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Enhancing Social Experience: Cognitive
Behavioral Interventions With Autism
Spectrum Disorders
NATIONAL ASSOCIATION OF SCHOOL PSYCHOLOGISTS (NASP)
ANNUAL CONVENTION
FEBRUARY 22, 2011
JESSICA B. BOLTON, PSY.D., NCSP
[email protected]
RAY W. CHRISTNER, PSY.D., NCSP
[email protected]
JENNIFER E. MCPOYLE-CALLAHAN, B.S.
[email protected]
SOUTH MIDDLETON SCHOOL DISTRICT
BOILING SPRINGS, PA
Today we will discuss….
 Cognitive Behavioral Therapy (CBT)
 What is CBT
 Basic Principles
 How does CBT address deficits in ASD
 Overview of the Literature
 Specific Techniques and Programs
 Measuring Effectiveness
 How to progress monitor groups and individuals /program
evaluation
Theoretical Background
 Autism is thought to be neurobiological disability that
affects normal brain development (McGrath and Peterson,
2009)
Genetic Risk Factors and Heritability
 Neuro-anatomical structures (structural and functional
abnormalities found in imaging research)

 Many theories of autism are present in the literature
regarding the explanation of the neurobehavioral
sequela of the disorder
Theoretical Background
 Executive Dysfunction Theory of Autism (Ozonoff,
Pennington, Rogers, 1991; Russell, 1997)
Research has found a profile of executive strengths and
weaknesses in children with autism.
 Weakness: cognitive flexibility/shifting
 Strengths: working memory
 Literature has studied role in social skill deficits

 Theory of Mind (Baron-Cohen, Leslie, & Frith, 1985)

Research has shown that children with autism have
difficulty with ToM tasks
So… What is CBT?
AND HOW DOES IT RELATE
TO ASD?
Cognitive Behavior Therapy
 Traditional Model
Activating
Event
Automatic
Thought
(Belief)
Consequence
(Behavior/
Feeling
Multidirectional Model
Situational
Behavioral
Problem
Affective
Copyright 2010 © Christner & Mennuti
Cognitive
Errors in Processing
 Cognitive Deficiency – the lack of information
processing
 Cognitive Distortions – an active but misguided way
of processing information
 Skill Deficiency – the lack of a specific skill
 Skill Dysfunction – the lack of implementation or
generalization of skill
Components of CBT with Children
 Appropriate session length
 Expand child’s emotional vocabulary
 Identify and dispute dysfunctional ideas
 Teach self-instructional techniques
 Teach problem-solving skills
 Role play specific skills
 Provide opportunity to practice skills learned (aka –
homework)
 Allow opportunity for generalization (break skills into
specific steps)
 Reinforce positive behavior and skill mastery
Structuring Your CBT Sessions
 Set Agenda
 Review
 Current status
 Events of past week
 Solicit feedback regarding previous session
 Review homework from previous session
 Focus on main agenda items
 Develop new homework
 Solicit feedback regarding current session
Case Conceptualization
 Helps inform when and how to use tools
 Continual/Dynamic/Fluid Process
 Requires hypothesis testing
 Helps broaden perspectives
 Differs from diagnosis
 Should be shared with client
 Leads to treatment plan
Modular-Based Interventions
 Benefits




Decreases the demands of following a manual-based program
Uses specific techniques from manual-based programs
Allows the use of outcome research to develop good interventions
Bases intervention on specific client needs
 Difficulties



Must have good case conceptualization skills
Must use single case design and progress monitoring more efficiently
to measure outcome
Must have a good understanding of the literature across various
disorders
Possible Modules
 Goal Setting
 Social Skills
 Cognitive Restructuring
 Communication Skills
 Exposure/Response
 Activity Scheduling







Prevention
Relaxation
Psychoeducation
Self-Monitoring
Self-Praise/Self-Talk
Problem Solving
Assertiveness Skills
Increasing Desirable
Behaviors
 Relapse Prevention/






Maintenance
Guided Imagery
Relationship Building
Personal Safety Skills
Emotional Awareness
Behavior Initiation
Decreasing Undesirable
Behaviors
What deficits in ASD does CBT address?
 Social/Cognitive deficits
 Perspective taking
 Emotional identification and regulation
 Inflexible/rigid thinking patterns
 Internalizing symptoms
 Verbal /language deficits
 Possible comorbid internalizing problems
STRATEGIES USED WITH
CHILDREN AND
ADOLESCENTS WITH ASD
THAT FOLLOW A CBT OR
META-COGNITIVE APPROACH
5 Point Scale (Buron & Curtis, 2003)
 Ranks emotions and
problems on a 1 – 5
levels
 Can be related to
reactions and strategies
Power Cards (Gagnon, 2001)
 Uses special interest and
a summary statement
(goal) from a social
story using the special
interest character as a
model.
 Model of appropriate
behavior
Jim Carrey looks at the person who
is talking.
Bibliotherapy
The use of books to help illustrate social situations or
demonstrate problem-solving
To be used in conjunction with other methods
Superflex curriculum has one lesson that utilizes
Bibliotherapy techniques
Some Good Books:
 Amelia Bedelia
 Junie B
 Berenstein Bears
Video Modeling (Bellini, 2003)
 Tape the child and play back to give feedback –
Video Self-modeling
 Tape another student doing the behavior - Video
Instruction
 Tape approximations by the student and show it to
the student as a complete behavior – Video FeedForward
SOCCSS (Myles, 2005)
 Strategy to help with
new situations






Situation
Options
Consequences
Choices
Strategies
Simulation
 Utilizes behavioral
rehearsal techniques
Social Autopsies (Lavoie, 1994)
Comic Strip Conversations
 Discussion of a problem
 Go over what happened
 What was the error
 What were people thinking and feeling
 What should happen next
 Can use Comic Strip conversations to make it a
visual process
Comic Strip Conversations (Gray, 1996)
 Comic Strip conversations helps children to identify
thoughts and perspectives of others as well as
responses and outcomes
 A form of social stories
More visual
 Draw what happens using stick people and thought
bubbles
 Use colors to show how people were feelings when you
write the words
 After student describes, fill in missing feelings or
misperceptions, and what should happen

Social Stories™ (Gray, 2000)
 Prescribed story giving students the rule of social
situations using the student as the main character.



Only say what should be done
Describe the setting
Give explanation of why
 Likely used as a part of treatment, not the entire
treatment
 Adaptation – Guided Social Stories (Livanis,
Solomon, and Ingram, 2007)
Hidden Curriculum (Myles, 2004)
 Teach “hidden rules” of various settings
 To help students gain an understanding of social
norms
 Goals is improve perception of the student’s
environment and social expectations
 Meta-cognitive approach to help improve expected
behaviors
PROGRAMS DESIGNED FOR
CHILDREN AND ADOLESCENTS
WITH ASD THAT UTILIZE A
CBT AND META -COGNITIVE
APPROACH
The Alert Program (Williams & Shellenberger, 1992)
 “How Does Your Engine Run?”
 Teaches awareness of energy levels and how
to bring the energy level back to the center
 Focuses on Self-Regulation skills
SelfRegulation
=
Exploring Feelings (Attwood, 2004)
 Tony Attwood’s books for managing anxiety and anger
 Uses direct instruction, activities, and self-awareness
lessons
 Teaches the affective component of CBT as well as the
thoughts and behaviors
 Serves as a preventative approach for internalizing
disorders
Thinking about You Thinking about Me (Winner, 2002)
Think Social (Winner, 2004)
 Thinking about You Thinking about Me
 Provides a theoretical background on the Social thinking
approach
 Provides some activities, but is not a curriculum/manual
 Think Social!
 Teaches how to observe others, make guesses about their
thoughts and actions, and change your own behavior based on
your observations
 CBT components – Affective education, behavior mapping,
parent communication (but no specific homework), and role
plays
Superflex.. .(Madrigal & Winner, 2008)
 “To teach social thinking and related social skills”
(www.socialthinking.org)
 To increase a student’s self-monitoring abilities of their
behaviors and the impact of their behaviors on others
 To increase a student’s knowledge of when they are
exhibiting inflexible thinking and to strategies to
overcome inflexible thinking
 Uses superheroes and villains to illustrate behaviors and
thought processes
Superflex…
 Currently there is no research published on Superflex…
 Not research-based, but based on research:
 Based on principles of CBT
 Includes agenda setting, homework, parent participation, practice
opportunities, feedback, psychoeducation, and some instruction
on the thought/behavior/feeling triad
 Addresses executive component/performance deficit

Teaches “Superflexible” thinking (cognitive flexibility), selfmonitoring and regulation, and planning skills
 Addresses Theory of Mind
 Teaches “thinking about others”
 Uses a multi-sensory approach
 Visual representation of abstract concepts
• Exploring Feelings
• Think Social!
• Thinking About You
Thinking About Me
• Superflex
• Exploring Feelings
• Think Social! *
• The Alert Program *
The Alert Program
Superflex
Power Card Strategy
Meet Thotso, Your
Thought Maker book
• SOCCSS
• Video Modeling
• Social Autopsy
• Social Stories*
• Comic Strip
Conversations
• Incredible 5 Point
Scale
• My Big Book of
Feelings
• Meet Thotso, Your
Thought Maker book
• Social Autopsy *
Behavioral
Instruction
Techniques
Affective
Education
•
•
•
•
• Exploring Feelings
• Think Social!
• Thinking about You
Thinking about Me
• Superflex
• The Alert Program
• Social Stories
• Comic Strip
Conversations
• Pwer Card Strategy
• Meet Thotso, Your
Thought Maker book
• Social Autopsy
Cognitive
Instruction/
Techniques
E VALUATING E FFECTIVENESS OF
YOUR I NTERVENTIONS
Evaluating Effectiveness
 Important in order to establish own evidence-base
for programs that are not yet established in the
literature
 Required by federal and state mandates
 Used to monitor:
 Groups
 Programs
 Individuals
Methods for Progress Monitoring
 Observations
 Frequency counts
 Percentages
 Duration
 Interviews
 Rating Scales
 Goal Attainment Scaling
 Self-report
 Video monitoring
 Homework completion
 Pre and Post comparisons
Goal Attainment Scaling (Kiresuk & Sherman, 1968)
 Method to help determine if your change is meaningful
 After collecting baseline, identify goal and write anchors
 Ex.:
+2
+1
0
-1
-2
Student makes more than expected progress (51% +/- in
behaviors)
Student makes expected progress (25 – 50% +/- in
behaviors)
(Baseline) No improvement; Less than 25% change in
behavior;
Student demonstrates a decline in functioning
(-25% to 50% increase/decrease in behaviors)
Student demonstrates a worse decline in functioning
(More than -51% increase/decrease in behaviors)
Good Resource: Coffee, G. & Ray-Subramanian, C.E. (2009).
Goal
Attainment
Scaling
+2
Meet Jeremiah
+1
0
Goal 1: Jeremiah
will decrease his
overall rating to
15.53 unexpected
behaviors within a
twenty minute
social setting.
X (10.33)
X (2.66)
X (14.00)
X
(20.7)
-1
-2
Baseline
Average
Week 1 - 6
Averages
Week 6 12
Averages
Post
Averages
Goal
Attainment
Scaling
+2
+1
0
Goal 2: Jeremiah
will increase his
expected behaviors
to 38.75 expected
behaviors within a
twenty minute
social setting.
X (42.66)
X (31)
-1
X (27.66)
X (23.66)
-2
Baseline
Average
Week 1 - 6
Averages
Week 6 12
Averages
Post
Averages
Individual Data Collection - Charting
Percentage Expected
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
25-Oct
1-Nov
8-Nov 15-Nov 22-Nov 29-Nov 6-Dec 13-Dec 20-Dec 27-Dec 3-Jan
10-Jan 17-Jan 24-Jan 31-Jan
7-Feb
Methods for Promoting Generalization: How to
continue progress
 Use “perseverative interest” in teaching
 Teach the “why” not just the “how”
 Use between session homework
 Challenge participants to try skills (behavioral
rehearsal) and report back
 Communicate with parents and teachers
 Provide opportunities within the naturalistic
environment during social skills training (with
support)
Methods for Promoting Generalization: How to
continue progress after termination
 Use cues and prompts to utilize taught skills outside




of session (shaping)
Provide positive reinforcement for spontaneous use
of skill outside of session
Offer “booster” sessions
Recommend social opportunities to parents (Boy
Scouts, sports, theatre, etc.)
Continue to progress monitor to determine true
generalization and adaption
References and Resources
 Association for Behavioral and Cognitive Therapies (2010). Evidenced-based

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mental health treatments for children and adolescence. Accessed
electronically from
http://www.abct.org/sccap/?m=sPro&fa=pro_ESToptions#sec13 on October 1,
2010.
Attwood, T. (2000). Strategies for improving the social integration of children
with Asperger syndrome. Autism, 4(1), 85-100.
Attwood, T. (2004). Exploring feelings: Cognitive behavior therapy to manage
anger. Arlington, TX: Future Horizons.
Avery, R.R. (2008). Meet Thotso: Your thought maker. York, ME: Smart Thot,
LLC.
Baron-Cohen, S. Leslie, A.M., & Frith, U. (1985), Does the autistic child have a
“theory of mind?”, Cognition, 21, 37-46.
Center for Disease Control, (2010). Autism information center: Frequently
asked questions - prevalence. Accessed electronically from
www.cdc.gov/ncbddd/Autism/faq_prevalence.htm#howdotherates on April 17,
2010.
References and Resources
 Christner, R.W., Stewart, J., & Freeman, A. (eds.). (2007). Handbook of

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cognitive-behavior group therapy with children and adolescents: Specific
setting and presenting problems. New York, NY: Routledge.
Coffee, G. & Ray-Subramanian, C.E. (2009). Goal attainment scaling: A
progress monitoring tool for behavioral interventions. School Psychology
Forum, 3(1), 1 – 12.
Elksnin, L.K. (2000). Teaching parents to teach their children to be prosocial.
Intervention in School and Clinic, 36(1), 27-35.
Friedberg, R.D., & McClure, J.M. (2002). Clinical practice of cognitive therapy
with children and adolescents: The nuts and bolts. New York, NY: Guilford
Press.
Gray Center (2009). What are social stories? Accessed electronically from
www.thegraycenter.org on May 21, 2009.
Ingram, D.H. (2006). Cognitive-behavioral interventions with autism
spectrum disorder. In Cognitive-behavioral interventions in educational
settings: A handbook for practice. Mennuti, R.B., Freeman, A., & Christner,
R.W. (eds.) New York: Routledge Publishing.
References and Resources
 Jaffe, A.V., Gardner, L. (2006). My book full of feelings. Shawnee Mission, KS:

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Autism Asperger Publishing Co.
Kiresuk, T.J., & Sherman, R.E. (1968). Goal Attainment Scaling: A general
method for evaluating comprehension community mental health programs.
Community Mental Health Journal, 4(6), 443-453.
Livanis, A., Solomon, E.R., & Ingram, D.H. (2007). Guide social stories: Group
treatments of adolescents with Asperger’s Disorder in the schools. In
Handbook of Cognitive-Behavior Group Therapy with Children and
Adolescents. Christner, R.W., Stewart, J.L, and Freeman, A. (eds.). New York,
New York: Routledge Press
Madrigal, S. & Winner, M. (2008). Superflex…A superhero social thinking
curriculum. San Jose, CA: Think Social Publishing, Inc.
McGrath, L.M., & Peterson, R.L. (2009). Autism spectrum disorder. In
Diagnosing Learning Disorders, Second Edition: A Neuropsychological
Framework. Pennington, B.F. (author) New York: Guilford Publishers.
Mennuti, R.B., Freeman, A., & Christner, R.W. (eds.). (2006). Cognitivebehavioral interventions in educational settings: A handbook for practice.
New York, NY: Routledge.
References and Resources
 Myles, B.S. & Simpson, R.L. (2001). Understanding the hidden curriculum: An
essential social skills for children and youth with Asperger Syndrome.
Intervention in School and Clinic, 36(5), 279-286.
 Myles, B.S., Trautman, M.L., & Schelvan, R.L. (2004). The hidden curriculum.

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Practical solutions for understanding unstated rules in social situations. Shawnee
Mission, KS: Autism Asperger Publishing Co.
Ozonoff, S., Pennington, B.F., Rogers, S.J. (1991). Executive function deficits in
high-functioning autistic individuals: Relationship to theory of mind. Journal of
Child Psychology and Psychiatry, 32(7), 1081-1105.
Russell, J. (1997). How executive disorders can bring about an adequate theory of
mind In J. Russell (Ed.), Autism as an executive disorder. Oxford, England: Oxford
University Press.
Williams & Shellenberger, (1996). How does your engine run? A leader's guide to
the alert program® for self-regulation . Albuquerque, NM: Therapy Works, Inc.
Winner, M.G. (2002). Thinking about you thinking about me. San Jose, CA:
Michelle Garcia Winner.
Winner, M.G. (2005).Think social! San Jose, CA: Michelle Garcia Winner.
Winner, M.G. (2005). Worksheets for teaching social thinking and related skills.
San Jose, CA: Think Social Publishing, Inc.
Web Resources
Autism
 www.autismnetwork.org/modules/social/index.html
 www.socialthinking.com
 www.autism-society.org
 www.aspergersyndrome.org/
 www.aspennj.org/
 www.thegraycenter.org/
 www.tonyattwood.com.au/
 www.research.chop.edu/programs/car
 www.oar.org
CBT
 www.beckinstitute.org
 www.abct.org
 www.nacbt.org