed
before accessing the next (Jolstedt et al., 2020). The
intervention consists mainly of self-directed exposure
therapy with asynchronous and personalized therapist
support provided on a weekly basis, through messages
on the treatment platform and worksheets within the
program (Jolstedt et al., 2020).
Moreover, it seems that ICT, and especially robotics,
can be extremely effective in socializing children with
ASD, but human presence is always necessary, in culti-
vating social skills and behaviors. The combination of
CBT with ICT is recommended to help children with
ASD engage in more effective interactions with peers
and enhance socio-cognitive understanding of social
structures and processes (Dautenhahn, 2003). Using this
combination, clinicians have the opportunity to cultivate
in children with ASD and various mental disorders, spe-
cific social skills, better cognitive understanding of
social structures and appropriate social behaviors. CBT
is currently equipped with a variety of modules that can
be implemented with the help of the robot-therapist.
This technique can lead to improved adaptive interper-
sonal function by modifying the way children with
ASD respond to social events and increasing their
understanding of their own behavioral responses
through the systematic application of cognitive strat-
egies. Indeed, the combination of CBT and ICT can
provide both cognitive and behavioral techniques to
enhance the social ability of children and adolescents
with ASD (Dautenhahn, 2003).
2. Methodology
The methodology of this review was based on the guide
by Ahn and Kang (2018) with the title ‘Introduction to
systematic review and meta-analysis’. According to this
methodology, a systematic review should be based on
five essential steps. Five methodological steps to con-
duct the review: (1) Formulation of research questions,
(2) Inclusion and exclusion criteria, (3) Rigorous litera-
ture search, (4) Data extraction and analysis, and (5)
Presentation of results.
2.1. Step 1: Research questions
The researchers formulated the research questions
which were:
1) which possible mental disorders co-exist with ASD
symptoms in children and adolescents?
VOL. 0 NO. 0
 C. K. Syriopoulou-Delli and Areti- Eirini Filiou
2) how effective can cognitive behavioral therapy
(CBT) or information and communication technol-
ogy (ICT) be to children with ASD and men-
tal disorders?
3) how effective can the combination of ICT and CBT
be to children with ASD and mental disorders?
2.2. Step 2: Inclusion and exclusion criteria
2.2.1. Inclusion criteria
 The study is presenting an intervention focusing on
treating symptoms of anxiety disorders, depres-
sion, ocd,
 The publication is in English,
 The intervention reported focuses on children aged
3–14 years with ASD and adolescents 14–18 years,
 The study focuses on comorbidity of mental disorders
with ASD,
 The study presents the intervention of these symptoms.
2.2.2. Exclusion criteria
 The publication is not an empirical study. Book chap-
ters, posters, and review articles were excluded from
the current review,
 The publication includes participants with Asperger
Syndrome, Rett Syndrome, Childhood Disintegrative
Disorder, Pervasive Developmental Disorder not
Otherwise Specified,
 The publication does not report on ASD.
2.3. Step 3: Literature search
A literature search was conducted in the databases of
PubMed, PsycINFO, MEDLINE, and Google Scholar,
using a combination of the keywords ‘Mental disorders’
AND ‘autism spectrum disorders’ OR ‘ASD’ AND
‘child’ AND ‘adolescents’ AND ‘intervention’. The
combination of the above keywords was applied to each
database from 2001 up until August 2021.
2.4. Steps 4 and 5: Data extraction and
interpretation of results
Data extraction and analysis: the analysis of results was
based on the evidence and data given by the chosen
articles. Interpretation of results: Interpretation was
based on the research questions. Each question was
answered separately. The specific bibliographic review
was carried out by two researchers who were relevant
with the article’s field of study. Any disagreements
were resolved after re-examining and discussing the
methodology and inclusion/exclusion criteria. The writ-
ing of the paper was based on the publication manual
of the American Psychological Association (APA).
Figure 1 shows the flowchart used in the selection of
papers, based on PRISMA, which is an evidence-based
minimum set of items for reporting in systematic
reviews and meta-analyses (Moher et al., 2010).
3. Results
As shown in Figure 1, the initial search yielded 200
relevant publications for the years 2001–2021. Removal
A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
Solutions and therapeutic methods
of duplicates and application of the first phase of the
study criteria left 159 articles, which on scrutiny led to
a selection of 41, of which 15 articles met the require-
ments of the review, and are listed in Table 1.
The 15 studies include children with ASD and a
mental disorder such as anxiety disorder, depression
and ocd. Table 1 presents the research articles that were
analyzed, the participants of the researches, the differ-
ent kind of these mental disorders, their symptoms, the
possible therapy, the strategies of this therapy and the
summary of the results of the article.
3.1. Research question 1: Mental disorders
In children and adolescents, the symptoms of ASD are
often seen to coexist with symptoms of various differ-
ent psychiatric disorders, including anxiety, phobias,
depression, various obsessions and compulsions.
As shown in Table 1, first the anxiety disorders
(specific phobia, social anxiety disorder)presents
comorbiditywith ASD, according to the results of 9
articles studied (Boulter, et al. 2014; Cabibihan, et al.
2013; Campbell-Sills, et al. 2006; Danial, et al. 2013;
Jolstedt et al., 2020; Layne, et al. 2003;Maskey, et al.
2014; Sukhodolsky, et al. 2016; van Steensel et al.
2011). Stress and poor stress management are common
concerns for many people of all ages. Surveys on anx-
iety disorders in children and adolescents estimate a
percentage in the general population ranging from 3%
to 8% (Boulter, et al. 2014; Cabibihan, et al. 2013;
Campbell-Sills, et al. 2006; Danial, et al. 2013; Jolstedt
et al., 2020; Layne, et al. 2003), point out that high lev-
els of stress have adverse effects on children and ado-
lescents with ASD. Data on anxiety disorders in
adolescents with ASD, it is clear that anxiety symptoms
are more common in children and adolescents with
ASD than in many other clinical and non-clinical popu-
lations (Boulter, et al. 2014; Cabibihan, et al. 2013;
Campbell-Sills, et al. 2006; Danial, et al. 2013; Jolstedt
et al., 2020; Layne, et al. 2003; Sukhodolsky, et al.
2016; van Steensel et al. 2011).
Stress symptoms can cause cognitive and behavioral
difficulties and increase the symptoms of ASD.
According to Boulter, et al. (2014), Cabibihan, et al.
(2013), Danial, et al. (2013), Jolstedt et al., (2020)
Sukhodolsky, et al. (2016), and van Steensel et al.
(2011), many of their stereotyped behaviors, such as
hoarseness, twisting, shaking, banging, clapping, and
repetitive questions, increase as children are distressed
or anxious. Moreover anxiety symptoms can cause
acute discomfort in children and adolescents with ASD
and cause more extreme behavioral difficulties such as
anger, aggression, self-harm and phobias (Boulter, et al.
2014; Cabibihan, et al. 2013; Campbell-Sills, et al.
2006; Jolstedt et al., 2020; Maskey, et al. 2014;
Sukhodolsky, et al. 2016; van Steensel et al. 2011).
They also can cause social isolation. In many people
International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0 5
C. K. Syriopoulou-Delli and Areti- Eirini Filiou A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
Solutions and therapeutic methods
Figure 1. PRISMA flow diagram.
with ASD, it is the anxiety symptoms that make them
avoid social situations and contact with others, not only
the symptoms of ASD (Danial, et al. 2013; Layne,
et al. 2003).
This is followed by depression with 5 articles refer-
ring to its coexistence with ASD (Choque Olsson, et al.
2017; Christner, et al. 2007; Dautenhahn, 2003;
Hudson, et al. 2019; White, et al. 2018). Many children
and adolescents with ASD have symptoms that meet
the diagnostic criteria for major depression (Choque
Olsson, et al. 2017; Christner, et al. 2007; Dautenhahn,
2003; Hudson, et al. 2019; White, et al. 2018).
According to Choque Olsson, et al. (2017), Christner,
et al. (2007), Dautenhahn, (2003), Hudson, et al. (2019)
and White, et al. (2018), people with ASD who are
depressed can experience a wide range of symptoms,
such as social difficulty, irritability, sadness, aggressive
outbursts, feelings of isolation, interpersonal struggles,
and even suicidal thoughts.
Many researchers have noticed that depression seems
to increase the symptoms of ASD. Children and
6 International Journal of Developmental Disabilities 2022
adolescents with ASD and depression may experience
an increase in ideological thoughts and behaviors and
rituals or, conversely, a complete loss of interest in past
concerns and interests. arousal, stereotypes, and self-
harm may increase with depression (Choque Olsson,
et al. 2017; Christner, et al. 2007; Dautenhahn, 2003;
Hudson, et al. 2019; White, et al. 2018).
OCD with 1 article (Uhre, et al. 2020). Although
ASD and OCD are distinct disorders, it is documented
that children with ASD show increased rates of obses-
sive-compulsive symptoms and children with OCD
often exhibit other features of ASD (Uhre, et al. 2020).
Children and adolescents with OCD and ASD have
recurring annoying and disturbing thoughts (obsessions)
and exhibit repetitive mental and behavioral rituals
(compulsions) such as controlling, repeating, and count-
ing behaviors that can help reduce stress and feelings
(Uhre, et al. 2020).
The most prevalent co-occurring diagnosis with the
Mental Disorders Diagnostic Tool (DSM-5) in children
and adolescents with ASD are Anxiety Disorders
VOL. 0 NO. 0
 Table 1. Presentation of research articles that were analyzed and general information.

n. Authors Participants Mental disorders Symptoms Therapy Therapy strategies Summary of results
1. Boulter, et al. 2014 224 Anxiety disorders Restricted and Repetitive Behaviors – – There is a high level of anxiety disorders in
8–18 years children with ASD
2. Cabibihan, et al. 2013 25 Anxiety disorders Restricted and Repetitive Behaviors ICT Robots Robots are successful in helping children
7–14 years with ASD in their social, emotional, and
communication deficits
3. Campbell-Sills, 30 Anxiety disorders, Social difficulties, Isolation CBT Acceptability There is a high level of anxiety in children
et al. 2006 8–17 years with ASD. CBT techniques such as
acceptability can help
4. Choque Olsson, 296 Depression Social difficulties, Isolation, irritability, CBT Activation, cognitive reconstruction, There is a high level of depression in
et al. 2017 8–17 years sadness, aggressive outbursts, Social Skills children with ASD. CBT for autistic youths
interpersonal struggles, in regular mental health services is feasible
suicidal thoughts and safe.
5. Christner, et al. 2007 146 Depression Social difficulties, Isolation, irritability, CBT Cognitive reconstruction, Metaphors, There is a high level of depression in
C. K. Syriopoulou-Delli and Areti- Eirini Filiou

6–17 years sadness, interpersonal struggles Progressive muscle relaxation children with ASD. CBT techniques
can help
6. Danial, et al. 2013 22 Anxiety disorders Restricted and Repetitive Behaviors, CBT Goal setting, Metaphors, Exposure, There is a high level of anxiety in children
8–14 years Social difficulties, Isolation Progressive muscle relaxation, with ASD. CBT techniques can help
social skills
7. Dautenhahn, 2003 23 Depression Social difficulties, Isolation, irritability, ICT Robots, Social skills, activation, deal Robots are successful in helping children
7–14 years sadness, aggressive outbursts, of emotion, relaxation with ASD in their deficits and in
interpersonal struggles, depressive symptoms
suicidal thoughts
8. Hudson, et al. 2019 136 Depression Social difficulties, Isolation, irritability, – – the rates of depressive disorders are high
5–18 years sadness, aggressive outbursts, among individuals with ASD. Compared to
interpersonal struggles, typically developing individuals, individuals
suicidal thoughts with ASD are 4-times more likely to
experience depression in their lifetime
9. Jolstedt et al., 2020 123 Anxiety disorders ICBT CBT techniques through internet There is a high level of anxiety disorders in
8–12 children with ASD. ICBT techniques can
improve it
10. Layne, et al. 2003 212 Anxiety disorders Social difficulties, Isolation CBT Goal setting, Metaphors, Exposure, There is a high level of anxiety in children
8–17 years Progressive muscle relaxation with ASD. CBT techniques such as
acceptability can help
11. Maskey, et al. 2014 9 Anxiety disorders- Restricted and Repetitive ICBT CBT techniques through internet There is a high level of anxiety disorders in
7–13 Specific phobia Behaviors, Phobias, children with ASD. ICBT techniques can
improve it
12. Sukhodolsky, 14 Anxiety disorders Anger, Irritability. Aggression CBT Emotion regulation, Problem solving There is a high level of anxiety disorders in
et al. 2016 7–16 years children with ASD. CBT techniques can
improve it

International Journal of Developmental Disabilities

13. Uhre, et al. 2020 645 OCD Obsessions, Compulsions CBT Goal setting, Metaphors, Exposure, There is a high level of OCD in children
8–18 Progressive muscle relaxation, with ASD.CBT techniques can improve it
social skills

2022
14. van Steensel, 31 Anxiety disorders Restricted and Repetitive – – There is a high level of anxiety and
et al. 2011 5–18 Behaviors, Aggression depression in children with ASD
15. White, et al. 2018 23 Depression Social difficulties, Isolation, irritability, CBT Goal setting, Metaphors, Progressive There is a high level of anxiety and

VOL.
8–17 years sadness, aggressive outbursts, muscle relaxation, activation depression in children with ASD. CBT

0
interpersonal struggles, techniques such can help
suicidal thoughts

NO.
0
7
A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
Solutions and therapeutic methods
C. K. Syriopoulou-Delli and Areti- Eirini Filiou A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
Solutions and therapeutic methods
estimated to occur in 11–84% for youth with ASD
(Boulter et al., 2014). The second most common mental
disorder in people with autism is Depression which
occurs in 2–30% (Boulter et al., 2014). Moreover,
Obsessive Compulsive Disorder (OCD) occur in 3–12%
(Boulter et al., 2014). These disorders and their symp-
toms cause discomfort and can have a significant
impact on the functioning of people with ASD, making
their daily lives difficult.
These disorders create functional problems in their
daily lives, exacerbating the damage caused by the fea-
tures that define ASD (Boulter et al., 2014; Berkovits
et al., 2017; Brockman et al., 2017). Through the litera-
ture it seems that children with ASD have difficulty
managing their thoughts, feelings and behaviors. They
show deficits in their sociability, empathy for others, as
well as in the Theory of Mind.
3.2. Research question 2: CBT or ICT and
children with ASD and mental disorders
CBT for children and adolescents with ASD focuses on
both the symptoms of ASD and additional psycho-
logical problems, such as anxiety and can help in a
number of ways. ICT can also be really helpful in chil-
dren with ASD and co-exist mental disorders.
Many articles recommend CBT and ICT as the ideal
treatment for children and adolescents with ASD and
anxiety symptoms (Cabibihan, et al. 2013; Campbell-
Sills, et al. 2006; Danial, et al. 2013; Maskey, et al.
2014; Layne, et al. 2003; Jolstedt et al., 2020;
Sukhodolsky, et al. 2016;). CBT techniques such as
goal setting, metaphors, exposure, progressive muscle
relaxation, social skills, problem solving, social skills,
can improve the anxiety symptoms of children with
ASD (Campbell-Sills, et al. 2006; Danial, et al. 2013;
Jolstedt et al., 2020; Layne, et al. 2003; Sukhodolsky,
et al. 2016;) Other propose the ICT therapy programs
such as robots, in order to help children with ASD to
deal with their anxiety symptoms (Cabibihan,
et al. 2013).
Many articles recommend CBT as the ideal treat-
ment for children and adolescents with ASD and
depressive symptoms (Choque Olsson, et al. 2017;
Christner, et al. 2007; White, et al. 2018). The techni-
ques in this case focus on depressive thoughts and
negative emotions in order to achieve cognitive
reconstruction.People help identify these thoughts and
feelings, evaluate them, and then replace them with
other thoughts that are more positive, optimistic, and
realistic also with the use of metaphors. CBT also
focuses on activation in patients with depression.
According to Dautenhahn, (2003), robots can also be
helpful to improve depressive symptoms in children
and adolescents with ASD with relaxation techniques.
Robots can also be used to enhance communication,
deal with emotions, and maintain social relationships in
8 International Journal of Developmental Disabilities 2022
children with ASD and depressive symptoms
(Dautenhahn, 2003).
3.3. Research question 3: Combination of ICT
and CBT be to children with ASD and
mental disorders
Applying CBT techniques, along with ICT techniques,
can provide effective treatment for mental health prob-
lems, helping children and adolescents with ASD to
develop cognitive, emotional, and behavioral strategies
for managing them (Maskey, et al. 2014). Thus children
with ASD are able to initially understand and identify
their dysfunctional-unrealistic thoughts, negative emo-
tions and behaviors and then be able to manage them
by making the way they think more realistic through
psychotherapy.
According to Maskey, et al. (2014), ICBT programs
(combination of CBT and ICT) can be more affective
in anxiety symptoms. ICBT is both effective and cost-
effective for young people with anxiety disorders and
has the potential to significantly increase the availabil-
ity of treatment (Maskey, et al. 2014).
In this endeavor, in addition to mental health profes-
sionals, the help and support of both family and school
is important.
4. Discussion
International research shows that children and adoles-
cents with ASD show symptoms of various psycho-
logical disorders along with the characteristics that
determine ASD. High rates of various psychiatric disor-
ders have been reported in people with ASD such as
anxiety, depression, cognitive problems, emotional
regulation difficulties and related behavioral problems
can occur in children of all ages with ASD (Boulter
et al., 2014; Berkovits et al., 2017; Brockman et al.,
2017). Indicatively, van Steensel et al. (2011).
The most common psychological disorder seems to
be Anxiety Disorders, including Specific Phobia and
social anxiety disorder. According to several research-
ers, children and adolescents with autism are as scared
as children of normal development, some animals,
objects, insects (van Steensel et al., 2011; Tyner et al.,
2016). What differentiates children and adolescents
with autism from those of normal development is their
phobia of specific auditory, visual and tactile stimuli
such as loud sounds, bright light, specific colors and
textures. Children with ASD appear to be annoyed,
frightened, and upset when they hear, for example, a
thunderbolt or loud music, when someone touches
them, or when they wear a woolen sweater (Hollon and
Beck, 2013; Tyner et al., 2016).
These movements follow the person with ASD from
an early age and continue into adulthood. They them-
selves can be strengthened and become more intense
when they coexist with intense anxiety and stress.
VOL. 0 NO. 0
 C. K. Syriopoulou-Delli and Areti- Eirini Filiou A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
Anxious dysfunctional thoughts and intense feelings of
anxiety reinforce the stereotypical movements that
occur in autism. Stress, in addition, creates intense
anger, which is difficult to manage the person with
ASD, but also avoidance and social isolation
(Grondhuis and Aman, 2012; Boulter et al., 2014).
Social isolation can also be caused by depressive
symptoms. People with autism are more likely to have
negative thoughts and intense sadness, which leads to
isolation and resignation. People do not find pleasure in
something, they find it difficult to handle their emo-
tions, as well as to express them (Campbell-Sills et al.,
2006; Cohen and Mendez, 2009; Sukhodolsky, Smith
et al., 2016; Sukhodolsky, Vander Wyk et al., 2016;
Tudor et al., 2016; Hudson et al., 2019).
Obsessive-Compulsive Disorder occurs in people
with ASD mainly in the form of obsessive-compulsive
disorder. Persistent ideas, routines and specific thoughts
make it difficult for people with autism on a daily basis
(Boyd et al., 2011). They themselves react when their
routine changes, they want specific things and this
stems from the compulsions that afflict them. In add-
ition, coercions such as repetitive - stereotypical move-
ments are common, which can make their daily and
social life difficult (Mulligan et al., 2014; Vause
et al., 2020).
It is observed that these disorders in children with aut-
ism show a common pattern. This pattern refers to the
difficulty of these children in locating their thoughts and
feelings, but also in their subsequent management. People
with ASD have strong dysfunctional thoughts, which lead
to negative emotions and then to a negative behavior or
social avoidance (Campbell-Sills et al., 2006; Cohen and
Mendez, 2009; Sukhodolsky, Smith et al., 2016;
Sukhodolsky, Vander Wyk et al., 2016; Tudor et al.,
2016; Hudson et al., 2019). The goal of therapy is to
make their thoughts more realistic and adaptable, in order
to change their feelings and behaviors.
Cognitive and Behavioral Therapy (CBT) has the
same intervention pattern and thus can help people with
autism recognize and manage thoughts, feelings and
behaviors (Neil and Sturmey, 2014; Kose et al. 2018).
She offers appropriate techniques that help both identify
and manage dysfunctional thoughts and feelings (Ost € et
al., 2016; Uhre et al., 2020; White et al., 2018). These
techniques are relaxation techniques, metaphors, guided
discovery, cognitive reconstruction and exposure to
phobic and anxiety stimuli. These techniques are
applied by mental health professionals independently or
within various treatment programs. These programs are
designed for children and adolescents with ASD but
also of standard development (Hollon and Beck, 2013;
Halldorsdottir and Ollendick, 2016; Tyner et al., 2016).
The most implemented are the I Can Problem Solve
Program, the Alternative Thinking Strategies Promotion
International Journal of Developmental Disabilities
Solutions and therapeutic methods
Program (PATHS), the Coping Program, and the Koala
Coping Program.
CBT programs and techniques appear through
research to be quite effective in the school context as
well. This therapeutic approach has techniques suitable
for application at school such as the exposure tech-
nique, in which the child is gradually exposed to the
phobic stimulus. A child, for example, who is afraid to
speak in public, may become resilient, may be exposed
through a school play and gradually stop being afraid.
In addition, the problem solving technique is applied in
CBT, but also in school through the mathematics les-
son, and thus it is easier for a child to understand it.
Research shows that ICT intervention is 45% effect-
ive in children and adolescents with ASD. ICT inter-
vention can help children and adolescents with autism
cope with symptoms of anxiety, depression, phobia, and
ocd. Through internet, online programs, virtual reality
and the use of robots it is possible to reduce the symp-
toms of mental disorders (Jolstedt et al., 2020).
ICT intervention can combine with CBT interven-
tion. Applying CBT techniques through technology
(internet, virtual reality-ICBT and robots) seems to be
quite effective, as it stimulates children and stimulates
their interest. Applying CBT techniques, along with
ICT techniques, can provide effective treatment for
these symptoms, helping children and adolescents with
ASD to develop different strategies for managing them
(Hollon and Beck, 2013; Halldorsdottir and Ollendick,
2016; Tyner et al., 2016). Thus children with ASD are
able to initially understand and identify their dysfunc-
tional-unrealistic thoughts, negative emotions and
behaviors and then be able to manage them by making
the way they think more realistic through psychother-
€ et al., 2016; Uhre et al., 2020; White et
apy (Ost
al., 2018).
These programs are good to be implemented early in
people with autism, in order to timely treat and manage
psychological symptoms. This facilitates their daily life,
their sociability and their subsequent work.
Limitations of this research are the existence of
many surveys in the US and England and only one in
Greece. An additional limitation is the need for quanti-
tative research, i.e. research that will be done in society,
at school or in a family context with interviews with
individuals and intervention. These techniques are
applied to children with ASD elements, which are quite
functional. To apply to non-verbal children, younger
children or people with intellectual disabilities they
need to be adapted. This adjustment can be made using
a robot, or using music, dance and other media.
Research needs to be developed to include the adapta-
tion of CBT techniques to non-verbal children, younger
children and children with intellectual disabilities.
The research can be used by people working in men-
tal health structures, psychiatrists, social psychologists,
2022 VOL. 0 NO. 0 9
C. K. Syriopoulou-Delli and Areti- Eirini Filiou A systematic review of dysfunctional thoughts, feelings and phobias of children and adolescents with autism.
Solutions and therapeutic methods
social workers. In addition, it can be used by specialists
working in the field of education such as, special edu-
cators, teachers. These people have the opportunity to
use the research for personal information, for personal
improvement, in their work as an aid but also for carry-
ing out various intervention research.
A proposal for future research is to conduct quantita-
tive research- intervention research, which will help to
apply all this theoretical knowledge in a practical level
and to present their effectiveness to children and ado-
lescents with ASD.
Disclosure statement
All authors declare that there is not conflict of interest.
Ethical approval
All procedures in studies involving human participants
were in accordance with the ethical standards of the
institutional and/or national research committee and
with 1964 Helsinki declaration and its later amend-
ments or comparable ethical standards.
Funding
This study is self-funded.
Informed consent
Informed consent was obtained from all individual par-
ticipants included in the study. dot before reference
indicates papers that were reviewed.
ORCID
Christine K. Syriopoulou-Delli http://orcid.org/
0000-0003-1490-8899
Areti-Eirini Filiou http://orcid.org/0000-0002-
9510-4739
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‘References marked with an asterisk indicate studies included in the
literature review’.
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