Charles C. Coleman, MD

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Treating a family in crisis because of a difficult-to-manage family member with autism spectrum disorder (ASD) can be overwhelming. The family often is desperate and exhausted and, therefore, can be overly needy, demanding, and dis­organized. Psychiatrists often are asked to intervene with medication, even though there are no drugs to treat core symp­toms of ASD. At best, medication can ease associated symptoms, such as insomnia. However, when coupled with reasonable medication management, psychoeduca­tional family therapy can be an effective, powerful intervention during initial and follow-up medication visits.

Families of ASD patients often show dys­functional patterns: poor interpersonal and generational boundaries, closed family sys­tems, pathological triangulations, fused and disengaged relationships, resentments, etc. It is easy to assume that an autistic patient’s behavior problems are related to these dys­functional patterns, and these patterns are caused by psychopathology within the fam­ily. In the 1970s and 1980s researchers began to challenge this same assumption in families of patients with schizophrenia and found that the illness shaped family patterns, not the reverse. Illness exacerbations could be mini­mized by teaching families to reduce their expressed emotions. In addition, research clinicians stopped blaming family members and began describing family dysfunction as a “normal response” to severe psychiatric illness.¹

Families of autistic individuals should learn to avoid coercive patterns and clarify interpersonal boundaries. Family members also should understand that dysfunctional patterns are a normal response to illness, these patterns can be corrected, and the cor­rection can lead to improved management of ASD.

Psychoeducational family therapy provides an excellent framework for this family-psychiatrist interaction. Time-consuming, complex, expressive family therapies are not recommended because they tend to heighten expressed emotions.

Consider the following tips when pro­viding psychoeducational family therapy:  
   • Remember that the extreme stress these families experience is based in real­ity. Lower functioning ASD patients might not sleep, require constant supervision, and cannot tolerate even minor frustrations.  
   • Respect the family’s ego defenses as a normal response to stress. Expect to feel some initial frustration and anxiety when working with overwhelmed families.    
   • Normalize negative feelings within the family. Everyone goes through anger, grief, and hopelessness when handling such a stressful situation.  
   • Avoid blaming dysfunctional patterns on individuals. Dysfunctional behavior is a normal response to the stress of caring for a family member with ASD.  
   • Empower the family. Remind the fam­ily that they know the patient best, so help them to find their own solutions to behav­ioral problems.  
   • Focus on the basics including estab­lishing normal sleeping patterns and regular household routines.  
   • Educate the family about low sensory stimulation in the home. ASD patients are easily overwhelmed by sensory stimulation which can lead to lower frustration tolerance.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.