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Uh huh. Oh, yeah, got it. Um Welcome everybody. Uh My name is Katrina Harris and I'm a consultant community pediatrician and I work in North London. Um and um I have a privilege to work with the team of professionals who are dedicating a lot of their time to support Children with autism. Um For the next hour, I just would like to really sort of reflect and think about autism as a condition, develop mental condition and I will mainly concentrate on assessment of Children of Children. Um When uh there is a sort of logistics um sort of divisions that really there, there is no sort of like a consensus in the UK how service for Children, for Children and by Children, I understand everybody under the age of 18. So how services for Children with autism is provided and there are some services which are split and pediatric services, they sort of are dealing with the assessing Children under the age of five and the age of five comes from the fact that by the type of the age of five Children go to school and then sort of uh a large bulk of support is transitioned to uh education and primary schools and then Children over five are assessed by community adolescent mental health services. Um There are also services where pediatricians really deal with Children until the age of 12. And the reason for that is that um you such of have all the Children in primary education and then by the time they go to secondary education, um they are again assessed by counts in our team. Uh we work very closely with comes we are community adolescent mental health services. We are very lucky in the sense that uh the adolescent mental health is just one floor above in the building where we we occupy second floor while they're on the search up. And the services are such of provided that under five Children are assessed by us above five that are assessed by, by that by community adolescent mental health. And in the end of the day, really, it doesn't matter because in order to get the diagnosis of autism, you have to have the features presenting from early childhood. So early developmental history needs to be taken by a whomever sort of participate in the assessment and the diagnostic process. Now, I suppose to read that young Children when they present, they also present with quite significant developmental delay. And uh perhaps because we are developmental pediatricians, um we're such of are particularly tuned into paying attention to child's development and spotting the signs of abnormal development. And by the time they present at the latest stage. Um uh The situation is slightly different in the sense that those Children tend to present with the normal um such of uh develop or normal. It isn't really a normal development, but there is no apparent uh learning disability in these kids. But uh they just present with the social communication difficulties. They can sometimes if they present in really late uh ages. And by that, I mean, teenagers, they may actually present with the mental health problems and then the situation is really even more difficult. And that's why such of it's actually quite go to have the colleagues from the mental health services involved in the assessment of those kids. But for today, semi, but this sort of lengthy sort of explanation, but I've changed that up because that's the title of these slides until such of today was just autism really. But I was just thinking actually, let's just try to sort of uh make it clear um where sometimes there is a logic for dividing autism assessments between young Children and then sort of older Children. Um There's also another aspect of these sort of autism and autistic assessment that there's a increasing recognition for the fact that girls tend to present slightly different because they're much better at mimicking and copying um more socially appropriate behaviors. If one compares to the voice, I haven't such of included any specific slides dedicated to the assessment of autism in girls, but I will try to such of uh include that and sort of mentioned that. Um So I hope that by the end of this hour today, sorry, I actually um somehow move too quickly. Apology for that. Yeah, by the end of this hour, I really hope that you get the appreciation that uh when we talk about autism, we mean uh problems with social communication. So with that how you use your communication rather than a problem with speech and language delay, because we're talking about a much bigger sort of area with development. Um I will try to mention how we die diagnose Children with autism. And our team tend to um use the gold standard tool for assessment of autism. And I will mention some of those really, which one can just sort of also use and then um I'll try to say as well a couple of words about what one can do for uh Children with autism. So maybe before we should go ahead already with talking about autism for the whole hour water luxury, let's just try to define it what we mean by autism. Um So when we talk about autism, uh we think about Children who have difficulties across three areas, firstly, communication and social interaction. So this is how the Children use uh they're sort of communication. Uh Some Children can speak and have really a fantastic vocabulary. Um They sort of uh can talk endlessly about ninja turtle. Detectives really. It's a, such a funny cartoon of little turtles which are running for all those who sort of don't know. Uh, or they can talk, Children can talk about dinosaurs or sort of solar systems and plummet and yet they're unable to say hello. Are such of not to be shy and hide every time they are meeting some of the strangers or understand the rules of a simple game that is played by the group of Chila. Um So, um when you see that situation, um then obviously you fulfill criteria for the social problems really in the communication and social and social interaction, Children also have a difficulty with their uh with the rigidity of their behavior and with the lack of flexibility of thinking and uh what it means, there is simply the sort of adherence to the sameness and adherence to um really like him doing things in exactly the same way. And really, when you such a can't such of get this way, then you just become very anxious because you don't understand why the world has to change all the time. And that really comes simply from the fact that they don't understand um that things can be done in different way. And sometimes it's a really difficult concept for people to understand. And I tend to compare it. For example, if you know that a person is visually impaired plan, you understand that they cannot see, they can't see, you know, they uh they can't see small things that they can't see big things, but they can't see. And this is a similar thing really. It is similar difficulty. They cannot accept that things are done differently because they lack flexibility of thinking. And then the sad area which is uh often impaired to a motor grated sort of level than in all other Children is sensor integration difficulties. Um We sort of until not long time ago, until 2030 years ago, we couldn't understand that some Children with the sort of difficulties, they struggled, they got very easily overwhelmed and they struggled with. These sort of sipping are just closing of excess of these sort of impulses and sort of excess of these sort of uh input really that they misbehaved in the shops, for example, that they did uh struggled really were set in publix that they were unable to sort of uh eat things that they were very rigid in the way they sort of tolerated things that were very fussy eaters, etcetera, etcetera. And now all that, which is part of the such of diagnostic such of criteria with the autism. We know that that simply comes from the fact that Children with autism have a very different appreciation of all the impulses and experiences that we get through our sensory existence. And whether it is the touch in the skin or whether it is or uh motor such of awareness or whether it is the as the sort of auditory awareness, they simply are either under stimulated or they're far too easily overstimulated and they can't such of regulate it in normal way. Now, there are the three areas about uh sort of difficulties which we talked about when we sort of uh see Children with autism. And until not really that many years ago, we talked about the triad of autism. This has changed. And actually, now look at this, it's actually quite a long time ago because it was in 2013, there's um five criteria, diagnostic criteria, diagnostic um uh schedule of the mental disease criteria and definitions. With the fifth sort of addition, they divided the criteria for the autism diagnose ation into two areas. So we still have the area of the social communication because in the end of the day, um autism is the condition of the impaired social communication. So in order to fulfill such of the diagnostic criteria, there have to be persistent difficulties in the social use of verbal and nonverbal communication across multiple context with functional impact. Now there are several sorts of like uh part of the information and each of these uh the information in the definition is really important really for the diagnosis because autism is a lifelong condition, you cannot grow out of the autism. Um It does change, it may present a in a person and child with the different level of difficulties in different sort of different times. Of their life. However, it's, you do not grow out of it. So the difficulties have to be persistent, slightly different at different times because a three year old child has different difficulties than a 10 year old child and 20 year old young person. Nevertheless, the difficulties are persistent and these difficulties are in a social use of communication, which I was trying to explain. It's not good enough to be good at vocabulary speaking and recognition of these sort of uh rheumatic rules. It has to be for social years. So you have to be able to express their emotions and needs, etcetera. Now, it also applies not only for spoken language. So not only for verbal communication, it applies also for nonverbal communication. Because when you think about our communication as humans, we use a fantastic range of nonverbal communication and it is really just as important as the verbal one, whatever you say, you sometimes can say really quite nasty things. And yet if you say it in a specific way, it will not necessarily have the same impact as if you just write it in your email and people just read it. Uh in addition to that, um there are other ways of communicating. We know that people who are death, they use uh sign language. So just because they can't speak, it doesn't mean that they are autistic. They use most beautiful uh such a form of communication and most beautiful language that they can convey the all, all the, exactly the same sort of uh messages just with the use of the gestures and their hands, really the same thing applies really to people who are not autistic, but they cannot speak language. Let's say that if you find yourself in a country which uses a language, you really do not understand because it's very different from your own language. If you need something, you will use any kind of other ways to show people what you want because you will draw things you will appoint, you will sort of maybe find pictures, etcetera, etcetera. So you are only an autistic person if you are actually lacking this communicative intent, if you know what they mean, really, I don't know, I can see that somebody was all right. OK, son. Okay. Sorry, I was just ready to check out that there wasn't anything, any sort of comment on in the chatter. Now, these difficulties, they have to present across multiple context and um multiple, multiple, multiple, but definitely more than one. What, what, where does the importance of that comes? Really? We tend to compare it really, at least at school and in the child social environment to the home environment. Um If it just presents in one environment, one has to think about other such of environmental factors that may such uh impact on the child's presentation in that specific such of situation, perhaps just to give a really quickly sort of example of that would be Children who suffer from profound neglect. So Children who are abused in very early childhood by very neglectful parents, um they tend to be spared uh possibility to progress with the normal development. And the communication is one of those areas which requires a good quality of interaction between the child and their carers. Children who really have been uh not given that opportunity to develop their sort of communication, they can present as in a similar way than Children. Um poor autistic and, and ready. So if you would have a child who would sort of present with the features of waters in the home environment, while for example, these features would not be present at school, you would always think about um what is the situation at home? What is the interaction between the carer and the child? Is there a problem there? And then the last thing really in that sort of part of, I'm sorry, I'm just spending so much time, but I think it's just quite important to understand really all these aspects of these sort of definition. So the last aspect of this first criteria for the diagnosis of autism relates to the functional impact, uh many of us can be introvert. Uh many of us can have different ideas. Many of us can sort of prepare uh own sort of uh company and really be not so sociable. However, if we function within the sort of expected norms of our society, then we do not necessarily get the diagnosis of autism if it doesn't impact on the child's learning on the child existence within this normal school and society. Um, the child doesn't necessarily need the diagnosis of autism because autism is not like diabetes, epilepsy that you have to take a tablet and treat because it's sort of life threatening. Actually, there are many groups of people with autism in adult life who really um you know, would not really except even consideration that they actually have difficulties, they just think they are different, but that doesn't matter. So the first part of the diagnostic criteria relates to the social use of the communications, the social communication. The second aspect of the uh the sort of diagnostic criteria relates to the restricted repetitive pattern of behavior, interest and activities and in that sensor problems are included. So let's just go and take a look at a little bit of examples. Sorry because uh okay, that's it seems to be both. Yeah. So I'm just really giving some examples of that's what the parents talk about. For example, when they come, are ready to us, to clinics really. And the parents, we get the referrals from the parents because the parents will say my child doesn't look at people and it has a massive impact on the such of how they interact. They don't smile to people as babies, for example, uh my child doesn't respond to his name when cold and yet I know that my child can here because if I put the TV on, um he comes search to the room straight away. Uh my child doesn't come and show me things. So that's sort of hints that my child hasn't got shared attention and share the tension. So showing interest in something what the other person wants to show you is really important for teaching. Think about school. How can a teacher teach a child something if the child doesn't share the interest with the person really does. Absolutely no possibility. So how it will impact on the child's learning. My child doesn't ask for help and they will do anything by themselves. Even if it is dangerous. Sometimes Children climb cupboards to get things, they fall, they hurt themselves and yet they will not ask for help. A little bit of that. What's happening with the such a parents were saying and the impact of the missing such of communication. Um She snatched things of other people. So Children lined the last year and they snatched toys from other Children. They only do it simply because they don't understand that there is other way to ask and to get something, they don't understand the purpose of the asking. Really my child can same anyway but cannot ask for simple things like water, food help. We talked about it that that's such apart when you have a child who's got a fantastic vocabulary and yet they can't express very simple needs. And then um if you don't have your needs focal it as a young child, then you become resentful and you start having behavioral difficulties. He doesn't point. So that goes back to those basic gestures, which we all develop and babies at a very early stage at 9, 12 months, they point to share attention with the parents really. It is all about learning from each other, how to sort of uh comm communicate and how to learn from shared experiences should repeat the words she's heard on TV. So if the child doesn't use spontaneous communication, they can only repeat what they have heard. Really, it's called a colonia. My child doesn't have a friend. He prefers to play alone. So you can see that the child as a good friends because they are not interested. But often, in fact, it's sort of slightly more complicated than that because often Children would like to have friends, but they don't know how to ask for friendship. They don't know how to sustain that friendship and uh resulting from that comes loneliness and awareness that they are different. It really comes really upset mood and misbehaving. He leads me to the fridge, but I do not know what he wants from the fridge. So we're talking about the very young child who wants something. Maybe he's hungry or thirsty cannot show the parents what they want. And then obviously they start to misbehave the 10 trans. And really, the parent really doesn't know what that comes from if we move to the behavior, behavioral problems and flexibility of the origin behavior and flexibility of thinking. What the parents say is, for example, there are just the examples, my child screams when we go to the supermarket. What happens is that uh several possibilities. One of the possibilities is that the child, the child doesn't understand that sometimes you just follow all the aisles in supermarkets and other times you just want to get something from the other side of the shop and you try very quickly to go. So this is like a flexible thinking. Other possibility is that in supermarkets, there's lots of shiny things, it's really very noisy and they simply get overwhelmed by the impulses. Really. We always get, we always have to take the same routes to the nursery. This is like in the supermarket, the child, like flexibility of thinking and doesn't understand that, you know, there is more than one way to get to the place really. And uh and obviously, if you don't follow the same route, they become extremely anxious and they have 10 to 10 tra he gets upset if we do something new. This is exactly the same sort of uh message he lines up the choice. So if they have the choice, they can only play in one way and that way they restrict their capacity to explore, generalize their experiences. And learn that there is more than one way to do things. She opens and closes doors and switches the lights on and off, etcetera. So they involved in the repetitive play really rather than exploring potential of environment and to learning other ways that has a massive impact on their learning capacity at school. Because um these sort of, you know, they restrict yourself to just one way of learning while life is a constantly changing conundrum, and really part of the being a child and such of doing things differently is to learn that there are many ways of solving the problem. The flaps when excited, this is such of a sensory uh way of regulating yourself, she's very active and cannot sit still. This is an area that shuttle can have to re too possibilities. One of them is the um the sort of sensory uh elements of really needing to raise additional arousal because you perhaps have two little such of sensory input into your awareness state. If you are such of low arouse or you perhaps make yourself active to sort of to be able to um sort of keep awake and so on. But some of the Children, they, if you think about autism as a neuro die, a developmental condition, there is a massive overlap of autism with attention deficit hyperactivity disorder and lazily to such of conditions such of overlap each other. And really um in many Children, we under diagnose A D H D I really apologize in each other. Just have to, in many Children, there is a I develop of the two conditions and there's such a high level of physical activity and not being able to still to sit, still actually represent the attention deficit hyperactivity disorder. He holds onto the train wherever we go. As I've already been saying, Children suffered from anxiety and having this such a little toy, whatever it is, it's such of gives them reassurance that there is. Despite that everything else around them changes, they don't necessarily always understand why it's changes, but at least something is constant and they just need that little toy for reassurance. Now, severity of the condition is based on the social communication impairment and restricted a repetitive pattern of behavior. And again and again, it has to have a functional uh impact because um it doesn't matter if you're just sort of uh you know, slight different. Otherwise, if we're always the same, the world would be really boring. We also would miss on a massive creativity if we all were exactly the same. However, once it has an impact on the functional function within the society, then obviously we're having a problem. No, as I mentioned, the core features in order to get the diagnosis of autism, the core features have to be present in early childhood. It is a very frequently occurring condition. The prevalence that the existence across the group of Children is significantly higher than 1% 1 half percent, maybe 2%. It is a lifelong condition. You cannot grow out of it. It simply changes its presentation depending on their social uh demands on the individual and it has significant impact on faction across multiple settings. Now, the autism bug, because it's a condition which originates from some level of impairment in the brain um will be obviously associated with many other conditions which also originates from the brain. And many times these conditions are under recognized. I already mentioned A D H D. Uh epilepsy is much more commonly presenting um in Children with autism. So you just have an impairment of how the cells are functioning. We have a very high level of anxiety. We have a very high level mental health problems and these old conditions, they further impair functioning of young people. Sometimes there are parents already in young Children and other times they become significant and nor in parent as such a time goes. So we've spoken a very long time about the autism and sort of the features. But how do we diagnose the autism? Really in the in the UK. Uh we tend to get a referral for assessment from either health visitors. So like uh district nurses by seeing young Children for their development and provide universal services. So, so they screen children's development, in fact, that has changed because when I was such a very young junior doctor, I used to see Children for the developmental assessments in early times. Nowadays, it's done by the nurses called health visitors. And when they have concerns about the child's uh sort of communication at two years of age. And so they make a referral to us. Sometimes it is the parents who go to their sort of general practitioner, a doctor, uh um how's doctor? And they say that they have concerned because their child is nonverbal, despite that there are 2.5, 3 years old or they have a problem with managing child's behavior or whatever problems they have. We also get the referrals from the nursery stuff because many two of them go through the nursery from young ages and obviously the nursery stuff can compare child's behavior and child's difficulties with other Children of the same age. So they make a referral to social communication team because at least in this country and America autism is a condition that ought to be assessed by multidisciplinary team. So you should have a speech and language therapist on the team because in the end of the day, it is the communication problem. You should have either the psychologist or occupational therapist on the team psychologist because you are dealing with the developmental condition and perhaps with the developmental delay. So cognitive or assessment would be useful if it could be assessed. Although due to lack of resources, it's not always done. And occupational therapist, um they tend to be supportive to sensory integration difficulties. And then in this country, all Children under five also should be seen by pediatrician because our role as pediatrician is to ensure that the medical conditions which could potentially contribute to the developmental problems are not missed. And that is all by an assessment of the developmental condition. Now, uh when the child comes to sort of to um uh for an assessment, especially for such a pedia pediatric, uh and we'll talk about the sort of difficulties in the brain functioning, etcetera. Then obviously, the parents want us to do an MRI scan because they have their child who looks almost identical, like any other child perfectly healthy and yet, right, really, um we sort of say that there is no point to do the MRI scan because we know that the scan will be completely normal. And at that stage, I try to sort of to sort of explain to the parents that our capacity to a scan brains is incredibly limited at the moment. If you have a neurological deficit, um like after stroke or tumor or whatever, then you know, so that there will be part of the brain which will be missing. And then obviously the MRI scan will be very, very useful. However, in Children with autism, the neurological examination is normal. And uh so we know that it isn't about the structural problem which can be detected by our MRI scam. It is simply about how such of the brain is such of wired of the pathways developing uh sort of the uh communication pathways. So um Children are healthy but they can see sometimes well from a different perspective. And that can be really very helpful and useful because that can start a new way of thinking, very such of uh in innovative, in uh for example, created world. And we speak about the strength in a second. So we do for the assessment. Um So the referral is for multidisciplinary assessment of difficulties. A chance is observed at home or in the nursery. Um Currently we stand online questioners really. And uh since products and 19 observations as from in person do not really happen. Uh In general, we miss quite a lot from that sort of shortened assessment. Nevertheless, we try to gather as much information as possible through our questioners and then the child is invited to a clinic for assessment and after assessment will give the feedback to the parents. Now, what we use is as a gold standard for the assessment is a dis autistic diagnostic observation schedule. And um the uh this means that there has to be more than one person involved in the process of these sort of assessment. And the assessment is consisting of like uh approximately 10 play activities. Uh Each of those activities has a very specific goal. So um you observe different sort of social responses during these sort of uh play assessments. So you look whether the child has normal, I contact, you, look at the facial expressions, you look, you look at the repetitive behaviors, you look at the mannerism, you look at their creativity, imaginative plague. So we tend to explain to the parents because sometimes it looks like, you know, there is one professional who's playing with the child with these sort of very basic choice. Then another one is scribbling something and the third one is maybe operating camera ready or sitting in another room. But as I say, there's a specific reason for doing uh these games and we sort of observe sort of specific responses. Now, it is really important to have a standardized collection of information during the child observation and currently interview. The reason for that is that as I said, it is a lifelong condition. You would never ever ex except if you receive the diagnosis of, uh for example, diabetes based on such of a few Winfrey conclusions, really your really want some sort of evidence based really standard test. Um There are some other um sort of diagnostic ways of assessing Children. For example, autistic diagnostic interview revised ready. It is the questioner which clinician is asking the parents and then you get the standardized formula um S A Q social communication questioner, um similar ones, three D I into you for diagnostic assessment. Uh These are these such a questioner that a clinician can ask the parents and draw conclusions about. But these question is already a little bit dependent on the what the parents feedback, really, what you get with a dose is that you see a child in front of you and the child's responsiveness to specific situations. And actually this is the strength also, it says such uh the uh diagnosis was based on the uh the sort of quotations of the sort of dinner. The number's really what you get, but also you get really uh the such a group conclusion really whether the child is sort of autistic or not. So it isn't just the view of one person, it is actually the group such a view, diagnostic view. Uh and then post diagnoses, we get their feedback. Now, um we tend to sort of explain that it is the sort of genetic condition. A parents shouldn't be upset really, particularly the mother's always feel guilty that they could have done or not done or eaten some thing or spoke too much, etcetera, etcetera. And so such of the impact of the environmental practice versus genetic autism is a genetic condition. We also we always ask for family history of the developmental conditions in the family really. But what is interesting as I say, autism with the social communication difficulties that really just talks about how the child response to social demands really. But in addition to that, we also have child's internal developmental capacity. So really how well the child will do in life depends not. So much on autism as on child's learning capacity and many of the Children will have also intellectual disability. Half of the Children, we don't measure their IQ S. But actually, if you have a luxury of having a psychologist who can sort of help you with the developmental assessment, it is really helpful because it helps the school and the parents to understand the child's difficulties. What we as pediatricians, our role apart from the search of involvement in the diagnostic process is also ready to trick medical needs because Children have quite a number of needs. So, epilepsy is quite common. Constipation is common. Sleep problems are common um fussy eating and iron deficiency causing peca's or eating non edible items, mental health problems, sleep problems, etcetera. So plenty to do for now, when you think about the difficulties which arise really uh one of the major problems which we try to control is behavioral issues because people with autism by simply not understanding changing world, they will buy, develop behavioral problems. And in order to understand and why they do specific thing, you have to ask question, why we have to use the civic model of the autistic ice bag or behavior of the iceberg. So you have these unwanted behaviors which is the childhood displays for Children in the nursery or want use toilet or shots or whatever. And in order to come to the bottom, um you have to understand really why they do it. The iceberg comparision is useful because what you see above the water is only a third of the iceberg, two third of the iceberg are invisible and the water. So in order to understand why things are happening, you have to unpick the two thirds of the eyes back, which is invisible. And just to understand then it will make sense really why things happen. I will progress because I think I spent too long time, really sort of at the beginning. So the time is moving out. So uh as I already mentioned, autism is not a disease, you can't cure it if you understand. And if you help others to understand that is the way such a forward. Therefore, if you think about the interventions, you really have to think, how do I understand the problem and how can I promote it and support it? So the aim of the intervention is in needs to help depends, to understand the diagnosis. Uh We have parents group with the variety of parents information sessions which help the families to sort of understand the condition and ready to help them to understand the importance of consistency. If you remember, we talked about really the fact that actually um they released Children with autism, struggled with the changing world really. And if the same thing happens in the nursery and at home, there is a much better possibility of a success. I have a little video after that, which sort of shows a little bit how the therapist is working with the parents. We see if it will be playing, but I think that on Zoom it does play that will just give you a couple of minutes of a sort of break it. Arcane. So let's just, hello. Sorry. I don't think the audio is being shared for the video. The parents start from Brisbane. I, and I think I'm meeting with Bill, just write it out. I haven't done anything differently that just happened. We use little pictures. So teach Children to initiate communication and the system is called tax recorrecting communication system. We talk about the various short lab. But one of the big things is also to create some groups in which Children can really feel like they have something to do and for the parents as well because they uh singled out and uh they sort of, they still don't cope and big groups of play a group, the parents don't have friends while you teach Children to show that they want more in a very simple way. You use very Stempel communication of one word and teach them initiation of interaction and making themselves understood. But the purpose of uh making sure that the behavior will, unwanted behavior will not take place. There's a little bit of a cricket, right? Let's just move on. So you can use, you can have different workshops, you can use um such a uh online uh sort of education ever think it's about the psych education. Now what work structure if the the activities are predictable and routines. A polyp visual problems are useful because autistic people are visual learners, language and communication, developing a functional mode of communication is one of the most important aspects of helping the child and play, extending the play, modeling the play beyond the sort of lining up and usually the same way small group work. So trying to teach Children how to turn take and understand the sort of simple social rules ready with the peers structure routine to reduce anxiety and to give the child warning and calm down is and how to such a help that situation. Uh No, and we tend to ask the parents, what strategies have you tried and tried to support the needs? But the most important strategy to develop is to find a way to communicate with your child really? Because communication is the basis of everything. If the child is nonverbal, we encouraging away, encourage using those pictures, a picture exchange communication system. So you have little activity or you have an object and you teach Children to choose between the two subjects or whatever. Now, why do we use? Because we try to teach them to initiate activity, we teach them functional communication, you do something and I respond to it, we teach them that if they ask for something, then hopefully they get it and then they don't need to be frustrated. And we just them choices. It's a universal system. It teaches spontaneous communication, not repeating something what they hear on TV. It's a very clear structure like in any kind of language and it's cheap, parents can do it themselves and really that gives just their parents opportunities. This is just an example of the visual timetable which can be used in nursery at the second level. So that the child comes to the Bursary, they see that they start with sitting around and listening to a story. There's a them play on the climbing. Pray there is a time for play after play. They have to tidy up. After that, they have to go to the toilet, they wash their hands, they get perhaps something to eat and after that, they could go home. So the child to learn over the time what's going to happen and it helps to reduce the anxiety. We have to remember that Children with autism uh several um strength really, they're visual learners. They learn much better from seeing things than from hearing. They have excellent memory. They often notice small details and that can be really very useful in some miller choices of their careers. They're very compliant with the rules providing that these rules are unchangeable and clear for them. Um They have a very good close connection with the family. They don't lie because they don't understand the purpose of lie because they haven't got the sort of capacity to imagine um some can learn alphabet and sort of numbers much earlier than their curier there. The other Children and the small percentage of them have special ability, but those special abilities are really only in very few people, less than 10%. So I put the picture of some famous people among different Einstein and some artists and more talk and so on because they probably were autistic from description of their personalities and yet they were geniuses, so true thoughts. And we're nearly done law knowing the Professor of Psychology in the UK, set those of us who live and work with Children and adults with autistic disorders have to try to enter their world. Since they cannot find their way into hours, we need to learn to comprehend and to emphasize with autistic experiences in order to find ways to help each individual to cope with the system of social rules ourselves, alien to them. So it is our duty to support them in our constantly changing world really because they cannot cope with it final thoughts. So each chart is individual, they have a lot of strength, they have a lot of needs. And because of that, people like uh our teams are really need it ready to support them trying to locate on their behalf. Um On this last slide, I put a sort of couple of you links to youtube videos which I'm not so sure if they're available from a broach, but you can try to see whether you can see um they, they show some adults who describe the route to the diagnosis of autism, what it meant for them ready to be on the spectrum during their teenage years and what it meant for them in adult life, they're successful professionals. And because of that, it's a positive image of the condition. And in the UK, again, we have nice guidelines which really tell us how we should diagnose Children and what should be given because parents try to get a lot of therapy. Um and such some American ideas really about how you can sort of support Children. Many of these ideas, very labor consuming, extremely costly and in the current uh sort of situation of austerity and financial crisis, totally impossible. Nevertheless, it's quite helpful to have the sort of like a consensus policy about what one can do. And I sort of put a sort of uh U K students, I try to encourage them to read the book, the Curious incident of a dog in the middle of the night because it's a book written by a teenager who was autistic and know the book is written by such of a author who describes a teenager actually, otherwise an altered Hollywood film. The arraignment is another really very positive picture of a very autistic manned and, and already it helps such of us all to understand the condition. Thank you very much. And do you have any questions I can, I will have a quick look in child's. Really, no, I think that's it. Really. I do have questions. Yeah. Go ahead. Uh But depends, uh like one of your points in the lectures wasn't, the neglect is one of the reasons for the autism to occur, but it's just pure neglect. Uh The neglect when the child needs a because if I say like the idea of autism or any mental health such as dyslexia or A D H D is not given us such a huge concern, the medical system in our country, but it's given to the other countries and, and this is all due to the perception base and the stigmatization of it is neglect. One of the main reasons where autism can in a chan. Uh No. Well, it wasn't necessarily um what sort of I wanted to say, uh what I wanted to say is that Children who suffer from early years neglect in particular. But we're talking about a really severe neglect. Children who such of uh in this case country are not spoken to. Um they sort of spend time really in front of TV, all the time or obstructing the buggies, etcetera, etcetera. We are aware that Children who are profoundly neglected, particularly in the first two years of life and not given opportunity to develop their skills and use their brains and develop the communication pathways they can present as extremely passive, socially shy Children who um really are very similar to Children who present with the autism. And um so this is the part of the sort of uh neglect really as a part of the sort of this type of phenotype. Really. Um I think that one has to remember really that young Children for their normal development babies, they really need a good quality social interaction with their carers. And if that doesn't happen, you can sort of present with the developmental conditions. Really. Now you're talking about the dyslexia, etcetera. Um we sort of consider dyslexia and uh educational diagnosis and we asked the teachers to look at the child specific because it's a specific learning disability. Uh We such of asked schools and teachers to assess it and to think about how you sort of how you support these Children because Children with dyslexia, they don't necessarily have a functional problem. So, you know, they're perfectly okay with all their gross motor skills, they're okay with eating and they're okay really with dressing and toilet ing, etcetera. So functionally, they're perfectly fine. The only thing they have a difficulty with is the difficulty with recognizing letters or sort of being able to read or, you know, seeing the words etc blank. Exactly. That's why it sort of considered educational diagnosis because the reason I said about the neglect factor is because uh in our country, like the mental health issues not taking that seriously until a movie is made about it. Like regarding dyslexia. There was a very good movie regarding the Stars on Earth. And uh there was another case in another of the lectures we had on Crisis Rescue Foundation regarding it was a D H D. And uh the doctor told us the real, real story about uh Arabic country. I don't remember which country it was, whether it was Qatar Bahrain or Emirates. Uh They said that in that country, there was no uh protocol in the medical system regarding helping for those kids or the Children who had a D H D dyslexia or any autism spectrum disorder. Until one of the governors or the kings of that country had a child who had this disorder. After that, after that incident, the king or the governor made it necessary to have that protocols to be followed in their medical system is just saying as same as when, when the politicians don't get hit uh with certain kind of uh disease or any kind of disorder, it will not be bringing up in the uh in the medical system saying in the manner until the US, former US president's were diagnosed with Alzheimer's or dementia, the United States medical system didn't have had any protocols regarding Alzheimer's and dementia. After that incident, they just started put all the research, all the money into the research after they found out the former Minister's of President's had that decision. Well, you're absolutely right. You touched on the politics and these sorts of politics of really how you support uh sort of mental health disorders. The developmental conditions are not classified the mental health disorders really. But um you know, um you can always debate about what causes, what really. And uh it is a little bit of a social construct in many ways really because you're not going to die from. It may be in the same way that you die, for example, from untreated diabetes where you can take just one blood test and you can evidence that there is a lot of shortage of insulin, but you can die because obviously, if you're suffered from a PSA to be a mental health problems, anxiety leading to depression, you can commit suicide and unhappiness also so important really in people, etcetera, etcetera. So yes, how such of all these conditions are uh sort of supported by countries and understood it's a lot, it's a sort of long learning lesson for all of us. The reason I said bring this issue was regarding do too. If a country doesn't have this kind of protocols in the medical system, then if there is an individual case in that country and the parents might because when it comes to autism spectrum or any mental health issue for the child, the treatment or the, as you said, the exercise of learning speech and everything comes very costly for that individual, that country doesn't have it, the state supports it. Then the then the more attention is given to these kind of Children and then it's easy for those parents as well. So they don't think that the child might lag behind and studies or in coming out as an adult. Yes, that is sort of unfortunate really reality. Um, at sort of dizzy how such as we understand really at the conditions. Indeed. And absolutely are right. Anyway, I, I think that's such of, it's a long debate really. And uh I entirely agree with you and uh we all are learning and we all sort of, uh you know, develop our views and really the point is to help people to live happy lives really. And also understand that the foundation for happiness, you're obviously set up in the young childhood because if you teach the person to communicate, then hopefully they will be, um, you know, more such a happy, less behaviorally um impaired really in their later life. That's part of the sort of uh goal with the early assessment. Doesn't autism have a strong genetic link as well. No, it does. It. Uh we sort of increasingly, uh no, that's simply because uh we, if you are in the autism as such of service, we sort of see so many families where more than one child comes with our two or three siblings really. Um Now the only issue is that there is no such of like uh clear sort of inheritance. So it isn't like such of, you know, um autism or recessive or dominant or whatever. Um There is up to 700 G S which are very strongly associated really with autism. But like, for example, tuberous sclerosis and the uh such of which uh is so strongly associated with a very, very severe epilepsy and system such of changes. It has up to 40% of association with autism. So, yes, we know that, unfortunately, not, unfortunately, fortunately as well, really. Um, it is a genetically inherited condition which we try to, um, feedback to the parents and particularly to the mothers because the mother's always feel incredibly guilty that they've done something or they haven't done something and, you know, often there are such a critical, er, things that they've eaten too much, something that they drink too little or slept too much or whatever. Really. Um, but just if you remove, if you try as a professional to support them, to know that actually they could not change their child sort of, uh, progression and really, it is really a genetic condition. They can concentrate on supporting the child rather than being struck in grief. Yeah. Sure. Because, I mean, that's what would be able to be able to see between a D H D and autism and a child because if it's got genetic link to it. Yes. Absolutely. That's where you're. Yeah. Absolutely. Thank you. Thank you. Thanks a lot. Thank you. See you next week.