Cognitive Behavioral Therapy
“Imagine your son was dropped in the middle of China, without a phone, a map or a grasp of the language and he was expected to find his way home by himself. Picture that and then you have an inkling of what life is like for him every day.”.
(Tsachi Manor, Clinical Psychologist)
If we consider the meaning of this statement, reactionary avoidance behaviors, prevalent in autistic children, will make perfect sense to us.
They are the go-to panic response when children attempt to cope with a flood of external stimuli.
We are familiar with terms such as ‘echolalia,’ ‘stimming,’ and ‘meltdowns.’ All of these are coping strategies to help manage and numb the constant inward flow of anxiety.
Also known as safety behaviors, they are fuelled by impaired functioning in social situations and by an intense lack of understanding of how to navigate the world successfully.
Reaction avoidance behaviors compound a negative cycle, reaffirmed by repeated self-activation that becomes ingrained and automatic over time. This is how the cycle can be understood:
External stimuli → anxiety → reactive avoidance → behavior emotional shutdown
According to this diagram, children with autism are living at the behest of their environment and are imprisoned by their limited skill set. Their reactive avoidance behavior helps to give them much needed short-term relief, to maintain control, and to provide peace of mind. Nevertheless, life continues to remain unstable, and the child remains in a state of unpredictable emotional turmoil.
Traditional intervention targets specific skills to support impairment in function. These targets focus on restoring what is impaired. For example, they work to develop good eye contact, impart knowledge of facial expressions, and clarify good communication behaviors.
This makes sense when we know that life and social skills are an integral part of functioning in society. Teaching such skill sets give children on the spectrum essential techniques for living. Such training boosts confidence and encourages independence to ease the symptoms of the negative cycle, as shown in the linkage diagram above.
The one drawback of this type of behavioral activation training, however, is that children on the spectrum still do not acquire self-regulation skills. Self-regulation can be defined as learning how to manage disruptive emotions and impulses by controlling one’s thoughts and behavior. Self-regulation skills not only reduce the frequency of reactionary avoidance behaviors but also help to eliminate them.
Intervention programs teaching neurotypical children how to self-regulate have a high success rate because they harness an individual’s natural capability for problem-solving. Despite the presence of significant difficulties in everyday social interactions, studies have shown that participants with autistic spectrum disorder (ASD) actually have more advanced perception and processing abilities than their counterparts.
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In a joint study between the Universities of Montreal and Harvard 1 researchers found that individuals with ASD were able to problem solve an average of 40 percent faster than individuals with neurotypical brain development. The study found that participants with ASD were able to do this because of their more advanced perception and processing abilities.
In her book ‘The Unwritten Rules of Social Relationships’ 2, Dr. Temple Grandin clarifies the importance of intervention programs providing individuals on the spectrum with knowledge and practical tools to help them succeed in the world around them. Dr. Grandin adds that we should not forget, “most importantly, that we are all responsible for our own behavioral choices.”
If traditional forms of intervention training that restore what is impaired were to be combined with secondary training that utilizes strengths already present in autistic children, this would allow autistic individuals to internalize their capability to take control of their own behavior. Intervention at an early age would maximize the effect of this combined training crucial for the development of self-esteem and feelings of self-worth from child to adulthood.
Considerable research has accumulated on the effectiveness of Cognitive Behavioural Therapy (CBT) for anxiety and depression3. CBT is based on the premise that how we think and feel impacts how we behave and interact. Specifically, our thoughts determine our feelings which impact our behavioural choices. The goal of CBT is to adopt specific skills that work to change patterns of thinking and troubleshoot new behavior choices, ultimately helping us learn how to self-regulate.
Integrating the principles of CBT with the principles of traditional intervention training to form a new hybrid intervention for children with ASD will give them a full range of tools to develop self-regulation capabilities. The autistic child would then be in a position to reduce the severity of his reactionary avoidance behaviors by replacing them with his own, conscious, positive choices.
Self-regulation intervention would target two cognitive limitations: rigid, negative thinking patterns, and lack of awareness of innate problem-solving capabilities. Identification skills would teach a child with ASD to recognize the difference between helpful and unhelpful ways to react to external situations.
The first step of such training would explore different methods to successfully change negative thought patterns, thereby reducing the possibility of an emotional shutdown. The second step would teach the child with autism how to recognize potential perspectives of all participants involved in a given situation.
Problem-solving skills identify other possibilities, both practical and emotional, encouraging exploration of emotional empathy and how one’s own behavior choices impact other people. In addition to boosting confidence and independence, problem-solving skills help alleviate depression, manage anxiety, and solve relationship problems, all of which reduce reactionary avoidance behaviors.
Based on the CBT approach, a new perspective of the negative cycle outlined above could look like this:
External stimuli → identify negative thinking patterns → create alternative thinking → positive feeling → positive behavioral choices → emotional intelligence and self-esteem
To recap, traditional intervention helps the ASD child manage their external responses to the world around them. By introducing the principles of CBT, we would be able to affect change at an internal level, allowing children on the spectrum to access their natural, proven abilities to create positive outcomes for themselves through problem-solving.
Research and work in this respect is at an early stage. Nevertheless, I believe that this combination of training would be the most effective way to help the child with autism spectrum disorder.
Montreal University and Harvard University 16th June 2009
Science Daily. Montreal University 17th June 2009
Unwritten Rules of Social Relationship, Dr Temple Grandin and Sean Barron
Future Horizons, 2005
PMC, US National Library of Medicine 31st July 2009
The Efficacy of Cognitive Behavioural Therapy
Authors: Stephan G Hoffman PhD, Anu Asnaani, M.A., Imke J.J. Vonk, M.A., Alice T. Sawyer, MA, and Angela Fang, MA.
This article was featured in Issue 103 – Supporting Emotional Needs