Episode Transcript
[00:00:00] Speaker A: Welcome to the Art of the Referral Podcast where we explore the nuances of mental health referrals to better serve our patients and our communities. I'm your host, Anna O'Brien, a practicing licensed professional counselor and co founder of Be well Private Practice Communities and theravera Care Connection Technologies. I'm passionate about creating a stronger professional community that works together to reduce provider burnout, increase continuity of care, and ultimately improve the lives of people living with mental health challenges. Each week we dive into a different specialty or supportive tool, bringing you expert interviews, practical advice and inspiring stories to help you master the art and ethics of referrals. Join us as we navigate the complexities of patient care, enhance our professional skills and build a more connected, health conscious community. Let's get started.
[00:01:03] Speaker B: Hi and welcome to this episode where we're going to be discussing gender differences in symptom presentation of Autism Spectrum disorder, what to do, what to look for, and when to refer. I'm here with Dr. Theobald. She's a clinical psychologist and completed a postdoctoral fellowship in neuropsychology. She earned her doctoral degree from LaSalle University and then worked within private neuropsychology practices, primarily within a pediatric population, but also with adults. She now specializes in neuropsychological evaluations for individuals with cognitive, academic, social and emotional challenges with a particular specialty in autism, ADHD and learning disorders.
She's a frequent lecturer on the subtle presentations of autism, particularly in girls and women, and on improving social outcomes for children with neurodevelopmental disorders. Welcome Dr. Theobald, thanks for inviting me.
[00:02:08] Speaker C: I'm so excited to talk about this topic. There's been a lot of discussion around adults receiving an autism diagnoses well into adulthood, some into middle age, and there's a lot of emerging research on this topic as well. Some folks have struggled their entire entire lives without being able to name or identify or a rationale for their difficulties at home or in relationships or in the workplace. And so it's going to be great to discuss a topic that I really love and I think needs a lot of attention, autism in broad diagnostic terms. And then we'll get into how the disorder presents differently in males and females.
[00:02:45] Speaker B: That's wonderful and I appreciate you being here. I see this through my career. I've seen this a lot. You know, oftentimes people will present and if you're not an autism autism specialist or aren't aware of the subtle ways, especially with women and girls, it can be very confusing about how to support them. And oftentimes the Techniques that we use, you know, we may be thinking of social anxiety or, you know, sometimes behavioral challenges. And sometimes the techniques that we are trained to use in other ways, like really aren't effective. And I know it can be very disheartening to folks who are seeking relief.
[00:03:18] Speaker C: Yeah, that's so important and very true. And I think my background and my perspective are a little bit different from some other providers. For one thing, I don't work in a dedicated autism clinic. I'm in a general neuropsychological practice. I trained at Children's Hospital Philadelphia. I trained in their ADHD clinic and then I trained at private neurology and developmental pediatrics practice called Neurabilities Healthcare. They primarily serve a pediatric population. And that's where I really learned how to evaluate autism. But I also had had some previous adult experience as well, working with adult adhd, brain injury dementia evaluations and various neuropsychiatric issues. So I think all of that combined really gave me a different perspective. I think sometimes with providers, even though like, you know, their training is fabulous and they're excellent clinicians, sometimes when you're just kind of, you know, practicing listen with blinders on whether you're solely in an autism clinic or solely, you know, assessing for only adhd, I think, I think you miss some of kind of the other symptoms or other ways of diving deeper to find out what is the source of an individual's issues. And for most of my patients who end up being diagnosed with autism, very few of them have that as the original referral question. Specifically in adults, for children, it's, you know, a different story. But adults might primarily get referred for like adhd, anxiety, anger issues or just a variety of things. But the majority of the time neither the referral source nor the, the, the patient is necessarily thinking about autism. And I'm talking about autism and not so much in the more like severe cases which are fairly clear cut, often diagnosed in early childhood. You know, I'm talking about the more subtle varieties. So that's a very different type of patient and a very different testing dynamic that you know than people who show up at an autism clinic because somebody noticed in childhood that, that they weren't developing typically from a milestone perspective or a social perspective. And that would have triggered some kind of evaluation for autism in those early childhood years. But for adults it's a different story.
[00:05:21] Speaker B: So that mimics a lot of what I've seen as well. I mean, I've worked with adults before where like it was kind of a light bulb went off or like maybe I'm missing something. And that's why it's so important to have this conversation with you because when you get that diagnosis and you understand it like shifts the whole perspective of treatment. And I know it can be, it's earth shattering often for these folks because their identity has been built around, oh, I am just the awkward kid, or, you know, I misbehave and finding out like what it is that's going on and perhaps sometimes, you know, it impact impacts obviously relationships a lot. You know, learning that is, is there's a lot to process in therapy, both from just the experience of like grieving and also developing skills. So I'm so supportive and grateful for the work that you and clinicians like you do because it's so important in the referral process so that we can learn from that information and shift how we approach our clients.
So share with me a little bit like, how was it that you got into this specific line of work and an interest in it?
[00:06:24] Speaker C: So that's kind of a funny story. I was working in a pediatric residential setting as part of my doctoral internship program. And you're basically assigned a caseload. It's usually large, you're very overwhelmed. And in a residential setting, most of the kids are there for pretty severe behavior problems. And I never, I don't see behavior issues in kids as an isolated thing. Kids just aren't inherently bad. There's so much involved from the nature nurture perspective. So I'm there and I meet the mother of a five year old who's residing at this facility because of laundry list of issues from toileting in various places of the house other than the bathroom, to spitting, biting, banging his head on the walls and floors, spinning in circles most of the day. Can only watch one certain program on YouTube. Tons of sensory issues. And by the way, he was premature and had very delayed speech. So from that list you can kind of say, okay, that's probably autism. But then I meet his mom and she initially came off as just like angry, sarcastic, seemed she didn't want anything to do with talking with me. Came off around her child as just kind of like aloof and maybe cold.
And she's of course completely overwhelmed and burned out from her child's difficulties. So as I gather some information, you know, her responses are like, yep, nope. And she tells me later as we're talking, she hated going to school. She didn't get along with her parents or siblings, really struggled to keep friends. She's been fired from four different jobs for being like, rude to customers. And as we're talking, I'm beginning to find so much evidence for autism, but it's subtle. You know, those things could easily be chalked up to having, like, a difficult child or a difficult, you know, growing up experience.
So meanwhile, she tells me that she was diagnosed as a child with depression, anxiety, and ocd. And as an adult, someone diagnosed her with bipolar disorder and borderline personality disorder. So after a few meetings with this mom, I broached the idea that perhaps she may be autistic, and she just immediately started to cry. She said she had no idea that all of her relationship issues could be stemming from autism. People just always thought she was rude, angry, or just mean. And from there, I begin to dive deep into the world of autism. And I began to realize that, you know, how many people often and primarily women have been either misdiagnosed or just plain missed. So now I've seen countless women with these stories where nobody's thinking about autism and that's what it ends up being. And it's really, you know, you mentioned this before. You said earth shattering. You know, it is almost life changing for them to get a diagnosis.
[00:09:01] Speaker B: Yeah, I mean, I have the chills right now just thinking about it, like, from watching people go through that experience and just also, like, the empathy of what that must be like. Right. It's when you are already struggling to keep up with, like, you know, people not understanding things, and then people are labeling you as, as, like, bad or wrong or giving you, like, harsh diagnoses that are associated with stigma. And not that autism isn't, you know, but at the same time, there's a lot, the lot that we can understand from autism. And I think that I'm noticing people are starting to be much more accepting of understanding that we kind of all fall on some sort of spectrum.
[00:09:40] Speaker C: Yeah. Yeah. And I, I kind of see a lot of, you know, neuropsychiatric, psychiatric, psychological concerns is all falling on some kind of spectrum. You know, it's not this idea of. I have these six out of nine criteria for adhd, so check. I have. I have adhd. You know, it is. It is a bit on a spectrum. And I think, I think we are beginning to realize, and clinicians and providers in general are beginning to realize that, you know, if I say ADHD or I say autism, two people can look very different. And there is a saying in kind of the mental health world that if you meet. If you meet one person with autism, you've met one person with autism. And I. And I really held true to that because I have found that it's, it is quite different individual to individual.
[00:10:24] Speaker B: Makes a lot of sense. So what do you see like as kind of the most common symptoms that occur in autism?
[00:10:32] Speaker C: Yeah, so there are, you know, I use, you know, the kind of standard guidelines of the DSM 5, which is the diagnostic manual for all, you know, a lot of these disorders. And so within the diagnostic criteria, there's two main pillars of an autism diagnosis. So first you need. The individual must have persistent deficits in social communication and social interaction in multiple contexts. So it's not just a person who has difficulty interacting with their partner or boss. It's across multiple settings. And what that basically means is an individual has trouble being reciprocal in their interactions with someone. So in everyday life that might look like a person who talks at you rather than talking to or with you. So they don't know when to pause. They don't really read facial and nonverbal cues. They tend to have a harder time developing, maintaining and understanding relationships, ranging from maybe sharing or making friends in childhood to having a hard time putting themselves in someone else's shoes in adulthood. The second pillar that must be present is restricted or repetitive patterns of behavior, interests or activities. So that can look like repetitive motor movements, like spinning in a circle, which we hear of often in autism, flapping hands or lining up toys in childhood. Or it can be insisting on symmetry, being pretty routinized in your schedule or routine. So maybe this person has a ritual they follow every morning or throughout the day. Like meals might be at really specific times. If dinner's not at 6, it's at 6:15. It's a little bit harder for them to kind of be flexible.
Maybe they need to take the same route to work every day without deviating. Or they show distress when like small changes to their routine come up.
So there can also be sensory interests like rubbing a soft blanket or you know, even like touching your face repetitively. Or there can be sensory aversions, things we don't like from a sensory perspective. Like maybe they can't be around people who chew loudly or, or struggle, you know, having meals with other people or just don't like loud noises in general, don't like, like crowds, that sort of thing. They may have like really intense interests or things that they just hyper focus or fixate on. So some examples could be like a child who knows every single type of construction vehicle or can only watch a specific show, and they'll watch that show over and over and over in adult this could look similar, but it might be something more. Like an adult who, like, reads the same series of books multiple times from start to finish. Like reading Harry Potter in the same order, having a fascination with history, like, beyond what would be considered a hobby or interest. Or maybe they're highly adept at math, or maybe they fixate on a craft like jewelry making. So we know that symptoms of office. Start that sentence again. We know that symptoms of autism don't just show up when someone's 25. They do need to be present since childhood. So even though they may look quite different now in adulthood than when they were a child, we still need to make sure that these symptoms were present in childhood to really be able to tell that story.
[00:13:43] Speaker B: That's great to know. So, really quick, I just wanted to kind of a short list of some of the misdiagnoses that you commonly see in adults. So when someone comes for testing and it's kind of discovered, what have they maybe previously been diagnosed with?
[00:13:58] Speaker C: Sometimes I'll call it like Alphabet soup. So often it's anxiety and depression. Obsessive compulsive disorder, adhd. Because you think about, you do need quite a bit of executive function skills when you're interacting with others. So if you're, if you're autistic, you're always thinking about, while you're interacting, the person. Did I say that correctly? What should I say next? What's their face looking like? Am I making enough eye contact? So the, you know, the kind of burnout from executive function is pretty profound in folks with autism, or it certainly can be. But, yeah, those are some of the most common ones that I see.
[00:14:35] Speaker B: That's great to know because it's kind of a little red flag for folks if they meet with someone who might have carried those diagnoses previously and some treatment seems stagnant. Something to look at. So tell me a little more about, like, why it happens that boys carry the diagnosis of autism more than girls do, or they tend to be caught more frequently.
[00:14:58] Speaker C: Yeah, that's what we've thought as a field and for many, many decades, experts assumed that autism occurred more in males than females. Most autism research relied on primarily male participants and examples. So what we know about autism is largely based on autism in males. And because of this, boys tend to be referred for autism diagnosis 10 times more than girls. Physicians and clinicians, some still don't have a very strong understanding of autism in females. The autism assessment tools that are currently used to detect and measure autistic traits, they were all established on A male baseline because of that prolific number of males that were in research studies. So identifying autism in females is harder if their traits don't match what's traditionally considered an autistic type of symptom. So the average age of being diagnosed with autism for boys worldwide is 8 years old. But for girls, that number is 13 years old. And why is that? Well, we know for sure from research that autism is under diagnosed in females. There's evidence that even when they're diagnosed, when girls are diagnosed, it's almost, it's several years later than boys. So if a boy and a girl have really similar symptoms, that boy will most likely get diagnosed a few years earlier. So that's a couple of years of intervention and understanding and support that that girl is missing. So that's huge. And it's, it's just more evidence that girls require or need to display more challenges and higher autistic traits to get diagnosed.
[00:16:37] Speaker B: Yeah, no, I mean, I'm just thinking 13. Oh my goodness, you're in the middle of middle school, where kind of that stage of development and lifespan development is all about like identity within a group and, and meeting people. And it's like well into that I, I can kind of see how like that's when they start noticing with girls as like this social climate gets more intense. But at that point there's so much development that's already been done. So there's a lot of work to do and like supporting someone and their, their personal narrative.
[00:17:06] Speaker C: And I'm, and I'm talking more also, just to be clear, more like in the diagnostic manual, there's autism spectrum disorder and then there's level one, level two, and level three, with level three being kind of the most profound challenges, or some may call it more severe autism. So that may be a child who really struggles to interact, perhaps could be nonverbal, like a lot of significant behaviors consistent with autism. Whereas the numbers I was throwing out earlier are more. The research studies were more individuals with level one, which is kind of the least impacted, not to say that they aren't struggling. It's just along that spectrum, those with who are able to be a bit more functional in their world than the other kids who are more severe or profound.
[00:17:49] Speaker B: So why do you think it is that so many girls are getting missed?
[00:17:53] Speaker C: It's a really good question. Well, so if a child had certain symptoms when they were young, like maybe they had really significant sensory sensitivity to noise when they were in preschool, but they don't seem to have it anymore, that still counts toward the diagnosis, because we want to look at this individual as a whole, even if they're coming in as an adult, what was their childhood like? What was their early childhood like? So that's why it's so important to get a strong developmental history and interview when that person comes in as an adult. And that honestly, that interview with, you know, if a parent is still alive and available, or even like a close sibling, someone who knew that person and can recall what their behaviors were like as a young child, that honestly is almost the single best way I can get a sense of what their symptoms were when they started and how they changed over time. But the reason it's important when particularly thinking about girls is they have a different timeline than boys. Like we talked about, research shows that girls with autism have fewer identified problems when they're young. Like when they're in the toddler age, preschool and early, early elementary school age, they have better adaptive functioning than the boys in those early years, but they have more problems, more a more rapid increase in their autistic symptoms during adolescence. And it's definitely been shown that girls tend to do better early on. Some girls, not every girl, of course, and they have more difficulty as they get older. And that's such an important point because so many people rule out autism if there's no obvious early history of it. But they have to remember that there's this timeline where girls can kind of hold it together. Hold it together, hold it together. And then somewhere around 5th or 6th grade, Girl World goes a little crazy and they just can't hold it together any longer. So I find that if a clinician does a really good developmental history, when an adult patient comes in, you're going to find the earlier problems. They're subtle, but they're there. And you just have to look more carefully. So before I go through the differences in how women tend to present with autism, that timeline itself is different.
[00:19:57] Speaker B: So, yeah, you were mentioning that there are some differences in struggles, but what do you see as far as the way they communicate and struggle with social reciprocity, which is probably like the first pillar of autism that you mentioned earlier, right?
[00:20:14] Speaker C: Yeah. So that first section, it's social and communication differences. And the first one is social reciprocity. So that has to do with every aspect of back and forth flow of interaction. So intuitively greeting people, responding to greetings, sharing personal information, showing interest in other people, taking a person's point of view, being reciprocal. And by that I mean that back and forth conversation, it's like a ping pong Game is what I how I like to think about when I'm evaluating someone, whether it's a child or adult, I'll leave like little invitations. Some people call them breadcrumbs for a social interaction. So I may say something like something really strange happened to me on my way to home from work. It's pretty obvious, right? You know, most people will probably stop and say what happened, right? And that's reciprocity. So compared to boys, girls with autism are absolutely more engaged in conversations, they're more reciprocal in conversations, they share their interests more, and essentially they have better basic social niceties and basic conversation skills, particularly in their topics of interest, and particularly when they're one on one with a supportive adult. So meaning in the testing situation, that's when they're at their best. And sometimes these girls can fool me and I'll have to continue to push or press until I can see or not see what would be consistent with autism. So there are absolutely times when the history and the test results are so clear that this girl has autism or this woman has autism, but she doesn't look like she has autism on the outside. So it's such an important point. And this is one of the reasons girls are overlooked. Parents might say, oh, she has friends at school. But in reality, this girl is more like hanging around other peers, but really not interacting reciprocally. And girls also have better imagination and pretend play than boys do. They look like they blend in more on the playground. And there have been studies showing, for instance, if you're a parent or teacher on the edge of the playground, just kind of monitoring and watching or whatever, a boy with autism will be more obvious. He'll be clearly maybe a loner on the playground. Whereas from a distance, the girls look like they're blending in. They're not really truly blending in, but they look like it from a distance. Women I see with autism tell me all the time I can pull off being social and being a pretty typical social person, but it's so hard for me. I'm working really, really hard. I'm thinking the whole time I'm not even present in this interaction because I'm five steps ahead of what I'm supposed to say, or questioning what their eye contact meant or wondering what they meant by that facial expression. So they're pulling it off. But the inner experience is so different. And it really speaks to how important it is to get at the, the girls or the woman's inner experience and not just go off their behavior.
[00:23:04] Speaker B: That's interesting. So really like Interviewing them about what that's like. And yeah, you know, you're, you're discussing a little bit about, like, relationships, right. And how, you know, when we have more surface transactional relationships, it can go under the radar. But what happens, like, when we go for those deeper relationships like friendships or, you know, where naturally, because it's deeper, there's going to be times of conflict or, you know, more of that kind of deeper level of give and take saying, you're seeing that show up for women a lot differently, huh?
[00:23:33] Speaker C: For sure, for sure. You know, if the patient's still in school, whether it's high school or college, I'll ask for their permission to send a questionnaire to, like, a professor, a teacher, maybe even a guidance counselor, someone who knows this person pretty well. And it's so funny because in these women with the more subtle presentations of autism, I get those questionnaires back and they're like, nothing is elevated. It's kind of like no concerns here.
So it just goes to show you that, you know, these folks do really fly under the radar for a long time until, and at that surface, like, superficial level, until you really start to have, like, a deeper conversation with them, which I'll talk about later, but that's when it comes up. But you know, teachers, professors, you know, other folks, like some, they don't really get that opportunity with these individuals.
[00:24:23] Speaker B: Yeah, well, women are taught just like to be people pleasers. Right. And to read social more. And like, we're just taught that stuff, so it makes sense. I mean, I'm sure there's a biological element for sure. And, but then also just the nature of just like a culture, you know, and being taught these skills that they can kind of mask more easily.
[00:24:43] Speaker C: Absolutely.
[00:24:45] Speaker B: Yeah. So a little bit, I mean, rigidity, right? It's like big part of something we notice with folks. And, you know, obviously with kids, you can think about that about, like, not wanting to share or having an idea and not wanting to listen to anyone else. But can you share a little more about what you see in terms of rigidity and the way that it impacts relationships with, with adults even as well?
[00:25:05] Speaker C: Yeah, that's a really good point. And I, I, I once had a female client explain to me that she and her partner didn't speak for two days, I think because he didn't follow her recommended route on the GPS to wherever they were driving. And it, it literally threw her into a tailspin. She couldn't cope. And more importantly, she couldn't understand why her partner would drive such a I think her word was ridiculous route. And when she had said, well, I planned that route out precisely, it was perfect. So it's that sudden, like jarring change that's very unmanageable. And we do see this in men and women on the autism spectrum, boys and girls, but it seems to present more of a problem in females.
So in school age girls, this could look like the rules of a game were changed mid game. And so she doesn't really know how to cope or understand and might even walk away or might get angry and have an outburst. So when I'm working with an adult female and doing that long, exhaustive history, I also want to include a parent, like I mentioned that, or a sibling or someone close to this person to really find out what this person was like during childhood. Did they have a tantrum when something changed within the house? Did they end friendships because a peer played with another child during recess? And I see this a lot in relationships where one partner explains that they need to speak in like exact terms or it throws the partner with autism completely off.
And we see this more in women than men. So, for example, if a woman is told, you might find this humorous, we're out of cereal. She may very well go look in the pantry and find one single box with maybe like 20 flakes in it and say, no, we're not. Because technically there is cereal. Is it enough for a bowl or a serving for a meal? Probably not, but that's kind of the nuance of it. The fact is there is there is cereal. So it was incorrect that they are the houses out of cereal. But I also see this rigidity in things like being intolerant of being late ever. So sometimes when adult women come in, it may even be that their teen child said, hey, and I'm not a huge fan of TikTok diagnosing at all. But this teen child may have said to their mother, hey, I was watching this thing on TikTok and it sounds a lot like you.
So sometimes I will ask for permission to speak to these kind of nearing adult children of patients that I see to, to find out kind of what is their experience with their, with their mother. So teen kids of a woman I've evaluated who she did wind up being autistic, told me that their mom considers on time as 20 minutes early and she would be like fully panicked whenever they did wind up being late or close to being late somewhere, almost like a panic attack. And I, and I think with this woman, one person diagnosed her with like panic disorder. And you could see how someone may click quickly come to that conclusion that, well, this is anxiety, when in fact it's not.
[00:28:00] Speaker B: It's interesting. Yeah. So a lot of this, like black, you know, we. We talk about black and white thinking sometimes in terms of the way people process emotional reactions. Right. Like they. They're either on my side or they're my enemy. Right. But this is kind of a form of black and white thinking that, you know, it's specific to. You know, it sounds like this. Is that kind of what you're referring to with that black and white.
[00:28:21] Speaker C: Absolutely. Absolutely. And in more of the child clients that could look like, you know, everyone hates me or the teacher's mean to me. Right. So girls can often go overlooked because their teachers might describe them as angels or model students and an adult. This black and white thinking just impacts us much more. Particularly if. If someone is autistic. So often an autistic male might be more likely to say, well, my way is correct. This is the only way to change a bulb. It's the best way. Any other way is wrong. And you really can't convince them that there's like an alternative. But in autistic women, they're more likely to be a little bit flexible in their thinking and tend to be more of like, the rule followers. So, for example, one. One woman I was interviewing said something about, like, she works nine to five and she only takes 30 minutes for her lunch because, like, any more than that would be taking advantage of her employer. But on the flip side, she's much less likely to agree to stay late for. Unless the reason is, like, so compelling because she's like, I work nine to five. That is my. Those are my hours, and I've been a good employee, and that is what I. That is what I shall work. So I see that black and white thinking a little bit differently in women.
[00:29:34] Speaker B: Absolutely. So can you share a little bit about, like, the concept of how oftentimes women or, you know, other folks as well might. Might end up camouflaging and why it is that females tend to look more subtle?
[00:29:49] Speaker C: Yeah, that's exactly. So one of the topics that, you know, we would be remiss if we didn't talk about, and I'm glad you brought it up, would be camouflaging when we're talking about females. Right. So that's one of the reasons why girls can look so much more subtle. Their behaviors are more subtle because they're just better at camouflaging than boys. They do it more, and they do it Better. And by camouflaging, for folks who may not be familiar with that term, they may be more familiar with a term called masking. And there's a great book called Unmasking Autism, and it really does highlight a lot of the things that we're talking about in more depth and detail, but just what that experience looks like and what it feels like for some of these folks who do have to mask. And women do tend to mask, more so than men, for sure. And really, what camouflaging is, it's this discrepancy between your inner experience and your outer behavior. And we all do it, all of us, depending on the situation. And any psychologist can tell you about camouflaging because there are days like, you've probably had a headache or your child's sick or, I don't feel great. And yet we put on our mask for our patients, and they really can't tell the difference. Our outer behavior doesn't match our inner experience, so we all camouflage. But people with autism have just have to do it more frequently, and they have to stain it for longer. It's probably harder for them to do. And the universal comment I hear is, it's exhausting for girls and women. Yeah, it is exhausting. I've heard it being likened to two ways. One was doing math in my head all day long, and another patient described it as running a mental marathon and then coming home and just absolutely collapsing and being somewhat like, you know, checked out for some period of time when they get home.
[00:31:36] Speaker B: Absolutely. Yeah. So, like, kind of after all this, back to the original question, what's at the meat of, like, why are we missing all these girls? Like, we have this information. People are beginning to talk about it. But what do you think it is, like, about clinicians or the work we're doing? Because, you know, we're human, too. But what are we doing? What do you think? How can we improve as a field?
[00:31:59] Speaker C: I think about that a lot. I think about it with myself, too. Like, I always want to improve. You know, sometimes it may take me, like, an hour into an evaluation to see, like, oh, okay, I see maybe why they came in, because they're having, you know, they've been complaining of, like, social difficulties or, you know, something else. And it's always on my radar, always. But it may take me a while to get there. So I feel like, truthfully, there's just some really common mistakes that clinicians make, and some of the top ones that I see, first of all, not even wondering about autism, and I see this one all the time. It's rare that I see a report that maybe this patient had an evaluation from somewhere else by someone else at some point in time. Where in the report did the clinician miss autism? Because they wrote, I consider the possibility of autism, but I ruled it out because of A, B and C. So they're just kind of looking at like the checkboxes of the diagnostic criteria in a vacuum and not really delving deeper at all. So it's really not even considered and it's not crossing people's minds. So the first thing is, I think, I feel like we all have to have it on our radar way more. So whenever you're working with a, you know, a female with, like, more than brief anxiety, depression, maybe an eating disorder, social difficulties, you really. Clinicians do really have to hit that pause button and wonder if there could be autism. And it's just really important to start right there.
[00:33:26] Speaker B: Yeah. Oh, that's interesting. Eating disorders, that's another one to consider. Right. Like, yes, eating are very rigid. Yeah.
[00:33:32] Speaker C: Yes, there. There's considerable evidence of comorbidity between eating disorders and autism because of that, like, rigidity. I'm going to be very much control of what I eat, when I eat, how I eat, how much. So there's a significant overlap.
[00:33:48] Speaker B: Yeah. So as providers, I'd love to learn a little bit, like what we can do in the office in terms of screeners or ways of, you know, we can figure out those questions.
[00:33:58] Speaker C: Yeah, there are some good screener measures for autism. There is, you know, to provide to an adult individual. There's the SRS2, the social responsiveness Scale. There's the Social Communication Questionnaire. The scq, which is. Has some, you know, the first side is current symptoms of autism. The reverse side is lifetime symptoms of autism. So if a parent or the sibling or someone close to this person who was close to the person during childhood, they could fill those out. So those are like some. Two good starting points. Beyond just, do you have social difficulties? Do you have any repetitive behaviors, like those kind of like super lean screener questions that some folks ask. But I also definitely ask about social problems. Even if they didn't start until middle school, were they bullied? I'll ask about, you know, current friendships or past friendships. What's their pattern of friendships? Do they make friends but then just kind of have a really hard time keeping them, or do they just struggle to make friends? In general, I'll definitely ask about persistent anxiety or depression. I will ask about perfectionism and difficulty with relationships. I also ask some medical questions about like chronic headaches and GI problems because there is considerable overlap with GI gut issues, gut health and autism. And you know, we know that's frequently associated with autism and really just kind of having a keen eye for people who seem like they've been chasing a diagnosis their whole life in this persistent sense of, well, I saw a speech therapist when I was in preschool and then I think I saw an occupational therapist because there were some, some sensory problems I had, like I can't, I couldn't handle fire drills and I couldn't be in large spaces. And then on and on and on. It goes like that sort of thing where there's kind of been this, you know, history of a parent or caregiver, like trying to get at the problem, trying to get some relief for their child, but it just always kind of missed the mark because that diagnosis was missed.
[00:35:57] Speaker B: Yeah.
So what are things that providers should kind of consider if we're running these screeners or asking these questions and it's starting to flag as this might.
[00:36:07] Speaker C: Yeah. So I think we all rely on prior diagnoses explaining too much. So patient comes in, it's like, yeah, I'm being treated with things for anxiety, I'm taking Zoloft and you know, I also have depression and I have ocd. So we kind of rely on the expertise of wherever that diagnosis came from. And I. This is a term known as diagnostic overshadowing. So statistically speaking, girls are likely to get another diagnosis first. Usually it's ADHD and, or anxiety. And then people say, well, of course she has no friends, she has social anxiety. Right. So it's things like that. I try to, even in students that I, that I train, I always tell them, don't let prior diagnoses explain too much. Do your own kind of, you know, you may not need to do an exhaustive ADHD evaluation, but at least like double check, make sure that's valid diagnosis and then question where the diagnosis came from. How were they diagnosed? Was it like a three question screener at an office visit or was it something more thorough? Another huge mistake is it's letting neurotypical behaviors lead us to rule out autism. So you really can't rule out autism just because someone has good eye contact or because they have friends or they have a sense of humor or we all know that myth that autistic people have no empathy. And that's something that's been in the media with famous figures and others. And that's really quite the contrary. So we know that girls have lots of socially neurotypical behaviors, especially girls with autism. But none of that should be a rule out for why an autism diagnosis wouldn't be considered as a provider.
[00:37:43] Speaker B: If we are running these screeners and we're noticing that, you know, there's some flags coming up that this, this could be autism, how should we go about looking for more information in terms of a referral. Referral to get a further evaluation? Do you have any suggestions regarding that?
[00:37:59] Speaker C: Sure.
And I think it can. It's a really difficult world that I feel like psychologists have made inherently difficult. And it doesn't have to be to figure out, you know, who evaluates for what.
So if an individual seeking an autism diagnosis or questioning what is this, or even if it's like a more broad question about overall neuropsychological functioning and maybe autism is a part of that question, there's a couple of things. So first stop, I usually say, and when this usually comes up is in maybe like a, well, visit with your family doctor, your primary care physician, like, hey, I'm really noticing xyz. How would I go about getting evaluated for that? Now, a primary care doctor wouldn't necessarily evaluate for, you know, autism. They may have like a quick screener they could give. And then you could certainly ask. Folks could certainly ask. Do you have a list of neuropsychologists who I could see in my area who specialize in autism? So you really want to ask for a neuropsychological evaluation? That's kind of going to be your comprehensive checking off, like cognitive, like IQ skills, overall functioning, you know, neuropsychiatrics, or things like autism, anxiety and, and depression and maybe even ocd. And not all neuropsychologists evaluate for autism. That does take special training. So you want to kind of ask whoever you get a list of neuropsychologists, whether it's from your insurance company or your primary care provider, or you just go online and you can Google neuropsychologists. In my area, you want to certainly ask, do they have specific training in assessing for autism? Because it is really specific. It takes time, it takes a lot of supervision to kind of be monitored because it. There is no checkbox of, you know, you get one point for this and zero points for that. It is really nuanced and the provider needs to be well versed and know these subtle differences. I'm in the Philadelphia area. My practice is called Clarity Neuropsychology. I'm in Fort Washington, Pennsylvania, which is in Montgomery County. And, and I'm seeing both adult and pediatric clients for full neuropsych evals, including autism. There's also the In Philadelphia, the University of Pennsylvania has an adult autism spectrum program. So they see individuals over the age of 16 for evaluations and for treatment. So that's another really good resource more locally.
[00:40:19] Speaker B: That's wonderful. Well, thank you so much and so appreciative of the time you spent with us and also you shared some great resources with me regarding some books and links to finding some screeners. So I will be putting those in the show notes so that everyone can benefit from that. But thank you. This is just so informative and like really important work that you're doing and spreading the word about. So grateful for you.
[00:40:45] Speaker C: Yeah, my pleasure. This is, you know, something that more research needs to be done. A lot has has been done, especially in the past five years and I'm grateful for that.
And you know, my goal is really just to help individuals get clarity they need and they deserve and just to kind of feel good about having like a good roadmap going forward.
[00:41:05] Speaker B: Absolutely. Yeah. And it helps the therapist do better work as well. So it's just great for everyone, you know, in the mental health ecosystem.
[00:41:14] Speaker C: Sure.
[00:41:15] Speaker B: Well, thank you so much and have a wonderful day.
[00:41:18] Speaker C: Thanks, you too. Bye.
[00:41:20] Speaker B: Bye.
[00:41:22] Speaker A: Thank you for tuning in to the Art of the Referral podcast. We hope you found today's episode insightful and valuable. Don't forget to subscribe and leave a review to help us reach more providers and clinicians like you. Follow us on social media and visit our website for additional resources and updates on upcoming episodes. Until next time, keep mastering the Art of Referrals and making a difference in patient care. Goodbye.
