We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH learn. Welcome to Mind the Kids. I'm Dr. Jane Gilmour, honorary consultant, clinical psychologist and child development programme director at UCL. And I'm Umar Toseeb, professor of psychology at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature and, in conversation with invited authors, sift through the data, dilemmas, and debates to leave you with our takeaways for academics and practitioners. Today, we'll be discussing interventions for young people with autism who have co-occurring conditions. This episode is called therapy in autism, actions for adaptions. I'm really looking forward to talking about autism. And particularly relevant because of the complexities around neurodevelopmental conditions. So children and young people who experience various neurodevelopmental conditions also experience other challenges. And that can be autistic children experiencing mental health difficulties. It can be autistic children also having ADHD. It can be children with DLD. For example, some of my own work, developmental language disorder, experiencing mental health difficulties. So there's lots of co-occurrence of different types of conditions and diversity and also difficulties. And for a while, I've been thinking about this challenge for a while where we need to think about how we support children and young people who have these various neurodiversities within child and adolescent mental health services because-- and you can hopefully clarify this a bit more-- but a lot of the support that's offered in CAMHS is verbally mediated. So it requires a reasonably good grasp on oral language. So I've always wondered the extent to which it's applicable. Yeah, I mean, I do think it's a good question. I think there are lots of ways to communicate. And I know this is a question that you've raised in the past about the impact that talking therapies would have in general, but also with young people who've got specific or individual needs. And I do think there are something, if we're thinking particularly about intellectual disability or general learning difficulties, my experience is that actually, IQ, let's say, as a predictor variable is not very useful when we're thinking about engaging with therapies. And I think we'll hear from our expert a little bit more about the general evidence here. But certainly on a case by case basis, I can think of one or two young people who were pretty significant in terms of having general learning difficulties, but who could engage with emotional concepts using lots of alternative media. So for example, one young person I used emojis, phone emojis, to describe different ideas and different emotional temperatures. And he took those ideas and ran with them brilliantly. So I'd be really interested to see what the general data show in terms of predicting those young people that are more likely to do best, but also recognising as any clinician will tell you that we sometimes just have to try it out and see what the experience is like. But it's a fair point. I have somebody who wants to do a PhD who wants to study this exact topic in CAMHS. So I think they're interested in whether the cognitive profile of a young person are entry to CAMHS, so child and adolescent mental health services, predicts their subsequent engagement with therapy and services and also outcomes, which I think is a really interesting question. And you've touched upon that a bit about MQ if we can say that. But what about language, as in, are there some concepts that require just a reasonable grasp of language? Well, I think if we're thinking about young people who have, let's say, autism and have some language vulnerabilities, it could be that their use of language is equivalent if the speed of delivery is the same. So there is lots of variability within the language. Difficulty, speed of processing, or it could be the type of language used. So my challenge as a therapist is not to use idioms or concepts that are so abstract that somebody with autism may struggle. So my challenge here is to get across ideas using concrete and identifiable language, and also potentially using a special interest as a vehicle into quite complicated ideas because you've already got a passionate interest in some otherwise challenging work. And my experience is that can be used very well. So I do take your point. If something is delivered entirely orally and the language is difficult, in inverted commas, then that decreases the likelihood of a young person engaging if they have language vulnerability. But I think there are so many versions of this and so many ways around the language difficulty. So for example, using visual analogue instead of words that I-- you know me, Umar. I'm unbearably optimistic sometimes. But I would always explore it with a young person because I'm inevitably surprised. Once I'm in a room, sometimes you find that a young person can connect in a way that you weren't expecting. So as long as it's not aversive and there's no frustration to the point of being an unpleasant experience, I would try it out and see where the parameters of understanding are. But yes, I mean, if somebody that you were trying to deal who you referred to as nonverbal, for example, you would have to find another way to connect. That's our challenge. I do have a follow up question, but I think I'll just put it out there. And then when we bring the guest in, we can talk about it. And it's about whether your ability to improvise on the spot or adapt your delivery or your engagement with the child or young person based on their neurodiversity, is standard practise, and whether that's in the gift of all practitioners within CAMHS, or whether that's because you're specifically interested in your developmental conditions and you're a very experienced person. So would that be different if we had a less experienced clinician, or a clinician who wasn't necessarily interested in neurodevelopmental conditions per se? So I don't know the data, but I suspect so. And I'll tell you why. I suspect that's the case. So I do quite a lot of training with Tourette's and tic disorders. So we know there's an effective treatment. But we know that many clinical settings don't offer the treatment that has a great efficacy, actually effectiveness. So I know that there are very experienced clinicians who are engaging with all sorts of complex presentations who say, well, I haven't dealt with this particular condition, so I'm cautious about engaging with it. Quite rightly, because one doesn't want to go into a clinical area without the appropriate training. But some of it, I think, is confidence and experience. That's true for us all. So I do think I can see, once there is delivery of some of the concepts, particularly experienced clinicians can understand and generalise immediately into where they might have dealt with something perhaps not neurodevelopmental in nature, but something that they can see some parallels. But I would say that doing adaptations, I find really interesting precisely because your requirement to pivot on the basis of what that young person can connect with is a creative process. And one must adhere to manualized therapies where we can. Absolutely We know that that has greater evidence base. But also, we have to have that flexibility. So it's a really interesting question. I do think it's also where we might be having to think about training, for thinking about the inside trainee population or any other therapeutic community. So for example, low intensity intervention therapists and so on to try and think about training in the first instance. And that's something that I'm involved with and very passionate about, because I think if we start our therapists with the expectation and the tools to start to think slightly differently depending on how that person presents. There will be much less caution about it, I think. Or appropriate caution, I think. I think it links to something that I said a few weeks ago about education, where I was like, if we start from the point of lots of children, young people in a school, we'll have some sort of neurodevelopmental condition or neurodiversity and design the curriculum and school system around that. I think if we apply that here, if we start from the point of lots of children, incomes will have some sort of neurodevelopmental condition, which I think is the case disproportionately. Then training could be more tailored and more inclusive, I think, is the word. Yeah, absolutely. I mean, I think, when I'm in clinic, it's unusual if a young person presents with one condition. That's noteworthy. It's much more usual to have co-occurring conditions, whatever their primary referral issue is. So I think that's exactly right. Just to say that I was looking at the data on co-occurring conditions, because you raised that right at the beginning, in terms of what we might most likely expect in this population. And there's a really wonderful systematic review by Mica or Misha. I'm not sure how you pronounce that name. Apologies if I'm mispronouncing. But looking across a vast database, anxiety, depression, OCD, absolutely. But gastral problems were often in the mix as well as epilepsy and gender dysphoria more often than we might predict across the equivalent populations. So there's clearly a complicated picture to be expected in your typical young person with autism presenting at clinic. Yeah, we need some expert help here, Umar. We do. Shall we bring the guest in? I think so. Today, we're joined by Professor Francisco Musich, professor of child psychiatry and neurological disorders at Favaloro University, Argentina. Francisco will be hosting the ACAMH webinar, Autism and Co-occurring Conditions, Adapting Psychological Therapies, on the 13th of February, 2026. Welcome, Francisco. It's very nice to be here. Francisco, we were having a chat, just before we went live, about terminology. Perhaps you can just explain that for us. I usually try to use an interchangeable language in regards to terminology, because there are very few studies that they actually tackle preferred terminology in autistic populations. So there is no clear evidence that either with autism or autistic or non-autistic or neurotypical, it's preferred. There are some tendencies that those research shows. For instance, on average, people with less functional impact, they tend to prefer autistic, non-autistic, or they identify as, I am autistic, same with the families of those people or population and professionals who treat those populations, whereas people with more functional impact on autism are non-verbal populations, they tend to see it more towards the other point of the balance, more in regards to disorder rather than a condition. So because there's no voice that is louder or should be louder, and I try to be as representative as possible, that's why I will be using interchangeable language across the podcast. Thank you. Let's start from the beginning. We were talking, Jane and I, about some co-occurring conditions that we might see within clinics. But when we think about autism, what are some of the co-occurring conditions. I think that that's a very interesting and it's a very complex question to answer straightforward because for me, it's a multi-layered problem, meaning that to make it more graspable for the audience, I would separate more traditional mental health conditions, anxiety, depression, et cetera, versus more neurological conditions that might co-occur alongside autism because they need a difference in the treatment and its approach and formulation. So if we go if we were to only analyse mental health or traditional mental health problems, as you guys were mentioning before, anxiety, depression, OCD-like symptoms, or proper OCD are among the top of the current conditions. It depends on the study that you prefer to read, but the prevalence usually fluctuates between 50% and 80%. And I think that that's not just a number. It's a very important conceptual number. I try to transmit to either my students or residents is that when you're facing with an autistic children and autistic adolescent or young adult, you need to try to take into account that at least half of the population that you're going to meet, they will have a co-occurring condition. It's more the rule rather than the exception. And at least here in Argentina, we have this bias when assessing neurodevelopmental conditions or traits is that it's very separate. People who are trained to assess autism, to identify autism, they are not trained to assess or identify mental health conditions, such as anxiety, depression, and vice versa. So it's really a problem because you have a population that you need to assess this as a golden rule, because you have more chances to face a concurrent condition rather than a pure condition, pure traits. And we lack the treatment to do that. So on the other layer, the new, more neurological problems are more cognitive problems. ADHD, it's a common occurrence. Learning disorders or learning difficulties, it's another probable comorbidity. And epilepsy or eating disorders might also be a problem. ARFID-like conditions or more eating disorders throughout adolescence might occur. And I've interpreted psychological therapies without you saying anything as mental health interventions or talking therapies. Is that what we're going to talk about when you say psychological therapies? Or are we talking about other types of interventions that focus on not mental health? That's a very good question. No, predominantly, we'll be addressing or we'll be talking about talking therapies. Sadly, there's a rationale for that because there's sparse research in regards of how to adapt therapies or are interventions for mental health problems. And the majority of those studies that we have available up to date, they only focus on cognitive and verbally able autistic population. So we do have a very serious lack of research in non-verbal populations or people struggling with intellectual problems or learning difficulties or other cognitive styles. And that's something that we need to continue to research. And, Francisco, I think you've raised a point that's really on my mind a lot. And I know I've been discussing this with lots of colleagues who work in this area that although it is wonderful that the understanding of autism has expanded quite significantly recently, and the parameters of what we might expect to be considered autism are much wider-- or a little wider, rather. And that's had an impact on the general population, understanding what autism is and so on. But there is a population who have autism, who have significant needs, sometimes 24/7 needs, and who may be nonverbal, who are being left behind, I think. And we must do both. I'm always asking for more. I always want more. But the population that is nonverbal and has a significant level of need is not really being addressed either in the mainstream narrative or in the literature. That's certainly the sense I'm getting. I read a fantastic paper that you had written. It's a wonderful paper because it's a really practical list of ideas and adaptations that you might consider. It really does unpack it in a way that some academic papers don't often do. So I'd recommend looking at that. But perhaps you could summarise your experience of what you might do if you're considering it. What do we mean when adapting therapies for somebody who's new to the concept of it? And if you can give me some examples becaus, yeah, I really enjoyed that paper. I'm honoured by the praise. So thank you very much, especially coming for from you. And I think that this is my bias as a child clinician. So usually, this runs a few years backwards. I was having a discussion in a good sense, like an exchange of ideas with one of my main trainers and former boss, Professor Eduardo Bunge. He works at Palo Alto University in the US. And he was quoting a conference that was held in the US where someone asked, how many of you people in the audience use manualized treatments. Everybody raised their hands. How many of you actually use it without making any modifications. Only a small percentage of the clinicians were raising their hand. And I think there's a rationale behind that, because as I think that you were mentioning this at the beginning of the podcast, I think that 80-90% of times that we are facing with an actual patient, client, consultant, whatever type we choose to use, we're facing with someone that is more likely going to have 2 plus more conditions. It's very uncommon to face someone with only one condition. And usually, treatments are designed for just a single condition. There are more newer protocols, transdiagnostic protocols and approaches, or more dimensional approach to psychopathology. But I think that it's really interesting and are trying to tackle this. So I think that many manualized treatments, obviously they're evidence-based and they're very helpful, but they need to be think of as logical steps to approach with someone. For instance, if I'm doing exposure therapy with someone with anxiety, it's not that I have to actually do section 1, section 2, section 3 in a strict way. It's just that it's logical steps. For instance, I can't go to do an in vivo exposure previously without doing a thermometer and trying to create a hierarchy about what is the most fearful thing for me and what is the least fearful thing for me. So in that sense, I think that clinicians already do adaptations and they do slight changes in non-autistic population. So it's not that uncommon for us to adapt to that specific client. So taking from that, I do think that there are some populations that they need more adaptations to that manualized treatment following those logical steps. It's not that we are going to adapt treatment in such a way that it's not going to resemble in any way the original protocol or the original intervention. But I do think, again, that some people, the way we deliver that treatment, it's not going to be graspable adequate for them. And we need to take that in mind. So if we do a very proper formulation of the case, trying to identify the strengths, the weaknesses, the specific social processing style, the sensory processing style, the language style, I think that we will be more specifically addressing what that people is going to be needing. Yeah, that's great. Can I just be a bit more probing there? So I recognise it'll be different for different young people who access support. But I just want to get more of an idea about-- for a case study, autistic child who might access mental health support, what kind of adaptions are we talking about? Jane talked about, at the beginning, concrete examples. And I think you said not using metaphors, I think was what you said. But other than that, what kinds of adaptations are we talking about that are needed for children and young people who are autistic. The best we have of research up to date. It's more close to guidelines, rather to a specific protocol. Let's say, for anxiety, the Coping Cat. But it's a very famous protocol. And everyone who has studied psychology or psychiatry probably knows this protocol. So it's not that we're going to have a separate protocol, but there are suggested modifications for, let's say, treating anxiety in children or adolescents with autism. One of them is to adapt, again, on a client need basis. So it's not that by default, we need to downgrade the language that we use. That's why I wanted to start the first step. It's a very good formulation of the case because we have the risk if we downgrade too much or we adapt too much, we might infantilize what the children or the adolescent, and they might feel that we are not treating him as we should. So there's a risk in adaptations that we need to be very mindful about. So on average, using more concrete language, it's one of the communication language adaptations that it's suggested, meaning that if we can use less metaphors, abstract language, et cetera, and we can transmit more concrete graspable concepts in an explicit way, that, on average, tends to be more friendly for autistic people. Not just using concrete language, but using a shorter way of language. What do I try to mean to transmit with this is instead of just explaining, let's say, for 10 minutes what I try to do is try to use short sentences, right on spot, trying to transmit one concept at a time, and checking whether I was able to transmit in an understandable way for the person. Again, trying to be mindful not to put the problem on the side of the person, but rather how we to translate from a neurotypical or non autistic communication style to an autistic type. I usually try to use phrases in like hey, probably I just heard myself, and I'm afraid that I was too complex, too difficult in explaining the idea, could you explain it back to me just so that I can double check that I did a good job. I tried to put the problem in me and not how the other person understands me. And I think that's a good-- or at least it has been very helpful for me to make it more friendly to the other person. If we can accommodate also language and try to have a sensory approach to communication, that's usually suggested, meaning some people are going to prefer more visual cues or visual adaptations in order for us to support the transmission of a verbal concept. That could be an emoji, as Jane was mentioning before, that could be a piece of a video from YouTube that you choose to exemplify and to, again, make it more tangible, an example for autistic client consultant. Those are adaptations that are suggested. Usually, they are more macro adaptations, meaning this is sometimes hard to do either in private practise or in services like the NHS or public health services, meaning sometimes sessions need to be longer because the processing time of the client just needs more time to process what we are, either to understand the concept or understand what we are transmitting. That means that as clinicians, we need to be patient. If we see that the client is not responding, we don't have to do rapid fire questioning, because that's going to be overwhelming, and it's not going to either clarify or help the person to understand. But again, on public settings or private settings, either it will increase the cost of the consultation or we just don't have, in public settings, the amount of time. Maybe instead of a standard 40-45 minute session, to extend that to an hour, an hour and a 15, or an hour and a half session. But that has proven that it's an adaptation that it's sometimes useful. Or the length of the treatment. Usually, standard treatments go from 16 to 20, 20 something sessions. Sometimes autistic populations, they need more sessions. And that's not usually possible. Sensory accommodations are really important. If a client is attending a hospital, comes office, private office, et cetera, and it's sensory overwhelming, they are not going to be processing what we are trying to communicate. They are not going to be comfortable. So it's not a very suitable scenario for them to feel comfortable and to actually take something that is already going to be hard for them, because going to therapy, treating things that are difficult are usually already hard enough. If we, on top of that, make it sensory complex for that population, it's going to be even more difficult. Obviously, we need to adapt the social style. I think that, especially when thinking about building rapport and alliance with the client, sometimes it's difficult to read the person. And I think vice versa, the person is probably a hard time reading us emotionally what we're thinking. So I think it's a very good practise to ask, hey, are you feeling OK, is this making sense to you, or did I say something that is making you uncomfortable, because sometimes alexithymia or what other issues might lead us to think, hey, this person is not engaging, or it's having a negative response, or it's not interested in the things that I'm saying, and it could be very much otherwise. On the other side, it's very good to explicitly say what we are going through as a clinician. Hey, I'm starting to get frustrated because I think I'm not making myself clear. Is that so, can you understand me. So an overall rule is to be as explicit as possible. I was just going to say, that's exactly-- because what you're describing is the thoughts that might be on one's mind as a clinician-- or I wonder if I'm getting this-- but actually, what you're saying is that you say out loud your thoughts, I'm checking with you, do you understand what I'm saying. I think that's really important. And I'm really struck by the sensory issue. In fact, we had a young person on our ECAMM series called Inside the Teen Brain. And she was a service user. And she talked about the importance of introducing the scenario and the physical setting to young people. And we discussed how that would be really useful just to have a website video of where you will be, what the room will be like before you're in the therapy room. We were talking about the importance of that because the physical environment can be a really impactful aspect of it and stop that young person from engaging. I've even had young people-- I always check out my accent because, of course, you might be able to tell. I don't know if you can tell, but I'm Scottish. And most of the young people are not used to hearing a Scottish accent if they're in the Southeast of England. And so sometimes, I've had, on occasion, it's a different auditory experience certainly to hear that accent. And we need to figure out is that OK. So I think you're walking us round so many factors and variables that we need to consider. Umar, is that bringing it to life for you, do you think? It is. But I have my research evidence-- That's what you're here for. --mindset of how. I have a follow-up question, which is in lots of parts of life and society, we accommodate lots of people's differences. And in this particular context, what I'm interested in is what is the evidence that the accommodations that you've been talking about make a difference to autistic children and young people's access to support and their outcomes because-- and the reason that's important is because you might feel it's helpful. The young people themselves might feel it's helpful. But actually, if the data shows that their outcomes, if you had an intervention group where you made these adaptations, and then you have a control group where it was business as usual and therapy as usual, and the outcomes are the same, or even worse in the ones where you've accommodate, then even if you think it's working and the young person thinks it's working, if in an RCT setting type situation, it shows that it's either not working or is harmful, then that's problematic. So what's the evidence that everything that we're speaking about so far actually works? It's a very lovely question because I think the same way. Something that might make sense, that does it necessarily doesn't mean that it's going to work. So sadly, as I mentioned before, so there's very few research available currently. And that research only focuses on or predominantly focuses on people who are cognitive and verbally able. So for that specific range of population that it's a very short percentage of the whole spectrum, there are RCTs mainly targeting anxiety and depression, that they show that if you do those accommodations, the effectiveness of the treatment, it's better than doing treatment as usual or the original protocol or waiting list. For instance, doing behavioural activation for adolescents, the Coping Cat. So exposure therapies or progressive exposure therapies for anxiety. Those sort of protocols, there's available evidence that if we do adaptations, they tend to work. I don't know why I forgot to mention this because it's one of my current main interests is autism and suicide. There's a brilliant researcher in the UK, Sarah Cassidy. I think she's in Nottingham University. So they adapted screening tools, for example, to try to identify depression in young adults and adolescents with depression. And they adapted the safety plan intervention that it's one of the first interventions you tend to do with someone with suicidal ideation or identification. And again, her research, or those sort of research, they show that if you do adaptation, that delivery form is more graspable, understandable, and the effectiveness goes up. In other sorts of therapy or therapeutical approaches, we have much less evidence, and we have 0 to none to non-significant evidence in nonverbal populations, because we don't have robust evidence of ways to actually assess if they are experiencing anxiety and depression. We can infer from changes from the behaviour, but it's a presumption. And at least now, not a very robust scientific way to be tackling this. So there's evidence. There's predominantly more evidence in anxiety and depression in children, mainly adolescent and young adults who are intellectually and verbally able. The whole other spectrum, we need to do more research and to understand whether these adaptations are indeed effective or not. I want to keep an eye on the evidence base now, and look at what predicts a good outcome on a group basis. And of course, case by case examples might be different, as we discussed at the beginning. But on a group basis, are there factors in the therapeutic characteristics or in the young person's characteristics that predict a good outcome? Do you know of these data? Yes. Usually, what tends to predict a better outcome is the ideal patient that we don't tend to come across in clinical settings so often. So if we have someone who is autistic with just one comorbidity, usually the outcome is better. If the language skills are really functional and it's just mild difficulties and challenges on daily basis-- so they're going to be able to grasp complex and abstract concepts-- that usually correlates with a better concept. If we have parental or school support, that usually also correlates with a better outcome. Going back to the previous question-- sorry that I'm jumping back and forth. But one other accommodation, especially in adolescents and young adults, that we don't tend to do on non-autistic population is to try to include more parents or other significant people in the person's particular life. For instance, if I'm seeing a 20-year-old, usually if I'm doing common therapy or adult therapy, I'm not thinking about bringing in the parents or bringing in the partner or a friend. But if I'm doing that therapy with someone who is autistic, data has proven that if there is a network behind, and there's people supporting them, that usually correlates with better outcomes. So we do have indicators about better outcomes. But again, research is really, really scarce, and we need to do more and more. But that's a very good question. One of the things that's stopping us from making these adaptations is that you talked about the cost if you're going to have longer sessions, for example. But one of the ways in which you can sell this idea to funders or people who fund the health service to governments, insurers, whoever is, for it to be across the board for everyone who accesses therapy. So rather than just thinking about these adaptations for neurodiverse children, young people, thinking about implementing them across the board. So my question is is universal adaptations the way forward? That's a very interesting question. I'm probably leaning more towards no, leaning more towards a formulation based approach to each case, meaning it would be good for us to have the flexibility that if that specific person that I'm treating needs more time, the system in which I'm working, private or public, lets me do that adaptation rather than by default doing it for everyone. So I'm leaning more towards it would be good to have the possibility, rather than by default to adapt everything for everyone, because not all autistic people need an hour and a half of session. Some, they're going to be brilliant and they're going to understand the way I'm transmitting certain concepts or ideas or interventions. And they are going to use a standard time of sessions. And other ones are going to be needing a bit more time. You were mentioning something about how do we sell this to the people responsible of saying, OK, we are going to enable the NHS, hour, an hour and a half sessions for people that they need this. And there's research published that if you see how much is the cost for the health system of someone with autism across their lifetime, it's about-- and this was studied in the US-- $3.2 million. So that's a big number. The majority of that cost amounts from adolescence to adulthood. And the majority of that cost, the responsible is comorbidities and co-occurring conditions. In most cognitive and verbally abled people, the most functional impact doesn't necessarily come from autistic traits, but rather than my comorbidities-- anxiety, depression, trauma. So if we want to lower that cost for the system, better treatments, faster treatment, better screenings. Eventually-- and this is a hypothesis-- I think it's going to translate into less need for services. If I become chronically depressed or I have recurrent depression because it's already chronic, that's going to be a huge cost for the person and for the system. If I'm able to provide very early interventions identified in an early way and provide an effective treatment, probably that person is going to suffer less and the cost for the system is going to be less. And if only we could get that. And I think that is so beautifully put, because that's a false economy to economise on intervention because of the long term outcome. I read a statistic recently. So every 1 pound invested in child health now is a 19 pounds saving for society in the future. And that's across child health, but includes mental health as well. So our challenge is about how to get that idea across when we are living political world or a policy world that has a fairly short term outcome. So we need to be able to develop that because it really is our-- it's a no brainer, as they say, isn't it? Francisco, we've talked a little bit about some of the themes in adaptation. But you've got a webinar coming up in the new year in February. And I know for any clinician who's working with this population, or any clinician who is thinking about how they might do adaptations, this is going to be wonderful. So can you give us a very brief elevator pitch on the webinar content? Yes, of course. So the main goal of the webinar-- so obviously, people who work with autistic population, it would be a good opportunity for them, but also for general clinicians or people who are in general medical services, because the idea is to try to transmit practical things that you can do with clients, not just theoretical and research data, into what sort of adaptations, depending on either the type of talk therapy and the mental health condition that you're facing. So the idea is to try to make it as practical and hands-on as possible, because as we were discussing later, I think that if we researchers and people working on the subject can help general clinicians, psychiatrists, psychologists to have more tools to address this interesting and relevant topics of mental health and conditions that people with autism might have, it's also going to be beneficial for everything. So the idea, it's just a short collaboration-- try to do something and transmit actual things and adaptations that we can do with clients. Wonderful. It sounds fantastic. Thank you so much for that really nice conversation, Francisco. And hopefully, we'll have lots of people signing up to the webinar where they can learn a lot more about this stuff that we've been talking about today, which, as you say, some practical suggestions for how to implement some of this stuff into practise. Thank you so much. It was a really enjoyable experience. And you guys saved me through in a very eloquent and elegant way. So thank you very much. It was very friendly for me. Thank you. I really enjoyed that conversation with Francisco. I think there were lots of questions that I really wanted to get to, but we've just run out of time. So making adaptations in therapy assumes that neurodiverse children or young people experience mental health difficulties, and they manifest in the same way as neurotypical populations. But the chances are that probably isn't the case. So even if you've got adaptations being made to clinical practise and therapy to accommodate for neurodiverse needs, the mental health difficulties and symptoms might be manifesting differently. So the model of therapy just might not be appropriate. But we didn't get to that. My question was going to be-- so the starting point is the therapy is appropriate if we adapt it. But is that starting point a valid starting point because the therapy might not be appropriate because the mental health difficulties are different? Umar, it's one of your massive questions that turns the table over on everything. But what I would say-- and it is interesting. Maybe there is really going back to first principles question. But I would say my experience is there is enough commonality to recognise that anxiety is recognisable as anxiety. And so a young person who's got autism may get anxious about change or feel uneasy about change, but that doesn't mean they have co-occurring anxiety. When you meet a young person who has anxiety and autism, they are experiencing it in very specific and in ways that is impacting on their functioning in a way that is very recognisable and the principles. And that my experience and certainly the emerging evidence. Now I think what we were discussing is really important. So most of the literature is looking at feasibility rather than efficacy or effectiveness. But the emerging literature that is there does suggest that an adaptation is effective. And it does make sense. If you think about broadly speaking, you're moving into personalised medicine, for example. The more bespoke something is for you, the more likely it is to have an impact. But I like your question. I always like your questions. Asking these big questions is important for all of us. But I guess I would say, on a case by case basis, I think there's more commonality than difference. And the reason I asked the question around what's the evidence that these adaptations work is because I was applying for some funding for education trials, or school based trials. And I was looking at some previous trials. And there are examples of when trials are actually harmful in schools. And so someone tested out an intervention and had a control group. And the intervention group has done worse at the end of it compared to the control group. So I think that's why I was like, well, we think we're doing an intervention here and making these adaptations. But we need to know that they help and they are not harmful. And that's where it came from, really. Yeah. No, I think it's an interesting question. I mean, again, if I about my parallel in work with young people who've got autism and working with doing behavioural therapy in relation to tics, there are situations in which young people just they're not finding the therapy helpful. And in fact, it could cause frustration or sometimes withholding a tic can be painful. So we have to be really cautious about offering therapy and understanding the cost and the benefit. I think that's a good question. And I do think, that there are very few trials, as I understand it. So as I was looking at the literature, the personalised anxiety treatment autism protocol-- and that's Jackie Rogers, Jeremy Carr, and Anne Le Couteur in Newcastle. And that's looking at autistic, rather anxiety in adults who are autistic. And that seems to be the most coherent manualized therapy for this group. But it seems to be at the forefront of any of the data. So it's a fair question. We don't know. And we mustn't assume until we've got the data. However, the case by case data does seem to be encouraging, I would say. What's your takeaway? My takeaway is that we have two problems, really. One is an emerging literature on evidence-based adaptive therapy. And the second challenge is we don't have as many clinicians as we would like to have that are ready to offer those adaptations. And I think we have to address both those problems if we're thinking about the future of our clinical populations attending services. My takeaway-- and before I tell you what it is, I'm going to put a caveat on-- which is you have those ACAMH awards. And I feel like there should be an ACAMH award for stating the obvious, which-- [LAUGHTER] My takeaways are always like, well, that's obvious. And so what I'm about to say, maybe obvious to lots of people, but when we were talking about the proportion of children or young people who access therapy and what other co-occurring conditions they have. And I think there was a figure of like 50% to 80%, somebody said. So lots of more than half of the children who you'll see in therapists have other stuff going on. So there's co-occurring conditions. So my takeaway for academics is when we're thinking about trials and we're thinking about testing whether something works and we do an RCT, there's good reason to have good, clear inclusion and exclusion criteria. But a lot of the time, I think we exclude children and young people with specific neurodevelopmental conditions. And we try and test out interventions on a sample that probably isn't that representative of what you're seeing in clinical practise. So I suppose my takeaway is when we're thinking about inclusion and exclusion criteria for trials, think about what is the population that we're going to see in practise, and does your trial map onto that population. Great point. Next week, we'll be taking a well-earned break, and we'll be handing over to Dr. Clara Faria, who's going to be talking all things digital with Prof. Johnny Downs, Dr. Alice Wickersham, and Zoe Frith from Cams Digital Lab at King's College London. They'll be exploring how digital innovation is transforming child and adolescent mental health services. Then we're back on New Year's Eve, talking to Dr. Nina Higson Sweeney about fatigue in an episode entitled Depression Symptoms-- Should Fatigue Be In the Major League. [MUSIC PLAYING]