What Gets Missed About Autism & ADHD

Good morning, Dr. Deanna Dow from Spectrum Psych, LA, and San Francisco, is that right? Yes, we are expanding to San Francisco, very exciting. Yes, I didn't know that until I looked it up this morning. How recent is that? Well, we have a few people there, and so we are probably gonna launch later this year, but we do have people who can technically see downtown San Francisco clients now, which is very exciting, but the infrastructure still kinda needs to be built up. Yeah, well, so much needed. I'm not part of the Bay Area, but I'm part of the Conejo Valley here in Southern California, and we reached out to you and met you a few weeks ago when you came out to our campus in Westlake Village to engage a treatment program to talk to some of our staff for a good, was it three hours? It was a three hour amazing conversation. I was so impressed by your staff. It was on our end, so I'm glad that you enjoyed it. It really was so engaging, and I wasn't sure what to expect, but your staff was just so lovely and really thoughtful in their questions and discussions. It was a great conversation. Good to hear, good to hear. We are proud of our people, and our staff will be built, so as you are, I imagine. So thank you for coming to look for the helpers, our podcast. Thanks for having me. I think we're on episode seven or eight or something, so we're still learning how to do this thing. So thanks for coming, and I'm really excited, because again, part of the podcast is to feature people that we really respect, that we have maybe some pre-existing relationship with like yourself, but want to learn more and want to share some of those learnings with our community, whether it's clinicians or families, local families. So that's important to us. So I wanted to kind of frame our conversation, again, around the autism spectrum, since that's what you specialize in and why we reached out to you and expertise, and first I want to just like focus on language, because my understanding is that some communities prefer to refer to, for instance, like an autistic teen or a teen with autism. So can we start there? Like what do you see as far as the- That's a great place to start. So most of our adult advocate population has advocated for identity first language. So identity first language means saying an autistic individual versus person first language would be a person with autism. There is some split though, and so the safest thing to do is to ask that individual how they would like to be referred to. But generally we use identity first language, so autistic individual. Got it. So in the professional community, in your office, you would default to an autistic youth, an autistic adult, and then there could be a preference. So that is something that kind of shifted for me and another thing that shifted for me and I want to kind of stick on that train there is a lot of times we've used in the past high functioning, right? Because like in our intensive outpatient program, we've always felt that like to do the program or to get anything out of it, someone needs to be higher on the spectrum to participate in our program, to get all the can out of it. Now that shifted for me in our train, which is why we do this and it's so cool to do with people like yourself. So can you kind of go into like that language versus maybe what's preferred? Yes, yeah. So a term like high functioning is a little bit too generalized, I think for one. So someone might be high functioning in terms of their cognitive strengths and abilities, right? But their adaptive independent living, their mental health, those things might be really, really impacting their level of functioning. And so it really isn't a great descriptive feature for us to use that. And so the community has really shifted more to support needs, higher support needs, lower support needs. And that really focuses on what they need to best fulfill their goals and live the most meaningful life they can. So we use lower support needs for those previously referred to high functioning folks. So lower support needs are higher support needs. Right, so it's kind of flip-flopped in that high-low language, right? So high support needs is someone who, or sorry, low support needs is someone who doesn't need as much support for daily functioning you're saying. Yes, exactly. And a high support needs would be someone that we would say would previously be low functioning on the spectrum. Yes, and we can talk about impact level and someone might be more impacted in social communication. They might be more impacted because of an intellectual disability, right? And so we can be more specific in terms of what that functioning level is in different domains. Right, so it kind of has to be globalized to that quick kind of heuristic way, right? Like they're high, they're low, what have you, but that doesn't really paint the whole picture now, does it? Exactly, and I think in our conversation, I sometimes refer to more subtle presentations. More subtle presentation just means they're more able to mass, they're more able to camouflage those tend to be the later diagnosed folks that we see and I know you all see as well. So I've kind of used some of that language myself as well. Yeah, how do people usually get to your practice? So we do see a lot of those later diagnosed folks and so we are treating mental health overall, right? We're not trying to change the autism, we're not trying to get rid of the autism, we're celebrating that, but we know that certain things come along with it that can impact mental health in a negative way and so often they're looking for support with emotion dysregulation, anxiety, their social relationships, they're really hoping for support to build, they have mood fluctuations, depression, mood concerns. Usually they're coming to us because something is getting in the way of their day-to-day whether that's more psychology, mental health focused or more tangible adaptive living. Our occupational therapists will see a lot of them to help with daily living skills, to help them really reach those goals, those tangible goals that they have. Cool, so yeah, so you are spectrum psych LA, so spectrum disorders is kind of your community that you serve, I think primarily, right? Or to focus on. Neurodivergence, so autism primarily and ADHD. Right, and it can go, it can be like hand in hand a lot of times. Often to come together, yes, I would say a lot of our clients have both diagnoses and they come in different presentations and often we are trying to support them in different ways because of those different symptoms that are coming up. And that's so cool and that is different because we engage or not specialist in spectrum disorder. We don't advertise that we're not, but we serve, to your extent and to your point, we serve depression and anxiety. And that does include youth that may fall on the spectrum and do fall on the spectrum. So that's why we wanna do the best job we can. Now, in your case, I say that your services are much needed because like a lot of other disorders, like we had Andrew Cohen on the podcast a few sessions ago and he specialized in OCD. And how many youth have OCD and are treated by maybe a general therapist, well-intentioned, well-read and they're not OCD specialists, they miss things, right? And maybe they treat the anxiety, maybe they make it worse, maybe they make it better, but maybe later, hopefully, they get to the right treatment of OCD, right? That's more specific. So in that kind of way, I feel like there's such a need for more, offices or practices like yours, right? That is so well-informed specifically on this population, but you're not treating the autism like you're saying. You're not an ABA center, you're not trying to change the autism, you're not trying to fit around begging a square hole, but you're treating other things with the lens of autism. Yes, yeah, I think the specialty is important because we do adapt treatments and that was a lot of our discussion too. We're still using the same empirically-validated treatments that everyone uses, but we're using them in a thoughtful way because we understand how neurodivergent might be impacting that individual's ability to learn those skills and use those skills and generalize those skills, so we really have to be thoughtful about that approach. And it is hard to be on the ground, right, as a therapist in any kind of a way, right? And have your mind on everything and be a specialist, or first of all, you can't be a specialist in everything. You try to, I say for us, we try to stay in our lane, do what we can do. But, so we try our best to refer out or identify, but I say this as along with what it's saying, I think we're all doing the best that we can as helpers, as therapists, and yet, what are the things that you see in your practice, maybe because people come to you later in life, maybe you're the second stop on the road, maybe you're the fifth, maybe you're the 10th, what do you see that maybe gets missed with this population? Yeah, well, and this is what those subtle presentations are often, they're masking throughout their life, right? And so they are missed, not because people weren't well-intentioned, it's just often people still have this more classic idea of what autism looks like. Those kids are the ones who get picked up early. ADHD as well, right? The more hyperactive, challenging behavior kiddo, right? We kind of always hear about the boys get diagnosed early because they're making a scene, they're hyperactive in the classroom, the preschool teacher says something, the girls are more inattentive. So they're just missing without creating the scene. Same with autism, right? The autistic girls tend to kind of fit in a little bit, right? During recess, they might be going from group to group, not really sticking with one, but they're also not standing out. And so people aren't noticing. And so often we'll see people who have gotten five diagnoses, 10 diagnoses, right? Over time, autism was never considered, potentially, but all the things that kind of came with it or some potential misdiagnoses as well, but we do know there's a lot of comorbidities. So often an adult might say, well, I've had an ADHD diagnosis for a long time. We thought that explained the things, right? We didn't realize that there was another piece to the puzzle. And so often we do see those who have been in a lot of higher levels of care or just a lot of therapy over their lifetime, but they've never really felt like it totally fit. Like they never really had the answer to why everything was going on or why everything felt different for them. So that's often the population will see. Yeah, so they've been through a tons of treatment. Let me say higher levels of care, so they might be in a program, they might have got a residential, people that have been chronically in treatment and it just hasn't stuck. We see that so often in our IOP too. As far as the general population you think, because I think a lot of people get misunderstood. Like ADHD, right? Lazy is one of the things that thrown out there. With autism in particular, what do you think is the most misunderstood or some of the misunderstandings of people with autism? You know, I think the autistic population that we're talking about, honestly, I think one of the things people don't understand is the effortful masking that goes on. So it's often somewhat of an invisible disability, right? You're functioning in your day-to-day life, you're going to school, you're trying to make friends, you're doing all these things, but it's so much more effortful, right? If looking someone in the eye while I talk to them is not just something I do without thinking about it, and I actually have to think about how many times did I look you and I think about the cognitive load that is going on during the day, right? And then if my sensory experience is different and doesn't totally fit with my environment, if my emotions trying to hold it in all day is really difficult, you know, I think the misunderstanding is, I don't know, why is my kid falling apart when they come home every day? And it's like, oh, I think I know, actually, they used all of the energy and resources they had to really hold it together all day and they don't have any more left, right? And you're their safe person too. Yeah, and so the insight into that on the parent's end, right, to be able to mentalize the experience of their child potentially, when it doesn't, like, it's not a one-to-one to their own experience, if they're not maybe on the spectrum, just like with ADHD, right? There's these wonderful books by, is it Blakely and, oh my gosh, I'm blanking on the other great one, but, you know, having a partner, a significant other with ADHD or autism, right? And not really understanding that insight piece, where do you see that fit in on both ends for the self and for the partner, for the parent? Like, how do you help families or individuals with that piece? Yeah, I think, like you said, with ADHD, right, that it can be conceptualized as lazy. And I think a lot of the internalized experience is why am I just bad at it or why can everyone else do this so easily? And so it really, that's a huge part of the therapeutic process. Also, the assessment process can be incredibly therapeutic for the family. If we're seeing a child or a teen for the first time diagnosing autism and explaining to the family, this is why, right? This is why this has been hard for this child and maybe you couldn't figure out why this was happening or, you know, a lot of the challenging behaviors might actually be because they were totally tapped emotionally, they were starting to burn out. And so parents often find a lot of relief in just that understanding of like, my kid is not bad, right? They're not, and I love reminding parents of that. No kids are trying to be bad, right? They're kids, they're really trying to do their best. And often there are reasons behind why they can't do that. And, you know, a lot of parents of autistic children are like, every morning is a struggle. Walking on eggshells all day, trying to keep them together. I'm continuously thinking of a strategy I can throw in and they may not even know, right? I don't know, I just got a hard kid. Everyone else looks like their parents. So without the insight, you have two people working really hard. Really hard. The kid and the parent, right? Exactly, it's really hard from a parent perspective too. And they're really trying to support their kid the best that they can. And so, you know, I think just that understanding of what is behind the reasoning, even if we can't change all those things, right? We can support certain things, but maybe some of that might not change. We do adult diagnoses too. And often those are, you know, you're not coming to me because we're gonna find the magic treatment thing that, you know, there's not gonna be one magic cure, but just the understanding of the self, right? Now I know why those things were hard. It wasn't my fault, it wasn't because I was just bad. And now I understand how my brain is wired and I can go from here. Yeah, I mean, it's making me think, you know, all of our, not all, a lot of our modalities have overlap, right? We named them different things and it's important to research them and make sure that they're effective and all that stuff. So it's not dismaying or labeling. But I'm thinking about one of the ways that we work with youth is in Gestalt play therapy, the Violet Oaklander model. And we look at polarities and sense of self, right? Then sense of self is not just based on self-esteem like rah-rah, I'm great at everything. It does include that though. But it also includes the things that maybe I'm less than average at or things I don't like about myself or the other end of that. So some of this insight could be, well, these are the things that are challenging for me. These are the reasons why my kid, when I picked them up at school, is just like not there or just drained. And I like to talk about, I wonder how you talk to parents and youth and themselves about like the superpowers of these neurodiversities. The things that maybe they have an advantage with both being autistic but also having ADHD. Definitely, we have that conversation all the time. And I'm a huge advocate for earlier diagnosis. They know parents can go either way, right? Some parents really want that diagnosis to get the support for their child. A lot of parents are thinking, they're actually doing pretty well. Or maybe the parent has some neurodivergence themselves and they're like, well, I actually did pretty well because of my neurodivergence, right? Because it is a superpower. I think my kid's gonna be fine. And I actually really encourage labeling it at some point either through a diagnostic evaluation or otherwise because then we can have that conversation with the child. Your brain is wired differently. It comes with some really amazing strengths and it comes with some things that are gonna be harder. Just like everyone has things that they're good at and some things that are harder. And then we can really put a name to it, explain, this is your experience and I'm validating it. And there are other kids who also have the same experience and there are supports that can help us, right? There are people in our lives that can help us. That is so freeing to know my brain's wired differently and that's not a problem. It just comes with things, right? And now I just, I need to move forward with this information and my parent has this information and it feels better, right? It feels so much more empowering. And when you talk to a president, when you conceptualize helping and supporting someone, what are your thoughts about in general accommodations, like really changing their environment or what they participate in or coping or finding ways to adapt in a way that square pegging around whole kind of thing, you know? Which is what naturally kind of happens like you're saying with masking, right? Like in certain situations, that just kind of to survive that, you know? How do you navigate that? I think it, you know, first you kind of have to start with the family's values because really some of that is gonna be really core and so what's important to that family and then how does the child fit into what's important to that family? And then we might have some pretty real conversations about, you know, if you're Saturday is normally going to six different activities and being in the hot sun and socializing with a bunch of people and not- Yeah, maybe that's something to think about. Right, not having structure, right? A lot of parents also don't have a lot of need for routine or structure but then they realize that their child really does and so how do we try to meet somewhere in the middle, right? How do we keep the family values while also realizing that a child might not be able to thrive in the environment that they would just naturally be in. We just maybe set up more routine. We preview a little bit more, right? We have some sensory breaks within the day and I think a lot of parents are really, really open to that. It does cause effort. Obviously it's like, okay, how do I shift my schedule? Well, you know, even the people like myself that may know of that, it's helped to be reminded. Totally, yeah. Like that sensory break, you know? Like when I volunteer in my daughter's classroom they do the wiggle time and that's not something that I had when I was in school. Maybe it would have been better if they did but, but so there's some things that we can, even in maybe group experiences, maybe in institutional settings, we can make a space that is more, you know, supportive of neurodiversity, right? And at the same time, there are times maybe where, you know, someone with a challenge, whether it's ADHD or autism, must kind of navigate a world that isn't necessarily specifically built customized for them. Right, because it takes both, right? You need the place that you can take the sensory break and then you also need the skills to know, I need a sensory break and I need to advocate for myself when I need a sensory break, but our world has to somewhat be adapted to that. And so I like that you brought up schools because I just think schools are doing such a better job than when we were kids, just the social emotional curriculums that are going on. I know in my kids preschool, like there's the calming tent in there, the more active area. And so really helping kids to label the emotion first, which they're starting to do right at ages three and four in schools. And then knowing based on how I'm feeling, what I might need in my environment, especially in a neuroaffirming environment, which hopefully we can create more and more of those over time. Well, again, it's so great because again, even setting up engage, you know, like even the space, I had a very intentional time thinking about making things more visual, you know, like posters and infographics and graphs and stuff rather than just written word. And that I was really on that. And then four years, five years went by and when you came, it reminded me like, oh, I need to like reset and like make things even like for my staff who, you know, there's neurodiversity everywhere, right? Within our groups and with the people we serve. So thank you for that. It's impacting, you know, as I'm building other things. That's amazing. And that idea really comes with inclusive communication, right? And inclusive communication can be for anyone. It's honestly better for everyone, whether you're a neurodivergent or not. And so right, can we make things more visual and you know, the more we can communicate in a straightforward, direct way. Also, sometimes writing out those steps, you know, as we've talked about in therapy, sometimes that's really helpful to have those visuals to make sure there's concrete steps that someone can follow. If that's what their brain is gonna do better, we really wanna be able to offer those options. And like with us and engage, we always struggle with like, we wanna customize experiences to be the most helpful for every client. And yet it's a program, right? So it's a group. And that's where, you know, we initially reached out to you because we knew we could do a better job, you know, of being, you know, neuroinclusive and sending people up for success in our programs, which does include a lot of family therapy, a lot of group. And you know, just thinking about the masking aspect, you know, and what we're asking and what options we give. So that was so helpful. Can you speak to that a little bit of like, you're saying, you do all the same empirically validated stuff. You treat anxiety, depression, all these other things. But within the frame of like, how do we do these interventions mindfully with autistic youth and autistic adults? Yes, yeah. Yeah, as we were just talking about, I definitely think about visuals and I think about making things very concrete and step by step. And also, you know, I know some of the conversations we had when I was here is really honing in on how do I engage this individual and it might be through a special interest. It might be through something that doesn't feel therapeutic, right? I might need to be building rapport with someone, talking about Metallica, talking about Pokemon, doing something that maybe unless I do that step first, we're actually not even gonna get to the therapy in a very useful way. So we definitely think about that, again, in ways that feel kind of unstandardized for therapists who are trained by like, this is the manual and I go to chapter two and I teach this, right? It's not quite as structured and manualized. And also, I always check in with that client to make sure that we're on the same page because motivation can be different, right? Especially there is this kind of personal social motivation that sometimes happens and sometimes doesn't happen with a non-neurotypical brain, right? So if I just, if you're my therapist and I just wanna please you, so I'm gonna go do my anxiety exposure homework and I do all the things, right? That might feel different if my social relationships feel different. So we might need to even consider more external motivators or just check in with that client. Are you actually ready to do this this week? If you're not, let's shift. Let's talk about something else. Let's talk about where you're at right now and just make sure we're in line with where their goals are at and where their engagement level is at to do that. And can you speak to, because some of the misconceptions I think about autism is that people on the spectrum don't want to be social. Can you speak to that? Yeah, social motivation can be different, I think for a lot of different reasons or it can be the same. So they can be incredibly socially motivated, although often we'll see those individuals over time get social anxiety because, right? I have continually tried to put myself in these situations and I haven't been that good at it and I've gotten rejected, right? Over time, there's been this complex trauma of rejection over rejection. And then I've actually withdrawn and my social motivation has gone down because it just hasn't been easy. It's not that I didn't have the social motivation in the first place. So it can be pretty complex. There are individuals who prefer to be more solitary. So social motivation can be different too, but it's definitely not an assumption that we can make. It's on an individual basis where we would ask that individual. So I don't know if you've heard this, I certainly have. Well, you know, they're not on the spectrum. They are actually anxious. They want to have friends. And I'm like, well, I don't know if that's what that means. Exactly, yes. We definitely cannot assume that the social motivation is not there. And most of the clients I see is very much there. And that's part of the reason, especially with adult clients, right? That's why they want to be there in therapy. They really want to feel more successful in those social relationships. So think about experience like you want this desperately. You need to participate in it to do the thing. And you have to mask and you have to like manage that and it's so difficult, right? So it's more effortful too. So even if it's really motivating, it's hard. Yeah, so I know you guys do a lot. You do OT, right? You do yoga, you do testing. You do provide psychotherapy and psychiatry, right? All that stuff. What are your thoughts about social skills groups? I always, that's been like the de facto, like we'll send the kid to this social skills group. I think the first thing to consider in terms of neuro-affirming framework is that in line with their goals and are they okay learning these skills that will set them up to mask, right? But when we talk about masking and camouflaging, this is not a good or a bad thing. It can be an adaptive thing that's super, super helpful, right? So those social skills can make me feel comfortable to go meet a new friend, to go date, to go to the job interview, right? So that can be a great thing. And often I feel like it is a great thing, but if the individual is not on that same page of being motivated, then we are basically telling them, you must change who you are, right? Who your authentic self is to fit in, which feels terrible, right? So like motivational interviewing, like it's what they want to change, right? So they want to get, they want to get there socially, right? And they're like, okay, I want to make a change. Then that referral is a good one, right? And maybe that's not always the case. Right, and I do think about it different with different age groups, right? Like if we have younger elementary school kids, often their insight is not going to be there to understand why this is actually gonna be very helpful to them. At that age, I tend to be more like, let's try and make it fun and engaging, but it should probably be part of the intervention in our therapy sessions. We integrate different things. So a child might be coming to us for emotion dysregulation and also have social skills deficits. And so we are helping with all the things in a way that's going to feel client-centered. Do you have a get-together this weekend? Would you like to have a get-together? Let's write out what would be the steps. What would you talk to that person about? So it just feels in line with like, okay, this is my goal, I want to have a get-together. As people get older, then it's much more like I would love to be client-centered and you tell me what your goals are. And sometimes we have to build insight into, okay, if the goal is to move out of your parents' house and get a job, probably some of these social skills are gonna be really important, right? Which are the ones that really feel like we should be focusing on that generally feels like a good place to start. Yeah, yeah, this is so great. And these are such great nuggets of like information that are applicable to so many people and I'm glad they're hearing it. Kind of stepping back into, if it's okay, a little more personal question. All of us helpers generally have a reason that we did this thing, right? Or run an IOP or treat depression or anxiety. What brought you, did it find you? The neurodiversity, did you seek it out? How did you land in working with Autistic? Yeah, yeah, so I in high school started volunteering through some kind of force, high school. What's the program you're gonna join? And started volunteering and the place that sounded the most interesting to me was a school that supported Autistic youth. And then from there, I did all the volunteer stuff. I did all the, got into the research program at the University of Michigan and just kept going. And then as things have progressed, I'm like, oh, I see these pieces of neurodivergence within my own family, within my own children. And so, part of it I think is like, we all seek this thing that answers the questions that maybe we've had over a lifetime. But I also feel like those are my people, right? I love working with Autistic populations, neurodivergent populations. And I feel such a connection to them that over time, I was like, oh, yes, this makes sense, how I got here. But it was just always- Can you speak to that, what you really love about working with neurodiversity? They're so fun and interesting, right? The interests and the quirks and the conversations that we'll have and just I think the authenticity of those people can be so refreshing. It's like, you get what you get. And they aren't generally trying to fake it or fit in in this way. They're just so interesting. I don't know, it's such a passion for me. I've never really tried to put it in words. Yeah, and it just makes me think, maybe this is pinballing a little too much, my ADHD, but identity, I feel like that's something that comes up a lot in our programs and with the Autistic population, it comes up in a way that's maybe anecdotal more. And maybe you know the research better as far as what the connection is with identity formation, which in our population, youth teenagers, like that's de facto kind of 1A anyways. You know, but with autism, it feels like there's a lot of questions about identity. Yeah, and I think that's why so many adults are seeking diagnosis for the first time because identity is so important and why we're shifting to this identity first language, right, is autism feels like such an important core part of identity. And that's why I find that it's so important to label it early for children and really have them be able to know, because it is, it's a social identity, right? If I am autistic and there's all these other autistic people out there, now I have my people who have the same life experience, which feels so much better. Yeah, like autistic burnout, I feel like that's been something that people have really latched onto of like, oh my gosh, I'm understood. Or that makes sense, you know? What has been your experience working with that? I guess, I don't know if it, it's almost like a TikTok, you know, level of viral thing. I think the burnout has really come with the late diagnosis, like, you know, that TikTok is all kind of the same. So autistic burnout is a lot of these maskers, right? These later diagnosed folks with more subtle presentations have been able to hang for a lot of their life. And often our high achievers, where, you know, we see a lot of adults who have even transitioned to college. And that's where, you know, it really is. You're like, no longer now, I'm living independently potentially. I'm trying to run my own social life. I'm trying to keep up with my grades in academics. There's just too many things at once. And so it's basically a nervous system shutdown of I cannot do it anymore. If you hit your container, you're past the container. It is no more. And so a lot of adults will find burnout on social media or wherever else, talking to other people, be like, wow, this sounds like me. Why can I not function like I could two years ago? And I've seen extreme cases where it was like doing all the things and now in a dark room, don't even want the blinds open, cannot function, right? And it's just like the system got maxed and we need to reduce demands to a point where we can start to build again. Yeah, and speaking to your experience, I don't know, I don't wanna speak for you, but like, you know, expanding the idea of it's a spectrum, right? And maybe everyone's somewhere on the spectrum of whatever that is, very low support needs, very high support needs. Have you experienced that maybe because of that and how we see autism? Because maybe in the past we saw it as really that high needs population, like that's what autism looks like. The kind of population that comes to you, even the late diagnosed that maybe in the past it really wouldn't be on the radar if that makes sense. Exactly, right? Burnout is not a term that we're using for the more high support needs folks, right? Because we can see that disability, they're not asking it, they're hopefully being supported from a very early age. So this is a different population, right? That the people that you guys probably are seeing as well in your clinics and yeah, those were not the same populations and they have different needs and different presentations than what you previously knew more about. Yeah, yeah, it's really changed. I think for the better. We have so much more awareness. Definitely, yes. And yeah, we get that question a lot of like, why is it just being diagnosed all the time? And I'm like, this is a good thing, right? We want support for these people, we want them to really understand the quirks. Yeah, and you had mentioned earlier that there's some things that may lead to not being identified early, right? Humans like gender being one. Maybe women, girls, maybe less likely or more likely to be missed as far as diagnosis concerned. Similar but different. What do you see as the resilience factors that helps people be maybe on the lower support needs or even not diagnosed because they're so functional, I guess. Right, so strong cognitive abilities is often something that we're seeing, I would say more often than not if I'm testing an adult, they have a very high IQ and very strong problem solving skills because that helps us use our environment to problem solve what we need to do, right? And how to do it. So a lot of it is self-taught and so sometimes I'll see individuals in adulthood and my reflection is their eye contact is actually really good and then I'll ask them, tell me about eye contact, tell me about looking at people and it is an entire learned process that is explained to me in a really intricate fashion, right? Well, over time, I realize that this but then I can't see her too much and so then I think about two seconds is that a three? Wow, wow, really that level of like scripting. Yes, it can be pretty detailed. And then some I ask and they're like, oh, I've never even thought about what my face looks like when I'm talking to someone. So, yeah, so those things are definitely coming up in that population. Yeah, I hear you. All right, well, Dr. Dow has been so lovely. Thank you for traveling all the way from the west side to come to our little neck of the woods and hopefully we can do it again, come back out and visit our staff and train us. I agree, I know, I'd love to see your team again. And I need to go out and visit you guys. Yes, please do. Anytime you're on the west side, let me know. Yes, well, thank you. Yes, thanks for having me.