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Can Autism be confused with schizophrenia?

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Can Autism be confused with schizophrenia?

The term autism was first used by the Swiss psychiatrist Eugen Bleuler in 1919 to describe a withdrawal from reality with a pathological predominance of inner life. The term autism was included within his description of dementia praecox, the original term for schizophrenia. In the first edition of The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 1952), autism was classified as an expression of childhood schizophrenia. It was not until the third edition in 1980 that autism was conceptualised as an independent disorder. A recent meta-analysis has indicated that around 6% (range 4-12%) of autistic adults have a Schizophrenia Spectrum Disorder (SSD) (Marin et al., 2018), with a prevalence of SSD in the general population of 1.1% (Rossler et al., 2005).

The differential diagnosis is one of the most difficult and complex diagnostic challenges and requires a high level of expertise in both areas. Clinicians involved in diagnosing autism and schizophrenia often come from different backgrounds and use different diagnostic methods. Similarities between both disorders can lead to misdiagnosis and inappropriate treatment. This article will explore the resemblances and differences.

Screening instrument

A new screening questionnaire is currently being developed to differentiate between autism and schizotypal disorder (SD). The SchiZotypy Autism Questionnaire (ZAQ) has 134 items, and when the research is completed, it will have a cut-off score and contribute to more effective discrimination between autism and SD (Parvaiz et al. (2023).

Diagnostic criteria for schizophrenia

The diagnostic criteria for Schizophrenia, according to DSM 5 TR (APA, 2022), include delusions, hallucinations, disorganised speech and behaviour and diminished emotional expression or avolition.

Delusions

The idiosyncratic beliefs of an autistic person can be confused with the delusional ideas of a person who has schizophrenia. However, in schizophrenia, delusions do not follow logical reasoning, whereas in autism, the beliefs are based on logical reasoning that is easy to follow. Clinicians recognise that severe depression and other mood disorders, such as bipolar disorder and anxiety disorders, can sometimes lead to psychotic features and mood-congruent delusions (Ghaziuddin, 2005a); for example, a person with severe depression may develop auditory hallucinations that are related to the depression, for example, voices telling the person to kill themselves, but there can be a qualitative difference from the voices associated with schizophrenia.

We now have a cognitive model for the emergence of delusional beliefs in autistic adults (Abell & Hare, 2005). Fundamental to these beliefs are cognitive deficits in executive functions, autobiographical memory and Theory of Mind.

A characteristic of autism is having special interests or passions and cognitive rigidity.  The interests may involve collecting objects or information, but some interests could be interpreted as indicating schizophrenia. We knew an autistic adult who had an intense interest in medieval church law and, due to his reading of obscure religious texts, made the logical decision that the current Pope was illegitimate. He was determined to travel to the Vatican to denounce the Pope based on the evidence he had carefully analysed and collated. There were no accompanying signs of schizophrenia, but he was admitted to a secure psychiatric hospital and discharged when he discovered a replacement interest in computer games.

One of the compensatory mechanisms for an autistic person, who may achieve limited social inclusion and acceptance, is to create a fantasy life that can include imaginary friends and imaginary worlds in which he or she is socially successful and popular. The contrast between the real and imaginary world can become quite acute during adolescence. Under extreme stress, the autistic adolescent may create a fantasy world that becomes not simply a mental sanctuary and source of enjoyment but a cause of concern to others, that the distinction between the fantasy world and reality is becoming blurred. A tendency to escape into one’s imagination as a compensatory mechanism can be interpreted as a delusional state of mind.

An autistic person may develop what appear to be signs of paranoia, potentially indicative of the delusions associated with schizophrenia, but this may be an understandable response to authentic aversive social experiences. Autistic children and adolescents encounter greater bullying and teasing than their peers. Once another child has deliberately tormented an autistic child, any subsequent confusing interaction with that non-autistic child can cause the autistic child to assume that the interaction was intentionally hostile. In addition, the extraordinary hearing abilities associated with autism can enable an autistic person to hear derogatory comments about them spoken at some distance or in another room, which are spoken with the assumption that their comments would be inaudible. Bullying and derogatory comments can eventually lead to long-term feelings of persecution and distrust and contribute to social withdrawal. The retreat to the safe sanctuary of a bedroom can resemble the social withdrawal associated with the prodromal stage of schizophrenia.

One of the concerns during a diagnostic assessment for schizophrenia in an autistic person is differentiating between the anticipated consequences of an impaired or delayed Theory of Mind and the paranoia and persecutory delusions associated with schizophrenia. A research study examined the potential link between impaired or delayed Theory of Mind and paranoia in young autistic adults (Blackshaw et al., 2001). An incident such as being ignored by a friend could be conceptualised in terms of the situation (he did not see you, was in a hurry, etc.), which uses the circumstances as an explanation, or it could be conceptualised in terms of his mental intentions (he did not want to talk to you, or he wanted to make you feel embarrassed or ignored). The study used a series of tests and questionnaires to measure the degree of impaired Theory of Mind and paranoia.  The autistic participants in the study scored lower on tests of Theory of Mind and higher on measures of paranoia than non-autistic controls. However, an analysis of the results of the study found that the paranoia was due to impaired Theory of Mind abilities and was qualitatively different to the characteristics of paranoia observed in people with a diagnosis of schizophrenia. The paranoia was not a defence strategy, as occurs in schizophrenia, but due to confusion in understanding the subtleties of social interaction, intentions and social rules.

Hallucinations

Sensory sensitivity associated with autism can be misinterpreted as hallucinations (Marin et al., 2018). The Sensory Perception Questionnaire (SPQ) was designed to explore the sensory perception of autistic adults (Tavassoli et al., 2014), and the questionnaire includes items such as:

I would be able to hear the sound of a leaf blown by the wind on a quiet street.

I can hear electricity humming in the walls.

I would be able to hear the sound of a vacuum cleaner from any room in a two-story building.

I would be able to smell the smallest gas leak from anywhere in the house.

I would be the first to hear if there was a fly in the room.

I would be able to smell the difference between most men and women.

I can see dust particles in the air in most environments.

I would detect a new smell in my house instantly before anyone else.

Non-autistic individuals would not perceive these sensory experiences and could accuse an autistic person of experiencing a hallucination.

We have noted that some autistic children and adults tend to vocalise their thoughts, unaware of how confusing or annoying this can be to others. The thought vocalisation can occur as a means of problem-solving, with some adolescents stating that they can improve their thinking by talking to themselves or have difficulty ‘disengaging mind from mouth’ when thinking. Such speech may occur out of a social context; the content is often a replay of the day’s conversations to understand the various levels of meaning or as a rehearsal of what to say for some future occasion. When lonely, the autistic adolescent can talk aloud to an imaginary person or friend and is not necessarily engaged in a dialogue in response to an auditory hallucination.

We know that many autistic children and adults think in pictures (Grandin, 1995), and when we enquire whether such children have an inner, conversational voice to help them manage emotions or situations, they are often bewildered and state that they do not have an inner voice or conversation within themselves when thinking. This characteristic is probably due to a delay in the self-reflection aspects of Theory of Mind. Non-autistic children achieve this ability when they are about five years old. However, during adolescence, this attribute can ‘switch on’ for the first time for an autistic teenager who then reports having voices and conversations in his or her head. This could be interpreted as a sign of schizophrenia. It is essential to distinguish between an inner voice as a natural aspect of thought and problem-solving and the auditory hallucinations of schizophrenia.

Disorganised speech

Autism is associated with problems with the pragmatic and semantic aspects of language, such as conversational clarification and repair, which can include a tendency to switch topics that can confuse the other person (Paul et al., 2014). This characteristic could be interpreted as evidence of the speech disorder associated with schizophrenia. If in doubt as to what to say, the autistic person may change the topic to something they know about and would prefer to talk about and may not perceive how confusing this would be for their conversational partner.

Another problem with the semantic aspects of language that occurs with autistic individuals is making a literal interpretation. A psychiatrist may ask a question such as, ‘Do you hear voices?’ to which Wen Lawson, who is autistic, replied, ‘Yes’ – the correct answer based on a literal interpretation of the question (Lawson, 1998).  He heard voices of people talking around him every day. His answer contributed to the psychiatrist’s opinion that he had schizophrenia.

Diminished emotional expression or avolition

Autism is associated with emotional dyskinesia, such that there may be limited facial expressions of emotions and being perceived by others as having a ‘wooden’ face (Attwood, 2015). There is also an association with alexithymia, which is a lack of words for emotions. These characteristics could contribute to the impression of diminished emotional expression. Avolition is the inability to initiate or sustain purposeful movement, and autism is associated with catatonia, which was originally recognised and described in schizophrenic patients (Shah, 2019).

Co-occurrence of schizophrenia and autism

Some of the characteristics of schizophrenia are central to the differential diagnosis, such as a later onset and a period of gradual deterioration before positive psychotic symptoms emerge. An exploration of early childhood may confirm that the characteristics considered as evidence of schizophrenia have been persistent throughout childhood and early adolescence.

The superficial similarities between some of the characteristics of autism and schizophrenia do not imply that an autistic person is ‘immune’ from schizophrenia. We have known autistic people who develop unequivocal signs of schizophrenia, which has been confirmed by research (Ghaziuddin, 2005a; Stahlberg et al., 2004). However, we need research on the most effective treatments for an autistic person who develops schizophrenia in terms of medication, psychological therapy and support and best practice guidelines (Foss-Feig et al., 2020).

In our extensive clinical experience, we have seen families with an autistic child who have a relative diagnosed with schizophrenia, an association confirmed in the research literature (Ghaziuddin, 2005b). In retrospect, we cannot be sure if the relative genuinely had schizophrenia or the characteristics of autism that resembled schizophrenia.

Before our current understanding of autism, an autistic adult with intellectual and language abilities within the normal range experiencing what would have been considered a ‘nervous breakdown’ would have been referred to a psychiatrist who would not have known about autism.  They may have received a diagnosis of atypical or undifferentiated schizophrenia (Perlman, 2000). Anti-psychotic medication would not be as effective as expected and primarily act as sedation. Electro Convulsive Therapy (ECT) and even leucotomy may have been used for a patient whose signs of schizophrenia were not responding to antipsychotic medication in a psychiatric hospital.

Tony obtained his clinical qualifications during the last days of the large mental hospitals around London that accommodated thousands of long-term psychiatric patients. With hindsight, he recognises that some of the patients in the old institutions with a diagnosis of atypical schizophrenia would today be diagnosed as autistic. The diagnosis of schizophrenia was a diagnostic label to justify admission and inpatient care (Schalkwyk et al., 2015). If such individuals are now residents in community psychiatric services, they may benefit from a re-assessment by a specialist in autistic adults.

A recent study of the prevalence of autistic patients in American psychiatric hospitals found a prevalence of 10%; almost all were diagnosed as having schizophrenia (Mandell et al., 2012). Psychiatric hospitals are not ‘autism-friendly’ in terms of staff knowledge of autism and adapting the environment to accommodate aspects of autism, such as sensory sensitivity, need for solitude and personal space and being emotionally sensitive to the distress of other patients.

We are concerned about the limited training and supervised clinical experience of adult psychiatrists in the diagnosis of autism. This is particularly relevant when considering the high level of autism associated with a range of psychiatric disorders, such as depression, anxiety, substance abuse, eating disorders and schizophrenia.  A recent study in Sweden screened new patients referred to an adult psychiatric outpatient clinic for autism. The prevalence of autism in this population was estimated as at least 19% and possibly up to 35%, two-thirds of whom had never been previously assessed for autism (Nyrenius et al. (2022).

Conclusion

Autism was originally conceptualised as an expression of schizophrenia and subsequently recognised as a distinct and separate condition. However, there are aspects of autism that could be confused with schizophrenia, and we must ensure that clinicians are trained and experienced in the differential diagnosis.

References

Abell and Hare (2005) Autism 9

American Psychiatric Association The Diagnostic and Statistical Manual of Mental Disorders (1952, 1980 and 2022)

Attwood (2015) The Complete Guide to Asperger’s Syndrome London, Jessica Kingsley Publishers.

Blackshaw et al. (2001). ‘Theory of Mind, causal attribution and paranoia in Asperger syndrome.’ Autism 5,147-163

Bleuler, (1911) dementia praecox oder Gruppe der Schizophrenien. Handbuch Der Psychiatrie.

Foss-Feig et al., (2020) Schizophrenia and other Psychotic Disorders in Autism Spectrum Disorder, In White, Maddox and Mazefsky (Eds) The Oxford Handbook of Autism and Co-Occurring Psychiatric Conditions, Oxford, Oxford University Press

Lawson, W. (1998) Life Behind Glass: A personal account of Autism Spectrum Disorder. London: Jessica Kingsley Publishers.

Ghaziuddin, M. (2005a). Mental Health Aspects of Autism and Asperger Syndrome. London: Jessica Kingsley Publishers.

Ghaziuddin, M. (2005b). ‘A family history study of Asperger syndrome.’ Journal of Autism and Developmental Disorders 35,

Grandin (1995) Thinking in Pictures New York, Doubleday.

Mandell et al. (2012) Autism 16.

Marin et al. (2018). Prevalence of schizophrenia spectrum disorders in average-IQ adults with autism spectrum disorder. Journal of Autism and Developmental Disorders 48

Nyrenius et al. (2022). Journal of Autism and Developmental Disorders 52.

Parvaiz et al. (2023). BMC Psychiatry 23

Paul et al. (2014). Communication in Asperger’s syndrome. In: Asperger’s syndrome: Assessing and Treating High-Functioning Autism Spectrum Disorders McParland, Klin and Volkmar (Eds) The Guilford Press, New York.

Perlman, L. (2000). ‘Adults with Asperger disorder misdiagnosed as schizophrenic.’ Professional Psychology: Research and Practice 31,

Rossler et al. (2005). European Neuropsychopharmacology 15.

Shah (2019) Catatonia, Shutdown and Breakdown in Autism London: Jessica Kingsley Publishers.

Schalkwyk et al. (2015). Journal of Autism and Developmental Disorders 45.

Stahlberg et al. (2004) ‘Bipolar disorder, schizophrenia and other psychotic disorders in adults with childhood-onset AD/HD and/or autism spectrum disorders.’ Journal of Neural Transmission 111, 891-902.

Tantam, D. (2000) ‘Adolescence and adulthood of individuals with Asperger Syndrome.’ In A. Klin, F. Volkmar and S. Sparrow (eds) Asperger Syndrome. New York: Guilford Press.

Tavassoli, Hoekstra and Baron-Cohen (2014) Molecular Autism 5:29

Autism over the age of 50

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Autism over the age of 50

As clinicians, we have seen an increasing number of adults, and especially women, over the age of 50 seeking confirmation of autism in their developmental history and current profile of abilities. This has provided an opportunity to explore the ageing process associated with autism using a cross-sectional approach, that is the changing expression of autism within specific decades and a longitudinal approach by regularly seeing some autistic adults over several decades.

Research has also recently been conducted on autism over the age of 50 using semi-structured interviews. A study by Wake et al. (2021) included 150 research participants with an age range from 50 to 80 years, and Tony has been an associate advisor to a PhD study that used a detailed thematic analysis of ten autistic adults aged 53 to 74 years (Ommensen et al.). These studies and our extensive clinical experience are the basis of this blog.

Confirmation of autism later in life

Our clinical experience is that the discovery of autism later in life is perceived as a positive experience, with research confirming that nearly 80% of participants feel a sense of relief and being liberated, as illustrated in the following quotations from the Wake et al. (2021) study.

“I felt I didn’t have to blame myself any more for being me … at least not so much.”

“It was so nice to have a name for it!  And it allowed me to join a support group and start learning more about myself, as well as being clearer about which aspects of being on the spectrum I could work on and which I would just have to live with.”

Most research participants in the Wake et al. study felt relieved and better about themselves following confirmation of autism but distressed that they had lived such a great part of their lives without knowing they were autistic. They were unable to benefit during their childhood and adolescence from our current understanding of autism and the new range of acceptance and support programmes at school, home, work and in relationships. They have also not had access to psychological therapy specifically designed for autistic individuals to reduce feelings of anxiety and depression.

The overwhelming majority in the Wake et al. (2021) study recognized they were different to their peers during early childhood (95%) but without knowing why. They were often intellectually able students but had miserable experiences at school, academically and socially. It seems that the greatest distress came from not just being different but from not having words or concepts to express their autism or someone to confirm the pattern of autistic characteristics. All research participants regretted not having autism confirmed earlier in life.

After the confirmation of autism in their senior years, there were changes in terms of feeling better about themselves (67%) and making sense of who they are. There was a reduction in self-blame, restructuring their lives based on strengths and abilities and finding support communities. There was also less inclination to engage in camouflaging autism (Bradley et al, 2021).  There were also beneficial effects of confirmation of being autistic on mental health, as expressed by one research participant who said:

“My depression lifted without medication”.

Changing characteristics of autism

Tony convened a focus group of 27 autistic adults over the age of 50 to explore if the degree of expression of the diagnostic criteria for autism changed during the adult years. Participants were asked if, from their perspective, the specified diagnostic criteria for autism remained stable, increased, or reduced.

Section A of the DSM 5 diagnostic criteria for autism refers to difficulties with social-emotional reciprocity, reading body language and making and maintaining friendships and relationships. Around 60% of participants considered that these autistic characteristics increased, and only 17% considered that they reduced over time.

Section B refers to routines and rituals, interests and sensory sensitivity. The majority of participants (76%) considered that routines and rituals and sensory sensitivity were stable with no clear pattern for interests. It seems there was greater acceptance of sensory sensitivity and determination not to let the sensory pain inhibit their quality of life.

The comments of the participants were interesting in that although the signs of autism increased, coping strategies improved, as in the quotation:

“My coping skills are better so even though my symptoms may be worse, they may not seem worse”, and there was greater self-agency “I know what I am bad at so I avoid situations. I have more agency as an older person in that I can choose whether I expose myself to situations or not”.

Another participant observed that since finishing work, his stress levels have decreased, and therefore his autistic characteristics were less dominant, and he was perceived as a friendlier person.

Social abilities

Our clients have described having a gradual improvement in social abilities and number of friendships, which included having autistic friends after confirmation of their autism. There is a desire to connect with others intellectually rather than emotionally and, in later years, a desire to help other autistic adults (Wylie et al., 2016). However, socializing and maintaining friendships remains effortful throughout life and energy-draining.  However, most participants in the two research studies reported being less bothered by a perceived lack of friends than they were during earlier stages of life, and they gradually acquired socializing strategies: With life experiences, you learn the rules slowly, and you learn to compensate for what isn’t there by inherent nature.

Employment

Nearly 60% of the research participants in the Wake et al. (2021) study indicated that autism had made employment difficult, but 26% indicated that autism had helped in their chosen career. Our recent self-guided workbook Autism Working provides advice, strategies and activities to manage the difficulties that can arise at work for autistic adults (Garnett & Attwood, 2022). The workbook is based on our clinical experience and the experiences of older autistic adults.

Relationships

A source of stress in later years was relationship difficulties, especially a perceived failure to meet the emotional needs and expectations of their partners.  

The Wake et al. (2021) study found that 26% of participants described how they have never really been close to anyone. The study also found more diversity in sexual orientation for both genders than in the general population. This is consistent with our clinical experience.

Quality of life

There have been several research studies on the quality of life for autistic adults. McConachie et al. (2009) confirmed that quality of life was associated with a positive autistic identity and other people’s understanding and acceptance of autism. Other factors affecting quality of life included mental health issues, the nature of friendships and external support and services. Mason et al. (2018) found that the quality of life was lower for autistic adults compared to the general population and that the positive predictors for quality of life were being employed, in a relationship, and receiving support. Negative predictors were mental health conditions and the severity of autistic characteristics.

Maja Toudal is a clinical psychologist and autistic colleague in Denmark. She conducted an Internet survey asking autistic adults to describe their concept of quality of life and well-being. Their responses included:

  • To not be disturbed
  • Not having to act a certain way just because it is supposedly normal or appropriate
  • Having my own place to hide
  • Being able to express myself and be understood
  • Being able to excel in what I love to do
  • Space to pursue interests/hobbies
  • Daily engagement with preferred interests
  • Freedom from excess sensory pain/disturbance
  • Having a purpose in life
  • Accepting my autism and working with it to create harmony in my life instead of difficulties

A sense of well-being and quality of life was associated with reduced aversive sensory experiences and being able to engage in a passionate interest. This is important information when supporting an autistic person of any age.

Mental health

Many research participants in the Wake et al. (2021) study experienced mental health problems since their teenage years, but they did not understand what they were going through at the time and were not able to explain their thoughts and feelings to family and professionals effectively due to problems with interoception and alexithymia. In the above study, high levels of anxiety were reported by 74% of research participants and depression by 72%. with suicidal thoughts reported by 38% of participants. One in three of the research participants reported having post-traumatic stress disorder with a history of experiencing abuse in childhood and adolescence.

According to both the Ommensen et al. study and that of Wake et al. (2021), there was distrust and disdain for most forms of conventional mental health treatment and mental health professionals. They felt they were not listened to or understood and were unfairly judged and misrepresented, as illustrated in the following quotation.

“They were not interested in me. They’re interested in the drugs they can sell”.

An aversion to prescription medication for a mental health diagnosis was a common theme. Some participants had been prescribed medication for anxiety or depression but found them either unhelpful or the side effects outweighed any beneficial effects.  There was also the issue of compliance in taking the medication. Alcohol and illegal drugs were used during the early adult years by 36% of participants in the Wake et al. study, but this was reduced to 16% over the age of 50.

Recovery from depression was slow and lengthy, but the majority of participants reported that as they had grown older, they had experienced an improvement in their mental health. This was often due to discovering strategies themselves through identifying patterns in their experiences and emotional reactions and reading and experimentation rather than advice or therapy from health professionals. Several participants in the Ommensen et al. study were of the view that psychological treatment was not worthwhile unless it was tailored to an autistic individual’s unique needs and circumstances. Since, for most research participants, professional help was not seen as a therapeutic option; alternative self-regulatory strategies were actively discovered and employed to regulate emotions. Some of these were maladaptive practices, such as the use of alcohol, but most were positive such as mindfulness, meditation, and physical activities, such as gardening. These were consistently mentioned as successful techniques for emotional self-regulation. These activities, and sometimes a combination of them, were typically enjoyed as calming solitary pursuits that had developed over the life span and were cited by several participants as important to helping them achieve a sense of peace and emotional stability without the negative side effects of medication.

Some conventional cognitive behaviour therapy techniques were successful, such as positive self-talk

 “I used to try and sort of gee myself up and say, “oh come on for goodness sake” you know you can manage this” and all that sort of thing.”

According to Ommensen et al., with time and life experience, participants developed greater self-awareness and, ultimately, self-acceptance and self-forgiveness. “I think I’ve become more friends with myself”. Their positive appraisal of life left less room for negative emotions such as regret and guilt. The sub-theme of resilience was prevalent throughout the two studies. The participants conveyed self-acceptance and a lack of self-pity as they each described how they managed, with persistence and determination, a lifetime of mental health issues, relationship and employment difficulties, and feelings of difference and failure. This suggests that acceptance-based therapies would be particularly beneficial for autistic adults.

Physical health

Throughout life, there were concerns regarding insomnia or other sleep disorders, allergies, obesity and migraine. Research and clinical experience indicate that menopause can be a difficult time for autistic women with an increase in autistic characteristics and more meltdowns, as illustrated in this quote: “During menopause, I was on 3 meltdowns per week” (Groenman et al, 2022; Karavidas & DeVisser, 2022; Mosely et al., 2020).  Several participants in the focus group described how menopause increased their sensory sensitivity and was associated with new aversive sensory experiences. There is also a decline in executive functioning ability.

Recent research has confirmed an association between autism and early-onset dementia (Vivanti et al., 2021). The five-year prevalence of dementia in autistic adults aged 30-64 years was 4.04%, and only 0.97% in the non-autistic population.  Autism may also be associated with Parkinson’s disease (Croen et al., 2015; Geurts et al., 2022), with between 17% and 33% screening positive. Common features include rigidity, stiffness, slowness, getting ‘stuck’ and tremors.

Factors contributing to a positive outcome

Our clinical experience and the two main studies described in this blog suggest that factors contributing to a positive outcome tend to be personal and interpersonal. Personal factors are self-acceptance and a lack of self-pity, such as the comment, “I can look back now and cut myself a bit of slack”, celebrating the qualities associated with autism and a positive outlook. This includes having a sense of humour, positive reframing, and less self-blame, such as the comment, “I used to think I could make people like me if I tried hard enough. Therefore, if they didn’t like me, it was my fault”.

Another factor was discovering new enjoyable activities such as volunteer work and community groups and feeling there was less pressure to conform to society’s standards and focus on activities that brought pleasure and a sense of fulfilment. For many, life experience engendered resilience and, in later life, increased self-awareness and acceptance. Interpersonal factors include connecting with other autistic adults and the development of autistic friendships and a sense of belonging.

As explained by Ommensen et al., relative to earlier life stages, later life in the typically developing population generally brings emotional stability and improved emotional well-being, reductions in mental health problems, contentment, and a positive outlook. It seems that this pattern is also reflected in the developmental trajectory of autistic adults. There is the potential for positive change in the mature years.

References

Bradley et al. (2021) Autism in Adulthood 3 320-329

Croen et al (2015) autism 19 814-823

Garnett and Attwood (2022) Autism Working: A Seven-Stage Plan to Thriving at Work London, Jessica Kingsley Publishers

Groenman et al (2022) Autism, 1563-1572.

Geurts et al (2022) Autism 26, 217-229

Karavidas and DeVisser (2022) Journal of Autism and Developmental Disorders 52, 1143-1155.

Mason et al. (2018). Autism Research 11, 1138-1147

McConachie et al. 2020 Autism in Adulthood 2  4-12

Mosely, Druce and Turner-Cobb (2020). Autism 24 1423-1437

Ommensen, B. University of Queensland PhD thesis recently submitted.

Vivanti et al (2021) Autism Research 1-11

Wake, Endlich and Lagos (2021). Older Autistic Adults in Their Own Words: The Lost Generation AAPC Publishing, Shawnee, KS.

Wylie et al. (2016) The Nine Degrees of Autism London, Routledge