Tony Attwood Hi there, this is Tony  Attwood. I’m a Clinical Psychologist,   and I’ve been exploring autism for over 50  years. It’s been a wonderful experience.   What I’m going to do is pass onto you  today some of my wisdom, as a Clinician,   working with children, adolescents, adults, and  aging individuals, on the autism spectrum [pause]. Now, first of all, you would send out  a variety of screening instruments,   that would be there to identify autistic  characteristics, often completed by a parent and,   probably, a Teacher, and you would score  and review those instruments. What you’re   going to do in the diagnostic assessment  is actually assess the authenticity of the   various components that have been, shall we  say, flagged by the screening instruments. Now, the actual diagnostic process itself may  be an individual Clinician, with considerable   wisdom and experience, or a multidisciplinary  team. Now, the crucial component, during the   diagnostic assessment, because this is autism, is  to engage with that individual. A major component   of autism is a difficulty understanding  people, so you need to present a good model,   and encouragement of engagement. You  give out signals of social interest,   and also check the child or adolescent’s  degree of reciprocity, response, and so on. Now, if you are having a conversation, you are  going to explore the person’s experiences and   concept of friendship, looking for any aspects  of developmental delay, bullying and teasing,   or any concerns. It’s also their social play,  for young children, to actually engage with them,   for adolescents, it’s more talking about  their interests and engagements with their   peer group. But you’re looking at the person’s  ability to read social situations, people,   facial expressions, body language,  and so on. Also, their interests,   you are exploring if there is anything unusual  in intensity or focus. And I find that’s a great   opportunity to understand what the autistic person  is like, when they’re engaged in their interest,   and it’s almost like having an on button,  and the person can become really quite   animated in talking about the things  that they’re particularly interested in. So, other aspects that we look at are in terms  of any challenges that may occur at school and   at home, especially sensory experiences,  and coping with change and uncertainty. So,   in other words, there are many dimensions  that you are exploring. From my point of view,   I have a, sort of, a script, but  what I will do is go with the moment,   I don’t always follow them in sequence, I  seize the moment and explore various aspects. Now, what you’re doing during the diagnostic  assessment is making a note of the degree of   reciprocity, reading your facial  expressions, body language, but,   also, the child’s use, or adolescent’s use,  of non-verbal communication. But you’re also   looking at the signature language profile. Now,  that can be pragmatics, pedantry and prosody,   but there is a signature language  profile associated with autism. Now, there are standardised instruments,  we’ve had them for a number of years,   and they’ve been really central in the diagnostic  process. Now, there may be the ADOS, the DISCO,   or the MIGDAS-2, etc., and each have their  particular qualities. But what I would do,   as a Clinician, I often supplement  my diagnostic assessment with some   of the things that I have used and learned by  stories, pictures, a whole range of things. So the ADOS, in particular, is very good  for what may be called classic autism,   but not so good with autistic girls, especially  teenage girls, those of higher IQ, etc. So,   I would not use the ADOS as the only instrument,  others that I would use. Now, there may be,   for example, the CARS2, or the Modified  Questionnaire of Autism Spectrum Conditions,   which I actually contributed to, which was  specifically designed to identify autistic girls. So, use additional instruments. Now,  if it’s a multidisciplinary team,   they will have their own instruments, the  Speech Pathologist will have their instruments,   the OT, and so on, Psychologists may look at  cognitive profile, and so on. But I also use a   range of activities to assess theory of mind  skills, they’re little activities, stories,   and so on, that you engage with, that help  you to understand theory of mind, empathy,   in particular, that is not only cognitive empathy,  but emotional empathy, and behavioural empathy,   and ability to read cues, and understand the  motives of people in a series of photographs. So,   you’re looking for, also, any indicators,  during the diagnostic assessment, of ADHD   or language or intellectual impairment, but,  also, motor co-ordination and dexterity. So,   it is a very complex process  and there’s a lot to go through. Another point that you need to do is also  discuss with the parents the, shall we say,   the authenticity of the actual replies. So, the  person may say, “I’ve got lots of friends,” but   the parents may say, “Well, actually, they’re  acquaintances,” they’re not really true friends,   as his peers would expect. And, really, you need  a second opinion as to the validity of what that   person may have said or done. Particularly in  the area of camouflaging, and many autistic   individuals, especially the girls, may camouflage  and may be a very different person in front of   you, as an adult, as they are with their peers,  or at home, in a way. So, it’s also that they can   confirm issues with emotion management, and  a whole range of areas of their concern. So,   that’s my answer to a very important question,  in terms of the diagnostic process [pause]. Now, obviously evidence-based programmes such as  applied behaviour analysis, cognitive behaviour   therapy and sensory integration therapy, but some  successful strategies have yet to be evaluated by   formal research studies. It doesn’t mean to  say that they’re not any good, is they’re not   confirmed yet. And this is where the individual  Therapist may decide what they are going to use,   from their own clinical experience, prior to  independent research confirming the validity   or evidence-based approach. So, it’s up to  the Therapist to decide what to include. Now, each autistic child is different. One  of the fascinating things about autism is   the heterogeneity of what’s involved. And I  prefer a very eclectic approach, that takes   various components of that autistic profile,  and the diagnostic assessment is identifying   the autistic profile, and you may find that you  can use bits from various therapy or intervention   programmes that are unique to that particular  child. So, I prefer an eclectic approach of   several interventions, based on knowledge of  that individual, that may change over time.  Now, it’s also important to assess the  practical nature of that intervention,   and that’s from the parents’ perspective. Do  they have the time, energy, and resources to   be involved with the programme? Sometimes with  multiple children, and all sorts of family crises,   etc., you may have designed the fantastic  programme and you know it’s going to work,   but they haven’t got the time, or they haven’t got  the energy, they’re burnt out, or resources. So,   you really do need to tailor the intervention  programmes for the home circumstances. But there’s also the question of, does that  individual on the autism spectrum actually   relate to you? And autistic individuals can be  very black and white in who they like and they   don’t like. And the trouble is, if they make a  decision that they don’t like you, it doesn’t   mean to say you’re not a good Therapist, it’s just  not a rapport between you, and the barriers may   come down. So, it’s very important to develop  a rapport with that individual person [pause]. Hmmm, what I would tend to do, clinically,   is create a list of concerns, both of the  parents and the autistic person themselves,   and there may be differences. Parents are  concerned with personal hygiene and managing   the meltdowns, but the autistic person is more  concerned about, “How do I make friends?” And,   “How do I spend more time on computer games?” So,  you’re going through what are the, shall we say,   important areas to address in intervention, you  make a list of them and put them in rank order,   with considerable weight given to the child or  adolescent’s personal choices. Now, if it is   something that they choose, then you’re going  to have far greater motivation and attention. Now, the decision needs to be made as to  whether an intervention programme is likely   to succeed for each challenge. So, if you’ve  got your list, this is very, very important,   but actually to achieve success in that is  going to be difficult to go through. So,   what you may do is start in your rank order,  at the lower ones, you’ve chosen the top five,   and what you may do is say, “Okay, let’s choose  something relatively easy, let’s succeed with it,   that’s going to give confidence, motivation,  and commitment to future interventions.” So, the decision of which area do you  move into and provide intervention   may be based on practical circumstances,  and then work up through the hierarchy,   to those things that are, shall we say, more of,  shall we say, a consistent and a daily concern,   but perhaps waiting until other  strategies have been learned [pause]. Well, my personal opinion is  the best measure of success is,   is the autistic person interested, motivated,  and co-operating with the programme? If they do,   then it’s successful. And that’s your best  measure of success, is that person engaged   in what you’re suggesting, actually applying  that, not only in the therapy sessions, but,   also, outside, in real life settings?  Then you know you’re onto a winner. So, it’s their enthusiasm for the intervention  I think is one of the best measures, is whether   they turn up. Because if you have a therapy  session, they’re making a choice between you,   as a Therapist and Minecraft, and that means  that you are probably better than Minecraft,   if they turn up. So, it’s motivation and attention  are going to be very important components. Now, there are a range of before and after  instruments, for example, instruments that measure   anxiety and achievement levels in a variety  of areas. So, yes, it is very important to be   evidence-based, and to have confirmation of change  over time. That can also be used with the autistic   child or adolescents to focus on the value of the  programme, and the changes that have occurred. Now, it’s also important to check on the  parents’ perception of the intervention,   and ask them to identify potential  barriers for the implementation,   and to work constructively together, in terms of  how to remove those particular barriers. Now, they   have extensive knowledge of their son or daughter.  They have a knowledge not only of their abilities,   but their personality, what has worked, and so on,  in the past. So, they are a central, an essential,   part of the intervention team. So, it’s very  important to consult with them, to say, “Hmmm, I’m   having a bit of a problem with trying to get  this particular concept across,” and say,   “Have you any ideas?” And they say, “Ah, relate  it to his special interest, it’s” – whatever it   may be, “Doctor Who.” Right, use the metaphor of  Doctor Who, that’s going to capture his attention,   that’s going to be a visualisation that he  can use. So, check with parents, can they   make any suggestions for the programme [pause]? Now, the primary professionals are obviously   Psychologists, Paediatricians, Speech  Pathologists, and Occupational Therapists.   However, due to the profile of autism,  and my extensive clinical experience,   I do recommend considering Music and Art  Therapists, yes, especially for concept of   self and emotion regulation, and communication  aspects for those who have difficulty speaking,   and so on. So, there’s a lot to be achieved  by work with Music and Art Therapists. And interestingly, the career of  that individual may be in the arts,   but it also may be somebody like a Personal  Trainer. I’m involved with emotion management,   which I sometimes call energy management, and they  may need a Personal Trainer, or Physiotherapist,   who will design physical activities that burn up  the energy of agitation, that are activities that   that person finds achievable, enjoyable, and are  very good are reducing excess emotional energy. But, also, there is increasing research  evidence and personal evidence, clinically,   in the value of yoga, mindfulness, and  meditation. Yes, not every autistic   individual responds positively. I found  about a third may not respond positively,   but two-thirds, one-third, very much,  another third, oh, take a bit of time,   can be very valuable for an autistic person.  So, it’s a very, very broad approach. Now, there’s also the question, should the  intervention be conducted individually,   sometimes one-on-one? ‘Cause in autism,  two’s company, three’s a crowd. But you   may also consider, especially for autistic  teenagers, autism groups. Now, this may be   if you’re dealing with eating disorders, gender  dysphoria, alcohol and drug consumption problems,   and so on, is having an autism group, which  is autism friendly and mutually supportive,   and they provide advice for each other. So, group  activities can be very, very successful [pause]. And one of the major things is to  determine their learning profile,   because they’re going to have  to learn how to socialise,   read non-verbal communication, to make  friends, all those sorts of things. So,   in therapy, you’re learning, and you need to  assess the learning style of that individual.  Now, for example, some autistic  individuals are visualisers,   they’re the natural engineers or artists. Now,  that means that it’s often computer-based,   or graphic design instruments and activities  that may be appropriate for that individual. Often, teaching, education and therapy  involves a social and conversational   context. In autism that’s not easy. So you may  have programmes on computer apps or computer   programmes. This is the big, shall we  say, frontier in autism now, is a lot   of programmes that range from communication  right the way through to emotion management,   or adaptations to Minecraft and various things,  and so on. You’ve got the person’s attention,   they enjoy those particular games, so it’s  using visualisation as much as you can. But, also, if you’re using a manualised approach  and the person has to complete and write their   comments into that manual, one of the problems  is going to be handwriting. So that needs to be   assessed, and consider that there can be typing,  or a scribe, or somebody to overcome that problem.   It’s also important in the adjustments that  are needed to consider the sensory aspects of   the room, and that may be in terms of the light  that’s coming in, it may be in terms of sounds,   aromas, furniture, colours, etc. It’s trying to  make the room as autism friendly as possible,   but, also, the number of people, and, also,  personal space for autistic individuals. It’s also important to acknowledge the attention  span. There is an association with ADHD,   and it may well be that the person needs to  have the activities that they can do within   their attention span, and you’re  very aware of when that’s ended,   then time to take a break. But, also,  to use relaxing and fidget toys,   because they are soothing and calming. Also,  have a look at positive reinforcement for what   they do right. One of the characteristics  of autism is a fear of making a mistake,   but a great delight in getting it right. They’re  going to need a lot more positive feedback and   reinforcement for what they’ve done right. And,  also, integrate the special into the therapy,   because you’ve got the attention and a  metaphor for whatever you’re trying to explain. For example, in emotion management, I had an  autistic person who was fascinated by the weather,   and I used weather systems as a metaphor for  emotion management. So, “You’ve got a depression   coming in, you’ve got foggy thinking,” and so on,  so it’s using that to include in your programme. But it’s also the cognitive inflexibility of  not knowing what else to do, and sometimes the   person needs external prompts or suggestions  of what to do, a consistency and a routine,   don’t have surprises, which can be very  upsetting. But, also, be aware of alexithymia,   difficulty converting thought and emotion to  speech, and issues with interoception. So,   those are some of the adjustments to  be made with regard to therapy [pause]. Well, the answer to that is really within  the previous question, it’s to become autism   friendly. Now, that’s autism friendly in terms  of the room and accommodating the learning style,   etc., but it’s also being very positive  in attitude towards autism. And it means   that you are interested in their interests,  and you may begin and end the session with a   focus on the special interest, to develop a  sense of rapport, but it can be to get that   degree of connection. Now, if they trust  you, and if the rapport is developing,   then they’re going to feel safe, relaxed,  and can then focus on the therapy [pause]. What I would recommend is that there  are now instruments specifically   designed to assess aspects of autism that are  standardised on autistic kids. For example,   if you look at anxiety, it’s  a major problem. One thing   that autistic individuals are very good at is  worrying. 85% have daily issues with anxiety. Now, Jackie Roberts in the UK, and colleagues,  have developed the Anxiety Scale for Children   with Autism Spectrum Disorder, and modified it  for younger children, and for adults too. So,   this will provide you with the specific questions  related to anxiety associated with autism. Now, in my own book, with Michelle Garnett,  “Exploring Depression, and Beating the Blues,”   we have a list of reasons why an autistic  person can feel sad or depressed. So,   you just go through those reasons, and ask  them to rate how important that is. Zero is,   nah, that’s not a reason, or ten, ah, that’s  a significant reason why I’m very depressed. Now, we also look at a recognition of a range  of emotional mechanisms for repair of intense   emotions. Now, we go through a range of tools,  of a emotion repair toolbox, but also with an   emphasis on things like mindfulness and yoga,  physical activities to burn off the energy,   strategies to improve interoception and  alexithymia. But also to improve social skills,   so if you’re dealing with someone with an eating  disorder, or gender dysphoria, etc., and you   explore what are their concerns, sometimes their  concerns are also related to social connection and   friendships. So, part of the intervention  programme may be to encourage particular   friendship skills, when the focus is on depression  and suicidal ideation, and so on, but friendship   is one of the major reasons that they’re  depressed, you need to focus on friendship. You also look at maladaptive thinking that  can occur. There can be a tendency to be   very catastrophic, huge explosion over  something, very black and white thinking,   and using strategies such as avoidance,  suppression and thought blocking,   like computer games, and so on. So, it’s looking  at adaptive thinking, particularly self-soothing,   can be difficult in autism, the ability  to disclose, with alexithymia and trust   of individuals about your feelings, but,  also, aspects of cognitive restructuring   and cognitive flexibility. So, those are the sorts  of approaches to traditional therapies [pause]. Well they are central. What you don’t want them  is to sabotage the programme. That you need their   commitment to it. That’s why they very much need  to be consulted, their advice accommodated, etc.,   and to encourage and give positive feedback to  the parents of what they’re doing. Sometimes   what I will do is go through what strategies the  parents have used, and then go through what have   been the value of those particular strategies, but  then say, “Okay, those are some of the strategies,   I can understand that you’re using, but  what I’m going to go through are some   additional strategies. I’m not saying that  we need to totally change your approach,   but these are some ideas for you to consider and  see how they work.” So, it’s the co-operation   and effective communication in the design and  implementation, they are there all the time. When I’m working with an individual, I will  often have the parents there sitting in,   because then they know what’s involved  and can then apply that and become a   mini-me in real life social situations [pause]. Okay, well, some of them are very obvious.  Waiting time for assessment and therapy,   it’s dealing months in years, and that’s  such valuable time. So, it’s waiting times,   I know the government is trying to deal with  that, but once you’ve got an assessment and   confirmed autism, the issue is then what  support is available? And some parents   are disappointed that, “Wow, we know we  have autism here in my son or daughter,   but where are the programmes to help that  individual?” So, it’s both assessment and therapy. It’s also at CAMHS, staff knowledge on  autism needs to be regularly updated,   to attend in-service programmes, but, also, to  have access to autism specialists. So that you   may have an autistic person, and you think, wow,  the complexity here is beyond me, I’ve not come   across this before, is there an autism specialist  in my local area or nationally that I can contact   to seek advice of what to do? And that person  may say, “Ah, yeah, I’ve known this before,   these are the things that are likely to work,  these are unlikely to work.” So, you need almost   like a tertiary referral system, an access to  expertise, beyond that, within the CAMHS team. But another problem is going to be staff  turnover, and the characteristic of autism   is having difficulty in forming a rapport  or relationship, and coping with change. So,   when there’s a staff turnover, that can also  be a problem, and can set things back. So,   those are the issues, and, hopefully,  there are some solutions [pause]. Now, one of the things that I found very helpful,  in looking at the future, is to focus with the   autistic adolescent on the concept of self,  “Who are you in terms of your qualities and   difficulties, your strengths, and the things  that you’re motivated and interested in?” Now,   it’s to use that to make a career choice, but  also relationship decisions. So, I do strongly   recommend that part of the intervention is, “Who  are you?” Very difficult for autistic teenagers   to answer, but in understanding the positive  qualities, you’re going to get much more,   shall we say, effective decisions in career,  further education, and relationships. Now, the person is also going to  need guidance in daily living skills,   such as budgeting and nutrition, and  avoiding junk food, as much as you can. So,   if they are going to eventually become more  independent, it is an assessment of daily   living skills and what needs to be covered. But  there’s also the preparation for the transition to   further education and employment. Change is very  difficult for autistic individuals to cope with,   but they need information as much as possible,  and preparation for the change in stages. So,   it’s finding out what university, college, have a  look at the place, find out what the courses are,   go around and have a look at the buildings,  etc., the geography of the campus. But,   employment, it’s trying to find out the  attitude, and so on, of various employers. Now, I am a strong advocate of the  publisher Jessica Kingsley Publishers,   jkp.com, and they have a lot of books on the  transition to further education and employment,   and to go through those books with the  individual. I’ve actually written one on   “Autism Working,” with my colleague, Michelle  Garnett, published by jkp.com, which is a   manual for the person to go through in finding,  seeking, and maintaining successful employment. It’s also how well does the university  or college or workplace cope with autism?   And it’s really looking at what we call  here in Australia Neurodiversity Hubs,   and connecting with that support  network for the individual. So,   how well does the university or work accommodate  autism, and what are their support systems? But   it’s also the issue of leaving home,  when, and how, and the confidence,   and so on. Sometimes there’s a developmental  delay, there is in most teenagers in modern   society anyway, but if they are going to leave  home, the various adjustments that may occur. But, also, long-term, guidance  in identifying good friendships   and not to be abused. This can be  a problem in their determination,   enthusiasm for developing connections with people  and friendships, it may not be the people that   would be good for them in the long-term, and  avoiding abuse and assault that can occur. So,   it’s the ability to identify someone who appears  friendly, but is not genuinely a good friend. So,   there are many things that need to be covered in  the transition to being a young adult [pause]. Ah, I’ve been specialising in autism for  50 years, a lot has happened in that time,   many things have come and gone. But one  thing I do know is autism describes a   very heterogeneous group, and there are  always exceptions. There are the outliers,   and they may benefit from a particular programme,  but it is unique to their origins of autism and   their autism profile. Thing is, parents who have  had that particular progress think it’s wonderful,   and it’s genuine for that person, and they want to  tell everybody that this is a universal programme   for all autistic kids. Well, it may work for  that individual, but not autism in general. So, it’s a very heterogeneous group, and there  are no universal therapies for all autistic   individuals. Now, obviously there are conventional  evidence-based therapies, and over the last 50   years or so, I’ve seen the rise and fall of a  range of interventions. One, holding therapy,   several decades ago became very, very popular,  it was in the media, now they realise, no,   it’s not as effective. Auditory integration  training, or dietary interventions to cure   autism. I think that the media is wanting a cure,  and as soon as something is looked at positively   may amplify the success of that individual.  So, it may be to be conservative about that,   and make your own clinical decision  about the various therapies, and so on. But it does mean parents will say, “What  do you think of? “Should I try this?” And   you need to be objective and supportive of  the parents, because they can be tempting,   and certain entrepreneurs may promote certain  programmes that will make a lot of money for   the entrepreneur, but may not be suitable for  that autistic individual, or the majority. But I also recognise, and this is my last  comment, the placebo effect. When you have   randomised controlled trials and a whole range  of investigations, and it’s uncertain whether   that particular child or adolescent actually had  the therapy, maybe the medication, for example,   that was supposed to be assessed, you find  that the control group, the placebo effect,   is considerable. They didn’t have the genuine  article, but there was actual progress, and   that is due to a positive attitude. Parents are  looking for success. They don’t know if they’re   actually having this particular medication  or therapy, but they are now thinking, oh,   they might be, and they change their attitude to  notice what the person is doing well, that could   be due to the tablet or the therapy, but it then  becomes a very positive way of genuine change. So, my particular view is encouraging  a positive attitude with parents and   Therapists, can have extremely powerful  effects. It’s basically not extreme,   but by being positive, you will  have positivity in response.