Ask the Expert – Cognitive Behavioral Therapy 101

It is not uncommon that a diagnosis of autism spectrum disorder (ASD) is accompanied by the presence of another mental health disorder. Most often, a comorbid diagnosis of an anxiety disorder or attention-deficit/hyperactivity disorder (ADHD) is present. Signs/symptoms of anxiety that may be displayed include: worried thoughts about performance, social interactions, and/or situation-specific concerns or fears. Hallmark features of ADHD include: difficulty sustaining attention, staying on-task and seated, and waiting one’s turn.

Research-supported interventions for the treatment of anxiety disorders include behavioral therapy and cognitive-behavioral therapy (CBT). Behavioral therapy may be chosen over CBT when the child is young, autism severity is greater, or the nature of the anxiety is fear-based or situationally-based in which exposure to the feared situation (for example: weather, toilets, or public speaking) is the most effective intervention. Behavioral intervention also may be favored over CBT due to challenges with perspective-taking that may interfere with being able to identify errors in thinking and challenging distorted thoughts.

CBT interventions include psychoeducation about diagnostic impressions, self-monitoring (i.e. feelings identification and intensity, duration, and frequency of symptoms), relaxation training/management of somatic symptoms (e.g. diaphragmatic breathing and muscle relaxation), cognitive restructuring (i.e. accurate thinking), problem solving, behavioral rehearsal (i.e. practice of new skills), exposure/behavioral experiments, and homework assignments.

Available modifications to CBT for those with ASD include increased incorporation of technology and visual aids, sensory breaks, enhancement of reinforcement strategies, more frequent review of content, and moving through content at a slower pace. More session time is devoted to feelings identification. In addition, detective thinking and selection of coping thoughts are often used rather than self-generated coping thoughts due to possible deficits in perspective-taking.  Social skill intervention is also helpful for addressing conversational skills, sportsmanship, and how to respond to bullying. Social skills can be taught within the context of a therapist-patient relationship, but need to be practiced and generalized within the context of a group. Caregiver involvement is also important to help prompt, coach, and reinforce use of skills to manage/minimize symptoms of anxiety.

ADHD is often associated with the presence of disruptive behavior. Parent training in behavior management includes helping parents determine antecedents to behavioral challenges and how consequences influence the child’s reaction or response. This then helps to understand the function or reason for behaviors and to develop an effective plan to minimize problematic behaviors. Parent training in behavior management also includes spending individual time with the child, developing a reinforcement plan to increase the frequency of positive behaviors (e.g. following directions with 3 or fewer prompts), how to use active ignoring in response to minor misbehavior (e.g. whining) and give effective commands, as well as identify developmentally appropriate consequences.  A therapist can work with caregivers to create an effective behavioral plan. It is important to consider the reinforcer or reward that is being used to increase the frequency of a positive behavior. The reinforcer has to be motivating to the child and more immediate and frequent when the plan is initially being implemented.  It should be considered whether the reinforcer should be a primary reinforcer (e.g. food), social reinforcer (e.g. high-five or hug), tangible reinforcer (grab bag prize), the opportunity to engage in special activities or earn privileges, or the use of tokens, which can be collected to earn a larger reward.

When high-functioning ASD and comorbid diagnoses of anxiety and ADHD are present, a two-pronged approach, which includes behavioral therapy/CBT and parenting training in behavior management is often recommended.  Caregivers are often unsure which mental health presentation should be addressed first. This will be discussed further with the patient’s therapist. In general, the goals that are identified dictate the treatment modality. The symptoms that cause the most impairment in daily functioning are likely to be addressed first.

It is important to adopt a strength-based approach and to choose goals that are measurable and objective.  The therapist should be considered an additional team member in meeting the family’s goals.

Dr. Kimberly Burkhart is a clinical psychologist at Rainbow Babies and Children’s Hospital in the Division of Developmental-Behavioral Pediatrics and Psychology. She is an Assistant Professor of Pediatrics and Psychiatry through Case Western Reserve University. Dr. Burkhart provides assessment and intervention for youth with autism spectrum disorder. She also conducts research in this area.