Content uploaded by د.عبدالاله السليس
Author content
All content in this area was uploaded by د.عبدالاله السليس on Mar 23, 2021
Content may be subject to copyright.
N U S A N TA R A BI O S C I EN C E
ISSN: 2087-3948
Vol. 13, No. 1, pp. 41-46 E-ISSN: 2087-3956
May 2021 DOI: 10.13057/nusbiosci/n130106
Impact of cognitive-behavioral therapy on daily living skills of high
functioning autistic children with anxiety disorders
ATALLAH KHALAF ALENEZI1,♥, KHADIGA ABD-ELGIED GOMEA HASSAN1,2,
TAHANY EL-SAYED EL-SAYED AMR1,3, ABDULELLAH ALSOLAIS4
1College of Applied Medical Sciences at Shaqra, Shaqra University. Shaqra, Saudi Arabia. Tel./fax. +966-55-5182868, email: atta@su.edu.sa
2Department of Pediatric Nursing, Faculty of Nursing, Port Said University, Port Said, Egypt
3Department of Maternal and Newborn Health Nursing, Faculty of Nursing, Menoufia University, Egypt
4College of Applied Medical Sciences at Dawadmi, Shaqra University. Shaqra, Saudi Arabia
Manuscript received: 5 August 2020. Revision accepted: 17 January 2021.
Abstract. Alenezi AK, Hassan KAG, Amr TEE, Alsolais A. 2021. Impact of cognitive-behavioral therapy on daily living skills of high
functioning autistic children with anxiety disorders. Nusantara Bioscience 13: 41-46. Cognitively Behavioral Therapy (CBT) is a
psychotherapeutic intervention that is used to improve mental health. It is known to have positive effect on the daily living skills of
autistic children with anxiety disorders. The aim of the current study was to evaluate the effect of cognitive-behavioral therapy on daily
living skills of high functioning autistic children with anxiety disorders. A Quasi-experimental research design was adopted in this
research. A purposive sample of 100 autistic children (50 in intervention group and 50 in control group) aged between 7-8 years were
included in this study. Three main tools were used: Vineland Adaptive Behavior Scale used to measure the everyday living skills of
children, Parent-Child Interaction Questionnaire (PACHIQ), and Diagnostic and Statistical Manual of Mental Disorders (DSM-V) for
assessing anxiety disorder in children and adolescents 6-18 years. The results showed an improvement in children’s daily life skills and
slight reductions in caregiver’s participation in the daily life skills of children. There was a significant difference between intervention
group and control groups (p < 0.001). The current results exhibit that CBT may help in increasing autistic children's independence
towards daily living skills.
Keywords: Anxiety disorders, autistic disorders, cognitive behavioral therapy, daily living skills
INTRODUCTION
Autism Disorders (AD) is a persistent deficit social
conversation, and social interaction as manifested by lack
of mutual conversation and emotional reciprocity, lack of
non verbal communication, and lack of developing,
sustaining, and emphatic relationship (DSM-5 2013). The
cause of autism is unknown. However, a lot of
predisposing agents, ecological and biological factors and
physical defects, have been associated with autism.
About eighty percent of children with autism have
anxiety disorders (Duvekot et al. 2017). Some researchers
reported that anxiety disorders interfere with daily living
practice; so autistic children are more liable to have poorly
developed on daily self-care which makes them more
needed for suitable intervention (Bishop et al. 2013). A
recent study suggested that children who are fully
dependent on their parents in basic daily self-care are at
high risk to remain anxious during their childhood life
(Huffman et al. 2011). Many strategies have been used to
improve clinical features of autism such as promoting
socialization and communication with others. Till now,
there is no effective intervention for improving basic daily
life activity for a child with high function autism, who has
seventy or more degrees of an intelligence quotient (Gillis
et al. 2016). Basic daily life activities are essential tasks
for human survival, which cover daily care, composed of
individual skills, all activities in house or school and
community (Huffman et al. 2011). In usual autistic
children do not carry out daily self-activity even if they are
able to do it.
Most mothers mention several difficulties in training
daily life activities for their children suffering from autism
(Gillis et al. 2016; Lord et al. 2005). Family-based
cognitive-behavioral therapy is an effective intervention
for managing anxiety disturbances in well-child and child
with autism (Scherer and Dawson 2011). CBT is an
intervention model in which new skills are established by
enhancing the child and his family through logic and
convincing manner and Socratic questioning (Stone et al.
2010). Hence, the current study examines the impact of the
primary parent-based CBT intervention on parental
perceptions of daily life skills of the child with autism and
synchronous anxiety disturbances.
MATERIALS AND METHODS
Study design
A non-randomized Quasi-experimental pretest-posttest
design was used in this study. The impact of primary
parent-based CBT on parental perceptions of daily life
skills of the child with autism and synchronous anxiety
disturbances was determined.
ALENEZI et al. – Cognitive therapy in autistic children
43
Setting and sample
This study was carried out in Al Amal Complex for
Mental Health in Dammam City, Saudi Arabia. The
intervention took place between 20 October 2018 to 16
April 2019. A sample of 100 children, aged between 7 to
13 years were included in this study.
Ethical consideration
A written informed consent was obtained from manager
of the facility and parents of children (mostly their
mothers), who was primarily accountable for supervision of
the children's everyday skills and were willing to
participate in this study. Before conducting the study,
confidentiality and anonymity of the children were assured
during collection of the data. Parents of children were
assured that the data will not be reused in another research
without their consent. The aim of this study was explained
to members of the facility, who were directly associated
with children.
Subjects and selection method
The sample used in this study were children suffering
from autism, who were visiting for follow-up at Al Amal
Complex for Mental Health in Dammam city, Saudi
Arabia.
Inclusion criteria
Autistic children, Asperger disorders or Pervasive
Developmental Disorder - Not Otherwise Specified.
Autistic children suffering from separation anxiety or
social phobia, or obsessive-compulsive disorder.
Exclusion criteria
Autistic children their verbal Intelligence Quotient less
than 70. Autistic children who participated in other
behavioral therapy. Autistic children who received
psychiatric drugs or changed dosage during the study.
Autistic children or parents disable to share in the current
study
Research hypothesis
Children with autism acquire an improvement in basic
daily life skills and reductions of parent's participation in
daily life skills after CBT intervention.
Method
Ethical approval was obtained from College of Applied
Medical Science at Shaqra and official permission for
conducting the study was secured at Al Amal Complex for
Mental Health in Dammam city, Saudi Arabia. Upon
approval, the daily living skills of children were measured
using the Vineland Adaptive Behavior Scale, and the
relationship of the child and parent was evaluated with the
use of the Parent-Child Interaction Questionnaire
(PACHIQ). The researchers developed a suitable
intervention program from literature for children with
autism and their parents to improved their basic daily skills.
This basic daily life skills program was developed to
promote child's skills independently (cognition
reorganization) that included a) Focusing on child's
establishing trust and self-fulfillment (b) Focusing on
social customs that enable the child to act alone. c) Giving
rewards with each attempt even if the child do simple steps.
A hierarchy plan for developing child’s daily life skills
(gradation of contact) was used. Families were instructed to
assist and encourage any attempts from their children
towards independence and give their feedback about this
new strategy. A pilot study was carried out on 5 children
with autism to examine validity of the questionnaires and
to test research feasibility, clarity, and objectivity of the
tools. The sample included in the pilot study was excluded
from the study sample, and necessary modifications were
done accordingly.
The sample of 100 autistic children was divided equally
into two main groups; intervention and control of 50
children each. The autistic children in the intervention
group were divided into five subgroups, with 10 children
for each practitioner. There were no dropouts in the study.
These practitioners were in the clinically psychiatric
training area at College of Applied Medical Science at
Shaqra University and they had experience of dealing with
autistic children. Practitioners attended 10 hours of primary
activity of the intervention, studied management guide,
watched videos of CBT, performed management with pilot
study children, and attended 10 workshops with clinical
researchers who established the program. Practitioners
implemented 8 sessions in 8 weeks, session per week for
each subgroup in the study group. Each session continued
70 minutes (about 25 minutes with the children and 45
minutes with the mothers /parents) and the treatment
fidelity was assessed by researchers.
Instruments
The study instruments had three tools. The first tool
was a structured questionnaire sheet. It included items
related to socio-demographic characteristics of children and
their families, such as age, child order, occupation, and
level of education of their parents. The second tool is The
Vineland Adaptive Behaviour Scales, (Vineland-2)
(Community-University Partnership for the Study of
Children, Youth, and Families 2012) that measures the
personality and social skills of individuals from birth
through adulthood. Because adaptive behavior refers to an
individual's typical performance of daily tasks essential for
personality and social adequacy, this scale assesses what
the individuals indeed do, not what they are capable to do.
The Vineland-2 assesses adaptive behavior in 4 areas:
Communication, Daily life Skills, Socialite, and Motor
Skills. Additionally, it provides an accumulation mark that
epitomizes the person's achievement over 4 areas of
investigation (Community-University Partnership for the
Study of Children, Youth, and Families 2012).
The third tool is the Parent-Child Interaction
Questionnaire (PACHIQ). It assesses how fathers and
mothers see the relation with their children (PACHIQ-
Parents form), and how the child assesses his/her relation
with his/her mother/father (PACHIQ-Children form). It
contains 21 elements in the parents form and 25 elements
in the children form, about communications strategies and
emotional effects (Lange et al., 2002). The researcher
N U SA N T AR A B IO SC I E N C E
13 (1): 41-46, May 2021
44
evaluated children with autism for anxiety disturbance and
daily life activities before and immediately after the
intervention and at the end of three months from
intervention. Diagnostic and Statistical Manual mental
disorders (DSM-V) was used to assess anxiety disorder in
children and adolescents 6-18 years. This scale composed
of 38 sections contains panic somatic, separation anxiety,
general anxiety, social phobia, and school phobia
(Community-University Partnership for the Study of
Children, Youth, and Families 2012). The data was
analyzed using Chi2 test using GraphPad Instat software.
RESULT AND DISCUSSION
Table 1 shows that most (95%) of the autistic children
were between 7 and 13 years of age. The mean age was 7.1
± 1.316 days. As regards to educational level, most of them
(59%) were at the primary phase. All the autistic children
(100%) had siblings and 3 % of them had affected siblings
with autism. Table 2 shows that majority (97%) of fathers
of autistic children had secondary education and majority
of them were employed. In addition, most (90%) of
mothers of autistic children had a high level of education
and 7% of them were house-makers. About 86% of
families were in the middle level of income.
Table 2 shows that majority of families of autistic
children faced behavioral, emotional, and physical
problems. Also, most (93%) of them had financial
problems. The behavioral and emotional problems were
expected. However, such high percentage of physical
problems (98%) seemed to be high. Saudi Arabia is one the
richest countries in the world due to natural resources and
many of the Saudis live a comfortable life. Surprisingly,
about 93% of the respondents told they have financial
issues.
Table 3 shows that there was a statistically significant
difference between intervention and control group at pre-
intervention, post-intervention, and at the end of three
months from intervention. The intervention produced a
significant improvement in daily life activities and this was
increased further in the 3-months follow-up (P<0.001).
Table 4 shows that there was a statistically significant
difference between intervention and control group
immediately and at the end of three months from
intervention (P<0.001).
Table 1 showed that most (95%) of the autistic children
were between 7 and 13 years of age. The mean age was 7.1
± 1.316 days. As regards to educational level, most of them
(59%) were at primary phase. All autistic children (100%)
had siblings and 3 % of them had affected siblings with
autism. Majority (97%) of fathers of autistic children had
secondary education and the majority of them worked. In
addition, most (90%) of mothers of autistic children had
high level of education and 7% of them were housewives.
Also, the comments (86%) of families were in the middle
level of income. There was no significant difference in the
socio-demographic characters between intervention and
control group.
Table 1. Socio-demographic characteristics of autistic children and parents
Items
Intervention group (n=50)
Control group (n=50)
Total (n=100)
No
%
No
%
No
%
Age
7- less than 13 years
2
4
3
6
5
5
13-18 years
Mean +/- SD = 7.1 ± 1.316
Family members
3-5 members
47
94
49
98
96
96
More than 5
3
6
1
2
4
4
Mean +/- SD = 3.94 +/- 0.848
Sex
Boy
34
68
35
70
69
69
Girl
16
32
15
30
13
13
Educational level
Primary
31
62
28
56
59
59
Preparatory
19
38
22
44
41
41
Having sibling
Yes
50
100
50
100
50
100
No
0
0
0
0
0
0
Child order
1st - 3rd
25
50
43
86
68
68
4th -9th
25
50
7
14
32
32
Affected sibling
Yes
1
2
2
4
3
3
No
49
98
48
96
97
97
Father education
Secondary
49
98
48
96
97
97
High
1
2
2
4
3
3
Father occupation
Do not work
2
10
0
100
98
98
Work
48
90
50
2
1
1
Mother education
Illiterate
0
0
1
2
1
1
Primary
3
15
0
0
3
3
Secondary
5
25
1
2
6
6
High
42
60
48
96
90
90
Mother occupation
Housewife
3
15
4
20
7
7
Work
47
85
46
80
93
93
Family income
Low
4
20
3
15
7
7
Middle
42
60
44
70
86
86
High
4
20
3
15
7
7
ALENEZI et al. – Cognitive therapy in autistic children
45
Table 2. Shows that the majority of families of autistic children
faced behavioral, emotional and physical problems. Also, most (
93%) of them had financial problems
Items
Intervention
group (n=50)
Control
group (n=50)
Total
(n=100)
No
%
No
%
No
%
Behavioral
problem
Yes
49
98
48
96
47
97
No
1
2
2
4
3
3
Emotional
problem
Yes
49
98
49
96
48
98
No
1
2
1
4
2
2
Physical
problems
Yes
49
49
49
98
48
98
No
1
1
1
2
2
2
Financial
Problems
Yes
46
46
47
85
93
93
No
4
4
3
15
7
7
Discussion
This study found that CBT produced improvements in
daily living skills of autistic children skills that received
cognitive therapy and completed three months program.
The CBT performances provide adaptation skills to autistic
study group children and reassure the primary parent for
helping their children to be more independent. However, it
should be noted that factors such as incorrect reports from
primary parents may influence the authenticity of the
results.
Table 3. Impact of CBT on basic daily life activities of autistic children (Intervention and control groups)
3months follow up ( n=99)
IIb ( n-100)
PIa ( n-100)
Basic activities of daily living
CG
N=49(%)
IG
N=50(%)
CG
N=50(%)
IG
N=50(%)
CGd
N=50(%)
IG
N=50(%)
Bathing and showering:
Need no support
Slight support
Complete support
0
0
0
0
0
0
4(8.2)
38(76)
5(10)
42(84)
5(10)
8(16)
45(91.8)
12(24)
45(90)
8(16)
45(90)
42(84)
(7.451)* P<0.001
(6.568)* P<0.001
(0.467) P>0.001
Dressing:
0
0
0
0
0
0
Need no support
Slight support
Complete support
33(67.3)
40(80)
35(70)
45(90)
35(70)
38(76)
16 (32.7)
10(20)
15(30)
5(10)
15(30)
12(24)
(7.695)* P<0.001
(3.851)* P<0.001
(0.346) P>0.001
Self- feeding:
0
0
0
0
0
0
Need no support
Slight support
Complete support
10(20.4)
30(60)
10(20)
42(84)
10(20)
15(30)
39(79.6)
20(40)
40(80)
8(16)
40(80)
35(70)
(6.603)* P<0.001
(5.724)* P<0.001
(0.717) P>0.001
Toilet hygiene:
0
0
0
0
0
0
Need no support
Slight support
Complete support
35(71.4)
40(80)
35(70)
43(86)
35 (70)
40(80)
14(28.6)
10(20)
15(30)
7(14)
15(30)
10(20)
(6.474)* P<0.001
(5.480)* P<0.001
(0.717) P>0.001
Oral care:
0
0
0
0
0
0
Need no support
Slight support
Complete support
36(73.5)
30(60)
37(74)
40(80)
37(74)
38(76)
13(26.5)
20(40)
13(26)
10(20)
13(26)
12(24)
(5.173)* P<0.001
(4.873)* P<0.001
(1.050) P>0.001
Total daily living skills
0
0
0
0
0
0
Need no support
Slight support
Complete support
37(75.5)
40(80)
37(74)
45(90)
37(74)
35 (70)
12(24.5)
10(20)
13(26)
5(10)
13(26)
15(30)
(9.846)* P<0.001
(5.853)* P<0.001
(0.406) P>0.001
Note: aPI: Before Intervention, bII: Post-intervention. cIG: Intervention Group, dCG: Control Group, *Statistically Significant Difference
Table 4. Relation between daily living skills and anxiety disorders among autistic children. (Intervention and control groups)
BIa ( n-100)
IIb ( n-100)
At the end of 3months ( n=99)
CGc
n=50(%)
IGd
n=50(%)
CG
n=50(%)
IG
n=50(%)
CG
n=49(%)
IG
n=50(%)
Total daily living skills
(0.41) P>0.001
(5.86)* P<0.001
(9.85)* P<0.001
Parent–Child Interaction
(5.601)* P<0.001
(3.449)* P<0.001
(0.406) P>0.001
Anxiety Disorders
(5.457)* P<0.001
(8.177)* P<0.001
(0.677) P>0.001
Note: aPI: Before Intervention, bII: Post-intervention. cSG: Intervention Group, dCG: Control Group, *Statistically Significant Difference
N U SA N T AR A B IO SC I E N C E
13 (1): 41-46, May 2021
46
The primary parents of children in the study group
recognized an increase in basic daily living skills that are
applied on a regular basis by children, such as oral care,
toilet hygiene, dressing, self-feeding, and easy health care,
compared with autistic children in control group. Earlier
reports suggest that without general external support and
guidance, autistic children and their primary parents may
find obstacles in developing daily living skills that match
children’s chronological age (Drahota et al. 2010; Duvekot
et al. 2017; Estes et al. 2015).
Additionally, primary parent encouragements, beliefs
about intervention and expectations, and intervention
obedience can play an important role in the modification of
basic daily living skills marks at post-test. CBT needs
primary parents to perform a dynamic role in implementing
the program. Primary parents should perform correct,
regular intervention in self-sufficiently, manner. Reportss
of parental belief suggests that managing reliability is
significantly accompanied with parent motivation to
practice intervention procedures, and parent expectancy of
intervention results anticipate parental intervention
adherences (Estes et al. 2015; Oswald et al. 2016; National
Autistic Society, 2016).
As a final point, primary parents of autistic children in
the study group stated that their participation in their
child’s basic daily self-care skills significantly reduced in
comparison with primary parents of autistic children in the
control group. A moderate influence was established in pre-
test and post-test scores related to the participation of
primary parents of autistic children in the study group,
whereas an insignificant influence was found for primary
parents of children in the control group. These are
significant outcomes to the CBT Program because primary
parent conducts, such as participation in their children’s
basic daily living skills, have been concerned as an element
in the preservation of anxiety and lessened daily living
skills (Lord et al. 2005; Drahota et al. 2010). Relating to
Wood’s model of parental invasiveness, if care-providers
take over tasks that children could be accomplished
independently, they limit children’s mastery and aid
dependence and sustained anxiety. Otherwise, children with
daily living skill insufficiencies may grow anxious due to
their extreme dependence on care-provider. Consequently,
reductions in parent invasiveness in their children’s basic
living skills develop independence and may help in skill
achievement and mastery, as well as possibly lowering
anxiety level (Duvekot et al. 2017; Estes et al. 2015). In the
circumstance, there is a relationship between modifications
in anxiety level and daily living changes score,
representing various relationships between these concepts.
So, elevating daily living skills may be associated with
falling in anxiety levels. Fascinatingly, when testing the
power of the correlation, correlation is not strong in the
study group as opposed to the control group, which would
be predictable in a right intervention association. It is
evident that primary parental perception of study outcomes
of CBT program was seen throughout the study period.
Finally, the study has slight limitations; parent’s
observations were used to judge the activities of their
children as well as their personal participation in the
children's self-care skills. As the parents are responsible for
the intervention program of CBT, parents' reports might
have been subjective by their wishes to achieve the aims of
this study. Future studies such as a randomized controlled
trial are recommended to support our results.
Parents' CBT program provides statistical and clinically
significant in basic daily life activities between autistic
children. Parents observed that their autistic children who
included in the program were capable to carry out basic
daily life activities alone when the program finishes.
Parents who included in the program stated that they
decreased their participation in their children’s personal
care, which may provide them with extra time for doing
other tasks.
ACKNOWLEDGEMENTS
The authors are thankful to the staff of Al Amal
Complex (Dammam) and staff of College of Applied
Medical Sciences for their help.
REFERENCES
Begeer S, Mandell D, Wijnker-Holmes B, Venderbosch S, Rem D,
Stekelenburg F, Koot HM. 2013. Sex differences in the timing of
identification among children and adults with autism spectrum
disorders. J Autism Dev Disord 43 (5): 1151‐1156. DOI:
10.1007/s10803-012-1656-z.
Bishop SL, Hus V, Duncan A, Huerta M, Gotham K, Pickles A, Kreiger
A, Buja A, Lund S, Lord C. 2013. Subcategories of restricted and
repetitive behaviors in children with autism spectrum disorders. J
Autism Dev Disord 43 (6): 1287‐1297. DOI: 10.1007/s10803-012-
1671-0.
Community-University Partnership for the Study of Children, Youth, and
Families. 2012 Review of the Vineland Adaptive Behavior Scales-
Second Edition (Vineland-II). Edmonton, Alberta, Canada.
Diagnostic and statistical manual of mental disorders: DSM-5. 2013.
American Psychiatric Publishing, Washington (D.C.).
Drahota A, Wood JJ, Hwang WC, Langley A, Piacentini JC. 2010.
Adaptive functioning in school-aged children: Linkages
with trait anxiety and anxiety disorders. J Autism Dev Discord 41 (3):
257-265.
Duvekot J, Hoopen LW, Slappendel G, van der Ende J, Verhulst FC, van
der Sijde A, Greaves-Lord K. 2017. Design and cohort characteristics
of the social spectrum study: A multicenter study of the autism
spectrum among clinically referred children. J Autism Dev Disord 47
(1): 33‐48. DOI: 10.1007/s10803-016-2919-x
Estes A, Zwaigenbaum L, Gu H, St John T, Paterson S, Elison JT, Hazlett
H, Botteron K, Dager SR, Schultz RT, Kostopoulos P, Evans A,
Dawson G, Eliason J, Alvarez S, Piven J, IBIS network. 2015.
Behavioral, cognitive, and adaptive development in infants with
autism spectrum disorder in the first 2 years of life. J Neurodev
Disord 7 (1): 24. DOI: 10.1186/s11689-015-9117-6.
Gillis JM, Roth ME, Sevlever M. 2016. Personal Hygiene. In J. K. Luiselli
(Ed.), Behavioral Health Promotion and Intervention for People with
Intellectual and Developmental Disabilities. Springer, Switzerland.
Huffman LC, Sutcliffe TL, Tanner IS, Feldman HM. 2011. Management
of symptoms in children with autism spectrum disorders: A
comprehensive review of pharmacologic and complementary-
alternative medicine treatments. J Dev Behav Pediatr 32 (1): 56‐68.
DOI: 10.1097/DBP.0b013e3182040acf.
Lange A, Evers A, Jansen H, Dolan C. 2002. PACHIQ-R: The parent-
child interaction questionnaire--revised. fam process. 41 (4): 709‐722.
DOI: 10.1111/j.1545-5300.2002.00709.x.
ALENEZI et al. – Cognitive therapy in autistic children
47
Lord C, Wagner A, Rogers S, Szatmari P, Aman M, Charman T, Dawson
G, Durand VM, Grossman L, Guthrie D, Harris S, Kasari C, Marcus
L, Murphy S, Odom S, Pickles A, Scahill L, Shaw E, Siegel B,
Sigman M, Stone W, Smith T, Yoder P. 2005. Challenges in
evaluating psychosocial interventions for autistic spectrum
disorders. J Autism Dev Disord 35 (6): 695‐711. DOI:
10.1007/s10803-005-0017-6
Maughan AL, Weiss JA. 2017. Parental outcomes following participation
in cognitive behavior therapy for children with autism spectrum
disorder. J Autism Dev Disord 47 (10): 3166‐3179. DOI:
10.1007/s10803-017-3224-z
National Autistic Society. 2016. https://www.autism.org.uk/about/what-
is/asd.aspx. 2016
Oswald TM, Winter-Messiers MA, Gibson B, Schmidt AM, Herr CM,
Solomon M. Sex Differences in internalizing problems during
adolescence in autism spectrum disorder. J Autism Dev Disord 46 (2):
624‐636. DOI: 10.1007/s10803-015-2608-1
Scherer SW, Dawson G. 2011. Risk factors for autism: translating
genomic discoveries into diagnostics. Hum Genet 130 (1): 123‐148.
DOI: 10.1007/s00439-011-1037-2
Stone W, Ruble L, Coonrod E, Hepburn S, Pennington M, Burnette C,
Bainbridge NB. 2010. Treatment and Research Institute for Autism
Spectrum Disorders 2nd ed. Vanderbilt Kennedy Center, Nashville,
TS.
