Skip to main content

Impact of Cognitive Behavioral Therapy on Observed Autism Symptom Severity During School Recess: A Preliminary Randomized, Controlled Trial

Abstract

This study compared cognitive behavioral therapy (CBT) and treatment-as-usual (TAU) in terms of effects on observed social communication-related autism symptom severity during unstructured play time at school for children with autism spectrum disorders (ASD). Thirteen children with ASD (7–11 years old) were randomly assigned to 32 sessions of CBT or community-based psychosocial treatment (TAU) for 16 weeks. The CBT program is based on the memory retrieval competition model and emphasizes the development of perspective-taking through guided behavioral experimentation supplemented with reflective Socratic discussion and supported by parent training and school consultation to promote generalization of social communication and emotion regulation skills. Trained observers blind to treatment condition observed each child during recess on two separate days at baseline and again at posttreatment, using a structured behavioral observation system that generates frequency scores for observed social communication-related autism symptoms. CBT outperformed TAU at posttreatment on the frequency of self-isolation, the proportion of time spent with peers, the frequency of positive or appropriate interaction with peers, and the frequency of positive or appropriate peer responses to the target child (d effect size range 1.34–1.62). On average, children in CBT were engaged in positive or appropriate social interaction with peers in 68.6 % of observed intervals at posttreatment, compared to 25 % of intervals for children in TAU. Further investigation of this intervention modality with larger samples and follow-up assessments is warranted.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. Akritas, M. G., & Brunner, E. (2003). Nonparametric models for ANOVA and ANCOVA: A review. In M. G. Akritas & D. N. Politis (Eds.), Recent advances and trends in nonparametric statistics (pp. 79–92). Amsterdam: Elsevier B.V.

    Chapter  Google Scholar 

  2. Anderson, M. C., Bjork, R. A., & Bjork, E. L. (1994). Remembering can cause forgetting—retrieval dynamics in long-term-memory. Journal of Experimental Psychology: Learning, Memory, and Cognition, 20, 1063–1087. doi:10.1037/0278-7393.20.5.1063.

    PubMed  Google Scholar 

  3. Anderson, M. C., Green, C., & McCulloch, K. C. (2000). Similarity and inhibition in long-term memory: Evidence for a two-factor theory. Journal of Experimental Psychology: Learning, Memory, and Cognition, 26, 1141–1159. doi:10.1037/0278-7393.26.5.1141.

    PubMed  Google Scholar 

  4. Bauminger, N. (2002). The facilitation of social-emotional understanding and social interaction in high-functioning children with autism: Intervention outcomes. Journal of Autism and Developmental Disorders, 32(4), 283–298. doi:10.1023/A:1016378718278.

    PubMed  Article  Google Scholar 

  5. Bauminger, N., Shulman, C., & Agam, G. (2003). Peer interaction and loneliness in high-functioning children with autism. Journal of Autism and Developmental Disorders, 33(5), 489–507. doi:10.1023/A:1025827427901.

    PubMed  Article  Google Scholar 

  6. Bellini, S. (2004). Social skill deficits and anxiety in high-functioning adolescents with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 19, 78–86. doi:10.1177/10883576040190020201.

    Article  Google Scholar 

  7. Brewin, C. R. (2006). Understanding cognitive behaviour therapy: A retrieval competition account. Behaviour Research and Therapy, 44, 765–784. doi:10.1016/j.brat.2006.02.005.

    PubMed  Article  Google Scholar 

  8. Chalfant, A. M., Rapee, R., & Carroll, L. (2007). Treating anxiety disorders in children with high functioning autism spectrum disorders: A controlled trial. Journal of Autism and Developmental Disorders, 37(10), 1842–1857. doi:10.1007/s10803-006-0318-4.

    PubMed  Article  Google Scholar 

  9. Chamberlain, B., Kasari, C., & Rotheram-Fuller, E. (2007). Involvement or isolation? The social networks of children with autism in regular classrooms. Journal of Autism and Developmental Disorders, 37(2), 230–242. doi:10.1037/0022-006X.66.1.7.

    PubMed  Article  Google Scholar 

  10. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7–18.

    PubMed  Article  Google Scholar 

  11. Chang, Y., Quan, J., & Wood, J. J. (2012). Effects of anxiety disorder severity on social functioning in children with autism spectrum disorders. Journal of Developmental and Physical Disabilities, 24, 235–245. doi:10.1007/s10882-012-9268-2.

    Article  Google Scholar 

  12. Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5–27. doi:10.1016/j.brat.2007.10.003.

    PubMed  Article  Google Scholar 

  13. 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–e23. doi:10.1542/peds.2009-0958.

    PubMed  Article  Google Scholar 

  14. DeRosier, M. E., Swick, D. C., Davis, N. O., McMillen, J. S., & Matthews, R. (2011). The efficacy of a social skills group intervention for improving social behaviors in children with high functioning autism spectrum disorders. Journal of Autism and Developmental Disorders, 41(8), 1033–1043. doi:10.1007/s10803-010-1128-2.

    PubMed  Article  Google Scholar 

  15. Eaves, L. C., & Ho, H. H. (2008). Young adult outcome of autism spectrum disorders. Journal of Autism and Developmental Disorders, 38(4), 739–747. doi:10.1007/s10803-007-0441-x.

    PubMed  Article  Google Scholar 

  16. Ferraioli, S. J., & Harris, S. L. (2011). Effective educational inclusion of students on the autism spectrum. Journal of Contemporary Psychotherapy, 41(1), 19–28. doi:10.1007/s10879-010-9156-y.

    Article  Google Scholar 

  17. Fujii, C., Renno, P., McLeod, B. D., Lin, C. E., Decker, K., Zielinski, K., et al. (2013). Intensive cognitive behavioral therapy for anxiety disorders in school-aged children with autism: A preliminary comparison with treatment-as-usual. School Mental Health, 5(1), 25–37. doi:10.1007/s12310-012-9090-0.

    Article  Google Scholar 

  18. Green, V. A., Pituch, K. A., Itchon, J., Choi, A., O’Reilly, M., & Sigafoos, J. (2006). Internet survey of treatments used by parents of children with autism. Research in Developmental Disabilities, 27, 70–84. doi:10.1016/j.ridd.2004.12.002.

    PubMed  Article  Google Scholar 

  19. Hess, K. L., Morrier, M. J., Heflin, L. J., & Ivey, M. L. (2008). Autism treatment survey: Services received by children with autism spectrum disorders in public school classrooms. Journal of Autism and Developmental Disorders, 38(5), 961–971. doi:10.1007/s10803-007-0470-5.

    PubMed  Article  Google Scholar 

  20. Horwitz, S. M., Hoagwood, K., Stiffman, A. R., Summerfeld, T., Weisz, J. R., Costello, J., et al. (2001). Measuring youth’s use of mental health services: Reliability of the SACA—services assessment for children and adolescents. Psychiatric Services, 52, 1088–1094. doi:10.1176/appi.ps.52.8.1088.

    PubMed  Article  Google Scholar 

  21. Ingram, D. H., Dickerson Mayes, S., Troxell, L. B., & Calhoun, S. L. (2007). Assessing children with autism, mental retardation, and typical development using the playground observation checklist. Autism, 11(4), 311–319. doi:10.1177/1362361307078129.

    PubMed  Article  Google Scholar 

  22. Kasari, C., Locke, J., Gulsrud, A., & Rotheram-Fuller, E. (2011). Social networks and friendships at school: Comparing children with and without ASD. Journal of Autism and Developmental Disabilities, 41, 533–544. doi:10.1007/s10803-010-1076-x.

    Article  Google Scholar 

  23. Kasari, C., Rotheram-Fuller, E., Locke, J., & Gulsrud, A. (2012). Making the connection: Randomized controlled trial of social skills at school for children with autism spectrum disorders. Journal of Child Psychology and Psychiatry, 53(4), 431–439. doi:10.1111/j.1469-7610.2011.02493.x.

    PubMed Central  PubMed  Article  Google Scholar 

  24. Kaufman, A. S., & Kaufman, N. L. (2004). Kaufman brief intelligence test (2nd ed.). Circle Pines, MN: American Guidance Service Inc.

    Google Scholar 

  25. Kendall, P. C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 62(1), 100–110. doi:10.1037/0022-006X.62.1.100.

    PubMed  Article  Google Scholar 

  26. Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65(3), 366–380. doi:10.1037/0022-006X.65.3.366.

    PubMed  Article  Google Scholar 

  27. Le Couteur, A., Lord, C., & Rutter, M. (2003). The autism diagnostic interview-revised. Los Angeles: Western Psychological Services.

    Google Scholar 

  28. Lickel, A., MacLean, W. E., Jr., Blakeley-Smith, A., & Hepburn, S. (2012). Assessment of the prerequisite skills for cognitive behavioral therapy in children with and without autism spectrum disorders. Journal of Autism and Developmental Disorders, 42(6), 992–1000. doi:10.1007/s10803-011-1330-x.

    PubMed  Article  Google Scholar 

  29. 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. doi:10.1023/A:1005592401947.

    PubMed  Article  Google Scholar 

  30. Lord, C., Rutter, M., DiLavore, P. C., & Risi, S. (2002). Autism diagnostic observation schedule. Los Angeles: Western Psychological Services.

    Google Scholar 

  31. Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism diagnostic interview-revised: A revised version of a diagnostic interview for caregivers of individuals with possible developmental disorders. Journal of Autism and Developmental Disorders, 24(5), 659–685. doi:10.1007/BF02172145.

    PubMed  Article  Google Scholar 

  32. Loveland, K. A., & Tunali-Kotoski, B. (2005). In F. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), The school-age child with an autistic spectrum disorder (pp. 247–287). Hoboken, NJ: Wiley.

  33. Marriage, S., Wolverton, A., & Marriage, K. (2009). Autism spectrum disorder grown up: A chart review of adult functioning. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 18(4), 322.

    PubMed Central  PubMed  Google Scholar 

  34. Matson, J. L., Hess, J. A., Neal, D., Mahan, S., & Fodstad, J. C. (2010). Trend of symptoms in children diagnosed with autistic disorder as measured by the autism spectrum disorders-diagnostic for children (ASD-DC). Journal of Developmental and Physical Disabilities, 22(1), 47–56. doi:10.1007/s10882-009-9167-3.

    Article  Google Scholar 

  35. Matson, J. L., & Horovitz, M. (2010). Stability of autism spectrum disorders symptoms over time. Journal of Developmental and Physical Disabilities, 22(4), 331–342. doi:10.1007/s10882-010-9188-y.

    Article  Google Scholar 

  36. McDougle, C. J., Scahill, L., Aman, M. G., McCracken, J. T., Tierney, E., Davies, M., et al. (2005). Risperidone for the core symptom domains of autism: Results from the study by the autism network of the research units on pediatric psychopharmacology. American Journal of Psychiatry, 162(6), 1142–1148. doi:10.1176/appi.ajp.162.6.1142.

    PubMed  Article  Google Scholar 

  37. Puleo, C. M., & Kendall, P. C. (2011). Anxiety disorders in typically developing youth: Autism spectrum symptoms as a predictor of cognitive-behavioral treatment. Journal of Autism and Developmental Disorders, 41(3), 275–286. doi:10.1007/s10803-010-1047-2.

    PubMed  Article  Google Scholar 

  38. Rao, P. A., Beidel, B. C., & Murray, M. J. (2008). Social skills interventions for children with Asperger’s syndrome or high-functioning autism: A review and recommendations. Journal of Autism and Developmental Disorders, 38, 353–361. doi:10.1007/s10803-007-0402-4.

    PubMed  Article  Google Scholar 

  39. Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: A randomized trial. Journal of Child Psychology and Psychiatry, 53(4), 410–419. doi:10.1111/j.1469-7610.2011.02486.x.

    PubMed  Article  Google Scholar 

  40. Reichow, B., & Wolery, M. (2009). Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA young autism project model. Journal of Autism and Developmental Disorders, 39(1), 23–41. doi:10.1007/s10803-008-0596-0.

    PubMed  Article  Google Scholar 

  41. 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:10.1111/j.1469-7610.2005.00411.x.

    PubMed  Article  Google Scholar 

  42. 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), 1203–1214. doi:10.1007/s10803-006-0262-3.

    PubMed  Article  Google Scholar 

  43. Spence, S. J., & Thurm, A. (2010). Testing autism interventions: Trials and tribulations. The Lancet, 375(9732), 2124–2125. doi:10.1016/S0140-6736(10)60757-X.

    Article  Google Scholar 

  44. Storch, E. A., Arnold, E. B., Lewin, A. B., Nadeau, J. M., Jones, A. M., De Nadai, A. S., et al. (2013). The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 52(2), 132–142. doi:10.1016/j.jaac.2012.11.007.

    PubMed  Article  Google Scholar 

  45. Szatmari, P., Bryson, S., Duku, E., Vaccarella, L., Zwaigenbaum, L., Bennett, T., et al. (2009). Similar developmental trajectories in autism and Asperger syndrome: From early childhood to adolescence. Journal of Child Psychology and Psychiatry, 50(12), 1459–1467. doi:10.1111/j.1469-7610.2009.02123.x.

    PubMed  Article  Google Scholar 

  46. Thomas, K. C., Morrissey, J. P., & McLaurin, C. (2007). Use of autism-related services by families and children. Journal of Autism and Developmental Disorders, 37(5), 818–829. doi:10.1007/s10803-006-0208-9.

    PubMed  Article  Google Scholar 

  47. Tulving, E. (1979). Relation between encoding specificity and levels of processing. In L. S. Cermak & F. I. M. Craik (Eds.), Levels of processing in human memory (pp. 405–428). Hillsdale, NJ: Erlbaum.

  48. Walters, S., & Weaver, K. (2003). Relationships between the Kaufman brief intelligence test and the Wechsler adult intelligence scale-third edition. Psychological Reports, 92, 1111–1115. doi:10.2466/pr0.2003.92.3c.1111.

    PubMed  Article  Google Scholar 

  49. West, L., Waldrop, J., & Brunssen, S. (2009). Pharmacologic treatment for the core deficits and associated symptoms of autism in children. Journal of Pediatric Health Care, 23(2), 75–89. doi:10.1016/j.pedhc.2008.12.001.

    PubMed  Article  Google Scholar 

  50. Wood, J. J., Drahota, A., Sze, K. M., Har, K., Chiu, A., & Langer, D. (2009a). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224–234. doi:10.1111/j.1469-7610.2008.01948.x.

    PubMed  Article  Google Scholar 

  51. Wood, J. J., Drahota, A., Sze, K., Van Dyke, M., Decker, K., Fujii, C., et al. (2009b). Brief report: Effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism. Journal of Autism and Developmental Disorders, 39(11), 1608–1612. doi:10.1007/s10803-009-0791-7.

    PubMed Central  PubMed  Article  Google Scholar 

  52. Wood, J. J., Fujii, C., & Renno, P. (2011). Cognitive behavioral therapy in high-functioning autism: Review and recommendations for treatment development. In B. Reichow, P. Doehring, D. V. Cicchetti, & F. R. Volkmar (Eds.), Evidence-based practices and treatments for children with autism (pp. 197–230). Berlin: Springer.

    Chapter  Google Scholar 

  53. Wood, J. J., & McLeod, B. (2008). Child anxiety disorders: A treatment manual for practitioners. New York: Norton.

    Google Scholar 

  54. Wood, J. J., & Schwartzman, B. C. (2013). Cognitive behaviour therapies for youth with autism spectrum disorders. In P. Graham & S. Reynolds (Eds.), Cognitive behaviour therapy for children and families (pp. 189–202). Cambridge, MA: Cambridge University Press.

    Chapter  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Jeffrey J. Wood.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Wood, J.J., Fujii, C., Renno, P. et al. Impact of Cognitive Behavioral Therapy on Observed Autism Symptom Severity During School Recess: A Preliminary Randomized, Controlled Trial. J Autism Dev Disord 44, 2264–2276 (2014). https://doi.org/10.1007/s10803-014-2097-7

Download citation

Keywords

  • Cognitive behavioral therapy
  • Autism spectrum disorders
  • School-aged children
  • School observations