Understanding Autism and Its Treatment Options - Essay Example

With the growing resources unearthed about various human illnesses and disorders, more and more research has been conducted to find more about developmental disorders that besiege children today. One developmental disorder that has captured the interest and attention of parents, educators and other professionals concerned with the well-being of children, is Autism. Weaver and Hersey (2005) report that at least 1.5 million children and adults have been diagnosed with Autism in America as estimated by the Centers for Disease Control and Prevention (CDC). According to this organization, about 6 out of every 1,000 individuals in the US have been diagnosed less than 10 years ago. This estimate have risen in recent years due to more awareness about Autism. The Spectrum Autism Spectrum Disorders (ASD), also known as Pervasive Developmental Disorders (PDD) along with the developmental disorders that fall under its umbrella are disorders are characterized by deficits in social and communication skills. The Autism Spectrum Disorders include: Asperger’s Syndrome, Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS), Autism Disorder, Child Disintegrative Disorder and Rett Syndrome. I. Autism Disorder In recent years, diagnoses of Autism have increased both in breadth and in depth. The increase in the prevalence of this developmental disorder to 1 in 88 children has become so alarming that many parents and practitioners have been more diligent in knowing more about it. Zalla et al. (2006) has encapsulated the definition of Autism as follows: It is “a complex developmental disorder characterised by severe difficulties in communication, social interactions, and executive functions. Social and communication disturbances are generally explained in terms of a defective neurocognitive mechanism responsible for the attribution of thoughts and feelings to oneself and to others” (p. 527). The many symptoms presented by individuals with Autism have been inconsistent in pointing to just one disorder that is why it had to be spread out to various disorders within the Autism spectrum. Although there are overlaps of symptoms, there are also categorical clusters that belong to one disorder that can be differentiated from another disorder. II. Asperger’s Syndrome Under the umbrella of the Autism Spectrum Disorders (ASD) exists the highest functioning Pervasive Developmental Disorder (PDD) subtype called Asperger’s Syndrome (Kurita, Koyama & Osada, 2005). This is characterized by several deficits in age-appropriate social interactions and restricted, repetitive patterns of behavior interests (American Psychiatric Association, 2000). III. Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) defines “children with symptoms such as restricted social interaction, poor verbal and non-verbal communication skills strict and/or stereotypical behaviors but without full diagnostic criteria of Autism” (APA, 1994 cited in Karabekiroglu & Akbas, 2011, p. 142) as Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). The symptoms for this disorder may be observed in other disorders under the umbrella of Autism which makes it difficult to differentiate PDD-NOS from the rest of the disorders in the spectrum. Examples of these shared symptoms are deficits in social reciprocity or communication, as well as the presence of restricted or repetitive behaviors, severe mental retardation or language delay as well as reactive attachment disorder, psychotic disorders (Karabekiroglu & Akbas, 2011). IV. Child Disintegrative Disorder It is more frustrating for parents to know that their healthy and normal children suddenly change for the worse after the first two years of life. Childhood Disintegrative Disorder (CDD) is one of the disorders that belong to the Autistic spectrum characterized by normal development of communication, social and motor skills during the child’s first two years of life followed by a drastic regression between the ages of 2-10 years in at least two of the developmental areas. Other names for childhood disintegrative disorder are Hellers syndrome, Dementia Infantillis and disintegrative psychosis (Encyclopedia of Mental Disorders, 2012) When CDD sets in, the child may manifest unexplained changes in behavior and express anxiety, agitation and becomes angry even if not provoked. These behavioral changes are then followed by the loss of communication, social and motor skills as well as bowel or bladder control and become withdrawn and unsociable. The also perform repetitive movements and may have difficulty transitioning from one activity to the next (Encyclopedia of Mental Disorders, 2012). Loss of speech that was supposedly acquired in the first two years is the main symptom of this disorder. It is a rare disorder and its exact nature remains unknown (Durukan, Tufan & Turkbay, 2009) The Handbook of Autism and Pervasive Developmental Disorders indicates that children with CDD lose their verbal and social skills, 90% lose their self-help skills and develop non-specific overactivity. After some time, the regression that began in toddlerhood stops but the child does not usually regain the lost skills over the years. Research suggests that CDD is about four times more common in boys than in girls and that for many girls diagnosed with CDD, they had Rett’s disorder, another one included in the Autism Spectrum, but mostly affects just girls (Encyclopedia of Mental Disorders, 2012). V. Rett Syndrome Another developmental disorder that involves regression and severe functional impairment is Rett Syndrome which only affects girls (Kurita, Koyama & Osada, 2005). Regression is manifested mostly before the age of two. There have been findings of reduced survival time for this disorder. In Western Sweden, most deaths of children with Rett disorder are sudden and unexpected, occurring during the night or when acute infections set in. Some deaths have been linked to pneumonia or include sudden unexpected death in epilepsy (SUDEP), brainstem autonomic failure with or without cardiac arrhythmias, pneumonia ⁄ aspiration, acute gastric dilatation and rupture, inflicted injury, and medication-related problems (Freilinger et al, 2010). Mercadante et al (2006) explains the chronology of Rett syndrome. According to them, the disorder develops from four stages, the first one called the precocious stagnation stage which begins between the ages of six to 18 months. This stage is characterized by development stagnation, deceleration of the brain perimeter increment, and tendency to withdraw from social interactions. The second stage, called rapidly destructive, begins between ages one to three years and lasts for weeks or months. Mercadante et al (2006) explain that in this stage, the child exhibits regression in his psychomotor skills along with crying spells and irritability. The speech acquired over time are lost. The child exhibits autistic-like behaviours and stereotypic hand movements which do not seem to be purposeful. Apart from those symptoms, the child experiences breathing irregularities such as apnea or stopping of breathing and hyperventilation. Epilepsy can also set in. The third stage is named pseudo-stationary, which happens between the ages of two to ten years. The child shows improvement in some symptoms manifested from the disorder especially in terms of social interactions. However, in terms of motor control, the child shows difficulty in moving, spasticity, scoliosis and grinding of teeth. There are likewise times when the child loses his breath, or expels air or saliva from his mouth. Finally, the last stage, also known as the late motor deterioration, begins at around the age of ten years. As the name suggests, the child experiences slow deterioration of his motor skills, develops scoliosis and severe cognitive deficits. Girls who are able to walk independently will present increasing difficulties and will usually need a wheel chair (Mercadante et al, 2006, p. S 13). Historical Background: In 1943, Leo Kanner, who is considered the first psychologist to describe autism, wrote “Autistic Disturbances of Affective Contact”, in which he described eleven children who had an apparently rare syndrome which he termed “extreme autistic aloneness.” (Kanner, 1943). Because these children’s symptoms started early in life, Kanner described autism as a specific condition called “Infantile Autism”. He concluded that the essential characteristic is a “biologically provided disturbance of affective contact”, which means that an autistic child was not born with an innate ability to form the usual biologically affective contact with people. In 1944, a German psychiatrist, Hans Asperger of Vienna, Austria, described a closely similar condition that later became known as Asperger Syndrome (Asperger, 1944). He published ‘Autistic psychopathology in childhood’, one year after Kanner’s paper, (though it was submitted before Kanner was published). Because of World War 11, he was obviously unaware of Kanner’s work. It appears that Asperger’s patients were somewhat less impaired in communicating than Kanner’s. Like Kanner, he also believed in a biological rather than psychological, cause (Frith, 1991). Asperger described children with this condition as having obvious social awkwardness and lack of interpersonal understanding (Asperger, 1944). Individuals with AS can exhibit a variety of characteristics, and the disorder can range from mild to severe (Wing & Gould, 1979). Uta Frith (1991) in her book, Autism and Asperger’s Syndrome also described AS individuals as “having a dash of autism.” Frith stated that the vocabulary of AS may be extraordinarily rich and that they sound like “little professors”. She also added that AS individuals can be extremely literal and have difficulty using language in a social context, exhibit a variety of patterns of cognitive and linguistic development in the average and above average range and are prone to clumsiness. (Frith 1997). Possible Causes: Currently, researchers are exploring different explanations for various possible causes of Autism (Autism Society of America, 2003). These include, genetics, neurological, prenatal exposures, metabolic diseases, environmental, food allergies, , vaccines and .an interplay of factors. 1. Genetics Wing (2001) and Newschaffer et al (2007) reported that Autism has a heritable component as evidenced by studies that observed patterns of disabilities among families as well as twin studies confirming this conclusion. 2. Neurological Factors Some researchers have come to the conclusion that individuals with Autism are affected by some damage to some parts of their brain (See portion on Biology). 3. Prenatal Exposures Some of the most recent research into the possible causes of autism and ASD has concentrated on prenatal exposure to chemical(s) or hormones in the womb. An example is maternal exposure to mercury (e.g. consumption of seafood high in mercury, mercury dental fillings, thimoral in Rhogam shots) can be very harmful to the fetus (Chugani, 2002). Furthermore, altered cerebellar serotonin levels during early postnatal brain development have been suggested as being an important contributing factor to the development of autism (Chugani, 2002). As such, it is important to understand any neuro-chemical issues which may contribute to the generation of such developmental disorders (Winter et al., 2008). 4. Metabolic Diseases Another theory as to the cause of autism is attributed to metabolic diseases such as Phenylkenonuria, Creatine Deficiency, Infantile Ceroid Lipofuscinosis and many others (Manzi, Loizzo, Giana & Curatolo, 2007). 5. Environmental Factors Some environmental factors have been suspected to have an influence on the development of developmental disorders like Autism. One is the excessive use of antibiotics and another is the lack of essential minerals zinc, magnesium, iodine, lithium and potassium. Exposure to pesticides and other environmental toxins as well as metals have been linked with adverse neurodevelopment outcomes in children and are also considered potential endocrine disruptors. However, evidence to suggest its association to autism has been inconsistent and inconclusive. Lead is a known neurotoxin and studies have found adverse effects of prenatal exposure on growth and development. Mercury also has been known to have adverse neurotoxic effects. It comes in several forms – the naturally occurring elemental found in the air and dental amalgams and inorganic and organic forms which accumulate in the food chain as methyl mercury. Other environmental toxins include too much consumption of alcohol, smoking and illicit drug exposure. One study of infants with prenatal cocaine exposure reported 11% of the children met autistic criteria for autism. Prenatal cocaine exposure may lead to hyperserotonemia in the fetuses. This is a mechanism of potential interest in autism etiology. Exposure to environmental pollutants such as solvents and other particulate matter during the prenatal period were moderately associated with autism but were also correlated with metal concentrations. 6. Food Allergies Research found that diet, food allergies or intolerance, or yeast may contribute to or may even cause Autism. Seroussi (2002) suggested that a diet consisting of high sugar levels, wheat, milk and additives may cause autistic-like behaviors. Also, a lack of essential fatty acids or the overgrowth of yeast or Candida is seen by Seroussi as the cause of such autistic-like behaviors. As such a dietary intervention of antifungal medicines supplemented by herbal treatments, gluten-and –casein- free food and the elimination of unhealthy foods in the diet such as processed food, food additives are recommended. 7. Vaccines Much controversy has ensued over vaccines being one cause of Autism. Parents have been instructed to get vaccines for their children to prevent diseases. Drug companies have developed a variety of vaccines, however, the increasing number of vaccines recommended and given to children may compromise their immune system. those that contained thimerosal, which is 50% mercury, have been known to be dangerous to one’s health. Mercury poisoning symptoms approximate autistic symptoms. The hypothesis springs from the suspicion that clinical signs of mercury toxicity are similar to the manifestations of autism. The onset of autism is temporarily associated with immunization in some children. It is possible that the recent increase in the diagnosis of Autism goes hand in hand to children’s exposure to higher levels of mercury in thimerosal (Nelson & Bauman, 2003). 8. An Interplay of Factors Increasing evidence suggests that the development and progression of autism spectrum disorders are caused by a complex interplay of environmental, genetic and other biological factors. Exposure to an interplay of environmental stressors and genetic symptoms may lead to Autism (Keller & Persico, 2003; Hertz-Picciotto et al., 2006; Herbert et al., 2006; Newschaffer et al., 2007). From conception, the fetus may already be at risk for maternal imbalance of hormones and other chemicals that would prove to be toxic to fetal development. It just goes to prove that pregnancy is a very sensitive and critical period in a person’s life, specifically for the unborn child in the womb. Symptoms: Majority of children with Autism appear normal at birth until one year however, subtle abnormalities in movement have been observed as early as 4 months of age. Sensory-motor disturbances have been detected at approximately 9-12 months and at 15-24 months, the full array of diagnostic impairments consistent with autistic symptoms come to surface. Bernard et al. (2002) contend that autistic symptoms may either emerge gradually or suddenly. There is no specific pattern. The complicated process of coming up with an accurate diagnosis of Autism is based on standards established by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) and the ICD-10 Criteria for "Childhood Autism" of the World Health Organization (see Appendix). Symptoms that yield positive for Autism include typical problems observed regarding limited eye contact, an absence of appropriate facial expressions and gestures, a lack of developmentally appropriate peer relationships, an absence of shared attention, and a general lack of emotional or social reciprocity (Hillman, 2006). Aside from these, children with Autism also manifest restricted or repetitive behaviors, interests and activities and compulsion to adhere to repetitive actions or rituals that do not serve any function such as hand flapping or twirling. These actions are also known as “stimming”. Language and non-verbal communication skills are also not manifested or are delayed significantly (Hillman, 2006). Assessment and Diagnosis Upon observation of manifested symptoms described above, the individual should be sent for assessment by a professional developmental psychologist or else he may be at risk of further developmental delay. The key characteristics of ASD, as summarized by Chowdhurry (2009) are the following: Qualitative impairment in social interaction Qualitative impairment in communication Restrictive, repetitive and stereotyped patterns of behavior, interests and activities A developmental pediatrician is a medical doctor specializing in the growth and development of children. This doctor is authorized to do diagnostic tests and dispense diagnosis and medical advice for possible interventions. He/She can validate whether Edward has a developmental disability based on the results of the tests and the observations of the parents and teachers of Edwards’s behaviors. Clinicians must rely on their clinical judgment, aided by guides to diagnosis, such as DSM-IV and the Tenth Edition of the International Classification of Diseases (ICD-10), as well as by the results of various assessment instruments, rating scales, and checklists (Practice Parameter: Screening and Diagnosis of Autism, 2000, p.472) Apart from valid observations, diagnosis of autism must include the use of accurate diagnostic instruments characterized by moderate sensitivity and good specificity for autism. A trained professional would need enough time to plan a parent interview to extract the necessary information regarding the child as they discuss their concerns and behavioral history as well as conduct direct, structured observation of the child’s social and communicative behavior and play. Aside from the diagnostic parental interviews facilitated by the developmental pediatrician or trained professional, recommended instruments include the following: The Gilliam Autism Rating Scale The Parent Interview for Autism The Pervasive Developmental Disorders Screening Test–Stage 3 The Autism Diagnostic Interview–Revised The Childhood Autism Rating Scale The Screening Tool for Autism in Two-Year-Olds The Autism Diagnostic Observation Schedule-Generic To supplement the diagnosis, a battery of tests and evaluation may be conducted to determine the best interventions for the child with autism. Among these are medical and neurologic evaluation by a licensed physician; a multidisciplinary evaluation by a host of specialists; speech, language and communication evaluation; cognitive and adaptive behavior evaluation which may include the instruments such as the Vineland Adaptive Behavior Scales and the Scales of Independent Behavior. These instruments may only be performed by a licensed psychologist or trained professional, as the standardized protocols need to be exactly followed. These provide evidence of the child’s abilities including social, verbal, and non-verbal skills. Sensorimotor and occupational therapy evaluations may also be conducted depending on the needs of the child. This assesses the child’s range of skills with regards to fine motor, gross motor and sensory processing. In case the child is observed to have sensory integrative dysfunction, the Sensory Integration and Praxis tests may also be administered. Finally, neuropsychological, behavioral and academic assessments evaluate the child’s cognitive abilities and social skills (First Signs Inc, 2010). Interventions Understanding autism, its causes and treatments, is still far from complete. Since autism was first identified as a developmental disorder, a variety of approaches and strategies have been suggested. These interventions and treatments have increased from the range of theoretical positions, some of which have shown to be effective with various populations of children. Because it may be difficult to teach, deal, and live with individuals with autism both at school and at home, parents, educators, practitioners, and everyone who works or will be working with these children need to have current understanding of the nature, possible causes, symptoms, and issues pertaining to different intervention programs in order for them to better serve the children. Although continued research on Autism is underway, what may be more important than finding the cause is finding the most appropriate intervention to help individuals with autism and their ability to cope with daily living in order to function well in society. It is apparent that there is now a growing awareness and respect for obstacles facing children with autism. After thorough evidence by several researchers, autism has now been established as a neurological disorder and not a psychological disturbance. The common bond shared by all authors is the understanding that children with Autism Spectrum Disorders are unique individuals, and there is no single explanation that accounts for the developmental profiles and challenges of all of these children. Thus, there is no single intervention, approach, or treatment modality that can address the varied needs of all these children. Clinicians and educators will need to explore and document the effectiveness of different specific interventions for each individual child with autism. Treatment options for ASD have evolved significantly in a relatively short period of time. Only twenty years ago, vast majority of people with autism were eventually institutionalized (Weaver and Hersey, 2005). For decades, autism was treated with psychoanalysis (Seigel, 1996; Bauman & Kemper 1994; Rimland, 1994). Over the years, several therapies have been designed to teach individuals with autism ways to communicate better and more actively participate in social activities. Supplemental educational interventions such as mainstreaming and inclusion programs with appropriately planned individual educational plans (IEP) have been available choices for the growing child diagnosed with autism. However, despite the increase in media interest and expansion of treatment options, there is a need for more information and resources for families needing help with their ASD family members. Parents and children navigating treatment decisions are sometimes faced with conflicting information, controversial therapies, and a shortage of specialized therapists and support networks. When these hurdles are overcome, however, and appropriate therapy is carried out, treatment is more likely to result in positive outcomes (Weaver and Hersey, 2005). An evolving issue that is now being addressed is services and opportunities for adults with ASD. BBC news reported claims that “early intervention will improve the lives of vulnerable children and help break the cycle of "dysfunction and under-achievement" (Sellgren, 2011, para.1). Hence, the following possible methods and strategies proposed below to help the individual with autism be considered as early intervention support strategies to prevent him from further developing further disabilities and help him develop better social, emotional and communicative skills. Educational Interventions For some cases of individuals with learning difficulties, a one-on-one tutor may help him with his lessons so he gains more confidence in his school performance. He must be provided with access to a broad, balanced and relevant curriculum usually in a mainstream or inclusive school. Mainstreaming is closely linked to the traditional form of refers to selective placement of special education students in regular education classes. It is assumed that some special education students may keep up with the work load in regular classes and may therefore join the group. Inclusion, on the other hand, believes that the child should always begin in the regular environment and be removed only when appropriate services cannot be provided in the regular classroom (Stout, 2001). Piaget (1959) believes that children’s interaction with the environment encourages learning. Still, Vygotsky (1962) inspires another perspective, as he theorized that a child learns through conversation and involvement with an adult. The interaction between adult and child is called ‘scaffolding’. This occurs when a knowledgeable adult gently guides a child through successive learning activities while relinquishing autonomy little by little to the child until such time he can manage on his own. Considering the recommendations of Piaget and Vygotsky for encouragement of learning, it would be beneficial for a student with Autsim in a mainstreamed or inclusive class with other children with a specially designed individualized educational plan (IEP) to implement for him. Individualized Interventions/ Therapies Applied Behavior Analysis (ABA): Based on Skinner’s Behaviorist Model, this intervention is a teaching approach consisting of various programs and activities that use the antecedent-behavior-consequence model. From the behaviorist’s point of view, reinforcement (positive or negative) is given for responses to different stimuli. This implies that the external environment plays a crucial role in the formation of behaviors. In giving positive reinforcement such as praising or smiling when a desired behavior is elicited and giving negative reinforcement such as scolding or correcting when an undesirable behavior emerges, it is assumed that the desired behavior is encouraged and will recur in another time. (Lindfors, 1987). In ABA, each action is considered related to a behavior and is analyzed to determine what came before it, how the behavior occurred and what happens after. This analysis is studied in order to encourage positive behaviors to occur more often (Lovaas, 1987). Greenspan or “Floortime”: Another intervention is the Greenspan method, also known as “Floor Time”. It is a Developmental Individual Difference, Relationship-based (DIR) and multi-sensory approach. Developed by Greenspan (1997), the intervention involves a parent or therapist who goes down on the floor with the child and just joins him in his play or any activity he chooses. Although it seems like a more informal and relaxed intervention, it teaches the adult how to be involved in a child’s activity while being happy and more relaxed while simultaneously teaching interactive context. This intervention addresses delays in sensory modulation, motor planning, sequencing and perceptual processing. There are six areas of functioning that are addressed which are meant to improve the child’s developmental skills. The first area includes regulating one’s attention and behavior while being stimulated by various sensations. The second area involves the ability to maintain quality and stability in the engagement in relationships. The third area is the ability in engaging in purposeful communication. This program encourages the child to open and close communication circles. (Greenspan, 1997). The fourth area is the stringing together many circles of communication into larger patterns which are linked to the fifth area dealing with the child’s ability to create mental representations or emotional through his pretend play and emotional intentions. Lastly, the sixth area works on the ability to make connections between different internal representations or emotional ideas . This capacity is a foundation of higher –level thinking, problem-solving, and such abilities as separating reality from fantasy, modulating impulses and mood, and learning independence (Greenspan, 1997). Picture Exchange Communication System (PECS): A communication training system where the child is gives a picture of a preferred item to a communicative partner (parent, teacher or therapist) in exchange for the item. Initially, the communicative target is requesting. When the child is able to successfully request, his behavior is reinforced by being given the preferred item requested. This training is designed to take place in a social context. Teaching a child with special needs to request is a useful skill, and often facilitates the teaching of other communicative intents. (Quill, 1995). “Social Stories”: This intervention will be able to help out the individual with Autism’s difficulty in social interaction skills. It was developed to help individuals deficient in social interaction to “read” and understand social situations by presenting appropriate social behaviors in the form of a story. Read repeatedly, the story will enable the child to successfully enact the skills appropriately taught and hopefully be able to apply them in social situations (Gray, 1993) Speech Therapy: To address language and communication deficits, speech therapy may also be included in the repertoire of interventions. Speech therapy builds on an individual’s strengths and can greatly improve both communication and behavior. A speech therapist addresses the use of language pragmatics or the “give and take” of conversation for social purposes (Charlop, 1989). Chomsky’s theories, known as many names… Linguistic, Nativistic or Innatist, uphold that language is inherent or “wired-in” in the child at birth and needs only to be triggered by social contact with speakers in order to emerge. (Brewer, 2001). He is equipped with a language acquisition device, a structure in the brain that made possible the learning of language (Chomsky, 1965). Special Diet: Recent research has hypothesized that diet, food allergies or intolerance and yeast may contribute or even cause Autism. Seroussi (2003) points out that sugar, wheat, milk and some additives may be the cause of some autistic-like behaviors. Hence, diets that are gaining popularity for autistic individuals include antifungal medications, herbal treatments, gluten- and casein-free foods and the elimination of processed food and food additives. Brewer, J.A. (2001) Introduction to Early Childhood Education. Boston: Allyn and Bacon Charlop, M.H. (1989). Teaching autistic children conversational speech using video modeling. Journal of Applied Behavior Analysis, 22,275-285. Chomsky, N. (1965) Aspects of a Theory of Syntax. Cambridge, MA: MIT Press. Chowdhury, U. (2009) Autistic Spectrum Disorders: Assessment and Intervention in Children and Adolescents, British Journal of Medical Practitioners, Volume 2, Number 4 Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC:American Psychiatric Association, 1994:70–71. Federal Development Disabilities Act of 1984. First Signs, Inc (2010) Diagnostic Testing, Available at http://www.firstsigns.org/treatment/dx.htm Gray, C.G. (1993). Teaching children with autism to “read” social situation. In Teaching children with autism: Strategies to enhance communication and socialization. Kathleen Quill, Delmar Publishers Greenspan, S.I. (1997). An integrated developmental approach to interventions for young children with severe difficulties in relating and communicating. In S.I. Greenspan and K.Kalmason. Lindfors, J.W. (1987), Children’s Language and Learning, 2nd Ed. Prentice Hall, Inc. Lovaas, I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Counseling and Clinical Psychology 55, 1, 3-9. Read More