The prevalence of autism spectrum disorders (ASD) continues to increase, and families and agencies face shortfalls in professionals to provide comprehensive services. The American Academy of Pediatrics adopted screening for ASD at 18- and 24-month well child visits. The American Academy of Child and Adolescent Psychiatry includes screening as a clinical standard for developmental and psychiatric evaluations of children.
Yet children who screen positive often face lengthy waits for comprehensive evaluations. School districts find similar challenges in securing evaluations for diagnosis and special education identification of school age children. Even when diagnosis is established, families likely encounter a shortage of treatment options.
Securing assessment and treatment is even more frustrating for adults with ASD, their families and medical and developmental disabilities agencies. The shortage extends across multiple disciplines but the dearth of psychologists is especially striking given the multiple roles our discipline can fulfill.
Psychologists as evaluators
Psychologists may function at the “front lines” screening children for risk of ASD. Those in primary health care settings may administer or review results of screening tools (typically parent or teacher rating scales). Schools may ask psychologists to determine whether a student has ASD. Some parents come to the psychologist with the results of an online questionnaire. The psychologist in clinical practice may use a screening instrument to create leverage for securing a more comprehensive evaluation. It must be emphasized that a screening tool identifies risk but is not sufficient for diagnosis or intervention planning.
The DSM-5 and ICD-10-CM do not require a comprehensive evaluation for diagnosing ASD, but while diagnosis based upon clinical judgment alone may suffice for eligibility to certain services, it provides little guidance regarding intervention. Multi-disciplinary comprehensive evaluations let the family and team clarify complex developmental profiles and identify strengths and challenges of the ASD individual.
Psychologists can enhance the process by:
- Administering and interpreting “gold standard” assessments of social communication and repetitive and restricted behaviors and interests (such as the ADOS-2 and the ADI-R).
- Collaborating with other professionals (the special educator, speech/language pathologist, occupational therapist and/or physical therapist) to identify the individual’s strengths and challenges.
- Assessing cognitive, social and adaptive functioning with evidence-based tools.
- Identifying emotional, behavioral, medical and other barriers to adaptive functioning and skill acquisition.
- Considering family, cultural and community strengths/stressors that affect functioning and treatment planning.
As professionals trained to integrate data from multiple sources, psychologists can ensure evaluation leads to a comprehensive view of the person and family in context of their community.
Psychologists in direct service
Direct treatment with individuals with ASD rarely fits the 90837 (individual psychotherapy) or 90847 (family therapy) procedure codes. Current literature identifies only a few psychotherapeutic methodologies than can be termed evidence-based, but there are multiple direct service roles for the psychologist.
One very efficient role is the psychologist-equivalent of the “family doctor” or “medical home.” Whether new to the world of ASD, facing a life transition for a son or daughter or struggling to determine a course of treatment, parents often express overwhelming confusion. Psychologists can help families perform parental and occupational roles while navigating the often byzantine systems of education, developmental services, insurance and the Internet. Psychologists may also serve as virtual case managers, facilitating communication among a seemingly endless cast of providers in an individual’s program.
Psychologists can also serve as a psychotherapists for individuals with ASD to develop more efficient cognitive and language skills. Cognitive behavior therapy (CBT) is an evidence-based intervention to teach self-management and daily living skills and reduce anxiety in children and adolescents with ASD. Family cognitive behavior therapy is particularly promising, as it increases the probability that the strategies will be generalized across environments. Adults with high-functioning autism (Asperger syndrome) report anecdotally that CBT strategies reduce anxiety and improve communication in social and work relationships. For children and adults who do not yet speak, developmental/relationship-based interventions may serve to teach and reinforce adaptive skills.
Behavioral assessment and interventions have the most robust research support. Every psychologist will be more effective if his/her toolbox includes thorough understanding of principles such as reinforcement, shaping and functional assessment of behavior. There is an urgent need for psychologists with specialized knowledge of applied behavioral analysis (ABA) methodologies for teaching specific academic, daily living, coping and vocational skills. Adults with ASD and emotional/behavioral challenges stand out as the most under-served group.
Virtually every individualized education program for students with ASD includes a social skills group. Yet many involve little more than eating lunch and playing a game with classmates. Even in a more structured group, students with ASD may acquire rote skills without understanding the “why” and “how” necessary for generalization to the real world. While the efficacy literature on social skills groups is less clear cut than for interventions such as CBT and ABA, the psychologist’s skill set for interpreting research findings increases the likelihood of identifying components essential for teaching social cognition and communication.
Perhaps the most under-recognized need is psychological treatment of parents and family members. Research likens the stressors of having a family member with ASD to having a family member with an acquired brain injury. Other research has identified physiological correlates of prolonged stress.
Well-meaning treatment teams can increase stress inadvertently through their recommendations: “Be consistent in responding to interfering behavior;” “Write in the home-school notebook every day;” “Make sure that she has her communication device in all environments;” “Fill out all of the forms necessary for developmental services, insurance and Social Security,” and “Don’t forget to take care of yourself!”
The impact on siblings is less understood, but there is likely less family time and energy for the typically developing brother or sister. Whether for parents or siblings, it is reasonable to suggest that therapy with a psychologist who understands ASD may be an essential tool for supporting and improving family functioning.
Aside from all the practical opportunities for working with individuals with ASD and their families, there is an enormous intangible benefit in sharing the life experiences of “folks on the spectrum” that can offer precious insights into the social and emotional world and remind us that there probably is no such thing as “neurotypical.”
References available from author
Teresa Bolick, Ph.D., is a New Hampshire psychologist and board certified behavior analyst with a special interest in autism spectrum disorders. She evaluates and treats children, adolescents and their families and consults to schools. She is a member of the New Hampshire Council on ASD. Her email is: firstname.lastname@example.org.