Counselling People On The Autism Spectrum 1656426040

Counselling People on the Autism Spectrum
of related interest
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An Asperger Marriage
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Counselling People
on the Autism Spectrum
A Practical Manual
Katherine Paxton and Irene A. Estay
Jessica Kingsley Publishers

London and Philadelphia
First published in 2007
by Jessica Kingsley Publishers
116 Pentonville Road
London N1 9JB, UK
and
400 Market Street, Suite 400
Philadelphia, PA 19106, USA
www.jkp.com
Copyright © Katherine Paxton 2007
All rights reserved. No part of this publication may be reproduced in any material form (including
photocopying or storing it in any medium by electronic means and whether or not transiently or
incidentally to some other use of this publication) without the written permission of the copyright owner
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Warning: The doing of an unauthorised act in relation to a copyright work may result in both a civil
claim for damages and criminal prosecution.
Library of Congress Cataloging in Publication Data

Paxton, Katherine, 1964-
Counselling people on the autism spectrum : a practical manual / Katherine Paxton and Irene A. Estay.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-84310-552-7 (pbk. : alk. paper) 1. Autism--Patients--Counseling of--Handbooks,
manuals, etc. 2. Autism--Patients--Rehabilitation--Handbooks, manuals, etc. 3. Autism--Handbooks,
manuals, etc. I. Estay, Irene A., 1949- II. Title.
[DNLM: 1. Autistic Disorder. 2. Child Development Disorders, Pervasive. 3. Counseling. WM 203.5
P342c 2007]
RC553.A88P39 2007
362.196'85882--dc22
2007002889
British Library Cataloguing in Publication Data

A CIP catalogue record for this book is available from the British Library
ISBN 978 1 84310 552 7

ISBN pdf eBook: 978 1 84642 627 8
Printed and bound in Great Britain by

Athenaeum Press, Gateshead, Tyne and Wear
Contents
Acknowledgments 9
Introduction 11
Why a counselling manual for people on the autism spectrum? 13
Organization of the manual 16
Part One: Understanding Autism – Autism

Spectrum Characteristics and Cognitive
Patterns
1. Autism: An Overview 21
History of autism and theoretical paradigms 21
Characteristics and implications of autism, Asperger’s,
and PDD-NOS 29
Autism and comorbidity 45
2. Autistic Thinking and Autistic Logic 49

Visual thinking 50
Literal thinking 53
Self-concept 56
Theory of mind 59
Difficulty with change and shifting attention 63
Executive functioning 65
Autism, empathizing, and systemizing abilities 71
Autistic thinking and autistic logic 72
Part Two: Counselling Issues and Approaches
3. General Strategies and Modifications for

Cognitive Behavioural Therapy 77
Setting up the counselling relationship 77
Basic modifications for counselling people with ASD 78
Cognitive restructuring 85
Transitions 96
Structuring choice for success 97
Problem-solving approaches 98
Self-monitoring and self-management 100
Self-talk 101
4. Depression and Treatment Approaches 103

Diagnosing depression 103
Treatment approaches for depression 106
Pharmacological approaches 106
Cognitive behavioural therapy 106
Helplessness and hopelessness: faulty attributions 112
5. Anxiety, OCD, and Treatment Approaches 115

Diagnosing anxiety on the autism spectrum 116
Cognitive behavioural interventions for anxiety 119
OCD and perseverative behaviour 133
Treatment of OCD 134
6. Relationships and Social Skills 137

Employment and employment issues 139
Marriage and intimate relationships 143
Couples strategies for ASD marriages 150
Adolescence and puberty 150
Social skill development 151
7. Stress and Relaxation 159
Meaning making and stress 160
Stress management 162
8. Emotional Expression, Identification, and

Regulation 171
Emotional identification 171
Emotional expression 175
Emotional responsiveness 176
Anger management 181
9. Some Final Words and Suggestions 185
References 189
Subject Index 201
Author Index 205

List of Tables
1.1 DSM criteria for autism 33
1.2 DSM criteria for Asperger’s syndrome 36
1.3 DSM criteria for pervasive developmental disorder, not otherwise
specified (PDD-NOS) 38
3.1 Cognitive restructuring chart 88
3.2 Definitions of cognitive distortions 90
3.3 Steps to consider when solving a problem 100
5.1 Safety assessment questions 125
7.1 Progressive muscle relaxation muscle group breakdown 165
8.1 Emotional scale including possible responses 174
List of Figures
3.1 Thoughts, feelings, and actions diagram 80
3.2 Emotional thermometer 81
3.3 Example of a response quality scale 82
3.4 Thoughts, feelings, and actions mobile 86
3.5 Worksheet of helpful and not so helpful thoughts 89
3.6 Examples of visual reframing 92
3.7 Sample of a choice and possible consequence chart 94
3.8 Sample self-monitoring checklist 101
4.1 Positive thoughts game scorecard 110
7.1 Stages of stress 168
Acknowledgments
This manual was originally written as a program requirement for

Campus Alberta Applied Psychology, Counselling Psychology Master’s
program. My sincere appreciation goes to Dr. Irene Estay for all of her
tireless work in supervising the original project, from which this manual
has been taken. I wish to express sincere appreciation to Dr. Tony
Attwood for his contribution of material and his support with the
creation of this manual. Special thanks go to Roger Meyer, whose enthu-
siasm and feedback brought this manual to publication. I also wish to
express sincere gratitude to my husband, James Paxton, whose assistance,
encouragement, and never-ending support made this manual possible.
Katherine Paxton
9
Introduction
Autism spectrum disorders (ASD), including autism, Asperger’s

syndrome, and pervasive developmental disorders, not otherwise
specified (PDD-NOS), present unique challenges to counselling profes-
sionals. Many of the features of autism spectrum disorders present a
confusing picture. People on the spectrum, many of whom have average
or above average intelligence, have significant impairment in social
understanding that sharply contrasts with their intellectual abilities.
Communication impairments are common with a strong positive correla-
tion between verbal ability and IQ. Those with greater cognitive impair-
ments may lack any social awareness. Regardless of intellectual ability
and language fluency, emotional expression, regulation, and recognition
are significantly impaired among individuals within the autism spectrum.
Stereotypical behaviour, often appearing very odd, is characteristic of
autism spectrum disorders (American Psychiatric Association [APA]
1994; Filipek et al. 1999). Early behavioural intervention appears to
improve the prognosis of people with ASD, resulting in greater com-
munity participation and higher functioning than was possible only a
decade ago (Larkin 1997; Ruble and Dalrymple 1996). The prevalence of
autism spectrum disorders is on the increase (Samuels 2005). Services
often disappear when people with ASD become adults. However, their
difficulties do not vanish (Aston 2003).
This manual is intended for counsellors who face the daunting
challenge of providing counselling services to people who are on the
autism spectrum, their families, families who have a member who is on
the spectrum, and partners living with someone who is on the spectrum.
This manual is not intended to give clinicians the tools directly to treat
11
12 Counselling People on the Autism Spectrum
the core features of autism, nor is it intended to be a manual of behav-

ioural approaches to teach people on the autism spectrum new
behavioural skills, although skill development will occur. The focus of
this manual is on counselling techniques that work with emotions,
cognitions, meaning making, and trying to cope with living on the
autism spectrum, or living with someone who has ASD.
This manual contains information for counsellors and clinicians to
develop tools to help people on the autism spectrum cope with their
emotions, anxieties, and confusion regarding the confusing world that
surrounds them. Included are research-based strategies and adaptations
to current counselling technology to better meet the needs of persons on
the autism spectrum. This writer has found these adaptations and strate-
gies to be useful and effective when working with people who have an
autism spectrum disorder, their support people, and their families. These
tools will assist the counsellor to work with the families and partners of
people on the spectrum, to facilitate greater understanding of why people
on the spectrum do the things they do, and facilitate improved overall
functioning of the client and their families. In addition, many of the tech-
niques will also be useful for use with people who share some of the char-
acteristics of those on the autism spectrum.
A cognitive behavioural framework has been utilized for this manual,
as there has been evidence that this is an effective approach with persons
on the autism spectrum, most particularly those who have well-
developed abilities to communicate and function at a higher intellectual
capacity (Attwood 1998, 2003; Heflin and Simpson 1998). Modified
cognitive behavioural approaches are also effective with people who have
mental retardation and counselling is effective with people who have the
cognitive functioning equivalent to a six- or seven-year-old (Kellner and
Tutin 1995), which implies that they would also be applicable for persons
with ASD who also have a mental handicap, providing that the person
functions at the cognitive age of at least six. It is most likely that people
who are on the autism spectrum who seek counselling services will be
verbal; it is to these people that this manual is primarily directed. It is
likely that those with a lower cognitive functioning will be referred for
treatment using an applied behaviour analysis approach, and not for
counselling.
Introduction 13
Much of the research regarding cognitive behavioural interventions

has been conducted on children and youth who are on the autism
spectrum (Aston 2003; Attwood 1998, 2003), but these interventions
can also be adapted and used in working with adults with some modifica-
tion. Attwood (1998) discussed how the logic inherent in a cognitive
behavioural approach is well suited to people who have an autism
spectrum disorder, as these people often respond to logic, although the
logic that people with ASD exhibit may be somewhat odd, as compared
to typical individuals. This has been confirmed in this writer’s experience.
Cognitive behavioural approaches are quantifiable and often concrete,
which in this writer’s experience facilitates the demonstration of effec-
tiveness. The purpose of this manual is to help counsellors to create
meaning to the autistic logic and to provide ways to work with this popu-
lation in an effective manner.
Case studies presented in this manual are composites of different
people with whom this author has worked. Any resemblance to a specific
and actual individual is unintentional, as each case study presents a
mythical person who shares characteristics of several people who are on
the autism spectrum. All names are fictitious.
WHY A COUNSELLING MANUAL FOR PEOPLE ON

THE AUTISM SPECTRUM?
Autism is a lifelong condition with symptomology that can be improved
through specific instruction and behavioural technology (Green 1996;
Rogers 1998a; Smith 1996). With the improvement in prognosis
available through the current teaching technologies, people with autism
are becoming more able and are more fully participating in mainstream
communities (Ruble and Dalrymple 1996). As Aston (2003) and Larkin
(1997) have noted, there are more psychological support services for
parents who have children on the spectrum than there are for adults.
Larkin commented on the prevalent perception of autism being a
childhood disease, and services for people who are on the autism
spectrum may be terminated or severely reduced when they become
adults. However, autism spectrum disorders do not end with reaching the
age of majority. Having a developmental disability implies that you will
not reach the same stage of development at the age of the onset of
adulthood as that of your more typical peers.
The prevalence of persons on the autism spectrum has been estimated
as being 0.5 per cent (Rutter 2005), and these numbers are increasing
(Samuels 2005). What is left unsaid is that these individuals will grow
into adults who will continue to be members of mainstream communities,
may find employment, and may begin families of their own. There is a
growing body of literature that suggests that persons on the spectrum
struggle with issues of anxiety and depression (Ghaziuddin, Weidmer-
Mikhail and Ghaziuddin 1998; Lainhart 1999; Prestwood 1999). In
addition, those with mental retardation are at a higher risk for physical,
emotional, and sexual abuse that will require counselling services (Cutler
2001). It is likely that many therapists and counselling professionals will
encounter persons on the spectrum throughout their career, particularly
as children become fully participating adults in mainstream communities.
It is this writer’s goal that this manual will provide tools for working with
the emotional needs of these individuals.
Currently, persons on the autism spectrum may be underrepresented
as clients in the counselling profession, although they do seek profes-
sional help (Aston 2003; Attwood 1998; Hare and Paine 1997; Jacobsen
2003; Meyer 1999). They are also underrepresented in the psychother-
apy and counselling literature (Stoddart 1999), though notably present in
the behavioural therapy literature. Perhaps the paucity of information can
be attributed to professional perception of this population as having little
to no emotion, as well as challenges stemming from aspects of
symptomology of the autism spectrum, and the use of behavioural
measures as diagnostic criteria (APA 1994). Behavioural approaches have
been primarily used as treatment approaches in autism to address the core
areas of deficit and behavioural issues. Behavioural approaches are seen as
the technology of choice when working with autism spectrum disorders
(Fombonne 2003; Green 1996; Rogers 1998a; Smith 1996).
While behavioural interventions have been at the forefront of treat-
ments for individuals with ASD, the emotional issues of these persons
have not been given much attention (Stoddart 1999).
Introduction 15
There are always emotional issues with which the children with
serious impairments struggle. Without a high level of staff training
in development (normal and disordered) and clinical work,
emotional issues may be easily missed and, therefore, not addressed.
(Ruberman 2002, p.265)
Failure to address these emotional issues is a disservice to this population.

It is likely that emotional issues, left unaddressed, can negatively impact
mental health. What is clearly indicated above is the need for more than
just a behavioural approach with persons on the autism spectrum. Behav-
ioural interventions are not known for their effectiveness in dealing with
emotional issues. Medication is still being explored in this population
with mixed results (Attwood 1998; Smith 1996). Many of the medica-
tions that have proven effective with the general population have
different results with those on the autism spectrum, often with serious
side effects. However, with the current focus on working with people on
the autism spectrum from a behavioural perspective, emotional issues
may not be recognized or addressed. Certainly there are many manuals
and textbooks offering behavioural intervention strategies, but little
published offering suggestions on how to work with emotional and
cognitive issues with persons on the autism spectrum (Attwood 2003;
Hare and Paine 1997). From what is reported in the literature, people
who are on the autism spectrum have no wish to be cured to become like
people not on the autism spectrum; they wish to be helped while main-
taining their identity (Meyer 1999).
Persons on the spectrum present as odd and may be misunderstood
by professionals who are unaware of the autism spectrum characteristics
(Attwood 1998; Jacobsen 2004; Shuttleworth 1999). Aston (2003)
reported that about 40 per cent of the couples with at least one partner
with Asperger’s syndrome indicated that they were dissatisfied with
previous counselling. The main reason for dissatisfaction was that the
counsellor did not understand autism spectrum disorders. There may be
the perception that persons on the autism spectrum do not experience
emotion because they may not display emotion in the socially acceptable
way that mainstream society is accustomed to. A common description of
people on the autism spectrum is that of having a flat affect (Attwood
1998; Jones, Zahl and Huws 2001; Ruberman 2002). Yet people on the
autism spectrum have higher rates of depression and anxiety than people
who are not on the spectrum (Ghaziuddin et al. 1998; Lainhart 1999).
Counsellors and clinicians may find that their talking and insight-
oriented therapies may not be effective with these clients (Jacobsen
2003), but may not find other interventions that are better suited for
working with them. The intent of this manual is to fill that gap and
provide counsellors and clinicians with the tools and strategies to work
with people on the autism spectrum in ways that can effectively address
the emotional, relational, and cognitive issues that they bring to the
counselling session.
ORGANIZATION OF THE MANUAL

This manual is divided into two parts. Part One, Chapters 1 and 2, covers
background information about the autism spectrum. These chapters are
intended to provide a solid base from which to work, and are by no means
exhaustive of the information that is available. This manual is not
intended to be a comprehensive exposition of what we know about
autism; it is more like a condensed survival guide. For those counsellors
who are experienced with people on the autism spectrum, these chapters
will provide a review, although there may be some information that is
novel to the experienced clinician. Most experienced counsellors and cli-
nicians who are familiar with working with people on the autism
spectrum may be tempted to skip into Part Two immediately. We suggest
that you skim through these chapters with an eye for new information. A
complete reading may not be necessary.
Chapter 1 provides an overview of autism spectrum disorders (ASD).
The first part of Chapter 1 discusses the theories of autism and their
history, including information regarding the aetiology of autism, the neu-
rological differences, prevalence, some issues regarding aging, and the
characteristics of autism spectrum disorders.
Chapter 2 provides a brief discussion on different aspects of
cognition found in people who are on the autism spectrum, and some of
the implications of autistic thinking patterns. Here the focus is on getting
Introduction 17
into the mind of someone on the autism spectrum, and to begin to under-
stand why they are so confusing to people not on the spectrum.
The remaining chapters comprise the Part Two of this manual, and
discuss specific issues and empirically supported treatments. Adaptations
of general counselling strategies are covered in Chapter 3. This is where
general counselling modifications and strategies are discussed. Chapters
4 through 8 focus on specific issues and their relevant counselling strate-
gies and modifications.
Chapter 4 discusses depression and modified counselling strategies
as relating to an individual on the autism spectrum. Chapter 5 explores
anxiety and obsessive-compulsive issues; counselling strategies modified
to work with individuals who have autism spectrum disorders are
presented. Included in this chapter are modifications to address autistic
perseveration. Chapter 6 explores the social arena in more depth. Social
difficulties and the implications of difficulty with social interaction are
explored, including interpersonal relations and employment social skills.
Social skill development and social strategies are examined. Chapter 7
addresses stress reduction, including modifications for stress reduction
strategies for individuals with ASD. Chapter 8 concludes with counsel-
ling techniques and strategies to address emotional regulation.
Chapter 9 concludes the manual with some quick rules of thumb
about working with people with autism spectrum disorders.
Part One: Understanding
Autism – Autism Spectrum
Characterisitics and
Cognitive Patterns
CHAPTER 1
Autism: An Overview
The intent of this chapter is to provide therapists with basic information

regarding autism. It is beyond the scope of this chapter to provide a
complete understanding of autism. In fact, in order to understand the
autism spectrum the reader should go to a variety of sources. A good
understanding can be gained from reading first-hand accounts of autism
(see Grandin 1996; Willey 1999). There are also excellent resources that
provide detailed overviews of autism, pervasive developmental disorder,
not otherwise specified (PDD-NOS), and Asperger’s syndrome (AS)
(Aston 2003; Attwood 1998; Jacobsen 2004; Janzen 1996; Quill 1995).
This writer will attempt to provide some history of the psychological the-
oretical underpinnings of autism, a basic understanding of the aetiology
of autism, and the characteristics of autism spectrum disorders (ASD).
HISTORY OF AUTISM AND THEORETICAL

PARADIGMS
It is sometimes helpful to know the history of autism and the theory
behind it in order to gain an understanding of some of the myths and per-
ceptions that have come to us in this millennium. Autism and Asperger’s
syndrome were both described within a year of each other. Leo Kanner
first described autism in 1943 (Fombonne 2003; Janzen 1996) at about
the same time as Hans Asperger (in 1944) described the syndrome to be
named after him (Attwood 1998; Perlman 2000). The word “autism” was
initially used by Bleuler to describe the onset of schizophrenia, and con-
tributed to the confusion between childhood schizophrenia and autism
21
(Fombonne 2003). Asperger’s work went largely unnoticed until Wing

published a paper based on 34 cases in 1981 (Perlman 2000).
Psychoanalysis of autism: refrigerator mothers and

ambivalent attachments
Treatment in the early 1950s and 1960s evolved from the notable diffi-
culties that children who had autism experienced with social attachment
and emotions. Post-World War II child psychiatry attributed autism to
attachment disorders in the mother and child relationships (Fombonne
2003), or by exposure to environments that were lacking in emotional
warmth and enjoyment (Jacobsen 2003; Koegal, Koegal and McNerney
2001). This created a professional perception of autism as being caused
by poor mothering, which may still be held today despite medical
advances that clearly indicate a primarily genetic aetiology (Fombonne
2003; Smith 1996). Psychodynamic theories of autism became prevalent
during this time (Koegal et al. 2001), led by the work of Bettelheim (Quill
1995).
Bettelheim perceived autism as being a disorder caused by “refrigera-
tor mothers” (Fombonne 2003, p.503) who were unable to form
emotional bonds with their children. Autism was seen to be caused by
parental rejection, specifically the child’s emotional withdrawal and
reaction to the parents’ lack of emotional attachment. In 1963
Bettelheim as quoted in Henley (2001) stated:
What is the difference, then, between separation anxiety – which is

man’s basic anxiety – and the anxiety that leads to autistic with-
drawal? I believe it is the infant’s correct reading of the mother’s
emotions when she reappears: that the reunion is unwelcome to her:
that she would rather it didn’t happen. This is when separation
anxiety turns to the certainty that one’s nonexistence is wished for.
With it, every separation becomes an experience of possible
desertion and hence annihilation, a fate that only desperate measures
may possibly ward off. (Henley 2001, p.223)
This initial professional perspective of parents of children who are on the

autism spectrum as being loveless, cold, and unwelcoming to their child is
Autism: An Overview 23
considered erroneous at present (Quill 1995). This misperception was

believed until fairly recently. This writer believes it is important for a
counsellor working in the field of autism to be aware that some of the
messages provided by physicians, and perhaps other professionals, may
still be based on the old paradigm of poor mothering. This psycho-
analytical perception of autism as an attachment disorder and anxiety
over annihilation continues to this day, and is one framework of modern
psychoanalysis of autism (Alvarez 1992; Henley 2001; Jacobsen 2004;
Maiello 2001; Prado de Oliveira 1999).
Psychoanalysis is well represented as a counselling approach for
autism, although it has been used with persons on the spectrum with
limited success (Henley 2001). However, there is some discussion that
indicates that psychoanalysis of children on the autism spectrum is
harmful (Gerland 1999; Sainsbury and Gerland 1999; Smith 1996). Psy-
choanalysis today continues to have a dim view of the biological
aetiology of autism, preferring to look for answers in family psycho-
dynamics and personal or family trauma (Maiello 2001; Prado de
Oliveira 1999).
Treatment for these children was aimed primarily at emotional
recovery and addressing attachment issues and parental trauma factors
(Henley 2001). However, psychoanalytical treatments did not show
dramatic recovery from autism, or good results (Ghaziuddin, Ghaziuddin
and Greden 2002), as treatment length could range from one and a half
years to about twenty (Alvarez 1992). Therapists began to search for
more effective ways to treat autism that would show results more rapidly.
In light of this, behaviour therapies were explored (Quill 1995).
Behavioural interventions and autism

Behaviour therapies have been shown to be very effective in teaching
new skills and behaviours for people on the autism spectrum and are the
most common treatment. Behavioural interventions are used to address
the core areas of autism and to teach new skills (Fombonne 2003; Green
1996; Janzen 1996; Rogers 1998a; Smith 1996). Behavioural
approaches are very effective in the areas of skill development and behav-
ioural change, but address only the symptoms of autism, and not the core
deficits. However, behaviour change and adaptive skill development are
key areas to improve the quality of life of both children and adults on the
autism spectrum.
There is little doubt that behavioural interventions are effective
(Green 1996; Rogers 1998a, 1998b). The main issues with behavioural
technologies are that they are powerful tools of compliance (Lovett
1997) and have sometimes been described as an approach that treats the
symptom and not the person. Cognitive and emotional issues that may be
“driving the behaviour” (Renna 2004, p.18) are seldom addressed by
behavioural interventions.
Aspects of thinking and feeling were often left unexplored, despite
the fact that people with autism spectrum disorders have difficulties with
understanding their environment and with emotional regulation. Under-
standing the reasoning or purpose behind a behavioural request may be
left unexplored, or may be meaningless to someone with ASD. Thus, the
request generates confusion. Why would someone do a meaningless
thing? Enhancing meaning and understanding combined with behav-
ioural change forms the basis of the cognitive behavioural approach.
Attribution of meaning to a situation will affect behaviour (Attwood
1998).
Behavioural approaches may prove to be ineffective with some of the
higher functioning people with ASD, as antecedent and consequence
management may not address the ASD individual’s perception or inter-
pretation of the situation. For many high functioning people, reinforce-
ment and consequence driven behavioural approaches will be resisted as
they may perceive the treatment “as being forced on them” (Heflin and
Simpson 1998, p.200). However, once a practical understanding is
reached regarding the reason for change, people on the autism spectrum
are often more amenable if the meaning makes sense to them, and they
can see the utility of changing their behaviour (Aston 2003).
Aetiology
The aetiology of autism is complex. There are genetic factors that appear
to cause autism, and environmental insults that can also lead to autism.
For a small percentage of people, no cause has been identified (Rutter
2005). Autism is usually diagnosed during childhood, although it is not
uncommon for people who have high functioning autism (HFA) or
Asperger’s syndrome to be diagnosed later in life (Aston 2003; Attwood

1998; Janzen 1996).
Non-genetic factors
Several non-genetic factors appear to play a role in the aetiology of
autism, including the use of prescribed drugs such as thalidomide or
valproic acid use during pregnancy. Recreational drug or alcohol use
during pregnancy seems to enhance the risk of the fetus developing
autism. Also, there seems to be an established link between congenital
rubella and autism. Research has not proved that thermisol, a mercury-
based component of the measles, mumps, and rubella (MMR) vaccina-
tion, leads to autism, despite the controversy, although there is some
speculation that children who become autistic after the MMR vaccine
may be more sensitive to toxins such as mercury. To date, however, no
conclusive link has been found (Rutter 2005).
Genetic inheritance
Twin studies have shown a rate of 60 per cent of twins both having
autism when the twins are identical. This is compared to a 5 per cent rate
of fraternal twins. When examining identical twins where only one has
autism, the rate of the other twin being somewhere on the milder side of
the spectrum is much higher than the rate of fraternal twins, showing
strong heritability: “Taken together with the population base rate for
autism, this implies that the heritability or underlying genetic liability is
about 90% – the highest figure among all multifactorial child psychiatric
disorders” (Rutter 2005, p.232). Families with one member diagnosed on
the autism spectrum report a 6 per cent rate of autism, much higher than
the 0.5 per cent rate in the general population. There are between 3 and
12 susceptibility genes for autism that act in a synergistic manner that
produces the variation of the autism spectrum (Rutter 2005).
Neurological differences
The ability of modern technology to unlock the mysteries of the brain has
shown that there are several differences in the brains of those who are on
the autism spectrum, as compared with those who are normal. Magnetic
resonance imaging (MRI) studies indicate that people with autism tend to
have larger brains overall, larger cerebellar hemispheres, parieto-
temporal lobes, and amygdala, with a reduced corpus callosum
(Brambilla et al. 2003). The limbic system, the seat of emotion, is reported
to be impaired (Rogers 1998b).
People on the autism spectrum do not use the fusiform face gyrus, the
area of the brain that is associated with facial recognition, when looking
at and identifying faces (Schultz 2005). Schultz suspects that the differ-
ences in facial processing may explain the difficulties in recognizing
facial emotions. It may also explain why people on the autism spectrum
may not acknowledge friends and acquaintances when they pass them on
the street or in the hall.
Cerebellum abnormalities are suspected as contributors to the behav-
ioural and cognitive phenotype of autism. The cerebellum is crucial in
learning motor sequencing and adaptation learning, and may explain
why people on the autism spectrum do not accommodate well to change
(Mostofsky, Goldberg, Landa and Denckla 2000).
There appears to be a hemisphere reversal of the brain areas that are
involved in language listening, from the normal left hemisphere to the
right hemisphere in autism. Left dominance for language is found in less
than 5 per cent of right-handed individuals with autism, and in more
than 95 per cent of right-handed people who are not on the autism
spectrum (Muller et al. 1999). As Euro-American educational systems
highly value verbal learning, people on the autism spectrum who have
clear brain abnormalities regarding language are at a disadvantage.
Nonverbal auditory patterns are also unusual, with reduced bilateral
superior temporal and cerebellar activities, and unusual activation of the
left anterior cyngulate gyrus. This demonstrates that the difficulty with
interpreting nonverbal communication lies in the difference in brain
physiology. The anterior cingulated gyrus is normally implicated in
cognitive-attentional and emotional functions, and could be related to
auditory hypersensitivity found in autism (Muller et al. 1999).
Müller, Cauich, Rubio, Mizuno and Courchesne (2004) reported
abnormal motor organization, with diffuse cerebral activation, instead of
the more focused normal activation in the ipsilateral anterior cerebellum.
Activation patterns for simple motor patterns showed a higher scatter
than that found in the control sample. People on the autism spectrum
often have difficulty with motor planning, which can be attributed to
these differences.
People who have autism tend towards having higher brain volume
than that of the normal population. This increase is not present at birth,
but brain volume increases after the age of two. This suggests that the
normal neural pruning which occurs during childhood does not occur in
the usual fashion for those who are on the autism spectrum. In contrast,
the corpus callosum, which is the brain structure that provides the com-
munication pathway between the two hemispheres, specifically the
posterior midsagittal corpus callosum, appears smaller, suggesting that
information may not travel between hemispheres as rapidly as in the
normal population (Palmen and van Engeland 2004).
Prevalence
The rate of schoolchildren diagnosed with autism has increased expo-
nentially. In the 1970s the rate of autism was less than 3 in 10,000
children, while in the 1990s the rate was about 30 in 10,000 (Blaxil
2005). The incidence of the larger autism spectrum disorders are between
30 and 60 cases per 10,000 (Rutter 2005), making autism spectrum
disorders “more prevalent in the pediatric population than cancer,
diabetes, spina bifida, and Down’s syndrome” (Filipek et al. 1999, p.440).
This increase is accounted for by actual increase in numbers, as well as
better diagnostic tools and wider diagnostic criteria, encompassing the
range of the autism spectrum (Samuels 2005). There is a prevalence of
males to females of 3:1, with mental retardation occurring in about 80
per cent of the cases (Fombonne 1999). About one in five first-degree
relatives have a much milder variant of autism. Autism appears to affect all
social classes and ethnicities equally (Rutter 2005).
Lifespan and adult outcomes

There is agreement that people do not “grow out of their autism” (Ruble
and Dalrymple 1996), and social deficits tend to persist. General
consensus is that outcome is poor, as the core deficits of autism do not go
away with age (Howlin 2000), although they will improve (Seltzer,
Shattuck, Abbeduto and Greenberg 2004). Often supports are pulled

away when a person appears to be doing well. Failure to continue to do
well is frequently the result. There is a delicate balance between support
needs and community success. Part of the support needed is consistency
and familiarity in day-to-day life (Ruble and Dalrymple 1996).
Between 10 and 20 per cent of people with severe forms of autism
have good outcomes by adolescence, perhaps holding a job and having
good language skills. The prognosis is much better for those who are less
severely affected. It is reported that between 1 and 2 per cent of individu-
als labelled autistic are able to live independently and that one of the
greatest predictors of good outcome is an IQ above 70 and some form of
communicative speech before the age of six (Stein et al. 2001).
Aging issues
People with ASD enjoy lifespans that are comparable to their peers who
are not on the spectrum (Howlin 2000), and will encounter the loss of
significant persons in their lives, as do typical individuals. However,
people on the autism spectrum may have more difficulty adapting to the
changes. Loss of a significant other may mean changes in living arrange-
ments, routines, and all of the familiar things that enable a person with
ASD to function in mainstream society. In a sense, the person with ASD
may lose their entire familiar world with the death of a parent or signifi-
cant other (Botsford 2000). For people on the autism spectrum, these
changes can be extremely challenging and debilitating, as the people
who know best how to support the person are gone. A good example as
to how changes can be extremely challenging was demonstrated in the
movie Rainman (Molen and Levinson 1988), where Raymond had to
suddenly live with his younger brother. In the movie, simple changes like
having the wrong toothbrush upset Raymond to the point where he
could no longer cope.
People with ASD do not always express emotions in the same manner
as those who are not on the spectrum. Grieving may go unrecognized, or
may be dealt with in an unusual manner. Communication difficulties will
negatively affect the grieving process and behaviours may surface as ways
to cope with grief. Social grieving rituals may be unfamiliar to people on
the autism spectrum. For many, odd behaviours may surface, such as
self-stimulatory behaviours (rocking, flapping, spinning) as a result of

feeling anxious. These behaviours can cause distress for other family
members who are dealing with their own grief (Aston 2003; Attwood
1998; Botsford 2000).
CHARACTERISTICS AND IMPLICATIONS OF

AUTISM, ASPERGER’S, AND PDD-NOS
Autism ranges from the more severe Kanner-type autism to people who
are very intelligent and have a milder variation called Asperger’s
syndrome, or Asperger’s disorder. A different and mildest variant of
autism is pervasive developmental disorder, not otherwise specified
(PDD-NOS; Attwood 1998; Janzen 1996; Quill 1995). Autism is con-
sidered a spectrum disorder, as there is a range of autistic symptomology
with no clear divisions between the different types of autism (Cash 1999;
Gillberg and Billstedt 2000). Although there are some who would
contest that Asperger’s and high functioning autism are different
disorders, for the purposes of this manual they will be considered as part
of the broader autism spectrum.
Diagnosis on the autism spectrum

Autism spectrum disorders are usually diagnosed in the first few years of
life, though later diagnoses are not uncommon (APA 1994; Attwood
1998; Filipek et al. 1999; Janzen 1996). Often diagnosis occurs when the
child enters school, as the situation is often more confusing and
demanding. In some cases, adults get diagnosed after their child receives
a diagnosis (Aston 2003; Quill 1995; Willey 1999).
Autism spectrum disorders, including PDD-NOS and Asperger’s
syndrome, share features of communication impairments, social impair-
ments, imaginative impairments, difficulty interpreting and/or express-
ing emotions, restricted and/or stereotypical patterns of behaviour, and
uneven development. People diagnosed with PDD-NOS have less of
these characteristics than those with Asperger’s, and those with
Asperger’s have fewer characteristics than those with autism (APA 1994).
Persons on the autism spectrum characteristically have sensory difficul-
ties, which impact their ability to relate to their environment (Attwood
1998; Filipek et al. 1999). A portrayal of a classic Kanner-type autistic is

found in the movie Rainman (Molen and Levinson 1988). Grandin (1996)
and Willey (1999) are examples of people who have high functioning
autism and Asperger’s syndrome, respectively.
Accepting the diagnosis of ASD

Dr. Tony Attwood (2006) has identified four common reactions to
receiving a diagnosis of ASD in children and adults. These are: “reactive
depression” (Attwood 2006, p.34), escape into imagination, denial and
arrogance, and imitation. For those who tend towards internalizing
thoughts and feelings, a reactive depression may occur. Often this is
accompanied with the perception that having a diagnosis of ASD means
that the individual is defective in some way. Those who internalize may
withdraw socially, and present with symptoms common to depression,
including suicidal ideation. For some individuals with ASD, the internal-
izing of the diagnosis leads to an escape into fantasy. In the fantasy
worlds they create, they are successful in all areas, including social. Often
this is combined with an abnormal interest in other countries or fantasy
literature.
For some, this fantasy escape provides material for writing fiction. In
some cases, this escape into fiction appears similar to lying, where the
individual tells fictional stories in which the individual is the hero; stories
about how the individual was successful in a situation. This often is
combined with the individual truthfully identifying their actions when
confronted with a specific situation. In this case, the lying was not to
avoid responsibility for something that the individual has done; it is a
fantasy creation of what the individual would like to have happened. On
occasion, this escape into fantasy is seen as being delusional. This writer
has experienced situations with people with an ASD who have visualized
the fantasy interpretation of a real-life situation so often that they can no
longer distinguish between the fantasy version and what actually
happened. This is different from lying, as the person loses awareness that
the fantasy version is not truthful. They can realize what really happened
with some reality testing. Often a question asking them if the event really
happened that way, or if their version is the way that they would have
liked to have acted, can help them to admit the reality.
Some individuals who receive the diagnosis of having an autism

spectrum disorder externalize their feelings and thoughts. They may
deny the diagnosis, and perceive the difficulty to lie with other people,
not with themselves. This often results in arrogance and acting as if the
individual is omnipotent (Attwood 2006). These individuals may engage
in coping strategies that would create a perception of always being
correct and highly intelligent. These individuals may resort to social
domination and intimidation to mask social deficits. They seek to control
social interactions as a strategy to appear socially competent. Negative
misreading of others’ actions often leads to hostile reactions to others’
behaviours as being deliberately malicious. Often they retaliate in these
situations, or seek revenge. Discussion and argument seldom changes
their perception of the situation.
A successful coping strategy is that of imitation of typical peers. This
may be referred to as passing as normal. An interest in drama and drama
classes may develop. Social situations may be re-enacted within the safety
of the home as a learning tool. Difficulties may arise when the social
models are inappropriate, or when the person is identified as something
of an impostor, or not quite authentic (Attwood 2006).
Explaining the diagnosis

When explaining a diagnosis of an autism spectrum disorder, it is helpful
to highlight that this is a spectrum disorder, which means that there are
varying degrees of autism. It is helpful to discuss that there are some
benefits to having an autism spectrum disorder, as well as some difficul-
ties. This may be highlighted through use of a chart of the individual’s
strengths that are related to having ASD, as well as a list of some of the
areas that are difficult. Attwood (2006) refers to this strategy as “Attrib-
utes Activity” (p.691). This writer has used a computer analogy to explain
that individuals with ASD are different, but not faulty or defective. They
have a different operating system, which gives them certain strengths and
certain areas where a computer that does not run an autism operating
system performs better. One parent this writer knows describes the
difference as running an Asperger (AS) operating system instead of a
neurotypical (NT) operating system.
Characteristics of autism
Autism consists of three major areas of difficulty (see Table 1.1): commu-
nication deficits, social deficits, and stereotypical behaviour (APA 1994).
Both receptive and expressive language are affected, impacting social
language as well (Maurice 1996; Quill 1995). Stereotypical behaviour
can include behaviours such as hand flapping, twirling, pacing, and
rocking (Janzen 1996). People with autism range from those who are
severely impaired with significant mental handicaps to those who have
average or above average intelligence. The more severe forms of autism,
which include stereotypical behaviours, and more severely impaired
communication, often associated with a mental handicap, are frequently
referred to as Kanner-type autism (Filipek et al. 1999; Fombonne 1999).
Relative challenges
As mentioned earlier, receptive and expressive communication is affected
with varying degrees of impairment, with those on the higher function-
ing end of the spectrum being least affected. Most frequently receptive
language is stronger than expressive. They have difficulty with expres-
sions of speech (colloquialisms) and are very literal in their interpretation
of language (Happé 1995; Noens and van Berckelaer-Onnes 2004).
People with autism have difficulty shifting their attention. There is
difficulty in shifting attention rapidly and smoothly from one thing to
another. This rapid attention shifting is essential in social conversation,
particularly if there is more than one conversational partner involved. The
inability to switch easily from one subject or activity to another makes it
difficult for someone to transition from one activity to another. Difficulty
with switching attention impacts the ability to switch sensory modalities as
well. It may be difficult for some people on the autism spectrum to switch
between seeing and hearing, or hearing and touching, for example. Activi-
ties that involve all the senses at once can be challenging (Attwood 1998;
Tsatsanis 2004).
Table 1.1 DSM Criteria for Autism

Must have at least six characteristics, including:
Impairment in social interaction, shown by two or more of the following:
Marked impairment of nonverbal Does not develop relationships with

communication behaviours, such as peers appropriate to stage of
facial expression, eye contact, gestures development
and body language
Does not seek to share interests or Does not reciprocate emotional and
achievements with others social cues
Communication impairments, shown by one or more of the following:
Lack of, or delay in acquiring, spoken Impaired ability to start and uphold
language, with no attempt to use reciprocal conversation
different communication systems in its
place
Use of idiosyncratic or stereotypical Lack of spontaneous social play and

language or repetitiousness imaginative play appropriate to stage
of development
One or more of the following characteristics of limited and stereotypical patterns

of behaviour:
Preoccupation with a particular limited Tends to have rigid and nonfunctional

pattern of interest to an unusual degree routines and inability to cope with
of intensity or with an unusual focal change
point
Preoccupation with components of Stereotypical and repetitive motor

objects patterns
Must also have delays or abnormal functioning (evident before 3 years of age) in
social interaction, communicative language, or imaginary play.
Note: Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn (APA
1994).
Case study: Thought stew

People with autism have great difficulty organizing their thoughts,
their possessions, knowledge and information, and their actions.
Jacob, a young adolescent who had autism, described his thoughts
as “things that float in stew. When you try to get the meat, bits of
vegetables and other stuff gets in the spoon, stuff that you may not
want. And, sometimes, you go for the meat but you don’t get any
on the spoon.” Jacob struggled with recalling specific bits of infor-
mation, often producing an “information stew” of unrelated bits of
information that were brought to the forefront during the process
of recall. Jacob often complained that his thoughts came out too
rapidly, often more rapidly than he could express or write down.
When others listened to Jacob, he made little or no sense, and his
line of thinking was impossible to follow. Some of his peers found
this very disturbing.
Paired with the difficulty in self-organization of thought comes a diffi-

culty of knowing what information is relevant when learning new things.
These people may attempt to learn all the information in a chunk, or may
learn unrelated bits of information, unless specifically told what is
important and how it is linked together. They cannot weigh the impor-
tance of each piece of information, nor how it may relate to a central
theme. Learning is often hindered by cognitive inflexibility where new
information may not supersede old information (Janzen 1996; Teunisse,
Cools, van Spaendonck, Aerts and Berger 2001; Tsatsanis 2004).
Motor difficulties are characteristic of autism, as are attention deficits.
Impulse control can be weak. Imitation deficits, including motor
imitation, are also common, particularly in children (Williams, Whiten
and Singh 2004).
Relative strengths
Although there are many deficits, there are some strengths that people on
the autism spectrum may have. People with autism are visual learners and
may have extraordinary visual discrimination skills, often noticing details
that most people miss. Often their visual spatial abilities are above average
(Grandin 1996; Tsatsanis 2004). Some may have the ability to illustrate
what they have seen with extraordinary precision.
One study validated that children (and probably adults) on the autism
spectrum are primarily visual thinkers, and do not visualize things differ-
ently from what they have seen in real life during day-to-day doings
(Frith and Happé 1999). With this in mind, this writer would postulate
that television images may act in a similar fashion, being visualized much
in the same way as day-to-day reality, perhaps blurring the boundaries of
reality and television. Aston (2003) commented that some of her clients
appeared to be learning social skills from the television. This author
wonders how accurately people on the autism spectrum can distinguish
reality from fantasy when they have seen it on television. It has been this
writer’s experience that many people who have autism spectrum
disorders have great difficulty distinguishing between what is
Hollywood glitz and glamour, and what is more representative of
everyday life.
Recall of rote memory learning is a particular strength, and can be
used to help teach new material (Tsatsanis 2004). This strength in rote
learning makes unlearning something very difficult, and, in this writer’s
experience, near impossible. When teaching someone on the autism
spectrum, this writer recommends that the individuals are instructed in
the correct method the first time something is taught, as it will be very
difficult to change how they complete the activity at a later date.
However, it is this writer’s experience that sometimes reframing a new
way of doing things as a rule change due to growing older can be helpful.
Framing a change as a way that adults (or people over 40) are supposed to
do it can sometimes help someone with an autism spectrum disorder
accommodate to the change.
Characteristics of Asperger’s syndrome

People with Asperger’s syndrome share the social difficulties and some of
the other symptomology of autism (see Table 1.2), such as stereotypical
behaviour or limited skill repertoire, but do not have the same language
difficulties. Language acquisition at an early age is a deciding factor for a
diagnosis of Asperger’s. Language acquisition is often odd or atypical.
Their vocabulary is often advanced for their age, and they have good
Table 1.2 DSM Criteria for Asperger’s syndrome

Impairment in social interaction, shown by two or more of the following:
Marked impairment of nonverbal Does not develop relationships with

communication behaviours, such as peers appropriate to stage of
facial expression, eye contact, gestures development
and body language
Does not seek to share interests or Does not reciprocate emotional and
achievements with others social cues
Stereotypical, limited, and repetitive behaviour patterns, and interests, shown by

one or more of the following:
Preoccupation with a particular limited Seemingly rigid adherence to specific

pattern of interest to an unusual degree routines that appear to be
of intensity or with an unusual focal nonfunctional
point
Stereotypical and repetitive motor Preoccupation with components of

patterns objects
These factors bring about impairment in social, occupational, or other kinds of

functioning. There is no significant delay in language, cognitive development,
and acquisition of self-help skills and adaptive behaviour apart from social skills.
Note: Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn (APA
1994).
verbal memory. They tend towards being higher functioning and have
normal to high intelligence and may have excellent logic skills, although
the logic may be based on faulty assumptions (Aston 2003; Frith 2004;
Perlman 2000; Tsatsanis 2004).
Often people with Asperger’s develop coping strategies that can hide
the social difficulties they experience, and can present as not having any
disability. Often they can integrate socially, although they may appear
shy, aloof, awkward, overly friendly, or too talkative. It is this ability to
cope and present well that confuses parents and professionals, as well as
delaying or hindering recognition that these people require support or
help (Portway and Johnson 2003; Willey 1999).
Problems with personal organization and time management are

common. Individuals with Asperger’s syndrome have a preference for
fixed, predictable routines and highly structured environments, and can
experience a great deal of distress when there is unexpected change, even
when the change appears minor. Often it is the other-than-expected
change that violates previous expectations that causes the most difficulty.
They often have great difficulty coping when something they expect to
happen does not happen, or happens differently from what they planned
(Sofronoff, Attwood and Hinton 2005; Tsatsanis 2004).
Social isolation is a problem, and can set the stage for childhood
bullying. Children and adults with autism spectrum disorders tend to be
socially isolated, a characteristic trait that bullies seek in their intended
victims. Children with autism spectrum disorders do not have the social
skills necessary to cope successfully with bullying, and may engage in
retaliatory behaviour, aggression, or social withdrawal (Attwood 2006).
People with Asperger’s syndrome have difficulty with eye–hand and
visual motor coordination, often resulting in teasing during school years
due to their difficulty with sporting and physical activities (Attwood
2004; Portway and Johnson 2003).
Girls with Asperger’s syndrome

Girls with Asperger’s syndrome are supposed to occur in one out of four
cases, but the real-life occurrence is much more rare, at about one in ten
cases. Attwood (1999) explains that this may be due to girls being more
eager to learn and quicker to understand concepts than boys, masking
their disability to some extent. Asperger mothers, Attwood notes, have
more empathic abilities towards their children than Asperger fathers,
perhaps an indication that the female tendency towards greater empathic
abilities acts as a buffer for Asperger women and girls. Seltzer et al. (2004)
report that females who have autism spectrum disorders are more likely to
be more severely impaired.
Characteristics of pervasive developmental disorder, not

otherwise specified
Pervasive developmental disorder, not otherwise specified (PDD-NOS) is
used as a diagnosis when the individual fits some but not all of the criteria
for autism or Asperger’s syndrome, when onset is late, or when the person
would be diagnosed with atypical autism (see Table 1.3). Often diagnosis
of PDD-NOS occurs when features of Kanner-type autism, such as
stereotypical and ritualistic behaviour, communication impairments, and
social skill deficits, are present, although not in a sufficient amount to
warrant a diagnosis of autism or Asperger’s (Filipek et al. 1999;
Fombonne 1999).
Savants and savant skills

About 10 per cent of ASD individuals show savant talents, many of these
people being of average or above average intelligence (Cash 1999).
Savant abilities have been popularized through movies such as Rainman
(Molen and Levinson 1988). Savant abilities include being able to paint
or draw far better than their peers, to count extremely fast, or being able
to calculate the day on which any given person is born. Savant abilities do
not always appear to be the function of practising the behaviour over and
over again, and may be the culmination of the skills found within the
autism spectrum.
Table 1.3 DSM Criteria for Pervasive Developmental

Disorder, Not Otherwise Specified (PDD-NOS)
The term PDD-NOS is used when there is a persistent significant impairment in
social interaction or communication skills, both verbal and nonverbal, or when
there are stereotypical behaviours and interests, but the criteria for other
developmental disorders cannot be met. Atypical autism, involving late onset,
subthreshold, or atypical symptoms, is included under this heading.
Note: Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn
(APA 1994).
Case study: Savant musician

One adolescent with ASD could perfectly reproduce a song after
only hearing it once. This skill was not always enjoyed by the lad’s
mother, who did not always appreciate her son’s pride in playing
songs that did not fit with the family’s religious and moral beliefs!
He did not understand his mother’s upset at some of his music
choices. He could play the song perfectly, but did not always
understand what the lyrics were all about. He did not think there
was anything wrong about singing the lyrics, even if he did not
know what they meant, as they must be socially acceptable if they
are played on the radio. As you can imagine, some of the more
popular music heard in high school does not espouse virtuous
behaviour or attitudes, and was not a hit with his parents.
Communication difficulties
Communication impairments increase with the degree of autism, and
both receptive and expressive language is impaired to varying degrees.
There is a high correlation between IQ and verbal ability in autism.
Nonverbal persons on the autism spectrum are much more likely to have a
learning disability or mental retardation, and a much poorer prognosis.
By the time an ASD child has reached high school, their level of commu-
nication closely resembles the level of their future adult abilities (Noens
and van Berckelaer-Onnes 2004).
Communication differences include egocentric speech, failure to
recognize the speaker’s meaning, and pragmatic language difficulties,
such as incorrect use of pronouns and odd prosody. Often their speech
has odd intonation patterns, a droning quality, and with inappropriate
volume. Nonverbal and paraverbal cues are not understood when given
by others, and are not used in the usual fashion by the person on the
autism spectrum. They may use words in an idiosyncratic manner, but
grammar and vocabulary may be intact. Communication errors also occur
around the distinctions of giving new information and information
assumed to be known, and failure to conform to conversational rules and
turn taking. People on the autism spectrum may also ask questions to
which they already know the answer, or ask questions in an abnormal
way (Perlman 2000).
Often language is taken very literally, and figures of speech or collo-

quialisms are misunderstood and can cause confusion (Happé 1995;
Noens and van Berckelaer-Onnes 2004; Ogletree and Fischer 1995).
Irony and sarcasm are almost always lost on ASD people, while
metaphors and jokes involving word play simply confuse them.
Verbal communication requires rapid processing of speech and
nonverbal cues that are fleeting. Noens and van Berckelaer-Onnes (2005,
p.134) describe an engineer who referred to himself as “seeing blind and
hearing deaf.” For this individual, processing conversation is taxing and
time consuming, with the result that he often cannot understand most
conversation. Verbose communication partners can overload the ASD
person with their conversation, which may cause emotional
dysregulation (Laurent and Rubin 2004).
Comprehension and expression

Comprehension is more impaired than language expression, particularly
for those on the higher end of the spectrum (Perlman 2000; Tsatsanis
2004). This is a result of language being learned in chunks and phrases
without necessarily fully comprehending exactly what is said. People
with Asperger’s tend to have fluent and articulate speech, although they
may have difficulty sustaining a social conversation (Martin and
McDonald 2004). Children with Asperger’s syndrome often gain
language at the same rate as their peers, but language use is odd, with the
vocabulary often more adult-like (Frith 2004). Symbolic aspects of com-
munication are often not understood (Noens and van Berckelaer-Onnes
2004).
An analogy that this writer often uses would be that of someone who
has learned a second language using a phrasebook. They may have
eloquent phrases to express themselves but might not fully comprehend
what the phrases mean. Nuances of meaning become lost. Impairment in
communicating tends to be stronger when emotional language is
involved (Attwood 2003; Meyer 1999). Often others fail to appreciate
that understanding of language is more limited than would be assumed
from the person’s ability to express himself (Noens and van Berckelaer-
Onnes 2004). Of course, the person on the autism spectrum is often
unaware that their meaning may be different from the meaning the
receiver has determined from the conversation.
Language may be well understood only in highly familiar situations
and topics of expertise. People on the autism spectrum will, to varying
degrees, perseverate on a topic of interest and fail to maintain the topic of
discourse if it is outside their subject interest (Noens and van
Berckelaer-Onnes 2004; Perlman 2000).
For some other ASD individuals, most notably ones that have more
severe impairment, receptive communication may be stronger, although
both are impaired. They may use echolalia to a greater degree, and not
always in a manner that conveys language fluency. These are the people
with word retrieval issues who cannot find the right words easily to
express themselves. Again, emotional language is the most impaired.
These people may be partly verbal, and rely on echolalic tendencies to
express themselves verbally (Attwood 2003; Meyer 1999).
Echolalia
There are two types of echolalia. Immediate echolalia involves the
immediate repeating back of what is said, while delayed echolalia is the
repeating back of something that was heard in the past. An example of
immediate echolalia would be when a person says the word “coffee” after
he or she were asked whether they would like a coffee. Delayed echolalia
would be the repeating back of something that was heard a while ago,
such as repeating back the news broadcast from the night before, word
for word, including commercials; or repeating back, word for word,
including vocal tone and intonation, the telephone conversation a parent
had a week ago. Most often echolalia consists of chunks of sentences, and
the person may not completely comprehend the nuances of the language
they are using. Echolalia can be a bridge for acquiring verbal language
(Janzen 1996).
Social impairments
Social impairment is profound in persons who have autism, with a lesser
impairment in those who have Asperger’s or PDD-NOS. The difficulty
arises from a lack of understanding of social rules, not from a lack of
desire to socialize (Aston 2003; Portway and Johnson 2003). “One

should recognize that such individuals, who may have adequate cognitive
capacity, lack basic social skills. It is easy to misinterpret disengagement
or obtuse behaviour as motivated by hostility or a lack of interest in
others” (Perlman 2000, p.224).
People with autism may fail to distinguish rude responses from polite
ones. This may be due to the impairments of the theory that other people
have minds also, and how they would perceive the communication. There
needs to be an understanding of why one would want to be polite, as the
impact of their behaviour on others is often left unconsidered. Respond-
ing with empathy is difficult, and often impossible, for people on the
autism spectrum. For someone on the autism spectrum, even those who
are higher functioning, it can be difficult to remain calmly engaged in
social situations when these situations are difficult to predict. One way to
gain some form of predictability is to monopolize conversations and
social situations. This often appears rude and obtuse (Baron-Cohen and
Wheelwright 2004; Cash 1999; Laurent and Rubin 2004).
Emotional impairments
People on the autism spectrum have difficulty both expressing emotions
and understanding others’ emotions. They may show difficulty in distin-
guishing between physical sensations and emotional arousal. There
appears to be more impairment in understanding emotions than in
expressing them, at least in higher functioning people with ASD. There is
an inability to discern others’ emotions from their eyes and significant
difficulties determining others’ emotions from vocal tone or prosody
(Rutherford, Baron-Cohen and Wheelwright 2002). Facial expression
can be flat, exaggerated, or unusual (Attwood 1998; Hill, Berthoz and
Frith 2004; Jones et al. 2001).
Emotional regulation
When in a calm state, children (and adults) with ASD can use their
language abilities to seek help or change the situation to maintain
emotional regulation. This breaks down, however, when they are no
longer emotionally regulated or are overaroused. Often the dysregulated
behaviours stand in sharp contrast with their abilities when they are emo-
tionally calm and are confusing to the people around them. Emotional
regulation, which is how one achieves an optimum arousal state to be
fully participating in social activities or to meet environmental demands,
is crucial to remain socially acceptable, solve problems, and communicate
effectively (Laurent and Rubin 2004).
It is common for people on the autism spectrum to show behavioural
signals that they are becoming emotionally dysregulated or overaroused.
Some of these signs can include toe walking, hand flapping, carrying
around a favourite toy or article and refusing to let it go, or chewing on
clothing. Signs of greater dysregulation are lashing out behaviours, with-
drawal, or tantrums. Often these signs of dysregulation are not responded
to as coping strategies indicating difficulty, and communication partners
may see these as problem behaviours. Punishing or ignoring these behav-
iours seldom helps the ASD person to regulate their emotions in the
social situation, and adds to the individual’s stress (Laurent and Rubin
2004).
Restricted range of interest and perseverations

People on the spectrum usually have a restricted range of interests, often
narrowly focused into one or two areas. Often they will seek to engage
only in these specific activities or will speak on these one or two topics,
whether or not their audience is interested. Sometimes the repetitive
interest appears to be like an obsession, interfering with the ASD person’s
ability to connect socially and daily routines, and limiting family interac-
tions. These restricted interests are experienced as pleasurable to the
person with ASD, thus distinguishing them from true obsessions, which
are done to bring relief from discomfort, while restricted interests are
engaged in for their enjoyment. For some, their expertise in a given area
of interest is a source of pride (Grandin 1996; Perlman 2000).
Sensory abnormalities
Sensory abnormalities are commonly found in people on the autism
spectrum, such as hypersensitivity to sounds and tactile defensiveness, a
case where different kinds of touch, often light or gentle touch, are felt as
aversive (Grandin 1996; Jones, Quigney and Huws 2003; Perlman

2000).
Approximately 70 to 80 per cent of people with ASD report sensory
abnormalities. Sensory overload is common. All of the senses are affected,
including kinaesthetic and proprioceptive senses. Depth perception and
motion perception may be affected. The person on the autism spectrum
may experience both hypersensitivity and hyposensitivity, and vary
between the two over time (Jones et al. 2003; O’Neill and Jones 1997;
Raymaekers, van der Meere and Roers 2004). One study of children
reported by Harrison and Hare (2004) indicated that about 70 per cent
were sound sensitive, about 50 per cent were tactile sensitive, about 40
per cent were smell sensitive, and 40 per cent taste sensitive. Harrison and
Hare reported that almost 25 per cent of the children were hypersensitive
to pain, and 45 per cent were hyposensitive to pain.
Sudden unexpected noises have been reported as being experi-
enced as painful, and other people talking can be distracting. Colours
can be experienced as being uncomfortable to look at. Food textures
can be experienced as aversive. These sensory sensitivities explain
some of the odd behaviour found in autism, such as when a person
wears socks inside out so the seam is not against their toes, when one
colour is avoided, or when sunglasses are worn inside buildings.
Sound or vision may suddenly go blank, to return again unexpectedly.
For some people with ASD during some of the time one sense may
become dominant, so that they are only aware of one sense at a time
(Harrison and Hare 2004; Jones et al. 2003).
When people with ASD are overstimulated by their senses, they lose
their ability to inhibit their responses. Sensory overstimulation reduces
their ability to cope. This helps to explain the common observation that
people, especially children, on the spectrum tend to lose their ability to
manage their behaviours in overstimulating situations (Attwood 1998;
Raymaekers et al. 2004).
People on the autism spectrum, particularly those who are more
severely affected, can experience synaesthesia, a condition where the
senses become mixed up, so that sounds may produce an experience of
seeing colours, and colours may produce the sensation of taste or smell, or
other mixing of senses (Cash 1999; O’Neill and Jones 1997).
Coping strategies for sensory issues

Jones et al. (2003) discuss that the people they researched had coping
strategies, like using the sense of touch when other senses were being
overloaded. Other coping strategies included being aware of overstimu-
lating situations and avoiding them. Sometimes focusing in on one sense
or one sensory aspect in a confusing sensory experience was used to cope,
such as focusing on carpet patterns. For one person with ASD in school,
they were unable to listen to lectures and take notes while looking at the
teacher. They could listen, or write, or look, but not more than one
activity at a time. Withdrawal into oneself was used as a coping
mechanism for overstimulating and overwhelming experiences. Another
common coping strategy to reduce overstimulation is gaze avoidance, as
another person’s eyes are often the most stimulating feature of a face
(Grandin 1996; Jones et al. 2003; Willey 1999).
Stereotypical behaviours
People on the autism spectrum have what are known as stereotypical
behaviours. These behaviours can consist of rocking, flapping the arms
and/or hands, twirling in circles, and pacing. Other behaviours that are
odd and repetitively done can also be included as stereotypical. An
example might be making odd noises, jumping, and twirling fingers in
front of the eyes. Stereotypical behaviours are within the individual’s
control, and are often engaged in as a stress releaser or for the sensations
they bring. When these behaviours are engaged in for pleasure, they are
called self-stimulatory behaviours. Often self-stimulating behaviour is
engaged in for the sensory pleasure it provides (Harrison and Hare 2004;
Janzen 1996; Jones et al. 2003; Sofronoff and Attwood 2003).
AUTISM AND COMORBIDITY

Having a diagnosis on the autism spectrum does not preclude having
forms of psychopathology. Differences in emotional expression or flat
affect may mask comorbid mental health issues. Symptomology of
mental health issues may look like problem behaviour in less verbal
people. The prevalence of comorbid conditions in persons who are on the
autism spectrum is higher than those in the normal population
(Ghaziuddin et al. 1998; Hare, Jones and Paine 2000; Lainhart 1999;
Ruberman 2002).
Comorbid mental health conditions

In the past there was an assumption that intellectual deficits took prece-
dence over psychiatric symptoms, resulting in the erroneous conclusion
that people with mental retardation and cognitive deficits could not also
have psychiatric illnesses. In a sample of people with Asperger’s
syndrome, obsessive compulsive disorder (OCD) was found in 19 per
cent of cases, and attention deficit hyperactivity disorder (ADHD) was
also common (Raja and Azzoni 2001). There is an increased risk of
bipolar disorder among people with ASD and their close relatives. About
80 per cent of people with a diagnosis of Kanner-type autism also have a
diagnosis of mental retardation, with an overall rate of about 10 per cent
when considering the entire autism spectrum. Fragile X syndrome can
occur with autism spectrum disorders, as can Tourette’s syndrome.
Tourette’s and Asperger’s syndrome appear to be more common than
Tourette’s with Kanner’s autism (Gillberg and Billstedt 2000).
Eating disorders can occur with people on the autism spectrum,
including anorexia. Other eating disorders, such as pica, otherwise
known as the eating of nonedibles, can also exist. Strong food prefer-
ences, refusal to eat foods that touch each other, and limited food reper-
toires are common (Attwood 1998; Gillberg and Billstedt 2000).
Depression and anxiety appear to be the most common conditions
that persons on the autism spectrum experience. People indicate that the
comorbid conditions of anxiety and depression are the most disabling
aspects of living on the autism spectrum (Ghaziuddin et al. 1998; Hare et
al. 2000; Raja and Azzoni 2001; Seltzer et al. 2004). Of the comorbid
anxiety conditions, social phobia can occur in about 62 per cent of the
cases (Tani et al. 2004). At least one clinical symptom of anxiety, if not
more, was found in all of the young adults studied by Tani et al. (2004)
with 65 per cent of the participants reaching the threshold for clinical
anxiety syndrome. Suicide is a concern, though underreported (Hardan
and Sahl 1999). Low self-esteem and low self-efficacy are common issues
(Attwood 1998), and can be compounded by having an IQ in the border-
line range for mental retardation, as diagnosed by DSM-IV (APA 1994).
Cognitive impairments may negatively impact intellectual development

and emotional development.
Comorbid medical conditions

It is estimated that about 10 per cent of people on the autism spectrum
have comorbid medical conditions (Rutter 2005). Seizures are common,
with rates of 25 to 30 per cent, while attentional disorders or overactivity
can range from 21 to 72 per cent. Up to 65.1 per cent of persons on the
spectrum may have sleep disorders (Lainhart 1999). Epilepsy and sleep
disorders are often found together in people who have autism, with sleep
and interrupted sleep facilitating seizure occurrence, and seizure activity
interfering with sleep. Often treating sleep disturbances can positively
affect this cycle. Sleep disorders are found in about 80 per cent of adoles-
cents on the autism spectrum, and it is likely that there is a high rate of
sleep disorders in adults as well (Øyane and Bjorvatn 2005). There is
evidence that anxiety disorders negatively affect sleep (Tani et al. 2004).
Tuberous sclerosis is commonly associated with autism (Rutter 2005),
with a high proportion of children with tuberous sclerosis diagnosed at
an early age as having comorbid autism (Gillberg and Billstedt 2000).
CHAPTER 2
Autistic Thinking
and Autistic Logic
One of the aspects of the autism spectrum that can be confusing for prac-
titioners is the cognitive distortions and unusual logic found with this
population. Given the sensory processing differences, the language
impairments, emotional impairments, and high rates of comorbidity,
there is little wonder that their way of thinking may be different from that
of the population that is not on the autism spectrum. Often their way of
thinking makes no sense given what counsellors know about the theories
of personality, relationships, and the unconscious:
What I knew about psychoanalytic and other personality theories,

psychodynamics, unconscious motivation, subtle or “understood”
meanings was not helping me to understand these people’s minds or
their experiences. They could seem self-centered, detached,
uncaring, or even hurtful. Yet, they were often attached to people in
their lives. They could be pleased or upset when they pleased or dis-
appointed others. Why another person was pleased or disappointed
was often a mystery to them. They seemed odd to others, and others
often seemed odd to them. (Jacobsen 2003, p.570)
Jacobsen prepares us with her statement that much of what we have come
to understand does not apply without taking into consideration the char-
acteristics of the autism spectrum. There are curious deficits in cognition
that are rather unique to this population, regardless of the level of intelli-
gence. Understanding how people on the autism spectrum think will
facilitate understanding the individual in the counselling room.
49
VISUAL THINKING
One of the hallmarks of the autism spectrum is their propensity to think
visually. For some people on the autism spectrum, there are only pictures
inside their heads (Grandin 1996; Willey 1999). Attwood (2003) quotes
an adolescent with Asperger as saying: “I have the picture in my mind but
not the thousand words to describe it” (p.82). This was demonstrated in
one experiment with children who were on the autism spectrum (Frith
and Happé 1999). Several children with autism recorded their immediate
experience or thoughts when a beeper went off during the day. The
results were primarily of images, including words written on the image to
make a thought. There was little, if any, difference between the visual
thought and what was seen in real life, as if the children could not
imagine something that was not true.
Grandin (1996) noted that most of the people who surrounded her in
college thought in verbal words. People on the autism spectrum do not
use verbal strategies to memorize information, and may seldom use
verbal strategies at all (Tsatsanis 2004). Verbal, language-based learning
is the primary modality of schooling in North America. As visual thinkers
in a language-based learning environment, people on the autism
spectrum are at a disadvantage in our educational systems. Attwood
(1998) indicated that people on the autism spectrum visualize informa-
tion instead of recalling words verbally in their head. This strategy leads
to poorer recall of verbal information. Attwood reports of one person on
the autism spectrum who indicated that verbal words did not seem to stay
in her head in any meaningful way. How much information is lost when
stories and text are converted to pictures and videos? What is gained in
the translation?
This visual thinking may not be exclusive in all people on the autism
spectrum, and some people with ASD may also talk to themselves as they
think, but current research seems to indicate that visual processing of
information and visual thinking are the norms for people on the autism
spectrum (Attwood 1998; Grandin 1996). The implications are
profound. Visual images tend towards the concrete, not the abstract. How
many abstract concepts have no visual image? Grandin discussed how she
made visual images for concepts, sometimes using printed words with the
images. What happens to meaning making and language comprehension
Autistic Thinking and Autistic Logic 51
when you can only recode it in your mind as a picture? Grandin wrote
that abstract concepts were translated into pictures of movies that showed
the concept or something closely associated to the concept. She reported
that things that are more abstract could be incomprehensible:
Growing up, I learned to convert abstract ideas into pictures as a way

to understand them… The Lord’s Prayer was incomprehensible
until I broke it down into visual images. The power and the glory
were represented by a semicircular rainbow and an electrical tower.
(Grandin 1996, p.33)
Many, if not most, social concepts are abstract, and may only be under-
stood by someone on the autism spectrum by translating the concept into
concrete examples of behaviours that would occur. Grandin (1996)
reported using this strategy to understand concepts like honesty. She
collected pictures and video examples of what honesty would look like in
real life, and stored these in her mind as a way to understand the concept.
She was able to understand abstract social concepts only when the
concept was made concrete and visual. She could not understand the
abstract concepts without translating them into images. Visual thinking
tends to be concrete in nature.
Fortunately, one can cope in our world at the concrete operational
stage, as only about 35 per cent of people in industrialized countries ever
progress past the concrete operational stage to the formal operational
stage of development. At the concrete operational stage, logic has
developed, although abstract thinking and thinking about the future are
not mastered (Huitt and Hummel 2003). However, the difficulty with
conceptualizing abstract concepts in visual modalities can lead to differ-
ences in the understanding of these concepts. People on the autism
spectrum may have idiosyncratic meanings and associations for abstract
concepts (Grandin 1996).
Frith and Happé (1999) noted that the children they studied did not
seem to be able to visualize anything other than what was in their
immediate environment. Aston (2003) writes about one partner of a man
on the spectrum who appeared to watch something on the television, and
then try it on his wife. He was using the television as a social model. This
demonstrates that television can provide the visual images and movies
that people on the autism spectrum learn from. The use of videos to
instruct people with autism spectrum disorders has been shown to be
effective (Charlop-Christy and Daneshvar 2003) and compares
favourably to in vivo modelling of a task. This demonstrates that informa-
tion is digested best when it is created in a visual format. The challenge is
to take counselling, which is based mostly on talking, and adapt it to a
visual mode.
Art therapy and autism

However, art therapy may not be an effective avenue for people who have
autism spectrum disorders. The communication difficulties that people
on the autism spectrum have and the difficulty with symbols and
symbolic language create difficulties when attempting to interpret art for
therapy (Noens and van Berckelaer-Onnes 2004). Often the symbolism
of objects and concepts is unique to the person on the spectrum (Grandin
1996). With people on the autism spectrum, interpreting drawings may
be impossible as there is often no hidden or symbolic meaning to the
drawing, although the process of creating the art has therapeutic value:
“Indeed, we have frequently found that an analysis of the final image
alone gives a misleading understanding or interpretation of what is going
on for the child” (Evans and Dubowski 1988, p.9). Evans and Dubowski
indicated that the drawing skill of many higher functioning children on
the autism spectrum misleads art therapists into thinking that the child
can communicate proficiently through art. Also, there is the possibility
that images may come from television programs and commercials that the
person on the spectrum has seen, and that the image itself may be
appealing with no deeper meaning attached to it, confounding attempts
to interpret art with these individuals.
Case study: The mushroom artist

Bill was a nine-year-old child with autism who enjoyed repeatedly
drawing a particular kind of mushroom, shaped like a long and
thin upside down letter “u”, which vaguely resembled a penis. You
can imagine the disturbance this caused at school, when the adults
interpreted Bill’s drawings. The school counsellor was positive that
Bill had been sexually abused. Despite evidence to the contrary,
and a rather large mushroom farm under his bed of these very same
mushrooms, the school continued to suspect abuse. However, in
this case, it was simply that Bill’s favourite activity and drawing
subject had a provocative shape. Sometimes the drawing is literally
exactly what it is – no more, no less. This writer concurred with the
school that a thorough investigation was warranted to determine if
there were any issues of abuse, but that the drawings themselves
may not be related to issues of sexual abuse. With most children,
repetitive drawing of penis-shaped mushrooms would be a cause
for concern; for a child with ASD who has a mushroom farm as his
favourite hobby, drawings of mushrooms may only be an expres-
sion of his favourite activity.
LITERAL THINKING
People on the autism spectrum are often literal thinkers (Happé 1995;
Martin and McDonald 2004; Noens and van Berckelaer-Onnes 2004;
Ogletree and Fischer 1995). Figures of speech confuse them, and are mis-
understood. It is this writer’s guess that this colloquialism confusion
makes sense from a visual thinking perspective, as many figures of speech
do not make sense as pictures. Take the example of the expression of
raining cats and dogs. What would it look like to have cats and dogs
falling from the sky? What would it sound like? What image comes to
mind when thinking about cats and dogs hitting the ground from that
height? The visual image is rather gruesome, don’t you think? Feeling
blue? How does that make sense? Does that mean that you would have
blue skin? What if having blue skin would make you happy? The thought
of having a frog in your throat might be rather disturbing. Would being
full of bull feel painful? If someone called you a smart Alec, would that
mean you were dumb if your name was Bill? It does not take many collo-
quialisms to demonstrate that they would be confusing to someone who
is a visual and literal thinker.
Case study: Catch you later

This writer was called in to work with Steve, an older adolescent
with Asperger’s syndrome who was attacking teachers and
students. During the initial interview it was discovered that Steve

was doing exactly as he thought he was being told to do. Steve’s
peers and teachers would say that they would catch him later. The
next time Steve saw them, he would run up to them and grab them
by the collar, smiling as he caught them. Steve would then become
very upset when they became angry with him for grabbing them.
The teachers and students thought they were being attacked. Steve
was confused. Steve stopped this when this writer explained to
him that the phrase “catch you later” was a way of saying that he
would meet this person at a later time, and was not a request that he
grab the person the next time they met. Steve became so enlight-
ened by this that he decided to create a book of expressions and
their meanings for himself, so that he would not frighten or anger
his friends. Steve’s social behaviour improved rapidly as his book
grew larger.
Literal thinking can also mean that there is no underlying meaning.

Words are taken at face value and hidden meanings are left unexplored. It
also means being very specific in thought and communication. Aston
(2003) commented on how literal people with Asperger’s are. She
recounted a client who insisted that she was not being unfaithful to her
husband when having an affair, as she would tell him if he asked. She
simply said that he never asked, so she thought he knew and it was okay
with him. For her, the affair was okay because she was not hiding it from
her husband. Aston also reported about a male who did not think he was
cheating on his partner when he was having sex with a man, because his
interpretation of having an affair meant that he had to be having sex with
another woman. Because the second partner was a man, there was no
affair, and therefore nothing to get excited about.
Case study: What you ask for is what you get

Many of this writer’s very intelligent clients are literal and specific
thinkers. They do not read any more into a communication than
what was exactly said. They follow directions to the letter, exactly
as they were given. This writer was called by a teacher to work
with a disruptive student. Joey, a bright young man with ASD, was
having difficulty in high school because he was sitting down on

the floor and disrupting the class. Upon observation it was deter-
mined that he was being extremely compliant. When the teacher
said to sit, Joey sat down immediately, on the spot. This spot was
often the floor. When directed to sit on his chair, Joey happily got
up off the floor and sat on his chair. Joey expressed that he was
often confused when the teacher got angry with him when he did
what she asked him to do. Joey could not determine that sitting on
the floor was not appropriate, and that the teacher meant him to sit
on the chair. Joey made many similar errors in interpretation
during class, earning him the labels of being oppositional and
defiant. When Joey was instructed to ask for clarification when he
was unsure of the instructions the teacher gave him, it became clear
that he could only understand what the teacher had specifically
said, and could not infer what she meant when the instructions
were unclear. Soon everyone was happy, as Joey was no longer
acting strangely, and the teacher was not losing her patience about
his actions.
Therapists need to be very specific with people on the autism spectrum. If

a therapist tells someone with ASD not to eat any sweets before dinner,
they will probably be okay with that and eat something salty instead, and
ruin their appetite anyway. You cannot assume that the person on the
autism spectrum will understand what you mean in a global, broad
fashion. This is due to an orientation to details and a weakness in central
coherence in thinking, which will be covered in more detail later in this
chapter.
Case study: Loophole thinking

This writer sometimes refers to literal thinking as loophole
thinking. Jack was above average intelligence. He was referred for
what was termed “flaunting the rules.” Jack’s high school teachers
were extremely frustrated with him, and did not believe that he was
on the autism spectrum as he appeared to be intentionally manipu-
lating the rules. Jack followed the rules or instructions given to him
to the letter. When instructed that he could not have his lunch
before the lunch break, he proceeded to eat his after school snack.
Jack became angry when stopped, as he was not instructed not to
eat his after school snack. He was asked not to eat his lunch, and no
one had said that he was not to eat any food at this time. When Jack
was given clear and detailed directions, covering all contingencies,
he complied. Jack was taught that finding a way around the rule
was called finding a loophole. Jack was given a rule to help him
out. That rule stated that if Jack could find a loophole or way
around a rule, he was to ask the person directing him if the
loophole was okay to do. Jack enjoyed this as a game, and it helped
the people around him to say what they meant and to mean what
they said.
Loophole thinking affects counselling in that the individuals with an

autism spectrum disorder may not provide sufficient information. During
counselling, it is important that you ask specific and detailed questions
when seeking information. It is not that individuals with ASD will be
consciously holding back information, it is just that they would not think
of sharing it without being specifically asked. Often the individual with
ASD will answer your specific questions, as this tells them exactly what it
is that you wish to know. Nondirective counselling strategies may prove
less than effective given this characteristic.
SELF-CONCEPT
Adults on the autism spectrum lack a sense of self or reference to self,
leading to problems in processing words related to the self. There appears
to be a profound deficit of self-consciousness (Toichi et al. 2002). It is as if
there is no concept of a self, no concept of personal identity. It may be
that self-concept and self-referents are too abstract to be made into visual
images for people on the autism spectrum to understand.
Children on the autism spectrum were shown to have greater diffi-
culty in remembering events that they had personally experienced than
events that they saw another child experience, yet there were no differ-
ences in free recall tasks. Millward, Powell, Messer and Jordan (2000)
postulated that having another person accompany the child may enhance
their memory, perhaps serving as a memory cue.
This writer proposes a different possible way to interpret their
findings in the light of the characteristic of visual thinking. It may make
sense from the perspective of the discovery made by Frith and Happé
(1999) regarding the random thoughts of the children they studied.
These children’s thoughts were mostly of the visual images that their
environment presented to them at the time when the alarm went off and
they were to indicate what they were thinking at that moment. Two
things are highlighted in this study. The first is that the recall was of
images only, and the second is that the images are from that moment in
time, suggesting that the children are highly visual and tend to experi-
ence life in the moment.
If you were to extend these findings to the recall of self versus others’
experiences, it would make sense that recall would be better for what the
individual with ASD saw another person experience, because there is an
entire visual image of a person in that memory, and actor in the play, so to
speak. If you consider how people experience sight, we do not see
ourselves performing a task unless we are viewing ourselves in a mirror.
Visually all we can see are parts of our bodies, perhaps our hands and feet,
participating in the task. We cannot see our whole body engaging in the
task. Perhaps from a person with autism’s point of view, disembodied
hands and feet are performing the task, or, if the visual orientation is not
on the parts of the body, there is no person seen doing the task. There is
no self attached to the task. On the other hand, when they watch
someone else perform the task, not only is there clearly a visual person
involved, but they themselves become another recall cue. Perhaps what
Millward et al. (2000) have indirectly shown is the difficulty that people
on the autism spectrum have with visualizing a self when the self is not
directly seen, and organizing memories around a self that visually does
not exist in any cohesive manner.
Case study: I’ll believe it when I see it

This was demonstrated by Jason, a young man on the autism
spectrum who had difficulty imagining anything that he could not
see, and could not understand that others could see him and his
actions. Jason lacked a sense of object permanence, and if he held

something out of his line of sight, he behaved as if it did not exist
anymore. He described things as if there were some invisible
person committing the actions, and, when asked, would insist that
things happened mysteriously, because he never saw anyone doing
them. Yet he had no difficulty describing others’ behaviour and
remembering their actions, and could describe himself as he saw
himself in the bathroom mirror. For him, something that was out of
sight was out of mind. Since Jason could not see himself unless he
was looking in a mirror, he only existed in the mirror. Until he was
caught on videotape engaging in inappropriate behaviour, he
appeared to have no awareness that he was responsible for the con-
sequences of the behaviour.
Most of the people this writer has worked with are not this extreme,
although they often do not completely understand their authorship in
their actions until they see themselves on videotape, or imagine the
situation as if they were a video camera watching from the sidelines.
Aston (2003) recounts an episode where one of her clients went for a
drive while crossdressing. He was locking his car and about to go into a
restaurant when a motorcycle gang saw him and harassed him. He was a
very large man and did not pass well as a woman. He was utterly
convinced that the reason the bikers knew he was a man was because he
wore men’s shoes. He could not see that someone with his body shape
could not pass as a woman. He had no sense of himself and how he
presented to others as a crossdresser.
Many children on the autism spectrum (and, assumedly, adults) lack
self-awareness and an awareness of how their actions impact others or
bring about consequences. They also have difficulty being aware of their
own mental states, and thus are unaware that their thinking impacts their
choices in acting. Understanding mental states is a skill required to
understand oneself and one’s social interchanges (Frith and Happé
1999).
When children are able to report their own mental states they are
also able to report the mental states of others. Conversely, when they
cannot report and understand the psychological states of others,

they do not report these states of themselves. (Frith and Happé
1999, p.5)
The ability to understand that others have minds, thoughts, and feelings
of their own develops around the same time as their sense of self, and
seems to be intimately related (Frith and Happé 1999). This lack of a
sense of self and a sense of others is often referred to as having a theory of
mind (TOM).
THEORY OF MIND
Theory of mind is the awareness that you have a mind separate and
unique to yourself and others have minds of their own that are unique to
them. This knowledge includes that these others do not necessarily expe-
rience and know what you know. This ability is often called mind reading
or mentalizing (Leudar, Costall and Francis 2004). The inability to
understand another’s thoughts, emotions, and intent is called mind
blindness. Having a theory of mind helps in the judgment and prediction
of others’ words and actions, and how they may respond to your words
and actions. People on the autism spectrum can seem “oblivious on every
level to their effect on others, and sometimes oblivious to their own
actions” (Jacobsen 2003, p.571). Having no theory of mind means that
you do not think about yourself or your actions. The ability to make infer-
ences regarding someone else’s mental state is pivotal to social relations
(Hill et al. 2004).
People with ASD often cannot predict or understand the conse-
quences of their actions, and may not attribute the end result to their
behaviour. Blame is often externalized, as they may not recognize their
part in the situation. Blaming others also occurs when the person with
ASD incorrectly interprets another’s actions (Attwood 1998). In this case
there may be theory of mind ability, but it is faulty.
Theory of mind abilities are on a continuum, with autism being at the
most impaired end of the continuum and those with Asperger’s
somewhat closer to the middle of the continuum, with people not on the
autism spectrum at the other end. Those with PDD-NOS show similar
impairments in theory of mind tasks as do those on the autism spectrum.

Low functioning people with autism tend to lack a theory of mind while
those with Asperger’s have a logic-based theory of mind that is hard
learned (Frith and Happé 1999). There are those on the higher function-
ing end of the spectrum who do express the desire for others to under-
stand them, indicating a working theory of mind (Leudar et al. 2004).
Poor theory of mind abilities lead to the inability to comprehend that
others, specifically people not on the autism spectrum, may not under-
stand or appreciate the personal experience of someone who has ASD.
Also, someone who has ASD may not appreciate that they may not under-
stand the personal experiences of other people on the autism spectrum.
There may be the assumption that the individual’s experience is the same
as others who have ASD.
There are two levels of theory of mind tasks. First order theory of
mind is when an individual can infer the beliefs of another person. In
other words, the individual is aware that other people have thoughts of
their own, which may be different from the thoughts of the individual.
Second order theory of mind is when an individual can infer a second
person’s beliefs about a third person. In this case, the individual can accu-
rately assess what a second person would think about a third person’s
thoughts. Theory of mind allows an individual to understand another
person’s intent or meaning. To understand metaphors, irony, similes,
communicative intent, and hidden meaning, an individual must have an
ability to infer what the other person is thinking. Irony is probably the
most difficult thing to understand, and requires second order theory of
mind (Frith and Happé 1999; Martin and McDonald 2004).
The most extreme impairment of theory of mind, more commonly
found in autism, involves no concept of mental states, no understanding
of mental states, and no representation of mental states. A lesser impair-
ment that is more often associated with Asperger’s is where there is some
kind of understanding of mental states, and some kind of representation
of mental states, but a lack of applying or manifesting this knowledge.
Thus a person who is higher functioning on the spectrum may be able to
tell you what they believe to be the other person’s thoughts, but may not
have any idea what to do regarding this knowledge. This can become
confusing in a counselling setting, when faced with a situation where the
individual can express an accurate account of another person’s thoughts,

yet cannot fathom what to do to address the situation. The immediate
assumption would be that an individual who could express what the
other person was thinking would also have the understanding of how to
react in the given situation.
Attributing meaning to behaviour of those on the autism spectrum is
often inaccurate. Attribution of meaning involves assumptions of
intentionality, which involves theory of mind abilities. To be able to take
someone else’s perspective, and to fathom intentionality, you must be able
to infer the other’s mental states, thoughts, and emotions (Jacobsen
2003). A great deal of social misunderstanding comes from the inability
to comprehend others, or the lack of theory of mind abilities.
Case study: Mind reading

Theo, a young adult with Asperger’s, described understanding
how other people think as akin to mind reading. Theo was positive
that everyone else could mind read, and this was how they knew
what the other person was going to say or do. He did not under-
stand the predictive value of having a theory of how minds work to
help predict what a person was most likely to say or do. To him it
was all like magic, and we were all magicians. Theo explained that
everything anyone said or did was a complete surprise to him, and
often startled him. When Theo began to think about the possible
thoughts the other person could have, he was better able to under-
stand the other person’s next action. When Theo used cartooning
and thought bubbles to draw out social interchanges, he began to
understand how the other person’s possible thoughts impacted
what they said or how they acted in the situation. Theo began to
appreciate his mother’s cross response to him when he routinely
asked her to do something for him when she was on the telephone.
Case study: Thinking about thinking

Sam, a ten-year-old who had PDD-NOS, when asked what a peer
thought about his hitting, seemed genuinely puzzled by the
question. Sam did not understand the concept of thinking. When
this writer explained to him that people said words silently in their
minds, or made pictures in their minds about things they knew or

things that happened to them, he appeared very confused. Sam
insisted that it was not possible that other people had pictures or
heard words in their heads, as he could not see any pictures coming
from their bodies or hear any words being said. When asked how
he knew that he thought, he said that he could see the pictures in
his head and hear the words. Since he could not see or hear other
people’s thoughts, they could not exist. Sam had no theory of
mind, and could not comprehend that his actions could affect
someone else. To him we were all like animated furniture. He
began to understand that other people have thoughts and pictures
in their heads through the use of comic strips, where thoughts and
pictures were in thought bubbles.
Making thoughts visible

The use of thought bubbles, or making thoughts visual, has been shown
to help people with ASD understand others’ possible thoughts as well as
their own. Using thought bubbles to make thinking visual may help teach
theory of mind concepts and mind reading to people on the autism
spectrum (Kerr and Durkin 2004). This technique is also called Comic
Strip Conversations, and was developed by Carol Gray (1994a). Cartoon-
ing someone else’s thoughts, and colour coding their emotions, can
provide the client with an understanding of the impact of their actions on
an intellectual level, not on an emotional level. Comic Strip Conversa-
tions will be covered in more detail in Chapter 6.
Jacobsen (2003) comments that, for individuals with ASD, learning
to cope in our world involves learning cognitive skills, and does not
involve an emotional understanding. People with ASD can understand
another person’s mind if they have an understanding of what knowledge
that person may have. Often the analogy of another person’s knowledge
coming from that person’s experience, much like a video camera records
events, is helpful. They cannot understand the emotional experience as it
relates to the information, however, much like a video camera does not
understand emotions.
DIFFICULTY WITH CHANGE AND SHIFTING

ATTENTION
One of the hallmarks of autism is difficulty with change and shifting
attention. Individuals on the autism spectrum have difficulty coping with
change and are often resistant to change. Difficulty with change includes
difficulty with changing activity levels. Change, even that of a change in
the environmental detail, may be experienced as something that must be
relearned and overwhelming (Jacobsen 2003; Tsatsanis 2004).
Landry and Bryson (2004) took children who had autism and
compared them to children with Down’s syndrome and a control group.
The children on the spectrum had greater difficulty disengaging from
two competing stimuli, and showed a subtle impairment in executing
rapid shifts of attention from one side to another. The children with
autism frequently became stuck between two visual competing items.
Intelligence had no discernible impact upon the inability to shift
attention. Landry and Bryson reported that similar studies of adults
indicate that about 45 per cent show similar attention-shifting difficul-
ties. Impairment in shifting attention interferes with the ability to
disengage from one activity to another.
Ory (2002a) discussed how this inability to shift occurs with behav-
iours as well. Taking action may be dependent upon external organiza-
tion, such as step-by-step prompting through an activity or task, or
someone else to initiate action. Shifting out of stuck, perseverative
behaviour (or stuck attention) can be facilitated through the use of
competing stimuli, such as presenting the person with an item, or
bringing in a new person to interact with. This inability to shift attention
can be exacerbated by anxiety.
Case study: Can’t get that commercial out of my mind

Peter, a young adult with autism, would perseverate on the last
television commercial that he heard. Peter would repeat it over and
over, until someone asked him a direct question. At that point he
would be able to answer, and move on to something else. Peter
described it as having the commercial “spin round and round in my
head, like a stuck record” and that he needed someone to “unstuck
the needle.” Without that help, he could not think of anything else.
Peter experienced great anxiety when his thoughts got stuck, as

when they were stuck he could not ask someone to do something
to help him shift his thoughts. His anxiety made the thoughts go
faster, making them even harder to shift. Peter was able to take a
cue card out of his pocket to give to a nearby person. This cue card
instructed the person to ask him a specific question. This strategy
enabled Peter to cope with his spinning thoughts by giving him a
nonverbal way to ask for help.
Anxiety regarding change, which hampers coping with change, may be

due to not understanding the expectations of the next activity. It is
difficult to move from a familiar activity or situation to one that is an
unknown. Being concrete thinkers, people on the autism spectrum have
difficulty thinking ahead into the future to plan for possibilities. Thus,
transitioning to an unknown activity becomes anxiety producing and can
immobilize the individual with ASD.
Case study: You want me to do what?

William could not transition to an unknown activity. This severely
limited him as a young adult, as he could not get himself out of the
house to do anything unfamiliar. His anxiety was so great that he
was unable to open the door at times. He refused to accept
community supports, which meant that he would have to engage in
new activities and meet new people. William, however, really
wanted to go on vacation with his family to a famous entertain-
ment park. William searched the internet to find pictures and
videos about the place. Having these videos and pictures helped
him plan the vacation, and to do something new. William stated
that he did not perceive the trip as novel, as he had seen pictures
and videos for months prior to the actual trip. These tools reduced
his anxiety, as he was able to see what to expect. When he returned,
this writer worked with the available community supports to
develop videos and photo albums to show William what he could
expect when out in the community. This enabled William to begin
to access the community services available to him.
EXECUTIVE FUNCTIONING
There can also be problems with executive function, or the ability to plan,
organize, and monitor one’s own performance. Executive functioning
means the metafunctions of the mind, and can be described as the
executive (or boss) that manages thoughts and awareness. Executive func-
tioning describes the metacognitive processes that monitor, assess, and
organize thinking. Executive functions include central coherence,
cognitive flexibility, organization abilities, source monitoring, inhibitory
functions, and meaning attribution.
Central coherence
Central coherence is the way that things are formed to make a whole of
the big picture. Strong central coherence gives someone the ability to
remember the gist of a story, to get a sense of the whole. It is the ability to
understand the theme or common thread in information. Central
coherence allows people to understand broad concepts without necessar-
ily knowing all the details (Martin and McDonald 2004).
Weak central coherence, on the other hand, means that details are
remembered, often in a disjointed manner, with no sense of a global
meaning. Every detail is as important as every other detail, and no weight
is given to more important information. There is no clear beginning or
ending. These are impairments in the central cohesion of thinking. In
other words, where people not on the autism spectrum tend to fit pieces
of information into some greater whole, people on the autism spectrum
tend to keep the parts separate and unrelated. Having central coherence
weaknesses means that people on the autism spectrum are detail thinkers
but do not think in themes or broad interpretations. Weak central
coherence leads to deficits in using sentence context in comprehension
but verbatim recall is excellent (Martin and McDonald 2004; Teunisse et
al. 2001). It is this lack of central coherence and orientation to detail that
creates what this author calls loophole thinking (discussed earlier in this
chapter).
Sense making may be fragmented and literal as details are not
combined on common themes. There may be a lack of ability to create
themes from several sentences. Central coherence is the ability to pull
information and sensory input together to acquire higher level meaning.

Higher level meaning is created by forming patterns of information into a
greater whole, something that is difficult to do when there are central
coherence difficulties. Higher level meaning making requires the ability
to weigh importance of information when deducing a more abstract
meaning (Martin and McDonald 2004; Noens and van Berckelaer-
Onnes 2004, 2005; Teunisse et al. 2001).
Metarepresentation is when information is given meaning beyond
the literal meaning. Often there are secondary messages hidden within
primary messages. People with ASD seldom reach the level of
metarepresentation, as they get lost in the details of the information.
Thus, hidden, dual, or global meanings are lost to them (Noens and van
Berckelaer-Onnes 2004).
Cognitive inflexibility
People with autism tend towards concrete thinking, which negatively
impacts their ability to change how they conceptualize things, known as
cognitive flexibility. Lack of cognitive flexibility of thinking impairs the
ability to make plans and creatively problem solve, as thinking remains
stuck. Transference of learning and information is often an issue, as
rigidity in thinking impedes the transfer of knowledge across situations
(Attwood 2003; Tsatsanis 2004).
Rigidity in thinking was studied by Russell and Jarrold (1998). Upon
examining the errors that children on the autism spectrum make, they
noted that the children with ASD both made more mistakes than their
peers, and corrected proportionately fewer mistakes than their peers,
although the ASD individuals corrected the relative same number of
mistakes as their peers. Thus, they tended to make more errors without
self-correcting their mistakes as often. The difference made in the
absolute mistakes was what contributed to the difference in the total
number of mistakes made by people with ASD. Some of the mistakes
made could be explained through cognitive inflexibility, where the
children could not easily change their responses to accommodate to the
change in rule of the task. The assumption is that this cognitive inflexibil-
ity continues into adulthood.
Cognitive inflexibility contributes to perseverative thoughts, where

one thought or idea gets stuck and will not change. These stuck thoughts
can create anxiety as they spin out of the person’s control. Sometimes the
only way to move the person on to something else is to put an object cue
in their hand, which calls upon a sensory function (Ory 2002a). This cue
distracts them from their thoughts while providing them with the cue to
become engaged in something else, therefore redirecting their thoughts
away from the ones they were stuck on.
Case study: Stuck thinking

James, a young adult with ASD, described his stuck thinking as
having a big collage that showed him what his whole day would be
like, from one moment to the next. If something should change in
his day, one of two things could happen for James. He could get
stuck on what his collage showed him as the next thing, and
become agitated if it did not occur, or James’s mental collage could
shatter into a million pieces, leaving behind a whirlwind of discon-
nected things that made him feel frightened and confused. When
that occurred, James withdrew, as he could no longer organize his
day or anticipate the next activity. If pushed to perform when this
occurred, James would become very anxious and agitated, and
could react strongly to demands that he get back to work. James’s
collage would remain intact, however, if he was forewarned of a
change; James could then mentally insert a piece that indicated
there would be a change, and the collage was reorganized around
this piece, enabling him to cope.
Organizational deficits
Organization is a challenge for people on the spectrum. For some people,
thoughts, tasks, and possessions are in total chaos as they do not know
where to begin or how to self-organize. Others show organization in
their possessions, and become upset if anything is moved out of place, but
this organization is externally created. Difficulty in organizing results in
the experience of memories as discontinuous and disconnected (Aston
2003; Attwood 1998).
Organizational deficits can be addressed using visual tools such as

calendars, personal organizers, lists, checklists, and alarms. The use of
visual schedules, in which the day is planned out visually, is also a helpful
way to organize. Tools such as cognitive mapping can help to organize
thoughts (Attwood 1998).
Consistent routines and scripts help people with ASD to be more
independently capable. Often organizational and executive functioning
difficulties limit what otherwise intelligent people with ASD can do. The
use of scripts, checklists, and reminders, as well as consistent routines,
helps the person with ASD become more competent at everyday tasks
(Attwood 1998).
This writer has experienced success in using a personal digital
assistant (PDA) with high functioning individuals with ASD. These tiny
computers come with reminder functions, where you can set multiple
alarms to remind the individual to perform tasks at any time of the day.
The benefit of these organizers is that they look good, and are often well
received by adolescent peers and adults. Some models can also be quite
inexpensive. This writer has helped set up these electronic assistants for
several high school students and adults with ASD to remind them of
regular daily activities, of tasks that are due, and as a cueing device with
lists that guide them through different activities, with reminders to look
at the lists. The organizers are small and can fit into a pocket or purse, and
require only a moderate amount of instruction to use. They synchronize
with a desktop computer, creating a backup in case the data on the PDA is
lost. Some students have purchased pocket-sized portable keyboards for
their PDAs, and use them to take notes in class, as they can type faster
than they can write. This also helped in making their work more legible.
Many PDA programs have spelling checkers, which can facilitate the pro-
duction of written work for people with ASD.
Case study: The late great Barry

Barry, an adult with ASD who was known for being late and
missing appointments, set up his PDA to remind him about the
appointment twice, both the day before an appointment and an
hour before. Barry went from being continually late to being
always on time. Barry uses his PDA to remind him to pay bills, take
medication, and to track his work shifts. His PDA became quite the
hit when it helped him to remember his anniversary and his wife’s
birthday.
This author has been made aware of PDA software that can utilize
touchscreen input to generate prerecorded words or phrases for individu-
als who cannot communicate vocally. The phrases are connected to
pictures, words, or symbols that are displayed on the touchscreen. A
different program for PDAs displays pictures or photographs of the steps
in a task. Each step is displayed singly, and the next step is shown when
the touchscreen is activated to indicate that the current step is completed.
This writer is unaware if any research has been conducted using these
software and hardware tools. These tools look promising for persons on
the spectrum who are nonverbal or illiterate.
Computers have been shown to be useful teaching aids for people on
the autism spectrum (Moore, McGrath and Thorpe 2000). Their ability to
provide reminders that can be set for differing time periods makes them
useful cueing systems for self-monitoring. A future possibility will be to
use portable computers to assist in cognitive behavioural treatment
programs, such as treatments for anxiety (Newman, Consoli and Taylor
1999; Newman, Kenardy, Herman and Taylor 1997). This writer has
successfully used handheld computers such as Palm Pilots and Pocket
PCs for self-management systems, as reminder devices, self-monitoring
devices, and reinforcers. These devices tend to be trendy, and therefore do
not stigmatize the person utilizing them.
Source monitoring
People on the autism spectrum have difficulty with source monitoring
tasks, or determining the origins of memory, beliefs, and knowledge.
Often they cannot tell if someone said something, which of two people
said something, or whether they themselves have said it, which is external
source monitoring, or whether they just thought it in their heads, which
is internal source monitoring. Source monitoring difficulties are often
shown when a person on the autism spectrum is unaware that they
expressed their thoughts out loud, or thought they had said something to
you when they only said it in their heads. This is different from the
inability to inhibit thoughts from being spoken out loud. An example of

this would be an individual who talks himself through a task without any
awareness of whether he said the script out loud, only said it inside his
head, or if the person beside him had said it. The individual would hear
the words, but have no idea where they came from (Hala, Rasmussen and
Henderson 2005).
Self-restraint and self-control: inhibitory functions

People on the autism spectrum tend towards impulsivity and dis-
inhibition, with poor ability to control emotions. Often the person with
an autism spectrum disorder responds to emotional cues without
thinking. The ability to inhibit action is impaired, often resulting with
acting upon impulsive thoughts. Some people with ASD have an inner
voice, but often cannot stop from speaking what the inner voice is saying,
no matter what the situation (Attwood 2003).
Individuals with autism tend towards having difficulty inhibiting
responses. Bishop and Norbury (2005a) found that a high functioning
autism (HFA) group did not make fewer responses, but made many more
mistakes than the control group. Their ability to inhibit incorrect
responses was less than the control group. Bishop and Norbury (2005b)
propose that the difficulty in inhibiting behaviour lies with failure to use
inner speech to prompt oneself from acting. Anxiety contributes to
disinhibition, often resulting in increased impulsivity.
The difficulties with self-restraint often lead to the characteristics of
in sight, in mind. When something is within sight, it becomes compel-
ling, and cues the person to do something with it. Resisting that compul-
sion can be very difficult (Ory 2002b), and can lead to many difficulties.
Case study: In sight, in mind

Tim had difficulties with self-restraint. Tim would impulsively
grab whatever he saw, even if it really wasn’t what he wanted. For
example, Tim would see a television remote control and immedi-
ately pick it up and channel surf, regardless of what he was
previously engaged in, and whether he really wanted to watch tele-
vision. Another example would be seeing a box of cookies;
resisting eating them may be near to impossible until all of the
cookies were gone. For Tim, this also meant that if all his tools were
laid out for a task he would feel compelled to complete the task,
whether or not he really wanted to. He became a very good worker
at his job placement, providing the tools were laid out within his
field of vision.
Meaning attribution
Individuals on the autism spectrum may have difficulty with attributing
meanings in a way that would appear logical to a typical individual. Diffi-
culty with understanding central coherence, combined with unusual
logic, can result in unusual meaning attribution. This can be seen in
Aston’s (2003) example of a male partner with ASD who did not
associate having sex with a man as committing adultery, and therefore did
not believe that he was being unfaithful to his female partner. Homosex-
ual activities had no meaning of unfaithfulness attributed to them.
AUTISM, EMPATHIZING, AND SYSTEMIZING

ABILITIES
There has been a recent focus on the autistic ability to systemize, or
understand how many systems work. There has been recognition that
people on the autism spectrum have great difficulty with empathy but
seem to have a strength in the ability to understand systems. Empathizing
is described as being able to identify another’s emotions and thoughts
and to be able to respond to these appropriately. Systemizing is described
as the ability to understand and build systems, and predict how a system
will perform given certain conditions. Systems can be mechanical,
natural, environmental, technical, abstract, or taxonomic (Baron-Cohen
and Wheelwright 2004; Lawson, Baron-Cohen and Wheelwright
2004). Systems do not include human systems, such as family systems or
office dynamics. These would fall under the empathizing types of
thinking.
Lawson et al. (2004) noticed that females who are not on the autism
spectrum scored highest on empathizing, more than males who were not
on the spectrum, while non-spectrum males scored higher than Asperger
males. Non-spectrum females scored worse on systemizing than both
groups of males, while both male groups scored about the same. These
results support the idea that people with autism spectrum conditions
demonstrate an empathizing deficit whilst having a level of systemizing
skills that is, at least, in the normal range (Baron-Cohen and Wheelwright
2004). These deficits in empathizing have a profound impact on personal
relationships.
AUTISTIC THINKING AND AUTISTIC LOGIC

People on the autism spectrum can have idiosyncratic logic that does not
make sense to others. This autistic logic can be more pronounced in
people who are more severely affected, but exists continuously through-
out the spectrum. This may be the most confusing aspect of autism for
counsellors and clinicians. Autistic logic is associational, and often not
logical. Things that are associated appear to be related in a logical way for
many people on the autism spectrum, such as planes flying high because
the person is not afraid of heights or planes (Grandin 1996). This appears
logical to them because all three things are related in some way. However,
this does not appear logical in a typical cause and effect manner.
Autistic logic is the base for autistic problem solving. This is why
many of the attempts to solve problems that are brought to the awareness
of counsellors and clinicians are strange. As with anyone, the attribution
of meaning to a situation will affect behaviour, although the meaning
that someone on the autism spectrum may attribute to a situation may not
seem apparent and may not be expressed. Often we cannot make sense of
the ASD person’s behaviours, and many people not on the autism
spectrum will attribute inaccurate meaning to the behaviours (Jacobsen
2003). The most common mistaken attribution that has been brought to
this writer’s attention is that the person on the spectrum engages in a par-
ticularly odd behaviour to annoy the people around them, or to be disre-
spectful. There is an implied intent to annoy added to the meaning of the
behaviour. However, the behaviour may be simply a case of unusual
problem solving that may seem logical to someone who has ASD. When
considering the logic provided by the person on the spectrum, some
sense can be made of the situation, although the logic is based on faulty
assumptions.
Case study: Autistic logic

One example of autistic thinking was a teenager, Bob, who used his
mother’s iron to heat a cheese sandwich. Bob’s mother had told
him not to use the stove because he often left it on and set things in
the kitchen on fire. Bob wanted a grilled cheese sandwich, and
decided that the iron would do nicely as a tool to heat it. As this
was not using the stove, he thought his solution was fine.
Case study: More autistic logic

Randy was a low functioning child with autism who left his school
without permission and travelled by bus to another city to see his
grandparents. This was a trip of several hours, including several
different modes of public transportation. His school and parents
were frantic when he was discovered missing. In Randy’s mind this
trip was perfectly fine, as the last trip he took was on a Friday the
thirteenth, so everyone knew where he had gone. Randy followed
the exact schedule of the previous trip that he had taken to visit his
grandparents.
Autistic logic may show up in their humour. Individuals on the spectrum

can have a sense of humour, although it may be developmentally simpler
and may not make sense to someone else. This author knew one teenager
who loved to tell knock-knock jokes, but without a punch line. He
thought this was hilarious. His audience was confused by his jokes.
In-the-moment thinking
Often people with ASD experience life in the moment, without a sense of
the past or the future. This is more pronounced in persons who are more
severely affected. When this is the case, it becomes very difficult for
learning from past experience to be brought into the present experience.
This may be one explanation of why people on the autism spectrum do
not transfer learning to different situations. It is difficult to recall learning
when your cognitive state and capacity fluctuate from moment to
moment (Ory 1995). This is compounded by the sensory abnormalities
and fluctuations that occur in persons who have ASD (Attwood 1998),
and the emotional dysregulation that occurs when overstimulated or

anxious (Laurent and Rubin 2004; Raymaekers et al. 2004).
Black and white thinking

People with ASD tend to think in polarities, in black and white. They like
firm answers and consistent routines, where things are the same and do
not change unpredictably. They like rules that are consistent, and will
follow these rules, expecting everyone else to also follow the same rules.
People on the spectrum tend to be rule bound, which means that their
behaviour is governed by rules. They may get stuck on the rule, and may
have difficulty coping with the exception to the rule. Rules and rituals
help make abstract social practices concrete for people with autism
spectrum disorders (Attwood 1998; Ory 2002a).
Grey areas are when there are exceptions to the rules. Often it helps to
use the framework of black and white areas, where rules are consistent,
and grey areas, which are exceptions to the rules. Black and white rules
are for everybody. There are no exceptions. It is always the same, at the
same place and time. There is only one way to do things. Examples of
black and white rules are things like you always wash your hands after
using the bathroom, or you always brush your teeth and comb your hair
before you go to work or school. Grey areas are when there are exceptions
to the rules. Examples are when there are different rules for different
people, such as for men and women, or when the rules change depending
on the time, such as travel costs change dependent upon the season (Ory
2003).
This writer has found it helpful to create rule books for clients that
spell out the black and white rules and the grey areas, dividing the book
into these two sections. For these clients, having a rule book that stays the
same provides a sense of security and predictability, even if the rules are in
grey areas and change under certain conditions. The fact that the book
does not change seems to bring them some comfort.
Part Two: Counselling
Issues and Approaches
CHAPTER 3
General Strategies and

Modifications for Cognitive
Behavioural Therapy
Individuals with autism spectrum disorders (ASD) require specific modi-

fications and adaptations to benefit from counselling. Adaptations and
modifications are required for both counselling strategies themselves and
the counselling relationship (Hare and Paine 1997).
SETTING UP THE COUNSELLING RELATIONSHIP

Clients on the autism spectrum may not have an understanding of the
expectations of a counselling relationship, or the “social ground rules for
a therapeutic relationship” (Attwood 2003). They may require instruc-
tion on turn taking and sharing of information. They need to understand
the rules of what information the therapist needs to know, and when
telephone contact is available, and its purpose. Clients will also need to
know that therapy can be effective for their problems when they work
with the therapist as a partner. Rules of working as a partnership may
need to be spelled out as well. The focus needs to be on concrete issues
and symptoms, details and not the big picture issues, and problem
focused (Attwood 2003; Hare and Paine 1997).
ASD people struggle with innuendo and double meanings. In couples
counselling and individual counselling this becomes an issue as the ASD
person may not be able to communicate on the feeling level, or may not
have the same perspective of the difficulty that the partner or therapist
has. They are therefore not going to bring that perspective into the
77
counselling room. In other words, if the client does not see something as
a problem they will not talk about it unless asked some very pointed and
specific questions (Aston 2003).
Clients on the autism spectrum will require a more structured
approach, longer time to process new information, and perhaps shorter
sessions and many more practice sessions. Typewritten notes may be
helpful and group settings may not have therapeutic value, as the ASD
client will struggle with the social aspects of groups. Groups are only rec-
ommended if the target for intervention is social skill development
(Aston 2003; Attwood 2003; Hare and Paine 1997).
Often it is helpful to find examples of times when the client was able
to maintain self-control or otherwise overcome their problem. Many
clients on the autism spectrum engage in all-or-nothing thinking and do
not notice or remember successes (Ory 2002a, 2003). From this you can
identify intact coping strategies and build upon this, as well as provide
evidence that the client is capable of solving their own problems and suc-
ceeding (Hare and Paine 1997).
BASIC MODIFICATIONS FOR COUNSELLING

PEOPLE WITH ASD
Several basic strategies and modifications to cognitive behavioural
therapy are required to maximize benefit for persons on the autism
spectrum. These modifications utilize the relative strengths of people on
the autism spectrum while providing support for their areas of difficulty.
The modifications appear to help most ASD clients, even those who are
very high functioning (Aston 2003; Attwood 2003). In this writer’s pro-
fessional experience, clients who have Asperger’s or high functioning
autism appreciate these modifications and benefit from them, even when
they appear not to need such modifications.
Case study: I’ll hear it when I see it

This writer has discovered that concepts discussed during counsel-
ling are understood more easily when accompanied by written
notes or diagrams. As Roger, a young adult with high functioning
autism, put it, “I can’t hear you until you write it down.” Roger
General Strategies and Modifications for Cognitive Behavioural Therapy 79
commented that he did not think the diagrams and notes were
necessary, but the notes “facilitated understanding and integration
of the concepts.” This writer has discovered that writing concepts
down during sessions and diagramming concepts facilitates client
understanding and focus. Giving the client a copy of the notes and
diagrams encourages follow through outside of sessions, and can
act as a touchstone for the beginning of the next session.
Primarily, modifications to cognitive behavioural treatments involve rep-

resenting the intervention in concrete and visual forms, utilizing the traits
of autism spectrum disorders of having strengths in visual thinking and
concrete thought processing. Making interventions concrete facilitates
working with people on the autism spectrum who also have mental retar-
dation (Cutler 2001).
Make interventions visual and concrete

Most cognitive behavioural interventions are amenable to visual forms.
Bibliotherapy types of cognitive behavioural interventions for people on
the autism spectrum are called Social Stories™, and were developed by
Carol Gray (1994a, 1994b). Gray has developed social articles for adults
with autism spectrum disorders. Social Stories™ graphically represent
situations, thoughts, and actions. Social articles rely primarily on
journal-type explanations of social situations. These are covered in more
detail in Chapter 6. Using visual outlines, time planners, and specific
notes supplement cognitive behavioural programming for people with
ASD (Fullerton and Coyne 1999).
It is the experience of this author that clients may be resistant to visual
aids and adaptations, particularly if they have not come to accept the
diagnosis of an autism spectrum disorder. Acceptance of visual aids such
as lists and notes regarding sessions may be facilitated by framing the aids
as a tool for the counsellor’s benefit, or as a standard practice in counsel-
ling. Copies of notes can be made so that the client can take a set home
while a set remains in the file for future work. Having notes from sessions
appears to be useful in having treatment generalize between sessions
(Aston 2003).
Cognitive behavioural concepts can be made visual through the use

of diagrams and checklists. One diagram that this writer has found useful
shows the relationship between thoughts, feelings, actions, and the indi-
vidual (see Figure 3.1). Diagrams such as these facilitate instruction of
how affect, cognition, and action are related in an individual. Often the
people on the spectrum with whom this writer works do not understand
how thoughts, feelings, and actions relate to each other until they see it
diagrammed out.
thoughts
feelings actions
Figure 3.1 Thoughts, feelings, and actions diagram This diagram can be helpful in explaining
how thoughts, feelings, and behaviours interact with each other. This is a useful visual
tool for ASD clients who are having difficulty understanding how their thinking,
behaviour, and feelings interconnect. The superimposed person connects the concept
to an individual. On occasion, this writer has used photographs of the client’s face for
the diagram, further connecting the thoughts, feelings, and actions to the client.
Other creative ways to make concepts concrete and visual are also
helpful. One client, who wanted to rid himself of disturbing thoughts,
wrote them down on toilet paper and flushed them. Once he saw the
paper swirl down the toilet, he knew it was gone, and since the paper was
gone, he could no longer get the thought back. By this client’s autistic
logic, once he saw the thoughts written on to paper disappear, they no
longer existed for him. He could then carry around new and better
thoughts on non-flushable paper so that he would have them when he
needed them.
Assessment tools
Assessment can be done with many of the clinical tools available, but
modifications may be required for emotional evaluation. Graduated
responses of emotion may best be represented visually, such as an
emotional thermometer, bar graphs indicating degree of emotion, or
number scales to show the degree of a quality (Attwood 2003). For some
examples, see Figures 3.2 and 3.3. What you are attempting to do is make
the abstract concept of degree, quality, or quantity of emotion or opinion
concrete and tangible to facilitate the identifying of the amount of what
the assessment tool is measuring. This writer has noticed that having a
visual scale measure may reduce some of the all-or-nothing thinking that
can occur with people on the autism spectrum (Portway and Johnson
2003).
L
Figure 3.2 Emotional thermometer This tool can be used to graphically display gradients
of emotion, satisfaction, or ratings of a particular characteristic, such as one’s ability to
cope. An emotional thermometer can help a client determine the various degrees of an
emotion that he or she is experiencing. For example, a child may use the thermometer to
visually rate how well they think they used their coping skills or how they were feeling
after attempting a new activity.
Strongly agree Neither agree Strongly do

or disagree not agree
1 2 3 4 5
J K L
Figure 3.3 Example of a response quality scale A response or quality scale visually divides a
particular quality into smaller increments, which can vary from five increments, shown
above, to seven or ten increments. This tool facilitates the scaling of different qualities,
such as emotion or satisfaction. Repeated use of a scale such as this to measure the same
quality over a period of time provides clinicians with a system to demonstrate change.
An example of using a rating scale is to rate agreement with a series of statements, such
as rating agreement to a statement regarding feeling happy most of the time or usually
engaging in self-calming behaviours when agitated. A sample statement could be “I am
usually happy.”
Ongoing use of the same informal visual measures allows comparison of

progress to the baseline of the initial assessment. It may also be helpful to
graph progress as a visual way to demonstrate that counselling is having a
positive effect. It is important to prepare clients that progress is always
uneven, and that the graph should look more like a mountain range that is
changing direction over time. In this writer’s experience, declining
changes may precipitate an emotional escalation and blow-up if the client
has expectations that the graph should only show improvement.
When creating number lines to indicate varying degrees of a
construct, this author uses a method similar to that of Hare et al. (2000).
Varying degrees of emotions, including appropriate words to express that
degree of emotion, the client’s way of describing or expressing that
emotion, and physical signs that may accompany that emotion, are
written on to a PostIt note. Then the PostIt note is arranged on the
number line. PostIt notes can be rearranged until a hierarchy is
developed. Distance between notes can provide information regarding
the differences in degree of the emotion. This is a useful way to determine
if the range of emotions escalates quickly or unevenly by how the PostIt

notes cluster on the line.
Few assessment tools have been developed for people on the autism
spectrum. One useful tool is a stress survey developed specifically for
people on the autism spectrum (Groden et al. 2001). It is in a checklist
format and can be self-administered by someone who has good reading
skills, or it can be read to the person. The tool can also be used by parents
or others who know the person on the spectrum well to facilitate assess-
ment of children or those people who are nonverbal.
Assessment should include behavioural changes, such as an increase
in perseveration or time spent on favourite activities, becoming more
rigid in routines or rituals, changes in coherence of thought, or
self-stimulatory behaviours. These may indicate emotional difficulties.
An increase in attempting to control other people in their lives may also
indicate emotional difficulties or a feeling of losing control. For example,
it may be helpful to ask questions regarding changes in time spent on a
favourite activity or time spent away from other people. Behavioural
incidents may also indicate emotional difficulties, especially ones that
involve aggression. All environments must be explored, as indicators of
emotional difficulties may only occur in a single environment, such as the
home. These indicators would be used in addition to more usual indica-
tors of emotional difficulties (Aston 2003; Attwood 2003).
Using multiple choice type questions instead of open-ended
questions may prevent word retrieval problems (Attwood 2003). In this
writer’s professional experience of working with children and adults who
are on the autism spectrum, when offering possible multiple choice
answers to a question, if none of the choices apply, the person can usually
respond that none of the possible choices apply to them. When the
person appears stuck on the choices offered, adding a choice of none of
the previous choices will often help them answer. It is the writer’s experi-
ence that by providing written choices the therapist can minimize verbal
processing difficulties. Care must be taken to remind the person that there
is no right answer to the questions. Some people on the spectrum, who do
not really understand the purpose of assessments and questions, will try
to answer with the answer that they think you want to hear, as if there
were a right and wrong answer. It is this writer’s belief that this may be a
reflection of the training provided by the education system, where the

person may have learned how to judge what the right answer is by
watching the instructor for cues.
An emotion dictionary can be helpful, and can be used for ongoing
assessment as well. Included would be pictures of emotions plus written
descriptions of behaviours that can go with each emotion. A dictionary
can be used for understanding both their own and other people’s
emotions. Relevant pictures and behavioural decryptions are required to
fully provide a complete understanding of each emotion. It would be
helpful to include the use or purpose of the emotion, such as fear, which
can alert us that there is danger nearby. In some instances this writer has
used emotion videos of familiar people to form a living emotion dictio-
nary. Although this can be time consuming, with some clients it can be
invaluable for learning how to read the emotions of their significant
people. Mood diaries can be useful in day-to-day assessment of
emotional difficulties. Including a page of emotion words or pictures can
facilitate the use of the mood diary (Attwood 2003; Kellner and Tutin
1995; Sofronoff and Attwood 2003).
Case study: A picture is worth more than a thousand words

This author has found that supplementing the written word with
stick figure cartoons or simple drawings has been widely accepted,
even with high functioning clients with strong reading skills.
Victor had a diagnosis of high functioning autism, and was highly
verbal with strong reading skills. He repeatedly went into a rage in
the cafeteria, but could not articulate why. It was discovered that
Victor would use the incorrect name for what he wanted, often sub-
stituting another food name from the menu. Victor needed to point
to the picture before the correct label was verbalized. This writer
was able to determine that, for him, having a picture as well as the
words alleviated errors in understanding and communication.
With this in mind, this writer tends to offer drawings of important
concepts to facilitate understanding.
COGNITIVE RESTRUCTURING
People on the autism spectrum tend to have errors in logical thinking,
cognitive distortions, and mistaken beliefs. Logic on the autism spectrum
is markedly different from what is considered to be normal logic, but
makes sense once the practitioner examines it from the perspective of
someone on the autism spectrum who may be basing the logic on
mistaken assumptions and lack of information. Often the cognitive
mistakes arise from a lack of information that would commonly be
available to a person not on the autism spectrum, combined with difficul-
ties understanding the invisible social rules, as people with ASD have
difficulty in correctly inferring social rules, and may have trouble under-
standing complex cause and effect relationships. People with ASD are
frequently literal and polarized thinkers and have faulty underlying
assumptions. Often they cannot predict the consequences of their actions.
They typically misread context and come to the wrong conclusions. This
may lead to cognitive distortions (Attwood 2003; Meyer 1999; Portway
and Johnson 2003; Prestwood 1999).
Cognitive restructuring can be used with clients on the autism
spectrum, including those with mild to moderate mental handicaps, as it
has been effectively used with people with below average intelligence.
Cognitive restructuring is not recommended when the client is out of
touch with reality or locked into inflexible thinking. Cognitive disputing,
which is the process of challenging cognitive distortions with more
realistic thoughts, may not be applicable with clients who do not have the
metacognitive ability to analyze their thoughts, but rational coping state-
ments can be quite effective (Gandy 1997; Grave and Blissette 2004).
The process of cognitive restructuring

The process of cognitive restructuring will take several sessions, as each
session will likely cover one aspect of cognitive restructuring. This writer
has found that it takes several sessions to practise the entire process before
the client is proficient with cognitive restructuring between sessions. For
some clients, skill transference is aided by coaching and support of family
members and school personnel between sessions.
It has been this author’s practice to explain the rationale of cognitive

restructuring through the use of a mobile that has three moving parts.
These parts consist of thoughts, feelings, and actions (see Figure 3.4). The
parts of the mobile are moved to demonstrate the interactions of
thoughts, feelings, and actions. By moving the thought component of the
mobile, this writer can demonstrate how actions and feelings follow, or
are the result of thoughts.
FEELINGS
THOUGHTS
Use a small stick or dowel to hang

the three pieces from the main string
as in illustration below. ACTIONS
Figure 3.4 Thoughts, feelings, and actions mobile The interactive dynamics between
feelings, thoughts, and actions may be difficult to grasp for people with ASD. This
writer has used a mobile to demonstrate the interaction between cognition, affect, and
behaviour. The demonstration involves moving one part of the mobile and directing
the client to observe what happens to the other parts of the mobile. For example, if a
counsellor wished to demonstrate how thoughts impact feelings and behaviour, the
counsellor would take the thoughts part of the mobile and move it, directing the client
to observe what the other parts do. This demonstrates how change in one area, such as
cognitive change, affects change in both behaviour and affect.
Cognitive distortions can be described or explained as mistaken thoughts

or thought poisons. For some computer literate clients use of the term
“thought virus” may be helpful. Cognitive restructuring becomes the tool
to use to correct mistaken thoughts, create helpful thoughts, provide an
antidote for poisonous thoughts, or as a virus scanner and checker for our
computer brain (Sofronoff and Attwood 2003).
Visual aids help to identify cognitive distortions and the process of
replacing distortions with coping thoughts (see Table 3.1 and Figure
3.5). Often clients are unable to give examples of cognitive distortions
until a troublesome incident is reviewed step by step. Often they do not
remember what thoughts they may have had, and sometimes the
thoughts are images, which need to be examined for faulty or distorted
perceptions (Frith and Happé 1999; Grandin 1996). Sometimes role
playing the situation can uncover the cognitive distortions (Cormier and
Nurius 2003).
When the client can identify distorted thinking, their homework
becomes recognizing and recording cognitive distortions to bring to the
following session. It is useful to warn clients that there will be some
distorted thinking about the usefulness of what they are being asked to
do, and that these thoughts should be recorded as well. Clients are given a
notebook specifically for that recording, with some examples of their
cognitive distortions as models of what to look for. In the next session the
client begins to learn to identify what cognitive distortion was made
(Cormier and Nurius 2003). For this, the use of Table 3.2 as a cheat sheet
and visual guide is helpful (Burns 1980).
Jointly in session the counsellor and client go through the recorded
thoughts and attempt to identify the cognitive distortions contained in
each. It may take one or two sessions before the client demonstrates that
they can identify the thinking errors. It is preferable to have the client
place each cognitive distortion on a separate page to minimize confusion
and visual overwhelm. Cognitive distortions are often sorted by their
environment, and separated by use of notebook dividers. This adaptation
allows clients to look up common distortions that occur in a particular
setting to review coping thoughts.
Table 3.1 Cognitive restructuring chart

Common cognitive distortions or poisonous thinking:
• All-or-nothing (black and white) • Fortune telling

thinking • Magnification or minimization
• Overgeneralization • Emotional reasoning
• Mental filter • “Should” statements
• Disqualifying the positive • Labelling and mislabelling
• Jumping to conclusions • Blaming others
• Mind reading • Personalization
Automatic thoughts Cognitive distortions Realistic responses – JKL

– poisonous thinking antidote thinking
Questions to ask:
Does this thought help me stay calm? Does this thought help me cope with the
situation?
• If yes, then it is a realistic response or antidote.
• If no, then this is a cognitive distortion, or poisonous thought.
The next step is to come up with some coping or helpful thoughts

(Cormier and Nurius 2003). This is where, in this writer’s experience,
clients have the most difficulty, as they often have difficulty coming up
with solutions (Baron-Cohen and Wheelwright 2004). Sometimes
offering several possible coping thoughts and having the client choose
from them is helpful (Attwood 2003). Framing these coping thoughts
as thoughts that other people on the autism spectrum may have, which
may be similar to the client’s possible coping thoughts, can be useful.
For some clients, pairing an antidote thought to a cognitive distortion is
the most that can be gained (Gandy 1997). They may not be able to
identify the schemata underlying their cognitive distortions. It is rec-
ommended that clients review coping thoughts prior to engaging in
various activities, such as before going to work or school. This can be
referred to as a booster shot, to prevent the thought viruses from
making the person feel bad.
Here is an example of unhelpful and helpful thoughts.
Unhelpful thought: Helpful thought:
I’ll never get it right.

I’m a failure.
I did okay. I passed.

Next time I’ll study
and do better.
Here is a place to put your own unhelpful and helpful thoughts. How do they
make you feel?
Your unhelpful thought: Your helpful thought:
Figure 3.5 Worksheet of helpful and not so helpful thoughts This is a worksheet to teach
cognitive restructuring. The illustrated facial expressions highlight how different
thoughts can result in different emotions. Clients are encouraged to provide their own
thoughts and related feelings to delineate how their thoughts relate to their emotions.
Table 3.2 Definitions of cognitive distortions

All-or-nothing thinking. You see things in black and white, all-or-nothing
categories. If you get one mistake in an exam, you see yourself as a total failure.
People are either superior to you or inferior.
Overgeneralization. You see one single negative event as a never-ending pattern of

defeat.
Mental filter. You focus only on the negative, filtering out all positive things that
have happened. You just do not see the positives even when they are right in
front of you.
Disqualifying the positive. You reject all positives and minimize them by insisting
that they don’t count and are not important. You just do not see the positive.
Jumping to conclusions. You make negative assumptions without sufficient

information.
Mind reading. You think you know what others are thinking, but have not asked
them what they think.
Fortune telling. You predict that something will turn out badly before trying it to
see if it really will turn out badly.
Magnification (catastrophizing) or minimization. You blow negative things out of

proportion until they are so large that they overshadow everything else and you
minimize positive things until they are insignificant and too small to be noticed.
Emotional reasoning. Your emotions form the base of your logic. If you feel bad,
then the situation is bad. If you “should” do something, that means that you are a
bad person if you don’t do it. If someone else “ought to” do something, he or she
is a bad person if he or she does not do it. “Should” statements.
Labelling and mislabelling. This is using labels to overgeneralize, such as thinking

you are a “loser” as part of who you are, when you don’t win the lottery.
Blaming others. You blame others and do not see how you contribute to the
situation.
Personalization. You blame yourself as the cause of negative things, but see others
or luck as the cause of positive things.
Note: Adapted from Burns (1980).

Attribution of actions
Often people with ASD will frequently blame others for the conse-
quences of their actions, or take the blame for others’ actions. They are
not aware of how their actions affect others (Baron-Cohen and Wheel-
wright 2004). Sometimes the person with ASD may act omnipotently or
arrogantly when they do not perceive themselves as being in control of
the situation. In this case, specific individuals may be held responsible for
the outcome and may be targeted for retribution if the outcome is not
what the person with ASD deems as the desired outcome. The person
with ASD does not perceive their contribution to the outcome in this
situation (Aston 2003; Attwood 2003).
When the client has low self-esteem, they may feel personally respon-
sible for everything, and may also believe that they are helpless to change
the situation or change their own abilities. This learned helplessness is
common and may contribute to feelings of anxiety and perhaps guilt
(Aston 2003; Attwood 2003).
Attribution retraining is where the client examines the situation and
correctly attributes responsibility in the situation (Cormier and Nurius
2003). Through logic and examination of the situation, the client learns a
new perception of themselves. Often this is accomplished by drawing the
situation into a cartoon. Using a cartoon format you can demonstrate
cause–effect reactions as well as explore other people’s possible inten-
tions and thoughts (Kerr and Durkin 2004).
Make it visual and concrete

Strategies that make cognitive processes visual tend to be more useful
with people on the autism spectrum than verbal ones. Using a notebook
for cognitive restructuring with cheat sheets listing the cognitive distor-
tions and the client’s common cognitive distortions provides them with a
visual reminder as well as notes to refer back to when needed. For some
clients, a list of cognitive distortions is used so they only have to circle or
highlight the type of distortion (see Table 3.1). For others, pictures can
remind them visually of what cognitive restructuring is about (see Figure
3.6). Pictures can be created in a storybook fashion to show the situation
and the process of cognitive restructuring. Using pictures to rehearse
Automatic thought
Ha! Hee-hee! Ha ha! Boy,
They’re laughing was that ever funny!
at me! That’s not
very nice! Grrr!
Coping/realistic
Thoughts
Ha! Hee-hee! Ha ha! Boy,
was that ever funny!
Oh… Maybe they’re talking

about that new movie… Not
me… It’s okay that they
are laughing.
Figure 3.6 Examples of visual reframing This cartoon shows cognitive reframing. The use
of cartoons to show the difference between automatic thoughts and reframed thoughts
enables a clinician to demonstrate the changes in related emotions. This added
emotional information may be helpful to people with ASD to understand how cognitive
reframing works.
cognitive strategies has shown to be effective with people on the autism

spectrum (Groden and LeVasseur 1995).
One technique used with children may be helpful for people on the
autism spectrum. Friedberg (2002) has child clients write cognitive dis-
tortions on old crumpled paper, and trade them in for cognitively restruc-
tured thoughts that they write on new clean paper and keep. The old
thoughts are taken to a “replace mint” (Friedberg 2002, p.7) to exchange
the worn out thought with a new thought, using the analogy of a
currency mint that takes in old dollar bills and replaces them with crisp
new ones. The coping thought is then written on new paper and kept.
This strategy takes the abstract concept of cognitive restructuring and
makes it concrete and visual – thus easier to understand for someone with
ASD. It is similar in form to the previous example of a person with autism
spectrum disorder’s idea of flushing cognitive distortions, although
perhaps not as colourful.
Choice mapping
Even the most profoundly cognitively disabled person with autism
exercises choice (Proctor 2001), although they may often not be aware of
the consequences of their choices (Baron-Cohen and Wheelwright
2004). A visual way to show choices and possible outcomes is through
the use of cognitive mapping of choices. In this manner, the initial choice
can be examined with the relationship of the other choices that were
made. Responses to the situations are also examined, as the client may
have a very limited response repertoire. During attribution retraining, the
client and the therapist can explore alternative responses and the possible
consequences that could be predicted when the response is given.
Attwood (2003) recommends using a list of possible responses to a given
situation with adults, and flow charts with children. This writer prefers
using flow charts with both adult and child clients, as they clearly
highlight the connections between choices and results. Often, when
working with children, this writer utilizes both flow charts and drawings,
particularly drawing faces to indicate emotions. Sometimes the stick
figure drawings and emotion faces have had a greater impact than the
flow chart, showing how incidents and actions are linked together.
Understanding of situational choices can be facilitated by using
visual choice trees or flow charts, with lines that connect the response to a
possible outcome (see Figure 3.7). Colour coding may help highlight
which person made what choice. This writer has used visual mapping
successfully with clients who could not link their actions to others’
responses very well, but who did have a sense that they somehow had
played a part. Mapping the choices and linking the actions and conse-
quences in a flow chart format appeared to help my clients link their
actions to the outcome, and helped them see what responsibility they had
in the outcome. This mapping strategy may not be effective with those
First choice
Ask boss for a raise.
Boss’s response Boss’s response

Demands you go back to work immediately. She says that she will consider your request.
Second choice Second choice Second choice

Get angry. Calmly state why you Go back to work.
Call boss a rude name. deserve a raise.
Boss’s response Boss’s response

Boss gets angry. She says that she will consider your request.
Boss fires you.
Third choice Fourth choice

NO CHOICE Arrange an Go back to work.
You have to leave your job. appointment to discuss
this later.
Fifth choice
Third choice Third choice Prepare before the
Struggle to find a job Decide not to look for interview. Have a list
when your boss gives a job. Go on welfare. of all the good reasons
you a bad reference. Blame your old boss why you deserve a
for your loss of anger raise. Prepare to
control. discuss calmly any
reasons why you don’t
deserve a raise.
Figure 3.7 Sample of a choice and possible consequence chart The choice and possible
consequence chart is a useful tool to show the chain of events that are possible from one
choice. Choice charts can also show how a single action can lead to a series of events.
Colour can be used to delineate choice trees, or to code emotions associated with a
choice. In the above example, colour was used to differentiate choices that were more
likely to have a positive result from those that would be more likely to generate a
negative result. This enabled the client to process the emotional component to the
choices he made and the results the choices could bring.
who cannot see that they play a part in how the scenario unfolds; they
first have to realize that their actions have later consequences. Mapping
choices can also facilitate exploring different possible choices and conse-
quences. This facilitates building a larger response repertoire as well.
Attwood (2003) recommends including choices of self-disclosure to
teach clients that others are interested in their experiences and emotional
state. Use of choice charts can also indicate where self-disclosure is not
appropriate.
Using special interests as a metaphor in therapy

Often people on the autism spectrum have special interests that are
amenable as metaphors for the process of therapy (Attwood 2003;
Jacobsen 2003; Meyer 1999). An example would be for someone who
enjoyed watching Star Trek: The Next Generation and liked the character
Lieutenant Commander Data (an android) to consider a situation where
Data has to understand the emotions of others so that he could adjust his
behaviour to fit in with the crew. The client would be able to use this
metaphor as a way to determine what strategies could be used, and how
to determine progress in emotional understanding, from the perspective
of someone who has difficulties with lack of feelings and emotions.
Relapse prevention
Framing relapses as a normal part of the change process addresses the
process of all-or-nothing thinking and perfectionism that can occur with
behaviour changes. Relapse prevention is a crucial component when
working with people on the autism spectrum, as they will not anticipate
relapses and have difficulty problem solving when relapse occurs (Grave
and Blissette 2004; Laurent and Rubin 2004).
Goal setting
Goal setting may appeal to many people on the autism spectrum, as it is a
concrete and measurable way to assess progress. Good goal setting is
specific, which appeals to people with ASD. Learning to set goals and
subgoals is part of learning to plan, a weakness of many people on the
autism spectrum. Use of a goal-setting worksheet with spaces provided
for progress evaluation is helpful (Cormier and Nurius 2003; Hurlbutt

and Chalmers 2004).
Many people on the autism spectrum are unable to break down a task
into smaller steps. Often clients need support creating a task analysis to
determine specific steps. Mapping the steps visually, such as using a
checklist format or flow chart, helps the client track progress as well as
visually showing how each step is linked to another. This linking helps
the client understand the progress of meeting their goals (Attwood
1998).
TRANSITIONS
People with ASD may have difficulty switching from one activity to
another, often referred to as transitions. Transitioning from one activity to
another can cause anxiety and confusion. Using visuals as cues and scripts
for transitions enhanced their predictability and lowers the confusion and
possible crisis situation. Provide advance warning that the transition will
be coming, and give the person time to prepare to get ready for the transi-
tion. Often questioning the person about what is happening next can
help them orient to their visual schedule or list that lets them know what
is next (Attwood 1998; Ory 1995).
Special case in transitions

Some people with ASD tend to perseverate on the next activity to the
exclusion of being able to accomplish the prior task. For these people,
their anxiety increases when they know that a particular activity is going
to happen. In this case, you minimize anxiety by lessening the advance
warning for the transition to just before it is going to happen (Ory 1995).
When prompting for a transition, it is this writer’s professional expe-
rience that sometimes the person with ASD is immediately ready to tran-
sition. In this case you transition immediately. If you are in a situation
where the transition cannot happen immediately, provide the person with
the contextual marker of when the transition can happen, such as when
you have gotten your car keys. One of the most difficult things that
someone with ASD can cope with is being told that it is time to transition,
and then being told to wait because someone else is not ready. This is
doubly confusing, as often the cue to transition is interpreted as an indica-

tion that the change will happen immediately, and, when they comply
with this immediate change, they are told the rule has changed and now
they have to wait.
STRUCTURING CHOICE FOR SUCCESS

People with ASD may have difficulty choosing between options when
more than one is presented. Often the ability to choose from several
options requires the ability to organize and weight choices in your head, a
task that is difficult when you have executive function difficulties. It may
be best to offer limited choices, such as a “yes” or “no” choice or a choice
from two or three options. It has been this writer’s professional experi-
ence that, if the person is not interested in any of the offered choices, they
will be able to tell you, through words or actions, that none of the choices
are interesting. Often people with ASD are unable to generate choices,
but can recognize whether a choice is something they would like.
One useful strategy is a choice board. This is a written or picture chart
that shows the possible choices for a time period, like free choice time, or
what to do on a coffee break. The person can use the choice board to help
them decide what choices they would like. Task lists are a similar strategy,
where the tasks that must be completed in a day are listed and the person
with ASD chooses what task is first, and what will come next. When the
task is done, it is crossed off the list.
Sometimes it is easier for someone with ASD to correct you than to
accept help or guidance. For example, it may be easier to hand someone
the wrong coat when wanting them to get ready to leave. When they
correct the mistake, you have the opportunity to let them know that their
idea of getting ready to go now is a great idea (Ory 2002b). Creating lists
and scripts for the person on the spectrum to proofread and correct can be
a way to facilitate acceptance of a visual tool. In this author’s professional
experience, offering visual supports in this manner places the client in the
position of being a capable helper, which facilitates acceptance. Few
clients have refused a copy of the proofed work, once they have read the
initial incorrect work.
Case study: Proofread to success

Gordon was a very intelligent young man who had PDD-NOS.
Gordon was extremely resistant to intervention, and in denial of
his disability. Gordon was a spelling and grammar perfectionist.
This writer presented scripts, checklists, and Social Stories™ to
Gordon for proofreading, ensuring that there was at least one
mistake for him to find (and often many more). When Gordon
proofread the materials, he retained the information. In many
cases, Gordon asked to have a finished copy. Asking Gordon to
utilize his proofreading expertise allowed him to benefit from the
materials without feeling inadequate.
Automatic refusals
Some people with ASD will automatically answer “no” to any choice,
whether it is a choice that they usually like or not. Often this initial refusal
is a strategy to buy time, or has been the learned response for someone
who has a history of being asked to comply with things they were not
interested in. To address this, talk about the possible choices without
expecting any response, and discuss the positives and negatives of each
choice. This gives the person with ASD the answers to the questions that
he didn’t think to ask before he has to make a choice. It also gives him or
her time to think before making the choice. With people who say “no” to
any offered choice, prepare them that they will be offered a choice within
five minutes, and briefly outline what the choices will be. For those with
language processing difficulties, follow up with some kind of visual to
represent the choices. Often, once the person with an autism spectrum
disorder is prepared to make a decision, they will accept a choice or
provide an alternative. Their initial refusal may stem from difficulty in
shifting attention quickly and the need for extended processing time to
make a decision.
PROBLEM-SOLVING APPROACHES
Effective problem solving can be taught to people on the autism
spectrum. Those with ASD often have difficulties with finding solutions.
The difficulty may be in generating solutions, but difficulties in assessing
the appropriateness of the solution may also be a problem (Baron-Cohen

and Wheelwright 2004). It is important to assess the person’s current
method of problem solving to gain an understanding of what skills they
already have, and where they may make errors in thinking (Miranda and
Presentación 2000).
Executive functioning difficulties, such as inhibition of responses and
planning ability, negatively impact problem-solving ability. Difficulties
with perspective taking compromise the ability to fully comprehend the
consequences of one’s actions. Challenges with executive functions, such
as the ability to organize and assess plans, interfere with the ability to
problem solve. Correctly reading others’ emotions is a key component to
social problem solving. Problem solving also requires the ability to
remain calm (Laurent and Rubin 2004; Miranda and Presentación 2000).
Problem solving can be broken down into five components. These
are: defining the problem, gathering information, generation of alterna-
tive solutions, decision making, and evaluation of the solution (Cormier
and Nurius 2003). Key phrases such as “I can handle that” and “I am
getting nervous. I need to calm down” (Miranda and Presentación 2000,
p.173) are taught as self-talk coping strategies.
When teaching creative thinking for the brainstorming part of
problem solving, focusing on thinking and problem solving, instead of
right or wrong answers, may facilitate learning. Once the ideas are
collected they can be analyzed to determine their usefulness. Provision of
a problem-solving script, perhaps in a checklist format, will help
someone on the autism spectrum to organize the sequence of problem
solving (Laurent and Rubin 2004). When designing worksheets to teach
problem solving, this writer includes questions to help with the decision-
making process (see Table 3.3). These questions ask specifically if the
solution is fair to everyone, and assess if anyone will get hurt. People on
the autism spectrum often need reminders to consider those questions to
determine if their solution is appropriate, as their answers do not come
spontaneously.
Table 3.3 Steps to consider when solving a problem

YES NO
Is it fair to everyone? o o
Is it safe? o o
Will everyone feel okay about the solution? o o
Will something bad happen if I try my solution? o o
Will it work? o o
Totals:
If all yeses, If there are any
do it! answered “no”,
don’t do it!
SELF-MONITORING AND SELF-MANAGEMENT

Self-monitoring teaches people to monitor their own behaviours and
deliver appropriate reinforcements once the behaviour has been
complete. Self-management through self-monitoring involves an internal
locus of control and has been shown to be effective with people on the
autism spectrum, both those that are higher functioning and those that
are not. Self-management involves defining the behaviour that is being
monitored, and teaching the person to use a tool to monitor the
behaviour as well as deliver their own reinforcement. Targeting the
behaviour for self-management should be a collaborative process
between client and therapist. Data on the behaviour can naturally be
collected through the use of checklists and tallies (Cormier and Nurius
2003; Quinn and Swaggart 1994).
Self-monitoring strategies can include the use of checklists, which
provide cues for what is expected within the items to be checked off
(Fullerton and Coyne 1999; Willey 1999). Use visual cues, whether
written words or pictures, to describe the behaviour that is being
monitored. Use of concrete, tangible markers may work best for lower
functioning people (Quinn and Swaggart 1994). When designing
self-monitoring programs, the criteria for reinforcement are built right
into the sheet in the form of filling in all the boxes before the reward is
earned (see Figure 3.8).
Today’s jobs
1 Complete math homework. S
2 Complete social studies homework. S
3 Study for math test. Do 10 practice math questions. £
4 Get your things ready for school tomorrow. £
5 Make your lunch for tomorrow. £
When that’s all done, you can play on the computer!
Figure 3.8 Sample self-monitoring checklist Sample checklist used for self-monitoring
work habits. Criteria for reinforcement and the cue to self-reinforce are built into the
sheet.
One of the important pieces of self-monitoring to teach is that of honest

recording. Many clients are very honest, but a few are reluctant to record
when they have not met criteria. When teaching self-monitoring, teach
record keeping and reinforce accuracy and honesty above and beyond the
reinforcement for meeting criteria for the behaviour. Engage in repeated
random inquiries to see if honesty is being maintained. Over the period
of many sessions, the client will have become proficient enough that
random checks for honesty will no longer be required.
SELF-TALK
Some people on the spectrum engage in self-talk that can be less than
helpful for them (Attwood 2003). Self-monitoring self-talk can be, in
and of itself, a successful intervention. Sometimes data collection can
impact behaviour, as taking notice of behaviour can influence the
frequency with which a person will engage in that behaviour. For
example, taking data on negative self-talk can decrease it, as the person
becomes more self-conscious of making negative self-statements, or it
can increase in frequency as the person becomes more focused on the
negative things that they may say about themselves. What may be a more
useful strategy, however, is to focus on the opposite of negative self-talk,
which is positive self-talk (Burns 1980). Data collection on positive

self-talk can increase the likelihood that it will increase, as attention and
focus are placed on the behaviour. As the individual gives positive
self-talk more focus, they begin to notice the positive in themselves,
which is likely to lead them towards making more positive self-state-
ments, eventually resulting in some improvement in mood as they focus
on the positive.
In this writer’s professional experience, collecting data can increase
the behaviour. Data collection on the behaviours that you would like to
see more of can increase those behaviours, provided that the person with
ASD can successfully perform those behaviours independently. The use
of self-monitoring of positive self-talk has proven to be an effective
strategy to decrease negative self-talk and positively change overall daily
mood ratings.
CHAPTER 4
Depression and Treatment

Approaches
Depression is common among people on the autism spectrum, particu-

larly those who are higher functioning, and may be the most common
psychiatric diagnosis in this group (Ghaziuddin et al. 2002; Hurlbutt and
Chalmers 2004). While rates of depression in the general population are
between 2.3 and 3.2 per cent for males and 4.5 and 9.3 per cent for
females (Glenn, Bihm and Lammers 2003), rates in persons on the autism
spectrum may be as high as 52.2 per cent, with 23.2 per cent having
major depression (Ghaziuddin et al. 1998). Comorbid depression rates
range from about 4 to 58 per cent (Lainhart 1999). Severe forms of
depression (at least two standard deviations above the general population
means) occur in about 17 per cent of people with high functioning
autism or Asperger’s (Sofronoff et al. 2005). Most of the reported cases
are young adults (Ghaziuddin et al. 2002).
Polarized, black-and-white, or “all-or-nothing” (Cormier and Nurius
2003, p.444) thinking, and less imaginative thinking of “constricted
thought processes” (Portway and Johnson 2003, p.440), and limited
ability to problem solve, tend to correlate with depression. These types of
thinking are commonly found in people on the autism spectrum. They
can be amenable to cognitive restructuring and other cognitive behav-
ioural approaches (Attwood 2003; Portway and Johnson 2003).
DIAGNOSING DEPRESSION
Vulnerability to depression may be more likely among higher function-
ing people with autism than those with comorbid mental retardation, as
103
those with normal or high intelligence tend towards reporting lower

self-worth and self-confidence. There is some evidence to suggest that
the higher functioning people on the spectrum, who have higher
reported social adjustment and more ability to understand others, tend to
view themselves more negatively. Social isolation and lack of social
supports, such as having a close friend in which to confide, can exacerbate
the risk of depression. The tendency to attribute failures to individual
efforts and characteristics, combined with the tendency to see success as a
factor of chance, occurs in people on the autism spectrum who are prone
to depression (Attwood 2003; Ghaziuddin et al. 2002; Portway and
Johnson 2003).
Symptoms of depression in individuals with ASD may be similar to
those of the general population, such as changes in appetite, sleep, crying
spells, depressed mood, and loss of interest in previously favoured activi-
ties, or may take on unique forms. There may be an overall deterioration
of functioning. Depression may be expressed through behavioural
changes, such as changes in ritualistic behaviour, perseverative behaviour,
withdrawal, or obsessive-like focus on high interest activities. Ritualistic
behaviours may show an increase or decrease. It may be that the ritualistic
behaviours increase to relieve discomfort, or may decrease when they no
longer decrease discomfort. Increases in perseverative behaviour may be
an indication of depression, or of anxiety that is often comorbid with
depression in individuals with autism spectrum disorders (Ghaziuddin,
Aleissi and Greden 1995; Ghaziuddin et al. 2002).
An increase in social withdrawal is another indication of depression.
Social withdrawal must be compared to previous levels of social activity,
as many individuals with autism spectrum disorders do not regularly
engage in a lot of social activity outside work and school. Social with-
drawal includes withdrawing from previously enjoyed social activities,
and may include a lack of interest in going to work or school (Ghaziuddin
et al. 2002; Gustein and Whitney 2002; Orsmond, Krauss and Seltzer
2004).
Case study: Depressive withdrawal

Todd was a high school senior who had Asperger’s syndrome. His
parents became concerned when he began to withdraw into his
Depression and Treatment Approaches 105
room after school, refusing to come out even for meals. Todd
became totally absorbed in computer games after school, often
staying up throughout the night. Todd stopped returning phone
calls from his one friend, and became reluctant to go to school.
Shortly after that, Todd expressed the desire to commit suicide.
Withdrawal into fantasy, whether through video or computer games,

fantasy stories, or incessant daydreaming, may be indicators of depressive
withdrawal. Often individuals with ASD retreat into fantasy as an escape
from their unhappy lives. Preoccupation regarding the fantasy worlds
may be an indication of unhappiness and possible depression (Attwood
2006).
Onset of depression often occurs around puberty (Ghaziuddin et al.
2002). Puberty is a time of confusing physiological change, as well as a
time where social dynamics change. This may be the time where
academic expectations change, with an increase in demands. It is the
writer’s opinion that the time of puberty may be when the adolescent
who has an autism spectrum disorder becomes aware of his differences
from his peers, and when peers become less tolerant of differences. Social
rejection may become a trigger for a depressive episode.
Case study: Losing the dating game

James was in his graduate years of high school. He was very intelli-
gent and was diagnosed with autism. James became aware of the
high school expectations around dating. He became extremely
depressed when he discovered that a neighbouring girl, whom he
had been friends with until high school, was dating a different
young man. James was very depressed when he became aware that
he was not interesting to members of the opposite sex, and when
he realized that none of his previous male friends wanted to spend
time with him. He expressed no interest in living, and could not
fathom what he could do differently to make and maintain friends.
James gained some hope when he discovered that there were ways
to learn social skills that would help him possibly make friends,
and even, possibly, a girlfriend.
TREATMENT APPROACHES FOR DEPRESSION

Often the first line of treatment for depression can be the use of antide-
pressant medication (Attwood 1998; Ghaziuddin et al. 1998). Cognitive
behavioural therapy has also been shown to be effective, often in con-
junction with antidepressant use. It is essential to be aware of whether a
client is taking medication for depression to monitor side effects and
benefits. Pharmaceutical approaches to depression may have unwanted
side effects, some of which may result in the client refusing to comply
with the prescribing physician’s directions regarding taking the medica-
tion. Often the positive effect of taking antidepressant medication disap-
pears when it is discontinued (Burns 1980). The positive effect of using
cognitive behaviour techniques tends to become habitual over time, and
can provide longer lasting benefits (Glasman, Finlay and Brock 2004).
PHARMACOLOGICAL APPROACHES
Antidepressant medication is often prescribed for individuals on the
autism spectrum, although there is little efficacy research reported with
this population. Selective serotonin reuptake inhibitors (SSRIs) are often
used, followed by non-SSRI medications. Neuroleptics are also
sometimes used but may not show good results (Ghaziuddin et al. 2002).
It is important to know the medication that a client may be taking and the
side effects that have been noted with use in the autism population.
COGNITIVE BEHAVIOURAL THERAPY

Cognitive behavioural therapy (CBT) has been shown to be effective in
treating depression in adolescents and in adults in the general population
(Beck and Weishaar 2000; McLellan and Werry 2003) and those with
autism spectrum disorders (Ghaziuddin et al. 2002). There are no side
effects associated with using cognitive behavioural therapy, unlike many
medications used with people on the autism spectrum. Cognitive behav-
ioural interventions facilitate the prevention of reoccurrence of depres-
sion and better long-term results when medication is discontinued (Beck
and Weishaar 2000).
Cognitive behavioural interventions

Interventions for depression focus on changing the distorted thinking
that accompanies depression and reality testing to disprove distortions,
called cognitive restructuring. Homework is a key component (Cormier
and Nurius 2003; Sofronoff and Attwood 2003). Exploration of depres-
sive schemata is most useful with people who have good abstract
reasoning abilities, and often does not occur with those who have ASD
(Gandy 1997). Cognitive restructuring is discussed in more detail in
Chapter 3.
Depression may best be viewed from a chronic condition perspective
in this population, in that successful treatment is ongoing. Depression
does not become cured overnight. Clients need to be prepared for
ongoing use of CBT strategies to combat a return of full-blown depres-
sion. Strategies need to be applied early on, before the emotions of
depression inhibit the ability to think (Glasman et al. 2004).
It is this writer’s professional experience that the lethargy associated
with depression is frequently exaggerated in persons on the autism
spectrum. The tendency to become emotionally stuck exacerbates the
lethargy that is common with depression. Learned helplessness can
become a factor, impeding the client’s sense of self-efficacy towards
recovering from depression (N. Ory, personal communication, May 19,
2004).
Cognitive distortions common to depression

People on the autism spectrum tend to have many errors in thinking and
logic, have faulty underlying assumptions, and cannot predict the conse-
quences of their actions. They often come to the wrong conclusions due
to misreading contextual cues and the secondary messages of conversa-
tions. The most common types of cognitive distortions that people on the
autism spectrum engage in are all-or-nothing thinking, overgeneralizing
negatives and filtering out or disqualifying the positive, mind reading
and fortune telling, and blaming others. The least likely cognitive distor-
tion is emotional reasoning (Aston 2003; Attwood 1998). Refer to Tables
3.1 and 3.2 (pp.88, 90) for a sample worksheet and list of cognitive
distortions.
Schematas are the underlying theme to a person’s cognitive distor-

tions and reveal the core beliefs driving the distorted perceptions
(Cormier and Nurius 2003). People on the autism spectrum have diffi-
culty with finding the central coherence or theme from pieces of informa-
tion (Martin and McDonald 2004; Teunisse et al. 2001). They may have
difficulty with schemata identification, but some people who are higher
functioning may be able to benefit from working with their schemata to
address global patterns of faulty core beliefs.
Reframing
People on the autism spectrum tend towards cognitive inflexibility
(Tsatsanis 2004). This can lead to “‘functional fixity’ – that is, seeing
things from only one perspective or being fixated on the idea that this
particular situation, behaviour pattern, or attribute is the issue” (Cormier
and Nurius 2003, p.394). They become stuck in one-way thinking,
without being able to see that there are alternative possibilities.
Reframing the meaning of a situation or attribute is a cognitive behav-
ioural technique to open thinking towards alternative possibilities,
thereby creating a change in meaning, which will affect behaviour.
Reframing context provides a positive function or usefulness for
behaviour and reduces generalization.
Care must be taken when reframing with people on the autism
spectrum, as they may have idiosyncratic meaning attributions that are
not amenable to reframing, or cannot discriminate between contexts
where a behaviour is acceptable. Cartooning can facilitate reframing and
provide sufficient boundaries for contextual reframes (Gray 1994b,
1995). An example of this is found in Figure 3.6 (p.92). The client draws
out his interpretation of the situation, and the counsellor draws the
reframed situation (Gray 1994b). Reframing in this visual format
resembles the use of comic strip conversations, which have been shown to
be very effective with people on the autism spectrum (Attwood 1998;
Gray 1994b, 1995).
Accepting that one has a diagnosis of autism can be difficult.
Cognitive restructuring regarding one’s disability may be effective as a
disability tends to remain permanent, but how one thinks about the dis-
ability is amenable to change. It is possible to use cognitive restructuring
to effect change in one’s core beliefs about life. However, this may not be
effective with people who have more severe forms of autism (Gandy
1977).
Case study: I’m special

John is an adolescent who was having difficulty accepting that he
had an autism spectrum disorder. The writer spoke with John about
having autism, which is a rare condition that made John rather
unique. John came to reframe it as being special, as only a few
people have autism, and many people who have autism can do
special things. In a typical black-and-white thinking fashion, John
decided that he did not want to be typical in any way, as that would
mean that he would not be special anymore. With that belief, John
resisted any help with any area in which he was having difficulties,
particularly difficulties with his peers. With a little more cognitive
restructuring John was able to see that he could still be special and
fit in with the people not on the autism spectrum as well, which is
probably a more helpful endeavour.
Keeping score: using thought tallies

One tool that can be helpful in working with clients who are very
concrete is a thought tally. Sometimes this can be framed as a game, where
the client wins if there are more positive thoughts than negative thoughts.
Each day (or hour, depending on the time frame chosen) is a new game.
Along with the game score, on the scorecard (see Figure 4.1) there is a
mood thermometer. The mood thermometer helps to show clients that
their mood is dependent upon their thoughts (Burns 1980; Cormier and
Nurius 2003).
Case study: Positive thoughts game

For some clients, the game consists of only monitoring positive
thoughts, and attempting to have one more positive thought than
the day before to win the game. This was effective with Sam, who
would perseverate on a negative thought until he became dis-
traught. Enlisting his perseverative tendencies, he began to per-
severate on positive thoughts only, as these were the thoughts he
was asked to pay attention to. It is of note that Sam initially

thought the whole idea was silly, but was amenable to the instruc-
tion to try it anyway for a couple of weeks. As expected, Sam’s
perseveration on positive thoughts resulted in an increase of his
self-report of positive thoughts as well as an increase in his
self-report positive mood. This change in mood was observable by
those who lived and worked with Sam.
What’s your score?

Positive thoughts Negative thoughts Overall, how did you
(good guys) (bad guys) feel today?
Total: Total:
Figure 4.1 Positive thoughts game scorecard Scorecards are helpful tools to keep data on
behaviours. Using an analogy of winning or losing a game can provide motivation to
track the data, especially if there are incentives for keeping score. For clients who are
uninterested in games and scores, a science experiment analogy can be used. The above
example tracks positive and negative thoughts. The emotional thermometer provides a
graphic display of the general emotion for the day, giving a visual link between the
number and type of thoughts with the overall daily emotion. For people with ASD, this
provides a link between thought and emotion.
Thought stopping and distraction

For some people on the autism spectrum, identifying and refuting
cognitive distortions may be too difficult to be effective (Gandy 1997).
For these people, a thought stopping approach may be more effective.
Thought stopping involves two concrete steps of identifying when you
are becoming depressed, and doing something you would enjoy that
would distract you from the feelings. For many clients this simplified
approach may be what they can handle. An addition of coping state-
ments, such as expressing confidence that doing something fun will
combat the depression, would prove beneficial (Glasman et al. 2004;
Singh, Wahler, Adkins and Meyers 2003).
Addressing lethargy
One characteristic of depression is lethargy. This is often seen with
people on the autism spectrum who are depressed. Inactivity is exacer-
bated by fortune-telling cognitive distortions that the activity will be
awful. Activity scheduling is recommended to combat lethargy associ-
ated with depression. Scheduling has many general benefits for people
with ASD such as reducing discomfort and anxiety, thus making this
intervention ideal for alleviating discomfort as well as lethargy (Burns
1980; Ghaziuddin et al. 2002; Glasman et al. 2004).
Before suggesting to your client that one way to combat the lethargy
associated with depression is to get out and do something different, you
must assess your client’s social functioning and skill repertoire. It may be
detrimental to ask your client to engage in novel social situations without
knowing if they have the skill base to do so, or if social anxiety prohibits
the use of this technique at this time. It may be preferable to begin with
activities the client is skilled at that may not involve intensive social inter-
action. Inactivity or lethargy may be a tool to avoid stressful social situa-
tions, and may be an indication that social skill training is needed (Aston
To assess possible activities, ask your client to make a list of things
that they used to enjoy doing, things that they enjoy doing now, and
things that they may like to try. This list can be written or done in
pictures, including old family photos. Each activity that is tried is rated on
an enjoyment visual scale (see Figure 3.3, p.100). Mood is also tracked
using a mood thermometer (see Figure 3.2, p.90). Overall improvements
can be tracked through the use of these scales.
Case study: Show me

Mike, a young adult who had autism, was diagnosed with depres-
sion, and was taking a selective serotonin reuptake inhibitor (SSRI)
on advice of his psychiatrist. Mike was not showing any improve-
ment. He was spending his days refusing to go to his day program,
which he used to enjoy, and would not leave the house. Nothing
that his parents or day program workers could say or do helped
Mike to leave the house. Mike utilized visual schedules to coach
him through everyday tasks, such as personal hygiene tasks. This
author built upon Mike’s use of visual schedules. Each day a previ-
ously favoured activity was inserted into Mike’s schedule. The
activity was shown in full colour photographs. Often the photo-
graphs were of past occasions where Mike was shown smiling and
participating. When Mike noticed the activities in his schedule he
reluctantly complied. While he was out in the community doing
his favourite things, he was asked to indicate if he was enjoying
himself, often using a happiness thermometer. These daily ratings
of activities were collected, often with new photographs added of
Mike enjoying himself. When Mike looked back through his
activity book, he came to realize that he could enjoy these activi-
ties, and came to expect them when they were embedded into his
daily schedule. Within two months Mike was willing to participate
in the previous activities at his day program that he enjoyed.
HELPLESSNESS AND HOPELESSNESS: FAULTY

ATTRIBUTIONS
Many people on the autism spectrum do not fully comprehend their con-
tribution to situations, nor do they understand what they can do to
resolve problems. Often they cannot see how their behaviour impacted a
situation (Aston 2003; Attwood 1999). Using visual choice charts (see
Figure 3.7, p.94) can help them to determine how they have contributed
to a situation, and to explore alternative actions that they can take.
Some clients may completely lack self-efficacy. Self-efficacy impacts
the results of therapy. People on the autism spectrum tend towards being
cue dependent, which may exaggerate feelings of helplessness, as the
ability to respond may be tied to external cueing. In this case, building
client self-efficacy is a primary goal. Demonstrating self-efficacy can

include creating a list of things that the person can do, or creating a
collage of things the person is good at. Once the client has an under-
standing that they can have an impact on their environment, you begin to
assign homework that is well within their reach. This homework
becomes the basis of reality testing to disprove that the client is helpless
(Janzen 1996).
Relapse prevention
Depression should be viewed from a chronic conditions framework, as
depression does not get cured overnight, and relapse is possible if all
interventions cease. Keeping depression at bay will be hard work using
the strategies provided by cognitive behavioural therapy over a long
period of time for continued success. Continual use of CBT has been
shown to be effective in keeping full-blown depression at bay. Vigilance
in monitoring and planning for relapses is important for ongoing success.
Clients on the autism spectrum need to know that depression will not just
go away without continual effort on their part. Relapse prevention
should be part of a depression treatment plan, with the option for return
appointments, or tune ups. The provision of written notes or audiotapes
of sessions and techniques may be useful for future reference (Glasman et
al. 2004; Sarafino 2002).
One tool that this writer has found to be useful is the creation of
relapse prevention books for clients. These books have specific individu-
alized instructions regarding different degrees of depression, using a
rating scale as the measure. At each stage, suggestions of interventions are
made. These books have specific instructions as to what tools may be
helpful, with a customized example of the client’s own cognitive distor-
tions and coping thoughts. Included in the book are directions regarding
seeking help when depression increases and/or items indicating an
increase of risk of harm to self or harm to others have been identified. At
the end of the book is a list of community resources that the person can
turn to for immediate help, such as community crisis lines. One
component in the book is the reminder that the client can call this writer
or another counsellor if they are unsure of how they are doing, or if they
feel the need for a booster session.
Case study: Stuck in a hole

Cathy is a young woman with ASD. Cathy was referred for help
with recurring depression. Cathy saw each depressive episode as a
complete failure and an indication that she would never get better.
Cathy had no comprehension of the treatment for depression as a
process. She thought taking medication for depression would cure
it forever. This writer worked with Cathy and described depression
as a path out of a deep hole that was seldom straight up, and had
many slippery sections, where sliding back a little down into
depression was to be expected. The writer explained to Cathy that
these occasions where backsliding occurred were signals that
something like a depressive trigger had been overlooked. This
backsliding was normalized to Cathy. This writer helped Cathy
develop a book of suggestions for the times when she had slid on
her path out of depression. It was framed as a travel guide for when
you encounter holes. One of the suggestions in the book was to
seek professional help when she got stuck in the hole. This was
normalized as well. Cathy reported that her guidebook was very
helpful. Just reading it when she was feeling somewhat unsure of
herself helped her to feel more in control of the depression. She
found that having a book of tools that she could use to combat the
depression was a source of both strength and comfort. For Cathy,
knowing what to do became a great stress reliever.
CHAPTER 5
Anxiety, OCD,
and Treatment Approaches
Anxiety is a common feature of autism spectrum disorders and may be

almost universally comorbid. Rates of anxiety in the population of
people on the autism spectrum range from 7 to 84 per cent (Lainhart
1999). Greater levels of worrying, non-situational anxiety, panic, specific
fears, and hypochondriasis have been reported in young adolescents with
Asperger’s (Sofronoff et al. 2005). Social deficits can lead to social
anxiety, social phobia, and agoraphobia (Attwood 2003). Social anxiety
is common. Social anxieties affect the chances of having intimate rela-
tionships, reduce levels of social support, negatively impact education,
and reduce workplace productivity. Lower education and poor workplace
productivity negatively impact career and earning potential (Elliott and
Gresham 1991). Obsessive compulsive disorder (OCD), which is a fear or
anxiety based disorder, is also common in people on the autism spectrum.
Everyday coping with sensory abnormalities, confusing social inter-
actions and social environments, and language impairments, result in
elevated levels of daily stress and are likely to contribute to anxiety
(Ruberman 2002; Sofronoff et al. 2005). Anxiety is often a factor in
attempting to work in a neurotypical world. The confusion of coping
with everyday changes, social fluidity, lack of predictability from one
moment to the next, and the inability to correctly judge if your actions are
acceptable by those around you can result in feelings of anxiety (Hurlbutt
and Chalmers 2004). A useful analogy here is that of being dropped into
a foreign land with no ability to understand the language and no under-
standing of the social rules, with the rules being so strange that they make
115
no sense at all, and where different rules apply to different people. No

interpreter or guide is available, or the one that is available is completely
incomprehensible. This writer would imagine that the experience would
be anxiety producing.
DIAGNOSING ANXIETY ON THE AUTISM SPECTRUM

Anxiety may be challenging to diagnose for this population. Verbal
clients will be able to express dislike or fear as an indication of anxiety,
but clients who are less verbal may only have behavioural indicators. This
writer’s professional experience is that many clients who are quite verbal
show anxiety through behaviour long before they verbalize being
uncomfortable. It is this writer’s experience that words do not come easily
to someone on the autism spectrum when they are anxious, upset, or
experiencing any increase in emotions, including joy. Too often
perseverative behaviours are seen as problem behaviours and not signals
that the individual is in discomfort or anxious. Changes in behaviour can
indicate an increase in anxiety (Ghaziuddin et al. 2002). Perseverative
behaviour can be an indication of anxiety (Gillott, Furniss and Walter
2001) or a way to release anxiety (Reaven and Hepburn 2003).
Perseverative questioning, social withdrawal, and attempting to “tune
out” (Roe 1999, p.251) may also indicate anxiety.
Some perseverative behaviour is engaged in for pleasure, and is not a
sign of anxiety (Meyer 1999; Reaven and Hepburn 2003). People
familiar with the person on the spectrum can help determine which
perseverations are stress reducers, if the person himself cannot tell you.
Fun and enjoyable perseverations are a form of activity similar to a hobby
for people on the autism spectrum, and are more like special interests than
perseverations. There is no need to intervene unless these behaviours are
preventing the client from fully participating in life.
Childhood anxiety
Anxiety in children in the general population is relatively stable, often
lasting from two to five years (Gillott et al. 2001). In the not too distant
past, childhood anxiety was discounted as something that children
would naturally grow out of (Kendall and Choudhury 2003). Children
Anxiety, OCD, and Treatment Approaches 117
on the autism spectrum tend towards being anxious (Sofronoff and

Attwood 2003; Sofronoff et al. 2005). Adult anxiety, increased risk of
substance abuse, and mood disorders are associated with untreated
childhood anxiety (Manassis, Avery, Butalia and Mendlowitz 2004). It
would not be unreasonable to assume that untreated childhood anxiety in
children on the autism spectrum would have a similarly detrimental
effect.
Social anxiety
Social anxiety is assumed to come from lack of social competence, hence
social skills training with corrective feedback is the most common mode
of treatment. Social skills training is covered in more detail in Chapter 6.
Often social skill instruction is paired with strategies to reduce anxiety.
Once skill level is adequate, cognitive restructuring for social anxiety is
used to address the anxious thoughts that occur in social situations.
Cognitive restructuring shows the best effect when it is used before,
during, and after exposure to social situations. In this use exposure is seen
as an opportunity to challenge and disprove inaccurate thoughts
(Rodebaugh, Holaway and Heimberg 2004).
Anxious perseveration
Perseverative behaviour and the insistence on keeping things the same
may be ways to reduce anxiety, or are driven by anxiety. Anxiety has been
discussed as being both a consequence of autistic behaviours and a cause
of these same behaviours. Stereotypical behaviours and repetitive behav-
iours may be coping strategies to reduce feelings of anxiety, as these
behaviours tend to increase when the person is emotionally distressed or
anxious. Obsessions and rituals are likewise possible anxiety-reducing
strategies, as interrupting these sequences can cause distress and anxiety.
Lack of approval regarding perseverative or stereotypical autistic behav-
iours can lead to feelings of anxiety, leading to more behaviour, creating
an escalating cycle (Gillott et al. 2001; Ory 2002a).
Anxiety and skill deficits

Treatments for anxiety are no replacement for being unable to perform
the skills required by the situation. It is a faulty assumption that therapies
to reduce anxiety will be effective if the skill base to successfully
complete the activity or act in the situation is lacking. Issues regarding
confusion must be addressed as well, as confusion regarding an activity
will result in anxiety. People on the autism spectrum often cannot judge if
they are performing a task correctly and may become anxious when
unable to determine if they are performing correctly. It is important to
provide the person with tangible ways to self-assess their performance
(Aston 2003; Attwood 1998; Quinn and Swaggart 1994).
Using a train analogy with anxiety

Friedberg (2002) uses the analogy of a train to discuss anxieties with
children. This analogy may lend itself well to working with people on the
autism spectrum, as trains are often a special interest (Attwood 1998).
Friedberg described anxieties as being like a train that is out of control, or
a train with no brakes. The client is then asked to draw the train, using
whatever colour best represents their anxieties. A track is then drawn,
with several stations representing action, mind/thoughts, emotions,
physical sensations, who, what, and where. Once the stations have been
discussed, and how anxiety interacts at each station, analogies can be
made regarding getting control of the anxiety being like putting the
brakes on your anxiety train, and being able to steer your anxiety the way
you want to. This latter analogy lends itself well to asking the question
regarding who is driving the train, and who you want to be driving your
train. It is important to remember that people with ASD do not under-
stand comments such as your anxiety is a train, but can understand that
anxiety is like a train (Happé 1995), as they are literal thinkers.
Case study: Runaway train

Tom was an adolescent with Asperger’s syndrome who drew his
anxiety as a train speeding down the tracks, heading towards a
bridge that ended in mid-air. Coping thoughts and self-calming
strategies were introduced as a set of brakes for his train. Cognitive
restructuring was seen as putting a switch into the tracks so that his
train could go a different way, one that did not involve a broken
bridge. With this image in mind, he was able to understand the
process of learning to control and cope with his anxiety.
COGNITIVE BEHAVIOURAL INTERVENTIONS FOR

ANXIETY
Cognitive behavioural therapy reduces anxiety in adolescents and adults.
It has been shown to be effective with children on the autism spectrum
(Sofronoff and Attwood 2003; Sofronoff et al. 2005). Cognitive behav-
ioural strategies and problem-solving approaches have been shown to
have a positive effect on emotional regulation. Cognitive behavioural
interventions target the distorted thoughts that occur with anxiety and
the behavioural avoidance that accompanies it. The most commonly used
interventions are cognitive restructuring, desensitization, and thought
stopping (Burns 1980; McLellan and Werry 2003).
Cognitive restructuring for anxiety

Anxiety-producing cognitive distortions tend to overestimate risks and
threats in a situation, and thoughts tend to catastrophize situations.
Avoiding the situation is reinforcing, as the feelings of anxiety decrease
when the situation can be avoided, reinforcing further avoidance and
cognitive distortions (Cormier and Nurius 2003).
When working with distorted thinking around anxiety, a distinction
is made between the coping self and the anxious self, with anxiety-
producing cognitive distortions attributed to the anxious self and the
accurate, rational thoughts attributed to the coping self (Manassis et al.
2004). Cognitive distortions are related to “poisonous thoughts” (Sofronoff
and Attwood 2003, p.5) and coping thoughts as an antidote. A list of
cognitive distortions is found in Table 3.2 (p.90).
Chapter 3 includes a more comprehensive and detailed set of instruc-
tions for teaching cognitive restructuring. Here are the details specific to
treating anxiety. This writer has found that the use of visuals is preferred,
to accommodate the visual learning style of people on the autism
spectrum. A useful metaphor is that the cognitive distortions are like
thought poisons, and the rational responses are antidotes, and that
anxiety and fear are like paralyzing poisons that make it more difficult to
act (Sofronoff and Attwood 2003).
People on the autism spectrum often have unusual or irrational fears
(Attwood 1998; Janzen 1996). It is important to normalize fear and
describe when fear is functional, such as when there is actual danger.
Specific examples, like that of a fire drill when there is no fire, can be
helpful. Anxiety problems are like when you know that the fire drill will
be occurring, and you feel anxious even when you know you are safe.
Feeling anxious when you are not sure there is a real fire or when you
smell smoke is a good thing. Your fear is appropriately warning that you
may be in danger. Anxiety is also functional if you are anxious about an
upcoming job when you have not made the necessary preparations. This
again is functional anxiety, as the anxiety is communicating to you that
you are not ready. In this circumstance, you would want to use problem
solving to address the anxiety. Sometimes the cognitive distortions occur
due to a misunderstanding regarding the risk of the situation. In this case,
providing information resolves the issue. It may be helpful to teach the
individual to ask for clarification or direction in a situation, to ease their
anxiety (Piacentini and Langley 2004).
When assessing a perceived risk of danger, it is important to clarify
the actual risk of harm. Some people on the autism spectrum do not have
an accurate sense of danger (Attwood 1998; Janzen 1996). This writer
has observed that sometimes the assessment of risk is due to the person
not knowing what to do and correctly concerned that they will injure
themselves attempting something that is unfamiliar, although a person
not on the autism spectrum would understand that they could not be
harmed in the situation. In these situations this writer has found that
teaching problem-solving skills, including asking for assistance and
direction, can reduce anxiety. Knowing what to do when one is confused
is an essential coping skill (Ory 1995). Teaching problem solving is
discussed in Chapter 3.
Anxiety can be assessed visually, using a thermometer or number line.
Measuring anxiety in this manner helps the individual with autism gain
an understanding that there are varying degrees of anxiety (Sofronoff
and Attwood 2003). This information can be used to track progress as
well. Some clients understand their progress best when these ratings are
graphed to show the gradual decrease in ratings of anxiety that they

experience daily. When graphing changes, it may be helpful to prepare
clients that progress is seldom a smooth continuation, and the graph will
probably look more like a gradually diminishing mountain range.
Once the client can identify the cognitive distortions, they are trained
to use rational responses to address the cognitively distorted automatic
thought. These rational responses are developed for future occurrences of
the automatic cognitively distorted thought. This writer has found that
writing the cognitive distortions and the companion rational responses
not only provides a visual reminder of cognitive restructuring, but can
also become a cue to use cognitive restructuring (see Figure 3.5, p.89, and
Table 3.1, p.88). Often clients are asked to daily review the rational
coping responses to prime their memory of how to respond to
cognitively distorted thoughts, and to pay particular attention to
cognitive coping thoughts that would be most useful to the upcoming
situation. This seems to help them remember to use the rational responses
when they notice a cognitively distorted thought. Daily reading of the
rational responses as a primer for your mind can be framed as giving
yourself a thought inoculation to prime your thoughts against the
cognitive distortions (Manassis et al. 2004).
Make it visual and concrete

Similar techniques used to cognitively restructure depression can also be
used for anxiety. Distortions can be written down, and then destroyed,
stepped on, buried, erased, or scratched out (Attwood 1999; Ory 2002a;
Sofronoff et al. 2005). Concrete actions may be helpful in reducing
anxiety.
Case study: Blow your worries away

Blowing worries into a balloon and then releasing the air, thereby
blowing the troubles away, has been effective with several clients.
Kevin, a highly anxious child on the autism spectrum, found that
he could reduce his anxiety by blowing his worries into a balloon.
Blowing into the balloon helped him slow his breathing, as he was
not able to slow his breathing on his own, and tended to hyperven-
tilate while attempting breathing exercises. One day, while
blowing his worries and fears into his balloon, the balloon broke.
Kevin’s mother froze, expecting an explosive outburst. Kevin
looked around and then smiled. He came to the conclusion that
there were no more worries, since there was no more balloon! On a
different day, Kevin’s balloon got away from him, and he laughed
as the balloon flew about the room, spraying his worries all over
the place. Kevin discovered that he could not feel afraid and laugh
at the same time.
Sofronoff and Attwood (2003) developed a cognitive behavioural

program for children on the autism spectrum that used the analogy of a
toolbox full of tools to work with anxiety. Tools were taught, such as
cognitive restructuring, and emotion diaries for happiness and anxiety.
Other tools included physical tools, such as physical activity to release
pent-up energy, and relaxation tools, such as deep breathing. Homework
included making a personal toolbox with personal coping tools.
Desensitization
Desensitization is one of the most effective ways to treat fears. Systematic
desensitization has been shown to be effective with people on the autism
spectrum (Jackson 1983; Koegal, Openden and Koegal 2004). This is
desensitization through reciprocal inhibition. Simply put, systematic
desensitization involves counterconditioning the anxiety response with a
relaxation response or competing enjoyable activity. The counter-
conditioning stimulus must be more powerful than the fear or anxiety it is
meant to inhibit. Usually a relaxation response is chosen as the
counterconditioning stimulus (Cormier and Nurius 2003).
As the person gains mastery over a graduated series of anxious situa-
tions, they develop self-efficacy regarding their ability to master their
anxieties. When using desensitization, it is important to teach ways to
self-calm or otherwise distract oneself from the feelings of anxiety. Part of
this self-calming instruction can include cognitive restructuring of
cognitive distortions. Instructions on teaching self-calming and relax-
ation skills are to be found in Chapter 7 (Cormier and Nurius 2003).
When using desensitization with clients on the autism spectrum, it is
best to progress more slowly to ensure success. Setbacks can occur when
clients are under undue stress, feeling ill, or are exhausted (Cormier and
Nurius 2003; Jackson 1983; Sofronoff et al. 2005).
Exposure therapy
Exposure is a key ingredient of cognitive behavioural approaches to
anxiety, where the client remains in an anxiety-provoking situation
despite distress. This is desensitization through extinction. Exposure is
based on the idea that the client must fully experience the anxiety-
producing situation for cognitive and behavioural change to occur.
Exposure leads to a new learning, which competes with the old fear,
taking the potency of the fear down to where it is manageable (Cormier
and Nurius 2003; Rodebaugh et al. 2004).
A fear and avoidance hierarchy is developed with the client, and
exposure to anxiety-producing situations begins with the least severe,
and progresses to the most severe, as each previous situation is mastered.
Exposure sequences follow the anxiety hierarchy, from lowest to highest.
The client is instructed to stay with the feared situation until a new
learning occurs or habituation happens. In-session exposures use role
playing and imagination/visualization, while homework involves
exposure to the actual situation. Exposure therapy has been shown to be
effective with people on the autism spectrum (Jackson 1983; Rodebaugh
et al. 2004).
Therapists should be aware that subtle avoidance, such as paying
attention to internal sensations, can undermine the effectiveness of
exposure therapy. This may be a common occurrence with social anxiety
or social phobia, and clients should be instructed to pay attention to the
situation and not distance themselves from it by focusing on internal
senses or by discounting the experience as artificial. The client needs to
actively engage with the situation for exposure to be effective
(Rodebaugh et al. 2004).
Safety behaviours are common, and often attributed to the success of
coping with an anxiety-provoking experience. These behaviours tend to
have negative consequences. An example of a safety behaviour is to hold
your hands behind your back when speaking in public. This may address
the fear of shaking in public, but it will not help your presentation as a
speaker. Safety behaviours interfere with habituation as the decrease in
anxiety is attributed to the safety behaviour and not to learning how to

cope (Rodebaugh et al. 2004).
The process of desensitization and exposure therapy

Whether you choose systematic desensitization or exposure therapy, the
rationale of the treatment must be explained to the client. Part of the
rationale is the explanation that mistaken fears and anxieties can be
learned, and, as such, can be unlearned, and helpful ways to cope can also
be learned. For some clients, knowing that they can learn not to be afraid
is encouraging. When explaining how fear can be unlearned, this writer
has used the example of very young children, and how they are afraid of
some things until they get older and learn that these things are okay.
Explain that learning to be calm and confident is like learning any other
skill, such as learning to write, in that it takes a while to master and
requires a lot of practice and homework (Cormier and Nurius 2003).
Creating an anxiety or fear hierarchy can be challenging for someone
on the autism spectrum who may have trouble ranking their emotions.
The use of a personal construct assessment of fear or anxiety can facilitate
the ranking of emotion (Hare et al. 2000). Clients often benefit from a list
of their personal symptoms when they are beginning to feel anxious or
fearful. It is helpful to use a number line to visually map anxiety, listing
the various symptoms at the corresponding places on the number line.
This helps the client identify when they are beginning to become
anxious, and when their anxiety is increasing, as they may be unaware of
the graduations or their symptoms of anxiety (Attwood 1998, 2003;
Jacobsen 2003; Meyer 1999; Sofronoff and Attwood 2003). A discus-
sion should occur around the varying degrees of anxiety and fear, and
how these can be measured using a number line system, gauge, or fear
thermometer. When creating a symptom hierarchy, it may be helpful to
use a number line and some PostIt notes. The symptoms are written on
the PostIt notes, and the client places the notes on the number line. In this
manner notes can be rearranged as needed, until the client is satisfied
regarding the creation of an anxiety or fear symptom hierarchy (Hare et al.
2000). At this point the number line is written more permanently, as it
will be used as a tool throughout therapy.
Part of this discussion is to teach a client how to identify if a fear or

anxiety is a warning signal that they may be in danger (Attwood 2003).
This writer has used a risk assessment checklist with some clients to
determine if a situation is really dangerous (see Table 5.1). Having a
checklist to refer to has brought a measure of calm to several clients who
used the list as a way to slow down their anxious thought processes.
Always the last thing on the list is the direction to ask for someone else’s
opinion if the person cannot determine the risk.
Many of the items on the hierarchy will be unrelated and placed into
their own hierarchy. Others can be grouped together. For some, the
situation is midway on the anxiety or fear scale, and smaller steps must be
identified (Cormier and Nurius 2003).
Case study: Anxious phone caller

Edward, a young man with ASD, became very anxious when he
was calling his friend on the phone, even when he had a script of
things he could say. Imagining the experience of holding the
phone, prior to making a call, was halfway along his fear thermom-
eter. For Edward, the mildest anxiety was discovered to be thinking
about a telephone. This became the first step in his hierarchy.
Table 5.1 Safety assessment questions

Anxiety is a warning signal that something may If yes, then it If no, then it
be unsafe. When you feel anxious, you may need is not safe is probably
to find out if something is not as safe as you and you need safe and you
would like. Ask these questions when you feel to make will be okay
anxious: yourself safe
Will it physically hurt you or someone else?
Will it break or damage something important?
Are the people around you also afraid?
Is someone saying to be careful or to watch out?
IF YOU ARE NOT SURE – ASK SOMEONE ELSE’S

OPINION OF THE SITUATION.
Actually looking at the telephone and touching it were the next

two steps. As you can see, the hierarchy gradually built towards
picking up the phone and calling his friend. In this situation, the
young man had all the skills needed to call his friend. He knew
what to say, how to dial the number, what to do if he got a wrong
number, and how to leave a message. His anxiety, however,
prevented him from doing these things.
Sometimes the items of the hierarchy indicate a deeper issue, such as fear
of criticism and not social phobia. Asking the client what would change if
they no longer had the fear may provide some clues as to any underlying
issues (Cormier and Nurius 2003). Do not be surprised, however, if the
client cannot contemplate their future in that manner, as people on the
autism spectrum are often unable to think about their future, particularly
those who are moderately or severely affected. Thinking about the future
is too abstract a concept for many people on the autism spectrum.
Clients need to learn how to self-monitor. A fear log is a tool to chart
anxiety between sessions, and to show progress (Moynahan 2003;
Sofronoff and Attwood 2003). A cheat sheet of relaxation or distraction
strategies at the front of the log may be a helpful reminder for clients.
They need to feel comfortable admitting and identifying their fear before
the fear log can be accurate. Included in the log is what the client did in
the situation, as well as ratings of the fear or anxiety. Part of the log can
include a list of things that worked well and things that did not work very
well (Kellner and Tutin 1995). This provides the client with a list of their
successes and a list of things to avoid doing. Clients may have trouble
coming up with their own solutions, as people on the autism spectrum
have difficulty generating solutions, and often do not recognize when a
solution is inappropriate or impractical.
Thought stopping
Thought stopping is the practice of becoming aware of your thoughts
and intentionally distracting yourself away from them. The use of
concrete cues for thought stopping have been shown to be helpful for
people on the autism spectrum. Thought stopping is the basis of mindful-
ness practices, where you consciously switch your focus from a thought
or emotion to some more calming or neutral thing, becoming more of an

observer of your body than a participant in what is going on. A modified
form of mindfulness meditation has been used successfully with a person
on the autism spectrum (Cormier and Nurius 2003; Singh et al. 2003).
Thought stopping can be facilitated through the use of cue cards.
This writer has routinely handed out cards that read stop, breathe, and
think. Some of the cards also have a suggestion to go ask for help. The
cards may have pictures of things that each client finds helpful and
calming, or colours that the client finds soothing. The people to whom I
have given the cards have expressed that they serve as a helpful reminder
of what to do when they feel flustered or confused.
Case study: Card of tranquil power

Cliff was a young adolescent with PDD-NOS. Cliff had serious
anxiety issues, and would often bolt from the room to hide when
feeling very anxious. His flight from the situation was blind, and he
was unable to assess the danger his headlong rush presented in
community settings. Cliff enjoyed playing a card game at school
that involved different characters who had magical powers. With
this interest in mind, the writer created a player enhancement
magic card of calming power, with instructions for use on the back.
The instructions were to stop, breathe deeply three times, and to
think. Cliff found the card very helpful, and he asked for several
copies to give to his friends. His friends found them helpful too.
Using Social Stories™ to treat anxiety

Social Stories™ are teaching tools that are effective with people on the
autism spectrum. This writer is not aware of any studies using Social
Stories™ to treat anxieties and fears. However, they have been used to
treat anxieties and specific phobias in this writer’s professional practice.
In some cases the Social Story™ provided a visual desensitization
process, and in other cases simply explained the fear so that it was no
longer irrational (Attwood 1998; Gray 1994a, 1994b, 1995).
This writer has found two key components that make this use of
Social Stories™ successful in her practice. The first component is that the
people surrounding the individual with ASD who has the irrational fear
must not respond to the fear trigger as if it is special. They need to ignore
the fear trigger. Often people around someone with a phobic-like fear
will become hypervigilant to protect the person from the fear trigger.
This sends an underlying message that there really is something
dangerous about the fear trigger. Ignoring the fear trigger communicates
that there is nothing to be afraid of. “The genesis of a child’s dog phobia
could reside in a direct traumatic experience…while the phobia is main-
tained by excessive attention from the parents” (Jackson 1983, p.194).
The second key component involves the use of digital image editing,
or creative cut and paste. This part of the intervention uses the strength
that individuals on the autism spectrum have of being visual thinkers
(Attwood 1998, 2003; Frith and Happé 1999; Grandin 1996). Within a
Social Story™ this writer placed digital photographs of the person and
the feared object or feared situation. As the story progresses, the feared
object is moved closer to the person’s image in the photo. All pictures are
of the person happy and calm.
Case study: Show me how to be brave

An example of this is a story to treat Zachary, a nonverbal child
with autism, who had a phobic-like reaction to squirrels. This
writer framed the story as a walk in the park. In each photograph
there was a photo of a squirrel, as well as a photo of Zachary in the
park, waving and smiling. In the first photo the squirrel was far off
in the distance, barely a dot. As the story progressed, the squirrel
moved closer to Zachary, and became bigger in the picture. The
final photo showed the squirrel on top of a slide as Zachary stood
happily in front of it. The squirrel was just above Zachary’s head.
In this situation the story would not show Zachary touching the
squirrel, as that is not a safe behaviour. At the very end of the book
were two coupons that Zachary could cut out and cash in for a treat
when he had read the story every day for a week, and every day for
a month. Zachary spent the winter reading the story every day. By
spring Zachary was no longer reacting with fear to squirrels. A
similar variation that this writer found to be successful was a story
about dogs, where Zachary not only learned about dog behaviour
but also became desensitized to dogs through the reading of the
book. It is noteworthy that the dog book included the directions

on how to approach and pet a dog only if the owner is nearby to
hold it and gives permission to pet the dog. These safety measures
must be explicitly taught, as people on the autism spectrum, like
Zachary, would not spontaneously understand that the dog
owner’s permission must be gained before touching the dog.
Case study: The cutting edge

A second example of this strategy is a young lady, Lisa, who was
terrified of knives, including table knives. From Lisa’s description it
appeared that she thought a knife could somehow animate itself
and cut her if she came within sight of it. Lisa’s story described
knives as inanimate objects that were tools, like pens, computer
mice, sewing machines, and scissors. The first part of Lisa’s Social
Story™ involved photographs of people using knives for ordinary
purposes. All the photos were of people she knew, and they were
smiling and calm-looking while they were using knives for
ordinary tasks. The second half of Lisa’s story involved photos of
her completing the same tasks with a knife, looking happy and
smiling. In this case she was photographed holding a popsicle stick
and the knife was digitally added in afterwards, as, at the point of
creating the story, Lisa would not enter a room where a knife was
visible. Once Lisa could see herself in the book using a knife safely,
she was able to tolerate knives, and could be taught how to use a
knife safely. Lisa only needed to read her story once. With most
other individuals, this process tends to gradually occur over time as
the story is reread many times.
Other approaches for autistic anxiety

Sometimes anxiety is due to the way in which a person who is on the
autism spectrum experiences the world, and may be approached in a
different manner. Some of the more common concerns are lack of
structure or predictability, lack of understanding, and perfectionistic
anxiety (Ory 1995, 2002a).
Use of structure to reduce anxiety

Lack of structure and unpredictability can cause anxiety for individuals
on the autism spectrum (Aston 2003; Attwood 1998; Hurlbutt and
Chalmers 2004; Sofronoff et al. 2005). People with autism find that
ambiguous or unclear situations make them anxious and contribute to
their acting out. One obvious way to prevent acting out is by using visual
cues and sequences so that people are able to predict more accurately
what is going to happen next (Lovett 1997, p.118).
The use of structure, scripts and task lists, and visual schedules can
alleviate anxiety from not knowing what to do next. Use scripting and
structured social interactions to help reduce anxiety. These organizational
tools help make life predictable, and therefore less confusing and scary.
For many people on the autism spectrum, chaotic time organization and
confusion are primary causes of anxiety (Sofronoff and Attwood 2003).
Lovett commented: “Sequencing may be an adaptive way of organizing
information for people with autism given their perceptual challenges”
(1997, p.118).
Case study: What’s next?

Bruce, a nonverbal man who had autism, would become very
agitated if no one else was in the room with him. If someone was in
the room, he would ask for assistance several times within five
minutes, even when the activity was one he enjoyed and had
completed previously. It appeared that Bruce could not structure or
organize his actions. A choice board was created with photos of
every possible activity that Bruce could engage in in that particular
setting during his free time. Bruce would be given the board when
it was break time at his day program. He was able to choose an
activity independently by using this board. Each activity contained
a photo album showing how to complete each activity, step by
step, using photographs. With these guides, Bruce no longer
requested help. This worked so well that an activity board was
made in a similar fashion, visually scripting Bruce’s jobs. Bruce
began proudly showing the completed activity or job to his
support people when the task was completed.
For many people on the autism spectrum, not knowing what to do can
create anxiety. They prefer to have some concrete rules to follow, a prop
that acts as a cue or reminder of what they are supposed to be doing, and a
role that fits into the situation. The use of rules and rituals can make the
abstract concrete, assisting the person with ASD in coping with the
abstract, and reducing anxiety (Ory 1995, 2002a). An example would be
to hand someone on the autism spectrum a dishtowel when they entered
the kitchen. The dishtowel becomes the prop, or cue that they should dry
dishes. The role of drying dishes has a definite set of rules and routines
that assists in completing the task correctly, and anxiety is reduced as the
script is familiar and routine.
Case study: Rule, prop, and role

Rusty, an adult with ASD, loved music, and expressed a desire to go
to a local dance for people who had special needs. However, he
would panic when he got to the dance and insist that he had to go
home, but was too panicked to take the bus, and would harass
anyone he knew for a ride home. The writer was called to help
when Rusty became aggressive towards a stranger in an attempt to
bully a ride home from this person. Rusty would panic when he did
not know what to do during the dance. When given the task of
helping the disc jockey find the next song to play, Rusty remained
calm and could participate throughout the entire dance. He was
unable to accept an invitation to get up to dance, however, but
enjoyed swaying to the music next to the disc jockey. Rusty had his
role, knew what the rules to his role were, and had the CDs as his
props.
Anxious questions
Often people with autism spectrum disorders ask questions that may be
interpreted by the receiver as a profound question deserving an abstract
answer, but this may not be the case if the answer is above the person’s
developmental level. An abstract answer may create confusion and
anxiety if the person with ASD cannot make sense of the abstract. Often it
is best to start with concrete answers and move to the abstract only if the
person on the spectrum pursues the matter. Double meanings and
ambiguity create anxiety for people on the spectrum (Ory 1995). It is

helpful to draw out the answer in a picture or as a cartoon to facilitate
understanding (Attwood 1998).
Perfectionistic anxiety
Many people with autism spectrum disorders will not attempt to do
anything unless they do it perfectly the first time. They may not attempt
an activity until they know all the rules and feel that they can complete all
the necessary steps correctly. Perfectionism may interfere with the ability
to produce work, as continual correction may mean that the work is
perfect but took many more hours to complete than the teacher or
employer may be ready to accept. Sometimes accommodations can be
made, like using a computer to produce written work, or the steps to the
task can be modelled prior to asking the person with ASD to attempt the
task. Preteaching tasks can help prepare people with ASD to attempt new
things. Using scripts and checklists can also facilitate trying a novel
activity or task. For many, helping someone else with the tasks is a low
anxiety way to facilitate their trying something new. There is no pressure
for them to do it correctly, as they are only the helpers (Ory 1995,
2002b).
Case study: The perfectionist

Jeremy, a young adult with Asperger’s, suffered from perfectionistic
anxiety. Jeremy did not demonstrate he could read until he was ten,
at which time he picked up an advanced children’s novel series and
read the entire set over a weekend. The amount of reading that
Jeremy completed would have been impossible for most adults.
Jeremy would strongly refuse to try anything until he was com-
pletely confident that he would do it right the first time. This
writer used a reframe of practice runs to introduce to Jeremy that
there are times when you do something just to practise, and that
they don’t count. Since they don’t count, you don’t have to do
them perfectly. Jeremy was able to try new things by calling them
practice runs. The writer recommended that Jeremy get a few
practice runs at something before his peers or classmates were
going to be taught the same thing. This preteaching gave Jeremy
some idea of what to expect, allowing him to feel less anxious

when new things were presented. Another strategy that worked for
Jeremy was helping this author to figure out how to teach a task to
someone else. This took the pressure off Jeremy to perform the task
correctly, particularly when he was instructed to try to find where
someone like himself would make a mistake. Once Jeremy went
through the task and worked out all the difficulties, he was able to
do it successfully.
OCD AND PERSEVERATIVE BEHAVIOUR

About 13 per cent or one in eight people with autism spectrum disorder
also have a diagnosis of obsessive compulsive disorder (OCD). While
most OCD symptoms are around checking, counting, or cleaning behav-
iours, OCD with people on the autism spectrum tends towards repetitive
telling or questioning, touching, or ordering. Obsessive thoughts are less
likely to be about aggression, religion, or have sexual overtones, unlike
people not on the autism spectrum with obsessive compulsive disorders
(Reaven and Hepburn 2003). There is some speculation that repetitive
and ritualistic behaviours serve a self-calming function in people who are
on the autism spectrum (Sofronoff et al. 2005). Cognitive behavioural
interventions have been shown to be effective in treating OCD
symptoms, and applications for people who are on the autism spectrum
are “rare, but promising” (Reaven and Hepburn 2003, p.147).
This is good news considering that pharmaceutical approaches for
OCD improve symptoms from about 20 to 40 per cent, and this is with
about 40 to 60 per cent of the general population who has OCD. In other
words, maybe half of the symptoms of OCD can be treated in slightly
over half of the general population. Effectiveness for people on the
autism spectrum may not be as high, as many people do not respond to
medication as anticipated. Often the antidepressant clomipramine
(Anafril) is used, as are selective serotonin reuptake inhibitors (SSRIs)
such as fluoxetine, fluvoxamine, and sertraline. Unfortunately, relapse
rates are about 90 per cent when medication is discontinued. Relapse is
less common and less severe when using CBT approaches (Reaven and
Hepburn 2003; Wilhelm, Tolin and Steketee 2004).
Cognitive behavioural treatment that includes exposure plus res-

ponse prevention has been shown to be the most effective for mild to
moderate OCD. Often medications are used as an adjunct treatment.
Treatment progresses from exposure to mildly anxiety provoking or
fearful situations to those that are more intense once the situation is
mastered. Most treatment gains are from exposure in the natural environ-
ment, often between sessions. For people on the autism spectrum, where
transference of skills is an issue, using response prevention strategies in
real-life situations is pivotal (Piacentini and Langley 2004).
Distinguishing between OCD symptoms and autistic

perseverations
When treating OCD in people who are on the autism spectrum, a distinc-
tion needs to be made regarding repetitive behaviours and perseverative
interests. Repetitive behaviours that serve as a self-calming strategy are
not obsessions per se, as they serve a coping function, even if they are not
considered appropriate in a given situation. These self-calming strategies
can be given a private place and time in which to engage in, or alternative
strategies that are more socially appropriate can be taught. If these behav-
iours interfere with daily functioning, they may be targeted in OCD
treatment. If the behaviours are not interfering with everyday living and
serve as stress reducers or coping strategies, they are often considered
functional for the individual and left untreated. Some perseverative
behaviours are engaged in for pleasure, and these are not the target of
OCD treatment. These behaviours are more like hobbies or special
interests, and often do not detract from daily functioning (Reaven and
Hepburn 2003).
TREATMENT OF OCD
Throughout the treatment of OCD, lists and session notes are helpful to
make the process more visual for the person with ASD. Pictures and illus-
trations can be used with people who have difficulty with written
language. Using pictures may be of benefit to many clients, and OCD
treatment can be written up in a social story format for use in between
sessions (Attwood 1998; Gray 1994a, 1994b, 1995). For some, drawing
their OCD and what they would be like without it may help them see the
benefits of treatment (Reaven and Hepburn 2003).
Treatment of OCD with people on the autism spectrum begins with
psychoeducation regarding what obsessive compulsive disorder is, and
distinguishing OCD from repetitive behaviours and perseverative topics
of interest that are normally found within autism spectrum disorders. A
list or chart can be created to visually illustrate what OCD is and what it is
not, and to dispel myths regarding OCD. The client should be asked to
supply their personal symptoms of anxiety, as behavioural symptoms
may be different from the symptoms we often associate with anxiety. Dif-
ferences should be discussed between perseverative interests and
favourite subjects, in that perseverative subjects and special interests
bring enjoyment, much as hobbies do, and therefore are not symptoms of
OCD. A list of OCD symptoms should be created, with estimates of how
much time is spent on OCD behaviours. This can later be used as an
assessment measure (Reaven and Hepburn 2003).
Define the OCD hierarchy

OCD symptoms are ranked into a treatment hierarchy, from easiest to
manage to the most difficult. When discussing situations, it is useful to
point out to the client that there are several situations where they were
able to manage their OCD successfully. Symptoms are assessed using a
worry or fear scale, as different behaviours tend to go with different levels
of fear, anxiety, or worry. This scale is made visual in the form of a linear
scale or an emotional thermometer (see Figures 3.2 and 3.3, pp.90, 100).
Increments of the scale should be in the client’s own language (Piacentini
and Langley 2004; Reaven and Hepburn 2003).
OCD behaviours can be constructed on a linear scale using PostIt
notes, with OCD symptoms or OCD trigger situations written on the
notes. The notes are then arranged on the linear scale to show severity.
Distance between PostIt notes can provide clues as to the changes in
severity of the OCD symptoms or trigger situations (Hare et al. 2000).
Exposure and response prevention

Exposure to the feared or worrisome situations without engaging in the
OCD behaviours reduces the OCD over time. Avoidance of trigger situa-
tions is discouraged, as situations are tackled from the least fearful to the
most, onwards up the hierarchy. It is helpful to explore the situations
where the client overcame the urge to engage in OCD behaviours to
determine what they know to do to stop their OCD from taking over.
Clients will usually have some effective strategies to start from. Identify-
ing already effective strategies demonstrates to the client that they are
capable of getting control over their OCD, as they have identified situa-
tions where they were successful (Cormier and Nurius 2003; Reaven and
Hepburn 2003).
Several different alternatives to the OCD behaviour must be taught
prior to the beginning of exposure and response prevention. Relaxation
strategies, distraction, and cognitive restructuring of anxiety-producing
thoughts are the tools for treating OCD. Reality testing of the cognitive
distortions regarding the consequences of refraining from engaging in
the OCD is essential. Reaven and Hepburn (2003) made the coping tools
tangible and visual for their ASD client by having their client create
drawings of tools with their cognitive behavioural names and placing
them in a cardboard toolbox. These tools were kept throughout the day
as reminders of the tools available to their client when she needed them.
Drawing tools may not be appropriate with adult clients or with higher
functioning clients, although the analogy may be helpful (Piacentini and
Langley 2004; Reaven and Hepburn 2003).
The use of Social Stories™ can highlight trigger situations, and
include helpful coping strategies. Illustrating situations can facilitate
understanding and provide opportunities to highlight salient social cues
(Attwood 1998). Social Stories™ can be created specifically to address
common recurring anxiety-producing situations.
It is important to discuss with clients that there will be setbacks and
times when progress goes more slowly, particularly when the client is
feeling overly tired or ill. It is important to do some contingency planning
around relapse and getting back on track. Often planning for a relapse
lessens the chance that the client will give up altogether (Piacentini and
Langley 2004; Sarafino 2002).
CHAPTER 6
Relationships and Social Skills
Interacting with other people is one of the primary areas of difficulty for
people who are on the autism spectrum (Attwood 1998, 2003; Filipek et
al. 1999; Rutter 2005). Some people on the autism spectrum do form
friendships and intimate partnerships (Aston 2003). Social skills are some
of the most important abilities for both academic and employment
success (Elliott and Gresham 1991). Quality of life in adults on the autism
spectrum is negatively impacted by poor social skills (Gustein and
Whitney 2002). Poor social skills do not appear to be from lack of social
exposure but lack of social understanding, although this author has
noted that poor social understanding can lead to social withdrawal:
Society tends to judge one’s disability on outward appearances. Indi-

viduals with AS look perfectly typical, their odd use of language and
atypical social behaviours are rarely understood by those around
them. Children with this disorder are often seen as “behaviour
problems,” “inappropriate,” or “cold,” which are inaccurate descrip-
tions of children who often struggle to fit in. (Church, Alisanski and
Amanulla 2000, p.19)
Adults are often judged by the same yardstick as children with ASD, with
perhaps the exception that their behaviour is perceived as more volitional
(Aston 2003). Their atypical behaviour and difficulties following the
social norms and practices result in varying degrees of social anxiety.
High functioning people with ASD may be aware of social rules as they
try to conform to them to fit in with the rest of the social world. However,
trying to conform may not be completely successful. Trying to make
137
sense of the social world has been described by some people with ASD as
“perpetual culture shock” (Jones and Meldal 2001, p.40).
Social situations can be overstimulating. The ability to inhibit
behaviour is negatively impacted by hyperarousal (Raymaekers et al.
2004). This may be why some people with ASD go out of control in
social situations. Social codes of conduct are often invisible to someone
on the autism spectrum. Not understanding the social codes of conduct
can be anxiety producing (Attwood 1998). Social anxiety tends to be
high among individuals with ASD.
An analogy would be the experience of being dropped in a foreign
land without understanding the language, knowing the social codes and
mores, and having no tour guide or guidebook to assist you. Imagine that
the culture is so different that everything that you know is wrong about
this culture. Imagine that you could be arrested and sent to prison for
doing the wrong thing. This could be similar to the experience of living
on the autism spectrum. If you were aware of the idea that engaging in
some behaviour can result in a jail term, you would be very anxious that
you did not engage in those things, even though you did not know what
they were exactly. If you were oblivious to the fact that some of your
behaviours could put you in jail, you would do whatever you thought was
right, and then become outraged and confused when the police arrested
you. Again, this may be similar to the experience of someone on the
autism spectrum who was not very aware of the social codes, or that their
behaviour impacted other people. Also, they may not be aware that others
may have a different perspective or different information than they have,
resulting in difficulty understanding the other person’s reaction towards
their behaviour.
The National Autistic Society of Great Britain conducted a study that
showed that 37 per cent of adults on the autism spectrum reported that
they engaged in no social activities and half reported going out only once
or twice a month (Gustein and Whitney 2002). In the Orsmond et al.
(2004) study, only about 8 per cent of their participants reported having
reciprocal friendships outside of “prearranged settings” (p.253), with half
reporting no peer relationships outside of school and work. Social
impairments can have a major negative impact on the ability to live inde-
Relationships and Social Skills 139
pendently in the community, even among very intelligent people with

ASD (Green, Gilchrist, Burton and Cox 2000).
Loneliness may be understood by people on the spectrum in a
cognitive sense, such as being alone, but not in the emotional sense, such
as the emptiness you can feel inside when you are lonely. Children with
ASD were more likely to describe friendship without emotional qualities
and more in terms of doing things together and close proximity than the
affective qualities of friendship. Often there are conceptualization diffi-
culties of friendship and relationships (Attwood 2003).
EMPLOYMENT AND EMPLOYMENT ISSUES

Employment is an important part of many people’s lives, including those
on the autism spectrum. Having employment is a source of pride and
accomplishment in our society, and there is a significant relationship
between job satisfaction and self-esteem (Nesbitt 2000). A British report
indicated that less than 6 per cent of high functioning ASD adults work
full time, with only about 2 per cent of lower functioning adults having
full-time employment (Beaumont 2001). People on the autism spectrum
who had supported employment placements had better outcomes than
those in sheltered workshops, especially those workshops that group
together many people on the autism spectrum (García-Villamisar, Ross
and Wehman 2000).
People with Asperger’s or high functioning autism have many
qualities to offer employers. They are punctual, detail oriented, love
routine and repetitive work, and are loyal to the employer. However,
overshadowing difficulties may hide these qualities. These difficulties
may bring the individual with ASD to the attention of professionals.
People on the autism spectrum may present to counsellors with employ-
ment issues, which may involve social skills, problem solving, employ-
ment seeking, on-the-job bullying, and specific issues related to the job
(Hurlbutt and Chalmers 2004).
Disclosing disability to employers

Although Gerber, Price, Mulligan and Shessel (2004) did not differenti-
ate persons on the autism spectrum from those who had other learning
disabilities, it is this writer’s opinion that their information is still valuable

to include here. There were many people with learning disabilities
(including autism spectrum disorders) who did not discuss their disability
with employers, and some who had negative experiences discussing dis-
abilities with past employers. One man described his disability in positive
terms, such as being a very visual thinker, and how this was an asset to the
position.
All of the American and most of the Canadian respondents feared
that asking for accommodations would have negative repercussions on
their jobs. Many expressed feeling inadequate as compared to coworkers,
and feared negative reactions from coworkers. Almost one-fifth had
experienced negative reactions from coworkers regarding their disability.
An equal number of Canadians had coworkers who were supportive and
helpful, although fewer of the Americans could make that claim (Gerber
et al. 2004). For most people, the decision to disclose should remain a
personal decision, and may be best after the person has been hired
(Hurlbutt and Chalmers 2004). This writer would suggest that the disclo-
sure occur after the probationary period, if the person on the spectrum
does not need adaptations or job supports, simply because it is often
harder to fire someone after they have passed their probation.
Younger workers with ASD may be more likely to disclose their dis-
ability. Recent support in the education system has taught young
employees with ASD how to maximize their strengths and how to ask for
adaptations. They have often had the support of career planning and
more access to governmental supports than their predecessors. Earlier
support and career planning assistance has resulted in higher self-esteem
among those people with ASD that have entered the workforce more
recently. As long as educational and governmental supports continue or
improve, this trend is likely to continue (Müller, Schuler, Burton and Yates
2003).
Counsellors must attempt to assess the potential ramifications of dis-
closure or nondisclosure with the client (Gerber et al. 2004). Autism
spectrum disorders in high functioning people are often mostly invisible.
Many people think of Kanner’s type autism or lower functioning,
nonverbal individuals when they hear of autism and may not believe that
a high functioning person is on the spectrum (Aston 2003). This writer’s
professional experience is that people on the autism spectrum who are

extremely intelligent and high functioning are often disbelieved when
they indicate that they have a pervasive developmental disorder, and
often perceived as wilful or socially abrasive. Many workplaces continue
to be disability unfriendly, and this must factor into the decision to
disclose. Considerations should include what is the purpose of disclosure
as well as the best way to disclose. These are all issues that may be brought
into counselling.
Job advancement and job loss

Job advancement was often slow and difficult to attain. Job loss was more
common than job advancement. Often the reason for being fired was
poorly understood. One participant in Hurlbutt and Chalmers’ (2004)
study commented that it was confusing not to understand the reasons he
was fired from many jobs. Reasons that typical individuals would under-
stand, such as bothering coworkers of the opposite sex, meant nothing to
this man. He required very specific guidance regarding what he was
doing wrong. Often the normal characteristics of people who are ASD
make it difficult to keep employment, as social skills and getting along
with coworkers are considered important work qualities. Finding new
jobs became increasingly difficult with each job loss, particularly when
periods of unemployment had to be explained to prospective employers
(Gerber et al. 2004; Hurlbutt and Chalmers 2004; Müller et al. 2003).
Case study: Faux pas failures

Jessie was a young adult with ASD who had successfully
completed college in a trade that was in demand. Initially Jessie
was able to attain work, but soon lost the job due to muttering
unusual and strange comments under his breath. Jessie could not
understand the reasons he was fired, as he was not conscious of
his mutterings. Jessie was fired from several jobs due to his inap-
propriate mutterings. Over the course of five years, Jessie’s spotty
work history became a significant barrier to finding new work.
Jessie’s other odd behaviours, combined with his muttering,
frightened his coworkers and employers, as they did not under-
stand that these social faux pas were part of Jessie’s disability.
With some employment support, where this writer discussed

Jessie’s social difficulties with an employer, Jessie was able to gain
employment as a general labourer in the construction industry.
He was unable to gain employment in his own trade.
Underemployment and overqualification

Many people on the autism spectrum cannot find jobs in the areas that
they are trained in, particularly those trained for professional careers. Fre-
quently they are underemployed and overeducated for the job. Often jobs
are poorly matched to the persons with ASD and vocational services are
nonexistent. Usually higher functioning people with ASD do not meet
the criteria for government support services, and do not get the support
they may require (Müller et al. 2003; Nesbitt 2000).
Some people with high functioning autism and Asperger’s felt
betrayed by the education system which encouraged them to go to uni-
versity but did not offer support in choosing degrees that would lead to
employment (Boslaugh 1999). With underemployment common, people
on the autism spectrum are done a disservice if the professionals around
them counsel them to enter training programs that do not facilitate
employment.
Functional employment challenges

Basic employment skills, such as interviewing skills, organizational skills,
and resumé creation skills, are often lacking. People with ASD need to be
specifically taught how to handle feedback and incorporate it to improve
performance. Adapting to new job routines can be a challenge. Having a
job mentor is often helpful (Grandin 1996; Hurlbutt and Chalmers
2004; Müller et al. 2003).
Procedures need to be written in great detail, as should job responsi-
bilities and expectations, to help people on the spectrum to understand
what they are supposed to be doing on the job. The ASD person needs to
be able to accept that others may not always follow the rules, and that
they are not expected to police others on rule following, as this impedes
relationships with coworkers. Expectations around productivity and job
conduct need to be spelled out, as well as employment rules. Sometimes
these rules need to be spelled out very specifically. One crucial piece of
information for an individual on the autism spectrum was knowing
whom to go to when help was needed. People with ASD benefit from
extensive on-the-job training. Extensive training facilitates generaliza-
tion of job skills to the job setting (Hurlbutt and Chalmers 2004).
Employment and social skill difficulties

Many ASD persons themselves found the social aspects of employment to
be the most difficult, and reported often having difficulty getting along
with their coworkers and employers (Boslaugh 1999). People on the
autism spectrum often refer to people not on the autism spectrum as
neurotypical (NT). Many people with ASD attempted to act like
neurotypicals to fit in, although this is rarely successful (Jones and Meldal
2001; Willey 1999). Trying to fit in tends to be emotionally and physi-
cally draining as well, and working can be anxiety producing and very
stressful. It is often left up to the individual with ASD to change so they
could cope with the employment situation, as employers are not often the
ones doing the accommodating (Nesbitt 2000). One participant in
Hurlbutt and Chalmers’ (2004) study expresses the issue eloquently:
It seems to me that most NTs have a way of interacting…with the

world handed to them on a plate. They don’t have to make it up from
scratch; they don’t have to find meaning, beauty, or emotional
expression. These things are provided and taken care of, so they are a
lot more free to work at any job. (Hurlbutt and Chalmers 2004,
p.219)
For many people on the autism spectrum, the social challenges of

employment are far more difficult than the actual job expectations. Social
issues are often the primary cause of employment termination (Boslaugh
1999; Gustein and Whitney 2002; Hurlbutt and Chalmers 2004).
MARRIAGE AND INTIMATE RELATIONSHIPS

In the past it was believed that people on the autism spectrum did not
form intimate relationships. Some do not, and the reason is seldom that
there is no interest in forming relations (Jones and Meldal 2001). Usually

they lack the social skills to form or maintain intimate relationships.
Currently it is understood that higher functioning people with ASD can
and will marry, have relationships, have children, and appear quite
normal to outsiders. As males are more often affected by autism spectrum
disorders, most of the research on marriage, family, and relationships is
from the perspective of the male having an autism spectrum disorder
(Aston 2003; Attwood 1998).
Men with autism spectrum disorders tend to choose partners who are
older with nurturing qualities. Women are attracted to these men for their
kindness, gentleness, and flattering attention. Frequently the men have
high status careers, such as in engineering or computers. Usually the
person with autism spectrum disorder has not sought counselling on his
own initiative and is often sent in by his spouse. Therefore ownership of
the problem and of seeking help are not often there (Aston 2003; Meyer
1999).
Aston (2003) notes that the male who comes into counselling will
appear intelligent, hardworking, and faithful, yet cannot complete any
task requiring foresight or intuition, and he will complain that he doesn’t
understand why his partner is never happy. Often the partner of the
person with an autism spectrum disorder will be doing most of the
changing in the relationship to make it work. For many of the wives and
partners, having a relationship with a man on the autism spectrum makes
little sense, and they may question their sanity. Yet often they continue to
stay as their nurturing side worries about how the ASD partner will cope
without them.
There is a profound difference between having ASD and choosing to
act in a certain way. A man who is not on the spectrum can choose to
engage in social small talk and express emotions to his partner. Someone
with ASD cannot choose what he can and cannot put into a relationship
as there are significant deficits in emotional and social functioning that
the ASD person has to cope with. Some of the main concerns that bring
couples with an ASD partner into counselling are the lack of empathy,
difficulty socializing, problems with sexual intimacy, and apparent self-
ishness. Often the person with ASD may want to be able to provide the
social small talk and emotional support, but is unable to do so because of
their deficits. Indeed, for some, social small talk and emotionality are so
foreign that they cannot comprehend them, let alone attempt to engage in
these kinds of behaviour (Aston 2003; Attwood 1998).
Domestic violence and ASD

AS men (and women) may become violent when they feel out of control
of a situation with their partners. Forty per cent of the AS men studied by
Aston (2003) said that they had been physically abusive to their partner
at some time in the relationship, with 10 per cent of the attacks described
as being unprovoked. About 70 per cent of the men responded affirma-
tively when asked if they had ever been verbally abusive to their partners.
Thirty per cent of the AS men indicated that their female partner was
abusive towards them. Men who are in denial of their diagnosis tend
towards being more violent, placing blame on their partners.
Often ASD men react to comments as if they were criticism directed
towards them. The men on the spectrum may not be able to tell when
someone is offering a suggestion or being very critical. This can lead to
frequent disagreement and arguing, which can spiral out of control
(Aston 2003).
Violent incidents may appear unpredictable to the partner. This may
be due to the characteristic of poor emotional regulation (Laurent and
Rubin 2004) and that of disinhibition when overstimulated, anxious, or
overaroused (Raymaekers et al. 2004). Anger or total shutdown may be a
coping strategy for situations where the ASD person feels the situation is
out of control (Aston 2003).
Changes in initial courtship behaviour: losing that loving

feeling
A common relationship issue occurs when the ASD partner stops the
courtship behaviour. Their partner will often begin to feel resentful that
they continue to do nice things for the person with ASD, but he does not
reciprocate. Although this is a common issue in couples counselling, it is
usually more extreme in couples where one partner has ASD. By the time
the issue is brought to counselling, the ASD male (as it is usually the male
who has ASD in the relationship) will probably also feel resentful as his
partner will probably have stopped being nice due to her resentment that
her ASD partner is not the wonderful giving man that she fell in love
with. Often it is simply a case that the ASD male does not realize that the
courtship behaviour, such as giving gifts and doing nice things for the
woman, should not stop when the relationship is secure, but should be
ongoing to a lesser degree. ASD men cannot respond to the subtle cues
that their partners send. If they are not told specifically that they are
appreciated and doing what their partner wants, they will get into diffi-
culties and become confused. Specific suggestions of doing something
special or nice for the partner at times may be necessary. This may seem
unromantic and mechanistic, but this specificity is what the person with
the autism spectrum disorder needs (Aston 2003). He just simply does
not intuitively know that being nice and doing special things for your
partner is something that needs to be ongoing in a relationship. He needs
to know when, how much, and, specifically, what things she would
consider pleasurable. After all, if he finds lightbulbs pleasurable, wouldn’t
he believe that his partner would share that same enjoyment? However,
this writer does not know many women who would welcome the gift of a
lightbulb.
Case study: Regaining that loving feeling

Joan, whose partner Jack was on the autism spectrum, complained
that he was no longer the romantic man she fell in love with. Jack
could not comprehend what it was that Joan complained about.
Jack stated that he did everything she asked of him. Joan, however,
did not think she should have to tell Jack everything she wanted
him to do to make her feel special. Joan felt that Jack should
naturally know what things made her feel special, and what things
most women would like. Joan did not understand that Jack would
not infer that she would like something if another woman liked it,
nor would Jack pick up on the subtle hints that Joan was feeling
neglected. The compromise that this writer and the couple
developed was to have Joan write down some things that she
thought were romantic (her girlfriend added some of her own
ideas to this list) which were placed on some recipe cards. These
cards were placed in a special box (called the romance box) for Jack
to use. Jack was given a smaller box with several copies of the days
of the week printed on them. Every Monday morning Jack was to
draw a card (after shuffling the deck) to determine which day of
the week he would do something from the romance box. Some
of the cards had “two days” written on them. His instructions on
the two-day cards were to pick two romance cards and do two
romantic things that week, one on each day. The instructions
included not telling Joan anything about the romantic thing, so it
would be a surprise. One instruction added later was to have Jack
inquire about Joan’s plans for the week, to ensure that there would
be no scheduling conflicts. They tried this system for two months
and decided that this met both of their needs. In fact, they both
said that they were enjoying being with each other again, and Jack
indicated that Joan was the wonderful woman he fell in love with
all over again. Joan commented that she enjoyed this so much that
she asked Jack to give her some cards with romantic ideas that
he would like her to do, because she felt that Jack was having all
the fun.
Autistic rituals and need for sameness

One of the most confusing relationship characteristics of autism is the
need for sameness, particularly when the rituals do not make sense to the
partner who is not on the spectrum. The rituals and demands for
sameness can be debilitating to the relationship. Partners are seldom
welcome to join in the rituals, and are certainly not welcome to change
them. Autistic rituals can interfere with family life, as it can be difficult to
work around the ASD partner’s demands that the ritual remain
unchanged. The need for sameness can isolate the partner and the family
as well, as socializing on a schedule does not often work. Conflict can
arise when social needs clash with the rituals, and the partner who is not
on the spectrum is not comfortable meeting her need for socializing
without her ASD partner (Aston 2003; Attwood 1998).
For most people not on the autism spectrum, variety is the spice of
life, as the saying goes. For the person on the autism spectrum, variety is
definitely not something that will spice up or enhance their lives. The
ASD partners would much rather have routine and predictability in their
home lives, as these are seldom found in their working or school lives.
Predictability and routines create order in an often confusing and over-
whelming world, and are a sense of comfort for someone on the autism
spectrum (Aston 2003; Attwood 1998).
Sexuality
Men with ASD cannot easily understand social signals or social cues. This
is even more the case when attempting to read their partner to determine
if sexual intimacy is welcome. Misinterpreting sexual interest cues can
have serious consequences when the partner is unwilling, and can lead to
a lot of confusion for the ASD male. Frequently there are communication
issues around intimacy. Partners who are not on the spectrum may find it
stifling and contrived to instruct their partner regarding their sexual
wants and desires, seeing this as unromantic. However, this level of com-
munication may be necessary for fulfilment of sexual needs when the
partner has ASD (Aston 2003).
About half of the couples that Aston (2003) studied indicated that
they had had no sexual relations in the past year, and that sexual intimacy
was not important in their relationship. Some of the men had homosexual
affairs but did not see this as wrong as they were not having sex with
another woman. From their point of view they were not being unfaithful
if they met their sexual needs with another man. For them there was no
relationship, just a mutual enjoyment. One man on the spectrum
explained to this writer that having a homosexual relationship was not
cheating on his marriage as it was simply physical, much like two men
playing a sport. He could not comprehend his partner’s emotions around
this. He could not understand why she was upset when he practised safe
sex with other men. He could only understand the concrete complica-
tions of contracting a sexually transmitted disease, but not the emotional
ramifications of cheating on his partner.
Some of the idiosyncratic interests found in people on the autism
spectrum can occur in the area of sexuality or attraction. Some ASD men
fixate on women’s body parts, and cannot understand their partner’s lack
of interest or disapproval. These fixations can be perceived as stalking,
with serious consequences, as the ASD male may not accurately read the
signals sent by the person to whom their interest is directed. ASD people
may choose their partners based on some of these fixations, such as par-
ticular hairstyles or body shapes (Aston 2003).
Adolescents tend to mature physically at the same rate as their peers,
but lag behind in social skills and emotional maturation. The media can
contribute to informal sexual education, but often misinform. This can
cause difficulty for people on the autism spectrum who cannot determine
what is realistic and what is show business. Growing sexual drives
without the corresponding social knowledge can lead to many embar-
rassing and potentially troubling situations. For those with moderate
mental handicaps, behaviours such as touching other people’s private
parts, public masturbation, and self-exposure can cause serious problems
(Koller 2000).
Dealing with masturbation

Koller (2000) recommends using a time and place approach with mastur-
bation; in other words, teaching the individual to engage in masturbation
only in appropriate places at appropriate times. This author highly rec-
ommends the place be the person’s bedroom with the door closed
(providing they do not share a room with anyone else). If masturbation
begins in public, the person should be redirected to wait until they can go
to their bedroom. If out in the community, remind the person when and
where they can masturbate and direct them to a different activity that
keeps both their hands busy with an object. It may help to redirect the
person to a task that involves a lot of physical activity. Teaching this can
be supplemented with visual scripts of where and when masturbation is
permissible. Scripts need to be very specific, as loopholes can create some
very interesting problems.
Masturbation, in private, can be an acceptable way to relieve sexual
pressure safely. It is this writer’s opinion that masturbation is a functional
skill that needs to be taught. The ability to safely relieve sexual tension is
an outlet that many individuals with ASD may require. Instruction in
masturbation should be part of the education around sexuality and sexual
safety that individuals with ASD require.
COUPLES STRATEGIES FOR ASD MARRIAGES

The partner who is not on the spectrum is often the person who makes
the most changes in the ASD marriage in accommodation to the develop-
mental disability of the partner. Often the use of visual supports, such as
checklists, memos, and cue cards, are recommended to address mis-
communication and apparent forgetfulness. Writing things down appears
to be a robust strategy to bridge communication gaps. Initially this may
feel stilted and less than romantic for the NT partner: “The NT partner
may find trying to change her way of communicating tiring and
unnatural. Encouragement and support while offering understanding
will be crucial to her well-being and self esteem that is probably already
very low” (Aston 2003, p.12). It is confusing for a partner to make these
accommodations when the ASD partner appears intelligent and often
quite capable in some areas. For some partners, it may feel like she is
parenting her partner. Offering a comprehensive understanding of the
characteristics of the autism spectrum can help the NT partner adjust. It
may be important to clarify that using visual tools and being exact in
communication will not lessen the relationship over time. In fact the
reverse will happen. Once the communication issues are cleared up and
the ASD partner understands how he can please his partner, the relation-
ship will begin to heal and build (Aston 2003).
ADOLESCENCE AND PUBERTY

Adolescents may lack self-esteem as they become aware of their differ-
ences as adolescents and do not feel like they belong to any social group.
The sense of not belonging may lead to depression, problems with
self-esteem, and self-concept. Often their social skills and social
awareness are those of a much younger child (Attwood 2003; Koller
2000; Smith-Myles and Simpson 2001).
ASD adults (and youth) can read more into a friendly act than
intended. A mentor can help this person understand the meaning of the
friendly act and how to determine who is likely to become a friend and
who is only a colleague or fellow student. Intense infatuations are
common, and can lead to difficulty. Desperation for a friend can lead to
vulnerability to sexual and physical abuse, as the other person’s dishon-

ourable intent may not be recognized (Attwood 2003).
However, lack of social skills and adolescent peer relationships may
be a protection from involvement with delinquent peers (Green et al.
2000). It is this writer’s observation that most youth with ASD are rule
enforcers (Attwood 1998), which would not make them very popular
with the delinquent crowd. This author has observed that their poor
social skills make the person with ASD a high risk in regard to exposing
delinquent peers in criminal activities, also making them unlikely compa-
triots of delinquent peers. This writer has seen children with ASD teased
and set up by delinquent peers, but never fully accepted within their
ranks, even as a scapegoat. Delinquent children tend to set up the child
with ASD knowing that they cannot adequately defend themselves. This
insidious bullying can lead to depression and anxiety (Attwood 2004).
Teasing
Teasing is a complex social behaviour that can initiate social engagement,
negotiate group membership and hierarchies, and ostracize. Teasing is
most common among peers and family members. This aspect of socializ-
ing is very difficult for children and adults on the autism spectrum as they
often cannot understand teasing and may take teasing literally. They may
not know how to tease appropriately, and often do not know when to
stop teasing. To understand teasing an individual must be able to under-
stand intent, hidden intent, pretending, and nonliteral communication,
all of which are areas of difficulty and deficit for people on the autism
spectrum. The nonverbal indicators of teasing may prove to be the most
challenging for people on the autism spectrum, as the nonverbal
language is difficult to interpret, and may be subtle or exaggerated, either
condition which is apt to be missed by someone on the autism spectrum
(Herrey, Capps, Keltner and Kring 2005).
SOCIAL SKILL DEVELOPMENT

Social skill development is a common area of intervention for people on
the autism spectrum, as their social impairments are often quite notice-
able. Skill development needs to include the teaching of skill components
as well as when to use the skill. There may be a need for some practice in
the actual situations before the skill transfers out of a clinical setting.
Social skill development is often successfully implemented in a group
format, as this provides a safe arena to practise social skills. Sometimes
individual instruction prior to group instruction is helpful (Attwood
2003; Marks et al. 1999; Sofronoff and Attwood 2003).
Poor social skills are related to the inability to understand other
people’s perspectives, known as theory of mind, and the inability to
process emotional information, as well as a difficulty with emotional rec-
ognition (Ponnet, Roeyers, Buysse, DeClercq and van Derheyden 2004).
People on the autism spectrum may appear to cognitively understand the
emotions of other people, but do not use visual facial emotion cues accu-
rately to read the relevant emotions. Reciprocal interactions may be
impaired. Only about 20 per cent of people on the autism spectrum can
pass a first order theory of mind task, which involves attributing different
beliefs to another person that the individual does not have himself. More
capable people on the spectrum can pass second order theory of mind
tasks, which is when you can correctly identify someone else’s beliefs
about a third person (Ochs, Kremer-Sadlik, Sirota and Solomon 2004).
Time needed to process social information to make inferences about
another’s thoughts and feelings is often much longer than the instanta-
neous processing that social situations require. Understanding social
nuances may lag far behind their intellectual ability. High functioning
people on the autism spectrum have difficulty inferring emotions
correctly using pictures of other people’s eyes and voice recordings of
intonation. These nonverbal cues, which guide typical individuals
towards a correct assessment of emotion, are not utilized effectively by
people who have ASD. Awareness of emotion is often lacking, and people
with ASD often respond poorly to others’ expressions of emotions (Ochs
et al. 2004; Ponnet et al. 2004).
Social awareness involves a sense of social consequences. Most
people with ASD lack insight into their own difficulties, but Green et al.
(2000) found that a third of their sample of youth and young adults with
Asperger’s had no insight whatsoever into their own difficulties. People
with ASD make fewer correct interpretations of intention and mental
state during tasks like understanding awkward moments, or when
someone is sarcastic or lying. People on the autism spectrum have

difficulty detecting when a faux pas has been committed, and often do
not recognize their own faux pas (Baron-Cohen, O’Riordan, Stone, Jones
and Plaisted 1999).
Social skill instruction

Social interactions are rapid and thoughts are invisible to people on the
autism spectrum. The ability to shift thinking rapidly is one of the best
predictors of social skill development. Unfortunately, as previously
discussed, this is an area of difficulty for people with ASD (Attwood
2003; Tsatsanis 2004).
Often it is the skill of social cooperation that is underdeveloped. To
facilitate the learning of cooperation, children with ASD should experi-
ence more cooperative games than competitive ones. Children with ASD
require a lot of instruction on how to lose gracefully. Cooperative skills
that need to be taught are: accepting of others’ suggestions, determining
the common goal and working towards it, and encouraging other peers
(Attwood 2003).
Conversation can be confusing, but can be explained using a
metaphor of a tennis game or catching and throwing the ball. Social con-
versation is like a tennis game, where the ball is bounced back and forth,
and the objective is to keep sending the ball back to the other person
(Marks et al. 1999). Staying on topic is framed as throwing back the same
ball. Teaching conversational turn taking with a talking object, like a
talking stick, to make the give and take of social conversation concrete,
may be helpful. Charlop-Christy and Kelso (2003) used cue cards and
written scripts to teach social conversation skills with good results with
children.
This writer recommends explicit instruction regarding identifying
emotional expressions, and then to take this instruction out into various
situations to facilitate generalization. The addition of social-interper-
sonal problem solving is also recommended. Even with social skill
instruction, many social situations are confusing at best. Often the
confusion can be cleared up with some interpretation. Tools that can
facilitate interpretation tend towards making social situations visual, such
as cartooning out the situation (Gray 1994b, 1995), including thoughts,
explaining the hidden social rules, and exploring choices and conse-
quences (Hodgdon 1995; Smith-Myles and Simpson 2001).
One strategy that is proving effective is using a video camera analogy
for the mind. With this strategy, the person with ASD is asked to imagine
that what other people experience is similar to that of a video camera that
has observed the same situation. For some unknown reason, individuals
with ASD can correctly infer what a person has seen or the knowledge
that they have gained from a situation when they imagine what a video
camera would know, hear, and see in the situation. The mind is compared
to that of a video camera, in that it becomes a storage device for sound,
sight, and knowledge. This framework has been effective in helping
children on the autism spectrum to understand what information and per-
ceptions another person would have of a given situation (Baron-Cohen et
al. 1996).
When examining social situations, the therapist and client need to
look for the salient features that provide clues about social rules, and then
brainstorm for possible options of ways to respond or solve the social
dilemma, and then look at the possible consequences of each of the
choices. Once a clear choice with good consequences is identified,
planning needs to happen to make the choice occur. All that is left then is
to try out the solution and evaluate the results. This process can be made
visual through a choice chart (see Figure 3.7, p.94). This problem-solving
process can be used to review a social situation that did not go as planned
to determine where it went wrong and what possible things could be
done differently in the future (Smith-Myles and Simpson 2001). Teach
how to use self-talk strategies, as these are successful social strategies used
by people who are not on the autism spectrum (Marks et al. 1999).
Hidden social rules and procedures need to be explicitly taught
(Smith-Myles and Simpson 2001). One format this writer has found
useful is called a book of life. All the relevant social information that an
individual with ASD would need is recorded and personalized to the
individual’s particular situation. The book details basic things like bus
rules, scripts for leaving messages on someone’s answering machine, and
rules about inviting someone over for a movie, and other sundry everyday
information. Social actions are also included in the book. Social actions
can be grouped into those that are friendly and those that are unfriendly.
Unfriendly actions are things like interrupting and standing too close,
while friendly actions are helping someone and coping with mistakes.
The ASD person needs to learn how to determine when acts are acciden-
tal or intentional (Attwood 2003). Sometimes using the aforementioned
concept of other people’s minds being like video cameras can facilitate
this understanding (Baron-Cohen et al. 1996).
Making social skills visual and highlighting social rules facilitates
learning. There is a need to teach coping skills, such as self-calming skills
and how to handle confusion or frustration, to combat the negative
thinking and faulty assumptions common with ASD social meaning
making. ASD people need to learn how to cope with things when they do
not go the way they want. Teaching key social phrases may help (Marks et
al. 1999).
Social skill instruction usually implies having social partners to facili-
tate teaching. Social skills groups have been shown to have good effect in
helping adolescents and adults on the autism spectrum develop social
skills. Specific performance feedback is essential. Use of videotapes to
show the learner’s performance of good social skills is helpful (Marks et
al. 1999).
Social Stories™
Social Stories™ are an adapted form of bibliotherapy developed by Carol
Gray. The social situation is detailed in a comic strip or story format
(Attwood 1998; Gray 1994b). The story highlights the salient features of
a situation, providing descriptions of the situation, what the expectations
are, and the reasons behind some of the occurrences of the situation.
Comic Strip Conversations take this a step further by detailing other
people’s thoughts in thought balloons. They are created with the individ-
ual who has ASD to determine their interpretation of the situation (Kerr
and Durkin 2004). Emotion can be colour coded by using different
colours in the thought or word balloons. This can provide the counsellor
with an idea of the person on the autism spectrum’s perception of
emotion, which can often be incorrect. The comic strip can be redrawn
with corrections to provide an accurate view of the situation, and some
possible options of what to do (Attwood 1998).
Social Stories™ have been used effectively to teach social skills, and
have been shown to have a positive effect on changing social behaviours,
although they are mostly used with children and adolescents (Sansosti,
Powell-Smith and Kincaid 2004). An adult adaptation of Social
Stories™, called social articles, can be expected to show positive results
based on the successful use with adolescents (Attwood 1998). “Based on
current research and informal experience my theory is that social articles
may be effective for some adults with ASD” (Carol Gray, personal com-
munication, October 29, 2005). Social articles are similar to Social
Stories™, with the exception that they are more like a newspaper or
journal article regarding a particular social topic. Social articles provide
more background, reasons, and detail regarding a social practice, and less
direction.
Social Stories™ and Comic Strip Conversations can provide social
scripts as well. People with ASD have fewer social cognitive scripts than
people not on the autism spectrum. This was confirmed by
Trillingsgaard’s (1999) study of children on the autism spectrum. These
children were unable to produce basic social scripts of common, everyday
social routines. People on the autism spectrum have greater difficulty
generating appropriate cognitive scripts for various social situations, but
can identify about the same number of core social scripts as controls
when viewing a videotape, indicating that they can recognize social
cognitive scripts but are impaired in generating them. When in a struc-
tured situation, predicting the next sequence in an unknown script
improved. However, Trillingsgaard (1999) discovered that although
verbal recall of scripts was evident, the ability to use these scripts effec-
tively in social situations may be impaired. People with autism can use the
understanding of social rules and scripts to follow the rules and scripts,
and to recognize script and rule violations.
Social Stories™ or articles become a guidebook to different social situ-
ations, providing instruction and guidance much like a traveller’s guide to a
foreign country: “The story itself becomes a ‘how to’ book for initiating,
responding to, and maintaining appropriate interactions for individuals
with ASD” (Sansosti et al. 2004, p.195). Social Stories™ are often read
prior to entering the target situation, becoming a reminder of the social
expectations and salient features. Social Stories™ can also be used to teach
problem-solving skills through the use of a problem-solving script.
Social Stories™ are created for each person with a focus around a
problematic situation or behaviour. The salient cues or features of the
situation are highlighted to provide understanding of what elements of
the situation indicate that a particular response is required. The story
provides the who, what, where, when, how long, and why information
that is hidden to people on the autism spectrum (Sansosti et al. 2004).
Stories are written at a level that the individual can easily read. For
nonreaders, the story is read to the person using language that the indi-
vidual easily understands. There are several types of sentences used.
Description sentences provide the description of the situation including
the salient features. Directive statements provide the instructions of what
is expected to be done in this kind of situation. Perspective statements
offer the perspectives and feelings of others, as well as the possible per-
spective of the person for whom the story was written. Affirmative state-
ments outline the cultural beliefs. Control sentences use analogies to
facilitate understanding, and cooperative sentences provide information
regarding who may be able to offer help when asked in this situation. It is
a general rule to use a ratio of two to five descriptive, affirmative, or coop-
erative statements for every directive or control statement. The emphasis
of the story is to provide information and facilitate understanding. The
understanding of the story must be assessed to determine if it will be
effective, and to clear up any misunderstandings (Attwood 1998; Gray
1994a; Sansosti et al. 2004).
Using computers to teach social skills

Computers and virtual reality formats have been shown to be successful
in teaching social skills (Moore et al. 2000). For many people on the
autism spectrum, using computers to teach social skills leads to faster
learning, as distractions and anxiety are lessened. These skills were
shown to be transferred into real life situations. People on the autism
spectrum tended to treat the virtual reality environment as if it were real.
This may become an avenue to provide therapeutic benefit between
sessions, if computer-based instructional programs were used as
homework. This writer has successfully used virtual reality games that
emulate real life situations as social teaching tools (Parsons, Mitchell and
Leonard 2004).
Video modelling of social skills

The use of videos for teaching social skills is a new intervention that
shows much promise. One of the useful features of videos as social skill
instructional tools is that the camera can focus in on the salient cues, thus
highlighting them for the individual. Watching a video also tends to
capture the individual’s attention and is likely to facilitate the screening
out of extraneous stimuli in the environment. Children on the autism
spectrum tend to learn scripts from videos, often displaying remarkable
recall of favourite movie videos. This propensity to learn from videos is
captured through video modelling. Life skills can be learned by imitating
the actions displayed on a video. Videos can be more effective as training
tools when the actors or actresses are similar to the learner Charlop-
Christy and Daneshvar 2003; Charlop-Christy, Le and Freeman 2000).
Case study: Why, hello there

Judy is a nonverbal woman with ASD who had an unfortunate
habit of coming up to strangers and hugging them. Judy did not
seem to understand that this was not appropriate. Several social
instructional methods failed, until this writer noticed that Judy
modelled what the characters in her favourite videos were doing.
Judy was given a video of how to say hello to strangers, with a
verbal commentary explaining what to do and why. The next time
the writer came to see Judy, she took my hand and gave it a hearty
shake, instead of the customary bone-crushing hug. When the
writer left, Judy waved a goodbye for the very first time in her life.
Using videos to model appropriate social skills appears to be effective,

and can be paired with self-monitoring to enhance effectiveness. The
individual needs to have adequate imitation skills for video modelling to
be an effective intervention. For some clients, videotaping their
behaviour for later review can serve as an intervention tool, as individuals
with ASD may be unaware of their behaviour (Meyer 1999; Nikopoulos
and Keenan 2003).
Video modelling is not effective when there are other behaviours that
interfere with performing the skill being modelled. Care must also be
taken to ensure that the skills being modelled are within the individual’s
ability to learn. On occasion, some of the modelled skills may require
preteaching (Nikopoulos and Keenan 2003).
CHAPTER 7
Stress and Relaxation
Stress is a constant factor in the lives of people on the autism spectrum,

particularly in situations that involve social interaction. Being and feeling
stressed is prominent in emotional disclosures of persons on the
spectrum. There is a high comorbidity of depression and anxiety
disorders in autism spectrum disorders, and stress is a contributing factor.
Sensory abnormalities common to autism spectrum disorders contribute
to stress levels as sensory information can be confusing (Gillott et al.
2001; Glenn et al. 2003; Groden et al. 2001; Jones et al. 2001; O’Neill and
Jones 1997).
Sensory overload can contribute to stress, and tends to result in
behavioural disinhibition (Laurent and Rubin 2004; Raymaekers et al.
2004). Behavioural disinhibition is when an individual loses the ability
to slow down or reduce a response, and cannot stop themselves from
responding impulsively. Disinhibition creates more stress as the person
loses control over their behaviour and levels of anxiety increase. This can
become a vicious cycle. Instruction in techniques that include stress
reduction has been shown to have positive results, including the
reduction of aggression, and can also be effective with people who have a
cognitive disability as well as an autism spectrum disorder (Mullins and
Christian 2001; Sofronoff and Attwood 2003).
Many people on the autism spectrum do not have strong social
support networks and may be socially isolated (Gustein and Whitney
2002; Orsmond et al. 2004). Social isolation negatively impacts stress
and coping (Sarafino 2002). Some people on the autism spectrum may
not know when to turn for help, or who to turn to. Having a social
support network has been identified as being a key component in the
159
success of people who are on the autism spectrum (Grandin 1996; Willey
1999).
Stress reduction strategies are often effective for people on the
spectrum. However, sources of stress must be considered as well. Much of
the daily stress revolves around social situations and not knowing what to
do, or misunderstanding what went wrong. It is often the unstructured
times, such as coffee break, lunch, or recess, which can be the most
stressful time periods. Unexpected change can be a great source of stress
or dealing with the other-than-expected. Advanced preparation, social
scripts, activity checklists, and regular routines are useful strategies to
reduce social anxiety, which lowers overall stress (Aston 2003; Attwood
2003). Change in environments can also be a source of stress for people
on the autism spectrum (Groden et al. 2001).
Groden et al. (2001) developed the first stress survey for people who
are on the autism spectrum. Although it has not been researched inten-
sively to date, it is the only stress measurement tool that recognizes the
unique characteristics of people on the autism spectrum. Some of the
areas of stress that loaded heavily were changes in environment,
transitioning activities, sensory components, and prevention of ritual
completion. Positive stress measures such as receiving reinforcement
were included in the survey, recognizing that good stress, or eustress, can
contribute to stress levels in people who are on the autism spectrum.
MEANING MAKING AND STRESS

Meaning attributions of situations can increase or alleviate stress.
Causality meaning attributions that people who are on the autism
spectrum make are often incorrect, and may contribute to feelings of
stress. Often they are unaware of how their actions impact situations,
which means that they make incorrect causal attributions in regard to
their own actions. Causation attribution and meaning making are based
on having good theory of mind skills. The difficulties in understanding
another person’s probable thoughts and feelings negatively affect causal
attribution and meaning making (Hill et al. 2004; Leudar et al. 2004; Park
and Folkman 1997).
Stress and Relaxation 161
The meaning of the personal significance of an event also impacts the

experience of stress. People on the autism spectrum make unusual associ-
ations between events, and it is reasonable to assume that they may make
incorrect interpretations of the personal meaning of events, possibly
creating higher stress levels. Rumination or perseveration on the meaning
of an event may also exacerbate personal stress (Park and Folkman 1997).
Case study: Bad shirt day

Thomas is a child with ASD who based his prediction that his day
would be difficult on the colour of his teacher’s shirt. He would
become anxious when the teacher wore black on his or her shirt.
Seeing black on the teacher’s shirt created anxiety, and therefore
stress. Thomas assessed his ability to handle the event of black on
his teacher’s shirt as something that he did not have the capability
to cope with. His assessment of coping ability also contributed to
increasing his stress. Thomas would perseverate on whether his
teacher would be wearing a black shirt every morning, creating
stress for himself early in the day. For Thomas, shirt colour had pre-
dictive meaning. In a sense, Thomas taught himself to be phobic of
black shirts. It took a long process of desensitization and reframing
before Thomas no longer considered black shirts a hallmark of a
bad day. Part of that relearning involved diagramming out how
events and actions link together, such as his thoughts about having
a bad day created stress, which lessened his ability to cope. The
diagram showed that shirt colour, in and of itself, affected nothing.
Shirt colour was an irrelevant information detail that was acciden-
tally mistaken as a causal factor. This logic helped Thomas to
understand how he fuelled his anxiety. Choice points to turn the
day around were included, to show Thomas where he had several
opportunities to change his thinking and change the day.
There are two stages in the appraisal of stress. In the primary stress
appraisal, stress is assessed for degree of harm/threat or challenge. The
secondary appraisal determines whether the person feels that he or she
has the personal resources to cope with the situation. Stress is the result of
perceiving the threat or challenge to be beyond the coping resources.
Meanings are attributed at both assessments. Stress is a result of the

cognitive appraisal of the stressor as being one that the person cannot
easily cope with and/or is perceived as a serious threat. People on the
autism spectrum tend towards having a low sense of self-efficacy and
have limited coping skills. They have difficulty knowing what to do in
new situations and frequently cannot take what they have learned from
one situation and apply it to another. People with ASD, given the above
characteristics, may correctly assess that they do not have the ability to
cope with a stressful situation, leading to an increase in secondary stress
(Sarafino 2002; Wagenaar and La Forge 1994).
Meaning reattribution
Meaning reattribution can reduce stress levels. Reattributions of
causation that increase the possibility of having some personal control
over parts of a situation tend to improve outcome. A sense of self-efficacy
regarding a stressful situation ameliorates the effects of stress. Attribu-
tions regarding self-efficacy lie on three dimensions: internal or external
locus of control, stable or unstable causes, and global or specific causal
factors. Faulty attributions or attributions that tend towards an external
locus and global and stable causal factors are more likely to result in lower
self-efficacy (Park and Folkman 1997; Sarafino 2002). In the case study
above, when Thomas was able to attribute a different meaning to his
teacher’s black shirt, such as that his teacher ran out of other colours to
wear, he was able to cope more successfully with black shirts on his
teachers.
STRESS MANAGEMENT
There are three primary intervention areas of stress management. These
are: problem-solving interventions, cognitive reappraisal strategies, and
relaxation training. Often stress reduction treatments involve a combina-
tion of all three approaches. No matter what approach you use, the person
on the autism spectrum may require assistance in learning to identify
their stress continuum and their related stress symptoms (Wagenaar and
La Forge 1994; Sarafino 2002).
Identification of stress symptoms

Identification of the signs and symptoms of various stress levels may be
facilitated with the use of visual aids like stress thermometers. Physical
symptoms and behavioural signs of the different levels of stress should be
recorded to show the progression of stress responses and symptoms.
Identification of the different stress levels lends itself to suggesting
different stress-reducing techniques for different degrees of stress
(Attwood 2003; Sofronoff and Attwood 2003).
Some people on the autism spectrum are not attuned to their body’s
signals. Specific instructions to pay attention to rates of breathing and
muscle tension may need to be provided. Identification of the early signs
of becoming stressed leads to earlier use of stress reduction techniques,
which are often more effective earlier on in the stress response (Sarafino
Stress coping responses can be described as a set of tools, much like
the coping toolbox described by Sofronoff and Attwood (2003). Coping
tools would involve the cognitive stress tools, such as meaning
reattribution, physical stress reducers, such as regular exercise, and
behavioural stress tools, such as taking three deep breaths or progressive
muscle relaxation techniques. Tangible items, such as worry stones or
stress balls, can serve as relaxation cues.
The stress and coping cycle is introduced to the client to provide an
understanding of the physical and cognitive components of stress, and
the key component of the cognitive appraisal. If the appraisal is that the
stressor is greater than the person’s ability to cope, then the situation will
be perceived as stressful. Self-talk is explored to determine how it con-
tributes to the experience of stress. Once the person’s experience of how
they create their own stress is understood, skills are taught to combat
stress and correctly assess the situation. In the final phase, skills are
practised (Hiebert and Malcolm 1988; Malcolm and Hiebert 1986).
Breathing to reduce stress

A common response to stress is to engage in shallow breathing. Deep or
diaphragmatic breathing alleviates stress and facilitates mental relaxation
(Cormier and Nurius 2003; Kabat-Zinn 1990). Learning to breathe

deeply may be the simplest strategy to combat stress.
When teaching a client on the autism spectrum to breathe deeply, it is
helpful to ask them to breathe out slowly first, as this promotes deep
inhalation (Ory 2002a). It is recommended that breath be passed
through the nostrils. Teaching the concept of breathing from the belly or
“belly breathing” (Kabat-Zinn 1990, p.54) is facilitated when the client is
instructed to place their hands on their belly and chest to monitor the
movement of their diaphragm while they are breathing. Identifying
which hand moves more allows the client to determine if they are
breathing deeply. The use of diagrams to show the movement of the
abdomen during belly breathing is helpful as well.
Deep breathing is a portable strategy that can be engaged in at almost
any time when feeling stressed. Practising deep breathing several times a
day will facilitate its use when facing a stressful situation (Cormier and
Nurius 2003).
Progressive muscle relaxation

Progressive muscle relaxation (PMR) is a concrete strategy that does not
rely on abstract thought or imagery, therefore lending itself for use with
people on the autism spectrum. Part of progressive muscle relaxation
involves scanning the body to identify areas that may be tense. This helps
the person on the autism spectrum to become aware of their bodily sensa-
tions. PMR promotes personal control over muscle tension, giving the
person some feeling of self-efficacy regarding their bodily sensations.
This sense of having some control can in itself alleviate some of the
feelings of stress. Being able to relax is an invaluable skill for someone on
the autism spectrum. This writer has experienced many positive results
from teaching someone who has ASD relaxation skills, including a
positive impact on task performance (Cormier and Nurius 2003; Sarafino
2002).
When teaching progressive muscle relaxation, be aware that the client
may interpret your language as indicating that they are to make their
muscles as tense as they possibly can, part of their all-or-nothing ways of
thinking. This extreme form of tensing can cause injury. Clients must be
made aware that they are to tense their muscles, but not to tense up as hard
as possible. The client should be reminded that if the tension is painful,

they are to not tense the muscle so hard. A helpful analogy when teaching
progressive muscle relaxation is that of a robot and a rag doll (Miranda
and Presentación 2000). The robot represents a tense body, while the rag
doll represents a relaxed body. Modelling what tense and relaxed muscles
look like is recommended. This writer has used toys to demonstrate this
concept, asking the client to feel the softness and hardness of each toy.
This author will also allow the client to feel her arm muscles while tense
and relaxed, to facilitate a comparison regarding tenseness. The client is
then instructed to try to do the same with his or her arm muscles.
The sequence of progressive muscle relaxation should involve a man-
ageable number of steps for the person with ASD. For those who have
some cognitive impairments, memory, or attention difficulties, this
author recommends that the sequence be shortened to seven or four steps,
such as those outlined in Table 7.1, breaking the sequence into four
groupings of the arms, face and neck, body, and legs. Some people cannot
coordinate both arms and both legs at the same time. For these clients,
Table 7.1 Progressive muscle relaxation

muscle group breakdown
Seven muscle groups Four muscle groups
1. Dominant arm, including forearm, 1. Right and left arms, including

biceps, and hand forearms, biceps, and hands
2. Nondominant arm, including 2. Face and neck
forearm, biceps, and hand 3. Stomach, chest, and back
3. Facial muscles, including forehead, 4. Legs, including upper legs, lower
nose, eyelids, jaws, and mouth legs, and feet
4. Neck, by pressing chin towards the
chest
5. Chest, shoulders, upper back, and
abdomen
6. Dominant leg, including thigh, calf,
and foot
7. Nondominant leg, including thigh,
calf, and foot
using seven steps may be preferable, where each arm and leg is treated as a
separate step (Cormier and Nurius 2003; Singh et al. 2003). Table 7.1
outlines the muscle group breakdown.
The sequence of progressive muscle relaxation can be made visual by
creating a picture script of the sequence, which has been shown to facili-
tate learning for people on the autism spectrum. Mullins and Christian
(2001) successfully used 13 steps with an adolescent that were described
and pictured in a relaxation book.
Progressive muscle relaxation is a key component to managing the
physical sensations of anxiety. Generally, clients are shown how to do
progressive muscle relaxation, and are then taught to use it daily, as well
as during everyday situations. This is known as applied relaxation. Over
time clients are asked to use progressive muscle relaxation during stress-
provoking situations, moving up their stressful situation hierarchy while
using PMR, building their skill as they progress (Rodebaugh et al. 2004;
Sarafino 2002).
Relaxation objects
Attwood (2003) suggests using tangible objects as relaxation cues. This
author has used relaxation items as props for engaging in relaxation strat-
egies. One prop that has been successfully utilized is the stress ball, which
consists of a squishy round object that is very difficult to rupture. Others
are soft, rubbery balls that have multiple soft protrusions, often known as
koosh balls. This author has taught progressive muscle relaxation using
the stress balls as props, where the client places the squishy object on a
spot on their body, such as between their chin and their chest. Muscle
tension is demonstrated by asking the client to hold the stress ball in that
location on their body. In a pinch, this author has used rolled up socks as
objects to squish. One caution is noteworthy, however. It has been this
author’s professional experience that using socks as relaxation objects
often involves a lot of laughter, particularly when the socks fall. Laughter
is a stress reducer, but may not be the appropriate strategy to use in a
situation where being quiet is valued.
Stress inoculation
Stress inoculation is the strategy of teaching someone proactive ways to
manage stress to enable them to cope with inevitable stress more effec-
tively. It involves both physical and cognitive coping skills. Stressful situ-
ations are anticipated, and stress inoculation techniques are part of a stress
action plan. Having an action plan can significantly reduce feelings of
stress (Cormier and Nurius 2003; Sarafino 2002).
Stress inoculation training involves education around the stress
response and identification of stress triggers, skill acquisition, and skill
application. Stress inoculation has been successfully used with
cognitively challenged adults (Malcolm and Hiebert 1986). Stress inocu-
lation is a preplanned and somewhat scripted process, which lends itself
well to use with people on the autism spectrum, as they benefit from
planned and practised responses. For people on the autism spectrum,
having a plan to address troublesome situations facilitates remaining calm
and coping. The rationale for stress inoculation is that there will always
be situations that trigger emotions such as anger or anxiety, where acting
on the emotion will not help the situation. When these trigger situations
are encountered, it is time to engage in stress reduction activities to help
the person cope with the situation, thus reducing stress (Cormier and
Nurius 2003; Sarafino 2002).
When teaching stress inoculation, the use of visual aids is recom-
mended. Stress thermometers or stress and anger symptom lists are
helpful visual aids for people with cognitive challenges, including those
with developmental disabilities (Malcolm and Hiebert 1986). Listing the
client’s cognitive distortions that escalate stress facilitates cognitive
restructuring of those thoughts. Breaking down the stress pattern into
different phases, such as the anticipatory phase, the confrontational
phase, the coping phase, and the assessment and reinforcement phase,
helps to identify which coping strategies are most useful for the particular
phase of stress (Cormier and Nurius 2003). These phases can be drawn in
a cartoon format to indicate progression and possible coping strategies
(see Figure 7.1). The stress inoculation plan can be created in a social
story format as well.
Anticipatory phase Confrontational phase
Oh, no! I have to I have to start writing…

finish this reprot by But I can’t think of
Monday! This is anything I’ll never
so stressful. do it!
Coping phase Assessment and reinforcement phase
They take a deep breath… Hey! I did it! I took some

Calm down… I CAN do it. deep breaths and asked
It will be okay. I can get for help, and it worked! I
help if I need to. See? followed my stress
It’s not THAT bad! plan, and everything
went okay!
Figure 7.1 Stages of stress Individuals who have ASD may not recognize that there are
several steps to feeling stressed. Cartoons that depict the stages of stress can provide
examples of the emotional increase and decrease that accompanies the stages of stress.
Cartoons allow the counsellor to include personalized stressful thoughts and coping
thoughts, which may facilitate active coping with stress.
Practising the strategies in a stress inoculation program should occur in

real, everyday situations for transference to occur. It may be helpful to
enlist the support of family members to facilitate skill use in everyday sit-
uations. Failure to use stress inoculation strategies in everyday, real situa-
tions results in less than optimal benefit for the client. Deliberate practice
may include the use of a stress hierarchy, where coping practice starts
with intentional exposure to mildly stressful situations, with coping
successes used as criteria to move to practising coping with more stressful
situations (Cormier and Nurius 2003). Of course, everyday stressors

provide opportunities to practise and fine-tune coping strategies.
Mindfulness-based practices
Mindfulness-based strategies, or mindfulness meditation, shift the focus
from the emotion, such as anger or fear, to a more neutral item, such as a
body part or breathing. Mindfulness-based anger control has been used
with persons on the autism spectrum, including some with mental retar-
dation. Mindfulness meditation is a relatively simple, four-step process of
identifying emotional arousal, shifting attention to a neutral part of the
body, calming down, and making a choice of what to do (usually walking
away with a smile when the anger was successfully controlled), thus
making this technique one that more challenged persons can complete.
Part of the shifting of attention is to change the body posture to one that
is neutral or calm, and breathing naturally. The person is instructed to
focus on their breath or a body part for several moments, thus distracting
them from their emotion and providing sufficient time to become calm.
Creating a visual script of the mindfulness meditative procedure facili-
tates learning (Singh et al. 2003).
Case study: Ticking time bomb

Nathan had difficulty remaining calm. As a student with ASD in
high school, Nathan found his life to be very stressful. Nathan
would succumb to the stress in class and would become emotion-
ally explosive. Nathan recognized that he felt stressed, but had dif-
ficulty following multiple step instructions to relieve his stress.
Nathan was able to identify when he was becoming stressed, and
could focus inward on his navel. Focusing on his breathing dis-
tracted him from his stress and gave Nathan an awareness of
slowing down his breathing, resulting in a feeling of greater relax-
ation. When he felt relaxed, he could focus on what was going on
around him. This enabled him to cope much better with high
school life.
CHAPTER 8
Emotional Expression,
Identification, and Regulation
People on the autism spectrum have difficulties with emotional identifi-

cation, expression, and regulation (APA 1994). Language to express
emotions is often impaired or developmentally immature. When asked to
identify their feelings, a person with an autism spectrum disorder (ASD)
will frequently and accurately indicate that they do not know what
emotion they are experiencing (Aston 2003; Meyer 1999). Feelings and
thoughts often seem unconnected. The inability to express emotions
verbally at times can lead to their behavioural expression (Attwood
1998).
Impairment of emotional expression, regulation, and identification
lead to social impairments, which have negative impacts on many
different areas of life, such as education endeavours, careers, and family
relationships (Elliott and Gresham 1991; Gustein and Whitney 2002). It
is often the difficulties with emotions that bring couples where one has
an ASD into counselling. Emotional dysregulation and inappropriate
emotional expression, including aggression, often bring children with
ASD to the attention of counsellors (Aston 2003; Attwood 1998).
EMOTIONAL IDENTIFICATION
People on the autism spectrum often do not identify the varying degrees
of emotions that they may experience and may require specific instruc-
tion in how to identify their internal emotions, including physical sensa-
tions of emotions (Attwood 1998; Meyer 1999). Often people on the
171
autism spectrum do not monitor their emotions effectively (Aston 2003).

They may also misinterpret the physical symptoms of different emotions.
Case study: Fast and furious

Danny was a young adolescent with Asperger’s syndrome who
came to counselling regarding emotional management, primarily
anger. When discussing emotions with Danny, this writer discov-
ered that his language and enactments of emotion tended to be
extreme. For example, he was either very mad or not mad, but there
was nothing in between. The writer drew a line with “not mad” at
one end and “very mad” denoting the other extreme, indicating to
Danny that there was a lot of room between these two feelings.
Danny, with the help of a feeling word list, was able to add to the
anger scale. Descriptions of how Danny would feel in his body
were added to these new words. Danny began to use the anger
scale as a way to assess his own feelings. With the addition of
words that described varying degrees of anger, Danny was able to
determine what degree of anger he felt, and to respond appropri-
ately. Although Danny had a lot more to learn, his expression of
anger reduced in severity as he understood that he could “express a
little anger at little things, like being a bit annoyed… I don’t have
to be furious at everything.”
Difficulty with interpreting emotions also occurs when attempting to

identify the emotions of others. Often people with ASD fail to use facial
cues, such as the appearance of another’s eyes, to read emotional expres-
sion. People with ASD tend to use fewer facial cues to interpret emotion,
with gaze aversion and poor eye contact being common. They often do
not use paraverbals, such as vocal tone, cadence, or rhythm, to determine
emotional content of communication (Baron-Cohen, Wheelwright, Hill,
Raste and Plumb 2001; Perlman 2000; Rutherford et al. 2002).
Case study: How do you feel?

Claude, who had autism, was referred by his mother who was
concerned that something was going wrong in his elementary
classroom. Her concern arose when Claude became distressed if
Emotional Expression, Identification, and Regulation 173
she raised her voice. He would ask her if she were angry with him,
regardless of the emotion she was displaying. It became apparent
that Claude could not interpret his mother’s facial expressions or
tone of voice for emotional content. This writer taught Claude a
game about guessing emotions from a person’s tone or face and
posture. Claude was instructed on what features to look for when
guessing emotion. Claude loved to play this game with his mother.
He began to play it with people on the television, particularly the
ones on his mother’s favourite soap opera. Claude would turn
down the volume and try to guess the emotion from the person’s
expression, and then turn up the volume and cover his eyes to guess
the emotion from the tone of voice. Although Claude was often
mistaken, he learned to confirm his guess, and was no longer dis-
tressed by others’ emotions.
Strategies to teach emotional recognition and identification

There are several ways to instruct someone with ASD to recognize and
identify emotions in themselves and others. However, true empathy or a
deep level of emotional understanding may not be possible. It is this
apparent inability to truly empathize that is addressed when instructing
the ASD person regarding appropriate responses to their own and others’
emotions, as this does not happen intuitively. Emotions, their meanings,
and possible responses must be explicitly taught for learning to be
effective with people who have ASD. People on the autism spectrum
appear to learn facial expressions for different emotions much in the way
as someone might learn a code. They may not comprehend that
emotional expression is a powerful form of social communication or
social deception (Dennis, Lockyer and Lazenby 2000).
Emotional recognition, in oneself and in others, can be facilitated by
creating visual supports to show and label emotions. Emotional ther-
mometers (see Figure 3.2, p.81) and response scales (see Figure 3.3, p.82)
can help clients understand the gradients of emotions or responses.
People develop their own unique model of reality, including emotions. As
such, each person develops their own continuum of emotions, with their
own language for degree of emotion. The use of cards or PostIt notes,
which can be ranked along a number line, can help develop such
continuum scales for people with ASD (Hare et al. 2000). Emotional
labels, descriptive phrases, and pictures of faces can be used to help clarify
the degrees of emotion (see Table 8.1). Clients can develop a list of the
physiological and behavioural cues that identify an increase in emotion,
and connect them to the particular emotion being experienced. It is
helpful to include the purpose that the emotion may serve, such as anxiety
or fear being an alert regarding possible danger, and anger being a signal
that you are being threatened with some kind of loss. Sometimes teaching
emotional identification involves attending to in-the-moment body
language, such as fist clenching or head shaking. Often the person with
ASD is unaware of the body language signals that they are displaying,
and may show conflicting signals such as smiling and shaking a fist
(Attwood 2003; Meyer 1999; Perlman 2000).
Table 8.1 Emotional scale including possible responses

The emotion How your body feels, Possible things you can do when you
acts, or sounds feel this way
Cross Forehead feels tight, Tell the other person that you are
other muscles may feel feeling cross. Explain why you are
tight, voice may get feeling cross.
louder.
Irritated Forehead muscles are Tell the other person that you are
tight, eyebrows move feeling irritated. Explain why you are
down, voice changes feeling irritated. Ask to be left alone
pitch, voice gets for a while, if this will help you calm
louder. down.
Angry Muscles are tight, Tell the other person that you are
eyebrows are pulled angry. Let them know what happened
down close to the eye, that angers you. Tell the person that
heart rate increases, you need a few minutes to calm
voice gets louder. down. Go somewhere quiet and calm
down.
Enraged Muscles are tight, Use your words. Tell the other person
eyebrows are pulled that you are very angry. Find a place
down close to the eye, to go to calm down. Do not come
heart rate increases, back until you are calm. When you
voice gets louder, fists are calm, explain what happened that
may clench. made you get angry.
Furious Muscles are tight, Use your words. Tell the other person
eyebrows are pulled that you are very, very angry. Find a
down close to the eye, place to go to calm down. Do not
heart rate increases, come back until you are calm. When
voice gets louder, fists you are calm, explain what happened
clench. that made you get so very angry.
Note: This tool can be used to graphically display gradients of emotion, and include
some of the ways that the individual can recognize this emotional state. Examples of
actions are included to guide the individual in how to express the particular emotional
state in a socially acceptable manner.
Emotional dictionaries can be used to identify others’ emotions, as these

are often misunderstood. Emotional dictionaries involve creating a book
of the different emotions, what they look like, feel like, and what to do
about them when you come across them. An appropriate range of
responses to others’ emotions can be added to this emotional dictionary
to facilitate the understanding of what response to another’s emotion is
expected and appropriate. Contextual cues need to be highlighted, as
people on the autism spectrum often fail to use context to extract
meaning. Some of the images and words that the ASD person associates
with a particular emotion may seem odd, as sometimes they may have
odd associations with feelings (Attwood 2003).
Case study: At a loss for words

Todd, an adult with ASD, sought counselling because he had diffi-
culty expressing emotions. Todd often described an image that was
associated with how he felt, as he could not always find the
language. However, many of Todd’s images were disturbing to the
people around him. He would describe knives and blood when he
was angry or afraid, and coffins and tombstones when he was
saddened. However, when Todd was happy or excited, he talked

about plumbing fixtures, such as shiny faucets and taps, as these
things were his favourite interests. A book was created that associ-
ated Todd’s expressions for feelings with words more commonly
used to express that feeling. Todd was asked to refer to his book
when he wanted to express how he was feeling, and to use the
feeling words in the book (listed in a column beside his descrip-
tions of the feelings).
Identification of these idiosyncrasies may facilitate better emotional

understanding. For example, a person’s favourite subject, like microchips,
may be one of the items found in their emotional dictionary on the page
dedicated to happiness words, and balancing cheque books may be found
on the page dedicated to frustration (Attwood 2003). It is helpful for the
person to learn that not everyone loves microchips and hates balancing
cheque books .
Emotional understanding can be facilitated by the use of Comic Strip
Conversations. Colours can be used to signify the underlying emotion of
a communication, as each emotion can be colour coded. The benefit of
using these visual approaches is that thoughts can easily be included in
thought bubbles. Using a Comic Strip Conversation format, you can
review situations that have occurred and highlight salient cues and link
emotions to thoughts and actions. Particular care needs to be paid to
identifying the salient emotional cues and behaviours, as often the wrong
cues are attended to, resulting in a misunderstanding of others’ emotions
and intent (Attwood 1998, 2003; Gray 1994b; Smith-Myles and
Simpson 2001). Attwood (1998) uses the metaphor of being a detective
or scientist who is looking for information regarding emotions being
expressed, and not to come to any conclusions until all of the information
is examined.
Attwood (2003) recommends teaching emotions starting with
simple and positive emotions such as happiness. He recommends
exploring emotions in related pairs, starting with the positive emotion
first, such as happiness and sadness, relaxation and anxiety. The happy or
positive emotions would be framed as “antidotes” (Attwood 2003, p.77)
to the negative emotion. Understanding the beginning signs of
emotional arousal can be described using a visual metaphor of noticing

the “warning lights and instruments on a car dashboard” (Attwood 2003,
p.77). This analogy may help clients pay attention to their emotions while
they are still manageable, or, if continuing this analogy, before the
radiator boils over and the engine seizes.
EMOTIONAL EXPRESSION
Learning to express emotions involves more than just words, however,
and the actions and nonverbals need to be explicitly taught and described
in the emotional dictionary. These skills also need to be practised, both in
session and between sessions, before the person with ASD will become
somewhat proficient. Videotaping clients as they practise expressing
emotions has been recommended as a useful feedback tool (Meyer 1999;
Moynahan 2003). Often people with autism spectrum disorders have no
idea how they present emotions, and can utilize video feedback effec-
tively.
People on the spectrum may use extreme emotional phrases to
describe how they feel without the sense of the emotional nuances. This
may be a part of their all-or-nothing type of thinking (Ory 2003;
Portway and Johnson 2003). Extreme expressions of emotion, such as
expressing a wish to be dead when frustrated or upset, are not unheard of.
This does not mean, however, that suicidal talk should be ignored.
Indeed, with depression being a common comorbid condition of autism
spectrum disorders (Ghaziuddin et al. 1995, 1998, 2002), such talk must
always be explored, as people on the autism spectrum are not immune to
being suicidal (Hardan and Sahl 1999).
Case study: Say what you mean

Adam was an ASD adolescent who panicked his parents when he
spoke of wishing he were dead when he was feeling sad or frus-
trated. Adam was referred to counselling regarding his suicidal
talk. When asked, Adam was shocked that his parents may have
thought he wanted to commit suicide, as he had never seriously
thought of taking his own life. Adam learned that he had to let
other people know how he felt without using suicidal language,
and that people would appreciate how distraught he was without

talking about killing himself. This writer worked with Adam to
develop language to express himself clearly, including how to ask
for help if he was feeling suicidal. Adam’s family were asked to
clarify Adam’s suicidal statements, and would ask him to say how
he felt in a different way when it was appropriate.
It has been this author’s clinical experience that exploring emotional

expression and the emotional language used with varying degrees of
emotion has been successful in facilitating appropriate emotional expres-
sion. Use of a number line, gauge, or thermometer to visually demon-
strate varying degrees of expression with appropriate emotional language
associated with the intensity of emotion has been a successful strategy
(see Figures 3.2 and 3.3, pp.81, 82). This visual tool appears to be helpful
when asking for clarification regarding extreme emotional language. It is
this author’s experience that the provision of emotional language facili-
tates the distinction between varying degrees of emotional states.
Children on the autism spectrum have been observed to display a mix
of emotions on their faces, including both positive and negative
emotions. This blending of emotional expression impedes others’ ability
to determine the emotion of the child on the spectrum. Sometimes the
expression of emotion is atypical, such as giggling when the expected
emotions would be remorse, flapping arms or hands when excited, or no
expression of pain when clearly injured. Avoiding emotional expression
can also be seen as a coping strategy when past inappropriate expression
has resulted in aversive consequences. This results in emotional needs not
being met (Attwood 2003; Travis and Sigman 1998).
EMOTIONAL RESPONSIVENESS
There appears to be a greater deficit in emotional responsiveness as
compared to emotional perception in others. Emotional responsiveness is
more than the ability to interpret others’ emotions. Once the emotion is
identified, one must have some idea of how to respond. ASD people often
do not know how to respond to others’ emotions, or they respond inap-
propriately (Attwood 2003; Travis and Sigman 1998).
Teaching social responses to others’ emotions can be facilitated by

use of Social Stories™ and Comic Strip Conversations, teaching tools
developed by Carol Gray (1994b). These teaching tools visually
represent thoughts and hidden intent, facilitating teaching theory of
mind thinking and empathic skills, and enable the process of exploring
emotional situations (Attwood 1998; Gray 1994b; Kerr and Durkin
TM
2004). Social Stories and Comic Strip Conversations are discussed in
greater detail in Chapter 6.
Emotional mirroring
Some people with ASD who appear to be “emotionally fragile” (Ory
2004), or emotionally volatile, also appear to reflect back the emotions of
those around them, sometimes called “emotional mirroring” (Ory 2004).
The implication of this is simple but profound. Those who work with
someone who tends to emotionally mirror need to monitor and adjust
their own emotions, as they will be reflected back to them by the emo-
tionally fragile person on the autism spectrum. The person with ASD will
get into whatever emotional state they perceive their caregiver as
showing, which may lead to difficulties when they misinterpret the other
person’s emotion (Attwood 1998; Ory 2004). It is this author’s profes-
sional experience that many people with ASD who are emotional mirrors
tend not only to reflect back any negative emotions of the people in their
environment, but also to amplify these emotions.
People on the autism spectrum have difficulty with emotional regula-
tion, which can often escalate towards anger (Laurent and Rubin 2004;
Raymaekers et al. 2004). In this author’s clinical experience, strong
emotional mirroring can lead to emotional dysregulation in people who
are on the autism spectrum. This can be troublesome in relationships, as a
partner’s strong emotions can disinhibit the ASD person’s emotions,
which can lead to angry outbursts or withdrawal (Aston 2003).
Emotional coping
Emotional coping involves strategies to negate or balance emotions to
facilitate coping. Strong negative emotions are reduced or avoided as a
way to cope. Emotional coping is most helpful when the situation cannot
be changed. Emotional coping skills are behaviours such as self-distrac-

tion, seeking social support, or framing situations in a positive light,
which change the experience of the emotion from unmanageable to man-
ageable (Sarafino 2002). These skills must be explicitly taught to people
on the autism spectrum, as they will not intuitively know what to do to
cope with emotions (Attwood 2003). An essential emotional coping skill
is to be able to self-calm (Amerikaner and Summerlin 1982; Hiebert and
Malcolm 1988; Malcolm and Hiebert 1986; Singh et al. 2003). The
ability to self-calm is a crucial component to treating anxiety (Bellini
2004; Jackson 1983; Koegal et al. 2004; Sofronoff and Attwood 2003;
Sofronoff et al. 2005), OCD (Piacentini and Langley 2004; Reaven and
Hepburn 2003), and anger management (Kellner and Tutin 1995;
Miranda and Presentación 2000). Cognitive behavioural strategies have
been shown to have a positive effect on emotional regulation (Burns
1980).
People with ASD who internalize their reactions with self-blame may
show signs of depression and anxiety, while those that externalize their
reactions may develop an intolerant personality, and often have difficulty
with anger management. Emotional coping can involve withdrawal into
video or computer games, fantasy novels, or a perseverative favourite
interest. Escape into fantasy can become a problem, as often the boundary
between fantasy and reality is blurry with ASD, and thinking can become
delusional. Reality testing and cognitive restructuring need to occur
when this happens (Attwood 2003).
With this in mind, this author recommends that children and young
adults with ASD, especially those with cognitive delays, should not be
encouraged to play violent computer or video games, as these may fuel
delusional thinking and cognitive distortions, and may teach violent
behaviours as problem-solving strategies. There is some evidence that
violent games and entertainment may increase violent behaviour
(Grossman and DeGaetano 1999). There is no reason to believe that this
does not apply to people who are on the autism spectrum, who have more
limited coping skills and may not be able to discern that violence is not an
acceptable resolution to difficulties when they observe violence modelled
as a solution on television, or have used it successfully in video game
activities (Attwood 2003). In this writer’s experience, violent games have
taught violent solutions to problem situations. In one case this writer was
involved with, a young child on the spectrum attacked his parent with a
knife. His explanation was that this was how problems were solved in his
games. When you kill it, the problem goes away. He was not malicious; he
simply modelled what he learned by game playing and transferred that
learning to a different situation.
ANGER MANAGEMENT
People on the autism spectrum have difficulties with emotional regula-
tion (Laurent and Rubin 2004; Raymaekers et al. 2004), particularly
anger control (Moynahan 2003). One of the best-researched areas
regarding the use of cognitive behavioural emotional control for people
with ASD is anger management (Kellner and Tutin 1995). It is logical
that many, if not all, of the interventions and steps that are successful in
teaching anger management and regulation should prove to be effective
in facilitating the regulation of other emotions as well.
Aston (2003) studied people who had a spouse with Asperger’s
syndrome. Forty per cent of the Asperger’s men and 75 per cent of the
Asperger’s women had been violent towards their partners. The women
used more hitting, kicking, and punching, while the men tended towards
shoving and restraining. Aston reported that anger is the most common
response when a partner with Asperger’s felt that he or she was losing
control over a situation: “It is at the point when the AS partner feels that
he is losing control that profound and illogical anger might unexpectedly
be directed at his partner” (Aston 2003, p.138). This anger is a result of
his losing control of his feelings and being unable to cope with the
situation.
Aggressive people on the autism spectrum often show cognitively
distorted thinking and a limited capacity for coming up with several
possible alternative solutions (Miranda and Presentación 2000;
Sukhodolsky, Kassinove and Gorman 2004). They may misread or mis-
interpret social cues, or fail to think about the consequences of their
actions. Often the cognitive distortions show a bias towards the attribu-
tion of hostility in other people’s actions. People on the autism spectrum
have difficulty interpreting other people’s emotions, or distinguishing
physical sensations from emotional arousal. Impulse control is also a

problem, as many people with ASD tend towards having comorbid
attention deficit and attention deficit hyperactivity disorder (ADHD)
(Ghaziuddin et al. 1998; Moynahan 2003).
Anger management intervention

The initial phase of teaching any emotional management intervention,
including anger management, is to show the client how to identify the
varying degrees of the emotion. The first step is to teach the internal
physiological signs of anger, so that the person can recognize the
beginning of the anger escalation continuum. This gives clients their
personal cues for when they need to start using anger management, as
management of anger is most effective in the beginning stages. As previ-
ously discussed, the use of visual supports to show varying degrees of
emotions can be useful (Miranda and Presentación 2000; Sofronoff and
Attwood 2003; Sofronoff et al. 2005). Teaching emotional recognition
may occur over several sessions.
Clients may need to be reassured that anger is a normal and natural
emotion, but what you do with it can be either acceptable or not. You may
need to make a distinction between feeling an emotion, which is always
acceptable, and acting upon that feeling, which requires self-control and
judgment (Kellner and Tutin 1995). The actions taken are either helpful
or not helpful.
Anger triggers are identified, and may be ranked regarding the
severity of anger response. Once triggers are identified, the cognitions
and behaviours associated with the trigger situations can be explored.
These can be grouped into helpful thoughts and nonhelpful thoughts, as
well as useful and not so useful behaviours. Skill instruction addresses
cognitions, physiology, and behaviours (Kellner and Tutin 1995).
Cognitive restructuring is taught to address nonhelpful thoughts
associated with anger. Coping thoughts such as “I can handle this” (Beck
and Fernandez 1998, p.64) can be printed on cue cards as reminders of
helpful thoughts. Attwood (2003) discussed that there are inappropriate
tools, such as retribution, violence, and suicide, which are not effective in
anger management or emotional repair. These need to be recognized and
clearly shown as less than helpful. Helpful tools, such as cognitive
restructuring, help seeking, and self-calming, are shown to be more

useful. Problem-solving approaches are helpful in addressing anger man-
agement. Strategies to control the physiological response of anger were
relaxation training, deep breathing, and counting to ten before reacting
(Kellner and Tutin 1995).
Anger management strategies need to be practised both in session, as
in role playing, and between sessions in real situations. Having the client
see an appropriate resolution to a problem before being asked to role play
a situation facilitates learning. It may be helpful to have a cheat sheet of
possible questions to ask the actors to determine the situation (Kellner
and Tutin 1995; Moynahan 2003; Sofronoff and Attwood 2003).
Visual adaptations
An adaptation to teaching anger management involves making lists of
triggers, lists of how anger was managed, both successfully and unsuc-
cessfully, and a list of coping strategies. These lists can be taken home as
reminders and cues of what to do when anger is identified (Kellner and
Tutin 1995).
The use of a diary to record daily situations in which anger may have
been triggered is helpful. This diary is often referred to as a “hassle log”
(Kellner and Tutin 1995). Diaries provide information regarding what
social situations require intervention. The hassle log records anger
triggers, settings, how the situation was handled, and self-appraisal,
including if there was an improvement in skills (Kellner and Tutin 1995;
Moynahan 2003).
Cue cards can be developed with coping thoughts and helpful anger
management strategies to facilitate anger management between sessions
(Kellner and Tutin 1995; Miranda and Presentación 2000). A different
visual format is a Social Story™. Social Story™ and comic strip formats
can provide scripts and strategies for coping with anger trigger situations.
These can be reviewed in advance if a specific trigger situation is predict-
able and reoccurs in the ASD person’s life. One advantage to using Social
Stories™ and Comic Strip Conversations is that the other person’s
thoughts can be shown, facilitating correction of misunderstood social
situations (Attwood 1998; Gray 1994a, 1994b).
Role playing adaptations

Moynahan (2003) uses a verbal analogue to Carol Gray’s Comic Strip
Conversations (Attwood 1998; Gray 1994b) called “bubble talk” (p.177)
to delineate one’s thoughts and internal experience from conversation
when role playing in a group setting. Others can request bubble talk at
any time to learn more about the person’s thoughts and feelings. This can
be adapted in individual therapy, as the counsellor can indicate that they
are speaking their thoughts out loud in a similar fashion, clearly indicat-
ing what are their thoughts and what are their words spoken aloud.
Moynahan (2003) also used the analogy of a “magic remote control”
(p.179) to rewind the role play to a point where the insertion of an alter-
native response can be made, and then the role play is resumed. The
remote control gives the observer the ability to move through the role
play as desired to make any changes. The use of the remote is cued with
an agreed upon signal, such as the word “remote.” It is this author’s
clinical experience that people with ASD often cannot piece together
parts of a role play to create a new one. With this in mind, this author
tends to complete any role-playing exercise with the corrected role play
performed intact, from beginning to end. This facilitates learning the
appropriate responses required for the target situation.
CHAPTER 9
Some Final Words

and Suggestions
Working with people on the autism spectrum, their families, partners, and
employers can appear to be a daunting task at first. Indeed, this writer
would expect that by the time you have finished reading this manual the
task may seem insurmountable. There are many factors to consider, espe-
cially when autism spectrum disorders may be unfamiliar. Working with
people on the autism spectrum may also be fascinating and exciting if
approached with an open mind. This author experiences autism spectrum
disorders as if they are facets of a different culture, with practices and
rules that are unique and interesting. As with working with any group,
this author has found that there are some helpful “rules of thumb” that
make the process easier.
First and foremost, write down anything of consequence or impor-
tance, as an aid for yourself, if not as a counselling aid. Practise this so it
does not interfere with counselling. Making the process visual will go a
long way towards making counselling work for people on the autism
spectrum. Use diagrams and doodles to get your message across. This
writer has found that the process of making counselling visual enhances
the counselling relationship as well as facilitating understanding and
growth. Provide tools for the person on the spectrum to write or draw out
their meanings, if they desire to do so.
Ask the person what might help them get the most out of counselling.
Often they can tell you what they need, or at least tell you what doesn’t
work for them. Ask them how they best learn and retain information.
Tailor what you do to meet these parameters. Try to feel fine with doing
185
something in an unusual way if it helps your client in session, within

reason. If your client prefers only to read things in purple ink, get some
different coloured pens. If they cannot look at you and talk at the same
time, let them look where they need. Sometimes it’s the little things that
can make a session manageable for the person with an autism spectrum
disorder. This writer had one client who could not focus while the clock
was ticking, or when the fluorescent lights were humming. We agreed
that he could feel free to move the clock to another room or turn off the
lights if they were interfering with his focus whenever he felt he needed
to. With a different client who needed to withdraw for a moment to
process what was being said, an agreement was made that this writer
would look away when asked to do so, and became quiet so as not to
distract the client from his processing. This writer’s experience has been
that these considerations, which are not usually brought up with other
clientele, facilitate the counselling process as well as demonstrate respect
of the person with ASD’s special needs. Other considerations are having a
small space in the waiting room that is quiet and not crowded, and using
soft lighting. Giving clients control over the external noise, such as a
radio in the waiting room, can also help them feel more comfortable.
Drawing paper and writing implements in the waiting room can help
some people wait, as not everyone is an avid reader. Computer magazines
are almost a must.
Try to keep the counselling goal oriented. This writer has found that
setting clear goals and charting progress frequently is not only good
practice, but can delineate the process of counselling for the client.
Setting out beforehand what the process will be and what can be
expected is also helpful. This helps the client to predict what is supposed
to happen, as well as giving them benchmarks on where they are in the
process. Charting progress can give hope, as well as highlight areas
where some work may still need to be done.
Do not be surprised if you, as a counsellor or clinician, do the
majority of the talking. This author has noted that often the person with
an autism spectrum disorder talks little, with many long pauses for pro-
cessing. Sometimes this author’s sessions seem more like lessons than
counselling, as there is a large amount of information sharing going on.
Some Final Words and Suggestions 187
At other times, though, this writer may not be able to get a word in
edgewise.
Case study: Uncommon common sense

This writer has noticed that people on the autism spectrum often
do not have what is considered to be common knowledge.
Sometimes an issue can be resolved by simply filling in the missing
information. Sandra, a young adult with Asperger’s, was complain-
ing about missing a friend that she knew in high school. When
asked why she did not talk to her, as she still had her phone
number, Sandra said that she did not like her friend’s father. When
it was suggested that she ask her friend to meet with her at a
coffeeshop, away from her father, Sandra was amazed. “You mean I
can see her when her parents are not around?” When it was
explained to Sandra that her friend, who was also an adult, could
agree to meet her for coffee or lunch without having her parents
come along too, Sandra realized that she did not have to avoid old
friends simply because she did not like their parents. We also
discussed how adults made agreements to social activities, and
what it might mean if a friend did not choose to accept Sandra’s
invitation. Sandra is not so socially isolated now that she under-
stands that some of the social rules change when you become an
adult. Sandra simply did not know what most people would know
about adult friendships. These are the kinds of things that people
on the autism spectrum do not understand or learn naturally. They
need to be explicitly taught.
Use language the client understands. Try to get the client to describe to
you exactly what his or her words mean. It may be very helpful to get an
understanding of how their favourite subject works, such as how
computers work, or plumbing. These can provide good illustrations of
how things work in real life. Choosing favourite topics as analogies or
frameworks to describe things can bring interest into the discussion. It
may also help your client bring to session his expert knowledge of how
something works, a strength that can help him move towards change.
Last, and perhaps not least, say exactly what you mean, and mean
exactly what you say. Be specific in your language. You will get far better
results. If you use figures of speech or colloquialisms, explain what they
mean. Some of your clients may need this explanation.
Working with people who are on the autism spectrum can be exhila-
rating, as it is never the same day twice. Along with many challenges and
unexpected surprises, people on the spectrum can provide some amazing
insights as well as some astounding perspectives on life. More than once
this author has stopped to wonder at what her clients who have an autism
spectrum disorder have taught her about life, honesty, and relationships.
And that wondering continues to this day with each novel insight from
the autism spectrum.
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Subject Index
Note: page numbers in italics and emotional symptoms 29, 32–45, 33,
refer to information contained in identification 172 36, 38
tables and diagrams. in girls 37 avoidance behaviour 45, 119,
social skills deficits of 139, 123
152
symptoms of 35–7, 36,
abstraction 50–1 40–1 behavioural approaches 14–15,
actions, misattribution of 91 assessment tools 81–4, 81, 82 23–4
activity schedules 111–12 attachment 22–3 beliefs, mistaken 85
adaptive skills 23–4 attention, stuck 63–4 bereavement 28–9
adolescence 105, 149, 150–1 attention deficit hyperactivity bibliotherapy 79, 155
aging, autism and 13, 27–9 disorder (ADHD) 46, 182 big picture 65–6
alcohol consumption 25 attention shifting 32, 63–4, 169 bipolar disorder 46
all-or-nothing thinking 78, 81, Attributes Activity 31 black and white thinking 74
90, 103, 177–8 attributions blaming 59, 90, 91
ambivalent attachment 22–3 faulty 91, 112–14, 160–2, body language, in-the-moment
analogy 31, 62, 118–19, 122, 181–2 174
154–5, 157, 165, 177, retraining 91 “book of life” 154–5
184, 187 auditory hypersensitivity 26, 43, brain 25–7
anger 172, 174–5, 179 44 breathing techniques 121–2,
management 180–4 autism 16, 21–47 163–4, 169
triggers 182, 183 adult outcomes 27–9 bubble talk 184
anorexia nervosa 46 aetiology 24–7 bullying 37, 151
anterior cyngulate gyrus 26 and aging 13, 27–9
antidepressants 106, 112, 133 atypical 38
anxiety, comorbid 14, 16–17, cognition of 59–60 cartooning 108, 132
46, 64, 115–33 and comorbidity 45–7 case studies 13
assessment 120–1 diagnosis 24–5, 27 adapted CBT 78–9, 84, 98
causes of 115–16 and emotional art therapy 52–3
childhood 116–17 identification 172–3 common knowledge
diagnosis 116–19 history of 21–4 deficits 187
functional 120 Kanner-type 29–30, 32, comorbid anxiety 118–19,
normalizing 120 38, 46, 140 121–2, 125–31
prevalence 115 prevalence 27 comorbid depression
train analogy of 118–19 strengths of 34–5 104–5, 109–10, 112,
transitional 96 symptoms of 32–5, 33, 114
treatment 119ù33 41–2 coping with change 64
see also social anxiety see also high functioning disorganized thoughts 34
anxiety hierarchies 123, 124, autism emotional issues 172–3,
125–6 autism spectrum disorders (ASD) 175–8
anxiety logs 126 11–17, 16, 21–47 faulty logic 73
art therapy 52–3 CBT adaptations for literal thinking 53–6
Asperger’s syndrome 11, 21, 29 77–102 organizational deficits
CBT modifications for 78 cognition of 16–17, 49–74 68–9
cognition of 50, 53–4, comorbid 45–7, 103–14, perseveration 63–4, 67
59–60 115–36 savant skills 39
common knowledge diagnosis 29–31 self-concept deficits 57–8
deficits 187 guidelines for working with self-control issues 70–1
comorbid 47, 104–5, 115, 185–8 social skills 141–2, 146–7,
118–19 prevalence 14 158
diagnosis 25, 29, 30, 31 and social skills 137–58 stress management 161,
162, 169
201
case studies cont. definition 85 desensitization 161

theory of mind deficits goal setting for 95–6 through extinction 123–6
61–2 process 85–9, 86, 88, 89 through reciprocal
central coherence 65–6 and relapse prevention 95 inhibition 122–3
cerebellum 26–7 for social anxiety 117 detail fixation 65–6
cerebral hemispheres 26, 27 and special interests 95 diagnosis of autism spectrum
challenging behaviour 53–5 visual, concrete tools for disorders 29–31
change 91–5, 92, 94 acceptance 30–1, 108–9
behavioural 83 colloquialisms 40, 53, 188 explanation of 31
difficulties with 28–9, 37, Comic Strip Conversations 62, Diagnostic and Statistical Manual of
63–4, 160 155–6, 176, 179, 183 Mental Disorders, 4th
learning to accommodate common knowledge deficits 187 Edition (DSM-IV) 33, 36,
35, 96–7 communication difficulties 38, 46
checklists 80 39–41 diagrams 80, 80
choice comorbidity 45–7 disclosure issues 139–41
mapping 93–5, 94, 112, medical conditions 47 disinhibition 159
154 mental health conditions disorganization 34, 37, 67–9
structuring 97–9 46–7, 103–14, 115–36 distraction 110–11, 169
clomipramine (Anafril) 133 mental retardation 14, 27, domestic violence 145, 181
cognition 16–17, 49, 49–74 32, 39, 46, 85, 103–4 Down’s syndrome 63
attention shifting 63–4 comprehension 40–1 drug misuse 25
difficulties with change computer analogy 31
63–4 computer games, violent 180–1
empathizing 71–2 computers, as teaching aids 69, eating disorders 46
executive functioning 157 echolalia 41
65–71 concrete concepts 50–1, 64 emotion dictionaries 84, 175–6
literal thinking 40, 53–6 answering anxious emotional assessment tools 81–4
self-concept 56–9 questions with 131–2 see also emotional
speaking thoughts aloud 70 of CBT 79–81, 91–3, 92, thermometers
systemizing 71–2 121–2 emotional impairments 14–16,
theory of mind 59–62 concrete operational stage 51 42–3, 171–84
visual thinking 50–3 confusion 118, 120 of coping skills 179–81
cognitive behavioural therapy contextual cues 175 of emotional expression
(CBT) 12–13, 24 control 31 171, 175–6, 177–8
autism-specific fear of losing 181 of emotional identification
modifications 77–102 locus of 100, 162 152, 171–7
for comorbid anxiety conversational turn-taking 153 of emotional information
119–33 see also Comic Strip processing 152
for comorbid depression Conversations of emotional mirroring 179
106–12, 113 coping strategies 88–9, 155 of emotional reasoning 90
for comorbid obsessive emotional 179–81 of emotional regulation 17,
compulsions 133–4, for sensory abnormalities 42–3, 70, 171, 179,
136 45 181
use of computers in 69 social 36 of emotional responsiveness
cognitive disputing 85 corpus callosum 26, 27 178–81
cognitive distortions 85, 87–91, crossdressing 58 of emotional stuckness 107
181 cue cards 64, 127, 153, 183 emotional response scales 173–4,
of comorbid anxiety 174
119–21 emotional thermometers 81, 81,
of comorbid depression danger, sense of 120, 125 135, 173–4, 178
107–8, 111 data collection 102 empathy 37, 42, 71–2, 173
definitions/types of 90 dating 105 employment 139–43
recording 87, 88, 89 delinquency 151 epilepsy 47
cognitive inflexibility 34, 66–7 delusions 30 executive functioning 65–71
cognitive reappraisal 162 denial 30, 31 attribution of meaning 71
cognitive restructuring 85–96 depression central coherence 65–6
for action misattribution 91 comorbid 14, 16–17, 46, cognitive inflexibility 66–7
for anger management 103–114, 177 organizational deficits
182–3 diagnosis 103–5 67–9
chart for 88 helplessness of 112–14 and problem solving
and choice mapping 93–5, onset 105 difficulties 99
94 prevalence 103 self-control 70–1
for comorbid anxiety relapse prevention 113–14 source monitoring 69–70
118–22 symptoms 104–5 exposure therapy 117, 123–6,
for comorbid depression treatment 106–12 134, 136
107, 108–9 reactive 30 externalization 31, 59, 180
Subject Index 203
facial cues, emotional 172–3 jumping to conclusions 90 mood diaries 84

facial recognition 26 mood thermometers 109, 110,
fantasy 111–12
discrimination from reality labelling 90 mothers, “refrigerator” 22–3
35 language motor difficulties 26–7, 34, 37
escape into 30, 104–5, acquisition 35–6, 40 multiple choice questions 83
180–1 expressive 32, 39, 40–1 musical ability 39
fear 120, 122–9, 136 receptive 32, 39, 40–1
logs 126 language listening 26
triggers 128 learned helplessness 91, 107 National Autistic Society of Great
fixations 65–6, 148–9 learning Britain 138
flow charts 93–5, 94, 96 rote 35 neural pruning 27
fluoxetine 133 verbal 26, 50 neuroleptics 106
fluvoxamine 133 visual 34–5 neurology 25–7
formal operational stage 51 lethargy 107, 111–12 nonverbal persons 39, 69, 158
fortune telling 90 limbic system 26 notes, written 78–9
fragile X syndrome 46 linear scales 135
friendships 138–9 literal thinking 40, 53–6
functional fixity 108 logic 49, 71, 72–4, 85 object cues 67
fusiform face gyrus 26 loneliness 139 object permanence 58
future, thinking about 126 loophole thinking 55–6, 65 obsessive compulsions 17, 43
love 143–50 obsessive compulsive disorder
lying 30 (OCD), comorbid 46, 115,
gaze avoidance 45 133–6
genetics 25 organization 34, 37, 67–9
getting fired 141–2 magic remote control analogy overgeneralization 90
girls 37 184 overqualification 142
goal setting 95–6, 186 magnetic resonance imaging
grief 28–9 (MRI) 25–6
group therapy 78 magnification (catastrophizing) paravocals 172–3
guidelines, for working with 90 parental rejection 22–3
ASDs 185–8 marriage 143–50 perfectionism 132–3
masturbation 149 perseveration 17, 41, 43, 63–4,
meaning 40–1, 175 67, 133–6, 161
hand–eye coordination 37 attribution of 24, 61, 71 anxious 116, 117
“hassle logs” 183 hidden 54–5, 60, 66 and depression 109–10
helplessness 91, 107, 112–14 reattribution 162 and obsessive compulsions
high functioning autism 29 and stress 160–2 134
CBT modifications for 78, medical conditions, comorbid 47 pleasurable 116
84 medication 15 working with 109–10
cognition of 60–1, 70 meditation 169 personal digital assistants (PDAs)
and depression 105 mental filters 90 68–9
diagnosis 24–5, 30 mental health conditions, personalization 90, 91
employment 139 comorbid 46–7, 103–14, pervasive developmental
symptoms of 32, 42 115–36 disorders not otherwise
homosexuality 148 mental retardation 12 specified (PDD-NOS) 11,
humour 73 comorbid 14, 27, 32, 39, 21, 29
hyperarousal 44–5, 138, 159 46, 85, 103–4 CBT adaptations for 98
hypersensitivity 26, 43–4, 186 mental states 58–61 cognition of 59–60, 61–2
hyperventilation 121–2 mercury 17 comorbid anxiety of 127
hyposensitivity 44 metacognition 65 diagnosis 29
metaphor 95, 119–20, 176 symptoms 38, 38, 41
metarepresentation 66 phobias 46, 128–9, 161
imitation 30–1, 34, 51–2 mind blindness 59 pica (eating nonedibles) 46
impulsivity 70–1 mind reading (cognitive politeness 42
in-the-moment thinking 73–4 distortion) 90 positive, the
infidelity 54, 71, 148 mind reading (mentalizing) 59, disqualification of 90
inhibitory functions 70–1 61 perseveration on 109–10,
insight 152 mindfulness 126–7, 169 110
Intelligence Quotient (IQ ) 11, minimization 90 problem solving 72, 99
39, 46 mislabelling 90 problem solving approaches
intentionality 61 MMR (measles, mumps, rubella) 98–9, 100. 120
internalization 30, 180 25 for anger management 183
irony 40, 60 mobiles, thoughts, feelings and for social situations 154
irrationality 127–8 actions 86, 86 for stress management 162
progressive muscle relaxation sertraline 133 thought viruses 87, 89

164–6, 165 service shortages 13 thoughts, feelings and actions
proofreading 97–8 sexual abuse 52–3, 151 representations 80, 80, 86,
psychoanalytic theory 22–3 sexuality 148–9 86
psychoeducation 135 sleep disorders 47 threat perception 161–2
social anxiety 115, 117, 123, time management 37
125–6, 137–8 Tourette’s syndrome 46
questions social articles 156 transitions, prompting 96–7
anxious 131–2 social control 31 tuberous sclerosis 47
multiple choice 83 social isolation 37 turn-taking 153
social phobia 46 twin studies 25
social rules 41–2, 85, 138,
Rainman (film) 28, 30, 38 154–5, 156
rational responses 121 social skills 11, 17, 32, 41–2, underemployment 142
reality testing 136 137–58 unlearning, difficulties with 35
recall 56–7 adolescence 149, 150–1
reciprocal inhibition 122–3 and Asperger’s syndrome
reframing 35, 108–9, 161 36, 37 vaccinations 25
refusals, automatic 98 employment 139–43 valproic acid 25
relapse prevention 95, 113–14 marriage 143–50 verbal ability 11, 39, 40
relaxation 122, 159–69 masking impairments 31 verbal learning 26, 50
relaxation objects 166 social skills training 78, 117, video camera analogy 62, 154,
relevant information 34 151–8 155
repetitive behaviours 133–6 Social Stories™ 79, 127–9, 136, video modelling 158
response prevention 134, 136 155–7, 179, 183 videos, instructional 52
response quality scale 82 social support 159–60 violence
restricted interests 43 social withdrawal 45, 104–5, and computer games
rigidity 66–7 137, 180 180–1
risk assessment 120, 125, 125 source monitoring 69–70 domestic 145, 181
rituals 104, 117, 131, 133, special interests 95, 135, 187 visual aids 79–81, 84, 185
147–8 specificity, need for 55–6, 187–8 for anger management 182,
role playing 87, 184 stereotypical behaviour 11, 32, 183
rote learning 35 45, 117 for anxiety management
rubella 25 stress 159–69 120–2, 124, 127,
rudeness 42 appraisal of 161–2 128–9
rules 74, 131, 142–3 identification of symptoms cartooning 108
see also social rules 163 for cognitive restructuring
rumination 161 management 17, 162–9 86, 86, 87, 91–5, 92,
stress balls 166 94
stress inoculation 167–9, 168 for emotional issues 173–6,
safety behaviours 123–4 174–5, 178
sameness, need for 147–8 stress surveys 83, 160
stress thermometers 163, 167 for obsessive compulsions
savant skills 38–9 134–5, 136
schemata, depressive 107, 108 structure 130–1
suicide 46, 105, 177–8 overcoming resistance to
schizophrenia 21 79, 97–8
scripts 130, 156 symbolic thought 52–3
synaesthesia 44 risk assessment checklist
seizures 47 125, 125
selective serotonin inhibitors systemizing 71–2
for self-monitoring 100
(SSRIs) 106, 112, 133 for social skills instruction
self, anxious/coping 119 tactile defensiveness 43–4 153–4
self-awareness, lack of 58–9 tantrums 43, 169 for stress management 163,
self-calming 122, 127, 133–4, task analysis 96 167
180 teaching aids 69 for structured choice 97–8
self-concept, lack of 56–9 teasing 151 for transitions 96
self-control 70–1 telephone calls 125–6 see also Comic Strip
self-disclosure 95 television 35, 51–2 Conversations; Social
self-efficacy 46, 112–13, 122, thalidomide 25 Stories™
162 theory of mind 59–62, 152 visual schedules 112, 130
self-esteem 46 first order 60, 152 visual spatial abilities 34–5
self-management 100–1 second order 60, 152 visual thinking 34–5, 50–3,
self-monitoring 100–1, 101, 126 therapeutic relationship 77–8 79–81, 84
self-stimulation 29, 43, 45 thought see cognition visualization 57–8
self-talk 101–2, 154, 163 thought stopping 110–11,
sensory abnormalities 43–5, 159 126–7
sensory overload 44–5, 159 thought tallies 109–10, 110
sentences 157
Author Index
Abbeduto, L. 27–8 Brambilla, P. 26 Fischer, M. A. 40, 53

Adkins, A. D. 111 Brock, D. 106 Folkman, S. 160, 161, 162
Aerts, F. H. T. M. 34 Bryson, S. E. 63 Fombonne, E. 14, 21, 22, 23,
Aleissi, N. 104 Burns, D. D. 87, 90, 102, 106, 27, 32, 38
Alisanski, S. 137 109, 111, 119, 180 Francis, D. 59
Alvarez, A. 23 Burton, B. 140 Freeman, K. A. 158
Amanulla, S. 137 Burton, D. 139 Friedberg, R. D. 92–3, 118
American Psychiatric Association Butalia, S. 117 Frith, U. 35, 36, 40, 42, 50, 51,
(APA) 11, 14, 29, 32, 46, Buysse, A. 152 57, 58–9, 60, 87, 128
171 Fullerton, A. 79, 100
Amerikaner, M. 180 Furniss, F. 116
Asperger, H. 21–2 Capps, L. M. 151
Aston, M. 11, 13–15, 21, 24–5, Cash, A. B. 29, 38, 42, 44
29, 35, 36, 42, 51–2, 54, Cauich, C. 26–7 Gandy, G. L. 85, 89, 107, 109,
58, 67, 71, 78–9, 83, 91, Chalmers, L. 96, 103, 115, 130, 110
107, 111–12, 118, 130, 139, 140, 141, 142, 143 García-Villamisar, D. 139
137, 140, 144–50, 160, Charlop-Christy, M. H. 52, 153, Gerber, P. J. 139–40, 141
171–2, 179, 181 158 Gerland, G. 23
Attwood, T. 12–16, 21, 24–5, Choudhury, M. S. 116 Ghaziuddin, M. 14, 16, 23, 46,
29–32, 37, 40–2, 44–6, Christian, L. A. 159, 166 103, 104, 105, 106, 111,
50, 59, 66–8, 70, 73–4, Church, C. 137 116, 177, 182
77–8, 81, 83–5, 87–8, Consoli, A. J. 69 Ghaziuddin, N. 14, 23
91, 93, 95–6, 101, Cools, A. R. 34 Gilchrist, A. 139
103–8, 111–12, 115, Cormier, S. 87–8, 91, 96, 100, Gillberg, C. 29, 46, 47
117–22, 124–8, 130, 103, 107–9, 119, 122–7, Gillott, A. L. 116, 117, 159
132, 134, 136–9, 144–5, 136, 164, 166–7, 169 Glasman, D. 106, 107, 111, 113
147–8, 150–7, 159–60, Costall, A. 59 Glenn, E. 103, 159
163, 166, 171, 174–80, Courchesne, E. 26–7 Goldberg, M. C. 26
182–4 Cox, A. 139 Gorman, B. 181
Avery, D. 117 Coyne, P. 79, 100 Grandin, T. 21, 30, 35, 43, 44,
Azzoni, A. 46 Cutler, L. A. 14, 79 45, 50–1, 52, 72, 87,
128, 142, 160
Grave, J. 85, 95
Baron-Cohen, S. 42, 71–2, 88, Dalrymple, N. J. 11, 13, 27, 28 Gray, C. 62, 79, 108, 127, 134,
91, 93, 99, 153, 154, Daneshvar, S. 52, 158 153, 155, 157, 176, 179,
155, 172 DeClercq, A. 152 183, 184
Beaumont, P. 139 DeGaetano, G. 180 Greden, J. 23
Beck, A. T. 106, 182 Denckla, M. B. 26 Greden, J. F. 104
Bellini, S. 180 Dennis, M. 173 Green, G. 13, 14, 23, 24
Berger, H. 34 Dubowski, J. 52 Green, J. 139, 151, 152
Berthoz, S. 42 Durkin, K. 62, 91, 155, 179 Greenberg, J. S. 27–8
Bettelheim, B. 22 Gresham, F. M. 115, 137, 171
Bihm, E. M. 103 Groden, J. 83, 92, 159, 160
Billstedt, E. 29, 46, 47 Elliott, S. N. 115, 137, 171 Grossman, D. 180
Bishop, D. V. 70 Evans, K. 52 Gustein, S. 104, 137, 138, 143,
Bjorvatn, B. 47 159, 171
Blaxil, M. F. 27 Fernandez, E. 182
Bleuler, E. 21 Filipek, P. A. 11, 27, 29, 30, 32,
Blissette, J. 85, 95 Hala, S. 70
38, 137 Happé, F. 35, 50, 51, 57, 58–9,
Boslaugh, S. 142, 143 Finlay, W. M. L. 106
Botsford, A. L. 28, 29 60, 87, 128
205
Happé, F. G. E. 32, 40, 53, 118 La Forge, J. 162 Noens, I. 32, 39, 40, 41, 52, 53,
Hardan, A. 46, 177 Lainhart, J. E. 14, 16, 46, 47, 66
Hare, D. J. 14, 15, 44, 45, 46, 103, 115 Norbury, C. F. 70
77, 78, 82, 124, 135, 174 Lammers, W. J. 103 Nurius, P. S. 87–8, 91, 96, 100,
Harrison, J. 44, 45 Landa, R. J. 26 103, 107–8, 109, 119,
Heflin, L. J. 12, 24 Landry, R. 63 122–7, 136, 164, 166–7,
Heimberg, R. G. 117 Langley, A. K. 120, 134, 135, 169
Henderson, A. M. E. 70 136, 180
Henley, D. 22, 23 Larkin, M. 11, 13
Hepburn, S. 116, 133, 134, 135, Laurent, A. C. 40, 42, 43, 74, Ochs, E. 152
136, 180 95, 99, 145, 159, 179, Ogletree, B. T. 40, 53
Herman, S. 69 181 O’Neill, M. 44, 159
Herrey, E. A. 151 Lawson, J. 71–2 Openden, D. 122
Hiebert, B. 163, 167, 180 Lazenby, A. L. 173 O’Riordan, M. 153
Hill, E. 42, 59, 160 Le, L. 158 Orsmond, G. I. 104, 138, 159
Hill, J. 172 Leonard, A. 157 Ory, N. 63, 67, 70, 73, 74, 78,
Hinton, S. 37 Leudar, I. 59, 60, 160 96, 97, 107, 117, 120,
Hodgdon, L. Q. 154 LeVasseur, P. 92 121, 129, 131, 132, 164,
Holaway, R. M. 117 Levinson, B. 28, 30, 38 177, 179
Howlin, P. 27, 28 Lockyer, L. 173 Øyane, N. M. F. 47
Huitt, W. 51 Lovett, H. 24, 130
Hummel, J. 51
Hurlbutt, K. 96, 103, 115, 130, Paine, C. 14, 15, 46, 77, 78
139, 140, 141, 142, 143 Maiello, S. 23 Palmen, S. J. M. C. 27
Huws, J. C. 16, 44 Malcolm, D. 163, 167, 180 Park, C. L. 160, 161, 162
Manassis, K. 117, 119, 121 Parsons, S. 157
Marks, S. U. 152, 153, 154, 155 Perlman, L. 21, 22, 36, 39, 40,
Jackson, H. J. 122, 123, 128, Martin, I. 40, 53, 60, 65, 66, 41, 42, 43, 44, 172, 174
180 108 Piacentini, J. 120, 134, 135,
Jacobsen, P. 14–16, 21–3, 49, Maurice, C. 32 136, 180
59, 61–3, 72, 95, 124 McDonald, S. 40, 53, 60, 65, 66, Plaisted, K. 153
Janzen, J. E. 21, 23, 25, 29, 32, 108 Plumb, I. 172
34, 41, 45, 113, 120 McGrath, P. 69 Ponnet, K. 152
Jarrold, C. 66 McLellan, J. 106, 119 Portway, S. 36, 37, 42, 81, 85,
Johnson, B. 36, 37, 42, 81, 85, McNerney, E. 22 103, 104, 177
103, 104, 177 Meldal, T. O. 138, 143, 144 Powell, S. 56–7
Jones, J. P. R. 46 Mendlowitz, S. 117 Powell-Smith, K. A. 156
Jones, R. 153 Messer, D. 56–7 Prado de Oliveira, L. E. 23
Jones, R. S. 44, 159 Meyer, R. N. 14, 15, 40, 41, 85, Presentación, M. J. 99, 165, 180,
Jones, R. S. P. 16, 42, 44, 45, 95, 116, 124, 144, 158, 181, 182, 183
138, 143, 144, 159 171, 174, 177 Prestwood, S. 14, 85
Jordan, R. 56–7 Meyers, R. E. 111 Price, L. A. 139–40
Millward, C. 56–7 Proctor, H. G. 93
Miranda, A. 99, 165, 180, 181,
Kabat-Zinn, J. 164 182, 183
Kanner, L. 21 Mitchell, P. 157 Quigney, C. 44
Kassinove, H. 181 Mizuno, A. 26–7 Quill, K. 21, 22, 23, 29, 32
Keenan, M. 159 Molen, J. 28, 30, 38 Quinn, C. 100, 118
Kellner, M. 12, 84, 126, 180, Moore, D. 69, 157
181, 182, 183 Mostofsky, S. H. 26
Kelso, S. E. 153 Raja, M. 46
Moynahan, L. 126, 177, 181, Rasmussen, C. 70
Keltner, D. 151 182, 183, 184
Kenardy, J. 69 Raste, Y. 172
Müller, E. 140, 141, 142 Raymaekers, R. 44, 74, 138,
Kendall, P. C. 116 Muller, R. A. 26
Kerr, S. 62, 91, 155, 179 145, 159, 179, 181
Müller, R. A. 26–7 Reaven, J. 116, 133, 134, 135,
Kincaid, D. 156 Mulligan, R. 139–40
Koegal, L. K. 22, 122 136, 180
Mullins, J. L. 159, 166 Renna, R. 24
Koegal, R. L. 22, 122, 180
Koller, R. 149, 150 Rodebaugh, T. L. 117, 123, 124,
Krauss, M. 104 Nesbitt, S. 139, 142, 143 166
Kremer-Sadlik, T. 152 Newman, M. G. 69 Roe, K. 116
Kring, A. M. 151 Nikopoulos, C. K. 159 Roers, H. 44
Author Index 207
Roeyers, H. 152 van Berckelaer-Onnes, I. 32, 39,

Rogers, S. 13, 14, 23, 24, 26 40, 41, 52, 53, 66
Ross, D. 139 van der Meere, J. 44
Ruberman, L. 15, 16, 46, 115 van Derheyden, E. 152
Rubin, E. 40, 42, 43, 74, 95, 99, van Engeland, H. 27
145, 159, 179, 181 van Spaendonck, K. P. M. 34
Rubio, M. A. 26–7
Ruble, L. A. 11, 13, 27, 28
Russell, J. 66 Wagenaar, J. 162
Rutherford, M. D. 42, 172 Wahler, R. G. 111
Rutter, M. 13, 24, 25, 27, 47, Walter, A. 116
137 Wehman, P. 139
Weidmer-Mikhail, E. 14
Weishaar, M. 106
Sahl, R. 46, 177 Werry, J. S. 106, 119
Sainsbury, C. 23 Wheelwright, S. 42, 71–2, 88,
Samuels, C. A. 11, 13, 27 91, 93, 99, 172
Sansosti, F. J. 156, 157 Whiten, A. 34
Sarafino, E. P. 113, 136, 159, Whitney, T. 104, 137, 138, 143,
162, 163, 164, 166, 167, 159, 171
180 Wilhelm, S. 133
Schuler, A. 140 Willey, L. H. 21, 29, 30, 36, 45,
Schultz, R. T. 26 50, 100, 143, 160
Seltzer, M. M. 27–8, 37, 46, 104 Williams, J. H. G. 34
Shattuck, P. 27–8 Wing, L. 22
Shessel, I. 139–40
Shuttleworth, J. 15
Sigman, M. 178 Yates, G. B. 140
Simpson, R. L. 12, 24, 150, 154,
176
Singh, N. N. 111, 127, 166, Zahl, A. 16
169, 180
Singh, T. 34
Sirota, K. G. 152
Smith, T. 13, 14, 15, 22, 23
Smith-Myles, B. 150, 154, 176
Sofronoff, K. 37, 45, 84, 87,
103, 107, 111, 115, 117,
119–24, 126, 130, 133,
152, 159, 163, 180,
182–3
Solomon, O. 152
Stein, D. 28
Steketee, G. 133
Stoddart, K. P. 14
Stone, V. 153
Sukhodolsky, D. G. 181
Summerlin, M. L. 180
Swaggart, B. L. 100, 118
Tani, P. 46, 47
Taylor, C. B. 69
Teunisse, J. P. 34, 65, 66, 108
Thorpe, J. 69
Toichi, M. 56
Tolin, D. F. 133
Travis, L. L. 178
Trillingsgaard, A. 156
Tsatsanis, K. 32, 34, 35, 36, 37,
40, 50, 63, 66, 108, 153
Tutin, J. 12, 84, 126, 180, 181,
182, 183

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Counselling People on the Autism Spectrum

Coming Out Asperger

Asperger’s Syndrome and Sexuality

Asperger Syndrome and Long-Term Relationships

Asperger Syndrome Employment Workbook

Katherine Paxton and Irene A. Estay

Jessica Kingsley Publishers

Copyright © Katherine Paxton 2007

Library of Congress Cataloging in Publication Data

British Library Cataloguing in Publication Data

ISBN 978 1 84310 552 7

Printed and bound in Great Britain by

Part One: Understanding Autism – Autism

2. Autistic Thinking and Autistic Logic 49

3. General Strategies and Modifications for

4. Depression and Treatment Approaches 103

5. Anxiety, OCD, and Treatment Approaches 115

6. Relationships and Social Skills 137

8. Emotional Expression, Identification, and

9. Some Final Words and Suggestions 185

Subject Index 201

Author Index 205

This manual was originally written as a program requirement for

Autism spectrum disorders (ASD), including autism, Asperger’s

the core features of autism, nor is it intended to be a manual of behav-

Much of the research regarding cognitive behavioural interventions

WHY A COUNSELLING MANUAL FOR PEOPLE ON

Failure to address these emotional issues is a disservice to this population.

ORGANIZATION OF THE MANUAL

The intent of this chapter is to provide therapists with basic information

HISTORY OF AUTISM AND THEORETICAL

(Fombonne 2003). Asperger’s work went largely unnoticed until Wing

Psychoanalysis of autism: refrigerator mothers and

What is the difference, then, between separation anxiety – which is

This initial professional perspective of parents of children who are on the

considered erroneous at present (Quill 1995). This misperception was

Behavioural interventions and autism

Asperger’s syndrome to be diagnosed later in life (Aston 2003; Attwood

Lifespan and adult outcomes

Shattuck, Abbeduto and Greenberg 2004). Often supports are pulled

self-stimulatory behaviours (rocking, flapping, spinning) as a result of

CHARACTERISTICS AND IMPLICATIONS OF

Diagnosis on the autism spectrum

1998; Filipek et al. 1999). A portrayal of a classic Kanner-type autistic is

Accepting the diagnosis of ASD

Some individuals who receive the diagnosis of having an autism

Explaining the diagnosis

Table 1.1 DSM Criteria for Autism

Impairment in social interaction, shown by two or more of the following:

Marked impairment of nonverbal Does not develop relationships with

Communication impairments, shown by one or more of the following:

Use of idiosyncratic or stereotypical Lack of spontaneous social play and

One or more of the following characteristics of limited and stereotypical patterns

Preoccupation with a particular limited Tends to have rigid and nonfunctional

Preoccupation with components of Stereotypical and repetitive motor

Case study: Thought stew

Paired with the difficulty in self-organization of thought comes a diffi-

Characteristics of Asperger’s syndrome