4 Separate Papers. Write a one-page review, single spaced of each of the assigned readings. Article responses should include a description of the article itself and a reaction to the article. I will a

With the increase in the number of children being diagnosed with autism, the literature on treatments and inter- ventions to assist children and their fam- ilies has also increased (Campbell, Schop- ler, Cueva, & Hallin, 1996; Gresham, Beebe-Frankenberger, & MacMillian, 1999; Howlin, 1998; Rogers, 1998). However, literature focused on inform- ing parents that their child has autism is limited. Literature on collaboration, parent- professional relationships, and partnerships offers various models that professionals can use to conference and collaborate with families (Dunst, Trivette, & Deal, 1988; Fine & Gardner, 1994; Fine & Simpson, 2000; Turnbull & Turnbull, 1997; Wise, 1995). These process-oriented models, written for school personnel such as teachers and school psychologists, pro- vide guidelines for working collabora- tively with families over an extended pe- riod of time. However, the assessment and interpretative conference for a diag- nosis of autism frequently occurs in a fi- nite amount of time. In these cases, pro- fessionals do not have the luxury of frequent and repeated visits with the fam- ily. Instead, the assessment occurs over a few days in a clinic setting with an inter- pretative conference scheduled soon af- terward. The majority of literature examining the interpretative conference is directed toward physicians who diagnose specific disabilities, such as Down syndrome (Cunningham, Morgan, & McGuckin, 1984; Pueschel, 1985; Sharp, Strauss, & Lorch, 1992), physical disabilities (Turner & Sloper, 1992), cystic fibrosis (jedlicka- Kohler, Gotz, & Eichler, 1996; Quittner, DiGirolamo, Michel, & Eigen, 1992), cancer (Greenberg et al., 1984), and chronic illness (Myers, 1983). These dis- at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 31 abilities often present with clear biologi- cal markers. This body of literature dis- cusses how the diagnosis could be shared with families around the time of birth but does not consider how parents and pro- fessionals felt about diagnosis and treat- ment suggestions offered during the early childhood years. Furthermore, there is limited information on how nonmed- ical professionals, such as educators and psychologists, should inform families that their child has a disability such as autism. Although many of the recom- mendations described in the medical lit- erature may be applicable to nonmedical professionals, these professionals have rarely been considered in most of the studies. Shea (1993) wrote one of the few ar- ticles about giving a diagnosis of autism to parents. She offers suggestions for the interpretative conference that include setting goals for the conference, stating the diagnosis, and allowing families to react emotionally to the diagnosis. Shea also emphasizes the importance of the physical setting, the use of language, and a discussion of the child’s future. How- Table 1 Information on Professional Participants Table 2 Information on Parent Participants Note. Participants 10 and 11 are spouses. Participants 12 and 13 are spouses. ever, her chapter does not consider par- ents’ and professionals’ perceptions of how the interpretative conference was conducted. The present study examined families’ and professionals’ perceptions of the in- terpretative conference that informed parents their child has autism. Both fam- ily members and professionals reported their perceptions of autism and discussed their reactions to giving and receiving the diagnosis. Based on this information, recommendations for the interpretative conference are offered.

Method Participants Twenty-eight participants were inter- viewed for this study: 11 professionals who have diagnosed autism and 17 par- ents of children with autism. Professionals. Eleven professionals from a medical center and a preschool were interviewed. The medical center was located in a large midwestern city (a Center for Excellence in Developmental Disabilities Education Research and Ser- vice), and the preschool was located in a smaller midwestern city (affiliated with the local public school district’s Early Childhood Special Education Program). In both settings, transdisciplinary or in- terdisciplinary teams offer assessments and provide a variety of diagnoses, in- cluding autism. Table 1 provides demo- graphic information for the sample of 11 I professionals. Families. Table 2 provides demo- graphic information for the 17 family members. The majority of the partici- pants were from affluent White families residing in one of the wealthiest counties in the country. Most participants worked outside of the home and had at least a college education. Although one partici- pant was a single mother, a majority of the participants interviewed were mar- ried. Two of the 15 mothers interviewed were the wives of the two fathers who participated in the study. Most family at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 32 members had a biological child between 2 and 5 years of age who had received a diagnosis of autism, Asperger syndrome, or PDD NOS within the past year. Diag- noses were obtained from various set- tings across the country and were not limited to the areas served by the profes- sionals who were interviewed. Two par- ents (both mothers) did not complete the study. One mother moved and did not leave a forwarding address or phone number. The second mother indicated that she no longer chose to participate in the study due to time constraints. In- formation obtained from their first round of interviews was included in the data analysis.

Procedure Recruitment of Participants. Pro- fessionals were individually approached by the first author in the work environ- ment and given an overview of the study. Professionals were asked to participate if they had experience diagnosing autism or other pervasive developmental disorders and if they were not physicians. All 11 professionals approached agreed to participate, and a time was set for the first interview. Two approaches were used to recruit family members. A letter describing the study was sent by the medical center to 60 families of children who had recently received a diagnosis of autism or another pervasive developmental disorder. Only two parents agreed to participate using this method of recruitment. The first au- thor recruited 15 family members by at- tending local parent support groups for families who have children with autism. An overview of the study was presented to the parent support groups. Parents who were interested in participating and had a child who had recently received a diagnosis of autism or another pervasive developmental disorder provided their names and telephone numbers on a sign- up sheet. The researcher then called all individuals who volunteered to partici- pate, answered any questions regarding the study, and set a meeting for the first interview. Reports and records were not collected regarding the child’s diagnosis of autism. Parent report and the first au- thor’s clinical judgment of autism were used instead.. , =- Data Collection. Collection of the data was organized into three phases based on Lincoln and Guba’s (1985) method of naturalistic inquiry. During Site Visit 1 (SV-1), the primary objective was to conduct unstructured interviews with the participants. Questions for Pro- fessional SV-1 were developed based on recurring themes in the literature. Pro- fessionals in the field and family members of children with autism reviewed the questions for relevancy. Questions for Parent SV-1 were based on themes in the literature and information obtained dur- ing Professional SV-1, and they were subjected to a review by professionals and family members. Site Visits 2 (SV-2) and 3 (SV-3) were conducted in order to obtain more specific information and to clarify information obtained in the previ- ous interview(s). Professionals partici- pated in three rounds of interviews and parents completed two rounds of inter- views. The sequence of interviews was as follows: Professional SV-1, Parent SV-1, Professional SV-2, Parent SV-2, Profes- sional SV-3. Most interviews with the professionals were conducted at the medical center or the school site. A few interviews were conducted in the professionals’ homes, and one was conducted at a neutral loca- tion due to scheduling difficulties. All family interviews were conducted at the participants’ homes. Interviews were recorded and lasted between 30 and 60 minutes. Prior to the first interview, professionals and families signed consent forms. To ensure confidentiality, all par- ticipants were assigned a code number that was written on the audiotape and on any notes taken during the interview. In- terviews were transcribed and unitized using word processing software. Approx- imately half of the interviews were tran- scribed by the first author, and the re- maining interviews were transcribed by a professional transcriptionist. When the transcriptionist returned the interviews, the first author reviewed them for accuracy. Data Analysis. The first author con- tinuously analyzed the data using Lin- coln and Guba’s (1985) method of nat- uralistic inquiry. Data analysis followed each round of interviews. Initially, inter- views were reduced to individual units of information that represented single ideas or thoughts. Units of information were assigned individual codes based on the following guidelines: a-b-c (a = phase of the study, b = person interviewed, c = in- dividual idea or thought from the inter- view ; see the Appendix). Each unit of information was then placed into a cate- gory that contained other units of simi- lar information. Definitions describing the characteristics of the units placed in that category were developed. Categor- ies were further refined and/or altered based on information obtained in subse- quent interviews. Collapsing the data into categories was a dynamic process. At least three units of similar information from different sources provided triangulation for data included in each category. Tri- angulation helped ensure reliability of data and information. Other means of ensuring reliability in- cluded a methodological log and a mem- ber check. The methodological log doc- umented the date of the methodological change and an explanation of the reason the change was made. A five-person member check was conducted. Partici- pants from the study included one mother, one professional from the school setting, and one professional from the medical center. The remaining two par- ticipants had experience sharing a diag- nosis of autism with families but did not &dquo; participate in the study. Member check participants were selected by the re- searcher based on their willingness and availability to participate in the member check activity. The first author furnished the member check participants with copies of the categorization system, the interpretation of the interviews, and the list of recommended practices. Member check participants were asked to inde- pendently review the documents and provide the first author with feedback within 2 weeks. Comments provided by the member check participants were in- corporated into the final drafts of the in- at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 33 terpretation and the list of recommenda- tions for practice. Resu Its The 65 interviews with participants yielded 2,260 units of information that were combined into seven categories and subcategories. Table 3 provides the fre- quency of responses for each of the seven categories. Family stories and miscella- neous comments are not discussed in this article.

Perceptions of the Definition and Outcomes of Autism Professionals described autism as a con- troversial disability’ that has a social stigma associated with it.2 Even though it is becoming more widely known,3 pro- fessionals still described autism as a &dquo;touchy label,&dquo;4 a &dquo;sensitive subject,&dquo;5 and a &dquo;heavy-duty diagnosis.&dquo;6 Profes- sionals described characteristics of autism as variable7 and encompassing numerous areas of development, such as language skills,8 motor skills,9 social skills,io sen- sory modulation and learning difficul- ties.l2 Many parents described autism as a &dquo;death sentence&dquo;13 or &dquo;lifelong sen- tence.&dquo;14 Prior to receiving the diagno- sis, parents reported having an inaccurate understanding of the characteristics asso- ciated with autism.15 In fact, some par- ents thought that all people with autism were like the character in the movie Rain Man.16 Prior to the diagnosis, many parents suspected something different or unusual about their child However, only a few parents suspected that their child had autism. 18 Most had never heard of autism, and as a result, they did not sus- pect that their child had the disorder.19 Table 3 Frequency of Responses in Categories * ’ . Some parents made excuses for the un- usual behaviors, such as their child’s &dquo;frenulum is too tight&dquo;20 or their child acts similar to a relative.21 Following the diagnosis, parents’ perceptions of their child ranged from feeling sorry for their child22 to being exceptionally proud of the child’s progress despite having autism.23 Parents and professionals presented different perspectives regarding out- comes for individuals with autism. Parents offered a positive outlook,24 whereas professionals typically described negative outcomes.25 In fact, many professionals indicated they would be devastated if their child was diagnosed with autism.26 Parents described their child as being &dquo;salvageable &dquo;27 and felt their child would &dquo;recover&dquo; from autism, 28 particularly if interventions were provided.29 How- ever, it is interesting to note that most families reported a negative perception of their child’s prognosis when the diagno- sis was first made.3o Although many parents currently be- lieve that there is a positive future for their child,31 some anticipated a negative outcome32 and questioned if their child would always exhibit characteristics of autism.33 Others indicated it would be difficult to determine the exact outcome because the severity of the characteris- tics34 and intensity of the interventions affect the outcome.35 Professionals described children with autism as always having characteristics of autism, thus resulting in a lifelong dis- ability36 with no cure.3~ Although many professionals described negative out- comes,3g a few indicated that the out- comes varied.39 Positive outcomes might be more likely if the diagnosis and inter- ventions were implemented early40 and if the child exhibited less severe autistic be- haviors.41 Many professionals felt that parents had unrealistic views of the out- comes of autism,42 with most expecta- tions being too positive.43 Although only a few parents described professionals as having a negative out- look on autism,44 even fewer felt that professionals had a positive outlook.45 Most parents believed that professionals did not have an awareness of the out- at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 34 come46 because they did not share any perceptions with families.47 One mother summed up her thoughts of the profes- sionals’ lack of awareness by stating, The people that we went to, I think are very good at diagnosing, but I don’t think that they really thought about the out- comes. They were thinking about the di- agnosis right now and what this child had. ... [They] mentioned absolutely nothing about what we could look for down the road with him and I don’t even think that was on their minds at that point.4g Professionals and parents indicated that professionals’ perceptions of the out- comes of autism affect how the profes- sional might discuss the prognosis.49 How the Diagnosis of Autism Is Presented to Families Professionals reported completing vari- ous tasks when preparing to give the di- agnosis of autism to a family. Many pro- fessionals emphasized the necessity of a good assessment to evaluate the child’s functioning and behaviors5o and to get to know the family.51 Professionals often meet with other team members to dis- cuss the data52 and results.53 As a team, professionals also discuss how informa- tion should be shared,54 who should be present,55 and the placement of individ- uals around the room.56 Professionals take the time to arrange the room5~ and determine the location of the child dur- ing the meeting.58 Many professionals, particularly those who diagnosed chil- dren in the school setting, reported con- sulting literature or research to obtain additional, updated information regard- ing autism.59 Professionals also prepare a packet of information on autism,6o complete essential paperwork,61 draw vi- sual aides,62 write a preliminary report,63 and develop recommendations64 prior to the interpretative conference. Profession- als complete these tasks regardless of whether the family suspects autism.65 In communicating the diagnosis of autism to a family, professionals attempt to use nonverbal communication skills,66 reflective listening, and simple lan- guage.67 When stating the actual diag- nosis of autism, professionals try to be honest 68 without overwhelming parents with too much information. The profes- sionals thought that pointing out the child’s strengths69 was also important, especially at the end of the meeting, so that the family leaves on a positive note.70 In addition, some stated that &dquo;a little humor and a few smiles can help take the edge off.,,71 Professionals dis- cuss the DSM-IV criteria for autism or explain how the child’s behavior meets the criteria for diagnosis.72 Educating the families about how autism differs from the disability that they might have sus- pected was also considered to be impor- tant.~3 Professionals often share scores by presenting graphical pictures that dem- onstrate ranges.~4 Almost all professionals attempt to ob- tain the parents’ level of understanding, feelings toward, and acceptance of the di- agnosis.~5 Professionals might ask ques- tions such as &dquo;Am I blowing you out of the water? Am I getting at what you need? Did you come here today with a specific purpose in mind, and have I ad- dressed that? &dquo;~6 Similarly, professionals try to answer all of the parents’ ques- tions. Professionals indicated that it is typically easier to give a diagnosis when there is a suspicion of autism because they do not have to convince parents that their child meets the criteria. Instead, the professional can begin talking about treatment options.~g Adversely, the less knowledge families have about autism, the more time professionals spend ex- plaining the diagnosis Following the diagnosis, professionals described how they might discuss the prognosis with families. Many profes- sionals inform parents that they cannot speculate on the prognosis.80 However, a few suggest improvement with appro- priate interventions,81 whereas others in- form parents that the child might always present with characteristics of autism.82 Professionals reported that the age of the child influences how the prognosis is dis- cussed. Many felt that the younger the child, the easier it is to discuss the po- tential improvement the child might make.83 With younger children, profes- sionals also discuss the necessity of a re- assessment to help determine the child’s long-term prognosis.84 When discussing interventions, only one professional indicated that she dis- cusses different treatment options.85 Professionals at the school setting often recommend that families pursue a med- ical evaluation.g6 Although professionals typically do not offer specific recommen- dations, many are concerned with how the families will access services in the community Parents sought evaluations to obtain a better understanding of their children.88 Most indicated that the evaluation was a positive experience.g9 Most parents re- called that when relaying the diagnosis, professionals sent positive nonverbal messages,90 such as listening well; having relaxed body language; and showing humor, empathy, compassion, and a gen- uine interest in the child and family. The environment91 and a relaxed atmo- sphere92 also helped parents feel com- fortable when hearing the diagnosis. Some parents were discouraged by pro- fessionals’ nonverbal behaviors, includ- ing having a tense or rigid body posture, looking at a watch, eating lunch, or al- lowing numerous interruptions while giving the diagnosis to a family.93 Parents indicated that these behaviors conveyed a lack of interest in the discussion.94 Parents also indicated that the lan- guage used to discuss the diagnosis was important. Although some parents felt that the diagnosis was not clearly stated,95 others felt it was stated too bluntly.96 In fact, one mother suggested that the di- agnosis was stated so bluntly that it was &dquo;kind of just thrown all at us. Like BOOM! We were not expecting it at all The DSM-IV criteria9g and the profes- sionals’ own words were used to describe autism.99 For the most part, parents felt that professionals attempted to use sim- ple and clear language100 to explain why the child had autism-101 Professionals often gave examples of the child’s behav- ior during the evaluation. 102 The child’s strengths were also discussed,lo3 which professionals considered reinforcing for parents.104 One mother even indicated that the professional praised her ability in handling her child’s behaviors.105 Some parents recalled that the professionals en- couraged them to ask questions. 106 at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 35 Other parents reported having a dis- cussion with the professionals about their child’s prognosis. Only a few parents re- ported hearing a positive prognosis for their child;107 more parents indicated that they recalled a negative progno- sis.lo8 Although some parents recalled that recommendations were not of- fered,109 many indicated that recom- mendations and resources were dis- cussed.110 Some recommendations, such as behavioral techniques, were even modeled.111 Packets of information on autism were frequently distributed, but some parents felt that the information was too technica1,112 inaccurate,113 and not comprehensive.114 One mother even described the reading materials as &dquo;two inches of crud to read.&dquo;115 Yet, others felt the reading materials were useffil. 116 Parents were pleased with the quality of the written reports.117 Who Should Give the Diagnosis? Parents recalled that psychologists typi- cally provided the diagnosis of autism 118 although a variety of other professionals, including speech pathologists, physical therapists, occupational therapists, pedi- atricians, and nurses,119 were represented at the interpretative meeting. Profession- als from both sites reported that the psy- chologist on the team usually shared the diagnosis.l2o Many professionals inter- viewed from the school setting, including the psychologist, indicated that giving the diagnosis of autism was not their re- sponsibility but that of a medical profes- sional These school-based profes- sionals stated that they preferred not to give the diagnosis because autism is a medical diagnosis, and therefore not a di- agnosis that they should make. However, many stated that a team of professionals was capable of making a diagnosis,122 particularly if a pediatrician was pres- ent.123 Nonmedical professionals at the medical center routinely give a diagnosis of autism to families. Some parents reported that the title of the professional did not have an effect on their acceptance of the diagnosis,124 but others indicated that it did influence their reaction.125 These parents believed that the title implies that professionals possess expertise in the area of autism. Families and professionals suggest that profes- sionals must have prior experience work- ing with children with autism and their families. These prior experiences should include knowledge of children126 (par- ticularly children with autism),12~ skill in administering tests to children with autism,128 and practice interpreting re- sults with families.129 Personality characteristics described as important when informing families that their child has autism include compas- sionl3O and honesty.131 Professionals mentioned that having the ability to un- derstand how well the families are ac- cepting the diagnosis of autism is also es- sentia1.132 When to Give the Diagnosis Some professionals drop hints through- out the course of the evaluation133 in order to raise the level of parents’ aware- ness regarding unusual behaviors. Most wait until the entire evaluation is over in order to decrease the likelihood of mis- perception by parents. 134 During the in- terpretative conference, all professionals have tried offering the diagnosis first, fol- lowed by a rationale as to why the child meets the criteria.135 Professionals have also described the child’s behaviors first and then stated the diagnosis. Although some professionals preferred to give the diagnosis first,136 others thought it was useful to talk about the child’s behaviors and then tie it together with a diagnosis in the end.l3~ The determination of when to state the diagnosis is dependent upon the family.138 Factors that profes- sionals consider are whether the parents suspect autism,139 whether the parents are ready to accept the diagnosis,140 and whether the family indicates that they want to know the diagnosis up front.141 Hedging the Diagnosis Many parents reported that professionals did not clearly state the diagnosis of autism.142 Professionals offered various reasons for why they would hedge a di- agnosis. Overwhelmingly, professionals reported that they consider the emotionsof the family and how much information the family can handle.143 Professionals also stated that for very young children, the diagnosis is not as important as ob- taining the appropriate services.144 Pro- fessionals also attributed their hesitancy to a fear of giving the diagnosis145 or a lack of confidence.146 A lack of training on autism,l4~ a poor evaluation,148 or even the young age of the child149 can result in fear or feelings of incompetence. Thoughts Regarding Giving Scores Most participants indicated that hearing scores obtained during the evaluation was helpfiil.150 One father stated that scores are helpful because &dquo;knowledge is power.&dquo;151 Similarly, a professional of- fered that sharing scores is important be- cause &dquo;if your bottom line [score] is going to call them a label, then they have a right to know why.&dquo;152 However, another pro- fessional questioned the appropriateness of providing scores because &dquo;it’s confus- ing and 2 days later it is not going to mean diddley.&dquo;153 Location of the Child During the Interpretative Conference Although some children were out of the room,154 most parents recalled their child being in the room155 when the di- agnosis was given. Parents who did not mind their child in the room156 sug- gested the child was too young to com- prehend the discussion.l5~ Yet, some parents preferred their child be out of the room158 because he or she might under- stand what was being discussed. 159 In ad- dition, parents need time to grieve with- out having to worry about their child. One mother explained why she preferred her child out of the room: Definitely it was better not to have him there because that’s a real big blow to give to parents. They need to deal with their emotions, or at least in our case, we needed to deal with our emotions and kind of get figured out how we were going to think about this and how we were going to deal with it. We needed time.l6o at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 36 Like parents, some professionals pre- ferred the child in the room,161 and oth- ers preferred the child out of the room when parents were told the diagnosis of autism. Some professionals thought that children in the room, particularly young children with autism, do not understand the conversation162 and can provide com- fort for parents.163 However, others were concerned children might understand164 or distract parents by misbehaving.165 Hope Many parents cried when discussing the need for hope.166 Hope provides parents with a sense of optimism for the fu- ture.l6~ One mother said hope was &dquo;why we wake up everyday. There is nothing that any of us cannot go through if we believe there is hope for progress.&dquo;168 Another mother stated that hope is the &dquo;carrot in front of our face.&dquo;169 Parents suggested that hope can be provided by being positive, describing the child’s potential for improvements discussing the positive effect of early interven- tion,171 and providing examples of suc- cess stories.l~2 z Interventions Some parents were pleased with available interventions for individuals with au- tism,l73 but a majority expressed dis- pleasure.l~4 Similarly, professionals also described positivel75 and negativel76 perceptions of interventions. Although most families recalled receiving general recommendations, they would have pre- ferred receiving information about spe- cific interventions 177 because such infor- mation would have assisted them in accessing services178 and would have provided a sense of direction.l~9 Families speculated that specific recommenda- tions were not offered because of pro- fessionals’ lack of knowledge 180 and con- cern for legal issues. 181 Professionals stated that the child’s service providers should develop appropriate interventions be- cause they have a better rapport and un- derstanding of the child.182 A speech pathologist stated that I tend to be a lot more general because even though I’ve spent time evaluating the child, I really haven’t got a chance to get in and manipulate things to see how they respond. I think when you really get in and you get down and dirty on the floor, I think that’s when you start to see more of the individualness and more of &dquo;that’s not going to work&dquo; because you’re actually try- ing.183 z Benefits of Receiving a Diagnosis . Parents said that relief is a benefit of a di- agnosis because they no longer feel they are to blame184 and they have an expla- nation for themselves185 and others186 as to why their child exhibits unusual be- haviors. The diagnosis serves as a &dquo;wake- up call because you realize that you just don’t have a child that’s, like, late talking or slow developing or whatever. You realize that you’ve got to do some- thing.&dquo;18~ A diagnosis of autism assists parents in obtaining informationl88 and access to services.189 Specifically, an early diagnosis is necessary to increase the like- lihood of progress. 190 Reactions to Giving and . Receiving a Diagnosis of .. , Autism Professionals stated that they experience emotional and physiological changes when giving the news of autism to par- ents. Most emotions are negative, in- cluding feeling sad,191 wanting to cry,192 feeling empathy for families,193 and having doubts about the diagnosis of autism.194 The most common and over- whelming emotion expressed is nervous- ness,195 particularly when professionals are uncertain of parents’ reactions.196 Professionals also described experiencing physical changes, such as nausea,l9~ in- creases in body temperaturel98 or heart rate,199 thirst,200 headache,201 and tired- ness, when informing families that their child has autism.2o2 Speech patterns are altered due to heavy breathing,203 stut- tering,204 or word retrieval difficul- ties.205 These emotional and physiologi- cal changes are often so overwhelming that professionals dread the interpreta- tive conference.206 These changes are often intensified when the family does not suspect autism.207 Parents under- stand that giving a diagnosis is difficult for professionals. 208 Professionals’ physiological and emo- tional reactions can have either a positive or negative effect on the presentation of the diagnosis. The positive effect is that empathy and sensitivity toward parents is increased.209 Negative effects include rushing, 210 failing to give relevant infor- mation,211 jumbling words,212 present- ing an unclear diagnosis,213 and using poor eye contact.214 These reactions may reinforce parents’ doubts in the pro- fessionals’ ability to make a diagnosis of autism2l and cause parents to become upset or uncomfortable.216 In fact, a so- cial worker felt that parents &dquo;can sense the tension in our voices and I think they react to it. They know that something is wrong with their child just by our be- havior. Our anxiety brings out their own anxiety. &dquo;217 Professionals reported that their emo- tional and physical reactions did not af- fect their discussion of the prognosis or interventions.219 In fact, professionals reported that discussing the prognosis was easier than presenting the diagno- sis,22o especially if a thorough discussion of the diagnosis was presented.221 Overall, professionals believe that par- ents’ main positive reaction is relief 222 Most reactions to the diagnosis of autism are negative, such as denial, 223 emotion- ality,224 misperception of the diagno- sis,22s and no longer listening to the professional.226 Parents also react by be- coming angry with or disliking the pro- fessional.227 An occupational therapist stated that parents often &dquo;hate the mes- senger&dquo;228 because he or she is telling the family something they do not want to hear. Many professionals admitted they would have a negative reaction if their child was diagnosed with autism.229 Most professionals described three groups of parents based on their prior knowledge of the diagnosis: parents who suspect autism,230 parents who suspect delays but not autism,231 and parents who do not recognize any problem.232 Parents’ reactions to the diagnosis vary and are dependent on the degree to which they suspect autism.233 Parents at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 37 who do not recognize a problem often have the most negative reactions.234 Par- ents suspecting a problem other than autism have a mixture of positive and negative reactions, including relief,235 re- ceptiveness,236 denial,237 anger,238 dev- astation,239 and a feeling of being over- whelmed.240 Parents suspecting autism typically have positive reactions,241 such as relief,242 acceptance of the diagno- sis,243 and receptiveness to additional in- formation.244 Professionals attribute some parents’ failure to accept the diagnosis to poor understanding of typical child develop- ment,245 incorrect and negative percep- tions of autism,246 characteristics of the family,247 and concern about the reac- tions of the extended family.248 In addi- tion, some parents continue to deny any problems,249 and as a result they make excuses for their child’s unusual be- haviors.250 The child’s age at the time of diagnosis is related to acceptance251 be- cause parents have difficulty differentiat- ing between typical and atypical behavior in young children.252 One professional suggested that parents of younger chil- dren &dquo;still envision this perfect child. There has not been enough time for them to realize how abnormal the be- havior is. We burst their picture of their child.&dquo;253 When parents suspect a dis- ability other than autism, the conference can be difficult because parents have a &dquo;preconceived notion of the reasons for their child’s behaviors. &dquo;254 Some profes- sionals indicated that parents from a high socioeconomic status and with a high level of education often have difficulty accept- ing a diagnosis of autism255 because Most of those [low SES] people didn’t ex- pect much in the beginning, but the peo- ple who just break down and sob and shake and just can’t get over it are the people who had such high expectations to begin with.... So I think the higher functioning people just find it a tremendous assault to their egos.256 Parents reacted to the diagnosis by crying;257 expressing relief,258 surprise,259 devastation,26o or helplessness;261 and wanting additional information about autism.262 Some parents did not believe the diagnosis,263 and some even became angry264 or questioned the professional’s ability.265 Many parents were concerned about how the other parent, extended family, and friends would accept the di- agnosis.266 Suspecting autism decreased the likelihood of shock.267 Many parents and professionals said family members went through a grieving process after hearing the diagnosis.268 Regardless of their reaction, families did not feel that a diagnosis of autism influenced their in- teractions with their child.269 Parental reaction to the diagnosis of autism varied. Although some families had a negative reaction,270 others were hopeful because early intervention could be initiated and changes could be made.271 One father summed up his op- timism nicely: It was so clear to us that there was some- thing wrong. We could not deny that he Table 4 Quick Reference of Recommendations for Practices When Informing Families Their Child Has Autism was acting and developing inappropriately. It seemed out of the ordinary compared to our experience with our other son and with other children that we had met. What was even better was we could get some early in- tervention and get started while he was still young. We were so glad to get it and get an early jump on this. I have heard from many families that they got their diagnosis when their child was older and they lost so much critical time for interventions. 272 Discussion Based on the findings of this study, rec- ommendations for practice were devel- oped that professionals may find useful in sharing a diagnosis of autism with a fam- ily. Table 4 offers a quick reference to the recommendations.

Recommendations for Practice Become Knowledgeable About Au- tism. Professionals need to be knowl- edgeable about the diagnosis, prognosis, and treatment of autism. Knowledge al- lows professionals to feel more confident in their abilities and decreases the likeli- hood that the parent will question the professional’s ability. Increased aware- ness of the diagnosis and treatments for autism may result in an earlier diagnosis, which, in turn, will allow the child to re- ceive services at a younger age. Profes- sionals’ expertise in the area of autism makes parents more confident of the vi- ability of the diagnosis and the recom- mendations for interventions. Establish a Family-Friendly Setting. Families need to feel comfortable, be- cause the interpretative conference can be stressful for both professionals and parents. The room should include com- fortable chairs or tables. Families and professionals should be seated as an inte- grated unit, and provisions must be made for both the child and the parents to be comfortable. Having tissues nearby does not disrupt the flow of the meeting if par- ents become upset. Understand the Family’s Needs. Learning that a child has autism often has at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 38 a profound effect on the family (Selig- man & Darling, 1997; Turnbull & Turn- bull, 1997 ; Webber, Simpson, & Bentley, 2000). Professionals must provide infor- mation about autism that the family un- derstands and that allows the family to seek appropriate interventions. Each family is unique in their needs and per- ceptions of autism. It is essential that pro- fessionals obtain an understanding of these needs and perceptions so that they can tailor the interpretative conference to the family. This information influences how the diagnosis is presented, the type of information shared, and the order in which the information is shared. Impor- tant areas to consider are prior knowl- edge of autism, diagnosis first versus overview first, location of the child, and sharing scores. It is essential that profes- sionals determine what information the family would find most useful. Use Good Communication Skills. The diagnosis should be presented clearly in language that parents under- stand. In addition, professionals should use reflective listening and other nonver- bal communication skills to put parents at ease. The interpretative conference should not be rushed and should be as relaxed as possible. Provide a List of Resources and In- terventions. Providing a list of inter- ventions and community resources is es- sential because it assists families in quickly obtaining access to services. Given the variety of interventions avail- able for children with autism, it is not surprising that parents want professionals to help them locate appropriate treat- ments for their child. Resources should be accurate and include phone numbers or the name of the individual(s) to con- tact. Although many professionals warn against giving specific interventions, rec- ommended treatments should be as spe- cific as possible based on the information obtained during the evaluation. Addi- tionally, prioritizing interventions is use- ful because it helps families determine which interventions are the most impor- tant to pursue. Provide Follow-up. The importance of follow-up with families cannot be overemphasized. Parents may be so over- whelmed at the interpretative conference that they stop listening to the profes- sionals. As a result, they miss important information. Similarly, after parents have had the opportunity to consider the di- agnosis and recommendations, they may have additional questions. Professionals can provide follow-up with a phone call or letter a few weeks after the interpreta- tive conference. When providing follow- up, professionals should help families by answering questions, providing addi- tional information, and assisting them to access interventions. Discuss Prognosis. Parents want in- formation about their child’s future de- velopment. Although professionals can- not predict the future, they should share their thoughts regarding the prognosis for children with autism. Although the child might always exhibit characteristics associated with autism, with intensive early intervention, improvements can be made. Provide Hope. Professionals must impart a sense of optimism to families about their child’s future. This optimism assists families in confronting the diag- nosis and obtaining interventions for their child. Hope gives families the mo- tivation to continue tackling the difficul- ties that often arise as a result of the char- acteristics and behaviors associated with autism. Hope can be provided to families by discussing the child’s strengths and likelihood of improvement in the future with the implementation of appropriate interventions. , . Recognize That It Is Not Unusual for Professionals to React to Giving a Diagnosis of Autism. Based on the re- sults of this study, it is apparent that giv- ing a diagnosis of autism elicits many negative reactions from professionals. Al- though it is expected that hearing a di- agnosis of autism is difficult for families, it is important to consider the difficulty that professionals experience when giv- ing the diagnosis. Questioning of one’s abilities, nervousness, increased heart rate, and quickened breathing are com- mon. Professionals need to be aware of the difficulty and realize that these reac- tions are not unusual. However, these re- actions must not be allowed to have a negative effect on the interpretative con- ference because they may influence how parents accept the diagnosis. Limitations Recommendations are based primarily on information provided by mothers who were married, White, and from one of the wealthiest counties in the nation. Even though attempts were made to re- cruit mothers and fathers from a variety of backgrounds, few families from cul- turally diverse and low-income homes chose to participate. Similarly, single- parent families, foster families, adoptive families, and same-sex parental relation- ships were not represented in this study. As a result, this study does not provide information about how fathers or fami- lies from a variety of parental relation- ships, cultures, and socioeconomic levels would react to learning that their child has autism. Furthermore, information about the severity of the child’s disability was not available. The severity of the child’s disability could influence families’ perceptions of a diagnosis of autism. Next Steps There is a need for further research to gain a better understanding of profes- sionals’ perceptions of the importance and utility of educational and medical de- finitions of autism. This information will help professionals clarify who is responsi- ble for giving diagnoses and will assist families in locating funding for interven- tions. In addition, perceptions and reac- tions to the diagnosis of autism need to be explored for different cultural, ethnic, socioeconomic, and family configura- tions. Such information would be useful in developing an inventory to help pre- dict families’ perceptions of autism and their needs and reactions to the diagno- sis. Such information could assist profes- sionals in addressing the recommenda- at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 39 tion for understanding the family’s needs. Professionals identified three different groups of parents (i.e., suspecting autism, suspecting a disability other than autism, not suspecting any problem). Further research is needed to increase our understanding of why professionals are willing to state the diagnosis of au- tism clearly to some groups of parents and not to other groups. Families want to leave the interpretative conference with hope. Additional research is needed to learn how professionals can provide hope to families. Although professionals might be em- ploying many of the recommendations offered in the present study, many of the recommendations are not being imple- mented because of time and financial constraints at their work sites. Providing a comfortable setting, an adequate follow-up, and a list of interventions might require substantial changes in the allocation of money and time. For exam- ple, money is needed to create a com- fortable environment for families and children. This might include architec- tural and interior design changes or the purchase of interesting toys to occupy the child. Additionally, professionals must be given release time from daily responsibilities to provide follow-up ser- vices to families or to visit various com- munity resources and interventions. Pro- viding follow-up and visiting various programs is time consuming but impor- tant if professionals are to provide fami- lies with accurate interventions and assist families in obtaining the best services possible for children with autism. ABOUT THE AUTHORS Michal S. Nissenbaum, PhD, has an academic appointment in the Department of Psychiatry and a clinical appointment at the Develop- mental Disabilities Center at the University of Kansas Medical Center. Her current interests include working with infants, toddlers, and preschoolers with disabilities and their families and assessment and interventions for young children with autism. Nona Tollefson, PhD, is a professor of educational psychology and re- search at the University of Kansas. She cur- rently teaches courses in qualitative and quan- titative assessment. R. Matthew Reese, PhD, is director of training at the Kansas CEDDARS and the coordinator of psychology at the Devel- opmental Disabilities Center at the University of Kansas Medical Center. He holds academic appointments in the Department of Human Development and Family Life and the Depart- ment of Pediatrics. Address: Michal S. Nis- senbaum, Developmental Disabilities Center, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160-7340; e-mail: [email protected] NOTES 1SV1-Pϒ1-CE 2SV1-Pϒ3-O, SV2-Pϒ3-E 3SV1-OT2-B, SVI -SL2-Q 4SV1-PO1-N 5SV1-PO1-D 6SV1-Pϒ3-N 7SV1-PO1-AT, SV1-OT1-DM 8SV1-PO1-AK, SV1-PT1-R 9SV1-PO1-AK 10SV1-OT2-S, SV2-PT1-R 11SV1-OT1-M 12SV1-Pϒ1-AB 13SV1-FM7-K, SV1-FD2-Q SV1-FD1-BS, SV1-FM1-AR 14SV1-FM7-K, SV1-FM11-AC, SV1-FM4-AS 15SV1-FD2 -BQ SV1-FM10-J, SV1-FM15-AO, SV1-FM3-B, SV1-FM7-BX 16 SV1-FM2-X, SVI -FM4-AN 17 SV1-FM1-W, SV1-FM11-BV, SV1-FM2-H, SV1-FM7-ϒ, SV1-FM9-DF 18SV1-FM1-F, SV1-FM2-AW, SV1-FM8-D, SV1-FM11-F, SV1-FD1-D, SV1-FD2-N 19SV1-FD2-BQ SV1-FM10-J, SV1-FM15-AO, SV1-FM3-B, SV1-FM7-BX 20SV1-FM5-AW 21SV1-FM10-G, SV2-FM9-K 22SV1FM15-P 23SV1-FM3-X 24SV1-FM7-AA, SV1-FD2-BF, SV1-FM-7- BK, SV2-FM9-I, SV2-FM5-A, SV2-FM1-D, SV1-FD1-AV, SV2-FM11-A, SV1-FM7-AQ 25SV1-SL2-AR, SV1-Pϒ2-AV, SV1-SL3-M, SV1-SO1-AL, SV1-PO1-BH, SV2-Pϒ3-J, SV2-Pϒ2-K,SV3-SL2-R, SV1-PT1-E 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SV2-FM7-N, SV2-FM13-G, SV2-FM5-K, SV2-FM11-V, SV2-FM15-K 126SV2-FM2-J, SV2-FM13-Q 127SV1-Pϒ1-AR, SV1-FM11-K, SV2-FM11- H, SV2-FD1-S, SV2-FD-F, SV2-FM1-AB, SV2-FM1-AB, SV2-FM6-L, SV3-SL1-M, SV3-SL3-B 128SV1-OT1-DJ, SV2-FM4-N, SV2-FM7-Q, SV2-FM9-AC, SV2-FD2-K 129SV2-FM13-N, SV2-FD2-M, SV2-FM12-I, SV2-FM15-L, SV1-OT2-A 130SV2-FM1-U, SV2-FM2-D, SV2-FM5-X, SV2-FM6-U, SV2-FM15-Q, SV2-FD1-Z, SV2-FD2-K, SV3-OT1-J, SV3-PT1-I, SV3- SO1-H 131SV2-FM1-T, SV2-FM5-W, SV2-FM11-ϒ 132SV3 -Pϒ3-P, SV3-OT2-P, SV3-Pϒ2-K, SV3-OT1-J, SV3-POI-1, SV3-Pϒ1-J 133SV1-OT2-B, SV2-Pϒ1-BO, SV1-SL1-DX, SV1-PO1-C, SV1-OT1-BU 134SV1-OT1-EP, SV1-PO1-AS, SV1-SL1-DW 135SV2-SL1-L, SV2-Pϒ1-O, SV2-OT2-AC 136SV2-Pϒ1-AX, SV2-SO1-E, SV2-OT2-AD, SV2-OT1-FS, SV2-SL3-AL, SV2-PT1-V, SV2-SL1-EC 137SV1-SL1-AE, SV1-Pϒ1-BQ, SV1-SL3-P, SV2-PT1-U, SV2-Pϒ2-U, SV2-SL1-N, SV2- Pϒ1-Q SV2-OT2-AA 138SV1-SL3-AN, SV1-SO1-CF, SV1-OT1-A, SV2-PT1-T 139SV2-Pϒ2-V, SV2-SO1-F 140SV2-POI1-V, SV2-SL2-L 141SV2-OT2-Z 142SV1-FM15-N, SV1-FM12-AE, SV1- FM11-E, SV1-FD2-J, SV1-FD1-M, SV2- FM11-E 143SV3-Pϒ3-D, SV3-SL1-P, SV3-Pϒ2-B, SV3- OT1-L, SV3-PO1-K, SV3-SO1-K 144SV3-OT2-A, SV3-SL3-L 145SV3-PT1-A, SV3-Pϒ1-M, SV3-SL2-O 146SV3-OT1-K, SV3-Pϒ1-N, SV3-SL3-M 147SV3-PϒS-B, SV3-SO1-A 148SV3-Pϒ3-E, SV3-PO1-A 149SV3-OT2-C, SV3-Pϒ2-A, SV3-SL3-K 150SV1-FM4-K, SV2-FM15-S, SV2-FM11-R, SV2-FM6-V, SV2-FM1-AE, SV2-FD2-L, SV2-FM5-S 151SV2-FD2-L 152SV1-OT1-BG 153SV1-SL1-DA 154SV2-FM6-X, SV2-FM9-X, SV2-FM14-R, SV2-FD2-H 155SV2-FD2-AN, SV2-FM1-AM, SV2-FM5-V, SV2-FM11-W, SV2-FM12-N, SV2-FM13-X, SV2-FM15-V 156SV2-FM2-N, SV2-FM4-P, SV2-FM5-O, SV2-FM7-V, SV2-FM10-M, SV2-FM11-N, SV2-FM13-K, SV2-FM15-P 157SV2-FM2-N, SV2-FM4-P, SV2-FM5-O, SV2-FM7-V, SV2-FM10-M, SV2-FM11-N, SV2-FM13-K, SV2-FM15-P 158SV1-FM14-C, SV2-FM6-R, SV2-FM12-O, SV2-FM14-J 159SV1-FM14-C, SV2-FM12-O 160 V2-FM14-J 161SV3-Pϒ2-M, SV3-OT2-J, SV1-OT2-BJ, SV3-Pϒ3-I, SV3-SO1-D, SV1-OT2-1, SV3- Pϒ3-W 162SV3-Pϒ3-I, SV3-SO1-D 163SV1-OT2-I, SV3-Pϒ3-W 164SV1-Pϒ3-ϒ, SV3-Pϒ3-J, SV3-PT1-E, SV3- Pϒ1-F, SV3-SL2-G 165SV3-SL1-F, SV3-Pϒ2-G, SV3-OT1-F, SV3- PO1-E 166SV2-FM2-O, SV2-FM4-Q at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 41 167SV2-FM6-S, SV2-FM15-D, SV2-FM14-K, SV2-FM11-O, SV2-FM13-L, SV2-FM9-V, SV2-FM7-F, SV2-FM4-Q SV2-FD2-I, SV2- FM5-P, SV2-FM1-G, SV2-FM10-N, SV2- FM12-Q 168SV1-FM5-BJ169SV2-FM5-P 170SV1-FM14-AI, SV1-FM15-AQ SV2- FM10-O, SV2-FD2-J, SV2-FM6-T 171SV1-FM12-R, SV2-FM2-R, SV2-FM7-G, SV2-FM5-Q 172SV1-FM11-AI, SV2-FM11-P, SV2-FM14-L 173SV1-FD2-BA, SV1-FM3-AV, SV1-FM4- BR, SV1-FM7-AG, SV2-FM2-C 174SV1-FD1-AH, SV1-FM7-CX, SV1-FD1-W, SV1-FD2-BG, SV1-FM10-AD, SV1-FM15- X, SV1-FM4-BK, SV1-FM5-AH, SV1-FM6- AC, SV2-FM7-R 175SV1-OT2-AO, SV1-PO1-AF, SV1-Pϒ2-V, SV1-SO1-BE 176SV1-Pϒ2-AZ, SV1-OT2-AD, SV1-SO1- BK, SV2-OT2-E 177SV2-FM15-I, SV2-FD2-G, SV2-FM14-M, SV2-FM1-AH, SV2-FM7-U, SV2-FM10-L, SV2-FD1-V, SV2-FM4-G 178SV1-FM4-CF, SV1-FM7-V, SV1-FD1-AS, SV1-FM5-AO, SV1-FM6-AB, SV2-FM4-J, SV2-FM9-Q, SV2-FM1-M, SV1-FM2-AT 179SV1-FM10-C, SV1-FM5-Q, SV1-FM4-CH, SV2-FM11-M, SV1-FD1-BE, SV1-FM14- AN, SV1-FM2-AR, SV1-FM7-CI 180SV1-FM5-BG, SV2-FM4-F 181SV1-FD2-AZ, SV1-FM2-AO 182SV3-SL3-J, SV3-SL2-N, SV3-PT1-J, SV3- Pϒ2-L, SV3-SL1-N, SV3-OT2-P, SV3- Pϒ3-Q SV2-Pϒ2-G 183SV3-SL1-N 184SV2-FM6-H, SV2-FM9-M, SV2-FM2-K 185SV2-FM13-N, SV2-FM1-V, SV2-FM11-U 186SV1-FM6-AI, SY2-FM9-N, SV2-FM13-F 187SV2-FD1-N, SV2-FM10-J, SV2-FM1-R, SV2-FM6-G 188SV1-FM1-G, SV1-FD2-V, SV2-FM6-AJ, SV1-FM8-O, SV1-FM13-Q, SV2-FD1-P, SV2-FM10-F, SV2-FM9-AA, SV2-FM13-O, SV2-FM1-W, SV2-FM6-W 189SV1-FM13-AJ, SV1-FM15-AJ, SV2-FM2- L, SV2-FD1-M, SV2-FD2-E, SV2-FM5-J, SV2-FM11-G, SV2-FM12-F, SV2-FM14-F, SV2-FM15-N 190SV2-FD1-O, SV2-FM6-E, SV2-FM14-G, SV2-15-F, SV1-SL3-CI, SL1-OT1-CV, SV1- OT2-AV, SV1-PO1-AG 191SV1-I-PT1-D, SV1-I-Pϒ1-V, SV1-Pϒ3-D, SV1-SL2-T, SV1-SL3-A, SV2-SL3-H 192 V1-PT1-Z, SV1-SL3-O, SV1-Pϒ1-D, SV1- OT2-G 193SV1-SO1-AK, SV1-SL3-L, SV1-Pϒ1-W 194SV1-SL3-R, SV1-SL1-V, SV1-Pϒ3-M, SV1- Pϒ2-AN 195SV1-PO1-W, SV1-Pϒ1-M, SV1-Pϒ3-ZT, SV1-SL1-I, SV1-SL2-AD, SV1-SL3-T, SV1- OT1-S, SV1-SO1-AF 196SV1-Pϒ1-H, SV1-OT1-N, SV1- Pϒ2-H, SV1-Pϒ3-C, SV1-SL3-Q SV1-SO1-Z 197SV1-Pϒ1-L, SV1-Pϒ3-A, SV1-OT1-T, SV1- SL1-J, SV1-SL3-ZX 198SV1-Pϒ1-K, SV1-Pϒ3-ZS, SV1-SL2-1, SV1- L3-I, SV1-SO1-O 199SV1-Pϒ1-G, SV1-PT1-H, SV1-SL2-ϒ 200SV1-SO1-AG 201SV1-PO1-U 202SV1-Pϒ2-L, SV1-SL1-EA, SV1-SL3-G 203SV1-SL1-N 204SV1-Pϒ2-J205SV1-PT1-ZZ 206SV1-PT1-G, SV1-SL2-AC, SV1-SL3-B 207SV1- Pϒ2-A, SV1-Pϒ3-G, SV1-SL3-D, SV1-PO1-P 208SV1-FD1-O, SV1-FM9-CV, SV1-FM4-I, SV1-FM3-AT, SV1-FM13-N 209SV2-SL3-D, SV2-SL2-A, SV2-Pϒ2-E, SV2- PT1-A, SV2-SL3-B, SV2-OT1-A, SV2- OT2-A 210SV2-SL3-A 211SV2-PT1-B, SV2-SL3-C 212SV2-Pϒ3-A 213SV2-PO1-A, SV2-SL1-A 214SV2-PO1-B 215SV2-Pϒ2-A, SV2-OT1-AD 216SV2-Pϒ1-A, SV2-Pϒ2-C, SV2-Pϒ3-C, SV2-OT2-B, SV2-SO1-A 217 SV2-SO1-A 218 SV2-SL3-N, SV2-Pϒ2-B, SV2-Pϒ3-F 219 SV2-Pϒ1-C, SV2-Pϒ2-D, SV2-PT3-H 220 SV2-SL3-N, SV2-Pϒ2-B, SV2-Pϒ3-F 221 SV2-SL3-N 222SV1-PT1-K, OT2-R, SV1-SL2-B, SV1-SO1- CC, SV1-PO1-AO 223SV1-OT2-H SV1-PO1-ZZ, SV1-SO1-BR, SV1-SL1-BO, SV2-Pϒ1-K 224SV1-OT2-L, SV2-SL3-AC, SV2-OT1-C 225SV1-OT1-BZ, SV1-Pϒ2-K, SV2-OT1-R, SV3-SL3-I 226SV1-PO1-F, SV1-SL2-AH, SV1-OT1-CG, SV1-SL1-F 227SV1-PO1-E, SV1-SL3-W, SV1-OT1-DF, SV1-Pϒ1-AF, SV1-SL1-E, SV1-SO1-CK, SV1-OT2-M, SV2-OT1-K 228SV1-OT1-DF 229SV1-OT2-J, SV1-SL3-BV, SV1-Pϒ1-ZZ, SV1-SL1-Q 230SV2-PT1-B, SV1-OT2-AS, SV1-PT1-B 231SV1-SL3-ϒ, SV1-SL1-I, SV1Pϒ2-D, SV2- OT2-F, SV2-Pϒ11-BE 232SV1-OT1-X, SV1-SL1-D, SV1-Pϒ1-D, SV2-OT1-L, SV2-Pϒ1-I, SV2-OT2-O, SV2- Pϒ3-L 233SV1-Pϒ1-A, SV1-Pϒ2-F, SV2-OT2-Q 234SV1-Pϒ3-AE, SV1-PT1-AA, SV1-OT2-N, SV1-SL3-CK, SV2-OT1-S, SV2-SL2-J, SV2- SL1-H, SV2-PT1-L 235SV1-SL2-AS, SV2-SL2-I, SV3-SO1-E 236SV1-SL1-B 237SV2-PO1-G, SV2-OT1-M, SV2-Pϒ3-M 238SV2-SL3-AB, SV2-Pϒ2-AC 239SV1-SL3-CL, SV3-OT2-K, SV3-OT1-G, SV3-PT1-F, SV3-SL3-G 240SV2-Pϒ2-N 241SV1-PT1-V, SV1-Pϒ2-AH, SV2-Pϒ3-K, SV1-SL3-CP, SV2-SL1-J, SV1-PT1-O 242SV1-OT1-DB, SV1-SL3-CJ, SV1-Pϒ2-B, SV2-PT1-K, SV2-Pϒ3-O 243SV1-SL1-BI, SV1-SL2-AQ, SV2-OT1-J, SV2-SL2-E 244SV1-PT1-AD, SV1-OT2-AX, SV1-Pϒ3- AA, SV1-OT1-DE, SV1-Pϒ1-BB, SV1-SL1- BM, SV2-PT1-N, SV2-Pϒ2-M, SV2-PO1- H, SV2-OT2-P, SV2-Pϒ3-N 245SV1-PO1-O, SV1-Pϒ2-AO, SV1-SO1-CA, SV3-Pϒ2-J, SV3-OT2-T 246SV3-OT1-I, SV3-OT2-M, SV3-SL1-K, SV3- PT1-H, SV3-Pϒ1-1, SV3-Pϒ3-A 247SV3-Pϒ3-O, SV1-PT1-X, SV1-SL2-Aϒ 248SV3-OT2-R, SV3-SL2-J 249SV3-OT2-S, SV3-SL1-L, SV3-Pϒ2-O, SV3- PO1-L 250SV1-PO1-BG, SV1-SL1-BT, SV1-SL2-S, SV1-OT1-R, SV3-Pϒ2-N, SV3-SL2-L 251SV1-OT1-Z, SV3-PO1-H 252SV2-OT1-W, SV2-OT2-AH, SV2-Pϒ2-X 253SV2-SO1-G 254SV3-Pϒ1-G, SV3-Pϒ2-H, SV3-PO1-F, SV3-Pϒ1-G, SV3-SL2-H 255SV1-SO1-AA, SV2-PO1-F, SV3-SL2-J 256SV1-SO1-AA 257SV1-FM1-J, SV1-FM5-AX, SV1-FM9-BM, SV1-FM13-U, SV1-FM14-I 258SV1-FM1-H, SV1-FM4-AO, SV1-FM5- AR, SV1-FM7-AN, SV1-FM8-F, SV1- FM10-I, SV1-FM11-AK, SV1-FM12-C, SV1-FM14-F 259SV1-FD1-AF, SV1-FM2-C, SV1-FM11-R 260SV1-FM1-ϒ, SV1-FM3-L, SV1-FM4-AK, SV1-FM5-CF, SV1-FM7-C, SV1-FM12- AH, SV1-FM15-O 261SV1-FM4-CD, SV1-FM7-AZ 262SV1-FD1-I, SV1-FD2-M, SV1-FM1-AB, SV1-FM2-M, SV1-FM3-C, SV1-FM4-C, SV1-FM5-AE, SV1-FM7-I, SV1-FM8-AC, SV1-FM9-ϒ, SV1-FM12-L, SV1-FM13-X, SV1-FM14-ϒ, SV1-FM15-V 263SV1-FM9-Q, SV1-FM15-BF 264SV1-FM3-M, SV1-FM7-BE, SV1-FM9-AJ, SV1-FM15-AI 265SV1-FM2-T, SV1-FM4-G, SV1-FM7-CC 266SV1-FM4-Aϒ, SV1-FM2-V, SV1-FM15-T, SV1-FM1-AS, SV2-FM1-E, SV2-FM6-N at FLORIDA INTERNATIONAL UNIV on June 16, 2015 foa.sagepub.com Downloaded from 42 267SV1-FD1-AN SV1-FD2-O, SV1-FM1-AD, SV1-FM2-ϒ, SV1-FM3-AF, SV1-FM4- AJ, SV1-FM11-AN, SV1-FM13-G, SV1- FM14-O, SV1-FM15-AR 218SV1-FD1-AG, SV1-FD2-U, SV1-FM3-AB, SV1-FM5-AM, SV1-FM7-CA, SV1-FM8-K, SV1FM11-AB, SV1-FM12-AJ, SV1- FM14-H, SV1-FM15-AK, SV2-FM12-E, SV2-FM10-D, SV1-SL2-H, SV1-Pϒ3-AN, SV1-POI-Zϒ 269SV1-FM11-AM, SV1-FM5-Aϒ, SV1-FM9- CG 270SV2-FM2-H, SV2-FM11-F, SV2-FM12-D, SV2-FM13-E, SV2-FM15-J 271SV2-FD1-L, SV2-FD2-D, SV2-FM7-M, SV2-FM11-F 272SV2-FD2-D REFERENCES American Psychiatric Association. 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