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Signs of Autism when first meeting a client

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Signs of Autism When First Meeting a Client

This blog is for clinicians, therapists, and counsellors to help identify the characteristics of autism in a client who has not previously been considered as autistic. We describe the signature characteristics of autism that may be apparent when first meeting a client or over several appointments when exploring their developmental history and profile of abilities. The blog is based on our extensive clinical experience and the formal diagnostic criteria for autism spectrum disorder (APA 2022).

Prevalence and pathways

According to the Centers for Disease Control and Prevention (CDC), the prevalence of autism in 2022 was estimated as one in 44 eight-year-old children. However, this is a conservative estimate, as many autistic adults camouflage and supress their autistic characteristics in social situations or choose a career that minimises the effects of autism, a form of compensation. Camouflaging and compensation may delay professional recognition of autism until the adult years.

There are many pathways for an autistic person to seek psychological, psychiatric, or mental health team support or counselling for career and relationship issues. We recognise that 79 per cent of autistic adults meet criteria for a psychiatric disorder at least once in their lives (Lever and Geurts 2016). The most common concerns are for high levels of anxiety and episodic depression. Other pathways are needing assessment and therapy for trauma, an eating disorder, borderline personality disorder, attention deficit disorder, gender dysphoria, addiction, and schizophrenia. There may also be issues regarding achieving and maintaining friendships, employment, or a long-term relationship. 

As the conversation with the client develops, the characteristics of autism may slowly emerge in their conversational abilities, social development, emotion communication, cognitive profile, ability to cope with change, interests, and sensory sensitivity.

Conversation abilities

The client’s conversation ability, while often demonstrating sophisticated vocabulary and depth of knowledge, may also include subtle difficulties with the pragmatic aspects of language, an unusual prosody, a tendency to make a literal interpretation, and difficulty with the comprehension and expression of nonverbal communication. The pragmatic aspects include the degree of reciprocity or ‘balance’ in the conversation: the person may talk too little or too much. When too little, there will need to be encouragement to say more than a few words in reply to a question and to provide some degree of elaboration and personal examples that illustrate a specific topic. When talking too much, the client’s conversation may be perceived as a one-sided monologue. There can be a difficulty in determining when the person has completed what they want to say, for example, failing to give eye-contact to indicate your turn to speak. In contrast, the client may frequently interrupt their conversation partner to make a comment or correct an error, oblivious of the signals not to interrupt, or that the person may be offended by the correction. 

There may also be difficulties knowing how to maintain and repair a conversation by seeking clarification and more information, as well as modifying language according to the social context. The client may also engage in too much or too little disclosure of personal or confidential information. 

Prosody may be unusual in terms of the speed, volume, rate, rhythm, and ‘melody’ of speech. There may be a lack of vocal tone and volume to indicate emotion and key words, and an unusual placement of stress and precise intonation. There can be a tendency to take a literal interpretation, which may become apparent when the other person uses idioms, sarcasm or ‘figures of speech’. 

One of the central characteristics of autism is a difficulty focusing on and reading nonverbal communication, which can become conspicuous during a conversation. There may be unusual aspects of eye-contact in terms of eye-contact frequency, duration, and ability to read another person’s facial expressions in order to modify the conversation. The person may be listening but not looking at the face of their conversation partner at key points in the interaction when eye-contact would not really be anticipated. One adaptation to autism is to appear to be looking at the person’s face, but instead focusing on their ears or forehead rather than their eyes, thus failing to determine what their conversation partner is thinking or feeling. And sometimes, even though there may be a focus specifically on someone’s eyes, there may still be difficulty reading facial expressions. As one autistic adult said, “People give messages with their eyes, and I don’t understand them.”

The difficulty reading nonverbal communication can occur for both conversation partners; the client’s facial expressions may be perceived as ‘still’ or ‘wooden’, and thus difficult to read. Their gestures may be limited or ‘stylised’, sometimes mimicking the gestures and posture of the conversation partner. There may be less use of nodding agreement, reciprocal smiles or complimentary sounds of compassion and interest. 

Social abilities

An exploration of social abilities and experiences may reveal difficulty making and keeping friends, delayed Theory of Mind abilities, a history of being bullied at school and work, and evidence of relatively effective but superficial social abilities. 

During childhood, there is likely to have been a time when the client first recognised that their social and friendship skills were not as advanced and complex as those of their peers. There may have been, and continue to be, a preference for solitary rather than social activities. During childhood and adolescence, there would have been a desire to establish and maintain friendships without a complete or realistic idea of what friendship entails. It is through extensive friendship experiences that we not only learn relationship skills, such as the art of compromise and conflict resolution, but also recognise the need for emotional as well as practical support. 

Theory of Mind is a psychological term to describe the capacity to understand and successfully relate to other people by determining what they may be thinking or feeling, and their mental state, knowledge, and intentions. This includes recognising that another person’s mental state may be different from one’s own. To develop Theory of Mind abilities, it is essential to be able to accurately read nonverbal communication and social context to infer someone’s thoughts and feelings and modify social behaviour accordingly. 

Many autistic adults have experienced rejection, humiliation and bullying from peers, especially in the high school years. Some of the incidents have been extremely distressing and traumatic. There is also an association between autism and all forms of abuse, which may lead to post traumatic shock disorder.

Social expressions of autism

A common perception of an autistic person is someone who considers social interactions as indecipherably complex, overwhelming and stressful, and chooses to be alone but does not necessarily feel lonely. However, there are autistic children and adults who are highly motivated to socially engage but may not be able to read the subtle social signals and social conventions of what to say and do. A metaphor to describe this expression of autism is that of a driver who does not see the traffic signals (nonverbal communication), or abide by the traffic code (social conventions). Their social behaviour may be perceived as intrusive or intense, such that the autistic person becomes bitterly disappointed that conversations, friendships and relationships are short lived. 

An adaptation to autism that creates the impression of social competence is for the person to acquire social abilities by supressing their autistic characteristics and instead observe, analyse, and imitate social behaviour, thus creating a social ‘mask’ and false persona. This adaptation may start in early childhood by avidly watching socially popular children, searching for patterns of social behaviour, and copying gestures, speech, interests, and topics of conversation. This adaptation is described as social ‘camouflaging’. 

Camouflaging requires the ability to suppress typically autistic behaviours, such as gently rocking to self-soothe, or talking excessively about a special interest, and instead appear interested in other people, making appropriate empathic gestures and comments: the creation of a social mask. While social success and acceptance may be achieved this way, the psychological cost is mental exhaustion in terms of being drained of mental energy by the effort of socialising. There is also the potential for the development of depression from energy depletion and the inability to express the authentic self.

During the initial conversation with the client, there may be the expected level of reciprocity and mutual reading of nonverbal communication. However, this may be due to their being very proficient and experienced in camouflaging their autistic characteristics. These abilities may have been achieved by intellectual analysis and practice rather than intuition. If the client has the autistic characteristics of difficulty coping with change, interests that are unusual in intensity or focus, and sensory sensitivity, it would be appropriate to compliment the client on their conversation and social skills, but also to ask how such social proficiency was achieved. An autistic client would describe using a range of sources of social information including observing, analysing and copying peers, watching television programmes (especially soap operas) to memorise scripts and responses, and seeking information on reading nonverbal communication and the art of conversation from literature, apps and YouTube. They may also rehearse their social and conversation scripts, or have a family member who provides social guidance.

Another social adaptation or compensation for autism during childhood is for autistic girls to prefer the company of boys, since their social dynamics are relatively simpler. They may feel safer and less likely to be bullied by boys, who often enjoy playing with a ‘tomboy’. An autistic adult may compensate by choosing a career that does not require much social engagement, such as a wildlife ranger; or they may develop an interest and talent in the arts, becoming an author, artist, musician, singer, or multi-linguist. Social eccentricities may be accepted and accommodated due to being valued by peers who recognise and admire a particular talent.

Emotion communication

Autism is associated with alexithymia, that is, the inability to focus attention on, recognise and accurately appraise, describe and moderate subjective emotions and body sensations, and then communicate those thoughts, sensations and emotions in words. Alexithymia is not exclusive to autism or a characteristic of all autistic adults but has been identified in at least 50 per cent of autistic adults, and in only 5 per cent of the general population (Kinnaird, Stewart & Tchanturia, 2019). Having alexithymia leads to a difficulty recognising internal emotional states, such that when asked ‘What are you feeling now?’, after some conscious thought, the reply may be, ‘I don’t know’. This is not being obtuse or evasive. There can be a genuine difficulty perceiving and converting internal states and emotions into speech. The full answer to the question would be, ‘I don’t know… how to mentally grasp the intangible emotions swirling in my mind, identify and label them accurately and communicate those feelings in speech so that you will understand’.

Another characteristic of alexithymia is to talk about experiences without reference to the emotional states of themselves and others. There is less spontaneous mention of emotions in conversation. This will affect autobiographical memory, such that an important event may be described primarily by the sequence of actions, rather than by the thoughts, feelings and intentions of others or themselves.

However, an autistic person is not oblivious to the emotional state of others, and may in fact be overly sensitive to another person’s negative mood. There appears to be a ‘sixth sense’ perception of someone’s anxiety, sadness or anger, which can lead to avoidance of some social situations or specific people due to the risk of being ‘infected’ by their distress, and being unsure how to help them. 

Having difficulty identifying and communicating internal emotional states can result in emotions increasing in intensity without sufficient cognitive evaluation and regulation, eventually leading to these emotions being released explosively as a meltdown. The developmental history and current concerns may include emotional meltdowns that are explosions of anger and anxiety, or implosions of intense despair and suicidal ideation.

Cognitive abilities

Autism is a different way of perceiving and learning, and this can lead to a cognitive profile that includes an ability to perceive and develop systems and patterns, and also to identify errors and detail that may not be recognised by others. There can also be an ability to store and recall information, and to find solutions to problems that are elusive to colleagues or employers. This may lead to a successful career as a recognised expert in a particular career or profession.

Ability to cope with change

The diagnostic criteria refer to distress at small changes and coping with uncertainty, as well as a tendency to insist on sameness and a preference for routines and consistency. For an autistic adult, variety is not the ‘spice of life.’ 

Interests and talents

Throughout childhood and into the adult years there is a history of hobbies or interests that are unusual in intensity or focus. Each interest has a ‘use by date’ that may range from hours to decades. The interests are associated with intense enjoyment and may also function as a thought blocker for anxiety or sadness. They also provide a sense of identity and social connection with those who share the same interest. 

During conversation, the client may be somewhat subdued and quiet, appearing to be reluctant to engage. However, when the topic of conversation is the person’s interest, they suddenly become enlivened, engaged and eager to disclose their expertise: almost an alternative persona.

While alexithymia is a difficulty converting thoughts and feelings into speech, a successful adaption to alexithymia is to express thoughts and feelings through the arts. The autistic adult may have a recognised talent as an artist, musician, composer, or author. The inner world is vividly expressed through the arts.

There may be a talent in the caring professions, especially psychology and psychiatry. The propensity from childhood to observe and analyse others to facilitate social engagement may evolve into achieving formal qualifications and a successful career as a teacher, therapist, psychologist, paediatrician, or psychiatrist. Autism is often associated with the altruistic desire help alleviate suffering and increase knowledge and abilities. There may also be a talent understand and caring for animals.

Sensory sensitivity

There can be an extraordinary perception of sensory experiences from the outside world, or ‘exteroception’. Specific sounds, types of lighting, tactile experiences, aromas, and emotional states of others can be perceived at such an intensity that the experience is aversive. In contrast, there can be difficulty sensing the internal world, or ‘interoception’. There appears to be a mind and body disconnection. The autistic person may not experience hunger or thirst to the same degree as other people, and may not be aware of the increasing heart rate and breathing that indicate rising anxiety or anger.

Screening for autism and recommending a formal diagnostic assessment

At the end of the first consultation, or after several consultations, some, but not necessarily all of the signs of autism may gradually become apparent. The next stage is to consider asking the client to complete screening questionnaires specifically designed to identify the characteristics of autism in an adult. These include the Autism Social Quotient (Baron-Cohen et al 2001) for men and women, and the GQ-ASD for women (Brown et al 2020). If their scores on these instruments are above the designated cut off, then a referral or subsequent appointment for a formal diagnostic assessment is warranted. 

References

APA (2022) Diagnostic and Statistical Manual of Mental Disorders-5 Text Revision. American Psychiatric Association 

Baron-Cohen et al (2001) Journal of Autism and Developmental Disorders 31 5-17 Available on the Internet at www.autismresearchcentre.com/research

Brown et al (2020) Autism in Adulthood 2, 216-226 Available to download at www.tonyattwood.com.au forms and questionnaires

Kinnaird, Stewart & Tchanturia (2019) European Psychiatry 55, 80-89

Lever and Geurts (2016) Journal of Autism and Developmental Disorders 46: 1916-1930

Can CBT be helpful for autistic adults?

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Can CBT be helpful for autistic adults?

There is considerable research which confirms that a high level of psychiatric conditions co-occur with autism, for example, Lever & Guerts (2016) found a co-occurrence rate of up to 79% and the majority of autistic individuals experience at least one co-occurring mental health condition (Lai et al 2019). Rates of anxiety and affective disorders, eating disorders, psychosis and traumatic stress are higher in autistic individuals than in non-autistic individuals (Hossain et al 2020) The therapy with the greatest empirical evidence for success in the treatment of psychiatric conditions, including anxiety disorders, depression, addiction and eating disorders to name a few, is cognitive behaviour therapy (CBT), but what is CBT and is CBT helpful for autistic adults who are experiencing mental health conditions? In this two-part blog, we firstly define CBT and examine its effectiveness as a therapy for autistic adults. In part two we describe important modifications to CBT which can be helpful when treating autistic adults who experience mental health conditions. Our recommendations are based on our extensive clinical experience and current empirical research.

The origins of CBT

In the 1930s psychologists began to explore aspects of behaviour and learning and Behaviour Therapy (BT) subsequently emerged as a reaction to psychoanalysis by focussing on how external events shape observable behaviour. In the late 1960s, BT included operant conditioning based on identifying the consequences of behaviour such as reinforcement and punishment. Operant conditioning and the functional analysis of behaviour became the basis of Applied Behaviour Analysis, which has many adaptations, including as an early intervention for autistic children.

CBT evolved from BT in the 1970s with the addition of social learning theory and cognitive theory. The cognitive theory emphasises the importance of information processing, including the role of memory and attention, and cognitive or thinking distortions. Social learning theory extended behavioural principles to include that we learn vicariously, by watching and imitating others. CBT accommodates aspects of a person’s cognitive interpretation and processing of events, as well as their capacity to learn by watching others. A central principle of the “C” in CBT  is that cognition and social learning mediate the relationship between life stress and psychopathology. Rigid and distorted beliefs about oneself, the world, and/or the future are explored and modified with CBT. In addition, CBT embraces learning by watching others, role-playing and skill rehearsal. The following definition of CBT from the American Psychological Association (APA, 2022) is helpful:

CBT is based on several core principles, including:

  1. Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
  2. Psychological problems are based, in part, on learned patterns of unhelpful behaviour.
  3. People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.

CBT treatment usually involves efforts to change thinking patterns. These strategies might include:

  • Learning to recognize one’s distortions in thinking that are creating problems, and then re-evaluate them in light of reality.
  • Gaining a better understanding of the behaviour and motivation of others.
  • Using problem-solving skills to cope with difficult situations.
  • Learning to develop a greater sense of confidence in one’s abilities.

CBT treatment also usually involves efforts to change behavioural patterns. These strategies might include:

  • Facing one’s fears instead of avoiding them.
  • Using role-playing to prepare for potentially problematic interactions with others.
  • Learning to calm one’s mind and relax one’s body.

Rational for CBT and autism

CBT has direct applicability to autistic children, adolescents and adults who are recognised as having delayed abilities in understanding, expressing, and managing emotions (Attwood 2007), and who, due to impaired Theory of Mind abilities, can make false assumptions as to the intentions and emotions of others (Baron-Cohen 2001). The therapeutic approach of CBT is to encourage the autistic person to be more consciously aware of their internal emotional state, their thinking and behavioural patterns and their bodily sensations or interoception. Recent research has confirmed that autism is associated with impaired interoception abilities (Suzman et al 2021).

CBT includes learning about and improving one’s ability to respond effectively to life situations, including social situations, transitions, highly stressful learning environments etc.  These life circumstances and others commonly cause anxiety and stress for autistic adults, leading to problems coping with strong emotions such as fear, worry, anger and depression. CBT includes improving self-reflection and reflecting on the thoughts and feelings of self and others. Both of these skills are necessary for emotion management but particularly difficult for autistic individuals who, due to their different neurology, tend to have a limited repertoire of responses to emotional arousal (Attwood 2007). Within CBT there is an opportunity to learn new skills to relax the autonomic nervous system and cope with social situations and other stressful life circumstances. Thus, CBT provides an opportunity to learn self-awareness and new strategies to manage, and in some cases overcome, mental health conditions.

Confirmation of the efficacy of CBT with autistic clients

Several studies have reviewed CBT as a treatment for autistic children (Perihan et al 2020; Selles et al 2015; Vasa et al 2014) and adults (Spain et al 2015) and found that over 70% of study participants responded positively to treatment, consistent with the expected response for the non-autistic population. A meta-analysis of 48 studies of CBT with autistic participants confirmed that CBT is effective using informant and clinician report measures (Weston, Hodgekins and Langdon 2016).

Our clinical experience has suggested that the effectiveness of CBT can be improved by recognising that a client may take some time to understand the concept of cognitive restructuring with more practice sessions required. There will probably be a need to increase the number of sessions from the conventional ten-session therapy to at least 20 sessions (Spain et al 2015).  The efficacy of CBT will be enhanced by encouraging belief in the client’s ability to regulate their emotions (Sharma et al 2014) and more experiential activities and increasing compliance with homework tasks.

CBT has been successfully applied to treat adult autistic clients who are anxious (Ung et al 2015) depressed (Attwood and Garnett 2016) and autistic children who have experienced trauma (Stack and Lucyshyn 2019).

New developments in CBT

CBT is constantly evolving and adapting to research and clinical experience and discovering new applications. The new developments include Mindfulness-Based Cognitive Therapy (MBCT) as well as Acceptance and Commitment Therapy (ACT) Dialectical Behaviour Therapy (DBT) and Cognitive Remediation Therapy (CRT). CRT has been suggested as a modality to increase cognitive flexibility (Stark et al 2021) in autistic clients. Modern technology is being used in incorporating CBT principles in popular computer games such as Minecraft in the new interactive CBT game Legend Land (2022).

A note on autistic burnout

We are increasingly recognising the potential for autistic burnout when demands exceed coping abilities or burnout as a response to stressful life events and long-term camouflaging (Higgins et al 2021; Mantzalas et al 2021).  Recovery is protracted and may last months or years.  Burnout affects mental health, energy levels and cognitive abilities. According to Higgins et al (2021), the degree of cognitive confusion and overload associated with autistic burnout could limit the effectiveness of conventional CBT. For example, many clinicians may treat depression using the traditional CBT methods of behavioural activation and increasing social contact. Both these methods are likely to increase burnout leading to a worsening of symptoms. Utilising cognitive restructuring may increase rumination and “analysis paralysis.” 

We are finding that modifying CBT to include skills training for the school and workplace to provide modifications including decreasing responsibilities and creating a more autism-friendly culture is more helpful than conventional CBT strategies. This may include consideration of part-time employment, and a review of career options and strategies to reduce stress and increase energy such as Energy Accounting (Attwood & Garnett 2016). There will also need to be consideration of attitude changes by educating work colleagues and line managers about the daily challenges faced by an autistic employee about coping with changes in work schedules and expectations, sensory experiences and social engagement (Garnett & Attwood 2022). Other recommended strategies for autistic burnout include connecting with others who have shared the same experiences and arranging more time to engage in their special interest.

Our clinical experience has indicated that emotion regulation and a positive sense of self have been achieved by greater self-compassion and self-acceptance, such as the comment “I can look back now and cut myself a bit of slack” CBT can include activities to celebrate the qualities associated with autism with a positive outlook encouraging greater resilience in coping with situations associated with distress and agitation.

Barriers to the acceptability and effectiveness of CBT for autistic adults

A recent study by Spain et al (2022) examined the perspectives of 50 CBT practitioners regarding potential barriers to CBT for autistic adults. Analysis of the data indicated six main factors, which are ranked from the most to least frequently reported barriers in the following list.

  1. Factors related to service providers such as long waiting times, lack of resources and autistic adults potentially being deemed ineligible or too complex for the service provider.
  2. Practitioner-related factors such as a lack of understanding and training in autism, diagnostic overshadowing, lack of knowledge of how to adapt CBT for autistic adults and appropriate metrics to measure change.
  3. Client-related factors such as multimorbidity, difficulties articulating thoughts and feelings, theory of mind impairments, sensory sensitivities, cognitive rigidity, difficulties tolerating change, generalising skills and adverse past experiences of therapy and services.
  4. CBT-related factors such as whether standard treatment protocols apply to autistic adults, and difficulties developing a therapeutic alliance.
  5. Factors relating to national guidelines such as the National Institute for Health and Care Excellence (NICE) in the United Kingdom.
  6. Considerations of the degree and nature of family support and engagement and poor links between service providers.

The study also made recommendations to enhance CBT services including increased practitioner knowledge of autism and having time to read relevant research and publications. Training is needed to include information on the core characteristics of autism and adapting standard treatment protocols for autistic clients and suggestions to enhance therapeutic communication and engagement.

Adaptations to CBT to accommodate the characteristics of autism

Learning profile

Throughout a CBT program, the autistic client will be required to learn about emotions within themselves and others and acquire new skills to regulate and express emotions, and manage challenging life circumstances. The distinctive learning profile associated with autism will need to be recognized by the clinician, through all aspects of the therapy including affective education, cognitive restructuring, learning new skills and the exposure therapy components of CBT.

Autism is associated with a different and distinctive way of perceiving, thinking, and learning and many autistic individuals function at the extremes of cognitive ability (Attwood 2007). Despite having a Full-Scale IQ in the normal range, they usually have a very uneven cognitive profile on an IQ test. For the clinician designing a CBT program, information from an IQ assessment can be invaluable in determining learning strengths and weaknesses. For example, if the autistic client has relatively advanced verbal reasoning skills, then understanding of the concepts and strategies used in CBT may be improved by the inclusion of relevant literature in the program. When reading a text, there are no interpersonal or conversational skills required, and the autistic client can give full cognitive attention to the text. If the autistic client has relatively advanced visual reasoning abilities, learning may be facilitated by computer programs, demonstration, role play, metaphor and visual imagery with less emphasis on conversation. The phrase ‘a picture is worth a thousand words’ is particularly relevant.

Attention and executive functioning

Psychologists divide attention into four components: the ability to sustain attention, to pay attention to relevant information, to shift attention when needed, and to encode attention – that is, to remember what was attended to. Autism is associated with problems with all four aspects of attention. These characteristics need to be recognised and accommodated during therapy, for example, more frequent breaks between and within activities, highlighting important text and ensuring full attention when explaining an important aspect of therapy.  Some therapy activities require the ability to shift attention during the activity and focus on new information. Unfortunately, autistic clients can have difficulty ‘changing track’ while engaged in a ‘train of thought’. There will need to be accommodation of a potential delay in processing time and cognitive closure before engaging in a new activity.

 Autistic clients often have problems with executive function, especially focussing on details rather than the ‘big picture’, conceptualizing and considering the potential outcomes of various decisions, and being able to plan and prioritize. There can also be difficulties modifying decisions based on results, that is flexible thinking. A metaphor for inflexible thinking is that of a train on a singular track, representing a ‘one track mind’. Unfortunately, our clinical experience has indicated that autistic clients tend to continue using incorrect strategies, not learning from mistakes – that is, failing to ‘switch tracks’ to get to the destination (i.e., finding a solution). This cognitive rigidity tends to become greater with increased anxiety. The inability to conceptualize an alternative response influences the progress of a CBT program. It is therefore important that the clinician encourages flexible thinking, asking, ‘What else could you do?’ and providing multiple choice options rather than anticipating the generation of spontaneous alternatives. Strategies to improve relaxation can also be used to facilitate flexible thinking within the CBT session and in real-life practice situations.

Another sign of impaired executive function is difficulty inhibiting a response (i.e., being impulsive) and using new strategies. The autistic client can be notorious for being impulsive in social situations, appearing to respond without thinking of the context, consequences, and previous experience. They can gradually become capable of thoughtful deliberation before responding, but under conditions of stress, or if feeling overwhelmed or confused, can be impulsive. It is important to encourage the client to relax and consider other options before responding and to recognize that being impulsive can be a sign of confusion and stress.

If the impaired executive function is formally confirmed, then the effectiveness of CBT could be enhanced by consideration of appropriate medication and implementing strategies designed to improve attention, memory, organization abilities and cognitive flexibility for autistic individuals (Moraine 2015). Another

strategy to reduce the problems associated with impaired executive functioning is to have someone act as an ‘executive secretary’. A family member may have already become an executive secretary, providing guidance with organizing and planning, promoting, and encouraging flexible thinking, especially with regard to completing the homework assignments of CBT and applying the new strategies in real-life situations. It is important during therapy to have regular communication with the client’s support network.

Fear of making a mistake

A learning characteristic of autism is a tendency to have a fear of making a mistake (Attwood 2007). When unsure what to do or say, the situation becomes a trigger for a flight, fight or freeze response. Research on the cognitive abilities of autistic children and adults has identified a conspicuous tendency to notice detail and errors more than typical individuals (Frith and Happe 1994). When combined with a fear of appearing stupid and having been ridiculed by peers at school or work, this can have a significant effect on the ability to learn. There can be a refusal to attempt a new activity that could fail, with the attitude of, ‘If you don’t try, you don’t make a mistake’.

It is important that the clinician encourages any suggestion without criticism and adopts a positive approach, implying that making a mistake is not a tragedy or a sign of intellectual disability. Making a mistake provides useful information to discover the elusive solution.  In other words, ‘we learn more from our mistakes than our successes’. Autistic clients can be very sensitive to any indication of being stupid. A valuable motivation in a learning situation can be to appeal to intellectual abilities with a comment such as, ‘that suggestion demonstrates your amazing intellectual ability and creativity which can be a more powerful motivator than pleasing others such as, ‘I am so delighted with that suggestion’.

Language profile

Autistic clients often have difficulties with the pragmatic aspects of language. Pragmatics refers to the use of language in social contexts and how people produce and comprehend meanings through language. Problems with pragmatics can occur in multiple areas of communication, such as talking in a monologue, lack of coherence (e.g., difficulty describing a sequence of events or providing a clear account of an event from a listener’s perspective), over-precise and technical information and turning the conversation to a favourite theme. The clinician may need to address and accommodate these characteristics, providing guidance in the ‘art of conversation’.

Autistic clients often make a literal interpretation of a comment, and this would affect the clinician’s use of idioms, figures of speech and sarcasm. It is important that the clinician provides very concrete examples of constructs and double-check that the autistic client has understood the information correctly. However, we have found that metaphors can be used as this provides a visualization of the theme or construct.

A central characteristic of autism is difficulty developing rapport and conversational reciprocity. An autistic client may not engage in social chit-chat or the give and take of conversation, making it harder for the clinician to sustain the interaction. Shorter sessions or encouragement of conversational skills may be helpful.  The clinician also needs to appreciate how direct or ‘blunt’ and honest the autistic client can be, due to difficulties with Theory of Mind and understanding the social conventions of conversation. It is important not to be offended by being frequently corrected or criticized.

The clinician will also need to be aware of their client’s preference to be addressed as an autistic person or a person with autism. There is the potential to offend by not using the client’s preferred form of address.

Special interests and talents

One of the central diagnostic characteristics of autism is the development of special interests. This can include information on topics such as the life cycle of a butterfly or an encyclopaedic knowledge of presidents of the USA or television programs such as Star Trek or Dr Who. The special interest has many functions, including feelings of enjoyment or euphoria in acquiring new items or knowledge on a specific theme and the intense mental focus acting as a thought blocker for feelings of anxiety, sadness, or anger. The interest can be constructively incorporated into a CBT program, for example, as an antidote to feeling sad, a thought blocker for anxiety and the ‘off switch’ for an emotional meltdown. A special interest in a character such as Harry Potter or Dr Who can be used to illustrate how a perceived hero copes with adversity, becoming a model of how they can cope with feelings such as anxiety and anger.

The interest can also be used to improve conceptualization. For example, if the special interest is weather systems, then emotions could be expressed as a weather report. The special interest can also be used in the affective education component of CBT. A project or field study for an autistic client whose special interest in aviation can be to visit an airport to observe the emotions of passengers saying farewell, greeting friends and relatives, and waiting for a boarding pass.

Consistency, certainty, and change

A characteristic of autism is a powerful desire to seek consistency and certainty in daily life, being able to relax when there is a clear routine or schedule of activities. Autism is also associated with having an intolerance of uncertainty (Maisel et al 2016; Stark et al 2021). There is also a positive correlation between intolerance of uncertainty, anxiety, repetitive behaviours, and sensory sensitivities (Hwang et al 2020).

The clinician must create a schedule of activities for the session, with clear information on the objectives and the probable duration of each activity. We now have CBT programs specifically for autistic clients who have an intolerance of uncertainty in their daily lives (Keefer and Vasa 2021; Rodgers et al 2017).

The DSM-5-TR diagnostic criteria for autism include in section B, insistence on sameness and extreme distress at small changes and rigid thinking patterns. CBT is based on the premise that the client can change their perceptions, thoughts, and reactions. However, there may be some resistance from an autistic client that change is warranted and feasible. They may require some convincing and positive feedback on the value of cognitive change.

Thinking styles

CBT addresses maladaptive and adaptive thinking styles that can affect emotion perception and regulation. We have recognised a tendency for autistic clients to catastrophize, potentially leading to an emotional meltdown and to personalize, that is blame themselves rather than consider how other people may have contributed to the situation. There is also a tendency to avoid emotional situations rather than cope with the situation and to suppress emotions by using a thought blocker such as playing computer games. CBT will need to encourage adaptive thinking styles such as self-soothing and motivating inner speech such as ‘I can cope with this’ and considering alternative perspectives and responses (Albein-Urios et al 2021). There can be a pessimistic thinking style which will affect cognitive restructuring and the clinician can encourage reality testing to reduce the propensity for a negative perception of outcomes. There can also be a concern with the disclosure of thoughts and feelings which can be affected by difficulties with alexithymia and interoception.

Alexithymia and interoception

Alexithymia is a difficulty recognising and accurately labelling different emotions and body sensations. A person with alexithymia can tell if they are feeling a “good” emotion or a “bad” emotion but could not necessarily tell you what they are feeling more accurately. A recent meta-analysis of studies on alexithymia and autism (Kinnaird, Stewart & Tchanturia, 2019) found that overall, the prevalence of alexithymia was much higher in autism at 50% than the 5% in the general population.

The affective education component of CBT can improve the vocabulary of an autistic client to describe their emotions, thereby diminishing the effects of alexithymia. One approach is to quantify the degree of expression such that if the precise word to describe a feeling is elusive, the client can calibrate and express their degree of emotion using a thermometer or numerical rating, thus indicating the intensity of the emotional experience.

Although the autistic client may have acquired, through the affective education component of CBT, a reasonable and precise vocabulary to describe a particular depth of emotion, there can still be considerable difficulty answering the questions, ‘What were you thinking and feeling?’ or providing a coherent and cogent answer to the question, ‘Why did you do that?’ However, there can be greater communication of inner thoughts and feelings using communication systems other than having a face-to-face conversation.

If the explanation is incoherent or elusive, there can often be greater clarity and insight using typing rather than talking. The clinician can request the explanation be included in an email or text message or working together on a computer. There can also be a greater insight into inner thoughts and feelings using music; for example, to choose a track on a CD or create a playlist that, through the music or lyrics, explains their inner thoughts and emotions. Sometimes, creating a drawing, cartoon or collage may help to express the inner workings of the mind of an autistic client. The efficacy of CBT may be enhanced by incorporating aspects of music and art therapy.

Interoception is defined as the cognitive sense of the internal state of the body. Several recent research studies have explored an association between autism and interoception (Suzman et al 2021; Trevisan, Parker and McPartland 2021). These studies have confirmed difficulty making sense of body signals unless they are very strong and limited cognitive awareness of heart rate, breathing and muscle tension. These are physiological indicators of increasing levels of anxiety or anger. As one of the autistic participants in the Trevisan et al study said: The best way I can describe this to health professionals is that I receive a signal from somewhere I’m not exactly sure, and I have difficulties interpreting what they might mean. There can also be a misinterpretation of internal signals as described by another research participant in the same study: When I’m really sad, it physically hurts. The best way I can describe it as it’s like my whole-body stings very very badly or is on fire.

In our clinical experience, we recall an autistic client who said I only know what I am feeling by seeing what I am doing. CBT for autistic clients will need to include a detailed assessment of behavioural, verbal and thinking indicators of increasing emotional intensity. Biofeedback technology can also be used such as smart and sports watches which indicate increasing heart.

CBT can be very effective when regulating relatively low levels of emotions and thereby prevent the emotions from escalating to an intensity that is difficult to regulate cognitively. Unfortunately, with impaired interoception abilities, an autistic client is often not cognitively aware of low levels of emotional intensity to consider using CBT strategies. The client, and those who support them, may only be aware of rapidly escalating emotions just a few seconds before they reach a critical level of intensity. A level when cognitive restructuring may not have sufficient ‘power’ to regulate the intensity of the emotion. At this point, the issue is not necessarily emotion management but energy management and the development of a plan to effectively discharge the energy constructively using a range of physical activities such as going for a run or slowly achieving emotional stability in solitude.

CBT for autistic clients will benefit from including strategies to improve mind-body connection such as Mindfulness-based cognitive therapy (MBCT) meditation and yoga (Tanksale et al 2021) and specific activities to improve interoception (Mahler 2019).

The sensory profile associated with autism

We have explained the difficulties an autistic client may have with interoception, that is being less sensitive to internal sensory information. We have found that autistic clients can have an extraordinary sensory perception for exteroception, that is perceiving sensory information from the external world. Specific sounds, types of lighting, tactile experiences, and aromas can be perceived at an extreme level of sensitivity that can be extremely painful. The frequency of these experiences in daily life can lead to hypervigilance and heightened levels of anxiety.

The assessment and evaluation of the nature and degree of problems associated with a specific emotion must include aspects of sensory sensitivity. Our clinical experience indicates that for many autistic clients, repeated exposure to the painful sensory experience does not lead to habituation. Any graduated exposure programme needs to accommodate the autistic person’s sensory profile, otherwise, there is a significant risk of increasing the person’s anxiety and facilitating a out dropout from therapy.

There is considerable research on the sensory profile associated with autism for children and recently for adults (Tavassoli et al 2014). It is important that the clinician is familiar with the latest conceptualization of sensory sensitivity (Bogdashina 2016) and consults an Occupational Therapist who specialises in autism and sensory sensitivity.

A component of exteroception that we have identified from our clinical experience and reading autobiographies is that for an autistic client the emotional states of others can be perceived by an almost ‘sixth sense’ and the emotional states of others may ‘infect’ an autistic client, as illustrated in the following quotations: There’s a kind of instant subconscious reaction to the emotional states of other people that I have understood better in myself over the years and If someone approaches me for a conversation and they are full of worry, fear or anger, I find myself suddenly in the same state of emotion. Another relevant quotation is I am able to distinguish very subtle cues that others would not see, or it might be a feeling I pick up from them

This may lead to the avoidance of some social situations and individuals due to being sensitive to ‘negative vibes’. Should this issue be identified in the assessment stage of CBT, the clinician needs to consider how another person’s emotional state can be contagious and to develop ‘protection mechanisms’ such as the metaphor of an umbrella in a storm or a shield.

Another aspect of sensory sensitivity is that the clinician needs to arrange the therapy environment in such a way as to be tolerated by the client and to promote their comfort and relaxation. For example, the lighting may need to be dimmed or changed to non-fluorescent. Smells, such as perfumes or deodorants, may need to be minimized. Therapists may need to ask their client about tactile sensitivity before engaging in any physical gestures, such as handshakes or tapping their arm to gain attention. Calming music could be played for clients that are over-sensitive to auditory experiences such as being able to hear conversations in another room or the noise of the refrigerator in the kitchen of the clinic rooms. In contrast, autistic clients may be under-responsive to some sensations (e.g., pain), and the clinician may need to find ways to identify if the client is experiencing sensations of discomfort that need to be addressed.

In summary

Our extensive clinical experience as CBT practitioners and many research studies have confirmed the value of CBT in reducing autistic adults’ anxiety and depression and improving their quality of life.  We would like to end this blog with a quotation from one of our clients who completed our Exploring Depression CBT program (Attwood and Garnett 2016).  A year after completing the CBT programme, we asked her whether she had experienced a return to depression. She replied “I’ve had quite a number of challenges that could have become depression, but I now have different coping mechanisms that have helped. I’ve had lowered mood at times, but I am getting better at bringing in the coping mechanisms and they have only lasted a couple of days not a couple of months.

Recommended resources

Gaus, V. (2019) Cognitive-Behavioral Therapy for Adults with Autism Spectrum Disorder, second edition The Guilford Press.

Scarpa, Williams White and Attwood (2013) CBT for Children and Adolescents with High-Functioning Autism Spectrum Disorders The Guilford Press

References

Albein-Urios et al (2021) Journal of Autism and Developmental Disorders 51, 3322-3330

Attwood, T. (2007) The Complete Guide to Asperger’s Syndrome London, Jessica Kingsley    Publishers

Attwood and Garnett (2016) Exploring Depression and Beating the Blues: A CBT Self-Help Guide to Understanding and Coping with Depression in Asperger’s Syndrome [ASD-Level 1] Jessica Kingsley Publishers

APA (2022). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults; https://www.apa.org/ptsd-guideline

Baron-Cohen S. (2001) Theory of Mind and autism: A review. In. L.M. Glidden (Ed.) International review of research in mental retardation: Autism (pp.169-184). San Diego, CA: Academic.

Bogdashina O. (2016) Sensory Perceptual Issues in Autism and Asperger Syndrome: Second Edition Jessica Kingsley Publishers

Frith, U. and Happe, F. (1994) ‘Autism: Beyond Theory of Mind.’ Cognition 50, 115-132

Garnett and Attwood (2022) Autism Working: A seven-stage plan for thriving at work Jessica Kingsley Publishers

Higgins et al (2021) Autism 25, 2356-2369

Hossain et al (2020) Psychiatry Research 287, 112922

Hwang et al (2020) Autism 24 411-422

Keefer and Vasa (2021) Journal of Neurodevelopmental Disorders 13:46

Kinnaird ,Stewart, and Tchanturia.(2019). Investigating alexithymia in autism: A systematic review and meta-analysis; European Psychiatry, 55: 80–89.

Lai et al (2019) The Lancet Psychiatry 6 (10), 819-829

Lever, A.G., Geurts, H.M. Psychiatric Co-occurring Symptoms and Disorders in Young, Middle-Aged, and Older Adults with Autism Spectrum Disorder. J Autism Dev Disord 46, 1916–1930 (2016).

Legend Land (2022), www.fullpotentialpsychology.com.au

Mahler, K. (2019) The Interoception Curriculum

Maisel et al (2016) Jr. Abnormal Psychology 125, 692-703

Mantzalas et al (2021) Autism in Adulthood

Moraine, P. (2015) Autism and Everyday Executive Function. Jessica Kingsley Publishers

Perihan et al (2020) Journal of Autism and Developmental Disorders 58, 1958-1972

Rodgers et al (2017) Journal of Autism and Developmental Disorders Vol. 47(12), pp 3959-3966

Selles et al (2015) Child Psychiatry and Human Development 46, 533-547

Sharma et al (2014) Autism 18, 244-254

Spain et al (2015) Research in ASD 9

Spain et al (2022) Journal of Rational-Emotive & Cognitive-Behavior Therapy Published online

Stack and Lucyshyn (2019) Journal of Autism and Developmental Disorders 49 1613-1625

Stark et al (2021) Trends in Cognitive Sciences

Suzman et al (2021) Molecular Autism 12:42

Tanksale et al (2021) Autism 25, 995-1008

Trevisan, Parker and McPartland (2021) Journal of Autism and Developmental 51, 3483-3491

Ung et al (2015) Child Psychiatry and Human Development 46, 533-547

Vasa et al (2014) Journal of Autism and Developmental Disorders 44

Weston, Hodgekins and Langdon (2016) Clinical Psychology Review 49, 41-54

Signs of autism when first meeting a client

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Signs of autism when first meeting a client

Introduction

This blog is for clinicians, therapists, and counsellors to help identify the characteristics of autism in a client who has not previously been considered autistic. We describe the signature characteristics of autism that may be apparent when first meeting a client or over several appointments when exploring their developmental history and profile of abilities. The blog is based on our extensive clinical experience and the formal diagnostic criteria for autism spectrum disorder (APA 2022).

Prevalence and pathways

According to the Centers for Disease Control and Prevention (CDC), the prevalence of autism in 2022 was estimated as one in 44 eight-year-old children. However, this is a conservative estimate, as many autistic adults camouflage and suppress their autistic characteristics in social situations or choose a career that minimises the effects of autism, as a form of compensation. Camouflaging and compensation may delay professional recognition of autism until the adult years.

There are many pathways for an autistic person to seek psychological, psychiatric, or mental health team support or counselling for career and relationship issues. We recognise that 79 per cent of autistic adults meet the criteria for a psychiatric disorder at least once in their lives (Lever and Geurts 2016). The most common concerns are high levels of anxiety and episodic depression. Other pathways are needing assessment and therapy for trauma, an eating disorder, borderline personality disorder, attention deficit disorder, gender dysphoria, addiction, and schizophrenia. There may also be issues regarding achieving and maintaining friendships, employment, or a long-term relationship.

As the conversation with the client develops, the characteristics of autism may slowly emerge in their conversational abilities, social development, emotional communication, cognitive profile, ability to cope with change, interests, and sensory sensitivity.

Conversation abilities

The client’s conversation ability, while often demonstrating sophisticated vocabulary and depth of knowledge, may also include subtle difficulties with the pragmatic aspects of language, unusual prosody, a tendency to make a literal interpretation, and difficulty with the comprehension and expression of nonverbal communication. The pragmatic aspects include the degree of reciprocity or ‘balance’ in the conversation: the person may talk too little or too much. When too little, there will need to be an encouragement to say more than a few words in reply to a question and to provide some degree of elaboration and personal examples that illustrate a specific topic. When talking too much, the client’s conversation may be perceived as a one-sided monologue. There can be a difficulty in determining when the person has completed what they want to say, for example, failing to give eye contact to indicate your turn to speak. In contrast, the client may frequently interrupt their conversation partner to make a comment or correct an error, oblivious of the signals not to interrupt, or that the person may be offended by the correction.

There may also be difficulties knowing how to maintain and repair a conversation by seeking clarification and more information, as well as modifying language according to the social context. The client may also engage in too much or too little disclosure of personal or confidential information.

Prosody may be unusual in terms of the speed, volume, rate, rhythm, and ‘melody’ of speech. There may be a lack of vocal tone and volume to indicate emotion and keywords, and an unusual placement of stress and precise intonation. There can be a tendency to take a literal interpretation, which may become apparent when the other person uses idioms, sarcasm or ‘figures of speech’.

One of the central characteristics of autism is difficulty focusing on and reading nonverbal communication, which can become conspicuous during a conversation. There may be unusual aspects of eye contact in terms of eye-contact frequency, duration, and ability to read another person’s facial expressions to modify the conversation. The person may be listening but not looking at the face of their conversation partner at key points in the interaction when eye contact would not be anticipated. One adaptation to autism is to appear to be looking at the person’s face, but instead focusing on their ears or forehead rather than their eyes, thus failing to determine what their conversation partner is thinking or feeling. And sometimes, even though there may be a focus specifically on someone’s eyes, there may still be difficulty reading facial expressions. As one autistic adult said, “People give messages with their eyes, and I don’t understand them.”

The difficulty reading nonverbal communication can occur for both conversation partners; the client’s facial expressions may be perceived as ‘still’ or ‘wooden’, and thus difficult to read. Their gestures may be limited or ‘stylised’, sometimes mimicking the gestures and posture of the conversation partner. There may be less use of nodding agreement, reciprocal smiles or complimentary sounds of compassion and interest.

Social abilities

An exploration of social abilities and experiences may reveal difficulty making and keeping friends, delayed Theory of Mind abilities, a history of being bullied at school and work, and evidence of relatively effective but superficial social abilities.

During childhood, there is likely to have been a time when the client first recognised that their social and friendship skills were not as advanced and complex as those of their peers. There may have been, and continue to be, a preference for solitary rather than social activities. During childhood and adolescence, there would have been a desire to establish and maintain friendships without a complete or realistic idea of what friendship entails. It is through extensive friendship experiences that we not only learn relationship skills, such as the art of compromise and conflict resolution but also recognise the need for emotional as well as practical support.

Theory of Mind is a psychological term to describe the capacity to understand and successfully relate to other people by determining what they may be thinking or feeling, and their mental state, knowledge, and intentions. This includes recognising that another person’s mental state may be different from one’s own. To develop Theory of Mind abilities, it is essential to be able to accurately read nonverbal communication and social context to infer someone’s thoughts and feelings and modify social behaviour accordingly.

Many autistic adults have experienced rejection, humiliation and bullying from peers, especially in their high school years. Some of the incidents have been extremely distressing and traumatic. There is also an association between autism and all forms of abuse, which may lead to post-traumatic shock disorder.

Social expressions of autism

A common perception of an autistic person is someone who considers social interactions as indecipherably complex, overwhelming and stressful, and chooses to be alone but does not necessarily feel lonely. However, some autistic children and adults are highly motivated to socially engage but may not be able to read the subtle social signals and social conventions of what to say and do. A metaphor to describe this expression of autism is that of a driver who does not see the traffic signals (nonverbal communication) or abide by the traffic code (social conventions). Their social behaviour may be perceived as intrusive or intense, such that the autistic person becomes bitterly disappointed that conversations, friendships and relationships are short-lived.

An adaptation to autism that creates the impression of social competence is for the person to acquire social abilities by suppressing their autistic characteristics and instead observe, analyse, and imitate social behaviour, thus creating a social ‘mask’ and false persona. This adaptation may start in early childhood by avidly watching socially popular children, searching for patterns of social behaviour, and copying gestures, speech, interests, and topics of conversation. This adaptation is described as social ‘camouflaging’.

Camouflaging requires the ability to suppress typically autistic behaviours, such as gently rocking to self-soothe, or talking excessively about a special interest, and instead appear interested in other people, making appropriate empathic gestures and comments: the creation of a social mask. While social success and acceptance may be achieved this way, the psychological cost is mental exhaustion in terms of being drained of mental energy by the effort of socialising. There is also the potential for the development of depression from energy depletion and the inability to express the authentic self.

During the initial conversation with the client, there may be the expected level of reciprocity and mutual reading of nonverbal communication. However, this may be due to their being very proficient and experienced in camouflaging their autistic characteristics. These abilities may have been achieved by intellectual analysis and practice rather than intuition. If the client has autistic characteristics of difficulty coping with change, interests that are unusual in intensity or focus, and sensory sensitivity, it would be appropriate to compliment the client on their conversation and social skills, but also to ask how such social proficiency was achieved. An autistic client would describe using a range of sources of social information including observing, analysing and copying peers, watching television programmes (especially soap operas) to memorise scripts and responses, and seeking information on reading nonverbal communication and the art of conversation from literature, apps and YouTube. They may also rehearse their social and conversation scripts, or have a family member who provides social guidance.

Another social adaptation or compensation for autism during childhood is for autistic girls to prefer the company of boys since their social dynamics are relatively simpler. They may feel safer and less likely to be bullied by boys, who often enjoy playing with a ‘tomboy’. An autistic adult may compensate by choosing a career that does not require much social engagement, such as a wildlife ranger; or they may develop an interest and talent in the arts, becoming an author, artist, musician, singer, or multi-linguist. Social eccentricities may be accepted and accommodated due to being valued by peers who recognise and admire a particular talent.

Emotion communication

Autism is associated with alexithymia, that is, the inability to focus attention on, recognise and accurately appraise, describe and moderate subjective emotions and body sensations, and then communicate those thoughts, sensations and emotions in words. Alexithymia is not exclusive to autism or a characteristic of all autistic adults but has been identified in at least 50 per cent of autistic adults, and in only 5 per cent of the general population (Kinnaird, Stewart & Tchanturia, 2019). Having alexithymia leads to difficulty recognising internal emotional states, such that when asked ‘What are you feeling now?’, after some conscious thought, the reply may be, ‘I don’t know’. This is not being obtuse or evasive. There can be a genuine difficulty perceiving and converting internal states and emotions into speech. The full answer to the question would be, ‘I don’t know… how to mentally grasp the intangible emotions swirling in my mind, identify and label them accurately and communicate those feelings in speech so that you will understand’.

Another characteristic of alexithymia is to talk about experiences without reference to the emotional states of themselves and others. There is less spontaneous mention of emotions in conversation. This will affect autobiographical memory, such that an important event may be described primarily by the sequence of actions, rather than by the thoughts, feelings and intentions of others or themselves.

However, an autistic person is not oblivious to the emotional state of others and may be overly sensitive to another person’s negative mood. There appears to be a ‘sixth sense’ perception of someone’s anxiety, sadness or anger, which can lead to avoidance of some social situations or specific people due to the risk of being ‘infected’ by their distress, and being unsure how to help them.

Having difficulty identifying and communicating internal emotional states can result in emotions increasing in intensity without sufficient cognitive evaluation and regulation, eventually leading to these emotions being released explosively as a meltdown. The developmental history and current concerns may include emotional meltdowns that are explosions of anger and anxiety, or implosions of intense despair and suicidal ideation.

Cognitive abilities

Autism is a different way of perceiving and learning, and this can lead to a cognitive profile that includes an ability to perceive and develop systems and patterns, and also to identify errors and detail that may not be recognised by others. There can also be an ability to store and recall information and find solutions to problems that are elusive to colleagues or employers. This may lead to a successful career as a recognised expert in a particular career or profession.

Ability to cope with change

The diagnostic criteria refer to distress at small changes and coping with uncertainty, as well as a tendency to insist on sameness and a preference for routines and consistency. For an autistic adult, variety is not the ‘spice of life.’

Interests and talents

Throughout childhood and into the adult years there is a history of hobbies or interests that are unusual in intensity or focus. Each interest has a ‘use by date’ that may range from hours to decades. The interests are associated with intense enjoyment and may also function as a thought blocker for anxiety or sadness. They also provide a sense of identity and social connection with those who share the same interest.

During the conversation, the client may be somewhat subdued and quiet, appearing to be reluctant to engage. However, when the topic of conversation is the person’s interest, they suddenly become enlivened, engaged and eager to disclose their expertise: almost an alternative persona.

While alexithymia is a difficulty converting thoughts and feelings into speech, a successful adaption to alexithymia is to express thoughts and feelings through the arts. The autistic adult may have a recognised talent as an artist, musician, composer, or author. The inner world is vividly expressed through the arts.

There may be a talent in the caring professions, especially psychology and psychiatry. The propensity from childhood to observe and analyse others to facilitate social engagement may evolve into achieving formal qualifications and a successful career as a teacher, therapist, psychologist, paediatrician, or psychiatrist. Autism is often associated with the altruistic desire to help alleviate suffering and increase knowledge and abilities. There may also be a talent to understand and care for animals.

Sensory sensitivity

There can be an extraordinary perception of sensory experiences from the outside world, or ‘exteroception’. Specific sounds, types of lighting, tactile experiences, aromas, and emotional states of others can be perceived at such an intensity that the experience is aversive. In contrast, there can be difficulty sensing the internal world, or ‘interoception’. There appears to be a mind and body disconnection. The autistic person may not experience hunger or thirst to the same degree as other people, and may not be aware of the increased heart rate and breathing that indicate rising anxiety or anger.

Screening for autism and recommending a formal diagnostic assessment

At the end of the first consultation, or after several consultations, some, but not necessarily all of the signs of autism may gradually become apparent. The next stage is to consider asking the client to complete screening questionnaires specifically designed to identify the characteristics of autism in an adult. These include the Autism Social Quotient (Baron-Cohen et al 2001) for men and women and the GQ-ASD for women (Brown et al 2020). If their scores on these instruments are above the designated cut-off, then a referral or subsequent appointment for a formal diagnostic assessment is warranted.

Training in screening for autism and conducting a diagnostic assessment

On September 7 and 8 2022, we will be conducting a live two-day masterclass in Sydney: Diagnosis and Therapy for Autistic Adults. Day one will focus on assessing and confirming autism using a range of instruments based on research studies and our extensive clinical experience. The Masterclass will explore the characteristics of autism in adults in more detail, and review the range of screening instruments and standardised assessments or scales for autism. Day one of the Masterclass will also include guidance in conducting a diagnostic assessment, dual and differential diagnosis, and how to explain the diagnosis and its implications for the individual, their family and colleagues. Day two will focus on therapy and support for autistic adults, including modifications that help.

The Masterclass is for professionals interested in increasing their understanding of autism, and how to provide support and treatment for their autistic clients.

Professionals can choose to attend live in Sydney, Australia, or via live webcast. The recorded training will be available for participants to view for 60 days after the event. The webcast will also eventually be posted in our library of webcasts that can be accessed for several months after the original date of webcasting.

References

APA (2022) Diagnostic and Statistical Manual of Mental Disorders-5 Text Revision. American Psychiatric Association

Baron-Cohen et al (2001) Journal of Autism and Developmental Disorders 31 5-17 Available on the Internet at www.autismresearchcentre.com/research

Brown et al (2020) Autism in Adulthood 2, 216-226 Available to download at www.tonyattwood.com.au forms and questionnaires

Kinnaird, Stewart & Tchanturia (2019) European Psychiatry 55, 80-89

Lever and Geurts (2016) Journal of Autism and Developmental Disorders 46: 1916-1930