**7. Cognitive behavioral therapy**

The cognitive behavioural approach assumes that a person's cognitive function and beliefs influence their behaviour, and that by helping a person dispute their irrational thoughts, they will be empowered to change their behaviour [159].

Each person's beliefs are developed through his or her own life experiences. These experiences can be lived as well as watched (observational learning, vicarious reinforcement etc.). Indi‐ viduals with autism can have problems on learning from society, and vicarious reinforcement is key aspects of Bandura's social learning theory [160]. Cognitive behavioural therapy is used primarily to help individuals with autism to regulate their emotions, develop impulse control, and improve their behaviour as a result. In addition, some individuals with autism struggle with fears and anxiety, or may become depressed. Cognitive behavioural therapy has been shown to be helpful for reducing anxious and depressed feelings and behaviour by making changes in thoughts and perceptions of situations through a change in cognition. The key ingredient of cognitive behaviour therapy based occupational therapy, which distinguishes it from regular behaviour therapy, is working on change in cognition or how thinking is processed [160, 161]. Occupational therapists seek to reduce challenging behaviours, such as interruptions, obsessions, meltdowns or angry outbursts, while also teaching individuals how to become familiar with and manage certain feelings that may arise during activities of daily living. Cognitive behavioural therapy can be individualized which matches client-centred approach of occupational therapy, and as a result, is very effective at improving very specific behaviours and challenges in each individual with autism. Stabilizing emotions and improving behaviour allows individuals with autism to prepare for and respond more appropriately in specific situations [159-161].

Occupational therapists working with individuals with autism refer to at least one behavioural approach, generally the frameworks of model of human occupation and biopsychosocial model in their therapy interventions [159, 162, 163]. Occupational therapists support the cognitive behavioural therapies implemented in line with these models with making changes in individual-environment-activity areas [159, 162-164]. Following cognitive behavioural therapy, occupational therapist assists an individual with autism to identify and change their irrational thoughts, then take this learning and use it in real life opportunities [159, 162, 163].

Although studies on mental health are frequently observed when cognitive behavioural therapy based occupational therapy interventions are reviewed, visually based interventions such as video modeling where behavioural changes are targeted with various activities have been demonstrated to be effective with children with autism. This approach has wide utility, is appropriate for a range of ages and abilities of children with autism. There are video modeling studies such as Video Self (modeling Tape the child and play back to give feedback), Video Instruction (tape another student doing the behaviour) and Video Feed-Forward Tape. These studies show the child the complete behaviour and promotes independent functioning, and can be used to address numerous learner objectives of occupational therapy, including behavioural, self-help, communication, and social objectives [164-166].

#### **7.1. Assessment**

Occupational therapists generally work in line with model of human occupation and biopsy‐ chosocial model in the interventions of cognitive behavioural-based therapies in individuals with autism [159, 162, 163]. Besides the assessments of occupational therapy frame of reference, assessments such as 5 Point Scale, Power Cards, Bibliotherapy, Video Modeling, Situations-Options-Consequences-Choices-Strategies-Simulation, Social Autopsies, Comic Strip Conver‐ sation, Social Stories and Hidden Curriculum are used [156, 167-173]. Furthermore, a review also found that ILAUGH Model had already been researched and demonstrated to be a relevant learning hurdle for individual with autism [174].

#### **7.2. Intervention**

with fears and anxiety, or may become depressed. Cognitive behavioural therapy has been shown to be helpful for reducing anxious and depressed feelings and behaviour by making changes in thoughts and perceptions of situations through a change in cognition. The key ingredient of cognitive behaviour therapy based occupational therapy, which distinguishes it from regular behaviour therapy, is working on change in cognition or how thinking is processed [160, 161]. Occupational therapists seek to reduce challenging behaviours, such as interruptions, obsessions, meltdowns or angry outbursts, while also teaching individuals how to become familiar with and manage certain feelings that may arise during activities of daily living. Cognitive behavioural therapy can be individualized which matches client-centred approach of occupational therapy, and as a result, is very effective at improving very specific behaviours and challenges in each individual with autism. Stabilizing emotions and improving behaviour allows individuals with autism to prepare for and respond more appropriately in

Occupational therapists working with individuals with autism refer to at least one behavioural approach, generally the frameworks of model of human occupation and biopsychosocial model in their therapy interventions [159, 162, 163]. Occupational therapists support the cognitive behavioural therapies implemented in line with these models with making changes in individual-environment-activity areas [159, 162-164]. Following cognitive behavioural therapy, occupational therapist assists an individual with autism to identify and change their irrational thoughts, then take this learning and use it in real life opportunities [159, 162, 163].

Although studies on mental health are frequently observed when cognitive behavioural therapy based occupational therapy interventions are reviewed, visually based interventions such as video modeling where behavioural changes are targeted with various activities have been demonstrated to be effective with children with autism. This approach has wide utility, is appropriate for a range of ages and abilities of children with autism. There are video modeling studies such as Video Self (modeling Tape the child and play back to give feedback), Video Instruction (tape another student doing the behaviour) and Video Feed-Forward Tape. These studies show the child the complete behaviour and promotes independent functioning, and can be used to address numerous learner objectives of occupational therapy, including

Occupational therapists generally work in line with model of human occupation and biopsy‐ chosocial model in the interventions of cognitive behavioural-based therapies in individuals with autism [159, 162, 163]. Besides the assessments of occupational therapy frame of reference, assessments such as 5 Point Scale, Power Cards, Bibliotherapy, Video Modeling, Situations-Options-Consequences-Choices-Strategies-Simulation, Social Autopsies, Comic Strip Conver‐ sation, Social Stories and Hidden Curriculum are used [156, 167-173]. Furthermore, a review also found that ILAUGH Model had already been researched and demonstrated to be a

behavioural, self-help, communication, and social objectives [164-166].

relevant learning hurdle for individual with autism [174].

specific situations [159-161].

180 Autism Spectrum Disorder - Recent Advances

**7.1. Assessment**

There are some programs designed for children and adolescents to teach awareness of energy levels and self-regulation. Alert Programme "How Does Your Engine Run? " is one of them and it teaches awareness of energy levels and how to bring the energy level back to the centre and it focuses on self-regulation skills according to sensory integration theory [175].

Occupational therapists also aim to improve the skills of exploring feelings in their activities with children with autism. For this purpose, programs of *Thinking about You Thinking about Me* [176], *Think Social* like ILAUGH [174, 177] are frequently used to improve communication skills and problem solving skills of individuals with autism. Additionally, books used to improve social thinking skills of children with autism are also frequently used in activities of occupational therapists. Again, ''Superfleks Series'' [178] by Winner is commonly used in occupational therapies planned specifically for behavioural changes in children with high functioning autism.

Anxiety can be debilitating for a child with autism. Learning about emotions helps children recognize connections between thinking and feeling, and helps them identify the physiological effects of anxiety on the body (sweating, increased heart rate, crying, etc.). Learning and teaching to explore feelings can help the child with autism to identify situations that make them anxious and learn how to perceive the situation differently [179]. Therefore, occupational therapists frequently refer to self-management training in coping with anxiety and stress in their studies with children with autism. Effectiveness of intervention in individuals with autism who receive cognitive behavioural therapy based occupational therapy is assessed with Goal Attainment Scale (GAS) [35].
