Cognitive Behavioral With Autism

Research in Autism Spectrum Disorders 45 (2018) 27–41
Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders

journal homepage: www.elsevier.com/locate/rasd
Review Article
Cognitive-behavioral approaches for children with autism

T
spectrum disorder: A trend analysis
⁎
Betty P.V. Ho , Jennifer Stephenson, Mark Carter
Faculty of Human Sciences, Macquarie University, NSW, Australia
AR TI CLE I NF O AB S T R A CT
Keywords: Background: Cognitive-behavioral interventions for children with autism spectrum disorders
Autism (ASD) have emerged in the last two decades, and these interventions are now regarded as evi-
Children dence-based. However, reviews conducted so far often focus on specific areas and do not examine
Cognitive-behavioral broad trends in the development of relevant research in this area.
Intervention
Method: This current trend analysis provided an overview of the development in the research of
Research design
cognitive-behavioral interventions for children with ASD.This study is based on a total of 103
Trend analysis
reports located through a database keyword search and ancestral search.
Results: It was observed that early stage qualitative case studies have been gradually replaced by
experimental studies, while the use of randomized, controlled trials is still limited. Participants
included were mainly children with ASD and typical cognitive ability, and demographic de-
scription was often incomplete. Programs used were heterogeneous and often replicated. A heavy
reliance on rating scales rather than behavioral observation and insufficient data on effect
maintenance and generalization were observed. Very recently, researchers conducted supple-
mentary analyses on intervention data and provided information not available in original trial
reports.
Conclusion: A trend to include younger participants (i.e., children at or below 8 years of age) was
observed. Although a substantial number of experimental group studies have been conducted, the
proportion of randomized, controlled trials and sample sizes did not increase as expected.
Consequently, there is the need for larger scale randomized, controlled trials. A major problem
was incomplete participant description, in particular measures of autistic symptomology and
intelligence. There is the need for more comprehensive participant descriptions that allow
readers to identify the characteristics of children with ASD who may benefit from the inter-
vention.
1. Introduction
Autism spectrum disorder (ASD) is a developmental disorder characterized by difficulties in social communication as well as
restricted and repetitive patterns of behaviors and interests (American Psychiatric Association, 2013). ASD may also be associated
with comorbid anxiety disorders, depression, other emotional difficulties, and problematic behaviors (Salazar et al., 2015). There is
considerable variation in symptomology among affected individuals (American Psychiatric Association, 2013), and their intellectual
ability may range from above average to intellectual disability (Centers for Disease Control & Prevention, 2016). Overall, the po-
pulation with ASD is extensively heterogeneous which means that an array of interventions targeting different issues may be
⁎
Correspondence author at: Macquarie University Special Education Centre School, Building X5A, Macquarie University, NSW 2109, Australia.
E-mail addresses: betty.ho@mq.edu.au (B.P.V. Ho), jennifer.stephenson@mq.edu.au (J. Stephenson), mark.carter@mq.edu.au (M. Carter).
http://dx.doi.org/10.1016/j.rasd.2017.10.003
Received 27 November 2016; Received in revised form 7 September 2017; Accepted 9 October 2017
Available online 17 October 2017
1750-9467/ © 2017 Elsevier Ltd. All rights reserved.
B.P.V. Ho et al. Research in Autism Spectrum Disorders 45 (2018) 27–41
required.
Cognitive-behavioral interventions have been practiced widely with the general population since mid-last century and are con-
sidered to be evidence-based (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Cognitive-behavioral interventions were developed
from traditional behavioral strategies integrated with cognitive therapy, emphasizing social cognition, and facilitating behavioral
changes through cognition (Beck & Fernandez 1998; Dobson & Dozois, 2010). Unlike traditional behavioral approaches, cognitive-
behavioral interventions include both training to address specific areas of cognition and behavioral strategies to address skill and
behavior deficits, with an emphasis on the development of self-control and coping skills, which are claimed to lead to greater
generalization and maintenance (Feindler & Ecton, 1986). The application of cognitive-behavioral interventions to the population
with ASD came several decades after initial use with the general population (i.e., first reported by Lord, 1996).
Research on Cognitive-behavioral interventions for children with ASD began to flourish in the mid-2000s, and now these ap-
proaches are regarded as evidence-based (National Autism Center, 2015; Wong et al., 2015 Wong et al., 2015). Intervention research
often evolves from small-scale or less-controlled pilot studies which establish a prima facie case for an intervention, to more-controlled
and larger experimental studies and, finally, to replications to confirm findings and provide evidence of external validity (Clark,
2013; Fraser & Galinsky, 2010). Single group pilot studies at earlier stages may assist in fine-tuning the intervention design, and
controlled single subject studies can be used to evaluate the contribution of individual components to treatment effect at later stage
(Kratochwill et al., 2010) with experimental randomized group studies at later stages also providing stronger verification of treatment
effectiveness. It is thus of interest to track how research designs used to explore the effects of cognitive-behavioral interventions for
children with ASD evolved over the last two decades.
Cognitive-behavioral interventions address a variety of mental disorders and psychological distress in the general population
(Hofmann et al., 2012) and behavioral problems and skill deficits in typically developing children (e.g., Little & Kendall, 1979).
Cognitive-behavioral interventions have also been used with individuals having different medical conditions, physical disabilities,
and intellectual disability (Hofmann et al., 2012; Taylor, Novaco, Gillmer, & Thorne, 2002). Noting the versatility of cognitive-
behavioral interventions when implemented with the general population, its feasibility with a wide range of individuals with ASD is
suggested. Given their potentially widely different applications, it would be informative to examine the change over time in the focus
of cognitive-behavioral intervention studies for children with ASD to determine the primary skills and problems addressed.
Cognitive-behavioral interventions are considered as a family of interventions for the general population (Hofmann et al., 2012),
and the cognitive-behavioral intervention programs for children with ASD are found to be very diverse in their features
(Danial & Wood, 2013) and are not limited to addressing psychological problems alone (Ho, Stephenson, Carter, 2015). Program
features of particular interest would include manualization, intensity, setting, the professional administrating the procedures, and
persons involved; all of which have the potential to mediate treatment effects. It would be of interest to outline this diversity and how
such features change over time, as such information would provide a reflection of the evolution of cognitive-behavioral interventions.
Examination of the variations in participant demographics would help to identify the characteristics of children included in
cognitive-behavioral intervention studies. In addition, clear information about such factors as severity of autistic symptomatology
and intelligence of participants is important to forming judgments regarding the external validity of the research (Reynhout & Carter,
2011). Consequently, determining the extent to which such information is present in research regarding cognitive-behavioral in-
terventions and changes over time may be of use in characterizing extant research and highlighting directions for future study.
A variety of measures have been employed in assessing outcomes of cognitive-behavioral interventions including self-reports and
behavior observations (Hofmann et al., 2012). Each approach has potential advantages and disadvantages. For example, self-reports
are easily conducted and provide access to subjective states, such as anxiety, but do not necessarily reflect objective changes in actual
behavior or performance. Objective performance data is more difficult and resource intensive to collect, but can provide evidence of
changes in real-world behavior, supporting self-report data. While changes in subjective outcomes, like anxiety, are undoubtedly
desirable in themselves, it would be surprising if they were not accompanied by at least some objective behavioral change (e.g.,
reduced school refusal, increased social participation, etc.). Understanding the types of measures employed and their change over
time may offer insight into the types of data on which evaluations of cognitive-behavioral interventions are based and suggest
directions for future research.
It is suggested that one particular advantage of cognitive-behavioral interventions is the potential for generalization and main-
tenance of treatment effect (Chalfant, Rapee, & Carroll, 2007; Sofronoff, Attwood, Hinton, & Levin, 2007). Thus, an important out-
come evaluation of cognitive-behavioral intervention studies would involve data on maintenance and generalization, and it is im-
portant to understand the extent to which these variables are addressed in research studies and how this may have developed since
the early years.
A number of trend reviews have been conducted to provide a broad overview of the development of behavioral intervention
research in children with ASD (e.g., Matson, Benavidez, Stabinsky Compton, Paclawskyj, & Baglio, 1996; Matson, Tureck, Turygin,
Beighley, & Rieske, 2012). These trend reviews have identified the prevailing patterns in behavioral intervention research and
suggested new directions for future research.
There are a number of systematic reviews of cognitive-behavioral interventions for children with ASD. For example, Danial and
Wood (2013) examined the methods and results of cognitive-behavioral interventions targeting anxiety, disruptive behavior, and
core autism symptoms. Ho, Stephenson, and Carter (2014) conducted a meta-analysis of cognitive-behavioral interventions effec-
tiveness based on randomized, controlled trials. Another meta-analysis was conducted by Ung, Selles, Small, and Storch (2015) who
included only anxiety treatments for youths with high-functioning ASD. These reviews all focused on specific areas and did not
typically examine broad trends over time. Trend analyses, unlike systematic reviews, do not focus on effectiveness or specific areas
but on the general characteristics and foci of research and how they change over time.
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With an accumulating number of relevant studies, there is a case for examining trends in the development of research on the use
of cognitive-behavioral interventions with children with ASD. The research questions addressed in this trend analysis are:
1. What is the nature of the research designs used to explore cognitive-behavioral interventions?
2. What are the primary skills and problems addressed?
3. What are the characteristics of the participants and how are they described?
4. What are the features of the intervention programs?
5. How are intervention programs evaluated including outcome measures used and reports on generalization and maintenance?
2. Method
2.1. Search and selection of studies
The current trend analysis was based on 103 reports, and the full list of these reports can be obtained from the first author. These
reports were located through a key descriptor search conducted in September 2015 in four databases, CINAHL, ERIC, ProQuest, and
PsycINFO using the descriptors “autism,” “autistic,” “Asperger∗,” “pervasive developmental disorders not otherwise specified,” “PDD-
NOS,” “cognitive behavio∗,” “cognitive-behavio∗,” “treatment,” “intervention,” “program,” and “training.” To maximize the number
of reports returned, no initial publication year was entered in the search. The key descriptor search located 694 unique records.
The following report inclusion criteria were used in the current study: it was written in English; it was a refereed journal article, a
dissertation/thesis at or above master’s level, or an original study reported in a published book to minimize the attendant risk of
publication bias (Schlosser, Wendt, & Sigafoos, 2007); the intervention was explicitly described as cognitive-behavioral by the au-
thors in their report or related publications (e.g., Laugeson & Park, 2014) or by the original program developer (e.g., Van Hecke et al.,
2015) unless described otherwise explicitly by the study authors (i.e., Crooke, Hendrix, & Rachman, 2008); all participants in the
study were aged 19 years or less with a reported diagnosis of ASD (i.e., autistic disorder, Asperger’s syndrome, pervasive develop-
mental disorder-not otherwise specified, or other labels that included the term autism); it was an intervention study and reported
outcomes of the direct intervention participants. Studies were excluded if they did not report on participant outcomes (i.e., Johnco
et al., 2015; Karst et al., 2015), or the active intervention elements were directed at parents only (i.e., Cortesi, Giannotti, Sebestiani,
Panunzi, & Valente, 2012). Studies were included if they provided supplementary analyses of participant outcomes from earlier
intervention trials (e.g., treatment maintenance and cost effectiveness of intervention; moderators, mediators, or other correlates of
participant outcomes.) Studies involving participants with and without ASD were included if their outcomes for participants with
ASD were reported separately (i.e., Vickers, 2002).
A flow chart of the item selection process is presented in Fig. 1. Following the key descriptor search, the first and second authors
independently reviewed all report titles and abstracts and decided whether to reserve each of the located records for detailed
screening. Agreement was calculated by dividing the number of reports the first and second authors agreed to be included by the total
number of reports screened, then converting the quotient to a percentage. Agreement was 91.4%. Where there was a disagreement,
the report was retained for full-text screening. Next, detailed screening was conducted again by the first and second authors, both of
whom separately examined the full text of all reserved reports to confirm they met all inclusion criteria. Agreement on the detailed
screening was 98.0%. The final status of all reports on which the first two authors disagreed was determined through discussion
between all three authors.
The key descriptor search was complemented by additional searching in the databases ERIC and PsycINFO, screening the re-
ference lists of all located intervention studies and relevant reviews. The database ancestral search used names of authors of selected
reports and names of specific programs researched in these reports. Out of the 35 additional reports located through this additional
search, 12 reports did not explicitly describe their intervention programs as cognitive-behavioral but their programs were identified
as cognitive-behavioral by the program developers or authors in other publications.
2.2. Data extraction
The first author independently extracted and coded data from all 103 reports regarding research design, primary intervention
aims, participant demographic characteristics, intervention program features, and outcome evaluation. The second author extracted
and coded the same data from 25% of the included studies, which were selected using a random number generator. Author agreement
on extraction and coding data was 98.7% for research design, 94.6% for primary intervention aims, 95.5% for participant demo-
graphic characteristics, 92.0% for intervention program features, and 91.8% for outcome evaluation. The second author reviewed the
data extracted and coded by the first author for the rest of the included studies. All disagreements relating to extracting and coding
data were resolved through discussion between all three authors.
2.3. Data analysis
Research designs were classified into six categories based on their method of collecting and analyzing data. When coding sup-
plementary analyses, research design coding was based on the supplementary analysis and not on the original intervention ex-
periment design (e.g., the supplementary analysis may have involved a single group pre-post comparison which the parent study may
have been a randomized, controlled trial).
29
Fig. 1. Flowchart for selection of research reports to be included in the trend analysis.
The primary intervention aims were identified from the title, abstract, and introduction of the reports and as explicitly defined by
the authors as the primary skills or problems addressed. In addition, the primary study aims for supplementary analyses also included
issues related directly to participant outcomes. Aims specified as secondary intervention aims or specified primary study aims that
were not related to participant outcomes (e.g., feasibility of intervention program; Reaven et al., 2015) were not extracted.
Participant demographic characteristics and diagnostic information were extracted. Participant age was coded into four ranges
and when only mean age and standard deviation were reported, participant age range was calculated as two standard deviations
above and below the mean and within any age limitation stated as inclusion criteria. Participant intellectual ability was coded into
three ranges and when only mean and standard deviation were provided, intellectual ability coding was based on the mean of IQ
score (as in Yoo et al., 2014), the inclusion criteria (as in Lopata et al., 2010), and relevant descriptors (e.g., “without intellectual
disability” in Laugeson, Ellingsen, Sanderson, Tucci, & Bates, 2014). The diagnostic labels used by report authors were extracted as
participant diagnosis. Based on the specific purposes for which the authors used an ASD instrument as described in their study, the
instrument was categorized either as an instrument to make an ASD diagnosis or as a measure to specify ASD severity.
Intervention program features extracted were treatment delivery method, time spent in the treatment course, settings, profes-
sionals of treatment administrators, others involved in the treatment, and frequency of specific programs being used.
Data on outcome evaluation included outcome measures used, and whether effect maintenance, effect generalization, and social
validity were measured. Outcome measures were extracted and coded according to how intervention results were evaluated.
30
Data on research design, primary intervention aims, and outcome evaluation were extracted from all reports. Data on participant
demographic characteristics and intervention programs features were extracted only from intervention trial reports and not from
supplementary analyses, because all supplementary analyses were based on intervention studies reported in the intervention trial
reports. Data from multiple reports on the results of a single intervention trial were combined and analyzed as a single trial. Multiple
coding was performed when data in an intervention trial such as participant age, IQ, or treatment modality fitted into more than one
data group (e.g., treatment was delivered both in a group and individually in Ames & Weiss, 2013; participants in Reaven, Blakeley-
Smith, Culhane-Shelburne, & Hepburn, 2012 included children between the ages of 7 and 14 years, fitting into the 5 to 8 years group,
9 to 12 years group, and 13 to 15 years group.).
All reports were grouped into three time-periods based on the in-print publication year. Since the vast majority of research was
conducted post-2006, the subsequent research was divided into two five-year intervals and pre-2006 studies were examined sepa-
rately.
3. Results
The final list of 103 reports included 81 journal articles, 15 theses, and seven book chapters. Seven of these reports were published
pre-2006, 26 during the period 2006 to 2010, and 70 during the period 2011 to 2015. Altogether these 103 reports presented
outcomes from 79 individual intervention trials, including 89 reports on participant intervention outcomes and 14 reports on 13
supplementary analyses of intervention outcomes. The proportion of journal articles increased over the three time-periods paired
with a gradual decrease in book chapters.
3.1. Research design
Research designs used in the intervention studies over the three time-periods are presented in Fig. 2. Pre-2006, more than two
thirds of the intervention trials were case studies (n = 5 trials). Since 2006, more than two thirds of the intervention trials were
experimental trials (n = 17 trials in 2006 to 2010; n = 38 trials in 2011 to 2015), but less than half of them were randomized,
controlled trials (n = 8 trials in 2006 to 2010; n = 17 trials in 2011 to 2015).
Overall, 1690 participants with ASD were included in the 79 intervention trials (See Table 1 for details). The 50 group trials
included 29 controlled trials, and the mean sample sizes remained only moderate over the three periods. Specifically, of the 26
randomized controlled trials, 14 treatment groups and 14 control groups had fewer than 20 participants.
3.2. Aims
The primary aims of the intervention trials and supplementary analyses are summarized in Table 2. Multiple aims were often
identified in the articles examined. Among the intervention studies, the proportion of trials designed to treat anxiety and related
problems increased over time, while the improvement of social skills was targeted consistently. In the two latter time-periods,
researchers extended their interest to areas such as ASD symptoms, specific areas of cognition, friendship skills, anger management,
and depression.
3.3. Participant demographic characteristics
Table 3 provides participant demographic data. There was a clear increase in the proportion of trials including participants aged
between five to eight years. Further, the majority of trials conducted pre-2006 included participants aged 16 years or older, and the
majority of trials conducted afterward focused on participants aged between nine and 12 years old.
Nearly all reports included participants with either full scale or verbal IQ at or above typical level, and participants with mild or
moderate intellectual disability were rarely included. In all three time-periods, intervention trials frequently included participants
labeled with high functioning ASD, high functioning autism, or Asperger’s syndrome, and infrequently included participants specifically
labeled with autistic disorder. An increased use of the broader label autism spectrum disorder was observed in the last two time-periods.
In all time-periods, participant full-scale IQ score was not provided in a substantial proportion of reports, and verbal IQ score was
not provided in half of the reports. Similarly, information on instruments used to confirm or make ASD diagnoses was often missing.
ASD symptom severity was reported by less than one third of the trials.
3.4. Intervention program features
The main features of the intervention programs are summarized in Table 4. Since 2006, the majority of the intervention programs
were manualized. Trials targeting anxiety management used more individual treatment, and trials targeting social skills used more
group modality.
Overall, there was a shift from longer to shorter treatment time spans and to fewer treatment hours. The time span of treatment
course varied from shorter than a month (Reid, 2014) to over a year (e.g., Humphrey, 2008; Lord, 1996), and most pre-2006 trials
spanned six months or more. The total treatment hours ranged from three and half hours (Reid, 2014) to 215 hours (Lopata et al.,
2013), and in all time-periods the most frequently reported treatment hours were 20 or fewer.
Across the three time-periods, there was an increase in the proportion of intervention trials conducted outside traditional settings
31
Fig. 2. Research designs used in cognitive-behavioral interventions for children with ASD in the three time-periods, pre-2006, 2006 to 2010, and 2011 to 2015.
Table 1
Participants in cognitive-behavioral intervention studies for children with ASD.
Participant Pre-2006 N = 92 2006 to 2010 N = 459 2011 to 2015 N = 1139
In all group design studies (No. of trials) 86 (2) 443 (15) 1112 (33)
Mean size of all group design studies (Range) 43 (15–71) 30 (6–54) 34 (6–79)
In all treatment groups 63 295 730
Mean of all treatment group sizes (Range) 32 (15–48) 20 (6–54) 22 (6–79)
In all control groups 23 148 382
Mean of all control group sizes (Range) 23 (23–23) 16 (8–23) 20 (5–34)
In randomized controlled trials (No. of trials) 71 (1) 257 (8) 710 (17)
Mean of size of randomized controlled trials (Range) 71 (71–71) 32 (15–47) 42 (12–70)
In randomized treatment groups 48 132 375
Mean of randomized treatment group sizes (Range) 48 (48–48) 17 (7–28) 22 (6 −47)
In randomized control groups 23 125 335
Mean of randomized control group sizes (Range) 23 (23–23) 16 (8–23) 20 (5–34)
Total male 78 (85%) 396 (86%)a 965 (85%)
Total female 14 (15%) 57 (12%) 174 (15%)
a
Note. One group research study did not report on participant gender.
32
Table 2
Primary aims in cognitive-behavioral intervention studies for children with ASD.
Pre-2006 2006 to 2010 2011 to 2015 2013 to 2015

Primary aim % (n = 7 trials) % (n = 23 trials) % (n = 49 trials) % (n = 13 supplementary analyses)
Targeted participant problems

Anxiety disorder & related problems 14% (1) 39% (9) 53% (26) 15% (2)
OCD & related problems 29% (2) 26% (6) 16% (8) 0% (0)
Depression 0% (0) 0% (0) 2% (1) 0% (0)
Anger 0% (0) 9% (2) 2% (1) 0% (0)
Other emotional functioning & related problems 29% (2) 13% (3) 22% (11) 0% (0)
Aggressive/violent/destructive behaviors 14% (1) 0% (0) 0% (0) 0% (0)
Other problematic behaviors 0% (0) 9% (2) 10% (5) 0% (0)
Social skills 29% (2) 48% (11) 45% (22) 0% (0)
Adaptive functioning 14% (1) 9% (2) 6% (3) 0% (0)
Specific areas of Cognition 0% (0) 17% (4) 14% (7) 0% (0)
Friendship skills 0% (0) 4% (1) 8% (4) 0% (0)
ASD symptoms 0% (0) 13% (3) 18% (9) 0% (0)
Other participant outcomes 14% (1) 0% (0) 14% (7) 0% (0)
Other study aims
Treatment mediators 0% (0) 0% (0) 0% (0) 15% (2)
Treatment moderators 0% (0) 0% (0) 0% (0) 39% (5)
Other correlates of participant outcomes 0% (0) 0% (0) 0% (0) 31% (4)
Treatment maintenance 0% (0) 0% (0) 0% (0) 23% (3)
Cost effectiveness 0% (0) 0% (0) 0% (0) 8% (1)
No or unclear information 14% (1) 4% (1) 0% (0) 0% (0)
Note: Percentage was calculated as the number of reporting trials divided by the total intervention trials during a time-period. Total percentage in all time-periods
exceeded 100% because multiple aims were stated in most reports. OCD = obsessive-compulsive disorder.
and in more natural settings where the participants were provided with opportunities to use their social skills or were exposed to
anxiety provoking stimuli (e.g., playground, shopping center, parent’s car). In addition to in-situ intervention, most programs in-
cluded between session practices, and home was always the most frequently reported practice setting. However, the assignment of
between session practices decreased over time.
In all three time-periods, a psychologist was the most frequently employed professional to deliver the treatment, and their
predominance increased. Psychologists also collaborated with school teachers in some of the school based intervention trials (n = 7).
Parents were involved in the treatment sessions in most trials, and this trend was rising.
Altogether, 27 specific multicomponent programs were implemented in the 79 reviewed intervention trials either in their original
format or with modifications. Sixteen of these specific programs were used more than once. The program most frequently researched
and replicated was the various versions of Behavioral Interventions for Anxiety in Children with Autism (Wood et al., 2009), researched
mainly by its developers and affiliates; followed by summer MAX (Lopata et al., 2015), researched solely by its developers and
affiliates. Among programs developed for non-ASD populations and researched by independent researchers not associated with the
developers, Coping Cat (Kendall & Hedtke, 2006), together with its various versions, were the most frequently studied. The largest
number of new programs were implemented between 2011 and 2015.
3.5. Outcome measures
Most researchers evaluated their intervention outcomes using multiple informants (See Table 5). Of all the reports and in all
times, parent rating was the most frequently used outcome measure, followed by participant self-reports. While there was an in-
creasing use of some other measures (i.e., teacher rating, clinician rating, diagnostic interviews, knowledge or ability test), outcome
measurement by direct observation of behaviors was limited across all years and decreased in the time-period 2011 to 2015. Of the 16
intervention trials in which behavior observation was used, three were single subject design studies.
Maintenance was measured in a minority of studies (n = 41%, 32 trials in all years), and generalization was much less frequently
measured (n = 10%, 8 trials in all years). Social validity was not reported pre-2006 and subsequently was reported in fewer than half
of the studies and mostly measured by consumer satisfaction (n = 21 trials).
4. Discussion
The objective of the current trend review was to identify the major features and track the changes over time in research in-
vestigating cognitive-behavioral interventions with children with ASD focusing on research designs, preliminary intervention aims,
participant demographic characteristics, program features, and outcome evaluation. More than a hundred reports were located with
nearly 90% being intervention trial reports and around 10% presenting supplementary analyses. Ninety-three percent of these reports
were published after 2005, the same period when U.S. data started to indicate a rise in the prevalence of ASD from 0.67% in 2002 to
1.47% in 2012 (Centers for Disease Control & Prevention, 2017a). Given the broad scope of the review, results will be discussed in
each area, followed by relevant implications and recommendations.
33
Table 3
Participant demographic characteristics and diagnostic measures in cognitive-behavioral intervention studies for children with ASD.
Pre-2006 2006–2010 2011–2015

Demographic characteristic % (n = 7 trials) % (n = 23 trials) % (n = 49 trials)
Age
5 to 8 years 29% (2) 48% (11) 61% (30)
9 to 12 years 43% (3) 91% (21) 78% (38)
13 to 15 years 14% (1) 48% (11) 41% (20)
16 years and above 57% (4) 9% (2) 20% (10)
Full scale IQ score
Typical and above 71% (5) 70% (16) 71% (35)
Mild intellectual disability 14% (1) 0% (0) 4% (2)
Moderate intellectual disability and below 0% (0) 0% (0) 2% (1)
No or unclear information 29% (2) 30% (7) 24% (12)
Verbal IQ score
Typical and above 43% (3) 39% (9) 43% (21)
Mild intellectual disability 29% (2) 9% (2) 6% (3)
Moderate intellectual disability and below 0% (0) 0% (0) 2% (1)
Diagnostic label
Asperger’s syndrome, HFASD, and high functioning autism 71% (5) 100% (23) 53% (26)
Pervasive developmental disorders-not otherwise specified 0% (0) 39% (9) 41% (20)
Autistic disorder 14% (1) 13% (3) 20% (10)
Autism spectrum disorder 0% (0) 9% (2) 24% (12)
Autism 14% (1) 13% (3) 8% (4)
Autism disorders 14% (1) 0% (0) 2% (1)
DSM V ASD 0% (0) 0% (0) 4% (2)
Instrument used to make ASD diagnosis
ADOS 14% (1) 35% (8) 57% (28)
ADI-R 57% (4) 39% (9) 47% (23)
DSM-IV 43% (3) 30% (7) 18% (9)
SCQ 0% (0) 4% (1) 14% (7)
Other less frequently used instruments 29% (2) 9% (2) 18% (9)
Measure used to specify ASD severity
ADOS 0% (0) 9% (2) 12% (6)
ADI-R 0% (0) 4% (1) 8% (4)
SRS 0% (0) 4% (1) 6% (3)
Other less frequently used measures 29% (2) 4% (1) 12% (6)
Note: Percentage was calculated as the number of reporting trials divided by the total intervention trials during a time-period. Total percentage exceeded 100% in all
data categories except full-scale IQ score in 2006 to 2010 and measure used to specify ASD severity pre-2006. HFASD = High functioning autism spectrum disorder;
DSM-V ASD = Autism spectrum disorder as defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013);ADOS
= Autism Diagnostic Observation Schedule manual (Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K., & Bishop, S. L., 1999); ADI-R = Autism Diagnostic Interview-
Revised (Rutter, Le Couteur, & Lord, 2003); DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 2000);
SCQ = Social Communication Questionnaire (Rutter, Bailey, & Lord, 2003), SRS = Social Responsiveness Scale (Constantino & Gruber, 2007).
4.1. Research design and sample sizes
The research designs employed shifted from being dominated by descriptive case studies to experimental research during the last
decade. The increase in randomized control trails and single subject design studies in the last two periods may reflect a response to
the prevailing movement toward evidence-based practice in the general area of psychological treatments (American Psychological
Association, 2006) and in autism (Mesibov & Shea, 2011).
Although randomized control trails have emerged in the past decade, constituting 35% of all studies in both 2006–10 and
2011–2105, they still represent a minority. The predominance of non-randomized studies may perhaps reflect ongoing attempts to (1)
test new programs, (2) to replicate program with different age groups or different settings, or (3) to refine interventions and identify
the most important components because cognitive-behavioral interventions are typically complex and multi-component.
Examination of studies in more depth, however, does not support the third contention as there appeared to be few studies that were
focused on evaluating specific intervention components. Given the state of research in the area, the case for conducting non-ran-
domized group studies that are not intended to pilot or refine treatments would appear to be weak. Such research is unlikely to
contribute meaningfully to our knowledge. Thus, at this point, given our current state of knowledge, it could be argued that it is
incumbent on researchers to provide specific rationales for conducting studies other than randomized controlled trials in this area.
Further, there are few single subject studies in this area. Such research designs allow clear demonstration of experimental control
and are suited to examining the effects of specific treatment components and to evaluating individual responses to treatment
(Kratochwill et al., 2010). The dearth of single subject research on cognitive-behavioral interventions stands in contrast to the
observation that most research studies published in autism-specific journals in the period 1997 to 2004 employed single-subject
34
Table 4
Features of cognitive-behavioral intervention programs for children with ASD.
Intervention trial feature Pre-2006 % (n = 7 trials) 2006 to 2010 % (n = 23 trials) 2011 to 2015 % (n = 49 trials)
Manualized intervention 43% (3) 91% (21) 82% (40)

Treatment modality
Group treatment 29% (2) 57% (13) 57% (28)
Individual treatment 43% (3) 52% (12) 55% (27)
Treatment time span
Under three months 29% (2) 48% (11) 45% (22)
Three to under six months 0% (0) 26% (6) 41% (20)
Six months and more 57% (4) 22% (5) 6% (3)
Treatment hours
20 h and under 29% (2) 39% (9) 51% (25)
21 to 60 h 0% (0) 30% (7) 20% (10)
61 to 100 h 14% (1) 4% (1) 0% (0)
Above 100 h 0% (0) 13% (3) 10% (5)
Geographic location
United States 14% (1) 57% (13) 61% (30)
Canada 0% (0) 9% (2) 12% (6)
United Kingdom 29% (2) 0% (0) 10% (5)
Australia 14% (1) 9% (2) 4% (2)
Israel 14% (1) 9% (2) 2% (1)
Netherlands 0% (0) 0% (0) 2% (1)
Ireland 0% (0) 4% (1) 0% (0)
Singapore 0% (0) 4% (1) 2% (1)
South Korea 0% (0) 0% (0) 2% (1)
Treatment setting
Clinic 57% (4) 52% (12) 53% (26)
School 43% (3) 22% (5) 20% (10)
Home 14% (1) 4% (1) 8% (4)
Other setting with stimuli or opportunities to apply learned 0% (0) 9% (2) 16% (8)
skills
Practice setting
Home 57% (4) 48% (11) 29% (14)
School 29% (2) 30% (7) 6% (3)
Other specific settings 0% (0) 13% (3) 4% (2)
Practice without specifying setting 43% (3) 70% (16) 67% (33)
No between session practice assigned 0% (0) 13% (3) 18% (9)
Treatment administrator(s)
Psychologist 43% (3) 52% (12) 57% (28)
Teacher 14% (1) 35% (8) 18% (9)
Therapist 29% (2) 9% (2) 27% (13)
Others 14% (1) 9% (2) 18% (9)
Others involved in treatment
Parent 71% (5) 78% (18) 88% (43)
Teacher 29% (2) 17% (4) 8% (4)
Peers 29% (2) 30% (7) 10% (5)
Others (other than parent, teacher or peer) 14% (1) 9% (2) 6% (3)
Frequency of specific programs being used from pre-2006
1 to 4 times 43% (3) 61% (14) 37% (18)
5 to 9 times 0% (0) 35% (8) 35% (17)
Note. Percentage was calculated as the number of reporting trials divided by the total intervention trials during a time-period. Total percentage exceeded 100% in all
data categories except Program being manualized, Treatment time span, and Treatment hours in all time-periods; and Treatment modality pre-2006.
designs (de la Cruz et al., 2006).

The sample size in group studies did not markedly increase over time in the reviewed research. In particular, the mean size of
randomized controlled trials remained modest at around 40 over the past decade. It is widely recognized that small studies with low
statistical power reduce ability to detect a true effect but other problems are less appreciated (Button et al., 2013). These include a
reduction in the probability that a statistically significant finding will represent a true effect and overestimation of effect sizes (Button
et al., 2013). In contrast, larger sample sizes are desirable as they offer better estimations of treatment effects and are less vulnerable
to random error (Borenstein, Hedges, Higgins, & Rothstein, 2009). The modest sample sizes in the research examined in this analysis
35
Table 5
Participant outcome evaluation in cognitive-behavioral intervention studies for children with ASD.
Pre-2006 2006 to 2010 2011 to 2015 2013 to 2015

% (n = 7 trials) % (n = 23 trials) % (n = 49 trials) % (n = 13 Supplementary analyses)
Outcome measures
Parent rating 43% (3) 70% (16) 69% (34) 92% (12)
Participant self-rating 43% (3) 43% (10) 45% (22) 38% (5)
Clinician rating 0% (0) 17% (4) 33% (16) 46% (6)
Teacher rating 14% (1) 17% (4) 20% (10) 8% (1)
Other rating 0% (0) 4% (1) 4% (2) 15% (2)
Diagnostic interviews 0% (0) 26% (6) 29% (14) 31% (4)
Knowledge or ability test 29% (2) 35% (8) 41% (20) 31% (4)
Specific measures developed by authors/program 14% (1) 26% (6) 33% (16) 38% (5)
developer
Behavior observation by observer blind to treatment 0% (0) 13% (3) 8% (4) 8% (1)
condition
Behavior observation by observer not blind to treatment 14% (1) 13% (3) 12% (6) 0% (0)
condition
Other outcome measures 14% (1) 0% (0) 18% (9) 23% (3)
Other outcome evaluation
Data at follow up/maintenance 43% (3) 39% (9) 41% (20) 31% (4)
Data for generalization of treatment effect 0% (0) 9% (2) 12% (6) 0% (0)
Social validity measured 0% (0) 43% (10) 43% (21) 8% (1)
No quantitative outcome data 29% (2) 13% (3) 4% (2) 0% (0)
Note. Percentage was calculated as the number of reporting trials divided by the total intervention trials during a time-period. Total percentage exceeded 100% in all
outcome measures.
might reflect problems in recruiting participants. While the sample sizes in cognitive-behavioral interventions may be consistent with
the size of typical intervention studies for children with ASD (i.e., 8 to 16 participants per group; Humphrey & Parkinson, 2006), they
are still problematic.
A notable development in the research examined was the emergence of supplementary analyses. Most supplementary analyses
combined data from several original intervention trials, allowing more powerful statistical analysis. They also focused on issues that
were often inadequately addressed in the original intervention trial reports, such as maintenance of treatment effect, cost effec-
tiveness, and possible mediators and moderators. As such, supplementary analyses filled some gaps in the literature.
4.1.1. Implications
The need to clarify the active and important components in cognitive-behavioral interventions for children with ASD has been
suggested previously (Ho et al., 2015), and single subject designs are suited to research of this type. Single subject design studies, in
particular multiple-baseline designs, have the potential to demonstrate experimental control with a limited number of participants
and allow the examination of relative contributions of specific components of interventions (Kratochwill et al., 2010), and thus,
further studies of this type are recommended. In addition, non-randomized group studies should be limited to piloting new inter-
ventions and refining existing interventions. Beyond these purposes, resources would be better invested in randomized controlled
trials where strong conclusions regarding causal influence can be drawn.
In view of the relatively modest sample sizes in group studies and a lack of an obviously rising trend, increasing sample size
should be a focus in future research. Collaboration between researchers in delivering the same intervention across multiple sites is a
feasible approach to recruit more participants and this strategy was adopted in two reviewed trials (Ehrenreich-May et al., 2014;
Wood, Ehrenreich-May et al., 2015). Another alternative is collaboration between researchers and schools in order to obtain access to
larger samples. This approach was used in the two reviewed trials with the largest numbers of participants (67 participants in
Kenworthy et al., 2014; 73 participants in Laugeson et al., 2014).
4.2. Primary skills and problems addressed as intervention aims
Researchers in some intervention studies did not precisely and clearly state any intervention aims in their introduction. Others
stated the aims of the original program in the introduction and included their specific intervention aims in the procedure section.
Most researchers targeted multiple skills or problems and often failed to specify primary or secondary intervention aims. These issues
compounded difficulties in identifying the intervention aims.
The predominance of anxiety management and social skills as primary interventions aims increased over the reviewed periods. On
the other hand, the potential of cognitive-behavioral interventions to address specific areas of cognition in children with ASD is yet to
be fully explored. Currently there are few studies of cognitive-behavioral interventions with a primary aim of improving cognitive
functioning (e.g., executive function and cognitive flexibility) in children with ASD, as has been reported previously (Kenworthy
et al., 2014). Cognitive dysfunctions or distortions are associated with impairment in adaptive functioning, family stress, decreased
independence, and poor outcomes in adulthood (Kenworthy et al., 2014). Interventions with a primary aim focused on specific areas
36
of cognition should be equally important for children with ASD.
4.2.1. Implications
Aim statements point to the specific skills or problematic issues in which improvement would be expected. Cognitive-behavioral
interventions usually contain multiple components, teach multiple skills, or address several problematic issues. It may be difficult for
a reader to establish the specific intervention targets in the absent of clearly articulated aim statements. Clearly articulated aims are
also important for synthesis of research effort because they allow accurate categorization of literature. In addition, a priori specifi-
cation of a limited number primary aims and associated outcome variables is important to interpretation of outcome data and reduces
the risk of apparently significant results being an artifact of multiple comparisons.
In contrast to the restricted focus for children with ASD, cognitive-behavioral interventions have been implemented successfully
with typically developing children to address a wider range of behavioral problems and skill deficits, including cognitive functioning
such as problem solving and self-control (Little & Kendall, 1979). Some common self-management strategies used in cognitive-be-
havioral programs have been demonstrated as effective with students with ASD (e.g., Deitchman, Reeve, Reeve, & Progar, 2010;
Holifield, Goodman, Hazelkorn, & Heflin, 2010). In the reviewed studies addressing specific areas of cognition, improvement was
reported in executive functioning rating (Kenworthy et al., 2014), and in theory of mind measures (Schmidt, Stichter, Lierheimer,
McGhee, & O'Connor, 2011). It is feasible to explore the implementation of cognitive-behavioral interventions for improving cog-
nitive functioning of children with ASD, and therefore, this is recommended.
4.3. Nature and description of participants
The participant samples did not comprehensively represent the population of children with ASD in regard to cognitive ability.
Most trials included participants with average or above intellectual ability and rarely included participants with intellectual dis-
ability. Both the increasing proportion of younger participants and more trials with participants having higher intellectual ability
were observed in the trend analysis of general intervention studies for individuals with ASD (Crosland, Clarke, & Dunlap, 2013).
The inclusion of children with ASD and average or above intellectual ability could possibly be explained by the perception that
cognitive-behavioral interventions were more suitable for this population and the increasing proportion of children identified with
ASD who have average or above intellectual ability (Centers for Disease Control & Prevention, 2017b). Prevalence reports indicate
that a substantial proportion of individuals with ASD have below average IQ (Centers for Disease Control & Prevention, 2016). The
possible feasibility of individually modified cognitive-behavioral interventions for children with both ASD and intellectual disability
was demonstrated in two of the reviewed studies which targeted this population (Danial, 2013; Moskowitz, 2012).
The gender ratio of the current samples at approximately 1 female: 6–7 males was higher than the widely reported ratio of 1
female: 4–5 males (Lai, Lombardo, Auyeung, Chakrabarti, & Baron-Cohen, 2015). Since researchers in only one study excluded female
participants explicitly, this may reflect some systematic male bias in the sample selection process (e.g., 24 of the 79 trials included
only male participants). It may also be related to the larger proportion of participants having higher intellectual ability because a
larger proportion of females with ASD have concurrent intellectual disability (Lai et al., 2015).
A noteworthy issue was incomplete demographic information in reporting participant characteristics. IQ scores and data on
severity of ASD symptoms were often omitted. This issue continued over the time-periods examined and was consistent with re-
porting in general intervention research for children with ASD (Humphrey & Parkinson, 2006). ASD is a heterogeneous disorder and a
complete description of participant characteristics would allow judgment of comparability across study samples (Gersten et al.,
2005). Incomplete demographic data had also interfered with evaluation of treatment effect moderators across participant char-
acteristics (Davis, Mason, Davis, Mason, & Crutchfield, 2016; Gevarter et al., 2016).
4.3.1. Implications
It is recommended that future researchers diversify the currently restricted representativeness of participant samples and include
more children with both ASD and intellectual disability. Future researchers should also provide complete participant demographic
information including IQ scores and measures of ASD symptomology. This effort to provide full participant description would assist
readers to make an informed judgment as to which specific children with ASD the researched intervention may be applicable.
4.4. Program features
A range of differences was present in the cognitive-behavioral intervention programs for children with ASD across the years.
Manualized multicomponent treatment programs emerged pre-2006 and have subsequently dominated the research following calls
for more manualized programs (Lord et al., 2005). These manualized programs were frequently replicated and often by the program
developers or their affiliates. While replication of any type is to be commended, replication by independent research groups would
enhance external validly and confidence in findings. Further, increasing numbers of studies were carried out in the United States since
2006, and this may limit the applicability of research results to other countries and cultures. Possibly the only cognitive-behavioral
program written in English and tested for both external validity and applicability in a non-English speaking location was the PEERS
program which was replicated once by an independent team of researchers (Schohl et al., 2014) and also in South Korea (Yoo et al.,
2014).
Another trend was the shortening of treatment duration and decreasing treatment hours. This was related to the decreasing
proportion of case studies that tended to last longer and use more treatment hours, possibly reflecting their exploratory nature, and
37
the increasing proportion of group studies, which tended to have more definite time frames and allocated hours. Treatment hour per
participant is probably a reasonable proxy of intervention cost. Although high treatment hours will render some programs un-
sustainable for community service providers, evaluation of optimum treatment duration was not conducted in any of the reviewed
reports. A reviewed intervention study investigated the issue of cost effectiveness by comparing different treatment administrator-to-
participant ratios (i.e., Lopata et al., 2015), and no significant difference was found in treatment effects.
Certain changes in program features over time have the potential to impact the generalization and maintenance of participant
outcomes. These include the decrease in use of school as a treatment setting, between-session practice, and involvement of others
(except parents) in treatment. The decreasing use of schools as treatment settings may be due to their dynamic nature, which is
difficult to control for experimental research (Stichter, Herzog, Owens, & Malugen, 2016). The reduction in between-session practice
is incongruent with the observation that home practice enhances effects of cognitive-behavioral therapies (Kazantzis,
Whittington, & Dattilio, 2010). The increasing dominance of psychologists as treatment administrators may likewise impact gen-
eralization and maintenance of treatment outcomes because unlike parents or teachers, psychologists do not have daily contact and
long-term relationships with the participants.
On the other hand, the increase in the conduct of interventions outside the traditional settings (i.e., clinic, schools, home) and
involvement of parents may facilitate the generalization or maintenance of participant skills. The increasing conduct of interventions
in non-traditional settings, where skills taught or problems addressed were directly relevant (e.g., Neufeld, Law, & Lucyshyn, 2014
conducted their intervention in shopping malls), may address the call for community application of research (Wood, McLeod,
Klebanoff, & Brookman-Frazee, 2015). Parents were frequently involved in the intervention trials and this was increasing. One re-
viewed supplementary analysis suggested that parent involvement is particularly helpful for both long-term maintenance and gen-
eralization of treatment effects (Mandelberg et al., 2014).
4.4.1. Implications
Future research should aim to extend external validity through replication of programs by independent researchers (Foxx, 1993)
and to extend applicability by testing locally verified programs across countries. It is also recommended that after the effectiveness of
an intervention program is established, optimum treatment hours should be investigated. Both treatment effect and treatment
duration of an intervention program would influence its cost effectiveness, which would in turn determines its feasibility in the
community.
Future researchers should develop specific program features with the potential to generalize and maintain participant outcomes
instead of relying on incidental address of these critical outcomes. Feasible strategies to improve generalization or maintenance could
include conducting interventions in community and school settings, delivering interventions through parents or teachers, and be-
tween-session practice. School is the natural social learning environment for children. This environment constantly provides op-
portunities to apply learned skills, thus promoting generalization (Schmidt & Stichter, 2012). There would appear to be a strong case
for further research on collaborative interventions between clinicians, parents, and school staff. The feasibility and benefits of col-
laboration between teachers and other professionals in the delivery of cognitive-behavioral interventions in schools to students with
ASD has been demonstrated (Lopata et al., 2012). However, researchers should also take note of the various potential difficulties of
conducting cognitive-behavioral interventions in school settings (Weeks, Hill, & Owen, 2016).
4.5. Evaluation of intervention outcomes
Increasing reliance on rating scales in the evaluation of participant outcomes was evident in the reviewed studies. Rating scales
are inherently subjective and may not always be valid or direct enough for monitoring progress (Riley-Tillman,
Kalberer, & Chafouleas, 2005). When rating scales were used with children with ASD, discrepancies have been found between parent-
rating and self-rating (Ooi et al., 2016). When used with a student without ASD, discrepancies have been reported between the
teacher-rating scale and participant self-rating scale (Weeks et al., 2016). Further, concerns regarding the construct validity, inter-
rater reliability between parent-rating and self-rating (Kaat & Lecavalier, 2015), and interpretation of self-rating (Mazefsky,
Kao, & Oswald, 2011) have been raised in studies investigating the use of rating measures in children with ASD.
Use of direct behavior observation was limited across all time periods. When specific skills are taught or problematic behaviors
are targeted, or when change is expected to impact on behavior, direct behavior observation would be an appropriate and valid
option for evaluating progress. Nevertheless, direct behavior observation may be more difficult and expensive (Riley-Tillman et al.,
2005), which may explain its limited use in the reviewed studies.
Data reported for other outcome evaluation elements including social validity, follow-up maintenance, and generalization were
also limited. These data are necessary for comprehensive evaluation of intervention outcomes. The importance of generalization and
maintenance of participant outcomes was often acknowledged (Neufeld et al., 2014; Reaven & Hepburn, 2003; Sze & Wood, 2007;
Van Hecke et al., 2015), but data were seldom reported. When reported, generalization data were measured by observers blind to
treatment condition and outside treatment sessions in less than half of the reporting studies (i.e., three out of eight studies). Three
supplementary analyses did provide data on long term maintenance of treatment effects from one to five years following treatment
(Mandelberg et al., 2014; Selles et al., 2015; White, Schry, Miyazaki, Ollendick, & Scahill, 2015).
Among the reviewed intervention studies, social validity was predominantly measured through consumer satisfaction, a sub-
jective measure. One supplementary analysis (van Steensel, Dirksen, & Bögels, 2014) provided investigation of intervention cost
effectiveness, offering a complementary objective measure of social validity.
38
4.5.1. Implications
A feasible approach that may meet the competing demands for precision in outcome measurement and careful allocation of
research resources would be to directly observe behavior to provide confirmatory evidence to support scores derived from rating
scales. Future researchers should include data on maintenance and generalization of treatment effects. Further, a range of more
objective measures to evaluate social validity should be employed.
4.6. Limitations
The current search was designed to identify all reports meeting the inclusion criterion of investigating cognitive-behavioral
interventions. Many reports did not identify the intervention as cognitive-behavioral and these reports were included because the
intervention was classified as cognitive-behavioral elsewhere, by either the report authors or by original program developers in the
case of replicated programs. These reports were missed in the first round key word search and were subsequently located through the
additional searches. It is possible that additional reports meeting the inclusion criterion were missed because the conducted searches
did not locate the specific report or review which classified them as cognitive-behavioral. Further; this review did not include any
reports written in languages other than English; and thus relevant research may have been overlooked.
The objective of this broad review is to present the trends observed in the research of cognitive-behavioral interventions for
children with ASD. The data collected are not intended for, and thus do not provide, comprehensive analysis of the details of the
reports or the quality of the research. The data do provide an overview of the nature of the research over time. This broad-brush
approach has the advantages of pinpointing major issues in research development that are of prime concern and suggesting possible
directions for future research.
5. Conclusion
The current trend analysis show that the number of experimental studies on cognitive-behavioral interventions for children with
ASD increased considerably during the last decade resulting from both new program trials and program replication by program
developers or their affiliates. However, the proportion of randomized, controlled trials did not increase as expected and sample sizes
of group studies remained modest at best. A major problem in the reporting of the research was incomplete participant description, in
particular measures of autistic symptomology and intelligence. There was also a notable lack of data to monitor the generalization
and maintenance of treatment effect. A range of recommendations has been offered subsequent to this trend analysis.
Conflicts of interest
The authors declared that they have no potential or competing conflicts of interest.
Ethical approval
This article does not contain any studies with human participants or animals performed by any of the authors.
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Cognitive Behavioral With Autism

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Research in Autism Spectrum Disorders 45 (2018) 27–41

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders

Cognitive-behavioral approaches for children with autism

2.1. Search and selection of studies

2.2. Data extraction

2.3. Data analysis

3.1. Research design

3.3. Participant demographic characteristics

3.4. Intervention program features

Participant Pre-2006 N = 92 2006 to 2010 N = 459 2011 to 2015 N = 1139

Pre-2006 2006 to 2010 2011 to 2015 2013 to 2015

Targeted participant problems

3.5. Outcome measures

Pre-2006 2006–2010 2011–2015

4.1. Research design and sample sizes

Manualized intervention 43% (3) 91% (21) 82% (40)

designs (de la Cruz et al., 2006).

Pre-2006 2006 to 2010 2011 to 2015 2013 to 2015

4.2. Primary skills and problems addressed as intervention aims

of cognition should be equally important for children with ASD.

4.3. Nature and description of participants

4.4. Program features

4.5. Evaluation of intervention outcomes

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