i'm going to give you it has to be top line um introduction or presentation on this very important category of disorders in the dsm-5 and what i will try to do and what i hope you will learn in the process is the following number one that you should have some sense of the classification of neurodevelopmental disorders as we have them in dsm-5 dsm-5 in fact was the first time that all these particular group of conditions have been put together in one chapter and i think that was a very important progression in the field of psychiatry and child and adolescent mental health the second thing i want you to do is to understand why neurodevelopmental disorders are important to identify and to treat and particularly to understand why the vicious circle what i might call the vicious cycle of difficulties that may come and that make her go with neurodevelopmentalists disorders i'd like you to have a basic approach to diagnosis and treatment of one of these i mean broadly of all of them but in particular of autism spectrum disorder and so i'll spend a little bit of time just focusing on autism spectrum disorders or asd as well and finally it will be important for you regardless of where you may be in the world and what kind of practitioner or non-practitioner you may be to understand and know the red flags or the risk markers for autism spectrum disorders so let's jump straight in the group called neurodevelopmental disorders or ndd as you might hear me talk about in dsm-5 is important for various reasons number one as you can see one in six children across the globe are likely to have one or more of these neurodevelopmental disabilities so the rates the prevalence is significant and the burden associated with neurodevelopmental disabilities is very high if we think about if you say so what is a neurodevelopmental disorder well number one they are neurological in onset now i don't quite like the word neurological in the sense but these are disorders of the developing brain so neurodevelopmental growth or progression as it happens and here what we're presenting are conditions that are associated with things that go wrong with um brain development and progression as it unfolds and because of their neurodevelopmental disorders it means that they manifest or the onset is in the developmental period of the brain now you will all know that the brain does major growth and development in the first few years of life but it actually continues physical and structural development at least into the mid-20s so that's the neurodevelopmental period that we're particularly interested in when we therefore talk about a disorder in the context of development it means that it's important for all of us to have a sense of developmental norms by which i mean what is typical development in order for us to be able to say that in this particular child or person development is not typical the third point about neurodevelopmental services that they lead to impairment in personal or social or academic or occupational functioning so there's a huge range of impacts they're not all health specific impact but as health practitioners as people interested in the overwhelming of individuals there are major domains of health of social of occupational and overall quality of life that can be affected by neurodevelopmental disorders the group of neurodevelopmental resources you will see range from some very specific limitations in particular areas of of neurodevelopment all the way to very global impairment in other areas and so you will as we go through the examples you will get a sense that some are very focused and some abroad a point that i will come back to is that neurodevelopmental orders very often co-occur and with one another and with other things as you will see and when we look for possible neurodevelopmental sources we might see two possible groups of difficulties first we may see a deficit or a delay in a typical behavior say for instance in language it's slower it's not quite right or we may see the presence of atypical behaviors or unusual things things we don't normally expect to see in a typically developing child or a typically developing brain and again as we talk through listen to the differences between delay and deficit versus an unusual atypical manifestation this will particularly be the case when we talk about autism and the seventh important point as i will come back to as well is neurodevelopmental disorders act as clues for other medical problems so whenever a health practitioner whenever a doctor sees somebody a nurse or anyone sees somebody who comes with a neurodevelopmental sword the immediate thought in our mind needs to be this might be a marker for other things that i should also look for identify and treat so on the right hand panel you can see the main categories of neurodevelopmental disorders as defined in dsm-5 intellectual disabilities communication disorders autism spectrum disorder or asd attention deficit hyperactivity disorder or you might even talk about it as adhd specific learning disorders motor disorders and there's always a box for other neurodevelopmental disorders what i'm going to do now is just briefly explain what each of these categories mean and what we look for very top level and then we will go into more specifics around other aspects so the first of those categories is intellectual disability or intellectual disabilities and this is where we see another nice word intellectual developmental disorder we see an a different pattern of emergence of intellectual skills and that includes all aspects of development reasoning problem solving planning language judgment all those kinds of things and this delay in development is associated with an impacting adaptive behaviors in the day-to-day skills of that person and therefore having an impact on their personal development on their ability to function in daily life there's one group in the dsm that's called global developmental delay and the only point to make about that is global developmental delay is a temporary or a provisional label that we should use only in children under the age of five and only when we are not yet able to make a comprehensive assessment of the intellectual level of a particular child so let's say a mother brings a two or three year old and it looks as though across the board all developmental milestones are delayed and the child seems to be delayed across their ability to problem solve and plan and talk and so on we may say this looks like a development a global developmental delay and at some point we need to do formal evaluation of the intellectual ability and the more systematic evaluation of their adaptive function and once we do that we will make the decision do they have an intellectual disability or do they have something else that explains their presentation so remember this is a only a provisional label and we should never use it over the age of five so let me explain just in a minute then how we evaluate the intellectual abilities of a person on the screen here you can see what one calls the normal distribution of intellectual abilities and some people call this the gaussian curve or the bell-shaped curve and the simple thing is that iq tests wherever we are in the world different countries different languages use different kinds of tools but an iq type test measures the overall brain skills of an individual in comparison to other people of the same age and so if we imagine if we take a hundred people and put them in a room and see how tall people are you will know that most people will be sort of of average height so imagine that's height most people are average time some people will be much taller and some people might be much shorter and iq works in exactly the same way so that the mean iq average iq once people have done a typical iq test is a hundred and you can see this the middle so one plus one standard deviation away from this mean and minus one standard deviation away from this mean this is average iq so 85 to 115 is an average iq range you could be above average if you fall in this group and you can be below average if you fall in this group and then if your intellectual ability the scores you get on that iq test falls below two standard deviations of the mean or below a score of 70. in other words only about two percent of people in the general population will fall in that group typically then we may say you have intellectual disability and we will only say it also if you also have evidence of problems in your adaptive behavior so this very broadly is how we get to a definition of intellectual disability and this is why it's important for us to do more structured and formal testing and look at the adaptive behaviors of an individual to make that final clinical judgment communication disorders is the second group this is where we're talking about a range of aspects of communication that might be affected so language is the main modality of communication and we may see language disorders of receptors understanding language of expression of language of both expression and receptive language and often people say well maybe somebody's just a late talker maybe it's not a language deficit but the short answer is if anybody is worried about the understanding or the expression of language in a child it's better to seek support than to wonder to assume or to say oh my husband my other son was also a slow talker let's just wait in neurodevelopmental disorders it's always better not to wait and to do something than not to do anything a second group of communication disorders is speech sound disorder so we call them problems with articulation of phenology so the ability to articulate and pronounce words so that's a second group of communication disorders children many children might have fluency disorders so that's when they stutter they stammer they struggle to stop they have to start again or in the middle of a word or particular sounds we also get a category called social pragmatic communication disorder so this is when people struggle with the pragmatics of language and pragmatics of language mean the social use of language so for instance struggling with indirect language not understanding humor or sarcasm or um for instance where to say well it's raining cats and dogs somebody who has a social pragmatic disorder might be looking for the cats and the dogs while it's raining and they don't quite understand that it has a different sort of meaning this is a category that's in dsm but from a clinical point of view whenever you see somebody who may have these sort of social difficulties in communication we're always going to think of autism spectrum disorders first because many people who have these difficulties actually have an autism spectrum disorder so i'll come back to that autism spectrum disorder is the third main category of neurodevelopmental disorders in dsm-5 and i'll come back and spend more time specifically just talking about that adhd many people have heard of adhd some people think there's too much adhd in the world but in the usa probably about five percent of children meet criteria for adhd some studies that have been done in africa show very similar rates in fact some have been even higher than that five percent um that has been identified in the usa and we get either predominantly inattentive presentation of adhd so a child is predominantly struggling to focus trying to pay attention struggling to sustain their attention etc or it might be predominantly hyperactive or impulsive the child or the person who's butts in who finds it hard to sit still who's really on the go etc of course all neurodevelopmental disorders also go into adulthood and as we our focus today is on the child and adolescent population but as these conditions go into adulthood they may start to present slightly differently we may look for different things so today's presentation is not specifically focused on neurodevelopmental disorders and how they make presenting adults we might get combined presentation of both inattentive and hyperactive subtypes of adhd as well the next main group of entities are specific learning disorders these are things that are often picked up in school in educational settings and this is when a child out of keeping with the expectation of the intellectual ability that we've talked about and out of keeping with the educational opportunities have difficulty in reading and it could be many aspects of reading like accuracy or right to fluency or understanding they might have difficulty with writing also different aspects of writing can be affected or they may have difficulty with mathematics um numbers memorizing figuring things out etc and just out of interest people often hear and use the word dyslexia and many people think dyslexia is associated with lots of different things but strictly speaking dyslexia really just means an inability or an impairment in reading so from a from a practical diagnostic point of view that's what we mean and so specific learning disorders are reading writing mathematics motor disorders this is a group where we see unusual or atypical development of motor skills in hr and the one group that we see is called developmental coordination disorders um and this is where child typically might have some problems with their gross motor skills they put out uncoordinated they might have somewhat fine motor difficulty as well building running jumping hopping etc and and these can be very mild and subtle or they can be actually very noticeable and lead to significant impairment in daily activities for children we also get so-called stereotypical movements this is when a child might have very particular unusual movements that they that they might make um it might be hand and finger movements although that might might make us think of autism as well it might be kind of ringing movements it might be biting movements they're very stereotypical and repetitive and if they are not part of another condition like autism we often actually see them in the context of conditions like intellectual disability or specific genetic syndromes for instance tic disorders tick disorders when we have sudden rapid unexpected movements of either motor skills or functions or of sounds and we can get a provisional tick disorder so this is when we have either unusual motor movers like a blink or a tick or twitch um for less than a year or make unusual stance like a throat clearing or cough or whatever any of those kinds of things um or many combinations of those for less than a year if we have a persistent or a chronic tick disorder it means we have either remote or some vocal tics that last for more than a year and we might meet criteria for tourette's disorder if we have both motor tics and vocal or phonetics that last more than a year these are all very specialized areas and there are many things that you can go and read about more about these conditions if you're interested so let me now come back to why these neurodevelopmental disorders are important and what i mean by the vicious cycle of neurodevelopmental disorders and i'm going to illustrate it by giving you some clinical numbers the first important thing for all of us to remember is that and if we use intellectual disability as an example is that about 40 percent of children that adolescents who have an intellectual disability will have a diagnosable other mental health disorder in contrast to that a child and adolescent without intellectual disability will have about an eight percent likelihood of having another mental health um diagnosable mental health condition so you can see if you have intellectual disability you are six times more likely to have other mental health disorders they are treatable but very often people don't look for them and therefore don't treat them and that's the key message to all of us today that if we see neurodevelopmental disorders we should think what can i do to help or to treat neurodevelopmental orders often co-occur with one another if i use the intellectual ability intellectual disability example again if you have id your chance of having autism is 33 times greater than if you don't have intellectual disability your chance of having adhd as well is eight times greater of ticks is five times greater so having intellectual disability is a major risk marker for other neurodevelopmental disorders like autism adhd or tick disorders for example neurodevelopmental disorders as if that's not enough they also co-occur with other psychiatric disorders i've already hinted to that so here you can see the intellectual disability example you are four times more likely to have an anxiety disorder if you have intellectual disability three times more likely to have a psychotic disorder five almost six times more likely to have conduct disorder so the neurodevelopmental disability makes us more at risk of other psychiatric disorders to compound that neurodevelopment disorders are also associated with environmental adversity the same author emerson that you saw earlier on the slides and did large-scale studies in the uk and found the high rates of poverty in families who live with intellectual disability the high rates of maternal mental health problems if you live with intellectual disability the higher rates of maternal physical health problems if you live with intellectual disability there are more single parents who have kids with intellectual disability and there are high rates of what they call chaotic climate so this is disrupted interrupted inconsistent families when you have intellectual disability and finally neurodevelopmental disorders are also associated with more physical health problems when you have high intellectual disability or autism we see much higher rates of epilepsy about 30 percent in intellectual disability and in autism it increases in adolescence we see much higher rates of diabetes of dental and oral problems of gastrointestinal difficulties like ulcers and reflux and constipation and have obesity now that might be associated with a combination of their activity levels difficult with exercise dietary things medications etc etc but what i wanted to illustrate to you is how and why neurodevelopmental disorders therefore poses the risk of what i call the vicious cycle of having one neurodevelopmental disorder that might lead to others that might be associated with mental health problems with physical health problems with family health mental and physical health problems with environmental challenges with poverty with lack of access to support and this is why neurodevelopmental services are so important for us to think about to be mindful of um and to think how do all sectors in health and education in social care in the non-profit sector and so on how do all of us play role in breaking the cycle at some point along the way and that i think in terms of the top line for narrow developmental disorders if you can imagine and keep that image of the vicious cycle and how we can break it in mind that would be a really really important thing so let me now come back to autism for for the rest of the presentation um a very common question i get asked is people saying so how common is autism because it seems to be getting more and more and more common is the whole world going to have autism in there and on the one hand it's true if you look at the rates in the 1970s in fact when i was in medical school now fortunately it wasn't in the 1970s but i was taught that about one in ten thousand children probably had autism and gradually as research and knowledge and evidence increased the rates have been going up and up and up and in 2018 a study in the u.s showed one in 59 children had met criteria for autism spectrum sort of one in 34 of the boys in that particular um cdc study a study in korea showed one in 38 children in schools met criteria for an for an autism spectrum disorder now epidemiological studies always have variation and i think if we put all the different studies together and we look at them put together the current estimates are that autism probably is at least one percent and maybe up to two percent of the population so it means that autism and autism spectrum disorders are at least as common as schizophrenia which has a prevalence of one percent so just a word then i think it's useful to remember the at least one percent which means we know very little about a condition that's actually much more common than we think but of historical background autism first described by a man called leo connor uh developmental pediatrician oh no actually he was the first child one of the early childhood characters in the in the us um in 1943 um and he described 11 children happiest when they're on their own oblivious to things around them a mania for spinning toys shaking head side to side tantrums when routines were disrupted and in the following year a man called hans asperger in austria described four gifted but withdrawn boys he said they didn't have empathy and they had little ability to form friendships they had were very one-sided in their conversations had a very particular absorption in certain things and because they came across so kind of pedantic and adult-like he called them his little professors and over time people have separated autism asperger's and what used to be called pervasive developmental disorders not otherwise specified or pdd you might have heard the term pdd in dsm-5 we have changed and we are grouping all those conditions in the same box as i will illustrate to you now this is the way i try to remember how to diagnose autism spectrum disorders some people think it looks a bit like a windmill whatever your analogy is for what it looks like you will see that there are two overlapping circles in the one circle there are three arrows in the other circle there are four and there's a red one in the middle and the simple message before i show you the the words that go with the arrows is that there are two main domains in which we look for abnormalities in autism and to meet criteria for autism we need to have problems in each of those two domains so you need to be here in the middle you need to have an overlap some in each domain in domain one you need to have we need to identify challenges in each of these three there are three subdomains and in domain b in the second domain we need to find difficulties in two of the four of those arrows if that makes sense let me put some words to this so you can see if it makes sense dsm-5 we look for persistent impairment in reciprocal social communication and social interactions across multiple contexts and we look for restricted and repetitive patterns of behavior interests or activities we need to see evidence in early childhood remember this is a neurodevelopmental disorder so if somebody has no problems and suddenly at the age of 13 they start or at the age of 25 that's not a neurodevelopmental disorder that's probably something else and we need to see evidence of impairment in their daily life in their functioning let me add more words to it in this domain one and domain two here you can see the three subdomains domain one we are looking for difficulties with socio-emotional reciprocity i will give some examples in a minute we're looking for problems in non-verbal communication used to interact socially and we're looking for difficulties in developing maintaining and understanding relationships on the second the second domain we look for two of do you remember i said two of those four arrows stereotype or repetitive movements use of objects or speech insistence on sameness this exact phrase comes from kana when he described it in 1943 being very inflexibly adhering to routines being very ritualized either in your verbal or non-verbal behavior having highly particular fixated interests and or having sensory hypo or hypersensitivity we don't have time to go into lots of examples and for those interested to learn more about autism i'm going to suggest you can look at some of the the references in the literature that i will give you at the end but just a few examples in each of those three sub-domains um of that first circle that i've shown in social emotional reciprocity we're really looking for difficulties in the normal to and fro of social relationship you know if you think about how do i interact with other people and they said to and fro i see and you're not i speak and you add we play and we take turns and so that's socio-emotional reciprocity and in autism this is a major problem for most people so we might see unusual social approach so people might have unusual overtures of the way they approach you they might use somebody else's body as a tool for instance to take them and lead them to things and they might struggle with to and fro conversation they might all be either one-sided or not at all or a monologue and not picking up that others want to speak they might be reduced sharing of interests or emotions for instance showing or directing attention offering to share sharing or seeking enjoyment with other people or people may not initiate or respond to social interaction so either not showing an interest in other children or other people or not quite knowing how to respond when other people approach them or doing it in an odd way in the domain of non-verbal communication here we're now looking to see how do people communicate using their non-verbal tools and so for instance we might see a integration between words and gestures or eye contact for instance or we may see people struggling to use their eye gaze in an integrated socially comfortable way we might see problems with their how they use gestures their facial expressions to regulate social interaction so for instance smiling or having a limited range or just using it in odd ways to communicate and we may also see that people struggle to understand and use gestures so there's one component about their own difficulty and then another is about reading similar things in others so not pointing for instance to express an interest in something nodding head shaking and different kinds of gestures the kind of thing that you see me do all the time it's called an emphatic gesture and often people in with autism don't use gestures in this kind of typical way and the third sub domain here is about developing maintaining and understanding relationships and so it's about not adjusting your behavior to others perhaps asking inappropriate questions or making inappropriate facial expressions not quite knowing how to share in play either not playing or wanting to play in the same way or not wanting to take different roles in play or even an absence of interesting peers some some children with autism may avoid other children who might hide behind mum and dad if they see other children approaching and the key thing is in this domain as well as the next domain we're going to look at briefly that it looks different for every child with an autism spectrum disorder so there's not one blueprint recipe and that's why i think it will be useful for you to go and look up and read up more about asd so just a few words then about that second circle we've looked at the one circle now the second one we may see stereotype or repetitive motor movements use of objects or of speech so you might see children flicking their fingers when they get excited or tippy-toeing or twirling around when either when they're very excited or when they get very distressed for instance by something they might line up their toys rather than play with them they might flip things they might open and close things they might take a car and rather than pushing it around saying room from room they might turn it around and spin the wheels or open and close the doors for instance um that's what we mean by repetitive use of objects or interested in any parts of objects and in terms of language we might see echolalia so this is repeating words or phrases that they've just heard immediate echolalia or delay declaring where a child or a person might use a phrase a chunk that they've heard maybe somebody else's language or on television or an advertisement or from a book and use it repeatedly people might even make up their own and have odd language have um what we call neologisms words they've made up and or just use unusual expressions insistence on sameness this lovely phrase from kana it's about people often having extreme distress at small changes difficulty with transitions very rigid thinking patterns they might have very particular greeting rituals take the same route eat the same food and even just having a different kind of white bread might be a problem or having the salt and pepper there on the table rather than there or having a different plate might be problematic and might lead to significant difficulties for people in terms of highly restricted or fixated interest often here we see people having a very particular interest now all of us might have a hobby that's about sport or about toys or cars or whatever but in autism we see that the intensity is extreme and we see that it is to the social exclusion of others when you or i are in a club with other people and we talk about football or rugby or activities or dinosaurs we do it because we like to share with one another if we have autism and we have this highly restricted interest we may do it because we're interested in it for ourselves in the facts it's not because we want to share it for instance and people might also show what we call preoccupations with unusual objects so this is being interested in unusual things like sticks and twigs and or wanting to look for toilet seats or radiators or wall plugs or all sorts of unusual things that might give us an example that this is something unusual or odd we don't expect in typical development do you remember that very early slide i showed we may see delay or deficit or we may see oddity and here we may see an example of an unusual kind of interest in behavior and the fourth domain which was added in dsm-5 is many people with autism might be either hypo or hypersensitive to particular sensory stimuli so that might be the sight the smell the look or the feel of something that might have really like the sight to smell the look or feel or they may be very sensitive to the sight to smile the look and feel of particular things and they can lead to very significant impairments in daily life for many people when we diagnose autism now i do remember i mentioned we used to say asperger autism we now only diagnose one box we say that you have an autism spectrum disorder and we define the severity level of your autism based on that social communication domain and on the repetitive and stereotype behavior domain oh so we may say you have autism with significant difficulties in social communication and modern difficulties in stereotypical repetitive behaviors and we might say and you have autism and intellectual disability or without intellectual disability with a language or without a language disorder with a known medical genetic condition or without with another neurodevelopmental or mental or behavioral disorder or that so you can see we list to be more descriptive because we know that autism is such a broad thing simply knowing that you meet criteria for asd doesn't tell us very much about what your interventional needs may be and that's why we define severity and we use specifiers to help us with clinical intervention planning so i hope that you will now understand my little umbrella or fan or lollipop or whatever you might want to call it that autism is two main domains with three subdomains in social affect four sub-domains and repetitive and stereotype behaviors we need to have difficulties in each of those three and we need to have difficulties in two of the four in order to say somebody has an autism spectrum disorder and the key thing for all of us to remember none of those behaviors examples that we have just talked about on their own are sufficient for us to say somebody has asd any one of us might have some of those difficulties at some point in our lives um i might have sensory sensitivities you might have had difficulties with eye contact somebody else might have had problems with play etc so none of them on their own are enough to say well it's enough to say i have asd that's why we need a diagnostic process in a systematic way works through all of these and then adds it up to say yes you do or no you don't meet criteria for autism let me now shift to the red flags for autism because they are related but not quite the same as diagnostic features of autism but let me first take a step back and tell you why people became interested in finding and promoting red flags or risk markers for autism across the globe all over the world and it's still very much the case in africa and in most low-middle-income countries where most people with autism lived um we realized that mums and dads and caregivers and aunties and uncles and grannies and grandpas typically pick up some concerns early on usually by about the age of two mom would say i'm worried about my child's development mom might say gran might say he's not yet saying words why is that and what we typically see is that all over the world from parental concern or family concern to diagnosis and actually starting some intervention there's a gap of at least two years if not more so if you're worried at the age of two about your child typically they are not going to see a specialist or a doctor who will diagnose or might diagnose autism or language or other disorder until about four or even five and that age between the age of two and three or four is the ideal time for us to start early intervention and so red flags and risk markers were identified through large scale research over many years and are being communicated and we are teaching the world about it so that we can try and reduce that gap from concern to doing something and you will see when i show you the right the red flags or risk markers that they are things that typically developing children do very early on in the first few years of life and the message to all of us is whatever kind of job we do whether we are child psychiatrists whether we are orthopedic surgeons whether we're general practitioners whether we're mums or dads or nurses in a clinic if we see any of these red flags it should make us think aha should i think about autism should i seek an assessment for autism or should i even start some basic supportive work to help this family who may have a child with autism or another neurodevelopmental disorder so here are the red flags and i'll just quickly show them to you number one is not responding to name by 12 months from very early on babies if you call their name will orient towards you they will look towards you and often they will then smile they'll make eye contact and smile if a child doesn't respond to their name by a year that's a red flag if they don't point at objects to show interest mommy look and usually they look back to see if you're looking where they're pointing by 14 months it's a very typical developmental milestone if children don't do that it's a red flag not having pretend play by 80 months pretend play could be anything from you know rocking a little baby or pushing the car or pretending to make tea and feeding people and changing nappies or any kinds of things that might be culturally appropriate but if my 18-month children don't do that it's a red flag avoiding eye contact wanting to be alone is a red flag because children most of us are social creatures we are we use our eyes to engage with people and we want to be with other people because that's how we learn we are social learners in the world if young children have trouble understanding other people's feelings or trouble talking about their own that's a red flag delayed speech and language skills is a very important red flag and it's the most common red flag that typically is why families would go to a clinic to a doctor to a nurse saying i'm worried he's too he's not yet saying words and what we don't want doctors to do is to say don't worry he's just the boy come back in a year if he's not improved this is the time we want you to start intervention not delay repeating words and phrases over and over you remember i mentioned echolalia and so that could be a red flag for autism giving answers unrelated to questions so if it really doesn't feel as though there's a conversation so um between a child and a parent and if you think where did that come from it has nothing to do with what we're trying to talk about at the moment getting upset by minor changes in routines having very obsessional interests flapping hands body rocking spinning in circles there's a motor red flags and also you remember i mentioned unusual reaction to sound smell taste look or feel often children show it by you know sound putting their hands and they get us distressed or anxious but sometimes people also have idiosyncratic responses to sensory stimuli and that usually makes them angry and it could be unusual things like the sound of a dog barking sound of um a baby crying the look of beards all sorts of things can lead to these unusual reactions so you can see some of them also link to diagnostic criteria but these are the key red flags or risk markers if you want to read more about them look at the cdc website but remember each one of them should make us think could there be autism and or another neurodevelopmental disorder and the more we see the more likely a child is to have an autism spectrum disorder or other neurodevelopmental disability let me wrap up and just say two words about intervention for autism very often and probably until 10 or 20 years ago many people believed that there was nothing we could do to treat autism and the one message that we should all remember is that there is now very clear evidence that we can treat autism and we can treat autism including the core deficits those things and those in those two domains that i showed you we can treat most of those things and we can help children to develop language to become turn takers to engage in the social world to reduce some of those difficult or unwanted behaviors but the key is we need to pick these things up and we need to intervene as early as we can it's never too late but the earlier the better we don't have time to go into details of intervention and i'm just going to leave you with kind of ten core principles for interventions for autism and in fact the principles on the whole will apply to most neurodevelopmental disorders but in autism specifically principle number one is that we need a comprehensive assessment to guide comprehensive intervention you've seen there are so many different components just in autism that we need to look for and each person with autism is going to look different and therefore the profile of needs will be different number two by definition no single intervention will work for everyone so if anybody's trying to sell you a particular treatment a particular pill a particular therapy and say this will be the solution to all the problems by definition they're probably wrong some things work for some but not all things work for all the third thing we are going to do is we are going to accommodate the challenges of people with autism this is what i mean by um simon baron cohen well-known british autism expert uses the word mind-blindness and he says that many people with autism struggle to understand and read the minds of others so imagine you have a blind child at home if you have a fancy coffee table and things that can break you will accommodate your blind child by moving those things away and in exactly the same way we're going to make the world a more autism friendly place we're going to use simple language straightforward language we're going to be clear we're going to produce create structure we can help um create scheduling for people we're going to be very deliberate in helping them teach and motivating them for communication and so on so that's what we mean by accommodate but we are also going to build skills through the core difficulties of autism and as i just said there's a whole world of intervention that have opened up that can help us build skills through the core deficits of autism we're also going to look for and treat the conditions that co-occur with autism do you remember how i said neurodevelopmental disorders co-occur with one another with physical health problems with mental health problems and so we're going to look for and treat those things because they might be just as important to treat as the autism itself number six we're going to be family folks we are going to do nothing without family participation and without making sure that we understand the needs and the priorities of the family a child and an adolescent with autism live their lives with their families and they only come to a clinic every once in a while so nobody knows a child with autism and with any neurodevelopmental disability better than their family and so we need to work with a family support the family empower the family give them skills and tools and you will see also increasingly also when you go and read more increasingly our interventional strategies are based at finding strategies to teach families to work with their children with autism we're going to use early intervention in the early years and early identification and treatment throughout the lifespan because some of these conditions might occur throughout the lifespan we're going to understand the meaning of behaviors we don't have time to talk about it today but children with autism and other disabilities often present with what people might call challenging behaviors behaviors that challenge others and rather than to say this is a difficult child or a naughty child we're going to ask ourselves what is this child trying to communicate to me when they bang their head when they hit out when they spit when they shout and once we understand the meaning the function of that behavior then it will guide us to the right treatment or intervention we're going to use evidence-based interventions not random things not things that don't have evidence and not things that might be dangerous or harmful to people with autism or other disabilities and the mainstay focus nowadays is we do parent education and training to empower families to give them knowledge and skills and we use what we call naturalistic developmental behavioral interventions or ndbis and that's a whole field of interventions that work in the natural context in the natural setting at home during daily activities doing usual things to build interventional strategies into that we've moved away from the approach where a child is sent into a therapy room with one therapist because the risk is that that doesn't generalize into the real world and it is in the real world that we want people with autism and other disabilities to be able to function to participate and to be seen as citizens with equal rights and equal and visibility as anyone else in the world further reading as i said this is a brief introduction and there are many many many other things you can go and read here are a few freely available resources so anyone can go and look for them and download them and read the yakipeps at the international association for child and adolescent psychiatrists and allied professions has an e-textbook here it is just google it you can download chapters you can download the whole book and it covers the whole range of childhood adolescent mental health conditions yakipap also has some moocs so these are massively online open courses and videos where experts like me would be talking about particular conditions so for those who like watching little movies there are movies to watch goodman and scott and robert goodman from the uk and um steven scott also from the uk wrote a textbook a very nice accessible textbook in childhood lesson psychiatry and this too is freely downloadable and through the internet and you can find that and for those who are particularly interested in finding out a bit more about autism and those early markers what autism looks like in very young people there's a wonderful resource um online called the autism navigator developed by dr amy weatherby and colleagues at florida state university and what you can do is you can go to the website register you have to register but then you can have access to a free training module on what a typically developing two-year-old might look like when they play when you talk to them when you call their name and right next to it what a child with autism might look like when you call their name you give them toys they play they interact and it's a great resource to give us a sense of how these things can differ quantitatively but also just the kind of quality of how autism might look different i highly recommend it to any of you who might be interested to learn more about early markers of autism that i'm going to stop and wrap it up and i sincerely hope that this was a useful overview to you on neurodevelopmental disorders a bird's eye view and i hope that if nothing else it's at least made you realize one the importance of near developmental disabilities um in all settings particularly in low middle income settings and number two hopefully i've stimulated your interest to go and read and google and search a little bit more about autism or about any or all of these other neurodevelopmental disorders thank you very much