Hello, everyone. I'd like to welcome you all and thank you for attending today's webinar, Autism Spectrum Disorder and Sexual Violence and Abuse Part 2, Recognize and Adapting the Response to Individuals with Autism. This webinar is being brought to you through IAFN's Technical Assistance Project. We are grateful to again host Travis Haycock and Stacey Whitney today. And to start off, I'll just let you know that I am your host for today. My name again is Angelita Oluwu. I'm Forensic Nursing Director with the International Association of Forensic Nurses. A few house, few little minor things to kind of go over really quickly. Sorry, I'm skipping too fast. I do want to let you all know that today's presentation is being supported by OVW grant funding. The planners and presenters, all the planners and presenters are the ones who created the content and their opinions do not necessarily reflect the views of the U.S. Department of Justice. At the completion of this webinar, you will get an evaluation. So that evaluation will be in the chat, but it'll also come to you via link once you log out. Please complete the evaluation. So one thing, we need your evaluation to give us input on how we did and to make sure that we're bringing you relevant information in the future. But additionally, in order for you to get continued nursing educations or a certificate of attendance, you will need to complete the evaluation first. And then finally, the International Association of Forensic Nurses isn't accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. So I just want to note that a contributor of the content for this webinar and our previous webinar, part one, Sondra Harrell, she's not with us today, but she is of activating change and she was a contributor to the development of the content today. Who we do have here with us today is Stacey Whitney, and I will turn it over to Stacey and Travis for their own introductions. Thank you guys for being here. Thank you, Angelita. So as Angelita said, my name is Stacey Whitney and I am the Senior Director for Modell Consulting Group. I am coming to you from the Nashville, Tennessee area today. I'm really excited to share some content with you on communicating with folks with autism. My experience as Senior Director is really on delivering and developing trainings like this one to professionals all over the country. So again, excited to be here with you. Prior to this role, I was the Senior Forensic Interviewer at a Child Advocacy Center in Rochester, New York, which is where I did the majority of my work and where a lot of my experience comes from. So took that into a specialty in interviewing crime victims with disabilities, including people of all ages. So interviewing both children and adults with disabilities and then older adults as well. So that's a little bit about me in a nutshell and where my stories and experience come from. So I will turn it over to Travis so he can tell you about him. Hi, everyone. I am Travis Haycook. I'm from Cleveland Clinic Children's Hospital Center for Autism. I am currently the Director of our consultative team that works with organizations around the country to develop programs for treatment programs for kids with autism. I've been with Cleveland Clinic Children's from the beginning of autism programs. I've been there for the last 23 years. I've worked with the autism population since 1997. So every time I say it, I feel massively old that I've been doing this for 26 years, almost 27. But I've worked with populations from as early as 10 months old through adults who are up or into their 60s. So I look forward to being part of the presentation and just kind of giving you guys a little bit some background and kind of working with Stacey to hopefully give you a lot more information will be helpful. All right, thanks, Travis. So hopefully between the two of us and our combined experience, we'll have some exciting things to share. So really, our hope at the end of our time together today would be that you have some increased knowledge about different strategies that we can use when talking with individuals with autism when they are in these medical care settings. And really, especially when they have experienced some sort of sexual violence, but they could apply to anyone you're working with, regardless of what they're being seen for. But that's really what our goal is to give you some additional skills and tools. So before we dive in to that, just want to give a little bit of background, because I think it's important for us to come from a place where we understand what the issue is. So when we talk about some statistics and realities for folks with autism, I promise I won't spend too much time on statistics. But we know that children with autism are about two and a half times more likely to have reports to the child abuse hotline by the time they reach age eight. So we already know that there's lots of reports to the child abuse hotline. But people with autism, we tend to see those kids' reports being higher. We also see that girls with autism were about six times more likely to have substantiated allegations of maltreatment compared to males. Now, I wish I could tell you why these things are true. We don't necessarily know. I'm sure there's a lot of contributing factors, as with all statistics. But we do know that these are going to be kiddos who are more likely to have reports called in. And for females compared to males, with this study, they talk about girls having higher rates of substantiation. As we think about adulthood with this increased risk for victimization, we can see here on the slide some data. The problem with the data is we don't have a lot of it. I think that's true with a lot of issues involving victimization, especially when it comes to abuse and assault, whether it be physical or sexual. But we do know that the adults in this particular study said that they are about three times more likely to experience unwanted sexual contact than people without autism. Now, this was adults, but it did include data and information from their lifespan. So, it could be that some of these things occurred in childhood but were reported into adulthood. But as we can see, kids grow up. So, regardless of age, between the last slide and this one, really telling us that people with autism are reporting higher rates of victimization really doesn't really matter on the type. So, whether it be physical maltreatment or sexual abuse, we're seeing these at much higher rates for folks with autism. And again, we don't necessarily know the reason, but we can think about some of the realities and the vulnerabilities that exist for folks with autism. So, for some folks, depending on what their needs are for support, they may have a reduced sense of privacy. And even their own body. They may have increased needs for having support around their activities of daily living. So, is it possible that people are assisting them with bathing and toileting? Again, depending on what their support needs are, that may be true or may not be true for an individual. We also see that, you know, there's this reduced expectation often for, like, life and achievement, where people don't necessarily think that someone with autism might be able to be independent in those daily living skills. Or perhaps they are not taught about what's okay and not okay. Because the people around them feel as though they will never have any sort of intimate or physical relationship with a partner, which we know is not, you know, not something that's true. So, a lot of these realities that kick in are based on myths and misunderstanding, which we, of course, want to break down. So, people may not be taught about things like consent and their ability to say no. So, those are things that we can see could potentially increase their risk. And even if they know that they can say no, there's this issue of socialization, where people are often taught to be obedient and passive, to get along, to not cause trouble. And that can certainly cause issues as well, where people feel as though they don't want to, you know, disappoint someone, or maybe they want the person to be their friend, or they've learned that in order to be friends with people, you know, you have to do the things they want to do, whatever the case may be. So, we have this sort of perfect storm of vulnerability that can exist. And even, you know, with some folks, they may have a history and potentially a documented history of what's considered maladaptive behavior. So, if they're having behaviors or those behaviors being misinterpreted, or if someone's seeing that this person has behaviors, and perhaps that that's a vulnerability, because they might be able to get away with, you know, the neglect or abuse that is going on, because they think that no one will pay attention to it. So, these are ugly realities, of course. And like I said, all based on, you know, some misconceptions and misbeliefs about people with disabilities, especially autism, and what their abilities are. Some other realities, just to sort of bring this all together with what increases risk, potentially for victimization. There is this issue of social isolation, where maybe people don't have access to, you know, services or outside of the people in their home, who are their primary caretakers, who may also be the people who are their perpetrators. So, there is this issue of social isolation. And for some folks, they may even have some difficulty being accepted because of the isolation, or just simply because of, you know, how they're feeling. I want to take you on a really quick journey back to this horrible phase of life that we call adolescence. Does everybody remember adolescence? Yeah. Anyone want to go back? Most people say no. Yeah, most people don't want to go back there. So, adolescence is, you know, not a great time for all of us. Everybody's kind of awkward and trying to figure ourselves out at some point during that time span that we call adolescence. So, I take you on that journey because it's hard already. Now, imagine that you have autism, and perhaps, you know, having those social relationships is even more difficult at a time when friendships are so important, right? And maybe you're feeling left out or isolated in some way. And for some folks with autism, that's true. For folks without autism, that's true. So, I think that's something we can all certainly connect on, that sometimes those relationship connections can be difficult. So, for folks that maybe have difficulty being accepted by peers or having trouble fitting in, we could see where this might be a time where they say, hey, I might do anything to make or keep a friend. And we can see where that victimization risk could also increase, because then they would maybe have someone say to them, hey, if you do this, I'll be your friend. Or if you don't do this, we can't be friends. Or this is what friends do. So, some of those manipulations that occur, that perpetrators use very intentionally, we might be able to see with all of these pieces put together, could create, again, the sort of perfect storm of vulnerability and ultimately victimization. So, just some realities to keep in mind as we think about communicating with folks with autism. So, we've talked some about the risk and realities. Travis, anything to add to what I've shared so far? Yeah. To build on what you just said, I mean, I've had multiple patients that were cognitively very close to neurotypical. And I had one individual specifically that was victimized in the way that in the neighborhood, he was so desperate to have friends that didn't have autism. And there were neighborhood children, he was a teenager at the time, that would come to his window at night, his bedroom, knock on his window, he would open it, and they would encourage him to go down to the local store and shoplift some things and climb into somebody's house and basically steal things. And that was something that he was so desperate to have a friend to go along with what you were saying, Stacey. The pitch that they were using for him was, well, don't you want to be our friend? We're your friend. Friends do these types of things. So, it's very unfortunate that our population are victimized because they do have such a need and such a desire to have those relationships. Yeah. Yeah. And that's such a great example, Travis, because I think it also highlights that it could be anything, right? It could be shoplifting, criminal behavior. It could be victimization. But really, it's the coerciveness of other people that leads to this vulnerability for folks. And that's really what it comes down to because other people see folks with autism as vulnerable, as someone who might be an easy target to manipulate. And that comes from lots of different things. Some of it's related to their diagnosis and some of it's just related to life. And sometimes it's hard to sort out where it's coming from because I've also interviewed lots of adolescents without autism who have said, oh, I did this because I wanted to keep or maintain or create a friendship. So, I'm not saying we have to say, oh, it's this or that, but just keeping in mind that we all are our experiences combined. And that's certainly going to be true for people that we work with with autism as well. So, it's just some additional considerations for susceptibility to victimization that we've talked about a little bit already. There are sometimes, depending on someone's skills and abilities, sometimes they have very fluent expressive communication. Sometimes they may speak a few words, may answer with single word responses. They may even use communication devices or not speak at all. So, expressive communication can certainly increase someone's risk because they may not be able to tell or have the means to tell about what's happened to them. I think referential communication is also important to understand. I'm going to put Travis on the spot to see if he has any examples of this. But what this means is often people with autism may sort of believe that you know all the same things that they do. So, as a result, it may seem as though they pick up in the middle of a thought or of a sentence. And this can be risky because they may feel like if something's happened that other people have the same information about it that they do. So, they may not give context all the time in the story that they're telling someone. So, that sometimes comes up. The thing that I can think of is, and it's a pop culture reference, it's not a clinic reference, is the Big Bang Theory in Dr. Sheldon Cooper, right? Where he just like makes these assumptions all the time that people know the things that he do or believe the things that he believes about life. Travis, do you have any other examples for some of those referential communication considerations? I do, not very specific to an individual, but it is something that we do see quite a bit. And as you said, some of our individuals, they are making an assumption that the information that they have is very common knowledge. And it is something that even in the process of trying to explain a situation, I've seen them have difficulty with that because the understanding is that you know what they're talking about. Now, this is something that we all deal with at certain times. We all tend to know more about a certain topic than others. And a lot of our guys with autism are the same way. And in the process, as it relates to being victimized, if they're believing that everybody has an understanding when a report is trying to be made or received from them, it's very difficult for them to express those specific pieces because a lot of the inferences, a lot of the unknowns that might come from a question being asked, they may approach it from what you already know it, whether they're even aware of that or not. They're answering it based on a level of prior knowledge that you actually don't have. So I think when you're interviewing an individual, giving them context within your questions without actually leading them on towards the answer, I think can be very helpful because even explaining to them, I don't understand what you're talking about. They may have a harder time wrapping their head around that because to them, a piece of knowledge they have is a piece of knowledge that everybody has. Yeah. So I think that's a great lead-in to, again, some of the vulnerability, but then also what do we do about it? So as providers, how do we overcome that if we notice it's happening, if we need context and it's not there? So one of the things that I've done before is I'll say to somebody, hey, I've never been to your house before. Maybe if they're describing something about the layout of their house, I literally say the words out loud, even though I know, and hopefully they know I've never been to their house, it's their reality, right? So maybe they expect that my house would be the same or that everybody would do the same kinds of things or have the same kinds of things in their house. So I tend to say, I've never been to your house, or I've never met so-and-so, or I wasn't there when the thing happened that you're telling me about. So tell me more about whatever the thing is. And some folks with autism can very easily say, oh, and then describe the thing for you that you need more info about. Other folks, as Travis is saying, may struggle with it. But just saying, I don't understand, they're going to be like, what do you mean you don't understand? Everybody understands. But if you say, I wasn't there, I've never been to, I've never met, sometimes those things can be helpful. And then they can sort of take it back and then describe what it is, the thing that you're looking for. Yep. Good. Good. And then a couple other susceptibility pieces specific to folks with autism. Sometimes, and I think this goes back a little bit to Travis's story about the shoplifting, folks with autism may not be able to detect deception and lying and danger are all things that people can't necessarily perceive, depending on, again, what their support needs are with autism. And I think that one thing that people do know about folks with autism is pretty widely understood. Hopefully this isn't me making assumptions about your guys' knowledge base on this. But most people know that folks with autism struggle with sarcasm. So sarcasm is something that people with autism don't always have a grasp on and sometimes need some additional information. Well, the reason is because sarcasm is lying. What do you think about it? Right? So if you understand that they don't, they struggle maybe with sarcasm, you can see how they would also struggle with detecting deception because ultimately it's the same because it's like me saying, Ooh, you know, I'm having a really good time when I'm not having a really good time. Cause that's what sarcasm can look like. So just something to add on to your sarcasm that deception goes on that list as well. And then the other thing that we often see with autism is this, and you don't have to remember these words, but the fundamental attribution error where people assume that if a person has a new behavior, that it's because of their autism diagnosis and not because something else is going on. So for people without autism, we may see a change in behavior. That's very sudden. And people go like, Oh gosh, hopefully from our trauma informed lens, you know, what's happened to this person or what's going on or what changed for them. Not that what's wrong with you, the, what happened to you mindset that we all try to be in. But what we see with autism is that people will say, Oh yeah, sometimes people with autism do that, or they have autism and you know, a new behavior has developed and that can be very risky. And we can miss a lot of red flags that way. Because those signs where a person might be trying to tell us that something's happening is ignored or overlooked and simply added onto a list of behaviors. And that's where we would want to definitely do something different and be paying attention to what the change is. So be watching out for those changes in behavior, just like we would with anybody else. And if there's a change in behavior, we do want to look a little deeper to have there been any other life changes for this person. So I had a case was a, it was a kiddo with autism and he started fecal smearing at school. So he was fearing, smearing his feces on the bathroom walls at school. And, you know, somebody was like, Oh, that's a sensory thing. People with autism do that sometimes. That was sort of the interpretation. And thankfully, someone else called and was like, hey, you know, we're concerned about this kid. This is a new behavior for him. And so, you know, we consulted on the case and I spoke with his mother and I was asking all sorts of questions about had there been any other changes in his daily routine, changes, you know, with people in his life, any major life events, has anybody moved, anybody born, anybody die, right? I start going through all these things. And mom's like, no, no, no, everything's been the same. It's like, okay, well, let's bring him in, you know, maybe do an interview, see what's going on. And so when she got there, I actually just sort of asked her again, I was like, hey, just want to check in. How's he doing today? Any major life changes? And then I think I must have gotten more specific with her. She's like, well, actually, you know, my dad was living with us and he was sick. So this would be the child's grandfather. And he passed away, you know, a couple of months ago, you know, came home on hospice to stay with them until he passed. And I was like, okay. And about how long ago was that? And she said like two months or whatever. And I was like, okay, and how long have these behaviors been going on? And it was like all the light bulbs went off in her head. And I was sort of like in my head, I'm like, gosh, that seems like a major life change, right? Grandpa dying at your house. Now we interviewed him anyway. He didn't make any disclosures of abuse necessarily, but we definitely want to take everything into consideration. So it doesn't necessarily mean that someone has been abused. Doesn't mean they haven't been abused, right? Could it have been that grandpa died and he was also abused? Absolutely. So we have to take all of those things into consideration. So people, just like people without autism may not come right out and say, hey, someone did something to me, or hey, this has been happening at home. They may talk about it or show or demonstrate it in different ways. And I know Travis, I was going to keep Travis up for a story he told us when we were prepping for this. So Travis, will you tell that story please? Absolutely. When we talk about change in behavior, when you see a drastic change in behavior, it's very easy to emotionalize that and try to assign it to a situation that may be occurring that we may be looking at it. Well, if this is a response to that, I would feel the same way. Something that we look at specifically for a lot of our patients, especially when you get into self injurious behavior, we look to see where it's localized. If an individual is hitting himself in the face or he's localizing more self injurious behavior to the head area, the first thing that we'll start looking at is, okay, is there some kind of underlying medical cause that could be doing that? I've seen kids that will engage in self injurious behavior to their jaw area because they have a toothache or to their facial area because they have sinus problems or they're getting headaches and things of that nature. So what you want to do is you want to, you can easily associate that to something that might be going on in their life from an emotional side of it, but you also want to be practical and look at it from the, what are some potential medical causes that could be leading to that? The other example that I do have with this is, we had an individual that had very high rates of behavior for many months and it had come down to nearly zero for several months. And then starting on one day back after a weekend, he had very high rates and it turned out his grandmother had actually passed away that has been living with them. And everybody began, including some of our staff, began attributing the behavior to, oh, well, he's sad because his grandmother died. He's gone through this traumatic event. Well, ultimately what was determined is he had two siblings as well, and they all had individual bedrooms. And then when the grandmother passed away, family were coming in for the funeral. So the parents put all three children in the same room and that child, because the adult is part of his routine, was completely thrown off. Now, I'm not saying he wasn't upset about his grandmother. That is something that is absolutely true. But when everybody left and he got his room back, the behaviors immediately decreased. Now, can we make true causation? Not necessarily, but it is something to factor in. So kind of looking at this, any change in behavior can be red flags, but you got to be really scientific about looking at it. And for us, atypical is atypical. So our kids have a typical pattern of behavior. And even if it may seem odd to us, it is their pattern. So when that changes, we tend to look for something else. But we always want to keep an open mind as to what is going on and not necessarily say, well, this behavior in a neurotypical individual would indicate clearly that there is some kind of abuse going on. It doesn't necessarily mean that with one of our individuals. So we want to always dig deeper. Great examples, Travis. And I agree, it's a change in behavior is a change in behavior. So are we talking about, and I don't mean to categorize them either, even if it's positive behavior, what is positive behavior, right? That's subjective. But even if it seems like a change, decreasing behaviors versus increasing behaviors, that's a change. What's going on here? And Travis's point, looking at that scientifically, as well as emotionally, because we can't always link cause and effect. And even as you're telling that story, Travis, I'm thinking about my case and like, gosh, maybe it wasn't the death of grandpa, maybe it was the disruption to the schedule as a result of the death of grandpa, right? Was it grandpa moving in that may be disrupted versus grandpa passing away? So hard to say for certain, but that was the event, right? Something about that change to their life, whether it be emotional or sort of structural, if you will, to their day-to-day routine, any of those things that disruption could cause, you know, an increase in behavior or decrease in behavior or a change that we're encouraging you to look for. Great. So things to think about. So I'm actually going to share a tool with you all. And this is the autism behavior checklist. And this is different. I'm going to make a very good, big note here, different than the aberrant behavior checklist. Did I say it right? Aberrant. I knew I was going to screw it up. The aberrant behavior checklist, which has the same acronym. So it can be difficult. So this checklist that I'm going to share with you all was originally developed actually for school settings for school professionals. But I do think that it can be helpful for professionals in any setting when looking a little bit more objectively at what this change in behavior can look like. So what we do is we gather some information from a reliable party could either be the person or a parent or guardian or someone else who is around an individual on a regular basis and sort of go through this checklist. And if four or more of these things get like a positive check, it should be an indicator to us that we should dig a little deeper. Now, it does not mean for sure that if we check four or more of these boxes that someone absolutely has experienced abuse, but it's just a helpful tool in sorting out what Travis and I have been talking about the difference between new behaviors, existing behaviors, how do we attribute those behaviors and not making assumptions about them. So like we said, it could be after a change in routine and maybe considered normal, because again, what's normal. But, you know, if there's a change or if they experience them over a long period of time, there are things that we may want to look at. So there is a handout for this that I believe you all got. And if you didn't, you will. So this breaks down the checklist one by one along these slides, but it is on like a checklist sheet as well. So if there's any new behavior that involves fecal soiling or bedwetting, other urinary accidents, or an increase in sensory seeking behavior, specifically oral, that did not exist previously for this person, this is where they would get a checkmark. Okay. On this checklist. So we would give it a check. Number two, you can see is where we would talk about things like oral sensory defensive behaviors related to things that maybe weren't there before. So could be a dislike of food textures, brushing their teeth, just as a couple of examples here. Thank you. And that just put the checklist in the chat box. So if you guys want to download it, you're welcome to. Tactile seeking behaviors that, again, didn't exist previously, or defensive behaviors related to things that, again, previously were not avoided. Pro-preceptive seeking behaviors that not previously exist. So this can be looking like people that are overly aggressive with their body, or if we see like humping around, bumping into each other, people, things like that, or defensive behaviors in the same way, avoiding body contact. I actually had a kiddo with autism. I interviewed one time and I was doing a safety talk with him about touches to the body that would be okay or not okay. And he goes, I actually don't like when anyone touches me ever anywhere. Okay. But that was a normal for him, right? That was his sort of baseline. So we wouldn't check that here because that's something that existed prior. So this is just for new or additional behaviors. So keeping that in mind and sorting those things out. Increases in echolalia. So echolalia is when folks will repeat phrases or words that they hear during conversation. And if that is increasing and previously wasn't there, are things that we would check for. Any increased anxiety, this noted under, again, normal conditions could be increased rocking, pacing, fidgeting, disruptions in sleep, things like that. Or if there's any sort of increase in what we would call those self-regulatory behaviors. So are they vocalizing more, hand flapping, things like that, or an increase in self-interest behaviors. And there's some examples here. Could also be that they have an increased sensitivity to any other sensory inputs like visual or auditory. So sights or sounds. Or if they have perseveration on new items or topics, especially if they're related to sex or sexual activity. And if they have increased difficulties with other transitions. So these are all broken off into five slides, but each of them is their own item. And if there's other behaviors, there's some space for that, too. But these are sort of the things to look for that often, like I said, get attributed to autism and overlooked, even if they're new behaviors. So it could be that it's ongoing. And that way we don't check it. But if it's a new behavior, that's where it would get a check. And then four more checks would tell us, let's dig a little bit deeper. So let's look at a case example for this. Keeping in mind the checklist and all the things we just went through. And we want to open the checklist to go over this example we can. So we have Emilio. Emilio is 20 years old and has a diagnosis of autism. Just like in the case I shared, mom reports that there have been no changes to his daily routine. He communicates vocal verbally, so he speaks. But when you first meet him, he's kind of echolalic. Now we talked about echolalia, an increase in echolalia. But it looks like for Emilio that this is a baseline behavior. We know that when he meets people, he's echolalic. So that wouldn't necessarily warrant a check. Presents with vestibular and tactile integration disorder. Again, ongoing. We see him rocking and constantly touching things. Now this could potentially be a check. So this is where we would want to look to mom or someone and ask some more questions like, hey, is this a new behavior or an increased behavior? So mom reports that the rocking and touching are new, although he's always liked to fidget. So we see the rocking and touching are new. That's going to be one check. All right. So you see how we're sort of sorting out what is ongoing and what's new behaviors. He recently started vocally perseverating about dogs having sex. That's going to be another check because that's a new behavior, vocal perseveration about dogs having sex. He can independently take a bath, dress and eat. So he's independent in those. Just helpful for us to know. Recently started having accidents. P accidents. So that's our enuresis. We're up to three checks. So we've got the new vocalization, the recent accidents and the rocking and touching. So three out of four. And we have another slide to go. Emilio is generally calm, but when he doesn't get his way, he tantrums by screaming and hitting. That's not new behavior. He sometimes has difficulty transitioning from one activity to the next, especially if he's really focused on that activity. Also not a new behavior, but good for us to know. When he gets nervous, he bites his hand, but that's also not a new behavior. Something that's been ongoing. Emilio is very rule governed, which a lot of folks with autism are rule governed. Recently, mom walked into Emilio's room and saw him mimicking sex with his stuffed bear and he was crying. Check number four. If we go back through the things. So we now have four things that we know about Emilio that are new behaviors or concerning behaviors. Two of them related to animals probably need to be asking some more questions of Emilio and sorting out what's going on. Now for me personally, as an interviewer and the role that I had, if I had this last bullet point, I wouldn't need the other three because I'm like, okay, what's going on here with Emilio? Seeing something, hearing something, experiencing something. Let's see if we can get that sorted out. So then we would use this checklist to try to sort through that. And again, we saw where those four checks lived. So it's not a completely foolproof tool, but it's just a way for us, I think as professionals to look at it a little bit more objectively and maybe even ask people around them, is this something that's happening? Is it new? Just as a way for us to sort through those new behaviors versus existing behaviors and not fall into that trap of believing that all behaviors that a person is having is a result of them having autism. So we want to make sure that we're just asking a few more questions and not missing red flags, but also not assuming that all behaviors are because someone's been abused either like we were talking about before. So just a way to look at it a little bit more. Travis, do you have anything to add or share with this behavior checklist piece? I want to hear what you're saying, but you're on mute. I always do that. Not specifically to what you were saying there, but I do agree that looking at all the list of behaviors here, I like the way that you approached it, that you're going to investigate it more. And I think that's the key with each component here is to investigate it and not immediately jump to a conclusion. But these are definitely indications that will steer you in a certain direction. So I think this is a great tool to encourage deeper conversation with the caregiver and eventually or at the same time with the patient to really see if there's, that's when you get into asking different probing questions and different questions that are a lot more open-ended. So you can get different responses back and you can then shift your conversation in that direction for sure. Yeah. Thanks, Travis. And upon further investigation, this is based on a real case, by the way. It was discovered that Emilio actually was being abused by someone in his home. And part of that abuse included some animal pornography that this person was showing him. So there was the animal pornography and then the sexual abuse to Emilio as well. So whether or not this was his process, his way of working through that new information, but this is how he presented with some of that with the talking about dogs having sex and then the stuffed bear are things that could be related to that or not seems pretty connected to me. But I'm glad that somebody saw those behaviors and said, hey, let's dig a little deeper, see what's going on with Emilio here because they did uncover some sexual abuse that was going on at home. All right. So that's the ABC in case we need it. You guys have it. Feel free to use it. All right. So now that we have some of the risks and realities and statistics figured out, let's talk a little bit more about communication with folks with autism, with and about folks with autism. So I want to start by talking about the difference between person first and identity first language. So person first language is sort of the way that Travis and I have been talking, individuals with autism, people with autism. And usually I'm going to encourage everybody default to that. Start with person first language. And then if you're corrected by somebody, you can adapt. Identity first language is just a little bit of a different spin. So it's founded on the idea of the social model of disability, which implies that while disability can limit individuals in some ways, it's really the inaccessibility of the environment and society that makes people have disabilities. So it's just a slightly different take on it. And for some folks with autism, they prefer to say I am autistic, right? They see autism as a piece of, you know, a sense of pride. Sometimes there's cultural associations with having autism. So if the person refers to themselves as autistic or their child as autistic, it's okay to use those words. Like I said, as a professional, I usually just default to that, you know, your child has autism versus your child is autistic. Travis, do you have any additions to that? I do. I mean, this is something that is evolving within the disorder right now, and even there, using the word disorder is something that, depending on the way somebody looks at it, in some circles, the term disorder can be offensive. So using person first language, we would say an individual with autism, a child with autism, an adult with autism, the identity first would be an autistic child, an autistic adult. But there are so many different viewpoints of that right now that I think, as you said, Stacey, asking first, like how do you, what do you prefer to be referred to, or how would you prefer us to refer to your child, something like that, is critical. Because you may have five different individuals, and they all may identify using five different sets of terminology. So whereas before, the default would be person first language, which we do at the hospital, but we are aware and sensitive to others, other viewpoints. Yeah, it's just constantly evolving, I think, like most things. And it's a matter of paying attention to the words people use. And like Travis said, sometimes just straight up asking people is really the best way. Like, let's just get this out there and make sure we're all on the same page as we begin our journey together, whatever that looks like for you in your role with them. Language is powerful, as we know, and I think it's important that we pay attention to the words that we use, and we're intentional with the words that we use. And that end, we're also going to talk about some of these terms. So I'm wondering if you all have heard terms like this before. Oh, you know, this is, this is Benny, he's 24, he has autism, and he functions like a five year old. Guys heard stuff like that before? Yeah. Or has the brain of a three year old or the capacity of a five year old, whatever it is. So these, I think people have good intentions when they use these words, I just want to be very clear about that. I think people use them with good intention. But there's some difficulty with them also. So my first struggle is that function does not have any universal understanding. If I were to ask you all, what does function look like? We would all have a different idea. I have the same issue with five year olds, quite frankly, because are all five year olds the same? They just aren't, right? 15 year olds aren't the same 55 year olds aren't the same 85 girls aren't the same. So we all have a different mental model of what a five-year-old can do or what they look like or what they act like. And my last issue with this, so there's three, function doesn't have universal understanding. We all have a different mental model of age, five, three, whatever, based on our experiences. And my last issue is that it's incredibly infantilizing. So if you have a 24-year-old and someone says they function like a five-year-old, you have now discredited 19 years of their life experience. And I think that that's one of the things that we can get really dangerous in because as a provider, if you walk into a room and you've read someone's chart says they're 24, but they function like they're five, chances are pretty good you're gonna treat them like they're five, subconsciously even. Like you're not gonna do it intentionally, but you're gonna walk in and think, ooh, I need to be at the level of a five-year-old, which again, we don't really understand what that means. We all have a different idea. So we want you to avoid using these words, function, brain up, capacity. And I know it's hard because we have a lot of things to talk about, but if you can avoid them, we would appreciate it for all the reasons that they are problematic. Instead of these words, I'm gonna give you some other ideas. So it is that they function like a five-year-old. Ask some more questions, okay? So what kind of assistance do they need, right? What are some of those activities of daily living? Even better, and you'll see that a lot of these are very strengths-based, what's their level of independence? What can they do well? What can they do on their own? What are they good at? What's their best skill? Do they have any support or behavior needs that we should be aware of? So much more useful than functions like a five-year-old. I'll give you guys an example. So if you have somebody that you're working with in a medical setting and someone says they're sick and you go, yep, they're sick, is that helpful, right? What does sick mean? Sick means different things to different people. So we have to be more descriptive. What are their symptoms? What does sick look like? Same thing, function, capacity, brain of. What does it look like? Give me observable skills. That's what I wanna see. And I wanna see that in documentation and in our conversations. I know it takes a little longer. We already have a lot to do, but it's gonna be more useful for you as a provider and the next person who reads their chart because that stuff goes there forever and they're gonna be reading it. Other people are gonna be reading and interpreting that information. Travis, anything to add on the function piece of that especially? Yeah, one more component with that. And speaking of the brain of a three-year-old or functions like a five-year-old, sometimes that concept can actually work in the opposite direction as well, where you might have a three, four or five-year-old who has autism who may be hyperlexic, meaning they can read anything that's put in front of them or they have memorized the whole series of dinosaurs and they may demonstrate some cognitive abilities that would seem very much higher than a five-year-old. So people will tend to approach them that way quote-unquote genius level when that changes your perception, the way that you're going to see somebody and you're seeing somebody who is chronologically five years old and you're thinking, well, they know this, this and this that a typical five-year-old wouldn't know. So they must be much higher functioning. And I'm using, again, those terms too, higher functioning, low functioning. But it becomes something where the perception then is their abilities are higher than they might actually be. And that can also change the way that people look at it behaviorally. They can see more of, oh, well, he's being non-compliant and he is just, he knows this, he can do this, he's just not. And that perception is put in place simply because again, that phrase functions like a five-year-old, but he has these other skills. So we try not to get anywhere near that as far as putting a specific age level. We do look at developmental milestones, but even then our guys develop differently and they may hit certain milestones at a much early age than the typical population. Some kids, I've seen kids that will go from not being able to move right to walking and they didn't crawl. And it doesn't necessarily mean that they're extremely advanced. It just means that's how they develop. So if you're using developmental milestones, even there, there's that, you should approach that with a level of caution as well. Thanks, Travis. Yeah, and I know that some of that, even like high and low functioning stuff we're trying to move away from, but we don't really have a good thing to replace it with yet. So for now, I would just say, observable skills is our best bet. What are the person's skills and abilities? Because that I think will speak more true to the person's abilities than functions like a five-year-old whether that be that we're overestimating, Travis' example, or if someone may be infantilizing the individual. Same issue that I have with non-verbal. So non-verbal also goes right up there with me, for me with function, capacity, and brain of. If I were to ask you all, what does non-verbal mean? We would all have a different definition based on our experiences. So it may mean that the person doesn't speak at all, may mean they use few words or have some sort of communication device. But what I found in lots of different areas is that people will put non-verbal, no interview attempted, or non-verbal, no history gathered. And that's where we really get into that dangerous territory of assuming that a person who doesn't speak or uses a device doesn't have anything to say. And I heard a quote that really spoke to me and I'm gonna share with you all. It was assuming that a person who doesn't speak has nothing to say is like assuming that an adult without a car has nowhere to go. And I think that that is really helpful because it's like people have experiences, they have stuff to share. And most of us have someplace to go at some point. So just remember that the vehicle in which they accomplish that could be different, but it doesn't mean they don't have anything to say. So please make sure they have the opportunity to share. If someone shares with you that a person is non-verbal, ask some more questions. Let's go to some more, you know, maybe helpful, useful prompts. How do they communicate? And you'd be shocked. You might say, do they speak? And someone might say, yes. Or do they have any gestures? Do they write, draw, text, type, any other way that they communicate? There's so much technology available and we need to make sure that we're asking all of these questions about how they communicate with folks. If the answer to all of those is no, the next one I like to ask is, how do they get their needs met? So how do they let the people know around them? I'm hungry, I'm thirsty, I'm tired, I don't feel well. How are those things communicated? Is it a change in behavior like Travis is describing or is it something different? Do they understand you? I like to follow that up with, how can you tell? Can they follow, you know, two, three, four step directions? What does that look like? And then do they have any devices or is there anything else I need to know about how they communicate? Way more helpful than nonverbal, no interview attempted. So please still try to gather information or at least find out how they share information. Anything to add to that, Travis, the nonverbal stuff? Yeah, one element with that is, again, probably going back to more statistics, but statistically 46 to 50% of the population with autism is neurotypically on balance, if not higher than the typical population. So when we're talking about an intelligence level, they're at the typical, if not higher. And thinking of that, there's a much higher percentage than 50% at times of individuals with autism that are nonverbal. So looking at that, I've had plenty of patients that were deemed nonverbal that intelligent wise, they were on level and they were able to understand what was being said, they were able to understand the situation going around them. They just didn't have the means to be able to communicate that back. So going into a situation, seeing a child who is deemed nonverbal or has a different level of communication, don't use that as an indication of their level of understanding. I had an individual that had selective mutism and he didn't speak until he was eight years old. And he would tell stories about situations that he had been in at a younger age, what people had said to him, and he could quote that verbatim, word for word. And this was an individual at the time who they had deemed completely nonverbal. He was aphonic, where he wouldn't make sounds. So everybody assumed he had no idea what was going on. He understood everything. And it was years later that he could tell me what was being said. In fact, he was telling me situations when he was nearly 60 about something that occurred when he was five. So you never know. That was such a great example too, Travis. One of the things we always say at MCG is we should be assuming that someone has normal intelligence, right? We should start there. Assume normal intelligence until we get more information. And I think that that helps in both directions, right? We don't want to, again, assume that a person doesn't know what's going on. We also, like you said, with some folks with autism are off the charts smart. So we don't want to assume that all people with autism have that genius level intelligence either, because I think both are misconceptions. So just start in the middle, you know? Just start in the middle, and then you can sort of work your way up or down if you need to in order to communicate effectively with folks. But for the most part, just assume normal intelligence with everyone you meet, and you're going to be a whole lot better off. We don't like to make assumptions, but we can make that one, I think. And that can help us to avoid, you know, going in either direction, which is good. Because, you know, there's a lot of folks, and there was a study that Scott did, my boss on, he did with peace officers about their interpretation of autism. And everybody, and it was a few years ago, it's an older study, which is why I don't include it anymore. I told him he needs to do a new one. But it was, everyone pretty much said that their understanding of autism was Rain Man, right? Like that's, when they hear autism, they think Rain Man, which can be a representation of what some people with autism may, you know, present like, but it's definitely not what we see in this wide spectrum of abilities with folks with autism. All right, so how do we take all of this into our communication with folks? So some things to keep in mind when you're working with a patient with autism. Some folks with autism, we have to take consideration on the pragmatics of communication. So it may be that a person with autism may talk really close to you. And I smile when I say this, because I always think of someone I interviewed who was very close to my face. So physical proximity may be that they're really close, really far away. They may talk really loud or really quiet, you know, not necessarily have some of the social graces nuance of those pragmatics of communication. It may be that the person does or does not make eye contact with you. And that is something that is okay. This part is interesting to me because having interviewed so many people who've experienced trauma, I never expect anybody to make eye contact with me anyway, but I think societally we struggle with that sometimes where if someone's not making eye contact, that's either seen as deceitful or as disrespectful. So just doing our best to sort of wash that away, but it's hard, especially culturally for us sometimes. Some folks with autism may laugh inappropriately or may even discuss topics that are not related. And that can be any topic, or it may be a hyper-focus on a particular topic or subject as well. And it may be that while they're talking, they are kind of monotone and maybe have a flat affect, which also just having talked to so many people who have experienced trauma, something we expect anyway. There was actually a study that was done with kiddos without disabilities, without autism. And they found that the more abuse incidents that they'd experienced, actually the more flat their affect was. So really shouldn't be an indicator one way or another, but sometimes people make judgments or assessments based on someone's facial reactions. But at the same time, we're trained to observe all those things, right? So it's hard to say, oh, ignore it, because we don't want you to ignore it, but we don't want to put too much stake in it either. So keeping in mind that communication may look like this or may look different, but just not making assumptions or conclusions based on someone's communication, their facial expression or lack of facial expression. Something that we can do to help people with autism. And really we do this with folks without autism too, but there's a specific tool that can be used and it's called a social story or a social script. And I'm gonna show you two examples of what those look like. These were both developed. One, the one on the left, I'll start with, with their gray background. So this is an individual social story. Someone I was interviewing uses a pod book, P-O-D-D, it's about this thick, and it had a bunch of tabs in it with different categories. So she did not speak, but she used this pod book to communicate and people used it to communicate with her. So when I asked questions, I would use her pod. And when she responded, she would use her pod. So before I interviewed her, I met with her speech pathologist and she developed the social story so that the child knew what to expect when I was interviewing her. So you can see the lines here and these are pictures from her pod that she was familiar with. So it says, I will be meeting and talking to a person named Stacy soon. And you see, there's even a picture of me. My hair is a little shorter, but that's me. There's a picture of me. So she's seen my face, not for the first time when I walk into the room. We did a multi-session interview with her. I met with her two times. So we wanted her to know that she sort of had two chances to talk with me. Stacy will ask questions. My pod book, so she knew that she could use the book. I can use my yes, no cards. I can say, I don't know, cause that's always an acceptable answer. Didn't want her to think she had to answer all my questions. She can take breaks, which is true. In this instance, I was doing the interview at a child advocacy center. So people were watching and we were making a recording. So we wanted her to know that. These are grayed out for confidentiality, of course. This is the interpreter, because at home, the family also spoke Spanish and I did not speak Spanish. So we had the Spanish speaking interpreter there with us. What I see is a picture of her. And then the message was, the team wants to keep me safe. So this was an individual. Not always easy to meet with a speech pathologist and get these things ahead of time, especially if you're meeting with someone in a more acute setting. So what we did also at My Child Advocacy Center in New York is we developed a social story that's on our website that anybody can access. So it's in PDF form and this is just one page of it, but it's multiple pages long. So that people knew what to expect when they came. So if you're working in a setting where you know that someone's going to be coming in, might be something to consider developing and having available for patients and caregivers to look through and have some familiarity with what to expect when they get there. And I know a lot of times people do like brochures and have conversations, but this is, the social story is a very specific tool that can be helpful. So again, this was just one page of the waiting room and has a simple phrase about what to expect when you're in this place. But there was also a page for the interview room, the medical exam and things like that as well. So people knew what to expect at each stage while they were at the Child Advocacy Center. So we found this incredibly helpful. It was something that we worked with experts, speech pathologists to develop, to make sure that we did it correctly because there's specific components that need to exist when developing them. And we were able to have people with and without autism access it so that they could see the whole thing. Yes, I will put the website in the chat box during our Q&A session when we finish our content to let you guys know where you can access and see that example. Absolutely. Travis, do you have any ads with social stories? Yeah, of course. I do. One quick add to this, to the example you have on the left in gray, it's a pod book. There's also something called a picture exchange communication system, PECS. They call it PECS. It's the same thing. So if somebody comes in and says, well, my son uses it or my daughter uses a PECS book, it's the same thing. Yeah, great example. Travis, in good addition, there are so many communication devices that exist. So I always like to point that out too. Someone may have an iPad, but there's also hundreds of applications for communication. So don't assume that just because you've met somebody who uses a device that you're familiar with it, because they're also customizable, right? So people will put things in there specific to them and their family and their likes and dislikes and things like that. So in another talk that I do, we talk about communicating with folks when they use devices. And I will spend an entire first session just familiarizing myself with the buttons in their device or the pages in their book. With this case, they actually had a duplicate of this book and I took it because I traveled to do the interview. I took it back to my hotel and I studied it the night before the interview, so I had a chance to prepare. So yes, communication devices are very wonderful, but very customized. A couple of things going on in the chat box just so you guys see. I put in the Child Advocacy Center that I used to work with Vovona, cac.org. So the social story is a tab on that website if you guys wanna see the whole thing and would be happy to talk more if folks wanna email me after about if you're looking to develop, happy to assist with that moving forward. All right, a couple other things that we wanted to talk about with communicating with folks with autism. So perseveration can often happen when a person maybe has difficulty transitioning from one activity to the next. That's something we saw with the Emilio case, especially if he's focused on something. Some ways that we can work through that is giving predictable warnings. So letting people know, like, or five more minutes, or, hey, we're gonna do this, and then this is the next thing that we're gonna do. So giving warnings instead of just saying, okay, stop doing this, now do the next thing, because I think that's hard for most people to just sort of shift gears. We need some in and out time. So make sure that people know what to expect. So if you're working with them in any sort of setting, giving them a sort of outline, even when they get there, about what's gonna happen. Now, that can also be difficult because we can't always predict what's gonna happen, but giving them a general outline of this will happen, this will happen, this will happen. But we don't wanna make promises either because we might not be able to keep those promises. So it can happen if a person is having difficulty transitioning, so making those transitions clear and predictable can be helpful with that. A person may also have a hyper-focus or perseverate about a particular item. For some medical providers I've talked to, it may be one of your devices, could be stethoscope, could be something that you're using to check the person's eyes or ears, may become sort of obsessed or have a lot of questions about it. Often redirection strategies will work. Some folks though, it doesn't work. I will say, don't ignore it if it happens is the one thing that I can say for certain. So if they have questions about the thing, just answer the questions because if you pretend they're not asking the questions, for some folks the perseveration will then get more intense. So usually it can be a simple redirection of, oh, I see that too, or thanks for telling me about this thing, or I see you have a lot of questions about my whatever, what were we talking about before? Or here's the next thing we're gonna do. And you might be able to redirect them off of the topic. It may also be that they are hyper-focused on an area of interest. So do they know a lot about, thinking about cases that I've had, trains, Travis mentioned dinosaurs, or anything else, a particular topic. I think about Dr. Sheldon Cooper and his fun with flags, his obsession with flags is something. So all of those things someone may perseverate about. We have a video example in one of our other trainings. There's a gentleman who perseverates about casinos, actually loves to talk about and go to casinos. So it could be anything. And again, we don't want to ignore it, but I do want to pay attention to it because what I found in my interviews with folks with autism is that they're engaging in perseveration, especially about a topic of interest. It's usually in response to something. So, because I'm asking hard questions, talking about hard topics, are they using that topic as their safe place? Because either they don't want to talk about it, they don't understand my question, they don't know the answer, and they maybe just don't want to tell me those things. So I always encourage people to pay attention if there's a pattern to the perseveration. Is it always when you ask a particular kind of question or try to talk about a particular kind of topic? If the perseveration increases, might just be an indicator to you that there's something deeper going on. So just paying attention to that. Travis, any notes about perseveration or hyperfocus? Just to, I think you've kind of touched on this already, but listen, I mean, when they're going through the perseverations, it is something that they're going to default back to. It tends to be something that they're very familiar with. But even within the middle of that, you can sometimes hear deviations from a topical perseveration that may indicate a little bit difference going on. That may be something that you may observe during your interview that you may bring up with the caregiver or somebody that's there would say, okay, you know, I noticed when he was talking about like all the trains, I know that that's one of his things, so to speak. But in the process of talking with him, I noticed that he brought up a very specific train and or a very specific time about when that train runs. And is that something that you see typically? Again, could very well be nothing, but it's something to continue that conversation with the caregiver, because that might be indicative of an alteration in pattern of behavior. Yeah, so again, just that change, right? Pay attention to it. Whatever's going on, don't ignore it. And listen, listen intently because you learn something. I learned a whole lot from the people that I've talked to with and without autism. People teach me things all the time. Something else that you may see is echolalia or delayed echolalia. This is when someone usually repeats words spoken by others, but it may be their own words as well. Echolalia is normal in language development in young children. But, you know, for some folks, something that carries through their lifespan if they have autism. Some folks will engage in echolalia through their whole life or delayed echolalia. Important to note that it's not random speech and it's not like Tourette's syndrome, right? Where you'll get this like sudden vocalization of some kind. Usually it happens when the person knows it's their turn to talk because the other person stopped talking. So they'll repeat maybe the last thing that someone said or something that they heard previously. So I had an interview I did with a kiddo with autism and every once in a while, he would say, talk to Ms. Stacy and see mom and dad soon. Talk to Ms. Stacy and see mom and dad soon because that was the last thing his mom said. And that was usually an indicator to me that, okay, what's going on here, right? He's got this increase in echolalia. So is he feeling nervous? Is he feeling uncomfortable? Does he not know the answer? Did he not hear me? Paying attention to that. So I would always just reassure him, yeah, we're talking and you can see your mom and dad whenever you'd like, they were right down the hall. So that was true, right? I don't wanna promise him something I can't deliver on, but that was true. And then usually I could redirect him and he would be able to come back to the conversation with me if he wanted to, knowing that he could leave if that was his desire at any time. So when we think about echolalia, time is a big one. We wanna take the time to not just give up if someone becomes echolalic. We also know that when we talked about this in session one, if you were able to join us, folks with autism have higher levels of cortisol at baseline. And when their cortisol increases because they're experiencing anxiety or stress, if we reduce that would also reduce them being echolalic, which requires patience. So time, patience, and taking that investment in reducing anxiety of the person you're talking to through building rapport or whatever that looks like because that anxiety could increase the amount that they are repeating or engaging in echolalia. The other element, just to factor into this as well when it comes to delayed echolalia, which is that repeating phrases, I have had patients that used a lot of delayed echolalia, but they learned to speak that way. And that became their form of communication. So I had a child who was repeating, oh, poor poo, you got your hand caught in a honey jar. Oh, poor poo, you got your hand caught. What he was doing is there was a situation where he was in trouble, quote unquote, and he needed to get out of the room and the room was locked, the door was locked, and he was pulling on the door handle. But he went back to that, and that was something that he related to a Winnie the Pooh story, that Winnie the Pooh was in a difficult situation, needed assistance, and it became, he was using that language because he didn't have the language to say, I don't know how to get out or I can't unlock the door, I need a key or something like that. Yeah, great example. See, Travis, I knew when we were talking that you were gonna have so many good examples of this. I love that one for a delayed echolalia. But once you know that, right, about the person, it can be helpful in understanding what it is they're trying to express to you. That's great. In communicating with anybody, just remember that we need to be cautious of our tone and avoid those conversational punctuations that can come off kind of sending, like, really, wow, good, you do? And even, I see. So I was interviewing a child with autism one time and I said, I see. And he goes, you didn't see, you weren't there. And he was correct. So even those conversational punctuations that we use regularly can be problematic. So be careful of those. With every person that we talk to, making sure that we're taking the time to really establish rapport. And establish a thorough baseline on how they communicate. So this comes back to a little bit of that assuming normal intelligence, meeting the person where they're at. And we call this narrative practice piece is something we use a lot in forensic interviewing, but it's also a great tool for anybody by saying, tell me the reason you're here today. Tell me about your family. Just asking those open-ended questions to see how the person does with them. Now, sometimes those questions are too big and we may need to adjust, but really asking questions in the most open-ended way possible to get a really good assessment of how the person answers questions. And just making sure that we're constantly thinking about establishing and maintaining rapport to reduce anxiety, get a good glimpse of what their skills are. And to make sure that we're meeting them really where they're at in that moment. So sometimes we hear things like, oh, people with autism can't handle, right? These kinds of questions. So this is a study about question type for both children with and without autism. What we found is that open-ended child-led recall prompts, which I'll give more information on what that means, gave us more accurate information. So asking questions like, tell me more about and using their exact words, which is also what we call a cued invitation, which is the third bullet here. That gives us more detailed accounts than any other prompt type. And option posing or multiple choice questions gave more errors, especially when there was a longer delay between when something happened and when they were talking about it. So we know that these open-ended child-led prompts really give us the best information. Interesting because I think when people have autism, we try to make our conversation easier for them in some way by like asking yes, no questions or reducing the mental load for people when asking them questions. But really that's where we get inaccurate information and that's what we want to avoid. So we want to use these cued invitations, also called anchoring or cued narrative prompts. They're called lots of different things. But if you say to a person, tell me the reason you're here today. And they say, I got hurt or something like that. And then you said, you said you got hurt. Tell me about you getting hurt. We're using their exact words and asking for more information about it. Take the last thing they said, ask for more information. Most of the time, we know that this is going to give us accurate information from those folks who can communicate vocal verbally. And even for folks who can't, when I say tell me about and they have a device, they take that prompt to the same way and we'll use their device to share with me as much as they possibly can. So really this all comes down to, like I said, establishing this baseline through the different question types. Now, for anyone who's had any sort of forensic interviewing training, this may look familiar. If not, it's going to look brand new to you and that's okay. So the question funnel, as we like to call it, is pictured on the right and it has narrative prompts, which are those tell me about questions at the top. The reason they're at the top is because they are the most reliable question type and they also give us the most amount of information. So we want to make sure that we start with those. But some folks do better with open focused questions. So the young lady I interviewed who used the pod book that I was telling you about, she did best with open focus questions. I could say who, what, where, she could answer those perfectly. I'd say, tell me about, and she would just stare at me. So that question type didn't work for her. So really we want to take the time to start at the top with our most reliable question type and sort of test the different questions and see how the person responds. And that's where we get that baseline of how they communicate. What we want to avoid is the, did you do this? Did you do this? Did this happen? Straight yes, no questions, which I know are hard because in the medical field, we get those questions a lot. Are you having any pain today? Are you having any symptoms? Those are often the kinds of questions that are asked, but just encouraging you to think more openly and narratively when getting histories from books. Few other strategies to think about. We're going to go through a few. The first is be concrete and literal. This sounds easy, but it's actually very hard because our English language is full of words that have multiple meanings. We can be most concrete and literal when we use their exact words because then we know that we're not paraphrasing or making any assumptions. We can also do this through using proper names instead of pronouns. Pronouns can be difficult. He, she, they, them, his, her. So just use the person's name or however the individual identifies them. If they use a nickname, that's fine. Go with the nickname, but use names instead of pronouns. Where was she when that happened? It's a really hard question because who's she and what's that, right? We want to be cued using their words and we want to avoid those pronouns. So that's one way that we can be concrete and literal. When talking with folks, we also want to avoid figures of speech, idioms, axioms, hyperbole, sarcasm, as we've talked about because sarcasm is lying. So we want to avoid that. Our language, again, is full of these figures of speech. So doing our best to avoid them so that people understand what we're saying and they know that we mean what we say and say what we mean. We also want to avoid any questions that are posed in the negative, like you don't like Frank. So that's a hard question because if I ask you don't like Frank and you do like Frank, you have to say, this is where I always get confused, you have to say, no, it's not that I don't like Frank. Yes, I do like Frank. So the double negative becomes very difficult. Compound and complex questions should also be avoided. So that's when we put more than one concept into a single question. One of the common ones I hear is, does anyone use drugs and alcohol at home or drugs or alcohol at home? Drugs and alcohol are two concepts. The other difficulty, let me go back to being concrete and literal, people don't use alcohol, they drink it most of the time. So anyone use drugs and we may even need to get more specific with how they use it. Does anyone drink alcohol? So avoiding questions that have multiple concepts within them. Does anyone hit, punch, kick, or slap you at home? Lots of concepts, we need to break that down. With stacking questions. So how are you doing today? What have you been up to? That's a stacked question because there's two questions there. So we need to avoid both questions that have multiple concepts and asking two questions at once. And then repeated questions can also be dangerous because you may feel that they got the question wrong and so they're gonna change their answer. Going back to some of that wanting us to like them thing. Something else that's a little bit more specific, a tool to put in your toolbox is what's called a high probability or an HP instructional sequence. So this is if someone becomes echolalic or begins perseverating or gets stuck in some way in your conversation with them. It's a way to build momentum to get them back to that response effort for you. And it can be done communicative with gesture or with motor movement as well. So I'm gonna give this example and I'm gonna let Travis share it cause it was an example that he put in here. So this is an example that you might use with a child for a high P example. This would be basically what you're doing. You're gonna ask three to four very simple questions before you ask the more difficult one. If this child has an issue spelling the word ball but they do know what's two plus two, four. That's great. What's four plus one, five. Nice work. What is three plus five? Hey, you got it. Now you're building behavior momentum. You're encouraging them. You're able to offer reinforce it. Then you can throw in a more difficult question. In this case, spell ball. You're increasing the likelihood that they're going to be able to answer it. You're increasing the probability of an appropriate answer. So basically three to four simple, easy, respondable questions and then throw in the more difficult one. I had a case also with a child where parents taught me that he would use an HP and it was a math question. And then the state's in alphabetical order. So I could ask him like, what's two plus two? You know, what comes after Mississippi? You know, and he'd be able to tell me very easily. So another example that was specific to him though which I think is good for us to be aware of. If you're working with an adult, you know, and the person appears maybe stuck and not answering and we're asking questions like, how did you get here today? Maybe they don't answer. Who came here with you today? Again, they don't answer. Maybe those are questions that are more difficult or require a higher response. So then we bring it down. How you doing? And they go, good, I'm doing good. And then we can sort of build that momentum back up. So just finding ways that we can ask questions that don't require quite as much work and then take it from there. Some things to think about as providers with folks with autism. We talked a little bit about visual aids and social stories. Taking time to establish rapport through some of the questions that we talked about, those open-ended narrative prompt and cue narrative type questions can help to reduce anxiety and help people be more present. Be clear and predictable. I'm gonna do this, this and this. Here's the tools I'm gonna use. Do you have any questions for me? Make sure that they're aware of every step along the way. You may need to, you may even feel like you're over-narrating what you're doing, but don't make any assumptions that they're gonna understand or have, even if they've had a medical exam before, just taking those steps to be clear and predictable and leave opportunity for them to ask questions. Some folks with autism don't have great incidental learning. So even if they've been to a provider before, this may feel like a brand new experience to them. So every time be thinking maybe that it's a brand new experience. And then figuring out whether they have a guardian, power of attorney, anything like that, that would need to consent or be part of that conversation, or maybe they're trying to insert themselves in that conversation and they shouldn't be part of it are things to think about as well. And then just some additional considerations. And Angelita, let me know if I missed anything. Things to think about when in the actual exam, are there any sensory needs that this person has? Are any of the lights or senses, sensations to touch that you may need to use going to impact them in a particular way? Questions we can ask them or caretakers prior to the exam, hopefully. And then as you can imagine, all the things we've talked about today may take you some extra time, which depending on your setting, I would just say most settings, right? We don't always have a great deal of that. So allowing extra time, whatever that looks like in your scheduling. Angelita, anything to add for additional exam considerations? Not necessarily, just really, I think the extra time piece is really important. We feel like, especially in acute situations that we don't really have time, but you do have time. You just have to actually make the time and take the time and it's okay to slow down. As a matter of fact, you need to slow down. So just kind of keeping that in mind and trying to plan for that slowdown process. There is one question before we wrap it up. I know we are at the top of the, well, we're just at 3.30 Eastern here and that is the time for us. But there is one question in the chat, Stacy, if you and Travis would like to address it. The question is, is this high probability sort of using an incentive or confidence-based, building-based approach? It is, it's trying to, you're increasing the level of reinforcing, you're increasing level of excitement, you're increasing their confidence in being able to answer questions because if they have a fear of answering a question incorrectly, you're giving them three very simple ones that they are able to answer it correctly. It increases their confidence level and the potential to answer that question more truthfully. Thanks, Travis. Hopefully that answered your question, Jennifer. So Caitlin, I see your question about part one. So part one, I can't remember if it's archived just yet or not, but all of our webinars that are done through SafeTA, if they're not archived at this point, will be archived on our SafeTA website. I'm just gonna go back one slide here so you guys can see the website. So it's literally just safeta.org. If you go to the webinars tab and drop down, you'll have access to all of the webinars that have been previously done. As far as this webinar, and if by chance the other one is not archived yet, we do send an email to everyone that was actually registered, even if you weren't in attendance, to let you know that archived webinars have been placed. I can also ask our project coordinator to also include that information when we archive this one on how to access part one so that you can have that information. Additionally, just as everyone knows, and I've said before, we are putting this webinar today through our SafeTA project. You do have the ability to reach out for technical assistance requests. Travis and Stacey, I cannot thank you enough for both of these presentations. You guys did a marvelous job and we appreciate you being here and taking the time to go through both of these webinars with us. And with that- Truly my pleasure. Yes, thank you so much. We do have two more webinars coming through SafeTA this year. One is on the NCA accreditation standards and the second one is on strategies for responding to patients involving youth and problematic sexual behaviors. So we hope that you will join us for those webinars. And we thank you all for being here today and for taking the extra few minutes to stay on. You should have gotten the evaluation link in the chat and we look forward to communicating with you all again. Thanks again, Stacey. Thanks again, Travis. Thank you.

autism spectrum disorder

ASD

sexual violence

abuse

vulnerability

recognition

communication strategies

person-first language

visual aids

concrete questions

indicators of abuse

trauma