Does autism and schizophrenia spectrum disorder comorbidity imply a separate diagnosis? If so, how can we conceptualize and treat this presentation in adolescence, when treatment is most critical?
Portions of this entry were submitted as part of a preclinical graduate school assignment, "Developmental and practical considerations for psychotherapy in a case of multiple complex developmental disorder."
IMAGE CREDIT: Gordon Johnson/Pixabay
Cognitive, social, relational, and physical growth, or ontogenesis, is a continual process which occurs well beyond childhood and continues throughout the lifespan (Baltes, 1987; Lindenberger & Baltes, 2000). That ontogenesis is the outcome of biological, personal, communal, and generational factors which impact neural plasticity, resilience, and cognitive and social reserve; modulate learning, behavior, and affective responses; and mediate cognition in novel situations (Guy Evans, 2022; Harrewijn et al., 2017; McLeod, 2022; Packard & Knowlton, 2002; Poppenk et al., 2010; Sarter et al., 2003; Staudinger et al., 1995; Uhlhaas & Singer, 2010). Developmental theories often recognize adolescence — or “emerging adulthood” — as a critical stage for the genesis and transformation of an individual’s identity, worldview, and personal ideology. For Freud, adolescence is a time when pleasure is derived from experiences outside the family, typified by sexual awakening (Knight, 2014; Simon & Gagnon, 2002); for Piaget, it's the stage in which logical and symbolic concepts and operations are unified toward goal-directed, abstract reasoning and social issues (McLeod, 2009); and for Erikson and Arnett, it's characterized by the development of personal identity, a sense of self-competency, and acceptance of, and intimacy with, others (Arnett, 2000; Darling-Fisher, 2019; Gobbo & Shmulsky, 2016; McLeod, 2008; Ratner & Berman, 2015; Rosenthal et al., 1981). All of these developmental theories represent vital contributions to the conceptualization of adolescents in a personal and social context and evoke critical considerations for psychotherapy. They are, however, broadly based on normative populations, and in many cases conceived through observation of samples of Western European descent.
Setting aside the latter criticism, it's to be expected that individuals with neurocognitive, developmental, or other disorders may experience the transition to adulthood differently than their peers, and their psychotherapeutic needs will vary accordingly. The flexibility in cognition and competencies required of adolescents, for example, is particularly challenging for those with autism spectrum disorders (ASD), who are consequently at higher risk of anxiety, depression, and suicidal ideation. ASD individuals’ familial and social support systems are critical contributors to self-perception and emotional and social expression, and so influence or inhibit the emergence of identity-in-relation inherent to adolescent development. Due to these and other factors, the transition to adulthood occurs later, and lasts longer, for ASD adolescents than for others (Mattys et al., 2018). Adolescents and young adults with ASD tend to exhibit deficits in goal-directed behavior, intimacy, and other factors which influence friendships and companionship — in part due to ASD symptoms, such as rigidity, need for structure, hypersensitivity to stimuli in social situations, and subjective isolation, and in part due to issues of personal and interpersonal identity arising out of a sense of being “different,” or even overt negative labeling by others, which often conflicts with the pressure to “fit in” and contributes to anxiety, fear of change, and emotional and physical exhaustion from attempting to appear “normal” (Aylott, 2000; Mattys et al., 2018; Ratner & Berman, 2015). These pressures and self-perceptions challenge the nurturance of personal identity or “fidelity” which typifies adolescence under the Eriksonian model, intimacy under the Freudian model, and abstract and social development under the Piagetian model, particularly when social or familial messaging about autism carries negativity, or when it is seen as a disability rather than a positive or neutral trait. Pressures and perceptions also serve as barriers to development of a sense of agency, healthy intimacy, sexuality, and social and occupational identity (Aylott, 2000; Gobbo & Shmulsky, 2016). Elicitation of positive self-perceptions, perhaps through the development of alternative narratives which avoid stigmatization, is therefore an important target for therapeutic intervention (Aylott, 2000; Gobbo & Shmulsky, 2016; Jones et al., 2015; Mattys et al., 2018).
Complex Presentations and Developmental Theory
The core features of ASD include deficits in social interaction and communication and restricted, repetitive behavioral patterns or interests, including stereotypies, inflexible adherence to routines, ritualized behaviors, fixations, and hypersensitivity or hyporeactivity to sensory input (American Psychiatric Association, 2013; Cochran et al., 2013). Approximately 70% of patients with an ASD diagnosis meet the criteria for an additional mental health disorder based on symptomatology which does not comport with the traditional ASD profile, and 40% meet the criteria for two or more mental health comorbidities (American Psychiatric Association, 2013). Although these comorbidities commonly include affective disorders, specific learning disabilities, attention-deficit/hyperactivity disorder, and developmental coordination disorders (American Psychiatric Association, 2013; Stahlberg et al., 2004), a subset of ASD patients also exhibit the positive, and perhaps negative, symptoms of schizophrenia spectrum disorders (SSD), over and above the social and communication deficits, poverty of speech, illogicality and thought derailment, eccentricities, and restricted cognition which characterize, or are common in, ASD and may be mistaken for psychosis (Cochran et al., 2013; Dvir & Frazier, 2011; Matson & Nebel-Schwalm, 2007; Stahlberg et al., 2004). These comorbidities may have a biological basis, as there is compelling evidence that ASD and SSD share genetic and neurobiological traits, including deletions, duplications, and mutations in specific genes and chromosomal regions and loss of prefrontal and superior temporal grey matter in adolescence, which may serve as predisposing factors, contribute to shared clinical features, or explain the development of, or conversion to, psychotic phenotypes in later adolescence and early adulthood (Cochran et al., 2013; Dvir & Frazier, 2011).
In light of these findings, it's been proposed that these symptom profiles do not represent unusual symptom clusters within ASD or SSD, but are instead the presentation of a multiplex developmental disorder (Klin et al., 1995; Paul et al., 1999; Towbin et al., 1993) or multiple complex developmental disorder (MCDD: Posar & Visconti, 2020; Sprong et al., 2008; Van der Gaag et al., 1995) which overlaps both diagnoses.
Beyond the social, practical, and identity challenges of ASD, adolescents with MCDD must cope with the positive (psychotic) symptoms of SSD. Even in non-MCDD individuals, patients often present with their first psychotic episodes during adolescence, and this is likely due to biological as well as psychosocial factors (Bronstein, 2020; Chiappelli & Beason, 2023; Coetzee, 2005; Samaey et al., 2023; Sprong et al., 2008). Bronstein (2020), a psychoanalyst, has noted that even normative adolescence can incur intense anxiety associated with an increasing separation from families of origin, a loss of childhood, and a heightened awareness of mortality. These anxieties, coupled with the intense aggressive and sexual drives of the adolescent body and mind, can contribute to an unstable sense of identity, leading to personal crisis (adolescent breakdown) or, in extreme cases, confusion, anguish, loss of symbolic thinking, and fear of disintegration which manifests as psychosis — temporary breaks with reality, such as self-harm, psychotic functioning (in the psychoanalytic sense), including anorexia, obesity, and addiction, and overt psychosis, exemplified by splitting, denial, projective identification, and delusion (Bronstein, 2020). Other theorists, including Chiappelli and Beason (2023), endorse a neurodevelopmental model of adolescent psychosis. Under this model, normative neurodevelopmental processes, including neocortical myelination, which contribute to maturation of creativity, cognitive control, and cognitive performance, are reflected in adolescent exploratory behavior and risk-taking as well as the consolidation of a sense of identity based on personal opinions, belief systems, values, and aspirations, but, in individuals with latent mental illness, may also lead to preoccupation with novel ideas, aberrant attributions of cause and effect, and the development of delusional ideation or apophany (Chiappelli & Beason, 2023).
So, while the psychoanalytic and neurodevelopmental models differ with respect to the ultimate causes of psychosis, both theories agree that psychotic symptomatology arises from a complex interplay of biology, experiential stressors, and aberrations in identity synthesis, and therefore comport with the Eriksonian psychosocial conflict between identity and identity confusion in adolescence. Additionally, a history of abuse or neglect in childhood is not only associated with the development of depressive, anxious, or psychotic profiles in adolescence, but such history, and the manifestation of internalizing or externalizing symptoms, also appear to be well-correlated with scores on the Modified Erikson Psychosocial Stage Inventory (MEPSI) and Dimensions of Identity Development Scale (DIDS) which are indicative of identity confusion, exploration, and distress (Samaey et al., 2023). The influence of childhood adversity, too, may be applicable to teens with ASD or latent mental health issues, given the stigma and social isolation these incur.
In summary, the formation of a positive, stable self-identity and identity-in-relation may be seen as critical aspects of both ASD and SSD: the physical and cognitive symptoms of ASD, including egocentrism, sensory hypersensitivity in social situations, and cognitive rigidity, can impair the formation and maintenance of relationships, even when such relationships are not already compromised by negative self-perceptions, stigma, or a sense of isolation. The biological and psychosocial symptoms of SSD may lead to ideological distortions and fixations which not only impair social functioning, but which may also be improved or accelerated by the social environment and self-percept. We have to approach complex cases like MCDD from both the biomedical and psychosocial orientations. Medically, however, MCDD represents a major challenge for the clinician with respect to both diagnosis (Miranda et al., 2021) and pharmacological treatment and treatment adherence, particularly since MCDD patients are often unresponsive to antipsychotics (Downs et al., 2017). It's therefore critical to consider the role of psychotherapy — the first-line treatment of choice for ASD (Goel et al., 2018; Hyman et al., 2020; Khan, 2020; National Center on Birth Defects and Developmental Disabilities, 2022; Popow et al., 2021; Wichers et al., 2022) and an important adjunct to pharmacotherapy for SSD (Best & Bowie, 2017; Bighelli et al., 2020; Solmi et al., 2023) — in meeting the needs of MCDD individuals, particularly during adolescence. Psychotherapeutic interventions, however, necessitate the careful consideration of personal, systemic, and developmental factors, and must address both the social, communicative, and praxis aspects of ASD symptoms and the positive and negative symptomatology of SSD. A case conceptualization and brief sample MCDD treatment plan is the focus of the remainder of this post.
Case Vignette
Simon is a 16-year-old, cis-gendered, heterosexual male previously diagnosed with ASD, schizoaffective, and post-traumatic stress disorder by a team of biomedical and mental health practitioners. He experienced multiple recurrent episodes of emotional, physical, and psychological abuse by his birth father in early childhood and now lives with his birth mother, Ann (43), sister Marie (14), and stepfather Lee (44). All family members identify as White, non-Hispanic/Latino, and middle class, and deny any strong religious or cultural affiliation. Simon received his ASD diagnosis at age 3 but has done well academically throughout elementary, middle, and early high school, largely due to occupational therapy through school (504 plan and IEP), and is now a rising junior at a public high school. His family denies any other history of developmental delay or language or learning disability. At age 13, Simon endorsed experiencing unremitting auditory and visual hallucinations, including multiple directive or critical voices, disembodied whispers, and violent visual imagery often involving mangled bodies. He also endorsed suicidal ideation and was admitted to an acute-care facility for one week, where he was diagnosed with schizoaffective disorder. He has received combination psychotherapy and pharmacotherapy since that time, including risperidone (4mg q.d.), fluoxetine (50mg, q.d.), and clonidine (0.1mg, q.d.). He currently meets criteria for moderately severe depression (PHQ-9), mild anxiety (GAD-7), and moderately severe schizophrenia spectrum symptoms (CGI-SCH). Ann and Lee have recently presented to therapy, with Simon and Marie, out of a concern that Simon appears unmotivated to meet the “milestones” they expect of his age: he consistently fails to carry out the three chores assigned to him (taking out the kitchen trash, cleaning his bedroom, and cleaning the bathroom he shares with his sister), has no friends, refuses to participate in any school, communal, or social activities, usually declines to participate in family activities, and has no plans for life after graduation. Instead, Simon prefers to spend his time in his room watching internet videos or playing video games. Ann and Lee endorse having worried “a lot” about Simon’s ability to have an independent, fulfilling life in adulthood, and this anxiety has increased as he approaches high school graduation with few signs of attaining what his parents perceive to be age-appropriate independence. For example, although Simon has held a job at a local fast food restaurant for approximately four months, and has applied for and received his learner’s permit, Ann and Lee state that he was extremely reluctant to carry out these responsibilities and only did so after they “delivered an ultimatum” that Simon could not “live with them for the rest of his life” and that Simon “needs to learn that he has, or can learn, necessary life skills”: maintaining personal hygiene (showering, brushing hair, using deodorant), earning and saving his own money, learning to drive, and eventually “living either on his own or with roommates.” Despite this “ultimatum,” however, Simon has continued to be reluctant to take on additional responsibilities, including learning to drive with supervision, making new friends, or reflecting on occupational or living plans which might interest him. His academic performance has fallen over the previous year and his few friendships have diminished to zero. Simon acknowledges his parents’ concerns, and endorses their accuracy, but states that he is afraid to be independent because he does not want to be “left on [his] own” or “cut off” from his family. He admits that, even when his parents or sister ask him to participate in activities, he “just want[s] to be alone” to “just chill.” Simon also endorses wanting to spend more time with his family, to be independent, and to feel more confident in his abilities to carry out activities of daily living, but feels “afraid to try,” “just forgets,” or “put[s] things off.” With respect to his future plans, Simon expects to continue working in fast food, perhaps joining a band, and developing a career as a “gamer” on live-streaming platforms such as Twitch. He admits, however, that he is “not very good at playing guitar” and “just an okay gamer.” Ann and Lee note that much of Simon’s paycheck goes to purchasing online video games, and add that they have recently insist that he pay for his own (used) car and car insurance, snacks, and sodas, in order to facilitate Simon’s “understanding that money is real, not an abstract thing.”
When asked how these disagreements typically play out, Ann states she usually reminds Simon “many times” to do something (e.g., chores, looking into a buying a car, applying to a driving school), and Simon will simply say “okay” and walk away. These reminders continue until Ann either becomes angry and “yells” at Simon, or “give[s] up” altogether, at which point Ann, Lee, or Marie carries out the task themselves, which they feel is “emotionally and physically exhausting.” Ann admits that Lee seems to be more patient with Simon, whereas she (Ann) tends to get “upset” more easily; however, Lee states that he becomes just as frustrated with Ann, but rarely “gets onto” Simon because he (Lee) doesn’t feel that “hand-holding [i.e., constant reminding] is doing [Simon] any favors.” Simon agrees with Ann and Lee regarding these dynamics, but admits that, although he wants to “do better,” he “just [hasn’t] been able to.” Simon adds that his individual therapist has been unable to help: he feels that some progress is made in session, but acknowledges that he does not complete his therapist-assigned “homework” because he “just forgets.”
The Developmental Theory-Informed Approach
Even for neuro-normative adolescents, the transition to adulthood is characterized by fundamental changes in cognitive, emotional, personal, familial, and social functioning — stressors not only consequent to biological maturation but which affect this maturation as well (Anniko et al., 2019; Colten, 2017; Romeo, 2017). For those with pervasive cognitive issues, this transition is even more complex. Several developmental theories are potentially applicable to such cases, and to the present vignette in particular. Bandura’s social cognitive learning model, for example, emphasizes a sense of competency and self-efficacy, highlights behavioral modeling by family members, peers, and other models held in high esteem, and underscores the role of motivation in the implementation of learned behaviors (Bandura, 2001, 2012; Bandura et al., 1999; Cannon & Rucker, 2022; Luszczynska et al., 2005; Nickerson, 2022). Bronfenbrenner’s bioecosystems model contextualizes individual development within the framework of biology and immediate family and peers (the microsystem), but also as a contributor to, and beneficiary or casualty of, interactions among microsystems, social structures, cultural influences, and shared and individual life events (the mesosystem, exosystem, macrosystem, and chronosystem), and comports well with the current theory and practice of systemically-informed psychotherapy (Guy Evans, 2022; Pokharel et al., 2020). And finally, Erikson’s seminal work continues to influence research and practice with adolescents even today; for example, it serves as a principal basis for the neurodevelopmental, and even the psychoanalytic, theories of adolescent-onset psychosis, and informs phenomenological research into the experience of adolescents with ASD, as previously described (Aylott, 2000; Bronstein, 2020; Chiappelli & Beason, 2023; Gobbo & Shmulsky, 2016; Mattys et al., 2018; Ratner & Berman, 2015).
To identify any one of these three developmental models as “key” to psychotherapeutic practice, particularly in cases as complex as MCDD, does a disservice to prospective clients and arguably contravenes ethical standards and principles such as beneficence, client welfare, professional competency, and sensitivity to client context and needs (American Association for Marriage and Family Therapy, 2015; American Counseling Association, 2014). The following case conceptualization and treatment plan will therefore attend to three fundamental concerns: (1) The role of social modeling, motivation, and self-efficacy, per Bandura’s social cognitive theory; (2) The first- and second-order cybernetic concepts of Bronfenbrenner’s bioecosystems model; and (3) the role of the psychosocial conflict between identity synthesis versus identity confusion, per Erikson, Arnett, and recent work on psychosis and identity development.
Selection of the Systemic-Relational Practice Model
Ethical considerations also dictate that clinical decision-making should be founded on the best available evidence obtained through well-designed research methodologies and carefully applied to clients’ sociocultural contexts and preferences — that is, better outcomes are more likely when treatment is formulated through evidence-based practice (APA, 2006; Goldet & Howick, 2013; Ramey & Grubb, 2009; Rousseau & Gunia, 2016; Titler, 2008; Zachar, 2012). Given the scarcity of compelling research evidence for specific interventions in MCDD, it is necessary to base these clinical decisions on support for ASD and SSD separately, while acknowledging that MCDD may present specific difficulties due to the effects of the combined symptom profile. In his regard, multiple randomized controlled trials have demonstrated moderate efficacy of cognitive-behavioral therapy (CBT) in reducing relapse and improving global functioning, functional status, social withdrawal, negative symptoms, and perhaps overall distress, in SSD when compared to standard care (Kavanagh et al., 1993; Laws et al., 2018; Pos et al., 2019), although evidence for sustained improvement following treatment cessation is mixed, and appears to be largely contingent upon treatment duration, clinician skill and training, and early intervention (Kavanagh et al., 1993; Laws et al., 2018; Onwumere et al., 2016; Pos et al., 2019). SSD outcomes are more favorable when CBT is combined with adjunctive cognitive support, skills training, neurostimulation, additional psychosocial support, or pharmacological interventions (Green et al., 2018; Jones et al., 2018). Similarly, CBT approaches, and particularly family-oriented CBT (described below) may be indicated for treatment of ASD-associated issues, although this research support is impaired by a dearth of high-quality evidence (Spain et al., 2017). CBT interventions have shown promise in improving social, emotional, and executive functioning and integration in adults with high-functioning ASD, and, as with SSD, this efficacy appears to be improved with adjunctive familial or psychosocial intervention programs, and treatment success contingent upon provider skill and the length and quality of the intervention (Baker-Ericzén et al., 2021; Bishop-Fitzpatrick et al., 2014; Ho et al., 2014; Maskey et al., 2019; Wood et al., 2010). Cognitive-behavioral family therapy (CBFT) extends the CBT concepts of dysfunctional, automatic thoughts and behaviors, and the underlying maladaptive assumptions, or schemas, and misperceptions which shape them, to the family system. For example, it posits that individuals incorporate perceptions of self and family into their personal schemas, and families develop collective familial schemas concerning family members’ roles, rules of interaction, and behavioral expectations, and these schemas are reinforced by the daily interactions which characterize their systemic status quo; consequently, the therapeutic objectives of CBFT are to identify, address, and modify extant thought patterns, both individual and familial (Dattilio, 2001; Dattilio & Collins, 2018; Friedberg, 2006; Goudarzi et al., 2019; Lan & Sher, 2019; Schwebel & Fine, 1992). CBFT interventions include Socratic questioning, discovery of schemas and their origin, “homework,” including keeping a “dysfunctional thought log,” enacting new behaviors, and solidifying change through repeated practice (Dattilio, 2001; Dattilio & Collins, 2018).
Application
Systemic Hypothesis
Simon and his family hold maladaptive beliefs about themselves, their capacity for change, and the world at large which determine their affective and behavioral responses to daily challenges. These beliefs are characterized by overgeneralization and all-or-nothing thinking (“Independence means my family will abandon me”; “I can’t do anything right”; “I’m doomed to fail at anything I do”), labeling (“Simon is the ‘problem child’/focus of most of our family conflicts”), magnification (“We end up doing most of Simon’s tasks ourselves — it’s exhausting”; “At this rate, Simon will never be an independent adult”), and selective abstraction (“The world is a scary place”). Simon’s negative perceptions of himself and his competencies prevent him from attempting novel experiences, and these failures not only incur personal dejection but are also interpreted by Ann and Lee as apathy, which engenders further frustration and conflict. Conflict resolution occurs when Simon himself completes his tasks, often after a great deal of “nagging” by his parents, or when another family member completes these tasks for him; in either case, this harrying or resolution of tasks by others negatively impact Simon’s sense of agency and self-competency, and since he is socially isolated, much of Simon’s self-percept is shaped by these interactions with his family, thereby reinforcing his negative self-perceptions.
Developmental Assessment and Theory- and Model-Informed Targets
The following treatment plan will address the bidirectional interactions among personal and microsystemic factors (underlying assumptions and affective and behavioral reactions to conflict, Simon’s subjective identity and agency, individual and familial motivation to change, and behavioral modeling by family members); Simon’s social skills and responses to social stigma; and the development of his personal support within his family and peer groups. Interventions will focus on Simon’s development of a positive personal identity as the primary target.
Sample Treatment Plan
Goal 1
Identify individual, familial, and cultural assumptions which contribute to behavioral responses and ongoing conflict.
Objective 1. Reframe presenting issues as systemic-relational and define existing transactional dynamics. By the end of the third session, each family member will be able to verbalize one way they contribute to, and reinforce, the cycle of conflict.
Intervention 1. Establish baselines for Simon’s developmental level and sense of identity using the MEPSI (Darling-Fisher, 2019; Rosenthal et al., 1981), and for familial adaptability and cohesion using the Beavers SFI, by the end of the second session. These scores will be reviewed in the third session.
Intervention 2. At the end of the first session, after explaining fundamental CBT concepts, assign each family member to complete a “dysfunctional thought journal” for the week, in which stressful situations and their cognitive and emotional consequences are recorded. This journal will be kept throughout the course of therapy. Psychoeducational materials regarding cognitive distortions will be provided at the end of the second session, and clients will identify the distortions associated with stressful events in subsequent entries.
Objective 2. Identify and explore current and historical maladaptive beliefs and thought patterns for the family and individual family members, ascertain their contribution to familial conflicts, and how they inform Simon’s sense of identity, his goals and motivations, and other family members’ preconceptions of him. By the end of the fourth session, each family member will be able to identify at least one way their beliefs and cognitions influence how they see themselves, and one way these beliefs and cognitions determine behavioral responses.
Intervention 1. Each client’s dysfunctional thought journal will be revisited during the second and third sessions and a list of cognitive distortions compiled. Alternative interpretations and responses will be established through collaborative dialogue and behavioral modeling.
Intervention 2. During the fourth session, the family will enact or discuss a recent conflict and discuss its outcomes. Automatic thoughts and behaviors, and their associated cognitive distortions, will be identified and its impact on each family member’s self-perceptions explored. The conflict will then be re-enacted with coaching on communication skills by the psychotherapist.
Intervention 3. Assess midpoint developmental, identity, and familial functioning using the MEPSI and SFI (sixth or seventh session).
Goal 2
Facilitate development of a positive, integrated sense of Simon’s personal and social identity by modifying personal and familial cognitive and behavioral processes, and solidify new communication skills and personal competencies with respect to collaboratively-identified life goals (both near- and long-term). By the end of the ninth session, each family member will be able to identify at least two aspects of their personal schemas, and at least one concrete behavioral change they have exhibited between previous sessions.
Objective 1. Address and modify individual and familial schemas through introspection and collaborative discussion.
Intervention 1. During the fifth session, the concepts of “questioning evidence” and “rating beliefs” will be introduced and psychoeducational reading provided as homework following this session.
Intervention 2. During the sixth session, clients’ journals and belief ratings will be revisited and potential barriers to change identified. The family will be asked to identify one significant goal to be targeted over the next three weeks and the development of a family action plan assigned as homework following the sixth session. This action plan should include concrete behaviors to be carried out by each family member. Progress on the action plan will be discussed during the seventh through ninth sessions.
Objective 2. Identify extrafamilial sources of stress, stigma, and isolation and possible ways to address them.
Intervention 1. Following the eighth session, each family member will be tasked with recording current and historical situations in which their own or others’ views (e.g., stigma, negative perceptions, or acceptance) of Simon’s ASD and SSD symptoms have influenced his exclusion from, or inclusion in, activities and discussions. This homework will be discussed during the ninth session.
Intervention 2. During the tenth session, the family’s action plan/progress toward their identified goal, as well as unforeseen barriers, affective and behavioral responses, and outcomes will be discussed.
Intervention 3. By the conclusion of therapy, Simon and his family members will identify one significant, long-term goal concerning his occupational or personal plans post-graduation, and/or his goals in adulthood. They will identify concrete steps toward this goal and formulate an action plan which include tangible actions by Simon and supportive actions by his family members.
Intervention 4. Assess developmental, identity, and familial functioning at termination using the MEPSI and SFI.
Conclusion
MCDD is a complex disorder which includes aspects of both ASD and SSD, and necessitates a combined pharmacological and psychotherapeutic approach to treatment. Theoretical considerations and phenomenological research indicate that adolescents with MCDD will be well-served by interventions which address issues of personal identity, facilitate positive identity synthesis, and attend to the nurturance of motivation, self-efficacy, and identity-in-relation. In this paper, a CBFT approach was examined as a potential basis for such intervention; however, MCDD research is still in its infancy, and much remains unknown about the treatment and lived experiences of these individuals.
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