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 ConventionFebruary 22, 2011Jessica B. Bolton, Psy.D., NCSPRay W. Christner, Psy.D., nCSPJennifer E. Mcpoyle-Callahan, B.S.South Middleton School DistrictBoiling Springs, PA
2 Today we will discuss…. Cognitive Behavioral Therapy (CBT) What is CBTBasic PrinciplesHow does CBT address deficits in ASDOverview of the LiteratureSpecific Techniques and ProgramsMeasuring EffectivenessHow 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 HeritabilityNeuro-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/shiftingStrengths: working memoryLiterature has studied role in social skill deficitsTheory 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 ModelActivatingEventAutomaticThought(Belief)Consequence(Behavior/Feeling
9 Errors in ProcessingCognitive Deficiency – the lack of information processingCognitive Distortions – an active but misguided way of processing informationSkill Deficiency – the lack of a specific skillSkill Dysfunction – the lack of implementation or generalization of skill
10 Components of CBT with Children Appropriate session lengthExpand child’s emotional vocabularyIdentify and dispute dysfunctional ideasTeach self-instructional techniquesTeach problem-solving skillsRole play specific skillsProvide 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 AgendaReviewCurrent statusEvents of past weekSolicit feedback regarding previous sessionReview homework from previous sessionFocus on main agenda itemsDevelop new homeworkSolicit feedback regarding current session
12 Case Conceptualization Helps inform when and how to use toolsContinual/Dynamic/Fluid ProcessRequires hypothesis testingHelps broaden perspectivesDiffers from diagnosisShould be shared with clientLeads to treatment plan
13 Modular-Based Interventions BenefitsDecreases the demands of following a manual-based programUses specific techniques from manual-based programsAllows the use of outcome research to develop good interventionsBases intervention on specific client needsDifficultiesMust have good case conceptualization skillsMust use single case design and progress monitoring more efficiently to measure outcomeMust have a good understanding of the literature across various disorders
15 What deficits in ASD does CBT address? Social/Cognitive deficitsPerspective takingEmotional identification and regulationInflexible/rigid thinking patternsInternalizing symptomsVerbal /language deficitsPossible 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 levelsCan 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 behaviorJim Carrey looks at the person who is talking.
19 BibliotherapyThe use of books to help illustrate social situations or demonstrate problem-solvingTo be used in conjunction with other methodsSuperflex curriculum has one lesson that utilizes Bibliotherapy techniquesSome Good Books:Amelia BedeliaJunie BBerenstein Bears
20 Video Modeling (Bellini, 2003) Tape the child and play back to give feedback – Video Self-modelingTape another student doing the behavior - Video InstructionTape 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 OptionsConsequencesChoicesStrategiesSimulationUtilizes behavioral rehearsal techniques
22 Social Autopsies (Lavoie, 1994) Comic Strip Conversations Discussion of a problemGo over what happenedWhat was the errorWhat were people thinking and feelingWhat should happen nextCan 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 outcomesA form of social storiesMore visualDraw what happens using stick people and thought bubblesUse colors to show how people were feelings when you write the wordsAfter 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 doneDescribe the settingGive explanation of whyLikely used as a part of treatment, not the entire treatmentAdaptation – Guided Social Stories (Livanis, Solomon, and Ingram, 2007)
26 Hidden Curriculum (Myles, 2004) Teach “hidden rules” of various settingsTo help students gain an understanding of social normsGoals is improve perception of the student’s environment and social expectationsMeta-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 centerFocuses on Self-Regulation skills=Self-Regulation
29 Exploring Feelings (Attwood, 2004) Tony Attwood’s books for managing anxiety and angerUses direct instruction, activities, and self-awareness lessonsTeaches the affective component of CBT as well as the thoughts and behaviorsServes 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 MeProvides a theoretical background on the Social thinking approachProvides some activities, but is not a curriculum/manualThink Social!Teaches how to observe others, make guesses about their thoughts and actions, and change your own behavior based on your observationsCBT 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” (www.socialthinking.org)To increase a student’s self-monitoring abilities of their behaviors and the impact of their behaviors on othersTo increase a student’s knowledge of when they are exhibiting inflexible thinking and to strategies to overcome inflexible thinkingUses 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 CBTIncludes agenda setting, homework, parent participation, practice opportunities, feedback, psychoeducation, and some instruction on the thought/behavior/feeling triadAddresses executive component/performance deficitTeaches “Superflexible” thinking (cognitive flexibility), self-monitoring and regulation, and planning skillsAddresses Theory of MindTeaches “thinking about others”Uses a multi-sensory approachVisual representation of abstract concepts
33 Cognitive Instruction/ Techniques BehavioralInstruction TechniquesExploring FeelingsThink Social!Thinking About You Thinking About MeSuperflexThe Alert ProgramPower Card StrategyMeet Thotso, Your Thought Maker bookSOCCSSVideo ModelingSocial AutopsyAffective EducationThink Social! *The Alert Program *Social Stories*Comic Strip ConversationsIncredible 5 Point ScaleMy Big Book of FeelingsSocial Autopsy *Cognitive Instruction/ TechniquesThinking about You Thinking about MeSocial StoriesPwer 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 literatureRequired by federal and state mandatesUsed to monitor:GroupsProgramsIndividuals
36 Methods for Progress Monitoring ObservationsFrequency countsPercentagesDurationInterviewsRating ScalesGoal Attainment ScalingSelf-reportVideo monitoringHomework completionPre and Post comparisons
37 Goal Attainment Scaling (Kiresuk & Sherman, 1968) Method to help determine if your change is meaningfulAfter collecting baseline, identify goal and write anchorsEx.:Good Resource: Coffee, G. & Ray-Subramanian, C.E. (2009).+2Student makes more than expected progress (51% +/- in behaviors)+1Student makes expected progress (25 – 50% +/- in behaviors)(Baseline) No improvement; Less than 25% change in behavior;-1Student demonstrates a decline in functioning(-25% to 50% increase/decrease in behaviors)-2Student demonstrates a worse decline in functioning(More than -51% increase/decrease in behaviors)
38 Goal Attainment Scaling +2X (10.33)X (2.66)+1X (14.00)X(20.7)-1-2Baseline AverageWeek 1 - 6AveragesWeek AveragesPost AveragesMeet JeremiahGoal 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+1X (42.66)X (31)X (27.66)-1X (23.66)-2Baseline AverageWeek 1 - 6AveragesWeek AveragesPost AveragesGoal 2: Jeremiah will increase his expected behaviors to expected behaviors within a twenty minute social setting.(More than -51% increase/decrease in behaviors)
41 Methods for Promoting Generalization: How to continue progress Use “perseverative interest” in teachingTeach the “why” not just the “how”Use between session homeworkChallenge participants to try skills (behavioral rehearsal) and report backCommunicate with parents and teachersProvide 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 sessionOffer “booster” sessionsRecommend 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 PressMadrigal, 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 www.autismnetwork.org/modules/social/index.html CBT