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Relationships for Autistic Women

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Relationships for Autistic women

Foundations for relationship skills

The foundations for relationship skills are created from friendship experiences throughout childhood. The skills include trust, loyalty, compromise, and emotional support. Autistic women may have had fewer but more intense friendships than non-autistic women during childhood and adolescence (Sedgewick et al., 2019). A series of single best friends can become the sole focus of their friendship experiences, and the intensity and difficulty of understanding and managing conflict can result in friends disengaging. There can subsequently be a tendency for the autistic adolescent to self-blame and assume the friendship cannot be rescued.

A friendship characteristic of autistic girls is to have social anxiety before and during time with a friend; as in the following quotation, I get anxious because I have to behave neurotypically to do the right thing. Engaging with a friend can be mentally exhausting, even if the time together is mutually enjoyable (Crompton et al., 2020). Another friendship feature described in the same study is knowing what other people want in a friend, which is the basis of knowing what a partner seeks in a long-term relationship. Autistic adolescents may also have experienced relational bullying, such as gossip, being deliberately excluded, teasing, humiliation, and peer rejection which will affect the ability to trust a friend or potential partner.

During adolescence, there is often limited sexual knowledge from peers, but an autistic adolescent or young adult may perceive engagement in sexual behaviour as a means of facilitating relationships and attaining social approval from peers (Pecora et al., 2022).

They may seek a relationship but may not realise they are being taken advantage of and misinterpret the sexual intentions of others. Recent research suggests that many autistic women have been victims of sexual assault and rape, usually in early adulthood or at university. (Sedgewick et al., 2019). A recent study of several hundred autistic adults found that 46.5% of autistic women reported experiencing sexual violence.  Autistic women were also less likely than non-autistic women to have confided in anyone about such experiences. (Gibbs et al., 2021)

An abusive partner

The relationship naivety, vulnerability and gullibility of young autistic women increase the risk of being in an abusive relationship. The abusive partner is attracted to their childlike innocence, lack of assertiveness and limited friendship and relationship experience. She probably does not have a network of friends to tell her what to expect in a relationship and to advise her on her choice of partner.

Our clinical experience and research indicate that autistic women are likely to stay in abusive relationships for several reasons (Sedgewick et al., 2019). Low self-esteem contributes to not perceiving that they are worthy of a conventional relationship; as illustrated in the following quotation, I set my expectations very low and, as a result, gravitated towards abusive people. There is also the reason of not having the intuitive relationship ‘radar’ to identify someone with malevolent intentions. There can be a tendency to take someone ‘at face value’ and believe what someone says rather than perceiving their covert intentions and risky situations. Even with an effective radar, there can be a reluctance to judge their abusive partner, as in the following quotation: Sometimes, we have good radar but talk ourselves out of it. We think we have to give them a chance, not make rash judgements, and we don’t want to treat people badly. We give them the benefit of the doubt. A relationship partner may take advantage of an autistic woman’s benevolent attitude.

Some autistic women are likely to stay in an abusive relationship because it is easier than finding a new one (Sedgewick et al., 2019), and we would add they may not have the self-confidence to end the relationship. However, we have found that confirmation of a diagnosis of autism while in an abusive relationship can lead to greater assertiveness and determination to end the abuse.

Nonautistic partner

Another choice of partner is a nonautistic person who genuinely falls deeply in love with an autistic woman, seeks to make her happy and fulfilled and provides social, emotional, and practical support. This may be someone who is socially motivated, talented, and gregarious and can understand and accept autistic characteristics in their partner. They may provide guidance in social situations, help moderate emotional reactions and makes accommodations for aspects of autism such as sensory sensitivity. The autistic woman feels safe and supported.

We have considerable literature on relationship support when the male in the relationship is autistic, but only two books when the autistic partner is a woman. Rudy Simone has written 22 Things a Woman with Asperger’s Syndrome wants her partner to know (Simone, 2012), and Alis Rowe, otherwise known as The Girl with the Curly Hair, has written Asperger’s Syndrome for the Neurotypical Partner: Helping Long-term relationships when the woman has ASD (Rowe, 2014).

Alice Rowe writes that an autistic woman may be loved because she is very honest and direct, has a strong sense of social justice, is creative and has a deep empathic connection with animals. She may love her non-autistic partner’s ability to guide and reassure her in social situations, explain her autistic features to herself and others, and moderate her intense emotions. Her partner can also help her cope with the unexpected and uncertainty, painful sensory experiences and the proximity of too many people. There can also be guidance when making small talk and on what to wear for a specific event.  A non-autistic partner may also tolerate and show compassion for her distress and agitation over what their partner perceives as a trivial event, such as a missing the apostrophe in a shop sign and the pharmacy opening at 9:04, not at 9:00. There is also the acceptance that she has limited social motivation and social energy, is reluctant to try new experiences, finds it hard to perceive her partner’s point of view and may tend to be critical and correcting (Rowe, 2014).

Our clinical experience and research on such a relationship indicate that both partners report low satisfaction with emotional communication, amount of leisure time together and intimacy (Ying Yew et al., 2021). The non-autistic partner will be confused when conventional emotional repair mechanisms they use are not effective and may be perceived by their autistic partner as aversive, as in the following thought dialogue from Alis Rowe when a non-autistic partner puts his arm around his sad autistic partner:

It makes me feel better hugging her when she is sad. I enjoy the physical closeness.

It’s too much. I feel overwhelmed being touched when I’m sad. I don’t want to be hugged right now.

What did I do wrong? She’s pushing me away.

His touch right now is unpleasant and physically painful.

I’m upset she doesn’t want me to hug her. It’s what couples do. I feel rejected.

Both partners may benefit from relationship counselling to explore each other’s perspectives, improve communication and enhance the relationship. There is a range of books on relationships where one partner is autistic published by www.jkp.com

An autistic partner

Another choice of partner is an autistic rather than a non-autistic partner. Research indicates that one in ten autistic men and one in three autistic women report having a partner who is also autistic (Dwinter et al., 2017). Adjusting and adapting to differences in autistic and nonautistic verbal and non-verbal communication styles requires considerable mental energy and can be the source of relationship conflict. When both partners are autistic, there is less need to mask or suppress autism, being the authentic self, with considerable mental health benefits (Crompton et al., 2020). When both partners are autistic, there can be mutual feelings of comfort and ease with similar communication styles and the ability to cope with social engagement.

There will be similar abilities, past experiences, and shared interests, such as animal welfare, opera, art or a career such as entomology or medicine. Both need and enjoy periods of solitude and can collude together in avoiding social commitments. Autistic individuals whose partners are also autistic report greater relationship satisfaction than those whose partner is not autistic (Ying Yew et al., 2021).

References

Crompton et al. (2020) Autism 24

Dwinter et al. (2017) Journal of Autism and Developmental Disorders 57

Gibbs et al. (2021) Research in Autism Spectrum Disorders 89

Pecora et al. (2022) Autism 26

Rowe A. (2014). Asperger’s Syndrome for the Neurotypical Partner: Helping long-term relationships when the woman has ASD Lonely Mind Books, London

Sedgewick et al. (2019). Autism in Adulthood 1

Simone R. (2012) 22 Things a Woman with Asperger’s Syndrome wants her partner to know Jessica Kingsley Publishers, London.

Ying Yew et al. (2021). Personal Relationships

Recent Research on Autism and Making Friends

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Recent Research on Autism and Making Friends

The diagnostic criteria for autism include criterion A3, …l difficulties in making friends…(APA 2022). From our clinical experience, we would add that when friendships are made, an autistic child or adolescent may also have difficulty maintaining friendships. Non-autistic children can intuitively know how to initiate, sustain and repair friendships. These abilities seem elusive for autistic children who often yearn for the quality of friendships of their peers. Non-autistic children have four stages in developing friendship abilities from preschool to the teenage years (Attwood, 2006). As clinicians, we recognise that autistic children tend to have a concept of friendship that is developmentally younger than their non-autistic peers, their duration and frequency of social engagement with peers is less, and their social and friendship network is consequently reduced. Our clinical experience over several decades is that autistic children and adolescents have difficulty identifying and defining the components of friendship and understanding the multiple dimensions of friendship, which has now been confirmed by research (Petrina, Carter and Stephenson, 2014). Reading non-verbal communication and social context can also be difficult, as well as accommodating alternative perspectives and managing conflict in a friendship. There is also the issue of sensory sensitivity when socially engaged with noisy non-autistic peers and the perception of chaos when social games are complex and fast-moving. They may seek a safe sanctuary on the periphery of social activities where they can relax, but being alone may cue non-autistic peers to see them as a target for teasing and bullying. We have also noted that when a friendship is made, it may be with another autistic student who shares the same interests and an autistic way of thinking and relating. However, they may meet after school less often than would be expected by non-autistic peers. Their friendship tends to be primarily school-based.

Over the last decade, there has been research comparing the friendship abilities and experiences of autistic girls in comparison to autistic boys. Autistic girls tend to have significantly better social interaction and communication skills than autistic boys, and this characteristic may not be captured by current diagnostic instruments (Wood-Downie et al., 2021). The Friendship Questionnaire was designed to measure friendship skills in autistic children and adults (Baron-Cohen & Wheelwright, 2003). A study of 10-16-year-old children using this instrument found that autistic girls and non-autistic boys tended to have similar Friendship Quotient scores, and autistic girls had greater friendship quotient scores than autistic boys (Head, McGillvray and Stokes 2014). This may partially explain why autistic girls’ friendship abilities are perceived as comparable to typical boys and, therefore, not of clinical concern, and contributing to autistic girls choosing boys rather than girls as friends.

Friendships in the preschool and primary school years

A study of autistic children in the preschool years found that only 20% had friendships at school and that while at school, adults rarely tried to intervene to encourage engagement with peers. The adults’ primary involvement was to correct behaviour (Chang Shih & Kasari, 2016). In the primary school years, autistic boys tend to be overtly excluded by peers, while autistic girls are more ignored or overlooked rather than actively rejected (Dean et al., 2014) Autistic children become less socially connected with increasing grade level, especially after grade 4 when social games and friendships become more sophisticated and for boys, greater sportsmanship required (Rotherham-Fuller et al., 2010). Our clinical experience is that when autistic children are asked to name their friends at primary school, the children named tend not to consider the autistic child as part of their friendship group. This may be due to an autistic child having difficulty differentiating between someone who is friendly and a true friend as defined by their peers.

The degree of social engagement can vary considerably after grade 4 and partly depends on the child’s motivation for social inclusion or isolation (Calder, Hill and Pellicano, 2013). Non-autistic children, increasingly after grade 4, seek emotional connectedness in friendships, while autistic children see friendship as primarily someone to play with rather than someone who provides emotional support.

Research has also explored the challenges an autistic boy experiences in initiating and maintaining friendships, with first establishing who might be a suitable choice for a friend, a desire not to be the one who initiates contact, trying not to violate the social hierarchy of peers at school, and concerns about not being exploited or considered a nuisance (Daniel & Billingsley, 2010). Thus, considerable anxiety is associated with making friends and uncertainty about how a potential friend perceives or could take advantage of them.

Friendships in the high school years

In the high school years, there are changes in the conceptualisation of friendship for non-autistic teenagers, with greater disclosure of thoughts, feelings and experiences and an expectation of emotional support. Autistic teenagers tend to less often refer to self-disclosure, empathic understanding and affection as defining characteristics of friendship (Platos & Pisula, 2021). They also have difficulty perceiving, following and responding to the covert social rules of adolescent friendship, understanding and managing conflict and experiencing anxiety due to being in a group and feeling watched and potentially judged by multiple people (Cresswell, Hinch and Cage 2019).
A study of adolescent autistic girls confirmed how exhausting socialising can be, especially in groups and coping with ‘too many opinions’ and feeling they needed to act as a peacemaker when conflict and disagreements occurred within a friendship group (Foggo & Webster, 2017). Adolescent autistic boys can have difficulty understanding and knowing how to respond to the joking behaviour of their male peers. They can misinterpret intentions and become confused and agitated (Sedgewick, Hill and Pellicano 2018), increasing peer alienation.

During their high school years, autistic adolescents can feel deeply lonely and yearn for connection with a group of peers. They cannot rely on intuitive abilities in social situations and often have to rely on cognitively processing social information, which is exhausting. Peers may criticise them for making social errors, and they invariably lack a best friend to provide social guidance and compliments rather than criticism for their friendship abilities. There can be an acute and distressing recognition of not being popular, as illustrated in the following quotations: I wasn’t rejected but did not feel completely included, and I was supported and tolerated but not liked. They may blame themselves or their being autistic for peer rejection, which inevitably affects self-esteem, self-identity, mood, and perception of autism. There will probably be anxiety about making a social mistake, as described in the quote: I live in constant fear of performance anxiety over day-to-day social encounters. Before falling asleep, the autistic adolescent may review and ruminate over the social experiences of the school day, which may lead to a conscious retreat into solitude: I’d rather just be alone, but I can’t handle the loneliness.

In the yearning for social connection and friendship, autistic adolescents may be accepted by marginalised groups of teenagers that engage in activities and interests that cause concern for parents. This can include peers who engage in alcohol and drug use, are developing eating disorders or exploring being an alternative gender. The group welcomes and ‘adopts’ the autistic teenager, who has an enjoyable role of collecting, collating and communicating information from the Internet, which the group values.

In their teenage years, autistic adolescents may engage in camouflaging their autistic characteristics by masking and compensation strategies to be accepted by their peers and to make friends (Hull et al. 2017). Masking involves creating an alternative persona based on their observation and analysis of the social behaviour of their peers, and compensation may include teenage autistic girls preferring the friendships of boys who do not tend to have the complex and subtle expectations of friendships that occur between girls.

In our clinical experience, we increasingly recognise the value of having an autistic friend. They may find each other on the periphery of social activities or during lunchtime or after-school interest groups such as robotics, computer programming, science projects, playing music and singing together, or simply sitting beside each other drawing or reading.

Programmes to encourage friendship abilities

There are several evidence-based programmes to encourage friendship abilities. Elizabeth Laugeson originally developed the PEERS programme for autistic adolescents and young adults (Laugeson et al., 2015). The programme includes components on developing and maintaining friendships, conversation skills, electronic communication, appropriate use of humour and romantic relationships and dating etiquette. A recent meta-analysis of research on the PEERS programme found moderate to large effects across measures and informants, with the largest effect in social knowledge, then social functioning and the smallest in the frequency of get-togethers. The PEERS programme has now been adapted for preschool autistic children (Tripathi et al., 2022). The programme themes include meeting and greeting friends, sharing and taking turns, asking a friend to play, joining a game, and asking for and giving help.

The Healthy Relationships on the Autism Spectrum (HEARTS) programme is an online manualised programme (Rothman et al., 2022). Each 90-minute class is taught by one non-autistic and one autistic team teacher, with participants undertaking the programme in the privacy of their own homes. The programme includes themes such as the motivation to keep the relationship going as described in the quotation: My challenge is actually staying in touch and making the effort to actually feel like I want to talk to them, emotional scars from previous friendships, self-disclosure and emotional intimacy, the ‘chemistry’ of friendship, distinguishing between ‘healthy’ and unhealthy’ friendships and setting social boundaries and trust.

The Secret Agent Society is a home or school based computer programme that includes activities to explain and enhance friendship abilities (Beaumont et al. (2021) with more information at www.sst.institute.net

Parents and teachers recognise the popularity of Lego and Minecraft for autistic children and adolescents. Daniel Le Goff has developed and evaluated Lego-based therapy to encourage social and friendship skills (LeGoff et al., 2017). Dundon and Scott (2019) have written a manual describing how Minecraft can be used to teach autistic children social skills. Jessica Kingsley Publishers (JKP) has published a range of books on Social Stories, originally developed by Carol Grey that can be used to encourage specific friendship abilities. JKP has also published several books by Jennifer Cook that explore and encourage social abilities for autistic children and adolescents. We also recommend the Social Thinking programmes developed by Michelle Garcia Williams and Pamela Crooke, with more information at www.socialthinking.com

References

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

Attwood, T. (2006) The Complete Guide to Asperger’s Syndrome. London, Jessica Kingsley Publishers.

Baron-Cohen and Wheelwright, (2003) Journal of Autism and Developmental Disorders 33, 509–517.
Beaumont et al. (2021). Journal of Autism and Developmental Disorders 51, 3637-3650

Calder, Hill and Pellicano (2013) Autism 17

Chang Shih and Kasari (2016). Autism 20

Cresswell, Hinch and Cage (2019) Research in ASD 61, 45-60

Daniel and Billingsley 2010 Focus on ASD and other Developmental Disorders 25

Dean et al. (2014) Journal of Child Psychology and Psychiatry 55, 1218-1225

Dundon and Scott (2019) Teaching Social Skills to Children with Autism using Minecraft London, Jessica Kingsley Publishers.

Foggo and Webster (2017). Research in ASD 35

Head, McGillvray and Stokes (2014) Molecular Autism

Hull et al. (2017) Journal of Autism and Developmental Disorders 47, 2519-2534

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

LeGoff et al (2017) How Lego-based Therapy for Autism Works Jessica Kingsley Publishers

Petrina, Carter and Stephenson (2014) Research in Autism Spectrum Disorders 8, 111-126

Platos and Pisula (2021) Research in ASD 81 101716

Rotherham-Fuller et al. (2010) Journal of Child Psychology and Psychiatry 51, 1227-1234

Rothman et al (2022) Autism 26, 690-702

Sedgewick, Hill and Pellicano Autism (2018)

Tripathi et al. (2022) Jr Autism and Developmental Disorders 52, 2610-2626

Wood-Downie et al. (2021) Journal of Child Psychology and Psychiatry 62, 922-936

The dating game and Autistic adolescents

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The Dating Game and Autistic Adolescents

Typical teenagers are usually enthusiastic about going beyond friendship and experiencing the dating game. They are exploring their new sexual awareness, who they find attractive, and who is attracted to them. Their romantic and sensual experiences become a major topic of conversation with peer advice on the ‘rules’ of the dating game. Our clinical experience suggests this may not be the case for autistic teenagers. They may be delayed by several years in being interested in a romantic relationship and have difficulty resonating with their peers’ interest in dating. They are also often socially isolated and may not have a circle of friends who discuss and disclose information on dating and sexuality.

In order to participate in the dating game, it is important to read subtle non-verbal communication that indicates mutual attraction and explore one another’s expectations in a romantic relationship. Typical teenagers understand dating conventions from intuition, observation and discussion with their peers. When dating, both partners progress along the relationship continuum at a reciprocally agreed and mutually enjoyed pace. Typical adolescents have considerable experience with many friendships, developing conflict management strategies and the art of compromise. They also know how much time to spend together and communicate through social media.

Autistic adolescents often need guidance and support in each of these dimensions.

Reading body language

There are many subtle ways that body language can indicate an interest in someone, such as the head tilted to one side, which means I am listening, nodding to indicate agreement or approval, smiling to indicate feeling happy with the conversation and looking at the other person’s face, especially the eyes to read the person’s feelings. There are other ways to tell that someone is interested in or likes someone, such as going out of their way to engage in a conversation, wanting to sit together and often giving compliments to the person they like. It is also important to know when body language expresses not interested such as frequently looking away, avoiding eye contact and a ‘closed’ body posture and flat facial expression.

A characteristic of autistic adolescents is difficulty accurately reading the intentions and personalities of their peers. Someone’s act of kindness may be interpreted as meaning more than was intended. Some personalities frequently engage in touch during a conversation due to their culture which may not be a sign of seeking a romantic attachment. Typical teenagers often have friends they can consult regarding the intentions of a potential dating partner.

Attraction

It is important to explore what aspects of personality, abilities, and appearance are attractive when seeking someone to date. There are differences in what adolescent girls and boys may seek. There is a general convention that girls may have a greater emphasis on personality and ability attributes and boys on physical attributes. When we have discussed attraction with autistic teenagers this convention can be maintained, but we have found that attributes such as intellect, being accepted and understood, sense of humour, and similar interests have been rated as more important for autistic than typical adolescents.

Asking someone for a date

An autistic adolescent may rehearse and need guidance on asking someone on a date or responding to an invitation for a date. They need to consider where the date will be and who may also be there. Autistic adolescents may be naïve, trusting, and unaware of being in a potentially risky situation.

There are also aspects of what to wear on a date, topics of conversation and knowing if the date is mutually enjoyable.

The development of a romantic relationship

A romantic relationship may evolve into disclosing deeper and more personal inner thoughts, emotions, and experiences. Some autistic adolescents may have alexithymia which is difficulty disclosing and explaining inner thoughts and emotions through speech. Their romantic partner may be concerned that self-disclosure may not have the same degree of depth and reciprocity.

The agreed ‘balance’ of touch, affection, and sensual experiences can be an issue. An autistic adolescent may need guidance on these aspects of a romantic relationship as a characteristic of autism can be a sensitivity to tactile experiences, especially those that may occur with gestures of affection and may extend to sensual and sexual experiences (Gray, Kirby and Holmes 2021) There is also the potential issue of reading the signals and context when the typical partner anticipates gestures and words of affection and compassion. There will need to be open communication and mutual understanding.

There may also be an issue of recognising the human sexual response for both partners and education with regard to sexuality (Attwood, 2008; Dekker et al 2017; Hartman 2014; Henault 2006 Visser 2017)

As the relationship progresses there could be concerns with regard to the amount of time spent together and communication on social media. There is potential for the enthusiasm of one partner to be perceived as too intrusive and intense, with a risk of them ‘wearing out their welcome’. Guidance from peers and parents can be very helpful.

The experience of love

A characteristic of autism is having difficulty perceiving and regulating emotions. Clinically we tend to focus on feelings of anxiety, sadness and anger, but love is a feeling. We have developed a programme From Like to Love to help young autistic children understand, express and enjoy love and affection with family and friends (Attwood and Garnett 2013). Many strategies apply to autistic adolescents embarking on the dating game, with age-appropriate adaptation, which includes expressions of love that are perceived as inappropriate or too intense, such as accusations of stalking (Post et al 2017)

An autistic teenager may also experience high levels of anxiety when meeting and being with a person towards whom they have strong feelings of affection and ruminate on their social/romantic performance. They may need guidance in coping with the emotion of love and anxiety.

Knowing the relationship is going well or not well

There are signs that the relationship is going well, such as both partners being happy to see each other, having a genuine interest in each other’s experiences, thoughts and feelings, smiling, laughing and having fun together with each feeling free to be their natural self and feeling safe and relaxed.

There is also the question of knowing the signs that the relationship is not going well. These negative signs may be the opposite of the positive signs described above, such as being critical and finding fault. We have found that another sign is one of the partners being possessive or controlling.

Adolescent romantic relationships often have a ‘use by date’ and may last from days to months and occasionally years. Adolescents may experience the ending of a relationship several times; sometimes, it is their choice, and sometimes not. There are many ways of ending a relationship; if an autistic person makes that decision, they will need guidance on how to do that appropriately. If the decision is from their romantic partner, they will experience rejection which may be reminiscent of rejection from previous friendships or romantic relationships. There will need to be time and support for recovery, to move on and not ruminate on the relationship, and to acknowledge what has been learned about the dating game from the relationship.

Long-term relationships

The focus has been on the dating game in adolescence, when romantic relationships may have a limited duration. However, many characteristics of autism contribute to a successful long-term relationship. These include kindness and a sense of social justice, loyalty and integrity, ability in a chosen career in science, technology, the arts and caring professions, passion for knowledge, and maternal and paternal abilities.

References and resources

Attwood S. (2008) Making Sense of Sex: A Forthright Guide to Puberty, Sex and Relationships for People with Asperger’s Syndrome. Jessica Kingsley Publishers

Attwood and Garnett (2013) From Like to Love Jessica Kingsley Publishers

Dekker et al (2015) Journal of Autism and Developmental Disorders 45 (6)

Gray, Kirby and Holmes (2021) Autism in Adulthood

Hartman D. (2014) Sexuality and Relationship Education for Children and Adolescents with Autism Spectrum Disorders Jessica Kingsley Publishers

Henault I. (2006) Asperger’s Syndrome and Sexuality. Jessica Kingsley Publishers.

Post et al (2014) Journal of Autism and Developmental Disorders 44:11

Uhlenkamp (2009) The Guide to Dating for Teenagers with Asperger Syndrome Autism Asperger Publishing Company

Visser, K et al., (2017) A randomized controlled trial to examine the effects of the Tackling Teenage psychosexual training program for adolescents with Autism Spectrum Disorder. Journal of Child Psychology and Psychiatry 58:7, (2017) pp 840-850

Understanding empathy and autism

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Empathy

We know that there are three forms of empathy, cognitive, affective, and behavioural and that the expression of each is underpinned by similar and different neurological structures in the prefrontal cortex. Cognitive empathy is the ability to determine what someone is feeling or thinking by ‘reading’ their facial expressions, gestures, vocal tone, and social context. An autistic person may need to use intellect rather than intuitive abilities to identify and process nonverbal communication that they see and hear. Affective or emotional empathy is the ability to ‘feel’ the emotions of others. A recurring theme from our clinical experience of talking to autistic teenagers and adults and reading autobiographies is an over-sensitivity to the negative feelings of other people. Behavioural empathy is knowing how to respond to someone’s feelings. Autism is associated with uncertainty in identifying what is expected to be said or done to alleviate or respond to someone’s feelings.

Emotional empathy

A central characteristic of autism is difficulty knowing how to read and respond to the emotions of others (Schwenck et al 2012). However, clinical experience indicates that there is a hypersensitivity to feeling another person’s negative emotions such as disappointment, anxiety or agitation. Autistic individuals have a remarkable capacity to mirror, or amplify within themselves, how another person feels (Fletcher-Watson and Bird 2020). As one of the participants in that study said, “We express empathy differently.” This capacity has been described as empathy over-arousal (Smith 2009) and occurs in both autistic males and females (Schwenck et al 2012).

We have yet to determine how this capacity is achieved but quotations from autistic adults may provide some indication.

I am able to distinguish very subtle cues that others would not see, or it might be a feeling I pick up from them.

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.

Emotional empathy can occur with all expressions of autism. Robert Hughes (2003) wrote about his non-speaking autistic son, Walker whom he described as being a “supersensitive emotional barometer who registered the true emotional pressure in the air, no matter how hard we tried to mask it”.

Exteroception

We have long recognized that a characteristic of autism is an extraordinary perception of sensory experiences from the external world which we describe as exteroception sensitivity. This can be a heightened sensitivity to sounds, light intensity, tactile experiences, aromas, and tastes. We speculate that exteroception may include a sensitivity to the emotions of other people. An extraordinary ‘sixth’ sense can be a response to being with someone who is experiencing negative emotions, but also responding to suffering on television news and in documentaries far more than is typical.

In contrast to heightened exteroception, an autistic person can have difficulty with interoception, that is perceiving their own internal sensory experiences, such as not being consciously aware of increasing heart rate and breathing that indicate rising anxiety or agitation. In his autobiography, Aaron Wahl (2019) wrote “I perceived the feelings of others often overly clear but could not find access to my own”.

Negative and positive emotions

Our clinical experience indicates that there is an extraordinary perception and sensitivity to another person’s negative emotions, as in the comment 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. Negative emotions in others are ‘infectious’ to an autistic person. One of our clients’ said Emotions are contagious for me. Emotional empathy may be one of the reasons why autistic individuals avoid crowds due to the risk of proximity to someone who is experiencing a negative mood and being ‘infected’ by that mood.

As psychologists, we often try to determine why an autistic person experiences a negative emotion, and one of the reasons may not be due to a specific event or thought but being ‘infected’ by someone’s negative feelings. This may also contribute to a characteristic of autism of avoiding eye contact since the eyes convey feelings (Smith 2009).

Social withdrawal for an autistic person is not exclusively due to social expectations and sensitivity to auditory, visual, and tactile experiences. Lilian said We don’t have emotional skin for protection. We are exposed, and that is why we hide. The sensitivity to the negative mood of others can lead to wanting everyone to be happy.

While we have found that someone’s negative mood can be contagious for an autistic person, they may not be equally ‘infected’ by someone’s positive mood. They can seem impervious to someone trying to ‘jolly them up’. Happy and exuberant positive emotions in others may sometimes cause an autistic person to be confused and uncomfortable and not know how to respond or resonate with others, for example, at a family celebration or reunion or when someone receives exciting news.

There seems to be a preference for a middle to a neutral range of emotions in others, both negative and positive emotions. If there is any greater intensity, the autistic person may become confused, overwhelmed and unsure of what they are expected to do or say.

Strategies for coping with empathic over-arousal

As clinicians, we help the person create a mental barrier using the metaphor of protection by putting on armour and using a shield or putting up an umbrella for protection from a downpour of emotions. We also use advice from autistic adults who share the same emotional empathy such as an autistic mother who said: We have lots and lots of empathy, but if it’s too much to deal with you have to just shut it off because it’s so overwhelming (Dugdale et al 2021).

We also advise family members and teachers to be aware of how their negative mood can be contagious to an autistic person and we teach strategies to stay calm and neutral to assist their loved one through difficult emotions. Sometimes parents and partners may try to temporarily suppress their feelings, although an autistic person may be able to sense the emotions behind their mask of neutrality.

We encourage autistic people to explain their sensitivity to someone’s mood and that the reason for their temporary withdrawal or avoidance of them is a coping mechanism due to emotional empathy and not a rejection of them as a person.

When an autistic person has difficulties with behavioural empathy, that is knowing how they are expected to respond to the distress of another person, they may need clear guidance and encouragement on what to do or say. This could be to suggest that the autistic person gives you a hug that is within their zone of tolerance or makes a reassuring comment.

We now have programmes to help autistic adults read nonverbal communication (cognitive empathy) and develop verbal empathic comments (behavioural empathy) (e.g., Koegel et al 2016).

We also recognize that increased emotional empathy may be an advantage when being with autistic children and adults by being aware of an autistic person’s tolerance of emotional states in others and adjusting their interactions accordingly. We know of many autistic individuals who thrive in the helping professions due to their high levels of emotional empathy.

References

Dugdale et al (2021) Autism 25, 1973-1984

Fletcher-Watson and Bird (2020) Autism 24 3-6

Hughes R (2003) Running with Walker Jessica Kingsley Publishers

Koegel et al (2016) Improving Verbal Empathetic Communication for Adults with Autism Spectrum Disorder Journal of Autism and Developmental Disorders 46, 921-933

Schwenck et al 2012 Jr Child Psychology and Psychiatry 53:6

Smith, A. (2009) The Psychological Record 59 489-510

Wahl A. (2019) Ein tor zu eurer welt KNAUR

Ageing and autism

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Ageing and autism

Over the last decade, we have seen an increasing number of mature adults seeking confirmation of autism in their developmental history and profile of abilities. This has provided an opportunity to explore ageing and autism using a cross-sectional approach, that is the 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 ageing and autism using semi-structured interviews. A study by Wake, Endlich and Lagos (2021) included 150 research participants with an age range from 50 to 80 years. Tony has been an associate advisor to a PhD study that used a detailed analysis of ten autistic adults aged from 53 to 74 years (Ommensen et al). In this blog, we examine autism and ageing based on both research and our extensive clinical experience.

Autistic adults over the age of 50, colloquially known as the Baby Boomers, were unable to benefit during their childhood and adolescence from our current range of support programmes at school and home that improve social understanding and friendships skills, as well as develop a positive sense of self.  They have also not had access in their early adult years to therapy specifically designed to reduce feelings of anxiety and depression in autistic adults and they missed out on the environmental and attitude adaptations that we now have to support autistic adults at work. It is interesting that despite a lack of understanding and support throughout their life, some mature autistic adults have achieved a successful and enjoyable quality of life and well-being that will be valuable information for those designing interventions and support for future generations.

Recognition of autism late in life

Our clinical experience is that recognition of autism later in life is 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 Wake, Endlich and Lagos (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 study felt relieved and better about themselves following confirmation of being autistic but upset that they had lived such a great part of their lives without knowing. The overwhelming majority 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. 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 their autism confirmed earlier in life.

After the recognition of autism in their mature 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 inclined to engage in camouflaging autism (Bradley et al 2021).  There were also beneficial effects on mental health as expressed by one research participant who said:

“My depression lifted without medication”.

Coping reactions over time

Attwood (2007) described two internalizing and two externalizing reactions to autism that can be recognised in childhood that can extend into the adult years. The two internalizing reactions can be depression and escape into imagination or academics. The two externalizing reactions are denial of being different and suppressing autistic characteristics and creating a social mask (camouflaging). Wake, Endlich and Lagos (2021) found that these coping strategies were more common in adolescence and early adulthood, but gradually reduced in midlife. This was probably due to using other coping strategies such as self-acceptance and a positive perception of autism. There were also improvements in understanding social situations, less need for rigid routines and time alone and being bullied and teased less often. Our clinical experience confirms the change in coping reactions over time.

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 and in the later years, a desire to help other autistic adults. However, socializing remains effortful and energy draining and a lifelong problem.

Ommensen and colleagues found that four out of five autistic adults described experiencing an improvement in social abilities in their mature years, but for one in five, these abilities declined. We speculate that improvement of social abilities may have been due to autistic adults using cognitive rather than intuitive abilities to process social information. A characteristic of ageing in later life is a reduced functioning of the frontal lobes which may explain their reported experience of a deterioration in social abilities.

Employment and relationships

Nearly 60% of the research participants in the Wake, Endlich and Lagos study (2021) indicated that autism had made employment difficult but 26% indicated that autism had helped them in their chosen careers. 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 and Attwood 2022). We wrote the book with the knowledge that many autistic adults struggle to find and maintain work, despite having many qualities and abilities that are advantageous in the workplace.

A source of stress in the mature years was relationship difficulties, especially a perceived failure to meet the emotional needs of their partners. The Wake, Endlich and Lagos (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 the 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 wellbeing. 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 and be understood

Being able to excel in what you love to do

Space to pursue interests/hobbies

Daily engagement with special 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

It is interesting to note that a sense of wellbeing and quality of life was associated with reduced aversive sensory experiences and being able to engage in a special interest. This is important information when supporting an autistic adult.

The study of Wake, Endlich and Lagos (2021) found that there was an overall improvement in the quality of life for autistic adults after age 50, both in terms of effective coping strategies and improved mental health.

Mental health

Many research participants experienced mental health problems in their teenage years, but not understanding what they were going through at the time and not being able to effectively explain their thoughts and feelings to family and professionals. In the above study, over the age of 50, high levels of anxiety were reported by 74% of research participants and depression by 72%. In the same age range, suicidal thoughts were reported for 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, Endlich and Lagos (2021) there was distrust and disdain for most forms of conventional treatment and health professionals, especially medical doctors. They felt they were not listened to or understood and 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 drugs was a common theme. Some participants had been prescribed medication for anxiety or depression but found them either unhelpful or the side effects off-putting.  There was also the issue of compliance in taking the medication as illustrated in the following quotation:

“She sent me off to see a psychiatrist and he told me … give me anti-depressants and I … said well, a. I don’t think I’m depressed, b. I’m still breastfeeding and c. you know, can we not talk about this? And he said if I wouldn’t take the antidepressants there was no point me seeing him. So that was the end of our visits. I didn’t take the antidepressants”.

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.

Mindfulness, meditation, and spiritual and physical activities, such as gardening, 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 to achieve a sense of peace and emotional stability without the negative side-effects of medication.

Some conventional cognitive 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 had developed greater self-awareness and, ultimately, self-acceptance and self-forgiveness. 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 stoicism 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.

Medical issues

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” (Mosely, Druce and Turner-Cobb 2020). Throughout life, there were concerns regarding insomnia or other sleep disorders, allergies and obesity.

There is ongoing research exploring whether there is an association between autism and early onset dementia (Vivanti et al 2021) and Parkinson’s disease (Croen et al 2015). Preliminary research indicates that there may be significantly increased rates of these two medical conditions in autistic adults.

Factors contributing to a positive outcome

Our clinical experience and research 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 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 wellbeing, 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.

Where to from here?

On September 7 and 8 later this year, 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 assist clinicians to recognise autism in a variety of presentations, assessing co-morbidity and differential diagnoses and will review the range of screening instruments and standardised assessments or scales. The second day will take the themes of this blog further, increasing the clinician’s knowledge of autism and how to modify therapy for a range of 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

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

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

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 to be 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.

Adolescent autistic friendships

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Adolescent autistic friendships

Typical adolescent friendships

Typical children go through four stages of friendship from pre-school to adolescence, with the fourth stage becoming apparent from around the age of 13. During the previous stage of friendship (9 to 13 years) there is usually a small core of close, same gender friends, but in stage four the number of friends, gender, and quality of friendship changes. There can be different friends for different needs, such as emotional comfort, humour and entertainment, or practical advice for schoolwork. A friend is defined in stage four as someone who ‘accepts me for who I am’ or ‘we think the same way about things.’ A friend provides a sense of personal identity, self-esteem, connectedness, and resonance with one’s own personality. There are less concrete and more abstract definitions of friendship, with what may be described as ‘autonomous inter-dependence’. The friendships are less possessive and exclusive, and conflict is resolved with self-reflection, compromise, and negotiation.

During the teenage years, friendships are often based on shared interests, such as academic achievements, mutual participation in sports and recreational activities, and passion for causes, such as climate change. There is a greater depth and breadth of self-disclosure, empathy, and sharing feelings and secrets. The teenager increasingly spends more time with friends than parents, and allegiance can be to friends and their value systems rather than to family. Peer group acceptance may be perceived as more important than the approval of parents.

When conflicts occur, friends will now use more effective repair mechanisms. Arguments can be less ‘heated’, with reduced confrontation and more disengagement, admission of mistakes and recognition that it is not simply a matter of winner and loser. A satisfactory resolution of interpersonal conflict between friends can strengthen the relationship. The friend is forgiven, and the conflict is put in perspective. These relationship qualities played out in typical adolescent friendships are the foundation of interpersonal skills for adult relationships.

Autistic friendships

In typical adolescents, the acquisition of friendship skills is based on an innate and evolving ability to make and keep friends that develops throughout childhood, in association with progressive changes in social reasoning and abilities modified through positive friendship experiences. Unfortunately, autistic children and adolescents are not as able to rely on intuitive abilities in social settings and must rely more on their general cognitive abilities to process social information. They often have had peer interactions which have been confusing, if not aversive. Due to relying on cognitive rather than intuitive abilities, autistic adolescents often have difficulty in friendship situations that have not been rehearsed or prepared for. They also have difficulty reading and following covert social rules and conventions. They may be criticized by peers for making social errors, often being labelled a ‘social retard’. Autistic adolescents have probably not had many opportunities for a friendship mentor – peer or adult – to provide guidance and constructive, positive feedback.

Thus, autistic adolescents work twice as hard intellectually at school than their peers, as they are learning both the academic and the social curriculum. As explained by an autistic teenager, ‘It takes all my brain power to be a friend.’ At the end of the school day, the autistic teenager has usually had more than enough social interaction, and desperately needs to relax in solitude to intellectually process the day’s social experiences. As far as the autistic teenager is concerned, friendships end at the school gate. They may resist parents’ suggestions to contact friends or engage in extra-curricular activities, local sports, and artistic activities such as drama. Parents may need to accept that their teenage son or daughter does not have the energy or motivation to socialize any more. If parents arrange social experiences, it is imperative that the experiences are brief, structured, supervised, successful, and, most importantly, voluntary.

Even when autistic adolescents are included in the activities and conversations of their peers at school, there may be an awareness that they are not popular. This is illustrated by two comments from autistic adults describing their teenage years: ‘I wasn’t rejected, but I did not feel completely included’, and, ‘I was supported and tolerated, but not liked.’ A common lament is feeling that others do not want to be around them – that they are perceived as a nuisance. Autistic adolescents often blame themselves, or the fact that they are autistic, for their peer rejection, and become anxious to avoid inadvertently violating their peer social hierarchy and expectations. A lack of genuine social acceptance by peers will obviously adversely affect the development of self-esteem, self-identity, and perception of autism.

Autistic adolescents can be increasingly aware of being socially naïve and making social faux pas. The worry about social incompetence and conspicuous errors can lead to the development of a social phobia and increased social withdrawal. An autistic teenager said that ‘I live in a constant state of performance anxiety over day-to-day social encounters.’ Aversive social experiences with peers can lead to the assumption that everyone is against them, and to misperceiving, or not recognising, friendly intentions when they do occur. This may be a contributary factor to becoming a recluse at home, and not wanting to leave the safe sanctuary of their bedroom.

The social performance anxiety can be especially acute at the end of the day, and before falling asleep, when the autistic teenager reviews the social experiences of school. He or she may now be very aware of what other people may think, and this can be a significant cause of anxiety: ‘I probably made a fool of myself’; or depression: ‘I always make mistakes and always will.’ There can be a conscious retreat into solitude: as an autistic adolescent said, ‘I’d rather just be alone, but I can’t handle the loneliness.’

The autistic teenager typically has fewer friends, and meets with friends less often at school and for a shorter duration, compared to peers. They can express feelings of deep loneliness and melancholy. Being isolated and not having friends also makes the adolescent vulnerable to being teased and bullied. The ‘predators’ at high school target someone who is alone, vulnerable and less likely to be protected by peers. Having more friends can mean having fewer enemies, being protected, and having someone to repair or refute derogatory comments and restore a sense of trust.

Peer acceptance and friendships can also benefit the autistic teenager in terms of providing a second opinion regarding the motives and intentions of others, thus preventing that sense of paranoia. Friends can provide an effective emotional monitoring and repair mechanism, especially for emotions such as anxiety, anger, and depression. If a typical teenager is sad, close friends will cheer them up, or if angry, calm them down and prevent them from getting into trouble. Friends can also offer guidance on what is appropriate social behaviour, helping develop a positive self-image and greater self-confidence.

Typical adolescents can easily identify their friendship ‘family’, and achieve a sense of connection and belonging to a friendship group with shared interests and values. Autistic adolescents, on the other hand, often yearn for a sense of connection, but usually experience rejection from popular friendship groups. However, they may be accepted by marginalised teenage groups that engage in activities and interests that tend to cause concern for parents – exploration of alcohol and drug use, sexuality and eating disorders, for example. The friendship family ‘adopts’ the autistic teenager, who acquires a new intense interest and may accumulate knowledge from the Internet that is valued by the group.

When a friendship does occur, one of the difficulties for autistic adolescents is knowing how to maintain that friendship. They may struggle with the unspoken rules, such as how often to make contact using social media; what are appropriate topics of reciprocal conversations on mutual interests; what might be suitable empathic comments and gestures; and how should they be generous or tolerant about disagreements. Autistic teenagers can tend to be ‘black or white’ in their concept of friendship, such that when a friend makes a transgression of a friendship expectation or ‘rule’, the autistic teenager may coldly end the friendship rather than seek reconciliation. Sometimes, when the neurotypical friend ends the relationship, the autistic adolescent can experience considerable emotional distress, especially when not knowing exactly why the friendship ended; they may experience a deep sense of betrayal.

One of the characteristics of autism is alexithymia, that is, a difficulty communicating inner thoughts and feelings in a conversation. This reciprocal disclosure is one of the core components of adolescent friendships, especially for girls, but extremely difficult for autistic teenagers who can be perceived as ‘shallow. This combines with another difficulty associated with autism, that is knowing how to respond empathically to a friend’s disclosure, and thus they may be perceived by peers as emotionally ‘cold’.

Autistic friendships for girls

The challenges in developing friendships for autistic adolescents described in the previous section can be applicable to both autistic boys and girls. However, we are increasingly recognising how autistic girls may have a different way of adapting to their autism when they make friends. At some stage during the primary or elementary school years, an autistic girl will start to recognise she is different to her peers in terms of social abilities, interests, and sensory sensitivity. She may then develop compensatory and camouflaging strategies to make and keep friends.

The autistic girl may not understand or feel comfortable engaging in the complex friendship dynamics of other girls, which often include gossip, relational bullying, judgements and ‘white lies. In contrast, typical boys’ social interactions are much simpler, and the autistic girl may share the boys’ interests in sports, science, computer games, construction toys, logic and adventure. The autistic girl thus becomes a tomboy, a compensatory mechanism for autism which can continue into the adolescent years, as she does not share her gender peers’ interest in fashion, or romantic feelings towards popular male heroes.

Another strategy is to acquire social inclusion with female peers by observing peer social interactions, analysing their behaviour, seeking social rules and conventions, and imitating the gestures, speech, persona, and interests of socially successful girls. She creates a social ‘mask’ and becomes an expert mimic. As a teenage girl said, ‘Why go to all the effort of figuring out what normal is when you can just copy it?’

When acting with friends she is briefly ‘cured’ of autism, but there is only a surface sociability; her lack of real social identity, and constant acting of socialising with peers can be a source of performance anxiety, cognitive and emotional exhaustion, and ultimately depression. The characteristics of autism are supressed at high school, so her social difficulties are not noticed by teachers; however, the supressed stress is often released at home. She becomes a chameleon, or ‘Jekyll and Hyde’ character.

Camouflaging autism by being an accomplished actor who has ‘learned the script’ enables the girl to acquire social acceptance and inclusion by her peers. She mimics appropriate social gestures, facial expressions and female prosody. However, this in turn may delay the identification of two of the central characteristics of autism, namely deficits in both social and emotional reciprocity, and the appropriate use of non-verbal communication. As one teenage autistic girl said, ‘I have done such a great job at pretending to be normal that nobody really believes I have autism.’

An autistic teenage girl can be overly sensitive to conflict between her female friends and take on the role of peacemaker. In a friendship group there can be several contradictory opinions and egos, and an autistic adolescent will have difficulty processing several conversations and feel uncomfortable being watched by several peers. An autistic teenage girl may prefer single close friendships, but have difficulty determining who would be an appropriate choice for a friend.

When a one-on-one friendship does occur, there can be concerns about the degree of intensity of the girl’s engagement with just one person. She can be overly controlling and possessive, and the one female friend becomes the sole focus of her social life. This interpersonal dynamic may shorten the duration of the friendship, which is ultimately broken by the neurotypical friend. The friendship may also be broken by the autistic teenager, who has a rigid conceptualization of what a friend should do and say. There is a limited ability to understand an alternative perspective, and to manage disagreements and conflict with re-appraisal, compromise, and forgiveness. Thus, there may be a total rejection of the relationship without having considered any relationship repair mechanisms.

During earlier childhood, young autistic girls may observe, analyse and consequently adopt the conversations and interests of their peers – fashion such as pink, frilly clothes, toys such as Barbie dolls, and the current popular films and tv shows. As these interests and preferences of their peers evolve, during adolescence, there is a continued determination by girls to stay abreast of this ‘currency’ of female friendship. However, as adolescence progresses, there may be a recognition by young autistic females that they do not feel as though they are a genuine member of the friendship group. They are exhausted after socializing with their peers, and spend considerable time engaged in a social ‘autopsy’, analysing their social abilities and fearing that they will be discovered as a fake. Social invitations may diminish, and there is a growing realization that this strategy of acting and camouflaging may never really work; there is an increasing feeling of alienation from peers, and a sense of not being true to the real self. The ‘pendulum’ can then swing the other way, such that the girl begins to despise femininity and defy social and gender conventions. She may become determined to join marginalised peers who are less judgemental and more accepting of someone who is ‘eccentric’.

Resources and programmes on friendship

We would not anticipate that an autistic adolescent could quickly and easily acquire the friendship abilities of their peers. However, there are strategies and programmes that can be used by parents, teachers, and therapists to improve friendship experiences, abilities, and confidence.

An autistic friend

Friendship is often based on two people sharing the same interests, beliefs, and values. We have observed that sometimes the most enjoyable and long-lasting friendships for an autistic adolescent is with another autistic adolescent. They have found each other. This may have been by chance, both being conspicuously on the periphery of friendship groups, or by design or circumstances.

In high school, there may be the opportunity to join interest groups at lunchtime or after school, shared interest topics such as science-fiction films, Japanese anime and manga, science or mathematics projects, and robotics and computer programming may be just some of the more popular topics. Friendships may then develop that are relatively safe from criticism and based on mutual interests. Another source of friendship can be two autistic students who are talented in similar areas, such as art and drawing, or music, who can then share ideas and techniques with each other.

Friendships with autistic adolescents may be achieved out of school hours by attending events such as Comic Book, Cosplay, and fan conventions, meeting like-minded peers. We have run many autistic adolescent groups on themes such as emotion regulation, building resilience to bullying, being the authentic self, and the dating game. We have found that many participants developed friendships during and beyond the group sessions.

Animals as friends

Animals provide unconditional acceptance. The family or personal dog is always delighted to see you, despite the day’s disappointments and exhaustion. The horse seems to understand you and wants to be your companion. The cat jumps on your lap, and purrs with delight in your company. Pets, and animals in general, can be effective and successful substitutes for human friends, and a menagerie becomes a substitute ‘family’. Animals identify with, and feel relaxed in the company of, a non-predator (the autistic adolescent), and pets can be a source of comfort and reassurance. A special interest in, and natural understanding of, animals can become the basis of a successful career. We have also found that autistic adolescents are often more able to perceive, and have compassion for, the perspective of animals than they are that of humans, with a greater sense of trust and mutual understanding.

Internet friends

An autistic adolescent may have achieved an advanced level of expertise on multi-player games and is genuinely admired by fellow gamers, who actively seek the autistic adolescent as a member of their team. They are accepted and valued because of their knowledge rather than their social persona and appearance.  This status and appreciation can be a rare and intoxicating experience. One of the advantages of this form of entertainment and friendship is that autistic adolescents have a greater eloquence in disclosing and expressing thoughts and feelings through typing rather than face-to-face conversation.  In social gatherings at school, the adolescent is expected to be able to listen to and process the other person’s speech, often against a background of other conversations, to immediately reply, and simultaneously analyse non-verbal cues such as gestures, facial expression, and tone of voice. However, when using the computer screen, the person can concentrate on social exchange without being overwhelmed by so many sensory experiences and social signals.

The Internet provides an opportunity to meet like-minded individuals who can get to know each other using game chat lines, web pages and message boards dedicated to autism. However, as in any social situation, the autistic adolescent may be vulnerable to others taking advantage of his or her social naivety and desire to have a friend. The autistic adolescent needs to be taught caution and not urged to provide any personal information until they have discussed the Internet friendship with someone who can be trusted.

Activities for parents

The end of the school day, when the autistic adolescent has recovered from the educational, social, and sensory challenges of their day at high school, may be a time to discuss any aspects of friendship that have been successful or confusing. The conversation may start with sharing positive friendship experiences, such as an enjoyable time with a group of peers in an academic or recreational activity, helping a peer, or sharing interests and knowledge. However, there may have been times when the autistic adolescent had difficulty accurately reading non-verbal communication and a peer’s intentions.

A game of ‘Puzzling Peers’ can be played: the adolescent is asked to describe the situation, and replay the dialogue, gestures, and facial expressions. The parent and adolescent are then detectives or scientists trying to decipher the message or intention. This can include anything from confusing facial expressions such as eye rolling, to inexplicable demands from the peer (why did they assume I would be interested in this topic?) Other puzzling situations can be not understanding why they would be shunned and criticized for telling the truth (she is obese and needs to go on a diet) or not saying a ‘white lie’.

A parent may explain how to elicit more information, with questions for the young person to ask, such as ‘are you saying that to be friendly or mean?’ or ‘I’m confused, are you being sarcastic?’ They can also help rehearse what to say and do in other situations, such as accepting or declining an invitation to meet and learning the cues and means of ending a conversation or interaction. It is important that friends are not offended by an abrupt ending to a conversation or social gathering, as offence was not intended.

We all of us have a limited capacity for the duration of social contact, and it may be helpful to apply the metaphor of filling a ‘social bucket’. Some typical teenagers have a large social bucket that can take some time to fill, while the autistic teenager has a small bucket – a cup – that reaches capacity relatively quickly. Conventional social occasions with a friend can last too long for the autistic adolescent, especially as social success is achieved by intellectual effort rather than natural intuition. Socializing is exhausting, and the teenager may need to emotionally recover in solitude at home.

It is important for parents to be aware of the friendship challenges faced by their autistic teenager, including a difficulty initiating social contact with peers, and finding someone that they want to talk to and spend time with. As an autistic teenager said, ‘It’s not that I’m antisocial, it’s that I don’t meet many people that I like.’ The parent may need to become a social secretary, arranging and rehearsing social events to encourage the development of friendships, and de-briefing after the event, focussing on what was socially successful and providing clarification and guidance where specific social skills need to be achieved.

Friendship curriculum for teachers and therapists

We now have resources and programmes for parents, teachers and therapists that are specifically designed to enhance friendship abilities in autistic adolescents.

We recommend the publications and programmes developed by Michelle Garcia Winner and Pamela Crooke, with more information available from socialthinking.com. They have developed resources and guide books such as: Socially Curious and Curiously Social: A Social Thinking Guidebook for Bright Teens and Young Adults Social Thinking graphic novels.

Carol Grey originally developed Social Stories to explain the social world to autistic children and adolescents. More information on Social Stories can be obtained from carolgraysocialstories.com. Carol has adapted Social Stories for adolescents; for example, Carol and Tony worked on a compliment guide and workbook for autistic teenagers and adults

https://carolgraysocialstories.com/wp-content/uploads/2015/10/Spring-1999-ISSUE-AND-INSERT-.pdf

Carol’s work has been extended by Siobhan Timmins who has written Successful Social Stories for School and College Students with Autism and Successful Social Articles into Adulthood. Both books are published by jkp.com

University College of Los Angeles’ Program for the Education and Enrichment of Relational Skills (PEERS) is an evidence-based social skills intervention that began with autistic adolescents, and has expanded to offer services for young adults. https://www.uclahealth.org/vitalsigns/peers-aims-to-improve-social-skills-for-young-people-with-autism-spectrum-disorder

Sessions cover topics such as:

developing and maintaining friendships.

romantic relationships and dating etiquette.

managing peer conflict and rejection.

conversation skills.

electronic communication.

developing friendship networks.

finding sources of friends.

appropriate use of humour.

The PEERS programme has been the foundation of a range of social and friendship programmes in many countries and in Australia by www.codeblueforautism.com.au

Minecraft is a popular pastime with autistic adolescents, and the computer game has been adapted to teach social skills by Raelene Dundon. Her book is titled Teaching Social Skills to Children with Autism Using Minecraft published by www.jkp.com

Drama activities can be used to teach social skills and there are two books that describe drama activities to improve the social skills of autistic adolescents. They are:

Acting Antics: A Theatrical Approach to Teaching Social Understanding to Kids and Teenagers with Asperger Syndrome by Cindy B. Schneider, published by www.jkp.com

Act it Out: One Year of Social Skills Lessons for Students Grades 7-12 Social Skills for Teens with Autism Spectrum Disorder by Jeannie Stefonek, published by www.aapcpublishing.net

There are a range of relevant books published by www.jkp.com, such as:

The Asperkid’s Secret Book of Social Rules: The Handbook of Not-So-Obvious Social Guidelines for Tweens and Teens with Asperger Syndrome by Jennifer Cook O’Toole

60 Social Situations and Discussion Starter to Help Teens on the Autism Spectrum Deal with Friendship, Feelings, Conflict and More by Lisa A. Timms

The Asperger Teen’s Tool Kit by Francis Musgrave

How to Start, Carry On and End Conversations: Scripts for Social Situations for People on the Autism Spectrum by Paul Jordan

Asperger’s Rules: How to Make Sense of School and Friends by Blythe Grossberg.

Social Skills Groups for Children and Adolescents with Asperger’s Syndrome: A Step-By-Step Program by Kim Kiker Painter.

Freaks, Geeks and Asperger Syndrome: A User Guide to Adolescence by Luke Jackson.

There are three resources not published by Jessica Kingsley Press.

Asperger’s Teens: Understanding High School for Students on the Autism Spectrum by Blythe Grossberg, published by Magination Press.

Communication Skills for Teens: How to Listen, Express and Connect for Success by Michelle Skeen, Matthew McKay, Patrick Fanning and Kelly Skeen published by Instant Help Books.

Unwritten Rules of Social relationships: Decoding Social Mysteries Through the Unique Perspectives of Autism by Temple Grandin and Sean Barron published by Future Horizons.

The autistic teenager may not know of their diagnosis, or reject books that include the terms autism or Asperger’s syndrome in their title or text. The following are publications that provide guidance in making friends without using the ‘A’ word.

Making Friends: A Guide to Getting Along with People by Andrew Matthews published by Media Masters.

A Good Friend: How to Make One, How to be One by Ron Herron and Val J. Peter published by Boys Town Press.

Awkward: The Social Dos and Don’ts of being a Young Adult by Katie Saint and Carlos Torres published by Future Horizons

The Science of Making Friends: Helping Socially Challenged Teens and Young Adults published by John Wiley and Sons

Autism in couples

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Autism in couples

There are many qualities associated with autism that are appealing to a prospective partner. The person can be attentive, knowledgeable, creative, kind, endearingly immature, physically attractive, quiet, and inexperienced in romantic relationships. There can be compassion for their naive social abilities and having been teased and bullied at school. The prospective autistic partner is often appreciated for being predictable, honest, and confident in their opinions, perhaps with shared interests and an admired career. They may have similar characteristics to one of the parents of the neurotypical partner, such that they are easily fluent in the language and culture of autism. In the early stages of the relationship, the characteristics of autism may be suppressed such that the neurotypical partner is not be aware of their partner’s autism, anticipating a conventional and fulfilling relationship. If autism is recognised or disclosed, there may be the assumption that love will provide the mutual understanding and accommodations within the relationship.

Clinical experience and research have identified that both autistic males and females may develop a compensatory mechanism of camouflaging social and interpersonal difficulties in the early, romantic stage of the relationship.  They may have acquired what appears to be expertise in being an ideal partner from watching romantic films which have provided a script and a role that can be acted, and successful in captivating their partner. This ability to act neurotypical, to camouflage autism and use a variety of scripts and roles can also be used successfully at work and social settings with friends, becoming a ‘chameleon’, but in the privacy of home, their partner gradually experiences living with the real person behind the mask.

The autistic person may be attracted to someone who has exceptional social expertise and empathy for their social difficulties, understanding their confusion and sometimes being overwhelmed in social situations and the subsequent exhaustion and need for solitude.  The autistic partner may recognise that they need and actively seek a relationship partner who can be a social mentor and ‘translator’ of the autistic perspective to friends and family and does not criticise their partner for being social naïve or ‘clumsy’. They continue many of the social and emotional support functions previously provided by a parent.

After several years of living together, the couple may find that the relationship may not be developing as they originally expected. There may be a sense of grieving for the elusive conventional reciprocal relationship they once hoped for. For the neurotypical partner, autistic characteristics that were endearing at the start of the relationship, such as an being an avid collector of model trains, subsequently becomes a source of conflict regarding the amount of time and money devoted to the interest. The initial optimism that their partner will gradually change and become more emotionally supportive and socially skilled can dissolve into despair; social skills appear to be static due to limited motivation to be more sociable, or require constant prompting from their partner.

The autistic partner needs periods of social isolation at home to recover from the social aspects of work, and joint social contact with friends and family can slowly diminish. Gradually, the neurotypical partner reluctantly agrees to reduce the frequency and duration of social contact for the sake of their partner, and slowly absorbs the characteristics of autism into their own personality and lifestyle.

A significant problem for the neurotypical partner is a sense of loneliness within the relationship. In contrast, the autistic partner can be content with their own company for long periods of time – alone, but not lonely. Conversations from the perspective of the neurotypical partner can be infrequent and superficial, but from the perspective of the autistic partner, are satisfying, and primarily an exchange of information, rather than an enjoyment of each other’s company and sharing experiences.

There is an expectation in a relationship of regular expressions of love, affection, and emotional support. What may be missing in the autistic/neurotypical relationship are those daily words and gestures of affection and compassion and emotional support and compliments. The absence of these aspects of a relationship can be a contributory factor to low self-esteem and clinical depression for the neurotypical partner who feels caged within the relationship. Due to having autism, the autistic partner may not be able to recognise and know intuitively how to respond to the subtle non-verbal communication of emotional and practical needs, and can feel that whatever they say or do is never enough to make their partner feel happy. They unintentionally keep getting it wrong and feel excessively and unjustifiably criticized and rejected.

The ability to read subtle, non-verbal communication and contextual cues to determine what someone is thinking and feeling, Theory of Mind, is impaired for autistic children and adults. However, the neurotypical partner can have an impaired Theory of an Autistic Mind. That is,  they have difficulty perceiving or determining what the autistic person is thinking and feeling by reading their facial expression and body language; this is because autistic adults often have a limited ‘vocabulary’ of facial expressions, gestures, and prosody. Another characteristic of autism is alexithymia, that is, having considerable difficulty converting thoughts and emotions into conversational speech, which inhibits the disclosure of thoughts and feelings in a conversation. Thus, there is a breakdown in communicating and understanding each other’s thoughts and feelings for both partners.

The dynamics and stress within the relationship will inevitably change with the arrival of children, presenting new responsibilities and sources of conflict, such as different parenting styles. The relationship may reach breaking point. The autistic partner will have less access to their stress management strategies, such as solitude or their special interest, which is a source of pleasure, relaxation, and an effective thought blocker.  The relationship could be deteriorating, with expressions of despair and anger for both partners who are unaware of what to do to support and repair the relationship.

Over several decades Michelle Garnett and Tony Attwood have provided therapy for couples where one or both partners have the characteristics of autism. On the 20th of February 2021 we presented a whole day web cast on strategies to strengthen the relationship with modules on the:

Qualities of the relationship in the early stages

Signs that the relationship is not as anticipated for both partners

Expressions of love within the relationship

The communication of thoughts and emotions

Managing stress, anxiety, and anger

Verbal, emotional, and physical intimacy

Working as a team and family responsibilities

The future together

The webcast will also include a description of ‘The Relationship Minefield’ programme designed and used by Michelle, Tony and colleagues. For further information to download the web cast, please go to www.attwoodandgarnettevents.com