This article will focus on those with Asperger’s Syndrome (AS) who have a co-morbid mental health diagnosis, as current research supports the effectiveness of cognitive behavioral therapy (CBT) for this sub-group on the autism continuum. This is not to say that those diagnosed with PDD-NOS or Autism could not benefit from CBT; however, the research does not support it yet. In general, two factors that will likely contribute to the effectiveness of CBT for those with ASD’s include the individual’s level of communication skills and intellectual functioning.
Individuals with Asperger’s Syndrome have an increased risk for developing mental health problems including mood and anxiety disorders. Individuals with Asperger’s appear susceptible to experiencing feelings of depression, with about one in three children and adults having a clinical depression (Ghaziuddin et al. 1998; Kim et al. 2000). For adolescents with AS, the current research suggests that approximately sixty five percent have an affective or mood disorder with the prevalence of depression being high (Konstantareas 2005). Individuals with AS may also experience dysthymia, a type of depression with less severe, but longer lasting symptoms than major depressive disorder.
There are several reasons people with Asperger’s Syndrome are prone to develop mood disorders. One being that they are aware of the difficulties they have with social understanding. This awareness can lead to overwhelming feelings of isolation and a desire to be accepted and understood. Consequently, a reactive depression can occur which can lead to strong feelings of grief, self-blame and criticism, criticism of others, and feelings of frustration or anger (Attwood, 2007).
When young children with AS feel socially secluded they can develop compensatory thoughts and attitudes (Attwood, 2004). For instance, children who struggle to develop friendships and achieve social competence can wind up internalizing their thoughts and feelings by being overly apologetic and gradually more withdrawn. The more withdrawn these children become, the fewer opportunities there are for them to develop their social skills. Children with AS can usually acknowledge their social isolation on an intellectual level, but want nothing more than to have friends. However, their difficulty lies in not knowing what to do in order to attain social success, as they lack the social skills that come so naturally to their peers.
Although those with AS may show signs of depression as early as childhood, it becomes more acute during adolescence when peer differences are more noticeable. During adolescence, the importance of and identification with the peer group increases while the influence of one’s parents lessens. As an adolescent with AS becomes more intellectually mature, this can lead to an increased realization of a lack of social success, greater insight into being different from other people, and a perception of oneself as being socially inept. Furthermore, because previous negative experiences can remain with people throughout their lifetime, children with AS who may have been bullied can feel lonely and misunderstood as an adolescent. For adolescents, problems with fitting in socially and achieving academic success can result in the development of a clinical depression. At the extreme, some adolescents and adults with AS who are clinically depressed may view suicide as the only way to ending their emotional suffering and the risk of self-injury also exists. While the symptoms of depression are often similar to those seen in neurotypical children and adults, clinicians specializing in AS have observed another characteristic that can be suggestive of depression. The restricted or stereotyped interests often seen in individuals with AS, which are frequently associated with pleasure, can become morbid when the person is depressed (Attwood, 2007).
The treatment of depression in individuals with AS should include, among other interventions, cognitive-behavioral therapy (CBT), a structured, problem-focused psychological treatment approach. CBT is based on a theoretical model, that maintains a person’s thoughts, feelings, and behaviors directly influence each other and play a role in the development and maintenance of psychological disorders, such as depression. Dubin (2009) posits that the fundamental idea of CBT is that changing thoughts to more accurately reflect external reality will, in turn, cause behavior to change to match the new, reality-based thoughts. Thus, the goals of CBT are threefold: 1) Increase clients’ awareness of their thoughts and help them determine whether those thoughts appropriately match up with the reality of the situation; 2) Help clients better understand their emotions and teach strategies to improve emotion regulation; 3) Examine and change behaviors that produce and maintain problematic thoughts and emotions.
Research studies have determined that CBT is an effective treatment to alter the way a person thinks about and responds to emotions such as anxiety, sorrow and feelings of anger (Grave and Blissett 2004; Kendall 2000). For individuals with Asperger’s Syndrome, CBT can help to manage emotions better and cut back on obsessive interests and repetitive routines, according to the National Institute of Neurological Disorders at the National Institutes of Health. CBT is therefore relevant for children and adults with AS who have difficulty understanding, expressing, and managing emotions constructively and a limited capacity to understand other’s mental states. CBT has shown success both by itself and in combination with medication. Importantly, research has demonstrated that CBT significantly reduces mood disorders in children and adults with AS (Bauminger 2002; Sofronoff, Attwood and Hinton 2005).
It is important that the treating therapist understand how to modify traditional CBT in order to accommodate the unique cognitive profile of an individual with AS. According to Dr. Natalia Appenzeller, Clinical Director of the Fay J. Lindner Center for Autism and Developmental Disabilities, “traditional cognitive behavioral therapy can effectively be modified and adapted to meet the cognitive styles of those with an autism spectrum diagnosis.”
Using a cognitive behavior model to treat co-morbid mental health issues in individuals with Asperger’s Syndrome usually follows a sequence:
- Assess the degree of the mental health concern: (e.g. level of depression or anxiety). This can be done using self-report and/or parent report rating scales and a clinical interview.
- Create a treatment plan: Visual supports often assist in providing a rationale to the patient for the treatment plan. A visual support could be in the form of a dry erase board or flip chart to outline to the patient the presenting problem, a plan to treat the problem and a description of the cognitive behavior model. A diagram can be drawn to help patients understand their diagnosis and conceptualize the treatment plan.
- Education: In this phase the therapist assists by teaching a skill set that has not yet been developed and increase patients’ knowledge and awareness of their own emotions. According to Gaus 2007, the most common skills that need to be taught are social and coping skills. Many patients with Asperger’s syndrome appreciate the concrete concepts taught as part of the cognitive behavioral model.
- Restructuring: Work to correct the distorted self-conceptualizations help patients to manage emotions and cope more effectively. An impaired ability to attribute beliefs, intentions and desires to others, as well as difficulty with cognitive flexibility often pose challenges when attempting to restructure distorted cognitions in those with ASD. Therefore, the use of visuals is an essential component of the treatment package. Often, therapists will provide patients with a handout highlighting material covered in the session or will write down goals or targets for each week.
- Maintenance Activities: During this phase, patient’s practice a more positive self-concept as well as coping behaviors when encountered with anxiety producing scenarios. Relaxation strategies associated with the physical symptoms of anxiety are usually more beneficial than the emotional concept of what provokes anxiety. Scripts and comic strip conversations (Gray, 1998) can assist the therapist in delivering information concretely and help to ensure that the individual understands the concept being taught.
To increase the likelihood for success when using CBT for those with Asperger’s Syndrome intervention components including the use of visual aids, social stories and conversation scripts, modeling and concrete examples of abstract concepts, and the incorporation of the individual’s special interests into therapy are critical to the success of the intervention program.
Natalia Appenzeller, PhD, is the Clinical Director of the Fay J. Lindner Center for Autism. She has worked in the field for over 20 years and has been the Clinical Director of the Brookville Center for Children’s Services’ Home/Community-Based Program for the past 15 years.
Melissa Caryn Braunstein, MS, is a graduate extern at the Lindner Center. She is currently getting her Doctor of Psychology degree in School-Clinical Child Psychology from the Ferkauf Graduate School of Psychology at Yeshiva University.
Edel McCarville, MSEd, is a graduate intern at the Lindner Center. She is currently a student in the PsyD School-Community Psychology Program at Hofstra University. Edel has worked with children on the autism spectrum and their families for the past 7 years in private and public school settings, and is a District Wide School Psychologist for Levittown School District’s Applied Behavior Analytic Programs in Nassau County. All references for this article may be obtained by contacting the authors.