Mar 5, 2015 | Author Videos, Volume 5 - Issue 2
Carl Sheperis, Donna Sheperis, Alex Monceaux, R. J. Davis, Belinda Lopez
Parent–Child Interaction Therapy (PCIT) is an evidence-based method for reducing disruptive behavior in children and improving parent management of behavior. PCIT is a form of behavioral intervention that can be used in clinical, home and school settings. Although initially designed for intervention related to oppositional defiant disorder and conduct disorder, PCIT has been found to be a promising intervention for addressing behavioral issues among children with special needs. We present methods, research-based instructions and a case example of PCIT with a child diagnosed with autism. This article is intended to assist professional counselors in designing appropriate interventions for both children and parents.
Keywords: autism, parent–child interaction therapy, special needs, behavioral intervention, case example
Counseling techniques for children stem from a myriad of theoretical perspectives, and professional counselors are often in the unique position to provide systems intervention and training to families when a child has disruptive behavior. Despite the seniority of behaviorism in the field of psychology, behavioral family approaches have only recently been acknowledged as an effective practice in professional counseling. According to Gladding (2011), the following three premises underlie behavioral family counseling: (a) all behaviors are learned, (b) maladaptive behaviors are the target for change and (c) not everyone in the family has to be treated for change to occur. With these assumptions, it is easily deduced that the following also are true: (a) behavior can be unlearned and that new behaviors can be taught, (b) underlying, unresolved issues are not the key components of treatment, and (c) positive changes for one family member will impact the entire family system and surrounding ecology.
When working with children of preschool or early elementary age, it is important to directly involve the child’s caregivers. Parents’ influence on their children is significant and some parenting practices may exacerbate some children’s problems (McNeil & Hembree-Kigin, 2010). Behavioral family counseling models recognize the relationship between the child’s behavior and the family system. One behavioral family counseling technique, Parent-Child Interaction Therapy (PCIT), helps families work together with their children in reaching therapeutic goals. PCIT involves teaching parents some fundamental relationship-building strategies, including therapeutic play techniques for parents to use in the home environment (Johnson, Franklin, Hall, & Prieto, 2000). The clinician typically teaches and models PCIT techniques for the parents over the course of 8–10 weeks.
The purpose of this article is to demonstrate the practicality of PCIT as a component of behavioral family counseling, to facilitate the professional counselor’s understanding of the model through a review of PCIT and to illustrate the utility of this model for children with special needs through a case study.
An Overview of PCIT
PCIT (Neary & Eyberg, 2002) is an assessment-driven form of behavioral parent training designed for families with preschool-aged children. We present a brief overview of PCIT, define the key components integral to the process, provide the framework for implementation and discuss the application of PCIT to special populations. The core of PCIT is twofold—to create nurturing parent–child relationships and to model prosocial behaviors while increasing a child’s appropriate, compliant behaviors (Eyberg & Boggs, 1989). Play therapy skills are introduced to parents within the PCIT model to enhance the relationship between the parent and child. Additionally, PCIT cultivates problem-solving skills with parents who can then generalize gains made in the therapeutic milieu into the family environment. Similar to other models of family counseling, PCIT begins with the assessment process. Counselors using PCIT collect psychosocial information from the family through either structured or semistructured clinical interviews. Because PCIT is a behavioral model, family dynamics also are assessed through direct observation of clients. Once clinical interview and observational data are collected and evaluated, the counselor can explore family relationship dynamics.
PCIT counselors attempt to identify family roles, interactions and maladaptive disciplinary techniques (e.g., yelling, lack of follow-through, unrelated consequences) inherent in the system. The ultimate goal of these observations is to derive methods for replacing current ineffective parenting strategies with more adaptive ones, thus creating greater stability in the family system. Similar to other parenting approaches, family counselors using PCIT offer support and assistance in improving parent–child relationships without placing blame on the child or the parents (Webster-Stratton & Herbert, 1993).
The Benefits of PCIT
There are many benefits to PCIT; it is a brief, short-term family counseling procedure that teaches effective parenting skills and helps parents interact better with their children on a daily basis. Fundamentally, PCIT’s two-tailed approach benefits both parents and children (Asawa, Hansen, & Flood, 2008) by reducing the internalization of problems and parent–child stress. Additionally, PCIT empowers parents through teaching positive interactive techniques that build parent–child rapport. PCIT fosters creativity and increases child self-esteem, decreases noncompliance or disruptive behavior, and increases the quality of parent-provided positive regard through developmentally appropriate play (Eyberg et al., 2001). These positive interactions effectively decrease problem behavior, resulting in a reduction or elimination of emergency counseling visits. One PCIT study reported that only 19% of participants in a randomized controlled trial with physically abusive parents re-reported physical abuse more than 2 years after the implementation of the PCIT model (Chaffin et al., 2004).
While PCIT sessions may focus on home and play, the behavioral skills that the parent learns can be generalized to other children and additional settings, building stronger interactions across a spectrum of familial and social settings. According to Urquiza and Timmer (2012), PCIT focuses on the following three essential non-fixed elements: (a) increased positive parent–child interaction and emotional communication skills, (b) appropriate and consistent discipline methods, and (c) direct scaffolding for parent training in the interventions. Thus, once the parent has mastered these skills in the session with the child and therapist, the parent is able to transfer the skills to any location or setting to maintain positive interactions, emotional communication and disciplinary consistency with the child.
The Effectiveness of PCIT
Eyberg and her colleagues have researched and published extensively on the efficacy of PCIT and have empirically supported the effectiveness of PCIT with children exhibiting a range of behavioral and emotional problems (Neary & Eyberg, 2002). Specifically, PCIT has proven effective with problems including attention-deficit/hyperactivity disorder (ADHD), conduct disorders, separation anxiety, depression, postdivorce adjustment, self-injurious behavior and abuse (Eyberg et al., 2001; McNeil & Hembree-Kigin, 2010). For example, Nieter, Thornberry, and Brestan-Knight (2013) conducted a pilot study with 17 families completing PCIT treatment and found a significant decrease in disruptive child behaviors as well as a decrease in inappropriate parent behaviors over the 12-week group program. This study was the first to deliver PCIT via group sessions. The researchers found that treatment effects remained in place for more than 6 months after the group’s completion.
Eyberg et al. (2001) investigated long-term treatment outcomes of PCIT for families of preschoolers with conduct disorders over a period of 1–2 years, and found that treatment effects were sustained over time. According to the researchers, the study was the first of its kind to include long-term follow-up with families receiving PCIT treatment (Eyberg et al., 2001). Hood and Eyberg (2003) established further evidence in another follow-up study on PCIT treatment effects over a period of 3–6 years. In the study of treatment effects on families with young children diagnosed with oppositional defiant disorder, the researchers found that treatment effects and behavioral change were again sustained over time. Thomas and Zimmer-Gembeck (2007) conducted a review of behavior outcomes in 24 studies on PCIT and another parenting intervention, Triple P—Positive Parenting Programs. All of the studies involved children aged 3–12 and their caregivers. Meta-analyses revealed positive effects for PCIT as well as the other intervention, adding support within the literature on the efficacy of PCIT.
To demonstrate the effectiveness of PCIT for treating ADHD, Guttmann-Steinmetz, Crowell, Doron, and Mikulincer (2011) examined the interactions of children with ADHD and their mothers. Their findings suggest that while Behavior Parent Training is useful in managing ADHD, PCIT may be highly effective in impacting the attachment-related processes during the child’s later developmental stages. These researchers suggested that parents’ successful adaptation of PCIT’s verbal and behavioral skills during interaction with their child might increase the child’s sense of security.
The effectiveness of PCIT has been expanded to other disorders such as separation anxiety. For example, Choate, Pincus, Eyberg, and Barlow (2005) conducted a pilot study involving three families with children 4–8 years of age diagnosed with separation anxiety disorder. The researchers found that the child-directed activities fostered children’s sense of control and reduced separation anxiety symptomology to normative levels by the conclusion of treatment. Again, the treatment effects were shown to persist long after treatment ceased. This study was replicated by Anticich, Barrett, Gillies, and Silverman (2012), providing further support of PCIT’s effectiveness in alleviation of separation anxiety disorder symptomology.
Individuals or populations with special needs also appear to respond positively to PCIT. Bagner and Eyberg (2007) found that mothers of young children diagnosed with mental retardation and oppositional defiant disorder reported a reduction in disruptive behaviors, increased compliance and less parenting stress after participating in a randomized, controlled trial study utilizing PCIT. PCIT also has been cited as a promising evidence-based intervention for autism (Agazzi, Tan, & Tan, 2013). Solomon, Ono, Timmer, and Goodlin-Jones (2008) conducted a randomized trial of PCIT for treating autism and found the same results as researchers studying other disorders have. PCIT was shown to reduce behavioral disruptions, increase adaptability and increase positive parental perceptions of child behavior. While PCIT was originally developed to address behavioral disorders, it clearly serves as an intervention for various other disorders that impact parent–child interactions.
The impact of PCIT on parents. PCIT has been shown to have equally effective outcomes for parent-related issues as it does for child behavioral disruptions. For example, Luby, Lenze, and Tillman (2012) reported highly favorable results for using PCIT to reduce behavioral disruptions and improve executive function among preschoolers. However, PCIT also showed significant effects for parents. Specifically, PCIT interventions helped to reduce depression severity and parenting stress while increasing emotion recognition. Furthermore, Urquiza and Timmer (2012) found that parental depression decreases the likelihood that the child will complete the treatment course. However, if the parents are persuaded to continue until completion, their own psychological symptoms may be relieved.
PCIT has been shown to have positive effects on parents in a variety of circumstances. For example, Baker and Andre (2008) suggested that PCIT might offer a unique and promising advantage in the treatment of postdivorce adjustment issues in children. PCIT also has been found to be effective in working with abusive parents, many of whose histories included depression, substance abuse and violent behavior (Chaffin et al., 2004). Although still effective in reducing parenting stress and child behavior problems, Timmer et al. (2011) found that PCIT was less effective in foster parent homes than in non-foster parent homes. While PCIT is clearly an effective intervention for both children and parents, in cases with complex systems like foster care placement and abuse, PCIT could be used in conjunction with other interventions. The same is true for clients with special needs.
Diverse population efficacy. Although we recognize that one size does not fit all, PCIT has shown significant results with ethnic minorities and underserved populations. Different cultural and ethnic group parenting styles (strict vs. relaxed styles) vary across the United States. In addition to effectively increasing positive parenting behaviors and deceasing behavioral problems in children, treatment outcomes and efficacy studies support the notion that PCIT is culturally effective and produces robust modifications among diverse groups (see Bagner & Eyberg, 2007; Borrego, Anhalt, Terao, Vargas, & Urquiza, 2006; Matos, Torres, Santiago, Jurado, & Rodríguez, 2006; McCabe & Yeh, 2009). Additional literature and empirical research is available for review regarding work with specific populations such as African Americans and Asians. There also is promising evidence pointing to PCIT’s efficacy in populations exhibiting neurological and behavioral disorders such as autism (Tarbox et al., 2009).
Efficacy through translation. Matos et al. (2006) conducted research in Puerto Rico with parents of children aged 4–6 with ADHD. The manual and handouts were translated into Spanish with a few modifications. Results showed significant decreases in behavior problems and hyperactivity. A recent follow-up study using the culturally adapted version further revealed that significant and robust outcome measures resulted from large treatment effect sizes. Mothers reported reductions in “hyperactivity-impulsivity, inattention, and oppositional defiant and aggressive behavior problems, as well as a reduced level of parent-child related stress and improved parenting practices” (Matos, Bauermeister, & Bernal, 2009, p. 246). Additionally, in a single-case study with a Spanish-speaking foster mother and a 3-year-old Mexican-Chilean-Filipina child, PCIT proved to be effective; reports from other family members noted substantive behavior improvement (Borrego et al., 2006). Thus, we can deduce that PCIT can be used effectively across cultural groups.
There are three main components of PCIT: child-directed interaction (CDI), parent-directed interaction (PDI) and cleanup. Depending on the session being held, the components are presented in 5-minute segments with varying degrees of parent control required. CDI is characteristically the first stage in PCIT. Similar in approach to filial play therapy, this first stage creates an opportunity to strengthen the parent–child relationship. Because PCIT is utilized in the context of dyadic play, it is conducted in a room conducive to play (McNeil & Hembree-Kigin, 2010). Thus, a room designated for CDI should contain a variety of toys, crayons, paper, modeling compounds and other developmentally appropriate activities for a child. As with other play techniques, in order to give children the opportunity to determine the rules by which they will play, games with rules are generally excluded from a CDI playroom. Children engaged in CDI should be allowed to play with any or all of the items in the room. Encouraging free play indicates to the child that he or she is the creator of the play, not the caregiver. This approach allows the time to truly be child-directed.
Within CDI, the establishment of a positive therapeutic relationship is a crucial step in building a foundation for the introduction of compliance training. Compliance training is simply teaching a child to mind or comply over a period of time, through small compliance goals set by the parents. To lay the groundwork for this process during CDI, the parents are instructed to praise, reflect, imitate and describe their child’s play, while not asking questions, placing demands or criticizing the activities that transpire unless harmful to the child (McNeil, Eyberg, Eisentadt, Newcomb, & Funderburk, 1991).
Another essential concept introduced during CDI, includes fostering the enthusiasm and willingness of the parent. Although responding positively to a child’s free play during CDI may appear simple, parents often need considerable practice to master this response set. For example, one of the toys in our clinic is a Mr. Potato Head. Young children can be very creative in their placement of the various accessories that come with the toy. Often they will place an arm on top of the head, lips on the ear hole or eyes over the mouth hole. In PCIT, we view this action as an expression of creativity. However, when we observe parents in free play with their children, we often witness the parents limiting their children’s creativity by redirecting the placement of the appendages on Mr. Potato Head. Parents often say, “No, honey, the lips go here,” or “That’s not where the arms go.” Instructing parents to refrain from making such comments is generally all that a PCIT counselor needs to do. PCIT counselors understand that this is a difficult skill for most parents to master, and they teach parents the acronym PRIDE for use during CDI as well as other elements of PCIT. PRIDE simply stands for praise, reflection, imitation, description and enthusiasm (Eyberg, 1999). Table 1 provides some practical examples of desired responses from parents during CDI using the PRIDE approach.
Responses Using PRIDE model
||Parent: “Thank you for putting away the toys.”
||Child: “I’m drawing a dinosaur.”Parent: “I see. You are drawing a dinosaur.”
||Child is playing with a car. Parent gets a similar car and begins playing in the same manner.
||Child is playing with a toy airplane. Parent says, “You are making the airplane fly.”
||Parent: “Wow. Your drawing is very creative.”
In the second stage of PCIT, PDI usually is initiated once parents master CDI. Mastery is evidenced during the child’s play by the parents exhibiting proper implementation of the PRIDE responses. PDI also is conducted in the playroom or room selected for CDI. PDI consists of teaching parents how to manage their child’s behavior and promoting compliance with parental requests (Bahl, Spaulding, & McNeil, 1999). Parents should understand that PDI is more difficult for children than CDI and will likely be challenging for both the child and parent. When beginning PDI, parents must understand the importance of appropriate discipline techniques and receive training in giving clear directions to their children. Because children require a great deal of structure, professional counselors emphasize the importance of consistency, predictability and follow-through in this training (McNeil & Hembree-Kigin, & 2010). In order to initiate compliance training, parents practice giving effective instructions to their child. McNeil and Hembree-Kigin (2010) offered several rules for giving good instructions as part of the parent training element of PDI that can be conceptualized in the following ways: Command Formation, Command Delivery and Command Modeling:
- Give direct commands for things you are sure the child can do. This increases the child’s opportunity for success and praise.
- Use choice commands with older preschoolers. This fosters development of autonomy and decision making. (e.g., “You can put on this dress or this dress” rather than “What do you want to wear?” or “Wear this”).
- Make direct commands. Tell the child what to do instead of asking whether they would like to comply (e.g., “Put on your coat”).
- State commands positively by telling child what to do instead of what not to do. Avoid using words such as “stop” and “don’t.”
- Make commands specific rather than vague. In doing so, the child knows exactly what is expected and it is easier to determine whether or not the child has been compliant.
- Limit the number of commands given.
- Some children are unable to remember multiple commands. The child’s opportunity for success and praise increases with fewer, more direct instructions given at a time.
- When giving too many commands, parents have difficulty following through with consequences for each command. Additionally, the parent’s ignoring some minor behaviors may be best.
- Always provide a consequence for obedience and disobedience. Consequences are the quickest ways to teach children compliance. Consistency when providing consequences is the key to encouraging compliance.
- Use explanations sparingly. Some children would rather stall than know the answer. Avoiding the explanation trap prevents children from thinking they have an opportunity to talk their way out of it.
- Use a neutral tone of voice instead of pleading or yelling. Interactions are more pleasant in this manner and the child learns to comply with commands that are given in a normal conversational voice.
- Be polite and respectful while still being direct. This models appropriate social skills and thus interactions are more pleasant.
After teaching parents to deliver effective instructions and allowing time for in vivo practice, professional counselors introduce appropriate discipline strategies to be used in PDI. The in vivo coaching model utilizes an observation room with a two-way mirror and the ability to for the counselor to communicate with the parent via microphone. The focus on training includes communication and behavior management skills with additional homework sessions (Urquiza & Timmer, 2012). In a study by Shanley and Niec (2010), parents who were coached via a bug-in-ear receiver with in vivo feedback during parent–child interactive play demonstrated rapid increases in positive parenting skills and interactions. Of these strategies, timeout is the most common as it is “a brief, effective, aversive treatment that does not hurt a child either physically or emotionally” (Eaves, Sheperis, Blanchard, Baylot, & Doggett, 2005, p. 252). Furthermore, Eaves et al. (2005) wrote that timeout benefits both children with problematic behaviors and those who view the technique being used on other children, in addition to those children and adolescents demonstrating developmental delays, psychiatric issues and defiance. However, for the parent to experience timeout’s full benefit, the technique must be appropriately and consistently administered. Eaves et al.’s (2005) article, “Teaching Time-Out and Job Card Grounding Procedures to Parents: A Primer for Family Counselors” is an excellent article on timeout and why it is an effective intervention.
All aspects of timeout are reviewed with the parents, such as the rationale for timeout, where timeout should take place in the home, what to do when the child escapes timeout, what to do if the child does not comply with timeout, the length of timeout, what should happen right before timeout and what should happen right after timeout. Parents receive written instructions illustrating each step of timeout and offering guidance on how to implement the procedure. These discipline strategies may not be necessary if a child is motivated to be compliant. Determining compliance is often a very hard decision for parents to make. According to McNeil and Hembree-Kigin (2010) there are several rules used to help parents determine compliance or noncompliance.
- Parents must be sure that the instructions are developmentally appropriate for the child. If the child is asked to bring the orange cup to the parent, one must know that the child can determine which cup is actually orange.
- Parents should know that the request is completely understood by the child. If there are any questions about this the parents should point or direct the child to help him or her fully understand the request.
- Parents should allow the child approximately 3 seconds to begin to attempt the task. If the child has not begun to attempt the task by this time it should be considered noncompliance.
- Parents should state the request only once. If the child pretends not to hear the request, this should be considered noncompliance.
- Parents should not allow the child to partially comply with instructions. If parents accept half-compliance then children will often repeat the negative behavior because they know they can get away with it.
- Parents should not respond to a child’s bad attitude in completing a request. As long as he or she completes the instruction, it is compliance.
- Parents should consider it compliance if a child does what is asked and then undoes what is asked. Compliance is compliance no matter how long it lasts.
When a parent determines that a child is compliant, verbal praise should be provided. This praise should be given immediately and focus on the child’s compliance. Parents are encouraged to practice the skills of giving good directions by delivering multiple commands to the child. These commands are given during the playtime and may include requests to hand things to the parent (e.g., “Give me the red block”) or play with certain toys (e.g., “Place the blue car in the box”). This activity allows the child to practice following directions, while also affording the parent the opportunity to practice praise (McNeil & Hembree-Kigin, 2010). The child begins to learn that when he or she follows directions, his or her parents are very appreciative and excited. After the small tasks are accomplished, parents begin to place demands on the child that are less desirable, such as cleaning up the toys or moving on to another task (McNeil & Hembree-Kigin, 2010). By assigning less desirable tasks, parents find themselves in a position to practice a timeout procedure with the child. The professional counselor is there to model timeout and coach the parents when practicing timeout.
The third and final component to consider is called cleanup, which occurs as part of PDI. This time during the PCIT process is exactly what one might think; it is intended to teach the child to clean up the toys at the end of the parent–child interaction in both the counseling and home milieus. Cleanup should be done without the parents’ help but with the parents’ direction. Although this component may seem simple, it tends to be a challenging situation, as significant behavior problems often are displayed during this phase. The expectation is that this phase lasts 5 minutes, but time varies depending upon the behavior of the child (McNeil & Hembree-Kigin, 2010). Cleanup occurs only at the end of parent-directed play, not at the end of child-directed play, to avoid confusing the child about the role of parental help during cleanup. All three components—CDI, PDI and cleanup—are opportunities for behavioral observation and data collection.
According to McNeil and Hembree-Kigin (2010), there are six steps in conducting PCIT with a family. These authors have briefly described the contents of each step as well as provided guidelines for the number of sessions typically devoted to completing the tasks within each step. Step 1 requires one to two sessions for the intake process, Step 2 requires one session to introduce and teach parents CDI skills, and Step 3 requires two to four sessions in which the parents are coached on these skills. Steps 4 and 5 introduce and coach the PDI and may take up to six sessions. The final session is the follow-up session. These six steps complete a 10- to 15-session triadic training program.
Step 1 is the initial intake and can be accomplished in one to two counseling sessions, unless classroom or other observations are warranted. These sessions consist of assessing family dynamics, obtaining the family’s perception of the presenting problems, probing for insights into the current disciplinary beliefs and methods held by the parents, and observing the natural interactions between parents and child. In addition to the information-gathering component, the clinician defines the parameters of the sessions as well as the rules and expectations. Certain parameters involve an understanding by the parents that this CDI time is designated for the child to lead and for the parent to follow—a time often described to the parents as time-in for the child. Thus, time-in is defined as a time when the child facilitates play by selecting the type of play and initiating all play interactions.
The initial informal observation usually takes place in a sitting area while the family is waiting to visit with the counselor. In this informal observation, the counselor looks for “the child’s ability to play independently, strategies the child uses to engage the parent’s attention, parental responsiveness to child overtures, parental limit-setting, warmth of parent-child interactions, and evidence of clinging and separation anxiety” (McNeil & Hembree-Kigin, 2010, p. 20). After this stage of observation, a more formal observation is completed using the Dyadic Parent–Child Interaction Coding System (DPICS; Eyberg & Robinson, 1983). This observation is typically accomplished in three 5-minute increments in which behaviors and verbalizations are marked on the DPICS sheet. The formal observation occurs over the three PCIT stages previously described—CDI, PDI and cleanup. Following the initial observations, a third observation may be executed as a classroom observation. This type of observation is done with students who attend day care, preschool or elementary school, and allows one to see the child interact within his or her daily environment. Observation occurring in an alternate setting increases the chances of obtaining normative behavior (McNeil & Hembree-Kigin, 2010).
In Steps 2 and 3, the counselor presents and provides coaching on the CDI skills. Step 2 typically requires one counseling session. During this time the parents are taught the behavioral play therapy skills of CDI. The third step, coaching the CDI skills, may take two to four sessions depending on how the family adopts these principles into their daily interactions with their child. Coaching is described as modeling the behavior for the family, allowing the family to practice in session with feedback and prompts as needed, assigning the family homework to practice, and then repeating these steps until the parents are comfortable and fluent in the process.
In Steps 4 and 5, respectively, the counselor teaches and coaches the parents about discipline skills. These skills include both PDI and compliance training. Step 4 is typically accomplished in one session. Coaching may last from four to six sessions. Again, coaching is described as modeling, in-session practice with feedback and prompts, assigning homework, and evaluating success.
Step 6 consists of having a follow-up counseling session. This session is an opportunity to assess the family’s progress with proper implementation of each component of the PCIT model, gauge the strides made in compliance and assess the overall family satisfaction gained throughout the journey. Finally, one should use boosters to help parents maintain learned skills as they face new challenges with their children. Table 2 delineates the steps to implementing PCIT over a typical 10–15-session treatment plan.
Number of sessions
|Informal and formal observation
|Coaching CDI skills
|Teaching discipline skills via PDI and compliance training
PCIT was selected for use in the treatment of Manny, a 6-year-old Hispanic male diagnosed with autism and noncompliant to his mother. Like many children with autism, Manny had difficulty with unpredicted changes and verbalization of concerns. As Manny’s frustration with communication increased, he demonstrated stereotypies such as hand flapping and eventually progressed to tantrum behavior. The two goals of treatment were to increase the frequency of appropriate verbalizations and to decrease the frequency of inappropriate behavior including physical aggression, noncompliance and making noises. Manny was experiencing other issues related to autism, but his mother indicated that the behavioral problems were preventing him from making progress in other area.
As a result, we decided to conduct a functional behavior analysis prior to beginning treatment. This assessment of Manny’s behavior indicated that some of the behavior disruptions were a means of seeking attention, and therefore it was determined that PCIT would teach the mother to provide more consistent attention for appropriate behavior and to encourage appropriate communication more effectively. If needed, the addition of the timeout component was available after the mother began adequately attending to Manny’s appropriate behavior and ignoring inappropriate behavior.
The counselor explained the procedure and rationale for PCIT to the mother, including CDI, PDI and timeout. CDI was modeled and demonstrated with Manny. The mother was uncomfortable about being judged on her parenting skills, so it was decided that she would practice the skills at home using the Child’s Game nightly with Manny. The Child’s Game is simply defined as any free play activity the child chooses. The family would return to the clinic in 1 week.
The counselor reviewed CDI and had the mother conduct the Child’s Game for 5 minutes. During CDI, the counselor observed and noted the mother’s responses. The mother included 13 questions, one criticism and one demand in the 5-minute session. The mother praised Manny frequently, but did not use the other desired skills often. Manny was compliant with the demand that the mother gave and did not exhibit any of the disruptive behaviors. Following the CDI, feedback was given to the mother about increasing descriptions, reflections, imitations and praises, and reducing questions. The mother also was encouraged to recognize and praise communication attempts. Overall, the mother was directed to allow Manny to lead the play. When queried about CDI practice at home, the mother reported that the activity the family had used for the Child’s Game was watching television. Because there is no inherent interaction in television viewing, the mother was directed to provide a choice to play with action figures or art materials, both indicated as reinforcing by Manny, in place of video games or television. The Child’s Game was again given as homework.
The professional counselor reviewed CDI and viewed the family during the Child’s Game. The mother showed improvement using descriptions (16), reflections (3), imitations (1) and praises (15). She also limited her use of questions (6), criticisms (0) and demands (0). However, Manny exhibited disruptive behavior in 23% of the observed intervals. The mother also reported that Manny continued to be noncompliant and make noises at home. The professional counselor introduced PDI and timeout. Each was modeled with Manny, and his mother was allowed to practice and receive feedback. Homework was to continue the Child’s Game, issue 10 demands throughout the day and follow through with the brief timeout procedure. Also, the mother was asked to develop five house rules to bring the following week. To keep a record of the number of instructions with which Manny complied before going to timeout, and the number of timeouts per day, the mother received a homework compliance worksheet to keep for 1 week. This log allows the parent to record the homework—in this case, using the Child’s Game daily, issuing 10 demands throughout each day and recording the Manny’s compliance to each, and using timeout as indicated.
The counselor reviewed PDI, giving effective instructions and timeout to begin the session. The counselor then observed the family during CDI/PDI. The mother gave clear, concise instructions six out of nine times, only failing to wait before reissuing instructions when Manny did not immediately comply. Manny complied with all issued demands except when the mother reissued the demands too quickly. The mother followed Manny’s compliant behavior with praise statements four out of nine times. Manny was put in timeout for disruptive behavior and the mother used the procedure correctly. Manny demonstrated disruptive behavior during 33% of the observed intervals. A review of the homework compliance worksheet from the previous week indicated that Manny complied with 10 out of 10 instructions on 5 out of 9 days, and nine out of 10 instructions the remaining 2 days. The mother was encouraged to continue generalizing the skills she had learned throughout the day. The house rules developed by the family over the previous week were discussed and worded in positive statements and then introduced to Manny. The rules were explained and both examples and non-examples were modeled. Homework was given to continue incorporating the Child’s Game, issuing 10 demands in a brief period of time, using timeout as needed and recording compliance rates for 1 week.
The counselor reviewed PDI, EID, timeout and the homework compliance worksheet. The mother indicated that Manny had been compliant before timeout 10 out of 10 times for 6 days and nine out of 10 times for 1 day. The mother also noted that Manny had been placed in timeout for breaking house rules. The mother reported that Manny’s behavior had improved and he had had fewer tantrums related to schedule changes. She was encouraged to continue using the PCIT skills and adapting them to more situations. Because compliance was increasing, it was not necessary to continue CDI and PDI in this session. The family was given homework to continue the Child’s Game, PDI, using timeout as needed and recording compliance rates. This time, the family was to work at home for 2 weeks before the next session.
The counselor reviewed the family’s progress and addressed further generalization and concerns about daycare. The mother indicated that the child had been compliant before timeout on 10 out of 14 days. Two of the other days Manny had been placed in timeout 10 times and six times for violating house rules. The zero out of 10 compliance rating occurred during his birthday party, and the six out of 10 compliance rating was primarily the result of an unexpected trip to the grocery store. The family was again given homework to continue practicing generalizing CDI, PDI, using timeout as needed and recording compliance rates for 2 weeks.
The counselor addressed concerns including the beginning of school in a few weeks and provided suggestions to ease the transition. While the mother indicated that Manny had been compliant before timeout on only 4 of the previous 14 days, a review of the compliance rates revealed that on the other 10 days, Manny was compliant no less than 80% of the time. These compliance rates from various family settings were indicative of behaviors being generalized across settings. The mother also showed evidence of her generalization of skills by adapting the house rules to address new problematic behaviors. The family was encouraged to begin reviewing material learned in the previous session and work on behavioral skills such as sitting for appropriate lengths of time. The mother was instructed to continue both the use of her attending skills in order to reinforce appropriate behavior, as well as the use of the timeout procedure to diminish inappropriate behaviors.
For the final follow-up session, the counselor reviewed the family’s progress and determined that treatment goals were met. Concerns about how to get other family, friends and teachers to use PCIT skills with Manny were addressed in this final session. The family noted the improvements made as a result of PCIT and felt equipped to maintain the behavioral changes gained as a result of this counseling approach. Termination of the PCIT intervention was appropriate at this time; the case provided clear evidence of the application and utility of the PCIT model. Manny’s mother was offered the opportunity to continue interventions related to the other autism-specific issues that Manny was experiencing.
Professional counselors, whether working with children who have disruptive behavior or providing parenting training to families, should be knowledgeable of the application of various behavioral techniques in order to utilize them effectively and to teach them to parents. Researchers have proven that when implemented appropriately, PCIT procedures are effective in reducing undesirable and problematic behaviors in children and adolescents. Furthermore, it is clear that PCIT can be effectively applied to behavioral issues faced by children with special needs. We suggest that counselors who are interested in PCIT seek additional training to develop mastery of the techniques.
PCIT is a complex process that is often mistakenly viewed as simplistic. Thus, counselors who use PCIT without appropriate training will likely provide ineffective parental coaching. This point is especially poignant when working with children who have special needs. These children often present with numerous significant issues and deserve appropriate application of evidence-based intervention. We strongly suggest that counselors complete the web-based training provided by the University of California at Davis Children’s Hospital. The training is free and can be accessed at http://pcit.ucdavis.edu/pcit-web-course//. Given that PCIT is an effective approach and that the effectiveness of the model increases with appropriate education, professional counselors who further educate themselves on PCIT’s uses and applications can benefit their practices and the families they serve through the correct use of this empirically validated method of behavioral family counseling.
Counselors who are interested in PCIT also should consider advancing research related to counseling applications. While PCIT has been shown to be an effective intervention for autism and other disorders, more research is needed. We encourage counselors to consider implementation of studies that determine outcomes of PCIT for various child disorders and to conduct program evaluation for PCIT-based clinics.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Carl Sheperis, NCC, is the Chair of the Department of Counseling and Special Populations at Lamar University. Donna Sheperis, NCC, is an Associate Professor at Lamar University. Alex Monceaux is an instructor at Lamar University. R. J. Davis and Belinda Lopez are Assistant Professors at Lamar University. Correspondence may be addressed to Carl Sheperis, Box 10034, Beaumont, TX 77710, firstname.lastname@example.org.
Oct 2, 2014 | Author Videos, Volume 4 - Issue 4
Michael D. Hannon
This exploratory, qualitative study analyzed the narratives of four fathers of sons with Asperger’s disorder, a form of autism, as they described the rewards, challenges and coping strategies associated with their lived experience. The author identified participants via a typical case sampling method; collected data with one-time, semistructured interviews; and utilized emergent theme analysis to highlight themes across the fathers’ narratives. Fathers identified finding a clear communication system with their sons as most rewarding, behavioral issues with their sons as most challenging, and acceptance of their sons’ condition as a coping strategy. Implications for humanistic counseling practice and future research are presented.
Keywords: fathers, autism, Asperger’s disorder, rewards, coping
The counseling profession has long embraced concepts of humanism in theory and in practice. Rogers (1957, 1961) articulated within the six necessary and sufficient conditions for counseling that counselors should seek to understand the lived experiences of their clients. According to Mize (2003), a primary tenet of humanistic counseling is the belief that clients actively assign meaning to their experiences. Scholl, McGowan, and Hansen (2012) wrote that “humanistic practices and approaches to counseling . . . may be understood as those that highlight relating to people in empathic, respectful, and growth-producing ways” (p. 7).
There is a greater need for counselors to understand the experiences of parents of children with autism as the diagnosis rates of these disorders increase (Centers for Disease Control and Prevention [CDC], 2014). Counselors whose orientations integrate behavioral interventions (e.g., cognitive-behavioral interventions, solution-focused interventions, rational emotive behavioral interventions) help parents use strategies to address the behavioral symptomology of autism in their children. Humanistic counseling interventions (e.g., narrative interventions, person-centered interventions) offer clients an opportunity to share their stories in an effort to develop self-capacities, stimulate change and be empowered when confronted with normative stressors of this experience (Rogers, 1986). The purpose of this exploratory study was to gain a more in-depth understanding of how fathers describe the rewards and challenges of raising their children with autism, and to report coping strategies for the challenges they have in common. Findings from the study help begin the process of using empirically based evidence to better understand the experiences of fathers of children with Asperger’s disorder, a specific form of autism, which informs interventions for these fathers should they seek counseling support. The findings also can provide direction for the designs of future studies investigating related topics.
Seligman and Darling (2007) reported that there are not enough studies of fathers of children with disabilities, and one must draw conclusions about these fathers’ adjustment cautiously. The majority of empirical research on fathers of children with autism has focused on three related and specific areas regarding fathers’ (a) reported stress levels, (b) feelings of stigma and (c) coping strategies (Hannon, 2013; Canary, 2008; DeMarle & le Roux, 2001; Dyson, 2010; Flippin & Crais, 2011; Gerstein, Crnic, Blacher, & Baker, 2009; Gray, 2002, 2003; Green, 2003; Hartley et al., 2010; Hartley, Barker, Seltzer, Greenberg, & Floyd, 2011; Meyer, 1995; Nixon & Cummings, 1999; Reichman, Corman, & Noonan, 2008; Rodrigue, Morgan, and Geffken, 1992; Seligman & Darling, 2007; Smith & Elder, 2010; Trute, Hiebert-Murphy, & Levine, 2007; Watzlawik & Clodius, 2011). It is important to note that most of these studies are not exclusive to fathers. The studies attempted to measure effects of autism on parent relationships, compare parent assessments, or compare effects between autism and other disabilities. A review of the literature for this study yielded only three empirical studies since 2000 that focused solely on fathers’ reported experiences (Hannon, 2013; Gray, 2002, 2003). Even with these limitations, the current literature does offer insight into the experience of fathers of children with autism and provides a starting point for additional empirical studies to specifically investigate fathers’ experiences with this phenomenon. Intentionally investigating the lived experiences of fathers—by using increasingly diverse methodological traditions—is important because of fathers’ historic and current roles in the family and influence on their children’s development.
Fathers of Children with Disabilities
The transition to fatherhood affects men’s mental health. This experience is even more pronounced for fathers of children with disabilities. Studies have documented that fathers of children with disabilities respond to stress differently, interpret experiences differently and cope differently from mothers of children with disabilities (Garfield, Isacco, & Bartlo, 2011; Guzzo, 2011; Chin, Daiches, & Hall, 2011; Shezifi, 2004). It is appropriate to consider how childhood disability can affect the family life cycle and to share research associated with the experience of fathering children with disabilities, and specifically autism.
Theoretical Framework: Disability and the Family Life Cycle
One way to understand the impact of disability on the family is to consider the situation through a family systems lens. Carter and McGoldrick’s (2005) family life cycle theory offers a family systems theoretical framework that captures the ways a childhood disability might both enrich and cause the family stress at different times. Carter and McGoldrick (2005) articulated six stages within the family life cycle, all requiring some emotional transition and possessing the potential for stress, which the authors refer to as vertical and horizontal stressors. Vertical stressors are family memories, traditions and expectations passed down through generations (e.g., family attitudes, expectations, taboos). Vertical stressors represent how individual family members respond to experiences based on a collective family identity and constructions of what is or is not acceptable. In contrast, a family experiences horizontal stressors over time as they cope with and adjust to the transitions in the family life cycle. Horizontal stressors can be predictable (e.g., young adults leaving home for education or career) or unpredictable (e.g., untimely death). The combination of vertical and horizontal stressors influence functioning based on a number of factors that include but are not limited to economic resources, community resources and coping strategies. The experience of becoming a father can be considered a horizontal stressor based on the normative social, emotional and familial changes associated with the transition (McGoldrick & Carter, 2003).
Autism’s Influence on Fathers
The CDC reported in March 2014 that approximately one in 68 children living in the United States is diagnosed with autism, and that diagnosis rates have been on the rise in recent years (CDC, 2014). Counselors in various settings (e.g., schools, rehabilitation centers, community agencies) have confronted the individual and ecological effects of the increase in diagnoses. The term autism generally encompasses a range of more specific autism spectrum disorders (ASDs), referred to as pervasive developmental disorders (PDDs) in the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). PDDs are considered Axis I diagnoses in the DSM-IV-TR, and described as being “. . . characterized by severe and pervasive impairment in several areas of development: reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests, and activities” (APA, 2000, p. 69).
When data were collected for this study (September–October 2011), the professional counseling community was employing the DSM-IV-TR. However, since the 2013 publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are new and revised diagnoses and associated diagnostic criteria for what is now considered autism spectrum disorder. One major change was the incorporation of previously separate autism diagnoses (e.g., autistic disorder, Asperger’s disorder, child disintegrative disorder and pervasive developmental disorder not otherwise specified) and the categorization of symptoms as severe, moderate or mild. Therefore, while Asperger’s disorder is not listed as a specific diagnosis in the DSM-5, individuals diagnosed with Asperger’s disorder would be considered to have autism spectrum disorder or autism, with severe, moderate or mild symptoms. The specific diagnosis influences treatment interventions that counselors, speech therapists, occupational therapists and other specially trained helping professionals may deliver. While some research has documented effective interventions or support for family members caring for children with autism, a significant amount of research has illuminated how families adjust to the diagnosis.
Stress, coping and stigma. An abundance of research exists on how children’s disabilities influence the experiences of their parents and typically developing siblings. A comparatively small amount of research has investigated how children’s disabilities specifically affect their fathers (Atkins, 1991; Barr & McLeod, 2010; Barr, McLeod, & Daniel, 2008; Canary, 2008; Dyson, 2010; DeMarle & le Roux, 2001; Gerstein et al., 2009; Green, 2003; Hannon, 2013; Iriarte & Ibarrola-García, 2010; Meyer, 1995; Nixon & Cummings, 1999; Reichman et al., 2008; Ross & Cuskelly, 2006; Seligman & Darling, 2007; Smith & Elder, 2010; Trute et al., 2007; Watzlawik & Clodius, 2011). Childhood disability places a horizontal stressor on families, challenging them to confront their own assumptions and beliefs about people with disabilities, and to adjust to the stress (i.e., vertical stressor) associated with the experience. The level of stress that families experience can be influenced by the type and severity of disability and contextual influences that might support or stigmatize disabilities. With autism diagnosis rates continuing to increase, special attention from the health care and science communities has yielded a deeper and broader understanding of autism including etiology, symptomology and effective interventions.
Normative responses to the stressors of raising children with autism can include mourning, stigma and partner/marital adjustment (Seligman & Darling, 2007). Another stressor for parents is the social challenges (e.g., peer interactions) that children with autism confront. Davis and Carter (2008) found that fathers experienced stress particularly about their children’s externalizing problems (e.g., interpersonal/behavioral challenges), whereas mothers were more concerned about their children’s ability to regulate their emotions. In a study measuring the interaction effects between stressors, social support, locus of control, coping styles and negative outcomes in parents of children with autism, Dunn, Burbine, Bowers, and Tantleff-Dunn (2001) found that fathers were more inclined to engage in escape/avoidant coping styles in response to stress. This type of response increased feelings of depression and isolation and predicted problems between parents.
In a comparative study of 60 fathers of children with autism, children with Down syndrome and typically developing children (20/group), Rodrigue et al. (1992) found that fathers of children with autism and Down syndrome reported more negative effects on their families than those in the comparison group and reported more avoidant coping strategies than other fathers, and that fathers of girls with autism reported lower levels of social support. These types of comparisons are useful because they place fathering children with autism within the context of the fathers raising the children. The findings seem consistent with more general studies of parents, but offer more specific implications about how gender may influence how fathers make meaning of their experiences. Hartley, Seltzer, Head, and Abbeduto’s (2012) study measuring the psychological well-being of 240 fathers of adolescents and young adults with autism, fragile X syndrome and Down syndrome found that fathers of children with autism reported higher depressive symptoms than fathers in the comparison groups, and that factors contributing to between-group differences in well-being included father’s age, extent of child’s behavior problems, presence of additional children with disabilities and maternal depressive symptoms. Two major limitations from this study include sample (majority of sample was college-educated, White men) and no reporting of the specific autism diagnosis.
Gray’s (2003) study illuminated how gender differences in coping occur. However, one of the study’s limitations is that it fails to provide any subsequent discussion on the influence that parents’ respective coping strategies have on the marital partnership or the entire family system. Gray (2002) studied how parents of children with Asperger’s disorder experienced felt stigma and enacted stigma, and found that the majority of parents in the study experienced felt stigma, or were made to feel different because of their children’s diagnoses. Parents’ feelings of embarrassment were the most common manifestations of this felt stigma. Gray (2002) defined enacted stigma as behaviors toward or in response to the parents based on the child’s disability (e.g., people staring, being avoidant or making rude comments). Fathers in the study reported experiencing less felt and enacted stigma than mothers.
It is important to acknowledge that there have been positive outcomes associated with raising children with autism and other disabilities. Reichman et al. (2008) argued that positive outcomes for families can include increased awareness, capacity for resolve, and enhanced family cohesion. In sum, these interrelated and complex findings shed important light on how differently fathers perceive this experience and cope with the stress related to it. Variations in parent perception, assessment of children’s needs and challenges, and strategies for coping with the challenges warrant attention. The present exploratory, qualitative study on the singular experiences of fathers of children with autism can offer a contribution to the counseling knowledge base.
The author used a narrative inquiry design for this study in order to obtain the perspectives of fathers of children with autism and to report their self-described coping strategies for the challenges associated with this lived experience. Narrative inquiry seeks to understand what stories reveal about individuals, recognizing that people form and share identities as they recount and disclose their stories to others. The products from the study’s data analysis process include a paradigmatic analysis of the data, which produces categories from common elements across the database (Polkinghorne, 1995).
Some studies about fathers of children with autism and other disabilities have used qualitative methodologies (Hannon, 2013; Gray, 2002, 2003), but much of the existing research has employed quantitative methodologies (Brobst, Clopton, & Hendrick, 2009; Freedman, Kalb, Zablotsky, & Stuart, 2011; Hartley et al., 2010; Hastings et al., 2005). The present study relied on the narratives of fathers of children with autism—derived from one-time interviews—as data. Their narratives offered new insight into how their specific experiences have influenced their identities. Given the current empirical literature on fathers of children with autism, this study’s primary research questions were as follows:
- What are the rewards of being the father of a child with autism?
- What are the most significant challenges associated with being the father of a child with autism?
- In what ways do fathers cope with the challenges of raising children with autism?
The author utilized a typical case sampling method for the study. Inclusion criteria of participants were fathers over 18 years old who spoke and understood English and had a child between the ages of 4 and 20 with autism. There was no incentive or compensation for participating. Miles and Huberman (1994) articulated that typical case sampling represents the average example of a particular phenomenon of study, which was useful in this case because it afforded the researcher the ability to study this phenomenon on an individual basis.
After the study received approval from the Institutional Review Board, the author sent 68 recruitment letters to parents and guardians of children currently receiving mental, rehabilitative, and behavioral health and support services from the local site of a multistate human service agency. The agency served children and adults diagnosed with addictive diseases, autism, and intellectual and developmental disabilities. Of the 68 letters, 54 went to parents whose children were receiving services specifically for diagnoses within the ASDs, as per the DSM-IV-TR. The letters asked potential participants to contact the author directly in order to confirm study eligibility. The author sought a sample of at least five participants in order to reach data saturation (Polkinghorne, 1989), although Boyd (2001) regarded 2–10 participants as sufficient to reach saturation. The letters yielded four inquiries from potential participants, all of whom were eligible. However, one participant was excluded from the study because of the inability to coordinate an appropriate interview time. The author identified one additional participant through snowball sampling recruitment, which is a method of expanding a study’s sample size by asking current study participants to recommend additional participants (Babbie, 1995; Crabtree & Miller, 1992; Dane, 1990). Therefore, the author conducted four interviews.
The author recruited participants from a small town in the northeastern region of the United States. This rural town has a predominantly White population. The recruitment letters asked for fathers of children with autism without specifying a particular diagnosis, and yielded four men reporting to be the biological fathers of sons diagnosed with Asperger’s disorder. The participants were all White, ranging from 36–59 years old. Their sons ranged from 6–16 years old and had been diagnosed with Asperger’s disorder between the ages of 3 and 8. Table 1 highlights descriptive information about the study’s participants and their sons.
Description of Participants
Highest level of education
Age of son with Asperger’s disorder
Son’s age at diagnosis
Historian/ Stay-at-home dad
Note. Mean participant age = 46.5 years; mean age of son with Asperger’s disorder = 11.75 years; mean age of son at diagnosis = 6 years old
Data Collection and Analysis
Collection. The author collected data during one-time, semistructured interviews with each participant, conducted at locations convenient for participants. One interview took place in a participant’s home, one in a participant’s work location and two in the author’s work location. The author conducted, audio-recorded and transcribed the interviews, which ranged in length from 35–60 minutes. The author inquired specifically about what the fathers identified as rewards of being fathers of children with Asperger’s disorder, the challenges of being the fathers of children with Asperger’s disorder, and the fathers’ coping strategies. The interviews also included broader, descriptive inquiries (e.g., tell me about your son) to better understand the complexities and nuances of the fathers’ experiences.
Analysis. Bogdan and Biklen (1998) offered theoretical and practical suggestions for appropriately analyzing qualitative data, which include systematically searching and rearranging interview transcripts, memos and other accumulated materials in order to increase understanding about these materials and to assist in presenting the researcher’s discoveries to others. Data analysis for this study included organizing the data, sorting them into manageable parts, synthesizing, looking for patterns, realizing what was important and what was to be learned, and determining what and how to report. The author analyzed data through analysis of narratives, using the emergent themes approach (Glaser & Strauss, 1999). This method required an extensive review of interview transcripts to identify at least two things: (a) commonalities in experiences and shared perspectives, and (b) interpretation of participants’ experiences. The emergent themes approach assumes that conceptual themes will emerge from the data. Analysis of narratives uses paradigmatic cognition to deduce categories and create order among narratives from the interview data (Polkinghorne, 1995). The analysis required identifying common themes and conceptual categories between the narratives by reviewing the interview data and member checking. Identifying the common themes and concepts required recursive movement from recognized themes to researcher-proposed categories (Hammersly, 1992).
Theme identification began with coding, in which the author labeled the raw data (Strauss & Corbin, 1990). The author examined participants’ narratives to determine what statements or phrases seemed essential or revealing about the nature of being the father of a child with Asperger’s disorder. The author categorized codes based on the frequency and consistency of shared experiences, perspectives and interpretations reported by participants (Lavlani, 2011). After organizing the identified codes under more abstract categories, with each category containing a cluster of codes that pertained to broader themes, the author created a matrix to identify and display the prominent themes that emerged across narratives (Miles & Huberman, 1994) and to determine which themes occurred most frequently.
Trustworthiness. Hays & Singh (2012) articulated that various aspects of the research endeavor involve trustworthiness, including the research process and design, data analysis, and reporting of findings. Furthermore, they wrote that there are criteria or standards for trustworthiness in a research study and strategies to maintain trustworthiness throughout the study. The strategies to meet the criteria for trustworthiness for this study included reflexive journaling, simultaneous data collection and analysis, member checking, and creating an audit trail. The author also met with two faculty mentors experienced in qualitative data analysis throughout the data collection and analysis process to discuss his personal experiences with this phenomenon and his own biases that could have influenced the data collection and analysis processes. The committee members also assisted in the review of transcripts and the coding process. The cumulative effect of these strategies provided a source of data triangulation and enhanced the study’s credibility, transferability, dependability and confirmability.
Researcher-as-instrument statement. Qualitative researchers have discussed the ways in which researchers should document their role in the context of their work (Anfara, Brown, & Mangione, 2002; Glesne, 2011; Hays & Singh, 2012; Wang, 2008). The author is a 37-year-old father of an elementary school-aged son diagnosed with a specific form of autism, PDD-NOS, and is married to the child’s biological mother. The author and his wife also are parents of a daughter 19 months older than their son. The author was a school counselor and cofounded a nonprofit advocacy organization with his wife to support parents of children with developmental disabilities, particularly autism, prior to enrolling in doctoral studies.
Reflexive exercises and simultaneous collection and analysis. Before beginning this research, the author engaged in epoche as an early reflexive exercise. Patton (2002) and Creswell (2006) wrote that epoche requires researchers to fully document and describe their personal experiences with the studied phenomenon in order to increase their awareness of how they are biased, and to be clear about the ways they are personally affected by the research process and eventual results. The author also engaged in reflexive journaling. He made journal entries after each interview and included reactions to participants, inclinations about potential findings, and thoughts and feelings about the data collection and analysis process.
Member checking. Member checking is the researcher’s ongoing consultation with participants to test the “goodness of fit” of developing findings, and Lincoln and Guba (1985) cited it as a key strategy for establishing trustworthiness. Member checking requires involving participants in the research process in order to ensure that the researcher accurately communicates their intended meanings when outlining overall themes. The member checking process for this study took place at two points—during interviews (e.g., asking for clarity and confirming understanding) and after interviews (e.g., sharing transcripts for review and validation).
Data saturation was achieved for each of the three research questions. Results from the interview data yielded three themes. The fathers described in detail the rewards of fathering children with Asperger’s disorder, the challenges of fathering children with Asperger’s disorder, and the ways the fathers cope with those challenges. The fathers described the most rewarding aspects of fathering their sons with Asperger’s disorder as experiences in which they could experience clear communication with their sons. The fathers described the most challenging aspects of fathering their sons with Asperger’s disorder as those related to behavioral symptoms. The fathers described their coping strategies for those challenges as activities that allowed them to experience respite and acceptance. Quotations from the fathers elucidate the identified themes.
Clear Communication as Most Rewarding
All of the fathers discussed the various ways clear communication with their sons shaped the rewards of this lived experience. The symptomology associated with autism makes this description logical. Individuals with Asperger’s disorder may not experience the verbal language communication barriers that others face with different forms of autism, but individuals with Asperger’s disorder can have great difficulty reading and interpreting social cues. The feelings associated with clear communication patterns, especially when communication barriers exist, can yield feelings of relief and reward. Participant D, whose son was 6 years old, expressed the rewards in terms of his son effectively communicating his affection and love. The thing I love about him most . . . like I’ve said before is his reciprocal love to people which is sort of, you know, not typical for Asperger’s children. But, you know, he loves to hug and those sorts of things. Participant B discussed the rewards of communication with his son regarding their shared interests in certain video games and how shared interests deepen their relationship. I know he went through a phase where he loved Texas Hold ’Em Poker and I like poker, too. So, we sat down and for months we would . . . just play for 3 to 4 to 5 hours and he didn’t get tired of it.
Devising an effective communication method can be important to fathers of children with autism. Hannon (2013) found that the process of becoming oriented to autism, which includes learning about the condition and helping others learn about the condition, can be stressful for fathers. The subsequent adjustments to autism—including adjustment of attitudes and defining success—can take a toll on fathers. The data indicated that fathers from the present study found effective ways to communicate, thereby helping them identify those processes as rewarding.
Behavioral Issues as Most Challenging
According to the data from this study, the most challenging aspects of fathering sons with Asperger’s disorder pertained to the behavioral symptoms associated with autism. Prior research has confirmed this finding. Davis and Carter (2008) found that behavioral symptoms, particularly interpersonal behavioral problems (e.g., inability to behave appropriately in social settings) in children with autism are a significant source of stress for their fathers. Each father discussed a different behavioral challenge. Participant C expressed frustration about his 11-year-old son’s arguing, manipulating and lying, even when the truth about a situation was obvious.
He’ll be caught in a lie and he’ll just deny it. . . . We know his mom didn’t do it . . . no one in the house did it. But he continues to not acknowledge that he was the one . . . running up some bills [on the cable bill ordering games and movies]. . . . So, the arguing, the lying, the manipulation . . . we’re trying to get him to be honest, is just one of the things we’re trying to work through with the therapist and in school a little bit.
Participant D shared his frustration with public outbursts and how it is hard for him not to be able to control or defuse the situation quickly. He shared the following:
Sudden outbursts . . . crying, being stubborn, “I’m not gonna do this, I’m not gonna do that,” . . . taking something very small and blowing it out of proportion. Whether it’s in the privacy of our house or in public . . . those are the kind of things that . . . sometimes I have to, as a father. I kind of lose it. . . . Those are the things I still have a really hard time dealing with. Like, this just came out of nowhere. This just doesn’t make any sense.
Acceptance as a Coping Strategy
Henderson and Bryan characterized coping mechanisms as “emotions and behaviors that allow an individual to adjust to problems. The survival of all people depends on their being able to regulate personal feelings, beliefs, and actions so that their anxiety remains at a manageable level” (2011, p. 157). All four participants reported coping strategies that indicated the value of accepting their sons’ conditions in order to cope effectively with the challenges.
Participants A and B talked about how they have come to accept the challenges of their sons’ conditions. Participant A shared how his Christian faith has helped him accept the challenges. He shared the following:
First of all, pray. Put your faith in Jesus and find Jesus and give it to him and he’ll walk you all through it together and it’ll all be all right. But you . . . can’t give up on the kid. It ain’t his fault he’s got what he’s got. So first of all don’t bail on him. You’ve got to be rock-solid for him because it’s hard enough for him because he’s already different.
Participant B discussed a similar acceptance of the emotional highs and lows of this experience:
You understand that there’s going to be certain situations where he’s not going to be able to deal well and you just have to understand that. And, [if] you as a parent or caretaker can’t understand that . . . society in general is definitely not going to understand that. Just dealing with knowing what he has to deal with. [He does] not look you in the eye when you’re talking to him, talk[s] under his breath instead of talking to you. I understand all those as part of his disorder . . . I don’t hold that personally, I don’t find that as a lack of respect. It’s just how he is.
Studies assessing the ways fathers of children with autism cope have been limited, and results have been mixed. Dunn et al. (2001) studied the interaction effects between stressors, social support, locus of control, coping styles and negative outcomes among parents of children with autism. Their study’s results indicated that escape/avoidant coping styles, which were higher among the fathers, correlated with increased feelings of depression, isolation and spousal problems in parents.
There is evidence suggesting that specific coping strategies predict more positive moods and overall greater psychological well-being in parents of children with autism. Pottie and Ingram (2008) found that coping strategies that were problem-focused, engaged social support, and used positive reframing, emotion regulation, and compromise predicted more positive psychological well-being and better moods in parents. A recent study found that effective coping among six fathers of children with autism meant engaging in activities that helped the fathers achieve a sense of personal balance (e.g., prayer, exercise, disk jockeying; Hannon, 2013).
It is worth considering the integration of humanistic counseling tenets when working with fathers of children with Asperger’s disorder. The results of this study point to the need for counselors to understand the lived experiences of fathers of sons diagnosed with Asperger’s disorder. The importance of instilling hope by focusing on the rewards of this fathering experience and demonstrating empathy can potentially assist counselors in their work with these fathers.
Instilling Hope Through Strength-Based Interventions
The instillation of hope has been associated with Yalom and Leszcz’s (2005) curative factors of group therapy. However, across theoretical orientations, counselors assist clients in finding hope in the ability to adjust to or overcome their presenting issues and eventually experience wellness. A humanistic, strength-based approach to counseling is one attempt toward this goal. Strength-based counseling interventions intentionally encourage clients to identify, acknowledge and take pride in their strengths and assets versus solely focusing on the challenges that presenting issues may elicit; such interventions also align with humanistic approaches to counseling (Whitmarsh & Mullette, 2009). As a result, clients are ideally better able to reconceptualize their presenting issues and construct a different, less pathologizing identity.
The participants articulated the rewards of fathering children with Asperger’s disorder as being able to communicate clearly (through verbal and nonverbal language) with their sons. Counselors can assist fathers with their adjustment to Asperger’s disorder by learning about ways Asperger’s disorder positively and uniquely enhances a child’s experience, and by helping fathers embrace the positive attributes associated with the disorder. For example, researchers have appropriately identified communication barriers as a symptom of autism. The notion of limited communication can be interpreted as absence of communication. Counselors can remind fathers that all family members communicate and can assist fathers in reconstructing ideas about communication to extend beyond verbal communication and highlight the ways their children do communicate (i.e., nonverbally through body language and other communication systems). The fathers in this study discussed how rewarding it was to find and use effective communication systems, most of which were not verbal. Counselors can use this example to highlight the strengths of fathers and sons in this situation. The fathers engaged with their sons enough to find effective communication systems, and the sons learned and practiced skills that require interpretation of verbal and nonverbal language, which can be delayed or impaired in children with Asperger’s disorder.
Empathy is the ability to communicate an understanding of another’s worldview or experience and is a core value in humanistic counseling (Hazler & Barwick, 2001; Krebs, 1975; Lyons & Hazier, 2002; Rogers, 1957, 1961). Integrating a humanistic orientation can facilitate counselors’ heightened understanding of how fathers of children with Asperger’s disorder make meaning of their experiences and, consequently, allow the fathers to experience empathy in ways they may have never experienced it before (Mize, 2003), particularly regarding the aspects of parenting that the fathers in this study described as most challenging. Scholl et al. (2012) wrote, “humanism is unified by an overarching philosophy of human irreducibility. Accordingly, humans can be understood only as whole beings and should never be viewed as by-products of other processes” (p. 7). Helping fathers grasp that neither they nor their sons can be reduced to a particular diagnosis or symptoms associated with the diagnosis might facilitate a healthier conceptualization of their experience as fathers of sons with Asperger’s disorder. Counselors can use the findings from this study along with Seligman and Darling’s (2007) work to better understand how fathers may make sense of the more challenging parts of fathering children with Asperger’s disorder. Seligman and Darling (2007) noted the following:
Fathers tend to perceive the diagnosis of the disability as an instrumental crisis, whereas mothers see it as an expressive crisis. . . . Fathers tend to be more concerned than mothers about the adoption of socially acceptable behavior by their children—especially their sons—and they are more anxious about the social status and occupational success of their offspring. (p. 223)
This study provides counselors with valuable information on the experience of fathers of children with Asperger’s disorder. However, there are three limitations within the study that warrant attention: (a) the small sample size, (b) the lack of racial and ethnic diversity, and (c) the inability to generalize the findings to the broader population of fathers of sons with Asperger’s disorder.
The small sample size of the study simultaneously strengthens and limits the findings. Qualitative methodological traditions usually do not engage large sample sizes due to their focus on collecting in-depth data and investigating processes of human interactions and phenomena (Buckley, 2010). The sample size in this study was particularly small for at least two significant reasons: low response rate to recruitment efforts, and the fact that mothers typically act as primary caregivers and coordinators of their children’s therapeutic services. The low response rate was no surprise considering the larger phenomenon of researchers not actively sampling fathers of children with various forms of autism for research about their experiences. Mothers of children receiving services at the recruitment site were overwhelmingly the most consistent parent with whom the agency interacted. Consequently, mothers were likely the ones who received and opened recruitment letters, and responses depended on whether they encouraged the fathers to participate.
A second and related limitation of the study is the lack of racial and ethnic diversity in the sample. It is important for counselors to intentionally find more diverse samples of fathers of children with Asperger’s disorder in an effort to understand this phenomenon more accurately. For example, Hannon (2013) sampled six African-American fathers of children with different forms of autism, and among the findings was a need to assess the fathers’ social and financial capital and consequent ability to secure quality services for their children based on their racial identity. Members of different racial and ethnic populations may or may not report the same concerns, but additional inquiry is important. A more diverse sample can inform the counseling knowledge base on any potential similarities and differences in experiences compared to the results from this study. Additional research can inform the broader and more effective practice of counseling fathers, but also help others understand the subtleties that may exist for members of different racial and ethnic groups; such work will enhance the counseling profession’s quest to provide culturally competent clinical interventions for diverse populations.
The last limitation of the study is the inability to generalize the findings to the broader population of fathers of sons with Asperger’s disorder. The importance of this topic for the professional counseling community warrants more qualitative, in-depth studies to inform the counseling knowledge base about the intricacies and nuances of the Asperger’s disorder experience that qualitative methodological traditions can reveal. However, the knowledge base also can greatly benefit from studies that use larger sample sizes to discover the extent to which findings can be generalized to the larger population of fathers of sons with Asperger’s disorder.
This study is a step toward better understanding the family and ecological influence of autism because it provides the counseling community with the knowledge necessary to more effectively offer counseling and related services to fathers of children with Asperger’s disorder. Counselors should continue to pursue this research agenda as the prevalence of this lived experience continues to increase in the identified population of fathers. As a result, effective strength-based interventions that consider the distinct needs and requests of this population must be further researched and developed. Continuing to investigate this phenomenon is beneficial for both research purposes and practical application.
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Eligibility and Interview Protocol
- Are you over 18 years old?
- Are you able to speak and understand English?
- Are you the father of a child with autism?
- Is your child with autism between the ages of 4–20?
- How old are you?
- How old is your child with autism?
- When was he diagnosed with autism?
- Does your child with autism have any siblings? If so, how many?
- What is your highest level of completed education?
- What is your occupation?
- How many people live in your household?
Semistructured Interview Questions
- Tell me about your son.
- Describe your experience as a dad of a child with autism.
- Discuss the most rewarding aspects of being a dad of a child with autism.
- Discuss the challenges associated with being the dad of child with autism.
- How do you cope with the stress of parenting a child with autism?
- Have you considered seeking help (counseling, support group, etc.) to adjust to the challenges of being the dad of a child with autism?
- Describe your relationship with the mother of your child with autism.
- How has your child’s diagnosis affected that relationship?
- How would you advise other dads of children with autism to prepare for the rewards and challenges of this unique experience?
Michael D. Hannon, NCC, is an assistant professor at Montclair State University. Correspondence can be addressed to Michael D. Hannon, Department of Counseling and Educational Leadership, 3190 University Hall Montclair State University, One Normal Avenue, Montclair, NJ 07043, email@example.com.
This study is supported by the Association for Humanistic Counseling 2012 Make-A-Difference Grant Award to support graduate student research in counseling that supports the humanistic philosophy and provides a significant, tangible benefit for the population under study.