Why do Neurotypicals have children? / Total Insanity

Since it’s Memorial Day, I thought I’d check out Asperger’s and Military participation: confusing, boring, highly subjective… but I came across a discussion about sending an Asperger to military school because he doesn’t turn in his homework…. edited to protect identity. 

Here we go!

My wife just brought up the idea of sending our 12 year old son who has Asperger’s to a military academy.

His grades could be better; his reading and comprehension scores are at college level but we have a strange situation. 50% of his English assignments have not been turned in so far this year. My wife and I check to make sure he’s done the homework, but he  does not turn it in. We have told him that routine is going to be a fact of life, so get used to it. We’ve told him to always put his homework in the same place in his backpack. That way he will always know where it is, and can turn it in.

Okay! As an Asperger, I see “problems” brewing from the get go: This kid is 12. He’s smart. He resents being treated like a ROBOT; telling him that he will live have to live out his life as a ROBOT is a disaster! His NT parents / therapist think he’s “dumb” – that is, he can’t remember to hand in homework. Really? Who is being dumb in this scenario? 

For some reason, everything we try, or his therapist and social skills teacher try, dies a flaming death within a week. His classwork is not the problem. He read his American history textbook in two days and he has not needed to read it since then. His test scores are excellent but his class participation grade is below average (as expected) but the problem is homework. He either does not do it or he does it, but doesn’t turn it in – which is 1/3 off his grade! If he were still in elementary school, I would probably be turning in his assignments for him, but a 12 year old in the 6th grade needs to step up and be responsible.

Wow! Describe how intelligent the boy is, but then, instead of being happy about that, focus on “obedience to routine.” Push, shove, manipulate; create a power struggle over a “trivial behavior”. Let him know that conformity to routine rules is what you value, not his abilities. This is exactly what not to do with an intelligent child…especially an Asperger type. Insistence on blind social obedience will simply drive him resist, and he will ponder why it is you are so unappreciative toward him.  

His therapist recently sat down with my son and laid out a strict schedule for completing homework and chores, as well as making time for personal hygiene and play. It looked like a military schedule and so my wife asked, via email, what the therapist thought of a military school about an hour’s drive from home.

The therapist said there would be benefits and there would be challenges. The shock of changing his living situation would be a major detractor. But the rigid schedule and not having a thousand distractions within arm’s reach could really help him focus. You also have to think of the “bully” mentality that seems to thrive in these places, and my son is a target of bullying at school. 

How stupid! It’s unbelievable: This is typical of people who think that shoving their child’s nose into a plate of food that he or she fervently dislikes, will “prove” that “the parent is the boss!” Is anyone concerned about him being bullied (not only by kids, but his parents and therapist / teacher!) Could it be that “the homework thing” is his way of reacting to the lack of attention by adults to the “real” problems – including their uncaring behavior? 

There are a number of other pros and cons to this discussion. No girls at the school  could go either way. A lack of human contact would probably be good with him but bad for his social skills in the long run. The money that we would have to pay is a major concern for us; we could not afford for him to fail. 

But my very simple question to the chat room is this: in your opinion, how would someone with Asperger’s fare in a military academy?

Aye, yai, yai! Why do NTs have children?

The following is the father’s response to various suggestions by “chat” participants… his initial “concern” is that some respondents are calling him a bad parent, even though that’s not the case.

Please don’t think we haven’t tried. We have…. over and over with anything we can think of. And it’s not actually not the homework thing, (then why 4 paragraphs that claim that it is?) but the lying and half truths that upset and disappoint me. Until 2 years ago, he did not know how to lie. Now, the lies are almost automatic. And there are the endless excuses. He sometimes tries to blame me or my wife, as if our constant reminders somehow made him not do his homework. (What happened two years ago?)

One day last week, I went into his room to ask if he’d done his homework, and he said yes. I asked him to show it to me. (I get daily emails from his teachers with all assignments and he knows this; however, I don’t always check his work. I always figured that his knowing that I know would be enough to keep him in line.) He actually spent a half hour emptying  his book bag. pretending to looking for homework that he hadn’t done. It was  pathological! I finally said, I can’t prove you didn’t do your homework, but you still have to turn it in tomorrow… So get working! He had a total Asperger’s meltdown. He thought it was going to be game night, and I ruined it by making him do his homework. 20 minutes later, he was yelling that it wasn’t fair. I finally told him that he was right… it wasn’t fair that the whole house had to listen to him yell for 20 minutes and it wasn’t fair that I had to sit outside his door reading a book instead of enjoying time with my family. (Apparently, this boy isn’t family; probably long ago he became labeled as the outsider-disobedient-problem child. Now the father is his “prison guard”)  He told me I was making fun of him…. I told him he was a spoiled brat and behaving like an asshole.

Well! Pretty revealing…if your “tactics” fail over and over again, model “being an asshole” for your child: it’s effective “social training.” 

This is not an isolated incident. He knows I’m going to check on him at least one night per week, but that is not enough motivation for him. I hate having to sit up until midnight to make sure he finishes. His therapist says that making my son stay up until midnight is a predictable consequence; that he will learn from having consequences.  My question is, why am I having to also suffer his consequences? (Because you are his parent. He doesn’t exist in isolation; this is a two-way street, and as the ADULT, you must take responsibility for creating the situation.)

OMG! Such an irrational mess! 

We don’t want to send him to military school, but where else to will he get the structure and discipline to live up to his full abilities? He is not an only child. We try to give him as much one on one time as possible (as remote and narcissistic antagonists), but right now we have him and his brother, age 2, plus 3 foster children, ages 5, 8, and 13, and the 13 year old is pregnant, so we have doctor visits to do. (A concerned citizen might ask, “Are these people qualified to be foster parents?” And, “How much are they being paid per foster child, per month?” That is, is there a profitable exchange for “taking in foster children” vs. “kicking out” your own child? 

Could this picture be any more clear?

No one made these people stretch their family size from TWO to FIVE children. The oldest “birth child” is 12 and an Asperger. He’s been abandoned in favor of 3 “strangers”. He’s expected to “shut up and obey” and to not expect any parental kindness or affection. 

Let’s see “who” is not taking responsibility for the consequences of his actions. It’s not the 12 year old.

I am more than willing to give my son the time he needs, but I cannot give him time I don’t have. As it is, I only get about 2 hours of “me” time at night, but that’s because I don’t go to bed until 1 or 2 a.m. I make breakfast at 5:30 a,m. My wife says I’m burning the candle at both ends; I think that’s why she mentioned military school as a solution to our issue with the 12 year old.

Again, it’s not really the homework thing, it’s the lying and deceit. He loves to correct my incorrect English, and he hates it when I catch his mistakes and quote his words back to him verbatim. It’s a skill he taught me. I have even recorded conversations on my phone when he’s upset, then replay them for him later so he can hear where he went wrong. He misses social cues, so I’m trying to help him by doing that. He gets mad and says I’m making fun of himif I wanted to do that, I’d play the recording back for the whole family to hear. 

He had a meltdown at a store a few months ago… had a kicking and screaming tantrum in public. I pulled out my phone and turned on the camera and got a 4 minute video which showed him taking off his shoes and throwing them at me. The store manager had called the police because he thought I’d hit my son. Luckily I replayed the video that showed it was the boy’s fault, or who knows what would have happened. One of the officers took him aside and warned him that he could be arrested for assault since he threw his shoes at me. They asked me if I wanted to press charges, and sorry, but I had to think about it. In the end, we just left without any groceries and he got a “timeout” when we got home. I wanted to take away his shoes for a day since he threw them at me, but the school would not allow him to attend barefoot. (Now there is a “logical” response. Gee whiz! NTs are so f&^%*d up.) The punishment for us was that we had to eat mac & cheese for dinner. He likes mac & cheese, so it was okay for him. (This was before we took in 3 foster children, so he didn’t have that as an excuse) Sorry for going on so long. I just want everyone on chat to know that sending him away to military school would be a last ditch effort.

Of course; if you are a social typical parent, bullying, abandonment, total lack of empathy and idiotic punishments are the complete “repertoire” for “dealing with” children you don’t like or want.   

What Will You Get “Paid” Monthly per child for Foster Parenting? 

  • Alabama: $490
  • Alaska: $720
  • Arizona: $828
  • Arkansas; $480
  • California: $657
  • Colorado: $475
  • Connecticut: $835
  • Delaware: $580
  • D.C.: $880
  • Florida: $484
  • Georgia: $479
  • Hawaii: $590
  • Idaho: $382
  • Illinois: $424
  • Indiana: Each county sets an individual scale; there is no statewide rate. Foster parents can negotiate with their county director.
  • Iowa: $585
  • Kansas: $640
  • Kentucky: $618
  • Louisiana: $620
  • Maine: $598
  • Maryland: $760
  • Massachusetts: $595
  • Michigan: $474
  • Minnesota: $640
  • Mississippi: $418
  • Missouri: $321
  • Montana: $485
  • Nebraska: $345
  • Nevada: $620
  • New Hampshire: $483
  • New Jersey: $518
  • New Mexico: $495
  • New York: Each of 58 local districts is allowed to set its own rates. The state only determines the maximum amounts it will reimburse to the local districts; there is no minimum. Maximum state aid rates for Metro/Upstate are $560 (average).
  • North Carolina: $432
  • North Dakota: $390
  • Ohio: Each county sets its own minimum and maximum per diem (day) rates, which range from $10.00 to $118.00 per day.
  • Oklahoma; $540
  • Oregon: $415
  • Pennsylvania: Varies for all areas.
  • Rhode Island: $510
  • South Carolina: $420
  • South Dakota: $489
  • Tennessee: $660
  • Texas: $690
  • Utah: $495
  • Vermont: $610
  • Virginia: $430
  • Washington: $470
  • West Virginia: $505

Why does GOD let people starve to death? / Insane Neurotypical Christian Response

FROM “Not Ashamed of the Gospel” website. (You ought to be ashamed…)  https://notashamedofthegospel.com/apologetics/why-god-doesnt-feed-all-starving-children/

3 Strange But True Reasons Why God Doesn’t Feed All the Starving Children in The World

Peter Guirguis / Apologetics 240 Comments

OMG! I will never apologize for being Asperger or Atheist. This is how “normal neurotypicals” see the world; the universe is a supernatural monstrosity.

Evil exists, but not in Nature; it is the consequence of the beliefs and behavior of Modern Social Homo sapiens. Why isn’t this dangerous “mental derangement” not featured in the DSM, and yet Autism is?

God, Can You Please Make it Rain Turkey and Gravy?

If God is all-powerful, then can’t He make it rain turkey and gravy from heaven to feed all the starving kids in the world? The answer is that of course God can do that if that’s what He wanted to do. But since God doesn’t make it rain turkey and gravy upon the starving kids around the world, then we have to ask, ”Why doesn’t He?”

If you’re not able to answer this question, then one of two things is going to happen to you. You’re going to struggle with your faith because you’re going to have doubts that God is a good God. Or you’re never going to find out the truth about God, and you’ll make the mistake of thinking that God doesn’t exist.

This article is for you if:

1. You’ve ever wondered why God doesn’t feed starving kids around the world, and you struggle with the answer.2. You’re skeptical of the Christian God or other gods. 3. You want to be able to answer this question when it’s asked of you in an accurate and positive way.

Why The “Strange But True” Title? The reason I call these reasons that I’m about to share with you “strange” is because if I were God, I would do things differently. But thank goodness, I’m not God. (OMG!)

What may be strange to one person may not be considered strange to another. So depending on how familiar you are with this subject, (NT insanity?) you may agree with me that these reasons are “strange but true”, or you may not. Either way, I hope this will spark a good dialog about this topic. (Totalitarian demand for obedience to supernatural hallucinations is a really good jumping off point for “good dialog”!)

I’ve thought of three different reasons why God doesn’t feed the starving children of the world.

Reason #1 – It Isn’t God’s Responsibility to Feed the Starving Children of the World

Every year, I have the privilege of going through the one-year Bible plan. That means that I will read the entire Bible in one year. I don’t share this to impress you. But I do share it to establish that I’m quite familiar with the Bible. Of all the times that I have read the Bible from cover to cover, I can’t think of a single Bible verse in which God makes a promise to feed all the starving children in the world. (But there are threats that “God” will make people eat their own children!) So when somebody accuses God of being unjust because He has the capability to feed starving children, and He doesn’t, then it’s that person that has a misunderstanding of God. (No misunderstanding here: your imaginary master is a true psycho-sociopath)

GOD: “Hey, it’s not MY JOB to control the vicious uncaring assholes I made in my image. LOL!” 

If God Isn’t Responsible For Feeding Starving Children, Then Who Is?

The answer is you and me. I can think of numerous Bible verses in which God instructs His children to feed the poor people of the world.

And Christians are doing such a great job of it! Bomb entire nations into a state that can only be called “Hell on Earth”, and then send “missionaries of democracy” with bags of leftover “dog food”. Take photos: lie, brag about how “empathetic” and compassionate you and your “god” are. And of course, “profit” from the crimes. 

Proverbs 28:27 says, “He who gives to the poor will not lack, But he who hides his eyes will have many curses.” James 2:15-16 says, “If a brother or sister is naked and destitute of daily food, and one of you says to them, ‘Depart in peace, be warmed and filled,’ but you do not give them the things which are needed for the body, what does it profit?” So if you’re one of those people that thinks God should feed the starving kids around the world, then you are shifting the responsibility.

God isn’t responsible for feeding starving children, you and I are. Then why not demonstrate ethical behavior by refraining from creating mass suffering by  committing predatory wars, practicing profitable poverty as “economics” and enforcing starvation? 

Reason #2 – God Isn’t Like Humans

Atheists make a mistake when they say things like, “If I saw a starving child and had the power to feed him and I don’t, then I am evil. (Uh-yeah! That logically is cruel uncaring behavior) That’s the same thing with God, He is evil because He has the power to feed starving children and He doesn’t.” (You said it! Why not believe your own “instincts” about all this Christian “we’re the good guys” social evil?)

The mistake that atheists make here is that they compare themselves to God, or they compare God to themselves. They put themselves in God’s shoes. (This is utterly BONKERS. God does not exist, and he certainly wouldn’t wear shoes if he did)

God’s goals are different than our goals. His purposes are different than our purposes. His way of justice is different than the human way of justice. But here’s the lesson that’s to be learned: any time you blame God for not doing something that you would do, you’are making an idol in your own image. (Christianity IS a religion of “idols”)

What does that mean? It means that you’re making up your own concept of how God is supposed to act, which is something the Bible warns us about. (My, my – mustn’t use what little intelligence humans have to realize that religion is a con game)

Reason #3 – God’s Justice is Coming Soon For All

You and I want to see justice have its way immediately. Think about all the hate crimes in the world, the rapes, and the murders. You and I want to see those people (Christians commit hate crimes, rape, murder and a long list of heinous behaviors, as a matter of religious and political policy) get what they deserve.

But while we judge others for their heinous crimes, we overlook the sins that we commit in God’s eyes. While God does see hate crimes, rapes, and murders as sins, He also sees lying, cheating, and hating people as sins too. (Your god hates human beings and other living things)

So since God is a just God, then He’s going to have to give justice to all if He were to judge the world today. That means that there would be a lot of people who would receive punishment for eternity for breaking God’s standards. (And how LOW these are!) So instead, God is saving His judgment for Judgment Day. That’s when everyone is going to get judged for what they did on earth.

Those who broke God’s standards and did not receive His son Jesus for salvation will end up going to hell.

This is deranged thinking by any standard; it expresses rage and hatred for all human beings; it’s sick, sadistic and “loves” torture. Why is “religious psychopathy” not in the DSM? 


But those who do put their faith and trust in Christ will end up going to heaven. So when you don’t see justice taking place immediately, it’s because God is giving everyone a chance to repent, and put their faith in Jesus Christ as Lord and Savior.

How About Other Reasons?

I have to admit, I’m not a know it all. That’s where you come in. Can you think of any other reasons why God doesn’t feed the starving kids around the world? (“He” is a hallucination: “He” doesn’t exist. Thank God!) 

Share them in the comments below.

I leave you to read the comments: I need to spend some time in Nature, where evil does not exist…

But millions of Americans believe it’s true…


Public Schools / Jr. Prisons?

American social institutions that “serve” children sanction child abuse. 

What is incredible is that we have to pass laws that make institutional child abuse illegal, otherwise it’s assumed by those that care for and teach children that abuse is okay.

website: autismfiles.com

In 2009, after completing its nationwide investigation into the use of restraint and seclusion in public schools, the U.S. Government Accountability Office (GAO) released its report on Selected Cases of Death and Abuse at Public and Private Schools and Treatment Centers. The investigation concluded that there were “no federal laws restricting the use of seclusion and restraints in public and private schools and widely divergent laws at the state level.” It also stated that there were “hundreds of cases of alleged abuse and death related to the use of these methods on school children during the past two decades.”

The report gave examples of these cases, including a seven-year-old purportedly dying after being held face down for hours by school staff, five-year-olds allegedly being tied to chairs with bungee cords and duct tape by their teacher and suffering broken arms and bloody noses, and a 13-year-old reportedly hanging himself in a seclusion room after prolonged confinement.

In terms of special needs children, the report found that those with disabilities are reportedly being restrained and secluded in public and private schools and other facilities, sometimes resulting in injury and death. The 10 closed cases examined by the GAO revealed that children with disabilities were sometimes restrained and secluded even when they did not appear to be physically aggressive and their parents did not give consent. They also were restrained facedown or using other methods of restraint that block air to the lungs, which can be deadly. The teachers and staff in these cases were often not trained in the use of restraints and techniques, and they continue to be employed as educators. So if they are trained, it’s okay?

Even worse, the reasoning behind the use of these practices makes every student vulnerable, not just those with special needs. Whether it is for convenience, discipline, or is, as some would claim, “therapy,” the misuse of restraint especially has become a dangerous standard of practice without any evidence to back it. According to the Alliance to Prevent Restraint, Aversive Interventions & Seclusion (APRAIS), research shows that aversive interventions, restraint, and seclusion carry no therapeutic value, and as we’ve seen, can compromise health and safety.

Let’s Just Call It Abuse


Who knew that torture subjects included American school children?

There’s nothing more frustrating in the advocacy world than opposing interpretations of the same word. Solutions are much more difficult to come by if one side feels there is no problem in the first place. We of course see this with the very label of our community—autism. Many in the community interpret autism, or being autistic, as a privilege, a gift; even something you are rather than something you have. Others see it as a “have” condition of pain, discomfort, limitation and risk.

Similar multiple meanings apply to restraint. Many educators believe restraints are used to maintain the safety and order of the classroom and students, while those who oppose their use believe they are dangerous to the physical and mental health of children, and may result in death. While restraint may be used for instances when immediate danger threatens any individual, its misuse for the purpose of controlling behavior, disciplining, or asserting authority should be called something else entirely.

Seclusion rooms—recently referred to as “scream rooms”—are not only harmful, they defeat the entire purpose of inclusivity. Unlike restraint, which has the “imminent danger” exception to the rule, forcing a child into an empty room, closet, stall or cage has no exception. “Aversive intervention,” which is a preferable and friendlier term over abuse or torture, encompasses restraint and seclusion, but also covers the use of random disciplinary actions ranging from force-feeding and forced exercise, to duct-taping and verbal assault. At a minimum, these practices cause trauma and regression in children with autism and are quite simply abusive.

The Dangers

It is estimated that more than 200 students, many with disabilities, have died due to seclusion and restraint practices being used in schools over the last five years. While restraining someone against their will is typically considered a crime, its continued allowable misuse in schools can cause postural asphyxia, unintended strangulation, death due to choking or vomiting and being unable to clear the airway, death due to inability to escape in the event of fire or other disaster, cutting off of blood circulation by restraints, and nerve damage by restraints. Other dangers include post-traumatic stress disorder, heart, gastrointestinal and pulmonary complications, decreased appetite and malnutrition, dehydration, urinary tract infections, incontinence, anxiety and agitation, depression, loss of dignity, sleeping problems, increased phobias and increased aggression, including SIB (self-injurious behavior).

As one advocate recently pointed out, the use of these practices could also increase a child’s tendency to run or elope, behaviors that have their own set of risks. According to my organization, the National Autism Association (NAA), at least 80 individuals with autism were reported missing between September 2011 and February 2012 following elopement. Of those, 25 percent were students who left school grounds.

A Long Overdue Federal Bill

The good news is that federal legislation has recently been introduced to protect students from these dangerous practices. The Keeping All Students Safe Act, introduced by Senator Tom Harkin (D-IA), would provide protections to students across the country by prohibiting interventions that compromise health and safety. It would require that schools conduct a debriefing with parents and staff after a restraint is used, as well as plan for positive behavioral interventions that will prevent the use of restraints with the student in the future. It also would prohibit:

  • Aversive behavioral interventions that compromise health and safety.
  • Physical restraint that is life threatening, including physical restraint that restricts breathing.
  • Physical restraint if contraindicated based on the student’s disability, healthcare needs, or medical or psychiatric condition.
  • The use of seclusions and/or restraints in a student’s Individual Education Plan or any other behavioral plan.
  • Seclusion in locked and unattended rooms or enclosures.

What an improvement: teachers and staff will be required to tell parents the methods that were used to abuse their child.

See related posts on notorious child abusers Dr. Bruno Bettelheim (left) and Dr. Matthew Israel (right).


See also:

A Violent Education

Corporal Punishment of Children in US Public Schools



Psychotropic drug “poisoning” of the U.S. population / Criminal Psychiatry


def. psychotropic medication

Psychotropic medication: Any medication capable of affecting the mind, emotions, and behavior. (This “generic” description covers any and all “brain functions” that control, in essence, “who we are” as individual organisms; how we think, behave and feel, as well as the actions these states produce. 


Types of Psychotropic Medications

From: GoodTherapy.orgRHelping people find therapists. Advocating for ethical therapy. Click here for extended text.

Several different types of medications are used to treat mental health conditions. The following is a list of the major categories of psychotropic medications: LIVE LINKS BELOW – read about each drug…

Most Frequently Prescribed Psychotropic Drugs

Based on 2013 data, here is a list of the 10 most prescribed psychotropic drugs in the United States (with the number of prescriptions written during one year):

  1. Xanax (alprazolam), 48.5 million
  2. Zoloft (sertraline), 41.4 million
  3. Celexa (citalopram), 39.4 million
  4. Prozac (fluoxetine), 28.3 million
  5. Ativan (lorazepam), 27.9 million
  6. Desyrel (trazodone HCL), 26.2 million
  7. Lexapro (escitalopram), 24.9 million
  8. Cymbalta (duloxetine), 18.6 million
  9. Wellbutrin XL (bupropion HCL XL), 16.1 million
  10. Effexor XR (venlafaxine HCL ER), 15.8 million

Medication that works well for one person may not work well for another. It is important to have an in-depth conversation about your medical history, symptoms, diagnosis, and goals with your medical provider before beginning a psychotropic medication. You cannot legally purchase psychotropic medication without a prescription. (Which drives individuals who have become “hooked on” psychotropics, but can no longer get prescriptions – or afford the fees imposed by psychiatrists for appointments – to move on to illegal black market drugs to “treat” their psychotropic addiction.) 


And then, there are the psychotropic drugs used for “other” conditions.

Pregabalin, marketed under the brand name Lyrica among others, is a medication used to treat epilepsy, neuropathic pain, fibromyalgia, and generalized anxiety disorder.[9][10][11] Its use for epilepsy is as an add-on therapy for partial seizures with or without secondary generalization in adults.[12] Some off-label uses of pregabalin include restless leg syndrome,[13] prevention of migraines,[14] social anxiety disorder,[14] and alcohol withdrawal.[15] When used before surgery it does not appear to affect pain after surgery but may decrease the use of opioids.[16]

Common side effects include: sleepiness, confusion, trouble with memory, poor motor coordination, dry mouth, problem with vision, and weight gain.[10] Potentially serious side effects include angioedema, drug misuse, and an increased suicide risk.[10] When pregabalin is taken at high doses over a long period of time, addiction may occur, but if taken at usual doses the risk of addiction is low.[1] Pregabalin is a gabapentinoid and acts by inhibiting certain calcium channels.[17][18]

Parke-Davis developed pregabalin as a successor to gabapentin and was brought to market by Pfizer after the company acquired Warner-Lambert.[19][20] There is to be no generic version available in the United States until 2018.[21] A generic version is available in Canada, the United Kingdom, and Australia.[22][23][24] In the US it costs about 300-400 USD per month.[10] Pregabalin is a Schedule V controlled substance under the Controlled Substances Act of 1970 (CSA).


In 2016, Lyrica generated a revenue of some 4.4 billion U.S. dollars. Lyrica is an anticonvulsant drug marketed by Pfizer. In the United States, it is most commonly used for neuropathic pain.  

Note the use of a this “psych drug” for nerve pain and many, many “off-label” conditions. No psychiatric diagnosis needed. 

Side effects: This is just ONE LIST from pages and pages of side effects for this drug!

Psychiatric side effects of Lyrica: for complete info go to: https://www.drugs.com/sfx/lyrica-side-effects.html

Common (1% to 10%): Confusion, euphoria, amnesia, nervousness, irritability, disorientation, insomnia, libido decreased, disturbance in attention, anxiety, depersonalization, stupor, abnormal thinking

Uncommon (0.1% to 1%): Cognitive disorder, mental impairment, abnormal dreams, agitation, apathy, aphasia, hallucinations, hostility

Rare (less than 0.1%): Delirium, delusions, manic reaction, paranoid reaction, personality disorder, psychotic depression, schizophrenic reaction, sleep disorder, disinhibition[Ref]

Defining Autism / The Unicorn Problem Re-Post

Fantastically Wrong: The Weird, Kinda Perverted History of the Unicorn (Substitute Autism myth for Unicorn Myth in the following:)


If you’re looking to figure out how an ancient myth started to get out of hand, a good place to start is with the great Roman naturalist Pliny the Elder, whose epic encyclopedia Natural History stood largely as fact for some 1,600 years. Problem was, Pliny wasn’t the most incredulous of writers, and crammed his encyclopedia with pretty much any account he could get his hands on. Autism is born – Autism as we know it…1980- Autism was added to the Diagnostic and Statistical Manual of Mental Disorders- Third Edition (DSM-III) as “infantile autism”. This addition made it possible for doctors to accurately diagnose Autism and gave the ability to easily differentiate Autism from schizophrenia. 1987- “Autistic Disorder” replaced “Infantile Autism” in the manual and gave a more expansive explanation of the diagnosis. 1991- Schools begin to identity and serve students with Autism following the federal government decision to make Autism a special education category. ($$$$$)

The unicorn,” Pliny wrote, “is the fiercest animal, and it is said that it is impossible to capture one alive. It has the body of a horse, the head of a stag, the feet of an elephant, the tail of a boar, and a single black horn three feet long in the middle of its forehead. Its cry is a deep bellow.”

Note the ever-increasing list of Autism “symptoms” (behaviors) without any logical coherence, just like the growing fantasy around the unicorn. The list grows and grows more fabulous with each recounting of the mythical beast called Autism. 

‘Unicorns huh? You look more like a couple of party animals to me.’

The unicorn then shows up in various places in the Bible, at least according to some translations (it’s sometimes instead referred to as the oryx, a kind of antelope whose antlers were indeed sold as unicorn horns in medieval times, or as the auroch, a massive type of cattle that went extinct in the 17th century). Here, its fierceness is affirmed. In Numbers 24:8, for instance: “God brought him forth out of Egypt; he hath as it were the strength of an unicorn: he shall eat up the nations his enemies, and shall break their bones, and pierce them through with his arrows.”

In the 7th century, the scholar Isidore of Seville chimed in, noting that the unicorn “is very strong and pierces anything it attacks. It fights with elephants and kills them by wounding them in the belly.” He also helped popularize the myth that would serve as a hallmark in European folklore for centuries to come: Catching a unicorn is impossible…unless you have access to a virgin woman. “The unicorn is too strong to be caught by hunters,” he writes, “except by a trick: If a virgin girl is placed in front of a unicorn and she bares her breast to it, all of its fierceness will cease and it will lay its head on her bosom, and thus quieted is easily caught.” It’ll suckle until it’s lulled to sleep. So…yeah.

Note the “behavior-based” description of the unicorn – subjective, imaginary, wildly illogical, supernatural – not a “real” animal at all.  

…Not only was the natural history of the animal given, but each was then compared to a biblical figure. And the unicorn stood for Christ, since he was captured and put to death like the unicorn is done in by the virgin (though pretty much every other animal was also compared to Christ, even the pelican, which was said to peck at its own breast to revive its young with blood, like Jesus shed his own blood for us).

Thus the unicorn became firmly implanted in  European lore. And Autism in American Psychology lore. What followed was a full-blown mania for their horns, which were said to detect poison if you stirred them around in your food or drink. They went for tens of thousands of dollars in today’s money, and were particularly popular among paranoid royalty. More industrious users who didn’t want to wait around to have their food poisoned would grind up the horns—usually those of the oryx or narwal (whose horn is actually a giant tooth)—to gain immunity from toxins.

Over in the East, royalty had a rather more complicated relationship with their version of the unicorn, the aforementioned kirin, or qilin. Its appearance was said to foretell the birth of a royal baby, which is nice of it, but can also predict an imminent death, which is not so nice. In the 15th century, a giraffe was brought to China for the first time and presented to the emperor as a kirin, which was a gutsy move considering its proclivities for letting royalty know they’re going to die soon. The emperor, though, dismissed it as a fraud and went on to live another 10 years. Does a giraffe look anything like the mythical unicorn? And yet … maybe it does! Who knows? But unicorns must surely exist? Autism surely must exist? Psychologists say so. 

No one seems to notice throughout this sad charade, that just like the unicorn, the mythical beast called Autism, does not require proof of its existence. No such animal called the unicorn was ever shown to be real; nothing more than a barrage of  anecdotal reports, subjective opinions and imaginary conclusions have ever been  presented by psychologists.   

A Myth Is Born / “Autism, 1994”

The myth of the unicorn may have come from sightings of antelope and such ungulates with only one horn, having either been born with the defect or lost the horn when scrapping with a predator or one of its own kind. Less likely still is seeing a normal antelope from afar in profile, since that would only last as long as the animal didn’t move.

Reality is of no importance; social typical inattentional blindness conveniently “denies” any physical evidence that is contrary to social dogma. Autism is “supernatural” – above scientific explanation.

A far more likely culprit is the Indian rhinoceros, and clues for this are sprinkled throughout the early accounts—indeed, the unicorn is sometimes referred to as the Indian ass. Pliny, for instance, mentions that the unicorn has “the feet of an elephant,” a rhino’s feet in fact being not hooved like a horse’s, but fleshy like an elephant’s. He also notes that it has “the tail of a boar,” much like a rhino’s, “and a single black horn three feet long in the middle of its forehead.” Writers would only later describe the horn as white.

Evidence? What evidence? Neurotypicals can look a rhinoceros in the face and call it a moose. If authorities say it is a duck, they will then call it a duck – or an Autistic duck.   

The ancient Greeks and Romans, you see, had been making forays into India and bringing back tales of the strange beasts there, and the facts tended to get a bit…lost. Cotton, for instance, was said to grow in India as an actual lamb that sprouted from the ground, just hanging there patiently producing cotton. And while Pliny actually did a pretty good job of describing the rhino, his popularization of the “unicorn” picked up more and more improbabilities as the centuries wore on. We also know that the ancient Chinese had contact with rhinos from art made out of their horns, so the animal could well have also inspired the kirin.

The tragedy of this story is that people who ought to know better – medical doctors, geneticists, and neuroscientists have “bought” the myth of Autism as a “thing” in itself, when it is merely a collection of symptoms due to real and specific causes that can be radically different from case to case.

Symptoms can be as “supernatural” as a brain that “lights up wrong” – or social difficulties judged to “be annoying” by self-centered adults; parents, teachers and Puritanical psychologists who demand obedience. Who enforce an rigid and unkind  social behavior regime specific to “certain Americans” but which is alien to many “diverse” groups, cultures and child-raising traditions. Kids are being declared “defective” by opinionated psychologists and miscellaneous imperious adults on the basis of utterly subjective criteria.

Autism is not a “disease, mental illness, or even a MEDICAL DIAGNOSIS. It is a grab bag of social behavior that is rejected by psychologists and proclaimed to be “defective”. It has become fear-induced hysteria in the U.S. 

Autism Spectrum Disorder  / DSM 5 299.00 (F84.0)

Diagnostic Criteria (What a joke!)

A.      Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text): This is utterly subjective; depends on the “opinion” of the person doing the “reporting” – hearsay evidence; not admissible in a court of law, but “good enough” for labeling a child as defective. No standards for comparison are provided: “behaviors” are not-quantifiable; those listed vary wildly from family to family and culture to culture. 

1.       Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. Abnormal and reduced compared to what standard? There are no objective criteria in these judgements. None of these blah, blah, blah criteria are even testable!

2.       Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. So vague, arbitrary and subjective as to be ridiculous. Where are the objective standards and “proof” that the vast majority of human children conform to these “undefined but absolutist” subjective interpretations of behavior? Where is the proof that any two people observing a child, will even agree with each other that these observations are factual? No “facts” are allowed – or considered to exist!

3.       Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. WOW! This paragraph is so general that it could apply to any human being alive on planet earth.

Specify current severity:

Severity is based on social communication impairments and restricted repetitive patterns of behavior (see Table 2).

B.      Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

Any child could be diagnosed as autistic using this “potpourri” of “socially objectionable” activities!

1.       Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). If you throw enough non-related behaviors at a wall, (and this is quite a mix of motor, language, organizational, speech and cognitive behaviors) then one or more will likely “stick”. 

2.       Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day). Describes half the people in any office environment every day; and 100% of humans at some point, depending on “what kind of day” they are experiencing. 

3.       Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest). Such as obsessions that “normal kids” display: playing video games, constant social media monitoring, texting, uploading selfies, extremely limited self-image conformity, incessant talking, cruelty to other children, foul language, and mutual verbal abuse – but these are “not unusual” and therefore acceptable. But that child who likes to arrange toys by size and color? A threat to the social order…

4.       Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Any reactions to the environment other than those displayed by a “perfect child” (a being as mythical as the Unicorn), are pathological. The perfect child notices nothing in the environment, even if it is dangerous, toxic or extraordinarily beautiful. No personal preferences are allowed. 

Specify current severity:

Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2).

C.      Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). How non-specific! Anywhere, anytime, any behavior, observable or not – pathological. 

D.      Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. What constitutes clinically significant? Your clinic, or mine? The gym teacher’s or school counselor’s office? The BA in psychology who “does” therapy? Anyone and everyone is “diagnosing” Autism today. 

E.       These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur WOW! How lame: Autism “symptoms” are the RESULT of specific disabilities due to birth defects, premature birth, emotional and physical trauma, injury or disease, rare genetic conditions and myriad unknown “causes” – including the fact that human beings are not identical “clones” of imaginary supernatural “templates” but individuals with a range of personalities and temperaments AND BRAIN ORGANIZATION; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level. Who sets the standards and parameters for “judging” and “rating” childhood behavior? Just who are these people? No one asks; neurotypicals accept social authority as being reliable in the same way that the Laws of Physics are reliable.  

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. Wow! Nothing like throwing you own previous diagnostic criteria under the bus! Why should anyone trust the DSM, or the existence of Autism to start with?

Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition (which is the ACTUAL PROBLEM) or environmental factor
(Coding note: Use additional code to identify the associated medical or genetic condition.)
Associated with another neurodevelopmental, mental, or behavioral disorder
(Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder[s].)
With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition) (Coding note: Use additional code 293.89 [F06.1] catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia.)

Codes – this Autism Diagnosis charade is driven by insurance reimbursement: that is the CODE that matters to the “behavior industry” and not the accuracy of the diagnosis.  

 Autism (the label) is a selective symptom-based system for socially pathologizing and isolating children who suffer from a range of effects previously known as “mental retardation” – conditions caused by real physical impairments.
Today, Autism has grown to be a highly profitable industry, by sweeping inclusion of non-medical, non-scientific labeling of children who are not “retarded” but “socially unacceptable” using vague and subjective opinions dictated by overblown psychological dogma, which is “prescriptive” in origin and structure. It is a “super-fraud” that destroys families and dooms children to a lifetime of social “subhuman” status. And prevents effective provisions for real treatment for real problems experienced by real people.   

Table 2  Severity levels for autism spectrum disorder “The Table of Social Doom”

Severity level Restricted, repetitive behaviors
Level 3
“Requiring very substantial support”
Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches
Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.
Level 2
“Requiring substantial support”
Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or  abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited  to narrow special interests, and how has markedly odd nonverbal communication.
Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in  a variety of contexts. Distress and/or difficulty changing focus or action.
Level 1
“Requiring support”
Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to- and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful.
Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

There is something terribly wrong with the neurotypical brain

Every Asperger knows this to be true, but we’re not allowed to say so.

Practitioner Review: Social (pragmatic) communication disorder conceptualization, evidence and clinical implications

Authors: Dr Courtenay Frazier Norbury, Department of Psychology, Royal Holloway, University of London, Egham, Surrey TW20 0EX, United Kingdom; Email: courtenay.norbury@rhul.ac.uk First published: 9 October DOI: 10.1111/jcpp.12154


Background: DSM-5 sees the introduction of Social (Pragmatic) Communication Disorder (SPCD), characterized by persistent difficulties using verbal and nonverbal communication for social purposes, in the absence of restricted and repetitive interests and behaviours. There is currently much confusion about the precise diagnostic criteria for SPCD and how this disorder relates to autism spectrum disorders (ASD), previous descriptions of pragmatic language impairment (PLI) and more specific language disorders (LD).
Method: Proposed criteria for SPCD are outlined. A selective review of the evidence considers whether these criteria form a cohesive and distinct diagnostic entity. Approaches to assessment and intervention are discussed. (No one knows if this is a legitimate disorder, but it’s already in the DSM-5 ?)
Results: Implementing the new diagnosis is currently challenged by a lack of well-validated and reliable assessment measures, and observed continuities between SPCD and other neurodevelopmental disorders. High rates of comorbidity between SPCD and other seemingly disparate disorders (including conduct disorder, ADHD and disorders of known genetic origin) raise questions about the utility of this diagnostic category.
Conclusions: SPCD is probably best conceptualized as a dimensional symptom profile that may be present across a range of neurodevelopmental disorders, although there is an urgent need to investigate the latent structure of SPCD using consistent diagnostic criteria. In addition, social communication and aspects of pragmatic language may be dissociated, with the latter heavily influenced by structural language attainments. Finally, there is a dearth of reliable and culturally valid assessment measures with which to make a differential diagnosis, and few rigorously tested intervention programmes. The implications for research and clinical practice are outlined.
Enhanced PDF; Standard PDF (139.3 KB)
Introduction / Successful communication requires us to go beyond the literal words uttered and draw on our knowledge and experiences to construct meaning. Sometimes this requires the use of linguistic context (pragmatics), in which children are expected to infer meaning or resolve ambiguities by integrating the surrounding language with their prior knowledge and experience. At other times, successful communication requires the use of language in social contexts (social communication). Here, a broad definition would include a child’s understanding of speaker intentions and the verbal and nonverbal cues that signal those intentions, as well as the child’s interpretation of the environmental context, societal norms and expectations and how these coalesce with structural aspects of language (e.g., vocabulary, syntax and phonology) to achieve successful communication. That some children experience difficulties with social communication, or that pragmatic language development can follow a qualitatively atypical course, is incontrovertible. However, the diagnostic status of children with atypical pragmatic and social communication development has long been debated (cf. Brooks & Bowler, 1992), fuelled most recently by the introduction of a new disorder, Social (Pragmatic) Communication Disorder, to the DSM-5 (http://www.psychiatry.org/practice/dsm/dsm5; American Psychiatric Association, 2013a) and proposals for Pragmatic Language Impairment (PLI) to ICD-11 (World Health Organisation, 2013). A resolution of the debate is hampered by inconsistencies in terminology and diagnostic criteria, a paucity of reliable, culturally valid assessment tools supported by adequate normative data, and limited comparison of social communication profiles across different neurodevelopmental disorders.

But that’s never stopped us before, so let’s jump right into a new “fiasco”

The idea that some children may have significant social communication and/or pragmatic language impairments without meeting diagnostic criteria for autism is certainly not new (Bishop & Norbury, 2002); nosologies of developmental disorders have included children with atypical social pragmatic development for more than 30 years. For the most part, investigators have used the terms interchangeably, such that social communication and pragmatic language skills encompass the same behaviours. For instance, Rapin and Allen (1983) first described ‘semantic-pragmatic deficit syndrome’ as a constellation of symptoms including verbosity, comprehension deficits for connected speech, word finding deficits, atypical word choices, unimpaired phonology and syntax, inadequate conversation skills, speaking aloud to no one in particular, poor topic maintenance and answering beside the point of a question (Rapin, 1996). Wow! is this control-freak creepy or what? Just about any child will display some of these “pathological” speaking habits! Most adults also!
Rapin and Allen used this as a descriptive term that was most commonly applied to the communication profiles of children with autism spectrum disorder (ASD), but they acknowledged that social communication and pragmatic language impairments were also seen in many other developmental disorders. Bishop and Rosenbloom (1987) considered ‘semantic-pragmatic disorder’ to represent a distinct subgroup of children who occupied a diagnostic space between ASD and specific language impairment (SLI). Both systems emphasized a deficit in social communication and/or pragmatic language abilities in the context of relatively age-appropriate phonology and grammar. In an effort to improve diagnostic accuracy and interrater reliability, Bishop (1998) created the Children’s Communication Checklist, which has rapidly become the most widely used, standardized measure of pragmatic ability in research and clinical contexts. However, Bishop (1998) reported that semantic items did not reliably distinguish children with suspected social pragmatic deficits from typically developing children or peers with SLI. As a result, the term ‘PLI’ became the generally accepted term for children with primary difficulties in the use of language in context (social or linguistic) who did not meet standard diagnostic criteria for pervasive developmental disorder. However, subsequent research made clear that many children identified with pragmatic deficits using the CCC had structural language impairments (Norbury, Nash, Baird, & Bishop, 2004) and that pragmatic deficits were manifest across a range of neurodevelopmental conditions, some of which involve impairments in general cognitive functioning (cf. Laws & Bishop, 2004). In ASD, deficits in pragmatic aspects of language are a recognized hallmark of the disorder (Tager-Flusberg, Paul, & Lord, 2005). However, children with ASD are commonly identified as having social communication disorders, rather than PLI, perhaps in an effort to emphasize the pronounced difficulties with face-to-face communication individuals with ASD may experience. (Got all that? Make sense? Yikes!)

Why does this debate matter?

The emphasis on identifying and delineating pragmatic and social communication deficits is surely welcome, so could there be any reason to object to the creation of a diagnostic category designed primarily to identify children who might otherwise slip through the net? A revealing use of words – society wouldn’t want a bunch of “communication renegades” running loose! I would argue that there are reasons to be concerned with the diagnosis in its current form, particularly as diagnosis typically carries with it a promise of tailored intervention and educational support. As differences in terminology highlight, there is considerable confusion surrounding the new diagnosis, and the different perspectives of the clinical practitioners who will be charged with making it. There is particular concern about the inclusion and possible exclusion criteria, which may mean that few individuals actually meet diagnostic criteria. This is complicated by clear overlaps with the diagnostic criteria for language disorder and ASD, making differential diagnosis particularly challenging. There is also legitimate concern that children receiving this diagnosis would not receive the clinical or educational services that they may require. It has been documented that federal funding for research into ASD far outstrips that for language disorder (Bishop, 2010) and that children with ASD receive far more intensive and consistent educational support for language than peers with language disorder, even when the latter group have more severe language impairments (Dockrell, Ricketts, Palikara, Charman, & Lindsay, 2012).

In this review, I will outline proposed criteria for SPCD and consider the evidence that SPCD is a valid diagnostic construct. Most of the research I will review previously identified nonautistic children with social communication deficits as having PLI, although children with structural language impairments were not always excluded from these studies. For consistency, I will use the term SPCD to refer to the children included in past studies. However, I will argue that social communication and pragmatic language skills are not necessarily one and the same, with the latter closely associated with structural aspects of language. I will argue that to assess and treat SPCD, it is vital to understand the continuities between SPCD and both ASD and language disorder, as well as consider the high rates of comorbidity between SPCD and other developmental disorders. Finally, I will argue that as with most neurodevelopmental disorders, SPCD is best conceptualized along a set of symptom dimensions, rather than as a discrete categorical entity, although there is an urgent need to empirically establish the symptom profile that is associated with social pragmatic deficits in the absence of autism. ESPECIALLY SINCE IT’S A “DONE DEAL” IN THE DSM-5

DSM-5 criteria for social (pragmatic) communication disorder (SPCD)

One reason for the inclusion of SPCD within DSM-5 and PLI in ICD-11 is the well-publicized changes to criteria for autism and related conditions, and the potential impact of these changes on provision for individuals who no longer meet criteria for ASD (Aha! The real reason for “invention” of this disorder and inclusion in the DSM-5 is political; now we have to put lipstick on this pig.) (Huerta, Bishop, Duncan, Hus, & Lord, 2012; McPartland, Reichow, & Volkmar, 2012). Whereas previous diagnostic frameworks specified a triad of impairments, the new systems will focus on two symptom dimensions: social communication deficits and restricted and repetitive interests and behaviours (isn’t the latter “repetitive” stuff supposedly a symptom of  ASD? (see Lord & Jones, 2012 for discussion). There have been discrepant estimates of how many individuals with existing diagnoses would still warrant a diagnosis of ASD under the new classification. For example, McPartland et al. (2012) reported that only 60.6% of participants with a current diagnosis would meet new criteria for ASD, whereas Huerta et al. (2012) reported that 91% of their sample would retain their current diagnosis (although specificity in this sample was remarkably low at .53). (Holy Crap! Could the DSM be any LESS medically or scientifically legitimate?)

A shameless conspiracy of “symptoms” selected and organized to match invented disorders! It’s as if these “experts” are fighting over the seating chart at a political dinner!  

Neither study was able to establish how many individuals would meet criteria for SPCD as the operational criteria for the new disorder are currently rather limited. However, Huerta et al. (2012) reported that only 1.5% of their participant pool met social communication criteria for ASD, but did not meet threshold criteria for RRIBs.

Such studies give rise to the concern that SPCD will be treated as a residual category for ‘not-quite’ ASD, rather like the previous PDD-NOS category (Skuse, 2012). A definition by exclusion could be particularly problematic as SPCD will come under the umbrella of Communication Disorders, a set of disorders that are typically the remit of speech-language pathologists. In this arena (in case you doubt that these are turf wars) restricted and repetitive interests and behaviours are not routinely assessed and definitively ruling out ASD may prove challenging.

Table 1 outlines inclusion criteria for SPCD (American Psychiatric Association, 2013b): Previous draft criteria acknowledged that SPCD could co-occur with disorders other than ASD, such as language disorder or intellectual disorder, but stipulated that social communication deficits could not be explained by deficits in vocabulary, grammar or general cognitive ability. Notably, current draft criteria for PLI in ICD-11 stipulate exclusion of both ASD and receptive/expressive language disorders. (Aye, yai, yai!) 

Table 1. Social (pragmatic) communication disorder (American Psychiatric Association, 2013b)
1.Persistent difficulties in the social use of verbal and nonverbal communication in four key areas, all of which must be present for diagnosis:

using communication for social purposes such as greeting or exchanging information;

changing communication to match context or the needs of the listener;

following rules for conversation or storytelling, such as taking turns in conversation;

understanding what is not explicitly stated and nonliteral or ambiguous meanings of language.

Wow! This is REAL pathology: the obsessive need on the part of social fascists (psychologists) to prescribe and script ALL human communication, from birth, until death! 

2. Symptoms must be present in childhood and result in limitations to functional communication, social participation and relationships, academic achievement and occupational performance.

3. Rule out Autism Spectrum Disorder (i.e., does not meet threshold for repetitive behaviours or restricted interests)

The following text / charts are examples of utterly irrational NEUROTYPICAL NUTTINESS: The “magic word” illusion that plagues NTs detaches their “thinking” from reality.

What do ‘diagnostic’ WARS have to do with real specific children? NOTHING. We’re talking about trivial social interactions (Have a Nice Day!) that are cultural defined and pertain to shallow repetitive NONCOMMUNICATION.   

Skuse (2012) raised a number of pertinent concerns about the SPCD diagnosis. First and foremost is how these diagnostic criteria will be operationalized and defined in such a way that they do not amount to ASD equivalent social and pragmatic deficits in the absence of restricted and repetitive interests and behaviours (RRIBs). Here, it may be helpful to consider whether SPCD is underpinned by the same cognitive constraints in different diagnostic groups. In ASD, there is an overriding assumption that SPCD is a consequence of core deficits in social cognitive processes such as theory of mind, while in other developmental populations, SPCD may occur in the absence of social cognitive deficit. Whether differences in the cognitive origins of SPCD yield qualitatively different communication profiles is an open question. A second concern is whether there is any evidence that children with SPCD form a coherent and etiologically distinct group, requiring a different course of intervention or educational support. A related issue is the developmental course and diagnostic stability of SPCD; at what point can a diagnosis be made reliably and how does the phenotype change over time? Finally, Skuse (2012) queries whether the presence of RRIBs yields a qualitatively distinct social communication profile, or confers more functional impairment relative to SPCD in isolation. In a similar vein, I suggest that it would be unwise to assume that co-occurring language and intellectual impairments necessarily cause SPCD, given the intimate developmental relationships that exist between social, linguistic and cognitive achievements (Chiat & Roy, 2008). We need to know much more about how individual differences in each of these developmental pathways influence social communication development and disorder.

To begin to answer these questions, however, we need to identify the relevant children. Below, I outline best practices for assessment of social communication and pragmatic language abilities and highlight some of the difficulties in measuring these skills. I will then consider differential diagnosis of SPCD from ASD and Language Disorder, as well as the presence of SPCD in other neurodevelopmental disorders.

Assessment and diagnosis of social communication and pragmatic language skills

Social communication and pragmatic language abilities are notoriously difficult to measure in standardized ways because they are a set of contextually dependent human behaviours that occur in dyadic exchanges; the structure provided by a standardized testing situation makes it difficult to capture social communication problems that may arise in everyday situations where the rules of engagement are less explicit and highly dynamic (Adams, 2002; Volden, Coolican, Garon, White, & Bryson, 2009). Social communication skills are also highly susceptible to cultural variation: discourse rules such as turn taking, interrupting, appropriate topic choices, use of eye contact and other nonverbal strategies for maintaining interaction, use of humour, and the ability to question and challenge communication partners, are largely determined by cultural rules and the child’s relationship with his or her interlocutor (Carter et al., 2005). Unlike structural aspects of language (e.g., vocabulary or grammar), there are also far fewer normative data for such behaviours (Norbury & Sparks, 2013).

Adams (2002) provided a summary of developmental social communication and pragmatic attainments and a detailed examination of popular methods for assessing these skills. A brief overview is provided below and in Table 2, focusing on methods of assessing conversational skill, narrative ability and the understanding/use of ambiguity (i.e. inferencing, multiple meanings and figurative language). Measures are organized according to the method of assessment, including checklist or rating scale, structured observation and formal assessments with pragmatic content.

Table 2. Methods of assessing social communication and pragmatic language abilities
Name of test Authors Age Aspects of social communication covered Pros/Cons
Checklists and rating scales
 Children’s Communication Checklist-2 Bishop (2003a, 2003b) 4–16 years Syntax, Speech, Inappropriate initiation, Coherence, Stereotyped conversation, Use of context, Rapport, Social interaction, RRIB Does not provide diagnosis, but can inform further assessment decisions
 Targeted Observation of Pragmatics in Children’s Conversations (TOPICC) Adams et al. (2011) 6–11 years Reciprocity, turn-taking, taking account of listener knowledge, verbosity, topic management, discourse style, response problems Quick index of conversational skill, but currently lacks adequate interrater and test–retest reliability
 Analysis of Language Impaired Children’s Conversation (ALICC) Bishop and Adams (1989) 4-adult Discourse participation; conversational dominance; assertiveness; verbosity; responsiveness; meshing (e.g., appropriate responses) Detailed profile of conversation that can distinguish SPCD from language disorder; time consuming
Structured observations
 Communication and Symbolic Behavior Scales Wetherby and Prizant (1993) 6–24 months Communicative, social, affective and symbolic abilities (including play) Most appropriate for young children; overview of nonverbal communication
 Early Social Communication Scales Mundy et al. (2003) 8–30 months Initiating and responding to joint attention; behavioural requests; social interaction behaviours Most appropriate for young children; overview of nonverbal communication
 Autism Diagnostic Observation Schedule (ADOS) Modules 1–4 Lord et al. (2001) 18 months – adulthood Play, Response to Name, Response to Joint Attention, nonverbal communication (gesture and facial expression), Functional and Symbolic Imitation, personal narrative, conversation, emotions, social relationships Later modules include ratings of conversation (4-part exchange) and aspects of social communication; does not specifically probe pragmatic language
 Yale Pragmatic Protocol Schoen and Paul (2009) 9–17 years Pragmatic probes within five conversational domains (discourse management, communicative function, conversational repair, presupposition, register variation) Structure probes of social communication in seminaturalistic setting; little evidence that it distinguishes SPCD from other language disorder
Formal assessments with pragmatic content
 Assessment of Comprehension and Expression (ACE 6-11) Adams et al. (2001) 6–11 years Sentence comprehension, Inferential comprehension, Naming, Syntactic Formulation and Semantic Decisions, nonliteral language, narrative retelling Combines structural language and pragmatic language tasks. Narrative is especially appropriate for school-aged children
 Test of Language Competence Wiig and Secord (1989) 5–18 years Ambiguous Sentences, Listening Comprehension, Making Inferences, Recreating Speech Acts Figurative Language Formal test which may not reflect abilities in everyday contexts
 Test of Pragmatic Language Phelps-Terasaki and Phelps-Gunn (2007) 8–18 years Physical setting, audience, topic, purpose (speech acts), visual-gestural cues, and abstraction Covers wide range of social communication behaviours
 Bus story Renfrew (1995) 3–8 years Narrative recall Good prognostic measure of persistent language deficits
 Expression, Reception and Recall of Narrative Instrument (ERRNI) Bishop (2003a, 2003b) 6-adult Narrative comprehension and recall Stories include a ‘theory of mind’ element
 Strong Narrative Assessment Procedure Strong (1998) 7–12 years Narrative generation and comprehension Unusual in that it does not involve a retelling and so may be more sensitive to social pragmatic deficits

Parent teacher report of children’s communication

Given the inherent difficulties of extrapolating pragmatic performance in clinical settings to everyday communicative competencies (Volden et al., 2009), standardized checklists of pragmatic and social communication behaviours have become a popular method of assessment. The Children’s Communication Checklist (CCC, Bishop, 1998; CCC-2, Bishop, 2003a, 2003b) is perhaps the most widely used checklist in clinical practice and research. The CCC-2 is a 70-item checklist comprised of 10 scales; eight scales tap structural and pragmatic language and two scales measure the social impairments and restricted interests more typical of ASD. Normative data are available on over 500 UK children and over 900 US children aged 4 to 17 years and it has been translated into more than 30 different languages. Respondents are asked to rate the frequency of communication behaviours on a four-point scale. In the original CCC, a pragmatic composite was derived by summing the scores of scales that tapped pragmatic language competence. These included inappropriate initiation, coherence, stereotyped language, use of context and conversational rapport. However, in the validation sample, this composite score had poor levels of interrater reliability and was not successful at discriminating children identified as having PLI from children with diagnoses of more specific language impairment (Norbury et al., 2004). One reason is that children with SLI obtained low scores on the pragmatic composite, highlighting an association between structural language and pragmatic language skill that has been consistently replicated (cf. Ketelaars, Cuperus, van Daal, Jansonius, & Verhoeven, 2009; Volden et al., 2009).

To address this issue, Bishop (2003a, 2003b) devised the Social Interaction Deviance Composite (SIDC), which identifies pragmatic abilities that are disproportionately impaired relative to structural language competencies. Thus, a positive score indicates relatively mild pragmatic difficulties in conjunction with more severe deficits in structural language. Scores around zero are indicative of a child with equally severe pragmatic and structural language deficits (i.e., a significant proportion of children with ASD) and negative scores would be more consistent with a profile in which scores on structural language tests were within normal limits, but the child experienced pronounced social communication deficits. An important caveat is that amongst a large cohort of children with communication disorders, scores on the SIDC were continuously distributed, with no clear categorical boundaries between specific language impairment, SPCD or ASD (Norbury et al., 2004). Therefore, the CCC-2 should be used to signpost aspects of communication for further assessment, rather than providing a clear diagnosis itself.

In addition to parent or teacher report measures, clinicians may wish to rate aspects of a child’s communicative behaviour more directly. Three main criteria for SPCD centre on the individual’s conversational skills, specifically initiation and response to conversational bids, adapting conversation to listener needs and environmental expectations and following conversational rules, such as turn taking. Quantitative approaches to analysing conversation in detail have been developed with acceptable levels of interrater reliability (Bishop & Adams, 1989). Conversational analysis may also provide an ecologically valid tool with which to demonstrate improvements in pragmatic and social communication competence following intervention (Adams, Lloyd, Aldred, & Baxendale, 2006). Despite these advantages, it remains a time-consuming assessment method, which may limit its clinical and research utility. Measures such as the Targeted Observation of Pragmatics in Children’s Conversation observation scale (Adams, Gaile, Freed, & Lockton, 2010) shows promise as a method of rating the quality of conversational exchanges, and is sensitive to developmental change (Adams et al., 2012). However, there is little research at present regarding its diagnostic sensitivity and specificity.

Structured observation

An advantage of structured observations is that the examiner can create naturalistic contexts specifically designed to elicit social communication behaviours, thus judging whether or not they occur and whether there are qualitative differences in the child’s communicative behaviours. ‘Conversational’ behaviours can also be assessed prior to the advent of spoken language. Three measures, the Early Social Communication Scales (Mundy et al., 2003), the Communication and Symbolic Behavior Scales (Wetherby & Prizant, 1993) and the Autism Diagnostic Observation Schedule (ADOS)-Toddler Module (Luyster et al., 2009) assess how infants and toddlers initiate and respond to interactions with adults. This may include observation of whether the child uses eye gaze, gesture or vocalizations to gain the adult’s attention, direct attention or respond to a direct request. Such measures usually include ‘presses’, which attempt to elicit specific communicative acts. For example, the child might be shown a very tempting wind-up toy. After demonstrating what the toy can do, the examiner will hold back and wait to see whether and how the child obtains help from an adult to make the toy move again. For older children and adolescents, measures such as the ADOS and ADOS-2 (Lord, Rutter, DiLavore, & Risi, 2001) and the Yale in vivo Pragmatics Protocol (Schoen & Paul, 2009) include more sophisticated ‘presses’ including observation of how the child greets an unfamiliar adult, whether the child spontaneously offers information about his/her own experiences and how the child integrates verbal and nonverbal (e.g., eye gaze, gesture) communication behaviours.

A rather blunt measure of conversational skill is also included in the ADOS (Lord et al., 2001). Here, the examiner attempts to engage the individual in a conversational exchange, providing ‘hooks’ to which the child is expected to comment or question the examiner further. The conversation is scored on a 4-point scale, with a score of 3 indicating total absence of conversation, and a score of 0 representing a conversation that has at least four coherent turns (e.g., examiner comments, child questions, examiner responds and child comments). Separate codes tap quality of initiations or response, use of facial expression and gesture, and the integration of verbal and nonverbal information for communicative purposes.

One strength of structured observations such as the ADOS is that they provide a consistent context in which to observe qualitatively different or unusual communication behaviours. A limitation of these assessments is that there are few normative data available on which to make judgements of conversational adequacy. Modules 3 and 4 of the ADOS cover a wide age range from 4 years to adulthood. While typically developing four-year olds are capable of sophisticated conversational exchanges, we might expect qualitative differences between conversational skills of children and adults. In addition, the degree to which children feel able to comment or question unfamiliar adults is culturally dependent (cf. Norbury & Sparks, 2013).

Formal assessments with pragmatic content

Narrative analysis constitutes an important tool for revealing pragmatic deficits, as it taps the integration of linguistic, cognitive and social pragmatic abilities. Narrative measures allow assessment of the child’s ability to convey a coherent sequence of events, provide the right amount of key information to the listener and use cohesive devices consistently. In addition, unusual or bizarre comments thought to be indicative of ASD may be revealed, although interrater reliability of ‘bizarre’ comments can be disappointingly low (Norbury & Bishop, 2003) and are present in only a minority of ASD narratives (Norbury, Gemmell, & Paul, 2013). Several standardized assessments of narrative exist, including the Bus Story (Renfrew, 1995), the Expression, Reception and Recall of Narrative Instrument (Bishop, 2003a,2003b) and the Strong Narrative Assessment Procedure (Strong, 1998). Less formal assessment measures include telling a story from a picture book (Norbury & Bishop, 2003) or generating narrative in response to a story stem (Demir, Levine, & Goldin-Meadow, 2010).

Narrative is an important part of clinical assessment not least because it is a foundational skill for academic achievement (Boudreau, 2008). However, narrative skills are vulnerable across a range of developmental disorders and direct comparisons of different clinical populations have yielded few quantitative or qualitative differences in narrative performance (Norbury & Bishop, 2003; Norbury et al., 2013; Finestack, Palmer, & Abbeduto, 2012). Furthermore, measures of structural language ability are typically the strongest predictors of narrative competence within clinical populations (Kay-Raining Bird, Cleave, White, Pike, & Helmkay, 2008).

More direct assessment of pragmatic language ability may also include measures of inferencing, understanding of humour or figurative expressions such as metaphor, idiom or irony, and referential communication, including the child’s ability to request clarification or identify messages that are ambiguous or underinformative. Standardized measures, such as the Test of Language Competence (Wiig & Secord, 1989) or the Test of Pragmatic Language-2nd Edition (Phelps-Terasaki & Phelps-Gunn, 2007) have distinguished groups of children with known pragmatic deficits from comparison groups (Young, Diehl, Morris, Hyman, & Bennetto, 2005). However, Adams (2002) argues that such formal testing measures are unlikely to reveal an accurate or comprehensive picture of the child’s pragmatic competence in more dynamic, context dependent communicative exchanges.

Social communication and pragmatic language: same or different?

Social (Pragmatic) Communication Disorder criteria stipulate that impairments should be evident in all four of the aspects of communication specified: using communication for social exchange, adapting communication style to the context, following rules of conversation or narrative convention and understanding implicit or ambiguous language. It would appear that this requirement presumes that social communication and pragmatic language skills are manifestations of the same underlying cognitive process(es). Indeed, these skills are closely associated; a recent population study demonstrated that pragmatic language skills were highly predictive of social competence, even after expressive language abilities had been taken into account (Ketelaars, Cuperus, Jansonius, & Verhoeven, 2010). However, there is mounting evidence that even within the autism spectrum, social communication deficits and pragmatic language impairments may be dissociated, and can arise from different underlying constraints.

Traditionally, social pragmatic impairments in ASD have been attributed to the absence or attenuation of the social instinct (Wing, Gould, & Gillberg, 2011) and a fundamental impairment in ‘theory of mind’ (Baron-Cohen, Leslie, & Frith, 1985). A lack of social motivation can readily explain conversational impairments such as a lack of initiation or minimal contingent responses. Reduced experience with social interaction may alter the course of pragmatic development, in that it limits exposure to nonverbal communicative gestures (facial expression, gesture) and the flexible nature of language use. Social cognitive deficits are hypothesized to lead to reduced ability to represent a listener’s state of mind; this could contribute the recognized limitations in providing the appropriate amount of information to minimize ambiguities in conversation (Capps, Kehres, & Sigman, 1998; Tager-Flusberg & Anderson, 1991) or conveying sufficient information of interest to the listener in conversation and narrative tasks (Capps, Losh, & Thurber, 2000). Difficulties understanding speaker intentions have also been attributed to reported deficits in understanding figurative language such as metaphor and irony (Happé, 1993; Martin & McDonald, 2004), and deficits in referential communication (Nadig, Vivanti, & Ozonoff, 2009).

However, it is important to realize that there is usually considerable variation within ASD groups on these tasks and that social communication abilities have been linked not only to mentalizing, but are often associated with structural language abilities (see Gernsbacher & Pripas-Kapit, 2012 for discussion in relation to figurative language). For instance, Norbury (2005) investigated metaphor comprehension in children with ASD and compared those with additional language impairments (ALI) with those who scored within normal limits on assessments of structural language competence (ALN). Notably, these groups did not differ with respect to social communication deficit, as measured by the Social Communication Questionnaire (Rutter, Bailey & Lord, 2003), nor do they typically differ on ADOS or Vineland Adaptive Behavior Scales social indices (cf. Norbury et al., 2009). Children with ALN did not differ from typically developing peers on the metaphor task, whereas those with ALI had significantly lower scores. Moreover, scores on measures of structural language predicted unique variance in metaphor understanding, whereas scores on Theory of Mind tasks did not.

Furthermore, studies employing experimental measures of inferencing ability and ambiguity resolution have found few differences between individuals with ASD and typically developing peers, providing the individuals with ASD had age-appropriate structural language abilities (Brock, Norbury, Einav, & Nation, 2008; Norbury, 2005; Pijnacker, Hagoort, Buitelaar, Teunisse, & Geurts, 2009). Structural language abilities reliably predict performance on these tasks, even within ASD populations (Volden et al., 2009). Thus, it would seem that social communication deficits may be evident in children who are indistinguishable from TD peers on measures of pragmatic language functioning.

Social communication undoubtedly draws on a number of skills, of which social cognition (as measured by theory of mind tasks) is just one. And it is possible that a stronger relationship would be found between social communication and pragmatic language abilities if different tasks were employed to measure pragmatic language skill. Nevertheless, the studies cited above suggest that to require both social and pragmatic deficits to be present may preclude diagnosis in young people with average or above average structural language skills. Conversely, those most likely to demonstrate impairments in both are very likely to have additional impairments in word knowledge and grammar, which may also preclude diagnosis.

Differential diagnosis of SPCD

Is SPCD a milder form of ASD?Crucially, DSM-5 and ICD-11 will require that children with SPCD do not exhibit clinically significant RRIBs. There has been some disagreement in the literature regarding the extent to which children identified as having primary SPCD show evidence of RRIBs. Reisinger, Cornish, and Fombonne (2011) explicitly compared children with ASD and children with SPCD on the ADOS and the SCQ. They found that the groups could be distinguished by the severity of social and communication deficits, but did not differ significantly on measures of RRIB. In contrast, Bishop and Norbury (2002) used similar methods and reported that children with SPCD as a group were less likely to display RRIBs. However, the majority of children with SPCD were rated as having speech abnormalities associated with autism and used stereotyped language. In addition, a significant minority were reported to have unusual sensory interests. Changes to DSM-5 criteria for ASD include the reclassification of stereotyped language as an RRIB, rather than a communication symptom, and include sensory interests. Thus, many of the children studied by Bishop and Norbury (2002) may meet new DSM-5 criteria for ASD.

These studies used the ADOS and the SCQ to quantify RRIB; the reliability of these algorithms is low (Lord et al., 2000) and the scales are perhaps not detailed enough to identify differences between diagnostic groups. A recent study by Gibson, Adams, Lockton, and Green (2013) utilized the Repetitive Behaviour Questionnaire-2 (Leekam et al., 2007) and reported that children with SPCD could be distinguished from peers with ASD on this measure. However, the children included in this study were young, aged between 6 and 11 years. A complication for differential diagnosis is that symptom profiles may change significantly with age (Bishop & Norbury, 2002; Howlin, Mawhood, & Rutter, 2000), with an increase in specialist interests and rigid behaviour becoming more evident over developmental time. Thus, a group difference in the early school years may be less apparent in adolescence. A further complication is that few studies have measured RRIBs in children with SPCD in relation to typically developing peers. It is likely that even if children with SPCD do not exhibit enough RRIBs to meet threshold for ASD, they have elevated levels of RRIB relative to peers. In short, it may not be possible to distinguish ASD and SPCD on the basis of behavioural profiles alone (Reisinger et al., 2011).

Is SPCD a form of Language Disorder?

DSM-5 criteria for Language Disorder stipulate that children will have impairments in any one of three areas: word knowledge, grammar and discourse. Discourse includes narrative and conversational exchange, thus overlapping with SPCD. Children with more ‘specific’ forms of Language Disorder have variable social interaction and social communication difficulties relative to TD peers. These may include difficulties establishing social relationships (Whitehouse, Watt, Line, & Bishop, 2009); poorer quality friendships (Durkin & Conti-Ramsden, 2007); difficulties with peer negotiation and conflict (Brinton, Fujiki, & McKee, 1998; Horowitz, Jansson, Ljungberg, & Hedenbro, 2006) and poorer social cognition (Marton, Abramoff, & Rosenzweig, 2005). In general, it is argued that these social deficits are secondary to the language impairment and strong associations between language test performance and measures of social deficit support this view (Gibson et al., 2013). However, measures do not always correlate, and there is some suggestion that social deficits might be concomitant with language impairment (Marton et al., 2005). It is also typically the case that on measures of social competence, there is a pattern of increasing severity in which children diagnosed with ASD demonstrate the most severe social impairments, children with language disorder the mildest deficits and children with SPCD falling between the two (cf. Gibson et al., 2013). Often performance is continuously distributed with little clear indication of where diagnostic boundaries lie.

Difficulties with pragmatic aspects of language are more consistently vulnerable in children with language disorders. For instance, compared with age-matched peers, children with ‘specific’ language impairment have deficits in narrative (Norbury et al., 2013), inferencing (Katsos, Roqueta, Estevan, & Cummins, 2011), figurative language comprehension (Norbury, 2005) and the use of language context to resolve ambiguities (Brock et al., 2008). Furthermore, distinguishing children with language disorders from those with SPCD on these sorts of pragmatic tasks has met with little success, typically because of the poor performance of children with language impairment. At a group level, differences have been reported in the severity of expressive language disorder (with SPCD experiencing less severe impairments) and in the severity of peer social difficulty (Gibson et al., 2013). However, this is not always the case and the distinction between the two remains one of degree (Norbury et al., 2004).

The clearest evidence for a distinction between language disorder and SPCD comes from detailed analyses of conversational adequacy (Adams & Bishop, 1989; Bishop & Adams, 1989; Bishop, Chan, Adams, Hartley, & Weir, 2000). In these studies, children with SPCD were more likely than language-impaired peers to violate turn-taking expectations, provide no response or pragmatically inappropriate responses to conversational overtures, and made little use of nonverbal communicative devices. Such studies emphasize the importance of measuring social communication in naturalistic conversational exchanges (Adams & Lloyd, 2005). However, the strength of group difference rests with the diagnostic profiles of the children with SPCD. Clearly, DSM-5 criteria were not employed in these studies and it is possible that the more severely impaired children may have met DSM-5 criteria for ASD (Bishop, Whitehouse, Watt, & Line, 2008). Given that the new diagnostic criteria focus so heavily on dyadic conversational exchanges, developing an appropriate analysis measure and honing in on aspects of conversation that yield stable, qualitative differences is an important priority for future research.

SPCD is a feature of other neurodevelopmental disorders

A number of studies have highlighted social and pragmatic deficits in diverse clinical populations, including ADHD (Bishop & Baird, 2001; Cohen et al., 1998; Geurts et al., 2004; Leonard, Milich, & Lorch, 2011); William’s syndrome (John, Rowe, & Mervis, 2009; Laws & Bishop, 2004; Philofsky, Fidler, & Hepburn, 2007), conduct disorder (Donno, Parker, Gilmour, & Skuse, 2010; Gilmour et al., 2004; Oliver, Barker, Mandy, Skuse, & Maughan, 2011), closed head injury (Dennis & Barnes, 2001) and spina bifida/hydrocephalus (Holck, Nettelbladt, & Sandberg, 2009). Where comparisons have been made between ASD and other clinical populations, children with ASD (meeting criteria in both social communication and RRIB domains) have demonstrably more severe social communication and pragmatic language deficits than other clinical groups (ADHD, Geurts et al., 2004; Williams syndrome, Philofsky et al., 2007).

There is intense research and clinical interest in using the CCC/CCC-2 to identify qualitatively different social communicative profiles that align with specific clinical diagnoses, with varying success. For example, Bishop and Baird (2001) reported that the CCC identified pragmatic deficits in children with pervasive developmental disorders, primary pragmatic language impairments and children with ADHD, but that there were no significant differences amongst the clinical groups in pragmatic profile. On the other hand, Geurts et al. (2004) reported that children with ADHD had more severe deficits on items tapping initiation relative to peers with ASD, while those with ASD had more impaired scores on scales tapping structural language and RRIB. Philofsky et al. (2007) reported that children with William’s syndrome had significantly better scores on CCC scales tapping coherence, stereotyped language, nonverbal communication and social relations relative to peers with ASD. However, it is important to bear in mind that most of the differences between clinical groups are a matter of degree and are reported at a group level. There remains much work to be carried out on the sensitivity and specificity of particular pragmatic profiles for differential diagnosis. In addition, clinical groups often differ with regard to structural language, social understanding, cognitive ability and the presence of other developmental concerns such as attention deficits, executive dysfunction and behavioural difficulties, all of which are strongly associated with social and pragmatic deficits (Ketelaars et al., 2009; Mackie & Law, 2010). Individual differences in social communication and pragmatic language are therefore likely to reflect a confluence of risk factors in each of these developmental areas. How these factors interact over time to affect social interaction and contextual processing is an empirical question. It is therefore unlikely that there is a syndrome-specific social pragmatic profile. Instead, there will be individual variation associated with the particular constellation of risk factors that the child experiences. One may hypothesize that ASD represents the extreme end of the distribution in which multiple risk factors are present, creating the least favourable conditions for pragmatic language and social communication to develop.

Clinical and educational implications: treatment

One advantage of creating a new diagnostic category is that it should indicate a specific course of treatment or educational support. If we identify SPCD as a clinical disorder, treatment is likely to be aimed at improving social communication outcomes, to foster improvements in social relationships and to prevent negative consequences such as disruptive behaviour and social withdrawal. There is a paucity of good quality intervention research, in part hampered by inconsistencies in diagnostic labels, lack of agreement concerning diagnostic criteria and valid instruments for measuring change (Gerber, Brice, Capone, Fujiki, & Timler, 2012). Adams et al. (2012) reported the first randomized controlled trial of a social communication intervention aimed specifically at children with SPCD. The Social Communication Intervention Project (http://www.psych-sci.manchester.ac.uk/scip/) is an individualized intervention approach that targets development in three areas: social understanding and social interaction; verbal and nonverbal pragmatic skills, including conversation; and language processing, including narrative, inferencing, and developing word knowledge. In the trial, 88 children with SPCD were randomly assigned to the intervention or treatment as usual. After 20 sessions of intensive intervention by a highly specialist speech-language therapist, significant treatment effects were reported for ratings of conversational competence (blind ratings), parent ratings of pragmatic skill and social communication (not blind) and teacher ratings of classroom learning (not blind). No significant treatment effects were seen for the primary outcome measure (the Clinical Evaluation of Language Fundamentals -4UK, Semel, Wiig, & Secord, 2003) or a test of narrative expression.

The study is very promising in demonstrating that observable differences in social communication behaviour can be achieved after a period of intensive intervention. However, there are clearly many challenges to overcome. Study participants were extremely heterogeneous, varying from the 3rd to the 95th percentile on all measures of structural language, nonverbal reasoning, and ASD symptomatology. Such extreme within-group differences make it difficult to discern treatment effects. In addition, the outcome measure bore little relationship with the treatment content or treatment aims. Treatment most commonly aims to optimize language and communicative function rather than ‘cure’ disorder. In that regard, it is unlikely that diagnostic instruments themselves are sensitive enough to show change. However, the need for standardized assessment of social communicative function is great and a top priority for future research. Given the complexities of social communication and pragmatic language, it is also perhaps unrealistic to think that we can expect significant change in a relatively brief period of intervention. It is likely that these children will require on-going support as they get older and the complexity of social communication and language context increases in the expectation for more intimate social relationships, and for using language for learning and employment.

Summary and future directions

At present, there is too little research evidence to fully support a new diagnostic category, or to help identify aspects of social communication that distinguish SPCD from other developmental conditions. Social communication disorders and pragmatic language impairments constitute a broad range of phenomena that are likely to be continuous in nature and influenced by a number of developmental achievements. Social communication and pragmatic language skills are not necessarily one and the same; if pragmatics is taken to be the understanding and use of language in context, many children will succeed at pragmatic language tasks such as inferencing and ambiguity resolution and yet be challenged by the nuances of successful social communication.

To establish the validity of SPCD as a diagnostic entity, clinical research must (1) describe a coherent clinical phenomenon; (2) develop culturally and ecologically valid assessment tools with adequate levels of interrater and test–retest reliability to improve consistency of diagnosis; (3) explicitly compare pragmatic profiles across different neurodevelopmental disorders; (4) chart the developmental trajectories of children with SPCD and monitor the stability of diagnosis over time; and (5) conduct family studies to begin to unravel the aetiology of this disorder and its relation with other neurodevelopmental conditions (cf. Robins & Guze, 1970). In addition, intervention studies are urgently needed as they will offer a means to test theories regarding the putative causes and consequences of social (pragmatic) communication disorders.

Clinical implications

Differential diagnosis of SPCD will be challenging, but the focus on social communication and pragmatic language abilities should be welcomed. Many children presenting for psychological or psychiatric assessment will have some degree of pragmatic language or social communication deficit (Cohen, Farnia, & Im-Bolter, 2013; Cohen et al., 1998) that will require specialist treatment and support. It would therefore seem prudent to obtain parental report of communication skills in everyday contexts, for example using the CCC-2 (Bishop, 2003a, 2003b). Such a measure can inform hypotheses and assessment plans; where there is evidence of a significant social pragmatic deficit, evaluation for ASD will also be essential. On the CCC-2, an index score of zero indicates that both structural and pragmatic language impairments may be evident; thus, an evaluation by a speech-language therapist for language disorder will be necessary. Although standardized measures for exploring pragmatic aspects of language exist, these may not reflect the individual’s ability to apply these skills in less formal settings. Observations of naturalistic interaction, in school or at home, may be most informative. Finally, intervention is likely to be multifaceted, incorporating techniques for improving social understanding and social interaction, structural aspects of language (e.g., vocabulary) and using linguistic context to improve comprehension. Thus, intervention should be centred on the profile of strength and need that emerges from the assessment process, rather than the diagnostic label obtained.


The open access fee for this article has been funded by the Economic and Social Research Council (ESRC). This review article was invited by the Editors of JCPP, for which the author has been offered a small honorarium towards personal expenses. The author has declared that she has no competing or potential conflicts of interest.

Autism researchers admit their reseach is CRAP / Yes, indeed it is.

Unthinking social obedience is not moral behavior.

Full article: http://www.nature.com/articles/srep04314

The relationship between moral judgment and cooperation in children with high-functioning autism

Jing Li, , Liqi Zhu, & Michaela Gummerum

For the rest of the blah, blah, blah see original. I’m posting this as an example of how ASD researchers are NOT SCIENTIFIC in their mental constructs; indeed they are socially biased in their assumptions. And ridiculously “childish” in their “belief” that subjecting a handful of supposedly Typically Developing Children (PC for normal) and a handful of supposedly High Functioning Autistic children (a label which appears to be interchangeable with an Asperger diagnosis – sloppy!) to “nice and naughty” stories and quizzes, pre-loaded with “socially prescribed” answers as to what is “correct” morally. They insist that morality is a question of socially-prescribed “naughty or nice” rules. 

As for the TD children, were they tested against a set of “normal” diagnostic symptoms? Were their brains scanned; were they the object of opinion surveys by parents, teachers, and strangers; tested for IQ across multiple intelligences, videotaped – and their every word, body motion or “magically evident thought processes” ridiculed? Of course not.


This study had two main aims: First, to examine whether HFA children could make correct moral judgments, similar to TD children (TD children are held to be exemplars of moral decision-making, intuition and action? REALLY? Their “moral choices” are CORRECT merely because they conform to the “naughty or nice” social response standards of the researchers); and second, whether an interaction partner’s morality affected cooperation in HFA and TD children. (Again, a conformist idea that “naughty people” ought to be exiled from interaction with “nice people”, permanently, for one or two contrived (fictional) behaviors. Remember these “tests” carefully simplified and dumbed-down moral tales that reflect Western religious prejudice.

None of that “Eastern” compassion stuff is allowed! 

Concerning the first aim, both HFA children and TD children could make moral judgment correctly in this study, consistent with Leslie, et al.13. Thus, following these authors and others(e.g., Grant, et al.19), HFA children seemed to have little difficulty in evaluating certain acts (such as hitting and sharing) in terms of their morality. On the contrary, HFA children judged harming others as significantly worse than TD children. This indicates that HFA children might have more rigid criteria for what constitutes morally naughty actions. (Could we please drop the naughty-nice stuff and use adult language?) This might be because HFA children are more rule-oriented when it comes to certain behavior because of their disorder. For example, stereotypy, compulsive behavior, sameness, ritualistic behavior, repetitive or restricted behavior have been associated as part of the diagnosis of autism27. Thus, HFA children might also be more rule-oriented when it comes to moral actions. (Wow! Talk about improper inference from a list of “symptoms, traits, behaviors” that are all assumed to apply to all Asperger individuals – “guilt by label of Autism”. Outrageous…) Similarly, Baron-Cohen28 argued that although autistic individuals are typically self-focused, they are highly moral people, have a strong sense of justice, and think deeply about how to be good. Well, gee whiz! Thanks B-C. That’s certainly a positive (indictment) of Asperger people. (Just wait – these admirable qualities are about to be turned into ‘defects”)

Naughty us for having strong moral principles in a society that promotes violence, bullying, lying, cheating and inequality; the good ol’ USA is undeniably lacking such “old-fashioned” Asperger notions of basic morality, Thank God! 

While HFA children can correctly judge the morality of nice and naughty acts, being partnered with persons of different morality did not change their level of cooperation. Furthermore, HFA children’s cooperation was not different when they played with a random stranger, compared with when they played with the nice child or with the naughty child. On the other hand, TD children cooperated more when they played with the nice child than that when they played with the naughty child or the random stranger. These latter findings are in line with previous research22,23 which shows that, beginning in the preschool years, TD children take into account their interaction partners’ previous moral behavior when deciding whether to act prosocially. (Yes, TD automatic social discrimination IS CORRECT behavior.)

HFA children essentially focus on their own self, and have lower empathic abilities than normally developing children3. (Here we go! Social indictment of an inherent Asperger egalitarian view of human worth! None of that “compassion-equality” stuff is allowed in the good ol’ USA.) While some HFA children show empathy with others and overcome their self-focus, this takes great cognitive effort28. Being less interested in others and the world outside their own might lead to HFA paying little attention to partner’s morality when they play in the PDG, even (when?) they had an idea about the morality of the partner. Thus, HFA children’s cooperative performance was not influenced by partner’s morality, although they could correctly judge others’ morality in basic moral judgment stories. (Does this not hint that Asperger types possess a more sophisticated and generous spirit toward the array of behavior that is human behavior? That people are NOT DEFINED by broad generalizations; by one or two “naughty choices” but by an overall PATTERN of behavior? The choice to “not cooperate or mingle with naughty people” is NEUROTYPICAL class prejudice. It is NTs who exclude “certain people” based on knee-jerk social rules; racism – explain that! Entire “categories” of human beings -minorities, women, non-Christian religious groups, “foreign” ethnicities and those of low economic status are considered by NTs to be “naughty people”…) 

What would Bhudda do? 

In addition, differences in peer experience between HFA children and TD children might also contribute to finding that TD children show different levels of cooperation with different partners while HFA children do not. HFA children have difficulties in social initiation and social-emotional understanding, but are not insensitive to social stimuli, as they were as likely to interact socially with peers29. Autistic children are in a vicious circle of social isolation. (Gee whiz; do you think social people, following rigid social rules, may have some part in creating this situation?) On the one hand, they want to interact with peers and to express the feelings of disappointment and loneliness in the absence of interaction. On the other hand, they do not know how to properly interact with peers due to their limited capacity and experience of social and emotional understanding30. Children with autism have poor experiences in interacting with peer group in daily life, which might make HFA children show similar levels of cooperation in experimental situations (such as the prisoner’s dilemma game) when they played with (a) partner of different morality. In contrast, TD children make many friends and accumulate rich experiences to get along with peers in elementary school, at which stage it is important to develop friendships31. Moreover, attention to moral principles, such as norm and promise32, becomes an important feature of friendships and peer relations33. Therefore, TD children might be more likely to take into account their partners’ characters, including their morality, compared with HFA children.

One may as well substitute all kinds of social prejudice – race, income level, ethnicity, non-Christian religion, non-conformist values, foreign birth, disability and neorodiversity for the euphemism of “morality”.

The brutal American childhood hierarchy of social rejection, exile, intimidation and violence against peers, which arises from rigid social hierarchy rules is so much better than compassionate open-mindedness.  

Furthermore, HFA children also have deficits in reciprocal peer interaction and social cognition. They perform more ritualized behavior and less social interactive behavior (such as prosocial behavior). Moreover, the social interactive behavior performed by autistic children is only to maintain similarity but not to share emotion and experience with peers29.

How dare the researchers condemn an entire group of people, whom they have defined and  segregated from the rest of humanity, out of their own prejudice, as “not human” robots without a desire to “share emotion and experience”

Here it is in one sentence: the true “message”-

Peer interactions provide opportunities to initiate and maintain prosocial behavior with individuals of similar power and status.

In these relationships children learn the principles of reciprocity and open communication34. Children develop a deep understanding about moral (SOCIAL)identity by thinking about moral events from different perspectives. Moreover, peers are able to provide warm and powerful resources, (yikes!) which is an important ingredient of prosocial behavior. Peers also give feedback by providing reward and punishment to promote and diminish moral and prosocial behavior. Peers and the experiences based on interacting with peers are important to children’s prosocial behavior, trust and intimacy, which are produced through reciprocal prosocial behavior and, are the foundation of the development of positive morals34. Peers and peer relationship are important to the development of children’s prosocial behavior35,36. HFA children’s deficiency in peer relationship might lead them to perform indiscriminate cooperation when playing with the naughty and the nice partner in the current study. 

In addition, HFA children have typically deficits in social function, based on their impairments in ToM and empathy, although they have normal IQ. Empathy is important for children’s development of moral judgment, prosocial behaviors, and social competence37. The strong relationship between moral judgment and ToM is also confirmed by neuroimaging evidence10,38,39. (Totally unproven non-scientific assumption) Furthermore, the relationship between theory of mind and cooperation has also been shown through behavioral evidence40 and neuroimaging41,42,43. Thus, HFA children’s deficits in social functioning might lead them to perform similar cooperation when they interacted with partners of different moralities in prisoner’s dilemma game, although they could judge other’s morality correctly. (OMG! Yes, there are no other possible explanations for this single “conclusion” to which these researchers  present as an “obsession” – some kind of “global truth” about “correct” human behavior. 

Some limitations of the current study should be acknowledged. Firstly, while HFA and TD children were matched on age, gender, and IQ; differences in children’s verbal ability were not controlled for. Future research should measure HFA children’s language ability before examining their social behavior.

Then why present a paper based on inadequate preparation, untested assumptions and hearsay evidence?

Secondly, although the autistic children in this study were evaluated by the expert clinician based on DSM-IV criteria and their diagnosis was confirmed by other multiple clinical evaluation (see details in Method section), their diagnosis was not confirmed by the Autism Diagnostic Observation Schedule (ADOS). Future research should use this more standardized clinical instrument to ensure a research-quality diagnosis. In addition, more sophisticated moral judgments should be used further in the future. For example, since HFA children might have particular difficulties with understanding others’ intentions moral judgments based on others’ intentions and cooperation with well- and ill-intended partners might be an interesting direction for future studies. (How garbled can this get?)

How novel: Researchers admit that their research is CRAP.

Overall, this study found that both HFA children and TD children could make correct moral judgments, and HFA children might have even more rigid criteria for what constitutes a “naughty” act than TD children. (How terrible!) HFA children’s cooperation was similar when they played with partners of different moralities, while TD children showed higher cooperation when they played with a morally nice child than that when they interacted with a naughty child. Therefore, HFA children’s cooperation was not influenced by partner’s morality, while TD children’s cooperation might be prompted by partner’s nice morality. This study thus gives an important insight into high-functioning autistic children’s moral judgment and moral behavior.

Fees Therapists Charge / Business Model / It’s just like selling Tacos


Welcome fellow clinicians and small business owners! My name is Mari and I love providing coaching support. The Counselor’s Coach Blog is a place to find free practical tips and solid tools for building and growing your practice – along with some authentic, keepin’ it real, no bullshit thoughts on business life. Please introduce yourself below, and take a moment to share about your journey as an entrepreneur, and…enjoy!

Therapist Fees: One Size Does Not Fit All

Important Note: Before you begin reading, it is important to share that this may stir up all kinds of feelings and thoughts, and some of those feelings and thoughts will likely be challenging. Though we therapists cannot have a public discussion of specific fees here in the United States as it violates antitrust laws, I do think it is an important topic to discuss without specifically sharing one’s exact fees.

Expanding the Dialog: One size does not fit all

While the subject of clinical fees and valuing one’s worth is not a new concept, I thought it would be helpful to blog on this topic because I find that it is typically not discussed from a comprehensive business point of view. I read and observe clinicians and coaches writing and sharing some pretty strong opinions on this subject, some of which do not take into consideration variables like client demographics, generational trauma with respect to money, personal preference, clinical experience, and societal influence.

Many business owners (especially women) have been taught not to discuss money and have been shamed into silence from an early age. Additionally, beyond the anti trust laws, there has been a veil of discouragement on having open and supportive conversations about money in the clinical community. Conversations that take into consideration many points of view.

Please Don’t Shoot the Messenger

As an aside, I have also felt subtle pressure from a handful of colleagues, even those that I respect and adore, to keep my thoughts on my business philosophy to myself because it differs somewhat from the current popular group think. I have experienced a reverse sort of shaming that sometimes feels to me like, “Mari, your thoughts on this topic of fees feels different than my thoughts. Your business model is now stirring up emotional stuff for me that I don’t like. I’d like you to please just hush up because what I am reading is activating challenging emotions.” I try hard not to personalize the push back, or in some cases the sudden with drawl or silence, but it does get a bit perplexing and draining at times. If we as therapists are all about people having a voice, does that apply only if the person sharing their voice agrees with your point of view?

Comment: Hmmm, some rather touchy therapists out there? Not so “grown up” themselves, needing all this apologetic “blah, blah, blah” because their “feelings” might get hurt? OUCH! 

I sincerely understand and accept that some colleagues will not pick up what I am putting down. My way is not the end all be all. It is my (key word my) fee structure model and heart centered way of doing business for over 30 years. I honor and value that you are working hard in your corner of the world. And, I appreciate that you will have your own thoughts, feelings, and perspectives on money management, business practices, and fee setting.

Are Therapists a bunch of Crybabies? 

If you have read my other blogs or worked with me as a coach, you know I am a generous and kind straight shooter, so here is the real deal-io: If you choose to move forward in reading this blog, I hope that you will not personalize anything that I am sharing. But, if you do, please understand that I will not take responsibility on how my sharing about my business philosophy regarding fees impacts your delicate sensitivities. We have all gone through healing work around financial fears and inadequacies, no one is exempt. However, like it or not, I am going to weigh in on this topic respectfully, compassionately, and without assumption or apology. 

Up to this point, the blog post is nothing but an apology!

My sincerest hope is that by offering a different perspective, and inviting other clinicians to share their own perspectives, we can begin to change the discourse on how we “should” be discussing money, fees, and so forth in the clinical community.  If you feel triggered in reading through this, I hope you will hold this gentle reminder close to your heart, and do what you need to do to take care of yourself.

If anyone is still reading along, let’s move forward and take a closer look…

Charging One’s Worth: What the heck does that really mean?

A tired old chestnut that is being tossed around is this strongly held notion that therapists must charge between $200-$300 per session or they are devaluing their work and the therapy community. The other rant I hear is that we should never, ever use sliding scales or accept insurance and, if we do, somehow we are not honoring our worth. What is not being discussed is how this big message sometimes pushes out other voices, and by doing so, is creating trauma and shame for some in our community.


The backlash pouring into my coaching sessions, my email, and face book messages are from therapists who are now sharing feelings of shame, envy and upset stating, “What does having a fee over $200 a session and not accepting insurance have anything to do with my worth and value as therapist or business owner?” Part of the coaching work I am doing these days is to have healing conversations about this topic. Conversations that support inclusiveness vs. exclusiveness. Conversations that look into what fears that therapist may have that is blocking abundance. And conversations to balance the idea that some therapists who have a higher fee must have it all figured out, while others who don’t are just failing miserably.

For example, without going into my specific clinical fees (in order to honor the US law), it is no secret to my clients or colleagues that I have always had a fee for service practice and have never worked with insurance panels. I have increased my fee judiciously only 3 times over the last decade for my individual sessions as my experience grows and evolves. My fee is now the highest in my area, as well as being at the high end of the average therapy fee nationally. I have had other colleagues tell me that given my level of expertise and experience, I “should” raise my therapy fee well over the $200 range, especially since I work with clients from the entertainment and sports industries.

My response to this unsolicited advise: “Thank you, I appreciate your feedback and confidence in my expertise. However, I will not be charging that amount for my clinical clients, no matter how wealthy my client is. I am happy with my current fee. It respects my business model and supports my clients. Perhaps I will raise it in the future, or perhaps not.”

And, I have had my own coaching clients share that, “Your fee is way too low Mari. I get more out my coaching with you than I have in spending twice that with other coaches.” My response? See above. (More than a bit NT narcissistic?)

And no, this does not impact my value or worth one iota. And, yes, I have done the work on my relationship with money and worth as a female business owner. My position is not to side with either camp based on my model. My position is to offer another perspective.


Sliding Scale? It’s Whats for Dinner

It is also no secret that I provide a sliding scale for clinical clients who really need this. I don’t mind offering a modest slide at all, not even a little bit, it has served me and my therapy clients well over the years, and is still within a very respectable fee structure. I refer out about 15-20 clients a month who cannot afford my fee even with the slide to clinicians I trust and respect. This is an ethical support to the client in need, as well as a nice support to my colleagues who are wonderful clinicians, but are still growing their clinical skills and practices. As colleagues will tell you, I have populated more than a practice or two (or ten) in my clinical career.


Over the years I’ve heard it all when it comes to the rhetoric and outrage with providing a sliding scale. And, yep, a few years ago as a new therapist, I espoused this same message with the other vocal zealots. I adamantly expressed my own outrage over the sliding scale. Fist in the air, NO more sliding scale was my loud mantra!And then, one day, I realized what a dumb ass I was being. When I slowed down for a minute and took into consideration my past business ownership experience, this was my a-ha moment and my evolution in turning the corner with respect to the infamous sliding scale…My first career was over 30 years ago as a 21 year old hair stylist and make up artist where I offered coupons to clients in order to build my client base. Eventually I founded a very profitable business in this industry. During those early first years in business ownership, I kept my fees comparable, more than the less experienced stylists, but in line with my expertise as I grew my skills (i.e. I raised my fees as my expertise grew).

I guess therapists ought to make at least as much as a hairstylist!!!

I sold that business a few years later, with a long client list, and for a very nice tidy sum while some of my more flashy and high priced colleagues (“I don’t get out of bed for less than $300 a cut) slowly saw their businesses dwindle, or were always on the hustle for the highest paying clients.Over those years, more than a few of their clients ended coming my way because they could receive the same beautiful beauty service, like hair and make up for their wedding day at $350 vs. hair and make up at $800. We also did a homeless hair day 2x a year where we offered cuts and shampoos (there are some hilarious, gag worthy, and heart warming and heartbreaking stories as you can well imagine). And, though media attention was not the motivating reason in providing this to the homeless, to my surprise, and as word got out, the media tuned in and also supported my business.This was the model that just worked for me as a hair stylist and business owner. I kind of made it up as I went along in my early 20s, and learned just as much from my mistakes (and there were many) as I did from the successes. My second business in my 30s was as an interior designer and founder of Eden Designs and Interiors. And once again, I offered discounts and created client packages as part of my business model. I refined this business model by using what I had learned in my first business. I had a long wait list, and my fees were much higher than some designers (again, in line with my evolving design skills), yet lower than less skilled designers in Brentwood or Beverly Hills because that client demographic was different than my client demographic when I first began in that industry.Over the years, as my reputation grew, those clients from Beverly Hills reached out to me.  While I did not raise my rates based on their zip codes, I also did not offer discounts for those design clients because they could afford my full design rate. Instead, I built in a travel fee that I openly shared with the client (I am one hour east of Beverly Hills and with Los Angeles traffic, that can add up to 2 hours in each direction).You know what that is called in my world? Ethical business practices.No sliding scale as a therapist? What freaking cool aid did I drink? Once I stopped bleating and braying along with the rest of the herd, and got very still, I realized that not offering a sliding scale simply did not make sense to me as a business woman (again, key words here: make sense to me). So, like the proverbial black sheep, I walked down a different path of my own making. I re-thought the concept of valuing my time and fees as a therapist, what that meant to me, examined any fears, and then added a sliding scale to my private practice business fee structure.No matter what direction our business compass points us in, I believe we can stand together and agree that we are NOT the only industry that offers discounts (and by the way, that tired old saggy jeans argument needs to be taken to the Goodwill already). We can get all sensitive and pouty when someone provides another point of view, we can personalize, and Facebook message our colleagues who also feel butt hurt and upset, or we can keep our chin up and keep on truckin’ like professionals. I find that when I am feeling all itchy and upset in my spirit, then that is a message for me to sit with. Growing pains, like ’em or lump ’em…we all will have them when creating and refining a business model.

YIKES! Who knew that therapists are raging drama queens under that “creepy soothing exterior”? 

Why is it so hard in our community of healers to simply give an atta’ girl or atta’ boy for another therapist’s good work, even if it differs from the work we are doing? Why does reading another point of view trigger such feelings of shame, anger, or competitiveness? Not one therapist, coach or organization has it all perfectly figured out. How about we all learn from each other instead of punishing or withdrawing from one another.

It’s a BOGO World After All

From time-to-time I observe therapists adamantly stating that, “No other industry offers a sliding scale or discounts so why should therapists?” I used to march to that message as well, but these days I respectfully disagree. Think about Taco Tuesdays, or Early Bird Specials, or BOGO, or any number of ways consumers save. What about groupon for accountants or attorneys, or discounted airfare, vacations, early sign ups for retreats or conferences, or spa discounts, or yoga, or medical procedures, and coupons, and you-name it- ons.

You betcha! In the Good “ol usa, a bucks a buck!!!

While I fully get that therapy is more sacred and important than Taco Tuesdays (well for some that is), my point is that we are a nation accustomed to bargaining and looking for a sale. I understand that what we offer is more valuable than buy two shoes for the price of one (as a shoe lover, I might have to re-think that). My point here is that our client may not understand the value of investing in clinical support, especially if they are new to therapy, on a budget, have their own money shame, etc. Like us, some of our client’s will have been socialized to think about how to save money. We need to know what our client’s mindset is. And part of that knowing includes considering ethnicity, poverty, institutionalized living and so on. We as therapists must do the education within our communities on the value of what we provide. Yet, even after all of our hard work, beating the drum on the value of therapy, providing a service of excellence, this may still not change deeply ingrained beliefs that our clients (yes, even our “ideal” clients) hold.

A CON ARTIST ALWAYS KNOWS Her MARK’S vulnerabilities; WHO BETTER THAN A THERAPIST TO KNOW how to manipulate her “sucker Clients”? 

You say Insurance, I say hell no!

Now, on to the much debated topic of insurance, for those who have heard it is not smart or cool or wise or whatever to work with insurance clients, let me state here clearly that there is not a single thing wrong with being on insurance panels. Though I have never worked with managed care (made that choice from day one given my specialization and other reasons that would fall into a whole other blog), I support colleagues who feel good with this business model. For me, a small slide and a comparable fee that takes into consideration my expertise, years of experience, my diverse client demographic, and so forth simply made sense for me.

This combo has worked like a dream for my business model for many years. Let’s stop here to take a deep breath. In for seven out, for seven. Ahhhhhh. If this information that I am sharing is stirring up some feelings in you regarding your business model, a model that does not include a sliding scale or insurance, then I stand in support of what feels best for you. I celebrate how you choose to structure your fees. I don’t use insurance because it doesn’t feel good for my model. I use a sliding scale because it does. Chin up buttercup, I am not writing this to anyone person in particular. I am writing this to the community as a whole. Bottom line: If we want a consistently full practice, in addition to being clinicians of excellence, we might need to be creative and a bit more flexible (and always ethical) about how we manage our fees. And that may include offering a small sliding scale at times. Or it may include accepting insurance. Or not.

Keepin’ it 100: What’s your Model Mari?

Who knew that your therapist could be a financial dominatrix?

For transparency and full ownership: I have a modest slide for my clinical clients, and I also have a slide fee for group therapy as well. If a client works with me and pays my full fee for weekly individual therapy they will be paying several hundred a month. If they are in my group therapy, then they will be paying an additional several hundred per month. Some of my clients can easily afford this without a second thought. However, some of my clients struggle to make this work. As a support for my clients who see me for individual and group, and work hard to budget in that money each month, I extend a lower fee in group by $25, and a lower fee for individual by $25. (How magnanimous!)

If this is still a challenge, then I offer to see them every other week. (OMG!) For clients who have received the slide for weekly sessions, and are ready to reduce meeting to every other week (e.g. they no longer need weekly), I ask that they pay full fee. And for clients who do occasional check ins, even if they were on the slide, I ask for full fee. I also keep one pro bono spot open in my groups (I close at 7 members, 6 are paid) for women and men in need of support who cannot afford therapy at all. Each year in January I increase fees for those clients who have been on the slide for the year prior to make room to support other clients who made need this support, and/or are doing much better financially. If a client is going to be working with me, healing issues around money is important and many of my clients begin to experience more financial freedom as they move through their healing work. If they are still in dire straights, well guess what my esteemed colleague, they get to keep their lower fee. And I don’t think that de-values my worth as a therapists by one red cent.

I’m sorry: I’ve reached my, “For the Love of god, please shut up” puke-level disgust limit. Read on, if you can. 

Fees and Fears and Frustrations…Oh My!

Could I demand a higher fee at this stage of my career? Sure I could. Is the reason I don’t because of fear or low self worth? Nope, not by a long shot. I’ve done my work in healing those old money demons.That said, it is a great question and one that I help clients examine in my coaching work. In fact, let’s move a bit deeper into this topic of fees and fears and frustrations to see what is really going on with some therapists. We will start with the ever popular topic, “Charging a Full/Higher Fee.”Every therapist needs to figure out their average client fee on a regular basis. If you have a fee for $185, do you actually get that for every single client? If so, hurray! If not, then that is not your accurate fee. Thus, this is not an honest portrayal of your fee structure. An ethical assessment includes your average client fee.For example, each quarter I meet with my CPA. We go over my PNL statements, set some quarterly goals, look at any potential red flags, and take a look at what I am grossing for an average hourly fee compared to the number of clients I see.For those of you who glaze over with numbers, this is a very, very easy formula, so stay with me. If we are true boss babes and bros we do not shy away from this kind of information.How this works:Add up your clients fees for one week like this (I’m using these numbers as a hypothetical example as a way of demonstrating this simple tool without pissing the law makers off):We will name our therapist Ima McCounselor. Ima sees 10 clients a week at $185 a session, with a sliding scale to $150, like this:Client 1: $185
Client 2: $185
Client 3: $185
Client 4: $150
Client 5: $165
Client 6: $150
Client 7: $150
Client 8: $160
Client 9: $160
Client 10: $185Ima’s total weekly therapy client fees = $1,675$1,675 divided by 10 week clients = $ 167.50Thus, Ima’s actual average hourly fee is not $185, it is $167.50. So Ima is unintentionally being dishonest when she proclaims from the rooftops that she is making $185. Ima needs to do her math.For those clinicians who share that they charge $225/per clinical session, fantastic! If they can do this without insurance, even better. If you are using insurance, then you must take into consideration the time involved outside of session to work with insurance billing and calculate that into your average. If you do not, then again, this is not an accurate portrayal of your fee. If a therapist can keep their practice consistently filled to their liking (as a “full” practice means different things to different therapists) at $225 or higher a session, without using managed care or a sliding scale, without having a niche, and has the expertise, reputation, public recognition, and experience to back up the fee, wonderful!(Side Note: Yes, we all know that the client relationship trumps the letters behind one’s name or the years under one’s belt. But please read on for a more nuanced look at other factors that influence a client…)However, what I have found is when you pull back the curtain and do the numbers to find your average fee, most therapists find that they are making at least $30-$40 less than their stated highest fee and, at the end of the day, are actually fairly in line with other clinicians in their area. Not all, but many. So, Ima is not the only one who is not actually making their claimed “high fee.”Another popular notion is to work with less clients for a higher fee. This is not a new idea. This is an idea that has been around for-ev-er. It’s called working smarter not harder. While some therapists are financially able to do this because of a second income in the home, many are not. So, working with 4 clients a week at $225 (or about $650 net per week) may be the sweet spot for some, it is not the sweet spot for all. I need and want more than $2,500 a month of net income. Just because a colleague shares they are making a certain high fee, doesn’t mean that they are meeting their income goals.

Fly on the Wall: A Coaching Call

So, how does one stand firmly in valuing worth while using wise assessment in setting a solid fee with fee increases? I thought it would be best to answer this question by taking you into a hypothetical (though not all that unusual) coaching call. Again, this is a hypothetical conversation role playing what usually transpires around managing expectations, valuing one’s clinical skills, honoring clients, while setting fair fees.In this example below, I am the one asking the questions with a new coaching client that we will call, Hope. Hope is my “avatar” client, she is someone who very realistically would reach out to me. So, let’s see what is happening with Hope:Mari: “Hi Hope! I am so glad we are meeting today. I reviewed your 360 form, and see that your top goal is to figure out the ebbs and flows of why your practice is not staying as full as you would like. Let’s start there today and roll up our sleeves.I see that you are 2 years into private practice, congratulations! And that you are a solo practitioner, 36 years old, married, one child, no employees, and that you charge $225 per individual session, and that you do not work with insurance. Is that correct? Yes? OK good, thanks.Also, please tell me what the average therapy fee is in your area, and the average percentage of clinicians in your area working with insurance, and what is the median household income in your area/for your client?”Hope: “Thanks Mari! Yes, that’s correct. Hmmm about $150 is the average fee in my area. And I’d say about 50% of the therapists work on insurance panels. BUT don’t even go there with me, I WILL NOT do that. I have no idea what the average income is around here, is that important?”M: “OK sounds good, no worries Hope, I’m not here to try and force you to do anything you are not comfortable with, but I will ask you to lean into some challenging parts of your business during our coaching call today, so hang with me and breathe. I just googled and it looks like your area is upper middle class income, and that your client, if they live in your city, will be making about $75,000 annually, so that is good for us to know.Also, your fee is $225, which is $75 more per session than the other clinicians in your area. Will you please share with me what informed your business decision to charge this fee?”H: “I offer EMDR and I believe in charging my worth, I need to value my time. NO bargaining or sliding scales! I think a client in my area can afford to pay that. I was told to decide on how much I want to make each year and then to raise my fee so that I could make that number.”M: “Yes, charging one’s worth is so important, I truly agree! So, let’s do the math here, if a client is seeing you weekly, they would be paying $900/month. If they are making $75K a year, they are taking home about $4,000 a month, so that is about 25% of their income that they would be spending on therapy with you.Are you the only EMDR therapist is your area?H: “Wow….25% is a lot when you put it like that, but I guess numbers don’t lie, right. No, I’m not the only EMDR therapist, in fact, there are several of us who provide EMDR in my area.”M: “OK, good to know this Hope! And are you the most experienced EMDR therapist in your area, or do you provide a higher quality of EMDR or therapy, do other’s provide EMDR though insurance?”

H: “I’m not sure, I think there are a couple who have been doing this for a few years, in fact one of them has a consulting group for EMDR therapists in the area, I really respect her work a lot! Yes, some use insurance, but that won’t be me.”

M: “I love that you have a colleague in the area that you trust and respect! Let’s hold good boundaries around the laws on fee setting, if you had to give an educated guess, do you know what her fee is?”

H: “$175 is what she has listed on her website, and she offers a small sliding scale, but I don’t want to do offer a sliding scale. It is old school thinking and cheapens our industry.”

M: “OK got it, and is she brand new to this work too?”

H: “No, I think she’s been doing this work for about 8 or 10 years. And she is ONLY fee for service like me.”

M: “Thanks, OK that is helpful to know. So then we can see that you are charging $50 more than her and she has been doing this work 9 years longer and is considered an expert in the area, is that right?”

H: “Yes, people really respect her – she is very good. I learn a lot from her too!”

M: “Wonderful! OK, let’s keep moving along here and figure out these gaps in your client schedule and income. Are there other therapists or organizations that hire you as a consultant and expert in this modality or method?”

H: “No, but one day!”

M: “Yes, definitely one day for sure! OK, hmmmm…are you hired to speak as an expert on the topic of EMDR anywhere?”

H: “No, not yet, but I would like to get paid to do this! How can I start lining up paid gigs like you do Mari for $5,000 a gig?”

M: “Let’s hold a good space for you getting paid for your EMDR expertise one day soon! For now we will book mark on that topic and let’s stay focused on filling these gaps as this is your stated goal for today.” OK, hmmm..do you have a book that you have written? The reason I am asking all of these questions is because I am gently assessing so that we can team up and figure out what sets you as a higher fee therapist in your area and add that to your marketing information.”

H: “Well, I believe I am just as good as most, and probably better than others. But no, I’m not hired as a consultant, nor do I speak as an expert, and I want to write a book…but haven’t found the time. Can we talk about a book today?”

M: “I think it would be a great idea to get that book started one day! But for our purposes today, let’s stay focused on your stated goal. I know this can be a challenging topic and it makes sense that you might want to discuss other more fun topics. But, part of my work is to support what you wanted to get done today. I hear that you have already set your mind to $225 per session. So, is the higher fee because of your years of working with clients, or other businesses you have owned, or some other work I am not aware of, and this is why you have the highest fee?”

H: “Well, like I shared, I’ve been doing this work for about 2 years. I feel like I do a great job, my clients tell me I do, and I deserve to charge a fee I am worth. But no, this is my first business and this is my first therapy role. BUT I have a lot of life experience. ”

M: “I agree 100%. Charging one’s worth is so important. And having life experiences to draw on as a clinician is truly so valuable. And listen, there are plenty of therapists out there who have been doing this work for 20 years and are burned out or just not really all that skilled. But help me better understand as a fairly new therapist with less than 5 years of experience, how did you decide to set your fee at $225? The reason I ask is, as an example, I really like my OB GYN, I really love that she is an expert and has many years of experience, and has a holistic point of view, and I am happy she has a vagina and understands first hand about women’s health because she is a woman, but….I don’t care too much beyond that in terms of her life experience, only as it relates directly to my specific care. Make sense?”

H: “Yes, makes a lot of sense actually. Well, how I came up with my fee. Um. Hmmm..I’m not sure, LOL! I guess because I worked with a coach, then joined a coaching group, listened to a couple of podcast interviews, and I read a blog that said I should be charging that amount! And a bunch of therapists on Facebook all say that we should be charging a lot more money. And when I broached the topic of moving my fee down a bit, they all lectured me on why I should never do that. And most of them are new too!”

M: “OK, makes total sense, we don’t know what we don’t know when we are new in business. I agree that historically therapists have undervalued themselves. The great news is that this has changed quite a bit in the last few years. You contacted me because you are having a hard time attracting and keeping clients. On the other hand, you share with me that clients don’t stay in your practice even though you receive great feedback for the work that you do. This is really good news in a very real sense because no matter how skilled a person is with marketing or fee setting, if they are not skilled as a clinician and cannot connect with the client, then clients won’t stay. Clearly that is not the concern here with you. So, let me ask you this, what is the first thing that clients say when you share your fee?”

H: “That they can’t afford it. But I am determined to charge my worth. No sliding scales!”

M: “Yes, I absolutely agree it is so important to value self. You know Hope, I think it may be helpful to share my perspective on fees and worth: since that is a topic you are coming back to again and again today. I believe that the support that we therapists give is priceless because we help people to step away from suicide, we help people recovery from addiction, and we help people heal relationships, to reduce anxiety and depression, to create lives they are proud of, to reach dreams and goals, and so much more. Providing skilled therapy to help hurting people grow and heal is priceless work as far as I’m concerned. But, in the real world people have budgets, and services have prices, and not many people can give a quarter of their monthly earnings to a therapist, some can, but not every one. And, I would imagine that might even be hard for you to give 1/4 of your income to your therapist. So, here is the thing…why do you think your clients don’t book a first session or stay on for more sessions with you?

H: “No, I could never afford to pay my therapist a quarter of my income. Well….I think clients don’t book or stay because they can’t afford my fee. BUT, I really am going to stand my ground on this. I DESERVE to value my service, no discounts, no other industry offers discounts but us. Like you said, the work is priceless [long pause]. But, yeah, I can see what you mean…I guess.

M: “I am with you 100% on this. However, it is good to remember that pricing services is about a business model and system. We cannot do that without taking into consideration a number of factors including the larger social system. What I mean by this is that we live in a culture where people are socialized to price shop and compare. Many people base their choice on where to spend their discretionary income on word of mouth, or if the product they are buying comes with great feedback (think about our Amazon review culture we live in), or the service they are investing in (be it a hair stylist, a mechanic, an attorney, a doctor, or a personal trainer) comes with either A) Great references or B) A high level of experience and expertise. And some people just want to get the cheapest. And some people don’t have it in their budget. Make sense?”

H: Silence.

M: “You still there Hope?”

H: “Yeah.”

M: “You OK?”

H: “Yeah. I’m just feeling a little shaken up and angry, but it is not fair of me to “kill the messenger” when what you are saying makes so much sense. I guess I am pissed off at myself because deep inside I was never comfortable with my $250 fee. I sort of felt peer pressured into it. I felt all pumped up at the coaching event, but then when I got home, and I followed their advise, it was just crickets. No clients were calling. And even though I already have 5 clients and all of them are willing to pay full fee, I sense that two of them are a little resentful, and one has started canceling session after I raised my fees.

M: “Thank you for the trust in sharing that with me Hope. That must feel pretty scary and frustrating. Did you talk to your coaching group? They can’t read your mind after all, you need to let them know this.

H: “Mari, I did! But one of the coaches publicly shut me down and shared that they built a full practice in the middle of the recession a few years ago, and if they can do it so can I. No excuses were allowed. I felt a lot of shame. Plus I spent a boat load of money to learn the marketing system they were selling, so I felt like I had to do what they were saying. They told me I needed to build a bigger list, or blog more, or attend a conference, or start giving out freebies, or put together all kinds of different income funnels that were incredibly exhausting and time consuming. So, I guess I feel some shame that even though I have jumped through all of their hoops, it’s not happening for me.”

M: “I know it can feel a discouraging, but here is the thing Hope, let’s look shame in the eye and ask it to pack its bags. You are the person paying your bills. Not me, not the other coaches, not your Facebook buddies. You. And when we really pull back the curtain, there are some coaches and other colleagues who do many other things to make money beyond a private practice when they are first getting started.

When someone says, “I built a practice in the middle of the recession in the middle of nowhere walking through 10 foot snow banks and so can you!” I’d be curious to know if they were also working another job, or taking on side projects like writing, or website building, or supervision, or agency work, etc. And, I’d also want to know what a “thriving practice” meant to them. How many clients did they consistently have on average? How long were they in practice? What was their actual average therapy fee, not just what they were advertising on their website, and what was their net annual income strictly from their clinical fees? Do they share those things with you Hope?”

H: “No. Sigh. I have no idea what the answers are to any of that. But, now that I think about it, I do believe that the coach was working at an agency part time, and had a part time business doing copy editing or website design, or teaching, or something when he first started his practice. And I think his fee was like $100 or $125 when he first started. I never really thought of it that way. I just figured I had to set my fee pretty high in order to value my worth. But you know what Mari, when I tell my colleagues in my area what my fee is, I can see them sort of looking confused because I am so much higher than they are, but can’t really back up my reason for being that much higher. Other than what I keep repeating which is, “I totally deserve to charge my worth!” I wonder if this is why they don’t refer to me?”

M: “Well, I think that is really courageous and I appreciate your transparency. I think it is perfectly wonderful to command a higher fee if that works well for one’s practice, aligns with one’s experience, and supports one’s business model. That said, I don’t know that any fee, no matter how high, will ever really be a statement about my worth as professional. And yes, we should get to make a great living doing this complex and challenging work. And we should only work with the clients that we want to work with.

I would imagine that some of your colleagues either feel your fee is too high given your experience, and/or are not therapists who refer often, and/or are ashamed because perhaps they have a very low fee, or are insecure, or who knows why. Let’s not get too wrapped up in worrying what other people are doing. Best not to compare. Are you open to my suggestions on how we might find that sweet spot between valuing your worth and keeping your practice filled with the number of clients you would like to see each week?”

H: ‘Yes, yes, yes please! That is why I reached out to you.”

M: “Great! So, this is going to require you to dig deep, and look through another lens, and think about worth and value a bit differently. Are you up for that?”

H: “I am so freaking up for that I need a new word for up for that!”

M: “I love your energy shift Hope! You have learned some great tools from your previous coaching so your investment in not wasted. There are some things we will dive into in our next coaching session to tighten up and refine your voice and website, your niche, and especially your blog. There are ways we can start branding you as an expert in your community while you grow your experience. There are ways we can build the relationships with other clinicians. And none of this is fancy, or a bright shiny new anything. And it won’t require a bunch of coaching sessions or big money investment.

But, for the sake of staying focused on today’s goals, and in order to get this train back on track, first thing we need to do is create a fee that is in line with what you bring to the table and so you have clients and income. What you bring to your clients is a lot! And is valuable! But…maybe not at $250/hour just yet – as your practice is showing you currently. Especially when we consider your current demographic and the other factors we discussed today. When you get very still in your heart, what is the fee that really works for you?”

H: “Hmmmmm….well….$165 has always felt like my number but I was told that was too low.”

M: “Why this number? Let’s really assess why this fee feels right for you. I want you to know in your business bones why this is your ideal fee for now.”

H: “Because it is just above the standard in my area which also keeps it marketable and fair for clients, and still honors my certification as an EMDR therapist. And it is just below the more skilled and experienced EMDR therapists in my area.”

M: “I like that Hope, that feels like a good solid fair fee and great insight. A fee that you are setting by using good business skills in assessing why this is the right fee for you. And a fee that respects your additional certification.

Now, what would need to happen for you to feel more comfy moving this up to say, $185 at a future date, maybe a year or two from now.”

H: “I’d want to get a couple’s counseling certification, and I’d want to get some consulting/coaching on how to facilitate therapy groups and workshops, and then start offering those and getting skilled in that area. And I guess, well, even though a part of me hates to admit this, it would be wise to have 2-3 more years under my belt to grow my experience so that I have more credibility with clients and colleagues in charging a much higher rate.”

M: “OK, I love that! Such clarity here. Now, what would need to be in place, let’s say 3-5 years from now to go from your current new fee of $165, to your future fee of $250?”

H: “I’d want to start speaking and teaching as an expert. Getting paid for consultations, be respected in my area and within my niche. And speaking of a niche, I thought it was working with women in transition, but after reading your blog on niching down your niche, I see that that is way too vague. And, I’d like to be paid for speaking, and write a book that would support my clients and possibility create materials like you have done on your therapist tool box store, and training that would support other colleagues.”

M: “You know what I call that?”

H: “What?!!”

M: “A very wise on ramp and ethical foundation to create a thriving practice with multiple income streams that will bring you abundance for many, many years ahead.”

Fast forward 10 months later…email from Hope to Mari:

“Hi Mari,

I wanted to take a moment to first of all wish you a happy holiday season. And to let you know that after meeting with you for 4 coaching sessions earlier this year, I refined my practice and fee structure based on our work. I am happy to report that I have had a full practice of 17 clients. While my fee is $165, I also added a small sliding scale and my average client fee is $155.

I also implemented our work and what you taught me about leveraged income and group therapy, and I now have a women’s weekly trauma group. I charge $85 a week per client, and I already have a wait list for next module! I even started a small mentors group that meets weekly via SKYPE and I charge $10 a person to facilitate this and we have 8 people. I went from less than 1,000 a week to over $3,200 a week in the last 8 months! I am taking home $9,030! This has given me such a boost of confidence. I stopped racing around for the easy shiny carrot (using a Mari-ism) and I started speaking at local businesses for free to increase my visibility in my community.

And guess what? I just got booked to speak at a woman’s group for guess how much? $1,500!!!! I am so so so happy, and so so so grateful. I work 4 days a week, and see on average 4 clients a day. It really is a dream come true. Thank you Mari! I know you are going to say it is my hard work that made it happen, and I agree, but I am grateful for our time together and all of the practical tools and good information that I learned from you and I wanted to share my progress! Once I stopped being so mad at you for telling me the truth, and I got out of my own way, and trusted my own business compass, I made it work!”


Final Thoughts

So, there you have it my fellow healers and colleagues, “Live” from the Counselor’s Coach. I realize this may not be the popular current group think that is resurfacing of late on fees and valuing worth. And I fully respect that you may have a very different way of approaching fees and business building, and that is 100% OK! Different strokes for different folks.

In closing, this is what I know from 30+ years of business ownership:

1. You can’t build a reputation over night;
2. Clients do their research, they compare fees, and they compare expertise and experience;
3. Not every therapist or every coach can be an expert right out of the gate;
4. You grow a business over 3 years – not 3 months;
5. The word “thriving” means different things to different people;
6. Not everyone tells the truth about their fees;
7. People/Coaches sometimes have an agenda on the whole “charge what you are worth” that has nothing to do with your success, and everything to do with their own agenda (i.e. if they charge a really high fee for coaching for example, then why would they not lead loud and proud with this message for you to charge a high fee too?);
8. Anyone, not just me, or you, or the man on the moon, can build a successful business with the following: Experience, and sometimes education and certifications, guidance, integrity, professionalism, flexibility, hard ass work, focus, dedication, gratitude, kindness, balance, reputation and trust (and for me prayer);
9. You can start making money over a short period of time as long as you have a business model that is realistic and consistent;
10. Always, always, listen to your heart and guts and not the roar of the crowd. Or the convincing of a coach, or a blog (even this blog). Trust and honor your own internal compass.

I would love to hear your thoughts on this topic as well in the comment section below (please keep in mind our anti trust laws on sharing your fees).  How did you assess and decide on your fee, and why did you choose that specific number? Gentle hint: Responding with, “I decided to charge my worth because my colleagues and coaches said so, and clients just paid what I told them to pay” is not a skilled or insightful answer.

Yes, I went there. And remember lovely reader, please don’t kill the messenger.

Kindly and in support,
Mari A. Lee, LMFT, CSAT-S



Insurance Providor Corruption of Diagnostic Process / Industry Confession

This article also applies to ASD / Asperger diagnosis. 

The Process and Implications of Diagnosing Oppositional Defiant Disorder in African American Males

Marc A. Grimmett, Adria S. Dunbar, Teshanee Williams, Cory Clark, Brittany Prioleau, Jen S. Miller

Research studies indicate that the number of African Americans diagnosed with oppositional defiant disorder (ODD) is disproportionately higher than other demographic groups (Feisthamel & Schwartz, 2009; Schwartz & Feisthamel, 2009). One contributing factor for this disproportionality is that White American clients presenting with the same disruptive behavioral symptoms as African American clients tend to be diagnosed with adjustment disorder. Feisthamel and Schwartz (2009) concluded, “counselors perceive attention deficit, oppositional, and conduct-related problems as significantly more common among clients of color” (p. 51), and racial diagnostic bias may influence the assessment process. Racial biases in clinical decision making are explained in a conceptual pathway developed by Feisthamel and Schwartz (2007).

See full article: (may have to copy/paste in browser)



The purpose of this study was to understand the diagnostic processes and implications associated with ODD. Findings suggest that a diagnosis of ODD can result from more factors than client symptoms fitting the diagnostic criteria. While none of the research or interview questions asked specifically about the role of insurance or managed care, every participant indicated that third party billing influenced the diagnostic process.

Specifically, the mental health counselors interviewed were keenly aware of the necessity of making a diagnosis for insurance reimbursement. It appeared that ODD is considered a reliable diagnosis for billing purposes; however, diagnostic necessity may also create an ethical dilemma for mental health counselors who want to provide quality care and need to earn a living. The possibility of racial diagnostic bias remains, even with insurance requirements, when African Americans are more likely to receive a diagnosis of ODD, while White Americans presenting with similar symptoms receive a diagnosis of adjustment disorder (Feisthamel & Schwartz, 2009; Schwartz & Feisthamel, 2009).

Professional ethical standards and best practices warrant full consideration of a diagnosis, including the purpose served and implications, as related to the health and well-being of clients (American Counseling Association [ACA], 2014). Even when a diagnosis is not warranted or conflicts with theoretical, philosophical or therapeutic approaches, mental health providers serving clients who do not pay cash for services are forced to accommodate diagnostic requirements. The use of a diagnosis as a therapeutic tool, designed to act in concert with others, has also come to serve as the gateway to mental health care services.

In the case of African American male clients, an ODD diagnosis can be particularly stigmatizing with immediate and long-term implications for marginalization and tracking (Cossu et al., 2015). Educational, judicial and incarceration data clearly demonstrate that African American males are disproportionately suspended and expelled from school compared to their peers (U.S. Department of Education Office for Civil Rights, 2014); receive harsher sentences in judicial systems for the same offenses as other defendants (Ghandnoosh, 2014; Rehavi & Starr, 2012); and are more likely to be stopped, searched, assaulted and killed by police officers than other community members (Gabrielson, Jones, & Sagara, 2014; Weatherspoon, 2004). Since ODD is categorized as a disruptive behavior disorder, it may be considered, intentionally or unintentionally, a justification, rationale or explanation for these disparate outcomes. When the diagnosis of a mental disorder is used for purposes other than helping the client, it opens the door to unintended and problematic consequences. (REALLY????)

The assessment process is critical to making an accurate diagnosis and should not be limited to the most readily available, convenient or confirmatory information. With ODD, alternative, viable explanations for client symptoms have to be considered that may include family history and dynamics, personal trauma and social–cultural context. Guindon and Sobhany (2001) noted, “often there are discrepancies between the counselor’s perception of their clients’ mental health problems and those of the clients themselves” (p. 277). Again, there may be a tendency to diagnose African American males with perceived behavioral problems with ODD without full consideration of historical and contextual variables that may better explain mood and behavior and warrant a different diagnosis altogether (Hays et al., 2010).

Mental health counselors also have certain biases, within and beyond personal awareness, that create diagnostic tendencies, which may undermine the diagnostic process and invalidate the results of the assessment. Assessment practices and structures appear to accommodate intrinsic and individual information, more so than extrinsic and systemic variables (Hays et al., 2010). For these reasons, the gathering of client information for diagnostic purposes must be as comprehensive and inclusive as possible, notwithstanding measures to limit mental health counselor bias, such as supervision and consultation.

The ACA Code of Ethics outlines the need for even the most experienced counselors to seek supervision and consultation when necessary (ACA, 2014). One potential blind spot for many counselors experiencing bias toward African American male clients is not realizing the need for supervision and consultation when it arises. Understanding that ODD diagnoses within the African American male community have been shown to be inflated is a first step toward decreasing counselor bias. Second, recognizing the subjective nature of making an ODD diagnosis, especially since many of the behaviors and emotions listed as diagnostic criteria also “occur commonly in normally developing children and adolescents” (APA, 2013, p. 15) is another critical aspect of ensuring accurate diagnoses are made.

Counselors are trained from a multimodal approach to diagnosis based on Western medicine; therefore, diagnosing clients is a culturally-based practice (Sue & Sue, 2015). Furthermore, most research in the area of mental and behavioral health has, in large part, not included people of color (U.S. Department of Health and Human Services, 2001). Cultural discrepancies also are evident in the demographic characteristics represented within the counseling profession. Approximately 71% of counselors in the United States are women, and only 18.4% of counselors identify as Black or African American (U.S. Department of Labor, 2015); therefore, most African American male clients will likely have different cultural backgrounds from their counselors. These factors create a need for consultation and supervision to ensure that the personal and professional worldviews of counselors are not inhibiting accurate diagnosis and treatment planning for African American male clients.

In addition to supervision, another measure to limit counselor bias would be to practice reflective cultural auditing, a 13-step process for walking counselors through how culture may impact their work with clients from initial meeting through termination and follow-up. This process allows counselors to reflect on what may seem like client resistance, but may instead be a “disruption in the working alliance” (Collins, Arthur, & Wong-Wylie, 2010, p. 345) based on cultural differences. In addition to utilizing reflective audits of individual cases, it also can be helpful for counselors to review case files regularly, taking into account race and ethnic background, along with symptoms and reported diagnosis. Finding diagnostic patterns within one’s own practice can help counselors reflect on their clinical work and identify areas of bias that may exist.

I would add that there are multiple cultures within the white population, and psychologists must recognize bias in their social “judgments” based on class prejudice.  

Insurance Influence

Most insurance companies require counselors to diagnose clients with a mental disorder in order to obtain payment for mental health services (Kautz, Mauch, & Smith, 2008). Many insurance companies require that a diagnosis be made during the first few counseling sessions, sometimes within the very first counseling session. All participants described the role and influence of insurance companies and managed care in the diagnostic process. One participant expressed, “the diagnosis is necessary to get paid, so you have to find something. You are not looking objectively. You are just giving them a diagnosis.” The participant continued:

We see this proportion of diagnoses [with African American males] because the insurance in managed care world drives agencies like this one and drives providers to say that an [African American] child is diagnosed a particular way . . . There is this incentive to diagnose and to diagnose in a short period of time.

Findings suggested that the assessment time allotted by insurance companies to diagnose a mental disorder undermines the diagnostic process and invalidates the diagnosis. One participant emphasized, “the client is not going to open up to you within that time frame; this is the first time the child is ever seeing you. Those types of things progress over time.” Further structural and systemic assessment problems also were identified by another participant:

You’re allowed to do one assessment per year for the client . . . The assessor would take the previous assessment, use a majority of that information, and then just ask what has changed between then and now . . . there [are] a lot of questions that the previous assessment didn’t answer or didn’t really look into. So that piece gets missed.

 WOW! Some honesty at last from people within the “helping, caring fixing” industry. 



This is what passes for “Behavioral Analysis” / NTs are CRIMINALLY STUPID

Why children with ASD / ASPERGER’s run away screaming and suffer traumatic meltdowns: Idiot adults like this woman.

Could any sane human not be driven BONKERS by 2 minutes with this harpy? 

For background on this low-hanging branch of psychology see:  https://www.appliedbehavioranalysisedu.org/state-by-state-guide-to-aba-licensing/

Courtney Peters, MA, BCBA / LBA

Behavior Analysis  |  Female
Courtney Peters, MA is a behavior analyst in Phoenix, AZ. She specializes in behavior analysis.


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