While CBT is a well-validated technique, it has not been used as widely with children with ASD. CBT can be a good match for children with ASD, however, as it is a structured and predictable therapeutic process (following the same session outline each week), and offers repetition, uses concrete evidence in problem solving, and offers opportunities to practice skills (Weiss & Lunsky, 2010). After a thorough assessment of the child with ASD, it would be clear what level of concrete language must be used, how much detail to go into in descriptions of behavioral expectations and how much practice may be needed to master skills. The child’s assessment will also determine the specific skills to be targeted during intervention.

There is also some evidence that emotion comprehension can be taught to children with ASD, which can help them benefit from CBT activities. Golan and colleagues (2010) found that children with ASD who were repeatedly shown an animated video designed to teach different emotions or mental states performed better on tests of emotional vocabulary and emotion recognition. Even if a child is showing difficulties on initial assessments prior to intervention, it is important not to immediately eliminate those elements, but instead focus on them more intensely throughout the intervention. The assessment prior to intervention can highlight areas in which intervention will be most important, as well as some possible modifications to the therapeutic process. CBT overall appears to be a promising intervention for children with ASD, when conducted with appropriate modifications.

The most common modifications to CBT interventions for children with ASD are provided in Table 10.1, and will be described here in more detail. Given the core difficulty of children with ASD in social skills, it is important to teach explicit social skills during intervention (e.g., Cardaciotto & Herbert, 2004; Sofronoff et al., 2005; Sze & Wood, 2008). Additionally, it may be necessary to use visual aides to teach important skills (e.g. Chalfant, Rapee, & Carroll, 2007; Reaven et al., 2009; Sze & Wood, 2008), and not rely on the child’s abstract thinking ability. Attwood (2004) suggests using social stories to help teach cognitive skills, having students create tangible objects, such as drawings or images to help them define emotions, and teaching students to use coping strategies that are not dependent on abstract language, such as deep breathing and other relaxation techniques. Lang, Regester, Lauderdale, Ashbaugh and Haring (2010) note that many common CBT modifications tend to focus on teaching practical skills, such as social and self-help skills, while reducing the emphasis on cognitive-based components of the treatment.

Other common methods used within interventions for children with ASD include using a child’s perseverative interests in order to increase engagement (Bryson et al., 2007), and using systematic reinforcement for appropriate behavior (Smith, 2001). Children with ASD often have perseverative or restricted interests (APA, 2013), and using those interests to motivate the child to learn new skills can be an effective way to encourage them to try new activities or to reach out to others when their inclination may be to avoid those situations. In addition, using reinforcements for approaching behaviors that they may otherwise avoid can also be an effective tool in motivating students with ASD to try new behaviors. For example, if trying to increase a child’s level of social interaction, the therapist may want to offer a tangible reward during the next session for initiating to peers as part of their homework. The child is then motivated to approach these peers and to try the behavior in order to get the tangible reward from the therapist. It is hoped that with repeated positive exposure to the peers (presumably achieved through appropriate approach behaviors), the child may be more willing to ultimately continue the behavior without needing a tangible reward in the future.

Given the differences in the spectrum of ASD, it is important to consider individualized modifications to the treatment that acknowledge the variability in how these children present for treatment. For example, as described in Table 10.1, children with limited vocabulary may need picture representations of information and materials to better understand core concepts. More universally, it is recommended to use concrete language (e.g., avoid the use of sarcasm or joking, as it is generally not as well understood by children with ASD), as well as to ensure probing for comprehension throughout sessions.

While it may appear that children with ASD understand core concepts, the application of these concepts across settings is often a core difficulty for these students (Bellini et al., 2007). While children may understand social rules in structured settings (e.g., classrooms—where rules are both explained and posted), unstructured settings can be much more challenging. For example, when walking into a cafeteria, it is not always readily apparent where to sit (even when tables are assigned to classes). Simultaneously, students also need to balance engagement with peers with the task of eating in a socially appropriate manner. Thus, it is important to be as concrete as possible about alternatives, and perhaps practice alternatives with the child, so that they are aware of the range of potential responding in ambiguous situations.

Practicing alternatives can be a large component of the CBT process, as children with ASD often hold strictly to the routine or script that they are taught. Thus, it is important not to suggest only one alternative, but to instead practice a range of alternatives that can occur in any particular situation. Practicing responding in these situations can be done with social stories or comic strip stories for students who need concrete representations about the situation, while other students may be able to role play or simply describe the situation more abstractly and discuss multiple potential outcomes. By prompting the child with different, but similar scenarios, the child can practice flexibility in responding to multiple situations that may occur within the same setting.

When using any intervention with children with ASD, it is also important to ensure that if a child has mastered a skill in one setting (e.g., initiating to peers in the cafeteria) that they are then able to understand when and how to adapt that skill to other settings (e.g., initiating to peers on the playground). Whereas typically developing peers may be able to learn a skill and apply that skill in all situations, this is far more difficult for the child with ASD (Rogers, 2000). Context specific learning is common, and children may have to be shown the direct linkages between how to behave in two similar, but different settings.

Another common challenge for children with ASD is a lack of understanding the thoughts or perspective of others (Theory of Mind ). While this understanding is not critical in all skill development, it is a key concern in social situations (which are often of concern within schools). Focusing directly on this skill of understanding the view of other people may be a key to helping students socially adapt. Using these perspective taking strategies during CBT may also allow the opportunity to show how the child can deduce another’s perspective in different situations. For example, for a child who is assessed to have poor perspective taking skills, it is important to review this skill repeatedly, asking about what another child might think or feel in each situation you discuss throughout each session (and generate multiple situations to practice this skill). Moving on to more complex social skills may be difficult when the child is unable to understand the perspectives of others.

Finally, a common modification to treatment when working with children with ASD, is to include parents in the treatment process (e.g., Reaven et al., 2009; Storch et al., 2013; White et al., 2010). Including parents in CBT interventions offers the best opportunity to help with the generalization of skills across settings, as well as to teach parents critical skills in working with their own child (Sofronoff et al., 2005). One study even compared family vs. individual CBT, and found greater effects from working with the family than the individual child alone (Puleo & Kendall, 2011). However, it can be challenging to get parental involvement for school-based services due to the timing of the sessions and/or some parents’ reluctance to participate in school-based activities. Interventions with parents may be more successful in the evenings after school hours, when parents are less likely to have conflicts with work, and run groups concurrently with students and parents to ensure childcare needs are addressed.

Schools can be an ideal setting to provide students with evidence-based mental health services. As mental health problems can produce barriers to student learning, it can be considered a school’s responsibility to provide struggling students with mental health services (Adelman & Taylor, 2003). Because many students, particularly those in urban settings, do not get the mental health services that they need, schools may increase rates of service delivery by removing some of the common barriers to services such as attendance difficulties and fear of stigma (Atkins, Frazier, Adil, & Talbott, 2003). Additionally, school-based clinicians often have information about students that a mental health worker in another setting might not have access to, such as students’ academic and behavioral records. They are also able to observe students interact with their teachers and peers (Creed, Reisweber, & Beck, 2011).

CBT as an intervention itself may be particularly well suited to the school setting. Because CBT sessions are often highly structured, clinicians are able to work around school scheduling constraints and use shorter, more frequent sessions in an effective way (Creed et al., 2011). Additionally, because students are used to being assigned homework in school, they may feel more inclined to practice using the skills outside of the sessions than they would if they were working with a clinician in another setting. CBT has already been used in schools to prevent and/or treat a variety of disorders, including anxiety (Bernstein, Bernat, Victor, & Layne, 2008; Mifsud & Rapee, 2005) and depression (Gillham et al., 2007; Shirk, Kaplinksi, & Gudmundsen, 2009), which also suggests its potential use for more populations within schools.

Despite these benefits, there are some specific challenges to providing mental health services in a school setting. Mental health workers in schools typically have very large caseloads and may not have the time to provide one-on-one or small group therapy. Additionally, because of high stakes testing, students’ academic days are usually very busy and it may be difficult to schedule times where teachers are comfortable with students being pulled out of class.

When considering modifications needed to make CBT more appropriate for children with ASD, other barriers arise. In order to fit CBT into students’ schedules, they often need to be pulled out of class or other activities. Because children with ASD do not respond well to changes in routine, they may be more resistant to attending sessions. It is recommended that children be told about sessions prior to the first one to prepare them for changing their routine from what they expect. It is also recommended that sessions be held at the same time each week on a regular basis in order to help make this part of a new routine for the child with ASD.

Another challenge conducting CBT in the school setting relates to the length of CBT sessions. For example, in McNally, Keehn, Lincoln, Brown, and Chavira’s (2013) study, a manualized CBT was adapted for the ASD population by extending the length of sessions to allow greater time for introducing and practicing concepts. However, due to the scheduling challenges during a school day, it may be unrealistic to adjust treatment in this way, even if it is recommended for a specific child with ASD. Instead, more frequent, shorter sessions may be a better way to increase practice opportunities. As stated above, this adjustment in session time (more frequent but shorter sessions) is also one of the advantages of using CBT within the school setting, where students are on site for intervention on a daily basis, instead of having to ask children and families to come to a clinical setting repeatedly during a week.

In explaining CBT to students with ASD, it may also be helpful to prepare them for the format of sessions, as well as what will be discussed ahead of time, as much as possible. Letting them know how much time you will spend together and some of the activities you might be doing together can help to ease any discomfort they may have from being pulled out of regular class routines for this new activity. Building a therapeutic relationship with the child (e.g., gaining trust or showing interest in the student’s favorite activities or topics) is also critical to increase the likelihood of participation in sessions, and allowing time for adjustment to a practitioner can be important by first focusing on building rapport over several sessions before introducing “work” to be done by the student.

Within the school setting, there can also be flexibility in who takes the responsibility for implementing therapeutic interventions. School counselors, social workers, and school psychologists are typically relied on within the school setting to provide mental health services. However, as previously mentioned, one of the only school-based studies of CBT found that students’ special education teachers were effective group leaders (Bauminger, 2007). Regardless of who provides the intervention, it is critical to maintain the same therapist once a therapeutic relationship has been established with a student. Changing therapists regularly can disorient the student to the purpose of sessions or meetings, and halt therapeutic progress.

Building the therapeutic relationship may take longer with children with ASD. Many of these children have often been exposed to numerous providers (e.g., doctors, therapeutic support staff, case workers, behavioral health professionals, etc.). With so many individuals involved in their care, it can mean that they are either more or less receptive to having new adults in their lives. It is important that the individual responsible for working with a child with ASD is both familiar with the child as well as general characteristics of ASD. Understanding common challenges for children with developmental delays can help the therapist to know what to look for, specifically, in assessments, and how to adapt interventions to meet these needs.

A big advantage to any intervention within the school setting is the opportunity to include peers in the practice component of the intervention. Having peers allows the possibility for group work, as well as practice opportunities during unstructured time. Peers can include those who are typically developing (perhaps serving as models), or those with different special needs within the school. Peers can be selected based on a common need for intervention or strength in a specific area (e.g., social skills). It is recommended, however, to have a heterogeneous group in terms of the type of problems and degree of impairment to provide opportunities for all students to be models as well as learn from others. Group work saves time for interventionists (who can work with multiple children at one time), as well as increasing the likelihood of generalization of skills for the child with ASD, as these group members can help each other during non-group times within the school. Practice opportunities (e.g., homework) are critical to the continued use of the skill within the school setting, and having peers who understand the assignment along with the child with ASD can potentially increase the likelihood that they will try the homework between sessions.