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.
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Hey folks, welcome back. This is part 2 of my interview series with Dr. Caroline Buzanko. She is talking with me about differential diagnosis of ADHD and autism spectrum disorder.
Last time we covered a lot of background and we dove deep into Criterion A of [00:01:00] the ASD symptom list. Today, we’re going to continue that, so we dive deep into Criterion B, and then we spend a lot of time talking about the assessment process, how it overlaps, and how it’s different when you’ve got ADHD and ASD in the mix. We also talk about gender differences and the pros and cons of looking at diagnosis through that lens and many other things.
So as always, lots to take away from this episode. I really enjoy talking with Caroline because there are plenty of concrete ideas and strategies that you can actually put into practice. Also some resources in the show notes. So Caroline does more in-depth training on this topic and you can access that through the link in the show notes. And she was kind enough to provide a coupon code for 25% off the training if you use the code TTP25. So definitely check that [00:02:00] out.
Before we transition to the conversation, if you are a practice owner or aspiring practice owner and would like some accountability and support, at the time this goes live, there might be a spot or two left in each level of my mastermind groups. The groups sit at the intermediate, advanced, and beginner levels. So something for everybody no matter your stage of development with your practice. I’d love to chat with you to see if one of those groups could be a good fit. It’s group coaching, there’s accountability, there’s support, and connection, all good stuff. So you can go to thetestingpsychologist.com/consulting and sign up for a pre-consulting call.
All right, let’s get to part 2 of differentiating ADHD and ASD.
Dr. Sharp: Hey Caroline, welcome back.
Dr. Caroline: Thanks for having me.
Dr. Sharp: Yes. I’m excited for part 2 of our conversation about differentiating autism and ADHD. We covered a lot the first time, but there is still a lot more to cover. And to that end, I think it makes sense to just dive right back into it. If I remember right, we wrapped up last time with a discussion of the criterion A items- symptoms of autism and the overlap there with ADHD. So what do you think? Do we just pick up Criterion B?
Dr. Caroline: Criterion B, yes.
Dr. Sharp: Yeah, let’s do it.
Dr. Caroline: We’ll jump right in there. Yeah, we’ll go there. There is always so much and I know that I’m just scratching the surface but hopefully it gets people thinking of different things to think about. [00:04:00] Criterion B is an important one. I find that so many, whether it’s parents or teachers, or clinicians, will use criteria A. Our ADHD kids will look for autistic based on criteria A. I covered all of that last time.
So B can really help us figure out what’s what. There’s still a lot of overlap of course, but this is usually where I find there’s not actually necessarily information to support an autism diagnosis with our ADHD kids. Of course, there’s some uniquely autistic traits; excessive, unusual fascination with different things, repetitive movement, and hand flapping. Some ADHD kids will hand flap, but there are some classical autistic traits there. Focusing on one part of a toy, the peering through the side, spinning the wheel on the CAARS. Those things are the classical things that I think we would all look for, but they’re [00:05:00] also classical male presentations of autism.
So there is still some overlap that we do see but usually, again, for different reasons, I talked a lot about that last time for criteria A. So for example, our ADHDers and our autistic kids can be really rigid, that rock brain that we talk about. But again, it’s looking at the function of those rigidities.
So a lot of the ADHDers’ parents will talk about how that child actually thrives with structure, thrives with routines, thrives with predictability, but it’s because it’s supporting their executive functioning deficits. And so that’s usually why we see that rock brain for those kids, right? There can be anxiety, and I’m not also talking about anxiety. That’s a whole other episode, teasing out what’s ADHD anxiety, right?
Dr. Sharp: Yes.
Dr. Caroline: But really oftentimes that rock brain is because we’re supporting the executive functioning deficits. [00:06:00] They might need everything to go back in the exact same spot because otherwise, they’re going to have no idea where they left it and they’re going to get in trouble or they’re going to waste hours trying to find it. So it’s supporting their executive functioning deficits versus rigidity. Or, I need to do things in the same order otherwise I’m going to forget what to do, right? I’m going to miss a step. And they get so much corrective feedback that anxiety does start creeping in, but a lot of times it’s to support those executive functions.
Autistic kids will have those rituals, not all the time, but a lot of the time they’re non-functional. There’s no reason, no how. I was talking with the kid two weeks ago about, “You keep getting in trouble with this routine. Why don’t we switch two things so we can do it this way? And they just couldn’t understand. “no, I’ve always done it this way. This is the way.”But it’s not functional. They don’t see it. It’s just that rigidity [00:07:00] or a lot of pseudo-superstitious behaviors.
Sometimes everything will fall apart. So that’s where the anxiety starts coming in. So I see non-functional rituals, non-functional lists. ADHDers will keep lists, but it’s to help support the working memory, whereas other kids will keep lists of all the Marvel characters or all the Disney princesses or the time schedules of the train or whatever that is, it’s not very functional. But like I said, if there is anxiety in there, it can look more rigid, non-functional rituals because of whatever else is going on. So that’s where we have to start teasing apart that anxiety.
And oftentimes with our ADHDers, that anxiety starts kicking in just because of the executive functioning deficits that we’re seeing. So forgetting instructions, forgetting homework, forgetting to hand in their homework when they do, whereas the autism, their anxiety is usually, the biggest autistic [00:08:00] anxiety challenge that they have is this intolerance to uncertainty. And we know anxiety is all about being fearful of the uncertainty and not being able to handle that uncertainty, but with autism, it’s really this intolerance to uncertainty.
And so they have this drive, they have to have sameness. But they also have a lot of weird things too. Weird phobias when we start looking at anxiety too, like men with beards or exposed wires or different things like that that we wouldn’t normally think about for our typically developing kids.
How kids respond to unexpected change can be a clue as well. So how are they when they initiate a change versus someone else forcing a change on them? It’s typical for any kid if you say, dude, I know you love swimming and we wanted to go swimming today and I’m [00:09:00] sorry we can’t go swimming, every child is going to get upset with that but even the slightest unexpected change, even if it’s a positive change, even if it’s a dude, I know we’re supposed to go to the dentist today, but we’re not going to go to the dentist, we’re going to go swimming. Even if it’s an awesome change, that can be so overwhelming for the autistic kid, whereas ADHDer will be like, awesome. This is fantastic. So we don’t see the same intensity of that stress and that anxiety with our ADHDers as we do with our autistic kids.
So flexibility with change is usually a good clue. Our ADHDers like novelty, they like change, and they like to mix it up. They look forward to going to new places and meeting new people. And so just getting out of the monotony of everyday life, the day in and day out is so important for them. The sameness gets so boring for them. That sameness can actually be quite [00:10:00] distressing and depressing for our ADHDers whereas for our autistic kids, that sameness is soothing. They want everything same, same, same. They crave order, they crave predictability, they crave just knowing every minute of my day is totally predictable. So they often will plan things out before they happen. They like having those step-by-step guides manuals of how to do things or how my day is going to go, whereas for the ADHDer, they can make a plan for themselves. They could be given a plan, but they just go for it. They’re not going to read it. They’re just going to jump in and hope for the best.
Actually, I just had an experience, last week my husband and I went away. I had a work retreat. I was looking at desserts. I saw the word banana and I saw a picture of a pie somewhere else on the screen because when I was looking, we were just looking at the menu online and I [00:11:00] assumed, oh great banana pie. So I didn’t actually read what it was, so we went to the restaurant and it was not a banana pie and it took forever, like half an hour for them to set up this dessert. They brought in this huge trolley and there was a huge cooker, like a little stove that she had and it was like a banana flambe. And I’m like, can we read the menu again? And no, there was a key lime pie.
I just didn’t take that two seconds to read the description, right? And that’s kind of the ADHD brain; they just jump in even if they have that plan. And so that’s why visuals are great for our autistic kids, but they’re not so great for ADHD kids. So they can have it. They know it’s helpful, but it’s really hard for their brain to follow that. So there are those pieces, black and white thinking, just being overly literal.
I love looking out for what they find humorous. I use [00:12:00] lots of different materials to try to get engagement with them just to see what they care about, what they think’s funny. So looking at the picture on the ADOS, just using things that I know we use within the assessment, I’m always talking about, oh man, I see something super funny on that picture just to see, well first of all, are they going to even respond to me? Are they going to even care that I see something? But just see what they think is actually funny.
And so if I say, oh, that little guy on the Niagara Falls going off over the barrel, that’s so silly. And they’re like, that’s dangerous. That over-literal, just I don’t think it’s funny, Caroline. I do a lot of jokes. I find that can be really helpful to differentiate. Again, there’s no hard and fast rule. A lot of our autistic girls get sarcasm and understand that, but I do tell jokes and see how they respond.
So the ADHDers might still not get it. [00:13:00] You still might need to explain it to them, but once they get it and you explain it, they laugh and they see the humor in it, whereas the autistic kids usually don’t.
Just the other day, I asked the joke, what’s the difference between broccoli and boogers? And the kid is like what? And I’m like, well, kids don’t like to eat broccoli. And so the kid, he got really upset and he’s like, first of all, that’s disgusting. And second of all, I do. I’m a kid and I do actually like broccoli. And so he’s definitely autistic. He meets his, but I don’t have the same reaction. The ADHD kid is like, eww that’s so gross.
It’s so funny. But it’s just that literal or dissecting everything. Like that’s not possible or whatever it is. So it’s not to say they don’t have a sense of humor. It’s just different. [00:14:00] And oftentimes parents will say, yeah, they get it, they get sarcasm, they have a sense of humor but it’s usually their own sense of humor. They don’t necessarily like those kinds of things.
With our autistic kids, I do see more of the stereotypical repetitive robotic language, the monotonous voice thing. but sometimes you really have to listen for it. Oftentimes those things I see more in the boys than I do the girls, but girls will often have little catchphrases. So I had one, I remember she would laugh at my jokes, but it was like, hahaha, that makes sense. But as I listened to her everything. she was always saying, that makes sense.
And so I started tallying how many times she was saying that repetitive catchphrase over and over, and I realized she really didn’t understand what I was saying some of the time, but sometimes it was just her pat response. She didn’t know what else to say in [00:15:00] the situation, that makes sense, and that was her transition into talking about something else.
And so I see a lot of those little things. Sometimes actually a lot of the kids will refer to people as humans or they’ll just say, a lot of my boys lately, they’ll say something or I’ll say something that they think is funny and so then they’ll repeat it back to themselves. I had one kid, IQ 146, brilliant. He can talk about, even when I started doing the academic testing, he’s like, is this really necessary? I am in grade 7 doing grade 12 math, is this necessary? And I’m like, well dude, yeah.
Dr. Sharp: Great question.
Dr. Caroline: He did have that echoing. I would say something and then he’d chuckle to himself and then under his breath, repeat whatever it was that I said.
Recently, I’d say since the holidays, so the past six weeks or so, [00:16:00] I’ve had 6 boys say defying gravity, out of the blue, at least more than once. And it’s weird that that’s their thing. I don’t know if they’re watching the same show, but several of them have been talking about defying gravity and repeating it like three or four times throughout the session. So it’s just really listening for those kinds of things.
Repetitive stereotype, stimming behaviors. So there could be motor, there could be verbal stims. And for those who aren’t really sure what stimming is, because I think we talk about those stims all the time. It’s just a way to stimulate our senses. And so oftentimes it’s to self-regulate, either we’re releasing all this built up tension out of us, or it’s to manage any sensory overload that could be happening.
Now, a lot of times, we really got to listen and make sure we’re getting clarification. Sometimes they even get videos. A lot of times parents will say, my kid has repetitive [00:17:00] stimming behaviors, but it’s really hyperactive, wiggle bottom, jiggling the leg, bouncing the leg behaviors. And so it’s really making sure we have a really good definition. Is it a hyperactive, fidgety behavior or is it actually more of that stimming repetitive behavior?
We have to be really good behaviorists. We really have to get to the function of the behavior. I said it last time and I’m going to say it again. We do see our ADHDers, they will engage in repetitive behaviors to wake up their brain. It’s to alerting their brain, right? That’s why we see a lot of the hyperactivity. So they’re stimulating themselves. That’s their way to self-regulate. For autistic, it’s usually, they’re all over the spectrum, which I’ll be talking about in a second but they could be alerting their brain, but more often it’s to self-soothe. It’s to calm themselves down. It’s to relax. And so we can look at how are they using those behaviors.[00:18:00] ADHDers also want to use up, if they have excess energy, sometimes they’ll engage in these behaviors just so that they can use up all of that extra energy whereas the autistic kid, again, it’s about moving to relax myself, to soothe myself. So we really want to get to that internal experience. Oftentimes the ADHDers don’t even realize that they’re engaging in those behaviors, whereas oftentimes my autistic kids who are verbal, who are older, the younger ones probably have a harder time, but the older ones do say, actually, I am rocking. I am doing these things because I find it really calming. The ADHD kid is like, what? I’m rocking, I didn’t even know Iwas rocking. So there’s those pieces.
Excessive interests we know happen for both our ADHDers and our autistic kids. ADHDers can easily hyperfocus. We talk about it all the time. It can look like a special interest that we see in the autism. They’re [00:19:00] passionate, they’re all in, but they get bored and they satiate. And so they learn all about it, or they have that initial excitement, and when that initial excitement burns up they hop onto the next stimulating thing, right? And so they’re shifting between those interests a little bit more frequently than we would expect our autistic kids to.
The autistic kids might focus on one thing until it’s done. Until they’ve learned everything that they’ve learned, they can’t direct their attention even if they want to. That’s that hyperfixation piece. And so I hear that a lot where they just can’t stop themselves even when they know they’re done and they want to be done, they just got to keep going. And so that hyperfixation is reinforcing their brain and they just can’t pull themselves away. Their pace is slow. Their pace is steady, whereas ADHDers, [00:20:00] the buzzing excitement and then we just see it drift off.
The ADHD brain, it’s like an energizer bunny, really. So, all in through the task until it becomes too boring or repetitive and then the brain just shuts off. And okay, now I got to wake it up again. So we do see the shifting interest. There’s a lot more flexibility. If they’re talking about something, you can interrupt them, even if they’re super excited. They’ve got that buzzing energy. You can interrupt them. They might be disappointed, but they can move on. Unless it’s screens, I find that can be challenging but there’s lots of different things that they can talk about, right? It’s that buzzing energy, whereas the autistic kid, it’s harder to redirect.
And I’ve had kids, I had one recently, Rubik’s Cube, he’s all about the Rubik’s Cube. And I’m like, hey dude; we got to talk about something else. He’s like, but no, I didn’t finish talking about all these 10 different kinds of Rubik’s cubes that I need to talk about. I’m like, okay, well we’re going to put that on the shelf. Here’s a [00:21:00] checklist. We’re going to do these three things. And he had such a hard time to shift away from that. And so we do see them shift interests, but usually not as frequently. These interests usually last a little bit longer. We do see a lot more repetition where they’ll read the same book 143 times. There’s watched the same movie 26 times.
So I do find those kinds of things and even when they do shift, like a lot of my girls, maybe their interests have shift, but there’s a similar theme, social justice or helping animals, for example. So they’re way more enduring. And for a lot of the women I’ve talked about or have talked to, it’s become part of their identity. It’s part of who they are, right? And so I think that we can look at those types of things.
A lot of times these interests self or a way to self soothe with the autistic kids, it’s just really [00:22:00] relaxing. It’s really calming, whereas the ADHDers it’s usually they become more excitable, and so we can start looking at a few of these different kinds of things.
Sensory sensitivities and interests true for both. Even though it’s only explicitly outlined with our autistic kids and not for the ADHD, we have no idea why it’s not in the DSM for our ADHD kids because we actually see more things like sensory interests in our ADHD kids than we do in our autistic kids. They’re the ones who are constantly touching things and smelling things and licking things- seeking out that sensory more than our autistic kids. And so I have no idea why it’s not in the DSM. It really should be.
Now this is interesting. For our autistic kids, it’s usually compounding stimuli. So there might be a bad smell, now there’s a bright light, and now the noise, it’s just too much. [00:23:00] It’s become too overwhelming for my nervous system. So it becomes that last straw. It becomes the tipping point. So I can’t do it anymore. I can’t focus anymore. It’s too overwhelming. So that’s when we see the emotional meltdown or shut down. It’s all pent up.
It looks the same for the ADHD Kid but it’s usually just one stimuli. One stimuli is enough to set them off. And the meltdown, it’s usually not from the sensory stimuli itself; it’s from the emotional dysregulation, because we know that’s a core deficit of ADHD. So the stimuli triggers a big emotion that I can’t handle. And so the meltdown comes from emotional dysregulation. It’s not actually the stimuli triggered that emotional meltdown, but it’s the emotional piece that is really tricky. For the autistics, it’s literally their nervous system is overloaded from the sensory input.
So again, it’s [00:24:00] tricky to start teasing apart. That’s why we want to get to their internal experiences because it looks exactly the same, both loud noises, both emotional meltdown but we got to look at what were those proceeding triggers. For a lot of kids with autism, it’s compounding. And as they get older, they can talk about; I had one girl recently talk about the word green. Actually physically was painful for her. And she’s like, I don’t have any other word other than it’s painful. That’s weird, right? So we’re looking for those weird things. And I use weird, I hate using words like that weird compared to what? But we don’t see it often in our neurotypical kids, whereas a loud noise, the best of us, even myself, anybody, if it’s just too much, we’re trying to focus, it can stress us out.[00:25:00] And so that brings me to their developmental profile. And I think that this is really important to consider when we look at everything. One thing that we got to think about is the ADHD brain develops the exact same way as neurotypical brains. It’s just delayed, right? There’s a 30% delay. Oftentimes, everything that we’re seeing with ADHD, it’s within the typical developmental trajectory, that profile, but it’s in excess and you hear it all the time. Parents will say, I was just like him.
All kids get bored with things that they don’t want to do. All kids avoid things that are hard and they don’t want to do. All kids are inattentive at some point, right? And so we hear these all kids. All kids, all kids, all kids. Yeah, they’re just being a kid. So that’s all true. Yeah, they all get overly silly when they’re with friends and a big party and they’re overtired and it’s hard to get started on things that are really boring. So [00:26:00] those challenges are true for all kids, but with ADHD, it’s in excess.
So when we look at the normal bell curve, the ADHD follows the neurotypical curve of development. It’s just way higher or way lower. So it’s either everything; fun, fun, fun, stimulating; go, go, go, go hard to stop. I just got to focus on that to absolutely nothing. Brain shuts down. It’s so boring. I can’t do anything.
And so a lot of the things that we see in the ADHD profile, we would see in maybe a younger child, right? Like being distracted, jumping from activity to activity, getting bored, having trouble focusing, hitting Johnny in the face when he takes a toy away from me. Like all the things that we would see in preschoolers, for example, that impatience, doing risky things like walking off of a ledge, not realizing they’re going to get hurt. All of those things we would see possibly [00:27:00] in a younger child. It’s their impulses. They’re exaggerated and their ability to control those impulses are minimal, right? And so there’s that impulse of quality to everything I talked about last time, like their social interactions.
So the ADHDers engage in “a typical” way of being as a child would, but it could be disruptive. For a 4-year-old, it’s okay, but for a 12 year old now it’s disruptive. So we call these negative behaviors because they’re in excess. They disrupt our social interactions if they’re interrupting. We don’t hear the same things from parents with autistic kids. It’s usually, my friend has an autistic son and I see these behaviors, or my nephew has autism and I see these behaviors. It’s not all kids have these behaviors. Their [00:28:00] profile is wonky, and so there’s no predicting what it’s going to look like.
So the more developmental delays they have in many more areas, ADHD might have two but with autism, they usually have way more markers and it’s way more severe. So it’s a whole suite of neurological differences and we don’t know what it’s going to be. It could be gross motor, fine motor, sensory, tension, social communication, emotion regulation, executive functioning. ADHDers do have those but we find the more hits that you have on all of those different markers, the more severe it is, the more perseverative kids are, the more stereotypical behaviors, the more splinter skills. We’re looking at autism, right?
And so, our autistic kids often are lacking what we call positive behaviors. So our ADHD have those negative, excessive disruptive behaviors. Our autistic kids are lacking some of these positive behaviors. [00:29:00] Nurturing relationships, for example. I see that especially a lot in a lot of my older girls and women. They want to have these friendships but it’s so effortful to put in the work to nurture those relationships.
The big thing when I’m looking at the developmental profile, we just don’t know what an autistic kid is going to look like. We have a pretty good idea what an ADHD kid is going to look like. And so yes, they’re all different, but we still have a pretty good idea. But with autism, do they like touch? Do they need firm touch? Do they need to hide and curl into a ball or do they need to spin to self-regulate? Do they want to line up cars? Do they want to do a math worksheet? Those are some of the basic behavioral things, but I also look for these big splinter skills.
So kids who can never remember their classmates’ name or their teacher’s name, but they can remember the name of every bridge in [00:30:00] town, that’s wonky. That’s a huge splinter skill, right? And so they can do it amazingly in one area, but the exact same skill in another area, they just can’t do it. They can speak eloquently, beautifully at one minute, and they can’t even string two words together at another minute especially if they’re feeling stressed out. For example, they might not be able to say hello to a friend but they can go up onto a stage. So we see this huge wonkiness in the profile.
They might have really strong morals and want to defend the rights of animals, but totally disregard how their peers are feeling or not even caring them. So when we look at the two, again, it’s the ADHD with that impulsive under-regulated profile. And with autism, it could be under-regulated, but oftentimes it’s overregulated. And so now I’m really rigid, I’m really fixated, all of those kinds of things going on.[00:31:00] I can get into the motivation piece as well. That’s another big difference that I see between ADHD and autism. With ADHDers, we know if they’re motivated, they’re going to jump right into it. It’s going to be awesome. This is going to be so much fun. I can’t wait to do it. And they’re gone before you’ve even given the instructions or they’re gone before they’ve even thought about what the consequences are. But for the autistic, they could have all the motivation in the world, but it’s so hard just to get going because they really have to get their head wrapped around it. They have to process, what do I have? Where do I start? What do I need?
So again, it’s that manual that they need. And we see too, if they’re not motivated, we see that medications can be really helpful with our ADHDers, whereas the medication isn’t quite so helpful with our autistic kids. So looking at that motivation piece can be really helpful as well.[00:32:00] That’s a lot to say. I don’t know if you have any questions or if I can just keep on going?
Dr. Sharp: Well, just want to highlight that the way you explain that makes a lot of sense with the ADHD developmental profile. It’s almost like you’re taking two bell curves that are superimposed on one another and shifting one to the side, right? Like it’s a similar process. It just falls in a different timeframe, typically behind, right?
Dr. Caroline: Yeah, exactly.
Dr. Sharp: I like that visual. And then the autistic developmental profile is a little more chaotic maybe is a good word for it, or it’s falling outside the typical developmental process. That absolutely makes sense.
And I do want to make a fine distinction maybe just to clarify that if I understand you right, you’re not necessarily saying that ADHD brains are structurally the same as neurotypical [00:33:00] brains, but the developmental profile is very similar just on a different time.
Dr. Caroline: Exactly. And I think I talked a little bit about the brain last time. So we do see a lot of differences in neurotypicals, but a lot of overlap in the autistic and ADHD brain. So yeah, very similar pathways. And so there’s alterations in the structure and the function of the brain that is very different from neurotypicals. Because we don’t have brain scans, it’s all about what can we see looking for those subtle differences that we see behaviorally because that’s what we got, right?
Dr. Sharp: Right.
Dr. Caroline: Yeah. Just in how it presents itself.
Dr. Sharp: That’s great.
Dr. Caroline: I didn’t talk about, and I’m not going to have time to talk about both autism and ADHD. And we know if you’ve got autism, chances are pretty good you also have ADHD. I think that’s a whole other conversation is when is it just pure ADHD [00:34:00] or pure autism but what happens if you’ve got both because I think that’s where things really get tricky. We can see the ADHD so much sooner, so much easier. And so that’s why kids, that diagnosis is usually made first and the autism doesn’t come until later on in life but it gets really complex. We didn’t even get into what if you’ve got an ADHD-gifted kid or if we add the anxiety, so that’s a whole other complex piece to think about.
I do have a two-day training that goes through all of that because there are so many different pieces that you have to think about. But I just want to keep that in everybody’s mind too, because oftentimes if you’ve got ADHD and autism, the ADHD completely overshadows the autism. And so we often will miss it. And so that’s why even now I’m getting 50 and 60 year olds who are coming and saying, I think I’m autistic, but I was always ADHD [00:35:00] because maybe they are wanting sameness and are really socially anxious. But the ADHD, the chattiness of them and then this part of the brain that seeks novelty, it can overshadow the autism.
I’ll give you the link to the training program if anybody wants to do that, but there is so much more to think about. Right now it’s just focusing on just these two because I know it gets complex and if people are thinking what about this and what about that? Well, these are some of the things.
One thing I noticed too well, and I’ll get into some of the assessment pieces. So maybe first I’ll just go into the gender differences briefly.
Dr. Sharp: Yeah, I think that would be great. There’s so much discussion around gender differences.
Dr. Caroline: There’s so much discussion. There’s so much work on the gender differences. A lot of it is [00:36:00] because the DSM doesn’t actually capture the female presentation of autism, right? So all of our assessment tools and criteria are based on male samples largely. And so we have a lot of women who are missed. They’re on this invisible end of the spectrum because:
A, we don’t know what it looks like, and
B, they’re masking, they’re camouflaging all their autistic traits.
And so the autism often doesn’t show itself for a lot of them until life becomes unmanageable. A lot of the teenage girls, I see them when they’re teenagers just because of the social complexities are now beyond what they’ve been able to cope with. But even so, so many of them are such good internalizers that it just looks like anxiety. When it’s unmanageable, it just looks like anxiety. And so they’re getting that diagnosis.
I actually hate all of the gender comparison talk, though, I got to say because what people [00:37:00] don’t also talk about is the fact that boys and girls have different brains in the first place. Autism aside, boys and girls have different brains. Of course we’re going to see differences. Just by being male or female, we’re going to see differences. And so it’s not about the sex differences in autism. It’s not related to autism at all. It’s related to, are you a boy or are you a girl?
We know the female brain, for example, develops more quickly. So those executive functioning deficits that we see both in ADHD and autism, they’re not as deficited later on. Although I would say women are more deficited just because there’s higher expectations. We let it slide if a boy interrupts, but if a woman does like, hold your horses there, right? We have a different perspective. But because their brain is developing more quickly, their autistic characteristics aren’t going to be as severe as [00:38:00] they are for our boys. And so we got to look at that. Their awkwardness is not going to be as acceptable as boys, but girls have more socially developed brains, they are just more social, right? And so we’ve got to think about those.
In the younger years, boys tend to be louder, they tend to be more behavioral than girls, and so of course they are seen more because they’re presenting way more behaviorally. Girls still might be stimming, but girls might not be the big, loud, hand flapping the very obvious stuff. It could be chewing inside their cheek. I actually had a girl who’s inside cheek was just shredded because she was just eating the inside of her cheek or pushing their toes. Like right now I’m sitting here pushing my toes, right? You can’t see my feet, but you wouldn’t know. If I had my hand slapping or was doing rocking, you’d be able to see that. So there’s really subtle things [00:39:00] that they might be doing that’s not as obvious.
Like I said, girls are just more social than boys, in the first place. They have better social language. They have more empathy. They can recognize how people are feeling better, right? They are more socially motivated most of the time. They’re more nurturing and engaging in comforting behaviors. So all those things that we think about on the ADI or the ADOS that we’re looking for.
Girls just meet the criteria of social success better because they have a girl of brain. They are more social in that way. They’re better at noticing things, at analyzing things and they will sit and observe how do people interact? What are they saying? How are they holding their body? Where are their eyes looking? They’re way better at analyzing and imitating behaviors than boys are. And that’s why we see girls masking and camouflaging so much more. That’s how the girl brain works.[00:40:00] So boys don’t really sit and observe and analyze like girls do. They just barge in. They just barge in or walk away completely. They’re not as socially motivated as girls, so they might not even care to try to fit in. They might not care to try to appease people and a lot of my IQ males, boys, teens, men that I’ve talked to, they do come across a little bit more arrogant, and part of that is just the brain differences. A lot of girls, most girls do want to connect. They do want to have those friendships. And so they are often socially successful.
When we look at the research, the quality of their relationships are very similar to neurotypical girls. They might not have as many friends but it’s not much lower than neurotypical girls. Just going back to that imitation piece, our girls become such great [00:41:00] imitators and chameleons that they would be great actresses or psychologists really. As psychologists, we’re analyzing people’s behaviors all the time, and so that masking piece just becomes so much more prevalent in the girls. It becomes a problem over time though, because they don’t know who they are anymore. So they’re always looking for creative ways to, how do I appear normal. That’s really important for them.
Girls have strong play skills, way stronger than boys. So play usually looks really good. With interests, they don’t usually tend to have outlier interests. Oftentimes, they might have special interests but they’re gender appropriate. They might be into the teenybopper boy group or [00:42:00] animals or a lot of their interests can be really similar and look very acceptable.
The difference though, and this is what we got to start doing, not comparing boys to girls, we need to start comparing our potentially autistic girls to neurotypically developing girls. So they might have similar interests, but our autistic girls, it’s too excess. Their level of knowledge of that boy band and when they were born and where they were born and everything that they did for their hobbies, it’s just far beyond what our neurotypical girls would be doing. And so it might be appropriate, but it’s too much. And so that’s what we need to start looking at.
The repetitive behaviors obviously aren’t as obvious as either that I’ve already talked about that. They do have a lot more internalizing challenges. So that’s why we see a lot more anxiety and depression and those kinds of things. What’s interesting is boys do have [00:43:00] more challenges with emotion regulation younger, girls do as they get older. And that’s when we start to see the masks cracking. And we can start seeing the diagnosis a little bit easier.
So there’s all those things, everything that I’ve already discussed but we really got to stop thinking about comparing the boys to the girls because we’re already missing the girls because we keep trying to compare them to boys. It’s really comparing neurotypical girls to our autistic girls. And that’s where we’re going to see the challenges really.
And so we have to have an understanding, and I’m going to be talking about this in the assessment, we have to have an understanding of what neurotypicals look like. And I think that it’s hard sometimes if you don’t have your own kids or if your kids have gotten older. It was super easy when my kids are young, because I’m like, oh my gosh, you’re brilliant. Look at all the things you can do because I’m so used to working with autistic kids or ADHD kids or learning challenged kids, right? And [00:44:00] so we still have to really have that idea.
I was just consulting with someone yesterday who just did an autism assessment who was like, I don’t know, like it seemed appropriate, but wouldn’t typically developing kid do that? I’m like, see, you got to go watch other neurotypical kids. You got to know what’s appropriate because with our girls, that’s really what we got to focus on. So we got to get the autistic picture out of our mind and start comparing them to the neurotypical girl,right?
And so in my training program, I do actually, I’m going to have videos of neurotypically developing kids and autistic kids and ADHD kids. So we can start looking at those differences. But that’s really what we need to start doing. We still need so much more research looking at the autistic brain but we are actually seeing a lot of research right now that the autistic, even though I just said stop comparing girls and boys, but one thing we are seeing is [00:45:00] the autistic girl’s brain is very similar to the neurotypical boy’s brain.
Dr. Sharp: Yeah. So I’ve seen them.
Dr: Caroline: Yeah, so autistic boys, they’re using different regions of the brain to process social interactions versus neurotypical boys but when we’re looking at the autistic girls, they’re using the brain the same way as our neurotypical boys would. And so again, comparing boys and girls, we don’t want to do that. We want to compare the girls to the girls because they are using their brain very differently. We don’t know why. It could be sex hormones. That’s one thing that’s been put out there. There’s still so much to learn.
That’s just my little rant but we got to stop comparing them. But it’s actually interesting even when we get into trans stuff. I can’t remember, I think it’s trans males, before their transition diagnosed autism, after the transition, they don’t meet criteria anymore. [00:46:00] So it’s really interesting when we start thinking about that and just knowing if the autistic female brain looks like the neurotypical, they’re going to present more like a boy. And so they get along with boys a little bit better. They have more similar interests. They’re just as nurturing as neurotypical boys and all of those kinds of things. Although the ADHD girls like playing with boys too, because they’re way more fun. They’re not just sitting around talking about girly stuff. I want to be up and like throwing a frizz, all of those kinds of things.
But I think that there’s a lot of things that we can start talking about or even just going into gender expression and gender identity, we see a lot of differences in our neurodivergent population. Higher rates of anorexia in our autistic girls than in our ADHD girls. [00:47:00] Bulimia, anorexia would be higher in the ADHD, but we see more anorexia. So there’s all those different things that I think we could go on to tangents with, but I think we should start focusing probably on assessment so we can get through that. But anything about the boy/girl, brain, I don’t think it’s anything new, but I just wanted to really highlight, we got to start comparing neurotypical girls with autistic girls.
Dr. Sharp: Yeah. There’s a lot that we could dive into there. Like you said, I don’t know that this is the episode to completely dissect gender differences in autism and ADHD. You raise an interesting point around this idea that boy/girl brains are different and how that impacts the comparison. Thinking down that line of reasoning, it’s almost [00:48:00] like why do that with any diagnosis, not just autism if we’re going to look at things through that lens.
It’s a complicated problem because you talk about, and I’m just voicing this, we’re not going to solve it by any means, but when we talk about comparing autistic girls or suspected autistic girls to neurotypical girls or boy vice versa, the fact that both of these diagnoses are spectrums and many diagnoses are spectrums, they’re not completely categorical. That becomes really challenging. I just want to validate that. That becomes very challenging. So then it’s the moving target of what is neurotypical. So what are we comparing to?
And this is why our jobs are hard. That’s what I’m going to [00:49:00] end with. That’s why our jobs are hard because it is hard to know exactly what’s typical and what’s not. That’s why people come to us.
Dr. Caroline: Yeah, exactly.
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Let’s get back to the podcast.
Dr. Caroline: And that’s why I said last time, I don’t think there’s a pure ADHD or and a pure autistic [00:50:00] person, right? I think there’s a little bit of everything and even in neurotypicals, we have a little bit of inattentiveness. I think that it’s just at what threshold? It’s really about when does it become impairing. That’s why we have the DSM. If it’s not impairing, same thing with ADHD, you might have all the symptoms, but if it’s not impairing across two contexts, it’s not a diagnosis, right? And so we got to look at that.
And I’m often talking, what is impair? I’ll be talking a little bit about this as we get into the assessment piece too, like stimming, is it a big deal if you’re flapping hands? Well maybe. In the context, maybe it is. You’re losing your job because you’re with clients who… but if not then is it actually a problem? There will be some stimming behaviors and I think on the whole neuro-affirmative movement, its, why does it matter if I have a special interest? Why does it matter if I have stimming behaviors? Absolutely, why does it matter? It becomes a problem [00:51:00] if it’s impairing somehow. And so that’s what we need to look at.
There’s so much still with assessment. I’m going to try to get through it all with the assessment piece. I do have two disclaimers. One is, we want to away diagnostic overshadowing because I see this all the time. And so that’s where we’ve other diagnoses. Oh, sensory processing challenge must be autism even though we know the sensory piece is huge for ADHD as well. And so our accuracy is not going to be very good if we just assume we see sensory processing, for example, and assuming it’s autism without looking at anything else. So we don’t want to do that.
And the ADOS and ADI, unfortunately they are limited assessments. And so, people get really fixated on getting a fixed diagnosis. And concluding exactly what you were saying, that categorical, yes you are autistic or no you are not. And then they [00:52:00] end up missing so much and that’s overshadowing. So if we’re doing assessments, I can’t emphasize this enough, I know I said it last time. We have to look at both autism and ADHD. You cannot look at one without the other.
In my clinic, and it sounds like it’s similar to your clinic, we work as a team. I think everyone even listening probably has more experience working with ADHD than autism. I think that’s part of the problem. But in my clinic, not everyone is an expert in autism, but as soon as they see some flags, they bring me in. So we’re working as a team. Even if they know ADHD better, just to make sure nothing’s getting missed.
And so knowing what ADHD looks like, what autism looks like, and what neurotypicals look like, that’s going to be really important. And so we got to think critically and start looking at some of these subtle differences. And I’m going to be talking about interpretation as well. So you just [00:53:00] can’t wait until you get more experience. I know some of my clinicians right now, they’ve had all the training and they’re just waiting for the next assessment to get a little bit more experience. I’m like, no, go out there, watch YouTube videos, watch vlogs of these autistic people. You got to get out there and start observing people of ADHDers, of autistic people, of neurotypical kids. There’s lots of things that you can be doing. Don’t just wait from one assessment to the next.
So we’ve got the overshadowing. There’s also diagnostic substitution, which I also see all the time too. Again, sensory issues is just the big one. That’s the easy one that I find becomes the problem. And so the substitution and overshadowing is very similar, where we’re either missing something or assuming it’s one thing and not the other.
So when we go through the process, we’re just really remembering that there’s so many [00:54:00] things why a child or influencing why a child might present behaviorally. So we just got to make sure we’re looking at the whole context. We’re not looking at a diagnosis. And I think a lot of us take a diagnosis centered approach. We cannot do that. So we’re going in to look, yes you do or do not have autism. We need such a broader assessment. We can’t just…
And I see it all the time where people are just doing the ADOS and ADI and that’s it. They’re not looking at cognition. They’re not looking at behavior or language or adaptive functioning or motor skills or sensory processing, considering trauma, looking at family history, all of those pieces are really important. What are these kids’ strengths? What are their differences? What are their skills to work on? How do we optimize their success? Those are parts that we should be doing anyway. But if you’re only doing one instrument or two instruments to look at, yes or no, that’s a [00:55:00] diagnostic centered approach and we just want to avoid that.
So we got to come into it with an open mind. We can’t go into the assessment intent on finding a label especially something like autism, right? So it’s taking a transdiagnostic approach where we’re looking at the lived experiences of the kids. That’s going to be way more helpful anyways when we get to intervention. So it’s not for the labels.
And I know in my, before when I was on your podcast talking about the assessment process, I actually don’t read intake forms. I actually don’t even want to know what’s going on so that I’m coming with an open mind. I am looking at…
Autism is a little bit different because obviously I do have to start looking at things for sure to implement into my assessment process, but the first time I meet a kid, I want to come in with a clean slate, not even knowing what’s going on, because we are very easily biased. And even [00:56:00] though we as professionals, it can be really easy to fall into confirmation bias. So just asking parents and teachers, looking at areas just to cross all of the different dimensions. I know it can get overwhelming, but it’s really important that we’re looking at all areas. So a wide range of things.
Looking for the patterns. That’s what I’m looking for. It’s not a symptom count, it’s looking for the patterns of differences from what we would expect developmentally. So taking that normal curve, what is deviating from that across a lot of different dimensions. So that’s going to be really important. It’s really important too, as best as we can, getting information from when they were babies from that infancy because before they start learning skills, I don’t know about you, but I have parents who are like, we taught this kid eye contact. We were always teaching them eye contact, so now it looks beautiful, right?
When they’re at babies, they haven’t learned skills, they haven’t learned to mask, they haven’t [00:57:00] learned those coping strategies. So asking questions, what were they like as a baby? Were they totally engaging and smiling and laughing and happy? And would they follow you around the room as you walked around the room? Or if they saw a cat for the first time, would they look back at you and be like, what is this? Am I safe? So you want to get those.
So getting them to watch videos again, or I have them send me lots of videos from baby, toddler years, preschool, kindergarten, like give me a little clip it so I can see some of that. So any historical data that we can get on eye contact and that engagement can be really helpful. A lot of the questions they do covering the ADI is still really important. I’m often prepping parents too so that they know when we go into the interview, the kinds of things that I’m going to be looking for.
So for them to watch videos and to look at pictures just to help them get their head wrapped around, okay, I want to come in because oftentimes, they’ll be like, oh, I [00:58:00] can’t really remember. Well, it’s hard to get really thick, rich details if they don’t know, right? And if they don’t know, then I give them homework.
I want to set up these different situations, so I want you to ignore them. Maybe they’re like, hey dad, dad?. How do they get your attention? Are they changing their strategy? Are they coming? Are they looking at you or are they just sitting where they are yelling, right? So giving them different things for homework too if they don’t know can be really helpful.
So we definitely want to hear all of those different clues that we can. And one clue that I really listened to is the yeah, but. So they might say he talked late, yeah but his sister always talked for him. So it was probably just that. Or yeah, can play great with sisters. So no imaginative play. The play looks [00:59:00] fantastic with a sister. With other kids though it all falls apart.
So if they try to explain away a challenge that their kid has with the yeah but, those are some clues that we really want to look into. We can’t just take the kid that comes into our office at face value; we got to look globally elsewhere.
And so how are they presenting in different situations? How are they when they’re comfortable versus when there’s some demands put on them- some stressors put on them in a fast-paced environment, right?
Even within our testing though, you might see some differences. So social skills, I find cognitive testing, they usually do awesome. They look great. They’re engaging because we’re doing these academic predictable types of tasks. They don’t know necessarily what they are.
I always do play dates. I don’t ever just see them with me because a lot of our kids look great with adults but it [01:00:00] all falls apart when they’re with same age peers. And so I’ll get videotapes of play dates, but I’ll also bring in new peers into the office and have a play date. So now there’s an unfamiliar peer here.
Sometimes if I’m doing assessments with two kids, I’ll bring in two of them. Bring them together. It’s really interesting actually because I was doing three and I brought all three girls in. So I had one neurotypical girl and all the other three, so she was the fourth, neurotypical girl and then three who were all, I was looking at autism and I could almost right away pick out. Oh, my gosh. You are ADHD for sure. Oh, my gosh. I can see the autism now. I get them to do improvisation kinds of things. So this is where we’re thinking outside the box, but I had them do improvisation game. Oh, my gosh, it was so interesting to see the differences. But those little pieces that I wouldn’t have gotten otherwise, the social referencing, me, social referencing [01:01:00] each other. It’s quite interesting.
Dr. Sharp: Can I ask more about that?
Dr. Caroline: Yeah.
Dr. Sharp: That’s interesting to me. Certainly this whole process. I think about logistics a lot and I’m just curious how you set this up. Do you purposefully schedule kids on the same day? And I imagine there’s a psychometrist involved if you’re somehow seeing 3 kids at once.
Dr. Caroline: Oh, not all at the same time yet. Okay, I’ll get that.
Dr. Sharp: Okay. I just have so many questions about how this actually plays out. Do parents give consent for their kids to meet other kids there? I could see privacy stuff. How do you set all of this up? This is interesting.
Dr. Caroline: I don’t come into it saying, oh, I’m doing these three. No, no. It’s after I’ve already seen them. I’ve already done my [01:02:00] testing, but I want to now see them with other kids. So with these three girls, I wasn’t seeing them at the exact same time. It’s just over, like right now, they’re going through the process, and I usually see them over…
I don’t see them in one day. I usually see them over three different sessions. But once I go through my pieces, then I will look at the opportunity to either have parents, that’s usually what I do, is have parents videotape their kid in a play date with other kids. That’s usually what I try to do. But if I’ve got kids around the same age, then I’ll ask permission and I’ll say, hey, I’ve got Friday morning open at 10.00, this is my idea and then I get written permission for parents to do that. So some certainly will say, no, don’t want to do it. Totally fine.
My justification is I just want to see them with other children and new children because even if I get a video of them with their sibling or with a play date, it’s [01:03:00] probably kids that they know ,that they’re familiar with, who have similar interests. And it’s snippets. I don’t get to see a whole play date. Parents will only do that.
So that’s the logistics. It’s just say saying, hey, this is another opportunity for me to see your kid in a different context with different children. If you’re interested, let me know. Here’s a consent form for that. And making sure privacy, no other children’s names are ever shared or anything and I let them play. So I just get to sit back and I’m an observer writing.
I”ll set up different things. I usually have them start with something easy like a board game. Usually it’s pretty good, but I get to see what their turn taking is like, if they’re looking at each other during different… So I start with something easy but then at one point, especially with my girls, I’ll take any games away and they have to come up with their [01:04:00] own. So who’s taking the lead? The neurotypicals, I usually say don’t say anything like you’re a follower. So I usually coach them because oftentimes if I don’t do that, they will just pick up and take over or that bossy ADHDers will too sometimes. So I’ll coach. And if I see one kid always taking over, I will step in and say, hey, this is your role for the next activity. And then the improvisation. The improvisation, I’m a little bit more engaged because I’m setting up the activity for them that way.
Dr. Sharp: Great. Thanks for digging into that.
Dr. Caroline: It’s all qualitative information. I really want as much qualitative information as I can get. We need quantity and quality, right? It’s not just a simple symptom count because there’s so many problems, and I’ll be getting into some of the tools.
We got to make sure too, again, this is getting really thick. [01:05:00] So parents will say, oh, they’re so generous. They’re so good at sharing. But we got to think, are they really truly thinking about the other person or is it a rule? If I have a cookie, I must give my sibling a cookie and so therefore I must share. So they might always be sharing, but is it because of fairness or is it because of I genuinely want you to have this cookie so we can share this moment together, right? So it’s looking at those things.
If they’re comforting their little sibling who’s freaking out crying, is it because they’re actually like, oh, my gosh, I want you to feel better. Or is it, oh, my gosh, you are so loud and it’s overwhelming. I want you to be quiet.
Dr. Sharp: Yes.
Dr. Caroline: Yeah, exactly. So it’s looking at all of those types of things. Can they respond appropriately if someone is very obviously mad at them because they’re yelling at them, but have no idea if someone’s disappointed or if they just hurt somebody’s feelings. In conversation, [00:06:00] are they talking about things only that they’re interested in? What would happen if you start talking about something that you’re interested in? So it’s really looking.
I think parents are like, yeah, they can totally have a conversation. Okay, but what if you started talking about your day? And I will ask them, do your kids ask you about your day because neurotypical kids do. How is your day daddy? And do they do that? I don’t think they realize the clinical significance. Like, oh yeah, they can totally engage, but about what, and is it about a few two things that they have experience with or can they really have that flexibility with lots of different things?
So experience is so important when we’re looking at how do we conceptualize ADHD. How do we concept conceptualize autism? Really it’s experience and we have to interpret the information correctly. It’s not [01:07:00] a symptom count. It’s about interpreting the information well, because a lot of the typical, gold standard tools that we use to follow, they follow the DSM but not actually what autism looks like. They’re not following autism. It’s just about do you meet these criteria? And that’s that diagnosis-centered approach.
And so we know, yes, there’s those classic symptoms like all our red flags, the reduced eye contact, the peering out of the side of their eyes, all of those kinds of things but we got to look at those pink flags too and look at the splinter skills. How they might be brilliant. Like I had one kid, brilliant with aquatic animals, could name every, and even doing, I think it was the EVT with them. And he told me not just that it was a pelican, but the exact kind of pelican or whatever animal that was in there but then can’t label a spoon. So that’s another example of some of those [01:08:00] splinter skills.
So we just got to look, dig a little deeper if we do see some of those pink flags, how things are manifesting. Looking at the attention, everything that I’ve already talked about. The emotional reciprocity. Is it because of inattention or because they actually don’t really know, right? So everything that I’ve already talked about. So yeah, we’re screening for both.
Now when we’re looking at the assessment, we already know all the basic things. We can’t rely on one person, one tool. None of the assessment tools are great anyways if we use them on our own. I think I could do another episode just picking apart all the different assessment tools.
Dr. Sharp: Oh, for sure. Yeah.
Dr. Caroline: I am going to talk a little about specific instruments and how we can modify them and look at them, but I can’t dig into all of them. I’ll just talk briefly.
Dr. Sharp: Yeah.
Dr. Caroline: I do always use autism screeners. If we want to look at both, that’s really important. [01:09:00] I often use them as part of the interview, especially if I’ve got my teenage girls or adults because it can be really hard to interpret some of those questions and we can never take a score at face value.
I actually don’t ever look at the score at first. I’m looking at their actual individual items on everything just to see how they’re responding, because if we’re just focusing on the score, we’re at a huge risk for misdiagnosis. And I get so much valuable information anyways from those in those individual items. But it’s really easy for them to misinterpret things because in almost all of those rating scales, they’re using neurotypical language that can be really hard for an autistic brain, for example, to understand and maybe they don’t respond for the same reason how we intended.
One of the popular questions is, I can’t put myself into somebody else’s shoes.
Dr. Sharp: If you take that literally, [01:10:00] that’s very hard to answer.
Dr. Caroline: Exactly. Like, well, what shoe size do they wear? Are they a 9? Because I’m a 9e, so I could put myself into their shoes if they’re a nine, but I wouldn’t be able to if it was an 8. And so, I really like using it as an interview. And so I see a huge amount of our ADHDers too over-identifying with symptoms of autism. And so that’s why I like, again, to really pick it apart. Oftentimes, they’re over-identifying because of how demanding it is to live with ADHD and all the executive functioning deficits they have. So they’re more likely to respond high on different self-report questionnaires.
And so even with others responding, they’ll see those deficits and they still come out high on autistic scale. We got to be really careful. And a lot of those instruments, they don’t differentiate between ADHD and autism, right? So a lot of our ADHDers do, like on the [01:11:00] BASC or CBRS, almost all of them are autistic based on those.
And when we look at the SRS, the Social Responsiveness Scale, it’s more about the behavioral pieces than the social behavior. And so it’s not great. ADHDers will look autistic on things like that. They probably won’t look autistic on a CAARS or a Gilliam Asperger’s Rating Scales, but it doesn’t capture their internal experiences either.
I do love the Autism Quotient because it really looks at how it feels to be autistic. The CAT-Q, I know you’ve talked about some of these things on your podcast before, that’s great for masking. And again, those are things that I really use as an interview to get into some of that. Repetitive Behaviour Questionnaire that can be useful to look at the repetitive behaviors for adults. And I do modify some of those in my interviews to ask for parents with children and teens as well.
I love the RAADS. [01:12:00] I think that that’s really good. I give it to all my teens. I give it to my adults. Sometimes I’ll give it to parents as well, just to pretend you’re your child. And I don’t have as many false positives that I see with ADHD with other rating skills, so I really like that one.
The Social Communication Questionnaire, it’s essentially an abbreviated ADI anyways. So it might be okay if a parent’s bringing a kid in for ADHD if we’re going to use it as a screen for autism, but if they’re already wondering about autism, it’s not going to be great for differential diagnosis.
I could go into all other comorbidities because it’s a problem. If we’ve got lower IQ kids, for example, that rating scale, it’s not good for younger kids or older kids or adults. It actually misses a lot of them, so if we are using something like that, we want to just change the cutoff [01:13:00] scores. Even with the RAADS, I changed the cutoff scores a little bit more because we don’t want to have too many false positives or vice versa.
I’m just starting to use, I don’t know if you’ve heard about this one or used it, but the Alexithymia Questionnaire.
Dr. Sharp: Oh, yeah. What do you think of them?
Dr. Caroline: I’m just starting to incorporate it. It’s pretty good. So that inability to recognize our own emotions, which is common amongst our autistics. It is true for ADHD too, but I do find it with the autistic population a little bit more. So I do like that one.
Atwood’s Girls Questionnaire. It reflects the girls presentation of all the different areas, the play, the masking, the sensory sensitivities, all of those kinds of things. It’s looking at what is out there, how is this kid presenting? You can’t just say, this is my battery for every child because it’s going to be different.
I wouldn’t need to do the CAT-Q if I’ve [01:14:00] got a classically stereotypical boy who’s coming in. So it’s really individualizing and we know that we need to individualize for everybody as well. And same thing if we were bringing in a kid for autism, we still want to screen for ADHD. So there’s those ADHD screeners that need to be part of it. For adults, the ASRS.
Some of those freebie ones can actually be pretty good. The WEISS Functional Impairment Scale, Wender Utah ADHD Rating Scale. I do like Conners and CBRS. I really don’t like the BASC. So those are my go-to there. But there are freebies like the Vanderbilt ADHD scales, and other freebie as well.
Once we get to the behavioral observation piece, it’s hard to solely rely on the ADOS. And I know you’ve talked about the ADOS lots on your podcast and I think a lot of us know some of the holes in it. I don’t know what it’s like there, but here you really do still need to do an ADOS and an ADI for [01:15:00] funding agencies to recognise the diagnosis. And if you don’t use those, they’ll be like, hmm, is it really autism or is it really not autism? So I still use it.
Definitely picks up autism better in men, obviously that’s primarily what the samples were developed, that tool is developed off them. So that makes sense. And there is a typical male phenotype of autism, but it excludes the girls.
So we can use it, but we have to understand that’s this is where that interpretation becomes really important. We have to be able to know, are they looking good to appear normal? Are they acting good? Faking good because we can’t observe the autism. And so the ADOS really isn’t good at differentiating. I’ll do it, but it’s not good at differentiating neurodevelopmental disorders. It’s great maybe for differentiating from neurotypicals, but not between ADHD.
So we get a lot of false positives, especially when you have someone who’s not very experienced and doesn’t [01:16:00] know the full range of what neurodevelopmental conditions look like or even how anxiety and depression can manifest as well. It’s just that piece in an ADHD DCD kid can look a lot like autism. So it’s knowing what that range looks like and knowing this is just one snapshot in time, 140 minutes or one hour that we’re doing.
For me, I love the using the ADOS for the qualitative information. There’s lots of things that I use the ADOS to explore. There is a lot of overlap with the ADOS and MIGDAS. I love the MIGDAS as well. I love bringing in the sensory materials. It’s so fascinating, especially with my women. I’m like, you’re looking fantastic. And then I bring out sensory stuff and it’s like, oh my goodness. I can see some of the stimmy things happening.
But I’m never hanging my hat on any anyone’s score for a final diagnosis because a lot of the scores, [01:17:00] it could be anxiety, it could be social inhibition, there could be so many different things. And so even things that we need to look at, so on the ADOS Module 1, for example, if you’ve got a kid who doesn’t do great, who scores high on Module 1, it could also be communication disorder. Module 2, it could be intellectual disability or ADHD. For Module 3, it could be ADHD or maybe you’re missing the repetitive behavior so it could look ADHD or oh sorry, it could look autistic, but be ADHD or we could miss the autism because it’s not capturing those repetitive behaviors that we would see in the Module 4 because there’s not a lot of opportunities, it’s a lot more interview. And so there’s lots of things to think about.
With the ADI, again, it doesn’t capture the female presentation. So the female differences in social communication disorders or the restricted behavior [01:18:00] section because it just looks a little bit different. The ADHDers can score really high on the ADI if they also have anxiety. So again, we got to really dig deep here. We know that ADI isn’t great for young kids either, it’s about using these but going in with a grain of salts, knowing what to look for, knowing how we’re going to interpret these things.
So it’s not about specific observable behaviors unless there’s obvious flags. Whatever instrument we use is we have to get at those personal experiences because what we see on the outside is not necessarily what’s actually happening on the inside, especially for our older kids and for our girls, right? And so that’s why the rating scale, so we can really just talk about it as an interview. It’s just getting behind the mask. That’s what we need to do, especially with our girls, right? It’s getting behind that mask as much as we can.
And [01:19:00] so listening for stories that they don’t fit in, that they don’t feel like they’re born on this planet, right? They feel like they’re on a different planet. That I love reading fiction and creating my own worlds because there I feel safe and there it’s predictable and there I don’t feel lonely, right? There’s all of these kinds of things. So we need to look at those.
I do ask directly about a lot of things. I ask about learn strategies. The CAT-Q is really good at digging into some of that. And I think we all have masking moments, even neurotypical people. You’ll have a meeting and will be like, oh, my gosh, did I just say that? Was it okay that I just said that? But for the autistic person, it’s every single conversation. Questioning, how do I hold myself? Where am I in position with the other person? What about what I’m wearing? Is this appropriate? How I’m talking? The words [00:20:00] that I’m saying, where do I put my hands? How should I respond to this? All the time they’re thinking. How can I escape if I do get anxious? If things start going sideway? What is my cover story going to be if I have to run away? So it’s all about asking how much effort it’s going into any one experience that they have.
So I’m just asking them flat out about their eye contact. Their first reaction is usually the answer that I’m looking for. It doesn’t necessarily matter what they say, it’s just how they react. So when I say, and there’s been times I’m like, are you actually looking at me or where are you looking right now because I can’t tell? Because they might be looking at my forehead or just a lot of the girls will look just past me and what does it feel like if you do look at me? So asking them, let’s chat about that. An ADHD girl will be like, what are you talking about? They’ve never thought about it before. But my autistic girls, I find really do, they have a different experience?
I had one who, this was [01:21:00] a young female, so in her early 20s, who had an algorithm. So she would count for 20 seconds, and so there’d be 20 seconds between every blink, and then there would be so many seconds between how often she looked away. So it’s not like she was staring intently. Oh, my gosh, how effortful is that? To try to pay attention to whoever’s talking plus counting in your head and to remember what eye pattern you’re using. So she’s really thought about it.
I worked with a woman fairly recently too, who described eye contact as though she was standing in front of someone naked. It’s that discomfort. That’s what it felt like. And so it’s looking at those experiences, not everyone will have an experience, but it’s important to look at common sense things. I hate using the word, like I said, weird. I hate using it. I hate using the word context blind, but it is this insensitivity to context that’s so [01:22:00] obvious.
So for example, if I say to okay, Jeremy, let’s go for drinks for Friday. And you’re like, yeah, sure, great. And I say, okay, cool. I’ll pick you up at nine. Awesome. Done. Right? Autistic person would say, morning or night? And so that’s just a really simple example of that sort of context piece. And I see it all the time.
I was just working with a kid not too long ago. The clarification, what do you mean? It all depends. Every question is, what do you mean? It depends, am I with my mom? Am I at home? Am I with my teacher? Like this one kid, literally everything that came out of my mouth, he was clarifying. And I said, what’s your favorite class? And he’s like, what do you mean? I’m only in one class, but he was thinking the classroom. And then later on he’s like, did you mean subjects? So just not thinking about, so everything depended on something else because the [01:23:00] context isn’t clear. And I see that for… He was to an extreme with everything. No context was clear at all, but for a lot of people that could be really challenging. And so just everything it was clarifying.
I asked one woman about and this is now a standard question that I ask about is how she knows how to text, this was a few years ago, because she was getting stressed. Someone had texted her and she’s getting stressed out about, do I respond now? And I said, well, how do you figure out how you respond to texts? And so it’s been amazing. I’ve actually asked this question as part of my standard battery is how do you know? And it’s fascinating to hear. My ADHDers are like, right away, as soon as I get it, but some track right down to the minute. So they have algorithms for different people and based on relationships, this was the most intricate.
So if it was a coworker versus a casual friend that I’ve gone out one once or twice [01:24:00] with versus someone that I’d like and so had made algorithms based on how the other person was responding to their texts. And so created this grid on, okay, for this person or this kind of relationship, you wait two hours. For this kind of relationship, you might wait two days and know the intricate, but just creating all of these algorithms to try to figure out social context. But it’s really hard because there’s so many rules.
How I present with you, Jeremy, today, is going to be different within how I present with a person that I’m meeting for the first time in person versus a boss in an interview. And it could even be like with my grandmother, this is how I present with grandmother but it changes from one minute to the next. Maybe she just got off the phone and had really bad news and now the whole context, the whole scenario has changed. And now I don’t know how to respond. There’s just so much. It’s just so exhausting.
And so our brain, we’ve [01:25:00] got, there’s a great book actually, I think it’s called The Influence of Psychology, and he talks about the shortcuts that we have in our brains to help us process information and how to make decisions. And there’s context and it helps us figure out really complex situations and ambiguous situations really quickly. So we’ve got these shortcuts and I think a lot of autistic people don’t have those little shortcuts. They actually do have to think of every situation.
So just as a really simple example is, he talks at the beginning of the book about turkeys. Mother turkeys, as long as her little baby goes chirp, chirp, she will take in that little baby and protect it. And so they had stuffed mold cats. They put one in, mold cat into, it was just a stuffed one into their little layer, I don’t know, their den and the [01:26:00] turkey mom attacked it right away. But then the researchers put a little tape recorder in the small cat, exact same old cat, but it said chirp, chirp. And the turkey actually took it in. So that chirp, chirp was that shortcut. I don’t have to think about the length and the size and the color and the shape and the smell. It’s just chirp, chirp, automatic I’m going to take it in. And so it’s that, right?
My daughter was just talking about the Truman Show the other day, and I’m like, that’s maybe what autism is. Everybody else has the script. Everybody else knows their position, they know what they’re supposed to say and do, but the autistic person is coming in and it’s like they don’t have the script. And they’re trying to ad lib and they’re trying to figure things out and figure out what’s going on. And I think for a lot of them, that’s what the world feels like.
And so it’s getting at that experience. How do you figure out the rules? When everybody’s got a script, how do you figure that [01:27:00] out? So it’s just looking at little things that come up spontaneously. I’ve got elephants everywhere in my office and a lot of my ADHD kids and neurotypical kids like, wow, you must really like elephants. That’s it. So my autistic kids though, will say, oh, you’ve got 22 elephants in here. So little things, really little subtle things that we’re just taking all of that. It’s just they were the matter of fact. It’s not the social component. So I’m always looking for those little spontaneous things that come up as well.
I love doing optical illusion. So these are some of the extra things that I’m adding into my assessment process just to see how they respond. So if you have like one is there’s two cups. One, it looks way bigger and one looks way smaller, but they’re both exactly the same size. It’s just the different perspective. The ADHDer usually enjoys this, like this is [01:28:00] awesome. They find it really stimulating. They might have some questions, but not like the autistic kids who are like no, that’s not true. I can clearly see that if we get a ruler, this one is going to measure very differently. They just want to get into the logistics and argument of it.
I’ll ask questions too. Are dinosaurs extinct? And I’ve actually stopped asking this one because it just drives me nuts now, but because the autistic kids will tell me all the reasons why I’m actually wrong when I say, no, they’re not extinct because birds are still, and then they will go into all the factual information about the lineage or whatever. And oftentimes it’s just hard for them to really answer. ADHDers will just go with the automatic, that one looks bigger. It’s really hard for the autistic. It all depends. They might go deep they just get too logical with it. So I like throwing those pieces in as well. [01:29:00] Just those kinds of questions. The dinosaur one I’ve dropped though, because I can get into like 5-hour discussions with kids about it.
Dr. Sharp: That’s a dangerous one.
Dr. Caroline: Yeah. So just fun little things that we add on to the different kinds of things too. I know this is another tool that you use as well or have talked about on your podcast. I don’t know if you use it, but you’ve talked about it. The Social Language Development Test. I use that for additional information. It can be lengthy, so I don’t necessarily use it all the way through, for some I do, but it’s all about how they’re interacting things.
I also bring in some of my own pictures because when we look at eye tracking research, our autistic kids can actually look at one person in a picture and respond to whatever question we have pretty good, even if it’s a social situation, but if they add more people, more than one person into a picture, now it gets really [01:30:00] complex. And so I like to show some socially complex pictures because they’re not as likely to pay attention because it’s harder for them to know what’s the important information to look at here.
And so I think that looking at those different things can be helpful. And even how people are feeling, they can almost identify how they’re feeling, happy or sad. But as soon as someone’s got what looks like a smile, but it could be discussed, they’ll say, oh, he is happy. Well, why is he happy? And they have a hard time looking at context. And one of the pictures, the girl is clearly scared. She’s down a dark alley, she’s clearly scared, and it’s, oh, she’s excited. Not looking at the bigger picture, just looking at one aspect of the face, maybe the wide eyes, oh, she’s excited. And so just missing on some of those details, again, it’s just all that qualitative information.
We just can’t take everything at face value. It’s really understanding, getting some of [01:31:00] their explanation. One thing that I do want to say is if you are looking at ADHD and autism, you can’t count the same symptom across both. So if sensory processing, and I think that’s common sense, but I don’t know if everybody necessarily does that. So they have to be independent. And so if you are going to use sensory processing as a hit, you can’t use it for both ADHD and autism. You got to use it for one or the other and justify your decision for why you’re making it. And so if we’re rating a restless, repetitive leg movement that jiggle, if we’re rating it for ADHD for hyperactivity, we can’t also use it for repetitive for autism.
Adaptive functioning, I think we all know that we need to really be looking at adaptive functioning. That’s important. I know we’re running out of time. Feedback and recommendations. I had a whole other section on that, but I think the biggest thing is maybe going back [01:32:00] to the previous episodes, not from last week, but just around the assessment process about how to bring along parents. We need to make sure they take up the information, whatever information that they give. So I let them know through the process what I’m seeing. I’m not leave leaving in the big reveal to the end because they’re going to be so overwhelmed with the motion.
And so by the end, that feedback meeting, it’s really about we already know what’s going on. Now let’s get into the recommendations. And so we really want to make sure because they’ll hold a brave face, right? They’ll be so brave and hold it all in. Maybe there’ll be some tears, but it’s so hard to process any information.
And so the biggest thing is if we’ve really gotten that qualitative information, we’ve really taken the time to figure out what’s going on. They are feeling better because they’re feeling hurt. They feel like you haven’t done a rush job. You’ve heard my story and now we can use that information to say, okay, [01:33:00] this is how I’m justifying. So autism because, hey, remember when you told me this story? Now we can start explaining those everyday experiences that they’ve had.
We don’t want to broadly say, this is what autism is, and so they have difficulties with social communication and repetitive behaviors. It’s going into those little details that parents have already told us so they can really understand their kid. And that’s helpful because oftentimes we all have one picture of what an ADHD kid or a Rain Man autistic kid would look like. And they’re like, that’s not my kid. And so we’re using their information to show them it is a spectrum, right? It is so different from one child to the next. And so it’s this collaboration and checking in, does this make sense to you? How do you see this play out in everyday behavior? What do you notice? So it’s a lot of those kinds of things.
Just getting down, I think it’s [01:34:00] important just to talk about prognosis because I think parents will ask about, what does this mean for my kid for the future? Will my kid go to college? Will they get married? Will they have a family? Can they live on their own? It’s really hard to answer, right? And I talk about that and especially with younger kids and especially if there’s cognitive delays. So talking about, broadly, the prognosis with supports. We see better outcomes with kids who have this supportive environment and are working on these skills but never any hard and fast.
Yes, they will go to college. We can never give that kind of profile, but based on your kid’s strengths, these are some of the things that I can see if we continue working on these skills and intervention looks different when they start at two or three versus 18 depending on when you’re coming in for this. So looking at what will support their success. I can’t give them the outcome, but [01:35:00] what are the things that we can do to optimize their success? That’s what I’m focusing on.
Man, there’s so much, Jeremy. I tried to stay on schedule, but I just ran out, so we didn’t get into recommendations, but I think that gives you a big, broad overview of at least what to look for in the assessment.
Dr. Sharp: Yeah. No, I think this is a great job over these past two episodes trying to pull together a pretty complex topic and diving deep enough. I think there’s lots to take away from each of these episodes and things that folks can put into practice right away without being overwhelming. I think you just struck the balance. And there’s always more, right?
Dr. Caroline: There always is. Yeah. And that’s why I’ve got, I do have the training. Actually, I’ll send you a coupon code if anybody wants to for 25% off the training. [01:36:00] And then we can deep dive into all of this a little bit more because this is just the surface, but at least things to start thinking about that we can, one little thing that we can tweak in our assessment.
Dr. Sharp: Yeah, absolutely. I think that’s the name of the game. Well appreciate again,. You’ve done two double episodes now on these different topics. I’m just really grateful that you took the time to come and share all of this with us. It’s such an important topic to dive into. It fits really well. I’ve done a lot of differential diagnostic episodes here lately, and I think that’s, as things get more complex and we see these tougher cases, that’s really important. So thank you.
Dr. Caroline: Well, thank you for having me.
Dr. Sharp: Absolutely.
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 [01:37:00] 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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