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Cognitive Behavioural Therapy and Autism Ranking: Very strong positive evidence

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Cognitive Behavioural Therapy (CBT) is a talking therapy that can help people to manage their problems by changing the way they think and behave.

CBT is designed to help people notice and understand how their thoughts, behaviours and emotions affect each other.  It is also designed to help them learn new ways of thinking about and responding to distressing situations.

The therapist breaks down problems into feelings, thoughts and actions to work out which are unhelpful or unrealistic. The therapist then teaches the client how to replace those feelings, thoughts and actions with more helpful and realistic ones.

There are numerous interventions for people on the autism spectrum which are based on, or which incorporate, the principles of CBT.

These include multi-component CBT programmes such as Behavioral Interventions for Anxiety in Children with Autism; Exploring Feelings; and Facing Your Fears.

Please Note

The National Institute for Health and Care Excellence (NICE 2013) reported that there is evidence for the effectiveness of CBT programmes for the treatment of coexisting anxiety in children on the autism spectrum, provided those programmes are modified to meet their specific needs.

It also reported that there is insufficient evidence to determine if CBT is an effective treatment for other coexisting mental health disorders (such as depression) in children on the autism spectrum.  However it recommended that CBT could be used for the treatment of those disorders in children on the autism spectrum, as this is in line with existing NICE guidance for those disorders.

The National Institute for Health and Care Excellence (NICE, 2012) reported that the evidence for CBT in adults on the autism spectrum is very limited. However it recommended that CBT might be appropriate as a treatment for anxiety and depression in many adults on the autism spectrum, as this is in line with existing NICE guidance for those disorders, provided those programmes are modified to meet their specific needs. 

Our Opinion

  • There is a reasonable amount of high quality research evidence to suggest that multi-component CBT programmes may help reduce the symptoms of anxiety in some primary school children and adolescents on the autism spectrum who have an IQ of 70 or more.
  • There is insufficient evidence to determine whether CBT programmes can help any child or adult on the autism spectrum with other issues, such as anger or depression.
  • There is insufficient evidence to determine whether CBT programmes can help people with the core features of autism
  • There is insufficient evidence to determine whether CBT programmes can provide any benefit to adults on the autism spectrum.”

We agree with the National Institute for Health and Care Excellence that CBT programmes might be appropriate for the treatment of anxiety and depression in people on the autism spectrum provided that the therapists providing CBT are appropriately trained, experienced and accredited. They should also follow established best practice which includes

  • Carrying out a detailed assessment of the individual, including any key strengths and weakness.
  • Modifying the therapy to take account of the needs of that individual, including any strengths and weaknesses.
  • Use of a longer assessment phase and an increased number of treatment sessions to help the initial engagement with the therapist, to enhance emotional literacy, and to practice, consolidate and generalise the techniques learnt.
  • Using a range of appropriate measures to evaluate the effectiveness of the therapy.

There is a need for further research which

  • Determines if cognitive behavioural therapy can help other groups on the autism spectrum with anxiety and sleep problems.
  • Determines if cognitive behavioural therapy can help people on the autism spectrum with other issues, such as anger or depression.
  • Evaluates the individual components of CBT programmes to see which, if any, are the most effective.
  • Compares CBT with other psychotherapeutic approaches, such as mindfulness training or counselling.
  • Evaluates the longer term effects of CBT in real world settings. 

Disclaimer

Please read our Disclaimer on Autism Interventions


Audience

CBT is most commonly used to help people with anxiety and depression but it is also used to help people with other mental and physical health problems.

CBT is likely to work best for those individuals who have the ability and the preference for understanding, monitoring and managing their own emotions and behaviour. It is therefore likely to work best for individuals aged 8 years old or over and who have a verbal IQ of 70 or more.  

CBT is less likely to work for individuals who are less than 8 years old, who have a verbal IQ of less than 70 or who have alexithymia (a condition which makes it difficult for them to describe and label emotions). 

CBT can also be considerably more challenging for some people on the autism spectrum. For example, they may struggle with certain cognitive tasks (such as creating an alternative perspective of a situation).

Aims and Claims

Aims

CBT is designed to help people to manage their problems by changing the way they think and behave.  For example, according to Spain et al (2013),

“CBT is a type of talking therapy ... which aims to help individuals to (1) notice and understand how their thoughts, behaviours and emotions are inter-related and (2)develop new ways of thinking about, coping with and responding to ... distressing situations.”  

The specific aim of CBT is to target distorted thoughts and feelings. For example, according to Anderson (2012),

“People often get stuck in patterns of thinking and responding that are not helpful, partly because they filter everything that happens through a “meaning-making system” that is skewed or inaccurate. Therefore, one way to change people’s feelings or behavior is to target distorted thoughts they have about themselves and their lives. This helps them shift the way they interpret situations, how they feel about those situations, and how they respond to them.”

This is done by challenging those distorted thoughts and developing more realistic thoughts and helpful behaviours. For example, according to Danial and Wood (2013),

“Cognitive behavioral therapy programs targeting anxiety aim to specifically identify the nature of the child’s fearful thoughts (e.g., that they will be kidnapped when away from parents), encourage the development of realistic ... beliefs that challenge irrational fears (e.g., that the probability of the fear is in fact very low), and gradually face feared situations with the new confidence arising from the [realistic] beliefs that have been discussed and rehearsed.”

Claims

There have been various claims for CBT as an intervention for people on the autism spectrum. For example the following researchers reported the following results:

  • Drahota et al reported a range of improvements (such as reduced anxiety and improved daily living skills) in primary school children
  • Reaven et al, 2012 reported reduced anxiety in adolescents.
  • White et al, 2013 reported increased social skills in some adolescents.
  • Andrews et al, 2013 reported increased affection in primary school children.
  • Sofronoff et al, 2007 reported decreased anger in primary school children.
  • Russell et al, 2009 reported decreased symptoms of obsessive compulsive disorder in adults.
  • Hesselmark et al, 2014 reported improved quality of life in adults.
  • Cortesi et al, 2012 reported increased speed of falling asleep in some primary school children (when used in combination with the drug melatonin).
  • Weiss et al, 2015 reported decreased stress in some parents of primary school children.

Key Features

Overview

CBT is a talking therapy that can help people to manage their problems by changing the way they think and behave.

CBT is designed to help people notice and understand how their thoughts, behaviours and emotions affect each other.  It is also designed to help them learn new ways of thinking about and responding to distressing situations.

The therapist breaks down problems into feelings, thoughts and actions to work out which are unhelpful or unrealistic. The therapist then teaches the client how to replace those feelings, thoughts and actions with more helpful and realistic ones.

CBT is a short-term approach in which individuals are encouraged to identify specific, measurable goals they would like to work towards.    

Different forms of CBT

There are several multi-component CBT programmes (such as Behavioral Interventions for Anxiety in Children with Autism; Building Confidence; Cool Kids; Coping Cat; Exploring Feelings; and Facing Your Fears) which have been designed for, or adapted to meet, the needs of people on the autism spectrum.

CBT can be delivered in a range of formats including:

  • individual therapy – one-to-one sessions with a therapist
  • group therapy – with others who wish to tackle a similar problem
  • a self-help book – where you carry out exercises from the book
  • a computer programme – known as computerised CBT (CCBT)

Common Elements

Most forms of CBT share some common elements including:

  • Assessment: Designed to provide an evaluation of the participants’ language, cognitive, and emotional skills before they begin the therapy.  This may include an evaluation of any key strengths, weakness and areas to work on.
  • Psychoeducation: Designed to increase the participants’ behavioural and cognitive skills and enhance their emotional development.  For example, the therapist may tell the participants about the symptoms of social anxiety and explain some of the different strategies for dealing with this. Or the therapist may teach the participants how to use one or more relaxation techniques.
  • Cognitive restructuring: Designed to help the participants identify negative thoughts and then challenge those thoughts with alternative thoughts or interpretations. For example, the participants may role play a situation that one of them finds distressing, learning how to replace unrealistic and negative thoughts about that situation with more realistic and positive alternative thoughts.
  • Exposure: This technique puts the participants into problematic situations in a controlled setting and teaches them to face their distress by using the skills they have acquired in the psychoeducation and cognitive restructuring components of therapy.

Adaptations for people on the autism spectrum

A number of authors (such as Spain et al, 2015) and the National Institute for Health and Care Excellence, 2012, have suggested how CBT should be adapted to make it more effective for use with people on the autism spectrum.  Those adaptations include:

  • Carrying out a detailed assessment of the individual’s language, cognitive, and emotional skills. This should include identifying any key strengths and weakness (such as difficulties in processing verbally presented information) before starting the therapy.
  • Longer assessment phase and an increased number of treatment sessions to help the initial engagement with the therapist, to enhance emotional literacy, and to practice, consolidate and generalise the techniques learnt.
  • Modifying the therapy to take account of the strengths and weaknesses of the participants (such as using thought bubbles for participants who have difficulties processing verbally presented information).
  • Placing greater emphasis on changing behaviour, rather than cognitions, and using the behaviour as the starting point for intervention.
  • A more structured approach, with clearly defined objectives, tasks broken down into smaller, more manageable steps and regular, predictable breaks
  • Giving explicit and direct instructions, such as providing a list of rules or social scripts.
  • Using plain English and avoiding excessive use of metaphor, ambiguity and hypothetical situations.
  • Incorporating participants’ special interests and strengths into therapy if possible (such as using computers to present information).
  • Involving a family member, partner, carer or professional (if the participants agree) to support the implementation of an intervention.
  • Using a range of appropriate measures to evaluate the effectiveness of the therapy (such as standardised assessment measures of anxiety that researchers understand alongside personalised assessment measures of anxiety that the participants understand).

Cost and Time

Cost

Within the UK, CBT should be available as part of the services offered by the NHS although you may have to wait. If you decide to pay privately you can expect to pay between £40 and £100 per session, depending on the therapist.

The cost of using computer programmes or books will depend on the specific computer programme or book you purchase.

Time

CBT is considered to be a short to medium term therapy, that is, it normally takes between 6 weeks to 6 months. However it may take longer for people on the autism spectrum. How long it actually takes will depend on the problem you are trying to solve and how well it is working for the individual.

If someone has individual therapy he or she will usually meet a therapist for between 5 and 20 sessions, either weekly or fortnightly. Each session will last between 30 and 60 minutes.

If someone is following a programme using a book or computer programme the length and frequency of treatment will depend on the book or computer, as well as on the individual.

Risks and Safety

Hazards

There are no known adverse effects of cognitive behavioural therapy for people on the autism spectrum.

Contraindications

There are no known contraindications (something which makes a particular treatment or procedure potentially inadvisable) for CBT for people on the autism spectrum.  However, some authors have suggested that CBT may be less effective in people on the autism spectrum.  For example, Scattone and Mong (2013) suggested 

“There are several potential barriers limiting the effectiveness of CBT for this population, including difficulty regulating emotions, communication deficits (e.g., comprehension, literal interpretation), motivation, cognitive inflexibility, concrete thinking, executive function deficits, therapeutic generalization across settings, and ToM deficits” 

Suppliers and Availability

Suppliers

In theory, CBT is freely available via the NHS to anyone in the UK who requires it. In practice, it is often extremely difficult to obtain CBT and even more difficult to find a CBT therapist with the skills, knowledge and experience required to work with people on the autism spectrum.

In the UK, The British Association for Behavioural and Cognitive Psychotherapies (BABCP) keeps a register of all accredited therapists in the UK and The British Psychological Society (BPS) has a directory of chartered psychologists.

In the USA, the Academy of Cognitive Therapy and the National Association of Cognitive-Behavioral Therapists both have a directory of CBT therapists.

Credentials

There are some nationally recognised qualifications for providers of CBT.  For example, in the UK, The British Association for Behavioural and Cognitive Psychotherapies has developed accreditation criteria for minimum standards in CBT. However, such standards do not imply that accredited therapists will necessarily be competent to work with complex cases, for example, such as individuals on the autism spectrum.

Related Suppliers and Availability


History

Albert Ellis, an American psychologist, developed Rational Emotive Behavioural Therapy in the 1950s. Aaron Beck, an American psychiatrist, developed Cognitive Therapy in the 1960s. In recent years, elements of these different therapies have been combined into cognitive behavioural treatment.

There are several multi-component CBT programmes designed for non-autistic children and young people (such as Building Confidence; Cool Kids; Coping Cat) which have since been adapted for use with children and young people on the autism spectrum.

There are several multi-component CBT programmes (such as Behavioral Interventions for Anxiety in Children with Autism; Exploring Feelings; Facing Your Fears) which were created specifically for use with children and young people on the autism spectrum.

Current Research

We have identified more than 40 studies of multi-component CBT programmes as an intervention for people on the autism spectrum published in peer-reviewed journals. (We have not included or evaluated studies looking at other interventions based on CBT, such as social stories or social skills groups which we have described and evaluated elsewhere.)

These studies included more than 1,500 individuals aged from pre-school to adult and included people with autistic disorder, Asperger syndrome and pervasive developmental disorder - not otherwise specified.   The majority of these studies looked at the treatment of mental health problems in primary school children and/or adolescents. Those mental health problems included various anxiety disorders (such as social anxiety disorder, obsessive-compulsive disorder, agoraphobia, and non-specific anxiety disorder) as well as low mood or depression, self-harm, post-traumatic stress disorder (PTSD) and sleep problems.

The vast majority of the studies reported positive results.

  • Some of the studies (such as Reaven et al, 2012) reported reduced anxiety in some participants.
  • Some of the studies  (such as Drahota et al) reported a range of improvements (such as reduced anxiety and improved daily living skills)
  • Some of the studies (such as White et al, 2013) reported increased social skills in some participants.
  • Some of the studies (such as Andrews et al, 2013) reported increased affection in primary school children.
  • Some of the studies (such as Sofronoff et al, 2007) reported decreased anger in primary school children.
  • Some of the studies (such as Russell et al, 2009) reported decreased symptoms of obsessive compulsive disorder.
  • Some of the studies (such as Hesselmark et al, 2014), reported improved quality of life
  • Some of the studies (such as Cortesi et al, 2012) reported improved sleep in some participants.
  • Some of the studies (such Weiss et al, 2015) reported decreased parental stress in some participants.

Only two studies (Santomauro et al, 2016; and Storch et al, 2015 b) reported mixed or limited results.

Status Research

There is a reasonable amount of high quality research studies on cognitive behavioural therapy as an intervention for people on the autism spectrum. However there are a number of limitations to all of the research studies published to date. For example

  • Some of the studies (such as Fitzpatrick, 2004; Greig and MacKay, 2005; Sze, 2008) had a single participant.  Other studies (such as Ooi et al, 2008; Schmidt et al, 2011; Storch et al, 2015) had less than 10 participants.
  • Some of the studies (such as Bauminger, 2002; Reaven et al, 2015; Weiss J. A. et al, 2015) were open label trials with no comparison control group.
  • Some of the controlled studies (such as Chalfant et al, 2007; Puleo and Kendall, 2011; Reaven et al, 2009) were non-randomised.
  • Some of the randomised controlled studies (such as Andrews et al, 2013; Hesselmark et al, 2014; Sofronoff et al (2007) were non-blinded.
  • Some of the controlled and randomised controlled trials (such as Andrews et al, 2013; Drahota et al, 2011; Fujii et al, 2013) used a waitlist or treatment as usual as a control condition rather than an active intervention.
  • Some of the studies (such as Drahota et al, 2011; Fujii et al, 2013; Vause et al, Epub) were undertaken by researchers who were not independent of the intervention being studied.  Those researchers may therefore have been biased towards the intervention, however unconsciously.
  • Very few of the studies looked at the following groups on the autism spectrum: females, individuals with a verbal IQ of less than 70, individuals from minority ethnic groups.
  • Very few of the studies looked at implementing CBT in real world settings (such as the home, at school or at work).
  • There was wide variability in reporting the age of initial onset of mental health co-morbidity, or the duration and trajectory of these symptoms.
  • There was wide variability in reporting of concomitant treatments including medication and psychoeducational and interventions.
  • There was wide variability in the choice of outcomes measures, which ranged from child self-report to parent and/or teacher reports of improvements and objective clinical ratings.
  • The fact that many of the studies investigated multi-component CBT programmes makes it difficult to be sure which of those components were the most effective.
  • There were only a few studies (such as Maddox et al, 2016; Selles et al, 2015) which followed up previous studies in order to evaluate the long term effects of the intervention.

For a comprehensive list of potential flaws in research studies, please see ‘Why some autism research studies are flawed’

Ongoing Research

Future Research

Summary of Existing Research

  • There is a reasonable amount of high quality research evidence to suggest that cognitive behavioural therapy may be effective in reducing anxiety in some children and adolescents on the autism spectrum who have an IQ of 70 or greater.
  • There is one very high quality research study which suggests that CBT, when used in conjunction with the drug melatonin, may increase the speed with which some children on the autism spectrum fall asleep.
  • There is insufficient evidence to determine if cognitive behavioural therapy is effective in reducing anxiety in other groups on the autism spectrum, such as adults or children and adolescents with an IQ of less than 70.
  • There is insufficient evidence to determine if cognitive behavioural therapy is effective in helping with other problems, such as depression, in anyone on the autism spectrum

Recommendations for Future Research

Future research studies should

  • Determine if cognitive behavioural therapy can help other groups on the autism spectrum (such as those with a verbal IQ of less than 70) with anxiety.
  • Determine if cognitive behavioural therapy can help anyone on the autism spectrum with other issues, such as anger or depression.
  • Evaluate the individual components of CBT programmes to see which, if any, are the most effective.
  • Compare CBT with other psychotherapeutic approaches, such as mindfulness training or counselling.
  • Evaluate the longer term effects of CBT in real world settings such as homes, schools and the workplace.
  • Be more rigorous in the reporting of issues such as comorbidities and concomitant treatments.
  • Using a range of appropriate measures to evaluate the effectiveness of the therapy (such as standardised assessment measures of anxiety that researchers understand alongside personalised assessment measures of anxiety that the participants understand).
  • Involve people on the autism spectrum to review the efficacy and ethical basis of CBT including individuals who may be non-verbal.

Studies and Trials

This section provides details of scientific studies into the effectiveness of CBT for people on the autism spectrum which have been published in English-language, peer-reviewed journals. You may be able to find more studies on CBT in our publications database If you know of any other studies we should include please email info@researchautism.net with the details..

Please note that we are unable to supply publications unless we are listed as the publisher. However, if you are a UK resident you may be able to obtain them from your local public library, your college library or direct from the publisher.

Related Studies and Trials


Other Reading

Related Other Reading


Personal Accounts

We have been unable to identify any personal accounts about the use of CBT for people on the autism spectrum.

If you know of any personal accounts we should include please email info@researchautism.net with the details. 

Additional Information

NICE guidance

The National Institute for Health and Care Excellence (NICE 2013) reported

“The evidence concerning the cognitive behavioural treatment of coexisting conditions is very limited and provides no specific evidence to support the development of adaptations to CBT to make it potentially more effective for people with autism. Effective psychological interventions, predominantly CBT, exist for depression and anxiety disorders, for which there is extensive NICE guidance. The GDG considered that these interventions could be appropriate for many adults with autism. However, the evidence reviewed in this guideline does not provide any guidance on autism-specific adaptations to psychological interventions for coexisting conditions. In the absence of such evidence, and given the high prevalence of depression and anxiety disorders in adults with autism, GDG members drew on their knowledge and expertise, both of psychological interventions and autism, to develop some recommendations on how CBT (and other psychological interventions) might be adapted in order to increase their effectiveness in autism. These included a more concrete, structured, approach with a greater use of written and visual information than might typically be the case in CBT. The GDG was of the view that an emphasis on the behavioural rather than the cognitive aspects of CBT could be beneficial as could shorter sessions or regular breaks. Careful consideration should be given to the use of group-based approaches and the excessive use of metaphors or hypothetical situations should be avoided. Consideration should also be given to the increased involvement of a family member or key worker as co-therapist to support the generalisation of benefits.”

The National Institute for Health and Care Excellence (NICE 2012) reported

“In the absence of evidence of how coexisting mental health disorders (including ADHD, OCD, PTSD, depression and conduct disorder) should be treated differently in autism, the GDG agreed that management should be in line with existing NICE guidance. There was, however, evidence for clinical efficacy of CBT programmes with autism-specific modifications on coexisting anxiety for children with autism. There was evidence for a positive treatment response to CBT in terms of no longer meeting diagnostic criteria for the anxiety disorder and/or showing global improvement in anxiety symptoms. Economic analysis suggested that group-based CBT is likely to be a cost-effective intervention for the management of anxiety in children and young people with autism, whereas, individual CBT is probably not cost-effective. However, the GDG were concerned that for some individuals with autism participating in a group-based intervention would be difficult or impossible, therefore, the GDG agreed that it was important that for these children or young people individual-based CBT could be considered. The GDG recognised that CBT may not be appropriate for individuals with coexisting learning disabilities given that the intervention dictates a certain level of cognitive functioning and verbal ability to enable participation.”

NHS Choices

The NHS Choices website, accessed on 18 July 2016, states that CBT has some disadvantages:

  • “To benefit from CBT, you need to commit yourself to the process. A therapist can help and advise you, but cannot make your problems go away without your co-operation.
  • Attending regular CBT sessions and carrying out any extra work between sessions can take up a lot of your time.
  • Due to the structured nature of CBT, it may not be suitable for people with more complex mental health needs or learning difficulties.
  • As CBT can involve confronting your emotions and anxieties, you may experience initial periods where you are more anxious or emotionally uncomfortable.
  • Some critics argue that because CBT only addresses current problems and focuses on specific issues, it does not address the possible underlying causes of mental health conditions, such as an unhappy childhood.
  • CBT focuses on the individual’s capacity to change themselves (their thoughts, feelings and behaviours), and does not address wider problems in systems or families that often have a significant impact on an individual’s health and wellbeing. “
Updated
31 Oct 2017
Last Review
01 Mar 2017
Next Review
01 Mar 2020