Greatest Hits - Dual Diagnosis: The Down Syndrome and Autism Connection

This summer, we're revisiting some of Hina and Marla's greatest hits from the first 10 seasons of The LowDOWN. On Season 2, Episode 8 of The LowDOWN: A Down Syndrome Podcast, Liv Meriano gives us the lowdown on Down syndrome and autism spectrum disorder.

Transcript

Today on The Lowdown, a Down syndrome podcast. Liv Meriano gives us the lowdown on down syndrome and autism spectrum disorder. Over to you, Marla and Hina. Thanks, Danielle. Hi there, and welcome to The Lowdown podcast. I'm Hina Mahmoud, the lead OT at the Down Syndrome Research Foundation. And joining me is my amazing co-host, Marla Folden, who is a speech language pathologist at the DSRF. So today we're going to talk about something near and dear to both of us, the dual diagnosis of down syndrome and autism spectrum disorder. This topic is hugely important because, in fact, a large number of our students that we see in clinic have a dual diagnosis, and this overlap isn't really well understood in medicine or the greater community. As you can imagine, a dual diagnosis is a huge deal for families and can bring up all sorts of emotions. Some families are relieved to know what is going on, others are devastated and others are confused as to what the whole thing is about. As clinicians, we know this area warrants more research and education, which is why it is a really good focus for today's episode. And today we have the chance to talk through this with one of our colleagues Liv Mariano, who is an SLP at the DSRF as well live completed her undergraduate degree in speech sciences at Brock University in Ontario prior to completing her Masters of Science in SLP with a minor in audiology at UBC here in British Columbia. Her undergraduate and master's research focused on applying theatre techniques to develop social skills in individuals with social pragmatic difficulties, otherwise known as difficulties with social skills and conversation. And prior to joining the DSRF, she was the creator and facilitator of several improv programs through Community Living and Autism Ontario. In her practice, she applies principles from reference and regulate social thinking and cognitive connections. Having a sibling on the spectrum Liv is passionate about understanding how we can better support people with autism to reach their full potential. Hi Liv! Welcome to the Lowdown. Hi guys. Thanks for having me today. We are delighted. Absolutely. Likewise. Great. Um, usually when somebody comes to the lowdown, we start with five secret non-related questions. Are you game? I'm game. All right. So question number one do you have a favorite improv show that you like to attend or watch? Oh, that's a really good one. Um, my favorite local one is the Sunday service. Oh, I haven't heard of it. What kind of programme is it? It'll change your life. Oh, they're probably the best improv troupe, I would say, in Vancouver. Okay. Um, they perform at the Fox Cabaret every Sunday evening. Um, and that's probably my favorite local troupe to watch. Cool. Um, and then I'm also a big fan of, like, Whose line is it, anyway? Yeah. Like the classic. The classic stuff? Yeah. Okay. Really cool. Um, question number two. What are you reading right now? Oh, God. Um, right now I'm reading a graphic novel called belonging. Oh. Oh. Is it Shaun Tan? No, no no, no. That's a different one. That's home or something else? Yeah, it's. I can't remember the author. Um, it's for one of the book clubs that I belong to. Um, yeah, it's really good. It's about, um, like a German girls, um, going back to, like, her roots as, like what happened after the Second World War and how that affected her and her family. Yeah, I highly recommend. Okay. I like a good graphic novel. I'm into it. Question number three. Do you have a de-stress routine after a long day in the Oval Office? I mean, yeah, I guess I would call it a routine. Yeah. Or an activity, whatever. Or activity. Yeah. I tend to go home and definitely eat dinner. I'm a big fan of, like, food. Yeah. When I'm stressed. Mhm. I usually like to wind down with like sometimes I'll have a glass of wine with dinner or a beer. Um, and I love to go for like walks around the neighborhood. Um, yeah. And just hanging with my partner who tends to de-stress me. And. Yeah, it makes me feel good. Perfect. Number four. I'm really excited for this one. Um, what is something that you really like to cook? Oh, so I'm Italian and grew up in a very Italian household, so I've been told that my lasagna is quite good, and I think that's like my go to when people are coming over. Um, and I do enjoy making it because it makes like a lot of portions. And I'm a huge fan of big portion sizes. Yeah. So I think that's probably like my go to dish that I make. The only way to eat lasagna is big portions. Honestly, as I learned at lunch, as you learned at lunch today. Yeah, I brought a tiny piece of lasagna for lunch and was very upset about it. It just was not enough, right? Yeah, you should have learned from you. Um, okay. Last question. What is your favorite thing to drink in the a m before you get to work? Ooh, okay. So I drink, I drink coffee, but, um, I drink coffee really slowly. Yeah. Um, and I've been told by my dentist, like, not to do that. Um, so I'm one of those, like, coffee drinkers who, like, leaves their coffee cup, you know, for hours and then comes back to it later. Um, so, um, yeah, I always kind of have a coffee on the go, but depending on like where it is, I don't know. Um, so yeah, I would say definitely coffee. Um. Just black. Don't like any sweet stuff in it. Um, yeah, that's kind of. It. Gets me going in the morning for sure. Yeah, I could see that. Well, thank you for indulging us with that. I hope it wasn't as scary as you thought it might be. Yeah, I felt that one up in my head. Yeah. Yeah. All right, so let's jump into our topic for today. And I want to start with you telling our listeners a little bit about yourself and your work history with people who have a dual diagnosis of DS and ASD. And what really made you want to know more about that? Yeah. For sure. Um, so I'm a speech language pathologist at the Down Syndrome Research Foundation, and get the privilege to work with you lovely ladies on a daily basis. Um, and I was just thinking the other day like it's been just over two years already, which is insane. Wow. I feel like I just got here some days. Um, but before dzfe, I worked in public health and private practice with individuals with developmental disabilities. Um, many of which had autism or were suspected to have autism. And, uh, personally, my brother is also on the spectrum. Um, so he was diagnosed with Asperger's when that was still a diagnosis. Yeah. Now, we know that it's just kind of a broader category of autism spectrum disorder. Um, but I've always kind of had this interest in autism because of that. Um, and wanting to understand more. And so when I lived in Ontario, um, I got involved with Autism Ontario and Community Living, uh, where I facilitated improv groups with teens and adults with down syndrome autism. Some of them had, like, social anxiety. Um, and you kind of see this, like, transformation in them and their improvement in social skills. Um, and so my research interest kind of fell in studying those effects of how drama and improv, um, affect the social skills of individuals with, um, social communication difficulties. Um, and so when I started at Dsph, it just so happened that a large majority of my students had a dual diagnosis. Um, I went back and realized, like at any given time, I would say a third to almost half of my students had a dual diagnosis, which is crazy. Yeah. Um, yeah. And, you know, I remember reading when I first got here, like, I think it's about 12% of our students have a dual diagnosis of ASD. Um, so seeking information kind of started out as like a necessity to better serve these families. Um, because it is a part of, like, our day to day work with them. Um, but it's kind of evolved to like, more of, like a passion and a huge interest area for me because it's, yeah, just so common within this population. Yeah, it is super common and not, known that it's common, which is always surprising to me. So we get feedback from families saying like, I feel so isolated and alone. I don't think there's any family in my situation. And I'm like, oh no, no, no. Like half of the people I see here are in your situation and actually think the same thing you do. Exactly. Yeah. I found the exact same thing. Um, yeah. It is it is an interesting sort of phenomena that we see. I think half of your caseload, roughly. Hannah also has a dual diagnosis, which doesn't really match with the population level research that's been done. Now, mind you, some of the newer research puts the estimate a little bit higher, but still it doesn't match. And I suspect that it is in part because kids with a dual diagnosis need more support overall. So we don't see a really representative sample of everybody with down syndrome. We see kids who need maybe more help than others. Yeah. Um. Let's go. Let's backtrack a wee bit. So many people don't even know that you can actually have both diagnoses. In fact, doctors used to say that you couldn't, which is a big source of confusion for a lot of people. So why do you think people don't know this? What's going on? Yeah. Great question. Um, like you said. Yeah, there's this like early view that autism was rare with people with down syndrome. Um, and it was believed that, like, the two couldn't exist together. Um, and, you know, parents were originally told that their child had down syndrome with, like, a severe to profound, maybe cognitive impairment, but like, nothing was really looked into um, or further investigated. Um, but today we know that's not the case, that a person can have both down syndrome and autism. Um, and in fact, it's estimated that people with autism, in individuals with down syndrome, it's like 10 to 25 times more likely to occur. Yeah. Um, and is more common than the general population. Um, and I think like this could be for a few different reasons. Um, one is unlike down syndrome, which is like conclusively, objectively diagnosed with a blood test. Autism spectrum disorder is a subjective diagnosis based upon observed behaviors. Um, social communication patterns. So to in order to be diagnosed with autism, a person needs to be observed as they develop and present with these symptoms that are consistent with autism. Um, and I think like even though these symptoms of autism need to be present from early childhood, I think they're sometimes harder to detect in our students. Yeah, totally. Um, for a few different reasons. Like, I wonder if because like, development is slower, these signs might not they might not show or be as clear until like later on. Um, there's also research comparing like children with autism and down syndrome to children with just autism. Um, and results of these studies have pointed to like a very distinct autism profile for them. Um, because when compared to individuals with just autism, they actually have strengths in imitation and gestures than what's typically kind of thought. Um, so yeah, some of the researchers have said like, maybe that's because, um, Down's syndrome presents with relative strengths in nonverbal communication. So it almost acts as like a buffer or like a social boost for these kids. And, um, but it doesn't really present as like typical autism, um, all the time, which makes it hard, right, for people on the diagnostic panel or the assessment panel. And then for us as clinicians to we'll often kind of have this question mark in the back of our mind, like, do we think there's something else and something more going on or maybe not. And we're kind of waiting to see what other skills are developed and added. And then is there going to be sort of a spiky profile, because that's what we're looking for, to send somebody for an autism assessment. Totally. Or, you know. Are things going to kind of level out and are we just at a plateau at the moment? It's really hard to tell when these guys are young. Yes. For sure. And I think sometimes people don't know what signs and symptoms are consistent with like autism versus what's consistent with down syndrome. Um, and as we know, and I'm sure we'll talk about like there is overlap between the two. Um, and it can go undetected because of that. Um, yeah. Like, anecdotally, my brother who was born deaf, um, a lot of the signs that we were kind of seeing, like not responding to his name or, um, you know, having difficulty making eye contact or making friends was kind of attributed to. Oh, well, he's deaf and and it was kind of like, pushed aside when, um, you know, actually, as he got to develop or like, know something else is different here. Um, and kind of. Yeah, prompted us to explore it more. Um, so I think, like many children with down syndrome or deaf children can demonstrate some behaviors that are similar to autism, but these permits should occur in the context of some really critical, strong social skills that are appropriate for their developmental level. Yeah. Yeah. Very well put. I agree. Um, in your experience, how does this second diagnosis impact families? It's a really big deal. We should not sort of minimize it at all. It's a huge deal to get this second diagnosis or even to go for the assessment and go through the process. It is. I think that second diagnosis impacts families in many different ways. Um, like you mentioned, some families feel a sense of relief when they get a diagnosis. Um, you know, they could feel like they understand their child, their behavior, um, know how to like, support them better or feel like now they have, like funding for various things, which is a good relief. Um, I remember one family saying to me, like, he's still the same person. It just helps explain some of the behaviors we were seeing. Um, and then for some families, I think, you know, where maybe it's less expected. They feel almost like a second wave of grief. Um, you know, one family had said to me, like, we feel like we were just getting a handle on down syndrome, and now this was added to our plate. Um, or feel like it's kind of like another added label for their child. Um, and I think you can feel both at different times during that process. Um, and in my experience, like it's extremely variable and extremely individual, even within the same family, you can feel different things. Um, yeah. And we actually conducted a survey earlier this year to see, like, how Dsph can better support our families, um, who have children with down syndrome and autism. Um, which came from those discussions with our families, like we said, where, um, you know, they feel sometimes a sense of like isolation, like they don't really belong to, like, the down syndrome community fully or don't belong to the autism community fully. They're kind of like a part of these two camps, when really a lot of them had lots of similarities and shared experiences raising a child with down syndrome and autism. Um, so it kind of shed light a lot on, like what the majority of our families feel. Um, so I can kind of talk about that survey if you want, and kind of shed light on that experience. I think it'll help listeners out there who are probably feeling like that, maybe feel like, okay, I'm not on my own here feeling this way. Um, yeah. So the survey, what it kind of showed us was that a majority of the families felt reported like they were they felt more confident understanding down syndrome rather than autism, which could be because maybe like the autism diagnosis came later. Yeah. Um, yeah. Reports of, like, feeling isolated or alone, navigating the system. Um, lots of them saying like they felt overwhelmed when this kind of diagnosis This was put on them, and there was also an overwhelming response that they perceived raising a child with autism and down syndrome was more challenging than just down syndrome alone. Mhm. Um, and in terms of support, there was a huge need for more information and support. So whether that's like a parental support group or um, some parents said they would rather they want to understand signs and symptoms more. Um, which kind of resulted us in creating like an ASD, um information tab on our website with some resources, um, which is like kind of the first step in our plan to support these families because it's a huge need. Um, and then more is to come later. And I think that support piece is really important because in my conversations with families, they've said that they can't even they have they're taking time to get a handle on this additional diagnosis. Navigating the system is very stressful. So they get this big binder with information that are pretty much and I've seen this binder. It's pretty much like photocopies of different things all put together. So not only are you dealing with this new thing that you kind of have to navigate towards, but now you have to figure out how to work the system. Like where's the funding? How do I, you know, if I need a behavior consultant, how do I do that? So like, how are those things going to it's great to have that additional funding, but like how do I use it. And I find that a lot of parents have told me that that is a source of stress for them, as well as just trying to figure that out. Absolutely. And for people who are listening from further away in DC, at least, the funding sources are separate for kids with down syndrome alone and kids with autism. And so if you have a kid with both, you technically get both kinds of funding. But there are different government agencies and knowing what services and supports go with which thing and who covers what is really, really complicated. And it doesn't apply to that many people. So there's not that much information. And a lot of the work, at least for autism funding, is on the parents, they have to fill out the paperwork. They have to request this, they have to upload this. So it's definitely kind of like, okay, here is the information and you're on your way. I don't really see much follow up. Much like support from that side to be like, hey, let's check in with you to see how things are going. So I think there's definitely a gap there as well. And even from the survey, I remember a lot of families being like, like, what do you need for support? And they would be like a secretary, like just like track and like, yeah. Help understand? Yeah. Where to? As if like managing appointments and things for kids with down syndrome isn't enough in terms of medical, then you have this added thing on top. So yeah, for sure. Um, so you mentioned that there is, you know, a lot of overlap between down syndrome and autism. So let's talk a little bit about that first. So what clinical signs kind of fall into that category of things that are common between both diagnoses. Yeah that's a really good question. Um because there are some clinical signs that are similar. Um, so if we talk about, like, play and behavior first, um, a lot of children with down syndrome as well as autism prefer like, sameness and insist on routines. Um, that's why they do so well with schedules. And yeah, when their routines kept the same. Um, many have like, restricted interests. So they might know, like, a lot about a certain topic, um, or very. Yeah. This interest area is very intense, which, you know, in our therapy sessions, we use to our advantage sometimes. Um, but, yeah, restricted interests, um, they could engage in some repetitive play and behavior, um, which we often see. I have a kiddo right now who he doesn't have autism, but his go to when we're playing is to make things fight. And so we're working on expanding our play and things. Um, we could also see challenging or problem behaviors, um, you know, like protesting or difficulties with transitions. That's very common in both populations. Um, and even though, you know, like I mentioned, uh, social communication is considered a relative strength for children with down syndrome. Um, they do have challenges in that area. So some things like issues with perspective taking or the ability to take reciprocal turns, um, also compared to when compared to typical peers, they have um difficulty with eye contact as well. Um, in terms of like speech and language skills, um, we see limited expressive language or stereotyped repetitive utterances in both populations. Um, and in terms of their understanding of language, um, they might not always respond to their name, which could be related to hearing loss or directions, especially if they're too long or complex. Um, and then we also see some other things like, um, it's common to have sleep and sensory issues as well as mental health needs like anxiety, um, obsessive compulsive disorder or depression. Yeah. So I just want to clarify for everybody listening, if this sounds like your child, it doesn't mean that they have a dual diagnosis. This is the common areas between both diagnoses. So even if your child just has down syndrome, they might check every box on that list that we just talked about. Yes, exactly. Yeah, that's a really good point. To clarify that they can demonstrate these behaviors that are similar to autism. Um, yeah. But but it doesn't mean that they have autism. Exactly. Yeah, right. Yeah. So then let's talk a little bit about what are some of those clinical markers that maybe would point to the need for an autism assessment, something that is maybe very autism specific. So yeah. Yeah. So we're often asked that by parents, you know, whether we think their child might have autism or whether they should get assessed. Um, so these would be things that I would consider, like more consistent with autism rather than in down syndrome, um, indicating that there is something more at play. Um, and I should say, too, like, the more signs that we observe, I would say like, the more a referral is warranted. Um, and for us, as speech language pathologists, we're usually looking and picking up on things that fall in the domains of play and social communication. Um, so one thing would be, you know, if they have little interest in communicating with others. So you might see this, you know, social withdrawal or kind of like an indifference if people are in the room or wanting to play with them. Um, one parent, you know, described it as I usually have to work harder to get them to interact or play with me, which I thought was like a good way of, um, yeah. How you feel? Um, sometimes we also see less, um, it's called social referencing or joint attention. So all that means is, you know, when two people have a shared focus on something, um, does the child shift their attention from the toy to the person, um, and kind of check on or check in with you to see what you think about that. Or say if you enter the room, do they look up to look at you or when they need help? Do they turn and look at you? Um. And join? Detention is a foundational skill for learning and often corresponds with their developmental level and children with down syndrome. So for individuals with autism, they might do it less or have less of that back and forth, like what we call gaze shifting between objects and people. Um, and usually that looks like more looking at the object. Yeah, I would say most often. So more really intense interest in a toy or an aspect of the environment, sometimes a light or something moving and less checking to see if you think that's also cool like they do. Yeah. Um, yeah. Or sort of how would I describe it? Sort of like, uh. Because I don't want to say indifference, because I think our students with dual diagnosis still care if you're there or not. So it's not about they don't care if you're there, but they might not acknowledge that they know that you're there now. Like if you walk into a room, they might have that awareness, right? But they're not actually outwardly outwardly showing. Yeah, exactly. So yeah, they might not do the quick checkup and look, which you probably don't even realize that you do all the time when somebody walks into a room. But you do a really good point. Yeah. Yeah. It's kind of those like innate things that we don't really think about until it doesn't happen. Yeah. Um, totally. Um, there's also like, if a child has a lack of verbal communication and this is coupled with like no attempts at using other modes to be understood. So if a child isn't using, say, like signs or gestures to supplement, um, yeah, their verbal language. So for instance, um, we look to see, you know, our kids pointing to things around the room, um, not only to request things, but are they, you know, to show us, like, they think that's cool too. Um, do they bring you things to show you? Um, do they wave at others? Um, you know, shaking their head. Yes or no? Kind of these, like, gestures. Um, we, you know, children with down syndrome usually have relative strengths with these nonverbal communication, um, tools like gestures and facial expressions. Um, so we tend to look at that as well. Um, yeah. You know, facial expressions, are they appropriate to the situation. Do they add valuable meaning to your interactions. Yeah I think that's a really that's a key piece because sometimes my students with a dual diagnosis have really extreme facial expressions is how I'd describe it. Or like stereotyped facial expressions, almost like they have a surprise face. And it's really big and it's really dramatic, but it doesn't fit with the situation context. Yeah. Yeah, exactly. You know, but they're trying they're trying something. Yes. But it's not quite matching up with what would be warranted in that moment. And from your guys's perspective in being experts in social communication, do you think they're picking this up from another situation that they've seen? And they're like, let me try it out. Like, what do you think the reasoning could be from their perspective as to why they're doing that? I think there's a lot of reasons it can happen. Sometimes I think it's from TV and mimicking a favorite character, and cartoons tend to be really exaggerated. And sometimes I can I'm like, oh, that seems like a Elmo face or whatever, you know, like, okay, you picked that up somewhere. And sometimes I wonder if it's just like a little bit of a misinterpreted thing that somebody tried to teach them how to do. Right? We've been working on like a social routine and how we smile, but it's just like the ability to sort of gauge how much of a smile would be needed is not there. It's like no nuance there. Exactly. Yeah yeah yeah, yeah. So that looks like. Yeah, it's extremely charming. Yeah, exactly. Yeah. You're right. Exactly. Um. Um, yeah. Another thing like that might be, um. Yeah. Consistent with autism. So development is slower than normal, um, in autism and down syndrome. But in down syndrome, it follows like a normal sequence just at a slower rate. So children learn language first by listening to people around them. Then they'll try out single words and then two words, then three words. They start making sentences and so on and so forth. Um, in autism, sometimes what we see is their development doesn't always follow this normal sequence. Um, so sometimes we see that a child can rehearse maybe a whole song or repeat like a whole sentence. Um, and usually it's said in the exact same way. Or like they hear how they hear other people say it. Um, but they don't make up their own sentences or use single words, or combine these single words together to make their own kind of novel sentences. So that's kind of a sign if we see they kind of like jump a step. Um, the other thing that we sometimes see in terms of language development in autism is sometimes you see like a regression in their development, whether that be in like cognitive language or social abilities. So that again, would be like another indicator. Um, let's talk let's talk more about those. Because for me those are both really big signs. If I'm working with a student who is essentially nonverbal, not saying any words, and then the first thing they say is a sentence for me, that's a huge red flag, because that is nowhere near the typical developmental sequence that we would expect. I mean, we usually expect some like ah ah, ba ba babbling and vowels, and then we get to maybe some single words. And I kind of that's the process that most kids have to go through. But, you know, if the first thing the kid ever says is, I want pizza, please, for me, that's a really big one. Totally. And on the other side of that, too, given what we know about the trajectories of autism, some portion of the population of people with autism, and I don't think we really know why yet, according to research, will develop in sort of a seemingly typical developmental sequence. And then they just lose skills and it can't really be attributed to anything else in the environment, because kids with down syndrome are prone to regression to if there's a major life stress, etc.. But if skills are just disappearing, we wonder about that. We've seen that with some of our kids. Yeah. For sure. Oh, yeah. Unexplained? Yeah. Totally. Yeah. Which can be really disheartening. It's really hard. I mean, that's really, really sad. And, like, parents don't have any warning that that's coming. And in fact, they often think things are going great. Yeah. And then all of a sudden yeah we couldn't, we can't do it anymore. Yeah definitely. Um some other things might be like you might see treating people as like almost like an object. So they might, you know, grab your hand as a tool to like push something. So usually that's. Yeah. Um, one sign that might be there or, um, there are like reported increased rates of sometimes those like odd behaviors of autism, like smelling objects flapping. Higher rates of um, impulsivity or hyperactivity, um, sometimes like self-injurious behaviors. Um, and often there's like higher rates of frequency or severity of these challenging behaviors. Um, so that could be something. Let's talk a little bit about hand as tool just so that everybody understands it. What we mean by that is in typical development, when a child wants something from you, they look at your face and even if they don't have words, they look at your face and then point to the thing that they want, or gesture to the thing that they want, or make some kind of noise to indicate I'm mad, I or I want that, or I'm done with that or whatever. Um, and for some children with autism, what happens instead is that they don't look at your face, but they just get straight down to business. They grab your hand and like, let's get this done. I want your hand because my hand can't do it. I want your hand to open this door. I want your hand to get this toy. I want your hand to open my raisins, that kind of thing. And I think Olivia and I, you may know, the the shared client that we had you live had given me this really good example where you guys are playing with dolls and you're pretending like the doll was hurt. And correct me if I'm if I'm getting this story wrong. But this little dude, pretty much. Instead of using the dolls hands to pretend like the doll's crying, he actually used his hands on the dolls eyes to pretend like, oh, so like, is that kind of similar to what you guys are talking about. Like maybe not necessarily using someone else's hand, but not, you know, not necessarily understanding the point of hands related to the person context of the play. Right? Yeah. Because using his hands instead of the doll's hands. Yeah, yeah yeah yeah. Totally tricky for sure. And it often is seen as like this very quirky and cute thing. And it absolutely is both of those. Um, but for us, it's also a sign that maybe you want to go for an autism assessment. Yeah. And it doesn't make it a bad thing. No, I still think it's awesome information. Yeah, totally. Yeah, I'll gladly be their pointer or like, you know. Exactly. Yeah, totally. Um, and the other thing I'll mention too, like, in terms of their play. So yeah, we started talking about play, um, which got me thinking like, um, another thing that we would look for is, you know, how do they play alone? How do they play with peers? You know how they play with you? Um, usually what we see in kids with autism is a lack of this symbolic or pretend play. Um, it's often labeled as, um, like less functional play. And what I mean by that is, um, toys aren't really played with in the way that they're intended to be played with. So, for example, if I have, um, you know, a car, instead of pretending to drive it, I might spin the wheels or I might, you know, line them up or, um, repetitively open and close the door, throw them them. Yeah. Um, and a very kind of cause and effect way. Um, and they're more usually interested in. Yeah, the parts of the objects, rather than using them in their intended way. Um, and they have usually difficulty moving past this stage without some support with their play. Um, but that's also kind of something we see is if, yeah, if a child isn't kind of moving past that cause and effect, um, level of play. Absolutely. And cause and effect play is an expected level of play that all children will go through. And it's sort of considered to be one of the first levels of play, where you're exploring your environment and seeing what happens. If I do this, what happens if I do that? And our students with a dual diagnosis have difficulty going past that, or they might take toys that are not really intended for that and make it into that. You know, so I had one student for a long time and we were working on play skills. So we had our pirate ship, something that he was interested in, Lego pieces, but the pirate ship was getting used as a cause and effect sort of launching pad, because there was a spring flag and he would just use it to fling things. Not really understanding the play aspect of Let's Play Pirates, right? So he's playing with the toy. It's not like he's avoiding it, but he's not engaging with it as a pirate toy, playing with it just that one way, right? Because I do. I have noticed that with some of my kiddos too, that a lot of the play is like in and out, like putting something or taking something out, right? Like that's pretty much it. Like you try any other way. But no. This is one very, like, predictable way that I know how to play. And that's what I'm going to stick to. So totally. And that would be the reason that we have so many slotting games here at the DSL. Yeah there are popular. It's a neat game. Yeah that make noise. So they have some form of like as live mentioned like a cause and effect thing. So yeah that's a really good point. Things disappearing into other things. Right. All those games where you feed the whatever and then the food is gone. Yeah, yeah yeah yeah. Popular choice. So live before we continue, can you tell our listeners a little bit about who actually makes that autism diagnosis? Is it the speech therapist, the OT, the doctor? Yeah, that's a really good question. Um, so I will say that, you know, when your child goes for an autism assessment, it's a team of professionals that do the assessment process. Um, and they all kind of give their input and their little piece to their developmental profile. Um, but ultimately it's up to a developmental pediatrician or psychologist that usually makes the final call. Um, but, um, yeah, like I said, it's kind of a team approach. Um, just so then they can holistically kind of see where your child is at. And like, from your perspective, you had mentioned earlier that you could, you know, look for signs that warrant a referral. So you could give your input from what you've noticing. Yes. Yeah. Yeah. Great. Yeah. We can't make the diagnosis here. And you can't just go to any doctor and get this diagnosis. It's usually quite a specialized panel and they kind of do it full time. That's their whole job is to do those assessments. Yeah, because it's a pretty in-depth process to get an assessment. When you look at the assessment pack, it comes in tubs. It's not like a piece of paper. It's like five Rubbermaid. It's not a question you're only. Exactly. Exactly. Yeah. Great. Thank you for clearing that up for our listeners. So why would we even care about getting an ASD assessment? Like, what would anyone get out of it for sure. Yeah. Like, why bother anyway? That's a really good question. Um, an accurate diagnosis I would say, is important for many different reasons. Um, it doesn't change who your child is, but it changes the level of support they'll receive. Um, and getting an accurate diagnosis could mean access to funding and more services for things like behavior consultants, SLP, um, Oh, and the earlier the better. So we know from research that early detection of autism is important for appropriate intervention, and outcomes could also help improve educational and behavioral outcomes. Um and wait lists are long. So sometimes I always tell families like, even though we can't say for certain, I'd recommend speaking to their pediatrician about getting referral, um, because waitlists are long. Um, and so when we see these concerns, we might want to start to think about getting on it, you know, just in case. And we can always take our child off if these concerns, you know, it's no longer a concern. But, um, I do encourage families to talk to their pediatrician if they have any concerns. Definitely. And I mean, we mean these lineups are really long, like over a year. So certainly things might change in that time and you might not be worried about it anymore. But what we want to avoid is a family feeling guilty or sort of kicking themselves thinking, oh, I should have got on that last year when it first got brought up. Now it's worse. Yes. Yeah. And we're going to have to wait another year or pay out of pocket this exorbitant amount. Yeah. And I think too, like, even though it's called, you know, the Autism Assessment Network, I like to remind families that, you know, it doesn't necessarily mean, you know, you're going to get the diagnosis or not, but regardless, you're going to it's going to guarantee an increased understanding of your child and their unique profile and the strategies that work for them. Um, and I think sometimes, too, when we think of autism, we think about and focus on the challenges when there's actually a lot of strengths that they could shed light on. Um, that. Yeah. Knowing their profile, you know, their learning profile better, um, could help us understand what's going to help them in school, what's going to help them in the community. Um, like a lot of our students with autism have really strong long term memory skills. Um, they're very detail oriented, um, have really good visual and concrete thinking. Um, some of my kiddos on my caseload have hyperlexia, so that's a strong ability, um, with reading, that's well surpassed what's expected for their age. And knowing that, you know, we use a lot of written communication in our sessions and things with words. So it's actually really powerful sometimes when you can understand, you know. Yeah. Where their learning challenges, but also their strengths. And I think these are all such great points for when we have to have that inevitable conversation with parents about the possibility. Um, and I think you guys, as SLPs, do it more often than us OTS because you're trained to look for those social communication, um, challenges. But I know that, um, Liv had mentioned something to me once, if you don't mind me sharing. You said that, you know, in talking to parents, kind of remind them that autism is a spectrum disorder so your kids can fall anywhere on there. So it's not necessarily, you know, I mean, if they do get diagnosed. They could be on the higher end or whatever, but that it is like if you've met one kid with autism, you've met one kid with autism. Like that age old thing. So don't use one kid as your as the example of what it might happen for your child. So just kind of keeping in mind, um, can you guys both just to backtrack a little bit, talk a little bit to our listeners about, um, why our kids with down syndrome get a diagnosis later on in life? Because that, I think, is a piece that's kind of a bit, you know, missing in the conversation. It is wrapped in mystery, and it affects funding because at least in BC, if you get a diagnosis before the age of six, you do get relatively way more funding than after. But to either of you or in combination, I would love if you guys could just tell our listeners a little bit about why it is hard for them to get a diagnosis early. Absolutely. So it kind of comes back to this developmental sequence and profile of learning. And we know that kids with down syndrome, they go through the typical developmental sequence, but at a slower rate. So often what happens is when a kid is, let's say two, if they're going to just have autism, it's already usually fairly clear. Yeah, but our students here who have down syndrome, who are two, are not functioning necessarily at a typically developing two year old level yet. So their chronological age is two, where we would hope to be making that diagnosis. But they're functional age and their skill level is not at a two year old stage yet. So what tends to happen then is people are unsure and they're kind of waiting to see is there going to be a development in some skills, but not other skills that would warrant us needing to make an assessment referral? Yeah, if that makes any sense. And the age for a dual diagnosis is much, much older. I think the average age was something like 14. It was shocking because the average age for a single diagnosis of autism is like two and a half. Yeah. Um, but it is hard to unpick it and it's misunderstood. So, you know, there are definitely still people who think that it can happen. And if that person is your pediatrician, then you get this misinformation and you stop looking. There's some of that diagnostic overshadowing too, because a lot of it is like explained away with, oh, it's a down syndrome thing, not an autism. Oh yes, I know, I've heard that from a lot of parents. Really fired up. Yeah. Yeah, exactly. Yeah. So diagnostic overshadowing means using one diagnosis to sort of explain away things that are happening that actually aren't relevant to that diagnosis. So if you're seeing, you know, somebody using hand as a tool and they don't acknowledge when somebody comes in a room and they only speak in whole sentences, maybe from movies, but they have down syndrome. Diagnostic overshadowing in that case would be like, well, they have down syndrome. So we expect things to be different. Yeah. Where it's just missing. Yes. Critical analysis essentially. Um, yeah. Causes a lot of big problems. Um, I think other reasons why the assessment might be late is that families are coping with the first diagnosis still. So sometimes when we make when we have that conversation and it's a hard one, don't get me wrong, um, with a family, they're not ready to hear that information necessarily. So they might not be willing or ready to put their name on that assessment list yet. Yeah, and I understand that because, um, any diagnosis is hard for sure. I think that's the thing. Right. And families will come to terms with it at their own stage and their own time, and often they grieve. You know, they think things are going great. And then their kid starts in elementary school and they realize this profound sort of differentness and skill levels between their child and their hopes and expectations for their child and the rest of the kid's class. And that grief process just happens again. Yeah. So if that's around the same time that you're also saying, hey, we think an autism assessment is a good idea, it's just too much. So it kind of gets pushed back a little bit. Yeah. I think that happens too sometimes. Do you think there's any other major reasons for it being so late? I think yeah. Basically those things like just not kind of picking up on the right symptoms and signs and like you said, because the development is slower. Um, yeah. We might see these kind of signs at a different time in their life, at their at different chronological, chronological, chronological age. Right. Yeah, absolutely. Yeah. And I think, like you had mentioned earlier, that, you know, there is a high incidence of a dual diagnosis of down syndrome and autism. So perhaps parents aren't necessarily aware that it does co-occur at a high incidence. They're not even really looking for something like that. Right. So I think that in part would you agree that possibly be a reason as well? Oh, totally. And that brings to mind another thing, which is that for families with kids with down syndrome, they probably know a few other kids with down syndrome, but not tons. And here we see tons. So we have kind of an eye for this kind of thing. But you know, let's say, you know, three other little kids with down syndrome around the same age as your kid and you think your kid is kind of quirky and cute, which is absolutely true, 100%, but you might not recognize it as quirky, cute, and a little bit different than these other kids, right? There's not enough of a comparison group. Exactly. That's a really good point. Yeah. So thank you again for both both of you for kind of just kind of going off topic a little bit there, but really giving our listeners a good picture of what the whole process is about. So live like, what changes from a therapy perspective, um, would you say for a student with a dual diagnosis? Yeah. Um, so I'm going to answer this question as best as I can, um, and with what I think is most relevant. But please let me know if I missed anything or if I'm not getting at what you're, um, wanting for this question. So, um, in terms of what changes from a therapy perspective when a student has a dual diagnosis? Um, so we did already talk about a little bit of funding and support. So usually what I find with, um, my kiddos with a dual diagnosis is they have access to a larger, supportive, interdisciplinary team. So we collaborate more with behavior consultants, interventionists, um, music therapists. Um, you know, we all kind of yeah, we have to collaborate with more professionals, which is fantastic with, um. Yeah. Meeting the needs of the family. Um, so that definitely changes. Um, I would also say, like, sometimes our therapy approaches. So there's comprehensive, like intervention programs out there that families can choose to utilize, um, like applied behavior analysis or ABA, we hear or, you know, anything from that to social pragmatic developmental approaches. And then there's like everything in between. Um, so there's specific kind of targeted interventions out there for kids with autism. Um, a few, you know, we use here are things like more than words like the Hanen programs, um, social thinking, um, PECS reference and regulate. Um, so these programs are specific and targeted for the autism population. So I find, you know, as a therapist, I tend to pull a lot more from these programs for kids with a dual diagnosis. Um, and it's also beneficial in knowing what sorts of treatment programs are out there that have evidence behind them that would be beneficial for these specific students. And then also something else that I find changes is, you know, implementing specific strategies for autism are super important. So things like using visuals, um, schedules with them, uh, work systems and I can yeah, let me know if you want me to elaborate. A big fan of work systems, a huge fan, right? Yeah. Makes all the difference. Yeah. Um, you know, video modeling or social stories are, you know, were originally created for this population. So I find I, you know, they work with our kiddos with down syndrome. But really for our dual diagnosed, um, families, they really benefit from these tools. I find, um, to be set up for success. I totally agree, and I think a lot of times for kids with a single diagnosis of down syndrome, you can kind of like scrape by without using visuals and things that we tell people to use all the time. But it's like you can kind of you can kind of manage it. It would be better. Yeah. And your kid would have an easier time if you used visuals. But you can make it. And if your kid has a dual diagnosis, it's like a non-starter. You've gotta you gotta do it. Yeah. And it makes just a huge difference to the child's ability to participate and stay calm. And, you know, even for the sort of family health, I would say, and just stress levels and frustration management. The strategies that we talk about are, are essential. Let's talk a little bit about work systems in case people don't know about that, because that is that is right on the money. We love it. Totally. I love work systems. Um, so all this means is like prior to a task, you give very clear expectations about what they're going to do, how many they need to do when they're done, and what's coming next. And usually I do this in a visual way. So like for instance, like I'm thinking of a kid right now I use work systems for, um, we're working on pretend play. Um, you know, I tell him with a visual, it's puppet time and what's going to happen afterwards. And he has to. I line up, you know, five foods on the table so he can visually see this countdown of how many things he needs to feed the puppet before we're done. And that makes a world of a difference, rather than me not using any visuals and just being like, we're going to play with a puppet or we're going to do five. Yes, the concept of five is not yeah, it's really concrete to, yeah, give a visual kind of system. You know, it helps with compliance because it reduces that anxiety for the student. Um, and then it allows them to feel successful because we completed that task. Yeah. Yeah, yeah. I highly recommend looking into it more. And it is honestly very simple to execute. You just have to like from an OT perspective, if I'm working on, let's say, scissor skills and I have five things that a student needs to cut. I will have those five things out there. So they have that concrete idea of like, okay, expects me to do these five things and then, you know, finish them, put them in a box, that means you're all done. And then on the schedule, what's next? So when they see, I think Mali, you talked a little bit about like they like to see objects kind of disappearing like or kind of going into things. So they're seeing from a visual perspective that this is complete. Because now that five that was on the table is not there anymore. So that it really works wonders. It does for for some of those more challenging tasks. And I think it's it's really respectful of our students, because certainly students with a dual diagnosis have a really what I would call a variable presentation day to day. So some days are good and some days are much harder. And what I think happens often is when it's a good day, people try and sneak in extra practice and our guys do not like that. You know, it's like, oh, you're calm today, okay, we're going to do three times as much work. Yeah. And by using work systems, we're showing that we're not going to make the task harder. Yes. Secretly. Yeah. You know, you're going to end of the five. Yeah. Holding up your end of the bargain, basically. Which means they're going to be more likely to participate with you the next time. Yeah. Like, if you like in your example, if, if you give them just a bowl full of plastic food to feed a puppet, that's like, no, no, no, because and and to to think if you think about it, it's like that anticipatory anxiety. They're like, well I don't know when this is going to be over. You could put more food in that bowl once it's done. Right. So once it's very clear cut on the table that that trust gets built and they understand the expectations. And I think that is such a key word you use earlier that the expectations need to be there. Because as we know, our kids with down syndrome and autism can't anticipate what's going to happen in the future. They can't they don't have that visual representation of, oh, you know, so it has to be very concrete. Would you agree? Yeah, completely. Yeah. Yeah. And like you said, that builds trust. Because for sure. Yeah, yeah. Holding up what we're going to do. They know exactly what is expected, and they can feel good about what they've done and what they've learned, and they're more likely to do it again the next time because they know that you're not. Yeah, exactly. And we always keep an eye to the future. You know, it's never worth it to us to do a lot of work one day if they're never going to want to do it with us again. Absolutely. So I would much rather do five, keep it successful and know that the kid's going to come back to me next week and do five again than do ten, and then never get to never do it again. Exactly. Yeah. Yeah. Yeah. Um, you were mentioning some really great, uh, therapy interventions that we could do, like, you know, some of the ones that you mentioned were routines and visuals. Why are those so important, as you know, universally helpful tools for our kiddos with a dual diagnosis? That's a really good question. Um, I think routine can be a really powerful tool in helping students deal with this like uncertainty that's inevitable in their day. I think it's a universal truth that we all like to know what's going to happen next. As we learned with Covid. Yeah, definitely a lesson learned with Covid, especially during Covid, right? Like I, I'm sure parents can attest that during Covid when your routine gets, you know, upside down suddenly how important it was to then establish a routine and maintain it in your home. So, um, you know, like we mentioned, individuals with autism and down syndrome, like routine, they like sameness, which brings about comfort for them, keeps them well regulated. If they know ahead of time what's going to happen in their day. Um, I think it can also be a great way for us to build in flexibility. Um, so taking them through the changes that they'll come to understand ahead of time, um, that things can be the same but different, you know? So maybe on Mondays we have swimming. Um, but then maybe it's canceled the following week and we have something else. But if we build that in our schedule. You know, we give our child forewarning beforehand, um, they can help with building and accepting that difference that's in their routine. You know, we all like to know what's what's happening next. Um, and understand what's expected of us. Um, it can also, I think you can get buy in with less preferred activities, with routines and schedules. Yeah. Yeah. So, like, if we have something more rewarding, if it follows something that's, um, you know, non-preferred activity, then, you know, they know that this non-preferred activity is not going to last forever, that there is something to look forward to, and there's something rewarding coming later. So I think that routines and schedules can really benefit our students. Um, what was the other one you mentioned? What about visuals? Because I mean, yeah, yeah, we all talk about visuals all the time. Yes. Yeah. Do not underestimate visuals. Um, there. Yeah, I would say they're extremely important for a number of reasons. Um, you know, we know individuals with down syndrome and autism have strengths in their visual processing as opposed to auditory processing. So visual supports work well as a way to communicate things in a very concrete way for them. Um, and helps their understanding when visuals are accompanied with words and directions. So if I'm giving a direction to a student in a classroom, I might pair it with a visual of what they're supposed to do. You know, maybe first put your backpack in the locker and, you know, backpack first and then locker makes a world of a difference, um, rather than just verbally saying it. Um, so, yeah, not only for their understanding, but it also can help support difficulties in, I think, their expression, um, so helps them better communicate with others if they have an alternate way to do so. Um, you know, and visuals when we talk about it, I should clarify, like, we mean, you know, real objects, they could be photos, drawings, um, Some words, including sign language. You know, it's a visual language. Um, so this can really be a way for them to supplement their verbal speech and language. Um, I give the example of, you know, sometimes we ask our students a lot, you know, what did you do today? Yeah. And it seems like a simple question, but it's actually really complex because not only do you have to, you know, have the memory to recall what you did in the day, but you have to understand the question. You have to have the language to express it. Um, but I bet, you know, if we give that student like a picture of what they did in the day or maybe their visual schedule to help them express it, um, you know, they would it would be easier for them to do so. Um, so, yeah, don't underestimate the power of visuals. I. Absolutely. So when you talk about routines and setting schedules, ideally those are visual versions, not just telling your kid, we're going to do this, we're going to do this, and then we're going to go swimming. Yeah. However, what that looks like for your individual kid might be very different. Yeah, depending on the child. Some children are great readers, and they would be able to read sort of the key words school snacks, swimming, whatever it is. Some children are not at that stage yet and might need drawings or even photos. And if you're wondering about what where to start with doing a visual schedule, I typically recommend photos. They're the most concrete and yet small enough and easy to carry around the actual object as close as possible. Yeah, so, you know, if it's school, then snack, then swimming. Then you take a picture of the student's actual desk or teacher or both, and then a picture of one of your kids generic snacks. It doesn't have to be exact. It's representing snack time and then a picture of a pool or photo of a pool, to be really clear. Yeah. Um, and sometimes that's too challenging for a student. And then you need to use a physical object to represent it, and that's that's possible too. It is a little bit more challenging to carry around with you and implement, but it's doable. I would recommend getting support from an SLP if you feel like you need to start up a system like that, but it does help and it certainly helps with anxiety. Yes, definitely. Yeah. Great. So, um, just wanted to end our our podcast with this, this last question that I think is really important as well. We've had questions from families recently about treatment for kids with a dual diagnosis. And from your perspective, are there any priorities, priority areas that you would like to start with? Yeah, I mean, I feel like we need to set up our kiddos for success from the beginning. Yeah. Um, so in order to engage a child with autism and down syndrome, I think our environment needs to be free of distractions so they can be well regulated and remain focused. I usually start with like, you know, regulation and sensory needs. If a child comes into our session and they're dysregulated, you know, that tells me we got to get you regulated first. Um, and, you know, they're called sensory needs for a reason. It's something a child needs in order to learn. That's why it's so important to have an OT on your team who can provide those insights on how to remain well regulated. You know what works for this student? Um, in order for them to feel safe and feel calm. Um, so I think what I like to start with is, yeah, are they well regulated? And how do we, well regulate this student in order to learn? Um, and then from an SLP kind of perspective, more specifically, um, I always kind of think about like, how does your child attend in and listen to others. So we talked briefly about joint attention and social referencing. Um, and honestly, communication begins with this kind of shared attention and engagement. So when a child doesn't notice, you know that you're trying to get him or her to include you or share an experience with them, there's not real much interaction going on between you two, or there's not much learning happening in those moments. So when a child with autism and down syndrome has difficulty attending to me, I like to start with a goal around attention and around referencing. Um, you know, and people with autism have the capacity to learn these skills, meaning that the hardware is there, they just need the input and the practice with it. Yeah. Um, and if we meet them where they're at with that and give them opportunities to practice, we get better outputs. Um, so, yeah, I like to start with attention or referencing. Um, and when I kind of try to explain this to families and why it's so important because I know sometimes it feels like we're going back to the basics, but if we start with attention and referencing, this leads to better listening. Listening leads to understanding language because over time, with consistent listening and attending to what you're saying, you know, our students learn to understand what you're saying, and they start to link that meaning to your words. And then understanding language leads to then using language and talking. So everything kind of falls into place, I think when you have these foundational skills of attending and referencing other people. Um, and I like to think of it as like a pyramid that you build on. Um, I had a student, uh, this past block where. Yeah, our goal was, you know, referencing me more often with different people looking at me faster for longer. Um, and it was awesome because by the end of the language block, even even though our goal wasn't language, his, his language did take off, so he understood way more. He was then starting to use some of those words spontaneously. So there is a correlation between consistent attention and referencing people more. That will lead to better results for language skills. Um, yeah, that's totally something. We see that children with better attention, uh, show better language outcomes. Absolutely. So when your therapist talks about, you know, the importance of eye contact or wanting to work on attention, um, truly, don't underestimate the power of. Yeah, referencing attention, I feel like it falls into place once you have that kind of strong foundation. Yeah, yeah. And you can kind of imagine, for some reason, the peanuts. Yeah. School comes to mind, you know, where it's like, wa wa wa wa wa wa wa in the background. And it sort of changes from that to, oh, that's directed to me. And like, I'm gonna I can learn from what's going on around me in my environment. And that's the skill that we're trying to teach. Because if your child has Poor or underdeveloped social referencing skill. I can be there signing up a storm, doing all kinds of things. But if they don't know that they're supposed to learn that learn from me, then they are not going to learn from me, you know? And it's wasting our time. So we need those sort of like roots of the communication tree before we can pick those fruits of words. Exactly. Nicely put. And a lot of our kids, I think. Yeah, they need to, like, learn to look before they can look to learn. I love that's a great way of putting like, reference and regulate. Um, because, yeah, you have to attend to in order to learn about the world. You have to attend to others that are trying to teach you about it. Um, yeah. That's great. That's a huge one. And regulating. So we've talked a lot about being regulated and dysregulated. Could you. Hanna, this is ot specialty. Um, could you give us the short rundown of what that even what that means? Sure. So for regulation, you have to kind of see your child's sensory processing, how they're taking in the information from the environment and processing it. Um, if, for example, we have a kiddo with a dual diagnosis that comes right after their school for a therapy session, um, they can be dysregulated because of a variety of reasons. It could be fatigue from having a long day at school, the traffic on the way here, having to come up and see Hannah, even if you don't want to that particular day because you're tired. There's a whole host of reasons why, um, their body is not ready to. It's not at its like balanced, optimum level to learn. So as OTS and SLPs, if we kind of see that and we know our students well enough, then we kind of work on getting their body at that equalized state so that they can attend and learn and to I mean, to actually provide their regulation. It's very different for each kid because each kid has their own sensory profile. Um, and that's something that as OTS that we can kind of help help you with. But that regulation piece is really important. And I think regulation has kind of become very common even in the classrooms. A lot of teachers and CEOs are really working on those kind of things for their kids. But at the end of the day, it's super important because you need to be able to have your body at a state where you can look and learn and then kind of go for what live was saying. Then you kind of then you add your new skill, your new skills. Yeah. So dysregulated. Looks like not able to sit down, not able to come join you in your room. Might be screaming, might be crying, might be very distracted by things in the environment and flapping and just, uh, even even I've had some students that will come and sit at the table but are distracted by every other visual stimulus in the room and are just not able to see me. So it definitely looks different for each kid. Totally. But if they're not able to attend to you, eye contact is a great way to to gauge that for sure. But not all of our kids will. At least our kids with autism won't always. Eye contact isn't always a measurement of attention, right? But once you get to know your kids, you can tell when they're able, when they're ready to learn and when they're not. And then our job is to get them to that point where their nervous system is at that optimum level, where all their sensory needs are met, and then now they can focus and learn the new skill that they need to. And it's kind of like, I guess, being distracted by your body, essentially. Absolutely. How your internal sensations, external sensations. There's a lot going on in terms of sensory processing. There might be hungry, but they're not able to tell you that they might be tired, they might be getting a cold or feeling pain. A host of reasons that can dysregulate. I've had students that have been dysregulated. They've had a great time coming out of school. There was a traffic accident on the way and they were stuck in traffic. That was the trigger enough to them become dysregulated. And then things just kind of went downhill from there when they got to the session. So it's my job as an OT to kind of, you know, get that information from the parents. Sometimes I find it super helpful. Like, how did their day go at school? How was their night the night before? Um, to kind of get that big picture of their regulation and then kind of go from there? Yeah. And if you as a as a parent or supporter, think about it like there's just a ginormous truck that drove past us, but think about how hard it is to focus and work when there's construction going on outside your window. And something in the environment is distracting you so much that you can't even think. And it's kind of that kind of, or you're really hungry and you can't focus. Yeah. Or you're like dysregulated moments. Totally. It's just that for us, sometimes it's a bit easier to either wait it out or come up with a tool on our own. But for our kiddos, we really do need to help. Not necessarily always provide it to them, but teach them to recognize it first and then how they can, you know, take care of it for themselves and become more independent. And so, yeah, thank you. Thank you for explaining that to everybody. Yeah. For sure. Well, yeah. Liv, it's been a huge pleasure to talk to you today. I think we've shared a lot of information with families out there who are hopefully feeling just a wee bit less alone. Yeah, I think, and as mentioned earlier, we do have a tab on our website. Um, and Liv actually has created this wonderful graphic kind of showing, you know, the characteristics of down syndrome and autism and what to look for when they intersect, which she's continually updating. So definitely check our website out. We'll put a link on the episode show page and that sounds great. Thank you so much. We really appreciate it because this was super great and helpful for everybody. So thanks for having me. That's great. Fantastic.