Interdisciplinary Scientific Journal.

ISSN: 2358-8411
Nº 5, volume 6, article nº 07, May 2019
D.O.I: http://dx.doi.org/10.17115/2358-8411/v6n5a7
Accepted: 10/12/2018 Published: 30/05/2019
I SEMINÁRIO DE SAÚDE MENTAL DO NORTE E NOROESTE FLUMINENSE
– 27 A 30 DE NOVEMBRO DE 2018 – CAMPOS DOS GOYTACAZES - RJ

AUTISM AND THE APPLICABILITY OF COGNITIVE-BEHAVIORAL THERAPY: A

CASE STUDY
AUTISMO E A APLICABILIDADE DA TERAPIA COGNITIVO-
COMPORTAMENTAL: ESTUDO DE CASO

Cristina de Fátima de Oliveira Brum Augusto de Souza1

Mestranda em Cognição e Linguagem

Bianca de Souza Fonseca2

Psicopedagoga

Cristiana Barcelos da Silva3

Doutoranda e Mestra em Cognição e Linguagem

Fernanda Castro Manhães4

Doutoranda em Ciências da Educação
Abstract
According to the latest edition of the Diagnostic and Statistical Manual of Mental
Disorders in the 5th edition (DSM-V), for a person to be diagnosed with autism, they
must present symptoms in two groups. The first is the deficit in communication and
social interaction and the second is the pattern of restricted, repetitive behavior,
interests and activities. Considering these two groups of symptoms, Cognitive-
Behavioral Therapy (CBT) is used in the therapeutic treatment of a young person
with autism. CBT has as its principles to work individuals in their totality,
strengthening their emotional and cognitive schemes, seeking to produce functional
behaviors to solve problems in daily life. The elaboration of the work plan in the
cognitive-behavioral approach will be based on the principles of learning,
reinforcement and behavioral modeling. The goal of therapeutic treatment with the
autistic youngsters is to maximize their potential in language skills, social skills,
problem solving, and self-care, freeing them from self-aggression, self-stimulation
and aggression. The technique of psychoeducation aims to teach patients to

1
Universidade Estadual do Norte Fluminense Darcy Ribeiro, Laboratório de Estudos de Educação e
Linguagem, Campos dos Goytacazes-RJ, cristinafbrum@gmail.com
2
Faculdade de Ciências, Educação, Pesquisa e Gestão, Cidade-Estado, bfonseca7075@gmail.com
3
Universidade Estadual do Norte Fluminense Darcy Ribeiro, Laboratório de Estudos de Educação e
Linguagem, Campos dos Goytacazes-RJ, cristianabarcelos@gmail.com
Universidade Autônoma de Assunção, Assunção-Paraguai, castromanhaes@gmail.com
4

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recognize their problems, which generate their difficulties and reinforce their
dysfunctional behaviors. CBT assumes that the patient can become his own
therapist, and knowledge about what is being done with him or her and how that
subject works is the first step in making this happen. The present work aims to
identify the behavior of a young man with autism, pointing to an effective intervention
using the cognitive-behavioral approach, scoring the symptoms, the contribution of
the therapy with the use of CBT and their impact on the quality of daily life.

Keywords: Cognitive-Behavioral Therapy (CBT); Autism Spectrum Disorder (ASD).

Resumo
De acordo com a última edição do Manual Diagnóstico e Estatísticos dos
Transtornos Mentais em 5ª edição (DSM-V), para que uma pessoa seja
diagnosticada com autismo ela deve apresentar sintomas em dois grupos. O
primeiro é o déficit na comunicação e interação social e o segundo é o padrão de
comportamento, interesses e atividades restritas e repetitivas. Considerando esses
dois grupos de sintomas, busca-se na Terapia Cognitivo-Comportamental (TCC)
embasamento para o tratamento terapêutico de um jovem com autismo. A TCC tem
como princípios, trabalhar o indivíduo em sua totalidade, fortalecendo seus
esquemas emocionais e cognitivos, buscando produzir comportamentos funcionais
para resolução de problemas e vida diária. A elaboração do plano de trabalho no
enfoque cognitivo-comportamental vai basear-se nos princípios de aprendizagem,
reforço e modelação comportamental. O objetivo do tratamento terapêutico com o
jovem autista visa o alcance máximo do potencial dele nas habilidades de
linguagem, sociais, na resolução de problemas e no autocuidado, livrando-o de
autoagressão, autoestimulação e agressão. A técnica da psicoeducação tem por
objetivo ensinar o paciente a reconhecer seu problema, o que gera suas dificuldades
e reforça seus comportamentos disfuncionais. A TCC parte do pressuposto que o
paciente pode vir a ser seu próprio terapeuta, e o conhecimento sobre o que está
sendo realizado com ele e como aquele sujeito funciona é o primeiro passo para que
isso aconteça O presente trabalho tem como objetivo identificar o comportamento de
um jovem com autismo apontando uma intervenção eficaz a partir da abordagem
cognitivo-comportamental, pontuando os sintomas, a contribuição da terapia com o
uso da TCC e o reflexo destes na qualidade de vida diária.

Palavras-chave: Terapia Cognitivo-comportamental; Transtorno do Espectro

Autista.

INTRODUCTION

Early in life, parents are already concerned about the development and
behavior of their children, expecting they will be typical of other children. When

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parents encounter a child who does not speak or exhibit “strange” behavior, or does
not show affection and pleasure in social life, a warning sign is lit.

When a child is diagnosed with Autism Spectrum Disorder (ASD), a whole

change happens in their family structure. Parents seek help, therapies, and exams so
that child to have a typical global development. And when they get to the therapeutic
offices they are faced with a world of new paths for their child, a great flood of
information. The role of the therapist is to guide and welcome this family and then to
draw up a therapeutic plan for the child.

Like other deficiencies, autism can be incapacitating without proper diagnosis,

treatment and intervention (Fonseca, 2014).

According to Sampaio (2005), Cognitive-Behavioral Therapy is a form of

psychotherapy that has been scientifically tested and seen as effective in more than
300 clinical researches for various types of disorders. It is a therapy for solving
patient problems.

For Leboyer (1995) considers that in the cognitive-behavioral approach it is

possible to intervene effectively in several disorders such as those of the autism
spectrum.

Autism is a neurodevelopmental disorder on which many doubts and

divergences remain about its etiological factors.

According to Assumpção Jr (2007) and Leboyer (1995), it was from the

definitions of Leo Kanner in 1943 that emerged the first conceptualization of autism
as a psychotic syndrome, related to phenomena of the schizophrenic line. This
conceptualization described under the name of autistic disorders of the affective
contact, a picture characterized by extreme autism, obsessive-type behaviors with
tendency to sameness, stereotyped movements and echolalia, involuntary repetition
of words or phrases that heard characterized by language alterations, represented by
the absence of communicative purpose (Zafeiriou et al., 2007). According to the
authors, in 1944 Hans Asperger described under the name autistic psychopathology
of childhood, in which children are quite like those described by Kanner, but without
any delay in the development of language. The concept of autism is attributed to both
Kanner and Asperger.

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 According to Watson (2008), in 1995, Dr. Simon Baron-Cohen proposed a
new theory on autism. He suggested that many people with autism suffered from
mental blindness, that is, the inability to understand that other people have their own
thoughts and emotions, with difficulty understanding the point of view, the ideas or
feelings of others. It is this inability to relate to the differences in the way of thinking of
others which results in the social and communicative difficulties of the autistic
individual (Oliveira, 2002).

Autistic disorder was characterized by a difficulty in contact with people, a

special connection to objects, language without communicative function, difficulties in
contact and interpersonal communication (Bender, 1959, apud Stelzer, 2010, p.6).
Kanner’s description in 1943 was organized around the disorder, which is the inability
of children to develop and establish interpersonal relationships and to react in a
normal way to situations, from the beginning of life. This disorder is defined as a set
of symptoms visualized as a specific disease of organic origin with neurological,
genetic and environmental implications.

Autism, when compared to other pathologies, presents a certain

incompleteness, since there are no tests that directly determine its diagnosis, being
established based on medical evaluations and behavioral observations. The various
spectrum stereotypes further increase these barriers to case identification. Even
today, autistic patients receive the most different medical diagnoses, such as
obsessive-compulsive disorder, schizophrenia, mood disorders, among others
(Baron-Cohen et al., 2009).

From this assumption, Assumpção Jr (2007) considers that autism is

described as a behavioral syndrome with multiple causes, due to a developmental
disorder. It is characterized by deficits in social interaction. It does not present
abilities to relate to the other, tied with language deficit and behavioral changes.

Thus, according to Assumpção Jr (2007) and Luppi et al. (2005), autistic

individuals can’t organize the thought to express themselves with clarity; they
experience difficulties in initiating conversations, interpreting attitudes and
communicative expressions in themselves and in others. And, regarding their
activities and interests, they are resistant to change and maintain routines and rituals.

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Routines and rituals for autistics translate an aptitude or a feeling to feel comfortable,
which makes their lives predictable and look safer to them.

In order to diagnose a child as autistic, it is necessary to know the criteria

determined by the Diagnostic and Statistical Manual of Mental Disorders in the 5th
edition (DSM-V). It is the agreement or not to those criteria that a condition
diagnosed as a disorder in the autism spectrum. The manual has been revised and it
was last updated in 2013.

With the changes in the DSM-V (American Association of Psychiatry, DSM-V,

2014), Autism Spectrum Disorder is considered if the symptoms appear in the early
stages of child development. These symptoms should cause clinically significant
impairment in social, occupational areas and areas that are significant to the patient’s
current functioning.

Among the deficiencies, those that are related to communication and social
interaction, where limitations in the emotional and social reciprocity are observed,
considering non-verbal communication behaviors and repetitive and restricted
patterns of behavior, using objects, body or speech in which there is an abnormal
intensity of focus on restricted interests and hyper or hypo reactive to sensorial
stimuli from the environment (APA, 2014).

It is important to emphasize that many individuals diagnosed with ASD may

also present intellectual and/or language impairments (speech delay and very poor
language comprehension). Motor deficits are common and frequent, one example
being atypical gait and lack of coordination.

DEVELOPMENT

CBT works by strengthening emotional and cognitive schemes, seeking to

produce functional behaviors for problem solving in the individual’s the daily life. It is
based on a formulation of continuous development of the patients and their
problems. This formulation begins with anamnesis, at which point the therapist
investigates the patient’s history (Beck, 1997).

According to Beck (1997), it is extremely important to build a therapeutic

alliance, with attention and cordiality. The therapist must have genuine empathy and

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respect for the patient and thus gain the patient’s trust. The patient should feel safe
and believe that the therapist can assist him or her.

Therapy should be seen as a cooperation, where the patient has active

participation, and both him or her and the therapist make exchanges. CBT is an
educational therapy that aims to teach the patient to be their own therapist. This is
the reason why psychoeducation is used, so patients can learn and identify their
issues (Beck, 1997).

CBT uses several techniques to achieve the expected results, to minimize the
problem and to seek a better solution. These techniques may be based on cognitive
or behavioral therapy, and both techniques can be used in combination when
necessary, being adapted for use with children, youngsters or adults.

Silvares (2000) affirms that a well-conducted follow-up and behavioral

assessment are necessary to adapt the techniques for the work with the autistic
youngster, since the techniques used seek a lasting behavioral change, and can also
be used preventively to minimize future problems.Still according to Silvares (2000,
p.231),

Behavioral assessment is intrinsically linked to treatment. Successful

interventions confirm hypotheses raised; interventions that do not
lead to the expected result lead to the reformulation of hypotheses or
the procedures used. The treatment program is considered to be
more important than the diagnostic label, although it is useful,
especially for parents, because it often reduces their sense of guilt
and eventually stops the search for new professionals.

The elaboration of the treatment plan in the cognitive-behavioral approach will

be based on the principles of learning, reinforcement and behavioral modeling. In this
elaboration the therapist will focus on the behavior emitted and not the description of
the disorder, and by this he or she will evaluate its functionality in the environment
and social development.

The goal of therapeutic treatment with autistic youngsters is to maximize their

language, social, problem solving and self-care skills, freeing them from self-
aggression, self-stimulation and aggression.

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 The first step is anamnesis, a set of questions that will put the therapist
abreast of the patient’s history, family structure, social interaction, and initial demand
(Rangé, 1995).

The second step is to use the cognitive restructuring technique in which the
patient must learn to identify dysfunctional thoughts (also known as cognitive
distortions), which reinforce the inappropriate behavior, identifying them, questioning
them so that they are worked and reconstructed. Cognitive restructuring is a change
in thinking, functionally and qualitatively (Rangé, 1995).

The third step is the use of Socratic questioning based on a structured

dialogue, where the therapist directs questions that help patients to study and
perceive their ideas in a rational and logical way, broadening the patient’s view of the
thoughts about a given situation. Thus, the objective is to see the situation in a more
rational and structured way (Rangé, 1995).

The fourth step is problem-solving training in which the individual works with
the possibilities and possible consequences of each choice. The patient makes an
evaluation and broadens his or her look of opportunities, seeking not only one but
several possible solutions to a certain problem, assessing each of them (Caballo,
2005).

The technique of psychoeducation aims to teach patients to recognize their

problems, which generates their difficulties and reinforces their dysfunctional
behaviors. CBT acts on the premise that the patient can become his or her own
therapist, and the knowledge about what is being done with it and how that subject
functions is the first step to make it happen (Caballo, 2005).

The coping card is another technique used, in which cards are produced
during the session and usedas reminders of what has been worked on, so that it is
reinforced for a thought or functional behavior (Beck, 1997).

There is also the technique of role-playing, where the therapist uses a specific
situation already worked in the session and, as in a small theater, the patient has the
opportunity to interpret roles that will vary according to the situation in question. The
therapist can also assume the role of the patient so that the patient can observe his
or her own actions. This technique is also used to train situations that generate

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anxiety or fear in the patient, as a preparation for when he or her must exhibit a given
behavior outside the therapeutic environment (Beck, 1997).

Also used is technique of modeling, in which the patient learns to observe the
other, his or her behavior and the consequence of the choices of the other. In this
way we work their behavior, modeling it from observed behaviors (Rangé, 1995).

The relaxation technique is another feature that can be used when the patient
arrives or becomes very anxious during the session. It can be done by using music,
breathing, and stretching. The technique can also be used by the patient in idle
moments outside the session. The training is done with him or her, then the patient
repeats it when the necessity arises in daily life situations (Rangé, 1995).

Training of social skills is another very important technique for autistic

individuals, since one of their main issues is the social deficit. Through this training,
patients works empathy, putting themselves in the place of the other, to improve their
interpersonal relationship, to seek more assertive behaviors in their relationships, to
recognize other people’s emotions and to express their emotions better (Beck, 1997).

And lastly, there is the assertiveness training, in which, to be effective, the

patient must be able to plan assertive reactions, matching with a previous positive
reinforcement.The individual then learns to respect him or herself, to know how to
behave without being passive or aggressive, say yes or no according to his or her
needs, without being selfish (Caballo, 2005).

DISCUSSION

The autistic subject on which this case study is based, R., is a 21 years old
male individual who lives with his recently divorced father, and is in his senior high
school year. He had speech therapy when he was a child and went without
psychological care for almost a year.

Initial contact was made with the parents, who sought help in response to their
son’s difficulty to relate, not wanting to leave home, taking initiative, making little eye
contact, presenting great anxiety in situations of social exposure and expressing little
or almost no emotions. Anamnesis was conducted in this first contact, followed by a

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quick psychoeducation about CBT and an explanation on how the work would be
carried out.

R. arrived for the first session sweating a lot and looking very uncomfortable to
find himself there. He stayed in the waiting room for some time, where he did not talk
or interact with anyone. Our first session served to gather information about his
needs and explain the reason for the therapy, thus doing a Psychoeducation.

The second session was a continuation of the previous one, an important step
required to emphasize that the patient presented cognitive conditions to be exposed
to the triple CBT, explaining about emotions, thoughts and behaviors.

From the third session on, the patient began to sweat less and put on a little
more. We began to identify which were the reinforcers of their dysfunctional
behaviors and emotions. We worked out a plan and a direction for what we were
going to work on.

In the following sessions, the patient began to report problems at school. He

felt alone and could not present work in front of the class or read aloud. Based on
these statements, we began to make a cognitive restructuring, using techniques such
as Socratic questioning and modeling.

R. took some time to feel safe and verbalize emotions such as fear, anguish,
anxiety and sadness, but as soon as he did it, he reported feeling free. We began to
associate emotions, situations, and behaviors that made him feel that way.

One session was separated to build the coping cards and do a

Psychoeducation on them. R. came to the following sessions reporting that the cards
helped him have the courage and requested that new cards be made.

Despite the advances, R. was still at home for a long time, since there was
already a therapeutic bond and a confidence that I was there to help him, we got him
one more step. He joined a football team that he attends three times a week and was
able to go out a few times with his teammates, including inviting them once to the
movies.

Currently, the parents report that R. is more open to conversing with them,
participating more in family dinners, going out with them and occasionally going out

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with a colleague. But he still has a good time in front of the computer and is very
worried about finishing his studies.

A session that marked a lot R. was the one when we worked with the
technique of “role-playing”, in which there was work to be presented to the entire
school class. He arrived at the session saying he would run, but he would not show
up. We went back to what had been worked until then, and then rehearsed how it
could happen during the presentation. In the following session R. reported that
instead of been booed, he was applauded in the class. Let’s recall all the
dysfunctional thoughts of the previous session by comparing with the thoughts of the
current session and separating which ones contributed to such situations.

R. still described feeling his hand freezing, some words did not go as he
wanted, nervousness, but now he can present all the work and read aloud. He said
that fear was his worst enemy.

Social skills training began at the end of the year, along with preparation for
leaving school. We listed his plans, his longings and his fears, structuring the
thoughts that would be worked on and those that would be avoided. In the latter
sessions, we worked on problem solving and together we decided that R. would look
for a technical course alone for that year. Still in this period R. reported to have
written a text for his teacher, in which he exposed some of his difficulties, the
repetition of series in previous years, the isolation, the intense feeling of failure and,
concluding the text, he said to have been taken to the therapy, and how much he
believed that he could go far at that moment. This account was passed on to the
parents, who passed it on to the author. We prepared what he was supposed to do
during this recess. After three weeks he enrolled in a technical computer course.

FINAL CONSIDERATIONS

At the cognitive-behavioral level, autistic youngsters present characteristics

that resemble those of other young people without the disorder, but present
themselves at different levels of intensity, duration and frequency of symptoms. Thus,
it can be stated that the behavioral deviations presented by this autistic individual
whose case is herein presented agree with the theories of learning to which the other
behaviors in general are subject. That is, through an assertive behavior modeling it is

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possible to obtain an improvement of the autistic picture. And to intervene the
therapist needs to encourage behavioral change. In this intervention, the therapist
must be aware not only of the deficits that a young autistic individual presents, but
also the behaviors that he or she is able to do successfully. All the behaviors that are
emitted by the young person, as well as the situations in which they occur, and
possible reinforcements to maintain these behaviors are essential to be surveyed,
studied and worked by the therapist.

It can be concluded with this case study that cognitive-behavioral therapy, for
its theoretical and practical foundation, can contribute positively to the therapeutic
treatment of a young autistic, albeit in a light frame, but within the characteristics
mentioned by the DSM-V, and as reported suffering the reflexes of these deficits.

The CBT approach, therefore, sought to value the potentiality and not the
incapacity of the human being, evidencing the need for diagnosis and intervention as
early as possible, as fundamental means to obtain a more efficient and effective
treatment, giving this young person with autism the opportunity to have a more
satisfying educational partner life.

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