November 1, 2025 • 55 mins
Guest: Dr. Gregory James Skinner, M.D., a Calgary-based family physician and leading advocate for accessible adult autism diagnosis.
Dr. Skinner shares his remarkable journey through international medical training, his personal connection to autism, and the challenges he faced building one of the few medical practices in Canada specializing in adult autism assessment. His story highlights the urgent need for better access, validation, and understanding for autistic adults who are often overlooked or dismissed.
Key Quotes:
“Autism isn’t invisible—it’s a visible neuro-minority. People see it, but it’s misunderstood.” – Dr. Gregory Skinner
“Diagnosis is not about weakness—it’s about validation, recognition, and access to support.” – Dr. Gregory Skinner
Resources & Links:
Learn more about Dr. Skinner’s Clinic, Autism Exists Diagnosis Clinic - https://www.autismexists.com
Visit Lives in the Balance to explore Dr. Ross Greene’s collaborative approach to care - https://livesinthebalance.org
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Paul Cruz (00:05):
Hello and welcome to the Neurodiversity Voices
podcast. I'm your host Paul Cruzand I'm thrilled to have you
join me on this journey ofexploration, advocacy, and
celebration of neurodiversity.Together, we'll have meaningful
conversations, share inspiringstories, and challenge
misconceptions aboutneurodiversity. This podcast is
(00:28):
for everyone, whether you'reneurodivergent yourself, an
educator, a parent, or justsomeone curious to learn more.
My goal is to amplify voices,foster understanding, and spark
change in the way we view andsupport neurodiversity.
I'm so excited to have you as wecelebrate the beauty of diverse
minds and work toward a moreinclusive future. So sit back,
(00:53):
relax, and let's get started.Welcome to the Neurodiversity
Voices podcast.
(01:16):
Today I'm joined by Doctor.Gregory James Skinner, a Calgary
based family physician who hasbecome a leading voice in adult
autism diagnosis. His journeyspans international medical
training in Europe, TheCaribbean, and Canada, and his
career took a meaningful turnwhen he recognized a major gap
(01:39):
in services for adults seekingan autism diagnosis. Doctor.
Skinner, welcome to the show andthank you for being here.
Dr. Gregory Skinner: thank you for having me, Paul. (01:51):
undefined
Paul Cruz (01:51):
Can you describe your journey through medical school
and how you eventuallyspecialized in adult autism
diagnosis.
Dr. Gregory Skinner (02:00):
Well, autism wasn't something that
really came up in medicalschool. In fact, I'm not even
sure I ever heard the wordautism. Psychiatry tended to
focus on the core issues,depression, anxiety, not even
really into the personalitydisorders. I started my
schooling in Europe, in TheCzech Republic, and I completed
(02:21):
four years there. And Itransferred to one of the feeder
schools for The USA, studying upand down the East Coast Of The
US for the core rotations.
Graduated with my medical degreefrom Saba University. I was able
to secure a residency as aforeign graduate in Manitoba and
(02:42):
I completed a standard two yearfamily residency there. That
left me ready to go into generalfamily practice, which I did for
a number of years, but it wouldbe later on after my son was
born when I started questioningif I would fit with the autism
spectrum and trying to do thatwithin medicine, lots of options
for psychology but doing itwithin the medical system, I had
(03:04):
five referrals dead end tonowhere. That was when I started
getting in identifying this asan area of need. Also, I wasn't
necessarily prepared to returnto a standard family practice at
that point.
So, I looked more and more intoautism assessment. We have, at
the University of Calgary, wehave the ACERT program. They run
(03:26):
the peers group for socialskills training and at the top
there we have Doctor. AdamMcCrennan, a psychologist, and
he recommended a specific autismassessment tool which I have
been using and adapting andadding more details to ever
since.
Paul Cruz (03:44):
How have your experiences across different
health care systems shaped theway you approach patients today?
Dr. Gregory Skinner (03:51):
So when I was in The States, depending on
the hospital, although we oftenhear about they have private
pay, there is a lot ofgovernment covered healthcare,
mostly emergency situations andhospitalizations. So it
certainly helped me realize thecost focus on it. I don't know
anybody who has 2,000 or $3,000just burning in their back
pocket that they were lookingfor something to spend it on and
(04:13):
yet that's what it winds upbeing when it comes to
psychology for autism. As a lowemployment group, I think The UK
National Survey put it at 16%full time employment compared to
pre pandemic Canadians had 66%full time employment, so that's
a difference of 50. They don'ttend to have insurance to help
(04:34):
cover those costs, so it is allout of pocket on a poorly
employed population.
So that actually helped with thedecision to not just leave it
with psychology because there'sjust no coverage for them. The
way I approach patients, I spentfour years in a country that I
do not speak their firstlanguage, so that helped me
understand the barriers aroundbeing understood in
(04:56):
communication and I guess autismwould be another reason for
people to struggle with thosesimilar barriers. It also helps
to recognize other people'schallenges that if you train
locally and work locally, youmay not ever experience in your
life. You may not have thatexperience for years of
struggling to get basic ideasacross, even while studying a
(05:17):
foreign language.
Paul Cruz (05:20):
What was the turning point that led you from family
medicine into building apractice focused on autism
diagnostics?
Dr. Gregory Skinner (05:29):
So for me personally, it would start with
that question, was I on theautism spectrum? And of course,
the answer remains maybe at thispoint, but at that time, with
all the difficulties of tryingto get the assessment, it was
also a key time in my life. Iwasn't returning to my previous
family practice after mypaternity leave, So I was
looking for a new direction andlooking to try something
(05:53):
different and certainly did findsomething different in doing
autism. So on the personal side,being unable to access service
and realizing that that mustapply to other people, looking
to you for more direction.
Paul Cruz (06:06):
Could you share what challenges you faced in creating
the Autism Exist DiagnosisClinic and what changes it's
brought for patients?
Dr. Gregory Skinner (06:17):
So challenges in creating the
clinic, certainly costs. It'snot as profitable business wise.
You can't really push peoplethrough quickly to try to keep
up with your overhead. So for anumber of years, I was working
alone and unsupported beyondsomebody managing the financing.
Well, I should say theaccounting would be a better
(06:37):
word.
So working mostly alone, tryingto manage both the phone calls,
the referrals, which for anumber of years I didn't I
eventually gave up because I wasgetting so many referrals and I
was spending more time tellingthem we're not a referral clinic
than it would take just toaccept the referrals. There's a
lot of barrier around otherpeople's beliefs, whether they
are professionals, medicalpersonnel, doctors or
(06:58):
psychologists, their personalbeliefs around autism or their
beliefs around a family doctordoesn't have the qualifications
to do that despite the fact thatI've got multiple hours,
multiple courses. I've taken theADOS and ADIR training, the two
tests that psychology generallyrelies on. So, disbelief that
the person in front of someonecould be autistic, you'll see a
(07:20):
lot of disbelief around it. Itoften feels like they don't
quite know, other people don'tquite know what this thing is
and they will use a minimum ofknowledge to make it so they
don't have to go any further.
They can just excuse themselvesbased on, You can't be autistic.
You made eye contact once. Yet,if you're smart and you get told
over and over and over and overas a child to make eye contact,
(07:44):
you might start making eyecontact even though you hate it
or struggle with it. So secondpart, what changes it's brought
for the patients? Again, ifpeople had lots of money or lots
of insurance, they might be ableto approach a private
psychologist for autism care.
For kids, there's lots of accessfor those things, but what about
for all the people who were inthe subtle but significant
(08:06):
range, the Level one socialcommunication where you might
not notice right away but overtime you might start to realize
this person is different? So,for those people, a lot of it's
validation. Some patients areconcerned they're autistic but
many more of them are convinced.Sometimes, even the way they
tell the story of what they didwhen they thought they could be
(08:27):
autistic and it became a newobsessive special interest or if
you're not autistic, what wewould call a passionate hobby. I
thought I might be autistic, soover the next couple of months,
I studied for hour after hourafter hour.
When they're bringing mearticles I've never heard of as
a part of their studies, I say,Okay. They're certainly showing
a deep, intense interest, apreoccupation with their new
(08:51):
area of autistic interest. So,of them are pre convinced and
they're just looking forvalidation. The fact that I'm
using a replicatable,transparent tool where you can
see what the decision was, notesbacking up why we made that
decision so that when somebodyelse offhandedly says, You can't
(09:11):
be autistic or You don't lookautistic, that's something that
I always love to hear peoplegetting told because autism
isn't a facial abnormality. It'snot an invisible difference.
It is a visible neuro minority.It's visible because these
people keep gettingdiscriminated on from jobs, so
people are seeing it, but it'snot color, it's not race, it's
(09:34):
not language, it's socialability, it's rigidity, it's
executive and adaptive problems.And people see it and people
marginalize people over it. Sopeople come to me and they find
out, yes, mostly yes or no,sometimes no, they're not
autistic, and then we try to atleast get them direction to what
(09:54):
we think it might be. Sometimespersonality disorders, sometimes
it's only ADHD.
I had at least one case where itwas only bipolar disorder. One
or twice that I've had peoplewho were only borderline,
although more often I thinkborderline was a placeholder for
they don't know what it is andwe remove that label or we tell
(10:16):
people, Congratulations, youlucked out and have both.
Unfortunately, though, they goexternally and they might get
their autism diagnosisinvalidated by a professional
and they might also have theprofessional hold steadfast onto
something that's still listed inthe hospital systems even though
we've gone through the criteriaof the label to prove they don't
(10:37):
have it, even when sometimes thediagnosis was made based on just
a few minutes of assessment inhospital and yet that is held
with more value than a formalreview of the criteria.
Paul Cruz (10:50):
Walk us through your diagnostic process. What makes
your approach unique compared totraditional assessments?
Dr. Gregory Skinner (10:59):
So a lot of the time, people are getting the
ADOS, which is a semi structuredinterview. By adulthood, a lot
of that's more about just theconversation. It's not involving
playing with toys, trying to getthem to respond with their name,
stuff like that. There's lessand less of that semi structured
interview that applies toadults. They also will do
(11:20):
typically the ADIR, which is theinterview of the parents, a
three hour structured interviewlooking for features that the
parents would identify.
In order to do that approach,though, psychologists are
required to do an IQ test todetermine where to send them
next. In terms of what I'musing, it's the first
recommendation in the NICEguidelines, N I C E, was at the
(11:43):
National Institute for HealthCommunication Excellence out of
England and they recommend forintellectually intact adults
using the adult Asperger's orautism assessment tool and it's
much more on the interviewstyle. Sometimes I do need to
extend out to relatives, topartners, to other people to get
(12:03):
additional information, but formost people, we can rely on self
assessment both in thequestionnaires and in the
discussion. The ADOS and theADIR have formal scoring sheets.
On the adult Asperger's orautism assessment.
It was a summary, Do you qualifyenough across the different
(12:24):
categories? What I'm doing evendifferent than that with my
Autism Spectrum Evaluation Tool,which is DSM-five, autism
spectrum disorder, update to theold Asperger's tool. The
symptoms are reordered. I'veadded in additional autism and
other questionnaires and itactually now breaks apart
multiple little features so thatwe can really make sure that
(12:47):
when we're talking aboutsomething like, Did you share as
a child? What does that mean?
Did you share food? Did youshare toys? If you saw something
interesting, would you bebringing it up to your mom or
your dad? You found like apencil and you're five and like,
Look, mom, isn't this cool?Versus you don't share those
things.
So, taking it apart at anin-depth level, trying to bring
(13:10):
this more accessible to more andmore people. My hope is that the
average psychologist with somebasic autism knowledge would be
able to do a fairly robust jobwith this tool and review all
the things that need to beconsidered rather than just an
off the hip, You look normal tome the first time I met you.
Diagnostic process, it is multihours. I think I'm averaging
(13:32):
nine hours assuming that theperson is good at organizing
themselves and it is justinterview. There's also a few
physical exams which all relatearound social.
For example, my decision on isyour posture socially normal?
So, proper good rigid posture,but actually the typical
(13:56):
comfortable slouch people do. SoI'm watching the eye contact,
how they use it, how theyrespond to being spoken to and a
few other things related tothat. Although a lot of those,
again, they may have learned tocamouflage as kids. So it's back
to the history, back to how theywere different as a kid, back
to, Are you thinking about eyecontact?
(14:19):
Versus most people who just makeeye contact. So, Paul, if you
are the average neurotypical notautistic person and I said,
What's your strategy for eyecontact? The average answer
should be something in theconfusion range of, Am I
supposed to have an answer forthat? Versus if you can tell me
what you're doing, Compare thatagainst the history, did people
(14:40):
get told about problems withtheir eye contact? Look at me,
look at me, look at me, you'renot paying attention.
For goodness sakes, look at me.Or more modernly, think about me
with your eyes. Your eyes arelike arrows.
Paul Cruz (14:53):
How do you handle cases where autism overlaps with
ADHD or other conditions likeBorder Personality Disorder?
Dr. Gregory Skinner (15:02):
So for ADHD, the current estimate is at
least fifty percent to seventypercent of people who have
autism spectrum disorder willqualify for ADHD. And that's a
change if you look at the DSMIV, they were talking about it
like you weren't allowed to haveboth. Some people, by the way,
were told they couldn't beautistic because they had ADHD
(15:25):
however, when you read thecriteria, it says you're not
allowed to diagnose ADHD duringthe course of autism or
Asperger's. What that meant wasback then you rolled in the ADHD
symptoms to the autism orAsperger's label. Today, we're
more in an era of you diagnoseeach label itself separately, so
(15:45):
if trying to figure out autismfor ADHD, it really comes down
to symptoms that are beyond whatthe ADHD would explain.
So, if you are let's use thewords let's pretend we can use
the word fidgeting to describethe moving behaviors in ADHD and
stimming to describe those exactsame behaviors but when you're
(16:06):
only autistic. Oftentimes, whatwe're going to see is symptoms
that you wouldn't tell apart.The way they tap the fingers,
the way they play with theirpen, you often wouldn't be able
to say that's clearly outsidethe range of ADHD. Now, if I
have somebody who is rubbing orflicking their fingers in front
of their face repetitively, nowwe look like we've left ADHD
(16:27):
behind. That's more extreme.
Or if somebody is spending hoursflicking light switches or tens
of minutes flicking lightswitches, or as a kid, they've
got in trouble over and over andover because they just sat there
and flicked the light switch onand off, on and off. That's not
something standard to ADHD. Inthe autism label, there's lots
of categories of things thataren't ADHD. So, people might
(16:50):
have trouble havingrelationships because of the
impulsiveness, especially ifthey don't have good emotional
regulation, but they wouldn'thave the same missing people's
emotions while paying attention.They might miss them because
they were distracted, but theywon't be blind to it while
they're fully attending to theother person.
So going across different socialsymptoms, ADHD wouldn't explain
(17:14):
why somebody was intolerant tophysical touch from loved ones
if the autistic person had thatsymptom. Also, on the
restrictive, repetitive, andrigid side, special interests
aren't explained within ADHD.You kind of have to stretch the
ADHD label to explain somebodyhaving obsessive interests in
things. It certainly doesn'texplain the overly ritualized or
(17:39):
routine behavior patterns or theidea that foods are not allowed
to touch on a plate, forexample, throw out the plate or
just eat the safe food that'snot contaminated. So you look
around the labels, basicallywhat's left.
If I blame everything I couldblame on ADHD, do I still see
significant autism symptoms? Youalso mentioned borderline
personality disorder, and thatis one that does seem to come in
(18:01):
more often. There's a questionthat doesn't have an answer. Why
is it that women tend to getborderline personality labels
and men tend to get autismlabels? There's no good answer
to that, but this is one ofthese quandaries that's out
there.
Is this where people put, Okay,this person's weird. This is
what I know is weird, so I'mgoing to call you that, but you
don't quite fit. I've hadactually similar for not
(18:23):
borderline but bipolar, wherebecause autistic people might
suddenly shift from theirresting face where they tended
to show one emotion most of thetime into another intense
emotion, people will label thatbipolar, but bipolar is quite
the opposite. Bipolar is days ofone mood, so that's when it's
easily thrown away. Back toborderline, when the borderline
(18:44):
person has the feature wherethey're very up and down about
their own self worth versus howthey value others, when they're
trying to judge the otherperson's emotions and meanings,
they are very precise.
They keep hitting the sametarget but they're hitting the
wrong target versus autism wherefrom this model, you're trying
to judge the other person'semotions and what they mean,
(19:05):
what their intentions are, it'smore like you're shooting wildly
unless you can get them to tellyou with words that are actually
what they mean or the otherperson is showing intense
emotions. They're crying, Okay,I know you're upset. Probably.
Or they get the other person totell the story of what led to
their current state because theycan understand the story. They
can't necessarily just look atthe person and feel those micro
(19:28):
expressions to get a prettyclose read on the starting
point.
Borderline people are able todetect those small
microexpressions, but they aremore in the misinterpreting them
consistently rather than blindto them. So, just like with the
ADHD, you look for what's left.We've satisfied enough for
autism. What about theborderline? Is there significant
(19:51):
symptoms of borderline stillthat are not explained in the
autism label and vice versa?
Are there significant autismfeatures that can't be explained
away by borderline? You can dothe same with borderline and
ADHD because both of them can beimpulsive. But if you're an
inattentive ADHD person, that'snot going to be explained by
borderline.
Paul Cruz (20:12):
Many patients describe their diagnosis as life
changing. From your perspective,what makes that moment so
impactful?
Dr. Gregory Skinner (20:21):
Yes. And yes, people have me. It always
makes me a little uncomfortableto hear more than just a simple
thank you, but many people dodescribe that. Most of the
people are fairly convinced tocompletely convince. Some people
are worried.
Some people don't want to beautistic, but the majority of
the people that are coming to mecurrently, they're coming
because they were the one whobrought it up to their doctor.
(20:42):
And it validates theirexperience and it validates why
they struggled. Some people aretearful over it, but they're
just thankful that this answersthat unanswered question, you
know, Why am I weird? Why am Idifferent? Or as one man
approaching 60 said, Is this whyI've been homeless since high
school?
And not being able to access anyhelp or any direction. Think
(21:05):
about that guy he's beenhomeless for the majority of
three decades, four decades,three decades. And after that,
was able to get Assured Incomefor the Severely Handicapped
because we were able to labelwhat he had been struggling with
in a way that other people couldunderstand it. Most people, the
struggles with maintainingfriendships or a history of
bullying, struggles inside theirown family, they often feel like
(21:28):
the pieces fall together andknowing that autism spectrum is
this is the kind of person I am,it's a difference. Autism
Spectrum Disorder Disorder isthe price I pay because other
people don't understand, theprice I pay because I can't sit
all day under fluorescentlights.
In my office here, the LEDswon't work in these
(21:48):
fluorescents, these fancy, fancyfluorescent boxes, so I have to
use fluorescent lights. So theones right above my head, I've
taken the bulbs out so that atleast we're not staring at this
sensory trigger for many, manypeople. So it's a lot about the
catharsis of knowing who youare. Sometimes it's about
accessing programs, althoughmany of those programs are quite
(22:09):
resistant. The disability taxcredit about three years ago
became easier to get again andthey also added specifically
nonverbal communication as asection.
Autism is the disorder ofnonverbal communication. The
only other disorder I readilythink about is nonverbal
learning disorder. And whenpatients come to me questioning
autism and having a history ofnonverbal learning disorder,
(22:31):
that was like code they didn'trecognize autism back then. So,
disability tax credit, althoughthe acceptance rates are quite a
bit lower because technicallythey did put a core feature on
that every autistic personshould have or maybe it's called
99 plus percent should havebecause there's a wide spectrum,
right? But almost all autisticpeople should be disabled in
(22:52):
nonverbal communication andthat's a section on the tax
credit.
People who are in the strugglingto succeed category, this might
be their one direction to helpthe programs. Some of them have
applied to ACE three, four timesthe Assured Income for the
Severely Handicapped here inAlberta. I know that BC has its
own similar program, but ifthey've applied before but
without the label, they oftendon't succeed because their
(23:13):
other labels are consideredtreatable. You don't treat
autism. That would be likesaying somebody has to be
treated for being homosexual.
It doesn't make sense. Now, willbe consequences in people's
lives in both cases, and youmight have to deal with those
consequences. Depression,anxiety, those need to be
treated. Masking. Some peoplewant to learn to mask more.
Lately, I'm hearing more peoplewho want to learn how to stop
(23:36):
faking being normal becausethey're exhausting themselves.
They want to learn what theyused to do to stim, to release
the stress so that they canfunction better. So the impact,
there's many, many differentones, but the main one is being
recognized. There's a reason.There's a pattern here.
This is a real thing. It's notmade up. It's not all in your
(23:59):
head, although the brain is inyour head. That phrase always
makes me double take it. It'sthe I'm not wrong and I exist
for a reason kind of approach.
Paul Cruz (24:11):
Since your clinic focuses on diagnosis rather than
long term treatment, How do youprepare patients for life after
they receive their results?
Dr. Gregory Skinner (24:23):
That hard part, that lack in the adult
community for programs unlesssomebody is in the low IQ
population, what's now calledintellectual deficit, I think we
all know the social words forall the past labels. So, if
you're in the intellectualdeficit, then you qualify for
the Alberta government's PDDprogram, Persons with
Developmental Disabilities, butthat has a strict IQ requirement
(24:45):
of 70 or less. So, everybodyelse, they're not going to find
a lot of adult supports outthere outside of the few
charities. So, I try to directthem to the few charities. Even
at their initial assessment,they get a resource list I put
together over years and thatcovers the main charities, it
covers off the existence ofprograms like EI or the Alberta
Program Income Supports, whichwould be our I'm blanking on the
(25:08):
name for the American programbut it's a minimal income
program for survival.
There's a medical version of itavailable through the Income
Supports Program of AlbertaWorks here. In terms of
preparing them for life, I talka lot about boundaries and at
their diagnosis, they get aletter of recommendations and it
talks about you have the rightto set boundaries. Blame the
(25:30):
doctor. Don't blame yourself.Hey, hey, Doctor.
Skinner said I need to do thesethings to protect myself. You
talk to him if you've an issuewith it. So, trying to socially
protect them but also pointingout that maybe socialization
isn't two cups of flour in therecipe of their life. Maybe it's
more like a couple spoons ofsugar or maybe it's more like a
teaspoon of salt. They're human.
(25:51):
They need it, but it's easy toget too much of it. Same thing,
setting limits around sensoryissues, around adaptive changes.
I'm sorry, we have all agreedI'm the person who needs three
days' notice for this kind ofchange. You want my in laws to
stay with us for Christmas? Imight need a year's notice for
that one.
Do you want me to pull over hereso you can go in that store?
(26:13):
Some autistic people can adapt.Some of them will have a small
autistic overwhelmed episode andhave to stay in the car, but
they can still do it. And someautistic people will know that's
not on the schedule and justkeep driving. So being allowed
to set the accommodations yourequire.
Also, sometimes it's aboutcoming back for employment, like
letters to supportaccommodations, although
(26:35):
unfortunately there's a lot ofresistance in that field. I find
that in the courtroom, it soundslike the lawyers treat a
doctor's accommodations as thewill of the Lord Himself in
terms of, Why didn't you dothis? This was clearly
indicated. But when it comes toemployers interpreting it, in
autism, I often find that youdon't look autistic thing again.
(26:57):
So they really don't want tofollow them and some employers
have gone out of their way tomisinterpret them and then
misinterpret the reexplanations.
So people can come back forsupport for accommodations and
sometimes it goes quite well.Sometimes they get their
diagnosis and they get theiraccommodations and now the other
people who would help each otherout but not that person start
(27:18):
supporting that person like partof the team, too. What else for
preparing them for their lifeafter they receive the
diagnosis? Guidance on thecharities and the programs. Most
of the people I'm seeing are thepeople who weren't easy to pick
out from a distance.
So, more severe autism, thinkabout the school psychologist
saying, Oh, that's the personright there, isn't it? Versus
(27:39):
Which one is my patient? So, thepeople I'm seeing are the ones
who weren't caught previouslyand a lot of the therapies and a
lot of the supports often willaim below somebody's skillset so
they don't need to spendthousands of dollars on programs
that they might have been betteroff teaching. I did have one
person who took some of thecourses that I thought she might
(27:59):
be skilled above and she saidthere some stuff that was quite
useful, she said, so opposite towhat I was thinking, and at the
same time told me that she's nowvolunteering teaching other
people, which is kind of what Isaid. Should you be taking this
program or should you beteaching this program, directing
them towards more effectivetherapies?
Cognitive behavioral therapy atits core relies on an assumption
(28:22):
of ability and what if you don'thave that ability? Is it right
to call somebody lazy for notsorting sweaters by color if
they are completely blind? Areyou going to motivate that
person to sort by color? It'snot going to fix the problem if
they can't see the color. So abetter approach and I will plug
the Ross Green approach, hiswebsite, livesinthebalance.org,
(28:46):
and if you start under theParents and Family section and
you take his tour, you don'tneed to be buying his book,
although I'm sure he'd be happyif you did.
He's provided the basicresources of a different
approach. If you're not doingwell and especially if you've
tried motivation based therapyand hasn't fixed it, maybe we
need to figure out why you can'tdo well and work on that
(29:06):
problem, which is a lot harderthan just calling it motivation.
So I direct people in therapytowards that. Actually, I have
several paragraphs in the letterthey get advising other people
what they need to do. Like maybethey need to learn about autism.
Maybe they need to stop sayingthings like, You can't be
autistic. You're a girl, whichI've had multiple people tell me
they were told. Yet, even in thepast, one in four are women or
(29:28):
one women to four men, to say itcorrectly. And today, we're
questioning, is it more like onewoman to three men? I prepare
them with communicationstrategies and there's when it
comes up how to deal with if youcan't get past an interview
should you choose to reveal thelabel because the question is
not should I reveal.
The question is if I always comethrough the interview looking
(29:50):
like there's something wrongwith me, do I let the
interviewer decide there'ssomething wrong with me and what
are they going to come up with?Lazy, crazy, some other
derogatory term, the wronglabel. You really had to want
this job. Oh, right. My faceisn't very expressive.
So, do I let them decide or do Ireveal that I have mild autism?
I do not think there's any suchthing as mild autism. This is a
(30:12):
social use of the word forreassurance. The employment
numbers are so poor out ofsocial groups is so consistent
that at the lowest severitylevel one, that's severe. At the
middle severity level two,that's more severe and the
highest severities are even moresevere.
And it's two severity scores. Iknow everyone's talking about
just one score, but when youlook at the DSM, there's a
(30:33):
social disability label andthere is a rigid, restrictive,
repetitive disability label. So,two scores. But socially, if you
can't get past an interview, youcan watch some videos, get some
advice on how to tell, which tokeep it quick for the listeners
would be, It turns out I havemild autism. Identify a weakness
(30:55):
because they always like it whenyou can tell your weakness, so I
might take you too literally.
I might struggle with thelighting, whatever it is. I
might struggle with changes inthe calendar, but then you got
to sell it on the strengths. Thekeen attention to detail, if
that's your case. Maybe don'tmention if you have ADHD at the
same time. The ability tounderstand processes, the number
of people who just halt theprocesses and their life is
(31:16):
about the process.
Those kind of things sell yourstrengths quick, quick, quick.
But most people who can getthrough the interview looking so
called normal on the videos Isaw from Sarah Hendricks out of
England on this topic, she saysmost people choose to conceal
because they're not being hiredbased on their social skills,
although you might say they'rebeing fired over them.
Paul Cruz (31:37):
What are the biggest barriers adults face in
accessing an autism diagnosis inAlberta and how do those
barriers affect patient care?
Dr. Gregory Skinner (31:48):
So, the biggest barriers are access,
access, access, and access.There's a small group of
psychiatrists in the Edmontonregion. I think they're out of
is it the Oliver PCN? Anyway,there's a group in Edmonton, and
their waitlist, when I lastchecked it, which has been
months, but last time I lookedat it, it was I think five years
they were citing. And we'veclosed my waitlist for the
(32:08):
simple reason why I don't wantit to be that long.
These people need to know thatthey need to look for
alternative access if they canfind it. There's a little bit
out there. There's some familydoctors who do some autism
assessment, a few of them that Ihave trained, but that's not all
they do. There's a couple ofpsychiatrists I trained,
although one retired to BCrecently, actually. One
(32:29):
psychiatrist I can remember, butoftentimes he sends referrals to
me.
So, accessing the assessment andthe costs, the psychology thing
where most people just simplydon't have the money to pay for
a psychologist or else I couldbe assessed quickly. The wait
lists, this is it. These peopleare hitting a wall. I've had
(32:49):
refugees referred to provethey're still autistic so they
can get onto programs, but thereisn't more me to go around. So,
it's about this problemaccessing it and everything else
is dependent on it.
If you have depression andanxiety, those are treatable and
disability services, disabilitygovernment programs want you
rightfully to have attempted andexhausted therapy options. But
(33:12):
if you have an untreatabledifference and you're being
forced into a world that doesn'taccept that difference, doesn't
allow space for people of thattype because we expect everyone
to fit in, get along, respond inthe correct way, say hi
correctly, understand when Isay, I'm fine, but I don't mean
it, you're supposed to knowthat. So, when we have people
who don't fit into the ruleswe've set and we won't recognize
(33:34):
their difference and we won'tsupport them as a result.
Depression? Go get more therapy.
Go get more counseling. Try morepills. It takes a lot to prove
permanent disability and that'swe have to get the labels right
at the beginning. So barriers,again, access, yeah, how do they
affect it? People can't accessreally anything.
The charities have stepped up. Iknow Autism Calgary for sure and
(33:56):
I think Sineve as well. They'renot waiting for the people who
have this subtle butsignificant, the ones who slip
through. They're not waiting forthem to be proven to be autistic
before they're allowed to joinsupport groups. They're saying
if you think there's asignificant risk, we will help
you.
Paul Cruz (34:13):
What are some of the most common myths about adult
autism that you find yourselfcorrecting?
Dr. Gregory Skinner (34:20):
Myths about autism? Well, even just you
can't be autistic because is oneof my favorite lists. I've even
put it into the other peoplesection of the letter people
get. Some of my favorites, youcan't be autistic because you're
a girl, you can't be autisticbecause enter derogatory term
for low IQ here, you can't beautistic because you made eye
contact. One person, my personalfavorite, they were told they
(34:42):
couldn't be autistic becausethey could sing karaoke.
The best I can do is that theyunderstood that in the older
label, there was an imaginationsection and they applied that to
that section, but many timesafter the Autism Calgary group
meetings pre pandemic, theywould go sing karaoke
afterwards. So it's not adiagnostic feature. I had one
person told by somebody who Ithought should have known
(35:02):
better, You have the features ofautism, but you're aware of it,
and autistic people can't haveinsight, which is nowhere on the
diagnostic criteria. Theassumption you have to have low
IQ. Now, we've come from aperiod where most autistic
people were diagnosed with lowIQ on the autism label.
We went through the separatingout the Asperger's for the ones
(35:23):
who were not speech delayed andwere not low IQ and now it's a
single spectrum again. Now it'swhat is it? It's more like ten
percent, I think they're sayingnow. The experts are saying more
like ten percent of people withautism will have an IQ
diagnosis, but I've had peopletold they didn't have low IQs so
they couldn't be autistic. Justlots of those.
Or the famous phrase from I'mnot going remember the doctor's
(35:49):
name, but the famous autismquote of, If you've met one
person with autism, you've metone person with autism. And
there you go, that's Doctor.Stephen Shore. I remember from
his story that he was labeled ashis kid and to keep it as a
short, sarcastic version of it,his mom was kind of told to
institutionalize him and forgethim. That's a real
simplification of the truestory, but now the fact that
(36:11):
he's Doctor.
Stephen Shore suggests he's donequite a bit better than what
they anticipated when theylabeled him autistic as a kid,
probably because they assumedalso low intelligence at the
same time. Common myths: empathy. Autistic people can't (36:21):
undefined
have empathy. When people ask meabout Do autistic people have
empathy? My answer is, What doyou mean when you say that word?
Because in autism, the empathyproblems are, Can I feel the
subtle nonverbal displays?Unfortunately, most people live
(36:41):
in the subtle emotional rangemost of the day. So can I feel
those? The answer is generallyno. There's the thing called the
mirror model where you justdon't feel other people's
feelings because you're notcopying the microexpressions
with your brain mirror nerves,the mirror model, and then in
autism, the broken mirror.
So, I need the more intenseemotions. Feeling other people's
(37:02):
feelings, intuiting them beforethey're really obvious? No,
that's an impairment. Displayingmy face right, motor empathy?
That's an impairment.
Other people often claim oftenclaim the resting faces, the
resting happy face, restingstoic face, resting flirty face,
which can be a dangerous one fora young lady to have, resting
bee face, the unapproachable,angry, rude face as just their
(37:24):
baseline face, whether they'rehappy or sad. They just kind of
have that for most of theiremotions. So sure, that's a
problem of motor empathy. Butmost people mean affective
empathy. They mean if you werein a certain situation, what did
you understand was happening andhow did you feel?
And would an average group ofcomparable people agree your
(37:46):
feelings were right? If youwitness somebody who seemed to
be enjoying kicking a puppy,most people will be upset,
disgusted, angry, afraid, youknow, is he going kick me?
Depending on the context.Confused. They'll have a
sympathetic desire to help thepuppy.
This is not the time to desireto help that person who enjoys
herding animals figure out theirproblem. This is the time to
(38:06):
help the puppy right now. And atest that was designed to show
problems of that in autism, itwas trending towards autistic
people being better at it. Theywere more empathic but it wasn't
powered to show that it waspowered to show they were less.
So, this entire testmisconstrued around the idea
that autistic people don't haveempathy.
(38:27):
Now, why can they come across asnot having empathy? Well, they
might not understand the samesituation, you know, if it's too
loud and you get overwhelmed andstart screaming. But other
people might think that'sstanding next to a jet plane
with no hearing protectionrather than the quiet of a fan
like in this room, the fan goingall the time. They might not
understand the social situationthe same. They might miss
(38:50):
obvious cues that someone'supset.
So they don't think the person'supset, so they're not responding
to them the way you'd expect.Also, they might not display it,
right? If they have resting,angry looking face all the time
and they're concerned aboutsomebody, they might not change
that tone or they might only doit with considerable conscious
effort. So, people with autismhave more affective empathy,
(39:15):
probably, at least the same, butprobably more. And given that
that's the main thing peoplethink of, that means autistic
people do have empathy.
But might they miss your subtlecues that you want to hug? Yes.
Might they not understand thesame situation at all? Might
they realize that you're upsetbut their experience has taught
them they are the last personyou should help? So now that
(39:37):
know that you're upset, they'rescared.
I only mess this up. I'm afraid.Does that sound like an
appropriate emotional reactionif you always feel like you mess
something up to have anxiety?Yes, it sounds appropriate.
However, the person's expectingyou to comfort them right now
when you don't because you feellike all you can do is make it
worse.
They don't feel you're veryempathic because of your lack of
response.
Paul Cruz (40:00):
You've also led workshops and spoken with
organizations aboutneurodiversity. What key
messages do you think healthcareproviders and the public need to
hear most?
Dr. Gregory Skinner (40:12):
And honestly, I really should do
many, many, many more of thosethan I do because of the need to
communicate about neurodiversityand neurospiciness. The first
thing right now, we're stillvery much at the bottom of the
curve of building people'sunderstanding and knowledge. So
right now, it's in the phase ofgetting people to understand
it's out there. Even when itdoesn't affect your own life
(40:34):
personally, it is the definitionof other people's lives is what
they're living. So, is real.
Neurodiversity is real. It'salways been here and the world
we're designing more and moreand more seems actually less
fit. Think about people who aregood at high technical jobs but
not good at social. The peoplewho could sit there and place
(40:55):
the rivets in the machine allday long. The people who notice
the small errors but more andmore we're requiring jobs to
have high levels of social skilland we've got a group of people
who are less socially skilled.
In the letter for in thereferral response, I give some
basic instructions to theoffices and I can sit here
saying, I'm not following my owninstructions because I'm not
(41:17):
wearing a name tag. Buteverybody, you know, making it
just that much socially easierso they know who they're dealing
with by something simple as nametags. I've been in clinics with
one light switch for the wholebuilding. How do you control
artificial lighting for lightsensitive people? Trying to
understand that these aredifferences and it's not
laziness.
Somebody with Level threerigidity could be very explosive
(41:39):
to the point they also get alabel of Intermittent Explosive
Disorder. And trying to helpthose people have care because
if something goes wrong at thereception desk, they're going to
get kicked out of the clinic,but they still need to be able
to access care. How do you dealwith people who can be difficult
(41:59):
when you realize that thatdifficult isn't a choice? It's
real. They misinterpret meaning.
People with autism might not getthe same message out of what you
said. It's almost like you'redealing with somebody who's not
that good in a second language,but you think they're good at it
and then they do something thattotally surprises you. So I
guess the website name for mesays it: Autism exists. It is
(42:22):
real.
Paul Cruz (42:25):
Looking ahead, how do you see adult autism diagnostics
evolving over the next five toten years?
Dr. Gregory Skinner (42:32):
So over that time span, I don't think I
see them evolving very much. Ithink they still seem to be
remaining on the same thing. Iam hoping that I can move my
version of the adult autismassessment tool from Cambridge
University back to them and havethat as an updated one for
Autism Spectrum, my AutismSpectrum evaluation tool, so
(42:52):
that that can help thepsychologists, the
psychiatrists, the familydoctors who are going to find
this falling on them because atone to two percent of the
population, instead of one intwo thousand or even older, one
in ten thousand data, There's alot more diagnosis needed than
there are specialists to do it.In terms of moving up, you know,
(43:13):
twenty percent, twenty fivepercent. Some studies showing
higher in terms of the geneticcauses they can identify for
autism.
There was a recent study I havenot read yet, but I have seen a
lot of people talking about itwhere they tried to divide four
genetic based behavior types ofautism. So, genetics someday
(43:33):
will play a bigger role. Still,although some people argue it
may be all genetic, other peopleargue there are still
environmental factors, so youwon't completely explain it with
genetics. MRI, I think it was inthe front of a Time magazine
years ago about the accuracy ofa functional MRI. I don't see
the health system gettingeverything set up for a
(43:54):
functional MRI to prove ordisprove autism diagnosis, and I
don't think I've seen thatanywhere.
The diagnosis still remains onclinical judgment and clinical
experience. More robust testing.At some point, we're going to
have to stop using the currenttests because the wording is out
of date. The estimates for thenon cis, non binary gender
identities, If you call it twopercent in the general
(44:17):
population, then people areestimating twenty percent in the
autism population. But we havetests with male data, female
data.
We don't know if we shouldfollow your assigned at birth
gender or your identifiedgender. We don't know. So, newer
studies and, of course, newerwording. The old inclusive tests
(44:37):
would say, Did he or she? Andthose were the inclusive ones,
trying to remember that therewere women.
And now, what about other peoplewho don't feel like they
identify clearly into he or she?Still, in ten years, probably
much the same tools.
Paul Cruz (44:52):
Finally, what keeps you motivated to continue this
work, and is there a particularpatient story that reminds you
why these matters?
Dr. Gregory Skinner (45:02):
What keeps me motivated is the need, is
knowing that they don't reallyhave anywhere else they can
afford to turn to and the comingback to it. Seeing it in
families. I've had familieswhere I've identified autism in
the mom, the brother, and theoriginal patient and then you
look into the kids afterwards.So many people coming because
(45:23):
their kids were identified. Thevariation.
I feel sometimes like I'vechosen the hardest part of
mental health medicine and madeit what I do all day long. So,
certainly, it's mentallystruggling but trying to
understand, Should I considerthis as different from average?
It's never the same person. Ihave people who, you know, they
(45:44):
can't chop vegetables while thestove is running. They can't
handle both tasks at the sametime.
I have people who running themicrowave leaves them in an
overwhelmed state for the restof the evening, so they have a
day ending crisis because theytried to heat up a frozen meal.
And these people are coming tome without any support. Some of
these things, it's like when yourealize they can't do it, it
(46:07):
seems so obvious they should besupported. But when you think
they just, well, that's weird.Don't you want to eat?
I think the person wants to eat.That's why they tried to manage
microwaving food yet again andthen wound up falling asleep in
their room after crying for afew hours yet again because they
can't manage it. So many littlevignettes on different people
for what it means for them.People telling me about failed
(46:32):
interactions with the policebecause they were assumed to be
doing differently or just madethem uncomfortable. I've also
had people telling me about goodinteractions with police, but
that struggle of beingdifferent, being different at
school, it's hard and manypeople don't see it.
Paul Cruz (46:51):
Do you have anything else to share with our listeners
that we have not discussed,Doctor Skinner?
Dr. Gregory Skinner (46:57):
Anything else that we have not discussed
regarding so many things wehaven't discussed, but what's
key. If you think about autismat between one to two percent of
the people in the subtle forms,that means you know people with
autism even if you don't thinkyou do. If you think you could
be a person with autism, it'squite possible because it is a
very individual diagnosis andthere are multiple pictures that
(47:20):
lead into it. There is room onthe autism spectrum for that so
called classical autism group,the people who are severely
disabled, and there is room onthere for the people who are
subtle but significant who'vekind of gotten along as just
kind of weird. It's easy to betaken advantage of because of
(47:40):
the over assumption of samenessin autism.
I used to try to use the wordegocentric to differentiate
autism from narcissism, but nowI've seen people, experts in the
narcissism field, the termegocentric, so I have to focus
on over assuming people are thesame. If I think I'm trust
worthy, I might mistake you astrustworthy, even though our
(48:01):
personal history might teach medifferently. I fall back on my
basic beliefs for other people,and everyone does. This starts
in a normal place, but the sizeof the holes autistic people are
plugging their own behavior intois much bigger. I could talk
about many other things, but I'mnot going to.
Paul Cruz (48:19):
Doctor. Skinner, thank you so much for sharing
your journey and insights withus today.
Dr. Gregory Skinner (48:24):
Thank you, Paul. Thank you for the time.
Thank you for reaching out. Thisis something people need to hear
more and more about, and you'reone of the people doing that
work. So thank you for all youdo for us.
Paul Cruz (48:35):
Your work shows just how powerful and life changing
an autism diagnosis can be,especially for adults who've
waited years for answers. To ourlisteners, if this conversation
resonated with you, please sharethis episode. Don't forget to
(48:55):
subscribe to the NeurodiversityVoices podcast whenever you get
your podcasts, and even rate ourpodcasts on your favorite
podcast app. If you have anyquestions, ideas or stories
you'd like to share, please feelfree to write us or sign up to
be a guest on our podcastwebsite at
www.neurodiversityvoices.com.We'd love to hear from you.
(49:21):
Until next time, take care, staycurious, and keep celebrating
the beauty of diverse minds.Thanks for listening to the
Neurodiversity Voices Podcast.Thank you for joining me today
on the Neurodiversity Voicespodcast. As an advocator with
(49:42):
lives in the balance, I'll leaveyou with this reminder: When we
collaborate with kids, we don'tjust solve problems, we change
lives.
Hello and welcome to the Neurodiversity Voices
podcast. I'm your host Paul Cruzand I'm thrilled to have you
join me on this journey ofexploration, advocacy, and
celebration of neurodiversity.Together, we'll have meaningful
conversations, share inspiringstories, and challenge
misconceptions aboutneurodiversity. This podcast is
(00:28):
for everyone, whether you'reneurodivergent yourself, an
educator, a parent, or justsomeone curious to learn more.
My goal is to amplify voices,foster understanding, and spark
change in the way we view andsupport neurodiversity.
I'm so excited to have you as wecelebrate the beauty of diverse
minds and work toward a moreinclusive future. So sit back,
(00:53):
relax, and let's get started.Welcome to the Neurodiversity
Voices podcast.
(01:16):
Today I'm joined by Doctor.Gregory James Skinner, a Calgary
based family physician who hasbecome a leading voice in adult
autism diagnosis. His journeyspans international medical
training in Europe, TheCaribbean, and Canada, and his
career took a meaningful turnwhen he recognized a major gap
(01:39):
in services for adults seekingan autism diagnosis. Doctor.
Skinner, welcome to the show andthank you for being here.
Dr. Gregory Skinner: thank you for having me, Paul. (01:51):
undefined
Paul Cruz (01:51):
Can you describe your journey through medical school
and how you eventuallyspecialized in adult autism
diagnosis.
Dr. Gregory Skinner (02:00):
Well, autism wasn't something that
really came up in medicalschool. In fact, I'm not even
sure I ever heard the wordautism. Psychiatry tended to
focus on the core issues,depression, anxiety, not even
really into the personalitydisorders. I started my
schooling in Europe, in TheCzech Republic, and I completed
(02:21):
four years there. And Itransferred to one of the feeder
schools for The USA, studying upand down the East Coast Of The
US for the core rotations.
Graduated with my medical degreefrom Saba University. I was able
to secure a residency as aforeign graduate in Manitoba and
(02:42):
I completed a standard two yearfamily residency there. That
left me ready to go into generalfamily practice, which I did for
a number of years, but it wouldbe later on after my son was
born when I started questioningif I would fit with the autism
spectrum and trying to do thatwithin medicine, lots of options
for psychology but doing itwithin the medical system, I had
(03:04):
five referrals dead end tonowhere. That was when I started
getting in identifying this asan area of need. Also, I wasn't
necessarily prepared to returnto a standard family practice at
that point.
So, I looked more and more intoautism assessment. We have, at
the University of Calgary, wehave the ACERT program. They run
(03:26):
the peers group for socialskills training and at the top
there we have Doctor. AdamMcCrennan, a psychologist, and
he recommended a specific autismassessment tool which I have
been using and adapting andadding more details to ever
since.
Paul Cruz (03:44):
How have your experiences across different
health care systems shaped theway you approach patients today?
Dr. Gregory Skinner (03:51):
So when I was in The States, depending on
the hospital, although we oftenhear about they have private
pay, there is a lot ofgovernment covered healthcare,
mostly emergency situations andhospitalizations. So it
certainly helped me realize thecost focus on it. I don't know
anybody who has 2,000 or $3,000just burning in their back
pocket that they were lookingfor something to spend it on and
(04:13):
yet that's what it winds upbeing when it comes to
psychology for autism. As a lowemployment group, I think The UK
National Survey put it at 16%full time employment compared to
pre pandemic Canadians had 66%full time employment, so that's
a difference of 50. They don'ttend to have insurance to help
(04:34):
cover those costs, so it is allout of pocket on a poorly
employed population.
So that actually helped with thedecision to not just leave it
with psychology because there'sjust no coverage for them. The
way I approach patients, I spentfour years in a country that I
do not speak their firstlanguage, so that helped me
understand the barriers aroundbeing understood in
(04:56):
communication and I guess autismwould be another reason for
people to struggle with thosesimilar barriers. It also helps
to recognize other people'schallenges that if you train
locally and work locally, youmay not ever experience in your
life. You may not have thatexperience for years of
struggling to get basic ideasacross, even while studying a
(05:17):
foreign language.
Paul Cruz (05:20):
What was the turning point that led you from family
medicine into building apractice focused on autism
diagnostics?
Dr. Gregory Skinner (05:29):
So for me personally, it would start with
that question, was I on theautism spectrum? And of course,
the answer remains maybe at thispoint, but at that time, with
all the difficulties of tryingto get the assessment, it was
also a key time in my life. Iwasn't returning to my previous
family practice after mypaternity leave, So I was
looking for a new direction andlooking to try something
(05:53):
different and certainly did findsomething different in doing
autism. So on the personal side,being unable to access service
and realizing that that mustapply to other people, looking
to you for more direction.
Paul Cruz (06:06):
Could you share what challenges you faced in creating
the Autism Exist DiagnosisClinic and what changes it's
brought for patients?
Dr. Gregory Skinner (06:17):
So challenges in creating the
clinic, certainly costs. It'snot as profitable business wise.
You can't really push peoplethrough quickly to try to keep
up with your overhead. So for anumber of years, I was working
alone and unsupported beyondsomebody managing the financing.
Well, I should say theaccounting would be a better
(06:37):
word.
So working mostly alone, tryingto manage both the phone calls,
the referrals, which for anumber of years I didn't I
eventually gave up because I wasgetting so many referrals and I
was spending more time tellingthem we're not a referral clinic
than it would take just toaccept the referrals. There's a
lot of barrier around otherpeople's beliefs, whether they
are professionals, medicalpersonnel, doctors or
(06:58):
psychologists, their personalbeliefs around autism or their
beliefs around a family doctordoesn't have the qualifications
to do that despite the fact thatI've got multiple hours,
multiple courses. I've taken theADOS and ADIR training, the two
tests that psychology generallyrelies on. So, disbelief that
the person in front of someonecould be autistic, you'll see a
(07:20):
lot of disbelief around it. Itoften feels like they don't
quite know, other people don'tquite know what this thing is
and they will use a minimum ofknowledge to make it so they
don't have to go any further.
They can just excuse themselvesbased on, You can't be autistic.
You made eye contact once. Yet,if you're smart and you get told
over and over and over and overas a child to make eye contact,
(07:44):
you might start making eyecontact even though you hate it
or struggle with it. So secondpart, what changes it's brought
for the patients? Again, ifpeople had lots of money or lots
of insurance, they might be ableto approach a private
psychologist for autism care.
For kids, there's lots of accessfor those things, but what about
for all the people who were inthe subtle but significant
(08:06):
range, the Level one socialcommunication where you might
not notice right away but overtime you might start to realize
this person is different? So,for those people, a lot of it's
validation. Some patients areconcerned they're autistic but
many more of them are convinced.Sometimes, even the way they
tell the story of what they didwhen they thought they could be
(08:27):
autistic and it became a newobsessive special interest or if
you're not autistic, what wewould call a passionate hobby. I
thought I might be autistic, soover the next couple of months,
I studied for hour after hourafter hour.
When they're bringing mearticles I've never heard of as
a part of their studies, I say,Okay. They're certainly showing
a deep, intense interest, apreoccupation with their new
(08:51):
area of autistic interest. So,of them are pre convinced and
they're just looking forvalidation. The fact that I'm
using a replicatable,transparent tool where you can
see what the decision was, notesbacking up why we made that
decision so that when somebodyelse offhandedly says, You can't
(09:11):
be autistic or You don't lookautistic, that's something that
I always love to hear peoplegetting told because autism
isn't a facial abnormality. It'snot an invisible difference.
It is a visible neuro minority.It's visible because these
people keep gettingdiscriminated on from jobs, so
people are seeing it, but it'snot color, it's not race, it's
(09:34):
not language, it's socialability, it's rigidity, it's
executive and adaptive problems.And people see it and people
marginalize people over it. Sopeople come to me and they find
out, yes, mostly yes or no,sometimes no, they're not
autistic, and then we try to atleast get them direction to what
(09:54):
we think it might be. Sometimespersonality disorders, sometimes
it's only ADHD.
I had at least one case where itwas only bipolar disorder. One
or twice that I've had peoplewho were only borderline,
although more often I thinkborderline was a placeholder for
they don't know what it is andwe remove that label or we tell
(10:16):
people, Congratulations, youlucked out and have both.
Unfortunately, though, they goexternally and they might get
their autism diagnosisinvalidated by a professional
and they might also have theprofessional hold steadfast onto
something that's still listed inthe hospital systems even though
we've gone through the criteriaof the label to prove they don't
(10:37):
have it, even when sometimes thediagnosis was made based on just
a few minutes of assessment inhospital and yet that is held
with more value than a formalreview of the criteria.
Paul Cruz (10:50):
Walk us through your diagnostic process. What makes
your approach unique compared totraditional assessments?
Dr. Gregory Skinner (10:59):
So a lot of the time, people are getting the
ADOS, which is a semi structuredinterview. By adulthood, a lot
of that's more about just theconversation. It's not involving
playing with toys, trying to getthem to respond with their name,
stuff like that. There's lessand less of that semi structured
interview that applies toadults. They also will do
(11:20):
typically the ADIR, which is theinterview of the parents, a
three hour structured interviewlooking for features that the
parents would identify.
In order to do that approach,though, psychologists are
required to do an IQ test todetermine where to send them
next. In terms of what I'musing, it's the first
recommendation in the NICEguidelines, N I C E, was at the
(11:43):
National Institute for HealthCommunication Excellence out of
England and they recommend forintellectually intact adults
using the adult Asperger's orautism assessment tool and it's
much more on the interviewstyle. Sometimes I do need to
extend out to relatives, topartners, to other people to get
(12:03):
additional information, but formost people, we can rely on self
assessment both in thequestionnaires and in the
discussion. The ADOS and theADIR have formal scoring sheets.
On the adult Asperger's orautism assessment.
It was a summary, Do you qualifyenough across the different
(12:24):
categories? What I'm doing evendifferent than that with my
Autism Spectrum Evaluation Tool,which is DSM-five, autism
spectrum disorder, update to theold Asperger's tool. The
symptoms are reordered. I'veadded in additional autism and
other questionnaires and itactually now breaks apart
multiple little features so thatwe can really make sure that
(12:47):
when we're talking aboutsomething like, Did you share as
a child? What does that mean?
Did you share food? Did youshare toys? If you saw something
interesting, would you bebringing it up to your mom or
your dad? You found like apencil and you're five and like,
Look, mom, isn't this cool?Versus you don't share those
things.
So, taking it apart at anin-depth level, trying to bring
(13:10):
this more accessible to more andmore people. My hope is that the
average psychologist with somebasic autism knowledge would be
able to do a fairly robust jobwith this tool and review all
the things that need to beconsidered rather than just an
off the hip, You look normal tome the first time I met you.
Diagnostic process, it is multihours. I think I'm averaging
(13:32):
nine hours assuming that theperson is good at organizing
themselves and it is justinterview. There's also a few
physical exams which all relatearound social.
For example, my decision on isyour posture socially normal?
So, proper good rigid posture,but actually the typical
(13:56):
comfortable slouch people do. SoI'm watching the eye contact,
how they use it, how theyrespond to being spoken to and a
few other things related tothat. Although a lot of those,
again, they may have learned tocamouflage as kids. So it's back
to the history, back to how theywere different as a kid, back
to, Are you thinking about eyecontact?
(14:19):
Versus most people who just makeeye contact. So, Paul, if you
are the average neurotypical notautistic person and I said,
What's your strategy for eyecontact? The average answer
should be something in theconfusion range of, Am I
supposed to have an answer forthat? Versus if you can tell me
what you're doing, Compare thatagainst the history, did people
(14:40):
get told about problems withtheir eye contact? Look at me,
look at me, look at me, you'renot paying attention.
For goodness sakes, look at me.Or more modernly, think about me
with your eyes. Your eyes arelike arrows.
Paul Cruz (14:53):
How do you handle cases where autism overlaps with
ADHD or other conditions likeBorder Personality Disorder?
Dr. Gregory Skinner (15:02):
So for ADHD, the current estimate is at
least fifty percent to seventypercent of people who have
autism spectrum disorder willqualify for ADHD. And that's a
change if you look at the DSMIV, they were talking about it
like you weren't allowed to haveboth. Some people, by the way,
were told they couldn't beautistic because they had ADHD
(15:25):
however, when you read thecriteria, it says you're not
allowed to diagnose ADHD duringthe course of autism or
Asperger's. What that meant wasback then you rolled in the ADHD
symptoms to the autism orAsperger's label. Today, we're
more in an era of you diagnoseeach label itself separately, so
(15:45):
if trying to figure out autismfor ADHD, it really comes down
to symptoms that are beyond whatthe ADHD would explain.
So, if you are let's use thewords let's pretend we can use
the word fidgeting to describethe moving behaviors in ADHD and
stimming to describe those exactsame behaviors but when you're
(16:06):
only autistic. Oftentimes, whatwe're going to see is symptoms
that you wouldn't tell apart.The way they tap the fingers,
the way they play with theirpen, you often wouldn't be able
to say that's clearly outsidethe range of ADHD. Now, if I
have somebody who is rubbing orflicking their fingers in front
of their face repetitively, nowwe look like we've left ADHD
(16:27):
behind. That's more extreme.
Or if somebody is spending hoursflicking light switches or tens
of minutes flicking lightswitches, or as a kid, they've
got in trouble over and over andover because they just sat there
and flicked the light switch onand off, on and off. That's not
something standard to ADHD. Inthe autism label, there's lots
of categories of things thataren't ADHD. So, people might
(16:50):
have trouble havingrelationships because of the
impulsiveness, especially ifthey don't have good emotional
regulation, but they wouldn'thave the same missing people's
emotions while paying attention.They might miss them because
they were distracted, but theywon't be blind to it while
they're fully attending to theother person.
So going across different socialsymptoms, ADHD wouldn't explain
(17:14):
why somebody was intolerant tophysical touch from loved ones
if the autistic person had thatsymptom. Also, on the
restrictive, repetitive, andrigid side, special interests
aren't explained within ADHD.You kind of have to stretch the
ADHD label to explain somebodyhaving obsessive interests in
things. It certainly doesn'texplain the overly ritualized or
(17:39):
routine behavior patterns or theidea that foods are not allowed
to touch on a plate, forexample, throw out the plate or
just eat the safe food that'snot contaminated. So you look
around the labels, basicallywhat's left.
If I blame everything I couldblame on ADHD, do I still see
significant autism symptoms? Youalso mentioned borderline
personality disorder, and thatis one that does seem to come in
(18:01):
more often. There's a questionthat doesn't have an answer. Why
is it that women tend to getborderline personality labels
and men tend to get autismlabels? There's no good answer
to that, but this is one ofthese quandaries that's out
there.
Is this where people put, Okay,this person's weird. This is
what I know is weird, so I'mgoing to call you that, but you
don't quite fit. I've hadactually similar for not
(18:23):
borderline but bipolar, wherebecause autistic people might
suddenly shift from theirresting face where they tended
to show one emotion most of thetime into another intense
emotion, people will label thatbipolar, but bipolar is quite
the opposite. Bipolar is days ofone mood, so that's when it's
easily thrown away. Back toborderline, when the borderline
(18:44):
person has the feature wherethey're very up and down about
their own self worth versus howthey value others, when they're
trying to judge the otherperson's emotions and meanings,
they are very precise.
They keep hitting the sametarget but they're hitting the
wrong target versus autism wherefrom this model, you're trying
to judge the other person'semotions and what they mean,
(19:05):
what their intentions are, it'smore like you're shooting wildly
unless you can get them to tellyou with words that are actually
what they mean or the otherperson is showing intense
emotions. They're crying, Okay,I know you're upset. Probably.
Or they get the other person totell the story of what led to
their current state because theycan understand the story. They
can't necessarily just look atthe person and feel those micro
(19:28):
expressions to get a prettyclose read on the starting
point.
Borderline people are able todetect those small
microexpressions, but they aremore in the misinterpreting them
consistently rather than blindto them. So, just like with the
ADHD, you look for what's left.We've satisfied enough for
autism. What about theborderline? Is there significant
(19:51):
symptoms of borderline stillthat are not explained in the
autism label and vice versa?
Are there significant autismfeatures that can't be explained
away by borderline? You can dothe same with borderline and
ADHD because both of them can beimpulsive. But if you're an
inattentive ADHD person, that'snot going to be explained by
borderline.
Paul Cruz (20:12):
Many patients describe their diagnosis as life
changing. From your perspective,what makes that moment so
impactful?
Dr. Gregory Skinner (20:21):
Yes. And yes, people have me. It always
makes me a little uncomfortableto hear more than just a simple
thank you, but many people dodescribe that. Most of the
people are fairly convinced tocompletely convince. Some people
are worried.
Some people don't want to beautistic, but the majority of
the people that are coming to mecurrently, they're coming
because they were the one whobrought it up to their doctor.
(20:42):
And it validates theirexperience and it validates why
they struggled. Some people aretearful over it, but they're
just thankful that this answersthat unanswered question, you
know, Why am I weird? Why am Idifferent? Or as one man
approaching 60 said, Is this whyI've been homeless since high
school?
And not being able to access anyhelp or any direction. Think
(21:05):
about that guy he's beenhomeless for the majority of
three decades, four decades,three decades. And after that,
was able to get Assured Incomefor the Severely Handicapped
because we were able to labelwhat he had been struggling with
in a way that other people couldunderstand it. Most people, the
struggles with maintainingfriendships or a history of
bullying, struggles inside theirown family, they often feel like
(21:28):
the pieces fall together andknowing that autism spectrum is
this is the kind of person I am,it's a difference. Autism
Spectrum Disorder Disorder isthe price I pay because other
people don't understand, theprice I pay because I can't sit
all day under fluorescentlights.
In my office here, the LEDswon't work in these
(21:48):
fluorescents, these fancy, fancyfluorescent boxes, so I have to
use fluorescent lights. So theones right above my head, I've
taken the bulbs out so that atleast we're not staring at this
sensory trigger for many, manypeople. So it's a lot about the
catharsis of knowing who youare. Sometimes it's about
accessing programs, althoughmany of those programs are quite
(22:09):
resistant. The disability taxcredit about three years ago
became easier to get again andthey also added specifically
nonverbal communication as asection.
Autism is the disorder ofnonverbal communication. The
only other disorder I readilythink about is nonverbal
learning disorder. And whenpatients come to me questioning
autism and having a history ofnonverbal learning disorder,
(22:31):
that was like code they didn'trecognize autism back then. So,
disability tax credit, althoughthe acceptance rates are quite a
bit lower because technicallythey did put a core feature on
that every autistic personshould have or maybe it's called
99 plus percent should havebecause there's a wide spectrum,
right? But almost all autisticpeople should be disabled in
(22:52):
nonverbal communication andthat's a section on the tax
credit.
People who are in the strugglingto succeed category, this might
be their one direction to helpthe programs. Some of them have
applied to ACE three, four timesthe Assured Income for the
Severely Handicapped here inAlberta. I know that BC has its
own similar program, but ifthey've applied before but
without the label, they oftendon't succeed because their
(23:13):
other labels are consideredtreatable. You don't treat
autism. That would be likesaying somebody has to be
treated for being homosexual.
It doesn't make sense. Now, willbe consequences in people's
lives in both cases, and youmight have to deal with those
consequences. Depression,anxiety, those need to be
treated. Masking. Some peoplewant to learn to mask more.
Lately, I'm hearing more peoplewho want to learn how to stop
(23:36):
faking being normal becausethey're exhausting themselves.
They want to learn what theyused to do to stim, to release
the stress so that they canfunction better. So the impact,
there's many, many differentones, but the main one is being
recognized. There's a reason.There's a pattern here.
This is a real thing. It's notmade up. It's not all in your
(23:59):
head, although the brain is inyour head. That phrase always
makes me double take it. It'sthe I'm not wrong and I exist
for a reason kind of approach.
Paul Cruz (24:11):
Since your clinic focuses on diagnosis rather than
long term treatment, How do youprepare patients for life after
they receive their results?
Dr. Gregory Skinner (24:23):
That hard part, that lack in the adult
community for programs unlesssomebody is in the low IQ
population, what's now calledintellectual deficit, I think we
all know the social words forall the past labels. So, if
you're in the intellectualdeficit, then you qualify for
the Alberta government's PDDprogram, Persons with
Developmental Disabilities, butthat has a strict IQ requirement
(24:45):
of 70 or less. So, everybodyelse, they're not going to find
a lot of adult supports outthere outside of the few
charities. So, I try to directthem to the few charities. Even
at their initial assessment,they get a resource list I put
together over years and thatcovers the main charities, it
covers off the existence ofprograms like EI or the Alberta
Program Income Supports, whichwould be our I'm blanking on the
(25:08):
name for the American programbut it's a minimal income
program for survival.
There's a medical version of itavailable through the Income
Supports Program of AlbertaWorks here. In terms of
preparing them for life, I talka lot about boundaries and at
their diagnosis, they get aletter of recommendations and it
talks about you have the rightto set boundaries. Blame the
(25:30):
doctor. Don't blame yourself.Hey, hey, Doctor.
Skinner said I need to do thesethings to protect myself. You
talk to him if you've an issuewith it. So, trying to socially
protect them but also pointingout that maybe socialization
isn't two cups of flour in therecipe of their life. Maybe it's
more like a couple spoons ofsugar or maybe it's more like a
teaspoon of salt. They're human.
(25:51):
They need it, but it's easy toget too much of it. Same thing,
setting limits around sensoryissues, around adaptive changes.
I'm sorry, we have all agreedI'm the person who needs three
days' notice for this kind ofchange. You want my in laws to
stay with us for Christmas? Imight need a year's notice for
that one.
Do you want me to pull over hereso you can go in that store?
(26:13):
Some autistic people can adapt.Some of them will have a small
autistic overwhelmed episode andhave to stay in the car, but
they can still do it. And someautistic people will know that's
not on the schedule and justkeep driving. So being allowed
to set the accommodations yourequire.
Also, sometimes it's aboutcoming back for employment, like
letters to supportaccommodations, although
(26:35):
unfortunately there's a lot ofresistance in that field. I find
that in the courtroom, it soundslike the lawyers treat a
doctor's accommodations as thewill of the Lord Himself in
terms of, Why didn't you dothis? This was clearly
indicated. But when it comes toemployers interpreting it, in
autism, I often find that youdon't look autistic thing again.
(26:57):
So they really don't want tofollow them and some employers
have gone out of their way tomisinterpret them and then
misinterpret the reexplanations.
So people can come back forsupport for accommodations and
sometimes it goes quite well.Sometimes they get their
diagnosis and they get theiraccommodations and now the other
people who would help each otherout but not that person start
(27:18):
supporting that person like partof the team, too. What else for
preparing them for their lifeafter they receive the
diagnosis? Guidance on thecharities and the programs. Most
of the people I'm seeing are thepeople who weren't easy to pick
out from a distance.
So, more severe autism, thinkabout the school psychologist
saying, Oh, that's the personright there, isn't it? Versus
(27:39):
Which one is my patient? So, thepeople I'm seeing are the ones
who weren't caught previouslyand a lot of the therapies and a
lot of the supports often willaim below somebody's skillset so
they don't need to spendthousands of dollars on programs
that they might have been betteroff teaching. I did have one
person who took some of thecourses that I thought she might
(27:59):
be skilled above and she saidthere some stuff that was quite
useful, she said, so opposite towhat I was thinking, and at the
same time told me that she's nowvolunteering teaching other
people, which is kind of what Isaid. Should you be taking this
program or should you beteaching this program, directing
them towards more effectivetherapies?
Cognitive behavioral therapy atits core relies on an assumption
(28:22):
of ability and what if you don'thave that ability? Is it right
to call somebody lazy for notsorting sweaters by color if
they are completely blind? Areyou going to motivate that
person to sort by color? It'snot going to fix the problem if
they can't see the color. So abetter approach and I will plug
the Ross Green approach, hiswebsite, livesinthebalance.org,
(28:46):
and if you start under theParents and Family section and
you take his tour, you don'tneed to be buying his book,
although I'm sure he'd be happyif you did.
He's provided the basicresources of a different
approach. If you're not doingwell and especially if you've
tried motivation based therapyand hasn't fixed it, maybe we
need to figure out why you can'tdo well and work on that
(29:06):
problem, which is a lot harderthan just calling it motivation.
So I direct people in therapytowards that. Actually, I have
several paragraphs in the letterthey get advising other people
what they need to do. Like maybethey need to learn about autism.
Maybe they need to stop sayingthings like, You can't be
autistic. You're a girl, whichI've had multiple people tell me
they were told. Yet, even in thepast, one in four are women or
(29:28):
one women to four men, to say itcorrectly. And today, we're
questioning, is it more like onewoman to three men? I prepare
them with communicationstrategies and there's when it
comes up how to deal with if youcan't get past an interview
should you choose to reveal thelabel because the question is
not should I reveal.
The question is if I always comethrough the interview looking
(29:50):
like there's something wrongwith me, do I let the
interviewer decide there'ssomething wrong with me and what
are they going to come up with?Lazy, crazy, some other
derogatory term, the wronglabel. You really had to want
this job. Oh, right. My faceisn't very expressive.
So, do I let them decide or do Ireveal that I have mild autism?
I do not think there's any suchthing as mild autism. This is a
(30:12):
social use of the word forreassurance. The employment
numbers are so poor out ofsocial groups is so consistent
that at the lowest severitylevel one, that's severe. At the
middle severity level two,that's more severe and the
highest severities are even moresevere.
And it's two severity scores. Iknow everyone's talking about
just one score, but when youlook at the DSM, there's a
(30:33):
social disability label andthere is a rigid, restrictive,
repetitive disability label. So,two scores. But socially, if you
can't get past an interview, youcan watch some videos, get some
advice on how to tell, which tokeep it quick for the listeners
would be, It turns out I havemild autism. Identify a weakness
(30:55):
because they always like it whenyou can tell your weakness, so I
might take you too literally.
I might struggle with thelighting, whatever it is. I
might struggle with changes inthe calendar, but then you got
to sell it on the strengths. Thekeen attention to detail, if
that's your case. Maybe don'tmention if you have ADHD at the
same time. The ability tounderstand processes, the number
of people who just halt theprocesses and their life is
(31:16):
about the process.
Those kind of things sell yourstrengths quick, quick, quick.
But most people who can getthrough the interview looking so
called normal on the videos Isaw from Sarah Hendricks out of
England on this topic, she saysmost people choose to conceal
because they're not being hiredbased on their social skills,
although you might say they'rebeing fired over them.
Paul Cruz (31:37):
What are the biggest barriers adults face in
accessing an autism diagnosis inAlberta and how do those
barriers affect patient care?
Dr. Gregory Skinner (31:48):
So, the biggest barriers are access,
access, access, and access.There's a small group of
psychiatrists in the Edmontonregion. I think they're out of
is it the Oliver PCN? Anyway,there's a group in Edmonton, and
their waitlist, when I lastchecked it, which has been
months, but last time I lookedat it, it was I think five years
they were citing. And we'veclosed my waitlist for the
(32:08):
simple reason why I don't wantit to be that long.
These people need to know thatthey need to look for
alternative access if they canfind it. There's a little bit
out there. There's some familydoctors who do some autism
assessment, a few of them that Ihave trained, but that's not all
they do. There's a couple ofpsychiatrists I trained,
although one retired to BCrecently, actually. One
(32:29):
psychiatrist I can remember, butoftentimes he sends referrals to
me.
So, accessing the assessment andthe costs, the psychology thing
where most people just simplydon't have the money to pay for
a psychologist or else I couldbe assessed quickly. The wait
lists, this is it. These peopleare hitting a wall. I've had
(32:49):
refugees referred to provethey're still autistic so they
can get onto programs, but thereisn't more me to go around. So,
it's about this problemaccessing it and everything else
is dependent on it.
If you have depression andanxiety, those are treatable and
disability services, disabilitygovernment programs want you
rightfully to have attempted andexhausted therapy options. But
(33:12):
if you have an untreatabledifference and you're being
forced into a world that doesn'taccept that difference, doesn't
allow space for people of thattype because we expect everyone
to fit in, get along, respond inthe correct way, say hi
correctly, understand when Isay, I'm fine, but I don't mean
it, you're supposed to knowthat. So, when we have people
who don't fit into the ruleswe've set and we won't recognize
(33:34):
their difference and we won'tsupport them as a result.
Depression? Go get more therapy.
Go get more counseling. Try morepills. It takes a lot to prove
permanent disability and that'swe have to get the labels right
at the beginning. So barriers,again, access, yeah, how do they
affect it? People can't accessreally anything.
The charities have stepped up. Iknow Autism Calgary for sure and
(33:56):
I think Sineve as well. They'renot waiting for the people who
have this subtle butsignificant, the ones who slip
through. They're not waiting forthem to be proven to be autistic
before they're allowed to joinsupport groups. They're saying
if you think there's asignificant risk, we will help
you.
Paul Cruz (34:13):
What are some of the most common myths about adult
autism that you find yourselfcorrecting?
Dr. Gregory Skinner (34:20):
Myths about autism? Well, even just you
can't be autistic because is oneof my favorite lists. I've even
put it into the other peoplesection of the letter people
get. Some of my favorites, youcan't be autistic because you're
a girl, you can't be autisticbecause enter derogatory term
for low IQ here, you can't beautistic because you made eye
contact. One person, my personalfavorite, they were told they
(34:42):
couldn't be autistic becausethey could sing karaoke.
The best I can do is that theyunderstood that in the older
label, there was an imaginationsection and they applied that to
that section, but many timesafter the Autism Calgary group
meetings pre pandemic, theywould go sing karaoke
afterwards. So it's not adiagnostic feature. I had one
person told by somebody who Ithought should have known
(35:02):
better, You have the features ofautism, but you're aware of it,
and autistic people can't haveinsight, which is nowhere on the
diagnostic criteria. Theassumption you have to have low
IQ. Now, we've come from aperiod where most autistic
people were diagnosed with lowIQ on the autism label.
We went through the separatingout the Asperger's for the ones
(35:23):
who were not speech delayed andwere not low IQ and now it's a
single spectrum again. Now it'swhat is it? It's more like ten
percent, I think they're sayingnow. The experts are saying more
like ten percent of people withautism will have an IQ
diagnosis, but I've had peopletold they didn't have low IQs so
they couldn't be autistic. Justlots of those.
Or the famous phrase from I'mnot going remember the doctor's
(35:49):
name, but the famous autismquote of, If you've met one
person with autism, you've metone person with autism. And
there you go, that's Doctor.Stephen Shore. I remember from
his story that he was labeled ashis kid and to keep it as a
short, sarcastic version of it,his mom was kind of told to
institutionalize him and forgethim. That's a real
simplification of the truestory, but now the fact that
(36:11):
he's Doctor.
Stephen Shore suggests he's donequite a bit better than what
they anticipated when theylabeled him autistic as a kid,
probably because they assumedalso low intelligence at the
same time. Common myths: empathy. Autistic people can't (36:21):
undefined
have empathy. When people ask meabout Do autistic people have
empathy? My answer is, What doyou mean when you say that word?
Because in autism, the empathyproblems are, Can I feel the
subtle nonverbal displays?Unfortunately, most people live
(36:41):
in the subtle emotional rangemost of the day. So can I feel
those? The answer is generallyno. There's the thing called the
mirror model where you justdon't feel other people's
feelings because you're notcopying the microexpressions
with your brain mirror nerves,the mirror model, and then in
autism, the broken mirror.
So, I need the more intenseemotions. Feeling other people's
(37:02):
feelings, intuiting them beforethey're really obvious? No,
that's an impairment. Displayingmy face right, motor empathy?
That's an impairment.
Other people often claim oftenclaim the resting faces, the
resting happy face, restingstoic face, resting flirty face,
which can be a dangerous one fora young lady to have, resting
bee face, the unapproachable,angry, rude face as just their
(37:24):
baseline face, whether they'rehappy or sad. They just kind of
have that for most of theiremotions. So sure, that's a
problem of motor empathy. Butmost people mean affective
empathy. They mean if you werein a certain situation, what did
you understand was happening andhow did you feel?
And would an average group ofcomparable people agree your
(37:46):
feelings were right? If youwitness somebody who seemed to
be enjoying kicking a puppy,most people will be upset,
disgusted, angry, afraid, youknow, is he going kick me?
Depending on the context.Confused. They'll have a
sympathetic desire to help thepuppy.
This is not the time to desireto help that person who enjoys
herding animals figure out theirproblem. This is the time to
(38:06):
help the puppy right now. And atest that was designed to show
problems of that in autism, itwas trending towards autistic
people being better at it. Theywere more empathic but it wasn't
powered to show that it waspowered to show they were less.
So, this entire testmisconstrued around the idea
that autistic people don't haveempathy.
(38:27):
Now, why can they come across asnot having empathy? Well, they
might not understand the samesituation, you know, if it's too
loud and you get overwhelmed andstart screaming. But other
people might think that'sstanding next to a jet plane
with no hearing protectionrather than the quiet of a fan
like in this room, the fan goingall the time. They might not
understand the social situationthe same. They might miss
(38:50):
obvious cues that someone'supset.
So they don't think the person'supset, so they're not responding
to them the way you'd expect.Also, they might not display it,
right? If they have resting,angry looking face all the time
and they're concerned aboutsomebody, they might not change
that tone or they might only doit with considerable conscious
effort. So, people with autismhave more affective empathy,
(39:15):
probably, at least the same, butprobably more. And given that
that's the main thing peoplethink of, that means autistic
people do have empathy.
But might they miss your subtlecues that you want to hug? Yes.
Might they not understand thesame situation at all? Might
they realize that you're upsetbut their experience has taught
them they are the last personyou should help? So now that
(39:37):
know that you're upset, they'rescared.
I only mess this up. I'm afraid.Does that sound like an
appropriate emotional reactionif you always feel like you mess
something up to have anxiety?Yes, it sounds appropriate.
However, the person's expectingyou to comfort them right now
when you don't because you feellike all you can do is make it
worse.
They don't feel you're veryempathic because of your lack of
response.
Paul Cruz (40:00):
You've also led workshops and spoken with
organizations aboutneurodiversity. What key
messages do you think healthcareproviders and the public need to
hear most?
Dr. Gregory Skinner (40:12):
And honestly, I really should do
many, many, many more of thosethan I do because of the need to
communicate about neurodiversityand neurospiciness. The first
thing right now, we're stillvery much at the bottom of the
curve of building people'sunderstanding and knowledge. So
right now, it's in the phase ofgetting people to understand
it's out there. Even when itdoesn't affect your own life
(40:34):
personally, it is the definitionof other people's lives is what
they're living. So, is real.
Neurodiversity is real. It'salways been here and the world
we're designing more and moreand more seems actually less
fit. Think about people who aregood at high technical jobs but
not good at social. The peoplewho could sit there and place
(40:55):
the rivets in the machine allday long. The people who notice
the small errors but more andmore we're requiring jobs to
have high levels of social skilland we've got a group of people
who are less socially skilled.
In the letter for in thereferral response, I give some
basic instructions to theoffices and I can sit here
saying, I'm not following my owninstructions because I'm not
(41:17):
wearing a name tag. Buteverybody, you know, making it
just that much socially easierso they know who they're dealing
with by something simple as nametags. I've been in clinics with
one light switch for the wholebuilding. How do you control
artificial lighting for lightsensitive people? Trying to
understand that these aredifferences and it's not
laziness.
Somebody with Level threerigidity could be very explosive
(41:39):
to the point they also get alabel of Intermittent Explosive
Disorder. And trying to helpthose people have care because
if something goes wrong at thereception desk, they're going to
get kicked out of the clinic,but they still need to be able
to access care. How do you dealwith people who can be difficult
(41:59):
when you realize that thatdifficult isn't a choice? It's
real. They misinterpret meaning.
People with autism might not getthe same message out of what you
said. It's almost like you'redealing with somebody who's not
that good in a second language,but you think they're good at it
and then they do something thattotally surprises you. So I
guess the website name for mesays it: Autism exists. It is
(42:22):
real.
Paul Cruz (42:25):
Looking ahead, how do you see adult autism diagnostics
evolving over the next five toten years?
Dr. Gregory Skinner (42:32):
So over that time span, I don't think I
see them evolving very much. Ithink they still seem to be
remaining on the same thing. Iam hoping that I can move my
version of the adult autismassessment tool from Cambridge
University back to them and havethat as an updated one for
Autism Spectrum, my AutismSpectrum evaluation tool, so
(42:52):
that that can help thepsychologists, the
psychiatrists, the familydoctors who are going to find
this falling on them because atone to two percent of the
population, instead of one intwo thousand or even older, one
in ten thousand data, There's alot more diagnosis needed than
there are specialists to do it.In terms of moving up, you know,
(43:13):
twenty percent, twenty fivepercent. Some studies showing
higher in terms of the geneticcauses they can identify for
autism.
There was a recent study I havenot read yet, but I have seen a
lot of people talking about itwhere they tried to divide four
genetic based behavior types ofautism. So, genetics someday
(43:33):
will play a bigger role. Still,although some people argue it
may be all genetic, other peopleargue there are still
environmental factors, so youwon't completely explain it with
genetics. MRI, I think it was inthe front of a Time magazine
years ago about the accuracy ofa functional MRI. I don't see
the health system gettingeverything set up for a
(43:54):
functional MRI to prove ordisprove autism diagnosis, and I
don't think I've seen thatanywhere.
The diagnosis still remains onclinical judgment and clinical
experience. More robust testing.At some point, we're going to
have to stop using the currenttests because the wording is out
of date. The estimates for thenon cis, non binary gender
identities, If you call it twopercent in the general
(44:17):
population, then people areestimating twenty percent in the
autism population. But we havetests with male data, female
data.
We don't know if we shouldfollow your assigned at birth
gender or your identifiedgender. We don't know. So, newer
studies and, of course, newerwording. The old inclusive tests
(44:37):
would say, Did he or she? Andthose were the inclusive ones,
trying to remember that therewere women.
And now, what about other peoplewho don't feel like they
identify clearly into he or she?Still, in ten years, probably
much the same tools.
Paul Cruz (44:52):
Finally, what keeps you motivated to continue this
work, and is there a particularpatient story that reminds you
why these matters?
Dr. Gregory Skinner (45:02):
What keeps me motivated is the need, is
knowing that they don't reallyhave anywhere else they can
afford to turn to and the comingback to it. Seeing it in
families. I've had familieswhere I've identified autism in
the mom, the brother, and theoriginal patient and then you
look into the kids afterwards.So many people coming because
(45:23):
their kids were identified. Thevariation.
I feel sometimes like I'vechosen the hardest part of
mental health medicine and madeit what I do all day long. So,
certainly, it's mentallystruggling but trying to
understand, Should I considerthis as different from average?
It's never the same person. Ihave people who, you know, they
(45:44):
can't chop vegetables while thestove is running. They can't
handle both tasks at the sametime.
I have people who running themicrowave leaves them in an
overwhelmed state for the restof the evening, so they have a
day ending crisis because theytried to heat up a frozen meal.
And these people are coming tome without any support. Some of
these things, it's like when yourealize they can't do it, it
(46:07):
seems so obvious they should besupported. But when you think
they just, well, that's weird.Don't you want to eat?
I think the person wants to eat.That's why they tried to manage
microwaving food yet again andthen wound up falling asleep in
their room after crying for afew hours yet again because they
can't manage it. So many littlevignettes on different people
for what it means for them.People telling me about failed
(46:32):
interactions with the policebecause they were assumed to be
doing differently or just madethem uncomfortable. I've also
had people telling me about goodinteractions with police, but
that struggle of beingdifferent, being different at
school, it's hard and manypeople don't see it.
Paul Cruz (46:51):
Do you have anything else to share with our listeners
that we have not discussed,Doctor Skinner?
Dr. Gregory Skinner (46:57):
Anything else that we have not discussed
regarding so many things wehaven't discussed, but what's
key. If you think about autismat between one to two percent of
the people in the subtle forms,that means you know people with
autism even if you don't thinkyou do. If you think you could
be a person with autism, it'squite possible because it is a
very individual diagnosis andthere are multiple pictures that
(47:20):
lead into it. There is room onthe autism spectrum for that so
called classical autism group,the people who are severely
disabled, and there is room onthere for the people who are
subtle but significant who'vekind of gotten along as just
kind of weird. It's easy to betaken advantage of because of
(47:40):
the over assumption of samenessin autism.
I used to try to use the wordegocentric to differentiate
autism from narcissism, but nowI've seen people, experts in the
narcissism field, the termegocentric, so I have to focus
on over assuming people are thesame. If I think I'm trust
worthy, I might mistake you astrustworthy, even though our
(48:01):
personal history might teach medifferently. I fall back on my
basic beliefs for other people,and everyone does. This starts
in a normal place, but the sizeof the holes autistic people are
plugging their own behavior intois much bigger. I could talk
about many other things, but I'mnot going to.
Paul Cruz (48:19):
Doctor. Skinner, thank you so much for sharing
your journey and insights withus today.
Dr. Gregory Skinner (48:24):
Thank you, Paul. Thank you for the time.
Thank you for reaching out. Thisis something people need to hear
more and more about, and you'reone of the people doing that
work. So thank you for all youdo for us.
Paul Cruz (48:35):
Your work shows just how powerful and life changing
an autism diagnosis can be,especially for adults who've
waited years for answers. To ourlisteners, if this conversation
resonated with you, please sharethis episode. Don't forget to
(48:55):
subscribe to the NeurodiversityVoices podcast whenever you get
your podcasts, and even rate ourpodcasts on your favorite
podcast app. If you have anyquestions, ideas or stories
you'd like to share, please feelfree to write us or sign up to
be a guest on our podcastwebsite at
www.neurodiversityvoices.com.We'd love to hear from you.
(49:21):
Until next time, take care, staycurious, and keep celebrating
the beauty of diverse minds.Thanks for listening to the
Neurodiversity Voices Podcast.Thank you for joining me today
on the Neurodiversity Voicespodcast. As an advocator with
(49:42):
lives in the balance, I'll leaveyou with this reminder: When we
collaborate with kids, we don'tjust solve problems, we change
lives.
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