 All right. Good evening, everybody. Welcome to the latest installment of our autism awareness programming. My name is Dan, I am the director of development programming for the bed for playhouse and I want to thank everybody for tuning in this evening. Before we introduce our moderator and she introduces the rest of our panel. Just a couple of quick reminders. Please feel free at any point during the conversation to ask a question. You can find the q amp a button to do so at the bottom of your screen on your laptops or PCs. It's at the top of your screen if you're on your phone or on your iPad. The bed for playhouse is a five and one C three nonprofit. So we rely on the support of the community for our many of our endeavors. So we humbly ask that if you are so inclined if you enjoy tonight's conversation, and you'd like to see us do more programming like this. We have one minute to visit our website which is bed for playhouse.org and consider making a donation. Any amount is useful and appreciated and we're very, very grateful for all the support that we get. With that being said, and without any further ado, I'd like to introduce our moderator Cassandra Newsome, who is going to tell you a little bit about herself and then introduce the rest of our panel hey Cassandra. Thank you for having me tonight. I'm excited about this talk and we have an excellent group of panelists who are going to be very informative. I am Dr Cassandra Newsome I am a licensed clinical psychologist at the University of Alabama at Birmingham and specialize in the diagnosis of autism and autism research. Also joining us tonight are Dr Michelle Gorenstein from Mount Sinai. I'm Dr Catherine Belone from the University of Texas Southwestern and Dr Peter Faustino, who is a national association school psychologist, and they're going to each take just a second and tell you a little bit about themselves and their background which might help you guys know what types of questions you want to ask as the panel starts Michelle. Sure. Well, thank you for having me. My name is Michelle Gorenstein, I am a clinical psychologist at the Seaver Autism Center which is located at Mount Sinai Hospital in Manhattan. And we are mainly a research center so most of what we do is the context of research to understand kind of genetic causes of autism. And I also want to better understand how to study autism and what are kind of best outcome measures, as well as clinical trials related to autism. My job there is pretty unique and that I'm not directly involved in research so I am the director of community outreach and I actually spend most of my time in the community. I'm funding through UGA Federation of New York, and I work with community centers across the tri-state area to help community centers better serve children, teens and adults on the autism spectrum. I do a lot of parent training. And then I have a faculty practice where I see teens and young adults on the spectrum who have comorbid anxiety and depression. Katie? Hi. So, Katie Pallone, I'm a psychologist and board certified behavior analyst. And as Cassandra mentioned, I work at UT Southwestern Medical Center and Children's Health in the Center for Autism and Developmental Disabilities. So I am a therapist in what I do every day. I work with children and adolescents and families impacted by autism or other developmental disabilities. Oftentimes, families are coming to see me when they have a child who has pretty significant emotional and behavioral challenges associated with their autism diagnosis. So that's what I get to do every day and I am so pleased to be here. Thank you so much. And Peter. Yeah, thank you. I'm also really excited to be here. I find that April being Autism Awareness Month, we get to have these conversations, you know, so frequently. And because it's such a passion for, I think the panelists, right? It's just a great opportunity. So I'm local. I was working in the Bedford school system for about 16 years. I'm a school psychologist, as well as a licensed psychologist. I'm currently working at Scarzell High School but maintain a private practice and tend to just get involved in a lot of different things. So I'm the past president of the New York Association of School Psychologists. I'm currently a board of directors member at the National Association of School Psychologists. And Westchester County has an association for psychologists and I'm the current president of that organization. And then related to autism, not only in the school systems where I've always worked, have I been able to, you know, help children and families diagnosed with autism. But many years ago got connected to some wonderful organizations and charities like Autism Speaks or the Autism Science Foundation and just have, you know, benefited from the interactions and the collaborations with those organizations. Great, thank you. So I thought I would just start by asking some general questions and any of you are welcome to chime in. So how common are anxiety and depression and other mood problems and people with autism and do you think there's a problem with them being under diagnosed? Sure, I can jump in. I think when we look to the research, the numbers really vary, but the research does show us that there is an extremely high rate of comorbidities in individuals on the autism spectrum. So for depression we see depression numbers is kind of three to four times more likely in individuals in the spectrum. Anxiety disorders, the numbers range from like 20 to 80% higher. So I think the issue that we have in terms of the research is that there are not necessarily specific tools for clinicians and researchers to use to kind of capture anxiety and depression in individuals on the spectrum. So I think that's kind of a big obstacle that we face, but I definitely think the comorbidity is extremely high when we're looking at individuals on the spectrum. Thank you. Other thoughts? I'm happy to pick up where Michelle was just saying around the idea that I think there are challenges inherent to autism spectrum disorders that put them at greater risk. I think children with autism or, you know, I tend to work with children, so I may say students and children, but it's really anyone at any age level can, you know, often be constantly anxious about the world around them. And so researchers have known, I think for some time that individuals with autism spectrum disorders and their family members tend to show increased rates of psychiatric conditions like anxiety, depression, ADHD. And I believe the numbers are sort of like one-third of children with diagnosed with ADHD also have sort of one of those other conditions, these comorbid conditions. But the two other things I just love to put out there is one is, you know, whenever we talk about it, and I'm sure people have heard this expression, but right when you meet someone with autism, you've really met one person with autism, everybody sort of is very unique and different. And I often like to put the framework out there that, you know, people with autism are not from a different planet, they just sort of speak a different language. So anything that neurotypicals might experience, I think we're going to talk about people with autism being at risk for as well. Okay, Katie, did you have something to add? Okay, so can some of you tell us what anxiety or depression might look like in a person with an autism spectrum disorder? Because as Peter, you just said they all look very different. And so you might have one person with autism who is very verbal and another person who struggles with communication and some that are, you know, adults and toddlers and children. So help us try to understand what anxiety or depression might look like, how it might present, what things should we be on the lookout for. Yeah, no, it's a good question. And I was, you know, thinking about the best way to answer the question. And it is a bit of a challenge. I mean, the two things I might share. One, the framework that I sometimes use is around hyperarousal and hypoarousal, you know, this idea that either side of that state of arousal is something to be on the lookout for. And so, you know, a person who is acting out loudly screaming maybe aggressive hitting others can actually be suffering from the same condition of anxiety or depression that the person who's hiding under their bed or constantly tired or avoidant of others is and so I wouldn't want to limit those but maybe just help with that understanding of those sort of like extreme ends of behavior. The other part of that is just the idea that it can be a little bit more difficult to really narrow down what it looks like in someone with ASD, simply because their behaviors tend to be a bit unique or out of the norm as well. And so what I sometimes share with families is, you know, living with an individual or knowing an individual right figure out what the baseline normally is what are the behaviors usually look like, and then look for differences in those behaviors. It's a really great way to describe it. I was thinking sort of along the same lines, you know, because I'm also a behavior analyst a lot of the referrals for severe behavior get routed to me in the clinic and a really significant portion of those referrals I would say you know when it's a really severe meltdowns or aggression or even self injury in my conceptualization are the ways that I think about those patients oftentimes I see anxiety at the root of it and you know whether that patient is able to tell me in words or not. There's actually some significant worry or situation that's going on in their lives that causes them such disruption and distress and so try to help families, sort of think about those behavioral episodes is rooted in anxiety, many times I think the other thing challenging maybe in the way we think about anxiety and depression kind of in general society is that so many of individuals on the spectrum aren't going to be able to use the feeling words that we look for. And so I think that makes it really tricky and we're trying to tease these things apart and so rarely going to say I'm feeling really worried or I'm feeling really sad today. A lot of us use picture faces and things that can serve as anchors to help with that but in my experience it's oftentimes the behavioral kind of I love the way you said it either like the behavioral excess of overly reactive or talking about being tired all the time kind of not wanting to eat even the limited diet they would usually eat or wanting to stay in bed are a lot of the descriptions that I might get from parents that lead me to worry about depression and in a child on the spectrum so more of the kind of obvious things we could observe about changes in their in their daily routine. Yeah, and I was going to just say since I work a lot with adults on the spectrum that sometimes you can see kind of like a loss of kind of skills so people that were bathing independently kind of regressing in kind of those areas of self care. We also sometimes see and again this isn't always indicative of kind of depression but kind of a change in restricted interest. So kind of taking on more morbid topics or preoccupation with death or dying. But I mean we do see that in individuals on the spectrum that don't aren't depressed as well. But I think as Peter and Catherine pointed out we're really looking for changes in behavior. So along those lines of, you know, starting to see themes of darkness or death that makes me wonder about suicidality. Do people with autism have suicidal thoughts. And what, how would you recognize those and what would you do. If you had a loved one who was expressing those kinds of feelings. You know maybe I'll take a quick stab or that's a terrible phrase sorry. I was going to say, I'll start but in my experience I mean they do they certainly talk about suicide but it's complicated. You know, I think sometimes it's been perceived as like a taboo subject that you know a lot of times, both clinicians families that it's a difficult topic to talk about. I think that a lot of research is starting to come out around suicide and autism, in particular in like the last few years and and some of that I think is related to when individuals on the spectrum end up in a hospital setting or in a, you know, a more severe sort of school setting and then they're sort of looking at those target behaviors. But the rates I believe are higher I mean I just think that sometimes when you have the diagnosis of autism, you are, you know, again at risk for just many, many of these things which is why this topic I think is just so critically important. So to your question about what could people listening, you know, do one of the things that we're, we're training a lot on in school systems is using like the Columbia suicide severity rating scale and this is sort of like a question, you know, answer guide that that's online to most people, but it's something to consider I mean it's, it's the things that I think are important about it without going too deep into that particular scale is the idea that talking about suicide is not going to make it happen or place ideas in someone's head. They're either there or they're not and so it's just really important I think for families to check in with, you know their their children or their loved ones. And the other thing that I think is really important in the creation thinking about suicide right is one form of problem solving when we are frustrated and overwhelmed and we feel like we're at our wits end thinking if life was over is something that pops into people's heads. I think it's important with individuals to help them understand that there are much better choices than taking your life and some of the important things to share is that when you are having this conversation. It's important to get a few to get a sense of the details that people are thinking about so I often use an acronym around like how specific accessible or lethal of a plan. If someone tells me that you know they are, you know, nine years old 12 years old, and they're going to get in a car and drive to the bridge and try to jump off the bridge. That doesn't seem too possible for a 12 year old, who doesn't have access to the keys or the pedal or the, you know, or the bridge or things like that. They say things like I'm going to go to the kitchen at night when my parents are sleeping and take something sharp out of the drawers that begins to really concern me and elevate me to the point where you want to seek help for those things as well as if you start to talk about this topic of suicide, and someone tells you that they've actually taken steps like I've looked in the medicine cabinet and to see what kind of medicine is in there that I could potentially take. Those are all really clear warning signs that I think people would, would want to, you know, not rest on but act on and just reach out to a psychologist or to a loved one and to help. Great, that's really helpful. Katie, did you want to add. I was going to say Peter covered a lot of the parts that I think about the only kind of thing I was also thinking about is, you know, I obviously can be so jarring for any parent to hear just even anything like I wish I was dead from a child especially. And I think, you know, one of the things oftentimes that might be a reason for for a lenticlinic as well of just kind of they said something at school and the school said we need to come get help. And so that is a really hard job for parents to try to decide is this something that means I need to go in immediately or should I wait and I think, you know, I kind of have those same conversations about a lot of times. It can be a situational factor that's really overwhelming and it's just this passive thought of like it'd be easier if I didn't have to deal with math anymore. And I think once you kind of have concrete conversations with kids about what they said actually means many times they're like oh I didn't want that I just didn't want to go back to math. And you are able to get such good information if they say yeah I know what it means. I do feel that way sometimes and, and it's really. I appreciate what you said Peter I think it's, it's so scary for us to imagine a child or an adolescent or adult, you know, harming themselves that it becomes something the family wants to avoid discussing. And then what I find is just having a really open conversation usually is able to help the parent feel so much more comfortable, and help us understand if it's something we really need to follow up on closely or just kind of check in about periodically because maybe they had a lot of stress and we're able to tell us in other ways. Perfect. Thank you. So let's turn and start thinking about what do we do about anxiety and depression and people with autism so what are the recommended treatments for mood problems in ASD, and does that change based on age and language level. So I can just start so I typically work with, I would say like school age children and above, who are fairly verbal, and I use cognitive behavioral therapy. So that is kind of an evidence based treatment for individuals on the spectrum who have anxiety and depression. And it's basically the idea that how we think about situations impacts how we feel impacts how we behave. And we all know that we can't just change our feelings. But if we can change maybe how we think about things that can impact how we feel and how we behave. And CBT is evidence based for neurotypical individuals and it looks similar when you're working with individuals in the spectrum but there are some modifications so we typically use more concrete language. We break things down simpler and then I think a big piece when working with individuals in the spectrum is to also support the skills that they're struggling with. So I work with a lot of teens and adults who are feeling depressed because they don't have friends or they're being bullied. And I think it's really important that we're addressing the anxiety and the stress and the depression, but we're also developing social skills and supporting them or helping them with executive functioning if they're failing out of college and getting stressed. So when I'm working with individuals on the spectrum and kind of what research supports is kind of like a two pronged approach, where you're kind of treating the symptom and the anxiety and depression but you're also building skills. Great. Katie, would you like to tell us a little bit about what your treatments look like for kids with autism problems. Yeah, so one of my most favorite things about my job is getting to do a lot of family therapy. So one of the other tricky things about anxiety and depression is they often run in families. So we will see very, very often the child in front of me has, you know, this comorbid anxiety and depression with an autism spectrum disorder but maybe one of their parents or both of their parents sometimes has anxiety or depression, whether they've been diagnosed with that or gotten treatment for that is often just up in the air but we do tend to see that a lot of the challenges that the child is going through in terms of anxious thought or kind of depressive symptoms is something that maybe someone in their family has also gone through and so I think it's a really wonderful opportunity when you can bring family members in to help kind of show how some of those patterns could be developing in the way the parent copes with things in life or maybe need some extra support that you're able to then get them connected to and so then we can kind of help the parent-child relationship which I think oftentimes in my work it's really hard for me to just treat the child individually because then if they're going back to a family where maybe someone else is struggling it tends to not be as supportive for their new strategies and so I really like to bring family members in and just see if that's a concern for them as well and how I can help either get them connected to services or do family-based strategies to help everybody kind of feel more supported and more aware of different tools to use. Those were two very comprehensive answers so I'm trying to think of what I could add to the conversation and maybe what I'll do is I'll try to break it up into students that I think of who have language and what we do for that versus you know maybe students that are more profound or nonverbal and so for the students that maybe are more profound I do think that we have to work really hard on the communication skills I know that was said maybe by both Catherine and Michelle but some of those feeling words being able to identify the emotional state they're in is very challenging and so I think we have to really work hard on identifying them giving them vocabulary to do that in many examples it's giving them visuals we can use the iPad we can use storyboards and other kinds of things and and I know sometimes the way we're building into that is really modeling the emotions and states as well as the problem solving so it's a lot of like you know it's early in the morning I'm feeling tired and grumpy and here's what I'm going to do or you know I just got some bad news and this is the way I would typically feel or someone did something to me and this is maybe how I would be feeling and what I would do with it and I think through those you know visuals and and giving them communication skills as well as sort of modeling the problem solving almost like in a social story kind of setting I think we get some some pretty good results as far as managing or treating the the anxiety and or the depression. In students that are a bit more verbal or or you know higher functioning. I think we're spending a lot of time looking for the triggers really trying to identify what it is in their world seems to be upsetting them or setting them off. Students with ASD really can be very sensitive to so many things or just perceive the world in such a way that if you can gain access to what those triggers are. It feels like half the battle sometimes and then I'd say that as a result of the pandemic. I have seen a tremendous rise on avoidant behavior and so specifically around like anxiety right when you get into that anxious state your first responses. I just want to stop it I want to just run away from it and avoid it. What I know in psychology is that and behavior analysis is that if you avoided it actually reinforces that anxiety. And so what you've got to do is sort of like build back almost like a systematic desensitization to putting yourself in those uncomfortable positions and then saying okay I did it I think maybe that's more for anxiety but sometimes the depression anxiety overlap is pretty strong. Since you mentioned COVID tell me and your practices what have you seen different this year as a result of COVID how is COVID impacted people with autism spectrum disorders, and maybe also how it's changed how you're delivering treatment. I mean I could start with one funny story that there was a young adult with autism who said to me when the pandemic hit I was hearing the news say that in order to save other people's lives I had to stay home not interact with anxiety and just like watch Netflix and play video games and he said I was built for this I could totally do this to save the planet right and and he made me laugh right the idea that some of that social anxiety and that communication he was now able to sort of like avoid these situations whether it be work or you know friends or things like that. But unfortunately I think for most, it's been really hard it's it's been hard on everybody, but unfortunately many of the treatment approaches and interventions and the things were really pushing students with autism to develop. And I translate as well on the computer or through zoom and so I think there's been a whole added layer to that and then whenever you talk about students with disabilities, more profound disabilities, you know the speech and OT the ABA services. And those are so much richer when it's in person in a school or in a setting, and we've had to adapt a lot of those so I know professionals have done an outstanding job with pivoting but it just has not been great. I think, you know, in terms of how it's impacted maybe anxiety and depression, our whole society I feel like has had worsened anxiety especially and and certainly I've seen that in all of my patients on the spectrum whether they're able to label it as such or not and so definitely much a specific almost phobia is developing around germ exposure or social experience of, you know, now that, at least here in Texas, people are getting out there as if I expect to normal in some ways and so I think it's hard because now a lot of parents are saying well that they don't want to even go to the grocery store with me they don't even want to go to the park anymore and and I really have to normalize a lot of that of, you know, this is such a huge adjustment back to going out and you know we're going to need to structure some short experiences that feel really successful for them and give them ways to feel safe and rules for how to engage that feel really comfortable, but I think definitely more kind of specific things that are just almost exaggerated versions of what all of us are going through worries about family members dying and not being able to say that so then maybe being really disruptive towards that family member. They're just kind of things themes that were kind of taken to an extreme degree because of the sort of rigidity in their thinking. Yeah, and I would kind of echo what both panelists said that I think we're definitely seeing an increase in the number of referrals. We're getting calls from parents individuals on the spectrum. I will say in my clinical practice I've kind of seen a divide and I've seen some teens and adults thrive right now, and really make use of virtual supports and are feeling less anxious. Now the anxiety is returning because in New York things are starting to reopen, and there's an expectation for a lot of students that they are going to be returning to school. So in some ways I'm seeing an increase in anxiety now because there is that return to social skills but then I do definitely have a large portion of clients that are struggling more their services have been disrupted their routines have been changed. So I would say, one of the main things that I've seen during the pandemic is the parental stress. So caregivers are just feeling a significant burden, having kids at home kids with autism at home all day having to provide the programming is putting a significant strain I would say on caregivers in my opinion. But I also want to point out, I was talking to a colleague yesterday who is at a school and she actually pointed out that she's actually seeing kids become much more independent, then she would have ever thought they could be so being able to kind of go on to a zoom and kind of learning some life skills that probably wouldn't have been taught to kids at age five. But we're required to be taught. So I know she was saying as a educator she's going to have to readjust her expectations when everyone goes back to school, because we have seen some kind of successes during the pandemic. Great. That's really helpful. Thank you. So how do you think autism acceptance or inclusion might play a role in abating anxiety and depression for people with autism. I think one of the most exciting things I've seen and I'm sure Peter can speak to this even better is the sort of inclusive education happening in school settings at really young ages so I've had multiple patients over the years have introduced to present to their classmates about what they wanted to teach about autism and it became such a positive opportunity where they didn't feel singled out but instead got to make cool picture slide shows of things about them and what they were passionate about and it's just been such an incredibly important shift to see certainly than what I can think about when I was in school and I think as all of us want to feel like we belong and we're accepted it goes such a way to help kids on the spectrum not feel alienated it changes a school culture so bullying is so much less likely and if it does happen other people are willing to stand up and say you know don't do that. I think has really a huge impact on both anxiety and depression for kids to not feel like they're going to be picked on or made fun of if they're struggling with something socially or have a speech disability or you know anything like that so definitely important. Catherine said that well that you know we I feel like schools are doing more than they ever have which is which is a great starting point I mean, you know to answer your question right I mean those basic psychological feelings of like safety love belonging. If you if you create that in a school setting or in a work setting or wherever an individual is then it is is absolutely going to lessen the impact of you know anxiety or depression. Take some intentional work I think to get there for you know systems and so many many years ago I had a young man at the middle school level who came to my office and said. I don't know how to talk to my friends about my younger brother who was just diagnosed with autism they want to come to my house. But his behaviors look very different and I just don't know what to say to them. And I think that was the impetus for conversations around awareness building and so. So I think raising awareness is one of those really important starts, you know and then better understanding about the behaviors and and why you know children do the things they do. Ultimately leads I think to to that more inclusionary sort of feeling like if we have people with autism working and in our classrooms and around us and we better understand that we're going to have more positive experiences with them. And that's going to lead I think to real inclusivity so and again kudos to the Bedford Playhouse right for raising awareness and having this conversation even tonight so. And again just to put like the young adult adult perspective on things I think even moving forward from the school setting thinking about like college programs. So there are more and more college programs bringing up that are giving individuals on the spectrum supports socially and with executive functioning so that high schoolers on the spectrum have the opportunity to go to college with their peers. And also inclusive hiring practices. I think when we think about causes of depression for all of us, thinking about unemployment, not having a peer group. So, as much as I think the neurodiversity movement really kind of helps those pieces, because it creates work environments and college environments where everybody's accepted and everyone is seen as unique and kind of having this unique perspective. So that definitely will be helpful in decreasing like the anxiety and depression. Great. So some questions are starting to come in from the audience. So I'm going to try to summarize those and get your reactions. So one parent is asking, what can they do to help motivate their teen who's on the spectrum to really commit to making behavioral changes so he might be going to therapy and he's fine with going to therapy but when it comes to actually making those behavior changes. And still, they're really struggling to figure out how to help them get really engaged and motivated. So what do you do and motivations at issue around therapy. I'm happy to share my perspective I think one of the first conversations I have with families of teens is that the teen has to want to come to therapy and has to want to work on the things that we're setting as goals and so it's really driving the ship in terms of why I think they should do this or I think they should do that. That's kind of one of our first family sessions of just talking through therapy has to feel voluntary therapy has to feel comfortable for everybody and so not always comfortable but at least the idea of going. And so I think I try to use a lot of sort of techniques to help get the child or adolescent to help me understand what their motivation might be to change so it's a really tough thing I have a lot of older teens on the spectrum who, whether it's because they've had such bad experiences in the past or maybe it truly is their experience internally, they're convinced they don't need to have friends. And their parents are bringing them to treatment saying we need you to get friends they need a social life they're so lonely. And you know I might spend multiple sessions really talking about these are some of the reasons people have relationships what do you think about that. And there's a subset of my patients who just really stick to that like you know I'm really happy being on my own I don't feel depressed I don't feel lonely. I have what I need in my gaming online relationships. And I have challenged parents to be open to accepting that for those those patients and certainly we're going to monitor them and make sure they don't start to experience any depression, but I think it's kind of broadening our ideas of what life can look like sometimes and accepting that maybe if it's not the right time for them right now it might be in the future maybe once they start wanting to have a romantic relationship or if that's something they're even interested in but you know I think it's a really hard thing with teens in general and then when you add on kind of some of the core symptoms of autism it just makes it even more difficult so motivation is a is a big piece for sure. Michelle, and another person kind of chimed in and asked, what about when they're an adult when they're legally an adult, and you are as a parent or concerned that they're, you know, struggling with things are like Katie said not having friends are not doing well, but they themselves are resistant to going to therapy. What do you do then. Yes I think similar to what was said about teens adults need to want to go. Similarly, we see some adults that are okay going to work coming home to their apartment, not really having a like rich social life but they are happy and they watch anime and maybe once you're they go to Comic Con. And some of it's talking to parents that like not everybody's life plan looks the same and obviously we want to monitor and if there's depression or self interest behavior or symptoms of anxiety. And that would be cause for concern but sometimes it is educating parents as to the idea that their expectations for what their adult child's life was going to look like might not be in line with what their adult child wants. And that's kind of a common theme that I see when working with young adults. And sometimes it's about finding the right match of therapist. So I, when people call me and I say you know, I could be the perfect therapist for one person and the worst therapist for another. And I think sometimes it's about just finding that right match the person that the adult or teen connects with on whatever level. And kind of just going from there and focusing on what the adult what is motivating the adult is it that they want to be able to travel independently. Okay, so that's what you want. Here's what like your family saying is getting in the way so can we work on that stuff so we can get you traveling independently. I think helping adults kind of reframe because I think sometimes when I work with adults in the spectrum parents still want to be very involved but adults want to be more independent. So negotiating that relationship and kind of helping adults feel like they have a voice but still acknowledging that they do need a lot of supports from their families and sometimes their family are seeing things that the adult might not be aware of. So I'm going to add to both of those I, I agree with so much of what was said right I mean in particular with the young adults right or the adults college age 20 years old or whatever. I think there is a very important concept about what are the personal goals what are the parent goals right and and sometimes just listing those out, you can really start to see I think I think the nuances. I think adults, you know, finding a hook finding a way to get them to understand that maybe they are happy and that things are okay in their mind but that they could maximize certain things. I think is an important concept and tied to that, you know, one of the things that I sometimes worry about just seeing it from a developmental perspective is that, you know, there are behaviors that sometimes just get reinforced and really young kids right like they run up and just hug a stranger. And then when they get to the middle school they run up and hug a stranger, and it's no longer socially appropriate. And then when they're an adult, they run up and hug a stranger and they get arrested for it, and they end up, you know, being involved in law enforcement or the courts. And so I do think for some parents right they are worried about that trajectory and they're thinking, if we don't work on some of these things what is it going to look like at the next stage, which maybe individuals in the spectrum aren't thinking about right as far as what's what's coming next. So, I think to reiterate right I mean that idea of just sort of helping understand what are those personal goals versus the professional goals. And I think it can't be understated that that notion about working with the right therapist right I mean, I do think that that there's not enough therapists that really have expertise in autism, but that you, you kind of have to find one or match one. I mean, I mentioned earlier like I work as, you know, volunteer for the for the Westchester County Psychological Association. I talked to lots of therapists right and they're really great at talk therapy. That I don't think works for kids with autism kids with autism would love to just sit and talk about their interests for hours and hours, but that isn't going to get them any closer I think to learning skills or addressing some of those issues and so it's more like psycho education it's, it's okay you're coming in here's what we're going to talk about here's the agenda here might even be rules that you've got to like, you know, fit into. And sometimes it could feel not like therapy but but more like you know really, maybe a mini classroom or a mini lecture or something but then really the important thing is, I can't work in isolation, you know, in my office I've got to teach us what it is we were doing so that they can then almost be the coach when they're outside of the, the, the office and stuff like that and I think that might answer a little bit of, you know, both questions that were asked that. Yeah, those are some thoughts to do. And another audience member asked, Well, how do you help and deal with kids at the same time that you help parents with like the subtle nuance navigation of the high school aged years. I think all of us can remember how difficult that was for us and then you add on the layer of having an autism spectrum disorder. This parents saying it's, it's a difficult time so how do you help teens and their families navigate those adolescent years and and all of the new things that come up with puberty and just the changes and and the social environment as they get older. One of the ways I think about when I get to do family therapy is that we're practicing how to have those conversations together. And I'm kind of modeling for the parent how to be open and neutral in the way that I respond because I think all of us want the best for our kids and sometimes the reactions that we think are showing how much we love them are actually like judgment or criticism and so I, I, I find it really helpful to practice those conversations together where I can kind of be like a mediator for parents and their children, especially at this age group. Because the truth is there's not really right answers to most of the questions there's not one correct way to do I just have an appointment tomorrow and the mom emailed me today to say you know, my daughter got this high school class and it's to watch this film that's a little bit over the level we would typically let her watch. So I'm going to say she can't watch it but I know she's going to be so upset because her friends are going to get to watch the film and that that'll be my morning tomorrow but you know what I do with that family is we talk about letting the daughter express how that's going to feel for her letting the mom express why it's important to her to kind of maybe make this hard decision and then helping them both sort of take each other's perspectives in a way that is more difficult for someone on the spectrum to do and then helping parents learn how to validate feelings without fixing feelings I think is another big thing that so much of high school will feel unfair and feel upsetting and that is true for everyone and especially when your emotions might feel more intense. And so, helping parents pause before they jump into a problem solving or fixing mode and just saying gosh that's so hard I'm sorry you're feeling really upset about this and as simple as that sounds and in the majority of families where I work that's not happening naturally because there's just so much stress on everybody and the child is is going through such difficult scenarios that the parents have just gotten into that mode of always fixing. And so it's been really an amazing thing I consider it a sacred privilege of mine to get to join families in those conversations because it is so intimate and it is so important to be able to be the kind of this ability to try a different way of communicating with each other. Great. Thank you. So, one person is is is kind of reaffirming this idea that you guys said that it can be really hard to find a therapist who has expertise in works with people with autism spectrum disorders. And that's sometimes they've had the experience where they're looking for a therapist and they call and when they say their child has autism. That's an automatic, you know, shut down we don't we don't do that we don't serve that so one someone kind of wanted to know how did you guys decide to specialize in autism what did you go into this area of expertise. And what do we think what do you think needs to happen in order to increase access to needed therapy services for people with autism. I mean, for me I got I got hooked. I, I think, I mean I tell the story sometimes right I mean my very first day as a school psychologist in a middle school. There was a sixth grade girl that ran out of the classroom and to the front of the school building and climbed up a tree. And, and that I mean this is 25 or 26 years ago, and no one was using the term autism they threw around a lot of other terms. But, you know, I wanted to know more I was fascinated by the way she saw the world and the way her brain worked and what her behaviors were trying to tell us. For me, I mean it just became almost instantaneous but I think that the part of that question is, almost like what we were saying about school age children and awareness building like, we have to let you know therapists and medical professionals know that this is not something, you know, so far and from another planet that they can't treat it, or that they can't learn some skills that will really benefit them the families that are that are in need in the communities and the individuals I think a lot more training, more awareness raising more training, you know, just that that would be my answer. Yeah, and I feel like similarly I entered this field 20 years ago working at why I kind of on a very broad range of all developmental disabilities, and I kind of just clipped with kind of working with the kids and adults on the spectrum. And then I did training at the Seaver Center. I did a fellowship at why I kind of always stayed in this area and kind of attend conferences and learn from other professionals. And something that the Seaver Center has been doing, and will continue to do is kind of as Peter was saying, giving general clinicians tools that to use and build their confidence to kind of increase the number of therapists that will work with kids and adults and teens on the spectrum. So we've done that at kind of within the Mount Sinai outpatient system, and then my kind of the grant that I have I work at Community Mental Health Center so WJCS. I'm working with their staff and kind of helping them kind of learn evidence based practices. So I think we're trying, but there's still kind of a lot to be done. I completely lucked on a practicum placement as an undergraduate student in Louisiana, where my match was to an autism clinic and I knew nothing about autism before I was sent there and really haven't looked back since yet. I'm so thankful that that happened because it really similar to you, Michelle, it clicked for me that day and it brings me so much joy. I think, you know, one of the things I noticed we have interns and postdocs who come through our clinic and for many of them, our clinic is the first place they're experiencing autism, even though they're at a more advanced level of training as psychologists and so they're very honest with me at the start that they're afraid of the patients that they they have not ever had experiences with anyone on the spectrum and they're intimidated by some of the challenges and so I think it's been really rewarding to get to see kind of how we're able to directly impact those groups of people as well as, you know, even though Dallas is such a big place. There's very few people in the community who are comfortable taking our referrals and so we similarly do a lot of training and outreach to try to teach community providers skills that they might be able to use to be able to serve people in their own communities instead of needing to send them to the center, as well as offering to do consultation so that if there is an autism specific question we can help with it but for some of the kind of more standard stuff they're totally able to run with those things so it is. It's a hard balance for sure. And I read the quote you said you get doors slammed in your face when you mention your child has autism and that is such a common thing that I hear and I'm really hoping we can change that. Thank you and yes someone just commented, please spread the word in your professional communities that working with people with autism can be very rewarding. Which I definitely agree with as well. So, someone asked if you could make some sort of change to the medical model of autism at present what would it be. Maybe kind of our understanding. I'm not sure if they're asking about like our understanding of autism or if they're talking about like how we treat autism, how we diagnose autism. Yeah, I mean I'm not sure the nuance of the question I, but two thoughts came to mind I mean one is, you know, we use the DSM the diagnostic statistical manual right I mean we collect observations about behaviors and, and I think for for a very long time we we didn't get it right we we were not looking for you know things like anxiety and autism or depression and autism we were just assuming. If you have an autism diagnosis it covers all this unusual behavior and we're not going to treat the anxiety or the depression so I think we're moving out of that model which is really great. And some of it is coming from the better science the better research that you know I'm sure Michelle could could cite even better than I. The other part is unfortunately sometimes our medical system is really built on looking at people's weaknesses and their symptoms. And those I find are not often leading us to solutions interventions and better outcomes I think we really do have to make this huge shift to people strengths to to the things that they, you know, offer that are unique that we had not thought about. Sometimes we're trying to fit it into the, you know, societies mold or the schools mold, but if we can change the environment the setting of the school we can change workplace environments. That's going to benefit that diversity is going to benefit all of us so. And I sit on so many boards with like self advocates and as a psychologist and coming from that medical model. And I'm talking about the DSM it, I know it does not align with self advocates it does not align with neurodiversity movement. I have a lot of conflicts but I also know that the diagnosis is the key to services, and that we know services are beneficial. So kind of agreeing, it's a systemic issue. And I hope that the team that you're, if you have a child or adult are working with doesn't just use that label to define the child and kind of uses the label to get services and supports in the school or accommodations in the workplace, but really is looking at that individual and their own strengths and weaknesses. One audience member also pointed out the fact that so few medications have been tested to see how effective they are for people with autism. And that may also be contributing to, you know, a lack of known effective treatments for people with autism. Do any of you guys want to speak to the problem of people with autism because of their diagnosis being excluded from from research and and drug trials. Yeah, I mean so I'll also talk about I was, I talk a lot about this with one of my colleagues who is a psychiatrist. Autism spectrum disorders are different than like ADHD. So ADHD there's a very specific mechanism and we know medication works. Autism spectrum disorders is a much more heterogeneous diagnosis. So the cause of autism is different from one person to the next, the presentation is different from one person to the next. So they think that the heterogeneity of autism is kind of what impacts, unfortunately the results in a lot of clinical trials. So, I know a lot of the psychiatrist that I work with do prescribe medication in individuals and spectrum for anxiety and depression with success. And I think it's important that if medication is the right thing for your family that you're seeing a psychiatrist who is familiar with individuals in the spectrum just because there can be different side effects, the doses can be might be adjusted. And there are some medications that work better and some medications that can actually increase anxiety. But I definitely, for most of the clients I see there is definitely a role of medication with therapy. And that's a great point that there's not necessarily a medication for autism. There may be medications that have been shown to be effective for certain symptoms, but there's not a medication for autism, per se. And in part because of the nature of the disorder, having so many multiple potential causes and respectors. Right. Well, it is one minute left. I just want to take a minute to thank all of you for joining us tonight I hope this was informative for the audience it was enjoyable for me. I always love to hear from from my fellow colleagues who have expertise in autism. And I think these types of events are very important for the reasons we talked about better acceptance awareness inclusion, both for the community but also for us as professionals as we try to expand the access to services for people with autism. So, thank you all. Thank you Cassandra. It was a great job. Really appreciate it and then everybody's time. Thank you again. And as we should mention that we did record tonight. So everybody who is tuned in will get a copy of the link to the recording. So if there's a part you want to revisit or forward to someone you think may find it useful. Please do so that'll be coming your way in the next next day or so. So thank you very much again everybody. What a pleasure. Thank you all. Have a great night. Good night.