NATIONAL ASSOCIATION OF SCHOOL PSYCHOLOGISTS (NASP)ANNUAL CONVENTION

FEBRUARY 22, 2011

JESSICA B. BOLTON, PSY.D., NCSPJBB@SMSD.US

RAY W. CHRISTNER, PSY.D., NCSPRWC@SMSD.US

JENNIFER E. MCPOYLE-CALLAHAN, B.S.JEM@SMSD.US

SOUTH MIDDLETON SCHOOL DISTRICTBOILING SPRINGS, PA

Enhancing Social Experience: Cognitive Behavioral Interventions With Autism Spectrum Disorders

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

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

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

AND HOW DOES IT RELATE TO ASD?

So… What is CBT?

Cognitive Behavior Therapy

Traditional Model

ActivatingEvent

AutomaticThought(Belief)

Consequence(Behavior/Feeling

Multidirectional Model

Copyright 2010 © Christner & Mennuti

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

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

Structuring Your CBT Sessions

Set AgendaReview

Current status Events of past week

Solicit feedback regarding previous sessionReview homework from previous sessionFocus on main agenda itemsDevelop new homeworkSolicit feedback regarding current session

Case Conceptualization

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

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

Possible Modules

Goal SettingCognitive RestructuringExposure/Response

PreventionRelaxationPsychoeducationSelf-MonitoringSelf-Praise/Self-TalkProblem SolvingAssertiveness SkillsIncreasing Desirable

Behaviors

Social SkillsCommunication SkillsActivity SchedulingRelapse Prevention/

MaintenanceGuided ImageryRelationship BuildingPersonal Safety SkillsEmotional AwarenessBehavior InitiationDecreasing Undesirable

Behaviors

What deficits in ASD does CBT address?

Social/Cognitive deficits Perspective taking Emotional identification and regulation Inflexible/rigid thinking patternsInternalizing symptoms Verbal /language deficits Possible comorbid internalizing

problems

STRATEGIES USED WITH CHILDREN AND ADOLESCENTS

WITH ASD THAT FOLLOW A CBT OR META-COGNITIVE

APPROACH

5 Point Scale (Buron & Curtis, 2003)

Ranks emotions and problems on a 1 – 5 levels

Can be related to reactions and strategies

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.

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 BedeliaJunie BBerenstein Bears

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

SOCCSS (Myles, 2005)

Strategy to help with new situations Situation Options Consequences Choices Strategies Simulation

Utilizes behavioral rehearsal techniques

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

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

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)

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

PROGRAMS DESIGNED FOR CHILDREN AND ADOLESCENTS WITH ASD THAT UTILIZE A CBT

AND META-COGNITIVE APPROACH

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

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

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

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 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

Superflex…

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

EVALUATING EFFECTIVENESS OF YOUR INTERVENTIONS

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

Methods for Progress Monitoring

Observations Frequency counts Percentages Duration

Interviews Rating ScalesGoal Attainment Scaling Self-report Video monitoringHomework completion Pre and Post comparisons

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)

0 (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)

Goal Attainment Scaling

Meet Jeremiah

Goal 1: Jeremiah will decrease his overall rating to 15.53 unexpected behaviors within a twenty minute social setting.

+2 X (10.33) X (2.66)

+1 X (14.00)

0 X (20.7)

-1

-2Baseline Average

Week 1 - 6

Averages

Week 6 - 12

Averages

Post Averages

Goal Attainment Scaling

Goal 2: Jeremiah will increase his expected behaviors to 38.75 expected behaviors within a twenty minute social setting.

+2

+1 X (42.66)

0 X (31) X (27.66)

-1 X (23.66)

-2Baseline Average

Week 1 - 6

Averages

Week 6 - 12

Averages

Post Averages

Individual Data Collection - Charting

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)

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

References and Resources

Association for Behavioral and Cognitive Therapies (2010). Evidenced-based mental health treatments for children and adolescence. Accessed electronically from http://www.abct.org/sccap/?m=sPro&fa=pro_ESToptions#sec13 on October 1, 2010.

Attwood, T. (2000). Strategies for improving the social integration of children with Asperger syndrome. Autism, 4(1), 85-100.

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, 37-46.

Center for Disease Control, (2010). Autism information center: Frequently asked questions - prevalence. Accessed electronically from www.cdc.gov/ncbddd/Autism/faq_prevalence.htm#howdotherates on April 17, 2010.

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), 27-35.

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 www.thegraycenter.org 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.

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), 443-453.

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.

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), 279-286.

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), 1081-1105.

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.

Web Resources

Autism www.autismnetwork.org/modules/social/index.html www.socialthinking.com www.autism-society.org www.aspergersyndrome.org/ www.aspennj.org/ www.thegraycenter.org/ www.tonyattwood.com.au/ www.research.chop.edu/programs/car www.oar.org

CBT www.beckinstitute.org www.abct.org www.nacbt.org