 Good evening and welcome to tonight's MHSN webinar. The topic is, as you can see there, and as you will know, if you're joining us, the collaborative mental health care to support adults in the autism spectrum. And this is a very popular topic and I think it's something that we're going to have a really interesting night teasing out the case study that you will have had a chance to read. So I'm Lina Grady and I'm a community psychologist. I work usually with the Australian Psychological Society managing some of our projects here. And I'll do some of this work with MHPN. So I'm very pleased to be here tonight. I'm very interested in this topic. It's not, I don't work with adults on autism spectrum, but I have done some work in the past with children. So I'm really interested to think about what might happen to those children later on. We do have a panelist of experts who I'll introduce to you in a moment and they're going to share their insights. And I think that'll be very valuable for you all. We have 728 people online at the moment. So thank you very much for joining us. It's fabulous that so many people are interested in this topic. And I'll talk to the panel in a moment about what might be so interesting about this in their view. And of course there'll be people who'll be joining us later looking at this as a podcast later on. So there's many, many people who are interested in the topic. I'd like to begin though with an acknowledgement of the traditional custodians of the land across Australia and from which our webinar presenters and participants are located. Pay respect to the elders past, present and future, the memories, traditions, culture and the hopes of Indigenous Australia. So you've would have had the panelist's names and bios already and hopefully you've had a chance to read those when you signed up for the webinar. But I will introduce each of the panelists for you so you get to see them and see who they are. So we'll begin with Aileen. Aileen is a general practitioner. And Aileen, I'm not sure if we're going to see you whether we're going to get to see you or smiling face. I'm wondering if you'd like to share your thoughts on why we might have a lot of interest. Why have we got 700 people out there listening to what we've got to share with them tonight? Any thoughts about why this topic's an interesting one? Yeah, hi everyone. Well, I think that one of the reasons why this is so popular is because it's a really hard topic. And we do see adults with autism spectrum disorder but we, I mean, I don't know whether other people share my views but it's often quite hard to, first of all, find out about them because of the communication issues and also where to refer them. So I think it's a conundrum. Okay, so people will be looking for some answers from us tonight then to help with some views. Yeah, okay, no pressure. Thank you. And next we'll talk to Amanda for Welcome Amanda. And any thoughts that you'd like to add today in terms of this topic and why we might have a lot of interest in it tonight? I think we've got a lot of interest in it because people have really begun to realise that autism spectrum disorder is much more common than we thought and children grow up to be adults. And there's also a large number of particularly adults who don't have cognitive impairment out there that aren't picked up until some time in adulthood and how do we find them and some people have asked. And also adults with intellectual disability are often missed as well. And so both from the perspective of a child growing up to be an adult with autism and the need for many of them to have continued support. We have the issue of adults who are coming to us and we think well maybe they do have an autism spectrum disorder and what can we do to help them? Okay, great, thank you. And welcome to you as well. Anna, you're coming to us from Brisbane. We've had our weather task and you said that it's nice and warm up there and you were in Melbourne recently. It was freezing even though we thought it was nice weather the last few days. So anything to add to that in terms of what you're thinking might be what people are interested in tonight what people might be looking for? Yeah, hello everyone. I think one of the biggest things is that there's a massive lack of information to guide practice in this area with adults on the autism spectrum. There's a lot more research done into how we can support young people and their families but as both Aileen and Mandy said that these children grow up and there's actually a very big lack of information as to what we can do to help support them in adulthood and a lack of evidence-based information and treatments which we can offer. Okay, fantastic, thank you Anna. And last but not least, Julian, any thoughts from you about this and what you're thinking what might be so attractive about this topic? Thank you, Leland. Hello listeners and those contributing today. I think from where I stand, the key is how we assess and manage individuals with more complex needs and how we deal with that in a collaborative framework seem to be the really key challenges as we put our heads together. Very big group of over 700 people actually quite the big issue. So I'm looking forward to hearing what other panelists say and looking forward to the contribution from the participants tonight. Thank you, Julian. And I think that's given us a lovely taste of what we're in for and already giving us a bit of a heads up about what we might expect. And of course MHPN do the work around collaboration. So this is very much the MHPN way of working used to really provide the collaboration. You can see already that we're doing that in terms of the different disciplines and backgrounds that we've got bringing to you tonight together. If you've participated in previous MHPN webinars, you'll know some of these rules. So I'll go over them briefly but I'm sure there are some people who haven't joined us before. So of course, the experiment rules are really important in any kind of environment like this. It's a professional development event. We can't see each other. But we know that you are there. And I always like to think about it that we're in a very big room together and we know we're there but we can't necessarily see what's happening. But it is important for you to think about this as if you were in a normal kind of space and not in a virtual space. So anything that you write in the chat box that other people can see. So thinking about that in terms of what you do share or questions and comments that you ask. You can use the participant chat box and this chat box is looking a little bit different if you've had it before. It's a little bit different because there's some new sort of platforms that's been required because of numbers because we've got so many people. So with the help of Redback we've been able to manage that. If you do have any technical concerns you do see the technical support tab and we have Redback who are there to help and there's a phone number there that you can see as well. You might just want to jot down but if you do put anything in that chat technical support tab you'll be able to get some support really quickly from Redback and always do a fabulous job. We also have people from MHPN behind the scenes who are providing support to the panel as well and sending me some questions and things that come through as well. At the end of the webinar we would like you to hold on so that you can just fill out the quick feedback survey for us. It's really important that I know MHPN draw upon that feedback and really take on board the suggestions and feedback that people provide. So it's really important that you do take a few minutes to do that if you can. Let me see where we're up to. Hopefully you have participated before and you are aware of the process that we go through. If you have joined us before you will know that there's a case study that hopefully you've all had a chance to read. David is our adult that we'll be talking about tonight and his family and we also have the panellists who will be providing some information a little presentation each from their perspective drawing out some of the things that they've been thinking about or information they think would be useful for us to be thinking about. And then we'll have some time for question and answer. We've already got some of your questions that came through when you registered and we'll be having a poll to help us prioritise what questions what area of questions we might want to focus on. But there'll be a quick poll and then we'll launch into some discussion and get as many of those questions answered as we can and including the various perspectives made to the panel. So I think that'll be a really useful and interesting section. So let's have a look at the learning outcome. So we'll be using David's story to give us the opportunity to describe the role of different disciplines in providing support to adults on the autism spectrum helping us to recognise the warning signs, prevalence and risk of mental illness for adults on the autism spectrum. So we've already heard from the panellists that even recognising autism and knowing if it is autism is difficult. So then the connection with mental illness as well is another complicating factor in there as well which we'll tease out. And then finally to identify tips, strategies and challenges in providing collaborative mental health care for adults on the autism spectrum. So set a big learning objective that we've got that we're working on there but I'm sure this panel will be up to it. So let's begin with our DP Aleen. But before I do that, I might just recap very briefly a little bit about our case study just so that if you haven't had a chance to read it you'll at least know a little bit about what we're talking about and you will be able to find the case study in the little folder that's available for you. So handouts and other information supporting resources there as well as the case study if you haven't had a chance to look at it. So I've been through this case studies and made a few notes. So David is in his 30s. He is living at home with his parents. So his parents are Linda and Dan. Linda has recently been involved in a car accident having some time in hospital and there's going to be a fairly lengthy inpatient rehabilitation process happening for her. And Linda has derived a lot of her life to be caring for David. And while she's in hospital, things are kind of becoming really quite tricky at home. So David doesn't seem to be coping very well with her not being there. So what we're really looking at is in presenting to the GP. He's looking gone to exhausted intent and he's talking about having a turn. So we've always got the physical signs happening as well. So that's just a snapshot to give you a bit of an idea. But hopefully you're aware of the background and all the other information that we've provided for you. So let's move on to you now, Eileen. And here from your perspective as a general practitioner, what are some of the things that you'd be thinking about once we read that case study? OK, so I guess one of the great things about being a GP who has actually been involved with the family for ever so long is that we actually know the full medical history of this patient, David, and also the family history and the background of the psychosocial issues that he comes with and obviously his diagnosis as well. And exactly the person he is because we've looked after him since he was a little baby and also know his sister and his father as well. So I guess as a GP, the main thing that I can stress here is that hopefully it's the doctor that actually knows the full medical history and the context of where this person comes from. And I can't stress that enough in a person with ASD or intellectual disability. Many times we find people with or adults with this condition not having a full medical history, and that is a difficulty when you're starting to build up this file or a profile of your patient in front of you. And I would like to encourage all the GPs out there to really go and find out if the patient who is the first time that's seen the patient with an intellectual disability or with autism as an adult, to really try and find out as much as they can about this person with research. And I know that we can transfer files, but it's one of the things that I find challenging as a GP not being able to get the full medical history. And there are some tips that I might be able to share with you as we go along in this webinar. But certainly it's important to know the background of this person and his context. And also having that existing report, understanding of David is really important to start off knowing about where to go from here because one of the things which he has presented with today or that day to his GP could be a physical, mental, or behavioral, or a combination of these conditions. So one of the things which we know in general practice is that behavior change is a really common reason for people with autism or intellectual disability to seek help from the GP. And it's great that David came because often I find that it's either the family member that will come or maybe the father or the sister. But in this case, obviously the mum is in rehab. But usually it's someone that's come in or if it's a support worker, someone who lives in the group home. So I think that it is great that David came. But often we can't jump into a conclusion that the person's come because of stress or whatever. It is true that often the behavior can be a tent for the person to communicate, discomfort and distress to you as a GP. Always got to have a high index of suspicion that there is something that this person is trying to tell you. But what is it? And to be able to get that down pattern 15 minutes, it's a real challenge. So I just encourage reflection on that and perhaps some strategies to put in place to deal with that. So the important thing is to come to you with these concerns. As a GP, it's my responsibility to do a physical assessment and take a medical history of exactly what is going on and not jump to the conclusion that it's anxiety or behavior or whatever, but really take the time to listen to the physical symptoms very carefully. He's come with a funny tummy and he looks gaunt as well and he's exhausted. Is there a physical problem that's causing this? We need to balance that with over-investigating because some of the things I find as a GP is often easier to send off or a test or do some investigation and inflict people with autism or people who have intellectual disability with multiple, multiple tests and send them to specialists without really assessing them properly. And I think that we need to do that as GP. And I know that I'm talking to quite a number of mental health workers and psychologists. So it is important that that's something that you can have a relationship with the GP with is to say, look, can you physically examine this person or maybe look at this person medically for me? GP's also trained now to look for mental health assessments. It's important that as a GP, I spend some time doing that as well. Impossible to do in 15 minutes. So I've got some tips later on if people want to hear about how to get that going. But I'll move on because I know I've got five minutes. So what do we know about people with autism or intellectual disability? Well, they will have definitely some existing or more physical issues. So we need to be aware of that. And the majority of people with autism have an intellectual disability. And also among these people, there's a high prevalence of psychiatric conditions. I won't go through these because I know our other mental health specialists will be talking about that specifically. But GPs have to have that in the back of their minds when they're with someone who has communication problems as David has and has some cognitive issues as well as their intellectual disability with their autism. So getting a diagnosis may be difficult. And this is when I think a team approach is really important. And using your mental health specialist is really great. I have a master's in mental health but I do like to get my mental health specialist an opinion or an opinion to exactly what is happening to this person. So don't be afraid to refer. I think it's really important. And don't jump to the conclusion that this person has behavioral problem or that they have anxiety or depression or whatever. It could be schizophrenia. It could be something else. So I think it's important to get a collaborative view on that. And it's really important to state that people with autism have the same right to access mental health services. I think it's really important as a GP to understand that. I think we do. But I think sometimes it can be dismissed. And I really would like to encourage our GPs out there to think further about this. On the other hand, we don't want to be quickly referring. Again, we don't want to inflict our patients who are already having difficulty in communication and going to different, you know, meeting different people, new people to have unnecessary assessment. So I think as a GP being the first port of call in primary care to really be able to have that assessment initially and to think very clearly and carefully about this patient that's sitting in front of you. So to finish off, some cardinal rules for successful interaction with patients with ASD become not afraid. Don't be dismissive. Speak slowly, not loudly. GPs and other health professionals, I know it's a little bit of frustration. It's human nature. People don't seem to understand or they're a little bit slow. We just tend to speak loudly. And I think that's poor form, but you know, we have to catch ourselves. Wait for 10 seconds before the person to speak. We speak very quickly and we are, you know, we are able to express ourselves well, but people in front of you might not be especially people with autism. You can use gestures or pictures and I often like to encourage, you know, looking at the computer. It's really great now to have computers in the practice and we use that quite a bit. But obviously in David's case, he might not need gestures because he's quite high functioning, but pictures are always important to clarify. Reinforce good behaviors and expressions pretty much not able to get that all in one day, but in one session, but just make sure that as a GP, you're able to say, yeah, good job. You know, that's really important and be upfront about giving them good feedback. Get assistance. I talked about the team approach, schedule a review. And maybe you need several long appointments to get to the bottom of things. So, I think that's my card and rules for successful interaction and being able to treat and manage David. Thank you very much, Hadeen. And I think there's a lot of tips there already for people to take away that I think would apply to a lot of people doing this work. And always, interestingly, when I hear DPs talking about there being first protocol and so much to think about and so much to be checking out. So, I think that last point around several appointments long to get to the bottom things is a really important one and taking the time sounds like it's really, very important when we're looking at patients or clients with really complex needs and lots of things going on. So, thank you very much for kicking us off. That's been a fabulous start. And there's lots of chat happening. So, we're really pleased that you're using the chat function and that you're using that so that we can get an idea of the sorts of things that you're looking for. So, thank you. And now, let's move across to Amanda from a psychologist perspective. What are some of the things that you'd like to share with us? Hello, everybody. I thought we might actually go back to basics and think about autism spectrum disorder as it's now called. And there is only one diagnosis and it's based on core difficulties to do with social communication and then second areas, routines, repetitive behaviours and sensory sensitivities. And if you look carefully about what's been written about David, particularly in his history, you can see these things here. I think very importantly, too, we need to remember that there are a number of comorbid conditions that come with autism spectrum disorder, which Aileen has already touched on to some more or less greater degree. So, mental health problems various anxiety disorders, mood disorders, insomnia and circadian sleep-rhythm disorders, gastrointestinal issues, but also people with autism, which is moving more into the psychologist's area and as well as particularly the OT's area, fine motor difficulties, poor adaptive behaviour, other mental health disorders and intellectual disability is also very common. And sometimes with an adult with autism actually from a psychologist's perspective, they may actually present initially with some significant mental health problem that they've come to see you with and they may not have a diagnosis of autism spectrum disorder and this might be when you may begin to suspect that something else is happening. In terms of going back to the core difficulties, we now diagnose levels of severity and if we thought about David, he's probably at a level one, so he might need some support in place or some help for social communicative issues and he may exhibit inflexible behaviours and like stick to routines and so on, so he might need some support with those. So, moving on, being conscious that we've only got five minutes. From a psychologist's perspective, I really like to think about the background that people come with and the family situation. So, very importantly, David's mother, it seems to be a bit of a warrior about David and he's really supported David all his life, as Aileen said. Dad seems to be a bit reclusive and the psychologist had to start to wonder if he fits on what we might call the broader autism phenotype and the sister we don't know much about, she's absent and interstate. From David's perspective, leading up to his life as an adult, he hasn't, because he was diagnosed late, he hasn't benefited from early interventional support when he was a very young child and most sorts of things can be very important and he does come with a history of social isolation and bullying at school and we find that bullying, even in the workplace as well for adults, bullying is a big issue in school and in social adult situations in the workplace for people on the spectrum and that can cause a lot of trouble for them. And then in terms of, in David's history, if I look through what we had about David, he has these somatic complaints to do with his gut or his funny tummy. It seems as if he's probably a bit anxious, he seems to have some sensory issues and routines. He's certainly got anger issues. He's ended up with some good qualifications that he's underemployed, which we see in the autism spectrum. This is a disability where more people are unemployed than in any other disability, according to the ABS. He does socialise and he has a socially acceptable interest depending on your football persuasions with the Collingwood Football Club and he's very heavily reliant on his mum. So those are the things he brings to the picture now and he's 30s. At the point of crisis of precipitation, he still seems to have his funny tummy, so something going on there that doesn't sound like it's ever been looked into, he's still got anger management problems, very reliant on his mother and his socialisation is very much around a specific interest. So when his mother's hospitalised, there's a big change in David's life and change is something that people on the spectrum don't deal with very well. So there's a change in relation to his transportation and therefore his ability to engage in his favourite social practices and hobby with the football and the football statistics and so on. There's a change in his meals and how much of that's got to do with his tummy and how much it might have to do with routines we don't know. And so overall there's been a routine change. Excuse me, I just had to cough there. So from outcomes from the psychologist's perspective, I'm seeing someone who's angry, who is self-injuring, who now has poor sleep, has an inadequate diet, has somatic complaints, he has poor personal hygiene, he's lost his social contact and because he's resigned, he's now unemployed. And some of those things are things that a psychologist might look at and some of those things are things that very importantly need to be looked at in a multidisciplinary sense with the GP and OT, maybe a psychiatrist as well. So to summarise, he's become isolated, he's sensed to escalate it with mental and physical health problems. So one of the things that psychologists need to think about when someone presents is, when they come with these things like a funny tummy, it may not be anxiety, it may not be a mental health problem that's making Phil ill, it may be a physical problem. And so as Aileen said, it's really important to get a medical evaluation. So if you're a psychologist seeing David first, you really probably should be sending him off to his GP to make sure there isn't anything physically wrong or trying to persuade him that he should go and see his GP. He, once you get into the mental health issues a bit more, you may want to send him to someone like Julian because he may need medication, he may need more than you can provide as a psychologist in practice. And because he's dropped out of work and he's got adaptive behaviour problems, you may want to send him to someone like Anna who's going to talk soon. From a psychologist's perspective, his mental health and his anger management and his sleep are issues that we need to deal with. And his mum's been organising, which suggests he's got some executive function difficulties. And so one of the things that's becoming, we're finding in research at least, which is important in the mental health arena for people with autism is, not surprisingly, difficulties with intolerance of uncertainty. And so that might be an area that we could work on. Anger management relates to people with autism can have some significant problems with emotion regulations, so dealing with regulating emotions. And then his sleep problems can be related to his mental health problems and his unemployment. And also, to this intolerance of uncertainty and problems with emotion regulation. Psychologists, to some degree, can help with essentially issues and adaptive behaviour as well, but also that's moving into the area of the OT and the OT may be better qualified there. You can make some suggestions that the OT may be better qualified. And really, that implies very much what Aileen has said. We're seeing here that we really need all of our parties involved. We need communication between all people for complex cases like David's that appears to be at least on the surface. OK, thank you very much, Amanda. Lots of other interesting things. And I can see in the chat that this is really creating a lot of interest and lots of things to be thinking about. Lots of things to be thinking about. You haven't finished? No, I'm sorry. I wasn't quite sure if I'd got on to my last slide. I did. I thought myself confused. That's all right, I just want to cut you off. I know you have lots of important things to say. I'm just noticing from the chat that there's quite a lot of people talking about their own experiences or family members' experiences. So I'm really mindful that we're tapping into a whole lot of different experiences people have who are joining us tonight. So just a bit of a reminder about that. We're trying to keep it to the case study and keeping the focus on that. But really mindful that there's a lot of impact on us all in lots of different ways. I just wanted to do a bit of a reminder about that. It didn't take long before someone talks about Collingwood. We put that in the case study and we thought that it might take a little while but someone, Amanda, you got it in pretty quickly that Collingwood might trigger a bit of discussion but that wasn't coming up in the chat just yet. But it might now. Julian, over to you. You're going to give... No, Anna, you're going to give a perspective from occupational therapists. We've got to hang on to Julian. So let's hear from you, Anna. What would an occupational therapist be thinking about in the case study? Thank you. So I wanted to start off giving a bit more of a broader picture of how autism might impact on an individual's ability to participate in everyday life and to participate in occupations and then focus specifically on David. So Mandy touched on this when she was talking about employment rates of people on the spectrum. They tend to be a lot lower than that of the general population and of other people with other disabilities. From the case study, we can see that David is now unemployed. He's decided to resign. In terms of education, individuals in the spectrum may have lower levels of higher education attainment. In terms of leisure activities, they might be restricted to their particular interests and as we see with David, that's really around his interests around football. And generally social participation tends to be restricted for individuals on the spectrum, maybe just to a few close friends or acquaintances or maybe participating in online situations rather than face-to-face interactions with other individuals. And we saw that with David who developed quite a close bond with one friend around his leisure activity of ASL. In terms of activities of David living, these are things such as cooking and sharing and kind of looking after yourself in your day-to-day life. And with David, we see that he does have difficulties at the moment with sharing and that that has been something which was a difficulty when he was young, but he did receive some earlier assistance from an occupational therapist to help with that. And we see that his mum has been cooking for him and particularly for his funny tummy most of his life. So whilst his mum was in the hospital, he isn't cooking meals for himself and he isn't eating the meals that are being provided for him either. And things such as instrumental activities of David living and things such as being able to manage the finances, being able to manage either public transport or driving independently. And what we see with David is that he's also been reliant on his mum for transportation to and from his activities. So as an OTI, I've been starting to think about, you know, in these areas, where is it that David would like to actually be able to do more of this on his own or to develop skills for him to be able to continue to engage things which are important to him. But as the case study says at the moment, it kind of seems that David is in quite a bit of a crisis. So generally in that sort of area, it would be really important to have the support of a psychologist, potentially a psychiatrist and his GP to really help manage that crisis. And then we can focus on getting David back through his valued occupations and doing the things which are important and meaningful to him. When thinking about or when doing an OTI assessment, it is really important to think about how, I guess, the core features of autism, which Mandy went into detail about, how they might impact on someone's ability to do what they want to do. So for example, with employment, there was an example there that sometimes David doesn't go along with his co-workers and that can be a cause for a disagreement or a conflict in the work scenario. So thinking about his social communication abilities and whether that's impacting on his ability to communicate and negotiate that social environment at work. Thinking about authorities' sensory sensitivities. So the case study didn't go into a lot of detail about whether or not he did have any hyper or hypersensitivity. But as an occupational therapist, this is definitely something that you'd want to look into in a lot more detail to see whether this is actually something that might be contributing to the problems that he's experiencing at the moment or something that's contributing to him not being able to engage in activities that he would like to be doing. Thinking about all of that, we need to also think about the individual's physical health and whether that's impacting on their ability to participate. And as this case study is particularly on mental health, so whether it is that David does have anxiety and how that is impacting on his ability to do things or whether there is something else going on as well. And as both Aileen and Mandy have mentioned, individuals on the autism spectrum may also have an intellectual disability. So when working with people with a comorbid intellectual disability, it's also important to think about how we can then further adapt our practice to meet their needs. So whether we need to adapt the way we're communicating with the individual to make it easier to understand whether we do need to provide materials which are pictures, whether we need to demonstrate things more carefully, that sort of thing. So the reason I put this slide in, in recent times, there's a lot more research being done into some of the potential causes or mechanisms for anxiety symptoms within autism. And I've included this because within the case study, although we don't know for sure what's going on and we need to do a thorough assessment to see whether it is a mental health problem which is causing David's current difficulties, some of the things which are there makes it sound like it could potentially be anxiety. And I've included this because the research at the moment in this area is quite interesting. So there is research to suggest that a typical sensory function, which is something that autism is really quite interested in and have a lot of knowledge in, they actually contribute to an individual's intolerance of uncertainty, which then can go on to contribute to anxiety. So if you could be nervous or anxious about potentially experiencing some unknown sensations, say, out from on the street, not knowing whether you're going to come across a really busy environment that you're not going to be able to deal with or manage well or really noise the environment. And also, there is research to suggest that electrosomnia or the inability to really be aware of your emotions and to be able to describe them and label them may also be related to sensory function, which then also impacts intolerance of uncertainty and the presence of anxieties in individuals on the spectrum. And it's really interesting as well because I've recently come across a research article, the first one that I've seen like this which has developed a intervention specifically for individuals on the spectrum based on cognitive behavior therapy, but around actually getting individuals to manage their sensory, or their reactions to sensory experiences in more appropriate ways than to change the behavior, which is showing some early promising results. So that's really interesting and something that OTs could get more involved in. Just to summarize, in terms of an assessment for David, it's really important to make sure that it's quite centered and that the goals that are coming up with those things that he really wants to work towards in his life. We need to think about all the factors which I mentioned which might contribute to participation restrictions more broadly with individuals on the spectrum and also those factors which might be contributing to any mental health problems that he's experiencing. So for example, if it is anxiety, as an OT we could really focus on those sensory atypicalities. One thing which has been touched on as well is the involvement of support persons in this assessment and in this goal setting. So David is heavily reliant on his mom whether we need to involve her or whether, as David is an adult, speaking to him about whether there are other people which would like to be involved or which would like to become very long sessions and have support in as well. Aileen touched on all of these kind of adaptations for autistic adults and I guess I just wanted to highlight that it's really important to have clear communication when working with autistic adults to avoid ambiguous language which may be misinterpreted to use visuals and videos and demonstrations when necessary and to check that the person has understood you because sometimes individual might just not along or they might look at their understanding but it's really important to double check that they are understanding what you're saying and particularly also thinking about the individual to stand through differences and making sure that your office or the environment that you're working in can be adapted to meet the needs of the individual so avoiding fluorescent lighting where possible when using the lamp not having noisy environments but you have a noisy waiting room maybe there's somewhere else that that adult inspection could wait whilst they're waiting to see and really being mindful of those things. And I'll hand over to Julie for the psychiatry perspective. Thank you. Thanks Anna. Lots of fabulous ideas there as well and again seeing the nuances I guess so talking about the same case study but really bringing out some different elements that can really show the benefits to the film working together and people commenting on how fabulous it is to have an OT perspective on the panel so it's great that you were here. Now, Julie, last but not least as I said before you've been waiting patiently so let's hear from your perspective now to round it off for the psychiatry what would you be thinking about? Thank you very much, Lynn. It's been really stimulating listening to the presenters that have come before and I think much of what needs to be said for really being said so I can move through my brief presentation fairly rapidly. One of the important aspects to me considering the mental health of people with autism is to recognise the diversity of this group not only in the mental health profile but also as individuals. Whilst we know that deficits in social and communication social communication interaction restricted range of interests and so forth are core elements of autism we also know that each person with autism is different and some of the useful ways clinically dividing up the group that I found helpful is to think about firstly whether the person has intellectual disability or not associated with their autism and the awareness that people with milder levels of disability to borderline, IQ to mild intellectual disability will largely have a mental health presentation that's very similar to this in population whereas people with moderate or severe levels of intellectual disability and autism will have quite a different presentation often dominated by behavioural changes that need to be interpreted and understood carefully to really recognise whether or not there's presence of mental ill health. There are other broad groupings that sometimes help people with and without language disturbances are important obviously because adaptations to clinical practice vary significantly between those two groups and also whether or not the autism is associated with a particular genetic condition which has a behavioural phenotype of which autism is part and I think those things to me help me understand individuals a little more easily clinically because I know that there are particular clinical aspects to those groups that are distinct in some ways. It's been a high rise of that mental ill health is generally overrepresented in autistic adults and indeed I think at a rural we could say overall that prevalence of mental ill health is about two or three times that of the general population to most of the core areas of mental health so I think we could use that as a template of understanding but then we need to go beyond that and think why is this individual vulnerable? When we think about that issue we can look at this schema and understand at a biological level that there may be some vulnerabilities not only by the autism itself but perhaps by a tendency for anxiety disorder. It seems like Linda is a somatiser and may have an undisclosed anxiety disorder. It seems like Dan, the father may have an autism spectrum disorder himself or at least be part of the broader phenotype as many said. We also know that psychological aspects play a key role so at the telecock there you can see if we apply that here to David he has relatively core frustration tolerance he somatises his distress he has a distant father and the anxious and other protective mother and aside those factors that are psychological vulnerabilities arguably to mental disorder he has his own issues to deal with which relate to his identity he has a relatively poor adaptation I would say to his diagnosis of autism and he's not being supported in the right way to enable him to attain the best possible standard of mental health and well-being at present. Down there at about four o'clock you can see that I've put past experiences and there we need to recognise that people on the autism spectrum may have higher rates of bullying and abuse experiences and these may provide significant vulnerabilities or risk factors for mental ill health. We see that six o'clock lifestyle issues including David's low levels of physical activity could be a risk factor but actually a relatively protective factor here is that we don't think that he abuses drugs or alcohol at this point so that's a strength. Over at about nine o'clock you can see that environmental factors that need to be considered here here mother has been hospitalised this is a little central event which has led to escalation of his anxiety and plummeting if he's moved and really quite graphic distress with evidence of self-harm and increased sanitisation. And we can see in the social domain at about eleven o'clock a series of negative experiences particularly as a child in the school setting and then perhaps avoidance of those socially based interactions partly because of previous negative experiences. All these factors together help us understand vulnerability to mental ill health in David's case. We see that being stated that people with autism as everybody have a right for highest attainable standard mental health and wellbeing including access to quality mental health services that are tailored specifically to the needs of the person on the spectrum. But when we think of this in reality we know that people with autism experience a number of barriers to effective treatment. I have another diagram here and you can see it about one o'clock communication difficulties are listed. Now while David's verbal communication is okay many on the spectrum are struggling in this area. At three o'clock we see that we can consider lack of skilled and specialised services as being a potential barrier to access to treatment. Aileen made an interesting comment earlier that don't be afraid of referral to a colleague but actually Aileen I think it would be fair to say you have very very well developed professional networks in this area and I wondered whether people participating today have those networks as richly developed and may in fact experience difficulty finding a suitable specialised service to which to refer. Down at about five o'clock David's and those around him's knowledge about health and mental health issues can provide a significant barrier. It's often the case that it's not until a major crisis that actually action is taken by families in this situation. I think in some ways it reflects low expectations of what mental wellbeing might look like for an adult on the spectrum. That's also low levels of literacy about mental health and available treatment and lack of ability to access those. At about seven o'clock we see health professional skills and training. We know that many in this field struggle because at an undergraduate and postgraduate level there is often very little contextualised training on developmental disorders within curricula and a few opportunities for professional development. Of course this panel and your participation is an exception to that. At nine o'clock we see care and disability professional skills and training as a potential barrier. This isn't relevant to David but in many people on the spectrum those with intellectual disability have significant severity. Often a barrier is the carers themselves not being aware of appropriate services and support and not knowing how to access them. And quite up high on that barrier treatment picture there you'll see interaction between services. For me the thing that I experience in clinical practice is a lack of cohesion in support for people on the spectrum with mental disorders. Often clinical service delivery being punctuated by demarcation of role rather than having a person centred an holistic framework of support. And what structural difficulties that we come together as professionals without a really clear model or a practice model on how to do that well and services to an extent and the funding sources can be against us as we seek ways to overcome that barrier and do things better. If I can progress to my next slide. So I think Aileen and others have outlined beautifully key adaptations and assessments in specialist psychiatry services these are very similar to what's already being stated. Preparing for the consultation knowing your documentation to come with a person seeking it if it hasn't been provided obviously effective communication with a person and those that have come with them engaging with carers where possible and appropriate having sought the permission of the person themselves taking that broad developmental perspective which is sometimes lost with adult clinicians as they set for them an adult not really taking that long-term view of how the disorder has impacted on the person as they've progressed through various life stages with various tasks to achieve at different life stages and how when autism has impacted that developmental pathway the impact on the person themselves and on their sense of mental health and well-being. Ana was outlined really in the sensory aspects that really need to be considered. Here we see David with very sharply developed inter-effective awareness. He summarises some of that sensory sensitivity around interception what drives some degree his hypochondriacal concerns about his gut and his need for a special diet. Aileen outlined physical health comorbidities and I'll put these here again just to highlight that to me there's a key hierarchy if I see somebody presenting with an apparent mental disorder one of the first and most important aspects here is assessment of physical health potential drivers of that change for the person. We know that in people with intellectual and developmental disabilities a large proportion of health conditions are not actively managed or inadequately managed and so this to me seems very important. And of course assessing behaviour there can be substantial diagnostic overshadowing and this is more of a feature of course in people with much more severe disabilities than David's but needs to be stated here. A key management issue is I think the need for a comprehensive formulation using multiple sources of information and incorporating the input from other disciplines is a key and incorporating that medical knowledge and the awareness of any influence of medical conditions on the mental health profile and developing from that clear hypothesis about what could be the key triggers and perpetuating factors in the mental health of David. Having a way of interdisciplinary practice that has the person at the centre and supports them without them needing to overcome the barriers that we create between our professional discipline that we practice in our silos. Obviously psychological therapies I see in David's case as in most people presenting in this way being the primary and enduring treatment modality but then having a sense of well what does responsible prescribing look like and rather like Handler 3, scene 1 to prescribe or not to prescribe that is the question in this situation dare I answer that. Would it be appropriate I guess the full case is that there's been a long-term vulnerability to anxiety demonstrated in David's case there's a relatively low risk treatment option available that might significantly lower his arousal anxiety levels and improve his mood against that though he's not had a good trial of a psychological treatment we don't know how he's going to respond and there are significant although small risks of side effects from medication. So I think that's probably where I'll end it and I think there are some key questions perhaps left unanswered that we can discuss. Thank you. Thank you, Julianne and I knew you could do it for us I knew you could take us from football to Shakespeare in one fell twist but thank you very much for that and I think what you did really well and I think coming last as well was probably really useful that idea around the multi-disciplinary approach and the complexities of cases like David and others and the need to actually work together to really tease out and to bring the sense and different workers and I can see in the chat as well to share some of those ideas and talking about different kinds of therapies and different practitioners and the role of NDIS and all those kinds of conversations starting to happen so people in the chat box have been doing a lot of giving each other support and ideas as well as what the panelists have been giving us I think it's been a very rich lot of information so far we do have a little bit of time for some questions and answers and as Julianne said there might be some questions that are looming for you so we do have a poll you can see there that this is going to pop up in a moment around some of the themes and these are the themes that came through on registration so when you registered and you were asked if you had a question and we did get lots and these were the kinds of themes that came up and I think they're the kinds of themes that I could also see coming up in the chat box as well so we're going to have a poll that's going to be put up right now so Ron can read back if you could do that for us and just take a moment and use the one theme that you'd like the panel to discuss and we could be taking some depth really to think about which ones might come up I'm not sure if anyone's got any ideas about which ones are most likely if people are polling now hopefully you get to do that and then we'll get to finish that in a very short time so that we can actually have a look and then I've got some pre-prepared questions which were prepared earlier of course that we can talk to as well and get a little bit more out of this panel so we'll stop that there and we can see that assessment diagnosis questions have come up the most and then strategies to engage so we can't go back to Hamlet I'm sorry Julian that's done so we do have some questions there that I can talk about in terms of assessment diagnosis so one of the questions that came through earlier and we can decide which panelist wants to jump in here and there might be a couple of you what is the most accurate assessment in diagnosing Aspergers but I think Mandy you said that it's autism spectrum disorder now rather than Aspergers it's the latest DSM-5 where do I find the clinical criteria now that it's no longer classified on DSM-5 so that's the question really so would you like to take that one Mandy in terms of the diagnosis and changes I'll start and anyone else who wants to jump in please do in the panel we consider it to be an autism spectrum and with a number of common conditions including intellectual disability and potentially language disorder for people with an intellectual disability and so we don't diagnose Aspergers disorder anymore person with Aspergers disorder would typically be someone who had that lower level support level 1 or may not actually might make some criteria but at that time they'll be doing quite well but I guess if they're doing quite well they're not going to be coming in to see you so we diagnose by DSM-5 that being said people on the autism spectrum they often like to hire function people very cognitively able people like to refer to themselves very often as being on the spectrum or they might refer to themselves Aspergers or ASPE and certainly if people have already had that diagnosis they'll come and I think it's going to remain there is something that we understand as typically reflecting a person on the autism spectrum who has good cognitive abilities but sometimes it's not helpful to focus on that because someone who has good cognitive abilities doesn't necessarily not need some assistance as we see with David so people with Aspergers disorder or Aspergers syndrome as it was in the past can still quite often need a lot of help so we should be using those levels and we should be using the DSM-5 criteria when we diagnose Great, thank you. Anyone else want to jump in with anything to add today? Are you happy with what Mandy has given us there? It's Anna here I just wanted to briefly mention a project which I'm part of it's being led by researchers based in the West of Australia but we're actually looking at developing a third national guideline called diagnosis of autism to be used across Australia and across the life there looking at what sorts of assessments should be used what sorts of health professionals should be used in the process and is it enough just to give a diagnosis or does there need to be additional assessments down around specifically what sort of support is making sure they have access to that so at the moment I actually have an honours student who is going to be doing interviews with adults on the spectrum who have been diagnosed as an adult or who are seeking an autism diagnosis at the moment or who are identified or just for whatever reasons have decided to not get an autism diagnosis to really inform that diagnostic guideline so I think that will be launched in September so for individuals to keep an eye out for that because that hopefully will bring a lot of good information to people working in the area and diagnosing autism I don't know whether there's any room for one more response at all here I think and it's on the money that there's significant concern around people who may not have received a diagnosis of course not everybody wants a diagnosis but where it's being actively sought the key I think is this is something that clinicians like me do really poorly I found the nice guidelines quite helpful from the UK that also in addition to really stressing the need for comprehensive and multi-disciplinary multi-team assessments and integrating all of that information recommend some specific tools including screening tool like the autism spectrum quotient of course but then more specific tools that often involve much more in-depth observation or interview so some of these are relevant to people more high functioning autism so there is a very specific diagnostic interview and of course there are many different tools more autism diagnostic interviews that can be used so I would recommend that if people are interested to pursue nice guidelines and the recommendations that's one of the things that I found especially helpful and that's available fairly on the website yeah just to add to that I think that if you use those guidelines that Julian is talking about but also in the DSM you do look at the levels of support you really need to do more and just make a diagnosis to determine the level of support that the person requires I think it's also important what some overseas research particularly showing that some of these adults who haven't been diagnosed are actually coming to practitioners first with a mental health problem so there was one recent study that I read from the UK in 2016 and it was published where about people who had been referred for a mental health problem usually anxiety or depression but not always and about half of those people actually had an autism spectrum had autism spectrum disorder came away with an autism spectrum disorder diagnosis and one of the things I think from memory with anxiety was more prevalent in particular in the people who came away with an autism spectrum disorder diagnosis okay so that comorbidity is a really important thing to tease out and again reinforcing the need for us to kind of work together I guess to make sense of what's happening now I'm really conscious that our time is getting away and the other area the other theme I guess that came to in the poll was strategies to engage so I'm wondering in wrapping up each of you might maybe think about what you think might be one of the key areas in terms of engaging we have had some of these conversations already what would be your take home tip in terms of strategy to engage David and perhaps even consider his parents because we do see that he's living with family and they're playing a really important role and I guess part of this might be engaging them in any of the strategies as well so who'd like to start in there kind of wrapping up take away message but maybe tailor it in that way who'd like to go first I am I on I'm not sure whether you can hear me yeah so I think that one of the key things is to really spend some time talking to David when he's one to one he's able to high functioning he's got anxiety as we know he's anxious but if he's comfortable with you and you're his primary health person or your psychologist I think that if you can have a conversation and tailor what he wants I think it's important to reflect to him that you want to hear what he has to say about who he wants to engage or help him engage with treatment or management I think sometimes as health professionals we tend to disregard we like to be the experts and tell people what to do and I think that people with intellectual disability and people particularly high functioning autism just because they can't communicate as well or have difficulty or we think they have difficulty communicating we need to try to give them the time to tell us what they want and I think we need to present some options and hear what they have to say then you're currently on mute I'm on mute so I'll say that again, thank you Eileen and I guess what we're trying to do with David is to encourage him to become more independent and thinking for himself which is part of that family dynamic that's been created Eileen, who'd like to build on that? I'd like to build on the communication because something's occurred to me that we possibly haven't touched on sufficiently in relation to communication and that is that David is high functioning and therefore his language will seem fine but he can potentially have subtle language issues that we may not think of as being a metaphor how we question or give information to him or suggest to him are open to misinterpretation potentially and this is in a slightly different context but this was born home to me when we did some work with tertiary students on the autism spectrum and we spoke to them and their families and also to take teachers and I'm reminded for example of one of our teachers a university tutor saying about a person with autism who was asked if they had finished their assignment and the student said yes the student failed the subject because part of the message that hadn't, that was implicit was that you now need to submit it so it can be marked and he never submitted the completed piece of work but we need to make sure our communications are very clear and unambiguous hmm yep thank you that's really important advice and again can be hidden in terms of people looking like they understand or seeming like they understand and that literal understanding is complex thank you who'd like to build on that Anna or Julian who'd like to go next I'm happy to go next I think I'm really just reiterating the importance of having time and taking time to get to know the person getting to be able to build that rapport so they do feel comfortable with talking to you and as Mandy mentioned really getting to know how they communicate and whether they are someone who has difficulties with understanding metaphors and things like that and really trying to understand how you need to communicate with them and you can ask them you can ask individuals about how is the best way for you to communicate with them and they will most likely tell you you know can you please write things down for me in advance or it's pretty important or some people might want to record conversations so they can then later go back to them when you're no longer with them so actually I think it's important to people about what are the best ways for you to communicate with them because in those cases they might be able to tell you what works for them Great, thanks Anna and that's another good practical tip I guess that we might not always think about doing or might not feel that that's a good thing to do so it's great to hear that and that leaves you again Julian how would you like to finish off? Thank you Here I think there are two aspects to engagement for me one is with David and thinking about how you are really engender a person centered approach in your clinical practice but be sensitive to perhaps David's acidity and anxiety in that that might actually make it more difficult for him to be at the centre of that consultation so gradually as reports developed and over a series of sessions I think that can be overcome so that he's truly at the centre and so that the clinician is really thinking of his perspective and actually checking in really what he wants to do as far as the next step and that he's adequately informed about the range of options the likelihood of success of those options and they can be carried out with his engagement I think the other aspect of engagement is between the professionals involved in supporting David to me this can be aided by improving our communication with one another with David's permission information sharing becomes a really important part of that often this is done in the form of letters or electronic communications but taking the time where possible for multi-disciplinary conferencing and the question again here is if that's really person-centred that should also involve spending time with David if he's able to tolerate that and support that idea but making sure that we're creating frameworks where we can share information regularly support and encourage one another and actually develop a priority in our management that really reflects David at the centre very difficult to do I'm being somewhat idealistic but I think we need to be challenged to move in that direction Thank you Julian and nothing like ending with a good challenge and idealism at the same time and I guess we're hearing the consistent messages around collaboration and working together and then how that actually happens of course it's much more difficult than it sounds so appreciate all those ideas that always go so quickly and it always feels like we've got so much more to talk about or we're just starting the conversation but I know there's been a lot of information that'll be really useful to people that's been shared I know there's been a lot of chat that's happened in the chat box and there are resources that you can access so that you can actually go away and all the questions haven't been answered hopefully some of them will be in there as well but I think core messages around collaboration working together supporting each other keeping client at the centre and things have come through really very clearly so thank you very much to everybody for their participation so thank you very much for the panel for their work in preparing for this evening and for being here and for sharing your expertise and we know that we've just touched the surface but we've got a lot of insights as well just to remind you again to wait to complete the exit survey just before you log out it'll come up on the screen as we close certificates of attendance for the webinar certificates and you'll also be sent a link to the online resources that come with the webinar and we do have the next webinar coming up on the 17th of August which is another challenging topic and big topic that I hope you will join us for coordinating mental health care for people experiencing suicide bereavement that's on Thursday 17th of August same time and channel really the other last point before we do finish off is if you're interested in joining CPC in networks and this is really about what the theme coming through was around supporting the engagement and ongoing maintenance practitioner networks and this is something that came through and particularly talked about that where clinicians from different disciplines meet regularly with other mental health practitioners and share tips, resources, build local for all pathways and engage in CPC activities so this is something that you can join and you can see there there's a list of networks in the setting up your own that there's opportunities to get some support to do that as well and there's a website if you're interested in doing more of that. Don't forget the panel on the little folder with all the information and just the survey again before you leave and thank you again everybody for your contribution and participation in this evening's event. Good evening.