According to estimates from the Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring Network, approximately 1 in every 54 children are identified with autism spectrum disorder (ASD). As the number of diagnoses continues to increase, there will in turn be an increased need for services, including mental health services.
As a licensed associate professional counselor, AutPlay therapist and registered play therapist-in-training, I am familiar with the mental health needs presented in those with ASD. As a mother of two children with ASD, I also have a personal perspective that gives me an empathetic understanding of the autism world and the families of individuals with autism.
There is a famous saying in the autism community credited to professor and researcher Stephen Shore: “If you’ve met one person with autism, you’ve met one person with autism.”
But what does that mean, and how does it relate to the world of counseling?
ASD is a neurodevelopmental condition characterized by severe and pervasive impairments in communication and social interactions and repetitive and stereotyped patterns of behaviors. ASD is a spectrum disorder or heterogeneous and not linear, meaning that individuals are autistic in different ways. In other words, ASD symptoms fall on a continuum and present in various combinations, with some individuals showing mild symptoms in an area and others showing more severe symptoms. This is important for counselors to consider because every single person with ASD can present with their own complex and unique symptomatology. It is also meaningful to note that ASD is a lifelong diagnosis and affects the entire family.
In plain language, individuals with ASD can be described as literal, direct, honest, persistent and loyal. Additional reported characteristics include the individual being uncomfortable with direct eye contact and preferring specific textures of food and clothing. Typical behaviors include stimming, which can consist of rocking, flapping of the hands, pacing or verbal repetition. Unexpected events or changes in routine can cause distress in individuals with ASD, and their social/emotional skills are behind, exaggerated or even nonexistent. That being said, it is important to remember the heterogeneous nature of ASD; not all of the characteristics will be present in every individual with ASD.
The autism community
Interestingly, a substantial amount of dissension exists in the autism community as a whole. As the mother of two children with ASD who are very different yet similar, I have many parental opinions. My children, who are actually autistic, have their own views on autism. Furthermore, the medical community has opinions on autism, and then those individuals who are autistic have their opinions. So, who is right? How do we tell the difference, and what is our role as counselors?
It is critical to consider all evidence-based research practices and the opinions of stakeholders (i.e., medical professionals, parents, and individuals with ASD). However, it is important to know how we, as counselors specifically, can help and what role we can play to assist the ASD population.
Within the autism community, there are individuals with ASD who dislike applied behavior analysis (ABA) therapy; they want the word disorder to be changed and have very insightful opinions. In addition, there must be a standard in identifying autism in the medical community. Some commonality through the newest definition in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders is the best attempt to have a standard definition for ASD for all stakeholders. Finally, parents of children with ASD, like myself, have a variety of opinions. As a parent, I want to hear the voices of those who are actually autistic, but I also know that certain therapies did work and helped my children achieve as much as they have so far in life.
As counselors, it is essential to think of our helping role and how we might have a positive impact on the mental health of individuals with ASD.
ASD and mental health
So, what mental health needs do individuals with ASD really have, and are those not just symptoms of the ASD diagnosis? Although that is an intriguing suggestion, it is just that — a suggestion. The research on ASD and mental health reveals that psychiatric comorbidity for children with ASD is as high as 70%-75%. The most common areas of comorbidity are anxiety disorders, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder (OCD), depression and eating disorders. Overall emotional regulation can be internalized (anxiety, depression or OCD) or externalized (tantrums, crying and acting out).
Anxiety and depression in ASD are common, and clinical studies have found that clinically significant anxiety symptoms are associated with increased irritability, sleep disturbance, disruptive behaviors, inattentiveness and health problems. Anxiety in ASD can exacerbate typical ASD symptoms such as social impairment, negatively affect daily living skills and adversely influence relationships with teachers, peers and family. Failure to recognize or treat anxiety associated with ASD leads to unhelpful management of symptoms, whereas treatment can improve independent function.
Depression is four times more likely to occur in individuals with ASD than in their neurotypical peers. Typically, depression occurs more in the teen or adolescent years and carries into adulthood. Studies on depression and ASD have found that depression increases with age due to social and communication deficits combined with perseverative behaviors.
Emotional regulation is another core area of concern. Emotional regulation is the concept of controlling the intensity of one’s emotions, at either a conscious or unconscious level, before or after a triggering event. In describing emotional regulation as it applies to ASD, Rebecca Shaffer and colleagues, writing in the Journal of Autism and Developmental Disorders (2019), concluded that emotional regulation can be adaptive or maladaptive. Adaptive regulation implements effective coping strategies, whereas maladaptive regulation is associated with behavioral challenges. Overall, children and adolescents with ASD struggle with emotional regulation, thus reducing their ability to cope with current and future stressors.
Individuals with ASD have difficulty with social and emotional understanding related to adopting the perspective of others or perspective-taking. Some research on individuals with ASD who have demonstrated higher levels of adaptive emotional regulation has also shown greater prosocial behaviors and increased social development.
ABA is considered the “gold standard” in the treatment of children with ASD. ABA is an empirically evaluated treatment that effectively reduces inappropriate behaviors and increases learning, communication and appropriate behaviors. The professionals who have the education and training to utilize ABA in practice are called board certified behavior analysts (BCBAs) and registered behavior therapists (RBTs). These professionals are trained in how and when to use specific approaches, with the BCBA establishing the plan and the RBT executing the plan. If the behaviors of an individual are deemed maladaptive or socially unacceptable, they can be altered or changed by applying ABA principles.
Although ABA is considered the gold standard, there are some limitations to ABA, such as defining socially acceptable behavior, which depends on the culture. Additional limitations can include waitlists to access ABA services, the time commitment for services (many BCBAs will recommend a minimum of 10-20 hours of ABA per week for individuals), and financial considerations, because these services are not consistently covered by all insurance plans. Within the field of ABA, researchers such as Justin B. Leaf and colleagues, writing in Behavior Analysis in Practice in 2017, have expressed concern that the training and assessment content is not extensive enough or consistent with current research for appropriate training in the overall implementation of behavior therapy.
Finally, it should be noted that ABA is a behavioral approach and does not address the mental health needs of children or adolescents with ASD.
What about CBT?
If I received a nickel for every time that cognitive behavior therapy (CBT) was suggested for my children with ASD, I would be a very, very rich mom. As a counselor, I understand the robust research basis of CBT, and I even use it in practice. So, why would I have any thoughts other than, “Yes, use CBT”?
In the world of ASD, children who understand their diagnosis even a tiny bit are told that they think differently, that their brain works differently. With CBT, we would suddenly be telling them that their thoughts are irrational. The mom in me is like, “Great, my children are going to need therapy on top of their therapy.”
In my practice, I have heard from many other ASD families and caregivers who have also been told to try CBT. They question whether their child possesses the mental understanding to comprehend CBT techniques. CBT is talk therapy. In addition, there is the question of whether CBT is developmentally appropriate. CBT requires more complex, symbolic, abstract, metacognitive, consequential and hypothetical thinking, consistent with the greater cognitive sophistication of adults, not that of children or adolescents with ASD.
There is limited research on counselors working with the ASD population and, again, ABA is typically the first treatment modality suggested. However, ABA is a behavioral treatment and not appropriate for social-emotional and overall mental health needs.
So, why are counselors hesitant? One of the first concerns is that individuals with ASD do not respond the same way to treatment interventions as neurotypical children do. That means that services are unprepared to adapt, support and treat this population. Some counselors mention a lack of training. Most counselors feel comfortable treating anxiety and depression, but the lack of training and understanding of individuals with ASD prevents some counselors from engaging in therapy with this population. Another concern counselors may have about working with the ASD population is that the therapy process can be challenging due to a lack of clear treatment goals, complex presentation, considerable time spent on care coordination and a slow rate of progress.
The good news? Despite these challenges, many counselors have reported a willingness to serve the ASD population, especially when provided with better training and interventions.
Therapeutic alliance and ASD
The counselor’s magic wand! The therapeutic alliance is a known contributor to treatment outcomes in counseling. The therapeutic relationship between child and counselor strongly influences the productiveness and progression in the child’s journey to personal growth and self-healing.
For children with ASD, the therapeutic alliance is thought to account for a significant portion of therapeutic outcomes. Overall, the therapeutic alliance encourages clients’ compliance with treatment and motivates them to engage in optimal emotional processing. Finally, the therapeutic alliance is essential with children with ASD because it:
- Serves as a model for relationships with others
- Provides them an environment in which to learn and practice social skills and receive feedback
- Helps them improve their overall functioning by providing them with a better understanding of themselves and others
A therapeutic working relationship is best established with a child through play, and building this relationship is an essential element of any therapeutic process.
Play is an instinctive way of expression and exploration for children. Play acts as a medium of expressing a child’s inner world and needs and allows the child to alter reality and make it more manageable. Play is critical because it provides a platform for the child to express symbolically what they are unable to put into words.
As defined by the Association for Play Therapy, play therapy is the “systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development.”
Play therapy has been shown to be effective in addressing a wide range of children’s presenting problems, including emotional and behavioral issues. In play therapy, children use toys, art supplies and sensory media (e.g., clay, play dough, sand) to communicate through action rather than through words, thoughts, feelings and experiences. Play therapy can be directive (structured/focused) or nondirective (humanistic) in nature.
Play therapy has been established as a developmentally appropriate intervention for children and adolescents, in contrast to the traditional counseling approach of talk therapy. Play therapy is appropriate for children because of their limited ability to think abstractly. Play is considered the natural form of expression for children, allowing them to work through issues that are appropriate to their developmental level. Play is naturally reinforcing, making it an easy way to engage children in working on their difficulties.
Counselors use skills in play therapy such as tracking to follow along with play and stating aloud what the child is doing in order to show attending. Play therapists restate things said in play, help summarize and organize what is happening in the play and reflect back feelings when expressed by the child.
Play therapy and ASD
Given the heterogeneous nature of an ASD diagnosis, a diverse intervention may be the best option to treat the variabilities. With a child with ASD, there is a need for therapeutic flexibility, which calls for a therapist possibly changing their style of work, expanding their theoretical orientation and actively seeking approaches that can best address a particular child’s needs and concerns. Play therapy is appropriate for children with ASD because it provides opportunities to engage in play activities, improving empathy through the development of social, language and cognitive skills and overall relationships.
Another challenge with children with ASD is communication. Through play therapy, toys become the child’s primary means of expression, giving them the ability to project their feelings on ambiguous stimuli. When play occurs in a safe, caring and culturally sensitive environment, children can freely express themselves. This expression allows them to work on self-esteem and social anxieties without fear of breaking the rules. With play as a therapeutic technique, children have the opportunity to learn about their world through inquiry and exploration.
There are various theoretical underpinnings for play therapy, including psychoanalytic and Jungian play therapy, child-centered play therapy, cognitive-behavioral play therapy, filial play therapy, Theraplay and AutPlay therapy. This is not a comprehensive list of all the play therapy modalities. Counselors can easily find a natural theoretical connection with play therapy.
Play therapy certification is a post-licensure credential and includes the following credentials: registered play therapist, registered play therapist supervisor and school-based registered play therapist. Play therapists undergo extensive training, supervision and education in play therapy to earn these credentials. The Association for Play Therapy (a4pt.org) is the national professional society that governs the play therapy credentials. It also provides many resources for professionals, including extensive research, training and education.
Jennifer Jenkins is a doctoral candidate in the counselor education and supervision program at Capella University. She is a licensed associate professional counselor and former school counselor. She works in a private practice in Warner Robins, Georgia, where she specializes in helping clients and families with developmental disabilities. Contact her at firstname.lastname@example.org.
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