This document discusses behavior therapy for teenagers and young adults with autism spectrum disorders. It begins by providing credentials for the author, Daniel C. Marston, who has over 15 years of experience providing behavioral health services to individuals with neurological disorders. It then discusses autism spectrum disorders and the diagnostic criteria for autism, Asperger's disorder, and pervasive developmental disorder based on the DSM-IV. The document discusses empirically-based practice in psychology and core principles. It covers neurological and psychological aspects and theories of autism based on research. Finally, it discusses psychological effects of autism, including personality traits, quality of life, gender differences, and anxiety/mood problems in adolescents with autism.

1. Behavior Therapy for Teenagers
and Young Adults with Autistic
Spectrum Disorders
Daniel C. Marston, PhD, ABPP
Private Practice in
Behavioral Psychology
North Huntingdon, PA

2. Credentials
• Board Certified in Cognitive & Behavioral Psychology,
American Board of Professional Psychology
• Fellow, American Academy of Cognitive & Behavioral
Psychology
• Fellow, Pennsylvania Psychological Association
• Member, American Psychological Association Division 6
(Behavioral Neuroscience)
• Member, American Association of Intellectual &
Developmental Disabilities (AAIDD)
• Over 15 years of practice specializing in providing
behavioral health services to individuals with
neurological disorders

3. Autistic Spectrum Disorders
– General category of disorders that includes Autism,
Asperger’s Disorder and Pervasive Developmental
Disorder
– Main symptoms of disorders include deficits in
socialization, communication problems, repetitive
behaviors and significant restrictions in terms of
interests
– Asperger’s Disorder does not include significant
communication problems
– Pervasive Developmental Disorder is seen as an
autistic spectrum disorder that includes some but not
all of the symptoms of autism
– All of these disorders are considered to primarily be
neurological disorders

4. Autistic Disorder—DSM-IV
• (I) A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each from (B) and (C)
• (A) qualitative impairment in social interaction, as manifested by at least two of the following:
• 1. marked impairments in the use of multiple nonverbal behaviors
• 2. failure to develop peer relationships appropriate to developmental level
3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people,
• 4. lack of social or emotional reciprocity
• (B) qualitative impairments in communication as manifested by at least one of the following:
• 1. delay in, or total lack of, the development of spoken language
• 2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with
others
3. stereotyped and repetitive use of language or idiosyncratic language
4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
• (C) restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least
two of the following:
• 1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal
either in intensity or focus
2. apparently inflexible adherence to specific, nonfunctional routines or rituals
3. stereotyped and repetitive motor mannerisms 4. persistent preoccupation with parts of objects
• (II) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
• (A) social interaction
(B) language as used in social communication
(C) symbolic or imaginative play
• (III) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder

5. Asperger’s Disorder—DSM-IV
• (I) Qualitative impairment in social interaction, as manifested by at least two of the following:
• (A) marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression,
body posture, and gestures to regulate social interaction
(B) failure to develop peer relationships appropriate to developmental level
(C) a lack of spontaneous seeking to share enjoyment, interest or achievements with other people(D) lack of
social or emotional reciprocity
• (II) Restricted repetitive & stereotyped patterns of behavior, interests and activities, as manifested by at least one
of the following:
• (A) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal
either in intensity or focus
(B) apparently inflexible adherence to specific, nonfunctional routines or rituals
(C) stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body
movements)
(D) persistent preoccupation with parts of objects
•
(III) The disturbance causes clinically significant impairments in social, occupational, or other important areas of
functioning.
(IV) There is no clinically significant general delay in language (E.G. single words used by age 2 years,
communicative phrases used by age 3 years)
(V) There is no clinically significant delay in cognitive development or in the development of age-appropriate self
help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood.
(VI) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia

6. Pervasive Developmental Disorder
NOS – DSM-IV
• “This category should be used when there is a
severe and pervasive impairment in the development
of reciprocal social interaction or verbal and
nonverbal communication skills, or when
stereotyped behavior, interests, and activities are
present, but the criteria are not met for a specific
pervasive developmental disorder, schizophrenia,
schizotypal personality disorder, or avoidant
personality disorder. For example, this category
includes "atypical autism" --presentations that do
not meet the criteria for autistic disorder because of
late age of onset, atypical symptomatology, or
subthreshold symptomatology, or all of these.”

7. What is EBPP?
• Stands for Empirically Based Practice in
Psychology
• It is expected with professional community that
treatment decisions will be based on principles
of EBPP
• Behavior therapy emphasizes empirical support
for treatment interventions
• Deciding what is EBPP for behavior therapy with
teenagers and young adults diagnosed with
autistic spectrum disorders will be primary focus
of this presentation

8. Core Principles of EBPP (APA,
2006; Kazdin, 2008)
• Evidence-based practice should have a ‘‘cogent
rationale for clinical strategies’’
• Research findings and clinical expertise are both
important for establishing an evidence base
• Research base should include randomized
controlled trials, but can and should take other
forms as well
• Clinical expertise can be reflected in experience
and professional reputation

9. Core Principles of EBPP
(continued)
• Interventions should be individualized
according to clients’ unique
characteristics.
• Intervention research should include real-
life outcome measures
• Truly effective treatments are those that
are generalizable to complex real-life
conditions and multiple cultures and
settings.

10. NEUROLOGICAL ASPECTS OF
AUTISM
• Evidence from number of disciplines
support that Asperger’s Syndrome &
autism are variations of the same
neurological disease (Coleman &
Betancer, 2005).
• Disciplines that address this issue and
supported that conclusion include genetics
& neurology.

11. In her book on the neurology of autism,
Coleman (2005) offered a summary of the
clinical symptoms of autism based on a
review of the neurological research:

12. Coleman (2005)
• Children with autistic syndromes have impaired
social interactions
• Children with autistic syndromes lack empathy
(defined as lack of ability to integrate the
cognitive and affective facets of another
person’s life)
• Children with autistic syndromes have a
disabling need for sameness
• Children with autistic syndromes exhibit
repetitive & stereotypal patterns of behaviors

13. Coleman (2005)----continued
• Children with autistic syndromes who do
speak begin to talk at unusually late ages
• Children with autistic syndromes who
speak often have qualitative impairments
in communication
• It is not clear exactly what the specific
neurological mechanisms are for these
symptoms

14. What neurologists are able to say
about the causes of autistic syndromes
• Autism likely due to problems with
neurological development at a very young
age
• General understanding from neurological
research is that likely culprit is impaired
connections of neural pathways

15. • Cause is likely either abnormally varied
neural circuit or abnormality of neural
components of one or more neural
pathways
• These problems lead to dysfunctional
information processing of behaviors &
cognition starting at a young age

16. Prefrontal cortex has been extensively
implicated in autism to explain deficits in
executive functioning, cognition, language,
sociability & emotion
• Rinaldi, Peroddin & Markram (2008)
• Price (2006)

17. Pregenual Anterior Cingulate
Cortex
• DiMartino, Shehzad, Kelly, Krain et al
(2009)—provided summary of research of
role this area may play in autism
• Plays a major role in person’s capacity to
reason about thoughts & beliefs of others
• Otherwise known as “theory of mind”
• Hypofunction of this area in autism
revealed in meta-analysis by DiMartino,
Ross, Uddin, Sklar et al (2009)

18. Pregenual Anterior Cingulate Cortex has also been
found to play roles in other disorders that
include:
• Depressive Disorders
• Anxiety Disorders
• ADHD
• Schizophrenia
This could help account for the large percentage of
individuals with autism who have comorbid
diagnoses

19. Chronic Stress & Prefrontal Cortex
• Chronic stress can significantly impact on development
of prefrontal cortex (Wilber et al, 2011)
• Chronic stress does not necessarily effect whether
autism develops but would significantly impact on how it
develops
• Could likely impact on the severity of symptoms
associated with autistic spectrum disorders
• One example would be chronic stress associated with
poverty (Evans & Schamberg, 2009)
• Impact of poverty on development of autism can likely be
seen primarily in the effect on the prefrontal cortex
region of the brain

20. Behavior Therapy & Neurological
Factors of Autism
• Behavior therapy can help address symptoms
associated with neurological aspects of autism
• Behavior therapy can help with development of
skills that are lacking due to neurological
aspects of autism
• Behavior therapy can less impact of person’s
environment on the neurological aspects of
autism
• Behavior therapy can help less impact of chronic
stress on neurological development

21. Additional Information about
Neurology & Autism
• Nancy Minshrew, Professor of Psychiatry & Director of
Center for Excellence in Research
• “Essential Pittsburgh” Radio Show on 06/08/12
• Neurological Research shows underactivity in more
advanced, frontal parts of brain & hyperactivity in more
basic, posterior parts of brain
• Means individuals with autism do not see comprehensive
view of what is happening but tend to get focused on
parts
• Also found that part of brain that gets person to focus on
themselves as part of situations is less activated in
autism

22. • Means that person with autism needs to
be in a situation in order to learn from it
• Would help explain why generalization is
such a problem in autism
• Also underscores importance of covering
skills in session to help individuals with
autism learn what to do

23. Case Example
• 14 year old female with Asperger’s
• Significant problems with social skills
• Particular concern because she will be
starting high school soon
• Used session for teaching and role playing
of social skills
• One issue that needed to be addressed
was issue of generalization

24. Case Example (continued)
• Learning skills for one situation would not
make her comfortable in other situation
• Even if those situations were similar
• Needed to address social skills in
classroom and then also social skills at
lockers
• Addressing multiple settings can help
individual start to generalize

25. PSYCHOLOGICAL
THEORIES OF AUTISM

26. Klin (2007) outlined two of the main
psychological theories of autism
• Theory of Mind: emphasizes a disruption in
capacity to impart mental states to others (e.g.
beliefs, desires, intentions & feelings) or to have
“theory of mind”
• Weak Central Coherence: emphasizes that
what is lacking in autism is the universal human
drive to integrate information into coherent
“wholes” or to link pieces of stimuli or meaning
into contextual entities

27. Weak Central Coherence (WCC)
Theory
• Much of the research for this theory came
from series of studies conducted at Yale
University
• WCC leads autistic individuals to be
insensitive to the social context and leads
them to respond in an over-literal manner
to social interactions

28. In their review of research on development of
Asperger’s Disorder Gutstein & Whitney (2002)
found:
• Social competence is major impairment in
Asperger’s
• Key deficit is experience-sharing relationships
• This process develops in manner different from
attachment & instrumental interactions
• Attachment issues would likely be more
consistent with Reactive Attachment Disorder

29. From a genetics perspective, autism is a
heterogeneous disorder on both the
phenotype & genotype levels
• Review of research is in Chen et al (2012)

30. PSYCHOLOGICAL
EFFECTS OF AUTISM

31. Anckarsater et al (2006)
• Conducted a study of the impact of autism on
temperament, character & personality
development
• Identified autism & ADHD as childhood-onset
neuropsychiatric disorders
• Studied personality characteristics of 113 adults
with autism
• Found that autism spectrum disorders were
associated with low novelty seeking and low
reward dependence

32. What is reward dependence?
• Reflects the degree to which the person responds to
cues of social reward
• Seen as being an inherited trait
• Individuals high in RD tend to be tender-hearted,
sensitive, socially dependent, and sociable
• Individuals low in RD tend to be practical, tough-minded,
cold, socially insensitive, irresolute, and indifferent if
alone
• Advantage to high RD: sensitivity to social cues which
facilitates affectionate social relations and genuine care
for others
• Advantages to low RD: personal independence and
objectivity not biased by efforts to please others

33. What neurological and personality
research says about autism
• Autism is caused by neurological problems at a
very young age or even prior to birth
• Neurological aspects of autism lead to low
Reward Dependence
• This leads person to have a low response level
of social reward
• Individuals with autism do not respond strongly
to the social reinforcers (praise, attention) that
tend to influence the behaviors of individuals
without autism

34. Teenagers with Autism &
Reinforcement
• Teenagers with autism face same issues as teenagers
without autism
• They tend to deal with them differently
• What motivates teenagers without autism do not tend to
motivate teenagers with autism
• It is during teenage years that you tend to see even
more the limited effect that social reinforcers have for
motivating individuals with autism
• Takes some work to determine what can be a reinforcer
for teenagers and young adults with autism

35. Choosing Reinforcers for
Individuals with Autism
• There is quite a bit of variability in autism
• No one reinforcer is going to work for everyone
• Asking the person about their interests and what they
find rewarding is a good starting point but will likely not
be sufficient
• Many individuals with autism otherwise will let you know
what they find reinforcing
• Topics of their perseverations and/or repetitive
statements often show what might be reinforcing
• You can also use scales and reinforcement surveys to
identify specific reiforcers
• Most important step here is to find reinforcers likely to be
effective for individual

36. Psychological Effect of Having a
Child with Autism
• Montes & Halterman (2007)
• Mothers of children of autism were likely to
report higher stress and mental health
problems than mothers in general
population
• No differences reported for different
economic levels

37. However, Montes & Halterman also
found mothers of autistic children
were more likely to report:
• Having a close relationship with their
children
• Better coping skills for parents tasks
• Less frequent episodes of feeling angry
with their children

38. Billstedt, Gillberg & Gillberg (2011)
• Conducted a follow-up study of 108 adults who
had been diagnosed with autism 13-22 years
earlier:
• Majority were still dependent on parents &
caregivers for support
• General quality of life was deemed to be positive
• Needs were identified in areas of occupational &
recreational activities
• 46% were diagnosed with severe intellectual
disabilities, 33% with mild intellectual disabilities
and 5% with average IQ

39. Gender Differences in Autism
• Lai et al (2011) reviewed research on
autism to find if there are any behavioral
differences between the genders.
• Found no significant differences in most
behavioral areas assessed

40. Gender Differences (continued)
• Females did show more lifetime sensory
symptoms, fewer communication
problems and more self-reported autistic
traits
• Authors propose that fewer
communication problems could be reason
autism is underrepresented in females
and diagnosed later for females

41. Research on anxiety and mood
problems in adolescents with autism
• Emotional distress increases as social milieu
becomes more complex (Sukhodolsky et al,
2008)
• Growing self-awareness & desire to form peer
relationships without skills to do so increases
anxiety and mood problems (Myles, 2003 &
Tantan, 2003)
• Social & evaluative anxiety often emerge during
adolescence for individuals with autism
(Kuusikko et al, 2008)

42. Problems Presented by Youths with
Autism
• Hurtig et al (2009) studied 43 teenagers with Asperger’s
or high-functioning autism
• Compared that group to 217 typically developed
adolescents
• Used Youth Self-Report for teenagers & Child Behavior
Checklist for their parents
• Autism group identified as having more clinically
significant problems
• Significantly higher rates of:
Social Problems
Anxiety Problems
Attention Problems
Mood Problems

43. Ooii, Ton, Lim, Ooh & Sung (2011)
• Reviewed archival data of 73 younger children
(ages 8-12)
• Interesting that the outcomes of problems were
same as the Hurtig study
• 61% were found to have reported significant
social problems
• When split by DSM diagnoses the children who
were identified with problems were split as such:
35.2% had attention problems
33.8% had anxiety problems
31 % had mood problems

44. Main reasons teenagers & young
adults with autism seek out therapy
• Social isolation/Social awkwardness
• Problems functioning at work or school
• Attention problems
• Depressed mood
• Legal troubles
• Anectodal data from my practice and other
practices

45. Psychological Issues faced by
teenagers/young adults with autism
• Similar to those faced by typical
adolescents and young adults
• Autism impacts how individuals develop,
not necessarily what general issues they
face
• Struggle for developing independence is a
major issue
• Fitting in socially is also a major issue

46. Psychological Issues (continued)
• Self-esteem plays a significant role for teenagers
& young adults
• Sexual development also plays a major role
• Issues related to sex is a major issue for
individuals with autism given its social context
• Some or all of these issues may play major role
in reasons individuals seek out psychological
treatment

47. Case Example
• 18-year old with Autism
• Had been receiving behavioral health
services for most of adolescence
• Made progress with help of behavior
therapy interventions
• But what would happen is that he would
have increased behavior problems with
each new major phase of adolescence

48. Case Example (continued)
• Included moving on to middle school, difficulties
in social relationships, increased interest in the
opposite gender, starting high school and
working to fit in socially when he got to high
school
• Behavior therapy had to focus on how he
implemented approaches to deal with each
phase
• Most recent issue was how he dealt with grief
about moving on after graduating high school

49. ASSESSMENT OF AUTISM

50. Importance of Assessment in
Treating Autism
• Baird, Cass & Slonim (2003)
• Solid assessment confirms the diagnosis
• Important for determining the appropriate
treatment
• Treatments appropriate for autism might
not be most appropriate for other
diagnoses

51. Core Assessment Battery for
Autism Should Include:
• Parental Interview
• Direct Observations of Child
• Intelligence Testing
• Language Assessment
• Adaptive Behavior Measure
• Ozonff, Goodling –Jones & Solomon,
2005

52. Core Assessment Battery
(continued)
• There is variability in specific measures
they suggest for each category
• And different measures will require
different costs and time commitments

53. Core Assessment Battery
(continued)
• For example two measures they suggest
for Parental Interview are Autism
Diagnostic Interview, Revised (ADI-R) &
Social Communication Questionnaire
(SCQ):
• ADI-R takes anywhere from 1 ½ - 2 hours
to administer
• SCQ only takes about 10 minutes to
administer

54. Core Assessment Battery
(continued)
• They also suggest Autism Diagnostic
Observation Scale (ADOS) and Child
Autism Rating Scale (CARS) for direct
observation instruments:
• ADOS takes 30-50 minutes to administer
• CARS takes 5-10 minutes to administer

55. Core Assessment Battery
(continued)
• There also is significant variations in the costs:
• Cost for ADOS-2 (available 05/17) is $1,995 for
introductory kit
• While costs for CARS is only $158 for
introductory kit
• Cost of ADI-R is $210 for kit that includes
materials for 10 assessments
• While SCQ is $115 for kit that includes materials
for 20 assessments

56. Core Assessment Battery
(continued)
• IQ tests will often be the most expensive and time-
consuming parts of assessments for developmental &/or
intellectual disabilities:
• Often important to determine if provider needs to do this
testing
• Check to see if it can be done elsewhere or if it has
already been done
• Parents can often request that schools do IQ testing
• If IQ testing done within past several years then results
can be used for eval and additional IQ testing will not be
needed

57. Core Assessment Battery
(continued)
• Purpose here is to keep the time commitments
and costs of a comprehensive evaluation for
intellectual &/or developmental disabilities to a
minimum
• This will then allow provider to provide accurate
diagnoses under the limiting conditions
associated with insurance coverage available to
people in poverty (e.g. Medical Assistance)

58. Autism Spectrum Quotient (Baron-
Cohen et al, 2006)
• Can be used for quick assessment of
autism severity
• Quantified autistic traits in adolescents
• This was an adaption of AQ for Adults
(Baron-Cohen et al, 2001)
• Rapidly quantified where adolescent is
situated from autism to normality
• Can be used to help with treatment
decisions

59. IMPORTANT ASPECTS OF
BEHAVIOR THERAPY
FOR TREATING AUTISM

60. Ricard Bromfield in June 11, 2011 edition of HuffPost
Healthy Living on the Huffington Post website:
“…this past summer I discovered that
since its founding in 1979 the Journal of
Autism & Developmental Disabilities, a
premier journal “devoted to all aspects of
autism spectrum disorders, including
clinical care and treatment for all
individuals, had published 2,262 articles,
not one of them focusing on
psychotherapy or counseling with a child
with Asperger’s”

61. Bromfield stresses psychodynamic
therapy
• But some aspects he stresses could also be part
of behavior therapy
Those aspects include:
• Being very accommodating to the individual
needs of the client
• Slow pace
• A lot of waiting
• Also involves sparse communication

62. Type of environments where individuals with
autism learn best are ones where:
• Physical & temporal environments
highlight salient stimuli
• Direct teaching & shaping of appropriate
behavior are supported
• Clear antecedent cues and discriminative
stimuli are used
• Climate of reinforcement is provided
• Heflin & Alberto, 2001

63. Learning & Autism
• Behavior therapy is most often based on
learning new skills
• Individuals with autism tend to learn best with
structured approaches
• Identifying how teenagers & young adults with
autism learn best can help to increase
effectivenss of behavior therapy interventions
• One empirically supported approach to helping
individuals with autism learn is called the
TEACCH method

64. TEACCH method
• Treatment and Education of Autistic and
related Communication-Handicapped
children
• Interventions for helping children and
teenagers
• Also called ‘‘Structured Teaching’’
• Based on evidence that individuals with
autism share a pattern of
neuropsychological deficits and strengths

65. Characteristics of TEACCH method
(Mesibov & Shea, 2010)
• Relative strength in and preference for processing
visual information (compared to difficulties with
auditory processing, particularly of language)
• Heightened attention to details but difficulty with
sequencing, integrating, connecting, or deriving meaning
from them
• Enormous variability in attention (individuals can be
very distractible at times, and at other times intensely
focused, with difficulties shifting attention efficiently)

66. Characteristics of TEACCH method
(continued)
• Communication problems, which vary by
developmental level, but always include
impairments in the initiation and social use of
language
• Difficulty with concepts of time including moving
through activities too quickly or too slowly and
having problems recognizing the beginning or
end of an activity, how long the activity will last,
and when it will be finished

67. Characteristics of TEACCH method
(continued)
• Tendency to become attached to routines and the
settings where they are established, so that activities
may be difficult to transfer or generalize from the
original learning situation, and disruptions in routines
can be uncomfortable, confusing, or upsetting
• Very intense interests and impulses to engage in
favored activities and difficulties disengaging once
Engaged
• Marked sensory preferences and aversions.

68. In a review of research on
psychological treatments for autism
Howlin (1998) found:
• Treatments need to be adapted for
meeting individual needs
• Functional analysis of problem behaviors
is very important
• Behavior problems often result from
communication problems, social
understanding problems &/or
perseveration

69. Functional Assessment
• Objective definition of behaviors to address
• Collect data in session
• Assign homework to collect data outside of
session
• Use data to identify antecedents &
consequences
• Identify potential reinforcers
• Generate hypotheses about behaviors
• Develop & implement behavioral treatment plan

70. BEHAVIOR THERAPY &
AUTISM IN TEENAGERS &
YOUNG ADULTS

71. Effectiveness of applied behavioral
analysis (ABA) programs for teenagers
and young adults:
• Vismar & Rogers (2010) reviewed
comprehensive ABA programs in
classroom & residential setting for
teenagers & adults with autistic spectrum
disorders
• These programs aimed to provide
continuum of services in educational,
residential & employment programs
• Services are delivered in multiple settings

72. Vismar & Rogers (2010)
----continued
• Involve trainers modeling target skills,
providing supervised practice
opportunities & delivering immediate
feedback
• Authors determined that there is still
insufficient evidence about long-terms
outcomes

73. Miller, N. & Neuringer, A. (2000)
• Conducted a study of reinforcement and
its effect of repetitive behaviors in
teenagers & adults with autism
• 5 adolescents w/autism, 5 adult controls &
4 child controls received rewards for
varying their responses while playing a
computer game
• Study focused on repetitive behaviors and
how this can result in lack of reinforcement

74. Miller, N. & Neuringer, A. (2000)----
continued
• Authors addressed whether increased
variability of responses could then
decrease their use of repetitive &
stereotypal behaviors
• Variability in all groups when variability
was directly reinforced
• Involved reinforcement of alternative
behaviors when addressing repetitive
behaviors

75. Effectiveness of Behavioral
Therapy with Teenagers
• White, E.R. et al (2011)
• Used prompting & reinforcement to teach three
pairs of adolescents with autism to use a
photographic activity schedule to cooperate in
completing multistep tasks
• Subjects did not coordinate their activities at
baseline
• But did increase cooperation after use of
prompting & reinforcement
• Small pieces of preferred food were used as the
reinforcers

76. White et al (2009)
• Studied a cognitive-behavioral treatment
program for anxious teenagers diagnosed with
autistic spectrum disorders
• Treatment involved individual therapy, group
social skills training and family training
• Called Multi-Component Integrated Treatment
(MCIT)
• Manualized-Based Treatment
• Reduced anxiety in 3 of the 4 subjects who took
part in this pilot program

77. White et al (2010)
• Expounded on that treatment program with
another cognitive-behavioral treatment program
for anxiety in adolescents with autism
• Changed name and called that program
Multimodal Anxiety & Social Skills Intervention
(MASSI)
• One of few programs focused on treating anxiety
in teenagers with autism as most others focused
on younger children

78. Essential elements of MASSI
• Focus on parent & family involvement
• Regular practice
• Immediate, direct & specific feedback is
provided
• Emphasis on corrective & positive social
learning experiences
• Modeling new skills

79. Parent & Family Involvement
• Helping parents accept & understand diagnosis
• Strengthening family supports system to
compensate for lack of support outside of family
• Encouraging adolescent to practice new skills at
home
• Cognitive-behavior therapy with parent
involvement has been found to be superior to
other types of cognitive-behavioral therapy
(Sdvanoff, 2005)

80. Regular Practice in MASSI
• Helps with generalizing skills
• Also addresses problems with context-
dependent learning
• Treatment involves ample use of role-play
& exposure exercises
• Parents are encouraged to help
adolescent practice at home & in
community

81. MASSI therapists
• Provide immediate, direct & specific feedback
• Bother MASSI therapist & family members
provide feedback on skills
• Immediate feedback helps to address difficulties
associated with autism
• Some of those difficulties include: failure to pick
up on subtle cues, difficulties with sustained
attention & difficulties distinguishing essential
from irrelevant details

82. Emphasis in MASSI on corrective,
positive social learning experiences
• Focus on creating supportive environment
• Addressing ways to help adolescents feel
safe in trying new skills
• Time dedicated to group sessions with
other teens who have autism to help build
cohesion
• Helps address years of social rejection
that these teens have experienced

83. Modeling new skills is important
part of MASSI
• Modeling by therapist in individual
sessions
• Modeling by peer tutor in group
component
• Model demonstrates what should be done
in given situation
• Model also attempt to explicitly state what
they are feeling & doing during modeled
skill

84. Structure of MASSI treatment
program
• Individual therapy
• Group treatment
• Parent education & training

85. Other information about MASSI
• Using individual therapy, group treatment
& parent training helps with generalization
• Also helps with individuation of the
treatment
• Initial feedback from program participants
has been positive
• No conclusive research findings yet on
effectiveness of program

86. Case Example
• 14 year old male with PDD NOS
• Particular difficulty with anger directed
toward parents
• Also anger directed towards babysitter
• Met with teenager and parents
• Focus on helping teenager learn better
anger management skills but also helping
parents learn better ways of addressing
his behaviors

87. Case Example (continued)
• Worked with teenager and parents on
what consequences should be for his
behaviors
• Got input from parents and also from
teenagers on how parents should address
his behaviors
• This collaborative approach seemed to
help with effectivess of behavioral
interventions parents used

88. Collaborative Problem Solving
• From Ross Greene’s 2005 book “The
Explosive Child”
• Greene has written about effectiveness of
this approach for different populations,
including teenagers with autism
• Effective way of helping parents and
teenagers work on ways of addressing
problems

89. Collaborative Problem Solving
(continued)
• Basic approach involves identifying problem and
then getting input from both teenager and
parents on what should be done about the
problem
• They then work together on plan for addressing
the problem
• Can be helpful for teenagers with autism since
they often may feel they are left out of
discussion of what to do about problems they
face

90. Lang et al (2010)
• Review study of cognitive-behavioral treatment
for anxiety in teenagers & adults with autism
• Reviewed nine studies addressing of anxiety in
autistic spectrum disorder using cognitive-
behavioral therapy
• Found cognitive-behavioral therapy was
effective when adding components typically
associated with applied behavior analysis

91. Lang et al (2010)----continued
• Two of the main components they
addressed were systematic prompting &
differential reinforcement
• Systematic Prompting: use of physical
and/or verbal prompts in structured way
• Differential Reinforcement: use of
reinforcement to increase frequency of
behaviors that are incompatible with the
problem behaviors

92. Case Example
• 15-year old male with Asperger’s
• Main problems include inappropriate
social comments and anger management
• Significant problems in weeks prior to
therapy with regards to him saying things
that embaressed his peers
• Also yelled frequently at his parents during
even small disagreements

93. Case Example (continued)
• Parents helped to set up reinforcement
chart where he could earn rewards for
choosing more appropriate anger
management and social skills
• Also focused on skills that would be more
effective alternatives to skills he had been
choosing to use
• Helped decrease frequency and severity
of problem behaviors

94. Social Skills Programs
• Williams et al (2007) studied social skills
programs the showed promise for
benefitting children & adolescents
• Did not find any one program that was
more effective than others
• Did identify aspects of programs they
studied that contributed to effectiveness of
programs

95. Social Skills Programs----continued
• Those aspects included increasing social
motivation, increasing social interactions,
improving appropriate social responding,
reducing interfering behaviors and
promoting skills generalizations
• Authors then went into specific steps that
contributed to effectiveness of each
general aspect they covered

96. Increase Social Motivation
• Foster self-awareness & self-esteem
• Develop nurturing & fun environment
• Intersperse new skills with previously
mastered skills
• Start with simple, easily learned skills

97. Increase Social Interactions
• Make social rules clear & concrete
• Model age-appropriate initiation strategies
• Use natural reinforcers for social situations
(e.g. follow individual’s communication
lead & interest level)
• Teach simple social scripts for common
situations

98. Improve Age-Appropriate Social
Responding
• Teach social response scripts
• Reinforce response attempts
• Use modeling & role-play to teach skills

99. Reduce Interfering Behaviors
• Make teaching structured & predictable
• Differentially reinforce positive behaviors

100. Promote Skill Generalization
• Involve parents in training
• Use homework assignments as way to
have individuals practice skills between
sessions

101. Behavioral Interventions to
increase independence
• Hume, Loftin & Lantz, 2009
• Most successful interventions targeting
increased independent skills emphasize a shift
in stimulus control from continuous adult
management (e.g., paraprofessional
support) during instruction to an alternative
stimulus.
• The alternative stimulus then provides cues and
information about expectations related to
behavior and/or social skills

102. Increasing Independence
(continued)
Three focused interventions that
incorporate this stimulus shift and have
proven effective in increasing student
engagement while simultaneously
decreasing adult prompting are:
• Self-monitoring,
• Video modeling
• Individual work systems

103. Self-Monitoring
• Individual is taught to discriminate and to make
a record of the occurrence or nonoccurrence of
a target behavior
• Increases independence because the individual
is the agent of the intervention (as opposed to a
teacher or another adult)
• In order to self-monitor, an individual must pay
adequate attention to his or her own behavior,
the conditions under which these behaviors
occur and the immediate and distal effects that
are produced

104. Self-Monitoring (continued)
• When individuals self-monitor, they attend
to select aspects of behavior on which
they may ordinarily not focus which can, in
turn, re-focus on the most salient elements
of behavior
• Self-monitoring interventions can be
designed to increase the incidence of
desired behaviors or to reduce problem
behaviors

105. Self-Monitoring (continued)
• Findings from various studies such as these
indicate that even core features of autism, such
as social functioning, can be improved with the
use of interventions that incorporate self-
monitoring
• In addition, increases in positive behavior that
occurred because of self-monitoring were often
accompanied by collateral reductions in
undesired behavior
• This included reductions in self-stimulatory and
repetitive/stereotypic behavior

106. Video Modeling
• Can be used to teach skills using minimal
adult prompting and interaction
• A model performs the target skill while
being videotaped
• Professionals or peers can serve as
models, or the person with autism can
serve as his or her own model on the
video

107. Video Modeling (continued)
• All prompts are edited out of the video so that
the person is seen performing the skill
independently
• Modeling videos are typically 2–4 min in length
• They are watched by the person with autism,
often times repetitively
• Person with autism can watch the videos alone
and as frequently as necessary to acquire the
skill

108. Video Modeling (continued)
• Then the viewer is given the opportunity to
imitate the skill observed on the video in
real-life contexts
• Video modeling is particularly well-suited
for people with autism since they are
usually better able to process and
remember visual information compared to
material presented verbally

109. Individual Work Systems
• Involves structured teaching as as addressed in the TEACCH
system
• Emphasizes visual supports
• Aims to increase and maximize independent functioning
and reduce the frequent need for consequences and/or prompting
• Individual work system is defined as a visually organized space
where individuals independently practice skills that have been
previously mastered
• Could be classroom or psychological therapist’s office

110. A work system visually communicates at
least four pieces of information to the
individual:
• Tasks the individual is supposed to do
• How much work there is to be completed
• How the individual knows he/she is
finished (progress towards goal)
• What to do when he/she is finished

111. Individual Work Systems
(continued)
• Practice of providing visual sequences of
activities (i.e., photographs or icon
representations) for students with autism to
complete has been proven effective
• Visually presenting the sequence of activities
enhances the individual’s ability to predict
upcoming activities, and provides a consistent
strategy for gathering information about what will
occur during independent situations

112. Individual Work Systems
(continued)
• Deliberate practice of previously mastered
skills that occurs through the use of an
individual work system is an important
step towards generalization across
contexts and provides necessary practice
to help students perform tasks
automatically, quickly, and independently

113. Cognitive Restructuring
• Can be useful for treatment of depression in
teenagers and young adults with autism
• Attwood (2008)
• Focuses on correction of unrealistic thinking
• Particularly useful with Aperger’s because of
emphasis on logic & evidence
• Challenge unrealistic beliefs with facts & logic
• Establish evidence for different ways of thinking
about situations
• Create appropriate & inappropriate responses to
problem situations

114. Types of Negative Thinking for
Teenagers/Young Adults with
Autism
• “There in only one correct way to do
everything”
• “I must have a lot of friends in order to be
happy”
• “Making friends means going to parties
and going out a lot”
• “If I am picked on there must be
something wrong with me”

115. Negative Thinking (continued)
• “It is not OK to be different from other
people”
• “If I have an opinion about something or
someone I must express it”
• “People who are popular always have
good social skills to imitate”
• “If I am upset about something then that
means something went wrong”

116. USE OF TECHNOLOGY IN
BEHAVIOR THERAPY
FOR AUTISM

117. Hoch, Taylor & Rodriguez (2009)
• Studied behavioral interventions with teenagers
• Used prompting & reinforcement to help
teenagers seek assistance
• Focused on increasing the frequency with which
they asked for assistance if lost
• Used cell phones as prompts
• Results indicated increased use of effective
steps for asking for assistance after use of
prompting & reinforcement to teach those skills

118. Similarly, Taylor et al (2004)
used pagers with teenagers
• Study involved 3 teenagers with autism
• Used the pagers as a prompt to use
communication card to get help when lost
• Tangible rewards were used to initially
teach the skills
• Verbal praise was used as a reinforcer
during the generalization phase
• Results indicated increased use of
communication card to get help when lost

119. HANDS Project (Ohstrom, 2011)
• Helping Autism-Diagnosed Teenagers
Navigate & Develop Socially
• Research Project
• Involves creation of an e-learning tool set
• This set of tools for electronic devices like
smart phones and tablets can be used to
support social development for teenagers

120. HANDS Project (continued)
• Purpose of HANDS software was to help
increase effectiveness of previously developed
software
• Focus was on increasing effectiveness of tools
by allowing students and their teachers to
individualize the software to the studen’s needs
• Research studying initial prototype found wide
variety of effectiveness & use.
• Some teenagers used frequently and found it
helpful while others did not
• Project continues to be in the development stage

121. HANDS Project involves five main
functions:
• Handy Interactive Persuasive Diary: helps
teenager in scheduling his or her daily life
• Simple Safe Success Instructor (SSSI):
presents social stories designed to help
teenager learn what behavioral changes
are effective for dealing with problematic
situations

122. HANDS Project (continued)
• Personal Trainer: also presents social
stories to help teenager learn what
behaviors are effective for handling
problem situations
• Individualizer: allows teenager to
individualize the appearance of the
HANDS software
• Sharing Point: allows teachers to share
their experience with HANDS software

123. CONCLUSION
• Autism is a neurodevelopmental disorder
• Impacts on brain development prenatally or
during early childhood
• Continues to impact on how individuals respond
to issues throughout their lives
• Chronic stress can impact on how autism
develops in teenage and adult years
• Teenagers and young adults with autism face
similar issue as typically developed individuals

124. CONCLUSION (continued)
• Autism impacts how the individuals
responds to those issues
• Independence is a very important issue for
these individuals
• Solid assessment is important for
developing effective treatment plan
• Behavior therapy can help individual
develop more effective skills for handling
limitations and stressors