Inclusion Criteria

Structural Family Therapy and Autism Spectrum Disorder: Bridging the Disciplinary Divide

M. L. Parkera and John Moltenib

aMarriage and Family Therapy Program, University of Saint Joseph, West Hartford, Connecticut, USA; bInstitute for Autism and Behavioral Studies, University of Saint Joseph, West Hartford, Connecticut, USA

ABSTRACT Applied Behavior Analysis (ABA) is an evidence-based practice approach for the treatment of individuals with autism. The systemic effects of autism suggest that family therapy would considerably enhance the treatment of individuals with autism. Marriage and family therapy (MFT) training does not routinely include exposure to autism beyond the associated diagnostic criteria. Structural Family Therapy (SFT) is a systemic model that is familiar to those trained in family therapy and appropriate for the needs of families affected by autism. Therefore, the authors have used SFT as a foundation for supervising MFT trainees working in an autism treatment setting.

The growing prevalence of Autism Spectrum Disorder (ASD) in the general popu- lation is resulting in a wealth of multi-disciplinary research to gain further insight into this trend (Blumberg, Bramlett, Kogan et al., 2013). Board Certified Behavior Analysts (BCBAs) are increasingly being called upon to provide Applied Behavior Analysis (ABA)-informed approaches that are strongly supported as evidence- based practice for individuals diagnosed with autism (National Professional Devel- opment Center for Autism Spectrum Disorders, 2014; National Autism Center, 2009). Although there is considerable empirical support for behavior analysis as a treatment for autism, interventions are primarily focused on the individual. How- ever, a comprehensive perspective of autism reveals the diagnosis to be a “complex, multi-systemic, environmentally affected condition” (Solomon & Chung, 2012, p. 253). Systemic effects of autism are outside the scope of training for behavior ana- lysts, as caregivers are included in treatment exclusively to develop appropriate parenting skills such as instruction, modeling, practice, and feedback to decrease the motivation for the undesired behavior (Shayne & Miltenberger, 2013).

An integrated treatment approach using ABA and systemically informed family therapy could enhance the types of analysis that behavior analysts undertake to

CONTACT M. L. Parker [email protected] Marriage and Family Therapy Program, University of Saint Joseph, West Hartford, CT 06117. © 2017 Taylor & Francis

THE AMERICAN JOURNAL OF FAMILY THERAPY 2017, VOL. 45, NO. 3, 135–148 https://doi.org/10.1080/01926187.2017.1303653

identify the contingencies of reinforcement that support ongoing, often maladap- tive, interactions within the system. Marriage and family therapists (MFTs) are particularly suited to provide systemically informed treatment for the effects of autism in the family. Yet developmental disabilities such as ASD are not routinely included in master’s level MFT curricula. As a result, many MFTs may believe that ASD is outside of their expertise or they are not qualified to work with such fami- lies (Solomon & Chung, 2012). Structural Family Therapy (SFT) is a traditional, systemic therapy approach that is familiar to practicing family therapists and addresses the needs of families with autism such as caregiver stress (Hall & Graff, 2011; Phelps, McCammon, Wuensch, & Golden, 2009; Trute, 2003), marital and sibling relationships (Orsmond & Seltzer, 2009; Ramisch, 2012; Seltzer, Orsmond, & Esbensen, 2009), and developmental influences on an ASD diagnosis (Moseley, Tonge, Brereton, & Einfeld, 2011; Smith, Seltzer, Tager-Flushberg, Greenberg, & Carter, 2008). We focus specifically on the executive subsystem that includes care- givers of the child with autism (Minuchin, 1974). However, SFT may also be implemented to address the concerns in parent-sibling and marital relationships of autistic families, addressing an important gap noted in the existing literature (Falk, Norris, & Quinn, 2014).

Our overall goal of this paper is to bridge the divide between the tenets of family systems theory and ABA principles by integrating some of the overlapping theoreti- cal concepts between these seemingly disparate perspectives. SFT is an ideal approach that is both familiar to practicing MFTs and applicable to many of the sys- temic effects associated with an autism diagnosis. We discuss specific adaptations of the approach that incorporate the existing literature on ASD. The article includes a case example from a structural therapy session that we have found beneficial in our efforts toward cross-disciplinary exposure to ABA and MFT students in our respec- tive programs. Consistent with traditional SFT training manuals (ReviewMinuchin, 1974), we include an ABA process column in the session excerpts as a means of creat- ing a connection between behavior analysis and family therapy.

Theoretical integration

Behavior analysis (Baer, Wolf, & Risley, 1968) and family systems theory (FST; Bateson, 1972) maintain distinct theoretical assumptions to explain human func- tioning. Behaviorists are concerned primarily, if not exclusively, with observable behaviors and the patterns of reinforcement that maintain them. ABA includes interventions targeted at individuals’ socially significant behaviors within the envi- ronment (e.g., communication, social skills, disruptive behaviors). Behavioral change is achieved using a linear perspective that is aimed at altering the reinforce- ment for an individual’s behavior. For example, minimizing the parents’ responses that reinforce a child’s disruptive behaviors will decrease that behavior. In contrast to the linear perspective used in ABA, FST assumes the principle of circular causal- ity to identify the reciprocal influences among family members that maintain a

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particular behavior (Bateson, Jackson, Haley, & Weakland, 1956). The internal and observable experiences of all members of the family system are incorporated into the treatment goal of family restructure. Despite such fundamental differences between behaviorism and family systems theory, however, there are overlapping principles that are significant to clinical practice. Namely, both perspectives emphasize the influence and interaction with the environment.

Behavior analysts aim to improve the behavioral performance of the identi- fied patient by replacing older patterns of behavior, thereby replacing the function of the behavior. ABA interventions include assessing the interactional patterns between caregivers and children in terms of antecedents and rein- forcement for challenging behavior by identifying the function of the behavior that is served for the individual (Dunlap & Fox, 2011). Similar to ABA, family therapists also work to identify the function of the behavior that is served for the family. Patterns of interaction between family members are used to describe the organization of the family members, or the family structure (Calapinto, 1991; Minuchin, 1974). Problem-maintaining patterns of interac- tion are altered through family restructure, which deems the behavior no lon- ger necessary to the system. We contend that exposing ABA trainees to a systemic approach in the treatment of autism enhances behavior analysis by offering a more comprehensive understanding of the individual’s behavioral reinforcements. MFT trainees have similarly benefited from the application of SFT to expand their clinical assessment and interventions skills that are con- sistent with the unique needs of families with autism.

Structural family therapy

SFT is considered one of the original family therapy approaches that developed out of a systemic framework and continues to influence the practice of family therapy. Ongoing process and outcome research continually monitor and validate the use of SFT as a relevant treatment approach for a variety of presenting problems in various treatment settings since 2000 (McAdams et al., 2016). As a systemically informed model of therapy, SFT assumes that individual presenting problems are a result of problematic family interaction patterns that make sense when taken in context. It follows that research has supported the association between child adjustment (Lindahl, Bregman, & Malik, 2012), children’s mental health symp- toms (Weaver et al., 2013), and children’s serious emotional disturbances (Radohl, 2011) and the use of SFT. The empirical support of structural therapy in the treat- ment of symptoms that often co-occur with an ASD diagnosis, highlights SFT as an ideal approach for the treatment of families affected by autism.

The overarching goal of SFT is to alleviate distress among family members by restructuring the current family organization that has become maladaptive (Cola- pinto, 1991). The traditional SFT approach assumes the family organization has become maladaptive when the system is unable to adapt to changing circumstances

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and the needs of family members go unmet. Maladaptive family structures are described as either disengaged or enmeshed as a function of the family boundaries (Minuchin, 1974). Disengaged families are considered overly distant and lacking strong emotional bonds. Disengagement is designated by rigid family boundaries that develop because closeness produces anxiety among family members (Minu- chin & Fishman, 1981). Conversely, enmeshed families are over involved and emo- tionally dependent on one another beyond the point that is considered developmentally appropriate (Minuchin & Fishman, 1981). The diffuse family boundaries that contribute to family enmeshment do not allow for growth and autonomy of its members. While structural interventions are essentially aimed at creating clear and flexible boundaries, there are relevant considerations for both enmeshment and disengagement when using SFT with families of a child with autism.

Family disengagement and autism

Disengagement is associated with overly rigid and impermeable boundaries that foster isolation and block mutual support among family members (Colopinto, 1991). Minuchin (1974) explains that families characterized by disengagement may “…lack feelings of loyalty and belonging and the capacity for interdependence and for requesting support when needed” (p. 55). Arguably, parents of children with autism are in even greater need of mutual support and interdependence than those of typically developing children due to the overwhelming parenting demands, shown to result in excessive levels of stress, anxiety, and depression (Barker, Seltzer, & Greenberg, 2011; Hastings et al., 2005; Hayes & Watson, 2013; Phelps, McCammon, Wuensch, & Golden, 2009). However, the high caregiving demands and fear of judgment often lead to a detrimental loss of social and familial support that strongly affects the family’s ability to cope (Ludlow, Skelly, & Rohleder, 2011). A structural therapist works to build connectedness and highlight mutuality among families with rigid boundaries. Therefore, we propose including fathers and grandparents in therapy is a necessary effort for reducing disengage- ment among families of ASD.

Our own experiences working with families of autistic children echo the trends of limited paternal involvement in treatment that is noted in the literature (Altiere & von Kluge, 2009; Flippin & Crais, 2011). Common reasons provided for minimal involvement by fathers in both treatment and research for autism include work obligations, marital/parental conflict, and involvement in caregiving (MacDonald & Hastings, 2010; Vacca, 2013). Despite the comparative difference between moth- ers and fathers of autistic children in clinical treatment and research participation, fathers also struggle with parenting stress and mental health symptoms (Falk et al., 2014; Myers, Mackintosh, & Goin-Kockel, 2009). Such factors can also indirectly affect maternal wellbeing in families of autistic children (Hastings et al., 2005). Therefore, we stress the significance of including fathers in the treatment of autism

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due to the noted personal and familial benefits to their participation (Hastings et al., 2005; MacDonald & Hastings, 2010; Vacca, 2013). Efforts such as calling the father directly to invite him to therapy, schedule flexibility, and overlapping appointments with other therapies (e.g., speech, occupational) have dramatically increased fathers’ participation in our setting. Participation by additional family members, such as grandparents also serves to increase connectedness in families characterized by disengagement.

Grandparents and other extended family members are frequently cited as sour- ces of support to parents that decrease parental stress (Preece & Jordan, 2007). Emotional and instrumental support of the child, respite care for the parents, and financial aid for the family are ways in which grandparents provide caregiving to their autistic grandchildren (Katz & Kessel, 2002). Despite the noted benefits of grandparents in families affected by autism, they are not routinely included in treatment efforts. Interventions dedicated to clarifying roles and expectations among caregivers will serve to strengthen the relationship between grandparents and their adult children (i.e., parents), which has shown to affect the quality of sup- port provided by grandparents (Katz & Kessel, 2002). We have found that inviting grandparents to participate in family therapy are often welcomed by the family so the grandparents may also receive information about ASD and reduce the stress associated with caregiving support. Grandparents of autistic youth also experience caregiving stress due to a sense of responsibility for keeping the family structure intact, often resulting in a blurred distinction between the roles of caregivers (Mar- getts, LeCounteur, & Croom, 2006). While including extended family members in the therapy process serves to build a sense of interdependence and reduce dis- engagement, SFT interventions also serve to clarify diffuse boundaries among care- givers within the family.

Family enmeshment and autism

Ramish (2012) explains that families affected by autism may easily become enmeshed as a natural response to meeting the child’s needs. Many of the deficits associated with ASD, such as problem solving and cognitive flexibility suggests parents of children with autism must provide intensive care and protection far beyond what would be appropriate for a typically developing child (Hartley et al., 2010; Kenworthy et al., 2009; Scheerer, Koot & Begeer, 2012). In other words, interactions that may be deemed pathological from the established structural lens are an unavoidable reality in families affected by autism. A typical characteristic of enmeshed family relationships is the instinctive demand for closeness among its members. Contrastingly, interviews with parents of autistic children reveal an awareness and discomfort associated with the excessive proximity that is required to parent a child with ASD (Ludlow et al., 2012; Myers et al., 2009). Boundary- making interventions directly intended to clarify diffuse boundaries between a par- ent and child with ASD often disregard the demands and expectations associated

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with autism in the family. Therapists must therefore reconceptualize enmeshment when working with families of children with autism.

Parents of autistic children repeatedly describe a life that revolves around par- enting their autistic child and feeling consumed by their children’s need for con- stant supervision (Ludlow et al., 2011; Myers et al., 2009). However, Altiere and von Kluge (2009a) found that parents also identified personal and familial benefits they would not have otherwise experienced, despite their struggles associated with parenting an autistic child. In fact, families of autistic children that were character- ized as enmeshed have demonstrated significantly higher coping mechanisms (Altiere & von Kluge, 2009b). Such findings highlight a distinction between the need for stronger boundaries between the caregiver—child subsystem and the need for role clarification among caregivers. We propose that therapists emphasize role clarification among caregivers (i.e., executive subsystem), as opposed to a dedi- cated focus on the caregiver—child subsystem. The following case example demon- strates our proposed adaptations.

Restructuring interventions

Minuchin (1974) describes the role of a family therapist as one who, “…often func- tions as a boundary maker, clarifying diffuse boundaries and opening inappropri- ately rigid boundaries.” (p. 56). There are many structural interventions that serve to alter family boundaries such as blocking, joining a subsystem, and enactments that are facilitated during the session. As opposed to relying on the family’s report of the concerns, boundary-making interventions allow the family to experience their current and alternative interactions during the session (Minuchin & Fishman, 1981). Families of children with autism are often well accustomed to tracking the targeted behaviors associated with their child’s ASD diagnosis. However, structural interventions designed to alter enmeshed or disengaged boundaries in families affected by autism allows the family members to experience new ways of interact- ing that are guided by the therapist. Specifically, the presence of additional care- givers and clarifying roles within the family during therapy sessions will allow the family to experiment with new ways of interacting with one another that address the specific needs of families of children with autism. The following case example demonstrates our proposed adaptations.

Case overview

Diagnostic information

Andy was a 16-year-old, Caucasian male, referred to therapy by the school system in a rural community located in the Southeastern United States. Andy was diag- nosed with Autism Spectrum Disorder—Moderate by his physician at the age of 12. With the onset of adolescence, Andy began to exhibit behavioral problems associated with ASD, such as externalizing behaviors, defiance of rules, and

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aggressive response to routine deviations (Kring, Greenberg, & Seltzer, 2008). He was experiencing significant impairment in the school and home settings associ- ated with his aggressive and threatening behavior. Andy demonstrated restricted interests around playing video games, which often led to social impairment and family conflict. His aggressive and threating behavior toward peers resulted in an inpatient hospitalization one week prior to his intake.

Family history

Family therapy initially began by including Andy and his mother. However, his father, younger sibling (14), and paternal grandparents were subsequently included in therapy sessions. The session transcript is from the sixth session with Andy and the first session with all the family members, except his mother. Although Andy’s mother was a participant in other therapy sessions, she did not wish to participate in this particular session for research purposes. His parents were recently sepa- rated, so Andy’s grandparents were highly involved in the caregiving responsibili- ties and active participants in therapy. Andy’s younger sibling had recently started to participate in delinquent activity and engage in substantial sibling conflict in the home. The family was limited in their resources for Andy due to financial con- straints and lack of availability to appropriate resources in the community. His father often traveled for work, which required a substantial financial and caregiv- ing contribution from Andy’s grandparents. Andy’s father and grandparents were struggling to collaboratively respond to the behavior, resulting in a diffuse hierar- chical boundary. This session was focused on engagement of additional caregivers and role clarification between the parents and grandparents.

Therapist Andy, I would like for you and (your sibling) to stay in the room, but I would like to talk to your grandparents and your dad to get some feedback on where they think we should go from here. Can you help me please?

Strengthening caregiving hierarchy and sibling subsystem

Andy’s and his sibling’s chairs are placed behind the grandparents’ and father’s chairs, outside of the circle.

Therapist So (Grandfather), I think you were on to something earlier when you mentioned “lax discipline.” It sounds like you and I were kind of coming from a very similar perspective in that the kids have been breaking rules and having some, quite frankly, some unacceptable behavior. One thing that comes to mind is when they both came up to work (to Grandmother) yelling and cussing at you when you wouldn’t do what they wanted. Then still getting to go on about their business as if it never happened.

Joining caregiving subsystem; Elevating caregiving hierarchy

Grandmother No telephone taken away. No computer taken away. Nothing. When they came in and showed absolutely no respect whatsoever. He tells me I put my job first, but I said, “my job puts the roof over your head and the food in

Evidence of reversed hierarchy

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your mouth.” And the disrespect that they give their granddaddy just tears me apart.

Therapist (To Grandfather) Do you agree? Aligning caregivers Grandfather She’s right on all that. I want to handle their

disrespect my own way, but I can’t. Therapist What’s your way? Grandfather Well, I would take everything they had from them. Therapist I don’t understand. Why can’t you do that? Challenging view of the problem Grandfather (Points to Grandmother). She’s sitting right there. Therapist So the two of you are working against one another

it sounds like. Challenging/reframing linear view of the

problem (To Father) Do you notice that? Do you see that

happening as well? Strengthening caregiving subsystem

boundary Father Well, they tell me about situations like when

(Sibling) left the house the other night and was outside on the phone. I was surprised the phone wasn’t taken away and (Sibling) was allowed to leave the house. But if that’s what they (motions to Grandmother and Grandfather) say to do, then I’m fine with it. But I do know that they need discipline.

Roles confusion between parent and grandparents.

Andy and his sibling begin to wave their hands in disagreement to get the attention of the therapist. They begin to whisper inaudibly to one another.

Blocking verbal communication

Father I had my tail tore up when I was young and if that’s what it takes, that’s what it takes. And it didn’t hurt me. It just hurt in the moment.

Therapist I’m seeing the non-verbals from Andy and (Sibling), over there. Is it OK, to speak to them quickly?

Reinforcing the hierarchy

(Adults nod) �SFT adaptation of collaborative stance (To Andy) You are going to get a chance to

respond, but right now I just want to hear from the grown-ups so we don’t get off track. Then you will both get your chance to respond. Just hang on to the piece of paper to write your thoughts. Thank you.

Aligning the authority figures

(To adults) So it sounds like you are actually all on reasonably the same page, as far as seeing that there’s a problem that needs to be addressed. You all agree that there needs to be more strict discipline, but that’s not happening.

Grandfather Well, when I say it’s all her (Grandmother) fault, it’s not really all her fault ‘cause I give in too. I think all we’re looking for is some sort of peace. And it looks like the more we try, the worse it gets.

Evidence of strengthened caregiver hierarchy

Therapist I agree. Grandmother One thing he does that makes me so mad is

saying, “well, if daddy gets his own place, I’m going to go and live with him. ”He says that to us all the time, so I finally just said, “You and daddy want to go live together, then go.” Then his dad tells him he can’t afford to move out yet, so I’m the bad guy because I won’t help them move out.

Therapist (To father) Are you experiencing the other end of that? I mean, does it feel like he’s playing you against them?

Engage father on authority discussion

Father (Nodding) Occasionally, yes. I have a tendency to give in too and be very lenient.

Align caregivers

Andy tries to interrupt; Therapist blocks him by holding up a hand

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142 M. L. PARKER AND J. MOLTENI

I don’t want to fight with him, so I say it’s OK. He’s my son and I don’t want to get him in trouble all the time. I know that’s probably not good discipline.

Therapist Well, if I take a step back from the situation, from the arguing and friction, it seems like there’s a lot of hurt and fear in this family.

Challenging family view of the problem through reframe

(To adults) Are you all afraid of Andy? Grandmother There was hurt for me because my job was thrown

up in my face a lot because I couldn’t spend as much time at home. And that does hurt.

Grandmother begins to cry Therapist So, Andy was hurt that you were putting the job

first and you were hurt that he felt that way. Blocks Andy’s attempt to interrupt

Therapist Regardless of the transaction…whether who said this or who said that, the rules of engagement are to hurt one another.

Grandmother Right. And if he doesn’t get his way, he’ll keep going. So, basically, I just give in.

Therapist OK. So you’re teaching him how to get what he wants, by hurting you?

Challenging view of the problem

Adults nod in agreement Reversed hierarchy Basically, you are all saying, “I’m sorry for the

hurt you’re feeling and I’m afraid of what you’ll do, so I’ll be lenient.”

Grandfather I think you hit the nail on the head right there. Grandmother We all want to do that. I have overindulged him;

given him anything and everything I can, to make up for a lot of things that happened. But I agree with my son (Andy’s father); the past is the past and we need to try to step forward and go on

Therapist Would you two agree with that? Align caregivers Grandfather Yeah Father Yes Therapist Ok. So first off, it sounds like the three of you need

to have “adult” communication and eliminate Andy from getting you off task.

Strengthen hierarchy; clarify role confusion

Therapist Ok. Could the two of you rejoin us? (Chairs moved back into the circle)

Sibling I just want to say, the only reason I say hateful things is because I’m mad and you know I tend to overreact when I’m mad but still…

Andy Ok. I’m mad because I don’t have any friends to talk to. I’m not in school because of stupid shit I did. Me. I don’t think I should get in trouble for anything. Yeah I have disrespect. I’m pissed off. What else should I be? I’m pissed I don’t talk to anybody.

Cognitive inflexibility and social isolation

Therapist Well, who is someone that you can talk to? Problem-solving skill development Andy (Points to Grandfather) Grandfather Well when you’re disrespectful it’s hard. You know

exactly what I’m talking about. Another thing you using the “f” word to whoever you’re talking to, but

I don’t need it in the house. Sibling I have one more thing to say. About the whole

playing them back and forth thing…OK, the only reason we every make threats is because we know we couldn’t ever do it. But we say stupid stuff when we’re mad.

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Therapist Yes, that’s playing them against each other. Reframing the problem (To family) Wow. It seems like we actually get

some things accomplished when there aren’t persistent interruptions? Do Andy and (Sibling) always divide and conquer you to get their way?

(Family members laugh and nod)

Treatment outcome

Over the course of treatment Andy’s father was able to assume greater accountabil- ity in his implementation of authority. However, it was a continued struggle to block the grandparents from attempting to resume the position of authority. This was addressed in therapy by identifying specific and appropriate consequences for Andy’s oppositional behavior that were implemented by his parents and reinforced by his grandparents. The family was seen in various subsystem forms (e.g., grand- parents-parents; father-siblings) for weekly sessions over the next four months to reiterate the new roles and boundaries. Andy and his sibling began to have devel- opmentally appropriate conflict in session through continual hierarchical bound- ary-making interventions. The agency psychiatrist assigned a prescribed a mood stabilizer after three months of participating in therapy. Over the course of treat- ment, emotional escalation and aggressive outbursts decreased for Andy and his sibling. The family has since been referred to the available community resources.

Implications for practice

The overarching goal of family restructure to clear and flexible family boundaries using SFT addresses many of the concerns that are noted in the relevant literature on autism and the family. Yet, there are relevant adaptations to the approach that should be considered for effective treatment. Family disengagement should be addressed by incorporating fathers and extended family members, such as grand- parents into therapy session to reduce the associated isolation and lack of mutual support. Multiple caregivers participating in therapy serves to disperse the high caregiving demands and rebuild family support that has shown to influence coping in families affected by autism (Ludlow et al., 2011). Family enmeshment must be conceptualized differently in families of ASD, in order to avoid pathologizing a natural byproduct of parenting a child with autism. As previously noted, parents frequently report discomfort with the excessive time and energy that is required to raise a child with autism, which is inconsistent with the pathological intolerance for distance associated with a traditional view of enmeshment. Therefore, we rec- ommend a focus on role clarification among caregivers, as opposed to strengthen- ing boundaries between parent and child to address enmeshment. We contend that increasing the availability of caregivers and clarifying their roles serves to build support and reduce familial stress through restructure are adaptations that specifi- cally meet the needs of families affected by autism. However, there are potential

144 M. L. PARKER AND J. MOLTENI

limitations to the use of SFT with autism that must be considered when imple- menting the approach.

Limitations

We have offered a theoretical rationale and clinical application that supports the use of SFT in the treatment of families affected by autism. It is worth highlighting that there is minimal outcome and longitudinal research to assess the effectiveness of SFT over time as a treatment approach for ASD. As such, we cannot make claims about the treatment effectiveness of SFT in comparison to any other family therapy approaches. There are, however, notable adaptations that suggest structur- ally informed approaches are beneficial in addressing family distress. For example, Ecosystemic Structural Family Therapy (ESFT) is gaining empirical support in the treatment of children with behavioral problems and shares common theoretical assumptions, such as identifying the function of a challenging behavior (Dunlap & Fox, 2013; Lindblad-Goldberg & Northey, 2013). Multisystemic Therapy (MST) is a systemically informed, evidence-based treatment approach for the treatment of difficult behaviors among youths (Henggeler et al., 2009). MST is currently in the initial phases of adapting and evaluating the approach for behavioral problems among children with ASD (Wagner et al., 2014). Due to the common theoretical foundations of these approaches, it stands to reason that SFT is a favorable alterna- tive for families that are not able to access in-home therapy services.

Directions for future research

As the empirical support for the systemic effects of autism grows, there is likely to be a greater need for exposure in the training in both ABA and MFT. We contend that SFT is gaining empirical support through innovative adaptations of the interven- tions specific to the needs of autism in the family. Ongoing research and training is needed to evaluate the effectiveness of SFT in reducing family distress and mainte- nance of progress over time. Such findings will serve to refine the training and super- vision of both ABA andMFT trainees to meet the unique treatment needs of families affected by autism. We have highlighted the relevant overlap in the theoretical per- spectives informing both disciplines, suggesting both disciplines are amenable to exposure of these distinct treatment perspectives. Therefore, it is our aim to provide on-going exposure to MFT and ABA trainees in the hope of offering more compre- hensive treatment to meet the needs of families affected by ASD.

Acknowledgments

The authors would like to acknowledge the Hospital for Special Care - Autism Center for the opportunity to develop the cross-disciplinary training opportunities that contributed to this article.

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