Dr Daniel Hoover   I’m Daniel Hoover. I am a Clinical Psychologist at  the Center for Child and Family Traumatic Stress,   Kennedy Krieger Institute, which is in Baltimore,  Maryland, United States, and Faculty Member at   the Johns Hopkins School of Psychiatry, Johns  Hopkins Medical School. I’m going to be talking   today about autism and trauma, the ways that  they overlap and interact with each other,   both diagnostically and for clinical purposes,  thinking about assessment and treatment. I want to mention that my work at the Kennedy  Krieger Institute is funded by the Center for   Supporting Trauma Recovery for Youth with  Developmental Disabilities, the TRY – the   STRYDD Center. That’s a National Child Traumatic  Stress Network Treatment and Services Adaptation   grant. And that we are a group who are exploring,  with research and clinical work and dissemination,   the overlaps between autism and developmental  disorders and post-traumatic stress disorder,   especially among children and adolescents. So, I’ll start out by talking about the  scope of the problem and what we’re looking   at with children, youth and to some  degree, adults, who have autism. So,   the diagnosis of autism is growing quite rapidly  over the last ten to 20 years, as approximately,   at latest estimate, about one in 39 youth  in the United States are – probably have   criteria or meets criteria or symptoms for an  autism spectrum disorder. And it appears that   the numbers that are in the US are pretty similar  to those coming out in international studies. So, it is a neurodevelopmental disorder that is  one of the more common developmental disorders,   which affects a range of learning abilities,  language, the ability to read and respond to   social cues, communication and adaptive and  executive functioning. And there’s a spectrum,   of course, with autism, ranging from those  who have lower levels of speech and language   abilities and intellectual disabilities, ranging  to those who are relatively more high functioning,   as is described in the criteria. Which may  include, also, some other language problems   or limitations in social functioning,  but not to the degree that others have. One thing I want to mention is that there is quite  a bit of comorbidity between autism and a range   of social, emotional and behavioural difficulties.  Much of that has to do with, sometimes, a mismatch   between having autism and the features of autism,  and current society. That there are demands in   society for a variety of fairly finetuned and  nuanced social qualities and the ability to read   social cues and sometimes, that doesn’t fit very  well with the autistic person’s strengths. And   while autistic folks tend to have great strengths  in certain areas, having to do with, you know,   concentration, attention and sometimes, they have  – they’re very much specialists in certain areas,   they don’t always fit – feel like they  fit in very well with general society. And also, people with autism are often grouped  in a category of those who have intellectual and   neurodevelopmental disorders and may, especially  in the United States, and in – to a degree,   in other parts of the world, are – as being  grouped in a – in those – among those with   developmental disorders, maybe in a siloed  system in which they receive services for   developmental disabilities whenever there are  behavioural challenges or emotional challenges,   rather than having access to, you know, the  usual trauma-informed mental health system that   other children and youth may have when they  have behavioural or emotional difficulties,   especially related to trauma. So, the siloed  service system can be quite a difficulty for   people with autism, as they may not have  full access to trauma-informed care. So,   it’s the goal of our group, with the  National Child Traumatic Stress Network,   to develop new treatments and adaptations  for therapy for those who have been exposed   to potentially traumatic events and to help  them to get the psychotherapy that they need. So, to talk specifically about the kinds of  trauma that people with autism may encounter,   physical and medical neglect, at times, happen,  physical and sexually – sexual abuse. There are   recent – a couple of recent studies that  suggest that contrary to what was once   believed about autism, these individuals are  more likely to have – be exposed to physical   abuse and sexual abuse and maltreatment, even  than neurotypically developing individuals.   And that – so, that they are often the subjects  of referrals for Child Protective Services,   and studies suggest that they often receive  more services and more family-level services   within Child Protective Service agencies  than children who don’t have autism. Also, there’s a great deal – there’s a literature  and a lot is beginning to be known about general   adversities and ACES, adverse childhood events,  that occur with people who have autism and their   families. Interestingly and sadly, children and  youth with autism are often exposed to a range   of adverse circumstances, in addition to trauma,  which may include parental mental health problems,   poverty and finance-related difficulties, parental  incarceration and relatively high rates of   parental divorce and separation. We believe, and  I think the evidence is supporting the idea, that   the adversities and traumas that occur with autism  may have something to do with the extra burden and   strain, financial pressures on families, as they  raise children with autism, who often need extra   help with learning and educational supports,  as well as mental health and physical supports. Children with autism, and youth with  autism, are also more often exposed to   being in settings where there may be physical  restraints and seclusion because of the,   sometimes, the necessity to intervene with  self-injurious behaviour, or aggressive   behaviour, or other challenging behaviours.  These children can be in settings where it’s   more likely that they may be restrained or  secluded. And while in many of the settings,   that restraint and seclusion is carefully  regulated, it may not rise to the level of abuse,   children with autism may experience  their restraints and seclusion as   abusive and traumatising, and that  can last over a long period of time. Also, as I mentioned, children with autism may  very well be subject to the child welfare system   because of reports of abuse, neglect or other  kinds of abuse. And once placed in a living – in   a placement – child – for example, foster care  setting, or a special education placement,   these children have less likelihood of being  able to move back into a less restrictive   setting. And once placed in a setting  that may not be a good match for them,   they have a higher likelihood of bouncing from one  setting to another, until educators and treatment   providers can find a good match for them. So, they  have, many times, multiple transitions between   living and educational placements, which can add  to adversities and traumas that they experience. Also, among youth and children with autism,  there’s an increased risk for peer victimisation,   bullying and exploitation by peers. And probably  the best, most thorough, research literature that   we have on trauma in children with autism  is around bullying and has to do with their   exposure to, not only physical assaults by peers,  but also has to do with teasing and ostracism.   There has been a, sort of, a fiction in the  past, the idea that children with autism   are not sensitive to psychosocial teasing or  bullying. But recent literature suggesting that   children are quite sensitive to it and that it  may lead to some of the outcomes that we see in   children with higher functioning autism,  especially with higher rates of suicidal   ideation and some rates of substance  use and self-injurious behaviour and   depression. And that this can lead directly  to post-traumatic stress disorder symptoms. In addition, people with autism tend to  have co-occurring – at least more often   than neurotypically developing folks, have a  higher rate of exposure to medical procedures   and medical – therefore, medical trauma.  So, if they have a co-occurring stomach   or gastrointestinal issues, hearing issues or  others, heart procedures that get done, other   kinds of invasive surgeries, they, of course,  get exposed to painful or restrictive procedures,   that are maybe medically necessary, but may  have lasting traumatic implications for them. I might also mention that diagnosing  autism and traumatic stress disorders   can be confusing and difficult, because  many of the symptoms of autism may very   well be misidentified as being related  to trauma and vice versa. For example,   in post-traumatic stress disorder,  we’re often looking for criteria such as   overarousal and hypervigilance and intrusive and  ruminative thoughts about a trauma. And people   who have autism may naturally have these kinds of  symptoms, even if they haven't been traumatised. For example, a child who has, excuse me, autism  and not necessarily trauma, may be very vigilant   to changes in their environment, may be very  over-aroused due to executive function differences   and weaknesses and anxiety, and may have worries  about being in new situations and struggles with   transitions. And so, they may look like they have  trauma, which – when they may not, or they may   look like they have autism and autism is driving  the condition, where it may be largely trauma. So,   the Clinician who’s working with a person who  may have co-occurring autism and trauma needs   to be very careful about diagnosis and assessment  to try to take those considerations into account. There is a bit of discussion in the literature  about whether people with autism are more or   less sensitive to trauma. Some are suggesting that  because of emo – problems with emotion regulation,   they may actually experience trauma to a greater  degree than people who don’t have autism,   and others who may feel that they may – they  are less sensitive to it. And that remains to   really be explored by the research literature  whether it’s they’re more or less sensitive. So, here are some ideas, kind of, longstanding  ideas, that people have had about youth with   autism and their ability to understand and engage  in treatment in general for mental health. One of   the thoughts has been that children with autism  cannot really engage with – because by virtue   of their limitations or differences, interpersonal  differences, may not be able to engage in therapy.   Another idea has been that – or – and  that they really need only behaviour   management or medication because they  don’t engage in therapy particularly well.   That standard mental health treatment’s really not  made for, or work – doesn’t work for children with   autism. And that because of the silos of care,  people who have a developmental disability,   such as autism, may very well be treated  within a developmental ‘disorders’ silo,   without having access to full understanding  of their mental health condition. Another of the misunderstandings has been  that – and I’ve mentioned this earlier,   is that people with intellectual disabilities  and/or autism don’t experience trauma because   of some sort of shielding effect of their  disability. And it is become more clear   through some of the in – the ongoing research  that they do experience trauma and that they   may experience trauma even to a greater  degree than people who don’t have autism. Another common misconception is that working with  a population of people with autism to help with   their mental health, requires a certain degree of  specialisation that goes way beyond what typical   treatment would look like. And while we are  finding that it requires some adaptation and   modification of approaches, and what we think  of, often, as a cultural competency around   people who have autism, it doesn’t appear that  it requires intense specialised training. It just   requires some experience and modifications  of some of the methods that we already use. So, you know, about – approximately,  according to the literature,   about 45% of people with autism also have  intellectual disabilities. So, really,   the majority don’t have a fully diagnosable  intellectual disability and many do and so,   when working with this population,  one needs to be aware of strengths,   weaknesses, neuropsychological profiles, in  order to make the best possible adaptations. So, overall, these – so, these  misconceptions are simply that,   myths and misconceptions. And  that we have found, in our work,   clinically and in some of the beginning research  protocols that have been done, that youth with   autism can be treated, and we’re going to  talk a little bit further about that today. Before I launch into more detail about assessment  and treatment of this population, I want to make   clear that working with them has both real benefit  – real strengths, that these folks come to therapy   with some real strengths, and also, there are  particular challenges to be aware of. Some of   the strengths that we’ve found clinically in our  population, in our clinic at Kennedy Krieger,   is that many of our families who bring their  children for treatment of trauma who have autism,   they’re very committed, dedicated to their  kids. Often fierce advocates for what their   children need and will – have often been on wai  – long wait lists, seeking treatment in multiple   places and often, very committed to joining their  kids in treatment to get them what they need. We often find, also, that despite some of  the complications of autism and developmental   disorders, that with this group of folks, often,  simple and fairly straightforward mental health   therapy interventions work pretty well. And  sometimes they work in a more straightforward   way than they do with youth who may be more  sophisticated in terms of interpersonal   willingness to be involved in therapy.  And we find that if we can join in an   essential therapeutic alliance with  children and families with autism,   we can often make great progress with  them, and we’re beginning to collect   data about that kind of progress with  the adaptations that we use in our model. We also find that children with autism usually  have their own particular preoccupations and   interests that we can make use of to helping  – help them to get engaged in therapy and be   invol – and excited by it and enjoy it. And  we find that working with these kids and   families can be highly rewarding. They’re very  – they’re often kids who – that may intimidate   people who are not very used to working  with those with autism, but once you get   to know them and have a standard sense of them,  they’re quite rewarding and make good progress. But having said that, I’ll mention a few  challenges that we do see with people who   have autism and come to therapy. One of ‘em  is that they have such a heterogeneity of   understanding about the words that we use,  the skills that we’re trying to help them   build as they work on overcoming their  traumatic symptoms. They may need some   particular supports for comprehension, for  example, may need more visual, in some cases,   visual supports to, kind of, see things,  and when they have less – and when they have   more non-verbal issue – non-verbal  strengths and verbal weaknesses. They also may have executive function  weaknesses, such as difficulties with attention,   concentration, working memory, generalisation,  staying engaged in a treatment. Many times,   trauma-oriented therapy requires the person  to have a – have some gradual exposure to   memories of traumas that they would really  not – would rather not remember. And so,   the executive functions and sometimes,  co-occurring anxiety that goes with autism,   can be a bit of a hurdle that the Therapist  needs to be aware of in order to help make the   best possible treatment plan and make adaptations  that will help the person get through the therapy. These folks often need case management  and Therapists are often called upon,   or need to advocate to get children and families  what they need in the educational world, and   to get them community resources, and to get them  services through developmental disability agencies   in their state. So, it’s often a greater case  management demand than typically developing kids. And then, one other thing I’ll mention,  which is that because of the nature of   comprehension and executive functions and the  co-occurring conditions that may be going on,   we usually find that our trauma-focused therapies  take a little longer, or sometimes much longer,   for people with autism than they do  for typically developing children.   So, those are some things to keep in mind. One thing that we find many times, when families  bring their autistic children to therapy,   is this common refrain, “We went to them,”  that is to mental health agencies and services,   “and they had no idea how to help us.” All too  common that we hear this and that is usually   because of that dual diagnosis difficulty  between the autism and autism features and   those associated with ‘em, and the trauma  and the way that those two go together.   That unless we have that cultural competence  and understanding about how to put the two   viewpoints and perspectives together in a  treatment plan, we may not be able to help   these individuals and families. And so, we need  to gain that in order to improve our services. So, I’ve talked about this already, but  just to highlight the silos of care issue.   That’s the same – very same symptoms  in a person with autism, say arousal,   overarousal, anger, irritation, aggression  and so on, with a person who has autism,   the same set of symptoms may be seen  very differently if they’re displayed by   a person who is – doesn’t have autism. And  they may be seen by very different systems   of treatment providers, and we’re going  – I want to – we’re going to talk about   the bias that’s often built into us in the form  of diagnostic overshadowing, which I’ll define   momentarily. And a tendency to see a child who  has autism in a particular way and to attribute   a lot of what they do to the autism, rather  than recognising some of the other emotional   and social issues that are operating and need  to be attended to in a therapy – an assessment.  And another thing to point out is that many people  who are trained, even chil – and even in child   orientated Clinicians, child and adolescent orient  Clinicians, are trained to treat people, see them   in the therapy office, are not very well trained  with developmental disabilities, even though they   might have a passing familiarity with it. And  that they may feel not prepared and rather – even   rather intimidated, when asked to take on  cases. And some clinics even will, very often,   limit the folks – limit from services people who  have intellect – IQs, for example, below a certain   amount, or people who have a developmental  disorder, and will refer them elsewhere. So, we did a study, Peter D’Amico  and I, and our group, a study – a   survey of certified Clinicians who were doing  trauma-focused cognitive behaviour therapy,   already certified people, and what their  experience was with people who have autism.   One of the things that they strongly mentioned in  that survey is that they reported some discomfort,   and this is the prioritised listing of types  of folks that they felt less comfortable   with. Number one, people who had low verbal  functioning, they just felt like they didn’t   know how to proceed with that. Number two, autism  spectrum and intellectual disability and so on. And there – so, there was a degree  of discomfort and interestingly,   though, we found that many of those providers who  responded to the study, despite their discomfort,   are pro – and of course, this may have been a sam  – this is probably a sampling bias, but probably   40% of those providers had treated somebody who  had a developmental difference or autism. And   most of the time, starting with people  who were relatively mildly affected by   the developmental disorder. And grew their  skills and their comfort level with that,   taking on cases more and more, who  ha – who are more severely affected,   and using some of the adaptations that we’re  recommending in our model that will be discussed. So, I want to mention diagnostic overshadowing.  This is a kind of, cognitive bias where symptoms   are inaccurately attributed to the developmental  disability, as I’ve mentioned. So that when a   person comes into our settings or offices,  whether we be Psychotherapists, Assessors,   Medical Clinicians or others, or even Educators,   and they have a certain set of behaviours and  challenging behaviours, our tendency is to be,   kind of, overshadowed by the diagnostic –  the developmental difference and to begin to   attribute everything that they pro – that they  show in their behaviour as being part of that   difference. Rather than seeing that some of those  interpersonal differences and emotional problems   as being related to emotional and interpersonal  problems, and not the disability itself. So, I’ll give an – a quick example  of that, and here’s a little vignette   and we’re going to assume that  this boy pictured has autism.   And this is a vignette that I think is  – kind of, illustrates what I’m saying.   “For the longest time we couldn’t understand  why Billy was always acting out and seemed   unhappy in our holiday trips to the mountains.  We didn’t realise that the smell of wood burning   in a fire was a reminder of the ski trip to  Colorado, during which Billy was assaulted.” So, we have this boy, Billy, he has an  autism spectrum disorder. He’s having   difficulty going on these vacation trips  and beginning to act out emotionally and   probably behaviourally or physically. It’s  pre – it would be easy for family members   to see this as really – and attribute this  as being related to his autism. You know,   “This is just Billy, he tends to act up when  there’s a change. He tends to resist anything   that’s different from what he’s used to.  It’s just Billy, it’s just his autism.” But then, if you start to dig deeper and realise,  as this family may have appeared to, that he may   be triggered in a reminder of some assault that he  had in just such a trip, and that those memories   of trauma are actually what may be driving the  challenging behaviour, not really so much the   autism. Although, the form of the challenging  behaviour might be shaped, in some part by the   autism. That the trauma itself probably has a lot  to do with it, and being able to be aware of how   both the autism and the trauma may be impacting an  individual. This is what we call, you know, ‘dual   diagnosis’. We have a person who has both elements  of autism, as we’ve described, and elements of   trauma. In order to do the best possible job of  assessment and treatment, we have to be able to   understand both sides and how we can best put them  together to provide treatment and understanding. A couple of – I want to move for a few minutes  and talk about assessment. Assessment’s really   important here in a clinical sense, because  the way that we understand this youth will   have a lot to do with the kinds of adaptations and  referrals that we make and what kind of therapy we   might provide them. And one of the troubles  in the field, or one of the growing areas,   is that we do not have very well-established  ways of measuring traumatic symptoms,   or trauma-related symptoms, for people who  have autism. And here are some reasons why. One is that, well, most of our measures that  we have – and there are a number of measures   of post-traumatic stress for children, and  those of you who are working in a clinical work   with traumatised kids, we know that  we have a number of choices about what   measures we might use for screening  and assessment. But very few or,   basically, none, of those measures has been  standardised for a – no – there’s not much   psychometric data. They haven’t been developed  specifically for people with autism. So,   the test items are written in a way that may  not be well understood by autistic individuals. There are often differences and there’s some  research evidence that people with autism   tend to have certain response styles that may be  different from typically developing individuals.   They may over-respond about – based on cer –  be – to certain words in the assessment. They   may under-respond or under-report, because they  may be looking for very concrete descriptions   of their experience. And if their concrete –  the perfect concrete description isn’t given,   they don’t see that as, necessarily,  something they need to endorse. There’s also this history of our tendency to  over-rely, as Clinicians, on caregiver and   parent reports with this population, rather than  giving them self-report measures, and what happens   when you over-rely on caregiver reports? You get  a certain skewed or biased set of information   about the person’s trauma history and trauma  experience. It really fleshes it out enormously   when we also have the child’s – the autistic  child’s report about their own experience,   which may be very different, subjectively, than  what the caregiver observes on the outside. So,   like, we always know, as Assessors, we need  to be able to get multiple informants and   it’s really important, but we don’t have very  many good self-report measures for these kids.  And then, one other thing I’ll mention is  that some studies have shown that in autism,   there seem – there’s a semi-reliable effect  that children who’ve been exposed to trauma   may show regressions and certain adaptive  behaviours. So, regressions in language,   regressions in toileting, maybe regressions in  stereotypical behaviours that were more under   control before the trauma. And that this is  probably an area that we need to be assessing   when we’re addressing a child who has autism,  is whether they’ve shown any regressions in   adaptive behaviour in a time synchronous  way with a traumatic event, or events. So, here are some measures that I would recommend  using, because we’ve had some good luck with them   and there’s reasonable data support for  these measures. One of ‘em is the Child   Stress Disorders Checklist- Short Form. Very  short screening instrument that has some good   validation that the – there’s four symptom items  on this measure that correlate very well with the   broader Child Stress Disorders Checklist scores  for screening for whether a person may have been,   you know, exposed and, also, if  they’re having trauma symptoms. Probably the – I would think the most commonly  used paper-pencil assessment measure is the UCLA   Post-Traumatic Stress Disorder Reaction Index,  the PT – the UCLA PTSD-RI. I don’t have it listed   here because the problem that we’ve found is  that the UCLA has a bit of a higher reading   level. A lot of our caregivers and children  don’t read that scale very well. It’s pretty   long and complicated. We have found that this  Child and Adolescent Trauma Screen is one that   we use often. It has a pretty good psychometric  basis, and it has a parent – good parent and   child self-report forms. The reading level’s a  bit more accessible, and the child self-report   age level, actually, is a  little lower, at age seven,   than most of the trauma scales that we have.  So, that’s one suggestion, is use the CATS. And then, there are several structured clinical  interviews that we also find helpful and also   have been shown to have sensitivity to people  who have autism. One is the K-SADS, which is a   – I think many Clinicians are familiar with.  It actually has an autism scale on it, which   isn’t the gold standard about diagnosing autism,  but it does give you some context, as well as   providing some – a good PTSD scale and anxiety  disorder scales and others that are helpful. Another one is the Anxiety Disorders Interview  Scale, ADIS. The ADIS has been studied quite a   bit by autism Researchers and Clinicians,  and there is good reason to thi – there’s   actually an autism specific version of  the ADIS by Connor Kerns and her group,   so that you can – to try to differentiate what are  some autistic specific characteristics of people,   versus true anxiety disorders? And it’s really  good at differentiating those two things,   and we have proper training on  how to administer and score it. And then, finally, the Diagnostic  Infant and Preschool Assessment,   the DIPA, which we use often with younger  children, under about age five or six,   and their families. Has a nice set of questions  that are – have some internal reliability and   help us to clarify trauma symptoms,  autism, or both, for young children. One thing we were working for looking at, in  our clinic, clinically, was something that we   could use as a measure, where we could get good  self-report data on this really tricky clinical   question about, “Is it autism, is” – I mean, “Is  it trauma, is it not?” in an autistic population.   So, I’ve developed this scale, the Interactive  Trauma Scale, which is an web-based, app-based   measure, that’s currently in development,  nearly complete and ready for dissemination.   And this measure is meant to be, sort of,  multimodal, more engaging and more able to   be responded to by a child with autism,  even those who are a little less verbal. So, first, they’re given a choice of an avatar,   with various skin tones and genders and  styles. So, they can choose their avatar   and then that avatar follows throughout the  questions on trauma exposure and symptoms.   For example, “Were you teased or called  mean names? Yes or no.” We’ve found that,   actually, in our review of the  literature about measures in trauma,   very few, or none, actually ask specific questions  about peer victimisation or bullying. And so,   we have found that, in our pilot studies  with this measure, that a large majority   of the children that we administer this to endorse  having been called – teased or called mean names. Being “in a car accident, or accident where  someone got hurt.” So, there is about eight   exposure items, including these yes or no  questions in the beginning, that the child can   just simply touch on a touchscreen. And then,  there’s a series of symptom items, including,   “I have bad dreams,” and they’re able to run the  finger along and say to what degree they may have   bad dreams, for example. So, it’s graphically  illustrated, it’s a voiceover, so they can hear   it, and they can read it, so it’s multimodal  and it can be responded to in a non-verbal way. So, we feel like this measure has some real  promise and our pilot testing of it suggests the   same. When lined up, it has convergent validity  with the UCLA Post-Traumatic Stress Disorder   Reaction Inventory, in the child version  and the parent version. So, we’re working   on getting that ready for dissemination, as an  example of what we’re looking for in assessment. So, let me move on in the last few minutes and  talk about treatment. So, once we have assessed,   and we’re pretty clear that there is a  trauma-related disorder going on – it may   not be a full post-traumatic stress disorder, but  it may be a trauma-related disorder. The person   may have some trauma symptoms. They may have an  adjustment disorder that’s related to specific   traumatic events. All of those may suggest that a  trauma-focused therapy approach could be helpful. And so, in our centre, we’ve been working  on adapting TF-CBT, trauma-focused cognitive   behaviour therapy, as a way of treating these  kids and families who have trauma. The – some   of the benefits of TF-CBT is that it is –  there’s a – it has a very strong empirical   basis as a treatment. It’s been used in a number  of different settings and with different aged   children. A lot of that – a lot of it – it  works because, I think, of its flexibility,   because of the cognitive behaviour therapy  components that are built into it. It includes   caregivers and families, which is just crucial  for our group of kids. They usually are – they’re   very typically not fully able to make full  use of psychotherapy on their own. And so,   we’re usually including non-offending caregivers  in this, as this clear stepwise pattern, and we   find it to be quite helpful and have developed a  Therapist Guide and manual for how to apply it. But I’ll just give you some of the high points  here today, in the few minutes we have left.   First of all, we want to explain to the child and  the caregiver the steps that we’ll go through in a   trauma treatment. First, there’s going to be some  learning and psychoeducation about what trauma is,   and this is all, kind of, driven by the – kind of,  a desensitisation, gradual exposure, framework.   Managing stress, learning relaxation  skills, just as many CBT treatments do,   in various ways. Expressing, learning  feeling identification and cognitive coping. And then, a big part of the therapy, kind of,  a pivotal part of therapy, is that narration   that is really going on throughout the steps,  as the child begins to tell their story about   the traumatic events that have happened, and then  share that story with their non-offending support   or caregiver who’s brought them for therapy.  And then, learning some safety skills and   assertiveness and also, in vivo desensitisation  to any areas, like school, or neighbourhood   or community, where they have felt traumatised  and maybe avoiding, and need some in vivo work. And so, we will show this graphic, or others, to a  child and their family, so that they know “These –   there are certain steps, and when we’re finished  with these steps, you will be able to graduate   from therapy.” And gives them, kind of, a timeline  and a sense for what that – what they’ll undergo. And the TF-CBT components are listed as  the ‘PRACTICE’ skills, the PRAC skills. So,   just to quickly define those. Psychoeducation  and parenting, it’s psychoeducation about trauma,   but it may also very well be, in these case,  education about the developmental difference,   like autism, and how autism and trauma are  going together for particular – this particular   child. And maybe some ways the parents can  use functional behavioural assessments,   or other kind of assessments and behaviour  management skills, with their particular   child who has this developmental difference  that’s affected by trauma. So, that’s the P. R, relaxation techniques of various types,  learned and practised. Affective expression,   so learning feeling words and learning how  to identify feelings and learning specific   ways or techniques for managing  feelings, and kind of, helping to   be able to calm your mind and calm your body in  various ways. And so, when we are adapting this   to people – kids with autism, we are wanting  to work especially around their physiological   and sensory comfort and their special interest,  to find ways that work specifically for them,   that may not work for every kid, but  that works for a child with autism. Cognitive coping, and then, doing  the narration that I talked about,   in vivo work and conjoint work, as well as,  kind of, establishing safety. Many times,   this E level, enhancing safety, might actually  go first, especially if the child is in a setting   where they might be re-abused or re-harmed,  and they need to learn some skills for how   to speak up or get the help that they need  to stay safe from further abuse or harm. And there are traumatic grief components, as well,  that are available. So, I have seen many children   with autism who have complicated griefs. I see one  now, for example, a child who was present when his   sister died of cancer and the grief component, the  grief part of that trauma, is a big part of his   dysregulation and symptoms. And so, that traumatic  grief needs to be, especially for him, built into   the treatment and done in an adapted way, so  that he can make use of that – those components. So, we came up with this, also, clinically,  trying to have a good heuristic for how to   think about this, we came up with the  ‘Matrix’. You recognise Neo, you know,   from the famous movie, The Matrix. And the  Matrix is, basically, a table or chart that   helps guide us, as Clinicians, to think up some  – in preparation for sessions in TF-CBT model,   what can we do in session to help make  adaptations for the child’s specific needs? So, the – you’ll see on the horiz – the  vertical axis, the practice skills I just   demonstrated psychoeducation, relaxation,  affect regulation and so on. And on the   horizontal axis at the top, a variety of  areas that we have pulled out, specified,   that appear to require adaptation for many youth  and families that we see who have trauma. And so,   at any given point, we’re going to be constantly  assessing at each stage, where is this child and   where is their caregiver in terms of, for example,  their verbal language comprehension? And what do   I need to be doing in therapy sessions  to do the psycho-ed and parent training,   but adapt it so that their verbal language is  taken into account, or the executive functions   or how well they can generalise skills? And we’re al – we’re looking not only at   the child’s level, but we’re also looking at  the caregiver level, because we find that,   in many cases, obviously, the child who has  a developmental difference, in many cases,   has a parent who has a developmental  difference, and they’re both involved   in therapy. We have to take both into account  in order to make sure that the entire treatment   gets finished and that it’s reasonable  and makes sense and sticks for the family. And so, we’ve, kind of, narrowed this down  to what’s called – we call the ‘Big 3’. The   Big 3 areas that we are finding in our research  and our clinical work, that requires consistent   adaptation in the – in these practice components  of TF-CBT. Number one, verbal comprehension,   conceptual understanding. We are asking ourselves  the questions, does the child understand key terms   that we often use in trauma treatment trauma,  trigger abuse, and so on? And the – do the   caregivers understand the terms? Do they have good  conceptual connections between what, I think, many   times, typically developing folks pick up almost  intuitively? They may need some more explanation,   tables, graphs, charts, visuals, to help with  the comprehension. And we’re slowing down,   we are checking for understanding  and we’re using some of our   more visuals and teaching tools that have been  identified in the autism literature for other   kinds of treatment, like for anxiety disorders  and other kinds of co-occurring conditions.   And we’re applying them to trauma treatments so  that we can make good adaptations in that area. Number two, executive function. So, one of the  things about autism is that many people with   autism have great brains, they think really well,  they’re very sharp, they have good memory about   things they’re interested in, but they often have  executive function limitations in ways that I’ve   discussed earlier. Things like working memory,  staying motivated, recognising the forest for the   trees, right? The being able to say okay, in the  big picture, this is what matters. Key – staying   intentional and staying clued into therapy.  There’s a tendency for them, often, to drop   out sooner from trauma therapy, is our experience,  because of these executive function issues that   get in the way of engaging in therapy and sticking  with it and unders – remembering it to the end. So, we’re asking ourselves these questions. Formal  assessments and informal assessments of where they   are at each stage in TF-CBT and what we can do and  what procedures and ex – and techniques we can use   to help support executive function. Our belief is  that people who have autism and their families,   they may drop out of trauma therapy. Usually, it’s  not because of unwillingness, it’s not because of   choices about they don’t want their child to  be treated for thera – for problem – for the   traumas. A lot of it has to do with executive  function issues, follow through, memory,   understanding why we’re doing this difficult  thing with their child, this gradual exposure. And then, the third big foundation  is generalisation. One thing that we   find in people who have autism and other  neurodevelopmental differences, is that   you can do a lot of good work in session with  them. Or there’s the whole literature on doing   social skills training with people  who have ADHD or autism, right? And   what’s our experience with some of that, is  that they may learn very well in session,   and they may walk out of the session and it’s  like you never said it, right? That they have to   – it has to be generalised. If you don’t,  you’re, kind of, working on this, kind of,   train and hope model, this idea that you’re  helping them with skills and you’re hoping they   remember it. That usually doesn’t happen unless  you are building steps in to help them generalise   what they’re learning in terms of skills,  relaxation and desensitisation, to other settings   outside the therapy. So, we’re building that in,  as well, both for the child and for the caregiver. So, this is my last slide and let me just sum  this all up by – this is what the Matrix – a   very simple form of the Matrix looks like for  kids with autism. So, we have, as you can see,   on the vertical axis, our PRACTICE skills listed,  and then, on the horizontal axis, comprehension.   The Big 3, right comprehension, executive  function/motivation and generalisation. And then,   if you’re going to do a therapy session with a  child and family in TF-CBT and you’re at the re   – say you’re at the relaxation stage, component,  you can go look at the Matrix. We have – actually,   this is, like I said, very small abbreviation, but  you can go to the broader Matrix and there’s lots   of ideas, because the model’s so flexible, for  training strategies and skills that you can use. So, for example, if we know that remembering  and generalising is a problem for this child,   and we’re trying to teach relaxation,  they need to be able to practice at home.   And they may not remember to practice at home, or  even know when to use their relaxation skills. So,   there’s some evidence that  video modelling, apps, charts,   check ins, at home check ins, with the parent as  well as the child, help increase generalisation   across from home – from session to home. And so,  we build that in very intentionally to the therapy   prog – procedure to help them with that. So, we’re  going to use the Matrix to help guide our therapy. So, to summarise, we have these kids and families  who have – the kids have autism, they have all   that goes with it, both strengths and limitations.  We are trying to better understand how to assess   them for exposure to trauma and symptoms which  are, sadly enough, much more common in this group   than in typically developing kids. And that we  want to be able to accurately assess, to rule out   and be aware of diagnostic overshadowing that –  and siloed care that tends to happen, and provide   some adaptations, sort of, culturally competent  adaptations, modifications, to trauma-focused   therapy, so that we can provide that therapy.  We’re beginning to find that we have good   results from this, and we will go on to – we’re  continuing to study this empirically, to find   out what – how we can adjust our model and what  works best for these kids and families. Thank you.