Employing evidence-based practices is integral to the mental health
counselor’s success in the managed care system that exists in the United States
today. This means that the counselor is responsible to remain cognizant of current
standards of therapeutic intervention strategies based on what has been proven
effective through rigorous empirical study. The managed care system values that
which is efficient and cost effective above all else, especially higher that which
is merely intuitively evident to a single individual. The high value placed on
empirically proven, yet succinct, treatment methods accounts for this relatively
recent development in the mental health services industry (Deegear & Lawson,
2003). Curkrowicz et al. (2005) suggests that there exists an ethical responsibility
on the part of the mental health counselor to focus their treatments around
Children with autism spectrum disorders (ASDs) suffer from a wide range of
deficits, the treatments of which vary to equally wide degrees. It is a daunting task
to effectively treat social and cognitive impairment while managing the debilitating
effects of lagging language development and repetitive behaviors that impede all
intervention strategies and it calls for a variety of skills. The effects of autism on the
family adds another level of treatment concerns to the counselor who must consider
the restrictive environmental forces that help stunt development as well as the
positive forces that may be utilized to promote skill development.
Challenges exist in identifying evidence-based practices. General ignorance
on the part of parents and counselors with regard to fundamental research
principles and the advanced knowledge needed to understand the finer flaws in
empirical research provides an opening for the dissemination of flawed data in
support of flawed treatment methods. For instance, many studies do not make an
effort at determining treatment integrity. Wheeler et al. (2006) found that only
11 out of 60 studies on behavioral treatment interventions for children with ASD
even assessed treatment integrity. This basic oversight on the part of researcher
to collect data on the level at which the independent variable is being properly
administered severely undercuts the results of these studies.
As practitioners of evidence-based practices, do we have the obligation to
advocate for our proven methods? And, as neutral empathic therapeutic forces,
do we have the right? Our profession is based on foundations laid by intrepid
individuals pursuing their vocations as philosophers, medical doctors, and
counselors; we may risk stunting such innovators by limiting treatment methods.
There is always room for research, but when the data point in one direction, yet
media debates and mass ignorance pull parents in another, are we obligated to
defend the truth or remain passive reflections of runaway nescience?
Autism spectrum disorders (ASD) compose a group of distinct pervasive
developmental disorders (PDD) classified under axis two of the current edition
of the Diagnostic and Statistical Manual of Mental Disorders. Children with ASD
exhibit; impaired social skills, including play and familial interaction; decreased
cognitive development, including communication skills; and repetitive behaviors
and interests, which can often be observed as simple repetitive motor activity such
as tapping, finger movement, rocking, or repetitious speech (Ruble et al., 2005;
Szatmari, 1999).ASD symptoms typically emerge in early childhood around the
age of two and, until recently, that age has marked the earliest opportunity for
professional screening and diagnoses (Layne, 2007).
Current prevalence rates for ASD range from 1 in 166 to 1 and 1,000,
although most cite the likely range as 1 in 500 to 1 in 1,000, ASD is more prevalent
among males than females by a ratio of 4 to 1 (Layne, 2007; Heidgerken et al., 2005;
Taylor, 2006). The incidence rate for ASD has been rising steadily over the past two
decades (due to increased diagnostic effectiveness, expanded range of diagnosis,
and actual rise in prevalence (Ruble et al., 2005; Heidgerken et al., 2005; Rutter,
2005; Layne, 2007). This rise in prevalence has significant implications for health
care service providers, educators, auxiliary service providers, and the systems these
professionals are a part of (Layne, 2005).
Although the precise causes of autism are not known, researchers
have identified many biological and environmental factors that contribute to its
development. It is unlikely that a single cause exists for the development of ASD as
even genetic research has moved to a multiple gene interaction theory, but the
commonalities shared among individuals with ASD will hopefully guide researchers
to a multidimensional understanding of the disorder and to more effective methods
for prevention, treatment, education, and a better quality of life for individuals with
ASD and their families. Put plainly, it’s complicated. As is true for most social
science inquiries, the debate over whether environmental or biological factors
contribute more to ASD persists, but because ASD is rooted in families and is really a
familial issue, the debate is especially heated. Although the overwhelming amount of
credible research suggests that roughly ninety percent of the projected contributors
to ASD are hereditary, some groups strongly believe that environmental
contributors such as early childhood inoculations play a causal role (Taylor, 2006;
O’Dell & Brownlow, 2005; Szatmari, 1999).
Perhaps the most well known misconception regarding ASD is the belief
of some that early childhood inoculations play a primary role in the etiology of
ASD. This belief has instigated a public debate, which has dominated the media’s
discussion of autism for years, and without any empirical evidence in support of the
In the late 1990’s, when ASD incidence began its current rise, attention
shifted to the combined measles, mumps, and rubella (MMR) vaccination that had
been administered since the 1980’s (O’dell & Brownlow, 2005). This shift was
partially due to wide-spread criticisms of giving 18-month-old children with various
chemical concoctions at once. The inoculation debate within the ASD community
began when Andrew Wakefield published a paper highlighting the correlation
between the typical age of children when they are inoculated and the average age at
which ASD was diagnosable at that time. In 1998, Wakefield published his paper in
The Lancet, a British publication and it immediately spurred the media into action.
The fact is that Wakefield’s study only reported that a small number of parents
indicated a correspondence between the two events, inoculation and symptom
expression. This finding held little empirical merit and even the United Kingdom’s
Chief Medical Officer described The Lancet’s material as poor science (Honda,
Shimizu, & Rutter, 2005; Taylor, 2006). Added to this inherent scientific weakness
is the fact that Andrew Wakefield accepted money from a personal injury lawyer
who files these terratogen-based lawsuits. If the answer to whether or not we
professionals should remain complicit in the spread of fraudulent practices by
highly educated charlatans is vague then I hope the answer to whether or not
researchers should accept bribes is still relatively clear.
Misconceptions like this can be profoundly harmful and can develop in the
most alarming ways. Taylor (2006) found that of 92 parents of children with ASD
who believed MMR played a causal role in their child’s developmental disability,
39% had expressed concerns about the child’s behavior previous to the vaccination,
yet only 1% remembered that occurring. How do these types of cognitive missteps
occur among so many and how great an impact do they have? It’s evident that the
misconceptions are spread through the media. A very clear example of how these
erroneous beliefs can be implanted into the minds of millions in a single instant is
that media-mogul Oprah Winfrey has dedicated entire shows to the MMR theory,
hosting figures like Jenny McCarthy who are staunch supporters of the inoculation
theory. Though I think the world of Ms. McCarthy for her ability to not only be a
great parent for her child with autism but to also work tirelessly as an activist, I
don’t get the impression that Research Methods was a prerequisite for Singled Out
and that she might do a lot of good by singling herself out of the discussion. The
need for reason is a powerful one, but when we are too hasty and fulfill that need
with junk information the effects can be devastating.
The United Kingdom, a country that had previously been nearly free of
measles and rubella, saw a marked increase in incidence following the intense
media coverage. The reduction of vaccination uptake was pronounce; it shifted
from 80% to around 30% between 1998 and 2005 and, in due course, 70 children
died from what have been preventable illnesses for decades (O’Dell & Brownlow,
2005; Taylor, 2006).
Pervasive misconceptions such as the one claiming a causal relationship
between the MMR vaccination and autism can incite huge media debates, topics for
afternoon talk shows, and political talking points, all of which are irrelevant to most
people. However, for individual families dealing with ASD they can be profoundly
important. Counselors dealing with families of children with ASD should be mindful
of these misconceptions and have the knowledge base to challenge them effectively;
it is key to incorporate learning into the counseling process and it is natural for
parents dealing with the stress of caring for a disabled child to put all of their energy
into finding reasons why. They are also often charged with maneuvering a complex
and often willfully obstructive system while struggling with the emotional impact
that autism has on their family life. Unfortunately, sometimes the reasons they
accept are far from the truth. In these cases it is difficult for some people to retract
all of the energy and commitment they put into their mistaken belief and they cling
even harder. Professionals experience the same effect, seeing beliefs and theories
as fact, but professionals have an ethical obligation to disregard those erroneous
beliefs and rely on empirical evidence and evidence-based practices, ensuring
the most reliable service to our clients. When working with individuals with ASD
amidst the widespread misconception that MMR vaccinations play a causal role in
the etiology of autism the question arises, is it a professional’s ethical obligation to
contest this misconception, or only to applaud each other at conferences and meekly
cower behind the power of proper investigation? I guess my perspective is clear.
The results of these investigations point away from MMR inoculations
and toward complex genetic and environmental forces interacting to cause this
developmental disorder. Twin studies have shown that the concordance rate of ASD
amongst monozygotic twins is around thirty-six percent and three percent among
dizygotic twins (Larsson et al., 2004). This relatively high level of concordance
among monozygotic twins points to a strong genetic component to the development
of ASD. Because the relationship is not perfect, however, other factors must be
involved. The search for these contributors has uncovered many risk factors that
are shared among individuals with ASD. For instance, prenatal exposure to rubella,
thalidomide, or alcohol has been shown to be associated with a higher risk for
ASD. Similarly, low birth weight and Apgar score have also been associated with
increased occurrence of ASD (Szatmari, 1999).
As mentioned above, many of the observable characteristics of autism
spectrum disorder relate primarily to social and cognitive disabilities, often
manifesting as impaired communication skills and interpersonal relationship
development. There are various theories as to why this occurs. For instance, some
believe that deficits exist in an individual with ASD’s ability to “read” other people’s
affect or underlying cognitions. Another theory focuses on the ability to share focus
between social demands and environmental stimuli, which is thought to be absent
in individuals with ASD (Gena, Couloura & Kymissis, 2005). Recent discoveries
in neuropsychology offer clues as to why these deficiencies exist and may offer
opportunities for more effective ASD diagnosis, treatment, and prevention.
Hughes (2007) reports findings that underconnectivity in and between key
regions of the brain is a consistent finding among individuals with ASD. The first
two years of life are key for the proper development of brain structures and is
when white-matter volume increases, synapses develop, and myelination occurs.
These processes connect brain regions and form the network that will allow for
speedy information processing and retention. In infants with ASD white matter
overgrowth is seen up to the age of two, but at that age growth stops abruptly and
degradation begins. The effects of this are seen throughout the brain, but the region
implicated the most in ASD is the corpus callosum and the thinning of that region is
associated with lower IQ and slower processing speed because the corpus callosum
is responsible for connecting brain regions and managing information sharing
Hughes (2007) describes connectivity within the frontal lobe and between
it and other brain regions as “…disorganized and inadequately selective… poorly
synchronized and weakly responsive” (pg.21). Limited frontal lobe activity affects
many cognitive and behavioral functions including language, impulse control, and
socialization. Research has found that the connecting fibers responsible for the
transfer of data between the frontal lobe and other brain regions are significantly
shorter in individuals with ASD than those with typical brain maturation.
Wang et al. (2006) studied the neural activity of autistic children during the
use of irony, a type of language that necessitates an understanding of the linguistic
mechanisms reflective of the speaker’s intent as well as the ability to process
complex contextual social cues. Children with autism were significantly less able to
identify irony and showed activation in areas not typically used for completion of
this type of task. This consistent finding of stray or atypical activation implicates the
disorganized connectivity referred to by Hughes in decreased linguistic and social-
It is important for professionals in the mental health services field not
to disregard nutrition and the possible effects of teratogens on their clients with
ASD, but placing the majority of their focus on these issues would be a mistake given
the lack of evidence supporting the MMR theory. This erroneous belief has spawned
intervention strategies such as chelation and gluten/casein free diets. Chelation is
the process by which “heavy metals” are cleansed from the body. This procedure
often involves orally administered medications and chemical showers that are
considered torturous by the children with ASD who are subjected to them. Also,
chelation can be extremely expensive and often incurs huge debt on to parents who
persist with the treatment at their alternative doctor’s behest. It is not unheard of
that parents will take out second mortgages on the off chance their child could be
cured. Committing to a gluten/casein free diet is also extremely expensive and
difficult to stick to in our world of processed, imported, and exported food. In their
review of the alternative medicine literature, Curtis & Patel (2008) relay many
instances of correlation data that point to higher levels of “heavy metals” and
exposure to other toxins in children with ASDs. However, few, if any, treatment
implications can be gleaned from these studies aside from the sage advice that
mothers shouldn’t treat their pregnant bodies so poorly and that parents should
have a base knowledge of nutrition for the benefit of their newborn.
Knowing what the empirical data points to as the likely genetic and
developmental underpinnings of autistic spectrum disorders begs the question,
what works? Which treatment method best addresses these varied and complex
skill deficits within the context of basic neurological impairment? Individuals
with an autism spectrum disorder require a wide variety of professional services
designed to help them overcome the many cognitive, behavioral, and emotional
delays that characterize the disorder. Many children with ASD receive funding for
services such as physical, occupational, behavioral, and speech therapy through
their local school districts as part of their individualized education plan (IEP). These
types of services are designed to increase the functional abilities of the children
through intensive specialized exercises that are often implemented in a one-on-
one or small group educational environment. Children with ASD suffer from an
array of disabilities. These delays can affect anything from their ability to walk to
their ability to control impulsive behavior. No two children are alike and, therefore,
individualized treatment from a team of specialized professionals is necessary to
address the breadth of issues affecting each individual. Improvements in social
functioning often have a positive impact on other areas of functioning and open up
new opportunities for education.
Applied behavior analysis is a treatment approach, not merely a method
used in education. ABA, in one form or another, can be implemented in hospitals,
can be used to eliminate negative behaviors such as self-injurious or aggressive
behavior and the rare eating disorder, pica. Conversely, ABA methods are used to
promote positive skills related to anything from academics and communication to
independent living (Hagopian & Boelter, 2005).
One form of ABA therapy that has seen a rise in use over the past few years is
video modeling. Video modeling incorporates the same methods used in typical “in-
vivo” modeling scenarios, but offers the consistency and efficiency of video, which
makes implementation easier and more cost effective. With video modeling the
goal is to promote generalizable social skill sets and not situation-specific learned
responses; video modeling is often used to teach appropriate affect responses. In-
vivo modeling (when a peer or therapist models desired behavior in person) has
shown to be effective, but specific to a given situation, which limits that efficacy
significantly. Video modeling has shown to offer that desired generalization and
to aid in the development of appropriate affect identification and response, which,
as mentioned above, is characteristically delayed in children with ASD (Gena et
al., 2005). Video modeling in counseling may resemble bibliotherapy, used when
treating typical adults or children.
Critics of applied behavior analysis cite the intense stress it can place on
an already strained family of children with ASD. To be effective, ABA needs to
be practiced for twenty to thirty hours a week and be used in the home, as well
as educational and clinical settings (Layne, 2007). This often places much of the
responsibility for therapy on parents, particularly mothers, who report higher levels
of strain, consistent with their participation in the ABA program. This criticism
is qualified, however, by the fact that mothers whose children participate in ABA,
but who are not responsible for as much of the therapeutic work themselves,
report less depressive symptoms than mothers of children not in ABA programs
(Schwichtenberg & Poehlmann, 2007). This provides further evidence for the utility
of applied behavior analysis and the possible need for more pervasive home-based
therapy in order to lessen familial strain and promote a better quality of life for both
the affected individual and their family.
Given what we know about autism spectrum disorders and the efficacy
of chelation versus ABA, do we have the ethical responsibility as advocates and
practitioners of evidence-based practices to actively educate parents, teachers, and
the public of the misleading claims made by the alternative medicine community?
Is it in the best interests of our clients to remain passive as they pursue such
costly and unproven paths of treatment? Do we, as practitioners, cow tow to the
emotionally overloaded decision making of often frightened and desperate parents
or remain steadfast advocates of our child clients and their family systems?
I firmly believe that we have that ethical responsibility and, larger still, the
duty to treat the parents of children with ASD in an effort to reduce stress, increase
confidence through competence, and improve their skills as parents of children
with disabilities. Parent studies have shown an increased risk for ASD among
children whose parents have a history of psychiatric disease, particularly those with
schizoid personality traits or affective disorders (Larsson et al., 2004). In a study
that controlled for the inherent stress of raising a handicapped child, Piven and
Palmer (1999) show that histories of families with multiple incidences of autism
reveal a significantly higher rate of axis one disorders, particularly major depressive
disorder and social phobia. Although both parental and prenatal influences
have correlational relationships with ASD incidence, research into the multiple
gene interaction theory may provide answers as to why some children are more
vulnerable than others to environmental stressors.
Parents of children with ASD may require an actively engaged
therapist to help them build the skill sets necessary to overcome the deficits
associated with their own disorders in order to make appropriate and well-
informed decisions for their children. From my experience working at the
Children’s Annex in Kingston, NY, which is a school for children with an ASD
diagnosis, I have come to appreciate that symptom expression is often a function of
family characteristics more than the child’s developmental deficit. ASD specialists
should start challenging parents by addressing just why they even consider these
unproven methods as viable options. This will, of course, incorporate a great deal of
empathic listening and a strong alliance. But specialists will need to be prepared
with knowledge and the ability to intervene on the level of the family system. This
is not a question of whether or not mental health counselors have the ethical
responsibility to, in effect, limit their treatment to evidence-based practices as
suggested by Curkrowicz et al. (2005). Rather, isn’t it so that counselors are
obligated to discount practices proven ineffective? As is true for all ethical
quandaries, the jury is out indefinitely and a continuing didactic discussion will
emerge, hopefully in support of an ever-improving string of therapeutic strategies
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