CM405-Co-occurring Mental Health Concerns & ASD

John McGonigle: Thank you, Kevin, for that introduction. Now, comes the tough part, right, keeping everyone awake after lunch. I’m happy to be here. Thanks for the invitation. As Kevin mentioned I am the Director of one of the ASERTs. So, you’ve heard references to the ASERT programs. There’s three of them. I’m directing the one in the western region.

This topic today is these co-occurring disorders are often sometimes referred as dual diagnosis. How many of you work in the mental health system? Okay. How many of you work in the ID system, Intellectual Disabilities? How many of you work in both systems? So, a few, so these are obviously individuals that meet criteria for both systems.

When we talk about the assessments of individuals with Autism and Co-occurring Mental Health conditions, you really have to separate all of them out, trying to figure out what is related to the core feature of somebody with Autism. And then what are mental health conditions that might come into play along the life of the person.

Well, give you information. I know the conferences give you practical things to do and hopefully, I can do that so you’ll see scales that I kind of developed easy, you can use them. You can make you own. Modify them to the folks that you’re serving.

The overview of what we’re going to talk about the next couple of hours here are Past Practices and Current Directions. What’s the current direction in not only the assessment, how do we identify mental health conditions in persons with neurodevelopmental disorders? How do you identify Mania in maybe a 50-year-old person with Autism that’s non-verbal and exposing themselves? How do you know that’s part of the manic episode or part of a social skills deficit or eccentric just that they have difficulty-keeping clothes on. It’s critical to be able to differentiate those because that’s going to drive our treatments.

We’ll talk about some of the Past Practices, where we are, what direction the field is going in. We’ll talk about assessing Psychopathology and that simply means that the mental health conditions that occur along with life. There’s a lot that goes into it and even in our life experiences, things that we experience along the way. We all in some point in time probably experienced depression in some way, a loss of a family member, relationship, pets in some cases. But being able to identify that, recognize that is important for a number of standpoints. So we said it drives the treatments but does the person need medicines to help them or can they just talk to somebody or have additional supports that get them through that difficult time period.

Barriers in obtaining an accurate diagnosis if you take somebody for a psychiatric evaluation if you’re meeting a clinician or a psychiatrist you may be lucky to get 45 minutes in that evaluation time period maybe an hour. So think about and you may have experienced this, again somebody who is unable to communicate or limited communication, difficulty with socializing, how is a clinician going to be able to accurately assess somebody who is not giving you an eye of contact, looks like they are suspicious, they are overwhelm with anxiety. And sometimes clinicians are quick to make a diagnosis without getting more information.

So we’ll talk about why it’s important to get as much information on the person as possible. And at least somebody knowing what a baseline level for that person is. What are they like at their baseline? And then we can begin to judge and look at the influences of any of these mental health conditions. We’ll talk about what goes into getting an accurate diagnosis. We’ll also talk about when I say common psychiatric diagnosis so there’s a number of them that kind of go together. Even in early childhood diagnosis, attention deficit, hyperactivity disorder, and oppositional defiant disorder sometimes will go together. And when we do evaluations on adults, it’s not unusual that that’s actually their first diagnosis when they’re in elementary school that they get this diagnosis. It’s obviously not accurate. They may meet criteria for it but even in those early ages, people are quick to give a diagnosis.

We’ll talk about some of the diagnosis that goes together and how to assess those. How do you begin to ask the questions around are we dealing with somebody who may have depression or anxiety or an adjustment disorder. We know that folks move from whether from school they graduate from home to a residential program. They move away to college. And a lot of times, they will experience adjustment difficulties, overwhelming anxiety, and difficulty with processing information, falling behind in their activities or ADL skills and it’s really just an adjustment problem. Sometimes you don’t have to do anything for it.

We’ll talk about that a little later on as well. You don’t have to be quick to go to the doctor and get out the prescription pad, right because taking a pill isn’t going to teach somebody to social or interact. It may help with some of the interfering symptoms but in terms of somebody learning something, it’s really our job in terms of how we support folks.

How many of you are Behavior Analysts here, FBAs, okay, so we’ll talk about how do we use functional behavioral assessments? This is critical today obviously for not only in ASD, but all mental health populations are required to get some understanding, etiology, presenting concerns of behaviors. So we’ll talk about how can you use in FBA, as we see here, not only look at the observable ideologies, you know, attention escape avoidance, getting access to tangibles, but you can actually use the FBAs to look at the non- observables, what I call them, beyond the observables. Say you saw maybe folks that will have explosive behavior for no apparent reason. Or you’ll hear things like was out of the clear blue, nothing was going on, the person was okay, but all of the sudden they were having difficulty so we can talk about and I’ll show you ways that you can begin to look at, and again, beyond the observables. When I say, beyond the observables, these are more internal. So internal could be medical, internal could be psychiatric, internal could be sensory. So how do we being to look at those things? Hopefully, I’ll be able to show you an easy way to do that.

The other things that we’re going to talk about are these Best Practice Approaches. There isn’t a best practice approach. There are things that fall under best practice, but everybody is different in terms of how they respond. So you can’t say well, this is the best combinations of treatments for somebody that has Autism and an anxiety disorder. These are the best therapies, treatments, and medicines. It doesn’t work that way. But in terms of best practice that goes along with evidence-based right. Evidence-based is taking data.

Hopefully, I’ll be able to share that information with you which is critical especially when you’re using medicines or looking at any treatments, response to treatments. You want to know are these interventions effective or not. We’ll talk about how to look at data. If you’re using medications, it’s critical for the psychiatrist or whoever is writing the script to know, does Zoloft decrease anxiety or rituals in the person. So if you’re just going in and doing verbal reports, you’re less likely to be successful, in most cases. We’ll talk more about that as well.

Least Restrictive Treatment Models, when I talk to hospital programs, residential programs we should operate from a Least Restrictive Treatment Model and that simply means that our interventions and supports are going to be less restrictive and intrusive to the person and again, based on behavior, based on lethality of what the behaviors that you’re working on. Because there are some programs that, continue or still use believe it or not some restraints or seclusions. If you work at an in-patient hospital acute psychiatric hospital program those are interventions, they are not treatment at all. Actually, the data and research on seclusions and restraints is that there’s no therapeutic value to a person that is in seclusion, restraint none at all. In the seventies and eighties when restraints were part of a behavioral management program, they were viewed as therapy. But today, all the data and literature tells us that there’s a lot of negative effects on the use of those.

But when we talk about seclusions and restraints and when I talk to residential programs that question comes up well, what about that person running out in the street what do we do just let him run out in the street or if they’re banging their head do you just let them bang their head. Absolutely not, but if you have to use those interventions you’re going to do a variety of other things, less restrictive, adapting the environment, adapt the way you communicate, interruption redirection.

How many of you have support people that use a PRN medication, medications to help reduce the anxiety? That also can be a part of your Least Restrictive Treatment Model. I can talk a little bit about how that should be used and how it is monitored. So these are what we’re going to talk about this afternoon and also preparing for the Psychiatric Appointment. I’m open to, along the way here, I’m open to questions so we can just – if you have a question along the way as I’m talking we can talk more specifically about it. You don’t have to wait until the end. You’ll see some forms as I said before easy things to adapt and modify to whatever setting that you’re in.

All right, so when we talk about dual diagnosis and actually some of the folks that we’re talking about have three diagnoses and maybe four. So if you have Autism, you have an anxiety disorder, you have diabetes, drug, and alcohol, seizure disorder. All of those are separate diagnosis and they are meaningful, so you can’t lump everything into one person and begin to treat it. Each one you have to separate and say, how is that expressed in this particular person. And that’s going to drive you again, to the different treatments.

As we know with Autism Spectrum Disorder this is a complex neurodevelopmental disorder. It’s a neurological impairment period. It’s not a mental illness, doesn’t cause mental illness. Believe it or not, there are some clinicians and physicians who don’t understand it. There’s a term called diagnostic overshadowing, right. So that when you go into the doctor’s office and talk about these presenting concerns. And then somebody says oh, Autism everything is explained to Autism and that should be history. Yeah, that person doesn’t really understand Autism.

And then the mental health is the wide range of these conditions, socially relating behavior, thought processes, it affects every domain of mental condition. We’ll talk again, more about that.

The past practices, you see that left-hand column there. I think you have these thumb drive, right. All of these slides are on the thumb drive just so you know. So the past practices, there’s a couple of things that have occurred in this culture of control. If you work in mental health not only nationally but in Pennsylvania, we operate from the recovered model, right. There are certain aspects of the recovery model that are critical in mental health treatment.

And then if you’re in the ID side, right, we’re working under positive approaches, philosophy. Actually, some of those there are two different philosophies but they based on human rights issues and they operate a number of them. They have very similar things that they share, empowering people. Mental health is non-linear, right, so that’s why you may support somebody who does very well for a very long time period and all of a sudden you have this backslide. It’s not a nice, neat trajectory and there’s a lot of things that occur along the way.

So there’s the change that we’ve gone from this controlling not only the behavior but also the person as well to recovery, care, and support, protocols. You know, I still see this on occasion if you work in a program or if you’re a family, member and you’re going to a treatment program. And if the inventions are the same for everybody – when I review a program at a residential facility I’ll see a behavioral support plan. I can pull up five of them and they all look that same just a couple of the names change. It’s not best practice at all. It’s all individualized to that person and family. So you want to make sure and ask the questions around these programs, are they individualized to the person that you’re supporting.

Diagnosis not accurate years ago much more accurate today even for our significantly cognitively impaired folks. We can do a pretty good idea assessment again of mental health conditions. Even though somebody may not be able to express or tell you that I feel, you know, I lost energy my sleep has been erratic. I’m not eating as much. But we’re able based on people that are supporting the person we’re able to get that information. We’re much more accurate today. I’ll show you on a couple of slides a little bit later, of how we’re able to do that.

Old generation meds, those are when I say old generation meds, there are new medicines all the time. What you should know about medicines is that how they are prescribed, right. So they are diagnosis driven in most cases. You formulated diagnosis based on symptoms or the presentation of that person in the office, anxiety, depression, mood disorder, bipolar disorder. And then there’s going to be medicines that are going to be tailored to that diagnosis.

There are also medicines now, that are more specific to behaviors not only symptoms but also behaviors. So when you get somebody who’s repetitive and does things over and over again there are medicines that are going to target that particular symptom or behavior and then the only other way is what’s called shooting in the dark and that’s not what you want. It happens a lot.

How many of you have people that are on four or five different medications, right, okay – when you’re looking at those – and we’ll talk more about this. The question that you would have if you’re a family member or if you’re getting treatment from your doctor, you want to know what is this medicine indicated for every medicine has an indication – every one. Every medicine that’s given it’s indicated for something. Even if you got to your PCP and have cold symptoms, you’re going to get a medicine that’s going to treat those symptoms, right. So that’s what it’s indicated for and the same way with psychiatric medications. The issue is with a lot of psychiatric medications that they are often prescribed off-label. So that’ means that for mood problems somebody may be given an anticonvulsant medication – Depakote, Tegretol. It’s off-label but it seems to be effective, the research says it’s effective for stabilizing moods especially mania in a lot of cases.

The whole point of this, moving from this old generation meds to new generation meds it’s actually easier to monitor and track. The old medicines actually quelled everything. So if you again, by raise of hands, how many of you worked with someone who spent a lot of time in a state mental health facility or a hospital program? Anybody, okay. So if you look at the history actually, the medicines if they’re fifty and sixty now, right, if you look at the history you’re going to see things like Stelazine, Mellaril which were just notorious for major problems not only medical problems but these disconnected movements, Tardive dyskinesia. These movements that are lifelong. The medicines today, are less likely to present those lifelong conditions in people.

Also, too, I see this in hospital programs in people that are medicated years ago you’d see a lot of people – it was referred to as the shuffle. You’re given so much medication you didn’t have the heel to toe gate, you kind of would just kind of glide along the floor. You were sedated – chemically restrained actually is what it was. You can’t even use the terms today, chemical restraints. You have to treat specific symptoms.

Today, how many people do you see like that that are chemically restraint, not a whole lot just because there are so many warnings and so many observations that need to be done now in the medications to make sure that they do work. Chemical restraints as I said were treating symptoms.

Behavioral modification, positive behavioral support, so your behavioral analysts who are trained in ABA, positive behavioral support they are off an extension of let’s say, but they’re really kind of in a lot of ways two different camps and positive behavioral supports that, is the direction that we’ve gone into. And that simply means that it’s more of a holistic approach. Looking at lifestyle, looking at medical conditions that might influence the behavior, but the interventions are very similar.

We’ll talk about FBAs. Those are critical in both areas. Finding out what the etiology is so positive behavioral support are less focused on the manipulation of dependent variables. In order to do an FBA – we’ll talk a little bit about that not to get too technical, but it’s an experimental functional analysis of antecedent, consequence.

Positive behavioral support really gets the idea of the person, information from the person of what might be causing some of the conditions or behavior. It adapts and modifies the environment, level of staff support, can still use reinforcement schedules, but really not much on the punishment side or reduction technique side the restrictive intervention, so a lot less. It’s all behavioral you’ll see as we talk about the interventions a little bit later on. And as I said, I do reviews in hospital programs.

Seclusions and restraints, so these, actually, nationally have changed. There’s a lot of programs that they’ve gotten rid of – seclusion rooms and they’ve changed them into what’s called sensory rooms, reflection rooms, comfort rooms. This is good stuff. So they are sensitive to the effects of somebody being secluded, in restraint and then obviously, the functional behavioral assessments.

So changing this mindset when I talk about this restrictive mindset I’m not saying that restrictive interventions can’t be implemented. When you get to that level, you’ve got to make sure that you’ve exhausted every other thing before you get to something that maybe considered restrictive for that particular person. But in the old days, when we look at individuals, people with Autism Spectrum Disorders and Co-occurring Intellectual Disability, these are folks who have been subjected to actually inhuman treatments if you look at the literature and history. This is why the sensitivity issue nowadays is being really aware of making sure that you’re not causing any undue stress, harm, or pain to the person.

So back in the day, if you read any literature on any of the interventions it was designed to inflict or cause something unpleasant or painful that the person hit themselves or hit somebody else and there was a consequence to that person who said hey, stop doing that. It teaches you not to do that. Again, those are history days. And that’s what I mentioned about we controlled everything not only the behavior of the person but the person as well. So that’s changed significantly.

Here today, this is part of the FBAs, right; if a person acts up, they are communicating something, a need, something that might be bothering them. So we’re looking for that underlying etiology.

Our job then now, this is the Positive Behavioral Support side, know that we know about the person what might be causing some of these presenting concerns or behavior we should be able to teach that person something else to do instead of biting themselves or cutting themselves when they’re anxious. We should be able to do that and we are successful in doing that, but that’s kind of how it operates today and we’re giving up control. Our job is not to control people. I don’t know about you but I wouldn’t want to be controlled in any way, so we’re empowering. Again, this is part of the recovery model empowering individuals, self-determination, and choice in options. But it should be based on what we know about that person and what’s important to them.

Let’s talk a little bit about what goes into somebody who may be showing or displaying some challenging behaviors. Again, I guess the terms was problem behaviors, right. It’s really our problem we haven’t figured it out yet. What goes into these presenting concerns? There’s a lot that goes into it obviously from the genetic side, right. There is a term behavioral phenotypes, right. I just listed a couple of the genetic disorders that an expression of those could be social skills deficit. Believe it or not, some aggression and self-injury are inherent in some of these genetic conditions, so we have to understand that. It’s all treatable. It doesn’t mean that you can’t do anything for it, but we just have to understand that somebody who scratches or bites themselves that has Lesch-Nyhan or Corneilia de Lange Syndrome we know that that’s part of the expression of that disorder and some of the other ones as well. We understand that from the genetic side.

Development, this is where it forms our personalities, right. It’s our experiences through life. So obviously, if you have deficits in certain areas then you may have a delay in communication. You may have a delay in social interaction, communicating feeding problems along the way. Delays in playing, socializing, relating to others and then these motor sensory areas that come into play but then the psychological risk factors. We talked to adults they are very successful even. They run companies and very successful. They tell the same thing. The give experiences even from early on in life, high school, even in their employments often overlooked for raises and performance appraisals are mostly negative. So these are labeling, ejective, restricted opportunities to participate in things.

And then these recent studies well, we know about the victimization and bullying you heard Scott this morning. He did his dissertation on the bullying. It’s there, so those actually play into somebody’s personality, development. It changes the way they interact, socialize, and relate to others based on those experiences. How does that express, is that a mental health problem? It can be if it rises to the level that the person cannot get through the day because of being overwhelmed and anxious and can’t participate in an activity then that may need some help or treatment.

As we look at this complexity of individuals, any one of these things can present with irritability, aggression, isolation, not eating, so the health and medical side. That’s the first thing you’ll see, that’s the first thing you’re going to look at with any condition is there a medical reason for this person to be behaving in a certain way. And then we begin to kind of differentiate or uncover some of these other areas.

Talk about neurological impairments, right. Autism Spectrum Disorder is complex. Neurodevelopmental Disorder, so there are neurological impairments in some form or fashion. It doesn’t rise to the level that doesn’t mean that somebody has a mental health condition, but could mean that they have seizures as well. How many of you work with people that have a seizure disorder on the spectrum? So a huge percentage of the folks that will have various types of seizures. How many of you work with people who have Pseudoseizures? How do you differentiate that? How we know that that’s a fake seizure or that that’s not a real seizure. Hopefully, I’ll begin to talk about maybe ways you can look at that with some forms a little bit later on.

And then we know that trauma is a big part of what we have to assess – everybody should be assessed for trauma. Not everybody has it but you should ask the questions for people who are able to tell you. You may find out that there is a trauma history. And if there is, if it’s identified whether physical, sexual, neglect somebody should be able to go to that treatment plan and it should have some accommodations. It should have a trauma informed model of care for that person if it is identified. So that’s important. When I look at a record and it says trauma then I’ll go to the treatment plan and say okay, have you made accommodations, what kind of language no coercive, non-threatening language. How are you empowering this person? How are you developing trust or relationship with this person if that’s something that’s been identified? So we’ll talk more about that as we go along here.

Psychiatric Diagnosis, so you should know this, the full range of every psychiatric condition is present in somebody with Autism. It’s present for people who are not on the Autism spectrum. We talk about psychopathology. It’s more severe – We talk about the individuals that are in severe, in the severe range, severely cognitively impaired, have Autism non-verbal – the psychopathology is more intense, more ingrained for that population. And we know that because if you look at the resources that somebody that might have mental health problems, aggression that is profoundly intellectually disabled and has Autism they are going to draw a lot of resources, noting staffing, house- wise so it’s more intense and more involved in those individuals. It doesn’t mean that they don’t improve and get better, but when we look at where are the resources allocated for that particular group it’s a lot higher than somebody who may have mild depression that is able to respond to individual therapy or a social skills program, limited coping skills, difficulty-handling stress.

We talk about this heterogeneity, right, so that’s why they call it a spectrum. Same way with not only the cognitive abilities but also the presentation of Autism core features. No two individuals are alike so these services are individualized. They are multifaceted so we talk about the complexity and co-occurring. One of the big problems is – well, there’s a couple of them. Navigating systems and also the communication between those systems, right.

I mentioned to you somebody had their hand raised before about somebody who has a seizure disorder, right. And somebody also has a mental health condition. How many of you work with somebody that gets medicines from both a neurologist and psychiatrist? How often do they talk to one another? Never, big problem. They are both sometimes one person is treating seizures the other person is treating mood they are using the same medications and it’s just all over the map. It’s real important that we have – we have a nurse where we are that can navigate that and get information from all of the settings or clinics that the folks are involved with.

These are some of the difficulties or the challenges that we have difficulty in securing an accurate assessment, somebody who knows – first of all, somebody who knows Autism. Secondly, somebody who knows mental health conditions. Depending on where you live, sometimes you’re more rich in resources. I know we’re in Allegheny County. We’re pretty rich in resources in terms of University Center. We are able to train a person in assessments. But in a lot of the rural areas, it might be a challenge trying to find someone, so that’s one thing. Obviously, more training needs to be done. The lack of expertise we talked about and it’s kind of split between all systems – Mental Health, ODP, Medical. Even though they cut across of all of these systems, the silos are still a challenge to navigate.

The impact of psychiatric co morbidity – we know this. I work in an in-patient program so we see this a lot. A lot of contact with police and lots of placements, in and out of hospital, revolving door, increase in medications.

Folks raised their hands before when you have people with four and five medicines from the same drug class. There’s a term that’s called polypharmacy, right. It is the worst thing you can do is be on three psychotic medications. A person who may be delusional but you always look for one medicine that might be an effective treatment. And we’ll talk about it when we look at data a little bit later, how we can assess that. So these are the difficulties that clinicians have. Everybody has this when we’re evaluating. Individuals that are high cognitive abilities it’s really a lot easier. I mean, you could even use some rating scales. So if somebody is depressed an anxious there are rating scales the Hamilton Anxiety Scale, the Beck Depression Inventory scales. They are not standardized for people with Autism but you can get information regarding sleep, how the person feels, how they look. They can give you an idea if anything is working or not. So that particular group is a little bit easier to work with.

Folks that are more involved, difficulty with communicating. I can tell you this as well even folks that have higher cognitive abilities, very verbal, they have difficulty putting the feelings to words, right. They have difficulty when you say well, what’s anxiety like. If I ask you what’s anxiety like for you. I’ll get probably 50 different ways. This is what it feels like, butterflies in my stomach maybe difficult breathing for somebody on the Autism spectrum. A fellow told me this, he feels like a needle in between two brick. I mean that’s meaningful. To somebody who doesn’t know that – well, what does that mean? I actually used that as part of the Likert scale that identifies when he gets to that level we need to do something quickly because he may end up in the hospital.

But the idea of looking at identification of mental health concerns these are what clinicians deal with. So if we fail to identify it then what happens if a person gets worse, symptoms increase, and they may be more disruptive, more aggressive and they may need to be hospitalized. The other one is making an inaccurate diagnosis. And then you’re off and running with different medicines and therapies and treatments. It’s real important to take your time and figure out what is going on before treatments are assigned.

When we approach this should be the approach, if you’re going in for an evaluation or taking somebody in you’re going in with some presenting concerns or problems, symptoms, or behaviors. This is a change in the person’s baseline. They’ve started to do something different or they may regress in some way. Those are very important things to know. Other important things to know is this an acute onset. Is this something that just happened two days ago, three days ago versus something that’s chronic – something that’s been there a long time that’s very important to know? And so, you would give that kind of information.

There’s a term you’ll hear differentiation of diagnosis differential, so that means that somebody comes in with some particular concerns but then we begin to ask the questions what caused this, how long has it been there, does anybody else in the family have this? So then, we begin to do this detective work to figure out okay, what are we working with here. This all happens really before your diagnosis. If you just started treatment or diagnosed on one behavior even though it’s intense you’re going to have major problems. What I mean by that is, if you have a person that just starts to engage in self-injurious behavior and maybe they hit themselves, bit themselves, or cut themselves. It just started and it is very intense, you can’t call it anything. It doesn’t meet the diagnostic criteria. It needs treatment. You need to do something, but until you get those – that other information. Okay, it started a week ago. What happened a week ago? What is sleep like? What is eating like? What does the person look like to you? So all of those things are going to formulate the diagnosis then you can begin your treatments.

As we look at differentiating, a lot of things come into play. You’re going to rule out non- psychiatric causes, right. How many of you admitted somebody to a psychiatric hospital for a non-psychiatric cause, anybody? Nobody. When I say non psychiatric cause somebody didn’t get the hot dogs for dinner, somebody didn’t get a phone call or a visit from mom or dad and they ripped the phone off the wall, police are called, they are in there. When they get in the hospital, you never see anything anymore. Do you guys experience that at all? Those are really non-psychiatric – it’s the environment. Now, the person has difficulty controlling the impulses but in terms of meaning depression, anxiety they will probably give it what’s called an impulse control disorder based on the behavior, but the point of this is we’re looking at everything, so non psychiatric conditions and that’s where our FBAs come in. Once we get all of that information then we’ll get the working diagnosis. We’re going to say, okay, with all of that information they meet this.

These are the areas when somebody is doing diagnostics, right, the DSM, the DSM five now. There’s also a manual if you’re a clinician – you can make a recommendation to your psychiatrist. There’s a diagnostic manual for intellectual disabilities, so if you working with somebody with an intellectual disability there’s an actual supplemental manual that’s put out and it’s by NADD. We’re going to talk a little bit of this. It has behavioral equivalence.

We’re going to talk about psychiatric diagnosis and what’s a behavioral equivalent for somebody that’s depressed that has ID or severe range of Autism. We’re going to review the records. What is important in that obviously is family histories. Is there anybody else in the family that suffers from depression or schizophrenia or anxiety? We know that there are family histories. And that’s important from a couple of standpoints not only from the diagnosis side but it could help with a first line medication. So if biological mom or dad has a mood disorder and they responded to Depakote then that might be a first line intervention for son or daughter who presents in the same. So that’s where that can help you out.

Observation method, rating scales I talked about and then your FBAs. So the factors that influence it and as I mentioned this before there are some people that for whatever reason correlate Autism and mental illness which is hard to believe but there are people who will do that and these are clinicians as well who have no experience. We said the psychiatrist could not formulate the diagnosis. Diagnostic overshadowing as I mentioned is everything is related to the Autism and nothing else.

Medication masking and then the medical conditions. Medication masking simply is somebody is given a medication that kind of quells everything. You don’t see anything. And then once the medications are gone you’ll see an increase in some symptoms or behaviors. We saw this actually if some of your folks that you’re supporting or have been in state facilities before they came out they would be given a lot of medication. So they were given medication kind of quelled everything, they transitioned to the community, then they get into the community and they go to their first psychiatric appointment. The doctor looks at the medicines that they are on and say, oh my god they’re on so much medicine. And then they decrease the medicine and then what do you get – you get this manic episode and they’re in the hospital right away. So that was a number of folks came from institutions, was in an in-patient hospital program shortly after just because of the medication masking. For us, clinicians, if you’re doing your assessments we’re determining is there something unusual about this person presentation.

So if we look at the intellectual distortion they are unable to report their experience and they’re not the best historians. That’s why we need family members, anybody else that’s supporting them, some records, to give us accurate information. For the hospital programs now and you should know this there is a term that’s called Medication Reconciliation. And that simply means that as much information about all the medicines that person has been on needs to be accessed. The hospitals do this. So they’ll be asking what was the first, second, third medication. Did they respond?

Why the hospitals do that is they don’t want to repeat costly medication trials. So somebody may have a manic episode, they come into the hospital, doctor puts them on Depakote, they have a three, four week trial, they get better and then all the sudden they have a white blood count problem with the medication, medical condition they take it away and they change it with something else. A year and a half later person is in the community they are having another problem they get into the hospital. As soon as they get into the hospital what does the doctor do, Depakote trial and you wasted all of this time and money. That’s really required so as much information around the medicines and also response why would the medication change, very important.

This psychosocial masking, so as we do interviews obviously when you’re talking to people getting the information you like to establish eye contact. Again, if you don’t know Autism you’re going to get this kind of suspicious look, if you will. And so, that’s one of the things that is important for clinicians to know as well. You don’t need to establish eye contact in these stressed induced situations where you have self-talk or imaginary friends. Oftentimes that is misunderstood, as psychosis in a lot of people and it’s not at all if you understand the person. Actually therapy, there are a couple therapies for ASD that require or include self-talking. Jeffery Wood from UCLA has a program where they help de-escalate self-talk. If you’ve seen it from afar then you’d say this person is hallucinating. A couple of other things we’ll get into some of the diagnostic stuff here in a few minutes. So these people with developmental handicaps suffer a full range. They usually present as maladaptive and that’s an old term. It’s adaptive whatever it is. So if you’re saying aggression is maladaptive because the person is aggressive to get a movie or to go out to eat that’s adaptive. That’s adaptive for them. It works for them. So that term maladaptive is less used.

The acute psychiatric disorders can present this as acute agitation. I mentioned this before about the severity of the problem when talking about diagnostically relevant. It really requires us to get a lot more information about other things that are going on in a person’s life. We said about the clinical interview. Folks that have higher abilities clinical interview is very good. You can really do an accurate assessment. If you’re working with somebody that’s nonverbal significantly cognitively impaired it is much more of a challenge that’s why it requires a lot of support around that person.

Some of the questions you should be asking in terms of is there a mental health condition here is there a problem that we should be concerned about if there’s a change in the person’s mood. We’ll talk more about this as well. You got these general terms – mood, irritability. That’s what the psychiatrist and the mental field need, but what you need to do when you’re working with somebody is to define how is that expressed in that person so that you’re all speaking the same language.

So if you went into the office and somebody says rate the person’s mood. What do you say? They are happy, they are sad. But you want to make sure you express that, you know, silly laughter is an expression of a mood change. Isolating to your bedroom is a mood change in people. Not interested in preferred activities is a mood change for people. So those are things how you would be defining it and it has to be changed across all settings. So if you have, a concern or think about well this person has depression but when they go to work, they are great. They have a great time out in the community. When they come home, they are depressed. It doesn’t leave you when you walk out the door. If you’re depressed, that depression is going to be there. There’s going to be changes in your affect, how you look, and in also how you behave and interact with others.

Little or no improvement in the person’s behavior so your FBAs you do your Functional Behavioral Assessments. Somebody’s writing medicines for a particular intervention and the person isn’t getting better for whatever reason. Your best laid plans, your best observations, your interventions – the person is not responding to it. You have to step back take another look because you’re missing something with that particular person. You just can’t continue with the interventions.

We talk about this decrease in ADL. The decrease in Activity of Daily Living, so when we’re looking at most mental health conditions even kids, children, and adultescence. ADLS, sleeping, neurovegetative, and eating, sleeping, taking care of your needs are affected even at young ages. So again, we’re looking at that change in that person’s baseline in some way. Decrease involvement with others. These are obviously more of depressive symptoms. Losing interest there’s a term called Anhedonia - preferred activities, interest area.

I work with an adult that part of one of the presentations to determine depression was he would carry around scratch and sniff markers. He carried them around all day long. He draws, smell them and then all of a sudden he left them in his room, not interested in activities it just happened pretty quickly. Sleep became affected, eating. So we go back and look at well does anybody remember when that started. It’s just something that obvious because that’s part of the person – it’s just like getting dressed this is what I carry around it could be transitional objects. Those things are very important to look at, subtle signs of depression. Because here’s the thing, if you don’t observe these subtle signs early on they will get worse. You want to be able to identify we have a change in this person right now so we have to make some – at least keep a better eye on it.

Here are the more common types of psychiatric diagnosis. Depression and mood disorders, anxiety disorders, and OCD, Obsessive Compulsive Disorder falls under anxiety. Intermittent Explosive – you’re going to see, or at least I see, a lot of diagnosis for people who may have a sudden intense explosive behavior. They hit themselves or destroy property for some reason. They are going to get this even though they don’t meet criteria, full criteria, for the intermittent explosive disorder. It is because of that sudden increase and sudden explosive behavior that gets them that diagnosis.

Post-Traumatic Stress Disorder as we said something that you need to be aware of, assess, and then design trauma, formed therapy depending on what the trauma history is like. Adjustment Disorders, Psychotic Disorders. Schizophrenia and Autism is a low incidence actually. For some people, if you don’t understand it, recognize what delusions are or hallucinations you could be off and running very quickly with a schizophrenia diagnosis. Again, that patient population doesn’t improve or get better just with the medicines or even therapy. So you have to step back with that group.

And then our Personality Disorders, if you remember that all of the factors that go into some of the challenging behaviors. Personality Disorders are chronic conditions. You’re going to see these early on in life, so ASD is there. That’s the other thing we’re looking at schizophrenia. There are time periods where you will see the onset usually 19 to 21 is a timeframe you might see that. Autism is there early on so if you go back into the history and look and ask the questions you’ll see that even the rituals or preoccupation of passions sometimes are misunderstood as psychosis and they are not at all. We’ll talk more about that in a little bit.

When you look at this history, there are certain things happen along the trajectory lifespan. Personality Disorders are typically developed early on, early adolescence – eight, nine up to 15, 16. There’s a variety of them obviously. The ones I guess I see mostly are borderline personality disorders because these are folks that will cut themselves or have risk taking behavior. I have actually have seen people with Asperger’s and anti-social personality disorder. It’s just misdiagnosed not accurate.

Personal Disorders require some perspective taking, manipulation, control over others, using behaviors to gain access to things. Now, people on the spectrum will do that. But in terms of predicting how somebody will behave in a certain way, it’s just not part of that development. So when I see that I really ask the question, what are you doing with this? Usually, they are in individual or group therapy and it is disastrous not only for the therapist but for the group. Because when you’re in group therapy if you’ve ever been involved in group therapy you’re listening to someone. Listening to their experiences. You’re taking that and incorporating it into what your life is like and then you’re giving feedback. It’s a group process.

People on the Autism spectrum have difficulty doing that. They can’t share those experiences even positive ones. You know if you talk to somebody and tell them about your vacation. I was in Florida. Most of us when we say where I went on vacation well I was there I did this or did you go to this particular place. People on the Autism spectrum will tell you about the state how many people are in there but they won’t jump on and share that experience over time.

There are other medical conditions to be aware of any one of these believe it or not can present irritability. We look at hyperglyceridemia low blood sugars. We have some people that low blood sugars increased irritability, increased rituals, hand movements, and sometimes self-injurious behavior and it’s all related to low blood sugar. We know that because we can get blood levels and look at glucose levels correlating those and you just teach the person that here are the parameters. Take your glucose level and then have snacks available for you. There are easy ways. We’ll get into talking more about the interventions and I’ll open it up so we can talk about some of the cases that you might have as well. You just have to know that anyone of these really plays a role in behavior.

The Psychiatric Diagnosis and this is where we talk about Behavioral Equivalents. How do we begin to know that, some of the presenting concerns are related to a mental health condition? These are the areas that you want to address first. I mentioned neurovegetative that’s simply, yeah, eating and sleeping are affected. Again, related to your own life, if there are things that are bothering you, you’re stressed out, what do you do maybe you eat more or eat less, you have difficulty sleeping, your focused on something, right. So that affects so we ask those questions.

The affective part is very important. If you have a mental health condition, your affect is going to change. Affect simply is the way simply, it’s the way that you look. There’s used to be a term years ago, affective disorders. You know, if you live with someone, around someone for a long period of time, they come walking in the room and you can look at them they don’t have to say a word. Hey, what’s wrong? That’s affect. People with mental health conditions will change the way they look. Kids, more intense, more preoccupied, look like they are under stress. So those are things that are observable.

Cognitive areas, we’re talking about people – a lot of folks have cognitive impairments meaning that they are processing, the way they take in information, the way they understand it and how they give it back. The neurocognitive function is affective. We’re talking about people with neurological impairments whether you have 160 IQ or severely and profoundly intellectually disabled there’s a difficulty with processing information. Now, you add on top of that a depressive disorder or a mood problem that’s going to affect how information comes in.

We see people in the large hall that are artists over there and have headphones on, right. Major influences so there are environmental factors that are going to affect your processing as well. But these mental health conditions it’s going to affect concentration and memory. And we’ll talk about how do you know – what do you look at. Because what is important in that is you’ve got to know, what is the influence because you’re treatments, behavior programs, or support plans are going to be directly related to that?

Somebody who has higher abilities they may be on a self-assessment, self-monitoring program where others may need visuals to help them get through the day. They may need a Likert scale. They may need a pain scale to assess okay, how am I feeling today. So those when you get to the visuals even though somebody maybe of a higher level of intelligence they have difficulty with complex verbal information when they are depressed. They operate more with something that they can see – lower amount of information going in.

Perceptual that has to do with our psychosis. So if you have delusions or hallucinations. If you have delusions, there are germs on that food or that pink pill you’re trying to kill me with that. How many of you work with people with delusions, anybody? So you know what I’m talking about right, that’s perceptual. It looks okay to me. There’s nothing wrong with the food. Look, I’ll eat it. But actually, for somebody who is severely cognitively impaired, non-verbal how do you assess delusions in someone like that? You can if you know the person. They can be suspicious. They could be looking over their shoulders. They could be smelling their food. Again, these are changes in baseline now. They refuse to eat. So it’s separating the old factory stuff from actual perceptual things. You know the person you’re around them enough you’ll see this change then you begin to formulate again this diagnosis. And then we have our behaviors here.

Examples of some depression risk factors. If you think somebody’s depressed then you’re going to be asking some of these questions. The first thing is, is there a family history of this. Anybody else in the family has it. Loss of parent or loved ones, break up in relationships. So these are things that you would ask to determine. Again, it’s all based on when did these things start. For depression, you should have signs, neurovegetative, eating, and sleeping affect, mood changes within a solid week time period. One week that you would see this if you have these symptoms, you may qualify or it may be diagnosed with depressive disorder.

Depending on the level and ability of the person – they want to be alone all of a sudden. They don’t want to be around people. Stop talking to people that, Anhedonia, decreased interest in activities. How about increase in rituals, so somebody who may be ritualistic in anything that they do. Patterns of Behavior. You might see a significant increase in that, believe it or not, during a depressed state, during mania for sure. Or you may see a decrease in that. So you want an increase or decrease in any kind of ritualistic behavior.

Agitation, Irritability, remember I said those are kind of the psychiatrist and clinician terms. You want to make sure that you define that clearly and how is that expressed for that particular person and then crying episodes, welling up and crying.

So here’s how it might look, these are the behavior equivalents now. So when you got into the doctor’s office or when you’re presenting what’s irritability or depressed state. For this particular person it could be decreased smiling, whining, short fuse, negative responses, everything is just real quick. So you see this decreased interest. It’s called Anhedonia, right. These are people, not activities that all the sudden or they are less interested in those things that they used to like before.

Fixation on certain things, this particular I work with a fellow that was fixated on 125 pounds because his mother told him that was his best weight. He happened to binge and purge so that he would stay at 125 pounds. So that’s a fixated preoccupation and it was obviously a problem with the way he was eating and purging.

Sleep chart, we are going to talk about that. Whatever condition you’re working with you have to take sleep charts because sleep is affected in one-way on another. We’ll talk about how do you monitor that or how do you show your psychiatrist or your PCP that whatever anybody is doing whether it’s medicines or non-medicines has improved sleep.

These are other Depression – agitation, aggression, self-injury, increased verbal confrontations, pacing back and forth, verbalizing these rituals to do harm. Some people will say that I’m going to hit you. I’m going to hit myself. Negative – this is one that is challenging for me. Negative self-esteem. When you ask somebody on the Autism spectrum about self-esteem, it’s real difficult. What does low self-esteem mean? But in these cases, I hear things like I’m no good. I’m retarded. This woman, a 42-year-old woman with PDD that I work with anytime that she refers herself as a marshmallow there’s a major problem here. That’s the onset of depression. The reason for that, this goes back to high school. She was overweight and her classmates would call her marshmallow. So that negative experience from that far back until now when I hear it the radar goes up. We need to look at her more closely and making sure that we don’t see other signs or symptoms as well.

Failing grades, death, suicidal thoughts. How do we get that of somebody who has difficulty telling us? I don’t feel like living. I feel dead. I don’t feel alive. I want to be with my grandparents. You’ll see some of this discussion.

This is a woman in a residential program. She had Autism. She was 27, 27, right. This was handed to me by residential staff. So it says, hello this is here. She’s talking here. Some things that I should know. She’s passing it off to me. I feel really depressed and I want to kill myself – trying to attempt. She attempted, overdosed before, suicide again. She can’t handle herself here in this home – stay here it was in a residential program. I will try to kill myself again. I need to go to the hospital. I will get a steak knife and stab myself in the chest so I will not be on this earth anymore. I don’t belong on this earth anymore. I want to be dead. I want to be six foot under with my grandparents. You see the death wishes. She’s writing it. So hand it to a staff person and the staff person thought this was humorous believe it not. Didn’t take it seriously, even though there were these attempts at suicide before. She was somebody who went into the hospital immediately.

Anytime that we see this when we’re looking at people with suicide ideation – there are people that when they say suicidal ideation they will talk about killing themselves or hurting themselves but there isn’t a plan. This woman had a plan and she had a history of it. When you get that flavor, you don’t play around. You get the person to the hospital immediately. It’s just too much of a risk to look at.

This is another woman here. She was hallucinating. She was talking about feeling anxious about this other person – seeing people who aren’t there, so visual hallucinations. And then she also was both homicidal, wanted to kill people and suicidal. She had PDD (NOS). She also had a stroke early on in life. She’s hearing voices, seeing people who aren’t there. She’s going to kill her housemate by putting a pillow over her face. It’s for my eyes only. She’s very suicidal and homicidal. She also did some drawings as well.

You have to look at anything that the person produces. Again, more information this can help us, believe it or not, if she starts taking medicines we can see a reduction in some of the productions that she makes. These are referred to as permanent product, things that you can monitor over a period of time. So you see how this kind of goes along here.

This person here, Laura, she had a Psychotic Disorder (NOS). The reason for that is she’s hearing voices, seeing things that aren’t there. In this case, voices whispering to her that she’s not worth living and there are a lot of reasons that she feels this way.

Post Traumatic Distress Disorder, physical abuse growing up with family. She also had Mild Intellectual Disability. She had a stroke at 14 and seizures that followed that. Even though she’s diagnosed with PDD (NOS) she really doesn’t have – I felt that most of her concerns or issues are related to the stroke that she had when she was 14. Problems with school. She had these rapid changes in mood. She had self-injury. She would cut the back of her hands with a lot of things. She would get CDs, break them up, and cut them. She did it to feel alive. I feel numb. I have to do this to feel something. And then she had these homicidal thoughts. She attempted suicide by taking an overdose of her medications.

How many of you work with people who cut themselves in any way? So, you know what I’m talking about, right. Anybody who is self-injurious that has any self-injurious behavior the very first thing that you want to do is differentiate suicidal behavior from self-mutilation and self-injury. There is a difference in terms of how it looks the levity of what they do. Now, anybody can accidently kill themselves by some of things that they do, but there usually is a strong history. For this particular lady, she really because of the trauma, sexual abuse wanted to kill herself.

Here’s the plan, if we look at these again, presenting concerns, cutting the back of her hand. Again, the reason why based on her FBAs and interviewing her, I feel dead. I feel numb. I don’t feel alive. I don’t feel anything so I need to do this to feel something. When you get somebody that presents in that way, and we talk about all the different reasons an FBA on cutting yourself is going to have everything from anxiety, escape, attention, gaining access to tangibles. I don’t feel alive. So you have to narrow it down to that and then your treatments and therapies are going to be in line with how do we teach an alternative. How do we keep this person safe and not cutting?

We use these heat packs here. You can get them anywhere. For this particular young lady here, let me just differentiate a minute on this. We know she cuts because she doesn’t feel alive. There are people who cut because they are anxious. They’re overwhelmed with anxiety. When I cut, I just feel so good. I just feel relaxed.

How many of you work with people like that? Okay, so these are two different etiologies. The same treatments will not be effective for those. For somebody who’s anxious, you may have them again, according to their ability talk about what are levels of anxiety for you. What do you do at lower levels? What do you start to do when you get anxious? What do you do right before you cut? You can actually develop a Likert scale for that person zero to three, one to four, whatever it is. And then you’re going to associate or assign what you need to do at that level. When you start to get up and pace and perseverate here’s what you can do instead. But it requires you to work with that person first of all to identify it. We don’t assign what they feel like. They tell us. I always recommend if you’re working with somebody ask them, tell me what it’s like, can you draw it make a picture of it. Can you tell me exactly in your words – because a lot of times, we put words in somebody’s mouth and we try to design a plan? So that’s for somebody who is anxious.

For this young lady, she cuts to feel alive, so what we have to do for her we have to go to her and have her apply some stimulation and say, do you feel anything. So what we did heat pads – these are the goals of the plan. Reducing episodes of cutting the back of her hand, teaching her alternative ways to feel something. She was on anti-psychotic medications and antidepressants so SSRIs. But the anti-psychotic were for hallucinations.

Unidentified Speaker: Was there any consideration that she might possibly have bipolar disorder?

John McGonigle: Yeah, so here is what you have to think about on bipolar disorder especially with people with trauma histories, it’s often misdiagnosed so some of the things that she may be experiencing could be related to a flashback of some sort. It’s a great question because there’s mood – a change in mood. We know that people who have trauma – trauma affects every domain everyone including neuro. So if you look at the MRIs of the Magnetic Resonance of brain functions, a neurocognitive function of people that have trauma histories there’s a change in that. Even from a biological standpoint, but talk about relating to others. That’s something you would look at. You’d probably look at mania if you’re looking at mood disorder, right. You would look at that manic episode. We didn’t really see mania here. But that’s an excellent question. The other thing is if there is a trauma history, we have to separate that out as some of the stuff related to trauma. Does that help?

Unidentified Speaker: Yes.

John McGonigle: Counseling, trauma focus therapy, self-assessment, self-monitoring. What we did – see down here, we presented 9:00, 10:00 – we just had her check things off. Initially, we went to her. She applied the heat packs to the back of her hand. Do you feel something? Yes. What we did was self-assess, great. Keeping yourself healthy and safe. Way to go. We gave her a way to feel something. This is really the approach that we used here. The only other thing you have to be concerned about people have a stroke or psychotic, psychosis they may apply something and not feel it. So you have to ask the questions there as well. Well, why don’t you feel it? It could be something neurological or it could be psychosis as well. What we did, along with the medicines and the therapy we did the self-monitoring problem solving checklist. Very effective for this young lady.

This is Chris’s case. This fellow here, forty years old he is still a good friend of mine so Chris, Autism, long history of self-injurious behavior, destruction of property. This is the artwork. This is 11 x 18 blank piece of paper. Chris had OCD as well. He had these magic markers and he would beautifully spend weeks on doing these things. If you can see with the magic marker, the bricks look very similar. But Chris would destroy things. He also hallucinated. He had visual hallucinations. He’d be sitting in this room. He would find the light switches – he would look at the light switches or at home, in the bathroom plumbing, he would see behind the walls. This is basically, what he did. He would look behind the walls and he would destroy – he would break holes in the walls and he would go from the light switch all the way up to the ceiling and just bust things open. That’s what he did on these visual hallucinations.

When he’s in his good state this is what he does he draws. However, when he’s having difficulties this is the first thing that he does, he gets this artwork that he spends a lot of time on. He becomes – this is depressed state, increased in irritability and depression so you start to see these cracks. That tells us there are things that we need to be concerned with usually when you see this he is hallucinating more. We know this now. Before we didn’t, so we needed data to tell us this.

This is data. We talk about evidence based. You don’t have to go to the literature and research to say evidence based. This is evidence based. If you know the person, you’re frequency counts or your permanent products or whatever anybody is doing is evidence based. When we don’t see it – when he’s in good shape this is what he does. Once he does this, this is evidence for us that we need to do something more.

Let me show you this, so you can use this form. You can make this up very easily. I call it symptoms ratings. If you have somebody who has symptoms that are being treated by medicines, see the symptoms on the left-hand side. This was for Chris here. I have a rubric down here. You can talk to the staff or family. A family member can simply talk about okay, is it high, and is it low. If you look here not observed zero all the way up to always, more than 10 times per day. This fellow is in a residential program. It’s easy enough for staff to monitor and track.

And then the way this form works we can do it across a whole week. We can look at increases in talking to himself. It correlates with distress and an increase in property damage and that’s what we looked at. So you get an idea. This is how it is graphed. You can get a day. You can monitor and track over time. See that bottom, two, two, four, eight, six and it’s going up so we know there’s a problem here. When you put it on the graph, it is varying enough to see the trend is up. You have to do something at day three or five because he’s just escalating to a point where he does this. So this is his worse. He takes his work and just destroys it and that’s when he’s in the hospital. We don’t let him get to that point anymore. We can tell when he starts to do some of these things and he has back slides every once in a while, but not to the point where he has to be hospitalized.

This is Chris we just talked about him. Here’s what we did with him. Autism, Psychotic Disorder, remember seeing behind the walls. He had anxiety and OCD. He had mild ID. I think probably 60, 55 or 60 score on IQ test and he had problems at the day program. Chris is presenting concerns. I call it x-ray vision. He can see behind walls. Property Destruction, we talked about that. His interest area – Chris was OCD, preoccupied by a number of things. He loved music and watched game shows. He would sit there and catalog the answers. Again, in his good state, he would do that. Wheel of Fortune was his favorite. He liked Kenny Rogers. With that, we said, okay, how can we – anytime that you’re looking at assessments you are going to look at interests, preferred activities, passions because you can use some of those actually for incentives or rewards.

Here’s what we did medications to treat the hallucinations and OCD. He had an antipsychotic on board and then Celexa I believe was the one. It was an anti-depressant but also has benefit for Obsessive Compulsive Disorder. Intervention, we taught him alternatives to the destruction of property, I’ll mention that in a minute. He became maintenance. So part of the residential staff, instead of, we know what the problems are, so we were trying to teach him to respect the property or keep it in good shape. What we did with him is he became a part of the crew that went around all the residential programs. His job was to check the windows. Make sure the plumbing was okay. Fire extinguishers, a lot of different things and he actually had a checklist. We went with his cataloging. We said okay, here’s the alternative, respect the property, and check it off. And then also, he got real pay. He was part of the staff so he got paid for it. It all worked together for him and that was the intervention for Chris. He still has difficulty but doesn’t destroy property. We can identify it a lot earlier now.

Mania, these are things you would look at for somebody who has a manic episode. Again, this is a change in mood. It’s a difference in the baseline of the person. As you see, it could be a lot of different things – deflated self-esteem. What you have to be able to do though is differentiate passions, knowledge of a particular area, interest area, astrophysics, computer technology. If you don’t understand that this is a passion area, it can often be misunderstood as psychosis in some people that you’re delusional in some way and it’s not.

To differentiate these just so you know, delusions are unwanted in most cases, hallucinations and delusions are unwanted thoughts. You want to get rid of them. They are negative thoughts. Passions aren’t – people are going to tell you about everything they know about that area. It’s a preferred activity. It’s something that they like. So you begin to look at the differences between those. At least when I’m looking at passions and people are delusional. Now, there are some people who are delusional like somebody who thought they were Michael Jackson or somebody who was a volunteer fire, not volunteer, but he would hang around the fire station. All of a sudden, he started to get uniforms, be around the fire station a lot. He really took on that role, which is a problem. There’s a point so what point does it become something that needs to be treated. That’s I guess, a big thing to look at because everything doesn’t need to be treated, right. So if the person can get through their day even though they need be obsessional in some ways. They could even be delusional to some degree, but if they can get through the day then it’s not a problem. It’s when those symptoms or behaviors interfere which is getting through the day that somebody has to do something about it. You can read these along the way. Mania, disorganized thoughts, requests.

For the hypersexuality part, so this is mania, full blown manic episodes for people who are not on the spectrum. Maybe they’ll tell you about their interest in having sex with people, increase in exposing, disrobing. For the group that we’re talking about you may see an increase in masterbational, rectal digging, smearing, and those kinds of things all of a sudden now. Along with, decreased sleep, silliness, laughing, so when you get those things together then you might be looking at a manic episode a change in mood and that might need treatment.

Here’s how you monitor and track, you can use this scale very easily. So if you have somebody who has a mood disorder, bipolar disorders use this form. When we talk about bipolar, you see this, these mood swings here right, and we have ups and downs. Bipolar disorder, up here it’s a bit stream mania and then you have these depressive episodes. You may have a period of wellness in between. It’s different for everybody. But the point of this is there is a cycle here. In this particular case, it’s about a week cycle mania and then four or five days depression and then we’re mania again. You can monitor and track these by simply circling this on a daily basis.

Let me give you a better idea of how this looks here. This is a fellow I worked with. Again, this scale is easy enough to make. So for Bobby, we have mania. He’s activated. He’s hypervigilant attending to the task. More perspective on things. That’s on the manic state. He’s laughing, playful, swearing wants to be around people as you see. He also has these brief shut downs where he just – it’s not a seizure, but he just kind of shuts down and doesn’t respond. And then that’s offset.

Do you see this depressed state? So, staying in rooms, swearing, aggression, destruction of property, non-compliance, shut downs are a lot longer. These are two very clear distingue mood changes in Bobby. We monitor and track this. Again, you’re going to have this rating here. Most of his stuff is on the manic side. We have a couple of days where there is some depression but mainly it’s on the manic side.

Now, when medicines are given, just so you know and when medicines are given it doesn’t eliminate bipolar. It doesn’t cure it. So, what it is going to do it’s going to make those mood swings closer to a baseline. You’re still going to have them but they won’t be extreme so that’s going to help your psychiatrist or PCP whoever is writing the order. You are still going to see swings but they’ll be much easier to redirect, get through the day. You can see a response to that.

Sleep charts so here’s our sleep chart. I can’t say enough about any mental health condition. You want to do a sleep record in some way. You can do this if you’re in a residential program 24/7, obviously you can do 24/7 observation. But if you can’t – some people can self-report as well. If you’re living at home, you have a family member, if you can sometimes eyeball brief time periods. You don’t need a whole lot of time, but you’ll see that it’s simply awake and sleep. As somebody who maybe increasing or decreasing in their hours of sleep. Again, that’s important information for the psychiatrist or whoever is writing medicines for sleep. This is the data here. I can very simply say see that dates from sixth to the eleventh, the person is getting almost no sleep.

How many of you have worked with somebody who hasn’t slept for like, four days? Yeah, right. You need to be in the hospital immediately really if they don’t sleep. Severe mental health problems going on at that point in time unless there is a medical condition. But this is how you’re going to help. So if somebody is on Trazodone or some kind of, if you start your sleep whether it’s supplements or Trazodone you can monitor and track that.

Okay, excessive compulsive, these are general terms so these would fall under the anxiety categories and they are people who are obsessed. Here you’ll see in a form right after our break differentiating stereotypy, self-stimulation, repetitive motor movements from OCD because they can look the same believe it or. It’s how that person reacts to when you either prevent it or re-direct it. So even though it might be a motor activity if you stop it in any way you might see an increase in anxiety or aggression. If it’s self-stim or stereotypy, it is going to go to a different mode of stimulation.

However, if it is OCD you do this, you redirect it, and that person has to get back to that same preferred stimulation. And if not, they may go to this stuff or go to grabbing you. It’s underlying anxiety that is a problem there. You’ll see a formula later when you look at self-stim behaviors how do you begin to separate that because that may need medicines. Maybe not, but that’s how you would look at that.

But obsessive compulsive, two things – there are obsessions that’s the thought, right. For a lot of us older folks when they had records you’d have this groove that keeps on going around. So it’s in the groove. You just obsess over and over. We all have these obsessional thoughts but most of us again, get through the day. You’re driving to work and say oh god did I turn the stove off this morning. You get five miles into work and you have to drive back. That’s a problem at that point. But the obsessions are the thought processes over and over again.

The compulsion is the action parts. It’s your thoughts saying you have to do it this way, it has to finish this way, and I need to get through this ritual. The compulsion part is actually acting on that. So you can have a problem with just one or both of them as well.

Here’s a form here that I use. You can make this up very easily in your residential program. If you’re looking at OCD, Obsessive Compulsive Behaviors for this particular guy here – barking, spitting, he was aggressive and slamming doors. So if you see that scale down here, we have C for Constant, 20 or more times during this time period here. You want to make sure, if you’re observing OCD you want to get blocks of time during the day where you can observe at different settings, different situations whether it’s work, free time, or out at an activity.

And then obviously, when medicines are given – this is to help to determine is medicines effective or not. We go from constant what you would see overtime is these behaviors that are constant, medication starts, and then they would go down to sometimes or not observed at all. Very easy to do, but the point I want to make with this you can identify the behaviors whatever you’re looking at as being obsessions or compulsions and then get blocks of times during the day, a brief time period where somebody can actually take the time, sit down, and monitor and track that.

This is the OCD. We’re looking at this. This fellow here, Aaron, Autism, OCD, severe intellectually disabled. This was really ritualistic. He was in a residential RTF program. He would come running out of his room and he would just start flipping furniture over around the whole residential area. He would just come out. It would be unpredictable. Never knew when it was going to happen. Come out and just flip things over. The other thing he liked to do was – he’s a tall fellow. He’d like to get himself into small places, so he would crawl under the sink and there were pipes that were under there. But he would just kind of just go in there just interesting to see. He was obviously, pretty sensory involved. So we observed this, FBA, tell me how it looks. There was a consistent pattern to this. He came out of his room and he would go around the facility, but it was ritualistic and then back into his room.

We looked at what his interest area is, old factory, he liked some deep pressure. The staff would give him kind of deep pressure rubs his back things like that. So what we did we got one of these kinds of balls that –.

Unidentified Speaker: Busy balls.

John McGonigle: What are they called?

Unidentified Speaker: My daughter had one.

John McGonigle: Yeah, I don’t know if that one lit up or something. We also had a vanilla smell to it as well because of the old factory. What we did was had a staff person outside of the room and as soon as he came out of the room we handed him the ball. It took a little bit of time to redirect him. Got the ball and was stimulation, he would smell it. And then they redirected him to sit down and the staff would just – the back of his shoulders.

When we’re looking at OCD, for you behavior analysts, when you’re looking at OCD, they are like links in a chain. When you see the whole ritual, they just don’t – somebody just doesn’t wake up to do that. These are built over a period of time whether they are mouthing, flicking things, ritualistic. They are built over a period of time. So look at the whole pattern of behavior. And then what you’re going to do is it’s kind of breaking the link in a chain. You want to try and start at the first part of it. There are some folks that will do an intervention that we’ll you’re not going to do that anymore. Starting on Monday, we’re not going to make that happen. So you just stop it and that makes obviously the problem worse. Increase in anxiety, aggression. And then you’re going to look is there any other thing you can, again, put into the links of the chain.

A fellow at school, this is in an educational program, one floor school probably about 10 different rooms. This little kido would come in and he’d go up against the door and click the back of his heels against the door. Would go to every door and then make sure the door was closed before he could go in and sit down so we’d look at that pattern. He would end up in the principal’s office as well and close her door. So we said okay, how can we make that OCD more functional and that’s what you want to be able to do. The OCD behaviors aren’t all bad. Can you make them more functional? For this guy here, we had the teachers put the class roles out on the back of the door so there are little bins that go on the door. We taught him he could get his ritual, take the class role, go to the next door, go to the next door, and he ends up in the principal’s office and puts them in on the desk. He still did his rituals but it was more functional for him.

It’s just like Chris if you remember, Chris who broke all the pipes. We made that more specific to what his interests were.

Unidentified Speaker: I’m just curious if you have any language to be sharing with the parent because the struggle I have is of course, with the parents who want to end it. They don’t understand that [indiscernible].

John McGonigle: Yeah.

Unidentified Speaker: I just wondered if you have any sort of tips for how to sell to the parents that we just – that making it more functional is still positive – enough it’s a positive thing and that need it.

John McGonigle: Yeah, well, I think one of the things you have to address is how much time it takes your son or daughter – how much time does it take to get them out from wherever they are, right. You are going to save time again when you’re making it more functional as well. This is something that somebody can use possibly depending on the behavior or the ritual. Is there something that is productive? Baseball cards, I’ll give you a great example did a teacher training. So I school this kido with rituals. He would do, make lists, he got into baseball cards, right. So we got him into baseball cards, checking things off. So I saw this teacher like, fifteen years later. The parents have a problem because he was making these lists all the time. But we taught him to get into buying these cards, cataloging them and so after a period of time these are very valuable cards now. This teacher said he’s still collecting them. I mean it’s a way that you can say, you know, can this person use this in life whatever it is. I don’t think there isn’t a ritual that you can’t look at and make it functional in some way. So selling it to the parents would be the amount of time that’s taking to do that. It’s typically a non-functional activity, right, if we’re talking about most rituals. There’s no benefit to that person, so you have to look at the ritual, and what is it that you can direct that to.

Unidentified Speaker: Yes, I understand that but sort of like, how do you communicate to the parents that the ritual – how do you communicate to the parents that a ritual does have a function for them? I get what you’re saying about making it more functional. But I feel as though the parents just want them all eliminated completely and do not see that they are part – I always use the word, how these kids or adults are wired, and necessary for them. I always argue let you kid go home and be Autistic for an hour. They don’t get to be Autistic all day. I have a hard time helping them to understand how necessary that is.

John McGonigle: Again, looking at the rituals a person is engaging because there’s a need, a drive, to do that. That won’t change unless there is an alternative to that. I guess the first question is, how much does it interfere with that person’s life throughout the day. Most of us have rituals that we get through and we’re good, right. So if it’s bothering somebody is it a problem for the parent or the kid. We said you can’t just stop it. This is something that the person is engaged in its part of their day. So just saying no, you can’t do that unless you have something else they can go to and if it’s an OCD if it’s anxiety driven when you stop it you’re going to have a much bigger problem so that’s going to increase to aggression, self-injury. You can find that out to say is it OCD related or is this self- stimulation, ritualistic, provides sensory input to the kid or to the person.

Unidentified Speaker: Do you have any suggestions for a quick read or something for them to get to the depth of OCD. We try to explain it but we only have an hour.

John McGonigle: Yeah, let me just go to a couple of the forms here. Let me see if I can get to, okay, so this is a form here that you can use. You probably have seen this. You’re going to ask the question on the behavior, whatever it is that they are doing that’s your behavior analysis. This is how it’s expressed. Then you’re going to begin to ask these questions, what important things are in terms of OCD and stereotypy. You want to be able to separate those. You’re going to find out when do they occur, who’s around, what activity because those behaviors are going to be increased and decreased in different situations.

First of all, you want to find out when they are occurring, when they are the highest rate. The other very important thing in any behavior is asking the question when don’t they occur. We know behavior serves a purpose or function they’re a reason for all behavior. So when the behaviors are not occurring maybe this is a thing that you look for as a parent, we don’t ever see this ritual or behavior during these time periods. That means that every motivation for that kido to engage in that behavior is being met whether it’s the environment, activity. Maybe that’s a starting point. You say hey, he doesn’t do it when he does fine motor activities. Just an example, the rituals are hand flapping, so when I get my hands busy then that solves the problem.

Another great example, classroom, hand flapping. What we did for this kido he had an interest in mountains and scenery. This kido would – hand flapping. You’d go in a room and you’d see it going a mile a minute. We actually, simply just got him a view master with these scenes of Painted Desert and all these things. So he’s in the classroom during free time. He’s in the classroom, he’s going a mile a minute with it for stimulation, but the point is its okay. It’s a replacement. He’s still engaging in the behavior.

These are kinds of things to look at so differentiating stereotypies from self-stim is that underlying anxiety. You interrupt and redirect. They have to get back to the same way. As I said earlier in the presentation, for self-stimulation you can replace that. I can replace this with this, head weaving, or something else. For OCD, you won’t it will go back to that same exact way that they have to do it. And that’s when you say okay when we interrupt and redirect that, prevent that does it go through the roof we have bigger problems. Even in that case, does it rise to the level where medicines might be helpful? But when you’re talking to a parent, I would address again these, tell me when he does it, where does he do it the most or where he doesn’t do it. Maybe when he’s not doing it may be increasing that activity or increasing that, you know, whatever he’s doing at that time period. Data for the parents is like anything else how often does it happen, you know, and then looking at okay, doing it less. But you have to replace it with something. You really do and it’s finding out that replacement behavior. That’s again, the ritualistic part of it. Is that helpful?

Let’s get into this fairly quickly. I’d really like to take the time to get more questions. Here’s a form that really should be done at any time. All of this stuff is very important because we know we have some behaviors that are specific to a person, an activity.

This one here, to get through this pretty quickly, I just pulled data out, so this kido here, has head hitting. He bites his hand, bites his finger, and hits the side of his head. When we look at this information here, he’s in school. He’s with his teacher. Here the first line there, art class. The teacher presented him with materials. He started to hit his head. The teacher takes the materials away. What happens to the behavior? The behavior goes away. This next one, he’s sitting at a desk. Pegs in a pegboard come out. The kid sees the pegs. Starts to bite his hand. The teacher comforts the student. Pegs go away, his behavior stops. Home, TSS worker going on outing. He was asked to tie his shoes and he bites his finger. A worker ties his shoes. Finger biting stops. And the last one, bedtime, mom, and dad putting on PJs, cues, head butting, mom helps, and behavior stops.

This is pretty clear, right, very clear, escape, but take a look at this data there’s something else that’s important in this information here. Is there anything that you need to look more closely?

Unidentified Speaker: He’s getting help every time [indiscernible] for help.

John McGonigle: That’s correct, but is it specific to anything – specific area?

Unidentified Speaker: Fine motor.

John McGonigle: Fine motor areas, that’s correct because he’s not doing it any other time period. What do you do? You don’t give him fine motor actions, no. You’re going to work on the fine motor area. That’s kind of an example of how this would present in somebody. Self-stim, we talked about this. The only thing you need to know about self-stim are typically we get reinforced through all of our senses. So that’s why you see kids, people engaging in stereotypies with their whole body, head, hair, down to the toes, sensory, so whatever it is auditory, visual, tactile, vestibular, walking. So it’s sensory input. We have to take a look at that.

In terms of what works for this, you see here interruption, redirection it will stop for a minute and they go back to it. So self-stim you can replace it as I said before this is not ritualistic. This isn’t OCD. The OCD part is if we interrupted and redirected them this loud humming then it would go up, it would increase in either aggression or disruptive behavior. So that’s specific to self-stimulation.

Here’s anxiety, so people are anxious. Anxieties are a problem here. These are the expression depending on who you’re working with and what level of ability of the person so that’s how it works. We spend so much time chasing this without really looking at the underlying etiology. We may be very effective in reducing – somebody has social anxiety. They are aggressive in a group, a social skills group, and we do something that’s unpleasant to that person remove them and they really want to be in it. That’s overwhelming for that person, right. That aggression is going to go away but it’s not going to solve your problem the anxiety is still there. So what can happen for some folks is that they may be in your group or sessions and instead of hitting, they are going to hurt themselves. It shifts. But we have to identify the underlying etiology.

Pain is another area. A lot of pain assessment. So we’re talking about probably folks that unable to tell you so either observers or pain scales. You could do if you look up there is pain assessment for non-verbal, folks that are non-verbal, people with dementia. There are rating scales that you can observe and see that somebody’s in pain. Again, self-injury is the end result. When you see a behavior, it’s the end result of something. A lot of things have occurred.

For this particular case, the person may be irritable they wanted something, denied request, so they hit themselves. The one over there isolated they are by themselves away from the group. They are asked to participate. They yell and scream. The point of doing any kind of assessment for people who are non-verbal you really have to take a look at that. So these assessments look at everything. Facial, how a person sits, vocal, whining, and again these are changes in the baseline from someone. Any one of these areas would indicate some kind of pain.

Seizures, right, we talk about how many of you have worked with people that have some type of seizure disorder. There are folks believe it or not who have aggression, irritability, disruption as an expression of the seizure. Temporal lobe, epilepsy, partial complex seizures they are not full-blown tonic-clonic seizures. They happen in the temporal lobe, deep down inside the brain irritability, but they’re seizures.

Does anybody work with anybody that had behaviors related to a seizure disorder, anybody here at all? So sometimes, they are grabbing on, clenching teeth, holding real tight, but these are seizures. It’s real important to monitor and track those. These are just some of the expressions of people who may have seizures. These are the types. You’re going to see these in Simple Partial and Complex Partial. They used to be called psychomotor seizures or Temporal Lobe.

The important thing as you’re identifying and looking at these is to differentiate tics from stereotypies real important. We know that tics as we look here. These are these brief, short, intermittent. And when you see behaviors related to seizures, you’re going to see tic behavior in a lot of ways – forehead creasing, snorting, grabbing, clenching teeth. Those are the involuntary movements. Different from cell stem or fluid there’s no premonition. They just keep on going they feel good. But in these cases when you talk to people who have tics or seizure related tics they’ll tell you exactly what it feels like. But it’s important to differentiate those. These are more meaningful to other problems that somebody might have.

Here’s the so this is temporal lobe epilepsy. I pulled out some data and information there was a lot more. This is a kid with his parents. He’s in his bedroom alone, rocking. He screams and does this. He screams and holds his head. And then there are other time periods where he bites his lip. He’ll bite sometimes through his – he has in the past, bit through the lip. Alone, bedtime, rocking, screams, hold head nothing, stopped in two minutes. Nobody did anything, so it stops.

This one here, they are in the living room watching TV, nothing observed. He screams, holds his head. Interrupted and redirected it stops in one minute.

Mall out shopping, out of the clear blue they run to an area of the mall that’s quite, and then he stops in three minutes.

The whole point of this, they run a course so for adults believe it or not this looks like an intermittent explosive disorder in some cases because they come in patterns. You can’t predict it. You’ll see two in May and then a couple in August. When you have patterns of these time periods, brief, intense episodes and if there are these involuntary movements during them, you might be dealing more with a seizure disorder than an impulse or intermittent explosive disorder. You have to look closely though because they are seizures they will run a course.

This is a fellow that I worked with it’s a self-portrait. He was on anti-psychotic medications because he was psychotic. He was hearing voices in his head. So I said tell me what it’s like and this was periodic. This is what he describes the feeling, his eyes are twitching, and he’s feeling sad, affective changes, talking things in his head. And it has a funny smell. To me, that was a trigger that there’s something else going on. The funny smell for him was like, onions but they all tied together. So when you have these symptoms that tie together then again we’re looking closely at seizure. That’s what he had a seizure disorder. It was an epileptic psychosis. He didn’t need anti-psychotic medications. He just needed an anti-convulsive medication.

GI problems we said, low blood sugars I mentioned that before. As we’re looking at etiologies for some of these behaviors you got to look across all of these areas from the biological genetic side, somebody is hungry, thirsty, medical, and psychiatric. These are things that you’ll be looking more closely at when you’re trying to differentiate some of the behaviors.

I am going to run back to a couple of things here because I think this is critical. We don’t have to spend much time on functional behavioral assessments, but we just talked a little bit about how to differentiate. I want to talk about processing. Processing is very important from a couple of standpoints. Remember what I said mental health conditions influence processing. Not only that, we’re talking about people who have some processing deficits regardless of your cognitive ability organization, executive functioning, abstracting, sequencing, problem solving is concern or an issue.

When we talk about processing this is the neurocognitive stuff input, the information goes in. Your brain is off and you’ll hear it. It’s equated – it’s like computers information goes in, you store it, a lot of information and then you pull it out when you need it. When you have a mental health condition even mild depression, it’s going to affect inputs, right. I mentioned earlier in the presentation if you experience mild depression you’re going to be focused on what you’re worried about, preoccupied with it. So that information is going to be limited in terms of going in. Processing, if you have delusions, hallucinations, thought distortion that’s going to be atypical. The information may get in but it’s skewed towards delusional thinking, not real, false belief whether it’s true or real that output is going to be atypical because it’s false belief. These three areas we have to take a look at.

What blocks? Things that block input – fatigue, stress, rituals, noise. All of these are going to influence how much information gets in. Again, when we’re working with somebody or doing programs or therapies, we have to make sure how do they take in information? How much can they take in at one time? Can you multitask, problem solve? We look at all of these and try to reduce some of this.

Here’s a good example, you may have seen this in our 101s, and somewhere you had to see this. This is perception. Everybody is seeing the same thing. Everybody sees this picture. By a show of hands, how many of you see an old woman? How come half the room raised their hand? How many of you see a young woman? See they are both up there, right. And so, that’s how you perceive. So people that are delusional they hallucinate it’s important to go the extra mile and ask them what are the expectations? What do you see? What’s your plan today so that you can provide that feedback to them? This just talks about how the person perceives.

This is problem solving again, which is if you have Autism it’s a challenge. Multitasking, problem solving we need. Actually, we need our working memories to problem solve. That’s how we get out of jams. We’re confronted with unpleasant situations we think quickly on what we need to do to get out of this and we use it in this way. See this reservoir that’s actually a reservoir. Here’s where it equates to computers in your RAM.

Your working memory by definition is how many bits of information can you hold in your head at one time before you become on overload. Once you become on overload too much information – I see a lot of faces that have that right now. It’s like, you know, enough already. This is very important when we’re working with people who are upset, angry, escalating, yelling, and screaming and we’re giving verbal directions. You need to calm down, take it easy. It becomes overwhelming and that’s when you get that explosive kind of behavior. So this reservoir simply tells us how information can they take in, when are they on overload, at what point?

So that’s going to help us in terms of whatever program, you know, the self-assessment, verbal escalation because once they get on overload it’s too much. But we need our working memory to problem solve. The way it works, we’re in a jam. You may be getting reprimanded by your boss or someone. You’re sitting there listening to these things about your performance and you’re upset but what do we do. Even know we’re mad we have the ability to keep a lid on that internal level of arousal and choose our words so we don’t get fired because we do this quickly in our head. I’ve been in this situation before. I know someone who did this. This is what they said. This is what they did and it worked for them. We do it that quickly, so I’m slowing it down a lot. Think about the difficulty that somebody would have that has difficulty with that multitasking.

Here are the areas that need to be addressed. I call it an internal level of arousal when somebody is mad you know when you get that knot in your stomach – you hear or somebody says something you get that – you can feel it. For a lot of the folks that we work with they have difficulty with keeping that down. It just takes a life of its own. The more you think about it. And think about your situation if something is bothering you sometimes the more you think about it, what happens? You get fired up more. It’s really important for us to recognize that. Try to give interventions – relaxation, anger management, verbal, visual, escalation whether you’re working with different populations. A way to keep that level of arousal at lower rates, so we focus on this. And so, why wouldn’t people follow your directions the output part that’s the last part. Information goes in and we understand it. Perceive it, why wouldn’t somebody follow our direction.

These are some of the other things, first of all, value. Even in your treatment plans if you’re a clinician or a therapist. There are often times where I meet with people who have been in treatment for a long time. I say, tell me is your treatment plan working. They say I don’t know. Well, ask the questions. What are you working on? If I am getting better, how would I be able to determine that? If you look at your treatment plan or whatever you call it, ISPs, making sure that your person is in their language in their words. When I see some of these treatment plans, you can see there is no input from the person being served. It’s just general stuff.

So make sure that that person has input in their words how we’re going to work on that and also, how do they know that they’re getting better. How do they know that the medicines are working? I’ve been in therapy for seven years and I don’t know if it’s working or not. You should be able to determine that in some way, so value, interests.

This is the impulsivity part. Do you see over on that far right-hand side, the output part?

Unidentified Speaker: I was just wondering if there’s a way to work with our non-verbal kidos to get them engaged in the treatment planning process.

John McGonigle: Sure, you could work with any level, any ability. First of all, it’s identified by a problem or a concern if somebody is aggressive or destruction of property. You could have a picture of a chair with a cross through it no throwing chairs. That gets onto the treatment plan. So any visuals that you can use to help that person understand that’s what we’re focusing in on, right. We taught preschoolers to self-assessments, self-manage. So preschoolers if you work in the school districts most of the teachers spend most of their time in the bathroom and changing, right, there’s little opportunity to do anything. So we set up a program where we have a bell that was on the teacher’s desk. We taught the kids that when the activity is over, go to their cubbies, put their stuff away, and when they are finished come up and ring the bell and then they get a reward for that. So we took a lot of bathroom time and transitioned time and these are just preschool kids and limited abilities as well. But they learned to be able to do that. Not that we taught them to assess themselves in terms of I’m using less time, but the point of that is you can tie anybody into a treatment plan make sure they understand what they’re doing.

Unidentified Speaker: Well, [indiscernible] when we’re writing treatment plan, when we’re coming up with those goals and what the family wants to work on, how can we include those other kids on what’s important to you and how we work – like, what do you want?

John McGonigle: Yeah, it’s like any treatment plan you’re going to get information from everyone, right. It’s a perspective that everybody has on this particular person so you need it from all – family as much as the person can give you in terms of what they can express. And then in the treatment plan is there some way if they can’t talk is there some way that not only can they visualize this is what we’re working on but is there some way for them to know that they’re not having the problem or that they’re making any gains. Give me an example when you say non-verbal.

Unidentified Speaker: I’m just saying when I talk like, when I’m working with some families and I’m working with a 12 year old non-verbal Autistic child and we’re sitting there well what are your goals and treatment? Well, they are not going to be able to answer that question. How can we make it so that we can ask that question when we’re working with something they care about?

John McGonigle: Yeah, would they be able to ask, I don’t know, would you be able to say, what makes you happy? If you said what do you like to do? Those are incompatible with your problems so if you focus on maybe asking them showing peers that that means when they’re engaged in those preferred activities they’re having less problems maybe. You might want to start from that point not just well, here are your problems, but maybe there’s a way that you can indirectly get to hey if you’re doing more of this stuff that you like then you’ll be doing better. Visuals it goes without saying, visuals are critical. Try to think of other ways that you can tie somebody into their treatment plan. That’s at least a starting point. I know it’s a challenge, but how do you get to somebody – when you’re talking about what makes you happy or the feelings part maybe family and the person may be able to be a little quicker. Instead of saying let’s get a treatment goal for you. Do you know what I’m saying, does that make sense.

Unidentified Speaker: Yes.

John McGonigle: Here, just quickly on this, on that output side, the behaviors if you have anybody that you’re working with that’s kind of explosive, impulsive. When you see, a behavior it’s the end result of some stuff happened, so it’s the end thing that happened. A lot of times when people have this impulsivity or this explosive out of the clear blue, the treatment happens on that behavior side and for people have impulse control, difficulties it’s after the fact. You know, just ask some people that are incarcerated for some of the things that they do to teach them don’t do that. It’s after the fact. When you’re working with somebody, you really have to look at the whole picture.

The input side, setting, events, what people are asking you to do, the people that are around you, and this internal – I refer to it always internal level of arousal. That’s the best way for me to describe it. It varies every day across us as well. You can get a phone call from one of your clients it’s an emergency and then what happens to your level of arousal. It goes through the roof. Then you have to figure out how do I get help, support. Our folks have difficulty doing that. This is the accommodation side. This is the prevention side. We know any one of these things can lead – I’m sitting next to this guy that I just can’t tolerate and every time I sit with him, I have to hit him. So you’re going to adapt and modify on that front side.

The thoughts and perceptions remember what we said to make sure they’re clear, make sure there are no interference there – true and clear thoughts. And then you see these thoughts and perceptions at emotion. For every thought and perception, whether we perceive it accurately or not there is an emotion that’s attached to that and we behave on that emotion. We say or do something on it. How many times have we been in family situations or situations where we see something, misperceive it, and say something, and then it’s like I wish – I shouldn’t have said that. I wish I could take that back. So that’s a misperception. That’s the emotion that drove us to say or do something.

Somebody who has these impulse control difficulties on the front side, make sure everything is clear – settings, preferred activities, visuals whatever it is that helps that person. Make sure thoughts and perceptions are clear for people who can tell you hey yeah, I understand. I know what are the expectations. This is what we’re doing. That emotion is a vulnerability. That’s our job. Our job is really to help that person when they become upset to give them the tools to keep a lid on that arousal because if you don’t as it increases, you don’t have to have Autism, the more upset and angry you get the more likely you’re going to say or do something impulsively. We need to give the tools to keep that at lower rates. If we’re good at that, we won’t even see that end result.

Okay, we’re not going to do functional behavioral assessments we already talked about that because I do want to leave some time here, so the only other things that we were going to talk about here, interventions. The interventions for persons with co-occurring mental health conditions are referred to as the Bio-Psycho-Social Model. Biological includes medicines. It’s biological treatment. Biological is genetics as well.

Psychological we have to understand the development of that person over time, the psychopathology their experiences in life does that have an influence. Do we need individual therapy or a specific type of therapy, trauma therapy depending on that experience? And then the social areas because a lot of the behaviors – a lot of the difficulties are observed in the social context – the social interaction with others, so that may need social skills or social supports. And then we operate under this recovery model, self-determination.

Best practice models have this for ASD. Bio-Psycho-Social Model obviously generalization of these programs, so whatever you’re doing. If you’re a therapist working in an office, working on relaxation, anger management, and self-assessment you got to make sure whatever you are doing when that person leaves your clinic and goes into the community make sure they can use that skill. If you work in a vacuum, you do something very unique in your office and nobody else does it then it’s not worth doing. It’s not going to help the person at all, so make sure it generalizes.

Applied Behavior Analytical approach, ABA approach not specific treatments there are a lot of ABA treatments – Lovaas, discrete trial, and contingency management. I’m talking about the analytic approach and simply what that is and it’s real important to have this. It always starts with the baseline. You got some information, baseline assessment on a person, behavior, cognitive, whatever it is and then the important part is systematic implementation of your treatments so whether using supplements or biomedical if it’s systematically implemented medicines and therapy that’s great. You don’t want to do two or three things at one time. You don’t want to start a person on Abilify, Depakote. Start a behavioral program or therapy at the same time and if the person improves what do, you say? What made the difference?

And then the data collection part, that’s the other part of it. So we have this baseline assessment, systematic implementation of interventions and treatments and then some way to say, whether there is a response to treatment here. The person is improving, get better, and get worse in some way.

Active person and family involvement talk about trying to tie the folks into the plan. I say motivations before medications. A lot of times, people are quick to ask the doctor to get out the prescription pad. Take a little bit of time. There are some behaviors or somethings that you need to do something immediately with, but in most cases, you can take a little bit of time to really get a good look at it because you want to make sure that you’re at least accurate in terms of what the etiologies are.

Multi-dimensional interventions go without saying. There’s no one cause for Autism. There’s no one cause for mental health conditions so there’s no one treatment. That’s why we said, you know, we’re trying to say well, there’s a best practice approach. It’s a variety of approaches that are going to be successful and across systems as well. You have neurology, PCP, psychiatrists, therapists, school. There are a lot of things that are going on and then this data to response to treatments.

Here’s a little bit on medicines here, a quick graph. The reason I want to put this up is because data is very important when you’re going to talk to the psychiatrist. This is a woman I worked with she was OCD – time in the bathroom so she cleaned everything. She had all these cleaning products. As you see, these are hours now. Hours a day in the bathroom. So one day, she’s up to 18 hours in the bathroom. We tried to redirect her. She would be aggressive, disruptive. She would just clean, and clean, and clean.

This is a medication and getting her out of the house so two things. You see Zoloft there. This is how data can help you. We looked at blocks of time during the day. Started on Zoloft and then it increased over a period of time. When she was up to 400 milligrams it really started to reduce. During that time period, she was more redirectable. We were able to do things with her. Before all of this, before she increased in OCD she loved to go out. She liked to go to the Stop and Go and get this slush deal. So they set this up. Along with the medicines, they planned activities and it really worked well together.

Things you need to know about OCD, medicines, or any medicine that’s treating OCD if it’s OCD its ritual. Somebody is doing something over and over and over again. The medicines, again, taking a pill isn’t going to teach them something else. The only thing that the medicine is going to do is turn down the drive, the thermostat that’s all it does. The behaviors are going to continue. You’re doing it a 1,000 times a day.

If you’re a smoker, right, if you smoke cigarettes, two packs a day your hand to mouth with two packs a day, 2,000 times a day you’re doing this. All the sudden you get this Zyban or you get your Nicorette whatever it is you don’t need the nicotine. But what you do, what are you left with or if you’ve ever tried to stop smoking what happens. You put on weight, right. Why do you do that because of this? You had or something has got to go in there. So that’s when you give people suckers or some other things.

The point of OCD and rituals that medicine just don’t think in your mind that oh they’re taking this now they’re going to stop doing it. It’s our job really again, to replace that with something else, do something else.

Here’s a program here that has a behavior program, self-assessment. This is where the data is important. We’re looking at aggression here in this particular person. Acuity levels we do acuity ratings and the GAF. What you see in this particular graph and this is what somebody would take to the psychiatrist. We have baseline data of about 15 episodes of aggression a day. Started on 10 milligrams of Zyprexa at nighttime. And then we got a decrease just with the Zyprexa. It went down significantly that trend. And then we implemented a self-assessment, self-monitoring program, which really helped. It was beneficial along the way as well.

The other things that you see here, the acuity level went down. GAF went up, so that’s what we like to see in programs. So what you want to take if you’re working with somebody to the doctor, making sure you put a line down when medicines are started.

Unidentified Speaker: What was the GAF called?

John McGonigle: It’s called the Global Assessment Functioning. It was in the DSM-4 TR. It goes from zero to 100. It is the impact of psychiatric symptoms on daily functioning. Lower scores 10, 15 usually in-patient hospital programs that the impact is severe. As you get the medicines and the therapy, you’ll see that score go up. That means that the symptoms are abating, they are improving, getting better. Those are monitoring measures that are very helpful and beneficial.

This is what I became aware of over a period of time. Any time you’re designing program information from a variety of people, willingness for the person to participate obviously. Guardianship is huge even for adults. I’ve experienced negative experiences over the years when I started programs without checking who speaks for the person. So you really want to make sure that you’re doing that to get input from them.

Advance directives this is actually I’m in the hospital program and there are advance directives under mental health. When somebody comes into the hospital, they have a trauma event. There could be an advance directive of not to use anything restrictive, restraints, seclusions, particular medications. So making sure that if you’re writing programs is there any advance directives for people that you’re supporting.

Treatment validity, easy enough to do so when you’re writing your program, your behavior analysts, you’re writing the steps in the programs, you have to make sure actually after the training that everybody is implementing it consistently. It’s easy enough to do. Pull up your program. If you have steps in your program on the right side put a line down, put yes and no. Your behavior specialist can go in and watch the TSS or whoever is doing the programs – the staff, you simply observe the behavior, you watch the interaction, and you check it off. Hey, you missed step two or step three so you can provide that feedback. Because we know that for some folks, well, everybody consistency is critical. It is referred to as the validity and integrity of the programs. People are trained. They know what they are working with. They are observed. They are getting feedback from the behavior specialists. People will improve.

All right, let me just wrap this up here, with this slide here and then I’ll take some questions. We already talked a little bit about mental health crisis.

Unidentified Speaker: Dr. McGonigle, I just want to let you know we do go until 4:15.

John McGonigle: Oh, okay, great, I didn’t know that I’m thinking 4:00, so okay. Somebody else talked about crisis as well. The principles here we’re looking at what encompasses a good program or a good way to approach somebody with some mental health concerns. The first thing is obviously the functional assessment. I would make some clarifications I guess. Who does functional behavior assessments? Here. Does anybody do experimental functional analysis, anybody? Okay, great. So they are two different things so we could address that as well. They are just more intense, more manipulation.

The folks that are doing functional behavioral assessments fall more under the category of writing positive behavioral support plans I mentioned that early in the presentation. You’re developing the hypothesis around that. And then if you’re selecting a medication. We talked about the medication that is specific or indicated for either for the diagnosis or the symptom or the behavior that you’re looking at.

And then you want to give that an adequate trial. If you’re a family member and I tell families this all the time when you go into an office and the doctor is prescribing a medicine. You can ask the doctor, what’s the indication what are we treating here because the doctor is going to say, irritability, and depression. What you’re going to say is more specifically aggression, talking a lot over and over again, hand flapping, isolating to room. Those are the things you’re going to say. You’re going to measure that because the doctor – because of billing and how the system works they have to identify these target symptoms if you will.

But ask the doctor, okay, we’re using this medication tell me how long should we wait before we see any improvement or change. The doctor should know that. Medicines as you know there are different medicines for different symptoms and behaviors and how long it takes them to get into your body. Some of them need blood work or blood levels, so they take longer periods of time to either increase or decrease. You can ask them how long does it take this, Zoloft to work. What should I see – at least some changes in them. So that will give you at least a time frame.

The other very important thing is how do I know the side effects, which side effects should I look for when this person is taking these medications. And then specify again, what constitutes a therapeutic trial. What treatment intervention after a system is in place? Again, that’s that baseline measurement. Before you start anything, how often is anything happening and then decide it in advance?

Now, this is for you behavior specialists as well, right. The behavior specialist should know if you’re writing a behavior program you should how long should we take before this works. I can’t tell you how many times I’ve been in school programs that you’re doing a consultation and it’s January and the kid had problems in September, aggression, and they’re using a timeout from positive reinforcement program. We know timeout from positive reinforcement. You’re removed from an area that reinforcement to an area that void of reinforcement. You’re paying the price for whatever you did over there. So aggression might be I don’t know, 10 times a week. And you go in, in January and it’s seven times a week and they’re still using the program. So it’s like okay it’s more of time in I think as opposed to time out. If there’s no success, you have to step back. You don’t scrap the program maybe you tweak and modify it. When you do for your behavior analysts again, an FBA it’s a process. It’s ongoing. It’s not a one shot deal. It isn’t at all.

And so, when you’re doing your FBAs you really want to make sure that, you know, you get enough information as possible. There’s no time period for completing it either. When I say that, sometimes you’ll hear well I need two weeks or three weeks of observation. That’s not the case. You can get a lot of information depending on how frequently the behavior is you can get a lot of information very quickly.

The other thing is you may need to start treatment today, so if some are self-injurious you’re not going to be doing two weeks of observation. You’re going to treat that person. You’re going to do something because you’re going to see what the response is even in that treatment that’s more information for your FBA, right. How do they respond to what you’re doing? We’re doing something immediately. Don’t get caught up in well, we need a lot more data. We can’t do anything especially if these behaviors are self-injurious or disruptive to someone.

Positive behavior support plans, a lot of you know what’s incorporated in those. How do we assess our plans? So your plan of support these are things that I always look at. When I pull up a plan or go into residential or a hospital program I’ll look at these and you have to answer yes to these questions. Is the plan individualized? Is it based on knowledge of that patient or that person? Believe it or not, I’ve seen programs that have no correlation with an FBA or the person. They are protocol. They are in hospital. Pull it out there a name that they just write a name in and it’s a Xeroxed sheet or copy.

I’ve seen programs – verbal de-escalation programs for people who are non-verbal. It’s like who wrote this program. You know what I’m talking about if you see residential programs they have these step wise programs and they are all the same. If step A doesn’t work, you go to step B regardless of the person. Makes sure it’s individualized. Make sure it’s based on a functional behavior assessment. Make sure it’s based in a positive behavioral supports approach. Make sure it increased behaviors not just decreases. You can use programs that decrease but make sure that there is something that is teaching that person an alternative that’s positive behavioral support. We’re going to replace that with something else. Is the person involved in that someway? Use their words, their terms.

Maybe if they have technology. I’m sure some of you use an iPhone or iPad. We use them for relaxation programs, de-escalation programs for people that when they’re escalating they can go to their iPhone or their iPad, press it and it tells you remove yourself to the least stimulating area. This is what you do first. This is what you do next, but it’s all right there because it’s hard for somebody to navigate everything that’s going on. But it is visually it’s helpful so incorporate any of that into the plan. Use the least restrictive treatment model, which you’ll see in a minute or two. And then include a database.

Behavioral interventions again, people are different in terms of some agencies for whatever reason use restrictive programs. They get approval. They have restrictive procedures committees. This is really the way to think about it, right. Our positive approaches, you know, accommodations – nothing you don’t have to do anything to the person but know about them their interests, activities, what their values are. You’re going to create an environment that they enjoy. I don’t care who you are if you’re involved in activities, preferred activities things that you like, you’re going to have less problems. It’s in the hospital programs as well if people are busy then they are less likely to have difficulty.

Then we have our positive programs, differential for people that are in the business DROs, differential reinforcement programs. Just to clarify, these are positive reinforcement programs are you know, reinforcing behaviors. You see something you like a great way to go. It could be tokens. It could be a variety of things but you’re increasing the behaviors. Differential reinforcement programs are response suppression programs. Using positive reinforcement, right but they are suppressant behavior.

For example, if somebody is aggressive you might say well if you’re not aggressive this morning then we can go watch a movie. You’re using a movie as reinforcement the idea of suppressing aggression. That’s the reinforcement of other or alternative behavior. This is DRO procedures.

And then reduction programs everybody is different. These are unpleasant consequences. I can just tell you if you’re designing something that way be very, very careful from a number of standpoints. Nobody likes to be punished, right. I can’t think of any programs where you really have to do something unpleasant to someone in order for them to make the connection. I think when you do a good job in knowing the person, knowing about them, knowing conditions that might present the problems, but you can adapt, modify the environment, and prevent these things from happening.

You’re going to have a plan in place for when you have a crisis, you got to, right. You got to ensure safety. I don’t know and I’ve worked over the years since the seventies really, where these painful interventions were evoked. I see the same patients today and never use any of those interventions that were unpleasant and painful for somebody a long time ago – we’ve learned over the years.

You can use this in any program whether at home, residential program. I call it the least restrictive treatment model. The first thing we do when we identify the person has had difficulty we’re going to adapt and modify our environment that’s just the prevention part. A couple of things on this, when we say adapt and modify that includes precautions. When I say precautions, somebody comes into your service and they are like some of the cases I had suicidal, homicidal, self-injurious, ingesting of in eatable objects. That should automatically alert a precaution to you in some way. That’s going to drive where the person lives, the room that they’re in, staffing levels, right, it does that. I’ve actually seen people on four to one – staffing four people to one person in community program. And there is reason for that, but that’s going to drive all of these things from the environmental side.

The next thing obviously is somebody is having difficulty we’re going to interrupt and redirect. We’re going to use communication. Communication depending on your program could be talking, it could be pictorial, and it could be a variety of auditory. It could be a variety of ways that people are going to be communicating.

Interruption, redirection two things, what’s important, there are two things. It’s just not an interruption. I see interruption programs for interruptive behavior. Stop it, don’t do it. Physical take your hand down. You’re going to redirect that person to what they can do. It’s just not saying stop it. But okay, I can’t do this what else can I do so if it’s stereotypy, directing to an alternative. If it’s disruption, what are you going to redirect you’re going to move them from the area to get them involved a different activity. You have to be sensitive to reinforcing the behaviors as well. But the point of it is its two parts its interruption and redirection.

Counseling, there’s a lot of programs that people use, cognitive behavior therapy probably you get the best mileage out of CBT programs for people on the Autism spectrum. How many of you have used Dialectical Behavior Therapy, DBT? Not successful for this particular group even Asperger’s. I haven’t seen data research usually for personality disorder borderline people that have some risk taking behaviors. But it requires you to have some inside awareness that you’re having difficulty. I haven’t seen a whole lot of success with that with Autism. CBT is the best program at least what I’ve seen.

Medicines also have a role, so very quickly on the medicine side. If you’re using PRN medications remember what is that medicine indicated for specific symptom and then parameters. So if you’re working with a doctor and they’re writing one milligram of Ativan for agitation, aggression whatever it is you want to make sure how many can the person get in a 24 hour time period. The order should be written one-milligram Ativan G-3 hours, three hours in between dose, not to exceed three doses in 24 hours.

That’s going to help you out because a lot of times staff wants to give everything right away. So even though you may have three or four time periods they might give all three or four at the same time, which is a problem. You want to make sure that it is that specific. And then obviously, monitoring and tracking that as well. Did the person respond to it? So you think most of the times somebody given a medicine calm them will calm them down. In a lot of case, it actually activates them and you have a bigger problem so you got to monitor and track that.

And then these other ones, blocking pads, anyone here use-blocking pads? These are actually blocking pads two by three, blocking pads for people who are impulsively aggressive. I mentioned somebody coming flying out the room yelling and screaming that can occur. Somebody may be calm and then all of the sudden come out and start whaling or flaring at somebody – blocking pads available. The person can engage in the behavior it’s not restrictive at all. They can engage in the behavior and then they move on. This is not anybody who is kind of predatory in their aggressive episodes. These are more this explosive stuff and then you just direct them on their way. If you are using hands on – this is all in lieu of hands on. The worst thing you can do is put your hands on someone.

We’ll do the crisis here, and then we’ll take some questions. Crisis programs, here’s a good question. How many of you are involved in a crisis with the people that you’re serving? It means crisis. It means you call somebody either internally, resources, externally, police to the emergency room. How many of you had successful outcomes in those crisis events? When the person has, a problem when the police show up, when they get to the hospital it’s rare and there are a lot of reasons why.

Obviously, people don’t understand autism and that’s one of the problems. We do training actually for emergency room personnel, first responders, and in the emergency rooms when people come in with an Autism spectrum disorder, how to adapt to the environment, how do you approach them, how do you do your vitals. These are some of the things to keep in mind when we’re looking at crisis plan.

You’re going to look at all the resources that are available. I’m shocked sometimes when I sit down and we have these big meetings, you know, we have the county involved, crisis team involved, case management. You’re sitting and there’s like 20 people that are providing resources and services. I’m thinking with all of this if you coordinated better you could really keep this person in the community a lot better.

We look at not only the paid resources, but we also look at nonpaid resources, family, neighborhood, ministries anybody that’s involved in this person’s life can have an active role. Those are the things you’re going to look at whether they’re in school programs or residential or even living at home if you can pull resources in to help. The whole goal is to keep the person there.

I tell family members or residential programs you’re going to look at what’s available for you internally whether you have a crisis team that can come to your house, administrators. You exhaust that and then you’re going to go external. It’s usually where you get these crisis teams. As I said before, in Alleghany County we’re pretty rich in resources. We have CIP offices. Actually, train the officers in ID and also Autism. So when they respond they know how to react – no, handcuffs. It’s the education of the folks when they go to these crises so you’re going to look at all of these.

And then transporting the person, so who goes to the hospital, who follows the person. Your job or if you’re a family member or residential or the person wants to go to the hospital your job is to get the person to the hospital in any way that they get there whether it’s you transporting them or somebody else. It’s the emergency room’s job to determine is there immediate risk or danger at that point. You may say yes this person is an immediate risk, danger they may not see it that way. You’re going to provide that information for them. It’s really the job of the hospital.

I’ll also say this as well, the hospital if you’re a staff person and you’re getting somebody in the hospital you’re in the emergency room, and they’re asking the staff to manage that person in that emergency room. I don’t know if you ever experienced that. I tell the staff, that’s the job of the hospital. That’s not your job. They have safety people around. It’s not a good idea for you to physically manage or manage the person while they are in the hospital. Especially, in an emergency, if they are being committed.

All right, we are going to wrap that up. We were just going to talk about the crisis I know there’s a lot of things that cause behavior health crisis. Talking about these resources, who do you have access to help you out? How do you keep the person out? On the recovery side, what we do a lot of if a person is in and out of the hospital a lot, in-depth evaluation in terms of what will work for you. We try to empower the person as well. We even ask questions, when you’re in a crisis what works for you? Do you want to be alone? Would you more prefer people around you? Who do you want to talk to? How do you want us to approach you? All of that important information if you have somebody that’s in crisis all the time that’s real important information getting it from them if you’re involved in a crisis it gets so chaotic at times. That’s one of the biggest problems. If you have somebody on the spectrum and two police offices and administrator, family shows up and everybody is giving directions it just makes it worse. So somebody has to take the lead in that, but that plan can be developed.

With that, I’m going to wrap this up and I’m going to take questions. You got a lot of information here. Hopefully, it was helpful for some measurement tools you should be able to use. There is nothing you can’t use or when you look these things up, they are easy enough to develop, look out, and fill out. Let me take some questions.

Unidentified Speaker: Back when you that anxiety slide, when you had that balloon and there are all the behaviors that come out of anxiety, one of the issues that I see a lot of is that like, those are all for the most part sort of outward manifestations of it. I feel as though there is such an under the awareness of the internal manifestations. For example, a kid that is in class and just spaces out not because of a seizure but because they are anxious. I guess my question is, why do you think it is that there’s such an under emphasis on that because I personally think that’s more prevalent in the spectrum population.

John McGonigle: I agree a hundred percent with you. The reason why – these are the ones that are expressed and we see so those are going to get the attention. But I agree with you. Anxiety is extremely debilitating depending on the level. Anxiety in itself it’s bad. Anxiety can help us. It can make us productive. It’s that negative side. The overwhelming anxiety that you shut down. You start to have negative thoughts about yourself – I can’t produce. I can’t do this. Heart palpitations, breathing, shutting down, and blank staring. All of those things are part of anxiety at different degrees.

By your observation, you mentioned two or three things, if somebody is shutting down in school, in the classroom should be able to see things like participation and activity, productivity, even writing samples, completion of tasks. Those are measurements, the more internal stuff not the acting out. But those are things that you would look at. Anxiety, even though they’re not doing this, you can see anxiety. You can see it in somebody, right. How they look – tenseness. Is there anybody rocking. Even we do that if we’re anxious it’s more socially acceptable but we deal with it in that way. I agree with you that looking at those more subtle things.

The question gets back again, to the degree in the severity of the anxiety. How much does it interfere with that person in whatever they are doing in school, grades, and interactions with others? If it’s not, if it rises to the level well, this is interfering in some way if they didn’t have this anxiety they would do much better. But then there are people who do okay even with higher-level anxiety. They learn to work with it. I agree with you though looking at those more subtle things. It’s usually isolative, hunking down, non- participation, over whelmed when thinking about things, deer in the headlights, yeah.

Unidentified Speaker: I just wondered if you could briefly touch on sort of when an Autism Spectrum Disorder may transition or present more like a Schizoid Personality Disorder. For example, I had a 19 year old who came in without any family members. He expressed a preference to me I just want to be by myself, doesn’t have a lot of interests, doesn’t want any relationships with males or females just kind of wants to be in his own world and that’s what makes him content. At what point, do you consider those other diagnostic considerations?

John McGonigle: Other diagnostics like what, if you talk about Schizoid Personality Disorder. So what that tells us automatically it’s not an acute onset. It is a chronic condition. As we said before, those conditions develop early on in life. It’s the experiences that they have with their environment, their people, and relationships. With Schizoid Personality Disorders, we’ll look at things like, how you dress, unusual, atypical, magical thinking. Sometimes you’ll get that diagnosis because of the passions that somebody might have in a particular area.

Let’s talk about treatment. There isn’t a medicine that a doctor can go to, and say, this medicine is for personality disorder. Even though let’s say your borderline personality disorders or your anti-social are risk taking, aggressive, homicidal there’s not a medicine you can go for that’s treating personality disorders. It is all behavioral so it’s adapting the environment, teaching skills, improving ADLs because ADLs are an issue, relationships.

The first thing you have to do is say okay, what is related to the core feature Autism whether it’s a relationship, particular way I dress, I don’t want to relate, so you’re going to look at that first. But in terms of the treatment side you’ll be doing skill development, putting the guardrails up, educating that person, self-assessment, self-monitoring. Medicines may help with some of the irritability, agitation that could be related to somebody telling you to dress differently, you don’t conform, or they may get upset and become explosive that’s going to treat something else. Differentiating first of all starts with ACS because that’s the issue. It’s not necessarily a Schizoid Personality Disorder. It can be. You can look at the history usually there’s some not trauma but there is something in that person’s life that created difficulty with relationships more so than social. This is avoidant.

It’s really your therapy programs they are going to help somebody with a personality disorder. If differentiating something else OCD, rituals that would rise to a different level. That would be treated differently, but any of your axis. It used to be Axis-2 intellectual disabilities feel under that. Personality disorders in the DSM-4, right. There’s not an Axis- 2. So what happens now, in the DSM-4 is that Axis-1, two, and three that was in the four, which is your primary diagnosis, your secondary Axis-2, your intellectual disability, and your 10 personality disorders and Axis-3 your genetics they are all incorporated in I. It’s a clear description. They’re not separated anymore. It’s a clear description that the person has Autism. They may meet criteria for Schizoid Personality Disorder. They may have Tourette Disorder on Axis-3. Those are all going to be treated. But in your description, it will be described that way. It’s individualized and that’s what makes it today, the DSM-5 more specific compared to the DSM-4.

The other very important things as we’re talking about this if you go in for an evaluation – DSM-5 you’re also going to get a level of severity which is very important, which wasn’t there before. It’s one, two, and three. Three is the most severe. That means that you may have Autism Spectrum Disorder, Obsessive Compulsive Disorder, and you may have severity level is extreme. That’s going to equate to your resources so insurance companies, and supports are going to be tied to that now. They go down to level one.

In around about way, I don’t know if that helps you or not. I can tell you that there’s not that one medicine that you’re going to give to somebody that’s going to help. That’s training, social skills, ADLs, showering. But you have to look at when you get into the ADLs, affect not relating to people you got to be very careful because those can be negative symptoms of Schizophrenia. Those are all part of the negative symptoms – not hallucinations but these other things.

You’re going to look at the time period where they occurred. When you’re talking about personality disorders, you’re going to see that in that person’s life 13, 14, 15 years of age. The schizophrenia you’re not going to see those until 19, 20, and 21. Then you would be able to differentiate Schizoid Personality Disorder from Schizophrenia based on that. At least I would base it on that information. Is that helpful?

Unidentified Speaker: Yes, that was helpful.

John McGonigle: Did I confuse a lot of people with that description, sorry. The Axis-1 when you get that Axis that’s the treatable syndrome that’s the medicine. Everything else unless it’s a medical condition, everything else is skill deficit or DBT or CBT therapy programs.