CBT for Autism

Great question. A common misconception about individuals on the autism spectrum is that they are not interested in having or maintaining social relationships. Research suggests that ASD youth and adults vary widely in levels of social motivation. With kids, I am especially hesitant to force them into social skills treatment, or making treatment goals about socializing, if they truly are not interested. 

When parents are concerned about their child’s lack of interest in socializing, I first investigate whether the child is truly disinterested. Often, a child or teenager may understandably say that they are disinterested because they have had negative social experiences before with teasing or rejection. In that case, it’s important to build up their skills and confidence, and manage any social anxiety present. If a child or teen says that they are truly disinterested, it may be helpful to discuss the benefits of socializing (e.g., finding someone who likes to talk about or engage in their interests with them) to see if there is any motivation there. But if there still is no motivation there, I would not push social skills-based treatment.

Being a teenager is challenging enough if you are neurotypical. ASD teens can have some additional challenges. Social-emotional maturity can lag behind their peers, which complicates friendships and peer relationships. Co-occurring psychiatric conditions like depression and anxiety are also common. I study emotion regulation issues, so I often see teens who, despite level of functioning, are experiencing emotional meltdowns or outbursts.

No- ASD teens are as unique and individual as all other teens! That being said, there are some things I see more often in people on the autism spectrum, like a strong sense of right and wrong and social justice, a respect for honesty, and a great sense of humor or wit. Unfortunately, with the teens with emotional difficulties that I see, negative self-thoughts are common too.

Both. There are evidence-based programs like the Secret Agent Society, PEERS, and Unstuck and On Target that use CBT-based skills like role-plays, didactic instruction, and skill scaffolding in treatment of core ASD symptoms. CBT has also been used to target co-occurring conditions in ASD, with most of the research on treating co-occurring anxiety. Other conditions or symptoms treated with CBT include anger, depression, OCD, and emotion regulation impairment. Third wave CBT (mindfulness- and acceptance-based therapies) also have research supporting their use for individuals with ASD.

Manualized CBT treatments and research studies describe a handful of modifications for ASD no matter the age of the client. These modifications mostly concern adapting treatment for ASD cognitive styles, things like using a concrete schedule, increasing visual supports, adding social skills when treating a condition that is related (e.g., social anxiety), incorporating the person’s restricted interests into the therapy, and managing attention or executive functioning difficulties (e.g., taking breaks, providing a checklist instead of generating ideas, planning exactly when and how to complete therapy homework).
Specific to teens, how or whether to incorporate caregivers is an important consideration. Comparatively, ASD teens are likely to rely more on their parents, and parents are also a key way to ensure that skills learned in therapy generalize outside of the therapy room. For this reason, it’s optimal if caregivers can act as a ‘coach’ to employing new skills.

There’s no alterations I can think of that applies to ALL of those with ASD. ASD has the word ‘spectrum’ in it purposely- the heterogeneity of individuals is huge. Maybe having a more structured session (a checklist of what topics/activities to be completed in session, either written out or visual)? Although I think that’s helpful for everyone!

This is a good question. We know from neuroscience that neural plasticity (the ability for brains to change) is much, much higher throughout our lives than originally thought. While some research has posited that emotional difficulties in ASD have a neurological basis, CBT-related treatments could still have an impact in changing that neural circuitry. Perhaps this is one of the reasons why ASD individuals seem to do better with more sessions than neurotypicals- maybe more time and practice is needed to change those pathways that lead to negative thoughts or emotions.

Many ASD teens may need more psychoeducation about emotions, including recognizing their own physiological and situational emotion cues. A subset of people on the autism spectrum struggle with awareness of their own emotions (alexithymia). Also, distinguishing between different emotions may not be as important as learning emotional intensity. Clients that I have worked with need help recognizing when they are getting upset before a meltdown occurs, not whether they were ‘angry’ vs. ‘frustrated.’ Developing a common language to talk about intensity is helpful, like an emotion thermometer or a SUDS scale.
It is often helpful to work “in the field” where emotionally arousing situations occur, like bringing in a caregiver to discuss a hot topic, to practice a coping skill. Relatedly, many ASD teens seem to have difficulties recalling and describing their emotional experiences, so it is important to ask caregivers and get multiple informants to understand the issue.

I haven’t seen sensory sensitivities specifically targeted in CBT.

CBT skills can definitely be useful for teaching perspective taking. Social and emotional awareness often go hand-in-hand. For instance, a therapist could discuss common cognitive distortions using language and examples of same-aged peers, clearly stating that different people have different thoughts and responses to the same situation. Psychoeducation about emotions can consist of discussing social vignettes or video examples that demonstrate how people have different emotional experiences.

Another great question! I think that a concrete thinking style that you often see in ASD is really well-suited to CBT. CBT is structured! An exposure hierarchy, making hypotheses about changing your behavior, and practicing a new skill is all pretty concrete. A therapist can also adapt or omit components of CBT as needed for a concrete thinker. Relatedly, this is the probably the #1 question I get about doing mindfulness-based interventions in ASD. In mindfulness, dropping the more esoteric language seen in some meditation practices is the biggest adaptation.

Yes, with a few caveats. The majority of CBT studies in ASD have targeted anxiety disorders in children and adolescents. And most of these studies have focused on individuals who do not have Intellectual Disability (i.e., IQs are above 70). If an adolescent on the spectrum does not have co-occurring ID, and the referral reason has an evidence-base in non-ASD, then I’d say CBT should be considered.

Good point. It depends on the ASD person that is in question. Think about the person’s amount of verbal speech and their listening comprehension. Some people on the spectrum are very verbal thinkers, and working on changing maladaptive negative thoughts can be a huge part of treatment. For other people, CBT is going to mostly consist of behavior change components since the cognitive component isn't really available.