1. PENT 2015 Cognitive Behavioral Intervention (CBI) for Individuals with ASD
Ann England, M.A., CCC-SLP-L Assistant Director, Diagnostic Center, Northern California, CDE PENT Leader * CAPTAIN Leader

2. 3 Important ASD EBP Resources
California Department of Developmental Services
(DDS)
National Professional Development Center (NPDC)
National Autism Center (NAC)
ASD Guidelines for Effective Interventions
27 Evidence Based Practices Briefs
EBPs for Young Children
National Standards Project Report
Evidence Based Practices in Schools Educator Manual
Parent’s Guide to EBP and ASD
NOT YET AVAILABLE

3. Systematic Reviews of the Literature for Evidence Based Practices (EBPs)
In 2009, 11 “treatments” or practices with an evidence base
Reviewed by National Standards Project from National Autism Center
Included (NOTE: Update to be released Spring 2015)
In 2010, 24 EBPs
National Professional Development Center (NPDC)
Included 10 years,
In 2014, 27 EBPs
Second review by NPDC
Included 22 years,
29,101 possible studies 456 studies
RCT (randomized controlled trial), quasi-experimental, single case design
Strength of evidence for assessment
Based on number, type of studies using each EBP
As we accumulate more knowledge of what is successful, the number of evidence based practices grows. In 2009, the National Standards Project conducted a comprehensive review of all the autism intervention literature. Using a systematic review protocol, they identified practices, which they called treatments.
In 2010, the National Professional Development Center on ASD (NPDC) reviewed a 10 year period of intervention research (from ), also followed a systematic process, and identified 24 evidence-based practices.
A comparison of the two sets of EBPs found substantial overlap.
This year, the NPDC published an updated review of practices that extended the literature review period from 1990 to It began with identification of over 29,000 possible studies, with the screening process finding 456 acceptable studies.

4. March
2014

5. Definition of EBP (NPDC)
NPDC definition of an EBP:
“Focused intervention practices that have substantial evidence for effectiveness in promoting positive outcomes for learners with ASD”

6. NPDC Criteria for EBP
To be considered an EBP for individuals with ASD, efficacy must be established through peer-reviewed research in scientific journals using:
At least two high quality experimental or quasi-experimental group design articles conducted by at least two different researchers or research groups OR
At least five high quality single case design articles conducted by at least three different researchers or research groups having a total of at least 20 participants across studies
A combination of at least one high quality experimental or quasi-experimental group design article and at least three high quality single case design articles conducted by at least two different research groups

7. Newest NPDC Report Findings (Literature review 1997–2011)
27 EBPs as compared to 24 EBPs identified in the previous review
Six new EBP categories:
Cognitive Behavior Interventions
Exercise
Modeling
Scripting
Structured play groups
Technology-Aided Instruction and Intervention

8. 27 Evidence – Based Practices (2014)
Pivotal response training
Prompting
Reinforcement
Response interruption/redirection
Scripting*
Self-management
Social narratives
Social skills training
Structured play groups*
Task analysis
Technology-aided intervention/instruction*
Time delay
Video modeling
Visual supports
* Added from 2014 literature review
Antecedent-based interventions Cognitive behavioral intervention* Differential reinforcement Discrete trial training Exercise* Extinction Functional behavior assessment Functional communication training Modeling* Naturalistic interventions Parent-implemented intervention Peer-mediated instruction/intervention Picture Exchange Communication System

9. The 27 EBPs are defined in Table 7 of the report!
What are these EBPs?
The 27 EBPs are defined in Table 7 of the report!

10. DEFINITIONS OF 27 EBPs

11. DEFINITIONS OF 27 EBPs

12. DEFINITIONS OF 27 EBPs

13. FACT SHEETS FOR EACH OF THE 27 EBPs
Definition of the intervention
Age range of participants
Type of outcomes it has generated
Citations for the specific articles that provide the evidence for the efficacy of the practice

14. Your Own Copy!

15. Ann’s CBI for ASD Info Template Includes Fact Sheet Information

16. What’s the research? See the Fact Sheet!
Research Studies Providing Evidence (CBI meets evidence-based criteria with 3 group design and 1 single case design studies):
Drahota, A., Wood, J. J., Sze, K. M., & Van Dyke, M. (2011). Effects of cognitive behavioral therapy on daily
living skills in children with high-functioning autism and concurrent anxiety disorders. Journal of
Autism and Developmental Disorders, 41(3), doi: /s
Singh, N. N., Lancioni, G. E., Manikam, R., Winton, A. S., Singh, A. N., Singh, J., & Singh, A. D. (2011). A
mindfulness-based strategy for self-management of aggressive behavior in adolescents with autism.
Research in Autism Spectrum Disorders, 5(3), doi: /j.rasd
Sofronoff, K., Attwood, T., & Hinton, S. (2005). A randomised controlled trial of a CBT intervention for
anxiety in children with Asperger syndrome. Journal of Child Psychology and Psychiatry, 46(11), 1152-
1160. doi: /j x
Sofronoff, K., Attwood, T., Hinton, S., & Levin, I. (2007). A randomized controlled trial of a cognitive behavioural intervention for anger management in children diagnosed with Asperger syndrome. Journal of Autism and Developmental Disorders, 37(7), doi: /s

17. What is CBI for ASD?
“Cognitive behavioral intervention (CBI) is based on the belief that behavior is mediated by cognitive processes.
Learners are taught to:
examine their own thoughts and emotions,
recognize when negative thoughts and emotions are escalating in intensity
and then use strategies to change their thinking and behavior.
*These interventions tend to be used with learners who display problem behavior related to specific emotions or feelings, such as anger or anxiety.

18. What is the Purpose of CBI for ASD?
“CBI can be used effectively to address:
Social
Communication
Behavior
Cognitive
Adaptive and
Mental health
outcomes for individuals with ASD”

19. Cognitive Behavioral Interventions Are Often Used In Conjunction With Other EBPs such as…..
social narratives/social stories
social skills training
reinforcement
parent-implemented intervention
self-regulation
visual supports/schedules
special interests

20. Who are the intended implementers?
Professionals who are trained and experienced in CBT/I and ASD.
CBI for ASD is sometimes implemented as a collaborative effort in clinic sessions, school and/or home in individual and/or group contexts (e.g., mental health professional, educators, speech-language pathologists, school psychologists, parents, etc.)

21. Applicable Populations / Grade Levels
According to the NPDC March 2014 report evidence-based studies, this intervention has been effective for:
elementary school-age learners (6-11 years) to
high school-age learners (15-18 years) with ASD

22. A Brief Description
Traditional CBT/I tends to require strong linguistic and abstract thinking abilities and these can be a challenge for individuals with ASD.
Researchers have been developing modifications to make it more effective with individuals with an ASD by making it better suited to the learning styles of individuals with ASD, for example, by making it more repetitive, visual, and concrete.

23. A Brief Description
Generally, CBT programs for youth with ASD have been clinic based and have not specifically and/or typically included:
school component
working collaboratively with others involved in the individual’s treatment and education (e.g., parents and school personnel)
as a modified CBT/I might…

24. A few examples of how to include EBPs for ASD in an individualized modified CBI:

25. EBPs: Visual Support * Self Management
Instead of just asking the individual with ASD to verbally rate their anxiety on a scale of 1 to 10, the interventionist might use the EBPs of Visual Support and Self-Management
Emotion Thermometer
Incredible 5 Point Scale
Individual points to show how high their anxiety is around a certain situation

27. The Incredible 5 Point Scale Kari Dunn Buron and Mitzi Curtis
Behavioral support that breaks down behaviors and social interactions into clear, visual and tangible pieces so that student can learn appropriate ways to respond and interact in difficult situations.
A scale can be created using colors, pictures, or a rating system of 1 to 5.

28. EBP: Special Interests
Incorporating the EBP of Special Interests in the sessions to motivate individual to engage in treatment activities. For example,
Using favorite cartoon characters to model coping skills
Or interspersing conversations about their special interest throughout treatment sessions to promote motivation and engagement.

29. Established Treatment: Antecedent Package Special Interests

30. Including Social Skills Development EBPs: Social Narratives/Social Stories/ Social Skills Training/Video Modeling
Gives the individual increased skills to be socially successful because….
….. the core social deficits of individual’s with ASD contribute to the experience of anxiety, which then serves to intensify the social problems.

31. EBP Social Narrative/Social Story

32. Social Skills Training

33. EBP: Video Modeling

34. Incorporating Peers EBP: Peer Mediated Instruction and Intervention
Incorporating natural supports of peers since the core deficit area is social communication and interaction and subsequent lack of friendships…. and this causes anxiety… …makes sense to incorporate peers as part of treatment program!

35. Decrease Verbal Demands Use EBP: Visual Support/Schedules
For example:
Provide a written or graphic weekly agenda showing when each session will occur and….
Provide detailed structure of each session allows the individual with ASD to predict activities and breaks throughout the session.

36. Include EBP: Reinforcement
Including the EBP of Reinforcement helps to keep the individual with ASD motivated and engaged.

37. Include EBP: Parent-Implemented Intervention
Working with parents collaboratively is a proven EBP that results in better outcomes!

38. When will the NPDC have guidelines available?
In Fall 2015 the NPDC will have the following information developed and available:
Brief: a file that contains key documents including an overview of the practice, evidence-base for the practice, step-by-step implementation strategies, and implementation checklists for fidelity)
Autism Internet Module on CBI for ASD

39. AFIRM NPDC Self-Learning Modules Autism Focused Intervention Resources and Modules
New EBP Learning Modules!

40. Implementation Fidelity is Critical!
What does this mean? “Implementing an intervention in the same manner in which it was done in the evidence-based research”

41. What’s “out there” now?
Modified version of CBT by Clinical Psychologist Jeffrey Wood, Ph.D. of the Center for Autism Research and Treatment at UCLA.
This modified CBT/program is described in the 2009 article, Cognitive Behavioral Therapy For Anxiety In Children With Autism Spectrum Disorders: A Randomized, Controlled Trial, Journal of Child Psychology and Psychiatry, 50, 224–234, Wood, J. J., et.al. available at:

42. Wood’s Enhanced CBT
Wood, et.al. developed an enhanced CBT program by expanding the traditional aspects of existing CBT treatments for anxiety in typically developing children.

43. Wood’s Enhanced CBT includes a school consultation component
incorporates concurrent skill building in core ASD symptoms suspected to contribute to anxiety symptomatology (e.g., social skills or preoccupation with restricted interests)

44. Wood’s Enhanced CBT
Provides in vivo parent training to address both the complex needs of youth with ASD and promote generalization of skills to school and community settings
Targets aspects of ASD that contribute to school adjustment—for example, providing skills and support for building friendships that can lead to inclusion in activities and games, and a more satisfying daily routine.

45. 27 EBPs Matrix Available on the CAPTAIN Website English and Spanish!

49. QUESTIONS?