Journal of Marital and Family Therapy doi: 10.1111/jmft.12012 July 2014, Vol. 40, No. 3, 319–331

MULTISYSTEMIC THERAPY FOR DISRUPTIVE BEHAVIOR PROBLEMS IN YOUTHS WITH AUTISM SPECTRUM DISORDERS: A PROGRESS REPORT David V. Wagner, Charles M. Borduin, Stephen M. Kanne, Micah O. Mazurek, Janet E. Farmer, and Rachel M. A. Brown University of Missouri

Youths with autism spectrum disorders (ASD) often engage in serious disruptive behaviors that interfere with their ability to successfully manage day-to-day responsibilities and contribute to relationship problems with caregivers, peers, and teachers. Effective treatments are needed to address the factors linked with disruptive behavior problems in this population of youths. Multisystemic therapy (MST) is a comprehensive family- and community-based treatment approach that has been effective with other difficult-to-treat populations of youths and holds promise for youths with ASD. In this article, we review the broad range of factors associated with disruptive behaviors among youths with ASD and discuss how MST interventions can be adapted to address those factors. We also present a framework for our adaptation of the MST model for youths with ASD. This framework includes a recently completed pilot study as well as an ongoing efficacy trial that together have served to identify key interventions for our adaptation of the MST model. Youths with autism spectrum disorders (ASD) present significant problems at several levels of analysis, and these problems argue for the development of effective treatment approaches.1 At an individual level, youths with ASD often exhibit a range of cognitive (e.g., intellectual impairment), adaptive (e.g., poor self-care), and interpersonal (e.g., impaired social skills) difficulties (Carter et al., 1998; De Bildt, Sytema, Kraijer & Minderaa, 2005; Kanne et al., 2011) that interfere with their ability to successfully manage day-to-day responsibilities and contribute to relationship problems with caregivers, peers, and teachers. At a family level, parents of youths with ASD report high levels of stress related to caregiving and are at risk for a range of mental health problems such as depression (Hastings et al., 2005). At a societal level, youths with ASD are overrepresented in the child mental health and special education systems (Brookman-Frazee et al., 2009) and incur lifetime costs to the public treasury as high as $3.2 million per youth (Ganz, 2007). Thus, the development of effective treatments for youths with ASD has the potential to substantially improve the quality of life for individual youths, their families, and communities. A number of effective treatments have been developed to address the core deficits associated with ASD (i.e., impairments in communication and social skills, restricted and repetitive behaviors; National Research Council, 2001). These treatments typically have focused on younger children and have often been based on applied behavior analytic (ABA) principles. Less attention has been paid to the development of interventions for older children (including adolescents) with ASD, especially youths who repeatedly engage in aggressive (e.g., physically harming caregivers, peers, or teachers) and other serious disruptive behaviors (e.g., punching a hole in a wall, smashing a television screen). The development of effective treatments for older children is imperative given that youths with ASD engage in higher rates of aggression and are less likely to show age-related decreases in aggression than their peers (B€ olte, Dickhut & Poustka, 1999; Farmer & Aman, 2011). Moreover, compared to nonaggressive youths with ASD, aggressive youths with ASD may be at higher risk for long-term adjustment problems, including employment difficulties, residential placement, and hospitalization (Benson & Aman, 1999; Matson, Wilkins & Macken, 2009; David V. Wagner, MA, Charles M. Borduin, PhD, Stephen M. Kanne, PhD, Micah O. Mazurek, PhD, Janet E. Farmer, PhD, and Rachel M. A. Brown, MD, University of Missouri. Address correspondence to Charles M. Borduin, Psychological Sciences, University of Missouri, 108A McAlester Hall, S. 6th Street, Columbia, Missouri 65211-2500; E-mail: [email protected]

July 2014

JOURNAL OF MARITAL AND FAMILY THERAPY

319

McIntyre, Blacher & Baker, 2002). Thus, the continued development of effective interventions for aggressive youths with ASD should be an empirical priority. Unfortunately, as noted in a comprehensive review (Warren et al., 2011), there have been few rigorous tests (e.g., randomized clinical trials) of the effectiveness of psychotherapies for aggressive youths with ASD. In addition, the vast majority of studies have included relatively serious methodological limitations. For example, most studies have used small samples and have relied on limited, if any, follow-ups. Furthermore, few studies have examined the broad effects of treatment on the key systems (e.g., family, peer, school) in which youths are embedded. Moreover, many studies have excluded youths with severe impairments in communicative, intellectual, or adaptive functioning and are not generalizable to the broader population of aggressive youth with ASD (see Levy & Perry, 2011, for a review). Given the need for an intervention that targets aggressive and other disruptive behaviors in youths with ASD, we are in the early stages of adapting an evidence-based treatment model, multisystemic therapy (MST; Henggeler & Borduin, 1990), for use with this clinical population. The purpose of this article is to present a rationale for our adaptation of the MST model. In the first section, we identify the multiple system-level factors that are associated with disruptive behaviors (e.g., interpersonal aggression, property destruction) in youths with ASD and discuss the need for a broad-based treatment. We then describe the theoretical and clinical foundations of MST and discuss how MST principles can be applied to youths with ASD and their families. Finally, we present a treatment development framework that guides our adaptation of the MST model for disruptive behavior problems in youths with ASD. This framework includes a recently completed pilot study as well as an ongoing efficacy trial that together have served to identify key interventions for our adaptation of the MST model.

CORRELATES OF DISRUPTIVE BEHAVIORS IN YOUTHS WITH ASD To provide an empirical rationale for the application of MST to youths with ASD, we first review the research literature on the correlates of ASD, with an emphasis on ASD and aggressive behavior. Because the onset of aggressive and other disruptive behaviors can vary across youths with ASD, this review includes findings on the correlates of ASD from early childhood to late adolescence. The empirical findings are consistent with the theory of social ecology (Bronfenbrenner, 1979), which assumes that youth behavior problems (e.g., aggression) are driven by key risk factors associated with the individual youth and the multiple systems in which the youth is embedded. The social-ecological systems that most directly affect the individual youth (i.e., family, peers, and school) are those that have received the most attention in the empirical literature on youths with ASD and, thus, are the focus of the present review. We recognize that not all youths with ASD are aggressive and that there are numerous studies documenting the resilience and strengths of youths with ASD and their families (e.g., Bayat, 2007). However, the focus of the present review is on the psychosocial correlates of ASD that are related to youth aggression and that represent likely targets of intervention. It must be emphasized that the majority of studies on ASD have been cross-sectional and, therefore, do not address the causes of aggression or other disruptive behaviors in youths with ASD. Individual Youth Factors On an individual level, the core deficits associated with ASD include impairments in the development of communication and social skills, atypical development of language, and restricted interests and/or repetitive behaviors (American Psychiatric Association, 1994). The severity of impairments in these areas can vary considerably among youths with ASD, resulting in substantial differences in symptom presentation from youth to youth. In addition, youths with ASD are at risk for comorbid health difficulties (e.g., gastrointestinal problems, seizures), cognitive deficits, intellectual disabilities, adaptive impairments, and sensory problems (Gurney, McPheeters & Davis, 2006; Horvath & Perman, 2002). Moreover, there is some evidence that these individual-level problems contribute to aggressive and other disruptive behaviors in youths with ASD (Dominick, Davis, Lainhart, Tager-Flusberg & Folstein, 2007), as more than half of all youths with ASD

320

JOURNAL OF MARITAL AND FAMILY THERAPY

July 2014

behave aggressively toward parents and teachers (Farmer & Aman, 2011; Kanne & Mazurek, 2011). Family Characteristics Caregivers of youths with ASD also experience a range of difficulties, including poorer mental health (Montes & Halterman, 2007) and greater isolation from community supports than do caregivers of typically developing youths (Gallagher, Beckman & Cross, 1983; Woodgate, Ateah & Secco, 2008). In addition, caregivers of youths with ASD and comorbid behavioral problems often experience aggravation and distress in their parenting roles (Estes et al., 2009; Schieve, Blumberg, Rice, Visser & Boyle, 2007), even when compared with caregivers of youths with other intellectual or behavioral difficulties (Blacher & McIntyre, 2006). Behavioral problems in youths with ASD have also been linked with depression in mothers (Hastings et al., 2005), higher child-related stress in fathers (Ornstein Davis & Carter, 2008), and lower marital satisfaction (Higgins, Bailey & Pearce, 2005), and are the strongest predictor of overall family stress (Estes et al., 2009). Furthermore, although findings have been inconsistent (e.g., Freedman, Kalb, Zablotsky & Stuart, 2012), there is some evidence that caregivers of youths with ASD are more likely to divorce than are caregivers of youths without ASD, and this risk of caregiver divorce remains high even as their offspring with ASD enter early adulthood (Hartley et al., 2010). Because youths with ASD and their siblings often share genetic and environmental influences, these siblings are at increased risk for social and communicative impairments (Rutter, 2005). Moreover, siblings of youths with ASD are at higher risk for emotional problems and psychiatric symptoms (Petalas, Hastings, Nash, Lloyd & Downey, 2009; Ross & Cuskelly, 2006). In addition, when youths with ASD have disruptive behavior problems, their siblings are at increased risk for behavioral and adjustment problems as well (Benson & Karlof, 2008; Hastings, 2003). Autism spectrum disorders can also have an adverse effect on the family system as a whole. Caregivers of youths with ASD report high levels of family stress both immediately following the youth’s diagnosis (Stuart & McGrew, 2009) and thereafter (Siegel, 1997). Moreover, caregivers of youths with ASD report lower levels of family adaptability and cohesion (Gau et al., 2012; Higgins et al., 2005), higher levels of family strain, less effective family coping strategies (Sivberg, 2002), and more problems with family finances (Fletcher, Markoulakis & Bryden, 2012). Caregivers of youths with ASD also report spending significantly less time engaged in enjoyable activities with their child than do caregivers of youths who are typically developing or intellectually impaired (Konstantareas & Homatidis, 1992). Recent longitudinal studies by Baker and colleagues point to the role that family and caregiver variables play in the development of problem behavior in youths with ASD. For example, Baker, Seltzer and Greenberg (2011a) reported that lower levels of adaptability (e.g., compromise, problem-solving) in families of youths with ASD were linked with increased youth problem behaviors (e.g., property destruction, interpersonal aggression) 3 years later. In addition, Baker, Smith, Greenberg, Seltzer, and Taylor (2011b) found that increases in maternal criticism were related to increases in problem behaviors in youths with ASD over a 7-year period. These studies suggest that family and caregiver factors are linked with changes in problem behaviors in youths with ASD and that family-based treatments have the potential to benefit youths with ASD and their families (also see Neely, Amatea, Echevarria-Doan & Tannen, 2012; Ramisch, 2012; Solomon & Chung, 2012). Peer and School Factors Outside of the family system, youths with ASD often encounter difficulties in their social relations with friends, classmates, and teachers. Indeed, youths with ASD are more likely to have friendships that are shorter (Bauminger & Shulman, 2003), lower in quality (Bauminger & Kasari, 2001), and less frequent (Koning & Magill-Evans, 2001) than those of their typically developing peers. These difficulties often extend into adulthood, when over 40% of individuals with ASD are reported to be friendless (Orsmond, Krauss & Seltzer, 2004). In their interactions with classmates, youths with ASD are more likely to be bullied (Little, 2002) and to engage in reactive aggression than are typically developing peers (Humphrey & Symes, 2011). These and other disruptive behaviors can interfere with the classroom learning environment and have been linked with lower

July 2014

JOURNAL OF MARITAL AND FAMILY THERAPY

321

employment satisfaction and higher burnout rates among educators of youths with ASD (Hastings & Brown, 2002). Summary Although evidence regarding the determinants of disruptive behaviors in youths with ASD is far from complete, the research literature suggests that the range of social and behavioral problems linked with ASD is very broad and encompasses multiple systems. In short, youths with ASD are more likely to have a range of adaptive, cognitive, medical, and behavioral problems when compared with neurotypical peers, and the systems in which youths with ASD are embedded are also at heightened risk of various difficulties (e.g., divorce, low family cohesion, sibling behavior problems).

MULTISYSTEMIC THERAPY The clinical implications of the research findings seem relatively straightforward. If the primary goal of treatment is to optimize the probability of decreasing rates of disruptive behaviors in youths with ASD, then treatment approaches must have the flexibility to address the multiple known correlates and causes of those disruptive behaviors. That is, effective treatment must have the capacity to intervene comprehensively at individual, family, peer, and school levels. MST is an intensive family- and community-based treatment that has been shown to be effective in addressing complex clinical problems in children and adolescents (see Henggeler, Schoenwald, Borduin, Rowland & Cunningham, 2009; Henggeler & Sheidow, 2012; for reviews). A crucial feature of MST is its capacity to address the multiple determinants of serious clinical problems in a comprehensive, intense, and individualized fashion. Indeed, across 22 published studies (20 randomized clinical trials), MST has demonstrated improved mental health in youths and their caregivers, reduced youth and sibling behavior problems, improved family and peer relations, improved youth performance in school, and less criminal activity in participants 22 years following treatment relative to comparison treatments and services (Henggeler et al., 2009; Sawyer & Borduin, 2011; Wagner, Borduin & Sawyer, 2012b). Furthermore, successful adaptations of the MST model with other clinical populations (e.g., youths with poorly controlled type 1 diabetes, youths with problem sexual behaviors) have shown promising results (see Henggeler et al., 2009). Theoretical Foundations of MST Family systems theory (Hoffman, 1981) and the theory of social ecology (Bronfenbrenner, 1979) are the foundations for treatment planning and case conceptualization in MST. From a family systems perspective, the family is conceptualized as a rule-governed system and an organized whole that transcends the sum of its separate elements. When applying this perspective to ASD, it is assumed that problematic individual behaviors (e.g., interpersonal aggression) of youths with ASD, their siblings, or their caregivers may be intimately related to patterns of interaction (e.g., high conflict) between family members and must always be understood within the context of those interaction patterns (see Lecavalier, Leone & Wiltz, 2006). Despite variations in how various schools of family therapy view systems theory, most attempt to explain how emotional and behavioral problems “fit” within the context of the individual’s family relations and highlight the reciprocal and circular nature of such relations. Thus, a clinician working from a family systems framework would consider not only how family conflict influences problem behaviors of youths with ASD, but also how those problem behaviors shape relations between caregivers, as well as the family-level function(s) of those behaviors. The theory of social ecology (Bronfenbrenner, 1979) views the youth as embedded within a complex of interconnected systems that include the individual youth, the youth’s family, and various extrafamilial (peer, school, neighborhood, community) systems. The youth’s actions are seen as the result of the reciprocal interplay between those systems directly involved with the youth and these systems, and of the interactions of the systems with each other. Thus, although the interactions between youths with ASD and their families and schools would be important, the interactions between the systems (e.g., between caregivers and teachers) would be perceived as equally important. It is assumed, then, that problematic interactions between relevant systems and 322

JOURNAL OF MARITAL AND FAMILY THERAPY

July 2014

within systems can maintain youth problem behavior and that behavior can only be understood fully when considered within its naturally occurring context. A clinical volume (Henggeler & Borduin, 1990) and treatment manual (Henggeler et al., 2009) describe MST interventions for disruptive youth behavior and discuss the process by which family and youth problems are prioritized and addressed. Using well-validated treatment strategies from strategic family therapy, structural family therapy, behavioral parent training, and cognitive-behavioral therapy, MST targets intrapersonal (e.g., social cognition, emotional regulation), familial (e.g., caregiver-youth and couple relations), and extrafamilial (i.e., peer, school, community) factors that are known to play a role in youth problem behavior. In addition, MST providers attempt to identify biological contributors to identified problems in family members (e.g., major depression, attention deficit-hyperactivity disorder) and, when necessary, to integrate psychopharmacological and other interventions. MST interventions are individualized and flexible to address the wide variety of factors that contribute to problem behaviors on a case-by-case basis. The adaptation of the MST approach for youths with ASD is guided by the same principles and uses many of the same evidence-based interventions as standard MST, with a particular focus on aspects of the youth’s ecology that are functionally related to problem behavior. Model of Service Delivery in MST Multisystemic therapy is based on the family preservation model of service delivery (Nelson & Landsman, 1992). An integral component of the family preservation model is that assessment and treatment delivery occur in the family’s natural environment (home, school, and neighborhood) to optimize ecological validity. This is especially important for youths with ASD, whose disruptive behaviors frequently occur at home or school and often in the presence of parents, teachers, or peers. Providing treatment in the natural environment also substantially minimizes barriers to service access, thereby ensuring that family members can participate (Higgins et al., 2005). As in standard MST, service provision for youths with ASD and comorbid problem behaviors is delivered by master’s level therapists with relatively small caseloads (i.e., three to four families). The MST therapist provides the majority of mental health services. For example, if a caregiver of a youth with ASD is feeling overwhelmed by stress, the MST therapist would directly intervene, as opposed to making a referral for individual therapy. The MST therapist also coordinates access to other pertinent services (e.g., medical, educational) and constantly monitors quality control. For example, when providing MST to a youth with ASD, the therapist collaborates with special education providers, psychiatrists, pediatricians, and case managers to ensure that they are working toward the same goals and communicating regularly with the family. MST therapists are available to the family 24 hr a day, 7 days a week. However, therapeutic intensity is titrated to the needs of the family, so the range of direct contact hours can vary based on family need. Generally, MST therapists for youths with ASD spend a greater amount of time with families during the initial weeks of therapy (i.e., 2–3 sessions per week) and taper off (as infrequently as once every 2 weeks) during a 5–7-month course of treatment. MST Treatment Principles Multisystemic therapy does not adhere to a rigid protocol in which therapists complete predetermined tasks in an invariant order. Instead, core treatment principles guide therapists’ case conceptualizations, prioritization of interventions, and implementation of intervention strategies. As discussed elsewhere (see Henggeler et al., 2009), the nine treatment principles described below are general guidelines for designing multisystemic interventions and evaluating treatment fidelity. Examples of how these principles can be applied to the treatment of youths with ASD and their families are provided below. Principle 1: The primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context. The goal of MST assessment is to “make sense” of problem behaviors in light of their systemic context. This principle is particularly relevant for youths with ASD because cognitive, adaptive, and communicative impairments can vary considerably from youth to youth and may jointly contribute to problem behaviors. When July 2014

JOURNAL OF MARITAL AND FAMILY THERAPY

323

considering the problem behaviors of a youth with ASD, known correlates of such behaviors are identified and targeted. For example, a youth’s cognitive and communicative impairments may lead to aggressive behavior toward others when trying to convey his or her needs. A caregiver’s reinforcement of the aggressive behavior and the youth’s lack of communication strategies may serve to increase the likelihood of future aggression. Other factors, such as a chaotic school environment or caregiver substance abuse, may also contribute to youth problem behaviors and ineffective caregiver responses. Principle 2: Therapeutic contacts emphasize the positive and use systemic strengths as levers for change. Identifying strengths begins during the MST assessment and focuses on the broad ecology of the youth and family. Families of youths with ASD often display resiliency and strength in the face of multiple stressors, and therapists may draw on these strengths to facilitate treatment progress. Therapists continually appraise each family member’s ability to use his or her strengths (e.g., high motivation, good problem-solving and organizational skills, high frustration tolerance) to accomplish tasks, while simultaneously working to develop additional strengths to accomplish goals. For example, a family strength such as living close to extended family members may be used to shore up a caregiver’s social support network to provide much needed assistance in raising a youth with ASD. Principle 3: Interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members. Conceptualizing the purpose of MST as enhancing responsible behavior is a point of view that can be readily communicated and understood by diverse groups of individuals, including family members, school personnel, agency colleagues, and case workers. For example, when working with a youth with ASD, the therapist might encourage the caregivers to review youth self-care responsibilities or ask the youth’s teachers to examine their role in home-school communication. Similarly, the therapist might encourage the caregivers to reward the youth’s sibling(s) for taking on additional household responsibilities to provide the caregivers with more time to meet the youth’s special needs. Principle 4: Interventions are present focused and action oriented, targeting specific and welldefined problems. Multisystemic therapy interventions emphasize changing the family’s present circumstances as a step toward improving future functioning. In light of the serious nature of the behavior problems presented by youths and families referred for MST, interventions aim to activate the family and their social ecology to make multiple, positive, observable changes. Targeting well-defined problems (i.e., objective and measurable) and setting well-defined treatment goals (e.g., reduce youth aggression toward caregivers through more effective use of behavioral management strategies) keeps family members, therapists, and other participants fully aware of the direction of treatment, the criteria used to measure success, and the effectiveness of various interventions. Principle 5: Interventions target sequences of behavior within and between multiple systems that maintain the identified problems. The MST therapist modifies those aspects of family relations and the social ecology that are linked with problems. MST for youths with ASD might target difficulties within the caregivers’ relationship, poor communication between caregivers and teachers, frequent conflicts between youths and their siblings, or inconsistent patterns of limit-setting across caregivers or settings. Principle 6: Interventions are developmentally appropriate and fit the developmental needs of the youth. Youths and their caregivers have different needs at different periods of their lives, and MST interventions are designed accordingly. As a result, the nature of family-based interventions varies with the developmental level of the youth. This is particularly pertinent for youths with ASD, who often have developmental delays in their social skills and peer relations. For example, caregivers and/or teachers of a 16-year-old youth with autism may fail to recognize that his or her levels of social and emotional development are not the same as those of many of his or her peers, suggesting that thorough assessment is needed to determine developmentally appropriate interventions (e.g., supporting caregiver management of day-to-day activities vs. preparing the youth for entry into the adult world). Principle 7: Interventions are designed to require daily or weekly effort by family members. Therapists can help families resolve their problems more quickly if everyone involved (e.g., caregivers, siblings, extended family, neighbors, social service providers) develops and agrees on 324

JOURNAL OF MARITAL AND FAMILY THERAPY

July 2014

intervention goals and strategies. Because intervention tasks occur frequently, the therapist has regular opportunities to provide feedback and praise to youths with ASD and their caregivers, who often feel discouraged and pessimistic about the future. Principle 8: Intervention effectiveness is evaluated continuously from multiple perspectives with providers assuming accountability for overcoming barriers to successful outcomes. Continuous evaluation using multiple informants and methods ensures that MST therapists have a relatively accurate view of treatment progress and informs the refinement of goals and strategies. For example, if a teacher reports continued disruptive behavior (e.g., aggression) by a youth with ASD, prompt feedback allows the therapist and family to consider alternative conceptualizations of the targeted problem and to develop new interventions. Principle 9: Interventions are designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members’ needs across multiple systemic contexts. Ensuring that treatment gains will generalize and be maintained is a critical and continuous thrust of MST interventions and is particularly pertinent to interventions with youths with ASD, who often experience longstanding problems across systems. To accomplish this, MST therapists (a) teach relevant behaviors or skills under the same conditions in which youths and their caregivers will eventually behave, (b) encourage and reinforce the development of family members’ problem-solving skills, (c) find individuals (e.g., relatives, friends) in the ecology who will reinforce family members’ new behaviors and skills across settings (e.g., home, school, community), (d) alert significant others (e.g., teachers, caseworkers) to the new behaviors of family members, (e) provide reinforcement when generalization occurs, and (f) allow caregivers and youths to do as much of the development and implementation of interventions as they can. Thus, through emphasizing family empowerment and the mobilization of indigenous resources, the MST therapist sets the stage for lasting change. Relevance of MST for Families of Youths With ASD The focus of MST on ecological and contextual factors offers a comprehensive approach for ameliorating behavior problems in youths with ASD. Addressing contextual factors seems especially important in the treatment of youths with ASD due to the number of providers, services, settings, and agencies involved, as well as the likelihood that those systems are under substantial levels of stress. MST increases the likelihood of generalization by (a) empowering families to resolve a range of individual and systemic problems and (b) delivering services in the natural environment (i.e., home, school, and neighborhood). Another strength of the MST model is that it provides a flexible approach for working with youths with ASD, who present with a wide range of core and associated symptoms.

STAGES OF ADAPTING MST FOR ASD In light of the relevance of MST for families of youths with ASD, we have begun to adapt MST for these families and are evaluating our adaptation. The evolution of MST adaptations follows a treatment development framework that can take a decade or more to complete (see Henggeler et al., 2009). Consistent with other MST adaptations, our adaptation is proceeding in several stages. Pilot Stage We conducted a pilot study (Wagner, Borduin & Sawyer, 2012b) to determine whether the model of service delivery, treatment principles, and types of interventions used in MST were a good fit for the problems typically encountered in families of youths with ASD. Referrals to the pilot (N = 3) included families in which the youth (a) had an ASD diagnosis that was confirmed by the Autism Diagnostic Interview-Revised (Lord, Rutter & Le Couteur, 1994) or Autism Diagnostic Observation Schedule (Lord et al., 1989), (b) had recently evidenced severe disruptive behaviors (confirmed by caregiver report of frequent interpersonal aggression and/or property destruction), (c) was living with at least one parent figure, and (d) was from 11 to 17 years of age (M = 14.3). The families of the youths (all boys) participated in MST for an average of 6.3 (range = 5.4–7.5) months. Pre- and post-treatment assessments indicated that there were marked decreases in youth behavior problems (as measured by the Child Behavior ChecklistJuly 2014

JOURNAL OF MARITAL AND FAMILY THERAPY

325

Parent Report; Achenbach, 1991), including both externalizing (i.e., aggression, rule-breaking, social problems) and internalizing (i.e., depression, anxiety, somatic complaints) behaviors. In addition, mothers reported a decrease in their own psychiatric symptoms (Brief Symptom Inventory; Derogatis, 1993) and parenting stress (Parenting Stress Index-Short Form; Abidin, 1995) and an increase in family adaptability and cohesion (Family Adaptability and Cohesion Evaluation Scales-II; Olson, Portner & Bell, 1982) from pre- to post-treatment. Moreover, fathers (N = 2) reported an increase in social support from friends over the course of treatment (Perceived Social Support—Friend Scale; Procidano & Heller, 1983). Overall, these results seemed promising to us and suggested that the continued development of MST for youths with ASD was warranted. Efficacy Stage Building on the results from our pilot work, we obtained grant funding to conduct a small randomized clinical trial for youths with ASD and severe behavioral problems (expected N = 30). Similar to previous efficacy trials of MST, a co-developer of the MST model is assisting with clinical supervision, and graduate students in clinical psychology are serving as therapists. We are using the same inclusionary criteria as in our pilot study and are randomly assigning referred youths and their families to MST or usual services (e.g., social skills groups, behavioral interventions). Unlike many clinical trials focusing on youths with ASD, we are not excluding youths based on cognitive, adaptive, or communicative impairments; core ASD symptom severity; comorbid mental health disorders; or health-related problems. Typical referral behaviors include frequent interpersonal aggression (i.e., hitting, kicking, and/or biting of caregivers, siblings, teachers, and/or peers) and property destruction (e.g., punching holes in walls, destroying televisions or computers). Although still in progress, our work to date has contributed greatly to our understanding of the types of adaptations that are needed to develop effective interventions for youths with ASD and disruptive behaviors. Indeed, we have observed that youths with ASD have somewhat different antecedents for aggressive behavior than those typically seen in other applications of MST. For example, the youths in our pilot study as well as our clinical trial have exhibited low rates of involvement with deviant peers and no alcohol or substance use, resulting in a reduced treatment emphasis on these areas. In addition, greater communication impairments in youths have required an increased focus on concrete versus abstract concepts. Similarly, youth limitations in understanding the perspectives and emotions of other people have reduced the effectiveness of some of the family interventions typically used in MST. As such, interventions designed to increase caregiver-youth warmth and caregiver control have relied less on caregiver‐youth discussions, which require perspective-taking, and more on caregiver and youth behavioral responses to each other. We have also observed that youths with ASD tend to react more strongly than neurotypical peers to changes in routine by engaging in aggressive and disruptive behavior toward their caregivers and therapists during treatment sessions. In response, therapists and caregivers have identified ways to manage these behaviors and to help the youths accommodate to having a therapist in their home. For example, therapists have assisted families with developing clearly defined rules and consequences for youth behaviors, including the elimination of caregiver reinforcement of youth aggression. In addition, therapists have helped caregivers to prepare youths for treatment sessions (e.g., reminding the youth of the therapist’s visit, discussing what will happen during the session) or to plan structured activities for youths who are unable to participate in therapy discussions due to cognitive impairment. In some cases, therapists have also assisted caregivers in safety-proofing their home (e.g., by removing sharp or throwable objects) to protect everyone from injury during possible outbursts from the youth. Our work to date also suggests that youths with ASD more frequently exhibit social skill difficulties and problems in their relationships with peers, teachers, and caregivers. Here, interventions often have focused on improving social competencies in youths by helping caregivers to practice appropriate social behavior with youths, provide rewards to youths for desired social behavior, and enroll youths in prosocial activities (e.g., martial arts, basketball). In addition, therapists have provided psychoeducation about ASD to adults and peers in regular con-

326

JOURNAL OF MARITAL AND FAMILY THERAPY

July 2014

tact with the youths and have helped caregivers to explain and discuss youth functioning with others. The caregivers in our pilot and efficacy studies have also had somewhat different strengths and needs than those of caregivers in standard MST programs. The caregivers have evidenced better developed adult support networks and greater access to highly trained service providers (e.g., pediatricians, occupational therapists, psychiatrists) than caregivers in standard MST programs. The caregivers also typically have had greater educational attainment, financial resources, and access to formal community services (e.g., respite care). Given these differences, therapists have spent less time helping caregivers to connect with tangible sources of support. On the other hand, the caregivers have often overestimated or underestimated the youth’s capabilities; in such cases, therapists have assisted caregivers in having more reasonable expectations for the youth’s behavior. Furthermore, when compared with caregivers seen in standard MST, caregivers in our project have reported feeling especially discouraged regarding the youth’s prospects for the future. As such, interventions have included normalizing such feelings, identifying youth capabilities and strengths, and developing realistic plans for their child. Our work has also indicated that families of youths with ASD encounter many of the same types of problems as those seen in standard MST. For example, caregivers have often reported that marital distress interfered with their ability to enact effective structure and discipline at home. Caregivers have also reported that they felt incompetent and that the youth’s behavior resulted in conflicts with relatives, school officials, and others in the community. Moreover, several of the caregivers of referred youths have had longstanding mental health problems (e.g., bipolar disorder, major depressive disorder) and substance abuse problems (including prescription medications) that had not been previously resolved. Furthermore, although the majority of youths had participated in other treatments, caregivers have reported that those treatments had not been successful and did not address salient caregiver and family issues (e.g., financial stressors, employment dissatisfaction, lack of recreational time). Effectiveness and Dissemination Stages Future stages of our adaptation of MST for ASD will follow the usual path to broader dissemination of the MST model (see Henggeler et al., 2009). If the results of our efficacy trial demonstrate that MST is an effective alternative to usual services in the treatment of youths with ASD, we plan to conduct an effectiveness trial using a different treatment team (i.e., supervisor and therapists) in a usual community setting (e.g., large public school system, provider network serving a major metropolitan area) to identify possible barriers to the implementation of this adaptation. Should the model provide continued evidence of promising outcomes, we plan to test the feasibility of our adaptation in several pilot sites located in other community settings. Consistent with previous adaptations of MST, future work would then focus on ensuring that desired outcomes are achieved when the model is disseminated with fidelity (i.e., quality assurance and training procedures are in place to support effective implementation). Only after these steps have been completed would broader dissemination of this adaptation occur.

CONCLUSIONS Our work to date suggests that MST may be a promising treatment approach to aggressive and other disruptive behaviors in youths with ASD. Given the broad range of social-ecological factors associated with disruptive behaviors in this clinical population, it is unrealistic to expect even the best conceived individually focused interventions to be effective over time and across settings due to their relatively narrow focus. Thus far, caregiver and therapist reports from our pilot and efficacy studies suggest that MST interventions are able to address key individual and contextual factors commonly associated with severe disruptive behaviors in youths with ASD, including communication difficulties, high caregiver stress, problematic family relations, and youth academic and social difficulties in school. Compared to office-based treatments, the delivery of MST in a variety of real-world settings (i.e., home, school, community) is designed to more effectively facilitate family participation and engagement, accurate assessment of identified problems and intervention results, and long-term July 2014

JOURNAL OF MARITAL AND FAMILY THERAPY

327

maintenance and generalization of treatment gains. Although the costs of providing services in the family’s natural environment may seem formidable when compared with the cost of less intensive community services, recent cost-benefit studies of standard MST for serious and violent juvenile offenders suggest that communities that invest in this treatment model will likely recoup their costs within the first few years after starting a program (Drake, Aos & Miller, 2009; Klietz, Borduin & Schaeffer, 2010). Of course, restrictive interventions (e.g., residential treatment) for youths with ASD are already associated with high costs to families and taxpayers and lack any evidence of clinical effectiveness. The findings from our ongoing work and subsequent evaluations will ultimately determine whether MST is both clinically effective and cost-effective in the treatment of youths with ASD. Nevertheless, given the significant problems that youths with ASD often present for their families and society, we believe that priority should be placed on the evaluation of promising family-based treatments such as MST.

REFERENCES Abidin, R. R. (1995). Parenting stress index (3rd ed.). Odessa, FL: Psychological Assessment Resources. Achenbach, T. M. (1991). Manual for the child behavior checklist/4–18 and the 1991 profile. Burlington, VT: Department of Psychiatry, University of Vermont. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Baker, J. K., Seltzer, M. M., & Greenberg, J. S. (2011a). Longitudinal effects of adaptability on behavior problems and maternal depression in families of adolescents with autism. Journal of Family Psychology, 25, 601–609. Baker, J. K., Smith, L. E., Greenberg, J. S., Seltzer, M. M., & Taylor, J. L. (2011b). Change in maternal criticism and behavior problems in adolescents and adults with autism across a 7-year period. Journal of Abnormal Psychology, 120, 465–475. Bauminger, N., & Kasari, C. (2001). The experience of loneliness and friendship in autism: Theoretical and practical issues. In E. Schopler, L. Marcus, C. Shulman & N. Yirmiya (Eds.), The research basis of autism intervention outcome (pp. 151–168). New York: Kluwer Academic. Bauminger, N., & Shulman, C. (2003). The development and maintenance of friendship in high-functioning children with autism: Maternal perceptions. Autism, 7, 81–97. Bayat, M. (2007). Evidence of resilience in families of children with autism. Journal of Intellectual Disability Research, 51, 702–714. Benson, B. B., & Aman, M. G. (1999). Disruptive behavior disorders in children with mental retardation. In H. C. Quay & A. E. Hogan (Eds.), Handbook of disruptive behavior disorders (pp. 559–578). New York: Plenum. Benson, P. R., & Karlof, K. L. (2008). Child, parent, and family predictors of latter adjustment in siblings of children with autism. Research in Autism Spectrum Disorders, 2, 583–600. Blacher, J., & McIntyre, L. L. (2006). Syndrome specificity and behavioural disorders in young adults with intellectual disability: Cultural differences in family impact. Journal of Intellectual Disability Research, 50, 184–198. B€ olte, S., Dickhut, H., & Poustka, F. (1999). Patterns of parent-reported problems indicative in autism. Psychopathology, 32, 93–97. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Brookman-Frazee, L., Baker-Ericzen, M., Stahmer, A., Mandell, D., Haine, R. A., & Hough, R. L. (2009). Involvement of youths with autism spectrum disorders or intellectual disabilities in multiple public service systems. Journal of Mental Health Research in Intellectual Disabilities, 2, 201–219. Carter, A. S., Volkmar, F. R., Sparrow, S. S., Wang, J. J., Lord, C., Dawson, G., et al. (1998). The Vineland adaptive behavior scales: Supplementary norms for individuals with autism. Journal of Autism and Developmental Disorders, 28, 287–302. De Bildt, A., Sytema, S., Kraijer, D., & Minderaa, R. (2005). Prevalence of pervasive developmental disorders in children and adolescents with mental retardation. Journal of Child Psychology and Psychiatry, 46, 275–286. Derogatis, L. R. (1993). BSI brief symptom inventory: Administration, scoring, and procedures manual (4th ed.). Minneapolis, MN: National Computer Systems. Dominick, K. C., Davis, N. O., Lainhart, J., Tager-Flusberg, H., & Folstein, S. (2007). Atypical behaviors in children with autism and children with a history of language impairment. Research in Developmental Disabilities, 28, 145–162.

328

JOURNAL OF MARITAL AND FAMILY THERAPY

July 2014

Drake, E. K., Aos, S., & Miller, M. G. (2009). Evidence-based public policy options to reduce crime and criminal justice costs: Implications in Washington state. Victims and Offenders, 4, 170–196. Estes, A., Munson, J., Dawson, G., Koehler, E., Zhou, X. H., & Abbott, R. (2009). Parenting stress and psychological functioning among mothers of preschool children with autism and developmental delay. Autism, 13, 375–387. Farmer, C. A., & Aman, M. G. (2011). Aggressive behavior in a sample of children with autism spectrum disorders. Research in Autism Spectrum Disorders, 5, 317–323. Fletcher, P. C., Markoulakis, R., & Bryden, P. J. (2012). The costs of caring for a child with an autism spectrum disorder. Issues in Comprehensive Pediatric Nursing, 35, 45–69. Freedman, B. H., Kalb, L. G., Zablotsky, B., & Stuart, A. (2012). Relationship status among parents of children with autism spectrum disorders: A population-based study. Journal of Autism and Developmental Disorders, 42, 539–548. Gallagher, J. J., Beckman, P., & Cross, A. H. (1983). Families of handicapped children: Sources of stress and its amelioration. Exceptional Children, 50, 10–19. Ganz, M. L. (2007). The lifetime distribution of the incremental societal cost of autism. Archives of Pediatric and Adolescent Medicine, 16, 343–349. Gau, S., Chou, M., Chiang, H., Lee, J., Wong, C., Chou, W., et al. (2012). Parental adjustment, marital relationship, and family function in families of children with autism. Research in Autism Spectrum Disorders, 6, 263–270. Gurney, J. G., McPheeters, M. L., & Davis, M. M. (2006). Parental report of health conditions and health care use among children with and without autism. Archives of Pediatrics and Adolescent Medicine, 160, 825–830. Hartley, S. L., Barker, E. T., Seltzer, M. M., Floyd, F., Greenberg, J., & Orsmond, G. (2010). The relative risk and timing of divorce in families of children with an autism spectrum disorder. Journal of Family Psychology, 24, 449–457. Hastings, R. P. (2003). Behavioral adjustment of siblings of children with autism engaged in applied behavior analysis early intervention programs: The moderating role of social support. Journal of Autism and Developmental Disorders, 33, 141–150. Hastings, R. P., & Brown, T. (2002). Coping strategies and the impact of challenging behaviors on special educators’ burnout. Mental Retardation, 40, 148–156. Hastings, R. P., Kovshoff, H., Ward, N. J., Espinosa, F., Brown, T., & Remington, B. (2005). Systems analysis of stress and positive perceptions in mothers and fathers of pre-school children with autism. Journal of Autism and Developmental Disorders, 35, 635–644. Henggeler, S. W., & Borduin, C. M. (1990). Family therapy and beyond: A multisystemic approach to treating the behavior problems of children and adolescents. Pacific Grove, CA: Brooks/Cole. Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (2009). Multisystemic therapy for antisocial behavior in children and adolescents (2nd ed.). New York: Guilford. Henggeler, S. W., & Sheidow, A. J. (2012). Empirically supported family-based treatments for conduct disorder and delinquency in adolescents. Journal of Marital and Family Therapy, 38, 30–58. Higgins, D. J., Bailey, S. R., & Pearce, J. C. (2005). Factors associated with functioning style and coping strategies of families with a child with an autism spectrum disorder. Autism, 9, 125–137. Hoffman, L. (1981). Foundations of family therapy. New York: Basic Books. Horvath, K., & Perman, J. A. (2002). Autistic disorder and gastrointestinal disease. Current Opinion in Pediatrics, 14, 583–587. Humphrey, N., & Symes, W. (2011). Peer interaction patterns among adolescents with autism spectrum disorders (ASDs) in mainstream school settings. Autism, 15, 397–419. Kanne, S., Gerber, A., Quirmbach, L., Sparrow, S., Cicchetti, D., & Saulnier, C. (2011). The role of adaptive behavior in autism spectrum disorders: Implications for functional outcome. Journal of Autism and Developmental Disorders, 41, 1007–1018. Kanne, S. M., & Mazurek, M. O. (2011). Aggression in children and adolescents with ASD: Prevalence and risk factors. Journal of Autism and Developmental Disorders, 41, 926–937. Klietz, S. J., Borduin, C. M., & Schaeffer, C. M. (2010). Cost-benefit analysis of multisystemic therapy with serious and violent juvenile offenders. Journal of Family Psychology, 24, 655–666. Koning, C., & Magill-Evans, J. (2001). Social and language skills in adolescent boys with Asperger syndrome. Autism, 5, 23–36. Konstantareas, M. M., & Homatidis, S. (1992). Mothers’ and fathers’ self-report of involvement with autistic, mentally delayed, and normal children. Journal of Marriage and the Family, 54, 153–164. Lecavalier, L., Leone, S., & Wiltz, J. (2006). The impact of behaviour problems on caregiver stress in young people with autism spectrum disorders. Journal of Intellectual Disability Research, 50, 172–183. Levy, A., & Perry, A. (2011). Outcomes in adolescents and adults with autism: A review of the literature. Research in Autism Spectrum Disorders, 5, 1271–1282.

July 2014

JOURNAL OF MARITAL AND FAMILY THERAPY

329

Little, L. (2002). Middle-class mothers’ perceptions of peer and sibling victimization among children with Asperger’s syndrome and nonverbal learning disorders. Issues in Comprehensive Pediatric Nursing, 25, 43–57. Lord, C., Petkova, E., Hus, V., Gan, W., Lu, F., Martin, D. M., et al. (2012). A multi-site study of the clinical diagnosis of different autism spectrum disorders. Archives of General Psychiatry, 69, 306–313. Lord, C., Rutter, M., Goode, S., Heemsbergen, J., Jordan, H., & Mawhood, L. (1989). Autism diagnostic observation schedule: A standardized observation of communicative and social behavior. Journal of Autism and Developmental Disorders, 19, 185–212. Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism diagnostic interview–revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24, 659–685. Matson, J. L., Wilkins, J., & Macken, J. (2009). The relationship of challenging behaviors to severity and symptoms of autism spectrum disorders. Journal of Mental Health Research in Intellectual Disabilities, 2, 29–44. McIntyre, L. L., Blacher, J., & Baker, B. L. (2002). Behaviour/mental health problems in young adults with intellectual disability: The impact on families. Journal of Intellectual Disability Research, 46, 239–249. Montes, G., & Halterman, J. S. (2007). Psychological functioning and coping among mothers of children with autism: A population-based study. Pediatrics, 119, e1040–e1046. National Research Council. (2001). Educating children with autism. Washington, DC: Author. Neely, J., Amatea, E. S., Echevarria-Doan, S., & Tannen, T. (2012). Working with families living with autism: Potential contributions of marriage and family therapists. Journal of Marital and Family Therapy, 38, 211–226. Nelson, K. E., & Landsman, M. J. (1992). Alternative models of family preservation: Family- based services in context. Springfield, IL: Charles Thomas. Olson, D. H., Portner, J., & Bell, R. (1982). FACES-II. In D. H. Olson, H. I. McCubbin, H. L. Barnes, A. Larsen, M. Muxen & M. Wilson (Eds.), Family inventories (pp. 5–24). St. Paul: Department of Family Social Science, University of Minnesota. Ornstein Davis, N., & Carter, A. S. (2008). Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: Associations and child characteristics. Journal of Autism and Developmental Disorders, 38, 1278–1291. Orsmond, G. I., Krauss, M. W., & Seltzer, M. M. (2004). Peer relationships and social and recreational activities among adolescents and adults with autism. Journal of Autism and Developmental Disorders, 34, 245– 256. Petalas, M. A., Hastings, R. P., Nash, S., Lloyd, T., & Downey, A. (2009). Emotional and behavioural adjustment in siblings of children with and without autism. Autism, 13, 471–483. Procidano, M. E., & Heller, K. (1983). Measures of perceived social support from friends and from family: Three validation studies. American Journal of Community Psychology, 11, 1–24. Ramisch, J. (2012). Marriage and family therapists working with couples who have children with autism. Journal of Marital and Family Therapy, 38, 305–316. Ross, P., & Cuskelly, M. (2006). Adjustment, sibling problems, and coping strategies of brothers and sisters of children with autistic spectrum disorder. Journal of Intellectual and Developmental Disability, 31, 77–86. Rutter, M. (2005). Genetic influences and autism. In F. Volkmar (Ed.), Handbook of autism and pervasive developmental disorders, Vol. 1: Diagnosis, development, neurobiology, and behavior (3rd ed., pp. 425–452). Hoboken, NJ: Wiley. Sawyer, A. M., & Borduin, C. M. (2011). Effects of multisystemic therapy through midlife: A 21.9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology, 79, 643–652. Schieve, L. A., Blumberg, S. J., Rice, C., Visser, S. N., & Boyle, C. (2007). The relationship between autism and parenting stress. Pediatrics, 119, S114–S121. Siegel, B. (1997). Coping with the diagnosis of autism. In D. J. Cohen & F. R. Volkmar (Eds.), Handbook of autism and pervasive developmental disorders (2nd ed., pp. 5–38). New York: Wiley. Sivberg, B. (2002). Family system and coping behaviors: A comparison between parents of children with autistic spectrum disorders and parents with non-autistic children. Autism, 6, 397–409. Solomon, A. H., & Chung, B. (2012). Understanding autism: How family therapists can support parents of children with autism spectrum disorders. Family Process, 51, 250–264. Stuart, M., & McGrew, J. H. (2009). Caregiver burden after receiving a diagnosis of autism spectrum disorder. Research in Autism Spectrum Disorders, 3, 86–97. Wagner, D. V., Borduin, C. M., Mazurek, M. O., Kanne, S. M., Brown, R. M. A., & Farmer, J. E. (2012a). Treating youths with autism spectrum disorder using multisystemic therapy: A case series. Unpublished manuscript. Wagner, D. V., Borduin, C. M., & Sawyer, A. M. (2012b). Long-term prevention of criminality in siblings of serious and violent juvenile offenders: A 25-year follow-up to a randomized clinical trial of multisystemic therapy. Manuscript submitted for publication.

330

JOURNAL OF MARITAL AND FAMILY THERAPY

July 2014

Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J. H., et al. (2011). Therapies for children with autism spectrum disorders. Comparative effectiveness review No. 26. Retrieved April 04 , 2011, from the Agency for Healthcare Research and Quality website. Available at: www.effectivehealthcare. ahrq.gov/reports/final.cfm. Woodgate, R. L., Ateah, C., & Secco, L. (2008). Living in a world of our own: The experience of parents who have a child with autism. Qualitative Health Research, 18, 1075–1083.

NOTES 1

We do not distinguish between categorical diagnostic subtypes of autism spectrum disorders (i.e., Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder—Not Otherwise Specified) because research findings provide strong and consistent evidence that these subtypes are not clinically or etiologically distinct (see Lord et al., 2012).

July 2014

JOURNAL OF MARITAL AND FAMILY THERAPY

331