By the time children with autism spectrum disorder (ASD) are approaching elementary school age, they are already exhibiting symptoms that typically lead to lifelong social difficulties. Among these symptoms: impaired communication and interaction, an inability to self-regulate and modulate emotions, very narrow and specific interests, and sensory processing difficulties that make it difficult for them to connect with the world at large.
Many counselor practitioners may question whether they are even qualified to work with clients who have ASD. According to the individuals interviewed for this article, however, professional counselors possess a range of skills that can be particularly helpful to this client population.
Stephanie Smigiel, a licensed professional counselor (LPC) who does mobile counseling with ASD clients in the Pittsburgh area as part of the state of Pennsylvania’s behavioral health services, says clients with autism aren’t that different from other populations with which counselors work. She acknowledges that these clients often require a little extra accommodation and counselor ingenuity, but this call to be creative is one of the reasons that she particularly enjoys working with the population.
It is essential, however, that counselors understand clients with ASD and their needs, cautions Smigiel, a member of the American Counseling Association. “Ask yourself, ‘Do I have a bias? Is this a population I can see myself working with?” She notes that people with ASD can have problems controlling their aggression and says it is not uncommon for these clients, sometimes including adults, to pull her hair or scratch her arms.
Neurology tells us that the brains of those with ASD work differently. Those on the spectrum are often labeled as atypical (as opposed to neurotypical). However, those with ASD and many of the people who work with them have begun advocating for a different view: neurodiversity — or the idea that there is no single, correct neurology.
“The neurodiversity movement in the field seeks to apply a culturally competent view of people diagnosed with ASD or other neurological or neurodevelopmental diagnoses,” explains Ali Cunningham, a licensed mental health counselor (LMHC) who specializes in ASD. “As with most cultural groups who are trying to acculturate to the majority group, it is about achieving a balance of honoring individuality and uniqueness while striving to be successful in the majority.”
Cunningham says that many clients with autism struggle with wanting to maintain what makes them unique while still being able to connect with others and navigate the worlds of friendship, romance and work. Culturally sensitive treatment of clients with ASD involves helping them identify how their individuality or uniqueness is a resource while also exploring what new skills or techniques they are willing to integrate into their lives to strike that balance, she says.
“I always try to communicate the message that treatment is not intended to change who you are,” Cunningham says. “Treatment can help highlight the strengths you already have and add to them with skills or techniques that will enhance how you navigate the world and help you meet your goals.”
Boy (and girl) meets world
Because ASD presents early in life, experts in the field emphasize the importance of early intervention. One of the primary ways that professional counselors can help clients with ASD manage the challenges that come with the disorder is by targeting and teaching social skills.
Tami Sullivan, an LMHC and registered play therapist, maintains a private practice in Brockport, New York, that includes ASD as one of its specialties. She uses play therapy to connect with child clients who have autism.
“Children often make sense of their world and the people in it through play,” says Sullivan, a member of ACA. “Play can be used as an intervention [because] it is the native language of childhood. Counselors can understand children, the child’s world and his or her perspectives in the context of play therapy.”
Sullivan notes that children with autism play differently than do their peers without autism. “Children with autism have a low level of engagement in play. Their play is more concrete, private, ritualized … and restrictive,” she says.
She explains that young children with ASD possess limited imaginary or “pretend” play skills. Their tendency to engage exclusively in solo play and difficulty participating in imaginary worlds isolates these children and often precludes them from developing meaningful relationships or friendships with other children.
Sullivan uses a nondirective play therapy approach to engage children who have ASD. This means that rather than using a prescribed set of games or toys, she lets the child take the lead, exploring at his or her own pace.
“In this nondirective approach, the relationship is the key therapeutic medium [that] communicates acceptance of the child,” says Sullivan, an assistant professor in the Counseling and Psychological Services Department at the State University of New York at Oswego. “I aim to make the critical emotional connections that support a reciprocal relationship between us. I … encourage [the child’s] initiative and play with the goal of deepening engagement, lengthening mutual attention and regulating emotion and behavior.”
Once these children feel fully accepted, they begin to communicate and engage in reciprocal social interactions, Sullivan says.
When Sullivan wants to target a specific therapeutic goal, she uses more directive play, choosing activities that help build particular strengths in children with autism. For example, by creating something with the child, Sullivan strengthens the child’s ability to take turns, joint attention (the ability to focus on more than one thing at a time) and social perspective.
Sensory exploration can further increase the connection between Sullivan and the child. Many children with ASD use sensory toys to self-regulate, so in addition to baskets of sensory toys, Sullivan has sand trays, big bean bags and pillows, donut balls, a tunnel and a small ball pit in her office. “I am often invited by them to join in as they self-regulate,” Sullivan says. “This can be a time to connect deeper with the child and build our relationship.”
Sullivan collaborates with her clients’ parents or caregivers using two therapeutic approaches: skills-based/solution-focused therapy and filial therapy.
The first approach involves identifying goals and solutions for the child’s behavior and challenges that are causing stress on the family system. Sullivan then works with the parents to identify ways in which they can support and encourage the child as he or she develops new skills and abilities.
For example, children with autism often express anxiety through their behavior. Sullivan teaches parents how to identify this and how to help children recognize what they are feeling. The parents can then prompt their children to use coping skills they have learned with Sullivan, such as relaxing their bodies, distracting themselves or trying to change the way they feel about a situation.
With filial therapy, Sullivan says the work centers around strengthening the parent-child relationship in the counseling process. This is done in part by teaching parents play therapy relationship-building techniques such as reflecting the child’s feelings, empathic listening, imaginary play skills and limit setting.
During the elementary, middle school and high school years, social skills become even more critical, Sullivan says, particularly as they relate to the making and keeping of friends. “These children [her clients with ASD] desperately want to have friends, but they don’t know how,” she says.
Sullivan uses group therapy to help children with autism cultivate stronger social and relationship skills. She holds one group for children of elementary school age and another for clients of middle and young high school age.
When designing the groups, Sullivan decided the training for the elementary school-age children would be more effective if it featured an element of play. She chose to incorporate Lego-based therapy, a method pioneered by neuropsychologist Daniel LeGoff after he noticed that when children with ASD worked together to build things, they were more naturally inclined to socialize with each other. Sullivan pairs the Lego therapy with a structured lesson. She says the underlying play therapy lessens the children’s anxiety about the group while the building exercises aid in teaching social and friendship skills.
The group meets for 90 minutes once a week for 10 weeks. It is run by a professional counselor (either Sullivan or her colleague) and a relational coach who demonstrates social skills by engaging in role-play with the counselor.
Each session starts with a sensory warmup in which group members can play with sensory toys. After the warmup, the leaders and participants decide, as a group, what kind of Lego structure they want to build that day. The building process is collaborative and uses defined roles such as builder, supplier and engineer. From session to session, the children take turns playing each role. Once roles are assigned, the group must work together to decide how to go about building the structure.
As the group is building, the leaders introduce that session’s topic, such as learning how to have a conversation. The counselor talks about what the skill involves — in this case, trading information — and demonstrates it through role-play with the relational coach. This often consists of “good” role-play and “bad” role-play. For example, you don’t start a conversation by going up and introducing yourself, but you do hang back and wait until a topic comes up that interests you and then join the conversation.
Sessions end in free play, during which the children, over time, begin to interact with each other on their own, Sullivan says. The children’s parents or other family members receive a sheet after each session that outlines the skills the group worked on that week. As homework, parents are encouraged to help their children practice the skills they learned in group.
If possible, Sullivan also provides packets for the children’s teachers. She says that in some cases, teachers call her to collaborate, whereas in others, the parents work with the teachers. Many of the children in Sullivan’s groups are in mainstream classrooms. So, she recommends that their teachers identify peers to serve as social mentors and then provide time for the students with ASD to practice their skills at school.
The group also explores appropriate humor, a topic for which bad role-play is particularly suited, Sullivan says. The relational coach will display inappropriate humor — for instance, using potty language or imitating one kid making fun of another kid — and the counselor will react. Afterward, the coach and counselor ask the group members what they saw: “Did you notice that Tami didn’t laugh and that she actually looked kind of sad?” Then the coach demonstrates appropriate humor by telling a joke, and in response, Sullivan or her colleague will laugh. Sullivan also gives the children (and their parents) a list of appropriate topics to joke about and recommends joke books.
The group also discusses how to be a good sport. “We talk about a lot of things that you don’t do when you want to play a game with someone,” Sullivan says. For instance, “You don’t want to be a policeman or a referee — you don’t want to remind everyone what the rules are all the time.” The lesson teaches children to focus on what their role is in the game and how to participate in a sharing way. The topic also offers an excellent opportunity to talk with group members about additional skills such as dealing with frustration by walking away, taking a break or engaging in deep breathing, she says.
In later weeks, the group experience involves more discussion, such as talking about how to choose an appropriate friend. The children compile lists of qualities that are appealing to them in a friend and what makes a person a bad friend, Sullivan says. She also works with parents to help them brainstorm places, such as school clubs, where children can make positive connections.
Sullivan says the group leaders routinely look for opportunities to point out when children are demonstrating some of the skills they have learned in the group. Recently, during freestyle play, one boy, inspired by the monster structures they had been building, talked about wanting to have a Halloween party. His fellow group members then asked one another about their Halloween costumes and activities.
Sullivan’s group for clients of middle school and younger high school age runs for 14 weeks. It also focuses on conversational skills but covers additional topics such as how to handle rejection, how to handle rumors and gossip and how to be a good host. This group doesn’t incorporate Lego therapy. Instead of starting sessions with sensory play like the younger group, participants in the older group talk about their experiences trying to implement the skills they are learning. They also receive more homework to reinforce those skills.
Sullivan says the group spends a significant amount of time talking about bullying, rumors and gossip. “We teach a lot about how to reinvent yourself,” she says.
For instance, the group leaders emphasize that it is counterproductive to handle rumors or gossip by addressing them directly or denying them because those actions merely create more rumors and gossip, Sullivan says. Instead, they teach participants to redirect by using a sense of humor, walk away if someone is getting in their face and establish support figures in school and at home. They also talk about what to do about a damaged reputation, how to not take rumors and gossip personally, how to find other groups to hang out with and how to identify and connect with supporters within the school.
Sullivan says participants practice skills together during the group sessions, but group leaders also encourage them to set up short get-togethers with friends outside of group. In doing so, the leaders emphasize the need for the group members to practice sharing and exchanging ideas with others during these get-togethers. What group leaders don’t want is for group participants simply to get together for parallel play, such as two people playing video games separately, side by side, Sullivan says.
Group leaders review the process of getting together in great depth, even covering actions as simple as answering the door. “You don’t just open it,” Sullivan tells group members. “Invite the friend in and ask what they want to do.”
Next, the host should present the friend with two possible activities to choose from and let the friend decide which sounds more fun. Once they complete that activity, the host should talk with the friend about what else they could do, Sullivan coaches.
The sessions for Sullivan’s group incorporate ideas from the Program for the Education and Enrichment of Relational Skills (PEERS) for Adolescents model, an evidence-based social skills intervention developed by UCLA’s Semel Institute for Neuroscience and Human Behavior. PEERS focuses on the following topics:
- How to use appropriate conversational skills
- How to choose appropriate friends
- How to appropriately use electronic forms of communication
- How to appropriately use humor and assess humor feedback
- How to start, enter and exit conversations between peers
- How to organize successful get-togethers with friends
- How to be a good sport when playing games or sports with friends
- How to handle arguments and disagreements with friends and in relationships
- How to handle rejection, teasing, bullying, rumors/gossip and cyberbullying
- How to change a bad reputation
Cunningham, who practices at the Children’s Center for Psychiatry, Psychology and Related Services in Delray Beach, Florida, also uses the PEERS for Adolescents program with middle school- and high school-age youth. The groups last 16 weeks, and participants must be accompanied by a parent or someone else who functions as a social coach, she says. The “coach” requirement is in place so that the youth will have support not only for practicing their skills but also for finding opportunities for social engagement, Cunningham says. The clients with ASD meet in one group, while the parents/social coaches meet in a separate group to learn about the skills the youth are acquiring.
Cunningham, an assistant professor of counseling at Lynn University in Boca Raton, says that sessions start with role-play. Facilitators model some common errors related to that week’s skill lessons so that group members can learn what not to do. The facilitators then use role-play to demonstrate scenarios for using the skills effectively. The group participants then rehearse the skills and are given homework requiring them to go out and practice their skills in the outside world.
The group spends a substantial amount of time on conversational skills, beginning with how to start one, Cunningham says. Most people might say that the way to start a conversation is by introducing yourself, but few people actually do that, she notes, because it makes it seem like you’re selling something. Instead, group members learn how to find something that they have in common with the person and then make a comment or ask a question to continue the conversation, she explains.
People with ASD often have very particular, idiosyncratic interests, Cunningham says, so group participants learn about things that most people like to talk about, such as books, TV shows, movies, music or video games. She also tries to help clients understand steps they can take to expand their own interests or to make connections between their interests and the interests of others. For example, one of Cunningham’s clients with autism listens to a niche kind of electronic music. She has explained to him that he might not be able to find other people who listen to that exact music, but he can seek out people who like music that is similar.
After learning to start a conversation, the group moves on to how to maintain one, focusing on elements such as listening and having an equal exchange of information rather than doing all the talking or asking question after question. Participants also learn how to use humor in a conversation, how to pay attention to feedback and how to join a group conversation, Cunningham says.
Bullying is another important topic, but the focus isn’t so much on how to cope with it as how to prevent it from happening in the future, Cunningham says. One thing that group members learn is how to distinguish between actual bullying and straightforward feedback that they may get from someone who is annoyed by their behavior.
Cunningham also runs a PEERS group for adults with autism that includes four weeks focused on dating. (Cunningham doesn’t include the topic of dating in her younger groups but not because she thinks participants aren’t interested. Rather, it’s because parents of children with ASD often aren’t comfortable with their kids exploring romantic relationships, particularly when they still aren’t savvy about friendships.) The dating portion of the program focuses on topics such as appropriate ways to engage in flirting and assessing whether another person is interested.
It isn’t uncommon for men with ASD to be perceived as creepy, Cunningham notes, because they don’t typically understand how to read other people’s cues and might continue pursuing someone who is not interested in them romantically. Meanwhile, there are others with ASD who, despite their desire for a romantic relationship, won’t engage with anyone because they can’t tell if the other person is interested, she says.
Other topics the group discusses include how to handle peer pressure and sexual pressure.
Many people with ASD have trouble finding and keeping a job due to several factors, including a lack of social skills, difficulty understanding workplace culture and sensory difficulties that can cause them to become overwhelmed more easily. However, Smigiel believes that the most significant factor keeping those with ASD from career success is a lack of support.
In essence, Smigiel says, career counseling for those with ASD is similar in spirit to providing career counseling to any other client — it is a matter of finding out the client’s strengths and weaknesses. Smigiel did her internship at a vocational services agency that provided job counseling for those with ASD and intellectual disabilities. The agency helped clients practice their interviewing skills and assigned them a job coach who would try to connect them with positions that matched their skill levels.
Smigiel has worked with people on the high end of the autism spectrum who have found their niche in computer work, but at the vocational agency, they tried to match all clients, including those on the lower end of the autism spectrum, with jobs. “I’m a firm believer that anyone can have meaningful activity,” she says.
The key is to play on the focused nature of those with ASD. “What are they obsessed with?” Smigiel asks. “What can I do with that?”
For instance, Smigiel says the agency had many clients with ASD who loved to clean, so the vocational center helped them set up a car detailing program. The clients’ attention to detail produced “the cleanest cars you ever saw,” Smigiel says.
Counselors working with people with ASD have to think creatively and find that person’s niche, says Smigiel, who believes that everyone on the spectrum possesses strengths. For instance, some clients might be obsessed with organizing, which might make them a good fit for working in a clothing store and keeping all the displays in order.
Clients with ASD also often need help retaining their jobs because they don’t necessarily understand the social skills involved in working with others. As a result, they might ask too many questions, not understand what is and isn’t appropriate to say to a boss or have trouble interacting with co-workers, Smigiel says. In more severe cases, people with ASD might have poor personal hygiene, neglecting to brush their teeth or take a shower either because they don’t see it as a need or because it creates a disturbing sensory sensation for them.
At the vocational center, staff members would provide lessons on the importance of brushing teeth and taking showers, Smigiel says. When teaching these kinds of lessons, counselors should be aware that people with ASD are forthright and won’t want to do something “just because,” Smigiel says. Instead, the staff would say, “You need to take a shower because, otherwise, you’ll smell,” and, “You need to brush your teeth because, otherwise, you’ll get cavities.”
Clients with ASD also need help acquiring the self-regulation skills to cope with stress and frustration on the job, says Jamie Kulzer. An LPC in the Pittsburgh area, Kulzer helps clients with ASD and other cognitive disabilities as part of a multiweek vocational training program that teaches cognitive, self-management and vocational skills. The program includes internships with local businesses.
“We have found that emotional regulation is really important because if you’re escalated, [you] can’t access the other resources that you have to deal with problems.”
The program has participants envision an emotional thermometer, with green representing a calm, rational state and red representing a state of extreme sadness, anger or excitement. When individuals are in the red, they are unable to make good decisions, so Kulzer teaches clients to monitor their thoughts and behaviors and to be vigilant to when they are in the “yellow.” She also teaches clients to practice techniques such as deep breathing, visualization or standing up and stretching to help themselves avoid going from yellow to red.
Once clients have returned to a green state, they can approach a problem by asking for help or by using a divide-and-conquer strategy that breaks problems down into smaller, more manageable pieces. They can also express their problem by using “I” statements, such as “I need” or “I don’t understand,” explains Kulzer, an ACA member and assistant professor in the clinical rehabilitation and mental health counseling program at the University of Pittsburgh.
Program participants also learn about the physical and emotional gas tank, which is a measure of mental and emotional fatigue, Kulzer says. A full tank enables the client to be fully alert, present and ready to take in new information. An empty tank makes the client susceptible to aimless daydreaming, flooding emotions, racing thoughts and frustration.
Clients are taught that they can help keep their gas tanks full through self-care measures such as healthy eating, drinking water regularly and getting enough sleep. Kulzer also teaches program participants to approach their work or other projects by breaking them down and doing the easiest parts first and making sure to take frequent breaks.
It is critical for clients with ASD to monitor their physical and emotional gas tanks and to take action when they feel themselves getting to half full, Kulzer says. This means stopping and asking themselves, what’s draining the tank? For one person, it might be staying up too late to play video games, which requires better self-management. For another, it might be the result of being in an overly stimulating environment and needing to take a break by briefly leaving the area, Kulzer says.
In anticipation of the second half of the program, participants work on their vocational skills, which includes an emphasis on general communication. For instance, clients are taught to use “I” statements to talk about their feelings and encouraged to repeat back any request made to them to ensure that they are hearing it correctly and are aware of the nonverbal messages they are sending, Kulzer says.
People with ASD often have difficulty looking others in the eye, which can mistakenly give others the impression of disinterest. Kulzer’s program teaches these clients to say things like, “Eye contact is difficult for me, but I am listening.” Clients are also encouraged to indicate their attention and willingness to work by sitting up straight and taking out their earphones, Kulzer says.
The group also talks about social interaction. Subjects include what is appropriate to discuss in the office and how office friendships can have pros and cons. For instance, although it may be great to have someone you like and get along with, if you favor that person and don’t treat everyone equally while working, it can result in hurt feelings and misunderstandings.
Kulzer also talks with group members about issues such as scheduling and making decisions independently without telling a supervisor. She uses the example of someone with ASD who takes a bus that gets them to work 15 minutes early and then assumes this means that they can also leave 15 minutes early. Kulzer explains to group members that they can’t change their schedules (or make other similar decisions) without first discussing possible options with their boss.
The group participants receive feedback from Kulzer and other instructors as they work in their internships. Together, they tackle problems that come up in the workplace and implement suggestions for improvement. Kulzer says that many of the group’s members go on to pursue associate degrees or certificates in their internship field.
To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:
Counseling Today (ct.counseling.org)
- “Achieving a better understanding of adult autism” by Kenneth J. Smith
- “Processing the ‘whole’ with clients on the autism spectrum” by Chris Abildgaard
- “Addressing challenging behaviors for individuals with autism spectrum disorders” by Chris Mann Sullivan
Practice briefs (counseling.org/knowledge-center/practice-briefs)
- “Autism Spectrum Disorder” by Carl J. Sheperis, Darrel Mohr and Rachael Ammons
Laurie Meyers is the senior writer for Counseling Today. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.org
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.