An Overview of Cognitive Behavioral Therapy with Autism

This article will tell you everything a parent or an educator needs to know about Cognitive Behavioral Therapy (or CBT).  The first years of life demonstrate cognitive manifestation of an individual through modes of developments in communication skills, play skills, imitation and participation in daily routines. Cognitive Development largely influences an individual’s motor, communication & social skills and aids in his/her emotional developments. Children with autism spectrum disorder usually demonstrate behaviors that are a stark contrast to typical/usual behaviors. This, is psychological terms, is referred to as Cognitive Difference or Cognitive Deficits.

Uneven cognitive capabilities are a trait with most of the autism-affected individuals but we must not think that this, in some way or the other, implies as mostly remarkable talents. Autistic savants are a different breed; it doesn’t come as easy. According to statistical data, such characteristics can be detected in 1 out of every 10 individuals on the autism spectrum.

Cognitive Deficits and Intervention Needs becomes apparent during learning

HFA/AS/borderline type autism or Asperger’s Syndrome make up for some of the cognitive deficits (underdeveloped skills) with others that shoot higher than what’s expected at that age level; thereby misleading people to interpret cognitive capabilities to savants. It’s more like compensating one shortage with another. Sounds too good, right?

In reality, it translates into academic difficulties but on the other hand, covert autism can become an autistic individual’s real strength, some of which can be:

  • Strong, visual-spatial skills,
  • Precise attention to details,
  • Intense focus in subjects of interests, and
  • An excellent, long-term and rote memory

These strengths become apparent during learning but we can talk about it later; for now, let’s try to see some of the cognitive disabilities that may start to show even in three-month olds!

The earliest symptoms may range from poor learning rates, lack of application any acquired skill sets in different or new settings, to imaginary playing. Once at school age i.e. upon entering the academic world, remaining cognitive needs starts to surface. It’s only through appropriate cognitive interventions that an Autistic child can be taught organizational skills; to be attentive and to develop a logical mind.

Theories of Cognitive Behavioral Therapy for Autism

Cognitive Behavioral Therapy - Autistic Children may have Cognitive deficits in these areas
Cognitive Behavioral Therapy is based on the following Cognitive deficits areas

The 3 cognitive theories impacting autistic children in their development are:

  • The Theory of Mind (ToM),
  • The Theory of Executive Function (EF), and 
  • The Theory of weak Central Cognitive Coherence (WCC)

The behavior of autistic individuals become intelligible through these three models, which aid in articulating the typical autistic thought processes. There is also a theory called ‘Context Blindness’ about which we’ll talk in detail afterward. As of now, let it suffice to say that Context Blindness is what the above three theories sum up to.

We shall also present specific and pertinent case studies that will prove how important it is to study underlying cognitive characteristics of Autism to design appropriate strategies and to address the cognitive disabilities and needs of individuals on the Autism Spectrum Disorder.

The most obvious answer is definitely through developing an effective program structure; however, to do that, it is important to underline his/her behaviors of concern. The following case studies, implying different strategies adopted via:

Visual supports

  • Prompting
  • Situation-specific instruction
  • Peer support, and
  • Use of special interests

Offer immense help towards teaching the affected about the various challenging concepts to deal with situations. But this is no generalized approach; for a strategy to be most effective for a given autistic individual, it must address the person’s particular cognitive disabilities that are forming the individual’s cognitive pattern.

Early Cognitive Deficits and Differences

What Are Cognitive Skills & How do you teach Them?

The collective influences of motor skills, communication skills, social skills, and emotional development shape cognitive development in children. Cognitive development, in the first few years of life, is demonstrated through the development of communication, play skills, imitation, and participation in daily routines. Children who are later diagnosed with ASD may begin to demonstrate behaviors that indicate possible cognitive differences from as early as three months of age.

Case Study I: Alison

The subject and her behavior

This 29-month-old girl, Alison, visited the psychologist with her parents, who were concerned to get an evaluation done of her behavior. The evaluation team found Alison’s attention always fleeted from social games to her actual, frivolous interests. This included anything from turning the pages of books or arranging letters on the blocks on the table. She never smiled socially but found smiling when looking at the blocks. Alison was better off doing her own things with the objects in the room and responded only twice out of the many times her name was called during the assessment session. Among her other activities, she repeatedly uttered a few lines from a TV commercial while moving around inside the assessment room.

Actions taken by the team

Mapping Cognitive Deficits
The right side – Cognitive Behavioral Therapy section – was filled in by Alison’s parents

The team used a checklist (featured above) that comprised sections to address the subject’s few areas of functioning, including social, restricted behavior patterns based on her interests and activities; communication; sensory-cognitive and motor differences; emotional vulnerability; medical and related biological factors. The assessment team also gathered as much information possible from the subject’s parents.

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The Theory of Mind (ToM)

It’s one’s cognitive ability to understand another person’s mental states, also his thoughts and beliefs, intentions and desires, perceptions and feelings. Applying these understandings helps an individual to predict others’ actions.

Cognitive Behavioral Therapy - Theory of Mind
CBT – Cognitive Deficits – Theory of Mind (ToM)

Typically developing children – from as early as four years of age – start making these inferences about others. In children diagnosed with high functioning autism/Asperger syndrome (HFA/AS) – researches have shown delays in such abilities; making inferences about others’ thoughts take considerably a longer span of time. The impaired ToM hypothesis is supported by these experiments.

Individuals with high functioning autism have been seen to develop an ability to use systematic and rule-based ToM skills but that’s again a limited ability compared to those not affected by autism who use these skills intuitively under demanding social situations.

This disruption in ToM development is called mindblindness. It is a difficulty in perceiving and understanding the feelings and thoughts of other individuals. To understand and help individuals with ASD, it is thus very important to become familiar with the ToM concept and readily recognize when mindblindness becomes a cause for high concern in an individual with ASD.

Case Study II: Rowan

The subject and his behavior

ice_skating_clip_art_22859Rowan, a 24-year-old man, completed high school but had difficulty transitioning into an adult life. A job coach was teaching Rowan the skills required for a new, cleaner’s job at a mall, which also has an ice-skating rink. Juan’s work-hours are when the skating rink stays closed; with the exception of occasional private lesson sessions for a handful of children. On one such occasion, the skating instructor called out one of his students (a girl named Susane) and instructed on her footwork. As Rowan passed the ice rink after some time, he called her out by her name and complimented her on her footwork. He was merely repeating the words of the skating instructor. This, however; made the girl afraid and she felt threatened.

Rowan’s mindblindness made him unable to detect the look of fear that immediately came to Susane’s face (a stranger knowing her by name); he also could not see the difference in ways to initiate a conversation with someone of his own age and with an unfamiliar child.

Actions taken by his job coach

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The Theory of Weak Central Coherence

Cognitive Behavioral Therapy -WCC Generalization Strategies
Cognitive Behavioral Therapy -WCC Generalization Strategies

Cognitive style often varies by the level of central coherence. Stronger tendencies for cognitive coherence help integrate information typically. This helps an individual to gather meanings and create a meaningful whole in a larger context, to understand higher-level. Weak Central Coherence or WCC, on the other hand, incorporates pieces of information with much difficulty or not at all.

WCC impairs an individual’s ability to process information within given contexts. So while the individual might be able to provide picturesque details of a situation, he will face many difficulties in identifying the connections, themes or the general ideas behind.

Extensive investigations on cognitive process and ASD have been carried out by the researchers Happé and Frith; and their speculations on WCC is, it helps to explain some of the core behaviors that ASD gives rise to.

For example, a resistance towards any kind of variation, too much attention to the details of an object and uneven cognitive profile that brings difficulty in understanding suggestive and figurative language (similes, metaphors, sarcasm). Most individuals on the autism spectrum exhibit one or more such conditions related to WCC.

An inability to see and use the bigger picture makes a person understand things through details, a variation in which – how much ever small it may be – makes it overwhelming. Sameness is a strong need for Individuals with HFA/AS, who also function their best when the environment is predictable.

Changing from one activity to another or moving from one setting to a different one is distressing for such people. Expressions for such transition-induced distress may show through persisting, repetitive questions, answers to which are, apparently, known to the questioner. The distress occurs even if those changes are rewarding and are to bring positive outcomes to the person. Such distresses make individuals with HFA/AS feel overwhelmed and they may engage in display of bad temper and social withdrawal apart from repetitive questioning.

The following case study illustrates how WCC contributes to unusual interpretations of emotional expressions or the difficulty experienced by the subject due to her failure of using the whole situation and drawing meaningful conclusions.

Case Study III: Maya

The subject and her behavior

mayaMaya, a 14-year-old girl with Autism showed her teacher the photographs from a recent trip she had. In one of them, she was attending a family picnic and was helping a younger cousin play on the swings and had a broad, bright-eyed smile on her face. Another photograph pictured her kneeling by her grandmother’s grave, placing flowers and smiling slightly, but her eyes were sad. Upon being asked about how she was feeling (in the second picture), Myla’s response was: “I must have been happy, because I am smiling.” This was not sarcasm.

Actions taken by his job coach

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The Theory of Executive Dysfunction

Cognitive Needs - Executive Function
Cognitive Behavioral Therapy – Understanding the Executive Function

EF or Executive Functions are cognitive processes unified under a broad group. These processes are inclusive of behavior inhibition, mental flexibility, working memory, planning, task initiation, performance monitoring and self-regulation.

This is not to imply that EF differences are the sole cause for all challenges Autism Spectrum Condition brings; neither all areas of EF are impacted equally by ASD. The theory of Executive Dysfunction just casts light upon some of the behaviors that ASD affected individuals often exhibit.

Difficulties that often arise from Executive Dysfunction are:

  • An inability to cope with changes in schedules and routines.
  • A lack of power to plan projects.
  • Faulty time assessments for completing tasks.
  • Incorrect performance and behavior (own) monitoring while trying to accomplish a goal or a target.
  • Haphazard, a disorganized manner of narrations instead of progressing sequentially, both in oral and written form.
  • Failure to memorize and retrieve information from memory.
  • An inability to initiate activities and tasks.
  • An inability to independently respond against open-ended questions.

Flexibility – as an element of Cognitive Behavioral Therapy:

Poor mental flexibility makes coping with changes difficult for HFA/AS-affected individuals. The rigidity is attributed to the theory of executive dysfunction. Alongside, we may also relate restricted or narrow interests and repetitive behaviors to such deficits in cognitive flexibility. 

Self-Regulation:

Intense temper outbursts (meltdowns) are common in children and adolescents affected with Autism. This can be called a lack of self-regulation, which arises from executive function cognitive deficits. From this perspective, we may say that they do not have the required skills to calm themselves.

Performance Monitoring:

Poor performance monitoring – another example of a lack of EF skill – partly explains the lack of social reciprocity (the natural, conversational call and response), which is another core characteristics of ASD.

Holding a conversation requires tuning in to the listener’s cues and adjusting the way you contribute to an interaction. This occurs through the monitoring of the match between the behaviors of the communication partners. In turn, self-monitoring helps in taking necessary pauses, identifying the questioning instances – and even, changing topics. With poor performance monitoring, an individual misses the key conversational and social cues.

School and EF:

EF differences often become most apparent during the school years. This is because successful completion of school tasks requires strong EF skills.

Case Study IV: Nemo

The subject and his behavior

portrait-of-a-6-year-old-boy-01This 6 year old boy, Nemo was in kindergarten when he was identified as having ASD. His difficulty was coping with center time; more so, when it used to be the days of free-choice. These days allowed students to select center activity according to their will and Nemo failed to make up his will on his preference for a center unlike other children. Nemo wandered from one center to another, after observing his peers and tending to one center briefly. Then, he moved to another group, even after periodic instructions from his teacher to pick a center and get started. Eventually, the teacher took Nemo by hand and guided him to a particular center, giving him instructions on the ways to participate in the activity.

Nemo, in fact, was doing his best, as much as his underdeveloped executive function skill of mental flexibility was allowing. It is responsible for making selections based on free-choice the and beginning a task. This also reflected from Nemo’s inability to finish a center project within time, because of cognitive disabilities in executive function skills that hampered estimating the time required to complete a task. Autism made Nemo deficient of executive skill of planning than his typically developing peers.

Actions taken by her teacher

This bewildered the teacher and her thought was why Syracuse was not cooperating like his peers despite the routine that ran for months?

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Context Blindness

Cognitive Disabilities in Context Blindness

The three theories of cognitive functioning (WCC, ToM, and EF), according to researchers like Peter Vermeulen, merges to form a single theory, which is Context Blindness. Vermeulen explains it as – “a cognitive deficit in the ability to use context spontaneously and subconsciously to determine meanings.” It doesn’t mean an ASD-affected individual is unable to see the context, but rather, his/her failure in understanding a situation using the specific context.

This is because Autism affected individuals are more prone towards tending to applying rules and facts in an absolute manner, without being able to see the subtle exceptions in those rules. This is certainly a disadvantage, since most rules come with exceptions, which again depend on the context or the situation.

As an example, we can cite the case of Maya, to whom, a smile means only happiness whereas in real life, a smile may also stand as an indication of deceit or of sadness. Or, just in Rowan’s case, a compliment is a good way to appear friendly but certain situations pose it as threatening or strange.

Not using context in intuitive and spontaneous manner is what people with Autism do most often. The only way out from it is learning to use context through compensation strategies, which is, pointing out a given situation and its context and describing the exceptions to its rules.

This is not just instructing an individual ‘what to do’ but also explaining why. Vermeulen’s explanations clarify contexts in a way to advocate individuals with ASD. Understanding the importance of context also impacts how competencies are taught and objectives are written.

Context Sensitive Cognitive Disabilities
The table showing a few examples of Context Sensitive Objectives for Cognitive Behavioral Therapy

CBT – Cognitive Strengths

Since each are different, people with are also unique in many ways. Some exhibit certain cognitive strengths that are stronger than in others. For example, the following strengths are considered while devising the right Cognitive Behavioral Therapy strategies for a child:

  • Excellent long-term and rote memory.
  • Visual spatial processing.
  • Prolonged attention in areas of strong interests.
  • Detail oriented.
  • Outstanding creativity i.e. thinking out of the box.

Any instruction provided or intervention offered must consider these cognitive strengths first. For example, refer to the table below for certain sample strategies for some of the above cognitive strengths.

Cognitive Intervention Strategies based on Cognitive Strengths
Cognitive Intervention Strategies based on Cognitive Strengths

Case Study V: Rowan and his Cognitive Strengths

The subject and his behavior

A further case study on Rowan revealed his cognitive strengths that were utilized later in his job training. Rowan is very detail-oriented but unpunctual.

Cognitive Behavioral Therapy Actions taken by his coach

To capitalize on these particular aspects of Rowan’s nature, he was made aware of the importance of cleaning thoroughly the snack-shop tables, without leaving any germs behind. Helping Rowan to focus on this level of detail resulted in a job well done.

On the other hand, Rowan’s long-standing fascination with public transportation was noted by the job coach, who found out that he memorized elaborately the train and the bus schedules. They reviewed the public transportation schedules together and the coach developed a plan that helped Rowan take the particular train that helped him arrive on time to his new job. This way, the job coach utilized both Rowan’s special interest and his detail-oriented mindset.

The procedure of action – Rowan’s Checklist

  • Use Clorox wipes
  • Always, start with Table # 1
  • Wipe each table in a consistent pattern to leave no part of the surface area untouched
  • Mark each completed table with a wipe to avoid confusion

Rowan was given the diagram of the arrangement of all the tables in the snack area, properly numbered for visual support, along with a checklist. The coach then modeled each of the steps on the checklist matching Rowan’s cognitive strengths. After wiping the tables for a few times in this manner, Rowan’s efficiency in cleaning increased and he could work without needing the checklist to follow through. A strictly auditory/verbal approach would fail to get the information in his memory, causing confusion and frustration and therefore, a lack of success.

Cognitive Deficits: Impact on Academics

Children diagnosed with ASD have been noticed to exhibit specific learning disabilities, especially in math and reading and it is usually in a higher than a normal rate. But whether a specific learning disability is present or not, ASD, amongst most students it affects, exhibits characteristics that make an academic setting challenging for them.

For example, let’s take weaknesses in comprehension skills. It’s noted more often than not; also much more difficulty with coherent and logical reasoning tasks. Tasks that require recounting facts and details are easier for them.

It is also often difficult for students with ASD to apply concepts and deal with real-life contexts. Lack of Generalization of skills is a difficulty related to a deficit in cognitive faculty. It makes difficult to relate past experiences to new stimuli. Such generalization difficulties must be addressed with instructional strategies. For example, to improve underdeveloped reading skills, opportunities must be given to practice literacy skills, in multiple environmental settings, not only comprising various adults and peers but also with a variety of reading materials.

Autistic Child pre-occupied with Cars
Autistic Child pre-occupied with Cars

Academic performance may also get impacted in diverse ways with the tendency for narrow but intense areas of interest. In cases where a student’s range of interest(s) is extremely narrow, it hampers engaging in learning activities unless it’s pertaining to the preoccupation(s) of the individual. Most extreme cases see the individual escaping into their own world of preoccupation. A focus on a favorite subject makes diversion almost impossible to another topic, but conversely, the intense interest(s) may result in creating an area of specialization that leads to academic excellence.

 

Cognitive Disabilities in Planning and Organization

This module reviews the deficits in executive function in a group. However, some EF related difficulties cause higher challenges during the school years and require additional discussion. Here we speak about deficits only with planning and organization, an area where children with Autism struggle quite often.

An individual with Autism may be knowledgeable enough to perform tasks but not master the required planning and organization skills to complete the tasks. Consequentially, the individual may, thus, give off the idea of being manipulative to others. It may appear that he or she is trying to avoid a task or a lack of specific knowledge rather than his or her ability to organize completion of the task.

Thus, it becomes important to recognize when such difficulties surface (with meeting expectations; completing a task etc), they are related to cognitive deficits in planning and organizational skills. Only by utilizing strategies such an individual can be helped to compensate. The strategy must follow the simple rule of keeping things simple.

Cognitive Behavioral Therapy for Planning and Organization
Cognitive Behavioral Therapy Strategies to assist with Planning and Organization

Resource: for children with ADHD, refer to our unique 30 Day Organization Blueprint

Help with Literal Understanding

Individuals with Autism interpret language more literally than figuratively. It’s a fact often overlooked and it results in reciprocal misunderstandings; the literal response from an ASD victim might appear as impudent, snotty or odd. This makes it important to use non-literal language when instructing an individual with Autism, much the same way as the UCC-HF (Underlying Characteristics Checklist-High Functioning) is designed. It captures behaviors that relate to the understanding of figurative language.

Cognitive Behavioral Therapy - UCC Items Addressing Literal Understanding
Cognitive Behavioral Therapy Items Addressing Literal Understanding

Case Study VI: Marc

Marc, an ASD-affected middle-school student understood conversations only in concrete and literal terms and expressed himself also in a similar way. For example, upon asking – “What do you want to do after school?” – Marc’s response was – “run to my bus.” While the question had to do with Marc’s goals after high school, the answer would come puzzling to anyone who might ask him the question. Marc was unable to put the question in context and such questions are common, especially from elders to adolescents. His answer, though honest, is a literal one and is enough to quick end a conversation.

Case Study VII: Annie

Annie, a 7-year-old girl with ASD, was in a process of evaluation through multiple subtests, between which, Annie stood up and stretched once. As the tests were nearing an end, the examiner said – “Okay, we are in the home stretch now; just a couple of more subtests to go” – to which, Annie’s response was – “Oh, no. I’m done stretching. I don’t need to stretch anymore. Thank you.” This would have infuriated anyone but the examiner, being familiar with ASD-related cognitive characteristics, understood that the girl took the idiom in its literal sense. The examiner included in her report recommendations about teaching Annie some of the most commonly used idioms and figurative language.

Case Study VIII: Ivory

Ivory, in her history class, asked a guest speaker from Turkey if turkeys are sold in his country. The teacher was disappointed at her efforts to be the class clown, which confused Ivory all the more. Since she never dresses like a clown. This disappointed her teacher further; she thought Ivory was not admitting her inappropriateness and that her behavior was far from apologetic. In plain words, Ivory appeared stubborn and rude to her teacher because of her literal use of language. This resulted in a loss of trust between the Ivory and her teacher.


Mary Alexa
Mary Alexa

Hello everyone my name is Mary. I studied at University of Michigan under Dr. Richard Solomon, founder of the P.L.A.Y. Project for Children on the Autism Spectrum. I live in the Dominican Republic working at an International School with children on the autism spectrum. Empowering parents with knowledge and techniques to support their children’s needs as well as the needs of the entire family and community has been my main focus for the past seven years. Read More

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