• Janet Ferone

As a consultant who supports schools in serving students with autism, I am concerned with lack of resources for the higher functioning students who experience high incidences of anxiety. Often ABA (Applied Behavioral Analysis) is seen as the "cure" for autism and while it has been useful, particularly with lower functioning students, there is danger in the "one-size-fits-all" approach. More resources are needed to address mental health issues of students with autism. This article by Lee A. Wilkinson provides an alternative perspective to meet the needs of students with autism also experiencing co-occurring mental health issues. #mentalhealth #autismspectrumdisorders #ASD #autism #CBT #anxiety


Cognitive-Behavioral Therapy (CBT) for Children on the Autism Spectrum


Introduction

Children with autism spectrum disorders (ASD) frequently have co-occurring (comorbid) psychiatric conditions, with estimates as high as 70 to 84 percent. A Comorbid disorder is defined as a disorder that co-exists or co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. Although anxiety is not a defining characteristic of ASD, prevalence rates are significantly higher in children with ASD than in typically developing children, children with language disorders, chronic medical conditions, disruptive behavior disorders, and intellectual disability or epilepsy. In fact, research suggests that approximately one-half of children with ASD would meet the criteria for at least one anxiety disorder. Several studies have also reported a bidirectional association between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youths with mood and anxiety disorders. Individuals with ASD also appear to display more social anxiety symptoms compared to typical control individuals, even when these symptoms are clinically overlapping with the characteristic social problems typical of ASD. With comorbidity rates so elevated in the ASD population, treatment options for anxiety have become increasingly important.


Cognitive-Behavioral Therapy

There is a strong evidence base for the use of cognitive-behavioral therapy (CBT) interventions for depression and anxiety in non-ASD populations. There are a variety of CBT approaches, but most share some common elements. The primary goals of traditional CBT are to identify and challenge dysfunctional beliefs, catastrophic cognitions, and automatic thoughts as well as change problematic behavior. With a therapist’s help, the individual is encouraged to challenge his or her beliefs and automatic thoughts through a variety of techniques. Through CBT, the individual learns skills to modify thoughts and beliefs, as well as problem-solving strategies to improve interaction with others in effective and appropriate ways, thereby promoting self-regulation.CBT models for the treatment of anxiety attempt to create a new coping pattern by using behavioral techniques such as modeling, exposure, and relaxation as well as cognitive techniques addressing cognitive distortions and deficiencies. These treatment models generally emphasize four critical components of therapy: assessment, psychoeducation, cognitive restructuring, and exposure. Using these four components, CBT has been shown to be an empirically supported treatment for typically developing children with anxiety issues. The most commonly used techniques to treat anxiety in children are exposure, relaxation, cognitive restructuring, and modeling in that order.


Cognitive-Behavioral Therapy for ASD

Although CBT has been shown to be an effective empirically supported treatment for typical children, there is a question as to whether or not it can be used with other populations. In recent years, there have been a number of attempts to adapt CBT for children and teens on the autism spectrum. Although there is no agreed upon set of modifications, there appears to be a general consensus that with certain specific modifications, CBT can be used to effectively lessen anxiety symptoms in higher functioning children with ASD. Evidence from the current literature supports a specific blend of techniques and strategies as the most effective approach to modify CBT for use with children who have an ASD. The primary modifications to CBT that have been shown to make them more viable for anxious children with ASD are the development of disorder specific hierarchies, the use of more concrete, visual tactics, the incorporation of child specific interests, and parent participation.A study published in the Journal of Child Psychology and Psychiatry illustrates how a standard CBT program can be adapted to include multiple treatment components designed to accommodate or remediate the social and adaptive skill deficits of children with ASD that serve as barriers to anxiety reduction. The study tested a modular CBT program incorporating separate modules focusing specifically on deficits associated with ASD such as poor social skills, self-help skills, and stereotypies as well as a modified version of a traditional CBT protocol utilizing primarily cognitive restructuring and exposure techniques. The participants were forty children (7–11 years of age) who met the criteria for ASD and one of the following anxiety disorders: separation anxiety disorder (SAD), social phobia, or obsessive-compulsive disorder (OCD). They were randomly assigned to 16 sessions of CBT or a 3-month waitlist (36 children completed treatment or waitlist). The CBT model emphasized coping skills training (e.g., affect recognition, cognitive restructuring, and the principle of exposure) followed by in vivo exposure. The parent training components focused on supporting in vivo exposures, positive reinforcement, and communication skills. Independent evaluators blind to treatment condition conducted structured diagnostic interviews and parents and children completed anxiety symptom checklists at baseline and posttreatment/postwaitlist. The researchers found that 92.9% of children in the active treatment group met criteria for positive treatment response post-treatment compared to only 9.1% of children in the waitlist condition. In addition, 80% of children in the active treatment group were diagnosis free at follow up. From these results, it is reasonable to draw the conclusion that with specific modifications, CBT can be an effective treatment for children with ASD and concurrent anxiety disorders.


Conclusions

The above referenced study, together with case studies and other clinical trials, provides evidence that incorporating disorder specific hierarchies, use of more concrete, visual tactics, incorporation of child specific interests, and parental involvement can facilitate successful results when conducting CBT for anxiety in children with ASD. Although there is support for the efficacy of an enhanced CBT program, there are some limitations to these modifications and adapted models. Specifically, the child’s level of functioning, variation in the use of each modification, and the utilization of different CBT programs across studies affect the generalization of the outcomes. Moreover, there is a need to examine to what extent CBT with these modifications could be used with more severe cases of ASD or in cases where there is more severe intellectual impairment. Children with higher functioning ASD may be able to better process the cognitive components of traditional and modified CBT than those who are lower functioning. Additionally, different CBT programs may emphasize different components of CBT making it difficult to determine which components are the most critical for treating anxiety in children with ASD. The next step for future research should be to focus on developing a standardized approach to treatment which incorporates specific modifications, randomized clinical trials to test the approach, and explorations of the boundaries within the ASD population for use and effectiveness of treatment. Given the elevated comorbidity rates, finding an effective, empirically supported treatment for anxiety in children with ASD is critical. Key References and Further ReadingMoree, B. N., & Davis III, T. E. (2010). Cognitive-behavioral therapy for anxiety in children diagnosed with autism spectrum disorders: Modification trends. Research in Autism Spectrum Disorders, 4, 346–354. National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. http://www.nationalautismcenter.org/national-standards-project/ National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices. http://autismpdc.fpg.unc.edu/evidence-based-practices Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S… Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group. cidd.unc.edu/Registry/Research/Docs/31.pdf Weitlauf AS, McPheeters ML, Peters B, Sathe N, Travis R, Aiello R, Williamson E, Veenstra-VanderWeele J, Krishnaswami S, Jerome R, Warren Z. Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update. Comparative  Effectiveness Review No. 137. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2012-00009-I.) AHRQ Publication No. 14-EHC036-EF. Rockville,  MD: Agency for Healthcare Research and Quality; August 2014. http://www.effectivehealthcare.ahrq.gov/reports/final.cfm Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial.Journal of Child Psychology and Psychiatry, 50, 224–234. http://doi.org/10.1111/j.1469-7610.2008.01948.xLee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).FacebookTwitterGoogle+Pinterest


  • Janet Ferone

UPDATE: Hours after this post, Supt. Chang abruptly resigned from Boston Public Schools.


Imagine living in a country where you face gang and organized crime violence daily, watching family members murdered and knowing you could be the next target to be killed, kidnapped, sexually abused with no help, and often additional harm, from the police. Imagine you are able to seek refuge in the United States and you and your family have settled in Boston where you attend school every day, eager for a good education.


While you initially felt safe in your new school and community, you watch the news of daily deportations, separation of family members, children put in cages. You feel a bit insulated living in the progressive Northeast, but then you see the latest news: Boston Public Schools are being sued by multiple organizations over sharing of information to federal immigration officials (ICE). (Boston Globe 6/22/18) You find out that a student was deported as a result of a school incident report shared with ICE and the school district refuses to reveal how often they give out personal student information to authorities.


You remember being assured by both Supt. Chang and Mayor Walsh in a visit to your school or in public documents stating that all students and their families would be welcome in Boston schools regardless of immigration status, but now you are afraid. You feel betrayed by adults you came to trust. Perhaps you watched as your East Boston classmate who had a verbal, not physical, altercation with another student was taken into custody on unsubstantiated gang involvement and held for 16 months before being deported. What if you have an argument with a fellow student and claims are made that it is gang-related? Would you face the same fate?


As a consultant who works in the Boston Public Schools and served as an administrator there for over 25 years, I have seen the fear on faces of undocumented students and their parents as they worried about being exposed. Yesterday I wrote a blog post on how we must create welcoming environments for all students, particularly in light of the increase in violence and hate incidents against students of color and immigrants. (https://www.feroneconsult.com/blog) Today, with evidence of a potential “school to deportation pipeline”, the need is even greater. Teachers and administrators face a potentially insurmountable barrier to reassure students of their safety in light of these allegations and the school departments continued refusal to disclose the number of police incident reports shared with regional intelligence centers for the past three years.

As an educator, I have seen the determination of students fleeing violence, arriving with little English, and succeeding in school beyond their wildest dreams. Of this year’s 38 valedictorians at Boston high schools, about half were immigrants and there are similar numbers from previous years. Many of their stories are both heartbreaking and heartwarming.


In 2017, a student at a school I’m affiliated with was detained by ICE, facing deportation. A teacher at his school led the charge to fundraise and support him through his legal challenges, raising the $6,000 needed for bond. His next hearing in 2019 will determine whether he stays or returns to his native Guatemala where his mother sent him as an unaccompanied minor for his safety. Thankfully school staff were able to assist him, but this is not sustainable if more students find themselves in similar circumstances.


Our overworked teachers in underfunded schools will be facing these students who will be increasingly afraid to attend school and participate. Having received an email from Roger Brooks, President and CEO, Facing History and Ourselves on “Dehumanization at the Border”, I would like to share this wonderful organization’s resources from his message:

“Teachers and others who search our website (www.facinghistory.org) will find over 150 articles addressing “Global Immigration”—including resources relating to “civic dilemmas”—which help teachers and their students address complicated issues of identity and belonging. Just last week, Facing History issued our annual summer reading list on our blog, Facing Today. In it, Tracy O’Brien, Director of Library Services, highlights two books (Refugee by Alan Gratz and The 57 Busby Dashka Slater), which “challenge readers to resist easy characterizations of people and situations, and instead to reflect deeply on ‘What is justice?’” We also have other materials, such as our teacher-created unit and webinar for teaching the book, Enrique’s Journey, by Sonia Nazario; our unit, My Part of the Story; and individual lessons that teach about exclusionary moments in our immigration history like the Chinese Exclusion Act and Japanese Internment.

With most schools ended or winding down for the year, we should think about supports for all students, but particularly immigrant students, during the summer and into the next school year.


In Boston, we have multiple sites providing free breakfast and lunch, as well as Guides for Immigrant Students and Families on its website (www.bostonpublicschools.org). Schools should use their social media outreach to connect with students and families who may be fearful of returning their child to school in light of the recent attacks on immigrants and the potential sharing of info with ICE and share community supports.

With school shootings on the rise, this potential “school to deportation pipeline”, along with funding cuts and policy reversals, our students are being attacked from all angles. If our children are our future, we must do better in providing schools where students feel safe enough to tackle the important job of accessing the best education they can.https://www.bostonglobe.com/metro/2018/06/21/chang-bps-sued-over-secrecy-surrounding-student-information-sharing-with-ice/AWsz0zx7M8xhRwya9qrvhM/story.html


Boston Globe: Chang, BPS Sued Over Secrecy Surrounding Student Information Sharing with ICE


  • Janet Ferone

A welcoming and inclusive environment can reduce stress and hostility in our schools.

Two recent articles in the Boston Globe, “An About-Face, Brigham and Women’s to Dismantle Gallery of Past White Male Leaders” in the hospital’s amphitheater, and a column entitled “Fixing the Name Game” referring to the fact that of 125 Boston Public Schools, only 10 are named for women and efforts to change that, highlight how important it is for people to be able to recognize themselves regardless of gender, race, ethnicity in our public institutions. In an era where we see increasing violence toward people of color, increases in hate incidents in our schools, and immigrant students living in fear of family separation and deportation, it is more important than ever that we, as educators, create safe and welcoming spaces where students are engaged, included, and able to learn. In my post, Hatred Not Tolerated, We Accept all, I echo the sentiments expressed in the two Boston Globe articles of having students see themselves in the visuals of an institution and hope it will provide some ideas for you to incorporate in your schools as you plan for the upcoming school year.

I’d been planning to write an article on “Creating Welcoming and Inclusive Schools”, in light of the marked increase in hate incidents in schools and increased stress, particularly among schools with majority students of color (UCLA study May 2017 Teaching and Learning in the Age of Trump: Increasing Stress and Hostility in America’s High Schools) I then found myself unexpectedly at Natick High School, as a last-minute judge for a Massachusetts speech competition and from the moment I entered, I could feel this was a comfortable and accepting place. You may wonder how I could pick up on this on a day when school was not in session with no principal or other staff to greet me. Visuals can create a strong impact, and directly above the main entrance hangs a large rainbow flag with word “PEACE” on it. That was my first clue. As I made my way through the school, I noticed the hallways were all named after famous figures. Head down Mahatma Gandhi Way and take a left on Maya Angelou Terrace. In addition to giving clues as to what subjects were taught in that area – John Philip Sousa Avenue was naturally the music section – the variety of ethnicities, races and genders of the names let students know that all are acknowledged and worthy. When I looked at what was hanging on the walls, I heard the voices of students. Lots of handmade signs and artwork, post-its with students’ ideas and gratitudes, not just computer-generated posters by school staff. A great deal of the artwork was racially diverse in a school that falls below the state average for minority enrollment. Teachers made their own efforts to ensure all students felt safe and comfortable. Just about every door had an LGBTQ safe space” sticker, along with other visuals such as the “Hatred Not Tolerated, We Accept All Poster” pictured here. Bulletin boards also told a story of diversity, with posters for Chinese Club, Gay Straight Alliance, and an International Women’s Day Poster urging females to “Be Bold”. Upcoming events included benefit concerts for girls’ education and international causes; clearly showing the school puts its money where its mouth is. I was also struck by the sparkling cleanliness of the building. Having spent many hours in grimy, litter-strewn urban schools, a clean building makes me feel that they care about those who enter. The architectural design, particularly with the full view of the library from all levels, gives the impression of openness to ideas. Inside the classrooms, students’ voices continued to speak, with many “off-beat” and humorous drawings and posters, which also communicated that all ideas were worthy and not just ones that conformed to society’s norms. And believe me, after spending almost ten hours there judging, the humorous artwork definitely helped my mood. So, what are some ways you think schools can create a welcoming and inclusive environment? Have you noticed increases in stress or hostile environment in your school?