INTRODUCTION

ASD has begun to enter the realm of public health as a diagnosis that affects millions of families each year. According to the Zeidan et al. (2022), approximately 1 in 100 children will receive a diagnosis of autism. Other reports have stated that ‘ASDs affect at least 1% of the population and often diagnosis is not made until late adolescence and early adulthood due to the diversity in the ASD symptom profile and clinical presentation’ (Govind, 2018, p. 908). ASDs affect individuals by compromising their ability to understand social cues; they may involve some intellectual and developmental delays, and they often are comorbid with other mental health issues. Govind (2018) also states, ‘Difficulties with learning and psychiatric comorbidities such as anxiety and depression are frequently associated with ASDs. These “comorbidities” further complicate and compound difficulties across multiple domains of functioning and intensify reliance on family members’ (p. 908). The pathway to gaining a concrete diagnosis for autism spectrum disorder is long and arduous. Many times, families are told to wait for signs of the delay of milestones, as each individual child may be behind in development; this often delays the support the family needs. In other families, children have significant displays of differing needs in development, and a diagnosis can be made sooner than usual. Families raising children who have ASD face unique and challenging circumstances that create conditions for mental health issues and relational problems such as depression, anxiety, isolation, marital discord, divorce, financial problems and sibling neglect (Hartley et al., 2011). When these various issues have room to fester, it ultimately negatively affects the structure and functioning of the family, which in turn creates more difficulties and challenges for the entire family (Hsiao, 2018; Miranda et al., 2019; Myers et al., 2009; Norton & Drew, 1994).

LITERATURE REVIEW

Lack of clarity in diagnosis

ASD is a developmental disability that currently has no clear biological marker and is evaluated and diagnosed through examining where there is a significant decrease and impact to a cluster of behavioural, emotional and perhaps physical realms (O'Brien, 2007). Furthermore, while a diagnosis can be given to children in their younger years with high reliability and validity, many children do not receive their diagnosis until they are school aged (Lord et al., 2006; Moh & Magiati, 2012). The delay of diagnosis of ASD within children of colour is even more pronounced, impacting the trajectories of children and families through their developing years (Lovelace et al., 2018; Sansosti et al., 2012). The longer that parents and children must wait for an official diagnosis from medical providers, the longer there is an endurance of behaviours without proper intervention, which increases the level of emotional turmoil for the parents and the entire family (Crowe & Lyness, 2014).

Systemic issues of families with children with ASD

ASD is a complex neurological diagnosis that is difficult to diagnose and treat, and it creates a lifelong impact on the individual and those they relate to. Systemic effects of autism are outside the scope of ‘training for behavior analysts, as caregivers are included in treatment exclusively to develop appropriate parenting skills such as instruction, modeling, practice, and feedback to decrease the undesired behavior’ (Parker & Molteni, 2017, p. 135). Families that have children who have been diagnosed with autism spectrum disorder face a unique set of issues that often go under-addressed. One of the primary issues that is prevalent within these families is the elevation of the diagnosis or behaviours enshrined in the diagnosis to one of power over all individuals in the system. Family routines are often adjusted around easing transitions and behavioural/emotional reactions of those with ASD. Little flexibility allows for adjustment, and if differences in routine are needed, a great deal of physical and emotional work may be needed to accomplish this. Another issue is that of emotional connection and reciprocity of feelings between child and parent(s). A very small amount of time is devoted to the actual deepening of interpersonal relationships within the family system. ‘Research shows that the non-ASD sibling possesses more negative views about their ASD sibling when compared to sibling pairs containing a child with mental retardation and a typical development child’ (McVicker, 2013). Children with an sibling with ASD have also expressed ‘only being able to talk with someone outside of the home about their sibling, feelings of loneliness and a desire to stay home, and feeling concerned about their siblings’ future’ (Smock-Jordan & Turns, 2016, p. 157). In addition, sibling issues often arise, namely in the competing of needs. Siblings of children with ASD often feel overlooked and dismissed, as their needs never fully rise to the same level of urgency as those with ASD. (McDowell & Bryant, 2023). This presents the opportunity for jealousy, emotional issues and resentment to fester. In addition, the siblings often receive a lack of attention from their caregivers due to the needs of their siblings with ASD. Often, the parents' journey is overlooked and under-validated and seen as being a part of the caregiving duties, as it is comparative to raising/experiencing normative stress of raising typically developing children. Despite positive movement emanating from the neurodiversity movement, parents experience a great deal of shame, hurt and guilt around raising their child without having the proper or necessary support to expand their roles, which are significantly different from raising a neurotypical child(ren) (Lovelace et al., 2018; Myers et al., 2009; O'Brien, 2007). Furthermore, given the inherent stress of role expansion without proper support, marital and relational stress is often left unchecked or untreated within the context of treatment (Zablotsky et al., 2013).

The structure of families is variable, and according to systemic theories, flexibility in structure and clarity of roles lead to an adaptability that allows for lower levels of anxiety and the successful management of problems, including transitions through life stages (Colapinto, 2019; Minuchin et al., 2021). The flexibility in structure and the clarity of roles can be seen across all constellations of families despite their cultural, racial and/or ethnic make-up (Lopez et al., 2018). Challenges arise when the family structure is misaligned in some form. Structural family therapy states that, when the parental subsystem is unable to be aligned and boundaried off from the child(ren) subsystem, the hierarchy of decision-making inherent in the parental subsystem results in the parents being unable to execute their duties of safety and support for the family (Colapinto, 2019). Families with children who have unique needs or disabilities often have challenges due to the ever changing emotional, physical and spiritual needs that imitate how dynamic their presenting problems are. ‘The literature on the adaption of families of children with disabilities repeatedly indicates that it is important for service providers to understand family belief systems, both in a general sense and with respect to each family as a unique entity’ (King et al., 2009, p. 50). It is extremely important to note that, at the foundational level, families are units and systems that have organisation and that self-regulate.

Before setting out to find out what is wrong with families, King et al. (2009) state that clinicians will need to examine and highlight where strengths may exist within the family. ‘The family's ability to ascribe positive meaning to life events is considered to be a factor that promotes their child's resilience’ (King et al., 2009, p. 51). In addition, ‘Understanding family's beliefs is considered to be an essential aspect of engaging parents in the therapy process’ (King et al., 2009, p. 51). These are basic joining techniques that are essential for working with parents of children with ASD. To prescribe the correct or the most culturally attuned intervention, clinicians (including doctors) should spend time understanding the culture (Lovelace et al., 2018; Suite et al., 2007) of the family, and they should be interested in some of the perceived and overt strengths that are present. In addition, creating systemic treatment modalities that are modified to address the needs of families with children who have ASD allows the caregivers more room to be flexible with their roles and support for one another when these roles fail to meet necessary standards. This is extremely helpful to parents who repeatedly verbalise the lack of family support for treatment for ASD (Kiami & Goodgold, 2017). Likewise, it provides the family with concrete ways in which they can celebrate when their accommodations and boundary-making contribute to the growth and development of the child, as well as family cohesion on a macro-level.

Disability justice

Critical disability justice is a theoretical framework that promotes the understanding of how disability is not necessarily the identification and examination of bodily and mental impairments, but how we categorise and normalise the characteristics and traits of these impairments onto individuals (Sami, 2017). These characteristics and traits are often generalised and are reinforced by societal interactions and impart definitions on what an individual can do and what they are unable to do without their consent. The reduction of abilities and the imposition of ideas onto individuals greatly impacts their ability to communicate where they need dependence/independence and communicates ideas of what they may be capable of. ASD is a part of the neurodiversity umbrella and is certainly subject to the critique of critical disability. While the needs of an individual with ASD vary from person to person, many times the reduction of what a person can achieve or even communicate about their lives or selves is predetermined as limited and unaware through societal messaging and relationships. This issue follows children with ASD throughout their lives. SFT for ASD utilises this theoretical frame to shift an understanding of parents, children and others to move from disabling families' members (that is, to see them on the basis of what they cannot do) as opposed to advocating for those who may have ‘disabilities’ to verbalise specific supports that they believe they need to be successful in tasks, relationships and even life.

Structural family therapy

Structural family therapy (SFT) is considered one of the original family therapy approaches that developed out of a systemic framework and continues to influence the practice of family therapy. Salvador Minuchin worked with several communities of colour which were disenfranchised and often did not find relief nor support in the psychotherapeutic world. The development of structural family therapy came about due to Minuchin's work with Black children and their families in the Wiltwyck School (Reiter, 2017) in finding that traditional forms of therapy did not produce change nor did the families engage with them. The invention of structural family therapy stood as a radical way forward in the field of family therapy. The model represented a reflexive framework tailored to families of colour by incorporating the realities of how racism, sexism and oppression impacted their lives and access to therapy.

The overarching goal of SFT is to alleviate distress among family members by ‘restructuring the current family organization that has become maladaptive’ (Parker & Molteni, 2017, p. 137). The review of research on SFT and its treatment of families with children with ASD reveals several areas that provide relief. The first area is family disengagement.

Disengagement is associated with overly rigid and impermeable boundaries that foster isolation and block mutual support among family members. Arguably, parents of children with autism are in even greater need of mutual support and interdependence than those of typically developing children due to the overwhelming parenting demands, shown to result in excessive levels of stress, anxiety and depression (Parker & Molteni, 2017, p. 138).

Although distance can be a preventive and health measure for coping with stress in relationships, consistently relying on moving away from one's feelings when raising a child with ASD can be damaging to the relationship between caregiver(s) and child as well as the family relationship. The second target for treatment is enmeshment. Either of these extremes impact healthy family relationships.

Ramisch (2011) explains that families affected by autism may easily become enmeshed as a natural response to meeting the child's needs. Many of the deficits associated with ASD, such as problem-solving and cognitive rigidity, suggest parents of children with autism must provide intensive care and protection far beyond what would be appropriate for a typically developing child (Parker & Molteni, 2017, p. 139).

Furthermore, boundary-making interventions directly intended to clarify diffuse boundaries between parent and child with ASD often disregard the demands and expectations associated with autism in the family. Therapists must therefore reconceptualise enmeshment when working with families of children with autism (Parker & Molteni, 2017, pp. 139–140). SFT offers a unique understanding of the level of closeness that is inherent when caring for a child with ASD. SFT gives space to not pathologise the emotional proximity of parent and child but to reshape it as a way of healthy functioning. Lastly, SFT speaks about restructuring interventions. ‘As opposed to relying on the family's report of the concerns, boundary-making interventions allow the family to experience their current and alternative interactions during the session’ (Parker & Molteni, 2017, p. 140). Allowing caregivers, parents, children with ASD and their siblings the opportunity to experience each other in ways that are not necessarily dictated through the lens of ASD is a powerful, relational-shifting intervention that can have profound effects in increasing family stability and cohesion, as well as in ensuring that parents are able to be flexible with their roles as caregivers.

This study utilises the systemic theory of structural family therapy and augments its ability to treat children with ASD and their families by integrating in the framework of critical disability justice/theory and heavy knowledge of ASD and the impact on family dynamics. The augmented theory provides clinicians the ability to de-pathologise the management of the symptomology of ASD and execute structural interventions that match the nuances of ASD.

SFT for ASD model

The SFT for ASD model is a blend of the Critical Disability Justice framework and the structural family therapy model. Structural family therapy in its purity and critical disability have a synergistic relationship, allowing clinicians to utilise tools to challenge harmful stereotypes about autism and shift a family's structure to support growth, independence and closeness. The goal of this augmented and modernised approach is to provide systemic treatment to children who have ASD and their families. In addition, the model is uniquely positioned to address the dynamics and issues that are inherent in neurodiverse families. SFT for ASD is delivered in six steps, which will be detailed below:

• Step One: The therapist takes time to validate the parental feelings and stories. This step should be completed with the parents only. All too often, parents present in therapy, not for themselves, but for the needs of their children. SFT seeks to integrate parental needs and limitations into the therapy, as they are often a mediating and/or moderating effect on the ASD behaviours of the child, have an impact on their own mental health and wellness and may prevent them from having deeper connections with their children. For example, parent(s) may present with overwhelming anxiety and depression regarding the state of their family and inability to manage both the needs of their child with ASD and the needs of the family (which include their romantic relationships). Validating this experience helps bring the parent(s) closer into the goals of therapy and helps the therapist begin to plot out how to address this issue. The joining of the therapist with the parent is one half of the process in joining and accommodating with the family.
• Step Two: The therapist should take time to understand and validate the experience of the child with ASD. This step is extremely important for several reasons. First, the therapist can make room to understand what the child understands and begin to piece together what the world view of the child is. Children with ASD and other neurodiverse presentations often do not have opportunities to explain and clarify to others not only how they feel but also what the impact of their neurological makeup is on their self and relationships. Centring the child in this conversation is valuable to creating change in the family work later. Second, during this time, the therapist should be gathering and exploring both the strengths that the child has and the areas of their life that they need support in developing. Lastly, gaining this information, alongside where the parent is, allows the therapist to begin understanding the relational issues that are present in the family dynamic and gaining possible insights on how to shift the family. Steps one and two together fully represent the joining and accommodation process within both SFT and SFT for ASD.
• Step Three: The therapist begins the four-step process made popular by Minuchin et al. (2006) but in an augmented manner. First, the therapist sources the understanding of the problem via family stories in session and sets up an enactment. Second, the therapist explores what solutions have occurred the past and explores the presence of ‘unsolvable’ issues. Third, the therapist investigates the past in a focused manner that helps them understand why the families does what they do or why they have made the decisions that they have. Last, the therapist works to create a consented vision of how the family can move forward to conquer the issue.
• Step Four: The therapist challenges unhelpful assumptions and challenges notions around ability and disability through unbalancing. Families naturally revert to previous dynamics and cognitive frameworks and will often need to be reminded of the shared vision during the assessment. This step is a defining piece of the model as the therapist directly challenges how families may actively ‘disable’ children by failing to see what they can or cannot do on the basis of their developmental ages and/or expression of ASD symptomology. In addition, during this step, therapists are encouraged to heavily privilege self-advocacy in self-determination from the children with ASD.
• Step Five: The therapist, alongside the family, should reconceptualise how dynamics and relationships can be transformed through revisiting the commitment towards the specific roles and rules of each person. The roles and rules of each person and even the family should be encouraged to be less rigid by being more flexible in how and when each person (or the family) embodies their roles or when rules are adhered to. This can be uncomfortable, as rigidity in the system provides for consistency in day-to-day interactions, which settles the ASD symptomology; however, it limits how the family is able to grow over time and tackle challenges that they developmentally face.
• Step Six: During this final step, the therapist works to deepen the relationship between the child with ASD and their family and vice versa. Now that the family can be free enough to be flexible in their roles, parents are able to understand more about their children outside of ASD and its symptomology and develop greater relational capacity between them. In addition, children with ASD can learn the innate skills around of safety in relationship and have a healthy template of social interaction and reciprocity in relationships.

Research questions

Based on the existing review of the literature, the needs of parents of children with ASD can be extreme, overwhelming and far-reaching – specifically, issues such as parental anxiety brought about by extreme role overload, dysfunction in sibling relationships due to presenting behaviours and the rigidity of boundaries and communication native in families with children with ASD. These are unique challenges that necessitate the need for the inclusion of family-based treatment. This study will specifically examine two questions:

1. Is SFT an appropriate therapeutic model to alleviate family-based (parent + child) anxiety with a family who has a child with ASD?
2. Does SFT increase family satisfaction in families who have children with ASD?

METHOD

The study aims to demonstrate the efficacy of SFT, investigate whether SFT can decrease anxiety in families who have children with ASD and determine whether family-based treatment is appropriate for families who have children with ASD. The study is a single-case experiment (SCE) design. SCEs have been utilised in research for over 50 years and have provided great insight as to how effective a particular treatment intervention may be and demonstrate intervention effectiveness in pilot studies (Hilliard, 1993; Krasny-Pacini & Evans, 2018; Thyer & Curtis, 1983). SCE designs demonstrate the effectiveness of interventions through repeated measures across time that span, at minimum, three phases: baseline, treatment and post-treatment (Dickey, 1996; Kratochwill et al., 2010). Analysis of data that are identified through measures that are appropriately chosen to answer hypothetical questions is mainly achieved through visual analysis (Kratochwill et al., 2010; Lenz, 2015). This study centred on five families (each family being a case) where the augmented SFT was administered in a biweekly fashion and packaged as intensive family therapy via telehealth. Each session was 90 minutes in duration, split such that 45 minutes were dedicated to therapy with every family member and 45 minutes were dedicated to therapy with the parents only. Data were collected prior to the first session (baseline), before the fifth session (treatment which is represented by the four-step assessment, psychoeducation on the effects of ASD on the family and family restructuring interventions) and, lastly, after the tenth session had elapsed. The measures used were the Anxiety Scale for Children – autism spectrum disorder – child version (ASC-ASD; Rodgers et al., 2016), the Anxiety Scale for Children – autism spectrum disorder – parent version (ASC-ASD; Rodgers et al., 2016) and the Family Adaptability and Cohesion Scale (FACES-IV; Olson, 2011). The treating clinicians for this study were therapist interns who have been trained in the SFT for ASD model, received training in the diagnosis of ASD, received telehealth training and received training in the Person of the Therapist model. These therapists were taught and supervised and trained by the author of this paper. None of the therapists in each case identified as being neurodivergent.

RESEARCHER

Qualitative research is made more legitimate through the reflexivity of the researcher (Creswell & Poth, 2023). Quantitative inquiry generally does not have that mandate; however, for this manuscript, I believe it will enhance the message of this research. I am a multiracial, Black-presenting individual who is neurodivergent [attention deficit/hyperactivity disorder (ADHD)]. I have worked with other neurodivergent individuals and families for over ten years and informally have heard of the struggles they experience when they are misunderstood and encounter medical doctors and clinicians who do not understand how it is to be neurodivergent or raise an individual who is. This research and its further iterations are for those families that I have worked with and that lent me their stories and trusted me to challenge the field of psychotherapy to be more inclusive.

Participants

Participants for this study were recruited from the local Seattle community and beyond through means of advertising the parameters of this study. Flyers, emails and other advertisements were sent to medical doctor's offices, the University of Washington Autism Center for Human Development, Seattle Children's Hospital, ABA Centers of America and various other medical facilities across the state of Washington, as participant families had the ability to participate in the study via telebehavioural health. Once participants had been selected for this study, they could receive services immediately. The study was open to participants from any constellation of family structure – that is, single parents, same-sex parents, heterosexual parents and grandparent(s) functioning as the main caregivers. Families needed to have at least one child residing with them who had confirmation of a diagnosis of autism spectrum disorder and was receiving ABA services at that time. Participant's demographics were collected, asking their age, sex, gender, religion, race, ethnicity and the severity of ASD in the child. Out of the five families, one set of parents were a same-sex couple, the remaining were cisgendered heterosexual couples. One family identified as Black; the rest identified as white. Parental age ranged from 32 to 50 years old. In one family, one parent identified as having ASD. Prior to being accepted into the study, parents and children were screened for anxiety, depression and other mental health issues which may have been too excessive and would best be referred out to other providers (no families were screened out). This step was essential to protect the health and safety of respondents who desired to be a part of the study but who may have been best served with receiving other services prior to being eligible to subsequent family-based treatment. The Patient Health Questionnaire-9 (PHQ-9; Kroenke & Spitzer, 2002) was used to screen for levels of depression, with results of severe depression having a score range of 20–27. Scores higher than 20 were referred out for individual-based treatment. In addition, the Generalised Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006) was used to screen for levels of anxiety, with results of severe anxiety having a score range of 15–21. Scores higher than 16 were referred out for individual-based treatment. All members of the family provided consent (or ascent where necessary) to participate in the study.

Measures

Anxiety scale for children – Autism spectrum disorder

The study uses the ASC-ASD parent and child versions (Rodgers et al., 2016) to assess anxiety levels in both the parent of a child with ASD as well as the child with ASD. The parent version of the ASC-ASD measures the parents' version of their children's perceived anxiety level. Both measures are twenty-four-item self-administered questionnaires that accurately gauge the level of anxiety present in the individual. The scale is Likert in type and ranges from 0 (Never) to 3 (Always). The scale also contains four subscales – Separation Anxiety, Uncertainty, Performance Anxiety and Anxious Arousal – but they were not used in this study. Only sum scores will be utilised. The ASC-ASD has demonstrated a Cronbach's alpha score of 0.94 for the parent full scale and 0.94 for the child version (Rodgers et al., 2016). Scores equal to or greater than 20 are considered to demonstrate significant levels of anxiety. Furthermore, the ASC-ASD was utilised in the longitudinal study of Australian students with autism where they confirmed the measure accurately discerned between autistic behaviours and anxiety and a Cronbach's alpha score of 0.93 was rendered (Den Houting et al., 2018).

Family adaptability and cohesion evaluation scales

The FACES-IV (Olson, 2011) is a scale that measures family functioning through cohesion and flexibility. These two dimensions of the scale are divided into two subscales, Balanced and Unbalanced scales. Within the Balanced scales, the measure highlights the level of cohesion and flexibility. Cohesion is defined as the level of emotional bonding present in the family. Flexibility is defined as the quality and expression of leadership and organisation, role relationship, relationship rules and negotiations. Within the Unbalanced scales, the measure highlights the level of Enmeshment, Disengagement, Rigidity and Chaos. Reliability of the subscales within the measure found alpha reliability values of 0.77 for Enmeshed, 00.87 for Disengaged, 0.89 for Balanced Cohesion, 0.86 for Chaotic, 0.84 for Balanced Flexibility and 0.82 for Rigid (Olson, 2011). To provide focus in data collection of this study, the ratio scores will be used to measure change in family cohesion, flexibility and communication. Each parent and child submitted scores with the assistance of the research assistant. This paper will report only on family satisfaction levels for both the child and parents. For reference and ease of interpreting the numbers, the range and interpretations follow. Values between 50 and 45 are interpreted as having very high satisfaction, with family members being very satisfied and relaying enjoying most aspects of their family. Values between 44 and 40 are interpreted as having high satisfaction, with family members being satisfied with most aspects of their family. Values between 39 and 36 are interpreted as moderate satisfaction, with family members somewhat satisfied and enjoying some aspects of their family. Values between 35 and 30 are interpreted as low, with family members being somewhat dissatisfied and having concerns about their family. Lastly, values between 29 and 10 are interpreted as family members being very dissatisfied and being concerned about their family.

Procedures

Prior to the first session (baseline), after the fifth session (midpoint) and 1 week after the tenth session (post treatment), the ASC-ASD (parent and child versions) and FACES-IV were administered to the family (both parents and child) by the family therapists. Children who were 12 years and older filled out their own measures (ASC-ASD – child version and FACES-IV) without the support of their family and had been confirmed by their parents to understand the questionnaires. Parents also filled out their respective forms (ASC-ASD – parent version and FACES-IV). Families who had more than one parent filled out one form representing both parents.

Analytic strategy

Preceding the commencement of the pilot study, participants were screened for inclusion in the study. Prior to treatment, the family received information about the study. The ASC-ASD (parent and child versions) and FACES-IV measures were given, tracking their baseline, treatment and post-treatment levels. After the last timepoint, the case was analysed visually to investigate the outcome of the experiment.

Data preparation and analysis

The preliminary tests conducted included visual analysis. In addition, investigators checked univariate and multivariate assumptions. Data were collected from all parent (the ASC-ASD – parent version was administered as one form per family) participants and measures; the ASC-ASD (parent and child version) and FACES-IV were given three times (baseline, treatment and post-treatment). Visual analysis of the data via graphs provided an explanation of the study.

Reliable change index

The reliable change index (RCI) is used to determine whether the change in research subjects scores ranging between the pre-test and post-test measures are statistically significant. While visual analysis of scores in single cases can produce results which indicate change, the use of RCI confirms statistically whether the observed change is real and uses the standard error of measurement (SEM; Guhn et al., 2014). This study utilised the following equations to find the RCI for each test: The sample mean for the family was calculated using the (∑x)/n. The sample variance was then calculated using S² ∑(x − x¯)/n − 1. The standard deviation was then calculated using √s². The SEM was then calculated using the equation SD/√n. RCI values greater than 1.96 denote that there is meaningful change in a participants score. The use of RCI alone does not denote clinical significance of any kind but does confirm statistical significance.

RESULTS

This study considers two important questions that will organise how the results are presented:

1. Is SFT for ASD an effective family-based modality to treat anxiety in children with ASD?
2. Is SFT for ASD effective in increasing family satisfaction, meaning that they feel content and fulfilled with each other?

The data evaluating anxiety levels of the child (self-rated level of anxiety) can be found alongside the means and RCI values found in Table 1. Two children (first and third families) demonstrated an increase of their anxiety, and three families (second, fourth and fifth families) showed a decrease of anxiety. The RCI values for the children rating their own anxiety were as follows: first family at 6.28, second family at −5.97, third family at 6.11, fourth family at 6.26 and fifth family at 6.26. Three children had RCI values that were higher than 1.96. These findings show mixed results, with most children demonstrating that SFT for ASD appeared effective in decreasing anxiety for most of the children.

The data from the parent version of the ASC-ASD can be found alongside the means and RCI values found in Table 2. One parent (first family) demonstrated no change overall in their perception of their child's level of anxety. Three families (second, fourth and fifth families) noted a visual decrease in their values of their child's anxiety ratings and one family (third family) saw an increase in their anxiety values. The RCI values for the parents rating their perception of their children's anxiety levels were as follows: first family at 0, second family at −5.45, thurd family at 3.16, fourth family at 3.16 and fifth family at 5.97. Most families that rated the level of anxiety in their child lower produced RCI values greater than 1.96; thus, it is possible to draw a conclusion that SFT was effective in lowering parents perception of anxiety in their children with ASD.

The data in Table 3 show the FACES-IV Satisfaction subscale across treatment time ranging from the first session to the tenth session for children. Upon analysis of the visual data in the tables, we see a visual increase of family satisfaction values in four families and no change overall in one family. The RCI values, found in Tables 3 and 4, for the children rating their own satisfaction levels were as follows: first family at 6.13, second family at 6.2, third family at 6.27, fourth family at 0 and fifth family at 5.17. All but one child had RCI values greater than 1.96; thus, we can interpret that SFT for ASD has been shown to increase family satisfaction in accordance with the perception of the child with ASD.

Data in Table 4 also show the FACES-IV Satisfaction subscale for parents rating their views of family satisfaction across treatment time. Visually, we see three parents (first, second and third) had an increase in their satisfaction, no change was shown for one parent (fourth family) and a slight decrease in value was noted for one family. The RCI values, found in Table 4, for the parents were as follows: first family at 6.32, second family at 1.52, third family at 6.27, fourth family at 0 and fifth family at −1.19. Three families had RCI values higher than 1.96; thus, most of the parents showed that SFT for ASD was impactful in terms of their views of increasing family satisfaction.

DISCUSSION

The purpose of this study is to examine whether SFT is a suitable model of therapy to address family-based anxiety within families who have a child with ASD. Existing literature reveals that parents often experience heightened levels of depression, anxiety, stress and fatigue, and a host of other issues that directly affect their mental well-being (Zablotsky et al., 2013). Many times, these stressors are related to issues of securing a diagnosis, navigating the system of care post-diagnosis and the inability for parents to have a safe place to process through their grief and loss (Spain et al., 2017). The current treatment protocol for children who have ASD is generally the referral to applied behavioural analysis (ABA) services, which is appropriate in some respects but falls drastically short in addressing the systemic issues present for families that have a child with ASD.

Implications

This study used an augmented model of SFT for ASD and, in these five cases, demonstrated efficacy in several areas that make a difference in the lives of families. SFT often has fallen to the wayside, as a model that is seen as archaic, or as reinforcing the patriarchy in some form (Vetere, 2001). This study demonstrates that SFT continues to be a relevant and useful theory to treat current issues of families. SFT gives the therapist additional tools to address numerous issues that plague families who have children with ASD, ranging from anxiety and depression, by adjusting the structure of a family and issues with double empathy, where communication breakdown occurs between two individuals who do not have compassion and reciprocity of differing worldviews/experiences. In addition, the increase of anxiety that many children rated for themselves in the study despite seeing an increase in their satisfaction ratings could be attributed to the anxiety of the dynamic changing in the family. It is well known that therapy brings about an increase of anxiety as individuals confront issues that cause them pain.

The system of care in many countries is largely based on the medical model that focuses on the pathology of an individual person while ignoring the systemic impacts of said pathology on the relational environment of the individual. The SFT for ASD model challenges the accepted medical model to either incorporate or reform practices to be more inclusive of a systemic neurodiversity approach. As said earlier, ASD is an individual diagnosis that does impact an individual's functioning but has a broad and wide impact on family dynamics and relationships (Govind, 2018; Miranda et al., 2019). The results, while native to these families, demonstrate that family-based treatment can provide positive outcomes for individual issues that traditionally have been treated only through the individual who has the said issue. This study calls to attention the need for more systemically based inclusive treatment for an individual within a family to address the needs of parents, siblings and children with ASD alongside their relationships. The presence of a systemically inclined, family-based treatment option that is a part of the system of care will make it easier for parents to find relief for their heightened anxiety, parental stress and depression (Zablotsky et al., 2013), for siblings of children with ASD to process through their isolation (Sansosti et al., 2012) and for children with ASD to develop relationships with their parents that are outside of the purview of their diagnosis (Norton & Drew, 1994; Spain et al., 2017). The last implication of this study is that using family therapy can produce change and treat ASD on a systemic level. While ASD itself cannot be ‘cured’, the systemic effects of the diagnosis that impact both the individual with ASD and their family can be treated as a family. The result is closer relationships, a greater ability to navigate future problems and an increase in qualified clinicians who can support this vulnerable, high-needs community.

Implications for the public

Increasing the number of available options of treatment for families with children with unique needs is paramount to their wellbeing and ability to thrive. This augmented model potentially advances options of support for the family unit as the primary and initial intervention choice for children with ASD. The choice between a parent's mental health needs and struggles are in competition with the needs of their child, and often, parents will prioritise the needs of the child while delaying and often worsening their own symptoms. This dynamic is even greater between siblings when one child has ASD and the other does not. The impact of this study is that the parent and child do not need to compete regarding the treatment of mental health issues, finding relief in problems with independence and dependence, and will acquire new skills as a family that can be extremely useful during future developmental milestones and issues later in the family life. Increasing the skills and ability to conquer future issues by supporting families in the present will mean a decrease of issues inherent with families who have children with ASD.

Suggestions for future research

In future iterations of this study, the recruitment of a large number of families and the use of a control-comparison group would strengthen the findings. In addition, increasing the number of sessions families receive would create comparative conditions to treatment in outpatient settings.