AUTISM SPECTRUM DISORDER: THE RELATIONSHIP BETWEEN BIOMEDICAL

TREATMENT AND HEALTHY FAMILY FUNCTIOING.

By

Jill R Tschikof

DR. LINDA REED, PhD., Faculty Mentor and Chair

DR. VICTORIA GAMBER, PhD., Committee Member

DR. STEPHANIE WARREN, PhD., Committee Member

David Chapman, PhD., Dean, Harold Abel School of Psychology

A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree

Doctor of Philosophy

Capella University

Add month Year (of approval)

1

© Jill Tschikof 2011

2

Abstract

3

Dedication

4

Acknowledgements

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Table of Contents

CHAPTER 1. INTRODUCTION 7

Background of the Problem 7

Background of the Study 8

Statement of the Problem 9

Purpose of the Study 10

Rationale 11

Research Questions 12

Significance of the Study 13

Definition of Terms 14

Assumptions and Limitations 16

Nature of the Study 17

Organization of the Remainder of the Study 18

CHAPTER 2. LITERATURE REVIEW 20

CHAPTER 3. METHODOLOGY 43

CHAPTER 4. DATA COLLECTION AND ANALYSIS

CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS

REFERENCES 53

APPENDIX A. PARENT PARTICIPATION FLYER DISTRIBUTED AT SITE 62

APPENDIX B. PROCEDURE AND INFORMATION FOR OFFICE STAFF 63

APPENDIX C. SURVEY FOR MOTHERS TO ANSWER 64

APPENDIX D. PROCEDURE AND INFORMATION FOR WEBSITES 65

APPENDIX E. FLYER 66

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CHAPTER 1: INTRODUCTION

This study examines the relationship between biomedical treatment and healthy family

functioning in families who have a child diagnosed with autism spectrum disorder. More

specifically, this dissertation will consider the idea that when biomedical treatment is used in

families who have a child diagnosed with autism spectrum disorder their family will have a

higher level of healthy functioning.

This chapter will provide an overview of the study. This chapter includes the

introduction to the problem, background of the study, a statement of the problem, and purpose of

the study. The approach used in this study is discussed within the research questions and

assumptions, limitations, definitions and an overall nature of the study are discussed in this

chapter.

Background of the Problem

Autism Spectrum Disorder (ASD) is defined by Jepson & Johnson (2007) as one having

varying degrees of impairment in communication skills, social interactions, and restricted,

repetitive, or stereotyped patterns of behavior. Charles, Carpenter, Jenner & Nicholas (2008)

state that the behavior problem exhibited by children with ASD should be closely monitored.

Some of the most common behavior problems include impulsive behavior, aggression, tantrums,

ritualistic behaviors, and unstable moods which can come from anxiety, depression, and

hyperkinesis.

According to Rao & Beidel (2009) the behavioral problems exerted by children with

ASD often cause elevated levels of stress, depression, anxiety and emotional exhaustion for the

entire family. These problems as stated by Rao & Beidel (2009) also affect the family system in

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other ways. For example, parents of ASD children reported having little or no time for family

activities such as outings or vacations, having no room for spontaneity, and reported having

career restrictions and marital stress. (Rao & Beidel, 2009).

Background of the Study

The research on biomedical treatment is somewhat limited as it is not a widely accepted

form of treatment for children with autism. (Jepson & Johnson, 2007). However, since Autism

Spectrum Disorder is becoming more and more prevalent, it is becoming a more common topic

to research.

What the data does show, is that biomedical treatment, or the multi-tiered treatment

approach, according to Jepson & Johnson (2007) is a type of treatment that is working for many

children with autism. This type of treatment aims to replace what the child is missing, remove

what is causing the child harm, and break any cycle of inflammation that is present or keeps

presenting itself in the gastrointestinal system. By doing these things, children with autism can

begin to heal and recover, and families can begin to see changes in behavior, health, and

eventually establish healthier functioning for the entire family. (Jepson & Johnson, 2007).

Wong & Smith (2006) also discuss the use of biomedical treatment for children with

ASD. The authors define biomedical or complementary and alternative medicine as a group of

diverse medical systems, practices, or products that are not considered part of conventional

medicine. According to the authors, biomedical or alternative treatments are becoming very

popular amongst parents of children with ASD. (Wong & Smith, 2006).

According to Wong (2008) Complementary and Alternative Medicine (CAM) includes a

broad range of healing resources and encompasses all health systems, modalities and practices

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and includes their theories, and beliefs, except for those that are included in the politically

dominant health system of a specific society or culture.

The use of CAM in children diagnosed with ASD is most often combined with the use of

conventional medicine. (Golnik & Ireland, 2009; Hanson et al., 2006; & Wong, 2008.)

Statement of the Problem

According to Kanne (2006) autism is a complex diagnosis affecting the child’s behavioral

and cognitive manifestations along with the family system as a whole. The effects of autism on

the family system can cause emotional stress beginning even before a diagnosis has been made.

Kanne (2006) stated that understanding the nature of your child’s difficulties (cognitively and

behaviorally) is just the beginning stressor of raising a child with autism. Next, parents need to

examine how their child’s future will be impacted by their recent diagnosis, and decide which

treatment(s) will be the most beneficial.

Further research focusing on the impact on the family system when a child has been

diagnosed with autism is warranted in order to explore potential treatment. By attempting to

show that biomedical treatment can improve the functioning of families who have a child

diagnosed with autism, psychologists can examine emerging theories, and patterns, and provide

therapy and support for these families while they research, experiment, and chose which type of

treatment is best for their family system as a whole.

According to Duarte, Bordin, Yazigi, & Mooney (2005) parents raising a child diagnosed

with Autistic Spectrum Disorder (ASD), mothers in particular, are at high risk themselves of

developing or presenting with mental health problems. The authors suggest that researchers,

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possibly psychologists, help parents find ways to deal with the stress of raising a child with ASD,

and in turn design better interventions. (Duarte et al., 2005).

This study will attempt to increase the body of knowledge available to researchers,

psychologists, and families, by determining whether or not biomedical treatment will increase

the level of healthy family functioning according to the FACES IV assessment by decreasing the

negative behaviors of children with ASD.

Life Innovations, Inc. is the founder of the FACES IV assessment and they provide a

spreadsheet and instructions which makes analyzing the results of their assessment simple and

manageable. Holding a Master’s Degree in Psychology meets the qualification requirement of

utilizing their assessment.

Purpose of the Study

Families who have a child diagnosed with autism spectrum disorder face various

challenges in their lives. This Ex Post Facto study will attempt to increase the body of

knowledge available to researchers, psychologists, and families, by attempting to determine

whether families using biomedical treatment will have healthier family functioning scores

according to the FACES IV assessment.

FACES IV is the assessment scale that will be used to determine the level of healthy

family functioning for each participant. FACES IV stands for family adaptability and cohesion

evaluation scales and the scales consist of six family scales, according to Olson, Gorall, & Tiesel

(2004). These scales assess the dimensions of family cohesion and family flexibility and include

two balanced scales and four unbalanced scales. According to Olson et al. (2004) there are 62

items on the assessment and address cohesion, flexibility, communication, and satisfaction.

10

FACES IV, has published levels of reliability and validity. According to Olson, Gorall & Tiesel

(2004) the reliabilities of the six FACES IV scales are as follows: Disengaged = .87, enmeshed

= .77, Rigid = .83, Chaotic = .85, Balanced Cohesion = .89, Balanced Flexibility = .80, and

Alpha reliability analysis was also run for the validation scales and ranged from .91 to .93.

The participants of the FACES IV assessment will be divided into two groups; mothers of

a child diagnosed with autism and have received biomedical treatment, and mothers of a child

who has been diagnosed with autism and has not received biomedical treatment. The scores that

are received through the FACES IV assessments will be used to determine if the families using

biomedical treatment have healthier family functioning. These scores might also lead to further

causation studies for autism, biomedical treatment, and healthy family functioning.

According to Harrington, Patrick, Edwards, & Brand (2006) some of the most popular

forms of biomedical or alternative treatments for Autistic Spectrum Disorder (ASD) include

dietary restrictions, dietary supplements, antifungals, chelation therapy, homeopathy, sensory

integration, secretin, and animal therapy. These different treatments can be used separately or

combined. Although the authors showed evidence of such treatment being used by many parents

of children with ASD, the authors discussed the treatment as being controversial and potentially

harmful. (Harrington et al, 2006). The authors suggested that practitioners use a non-judgmental

tone, and inquire about parental beliefs and current treatments in order to establish a more

trusting relationship with parents.

However, like most articles on ASD treatments, there is no mention of the psychological

impact biomedical treatment has on both the parents and the child. (Levy & Hyman, 2005;

Harrington et al., 2006). Harrington et al (2006) discuss the use of biomedical treatment; but

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they do not discuss how many parents achieved better behavior from their child after

implementing various treatments.

Rationale

This Ex Post Facto design will have an independent variable, biomedical treatment

(variable x) and a dependent variable, level of healthy family functioning (variable y). Using an

Ex Post Facto design, according to Leedy & Ormrod (2005) allows the researcher to make a

generalization about the population being studied, this factor is important when limiting the

study to parents of children with autism.

Research Questions

Research Question:

Is there a difference in the scores of healthy family functioning between families with a child

diagnosed with Autism Spectrum Disorder (ASD) who have received biomedical treatment and

families who have not received biomedical treatment according to the scores on the FACES IV

assessment?

Research Question 1a: Are families who use biomedical treatment more cohesive according to

the scores on the FACES IV assessment?

Research Question 1b: Are families who use biomedical treatment more flexible according to

the scores on the FACES IV assessment?

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Research Question 1c: Do families who use biomedical treatment have better communication

skills according to the scores on the FACES IV assessment?

Research Question 1d: Are families who use biomedical treatment more satisfied according to

the scores on the FACES IV assessment?

Significance of the Study

According to Kanne (2006) autism is a complex diagnosis affecting the child’s behavioral

and cognitive manifestations along with the family system as a whole. Autism begins to affect

the family system even before a diagnosis has been made. Kanne (2006) stated that

understanding the nature of your child’s difficulties (cognitively and behaviorally) is just the

beginning stressor of raising a child with autism. According to Kanne (2006) understanding how

autism can impact your child’s future, and which treatment options best suit your family, are just

a few of the stressor a parent raising a child with autism must face.

Further research focusing on the impact on the family system when a child has been

diagnosed with autism is warranted in order to explore potential treatment. (Duarte, Bordin,

Yazigi, & Mooney, 2005). By attempting to show a relationship between biomedical treatment

and healthy family functioning, psychologists can better understand the various treatment options

available to those raising a child with autism. Psychologists cannot offer biomedical treatment

themselves, but they can offer therapy services and support for those who are struggling with

their child’s diagnosis, and their journey toward a healthier family system.

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According to Duarte et al. (2005) parents raising a child diagnosed with Autistic

Spectrum Disorder (ASD), mothers in particular, are at high risk themselves of developing or

presenting with mental health problems. The authors suggest that researchers, possibly

psychologists, help parents find ways to deal with the stress of raising a child with ASD, and in

turn design better interventions. (Duarte et al., 2005). This study will attempt to increase the

body of knowledge available to researchers, psychologists, and families, by determining whether

or not biomedical treatment will increase the level of healthy family functioning according to the

FACES IV assessment by decreasing the negative behaviors of children with ASD.

Definition of Terms

Autism Spectrum Disorder – Autism, according to Secco, Ateach, & Woodgate (2008) is

defined as a complex developmental disorder and is characterized by a triad of impairments in

reciprocal social interaction, communication, and restricted, repetitive and stereotypic patterns of

behaviors, interests, and activities. (Secco, L, Ateach, C, & Woodgate, R.L., 2008).

According to Crane & Winsler (2008) Autism has been described as being one of the

most devastating developmental disorders of childhood because it can cause disabilities in all

areas of psychological development, ranging from cognitive, language, and behavioral deficits to

impairments in social interaction. (Crane, J.L., &Winsler, A, 2008).

Biomedical Treatment – According to Baker (2007) the term biomedical refers to the

idea of medical problem solving. Baker (2007) states that it does not suggest a fixed set of tests

and treatments, but an approach that will help each individual child that is diagnosed on the

spectrum. According to Baker, (2007) it is the patient, not the protocol that is the expert and

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expresses their expertise by how they respond to treatments and tests which provides a guide for

further understanding the various biomedical options available.

Diagnoses – According to Crane & Winsler (2008) correctly diagnosing ASD is often

difficult because of the wide variation in the behaviors that are related to the diagnosis. Because

of this wide variety of behaviors, the creation of a category to include several diagnoses was

necessary. Found in this category, also referred to as Autism Spectrum Disorder includes the

classic diagnosis of Autistic Disorder as well as Asperger's Syndrome, & Pervasive

Developmental Disorder-Not Otherwise Specified [PDD-NOS], (Levy & Schultz, 2009). This

category, according to Levy & Schultz (2009) is found in the fourth edition of the Diagnostic and

Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) and

is labeled Pervasive Developmental Disorders.

FACES IV – FACES IV stands for family adaptability and cohesion evaluation scales and

the scales consists of six family scales, according to Olson, Gorall, & Tiesel (2004). These

scales assess the dimensions of family cohesion and family flexibility and include two balanced

scales and four unbalanced scales. According to Olson et al. (2004) there are 62 items on the

assessment and address cohesion, flexibility, communication, and satisfaction. The published

rates of validity and reliability are as follows: Disengaged = .87, enmeshed = .77, Rigid = .83,

Chaotic = .85, Balanced Cohesion = .89, Balanced Flexibility = .80, and Alpha reliability

analysis was also run for the validation scales and ranged from .91 to .93.

15

Family Systems Theory – According to The Bowen Center (2009) the family systems

theory is a human behavior theory that views the family as an emotional unit. It uses systems

thinking to describe the complex interactions within the unit. It is stated by The Bowen Center

(2009) that if one person in the family changes their functioning than it can be predicted that

there will be reciprocal changes in the functioning of others in the family. Bowen’s family

systems theory is based on the idea that the emotional system will affect most all human activity

and it is the principal driving force in the development of clinical problems. (The Bowen Center,

2009).

Healthy Family Functioning - According to Olson et al. (2004) FACES IV has a manual

that contains materials that can be used for administering the assessment, scoring the test, and

plotting the results. The scores of the two groups will be compared using a t-test. The t-test will

show the mean score of both groups and will in turn show which group has a higher level of

family functioning.

Assumptions

1. All mothers (participants) have a child with an Autism Spectrum Diagnosis.

2. Each participant will only take the assessment one time.

3. Each participant will fill out the assessment honestly.

4. All diagnosis will be given by qualified professionals.

5. All participants using biomedical treatment are honest about their treatment plans.

Limitations

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The present study will hope to add some very important findings to the current body of

knowledge regarding autism and family functioning. However, there are some limitations to

consider. First of all, this study asks volunteers to answers questions in a survey type format,

which could bring up issues as to how reliable their responses might be. Another limitation to

this study is the sample itself. For example, only mothers of children diagnosed with Autism

Spectrum Disorder are participants of this study, leaving out the feelings, and thoughts of fathers.

The family functioning scores might be different if both parents were to complete the survey.

However, the results are still important because it gives us an idea of how families are

functioning when they have a child diagnosed with autism and are or are not receiving

biomedical treatment. The results will give ideas and recommendations for future studies.

A third limitation to this study is that it uses self report data only. The study might be

more valid if the physicians of the children being diagnosed were able to give information on

how well the biomedical treatment is going, or even simply verify that each specific child has

been diagnosed and is or is not receiving biomedical treatment. However, for confidentiality

reasons, it is not possible to contact the physicians because the patient’s names will not even be

presented in the study. Another limitation for this study is that all participants will complete the

survey in an honest manner, whether or not the mothers are honest when answering the questions

will be up to them. Every child diagnosed with ASD functions at a different level and in a

different manner, which is a limitation for this study because each parents observations of their

child’s functioning might vary. One last limitation to this study is that not all doctors treating

autism in a “biomedical” way use the same protocol. Each case is looked at differently so there

cannot be any casual statements made about the protocol and how it could possibly work for

every child with autism, it can only be tried on each case.

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Nature of the Study (or Theoretical/Conceptual Framework)

Family Systems Theory

Individuality and togetherness, according to Kerr & Bowen (1988) are the two

counterbalancing life forces that are reflected from the operation of the families’ emotional

system. This system focuses on the development of the physical, emotional, and social

dysfunctions that bear a significant relationship to individuals and families, and how these family

systems respond and make adjustments. Autism Spectrum Disorder (ASD) is an example of a

dysfunction that can bear a significant impact on a family system.

Bowen (1985) discusses the family systems theory as a triangle, or a three-person system.

His best example of the family system or triangle system, is the father-mother-child triangle.

Although the pattern can often change, one parent is passive, distant, or weak and leaves the

conflict between the other parent and the child. The child is the weaker of the two and often

loses the battle and therefore comes to expect to lose. If the passive parent ever decides to attack

or challenge the aggressive parent the child will eventually learn how to take the outside position

and play the parents against each other. (Bowen, M., 1985).

According to The Bowen Center (2009) the family systems theory is a human behavior

theory that views the family as an emotional unit. It uses systems thinking to describe the

complex interactions within the unit. It is stated by The Bowen Center (2009) that if one person

in the family changes their functioning than it can be predicted that there will be reciprocal

changes in the functioning of others in the family. Bowen’s family systems theory is based on

the idea that the emotional system will affect most all human activity and it is the principal

driving force in the development of clinical problems. (The Bowen Center, 2009).

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Organization of the Remainder of the Study

Chapter 1 will present the introductory remarks that are related to Autism Spectrum

Disorder and the relationship between biomedical treatment and healthy family functioning. In

addition, descriptive information that describes the current study will be provided. The

statement of the problem, the purpose, significance, assumptions and limitations of the study,

and definitions of significant terms will also be provided in chapter 1.

Chapter 2 will provide a review of the contemporary and first hand literature that is

related to Autism Spectrum Disorder, biomedical treatment, and healthy family functioning. The

relationship between biomedical treatment and healthy family functioning in families with a

child diagnosed with Autism Spectrum Disorder will be assessed in this chapter.

Chapter 3 will review and report the methods used to address both the hypothesis and the

research questions.

Chapter 4 will present the analyses of the data that has been collected from the surveys

that mothers with a child diagnosed with ASD have taken. The results in relation to the research

questions will be discussed here as well.

Chapter 5 will present an analysis of the discussion of the findings and any implications

of the study. Conclusions will be made and recommendations for future studies will be

discussed.

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CHAPTER 2. LITERATURE REVIEW

Introduction

Autism Spectrum Disorder (ASD) is used by Myers, & Plauche’ Johnson (2007) to

include autistic disorder, Asperger’s disorder, and pervasive developmental disorder-not

otherwise specified, defined by the Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition, Text Revision (DSM-IV-TR) (2000) as the child having varying degrees of

impairment in communication skills, social interactions, and restricted, repetitive, or stereotyped

patterns of behavior. Charles, Carpenter, Jenner & Nicholas (2008) state that the behavior

problem exhibited by children with ASD should be closely monitored. Some of the most

common behavior problems include impulsive behavior, aggression, tantrums, ritualistic

behaviors, and unstable moods which can come from anxiety, depression, and hyperkinesis.

According to Rao & Beidel (2009) the behavioral problems exerted by children with

ASD often cause elevated levels of stress, depression, anxiety and emotional exhaustion for the

entire family. These problems as stated by Rao & Beidel (2009) also affect the family system in

other ways. For example, parents of ASD children reported to having a compromised quality of

life. (Lee, Harrington, Louie, & Newschaffer, 2007). According to Lee, Lopata, Volker,

Thomeer, Nida, Toomey, Chow, & Smerbeck (2009) even families whose child is considered to

be on the higher end of the autism face challenges in many aspects of everyday life. Volkmar &

Klin (2000) reported that children who are at the higher end of the autism spectrum still have

circumscribed interests that can limit the family’s activities, and narrow participation in any

other activities of interest for the rest of the family.

This chapter presents a significant amount of information regarding the critical issues and

theoretical structures of ASD, their secondary responses, and their effect on family functioning.

This chapter will also present a significant amount of information regarding biomedical

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treatment (what is also referred to in the literature as complementary and alternative medicine,

CAM) and the idea that it can affect the secondary responses of ASD and improve family

functioning.

The current literature regarding ASD, biomedical treatment, and it’s relevance to family

functioning was limited at Capella University’s library when conducting a search, using a variety

of database (e.g. ProQuest Journals, PsychArticles, Psychology: A SAGE Full-Text Collection)

with searches using key words such as “autism + family functioning”, “autism + biomedical

treatment”, “complementary and alternative medicine + autism”, “autism + diagnosis”, “autism +

behavior problems”, “autism + communication”, “autism + stress”, “gluten free + autism”,

“casein free + autism”, “autism + supplements”, “autism + antifungals”, and “autism + FACES

IV”. Supplementary resources in the form of published books; journal articles; and relevant,

reputable websites were used in the literature review in order to expand and synthesize the

relationships among the constructs that will be empirically tested.

The Origins of Autistic Disorder

It was in the year 1943 that Dr. Leo Kanner discovered the disorder that is now called

Autistic Disorder (National Institute of Mental Health, 2004). Dr. Kanner of the Johns Hopkins

Hospital studied a group of 11 children and introduced us to the label, Early Infantile Autism.

Dr. Hans Asperger, a scientist from Germany, introduced us to another label or disorder, his

label was called Asperger’s Syndrome, a milder form of Early Infantile Autism. (National

Institute of Mental Health, 2004).

Autistic Disorder as defined by The American Psychiatric Association (2000) as having

noticeably abnormal or developmental impairments in the areas of social interaction and

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communication and a distinct restricted selection of interests and activities. The degree of

impairment, whether it be abnormal or developmental will vary greatly between individuals,

depending on their developmental level and chronological age. According to the American

Psychiatric Association (2000) impairment due to Autistic Disorder can be found in the child’s

social interactions, nonverbal behaviors, peer relationship development, and impairment in

communication, both verbal and nonverbal.

The American Psychiatric Association (2000) also notes that individuals who live with

Autistic Disorder have markedly different patterns of behavior. These patterns are abnormal in

their intensity and focus and include activities and interests that are restricted, repetitive, and

stereotyped. By definition, the American Psychiatric Association (2000) state that any period of

normal development must not extend past the age of 3. According to Crane & Winsler (2008)

Autism has been described as being one of the most devastating developmental disorders of

childhood because it can cause disabilities in all areas of psychological development.

Background of Autism Spectrum Disorder

According to Levy et al., 2009 and Myers & Plauche’ Johnson, 2007 the term Autism

Spectrum Disorder (ASD) has been used to include and discuss Autistic Disorder, Asperger’s

Syndrome, and Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS), as

they are diagnosed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,

Text Revision (DSM-IV-TR). Levy et al., 2009; Jepson & Johnson, 2007; & National Institute

of Mental Health, 2004, describe autism spectrum disorders as being characterized by varying

degrees of impairment in communication skills, social skills, and restricted, repetitive, or

stereotyped patterns of behavior. According to Levy et al. (2009) clinical signs of autism can

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usually be detected by age 3, but typical language development might inhibit identification.

Volkmar (2008) stated that younger siblings of children with autism have shown signs of autism

in their lack of social responsiveness, inhibited communication, and characteristic play by the

age of 6-12 months.

Autism Spectrum Disorders affects approximately 1 in 110 children, according to the

Centers for Disease Control (CDC) and Prevention (2006). The CDC (2006) reports that of the

children diagnosed with Autism Spectrum Disorders, 1 in 70 are boys and 1 in 310 are girls.

These numbers support the data that the prevalence of ASD’s have increased from 2002 to 2006.

Delay in language skills, according to the CDC (2006) is the most common concern that is

noticed by the child’s parent, teacher, or health care provider. A developmental loss of skill or

“regression” has been noted as grounds for ASD assessment. (CDC, 2006).

Impairment of Communication and Social Skills

Communication Skills

Children with Autism Spectrum Disorder, according to Myers, Plauche’ Johnson, & the

Council on Children With Disabilities (2007) have deficits in social communication. Levy et al.

(2009) discuss the core deficiencies of communication in children with autism as including:

Delay in verbal language without non-verbal compensation (e.g., gestures);

impairment in expressive language and conversations, and disturbance in

pragmatic language use; stereotyped, repetitive, or idiosyncratic language; and

delayed imaginative and social imitative play. (p. 2)

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According to the American Psychological Association (2000) children who are diagnosed

with ASD have impairments in communication skills which inhibit their ability to understand or

respond to simple direction and questions. A. Davis (personal communication, 2009) stated that

the inability to communicate is one of the reasons why children diagnosed with ASD turn to

tantrums and other behavior problems. If they are unable to tell with others what they need, or

how they feel, they have to turn to other methods of non-verbal communication. (A. Davis,

personal communication, 2009) Hundert & Delft (2009) stated that most children with autism

spectrum disorders need to be taught beginning communication skills. In a study conducted by

Peterson, Larsson, & Riedesel (2003), children with ASD have to be taught simple receptive

discrimination such as touching requested objects. Hundert & Delft (2009) reported that there

are multiple studies that suggest children who function on the higher end of the autism spectrum

are successful at learning how to answer factually based “wh-“ (who, what, when, where, and

why) questions, which is the first step in learning how to ask “wh-“ questions.

Social Skills

The Autism and Developmental Disabilities Monitoring (ADDM) Network (N.D.) state

that children with ASD have can have difficulties, or even show an absence in the ability to

engage in the following social skills: pretend play, showing interest when another person points

out an object, pointing to an object of their interest, making eye contact with other individuals,

understanding feelings whether it be their own or someone else’s, listening when other people

talk to them, cuddling or showing affection to others, knowing how to play and relate with

others, speak in normal language with others (not echolalia), expressing their needs, appropriate

use of toys, and appropriately reacting to smells, sounds, tastes, and the feel or look of certain

objects. The ADDM network (N.D.) also state that children with ASD commonly engage in

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repetitive or unusual behaviors such as arm flapping, making inappropriate or unusual noises,

racking from side to side, and walking on their toes. Levy et al. (2009) stated that social deficits

can be present in those as young as 6-12 months of age, and early detection will result in quicker

support for families with the use of intervention services. According to Levy et al. (2009) some

of the domains of socialism that are affected by ASD include:

Impaired use of non-verbal behaviors to regulate interactions; delayed

peer interactions, few or no friendships, and little interaction; absence of

seeking to share enjoyment and interests; delayed initiation of interactions;

and little or no social reciprocity and absence of social judgment. (p. 2)

Behavior Problems Exhibited by Children With Autism Spectrum Disorder

According to Baker, Blacher, Crnic & Edelbrock (2002) children who have

developmental disabilities are more likely to exhibit behavior problems than children who are

typically developing. Charles et al. (2008) state that the most common behavior problems

exhibited by children diagnosed with ASD include impulsive behavior, aggression, tantrums,

ritualistic behaviors, and unstable moods which can come from anxiety, depression, and

hyperkinesis. Koegel, Schreibman, Loos, Dirlich-Wilhelm, Dunlap, Robbins (1992) report that

these behavior problems decrease family quality of life. According to Cale, Carr, Blakeley-

Smith & Owen-DeSchryver (2009) problem behavior can inhibit children with autism from

completing common routines. Such common routines include (a) being able to transition

between settings or activities, (b) appropriately terminating a preferred activity (c) and being

presented with the presence of a feared stimulus. (Cale et al, 2009).

Secondary Responses of Autism Spectrum Disorder

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Levy et al. (2009); & Granpeesheh, & Dixon (N.D.) describe the core symptoms of ASD

as being affected domains of socialization, communication problems, and behavior problems.

However, Granpeesheh, & Dixon (N.D.); & Jepson & Johnson (2007) state that although there

are diagnostic features of ASD, there are also secondary responses of the disorder. The authors,

Granpeesheh, & Dixon (N.D.); & Jepson & Johnson (2007), report that three of the most

common problems include increased immune dysfunction, inflammatory gastrointestinal

disorders, and nutritional deficiencies. Although there is yet to be conclusive evidence to

support a link between these secondary responses and ASD, it has become clear that children

with ASD might also be suffering from a variety of biomedical problems. (Granpeesheh &

Dixon, N.D.) In a conversation with autism researcher Dr. Amy Davis (personal

communication, 2009), it was stated that the behavior problems exhibited by children affected by

ASD come from the side effects of the secondary responses of ASD and not the symptoms

themselves. For example, a child who suffers from ASD and has inflammatory bowel disease

might be exhibiting severe behavior problems because of severe stomach pain, however, because

their communication skills lack appropriate development, the child is not able to communicate

properly to the parent. (A. Davis, personal communication, 2009)

Immune Dysfunction

According to (Sweeten, Bowyer, & Posey ,2003; Ashwood, Willis, & Van De

Water, 2006) an increased number of immune deficiencies have been reported in families with a

child diagnosed with autism. Ashwood et al. (2006) state that children with ASD are prone to

infection, chronic inflammation, and autoimmune reactions. They state that this immune

dysfunction can affect any organ in the body, but most commonly, the GI tract and the brain.

Comi, Zimmerman, & Frye (1999) support this claim by reporting that 46% of families in their

26

study who had a child with autism had two or more members of the family with autoimmune

disorders. Jepson & Johnson (2007) noted that although immune dysfunctions are present in

most children with ASD, they are not present in all.

According to Sweeten, Bowyer, Posey, Halberstadt, & McDougle (2003) the autoimmune

disorders that were most commonly coupled with autism were hypothyroidism, Hasimoto’s

thyroiditis, and rheumatic fever. In another study, Molly, Morrow, Meinzen-Derr, Dawson,

Bernier, Dunn, Hyman, McMahon, Goudie-Nice, Hepburn, Minshew, Rogers, Sigman, Spence,

Tager-Flusberg, Volkmar, & Lord, (2006) looked at the family history of autoimmune disorders

in families with a child diagnosed with ASD and found that 57% had a first or second degree

relative with an autoimmune disorder. The authors stated that there were a higher number of

autoimmune disorders in children who showed regression, and thyroid disease was the most

commonly associated autoimmune disorder. (Molly et al., 2006).

Campbell, Sutcliffe, Ebert, Militerni, Bravaccio, Trillo, Elia, Schneider, Melmed, Sacco,

Persico, & Levitt (2006) also found an association of immune dysfunction and children with

autism. The authors found that children with autism presented with a genetic variant of MET, a

cell receptor that is important for normal growth and maturation of the brain, for proper

regulation of the immune system, and for gastrointestinal repair. (Campbell et al., 2006).

Gastrointestinal Disorder

Levy & Hyman (2005) stated that some children with autism appear to have increased

frequency of gastrointestinal tract problems or inflammatory bowel diseases. Such problems

might include diarrhea, constipation, and gastro esophageal reflux. Although there are reports of

a link between ASD and increased gastrointestinal tract problems (Horvath, Papadimitriou, &

Rabsztyn, 1999; Horvath, & Perman, 2002) there is no epidemiological data, according to Kuddo

27

& Nelson (2003) to support this claim. However, a tertiary care clinic that cares for children

with ASD reported that 24% of the children seen had a history of at least one gastrointestinal

problem. (Levy & Hyman, 2005).

Valicenti-McDermott, McVicar, Rapin, Wershil, Cohen, & Shinnar (2006); Melmed,

Schneider, & Fabes (2000) stated that in a study conducted with both children with autism and

neurotypical children, 70% of the children with autism presented with gastrointestinal symptoms

(GI) and 27% of the neurotypical children presented with GI symptoms. According to Jepson &

Johnson (2007) constipation and diarrhea are very common in children diagnosed with autism.

In one study conducted in a gastroenterology referral center, 78% of the children presented with

diarrhea, 59% presented with abdominal pain, and 36% presented with constipation.

According to Jepson & Johnson, 2007 and A. Davis, personal communication, 2009,

some physicians believe the symptoms of GI issues are the result of behavior problems rather

than the cause of the behavior problems. However, in a conversation with Dr. Amy Davis

(personal communication, 2009) she stated that constipation, reflux, abdominal pain, and

diarrhea (or “leaky gut” syndrome) come mostly from food allergies, food sensitivities, or the

body not being able to properly use the nutrients from the food that is being eaten. Davis (2009)

stated that the behaviors that are exerted by children with autism most likely come from the

severe pain or irritability that the gastrointestinal disorders are causing.

Food Intolerances

Gluten, is a protein, according to Jepson & Johnson, 2007 and A. Davis, personal

conversation, 2009, processed from wheat, oats, rye, barley, spelt, and some other types of grain.

According to the authors, gluten presents a sensitivity in children with ASD because it is hard

(sometimes impossible) for them to digest. Casein, a protein that comes from cow’s milk,

28

presents another sensitivity in children with ASD. Sections of the proteins (peptides) in gluten,

along with casein, according to Jepson & Johnson, 2007; A. Davis, personal communication,

2009; Milward, Ferriter, Calver, & Connell-Jones, 2004, are similar in structure to opiates

(which are present in morphine and heroin) and can cause addictions to foods that contain gluten

and casein and trigger withdrawal when they are removed from the diet.

Horvath, & Perman (2002) reported that studies have been done regarding endoscopic

evaluations of the upper GI tract in children with autism. According to the authors, treating the

GI problems found in these evaluations often improves behavior problems in children with ASD.

According to Levy & Hyman (2005) if a food allergy is documented in a child with ASD

behavioral responses and non-behavioral responses such as irritability, food refusal, and

disturbances in sleep are also reported to be increased. Lucarelli, Frediani, Zingoni, Giardini, &

Quintieri (1995) found evidence of an elevated level of antibodies to casein in children

diagnosed with ASD. When casein was removed, the authors stated that the children

demonstrated an improvement in behavior. Lucarelli et al., 1995).

According to Mulloy, Lang, O’Rilley, Sigafoos, Lancioni, & Rispoli (2009) the existing

literature regarding special diets for children with autism is very limited. Of the 14 studies they

researched, they felt that few showed quality research. According to Mulloy et al. (2009) the

studies that showed improvement for children on the gluten free/casein free diet should be

discounted because they either do not include a control group, or include measurement

conditions subject to bias. As the authors noted, the literature is limited, which makes research

on special diets (part of biomedical treatment and healthy family functioning) that much more

important. (Mulloy et al., 2009).

29

Impact of Autism Spectrum Disorders on the Family

Quality of Life

According to Lee et al. (2007) research shows that families who have a child diagnosed

with ASD have reported a decreased quality of life than control families. The affected families

reported that they were significantly less likely to be able to attend religious services; that their

children are more likely to be absent from school which poses a problem for the parent, as they

must find someone to take care of the child during these absences otherwise be absent

themselves; and they are less likely to be involved in organized activities, individual, or as a

family. (Lee et al., 2007). Bouma & Schweitzer, 1990; Donenberg & Baker, 1993; Seltzer,

Shattuck, Abbeduto, & Greenberg, 2004, report that parents who have a child with special needs

have less time to meet their own needs because of the child-caring stress that occurs every day.

Stress on Mothers

Phetrasuwan & Miles (2008) stated that significant challenges are presented to parents,

particularly mothers (often the primary caregiver) when they are raising a child diagnosed with

ASD. According to Phetrasuwan & Miles (2008), when parenting a child with ASD, the highest

sources of stress were found to be the following:

Managing demanding behaviors and upset feelings, discipline, and managing

behavior in public places were the highest sources of overall parenting stress.

Symptom-related stressors that were most salient were the child’s emotional

responses, expressions of fear or nervousness, verbal communication issues, and

relating to people. (p. 162)

In studies conducted by Dunn, Burbine, Bowers, & Tantleff-Dunn, 2001; Tomanik,

Harris, & Hawkins, 2004, there is a relationship between parental stress and the behaviors

30

exerted by children with ASD. A relationship has also been found between the severity of

behavior problems in children with ASD and the level of parental stress. (Abbeduto, Seltzer,

Shattuck, Krauss, Orsmond, & Murphy, 2004; Baker et al., 2002; Perry, Harris, & Minnes, 2005.

According to a study conducted by Hoffman, Sweeney, Hodge, Lopez-Wagner, & Looney

(2009) mothers of children with autism presented with extremely higher levels of stress than the

control group. Mothers with a child with autism reported higher levels of stress on 6 of the 7

Parent Domain subscales when compared to the control group. The authors also reported that the

severity of the child’s symptoms were related to the mother’s stress level scores. (Hoffman et

al., 2009). Mothers in this study also reported that the more stressful and problematic their

child’s behavior was, the less closeness they felt towards the child. (Hoffman et al., 2009). The

study showed that it was the higher levels of problematic behavior in children with autism, and

not the level of autism itself that contributed to lower levels of closeness in the reports of

mothers of children with autism. (Hoffman et al., 2009).

Stress on the Family

According to Brobst, Clopton, & Hendrick (2009) stated that when parenting a child with

special needs, more time and effort must be provided by the parents which causes a great deal of

stress and strain on the couple. Although there is limited research regarding the specific impact

parenting a child with ASD has on the couple, there is an adequate and increasing amount of

research to support the idea that the behaviors exerted by children with ASD can create a very

challenging environment which affects the family. (Brobst et al., 2009). When comparing

couples with a child diagnosed with ASD and a control group comprised of couples who do not

have a child diagnosed with ASD, it was found that more parental stress and trouble with

behavior problems existed in couples who had a child diagnosed with ASD. The parents of

31

children with ASD also reported lower relationship satisfaction and overall social support.

However, the study did not find significant differences in perceived spousal support,

commitment to each other, or respect for each other. (Brobst et al., 2009)

According to Blacher & McIntyre (2006) higher levels of stress are reported in parents of

children with autism than in any other type of disability. In a research study conducted by

Osborne, & Reed (2009), it was found that parenting stress is associated with the behavior

problems exerted by children with ASD and not the severity of the child’s ASD, except in very

young children. The authors also stated that the parenting stress as a result of behavior problems

will in turn affect future behavior problems. (Osborne & Reed, 2009). Donovan (1988) stated,

in his research study, that family problems exist more in families of children with autism than in

other families with children with cognitive disabilities.

One specific challenge that affects families, who have a child with autism, is the financial

burden or responsibility that families with normal developing children do not have to face.

According to Brobst et al., 2009 and Parish, Seltzer, Greenberg, & Floyd, 2004, raising a child

with autism has been associated with increased medical costs and higher rates of job loss than

families who do not have a child with children with autism. According to Benson (2006)

parental depression, which can affect the entire family, was frequently reported in families with a

child diagnosed with ASD. (Lee et al., 2009). Brobst et al. (2009) stated that additional research

is needed regarding the affects (including individual, dyadic, and family systems) on parental

relationships when raising a child with ASD.

Psychological Foundations of Autism Spectrum Disorder

Individuality and togetherness, according to Kerr & Bowen (1988) are the two

counterbalancing life forces that are reflected from the operation of the family’s emotional

32

system. This system focuses on the development of the physical, emotional, and social

dysfunctions that bear a significant relationship to individuals and families, and how these family

systems respond and make adjustments. Autism Spectrum Disorder (ASD) is an example of a

dysfunction that can bear a significant impact on a family system. (Brobst et al., 2009).

According to Brobst et al. (2009), a great deal of stress and strain can be placed on a couple who

are parenting a child with special needs, this, according to the authors, is due to the fact that the

children with special needs require a lot more time and attention than normal developing

children.

Bowen (1985) discusses the family systems theory as a triangle, or a three-person system.

His best example of the family system or triangle system is the father-mother-child triangle.

Bowen (1985) discussed that the triangle functions in different periods, periods of calm, periods

of stress, and periods of tension. In all of these periods, the triangle follows a pattern, and

although the pattern can often change, one parent is passive, distant, or weak and leaves the

conflict between the other parent and the child. ( Bowen, 1985). The child is the weaker of the

two and often loses the battle and therefore comes to expect to lose. If the passive parent ever

decides to attack or challenge the aggressive parent the child will eventually learn how to take

the outside position and play the parents against each other. (Bowen, 1985). According to

Phetrasuwan & Miles (2008) parents, but mothers in particular, since they are often the primary

caregiver, are often presented with significant challenges, such as behavior problems, etc, that

cause varying degree of stress when raising a child with ASD. This type of stress, (Phetrasuwan

& Miles (2008) can lead to passive or aggressive attack on the child or the other parent, causing

dysfunction in the family system. (Bowen, 1985). According to Bartle-Haring & Lal, 2010 and

Ng & Smith, 2010, Bowen theory suggests that when the emotional system is in turmoil, it is still

33

possible to maintain emotional objectivity and keep the family in the system, this is what Bowen

(1985) refers to as a differentiated self.

According to The Bowen Center (2009) the family systems theory is a human behavior

theory that views the family as an emotional unit. It uses systems thinking to describe the

complex interactions within the unit. It is stated by The Bowen Center (2009) that if one person

in the family changes their functioning than it can be predicted that there will be reciprocal

changes in the functioning of others in the family. Bowen’s family systems theory is based on

the idea that the emotional system will affect most all human activity and it is the principal

driving force in the development of clinical problems. (The Bowen Center, 2009). Brobst et al.

(2009). Reported that in families with a child with ASD, there are often outside factors that can

cause stress and strain on one or both of the parents. According to Brobst et al., 2009 and Parish

et al., 2004, increased medical costs and higher rates of job loss have been associated with

raising a child with autism than in families who do not have a child with autism. This type of

outside stress is an example of how family functioning can change, especially if the parents

disagree about how to address the outside factors or issues. (Bowen, 1985).

Family Functioning and FACES IV

FACES IV stands for family adaptability and cohesion evaluation scales and consists of

six family scales, according to Olson et al. (2004). These scales assess the dimensions of family

cohesion and family flexibility and include two balanced scales and four unbalanced scales.

According to Olson et al. (2004) there are 62 items on the assessment and address cohesion,

flexibility, communication, and satisfaction. FACES IV is the newest version of a family self-

34

report assessment and it is designed to evaluate family cohesion and family flexibility. (Olson et

al., 2004). According to Kouneski (2002) there have been more than 1,200 articles and

dissertations published which used some version of FACES or the Circumplex Model of Marital

and Family Systems.

Multiple studies regarding aspects of family functioning have been conducted (Barber &

Buehler, 1996, and Werner, Green, Greenberg, Browne & McKenna, 2001) but the importance

of cohesion and flexibility in the family system has remained constant in all of them. (Olson,

2010). Cohesion, according to Olsen (2010) is defined as “the emotional bonding that family

members have toward one another” (p. 2). Olson (2010) defines family flexibility as “the quality

and expression of leadership and organization, role relationship, and relationship rules and

negotiations” (p. 2). Olsen (2010) stated that when using the Clinical Rating Scale (CRS) which

is based on the Circumplex Model, balanced levels of cohesion and flexibility are related to

healthy families and unbalanced levels are more characteristic of unhealthy families.

According to Olson et al. (2004) the reliabilities of the six FACES IV scales are as

follows: Disengaged = .87, enmeshed = .77, Rigid = .83, Chaotic = .85, Balanced Cohesion

= .89, Balanced Flexibility = .80, and Alpha reliability analysis was also run for the validation

scales and ranged from .91 to .93. In another study conducted by Olson (2010) the six scales

created for FACES IV were proven to be reliable and valid based on reports from the American

Association for Marriage and Family Therapy.

Biomedical Treatment and Autism Spectrum Disorder

The research on biomedical treatment is somewhat limited as it is not a widely accepted

form of treatment for children with autism. (Jepson & Johnson, 2007). What the data does show

35

is that biomedical treatment, or the multi-tiered treatment approach, according to Jepson &

Johnson (2007) is a type of treatment that is working for many children with autism. This type

of treatment aims to replace what the child is missing, remove what is causing the child harm,

and break the inflammatory cycle. (Jepson & Johnson, 2007). By doing these things, children

with autism can begin to heal and recover, and families can begin to see changes in behavior,

health, and eventually establish healthier functioning for the entire family. (Jepson & Johnson,

2007). Wong & Smith (2006) also discuss the use of biomedical treatment for children with

ASD. The authors define biomedical or complementary and alternative medicine (CAM) as a

group of diverse medical systems, practices, or products that are not considered part of

conventional medicine.

In a study conducted by Harrington et al. (2006) 87% of the participating parents

reported to using at least one biomedical or drug treatment for their child’s autism. The authors

noted that their survey did report a much greater use of biomedical treatments than previously

reported (Levy, Mandell, Merhar, Ittenbach, & Pinto-Martin, 2003; Nickle, 1996) for children

with autism, and they attribute this difference to differences in survey techniques or differences

in demographics of participants. (Harrington et al., 2006). In other survey’s it has been shown

that 50-70% of children with autism are using biomedical treatment. (Wong & Smith, 2006;

Hansen et al., 2007).

According to the American Academy of Pediatrics (2010) physicians treating children

with ASD should be aware that there is a great possibility that these children are undergoing

biomedical treatment and therefore should become knowledgeable about biomedical treatment,

current and past use, in order to provide balanced information and advice to any parents seeking

treatment options. The American Academy of Pediatrics (2010) also discourages physicians

36

from being dismissive of biomedical treatment or showing a lack of sensitivity or concern in

their conversations. It is recommended that physicians continue to work with families who have

a child with ASD and are seeking biomedical treatment even if there is a disagreement about

treatment choices, and continue to emphasize the scientific merits of traditional therapies.

(American Academy of Pediatrics, 2010).

Supplements Used For Children with Autism Spectrum Disorder

According to Levy & Hyman (2005) dietary supplements include vitamins, minerals, and

other substances that are “natural” and are available without a prescription. Although evidence

for deficiencies of dietary nutrition has not been scientifically proven, according to Hyman &

Levy (2000), research shows that supplements are used in children with ASD for the

enhancement of neurotransmitter function by increasing the availability of certain substances or

cofactors. Another reason for dietary supplements, according to Pfeiffer, Norton, & Nelson

(1995) is compensate for any biochemical deficiencies in children with ASD. In a study

conducted by Harrington et al., (2006) out of 62 parents reporting the use of biomedical

treatment, more than half of the parents reported the use of dietary supplements. In another

study, conducted by Hanson et al., (2007) out of 112 participants, 33 parents were giving dietary

supplements for their child with ASD.

According to Levy & Hyman (2005) in a survey conducted by the Autism Research

Institute, the most common dietary supplements being used were magnesium, vitamin B6,

dimethyglycine (DMG), and vitamin C. In a conversation with Dr. A. Davis (personal

communication, 2009) she stated that there are two main importance’s of dietary supplements,

the first being because some children with ASD do not properly break down and digest the foods

they eat, they lack many nutrients that their body needs for optimal health. The second reason is

37

that a lot of children with ASD are on special diets and they do not take in proper amounts of

specific nutrients so it is important to supplement them. (A. Davis, personal communication,

2009). Of course more research is warranted on nutritional supplements, but in the children seen

in the clinic, vast majorities are nutritionally deprived, and should be treated with basic dietary

supplements to include digestive enzymes, probiotics, multivitamins, and other basic

supplements. (A. Davis, personal communication, 2009). Whether autism is the cause or the

result of dietary deficiencies, Jepson & Johnson (2007) explain that the most important strategy

in treatment should be re-supplying the body with the nutrients that are essential for the child’s

body to perform on a more normal basis.

Antifungals and Probiotics Used For Children with Autism Spectrum Disorder

Probiotics, according to Kaila, Isolauri, Soppi, Virtanen, Laine, & Arvilommi, (1992);

Itoh, Fujimoto, Kawai, Toba, & Saito (1995) contain an ingredient known as Lactobacilli and aid

in the production of molecules that fight pathogenic bacteria, they also lower the pH of the stool,

and aid in the formation of oxidants that keep harmful bacteria from colonizing. Saccharomyces

boulardii is another “good yeast” that encourages the growth of “good bacteria” while

discouraging the growth of pathogenic bacteria and yeast. (Levy, 1998; Haskey, & Dahl, 2006;

Buts & De Keyser, 2006). In other studies, probiotics have been used in children to shorten the

lifespan of diarrhea, eliminate Clostridium difficile infections, prevent diarrhea, and shorten the

spreading of rotavirus. (Isolauri, Juntunen, Rautanen, Sillanaukee, & Koviula, 1991; Biller,

Katz, Flores, Buie, & Gorbach, 1995; Saavedra, Bauman, Perman, & Yolken, 1994).

According to Jepson & Johnson (2007) there is currently a lack of scientific research

regarding the use of antifungals for ASD. However, the authors suggest that antifungals are

most often put at the top of the treatment plan by biomedical doctors for children with ASD

38

because they often bring about behavioral improvement. (Jepson & Johnson, 2007). The

question that biomedical doctors have yet to answer (because there is not enough research

regarding the topic) is whether or not these antifungals work on behavior problems by killing the

yeast itself, decreasing the levels of yeast-produced neurotoxins, or because they affect the

metabolic pathway directly. (Jepson & Johnson, 2007). Jepson & Johnson (2007) reports that

when antifungals are used, behavior often gets worse (for approximately 1 week) followed by a

significant improvement, because of a “die-off” effect as the yeast is killed. According to Levy

& Hyman (2005) there aren’t any known negative side effects to using probiotics agents, but the

chronic use of antifungals requires monitoring because they can cause liver toxicity and

exfoliative dermatitis.

Special Diet Used For Children with Autism Spectrum Disorder

According to Adams, Edelson, Grandin, Rimland (2004) the gluten free/casein free diet is

one of the most common diets used for children with autism. It was in 1980 that an association

between a diet containing gluten and casein and autistic behavior was found. (Ashkenazi, Levin,

& Krasilowsky, 1980). Levy & Hyman (2005) state the popularity of this diet is frequently used

because it is presumed to be a healthy, noninvasive approach and is presented to parents in an

optimistic way which promises rapid results. The rationale behind the gluten free/casein free

diet is based on the assumption that children with ASD experience “leaky gut” syndrome, which

is described as the inability to break down the proteins found in both gluten and casein which

results in the absorption of peptide fragments. (Gilberg, 1995, and Shattock & Whitely, 2004).

The reaction, according to Gilberg, 1995; Shattock & Whitely, 2004, results in an opioid effect.

Although there are a number of studies regarding positive effects of the gluten free/casein free

39

diet used in children with ASD, various methodological flaws prohibit them from being

perceived as definitive. (Christison, & Ivany, 2006).

Jepson & Johnson (2007) reported that in several research trials that incorporated a strict

gluten free/casein free diet for several months, at minimum, immediate results were received in

the areas of eye contact, behaviors, sleep problems, bowel problems, communication issues, and

attention. The authors report that removing gluten and casein form the diets of children with

ASD can result in a short lived behavior regression, but should be immediately followed by a

significant improvement in behavior problems. (Jepson & Johnson, 2007). Jepson & Johnson

(2007) also stated that removing chemicals and artificial colors from the diet can improve

nutrition and behavior in children with ASD. Another popular diet used for children with ASD

is called the Specific Carbohydrate Diet. (Gottschall, 1994). The author stated that yeast and

bacteria can cause gastrointestinal inflammation and problems with absorption because of the

overproduction of mucus. (Gottschall, 1994). When complex carbohydrates are removed from

the diet, the yeast and bacteria living in the system are starved, causing them to “die off” and the

gut will heal. (Gottschall, 1994). According to Levy & Hyman (2005) more evidence on diet

based treatments is warranted because as with any intervention, families who don’t utilize special

diets incur feelings of guilt when they learn that other families have tried special diets and

achieved results.

Biomedical Treatment and Family Functioning

Jepson & Johnson (2007) stated that the treatment of ASD consists of three components;

“replace what the child is missing, remove what is causing harm, and break the inflammatory

cycle” (p. 183). In a conversation with Dr. A. Davis (personal communication, 2009) she

40

mentioned that every child is different, therefore treatment must be altered to their own specific

needs. Although a basic plan is followed, most include discovery of food sensitivities, addition

of basic dietary supplements, antifungals and probiotics if yeast and bacteria is found in the gut,

and a special food diet if deemed necessary. According to Jepson & Johsnon, 2007; A. Davis,

personal communication, 2009, reports from parent’s state that changing the child’s diet is often

the most difficult of all, but often shows the most immediate improvements in behavior. When

parents see improvements, it encourages them to continue with other changes. (Jepson, &

Johnson, 2007; A. Davis, personal communication, 2009).

According to Baker et al., children with developmental disabilities exhibit

behavior problems more often than typical developing children. In a conversation with Dr. A.

Davis (personal communication, 2009) she stated that the behavior problems exerted by children

with ASD most often come from the side effects of secondary responses of the disorder. If you

remove the sensitivities or other issues, the child’s behavior will improve. (A. Davis, personal

communication, 2009; Jepson & Johnson, 2007). For example, Dr. Amy Davis (personal

communication, 2009) stated that in her research, children who are suffering from GI issues and

food sensitivities have behavior problems because they have no other way to communicate their

feelings of discomfort, but if you remove the GI issues (with probiotics and antifungals) and

remove foods such as gluten and casein from the diet that trigger sensitivities (Lucarelli et al.,

1995; Jepson & Johnson, 2007) you will see a change in behavior because they will feel better

and most often, begin to express better communication and social skills. (A. Davis, personal

communication, 2009).

As stated by the American Psychological Association (2000) children with ASD have

impairment in communication skills which inhibits their ability to answer or even understand

41

simple directions and questions. According to Johnson & Jepson (2007); & A. Davis (personal

communication, 2009) using biomedical treatment can improve communication and social skills.

According to Brobst et al., 2009; & Hoffman et al., 2009, the behaviors exerted by children with

ASD create a challenging environment that affects the family, both mother and father. Once

again, as stated by Jepson & Johnson, 2007; & A. Davis, personal communication, 2009, treating

the side effects of secondary responses of ASD with biomedical treatment can alleviate the

behaviors that affect family functioning in a negative way.

Summary

To briefly review, chapter two expanded upon the current and past literature regarding

the topics of research in the current study, autism spectrum disorders, biomedical treatment, and

healthy family functioning, in an attempt to assist in the understanding of their theoretical

development and concept. The literature review also provided a description of Bowen’s Family

Systems Theory, and the FACES IV assessment, which will be used to answer the research

questions in the current study. In the next chapter, a description of how the study was conducted

can be found.

42

CHAPTER 3. METHODOLGOY

Introduction

The purpose of this chapter is to explain the methodology that will be used to answer the

research questions in this study. The current chapter begins by discussing the purpose of the

study, the rationale, and research design. Discussed next will be the target population and

participant selection, followed by the data collection and procedures explaining the instruments

and statistical analyses that will be used. The research questions and hypotheses will be

discussed next and data analysis will follow. The final portion of this chapter will discuss the

expected findings of this study.

Purpose of the Study

Families who have a child diagnosed with autism spectrum disorder face various

challenges in their lives. (Kanne, 2006; Levy & Hyman, 2005; Jepson & Johnson, 2007). This

Ex Post Facto study will attempt to increase the body of knowledge available to researchers,

psychologists, and families, by attempting to determine whether families using biomedical

treatment will have healthier family functioning scores according to the FACES IV assessment.

FACES IV, according to Olson et al. (2004) is a 62 item assessment that addresses

cohesion, flexibility, communication, and satisfaction. This assessment scale stands for family

adaptability and cohesion evaluation scales and will be used to determine the level of healthy

family functioning for each participant. There are two balanced scales and four unbalanced

scales in the FACES IV assessment and the published rates of validity and reliability are as

follows: Disengaged = .87, enmeshed = .77, Rigid = .83, Chaotic = .85, Balanced Cohesion

43

= .89, Balanced Flexibility = .80, and Alpha reliability analysis was also run for the validation

scales and ranged from .91 to .93.

The participants of the FACES IV assessment will be divided into two groups; mothers of

a child diagnosed with autism and have received biomedical treatment, and mothers of a child

who has been diagnosed with autism and has not received biomedical treatment.

The scores that are received through the FACES IV assessments will be used to

determine if the families using biomedical treatment have healthier family functioning. These

scores might also lead to further causation studies for autism, biomedical treatment, and healthy

family functioning.

According to Harrington, Patrick, Edwards, & Brand (2006) some of the most popular

forms of biomedical or alternative treatments for Autistic Spectrum Disorder (ASD) include

dietary restrictions, dietary supplements, antifungals, chelation therapy, homeopathy, sensory

integration, secretin, and animal therapy. These different treatments can be used separately or

combined. Although the authors showed evidence of such treatment being used by many parents

of children with ASD, the authors discussed the treatment as being controversial and potentially

harmful. (Harrington et al, 2006). The authors suggested that practitioners use a non-judgmental

tone, and inquire about parental beliefs and current treatments in order to establish a more

trusting relationship with parents. However, like most articles on ASD treatments, there is no

mention of the psychological impact ASD has on both the parents and the child. Harrington et al

(2006) discuss the use of biomedical treatment; but they do not discuss how many parents

achieved better behavior from their child after implementing various treatments.

Rationale

44

This Ex Post Facto design will have an independent variable, biomedical treatment

(variable x) and a dependent variable, level of healthy family functioning (variable y). Using an

Ex Post Facto design, according to Leedy & Ormrod (2005) allows the researcher to make a

generalization about the population being studied, this factor is important when limiting the

study to parents of children with autism.

Research Design

The purpose of this quantitative study is to determine if there is a relationship between

biomedical treatment and healthy family functioning scores as determined by FACES IV. In

order to determine if a relationship does in fact exist between biomedical treatment higher family

functioning scores, an Ex Post Facto research design will be used in this study.

A 2 group Ex Post Facto design will be used. According to Leedy & Ormrod (2005) Ex

Post Facto refers to something “after the fact”. Leedy & Ormrod (2005) state that the intent of

Ex Post Facto designs is to provide a different means in which a researcher can investigate how

the dependent variable can be affected by a specific independent variable(s).

Target Population and Participant Selection

The population of interest for this study will consist of mothers who have a child that has

been diagnosed with autism spectrum disorder. The child must be diagnosed by a doctor and the

mother can be married, living with a mate, separated, or divorced. The child with autism can be

of any age, as can the mothers. These children are not required to all have the same symptoms of

autism, and the mothers are not required to experience all the same day to day issues. Sampling,

according to Leedy & Ormrod (2005) is defined as a subset or part of population that will be

45

studied when the entire population of interest cannot be studied. The entities that are selected are

called the sample, and the way in which they are selected is called sampling. (Leedy & Ormrod,

2005). A website, which will include information regarding the current study, will be created

and will include a hyperlink that will take the participants directly to the survey, hosted by

Survey Monkey. The survey on Survey Monkey will include a set of background questions for

the mothers as well as the FACES IV assessment. The link to this website

(www.autismdeal.com) will be posted online by Age of Autism. There will also be flyers and an

information page placed in Dr. Amy Davis’s office, Crossing Back to Health, a doctor’s office

that treats patients with autism.

As this study uses a convenience sample, the sample will include any mother who has a

child who has been diagnosed with Autism Spectrum Disorder. There is no exclusion to this

study. All regions/areas of the United States will be included in the in this online study.

The goal sample size for this study is 200 participants. However, if snowball sampling

plays a part the number of participants could increase by any number of volunteers. The sample

size was calculated by looking at past studies that have been done on Autism Spectrum Disorders

and Family Functioning Studies. Fiske, K.E. (2009). discussed using a sample size of 106 in the

cross-sectional study of patterns of renewed stress among parents who have a child diagnosed

with autism. According to the author, this was an adequate sample size to show that mothers and

fathers who have a child with autism have different levels of stress, depending on their

experiences with the child. (Fiske, K.E., 2009).

In another study, Berry, L.N. (2009) reported that 189 children participated in a study

regarding early treatments for optimal outcomes in children diagnosed with autism spectrum

disorders. Neither of these studies used snowball sampling in order to gain participants but both

46

were valid and reliable studies. If the current study has close to 200 participants then it will also

be valid and reliable.

Procedure

Preparatory Collection: A website will be created (www.autismdeal.com) and will

include information regarding the study for Mothers of children who have been diagnosed with

Autism Spectrum Disorder. The website will post information about the study, instruction,

information about the researcher, information about confidentiality, and a hyperlink to the survey

itself which is hosted by Survey Monkey.

Survey Monkey will be used as the host for the survey itself. The participants will read a

consent form and click “next” if they agree to participate in the study. At that time, the survey

will begin. The results from each survey will be kept on a database that only the researcher will

have access to.

Mothers of children diagnosed with autism will learn about the study via Age of Autism,

or Dr. Amy Davis, and she will volunteer to complete a survey through Survey Monkey. The

survey will ask 8 background questions about the child who has been diagnosed and ask for his

or her permission to participate in the assessment. The FACES IV assessment package

(purchased by researcher) includes an excel spreadsheet for storing and scoring the FACES IV

profile. This spreadsheet will make it possible to track the participants answers even though he

or she will not give names in order to remain anonymous. The assessment itself, is a 62 item

assessment that measures flexibility, adaptability, cohesion, communication and satisfaction.

Participants will answer questions in a “rating” form and his or her answers will be scored.

47

Instruments: The testing scale being used, FACES IV, has published levels of

reliability and validity. According to Olson, Gorall & Tiesel (2004) the reliabilities of the six

FACES IV scales are as follows: Disengaged = .87, enmeshed = .77, Rigid = .83, Chaotic = .85,

Balanced Cohesion = .89, Balanced Flexibility = .80, and Alpha reliability analysis was also run

for the validation scales and ranged from .91 to .93. By publishing these numbers, participants

will know beforehand how reliable and valid the assessment being used is. Using SPSS will help

to alleviate any miscalculations when analyzing and evaluating the data.

Post Data Collection: After the participants have completed the survey the results will

be stored in the database provided by Survey Monkey and the FACES IV spreadsheet. Once the

researcher has received the required or an adequate number or survey’s they will be exported to

SPSS 16.0 for further evaluation

Measures

Participants will be completing the FACES IV assessment. According to Olson, Gorall,

& Tiesel (2004) FACES IV will evaluate communication styles, family interactions, and

flexibility. The evaluations can be hand scored and imputed into SPSS or they can be scored

online and imputed into SPSS.

The scores that are received through the FACES IV assessments will help to determine

whether or not biomedical treatment for autism has an effect on healthy family functioning. If

the hypothesis is accepted, the information may be very beneficial to psychologists and medical

professional who are dealing and treating families who have a child diagnosed with autism

spectrum disorder. The results of this assessment might also show how the family systems

theory can be impacted by a diagnosis of autism spectrum disorder.

48

The testing scale being used, FACES IV, has published levels of reliability and validity.

According to Olson, Gorall & Tiesel (2004) the reliabilities of the six FACES IV scales are as

follows: Disengaged = .87, enmeshed = .77, Rigid = .83, Chaotic = .85, Balanced Cohesion

= .89, Balanced Flexibility = .80, and Alpha reliability analysis was also run for the validation

scales and ranged from .91 to .93. By publishing these numbers, my participants will know

beforehand how reliable and valid the assessment being used is. SPSS will also be used in order

to help alleviate any miscalculations when transferring numbers and scores and doing the t-test

graph.

Research Questions and Hypotheses

RQ1:

Is there a difference in the scores of healthy family functioning between families with a child

diagnosed with Autism Spectrum Disorder (ASD) who have received biomedical treatment and

families who have not received biomedical treatment according to the scores on the FACES IV

assessment?

According to Rao & Beidel (2009) the behavioral problems exerted by children with

ASD often cause elevated levels of stress, depression, anxiety and emotional exhaustion for the

entire family. These problems as stated by Rao & Beidel (2009) also affect the family system in

other ways. For example, parents of ASD children reported having little or no time for family

activities such as outings or vacations, having no room for spontaneity, and reported having

career restrictions and marital stress. (Rao & Beidel, 2009). Biomedical treatment, according to

Jepson & Johnson, 2007; Davis, 2009, can alleviate the symptoms of the secondary responses of

ASD that most often cause the behavior problems exerted by children with ASD. Since behavior

49

problems in children with ASD affect the family system and family functioning, it is assumed in

this study, that using biomedical treatment to alleviate the behavior problems will in turn

encourage better family functioning and a healthier family system.

Hypothesis: Mothers with a child diagnosed with Autism Spectrum Disorder and have received

biomedical treatment will have a higher rate of healthy family functioning as measured by

FACES IV than mothers whose child has not received biomedical treatment.

Null Hypothesis: Mothers with a child diagnosed with Autism Spectrum Disorder and have

received biomedical treatment will not have a higher rate of healthy family functioning as

measured by FACES IV than mothers whose child has not received biomedical treatment.

RQ1a. Are families who use biomedical treatment more cohesive according to the scores on

the FACES IV assessment?

Hypothesis: Families who use biomedical treatment will be more cohesive according to the

scores on the FACES IV assessment.

Null Hypothesis: Families who use biomedical treatment will not be more cohesive according to

the scores on the FACES IV assessment.

RQ1b: Are families who use biomedical treatment more flexible according to the scores on the

FACES IV assessment?

Hypothesis: Families who use biomedical treatment will be more flexible according to the scores

on the FACES IV assessment.

Null Hypothesis: Families who use biomedical treatment will not be more flexible according to

the scores on the FACES IV assessment.

50

RQ1c. Do families who use biomedical treatment have better communication skills according to

the scores on the FACES IV assessment?

Hypothesis: Families who use biomedical treatment will have better communication according

to the scores on the FACES IV assessment.

Null Hypothesis: Families who use biomedical treatment will not have better communication

according to the scores on the FACES IV assessment.

RQ1d. Are families who use biomedical treatment more satisfied according to the scores on the

FACES IV assessment?

Hypothesis: Families who use biomedical treatment will be more satisfied according to the

scores on the FACES IV assessment.

Null Hypothesis: Families who use biomedical treatment will not be more satisfied according to

the scores on the FACES IV assessment.

Data Analysis

T-tests, according to Leedy & Ormrod (2005) are used when the researcher wants to

determine whether or not there is a statistically significant difference between two means. In this

study, the first mean would include levels of family functioning in families whose children have

not received biomedical treatment for their autism, and the second mean would include levels of

family functioning in families of children who have received biomedical treatment for their

autism.

The information used in the t-test will come from the results of the FACES IV

assessment the participants will be completing. According to Olson, Gorall, & Tiesel (2004)

FACES IV will evaluate communication styles, family interactions, and flexibility. The

51

evaluations can be hand scored and imputed into SPSS or they can be scored online and imputed

into SPSS.

The scores that are received through the FACES IV assessments will help determine

whether or not biomedical treatment for autism has an effect on healthy family functioning,

cohesion, flexibility, communication, and satisfaction. If the hypothesizes are accepted, the

information may be very beneficial to psychologists and medical professional who are dealing

and treating families who have a child diagnosed with autism spectrum disorder. The results of

this assessment might also show how the family systems theory can be impacted by a diagnosis

of autism spectrum disorder.

Expected Findings

In general, it is expected that families who have used biomedical treatment for their child

with ASD will have a higher mean of family function according to FACES IV than families who

have not used biomedical treatment for their child with ASD. That is, biomedical treatment is

expected to minimize behavior problems in children with ASD and therefore increase the rate of

healthy family functioning according to FACES IV.

52

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Sweeten T.L., Bowyer S.L., Posey, D.J., Halberstadt, G.M., & McDougle,C.J. (2003). Increased prevalence of familial autoimmunity in probands with pervasive developmental disorders. Pediatrics 112, e420–e424.

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Personal Communication

Davis, Amy. (2009).

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APPENDIX A. PARENT PARTICIPATION FLYER DISTRIBUTED AT SITE

10/10/2010

Dear Parent:

I am a doctoral student working under the direction of Professor Linda Reed in the School of Psychology at Capella University. I am conducting a research study, titled Autism Spectrum Disorder: The Relationship Between Biomedical Treatment and Healthy Family Functioning, in an effort to determine whether or not biomedical treatment used in children diagnosed with Autism Spectrum Disorder can create a higher rate of healthy family living. I invite you to participate in this study. It will involve answering ten background questions and 62 questions regarding the FACES IV survey about your family. FACES IV is an assessment scale that measures family adaptability, cohesion, communication and satisfaction. These questions are available through the website www.autismdeal.com. Answering these questions should take no more than 20 minutes. Your participation in this study is completely voluntary, and you can chose not to participate. The results of this research study will be published but your child’s name and your name will not be included or requested anywhere in this study or survey.

Please copy this link into your internet browser

http://www.autismdeal.com

This survey does not provide a direct benefit for you, but your participation will hopefully result in increased education of how biomedical treatment might increase the rate of healthy family functioning.

If you have any questions concerning this research study or your participation in this study, please call me at 843-377-6837 or email me at jreneej1@hotmail.com or Dr. Linda Reed at 937-550-4269, Linda.Reed@capella.edu.

Sincerely,

Jill Tschikof

If you have any questions about your rights as a research participant or any concerns about the research process, or if you’d like to discuss an unanticipated problem related to the research, please contact the Capella Human Research Protections Office at: 1-888-227-3552, extension 4716. Your identity, questions, and concerns will be kept confidential.

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APPENDIX B. PROCEDURE AND INFORMATION FOR OFFICE STAFF

10/10/2010

I am a doctoral student under the direction of Professor Linda Reed in the School of Psychology at Capella University. I am conducting a research study, titled Autism Spectrum Disorder: The Relationship Between Biomedical Treatment and Healthy Family Functioning, to determine whether or not biomedical treatment used in children diagnosed with Autism Spectrum Disorder can create a higher rate of healthy family living. I invite you to participate in this study. I am inviting mothers with a child diagnosed with Autism Spectrum Disorder to participate in this study, which will involve answering 10 background questions and 62 questions regarding the FACES IV survey about their family. FACES IV is an assessment scale that measures family adaptability, cohesion, communication and satisfaction. These questions are available through the website www.autismdeal.com. Answering these questions should take no more than 20 minutes.

Parent participation in this study is voluntary, they can choose not to participate. The results of this research study will be publish, but the mother and child’s name will not be known in the survey and will not be used for any part of the research.

Please place my business cards and flyers in an accessible place in your office. If mothers ask about the survey please tell them that they can find more information online at the following website:

http://www.autismdeal.com

This survey does not provide a direct benefit for you or the participants, but your participation will hopefully result in increased education of how biomedical treatment might increase the rate of healthy family functioning.

If you have any questions concerning this research study or your participation in this study, please call me at 843-377-6837 or email me at jreneej1@hotmail.com or Dr. Linda Reed at 937-550-4269, Linda.Reed@capella.edu.

Sincerely,

Jill Tschikof

If you have any questions about your rights as a research participant or any concerns about the research process, or if you’d like to discuss an unanticipated problem related to the research, please contact the Capella Human Research Protections Office at: 1-888-227-3552, extension 4716. Your identity, questions, and concerns will be kept confidential.

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APPENDIX C. SURVEY FOR MOTHERS TO ANSWER

Capella University225 South 6th Street

Minneapolis, MN 55402

1. How old is your child?a. 0-3 b. 4-6 c. 7-10 d. 11-14 e. 15-18

2. What is your child’s diagnosis?a. Autistic Disorder b. Asperger’s Disorder c. Pervasive Developmental Disorder- Not Otherwise Specified

3. How long has it been since your child’s diagnosis?a. 0-2 years b. 3-5 years c. over 5 years

4. What type of doctor diagnosed your child?a. Neurologist b. Developmental Pediatrician c. Child Psychologist d. Team of doctors e. Other

5. Are you familiar with Biomedical Treatment?a. Yes b. No

6. Have you used any of the following forms of biomedical treatment for your child?a. Special Diet b. Supplements c. Anitfungals

7. Are you still using any of the following forms of biomedical treatment for your child?a. Special Diet b. Supplements c. Anitfungals

8. Are YOU currently seeking any form of marriage, family, or individual counseling therapy?a. Yes b. No

9. What is your current marital status?a. Married b. Separated c. Divorced

10. What is you annual household income?a. 0-24,999 b. 25,000-49,999 c. 50,000-74,999 d. 75,000-99,999 e. 100,000

and over

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APPENDIX D. PROCEDURE AND INFORMATION FOR WEBSITES

10/10/2010

I am a doctoral student under the direction of Professor Linda Reed in the School of Psychology at Capella University. I am conducting a research study, titled Autism Spectrum Disorder: The Relationship Between Biomedical Treatment and Healthy Family Functioning, to determine whether or not biomedical treatment used in children diagnosed with Autism Spectrum Disorder can create a higher rate of healthy family living. I invite you to participate in this study. I am inviting mothers with a child diagnosed with Autism Spectrum Disorder to participate in this study, which will involve answering 10 background questions and 62 questions regarding the FACES IV survey about their family. FACES IV is an assessment scale that measures family adaptability, cohesion, communication and satisfaction. These questions are available through the website www.autismdeal.com. Answering these questions should take no more than 20 minutes.

Parent participation in this study is voluntary, they can choose not to participate. The results of this research study will be publish, but the mother and child’s name will not be known in the survey and will not be used for any part of the research.

Please place the following link to my study on your website:

http://www.autismdeal.com

This survey does not provide a direct benefit for you or the participants, but your participation will hopefully result in increased education of how biomedical treatment might increase the rate of healthy family functioning.

If you have any questions concerning this research study or your participation in this study, please call me at 843-377-6837 or email me at jreneej1@hotmail.com or Dr. Linda Reed at 937-550-4269, Linda.Reed@capella.edu.

Sincerely,

Jill Tschikof

If you have any questions about your rights as a research participant or any concerns about the research process, or if you’d like to discuss an unanticipated problem related to the research, please contact the Capella Human Research Protections Office at: 1-888-227-3552, extension 4716. Your identity, questions, and concerns will be kept confidential.

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APPENDIX E. FLYER

www.autismdeal.comI am a doctoral student working under the direction of Professor Linda Reed in the School of Psychology at Capella University. I am conducting a research study, titled Autism Spectrum Disorder: The Relationship Between Biomedical Treatment and Healthy Family Functioning, in an effort to determine whether or not biomedical treatment used in children diagnosed with Autism Spectrum Disorder can create a higher rate of healthy family living. I invite you to participate in this study. It will involve answering ten background questions and 62 questions regarding the FACES IV survey about your family. FACES IV is an assessment scale that measures family adaptability, cohesion, communication and satisfaction. These questions are available through the website www.autismdeal.com. Answering these questions should take no more than 20 minutes. Your participation in this study is completely voluntary, and you can chose not to participate. The results of this research study will be published but your child’s name and your name will not be included or requested anywhere in this study or survey.

If you have any questions regarding the current study, please contact Jill Tschikof at 843-377-6837, jreneej1@hotmail.com, or Dr. Linda Reed at 937-550-4269, Linda.Reed@capella.edu.

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