 Good morning. I'm very excited to be here with all of you. And I want to welcome you to our 17th annual symposium. I'd also like to recognize all the organizations that have come that we've, this is, I think this is our six or 70th year we've done this for networking. So I really do encourage you to take the time and opportunity during lunches and the breaks to network them. I also know we have a couple of the high school students in the audience today. Every year we do this, we have scholarships for high school students, which I think is a great program that we have. And I think that they have a very, one of the hardest challenges is taking what they've learned today and conveying that to their peers in a non-judgmental way. So my brother John was 23 years old when he passed away. And over the years as I have transitioned through my life, now as a husband versus a husband and now as a father of two girls who will probably be at a four and two who will, who think they're adolescents, I can't help but wonder what John's life would have been like today. And although I believe that this symposium, even though it bears his name, I believe it has come to represent all the families that struggle with mental illness, drugs, violence and other critical issues that affect our youth. My family and I are incredibly gratified to have seen this symposium in memory of John, develop over the years into the widely attended event of today. And as difficult as our loss continues to be, the community coming together is a very healing force. We continue to be impressed by the diversity of the attendees, the clinicians, the counselors, educators, parents and public safety officials that have attended the symposium over the years. The post symposium comments and the number of attendees that return year after year really tell me that we are making a real impact on our community. Our deepest appreciation goes out to all those who plan the details of each annual symposium. And we are particularly grateful to George Jaro for his leadership and the advisory committee. You know, these great speakers, they don't just magically appear. They are contacted through months of emails and hard work. I have never met a more passionate group of people that sit on our board and I'm honored to be associated with them. Though of course the tireless volunteers who help do the logistics of the event and also the Dominican Foundation, which is the philanthropic arm of the symposium, and with their support we are able to, we've established the Johnny Natterney Endowment Fund. And we could not continue our symposiums without their support. But most importantly, I want to thank all of you for attending and your devotion to your work. You know, for nearly two decades the symposium has expanded on topics ranging from suicide to autism. And it is your continued quest for knowledge that allows us to bring you such wonderful speakers year after year. So in summary, I want to thank all of you for being a part of this symposium today and hope you find that the information presented will be beneficial in your work and help you will come to join us year after year. And so in the words of my mother, these symposiums are a wonderful legacy and give a real sense of purpose to John's life. Thank you. And now, as my distinct pleasure to introduce Dr. Grampashe, Dr. Grampashe has devoted over 30 years to the study and treatment of autism spectrum disorder and is recognized as a leading expert in the field. Dr. Grampashe earned her PhD in psychology from the University of California Los Angeles and she is a licensed psychologist in California, Texas and Arizona as well as a board certified behavioral analyst, Dr. Grampashe is a pioneer in the field of autism treatment and recovery and also a very active member of the autism community. With endless endurance and a resilient spirit, Dr. Grampashe leads educational efforts for parents, teachers and health care providers. It takes part in the conferences and joins and walks and other efforts to promote awareness of autism spectrum disorder and the resources available to which she treats. Dr. Grampashe. Good morning. Thank you very much. What a wonderful introduction. Let me begin by thanking all of you for coming and thanking the Nadirni family. Did I pronounce that right? I hope. And I don't know if it's two families, the Calciano also or is it the second last name, but I want to thank the families because I think this is a fantastic thing they've done. Very sad thing that happens to their son but look at what they've turned that into. It's fabulous and it's amazing what you are doing for the state and for this region and the awareness that you're bringing to all of the professionals in this room and hopefully helping all of the families who need that awareness. It isn't uncommon to have children who are undiagnosed. It's pretty common and I have contact with a lot of families who struggle because their children reach a certain age and start to show problems that no one knows what to do with simply because they were not diagnosed at the right time. So this is a fantastic thing. I am very sad that I won't be here for the afternoon speakers because they are fantastic and I will definitely be asking to see a video of this because I'm very excited to hear about their talks as well. As I was walking in I saw all the beautiful presentations that have happened here and I wanna thank all the panelists and people who've worked very hard to make this conference so wonderful. It's not easy to bring 400 people together and give them a nice presentation. I hope that you will enjoy my presentation. I am primarily a clinician. I have 32, well now it's 36 I think clinics in the United States where we treat children, adolescents and adults with autism. I started in this field in 1978 at UCLA and of course we did a lot of research developing what behavioral interventions should be done for individuals with autism and I do a lot of research right now as well. My primary goal before I retire is to try to sub phenotype autism, to find subtypes of autism clearly from a behavioral perspective because my goal is to try to make the treatments more efficient and more pertinent to each individual rather than trying to do sort of a cookbook of interventions for each person. So today what I'll be doing is, let's hope this works. Yeah, so we'll be talking first about the diagnostic manual changes. I was asked to put into place some of the review of DSM-5 and what we see now as sort of the definition of autism as we see it as clinicians. I understand most of the people in this room are professionals, correct? And not parents, okay. Are there parents in this room? Okay, wonderful. Thank you. And then I'm gonna talk about sort of my treatment approach and then of course ABA and try to give an overview of what applied behavior analysis is. Applied behavior analysis is a broad term. It is important to kind of know what this is because it is the single intervention that is right now covered in about 40 states through medical insurance. So it's a very effective intervention and a lot of times people misunderstand what it is. So I'll try to give some, a broader view of that. It is 920 and I'm gonna have to go fast because I always go over and George asked me to not go over today. So I'm gonna try to do that. So we'll quickly take a look at DSM-4's definition, the diagnostic manual. And the reason I wanna do that is because I want you to be able to see some of the changes that DSM-5 came into place last year, the diagnostic manual that we used for diagnosis changed last year. From the time that I've been treating autism it has changed four times, which essentially tells me we don't really know what we're talking about. So the first, the diagnostic manual prior to this was in place since 1997 and in order to diagnose autism, you were looking essentially for six or more symptoms and the symptoms had to fall in three areas. Social deficits where you required two symptoms, things like eye contact being limited, the individual is not sharing information or showing you something that's on their mind and then they lack emotional reciprocity. That would be one content area. The second would be communication. There would be a delay or deficit in the area of communication. That could be language, pretend to play oddly is classified under a form of communication and of course a lot of individuals with autism have delays in conversation or that verbal communication. And then of course the third area was stereotypic repetitive behaviors and if any of you know individuals with autism you would know that these vary greatly. So these could include things like having a routine or being preoccupied with something or intensely focusing on the details of an object or having motor repetitive motor mannerisms such as hand flapping and so on. Now, oops, okay. The DSM-4 also had other classifications in the overview chapter of pervasive developmental disorders. We had autistic disorder. We also had Asperger's syndrome and we had PDD-NOS which is pervasive developmental disorder not otherwise specified. We also had RETS disorder and we also had disintegrative disorder which are both all gone now. But it's important to point out that these have in the new DSM they've all been merged and so I'll talk about that in a minute. But up till last year we would diagnose individuals with Asperger's who had social deficits and who had some of the stereotypic or repetitive sort of routine type behavior but they didn't really show a communication deficit per se. Although I will say that most individuals that I see with Asperger's do have a communication delay or disorder. It's just not a language delay. They just have difficulty more in abstract communication like social speech and so on. And of course PDD-NOS was sort of the catch-all category for anyone who didn't have six symptoms or more but they definitely showed some social delays, some communication delays and the persistence of those repetitive behaviors. Now we look at DSM-5 and this is I have to say, as I said I've seen four other changes to the diagnostic manual. I would say this is probably the most pervasive change I've seen over the years. It's a huge change for us. And I'm not sure yet if I like it, we'll see how it impacts the world. But instead of three areas we are now looking at two primary areas. The first criteria is persistent deficits and social communication and social interaction. So they've kind of put all of that in one and taken out a requirement of delays in language that is no longer a requirement. You can imagine that if you merge Asperger's with autism then you have to remove the language delay component because individuals with Asperger's generally don't have a language delay. So what we're saying in criterion A is you have to have a deficit in social emotional reciprocity. I'm gonna give some examples. I'm also gonna show a bunch of videos. So I'll go a little bit faster on the technical language. There are deficits in nonverbal communicative behaviors. For instance, the child will stand much closer than he should, will avoid eye contact, will maybe have physical contact when it's not appropriate. And of course this will lead to deficits in developing and maintaining relationships. Then criterion B, we have those restricted repetitive patterns of behavior but now we have to have two whereas up till now one symptom in the stereotypic behaviors was enough. Now we need two. Stereotypes or repetitive speech. This is children sort of most of the time repeating. This could be echolalia we refer to it where they're echoing exactly what they've heard somewhere. It could be just sounds that are jargon like ee, that sort of thing where they're repeating sounds. And it could be delayed echolalia or an advanced form of it where the individual is repeating out of context the things they've heard in a movie for instance. And in my mind of course all of this is pretty functional but we'll get to my opinion next. Okay and then we have excessive adherence to routines. A lot of the children that I see have this type of issue where basically they will be upset if you drive them a different direction, if you put their clothes on in a different order and all sorts of things will disturb their child. Which I tend to go on a lot of tangents because I have been in the world of autism for over 35 years so I have so many opinions about every aspect of autism. On this one on the whole issue of restricted repetitive patterns of behavior in my opinion these behaviors are either, they're very very much related to sensory deficits which I'll talk about in a second. But in a lot of cases they are also just a sign of anxiety they're very similar to obsessive compulsive behavior. So I will talk about that a little bit. And then we have, maybe I should be pointing that way, yes, highly restricted fixated interests that are abnormal and intense to your focus. These are our kids who will talk about the same subject. They'll endlessly talk about something that they wanna talk about and not anything else. For example, and then finally hyper or hypo reactivity to sensory input. And yay this is the first time ever that sensory is now mentioned in the diagnostic manual and that's a thrilling accomplishment. So I'm very happy that finally came into place. Of course like all other disorders it's important that these symptoms must be present in early childhood. Children's disorders usually require that. And of course the symptoms must impair everyday functioning. And I find it really kind of funny that this is listed as a criteria. This is the general rule in regards to any disorder in the diagnostic manual. It's not really a disorder unless it makes you non-functional but we need to mention that this is a requirement. So the main differences are we now have two domains to look at, the social and the repetitive behaviors. There's a very significant shift from categories of behavior to sort of more of a dimensional approach. We now require two repetitive types of behaviors and language delay is not a necessary component. This is, you know, and please remember that I would say probably all of the children that I diagnosed with autism do have a language delay and it would only be individuals with Asperger's type ASD that don't really have a language delay when they first begin. And now we have also the specifiers which I'm gonna talk about in a minute on the diagnosis and we also now speak about the level of severity. And these are pretty important factors. So the specifiers we now have, the child will receive a diagnosis which talks about the etiology or brings in the etiology of the disorder. For instance, we can say ASD with Rett syndrome or ASD with Fragile X. So that is one aspect of the new diagnosis. Or we can add a specifier or modifier indicating another factor that's important. For instance, ASD with Tonic-clonic seizures or with intellectual disabilities. Isn't that amazing? You know, I remember when I was first training on the SM3 or 2-3, it said it was, we believed at that time that about 80 somewhat percent of individuals with autism also had mental retardation. And of course it took a long, long, long time to realize that isn't really true. We're just using verbally loaded tests with our kids and so of course they show mentally retarded but in fact they're actually, some of them are incredibly intelligent. And once we started using non-verbal tests of IQ, we realized, oh, some of our kids are past the genius level. So it's fascinating that now we've brought this back as a subtype or as a specifier. And then of course, early history is now specified. So we can say, for instance, ASD with onset before 20 months and loss of words. And some of these things are pretty important because once you start looking back at kind of the demographics and the development over time of autism, it's really important to have this information about an individual. In fact, for me, it's actually a very important prognostic factor when I know when the loss of speech occurred, for instance. ASD with onset before 32 months and loss of social skills. So these are the types of things we write now in the diagnostic when we do a diagnostic review and or ASD with no clear onset or no loss. And of course you have the subtype ASD Asperger's type. We are still instructed to honor diagnoses of the past such as Asperger's. People with Asperger's don't have to go back and get read diagnosed, obviously. But the single diagnosis right now is just autism spectrum disorder. And so we have to specify all of these things. And the most important change is the level of severity. Now the levels of severity go based on how much supports the individual needs. So for example, if you require some support in each area, for instance, social communication, then you would be having a level one, which indicates that you with some support, some significant delays in social communication. Or if you're at a level two and require significant substantial support, or level three would be very substantial support in each of those two areas, okay? So a correct diagnosis or an accurate way of writing a diagnosis on a report, believe it or not, is something like this. ASD, with intellectual disability, onset before 36 months with a loss of language, requiring support for social communication and very substantial support for restricted interests and repetitive behaviors. It's a little bit crazy, but realistically that's how you're supposed to diagnose. Up till now, we didn't, and you can see that it's very valuable, obviously. It gives you a ton of information, whereas in the past we would just have Autistic Disorder 299.00. And now we have a lot more information about an individual just from the diagnosis, okay? So having said all that, I will now put away my sort of, you know, standard, legitimate hat and talk to you about how I feel about autism. And what does ASD actually look like? When I see children, and I've seen thousands of children, adolescents, and adults with autism over the years. And what does it look like? So there's, most of the individuals with autism will have definitely a delay in language. And even those who are very, very high functioning will have a delay in advanced pragmatic language. There's generally very limited eye contact. If there is eye contact, it decreases the minute you request it. There's social behavior is limited. So most of the children, when they first come to me, are very isolated, very interested in just doing their own thing, playing with their own toys, interacting with some objects rather than with some person, not playing with others, not asking for help. This is a very big factor. And there's a lot of different types of stereotypical behavior. For instance, repetitive behavior is lining up of objects, opening, closing the door, turning on and off the lights, many inflexibilities and adherence to specific routines. And so those are the things that give me the ability to count enough symptoms that I need for the diagnosis. But what else is there? What do we see in our children at the very, very beginning of intervention when they're very young, two or three? I'm currently diagnosing children as young as probably one and a half. I think the youngest child I've ever diagnosed was nine months old. And it was very, very obvious because the child was nonstop hand flapping and absolutely avoided eye contact even at nine months. So that is a very, very severe case, not necessarily the most common. But having said that, what are the things, and we have a room full of professionals here, so help me out. What do you see? What is the common belief about autism? What are some of the things that we're supposed to see? How about challenging behaviors? Don't most people believe that children with autism, tantrum and hit and they're aggressive and all that sort of stuff? Yes, a lot of the children have challenging behaviors. A lot of the adults have challenging behaviors. But you notice they're not part of the diagnosis. They have nothing to do with the diagnosis. So why do you think most of our individuals have challenging behaviors like tantrums and aggression and hitting and running and spitting and all sorts of things? Why do they do that? Yes, sensory challenges perhaps, that's right, will definitely lead to it. How about just frustration? How about it's their way of communicating? So as a behaviorist, the first thing is to believe and understand that challenging behavior is just a form of communication. And that's very, very key to behavioral intervention because the whole goal of effective ABA is to find out why is the person hitting, biting, being aggressive, why? What's the function? What is the reason? And most of the time it's just frustration and this is how they're communicating. Sensory sensitivities, obviously. And as I said, this is the first year that we have this now in the diagnosis. So many of my children have either, some form of dysregulation of sensory input. So either lights bother them significantly or they're completely obsessed with staring at lights in odd ways. Or sound disturbs them. One of my recovered children who's actually Asperger's, quite Asperger's, but he's very, very functional. And he says to me, when I was younger, it was really hard for me to listen to language because the more prevalent sound for me was things like doors opening and closing and creaking sounds in background were always much more prevalent than sounds of language. Which is really fascinating if you think about things like that, right? And I will go into kind of what I've learned from my kids and how they take in the world because that is, I think, very important to how we interact with them as professionals. And then, of course, medical illnesses. A large number of my children have, and I've done a lot of research on this. We actually, at Card Center for Autism, my company, we have a pediatrician on staff as well. So we gather a lot of data in regards to the co-morbidities that these children struggle with, particularly gastrointestinal issues that they have. I have children who, and I mention this, although I don't have the time to go into it in this speech, but it is one of those things that I'm passionate about because just as the family is bringing awareness, I wanna bring awareness to this. When you have a diagnosis of autism, it doesn't mean that all your other problems need to be ignored. A lot of children will come to me where their parents will say, oh, yeah, he has diarrhea 10 times a day. But they told me that's sort of common with kids with autism. And it has nothing to do with the symptoms of autism, right? It wasn't in the diagnostic criteria, but this is called diagnostic overshadowing. When you have a sort of more prevalent diagnosis, which is autism, people tend to ignore your other issues. How many people here know of children with autism who don't sleep? That's the sleep problem. Someone needs to deal with that. And it tends to be ignored. And yet if we don't sleep, we don't function. And we think it's okay for our kids to wake up every two hours. How about anxiety? How many people know kids who have anxiety? They have significant anxiety, yet no one really deals with the anxiety. So it's very important that, and I will go into this, that we don't just think of the symptoms of autism, per se, the ones that we use for diagnosis, but that we treat the whole child, the whole individual, and we look at all of the issues that they're experiencing. So from my perspective, when I look at autism, and I don't know how many of you read the article that came out yesterday, there was a publication yesterday that showed that the genetic sort of predisposition can be as, can have a variance or an influence as high as I believe 76% to the genetic component, which is actually pretty high, I had not thought of that. But then we all know that there are environmental factors that trigger the diagnosis. The very first child that I ever worked with in 1978 was an identical twin, and his brother did not have autism, which is very, very unusual. And we noticed with that child that there was a lot of, he was actually pretty severe and his brother was completely normal, which is very, very strange to see, very, very unusual. But as time goes on, of course, we all know the genetic composition changes is modifiable by the environment. There are so many environmental factors that are toxic to us right now. Forget about just autism. There's a lot of toxicity in the environment right now as many of you may know. And these with the studies that have been published show that a lot of individuals on the spectrum of autism also have other issues, for instance, high oxidative stress, low methylation, which means they're detoxifying from these toxins slower than we are. A lot of people ask me, how come we're all exposed to the same stuff but they have problems with it? Well, from my perspective, and this is my theory having read tons of literature and having seen lots of kids and talked to a lot of parents over 35 years, my feeling is that what's happening is that a lot, depending on when the environmental factor influenced you or triggered your symptoms, a lot of the children have various physical conditions such as inflammation in the guts and so on that will then influence how they, their sensory impact and how they learn. So for instance, if you have hyperperfusion or low blood flow to certain parts of the brain, you're actually going to develop over time different sensory abilities. And I strongly feel that the sensory ability, the sensory regulation of the children that I see impacts how they learn. After all, everything we learn is from through sensory input, right? It's visual, it's auditory and so on. I have children who, for instance, will not see an object when it's held up close but see it accurately when it's about four feet out. So, and as you know, many of you who are my age, we have three different visions, right? Our normal eyes, our distance eyes and our reading eyes. So you know that how you see the world impacts you, impacts your learning, impacts your experience of the world. If I'm disturbed by these lights, I'm not going to be looking up. Most of my life I'm going to be looking down and therefore learning quite differently. So what we generally do is in treatment, we first of all minimize exposure, which is a good thing anyway. We all do that with ourselves. Why are there so many whole foods now over the last 10 years? Isn't that interesting? We treat the underlying medical disorders, whether it's sleep or it's anxiety or whatever it is. We identify the individual sensory issues because that's my in to their learning. That's the way I can get in. Some of my kids won't learn at all verbally. If I give verbal instruction, it sounds like blah, blah, blah to them. But if I write it down, because it's a stimulus that's visually present in front of them, they will learn it. So it's important to identify the sensory deficits and skills of each person. And then of course we do behavioral interventions, teach new learning patterns. And when you do all of these things kind of in the right order and at the right intensity for the right length of time, it is possible to reduce and even eliminate symptoms. Okay. So I'm going to jump right in to ABA now. How much time do I have? 45 minutes, fantastic. So the Surgeon General back all the way in 1999 said, ABA is good, it reduces inappropriate behavior, it increases communication, learning, and social behavior. And there have been a ton of studies on the efficacy of ABA. I will scan through some of them pretty quickly because I want to kind of get to my own stuff. I was on this study, so this is, I find that I consider this part of my own stuff because this was one of the biggest studies in ABA and I actually treated these kids and worked with them. This was at UCLA, behavioral treatment and normal educational intellectual functioning. This was the first study that showed kids with autism can recover. And we had three groups of children. We had the experimental group, which was 19 children in our clinic, the autism project at UCLA, who received intensive treatment and then they received 40 hours of one-to-one therapy for three years, okay, and that's very intensive. And then there was control group one, which were kids also in our clinic and they received 10 hours a week for three years. And then there was control group two, which received 10 hours a week from another clinic at UCLA, the neuropsych Institute, which is now called Semmel Institute. Has that changed again or it's still Semmel Institute? And for three years, and they were receiving sort of a less defined, discrete, not so much of the same, of the level of structure that we were providing the kids. So there were three separate groups and of course the experimental group, 47% were considered recovered. And at that time, the testing that individuals were going through included IQ as well as normal placement in school and they had friends. So those were sort of the three criteria. And of control group one and two, 2% had met that criteria. So it was a pretty significantly large difference between the groups and it showed that intensity matters. It was very important and this is the publication. 40 hours for two or more years, 47% achieved average IQ and required no special ed. And then in 1993, one of my colleagues, John McCacken, followed up and looked at nine of those children who had recovered and eight of them at the age of 12 had maintained their gains. And the one child who had not was very, very close but didn't quite fit all the criteria. Glenn Salos a few years later looked at a group of children and found that with intensive, intensive always meaning above 25 hours. So 25 to 40 hours of intervention, 48% of his group reached average IQ, 34% of which had no support in regular education, 42% had no impairments in communication, 42% had no impairments in socialization. And 34% did not qualify for the diagnosis of autism according to the ADIR, which is one of the two gold standards for the diagnostic procedures. Again, later, Howard Cohen did a study, looked at three years of ABA and found that average IQ, 57% reached average IQ. And as you can see, about 30% had no support and about almost 40% did very well on the Vineland. Another replication, I can say this was one of my students. He did a replication in Norway where he found that 54% reached average IQ and so on. And another replication was in England. Bob Remington found that 25 hours for two years there were significant gains in language, intelligence, daily living, positive social behavior and no increase in parent stress. Just kind of interesting. It's pretty stressful. You have 40 hours of intervention in your house. Let me tell you, there's people in and out all the time. There was a replication in the Middle East showing that scores on a non-ASD range on an ADOS after treatment was 21% of the children here. The length of time on this study was lower. And then there was a study in the province of Ontario where 332 children were given ABA. 71% made significant gains. 11% reached the average range. So it was a pretty poorly controlled study because there were lots of different types of providers but still had pretty large effects. And essentially the conclusions of these outcome studies show that every published study demonstrated large treatment effects. So these are we're talking about big changes in the children who received intervention. These studies were done across research groups, university settings, community settings, and across continents. And the two main conclusions were that intensity matters. So if you do more than 25 hours, it is more effective. It is, that's what we now call a comprehensive program as opposed to a focused program. And if you do, and duration matters. So it has to be two or more years. So these are kind of the two caveats when we talk about ABA is that if you have a young child and you're shooting for trying to do a comprehensive program where you can actually assume that you're going to reach recovery, then you wanna be shooting for anywhere between 25 and 40 hours for two to three years, okay? I'm about to publish a paper that says, I was part of this, we picked 40 hours. It doesn't mean that you can't do 50, all right? We just picked 40 because that was so outrageous back in the 70s. And so now that's when you look at it and you think, why did we pick 40? And I emailed my colleague, Trish Smith, who's the only other person who was on that study with me who's still alive. And he said, I don't know. I think we did it just because it was so crazy to say 40 hours and it was like the equivalent of full time. So we're now going to publish on the fact that depending on the child's needs and severity and environmental factors, other things like illnesses, comorbidities, parents, is it a single mom, do they, do you have multiple children? Depending on what the issues are, you could keep going. And 40 should not be the upper limit. Okay, this is a study we just, we published a couple of years ago, Effects of Asian Treatment Intensity on Outcome. We looked at 245 children in our clinic and it just showed an accurate, it just showed it doesn't matter what age you are, the more hours you get, the more you will learn, okay, and you'll continue to learn. If you're 12, you're learning about the same rate of acquisition as if you're three. And this is very important because most people think maybe it doesn't work for older kids. It does, or for adults, it does. The only problem is there's more to learn, right? So whereas I take a two year old and I teach them a ton of stuff, by the time they're five and six, they can kind of merge into normal life. But if I take a 15 year old, there's so much that I still have to learn, teach now. There's so much delay that I'll never catch up. That's what the issue is. So this was published. And then this is another study we published which was I took 38 of my cases and reviewed their IQs and their adaptive behavior and showed the dramatic increases in pre and post testing on these kids. And this was published as well. I actually got a cool award for this. I actually made a film also called Recovered Journeys into the Autism Spectrum and Back. I think I made that in 2005 or so. And I recommend it. It's on Amazon if you're interested. It's a documentary and it is, it won a bunch of awards back then. It's kind of a cool film because it shows four children and their families and all of these families were told to either institutionalize or put their children in special ed. And you see the interviews of the parents and you will see those kids when they're two and three and then when they're 11, 17 and so on and you see them go through intervention and change from completely being autistic and going through the very beginning of ABA all the way through college and so on. So it's kind of cool to see that film. And I have, if you go online on, I have a, sorry that I'm plugging this but it's kind of an interesting thing. We follow our kids weekly. And so we have these various video programs on YouTube channels. One of them is called the A-word and it is a weekly chronicle of treatment. So it shows you every week how the child is progressing over the course of three years. And then another one is called Mission Possible which is about 20 families who show video and talk about their journeys from the beginning to the end. So those are kind of interesting things to see. So to summarize, ABA has been supported. It is what we do. It's what we do with autism right now and as I said it's about 40 states that have full insurance coverage unlimited for ABA. But before I move on, I wanna again say that in my opinion it is extremely important that this be done in an integrative way where medical treatment, where we're eliminating the triggers, we're stabilizing the child, whatever is causing, we're achieving health. I can't really ethically do 40 hours of therapy with a child who's not sleeping or has diarrhea 10 times a day. I can't do it. Even if I could, the child can't focus. So it's very important for me that the kids are healthy when we start treatment. Now of course it's important to develop and regulate their sensory input as we teach them new patterns of learning. Okay, are we doing okay? Because we're going into a whole different series of slides now. So a healthy child feels better, sleeps better and can obviously learn better. So we're gonna talk a little bit about what ABA is and then I'm going to show you videos of different kids so that you can see the different things we teach our kids. And I in fact have done this talk in eight hours so I'll do my best to cut it down. So ABA is based on the principles of operant conditioning which is sort of one of the areas of psychology and essentially it just says that human behavior is affected by events that preceded and events that follow it. And these are called antecedents and consequences. And if we can modify, to change these events we will change the behavior. So if we can modify the antecedent or we can modify the consequence we're gonna change the behavior, okay? It's really that simple. So in ABA we change behavior by changing antecedents and consequences. What's the behavior? Behavior is anything you do. What is an antecedent? It's what happened right before the behavior. What is the consequence? It's whatever happens after the behavior. How do we change behavior? Well, you tell me. If I want to, if I give someone a positive consequence what will happen to their behavior? It'll probably increase, right? I just rewarded you. You did something good, good job, very nice. Their behavior will increase. This morning as I was walking here on this gorgeous boardwalk down the street, on State Street there was some homeless person who asked for money and I gave them money and immediately several other people came up and asked for money. And I just thought to myself, I just reinforced that person, the others saw it and it was enacted, my reinforcement of one person acted as an antecedent for the others. So, and if you remove a positive consequence if I take away, if you do something and I take something good away from you what'll happen? Your behavior is called response cost or extinction. What happens is it'll decrease your behavior, right? And if I give you a negative, what's that called? That's called punishment, right? You get punished for something that you just did. You get a ticket for driving too fast. What happens? Your behavior goes down temporarily. That's why punishment doesn't work. And you remove a negative, what happens? It's called negative reinforcement and what happens is in response to that is your behavior increases. People often get negative reinforcement confused. Negative reinforcement is having uncomfortable heels and when you take them off, you actually feel really good. So taking them off rewards you, okay? So negative reinforcement is always a reinforcer. Remember that. It's just the removal of something aversive. Okay, so now let's take those principles and apply them to autism. What do we wanna change in autism, right? There's deficits. I'll talk about what theory of mind and executive functions are for those who aren't familiar with those terms and there's excesses. So symmetry, repetitive behaviors, maladaptive behaviors, like tantrums. Let's not worry about the fact that they're not part of the diagnosis or the diagnostic criteria. They are prevalent in each person. So what we wanna do is we wanna increase the skills or the behaviors in the areas that are deficient and we wanna decrease the ones that are excessive, right? Because our goal is to try to bring them into normal, into the normal charts. And so this is called skill teaching or skill repertoire instruction and you reward behaviors in these areas and this is called behavior management and you remove rewards for these because you want those behaviors to decrease. It's really as simple as that. Remember how we change behavior by changing the antecedents or the consequence or both. So let's take a look at some examples of this. Excuse me. So Todd wants a toy. So Todd hits his sibling and he gets the toy, which is a very common scenario with children. So when he gets the toy, of course he learns that hitting my sibling is effective. I think I will continue to do this. This is where I was saying that tantrums and aggression are communication. If we were to turn his hitting into language, it would be give me that toy, okay? But he doesn't have that language so the other effective thing is to hit someone to get it. Now if we prevent him from getting the toy, in other words, we remove the toy, which is a negative, right? What happens is it won't be effective anymore. He's not gonna keep hitting his sibling, but if the reason he's hitting is because he wants that toy, he's just not gonna keep going because it's ineffective. So what if we teach Todd to ask when he wants the toy and he gets the toy when he asks, but he doesn't get the toy when he hits, okay? So of course, our kids are intelligent, they figure out, oh, when I hit, it doesn't work. When I ask, it works. Asking is better. How about John hates school? John screams, and what happens when a child screams in the classroom? They go home. Very effective communication. I don't know why all kids don't do this. They don't do it actually because typically developing kids have embarrassment. They want social approval. And our kids on the spectrum aren't aware of the kids around themselves, so they're not so into gaining social approval, so they scream. Very effective. And of course, his screaming behavior increases. If he's not sent home, his screaming behavior will go down. If he learns skills so that he begins to like school, he's not gonna scream. How about this? Mark wants attention. Mark cries in tantrums, and generally speaking, gets attention. Okay, that's what we do with our children when they cry and scream. And his crying and tantruming increases. And what if he doesn't get attention? Then his crying and tantruming will decrease. And what if we teach Mark to do something better for attention, whatever it is? And then he does that appropriate thing, and then he gets attention. So then doing that appropriate thing now increases. So you see, this is a very oversimplification of what we do over four years. Okay, we reward all the good stuff we want, and we don't reward the stuff we don't want. Always remember, you identify what the child wants to communicate. You teach the child more appropriate ways to communicate. If we teach appropriate communications, they will replace the challenging behaviors. And challenging behaviors are not part of the diagnosis. Remember that, they are form of communication. Now, I'm gonna show you two videos that essentially show two, the technical words. The first one is extinction. The second one is extinction and DRO. DRO is Differential Reinforcement of Another Behavior. Essentially what that means is that in this video, she's ignoring the child because he's requesting in a bad way. He's a child where he knows how to request, but we don't want to reward him when he requests shouting or whining. We want him to request properly. Then in the second one, you see that she is rewarding him when he requests correctly. So let's watch this one first. I want to go to the bunker. I want to go to the bunker. I'm still alive. She's cold as ice. That therapist, right? If you look at, now we can go, I'll take us to the next slide. And now we can look at this. Sure, here's your peanut butter. You got butter? There you go. Of course it would be good if she didn't hand him the knife. But nevertheless, it's a good example of teaching the child to ask properly. That's just one example of how behavior changes. And I have tons of videos of these things. I like this one because it's humorous that she hands him the knife after all that. Anyway, okay, so let's move on. So the real secrets to being successful in behavior intervention is to teach the appropriate skill because that automatically takes care of all the challenging behaviors. When you have skills, you use them and you don't tantrum. If the child has appropriate skills and they're easy to do, he just won't engage in challenging behaviors. And you can't just extinguish the bad behaviors because they'll always be replaced by something else unless you have appropriate skills. So remember this whole thing where we had, oh, sorry, that one's very fast, where we had the behaviors that we want to change? So now we're gonna look at each of those areas, the language, place, social, theory, mind, all that sort of stuff and take a little bit more in-depth look of how we teach these things. And these are the areas of our program. And all of my stuff is on a website called Skills. Skills for Autism because it shows everything that we teach, our entire curriculum. And it's massive. It's like 4,000 something, 800 programs. So I'm gonna just show you some of these. I'm just gonna skip forward. I apologize, I believe my presentation or longer version of this presentation is already on the website here. So you can always access that. You can also get my book, which is teaching evidence-based interventions for children with autism, the card model. The entire curriculum is in there. Everything is in there that I just spoke about. And what I'm gonna do is I'm gonna skip through. These are, for instance, some of the lessons, areas that we teach. And the whole purpose of this one is to show you that we teach things based on developmental age. So I'm not going to take a, let's say, three-year-old and teach them functions of objects because it's not necessarily age-appropriate yet. And this is actually a very important thing because I know a lot of other providers who actually teach kids things that are very above their age range. And the sequence of how you teach things, using those techniques, how you change behavior, is important. But this is our language curriculum, or this is sections of our language curriculum. Notice that it starts with extremely basic stuff, like just following instructions. And it goes to things like observational learning. So that means when a child asks you a question, you teach them how to observe their environment to gain the answer for that. Okay? So they're advanced things. This is a lesson that just will show you, it's a basic view of teaching a child a series of language things mixed together. Operants are small, not the smallest, but small measures of learning. And this is just a mixed operant. So I think the child here is doing things like occupations and we're trying to work on a variety of different things. I don't, labels and so on. So we'll watch this video quickly. Now. Can you ask nicely? I want a book. I want a book. I noticed that she didn't give it to him until he gave eye contact. Look. It's a fireman. That's right. A fireman. And? It's a ballerina. Ballerina. You're a smart boy. What a smarty you are. What about that one? Yeah, that's a cook. A musician. So we can stop this one because some of these videos are long and I have a lot to show you. So I'm going to interrupt them just to move on. The point of this was just to show you that therapy is pretty. This is actually a discrete trial and people think discrete trial is sitting down at a table, doing it very rotally, remotely. It's not necessarily anymore. It's very much child oriented. It's very mixed. It's fun. Most of the kids really enjoy their work with our therapists because they have found someone who understands them and with whom they can communicate. The play curriculum is, and I apologize because there are so many different versions of PowerPoint. Sometimes these slides come up weird. But the play curriculum is based on normal developmental play. So for instance, beginning play areas which are sensory motor play, task completion play, initiating play. So sensory motor for instance is stuff that involves your senses and motor abilities. Task completion is puzzles. So sensory motor is like pushing a button and the lights pops up. That's sort of the very early stuff. And interactive play has many different areas. Pretend play obviously is a huge area that's lacking in autism. And I'll talk about theory of mind which is probably the reason that a lot of pretend play is lacking in our kids. Pretence as a whole is lacking in our kids. Electronic play we had to add because of how the world is now. And constructive play obviously, anything that has a work product like making a structure or clay constructions, arts and crafts. All of these types of things obviously we have to teach our kids, right? We're not just teaching language. We're not just teaching social skills. They don't know how to do any of these. And these things lead to normal development. They lead to interacting with other kids. This is showing you a play date. The little girl is my daughter. She's now a teenager. This is an old video. I miss those days. And she was of course a play date. All of my kids were play dates for years. And the little boy is now also recovered. He is, I think he's 15 right now. He has a band and he's taking it on the road. Like he's about to actually cut an album. He's very incredible. And I'll tell you afterwards what instruments he plays. But let's watch this video. Wow. I think something different. What else can you sing? It's broken. So this is from a series of about 20 different things that we would use a peer buddy or play date to teach our child. So this was just one. But because one of the things that happens is that our kids learn so much from adults that they learn to ignore children. And that's not necessarily a good thing obviously because we learn play and language from our peers. So in this we would literally use other children typically developing children a lot to do our play curriculum. Did you notice when he did this with his hand? Okay, so we turned that into drumming. This kid is an unbelievable drummer. You should see him. It's ridiculous. And throughout middle school he was one of the most famous or liked by the girls. In fact, there's a talent show video that I have that his mom sent me where he's playing the drums and then he takes the stick and twirls it and stuff and the entire front row of girls are cheering for him. So it's pretty cool. He's a lovely boy, lovely boy. So this is just an overview of some of the adaptive skills that we work on. Everything from feeding, I mean a lot, we get children who come in because they're so selective in terms of the foods they eat that they are on G-tubes. So we have to get them to regular feeding and I have tons of video on that too and a lot of lectures on that. But that has same process, same procedures. We use the same exact procedures of shaping and chaining behavior to get someone off of a G-tube and swallow. So all of these types of things are part of what we have to teach. And part of the reason I'm showing you all of these and here's our motor curriculum which involves everything from oral, visual, fine, and gross. The reason I'm showing you all of these is because I want it to make sense why two hours of ABA is not enough. I want people to realize why we say 40 to 50 hours because it is important to touch on all of these. When I have a child who's 40 hours, I am doing a little bit of each of these areas. That's what a standard program is. It's at any given time, it's between 20 to 30 lessons within all of these areas, depending on the need of the child. Obviously a child might not have motor needs, another child can't even sit up. Or one child might be very high functioning and we're gonna talk about the higher area of our curriculum in a minute. Don't forget by the time our child gets to age five, we now also have to keep them up academically which is really awful because to me, teaching a child math is a waste of time when I wanna teach him language. But we have to keep our kids up. So, and because our goal is to mainstream them, our goal is to get them into college. Okay, and then of course, and by the way, what I meant by non-academic skills is we're also teaching our kids a lot of stuff what do you do in school when you want attention? This is what you do, right? Not shout out. These are non-academic things that are important for school. All right, so the higher areas of our curriculum, I'm going to review those a little bit now and these are kind of important because it shows that ABA or our version of ABA has kind of morphed a lot into cognitive behavioral intervention. When we talk about cognition, we talk about metacognition and social cognition and metacognition is identifying your own and social cognition I refer to as inferring other people's emotions, thoughts, knowledge, desires, beliefs, and intentions. So I'm trying to teach a child how to understand his own thoughts and knowledge and where it came from and also infer his mother's or his father's or his friends, why is that important? You'll see shortly. This area of cognition, which also involves our theory of mind curriculum, is very, very important to development. So all of this came out of early studies in Cambridge in the United Kingdom in England. Simon Baron Cohen about, I would say probably about 15 years ago now, did a study called the Salian task. I don't know how many people here have heard about this. It was also called the Smarties task. So what he did is he had a bunch of children, children with typically developing kids, kids with autism and kids with Down syndrome, watch a cartoon and this is the cartoon. Sally has an object and there are two containers. Sally will take the object and place it in a container and then she will leave the room and when she leaves the room while she's gone and goes over to the one container, takes the object and moves it to the other container. Now Sally comes back and then the children who are watching are asked the questions, where will Sally look for her ball? Where does she think her ball is? So if you're a typically developing child, you would say Sally's going to look in the box because that's where she placed it and then she left, right? So she doesn't know that Anne moved it. But the kids with autism predominantly said she's going to look in the basket, which is kind of interesting because they thought, because they saw it and they knew it, then so does Sally. And that is what came, that started the whole field of there's a theory of mind deficit in autism, which means some children with autism don't realize that their mind is different from the mind of others. It is enclosed. What I'm thinking, you don't know. What you're thinking, I don't know. And that leads to a ton of other stuff and this is how typical social cognition develops. In the very first few months, we develop a sense of self. By nine months, we're already doing a lot of what's called joint attention or social referencing. This is like a baby will look at mother's eyes and track what she's looking at, right? So that's the beginning of joint attention. At 15 months, we already know pretense, which kids with autism very rarely develop. Now think about pretense, pretending something means you don't know what's in my mind because I'm pretending, right? At 18 months, we realize that people have different desires and intentions and we read their intentions based on what they do. There's these series of studies done where an adult was sitting with a child and they would take a doll and take like a body part off the doll, like the head. And they can't do it. So the adult sits there and struggles to take this body part off and then they put the doll down and the 18 months old baby will pick up the doll and do what you were trying to do for you because they read your intention. That's what your goal was. These are the things that our kids cannot do and we've broken it down to this level because we have to teach it to them. And two years, we're able to identify other people's own emotions and by three years we are recognizing that people know and think different things, which is why at four years we learn to lie, right? And we teach our kids how to lie because lying is an extremely adaptive skill. Imagine if you don't lie in white lies at least, you're gonna fail. You're gonna be very, very obviously autistic. So this is one of the things that actually if I have time I'll show you some video of that. By five years we understand people's intentions on a very advanced level in terms of what's an accident. Whereas our kids will come on their extremely upset because someone accidentally tipped over their backpack at school but the child thought he did it on purpose. So those things are very important. So we have 13 lessons currently in our cognition curriculum. They deal with things like teaching your own physical states, understanding emotions, understanding cause and effect, recognizing your senses, your sensory perspective. So for instance, my sense, we all know these things and we take it for granted but look at my sensory perspective right now is the back of the room. Yours is, your visual perspective is the front of the room. So if there was, God forbid, a fire at the back of the room, I would be seeing it first and you would have to identify or gain that knowledge through my reaction. That's second order perspective taking. And so these are the types of things we teach our kids at a very detailed level so that they realize how a person's sensory perspective changes how they think. Okay, because that's the kind of stuff that comes into which time we have 10 minutes approximately. So I think I might show some of this. This is one of my favorite videos. It's a little bit long but it's about teaching this child other people's perspective. So bear with me, it's about seven minutes and maybe we can watch it. So I'm going, I need you to tell me how to get from here to the chair. I want you to tell me how to get over there and sit in the chair, okay? Good job. Okay. Wait, now here's the trick. Can I see where I'm going? No. So. So I try. Okay, and I spin around. So I have no idea. I'll spin around you really fast. Oh man. Okay, I'm totally confused now. And I don't want to crash. I don't want to step on anything. So, do I know where to go? Okay, go that way. See? See. You don't realize that she can't see what that way is. That's not gonna work. All right, I want to switch places with you for a second. All of you switch places. Now, remember when we were playing the Lego game? Yeah. And you were telling me, like, put this one there. Yeah. What was the problem with that? If they put this one, you didn't know which one was which. Right. So, I want you to put the blindfold on. Why is it so dark? Can you see? No. Okay. Spin it, spin it. Go that way. Oh, no, I meant that way. Does that tell you which way to go? No. Okay, why not? Can you see where I'm pointing? No. Okay. So, if I say, go that way. No. Go that way. Tell me if I'm giving you a bad instruction. That's a bad instruction. I can ask you where I know it. Okay. So, now, I want you to try this again. Well, that thing was falling off like, falling off, so I didn't see. Oh, so that makes it easier. All right, I can't see. I want to just spin it really fast. Whoa! That's not funny. Spin it. All right, I don't know. Okay, go to Nintendo. Don't push me. No. I need you to tell me. Go. Jump. Jump. Go forward. Okay. Go sideways. Oh, wait, I just bumped something. Am I gonna crash? Yes. Okay. Okay, go that way. Wait, so stop. You told me go forward. Stop. Stop, okay. Go this way. Uh, go. Go, go east. Go east. I don't know which way east is, because I can't see. Okay. Which way I'm facing. Go. Right or left? Uh, go left. See him standing behind her and taking her perspective. Keep, go moving. Please stop. Jump over it. Oh, I don't want to jump, because I might crash. So can you tell me a different way where I don't have to jump over it? Okay. Go, go, go left. Okay, stop. Go this way. Go forward. Go ahead, William. Okay, we can stop this video so I can go to the next one. Go left. But it goes on for a while, and he gets her there. He gets her to the chair, and it is beautiful. And you see this with our kids, and it's pretty amazing when you see that click, you know, and you see it happen for them. But I do want to show you, in the next four minutes, the other areas of the curriculum, there are two other areas that are pretty important to me. One of them, of course, is the social skills curriculum. And of course, there are so many social skills that we work on with our kids from basic eye contact to social language. One of the things that's very important, that often I'm told, people ask me, like, you know, my child has deficits in conversation, has problems with conversation. Can I just work on that? And they don't realize that conversation in itself is, it's not just a basic one thing that you teach. Conversation has, for instance, all of these different areas in it. For instance, you have to teach the child how to greet appropriately, how to ask important identification questions, prosody or the sound of speech has to be normal. Question, there's a lesson we have called asking questions versus making statements, just so our child intonates properly. You have to know how to regulate other people in your conversation. Who's your audience? If it's an adult, if it's a child, if it's an acquaintance, a friend that impacts your conversation. Where are you? Physical context of the conversation. Are you in a school? Are you on a stage? Where's the conversation taking place? You have to listen to other people at an adequate amount. You have to initiate appropriately. You have to join appropriately and you join one other person differently than you join a group. You join a group differently if you know them or you don't. All of those things. You have to maintain. You have to repair. You have to observe other people and see that they're losing attention because you're talking about geography for the last hour. And so you have to give them a turn now. This is all just conversation. So that's why these lessons take such a long time. As I said, I'm just gonna skip through these self-esteem. We teach our kids how to deal with conflict. How to deal with bullying. I noticed one of the speakers last year I think or one of the previous years had talked about that. That's a big issue for our children, obviously. And then social rules. And let's not forget how to behave in a group. And then of course the absurdities. The big area that's lacking with our kids. Telling jokes. Making fun. And all that sort of stuff. So there's a lot in. So this is a very cool video which I wanna show you. Still have a couple of minutes left. This is same little boy and he had very little language at this time. But we're teaching him what's called responding to social cues. So I want him to look at the therapist and look at her physical cues, visual and auditory cues in order to identify if she wants the lollipop or the salad dressing. We picked those two items because when we first met him he was obsessed with lollipops. And he used to gag on salad dressing. So from his mind you must like the lollipop, right? But she's going to show him through her body that she likes the other thing. You can watch this video. Dressing. Good. Good gags. That's hungry. Which one do I want? Take the lollipop. Are you out of your mind? He's thinking. That's good. I'm hungry. Can I have some food? That's what I want. What do I want? The dressing. So that's sort of an example of one lesson that gives the child the ability to start looking at you and reading your body language. Finally, and I'll take one minute just to talk about this because our executive functioning program is very important as well. This is a series of programs that essentially helps the individual learn how to plan. And because executive functions sort of are the functions that control all the other things that we do. And most of the times that we have a goal, we have to do several things. We visualize what we want. We identify an objective. Let's say I visualize that I'm going to lose weight and I will identify a desired objective. I want to lose 10 pounds. I'm going to determine a plan. I'm going to pick one of these diet plans. And I will monitor my own progress, which means I'll weigh in every day. And I will inhibit distractions, which means I won't go to my mother's house where she will feed me, okay? So this is very normal behavior that we do all day long. You park a car and get to a seminar. You're doing all of this stuff. And we find that our kids have deficits in these areas. They lose attention when it involves some sort of goal-directed planning. So there's all of these areas. Why do they lose attention? Okay, because they don't have flexibility. So they don't have the ability problem solved. They're stuck with I have to do things this way. We have to go down this road. If we don't, I'm going to lose it. So lots of flexibility lessons. In fact, we will do lessons with our kids where we take board games and play them in order to lose. We change rules on our kids. Attention, paying attention to the right thing. In fact, let me put these up quickly. Paying attention to the right thing, alternating attention. When mom calls, you can stop paying attention to the TV, pay attention to mom, and then come back to the TV. These are individual lessons that we want to work on. Or saliency, what is the most important thing to pay attention to? Is it the teacher or is it the leaves on the tree outside? And memory, we find through testing that our kids have a lot of issues with working memory, adding new concepts to things they've already learned and modifying what they've learned. And problem solving, of course, and then all the areas of planning, whether it's metacognition or just basic planning, and then inhibition, which is all of our kids that they can't inhibit their response. They respond so quickly. So, of course, unfortunately, these are some of the tests that we use and our kids don't do very well with these tests, obviously. This one is the color trail test, which is kind of cool. For you, it'll be easy. You go from one red to two yellow, to three reds, to four yellow. What you're doing is set shifting. You're shifting a color and a number in your brain at the same time. Our kids have a hard time with these things. So we teach these concepts through different visuals so that their brain becomes, you know the new games, brain games? Have you heard those? Well, we have about 38 games that we do with our kids on computer technology that does this sort of thing with them, as well as Stroop, which is where I will ask you to read the first line. That's easy, and I'll tell you. Tell me the colors of the second line, orange, blue, so on. The third line, I'll say, give me the color. All right, it's hard, it's confusing because you wanna tell, you wanna read it instead of saying the color. So that's set shifting, and we do a lot of those activities. I'll skip this because we don't have time, and this, unfortunately, I'll just give you my summary. So a good ABA program requires a really good assessment of the child because the children are extremely different from each other, and a good ABA program needs lots of hours. If someone you meet tells you I do ABA and they say I do three hours of ABA, tell them to stop. They'd rather, they should use that money for something else because it's like taking five milligrams of a medication that requires 40. Okay, so it won't be effective. It'll be minimally effective, and it's fooling yourself if you think you're doing the right thing for the child. So please make sure people get what they're supposed to get because there's a lot that we can do. Treat each child differently. Identify the medical issues that need treatment, and treat them so the child is feeling well and sleeping well and paying attention. Identify the child's sensory deficits because they might be prohibiting normal learning, and then use the techniques of ABA to teach the child everything that he's lacking. And I hopefully, that's the last slide. Thank you very much. It's been a pleasure. Thank you. So I believe you have a break now. I will not be here for the panel in the afternoon, so I'm happy to hang around while the break is happening and if those of you who want to stay and ask questions, please do. If not, you can find me here and I'll answer questions for the next 15 minutes while you're on break. Thank you.