Identifying Autism Spectrum Disorder

Mental Health Awareness

Thanks to social media platforms, like TikTok, awareness is being raised about a variety of mental health disorders, most recently autism, dissociative identity disorder, and ADHD. Mental health professionals, especially testing psychologists, are seeing an uptick in requests for evaluations by people who believe they have one of these disorders. I personally am excited to see more people talk about mental health so that we can remove the mystery and stigma that continues to be pervasive in our society despite the growing prevalence of mental health problems. I am thrilled to see people are seeking to better understand themselves and accessing resources that will help them to answer what are often lifelong questions of “Why am I the way I am?” and “Why do I do what I do?”. One of the reasons I enjoy psychological testing so much is that I get to help people answer those questions.

While I applaud and support efforts to raise awareness on social media platforms, there is growing concern among mental health professionals about the abundance of misinformation being shared. Too often, how disorders are being described are watered down or limiting. Diagnosis of a psychological disorder must be done by a skilled clinician because it requires a proper assessment and a comprehensive understanding of the nuances and range in which a disorder develops. The boon of awareness raising has also brought with it too many people latching on to a label or diagnosis without a proper assessment.

ASD

One such diagnosis is autism spectrum disorder (ASD). ASD is a neurodevelopmental disorder with symptoms of impaired social communication and repetitive/restricted behaviors that result in clinically significant functional impairment. Research indicates that 1 out of 68 children in the U.S. have ASD, and it is thought to be 4x more likely to occur in boys than girls. One unique aspect of ASD that separates it from other psychiatric and neurodevelopmental conditions is that it is quite extreme in the way it presents. Like many other conditions and disorders, there tends to be a range in the ways the condition can present, but ASD is highly variable. This variability can make ASD difficult to identify people who may have it.

ASD in Girls

It can be particularly difficult to identify girls with ASD. Girls with autism are likely to be diagnosed later than boys, by almost 2-3 years; in part because autism is associated with boys, and in part because the way in which autism manifests in girls is different than boys. For example, girls with autism tend to be social, have fewer behavioral issues, and have less fixed interests, especially in the early developmental years. Social communication challenges are handled through camouflaging which allows a child to contain anxiety and mimic socially accepted behavior. As a child grows, and social interactions become more complex and demanding, it becomes more difficult to camouflage.

Symptoms

There is no one symptom that unequivocally indicates that ASD is present or absent, but there are several “red flags” (classic symptoms), particularly in individuals who are more severely impacted by ASD. In more recent research aimed at greater accuracy in diagnosis, “pink flags”, or the more subtle features, are being identified and studied (Duvall et al, 2021).

Red flagged symptoms include reduced eye contact from a young age across all settings, restricted interests/play, sensory seeking behaviors, repetitive movements, cognitive rigidity/inflexibility, poor reciprocity in relationships, and seeks relationships for practical purposes (this is not an exhaustive list). Pink flag symptoms/behaviors are not as obvious but important to look for when assessing for ASD. Some examples include an inflexible thinking style, difficulties with transitions, lower than typical daily living skills despite strong intellectual abilities, non-specific repetitive movements, niche areas of interest, some sensory sensitivity, difficulty understanding and/or expressing emotions, scripted communication patterns, and difficulty understanding the nuances of social communication (also not an exhaustive list).

Without the more obvious red flag symptoms/behaviors, particularly early in childhood, it can be difficult to identify a child with ASD. Additionally, many of the pink flags can reflect normal development and may be better explained by another disorder. For example, many of the social and emotional challenges experienced by people with the less severe features of ASD are experienced by people with ADHD. Individuals with ADHD often have difficulty reading social cues, inferring the emotional states of others, and engaging in reciprocal conversations. Tic disorders share features with ASD, as do sensory and motor disorders, intellectual disabilities, and depression and anxiety.

The Power of Assessment

As you read this short blog, I hope you get the sense that there is much to consider when determining whether a person has ASD.  It is not something that should be done without professional guidance from a qualified clinician. A thorough psychological assessment, at a minimum, will identify the presence (or absence) of red and pink flags and consider developmental history, biopsychosocial functioning, and collateral data from loved ones. Answering the questions of “Why am I the way I am?” and “Why do I do what I do?” can be incredibly empowering. Trust your intuition, but it is important to not latch onto one label or diagnosis. Instead, approach the assessment process with openness and curiosity. You never know what you will discover about yourself.

Duvall, S., Armstrong, K., Shahabuddin, A., Grantz, C., Fein, D., & Lord, C. (2021). “A road map for identifying autism spectrum disorder: recognizing and evaluating characteristics that should raise red or “pink” flags that guide accurate differential diagnosis”. The Clinical Neuropsychologist,  doi: 10.1080/13854046.2021.1921276