Review Article

Cognitive Behavioral Therapy for Children With Autism:

Review and Considerations for Future Research
John T. Danial, MA, Jeffrey J. Wood, PhD

ABSTRACT: Objective: Cognitive behavioral therapy (CBT) is now commonly used for high-functioning chil-
dren with an autism spectrum disorder. The objective of this article was to describe the methods and results
of cognitive behavioral interventions for children with autism. Method: This article reviews CBT programs
targeting anxiety, disruptive behavior, and core autism symptoms for children with autism. Results: There is
emerging evidence suggesting that CBT is possibly efficacious for anxiety and autism symptoms, but meth-
odological weaknesses must be addressed before clear conclusions can be drawn. Conclusion: More re-
search needs to be conducted to examine the effectiveness of CBT for children with autism. Specifically,
future research should use more stringent methodology and assess the effectiveness of specific cognitive
strategies and autism-related adaptations.
(J Dev Behav Pediatr 34:702–715, 2013) Index terms: cognitive behavior therapy, autism treatment, anxiety, disruptive behavior, social functioning.

C ognitive behavioral therapy (CBT) and other talk-

based therapies are increasingly used for children with an
autism spectrum disorder (ASD) who are able to engage in
verbal communication.1 Within this “high-functioning”
population of children with ASD, talk-based therapies like
CBT have been used to address an array of co-occurring
symptoms, such as anxiety, aggression, and social func-
tioning deficits. Although some research has indicated
CBT as a promising treatment for individuals with ASD,2–4
further evaluation of the overall body of evidence is nec-
essary because of the preliminary nature of the extant
studies, which have generally been conducted with
modestly sized samples of children with ASD.
CBT treatments for individuals with ASD have focused
on both the core aspects of ASD (e.g., social communi-
cation difficulties) as well as co-occurring emotional and
behavioral problems like anxiety and aggression. Comor-
bid disorders are found at higher rates among youth with
ASD than in typically developing youth or youth with
other serious behavioral conditions.5–8 It is also clear that
most individuals with ASD have substantially impaired
functioning in daily life (e.g., in social interactions, in
school, and in self-care skills9,10) and a range of manifest
symptoms related to communication deficits, attentional
control, and emotion regulation. CBT has recently been
offered as a potential avenue of treatment to address these
From the Psychological Studies in Education, Department of Education, Uni-
versity of California, Los Angeles, CA.
Received March 2012; accepted June 2013.
Some of this project was funded by the Graduate Summer Research Mentorship
program at University of California, Los Angeles.
Disclosure: The authors declare no conflict of interest.
Address for reprints: John T. Danial, MA, Moore Hall 3132A, 405 Hilgard Avenue,
Los Angeles, CA 90095-1521; e-mail: jdanial@ucla.edu.
Copyright Ó 2013 Lippincott Williams & Wilkins
symptom areas and can potentially provide lasting bene-
fits for those with ASD. However, it is important to
identify the quality of current CBT protocols and specifi-
cally investigate what age groups, functioning levels, and
symptom areas are most effectively addressed by CBT.
The goal of this review was to provide a summary of
extant CBT research targeting the symptom areas of
anxiety, disruptive behaviors, and core autism symptoms
(such as social communication deficits) for children and
adolescents with ASD.
COGNITIVE BEHAVIORAL THERAPY
According to Dobson and Dozois,11 cognitive behav-
ioral therapies fundamentally consist of 3 primary
assumptions. First, cognitive activity affects behavior;
second, cognitive activity may be monitored and altered;
finally, behavioral change can subsequently be affected by
cognitive changes. Cognitive behavioral therapy (CBT)
uses both cognitive and associative methods as comple-
mentary approaches.12 For example, cognitive restruc-
turing, one aspect of CBT, aims to modify current
thoughts about an aversive stimulus to create retrievable
and adaptive replacement thoughts. As the individual is
successfully able to face increasingly difficult situations,
newly rehearsed positive memories developed during
treatment become more readily retrievable than previous
memories of ineffective coping skills, negatively biased
perceptions, and maladaptive automatic emotional and
behavioral responses (e.g., anger, aggression, or avoid-
ance).13 In this way, cognitive change is integral in pro-
moting behavioral change and vice versa.
Most studies of CBT for youth with autism spectrum
disorder (ASD) have modified programs developed for
typically developing youth with anxiety or disruptive
behavior as a foundation for their ASD-specific programs.
Various adaptations to the original protocols have been

702 | www.jdbp.org Journal of Developmental & Behavioral Pediatrics

designed to meet the needs of youth with ASD in these
CBT programs. For example, Wood et al3 noted that re-
gardless of symptom focus (e.g., anxiety, aggression),
CBT programs for children with ASD should also focus
on social skills deficits, encourage the development
of self-care skills to combat adaptive deficits, and capi-
talize on children’s circumscribed interests as a means
of therapy engagement. These types of adaptations,
although not investigated empirically, seem to make CBT
programs more appropriate and accessible for youth
with ASD. Many of the CBT studies reviewed below
incorporated aspects of these and related adaptations
into their treatment protocols.
In line with the definition put forth by Dobson and
Dozois,11 we only included studies that explicitly tar-
geted cognitive change as a means of producing behav-
ioral modifications. In our review of CBT intervention
programs for children with ASD, we intentionally
excluded programs designated as “social skills training,”
and programs that were primarily based on the princi-
ples of applied behavior analysis, which have been
reviewed comprehensively elsewhere14,15 and do not
emphasize intervention on conscious cognition (e.g.,
expectations, attitudes, attributions). We reviewed the
extant CBT literature for children and adolescents with
ASD based on computer database searches, published
reviews, and literature trails. Studies were included in
our review if they included children or adolescents
(ages, 5–18 years), incorporated cognitive therapy tech-
niques as a primary treatment strategy, and used a causal
research design (i.e., randomized trials, group compari-
son studies, multiple baseline designs). Due to the talk-
based nature of most CBT protocols, all participants
were considered “high-functioning” with IQs in the
normal range. IQ-based inclusion criteria ranged from
informal reports from the children’s health pro-
fessionals16 to standardized assessments.17 Although we
excluded some case studies from our review, we made
an effort to include representative group design studies,
single-case experimental studies, and open trials for 3
areas of symptomatology: anxiety, disruptive behavior,
and core autism symptom domains, such as social
interaction deficits.
Cognitive Behavioral Therapy for Anxiety
Clinical anxiety has been found to be highly prevalent
among those with a diagnosis of an ASD.5 For children
with ASD, a clinically significant level of anxiety likely
exacerbates the child’s social and communication deficits
as well as his or her proclivity to engage in restricted and
repetitive behavior.8,18,19 Coupled with the core deficits
of autism, the behavioral rigidity and excessive worry of-
ten associated with anxiety can greatly affect a child’s life
at school, home, and in the community.
The anxiety-focused studies presented here were
chosen if CBT strategies were implemented, participants
were youth with ASD, and if a diagnostic standardized
measure of anxiety (e.g., Anxiety Disorders Interview
Vol. 34, No. 9, November/December 2013
Schedule [ADIS20]) was incorporated as an outcome
measure. Based on diagnostic measures, the anxiety
disorders included here targeted Social Phobia (SoP),
Generalized Anxiety Disorder (GAD), Separation Anxiety
Disorder (SAD), Obsessive-compulsive Disorder (OCD),
school anxiety, Specific Phobias (SP), and Panic Disorder
(PD). The anxiety-focused CBT studies presented here
include children aged 7 to 17 years old.
Cognitive behavioral therapy has received empirical
support in otherwise typically developing youth with
anxiety disorders,21 with promising evidence emerging
for youth with ASD.22 Elevated anxiety promotes avoid-
ance of feared situations and may include the presence
of intrusive and distressing thoughts.23,24 Depending on
the form of anxiety, these symptoms manifest in various
ways. For example, a child with separation anxiety may
cling to a caregiver or cry uncontrollably when asked to
attend school or extracurricular activities, in an effort to
avoid separation from caregivers; whereas a child with
high-generalized anxiety may experience excessive
worry about everyday issues such as school perfor-
mance. In both cases, the anxiety is typically linked to
irrational feared consequences that are unlikely to occur.
Cognitive behavioral therapy programs targeting
anxiety aim to specifically identify the nature of the
child’s fearful thoughts (e.g., that they will be kidnapped
when away from parents), encourage the development
of realistic adaptive beliefs that challenge irrational fears
(e.g., that the probability of the fear is in fact very low),
and gradually face feared situations with the new confi-
dence arising from the competing adaptive beliefs that
have been discussed and rehearsed. Although most CBT
programs for ASD include these general principles, spe-
cific protocols vary considerably both in the imple-
mentation of these principles and in the adaptations
incorporated for children with autism.
In an early study on CBT for anxiety in children with
ASD, Sofronoff et al25 randomly assigned participants to
1 of 2 CBT treatment groups (1 with a parent component
and 1 without) or a wait-list control group. Subjects aged
10 to 12 years (N 5 71) participated in 6 two-hour ses-
sions presented in small groups of 3 children and 2
therapists. Key treatment components consisted of
emotion recognition, ratings of anxiety, presentation of
coping strategies, testing of fear-based hypotheses and
expectations, emotion regulation strategies, and cogni-
tive restructuring. Adaptations for ASD included the use
of visual stimuli (e.g., emotion “thermometers”), in-
corporating motivating metaphors, and the use of Social
Stories26 to target social deficits common to ASD. Both
treatment groups experienced significant decreases in
anxiety symptoms according to parent reports, with
some additional benefits reported for the combined child
and parent treatment group. Also, participants in the
intervention group generated more adaptive coping
strategies in the posttreatment assessment. One limita-
tion of this study was that participants had not received
a formal diagnosis of anxiety before treatment and
© 2013 Lippincott Williams & Wilkins 703
therefore it was not possible to test for remission of an
anxiety diagnosis at posttreatment. Chalfant et al16
implemented a group CBT program with random assign-
ment (compared with a waitlist control) presented to
participants with a mean age of 10 years (N 5 47).
Treatment was delivered in groups of 6 to 8 participants
over 12 weeks. Key components of treatment included
recognizing anxious thoughts and somatic responses to
anxiety, cognitive restructuring, coping self-talk, and ex-
posure to feared stimuli. Chalfant et al16 included a struc-
tured diagnostic interview, the ADIS (child/parent), self-
report, parent report, and teacher report of anxiety as
outcome measures and found that all indicated a decrease
in anxiety for those in CBT treatment relative to those on
the waitlist. However, the diagnostic interviews were
administered by the child’s therapist rather than
a diagnostician blinded to the treatment condition, thus
adding some ambiguity to outcomes assessment. Also, in
both of these studies, treatment fidelity was not assessed.
Reaven et al27 conducted a similar study in which
participants (N 5 33) were assigned (nonrandomly) to
a group CBT treatment or a waitlist condition. Partic-
ipants were grouped based on their age and underwent
12 weekly sessions of 90 minutes. Each session included
a large group time, separate group meetings for parents
and children, and parent-child dyads. For children, the
major concepts covered were an introduction to anxiety
symptoms and the individual manifestations of these
symptoms for each child, as well as generating “tools”
and coping strategies (i.e., relaxation, deep breathing,
and positive coping statements). A hierarchy of feared
situations was developed and children were gradually
exposed to anxiety-evoking scenarios. Parent sessions
primarily involved psychoeducation, awareness of their
child’s anxiety symptoms, instruction of how to imple-
ment graduated exposure assignments, and development
of adaptive parenting strategies. Results indicated sig-
nificant decreases in anxiety in the CBT group based on
parent report of symptoms; however, possibly because
of floor effects of the original assessment, no significant
decreases were found for child-reported symptoms. In
a more recent study, Reaven et al28 assessed the efficacy
of a CBT program in treating the anxiety adolescents
(N 5 50), aged 13 to 18 years. Therapy was administered
in large groups (with teens and parents), in teen groups
and parent groups, and in parent/teen dyads. Key CBT
strategies included graded exposure, somatic manage-
ment, emotion regulation strategies, and use of cognitive
self-control. ASD-specific adaptations included a social
skills module, parent/teen dyads, the use of handheld
devices (e.g., iPod touch) to help participants monitor
anxiety and guide them through coping strategies, an
increased number of exposures, and extended psycho-
education for parents. Results were assessed by clinician
ratings of parent reports based on clinical global severity
ratings, clinical improvement ratings for primary di-
agnoses, and parent reports. The overall severity scores
of participants were significantly decreased at posttreat-
704 CBT for Children with Autism
ment, with 46% of participants showing positive treat-
ment response for their primary diagnoses, 33% having
“some improvement,” and 21% showing no changes.
Significant decreases in anxiety were found based on
both parent and teen reports. Several limitations make it
difficult to draw absolute conclusions from this study.
There was no control group, treatment fidelity was not
assessed, and raters knew that the participants had
completed treatment, which leaves open the possibility
of rater bias.
Another study evaluated the effectiveness of a modi-
fied version of the Coping Cat program (an established
CBT program for typically developing youth) in treating
the anxiety of children and adolescents (N 5 22; ages
8–14 years) with autism.29 Participants were randomly
assigned to treatment (16 weekly sessions) or a waitlist
control group (16 weeks). The Coping Cat manual
focused on affective education, recognizing physical
responses to anxiety, cognitive restructuring, coping
strategies, self-evaluation, and self-reinforcement. Adap-
tations included a review of content and assigned
homework with parents immediately after child sessions,
increased length of session to 60 to 90 minutes, visual
measures (e.g., schedules and visual scale of anxiety),
incorporation of participants’ restricted interests, sen-
sory breaks, individualized emphasis of techniques, and
individualized rewards. At posttreatment, 58% (7 of 12)
of CBT participants no longer met criteria for their pri-
mary anxiety disorder (measured by the ADIS), whereas
100% (10 of 10) of waitlist participants still met criteria.
The researchers also found a significant main effect for
time and a significant group 3 time interaction on
a secondary anxiety measure (Spence Childhood Anxiety
Scale30), but only for parent reports. Limitations to this
study include the small sample size and reliance on
parent reports. Another major limitation is that the pri-
mary author of the study delivered all the treatment so
the level of expertise and experience needed to deliver
this treatment remains unclear.
Although many studies implicitly included social skill
development throughout treatment, White et al31 ex-
plicitly targeted both anxiety and social functioning in
a cognitive-behavioral intervention for youth with an
ASD and high anxiety. Participants (n 5 4) aged 12 to 17
years received a novel treatment, which incorporated
techniques for social skill development (e.g., modeling,
feedback, social reinforcement) with evidence-based
techniques for anxiety (e.g., exposure, emotion educa-
tion, cognitive restructuring). Treatment included 12 to
13 individual therapy sessions, 5 group therapy sessions
to practice social skills, and concurrent parent education
at the end of each individual session. Parents were asked
to encourage their child to engage in exposure tasks at
home to promote generalization. Primary outcomes
were based on comparing baseline scores of anxiety to
posttreatment scores. Results indicated that 3 of 4 par-
ticipants exhibited decreased anxiety on targeted anxi-
ety symptoms, although all 4 participants achieved social
Journal of Developmental & Behavioral Pediatrics
improvements indicated by parent reports. Although the
primary outcome measures indicated relative improve-
ment, other diagnostic instruments (ADIS-C/P; Multidi-
mensional Anxiety Scale for Children32) yielded mixed
results. The limited sample size, lack of a control con-
dition, and mixed results of this study were clarified in
a more recent study, in which White et al33 implemented
a randomized controlled trial with 30 participants (ages,
12–17 years) to investigate this intervention. Participants
were randomly assigned to either the treatment condi-
tion or a waitlist control group. Using the same general
treatment protocol outlined above, participants received
individual therapy (up to 13 sessions), group therapy to
practice social skills (7 sessions), and concurrent parent
education. For the individual sessions, therapists selected
modules from the manual based on the youth’s most
significant anxiety and social impairment issues. All
participants received the same group therapy sessions
that also included a typically developing peer volunteer
to model appropriate social behaviors. Results indicated
positive feasibility outcomes. Although there was
a significant change based on between-group analyses of
social skills scores posttreatment, there was no corre-
sponding treatment effect for anxiety scores. Therefore,
the efficacy of this particular intervention for anxiety in
ASD remains undetermined.
In another recent group therapy-based CBT program
for anxiety in children with ASD, Sung et al34 compared
CBT to a social recreation program (N 5 70). With 36
participants in the CBT condition and 34 in the social
recreation condition, each condition was additionally
split into an older group (ages, 13–16 years) and
a younger group (ages, 9–12 years). Participants were
placed in groups of 3 to 4 based on their age group with
2 therapists in each group. The CBT protocol included
emotion recognition, anxiety management techniques
(including an acronym for the overall coping plan), and
hierarchical exposure. Adaptations for ASD included
added structure, visual strategies (e.g., cue cards with
written treatment material), role-playing, and use of So-
cial Stories. Both the CBT and the social recreation
groups exhibited significantly decreased anxiety after
treatment, but there was no difference between groups
for either age group. Although the social recreation
program did not explicitly include cognitive compo-
nents, it is possible that overlapping aspects of treatment
produced decreased anxiety (e.g., structured and con-
sistent sessions, visual stimuli, social exposure). It is
commonly found that the comparison of 2 active treat-
ments leads to a reduced effect size in comparison with
a treatment versus waitlist comparison.35,36
One CBT treatment protocol (Behavioral Inter-
ventions for Anxiety in Children with Autism; BIACA)
has been examined in 3 separate randomized controlled
trials.2,37,38 In the first,2 40 children were randomly
assigned to either immediate CBT treatment or a waitlist
condition. In the CBT manual used in this study, children
were taught to identify feelings of anxiety and generate
Vol. 34, No. 9, November/December 2013
cognitive coping strategies (e.g., focusing on the low
probability of their fears being realized and learning to
coach themselves into a more courageous mindset).
Children were involved in the development of motivat-
ing metaphors based on their circumscribed interests
designed to encourage their participation in treatment,
particularly exposure therapy. Visual stimuli based on
these circumscribed interests (e.g., hand-drawn cartoons
of the child’s favorite video game character engaging
in targeted courageous behavior, using “thought
bubbles” to model appropriate coping thoughts) were
incorporated throughout treatment to increase engage-
ment and promote the child’s understanding. Children
then faced increasingly difficult feared situations to
practice these new coping strategies. Throughout treat-
ment, attention was given to social deficits and in-
dependent living skills that may have undermined
successful functioning in anxiety-provoking situations if
left unaddressed. School collaboration was also empha-
sized through teacher consultations and involvement in
helping children embark on school-specific goals (e.g.,
socializing with peers). Parents received concurrent
sessions in which they were taught strategies to help
their child deal with anxiety. Parents were encouraged
to use planned ignoring of negative and avoidant
behaviors, provide choices to give their child a sense of
control, and offer praise to the child for doing assigned
tasks and facing feared situations. Children were
assigned weekly homework to promote practicing of
new strategies in the home and community settings. This
study yielded medium to large CBT versus waitlist effect
sizes at the posttreatment time point, with more than
half of the children in CBT no longer meeting criteria for
an anxiety disorder following treatment (participants
averaged approximately 4 anxiety diagnoses at intake).
Additionally, parents of children in CBT reported signif-
icantly decreased anxiety symptoms. These results were
similar to the effects of treatment found in studies of CBT
for typically developing children with anxiety dis-
orders.21,39–41 Similar to Reaven et al,27 there were no
significant decreases in child-reported symptoms, but
this was possibly because of a floor effect (low initial
child-reported anxiety symptoms on an instrument not
validated for use in children with ASD).
A separate investigation of the BIACA treatment
manual was also implemented by an independent re-
search group.37 Forty-five children, aged 7 to 11 years,
were randomized to either the BIACA CBT program or
treatment as usual (TAU). As noted above, BIACA treat-
ment consisted of sixteen 60- to 90-minute weekly ses-
sions, with identical session content. Results indicated
significant group differences on the primary measures of
anxiety with the CBT group showing a greater decrease
in anxiety symptoms after treatment.
In a recently published study, Fujii et al38 also exam-
ined the role of the same individual CBT protocol in
treating anxiety symptoms of children with ASD. This
study additionally incorporated school collaboration
© 2013 Lippincott Williams & Wilkins 705
(along with parent training) as a means of transferring
skills learned in therapy to real-world contexts, leading
to an extension of treatment length to 32 sessions. Six-
teen participants, ages 7 to 11 years, were randomly
assigned to immediate CBT treatment with BIACA (CBT)
for 32 weeks or TAU for 16 weeks. All participants met
criteria for moderate to severe anxiety as measured by
the ADIS. The first 16 CBT sessions focused on reducing
anxiety and the following 16 sessions focused on rela-
tionships and skills needed to face anxiety-evoking sit-
uations successfully. Participants received social
coaching by parents, therapists, and school providers.
Feedback was provided immediately before entering
a social interaction at home, school, or in the commu-
nity, and the discussion was based on thoughts and
feelings that were previously discussed during the initial
16 sessions. Some sessions involving social coaching
took place on playgrounds, at schools, or in other places
where children were present. Teachers and one-on-one
aides were given consultation to facilitate the extensions
of treatment gains into the school setting. Therapists met
with teachers a minimum of 2 times and additional
consultations were offered if requested. Four partic-
ipants dropped out of treatment due to many missed
sessions, leaving 12 participants included in the analysis.
Results indicated that the CBT participants benefited
from treatment in comparison with TAU. Specifically, 5
of the 7 CBT participants no longer met diagnostic cri-
teria for their primary anxiety diagnosis at posttreatment,
whereas all 5 TAU participants still met diagnostic cri-
teria for their primary anxiety disorders. The strengths of
this study include the focus on school collaboration and
in vivo social skill training as a means of promoting be-
havioral change, a key expansion of the CBT model that
incorporates principles of autism treatment developed in
the applied behavior analysis literature.42 Limitations of
this study include the small sample size and the dispro-
portionate number of TAU sessions (16 sessions) com-
pared with IT sessions (32 sessions).
All 11 studies included here included participants with
GAD and SoP. Nine of the studies included participants
with SAD2,16,25,27–29,34,37,38; 7 included participants with
OCD2,25,31,33,34,37,38; 5 had participants with
PD16,25,27,28,34; 4 included participants with SP16,31,33,34,38;
and 2 included children with school-related anxieties.27,28
Five studies reported outcomes specifically for GAD,
with 4 of them indicating positive treatment out-
comes25,27,28,34 and 1 indicating mixed results.31 Five
studies reported outcomes specifically for SoP, with 3 of
them indicating positive outcomes,25,27,28 1 indicating
mixed results,31 and 1 indicating no change.34 Four
studies reported outcomes specifically for SAD, with 3
indicating positive treatment outcomes25,27,28 and 1 in-
dicating no change.34 Three studies reported outcomes
specifically for PD, with 2 indicating positive out-
comes25,27 and 1 indicating no change.34 Three studies
reported outcomes specifically for OCD with 2 in-
dicating positive outcomes25,31 and 1 indicating no
706 CBT for Children with Autism
change.34 Other studies reported results based on par-
ticipants’ primary diagnoses without distinguishing out-
comes based on specific diagnoses.2,16,29,33,37
Although each of these studies included at least some
components of CBT, specific methods varied from treat-
ment to treatment. Group therapy format was used in the
majority of these studies. This format may normalize the
experience of anxiety for participants by introducing
them to same-age peers who face similar difficulties. Ad-
ditionally, group therapy sometimes requires fewer
resources than individual sessions. However, individual
CBT provides an opportunity to address specific anxiety
and other symptoms unique to each child. In a recent
study, an individualized, modular form of CBT has been
found to outperform an invariant, structured form of CBT
in typically developing children with emotional prob-
lems.43 A clinical comparison between group and in-
dividual CBT will be a valuable contribution to the field
and could help determine the level of complexity needed
in achieving decreases in anxiety through CBT.
These studies also varied widely in regards to the actual
CBT components that were used. One key variation was
differences in the utilization of exposure therapy. In
a study of CBT for typically developing youth with anxi-
ety, Kendall et al40 found that the cognitive portion of
therapy (i.e., cognitive restructuring, emotion recogni-
tion, generating coping strategies) did not yield a signifi-
cant decrease in anxiety symptoms without
complementary in vivo exposures to provide opportuni-
ties to test and practice the new cognitive strategies in
actual anxiety-provoking situations. The extent to which
CBT programs for children with ASD incorporate expo-
sures has varied widely. For example, BIACA2 entails daily
exposures through homework assignments throughout
most of the treatment, whereas the Sofronoff et al25 group
treatment did not directly use in vivo exposures. Another
difference between these studies was the extent to which
parents were included in treatment. Although many
studies included parent participation as a component of
treatment, Sofronoff et al25 directly compared the effec-
tiveness of CBT with and without a parent component.
They found that including parent training concurrently
with child-focused CBT resulted in greater decreases in
anxiety than did child-focused CBT alone. This parent
component may be especially important for children with
ASD. Puleo and Kendall44 investigated the presence of
autism spectrum symptoms among a sample of typically
developing youth with anxiety (N 5 50) that had been
previously randomly assigned to receive either individual-
or family-based CBT. The authors found that the presence
of moderate levels of autism symptoms (based on parent-
report) was predictive of decreased treatment effects
for children who received individual CBT but not for
those who received family CBT. A separate analysis
indicated that children with moderate autism symptoms
who received individual CBT were less involved in treat-
ment sessions than those who received family CBT. Thus,
parental involvement in treatment sessions may serve to
Journal of Developmental & Behavioral Pediatrics
facilitate the child’s involvement in therapy when ASD is
part of the clinical profile. Also, it was found that children
in the family CBT condition (regardless of autism symp-
toms) completed more at-home exposure tasks. These
studies indicate that there is an added benefit of including
parents in CBT programs for children with autism.
In summary, CBT may be a useful method of treat-
ment for anxiety in high-functioning children and ado-
lescents with ASD (Table 1). None of the protocols
described here meet American Psychological Association
(APA) Division 12 criteria for being “well-established”
treatments.45 At this point, only 1 of these CBT protocols
for anxiety (BIACA) meets APA Division 12 criteria as an
efficacious treatment45,46 because it was investigated in
3 separate randomized controlled trials,2,37,38 was stud-
ied by 2 independent research groups, included in-
dependent evaluators, established an anxiety diagnosis at
baseline, and used a “treatment as usual” control group.
Although this type of control is not superior to an active
treatment control, it provides a more adequate compar-
ison than a waitlist control. Future research should in-
clude active treatment control groups, large sample
sizes, and multimodal outcome measures.
Cognitive Behavioral Therapy for Disruptive
Behaviors
Cognitive behavioral therapy has been used as
a method of treatment for behavioral issues such as ag-
gression and other externalizing disorders among youth
with ASD in a small number of studies. Some of the
components of CBT are similar to those used in treating
anxiety (i.e., cognitive restructuring, emotion recogni-
tion, generating coping plans). We included studies that
involved cognitive components and were designed for
children and adolescents with autism. The ages of par-
ticipants ranged from 5 to 17 years.
Sofronoff et al47 examined the effectiveness of a CBT
program targeting excessive anger with Asperger syn-
drome. Participants aged 10 to 14 years (N 5 45) were
randomly assigned to a 6-session CBT treatment or
a waitlist condition. Treatment was delivered in pairs
(with 2 therapists assigned to each pair) and comprised
of emotion recognition training, generating coping
strategies, and assigned homework. To address theory
of mind deficits, participants were encouraged to be
flexible in their thinking and seek clarification of others’
intentions (e.g., ask if someone was “just joking”). A
“toolbox” was also developed for each child to provide
participants with strategies to “fix” problems, such as
anger, anxiety, and sadness. This program also in-
corporated the use of comic strips, social stories, and
role-play to provide opportunities for participants to
generate appropriate coping strategies in hypothetical
situations. Parents attended concurrent group sessions in
which a therapist covered information from their child-
ren’s sessions and encouraged parents to help their child
with home-based assignments. This study used a struc-
tured test of children’s ability to generate coping strate-
Vol. 34, No. 9, November/December 2013
gies, parent report of anger and confidence in managing
anger, and the novel incorporation of qualitative data to
assess the child’s ability to generate appropriate coping
strategies. Parents assigned to the CBT program reported
significant decreases in their children’s anger outbursts
as well as increase in their children’s ability to generate
appropriate coping strategies. Some limitations of this
study include use of parent reports as a primary outcome
(with the notable exception of qualitative interviews
with teachers) and no specific diagnostic criteria for
admission into the program. Nonetheless, Sofronoff et al
incorporated a number of different CBT components in
their treatment,47 and the initial results are impressive
considering that the treatment was only 6 sessions.
Mindfulness training is another cognitively-oriented
treatment for children with ASD and externalizing dis-
orders. However, none have been studied using con-
trolled trial methods. Singh et al48 conducted an analysis
of mindfulness training on 3 adolescents who were di-
agnosed with ASD and exhibited high levels of aggres-
sion (e.g., hitting, kicking, and biting). Parents were first
trained on how to implement the technique. Parents
then taught their children mindfulness strategies, which
encouraged participants to focus their negative emotions
(e.g., anger) on a neutral object (the soles of their feet).
Training occurred for 5 consecutive days and was de-
livered by the parent. Then participants were instructed
to use the technique at least twice a day until the
adolescents demonstrated effective use of the strategy
for 4 consecutive weeks. Results indicated markedly
decreased incidents of aggressive behaviors as reported
by parents and siblings. These decreases were main-
tained over the course of 3 years. The main limitation of
this study is its small sample size and reliance on family-
report of symptoms rather than direct observations.
Nonetheless, mindful awareness strategies are worthy of
further study for promoting emotion regulation skills in
individuals with ASD.
In summary, the role of CBT in the treatment of
externalizing behaviors among individuals with ASD is
still unclear (Table 2). The data remains limited with very
few studies available at present. More research needs to
be conducted to determine the efficacy of such
approaches among individuals with autism. The few
extant studies are preliminary, with limited sample sizes,
reliance on parent-report, and other methodological
weaknesses.
Cognitive Behavioral Therapy for Core Autism
Symptoms
Autism is defined by marked impairments in the social
and communication domains as well as a tendency to
engage in repetitive behaviors. Joint attention deficits,
lack of eye contact, and perseveration on preferred
topics are common symptoms in ASDs. It is clear that
these types of deficits, along with lowered social moti-
vation, make it difficult for individuals with autism to
develop meaningful, reciprocal social relationships. As
© 2013 Lippincott Williams & Wilkins 707
Table 1. Studies of Cognitive Behavioral Therapy for Youth with Autism and Concurrent Anxiety
Study Participants Study Type Method Outcomes
Chalfant et al16 N 5 47 Randomized controlled 12 Sessions Six of 9 tests of posttreatment group
trial (wait-list control) differences were significant
8–13 yr old Group CBT
Parent and child groups
Fujii et al38 N 5 16 Group comparison 32 sessions Two of 2 tests of posttreatment group
differences were significant
7–11 yr old Individual CBT 1 school
component
McNally Keehn N 5 22 Randomized controlled 16 sessions Six of 9 tests of posttreatment group
et al29 trial (waitlist control) differences were significant
8–14 yr old Individual CBT
Reaven et al27 N 5 33 Group Comparison (no 12 sessions Two of 4 tests of posttreatment group
random assignment) differences were significant
8–14 yr old Group CBT
Parent and child groups
Reaven et al28 N 5 50 Group Comparison 12 wk Seven of 11 tests of posttreatment group
(random assignment) differences were significant
7–14 yr old Group CBT
Combined child 1 parent
group
Sofronoff et al25 N 5 71 Randomized controlled 6 sessions Seven of 7 tests of posttreatment group
trial (wait-list control) differences were significant
10–12 yr old Three groups (child, child Both treatment groups better than waitlist;
and parent, waitlist) combined group with greatest
improvements
Storch et al37 N 5 45 Randomized controlled 16 sessions Eight of 12 tests of posttreatment group
trial (TAU control) differences were significant
7–11 yr old Child, parent, and
combined portions of
each session
Sung et al34 N 5 70 Group Comparison 16 sessions No tests of posttreatment group differences
(random assignment) were significant
9–16 yr old Group CBT vs social
recreation group
White et al31 N54 Open trial 18 sessions Three of 4 participants no longer met
criteria for anxiety following treatment
12–17 yr old CBT 1 social skills
Individual therapy, parent
education, and group
therapy
White et al33 N 5 30 Randomized controlled 20 sessions Zero of 3 tests of anxiety-related
trial (waitlist control) posttreatment group differences were
significant
12–17 yr old CBT 1 social skills
Individual therapy, parent
education, and group
therapy
Wood et al2 N 5 40 Randomized controlled 16 sessions Four of 5 tests of posttreatment group
trial (wait-list control) differences were significant
7–11 yr old Family CBT
CBT, cognitive behavioral therapy; TAU, treatment as usual.

708 CBT for Children with Autism Journal of Developmental & Behavioral Pediatrics
Table 2. Studies of Cognitive Behavioral Therapy for Youth with Autism and Disruptive Behaviors
Study Participants Study Type
Singh et al48 N53 Open trial
14–17 yr old
Clinical diagnosis of ASD
High levels of aggression
reported
Sofronoff et al47 N 5 45 Randomized controlled
trial (wait-list control)
10–14 yr old
Diagnosis of ASD
High levels of anger
reported
CBT, cognitive behavioral therapy; ASD, autism spectrum disorder.
such, many autism treatment programs have focused on
teaching individuals with ASD social skills in an effort to
promote the development of social relationships and
improved adaptation in school and home settings.
Cognitive behavioral therapy programs targeting
social responsiveness, a core autism deficit, aim to
help individuals acquire cognitively mediated abilities
that may promote successful social interactions (e.g.,
perspective-taking). By encouraging understanding of
others’ thoughts, goals, and intentions, for example,
participants may develop an improved ability to act in
a reciprocal manner with others. The studies included
here explicitly targeted at least 1 core autism symptom
(i.e., social deficits, communication deficits, or repetitive
behaviors), incorporated CBT strategies, included youth
with ASD, and measured treatment gains by direct
observations or other standardized procedures designed
to measure social skill or social responsiveness. Partic-
ipants ranged from 6 to 17 years of age.
Bauminger17,49,50 implemented a series of CBT-based
social interventions developed specifically to target core
social deficits common to autism. A key component of
each of these 3 treatment studies was the usage of
observational measures of treatment effects; however, it
should be noted that these studies were open trials with-
out a control group, and as with most of the other studies
of CBT interventions for core ASD symptoms, evidence-
based measures of core autism symptoms (e.g., the Autism
Diagnostic Observation Schedule) were not included.
Bauminger17 conducted a 7-month intervention with
15 children with autism, aged 8 to 17 years. Participants’
teachers delivered treatment for 3 hours every week in
the school setting. Teachers, peers, and parents were all
included in the intervention. Participants formulated
concepts of friendship, such as what a friend is, why and
how to listen to a friend, and ways friends are alike and
different. Affective education was also a key component
Vol. 34, No. 9, November/December 2013
Method Outcomes
Parent training Decreases in occurrences of
aggressive behavior for all 3
participants
5 training sessions
(conducted by
mothers)
Self-practice twice a day
6 sessions Five of 5 tests of posttreatment group
differences were significant
Child and parent group
of treatment, with participants learning how to identify
emotions in themselves and in others during social sit-
uations. This approach was used as a means of increasing
theory-of-mind skills by improving the ability to recog-
nize the emotions of others. Finally, children were taught
strategies for interpersonal problem solving, including
learning a number of social goals (i.e., initiating a con-
versation, comforting a friend, sharing experiences), and
reading vignettes for each goal to practice strategies to
successfully achieve these goals. The method is unique
in that it incorporated an ecologically valid approach by
incorporating teachers, peers, and parents in the treat-
ment. Teachers were responsible for delivering the ac-
tual instruction, choosing and supporting assigned peers,
and informing families about which targeted skills would
be practiced for the week. Participants met with
assigned (typically developing) peers twice a week to go
through each of the 13 lessons. Every week, participants
were encouraged to practice previously learned skills
with the peer and the target skill for the week. Results
indicated an increase in children’s observed prosocial
behaviors during recess/free-play, especially speech
expressing interest in a peer and increased eye contact.
Bauminger49 replicated these findings among 19 pre-
adolescent children with ASD. This study expanded on
previous findings by using an independent teacher for
ratings of improvement, using a long-term follow-up
(4 months), and testing for changes in children’s self-
reported loneliness and self-perceptions across 6 domains:
social acceptance, academic competence, athletic com-
petence, behavior conduct, physical appearance, and
general self-worth. The study found similar results, with
observed responding and initiating behaviors being the
primary improved social skills. In addition to these find-
ings, repetitive behaviors decreased, and children
exhibited improved social problem-solving abilities. These
results were generally maintained at a 4-month follow-up.
© 2013 Lippincott Williams & Wilkins 709
Table 3. Studies of Cognitive Behavioral Therapy Targeting Core Autism Symptoms
Study Participants Study Type Method Outcomes
Bauminger17 N 5 15 Open trial Three hours a week for 7 mo Four of 4 tests of pre-post
differences were significant
8–17 yr old Involved child’s main teacher,
parents, and typical peer
Diagnosed with
ASD
Bauminger49 N 5 19 Open Trial Three hours a week for 7 mo Ten of 14 tests of pre-post
differences were significant
7–11 yr old Involved child’s main teacher,
parents, and typical peer
Diagnosed with
ASD
Bauminger50 N 5 26 Open Trial Two weekly sessions for 7 mo Ten of 15 tests of pre-post
differences were significant
Mean age: 8 yr old Teacher-led small social skills
group (typical and ASD students)
Diagnosed with
ASD
Beaumont and N 5 49 Random assignment to 7 sessions Four of 5 posttreatment group
Sofronoff51 treatment or waitlist differences were significant
condition
7–11 yr old Group therapy, parent training,
teacher handouts
Diagnosed with
Asperger
syndrome
Crooke et al54 N56 Multiple baseline 8 weekly sessions Both tests of pre-post differences
were significant
9–11 yr old Group therapy
Diagnosed with
ASD
Koning et al52 N 5 15 Random assignment to 15 sessions Four of 6 posttreatment group
treatment or control differences were significant
group
10–12 yr old Group therapy
Diagnosed with
ASD
Lopata et al55 N 5 21 Randomized 6 hr a day; 5 d a week for 6 wk Zero of 3 tests of posttreatment
controlled trial group differences were
significant
6–13 yr old Two groups: social skills training Both intervention groups
and social skills training with demonstrated treatment gains
behavioral supports
Diagnosed with
ASD
Lopata et al56 N 5 54 Randomized 6 hr a day 5 d a week for 6 wk Three of 14 posttreatment group
controlled trial differences were significant
6–13 yr old Two groups: social skills training Both intervention groups
and social skills training with demonstrated treatment gains
behavioral supports
Diagnosed with
ASD
(Table continues)

710 CBT for Children with Autism Journal of Developmental & Behavioral Pediatrics
Table 3. Continued
Study Participants Study Type
White et al33 N 5 30 Randomized
controlled trial
(waitlist control)
12–17 yr old
Wood et al3 N 5 19 Randomized
controlled trial
7–11 yr old
Diagnosed with
ASD and an
anxiety disorder
ASD, autism spectrum disorder; CBT, cognitive behavioral therapy.
Using a group-therapy format for the treatment, Bau-
minger50 enrolled 26 children with ASD in a separate
study, again lasting 7 months. The study sought to im-
prove the participants’ social interactions within a group
and their social-cognitive skills. Teachers again delivered
the intervention, with each group consisting of 2 typical
children and 1 to 3 children with high-functioning au-
tism. The goals of treatment were similar to Bauminger’s
previous 2 studies, with more of a focus on cooperative
engagement. Unlike the first 2 individually administered
intervention studies, although participants exhibited an
improvement in social interactions within the structured
group setting, these gains did not generalize to the un-
structured playground setting. The major limitation in all
3 of these studies was the lack of a control group.
However, the initial results suggest that social-cognitive
interventions have potential for improving participants’
social awareness and social behavior, and should be
studied further in controlled trials. The lack of general-
ization in the group-therapy study calls for further con-
sideration of the merit of using a group approach as
opposed to individual therapy. Overall, this treatment
protocol seems promising for further investigation.
Beaumont and Sofronoff51 investigated a 7-week
multicomponent treatment intervention among 49 chil-
dren, aged 7 to 11 years, diagnosed with Asperger dis-
order. Participants were randomly assigned to
a treatment (n 5 26) or waitlist condition (n 5 23). A
computer game program was incorporated to teach
children to identify and respond to characters’ emotions.
Group therapy sessions were then conducted to allow
participants to practice what they learned from the
computer game among fellow participants (with
Asperger syndrome). Parents received concurrent train-
ing to help them understand the skills their children
were learning and how to encourage their children to
implement these skills at home. Finally, weekly handouts
were provided to teachers to keep them aware of what
behaviors were being targeted. Compared with the
waitlist condition, treatment participants achieved
improved social skills according to parent reports, with
evidence that these results maintained over a 5-month
follow-up. Perhaps because of ceiling effects, treatment
Vol. 34, No. 9, November/December 2013
Method Outcomes
See Table 2 Two of 2 tests of social-related
posttreatment group differences
were significant
16 sessions Both tests of posttreatment group
differences were significant
Family CBT
participants did not outperform the control group on
emotion recognition tasks. However, treatment partic-
ipants did exhibit greater gains in generating emotion
regulation strategies. No measure was included to
examine whether these strategies were being used in
everyday contexts. Limitations of this study include no
independent diagnoses or evaluations of participants and
their treatment response, low-response rates of teachers
making it difficult to interpret teacher data, and primary
reliance on parent-report measures.
Koning et al52 investigated a 15-week CBT treatment
for high-functioning boys with autism aged 10 to 12 years,
in which participants were assigned to an intervention
group (n 5 7) or a control group (n 5 8) that did not
receive treatment. Participants attended weekly 2-hour
group sessions targeting self-monitoring skills, social per-
ception and affective knowledge, conversational skills,
social problem solving, and friendship management skills.
Results indicated that the treatment group outperformed
the control group on structured tasks designed to test
understanding nonverbal cues. Treatment participants
also outperformed the control group on peer interaction
measured by a structured but naturalistic play scenario
and answering questions on how to respond to social
problems. However, based on parent reports, there were
no significant differences between groups on core ASD
symptoms, including social skills, outside of the clinical
setting. This indicates a possible lack of generalization of
treatment effects to real-world situations—a common
finding in traditional social skills treatments for ASD.53
Limitations of this study include the small sample and
limited generalization data.
Using a multiple baseline design, Crooke et al54
assessed the effects of a social thinking treatment on 6
children, aged 9 to 11 years, with a high-functioning
ASD. Treatment was delivered over the course of
8 weeks and included 4 generalization sessions to mea-
sure improvement. All sessions lasted 60 minutes and
were recorded for future transcription and data analysis.
Cognitive portions of treatment included discussion of
“why” social skills are important and understanding how
others’ thoughts are affected by the child’s own behav-
ior. Outcome measurements were based on coding of
© 2013 Lippincott Williams & Wilkins 711
two 15-minute video-taped segments; one segment was
from baseline and the other was from the final general-
ization probe. Each segment was observed by 2 raters
masked to condition (i.e., baseline or generalization)
who then coded behaviors into “expected” positive
behaviors and “unexpected” negative behaviors. Results
revealed evidence of increases in overall socially appro-
priate behaviors and decreases in overall inappropriate
behaviors in response to the onset and progression of
the treatment. Additionally, subcategories of positive
verbal behaviors (initiations and on-topic comments) and
eye contact also showed improvement. Limitations in-
clude a small sample size, no treatment fidelity measure,
and the lack of a control group inherent in multiple
baseline studies.
Using a more intensive intervention design with
a 6-week summer camp program, in which CBT ele-
ments were embedded within a larger intervention cur-
riculum, Lopata et al55,56 conducted 2 randomized
controlled trials in which children with ASD were ran-
domly assigned to 1 of 2 treatment conditions. In the first
report55 (N 5 21), children with an ASD were assigned
to either a social skills (SS) group or a social skills plus
behavior treatment (SS 1 BT) condition; 4 participants
were assigned nonrandomly to the SS condition in the
first year of this study, whereas the remaining 17 were
randomly assigned to 1 of the 2 conditions in the second
year of the study. The first condition was a CBT-oriented
treatment targeting SS and the other was the same
treatment with additional behavioral supports for man-
aging disruptive behavior (SS 1 BT). The protocol was
quite extensive with treatment delivered in the context
of a 6-week, 5 days a week summer camp with 6-hour
structured days. Treatment focused on improving social
behaviors, recognizing emotions, and engagement in the
interests of others. Social skills training was delivered in
groups and consisted of teaching, modeling, role-play,
and performance feedback. Therapeutic activities were
incorporated to provide participants opportunities to
practice newly learned skills. For participants who re-
ceived the additional behavioral component, a token
system was implemented to promote engagement in
prosocial behaviors. This study was then replicated56
among 54 children with an ASD (aged 6–13 years). In
both studies, no group differences were evident on
parent and teacher report measures of social skills at
posttreatment. The lack of a nonactive control group and
small-to-moderate effect sizes preclude strong con-
clusions about the treatment. However, the embedding
of CBT in participants’ everyday routines (e.g., summer
camp) is a novel approach that may have implications for
development of future CBT protocols delivered in natu-
ralistic settings in the child’s home, school, and
community.
In another randomized controlled trial, Wood et al3
reported on the effects of a CBT program (BIACA) on the
core autism symptoms (e.g., social responsiveness) of 19
participants (aged 7–11 years). Nine participants were
712 CBT for Children with Autism
randomized to treatment, and the remaining 10 were
randomized to a waitlist control. The procedures
were the same as in the original CBT protocol for anxiety
described above,2 with some participants overlapping
with that study. As noted above, the program empha-
sized in vivo exposures for anxiety reduction and school
collaboration to encourage the development of emotion
regulation and social communication skills. Social
coaching, which consists of parents or clinicians offering
in vivo feedback to the child, was provided during real-
world situations (e.g., conversations with new or familiar
people, during play-dates). Socratic questioning was also
used by clinicians and parents in these situations to
promote online comprehension and retention of social
concepts in the context of social interactions with typi-
cal peers and adults. By learning to identify how their
own behavior affects other people’s thoughts and feel-
ings, children were better prepared to face novel social
situations. Parents of children in the CBT treatment
condition rated their children as lower in overall autism
symptoms than did parents of children in the waitlist
group at the posttreatment assessment. A medium to
large treatment effect was reported, suggesting possible
application of this CBT protocol for reducing severity of
core autism deficits. This finding was replicated by
Storch et al37 in a randomized controlled trial of CBT
(BIACA) versus TAU (N 5 45), in which parent-reported
autism symptoms at posttreatment favored CBT. How-
ever, these studies were limited by a small sample size
and reliance on parent reports, so further study is needed
to determine the extent to which these treatments affect
more objective ratings of outcome (e.g., blinded in-
dependent evaluators).
A follow-up study57 of the original BIACA randomized
controlled trial2 (N 5 40) revealed CBT treatment effects
for independent living skills, a key area of deficit often
associated with childhood ASD. Although technically not
a core autism symptom, daily living skills have been the
focus of many broad early intervention programs for
children with ASD58 and it is noteworthy that collateral
gains may be made in this area for school-aged children
participating in outpatient CBT.
In short, although all these studies reported some
positive outcomes, they varied widely in treatment
approaches, research designs, and outcome measure-
ments (Table 3). Treatment took place at clinics, schools,
and summer camps and differed between individual and
group sessions. The length of treatment also fluctuated,
ranging from 90 minutes to 30 hours per week. A com-
mon component was the inclusion of parents, teachers,
and peers in an effort to extend treatment gains to real-
world contexts. Individual components of treatment, al-
though varied, commonly included emotion recognition,
development of cognitive strategies and corresponding
social skills, and exposures. Because of the incorporation
of various CBT strategies with other components of
treatment, it is difficult to assess which specific strategies
were responsible for producing the desired changes.
Journal of Developmental & Behavioral Pediatrics
Outcome measures varied across studies and included
observational data, parent reports, and child reports. In
general, it seems that implementing intensive and in-
dividualized protocols during middle-childhood and early
adolescence may produce measureable improvement in
core autism symptoms. The evidence remains pre-
liminary, however, and further investigation with more
stringent methodology and evidence-based outcome
measures is needed.
FUTURE DIRECTIONS
The studies included in this review have tested cog-
nitive behavioral therapy (CBT) in the treatment of
anxiety, externalizing behaviors, and autism symptoms
among children with an autism spectrum disorder (ASD).
Given the prevalence of concurrent emotional and
behavioral disorders among children with autism,59,60
investigating CBT treatments for this population is
a sensible direction for intervention research in ASD.
Additional symptoms can exacerbate the difficulties al-
ready faced by children with autism and further impair
daily functioning. Fortunately, it seems that symptoms of
many comorbid conditions are responsive to CBT treat-
ments and may even result in collateral gains in social
skills and independent living abilities.3,56 This review of
the literature provided above offers some initial evidence
of the potential of CBT for targeting anxiety and social
and adaptive functioning for children with autism, with
limited evidence for effectiveness in treating disruptive
behaviors. However, only 1 protocol61 meets American
Psychological Association Division 12 criteria for desig-
nation as efficacious46 for anxiety and social re-
sponsiveness at present, as results have been replicated in
separate, independent randomized controlled trials37,38
using a variety of robust methods (e.g., randomized con-
trolled trial design; independent evaluators). Most studies
had some limitations in the domains of methodology and
outcome measures (many relying on parent report).
A major limitation of the research presented here is
that studies generally did not measure the level of cogni-
tive change (e.g., theory of mind skills) along with be-
havioral changes. Since CBT is predicated on the notion
that cognitive and behavioral changes occur synchro-
nously, it will be important to establish whether this
actually occurs in the treatment of individuals with au-
tism. Future research could also focus on specific cogni-
tive strategies that may be effective in promoting
behavioral change rather than large CBT programs with
many additive components, which make it difficult to
discern which components are responsible for treatment
gains. All these programs included some adaptations to
promote accessibility for children with autism. However,
these adaptations have not been investigated empirically.
Future research could focus on whether these adaptations
are in fact necessary and which adaptations promote
positive outcomes for children and adolescents with au-
tism. Future research should also focus on using more
stringent methodology and evidence-based outcome
Vol. 34, No. 9, November/December 2013
measures to draw clearer causal conclusions.46 Although
future studies will also likely use parent reports of symp-
toms, multiple informants should be incorporated to
provide more convincing data. Independent evaluators
blind to treatment conditions should be incorporated
whenever possible. Evidence-based structured observa-
tional methods (in the clinic or in the school setting)
should also be used to corroborate parent and child
reports and measure the generalizability and durability of
treatment gains.
In addition to these methodological suggestions, future
research should investigate how CBT treatments can
be broadened to address previously untargeted sub-
populations and symptoms within ASD. For example,
cognitive-behavioral treatments have only been used
among high-functioning individuals with ASD. It would be
useful to examine whether components of CBT can be
adapted to meet the needs of individuals with autism who
also have an intellectual disability. Individuals with autism
and an intellectual disability also experience comorbid
psychopathology (e.g., anxiety) at high rates,62,63 but treat-
ments for these comorbidities have largely been focused on
the higher-functioning population at present.64
Although some evidence has indicated positive effects
of CBT for core autism symptoms,3,37,49,50 a few symptom
areas have remained unaddressed. The studies presented
primarily focused on social and communicative deficits,
2 of the core features in autism. With few exceptions,17
most of the included studies did not report on the effects
of CBT for repetitive behaviors commonly found among
children with autism.
The optimal intensity of CBT treatments should be in-
vestigated. Other autism treatments, such as applied be-
havior analysis programs and Pivotal Response Treatment,
are consistently delivered over the course of many
months or years and in multiple settings (i.e., in a child’s
home, school, and community). Future research should
examine the effectiveness of more intensive CBT pro-
grams over the course of a longer timeframe designed to
meet the needs of participants in their daily lives and to
make an even more pronounced impact on their overall
symptom severity in the emotional, behavioral, and social
domains while still retaining the relative efficiency of
CBT’s outpatient treatment model.
Brewin13 presented a conceptual framework of CBT in
which he indicated the primary pathway for effective
treatment is for participants to develop retrievable and
adaptive mental representations of target stimuli (e.g.,
fears, social interactions, novel interests) to directly
compete with deeply ingrained negative associations with
such stimuli. These representations are developed
through deep semantic processing of concepts (as op-
posed to repetition), which weaken negative associations
and build up adaptive representations. Increased focus on
promoting conceptual scaffolding by presenting cognitive
components in an appealing, child-friendly format is likely
needed to promote deeper cognitive processing, un-
derstanding, and ultimately, an increased strength of
© 2013 Lippincott Williams & Wilkins 713
adaptive representations. Through this mechanism, it is
possible that adaptive mental representations of the self,
the world, and how to engage successfully with the outside
world may be achieved. The studies presented here pro-
vide support for continued investigation of CBT as a treat-
ment for children and adolescents with high-functioning
autism. Although further research with more stringent
methodologies is necessary, the results presented are en-
couraging. At least 1 CBT protocol2 seems to meet criteria
as efficacious for anxiety and social responsiveness in
children and early adolescents with high-functioning ASD.
Researchers are encouraged to further develop CBT pro-
tocols for affected youth while using assessments of core
autism symptoms as well as emotional and behavioral
functioning as key outcome measures.
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