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Dr. Sharp: [00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR.

The FAW Interpretive Report available through PARiConnect provides scores for all FAW subtests and can aid clinicians in creating personalized and targeted intervention recommendations. Visit parinc.com\faw to learn more.

Hey everyone. Welcome back. I’m excited to have her return guest today. Dr. Caroline Buzanko is back talking about differentiating ADHD and autism spectrum disorder. She is a psychologist, mother, International speaker, Yoda of anxiety, ADHD Superhero, and [00:01:00] Changer of Lives. With over 20 years of working with children, teens, and their families, Caroline’s focus is on developing long-term success and maximizing their resilience. She also trains other mental health professionals and educators to optimize their effectiveness in conducting psychological assessments in working with children and teens.

So Caroline is here, like I said, talking with me about differential diagnoses of ADHD and ASD. In part 1 of this two-part series, we get into why it’s important for us to have knowledge and be able to tease these apart. We talk a bit about neuroanatomy and the similarities and differences between the two diagnoses, and we dig deep into the part A symptoms for ASD, how they overlap and are also different from ADHD symptoms, and how one can masquerade as the other.

[00:02:00] You’ll see in the episode that we come to a bit of a screeching halt. And that’s okay. We just realized that we were running out of time and there was lots more to talk about. So we’ll come to a bit of a halt here at the end of part 1 and continue in part 2, which will be out next week. So stay tuned. I hope you get a lot from these episodes.

Hey Caroline, welcome back.

Dr. Caroline: Thanks for having me. I’m excited to be back again.

Dr. Sharp: Me too. It’s always an honor when folks come back. I’m excited to talk with you again about a topic that is very important and that a lot of people are thinking about these days. So very grateful for your [00:03:00] time. Thanks for being here.

Dr. Caroline: Yeah, it’s definitely something I’ve been thinking about for years, reaching out to chat about, just because I see so many questions and misdiagnoses. It’s definitely an important one for us to talk about.

Dr. Sharp: Absolutely. Well, let’s dive right into it. I know there’s so much to cover here and we’re likely going to have a part 1 and a part 2, so this will be part 1, theoretical background for this question. And then we’ll dive into more of the applied stuff in part 2, but there’s a lot to cover. So I’ll start how I usually start, and I think that’ll really get us off to the races.

Let’s talk a little bit about why this is important: why did you choose to focus on this out of all the things in our field?

Dr. Caroline: There are so many different things but this one, I think for us as professionals, there’s been a bit of a loss of faith in the profession to be quite honest, just because [00:04:00] of lots of frustration amongst psychologists, a lot of frustration with parents, a lot of frustration in the ADHD community, the autism community. There’s so much information out there, but there are still so many misdiagnoses. And ADHD and autism are the two most misdiagnosed diagnoses out there. And so I think that there is…

And we’re hearing stories time and time again of kids who are being messed up or adults not getting in diagnosis until they’re older because it was just overlooked. And I think this is important not just for testing psychologists, but for teachers, what to look out for in the classroom. There are so many different pieces.

And there’s lots of information out there. You’ve even had episodes about girl presentations- what the female presentation looks like in autism, for example. So we still have lots of information, but there’s not a lot about ADHD and autism [00:05:00] specifically because there is so much overlap. It’s one thing to know. I find a lot of professionals know everything there is to know about autism or everything to know about ADHD.

I would say the majority of us, and actually, there’s a lot of research around this, have been trained in ADHD assessments and we have so much more knowledge about ADHD. And so we get our ADHD glasses on or autism glasses on, and we need to be able to see both lenses. So I think that that’s really important, getting skilled in spotting both.

And even just training, there’s not a whole lot of training when we’re looking at both of these things. There’s a lot of ambiguity in the definitions for all of them. So there’s lots of misinterpretations. DSM isn’t fantastic for autism or ADHD traits. So there’s just not a lot of [00:06:00] knowledge really about what those actually look like. So I think, all of those pieces aside, that’s just the one thing for the profession. But then for the individuals themselves, being able to go in and feel like they’re coming out of the assessment on the other side, totally confident is just so important.

We see this certainly with our women where they’re getting misdiagnosed, they’re being treated for the wrong things. They are or are not getting medications. And it just can become more impairing and they’re at greater risk. So just looking at those outcomes is really important too. I find so many women, they get to the point they don’t even know who they are anymore.

I remember doing an assessment with someone who’s talked so much about this masking and how exhausting it is to do [00:07:00] all of this masking. And I said, well, “What would happen if that mask fell away? Who would this person be?” And she’s like, “I don’t even know anymore.” Loss of identity, right? There are so many women who’ve said they’ve masked for so long they just don’t know who they are anymore.

So I think, over time, for us as a profession to have a little bit more faith, a little bit more confidence in our work, but then for them too, just knowing that they can move forward and not develop unhealthy patterns. So those are the two big reasons why I would say that’s really important.

Dr. Sharp: Yeah. A lot of what you said resonated; this losing faith in the field. I think that’s a good way to put it. I might take it a step further and say that a lot of clinicians are maybe losing faith in themselves because there is a lot of ambiguity around these diagnoses and separating them and of course the gender [00:08:00] dynamics. It is complicated. I know we’re dealing with this in our practice. We talk about this a lot in our testing consult that it’s hard to know. Not like we “had the right answer” all along over the years, but it feels like we’re getting further away from that as time goes on.

Dr. Caroline: Yeah. I went through that period too a few years ago. It was like, am I autistic because I’m pretty sure I know what autism and ADHD are?

Dr. Sharp: Right.

Dr. Caroline: There’s just all of this confusion and I’m like, well, if people are basing it just on the DSM criteria, I must be autistic too. But understanding, and that’s why I really have spent the past several years really digging into this to tease out exactly what is what, because we can’t just take symptoms and I’m going to be talking a lot about this, but we just can’t take symptoms at face value for what they are.

[00:09:00] Dr. Sharp:  Right. Which is complicated. Why can’t we just do that? That’d make things so simple.

Dr. Caroline: It would, yeah.

Dr. Sharp: And there’s this component too, I just want to highlight, is like the hammer nail problem. Like if you’re trained primarily in ADHD assessment or autism assessment or some other kind of assessment, you tend to see what you know. And when you have the hammer, everything is a nail, right? Stephanie Nelson talks a lot about this and confirmation bias and all of those kinds of things. And so we’re really fighting this battle to keep ourselves aware and open and non-biased, which is an uphill battle. Lots of layers here.

Dr. Caroline: Which is great. You consulting. I have a team and I’ve got tons of psychologists that I consult with. I think you have to so that you’ve got someone playing devil’s advocate and poking holes. And I was actually just with a consultee yesterday who, she’s like, “Nope. I’m just going to say it right [00:10:00] now. It’s not autism. I’ve ruled it out” and then I started poking holes and she’s like, “Oh my gosh, I think it’s autism”.

And so just having that other set of eyes, I think that that’s an important part of that process too. So it’s good to hear that you do a lot of consultations because I think we need to have different people talking.

Dr. Sharp: Yeah. Agreed. I feel grateful for that. If you don’t have a consultation group, now is a good time to go find one.

Dr. Caroline: Exactly.

Dr. Sharp: It’s only getting more complicated.

Dr. Caroline: Yeah. 

Dr. Sharp: Yeah, go ahead.

Dr. Caroline: I was going to say, maybe I can go into some of the overlaps just because autism and ADHD, we do know that those are the two hardest diagnoses to tease apart. So if that’s good, we can go into the overlaps between the two.

Dr. Sharp: Yeah, let’s do that. That’s a great place to start.

Dr. Caroline: Okay. To be honest, I am going to put this disclaimer out there, and I think this is why it makes it so tricky. I don’t [00:11:00] really think there’s pure autistics and pure ADHDers. Maybe there is, but they’re probably rare. The chances are pretty high. We all already know the chances are pretty high if you have an autism diagnosis, 80 to 90% good chance you also got ADHD, right? So there’s a high, high if you’re autistic that you’ve got that ADHD piece.

ADHD is the most common comorbidity with autism even more so than anxiety. So we do see, just because there are so many overlaps, which I’ll talk about what’s happening in the brain. And so usually ADHD is easier to see, and so that’s why autism is missed, especially if you’ve got someone who is more hyperactive, for example. The boys are usually more hyperactive, so they’re easier to spot. And so that’s what we look at.

There have been a lot [00:12:00] of researchers who’ve come to the conclusion that the ADHD symptoms are just part of autism because of the core symptoms, and we see the core symptoms of ADHD in our autistic population. So inattention, impulsivity, and hyperactivity. It’s not the same way around though because if you have ADHD, it’s not as high of a likelihood that you also have autism. It’s anywhere from 20 to 75%. The research is way more variable there.

Dr. Sharp: That’s a lot of difference. Yeah.

Dr. Caroline: It’s a huge difference. So you’re more likely to have ADHD if you’re autistic, but not necessarily the other way around but still way more likely than the general population, typically developing kids. So I think that that’s important and part of the reason why it’s so important or so difficult to tease these things apart. So that’s one piece. There’s probably not a pure population.

The other piece is there are a lot of people who probably have subclinical traits.[00:13:00] So the rest of everybody else might have a little bit of autism or a little bit of ADHD. It’s just not enough to say you meet the full criteria. So it makes it really hard for us to categorize a diagnosis, whether you do or do not for a lot of those people, because it is a spectrum for both things, right? And so you’ve got, and I see a lot, certainly, you have autistic traits, but it’s not enough to say it’s autism, so being able to flesh that out. It’s definitely more problematic. The more severe the ADHD is and the milder the autistic traits are- you really could end up going either way and it can get even trickier to tease those pieces apart.

The DSM sucks. I’m just going to say it. I’m sure there’s other people who feel that way too for so many reasons, but a crucial one is the fact that it’s a [00:14:00] dichotomous platform. You either do or do not have the diagnosis. It’s really categorical in that way and it creates so much rigidities in the research. And so we’re focusing on a singular presentation of a diagnosis, which means we’re missing so much data on there, on those really complex kids. The subclinical traits, all of those different variations were missing because of the categorical setup that we have with the DSM. There’s arbitrary thresholds and there’s all sorts of different things that we have.

Autism and ADHD, when we look at the diagnostic criteria are so different. Why are we been having this conversation when we’re just looking at the DSM? But in real life, they’re so similar, and so that’s why it’s really hard to follow that. So if you’ve got this person right here in front of you, that’s why it can be so really tricky when we’re looking at this.

[00:15:00] So we really have to have way more research looking at people’s lived experiences, and that’s what I tap into. And later on, when we talk about the assessment process, we’ll be really talking about the lived experiences because, otherwise, if we don’t, you’re never going to be successful in teasing out what’s autism and what’s ADHD. So I think that that’s important to think about.

But when we look at the overlap, they’re both neurodevelopmental disorders, right? So it’s happening in the brain, in the developmental period in childhood. We see clinical overlap, genetic overlap, phenotypical overlap, and neurobiological overlap. Even just genetic factors alone, it’s like 50 to 70% of the variants that overlap between autism and ADHD.

There’s a lot of overlap in the brain differences and what’s happening in the brain. The alterations in the brain are very similar, so we have less wiring between the two hemispheres. Our [00:16:00] cerebellums are smaller, our motor control, our cognition. The part of the brain that processes sensory information. It processes information differently from our neurotypicals. The pathways controlling attention, the pathways controlling our social communication, and executive functions. All of those things are affected in both ADHD and autism.

So we can see why this is such a complex issue. There’s a huge major pathway that we found between hyperactivity and repetitive behavior as well, right?

Dr. Sharp: Yeah.

Dr. Caroline: And we’ll be getting into some of those as well. So a lot of hyperactive kids, they’re not able to control their motor control. It’s excessive, the amount of motor activity that they’re engaging in. And they are more likely to also engage in stereotypical behaviors which can include hand flapping when they’re excited, even in our ADHD kids. So that’s not just [00:17:00] automatically. We would assume toe walking and hand flapping are automatically autism, but it’s not necessarily so.

Hyperactivity, we also know is related to social pragmatic communication, especially things like initiating interactions. And so we’re seeing all of these different similar pathways, things that are happening in the brain. With these pathways, we see that kids with more severe ADHD, they’re more likely to also look autistic and have more autistic symptoms, whether it’s clinical or subclinical so we just know that.

The sensory processing, I mentioned that. So ADHD and autism map similarly onto the part of the brain that processes information and so processing information across all modalities. So our sight, hearing, tactile, smell, and taste. [00:18:00] There’s also proprioceptive, all of those kinds of things that we talk about as well.

Behaviorally, we see stimming in both. There are sensory issues in both, hyperfocus in both, intense interests, it is a little bit more excesses. I will get into some of the differences, but they are, they can hyperfocus, and we know in an ADHD child, it’s not an attention deficit. It’s being able to control their attention to things other people want them to pay attention to. But when they’re engaged in their thing, they could sit for hours focusing on and talking about things that they’re interested in way too much.

All of the executive functioning challenges that we see, transitioning eye contact differences, not looking in the eye region social challenges, I could go through, the social awkwardness. There’s so many different pieces. Limited empathy, responding to others, being really sensitive to corrective feedback, bowel issues, [00:19:00] anxiety, OCD. We see so many of these different things overlapping. Learning disabilities, that interceptive awareness that’s so important, that’s limited for autism and for ADHD. So they’re not picking up the signals that their body is telling them like I need to go to the bathroom. Feelings are important here too. They have a really hard time.

I do a lot of somatic therapeutic intervention and oh, it’s so hard even with my ADHD kids. Even if I say, hey, what does your elbow feel like? They’re like, “I have no idea.” They literally have to touch whatever and make a feeling happen in their body. They have such a hard time. But it’s also being able to be flexible, responding flexibly to what’s going on emotionally, what’s coming up for me. And we know emotion regulation is a core deficit of ADHD, which is not again, in the DSM.

[00:20:00] So we see so many of these overlaps but really both are misunderstood. With a lot of them, they look like they don’t care. Disregard, I think that’s on the CBRS, they disregard the rights and feelings of other people. They just don’t have empathy. They look lazy, they look weird, and they look manipulative, but really it’s their automatic response to a situation is different from neurotypicals.

And so being normal is hard for both ADHD and for autistic kids. Having a successful social interaction is hard. They use the same similar coping mechanisms, like self-medicating and self-harm as they get older. So we see so much of that overlap. Those are just a few things. I could probably spend a whole episode just talking about the overlap, but I think it’d be helpful to go into the differences as well.

Dr. Sharp: That’s fair. I think you’re right on. There’s a ton of [00:21:00] overlap. When I try to break it down and go super simple, sometimes oversimplifying, I think of, executive functioning, of course, is a huge component but regulation of attention, social skills, and emotional regulation, are some of those core overlaps between the two. It’s hard to tease those apart, but we’re going to try to do that.

Dr. Caroline: Well, and I suppose we’ll be getting into the assessment piece. It’s all about behaviors and what we observe behaviorally. There is some more and more research if we could do brain scans- if we could spend $10,000 for every client and get brain scans and see what’s going on maybe, we could do that. That we do see some differences, but there’s also a lot of similarities with what’s happening in the brain.

All this to say, even though they do look so much [00:22:00] alike in so many different ways, there are some differences. And that’s why we do have two different diagnoses. I know that there was a time they were wondering if it was all one same spectrum but now researchers have really said no, they still are their very own distinct diagnoses. And so, in the brain, there are still some differences and this is where a brain scan would actually be really good. We do see the amygdala and total brain volume is bigger in autism.

Our ADHD kids, I always joke that I’m screwed because I’m never going to have, I have ADHD and I didn’t start taking medications until I was in my 40s. And so there’s no way my brain was able to fully develop to its full form or its full potential, whereas we do know actually kids who start young on medications, their brain can actually develop to its fullest in adulthood. But in autism, it is bigger. But we [00:23:00] don’t all have to do brain scans. And that’s why I thought this episode would be really helpful. It’s just really subtle, the differences that are going on.

Obviously, the stereotypical kids are going to be obvious, right? There’s rare aspects of autism that aren’t associated with ADHD, like when they regress in skills, for example, the special abilities, but those are rare. We hardly ever see those sorts of populations. So really when we’re looking at the differences, we have to be skilled at not the stereotypical things that we’re looking at, the more subtle, the non-stereotypical presentations because the differences are not obvious on the outside, and yet we’re still doing all of these behavioral assessments, which are still valuable, and I will be talking about that next time but what’s really happening is not so much on what’s happening differently on the outside, it’s what’s happening differently on the inside. And that’s [00:24:00] a big piece of how we’re going to differentiate between autism and ADHD.

So they share similar behaviors and it manifests very similarly, but the reason for those behaviors, those functions of the behaviors. That’s what’s really critical to understand. And we got to understand. We’ve been talking about masking. This is not a new thing, but so many people become so skilled at masking. So we need to see how much effort are they actually putting into this masking. And what does that masking look like when it’s full, when it’s strong, working well and what does that masking look like when it starts to crack? When they’re just too distressed, too tired to keep it going, we got to be able to explore that.

Everybody’s different. So as I get into these differences, I can’t say this is the consistent profile that’s true for ADHD and that’s true for autism. We just can’t do that. We can’t say 100% sure; these are the hard and fast rules. We just know though, [00:25:00] from one kid to the other, and the presentations can be so inconsistent, but these are guidelines. It’s things to start to consider when we’re looking. So I think the easiest way is to maybe go through the DSM criteria for autism and we can look at some of the similarities and differences just from there and what separates them.

Dr. Sharp: I like that. Great.

Dr. Caroline: So with criteria A again, pretty much anything from criteria A can look autistic, but it can also look ADHD. Well, obviously it’s going to look autistic, but it can also look ADHD. So it’s looking at the underlying mechanisms of what’s going on, what’s happening for both.

Looking at the differences at social communication, the interaction piece, considering the social aspect piece is going to be really important. We know the very core of ADHD is attention, self-regulation, right? Those challenges, it’s not so much the social [00:26:00] challenges that we see in these kids. So the social differences that we see aren’t part of the core criteria like they are for autism, but that’s not to say they don’t have social challenges. We know our ADHD population has a lot of social challenges. It’s just secondary to the ADHD.

I’ll give some examples. Conversationally, both suck or both can suck. I don’t want to paint everybody with a broad brush, but autistics do have more trouble than ADHDers with reciprocal conversation. That fluency with the back and forth, whether it’s the content that we’re actually talking about, but even the emotional reciprocity, they’re not necessarily sharing their feelings and these interactions or thinking about sharing these feelings.

I was just doing an assessment the other day with a very gifted young man, and he saw, I still do parts of the ADOS and I will be going into how can we use the ADOS even with [00:27:00] our really smart kids and our masking kids. But he’s reading the story Tuesday with the frogs and he’s chuckling and he’s picking up on the emotions, but it’s all to himself. He’s not engaged with me. I wish I recorded it.

I was doing an assessment where I had a few kids, and a few of my teenage girls were looking at autism. I’m like, you know what, I’m going to bring them all in at the same time, mixed with an ADHD girl and some neurotypical girls. So I had a big group of these teenage girls and it was so fascinating to watch because of just the fluidity with the reciprocity. So my ADHD girls did look like the autistic ones, but they would check in with me sometimes or with each other. They would watch each other, whereas the autistic girls almost only ever looked at [00:28:00] me, but not with each other. And they’re not looking down the line.

I’m going to talk about this when we get to the assessment, but sometimes bringing a mix of these girls in together and just seeing, because I think we lose track. I remember working with little guys for many years and then I had my own children and I’m like, oh my God, my children are brilliant. They are so smart and they’re so engaging. They are just amazing. I’m like, no, those are just neurotypical, well, they’re ADHD but more neurotypical, right?

And so I think we lose sight of what teenage girls actually do, but I’ll talk about that next time. But a lot of the differences we see with that emotional reciprocity with our autistic kids, it’s usually gone when they can talk about their shared interests.

So this one kid I was doing the assessment with, he’s chuckling to himself, there’s not the social reciprocity, but as soon as you heard him talking about World War II, Oh my goodness, he was engaged and he’s looking at me and he’s [00:29:00] gesturing, and that emotional reciprocity is really different. They can engage beautifully when they’re talking about their interests. The integrated eyes gaze with the gestures. It can look really beautiful when they’re in the zone, but it all far falls apart when they need to talk about other things.

With ADHD, it’s more about the impulsivity and the attention pieces that get in the way. It’s not so much the social communication differences like it is in autism. So again, they might have trouble conversationally, but it’s because they are going to forget what they need to say and so I just need to blurt it out. I need to say it now. And then they might seem self-centered. They might seem rude if they’re interrupting other people or they’re losing focus. They get distracted. They don’t know what other people just said. They lose where they are in the conversation. So they might change the topic. They might interrupt. Other people might be like, what are you talking about? That’s not even what we’re [00:30:00] talking about. So it looks still awkward. They’re not keeping up conversationally. But it’s more about those executive functioning pieces that are going on.

And actually, our ADHDers tend to interrupt way more than our autistic kids. They tend to monopolize conversations way more. They have a lot of trouble listening to someone else. So it’s not because they’re disinterested necessarily and it’s not because they only know how to talk about one thing like some of our autistic kids do, they just can’t focus for that long. They’re going to lose their train of thought. So again, it might look the same, but we got to look at the reasons why.

ADHDers can go on tangents that can be so hard to follow. And we talk about that story, the narrative coherence that they can have. Our ADHDers will talk and talk. So they look like they’re monologuing and [00:31:00] monopolizing, but they just get so excited and that emotion overwhelms them, and they just can’t think, oh, hold on, take a step back. What’s the context here? It’s just those executive functioning differences can get in the way.

Our ADHD kids are so motivated by stimulation and if they’re talking about something that’s interesting, they’re stimulating their brain, they’re just going to keep talking. And they’re not going to notice the context how their words and behaviors are affecting other people, like people are being bored or whatever. So for the ADHDers, the function behind it all, it’s the attention, it’s the hyperactivity, it’s the impulsivity, it’s the chattiness that gets in the way. That’s a huge part that we see. It’s not so much the same in the autistic profile, right?

Dr. Sharp: Sure.

Dr. Caroline: And so I think that that’s important. When that’s not going on, they can engage in a conversation. Our ADHDers, [00:32:00] they really can, quite nicely. They have the skills. It’s a performance deficit versus a skill deficit. Just knowing in the moment what I’m supposed to be doing.

So for the autistic kid, they might interrupt, but it’s because they’re unable to read the social cues in the moment. They don’t know whose turn it is. Oh, there’s a pause, it must be my turn. And not realizing, oh, the other person was just thinking of their thought. So not knowing whose turn it was. They’re always looking for that gap. And I’ve had my adults talk about that. The telephone is so definitely hard because there’s very limited cues to know exactly what’s going on. So they’re looking for the gap in the conversation or they’re listening because they’re having a hard time processing the information. And if they talk about their interests, they can’t tell. They can’t read the social cues, even if they’re trying to, [00:33:00] that you are necessarily interested and want to keep talking.

Chit chat can be hard. It’s not great for autistic kids, but it can be really painful for the ADHDer. And this was one of the things for me, I’m like, I hate social chit chat. I hate it. And I’m always the person that people in the grocery store, like I loved Covid, we had to stay away from each other. Didn’t actually even go into the grocery store because everybody, it’s like I’m a magnet for people to come and talk to me. And so I’m like, maybe I’m autistic because I hate this kind of conversation.

But with the ADHDer, it’s boring. It’s not stimulating enough. They can’t focus on it because I’ve got a million other things. For me, I’m in a rush. Like I would love to sit and chat with you about your entire lifeline and all the different generations in your life, but I just don’t have time. And so I’m thinking about all the other million things that I need to do. Even when I do go to the grocery store, I’m always like, okay, I’ve got two children. You go stand in that line, I’m going to stand in this line. And whoever’s going through [00:34:00] first, that’s my ADHD. It’s just kind of go, go, go. But they can do it. I can do it. If I need to do it, I can do it on the fly.

For the autistics, the small talk is really painful because it’s exhausting for them. It’s exhausting, it’s confusing, why are you bringing this up? I don’t understand. And actually, I don’t know if a lot of people know this, small talk can actually be a huge sensory demand for autistic. Just the input that they’re trying to take in and processing all the information, everything that’s going on.

I’ll be talking about context. I don’t like the word, but context. I was going to say blindness, but the better word is insensitivity. There’s just so much that they have to take in to think about it. So in the moment, they might get by. They might be able to do it in the moment, but they then need way more absolute isolation at the end of the day. They need that time to recharge. [00:35:00] It can be really confusing for them. They’re not sure why are we talking about this? Is there a purpose? Is there a secret message in here? Are you flirting with me? What am I supposed to say? What’s appropriate? It just becomes just so demanding for them.

And a lot will say they just have no idea what small talk is or why even someone is trying to talk to me. So they’re just trying to process all of this information and just not understanding the social norm or the expectation. It’s like, I just came here for my milk. That’s it. I don’t need anything else. Again, not true for everybody but for a lot.

So many of my older teens and adults have developed scripts to follow because it’s so hard spontaneous, and so they’ve got these different scripts that they follow in these different situations and based on, I used to deal with younger kids, these circles of intimacy. And so in their middle circle, these are your family members that you can hug and kiss. And then out [00:36:00] here, the people that you can high five. And some of my adults and teens have actually done something like that. This is what I say. I say I’m fine if it’s the people on the outer edges. I’ve never met them before. They’re complete strangers. I’m fine. Keep walking. So they have those things. Same behavior. The ADHD and the autistic person might look exactly the same, but for the ADHDer it’s the lack of stimulation versus a complete lack of understanding about what’s expected.

ADHDers do get drained socially too, but they don’t necessarily need to have that absolute isolation from it all. And this was another one for me. I’m like, I get exhausted. My social battery is about 5% compared to anybody else that I ever see. But I can come home and still be with my kids and still be with my family, whereas I do have a lot of autistic adults that I work with, they’re like, I can’t see my children. I need to go into sensory deprivation tank [00:37:00] to unwind.

And so, I can work with the most ADHD kids in the universe and be energized by it or go and do huge presentations and be energized by it, just like other autistic people as well. And I’m socially exhausted, but I don’t need the absolute lockdown. And a lot of, especially the adults that I talk to, they just need that absolute lockdown. And some of my teenage girls hours and hours. They can’t even come up for dinner because they just need that time.

I will ask that we don’t have music playing as we’re also eating dinner. The sensory overload can still, and so we got to make sure that we’re looking at that. When our executive functioning battery is drained, any sensory stimuli, and I’ll get a little bit more into the sensory pieces when we get into criteria B, but everything just starts to shut down.[00:38:00]

Dr. Sharp: Can I ask a really dumb, simple question that I’m curious what your thoughts are?

Dr. Caroline: Yeah, there is no dumb questions.

Dr. Sharp: Thank you. Here’s a question. Do you think being an extrovert and being autistic are mutually exclusive?

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Dr. Caroline: I don’t think so, [00:39:00] because I know a lot of my and again, I keep going back to girls, but actually I have a lot of men too that I work with who publicly are huge extroverts. And I don’t know what you would think of me, but everyone who meets me, especially in the professional field, assumes I’m an extrovert but I am not, I’m the very opposite. And I find too with the autistic, it depends on what role they’re playing, if that makes sense.

Dr. Sharp: Yes.

Dr. Caroline: And so many of them are actors. They love going out onto the stage and performing. I actually had a girl who had severe selective mutism autism, and she wouldn’t talk to anybody other than her family, but boy, she could go up on stage and read a script and act out a role. And so, there’s extraversion in them. I don’t think that they are one or the other.

[00:40:00] Dr. Sharp: Yeah. And it’s a super reductionistic question. You can’t say anything 100% for any group but it’s also an interesting question, in a diagnosis that is theoretically defined by social challenges, can those individuals also truly feel energized and get more energy from social interaction and connecting with other people.

Dr. Caroline: Absolutely, they can especially when they’ve got similar interests. I actually do an energy gauge of your green people are the people you feel energized leaving, yellow, sometimes energized, sometimes drained, red. And it’s always the people that we could talk for hours and hours and not see each other for three years, and then we can come back and pick it up right again. 

Dr. Sharp: It’s a good way to put it. I think you’re right on. I was going to [00:41:00] say something else and I forgot, so maybe it’ll come back. But thanks for going down that, not your fault at all. This happens startlingly frequently for me. But yeah, thanks for going back.

Dr. Caroline: And almost everyone that I’ve worked with that is autistic do want relationships, do want to go out, and for some it looks a little bit different. And some might, this is really stereotypical, I don’t even know if I should bring this up as an example, but D&D, they look forward to going out on their D&D nights once a week with their friends and they want more of those kinds of opportunities.

I actually had one young man who was joining all sorts of clubs like recreational volleyball and just to get out and meet people. It was so hard and exhausting for him because he wasn’t making the same connection and he was making sure he was joining leagues or doing social things where it was singles meaning people couldn’t come in [00:42:00] as friends or as partners or things just because he’s like, I want to be on the same playing field. And so for him it was just frustrating because right away people would start connecting and he would be the one leaving. So, great. I just did 12 weeks of volleyball and still don’t have a friend but he really seeking out those kinds of things.

Our autistic kids have a harder time talking about thoughts and feelings. It’s still hard for ADHD, but not quite so hard. The interceptive piece is really hard for both of them, but they can usually talk about their emotions at least a little bit. And I will be going into lots of different examples in assessments, but I do find like some of my autistics, well, even just the ADOS, what does it feel like if you’re scared? What do you mean? Scared is the feeling. This is a stupid question. I don’t know what you mean. What are you talking about? That just is the feeling, right? And [00:43:00] so differences in understanding communication and social cues.

I think one thing that I watched out for, and we talked about this briefly in our pre-chat, was just the fluidity. I’ve worked with kids who were best outcome, meaning they, I don’t want to say cured, but didn’t meet the criteria for autism anymore. But I still see fluidity and so some kids I don’t think actually were autistic in the first place because they are so natural. It’s so intuitive. There’s this sort of intuitive knowing of being, it was communication issues or something else getting in the way versus these rigid. It’s kind of clunky as I interact.

And so when we’re looking diagnostically, is it attention or is it this lack of intuitive knowing? So for autistic, they’re going to learn; they’re going to learn to read and understand nonverbals. [00:44:00] They’re going to learn actually, just the kid with World War II, he was doing really great with idioms and jokes and he had a wonderful sense of humor and he didn’t monologue, but his dad’s like, “I cannot tell you how many years we have worked on that, working on sarcasm”. And it’s his own sense of humor. “And you’re neurodiverse Caroline, so you understand his sense of humor,” but a neurotypical and so he knows he can’t monologue anymore. Its just to rule. It’s a rule bound behavior. And so he stops himself. And so they can learn it, but it’s not necessarily natural or intuitive for them. They’re not naturally interpreting those cues.

And so when we look at context and sensitivity, and I’ll be getting into this, but they’re just not able to pick up on those things. So the decisions that they make, it’s based on logical problem solving. It’s like Spock, right? They’re trying to figure out how do I respond in this moment? He did learn to tap into his [00:45:00] emotions eventually, tap into the human part of themselves, but they create these complex rules to follow so they can learn how to respond appropriately to look at others but they still need lots of learning and overlearning and explicit instruction, whether it’s from themselves. A lot of people will say that they’ve spent years watching other people, watching movies, trying to figure it out. But even if they learn it, for some, I find it can still look a little stiff.

Dr. Sharp: Sure that makes sense.

Dr. Caroline: But not always. So we need to ask them, and I’ll get that into that with the assessment piece, but we need to ask them about it. And even if they are, they might still be constantly thinking, how do I position myself? Am I too close? Am I too far away? How far away should I be? I read an analogy not too long ago. The Son of the Man picture with the apple, the green apple in his face, that painting.

Dr. Sharp: Yes.

Dr. Caroline: We can’t tell how the man is feeling. And it can be a lot like that for our autistic [00:46:00] people because their brain picks up on different cues and it takes them a lot longer than our ADHDers to tell how they’re feeling. And so it’s like that most important information is blocked for them because their brain just isn’t picking up on that information. It’s more so, they can usually do it if there’s one person involved. And I do a lot of pictures; I show them different pictures of what’s happening. They can usually do pretty good if there’s one, maybe two people in a social interaction, but if there’s more than one person involved, things start to break down.

There was a great example that’s come up tons of times. I can’t remember what the movie was, but essentially it’s a big classical movie. I can’t remember what it is, but in the research they had autistic people and neurotypical people watch this movie. And it’s essentially, I can’t remember, a husband or a wife who walks in on their partner having [00:47:00] an affair. And so the neurotypicals are like, huuuh but the autistics are like, what’s that light switch doing on that side that close to the door or something like that; just completely missed the whole big picture of everything that’s going on because they’re looking at the wrong information.

And so it could be, that’s part of the reason why things like conversations and social interactions are just so exhausting because they don’t know what’s the important piece to look at. And so their skills are just so rote and so logical that it’s really hard for them to generalize their rules, any coping mechanisms from one situation to another. And then they flounder whenever they’re in a new situation. And so they don’t want to be in a new situation. So it can be really hard.

Understanding facial expressions can be hard unless they’re extreme, right? Unless they’re extreme, it can be really obvious or they’re trying to constantly figure [00:48:00] out; are people happy? Are people sad? Are they mad at me? And especially as they go into the teenage years, because that’s just a part of being a teenager, and so they’re picking up all the wrong information. It’s really hard for them. They don’t naturally know how to decode that information.

Whereas our ADHDRers might have trouble and not realize mom’s crying. It’s not because they can’t do it. It’s really about, are they even paying attention to read the social cues in the first place? So anything I talk about reading social cues, shared enjoyment, understanding how other people are feeling, it’s because they’re not paying attention. That’s the core deficit of ADHD, which can look really autistic, but it’s for a different reason, because when they are paying attention, they can do it.

So you might have your ADHDer and your autistic student who both might say something totally insensitive to someone. [00:49:00] They’re completely oblivious to the context or to the emotional state of the other person. But the why is so very different, the ADHDer, they’re just not paying attention to those context cues. So they might say, “Hey, dude, read the room.” We might say that to the kid, read the room and they’d be like, “Oh yeah, shoot. Oh my gosh, I’m so sorry.”

The autistic person, when you’re like, dude, read the room. Okay. That makes sense. I actually had a teenager who was always like, that makes sense. Yeah, that makes sense. That was the repetitive thing. That was their phrase, “That makes sense” but they had no clue. They might say sorry, they might climb up, but they’re completely confused what was wrong. What did read the room mean?

Okay. I’m looking at what’s important information here. They don’t know what to do. They don’t know what feedback they need to pick up on. They still don’t know how somebody’s feeling until they’re explicitly told. So they just really have to [00:50:00] wrap their brain around what’s going on, and it’s just not intuitive for them. And so they’re not understanding the subtext of what’s going on. ADHDers just aren’t paying attention to the subtext.

Dr. Sharp: That’s fair. I’m compelled to say that makes sense and I’m aware that that’s not.

Dr. Caroline: Well, it was funny because at first you’d be like, oh yeah, that makes sense, but then as we’re going in the assessment, like everything, oh, that makes sense. And I’d tell a joke. Oh yeah, that makes sense. But I was just like, oh my gosh. It can be really hard for autistic people to control their facial expressions too when something’s happening. I don’t know if you’ve ever watched Modern Family.

Dr. Sharp: Oh, sure.

Dr. Caroline: Claire, the mum, whenever there was bad news or someone died, she’d be smiling, laughing, and she’d like try to control it and she’d try to get away. It’s like that, it can be really hard for them. We know the flat expression. They don’t show as much facial expression than what we’d expect, and they don’t necessarily direct them [00:51:00] to other people,whereas our ADHDers, we usually do have a bigger range of emotions, but they can be exaggerated and we got to be careful because if there is comorbid anxiety or depression or things like that, they can present pretty flat as well.

Eye contact and eye gaze. Again, a lot of autistics, it’s either they’ve learned it from a young age, they don’t even know that that was something and parents forget that that’s what they taught them, but they often learn it or find ways to make it look like they’re making eye contact. Maybe they’re looking between the eyes or just past the face. I just did an assessment with the girls, when I brought the girls and I noticed with me it looked really good, but when I looked from a side when she was interacting with her peers, she was looking just past the one eye all the time. That was the only place she would look. And so then when I asked her about it, she’s like, oh yeah, it’s just [00:52:00] easier for me because it, I don’t know. It’s just a habit. She didn’t even necessarily know, but she’s like, that’s where I need to look. It just makes the most sense for me.

Or they use it wrong completely when they’re anxious. And just knowing, we really got to get their experience of eye contact at the end of the day. That’s what we need to do. Some do say that it’s uncomfortable. For her, she just didn’t know where in the eyes. And so for her that made the most sense was just to the right. It’s just easier for her. But a lot will say it’s uncomfortable. Some will say it’s overwhelming. Others will say there’s no information there at all, so why would I look there if there’s more other information elsewhere? So again, it’s that fluidity with integrating eye gaze and the verbals. Speaking in isolation. Oftentimes, they can look really good. It’s just being able to integrate them.

Again, I’ll use the ADOS just because that’s what most people are familiar [00:53:00] with, but in the demonstration task, when we have to show how to brush our teeth, I find they can look at me fantastic and maybe talk but not also gesture. And if they have to gesture, they’re looking away to think about that gesturing. ADHDers do too. I have terrible eye contact. I really do. I’m always looking, and you see me on the video, I’m always looking up in away when I’m talking. When somebody else is talking, I am right on you. I’m looking right at you. I’m all over the place because I’m thinking. It’s just my way of processing and trying to think of what I’m going to say next.

So a lot of times with the ADHDer, there’s an overactivity, there’s inattention, and they might not have the opportunity to make as much eye contact because they’re moving, they’re losing focus but when they do sit and they’re regulated and they’re looking, [00:54:00] it’s fine. The integration is fine, the modulation is fine. And so we do see a lot more inconsistencies with that as well.

Differences with making and keeping friends. They’re both socially motivated. And a lot of our autistics and ADHDers, actually the consultee that I was talking with yesterday. She’s like, “No, I know it’s not autism,” like, before I even said anything, I know it’s not autism because she’s got all these friends and she’s socially motivated. And I’m like, well, what does she do with her friends? And it’s video games. And she’s like, oh my gosh. She was looking back through my notes. They’re all autistic. All of her friends are autistic. And so able to connect with those.

Peer rejection is common for both our ADHDers and the autistic population too. This peer rejection with the ADHDers, it’s their breaking rules, they’re interrupting, they’re attention seeking, they’re bossy. I was the bossy kid myself. Autism, it can [00:55:00] be hard for them to develop rapport. I have a family member who I know is autistic, undiagnosed, so I can’t say or do anything, but there’s just awkwardness. And my kids noticed it from a very young age. Why is that family member so weird? Like, it’s just, you can’t develop that rapport. So it’s not something, that’s more clinical intuitiveness when we’re in interacting with them.

Initiating interactions can be hard. Our ADHDers are likely to be really disruptive, really annoying. They’re going to interrupt, they’re going to bring up random ideas, they’re going to be bossy or lose focus. A lot of the autistic probably don’t initiate, but it’s just way more awkward. It’s not quite as disruptive the same way as the ADHD kid might be. They might say something inappropriate.

[00:56:00] I actually was working with a young man who was mandated for an assessment because he was in the legal system, but he lived in an apartment building. And one day he was getting his mail and another woman in the building smiled and said, “Hey, how’s it going?” And he took that as she likes me. And so the next time he saw her, he flashed her. He was wearing a bathrobe and flash because he thought she liked him, and so now he’s going through criminal charges of indecent exposure and all of this stuff and restraining order and blah, blah, blah. Really inappropriate way to initiate, right?

Dr. Sharp: Yeah. That’s a bold move.

Dr. Caroline: Yeah. And I see that and it’s just like, what? I don’t understand. This is a mating ritual. It’s kind of interesting. So initiating, making [00:57:00] friends, keeping friends is tricky for autistic. Some it might be because they prefer to be alone, but it’s just that exhaustion. Keeping up with friendships and nurturing those relationships can just be so much work. Way easier if they do have friends with similar interests. But how many 8-year-olds love birds or know the train schedule? Those are classic.

Girls have a little easier because their interests are a little bit more similar, but a lot of them will prefer connections with people with similar interests which is harder for our younger kids. I think as adults they do find those people. Both can be really naive about friendships, but the autistic kids are usually way more naive.

Well, even just this kid who I was working with, teenager, super bright guy, and I’m asking, what does a friend mean? What does it mean to be a friend to you? He’s like, “Why are you asking me that? I don’t understand the question. These are my friends, Bob [00:58:00] and Billy and Bababa.” And I’m like, well, how do you know that you’re friends? Because I said. Where do you hang out with them? Well, I just see him at school. How do you know they’re your friends and not just kids in your class? And he is like, “I don’t know.”

A lot of my autistic kids can say, you spend more time with them, the logistical things it’s all about the behaviors that they see but not necessarily that feeling. And like, I could open my heart and soul to this person and know they’ve got my back. Those things are often missed. So they are way more naive in those kinds of things and misreading situations like, oh, they smiled at me. I should show off my junk because she must like me, right?

Dr. Sharp: Sure. It’s so hard to not leap in with comments on the assessment process. I know we’re going to get there in the second part of our podcast, but just like you’ve said, the internal experience is [00:59:00] really important and just digging in and not taking things at face value. Like if someone says yes, I have friends or parents are like, yeah, of course my kid has friends. And then digging deep into, well, what do they do together and what’s your experience of this friendship? What is your friend’s favorite color? Or what is your friend’s favorite, whatever? And they’re like, Hmm, I don’t know. That’s interesting, right? That is telling.

Dr. Caroline: What’s their name?

Dr. Sharp: Or even what’s their name? Sure.

Dr. Caroline: My older ones always know, but some of the younger ones like, I don’t know. I just invited myself to their birthday party and now we’re best friends.

Dr. Sharp: Right. Yes.

Dr. Caroline: Man, there’s so much. I’m not even like, I don’t know, we might have to do five parter here. There’s so much information. I have so much. Literally, I went through the whole criteria, but it’s about looking at all of the social stuff. I’ll just jump ahead a little bit here. An [01:00:00] analogy that I often use with ADHDers is a migraine headache.

If we’ve got a migraine headache, we could smile. We know how to smile. We’ve got the skills to engage socially, right? And if someone looks at us and smiles, we might not smile, but we know we could smile. We’re just not thinking about it because we’re so wrapped up in our migraine headache. We just want to go and lay down or whatever. We’ve got the skills, we’re just not doing it in the moment for whatever reason. But if someone said, “Hey, Caroline, smile at me” I can look up and do it. It’s just maybe hurting my head but they just don’t think of it. In that moment, I’m just not going to think to smile to you when I see you because my head is killing me.

And so that’s the ADHDer, they’re just not thinking of it in the moment. They can do it, but they’re so preoccupied with something, they’re just not thinking about what it is that they need to do right now. And that’s why we call it the performance deficit. It’s a really disorder of doing the skills that they have in [01:01:00] the moment. So it’s not a skill deficit, it’s really more that performance deficit that we see. Whereas the autistic person, it’s not that they have a migraine, it’s just that they have no idea that they should be doing that thing in the moment. Why should I be doing it?

And so we see things too with context shifting, which can be hard for both with the ADHD and the autistic kid. Our behavioral disinhibition where we know that this is how I act in the classroom. This is how I act in the gym. This is how I act in the doctor’s office. This is how I act at grandmother’s house.

For the autistic person, it’s all so confusing. Why are there so many rules for this person even if I go to one family member’s house to another family member’s house? There’s so many rules. There’s so much work to do. Just to think about being with this one person. And going into this different context, even if I’m with this person, but now in a different context, there’s just too much, too many rules.

[00:02:00] The ADHDer, they know it, they just might have a hard time in the heat of the moment because of impulsivity or hyperactivity or whatever else is going on. So they know they’ve got to sit at the doctor’s office and why that’s important but it’s really cool to get up and jump and look at all the things that are on the wall and check in your ear and take your temperature and all of those kinds of things.

When we’re looking at the criteria in criteria A, they have to meet all of them to be autistic. They have to be impairing. The reason why, and I think this is an important piece too, for ADHD and even autism, the reason the DSM manual was created was to document things that were impairing people’s functioning; their day-to-day life. So if there’s no impairment happening, are we actually going to be giving a label of ADHD? Well, well we know we can’t. It’s got to be impairing and it’s explicitly, but it’s the same thing with autism, if there is no impairment, maybe they have [01:03:00] intense interests. Maybe there are sensory sensitivities, but they’ve learned to cope and they’ve learned to manage. And there’s no impairments, do we need that label?

I’ll be talking about that in the assessment. I haven’t even gotten to criteria B yet. Should I try to fly through it or? I know that there’s so much for us to talk about.

Dr. Sharp: There is.

Dr. Caroline: Yeah.

Dr. Sharp: That’s okay. I’d rather give it some space and maybe we just say, hey, we’ve spent the amount of time that we need to spend on Criterion A and some of this background information, and we just know for next time that we will dive deep into Criterion B and then transition into the assessment.

Dr. Caroline: Okay. Yeah, because I do have lots to say. The boy versus girl presentation drives me nuts. I do want to mention why. So I’ll leave that as a cliffhanger and then we can get into the assessment piece as well.

Dr. Sharp: That sounds good. That’s a fantastic cliffhanger because I know that folks are, it’s right in our faces these days over the last few years and there’s a lot of discussion around it. [01:04:00] So there’s your cliffhanger, audience. We’ll dive into lots of different things in the next part, but for now, thanks. This is great information and a lot for people to be thinking about, so appreciate your time.

Dr. Caroline: Awesome. Glad it was helpful.

Dr. Sharp: All right, y’all, thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.

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Thanks so much.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. [00:06:00] Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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