The$First$Session - Woodviewwoodview.ca/wp-content/uploads/2014/04/Session-A3... ·...

The First Session

  Introductions, establish roles and responsibilities, provide structure and expectations

  Assessment – Conceptualization, Goals and Evaluation of Outcomes

  Socialization to the CBT Model, start by setting an Agenda

  Psycho-‐education to build awareness of thoughts, behaviors, physiology and their interactions

Agenda 1)  Check in – set the agenda, timelines, check homework, forms

2)  Overview of CBT Model or “Socializing to treatment”

3)  Recap of ASD Strengths and Challenges

4)  Review some Literature on CBT and ASDs

5)  Introduce some CBT Specific Tools and Strategies

6)  Explore treatment options to common challenges faced by individuals with ASDs -‐ anxiety, depression, phobias, affect regulation, PTSD

7)  Jenn’s Story

8)  Clinical Examples of interventions

9)  Questions and Discussion

Socializing to the CBT model

  Structure of the session

  Roles of the therapist, roles of the client, expectations of each

  Goals for time together, goals for time in between sessions

  Rationale for interventions

  Maintains consistency, trust, boundaries and comfort while building effective therapeutic rapport

Cognitive Behavior Therapy What you think and do affects the way you feel

(cognitive) (behavior) (emotional)

Changing how we think and act can change how we feel

CBT Therapists understand situations by looking at 5 Factors: -‐ Situation/ Environment

-‐ Thoughts

-‐ Behaviors

-‐ Physiological Reactions

-‐ Emotions

Five Factor Model

What do we know about Autism Spectrum Disorders?

Strengths: Challenges:

  excellent memory for detail need help fitting to the bigger picture

  vivid recall of experiences recall can be a negative, visceral experience

  grasp concrete concepts well poor connection to emotional and physiological awareness

  calculated decision making difficulty generalizing new skills

  data and fact driven get ‘stuck’ on specific thoughts, moods, topics of conversation

Thrive in: predictable, data driven, concrete situations where roles are clearly defined, expectations are clearly set ahead of time, timeframes are concise, visual tools augment and support verbal material, abstract concepts are translated into concrete Have often developed creative, innovative ways of coping to learn to live with, and even overcome many of the challenges that go along with having an ASD

Common Presenting Problems with Autism Spectrum

Disorders   Depression

  Anxiety

  Social Phobia

  Panic Disorder

  Other Specific Phobias Aversions/Avoidance

Why CBT for ASDs?

  CBT originally developed for depression

  Accidently found to be effective for anxiety

  CBT has since been shown to be effective within the general population for common presenting problems found within the ASD population including depression, anxiety, panic, phobias and post traumatic stress disorder (see; Butler, Chapman, Forman & Beck, 2006).

But is CBT suitable for individuals with ASD?

Break the stigma around “therapy”

Break the stigma of ASD’s

“CBT, as mentioned, teaches people to monitor their own thoughts and perceptions with the hopes that they will become more aware of their interpretive errors. There is no reason to believe people with AS/HFA cannot learn to do this within a psychotherapy context” – Dr. Valerie Gaus

Asperger’s and Social Anxiety Disorder

Cardaciotto & Herbert (2004) Cognitive behavior therapy for social anxiety disorder in the context of Asperger's Syndrome: A single-‐subject report, Volume 11, Issue 1, Winter 2004, Pages 75–81

Asperger’s and SAD Diagnostic criteria overlap: -‐ social impairment -‐ highly circumscribed interests -‐ repetitive behaviors -‐ motor clumsiness

Both high rates of comorbidity with depression

Both show effective responses to CBT treatment (x14 weeks) with improvements in: decreased symptoms of anxiety, depression increased conversation skills and eye contact

Rotheram-‐Fuller and MacMullen (2011)

  In their review of studies of CBT with children with ASD, Rotheram-‐Fuller and MacMullen found significant improvements in students with HFA and AS in concurrent areas of difficulty such as separation anxiety, social phobia, social anxiety, OCD, generalized anxiety, panic disorder and specific phobia.

  Across all studies using CBT with youth with ASD they found decreased symptoms of anxiety, “social worries” and interpersonal conflicts, with increased problem solving abilities, social interactions, and positive changes in automatic thoughts.

  CBT seems to be an effective approach to treat the concurrent difficulties faced by individuals with HFA and AS!

Why CBT for ASDs?

How does CBT fit for ASD?

  Elements: The 5 C’s   Consistent – time, length, place, format, expectations   Collaborative – content, decision making, evaluation,

generalization   Compassionate – sense of understanding and function

of current ways of being   Curious – genuine, intentional questioning   Concrete – making abstract concepts concrete, visual,

manageable

Laying the Groundwork   Are we speaking the same language?

Assessment   Self Report? Family/Friend Input?

  Symptoms (emotional, physical, behavioral…)

  Prevalence (lifelong? Sudden/gradual change?)

  Developmental and Historical Information

  Genetic/Biological Factors?

  Coexisting conditions/contributing factors?

  Alternative explanations?

  Protective Factors, strengths, supports

  Coexisting skills, treatment, care providers

Assessment   Self Report? Family/Friend Input?

  Symptoms (emotional, physical, behavioral…)

  Prevalence (lifelong? Sudden/gradual change?)

  Developmental and Historical Information

  Genetic/Biological Factors?

  Coexisting conditions/contributing factors?

  Alternative explanations?

  Protective Factors, strengths, supports

  Coexisting skills, treatment, care providers

* Is ONGOING! Keep these in the back of your mind ALWAYS

Instead of only asking: “what is the function of this behavior?”

Also take the time to ask: “What has happened in this person’s life

that has contributed to how they are now trying to cope?”

Formulation Tool

Early Experiences

Core Beliefs

Rules I Live By

Critical Incidents

Thoughts

BodySensations

Feelings Responses

PSYCHOLOGYT LS.org

CBT Case Conceptualization

Judith Beck Formulation Relevant Childhood Data

Core Beliefs

Conditional Assumptions / Attitudes / Rules (If ... then ...)

Coping Strategies

Situation

Automatic thought

Meaning of Automatic Thought

Emotion

Behaviour

Situation

Automatic thought


Emotion

Behaviour

Situation

Automatic thought


Emotion

Behaviour

PSYCHOLOGYT LS.org

Core Beliefs

Old Rules For Living

New Rules For Living

Situation

Automatic thought

Physical Symptoms

Feeling/EmotionBehaviour

Presenting Problem / Effects Of These Old Rules

Precipitating / Triggers

Protective Factors

(If... Then... )

Situation

Automatic thought

Physical Symptoms

Feeling/EmotionBehaviour

BadNot good enough

UnacceptableWorthlessUnlovable

UnimportantInferiorStupid

Are theseworking for you?

Early Experiences

PSYCHOLOGYT LS.org

Longitudinal Formulation

Psychoeducation

  Physiological Awareness

  Interpretation of physical reactions:

i.e.; heart racing, breathing shortens

Automatic thought: “I’m having a heart attack!” Subsequent reactions: pay more attention to breath, heart rate (both will naturally speed up) Maintained thought: “I’m having a heart attack and I’m going to die!!” ….Panic

Physiological Awareness

Threat System

Thoughts racing

Breathing becomesquicker and

shallower

Heart beats faster

Adrenal glandsrelease adrenaline

Bladder urgency

Palms becomesweaty

Muscles tense

Dizzy or lightheaded

The ‘fight or flight’ response gets the body ready to fight or run away. Once a threatis detected your body responds automatically. All of the changes happen for goodreasons, but may be experienced as uncomfortable when they happen in ‘safe’ situations.

helps us to evaluatethreat quickly and makerapid decisions, can be hardto focus on anything butthe feeling of danger

to take in more oxygenand make our body moreable to fight or run away

adrenaline signals otherorgans to get ready

feeds more blood tothe muscles and enhances ability tofight or run away

the body sweats to keep cool, thismakes it a more efficient machine

Changes to visiontunnel vision, or visionbecoming ‘sharper’

Dry mouth

muscles in the bladder relaxin response to stress

ready to fight or run awaythey may also shake ortremble

Hands get coldblood vessels in the skincontract to force bloodtowards major musclegroups

PSYCHOLOGYT LS.org

Psychoeducation   Emotional awareness:

Thoughts are different than feelings! And thoughts are not predictions of future events or actions!

How are emotions connected to our thoughts, and our bodies?

How we interpret situations can change our moods, behavior, even physiological responses

Provide an example that can be related to, but not reacted to (not super specific at this point)

Visual: Vicious Flower

Vicious Flower Formulation

http://media.psychologytools.org/Worksheets/English/Vicious_Flower_Formulation.pdf

Vicious Flower Formulation

Symptom Maintenance Cycle: What if I panic?

Focus on physical feelings

Increase physical

symptoms

Scared/Anxious Focus on physical

reaction”

I’m having a heart attack

Start: felt out of breath, + HR

Cognitive Awareness What are you thinking?!

We need help to:

  Identifying Thought Patterns, Isolate the Hot Thoughts, Assumptions, Cognitive Distortions, Core Beliefs, Schemas

Tools to do this include:

  Skillful and Socratic Questioning

  Downward arrow Technique

  Thought Records, Thought Chains

Simple Thought Record

Situation Feelings ThoughtsWho, what, when, where? What did you feel?

Rate your emotion 0 -100%What was going through your mind

as you started to feel this way?

PSYCHOLOGYT LS.org

Isolating the “Hot Thought”

  Hot Thought – the thought that is connected to the emotion

Clues: is the thought about Myself? Others? The world?

Is there a hidden thought beneath this “Hot Thought?”

Downward arrow technique – Ask, if this thought were true, what would that mean? And if that thought were true…?

Lets try an example together:

Sample Thought Record

Looking for evidence   Try examining the evidence to support the thought first THEN look at the

evidence that doesn’t support the thought

Ask: What is the evidence that would support this idea? When are times that this has been true? What is the quality of the evidence? Are there multiple specific examples? Would a good lawyer defending you think this is good evidence?

  Look at the Logic: “the cross examination”

Ask: I wonder, how does someone not liking you make you worthless? If one person likes you and another does not, does that make you worthless? Or worthwhile? Or something in between

  Is there a “Double Standard?”

Ask: Do you know anyone who is liked by everyone? No? Then does that mean everyone is worthless? Lets think of someone who you admire and like – if someone happened to dislike them, would that make them worthless?

Modifying the Hot Thought

  After examining the evidence for and against the Hot Thought, can we come up with a more balanced thought?

  Rate how true you feel this new, balanced thought is.

  How are you feeling now? Rate your mood

Data Driven

  The data driven nature of CBT is also a benefit when working with the ASD population, who tend to thrive when tangible results can be seen in visual form: (numbers, percentages, statistics on charts, graphs, etc.)

  Thoughts, feelings, behaviors can be externalized and made to feel more manageable

  Can be posed as “experiments” or “super-‐sleuths” looking for clues, evidence, testing out new ways of thinking, feeling, acting

Behavioral Experiments

  Testing out predictions, tracking their accuracy

  Teasing apart thought – action fusion

  Delaying/avoiding “safety behaviors”

  Gathering data/evidence to test out predicted vs actual outcomes

  Trying out new ways of interacting, thinking, reacting, gathering data to motivate and support new ways

Activity Scheduling

  CBT interventions for depression have been proven to be as effective as psycho-‐pharmaceutical interventions, regardless of severity of depression symptoms

i.e.; Butler, A. C. & Beck, A. T. (1995). Cognitive therapy for depression. The Clinical Psychologist, 48(3), 3-‐5.

Treatment involves: Cognitive Restructuring, building Adaptive Coping Skills, Activity Scheduling, Mastery and Pleasure monitoring

Vicious cycle of sedentary lifestyle on cognitive rumination, mood, physiological symptoms… Get moving!

Mastery and Pleasure Pick an activity that you enjoy or that gives you a sense of accomplishment that

you do not usually engage in. (It may be an activity you used to do, but have stopped; or it may be a new activity. You can refer to the Mastery and Pleasure List which is just after this exercise for ideas):

Activity: Cooking, trying a new recipe Plan a time to engage in the activity: Thursday, dinner time (6pm)

Note your mood on a scale of 1-‐10 before and after engaging in the activity: (1=very low mood; 10=very positive mood)

Activity: Cooking (tried a new recipe)

Mood Before: Tired, after long hard day, but in a good mood, glad to be home: 7

Mood After: Felt rewarded, and content that new recipe worked out well: 9

Comment on your experience :

Challenging Cognitions “Cognitive Restructuring”

fancy term for identifying unhealthy thinking patterns and changing them

may involve examining past evidence, identifying common thinking errors, conducting a real world experiment to test assumptions about the world, and using written and verbal exercises to address problematic thinking

Example, an adult with Asperger’s may present to treatment with a belief that others appreciate being corrected on grammar. As a behavior experiment, he or she may be asked to take an informal survey of neighbors and colleagues to test this assumption -‐ to see if people typically appreciate having their conversational grammar corrected. Such an experiment would return data that might likely show that people actually dislike being corrected on their speech, a discovery that may help the patient reject his or her mistaken belief

Cognitive Distortions   Mind Reading: “She thinks I’m lazy and stupid” – making an assumption that I know

what someone else is thinking without any evidence to support it.

  Personalizing: “We lost the game today because I played horribly” You assume that what people are saying, or doing, is about you, even though there is not necessarily any indication. You often compare yourself to others, trying to determine how you compare to the other person in a variety of attributes, such as intelligence, competence, looks.

  Blaming: “It’s all his fault that we broke up” –focus on another person as a source of the problem without taking any responsibility.

  Dichotomous thinking: “I am a complete failure!” –view self in an all-‐or nothing term.

  Fortunetelling: “I’m not going to get that raise” – negative prediction of the future.

  Discounting positives: “Everyone gets an A in this class, it has nothing to do with how hard I studied”. – Do not take responsibility or credit for positive things that happen.

Cognitive Distortions   Filtering. Filtering involves focusing on negative details while other positive aspects of a situation are ignored.

  Overgeneralization. You make a broad generalization, which is only based on one piece of evidence.

  Polarized thinking – You or others are either black or white, good or bad, perfect or failure. In such thinking there is no room for grays or middle ground in evaluating yourself or others. Aka: Black and White thinking

  Making assumptions / mind reading – You assume that you know what people are feeling and thinking, and why they are acting that way. usually how they are thinking or feeling about you, and it is almost always negative.

  Personalizing – You assume that what people are saying, or doing, is about you, even though there is not necessarily any indication. In addition, in personalizing, you often compare yourself to others, trying to determine how you compare to the other person in a variety of attributes, such as intelligence, competence, looks.

  Catastrophizing – Individuals expect, and often have, an image of disaster occurring because of the initial difficulty or situation. Catastrophic thoughts often start with “what if.” For example, your child borrows the car in the evening, and you think, “What if he has an accident? What if the car breaks down? What if his friends are drunk and cause him to also drink and drive?”

  Magnifying and Minimizing – The degree or intensity of the problem is exaggerated so that anything difficult is evaluated as overwhelming; and anything positive is ignored or seen as irrelevant.

  Shoulds – Individuals believe that they know how both themselves and others “should” behave.

Clues about Cognitive Distortions

  Comparison of self to others

  Using words like “always” or “never”

  Stating rules like “should”

  Making predictions about the future

  Assuming that you know what others are thinking

Unhelpful Thinking Styles

All or nothingthinking

Mental filter

2 + 2 = 5

Jumping toconclusions

Emotionalreasoning

!"#$%&'

Labelling

Over-generalising

“everything isalways rubbish”“nothing goodever happens”

+++

Disqualifyingthe positive

Magnification (catastrophising)

& minimisation

should

must

“this ismy fault”

Personalisation

Sometimes called ‘black and white thinking’

If I’m not perfect I have failed

Either I do it right or not at all

Only paying attention tocertain types of evidence.

Noticing our failures butnot seeing our successes

There are two key types ofjumping to conclusions:

Mind reading (imagining we know what others are thinking)

Fortune telling (predicting the future)

Assuming that because we feel a certain way what we think must be true.

I feel embarrassed so I mustbe an idiot

Assigning labels to ourselves or other people

I’m a loserI’m completely uselessThey’re such an idiot

Using critical words like ‘should’, ‘must’, or ‘ought’can make us feel guilty, orlike we have already failed

If we apply ‘shoulds’ toother people the result isoften frustration

Seeing a pattern basedupon a single event, or being overly broad in the conclusions we draw

Discounting the goodthings that have happenedor that you have done forsome reason or another

That doesn’t count

Blowing things out of proportion (catastrophising), orinappropriately shrinkingsomething to make it seemless important

Blaming yourself or takingresponsibility for something that wasn’tcompletely your fault. Conversely, blaming other people for something that was your fault.

PSYCHOLOGYT LS.org

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Worry Time

  When chronic worrying takes up most mental and physical energy throughout the day

  Learn to delay the worry by setting aside specific times (i.e. worry for 20 minutes straight) and mechanisms in which to worry (make a list of all the things you’re worried about)

  Learn that some worry can be productive – if supplemented with appropriate problem solving strategies and tools

  Other worry can be meaningless and easier to let go of

Social Skills Training   CBT can help individuals with ASD build social skills needed to

navigate the complex social world

  Includes psycho-‐education and role play to practicing social rules

i.e.; do not discuss your lousy day in depth when a stranger asks how you are doing today

and social principles

i.e.; it is sometimes okay to tell a white lie to avoid upsetting somebody

Treatment will also include discussing and practicing higher level skills, like understanding the emotions and intentions of others

Relaxation Training

  Noticing Physical Symptoms of tension, anxiety

  Normalizing physical sensations

  Identifying Anxious Thoughts

  Practice, training in being calm, relaxed through:

-‐ Breathing excercises

-‐ Progressive Muscle Relaxation

-‐ Guided Imagery

-‐ Mindfulness and meditation practice

Stress Inoculation Training

  Meichenbaum, (1977, 1996)

  Three Phase Approach to helping individuals cope after exposure to high stress situations and/or as a preventative to help tolerate future stresses

-‐ Conceptualization

-‐ Skills acquisition and rehearsal

-‐ Application and follow-‐through

Assertiveness Skills Training

  Assertiveness is not the same as aggression

  Assertiveness is being able to stand up for your personal rights

  Requires good self awareness and effective communication skills in order to: -‐express thoughts, feelings and beliefs -‐be direct, honest and appropriate

Role Playing, Generalization, Behavioral Experiments

Behavioral Modification   Habit Reversal and Ritual Prevention

Individuals with ASD can often present with repetitive movements, rituals, routines – and sometimes these can be harmful or maladaptive

CBT strategies have been developed to specifically address concerns for other types of problems and can be helpful for those with ASD.

Delayed gratification (learning to tolerate anxiety of waiting)

Elimination of “Safety Behaviors” (checking phone, email)

Reduction of patterns of avoidance (crowds)

Exposure

Types of Exposure

 In Vivo (Exposure to actual feared object or situation)

 Virtual (Use computers)

 Imaginal (visualize, think about encountering and mastering interaction with feared object)

Exposure

  Graded Hierarchy to work up to most feared situation slowly

  Can use group format for graduated experience i.e.; Reading out loud -‐> social interactions -‐> trying new things

  Make predict, do the activity, process accomplishment “experiment style”

Challenges/Cautions

  changing maladaptive thought patterns

  use of overdeveloped interests/icons in session

  avoiding use of euphemisms

  homework/practice needed to improve generalization

  Collaborative approach with client and other care providers essential

  Making Abstract Concrete – comic strips, thought logs

  Rumination….

Rumination What is it? -‐ Dwelling on difficulties/ things that bother us -‐ Repeatedly thinking about things from the past -‐ Becoming preoccupied with something and not being able to get it out of our thoughts -‐ Something we do to try to deal with our problems

Is it normal? -‐YES – to some extent we all do this Thinking about problems can often help us solve them, come up with actions, plan ahead Usually rumination is time limited – stops when problem is solved Excessive rumination can interfere with daily life

Rumination Continued

When is it a problem?

When the focus is on the causes and consequences instead of the solution

  i.e.; “What did I do to deserve this?” “Will this ever get better?” instead of “What can I do to make things better?”

-‐Excessive rumination linked to depression and anxiety

-‐Can lead to decreased activity and avoidance instead of problem solving

Rumination Continued

Integration of Interests

Rotheram-‐Fuller and MacMullen (2011):

-‐use of individual perseverative interests can also incorporated into therapy to engage and motivate clients (i.e. “What would batman do if…?”)

-‐caution: this can be limiting when trying to promote increased cognitive flexibility as an individual with AS who has dedicated many hours collecting “the facts” on a particular area of interest will have a very difficult time if he has to manipulate any of those facts to suit a real life situations.

Visual tools and role play

  Thought Chains

  Thought Records

  Body maps

  Social StoriesTM

  In-‐vivo role-‐plays

  Video modeling

  Comic Strip ConversationsTM

Show me what happened…

Post Traumatic Stress Disorder

  In reaction to an “extreme” traumatic event (death, threat of death, serious physical injury, threat to physical integrity)

  Three cardinal sets of symptoms: 1) re-‐experiencing of the trauma (memories, nightmares,

flashbacks) 2) avoidance of internal and external cues associated with

the trauma (incl. feelings of numbness or detachment) 3) increased arousal (insomnia, irritability, trouble

concentrating, hypervigilence)


Dr. Donald Meichenbaum

www.roadmaptoresilience.org

http://www.melissainstitute.org/

“Post Traumatic Growth”

Fostering Resilience (aka ‘True Grit’):

-‐ connection to a community

-‐ ‘re-‐storying’

-‐ forum to “make a gift” out of story


General CBT Treatment Plan for PTSD:

Assessment – clinical evaluation of trauma, symptoms, patterns of avoidance, physical examination, consideration of medication

Socialize to treatment

Anxiety management training

Exposure – Imaginal to trauma memory and cues -‐ In vivo to avoided situations

Cognitive Restructuring

Problem solving skill development

Phasing out treatment

Jenn’s Story

Graded Exposure Hierarchy

  Make a list of most feared situation (10/10) to least feared situations (0/10)

  Important to always have an anchor (0/10) to start from

  Throughout: – normalize anxiety, function, purpose -‐ plan to accept and tolerate arousal -‐ take the danger away (facts, data) -‐ challenge negative thoughts -‐ learn from the past (thoughts/predicts)

Cognitive Distortions linked to Trauma

CBT Treatment Plan for Anxiety

CBT Treatment Plan for Depression

CBT Treatment Plan for Panic Disorder

CBT Treatment Plan for Specific Phobias

Evidence Based Support for CBT for Panic

Resources   Greenberger, D. & Padesky , C. (1995). Mind over mood.

New York: Guilford Press

  Leahy, R. & Holland, S. (2000). Treatment plans and interventions for depression and anxiety disorders. New York: Guilford

Guided Relaxation and Meditation Recordings:

http://www.youtube.com/watch?v=6W31vHDjyng

Progressive Muscle Relaxation Links, from the York University CDCV websitehttp://www.hws.edu/studentlife/resources/counseling/relax.asp

Resources

  Psychology Tools -‐ Free Resources for Therapists to Share: http://www.psychologytools.org/

  Victim Services: for access to VQRP funds for counselling support following a crime:http://www.attorneygeneral.jus.gov.on.ca/english/ovss/default.asp

  Resources for Trauma and Resiliency:   The Melissa Institute: http://www.melissainstitute.org/   Road Map to Resilience:

http://www.roadmaptoresilience.org/

References   Anderson, S. and Morris, J. (2006). Cognitive Behaviour Therapy for people with Asperger syndrome. Behavioural

and Cognitive Psychotherapy, 34, 293–303.

  Attwood, T. (2004). Cognitive behaviour therapy for children and adults withAsperger's syndrome. Behaviour Change, 21(3), 147-‐162.

  Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond. New York: GuilfordKendall, P.C., Choudhury

  Butler, A. C. & Beck, A. T. (1995). Cognitive therapy for depression. The Clinical Psychologist, 48(3), 3-‐5.

  Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2006). The empirical status of cognitive-‐behavior therapy: A review of meta-‐analyses. Psychology Review, 26(1), 17-‐31.

  Cardaciotto & Herbert (2004) Cognitive behavior therapy for social anxiety disorder in the context of Asperger's Syndrome: A single-‐subject report, Volume 11, Issue 1, Winter 2004, Pages 75–81

  Gaus, V. (2000). “I feel like an alien”: Individual psychotherapy for adults with Asperger’s disorder using a cognitive behavioral approach. NADD Bulletin, 3, 62-‐65.

  Gray, C. A. (1998). Social stories and comic strip conversations with students with Asperger syndrome and high-‐functioning autism. In E. Schopler, G. B. Mesibov and L. J. Kunce (Eds.), Asperger Syndrome or High-‐functioning Autism? New York: Plenum Press.

References   Kim, J. A., Szatmari, P., Bryson, S. E., Streiner, D. L. and Wilson, F. J. (2000). The prevalence of

anxiety and mood problems among children with autism and Asperger syndrome. Autism, 4, 117–132.

  M., Hudson, J., & Webb, A. (2002). The C.A.T. Workbook for the Cognitive Behavioral Treatment of Anxious Adolescents. Ardmore, PA: Workbook Publishing.

  McKay, M. Davis, D. & Fanning,P. (1997). Thoughts and Feelings: Taking control of your moods and your life. Oakland, CA.: New Harbinge

  Meichenbaum, D. (1996). Stress inoculation training for coping with stressors. The Clinical Psychologist, 49, 4-‐7.

  Reaven, J.A. (2009). Children with high-‐functioning autism spectrum disorders and co-‐occurring anxiety symptoms: Implications for assessment and treatment. Journal for Specialists in Pediatric Nursing, 14(3), 192-‐199.

  Rotheram-‐Fuller, E. and MacMullen, L. (2011). Cognitive-‐Behavioral Therapy for children with autism spectrum disorders. Psychology in the Schools, 48(3), 263-‐271.

  Stallard, P. (2005). A Clinician’s guide to think good – feel good. Using CBT with children and young people. West Sussex, England: John Wiley

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