COMMUNITY PSYCHIATRY

COMMUNITY PSYCHIATRY

During the second half of the 20th century and specially in its last decade, mentally ill people have been moved out of the relative simplicity of the large Institution with its clear structure and hierarchies and into the community which may be regarded as a third Psychiatric revolution. Prior to that Phillippe Pinel in France, William Tuke in Greet Britain, Dorothea Dix in Columbia (USA) tried to provide moral treatment for the mentally sick person by treating them in the Asylums.
In 1909 Adollph Meyer with William Jones and Beers started the Mental Hygiene movement in USA.

During World War II, Thomas Salmon first started the short term model for crisis intervention for soldiers emphasizing immediate treatment close to the stressful situation. Thereafter Social Science Researchers like Maxwell Jones advocated the concept of Therapeutic Community. The Menninger Hospital first established the first day hospital.
The advent of the first anti psychiatric drug Chlorpromazine has led to the deinstitutalization of many of the mentally sick persons to start Community Psychiatry programme.

Definition of Community Psychiatry (Oxford Textbook of Community Psychiatry Thornicroft and Szmukler)

Community Psychiatry comprises the principles and practices needed to provide mental health services for a local population by –
(i) Establishing population based needs for treatment and care.
(ii) Providing a service system linking a wide range of resources of adequate capacity, operating in accessible locations and ,
(iii) Delivering evidence based treatment to people with mental disorders.

The American Heritage and Stedman’s Medical Dictionary 2nd edition defines Community Psychiatry as the discipline focusing on detection, prevention, early treatment and rehabilitation of emotional and behavioural disorders as they develop in a community.

Thornicroft and Tansella (1999) defined a Community based mental health service is one which provides a full range of effective mental health care to a defined population and which is dedicated to treating and helping people with mental disorders, in proportion to their suffering or distress, in collaboration with other local agencies.

Background information:
Mental disorders have been viewed as a curse, as a result of bad deeds in the lifetime or in the past, or as an infliction caused by others for revenge. In India, even in the Vedic age of Charaka and Sushruta, efforts were made to under stand and classify mental disorders. There had been mention of these as ‘Unmads’ in the Charaka Samhita. In Ayurveda there was mention of management of the mentally ill by religious rituals, prayers and herbal medicines like Rowlfia Serpentina ,Cannabis, and Alcohol along with restriction of certain foods.

Organized mental health care in the form of Mental Asylum was started in India by the British in the year 1745 in Bombay. As such it was not for proper treatment of the mentally ill persons, rather they were kept in the asylum isolated, so that they could not disturb the normal people in the society. The set up was inhumane as the patients were kept in the asylum like the convicts in a jail. There were however public movements in France, Britain and the United States of America against such ill treatment and moral treatment was subsequently started which included human care, avoiding physical restraints, better staff patient interaction and an open door system.

In 1909, Adolf Meyer advocated management of mentally ill patients outside the institutions and proposed a comprehensive ‘community mental health approach’ in which psychiatrists, family physicians, police, teachers and social workers would work together to organize primary, secondary and tertiary preventive measures in the community.

The community programme in the real sense is a peoples programmes.

In 1952, the committee on mental health of the World Health Organization recommended components for a community mental hospital which included outpatient treatment, part time service, rehabilitation, research and community education.

In the USA the community mental health movement had its rise and fall between 1950s and 1980s. There were a very large numbers of mental patients in the state hospitals. In New York City itself there were 91,000 beds for mental patients. In 1963, President J. F. Kennedy passed a resolution and the US congress passed the community mental health centre act to establish community mental health centers to offer care to the patients discharged from the mental hospitals. These centers provided outpatient as well as inpatient care, emergency services, crises management, community consultation and education. These centers had multidisciplinary team consisting of psychiatrists, clinical psychologists, psychiatric social workers, occupational therapists involved in the service, and linkage were established with schools, welfare workers and agencies and families of the mentally ill in the community. By this approach there was effective management and the total number of mental hospital beds of 5,60,000 in 1955 was brought down to 61,000 in 1992.

In spite of all such community approach movement in other parts of the globe, in India, the situations remained same and new mental hospitals were established till 1966; and number of hospitals from 17 in 1946 rose to 48 in 1992. But barring a few exceptions, the conditions of most of these hospitals remained unsatisfactory because of paucity of fund, lack of mental health professionals, lack of training of the existing staff and poor administration. The general hospitals in 1960s and 1970s opened up psychiatric department in many places with inpatient facilities. The Mudaliar committee in 1962 envisaged that within the next 10 years psychiatric units would be set up in all the district hospitals of the country. Even now, majority of the districts except in Kerala, Karnataka and Tamil Nadu, do not have such units. In Assam, out of 23 districts there are only 5 district hospitals with psychiatric units. Such unit in the district hospitals would have the advantage over the mental hospitals because they would be easily accessible, approachable without stigma, would facilitate outpatient treatment for minor mental health problems and would help in integration of psychiatric services into the general health system.

The inspiration for the community mental health movement in India comes from the sources like:
1. The adoption of community mental health programme by USA in 1963 when the American Psychiatrists realized about Social Breakdown Syndrome resulting from long term hospitalization.
2. The realization of the fact that Institution based psychiatry through trained professionals is very expensive and countries like India do not have sufficient manpower and facilities to deliver Mental Health services through conventional method.
3. The discovery in poor countries like India that para professional ]s and non professionals too can deliver reasonably adequate mental health care after undergoing simple and short innovative training.

Psychiatric Unit in General Hospitals –
As a part of deinstitutionalization, many part of the country established General Hospital Psychiatric units, the first one was set up in 1933 at the R.G. Kar Medical College at Kolkata. Most of such units came up after 1960's after advent of antipsychotic drugs. In the west, the GHPU were created to attend to Neuroses and psychiatric illness, but those in India handled all kinds of psychiatric problems. This gave a new sense of confidence to both the Psychiatrists and patients.

In India, however the pathetic scenario continued for a long time. Queen Victoria of England, in 1920 passed an order to convert all the mental asylums as mental hospitals and the order was carried out in India also. The conditions of the asylum and the administrative functions remained same with the same design for detention and safe custody without regard for curative treatment. The existing accommodation was also not adequate for the number of patients kept. At the time of independence, there was only one mental hospital bed for 40,000 population in India, whereas in England it was one for 300 population.

As per recommendation of the Bhore Committee set up in 1946, the National Institute of Mental Health and Neurosciences (NIMHANS) was established in Bangalore in 1954 for training of mental health professionals. In 1957, Dr. Vidya Sagar, the then Superintendent of Amritsar Mental Hospital started involvement of family members in treatment of the patients by keeping the patient with family members in open tents pitched in the hospital campus. The result was very much satisfactory as the patients recovered rapidly and could go back home with the family members. The family members also could understand the procedures to tackle the problems of the patients and relapse rate was low. Based on the success of this approach NIMHANS of Bangalore and Christian Medical College of Vellore established family wards in their hospitals. This happened before the era of major tranquilizers.

In the 1970s another approach was considered for mental health care. The existing centers offering mental health care served only 20% of the population and that too in urban areas only, whereas 70% of the total population used to live in rural areas. All the epidemiological studies conducted in India revealed that mental morbidity was almost same in rural and urban areas. People could not or did not make use of the available services because of the following reasons:-
1. Ignorance about the available services
2. Existing belief that mental disorders are caused by evils spirits or black magic or due to bad deeds.
3. Lack of knowledge regarding modern method of treatment available
4. Long distance to the centers offering services
5. Social stigma
6. Lack of financial resources to meet the cost of transport, accompanying persons and other costs.

A primary care approach was therefore necessary to cover the rural population through the primary care centers available in rural areas. In 1975, the World Health Organization (WHO) established a report on organization of mental health care in developing countries. In the report, WHO strongly recommended the delivery of mental health services through primary care system as a policy for the developing countries. Efforts were made to implement the primary care approach in the country. One center was established by the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, in 1975 at Raipur Rani Block of Ambala district of Haryana and another by NIMHANS, Bangalore, in 1976 at Sakalwara village in Karnataka. The Central Institute of Psychiatry Ranchi first started Rural Mental Health Center in 1964. A workshop at Madras in 1971 organized by Indian Psychiatric Society recommended that adequate training in mental health should be imparted to increase the workforce including General practitioner, Medical Officers, Nurses, health visitors, midwives, social workers ,gramsewaks and voluntary organization.

The NIMHANS Crash Programme
At the initiative of the Director Dr. R. M. Varma and Dr. Karan Singh, Minister of Health in the Central Govt. a crash programme for community based mental health was introduced at NIMHANS along with the starting of Community Psychiatry Unit in October 1975.

The following experimental programme was launched by this unit -
1. Primary Health Center based rural mental health programme - training of multipurpose workers and PHC doctors were organized.
2. General Practitioner (GP) based urban, mental health programme - a manual was prepared to train GPS in treating common mental health disorders.
3. School Mental Health programme - where teachers were trained to diagnose children with emotional problems with counseling.
4. Home based follow up of psychiatric patients where nurses were trained to follow up patients by home visits.
5. Psychiatric camps were organized like other health check up camps.

A feasibility study was conducted from 1975 to 1980 in both the centers of NIMHANS and PGIMER i.e. Sakalwara and Raipur respectively. The study revealed that;
1. Majority of the mentally ill Epileptics and mentally retarded children remained untreated in spite of being nearer to a well established Psychiatric hospital.
2. All the families of the affected had approached traditional healing centers and local healers but in vain.
3. Majority of the patients with psychoses and epilepsy were ill for more than two years.
4. Key informants, health workers and others could easily identify and report.
5. A limited numbers of drugs like Chlorpromazine, Trifluperazine, Diazepam, Fluphenazine decanoate, Imipramine, Phenobarbitone, Trihexyphenidyl were sufficient to manage almost all cases.
6. Most of the Psychotics improved with medication and were rehabilitated within their villages. Improved patients were accepted to join the mainstream of life without stigma.
7. Medical and non-medical workers were able to learn to manage priority mental disorders in short term courses.

Considering the various factors NIMHANS and other institutions developed other alternatives to institutional care, such as :-
Extensive use of outpatient services.
Extension programme by satellite clinics.
Domiciliary care programme through trained paramedical staff.
Organizing care through private general practitioners.
Training of school teachers in mental healthcare and promotion of mental health care through schools.
Involvement of ICDS personnel in child mental health care.
Training of non-medical volunteers.
Training of college student volunteers.
Training of village leaders
Student enrichment programme.
Involvement of non governmental voluntary organizations.

National Mental Health Programme ( 1982 ) :
In 1982, the health administration in India recognized the need for mental health care and the National Mental Health Programme 1982 (NMHP) was launched all over the country. The main objectives of the programme are –
1. Prevention and treatment of mental and neurological disorder and their associated disabilities and to promote community participation in the organization of services.
2. Use of mental health technology to improve general health services.
3. Applications of Mental Health Principles in total National development to improve quality of life.

The approaches to achieve these objectives are –
1. Diffusion of mental health skills to the periphery of the health service systems.
2. Appropriate allotment of task in mental health care for different levels of health personals.
3. Equitable and balanced territorial distribution of resources.
4. Integration of basic mental health care into general health services.
5. Linkage to community development.

Early Diagnosis of Autism

Early Diagnosis of Autism

Autism is a behaviorally defined neurodevelopment disorder, which is the endpoint of several organic etiologies. The term "Autistic Spectrum Disorder" (ASD) is often used to include severe classic autism and other related conditions in the autism spectrum. Although its exact cause is not entirely known, it has been well established that early diagnosis and intervention are associated with better long-term results for management of the disorder.

But to the consternation of many parents, children with autism rarely receive a diagnosis before age 3 or 4. Early diagnosis is challenging because there is no laboratory test to detect it, nor one set of primary symptoms that define it. Therefore, the diagnosis is based on the presence or absence of a group of symptoms. Autism is difficult to diagnose in very young children because several of the disorder’s main symptoms—such as the child’s relationship with peers—involve behaviors that don’t fully develop in children until later in childhood. Diagnosis of autism is also difficult because the best early indicators involve the absence of consistent social and communication behaviors rather than the presence of an abnormality. There could be lots of reasons for not seeing a particular behavior because it’s either not developing, or it could be that the child is not showing it at that time. But behavioral researchers believe they are homing in on specific behaviors that should drop the age of first diagnosis down to as young as 18 months. Developmental researchers increasingly find that there are critical periods of child development after which certain systems—such as language, vision and motor skills—become less malleable. Therefore, it is speculated that if researchers can learn how to diagnose autism in children at birth or several months after, they may be able to design interventions which will arrest the disorder before it develops. As geneticists begin to locate potential 'autism genes', behavioral researchers are fast developing behavior-based diagnostic tools that will work at increasingly younger ages.

Although autism is usually diagnosed when the child is 3 to 4 years old, parents often sense that something is wrong much earlier. On average, parents start to worry about their child's development by 18 months of age and express their concerns by age 2. Early concerns noted by parents of children with autism can be due to additional learning disabilities rather than to specific impairments associated with autism. However, early videos taken by parents at around the first birthday may show the features which discriminate the child later diagnosed as having autism from other children of the same age .But physicians and professionals are hesitant to diagnose autism at very early ages because, the early development of children varies and often uncertain if a behavior will persist into being considered atypical. If the child is labeled with a problem too early, parents may reduce expectations for the child and restrict the child's access to typical experiences and opportunities. Thus, professionals may take on a "wait and watch" stance that delays diagnosis, and ultimately the commencement of intervention services. Although such concerns are valid, the benefits of early diagnosis vastly outweigh the risks. As many studies have now shown, early intervention is critical for the best outcome in children with autism. A developmental "window," that is, the readiness of the brain for a specific learning, is open only for a certain period. When that opportunity is missed, the learning is likely to be limited in spite of the best efforts. So, the earlier the diagnosis, the better is the prognosis. However, it has not been possible to act because we did not have effective means of evaluating and diagnosing the condition of autism in the first couple of years of life. An accurate diagnosis must be based on observation of the individual's communication, behavior, and developmental levels. However, because many of the behaviors associated with autism are shared by other disorders, various medical tests may be ordered to rule out or identify other possible causes of the symptoms being exhibited.

A brief observation in a single setting cannot present a true picture of an individual's abilities and behaviors. Parental (and other caregivers') input and developmental history are very important components of making an accurate diagnosis. At first glance, some persons with autism may appear to have mental retardation, a behavior disorder, problems with hearing, or even odd and eccentric behavior. To complicate matters further, these conditions can co-occur with autism.

Philip Teitelbaum (1998) reported that disturbance of movement in autistic child may be detected clearly at the age of 4-6 months and sometimes even at birth. The Eshkol–Wachman Movement Analysis System in combination with still-frame videodisc analysis was used to study videos obtained from parents of children who had been diagnosed as autistic by conventional methods, usually around 3 years old. The videos showed their behaviors when they were infants, long before they had been diagnosed as autistic. The movement disorders varied from child to child. Disturbances were revealed in the shape of the mouth and in some or all of the milestones of development, including, lying, righting, sitting, crawling, and walking. Every single autistic child demonstrated at least one movement disturbance by six months of age. Moebius mouth (flat lower lip and arched, oval shaped upper lip) was also present in a number of the children. According to Dr. Teitelbaum, not all autistic children have this feature, but when a child does have it, it’s a possible indicator of autism. And since the condition is noticeable in autistic infants as young as one month old, moebius mouth may prove to be one of the very earliest signs of the disorder. The findings support the view that movement disturbances play an intrinsic part in the phenomenon of autism, that they are present at birth, and that they can be used to diagnose the presence of autism in the first few months of life.

According to Professor Teitelbaum, autistic children learn to sit up, turn over and crawl in noticeably different manner than normal children. He believes that this difference in movement is caused by the same wiring problem in the central nervous system that later causes the social/verbal symptoms commonly associated with the condition.

Jennifer Pinto-Martin and Susan E Levy (2004) also noted disturbances of movement detected clearly at the age of 4-6 months, and sometimes even at birth using the same method. Many autistic children display hyperagility and hyperdexterity. In infancy, the movement disorders present in autism are clearest, not yet masked by other mechanisms that have developed to compensate for them. It is possible that they may vary according to the areas of the brain in which developmental delay or damage has occurred. For instance, Kemper and Bauman have pointed out from anatomical analysis of the brains of autistic individuals that the limbic system as well as the cerebellum may show small shrunken cells. Courchesne has evidence from MRI analysis that the cerebellum may show hypoplasia or even hyperplasia in certain regions of the cerebellum. By combining movement analysis in infancy with MRI analysis, it may be possible eventually to diagnose differential areas of brain involvement in different subtypes of autism.

In the screening for autism the following points are very important.
1) Does the baby respond to his or her name when called by the caregiver?
2) Does the young child engage in "joint attention"?
3) Does the child imitate others?
4) Does the child respond emotionally to others?
5) Does the baby engage in pretend play?

It is important to note that in each of the 5 areas concern is with behaviors that are absent or occur at very low rates. The absence of certain behaviors may be more difficult to pinpoint than the presence of atypical behaviors. But concerns in any of the above areas should prompt thorough evaluation for autism.

A "developmental screening" asking specific questions about baby's progress is very crucial in diagnosis of Autism. The role of pediatrician is very important. Several screening instruments have been developed to quickly gather information about a child's social and communicative development within medical settings.

Some screening instruments rely solely on parent responses to a questionnaire, and some rely on a combination of parent report and observation. Key items on these instruments that appear to differentiate children with autism from other groups before the age of 2 include pointing and pretend play. Screening instruments do not provide individual diagnosis but serve to assess the need for referral for possible diagnosis of ASD. These screening methods may not identify children with mild ASD, such as those with high-functioning autism or Asperger syndrome.

The second stage of diagnosis must be comprehensive in order to accurately rule in or rule out an ASD or other developmental problem. This evaluation may be done by a multidisciplinary team that includes a psychologist, a neurologist, a psychiatrist, a speech therapist, or other professionals.

Diagnostic Tools:
1. CARS (Childhood Autism Rating Scale), developed by Eric Schopler in the early 1970s. It aids in evaluating the child's body movements, adaptation to change, listening response, verbal communication, and relationship to people. It is suitable for use with children over 2 years of age. The examiner observes the child and also obtains relevant information from the parents. The child's behavior is rated on a 15-point scale based on deviation from the typical behavior of children of the same age

2. The Checklist for Autism in Toddlers (CHAT) is used to screen for autism at 18 months of age. It was developed by Simon Baron-Cohen in the early 1990s to see if autism could be detected in children as young as 18 months. The screening tool uses a short questionnaire with two sections, one prepared by the parents, the other by the child's family doctor or pediatrician.

3. The Autism Screening Questionnaire is a 40 item screening scale that has been used with children four and older to help evaluate communication skills and social functioning.

4. The Screening Test for Autism in Two-Year Olds, developed by Wendy Stone, uses direct observations to study behavioral features in children under two. She has identified three skills areas - play, motor imitation, and joint attention - that seem to indicate autism.

5. The Developmental Behaviour Checklist (DBC) Early Screen was developed by Ms Kylie Gray .The screening device is just for the use of GPs, pediatricians and early childhood services, to flag children who may be at risk of autism. The results will indicate if a child needs to be taken for specialist autism assessment.

6. Autism Diagnosis Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS-G). The ADI-R is a structured interview that contains over 100 items and is conducted with a caregiver. It consists of four main factors-the child's communication, social interaction, repetitive behaviors, and age-of-onset symptoms. The ADOS-G, designed by Catherine Lord, is an observational measure used to "press" for socio-communicative behaviors that are often delayed, abnormal, or absent in children with ASD.

7. The Early Screening for Autistic Traits or ESAT developed in Holland and designed to try to identify children with autism around age 15 to 18 months.

The problem with these screening tests is the opposite of what is expected. Missed diagnosis and misdiagnosis are common. The use of standardized assessment instruments and the strict application of the DSM and ICD diagnostic criteria need to be employed with caution. An expert clinical view has been shown to be more effective. An important aspect of early diagnostic consultation is an open and straightforward approach to the negotiation of the diagnostic view with parents over time.

Researchers face a paradoxical situation while developing behavioural tools for screening and diagnosing children with autism at age 2 and younger. It is difficult to prove that their early diagnosis was right if the children they diagnose at 18 months enter into interventions that help treat their dysfunction. It is difficult to say whether the diagnosis was wrong at age 2 or whether the intervention worked so well that the diagnosis is no longer valid.

That’s why most researchers hope they will find some biological markers .There is some progress in this area e.g. elevated levels of immune system B cells and natural killer cells, and more than 100 proteins (Amaral) and lower levels of cytokines (Water). Genetic markers for autism (e.g.endophenotypic traits such as large head size in family members, parents' abnormal brain processing of faces, and the degree to which relatives of autistic children can read another person's mental state) that could accurately diagnose autism at birth and would bolster the behavioral measures are being studied. Some teams are well on the way toward finding one or several autism genes, and others are using neuroimaging to search for specific anatomical or functional differences in the brains of people with autism.

Although autism is now agreed to be a neurobiological disorder, results from structural brain scans have not shown consistency of diagnostic markers. However, functional imaging has shown abnormalities of face processing (the area of the fusiform nucleus) in several studies. However, having something that is solid enough for diagnosing the disorder is still a far cry.


References:
1. Philip Teitelbaum, Osnat Teitelbaum, Jennifer Nye, Joshua Fryman, & Ralph G. Maureer (1998), Movement analysis in infancy may be useful for early diagnosis of autism. Psychology, Vol. 95, pp. 13982–13987,
2. Jennifer Pinto-Martin and Susan E Levy (2004), Early Diagnosis of Autism Spectrum Disorders. Current Treatment Options in Neurology 2004, 6:391-400
3. Lenny Schafer(2000).Guidelines for the Early Screening of Autism ;Early Detection Critical. The American Academy of Pediatrics
4. The Diagnosis of Autism: An Expert Interview with Catherine Lord, PhD; Posted 07/11/2005; http://www.ynhh.org
5. Kim Painter (2005). Autism now diagnosed early. Special for USA TODAY

Training Series for Autism Spectrum Disorder

An interesting opportunity to get up to speed with the latest in the field of Autism Spectrum Disorder


2008 WEB CONFERENCE SERIES Practices to Promote Inclusion for People with Autism Across the Lifespan


Register Today! http://www.tash.org

Overview of Series
Learn about new research and information being documented on people who have the severest communication impairments and autism. Explore ideas for addressing needs in comprehension, fluency, and vocabulary. Get answers to several commonly held, but often erroneous assumptions about autism. Our series will conclude with a session given by a parent and self-advocate. Hear from them about life experiences.

Session 1: Building Communication through Education, Literacy, and Support...
Presenters: Darlene Hanson, Hanson Communication Service LLC and Christi Kasa-Hendrickson, University of Colorado at Colorado Springs
Date: Friday April 4 Time:4:00 - 5:30 pm EST
3:00 - 4:30pm CST
2:00 - 3:30pm MST
1:00 - 2:30pm PST
They will talk about FC in the session, but want to spring board off the new research and information documenting that people who have the severest communication impairments, and autism, have literacy, learn, and perhaps score so low because they can't communicate. (Not such a new idea to many of us, but at least someone else is writing it down).

Session 2: The Science of Autism: Beyond the Myths and Misconceptions
Presenter: Morton Ann Gernsbacher, University of Wisconsin
Date: Monday, April 21
Time: 1:00-2:30pm EST
12:00 - 1:30pm CST
11:00 - 12:30pm MST
10:00- 11:30am PST
Scientific and societal interest in autism has burgeoned in the past decade, as documented by over 20 million websites, over 10,000 entries in PubMed, and a weekly focus on autism by the national media. With this surge of scientists and society turning their attention toward autism, it becomes exceedingly important to distinguish uninformed stereotype from scientific reality, to move beyond myths and misconceptions. In this presentation I shall present the science to answer several commonly held, but often erroneous assumptions, for example: Is autism an attachment disorder? Do autistic individuals really lack a theory of mind? Is there an epidemic of autism? Does ABA therapy cure autism? What is the most promising interpersonal intervention?

Session 3: "A Land We Can Share": Teaching Literacy to Students with Autism
Presenter: Paula Kluth, Consultant
Date: Monday, April 28
Time: 2:00 - 3:30pm EST
1:00 - 2:30pm CST
12:00 - 1:30pm MST
11:00am - 12:30pm PST
Come and learn about how we can give all students- including those with significant disabilities- access to the literate community. Dr. Kluth will explain how all students can be given learning opportunities that are rich, challenging, and meaningful. Participants will also learn strategies for including and supporting students with autism labels in reading, writing, speaking, and listening activities. Specifically, we will explore ideas for addressing needs in comprehension, fluency, and vocabulary.

Session 4: Getting A Life: A 50 Year Personal Retrospective of Autism
Presenters: Barbara C. Cutler, EdD, mother/educational consultant, and Robert W.P. Cutler, Jr, Self-Advocate and Mentor
Date: Monday, May 5 Time: 2:00 - 3:30pm EST
1:00 - 2:30pm CST
12:00 - 1:30pm MST
11:00 - 12:30pm PST Drawing on Rob's diagnoses, life experience and communications as well as Barbara's experience as parent, advocate and consultant, these two will review autism from the late 1950's to present day. The presentation will touch on issues raised in earlier sessions of the series including education, family support, communication, movement difficulties, etc.

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