CBT for the Treatment of Emotion Regulation in Children with Suspected Autism Traits

May 28, 2021

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterised by deficits in social-emotional interaction, and patterns of restricted and repetitive behaviour or interests (American Psychiatric Association, 2013). While currently subsumed under the ASD label, Asperger’s Syndrome may be a qualitatively distinct variant of ASD characterised by well-developed verbal language skills (Holdnack et al., 2011). Children with ASD, including Asperger’s Syndrome, face unique difficulties regarding self-regulation compared to typically developing children, including a tendency towards instant and aggressive reactivity to emotional cues (Attwood, 2012; Sofronoff et al., 2007). Possible reasons for this include deficits in cognitive processing speed, social perception and communication, and co-occurrence with alexithymia: difficulty identifying internal states (Fitzgerald & Bellgrove, 2006; Haigh et al., 2018; Holdnack et al., 2011; Mayes & Calhoun, 2008; Nader et al., 2015; Oliveras-Rentas et al., 2012; Samson et al., 2012). 

These processes may contribute to difficulties with meta-emotive understanding, a key component of effective emotion regulation, which involves an understanding of antecedents and consequences of emotional responses, as well as a working knowledge of strategies that effectively modulate such responses (Thompson, 1991). Individuals with ASD have been found to have difficulties with cognitive reappraisal of situations, a necessary component of meta-emotive understanding (Samson et al., 2012). Given this, it is unsurprising that an association has been found between externalising behaviours and social functioning among individuals with ASD (Shea et al., 2018). Indeed, clinical levels of anger have been found to be common among young people with ASD (Quek et al., 2012).

While the presence of these difficulties in children who struggle with emotion regulation is not diagnostic of ASD, interventions that have been developed for children with ASD may prove successful if both the underlying difficulties and subsequent behaviour align with the patterns seen in ASD.

Attwood (2012) outlined several key features a successful intervention of emotion regulation for children with Asperger’s must include. Firstly, given difficulties individuals with ASD have in identifying their internal states, successful interventions must include a psychoeducation component that is aimed at helping the child to identify and label their emotions, and notice differences in the intensity of emotions. For children with ASD, a strategy that externalises their emotion can foster such awareness within the child of their emotions, by giving them a sense that their emotions can be controlled, as well as providing a symbolic representation of their more difficult emotions (Johnson, 2012). Metaphors for emotions allow the child to adopt a meta-position that takes the focus of their problem away from themselves, and by extension, their identity, allowing space for reflection (McGuinty et al., 2012).

Secondly, Attwood recommended cognitive restructuring aimed at promoting cognitive flexibility, particularly in understanding the behavioural motivations of others. This is an important consideration given his observation that individuals with Asperger’s are prone to making inaccurate assumptions about the intentions of others’ behaviours (Attwood, 2012). This is consistent with a recent theory of ASD suggesting that reactivity may occur when sensory input resulting from expectancy violations are experienced as overwhelming (Musser, 2018). Given this, providing children with ASD with a variety of different perspectives and motivations of others’ behaviour may offset expectancy violations. CBT has been adapted for the treatment of social perception among children with ASD, however there is little evidence for their generalisability beyond the intervention setting (Danial & Wood, 2013). However, 3-month follow up on a CBT program with adolescents with ASD has found sustained improvements in social functioning (Maddox et al., 2017).

Attwood (2012) also indicated the necessity of providing the child with an emotional toolbox that contains a diverse collection of tools to aid self-regulation, including emotional, social, and physical tools that the child can deploy as required. Taken together, a CBT program designed for children with ASD considering Attwood’s recommendations has shown a significant reduction in displays of anger (Sofronoff et al., 2007). 

The Zones of Regulation, designed by occupational therapists, is a structured program designed to build awareness of internal states among children, and develop a toolbox of strategies for self-regulation including social skills, and self-care (Kuypers & Winner, 2011). Taking a cognitive-behavioural perspective, the program includes conceptualising emotional arousal with a traffic light metaphor; where blue represents little arousal and red signifies extreme arousal. By teaching children to understand differences in how they are perceived by other children depending on what ‘zone’ they are in and understanding that differences exist between what zone they are in and what zone may be expected of them, children are provided with a systematic way of understanding their emotions and emotional intensity. By encouraging children to recognise that the ‘green zone’ is the most ideal zone to maintain, they are provided with a set of tools to help downregulate when they notice their emotional intensity increasing.

While there is a dearth of research on the program’s effectiveness, extant studies have found immediate positive effects among children while they are engaged in the program (Quale, 2019), the generalisation of skills among preschool children outside the intervention setting (Sanger, 2020), and improvements in social and emotional competency among 9- and 10-year olds (McQuaid, 2018). 

The long-term effects on the program on older children, particularly those with ASD, have yet to be researched. However, a longitudinal study investigating the effects of a program that incorporated the Zones of Regulation as part of a wider intervention on social communication and self-regulation among children with ASD has been found to be effective for social cognition (Nowell et al., 2019). 

Despite the limited research available, the program appears consistent with Attwood’s recommendations. Psychoeducation provides children with a novel and engaging metaphor for conceptualisation their emotions, a toolbox of diverse strategies and skills to help self-regulate (particularly in downregulating to the green zone), and aids in helping children choose the best tool to match the context and emotional intensity they find themselves in. Given this, the Zones of Regulation may be a suitable intervention for children with ASD traits who struggle with emotion regulation.


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