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PENT 2015Cognitive Behavioral Intervention (CBI)
for Individuals with ASD
Ann England, M.A., CCC-SLP-LAssistant Director, Diagnostic Center, Northern California, CDE
PENT Leader * CAPTAIN Leader
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California Department of Developmental
Services (DDS)
National Professional Development Center
(NPDC)
National Autism Center (NAC)
1. ASD Guidelines for Effective Interventions
1. 27 Evidence Based Practices Briefs
2. EBPs for Young Children
1. National Standards Project Report
2. Evidence Based Practices in Schools Educator Manual
3. Parent’s Guide to EBP and ASD
www.asdguidelines.org http://autismpdc.fpg.unc.eduhttp://asdtoddler.fpg.unc.edu
www.nationalautismcenter.org
3 Important ASD EBP Resources
NOT YET AVAILABLE
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Systematic Reviews of the Literature for Evidence Based Practices (EBPs)
• In 2009, 11 “treatments” or practices with an evidence base– Reviewed by National Standards Project from National Autism Center– Included 1957-2007 (NOTE: Update to be released Spring 2015)
• In 2010, 24 EBPs– National Professional Development Center (NPDC) – Included 10 years, 1997-2007
• In 2014, 27 EBPs – Second review by NPDC– Included 22 years, 1990-2011
• 29,101 possible studies 456 studies• RCT (randomized controlled trial), quasi-experimental, single case
design– Strength of evidence for assessment – Based on number, type of studies using each EBP
http://autismpdc.fpg.unc.edu
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www.captain.ca.govhttp://autismpdc.fpg.unc.edu
2014March
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Definition of EBP(NPDC)
NPDC definition of an EBP:
“Focused intervention practices that have substantial evidence for effectiveness in promoting positive outcomes for learners with ASD”
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NPDC Criteria for EBP
To be considered an EBP for individuals with ASD, efficacy must be established through peer-reviewed research in scientific journals using:
– At least two high quality experimental or quasi-experimental group design articles conducted by at least two different researchers or research groups
OR– At least five high quality single case design articles conducted by at least
three different researchers or research groups having a total of at least 20 participants across studies
OR – A combination of at least one high quality experimental or quasi-
experimental group design article and at least three high quality single case design articles conducted by at least two different research groups
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Newest NPDC Report Findings(Literature review 1997–2011)
• 27 EBPs as compared to 24 EBPs identified in the previous review
• Six new EBP categories:1. Cognitive Behavior Interventions
2. Exercise
3. Modeling
4. Scripting
5. Structured play groups
6. Technology-Aided Instruction and Intervention
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27 Evidence – Based Practices (2014)
Antecedent-based interventions
Cognitive behavioral intervention*
Differential reinforcement
Discrete trial training
Exercise*
Extinction
Functional behavior assessment
Functional communication training
Modeling*
Naturalistic interventions
Parent-implemented intervention
Peer-mediated instruction/intervention
Picture Exchange Communication System
Pivotal response training
Prompting
Reinforcement
Response interruption/redirection
Scripting*
Self-management
Social narratives
Social skills training
Structured play groups*
Task analysis
Technology-aided intervention/instruction*
Time delay
Video modeling
Visual supports * Added from 2014 literature review
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What are these EBPs?
The 27 EBPs are defined
in Table 7 of the report!
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DEFINITIONS OF 27 EBPs
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DEFINITIONS OF 27 EBPs
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DEFINITIONS OF 27 EBPs
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FACT SHEETS FOR EACH OF THE 27 EBPs
• Definition of the intervention
• Age range of participants
• Type of outcomes it has generated
• Citations for the specific articles that provide the evidence for the efficacy of the practice
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Your Own Copy!
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Ann’s CBI for ASD Info TemplateIncludes Fact Sheet Information
http://www.pent.ca.gov/cdr/f15/forum2015.html
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What’s the research?See the Fact Sheet!
Research Studies Providing Evidence (CBI meets evidence-based criteria with 3 group design and 1 single case design studies):
Drahota, A., Wood, J. J., Sze, K. M., & Van Dyke, M. (2011). Effects of cognitive behavioral therapy on daily
living skills in children with high-functioning autism and concurrent anxiety disorders. Journal of
Autism and Developmental Disorders, 41(3), 257-265. doi: 10.1007/s10803-010-1037-4
Singh, N. N., Lancioni, G. E., Manikam, R., Winton, A. S., Singh, A. N., Singh, J., & Singh, A. D. (2011). A
mindfulness-based strategy for self-management of aggressive behavior in adolescents with autism.
Research in Autism Spectrum Disorders, 5(3), 1153-1158. doi:10.1016/j.rasd.2010.12.012
Sofronoff, K., Attwood, T., & Hinton, S. (2005). A randomised controlled trial of a CBT intervention for
anxiety in children with Asperger syndrome. Journal of Child Psychology and Psychiatry, 46(11), 1152-
1160. doi: 10.1111/j.1469-7610.2005.00411.x
Sofronoff, K., Attwood, T., Hinton, S., & Levin, I. (2007). A randomized controlled trial of a cognitive behavioural intervention for anger management in children diagnosed with Asperger syndrome. Journal of Autism and Developmental Disorders, 37(7), 1203-1214. doi: 10.1007/s10803-006-0262-3
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What is CBI for ASD?“Cognitive behavioral intervention (CBI) is based on the belief that behavior is mediated by cognitive processes.
Learners are taught to:o examine their own thoughts and emotions,o recognize when negative thoughts and emotions
are escalating in intensityo and then use strategies to change their thinking
and behavior.
*These interventions tend to be used with learners who display problem behavior related to specific emotions or feelings, such as anger or anxiety.
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What is the Purpose of CBI for ASD?
“CBI can be used effectively to address:
•Social
•Communication
•Behavior
•Cognitive
•Adaptive and
•Mental health
outcomes for individuals with ASD”
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Cognitive Behavioral Interventions Are Often Used In Conjunction With
Other EBPs such as…..– social narratives/social stories
– social skills training
– reinforcement
– parent-implemented intervention
– self-regulation
– visual supports/schedules
– special interests
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Who are the intended implementers?
• Professionals who are trained and experienced in CBT/I and ASD.
• CBI for ASD is sometimes implemented as a collaborative effort in clinic sessions, school and/or home in individual and/or group contexts (e.g., mental health professional, educators, speech-language pathologists, school psychologists, parents, etc.)
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Applicable Populations / Grade Levels
According to the NPDC March 2014 report evidence-based studies, this intervention has been effective for:
- elementary school-age learners (6-11 years)
to
- high school-age learners (15-18 years) with ASD
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A Brief Description
• Traditional CBT/I tends to require strong linguistic and abstract thinking abilities and these can be a challenge for individuals with ASD.
• Researchers have been developing modifications to make it more effective with individuals with an ASD by making it better suited to the learning styles of individuals with ASD, for example, by making it more repetitive, visual, and concrete.
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A Brief Description
Generally, CBT programs for youth with ASD have been clinic based and have not specifically and/or typically included:o school componento working collaboratively with others
involved in the individual’s treatment and education (e.g., parents and school personnel)
as a modified CBT/I might…
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A few examples ofhow to include EBPs for ASD in an
individualized modified CBI:
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EBPs:Visual Support * Self Management
• Instead of just asking the individual with ASD to verbally rate their anxiety on a scale of 1 to 10, the interventionist might use the EBPs of Visual Support and Self-Management
Emotion Thermometer
Incredible 5 Point Scale• Individual points to show how high their anxiety
is around a certain situation
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The Incredible 5 Point ScaleKari Dunn Buron and Mitzi Curtis
• Behavioral support that breaks down behaviors and social interactions into clear, visual and tangible pieces so that student can learn appropriate ways to respond and interact in difficult situations.
• A scale can be created using colors, pictures, or a rating system of 1 to 5.
www.5pointscale.comwww.autisminternetmodules.org
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EBP: Special Interests
• Incorporating the EBP of Special Interests in the sessions to motivate individual to engage in treatment activities. For example,
– Using favorite cartoon characters to model coping skills
– Or interspersing conversations about their special interest throughout treatment sessions to promote motivation and engagement.
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Established Treatment:Antecedent Package
Special Interests
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Including Social Skills DevelopmentEBPs: Social Narratives/Social Stories/Social Skills Training/Video Modeling
Gives the individual increased skills to be socially successful because….
….. the core social deficits of individual’s with ASD contribute to the experience of anxiety, which then serves to intensify the social problems.
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EBPSocial Narrative/Social Story
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Social Skills Training
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EBP: Video Modeling
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Incorporating PeersEBP: Peer Mediated Instruction and Intervention
Incorporating natural supports of peers since the core deficit area is social communication and interaction and subsequent lack of friendships….
and this causes anxiety…
…makes sense to incorporate peers as part of treatment program!
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Decrease Verbal DemandsUse EBP: Visual Support/Schedules
For example:
1. Provide a written or graphic weekly agenda showing when each session will occur and….
2. Provide detailed structure of each session allows the individual with ASD to predict activities and breaks throughout the session.
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Include EBP: Reinforcement
Including the EBP of Reinforcement helps to keep the individual with ASD motivated and engaged.
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Include EBP: Parent-Implemented Intervention
Working with parents collaboratively is a proven EBP that results in better outcomes!
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When will the NPDC have guidelines available?
• In Fall 2015 the NPDC will have the following information developed and available:
– Brief: a file that contains key documents including an overview of the practice, evidence-base for the practice, step-by-step implementation strategies, and implementation checklists for fidelity)
– Autism Internet Module on CBI for ASD
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AFIRMNPDC Self-Learning ModulesAutism Focused Intervention Resources and Modules
http://autismpdc.fpg.unc.edu/npdc-resourceswww.captain.ca.gov
New EBP Learning Modules!
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Implementation Fidelity is Critical!
What does this mean?
“Implementing an intervention in the same manner in which it was done in the evidence-based research”
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What’s “out there” now?• Modified version of CBT by Clinical Psychologist
Jeffrey Wood, Ph.D. of the Center for Autism Research and Treatment at UCLA.
• This modified CBT/program is described in the 2009 article, Cognitive Behavioral Therapy For Anxiety In Children With Autism Spectrum Disorders: A Randomized, Controlled Trial, Journal of Child Psychology and Psychiatry, 50, 224–234, Wood, J. J., et.al. available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231198
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Wood’s Enhanced CBT
Wood, et.al. developed an enhanced CBT program by expanding the traditional aspects of existing CBT treatments for anxiety in typically developing children.
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Wood’s Enhanced CBT
• includes a school consultation component
• incorporates concurrent skill building in core ASD symptoms suspected to contribute to anxiety symptomatology (e.g., social skills or preoccupation with restricted interests)
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Wood’s Enhanced CBT
• Provides in vivo parent training to address both the complex needs of youth with ASD and promote generalization of skills to school and community settings
• Targets aspects of ASD that contribute to school adjustment—for example, providing skills and support for building friendships that can lead to inclusion in activities and games, and a more satisfying daily routine.
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27 EBPs MatrixAvailable on the CAPTAIN Website
English and Spanish!www.captain.ca.gov
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www.captain.ca.gov
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www.captain.ca.gov
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QUESTIONS?