Journal of Autism and Developmental Disorders

, Volume 43, Issue 12, pp 2866–2877 | Cite as

Cognitive Enhancement Therapy for Adults with Autism Spectrum Disorder: Results of an 18-month Feasibility Study

  • Shaun M. Eack
  • Deborah P. Greenwald
  • Susan S. Hogarty
  • Amber L. Bahorik
  • Maralee Y. Litschge
  • Carla A. Mazefsky
  • Nancy J. Minshew
Original Paper


Adults with autism experience significant impairments in social and non-social information processing for which few treatments have been developed. This study conducted an 18-month uncontrolled trial of Cognitive Enhancement Therapy (CET), a comprehensive cognitive rehabilitation intervention, in 14 verbal adults with autism spectrum disorder to investigate its feasibility, acceptability, and initial efficacy in treating these impairments. Results indicated that CET was satisfying to participants, with high treatment attendance and retention. Effects on cognitive deficits and social behavior were also large (d = 1.40–2.29) and statistically significant (all p < .001). These findings suggest that CET is a feasible, acceptable, and potentially effective intervention for remediating the social and non-social cognitive impairments in verbal adults with autism.


Cognitive Enhancement Therapy Cognitive rehabilitation Cognitive remediation Psychosocial treatment Cognitive therapy Adult treatment Autism Autism spectrum disorder 


  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.Google Scholar
  2. Baron-Cohen, S. (1990). Autism: A specific cognitive disorder of ‘mind-blindness’. International Review of Psychiatry, 2(1), 81–90.CrossRefGoogle Scholar
  3. Ben-Yishay, Y., Piasetsky, E. B., & Rattok, J. (1985). A systematic method for ameliorating disorders in basic attention. In M. J. Meir, A. L. Benton, & L. Diller (Eds.), Neuropsychological rehabilitation (pp. 165–181). New York: Guilford Press.Google Scholar
  4. Berger, H. J. C., Aerts, F. H. T. M., van Spaendonck, K. P. M., Cools, A. R., & Teunisse, J. P. (2003). Central coherence and cognitive shifting in relation to social improvement in high-functioning young adults with autism. Journal of Clinical and Experimental Neuropsychology, 25(4), 502–511.PubMedCrossRefGoogle Scholar
  5. Bracy, O. L. (1994). PSSCogRehab [computer software]. Indianapolis, IN: Psychological Software Services Inc.Google Scholar
  6. Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., Kneipp, S., et al. (2005). Evidence-based cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Archives of Physical Medicine and Rehabilitation, 86(8), 1681–1692.PubMedCrossRefGoogle Scholar
  7. Couture, S. M., Penn, D. L., Losh, M., Adolphs, R., Hurley, R., & Piven, J. (2010). Comparison of social cognitive functioning in schizophrenia and high functioning autism: more convergence than divergence. Psychological Medicine, 40(4), 569–579.PubMedCrossRefGoogle Scholar
  8. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., et al. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics, 125(1), e17.PubMedCrossRefGoogle Scholar
  9. Dempster, A. P., Laird, N. M., & Rubin, D. B. (1977). Maximum likelihood from incomplete data using the EM algorithm. Journal of the Royal Statistical Society: Series B (Methodological), 39(1), 1–38.Google Scholar
  10. Eack, S. M. (2012). Cognitive remediation: A new generation of psychosocial interventions for people with schizophrenia. Social Work, 57(3), 235–246.PubMedCrossRefGoogle Scholar
  11. Eack, S. M., Greenwald, D. P., Hogarty, S. S., Cooley, S. J., DiBarry, A. L., Montrose, D. M., et al. (2009). Cognitive Enhancement Therapy for early-course schizophrenia: Effects of a 2-year randomized controlled trial. Psychiatric Services, 60(11), 1468–1476.PubMedCrossRefGoogle Scholar
  12. Eack, S. M., Greenwald, D. P., Hogarty, S. S., & Keshavan, M. S. (2010a). One-year durability of the effects of Cognitive Enhancement Therapy on functional outcome in early schizophrenia. Schizophrenia Research, 120(1), 210–216.PubMedCrossRefGoogle Scholar
  13. Eack, S. M., Hogarty, G. E., Cho, R. Y., Prasad, K. M. R., Greenwald, D. P., Hogarty, S. S., et al. (2010b). Neuroprotective effects of Cognitive Enhancement Therapy against gray matter loss in early schizophrenia: Results from a 2-year randomized controlled trial. Archives of General Psychiatry, 67(7), 674–682.PubMedCrossRefGoogle Scholar
  14. Eack, S. M., Hogarty, G. E., Greenwald, D. P., Hogarty, S. S., & Keshavan, M. S. (2011). Effects of Cognitive Enhancement Therapy on employment outcomes in early schizophrenia: Results from a 2-year randomized trial. Research on Social Work Practice, 21(3), 32–42.PubMedCrossRefGoogle Scholar
  15. Fitzpatrick, L. B., Minshew, N. J., & Eack, S. M. (2013). A systematic review of psychosocial interventions for adults with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(3), 687–694.Google Scholar
  16. Ganz, M. L. (2007). The lifetime distribution of the incremental societal costs of autism. Archives of Pediatrics and Adolescent Medicine, 161(4), 343–349.PubMedCrossRefGoogle Scholar
  17. García-Villamisar, D., Rojahn, J., Zaja, R. H., & Jodra, M. (2010). Facial emotion processing and social adaptation in adults with and without autism spectrum disorder. Research in Autism Spectrum Disorders, 4(4), 755–762.CrossRefGoogle Scholar
  18. Gilotty, L., Kenworthy, L., Sirian, L., Black, D. O., & Wagner, A. E. (2002). Adaptive skills and executive function in autism spectrum disorders. Child Neuropsychology, 8(4), 241–248.PubMedCrossRefGoogle Scholar
  19. Goldstein, G., Minshew, N. J., Allen, D. N., & Seaton, B. E. (2002). High-functioning autism and schizophrenia A comparison of an early and late onset neurodevelopmental disorder. Archives of Clinical Neuropsychology, 17(5), 461–475.PubMedGoogle Scholar
  20. Green, M. F., Nuechterlein, K. H., Gold, J. M., Barch, D. M., Cohen, J., Essock, S., et al. (2004). Approaching a consensus cognitive battery for clinical trials in schizophrenia: The NIMH-MATRICS conference to select cognitive domains and test criteria. Biological Psychiatry, 56(5), 301–307.PubMedCrossRefGoogle Scholar
  21. Guilmatre, A., Dubourg, C., Mosca, A. L., Legallic, S., Goldenberg, A., Drouin-Garraud, V., et al. (2009). Recurrent rearrangements in synaptic and neurodevelopmental genes and shared biologic pathways in schizophrenia, autism, and mental retardation. Archives of General Psychiatry, 66(9), 947–956.PubMedCrossRefGoogle Scholar
  22. Gur, R. C., Schroeder, L., Turner, T., McGrath, C., Chan, R. M., Turetsky, B. I., et al. (2002). Brain activation during facial emotion processing. Neuroimage, 16(PA3), 651–662.PubMedCrossRefGoogle Scholar
  23. Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., & Curtiss, G. (1993). Wisconsin card sorting test manual: Revised and expanded. Odessa, FL: Psychological Assessment Resources Inc.Google Scholar
  24. Hobson, R. P., Ouston, J., & Lee, A. (1988). Emotion recognition in autism: coordinating faces and voices. Psychological Medicine, 18(4), 911–923.PubMedCrossRefGoogle Scholar
  25. Hogarty, G. E., Flesher, S., Ulrich, R., Carter, M., Greenwald, D., Pogue-Geile, M., et al. (2004). Cognitive enhancement therapy for schizophrenia. Effects of a 2-year randomized trial on cognition and behavior. Archives of General Psychiatry, 61(9), 866–876.PubMedCrossRefGoogle Scholar
  26. Hogarty, G. E., & Greenwald, D. P. (2006). Cognitive Enhancement Therapy: The training manual. University of Pittsburgh Medical Center: Authors. Available through
  27. Hogarty, G. E., Greenwald, D. P., & Eack, S. M. (2006). Durability and mechanism of effects of Cognitive Enhancement Therapy. Psychiatric Services, 57(12), 1751–1757.PubMedCrossRefGoogle Scholar
  28. Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2004). Adult outcome for children with autism. Journal of Child Psychology and Psychiatry, 45(2), 212–229.PubMedCrossRefGoogle Scholar
  29. Hughes, C., Russell, J., & Robbins, T. W. (1994). Evidence for executive dysfunction in autism. Neuropsychologia, 32(4), 477–492.PubMedCrossRefGoogle Scholar
  30. Kanner, L., Rodriguez, A., & Ashenden, B. (1972). How far can autistic children go in matters of social adaptation? Journal of Autism and Developmental Disorders, 2(1), 9–33.CrossRefGoogle Scholar
  31. Kasari, C., & Lawton, K. (2010). New directions in behavioral treatment of autism spectrum disorders. Current Opinion in Neurology, 23(2), 137–143.PubMedCrossRefGoogle Scholar
  32. Kohler, C. G., Turner, T. H., Bilker, W. B., Brensinger, C. M., Siegel, S. J., Kanes, S. J., et al. (2003). Facial emotion recognition in schizophrenia: Intensity effects and error pattern. American Journal of Psychiatry, 160, 1768–1774.PubMedCrossRefGoogle Scholar
  33. Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2(3), 197–207.PubMedCrossRefGoogle Scholar
  34. Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L., DiLavore, P. C., et al. (2000). The autism diagnostic observation schedule—generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30(3), 205–223.PubMedCrossRefGoogle Scholar
  35. Lord, C., Rutter, M., & Couteur, A. (1994). Autism diagnostic interview-revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24(5), 659–685.PubMedCrossRefGoogle Scholar
  36. Mayer, J. D., Salovey, P., Caruso, D. R., & Sitarenios, G. (2003). Measuring emotional intelligence with the MSCEIT V2.0. Emotion, 3(1), 97–105.PubMedCrossRefGoogle Scholar
  37. Mayes, S. D., & Calhoun, S. L. (2007). Learning, attention, writing, and processing speed in typical children and children with ADHD, autism, anxiety, depression, and oppositional-defiant disorder. Child Neuropsychology, 13(6), 469–493.PubMedCrossRefGoogle Scholar
  38. Minshew, N. J., Goldstein, G., & Siegel, D. J. (1997). Neuropsychologic functioning in autism: Profile of a complex information processing disorder. Journal of the International Neuropsychological Society, 3(4), 303–316.PubMedGoogle Scholar
  39. Minshew, N. J., & Williams, D. L. (2007). The new neurobiology of autism. Archives of Neurology, 64(7), 945–950.PubMedCrossRefGoogle Scholar
  40. Mizuno, A., Liu, Y., Williams, D. L., Keller, T. A., Minshew, N. J., & Just, M. A. (2011). The neural basis of deictic shifting in linguistic perspective-taking in high-functioning autism. Brain, 134(8), 2422–2435.PubMedCrossRefGoogle Scholar
  41. Olazaran, J., Muniz, R., Reisberg, B., Pena-Casanova, J., del Ser, T., Cruz-Jentoft, A. J., et al. (2004). Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease. Neurology, 63(12), 2348–2353.PubMedCrossRefGoogle Scholar
  42. Ozonoff, S. (1995). Executive functions in autism. In E. Schopler & G. B. Mesibov (Eds.), Learning and cognition in autism (pp. 3–27). New York: Plenum Press.Google Scholar
  43. Penn, D. L., Corrigan, P. W., Bentall, R. P., Racenstein, J., & Newman, L. (1997). Social cognition in schizophrenia. Psychological Bulletin, 121(1), 114–132.PubMedCrossRefGoogle Scholar
  44. Pilowsky, T., Yirmiya, N., Arbelle, S., & Mozes, T. (2000). Theory of mind abilities of children with schizophrenia, children with autism, and normally developing children. Schizophrenia Research, 42(2), 145–155.PubMedCrossRefGoogle Scholar
  45. Pinkham, A. E., Hopfinger, J. B., Pelphrey, K. A., Piven, J., & Penn, D. L. (2007). Neural bases for impaired social cognition in schizophrenia and autism spectrum disorders. Schizophrenia Research, 99(1–3), 164–175.PubMedGoogle Scholar
  46. Rapp, S., Brenes, G., & Marsh, A. P. (2002). Memory enhancement training for older adults with mild cognitive impairment: a preliminary study. Aging and Mental Health, 6(1), 5–11.PubMedCrossRefGoogle Scholar
  47. Raudenbush, D. S. W., & Bryk, D. A. S. (2002). Hierarchical linear models: Applications and data analysis methods. Thousand Oaks, CA: Sage.Google Scholar
  48. Samson, A. C., Huber, O., & Gross, J. J. (2012). Emotion regulation in Asperger’s syndrome and high-functioning autism. Emotion, 12(4), 659–665.PubMedCrossRefGoogle Scholar
  49. Sasson, N., Tsuchiya, N., Hurley, R., Couture, S. M., Penn, D. L., Adolphs, R., et al. (2007). Orienting to social stimuli differentiates social cognitive impairment in autism and schizophrenia. Neuropsychologia, 45(11), 2580–2588.PubMedCrossRefGoogle Scholar
  50. Schneider, S. G., & Asarnow, R. F. (1987). A comparison of cognitive/neuropsychological impairments of nonretarded autistic and schizophrenic children. Journal of Abnormal Child Psychology, 15(1), 29–45.PubMedCrossRefGoogle Scholar
  51. Selman, R. L., & Schultz, L. H. (1990). Making a friend in youth. Chicago, IL: University of Chicago Press.Google Scholar
  52. Sergi, M. J., Rassovsky, Y., Nuechterlein, K. H., & Green, M. F. (2006). Social perception as a mediator of the influence of early visual processing on functional status in schizophrenia. American Journal of Psychiatry, 163(3), 448–454.PubMedCrossRefGoogle Scholar
  53. Shattuck, P. T., Wagner, M., Narendorf, S., Sterzing, P., & Hensley, M. (2011). Post-high school service use among young adults with an autism spectrum disorder. Archives of Pediatrics and Adolescent Medicine, 165(2), 141–146.PubMedCrossRefGoogle Scholar
  54. Simon, H. A. (1979). Information processing models of cognition. Annual Review of Psychology, 30(1), 363–396.PubMedCrossRefGoogle Scholar
  55. Sugranyes, G., Kyriakopoulos, M., Corrigall, R., Taylor, E., & Frangou, S. (2011). Autism spectrum disorders and schizophrenia: Meta-analysis of the neural correlates of social cognition. PLoS ONE, 6(10), e25322.PubMedCrossRefGoogle Scholar
  56. Temple, E., Deutsch, G. K., Poldrack, R. A., Miller, S. L., Tallal, P., Merzenich, M. M., et al. (2003). Neural deficits in children with dyslexia ameliorated by behavioral remediation: Evidence from functional MRI. Proceedings of the National Academy of Sciences, 100(5), 2860–2865.CrossRefGoogle Scholar
  57. Volkmar, F. R., Lord, C., Bailey, A., Schultz, R. T., & Klin, A. (2004). Autism and pervasive developmental disorders. Journal of Child Psychology and Psychiatry, 45(1), 135–170.PubMedCrossRefGoogle Scholar
  58. Wang, A. T., Lee, S. S., Sigman, M., & Dapretto, M. (2006). Neural basis of irony comprehension in children with autism: the role of prosody and context. Brain, 129(4), 932–943.PubMedCrossRefGoogle Scholar
  59. Wechsler, D. (1999). Manual for the Wechsler abbreviated intelligence scale. San Antonio, TX: The Psychological Corporation.Google Scholar
  60. Williams, D. L., Goldstein, G., Carpenter, P. A., & Minshew, N. J. (2005). Verbal and spatial working memory in autism. Journal of Autism and Developmental Disorders, 35(6), 747–756.PubMedCrossRefGoogle Scholar
  61. Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., & Czobor, P. (2011). A meta-analysis of cognitive remediation for schizophrenia: Methodology and effect sizes. American Journal of Psychiatry, 168(5), 472–485.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Shaun M. Eack
    • 1
    • 2
  • Deborah P. Greenwald
    • 2
    • 3
  • Susan S. Hogarty
    • 2
    • 3
  • Amber L. Bahorik
    • 1
    • 3
  • Maralee Y. Litschge
    • 2
    • 3
  • Carla A. Mazefsky
    • 2
    • 3
  • Nancy J. Minshew
    • 4
  1. 1.School of Social WorkUniversity of PittsburghPittsburghUSA
  2. 2.Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghUSA
  3. 3.Western Psychiatric Institute and ClinicUniversity of Pittsburgh Medical CenterPittsburghUSA
  4. 4.Departments of Psychiatry and NeurologyUniversity of Pittsburgh School of MedicinePittsburghUSA

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