Beyond the Spectrum: Diagnosis, Myths & Management - Caitlin Couch & Leslie Lopez - APP Conference 2026

Cool. Alright, we're gonna get started. I'm Caitlin. This is Leslie. We're nurse practitioners and DDVP. I'm also the DVP educator. We're gonna talk all things autism today, so we're gonna talk about clinical features, etiology, evidence-based evaluation and treatment strategies, um, distinguishing between common misconceptions, uh, oh. Yep, is that better? OK. And then we're going to identify clinical indications and appropriate timing for referral to our um division. Big picture, autism, um, about 1 in 31 children ages 8 years old have been identified as having autism. Um. More common in boys than girls, about 3 times more common in boys than girls. We definitely see that clinically as well. Is autism on the rise? It sure is. Um, why? Well, we have increased awareness. Um, we have increased accessibility to specialists and evaluations, and we have a more uniform criteria for diagnosis. Um, we used to call, you know, we used to have pervasive developmental disorder, we used to have, um, Asperger's, and now we call it autism spectrum. Um, we have more uniform criteria, or I'm sorry, we have a broader range of a diagnosis and then we have early identification. So we're doing a lot more screening tools, um, on kids much earlier through primary care, um, and, uh, and schools actually. We have a nice fun video, get rid of this. Hello, I'm Doctor Meg Stone Heberlin, a licensed clinical psychologist at Cincinnati Children's Hospital Medical Center, and you're probably wondering, what is autism? Well, a quick explanation is that autism spectrum disorder, or autism for short, is a term that describes a variety of developmental differences in social interaction, communication, and behavior. The Autism spectrum represents a diverse group of people with various skills and interests. For example, some people with autism can speak fluently, while others may have difficulty communicating. Some people with autism might communicate using pictures or devices. Research suggests that autism develops from a combination of genetic and environmental influences. These influences Increase the risk that a child may have autism. Factors that may increase a person's risk for autism include family history of autism, advanced parental age, pregnancy and birth complications, and pregnancy space less than one year apart. However, keep in mind that risk is not the same as known cause, and there is no known cause for autism. Diagnosis comes from a medical doctor or psychologist after evaluating a child's developmental history, social interaction, behavior, social communication skills, and developmental or intellectual skills. Direct assessment and caregiver report are both important components of comprehensive autism evaluation. Autism can be detected as young as 18 months of age. The American Academy of Pediatrics recommends routine early screening by each child's primary care doctor, because early detection and intervention lead to improved outcomes. Autism symptoms can vary from one person to the next, and may present as difficulties in the following areas, speech and nonverbal. Communication, making eye contact, understanding facial expressions or other people's feelings, playing or engaging interactively with peers, initiating pretend or imaginary play, sensory processing, including sensitivities to sounds, touch or movement, flexibility, and adjusting to changes in routine. For example, some individuals with autism show a strong preference for routine or repetitive behaviors, or a tendency to hyperfocus on topics of interest. People With autism also have many strengths that are unique to each person, but might include learning and remembering facts, events, and stories, visual problem solving, like doing math problems, puzzles, and figuring out how things work, following routines and schedules, thinking about the world from a different perspective, leading to innovative and creative ideas or solutions to problems. The three most common myths about autism are, people with autism don't feel empathy or emotions. This is not true. In fact, people with autism have empathy, emotions, and feelings. They may just have a harder time showing their feelings or will demonstrate their emotions differently. Another myth is that people with autism can't handle change. That's not true either. The reality is, predictable routines and structure help all people feel safe and comfortable. Change can cause anxiety for anyone. People with autism may be more likely to perseverate or get stuck when something unexpected happens. Preparation, planning ahead, and time to adjust are three easy tools that can help people with autism cope with change. And the last one is people with autism are not interested in having friends. Nope, that's not right. Children and adults with autism are often very interested in interacting with their communities and making friends. Just like everyone else, people with autism have a wide variety of interests and talents, and particularly enjoy connecting with others with similar experiences and interests. So, remember. Autism affects the development of social interaction, communication, and behavior. No two individuals with autism are alike. People with autism have different strengths and challenges, just like all people. This is why it's called autism spectrum disorder. Some factors that may increase the risk of autism have benefit. Identified through research. Just because a factor has been associated with an increased risk of autism, does not mean that it causes autism. More research is needed to understand the causes of autism. People with autism have many strengths and view the world from a different perspective, adding rich diversity to our world. For more information, go to Cincinnati Children's.org and search for autism. A message from Cincinnati Children's. All right, any questions? That's like our whole presentation in a nutshell. Um, so, autism spectrum disorder, uh, the current diagnostic criteria includes, um, how wants and needs are expressed, um, eye contact gestures, conversations, emotions, um, things within that social communication realm, and then we also have to have, um, intense or unique. Interests, unique body movements, formal or unique speech, um, and you sensory sensitivities that kind of falls within that repetitive behaviors and restricted interest category and you have to kind of fill those buckets both to a certain amount. Um, you cannot just have one or the other. So all kids with sensory sensitivities do not have autism. Um, so this is a question we get every day in clinic. Um, what level is my child? Um, the question or the answer is we don't really do levels. Um, autism is a fluid diagnosis. So we've done a couple of studies in DDBP where we did use levels. You might see that in their chart. You might see family or you might have families ask you about that, but the truth is every child's, um, level is fluid and changes over time. So some. Someone might have an average IQ but doesn't communicate verbally and has um pretty intense behaviors. Are they a 1? Are they a 2? Are they a 3? Where, where, what kind of support, um, so that's why we kind of don't use those in DDBP. Insurance um can sometimes um limit therapies based on a certain level as well. So sometimes we have to kind of manage that um in DDBP. Um, Associated symptoms and conditions, a child with autism rarely just has autism. Um, we see a range of intellectual skills. Um, 40 to 59% of individuals with autism have average or above average IQ. Um, and a higher IQ is actually associated with more camouflaging and that kind of where you, they don't look like you would see a child in the waiting room, maybe flapping or verbalizing. They don't look like that and they can kind of act pretty typical otherwise. That can be challenging from a mental health perspective as well. We see that a lot more commonly in girls than boys. Um, language and communication differences, so 25 to 30% are non-speakers, um, or have minimally functional verbal communication. So some kids will just repeat things that you say, um, or repeat parts of what you say or repeat parts from their favorite show, but they don't necessarily ask questions, uh, or answer questions appropriately. Um, we also see a lot of medical and genetic conditions in individuals with autism. So, we see about 25% have GI issues that can range from celiac disease to constipation. Uh, we see another 25% also have seizures. We see a lot of mental health difficulties. We can see anxiety, we can see OCD, we see um depression, we see suicidality as well. So just because a child has autism does not mean we shouldn't be asking about firearms, suicide, and homicidal ideation. Um, we also can see a range of behavioral challenges from, you know, stemming behaviors or flapping, verbalizing, rocking, um, to aggression, irritability, and some pretty unsafe, um, circumstances. Common concerns, um, that come to us. So we see very restricted, um, eating patterns. Um, we have a lot of friends who are also seen in GI, uh, for our fed, um, we have a lot of like kids that do intensive or intensive, um, feeding therapies and things like that. And this. Most of the time, um, they'll eat chicken nuggets, right? But sometimes it's pretty severe in that they will only eat McDonald's chicken nuggets, and it doesn't matter if you put other chicken nuggets in the McDonald's box, they will notice it. Um, we see kids with paika are eating non-food items. So we have, I've have a lot of stories. I'm sure you guys have heard them as well, but they will eat the wall, they'll eat dirt. Eat rocks, um, toys, lots of things in orifices that they shouldn't be in, um, and so that can be challenging for families to navigate. We do manage that from a medical perspective. We'll do some kind of PICA labs, um, and things like that as well. Um, we see lots of sleep difficulties, so, um, difficulty falling asleep, difficulty staying asleep, and the additional challenge we also face is our patients are often not safe. At night when they're not asleep. So, are we eloping? Are we going out windows? Are we, um, you know, getting into things or eating things that are not safe for us? Um, we see a lot of toileting difficulties. So lots of kids are, we have a range of toilet trained children. Um, some kids will pee in the toilet, some kids will only go pee in certain places like school maybe, but not at home or vice versa. Some kids will not go in public restrooms, um. And so we manage that also, we have a couple of different classes. We also have um a couple of um specific intensive therapies that can occur in DDBP. Lots of sensory processing differences, so lots of therapies like OT and things like that. We see a lot of disruptive behaviors. So we rely heavily on our psychology friends in DDBP as well. Causes a mess. Yeah, I. I believe we have our first poll of the day. Which of the following is a cause of autism? Genetics. Vaccines. Tylenol during pregnancy or all of the above. I'm coming in. We've been very popular in the news lately. I know. All right. And there we go. Causes of autism. A lot of times can break down into three different things. Um, genetics definitely plays a factor, epigenetic and environmental. Um, you may ask if one child in a family has autism, what is the chance of another child that has autism? Roughly in the population, I think Caitlin mentioned before, about 2%, 3% of children are diagnosed with autism. If your family has one member. That already has a diagnosis of autism. You're for a younger sibling, it's around 20% that they might have that diagnostic characteristic as well. There are certain risks that can change this, um, such as boys have a higher risk than girls, um, and the more siblings that you have that are affected, that increases your risk as well. Um, from an environmental factor, there are definitely prenatal factors, um, advanced maternal age, if the mom is a little overweight, diabetes, if there's autoimmune infections or exposure to toxins such as heavy metals and pesticides can also increase your risk of autism. For perinatal preterm birth, we have a lot of kids with low birth weight who were born preterm and some birth complications that are diagnosed with autism in our division. Air pollution in the 3rd trimester, so people in busy cities, things like that, um, medication use, valproic acid, sometimes have an implicated cost. However, we wanna make sure that you know that based on research and literature and plenty of scientific data, that vaccines, including the MMR, have no causal link to causing autism. One thing that you can do as a provider if you're in the community or you're curious as to what we can do, um, genetic testing is highly recommended, um, for our kiddos with, um, growth developmental delay, intellectual disability, or autism, um, about 50% are accounted for in these ideologies. The gold standard, there's a couple of things you can do. One, if you're really confused and you're like, the family asked you, you can always refer to genetics here for some genetic counseling who can walk through the process because one, consent is pretty lengthy. Um, two, and it's just, it can be very overwhelming for you, the provider, and for the family members as well. Um, and insurance can be, um. A positive or a negative, it depends on your insurance. So always recommend that the family calls their, we'll call their insurance company to see if they'll cover it. You can do a couple of different things. The gold standard is the whole genome sequence, um, but that one usually is denied. Um, however, you can do a microarray, a microarray first, and then that kind of reflexes to a couple of different things, um, based on what it finds. So it typically will move to a fragile X panel and then it can move on to the MECP2 or the PTN, which is based on head size. The PTN is if you have a larger head size on your Rollins, and the other one is for more, more smaller size, which are more like your Rett syndrome kids. Genetics and neurodevelopmental differences, global developmental delay, autism spectrum disorder, and intellectual disability. Why should I consider genetic testing for my child? Though neurodevelopmental differences are diagnosed clinically, genetic testing can help us understand why a person has this diagnosis. The American Academy of Pediatrics and the American College of Medical Genetics recommends genetic testing for people with global developmental delay, autism and or intellectual disability. Chromosomes are made of genes that provide the instructions for our bodies to grow, develop, and function. We all have changes in our genes that make us unique. Changes that will make a gene work improperly are called pathogenic variants. Identifying a genetic condition that may be linked to neurodevelopmental differences has several benefits. It can help understand the cause of a person's diagnosis, provide information about what to expect in the future, foster connections with other people with the same condition, and guide appropriate medical management. Though there will not likely be a cure for neurodevelopmental differences, sometimes there are targeted treatments that may improve a specific genetic condition. Also, a genetic diagnosis can provide information about the chances of this condition happening again in future pregnancies, as some genetic conditions can be inherited from family members. While genetic testing is a valuable tool, it does not always lead to clear next steps for medical management. There are complexities in understanding neurodevelopmental differences, and genetics is only one part of the big picture. For additional information about genetic testing, please contact your medical team. However, With genetic testing, while there's benefits where you can get some diagnostic clarity, it has the ability to connect you with other families, um, and find more supports, and it makes awareness of more comorbid conditions that can arise. Um, there are some risks. Um, it could affect life insurance in the future for your. Daughter or son, um, based on the secondary findings that are not associated with autism or intellectual disability, um. They might find some adult onset things that could happen such as cancer or heart conditions. Sometimes too, it can identify like glaucoma and then we, the benefit of that is that we can send them to the specialty to continually monitor it. Um, you don't have to know about your secondary findings if you don't want to. All parties involved have to agree to wanting to find it. And if you wanna do this in an outpatient lab and you're or in an outpatient and primary care, just reach out to DDBP you've got clarifying questions. Or again, you can go to genetic counseling. Vaccines, we kind of hit about it earlier in the one in the low poll. um, decades of high quality research has not shown a link. Um, they have that while you've probably read about studies, many studies didn't adequately adjust for confounders such as genetics, the maternal health conditions, or lifestyle and environmental factors. Um, if they're doing a si sibling controlled analysis, um, comparing siblings where one pregnancy involved Tylenol and the other did not, the association disappeared. Um, measurement problems. Most of these things are like self-reported and they're done after the fact, like, oh, I did take Tylenol. Maybe I took it for a fever, maybe I took it for back pain. Um, it's kind of hard to see or remember retrospectively what happened. Um, and like low quality or inconsistent evidence, a lot of the umbrella reviews, um, rate the confidence of finding this low to critically low. Uh, many, many of the reviews lacked rigorous methods or comprehensive searches or bias assessments. So our key takeaways. OK. Oh, wait, it does this. Vaccines are safe And Tylenol is safe during pregnancy. Um, untreated high fever in pregnancy can result in miscarriage and or maternal death. Always please advi go back to your, um, your OBGYN when you're pregnant and ask questions if it's safe if you got further clarifications. And while we're at it, Told you we were in the news a lot. Um, Lukovorin, how many of you heard about it? How many of you had people ask about it? Quite a bit. OK. You should know that the FDA is not recommending leucovorin for all children with autism. There's a very, very specific and small patient population that have benefit for it, and it's a cerebral folate deficiency. No. So what is it? Um, it's a rare medical condition in which children may have a small head size, seizures and developmental delays or autism. How do you treat it? You need a form of folate that can more easily pass through your bloodstream into the brain, making more folate available. Um, are we prescribing it here at Children's? Currently there's not enough evidence to support prescribing leucovorin to all the children with autism at this time. Um, a big FDA plug is that recently in March they released that it was not recommended and their statement was it was only for a confirmed variant in the folate receptor one gene, um, which is an ultra rare brain disorder that can resemble autism. Um, to find out if someone is curious if they have that, the genetic testing would pick up, um, this deficiency, um, or a spinal tap could also do that. Um, if you heard about the FRT testing, frat testing's been in the news. Currently not available here at Children's. Um, there's not enough data. To say that it's a a good way to find out if you have this deficiency, so it would not be recommended. Let's see Evaluations and treatment. If there's concerns, you can go to primary care, um, for an early return visit for or even at their checkup. Um, they can do things like an MCHT to kind of see if a patient might be at risk for autism, um, and may need a referral to us. Um, there is also early in our. Invention referrals. Anyone can refer to early intervention. That's the parents, the teachers, you guys, um, as other divisions. And so if there are concerns, that's a great place to start. Um, that is called Help Me Grow in Ohio, um, but there are other terms for that, so. Depending on the state, um, there are school-based evaluations. So for an IEPR 504 plan, if there are concerns for developmental delays and the child is over 3, they no longer qualify for early intervention, and the schools can do some testing to see if there are any developmental delays. Um, and then number 3, is us. We can do a comprehensive, um, evaluation for autism. Um, and if it's not autism, what are we seeing? Why, why, um, are the challenges there? Um, that's either with a psychologist or a developmental pediatrician. Behavior supports. Um, here are a couple of our simple behavior supports there, except the Neos because we can't find those anywhere, um. Unless you're Leslie, she's got one. these are just some sensory toys. We keep these in all of our rooms, um, whether we're seeing patients at our medical office building, at our home, or we're seeing them in the satellite locations, we also have boxes, um, for support and bubbles, a lot of bubbles. Um, we're gonna pass around a couple of examples of some of our sensory toys and things that might be helpful to get through a visit. Um, we also have child life. Um, we have ACT plans, that's an adaptive care team that can create a plan to make the visits go well and safe for our patients. Um, they can help with calming a patient. They can come in during the visit, um, and that is only if you are at a location that has child life. Um, they're not everywhere. Um, in, within our division, we have our own amazing child life specialists that do work with our patients. Um, within an ACT plan, you may. For example, they may go meet the family in the parking garage, put them in a wagon, and roll them in, um, because the transition to get in the door, up the ramp, past the vending machine, through the cafeteria, wherever they are, uh, might just be too stressful. So, um, sometimes we have things set up a specific way in the room, uh, if we know a kid has issues with water, so that's a big fun thing. Um, so we might have them in a room, specially with where we can lock up the water, um. The behavior safety team or behavior support team, um, some kids need BST for every visit, and that might include your, um, division as well. So, if they have aggression or self-injury to the, to the point of leaving marks or causing injury to themselves, um, we may have a behavior support team. Both the act plan and the behavior support team flags will be in the patient's chart. Um, there's literally a flag, a little circle at the top of your epic with a flag. If you hover over that or click on it, you'll see BST or ACT. Those are ways you can know your patient might need a little extra support. Um, Obviously, DDBP, we can help with a lot of behavior supports. We'll continue on with our supports, um, in the next few slides. Um, psychiatry can be helpful, especially for, um, some of our individuals with autism can qualify based on their IQ and communication levels. Um, and then we also have neurobehavioral psychiatry who are, um, our besties. They help with medication management, behavior therapy, outpatient, inpatient, um, both. Some other things we may need that could be helpful for our patients to get through visit is um a PX uh or a picture exchange communication system. You can see that on the, oh, I have a, we'll put a. No, oh, this guy. Um, so some families walk around with these. Sometimes child life can make them ahead of, uh, your visit, and basically you might put A picture of talking and then a picture of, you know, a stethoscope where you do a checkup, and then you might have a picture of a sticker saying like, OK, first talk, then, um, checkup, then you can leave, right, and go get your sticker. Uh, and so we're not really creating these even as GDBP providers. This is all child life or speech therapy, um, but they can be really, really helpful. And so if your patient struggles in your visit, we need. To know about it because um we can help with that in the future. Um, you may see individuals with an AAC device and so allowing them to communicate and allowing time and space for them to be able to respond is vastly important. They can become really frustrated when you're not listening. Um, sometimes we might hear go home, go home, go home, the whole visit, that's OK. You can still kind of revert back to that language I was talking about, which we'll get into more in the, in. Later slides, but, um, first talk, then home, right? So just when they're using their device, respond to them as you would if they were using their voice. Um, and we may see people with letterboards, um, so it looks like a little keyboard, but they kind of carry it around similar to like with this, um, lanyard or a strap or something. Um, some individuals can communicate through like typing, if you will. Um, and then sometimes, um, social stories can be really. Helpful to make visits successful as a whole. So just so they know what to expect, the parents can do this or go over it with them in, um, at home before the clinic. These aren't things that we are like you guys would be creating or I would be creating. These are all done through Child Life, and she's gonna pass around some for me. Um, there's different versions of these. Sometimes it's for a vaccine, sometimes it's for a blood draw, and then we have one for Didi. CBP visits specifically. Um, if you need help with those, Childlife can help with those. We have them for when cicadas come out, we have a lot of kids with very significant fears related to bugs, and they will literally not go outside all summer long. Like that is so sad, right? So we can make, before they come, we can make them a social story about bugs, and that like, guess what? These come out, but they also go away. They don't bite you, they don't sting, you know, it's sort of like a little book. Oh. Is this? OK. I don't know what this is. OK. Um, so we can create a little book to kind of help cope through some of these, um, times that are a little more challenging or it could be really scary. I have a patient who during COVID, um, she went home, you know, they sent all the kids home with, uh, computers. She went home with the computer. Her mom was like, this is ridiculous. She doesn't understand how to use a computer. And it turns out she started asking or started typing out complete sentences with the keyboard. Um, so she knew a lot. So now when I see this friend in clinic, she's asked me questions. Will I ever talk? And I'm like, wow, that's loaded and heavy. Um, she will, yeah, so always presume competence and always respond to their modality of communication because it might just look different, but it might be just as fluent as you and I speaking verbally. Some of our friends have a little more difficult time in things like doctor's visits. Um, so, a couple of things we can do for safety as a whole, um, is just remove any potentially dangerous items. Sometimes you may move the chair, the wheely chair out of the room and you just stand up for that visit. Sometimes there's these big. Light contraptions, probably for gynecology maybe at Mason. I'd like never see a patient with those. Those are like a lot. They come swinging at me like, because they're curious, like, what is this? I want to see this. This is really fun. Um, so anything that potentially could be harmful to them, um, but also us and family. So just removing those from the room can be huge. Um, change your positioning. So I rarely do a visit where I'm not sitting by the door with my back on the door. Um, we have a lot of elopers. Kids, what do you, what do you do when you feel fight or flight? You want to run, right? So, um, they may want to get out and so just position yourself if you see them escalating or even before then. Um, one person talking in the room can be quite helpful. So if everyone's like da da da da da at the same time, that's really stressful for someone with a language disorder. Um, using fewer words, I was just mentioning in the next one, or one, a couple down, first then language. First talk, then checkup, or first checkup, then bye-bye. Um, super simple, few words, no questions asked. They know what those things mean. Um, avoid the word no or denying access to things if possible. If they want to see the otoscope and flash the light around, as long as they're not banging their head or banging the floor with it, like, let them see it. It's OK. If that keeps them busy for a few minutes, you can get what you need done with the parent, then, then that's fine. Um, but saying no, no, no, stop, stop, stop, that is really stressful, um, and, and creates a lot of negative attention to something that they're going to keep doing. Um. Visual schedules and social stories like we talked about, not touching the patient. A lot of our friends with autism don't necessarily like to be touched. Um, so, instead of touching them or moving them around the room, Let them be, stand by the door and remove all the other things that could be potentially harmful for them. Minimize the demands when you can. Don't tell them to do things, even simple things like, oh, pick up your shoe or put this in the trash. Sometimes that is overwhelming, um, as they're beginning to escalate. Um, I know inpatient restraints sometimes can't be avoided, but let's use them as a last resort. Um. And for the least amount of time we need it because they do, they can escalate um our patient population. And sometimes it's as simple as a PRN medication. Um, some kids do not tolerate procedures well, and that's OK. That's across the board with or without autism. Um, sometimes a little Klonopin, a little Risperdal, something like that. We don't expect other divisions to be prescribing these, but reach out to us and say, hey, we tried to do this procedure. It didn't go well, and we can talk with the families about a safe option that might make it successful. Our kids don't have to be sedated for every dental exam. Wouldn't that be great? Um, and so we can talk about, um, some of those options. Other things that you can do um when we are escalating. So in that moment, things are starting to climb, um, dim the lights, stop unnecessary demands, give them lots of positive praise. I like that you're being really patient. Thank you for sitting quietly. Um, it feels a little silly at first, but you. Get pretty good at it after a while. Um, good job for using your inside voice. Um, one person in the room talking, like I mentioned before, that can be something to prevent and create safety, but it also can de-escalate as well. Provide them with something to do with their hands. Um, sometimes we just need. Something to keep ourselves busy. Um, and so would you like a toy to keep your hands busy, um, or just bring it in with you? We usually have them everywhere, um, in DDVP. Sound machine, projector machine, really brings down the stimulation in the room and just kind of gives them something to look at and focus on other than what they think you're going to do. Whether you tell them 100 times you're not going to do it or not. Um, and utilize the resources. I think the most important thing in this entire PowerPoint. I ask the parents if you see a patient starting to struggle or escalate in any way, ask the parents, what typically makes this better for him? Oh, OK, he doesn't like bright lights. Easy, right? Um, turn the lights off and, and kind of help with that de-escalation in that way. You can always reach out to Child Life as long as they're available at your location, um, and behavior safety team, um, which are also, both of those things are, um. Inpatient and outpatient in most cases. Got another poll. If you have a patient beginning to escalate in the room at the beginning of the visit, or when entering the room upon an admission, what do we do? First, this is like, first and foremost, call Child Life, call DDBP. As a family member what helps when the patient escalates, or call Behavior Response Team immediately. So, I will say, and I don't see anyone has picked it yet, don't call us because it'll be a long time before you hear back from us. We're not here on weekends, holidays, um, and sometimes I might be the provider and I'm out for the week on vacation. Don't call us, we're not gonna be able to help you. Um, you can, however, send us a love note in my, in Epic, um, and just let us know, hey, we really struggled in this visit. I tried A, B, and C, and it didn't work. Do you think you have any support? I don't care where you are, inpatient, outpatient, it doesn't matter. We can still kind of navigate that process with you guys. So I think you guys got it for the most part and, and often. Oftentimes I think there was a poll earlier and it's like, often we're doing these things simultaneously, um, and we're doing them simultaneously in this moment. I might peek my head out because we have Child Life at the ready, right? I might peek my head out and Child Life is already hearing the patient escalate and they're already waiting for me. Um, so, we're calling Child Life and asking a family member, oh. Well, I guess I didn't put the answer on there. The answer is ask the family. They have all the answers. They know that kid the best. They've seen this behavior before, most likely, so. Good job. So family resources and what can you do in the community or in your setting? If you're in primary care and you're outside children's, the first thing you can do is you can make a DDBP DDBP referral. Um, they would come and see us, whether they get scheduled with one of our physicians or whether they're scheduled with one of our, um, psychologists with a speech therapist, um, for that new, um, visit. It, it varies. Um, something that you can do short term to get help. If there's a weight, because there probably is a weight, um, therapies, you, you could speech, OT, PT if they're a little clumsy for body awareness, OT working on the sensory overload, um, you can really utilize OT for more than just fine motor skills and just how our kiddos can help process those big, big emotions that they have. Um, we do have a family support team. Um, their information's up there. Our family support team are wonderful. Their parents, we call them other navigators, um, but they're really in tune with school districts and like if like finding an advocate that you might need, um, what, uh, schools are up there? We have an autism scholarship. Excuse me, how do I go about, um, going to apply for it? What can I do to get connected with my county services? Your local school district can also be of help to start the IEP 504 process if there's a concern for developmental delay and Caitlin hit on that before. DDS is what I was talking about with your county support. Um, it's can be a little bit of an undertaking at first to get connected, but once you're connected and they do their visit, um, it's really beneficial, especially when they're adults in Ohio, for the amount of services that our kiddos can get, um. Help me grow as under 3. We also have our tribe, which is for our African American patient population where they can be connected with families who have similar children, similar concerns, and just build a network amongst that community. And we also have Autism and We, which is a collaborative of parents and clinicians, caregivers and educators who the common goal is just to support and provide knowledge, um, to the public and for other family members on how to support our kids. We got a lot of ways you could connect with us. Um, we're pretty good on social media. We have lots of good people who are posting things that are available to the community. Um, our newsletter is wonderful, lots of resources can talk about classes. We have our own library. We have Mr. Matt. He's a wonderful librarian. So if you have a kid who's looking to work on speech and the family wants like pecs or those picture things that Caitlin talked about, he can help set that up for you so you can make communication a little easier until you get into your visit. We have lots of videos online, lots of, lots of, there's lots of things available to you in the community or even in another division that you might not know exists. Yeah, I know. Very good. And Matthew also does a really nice job. Um, I've asked him, for example, I had a patient with an intellectual disability and pretty extreme fears of um. Blood. Um, she hadn't been seen by gynecology yet, had not started her menstrual cycles, but Matthew was able to get me a long list of menstrual, um, age appropriate menstrual cycle resources. So he also can do that for you. Um, and so I really have been. Utilizing our Rubenstein library a lot lately, um, so this is my plug for our Lynd program is what we call it, it's leadership education in neurodevelopmental and related disabilities. So essentially this is a group of graduate, um, level or higher individuals, and this can be any. Discipline, um, speech, OT, psychology, APRNs, um, and it's a specialty program where we learn to advocate for and, um, learn didactic information on disabilities as a whole. Myself and Grace, our team lead, have graduated from L Lent like in 2017 or 202018 and 201919, something like that. Um, and so Saosha Schwar is now our um APRN person for that. So if you're interested in learning additional information on neurodevelopmental and related disabilities, we are happy to have you. It is an academic calendar. You do get a stipend, um. Talk to your um program directors to um figure out um your clinic schedules. But let us know if you're interested in learning more. All right, this is a fun game. Oh no, look, the answers. The answers on there. Two truths and a lie. Um, so, first thing, autism is not caused from vaccinations or taking Tylenol while pregnant. Oh, look at this. Which one? Good job. Thank you. Which one is, um, a lie? Autism can be caused from a combination of genetics, epigenetics, and environmental factors. Autism is when there is a social communication difference or a repetitive behavior or restrictive interest. Remember, um, we cannot have one thing without the other. We must fill both barrels to a certain level to be able to, um, diagnose an autism spectrum disorder. Um. Despite the media. Looks like we understand what autism is not caused by. Um, and then. We got, we got some stragglers. It's That's what I think, alright. So, the answer is autism can be caused from a combination of genetics, epigenetics, and environmental factors. The trick in the bottom one, or I'm sorry, that is correct. Autism is not caused by vaccines. It can be caused from a combination of these things, but the lie is that autism is when there is a social communication difference and not or repetitive behaviors and restrictive interests. Yeah. Oh, there it goes, references if you'd like them. And then we were going to send out, we have a lot of QR codes, lots of really good videos online as well. DBP loves videos and, um, you know, visual supports. So those will all be, I believe we were going to send those out if I'm not mistaken. Any questions? Yeah, we got a couple of questions online. The first one is we have a participant that works at a CCHMC school-based health center. Is there a way to collaborate with child life for resources or materials, or is there a certain point person? Yeah, so I would say absolutely, um, we have Leslie and Lauren, our child life specialists. If we could get your name, is my name on here? Can you email me? Online participant, that would be a great way. You can email myself or any of the APRNs and we can um connect you with our child life specialists. Great. The next question is, do you have any recommendations for respite care for families in which a parent might be the sole caretaker of a kiddo with autism that has a higher level of needs? Is that is the family support team a good resource for this? Absolutely. The family, many members of the family support team are actually parents of children with disabilities themselves, um, so they're really savvy as it pertains to the community supports. I'll be honest and say that respite care for children with disabilities as a whole is really, really challenging, but, um. In Ohio, we have DDS like we talked about, and DDS can be a really good support for families in terms of, um, respite, depending on the county. Um, and then also, um, our, um, family navigators can connect you with people. We used to have a babysitter list, for example, within DDBP. I assume they still have that running. All right. And the third question is, do you have advice for PCPs or healthcare providers to better understand when to refer to DDBP versus neuropsychiatry versus psychiatry? Oof, a really good question. So if they have a developmental disability, autism, Down syndrome, um, Cerebral palsy, intellectual disability, global developmental delay, you can send them to us as a first pass, and then if we, from a medication, we can get them resources, medication, all of the above. Um, but if we tap out from a medication perspective and need like they need a higher level care, that is when we would typically refer to neurobehavioral psychiatry. I don't see many cases where PCPs. They're at a level that they are ready to be referred to neurobehavioral psychiatry level of care, they should go through us first, probably. Most of our patients with autism do not um qualify for psychiatry, although some do. Those are very, very high functioning children that can communicate um fluently, uh, in a verbal manner. Thanks ladies. Um, this is great. So in the past year or so there have been some heartbreaking stories of our kiddos who have eloped, um, and they've had unfortunate deaths. Can you talk a little bit about that safety discussion you have with families and resources? Yes. So we also have um a QR code for that, Grace. Um, we have a plethora of, um, so we have a lot of kids with autism that will elope or run off. Um, many of them also love water, like I mentioned. And so if there are safety concerns from an elopement perspective, whether the family has a pond or pool at their home or near their home, we still offer the exact same resources. Um, we have a laundry list of safety products for the community. We have window door alarms, um, that we will give out in clinic as well as, um, families can order online if that's feasible for them. We have, we recommend leashes, um, a lot, um, and we also recommend or we utilize, um, our wheelchair clinic a lot for adaptive strollers for community when we feel that they can't be safe, um. What else do we have? Oh, we have a, um, swim class. We have, um, a couple of classes for families specifically related to elopement. And this past year, I think it was, we did, um, teach some kids how to swim. Um, and that was a really cool and fun thing and they realized it was very, very effective, um, in a lot of ways. So, always reach out to us if that is a concern that comes up in your visit. That it? OK. Just like we did it.