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CBT for people with autism

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GinaGomez
GinaGomez

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I'm really interested in how we can adapt psychological therapies such as CBT for people with autism. There are a few really useful articles so far on Network Autism (e.g. Professor Ann Ozivandijan's presentation and Tim Lacey's article on treating depresson, but I'm really keen to hear other people's professional experience. What aspects of CBT are useful for people on the spectrum? What needs to be adapted? What research needs to be done in future? What has worked for you?
 

Edited on February 23, 2017 - 9:20am

Dawn

February 17, 2012 - 5:10pm

Hi Gina

I was looking into this for my thesis proposal; specifically CBT for anxiety in young people with ASC but from an educational perspective.  The majority of studies are from the clinical perspective, as might be expected, but my interest is how such approaches can be used within the naturalistic setting before presentation of symptoms becomes more severe and requires targeted support at CAMHS Tier 3.

I also felt that targeting this within the educational setting was a consideration as the research highlights the importance of engaging the wider context (schools, families, parents) in applying CBT approaches with young people with ASC.

Unfortunately I haven’t been able to actually explore this further in my thesis due to time factors and am exploring need for young people with ASC and anxiety in schools instead.

However, I did complete most of a literature review regarding CBT for YP with ASC and anxiety and the following excerpt may be useful:

Modification of CBT for ASC

Traditional CBT, which relies heavily upon good linguistic and abstract thinking skills (Reaven, 2009), needs to be modified to take into account the specific needs of CYP with ASC (White et al., 2009).  Instances of this include: a more visual and concrete approach, use of practical activities, incorporation of specific interests, and use of ASC specific hierarchies (Moree & Davis III, 2010; Reaven, 2009).  The various studies of CBT and ASC highlight successful elements of this to different degrees, but summary tables  have been provided in 3 recent papers (see Donoghue, Stallard, & Kucia, 2011; Lang et al., 2010; and Rotheram-Fuller & MacMullen, 2011), and  the full paper by Moree & Davis III (2010) considers the various modifications.

Also, I carried out some work last year with some YP who were struggling with anxiety and their support staff in mainstream secondary.  I worked with the YP and staff on understanding psychoeducation, and simple CBT type approaches - not full CBT, but core concepts such as scaling, helping YP identify their worries and typical behaviour when anxious (including identifying physical signs and symptoms of anxiety), seeking out supporting and conflicting evidence for thoughts, considering possible alternative thoughts and gaining evidence for these etc.  Using lots of visual approaches etc. Seems to have had a positive impact so far. 

It’s something I’d like to follow up further when I have the time/opportunity.

Interested to hear of others experiences too…

Dawn

February 17, 2012 - 5:12pm

Oh, apologies, my first posting and apparently it doesn't like lines between paragraphs!  Hope it makes sense all scashed up together

GinaGomez

February 17, 2012 - 7:16pm

Hi Dawn,

Thanks very much for this- really useful information. I'm also interested in getting mental  health work into schools- am currently researching the effectiveness of parenting classes on preventing mental health problems escalating in young children (reception class). Have you published any of your work as I'd be very interested to read it? Were they people with autism you did your anxiety work with or more broadly?  I wonder how easy it is to help students with autism to recognise their emotions, and also to challenge their thoughts (I am thinking of students I know who are convinced that they are correct and their autism means they find it hard to see a different perspective)?

Anyway, it's all very interesting! thanks for replying!

Gina

Dawn

February 20, 2012 - 8:57pm

Hi Gina,

That sounds very interesting – getting in early with these needs is so important. Is your research with the parenting classes specific to autism or the wider population of students?

 

My work was primarily young people with Asperger’s (some with diagnosis of autism, but higher functioning).  However, it was practice based work and so not formally evaluated or written up, but it led to my considering it as a research possibility.  Unfortunately time constraints didn’t make that a feasible option to follow through and I have opted for another related piece of research re needs and best practice for young people with ASC and anxiety in mainstream secondary schools.  I hope to have completed it by the end of the year.

 

With regards to the recognition of emotions, it’s a difficult one.  Many of these young people seem to have learnt to be able to ‘label’ certain emotions but how they relate to them and understand them in relation to our frames of reference is another matter.  Research suggests that they can find understanding of the physical/bodily feelings related to emotions easier to understand than the language and facial expressions associated with them and therefore I have tended to use that as a focus for developing understanding of their own feelings/emotions.  Also, using concepts such as them developing their own frames of reference for their emotions such as labelling them (the described bodily/physical sensations) with colours, or creating their own made up names that have more meaning for them to help them understand and recognise their emotions more easily in the first instance.

 

Challenging their own thoughts is a difficult one, but the court room prosecution/defence analogy (depending on levels of understanding and age), or being a detective gaining evidence strategy can be helpful to use along with visuals to explore some of the CBT Socratic questioning etc with them. E.g. gaining ‘evidence’ for or against their possibly ‘distorted’ thought processes (to use CBT language) and carrying out ‘experiments’ with regard to how they respond to these. Obviously this isn’t going to work for everyone and it’s very important to consider levels of comprehension and functioning, and use of visuals, video etc to support this etc. I have found some usefulness with some young people with AS with these approaches though, but obviously, as with any intervention/support, it isn’t suitable for all.

 

This is an interesting paper regarding use of CBT with a young person with AS using meta-cognitive visual aids, which they have since been developing further.  

 

Greig, A., & MacKay, T. (2005). Asperger’s Syndrome and cognitive behaviour therapy: New applications for educational psychologists. Educational and Child Psychology, 22(4), 4-15.

 

Would be interested to hear of any work others have been doing in this area….

Dawn

Zoe

March 23, 2012 - 6:02pm

There is another way to think about this.  If we agree that anxiety in autism is often about difficulties and challenges with coping with uncertainty, novelty and change, then resilience, social understanding and emotional regulation could be improved by enabling people with autism to cope with (and enjoy) change.

I have helped to address the distorted 'catastrophic thinking' of a 12 year old with autism who was verging on depression by enabling him to access opportunities for promoting his competence (helping to develop resilience), improving his self-esteem and self confidence.  Adapted CBT didnt help him at all - this would be confirmed by the Clinical Psychologist who was treating him at the time.

Different approaches are needed for children with different autism profiles and personalities.

Zoe

GinaGomez

March 24, 2012 - 8:44am

Hi Zoe,

Yes - I agree with you. It's clear that CBT doesn't work for everyone (even if no autism present), and we need to be creative in helping children and adults overcome their anxiety. It's about figuring out what the causes are for that particular individual and then coming up with possible solutions. I'd be really interested in hearing about how you helped the boy you talk about access opportunities to improve his self-esteem and self-confidence. What did you do, how long did it take, and in what ways did  it help him?

Thanks,
Gina

Zoe

March 25, 2012 - 1:42pm

 

Hi Gina

At the time, I was already using a social communication intervention that has a clear focus upon affected individuals’ capacity and motivation for interpersonal engagement and is informed by a sophisticated view of the developmental psychopathology of autism. The origins of this approach are summarised in two books by Prof Peter Hobson 1993 and 2002/4.

According to this perspective, the children’s primary handicap is in the human propensity to identify with the mental states (and especially feelings) of other people. This limitation in engaging with other persons as persons is a motivational as well as cognitive disability. It has profound implications for the children’s abilities to develop context-sensitive language, to think flexibly and creatively, and to participate in social and cultural life.

The child I'd been working with is my son. Over the course of about 3 years, with lots of hard work in everyday situations in the family setting, he had mastered many of the developmental milestones that underpin positive social and interpersonal engagement: social referencing, joint attention (you should see his initiation of JA now and his ability to carry through a meaningful reciprocal conversation where he is genuinely interested in the other communication partner's thoughts, feelings and views smiley), co-regulation; some of the foundations of perspective-taking.

Examples of everyday interactions we used include: hanging washing out; loading and unloading the dishwasher; shopping; playing simple games like Kerplunk and Buckaroo; making lemonade; lots and lots of cooking. I write a blog called 'Food for Thought' about how we worked on some of these social communication milestones http://notnigellanotjamie.blogspot.com

In the course of using this approach, his ADOS score had reduced from 19 out of 22, to 12. So.....a long road, still a way to go, but we were doing pretty well. Then events conspired (as they do sometimes for all of us) that were particularly challenging for a young person with autism who has vulnerabilities associated with emotional regulation and social reciprocity. These events caused my son to experience the beginning of mental health difficulties (referral to CAMHS, Clinical Psychologist input etc).

Our family RDI Consultant gently helped us to realise that our RDI programme (the approach I am describing above) had slipped (we were in the middle of setting up a school that uses the principles and practice of RDI to inform teaching - securing funding, finding building, training teaching staff, lots of related admin and organising). Juggle too many balls and you end up dropping one of them......wrong one to drop though!

So we then had a concerted effort at putting our RDI programme back in place and within about 3 months we had pulled him back from the abyss. This included some intensive work on scaffolding interactions with peers, looking closely at our own (parents) behavioural dialogues with him, as well as keeping up with the ongoing RDI programme that we had let slide.

During this time I had access not only to our own family RDI Consultant, but (because I was also training to become an RDI Consultant myself....more ball jugging) also to a wide range of other RDI professionals who are also trained in allied disciplines such as clinical psychology, speech and language therapy, social work, family therapy...as well as (crucially) other parents who had been through similar challenges with children of a similar (very challenging) autism profile.

What helped my son was the re-investment in family relationships that comes with RDI, as well as promoting his self confidence and self esteem by providing opportunities for him to competently resolve problems in a co-regulated interaction (the basic work of RDI). In RDI, competence is spotlighted so that positive episodic memories are laid down (we know from research that EM is impaired in autism). The more positive EM, the more resilience is built. Arguably (and according to work done by our government in this area), resilience is the cornerstone of good emotional wellbeing.

RDI is all about promoting competence in co-regulated interactions...so that there is a joint sense of achievement 'we did this together' and 'my input was just as important as Mum's'......in psychology terms, it's joint engagement I guess.

Some preliminary research on RDI was presented at IMFAR last year.

http://imfar.confex.com/imfar/2011/webprogram/Paper8196.html

There are further studies in progress, some due to be published soon (just in review).

I'm just about to do the same sort of things (adapted off-site programme using principles and practice of RDI) with another child whose local authority have asked us to place him at our school following the breakdown of placements at 3 special schools (2 of them very well known specialist autism schools).  It was the Clinical Psychologist who saw my son at his lowest and saw what we achieved with re-instating our RDI programme, who suggested to the local authority that our school might be a good placement for this young man.  I may well blog about our experience if its ok with the family in question.

Zoe

Anne Donohoe

September 12, 2012 - 6:07pm

Hi there,

I have just found this conversation and found it very interesting. I have worked in mainstream and special ed and have a son on the spectrum ...I have worked from early intervention to adults and with the mildly affected to the very significantly cognitively and behaviourally different.  I also worked intensively with my son, used ABA, TEACCH, Sensory Integration, Speech, Occupational and Physiotherapy etc.. My son also has done very well. I got very interested in Psychology and ended up doing some extra qualifications. I know all about juggling too!Thanks for your info and I am going to look at your links. Where is your school and how is it going? I am based in the South West of England.

Thanks, Anne

Zoe

September 12, 2012 - 6:48pm

Hi Anne

Our school is in Oldham, near Manchester www.brightfuturesschool.co.uk

This academic year we have reconfigured our provision so that now each pupils has an individual timetable tailored to their specific needs and interests.  Into this we programme our guiding activities which work on social and emotional development.  So far its going really well.  One or two hiccups with our newest pupil but these are to be expected where changes to our approach are involved and I am confident that we are flexible and creative enough to address the hiccups.

Zoe

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