Autism 208: Hiding in Plain Sight: Girls With Autism Spectrum Disorder (2018)

thank you guys all for for being here today we're really excited to talk about this topic so we're going to start off just introducing ourselves and so my name is dr. Karen Barnes I'm a psychologist at Seattle Children's Autism Center hi everybody and I'm at dr. J's Peterson I'm also a clinical psychologist at the Autism Center excited to see you guys all we have one more hello I'm Natasha Lewis Harrington I'm here as a community partner I am on the spectrum myself and I'm also I also have my doctorate in clinical psychology and I'm doing postdoctoral training at UW Natasha with us today so what we're going to be doing is Jess tonight we're gonna be providing a lot of the content today in our presentation and then and we'll have some opportunity for dr. Harrington to to come and share her personal experience and then at the end we're gonna have about 30 minutes just open for questions discussion that will be for all three of us so thank you all for being here in person who are here thank you for our sites that I know are participating online and Facebook live as well so we're really excited to have everyone here so start off talking about Julia so for those of you who don't know this is Julia she's a new character on Sesame Street and Julia's a girl diagnosed with ASD and this was done intentionally because most media portrayals of individuals with autism tend to be males so Sesame Street's workshop executive vice president talked about why they developed this character and they said we made sure she was a girl namely because autism is seems so much more often in boys we want to make it clear that girls can be on the spectrum too we're trying to eliminate misconceptions and a lot of people think that only boys have autism what I also love about Julia is they talked about her strengths she's a budding artist she loves to draw so I think that's great them they highlighted that as well so our goals today are gonna be talking about and basically how what are the rates between males and females currently in diagnosing autism how autism may present differently in females with ASD some specific challenges that might be specific to females with ASD we want to identify strengths and supports for females with ASD and then allow some time at the end for questions and discussion so just starting off just with some background terms you know we want to make it really clear and when we're talking about gender and and sex you know that these are two different concepts so sex is really the biological and anatomical expression but gender is more socially constructed right so it's they're socially constructed roles behavioral attributes that society kind of attributes there's two different parts of gender there's gender identity which is one's internal cell sends itself and there also can be gender roles so the behavioral expression of that and so it's just an important reminder that you know we're not thinking of for everyone that biological sex necessary equals gender another thing we just want to review is talking about really how we make the diagnosis for autism because I think this is really important to talk about in terms of how we think about how girls may present differently so we diagnosed in two main areas so the first one is social communication challenges or deficits or differences so one is social emotional reciprocity so kind of back and forth engagement the second one is nonverbal communication so that includes things like eye contact use of gestures the third one is relationships the difficulty and developing maintaining and understanding social relationships and also the second category is really more the presence of certain behaviors and so to meet criteria you have to meet two out of these four symptoms so the first one is repetitive behaviors the second one is insistence on sameness or rigidity the third is fixated or intense interests and the last one is sensory differences so it could be sensory sensitivities but also sensory seeking behaviors as well what's I think it's a really important addition to the dsm-5 which is kind of our diagnostic all statistical manual for diagnosing autism is that the developers put in this clause and it says symptoms must be present in early developmental period but nain may not become fully manifest until social demands exceed limited capacity meaning that we might not see these challenges until later in life maybe adolescence maybe adulthood where kind of social demands become more complex or they may be masked by learning strategy learned strategies lit in later life and so we'll talk more about this concept but this may especially be true for girls for females who are learning strategies to kind of compensate for some of their challenges so there's a great book out there called girls growing up on the autism spectrum by shana nichols and in their book they talk a lot about some common descriptors for girls and women so the idea that girls and women are often under diagnosed it sometimes takes longer to get a diagnosis girls tend to flying under the radar tend to be more shy so they might not be referred they seem to have fewer communication deficit deficits girls tend to be less aggressive and intrusive and girl symptoms tend to be more internalized so anxiety shyness which can often be overlooked so you know how do we how do females you know come to receive a diagnosis of autism so there's lots of different paths that paths that may be different than males so one path we see is that sometimes like I mentioned before there may be increased difficulties as social and academic worlds become more complex and so this challenge has become more apparent a second idea is that there may be is this miss diagnosis so meaning that clinicians providers didn't see ASD for an that person or a miss diagnosis meaning that they maybe receive different diagnoses instead so we hear a lot about you know diagnoses such as ADHD OCD anxiety eating disorders being really common in females until and they don't we see the diagnosis of ASD until later in life so and it could be that there is also these symptoms as well in addition to the ASD but I think what happens with some clinicians are only looking through that lens and they're not thinking about the possibility of ASD as well sometimes we see that females maybe have difficulties coping with puberty or just a lack of typical adolescent female interest and sometimes it happens that maybe there's a sibling or another family member who has a diagnosis of ASD who receives one and then it starts to be that oh it's maybe similar or similar characteristics or traits and other family members so now I'm gonna turn the mic over to dr. Peterson and we're we're gonna start our focus just looking at the differences in rates of autism between males and females which i think is you know makes this subject a great area of interest because there is differences in the rates and we're gonna look at that a little more closely and kind of examine how that falls out so most most folks or many folks have heard of the current kind of updates in terms of the prevalence of of autism in the United States so the Zener center of Disease Control the current kind of estimates of how common it is it's one in 59 children in the United States have a diagnosis of autism or ASD and that's updated as of 2014 so clearly it's a big significance to a lot of folks and when we look at that prevalence one in 59 we look at that by gender or sex we see it's much more common in males just in terms of the the data that we're seeing there's you know for males diagnosed with autism for every female diagnosed with autism so that's a pretty significant difference there and we even know so it's four to one right now but that gap has closed even a little bit just in the last couple years and that's due to kind of a relative increase in the prevalence of ASD and females since about 2012 so they're coming a little bit closer but there's still a pretty significant gap there all right and if we break that larger number so one and fifty-nine kids right if we break it down by gender or sex we see that that turns into one in 38 males and one in 167 females so I think that difference becomes kind of even more striking there but we don't really understand why this is the case why there's this suppose that kind of male bias that we're seeing across at least within the United States and other countries here so we're trying to understand there's probably a lot of factors that come into play and we're going to be discussing a lot of those today but it leads to a lot of questions in terms of you know why do more males have autism at least from what we've collected in terms of the studies is there you know why tell us females get the diagnosis and is there a true kind of difference in susceptibility are males more susceptible to this diagnosis or this condition today all right and major organizations like the National Institute of Health so the NIH are starting to kind of be interested in this topic as well they're starting to highlight it they're starting to ask questions kind of in the public and in the research community about what's what's kind of underlying this difference in diagnostic rates by sex you know are there females that are passing under the radar is there an under diagnosis of females going on and I will switch back over to Karen who will talk about that a little more so yeah these questions of why are these and maybe females not being identified right so one idea out proposed out there is that you know maybe and we're seeing more media portrayals of males right and that's kind of part start to be part of our prototype and what we have as clinicians or as parents or as you know people in society in general have as our idea of what autism is so you know for instance you know we hear about Rain Man you know there's a boy on parenthood who has a diagnosis and recently Netflix has a show called atypical and although not stated the ideas Sheldon from Big Bang Theory and likely is also on the spectrum so I think you know this we have to think about how this may influence our own idea of what autism is and there's this you know start to become what we think is the only example and you know then we have to ask the question like are people in general just more biased towards more of this you know classic more of what would be a male prototype right so not saying that only males are diagnosed but this is kind of what was first identified and described in primarily males and really either sex or gender could be present with us but um you know the idea is that you know maybe we're missing some of these girls if they don't fit into this certain prototype that we have in our minds and so there's been a theory out there Tony at work would has done a lot of research on females with ASD and there's lots of recent research that will start to highlight that looks at differences that how females may present and so there's a hypothesis hypothesis out there called the social camouflage hypothesis and it's the idea that females with ASD may develop social skills and coping mechanisms that allow them to blend in or camouflage themselves into society so it may be that girls you know look to other female you know girls in society and kind of look to see how they're interacting and kind of develop these internal scripts of ways to and interact socially with other people so one example of this this was an example saying like one six year old girl I met several years ago seemed at first to have good social skills she responded appropriately when I introduced myself complimented my outfit and politely answered all my questions it was only when I saw her again a few days later after I just I understood her family's concerns she made nearly identical overtures as if our interaction were part of a place she had rehearsed so I think this is an example of we only see um you know kids or teens once we might not really capture and the whole the big picture and this is why it's so important to get other reports of functioning like you know parent report or teacher report another way that um females may present differently is that you know we actually classically here sometimes that people in the spectrum maybe don't have a strong imagine it play and we actually see that females tend to report and their parents can tend to report that they actually have really strong sometimes imaginative play or imagination but what may be different is that maybe their imaginary play it tends to be more rigid or it has to be set up the same way or it tends to be more scripted and so it's not as flexible and so there's also this idea of masking symptoms which I talked about a little bit when we talked about the dsm-5 and the new criteria they talked about so maybe that girls may behave very differently in schools and suffer a social confusion and isolation on the playground that may appear quite differently at home so the opposite of cooperative and compliant they're more likely to meltdown at home where it's safe so we kind of hear this from families where you know and you know individuals themself where they're trying to keep it together and hold it together during the day and kind of come home and kind of able to to let it all out and so there was a mom who talked about much of this rings true for my 10 year old daughter with ASD particularly masking her symptoms at school and we're not socially being play and giving eye contact and you know remember from the dsm-5 you know one of the criteria is fixated or restricted interests so in general you know clinical observations and reports from parents suggests that both males and females have restricted and repetitive behaviors however from males sometimes they tend to be more kind of classically people think about you know like vacuums or training schedules whereas girls may have similar interest as other females but they just tend to be more intense so examples we hear about a lot are you know animals like horses or cats sometimes pop stars like Taylor Swift here art tends to be a really big interest or a fantasy or kind of sci-fi and that tends to be another area and so really when you're asking these questions you have to dig a little bit deeper and think about okay you know a clinician might hear like oh they like horses you know other girls like horses too but how impairing is it from them to talk about other topics of interest or do they only want to talk about horses or only play you know with horses I'm gonna hand it back over to you so um one thing we we thought was important to highlight or kind of ask ask ourselves and ask of you guys too is is this even appropriate what we're doing right should females with autism be compared to males with autism there's sort of this belief right that among folks on the autism spectrum that males and females aren't different right kind of how they behave how they are emotionally in terms of their kind of intellectual functioning or or capacity but do we actually believe that for males and females kind of in the wider population and we wanted to highlight that generally the answer is no we know there's a lot of differences between between people in terms of gender and sex right large scale studies with you know the general population that have found that that females demonstrate kind of ant on average more advanced skills kind of inter personally emotionally in terms of their their social skills so they might on average show more advanced you know face and emotion recognition skills knowing when others are in distress or need comfort kind of pro-social behaviors like comforting they might also show an advantage in terms of perspective taking compared to males so these are important differences for us to recognize and you can see how a lot of these you know it's not that that males to develop these but on average females might have somewhat of an advantage and you can see how a lot of these characteristics are kind of symptoms of autism or at least challenges that are listed as part of what autism looks like a lot of the times so if we think that in general there's differences by sex or gender that's probably going to influence the expression of autism symptoms according to gender and sex things like that so it's just important important to keep in mind the other the other important point we wanted to make was that you know this difference in diagnostic rates by male versus female is seen in other conditions and other concerns so intellect things like intellectual disability and ADHD and disruptive behaviors are have been found to be more common in males than females there's a higher proportion of males diagnosed with these conditions than females same with what we call internalizing disorders so things like anxiety and depression from you know large-scale epidemiological studies we see that and you know females are at higher risk for these - these conditions over the lifetime females are twice as likely as males over the lifetime to be diagnosed with an anxiety disorder and when females reach adolescence they start to be about you know almost you know anywhere from 1 to 3 times as likely to be diagnosed with some type of depressive disorder as as their male counterparts so it's not just autism that we're seeing this discrepancy all right and at this point we would love to bring up an Natasha here even make some comments about her own so I have experienced some of these diagnostic difficulties that they're talking about my diagnostic journey ended up being kind of secure circuitous so I was in some of the ways I was a lot like what they talked about with the the typically development or the typical autistic girls like I was very imaginative but it was really scripted I had my interests that were celebrities animals cats wolves those kinds of things and I was you know the shy and cooperative girl and on the other hand I was different in a lot of ways I don't think I did a lot of the masking when I was young I remember having a lot of difficulty I was very focused on my interests and it was well into I think high school before I started kind of learning to to dial that back and to understand what people expected of me so I'm not entirely sure why I wasn't diagnosed as a young child um by my mom I remember had the I think it was the tony atwood book all the dog yard pages that sounded just like me but I think maybe the awareness just wasn't there when I was a kid and then by the time I got into high school I was starting to get a handle on some of these things and so I actually did ask my psychiatrist when I was in high school I said you know do you think I have Asperger syndrome that's what it was at the time and she just totally laughed the idea off she didn't look into it she didn't even give me a reason for why she didn't think that was the case but um yes I just didn't seem autistic to her and so that you know she she laughed at me basically and I was so horrified that I didn't bring it up again for years and years and then I went in to college and I really struggled with making friends I got kind of the typical package of Miss misdiagnosis I was diagnosed with ADHD OCD anxiety depression social anxiety and then I started to figure things out I did a ton of reading I got really interested in psychology and sociology and those kinds of things and I just did a ton of reading to figure out how people thought what people wanted and so on and you know eventually I got to grad school and I was doing well I was mayor I got married I had you know I was doing well in school I was doing well for the most part doing well in the workplace and so I looked back and I thought oh well I guess you know maybe maybe it wasn't autism I guess it looked like autism but I outgrew it so and then actually I was I think I was about 28 27 or 28 and one of my friends got diagnosed one of my female friends got diagnosed with autism so I started learning about how autism looks in women and you know I realized that I really needed to look into this and once I started really looking into it it became clear how many things were still present that I'd managed to kind of gloss over so like you know I thought oh I make friends well but I was only making friends with men or I was only making friends through you know playing playing magic cards I wasn't I was just avoiding kind of the free-form socializing that's typically expected of women or like I was doing well in school but you know I was still upsetting my professors all the time by correcting and that was my thing um and so my first evaluation was pretty much exactly what they're talking about with people you know not taking it seriously in women because who looks so different so it's just like a laundry list of the things the reasons she said there were some things like executive functioning that's a whole thing but like she was saying oh you have a sense of humor you laugh that neurotypical stuff you have empathy you can take you know you could take other people's perspectives and you know I'm looking at it I was like you know I have a doctorate in psychology like you know I spent four years learning how to take perspectives but she just totally blew the idea off and so I went back and I'm uh you know stressing about it unfortunately I have friends who know a lot and they're like you know get-get reevaluate and I went to my psychiatrist she says get reevaluated and i went to go see someone else and this time I said you know are you experienced at you know looking at autism and high achieving women and this person was and so she did she did the testing and I was finally officially diagnosed at I think it was 28 years old after you know almost a decade of being involved with the autism community as an ally you know I'm finally figured out you know there's a reason that I'd been fitting in so well so yeah I've definitely seen a lot a lot of the difficulties that they describe thank you so much for sharing that Tasha all right so um now we're gonna you know switch gears a little bit with the presentation and focus on what the research findings are in this area right so a lot of what we've been talking about so far the experiences in the descriptions are based on you know what we hear from families you know clinical experience even case studies but for a long time there hadn't been any research nobody was really looking into this or asking these kind of questions and more of a systematic way but more recently that has changed so which is really exciting and we have some findings to kind of talk about and review and see if the things that people have been talking about are are showing themselves to be true when we look at it from from a research study perspective so I'll be going over some of that and really there's a lot of questions that come up in this area and you know females with ASD and what that looks like and and you know these questions are connected but they're also kind of distinctly different to you know things like do females with autism have different characteristics than males with autism is that is that true why are males right more diagnosed with autism in terms of the rate than females in and is there a difference in susceptibility you know truly is there difference in in how susceptible folks are based on their gender or sex and we need to look at these questions in kind of different ways so there's still a lot a lot to work to do and a lot to learn but in an important point that we like to make when we're kind of opening this box of the research and in terms of females and ASD is to point out that you know there has historically long term has been a very significant male bias in the research so a lot of what we know about autism in terms of you know in terms of genetics and brain development and symptoms is based on research that primarily included males to kind of the document of females right females were often excluded from research samples just be just from sheer lack of ability to kind of identify these folks so that right there you know is a big limitation the other thing that comes up is there's probably and there's you know clinical ascertain MIT bias and there could be biased and the tools we use to include folks and studies so we use tools like the a das or the a dir these are our ways of measuring autism symptoms and you have to meet a certain score on them and we use them right to include females and studies but we don't actually know if they're a proper appropriate to be using in the same way with folks across gender and sex so that could be excluding people from studies who should be included the only thing is there might be bias in reporting so teachers people who are providing information to us in forms of data might have might be biased in how they report they might have just naturally have different expectations for males and females and how they should socialize and that might kind of skew things or obscure things more so we like to keep all those all those kind of facts in mind as we're we're thinking about this we want to first dig deeper into that rate that like I said before the you know one in 167 females versus one and 38 males there is we found that there are some factors that seem to influence those those statistics those rates if we look at intellectual functioning so in folks with intellectual disability so having you know more of a significant cognitive impairment we find that that rate actually shrinks to two males from one female so that similarity in terms of diagnostic rate becomes much more similar but if we look at folks without intellectual disability without kind of major major cognitive impairment the rate varies but it becomes much larger in terms of the discrepancy nine males on average - one female and we know that is that autism as we've been speaking about and Tasha shared are on average kind of diagnosed later then then males specifically in this group who um do not have intellectual disability so a lot of the research I'm going to be chatting about is focused on that 9 to 1 difference what's what's going on in there is there an under diagnosis is there what is creating that discrepancy and is it a true does it truly exist or are we missing some girls the only thing that comes up is we know that females are diagnosed later regardless of kind of having the same age of first concerns or how many times they go to see a doctor about this so even though I'm a female you know without intellectual disability might go to the doctor the same amount of times with her parents for expressing concerns as a male in the same situation that females still for whatever reason on average diagnosed later and females kind of without intellectual disability or without kind of major behavior problems research has shown are less likely to receive a diagnosis they're less likely to meet criteria based on you know a clinicians judgment even if they have kind of similar level of traits and that could be for a lot of reasons maybe some of it might be those masking qualities or or kind of adapting in a way that leads to less you know problems from clinicians perspective but it's definitely worth digging into an understanding better so the next area I'll talk about in terms of research findings are whether or not there is actually differences in symptoms for males and females with ASD and first we're going to look talked about the core symptoms so this brings us back to that picture that dr. Barnes showed in the beginning with the two bubbles right one area being social communication and one area being restricted and repetitive behaviors and we do see some differences that are arising for between males and females and in our larger studies we see that males on average are showing kind of more repetitive sensory or motor behaviors so some of these motor behaviors that we see not sysm are things like hand flapping or repetitive spinning or more complex mannerisms seems to occur more and males with the diagnosis of autism kind of as a generalization there seems to be more restricted or focus interests and they're often on things like video games or technology other more kind of you know often typical interests in terms of gender stereotypes and in general just restricting repetitive behaviors have been found to be higher more symptoms in that area for for males as compared to females so on the other side you'll see again yeah fewer repetitive motor behaviors have been found in this female group there's also differences in the types of interests that you might see in this group which I'll talk about a little more in a second and for some folks there is there's also some indications that nonverbal communication might be in conversation skills might be improved for females so some of the rights people have been seeing this you know that females might have you know better eye contact better conversation skills and some of this is showing up in in the research that's been done when they've looked at it closely the other the other thing that researchers have done more recently is thinking about you know the diagnostic criteria for for autism again those two bubbles that we showed you are there differences in how individuals meet so folks to have a diagnosis of autism you know have to have dr. Barnes mention symptoms in all of these areas but there's a lot of different symptoms that go into each of those areas so it can look really different for different people so we wanted researchers wanted to know is that true for males and females and they were looking again at that kind of the sample without intellectual disabilities so where you have that nine to one discrepancy there and they did find that there are differences in how males and females kind of met criteria and the first one again kind of as expected is there you know we're better expressive behaviors like sharing of interests imagination skills looked improved even adjusting behavior to fit the social context so kind of picking up on how you should act in different social situations seemed to be a skill that more of these females with with ASD diagnosis had in the second category their nonverbal again better kind of integration of nonverbal so talking while using eye contact and using gestures this seemed to be an area that was kind of resilient in in females however it did appear that females and males in this group had a similar level of difficulty in terms of reading other people's nonverbals so their facial expressions their gestures things like that that was a similar kind of challenge even between the genders or sexes and then in this last category relationships there were some qualitative differences kind of in in the challenges so for for females it was looking like you know they could initiate they could create friendships but they had a much harder time keeping those friendships going they tended to be kind of overlooked or ignored by peers versus like rejected by peers so so males in in this in this study in particular were more likely to be rejected and less likely to have you know success starting friendships and then lastly just over all the girls were reporting kind of better quality of friendships that their parents were also recording just reporting a better quality than the males in this group and one other interesting thing I'll point out about this study that the authors highlighted this was Hillier and colleagues a recent study was that for a lot of these these characteristics these these symptoms that we see like sharing interests and conversation skills a lot of the on average the females were often it was often the difficulties were endorsed as as somewhat so occur you know challenges occurring some of the time versus you know more more common or kind of all of the time they were struggling with these things so the level of challenge was maybe not as high as you might expect for a for a person with with ASD the other piece was they looked at how clinicians who diagnosed these females described them and they found that the description was a lot more ambiguous in terms of symptoms sometimes they struggle with this sometimes they don't here's all these skills that are intact things like that so they discussed how you could imagine those folks were really highly trained in diagnosing autism and and it was still kind of an ambiguous situation and imagine folks in the community if a parent you know has concerns talks to their primary doctor things like that you can imagine could be really difficult for for those girls to get kind of picked up alright and then the other side of the bubble the places where girls were meeting criteria in a different way kind of on average is in these restrict and repetitive behaviors and again we kind of talked about it antidote early but they had they showed to have less kind of restrictive repetitive behaviors or our bees as we call them overall and they different types of our bees just less I'm dr. Barnes was mentioning they were they had obsessions about things like shells and stickers tended to collect more items kind of called hoarding items or kind of putting things together that was more of the repetitive behaviors they were doing and when it came to repetitive play you know with males we often think about things like flipping you know flicking the wheels of the car or lining things up or you know driving a car back and forth with with females it showed in different ways it was this kind of repetitive play schemes a lot of the time so maybe it's you know family going out to dinner and it looks really great and imaginative just maybe somebody who sees the play the first time but then you notice they're doing it over and over and over again and that's kind of all they're doing so kind of similar to the story we discussed earlier of having scripts or routines in the last two areas I'll talk about our studies that looked at how kids present in social settings like playgrounds and things like that in terms of differences between males and females with autism and researchers actually at Seattle Children's and also colleagues at UCLA did a study where they did just that they looked at how younger boys and girls with with autism diagnosis how they presented on the on the playground and they found that there was some you know pretty significant differences over and what they saw and that was for for the boys they often saw you know it's very obvious that they were having challenges they were off on their own they were doing their own thing there on the perimeter of the playground you know off by a tree it was clear that they were struggling whereas a lot of the girls in the study with autism were able to kind of look like they were making it happen like they were they were fitting in they tended to be around other girls or flitting between groups of other girls but when you look closer they really weren't making those meaningful connections that the other girls were making it was kind of on more of this superficial official level and so and the other point is that you know for boys typically a lot of times at younger ages its sports and in roughhouse and for girls it's more conversation and kind of discussion and the girls seem to be more motivated they were having a hard time kind of keeping up with that that kind of play and being accepted there's also evidence kind of growing body of research showing that girls with ASD present differently than boys at school so we talked a little bit about this earlier today kind of through through parents stories histories that girls might be able to kind of hold it together teachers might see less challenges at school for girls with autism versus their male students with autism and in it it the research does show that you know on average teachers are reading you know reading boys with autism as having more problems overall thin girls with autism in their classrooms they they rate and the rate girls is having lower social problems than clinicians would so psychologists who might see they're noticing their challenges less and we also know that female sex or female gender predicts timing of teacher concern so typically for for girls without intellectual disability it's it's later in life and for a group of girls who are diagnosed later without intellectual disability there's a higher proportion where no teacher has ever had a concern in this in the study that I'm citing so in this kind of later diagnosed group 25% of these females had never had any teacher concerned Express whereas that was only the case first 7% of the of the male group so clearly there's a difference there and how they were presenting to teachers at school or teachers perceptions and then the last area I'll talk about in terms of research findings is looking at these associated features so other other kind of concerns and the research in this area really mirrors the general population right females with autism are you know at increased risk compared to boys for things like anxiety and depression and also interpersonal there's a kind of a higher rate of at least expressed kind of interpersonal problems in terms of relational aggression like social exclusion or gossiping things like that again probably see more of that in females in any population and then the males are at increased risk for things like aggression and more disruptive behaviors but this difference you could see how this could also affect the diagnostic rate boys have behaviors that are in your face right and they're they're challenging and so the referrals might be coming and more for males than females who are that might have these more easy-to-miss kind of symptoms that go along with it all right I'm gonna hand it over to dr. Barnes here okay so kind of talking segwaying from that talking about what are the special considerations for females with ASD right so we've talked about how they may have this unique presentation so we have to think about considerations for that so since we've talked about so much about this kind of difficulty with identification we included some suggestions next steps so again I this idea that females may not present with that same level of disruptive behavior and so it's really important to consider that in terms of the referrals we get or even making a referral if you're a provider and this idea that signs of impairment and female may manifest more clearly over time right so it might be that these females did re-evaluation down the road you know and that it might be that so you know some of these challenges don't emerge until later so we need to be monitoring that um I think it's really important like we've highlighted to really think about when we're evaluating a female really comparing what we would expect to another female of their same age and cognitive ability so again just like we don't expect the same behaviors and social emotional functioning for males and females in general we also wouldn't expect that for males and females in ASD so it's really important to compared to females and there is some data showing that mothers report parents report they're noticing those concerns right even though the teachers maybe aren't as much and so like a lot of times you know parents and some other saying like there's something different right there's something you know I'm putting my finger on it might be they're thinking about compared to other females their age and it's really important to to think about like even if it's these subtle difficulties that can still have a tremendous impact on a person's life and that really warrants more evaluation and support so that's important to consider and then it might be that as we move forward you know that the research is young kind of even the clinical evaluation and processes for the sort or are not there yet but we want to think about considering female specific measures right or kind of ways to compare to other females to determine screening diagnostic and even treatment so um obviously every young woman's gonna have their own experience of going through adolescence but there's you know the know two girls are the same but there are some common characteristics associated with ASD that can present the challenges during adolescence so one of the things we hear about is puberty and hygiene and grooming so you know when you think about this time it's a tumultuous time in general there's a lot of change right and going back to this criteria about ASD and change can be difficult for some people in this spectrum so there's a lot of novelty and change during this time thinking about puberty and hygiene and grooming there's lots of sensory challenges that can overlap but those those difficulties difficulties regulating emotions communicating feelings during that time and just this idea that sometimes there's this delays social mature can all impact these factors so I think you know clinicians and parents and people working with people in the spectrum need to be really am thinking about these areas and that girl you know females may need more support during this time there's some great books out there we highlighted those here there's this book called the carer and keeping you the body book for girls and growing girls growing up in the autism spectrum has like whole chapters diagnosed you know relevant to this topic and there's some good books out there by I'm self advocates who themselves identify as having autism spectrum disorder so one is asper girls and I love this title just empowering females with Asperger's syndrome right so thinking about from you know personal anecdotes ways that they you know feel like you know could be support during these times as we kind of already highlighted and same-sex friendships specially female relationships are often sometimes difficult to navigate for any female right and especially I think for am someone on the autism spectrum where there's a lot of these more subtle nuances and especially as girls go into middle school high school you know like and dr. Peterson mentioned it's more focused on conversation so it's not just running around on the playground or playing with toys it's really expected that you have a deeper level of connection and sharing of emotions and feelings and asking social follow-up questions of the other person and so that can sometimes impact females in the spectrum and we know that females tend to be prone to more of the mean-girl behaviors right victims of bullying due to their uniqueness often being socially excluded or that relational aggression gossiping so thinking about supports for there's those females right and how to help them navigate that really complex social world is really important to consider social media I mean that's a whole topic into itself right and for every parent navigating this challenging world with their teen but you know there's a lot of texting phone calls Facebook snapchat social media right and so girls with ASD may need more explicit teaching on how to use media and how to communicate so there's often these implicit rules that make it difficult so we might need to think about providing a specific social skills support addressing these topics and again this is a whole nother topic that can be a whole autism 200 series and that idea of this gender identity so there's increasing evidence that gender nonconforming and transgender maybe rates may be increased in ASD and so there's among individuals with gender dysphoria and receiving clinical services there is increasing evidence of a higher prevalence rate of ASD compared to the general population and so there's these guidelines that been put out related to ASD and gender dysphoria and kind of the idea is that when you're evaluating for one you should also evaluate for the other right and consider that and just understand also that there is more this gender diversity and that people may be identifying in different ways it's important to think also about just as you know girls and females get older more intimate you know relationships and sexuality so really again providing specific skills about this there's a great book called safety skills for Asperger women and that was also written by a self-advocate and so defining you know what are appropriate boundaries modeling appropriate behavior and thinking about safety issues especially for individuals who may be more socially naive more trusting we have to really think about that and prepare you know our females to to manage that this is a great website autism risk management types of a lot about safety issues and then just as females you know get older if they're kind of college bound um you know thinking about you know kind of more independent living skills personal care you know self-advocacy and and you know thinking about social relationships how you know you know to relate to other peers you know teachers professors kind of dorm life I mean that's challenging for anyone right but they made me more explicit instructions support during that time and just you know hearing from females with ASD there's some other like just common themes that they talk about in terms of their experience so maybe there's this idea that there's these you know societal cultural expectations for females and kind of managing that struggles with their identity or self-esteem sometimes just fears related to growing up um you know some females identify just being more hypersensitive and you know like we talked about just sometimes it's really you know great intense interest in connection with animals which we just see kind of this characteristic right that we often see sometimes in females it's a generality but you know we definitely see it clinically too so I think just to to highlight um you know it's really important to also build on strengths for females so Temple Grandin who's a famous and woman with ASD it says we have to work with our strengths not our deficits and that common special interests are the most important social tool and basis for social contact with other women with ASD so really helping um females identify groups clubs volunteer work you know that's related to their interests and topics is special and just like their you know maybe you know art or music or science whatever their gifts may be he was really I'm highlighting those and building on those self-advocacy so really you know helping and women you know self-determination really allows women with ASD to advocate their own needs and so identifying their strengths and challenges there's some great online resources so an active online presence so there's autism Women's Network there's autistic self-advocacy Network I'm sure there's others out there we'd love to hear about them and the idea that you know if girls and women with ASD are empowered with self-determination and advocacy skills we often see higher rates of employment and higher wage after graduation so as a research to study actually showing that so I think it's just even more evidence that we need to really support females and so this is just a slide you know identifying some women who share their experience and I'm you know all women who would share their experience are really providing really invaluable insight to the community so we we really appreciate that so kind of some take-home messages here and this comes from a quote from a woman who is also a self-identified as ASD and she says under diagnosing of women with ASD contributes to the marginalization of females if we do not appropriately identify girls in an early age women will continue to stay in the background and live in seclusion they will continue to live in isolation so obviously something to really think about into um you know as clinicians as parents as providers as um you know to think about are we are we under at diagnosing these females not giving them appropriate support so it's important to really support and embrace uniqueness of females we want to you know part of our goal is just to increase awareness if how females may present differently and it's not just about getting the label but it's also about getting appropriate services and appropriate educational supports so I think that's important to consider is a great resource here it's on lines from the Child Study Center they have a whole kind of special service devoted to women on the spectrum and they have a whole list of book resources here and it's a lot of the ones that we talked about today are in this list and so you know what do you do if you have concerns maybe about your daughter or yourself or a family member you know so refer to an ASD evaluation and talk to your primary care provider and then you know sometimes there are weights unfortunately but identifying the primary obstacles and finding those appropriate supports while waiting for the evaluation so it might be speech or communication or might be social skills or other mental health concerns and really addressing those and then we just bit up here just some local girls groups that we know about that are kind of focused on you know girls specific and social skills because that's something we hear a lot about is that you know families often ask like oh whether other you know other females in the group because again like we know there's sometimes different needs and different unique supports for those so I think we will end our content there and so we're gonna open up to questions what's gonna happen is all three of us are going to set at the table first gonna open it up to the people here in the room for questions and then I think we'll open it up to our other people watching online so thank you so much I feel like she sees his lifestyle that it's been challenging for him and we've done our very best to make sure that she is aware of Vaught ism special disorder and I just greatly appreciate you guys doing this today for us I just wanted to say thank you to all of you yeah so we were the question or the comment was about having a child too you know with with suspected or has gone through a evaluation for for autism diagnosis but seems to have some of the characteristics that you often see in females with with ASD some of the you know maybe some of the more scripted behaviors or some of the things that come off is really socially skilled when really there's challenges underneath there right we were actually just having this conversation I don't know if Natasha wants to comment on this because but because you brought this up earlier it'd be great to hear your thoughts if you're yeah honestly this is a big concern I have I have a number of friends who are transgender gender non-conforming and suspected of being autistic and the my friends who are kind of conventional you know nerdy wider Asian male went in and got evaluated and got their diagnosis like that um friends who are gender non-conforming got the you know oh you're too social you're a performer you're Ike your facial expressions are good and so yeah I think the current understanding is really not equipped to deal with these issues and so I was saying one of my big concerns when we talk about you know the female phenotype girl autistics do this girl autistics do that is that we might start seeing cases where someone comes in either you know assigned male assigned male at birth and you know the doctor might go if it was a girl I might think it's autism but they're not so it's not and so that's you know I'm sorry sorry you're in this difficult situation I am yeah you know it's great to hear that my concerns are like something that I really should be pushing that this is something to be concerned about and I will also say a lot of the autistic community is supportive of self-identification so even if someone doesn't meet the full criteria according to the doctors the autistic community a lot of them understand that there are lots of reasons why that might happen and so are supportive of self-identified be autistic people and going back to that last slide I'd like what supports can you still provide to him right I know sometimes the diagnosis does open more doors in terms of coverage and but um you know thinking about other specific social skills groups or a therapist you could find that would work with him developing those specific skills that you kind of see that he's maybe you know doesn't have yet all right so now we will take some questions that have come in from our Facebook audience so the first question is from Jen zona I'd love to hear about if you guys can speak to a dual diagnosis for a female with Down syndrome and ASD and if there's anything specific about that you can share okay um so you know like we talked about a lot of the research that we're looking at is in you know the they're studying girls and women with autism and without intellectual disability and so I think we just don't have as much information about these dual diagnosis but there's still you know lots of issues that are still relevant the you know puberty and hygiene the sexual health the safety skills a lot of that is you know going to be very similar and then the next question we have is from Jackie and so Jackie's question is could you please ask the presenters if the legs can speak to the connection between Oh Dee Dee and ASD with or without an autism diagnosis sorry can you say that one more time yes so she is I'm looking if you can speak to the connection between Oh Dee Dee and autism with or without an autism diagnosis sure yeah so um you know I think within you know within you know kind of population with autism you might see you know especially in a generalization with males right there is increased kind of co-occurring or increased kind of rate of having challenging behaviors like oppositional defiant problems in in that population kind of increased risky you know relative to the general population so you might see might see some more of those kind of code diagnosis also around language challenges communication challenges and you know being within being a common theme within autism - you'll see kind of disruptive behaviors and challenging behaviors around difficulties with with communication so some of that might get attributed to be more oppositional might underlie more communication challenges and then in terms of you know I think to behavior challenges can be misinterpreted as not autism right can can be overlooked as when really what's going on is some challenges socially and and maybe sensory wise or otherwise in terms of repetitive restricted behaviors that are resulting in these more severe kind of you know disruptive disruptive behaviors as a whole so it might be losses might be kind of overlooked and kids who are having more of these challenges anything else you want to you guys want to add the idea that a lot of maybe females present with more oppositional defiant behaviors or at least the diagnosis before they get ASD and it's kind of that filter how you're looking at it you know like dr. peterson mentioned like it might be that there's other sensory needs or you know other reasons why they may be displaying those behaviors so again it's in terms of like the the misdiagnosis we often see a lot of females having that o DD oppositional defiant disorder diagnosis sometimes before arriving at the autism diagnosis and it can also Co occur as well thank you the next question we have is do you have any recommendations for good resources for teachers so that they can best support their students in this for females specifically or just generally we do have we do have some good resources that we can connect with whoever would like that in terms of like reading materials recommendations for teachers educational supports nothing specifically for you know kind of supporting females with ASD but in general how teachers can kind of support or structure the classroom or strategies and things like that though we're happy to provide for folks and so with that what is the best way to refer the person with a question to you to possibly get those resources what would you recommend for the best way to proceed for next steps are they listed on the autism centers website or what would where would how would I connect the person asking to get those sure if they provide their email we can send those via email great thank you my question actually segues pretty well it's kind of the other side of that coin our little one who's been chirping up from the center the center state here is diagnosed with ASD she was diagnosed when she was three we were very lucky to get an early diagnosis despite her being very high functioning my question is the example that you gave about the playground where the boys tend to be more openly isolated and the girls tend to appear as though they are having a good interaction my question is I know that she tends to spend time playing by herself which she enjoys obviously it's much more low-stress to play independently than try and to try and get friends to follow your particular idea but we were wondering from the kind of parent side of the teacher question what can we do or what should we do I suppose to make sure that her special education resources and that her teachers can address what could be limited social skill that is masked by appearing to be you know normal social interaction yeah sure yeah so the we there's a lot of I think ways that we you know suggest for families that schools and teachers provide support when especially when kids have a autism diagnosis and they can have something like an individualized education plan and can have certain supports written into that you know obviously one of the primary ones being direct support and social communication so that might look like things like for older kids or maybe even some younger kids having available social skills groups things like that and not only that but having someone like a para or a special educator be a part of that group and then being able to help in situations that are unstructured like recess or lunch or things like that provide that kind of in in vivo or in in live-action support to kind of help facilitate those skills so asking for those types of supports from your school and from your educators and things like that is something that we think can be really helpful um so I've always benefited like to this day I still benefit from really structured social activities and I think there's a big like people want to see kids doing typical things and so they just want to say oh let's get them good at unstructured social activities and I've gotten pretty far in my life and I've honestly benefited from trying to dodge it I guess more than trying to fix it because I did these social activities I was a big gamer I I mean she's a little young but maybe like if there's clubs activities that they can do at lunch and then that helped me build up the relationship getting to know an individual person before I'm able to move on to an unstructured thing and so I really encourage you know giving her opportunities to practice the skills in an environment that you know plays to her strengths in order to develop in order to develop those friendships yeah and along with that just kind of finding like a peer as that would be you know receptive kind of peer models right you know peer mentor is so finding like a smaller so she might be overwhelmed by the large playground and it might be sensory overwhelming for her right you know it's so thinking about like oh maybe they have an indoor activity that's a strength or something she likes you know to do and they invite she gets to invite one or two other friends you know that are and it becomes less overwhelming right and more structured yeah and I will say I think there's a big push for people to say oh get in typically developing peers they you know the you need good role models and so on but the thing that has been most helpful for me in developing my social life was successful autistic people because typically developing people were doing things that I was never gonna do or that I didn't want to do so I think it is to autistic friendships I think are really underappreciated and undervalued that's absolutely exceptional to hear we definitely wanted to make sure that we weren't kind of putting a very neurotypical and typically-developing kind of pathway there so hearing that it is okay and even preferable for her to practice her social skills and her interest groups and then expand from theirs is really good to hear and it's been excellent to hear from you as well as a successful woman with ASD to kind of get a sneak peek at what potential she she has to yea when one of the things that I talked about actually is once I got to college I was masking pretty well so I learned all these skills for getting people to like me and by the middle of my freshman year of college I had lots of people like he would go to lunch with me whenever I wanted lost people like I didn't like any of my friends anything and so at the end of the year I just got sick but I just dropped all my existing friendships I had I had a boyfriend that I was close with and you know it was mostly just the two of us and then we started getting into the gaming and I started meeting people that I liked and so socializing became motivating and it was just a night and day difference and when kids are older you know we talk a lot about common interest right building foundations for for friendship right and that's true no matter what so finding what her strengths are finding her areas of interest and finding other people with the same interests are important microphones coming your way I have two questions the first question is does the Caird keeping a view the body book for girls does that go over issues like boundaries like when they're getting in and out of the shower like if they like let's say they walk out with a towel in front of guests and they don't make that connection that hey yes you are covering up yourself but this person isn't mom or dad or someone that you should trust to be like that are those types of certain areas in that book or are there other ways to kind of go over boundaries I mean with boys and girls with boundaries and privacy and like going in the bathroom and making sure that you're private and stuff like that a lot of those books do you address that I haven't read that one recently so I'm not sure it's specific about that but the idea is that yeah you make a lot of rules right and kind of and sometimes with you know people in the spectrum the insistence on the sameness or wanting rules gonna be Hillary helpful right in terms of thinking about okay this is the rule here and so sometimes just laying that out and and practicing and role-playing with what things can be role played and so that you know she can use that and you know other situations anything to add to that I think in a lot of those books is a lot about like kind of yeah what are social expectations and we know what our appropriate behavior is when you know different places and kind of like we teach anyone right you know you can do certain behaviors in certain locations there were certain people and not another ones and I think people on that doesn't spectrum might just need a little bit more explicit instruction or not that yeah I do think it covers privacy kind of issues of personal privacy right which I think would apply in that situation and and went you know when when different types of privacy situations I just can't I also can't remember if that book in particular covers that there's a lot of like resources out there in general not just specific to ASD my second questions not that one yes my second question is since girls and boys have problems girls with ASD have problems with making friendships do this is there any evidence that shows that they suffer when they don't have these relationships anymore like let's say that the parents have to move around a lot or like even boys with ASD do they are there any problems that come with that like are they emotionally affected deeply by that once they do have those friendships and then all of a sudden that routine of seeing that person is gone and Mia might go back to this idea of like motivation right and you know even kind of Natasha's point like maybe she had all these friends but no did she like that was it enjoyable so I you know we hear from people that like they just want you know maybe one close friend and that's all they want right they don't want to have maybe a lots of different friends so I think meeting them where they're at in that regard and kind of thinking about you know what stage and what quality friendship they want and then providing the skills to support them in that it could be important other ideas I'm trying to think of it just I mean if the family's moving around a lot I do think it's probably gonna be tough for kids if they have you know it's it's tough on any kid they say to move around so I think if you have trouble making the new friends and it is gonna be tough but I mean I think parents don't generally just uproot their children for no reason he's surprised and so you know in in those kinds of cases he just got a you know work with them on resilience and make the best of it and they you know autistic kids can be very resilient okay then we have one more resource actually that came from someone on Facebook from Jackie and Jackie just wanted to share with everyone that the American Girl book series and has uh has great books that cover boundaries but it's also important to support personal comfort as well so she just wanted to share that with everyone so anyone else in the room have questions tonight can people request evaluators who have more skill and diagnosing girls are like why would you kind of make sure your practitioner knows how to take valuate girls talk about that so right now childrens we're doing this team model and I think one of the ideas behind that is that we have two to three sets of I is like two to three different practitioners that are working with each family and so in that way we're not in our own little bubble and we're getting we're getting to consult with different colleagues and talk about this and saying like I don't know I'm not sure like what do you think right and so and if we're not sure we bring you bring families back right we bring kids back and so um right now there's not a way as we said at the autism center to say a specific provider but dr. Pearson and I actually gave rounds at our talk and I think everyone there at Seattle's an autism center is very aware of this idea of females we all talk about it a lot actually um and then yeah there are providers in the community too who do evaluations and um and and I'll also also say you guys can you know say say if you agree but you know if you are having this difficult time if it's too subtle or whatever as they talked about sometimes it becomes clearer as they get older so you can also you know document your concerns over time and then try again once the picture has become clearer and I will say too I think at the autism center children's - right where part of the issue too is is you know we're really realizing the importance of having you know you know a lot of time with with parents to get information right outside of the clinic and outside of what we see in the importance of that you know of listening to parents listening to their experience and and really hearing that and in in working very closely with families to kind of get to the bottom of the question and and try to best help right because it can be can be challenging mm-hmm yeah it's kind of this idea that we say you know females gonna be tricky to diagnose kind of for all these reasons right and I mean and that's not specific to females we definitely get cases we're like we're stumped I don't know it's you know get teacher report or see in three to six months right after this is maybe calm down so you know we're all and we're fallible right we can make mistakes in terms of our diagnosis and we might just say like okay come back later mm-hmm yes we often see later diagnosis about and the idea was about a color the question was about race and ethnicity and kind of like different rates and I don't I'm not up to date on like the numbers but I know that's a later diagnosis yeah and in terms of like um ethnic minorities and things like that the the age of diagnosis on average it's like a couple year you know sure what the exact rate is but it's it's a couple years later and then not minority kind of groups in terms of being seen right and getting the evaluation and it's and it's really unfortunate and you know I know there's a big effort to kind of close that gap and reach more families and serve more families who fall into that population that right that might not be getting kind of underserved or under identified that I did just health pack what are you right in general you know and we definitely see that specific you know and we see it in ASD as well and just access to services and even awareness you know and kind of um maybe biases you know and then community people looking at things a certain way so and we're you know definitely at Children's and you know hard to work here because we have interpreters or working with cultural navigators you know and so we get to see families from lots of different backgrounds and experiences and cultures and and that's you know I love doing that work to be able to serve those populations all right so we have two more questions that have come in from Facebook one is do you are there any evidence-based treatments out there that are specific to girls and the specific needs that were discussed I wish yeah unfortunately not not yet not yet I'm sure people are working on it I mean it's kind of you know setting the stage right there's these differences and next comes like this the treatment right I think I'm kind of in general I will say though there there has been groups I I suspect I know what children's right devoted to kind of more you know girl or female based issues right around things like hygiene or sexual education and things like that like kind of education kind of girls groups right in the past and there might be in the future and there is it you know probably you know these aren't evidence-based they're not you have been run through research trials or anything but kind of more geared to support you know this kind of specific population and that might be happening in the community I'm sure as well I don't know anything else yeah then we did share the three links to the girls groups from from the slide deck so that is in the comment great where everyone as well the next question is are there access to groups and resources that don't charge or are there baby programs available that someone could get assistance financial assistance to assist with access yeah that's a well one yeah it'd been spent yes are you thinking of we talk to our families a lot about Ben's fund which is the program that Washington residents who have kind of a verified diagnosis of autism could be could be eligible for there's need kind of a provider letter verification of the diagnosis and kind of support and it's kind of a financial support grant for up to a thousand dollars that you can apply for every year but and you have to identify like a specific treatment or therapy or therapy piece of equipment you know I you know occupational therapy weighted blanket or something used to identify something but you can kind of ply for that annually so I will I I will plug it's not a clinical group but the square pegs meetup group that we have it's not like social skills it's not teaching it's a socializing group for autistic people to be with other autistic people I've been to a couple of the meetups you know I like really enjoyed and really enjoyed talking to the folks and found that pretty great I don't know if they have anything to offer to help children so people could reach out to them and see if they do have anything but for adults I really like that as a resource the square pegs meetup group another thought I just had is and social skills groups often aren't covered unfortunately my insurance sometimes but speech therapists often are especially with a diagnosis of autism or a communication disorder so um sometimes what I do is you know navigate families to find maybe a speech therapist who has a expertise and social skills and can do that in a more like one-on-one environment or sometimes they might bring in like another and kid who's working on those same skills and they kind of work together to practice those social skills so that's another avenue that sometimes does then get covered by insurance but it's not the classic like social skills group and sometimes they are covered by insurance but usually I'd say a lot of times out-of-pocket unfortunately right this moment one more we have so this is from Rachel and Rachel I apologize because I just saw your comment so if you are still watching Rachel is really hoping are there is there any advice for adult females searching for diagnosis I mean that's a very broad question I guess again I'll go back to what I told her which is you know regardless of what the professionals say if you feel that you belong in the autistic community you're gonna find a lot of people who will welcome you and they can kind of guide you through the process if it gets difficult and through finding resources that you know might be accessible even without a formal diagnosis so I I hope that getting a diagnosis goes smoothly but you have options if you don't so that is all the questions we have from our Facebook audience does anyone in the room have any more that one awesome right there with the mic this is kind of a specific rather than a general question but I was interested in the kind of topic of conversation of female and female friendships for girls with ASD I know that my little one has some trouble sometimes with the nuance of social interactions where she'll play with a female friend one day and their friends and it's great and they have the same ideas but then if the next day her friend wants to play with someone else she has a hard time understanding the distinction between they just want to play with someone else today versus they don't like me is there anything that we can do to kind of explain that or or give her a better understanding of of that nuance of social interaction do you do social stories I do not we do not I think those can be a really valuable resource it's do you guys have a resource for how to do we do social stories yeah we have them we do yeah we have some good links so you can create your own social stories around like a specific topic like that like friends and doesn't blog I might have I think it has a whole topic once on social stories and yeah - I mean to this day I'll kind of make like little informal social stories for myself because even though you know I have a doctor and everything and I have the cognitive ability to grasp these difficult things just because the way my brain works being able to see it and go over it over and over is incredibly helpful so I really recommend social stories for anybody who's dealing with a variety of challenges Carol gray right yeah Carol great it's like gray social stories calm I think yes though is the website since she's kind of one of the people who's developed a lot of social stories and for those who don't know what those are it's basically it's pictures along with stories so it's like going into the dentist and this is what happens when I go to the dentist and so it definitely there's lots that go on social skills as well on friendships and then with the with the social skills you can also do like speech bubbles and thought bubbles so say like you know my friend says you know I want to play with someone close someone else and then show that they're not thinking anything bad so Mike do you come back there last question anyone one more hold that one let's get you the mic oh I just also wanna say I'm also a therapist I think this is a really misunderstood area in our field to be really amazing if you all could repeat this for like mental health clinicians and therapists because I feel like we're I don't know if like we're under taught in this area we'd love to and then just a reminder for anyone who wants to share this the video of this class with anyone or rewatch it may be pieces of it it's available in full as soon as I turn off Facebook live when this class ends anyone can watch the video in full right on Seattle Children's Facebook page immediately so and then I think that is all for the questions for now so thank you thank you thank you to our speakers for being here and leading this we really really appreciate it you guys have any last words for the class and audience watching yeah just thanks everybody for your interest in for for being here tonight either in person or live and I think especially thank you to Natasha for being with us so so invaluable to have her here with us tonight and volunteering her time so she's really wonderful you

Channel: SeattleChildrens

Views: 59,884

Rating: 4.7855229 out of 5

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Id: XJ0weHzBagU

Length: 84min 47sec (5087 seconds)

Published: Mon Jun 29 2020