Considerations for ASD Specific Treatment Modifications: Suggestions for ASD Specific TF-CBT adaptations. Systematic empirical evaluation of these proposed adaptations is needed to assess efficacy.
Communication Strategies
●	Provide clear, simple instructions: Use fewer words. Provide longer wait time processing time during communication. “First, then…” instructions (e.g., “First we finish this worksheet, then you can play with the iPad”) may be a helpful communication structure.
●	Utilize caregivers and other providers (e.g., speech language therapist, behavioral analyst) to acquire information regarding the most effective communication strategies for a specific client.
●	Utilize augmentative and alternative communication methods (e.g., picture-exchange systems, speech-generating devices, sign language), as needed.
●	Combine methods of presenting information (i.e., oral, visual) whenever possible.
●	Use visual schedules to help the client orient to what you will be doing in session and what to expect.
●	Social stories and picture schedules may also be helpful when teaching a new skill.
●	Break lessons down into smaller steps and scaffold the client’s skill-building (e.g.,“show, tell, do”).
●	Increased repetition and practice may allow for better generalization of learned information and skills.
●	Include opportunities for increased use of information and skill practice across contexts (e.g., school, home, community).
●	Due to variable language and attention capabilities, clients may benefit from the use of technology (e.g., iPads, computers) in both therapy lessons and practice.
●	If client is struggling to stay on topic or is talking for long periods of time about a restricted interest: Provide clear redirection to the topic you are working on and set limits around discussion of restricted interests. (e.g., “I can tell you really love Minecraft. We’re not going to talk about Minecraft right now because we have some work to do. When we have a break in 10 minutes, we can talk about Minecraft some more.”).
Social Strategies
●	It may take more time to build rapport. Learn the client’s individual communication and interactions styles. Capitalize on special interests. Spend time engaging in a preferred activity to put client at ease (e.g., draw picture, listen to favorite music, build Legos).
●	Social skills, particularly regarding appropriate and inappropriate social behaviors, may need to be explicitly taught in session.
●	Well-established social skill group curriculum materials and lessons may be helpful resources for therapists in teaching these skills.
●	To help generalize social skills, clients may benefit from opportunities to practice skills in multiple contexts with help from caregivers, peers, and providers.
●	Clients may struggle with social boundaries and may engage in socially disinhibited behavior or topics of conversation. Set clear expectations around physical contact or appropriate topics (e.g., requesting high fives instead of hugs, redirecting if the client asks too personal a question).
●	Help to elucidate “hidden” rules of social interaction and everyday activities (e.g., when someone comes to the door, say, “Hello”) or new therapeutic skills (e.g., when I feel sad, I will use this coping skill).
RRB Strategies
●	Consider the client’s unique presentation of restricted and repetitive behaviors during therapeutic planning and how these symptoms may change or interact with presenting concern (e.g., traumatic stress symptoms, anxiety). Exacerbation of RRBs may occur in response to emotional distress, resulting in treatment targets focused on reduction of severity and frequency to baseline levels.
Restricted Interests and Repetitive Behaviors
●	Given the pervasive nature of restricted interests, clients may refer to their own experiences, including events perceived as traumatic, within the context of their restricted interests.
●	Circumscribed interests can be a source of motivation and a key anchor or framework for communication throughout treatment. Utilize the client’s restricted interests while teaching new skills (e.g., create instructional materials with theme of preferred interest) and provide tangible reinforcements (e.g., access to preferred interest with completion of task demand).
●	Avoid punishment of repetitive behaviors (e.g., repetitive hand mannerisms, use of objects), which may be associated with anxiety or distress. Instead, teach replacement behaviors such as adaptive coping strategies.
Routine, Rigidity, and Rules
●	When a client has strong preferences for routine, organization and consistency of agendas during treatment may improve compliance and alleviate anxiety.
●	Rigidity and tendency towards rule-based thinking can be capitalized on in treatment to teach new skills.
●	Develop clear rules about what should be done and when that are structured and easy for a client to follow. It can be helpful to present rules visually or to develop tangible materials such as ‘rule books’ using pictures and words.
●	Positively phrased rules (e.g., “When this happens, do this…”) are generally more helpful than negatively phrased rules (e.g., “Don’t do this…).
Sensory Sensitivities
●	Individuals with ASD may seek out certain sensory sensations (e.g., seeking external pressure, smells, tastes, touch), while others may have aversions to different sensory experiences (e.g., sensitive to noises, smells, textures). Sometimes an individual can present with both.
●	It is important to find out about a client’s preferences in order to better understand his her behaviors, as well as to provide potential strategies for calming a client.
●	It may take some trial and error to find sensory activities that are calming. For example, play-doh may be a highly preferred sensory activity for one client, but it may be aversive to another. Asking caregivers and teachers what works at home and at school is a good place to start.
●	Introduce relaxation activities that are mindful of a client’s sensory sensitivities or needs (e.g., listening to calming music, dimming the lights, providing a weighted blanket or vest).
●	Sensory-seeking tendencies may make clients vulnerable to risky or unsafe situations. For example, an individual’s desire to touch other people’s hair or ears for the sensory input may cause them to approach strangers inappropriately, thus potentially putting them in a vulnerable situation or putting them at risk of being misunderstood.
Additional Behavioral Strategies
●	In general, evidenced-based behavioral strategies for addressing non-compliance and disruptive behaviors in neurotypical populations (e.g., clear instructions expectations, praising desired behaviors, planned ignoring, structure routine, and rewards) are likely to be helpful for individuals with ASD.
●	Continually evaluate the appropriateness of task demands during treatment.
●	If the client becomes dysregulated during session, it is important to consider whether they “cannot” or “will not“ participate. If the demand is incongruent with the individual’s skills, the structure of sessions and the clinician’s expectations may need to be adjusted.
●	Individuals with ASD often need additional time to transition from one activity to another, especially from preferred to less preferred activities.
●	Give advanced warning before a transition (e.g., “In 2 minutes, iPad time will be over and it will be time to work.”) Be accurate and follow through on time limits. Visual timers can be used to delineate time spent working vs. playing.
●	Build in frequent breaks during sessions, as clients may have more trouble sustaining attention and motivation compared to typically developing peers.
●	Provide praise for positive desired behaviors.
●	Tangible incentives or time engaging in preferred activities may help increase participation and compliance.
Safety Strategies
●	If a client begins exhibiting aggressive or self-injurious behaviors, pay attention to ways to make the environment safe for your client and those around them (e.g., removing dangerous objects, creating space between you and the client).
●	Use concrete, firm language depending on the client’s developmental level (e.g., “no hitting,” “keep your body safe,” “I don’t feel safe”).
●	If a client becomes dysregulated, reduce task demands and decrease the amount of sensory input in the room (e.g., quiet the room, dim bright lights).
●	It may take more time for an individual with ASD to return to baseline Allow space, and look for the first appropriate behavior you can praise after a client has calmed.
●	As mentioned previously, individuals with ASD may struggle with understanding and respecting social boundaries, both physically and in conversation. Set clear and concrete expectations about appropriate topics or gestures of affection, as needed.