We are frequently reminded that often we do not in fact treat “autism,” but rather the co-occurring mental health and behavioral issues associated with ASDs. Youth and adults with ASDs have social and emotional difficulties which, if not addressed as part of a comprehensive intervention program, often lead to significant mental health issues. Not only do social skills deficits make it difficult for youth with ASDs to understand the thoughts and emotions of others, they also contribute to difficulties understanding and interpreting one’s own thoughts and feelings. These deficits in turn can lead to difficulties with modulating emotions and behavior. Further, coping skills, or our ability to manage challenging life situations, are learned socially, most often in ways that are not explicitly taught. Therefore, many high functioning youth and adults with ASDs struggle with experiencing negative thoughts and feelings without possessing the skills necessary to problem solve and cope with such situations. The unfortunate combination of experiencing difficulties with emotion regulation along with having ineffective coping skills can lead to behavioral episodes, social rejection, impaired self-esteem, anxiety, and depression, and can increase the risk of inpatient hospitalization. These outcomes place stress on the importance of effective psychotherapy for individuals with ASDs.
Almost 10% of children presenting in community settings have an ASD (Brockman-Frazee, 2010). Psychotherapy for these youth is intended to treat co-occurring symptoms such as emotion dysregulation, anxiety, and depression. These tend to be individuals with average to above average cognitive abilities who are therefore expected to play an integral role in the therapy process and use behavioral as well as cognitively mediated strategies. However, they often cannot understand and take part in therapy. Emotion identification and understanding are pre-requisite skills for therapy, as is metacognition, or thinking about thinking. With neurotypical youth, it is assumed that they possess the underlying skills necessary to begin cognitive behavioral therapy (e.g., can identify their own and others’ emotions, can label thoughts). With youth, and often adults with ASDs, the discrepancy between ability and required skill, necessitates either the teaching of these skills to increase “therapy readiness” or the adaptation of treatment strategies. In our clinical practice, it is a combination of these two approaches which we have found to be most effective in treating mental health issues facing individuals with ASDs.
Laying the Foundation
Cognitive behavioral therapy (CBT) is an evidence-based form of psychotherapy that is structured and goal oriented. It was initially developed for the treatment of depression but has been successfully adapted for the treatment of a wide range of issues, including anxiety, social skills deficits, and anger management. Although originally developed for adults, CBT has been shown to be highly effective in the treatment of children and teens. CBT focuses on the thoughts, feelings, and behaviors that contribute to an individual’s distress. By focusing on the connection between thoughts, feelings, and behaviors CBT teaches children and teens to develop more effective coping skills. CBT also targets social skills deficits by directly teaching social norms and expectations as well as strategies for successful social interactions and relationship development. Several studies as well as anecdotal evidence support the use of cognitive behavioral therapy in autism spectrum disorders (Reaven et al., 2009; Wood, Drahota, Sze, Har, Chiu & Langer, 2009; Sze & Wood, 2007; Gaus, 2007; Anderson & Morris, 2006).
When deciding how to adapt CBT for use with an individual client with an ASD, it is important to assess the individual’s particular strengths, weaknesses, interests, and preferred learning style. For example, many individuals with ASDs report that information presented visually is easier for them to process and retain. The CBT approach typically utilizes visually presented information and worksheets and these tools should be emphasized with the ASD population. Additionally, an individual’s special interests may be used to increase motivation and facilitate the therapeutic process. When conducting CBT with youth with ASDs it is important to adapt the components to best fit an individual’s needs based on a comprehensive understanding of the individual’s cognitive and developmental level, areas of strength and weakness, preferred learning style, interests and presenting difficulties. These factors help to determine where therapy needs to begin and how to best teach new skills, as well as set initial goals.
For individuals with ASDs, CBT facilitates the development of adaptive coping skills to modulate emotional reactions and reduce depressive and anxious symptomatology by focusing on increasing understanding of both thoughts and feelings. By teaching pre-requisite skill as well as modifying strategies to best suit individual needs and abilities, CBT can be used successfully to treat co-occurring mental health issues for individuals with ASDs.
For more information about the ASPIRE Center for Learning and Development’s CBT Clinic and opportunities to participate in treatment, please contact Samara Tetenbaum, PhD, Psychology Fellow at ASPIRE at (631) 923-0923 or firstname.lastname@example.org. You may also visit our website at www.aspirecenterforlearning.com.