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Contemp Fam Ther (2012) 34:555565

DOI 10.1007/s10591-012-9213-7
ORIGINAL PAPER

Treating Couples Raising Children on the Autism


Spectrum: A Marriage-Friendly Approach
Jake Johnson

Published online: 2 October 2012


Springer Science+Business Media New York 2012

Abstract Available research demonstrates that autism spectrum disorders (ASDs) affect
couples in a variety of different ways. Some partners draw closer to one another through
the experience of caring for a child on the autism spectrum while others experience
relationship dissatisfaction, separation, and divorce. Yet other research reveals that many
couples raising children with ASDs may experience an initial dip in relationship satisfaction but, after adjusting to a new way of life and developing new expectations for their
children, are later able to bond in novel ways. Thus, a marriage-friendly approach to
therapy, which focuses on helping partners remain committed to each other through the
trials and tribulations of life, may allow these couples to work through the difficulties of
raising children on the autism spectrum without resorting to separation or divorce. Ethical
implications of a marriage-friendly approach to therapy with couples raising children with
ASDs are also considered.
Keywords Autism spectrum disorders  Marriage  Intimate relationships 
Marriage-friendly therapy

Autism in the Context of the Family


Recent research on autism spectrum disorders (ASDs) has begun to reveal some of the
systemic effects of having, and caring for, a family member on the autism spectrum.
Specifically, studies on the impact of ASDs on the family system have found that having an
autistic child in the family can negatively impact the physical and mental wellbeing of
mothers (Allik et al. 2006; Barker et al. 2011; Hastings 2003; Wolf et al. 1989), fathers
(Hastings 2003; Mugno et al. 2007) and other primary caregivers (Higgins et al. 2005), as
well as that of siblings (Orsmond and Seltzer 2007). However, the literature on how
couples, as a dyadic unit, adjust to raising children on the autism spectrum is scant. That
J. Johnson (&)
Department of Human Development, Virginia Polytechnic Institute and State University,
840 University City Boulevard, Blacksburg, VA 24060, USA
e-mail: jake.johnson@vt.edu

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which does exist paints conflicting portraits of the outcomes for intimate partners raising
children with ASDs. Some studies suggest couples raising children with ASDs are more
susceptible to negative relationship outcomes (Hartley et al. 2010; Higgins et al. 2005;
Rodrigue et al. 1993), while others indicate that these couples may experience new levels
of relationship satisfaction in light of raising special needs children (Cowan 2010; King
et al. 2006). Thus, it appears that some couples are able to rally in the face of raising
children with ASDs while others buckle under the pressure.
Given the mixed results found in the literature on couples raising children with ASDs,
family therapists must be particularly sensitive when working with such couples, helping
those already struggling to maintain their relationships under the pressures of caring for a
child on the autism spectrum from rushing toward relationship dissolution too quickly.
Instead, as this paper will suggest, a marriage-friendly approach to couples therapy
(American Psychological Association [APA] 2006; Doherty 1995, 2001, 2002, 2006), in
which the therapist encourages couples to consider not only issues of individual happiness
but also those of commitment to ones partner and family, is most appropriate when
working with this special population. However, before providing a broader definition of
marriage-friendly therapy and detailing why this approach may fit well with couples
raising children on the autism spectrum, a brief overview of ASDs, the stressors related to
caring for children with ASDs, and how these stressors have been shown to impact couples
will be provided. Lastly, the ethical implications of a marriage-friendly approach to
treating couples with children on the autism spectrum, and suggestions for addressing these
implications, will also be considered.

An Introduction to Autism Spectrum Disorders


Autism spectrum disorders are particular types of developmental disabilities that manifest
themselves through one or more of the following conditions: impairment in social interactions, impairment in language and communication skills, and repetitive and stereotyped
interests and/or behaviors (American Psychiatric Association 2000). The most common
types of ASDs are autism, Aspergers syndrome, and pervasive developmental disorder,
not otherwise specified (PDD-NOS). According to recent research conducted by the
Centers for Disease Control and Prevention (CDC), ASDs affect one out of every 88
children in the United States (one in 54 boys and one in 252 girls), roughly double the
figure of one out of every 150 children reported by the CDC just a decade ago (CDC
2012a). Gender notwithstanding, ASDs do not discriminate with regard to their prevalence.
Neither race, nor ethnicity, nor socioeconomic status, nor educational level, nor lifestyle is
a significant predictor of the occurrence of autism in children being raised in the United
States (Autism Society of America 2000; CDC 2012a).

ASD-Related Stressors and the Family


Unlike other developmental disabilities, ASDs have no known cause and are not apparent
at birth. Rather, children with ASDs develop typically for the first 1424 months of life.
Only after this initial period of typical development do impairments associated with disorders on the autism spectrum become evident (Landa and Garrett-Mayer 2006). As such,
parents and other primary caregivers are often taken by surprise when their children begin
showing signs of retarded social and communicative development. Many refer to this

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experience as an ambiguous loss (Boss 2000) in that these children are still physically
present in their parents lives but are no longer socially and emotionally who they used to
be. For these parents, the unclear nature of their loss keeps them from moving along with
the grief process as they become stuck in a paradox of the simultaneous absence and
presence of their children (Boss 2006). Simply put, for parents of children with ASDs the
child they thought they had is not the child they must learn to live with (OBrien 2007,
p. 135).
Additionally, as these children grow older their parents, other primary caregivers, and
siblings must deal with the presentation of ASD-related behaviors. Examples of these types
of behaviors may include: self-stimulatory behaviors (e.g., fixating on or repetitively
touching an object or part of ones own body for an extended period of time, or fixating on
or repetitively engaging in a particular type of body motion for an extended period of
time), self-injurious behaviors (e.g., repeatedly pounding ones head against the wall), and
temper tantrums (Higgins et al. 2005). Moreover, some children with ASDs may act in
aggressive and violent ways toward others (Gray 2002). All of these behaviors have the
potential to engender stress, frustration, and exhaustion in caregivers and family systems
(Ramisch 2012).
Having a child with an ASD diagnosis can be financially taxing to families as well. A
recent study on the average annual medical costs for Medicaid-enrolled children with
ASDs found that these children accrued $10,709 in medical expenses per child, nearly six
times higher than the average costs for children without ASDs ($1,812; Peacock et al.
2012). These figures corroborate the findings of Shimabukuro et al. (2008) who report
that yearly medical expenditures for individuals with ASDs are four to six times greater
than those for individuals without an ASD. Additionally, Ganz (2007) notes that direct
medical costs associated with caring for a child with an ASD average $35,000 annually
through the first 5 years of the childs life, while direct nonmedical costs (e.g., behavioral
therapy, occupational therapy, sensory equipment) vary from $10,000 to $16,000 per year
over the first 20 years. More intensive behavioral interventions for children with ASDs,
such as in-home therapy, may range in cost between $40,000 and $60,000 per child per
year (Amendah et al. 2011). Thus, on top of all the other systemic stressors related to
children on the autism spectrum, raising a child with an ASD is also a very expensive
endeavor.
Parents of Children with ASDs
Given the aforementioned stressors involved in raising children with ASDs, it stands to
reason that parents would experience many individual and personal strains related to caring
for their special needs children. Some evidence of this has been demonstrated in the
literature on autism and its impact on parents, both as individuals and as partners. Namely,
available research demonstrates that, as compared to parents of children with typical needs,
mothers and fathers of children on the autism spectrum report lower individual levels of
marital happiness and relationship satisfaction (Brobst et al. 2009; Higgins et al. 2005),
lower levels of social support (Higgins et al. 2005), greater parenting stress (Brobst et al.
2009), and greater individual emotional distress and sense of isolation (Hamlyn-Wright
et al. 2007; Woodgate et al. 2008). Moreover, extant literature on the effects of autism on
the family system has shown that raising a child with an ASD can lead to heightened
experiences of both parental depression (Benson 2006; Gray 2002; Parkenham et al. 2005)
and anxiety (Gray 2002; Parkenham et al. 2005).

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Couples Raising Children with ASDs


Despite the mostly negative individual outcomes for mothers and fathers with children on
the autism spectrum, how parents as couples are impacted when raising children with
ASDs seems to vary greatly. For instance, some autism experts (who have not engaged in
evidence-based research) argue anecdotally that more than 80 % of married couples who
have children with ASDs divorce before their children reach adulthood (Bolman 2006;
Doherty 2008; Solomon and Thierry 2006). Other empirical studies have come to similar,
though less dramatic, conclusions. Namely, Hartley et al.s (2010) study on the risk of
divorce for couples raising children with ASDs found that married couples raising children
on the autism spectrum were at least 10 % more likely to divorce than couples whose
children had no known disabilities. This study also found that although the risk of divorce
for parents of typically-abled children decreased as their children reached young adulthood, the risk of divorce remained high for parents of children with ASDs. In this same
vein, a number of other studies noted that parents and primary caregivers of children with
ASDs experienced lower levels of marital satisfaction than parents of children with typical
needs (Higgins et al. 2005; Rodrigue et al. 1993).
Despite the data suggesting that raising children with ASDs negatively impacts intimate
partner relationships, other researchers have arrived at different conclusions. For example,
the somewhat dated research conducted by Koegel et al. (1983) indicated that relationship
satisfaction for couples raising children on the autism spectrum may not necessarily differ
from couples with typically-abled children. More recent research by Brobst et al. (2009)
comparing a variety of relational variables for couples with and without children with
ASDs also noted that although marital satisfaction does decrease for some couples raising
children on the autism spectrum these couples do not have significantly different levels of
perceived spousal support, respect for ones partner, and relationship commitment when
compared to couples with typically-abled children. Finally, Cowans (2010) phenomenological study of five couples raising children with ASDs and King et al.s (2006) focus
groups with 19 parents of children with ASDs or down syndrome both found that, after an
initial dip in relationship satisfaction, over the long-term some parents may actually feel
closer to one another through sharing the experience of caring for an autistic child.

Marriage-Friendly Therapy
The marriage-friendly therapy movement (also referred to as pro-marriage therapy; APA
2006; Doherty 1995, 2001, 2002, 2006) was born out of a belief that marriages in contemporary American society had become too heavily influenced by a culture of individualism and consumerism. These influences, marriage-friendly therapists argue, have
caused many marriageswhich, for the purposes of this paper will also be defined as
including gay and lesbian couples in committed relationshipsto dissolve unnecessarily.
That is, husbands and wives, under the influence of the prevailing sociocultural norms,
have traded in duty and commitment to ones relationship for personal happiness (Doherty
2002, 2006).
This culture of individualism and consumerism has also permeated the field of psychotherapy (Doherty 2001, 2006). Starting with Freud and psychoanalysis, the self has
consistently been valued in therapeutic settings over obligation to ones significant relationships. Today, marriage-friendly therapists maintain, many therapists (including marriage and family therapists) continue to provide deferential treatment to issues of individual

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happiness and ignore matters of responsibility and obligation to couple and family relationships. This is evidenced by the fact that therapists tend to be more comfortable asking
clients what they need and deserve from other family members than asking them what they
might owe to their families (Doherty 2001).
Because marriage-friendly therapists perceive many therapists to be biased toward
emphasizing individual desires over collective values when working with distressed couples, they distinguish themselves from other therapists in the following ways (Marriage
Friendly Therapists 2011):
1. They acknowledge the goodness and benefits of marital commitment for individuals,
couples, and families.
2. They believe that when treating couples in distress, the first course of action should be
working toward preservation of the relationship.
3. They recognize that promoting relationship commitment for distressed couples is not
something that should occur in situations where abuse or neglect between partners is
known or otherwise suspected.
4. They ultimately respect decisions couples make about staying together or divorcing,
even if those decisions differ from what the therapist would hope for.
5. They are explicit with couples about the potential systemic effects of their decisions to
remain together or divorce (e.g., how their children will be affected, how extended
family and their larger community will be impacted).
6. They promise to make use of supervision or consultation when feeling stuck in therapy
or when they believe a couple is moving prematurely toward a decision to divorce.
Generally, when working with clients considering divorce, a marriage-friendly therapist
views his or her role as holding onto a sense of hope that the relationship can be salvaged.
Thus, a marriage-friendly therapist will encourage a couple to make one last, valiant effort
to save their marriage before deciding to divorce, contending that a lifetime commitment
should not be withdrawn without an all-out effort to work things out. A therapist taking a
marriage-friendly therapy approach will also point out to the couple that many people who
decide to divorce do not consider the processes that lead to the dissolution of their relationships and, thus, go on to repeat the same patterns of behavior in future relationships.
Having called attention to a number of reasons why the couple should try to reconcile, the
marriage-friendly therapist will then ask the couple to agree to work together in couple
therapy for a period of time (ideally 6 months) with the topics of separation and divorce off
the table. If after this predetermined period of time one or both partners still feel divorce is
the best option, then the therapist will help the couple end their relationship on the best
possible terms (APA 2006).

Marriage-Friendly Therapy for Couples Raising Children with ASDs


Because the literature on couples raising children with ASDs demonstrates that the
stressors related to caring for children on the autism spectrum may lead some couples to
divorce and others to experience a noteworthy drop in their levels of marital satisfaction
before they are able to regain a sense of stability in their relationships, a marriage-friendly
approach to therapy may help many couples to battle through the myriad challenges related
to caring for their special needs children. The ways in which marriage-friendly therapy
may help these couples will be enumerated below.

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First, marriage-friendly therapy with a distressed couple raising a child on the autism
spectrum can help the couple to carve out for themselves time and space to focus on their
relationship. This point is especially salient given the fact that many couples who survive
the difficulties of raising children with ASDs do so only after making it through a period of
decreased marital happiness and diminished relationship satisfaction (Cowan 2010; King
et al. 2006). As such, persuading a couple to agree to work on their marriage for a set
period of time, with the option to separate or divorce off the table, may very well prevent
the couple from ending their relationship during a dip in relationship satisfaction. In
addition, as many couples raising children with ASDs are unable to focus on their intimate
partnerships because of the demands placed on them by their children, a set period of time
to concentrate on a couples relationship in therapy can provide a place for both partners to
tease apart the issues contributing to their relational difficulties. This may also be a time for
the couple to work to make new meaning of their marriage vis-a`-vis the caregiving
responsibilities they have to their autistic child.
A second way marriage-friendly therapy may help distressed couples raising children
with ASDs relates to the therapist challenging couples individualistic, me-first views on
the nature of relationships. Challenging these views may be especially poignant for parents
of children with ASDs who are already experiencing lower individual levels of marital
happiness and relationship satisfaction (Brobst et al. 2009; Higgins et al. 2005), lower
levels of social support (Higgins et al. 2005), greater parenting stress (Brobst et al. 2009),
and greater individual emotional distress and isolation (Hamlyn-Wright et al. 2007;
Woodgate et al. 2008). This is because partners who are already feeling isolated, alone,
unsatisfied by their relationships, and in need of outside support may be more likely to
focus on what they believe they need for themselves to get by, as opposed to what their
relationships need to survive the stressors of caring for their special-needs children. As
such, a marriage-friendly approach can help individuals in these situations to see that
concentrating on what they deserve from their partners versus considering what they need
to do to maintain their marriages is to fall victim to the prevailing sociocultural norms that
do not value obligation, responsibility, and commitment. Instead, marriage-friendly therapy can help partners to see that focusing on their own wants will not help them to resolve
future relational problems, and that a lifetime commitment is worth one last shot despite
ones personal level of distress.
Finally, a marriage-friendly approach to therapy can help couples raising children with
ASDs to consider the potential implications of divorce for their children. Namely, although
studies on the effects of divorce on children suggest that some children adjust quite well in
the wake of their parents divorce and demonstrate increases in maturity, self-esteem, and
empathy (Coontz 1997; Gately and Schwebel 1993), children on the autism spectrum may
experience their parents divorce as a particularly trying process to adjust to. This is not to
say that children with ASDs are necessarily less able to adapt to parental divorce than
typically-abled children (as little to no research has been done on this subject). Rather,
because many children with ASDs often require a great deal of stability and predictability
within their environments, when these children are forced to deviate from their established
routines, they may become frustrated, throw temper-tantrums, or act violently toward
themselves or others (CDC 2012b). In the case of parental divorce, children with ASDs
may struggle in adapting to parental visitation schedules, following different rules in each
of their parents homes, and becoming accustomed to stepparents and stepsiblings. As
such, a marriage-friendly approach to therapy could help couples to consider the potential
systemic effects of divorce on their developmentally disabled children. Moreover, even if a
couple does decide to divorce, raising the issue of how ones children may be impacted by

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the divorce, and what the couple needs to do to help their child adjust to a restructured
family environment (Jennings 2005), may help parents think more specifically about how
to help their children on the autism spectrum deal with the transition.

Ethical Implications for a Marriage-Friendly Approach to Treating Couples


with Children on the Autism Spectrum
Despite the fact that a marriage-friendly approach to working with couples raising children
with ASDs may be beneficial for many family systems, there are a number of ethical issues
to consider when taking this therapeutic approach.
The first implication is related to the notion of autonomy, or an individuals freedom of
choice and thought, so long as these choices and thoughts do not infringe upon the rights of
others (Zygmond and Boorhem 1989). Namely, when a marriage-friendly therapist is
treating a distressed couple raising a child on the autism spectrum, the therapist must be
careful about how he or she frames the idea of asking the couple to commit to working in
therapy for a period of time with separation and divorce off the table. The issue is that this
therapeutic intervention may not take into consideration the idea that one of the partners
may, in fact, be coming to therapy as a way to facilitate the process of uncoupling from his
or her partner. Thus, a marriage-friendly therapist working with a couple such as this may,
by an act of commission, violate an individuals right to autonomy through pressuring this
person to agree to work on a relationship he or she has already given up on. In order to
avoid such a conundrum, a therapist may consider meeting with each partner individually
to gauge the degree to which each is interested in pursuing a course of therapy in which
separation and divorce is off the table. If in their individual sessions both partners are
willing to work on their relationship for a certain period of time, the therapy may continue
as planned; if not, the therapist must respect the wishes of the partner who wants to end the
relationship and work with the couple toward dissolving their relationship as amicably as
possible.
Relatedly, by pressing certain couples to commit to working on their relationship for a
set period of time, a marriage-friendly therapist may be acting in violation of the ethical
principle of nonmaleficence (Zygmond and Boorhem 1989). This principle of first do no
harm is of particular concern for individuals who are experiencing physical, psychological, or sexual abuse in their intimate relationships. If the therapist is unaware of active
or previous abuse in a couples relationship, he or she may inadvertently cause harm to the
abused partner by asking that individual to agree to work on resolving outstanding relational issues when the more appropriate course of action would be for the therapist to help
the victim get out of the relationship. Even when a couple is merely experiencing psychological distress regarding their relationship (e.g., one or both partners just want to put
an end to the agony of the relationship), the therapist must be sensitive to how much
psychological pain is permissible in the short term when attempting to help the couple
improve their relationship over the long run. This question becomes all the more significant
when one considers the temporal and financial commitments that marriage-friendly therapists ask couples to make at the onset of therapy. Again, for these situations, a marriagefriendly therapist must consider seeing each partner individually to more thoroughly assess
for abuse in the couples relationship before moving forward with couple therapy. If the
abuse is active and ongoing, relational therapy of any kind may be contraindicated. In these
situations, the therapists mandate must help to ensure the safety of the partner experiencing the abuse prior to engaging in any future relational therapy.

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Another ethical consideration for marriage-friendly therapists working with couples


raising children with ASDs who are considering divorce relates to the potential imposition
of a therapists moral leanings on his or her clients. That is, because inherent to a marriagefriendly approach to couples therapy is the belief that commitment and obligation to ones
family comes before ones own individual wants and needs, some individually-minded
partners being treated by a marriage-friendly therapist may feel they are having their
therapists values imposed upon them. As such, it is important for a marriage-friendly
therapist to be explicit about his or her values, to create a space for open dialogue with
clients who may not share the same beliefs, and to respect the clients beliefs. One place
for the therapist to consider how his or her values may interface with those of the couple
would be in a peer supervision group. In such a group, the therapist could meet with other
therapists to discuss how his or her beliefs and values might positively or negatively impact
the therapy he or she provides a particular couple.
A final ethical implication of a marriage-friendly approach to treating couples with
children on the autism spectrum deals with the treating therapists knowledge of ASDs as
well as his or her ability to tease out what issues presented by a couple are related to caring
for a child with an ASD and which are not. Given that ASDs present in a variety of
different ways and that couples deal with these issues in a variety of different manners,
marriage-friendly therapists working with these couples should be both informed about the
most common characteristics of ASDs and able to understand common ways couples
appraise and cope with the stressors related to raising children on the autism spectrum.
Therapists unable to do so will have difficulty helping couples understand which of their
presenting issues relate to caring for a child with a developmental disability and which do
not. In order to learn more about ASDs, the therapist may visit websites of organizations
such as Autism Speaks (www.autismspeaks.org) or the Autism Society (www.autismsociety.org), attend an autism support group in his or her local community, or find
continuing education classes on ASDs and the family (e.g., for the past few years the
national conference of the American Association for Marriage and Family Therapy has
offered sessions related to ASDs and family therapy).

Conclusion
Autism spectrum disorders affect couples in a variety of different ways. For some, raising
children on the autism spectrum can cause them a great deal of stress, contributing to the
demise of their relationships, while others feel drawn closer together through the shared
experience of caring for an autistic child. Yet other couples experience an initial dip in
relationship satisfaction but, after adjusting to a new lifestyle and routine and developing
new expectations for their children, are later able to bond in new and meaningful ways. As
such, a marriage-friendly approach to therapy with couples raising children on the autism
spectrum can be beneficial as it allows a distressed couple to take time and space to focus
on their relationship and, potentially, be able to work through the dip in their relationship
without resorting to separation or divorce. This approach may also benefit autistic children
whose parents are considering divorce in that, if the parents are able to work through their
troubles, then the children will not have to experience a difficult change in routine and
family structure.
Despite the benefits of marriage-friendly therapy with couples raising children with
ASDs, there are several ethical implications that must be considered as well. Especially
important when taking a marriage-friendly approach to treating such couples is to

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recognize that, for some partners who are being actively abused, under a great deal of
duress, or ready to leave their intimate partnerships, taking such an approach may actually
cause more harm than good. However, if a therapist finds no contraindications to
employing a marriage-friendly approach with couples who have children on the autism
spectrum, this approach may go far in supporting couples dealing with relational distress
related to raising their special needs children.

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