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AutismAndrew Carpenter
London Brokerage Network
First Reactions
What do you think you know about autism?
What experience do you have?
What words or phrases come into your mind when thinking
about autism?
A little bit of history
- First identified by Leo Kanner (1943) & Hans Asperger
(1944)
- 1960’s – First person in UK diagnosed with autism
- Lorna Wing and Judith Gould (1979) – Triad of
Impairments
- Asperger’s Syndrome (1980’s)
- Ongoing research, leading to new & increased
understanding – DSM 5, etc.
Terminology
What do the following stand for in terms of autism?
ASC – ASD – AS – HFA – PDA – PDDNOS
What terms should we use?A person with autism?
An autistic person?
Someone who has autism?
True or False?
• Autism is classed as a type of learning disability
• Autism is caused by the MMR vaccine
• The majority of people with ASC find socialising very
important
• Women cannot be autistic
• Autism is a ‘spiky’ condition, affecting people differently
at different times
• All autistic people have remarkable ‘special skills’
• Autistic people are emotionally ‘cold’
Terminology (2)
High and Low Functioning
Mild and Severe
What does that mean to you, when you hear those
terms? What criteria are you using to make those
judgements?
“I’m a little bit autistic” /
“Everyone’s somewhere on the spectrum” ???
Triad of impairments
However… really a ‘dyad’
Social
communication
and interaction.
Restricted, repetitive
patterns of behaviour,
interests or activities.
And…
More emphasis on
sensory issues
What does that really mean? (1)
Social and Emotional
Difficulties with:- Friendships
- Managing unstructured parts of the day
- Working co-operatively
What does that really mean? (2)
Language and Communication
Difficulties with:
- Processing and retaining verbal information
- Understanding jokes, sarcasm, social use of language,
reading between the lines (literal interpretations)
- Body language and facial gestures
What does that really mean? (3)
Imagination
(Flexibility of Thought)
Difficulties with:
- Coping with change
- Generalisation
- Empathy (but… the double-empathy problem)
But also…
• Sensory issues (hyper or hypo)
• Anxiety and depression
• Knock-on physical effects
• Sense of identity
• Poor balance / bad at sports / clumsy
• Food intolerances / bad tummies
• Memory…? (‘selective’)
• Alexithymia
• Strong sense of right and wrong and sticking to the rules
• Conventional presentation for unconventional reasons
• THERE IS A DISTINCT LACK OF RESEARCH!
Alexithymia
May or may not be good at ‘cognitive empathy’ and
reading other people, but very poor at noticing own
emotions, unless obvious
Need extra time to process information or answer
questions anyway, especially about feelings. May
need help to work it out.
Autism and Mental Health
Particularly vulnerable to mental health problems
65% individuals have a psychiatric disorder
(Ghaziuddin et al 1998)
Often regarded as having ‘treatment resistant’
mental illnesses (Dossetor, 2007)
Difficulties in communication mean anxiety and
depression goes undiagnosed and untreated (Howlin
1997)
Autism and Mental Health (2)
Anxiety – Almost universal!
Depression – Awareness of difference, social exclusion,
bullying, maintaining relationships and jobs, sensory differences,
etc)
PTSD – more common than we think, experiencing events in a
more stressful and threatening way due to differences in
understanding the world, visual memories more prone to
intrusive flashbacks
Drug/Alcohol – self-medicate to reduce inhibitions
Autism and Mental Health (3)
Phobias – for unconventional reasons?
OCD – ordering, hoarding, routine, repeated questioning,
overlapping with Tourette’s/tic-like disorders and need to
differentiate from coping mechanisms & special interests
ADHD – 31% meet criteria for ADHD (Leyfer et al 2006)
65% inattentive, 12% hyperactive, 23% combined
Eating disorders – 20% of anorexia cases could be diagnosed
as ASD (Gillberg et al 1994-5)
Autism and Mental Health (4)
Catatonic-like symptoms – increased passivity, slowness,
initiating and completing actions. Also, increase in repetitive
behaviour, reversal of day and night.
Psychosis/delusional beliefs – paranoid ideation (being
treated unfairly), grandiosity are prevalent. Often linked to everyday
worries and anxieties, acute and stress-related, attempts to
interpret a confusing world and other people.
Schizophrenia – common misdiagnosis, but no evidence of
increased incidence with autism.
Borderline PD – common misdiagnosis for autism
Autism and Mental Health (5)
What is autism and what is a
mental health issue?
BE CAREFUL!
A need for specialist approaches
and attitudes to commissioning
- Recovery model / throughput are not helpful
- Kingwood Trust and ASPiration service
- Personal experience and Coventry research
Communication
Differences may include:
- Non-verbal, or limited speech
- Highly articulate (but… what is actually being processed?)
- Understanding language
- Literal interpretation
- Non-verbal communication (reading and showing)
- Andrew speaks Portuguese, but…
Strategies
- Say less (My TEFL experience)
- Wait for an answer (6-second rule)
- Check understanding (Echolalia / The paradox of choice)
- Watch your language and don’t make promises you can’t keep
(“I’ll be back in 5 minutes”). Avoid the world of ‘-ish’ and build
trust
- Patience (50 Shades Safe Words!)
- Teach, not cure
- RESPECT THE AUTISM!
Social Interaction
Differences may include:
- Preference for being alone and avoiding interaction
- Initiation of / response to social contact
- Eye-contact
Social Imagination
Differences may include:
- Focused interests (and not knowing when focus needs to
stop)
- Imaginative thought
- Reading between the lines / taking things at face value / not
spotting ulterior motives
- Desire for routine and sameness (but… )
- Adaptation to change
- Organisation and planning (lists, pre-knowledge)
Sensory processing
How many senses are there?
- Visual
- Auditory
- Olfactory
- Gustatory
- Tactile
- Proprioceptive
- Vestibular
Sensory processing (2)
Differences may include:
- Hyper and Hypo
- Mono-processing (one thing at a time)
- Filtering
And may lead to:
- Poor balance/co-ordination, unusual walk, dizziness
- Rocking, flapping, jumping, ‘tics’
- Unusual reaction to pain
- Dislike of touching, hearing/light/patterns sensitivity
- Dislike of certain clothing
- Impact on diet and eating
Sensory processing (3)
“I have a constant sensory fidgeting, making it hard to
concentrate.”
“It’s overwhelming”
“I’m constantly thinking about what others are thinking of me”
“Sensory sensitivity in any form can make it difficult to
concentrate, to trust, at attending to things other than the
source of hypersensitivity to join in or to relax. If the
discomfort or distraction is extreme enough, they can distract
from the abilities to learn.” (Donna Williams)
“I have no idea what ‘relaxed’ means or would feel like”
And don’t forget…
• Anxiety, depression & PTSD
• Knock-on physical effects
• Sense of identity
• Alexithymia
Anxiety
“Imagine how you felt when you did something really anxiety
provoking, such as your first public speaking engagement… Now
just imagine if you felt that way most of the time for no reason” (Temple Grandin)
Possible Causes of increased anxiety
• Communication
• Emotional responses (inc ‘Am I getting it right?’)
• Environment
• Sensory differences
• Interaction
• Planning and preparation and choice
• Unfamiliar experiences and changes to familiar environments
What kind of things / areas do you
need to think about?
Adapting Practice
Issues include:
- Environment
- Session structures
- Visual rather than reading
- ‘Internal vocabulary’ may be different
- Processing information
- Sometimes doing the opposite of ‘best practice’ for
non-autistic people
Adapting Practice: Environment
What
should we
consider?
Environment
Lighting
Noise
People
Waiting room
Clear signs
Partitions
Clutter
First and last appts
Adaptations: Session Structure
What
should we
consider?
Session Structure
Duration
Tel or face-to-face
Intervals between
sessions
Importance of agenda-
setting
Reminders for appts (e.g.
by text)
Keep it Visual!
Keep it Visual!
Use of pictures/photos
Use of diagrams/Body or emotion maps
Having handouts that back up what you have said
Use of session summaries
Use of multi-media / apps
Make it appropriate to the person (e.g. use any special interest)
Watch your language!
Language
Avoid metaphors / abstracts
Clear / simple
Pacing and processing time
Backed up with visuals
Find out how they talk about their
emotions and inner world
More ‘Dos’ than ‘Donts’
Always check, check and check
again!
Don’t overload!
Self Awareness:
Laying the Foundations
Spend time checking out awareness of thoughts,
feelings, cognitions, behaviours
Explore/explain the links between thoughts and
feelings, etc.
Remember to keep this visual and accessible
Use their language, not yours
Example: My Feelings Sheet
My Feelings
Sometimes it can be difficult to know how we are
feeling. Maybe we feel upset, but we are not sure
if we are sad or anxious or angry.
It can be helpful to write down what we do, what
we think and what our bodies are doing to help
us recognise our feelings.
So let's first think about being sad…
Behavioural Techniques
Relaxation and sensory
techniques
Chill-out boxes
Sleep hygiene
Exercise
NB: remember any
adaptations when setting
these up.
Other Behavioural Things
Nature (pets, gardens, etc)
Concrete relaxation techniques (mindful activity,
etc)
Solitude / low arousal
Increase opportunities for self-expression (art,
music)
Use sensory stuff to help relax
Cognitive Interventions
Thought diaries
Panic diaries
Problem solving
Worry management
With autism, remember it’s often a case of ‘cognitive
deficit’ rather than ‘cognitive distortions’, so that
information giving and developing skills around managing
thoughts are more useful than trying to thought-challenge,
per se.
i.e. they are often unable to think of alternatives due to
cognitive deficits.
Summary
Use of the special interests
Be prepared to give an opinion sometimes (helps the
person learn)
Be prepared to lead and give structure
Choice can be overwhelming, so sometimes better to
limit it
RESPECT THE AUTISM!
Watch out for…
Misdiagnosis due to other underlying issues
E.g. “Do you hear voices?” Yes (but not in my head…)
Eating disorder, or related to presentation and texture of food?
OCD or linked to routines and sensory issues?
Phobia or literal interpretation?
(If you sit too close to that screen, you’ll get square eyes)
Becoming mired in ‘best practice’ and YOUR way of doing
things. DON’T steer away from safety behaviours if these comfort
the autistic person (e.g. earplugs, stress ball, favourite pen)
Conventional presentation for unconventional reasons
Scared of dogs, but not because they bite and bark
Over to you…
What things might you personally
change, or how might you work
differently with an autistic client?
Final thoughts
“The thinking is different, potentially highly original, often
misunderstood, but not defective” (Tony Attwood)
“When you live in a world where people think it is a
compliment to tell you ‘but you seem normal’, and where
you are under constant pressure to appear as non-autistic
as you can, that creates an environment where it is
supremely uncomfortable to disclose that information”
(Lydia Brown)
“I am different, not less” (Temple Grandin)
