How does the implementation of CBT work for young people with a disorder that falls within the autism spectrum disorders? - Chapter 13

What is this chapter about?

Autism spectrum disorders (ASD) are one of the most common developmental disorders that occur in childhood. It affects 1 in 91 children. The comorbidity (with, for example, an anxiety disorder) is extremely high. The core symptoms are broad and have many facets, from specific social cognitive deficiencies (such as limited theory-of-mind [ToM] skills), to pragmatic language deficiencies, and the routine repetition of (non-functional) behaviors. Nuclear symptoms are often stable over time and difficult to change using interventions. Children with less severe core symptoms, as is the case with Asperger's syndrome or PDD-NOS, have better prognosis, and better quality friendships and relationships with others compared to children with more severe symptoms.

There is a great need for evidence-based treatments for children with ASD that have a clinical impact, because this does not seem to be the case for current psychological treatments and also not for the often prescribed atypical antipsychotic medication. CBT could address the core symptoms and comorbid disorders in "highly intelligent" school-age children. Children with "high-functioning ASD" by definition have an IQ of average to above average. However, the evaluation of the effectiveness of CBT in such cases is still in its infancy.

What adjustments in CBT for school-age children with ASD exist?

There are four strategies to adapt the CBT treatment for school-age children with an ASD. In order to increase the effectiveness of treatments, at least one of the following problems of children with ASD needs to be targeted:

• Their reduced attention span and reduced motivation for subjects outside their area of interest;
• Their reduced ability to understand abstract language use;
• Difficulties in generalizing coping skills, and/or;

The scope of the symptom domains (such as problems in social and emotional domains).

1. Strategy 1: Use the child's interests and activities to increase motivation and strengthen the therapeutic partnership. Use examples and metaphors in the CBT techniques used that are related to their hobbies, so that the sessions are interesting and understandable and better remembered.
2. Strategy 2: Use visual aids to clarify. In traditional CBT for children, the first or second session is used to explain the interaction between thoughts, feelings and behaviors. Children with ASD need a little more guidance in this, by really using as little abstract language as possible and using even more visual aids to better convey CBT concepts.
3. Strategy 3: Provide sufficient psycho-education about ASD. Normally, the first sessions involves psycho-education about the symptoms of the disorder and the relationship of the disorder with the problems experienced. This is then linked to the purpose of the treatment. The disorder is best conceptualized as something external of the child, so that it can be "fought against". By teaching the child that the autism disorder (AD – autism disorder) can be seen as "a bad advisor" (leading to the symptoms) is often useful, taking into account strategy 2).
4. Strategy 4: Train the parents! Parental involvement is especially important in conveying the intervention to children with ASD. Among other things, they can apply a reward system to maintain the level of motivation for treatment, and to encourage the children to apply the skills at home.

Compared to school-age children suffering from other mental health problems, children with ASD are more likely to experience comorbid disorders. Social anxiety disorders are very common, but other anxiety disorders, attention deficits, behavioural problems and depressive disorders are also common comorbidities. The comorbid disorders worsen as the children enter adolescence.

What CBT treatments are used for children who have ASD and comorbid disorders?

In recent years, a lot of research has been conducted on the adaptations of CBT treatments in the case of children with ASD and a comorbid anxiety disorder. For example, Sofronoff and colleagues (2005), Chalfant and colleagues (2007), Reaven and colleagues (2009) and White and colleagues (2010) conducted well-controlled studies. Their results are promising, meaning that not only the ASD symptoms decreased, but also symptoms of comorbid disorders (such as anxiety). Such combined interventions are superior to independent interventions, especially when parents are also involved.

There has been significantly less clinical research on an adapted form of CBT in the case of children with ASD and behavioural disorders (such as an ODD – oppositional defiant disorder). Although the results of the study of Sofronoff and colleagues (2007) are promising, the only outcome measures were the self-reports of the parents and the self-reports of the teachers.

In the field of children with ASD and social disabilities, Bauminger (2002, 2007a, 2007b) and Wood and colleagues (2009) have mainly conducted research on the effectiveness of an adapted form of CBT. It turns out that the treatments that lead to the most positive outcome are the ones provided in late childhood (and possibly early adolescence). These treatments have an intensive, individual character where the child is mainly trained in noticing and understanding other people's perspectives and emotional states.

What are the future prospects of CBT for the treatment of autism?

There are a number of CBT programs for school-age children with ASD that have been carefully developed and described. However, these interventions are not as effective as the interventions used for treating other disorders, including anxiety disorders. In the future, more research will need to be conducted on developing more robust methods that – unlike most social skills training – are not subject to 1) the generalisation problem, and 2) the problem that skills are not preserved over time (maintenance problem).

According to the authors, when developing new treatments, the social communication domain should be emphasized. First, when determining which social skills need to be improved, this has to be based on the unique ASD symptoms and unique characteristics of the child. There should also be hypothetical scenarios and role-playing integrated into the treatment. This can help to generalize and maintain skills. Furthermore, there is a need for valid measurements to be better able to identify the core symptoms of autism, as well as the degree of generalisation and preservation.

Autism spectrum disorders (ASD) are one of the most common developmental disorders that occur in childhood. It affects 1 in 91 children. The comorbidity (with, for example, an anxiety disorder) is extremely high. The core symptoms are broad and have many facets, from specific social cognitive deficiencies (such as limited theory-of-mind [ToM] skills), to pragmatic language deficiencies, and the routine repetition of (non-functional) behaviors. Nuclear symptoms are often stable over time and difficult to change using interventions. Children with less severe core symptoms, as is the case with Asperger's syndrome or PDD-NOS, have better prognosis, and better quality friendships and relationships with others compared to children with more severe symptoms.