Supporting individuals with autism spectrum disorder in understanding and coping with complex social emotional issues

Abstract

Core deficits in autism spectrum disorder (ASD) center around social communication and behavior. For those with ASD, these deficits complicate the task of learning how to cope with and manage complex social emotional issues. Although individuals with ASD may receive sufficient academic and basic behavioral support in school settings, supports for dealing with complex social emotional issues are more difficult to access, even though these issues significantly impact student learning. When addressing these challenging social- and emotional-based issues, school and professional personnel need more specific instructional skill sets and resources to effectively and compassionately support students with ASD. In this article, we address three challenging areas of social emotional development that are commonly experienced by individuals with ASD: Anxiety, social isolation, and grief. We briefly explore the existing research on these three topics, identify evidence-based practices and learning strategies to support social emotional learning in individuals with ASD, and include descriptive lists of practical resources that address anxiety, social isolation, and grief.

Keywords

anxiety autism spectrum disorder grief social emotional learning social isolation social stories

All individuals face the challenge of learning how to manage complex social emotional issues. Over time, we develop the resilience and skills to navigate life’s challenges, including shouldering stressful responsibility, meeting deadlines, coping with grief following the death of a loved one, repairing damaged relationships, and surviving traumatic events. However, we are not alone in meeting these challenging situations. We acquire social emotional skills through life experiences and with the support of peers, family, caregivers, and teachers. These key people help us to incorporate our personal strengths into adaptive coping and learning strategies (McCrimmon, Matchullis, & Altomare, 2016). This is a difficult process for most, but for individuals with autism spectrum disorder (ASD) the need for informed, individualized, and effective support is especially critical. Unfortunately, meeting the social emotional needs of this unique population may exceed the existing skill sets of many parents, educators, and school psychologists.

ASD and implications for addressing social emotional needs

Although each person with ASD is unique, there are common categories of symptoms that define the disorder (American Psychiatric Association [APA], 2013). Key diagnostic markers include social communication deficits, reflecting difficulties with the give-and-take of social interactions (social reciprocity); difficulties with nonverbal communication behaviors (e.g., eye contact, gestures, facial expressions, and nonverbal social cues); and deficits in developing, maintaining, and understanding relationships. Additionally, restricted and repetitive interests and behaviors, difficulties with changes in routine, and sensory hyper- or hypo-sensitivity may also be present. Some with ASD also have intellectual disability and language impairment (APA, 2013). Without supports that are specifically suited for individuals with ASD, each of these challenging symptoms pose significant obstacles to social emotional learning.

As the global prevalence of individuals identified with ASD increases (Elsabbaugh et al., 2012), more diversity and a broader spectrum of symptoms and impairments are evident (Tager-Flusberg & Joseph, 2003). Additionally, regardless of their unique symptoms, individuals with ASD face similar complex social issues, particularly in relation to anxiety, social isolation, and emotions associated with grief or loss.

For example, consider the case of Rajh, a 10-year-old male with ASD. Rajh has age-appropriate language and cognitive abilities, but needs behavioral support in school because of his heightened anxiety, typically triggered by changes in routine. Prior to this year, he reported being happy at school and home. However, this year his parents divorced. Additionally, he is noticing that classmates do not include him in games and conversations. He is also experiencing more bullying from his peers. Previously not easily provoked, Rajh is now aggressive with peers, hitting, pushing, and shoving when frustrated. These aggressive behaviors are noted across settings.

Rajh’s support needs are complexly intertwined—he is facing significant anxiety in everyday situations, he is experiencing social isolation, and he is saddened by his parents’ divorce. In addition to the supports he has typically received to help him cope with anxiety, he now needs targeted supports that address social isolation and grief and loss.

Anxiety and social isolation are frequently occurring issues for individuals with ASD. Researchers estimate that anxiety disorders co-occur in approximately 40% of individuals with ASD, though rates between 11% and 84% have been reported in community- and clinic-referred samples (van Steensel, Bögels, & Perrin, 2011; White, Oswald, Ollendick, & Scahill, 2009). Among the findings of The National Longitudinal Transition Study-2012 (NLTS-2012), adolescents with ASD reported low rates of seeing friends outside of school (29%, compared to 52% of all children with disabilities); and communicating with friends by text, social media, or phone (22%, 18%, and 20% for ASD compared to 54%, 43%, and 38% of all with disabilities). These data indicate much higher levels of social isolation for adolescents with ASD than for students with intellectual disabilities or multiple disabilities (Lipscomb et al., 2017). As such, response to loss (e.g., parents’ divorce, death of a loved one, separation from a loved one, etc.) may be magnified and complicated by pre-existing anxiety, social communication deficits, and social isolation.

Purpose and overview

Noting the complexity and interconnectedness of social emotional challenges associated with anxiety, social isolation, and grief, in this article we will address each of these topics. First, we will explore misconceptions about individuals with ASD; then, we will identify appropriate intervention strategies and supports that are grounded in research and practice. We also provide tables and appendices with resources to assist parents, teachers, and therapists (including school psychologists, counselors, and mental health professionals) in more effectively supporting the social emotional needs of youth with ASD. Although the majority of resources given are designed for individuals with some language abilities, many are adaptable for minimally verbal individuals.

Misconceptions about individuals with ASD

In this section we will discuss three common misconceptions related to the social emotional needs of individuals with ASD. These three misconceptions include the following: (a) anxiety is just part of ASD (Mason & Scior, 2004); (b) individuals with ASD don’t want friends (Autism Speaks Family Services and Science Dept. [Autism Speaks], 2017; and (c) individuals with ASD can’t express emotions and can’t understand the emotions of others (Autism Speaks, 2017).

Misconception: Anxiety is just part of ASD.

Anxiety is a general term encompassing multiple disorders with adverse emotional reactions to specific fears of real or perceived imminent threat (phobias), or anticipation of future threats in specific situations (social anxiety, separation anxiety), or sometimes less specific threats (generalized anxiety). In the presence of anxiety symptoms, individuals alter their behaviors, often limiting their ability to function (APA, 2013). Recognizing that individuals with ASD experience anxiety is not new, as Kanner (1943) observed that numerous children with classic autism had substantial problems with anxiety. However, until recently, the research on the relationship between anxiety and autism has been sparse. Mason and Scior (2004) postulated that diagnostic overshadowing (i.e., ignoring the presence of mental health symptoms because they seem to be part of another disability, in this case ASD) might have contributed to the delayed exploration of anxiety symptoms in individuals with ASD. During the past decade there has been a proliferation of research examining the manifestation of anxiety in individuals with ASD, including meta-analyses that show anxiety to be more prevalent (31 studies: van Steensel et al., 2011) and more elevated (83 studies: van Steensel & Heeman, 2017) in children with ASD, especially in children with higher cognitive function. Some of the most common anxiety disorders reported with ASD are generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and phobias (White et al., 2009).

Researchers have recently begun asking whether symptoms of anxiety are to be expected as an appropriate response to daily challenges or whether these symptoms are indicative of a comorbid psychological disorder in need of targeted intervention to reduce impairment (Kerns et al., 2014). If anxiety disorders and ASD co-occur as comorbid disorders, anxiety symptoms in individuals with ASD should match the symptoms of anxiety disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders–5th ed. (DSM-5; APA, 2013). For instance, a child may be resistant to socially engage with same-aged peers for several reasons, including anxiety-related fears of being negatively evaluated by peers (i.e., social anxiety disorder), ASD-related social skills deficits, or an interaction of both disorders (Renno & Wood, 2013). Thus, there may be a two-way relationship between social anxiety disorder and ASD-related social skill deficits, as social anxiety could be both a result of and contributor to social awkwardness and avoidance of social interactions (Kerns & Kendall, 2012; White et al., 2009).

In a study of youth between ages 7-years-old to 17-years-old who were diagnosed with ASD, Kerns and colleagues (2014) observed traditional (consistent with DSM criteria) anxiety disorders in 48% of the sample. The anxiety symptoms were independent of ASD severity and were associated with well-known predictors of anxiety in youth without ASD (e.g., a more anxious cognitive style, sensory hypersensitivity), suggesting that traditional anxiety, as it presents in typically developing children, may also occur in individuals with ASD (Kerns et al., 2014).

Kerns and colleagues (2014) also found the presence of atypical anxiety symptoms, which were considered qualitatively different from the traditional anxiety disorder categories and were possibly linked to difficulties specifically common to individuals with ASD. Some examples of anxiety symptoms that would be considered atypical include excessive and interfering worries regarding schedule changes; specific phobias with an unusual focus (e.g., running water, men with beards); and consistent social discomfort and fearfulness, not stemming from the fear of negative social evaluation (Kerns et al., 2014). These findings illustrate both separate and ASD-specific anxiety types.

Researchers have noted that individuals with ASD develop anxiety for many of the same reasons that individuals without ASD develop anxiety disorders. Furthermore, family psychiatric difficulties—that may be transmitted by genetics, social-environmental factors, or both—may be risk factors that trigger and exacerbate anxiety in individuals with ASD (Kerns, Rump, et al., 2016). Age and developmental level should be considered, as Davis and colleagues (2011) demonstrated that the trajectory of anxiety symptoms in individuals with ASD approximates that of typically developing individuals (i.e., peaking in adolescence). Additionally, negative life events, difficulties with emotion regulation and hyperarousal, and skill deficits (e.g., deficits in social skills, daily living skills, and academic proficiency) may increase the likelihood of individuals with ASD developing anxiety disorders (Bellini, 2006; Kerns, Newschaffer, & Berkowitz, 2015; Kerns, Rump, et al., 2016).

Misconception: Individuals with ASD don’t want friends.

Despite central deficits in social communication in ASD, not all individuals with ASD experience negative social outcomes and require intensive intervention in school settings (Locke, Williams, Shih, & Kasari, 2017). Many individuals with ASD are capable of forming reciprocal friendships (Bauminger et al., 2008a, 2008b; Kasari, Locke, Gulsrud, & Rotheram-Fuller, 2011). However, the capacity to form friendships does not guarantee that these individuals are included socially by their peers (Locke, Williams, Shi, & Kasari, 2017). Locke, Ishijima, Kasari, and London (2010) found that individuals with autism can experience loneliness and also recognize the poor quality of their friendships.

Jones and Frederickson (2010) noted that those with ASD who were rated as having prosocial behaviors were not necessarily included in social interactions with peers. Some peers purposefully exclude individuals with ASD. For example, peer-bullying and a lack of education on the part of both typical peers and teachers have been identified as factors contributing to social isolation (Majoko, 2016). Ultimately, regardless of who is to blame, difficulty connecting with others leads to individuals with autism feeling lonely and socially isolated (Ozonoff, Dawson, & McPartland, 2002). For example, the NLTS-2012 reported 45% of youth with autism choose to do activities with their friends, and 76% report knowing how to make friends (both significantly lower rates than other disabled peers). Peers with intellectual disability (ID) reported similar rates of choosing activities with friends (48%), but more consistent, higher rates of weekly get-togethers (42% for ID versus 29% for ASD). Although those with ASD and co-morbid ID were not separately identified, 50% of the ASD sample reported difficulty communicating by any means (compared to 60% in the ID group) and similar rates of not being able to understand what people say to them (70% and 69%, ASD and ID respectively), so it is likely that the results reflect individuals across the spectrum of cognitive abilities. Taken together, these findings indicate that though many individuals with autism desire to have friends, they are not as successful in engaging socially with friends (Lipscomb et al., 2017).

Misconception: Individuals with ASD can’t express emotions and can’t understand the emotions of others.

Prior to 1960, minimal research was conducted on the effects of grief and loss (Forrester-Jones & Broadhurst, 2007). Grief is a complex emotion that manifests in different ways in children and adults. Symptoms may include behavior changes as well as attempts at emotional expression. Children and adolescents may grieve intermittently and can re-experience grief as they develop and gain more understanding (Himebauch, Arnold, & May, 2008). Very little research has been done on the effects that grief has on those with autism, so most information available is from websites or books from people who have worked with children with autism who are grieving. It is sometimes erroneously assumed that individuals with autism lack the ability to empathize with others and that they have no connection with or insight into their own emotions. Behavioral outbursts displayed during times of stress tend to reinforce this misperception. However, while those with autism might grieve in ways that differ from typical expressions of grief, researchers acknowledge that these individuals grieve (Lipsky, 2013).

At times, individuals with ASD might focus solely on their own schedule and routines and appear disinterested in the death of a loved one. However, during stressful times, routines may give them a comforting sense of order. The need for this order may dominate the thoughts of individuals with ASD and this preoccupation may give the impression that they are indifferent to the loss. In reality, this preoccupation may be their way of managing strong emotions associated with grief.

Following the death of a loved one or other significant loss, communication difficulties are common for individuals with ASD due to limited language abilities, a lack of social understanding regarding situations involving grief, and a lack of motivation to respond in a socially acceptable manner (APA, 2013). When general rules of social interaction are not followed, the individual may appear rude and disinterested. The individual may ask questions that seem awkward or inappropriate. Additionally, the individual may impulsively make comments without considering how these comments affect others. An individual with autism may have a difficult time interpreting others’ feelings or the way others are perceiving the situation. Likewise, others may misunderstand what an individual with ASD is trying to convey, due to distracting body movements and facial expressions that may be incongruent with the individual’s feelings (Helbert, 2013).

Strategies to support the social emotional needs of students with ASD

Providing social emotional supports to students with ASD is primarily a teaching/learning process. In addition to specific interventions (i.e., cognitive behavior therapy, social skills packages and peer training packages discussed later), several learning strategies have been identified as established interventions to improve outcomes for students with ASD (National Autism Center [NAC], 2015a, 2015b). Among this list are four strategies well-suited to social and emotional support that may be part of package interventions. These strategies include schedules, modeling, story-based interventions, and scripting, each of which can also be effective as standalone interventions across the spectrum of language and cognitive abilities. In the following paragraphs, these strategies are briefly described.

Schedules involve using a chart or list with pictures or words that show sequential activities or ordered steps throughout a discrete event (e.g., getting ready for school) or the entire day. Charts can be created to teach independence in routines or to decrease anxiety about a new situation (Knight, Sartini, & Spriggs, 2015). Using positive reinforcement, a child can also be taught to accept the unexpected by practicing (allowing for) at least one unexpected event each day, with a reward for showing positive or neutral reactions when the unexpected event occurs. For example, a schedule might prepare a child for an assembly at school or a field trip as departures from typical routines, or changes in routines, following a loss. Resources for schedules are included in Appendix A.

Our second strategy is modeling. In this strategy, appropriate, situation-specific, social behaviors are modeled on video by others or by the individual. Then, children watch the video. After watching the video, children practice the skills and receive feedback. Since the original research of video modeling conducted by Bandura, Ross, and Ross (1963), this technique has been strongly supported in the literature. This strategy is also effective with students with ASD, particularly when teaching a new skill (Bellini & Akullian, 2007). Some research has shown video modeling to be superior to live modeling (Charlop-Christy, Le, & Freeman, 2000; McCoy & Hermansen, 2007). Video modeling has also become increasingly affordable and accessible with rapid advances in technology and personal electronic devices (Kellems & Morningstar, 2012). Modeling can be used to show what to expect and what to do at a funeral or how to deal with bullying, for example. Modeling resources are listed in Appendix A.

The next strategy is based on the power of a story to help increase understanding and compliance in children with autism. Story-based interventions are practical, easy to implement, and effective. The most popular and most widely used story-based interventions include Social Stories™ developed by Carol Gray (2010). These brief structured stories use visual information (simple drawings, pictures, photos, or video) with a short narrative to clearly and simply state what the individual will encounter in a given social situation, how to respond or act in a socially appropriate way, and the subsequent rewards and/or satisfaction for acting in a socially appropriate manner. Research indicates that social stories help children improve their social interactions (Stary, Everett, Sears, Fujiki, & Hupp, 2012). A social story may portray how to ask to join a game at recess, for example. Story-based resources are listed in Table 2.
Table 2.
Resources for social isolation: Supporting children with autism.

Resource Reference Information about resource Type of resource

We’re amazing 1,2,3! http://autism.sesamestreet.org/storybook-we-are-amazing Kimmelman, L., & Nelson, M. (2017) Sesame street book to introduce a new character with ASD and how to include her in play Children’s book (online) also available in Spanish

Superflex: A superhero social thinking curriculum https://www.socialthinking.com/ Madrigal, S., Winner, M. G., & Knopp, K. (2008) Curriculum using comic book characters to teach skills in social thinking, social behaviors, and self-regulation; comes with manual, first comic book; CD for individualizing the curriculum Educator, parent, therapist + children’s book

The PEERS® curriculum for school-based professionals: Social skills training for adolescents with autism spectrum disorder (1st ed.) https://www.semel.ucla.edu/peers Laugeson, E., & Frankel, F. (2013) Weekly social skills direct instruction curriculum for adolescents with ASD; group format; also available in clinical setting and Korean language versions Educator, therapist

The incredible 5-point scale, The significantly improved and expanded second edition: Assisting students in understanding social interactions and controlling their emotional response Buron, K. D., & Curtis, M. (2012) Concrete framework for describing escalating emotions (including the anxiety curve); includes five-point scales and concrete explanations of when social behaviors are appropriate, depending on context Parent, educator, therapist

The new social story book (10th ed.) http://carolgraysocialstories.com/ Gray, C. (2010) Specific methods for constructing effective social stories; examples of social stories for a variety of situations Parent, educator, therapist

Resources were chosen by prioritizing those that were free or low cost, those available in multiple languages, those with established evidence base, or those commonly used in practice. Resources listed are available via Internet, online booksellers, website or other information about availability is provided. For additional parent, educator, and therapist resources that address social isolation, see Appendix C.

The last of the four strategies is scripting. Scripting involves practicing (in advance) what to say in common social situations. This advance practice helps individuals with ASD appropriately join social interactions (Bellini & Peters, 2008). Scripting may also help individuals with ASD to avoid saying impulsive and unintentionally hurtful comments. For example, when a peer is grieving the loss of a loved one, the individual with ASD will practice and deliver a scripted statement, such as ‘I am so sorry for your loss’. Resources that include scripting strategies are included in Appendix A.

Interventions for anxiety and ASD

Researchers have demonstrated that self-injurious behavior, depressive symptoms, parental stress, social skill deficits, and decreases in academic performance are associated with the co-occurrence of anxiety and ASD (Kerns, Kendall, et al., 2015; Sze & Wood, 2007). These difficulties, on top of difficulties associated with symptoms of anxiety, provide strong evidence regarding the need for anxiety-focused treatment in individuals with ASD (Kerns, Rump, et al., 2016). Moreover, researchers have demonstrated that without intervention, anxiety in individuals with ASD does not diminish, but extends across the life span (McNally Keehn, Lincoln, Brown, & Chavira, 2013). Importantly, Kerns, Kendall, and colleagues (2015) noted that interventions directed solely towards ASD might not adequately address the interaction of anxiety and ASD. Therefore, evidence-based treatments for the co-occurrence of anxiety and ASD are critically important.

Kerns, Wood, and colleagues (2016) noted that several characteristics of individuals with ASD—such as their social communication deficits, restricted and repetitive behaviors, limited insight, and unique expressions of anxiety—might lessen the effectiveness of standard practice cognitive behavioral therapy (CBT) for individuals with anxiety. Consequently, CBT protocols for anxiety have been adapted to more adequately address the needs of individuals with ASD and shown to improve symptoms in multiple randomized control trials and through meta-analysis (Spain, Sin, Chalder, Murphy, & Happé, 2015; Reaven, Blakely-Smith, Culhane-Shelburne, & Hepburn, 2012; Storch et al., 2013; Sukhodolsky, Bloch, Panza, & Reichow, 2013; Ung, Selles, Small, & Storch, 2015; Vasa et al., 2014; Wood et al., 2009; Wood et al., 2015).

A recent meta-analysis to examine the efficacy of 14 studies involving 511 participants with high-functioning ASD concluded that CBT was moderately effective for individuals with high-functioning ASD. Additionally, the researchers outlined the common components of CBT that were used across the studies included in the meta-analysis. These components included psychoeducation, creation of a fear hierarchy, exposure to feared stimuli, cognitive restructuring, relaxation techniques, and social skill development. Furthermore, in order to modify the protocols to better suit individuals with ASD, adaptations included the use of role play, visual aids, structured worksheets, social stories, video modeling, and a wide variety of reinforcement strategies (Ung et al., 2015). Along with these adaptations, other researchers recommend modifying CBT procedures to tap into special interests of individuals with ASD (Vasa et al., 2014) and slow down the pace of the CBT sessions to allow extra processing time for individuals with ASD and co-occurring intellectual disabilities (Spain et al., 2015). Additionally, the specific treatment protocols used across studies were based on treatment manuals. The effects of CBT adapted for individuals with ASD have been shown in the same magnitude as the well-established effects of CBT in typically developing individuals (Sukhodolsky et al., 2013).

While the majority of studies on using modified CBT for individuals with high-functioning ASD have been conducted in clinical settings, Luxford, Hadwin, and Kovshoff (2016) conducted a randomized controlled trial measuring the effectiveness of a school-based CBT intervention with adolescents who were identified with ASD. Notably, Luxford and colleagues (2016) demonstrated that, in comparison to a waitlist control group, adolescents with ASD showed a greater reduction in anxiety symptoms and that these improvements were maintained at six weeks post intervention. Furthermore, parents and teachers were included in the manualized CBT intervention. Additionally, the successful results of this study generalized across settings. This study’s intervention was based on Attwood’s (2004) book that is listed in Table 1. Other manuals and resources are listed in Appendix B.
Table 1.
Resources for anxiety: Supporting children with autism.

Resource Reference Information provided Resource relevance

Autism speaks: Managing anxiety in children with autism https://www.autismspeaks.org/blog/2014/05/29/managing-anxiety-children-autism Wood, J. (n.d.) Short article about what anxiety looks like in children with autism, links to articles and books, link to find therapists, links to toolkits Parent, Educator, Therapist

When my worries get too big! A relaxation book for children who live with anxiety Buron, K. D. (2006) Picture book with activities based on the five-point scale and anxiety curve, developmental age 5-years-old to 10-years-old Children’s book

Indiana Resource Center for Autism: Anxiety and Autism Spectrum Disorders https://www.iidc.indiana.edu/pages/anxiety-and-autism-spectrum-disorders Merrill, A. (n.d.) Explanation of anxiety in autism, treatment options, links to other websites, additional resources including helpful apps Parent

Exploring feelings: Anxiety: Cognitive Behaviour Therapy to manage anxiety See Appendix B for more information. Attwood, T. (2004) Guide for learning about emotions to help children connect the thoughts, feelings, and behaviors they experience related to anxiety Parent, Therapist

Cognitive-Behavioral Therapy for anxious children: Therapist Manual (3rd ed.) See Appendix B for more information. Kendall, P. C. & Hedtke, K. A. (2006) Evidence-based manual for therapists to target anxiety symptoms using cognitive-behavioral therapy techniques, the Coping Cat curriculum Therapist

Resources were chosen by prioritizing those that were free or low cost, those available in multiple languages, those with established evidence base, or those commonly used in practice. Resources listed are available via Internet, online booksellers, website or other information about availability is provided. For additional resources refer to Appendix B.

Rosen, Connell and Kerns (2016) highlighted that CBT is a verbally demanding treatment and includes a focus on labeling emotions, abstract thinking, and verbal coping strategies (e.g., cognitive restructuring, problem solving). Considering these demands, CBT may be a poor fit for individuals on the autism spectrum who have lower verbal abilities. However, they provided preliminary evidence that behavioral treatments with lower functioning individuals with ASD are efficacious and might be a promising avenue for anxiety treatment for individuals who struggle with higher levels of symptom severity, intellectual disability, and/or significant language impairment. They summarized common treatment components across studies, including desensitization, reinforcement, modeling, and prompting.

Interventions for social isolation

There are two basic approaches to improve outcomes for individuals with ASD who are socially isolated (Kasari et al., 2011; NAC, 2015a, 2015b). The first is a skill-building approach to increase appropriate social interactions and motivations through direct instruction, social stories, and scripting (NAC, 2015a, 2015b). The other approach is to increase the capacity of peers to include students with ASD in age-appropriate peer activities (Kasari et al., 2011).

There are numerous published social skills intervention programs designed specifically to build social interaction and communication skills in individuals with ASD. Some, such as the University of California, Los Angeles (UCLA) Program for the Education and Enrichment of Relational Skills, or PEERS^(R) curriculum, have been researched as a stand-alone package (Laugeson, Frankel, Mogil, & Dillon, 2009); replicated by Schohl et al. (2014); and implemented across cultures and languages (Yoo et al., 2014). Although other curricula may not have this level of package-specific evidence, many programs incorporate established elements of effective social skills interventions. Programs that include the following evidence-based components are identified as established interventions: (a) group instruction with typical peers in the group; (b) clear, concrete social rules; (c) generalization opportunities (e.g., free time to play or talk, field trips, homework); (d) high interest, hands on, fun, age-appropriate activities; (e) self-monitoring of social behaviors; (f) video modeling and/or role plays; (g) social stories or social scripts; (h) structured and predictable sessions; (i) progression of skills with errorless teaching; and (j) positive reinforcement for demonstration of skills and ‘homework’ completion (Gresham, Sugai, & Horner, 2001; Krantz & McClannahan, 1993; Krasny, Williams, Provencal, & Ozonoff, 2003; NAC, 2015a, 2015b; Williams White, Keonig, & Scahill, 2007). Social skills intervention packages with these elements have been shown to increase communication skills, learning readiness, and play, while decreasing general ASD symptoms and problem behaviors. Social skills package interventions have also shown effects of decreasing socially isolating behaviors, such as engaging in restricted and repetitive behaviors and sensory or emotional regulation difficulties (NAC, 2015a, 2015b).

Peer training is also an established intervention for students with autism (NAC, 2015a, 2015b). Multiple approaches for changing peer behaviors have been shown to decrease social isolation in students with ASD. Kasari and colleagues (2011) worked with elementary-aged peers each week to teach strategies for involving students who were not included (without specifically mentioning students who were identified with ASD). During recess, trained peers were then observed. Observations and data indicated that trained peers spontaneously engaged with students with ASD and nominated these students more often as a peer they would like to play with or who was their friend (Kasari et al., 2011). Ochs, Kremer-Sadlik, Solomon, and Sirota (2001) found that when students (ages 8-years-old to 12-years-old) with ASD disclosed their diagnosis to peers, peers’ social support increased. Another approach with middle-school typical peers (ages 12-years-old to 15-years-old) was to include first person narrative information (self-introduction) about ASD. First person narrative information resulted in increased positive attitude about students with ASD (Campbell, 2007).

When implementing interventions that include typical peers, one of the more challenging aspects is finding typical peers who are able to attend the group. This difficulty is perhaps due to concerns about taking typical peers from class to participate in social skills interventions. To encourage parents and teachers to include typical peers, it may be helpful to cite Asmus et al. (2017). They found that typical high school peers engaging in peer support networks showed their own academic improvements following participation in social interactions with students identified with disabilities. To assist schools in implementing interventions to improve social skills specific to ASD, five resources are listed in Table 2. A more extensive list is included in Appendix C.

Additionally, Carter, Hughes, Copeland, and Breen (2001) found that in comparison to those high school students who did not volunteer, adolescents who volunteered in peer training programs experienced more growth in knowledge and willingness to interact with students with disabilities. Their research also indicated that peer training programs helped to reduce the social isolation of students with disabilities. Later research found that the proximity of a typical peer increased the frequency of social interactions and positive social skills of students with disabilities (Carter, Hughes, Guth, & Copeland, 2005). Finally, based on applied practice, Maich and Belcher (2012) outlined 10 principles for choosing bibliotherapy resources (picture books) to teach peers about ASD. Specific titles and resources are listed in Table 2 and Appendix C.

Interventions for coping with grief

The intersection of research on autism and grief is just beginning to emerge in the literature. Only one published article (not a research study) was found on supports for grief in children with developmental disabilities (Sormanti & Ballan, 2011) along with one unpublished dissertation which addressed grief in children with autism spectrum disorder specifically with a video game intervention (Johnson, 2016). Following a death or loss, an individual with ASD will face many challenging social situations: Others may attempt to offer the individual comfort; the individual may want to comfort others in their grief; in the case of a death, the individual may attend an open-casket viewing of the deceased loved one; and the individual may attend the funeral or memorial service.

According to Ozonoff, Dawson, and McPartland (2002), current research has shown that social scripts (scripting) can be useful tools for helping to prepare those with autism for unfamiliar social situations. This could be beneficial in preparing them for how to handle events relating to death. Scripts offer individuals specific phrases to use in these situations, which could offer the individual guidance for an event such as a funeral or memorial service. As individuals with autism may not have appropriate existing social scripts, this advanced preparation can help the individual feel more comfortable in their interactions with other grieving individuals. Social Stories™ (Gray, 2010) are designed to preemptively prepare the individual for typical social situations before encountering them. Ozonoff and colleagues (2002) state that rather than solely offering exact phrases to use in situations, social stories focus more on critical social cues, why people are behaving in certain ways, and why it is important to respond in a particular manner. For example, a story can be created (using any medium) to describe what can happen at a funeral, what will happen when people try to offer comfort, and what will happen at school when the individual feels the intense sadness associated with loss. Social stories have the added benefit of reducing anxiety by showing the child what to expect. Because social stories are designed for repetition, the stories could also offer comfort by reviewing what happened in the past (similar to a memory book), including the feelings and actions of people in the story.

Wharff (2015) stated that although those with autism benefit from advanced preparation for changes that might alter their normal routines, this is not always possible. When an unexpected event occurs (e.g., the sudden death of a loved one, divorce, a loved one moving away, military deployment) multiple unplanned changes in daily routines are inevitable. Following a death or substantial loss, life becomes chaotic. According to Helbert (2013), the ensuing disorder, confusion, and uncertainty often contribute to emotional outbursts. Anxiety associated with the uncertainty may be reduced by making a schedule of the altered routines, so the events of the day become more predictable.

Wheeler (2016) states that interventions based on principles of CBT, adapted for children with autism, may support an individual with ASD through their grief process and help the individual become more aware of their thoughts, emotions, and behaviors. According to Wheeler, as an individual becomes more aware of the way they think, they are able to have more control over their actions and outward expressions. Family and teachers need to consider that it may take longer for a child or adolescent with ASD to learn to cope with grief and that the effects of grief may be more unpredictable than in typically developing individuals. In the grief process, individuals with ASD may become ‘stuck’ on an idea (perseverative interests; APA, 2013, p. 50). This rigidity may restrict adaptive coping and the ability to manage feelings associated with grief, and continued support will be needed. To help children learn to cope with their grief, Table 3 and Appendix D include user-friendly resources, including children’s books.
Table 3.
Resources for grief: Supporting children with autism.

Resource Reference Information about resource (ages are developmental age) Type of resource

Goodbye Mousie Harris, R., & Omerod, J. (2004) A story about death, feeling angry and sad, and then coming to terms with the loss; ages 4-years-old to 8-years-old Children’s book

Help me say goodbye: Activities for helping kids cope when a special person dies Silverman, J. (1999) Activity book includes art activities to help children cope with grief Children’s Book

Lifetimes: The beautiful way to explain death to children Mellonie, B., & Ingpen, R. (1983) Story helps explain life cycles, including the beginning and the end of life; ages 5-years-old to 8-years-old Children’s book

What on earth do you do when someone dies? Romain, T. (1999) Story addresses the topic of death and offers comfort and reassurance; ages 5-years-old to 10-years-old Children’s book

Finding your own way to grieve: A creative activity workbook for kids and teens on the autism spectrum Helbert, K. (2013) Concrete explanations and activities to help understand death and grief; ages 5-years-old to 18-years-old Children’s and teen’s workbook

When a pet dies Rogers, F. (1998) Story helps explain the death of a pet, what events might occur, and what feelings a child might have; ages 4-years-old to 8-years-old Children’s book

Case example

Returning to the case of Rajh, who is experiencing everyday anxiety associated with autism, increasing social isolation and bullying, and grief over his parents’ divorce, several available resources can help his family, teachers, and therapists to address his needs. Because of his age-appropriate verbal ability, he is likely to respond well to CBT techniques adapted for children with autism, including the support of modeling and the concrete visual models for linking feelings and thoughts to actions, such as those provided in The Incredible 5-Point Scale book (details about this resource are listed in Table 2). Using the scale format and/or the anxiety curve can help him learn skills to gain self-control and better regulate his emotions. Using these therapeutic and visual tools, he can be better prepared to use CBT coping strategies for anxiety when faced with changes in routine. As his feelings about his parents’ divorce overwhelm him, these same resources can help him to know what he can do to feel better. Rajh can also benefit from modeling as part of a social skills intervention group to improve his own social skill levels and allow him safe opportunities for supported, successful socialization at school. Individualized Social Stories™ and scripting can teach him specifics of what to do and say when he experiences bullying and social isolation. Finally, reducing levels of anxiety using schedules (e.g., days he will be spending at Dad’s or Mom’s house, how he will get to school, who will pick him up, and what will be happening each day) can reduce the overall burden of social-emotional stressors in Rajh’s everyday life.

Conclusion

The resources that are included in this article’s tables and appendices are offered to assist caring adults in supporting children with ASD who are experiencing anxiety, social isolation, and grief. Many individuals with ASD experience anxiety and social isolation on a regular basis. Additionally, although a universal experience, grief is complicated by deficits in social communication and emotional understanding that are inherent in ASD. Intervention packages (i.e., CBT, social skills instruction, and peer training) can make use of established strategies such as schedules, modeling, story-based interventions, and scripting to specifically increase social emotional understanding and skill in individuals with ASD. Caregivers, educators, mental health professionals, and peers can provide needed support as individuals with ASD learn strategies for understanding and coping with complex social emotional issues.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Resource	Reference	Information about resource	Type of resource
We’re amazing 1,2,3! http://autism.sesamestreet.org/storybook-we-are-amazing	Kimmelman, L., & Nelson, M. (2017)	Sesame street book to introduce a new character with ASD and how to include her in play	Children’s book (online) also available in Spanish
Superflex: A superhero social thinking curriculum https://www.socialthinking.com/	Madrigal, S., Winner, M. G., & Knopp, K. (2008)	Curriculum using comic book characters to teach skills in social thinking, social behaviors, and self-regulation; comes with manual, first comic book; CD for individualizing the curriculum	Educator, parent, therapist + children’s book
The PEERS® curriculum for school-based professionals: Social skills training for adolescents with autism spectrum disorder (1st ed.) https://www.semel.ucla.edu/peers	Laugeson, E., & Frankel, F. (2013)	Weekly social skills direct instruction curriculum for adolescents with ASD; group format; also available in clinical setting and Korean language versions	Educator, therapist
The incredible 5-point scale, The significantly improved and expanded second edition: Assisting students in understanding social interactions and controlling their emotional response	Buron, K. D., & Curtis, M. (2012)	Concrete framework for describing escalating emotions (including the anxiety curve); includes five-point scales and concrete explanations of when social behaviors are appropriate, depending on context	Parent, educator, therapist
The new social story book (10th ed.) http://carolgraysocialstories.com/	Gray, C. (2010)	Specific methods for constructing effective social stories; examples of social stories for a variety of situations	Parent, educator, therapist

Resource	Reference	Information provided	Resource relevance
Autism speaks: Managing anxiety in children with autism https://www.autismspeaks.org/blog/2014/05/29/managing-anxiety-children-autism	Wood, J. (n.d.)	Short article about what anxiety looks like in children with autism, links to articles and books, link to find therapists, links to toolkits	Parent, Educator, Therapist
When my worries get too big! A relaxation book for children who live with anxiety	Buron, K. D. (2006)	Picture book with activities based on the five-point scale and anxiety curve, developmental age 5-years-old to 10-years-old	Children’s book
Indiana Resource Center for Autism: Anxiety and Autism Spectrum Disorders https://www.iidc.indiana.edu/pages/anxiety-and-autism-spectrum-disorders	Merrill, A. (n.d.)	Explanation of anxiety in autism, treatment options, links to other websites, additional resources including helpful apps	Parent
Exploring feelings: Anxiety: Cognitive Behaviour Therapy to manage anxiety See Appendix B for more information.	Attwood, T. (2004)	Guide for learning about emotions to help children connect the thoughts, feelings, and behaviors they experience related to anxiety	Parent, Therapist
Cognitive-Behavioral Therapy for anxious children: Therapist Manual (3rd ed.) See Appendix B for more information.	Kendall, P. C. & Hedtke, K. A. (2006)	Evidence-based manual for therapists to target anxiety symptoms using cognitive-behavioral therapy techniques, the Coping Cat curriculum	Therapist

Resource	Reference	Information about resource (ages are developmental age)	Type of resource
Goodbye Mousie	Harris, R., & Omerod, J. (2004)	A story about death, feeling angry and sad, and then coming to terms with the loss; ages 4-years-old to 8-years-old	Children’s book
Help me say goodbye: Activities for helping kids cope when a special person dies	Silverman, J. (1999)	Activity book includes art activities to help children cope with grief	Children’s Book
Lifetimes: The beautiful way to explain death to children	Mellonie, B., & Ingpen, R. (1983)	Story helps explain life cycles, including the beginning and the end of life; ages 5-years-old to 8-years-old	Children’s book
What on earth do you do when someone dies?	Romain, T. (1999)	Story addresses the topic of death and offers comfort and reassurance; ages 5-years-old to 10-years-old	Children’s book
Finding your own way to grieve: A creative activity workbook for kids and teens on the autism spectrum	Helbert, K. (2013)	Concrete explanations and activities to help understand death and grief; ages 5-years-old to 18-years-old	Children’s and teen’s workbook
When a pet dies	Rogers, F. (1998)	Story helps explain the death of a pet, what events might occur, and what feelings a child might have; ages 4-years-old to 8-years-old	Children’s book

Footnotes

Author biographies

Kaitlyn P. Ahlers, MA Doctoral Student in Clinical Psychology at the University of Montana, researches dissemination and implementation of evidence-based practices for youth mental health. She focuses on the mental health of children and adolescents in relation to traumatic stress and living with chronic conditions.

Terisa P. Gabrielsen, PhD Assistant Professor of School Psychology at Brigham Young University, specializes in autism research and assessment. Her research focuses on early identification, social skills development, and brain differences in individuals with autism spectrum disorder. She is a licensed psychologist and Nationally Certified School Psychologist.

Danielle Lewis BS a graduate student in Brigham Young University’s School Psychology program (Provo UT, USA), conducts research on the topics of childhood grief, autism, and bibliotherapy.

Anna M. Brady MS is a Doctoral candidate in Utah State University’s Special Education and Rehabilitation’s Disability Disciplines Program (Logan UT, USA). She has worked as a high school special education teacher, instructor for social skills therapy programs for elementary children, and as a case manager delivering applied behavior analysis interventions for preschoolers.

April Litchford MS is a nationally registered dietitian. She is a doctoral candidate at Utah State University (Logan UT, USA) where she researches prevalence, intervention, and nutritional implications of pediatric feeding disorders.

References

American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Arlington, VA: Author.

Asmus

Carter

E. W.

Moss

C. K.

Biggs

E. E.

Bolt

D. M.

Born

T. L.

Weir

(2017) Efficacy and social validity of peer network interventions for high school students with severe disabilities. American Journal on Intellectual and Developmental Disabilities 122(2): 118–137. doi: 10.1352/1944-7558-122.2.118.

Attwood

(2004) Exploring feelings: Anxiety: Cognitive behaviour therapy to manage anxiety, Arlington, TX: Future Horizons.

Autism Speaks Family Services and Science Department (2017). 11 myths about autism. Retrieved from https://www.autismspeaks.org/node/113471.

Bandura

Ross

(1963) Imitation of film-mediated aggressive models. Journal of Abnormal and Social Psychology 66: 3–11. doi: 10.1037/h004868.7.

Bauminger

Solomon

Aviezer

Heung

Brown

& Rogers

S. J.

(2008a) Children with autism and their friends: A multidimensional study of friendship in high-functioning autism spectrum disorder. Journal of Abnormal Child Psychology 36: 135–150. doi: 10.1007/s10802-007-9156-x.

Bauminger

Solomon

Aviezer

Heung

Brown

& Rogers

S. J.

(2008b) Friendship in high-functioning children with autism spectrum disorder: Mixed and non-mixed dyads. Journal of Autism and Developmental Disorders 38: 1211–1229. doi: 10.1007/s10803-007-0501-2.

Bellini

(2006) The development of social anxiety in adolescents with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities 21: 138–145. doi: 10.1177/10883576060210030201.

Bellini

Akullian

(2007) A meta-analysis of video modeling and video self-modeling interventions for children and adolescents with autism spectrum disorders. Exceptional Children 73: 264–287. doi: 10.1177/001440290707300301.

10.

Bellini

Peters

J. K.

(2008) Social skills training for youth with autism spectrum disorders. Child and Adolescent Psychiatric Clinics of North America 17: 857–873. doi: 10.1016/j.chc.2008.06.008http://ecx.sagepub.com/content/73/3/264.abstract.

11.

Buron, K. D. (2006). When my worries get too big! A relaxation book for children who live with anxiety (2nd ed.). Lenexa, KS: AAPC Publishing.

12.

Buron, K. D. & Curtis, M. (2012). The incredible 5-point scale: The significantly improved and expanded second edition. Lenexa, KS: AAPC Publishing.

13.

Campbell

J. M.

(2007) Middle school students’ responses to the self-introduction of a student with autism: Effects of perceived similarity, prior awareness, and education message. Remedial and Special Education 28: 163–173. doi: 10.1177/07419325070280030501.

14.

Carter

E. W.

Hughes

Copeland

S. R.

Breen

(2001) Differences between high school students who do and do not volunteer to participate in a peer interaction program. Research and Practice for Persons with Severe Disabilities 26: 229–239. doi: 10.2511/rpsd.26.4.229.

15.

Carter

E. W.

Hughes

Guth

C. B.

Copeland

S. R.

(2005) Factors influencing social interaction among high school students with intellectual disabilities and their general education peers. American Journal on Mental Retardation 110: 366–377. doi: 10.1352/0895-8017(2005)110[366:FISIAH]2.0.CO;2.

16.

Charlop-Christy

M. H.

Freeman

K. A.

(2000) A comparison of video modeling with in vivo modeling for teaching children with autism. Journal of Autism and Developmental Disorders 30: 537–552. doi: 10.1023/A:1005635326276.

17.

Davis

T. E.

Hess

J. A.

Moree

B. N.

Fodstad

J. C.

Dempsey

Jenkins

W. S.

Matson

J. L.

(2011) Anxiety symptoms across the lifespan in people diagnosed with autistic disorder. Research in Autism Spectrum Disorders 5: 112–118. doi: 10.1016/j.rasd.2010.02.006.

18.

Elsabbaugh

Divan

Koh

Y.-J.

Kim

Kauchali

Marcin

Fombonne

(2012) Global prevalence of autism and other pervasive developmental disorders. Autism Research 5: 160–179. doi: 10.1002/aur.239.

19.

Forrester-Jones

Broadhurst

(2007) Autism and loss, Philadelphia, PA: Jessica Kingsley Publishers.

20.

Gray

(2010) The new social story book, Arlington, TX: Future Horizons.

21.

Gresham

F. M.

Sugai

Horner

R. H.

(2001) Interpreting outcomes of social skills training for students with high-incidence disabilities. Exceptional Children 67: 331–344. doi: 10.1177/001440290106700303.

22.

Himebauch

Arnold

R. M.

May

(2008) Grief in children and developmental concepts of death #138. Journal of Palliative Medicine 11(2): 242–243. doi:10.1089/jpm.2008.9973.

23.

Helbert

(2013) Finding your own way to grieve: A creative activity workbook for kids and teens on the autism spectrum, Philadelphia, PA: Jessica Kingsley Publishers.

24.

Johnson

K. B.

(2017) I don't like the talking part: The use of videogames to facilitate grief therapy for adolescents with autism spectrum disorder. Dissertation Abstracts International 77(10–B)): (E).

25.

Jones

A. P.

Frederickson

(2010) Multi-informant predictors of social inclusion for students with autism spectrum disorders attending mainstream school. Journal of Autism and Developmental Disorders 40: 1094–1103. doi: 10.1007/s10803-010-0957-3.

26.

Kanner

(1943) Autistic disturbances of affective contact. Nervous Child 2: 217–250.

27.

Kasari

Locke

Gulsrud

Rotheram-Fuller

(2011) Social networks and friendships at school: Comparing children with and without autism. Journal of Autism and Developmental Disorders 41: 533–544. doi: 10.1007/s10803-010-1076-x.

28.

Kellems

R. O.

Morningstar

M. E.

(2012) Using video modeling delivered through iPods to teach vocational tasks to young adults with autism spectrum disorders. Career Development and Transition for Exceptional Individuals 35: 155–167. doi: 10.1177/0885728812443082.

29.

Kendall, P. C. & Hedtke, K. A. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore, PA: Workbook Publishing.

30.

Kerns

C. M.

Kendall

P. C.

(2012) The presentation and classification of anxiety in autism spectrum disorder. Clinical Psychology: Science and Practice 19: 323–347. doi: 10.1111/cpsp.12009.

31.

Kerns

C. M.

Kendall

P. C.

Berry

Souders

M. C.

Franklin

M. E.

Schultz

R. T.

et al. (2014) Traditional and atypical presentations of anxiety in youth with autism spectrum disorder. Journal of Autism and Developmental Disorders 44: 2851–2861. https://dx-doi-org.web.bisu.edu.cn/10.1007/s10803-014-2141-7 .

32.

Kerns

C. M.

Kendall

P. C.

Zickgraf

Franklin

M. E.

Miller

& Herrington

(2015) Not to be overshadowed or overlooked: Functional impairments associated with comorbid anxiety disorders in youth with ASD. Behavior Therapy 46: 29–39. doi: 10.1016/j.beth.2014.03.005.

33.

Kerns

C. M.

Newschaffer

C. J.

Berkowitz

S. J.

(2015) Traumatic childhood events and autism spectrum disorder. Journal of Autism and Developmental Disorders 45: 3475–3486. doi: 10.1007/s10803-015-2392-y.

34.

Kerns

C. M.

Rump

Worley

Kratz

McVey

Herrington

Miller

(2016) The differential diagnosis of anxiety disorders in cognitively-able youth with autism. Cognitive and Behavioral Practice 23: 530–547. doi:10.1016/j.cbpra.2015.11.004.

35.

Kerns

C. M.

Wood

J. J.

Kendall

P. C.

Renno

Crawford

E. A.

Mercado

R. J.

Storch

(2016) The treatment of anxiety in autism spectrum disorder (TAASD) study: Rationale, design and methods. Journal of Child and Family Studies 25: 1889–1902. doi: 10.1007/s10826-016-0372-2.

36.

Kimmelman, L., & Nelson, M. (2017). We’re amazing, 1,2,3! Retrieved from http://autism.sesamestreet.org/storybook-we-are-amazing/.

37.

Knight

Sartini

Spriggs

(2015) Evaluating visual activity schedules as evidence-based practice for individuals with autism spectrum disorders. Journal of Autism & Developmental Disorders 45: 157–178. doi: 10.1007/s10803-014-2201-z.

38.

Krantz

P. J.

McClannahan

L. E.

(1993) Teaching children with autism to initiate to peers: Effects of a script-fading procedure. Journal of Applied Behavior Analysis 26: 121–132. doi: 10.1901/jaba.1993.26-121.

39.

Krasny

Williams

B. J.

Provencal

Ozonoff

(2003) Social skills interventions for the autism spectrum: Essential ingredients and a model curriculum. Child and Adolescent Psychiatric Clinics of North America 12: 107–122. doi: 10.1016/S1056-4993(02)00051-2.

40.

Laugeson, E. A., & Frankel, F. (2013). The PEERS® curriculum for school-based professional: Social skills training for adolescents with autism spectrum disorder (1st ed.). New York, NY: Routledge.

41.

Laugeson

E. A.

Frankel

Mogil

Dillon

A. R.

(2009) Parent-assisted social skills training to improve friendships in teens with autism spectrum disorders. Journal of Autism and Developmental Disorders 39: 596–606. doi: 10.1007/s10803-008-0664-5.

42.

Lipscomb

Haimson

Liu

A. Y.

Burghardt

Johnson

D. R.

& Thurlow

M. L.

(2017) Preparing for life after high school: The characteristics and experiences of youth in special education. Findings from the National Longitudinal Transition Study 2012. Volume 2: Comparisons across disability groups: Full report (NCEE 2017–4018), Washington, DC: US Department of Education, Institute of Education Sciences, National Center for Education Evaluation and Regional Assistance.

43.

Lipsky

(2013) How people with autism grieve and how to help, Philadelphia, PA: Jessica Kingsley Publishers.

44.

Locke

Ishijima

E. H.

Kasari

London

(2010) Loneliness, friendship quality and the social networks of adolescents with high-functioning autism in an inclusive school setting. Journal of Research in Special Educational Needs 10: 74–81. doi: 10.1111/j.1471-3802.2010.01148.x.

45.

Locke

Williams

Shih

Kasari

(2017) Characteristics of socially successful elementary school-aged children with autism. Journal of Child Psychology & Psychiatry 58: 94–102. doi: 10.1111/jcpp.12636.

46.

Luxford

Hadwin

J. A.

Kovshoff

(2016) Evaluating the effectiveness of a school-based cognitive behavioural therapy intervention for anxiety in adolescents diagnosed with autism spectrum disorder. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-016-2857-7.

47.

Madrigal, S., Winner, M. G., & Knopp, K. (2008). Superflex: A superhero social thinking curriculum. San Jose, CA: Think Social.

48.

Maich

Belcher

E. C.

(2012) Using picture books to create peer awareness about autism spectrum disorders in the inclusive classroom. Intervention in School and Clinic 47: 206–213. doi: 10.1177/1053451211424600.

49.

Majoko

(2016) Inclusion of children with autism spectrum disorders: Listening and hearing to voices from the grassroots. Journal of Autism and Developmental Disorders 46: 1429–1440. doi: 10.1007/s10803-015-2685-1.

50.

Mason

Scior

(2004) ‘Diagnostic overshadowing’ amongst clinicians working with people with intellectual disabilities in the UK. Journal of Applied Research in Intellectual Disabilities 17: 85–90. doi: 10.1111/j.1360-2322.2004.00184.x.

51.

McCoy

Hermansen

(2007) Video modeling for individuals with autism: A review of model types and effects. Education and Treatment of Children 30: 183–213. doi: 10.1353/etc.2007.0029.

52.

McCrimmon

A. W.

Matchullis

R. L.

Altomare

A. A.

(2016) Resilience and emotional intelligence in children with high-functioning autism spectrum disorder. Developmental Neurorehabilitation 19: 154–161. doi:10.3109/17518423.2014.927017.

53.

McNally Keehn

R. H.

Lincoln

A. J.

Brown

M. Z.

Chavira

D. A.

(2013) The Coping Cat program for children with anxiety and autism spectrum disorder: A pilot randomized controlled trial. Journal of Autism and Developmental Disorders 43: 57–67. doi: 10.1007/s10803-012-1541-9.

54.

Merrill, A. (n.d.) Anxiety and autism spectrum disorders. Retrieved from https://www.iidc.indiana.edu/pages/anxiety-and-autism-spectrum-disorders.

55.

National Autism Center (2015a). Findings and conclusions: National Standards Project: Addressing the need for evidence-based guidelines for autism spectrum disorder, phase 2. Randolph, MA: Author. Retrieved from http://www.nationalautismcenter.org/090605-2/.

56.

National Autism Center. (2015b). Evidence-based practice and autism in the schools: An educator’s guide to providing appropriate interventions to students with autism spectrum disorder (2nd ed.). Randolph, MA: Author. Retrieved from http://www.nationalautismcenter.org/resources/for-educators/.

57.

Ochs

Kremer-Sadlik

Solomon

Sirota

K. G.

(2001) Inclusion as social practice: Views of children with autism. Social Development 10: 339–419. doi: 10.1111/1467-9507.00172.

58.

Ozonoff

Dawson

McPartland

(2002) A parent’s guide to Asperger syndrome and high-functioning autism: How to meet the challenges and help your child thrive, New York, NY: Guilford Press.

59.

Reaven

Blakely-Smith

Culhane-Shelburne

Hepburn

(2012) Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: A randomized trial. Journal of Child Psychology and Psychiatry 53: 410–419. doi: 10.1111/j.1469-7610.2011.02486.x.

60.

Renno

Wood

J. J.

(2013) Discriminant and convergent validity of the anxiety construct in children with autism spectrum disorders. Journal of Autism and Developmental Disorders 43: 2135–2146. doi: 10.1007/s10803-013-1767-1.

61.

Rosen

T. E.

Connell

J. E.

Kerns

C. M.

(2016) A review of behavioral interventions for anxiety‐related behaviors in lower‐functioning individuals with autism. Behavioral Interventions 31: 120–143. doi:10.1002/bin.1442.

62.

Schohl

K. A.

Van Hecke

A. V.

Carson

A. M.

Dolan

Karst

& Stevens

(2014) A replication and extension of the PEERS® intervention: Examining effects on social skills and social anxiety in adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders 44: 532–545. doi: 10.1007/s10803-013-1900-1.

63.

Spain, D., Sin, J., Chalder, T., Murphy, D., & Happé, F. (2015). Cognitive behavior therapy for adults with autism spectrum disorders and psychiatric co-morbidity: A review. Research in Autism Spectrum Disorders, 9(2015), 151–162. https://dx-doi-org.web.bisu.edu.cn/10.1016/j.rasd.2014.10.019.

64.

Sormanti

Ballan

M. S.

(2011) Strengthening grief support for children with developmental disabilities. School Psychology International 32(2): 179–193. doi: 10.1177/0143034311400831.

65.

Stary

A. K.

Everett

G. E.

Sears

K. B.

Fujiki

Hupp

S. A.

(2012) Social stories for children with autism spectrum disorders: Updated review of the literature from 2004 to 2010. Journal of Evidence-Based Practices for Schools 13: 123–140.

66.

Storch

E. A.

Arnold

E. B.

Lewin

A. B.

Nadeau

J. M.

Jones

A. M.

De Nadai

A. S.

Murphy

T. K.

(2013) The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of The American Academy of Child and Adolescent Psychiatry 52(2): 132–142. doi:10.1016/j.jaac.2012.11.007.

67.

Sukhodolsky

D. G.

Bloch

M. H.

Panza

K. E.

Reichow

(2013) Cognitive-behavioral therapy for anxiety in children with high-functioning autism: A meta-analysis. Pediatrics 132(5): e1341–e1350. doi: 10.1542/peds.2013-1193.

68.

Sze

K. M.

Wood

J. J.

(2007) Cognitive behavioral treatment of comorbid anxiety disorders and social difficulties in children with high-functioning autism: A case report. Journal of Contemporary Psychotherapy 37: 133–143. doi: 10.1007/s10879-007-9048-y.

69.

Tager-Flusberg

Joseph

R. M.

(2003) Identifying neurocognitive phenotypes in autism. Philosophical Transactions of the Royal Society B: Biological Sciences 358: 303–314. doi: 10.1098/rstb.2002.1198.

70.

Ung

Selles

Small

B. J.

Storch

E. A.

(2015) A systematic review and meta-analysis of cognitive-behavioral therapy for anxiety in youth with high-functioning autism spectrum disorders. Child Psychiatry and Human Development 46: 533–547. doi: 10.1007/s10578-014-0494-y.

71.

van Steensel

F. J. A.

Bögels

S. M.

Perrin

(2011) Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review 14: 302–317. doi: 10.1007/s10567-011-0097-0.

72.

van Steensel

F. J. A.

Heeman

E. J.

(2017) Anxiety levels in children with autism spectrum disorder: A meta-analysis. Journal of Child and Family Studies. doi:10.1007/s10826-017-0687-7.

73.

Wharff, J. (2015). Helping kids with autism understand death. Retrieved from http://blog.stageslearning.com/blog/understanding-death.

74.

Wheeler, M. (2016). Supporting individuals on the autism spectrum coping with grief and loss through death or divorce. The Reporter, 20 (20). Retrieved from https://www.iidc.indiana.edu/pages/supporting-individuals-on-the-autism-spectrum-coping-with-grief-and-loss.

75.

White

S. W.

Oswald

Ollendick

Scahill

(2009) Anxiety in children and adolescents with autism spectrum disorders. Clinical Psychology Review 29: 216–229. doi: 10.1016/j.cpr.2009.01.003.

76.

Williams White

Keonig

Scahill

(2007) Social skills development in children with autism spectrum disorders: A review of the intervention research. Journal of Autism and Developmental Disorders 37: 1858–1868. doi: 10.1007/s10803-006-0320-x.

77.

Wood

Ehrenreich-May

Allesandri

Fujii

Renno

Laugeson

Storch

E. A.

(2015) Cognitive behavioral therapy for early adolescents with autism spectrum disorders and clinical anxiety: A randomized, clinical trial. Behavior Therapy 46(1): 7–19. doi: 10.1016/j.beth.2014.01.002.

78.

Wood

Drahota

Sze

Har

Chiu

Langer

D. A.

(2009) Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized control trial. Journal of Child Psychology and Psychiatry 50(3): 224–234. doi: 10.1111/j.1469-7610.2008.01948.x.

79.

Yoo

Bahn

Cho

Kim

Min

et al. (2014) A randomized controlled trial of the Korean version of the PEERS® parent‐assisted social skills training program for teens with ASD. Autism Research 7: 145–161. doi: 10.1002/aur.1354.