Welcome to the Art of medicine, the program that explores the arts, business and clinical aspects of the practice of medicine. I'm your host, Doctor Andrew Wilner.

I've planned a great program for today. But first, a word from our sponsor Locum story.com. Local story.com is a free, unbiased educational resource about locum tenants.

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Possess and NPS at locum story.com. Today I'm pleased to welcome Doctor Barry present. Doctor present has worked with children with autism for more than 50 years.

He's the author of the bestselling book Uniquely Human. Doctor present also co-hosts the Uniquely Human podcast with Dave Finch. Dave provides his perspective as an audio engineer, family man, and adult with autism.

By the way, for those interested in the topic of autism, please see prior episodes with Temple Grandin, Eric Garcia, and Emily Santa Katie. There'll be links in the show. Notes.

I'm eager to speak with Barry because his knowledge and practical experience with autism is so extensive. And now to my guest. Welcome, Doctor Barry. Present.

Thank you so much, Angela. It truly is a pleasure to be here with you today. Thanks for joining me. We've I gave you the parameters, you know, 20 to 40 minutes.

But, you know, I feel like we could definitely talk all day, but we won't. So we're going to be, try and be, focused. And I do have a lot of questions for you, but before we get started, you know, I know your story.

One of the reasons I wanted to have you on the program is, like, you are like, a national resource. I mean, how many people on the planet have worked with people with autism for 50 plus years and studied it in depth as, as as a human being and as a scholar?

And, and I think that's a small number. So you're kind of, very special. So how how did this all start for you? It it all started, as an older teenager working in summer camps.

And I am so grateful for the opportunity to, work with children and adults on the autism spectrum, but many other people with disabilities, and, these summer camps, starting in upstate New York with residential.

So I was, essentially a surrogate parent, 24 seven for two months every summer over 6 or 7 summers. And and the reason I'm so grateful for that experience is I got to know people with very disabilities.

And of course, the, diagnosis of autism was much more rare at that time. But but some of the people I work with, some of the kids, you know, for whom I was responsible for in terms the happiness, their well-being, their safety, had autism diagnoses at that time.

And it was only after the first couple of summers of those experiences that I kind of steered academically in that direction. All right, so nitty gritty.

What is autism? Autism. If you want to go by the DSM five definition, has to do with problems in developing social relationships and social communication, and also what's called the restricted range of behaviors and interests.

And I say according to the DSM five, there are many people who wish those definitions can be modified and changed to some extent. So for example, even though it's included under a restricted range of behaviors and interests, sensory issues are now reported to be so dominant, affecting the lives of people on the autism spectrum.

Being too sensitive to sounds, being hypersensitive to touch or in some cases under reactive or, under responsive. And probably it was Temple Grandin who really emphasized the sensory issues way back when, before that was included in the DSM five, serial of definitions over time.

But one of the problems with the DSM five definition is that it results in under identification of girls and women. So right now people are even saying maybe there needs to be a different set or a modified set of criteria for girls and women because they present slightly differently, than men.

And boys do. Let's continue our definitions with neurodivergent. Yes. Neurodivergent, you know, comes out of a movement which is referred to as the neurodiversity movement.

And in its simplest form, the definition of neurodiversity has to do with the fact that we all have different brains and we all process our lives on a sensory level, on a social level.

We all think differently cognitively. We have different learning strengths and challenges. So that's what neurodiversity is across all of humanity. Recognizing that neuro divergence is when if you look at the old bell curve, where we see individuals who kind of fall out of your typical profile, even within the differences that neurodiversity defines.

And, you know, something that's not emphasized enough most often when we talk about neurodivergent people, talk about different clinical categories such as ADHD, such as mental health conditions, anxiety disorders, learning disabilities, autism spectrum disorders.

But, what is getting a lot more attention now is the other side of the bell curve. And that's giftedness. So you could be a person who meets criteria for being gifted.

It might be in music. It might be in your your knowledge of history, but you are so superior in those areas that that's a form of neuro divergence. As well.

There's actually a category now that's known as two e twice exceptional, which is defined as having a clinical condition that presents challenges to you.

And it might be learning or social difficulties, but that you are also gifted in some areas as well. Specific to autism. The term savant comes up. So a person who has savant abilities and an autism is estimated to be about 10 to 15% of people with an autism diagnosis have savant abilities that would be on the gifted side, but still, those people may have major difficulties in social understanding, might have major sensory issues that they have to deal with that are truly debilitating in everyday life.

Okay. I was going to bring that up later, but since you bring it up now, I'm a neurologist and my everyday job is trying to understand usually what's wrong with the brain.

Why is this patient paralyzed on one side? Why do they have severe headaches? Why are they having seizures? What is different about the brain? So you've described it as a situation where there are people who have, challenges who could be speaking or understanding social situations and yet can be gifted off the bell curve, phenomenal memories or ability to calculate.

I mean, the movie Rainman comes to mind. People often refer to that, what's going on? Yeah. I always go back to, Howard Gardner's work, and it's not without some controversy, but Gardner's theory of multiple intelligences that he began to write about in the 1970s and 1980s.

And, of course, what he was trying to get across was that it is so overly simplistic to talk about one or even two types of intelligence, such as verbal intelligence and nonverbal.

So depending upon which current model you look at, some folks talk about 8 or 9 different kinds of intelligences. There could be visual spatial intelligence.

There could be musical intelligence, logical mathematical intelligence, linguistic intelligence, bodily kinesthetic intelligence. So then when you think about people who are exceptional in any one of those areas, let's start with bodily kinesthetic intelligence.

You might become a great ballet dancer if you have this great sense of coordination and movement and body and space, linguistic intelligence, you might become a poet.

Or just become extremely competent in acquiring many languages. You know, in some cases, essentially without the effort that other people have in doing that, visual spatial intelligence.

Let's talk about Temple Grandin. I mean, how she designs in her mind, blueprints are very, very complex animal handling facilities to be your more humane in the way we treat animals.

And we could go on and on with musical intelligence, with people who are incredibly artistically gifted. Some people now talk about naturalist intelligence that you just have this intuition about the natural world and about animals in the natural world, and maybe you become a park warden in a national park.

So, so the whole point is that you can be extremely gifted in some areas and not so much in others. And, and let me give a specific example of this, which is a big area of controversy in the autism sphere.

And that is you could have non-speaking people on the autism spectrum, and they might be non-speaking because they have significant motor challenges in terms of being able to produce a speech that's articulate or even to be able to vocalize relationally, voluntarily, at all.

Yet we're discovering many of these people might be brilliant in other ways. And I say it's controversial because we're discovering many people. Let me give an example of a woman who I've gotten to know pretty well, Elizabeth Bunker, who was thought of as significantly intellectually, disabled up until her teen years.

And then she learned to type to communicate and was about one of the valedictorian recipients at her college two years ago. You can see her valedictorian address on YouTube.

It's like, have, like, I don't know, 5 million hits. And she gave this brilliant speech about how literally. And she mentions this. I think it was a high school principal who heard she had been picked as a valedictorian.

And he said something like, I never thought that retard could go so far. And it has to do so much with how we conflate intelligence with verbal skills in Western culture.

The more you speak and the more you can come across and articulate, articulate your thoughts with thought. Oh, that's a more intelligent person. So, you know, but what about Stephen Hawking's now?

He developed typically than had an acquired condition. And he lost all the ability to speak. But nobody ever questioned that. He was a brilliant man. And I think in part because he had developed typically and I believe was in his teen years.

He lost his or all of his ability to speak. But there are many people who never are capable of speaking, but still can demonstrate brilliance in many areas.

You know, we could go on and on about extremely well known people. So another good example is Richard Branson. He's very open about being learning disabled, a dyslexic.

He had problems reading, but he had this incredible entrepreneurial business sense that led him to become one of the most successful entrepreneurs in the world.

Okay. We could go down the paths of so many people right now. Elon Musk, of course, who does have an autism spectrum diagnosis of Asperger's, who, you know, kind of violates social principles of the way you act and the way you speak in many ways.

And yet look at what he's done in terms of his entrepreneurship. Especially you know, in science related topics. So, so the point is that we have so misunderstood so many people who do not excel in so many ways that we would expect them to excel.

Whether it's the way they speak, whether it's their social appropriateness. Yet Einstein supposedly was a social, not only social recluse, but was extremely clumsy socially.

In many ways. Yet it does seem in our culture, if you develop the level of ability, that, extreme ability that society values, then we call that person genius and eccentric.

And we allow for things that might be very off putting in other people who do not have that special ability. And so that pretty much sums up neurodiversity in neuro divergence right now.

It is really changing the way we're looking at people who we thought of as primarily disabled and looking at these people and saying, well, let's look at the differences.

Let's look at the strengths, and let's put the right supports in for the challenges. All right. One. All right. Now one thing we have to get out of the way.

Is there an epidemic like I read in the news of autism? Yeah. Again, there are many different opinions. I will tell you mine. And it's very consistent, with, a person whose book you read, neuro tribes, the late Steve Silberman, actually became a good a close friend of mine, because my book, Uniquely Human and Neuro Tribes were both published in July of 2015, and they were actually reviewed as companion volumes by nature magazine, by Chicago Tribune.

As Stephen, I thought of the book, the books that way. So why am I mentioning Steve? Steve was one of the first people to put out there in public. A very strong statement that there is no epidemic of autism.

We are just recognizing autism. Because in many more people, because the criteria have become much, much more inclusive and looser over the years. And I mentioned earlier the issue of autism and girls and women.

One of the reasons in general that we're seeing a much higher incidence is late diagnosed autism. Autistic people, self-diagnosed people. But that doesn't really account for the numbers of increase that we're seeing in diagnosis in younger individuals.

And kids. And it really is, in my opinion, due to the greater flexibility. So kids right now who show more social connectedness, even more social quote unquote intuition than other kids might be thought of as being on the spectrum.

As you know, that whole Asperger's diagnosis was tossed out in DSM 5 in 2013. But we are now looking at many, many kids who we would have thought of as being too social, and too engaged, if you will.

The same thing on the other end, for maybe kids who were thought of as primarily intellectually disabled, because they didn't speak. Because cognitive testing was very difficult to get an accurate picture of their intelligence.

Now we're looking at broader criteria, and some of those individuals are now getting autism diagnoses, as well as diagnoses of possible intellectual disability.

And then I think that goes for a lot of diagnostic categories. It used to be more mutually exclusive that if you got a a diagnosis of attention deficit hyperactivity disorder, you couldn't get a diagnosis of autism.

And there's much more allowance for co-occurring conditions now that it's okay to have a diagnosis of autism ND, ADHD and autism and anxiety disorder and autism and bipolar, many, many more co-occurring conditions that allow for a diagnosis of autism.

Whether or not the say, a child has a special ability and and it does seem to be a minority of of children. You gave a number of 10 to 15% of having something really off the scale.

Some of you know, for parents, these children can be very, very challenging. You know, the lack of, social abilities or difficulty speaking translates into, picky diets.

You know, afternoons of therapy and screaming and difficulties going out in public and with meltdowns and, Oh. What advice? Oh, I want to take advantage of your 50 year sort of, longitudinal view.

Did those children, can they overcome that so that they can when there are adults, that they have what we consider to be a typical productive life? You know, a job, family, hobbies, friends.

Does that happen? Or is this sort of a permanent condition? Well, you know, the best way to answer that is with specific examples. Okay. You mentioned Jerry Fleming.

And, an adult on the spectrum who wrote How to Be Human. The book. We interviewed him on our podcast, and he said he had wild tantrums up until, I think he said 8 or 9 years of age that he was considered to be, at times, an out of control child.

Well, he was the first Rhodes Scholar with autism. Okay. I thought that was pretty impressive. Yeah, yeah. And, he has a PhD. He is a scientist. Very nice man to speak to.

And again, we could go on and on. Even Temple Grandin, a lot of people don't realize that, you know, probably the most famous autistic person in history.

She didn't begin speaking until she was 4 or 5 years of age, where traditionally you would look at that and say, oh, well, you know, a prognostic indicator for a better outcome would be communication abilities very early on.

And and look at her now. I mean, again, she's written about a, I think about 15 books all together with about half of them being on autism and the other half being on animal science.

So we could go on and on with examples of individuals. Jordan Zimmermann, a non-speaking woman who still is non-speaking, who was thought of as significantly intellectually disabled.

Not only as she finished her bachelor's and master's degree in education. But she serves on some of the highest level committees, on research on autism in the country.

And Elizabeth Parker as well. I mean, Elizabeth was thought of as severely intellectually disabled. She has an international foundation that she started with her mother.

It's called communication for all. So many examples. It's one thing that I still believe is very true is you cannot take a snapshot of a younger person.

And what I mean by snapshot is a developmental profile based upon testing and so forth, and predict to what they will look like as a teenager or as an adult.

I know some autistic people who didn't begin speaking until they were young adults. If you just want to hold up speech as kind of a marker of of progress in individuals.

There's so much we don't know. And there's so much more we need to learn. And a lot of that's coming out of the non-speaking community right now. Because those are the people who I feel are so misunderstood, primarily because in Western culture, we look at, as I mentioned earlier, speaking ability as kind of such a firm marker of intelligence and also positive prognosis.

And I would say it's a marker of how misunderstood you might be. And yeah, so there's so much we need to learn about what are the signs that when you mentioned, well, what about those kids who has so many tantrums, those kids who are picky eaters on and on and on, especially engaging in what's considered to be problematic behavior.

And I always like to say problematic not only to other people, but to themselves. Okay. We're talking about one of the areas that I feel. We actually introduced this concept into autism in the 90s.

And that is the concept of emotional regulation. And it's not just emotional. Being able to regulate your emotions, your anger, your anxiety, even your joy if you get too excited, but also physiological regulation.

Okay. These go hand in hand. Emotional physiological regulation. I think the more we support people and it's a big part of our educational model, which is called the circuits model.

CRT is the air is emotional regulation. Okay. And the more we can support a well-regulated physiological and emotional state, the better the prognosis for a person with a neurodevelopmental disability such as autism.

And I don't want to get too much into the weeds here, but many co-occurring conditions, conditions you're very familiar with is co-occurring with autism, severe gastrointestinal issues, the sensory issues, many of these conditions result in a highly dysregulated state in a child or an adult.

And we define emotional regulation very simply. And that is the ability to stay available for learning and engaging. The better regulated we are, the less anxious we are, the less we are debilitated by all the sensory input in the world, the less we have social anxiety where other people might challenge us to be well regulated.

By the way, a lot of autistic adults say the most challenging aspect of their lives is other people. People who get it. That's true for a lot of us, I think, you know.

Yeah. And by the way, on that point, I've said many times that autistic people are challenged by the same things. All people are challenged by. What's the difference?

We have better coping strategies. We have better ways to deal with that. So if you are going to a concert and you're in an environment that's overwhelming because the music is too loud, you will say, I can't stand it, I need to leave.

You might actually go in with earplugs knowing it might be loud music. You might take a lot of breaks. You put an autistic person. Even if they like the music in that setting, they might have a meltdown because their sensory system is overwhelmed.

The neurological system is overwhelmed. What about foods? Okay. We do know that many autistic people with neurodevelopmental issues have more food sensitivities and food allergies co-occurring conditions than many of us have.

Yet we will avoid those foods. We will make sure we don't eat those foods yet. Parents, well-meaning parents may not understand that child has those food sensitivities and allergies until they get tested.

So you might have kids who are literally just overcome with pain in their belly because of those food sensitivities. So we are more aware and we're able to communicate to request assistance with many of our challenges in life.

Whereas many people with neurodevelopmental issues, not just autism, may not develop that awareness to advocate or may not have people to advocate for them.

And so that really comes down to what kind of supports do we put in the lives of people, and do we teach and help autistic people to be very self-aware where they can say, and I that, you know, I have many friends who are autistic, you know, where they can say, I can't go into that restaurant because it's too noisy.

Okay. Or my friend Roz Blackburn, an autistic woman from England, I have presented with her, traveled with her. We if we go to a restaurant, she'll say, I need to sit at that table back in the corner because I can't sit in the middle with all this noise around me.

What she actually says is I can't stand quadraphonic sound. Temple Grandin is the same way. You know, she said, I need to know what my schedule is. I don't do well with uncertainty in my life.

I don't do well with loud sensory environments. I need things, and this is a huge issue for people on the autism spectrum. I need things to be predictable.

Now I again, I like to say we all benefit from predictability in our lives. And we may benefit from it. We may know how important it is to have our schedule, a new schedule, going to a new setting or to a new job.

Autistic people crave predictability to the extent that if things are uncertain, you're likely to see a much more anxious person who might be at much higher risk for having severe anxiety, leading to meltdowns.

So these are very, very important issues. The overlap between all of us and autistic people. So we know how to support ourselves better. And we surround ourselves with people who support ourselves better.

It's not always the case with autistic people. Last point the way an autistic or another developmentally disabled person may react may be seen by some people as bad behavior.

It's intentional. He knows what he's doing. He's too smart to have a meltdown at this time. And right now, there's much more of an effort to try to really understand the experience that a person with autism or a neurodevelopmental condition, what is their experience from the inside out?

And we're finally having enough adults who now talk about what it was like in their lives. I asked Gerry Fleming, was he aware of the difficulties he was having that led to a meltdown?

And he said, not really. He said, all of a sudden I'd be in a situation or a setting that I needed to kind of survive and protect myself, you know, grow, fight and flight reactions.

And he was saying, no, it's I wasn't aware. I became gradually aware with the help of people. And my parents were very conscious of what situations not to put me in.

But the awareness that I have now helps me so much because I will not basically shoot myself in the foot by putting myself in an at risk situation. For a lot of parents, you know, the child goes to pre-K or kindergarten and the next thing you know, there is a phone call from the principal or the teacher that, you know, your kid keeps running out of the room and is not paying attention.

And we think there's a problem. And after testing and visits to the pediatrician, there's a diagnosis of autistic spectrum disorder. And then the next thing is your kid needs 40 hours of ABA a week.

Right. What do you think of that? Does that make sense? Is that. That's what's happening. And is that the right way to go? That's that's what's happened for many years.

So let me be blunt. And anybody who knows the work that I've done over decades with my colleagues, this won't be a surprise. ABA and the field of applied behavior analysis has done an incredible job of selling their product.

Okay. I'm not saying that ABA therapy and what we learn from applied behavioral analysis might, in some cases, give us a different window into looking at what's going on.

But for decades, for decades, it was stated without the evidence, that this is the gold standard of therapy, to the point that many people would tell parents don't even look at other approaches or other therapies because this is what you need.

Now, we're not going to have time to go into the weeds. There are very traditional forms of applied behavior. Analytic therapy based upon learning theory.

There are more modern approaches that still are based in kind of what we used to call behavior modification and learning theory, based upon Skinner's work early on.

Every child is different. Okay. Current meta analysis of research now indicate that what is called developmental and relationship based approaches actually result in better results than applied behavior analysis.

Okay. There is now an effort, and I'm part of a team of a number of professionals, including pediatricians, child psychiatrists, and really getting out to the world.

This category of approaches called developmental relationship based interventions. D r b I okay. There's an article that was just published about the RB approaches.

And we had an interview, shameless plug here on Uniquely Human, the podcast, with Josh Fader, who is an autistic psychiatrist who has an autistic son.

Andrea Davis is a clinical psychologist, about DARPA and I, you might say. Okay, well, I've never heard of Debbie. What falls under that category? Many people are familiar with the work of Stanley Greenspan and for time.

Right. I was just going to ask about DDR. Is this sort of a derivative of floor time? Yes, dear, is developmental intervention. Developmental individualized relationship intervention.

Dear falls under the new category, the broader category of developmental relationship based intervention approaches. For example, doctor Josh Fader, who I just mentioned.

Work with Stanley Greenspan. I work with Greenspan also for a number of years, for about five years before he passed away. Which is more than ten years ago.

And now it's hard to believe. The search model, the model that I've developed, which is an, evidence based model used internationally, also falls under this category of developmental relationship based intervention.

The play project. Richard Solomon, who's a pediatrician out of University of Michigan, the play project falls under this category. Okay. The packed approach out of, the UK, founded by Jonathan Green, a very heavily evidence based and researched approach.

He is a psychiatrist. So we are finally getting together. And that has been done in ABA for a number of years. There are about 6 or 7 different approaches under ABA pivotal response training, Globus therapy, and on and on.

Let me give you my major, major concern. Besides the commercialism of ABA. Okay. And that is people who are trained and even highly credentialed in ABA who get a bcba have no training in child in human development.

It's not required. They have training in how to use and how to write behavior plans to modify and change behavior. I think some of the, the greatest misuses of ABA and there have been many.

I'm not the first to say this is when you're dealing with people who do not look through a developmental lens and do not understand that all human beings go through stages of development, that in some cases may be looked at as problem behavior.

Yet it's a child who is going through stages of self-determination. Which all children do. Okay. Where they push back a little bit. And probably one of the greatest concerns is the overwhelming majority of autistic adults who have gone through ABA as kids have great concerns about how that affected their lives, and some even say it caused trauma for them.

I mean, you have autistic adults who say they have experience, they experience PTSD after years of ABA therapy. Now, that would probably be much more in the traditional ABA therapy.

My doctoral dissertation in 1978 it was completed challenged low vas the grandfather of applied behavior analysis in autism. He said clear example that repeating speech which is known as echolalia was an autistic behavior that was aberrant.

He called it psychotic speech, and it needed to be extinguished. It needed to be punished or ignored. Okay. I being the developmental this my training is all in child and human development.

Language development, cognitive development. After working with kids for a few years who were echolalia could repeat his speech a lot. I said, no, you know, there's more going on here.

Back in the early day of video tape analysis, I followed for children for a year who repeated speech a lot and found that it served a lot of different functions, that it was a part of their language development, and it changed 180 degree different.

Look at echolalia. Another example is stims for years in applied behavior analysis. If you see kids who dropped or flapped their hands, repetitive movement and motor behaviors known as soft stimulatory behaviors, it was thought of okay, we need to punish that.

There are studies using shock in the 60s and 70s from an ABA perspective to try to stop that behavior, because how do you treat autism? You stop autistic behaviors.

But nobody asked the deep, why? Why are these individuals doing this? What do we now think about self stems? It serves different purposes. The most common purpose is it is a way to self-soothe or to self-regulate when feeling dysregulated or highly anxious.

Now we all rock. Now and then, but we usually will not rock when people are watching us. We might rock in our house, or we might tap the desk. If we're trying to solve a problem.

If an autistic child does that very often, there needs to be a behavior plan to stop the behavior or extinguish the behavior. And that's what a lot of autistic adults say, that a lot of what they were doing and even saying as an attempt to communicate or regulate themselves was not only discouraged, but in some cases ignored or punished.

Yet it was their neurology trying to help them be in a better state for learning, being more focused, being less anxious, needing to move your body especially if you are a high arousal person and you need to move around a lot.

All of that was seen as problematic behavior. And now we need and this is a theme of my book, Uniquely Human. What I've learned from autistic people. We need to ask what we call the deep.

Why you can't just say it looks different, so stop it. You have to say, why is this person doing this? And in some cases, teach them other ways to regulate, especially if what they're doing may be seen as stigmatizing or socially undesirable.

Let me, just say I read your book. And I also read neuro tribes, and I would agree that they are very complementary neuro tribes is like this encyclopedic history of autism that is, it's not an easy read, but it is fascinating.

Your book is much easier to read and, much more accessible. And I would say read that one. Read Barry President's book first. I and then and then move on, from there.

And of course, it's available in all the usual places Amazon and and your website. Barry, before we wrap up, I want to just one more kind of sticky issue.

And that is we've talked a little bit about treating autism. You know, is it a condition, is it curable. How do you look at it? Yeah. I look at it as a lifelong condition.

Under which you might see people who have a wonderful quality of life. I have very accomplished friends, clearly accurately diagnosed on the autism spectrum, who have families who have children, who have careers they're proud of.

They still might have challenges. The people that I know, the adults that I know who have the best quality of life, are also the ones who are most self-aware.

They can communicate what they need. They can avoid the foods that might be, you know, physiologically dysregulated for them. They know how to surround themselves with people who get them.

And and that's that's huge. I would say most adults with autism, who you may not even know, they're on the autism spectrum at times. Okay. When you see them, they would say, no autism and subprogram.

This is a part of who I am and will always be a part of who I am. But that does not translate into a poor quality of life. That does not translate into needing a high level of support 24 over seven.

Now, some people definitely need more. Some, more support. There's no doubt about that. I know people on the spectrum who need a fair amount of support, but they're happy people now.

Happy kids. And so it depends upon how you define outcome. All right. And that's a very, very important consideration. I mean, you have people who are genius level.

And by all measured assessments you would say, oh my God, this is a brilliant person who's, you know, is so debilitated by anxiety that life every day is just hellish for them.

Okay, I knew a college professor like that will eventually lost his job on the autism spectrum. I mean, the level of anxiety that he experienced every day just limited his ability to go into certain situations to be with certain people.

And he was misunderstood by a lot of people. You know, just as this eccentric recluse and don't go near him because his anxiety will spill over into you.

You know, it's so a lot of it has to do with the right supports helping people be self-aware, supporting families, of course, from the get go. That's, you know, one of the most important prognostic, indicators is family understanding and family support and raising their family member of their child who's on the autism spectrum.

But there are many other prognostic indicators. And, it's really getting a person being highly sensitive to who they are, putting the right supports in place.

And trying to the best that we can. If you're not on the spectrum to understand their world, very important. Very. This has been great. Is there anything you'd like to add before we close?

I would say, listen to what autistic people have to say. Listen, if you're in a position to work with families, listen to what family members say. That includes siblings.

They are a wealth of knowledge. And everybody really wants to be heard. You know, autistic people want to be heard. Parents want to be heard. And so I always like to say, let's move out of an expert model.

Like, I got all the answers. If you're a professional listening to this, to a collaborative model, the best way that we work is holding hands together and moving forward together.

Doctor Barry present, thanks for joining me on the Art of medicine. Andrew, thank you so much. It's been a pleasure. And now, a final thanks to our sponsor Locum story.com.

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