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National Association of School Psychologists (NASP) Annual Convention

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Presentation on theme: "National Association of School Psychologists (NASP) Annual Convention"— Presentation transcript:

1 Enhancing Social Experience: Cognitive Behavioral Interventions With Autism Spectrum Disorders
National Association of School Psychologists (NASP) Annual Convention February 22, 2011 Jessica B. Bolton, Psy.D., NCSP Ray W. Christner, Psy.D., nCSP Jennifer E. Mcpoyle-Callahan, B.S. South Middleton School District Boiling Springs, PA

2 Today we will discuss…. Cognitive Behavioral Therapy (CBT)
What is CBT Basic Principles How does CBT address deficits in ASD Overview of the Literature Specific Techniques and Programs Measuring Effectiveness How to progress monitor groups and individuals /program evaluation


4 Theoretical Background
Autism is thought to be neurobiological disability that affects normal brain development (McGrath and Peterson, 2009) Genetic Risk Factors and Heritability Neuro-anatomical structures (structural and functional abnormalities found in imaging research) Many theories of autism are present in the literature regarding the explanation of the neurobehavioral sequela of the disorder

5 Theoretical Background
Executive Dysfunction Theory of Autism (Ozonoff, Pennington, Rogers, 1991; Russell, 1997) Research has found a profile of executive strengths and weaknesses in children with autism. Weakness: cognitive flexibility/shifting Strengths: working memory Literature has studied role in social skill deficits Theory of Mind (Baron-Cohen, Leslie, & Frith, 1985) Research has shown that children with autism have difficulty with ToM tasks

6 And how does it relate to ASD?
So… What is CBT? And how does it relate to ASD?

7 Cognitive Behavior Therapy
Traditional Model Activating Event Automatic Thought (Belief) Consequence (Behavior/ Feeling

8 Multidirectional Model
Problem Situational Cognitive Affective Behavioral Key Terms of CBT Automatic Thoughts – thoughts that occur without much consideration (habitual and reflexive) Core Beliefs – fundamental beliefs that influence response to a situation (e.g., how we think, feel, and act) Schema – a cognitive framework that serves as a basis for screening, organizing, and interpreting situations based on past experiences (e.g., clusters of core beliefs about the self, others, and the future) Schema – these operate outside of the individual’s awareness and often are not clearly verbalized. CBT Model The way we view ourselves, the world, and the situations that confront us shapes how we feel, what we think, and how we act. Fosters change in the way people think and behave. Interventions target the situational, cognitive, affective, and/or behavioral components of the individual’s presenting problems. Copyright 2010 © Christner & Mennuti

9 Errors in Processing Cognitive Deficiency – the lack of information processing Cognitive Distortions – an active but misguided way of processing information Skill Deficiency – the lack of a specific skill Skill Dysfunction – the lack of implementation or generalization of skill

10 Components of CBT with Children
Appropriate session length Expand child’s emotional vocabulary Identify and dispute dysfunctional ideas Teach self-instructional techniques Teach problem-solving skills Role play specific skills Provide opportunity to practice skills learned (aka – homework) Allow opportunity for generalization (break skills into specific steps) Reinforce positive behavior and skill mastery

11 Structuring Your CBT Sessions
Set Agenda Review Current status Events of past week Solicit feedback regarding previous session Review homework from previous session Focus on main agenda items Develop new homework Solicit feedback regarding current session

12 Case Conceptualization
Helps inform when and how to use tools Continual/Dynamic/Fluid Process Requires hypothesis testing Helps broaden perspectives Differs from diagnosis Should be shared with client Leads to treatment plan

13 Modular-Based Interventions
Benefits Decreases the demands of following a manual-based program Uses specific techniques from manual-based programs Allows the use of outcome research to develop good interventions Bases intervention on specific client needs Difficulties Must have good case conceptualization skills Must use single case design and progress monitoring more efficiently to measure outcome Must have a good understanding of the literature across various disorders

14 Possible Modules Goal Setting Cognitive Restructuring
Exposure/Response Prevention Relaxation Psychoeducation Self-Monitoring Self-Praise/Self-Talk Problem Solving Assertiveness Skills Increasing Desirable Behaviors Social Skills Communication Skills Activity Scheduling Relapse Prevention/ Maintenance Guided Imagery Relationship Building Personal Safety Skills Emotional Awareness Behavior Initiation Decreasing Undesirable Behaviors

15 What deficits in ASD does CBT address?
Social/Cognitive deficits Perspective taking Emotional identification and regulation Inflexible/rigid thinking patterns Internalizing symptoms Verbal /language deficits Possible comorbid internalizing problems

16 STRATEGIES used with Children and Adolescents with ASD that follow a CBT or Meta-cognitive approach

17 5 Point Scale (Buron & Curtis, 2003)
Ranks emotions and problems on a 1 – 5 levels Can be related to reactions and strategies

18 Power Cards (Gagnon, 2001) Uses special interest and a summary statement (goal) from a social story using the special interest character as a model. Model of appropriate behavior Jim Carrey looks at the person who is talking.

19 Bibliotherapy The use of books to help illustrate social situations or demonstrate problem-solving To be used in conjunction with other methods Superflex curriculum has one lesson that utilizes Bibliotherapy techniques Some Good Books: Amelia Bedelia Junie B Berenstein Bears

20 Video Modeling (Bellini, 2003)
Tape the child and play back to give feedback – Video Self-modeling Tape another student doing the behavior - Video Instruction Tape approximations by the student and show it to the student as a complete behavior – Video Feed-Forward

21 SOCCSS (Myles, 2005) Strategy to help with new situations
Options Consequences Choices Strategies Simulation Utilizes behavioral rehearsal techniques

22 Social Autopsies (Lavoie, 1994) Comic Strip Conversations
Discussion of a problem Go over what happened What was the error What were people thinking and feeling What should happen next Can use Comic Strip conversations to make it a visual process

23 Comic Strip Conversations (Gray, 1996)
Comic Strip conversations helps children to identify thoughts and perspectives of others as well as responses and outcomes A form of social stories More visual Draw what happens using stick people and thought bubbles Use colors to show how people were feelings when you write the words After student describes, fill in missing feelings or misperceptions, and what should happen


25 Social Stories™ (Gray, 2000)
Prescribed story giving students the rule of social situations using the student as the main character. Only say what should be done Describe the setting Give explanation of why Likely used as a part of treatment, not the entire treatment Adaptation – Guided Social Stories (Livanis, Solomon, and Ingram, 2007)

26 Hidden Curriculum (Myles, 2004)
Teach “hidden rules” of various settings To help students gain an understanding of social norms Goals is improve perception of the student’s environment and social expectations Meta-cognitive approach to help improve expected behaviors

27 Programs designed For Children and Adolescents with ASD that utilize a CBT and Meta-cognitive approach

28 The Alert Program (Williams & Shellenberger, 1992)
“How Does Your Engine Run?” Teaches awareness of energy levels and how to bring the energy level back to the center Focuses on Self-Regulation skills = Self-Regulation

29 Exploring Feelings (Attwood, 2004)
Tony Attwood’s books for managing anxiety and anger Uses direct instruction, activities, and self-awareness lessons Teaches the affective component of CBT as well as the thoughts and behaviors Serves as a preventative approach for internalizing disorders

30 Thinking about You Thinking about Me
Thinking about You Thinking about Me (Winner, 2002) Think Social (Winner, 2004) Thinking about You Thinking about Me Provides a theoretical background on the Social thinking approach Provides some activities, but is not a curriculum/manual Think Social! Teaches how to observe others, make guesses about their thoughts and actions, and change your own behavior based on your observations CBT components – Affective education, behavior mapping, parent communication (but no specific homework), and role plays

31 Superflex.. .(Madrigal & Winner, 2008)
“To teach social thinking and related social skills” ( To increase a student’s self-monitoring abilities of their behaviors and the impact of their behaviors on others To increase a student’s knowledge of when they are exhibiting inflexible thinking and to strategies to overcome inflexible thinking Uses superheroes and villains to illustrate behaviors and thought processes

32 Superflex… Addresses executive component/performance deficit
Currently there is no research published on Superflex… Not research-based, but based on research: Based on principles of CBT Includes agenda setting, homework, parent participation, practice opportunities, feedback, psychoeducation, and some instruction on the thought/behavior/feeling triad Addresses executive component/performance deficit Teaches “Superflexible” thinking (cognitive flexibility), self-monitoring and regulation, and planning skills Addresses Theory of Mind Teaches “thinking about others” Uses a multi-sensory approach Visual representation of abstract concepts

33 Cognitive Instruction/ Techniques
Behavioral Instruction Techniques Exploring Feelings Think Social! Thinking About You Thinking About Me Superflex The Alert Program Power Card Strategy Meet Thotso, Your Thought Maker book SOCCSS Video Modeling Social Autopsy Affective Education Think Social! * The Alert Program * Social Stories* Comic Strip Conversations Incredible 5 Point Scale My Big Book of Feelings Social Autopsy * Cognitive Instruction/ Techniques Thinking about You Thinking about Me Social Stories Pwer Card Strategy

34 Evaluating Effectiveness of your Interventions
If you want information on forming groups, writing goals, etc., please contact us.

35 Evaluating Effectiveness
Important in order to establish own evidence-base for programs that are not yet established in the literature Required by federal and state mandates Used to monitor: Groups Programs Individuals

36 Methods for Progress Monitoring
Observations Frequency counts Percentages Duration Interviews Rating Scales Goal Attainment Scaling Self-report Video monitoring Homework completion Pre and Post comparisons

37 Goal Attainment Scaling (Kiresuk & Sherman, 1968)
Method to help determine if your change is meaningful After collecting baseline, identify goal and write anchors Ex.: Good Resource: Coffee, G. & Ray-Subramanian, C.E. (2009). +2 Student makes more than expected progress (51% +/- in behaviors) +1 Student makes expected progress (25 – 50% +/- in behaviors) (Baseline) No improvement; Less than 25% change in behavior; -1 Student demonstrates a decline in functioning (-25% to 50% increase/decrease in behaviors) -2 Student demonstrates a worse decline in functioning (More than -51% increase/decrease in behaviors)

38 Goal Attainment Scaling
+2 X (10.33) X (2.66) +1 X (14.00) X (20.7) -1 -2 Baseline Average Week 1 - 6 Averages Week Averages Post Averages Meet Jeremiah Goal 1: Jeremiah will decrease his overall rating to unexpected behaviors within a twenty minute social setting. (More than -51% increase/decrease in behaviors)

39 Goal Attainment Scaling
+2 +1 X (42.66) X (31) X (27.66) -1 X (23.66) -2 Baseline Average Week 1 - 6 Averages Week Averages Post Averages Goal 2: Jeremiah will increase his expected behaviors to expected behaviors within a twenty minute social setting. (More than -51% increase/decrease in behaviors)

40 Individual Data Collection - Charting

41 Methods for Promoting Generalization: How to continue progress
Use “perseverative interest” in teaching Teach the “why” not just the “how” Use between session homework Challenge participants to try skills (behavioral rehearsal) and report back Communicate with parents and teachers Provide opportunities within the naturalistic environment during social skills training (with support)

42 Methods for Promoting Generalization: How to continue progress after termination
Use cues and prompts to utilize taught skills outside of session (shaping) Provide positive reinforcement for spontaneous use of skill outside of session Offer “booster” sessions Recommend social opportunities to parents (Boy Scouts, sports, theatre, etc.) Continue to progress monitor to determine true generalization and adaption

43 References and Resources
Association for Behavioral and Cognitive Therapies (2010). Evidenced-based mental health treatments for children and adolescence. Accessed electronically from on October 1, 2010. Attwood, T. (2000). Strategies for improving the social integration of children with Asperger syndrome. Autism, 4(1), Attwood, T. (2004). Exploring feelings: Cognitive behavior therapy to manage anger. Arlington, TX: Future Horizons. Avery, R.R. (2008). Meet Thotso: Your thought maker. York, ME: Smart Thot, LLC. Baron-Cohen, S. Leslie, A.M., & Frith, U. (1985), Does the autistic child have a “theory of mind?”, Cognition, 21, Center for Disease Control, (2010). Autism information center: Frequently asked questions - prevalence. Accessed electronically from on April 17, 2010.

44 References and Resources
Christner, R.W., Stewart, J., & Freeman, A. (eds.). (2007). Handbook of cognitive-behavior group therapy with children and adolescents: Specific setting and presenting problems. New York, NY: Routledge. Coffee, G. & Ray-Subramanian, C.E. (2009). Goal attainment scaling: A progress monitoring tool for behavioral interventions. School Psychology Forum, 3(1), 1 – 12. Elksnin, L.K. (2000). Teaching parents to teach their children to be prosocial. Intervention in School and Clinic, 36(1), Friedberg, R.D., & McClure, J.M. (2002). Clinical practice of cognitive therapy with children and adolescents: The nuts and bolts. New York, NY: Guilford Press. Gray Center (2009). What are social stories? Accessed electronically from on May 21, 2009. Ingram, D.H. (2006). Cognitive-behavioral interventions with autism spectrum disorder. In Cognitive-behavioral interventions in educational settings: A handbook for practice. Mennuti, R.B., Freeman, A., & Christner, R.W. (eds.) New York: Routledge Publishing.

45 References and Resources
Jaffe, A.V., Gardner, L. (2006). My book full of feelings. Shawnee Mission, KS: Autism Asperger Publishing Co. Kiresuk, T.J., & Sherman, R.E. (1968). Goal Attainment Scaling: A general method for evaluating comprehension community mental health programs. Community Mental Health Journal, 4(6), Livanis, A., Solomon, E.R., & Ingram, D.H. (2007). Guide social stories: Group treatments of adolescents with Asperger’s Disorder in the schools. In Handbook of Cognitive-Behavior Group Therapy with Children and Adolescents. Christner, R.W., Stewart, J.L, and Freeman, A. (eds.). New York, New York: Routledge Press Madrigal, S. & Winner, M. (2008). Superflex…A superhero social thinking curriculum. San Jose, CA: Think Social Publishing, Inc. McGrath, L.M., & Peterson, R.L. (2009). Autism spectrum disorder. In Diagnosing Learning Disorders, Second Edition: A Neuropsychological Framework. Pennington, B.F. (author) New York: Guilford Publishers. Mennuti, R.B., Freeman, A., & Christner, R.W. (eds.). (2006). Cognitive-behavioral interventions in educational settings: A handbook for practice. New York, NY: Routledge.

46 References and Resources
Myles, B.S. & Simpson, R.L. (2001). Understanding the hidden curriculum: An essential social skills for children and youth with Asperger Syndrome. Intervention in School and Clinic, 36(5), Myles, B.S., Trautman, M.L., & Schelvan, R.L. (2004). The hidden curriculum. Practical solutions for understanding unstated rules in social situations. Shawnee Mission, KS: Autism Asperger Publishing Co. Ozonoff, S., Pennington, B.F., Rogers, S.J. (1991). Executive function deficits in high-functioning autistic individuals: Relationship to theory of mind. Journal of Child Psychology and Psychiatry, 32(7), Russell, J. (1997). How executive disorders can bring about an adequate theory of mind  In J. Russell (Ed.), Autism as an executive disorder. Oxford, England: Oxford University Press. Williams & Shellenberger, (1996). How does your engine run? A leader's guide to the alert program® for self-regulation . Albuquerque, NM: Therapy Works, Inc. Winner, M.G. (2002). Thinking about you thinking about me. San Jose, CA: Michelle Garcia Winner. Winner, M.G. (2005).Think social! San Jose, CA: Michelle Garcia Winner. Winner, M.G. (2005). Worksheets for teaching social thinking and related skills. San Jose, CA: Think Social Publishing, Inc.

47 Web Resources Autism

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