It's a particular pleasure to introduce Eric Hollander, the current speaker, since we first interacted, it's gotta be 35 years ago, probably. I haven't seen you in a few years, but nice to see you again. Dr. Eric Hollander is Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine and Director of the Autism and Obsessive-Compulsive Spectrum Disorders Program at the Psychiatry Research Institute of Montefiore Einstein. He's also Director of the Spectrum Neuroscience and Treatment Institute. Dr. Hollander is editor of the American Psychiatric Publishing Textbook on Autism Spectrum Disorders and is recipient of numerous federal R01 and center grants on autism spectrum disorders from NIMH, NINDS, DOD, and FDA. So with that, Eric. Well, thank you so much, Ron, for that kind introduction and for inviting me to be here today. And wow, we've got a great crowd here today. So I don't have to tell you why thinking about autism is important for psychiatrists because you're all psychiatrists and you're here at the program today. This is our textbook of autism spectrum disorders edited by myself and Randy Hagerman who's a neurologist at UC Davis and Cassara Ferretti who's a psychologist at Einstein. I encourage you all to go out and buy it from the Appy Press booth today. And here's my funding. I'd like to acknowledge funding from the Department of Defense, the Orphan Products Division of the Food and Drug Administration, Roche, Jazz, Brainsway, the Foundation for Prader-Willi Research, and Paula Oppenheim. So my first question for you all is why would adult psychiatrists wanna be interested? Why should they care about autism? Because we all know that autism is untreatable. It's a rare disorder. It involves infants and children and that behavioral pediatricians and pediatric neurologists are the ones who treat these individuals. So why would psychiatrists, and particularly adult psychiatrists, be interested in this area? Well, one reason is that 2.7% of the population now has an autism spectrum diagnosis and the prevalence is rapidly increasing. And that many of your patients that you're seeing actually have an autism spectrum disorder. And one huge gap is that adult psychiatrists really aren't trained to assess for developmental disorders. So we have a gap here. Adult psychiatrists aren't trained to recognize and screen for autism spectrum disorder. And pediatricians and neurologists really can't manage the emotional and the behavioral symptoms that are associated with autism spectrum disorder. So it's a big gap. Another reason is that young children with autism transition into adolescence and then adults with autism. So they don't go away. It's a lifelong illness. So they persist into adulthood. And that this is having a huge impact now on our schools, on our universities, in the workplace now, and then also in terms of relationships. So universities have to struggle with these issues. The workplace has to struggle with these issues. And then couples and relationships have to struggle with this issue. Now another reason that psychiatrists might wanna care about autism is that it's really the mental health comorbidity that really drives all the negative outcome in autism. It's the mental health problems that are comorbid or associated with autism that are associated with the emergency room visits, the hospitalizations where hospitals don't really know what to do with these individuals and they have a hard time discharging them. And then it's the mental health comorbidity that drives suicide attempts as well. And then when we think about it, it's all of these comorbid conditions like obsessive compulsive disorder, attention deficit hyperactivity disorder, social anxiety disorder, generalized anxiety disorder, panic disorder, bipolar spectrum disorders and intermittent explosive disorder. That's the comorbidity that drives the negative outcomes. Now one of the issues is that many of these individuals come in in adulthood and they carry other diagnoses. It's not unusual for them to carry cluster B personality disorder diagnoses. This is particularly true in young women who are high functioning, who have normal IQ, good verbal skills and some camouflaging skills. So they may not be diagnosed as an autism spectrum disorder and because of the self-injury and the emotion regulation issues and the disruptive behavior, they often get a cluster B or borderline personality disorder issue. And then it used to be thought that people with ASD have a low rate of substance use, but that's not true as well. So many individuals will self-medicate their symptoms with alcohol or cannabis or stimulants, for example. And the other reason that adult psychiatrists may be interested is that there's at least three different buckets. You have the low functioning individuals. So the low functioning individuals are identified very early on because they're exploding and they're not speaking. You have the high functioning individuals who often are not picked up until middle school or high school or early adulthood. And then you have the broader autism phenotype. So you have symptoms and traits of autism that tend to run within families. And these individuals often are picked up because they have a child with autism. And then you make the diagnosis of a broader autism phenotype in the adults. Or you have people who do self-screening online. So there are screeners like the autism spectrum questionnaire where social media tells you to go online and complete the survey and you get a score. And then it tells you, well, you have an autism spectrum disorder. And so we have all of our medical students at Albert Einstein coming into the mental health clinic saying, well, I did this AQ questionnaire and I have autism spectrum disorder. Now there are also sexual and gender issues as well which are common and can be challenging and can have an impact in terms of clinical treatment. So there are higher rates of being diagnosed with LBGTQ in individuals with autism spectrum disorder. There are higher rates of individuals who identify as being transgender or who have gender dysphoria. They're uncomfortable with their body image and their sex assigned at birth. And there are lots of inappropriate sexual behaviors. Men with autism spectrum disorder have a hard time expressing their sexual needs to others and that causes all kinds of problems on college campuses or in the workplace as well. These individuals have different ways of thinking but you can think of a broader grouping within the population that has neurodivergent features. So they think a little differently and they can have narrow but overdeveloped skills. They can have skills that are really great in certain areas. And now neurodiversity is actually an important part of diversity, equity and inclusion, so DEI. So this is a big issue in terms of the workplace and in terms of educational settings and it's a big issue for neurodivergent populations. So let's talk a little just about neurodiversity across the lifespan. So what is this term, neurodiversity or neurodivergence? Well, people go online and they say, well, it's someone whose brain processes information in a way that's not typical of most individuals. And so these individuals can be clumsy or have some subtle motor type deficits. They can have a hard time coping in crowds. They can have sensory sensitivity, being sensitive to bright lights, loud noises, sudden noises, social situations. They can have difficulty focusing or keeping still. They can have a lack of social, emotional reciprocity, so not smiling, deficits in the back and forth of social reciprocity. So one of the issues is trying to identify and intervene early on in terms of neurodiversity. And by the way, neurodiversity is not a clinical concept. It's more of a popular culture concept and it includes different conditions, including ADHD and autism spectrum disorder and other learning disorders as well. But it's important to identify and intervene early on. Adults who have neurodiverse symptoms need diagnosis and support. Clearly, it impacts employment opportunities. And many large companies now are seeking out people who have neurodiverse ways of thinking because there are some strengths and weaknesses associated with this. These individuals may be particularly good at problem solving, puzzles, coding, pattern recognition. So there may be some positive aspects in terms of recruiting a neurodiverse workforce. It's a big issue, as I mentioned, in education and also in transition services. So we have services for young people with autism. Everything falls apart when they transition to adulthood. And there are all these services that families are supposed to put together for young adults, but in practical reality, people fall through the cracks as they transition to adulthood. There's not that much known about the aging process in autism. And then there's a lot going on in terms of advocacy and increasing acceptance of neurodiversity. So many psychiatrists think that this is the typical presentation. These are individuals who present in your emergency room because they're having severe aggression or terrible self-injurious behaviors. They're hitting their head against the wall. They're punching themselves in the head. They're attacking other individuals. Here's a woman who probably has Prader-Willi syndrome, who compulsively eats and has obesity with a lot of self-injurious behavior in terms of her legs picking at her skin. So here are many different faces associated with autism and neurodivergence. There have been a bunch of books recently that have highlighted different individuals who are popular in our culture who have been identified as having autism spectrum disorder. So Elon Musk self-identifies as having autism spectrum disorder. Sam Bankman Freed, the crypto person who's now in prison, there was a book written about him where he is a great puzzle solver. He was recruited to a hedge fund because of his puzzle abilities. Ludwig Wittgenstein was a famous mathematical philosopher who had problems in his career as a result of his ASD. And then Michael Burry from the Big Short, well, he was someone also who was a resident in neurology, actually, at Stanford before he transitioned to working for a hedge fund. Now, maybe you guys can recognize these other faces. So who's this person here? Okay, who's this guy? All right, who's this one? Temple Grandin, right? Who's this? Greta Thunberg, okay. Who's this? Dustin Hoffman, right? Rain Man. Who's this? Pedro, vote for Pedro. Who's this? Yeah. And who is this? Okay. So these are all people who have self-identified also or been identified or in the popular culture. So these would all be examples, probably with the exception of Rain Man who had special skills but had a big split, I guess, in terms of his verbal and mathematical abilities. The rest of these individuals are in the high-functioning bucket. So one idea is that people present with different symptoms when they come in at different ages. So early on, people are picked up because they're not speaking or they're engaging in a lot of disruptive behaviors. So they are exploding, they're having temper tantrums, they're injuring themselves, they're hitting their head against the wall or they're aggressive, they're attacking their siblings or their parents or other kids in class. So this is a very typical case. So early on, people are picked up because they're not speaking or they're injuring themselves. So early on, people are picked up because they're not speaking or they're attacking their siblings or their parents or other kids in class. Many of them have hyperactivity and there's a lot of comorbidity with ADHD. They have problems with joint attention. They may not be responding to their name. They have social communication deficits. They're having a particularly hard time in school and in group settings. They do better with adults than they do with their peers. They do better one-on-one than they do reading more complicated social group situations. Now, one important component that I've been focusing on that's under-recognized and under-appreciated is the rigidity and repetitive behaviors, narrow restricted interests and self-stimulatory behavior. So the repetitive behavior domain. So this can be present early on, but this persists throughout lifespan and really, over time, it's the rigidity domain that causes most of the difficulties in terms of transitioning into the mainstream. It's not the social communication problems. It's the rigidity and repetitive behaviors. In middle school and high school, well, they're presenting with social anxiety, terrible social anxiety, depression associated with being rejected. Then they develop relationship issues. Usually the wife will bring the husband in because the husband is insisting that the wife do things according to certain rules. Albert Einstein had a good example of this. He had a list of all these activities that he insisted that his wife do for him. And it was written out in detail, actually. Workplace issues, so HR departments have to deal with this all the time because these individuals can be challenging and it's the rigidity that creates a lot of the issues in the workplace. And then the impulse control problems, internet addiction. Most individuals with ASD have internet addiction. The internet was created by people with autism spectrum disorder and they make use of it. So in the last 20 years, the diagnosis has increased tenfold from one in 350 to one in 36. So that's a big increase. So is it due to our changing diagnostic concepts? In DSM-5, well, instead of having three different disorders, pervasive developmental disorder, Asperger's, thank you, and autism, now there's just autism spectrum disorder. Instead of having three domains, social domain, communication domain, and repetitive behaviors, there's two, social communication and repetitive behavior. The question is, is there changes in the diagnostic construct? Is it that we're picking up a lot of the milder cases and that some of these people used to be called other things, intellectual disability, obsessive-compulsive personality disorder, social anxiety, obsessive-compulsive disorder, learning disabilities. Comorbidity, is it that there's more comorbidity and the comorbidity is causing individuals to present and then they're getting diagnosis? About location, so urban and rural, turns out that autism is diagnosed much more commonly in urban settings than rural settings. So is that an ascertainment bias or is there something in the environment that's maybe protective in rural settings that brings it about in urban settings? Service availability, so one of the reasons to get a diagnosis of ASD is because then you get all kinds of services. If you don't have the diagnosis, you don't get the services. So that's a huge driver, actually, is getting a diagnosis in order to obtain the services. Environmental factors, there's a whole range of different environmental factors that people have looked at. And then another question is, is there really an increase in true new cases? So if you look at it, actually, many of the individuals who were picked up before with severe autism spectrum disorder who have intellectual impairment, low-functioning individuals, that's fairly constant over the last 20 years. It's really the intellectually capable individuals that there's a dramatic increase, again, because we're thinking about it, we're screening for it, we're getting services for it, but are there other factors that are also playing a role? Is there some kind of gene-by-environment interaction that's increasing the true frequency? So these are the three buckets. There's the low-functioning bucket, there's the high-functioning bucket, and there's the broader autism phenotype. And the low-functioning have impaired IQ, they may be nonverbal, they have problems with eye contact, they're asocial, they have lots of behavioral problems, including severe, restricted, and repetitive behaviors. They get the diagnosis early on. They're seen in a specialized setting. Because of the specialized setting, they have low sort of social stress. They're the ones who have high rates of seizure disorder, a lot of hyperactivity and irritability, a lot of disruptive behaviors. They come into treatment for the autism diagnosis. They don't procreate, so they're unlikely to have offspring and the prevalence is relatively stable. Then you have the higher-functioning bucket where the IQ is intact, they have good verbal skills, their eye gaze may be pretty good, they may be social, they have sort of a milder variant with the social-emotional reciprocity issues that are more subtle. They usually get a diagnosis later on. They are in a social and a mainstream setting, so they're subject to a lot of stress in these social situations. They may be diagnosed for their comorbid conditions like social anxiety or OCD first. They may be coming in for mental health services and then they get the ASD diagnosis. They may be having children, so they may be coming in because their children are being diagnosed and the prevalence is increasing. And then you have the broader autism phenotype which are the subtle traits that run within families both in terms of subtle social reciprocity and subtle restricted and repetitive behaviors and rigidity. So these are the symptoms deficits in social communication and social interaction across multiple contexts. Social emotional reciprocity that back and forth of conversation. Also difficulty developing maintaining and understanding relationships. Then we have the restricted repetitive behaviors interests and activities. So stereotype behaviors or self stimulatory behaviors. So lining things up, flipping objects, repeating phrases. Insistence on sameness and flexible adherence to routines. Ritualized patterns of verbal and nonverbal behavior. So these are individuals if there's a unexpected change in their routine or their schedule they get uncomfortable and they protest and then they explode. Highly restricted fixated interests and then the sensory hypersensitivity as well. So when you see them in your office while you want to conduct a psychiatric interview and do mental status exam, get a developmental history. That's really key. Ask about a history of seizures. Up to a quarter of individuals may have EEG abnormalities, particularly the lower functioning individuals. There are these self raters, the autism spectrum quotient. So the AQ, that you can go online. It's a self-report 50 questions. So many of the Aspies, the so-called Aspies, self diagnosed themselves with this autism spectrum questionnaire or quotient. Many of the medical students. This was developed by Simon Baron Cohn back in 2001. What do you need in order to get services? Well, a chat is an early screening. It's a screener that's done usually by behavioral pediatricians and then if there's a developmental delay then these individuals are then referred to a specialist. The ADOS is the gold standard. So this is often a play, sort of structured interaction. The ADOS varies based on IQ and age. So a higher functioning older individuals may be doing different components than younger individuals or lower functioning. The ADIR is a detailed history taking of a parent on the child's early behavior. And then some of these other scales are the CARS, the social responsiveness scale and others. I think it's important to get IQ testing in these individuals and many of these individuals have a high scatter. So they may be very good in mathematical skills but poor in verbal skills or they may have certain areas where they're very good and other areas where they're really not so good. The Vineland gives you a good idea of adaptive functioning and on the Vineland there are subscales looking at social functioning and communication. Many of the recent clinical trials have utilized this Vineland in the social communication subscales as an outcome measure. And then there's also testing for schools because schools want to have the right adaptations and the right settings for these individuals. Also there has to be a good medical workup. So physical exam looking for congenital anomalies, growth parameters, laboratory testing, genetic screening, hearing as well. The ADOS is sort of the gold standard instrument. So clearly there are genetic factors. I'm not going to go into this too much other than to say that there's a high concordance rate. So identical twins have 50 to 80 percent concordance. There's a 20 percent recurrence rate for siblings. There's a broader autism phenotype that runs in the family members. 60 percent of the autism risk is due to genetic variation, mostly due to inherited common variants. And genetic testing should be done in everybody but most individuals don't have a clear-cut genetic cause. Only about 10 percent of patients may be picked up having one of these syndromal genetic forms of autism which include things like fragile X syndrome, Rett syndrome, tuberous sclerosis, Prader-Willi syndrome, Angelman's for example. And there are special tests that you can order for each of those things. So there's the chromosomal microarrays that are commercially available that pick up these copy number variations or deletions or duplications. There's whole genome testing that picks up all of these rare syndromal forms or genetic forms of autism. So 16p11.2, Shank2, SynGAP1, CHD8, the neuroligin genes, there's CAC, NAC, CAT, NAP, and ANCS1B. And then again these syndromal genetic forms that I mentioned before like fragile X, Prader-Willi, Rett. So when you see people with autism you want to look for medical problems that co-occur. So seizures, so there's a childhood onset and then there's an adult onset of seizures. Most individuals with autism have a lot of gastrointestinal complaints. So they have severe constipation, they have reflux, very common, and their their behavior changes associated with their GI problems. They need to have good dental care, have lots of food allergies, there's a high rate of autoimmune illness in first-degree family members, and high rates of autoimmune illness in individuals with autism. Ear infections, headaches. So here here's our idea again of autism. We have the social deficits, the speech and communication problems, the restricted interests and repetitive behaviors. We have lots of impulsivity and aggression, high rates of OCD, high rates of EEG abnormalities, subtle language-based problems, high comorbidity with ADHD, lots of social anxiety, and other cluster B and cluster C personality disorders. So again remember that the symptoms that you're going to see in these individuals differ based on the age that they're presenting. So again early on the language-disruptive behaviors, hyperactivity, later on the social reciprocity and repetitive behaviors, and anxiety, depression, relationship, workplace, and impulse control problems. Different symptoms really at different ages. So when I do an interview I always ask what medicines have you been on and which ones did you respond to well or which ones did you have side effects. Have you had applied behavioral analysis or ABA treatment, occupational speech, educational therapy, dietary supplements, assessed for the seizures, immune dysfunction. I do a workup for immune dysfunction. Sleep problems are really a big issue as well as GI. All of these comorbid issues that we talked about. Family history of autoimmune problems, mood disorders, OCD, ADHD, the developmental history, a social history, and then the genetic testing. I do this basic inflammatory workup. I look for reactive protein. I do a sed rate. I look for IL-6. I look to see if the white blood cells are elevated. Do a thyroid panel. I always check for hemoglobin A1c because of high rate of obesity and metabolic issues in these problems and other autoimmune panels. I check for things like antibodies to strep and Lyme and mycoplasma. In our patients now we are doing metabolomics, lipidomics and immunomics in our patients and you can also test for endocannabinoids in your patients. Then you want to get comprehensive neuropsych testing and ADOS and the ADI. EEG may be warranted, particularly overnight EEG. Structural imaging is important. There are subgroups of individuals with white matter problems. So their corpus callosum and their white matter fibers are overly thin and this may be associated with some of the sensory hypersensitivity and in the inflexible thinking that these individuals have. So these people have social deficits. They are mind-blind. They have problems with empathy, eye gaze, nonverbal reading, all the facial expressions and keeping the conversation going. They do have obsessive thoughts. All of these are thoughts about contamination or aggression or sexual, religious, somatic concerns. They have all of the typical OCD compulsions but then they have these lower-order self-stimulatory rocking, swaying, rubbing, repeating phrases and then if you were in the last panel here they have hoarding behaviors as well. Very high rates of hoarding. So we developed a scale that looks at rigidity and we've broken it down into behavioral rigidity, dealing with changes in the environment or in the schedule. Cognitive rigidity, impairment inflexible thinking of black and white thinking and then protest. So in response to the deviations these individuals experience discomfort and then they protest and that's part of the rigidity. They have cognitive inflexibility. So they have problems in terms of set switching, letting go of thoughts and refocusing on other thoughts. They have black and white thinking. They have a hard time transitioning from one thought or behavior to another. They focus on their own thoughts rather than others. It interferes with their flexible problem solving. It interferes with the ability to adapt to a changing environment. As a result of COVID people who had inflexible thinking had a hard time dealing with change in the environment and then when COVID ended and they were supposed to get back into the world these individuals had a very hard time getting back into the world because they have a hard time adapting to a changing environment. It turns out that this cognitive inflexibility is very very hard to treat and this is what causes all kinds of long-term problems. Now the inflexible thinking clearly it's present in autism but think of it as a trans-diagnostic symptom domain that cuts across different conditions. So people with problematic use of the Internet have inflexible thinking. People with body dysmorphic disorder have inflexible thinking. Other mood and anxiety disorders, eating disorders like anorexia, flexible thinking. Obsessive compulsive personality disorder, obsessive compulsive disorder and others. So this is a symptom domain that cuts across different conditions. Now if you have inflexible thinking early on and you have problems with social reciprocity then when you get into school you know you're going to realize that you're different from other kids and the other kids are going to recognize that you're different as well. As a result of that you're likely to be bullied. So you're going to be bullied in middle school. If you have ASD and you have problems with emotion regulation when you're bullied that's going to cause you to have this obsessive or ruminative brooding. So these people they're picked on, they're bullied and they obsess about that. Then they get a little bit older into high school they still have this obsessive brooding. Maybe they also meet criteria for PTSD and then they start to experience the externalizing behavior. They're aggressive, they're attacking other individuals, they have outbursts in response to their reenacting of the earlier bullying incidents or they have the internalizing symptoms of anxiety and depression, self-loathing. So this is interesting sort of gene by environment interaction here where you have rigid inflexible thinking with some social reciprocity and then you're picked on and bullied and then you respond to that with the ruminative brooding, obsessive brooding and then you have these outbursts. So here's the idea is that there's a high correlation between autism spectrum disorder and post-traumatic stress disorder but that the correlation is that it's really the autism leading to the brooding and it's the brooding that mediates the PTSD. Okay so what are the treatments of the interventions? Well early on you're going to do implied behavioral analysis to deal with these disruptive behaviors. You're going to do peer interventions to get people to interact with healthy peers, video modeling, all these new technology-based interventions, cognitive behavior therapy. Cognitive behavior therapy is very good for OCD. You know it's not as effective for patients with autism who also have OCD. They have a hard time generalizing so that you do exposure to one type of a dog but there are hundreds of different types of dogs and they can't generalize that to all of the other dogs. It's the generalization piece that falls apart. So speech therapy, occupational therapy, physical therapy, dealing with their medical and neurologic needs, all kinds of treatments out there, chelation, stem cell treatment, hyperbaric oxygen and others. What about the the politics relating to autism and disability and neurodiversity? Well many of the high-functioning autistic individuals, they feel that they should be called autistic people. The autism sort of defines them. They have good verbal skills and high IQ. Families of low-functioning individuals, they insist that they're people with autism, a disorder. Autistic people say well maybe it's not a disorder. This is this defines us as an identity. So you have this neurodiversity, neuroatypicality, Aspies and a lot of camouflaging behavior to fit in among the higher functioning and women in general have better social skills and maybe verbal skills and they probably do a better job with camouflaging which is why they're more likely to be missed and then picked up later on. There was this book on neurotribes that came out a long time ago which gave sort of a historical perspective to neurodiversity and literature and medicine and society. Change in societal attitudes. You have all of these different insights from individuals. Changes in diagnostic criteria. A lot of personal stories. Now a social media, everybody is telling their personal stories and those are having an impact socially and culturally in terms of acceptance in the wider culture and society and media and there's a whole neurodiversity movement with lots of advocates for acceptance and to celebrate neurological differences. So workplace, the neurodivergence or neurodiversity really is part of DEI, diversity, equity, inclusion and the idea is practice this to support people with varying ways of thinking and give them the resources to thrive in the workplace. The recognition of both skills and deficits in terms of their neurocognitive functioning. I mentioned some of these individuals have great pattern recognition skills. The Israeli Defense Forces had a autism unit and that's what they did is pattern recognition from satellite images. Puzzle-solving, the idea of systemizers as opposed to empathizers, math ability, coding, creative, nonlinear thinking. These individuals prefer routine. If you have a job where there's a lot of routine these individuals may be a good fit. So you want to match their interests and their skills to the job opportunities. And then there are lots of issues in terms of LGBTQ, transgender, gender dysphoria and BDD issues. The high prevalence, understanding unwritten rules of gender expression and sexual orientation could be a challenge. Unique experiences, self-discovery and identity formation, support needs, so being able to see knowledgeable health care providers. Many individuals who have transgender issues want to be seen by transgender therapists. And then acceptance and inclusion also. All right, so what about the standard medicine treatments for autism? Well the standard treatments are the atypicals. So that this is for the irritability, the disruptive behaviors. So the aggression and the self-injury. You do have FDA indications for risperidone and aripiprazole for disruptive behaviors. These treatments really work. There's a high effect size but there are adverse events. Mostly the weight gain and metabolic issues which are a huge burden. Now with the GLP1 drugs many of these individuals may end up on the GLP1 drugs to deal with metabolic issues, prolactin issues, movement problems, sedation. So SSRIs are very good for decreasing anxiety. They may be helpful for depression. They may help with OCD and flexibility. So targeting the repetitive behavior domain. However, many of these individuals can be activated by SSRI. So you have to start with tiny doses and go up slowly. You know otherwise they're gonna have trouble sleeping. They're gonna be more anxious. They're gonna be more agitated. Anticonvulsants are pretty good. So Depakote, Lamictal and others. So they're good for seizures. They're good to decrease cortical excitation and to decrease irritability. They have some side effects as well. And then stimulants are frequently used when individuals have comorbid ADHD. They're good for sustained attention. They can be helpful for the hyperactivity. They can have side effects including sleep related problems or irritability or appetite suppression. So here's some studies showing that SSRIs can be better than placebo in reducing repetitive thoughts and behaviors. How about other peptides like oxytocin or vasopressin? So oxytocin is a peptide. It's synthesized in the pituitary. It's released into the periphery. It's involved in the social cognition brain networks. Recognition, memory, trust. There's an important communication between the peripheral and the central oxytocin and vasopressin system. It's also, these have profound effects on wound healing. They have anti-inflammatory effects and anti-obesity effects. So if you knock out the gene for oxytocin, then mice don't recognize other mice. Social recognition. The species differences. So species that have a lot of vasopressin and oxytocin receptors are the more social species, plays an important role in recognizing social threat and amygdala activation. And then we found early on that administering oxytocin paired with doing a task enhances the learning of that task. So it actually facilitates laying down social memories. So there was an interest in developing vasopressin 1A antagonists for similar reasons. And there were pretty large effect sizes when this was studied in adults, specifically for the reciprocity, the social communication domain. But then when these studies were repeated in kids, it didn't seem to work. So there was no improvement in the social communication domain. There was no improvement in global functioning. And there was no improvement in the stereotypy or the hyperactivity or irritability or inappropriate speech. So that was a letdown, but made us think that we'd need to develop better biomarkers because a lot of the clinical measures that we use aren't that sensitive to change. The other thing that it suggested is maybe we want to try to study more homogeneous populations because there's a lot of genetic heterogeneity. So if you study a monogenetic form of autism, maybe you'll get a better drug placebo difference. Now there was a lot of interest in cannabis or weed. Many of these families who had kids with terrible outbursts, so they were constantly exploding, they couldn't take them out of the house because they would be attacking other individuals or injuring themselves. So they started treating their kids with cannabis or marijuana for the explosive episodes. And that led to an interest in studying more about endocannabinoids than phytocannabinoids. We have these endogenous cannabinoids, anandamide, which is the bliss compound, which binds to these cannabis one receptors in the brain. And we have plant-based cannabinoids like THC that bind to the CB1 receptor. But there's 400 compounds in cannabis, including CBD and CBDV and lots of others. And all kinds of things affect our endogenous cannabinoid system, obesity, stress, food, exercise, inflammation, tissue injury. And the endogenous cannabinoids drive our interest in food and affect mood and anxiety and make us hungry or not hungry. And they have all these potent anti-inflammatory effects as well. So THC binds to the CB1 receptor and hits all these second messengers, including the mTOR pathway and arachidonic acid. The CBD and CBDV don't bind to that receptor. CBDV binds to this GPR55 receptor. It pulls this lipid called lysophosphatidyl inositol off of the GPR55 receptor. That receptor modulates excitation inhibition or glutamate GABA function in the brain. And CBDV has a six-fold greater binding on this system than CBD. So we said, well, why don't we take a look at this rare form of autism, Prader-Willi, where there's only one gene involved. These people have mild intellectual problems, but lots of compulsive behaviors. So they're compulsive eaters. They have lots of repetitive and compulsive behaviors, terrible skin-picking, tantrums, some social cognition. So it's a genetic form that you can think of, of compulsivity and autism, including hyperphagia, severe rigidity. We looked at this rigidity scale, and we saw that if we treated Prader-Willi kids with CBDV, that there was less behavioral rigidity, there was less total rigidity, not as much reduction in cognitive rigidity, a nice reduction in the protest and in the total score. So one potential avenue for further research is understanding the role of the endocannabinoid and the phytocannabinoid system for certain target behaviors, like repetitive behaviors or rigidity in autism and related disorders. We also looked at the relationship between immune inflammatory pathways, and we found all kinds of correlations between inflexible thinking and these pro-inflammatory cytokines in the blood. And we found that those individuals with greater behavioral rigidity and those with greater irritability tended to have greater activation of pro-inflammatory cytokines. So another potential approach in this population is to use immune modulating treatments. This was a wacky idea of using Trichuris ova, TSO, which is the pig whipworm. So it's found in rural areas, not urban areas where there are pigs. And this is used to treat people with Crohn's or some other rheumatoid arthritis. We found some reduction in rigidity in that population. Also we've been treating people who have depression who also have other compulsive problems with escadamine, which is just the intranasal form. Asif Rahman is here, and he's the one who's been administering much of this. So escadamine blocks the NMDA receptors and causes a surge in glutamate, which activates AMPA and affects neurotropic signaling and BDNF and mTOR activation and enhances synaptogenesis. These individuals who had depression, but they also had comorbid OCD or autism spectrum disorders, 60% of them had some improvement with treatment with intranasal escadamine, but 40% didn't have any benefit. And then here you see many of them were rated as being very much improved or much improved. And here you see baseline and endpoint ratings on the CGI severity rating. So that could be another pathway in some individuals. And then neuromodulation. So identify the circuits and then treat those circuits with different modulating treatments. One is with TMS and deep TMS, the brain's way. This was one publication done in individuals with OCD. So many individuals, again, with autism spectrum disorder will get a diagnosis of OCD. And these individuals, when you target the anterior cingulate cortex, had a reduction in the obsessive thoughts and the compulsive behaviors. Some of the newer approaches involve targeting the relevant circuits in your patients with ASD, decreasing cortical excitation or enhancing cortical inhibition. So improving the excitation, inhibition, and balance. Enhancing the inflammatory pathways. One new approach is enhancing oligodendrocytes, which make myelin. Myelin coats the axons. And a subgroup of individuals with ASD and related disorders may have white matter abnormalities. And there are treatments that can enhance the maturation of oligodendrocytes. Another approach is to try to look at these rare disorders where there's a single gene, but they express symptoms of autism. To understand a little bit more about why all of our clinical trials have a high placebo response rate and then develop better biomarkers. So the overarching approach in terms of working with your patients is to target the core symptoms, but also the associated symptom domains. Most of the available treatments are for the associated symptom domains. Combine the psychosocial treatments, like social skills training, for example, with medication approaches. And possibly combine them to get an enhanced effect. These individuals really need structure and routine. So during the COVID crisis, when they lost their structure and routine, they all got worse. These individuals really need to be kept busy doing things that are meaningful with a lot of structure. You have to address the inflexible thinking, which is a key problem throughout the lifespan. And then treat both the psychiatric and the medical comorbidity. And then recognize the unique issues that present at the different developmental stages. Because they're going to present with very different symptoms depending on what stage they come in. And they're going to have different issues depending on whether they're in the low-functioning or the high-functioning or the broader autism phenotype. So thanks so much for attending. I guess we have time now. Thank you, Eric. So we have, Kathy will sit here. We have a couple of questions from our remote audience. And also questions from our live audience. We will alternate. And please, try to keep your questions relatively brief and generalizable and not just about one patient. Thank you very much for a most excellent presentation. I thoroughly enjoyed it. When I was doing my training more than 10 years ago, we didn't even talk about autism spectrum in adults. And I think it's so great that we're now talking about it as a lifespan disorder. My name is Karishma. I'm a psychiatrist and psychotherapist from Melbourne in Australia. I have two questions. My first question is, I get a lot of patients who come for assessments as adults. And I was just wondering whether there was an ADOS equivalent that we can do in adults. That was my first question. My second question is, with respect to the inflexible thinking, I see so much of it. And I can see that there are ways and means to kind of deal with it. But what I have found downstream of that is that there's a lot of anxiety, depression that people kind of present with. And sometimes they don't work so well with therapy. So I was wondering whether there are any of these treatments that are actually translatable presently. Or if we should just accept it as this is part of their neurodivergence and we may not be able to directly treat it. Thank you. So the issue with inflexible thinking and I guess the repetitive behaviors is, do you sort of accept that or do you try to modify it? And you know, here's an interesting challenge. In the obsessive compulsive world, parents are told that they can't give in to their children's requests. And that really what you need to do is you need to expose them to things that make them uncomfortable and resist doing the rituals. And if the family sort of gives in to those demands, then there's going to be a bigger problem. That's hard to use the same advice in the autism spectrum population because this is a population where if you don't accommodate to some of their requests, you know, they're going to explode or they're going to punch holes in the wall. They're going to end up in the emergency room. So clinically, there's a much finer line and the issue really is to get them to go outside of their narrow circumscribed interests and try to be more flexible. One situation for young adults is to get them to go to an improv thing where they have to be completely spontaneous, where they can't plan ahead and there's no structure. I mean, because that's the thing that's going to be most uncomfortable for them. If there's a deviation from a rigid schedule and routine, they're going to experience discomfort. That's the nature of it. But get them to understand that the discomfort they experience doesn't last forever. And in fact, you know, if they can be more present and react in real time to deviations and make it fun or make it something that's amusing, then you have some chance to enhance that flexibility. Groups are good also because then they're practicing interacting with multiple different individuals as well. But it has to be fine-tuned and individualized and there's no one fit that's going to fit for everyone. And I didn't hear your first question fully, but... The ADOS can be used in adults or in children or high-functioning or low-functioning, but it's different. You're using different components. So it's a different kind of testing. Okay. A question from our remote audience. Just to wake everybody up. So what is the role of imantadine in the treatment of patients with autism and what would be the mechanism of action? Well, that's interesting. You know, imantadine is actually used for some individuals with autism. So originally it was used to deal with individuals who were on atypical antipsychotics who had either some akathisia or other kinds of side effects. But imantadine is an antiviral treatment, actually, and has a range of different effects. It does enhance dopamine release. It has these anti-inflammatory effects as well. So it's kind of unknown, but there are some individuals who do benefit a little bit from imantadine and some individuals who have a little bit more like a motivated behavior as well. It can also help a little bit with some of the weight and food-related issues. Your question? Thank you for the talk. This is more of a systems question. So I work in community mental health, and as part of that we have group homes. And occasionally we will end up with somebody in a group home who very clearly has autism, and they are very, very poorly managed in those settings. It's not a good fit. But there's no place else to go, because oftentimes they weren't diagnosed early on. So I'm wondering if you can kind of speak to that particular situation, where there's really a mismatch, right, between the care that's being provided, the specialization of that care, and what the client might actually need. Well, you are right. It's a systems issue. And you are right also in terms of like those individuals who get an ASD diagnosis early on and are in the lower functioning category and in a more specialized setting may be put onto the waiting list for like a residential sort of placement from an earlier age. Those individuals who are more in a mainstream setting but then have more challenges and then they graduate from let's say a high school and then they are stuck because it's hard to put together all of the resources to give them a fully structured, meaningful kind of a program. And then they may need to be placed later on, and if they haven't been put on the waiting list early on, it's going to be much harder to place them. It is true also that when you put individuals with ASD in other residential settings with let's say patients with schizophrenia, it's not a great match. And sometimes they can be attacked. They can be bullied. They can be taken advantage of in those settings as well. Just as like individuals with ASD don't do very well in a prison setting either, and they can also be taken advantage of. One of the issues, and this happens with higher functioning women as well also who can be put into positions also where they get taken advantage of as well. You know, there's a state hospital affiliated with my medical school and a young woman with an autism spectrum disorder who was placed there and she was recently murdered by one of the other patients who had schizophrenia. So that was not a good outcome. »» So it says you've listed many treatment options. Which of them have enough evidence for a clinician in the community to apply with their adult patients? Okay. So I'm going to repeat that. You listed many treatment options. Which of them have enough evidence for a clinician in the community to apply to their adult patients? »» Well, there are two issues. There are two medicines that have an FDA approval, although if you look at the FDA approval, it's for irritability and disruptive behavior in children with autism spectrum disorder. Resperidone and Abilify have an indication. The atypicals are not good for the social reciprocity. In general, they're not very good for the rigidity and repetitive behavior. So they don't address the core symptoms of autism. They have a pretty large effect size for the disruptive behavior. So it's aggression and self-injury. If you have aggression and self-injury, those treatments are going to be pretty effective and are widely used in the community. Stimulants are pretty widely used. SSRIs are often used, although the dosing is way too high and people aren't sensitive to the idea that individuals can be activated. And then some of these glutamatergic approaches now are becoming more popular. Even though there aren't large-scale clinical trials, I mentioned that people are presenting with all kinds of different symptoms and families are looking for help. That's why I mentioned that you have families who are treating their children with cannabis, for example, for the explosive behaviors. So I think that clinicians need to be aware of the range of treatments, and then they need to select those treatments where there's adequate potential benefit relative to the risks associated with that. And it's an individualized risk versus benefit decision for each individual. Working with the family and the clinician, the more knowledgeable that the clinician is to the entire range of different treatments, the more they can collaborate with the family, the more they can personalize the treatment. Yes. Thank you for the great overview. Just a few more treatments that I wonder about are anti-anxiety, anxiolytic medications that are used, Buspar, and I hate to say it, benzodiazepines. So I've heard, you know, I'm doing a lot of research, some more newer possible treatments. There's this thing, central folate deficiency, where some people measure folate receptor antibodies and if there are those, there are two types, binding and blocking high-dose folinic acid can be used. And then there's this assay called the mitoswab, which allegedly looks at respiratory chain function disorders, and in those cases sometimes so-called mitochondrial cocktails are used with things like Coenzyme Q and things like that. So please comment on those. Thank you. So first, anti-anxiety treatments. Many individuals who have severe, like, explosive behaviors and are getting hospitalized in specialized inpatient settings, like Kennedy Krieger, get this diagnosis of catatonic excitation. Some of the individuals with catatonic excitation end up on relatively high doses of benzodiazepines that are used to treat catatonia. So you do, you have some patients who come in and they're on really high doses of benzos. Some of those individuals benefit. Other individuals, you know, you want to slowly titrate them down if you can. So it's a mixed bag. I mean, some people use benzos on a PRN basis for severe anxiety and temper tantrums. Sometimes it's helpful. Occasionally people get this inhibited from the benzos. Buzepar is frequently used. Buzepar has some mild anti-anxiety and anti-irritability effects. And there are some patients, they don't get activated on the Buzepar like they do the SSRIs. So that's a reasonable alternative. Nutritional supplements, NAC and acetylcysteine, is used for things like skin picking and hair pulling and things like that, and can be helpful, 2,400 milligrams a day. Propionic acid, which is a metabolite of the gut bacteria, can have some association with increase in irritability, whereas butyric acid dampens down both gut and brain irritability. So some people take probutyrate as a natural supplement with some benefit. There was just a recent clinical trial with charcoal beads that would sop up all of the metabolites from gut bacteria, with the idea being that it would reduce some of the irritability and the explosive behaviors. That trial was negative. It didn't separate from placebo, so that wasn't very effective. This whole, other approaches that try to deal with sort of mitochondrial energy production, there are, I mean, so achelation is like one approach that can be associated with some negative effects. Some people will use things like glutathione, for example. Doesn't seem to have side effects. I don't think there's a well-established literature there, but. So why test for endocannabinoids in the assessment? Why test for that? Well, so there is a literature actually for endocannabinoid dysfunction in autism spectrum disorder with alterations in things like anandamide levels. That was one of the reasons why people were interested in then studying the plant-based cannabinoids as well. You could measure these endocannabinoids before and after treatment and see if you're getting some changes in terms of that profile with clinical treatment using endocannabinoids. So there are commercially available treatments. So Epidiolex is a FDA-approved treatment for three rare forms of autism associated with epilepsy. That's a high-potency liquid formulation of CBD where you can go up to relatively high doses of like 800 milligrams a day. That has good anti-seizure effects. And I think that CBDV is particularly interested because you're getting a bigger effect on this excitation inhibition imbalance with fewer side effects. And so that's another plant-based cannabinoid treatment that doesn't involve THC that can decrease like cortical excitation and where we think it may help particularly for this rigidity and repetitive behaviors. Yes. Hi. I was wondering if you could speak something to reality testing in people with adults with autism. You know, where they get this idea that when they're young that people don't like them. They become very obsessed with that idea. They keep going into college. They have difficulties there. And at what point when they start telling you, for example, I know they're talking about me. They're gonna be talking about me. They really don't like me. At what point do you say use an antipsychotic? Is there any role for that? You know, it's an important issue. So the question is like a reality testing, but also in terms of like differences and people not liking them because of the differences. People with ASD are different. You know, they have rigid thinking and they have problems with social reciprocity. They identify as being different. People around them can sense that they're different as well. And young people feel the same way as well. So young people are constantly comparing themselves to others and then finding fault with themselves compared to others. That's the example of body dysmorphic disorder. They compare their appearance to people around them. They feel that other people look better than they do. They feel judged or evaluated because of that. And they feel less than. And then you add social media where you bombard people with unrealistic expectations and where people are targeted online. Well, that just ramps up the issues around differences. Now with reality testing, yeah. I mean, so people do have subtle differences, but that's okay. And you can be accepted for your differences. Everybody's a unique individual. So I think the idea is to try to get them to accept their authenticity and in fact, to thrive on their authenticity because it's what makes people different. It's what gives them a little bit of character. So if they have something like almost a post-traumatic stress disorder kind of situation where they've really been bullied a lot throughout their lives, do you use an antipsychotic? Would you use an antipsychotic in someone who's- Well, and that's the issue with this obsessive brooding and PTSD. So yeah. So these people really get worked up and they re-experience the bullying over and over again. They get angry and then they can explode as well. Yeah, I do use antipsychotics. That's pretty good actually in decreasing, these people get overstimulated and really angry and then they have outbursts. So the atypicals are pretty good in terms of reducing the outbursts and the disruptive behavior. And also not being overly fixated on things. Yeah. Is there one that you tend to use? I'm sorry, is there one that you- Oh, so there's, you know, the Risperidone and Abilify are approved, but I also use all of the newer atypicals as well, where I find that some of them have better tolerability. Thank you. Kathy. One of the online audience says, I seem to have more young adult women who are interested in the evaluation, to be evaluated for autism who are high functioning. Would the autism spectrum quotient self-report be a useful screening to determine whether a full evaluation is warranted? Well, it's not a bad first step using this autism spectrum quotient or AQ. I mean, it's a self-report that you can get online and then it gives you a bunch of these kind of traits and symptoms and you can score high or not. That doesn't give you a diagnosis of an autism spectrum disorder. I guess if you, so here's the issue also is young people are self-identifying themselves as being neurodivergent and having autism spectrum disorder. Many of those people don't have a autism spectrum disorder. So it's maybe overly broad and inclusive and then you can have more specific screening. You know, remember to get an ASD diagnosis, you have to have significant distress and impairment and functioning. If you just have symptoms and traits, but it's not causing distress or interfering with functioning, then it's not a disorder. I just like to make a comment about individuals who are highly enough functioning that they are able to mask the social problems. I've seen a number of people over the years, gone through a variety of psychotherapies about their interpersonal issues, mostly about their struggle to fulfill what they expect to be society's demands for how they should interact and have friends. And when it's been redefined to them that you know you are neurodivergent, you're high on the ASD spectrum, there's an enormous sigh of relief. And describing the experience of spending years faking it because they're expected to. Any comments about that? It's a very important point, Ron, because a lot of these people start off in ABA where they're trained over and over again, look at my eyes, look at my eyes, look at my eyes, look at my eyes. And the higher functioning individuals rebel against that. They say, I'm not a social person. I don't need to be a social butterfly. I don't need to look at people in the eyes. I don't need to develop my social skills. I'm fine being left alone. I have these pursuits that I enjoy. So recognizing that there are differences and sort of accepting those differences rather than trying to force everybody into the same mold, I guess that's part of the issue in terms of the whole neurodivergence movement. On the other hand, you are right. A lot of the therapy kind of trains people to mask or camouflage their symptoms. And then they're trying to make it in a world, but they're experiencing a lot of discomfort and stress. Maybe it's a good thing because they develop their skills or maybe it's difficult because they're in a lot of stress and discomfort. I would just also emphasize the element that I'm not sure what good they've had in a number of their psychotherapies where the message was somehow reinforced. Oh, it's good to have lots of social contacts. It's good to know many people. And they would work very, very hard at it. And is that consistently true for everybody? Well, I mean, you're right that some of the people do develop those social skills and improve their reciprocity and that leads to good things in their life. But you are right. Getting a diagnosis can be a relief because you know, well, all right, it's not like there's a character fault on your, or you're not trying hard enough. You think differently. That is a different way of relating. I'll finish just with just one statement. It reminds me of the patient many years ago came to my office and when she recognized through the course of the diagnostic process, she had a clinical diagnosis of major depression. She started to cry. And I said, well, what are you crying about? And she said, thank God it's just my brain. I thought there was something wrong with me. Yeah. All right. Next question, please. Yes. My name is Haldora. I'm from Iceland. Thank you for a wonderful talk. I have one question. Is there any evidence that young people, particularly men on the autistic spectrum can become very dangerous occasionally like young men that do the mass shootings in schools or colleges? And you see it, of course, a lot in the States and sometimes in other countries like in Norway. Yeah. If you have very rigid thinking and you think in black and white terms, and if you lack empathy, and if you're bullied and traumatized, and then you have this obsessive brooding, then you can explode and take it out on other people. So, I mean, you are right. There are some individuals who have these symptoms and traits and developmental trajectory who do really bad things. Has it been investigated scientifically? So the issue is like doing like a forensic autopsy or studying individuals who are shooters or things like that who have, they may have some of these symptoms and traits, although they may have other things like schizophrenia, for example, or antisocial personality disorder as well. Okay, thank you. Any recommendations for persistent self-harm in severe autism, which has failed second generation antipsychotics? Okay, well, I mean, this is a big issue. Again, these people often end up in the emergency rooms over and over again, and it limits their ability to live in the mainstream kind of a setting. So the atypicals are the first treatment for the aggression and self-injury. Anticonvulsants are another frequently used approach. The other things that you can pull out or naltrexone can sometimes be helpful for people who have really bad self-injury and aggression as well. I like a new dextromethorphan. So it's one of the glutamatergic drugs that has some quinidine in it. So it prevents breakdown by the liver. You get higher levels in the brain. This has effects on NMDA and sigma-1 receptors. I think it allows people to be more flexible. And then we see a decrease in those explosive behaviors as well. So that's something I'd go to. Would that be preferable to ovality? Is there a problem with the stimulating aspect of the Welbutrin? Well, that's the other approach as well, is ovality, because it's a relatively lower dose Welbutrin or bupropion, and it has the same idea. You're enhancing the dextromethorphan and the NMDA antagonist effects. Also like giving the cannabinoids. So we use CBDV or Epidiolex or high-dose CBD as well also. So those are other approaches. Yes. Hi, do you have any suggestions for improving executive function, specifically planning or being able to chunk a project into its parts and then execute? And then separately, any suggestions for repetitive thinking, repetitive speech? Right, so the first is like executive function issues. And cognitive inflexibility or inflexible thinking is one sort of component of executive functioning as well. If people are having inattention and hyperactivity that are getting in the way, then stimulants can help, and then that can sometimes have some effects in terms of executive function as well. Cognitive remediation, and neuropsychologists will test for the strengths and weaknesses and make some suggestions, both from an educational and a psychological approach to try to target some of the executive function issues. Occupational therapy is actually pretty helpful in matching sort of the strengths and weaknesses and then adapting that a little bit to the workplace as well. So working with occupational therapists. I mean, we will sometimes use also glutamatergic treatments, like memantine as an example, which has been used for memory-related issues. And it's frequently used in individuals with autism. Try to address executive function, working memory-related issues as well. And the repetitive speech? Well, the repetitive speech is often not your typical OCD. It's more of a lower order self-stem, repeating phrases over and over and over again. So it's a kind of perseveration. So with the perseveration, sometimes stimulants help. Sometimes it makes it worse. Sometimes atypicals help. Sometimes the atypicals don't. Sometimes SSRIs can help with flexibility. Often SSRIs don't help with that perseveration. Sometimes cognitive behavior therapy helps, often it doesn't help actually. That's tough actually. And that's one of these components of like cognitive inflexibility that's tough to treat actually. Also Depakote, anticonvulsants actually. That's one anticonvulsant that helps with some compulsive and impulsive behaviors as well. Thank you. So there's sort of a combined of a couple questions about do people with autism spectrum disorder respond differently to recreational slash medical cannabis? And then someone else is asking about what the most common substance use disorder, comorbid with autism is, and is it good to actually encourage patients who use cannabis? You know, it's actually a good question because I mentioned that there are some families that have reached out for cannabis for the extreme explosive behavior. So it's better to have a kid chill out than to be exploding and threatening or hurting other people or hurting themselves. So sometimes it's utilized that way. You know, we have Michael Van Ameringen here and he's from Canada. He's been studying cannabis and OCD and ADHD as well. Is actually gonna be talking tomorrow at Albert Einstein for the next generation treatments for obsessive compulsive disorder conference. You know, I mentioned epidiolex and other non-THC related cannabinoids that may help with decreasing cortical excitation and might help with some of the components of inflexible thinking. We'll take one more question. Thank you. So first of all, thank you for the very comprehensive and inspiring talk. I'm an outpatient psychiatrist at UMass. And my, I guess I had two questions, but one question. For higher functioning adolescents and adults, what are the resources that are non-pharmacological resources for core symptoms of ASD? So as opposed to, you know, we know already what could be used for anxiety and depression, et cetera. I thought I detected a Massachusetts accent. Yes, very slight. It's a Russian accent. No, I think that social skills training can be very helpful. I think working with occupational therapists can be very, very helpful in matching these people with their skills and deficits to work related opportunities. I think group can be very good, but you have to match people with other people who have similar strengths and weaknesses. Otherwise, the groups really don't work if you match low functioning with high functioning individuals. You know, applied behavioral analysis is helpful to kind of eliminate certain problem behaviors. This acceptance and commitment therapy is a interesting approach that can be helpful in some of these patients as well. And I think anything that allows people to initiate and maintain conversations is really important because when these people are in therapy, you can see sometimes a dramatic improvement where it's tough to do therapy with someone with autism because they sit there and they don't talk. Over time, if you can get them to engage in conversation where they can keep the conversation going, that's really important. And then you're enhancing the social reciprocity. Thank you. And then for some of the adolescents and adults who have never been diagnosed with autism spectrum disorder and they come to my clinic, for example, how do they find those resources and how to get the insurance to pay for it? Well, you can go to certain organizations like Autism Speaks. Autism Speaks has all kinds of referral type services and they also have support in terms of being able to access insurance or OPWDD funding and things like that. So I would suggest like an organization like Autism Speaks could be very helpful. Thank you. Thank you very much. It's time we're going to have to release our great speaker.

Eric Hollander

autism

adult psychiatry

autism spectrum disorder

psychiatric care

comorbid conditions

neurodiversity

behavioral therapies

medication

cognitive rigidity

individualized approach

cannabinoids

glutamatergic drugs