Prevalence Among 4-Year-Olds

In The Politics of Autism, I discuss the uncertainty surrounding estimates of autism prevalence.

Deborah L. Christensen and colleagues have a study at MMWR titled: Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 4 Years — Early Autism and Developmental Disabilities Monitoring Network, Seven Sites, United States, 2010, 2012, and 2014,  

It finds that prevalence was higher in 2014 than in 2010 in New Jersey, but was stable in Arizona and Missouri. From the abstract:

The findings suggest that ASD prevalence among children aged 4 years was higher in 2014 than in 2010 in one site and remained stable in others. Among children with ASD, the frequency of cognitive impairment was higher among children aged 4 years than among those aged 8 years and suggests that surveillance at age 4 years might more often include children with more severe symptoms or those with co-occurring conditions such as intellectual disability. In the sites with data for all years and consistent data sources, no change in the age at earliest known ASD diagnosis was found, and children received their first developmental evaluation at the same or a later age in 2014 compared with 2010. Delays in the initiation of a first developmental evaluation might adversely affect children by delaying access to treatment and special services that can improve outcomes for children with ASD.

Public Health Action: Efforts to increase awareness of ASD and improve the identification of ASD by community providers can facilitate early diagnosis of children with ASD. Heterogeneity of results across sites suggests that community-level differences in evaluation and diagnostic services as well as access to data sources might affect estimates of ASD prevalence and age of identification. Continuing improvements in providing developmental evaluations to children as soon as developmental concerns are identified might result in earlier ASD diagnoses and earlier receipt of services, which might improve developmental outcomes.

With All Deliberate Speed: DeVos and a a Court Order

In The Politics of Autism, I write about special education and the Individuals with Disabilities Education Act.

Christina Samuels at Education Week:

Nearly a year ago, the U.S. Department of Education said it was putting on hold for two years the implementation of an Obama-era rule that had the potential to affect how millions of dollars in federal special education dollars could be spent.

Nearly a month ago, a judge reversed the Education Department's delay, saying it was an "arbitrary and capricious" decision.

On Wednesday, Education Secretary Betsy DeVos was pressed by Rep. Donna Shalala, a Democrat from Florida, on the department's plans in the wake of the court decision.

"We are currently reviewing the district court order and deciding on next steps. We are moving toward implementation," DeVos told Shalala—similar to the response she gave when she was asked the same question by Sen. Chris Murphy of Connecticut in late March.

"You've had a month to review the order. The order isn't very complicated," Shalala told DeVos.

 The underlying issue, though, is complex. The Individuals with Disabilities in Education Act requires states to monitor how districts identify minority students for special education, discipline them, or place them in restrictive settings. 

New York Emergency

In The Politics of Autism, I analyze the discredited notion that vaccines cause autism.   This bogus idea can hurt people by allowing disease to spread.

Tyler Pager at NYT:

The Vaccine Safety Handbook” appears innocuous, a slick magazine for parents who want to raise healthy children. But tucked inside its 40 pages are false warnings that vaccines cause autism and contain cells from aborted human fetuses.

“It is our belief that there is no greater threat to public health than vaccines,” the publication concludes, contradicting the scientific consensus that vaccines are generally safe and highly effective.

The handbook, created by a group called Parents Educating and Advocating for Children’s Health, or Peach, is targeted at ultra-Orthodox Jews, whose expanding and insular communities are at the epicenter of one of the largest measles outbreaks in the United States in decades.

On Tuesday, Mayor Bill de Blasio declared a public health emergency in parts of Brooklyn in an effort to contain the spread of measles in ultra-Orthodox neighborhoods there. He said unvaccinated individuals would be required to receive the measles vaccine — or be subjected to a fine — as the city escalated its campaign to stem the outbreak.

Delthia Ricks at Governing:

Dr. Aaron Glatt, chairman of medicine at South Nassau Communities Hospital in Oceanside, told Newsday two weeks ago there is nothing in Jewish religion that prohibits vaccination. "The religion was in place long before vaccines were developed," said Glatt, who is also a rabbi.

He blamed the outbreaks on well-meaning parents who have been duped by rampantly spreading pseudoscience, which links the MMR vaccine to autism. Vaccine hesitancy is also common among a growing number of people who aren't Jewish, Glatt added.

"Misinformation is very, very dangerous," Glatt said, "and there is no evidence whatsoever that vaccines cause autism."

A study published last month in the Annals of Internal Medicine involving more than 600,000 people proved again that MMR vaccine does not cause autism. The study was the largest, but one of dozens that have found no links between vaccines and the neurodevelopmental disorder.

Trump Budget v. People with Disabilities

In The Politics of Autism, I discuss the issue's role in campaign politics.   In the 2016 campaign, a number of posts discussed Trump's bad record on disability issues more generally.   As his actions as president indicate, he has little use for Americans with disabilities.

From Senator Sherrod Brown (D-OH) and Bob Casey (D-PA):

Director Mulvaney:

We write to address a pernicious theme in the Trump Administration’s Fiscal Year 2020 (FY20) Budget: across multiple agencies and offices, the budget targets people with disabilities. Whether in housing, education, employment, aging, health care, civil rights, transportation, research or any of the other governmental functions that assist people with disabilities and their families, this budget strips the resources that make access and opportunity possible. Any budget proposal by any administration should reflect the goals of the Americans with Disabilities Act: equal opportunity, independent living, full participation, and economic self-sufficiency. Your budget not only doesn’t reflect those goals, it actively inhibits their achievement.

In the Trump Administration’s FY20 budget you have cut funding to:

• the Traumatic Brain Injury program
• the Paralysis Resource Center
• the state Council on Developmental Disabilities
• the University Centers on Developmental Disabilities
• the National Institute on Disability, Independent Living, and Rehabilitation Research
• the Independent Living Centers
• the Limb Loss Resource Center
• Gallaudet University
• the Voting Access for People with Disabilities program
• the state Assistive Technology programs
• the Family Caregiver Support Services program
• the Native American Caregiver Support Services program
• the Alzheimer’s Disease program
• the Lifespan Respite Care program
• the Autism Surveillance program
• the Interagency Autism Coordinating Committee
• the Office of Disability Employment Policy
• Section 811 Housing for Persons with Disabilities

Unfortunately, there are even more examples of cuts to programs that support people with disabilities to work, live in their own homes, get to their jobs, and have access to the opportunities that all Americans enjoy.

We are concerned about all of these cuts to disability programs, but none more so that the proposed cut to Social Security Disability Insurance and Medicaid.

You have proposed $84 billion in cuts, chiefly, to Social Security Disability Insurance. These are funds that support hard working Americans who have developed disabilities over the course of their lives. The workers who would be denied benefits under your cuts are people who have not only contributed to our economy over decades but have also paid into the Social Security Disability Insurance fund. Our government promised American workers that if they work, grow our economy and they develop a disability – we will take the funds they have contributed in their taxes to provide some care, relief, and dignity.

The proposed cuts to Medicaid are an abomination and insult to American values. The 1965 Social Security Amendments Act created Medicaid and in so doing established a contract with Americans that if they met the eligibility requirements for Medicaid their government would provide the health care and supports they need. The proposed cuts to Medicaid, $1.5 trillion over ten years, would break that contract with Americans and leave hundreds of thousands of children, older adults, and people with disabilities without the health care and long-term services and supports they need to be part of our society. In addition to the proposed cuts, the Budget proposes to impose mandatory work requirements as a condition of coverage in Medicaid – a policy that would create unnecessary burdens on individuals with disability and threaten their coverage.

The systematic targeting of people with disabilities, their families, and those who serve them will weaken our nation and hurt our economy. The proposal to cut funding for the Special Olympics, a featured cut in each of this administration’s three budgets thus far, garnered widespread bipartisan backlash causing President Trump to abandon the proposed cut. However, it is evident that this cut is the tip of the iceberg and indicative of a larger-scale assault on the supports for people with disabilities in this country. We urge you to direct each of our Secretaries and Administrators to review their budgets for cuts to disability programs and act to restore the recommendations for funding.

Sincerely,
Senator Robert P. Casey, Jr.
Senator Sherrod Brown

Measles: 465

In The Politics of Autism, I analyze the discredited notion that vaccines cause autism.   This bogus idea can hurt people by allowing disease to spread.

From CDC:

From January 1 to April 4, 2019, 465** individual cases of measles have been confirmed in 19 states. This is the second-greatest number of cases reported in the U.S. since measles was eliminated in 2000.

The states that have reported cases to CDC are Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Kentucky, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oregon, Texas, and Washington.

Summer Ballentine at AP reports on a Missouri legislative hearing:

Parents testified to lawmakers that their unimmunized children were turned away from daycares and doctors. Republican Rep. Lynn Morris, a pharmacist from southwest Missouri, said parents are being pressured to vaccinate their children.

“Parents are getting bullied,” Morris said. “They’re getting bullied by county health departments. They’re getting bullied by schools. They’re getting bullied by their doctors. They’re being intimidated, and I just don’t think that’s right.”

The Republican’s bill would ban discrimination against unimmunized children in doctors’ offices, daycares, public schools and colleges if families have legal exemptions. Missouri grants exemptions for religious and medical reasons.

...
Janessa Baake, from the city of Peculiar in southwestern Missouri, cited concern over potential medical risks and told lawmakers Monday that her 3-year-old daughter is unvaccinated. She said after being denied by a Missouri doctor, she now takes her daughter to a Kansas pediatrician.

Another man said his two children developed autism after being vaccinated as toddlers.

“All of the stories and the anecdotes that we heard are very important, but I don’t think that they can be used to refute science,” Ferguson Democrat Rep. Cora Faith Walker said during a break in the hearing.

Multiple studies have debunked claims that measles, mumps and rubella vaccinations increase the risk for autism, and the National Institutes of Health says reports of serious reactions are rare: about one every 100,000 vaccinations. In the U.S., more than 90 percent of the population nationally is properly vaccinated.

Antivaxxers Hijack the Star of David

In The Politics of Autism, I analyze the discredited notion that vaccines cause autism.   This bogus idea can hurt people by allowing disease to spread.

From the Anti-Defamation League:

In recent months, some anti-vaccine activists (known as anti-vaxxers) have appropriated the yellow Star of David badge, which some European Jews were required to wear during the Holocaust, to symbolize their “persecution” at the hands of government vaccine rules.

The stars, emblazoned with the stylized words “No Vax,” are showing up on social media, especially on Facebook, and at anti-vaccine events. This is a hugely inappropriate use of this enduring symbol of the persecution of Jews by the Nazis during World War II and minimizes and trivializes the experiences of the survivors and victims of the Holocaust.

“The Holocaust was a unique event in human history. European Jews were forced to wear yellow Stars of David by the Nazis as a kind of scarlet letter, a form of persecution and forced exclusion from society,” Jonathan A. Greenblatt, CEO of the Anti-Defamation League, told the Washington Post. “It is simply wrong to compare the plight of Jews during the Holocaust to that of anti-vaxxers. Groups advancing a political or social agenda should be able to assert their ideas without trivializing the memory of the six million Jews slaughtered in the Holocaust.”

The anti-vaccine movement has been gaining momentum in communities across the country, and recent measles outbreaks have moved their campaign back into the spotlight, with some local governments responding by enforcing stricter vaccine requirements.

In Arizona and New York, new vaccine rules have been met with protests, some of which lean heavily on Holocaust analogies. On Facebook, the Star of David imagery is commonly used by anti-vaxxers, who also draw comparisons between vaccine rules and state-sponsored genocide. Facebook recently announced they will no longer support or promote anti-vaccination “news” stories or ads; the crackdown will be carried out in partnership with the World Health Organization and the U.S. Centers for Disease Control and Prevention.

The Star of David trend gathered additional momentum in late March, when anti-vaccine activist Del Bigtree took the stage at a “Parents Call the Shots” event in Austin, Texas, to rail against vaccines.

Bigtree, the chief executive of ICAN (Informed Consent Action Network), quoted from Rev. Martin Niemoller’s Holocaust-era poem “First They Came,” then referred to the Hasidic community in Rockland County, NY, where many parents have refused to vaccinate their children, and which is currently experiencing a measles outbreak. “How will we know if you’re not vaccinated?” Bigtree shouted in a mocking tone, referring to measures the local government is taking to bar unvaccinated children from public spaces.

“How will we know to arrest you? Maybe we’ll do it the same way we did the last time. So for you, for all the Hasidic Jews in New York, who never thought this moment would come, I stand with you! I stand for your religious convictions. We will let you believe in your God.” As the crowd cheered, Bigtree pinned a yellow “No Vax” Star of David to his lapel.

Poland’s Auschwitz Memorial and Museum quickly rebuked Bigtree’s theatrics:

“Instrumentalizing the fate of Jews who were persecuted by hateful anti-Semitic ideology and murdered in extermination camps like #Auschwitz with poisonous gas in order to argue against vaccination that saves human lives is a symptom of intellectual and moral degeneration.” Other organizations, including ADL, weighed in with similar condemnations.

This abuse of Holocaust-era imagery does not appear to have caught on in the white supremacist community, although Roy Batty at the neo-Nazi website Daily Stormer ridiculed the backlash, writing, “Don’t they know that the yellow star is a symbol of Jewish pride and therefore not to be used by the goyim?”

One commenter on Daily Stormer offered this plan to further inflame the situation: “Every minor slight, insult and emotionally jarring event should now be symbolized with the gold star. Dilute the f--- out of its meaning.”

Autistic Strengths and Weaknesses: Sometimes a False Dichotomy

In The Politics of Autism, I discuss the employment of adults with autism and other disabilities. Many posts have discussed programs to provide them with training and experience.

At Autism in Adulthood, Ginny Russell and colleagues have an article titled "Mapping the Autistic Advantage from the Accounts of Adults Diagnosed with Autism: A Qualitative Study."  The abstract:

Background: Autism has been associated with specific cognitive strengths. Strengths and weaknesses have traditionally been conceptualized as dichotomous.

Methods: We conducted 28 semi-structured interviews with autistic adults. Maximum variation sampling was used to ensure diversity in relation to support needs. We asked which personal traits adults attributed to their autism, and how these have helped in the workplace, in relationships, and beyond. Data were collected in two stages. Responses were analyzed using content and thematic techniques.

Results: The ability to hyperfocus, attention to detail, good memory, and creativity were the most frequently described traits. Participants also described specific qualities relating to social interaction, such as honesty, loyalty, and empathy for animals or for other autistic people. In thematic analysis we found that traits associated with autism could be experienced either as advantageous or disadvantageous dependent on moderating influences. Moderating influences included the social context in which behaviors occurred, the ability to control behaviors, and the extent to which traits were expressed.

Conclusions: Separating autistic strengths from weaknesses may be a false dichotomy if traits cannot be isolated as separate constructs of strengths or deficits. If attempts to isolate problematic traits from advantageous traits are ill conceived, there may be implications for interventions that have reduction in autistic traits as a primary outcome measure.

Special Education Service Use

In The Politics of Autism, I write about special education and the Individuals with Disabilities Education Act.

Christin A. McDonald and colleagues have an article in The Journal of Autism and Developmental Disorders titled "Special Education Service Use by Children with Autism Spectrum Disorder." The abstract:

In the last decade, the prevalence of children with autism spectrum disorder (ASD) without intellectual disability (ID) in schools has increased. However, there is a paucity of information on special education placement, service use, and relationships between service use and demographic variables for children with ASD without ID. This study aimed to describe and explore variation in type and amount of special education services provided to (N = 89) children with ASD. Results indicated that the largest percentage of children received services under the Autism classification (56.2%) and were in partial-inclusion settings (40.4%). The main services received were speech (70.8%) and occupational (56.2%) therapies, while few children received behavior plans (15.7%) or social skills instruction (16.9%). Correlates with service use are described.

California, Vaccines, and Measles

In The Politics of Autism, I look at the discredited notion that vaccines cause autism. The antivax movement has led to outbreaks of measles, which are costly. There are already more cases of measles than in all of 2018.

Cathie Anderson at The Sacramento Bee:

UC Davis Health said Wednesday they sent out roughly 200 letters to people who may have been exposed to the highly contagious measles virus March 17 in the emergency department at UCD Medical Center. A young girl taken care of there was diagnosed with the illness.

The letter from UC told recipients: “You will need to notify your primary health care provider(s) and your child’s provider(s) of this possible exposure to discuss your possible risk of infection, vaccination history, and other questions you may have.”

One mother, Rayna Souza, told Fox News 40 that she was dismayed that her terminally ill son, 7-year-old Jackson, had been in the hospital’s ED within an hour of the Calaveras County girl who was diagnosed with measles. Souza didn’t immediately respond to The Bee’s requests for interviews, so it was not immediately known whether Jackson was vaccinated for measles.

Barbara Feder Ostrov at California Healthline:

Doctors in California have broad authority to grant medical exemptions to vaccination, and to decide the grounds for doing so. Some are wielding that power liberally and sometimes for cash: signing dozens — even hundreds — of exemptions for children in far-off communities.

“It’s sort of the Hail Mary of the vaccine refusers who are trying to circumvent SB 277,” the California Senate bill signed into law by Gov. Jerry Brown in 2015, said Dr. Brian Prystowsky, a Santa Rosa pediatrician. “It’s really scary stuff. We have pockets in our community that are just waiting for measles to rip through their schools.”

The number of California children granted medical exemptions from vaccinations has tripled in the past two years.

A release from State Senator Richard Pan:

Dr. Richard Pan, a pediatrician and state senator representing the Sacramento region and Assemblywoman Lorena Gonzalez who represents the San Diego area, introduced SB 276 today to strengthen oversight of the medial exemption process which a handful of doctors in the state are abusing by selling medical exemptions to parents.

“Medical exemptions have more than tripled since the passage of SB 277. Some schools are reporting that more than 20 percent of their students have a medical exemption,” said Dr. Richard Pan. “It is clear that a small number of physicians are monetizing their exemption-granting authority and profiting from the sale of medical exemptions.”

“Three years ago, we stepped up our state’s vaccination laws to protect students and the entire public from being exposed to potential diseases. Now, we’re seeing ant-vaccination parents and a few doctors get around that law by loosely seeking and issuing medical exemptions when families are willing to pay,” Assemblywoman Gonzalez said.

“The real cost is a threat to herd immunity and public health. That’s why I am co-authoring legislation today with Sen. Pan to say enough is enough,”

To combat the proliferation of fraudulent medical exemptions, Senate Bill 276 will reshape California’s process to require state-level public health approval of all exemptions. Senate Bill 276 is co-sponsored by the California Medical Association, the American Academy of Pediatrics, California and Vaccinate California.

Under SB 276, medical exemptions will be granted by the California Department of Public Health (CDPH). Physicians will submit information to CDPH, including the reason for the exemption, the physician’s name and license number and they will need to certify that they have examined the patient.

Additionally, under SB 276, CDPH will create and maintain a database of medical exemptions, and CDPH and County Health Officers will have the authority to revoke medical exemptions granted by licensed physicians if they are found to be fraudulent or inconsistent with contraindications to vaccination per CDC guidelines.

Colorado Approves Medical Marijuana for Autism

In The Politics of Autism, I write:

The conventional wisdom is that any kind of treatment is likely to be less effective as the child gets older, so parents of autistic children usually believe that they are working against the clock. They will not be satisfied with the ambiguities surrounding ABA, nor will they want to wait for some future research finding that might slightly increase its effectiveness. They want results now. Because there are no scientifically-validated drugs for the core symptoms of autism, they look outside the boundaries of mainstream medicine and FDA approval. Studies have found that anywhere from 28 to 54 percent of autistic children receive “complementary and alternative medicine” (CAM), and these numbers probably understate CAM usage

These approaches sometimes include marijuana.

Kieran Nicholson at The Denver Post:

A bill allowing Coloradans with autism to use medical marijuana was signed into law Tuesday by Gov. Jared Polis.

The new law — HB19-1028 — adds autism to the list of disabling medical conditions that allow a person to legally use medical marijuana, according to the bill.

The bill, sponsored by state Reps. Edie Hooton, D-Boulder, and Kim Ransom, R-Littleton, passed through the house on Feb. 7 without a single “no” vote; it passed through the Senate on March 20 by a vote of 31-4. Earlier, the bill passed the health committee by a 10-1 vote.

Under the law, “autism spectrum disorder” must be “diagnosed by a primary care physician, physician with experience in autism spectrum disorder or licensed mental health provider.”

Autism Society Backs Autism CARES Act

The Politics of Autism discusses legislation before Congress.

From the Autism Society:

In celebration of Autism Awareness and Acceptance month, please contact your Members of Congress and ask them to co-sponsor and help move the bill to reauthorize and improve the Autism Collaboration, Accountability, Research, Education, and Supports (CARES) Act (S. 427/HR 1058). If your member(s) are co-sponsors now, please thank them (see list of current sponsors below).

Since enactment in 2006, this law has gone a long way toward training health professionals to diagnose and provide evidenced-based services to individuals on the spectrum and increasing research and awareness regarding this complex neurodevelopmental disability (see Issue Brief and ASA campaign page for more information about the law).

The bill reauthorizes the law for another five years; further expands the mission of the law to provide research, surveillance, education, and services to individuals with autism and other developmental disabilities across the lifespan. It also provides added focus on expanding services and supports for individuals with autism, among other minor improvements.

These activities will end if the law is not reauthorized by September 30, 2019!
Action Needed:

Please contact your representative and Senators. Message: Please co-sponsor the bill to reauthorize the Autism CARES Act (S. 427 and HR 1058)

Call by phone using the Capitol switchboard at (202) 224-3121 or email using the Action Center(all you need is your zip code). A sample letter is provided and can be edited.


See list of 35 House co-sponsors of House bill (HR 1058)
See list of 7 co-sponsors of Senate bill (S. 427)

Already More Measles Cases Than In All of 2018

In The Politics of Autism, I look at the discredited notion that vaccines cause autism. The antivax movement has led to outbreaks of measles, which are costly. There are already more cases of measles than in all of 2018.

CDC reports:




Lena Sun at WP:

In Austin, Del Bigtree, chief executive of an anti-vaccination group called ICAN, wore a yellow star during a rally last Thursday to identify with parents who decline to vaccinate their children. A spokesman for Bigtree said he took the action “to let the Jewish community of Rockland County know he stands with them.”

After photos of Bigtree were posted on Twitter, the official account of the Auschwitz Memorial and Museum in Poland tweeted in response: “Instrumentalizing the fate of Jews who were persecuted by hateful anti-Semitic ideology and murdered in extermination camps like #Auschwitz with poisonous gas in order to argue against vaccination that saves human lives is a symptom of intellectual and moral degeneration.”

Jonathan Greenblatt, chief executive of the Anti-Defamation League, said in a statement: “Groups advancing a political or social agenda should be able to assert their ideas without trivializing the memory of the six million Jews slaughtered in the Holocaust.”

Autism Alliance of Michigan

In The Politics of Autism, I discuss the employment of adults with autism and other developmental disabilities. Many posts have discussed programs to provide them with training and experience.  The book also discusses insurance coverage of applied behavior analysis.

Ron Fournier at The Detroit News:

[T]he Autism Alliance of Michigan has created an industry of autism support in 10 years. Michigan has gone from one of the worst states for someone with autism to live in, to one of the best.

A decade ago, there were 30 behavior therapists in Michigan who treated autism. Today, that number is in the thousands.

What changed everything was a law championed by the Autism Alliance of Michigan that requires insurance companies to cover behavioral therapy for autism. The insurance coverage attracted therapists and physicians to Michigan and created desperately needed avenues of support and treatment. Today, the average age of diagnosis and start of treatment in Michigan has dropped from age seven to age four. We know from research, the earlier a person can receive therapy and support the more likely they are to thrive long-term.

Brian Calley at Bridge Michigan:

As lieutenant governor from 2011-2019, and a member of the Autism Alliance of Michigan (AAoM) board of directors, I’ve proudly worked side-by-side with advocates, legislators and friends to change how people with autism are treated in Michigan.

In the last decade, we’ve made enormous progress. Because of the work of AAoM and autism advocates across our state, behavioral therapy for someone with autism is now covered by health insurance including Medicaid. This was a huge step in attracting therapists to Michigan to ensure those in need received early support. We also helped change someone with autism’s school experience by eliminating restraints and supporting inclusive teaching practices. This is a strong start, but we can do more.

People with autism are an amazing, untapped pool of talent that are patiently waiting for the right job. Waiting patiently for an open-minded employer is not enough. We can change this, but it involves widening our view of the right workforce. During my time as lieutenant governor, I had the opportunity to work with and learn from companies doing innovative things to recruit diverse talent. For example, Meijer has found great success by hiring people with autism by focusing on what an employee can do and excels at and tailoring jobs and responsibilities to fit the person. This is what everyone wants in the workplace: to be understood and have the opportunity to excel.