Hello. We are the Association for Child and Adolescent Mental Health, or ACAMH for short. Hi, everyone. And a very warm welcome. Thank you for joining us today. We are really pleased to have you with us. My name is [INAUDIBLE] and I am the content and events producer at ACAMH. It's a pleasure to welcome our speaker today, Francisco Musich, professor of child psychiatry and neurological disorders at Universidad Favaloro in Argentina. His current research and clinical work focus on autism and its co-occurring conditions with a particular interest in adapting psychological treatment to better meet the needs of autistic individuals. Today's session, autism and co-occurring conditions, adapting psychological therapies, we'll explore the gap between evidence-based protocols and their effectiveness when applied to autistic individuals without adaptations. Francisco will discuss transdiagnostic and trans protocol adjustments, identify specific protocol adaptations, and discuss how addressing these gaps has the potential to improve clinical effectiveness and promote more inclusive practise. This session will run for two hours. We'll have a short break halfway through. And Francisco will leave around 20 minutes at the end for questions and discussion. Please feel free to submit your questions throughout the session at any time using the Q&A function in Zoom that you see in the bottom of your screen. As a gentle reminder that delegates are not permitted to record, transcribe, or capture any part of this session using any device or software, including AI-based tools, such as Otter.ai. Thank you, again, for being here today, Francisco. Everyone, welcome. And over to you. Hi, everyone. It's a pleasure to be here. Hopefully, we can start approaching and tackling this, for me, really interesting subject which still needs a lot of research. Because currently, we do have some better understanding, and then maybe a few years ago, regarding what people with autism need when we try to help them with their current conditions. But still, much research is needed. So first, before we start, a few disclaimers. You will hear me, and this is on purpose, throughout the presentation, using different terminology terminology, people with autism, autism, autism conditions, autism disorders, autistic individuals or autistic people. As I was saying, this is on purpose. Mainly because what little research we have on preferred terminology, it doesn't show a clear direction regarding which is the preferred terminology for people within the autism spectrum. What we do know from those few studies is that on average, and again, this is on average, people with a more severe functional impact, meaning that their autistic traits, and cognitive style, and social style have more impact on their daily functioning, they tend to identify more with autism, with having autism as a disorder or a condition, and people with less functional impact, they tend to identify more with I am autistic, similarly to professionals and families of this population. So long-- the best approach, I think, is for us who do teaching and research, and it's try to be as representative as possible. That's why I will be using different types of terminology. And when we are approaching the patient client regarding which part of the world you are and how do you tag someone that you're trying to help, it's to ask them what sort of terminology they prefer. The other big disclaimer is that 90% of what we're going to be discussing today is predominantly based on research done with autistic individuals without cognitive-- major cognitive impairment, without intellectual disability, or without language disabilities or deficits, meaning that they are not representative of the whole spectrum. We do still, people who are with moderate or profound autism, we do owe them still research regarding how we try to help them when they present co-occurring conditions or comorbidities. So you should or advise you to understand that what we are going to discuss in this session, its focus on people in a very short percentage of it, represents a very short percentage of the population in the spectrum. Again, mainly people without ID and without any language or severe language difficulties. So some statistics, which they have a goal-- I have a goal in mind for this. So depending on which epidemiological study, you choose to focus-- to focus yourself, they vary. But most studies agree that between 70% to 90% of children and adolescents with autism have at least one co-occurring condition, and about half of them, around 40% to 60%, they have two or more co-occurring conditions. So why this statistical data, it's important for us clinicians. Because it means that on average, when we are facing with a adolescent, a young adult or a child with autism, most likely, that person, it's going to have another mental health condition or it's going to have a mental health condition concurrently with the autism presentation. Why do I think this is important? Because here in Argentina, obviously, it's not representative of the world. I did my training and work at the NIH in the UK. So in my experience in different settings around the world, usually, psychopathology or general mental health services, they do go and assess mental health conditions, such as anxiety, depression, OCD, et cetera, but they refer to specialised services for neurodevelopmental conditions. But neurodevelopmental conditions services they don't tend to probe as thoroughly co-occurring conditions. So there is a gap between what we know happens and how services, can services approach people with neurodevelopmental conditions. As a big takeaway, usually, when we are facing, again, a client or a patient with autism, we should take it-- take it as a gold standard to always assess the presence of mental health conditions. Because on average, from one out of two patients that we are going to see will have one or more co-occurring conditions. And if we don't assess them, we're going to miss that. And if we miss that, we're going to actually miss having a meaningful impact in the patient's treatment or the way we help them. So it's important to always ask and look for them. A professor of mine had a brilliant phrase which says, you know or you're going to understand things about the patient that you ask. What you don't ask, probably the patient either won't tell you, doesn't know he has to or they have to tell you, or you're not going to find out. So we need to ask questions about co-occurring conditions. Most common co-occurring conditions are depression, around 25% to 30% depending on the study. Anxiety disorders, they have a higher rate of co-occurring presentation associated with autism. Also ADHD, OCD. OCD, small parenthesis, if we focus on strict-- either ICD or DCM criteria, the percentage of concurrency is lowered, 15% to 20%. But if we focus on more subclinical or subsyndromal presentation, it goes up to 40% or even higher, so around 20% to 40%. That's why the height spread between percentage in this particular condition. Also, suicide risk and self-harm. We understand that it's something and the prevalence is huge. And it depends on the study. The UK has very strong tradition in research associated to suicide risk and self-harm, particularly for a researcher that I really agree with her, Sarah Cassidy. You should-- if you are interested in the subject, she's a great source to go to consult. And lastly, emotion dysregulation. In a few recent years, emotional dysregulation has shifted from condition-specific symptom to a more transactional transdiagnostic presentation or symptoms that might occur. We know that now that people with neurodevelopmental conditions, ADHD, autism, and other developmental conditions might present or most likely will present with emotional dysregulation. And that doesn't necessarily mean that they have a personality disorder or another co-occurring condition. Most likely, it's part of symptoms that might occur within those developmental conditions. So again, why this matters or why this should matter, either you're a clinician or you're someone in a position in the decision making area, CAHM services, or governments, or other institutions? There are some studies that show that most costs associated with the treatment of autistic individuals, particularly adolescents and young adults, they are not so much-- again, within the spectrum of people without ID and adequate language, they are not so much associated with core autistic features, but they are much more related to co-occurring conditions. So the biggest reason why people they tend to need treatment, they tend to need either psychological, or psychiatric, or other com services, it's more related to co-occurring conditions rather than the core autistic features in that particular population. Yet despite this, and the huge economic impact, as I was saying at the beginning, comorbidities in autism, they are quite underrepresented in research. Progressively, we are understanding more and more and more funding is being allocated to understanding our current conditions, and how we approach them, and how we treat them. But still, much research is needed. So what we know so far is that if we apply standard treatments or treatment as usual, for instance, behavioural activation for depression, or progressive exposure, or anxiety treatment, CBT treatments for anxiety, and so forth, it's not that they are not-- those protocols are necessarily not going to work, but we know that for some people or some autistic individuals, they are going to be less effective. Either we are going to get less results, we're going to need more time, more therapy time. And if you are in a public setting, sometimes that's not possible. If you're in a private setting, sometimes, that increases the cost for the patient too much, and they can't afford it. So applying more effective and-- more effective treatments is really important. And so far, from research, we know that due to some neurodevelopmental differences, there might be some of the reasons why these protocols are less effective, mainly due to language and social communication style, sensory, sensitivities, and sensory processing differences, cognitive style, like lower or reduced cognitive flexibility, literal interpretation, processing speed, emotion processing. And last but not least, structural and contextual barrier to treatment. So this is a two-way variable problem. It's not that because you're autistic, treatments are going to be less effective. So because some autistic features and traits might influence or are not so adequate for treatments that are, on average, designed for people who are not non-autistic. But there are also several barriers to treatment, such as access to care. How much training clinicians, psychiatrists, psychologists, and other professionals have received. And they understand about autism conditions that usually, it's a severe barrier to provide adequate treatment for people within this community. Probably not so much in the UK, but for instance, here in Argentina, sometimes it's quite common to find adult or teenager clinicians that they have really, all understanding of why autism might happen or what is autism, for instance. If you go to secondary school, and you don't need accommodations, and you have maybe one or two friends, some professionals might tell you, no, because you have one or two friends, you don't have autism. And we know that that's not so. So there are many barriers and difficulties associated to access to care that are on our side and not on the patient side that we need to address eventually in the future. So problems from these differences in the cognitive sensory, et cetera style. And the barriers and difficulties associated with clinicians and services. They mean that if we don't adapt therapy or therapeutical approaches, we have a higher risk of reduced effectiveness, lower engagement from the patient, and therefore poor outcomes. So adapting clinical therapies or adapting protocols, it's not moving away from evidence-based therapy. But in this particular case and population, it's a necessity. Because we know that, again, if we apply standard protocols, we are going-- we have a higher chance of being less effective. A few years ago, probably more than 10, 15, there was a huge conference in the US, and this was for non-autistic population. There was a presenter, speaker. And he asked-- it was an audience of all clinicians. And he asked them a few questions. One of them is how much you trust and you think it's adequate for having protocols, evidence-based research, et cetera? Everyone said, yes, we agree. And then he asked, how much in your clinical setting in real life do you apply protocols strictly as they are? And probably 20% or 30% of the audience said, yes, we do. So already, in common clinical settings, we need sometimes to have some adaptations to evidence-based protocols. Because most protocols are for one condition, nor not for the real-life patient that they have-- they might have two or three or more conditions simultaneously, or they don't particularly apply to that client, or that client needs or have some particular needs that we need-- that they need to be meet, and the standard protocol doesn't necessarily cover them. So this is not an application of adapt everything flexibly, and protocols are not useful. Protocols are extremely useful. They allow us to have evidence-based treatments, and research, and understanding on the outcome, risk, side effects, et cetera. But have a flexible mind, meaning that some people, autistic and non-autistic, might need certain adaptations for us to better serve them. When we are in the process of starting therapy with a client, independently of the type of therapy, CBT, DBT, et cetera, it's usually recommended within the set of adaptations that we won't do with a non-autistic or someone without a neurodevelopmental condition is to assess communication and language. Ideally, early within the assessment process, this can be done either formally throughout questionnaires or a proposed speech and language assessment, or even more informally while conducting the first interviews with the patient. But it needs to be assessed. Because ideally, we need to understand how much we are going to be able to transmit to the client in a way that they are going to understand. I usually have a very repetitive phrase when either doing assessments or engaging in therapy with patients that I would-- because I honestly think that way. I try to say, did I explain things right, or was I too confusing explaining blah, blah, blah? Trying to put the focus in maybe I'm not explaining things in a way that you need rather than you are not understanding me. That usually, it's a more friendly way to try to assess if the person is understanding us or not. Another thing regarding adaptations is not to assume, as I was saying at the beginning, which sort of terminology the patient prefers independently of what do I think it's better. Either to call to use autistic person or a person with autism, or if I'm more leaning towards it's a disorder or more leaning to it's a condition within the setting of a treatment. Similarly, to gender identity, the most effective way of approaching this is asking and using the terminology that the person prefers. As I was saying, with gender diversity, there is increasing evidence that there is greater gender diversity within the autism population. So either using gender neutral or explicitly asking about preferred pronouns, it's also recommended. And we need to be really careful to communication style, our communication style, and language use. I'm going to say some things about this. So we need to use ideally. And this is a thin red line between-- or sometimes, we're going to require some trial and error, understanding-- because not all patients are going to need for us to be so precise, so short, no language. Some are going to need a more eloquent language. So we need to adapt to a client. But on average, if we use more clear, precise, and short language, it's on-- it's, on average, more effective for people within the autism community. Sometimes, it could be useful for us to support what we say with written language summaries. A summary of the session. I sometimes, while in session, keep a log with the patient. And we do bullet points of, hey, so what we have learned or what is the conclusion so far? So we write on that blog. So at the end of the session, we can have a summary that either send through text message, WhatsApp, email, the patient takes away in a written language, in a note, or in a written paper, on a notebook, et cetera. So having this sort of support, not only depending on oral language, it's really important. Again, independently of language and cognitive level. Also, trying to avoid the use of jargon, vague expression, undefined terms. Or if we use them, it's really important for us to check if we were able to transmit the message to the person and if the person understood us. This is mainly because difficulties understanding ambiguous language should not be interpreted as cognitive, or verbal, or language impairments rather than literal interpretation or the reduced use of contextual cues. So this is not an impairment. If we are with a patient that is having a hard time understanding us if we use too much vague expression, or undefined terms, or too much jargon, it's not that they have a language problem, but it's more related to their autistic traits. Also, and this is not new for probably the most of you, therapeutic alliance. It's a robust predictor of treatment outcomes, meaning it's a huge percentage of the effectiveness of the treatment. So this is how basically how well we connect with the parent, with the patient and how well the patient connects with us. So therapeutic alliance mainly comes from agreement on therapy goals. So we need to, in a collaborative way, agree with the client or with the patient what they want to achieve with therapy. We can propose ideas, but we need to respect what the patient wants to achieve from an affective bond between the patient and the clinician. It's a two-way street. So the alliance is not only dependent on the clinician, and it's not only dependent on the patient. But we know from research that, again, independently of the type of therapy, cognitive mindfulness, social skills intervention, DBT, et cetera, still in autistic population, in the therapeutic alliance, it's really important, but it's harder to get. Most of the times, it's harder for the clinician. Sometimes, it's because we have a hard time understanding emotional states of the patient, understanding if they are identifying with us, if they are OK with us, if they are happy with treatment, if they are happy with the way things are going. So we need to be much more explicit when we probe and we try to understand that, and not necessarily assume that the patient is not connected with us. So sometimes, other factors that might influence a more robust therapeutic alliance in autism might come from social motivation and reciprocity. Sometimes, if you're in session, and you are asking questions to the parent, to the patient, and the patient just replies to you, but there's not a follow up question or just answers and not a reciprocal interaction, some clinicians might conclude, hey, we are not connected, and that not necessarily may be the case. Also, the quality and quantity of social initiatives or overall to some traits, it's sometimes a factor that might not contribute to adequate therapeutic-- or therapeutic alliance for clinicians, mainly. Co-occurring conditions, such as social anxiety, low mood, or negative symptoms, or even emotional regulation difficulties might also contribute to a poor therapeutic alliance. Also, and this is really important, especially during the assessment and formulation of the case, cognitive and relational factors. Usually, if we are treating co-occurring conditions, so I forgot to mention before, the trend is not that different from general population, meaning that on average, on younger people, let's say infants, and toddlers, and children in primary school, we tend to see more learning difficulties, more behavioural problems presentation as current conditions. Some anxiety disorders, such as separation anxiety disorder, selective mutism, et cetera. But as the person starts to grow up hitting adolescence and/or young adulthood, the prevalence of co-occurring conditions tends to shift to more depression, anxiety, OCD, et cetera. So sometimes, when we are treating these conditions, depression, anxiety means that we are going to be in the presence of an adolescent or a young adult. So they have a whole life of experiences and interactions with other people. Sadly, most of those interactions, they tend to either be negative or aversive to the patient. So they start growing and having negative beliefs about the others. This could be about the others as my peers, adults, people in general. This could also be other negative beliefs about the system, CAHM services. There was a client, a patient of mine. He was an adult. He had a long standing history of recurrent depressive episodes. The first time that I met him, he was-- it was his fourth depressive episode. He had visited many CAHM services. And he was very distrustful about going again for therapy because-- and he was very explicit, describing all of my former therapists, they told me that the way I think it's wrong, the way I am, it's wrong, that I should have more friends, which I don't want to because that's part of why-- we ended up understanding that that was part of his cognitive and social style rather than depression symptoms. So sometimes, past experiences with CAHM services might contribute to negative beliefs about CAHM services and therapy. That's also we need to-- something that we need to assess and take into account. Adverse life events, victimisation, bullying, exploitation, et cetera, they might also contribute to negative beliefs associated to interacting with people, hence hindering therapeutical therapeutic alliance or limited opportunities to develop social skills. So there are many, many factors that we need to understand when we are addressing and treating a client with autism. So that we need to try to have a more open mind that probably, someone, an autistic person, it's not going to react to us in the same way as a non-autistic person. That doesn't necessarily mean that they are not engaging with us or that probably means that they need something different from other patients or other clients that we might have. And ideally, we need to try to adapt to them, be explicit, asking, hey, are you OK with this? Was my intervention adequate? Does this make sense to you? So questions of those sorts, they tend to help to understand and have a more compassionate approach to patients. Something that is really important is that most research, and this falls within the adaptations, they tend to show that even for adolescents and adults, having family members participating in therapy, it's something that is really helpful. Obviously, we always need to get consent either from the teenager or from the young adult. This shouldn't be made in a way without their consent because that might feel really violent or for the person. But we know that having family members, it could be a partner, a friend, my mum, my dad, et cetera can be really helpful for generalising skills or things that we might approach and tackle through throughout therapy. Also, as we said before, understanding and within the assessment and formulation, the communication style might help us understand if the patient is connecting with us. We need to know how much comfortable they are with eye contact, the facial expressions that they use to convey emotion, preferences regarding social interaction within therapy. That means do you want me to send you emails, text messages. You want to ask for us to take notes? Do you want for us to have really short interactions? Do you prefer for me to use more broader explanations? Some clients, they might prefer small talk, and we need to explicitly ask this. Some other clients, they don't. Yesterday, I was seeing he's a young adult. He's studying for his PhD in physicist. Brilliant person. Much more brilliant than I am. Really focused person. And he really dislikes small talk. So therapy, for instance, with him, it's shorter than I would have with other patients. Because he just wants to address specific issues that he brings to therapy. He only wants to talk about that. He doesn't-- he hates when people ask him, hey, how was your week? Did you do anything fun, et cetera? That's irrelevant for him. And adapting to that means that he is much more likely to keep on engaging and committed to therapy rather than forcing. Hey, no, but tell me about your week. Tell me how you work, et cetera. Also, sometimes we need to-- due to differences in cognitive and social style, we need to be really explicit about how therapy works, how much us, as a clinician, we're comfortable of contact, frequency and contact, ways of contacts. Some people, they give away their mobile number. Some people they only prefer to be contact through official channels, such as the phone from my services or my work email. It's important to set boundaries. You can contact me from this hour, from this hour, during weekdays. Or if it's an emergency, you can contact me during the weekend, or I won't reply unless it's an emergency. If it's admin question, I will reply you only within working. So we need to be really explicit with all the therapy boundaries. Again, some people might struggle with some social etiquette that we might presume. It's very common, and some people might not have it. It's really important, if we can, to introduce the patient special interest within the case formulation, within our examples, and trying to address this. What do I mean with this? I have-- he's currently in therapy, a young adult with autism, anxiety and-- anxiety, generalised anxiety disorder, and OCD, who is very knowledgeable about Star Wars. I do like also Star Wars. So that's an advantage. For instance, he was having a difference in opinion with his sister regarding gun ownership and who should have guns. So he was building the belief that anyone in favour of having guns is evil. Long story short, but roughly that was his belief. And he was really struggling to have a more broad spectrum, meaning that not everyone who supports guns might be or we were questioning, hey, does everyone that supports guns support killing, supports shooting people, supports, et cetera. We try to use many cognitive restructuring exercises, et cetera. And what helped him understand that, hey, if I have a binary approach to problems, probably I'm missing a whole spectrum of options was a phrase from a movie from Star Wars, the third instalment in which one character tells the other one only a Sith, the bad guys, deals in absolutes. So that phrase from his special interest helped him grasp the concept that hey, it's not ideal, or it's probably something that's not going to be useful for me to think in a binary way. So including the patient or the client, special interest usually helps us, either to transmit ideas or concepts we want to transmit through our therapy or to help with engagement. If the patient feels that we listen to them, we share their interests, that we ask questions about their interests, they sometimes feel really understand. Some people, they don't have with whom to discuss their personal special interest, and maybe allocating five or 10 minutes of therapy just to have small talk about their special interest. It's something that might be really, really helpful. Again, similarly to what we were discussing before, throughout the process of the first interviews, and explaining the boundaries, and how therapy works, we need to provide really clear expectations about what we are going to expect. Some people, they are going-- if they come because they have anxiety, we might aim for remission of the symptoms. Some people, they might have a more chronic presentation, and we need to get clear that we can try remission of the symptoms. But sometimes, that's not achievable. But an adequate management and functional living or functional approach might be more useful. So we need to be really clear about this. Also, within the assessment in autistic individuals, we need to understand, not just the difficulties that the person has presenting, but the strengths, challenges, difficulties in their social environment. We need to understand that autism. It has an heterogeneous presentation. That means-- and I don't remember who said this phrase, but it's very common, very famous within the autism community, that once you meet someone with autism, you have met one person with autism, meaning the following person might be completely different, and that is something that is really important to always keep in mind when we do the assessment. If we-- because many CAM services or clinicians, they use questionnaires and scales, which are OK to use. But if we use questionnaire, self-report, questionnaires, et cetera, we need to understand that many, or I would say almost every available questionnaire, they are not specifically for comorbidities. Anxiety, depression, et cetera. They are not specifically designed for people with autism. There are a few that in a research-based approach, they are being tested, for instance, probing depression in young adults or adolescents, which they include more items within the questions trying to assess how depression presents in people with autism. But most questionnaires or validated questionnaires, they are not designed for people with autism. So they might-- the results that they end up showing might be not as representative as if we use those questionnaires within general population. Does that mean that we don't have to use questionnaires? Obviously, no. But if we do, we need to take into account that sometimes, that's more of a guiding rather than something that is more definitely. So it will be supporting information rather than something that it's really meaningful or impacting. Some people might need more time to complete than support completing it, either from a family member, from a therapist. Sometimes, we need to ask the questions rather than the patient writing or completing it on its own. Sometimes, they need to go through it, and afterwards, we need to go through each item with the person. So we can use them. Having in mind that probably, we are going to have to go through them with the patient, or help the patient complete them, or take them as a guidance rather than something that will support our final diagnosis or formulation as it supports, maybe with someone without autism. As I was saying, psychometric properties are not that well established. Again, it should be take-- these questionnaires should be taken as starting points, not conclusions. Also, within the assessment period, we need to take into account sensory considerations. Sometimes, how, and when, and in which setting the patient is answering those questions might change the results. So sometimes, they might struggle with, for instance, understanding of certain time measurements. This week, the past month, do you currently feel this way? And they might literally respond currently as now, but throughout the week I feel depressed. But now, I don't feel depressed. So they might end up answering, now, I don't feel depressed. So that's why, again, we need to take these questionnaires as a starting point and go through them with the patient. Also, when we are assessing comorbidities, we need to assess sensory traits and sensory processing style. Occasionally, it might be difficult to differentiate. For instance, I had a client-- I had because now she was discharged, but I had a client who came refer as having autism with social anxiety. Because she was a young adult, she was starting to work. And she was having a really hard time going to the after office. Many of his coworkers went for either a pint or to have a drink after work specifically or usually Thursday and Friday, and she was having a really hard time coping with that. So she was assessed, and she was referred as having social anxiety. But when assessing her, or reassessing her, and trying to check, are you worried about social outcomes, what people or if your coworkers might build a negative belief about yourself, et cetera, all of her answers were, no, no, no, no, no. So what is this-- so what is stressing you about going to these social events, the noise? So she was avoiding those social situations because of a sensory processing issue rather than a social anxiety issue. But sometimes, it is a recommended practise independently of language intellectual abilities to always assess sensory processing style. Because either it can explain some symptoms, it can help to understand or to build a better differential diagnosis, or sometimes it can contribute to an actual co-occurring condition. Also, the sensory processing style should be taken into account within our clinical settings. And this is not always possible. But we try to bear in mind that some clients either might be too sensitive to certain odours. And if we use perfume or whatever in our office, that might not be adequate to them, or certain lighting, or noise, temperature, et cetera. For instance, I have a client which I admit, sometimes it's hard for me because he suffers from elevated temperatures a lot. So each time that he comes to my office, I need to set the AC, it's really low, and so it's really, really cool for him to be comfortable. Because otherwise, he gets awfully distracted throughout therapy. He starts doing, I'm hot. I can't think. I want to go home. So obviously, I don't have a problem adapting to that, but some other clinicians might have. So if we can, again, adapting to sensory preferences sometimes can always help to therapy. If you use a formulation-based approach, you already know that we don't only need to focus on comorbidities and difficulties, we also need to assess strength and abilities because they are going to be a starting point for treatment. So asking to describe me a typical day or ask me-- or asking them to tell us what they can do, what they are good at, what they enjoy doing, it can shed some light regarding their abilities, their strengths, the level of autonomy, how independent they are so that we can design a better treatment for that particular client. And at a more broader accommodations, sometimes, and again, this is on demand or needs basis. Sometimes, we need to have more sessions, which not, as I was saying, at the beginning, that's not always possible in a public setting or in a private setting. Sometimes, we need to have more frequent sessions. Maybe some client with a non-autistic client might need one once a week, and an autistic client might need twice a week. Sometimes, we need to play a bit with the duration of each session, meaning sometimes we need short sessions, as the patient, I was saying. Or sometimes, we need longer sessions because their processing speed is slower, and they need more time to process information, or we need to adapt that the amount of information or things that we are going to approach on each therapy session, they might need to be reduced, and it needs to be taken into account. Always, it's helpful, as an accommodation or adaptation, to understand that most protocols for anxiety, depression, et cetera, although they are divided by sessions, try to think them more as logical steps we need to take. So it's not that we always need to do session 1 in session 1. Sometimes, session one might be three encounters, four encounters with a patient. But we can't jump to session two until we have achieved or the patient has understand all the content of session one. For instance, I can do in vivo exposure if I didn't do first a thorough understanding of what things they are anxiety triggering for the patient in which intensity and agree with the patient, which is the lower intensity 1 that we are going to approach first. So try to think them as logical steps, that sometimes with autistic patients, we might need more sessions, more frequency, or shorter, or longer sessions. Sometimes, and this is quite common, we might need to take breaks throughout the session, meaning short breaks, maybe five minutes, 10 minutes talking about something else. We can shift to talking about special interests, or we just can have a pause for the patient to go to the bathroom, to catch a drink, et cetera. But sometimes, those short breaks are helpful because differences in cognitive style, inattentional span, differences in motivation, et cetera might be helpful to have more breaks. We already went through this. But just a short reminder, we need to fold the session structure, agree on a preferred mode of communication, email, text message, phone. Most guidelines suggest to elaborate summaries of what we are discussing through therapy and to have some sort of either visual drawings, written, et cetera video support for the patient to take away home so that we can have-- so that we don't depend only on oral language, and that tends to increase better understanding of things that we are trying to transmit throughout session. Goal setting in therapy. This is extremely important. It needs to be respectful. We need to agree on it. Obviously, we can suggest hey, I think you could benefit yourself from this or this or this, but we need to respect that it might not be the same goal for the patient or why the patient comes to therapy. The client that I was mentioning before, the one that needs the AC to be really, really low. Here in Argentina now, it's summer. It's a really hot summer. That's why the meeting of the AC. For instance, he's a very intelligent young man, but he's not studying. It's not important for him to study. He lives with his parents. He's happy not working and not studying. And he only comes to therapy because he wants to reduce his anxiety symptoms. He gets really anxious when he goes outside. It was suggested when the formula-- for the formulation phase was being done, hey, I think you should benefit from being more independent, thinking about, in the future, having a job, a way of supporting yourself, et cetera. And the patient was really blunt in, I don't want that right now. I just want not to feel anxious when I go outside and have meetings with my, he has friends, with my friends. And again, as clinicians, we need to be really respectful of that. Always, if you're tackling co-occurring conditions, it's important to address them. Some clients might come for therapy because other reasons, I want to be more autonomous. And we might assess that they have a character and condition. Hey, I think that you have anxiety, depression, or they have OCD, and they might choose not to address that. And if it's not risky for the patient-- for the patient, we need to respect also that. Goals should be really explicit, specific, realistic. Why do I say realistic? Some clients or some patients might come to therapy, and I think this is not exclusive to autistic community with very valid goals, but that they are not therapeutical, or psychological, or therapy goals, for instance. I had one autistic client who came to therapy because he wanted-- the result from therapy was, I want to have a girlfriend. But it was proposed to him, we can work on social skills and affective skills, and that might lead or not for you to meet a partner. And he was really angry about that. Because, no, no, I don't want that. I want you to help me to have a girlfriend. So, so and therapy, it's not about achieving or we can't promise him to achieve, in that case, having a girlfriend. So we need to be realistic when we communicate what goals are going to be tried to get. It's not uncommon for adolescents and young adults not to come to therapy on their own, but to get therapy because their parents told them, their partner told them, the school sent them, university send them, their work send them. And in that low motivation case or concerns about change, effectiveness might be not that great as in a patient who is motivated. And sometimes, we need to allocate some sessions to increase the motivation, or to create a motivation, or to address concerns about change. We can do pros and cons, et cetera. So there are different strategies that we can do. Some people, they might have, with autism, executive functioning difficulties, which might contribute to not achieving the goals that we set. And we need to address that. For instance, a patient of mine who, again, one of his-- he started moving a lot. He started living on his own. And one of his goals was to be more independent, to be more clean within his apartment, not to be so-- not to have so many garbage in the bin, et cetera. So we started setting goals, and he was really struggling to the steps to do each goal. So we needed to listen-- to break down each step in sub steps for him, and creating checklists, and reminders. So it was more like a cognitive extension executive training rather than a general autonomy guidance. And sometimes, we are going to be needing to do that with each patient. Depending on the level and aural skills of the patient, some people are going to be more dependent on oral communication and just written summaries or written communications. Some people are going to need thought bubbles, visual representation videos. For instance, doing with a much younger client. I think he was 13, 14 at the time, who was having panic attacks within the context of being autistic. During the psychoeducation phase, there is a brilliant part from a movie from one of the Iron Man movies from the Marvel-- from the Marvel Cinematic-- from the Marvel universe in which the main character, Iron Man, experiences panic attacks. So, for instance, for that client, instead of explaining the symptoms of what a panic attack was or is, it was much more helpful to use his special interest, his preferred character, having the symptoms. So he was able, OK, Iron Man is going through this. He's having a hard time breathing. He thinks that his heart is failing. He thinks that-- that happens to me. And if it happens to Iron Man, well, it's rather-- it might be OK that it's also happening to me. So it's not that bad that it's happening to me. And if Iron Man was able to overcome and we went each session, he had, as homework, to watch a bit of the movie, which he already had watched. But it was really, really fun for him to have us as a homework. Hey, you need to watch this part of the movie. And it was really engaging for him. But it was helping him understanding how Iron Man overcame his anxiety symptoms, mainly exposing himself to the things that were worrying or concerning him. And he was able to incorporate that into his personal experience. As we said before, some people might need additional external support to generalise skills, parent, carer, et cetera. If the patient supports that, some people, they don't. So there's sometimes a thin red line between adapting and over supporting or infantilization of the patient. And this is really important. Particularly within the range of later teenagers and young adults, that they still, on average, function quite a lot with their families. For me, it's really common to have an assessment or a therapy request, maybe for someone in their 20s or even 30s. And the family contacts. Me and the family wants to get together first. And hey, don't tell him that we met. Obviously, that's not possible. Or at least by Argentinian laws, we need to always discuss and address this with the patient. So always, it's important to adapt, not to over support. I would love to tell you the exact formula to do that. Sometimes, it's just experience and trial and error with some patients and/or some client. And rechecking always if what we are suggesting to the patient makes sense, it's OK, or he feels that, hey, you're stepping over the boundaries or no, I need more help with this. So I think that one of my biggest takeaways is always explicitly ask more than with regular therapy clients. And don't assume. Because that's a very good way to get more information and to be more adequate. Hi, everyone. Welcome back. Hopefully, I'm not boring you. So now, thinking about adaptations in more regarding steps within therapy. These are general steps. Some therapeutical approaches might differ in the amount of steps and steps in between. But overall, you can find in either CBT, et cetera, or DBT other traditional therapy these steps. And the first one, it's always psychoeducation to explain to the patient what's going on in terms, in ways that they can understand, that are meaningful for them. This is really important. And autistic people don't-- they don't-- they are not an exception in this regard. Sometimes, we need to first do psychoeducation about autism, either with the patient, with the family, and psychoeducation about emotions because of alexithymia or differences in emotion processing. So we need to take into account that sometimes, if we're treating a co-occurring condition, let's say depression, psychoeducation might not be only about depression. And first, we need to allocate some time to talk about autism, to talk about emotions, to understand how the patient processes emotions, how they understand emotion, how they are able to understand emotions. Some autistic people, they have their own way of categorising their emotions, their own language when explaining emotions. For instance, I joke with a patient of mine. She's a female in her 20s with bipolar disorder and autism. Amazing and really good patient. She's very-- she always does everything that we agree on therapy. She's very, very thorough. But we always joke. Because when I ask her, hey, how was this week? How were you feeling? She said-- she always says, OK. So we always have to understand or we came to understand that her OK was a spectrum, and she might underwent being a bit down on her mood, and she reports OK. And she might be really, really happy, and she reports OK. So we always have her OK thermometer. So she tells me how much OK she was. So sometimes, we need to construct another way of assessing and understanding the emotions and how the patient was, and that this can be done within the psychoeducation part. If we are going to try to do cognitive restructuring, to try to change the way the patient understands something, most cognitive, traditional cognitive restructuring exercises are to verbal. They tend to depend too much on explanations, trying to change the point of view. On average, most autistic people, they are going to benefit much more from behavioural experiences to change their beliefs rather than traditional cognitive restructuring exercises. Sometimes, they might feel that we are pushing too hard for another point of view, or that we are pushing too hard for our point of view. And they might feel pressure, or they might have challenges changing their negative beliefs or their negative thoughts. Not always. We are going to need to do cognitive restructuring. Sometimes, we can try to do attentional redirection exercises, or mindfulness-based approach, or just problem solving strategies. It's always important to validate negative beliefs. Sometimes as they might be realistic, they are going to create much distress to the patient. If we approach them in an invalidating way, probably, we're not going to have a good result on the patient is not going to feel that much engaged to us. So we need to take into account that sometimes, doing cognitive restructuring with clients, with autistic clients might be much more difficult, and that we might need to consider other options, rather than just traditional cognitive restructuring exercises, or more behavioural experiences, or more behavioural change approaches rather than traditional cognitive restructuring. If we are going to aim for that, in similar lines to what we were discussing before, not just verbally, probably using visual examples, movie shorts, YouTube, something that my favourite YouTuber said, et cetera might contribute to changing those beliefs. And all the information that we can include on that, that would help to gain another perspective. Let me show you-- sorry, I don't know. I have it in another part. Sorry. So some autistic people, they are going to have a tendency to sameness. They are going to prefer routines, things that are predictable. So changing, doing behavioural changes might trigger anxiety or worry on them. So we need to, first, address that if that is the case with our clients. Sometimes, we might need to address-- before giving a behavioural intervention or suggestion, we might need to address the anxiety associated with change. And if that's going to be-- or that we might need to plan that behavioural strategy in a much more progressive way rather than with another client, we need to explain the rationales, the goals, and what we try to do when we are suggesting them to expose them. With one client, he goes back and forth with the same thing. He wants to be more autonomous. But each time that we set a goal, he agrees on those goals. For instance, he's in driving age, and he started driving, and he now for a few months. So one of the goals was for him to get to my office, to come to my office, driving. So he agreed on that. He was able to achieve that one once. And when he came to that session, hey, I did this for you. But I'm not going to do it anymore because it's really an anxiety-triggering situation for me. So we went back to hey, remember what we agreed, what you wanted to achieve? You wanted to be more autonomous. Within being more autonomous, you wanted to not depend on your mum to get to places. So in that line, you thought that coming here to therapy once a week, driving was a good first step. I understand that it's new. It's worrying. It triggers anxiety on you. You need to deal with a lot of things that you are not used to it. So then we reshape our goal to hey, OK, you're going to drive here halfway, the more calm part of the route. Then the other-- the other half of the route, your mum is going to drive. So we're going to do that maybe three or four weeks. And then we are going to give it another try for you to try, but with your mum besides you then. So we needed to reshape the plan, the behavioural change, the behavioural intervention. And sometimes, we can think, even with the patient agreeing a really good strategy that we need to adapt because of the environmental outcome. Also, modelling role playing might help to generalisation even more with non-autistic population. We can use things as coping cards, mobile phone reminders, apps that might help us to reduce the cognitive load that usually it's a really good recommendation. Power cards, for instance, with my clients that he was a fan of Iron Man we did together. And now, thanks to AI apps, it's much more easy than in the past. So we did together a card that he then printed. He had a printed version and a PDF, where there was a picture of Iron Man and three or four bullet points reminding him how Iron Man overcame his anxiety problems. So he had that. And each time that he was about to have an episode, he was really good at identifying the precursors of anxiety. So he went through that power card, through that card, remembering what Iron Man did so that he would apply it to him. So those sort of visual reminders, et cetera, are really, really good. Other patients might help or might benefit from other sort of digital reminders. And again, I think that nowadays, with AI apps, it's going to be really helpful where you can set reminders, explanations, et cetera. It needs to have a careful prompt and build. We need to understand much more. I would really love to hear at the end, if you guys can comment your opinion about whether you think AI is going to be beneficial in therapy and in therapy settings, or you think that we need to research and understand more about it before diving into using it so massively as it's currently being used. And I would really like the opinion of the audience on this. And sometimes-- and this takes me back to what I was saying before. The thin red line with not infantilizing the client. But sometimes, therapy need to be more directive, need to be more straightforward than with non-autistic people. We need to offer concrete options, rather than hey, let me know what you think. For instance, instead of telling the patient, how would you do this, it might be better for us to, hey, we can do this, and this way, this way, and this way. Which one suits you best? Which one do you prefer? That might be a better approach. Also, when addressing activities between sessions, homework, some clients might need reminders. Some clients might need for us to ask someone from their environment to help us do that between sessions. We need to anticipate potential obstacles, address executive functioning difficulties, as I was saying before. So usually, homework or between session activities is a challenge. And we need to pay more attention and to be more present between sessions. I always discuss this with a friend of mine who's a DBT for personality disorders. And we have the same experience. Helping your developmental people with neurodiversity or neurodevelopmental conditions implies that you need to be more present, receive more contact, et cetera similarly to and therefore the workload for the therapist, usually it's much higher than with a regular therapy patient. Similarly to what happens to someone that does DBT, for instance, that they have a lower load, case load. Because the amount of time that they need to pay attention to each case is higher in comparison to just someone with depression and just depression. So that sometimes happens to therapists, and we need to bear in mind that if we are going to assign sessions between therapy, we have to be much more present. I'm going to talk about CBT and DBT, not because they are the other forms of therapy. They don't have proposed adaptations, but because DBT and CBT are the ones that currently have been most studied. So it doesn't-- don't take this as an implication that the other ones don't have adaptations. They do have, or they are proposed adaptations, but they are less studied than CBT or DBT. So basically, we need to-- this is kind of a summary of what we've been discussing, to have more concrete and highly structured cognitive work, more written or visual formulations, more step by step worksheets. Behavioural interventions, experiments, they need to be much more clear with much more steps, predictions. We need to debrief explicitly and explain the patient. We need to integrate sensory anxiety regulation before each change work that we are going to address. For instance, either cognitive restructuring, an exposure and behavioural intervention, et cetera. We need to differentiate adaptive avoidance because the patient is trying to-- its overload, and it's trying to not face something that is really difficult for them against maladaptive avoidance. Because I'm really very concerned and I have serious anxiety symptoms about specific change. Usually, homework should be really small, specific, predictable, written with checklists, reminders, graded tasks, et cetera. This is, for instance, an example of visual cues. This is a to do mask progressive muscular relaxation. For instance, I'm going to tighten my fist as if I were squeezing a lemon. I'm going to scratch like a cat. I'm going to chew a carrot. I'm going to hide my neck in my shell as if I were a turtle. I'm going to swim if I were-- I'm not getting the word in English, sorry. And so forth. So this is-- this was meant for a really young patient. He was in his 12th. He was 12. If we are addressing a teenager or a young adult, this will be inadequate. So sometimes, usual cues might be really helpful for some patients and not for others. This was another way. Sorry, it's in Spanish. I wasn't able to translate it in English, but this is another visual arrangement to help them understand how we progressively relax our muscles for an anxiety patient. This was us building the hierarchy of where we were going to expose ourselves to certain concerns and fears that he had. So it was a progressive ladder. And at the end of the ladder, he would became-- he was going to became a Jedi. He was another Star Wars patient. Luckily, most of my patients, they share my interests. So that makes things much more easy-- much more easy. So within DBT and emotional regulation. Why did I chose DBT is because as we were talking at the beginning of the presentation, most patients with neurodevelopmental conditions are going to have emotional regulation difficulties. That's spectrum, some emotional regulation difficulties might mean I need to be locked down at my house for the entire weekend because I was socially overload. And some patients, the emotional regulation difficulty might mean they harm themselves, or they have suicidal ideation. So take in mind that it's a spectrum. Not all emotional regulation difficulty means high risk for the patient. We need to assess whether the patient, apart from having emotional dysregulation, has potential risk. And that's important to differentiate. So when we do see DBT or DBT strategies, we might not do a full DBT approach. There need to be similar adaptations when adapting DBT. It needs to be highly structured, visual, and concrete. DBT depends on metaphors, analogies, et cetera as CBT. So we need to try to simplify, try to be more literal, non-metaphorical unless the patient really wants to. Sometimes, apart from the interpersonal effective modules, we need to add maybe socialisation skills modules to complement those interpersonal effective modules. We need to give scripts for when we address boundaries and assertiveness. Sometimes, the group format is not the ideal, or if the group is too numerous, it's not going to be beneficial for the patient and they need to have smaller groups or lower social demand, or even-- instead of a group training, individual skills coaching. So those adaptations sometimes are recommended. Sometimes, we need-- the patient needs to have additional training on understanding emotions, recognising emotions on themselves and other ones. Most time-- most of the times, we need to do this in an explicit way of teaching. And sometimes, we need to understand that without emotion, the rationale to addressing emotion regulation and using DBT strategies, it's not the only approach, but DBT has shown has robust evidence, that cognitive work, either that I'm doing anxiety treatment, depression, et cetera, trying to help the patient to be more autonomous, to have more social skills for certain social situations, those that sort of cognitive work, it's often unaccessible or not possible or less effective to try to achieve if the patient can regulate its own emotions. So that's why it's really important to address emotion regulation if emotion dysregulation is present. DBT has a strong tradition of addressing crisis survival skills. They're essential to prevent escalation, to interrupt, or to try to reduce suicidal risk. Usually, those strategies are the tip skills. It means faith breeding, temperature change, and intense exercise, which are really concrete behavioural strategies, distraction strategies to focus on an external rather than an internal stimuli, self-soothing, and we need to adapt that to sensory preferences. Sensory considerations here are really focused. Some DBT skills might be too overwhelming to the patient. For instance, you need to smell this candle. And if the patient has a hypersensitivity for olfactory stimuli, that intervention might be too much and might trigger another set of symptoms that we are not trying to get the patient to do. So we need to take that into account. On average autistic patients, they need to rehearse skills more repeatedly, more written, as I was saying, are more precise outside greasy states. So we need to repeat and repeat and have much more practise than non-autistic patients. Not exclusive to DBT. But DBT has a safety plan. Safety plan intervention. It's one of the most effective, less expensive, and it's really well studied intervention for suicide risk or for risky situations. DBT has its own formulation. There is a publication from the research that I mentioned, the researcher that I mentioned before, Sarah Cassidy. They have adapted a safety plan intervention, a standalone intervention for people with autism and risk of suicide ideation or suicide behaviour. So the safety plan intervention, it's a standard intervention that has different steps to try to reduce the risk of someone attempting a suicide attempt. Sorry for the redundancy. If you are going to use that safety plan intervention in people with autism, it needs to be explicit. It's much more break down in the step by step, externally available either printed phone, wallet, PDF, on an app, et cetera. Family involvement. It is critical, again, with the consent of the patient, but it's critical to have family involvement. Obviously, it's really difficult to handle this sort of situations when the patient doesn't have a family available or they live on their own. But on average, if we can include someone else, that tends to be a really good recommendation. So usually, you're going to watch that we have much more steps than on average in a regular safety plan intervention. So we are going to write the warning sign. I'm sleeping less. My mood change. I'm more withdraw. I'm having a hard time following my routine. We are going to write down which distraction strategies can I do. I can start doing my hobby. I can do physical activity, relaxation techniques, et cetera. I can-- and this is sometimes an issue with autistic people, who I can contact. Sometimes, they don't have nobody they can contact. And we jump to the following one. What professional support can I reach out? for instance, suicide lines, A and E, my therapist. What happens if my therapist is not available, et cetera. And we need to always make this in a really explicit. Try to think that if the patient is referring to the safety plan, they are going through a crisis. And if I'm going through a crisis or anybody going through a crisis, we have less ability to think alternatives and to think solutions. The idea of the safety plan intervention is to reduce the cognitive load so that everything should be, as best we can, really explicit so that I don't have to think in that moment. I just have to follow these instructions. How can I do my environment safer? For instance, if I frequently think of cutting myself, I shouldn't be having available knives, or scissors, or something that I can. Or if I frequently think about taking pills, maybe-- and if I live with my parents, maybe my parents can handle my medication and give it to me so that I don't have free access to that medication. How others can help me? And this is something that is not included, maybe in typical safety plan intervention sheets. How do I show distress? Because that can be really specific to each autistic people. What calms me down? For me, it calms me down to play Minecraft. What are my communication preferences? I want to be talked in a very explicit way. I want to be text message. I want to be whatever. Who I want to contact? So who I want to share my safety plan for, my family, my GP, my therapist. And where I'm going to put this plan? So it has much more-- my phone, et cetera. So it has much more-- much more steps than a regular safety plan. If anyone is interested, later, before we finish, I can give you my email, and I can share the publication, or you can search for it. I think it's from the University of Liverpool, if I don't mistake-- if I'm not mistaken. But it's available. Take into account that it's still a research proposal or a research intervention, so it has to have more evidence supporting it. But it's a really good-- really good intervention in its research phase that it's, at least until now, shown to be really promising. So before we jump to the Q&A, things that we have been talking about today. In people, teenagers, young adults without ID and without language difficulties, most of the cost and psychological distress is associated with the concurrent mental health conditions, not the autistic core futures. We have been talking about that standard protocols they use-- they usually have, reduced effectiveness for people with neurodevelopmental conditions, particularly with autism due to differences in communication, sensory processing, cognitive style, emotional regulation, and access to barriers, and the way therapists or common general CAMH services understand on the training that they have regarding autism. Not adapting treatments. It means that we are going to have less success. And that doesn't mean that the patient was a poor fit. It means that we lack an adequate treatment for that specific patient. So in those lines, current evidence suggests that adapting is the best evidence-based practise when tackling co-occurring conditions within the autistic population. That improves engagement, improves outcomes. It reduces distress and heterogenic harm. It enhances safety. Adaptations should be mechanism focused. For instance, emotion regulation, intolerance to uncertainty, rigidity, cognitive rigidity if I want to work with cognitive restructuration. Individualised adaptations should be tailor made for each patient. Not generic, because again, it's a spectrum. It's a very-- we can find very different people within the spectrum. And if we always do the same adaptations for everyone, sometimes we're going to be really effective, and sometimes we're going to infantilize or to downgrade the person. And that's going to be really not well taken. Most adaptations are compatible with whatever model you choose to apply. DBT, CBT, EFT, EMDR. Most behavioural and emotional regulation are often primary, meaning that we need to first address emotion regulation, behavioural change, and stability before addressing other things. Most across-- across different protocols and therapy models, most commonly, adaptations are concrete and developmental appropriate language. Other more involvement from the carers or meaningful people from the patient's environment. Changes in either duration of the session, frequency, amounts of sessions. More role play. More visual cues. More visual support. More concrete and tangible materials. The use of the special interest. I don't fancy the word restricted interest, but you're going to find in the literature that still, it's very common to address special interest in the autistic community and referring to them as restricted and repetitive behaviour. Currently, most neuro affirmative approaches, they tend to conceptualise this sort of interest as special interest or autistic interest, or something in the line rather than restricted, and it's maybe pejorative approach. And similarly, you're going to still find that many protocols, they speak about adding social skills modules. More newer ones, they speak about socialisation interventions. Independently of the term, what we need to always do is to assess the social style of the patient, the social goals of the patient, and to help them with the required skills to actually achieve those social goals. What most recent research agree is that we shouldn't impose social goals, meaning it's inadequate to say you have to contact your friends every week. Because some autistic people might feel more comfortable having a two-month frequency, or three-month frequency, or a yearly frequency with their acquaintances, rather than a weekly frequency. So we need to adapt to those goals. This is always difficult for clinicians, but more in vivo practises and emphasis on behavioural change rather than cognitive strategies. It's desirable or recommended. Also, try to think that sometimes we need to include emotion training, or emotion identification modules, or tailored-rating scales. As I was saying, the emphasis is more on the behavioural part of treatment or protocols rather than the cognitive part. And on average, it tends to be more directive and less socratic questioning rather than frequent treatments, and errorless learning rather than trial and error due to cognitive rigidity. Sometimes, addressing emotion regulation is central to treatment. We discussed that at DBT, it's possible with its according accommodations, which are really similar to what we discussed before. But sometimes, it's important to try to during the formulation part, assess if emotional dysregulation is present, and if we need to address that first before tackling anxiety, for example, or tackling depression. I hope it was useful and beneficial for the audience. And I'm open to questions and to hearing your opinions about the subject. Well, thank you. Thank you, Francisco, for an amazing, definitely amazing talk. And lots of-- I think, everyone will leave this with lots of new skills, and ideas, and thoughts to apply in their practise. And we had a number of questions throughout the session. So if you're OK with this, I can start reading them, and we can try to address them. Great. And there was an initial question at the very beginning of the start of the talk about you mentioned social skills interventions. And someone asked, what do you mean by that? I thought maybe, yeah, if you want to expand a bit more about these sort of interventions for people that are not so familiar with them. Great. So I think it's Edith. That's a great question. So social skills, as a construct, ironically, we know that social communication is a core feature or social communication differences, it's a core feature in autism. But the operationalization of the concept and social skills is still much debated. We have even contradictory evidence and research. So on average, traditionally, there was a more deficit-based approach in which the patient had social skills deficits. So social skills training was to normalise those deficits. Current research shows that that approach to pejorative and actually increases masking, and therefore increases the risk of co-occurring mental health condition. So more newer approach, they have the tag of socialisation-based approach or socialisation interventions. What they do mean by that is identifying with each patient what they want to achieve socially. I want to have more friends. I want to be able to speak at work. I want to be able to speak with my teacher. And what skills do I need to be able to function in that social situation? So currently, that's the more neuro affirmative and evidence-based approach rather than the traditional deficit approach. Thank you. Thank you for that response. Another question that was dropped in the chat, also during the first part of the talk, it was about digital therapeutic games. Regarding-- I will read the question. Regarding different mediums and modalities to engage and special interests, what are your thoughts about digital therapeutic games and gamified apps that are currently nice, recommended, evidence-based, and deliver CBT-based therapies? I think that there can be a really good complement to therapy, particularly because some clients, they respond much better to digital means rather than in-person or remote therapy approaches. I don't think that yet we have the evidence that for most interventions, they can be a standalone intervention. So they can be a good complement to a holistic approach of the patient but not necessarily a standalone intervention. For instance, if we think about socialisation skills, one of the most robust programmes is the social skills intervention from UCLA, which I think has the main creator, the researcher, as a guest speaker. And that one has an app that it's like a step by step game that you play. And they touch bases with all without them because it's called peers. Sorry, the name wasn't coming up. So it's the peers intervention. So you have an app that is for peers. Actually, you can download it, and you don't need to do the programme if you have a therapist that helps you. And it can be a really good support, but still you need the therapy. So they can be really good complements. Great. Great. Thank you for that one. Time for promotion. We have on ACAMH Learn or our free video-based learning portal, a video from Elizabeth Lawson describing peers. So good that you mention everyone can go and have a look at that. And next question is about the double empathy problem. The question is, would having autistic clinicians deliver therapy to autistic individuals be another good adaptation? And then is there any research on this being more effective? There is research about autistic clinicians delivering therapy to a stretched out autistic individuals. I think it would be, and this is my personal opinion, not so evidence based. I think it would be a really good adaptation, but I think that it would be insufficient. Meaning that yet, we don't have that much-- we don't have that much clinicians that can work with autistic population, yet less autistic clinicians. So if we-- the adaptation would be for only autistic clinicians to deliver therapy to autistic individuals, it would be a serious neck bottle, and it would hinder the capacity of the mental health system to deliver and to provide assistance to many autistic individuals. I think that the best approach is to try to research and with co-production alongside autistic individuals. So researchers, either autistic researchers alongside non-autistic researchers and autistic patients, they all work together to come up with either new adaptations or with specific new protocols co-occuring conditions. I think that would be a much more efficient and realistic approach, rather than only having autistic clinicians working with autistic people. Brilliant. Thank you. Next question. I think this is a very interesting about treatment targets. So the question goes like this. I have a young client, eight years old on the spectrum, who has obsessive thoughts about not being able to fit in anywhere and not having any friends. And his parents and teachers claim that he does have friends and is accepted. So when discussing the objectives for therapy, the teachers and parents ask for his obsessive thoughts to be tackled, and the child is asking for more social skills and tools to integrate better. So I think the question is, what should we do? And the delegate says, my gut feeling is to follow the child wishes, as he's my client. So yeah. It's a very interesting therapy question. And I think that you're right on the spot. Always with young clients, which they have less ability to identify what is impacting their functioning rather than an adolescent or a teenager, we are going to depend a bit more on teacher and parent reports and our clinical decision. But I think it's a really good starting point to always, to start with something that is meaningful for the patient for this 80-year-old young man-- young person, sorry. So that he can learn from you, hey, I'm coming to this person. This person is being helpful to what I want. And maybe next, he's more open to tackling obsessive symptoms. Because he has learned that therapy is helpful, and he's being listened, and he's being validated. So it's always a good-- and this should-- this rational should be explained to the parents and teachers that this is going to be done on purpose. We're not going to address obsessive symptoms right now because it's important to build up the therapeutic alliance, to build up trust. So first, I'm going to address social things that are important to this person so that he can learn that therapy works, that he can learn, that he can trust me so that eventually, we can move onwards to our sepsis symptoms. I think that that would be a good clinical approach. Great. Thank you. Very strategic. And next question is about pathological demand avoidance. And it seems to be a very recurring topic lately. Is there anything on adaptations for people with PDA. Presentation? Like for example, the lady says, I like to ask lots of checking questions, as you suggested, but I'm aware that some people can struggle with questions. So any thoughts on this? No, there's no much-- so there's no much specific research adapting specific protocols for that specific presentation. So that would fall in line with general adaptations that are recommended. Meaning that with patients, let's forget that they have PDA, that they struggle with demand, either emotional demand, social demand, et cetera. We need to adapt our base to that specific client, and maybe we need to adapt our expectations. We can-- which can be really frustrating for clinicians. It does happen to all of us. Sometimes, we want to move forward much faster, and we have much questions because we want to understand the patient thoroughly. And sometimes, we need to understand that the patient has its own pace. So instead of rapid firing, or we need to ask a question, maybe work with the patient to cope with the-- receiving the question, to cope with answering with responding at demand, and then moving forward to another one. But answering your question, sadly, there are, to my knowledge, there is no specific adaptation for that specific presentation. OK, thank you. Lots of questions on mentioning comments about thanking you for such an inspiring talk. And then next question, it will be very interesting to hear your-- hear how you manage identifying assessing dynamic risk to self alongside the therapy process. For example, with clients who struggle with anxiety or depression, especially with children. So I understand assessing risk means self-harm or either suicide risk. You mentioned a very good term. It's a dynamic assessment. Because a patient that might have a low risk today might have a higher risk tomorrow. So usually, having some questions to assess very explicit ones. So research on non-autistic population suggests that the prevalence rate of suicidal ideation and self-harm in adolescence and young adulthood is around 40% to 60%. So it's something that is really common. So because it's really common, we need to ask if it's present. So it's usually a good common practise, especially with someone with either anxiety, depression, or other co-occurring condition and autism to explicitly ask, have you been thinking about hurting yourself, suicide, killing yourself, not wanting to live, et cetera? Which I know that sometimes, it's much harder to for the clinician to ask, rather, from the patient to receive the question. Research shows that asking, explicitly asking reduces the risk for a risk situation rather than increases the risk. So that's the first thing in a dynamic assessment. We always need to ask. Sometimes, with patients with autism, we need to be much more explicit in what we mean self-harm. Because self-harm could be having a meltdown, and I'm pulling my hair, and I'm hitting myself. And that's not necessarily a risk situation or I'm not having a suicidal episode. And sometimes, it can be, I want to kill myself, or sometimes they mean it in another way. Ideally, if I have a patient that is reporting either self-harm or suicidal ideation, it's a dynamic. We need to check this on each session until the patient becomes more stable, and we need to decide which strategy we implement. If, as a clinician, I don't have a thorough training in suicide risk or suicide behaviour, always it's a good practise to refer to specialised services. If not, the safety plan intervention, it's a good intervention, a standalone intervention. If I don't have, for instance, training in DBT, or other strategies, or CBT for suicide to do in the meantime until I can get the patient referred to a specialised service. I hope that I answer the question. Yeah, yeah. Yeah, absolutely. And I think the interesting lots of comments in the chat I think an interesting-- Sorry just one because it popped into my mind. I know that it's not that well known in the UK. But in the US, there's a programme that it's called collaborative assessment and management of suicide behaviour. There's a book available. You can get it. You don't need to do-- ideally, you need to do the training, but you can get the book. And it's a four to six session intervention to manage and stabilise a patient with suicide risk that really needs-- it's a low training and low intensity intervention. Again, similarly to the safety plan intervention, that can be a good complement if I not-- if I'm not specialised in suicide risk. But I need to do something until I can get the patient refer. Brilliant. Thank you. Thank you for sharing that one. And yeah, I think we have-- I think we have time for one more question and lots of other questions. But there was one, I think, to a similar question. Questions 1 was how we decide that therapy is appropriate for people with autism, such as not everyone is appropriate due to communication difficulties and some other problematic behaviours. And there was another, again, about if these same adaptations are possible across the whole spectrum to level three autism. So yeah, where can we move more support materials to help with more non-verbal or visually impaired members on the spectrum? Sadly, as I was saying at the beginning of the presentation, all the accommodations and adaptations that we discussed throughout the presentation were study for a very non-representative percentage of autistic people, people with a good cognitive level, no idea, and a good language level. It's a huge depth that we have to understand how we can help people with cognitive impairment, or with language difficulties, or autism, nonverbal autism. I would love to give you more information about it. Sadly, they are not specific research or protocols associated to that. My thoughts on that is for people with more cognitive difficulties and less language abilities, or nonverbal, or less language abilities, but with some verbal abilities, probably we will have to adapt much more. We will need to do the intervention almost exclusively behavioural with very little cognitive restructuring work or very little cognitive work, supporting ourselves dominantly with visual information, visual explanation. So make it more concrete, shorter, more behavioural, and more visual if the person has less cognitive or language skills. Probably, research might go on those lines. Fantastic. Well, thank you. Thank you, Francisco. We are on time. So we need to wrap up for today. Thank you so much. I think it was a brilliant talk. And we have more questions and comments. And everyone is saying thank you. So sharing this with you. And thank you everyone for joining today. We will be sharing the slides and the link for you to watch the recording of these talks. And this talk, in the coming days, with the transcriptions and lots of materials to complement what we learned. And yeah, thank you, one more time, for collaborating with us. Hope to see everyone else in next trainings with ACAMH. Great. If anyone wants more complementary information or whatever, you can ask either for my work email, and I'm happy to share information. I do tend to receive many emails per day. So if I don't respond immediately, please don't take it as I'm not paying you a proper attention. Just resend me the email so that I can get that email on top of my list. And eventually, I promise to answer. Great. Thank you. Thank you, Francisco. And yeah. Take care everyone. See you next time. [AUDIO LOGO]