Cognitive Behavioural Therapy modifications for those on the autism spectrum

Professionals working with people on the autism spectrum may need to adapt this therapy to better meet autistic people’s needs, writes researcher Julie Peake.

THERE IS SOME consistency in the adaptations recommended as a therapeutic intervention in that strategies are often more visual, repeated and concrete.

This is however dependent on age, person’s preference and specific reason for utilising Cognitive Behavioural Therapy (CBT).

What is CBT? 

CBT approaches are designed to teach people how to monitor their own thoughts and perceptions as a way of becoming more aware of possible interpretive errors.

As the name suggests, CBT attends to both cognition (thinking) and behaviour (action) and is frequently used as a form of therapeutic intervention for neurotypicals with anxiety and depression.

Anxiety and depression are common co-occurring conditions for those on the autism spectrum so it makes sense to consider this as a potential psychosocial intervention (Spain, Sin, Chadler, Murphy & Happe, 2015; Kerns, Roux, Connell & Shattuck, 2016).

Relevant research

There is some evidence that psychological interventions adapted for adults with autism can be effective (Spain et al, 2015; Kerns et al, 2016).

Spain et al (2015) located a small number of studies that utilised CBT to treat and reduce co-occurring anxiety and depression symptoms.

These studies used different methodologies however narrative analysis of the data found that CBT interventions (including behavioural, cognitive and mindfulness-based techniques) were moderately effective treatments.  Given the small sample size and different methodological approaches, further empirical research was recommended to fully investigate (1) the acceptability and effectiveness of a range of CBT interventions for autistic adults with co-occurring anxiety and depression and (2) to identify which adaptations would optimise CBT techniques and outcomes.

Kerns and others (2016) identified that CBT approaches have been modified successfully to treat anxiety and depression in early adolescents. They provide a more conceptual article that explores the vulnerabilities present for those in later adolescence and emerging adulthood and draw from their own clinical experience alongside the literature to offer some potential modifications.  The table below is adapted from Kerns et al (2016 p.333) and highlights adaptions that could enhance a collaborative therapeutic relationship.

 

CategoryAdaptions to enhance CBT for emerging adults on the Autism Spectrum
GeneralRegular practice in real world settings is crucial for skill generalisation.  With the individual’s permission and input, enlist trusted relatives, friends, and any other appropriate people to help the person practice skills outside of session
Support structure, routine and achievable goals as well as pleasurable activities into daily life
Therapist’s flexibility and patience is key. Use flexible and creative approaches to explain concepts and understand the individual’s perspective and time frame for acquiring skills
Incorporate special interests into the session to enhance engagement and motivation
Use interactive, multimodal teaching methods
Make abstract concepts into concrete tasks and activities
Use data and technology- some individuals may prefer an evidence based and structured approach that incorporates electronic applications (e.g. mood trackers, heart rate monitors)
Support executive functioning by creating routines, reminders, checklists, encouraging the individual to pick, rather than generate strategies and setting attainable goals
PsychoeducationProvide psychoeducation about both anxiety disorders and ASD
Take time to explore individual’s understanding and experience of ASD or their ASD related difficulties
Normalise symptoms and instill hope. Psychoeducation may provide an important space to build rapport and improve the subjective well-being needed to engage in later, more challenging sessions
Teach multiple strategies for affect recognition –e.g. physical, behavioural and social. Focus on cues that work for the individual
Personalise therapy tools – use custom anchors e.g. examples form the person’s own life for fear rating scales and new concepts
Cognitive restructuringProvide samples of thinking traps and coping thoughts from which the individual can choose. Use coping “stems” that the client can personalise (e.g. “I can help myself by……”)
Develop simple, multiple purpose coping thoughts that can apply to varied situations
Behavioural activationEstablish routines and attainable goals (S.M.A.R.T goals)
Coordinate efforts with trusted family and friends (with permission) to develop a successful and attainable activity schedule
Integrate social skills training sessions and/ or social skills groups into activity scheduling. Groups can serve a dual purpose of targeting social skills challenges and increasing social opportunities
Teach problem solving strategies before scheduling and targeting more challenging activities to enhance self-efficacy, motivation and the likelihood of success

 

Vasa and others (2014) systematically examined the efficacy and safety of psychopharmacological and non-psychopharmacological anxiety treatments for youth with autism spectrum disorders. They found moderate efficacy when CBT was utilised. CBT modifications included: visual supports, concrete language, modules to address special interests, social skills and emotional regulation. These researchers highlighted the importance of considering adaptations to the instruments used to assess anxiety in addition to focusing on intervention strategies.

Ung and others (2014) systematically reviewed the literature and provided a meta-analysis examining the efficacy of CBT for anxiety among autistic youth. Findings suggested that CBT demonstrated robust efficacy in reducing anxiety symptoms in youth with “high-functioning” autism. The modifications made to CBT were: inclusion of social stories that explain the thoughts and feelings of others; social coaching to develop social skills; visuals aids and structured worksheets to employ CBT components.

Weston and others (2016) conducted a meta-analysis and systematic appraisal of the effectiveness of CBT for autistic people. They found a small to medium positive effect depending on the outcome measure used. Common adaptations were: increased use of social stories and vignettes, increased use of role play, and the involvement of family members in the intervention sessions and homework activities.

Walters and others (2016) evaluated studies that effectively employed CBT to alleviate symptoms of mental health problems of young people. The results indicated that modified CBT led to a reduction in anxiety, obsessive-compulsive disorder (OCD) and depression. This review summarised the consistently reported modifications to the content and delivery of interventions for:

Anxiety as (2016, p 147);

  • Longer durations of sessions to allow more time to match children’s pace and repeat content to aid learning
  • Use of metaphors, e.g. child as scientist to encourage guided discovery (NB – this contrasts with other adaptations that suggest making interventions more concrete)
  • Use of acronyms e.g. STAR to introduce problem solving and cognitive restructuring
  • Use of social stories for cognitive restructuring and problem solving
  • Use of idiosyncratic ratio scales (e.g. a feelings thermometer to concretely measure change instead of asking about feelings directly)
  • Incorporate a relaxation strategy section into the programme
  • Tangible reinforcement programme in session which can be translated to home and school
  • Use of video modelling and role play to teach coping strategies
  • Increased use of games to convey concepts and maintain interest for younger children
  • Employ an additional parenting component to help parents support their child
  • Link with schools to increase school-based support and generalisation of concepts

Additional modifications for treatment of obsessive-compulsive disorder as (2016, p. 147);

  • A longer assessment and intervention period to allow for differentiation of compulsions and rituals and better understand meanings given to thoughts
  • Exposure and response prevention (ERP) using graded hierarchy and home practices

Summary of specific modifications to treat depression with young people as (2016, p. 148);

  • Shorter programme
  • Emphasis on challenging negative thoughts
  • Introduction of thought records
  • Mindfulness rather than relaxation
  • Less of a behavioural emphasis
  • Strategies to manage the “internal critic” through thought catching and replacing
  • Highlighting links between behaviour and mood
  • Improving social resources

Relevant books: There are also books that may support clinicians in their practice. For example, CBT for Children and Adolescents with High-Functioning Autism Spectrum Disorders (2016) edited by Angel Scarpa, Susan White and Tony Attwood. Chapters are presented as session-by-session overviews and review program evidence base and practical considerations in treatment. The book provides a framework for assessment and case conceptualisation that draws from the DSM-5.

Summary
There is some research evidence to suggest that modifications to CBT may be a useful intervention for those on the autism spectrum. Further rigorous study is required to advance knowledge in the effectiveness of this as a psychosocial intervention.

  • Julie Peake was a researcher for Altogether Autism and Parent to Parent.

References
Kerns, C., Roux, A., Connell, J., & Shattuck, P. (2016). Adapting Cognitive Behavioural Techniques to address anxiety and depression in cognitively able emerging adults on the autism spectrum. Cognitive and Behavioural Practice, 23 (3), 329-340.
Salt, A., Crowe, B. (2015). Autism: the management and support of children and young people on the autism spectrum (NICE Clinical Guideline 170). Arch Dis Child Educ Pract Ed 2015;100:20–23.

Spain, D., Sin, J., Chalder, T., Murphy, D., Happe, F. (2015). Cognitive behaviour therapy with autism spectrum disorders and psychiatric co-morbidity: A review. Research in Autism Spectrum Disorders, 9, pp 151-162.

Ung, D., Selles, R., Small, B., Storch, E. (2014). A systematic review and meta-analysis of cognitive-behavioural therapy for anxiety in youth with high-functioning autism spectrum disorders. Child Psychiatry Human Development. Springer – published online September 2014.

Vasa, R., Carroll, L., Nozzolillo, A., Mahajan, R., Mazurek, M., Bennett, A., Wink, Lo., Bernal, M. (2014). A systematic review of treatments for anxiety in youth with autism spectrum disorders. Journal of Autism Developmental Disorder, 44: 3215-3229.

Walters, S., Loades, M., Russell, A. (2016). A systematic review of effective modifications to cognitive behavioural therapy for young people with autism spectrum disorders. Journal of Autism Developmental Disorder, 3: 137-153.

Weston, L., Hodgekins, J., Langdon, P. (2016). Effectiveness of cognitive behavioural therapy with people who have autistic spectrum disorders: A systematic review and meta-analysis. Clinical Psychology Review. 49: 41-54.

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