Throughout our years working with the ASD population, parents often inquire about whether their child should be receiving speech-language or psychological services. The answer is frequently “both.” Research demonstrates that individuals with ASDs are at great risk for developing significant mental health concerns which often stem from the core social and communication impairments associated with their spectrum diagnosis (Gjevik, Eldevik, Fjæran-Granum, & Sponheim, 2011). Effective treatments must address the core social and communicative deficits while at the same time promoting coping and emotion skills development through the use of evidence-based techniques.
As professionals, we need to move away from “silo treatments” for the individual difficulties facing our bright verbal clients with ASD based on our area of expertise (e.g., speech language, mental health). Rather, we need to consider utilizing a multidisciplinary approach. We know that individuals with ASDs struggle with gestalt processing – that is taking individual pieces of a puzzle and recognizing how they all fit together to create one picture or main idea. If a child sees a psychologist for emotional regulation and coping strategies and then separately sees a speech-language therapist to work on conversation skills, their core deficits make it difficult for them to understand how those two sessions fit together – that their difficulty initiating an interaction with a peer is causing an emotional response.
What is the Role of the Speech-Language Pathologist (SLP)?
Given the nature of ASDs, speech-language therapy is considered a primary intervention at all ages, and has been shown to be critical for promoting social communication, relationships and social cognition (National Research Council, 2001). Current research is demonstrating a need for a new type of communication-based treatment for individuals with more complex language abilities, such as those with diagnoses of Asperger Syndrome (AS) and High-Functioning Autism (HFA). This new method not only teaches this population how to apply social communication skills within the social word, but also how to analyze and think about why social communication is necessary in their own lives.
A specific treatment program that promotes this goal is Social Thinking® (Winner 2000, 2002). SLPs working with this program will target skills such as perspective taking, nonverbal communication, and social interaction by exploring why these skills are important to the specific client. They provide ample opportunities for their clients to practice these skills in a variety of activities and environments.
Social Thinking starts by breaking down abstract concepts into smaller, more concrete pieces. For example, the concept of listening is taught through use of concrete vocabulary such as listen with our eyes™, listening with ears, and body is part of the group™. These are taught individually using multiple modalities such as discussions, visual stories, role-playing, and self-monitoring via video. While clients are building their social thinking vocabulary, they are taught to understand how these concepts are linked and why they are imperative for social success. Clients directly learn how their social behaviors impact the thoughts and feelings of others. They then learn why and how they can modify their behaviors (verbal and nonverbal) to allow others to think and feel positively about them. This program does not teach discrete social skills using behavioral methods like reinforcement. Instead it teaches clients the core skills required to explore the intentions and reactions of others across situations.
A recent research study targeted how the Social Thinking program could facilitate social communication and interaction skills in six 9-11-year-old boys with AS and HFA (Crooke, Henrix, Rachman, 2007). Participants were taught the Social Thinking Vocabulary of expected and unexpected behaviors (Winner, 2002). The boys participated in 60 minute group treatment sessions across 8 weeks. They were directly taught how their verbal and nonverbal actions have an impact on the thoughts and feelings of others. Other sessions targeted whole body listening; how to create social files to remember information about people, and filtering their comments. During four generalization sessions, the participants were rated on: expected behaviors (on-topic remarks, maintaining an interaction through single-word comments, initiating an interaction with a question or comment, and listening with eyes) and unexpected behaviors (negative or off-topic comments, perseverative topics, talking to self/mirror, and random body movements). Results demonstrated significant positive changes in the use of expected behaviors, even though these discrete skills were not directly targeted! Participants were also able to demonstrate the skills during real-life interactions.
Incorporating Cognitive Behavioral Therapy (CBT)
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 with ASDs struggle with experiencing negative thoughts and feelings without possessing the skills necessary to problem solve and cope with such situations, leading to significant mental health concerns.
Cognitive behavioral therapy (CBT) is a structured and goal-oriented form of psychotherapy that has a large evidence base. CBT 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. CBT teaches children and teens to develop more effective coping skills through exploring the connection between thoughts, feelings, and behaviors. Within a CBT framework, a therapist can also target social skills deficits by directly teaching social norms and expectations as well as strategies for successful social interactions and relationship development. The targets of CBT as well as the structured nature of the approach, allow for effective adaptation for individuals with autism spectrum disorders. Several studies as well as anecdotal evidence support the use of cognitive behavioral therapy in autism spectrum disorders, though to date most of the research has focused on addressing anxiety (Reaven et al., 2009; Wood, Drahota, Sze, Har, Chiu & Langer, 2009; Sze & Wood, 2007; Gaus, 2007; Anderson & Morris, 2006).
The modification of CBT for use with an individual child with an ASD requires an initial assessment of 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 when working with children with ASDs. Additionally, a child’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.
A randomized, controlled trial of individual CBT to target anxiety in children (ages7-11) with ASDs provides an example of how treatments can be modified and the utility of CBT for children with ASDs. The researchers modified and augmented a standard CBT intervention for the treatment of anxiety disorders to both accommodate and intervene on adaptive and social skills deficits specific to the ASD population (Wood et. al, 2009). The core CBT interventions included coping skills training and in-vivo exposure to feared stimuli. Modifications were made to the existing curriculum by using specific interests to teach therapeutic concepts and providing reinforcement throughout the intervention. Additional modules were added which provided specific social skills instruction and focused on building independence in self-help skills. The researchers compared children who received the modified CBT curriculum with wait list controls (N=36). After 16 weeks of treatment, 78.5% of children who had received the intervention showed significant improvement, whereas only 8.7% of children in the wait list group showed improvement.
The Power Combination
For individuals with ASDs, the power combination of CBT and Social Thinking® facilitates the development of both social skills and adaptive coping skills. Together, these strategies improve the ability to modulate emotional reactions, facilitate social communication and interaction, and reduce depressive and anxious symptomatology. By working collaboratively as well as modifying strategies to best suit individual needs and abilities, psychologists and speech language pathologists can together best meet the therapeutic needs of bright, verbal individuals with ASDs