Mental Health Services for ASDs

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Sigmund Freud

Sigmund Freud (Source: Flickr)

Students with Autism Spectrum Disorders (“ASDs”), including Asperger’s Syndrome and Pervasive Developmental Disorder, Not Otherwise Specified (“PDD-NOS”), are often challenged by anxiety, which is an emotional health need. Many school districts contract with county mental health agencies or other providers for forms of individual psychotherapy services that may not be appropriate for some students with ASDs. Further, they may have no other service to offer to address ASD-related anxiety issues.

To add to the confusion, many county mental health agencies have recently re-identified themselves as county behavioral health agencies, yet they do not provide Applied Behavioral Analysis (“ABA”) or any other type of peer-reviewed behavioral intervention. ABA is supported by research to be effective in not only contending with undesired behaviors among persons with ASDs but also in providing explicit instruction to teach the skills these individuals lack.

Explicit instruction in social skills such as greetings, farewells, maintaining a topic of conversation chosen by another person, initiating conversations, and other aspects of human interaction have to taught to many children with ASDs as explicit, scripted procedures. Those procedures can then be generalized into real life by reinforcing them when they occur in natural settings and pointing out to the individual, in vivo, when he/she has engaged in the steps of the procedure so that he/she learns to recognize social contexts in which each script is to be applied.  Eventually, it becomes a learned, rehearsed strategy to deal with specific types of situations.

The degree to which persons with ASDs can master various scripted procedures, or even need this level of support, varies from individual to individual. The same for the degree to which someone with an ASD can generalize knowledge from one context to another, such as from the instructional setting to real life.  It’s called a spectrum disorder for a reason. The range of severity between mild and severe is quite broad and anyone can fall anywhere along it.

Traditional “talk therapy” that promotes developing one’s insight and insight into other people’s perspectives to sort out one’s issues is not necessarily appropriate for some individuals with ASDs. Because there are so many differences among people with ASDs, it’s not fair to say that no one with an ASD can benefit from traditional talk therapy. But, it is safe to say that there are a significant number of students with ASDs who truly cannot benefit from traditional talk therapy but still have emotional health needs that require mental health services as part of their special education programs.

The matter comes down to, “What form of mental health services are appropriate for students in special education who have ASDs and require mental health services in order to benefit from their IEPs?” Well, as with anything in special education, you can’t take a cookie-cutter approach and say one specific type of program will fix everything for everybody. For one thing, no such statement will ever be true; learners with disabilities, even within a population impacted by the same condition, are too diverse for one-size-fits-all programming. Federal law requires individualized programming for this very reason.

That said, there are certain approaches that are generally known to be more effective with students who have ASDs than others. These may work with many students with ASDs, but whether or not they will be effective with an individual student really depends on that student.  The following are possible methods by which effective mental health services can be delivered to some persons challenged by anxiety associated with ASDs.

For students who are verbal and can orient to others, therapists can teach students social scripts and strategies in therapy using social stories, social games, and role-plays to rehearse the appropriate strategies and scripts. The therapist then confers with the speech-language specialist, behaviorist, and school psychologist members of the IEP team to inform them regarding the strategies taught in the therapy sessions. Then the specialists work with the teachers and any aide staff to teach them the strategies the student is mastering in therapy so he/she can be prompted to use the strategies in natural settings and reinforced for their appropriate use, thus generalizing the skills.

For many high-functioning students with ASDs, their anxiety arises around social situations and the lack of predictability in their day-to-day lives. Because many students with ASDs miss the subtle nuances of social communication, they are unable to identify the relevant variables in complex social environments (like classrooms, playgrounds, and cafeterias) that must be monitored in order to reasonably predict social outcomes with sufficiently reliable accuracy. It is the difference between what makes someone functional within an environment or not.

An impaired ability to predict outcomes in day-to-day life can make each experience seem novel. Think of what it feels like to be in a novel environment where you aren’t sure of how you’re supposed to act or who you can ask for help (or, worse, thinking that there is no one who can be asked for help or having it never occur to you that you could ask for help). For some students with ASDs, feelings like these are very anxiety-provoking.

Providing these students with scripted routines, procedures, schedules, and strategies provides them with the tools to regain some control over their situations and create predictability for themselves. The hard part is equipping them with enough scripts to cover a diverse-enough range of issues that will leave them functionally equipped for as many real-life challenges as possible. You can’t write a script for every possible scenario in life.

The trick is to write scripts that are general enough to fit a number of common contexts and then teach the student how to adapt each script to fit unique situations during the in vivo support that is provided to help the student generalize the skills from the therapy sessions to real life. That can often require the expertise of a behaviorist, if not a Board Certified Behavior Analyst (“BCBA”), to work with the mental health therapist to help tailor the approach to fit the individual student.

During the course of therapy, the student could also be assisted to the degree necessary with learning how to identify and label his/her emotions. There are curricula that target this very need and speech-language pathologists use them all the time. I’m not going to get into specific products; just suffice it to say that whatever product is chosen needs to be based on its fit to the student’s actual needs and not just on the basis of that’s what was already in the supply closet or installed on the computer in the speech room.

It seems to me that a possible model of service delivery that could prove effective would be one in which a county behavioral health agency creates a treatment team for students with the kinds of needs I’ve been describing here that includes a mental health therapist, a BCBA for assessment and on-going consult, and a behavioral aide who is trained to support the student in the school setting according to a cohesive mental and behavioral health treatment plan that includes a behavior intervention plan of some kind.

This would not be for the purpose of positive behavioral interventions to remediate maladaptive behaviors; it would be for the purpose of ameliorating anxiety, which is a mental health treatment need. The issue here is simply that the student at issue requires a behavioral approach to a mental health need. That’s something a county behavioral health agency should be able to handle.

The thing is, this is just an idea I’ve had. I’ve yet to see it in action so I can’t say for a fact that it would work out as I envision. I’d love to build a clinical trial around it, but I don’t have the time for something like that right now. (If anybody wants to take the idea and run with it, please let me know!)

For students with more severe presentations of ASDs, any approach that relies too heavily on verbal conversation may be inappropriate. There may be a greater need to use prompting and extrinsic reinforcement of desired behaviors throughout the execution of a scripted process in order to rehearse it successfully with these students. And, it may take a significant amount of rehearsal before the skill is mastered. It is very high-maintenance at first, and sometimes for a long time, but the payoff is totally worth it once a student develops increased independence from mastering the skill.

Even if you have to start with the most basic, foundational skills, you can get the process in motion for a lengthy, involved, intensive level of instruction that will gradually increase the student’s independence over a period of several years. It may seem like you’re building a castle out of grains of sand at first, but eventually the process can pick up momentum and the next thing you know, part of a wall is built. Anything you do to decrease the student’s need for adult assistance is both liberating for the student and minimizing of the costs of his/her intervention.

Rendering effective mental health services to students in special education who have ASDs and need mental health services in order to benefit from their IEPs can be done cost-effectively. It requires that the right combination of expertise and skill assembled for each student’s treatment team. It also requires well-designed mental and behavioral health treatment plans that include detailed descriptions of how the skills taught in therapy will be generalized to natural settings such as the classroom, playground, cafeteria, or school bus. The treatment team would need to function like a well-oiled machine, each complementing the work of the other.

The savings to society of doing it right would far exceed the costs of delivering a successful program. More importantly, there are just some aspects of independence upon which no dollar value can be placed. To be supported in becoming as independent as possible by one’s fellow citizens affords some of our most compromised citizens access to their Constitutional liberties, and that’s something of which one can be proud to be a part.

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4 thoughts on “Mental Health Services for ASDs

  1. Dr.S

    This post is very helpful for helping parents navigate this often confusing terrain. However, let me point out some things. BCBA’s seem to be quite “hot” in the field of education, presumably because of their ability to perform ABA services. However, I often run into parents and schools that feel that these are the only folks who can help and provide therapy for student’s on the spectrum. Behaviorism is an umbrella for many types of treatments (ABA being among these). Doctoral level Clinical Psychologists and school psychologists who have training in behaviorism (Most do) also provide these services. ABA is only one form of treatment and usually the only form that BCBA’s provide (unless a BCBA with Doctorate and license to practice independently). However, BCBA’s often are not trained in other forms of behavior therapies that may be required in working with student’s. Often with higher functioning student’s I find a blend of behavioral therapy, skills training, and cognitive-behavioral approaches, which are especially useful at helping student’s who also experience anxiety or depression. Parent’s may be surprised to learn that a substantial amount of school psychologists are trained in behaviorally oriented therapies, such as contingency management, Positive Behavior Supports, Token Economy, etc. I am not writing this to “bash” behaviorists as they have an important role. However, I see that the training and limitations of school psychologists are pointed out on this site, I think that it should be pointed out that BCBA’s require a master’s degree (though not necessarily in psychology, it can be natural science, education, human services, or even engineering) and supervised hours. The school psychologist typically requires a specialist level degree (3 years after the bachelor’s degree), supervised practica, and internship. Neither are licensed to practice independently (in most states). Parents will have to decide who they feel most comfortable with providing the services, but there are many reasons why a licensed doctoral psychologist or school psychologists may be the better selection to provide behavioral services, the least among these being their assessment, diagnostic skills, and broader range of theraputic services provided. Doctoral level and school psychologists with training in behavioral approaches (most do) do not need BCBA’s to “tailor the approach” as is mentioned above as they most often always have a good deal more education, training, and experience than the BCBA’s. In sum, Parent’s need to ask their professional about their education and training and if they can provide behavioral services that they may need. Understand that good quality services can come from BCBA’s, school psychologists, and licensed clinical psychologists.

    Best,

    Reply
    1. Anne M. Zachry Post author

      Dr. S.,

      Thanks again for excellent input. You’re right that BCBAs can have a master’s in anything and I agree that can be a shortcoming in how they are certified. In some states, school psychologists must complete a 2-year master’s program that includes coursework towards the appropriate credential and then pass a written exam plus do their intern hours to get the credential. I think that’s part of the problem – we have different licensing, credentialing, and certification programs that vary by state, so people with the same titles are held to different degrees of responsibility from state-to-state and it confuses people as to what these titles really mean. People tend to assume what they mean based on past experience rather than questioning what they mean in the current context.

      When it comes to providing mental health services to students with ASDs under IEPs, what we’ve encountered in the field is county mental health agencies that are contracted with the public schools claiming that they don’t “treat autism,” which they expand to include the types of anxiety often common among those with ASDs. This is because they want to sit and chat with these students about their feelings and the feelings of others, which – for at least some of these kids – is entirely off-base and ineffective. That’s the treatment model they follow and they don’t deviate from it. They call it “individual therapy” and it only comes in one Freudian form.

      I had one county mental health therapist tell me that the works of Skinner and Pavlov were only cursory curiosities from an undergraduate course he vaguely recalled taking decades before and he couldn’t remember what exactly “their deal was” except for a sketchy recollection of the Pavlov’s Dog experiment. I heard another testify in hearing that his agency refused to fund training on treating mental health conditions in those with ASDs, so none of his staff had received any such training.

      I think most people can appreciate how it should be in the field, but, what actually happens is often something very different. That’s what we’re trying to fix. 🙂

      Anne

      Reply
  2. Anne M. Zachry Post author

    Nell,

    We are so glad you found it helpful. You may also want to check out our article “Velcro(R) Aide” vs. Learning Facilitator, since you’re concerned about aide dependence. Too many students who have ASDs are either given aides as accommodations rather than as instructional supports, which creates learned helplessness, or they are warehoused in special day classes where a teacher and an aide or two can keep everybody corralled. An intelligent plan that blends special education supports with general education placement can make all the difference for many children with ASDs.

    Anne

    Reply
  3. Nellspecials

    This is truly awesome information. My son was diagnosed at age 2, receives district paraeducator support, is highly dependent on this support – but the district has not assessed his need in this area for over 8 years. Is it job security they’re seeking through my child’s continued dependence? This gives me ideas of how to present my request for ABA support at the next IEP. Thank you.

    Reply

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