February 19, 2025 • 51 mins
Autism Spectrum Disorder (ASD) has long been misunderstood, especially in women and girls. In this episode, we’re joined by Dr. Brady Bradshaw and Dr. Allison Brazendale, two experts in adolescent and adult mental health, to break down why ASD is often underdiagnosed in females. We dive into pink flags, the subtle signs that might indicate ASD, and discuss why so many girls and women go undiagnosed for years. Plus, we explore the overlap between ASD and ADHD, the role of sensory sensitivities, and how understanding ASD can lead to greater self-acceptance and connection.
Episode Highlights:
[00:03] – Welcome back! Introducing our expert guests, Dr. Brady Bradshaw and Dr. Allison Brazendale, and today’s topic: ASD in women and girls.
[01:55] – Why is autism so often underdiagnosed in females? Breaking down outdated stereotypes and the challenges of diagnosis.
[04:18] – Pink flags: The subtle early signs of ASD in girls that are often overlooked.
[06:50] – The effortful nature of social interactions and why masking can be exhausting.
[09:56] – How girls on the spectrum struggle with friendships and group dynamics.
[12:36] – The overlap between ADHD and autism—how to tell the difference.
[14:45] – What’s happening in the brain? Understanding the neurobiological differences of ASD.
[23:37] – Sensory sensitivities: Why environments like grocery stores can feel overwhelming.
[26:25] – Breaking the stigma: How the conversation around ASD is shifting, and why some are resistant to the diagnosis.
[33:13] – Signs of ASD in adult women—what to look for if you suspect you or someone you know might be on the spectrum.
[38:45] – ASD and relationships: Challenges in communication, perspective-taking, and emotional connection.
[47:55] – The strengths of ASD: Deep focus, intelligence, and unique ways of seeing the world.
Resources:
Dr. Brady Bradshaw’s website: https://www.bradybradshawmd.com/
Book: Is This Autism? https://www.amazon.com/This-Autism-Donna-Henderson/dp/103215022X/ref=asc_df_103215022X?mcid=c3343feccc2d380f97695f5d35
For more on this topic visit our website insightsfromthecouch.org If you have questions please email us at info@insightsfromthecouch.org we would love to hear from you!
If today's discussion resonated with you or sparked curiosity, please rate, follow, and share "Insights from the Couch" with others. Your support helps us reach more people and continue providing valuable insights. Here’s to finding our purposes and living a life full of meaning and joy. Stay tuned for more!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Laura Bowman (00:03):
Hi everybody.
Welcome back to another episodeof insights from the couch. We
are welcoming back Dr BradyBradshaw to the podcast. She was
on our ADHD episode. If you doremember, she is the owner of
Bradshaw and Associates inBaldwin Park. Dr Bradshaw is
double board certifiedpsychiatrist in both adult
psychiatry and Child AdolescentPsychiatry. And also joining us
(00:27):
is Dr Allison brazendale, alicensed clinical psychologist
specializing in child assessmentand therapy. Dr brazendale works
with children with ADHD learningdifferences and Autism Spectrum
Disorder. Dr brazendale is basedBradshaw and Associates. Also
(00:47):
Welcome guys. I'm so excited tohave you guys to talk about ASD
autism spectrum disorder inwomen and girls. This is a huge
new thing, right? Like this issomething that women are now
being identified at recordnumbers. So talk to us. What are
you seeing?
Brady Bradshaw, M.D. (01:07):
We are definitely diagnosing more, and
I know in my practice, I'mhearing more parents coming in
and bringing their daughterswith a concern for autism, or
even adult patients coming inand saying that they think that
they have autism. So I thinkthere's more of an awareness,
(01:27):
and people are starting topresent with that question a
little bit more frequently,maybe than we saw in the past.
There is still a huge underdiagnosis in women and girls
with autism, so especially forwhat we would call like high
functioning or highcamouflaging, higher IQ
patients, a huge under diagnosisis still is still there, but we
(01:53):
are seeing it more, which isgood.
Colette Fehr (01:55):
Can you guys explain a little bit about why
this is so often underdiagnosed, misdiagnosed in women
and girls in particular.
Dr. Allison Brazendale (02:05):
Yeah. So I think that, you know,
especially when I was getting mydoctorate, I think autism was,
you know, thinking about thosekids who don't make eye contact
and are having self injuriousbehaviors, or are non vocal, non
verbal, but what we have foundis that actually, you know, the
(02:27):
diagnosis is so much more vastthan that, and it's really about
a different variation in the waythat they think, right? And just
because you don't make eyecontact doesn't mean you don't
have autism. And I think that'sone of the main things that I
see. Is when a parent comes in,they're like, oh well, they make
(02:47):
eye contact with me. So it justcan't be autism, right? But the
diagnosis is there's sevendifferent criteria that you have
to meet in order to be diagnosedwith autism, and eye contact is
part of what we call a two whichis non verbal difficulties, and
that can include anything fromeye contact, how close you stand
(03:09):
to other kids understanding nonverbals, perspective, taking non
verbally so it's just so muchbigger than that. So I think
that in the past, maybe thesegirls were diagnosed with
oftentimes, I know Dr Bradshawand I see a lot oppositional
defiant disorder because they'rereally strong willed, or ADHD
(03:30):
because they're so impulsive.
But that doesn't explaineverything, and so what I feel
like we do as a practice isreally go deep into the history
and looking for what Dr DonnaHenderson, who's an expert in
diagnosis of high functioningautism, specifically in girls,
these pink flags from theirhistory, that kind of explains
(03:52):
some of these behaviors as theyget older. And as they get
older, the gap gets wider, andso I think that's often when
they come into us, and parentsare like, you know, they were
diagnosed with ADHD, but it'sjust not explaining everything.
There's something else there.
And when we do that deeper dive,we can see it,
Laura Bowman (04:12):
Ooh, what's a pink flag?
Colette Fehr (04:14):
Yeah, what are some of the pink flags? That's
what I want to know.
Dr. Allison Brazendale (04:18):
Some of those pink flags are, you know,
often we see emotionaldysregulation when they're
younger. So that's somethingthat I pick up on a lot. And of
course, that can mean manythings, right, anxiety, you
know, ADHD, some mood stuff,right? But when I see that, I'm
kind of like, okay, but meaning,
Colette Fehr (04:34):
meaning, like, for the listener, that their
emotions are kind of all overthe place, and they struggle to
regulate themselves when theyget emotional.
Dr. Allison Brazendale (04:43):
Yes, and big behavioral outbursts. You
know, big behavioral outbursts,we say big reactions to maybe
small problems. Well, we woulddefine as small problems, also
difficulties with personalspace. Sometimes they're like,
oh well, they never really knewa stranger. They would go and
hug kids. At the park, or adultsthat they had just met. And of
course, that can be typical too,but it's something that you
(05:06):
know, as the data, I like to sitin my data, and as the data is
coming together, that'sdefinitely something that I pick
up on as well.
Brady Bradshaw, M.D (05:13):
Interesting I was going to just add to back
to the question of, why are wemissing it in girls, or why is
there an under diagnosis ingeneral? And this is true for
autism, and people who are notautistic, females tend to have
more internalizing symptoms. Andso our diagnostic criteria for
(05:35):
autism, similar to ADHD, arereally focused on external
symptoms or things that we cansee. And so, you know, you can
see a child flapping, and it'slike, okay, they're having a
repetitive movement. That's acriteria. That's like, you know,
a check box. But if you have,especially a girl, their their
symptoms are more likely to beinternalized. So they might have
(05:59):
struggles with relationships,socially. They might know when I
meet somebody I'm supposed tomake eye contact, but it's not
intuitive, right? So it takes alot of effort that they have to
put in to say, Okay, I'm meetingsomeone. I'm supposed to make
eye contact. I'm supposed tosay, I have one little girl
every time she sees me, I likeyour shoes. She just like says,
(06:19):
I like your shoes, so
Colette Fehr (06:23):
something socially lubricating, right? Effort. It's
Brady Bradshaw, M.D. (06:28):
not intuitive, and they it requires
some effort. And I think thatthat also sort of hints at, or
sort of suggests that it can bean internal struggle, and like,
very draining for these kids.
Even if they can present on theoutside like they have it
together, it's a lot of effortto make it look like that on the
(06:48):
outside. And
Dr. Allison Brazendale (06:51):
speaking of effortful too, and that's a
really good point. A lot ofthose things that you know, even
having reciprocal conversation,they can absolutely specifically
on things that they really enjoyand their interests, but they
know by watching TV and watchingother people that you are
supposed to ask questions. Butagain, can be very effortful.
(07:11):
And when I am testing and youknow an adolescent female who is
on the spectrum, and I ask themabout that, they say it's very
taxing. It takes a lot ofeffort. It's not natural for
them to do that, but they knowthey should. And so that
experience can be reallyexhausting. And, you know, just
it doesn't feel it doesn't feelgood. So that, yes, I totally
(07:34):
agree that was
Colette Fehr (07:35):
it takes a lot of effort. And then are these,
like, let's say I'm a mom of agirl, and I'm not sure if some
of this is applying, is one ofthe things I might see that's
perhaps a pink flag reallystruggling with social
friendships and maintainingthose social friendships in a
fluid way.
Brady Bradshaw, M.D. (07:53):
Yeah, yeah. So that is some that is
part of the history that we getand the detail that we go into
when we're doing a diagnosticevaluation on like a teenager,
so who was their friend in firstgrade? Who was their friend in
second grade? Not that directly,but we're listening for that.
Can they maintain friendships?
Sometimes the girls on thespectrum are more able to make a
(08:14):
friend, but they struggle tokeep the friend because of their
rigidity socially, so theymight, you know, if a third
person comes in that throws themoff, and they can't, you know,
tolerate that, and so they, theystruggle to maintain
friendships. We can hear that alot of times in their history.
So relationships is a big one,
Colette Fehr (08:37):
and it's a rigidity. Brady, like it's a
rigidity around friendships, isit also difficulty picking up on
social cues,
Brady Bradshaw, M.D. (08:47):
all of those things. It's all of those
things. Yeah, so it's therigidity, it's the black and
white thinking, you know, in theyounger girls with autism, if
you're my friend, then you can'tbe her friend because you're my
friend, you know, or they justaren't sure how to navigate
that. I mean, navigating threepeople in a friendship can be
hard for girls who aren't on thespectrum, but the the nuance and
(09:10):
the non verbal communication andbeing able to tolerate maybe
feelings like you're being maybenot as favorite as the other
friend, they it's just it's toomuch, it's overwhelming, and
they struggle with navigatingthat. It's very difficult for
them to maintain friendships.
Laura Bowman (09:25):
Wow. It's so interesting, though too. It's
like the language of girls is sointricate, like, if you watch
girls, you know that areplaying, like on a cheer team or
a volleyball team. There's somuch language and so much
behavior that is intuitive andinstinctual, and if you can't
play along, if you can't rollwith it, you get, like, kicked
(09:47):
out pretty quickly. So I'massuming, like, are girls on the
spectrum? Are they notparticularly successful in group
dynamics? Yes,
Brady Bradshaw, M.D. (09:56):
that's true. They might be able to play
along. Young like, do the act oflike, okay, I make eye contact.
Oh, I laugh when she sayssomething, yeah. But they might
then also miss other people'snon verbal. So it's not just,
can I put out the non verbal?
Can I read the non verbal too?
So not realizing, like, theshifts that are non verbal, that
(10:17):
would be really, that would bereally a hard, a hard thing for
them to
Colette Fehr (10:20):
know, and I can see why this would require a lot
of effort and emotional energy,because these are things that
some people are doingsubconsciously, intuitively.
They're not giving any energy toit. They're not thinking about
it. You know, I just think aboutmyself. Navigating a social
situation requires nothing,whereas I'm thinking about it
(10:41):
like if I got into a piece ofmachinery that I had to learn
how to operate, and I read themanual, and I'm like, Okay, now
I need to do this. Or when Ifirst learned to drive a stick
shift car, right when the RPMsare here, I need to downshift,
and then I need to put theclutch in. So you're really
having to be so conscious andintentional, and then I would
(11:02):
imagine maybe the experience ofoften feeling like, despite that
effort, you're getting it wrong,and that must be so hard.
Dr. Allison Brazendale (11:10):
And that is how it's described. Often
when I'm doing diagnostics,thinking about group dynamics,
one of the things that I try tohelp them navigate is, what are
you interested in? Becausetypically, there's the double
empathy theory, which is like,you know, people who are alike
tend to obviously connect more.
And so figuring out what exactlyare you interested in and what
(11:32):
might be a good group dynamicfor you to be involved in. So
whether that's, you know, a lotof kids are into dungeons and
dragons or anime or arts, or,you know, there's like a few
like coding so there's somecoding classes. So those type of
things, I think that they have abetter experience because it's
(11:52):
of their interests, and theyfeel really comfortable in that
space. And then also, there areother kids that are probably
similar to them in that samesetting. That makes so
Colette Fehr (12:04):
much sense. It gives you a shared interest that
you can maybe more easily bondand engage Exactly.
Laura Bowman (12:11):
Let me ask you, I'm assuming that some that some
of these diagnoses just reallycross over and it's hard to pull
them apart, like ADHD andautism, how many of these things
kind of fly together? And whatdo you see in kind of like a
cluster, or where people come inand they're confused, like, is
this autism, or is this thisother thing? And how do you
(12:33):
decide if it's like autism?
Brady Bradshaw, M.D. (12:36):
There is a lot of overlap, that's for sure,
and there's a lot ofcomorbidity. So people with
autism do have higher rates ofADHD, think it's like 70% they
also have higher rates ofanxiety. So there is a lot of
overlapping symptoms, especiallybetween ADHD and autism. One of
(12:57):
the main differentiators that Ifeel and then Dr brazendale,
please take it from here. Butone of the main things that I
notice and feel pretty quicklyis the rigidity that people on
the spectrum can have. Becausepeople with ADHD can be very
flexible by nature, you know,they can kind of roll with it.
(13:17):
They can be impulsive, you know?
They can sort of go with things,but the rigidity that you can
feel with someone on thespectrum is very intense, and it
can be like, one example I'mthinking of is I had an adult
patient who wouldn't go out inthe rain because of that sensory
experience of getting rain donewas so uncomfortable that, like,
she needed to go to the grocerystore, and She wouldn't go
(13:39):
because it was raining. So, youknow, me introducing this idea,
like, well, could you just getan umbrella? Like, and it was
like, not like, no. I mean, ithadn't occurred to her, first of
all, and second of all, she waslike, Are you crazy? Like, it's
raining, you know. So therigidity, that's an that's an
extreme example, but therigidity is, like, palpable. It
feels really intense, especiallyif you're working with someone
(14:01):
therapeutically, or you're aparent trying to coach a kid to
go do something that they don'twant to do. That rigidity is
very intense. It's not easilyswayed. Like, oh well, we'll go
to Target afterwards. If you cancome with us to this restaurant.
It's like, right? No dice, youknow.
Colette Fehr (14:19):
Okay, so I have a question, as we're talking about
a lot of the symptoms and howthis can present, can you
explain just a little bit, evenfor the average person, what is
going on in the brain that leadsto this? Is this? Is this a
difference in brain functioning,or is it something else
(14:40):
altogether, because I don'treally know much about the
etiology or how it manifestsinternally.
Dr. Allison Brazendale (14:46):
Yeah, so it is a neurobiological
disorder, and so it is aboutlike the way that the brain
functions, the way that I liketo think of it, is really a
variation of the way that aneurotypical individual would
think. You know, in general. Allthe way that they experience the
world is just really different,or not really different, but it
(15:06):
is different from neurotypicalindividuals, and that is part of
the rigidity. And they tend tosee things more in black and
white and less in the gray. AndI think that is the way that
they are, that they think, andthat's what we know. And what Dr
Bradshaw was saying is probablyone of the biggest differences,
(15:28):
is that rigidity. And the otherthing I wanted to say too is I
also think the stereotypes arerepetitive. Motor movements is
another thing that reallydifferentiates it for me,
because commonly, a child withADHD, let's say may do something
repetitively, like, you know,they like to play with a certain
(15:49):
thing, or, you know, a certainway, or, you know, maybe they
have some very specificinterest. Or a gifted ADHD kid
might really hyper focus on onething, but once they master it,
they kind of move on. Typicallywith autism, you'll see more of
those repetitive motor behaviorslike flapping or pacing or
visual stimming, like looking atsomething as it's going around,
(16:12):
like wheels on a car, lining up,and then these very focused
interests that typically are onthings that maybe are a little
bit different for their age.
Like I had a seven year old whowas very interested in the
mechanics of roller coasters.
Knew everything about rollercoasters, how they functioned,
how they were built. It'samazing. Like, the interest they
have and the amount of I mean,it's such a gift, in my opinion.
(16:36):
I think it's awesome. Like thatpart of it is so cool. So I
think that those are the twothings that differentiate it.
And yes, I do believe that thebrain and the way that their
brain functions is more in thiskind of very structured
predictability is verycomforting to them. These motor
behaviors are very comforting.
Knowing everything aboutsomething is very comforting,
(16:56):
and that feels good to them,versus, you know, with ADHD, it
might be a different story. Itmight be just something that
they're super they want to go ona deep dive, and then they're
done. And it's
Brady Bradshaw, M.D. (17:06):
genetic.
There's a heritability to it aswell, which I think is another
indicator for us, theneurobiological way that this is
inherited. So it's oftengenetic. Sometimes there's a
parent further back, or agrandparent that had, you know,
was different, or, you know,didn't leave their house, or
whatever, you know, you can kindof hear it in the family
(17:26):
history. So it is genetic. Wethink it's related to mirror
neurons. We don't totallyunderstand the entire story, but
there's some involvement ofmirror neurons, which are
probably part of that socialhandbook that we were all born
with that they didn't get, youknow, and so that's some of the
theory, like most of psychiatry,a lot of it is theory that we're
(17:47):
trying to understand better that
Colette Fehr (17:52):
makes a lot of sense, though, mirror neurons,
because you end up connectingwith someone, because your
nervous systems kind of sync upand replicate without any
conscious effort due to thosemirror neurons. So I could see
that making sense, butinteresting to know that it is
different, and yet maybe it'snot fully understood why or how,
but it's inherited. Tends to beinherited, and then when you get
(18:16):
somebody coming into you, let'ssay with a daughter, are they
typically coming in saying, Isuspect my daughter may be on
the ASD spectrum, or are theycoming in for something else?
And then they're surprised thatthis is maybe what it is. I
mean, I'm sure you seeeverything. But what's the
typical scenario, or the mostcommon scenario
Brady Bradshaw, M.D. (18:42):
that's I'm laughing because Dr brazendale,
I feel like, has a reputation inthe community now, and so we're
often seeing people who havebeen seen by three or four
people before they've been seenby us. Interesting, and there's
still some lingering questions,or like Dr brazendale was saying
some things that are still notexplained by ADHD or anxiety,
(19:04):
and the parent still has thisfeeling like I'm not we're not
being totally understood here.
That's
Dr. Allison Brazendale (19:11):
exactly why I was smiling and laughing,
because I feel like by the timethey come, usually it's because
of that they've had a previousevaluation, and there's still
some stuff missing. And also Ifeel like I have a good
relationship with a lot of theschools around here. And
they'll, they'll kind of send mea text and say, hey, you know,
we're not really sure, but wethink, you know, we want to send
(19:32):
them to you. And then I'm kindof, you know, in my mind, like,
okay, you know, this may be morecomplex, and I like the more
complex cases, to be honest, andpart of my evaluation actually,
because I do find highfunctioning autistic individuals
like we were talking aboutbefore, they tend to mask really
well, and they do really wellwith adults. So when, you know,
(19:55):
commonly, a lot ofpsychologists, when they do
their diagnostic testing, theymeet with the kids one or two
times. Times in their office,and, you know, I'll read past
reports, and they're like, oh,they did really well. They made
good eye contact, they asked mea lot of questions. That's not
the full picture, right? BecauseI'm not a peer, so I'm not I'm
not stressful for them, becauseI, I don't have any expectations
(20:16):
for them socially, right?
Versus when they're with theirpeers. It commonly looks very
different. So actually, arequirement when I do diagnostic
testing is I go in and observethe child in their natural
environment with their peers,before they know who I am. And
so if I'm doing an autismdiagnosis or diagnostic
(20:37):
assessment, I will go to theschool and I will do an an
observation, not in theclassroom, because I if it's a
dual diagnosis, maybe ADHD, I'lldo half and half classroom. But
where I really want to see themis in that naturalistic peer
environment, lunch, pe recess,those environments, I want to
(21:01):
see what they look like whenthey have to socialize on their
own with their peers. Well, notsitting next to someone that
they had to write. I also wantto see what happens when they
get excited on the playground.
Are they flapping? Are theyposturing when they run? Are
they asking peers to dosomething over and over again?
Are they stimming? Are theytalking to themselves? Are they
talking to others? So that's asuper important part of my
(21:23):
evaluation, and I think thatgives me a lot of data. Yes, we
get both, but commonly they'recoming to me because they
haven't had answers. And thatpiece of data collection is the
most valuable thing that I cando in these diagnostic
assessments
Colette Fehr (21:43):
that makes so much sense. Okay, two quick
questions. I don't know. I hearthis all the time. I don't know
what stimming is. Stimming
Dr. Allison Brazendale (21:51):
can be a lot of different things.
Stimming can be things like weall stim, right? It's a
repetitive movement andbehavior. So my stim is, I, I
bite the inside of my mouth thatif I don't know it's an anxiety
stim, I It makes me feel calmer.
Some people pick their nails.
That's a stem. People can bouncetheir legs. That can be
(22:13):
considered a stem. Or, commonlyin autism, it may look like
flapping. Or they may take anobject, like I said, and look at
it from different angles. That'sa visual stem. So it's
Colette Fehr (22:25):
a repetitive kind of unconscious behavior that is
just constantly happening. I'mtrying to think of what I do as
a stem.
Brady Bradshaw, M.D. (22:35):
It's usually in an effort to soothe.
So it usually happens whenthey're over stimulated. So
like, if they're excited orthey're in an overstimulating
environment, it's a way thatthey're able to soothe their
nervous system is to have theserepetitive movements. So
sometimes it's even just likelittle finger movements that
they're doing with their handsin their lap. So it's not very
(22:57):
obvious, could be vocal stems?
Colette Fehr (23:01):
What's a vocal stem? What might be a vocal
stem? So it could
Dr. Allison Brazendale (23:04):
be like grunting repetitively or saying
specific noises, or just makingnoises repetitively with their
mouths. So oftentimes it canlook like a tick too. And so
teasing that apart is also canbe challenging. Same with OCD,
okay? And this is a way
Colette Fehr (23:22):
to, like, down regulate your nervous system,
seek comfort, self soothe. Sothen over stimulation is also a
part of this, often gettingeasily over stimulated by social
environments or so that's
Brady Bradshaw, M.D. (23:38):
the sensory piece that we see.
That's part of the diagnosticcriteria for autism, that they
tend to be either hypo or hypersensitive to different sensory
experiences, so loud noises orbright lights or the grocery
stores like hell for these kids,you know so or you know, too
(24:01):
much chaos in a classroom orsomething that's really, really
exciting. So I think a lot ofpeople in the common knowledge
about sensory experience can belike tags and clothes, or that
socks don't feel right, or shoesdon't feel right, jeans textures
of fabrics, you know. So there'sa lot of sensory challenges, and
(24:22):
we see more sensory issues ingirls, and so that can be
another pink flag. Compared toboys, they tend to be much more
sensory sensitive. Smells are abig one. They can be very
sensitive to different smells,and that can contribute to a
feeling of being overstimulated, and that might be
(24:42):
when you see some of thatstemming behavior.
Dr. Allison Brazendale (24:45):
Sorry, I was just going to say food,
eating. Oh, right, rituals andsensory differences related to
food or rigidity around eating,yeah,
Laura Bowman (24:54):
like certain foods, really, yeah. I mean,
I'll just disclose this, like myfather is probably. On the
autism spectrum, and was never,you know, back in the day, was
not diagnosed. He was just kindof a introverted chemical
engineer, right? And then Imarried probably the most ADHD
human on the face of the earth,and we reproduced. So you can
(25:16):
imagine what my kids are like.
It's just I have two that areprobably ADHD ASD combined, very
high functioning, very highmasking. But I live with all of
this stuff, and it's fascinatingto watch the genetic coil kind
of unravel in retrospect, likeeven because my my one cousin's
son is fully on the autismspectrum, and I even watch him
(25:39):
in meetings, and he'll grunt,he'll go, and I'm just looking
at all of us, and I'm just like,I see it now so clearly, but I
didn't see it. You know, whenyou're living it forwards, it's
hard to understand what you'relooking at. But now I do
understand. One of the things Iwanted to ask about is the
(26:00):
stigma. Are people coming in,like, afraid of this diagnosis,
not wanting it, especially ifthey have high masking kids
where, like, by all intents andpurposes, they're doing well in
school, they're they're prettywell, you know, everything's
fine, you know, but it's notfine, but it's fine. Are they
wanting this diagnosis? Are theypushing against it?
Dr. Allison Brazendale (26:25):
So I see a little bit of both. I will say
that as there's been more highlysuccessful individuals coming
forward, and, you know, sayingthat they're on the autism
spectrum, and, you know, withthis kind of neuro affirmative
push more the social modelversus medical which I, you
(26:46):
know, really believe in. And Ialso have been doing this for,
you know, 15 years or so, and Ifeel like autistic people are my
favorite people. I just findthem really amazing and awesome.
I also have several familymembers on the autism spectrum
who did not get diagnosed untilmuch later, my uncle, my cousin,
and there's a lot of phenotypein my family too. But anyway, I
(27:09):
feel like there, there is both.
And you know, oftentimes, DrBradshaw and I will recommend
this book, the book that youknow Donna Henderson wrote. It's
called, is this autism, and itis a very neuro affirmative book
about high functioning autism,and it takes the voices of
autistic people and it puts itin the book, and they explain
from their voice how each of thediagnostic criteria feels within
(27:34):
them. And I think it's a verypositive experience for parents
to read that, especially whenthat's on the table. And I try
to during an intake, I do a twohour very thorough intake, if I
do hear these pink flags that isan like a homework assignment, I
assign to the parents say, hey,you know, I want you to read
(27:55):
this book, and I want you to seewhat resonates with you, because
that kind of sets up the neuroaffirmative process for this
diagnosis. And I think it doesfeel comforting and good to read
about. You know, these, likechemical engineers and CEOs of
large companies, surgeons, youknow, these very focused, very
successful individuals in theircraft and how they're so
(28:17):
successful and also on theautism spectrum. So I do feel
like the stigma is less, butit's definitely still there. But
I do think there's, there's abig push. I know on Tiktok,
there's a lot of teenagers theyI forget what they call it, but
I don't have Tiktok, but maybeDr Bradshaw would know better
than me, but I know that theycall it something where they
(28:39):
want to be on the autismspectrum, because it's part of a
community, which I think iscool. I
Colette Fehr (28:45):
think it's become kind of en vogue among younger
people, particularly right now.
So I'm curious, as you say this,I have a client who comes to
mind, who's an adult female, andobviously this is not something
I know a lot about hence myquestions. I can think of
clients who probably fit some ofthis, but it's not something I'm
(29:05):
super plugged into, and thisparticular female client was
recently diagnosed being ASD. Inever in a million years would
have guessed that by any way shebehaved or presented, just with
my kind of very average,rudimentary, probably
(29:26):
stereotypical, you know, otherthan taking psychopathology and
like the brief dive into it inthe DSM, this is not really
something I've thought aboutmuch since then, you know, 1520,
years ago. So what is it looklike in an adult woman who maybe
hasn't been diagnosed, and I'msure there's variability, but
let's say a high functioningadult woman who may be ASD and
(29:50):
not realize or have suspicions.
Brady Bradshaw, M.D. (29:56):
I think that's such a wonderful
perspective that your brain.
Being because what I wasthinking of when you were
describing her, the banner issueI feel for for folks on the
spectrum, when they present to atherapist, is feeling
misunderstood. Yeah, so youdon't need to be knowledgeable
in autism to help someone feelunderstood. And so for if I had
(30:19):
an adult present with autism asa therapist, and I was kind of
working with them, I wouldreally want to be so curious and
hold space for her. Tell me,what does that mean for you?
Like, what? How does that lookfor you? And really empathizing
with my God, how much you havebeen through how much effort you
(30:40):
must have made to pull this offto be able to get this far and
not get diagnosed. I mean, youmight, I mean, how exhausting
these social experiences were,how invalidating, you know, was
your home life when you weremade to take a shower, even
though it was so sensoryoverload painful for you, you
know? I mean, I think we cancome with a perspective of help
(31:00):
me understand absolutely notbecause I want you to teach me
that's not your job, but becausethat, I think, is the work of
therapy, and really therapeuticfor someone who feels like
they've been misunderstood theirentire life, I think when they
present to you, They might lookneurotypical and look like
there's no autism underlying butif you give them permission to
(31:23):
open up about their experience,you might see more as they
become more comfortable withyou, that you're a safe place.
And like, if they need to stem,they can stem if they I have
somebody who sits in differentcolored lighting now, you know,
you know. So it's almost likegiving permission to sort of,
you don't have to camouflagehere if you need to turn your
camera off because my eyecontact is freaking you out.
(31:46):
That's okay, you know. But justsort of asking, What does this
look like for you? And, youknow, being really sensitive to
their experience and their innerexperience,
Colette Fehr (31:58):
I mean, that all makes perfect sense. And I just
wonder if there are typicalthings that are part of the
process, because some of thethings, and I know this is like,
everything, right? When you're atherapist, a psychologist,
you're you're learning aboutdisorders, you find like, 10
things in the DSM that you'relike, oh my god, I'm kind of
(32:20):
this, or I'm kind of that,right? I mean, some of the
things you described, I don'tthink that in any way, that I'm
probably ASD, but, you know, Ihave tactile issues. I'm
impulsive. I There's a millionthings. So I guess I'm just
wondering too, because even thisclient I'm describing, you know,
I have a wonderful rapport withher, and she was and she has a
(32:44):
lot of complex PTSD, so there'slike, a lot going on there that
I don't think she had any cluethat any of this applied to her.
So I would imagine there may bewomen out there in middle age
who don't realize that thiscould be a thing, like, what
(33:05):
could they look for? What mightbe some of the signs that
there's high functioning autismpresent in an adult female?
Brady Bradshaw, M.D. (33:14):
So the rigidity, like we talked about,
the rigidity, is one thing. Sohaving, like, a really strong
insistence on it being this way,or it has to be this way, there
can be a concrete use oflanguage. So that's another way
in the therapy office that theymight look different. So not
understand, you know, not beingable to understand jokes is the
extreme example of it. But theycan be very concrete in how they
(33:37):
interpret language. Concrete,
Colette Fehr (33:39):
okay? So like somebody, I'm just thinking,
sorry to interrupt you, but ifsomebody who in my office, we
have these two pictures in thewaiting room, this is so funny,
actually, and telling and how Idon't pay attention to certain
things. So I bought them as aset. I thought they like went
together. Well, it's actuallythe same exact picture. It's
(34:00):
like an abstract I bought thesame picture twice, and I hung
them up. They're still out thereas like, here's this set. One of
my ASD clients was waiting forme one day, and she was like, Do
you know that's the exact samepicture? I said, No, no, they're
they're a set. And she's like,No, look, this is the same as
this. And I was like, wait,what? And I'm like, Oh, my God,
(34:23):
I bought two of the same pictureand tried to make it like an
artistic moment. In a millionyears, I wouldn't notice that.
I'm just like, oh, this ispretty here. Grab it, right? But
like, she had zoomed in on itand, like, found this thing. And
was like, these are the same,right? So is that some of the
like honing in on things and,
Laura Bowman (34:46):
yeah, so interesting. And is it, can I
also say, is it just a littlebit of a felt sense? I mean, I
know we all have our diagnosticcriterias and we have our
checklists, and we have to ask,we have to do a lot of good. Um.
Information taking and historytaking. But is there a felt
sense, you know, just like alittle bit of space between
(35:07):
beats, a little bit of, like,woodenness, or that you're just
like, oh, or am I making thatup?
Dr. Allison Brazendale (35:14):
Yeah, no, that's part of the
diagnostic process for autism.
Is what I use is somethingcalled the ADOS. It's the autism
diagnostic observation schedule.
It's been coined kind of likethe gold standard of autism
testing, although it does missmany girls. So there's a lot of
controversy kind of surroundingthat, but I do find it a helpful
(35:36):
measure. But one of the thingsthat you code on in the ADOS is
reciprocal communication. Andthen, you know, kind of this,
like, social initiation, orovertures, like, how does it
feel? And so kind of what you'resaying, you know, if I'm
dropping a bid, and I'll saysomething like, Oh, I'm going on
vacation next week, right? Youwould expect, where are you
(35:57):
going? Yeah. So if there's alittle bit of like, and then
there's that awkward silence,and then it's, Oh, where are you
going? Or, you know, Dr Bradshawand I had a child that we were
sharing, and we like to co treatas well, because it's really
helpful to be able to bounceideas off each other, especially
when there are these morecomplex, high functioning cases.
(36:20):
And she seemed very social, butthen lacked depth. And so that's
something that you would justexpect a little bit more from.
So in that way, it is a sharedexperience, right? Like you're
answering the questions, butthere's not like more to it as
we're peeling away the onionkind of so yes, that is
(36:42):
definitely something that I lookat. I drop a lot of bids to see
what's picked up, like breadcrumbs, you know.
Brady Bradshaw, M.D. (36:48):
And I think for adults, if we're
thinking about adults,especially the concreteness,
when you're especially trying todo therapy, where you're asking
about, well, you know, some kindof deeper meaning, or, like,
their inner experience, and it'sgets brought back quickly to
whatever the concrete facts are.
And it can have a feeling tosomeone who's not on the
(37:08):
spectrum and in the room withyou therapy, I'm kind of like,
why are we back here? Like,wait, no, I'm trying to connect
a meaning here, you know. Sothat depth and meaning piece, I
think, can, it can feel harderto get to sometimes, because
they're so focused on, like, theblack and white, like data
points of like, well, but thisis the reality my, you know, I
can't pay my mortgage, orwhatever it is, and it just
(37:30):
keeps coming back to that, andit feels like you're hitting a
wall almost.
Colette Fehr (37:36):
I bump into that in couples therapy, for sure,
especially with the type ofcouples therapy I do Emotionally
Focused, that is a lot aboutexploring your inner world and
nuance, and what does that meanto you? And you know, having a
lot of people from like Lockheedand engineers and surgeons, and
(37:58):
they just don't have and some ofthem, ASD may be a part of it,
they just don't have much there.
And the last thing I want to dois, you know, pursue someone for
something that isn't in theirnatural repertoire, but that can
be a challenging connection. SoI feel like I would be remiss to
not ask you a little bit aboutthe relationship front here,
(38:20):
because I would imagine that itmay be challenging to be in a
relationship someone who's moreclassically neurotypical with
someone ASD Do you see that thatcan be a struggle? Because I
feel like that's probablyshowing up in my office,
(38:41):
probably even more than Irealize.
Dr. Allison Brazendale (38:45):
Yeah, I do. I think that, you know,
going back to, you know, thefriendship and relationship
piece, it can be hard tonavigate and, you know, look at
perspective taking right? So howdoes someone else feel in this
situation and that concretenessof like, well, no, because that
doesn't feel good for me, or Idon't want to do that. And so
the answer is no versus like,okay, the answer is no, but and
(39:10):
I can maybe be flexible and tryto think about it a different
way. I think that is somethingthat can be more challenging. I
Brady Bradshaw, M.D. (39:18):
think that we can hear for couples,
sometimes they can feel a littlenarcissistic and ASD partner,
because they have that strugglewith perspective taking. So I'm
not really always aware of myown inner world. And now you
want me to try to be aware ofsomeone else's inner world
experience. It's like, wow,that's a big leap, you know? And
(39:38):
so I would guess I'm not acouple's therapist. You can
correct me, but I would guessthat the effort is to understand
the ASD individuals experiencein the relationship, and what
are they capable of? Becausethey have a great sense of
empathy, and they can sense thatsomething's up. They just might
not be sure what the meaning is.
Yeah. So you're mad at me, butwhat? Actually, maybe they're
(40:01):
like, stressed about somethingthat happened at work, you know?
So there can be an effort tounderstand on both sides that it
can work. It's not doomed, butit's just, it's not, maybe, as
intuitive the understanding,
Colette Fehr (40:16):
yeah, I think it's really important. I've had
multiple people when theirpartner or spouse has been
diagnosed ASD say it's such arelief, because now at least I
may not take certain things aspersonally. You know, sometimes
people who are reallyemotionally fluent and attuned,
they're coming in going, what isthis response like, What the
(40:38):
fuck is wrong with you? I saythis heartfelt thing, and then
you look at me with a blankstare, like, fuck you. You know
they're so offended and hurt byit. And if this is at least part
of what's at play, and there area host of other things that can
be factors too, of course, butif ASD is part of it, then it's
like, Oh, okay. You know you'renot not caring. You show caring
(41:00):
differently, and let's work onthis as a team so that we can
understand each other with alittle more explicitness and
grace.
Laura Bowman (41:11):
To that end, I'm wondering, what is it? Because
I'm thinking about it, even thework I do with my own children
in my house is the role of thetherapist with a client, and
what, what people on thespectrum can really get out of
therapy? Because I do a lot ofyou know, I have very black and
white thinking children rightand wrong. And I'm doing, I'm
(41:32):
lending out a lot of my graybrain, you know, of let's think
about it this way. Can you takethis particular perspective? Can
we what kind of meaning I'm, youknow, I'm making this meaning.
What meaning are you making? I'mdoing a lot of that work all the
time, naturally. Is thatsomething that people with ASD
can work a lot on in atherapeutic relationship and
(41:54):
have somebody to sort of bouncethat off of?
Dr. Allison Brazendale (41:59):
Yeah, absolutely. I think those are
all, you know, things that I doin my own practice. A lot of
what you're saying. I also thinkthat, you know, I feel like back
in the day, when we were first,you know, diagnosing, or before
we had a lot of knowledge, therewas a lot of push to change
autistic individuals to lookneurotypical, and that is no
(42:20):
longer, at least how I dotherapy. I know at our practice,
we don't do that becauseultimately, sometimes it's a
them problem, like, if it feelsuncomfortable for you that your
child isn't making eye contactwith you, what? Why is that
uncomfortable for you? Right?
Because if it feels souncomfortable for them, and
that's not part of how they liketo experience the world. Why are
(42:43):
we making them make eye contact,you know? And so I think a lot
of what I do, too, is likeperspective taking like, yeah,
look, if eye contact doesn'tfeel good for you, don't make
eye contact. Or if stimmingfeels great for you, stim.
However, here's how other peoplemight interpret that, and so you
just think about that as you'redoing it. Because that's, that's
the the knowledge I feel is, youknow, you need to do what feels
(43:08):
good for you, just like we woulddo for anything, right? So
someone who's having a panicattack, if you're having a panic
attack, and you're having apanic attack in front of a lot
of people, here's what it'sgoing to look like to the
outside world, even though thisis your internal experience,
it's kind of the same thing. Sohow do we do that differently or
not? But then it kind ofaccepting that this is what
(43:29):
feels good for you, and feelingfine about it, right? So I think
that's a big part of what I do,too, you know? But I think
flexibility teaching isimportant because, yeah, like,
we do a lot about a lot of workaround cognitive flexibility,
and I think that's good foranyone and how for everyone,
yeah, and how, if you are blackand white, here's how other
(43:50):
people are going to experiencethat. Yeah, yeah, no,
Colette Fehr (43:54):
oh, God. I'm married to someone who is like
the king of black and white,concrete and rigidity, whatever
the heck. In fact, I'm thinking,maybe I need to have him come
see you guys and take a littletest. To that end, Sorry, Steve,
you'll be hearing this live onYouTube. Nothing new. I'm pretty
(44:15):
outspoken about every thoughtthat crosses my mind. But To
that end, what is the processfor, let's say, an adult. Do
they make an appointment withyou guys, or someone like you
guys, and are there they takesome tests like, how do you if
you're an adult and you suspectthis may be a factor, how do you
go about figuring that out?
Brady Bradshaw, M.D. (44:35):
So it is a clinical diagnosis similar to
ADHD. So there can be, you know,a psychologist or a
neuropsychologist who might doformal testing for autism. You
could also see a psychiatrist,an MD, who specializes in
diagnosing adults with autism.
Usually, that means they havesome background in adult
(44:56):
psychiatry and child psychiatry.
Tree, because it's neurodevelopmental so the child
psychiatrists tend to get alittle more training in that
background, but you certainly ifyou were seeking to understand
more or you suspected some typeof neurodivergence, you would
want to make sure that theperson you're making an
(45:18):
appointment with has experienceand a reputation for knowing how
to diagnose adults with autism,because it's not every
psychiatrist and everypsychologist, it definitely can
be missed,
Colette Fehr (45:29):
okay, and that is something you all do correct,
not just children, but alsoadult diagnoses. I do,
Brady Bradshaw, M.D. (45:35):
Dr brazenda Does it? Okay? Yeah,
Dr. Allison Brazendale (45:37):
I do up to 18 typically, is where I feel
the most comfortable, but I haveother colleagues that are
psychologists that do it, andthen Dr Bradshaw does it as
well,
Colette Fehr (45:46):
right? And Dr Bradshaw, you have that dual
board certification, right?
Child psychiatry, adultpsychiatry, so that's that
important criteria. You want toreally make sure, like so many
of these things with therapytoo, right? You don't want to go
to someone, well, I was going tosay something, but some people
may not like that. You don'twant to go with someone with a
(46:07):
cert if they don't have traumaexperience. Let's just, let's
just leave it at that, if youhave complex PTSD. So it's
really important to find theright professional. And it
Brady Bradshaw, M.D. (46:23):
takes time. And it does take times. I
don't you know if I'm doing anevaluation like this, it's an
hour, and then I might be seeingyou at another hour, and it
might take me to hour three orhour four before, not that
that's all part of theevaluation, but I'm getting to
know the person, and then I'mthen I'm seeing, like, okay,
there's like, a super you know,either there's a concreteness
(46:43):
that we're not getting past, or,like, there's a sort of non
verbal issues I'm picking up onthat, like, weren't just anxiety
about a first visit. So it takestime. It's, it's, there's a lot
of overlapping symptoms withother disorders like we
mentioned. You know, I'm gladthat there's more out there on
social media, on Tiktok and allof that. And so when patients
(47:04):
bring it to me and say, youknow, I saw this on Instagram,
and now I think I have it, Itake that really seriously. It's
not like, I'm gonna say, Oh,well, if Instagram said it, then
you do. But I'm like, okay,like, what is that resonating
with? Because I may not beseeing it all. I might not be
seeing inside what's going onfor you. So tell me about why
that resonated. What did younotice? So it can take some time
(47:24):
to get to know someone to makethe diagnosis. Also, sometimes
for women, especially if theyhave a history of multiple
diagnoses. So this doctor toldme I had borderline personality.
This doctor told me I hadoppositional define as a kid.
This doctor told me I hadbipolar, you know. So if I start
to hear multiple diagnoses,that's another thing that I'm
(47:45):
like, okay, maybe we've missedone, you know, underlying
unifying diagnosis here withautism,
Laura Bowman (47:55):
that's fascinating. And just to, just
to, kind of like, end on more ofa positive note, like, what are
some of the really cool thingsabout people that have ASD and
especially some of the uniquethings you see their abilities
or strengths?
Dr. Allison Brazendale (48:13):
I mean, like I mentioned before, the
fund of knowledge that they haveabout things that they're
interested in is, I mean, it'sjust absolutely incredible. And
the way that they can interpretthe world, I think, is also
pretty amazing. I also, I saythis often, because oftentimes
they know when to be like, No, Idon't want to be in this social
(48:34):
situation, which I think a lotof times. I mean, even for
myself, I'll push myself intosituations where I'm like, Oh,
well, I need to go talk to theseparents, or I need to go to this
birthday. Go to this birthdayparty where I would rather just
be at home and recharge. And Ithink they have a, honestly,
like, a better handle on that.
And I think that's a reallyadmirable thing. They're
extremely intelligent, and Ithink that the way that they can
(48:56):
focus on a craft is, you know,unmatched. It's very, very cool.
Wow.
Brady Bradshaw, M.D. (49:03):
You can definitely see like a giftedness
in certain areas and differentpeople. And it depends on the
individual. Of course, that isstunning. And, you know, can
bring tears to my eyessometimes, when I'm hearing them
talk about something thatthey've come up with, it's
usually Uniquely Creative andjust blows you out of water.
Laura Bowman (49:25):
Yes, I've seen that too, and I think it's this
fine dance between learning howto be in a world full of
neurotypical people and alsoreally honoring your own the way
your brain works and the way youneed your environment set up and
moving between those two things.
But I'm glad we're talking aboutit, and I'm glad it's out there
(49:45):
more and that people are beingable to understand themselves,
because there's nothing worsethan like, being diagnosed with
like, four different things andgoing, what the hell is going on
with me? And
Colette Fehr (49:58):
like you all said, the experience that. Being
misunderstood is so painful andso isolating. So I think it is
really important that we allunderstand it better and make
space for everyone to feel moreunderstood and have permission
to be who you are, right, and ifother people don't like it,
tough shit.
Dr. Allison Brazendale (50:19):
Yeah, exactly perfect
Colette Fehr (50:22):
way to end our time together. Ladies, thank you
so much. I have learned atremendous amount. It's
fascinating. It's so importantto understand, and I know our
listeners will have to we're sograteful to you for your time
and expertise. And of course, ifpeople who are local or in
(50:43):
Florida, right, can makeappointments with you all if
they would like to. I mean, Iknow you don't have a ton of
free space, but is thatsomething that it's okay to say?
Dr. Allison Brazendale (50:54):
Yeah,
Brady Bradshaw, M.D. (50:57):
I'm really do. We are both very passionate
about raising awareness aroundthis topic, so we appreciate you
guys giving the time to it andletting us talk about it. Yeah,
Colette Fehr (51:07):
I think it's really important. And we'll link
to how to get in touch with youin the show notes and everyone
listening. Thank you so much. Ifyou have questions for us,
please reach out to us at info,at insights from the couch.org.
We hope you got some valuableinsights from our couch today,
and we will see you next time.
Bye guys. You.
Hi everybody.
Welcome back to another episodeof insights from the couch. We
are welcoming back Dr BradyBradshaw to the podcast. She was
on our ADHD episode. If you doremember, she is the owner of
Bradshaw and Associates inBaldwin Park. Dr Bradshaw is
double board certifiedpsychiatrist in both adult
psychiatry and Child AdolescentPsychiatry. And also joining us
(00:27):
is Dr Allison brazendale, alicensed clinical psychologist
specializing in child assessmentand therapy. Dr brazendale works
with children with ADHD learningdifferences and Autism Spectrum
Disorder. Dr brazendale is basedBradshaw and Associates. Also
(00:47):
Welcome guys. I'm so excited tohave you guys to talk about ASD
autism spectrum disorder inwomen and girls. This is a huge
new thing, right? Like this issomething that women are now
being identified at recordnumbers. So talk to us. What are
you seeing?
Brady Bradshaw, M.D. (01:07):
We are definitely diagnosing more, and
I know in my practice, I'mhearing more parents coming in
and bringing their daughterswith a concern for autism, or
even adult patients coming inand saying that they think that
they have autism. So I thinkthere's more of an awareness,
(01:27):
and people are starting topresent with that question a
little bit more frequently,maybe than we saw in the past.
There is still a huge underdiagnosis in women and girls
with autism, so especially forwhat we would call like high
functioning or highcamouflaging, higher IQ
patients, a huge under diagnosisis still is still there, but we
(01:53):
are seeing it more, which isgood.
Colette Fehr (01:55):
Can you guys explain a little bit about why
this is so often underdiagnosed, misdiagnosed in women
and girls in particular.
Dr. Allison Brazendale (02:05):
Yeah. So I think that, you know,
especially when I was getting mydoctorate, I think autism was,
you know, thinking about thosekids who don't make eye contact
and are having self injuriousbehaviors, or are non vocal, non
verbal, but what we have foundis that actually, you know, the
(02:27):
diagnosis is so much more vastthan that, and it's really about
a different variation in the waythat they think, right? And just
because you don't make eyecontact doesn't mean you don't
have autism. And I think that'sone of the main things that I
see. Is when a parent comes in,they're like, oh well, they make
(02:47):
eye contact with me. So it justcan't be autism, right? But the
diagnosis is there's sevendifferent criteria that you have
to meet in order to be diagnosedwith autism, and eye contact is
part of what we call a two whichis non verbal difficulties, and
that can include anything fromeye contact, how close you stand
(03:09):
to other kids understanding nonverbals, perspective, taking non
verbally so it's just so muchbigger than that. So I think
that in the past, maybe thesegirls were diagnosed with
oftentimes, I know Dr Bradshawand I see a lot oppositional
defiant disorder because they'rereally strong willed, or ADHD
(03:30):
because they're so impulsive.
But that doesn't explaineverything, and so what I feel
like we do as a practice isreally go deep into the history
and looking for what Dr DonnaHenderson, who's an expert in
diagnosis of high functioningautism, specifically in girls,
these pink flags from theirhistory, that kind of explains
(03:52):
some of these behaviors as theyget older. And as they get
older, the gap gets wider, andso I think that's often when
they come into us, and parentsare like, you know, they were
diagnosed with ADHD, but it'sjust not explaining everything.
There's something else there.
And when we do that deeper dive,we can see it,
Laura Bowman (04:12):
Ooh, what's a pink flag?
Colette Fehr (04:14):
Yeah, what are some of the pink flags? That's
what I want to know.
Dr. Allison Brazendale (04:18):
Some of those pink flags are, you know,
often we see emotionaldysregulation when they're
younger. So that's somethingthat I pick up on a lot. And of
course, that can mean manythings, right, anxiety, you
know, ADHD, some mood stuff,right? But when I see that, I'm
kind of like, okay, but meaning,
Colette Fehr (04:34):
meaning, like, for the listener, that their
emotions are kind of all overthe place, and they struggle to
regulate themselves when theyget emotional.
Dr. Allison Brazendale (04:43):
Yes, and big behavioral outbursts. You
know, big behavioral outbursts,we say big reactions to maybe
small problems. Well, we woulddefine as small problems, also
difficulties with personalspace. Sometimes they're like,
oh well, they never really knewa stranger. They would go and
hug kids. At the park, or adultsthat they had just met. And of
course, that can be typical too,but it's something that you
(05:06):
know, as the data, I like to sitin my data, and as the data is
coming together, that'sdefinitely something that I pick
up on as well.
Brady Bradshaw, M.D (05:13):
Interesting I was going to just add to back
to the question of, why are wemissing it in girls, or why is
there an under diagnosis ingeneral? And this is true for
autism, and people who are notautistic, females tend to have
more internalizing symptoms. Andso our diagnostic criteria for
(05:35):
autism, similar to ADHD, arereally focused on external
symptoms or things that we cansee. And so, you know, you can
see a child flapping, and it'slike, okay, they're having a
repetitive movement. That's acriteria. That's like, you know,
a check box. But if you have,especially a girl, their their
symptoms are more likely to beinternalized. So they might have
(05:59):
struggles with relationships,socially. They might know when I
meet somebody I'm supposed tomake eye contact, but it's not
intuitive, right? So it takes alot of effort that they have to
put in to say, Okay, I'm meetingsomeone. I'm supposed to make
eye contact. I'm supposed tosay, I have one little girl
every time she sees me, I likeyour shoes. She just like says,
(06:19):
I like your shoes, so
Colette Fehr (06:23):
something socially lubricating, right? Effort. It's
Brady Bradshaw, M.D. (06:28):
not intuitive, and they it requires
some effort. And I think thatthat also sort of hints at, or
sort of suggests that it can bean internal struggle, and like,
very draining for these kids.
Even if they can present on theoutside like they have it
together, it's a lot of effortto make it look like that on the
(06:48):
outside. And
Dr. Allison Brazendale (06:51):
speaking of effortful too, and that's a
really good point. A lot ofthose things that you know, even
having reciprocal conversation,they can absolutely specifically
on things that they really enjoyand their interests, but they
know by watching TV and watchingother people that you are
supposed to ask questions. Butagain, can be very effortful.
(07:11):
And when I am testing and youknow an adolescent female who is
on the spectrum, and I ask themabout that, they say it's very
taxing. It takes a lot ofeffort. It's not natural for
them to do that, but they knowthey should. And so that
experience can be reallyexhausting. And, you know, just
it doesn't feel it doesn't feelgood. So that, yes, I totally
(07:34):
agree that was
Colette Fehr (07:35):
it takes a lot of effort. And then are these,
like, let's say I'm a mom of agirl, and I'm not sure if some
of this is applying, is one ofthe things I might see that's
perhaps a pink flag reallystruggling with social
friendships and maintainingthose social friendships in a
fluid way.
Brady Bradshaw, M.D. (07:53):
Yeah, yeah. So that is some that is
part of the history that we getand the detail that we go into
when we're doing a diagnosticevaluation on like a teenager,
so who was their friend in firstgrade? Who was their friend in
second grade? Not that directly,but we're listening for that.
Can they maintain friendships?
Sometimes the girls on thespectrum are more able to make a
(08:14):
friend, but they struggle tokeep the friend because of their
rigidity socially, so theymight, you know, if a third
person comes in that throws themoff, and they can't, you know,
tolerate that, and so they, theystruggle to maintain
friendships. We can hear that alot of times in their history.
So relationships is a big one,
Colette Fehr (08:37):
and it's a rigidity. Brady, like it's a
rigidity around friendships, isit also difficulty picking up on
social cues,
Brady Bradshaw, M.D. (08:47):
all of those things. It's all of those
things. Yeah, so it's therigidity, it's the black and
white thinking, you know, in theyounger girls with autism, if
you're my friend, then you can'tbe her friend because you're my
friend, you know, or they justaren't sure how to navigate
that. I mean, navigating threepeople in a friendship can be
hard for girls who aren't on thespectrum, but the the nuance and
(09:10):
the non verbal communication andbeing able to tolerate maybe
feelings like you're being maybenot as favorite as the other
friend, they it's just it's toomuch, it's overwhelming, and
they struggle with navigatingthat. It's very difficult for
them to maintain friendships.
Laura Bowman (09:25):
Wow. It's so interesting, though too. It's
like the language of girls is sointricate, like, if you watch
girls, you know that areplaying, like on a cheer team or
a volleyball team. There's somuch language and so much
behavior that is intuitive andinstinctual, and if you can't
play along, if you can't rollwith it, you get, like, kicked
(09:47):
out pretty quickly. So I'massuming, like, are girls on the
spectrum? Are they notparticularly successful in group
dynamics? Yes,
Brady Bradshaw, M.D. (09:56):
that's true. They might be able to play
along. Young like, do the act oflike, okay, I make eye contact.
Oh, I laugh when she sayssomething, yeah. But they might
then also miss other people'snon verbal. So it's not just,
can I put out the non verbal?
Can I read the non verbal too?
So not realizing, like, theshifts that are non verbal, that
(10:17):
would be really, that would bereally a hard, a hard thing for
them to
Colette Fehr (10:20):
know, and I can see why this would require a lot
of effort and emotional energy,because these are things that
some people are doingsubconsciously, intuitively.
They're not giving any energy toit. They're not thinking about
it. You know, I just think aboutmyself. Navigating a social
situation requires nothing,whereas I'm thinking about it
(10:41):
like if I got into a piece ofmachinery that I had to learn
how to operate, and I read themanual, and I'm like, Okay, now
I need to do this. Or when Ifirst learned to drive a stick
shift car, right when the RPMsare here, I need to downshift,
and then I need to put theclutch in. So you're really
having to be so conscious andintentional, and then I would
(11:02):
imagine maybe the experience ofoften feeling like, despite that
effort, you're getting it wrong,and that must be so hard.
Dr. Allison Brazendale (11:10):
And that is how it's described. Often
when I'm doing diagnostics,thinking about group dynamics,
one of the things that I try tohelp them navigate is, what are
you interested in? Becausetypically, there's the double
empathy theory, which is like,you know, people who are alike
tend to obviously connect more.
And so figuring out what exactlyare you interested in and what
(11:32):
might be a good group dynamicfor you to be involved in. So
whether that's, you know, a lotof kids are into dungeons and
dragons or anime or arts, or,you know, there's like a few
like coding so there's somecoding classes. So those type of
things, I think that they have abetter experience because it's
(11:52):
of their interests, and theyfeel really comfortable in that
space. And then also, there areother kids that are probably
similar to them in that samesetting. That makes so
Colette Fehr (12:04):
much sense. It gives you a shared interest that
you can maybe more easily bondand engage Exactly.
Laura Bowman (12:11):
Let me ask you, I'm assuming that some that some
of these diagnoses just reallycross over and it's hard to pull
them apart, like ADHD andautism, how many of these things
kind of fly together? And whatdo you see in kind of like a
cluster, or where people come inand they're confused, like, is
this autism, or is this thisother thing? And how do you
(12:33):
decide if it's like autism?
Brady Bradshaw, M.D. (12:36):
There is a lot of overlap, that's for sure,
and there's a lot ofcomorbidity. So people with
autism do have higher rates ofADHD, think it's like 70% they
also have higher rates ofanxiety. So there is a lot of
overlapping symptoms, especiallybetween ADHD and autism. One of
(12:57):
the main differentiators that Ifeel and then Dr brazendale,
please take it from here. Butone of the main things that I
notice and feel pretty quicklyis the rigidity that people on
the spectrum can have. Becausepeople with ADHD can be very
flexible by nature, you know,they can kind of roll with it.
(13:17):
They can be impulsive, you know?
They can sort of go with things,but the rigidity that you can
feel with someone on thespectrum is very intense, and it
can be like, one example I'mthinking of is I had an adult
patient who wouldn't go out inthe rain because of that sensory
experience of getting rain donewas so uncomfortable that, like,
she needed to go to the grocerystore, and She wouldn't go
(13:39):
because it was raining. So, youknow, me introducing this idea,
like, well, could you just getan umbrella? Like, and it was
like, not like, no. I mean, ithadn't occurred to her, first of
all, and second of all, she waslike, Are you crazy? Like, it's
raining, you know. So therigidity, that's an that's an
extreme example, but therigidity is, like, palpable. It
feels really intense, especiallyif you're working with someone
(14:01):
therapeutically, or you're aparent trying to coach a kid to
go do something that they don'twant to do. That rigidity is
very intense. It's not easilyswayed. Like, oh well, we'll go
to Target afterwards. If you cancome with us to this restaurant.
It's like, right? No dice, youknow.
Colette Fehr (14:19):
Okay, so I have a question, as we're talking about
a lot of the symptoms and howthis can present, can you
explain just a little bit, evenfor the average person, what is
going on in the brain that leadsto this? Is this? Is this a
difference in brain functioning,or is it something else
(14:40):
altogether, because I don'treally know much about the
etiology or how it manifestsinternally.
Dr. Allison Brazendale (14:46):
Yeah, so it is a neurobiological
disorder, and so it is aboutlike the way that the brain
functions, the way that I liketo think of it, is really a
variation of the way that aneurotypical individual would
think. You know, in general. Allthe way that they experience the
world is just really different,or not really different, but it
(15:06):
is different from neurotypicalindividuals, and that is part of
the rigidity. And they tend tosee things more in black and
white and less in the gray. AndI think that is the way that
they are, that they think, andthat's what we know. And what Dr
Bradshaw was saying is probablyone of the biggest differences,
(15:28):
is that rigidity. And the otherthing I wanted to say too is I
also think the stereotypes arerepetitive. Motor movements is
another thing that reallydifferentiates it for me,
because commonly, a child withADHD, let's say may do something
repetitively, like, you know,they like to play with a certain
(15:49):
thing, or, you know, a certainway, or, you know, maybe they
have some very specificinterest. Or a gifted ADHD kid
might really hyper focus on onething, but once they master it,
they kind of move on. Typicallywith autism, you'll see more of
those repetitive motor behaviorslike flapping or pacing or
visual stimming, like looking atsomething as it's going around,
(16:12):
like wheels on a car, lining up,and then these very focused
interests that typically are onthings that maybe are a little
bit different for their age.
Like I had a seven year old whowas very interested in the
mechanics of roller coasters.
Knew everything about rollercoasters, how they functioned,
how they were built. It'samazing. Like, the interest they
have and the amount of I mean,it's such a gift, in my opinion.
(16:36):
I think it's awesome. Like thatpart of it is so cool. So I
think that those are the twothings that differentiate it.
And yes, I do believe that thebrain and the way that their
brain functions is more in thiskind of very structured
predictability is verycomforting to them. These motor
behaviors are very comforting.
Knowing everything aboutsomething is very comforting,
(16:56):
and that feels good to them,versus, you know, with ADHD, it
might be a different story. Itmight be just something that
they're super they want to go ona deep dive, and then they're
done. And it's
Brady Bradshaw, M.D. (17:06):
genetic.
There's a heritability to it aswell, which I think is another
indicator for us, theneurobiological way that this is
inherited. So it's oftengenetic. Sometimes there's a
parent further back, or agrandparent that had, you know,
was different, or, you know,didn't leave their house, or
whatever, you know, you can kindof hear it in the family
(17:26):
history. So it is genetic. Wethink it's related to mirror
neurons. We don't totallyunderstand the entire story, but
there's some involvement ofmirror neurons, which are
probably part of that socialhandbook that we were all born
with that they didn't get, youknow, and so that's some of the
theory, like most of psychiatry,a lot of it is theory that we're
(17:47):
trying to understand better that
Colette Fehr (17:52):
makes a lot of sense, though, mirror neurons,
because you end up connectingwith someone, because your
nervous systems kind of sync upand replicate without any
conscious effort due to thosemirror neurons. So I could see
that making sense, butinteresting to know that it is
different, and yet maybe it'snot fully understood why or how,
but it's inherited. Tends to beinherited, and then when you get
(18:16):
somebody coming into you, let'ssay with a daughter, are they
typically coming in saying, Isuspect my daughter may be on
the ASD spectrum, or are theycoming in for something else?
And then they're surprised thatthis is maybe what it is. I
mean, I'm sure you seeeverything. But what's the
typical scenario, or the mostcommon scenario
Brady Bradshaw, M.D. (18:42):
that's I'm laughing because Dr brazendale,
I feel like, has a reputation inthe community now, and so we're
often seeing people who havebeen seen by three or four
people before they've been seenby us. Interesting, and there's
still some lingering questions,or like Dr brazendale was saying
some things that are still notexplained by ADHD or anxiety,
(19:04):
and the parent still has thisfeeling like I'm not we're not
being totally understood here.
That's
Dr. Allison Brazendale (19:11):
exactly why I was smiling and laughing,
because I feel like by the timethey come, usually it's because
of that they've had a previousevaluation, and there's still
some stuff missing. And also Ifeel like I have a good
relationship with a lot of theschools around here. And
they'll, they'll kind of send mea text and say, hey, you know,
we're not really sure, but wethink, you know, we want to send
(19:32):
them to you. And then I'm kindof, you know, in my mind, like,
okay, you know, this may be morecomplex, and I like the more
complex cases, to be honest, andpart of my evaluation actually,
because I do find highfunctioning autistic individuals
like we were talking aboutbefore, they tend to mask really
well, and they do really wellwith adults. So when, you know,
(19:55):
commonly, a lot ofpsychologists, when they do
their diagnostic testing, theymeet with the kids one or two
times. Times in their office,and, you know, I'll read past
reports, and they're like, oh,they did really well. They made
good eye contact, they asked mea lot of questions. That's not
the full picture, right? BecauseI'm not a peer, so I'm not I'm
not stressful for them, becauseI, I don't have any expectations
(20:16):
for them socially, right?
Versus when they're with theirpeers. It commonly looks very
different. So actually, arequirement when I do diagnostic
testing is I go in and observethe child in their natural
environment with their peers,before they know who I am. And
so if I'm doing an autismdiagnosis or diagnostic
(20:37):
assessment, I will go to theschool and I will do an an
observation, not in theclassroom, because I if it's a
dual diagnosis, maybe ADHD, I'lldo half and half classroom. But
where I really want to see themis in that naturalistic peer
environment, lunch, pe recess,those environments, I want to
(21:01):
see what they look like whenthey have to socialize on their
own with their peers. Well, notsitting next to someone that
they had to write. I also wantto see what happens when they
get excited on the playground.
Are they flapping? Are theyposturing when they run? Are
they asking peers to dosomething over and over again?
Are they stimming? Are theytalking to themselves? Are they
talking to others? So that's asuper important part of my
(21:23):
evaluation, and I think thatgives me a lot of data. Yes, we
get both, but commonly they'recoming to me because they
haven't had answers. And thatpiece of data collection is the
most valuable thing that I cando in these diagnostic
assessments
Colette Fehr (21:43):
that makes so much sense. Okay, two quick
questions. I don't know. I hearthis all the time. I don't know
what stimming is. Stimming
Dr. Allison Brazendale (21:51):
can be a lot of different things.
Stimming can be things like weall stim, right? It's a
repetitive movement andbehavior. So my stim is, I, I
bite the inside of my mouth thatif I don't know it's an anxiety
stim, I It makes me feel calmer.
Some people pick their nails.
That's a stem. People can bouncetheir legs. That can be
(22:13):
considered a stem. Or, commonlyin autism, it may look like
flapping. Or they may take anobject, like I said, and look at
it from different angles. That'sa visual stem. So it's
Colette Fehr (22:25):
a repetitive kind of unconscious behavior that is
just constantly happening. I'mtrying to think of what I do as
a stem.
Brady Bradshaw, M.D. (22:35):
It's usually in an effort to soothe.
So it usually happens whenthey're over stimulated. So
like, if they're excited orthey're in an overstimulating
environment, it's a way thatthey're able to soothe their
nervous system is to have theserepetitive movements. So
sometimes it's even just likelittle finger movements that
they're doing with their handsin their lap. So it's not very
(22:57):
obvious, could be vocal stems?
Colette Fehr (23:01):
What's a vocal stem? What might be a vocal
stem? So it could
Dr. Allison Brazendale (23:04):
be like grunting repetitively or saying
specific noises, or just makingnoises repetitively with their
mouths. So oftentimes it canlook like a tick too. And so
teasing that apart is also canbe challenging. Same with OCD,
okay? And this is a way
Colette Fehr (23:22):
to, like, down regulate your nervous system,
seek comfort, self soothe. Sothen over stimulation is also a
part of this, often gettingeasily over stimulated by social
environments or so that's
Brady Bradshaw, M.D. (23:38):
the sensory piece that we see.
That's part of the diagnosticcriteria for autism, that they
tend to be either hypo or hypersensitive to different sensory
experiences, so loud noises orbright lights or the grocery
stores like hell for these kids,you know so or you know, too
(24:01):
much chaos in a classroom orsomething that's really, really
exciting. So I think a lot ofpeople in the common knowledge
about sensory experience can belike tags and clothes, or that
socks don't feel right, or shoesdon't feel right, jeans textures
of fabrics, you know. So there'sa lot of sensory challenges, and
(24:22):
we see more sensory issues ingirls, and so that can be
another pink flag. Compared toboys, they tend to be much more
sensory sensitive. Smells are abig one. They can be very
sensitive to different smells,and that can contribute to a
feeling of being overstimulated, and that might be
(24:42):
when you see some of thatstemming behavior.
Dr. Allison Brazendale (24:45):
Sorry, I was just going to say food,
eating. Oh, right, rituals andsensory differences related to
food or rigidity around eating,yeah,
Laura Bowman (24:54):
like certain foods, really, yeah. I mean,
I'll just disclose this, like myfather is probably. On the
autism spectrum, and was never,you know, back in the day, was
not diagnosed. He was just kindof a introverted chemical
engineer, right? And then Imarried probably the most ADHD
human on the face of the earth,and we reproduced. So you can
(25:16):
imagine what my kids are like.
It's just I have two that areprobably ADHD ASD combined, very
high functioning, very highmasking. But I live with all of
this stuff, and it's fascinatingto watch the genetic coil kind
of unravel in retrospect, likeeven because my my one cousin's
son is fully on the autismspectrum, and I even watch him
(25:39):
in meetings, and he'll grunt,he'll go, and I'm just looking
at all of us, and I'm just like,I see it now so clearly, but I
didn't see it. You know, whenyou're living it forwards, it's
hard to understand what you'relooking at. But now I do
understand. One of the things Iwanted to ask about is the
(26:00):
stigma. Are people coming in,like, afraid of this diagnosis,
not wanting it, especially ifthey have high masking kids
where, like, by all intents andpurposes, they're doing well in
school, they're they're prettywell, you know, everything's
fine, you know, but it's notfine, but it's fine. Are they
wanting this diagnosis? Are theypushing against it?
Dr. Allison Brazendale (26:25):
So I see a little bit of both. I will say
that as there's been more highlysuccessful individuals coming
forward, and, you know, sayingthat they're on the autism
spectrum, and, you know, withthis kind of neuro affirmative
push more the social modelversus medical which I, you
(26:46):
know, really believe in. And Ialso have been doing this for,
you know, 15 years or so, and Ifeel like autistic people are my
favorite people. I just findthem really amazing and awesome.
I also have several familymembers on the autism spectrum
who did not get diagnosed untilmuch later, my uncle, my cousin,
and there's a lot of phenotypein my family too. But anyway, I
(27:09):
feel like there, there is both.
And you know, oftentimes, DrBradshaw and I will recommend
this book, the book that youknow Donna Henderson wrote. It's
called, is this autism, and itis a very neuro affirmative book
about high functioning autism,and it takes the voices of
autistic people and it puts itin the book, and they explain
from their voice how each of thediagnostic criteria feels within
(27:34):
them. And I think it's a verypositive experience for parents
to read that, especially whenthat's on the table. And I try
to during an intake, I do a twohour very thorough intake, if I
do hear these pink flags that isan like a homework assignment, I
assign to the parents say, hey,you know, I want you to read
(27:55):
this book, and I want you to seewhat resonates with you, because
that kind of sets up the neuroaffirmative process for this
diagnosis. And I think it doesfeel comforting and good to read
about. You know, these, likechemical engineers and CEOs of
large companies, surgeons, youknow, these very focused, very
successful individuals in theircraft and how they're so
(28:17):
successful and also on theautism spectrum. So I do feel
like the stigma is less, butit's definitely still there. But
I do think there's, there's abig push. I know on Tiktok,
there's a lot of teenagers theyI forget what they call it, but
I don't have Tiktok, but maybeDr Bradshaw would know better
than me, but I know that theycall it something where they
(28:39):
want to be on the autismspectrum, because it's part of a
community, which I think iscool. I
Colette Fehr (28:45):
think it's become kind of en vogue among younger
people, particularly right now.
So I'm curious, as you say this,I have a client who comes to
mind, who's an adult female, andobviously this is not something
I know a lot about hence myquestions. I can think of
clients who probably fit some ofthis, but it's not something I'm
(29:05):
super plugged into, and thisparticular female client was
recently diagnosed being ASD. Inever in a million years would
have guessed that by any way shebehaved or presented, just with
my kind of very average,rudimentary, probably
(29:26):
stereotypical, you know, otherthan taking psychopathology and
like the brief dive into it inthe DSM, this is not really
something I've thought aboutmuch since then, you know, 1520,
years ago. So what is it looklike in an adult woman who maybe
hasn't been diagnosed, and I'msure there's variability, but
let's say a high functioningadult woman who may be ASD and
(29:50):
not realize or have suspicions.
Brady Bradshaw, M.D. (29:56):
I think that's such a wonderful
perspective that your brain.
Being because what I wasthinking of when you were
describing her, the banner issueI feel for for folks on the
spectrum, when they present to atherapist, is feeling
misunderstood. Yeah, so youdon't need to be knowledgeable
in autism to help someone feelunderstood. And so for if I had
(30:19):
an adult present with autism asa therapist, and I was kind of
working with them, I wouldreally want to be so curious and
hold space for her. Tell me,what does that mean for you?
Like, what? How does that lookfor you? And really empathizing
with my God, how much you havebeen through how much effort you
(30:40):
must have made to pull this offto be able to get this far and
not get diagnosed. I mean, youmight, I mean, how exhausting
these social experiences were,how invalidating, you know, was
your home life when you weremade to take a shower, even
though it was so sensoryoverload painful for you, you
know? I mean, I think we cancome with a perspective of help
(31:00):
me understand absolutely notbecause I want you to teach me
that's not your job, but becausethat, I think, is the work of
therapy, and really therapeuticfor someone who feels like
they've been misunderstood theirentire life, I think when they
present to you, They might lookneurotypical and look like
there's no autism underlying butif you give them permission to
(31:23):
open up about their experience,you might see more as they
become more comfortable withyou, that you're a safe place.
And like, if they need to stem,they can stem if they I have
somebody who sits in differentcolored lighting now, you know,
you know. So it's almost likegiving permission to sort of,
you don't have to camouflagehere if you need to turn your
camera off because my eyecontact is freaking you out.
(31:46):
That's okay, you know. But justsort of asking, What does this
look like for you? And, youknow, being really sensitive to
their experience and their innerexperience,
Colette Fehr (31:58):
I mean, that all makes perfect sense. And I just
wonder if there are typicalthings that are part of the
process, because some of thethings, and I know this is like,
everything, right? When you're atherapist, a psychologist,
you're you're learning aboutdisorders, you find like, 10
things in the DSM that you'relike, oh my god, I'm kind of
(32:20):
this, or I'm kind of that,right? I mean, some of the
things you described, I don'tthink that in any way, that I'm
probably ASD, but, you know, Ihave tactile issues. I'm
impulsive. I There's a millionthings. So I guess I'm just
wondering too, because even thisclient I'm describing, you know,
I have a wonderful rapport withher, and she was and she has a
(32:44):
lot of complex PTSD, so there'slike, a lot going on there that
I don't think she had any cluethat any of this applied to her.
So I would imagine there may bewomen out there in middle age
who don't realize that thiscould be a thing, like, what
(33:05):
could they look for? What mightbe some of the signs that
there's high functioning autismpresent in an adult female?
Brady Bradshaw, M.D. (33:14):
So the rigidity, like we talked about,
the rigidity, is one thing. Sohaving, like, a really strong
insistence on it being this way,or it has to be this way, there
can be a concrete use oflanguage. So that's another way
in the therapy office that theymight look different. So not
understand, you know, not beingable to understand jokes is the
extreme example of it. But theycan be very concrete in how they
(33:37):
interpret language. Concrete,
Colette Fehr (33:39):
okay? So like somebody, I'm just thinking,
sorry to interrupt you, but ifsomebody who in my office, we
have these two pictures in thewaiting room, this is so funny,
actually, and telling and how Idon't pay attention to certain
things. So I bought them as aset. I thought they like went
together. Well, it's actuallythe same exact picture. It's
(34:00):
like an abstract I bought thesame picture twice, and I hung
them up. They're still out thereas like, here's this set. One of
my ASD clients was waiting forme one day, and she was like, Do
you know that's the exact samepicture? I said, No, no, they're
they're a set. And she's like,No, look, this is the same as
this. And I was like, wait,what? And I'm like, Oh, my God,
(34:23):
I bought two of the same pictureand tried to make it like an
artistic moment. In a millionyears, I wouldn't notice that.
I'm just like, oh, this ispretty here. Grab it, right? But
like, she had zoomed in on itand, like, found this thing. And
was like, these are the same,right? So is that some of the
like honing in on things and,
Laura Bowman (34:46):
yeah, so interesting. And is it, can I
also say, is it just a littlebit of a felt sense? I mean, I
know we all have our diagnosticcriterias and we have our
checklists, and we have to ask,we have to do a lot of good. Um.
Information taking and historytaking. But is there a felt
sense, you know, just like alittle bit of space between
(35:07):
beats, a little bit of, like,woodenness, or that you're just
like, oh, or am I making thatup?
Dr. Allison Brazendale (35:14):
Yeah, no, that's part of the
diagnostic process for autism.
Is what I use is somethingcalled the ADOS. It's the autism
diagnostic observation schedule.
It's been coined kind of likethe gold standard of autism
testing, although it does missmany girls. So there's a lot of
controversy kind of surroundingthat, but I do find it a helpful
(35:36):
measure. But one of the thingsthat you code on in the ADOS is
reciprocal communication. Andthen, you know, kind of this,
like, social initiation, orovertures, like, how does it
feel? And so kind of what you'resaying, you know, if I'm
dropping a bid, and I'll saysomething like, Oh, I'm going on
vacation next week, right? Youwould expect, where are you
(35:57):
going? Yeah. So if there's alittle bit of like, and then
there's that awkward silence,and then it's, Oh, where are you
going? Or, you know, Dr Bradshawand I had a child that we were
sharing, and we like to co treatas well, because it's really
helpful to be able to bounceideas off each other, especially
when there are these morecomplex, high functioning cases.
(36:20):
And she seemed very social, butthen lacked depth. And so that's
something that you would justexpect a little bit more from.
So in that way, it is a sharedexperience, right? Like you're
answering the questions, butthere's not like more to it as
we're peeling away the onionkind of so yes, that is
(36:42):
definitely something that I lookat. I drop a lot of bids to see
what's picked up, like breadcrumbs, you know.
Brady Bradshaw, M.D. (36:48):
And I think for adults, if we're
thinking about adults,especially the concreteness,
when you're especially trying todo therapy, where you're asking
about, well, you know, some kindof deeper meaning, or, like,
their inner experience, and it'sgets brought back quickly to
whatever the concrete facts are.
And it can have a feeling tosomeone who's not on the
(37:08):
spectrum and in the room withyou therapy, I'm kind of like,
why are we back here? Like,wait, no, I'm trying to connect
a meaning here, you know. Sothat depth and meaning piece, I
think, can, it can feel harderto get to sometimes, because
they're so focused on, like, theblack and white, like data
points of like, well, but thisis the reality my, you know, I
can't pay my mortgage, orwhatever it is, and it just
(37:30):
keeps coming back to that, andit feels like you're hitting a
wall almost.
Colette Fehr (37:36):
I bump into that in couples therapy, for sure,
especially with the type ofcouples therapy I do Emotionally
Focused, that is a lot aboutexploring your inner world and
nuance, and what does that meanto you? And you know, having a
lot of people from like Lockheedand engineers and surgeons, and
(37:58):
they just don't have and some ofthem, ASD may be a part of it,
they just don't have much there.
And the last thing I want to dois, you know, pursue someone for
something that isn't in theirnatural repertoire, but that can
be a challenging connection. SoI feel like I would be remiss to
not ask you a little bit aboutthe relationship front here,
(38:20):
because I would imagine that itmay be challenging to be in a
relationship someone who's moreclassically neurotypical with
someone ASD Do you see that thatcan be a struggle? Because I
feel like that's probablyshowing up in my office,
(38:41):
probably even more than Irealize.
Dr. Allison Brazendale (38:45):
Yeah, I do. I think that, you know,
going back to, you know, thefriendship and relationship
piece, it can be hard tonavigate and, you know, look at
perspective taking right? So howdoes someone else feel in this
situation and that concretenessof like, well, no, because that
doesn't feel good for me, or Idon't want to do that. And so
the answer is no versus like,okay, the answer is no, but and
(39:10):
I can maybe be flexible and tryto think about it a different
way. I think that is somethingthat can be more challenging. I
Brady Bradshaw, M.D. (39:18):
think that we can hear for couples,
sometimes they can feel a littlenarcissistic and ASD partner,
because they have that strugglewith perspective taking. So I'm
not really always aware of myown inner world. And now you
want me to try to be aware ofsomeone else's inner world
experience. It's like, wow,that's a big leap, you know? And
(39:38):
so I would guess I'm not acouple's therapist. You can
correct me, but I would guessthat the effort is to understand
the ASD individuals experiencein the relationship, and what
are they capable of? Becausethey have a great sense of
empathy, and they can sense thatsomething's up. They just might
not be sure what the meaning is.
Yeah. So you're mad at me, butwhat? Actually, maybe they're
(40:01):
like, stressed about somethingthat happened at work, you know?
So there can be an effort tounderstand on both sides that it
can work. It's not doomed, butit's just, it's not, maybe, as
intuitive the understanding,
Colette Fehr (40:16):
yeah, I think it's really important. I've had
multiple people when theirpartner or spouse has been
diagnosed ASD say it's such arelief, because now at least I
may not take certain things aspersonally. You know, sometimes
people who are reallyemotionally fluent and attuned,
they're coming in going, what isthis response like, What the
(40:38):
fuck is wrong with you? I saythis heartfelt thing, and then
you look at me with a blankstare, like, fuck you. You know
they're so offended and hurt byit. And if this is at least part
of what's at play, and there area host of other things that can
be factors too, of course, butif ASD is part of it, then it's
like, Oh, okay. You know you'renot not caring. You show caring
(41:00):
differently, and let's work onthis as a team so that we can
understand each other with alittle more explicitness and
grace.
Laura Bowman (41:11):
To that end, I'm wondering, what is it? Because
I'm thinking about it, even thework I do with my own children
in my house is the role of thetherapist with a client, and
what, what people on thespectrum can really get out of
therapy? Because I do a lot ofyou know, I have very black and
white thinking children rightand wrong. And I'm doing, I'm
(41:32):
lending out a lot of my graybrain, you know, of let's think
about it this way. Can you takethis particular perspective? Can
we what kind of meaning I'm, youknow, I'm making this meaning.
What meaning are you making? I'mdoing a lot of that work all the
time, naturally. Is thatsomething that people with ASD
can work a lot on in atherapeutic relationship and
(41:54):
have somebody to sort of bouncethat off of?
Dr. Allison Brazendale (41:59):
Yeah, absolutely. I think those are
all, you know, things that I doin my own practice. A lot of
what you're saying. I also thinkthat, you know, I feel like back
in the day, when we were first,you know, diagnosing, or before
we had a lot of knowledge, therewas a lot of push to change
autistic individuals to lookneurotypical, and that is no
(42:20):
longer, at least how I dotherapy. I know at our practice,
we don't do that becauseultimately, sometimes it's a
them problem, like, if it feelsuncomfortable for you that your
child isn't making eye contactwith you, what? Why is that
uncomfortable for you? Right?
Because if it feels souncomfortable for them, and
that's not part of how they liketo experience the world. Why are
(42:43):
we making them make eye contact,you know? And so I think a lot
of what I do, too, is likeperspective taking like, yeah,
look, if eye contact doesn'tfeel good for you, don't make
eye contact. Or if stimmingfeels great for you, stim.
However, here's how other peoplemight interpret that, and so you
just think about that as you'redoing it. Because that's, that's
the the knowledge I feel is, youknow, you need to do what feels
(43:08):
good for you, just like we woulddo for anything, right? So
someone who's having a panicattack, if you're having a panic
attack, and you're having apanic attack in front of a lot
of people, here's what it'sgoing to look like to the
outside world, even though thisis your internal experience,
it's kind of the same thing. Sohow do we do that differently or
not? But then it kind ofaccepting that this is what
(43:29):
feels good for you, and feelingfine about it, right? So I think
that's a big part of what I do,too, you know? But I think
flexibility teaching isimportant because, yeah, like,
we do a lot about a lot of workaround cognitive flexibility,
and I think that's good foranyone and how for everyone,
yeah, and how, if you are blackand white, here's how other
(43:50):
people are going to experiencethat. Yeah, yeah, no,
Colette Fehr (43:54):
oh, God. I'm married to someone who is like
the king of black and white,concrete and rigidity, whatever
the heck. In fact, I'm thinking,maybe I need to have him come
see you guys and take a littletest. To that end, Sorry, Steve,
you'll be hearing this live onYouTube. Nothing new. I'm pretty
(44:15):
outspoken about every thoughtthat crosses my mind. But To
that end, what is the processfor, let's say, an adult. Do
they make an appointment withyou guys, or someone like you
guys, and are there they takesome tests like, how do you if
you're an adult and you suspectthis may be a factor, how do you
go about figuring that out?
Brady Bradshaw, M.D. (44:35):
So it is a clinical diagnosis similar to
ADHD. So there can be, you know,a psychologist or a
neuropsychologist who might doformal testing for autism. You
could also see a psychiatrist,an MD, who specializes in
diagnosing adults with autism.
Usually, that means they havesome background in adult
(44:56):
psychiatry and child psychiatry.
Tree, because it's neurodevelopmental so the child
psychiatrists tend to get alittle more training in that
background, but you certainly ifyou were seeking to understand
more or you suspected some typeof neurodivergence, you would
want to make sure that theperson you're making an
(45:18):
appointment with has experienceand a reputation for knowing how
to diagnose adults with autism,because it's not every
psychiatrist and everypsychologist, it definitely can
be missed,
Colette Fehr (45:29):
okay, and that is something you all do correct,
not just children, but alsoadult diagnoses. I do,
Brady Bradshaw, M.D. (45:35):
Dr brazenda Does it? Okay? Yeah,
Dr. Allison Brazendale (45:37):
I do up to 18 typically, is where I feel
the most comfortable, but I haveother colleagues that are
psychologists that do it, andthen Dr Bradshaw does it as
well,
Colette Fehr (45:46):
right? And Dr Bradshaw, you have that dual
board certification, right?
Child psychiatry, adultpsychiatry, so that's that
important criteria. You want toreally make sure, like so many
of these things with therapytoo, right? You don't want to go
to someone, well, I was going tosay something, but some people
may not like that. You don'twant to go with someone with a
(46:07):
cert if they don't have traumaexperience. Let's just, let's
just leave it at that, if youhave complex PTSD. So it's
really important to find theright professional. And it
Brady Bradshaw, M.D. (46:23):
takes time. And it does take times. I
don't you know if I'm doing anevaluation like this, it's an
hour, and then I might be seeingyou at another hour, and it
might take me to hour three orhour four before, not that
that's all part of theevaluation, but I'm getting to
know the person, and then I'mthen I'm seeing, like, okay,
there's like, a super you know,either there's a concreteness
(46:43):
that we're not getting past, or,like, there's a sort of non
verbal issues I'm picking up onthat, like, weren't just anxiety
about a first visit. So it takestime. It's, it's, there's a lot
of overlapping symptoms withother disorders like we
mentioned. You know, I'm gladthat there's more out there on
social media, on Tiktok and allof that. And so when patients
(47:04):
bring it to me and say, youknow, I saw this on Instagram,
and now I think I have it, Itake that really seriously. It's
not like, I'm gonna say, Oh,well, if Instagram said it, then
you do. But I'm like, okay,like, what is that resonating
with? Because I may not beseeing it all. I might not be
seeing inside what's going onfor you. So tell me about why
that resonated. What did younotice? So it can take some time
(47:24):
to get to know someone to makethe diagnosis. Also, sometimes
for women, especially if theyhave a history of multiple
diagnoses. So this doctor toldme I had borderline personality.
This doctor told me I hadoppositional define as a kid.
This doctor told me I hadbipolar, you know. So if I start
to hear multiple diagnoses,that's another thing that I'm
(47:45):
like, okay, maybe we've missedone, you know, underlying
unifying diagnosis here withautism,
Laura Bowman (47:55):
that's fascinating. And just to, just
to, kind of like, end on more ofa positive note, like, what are
some of the really cool thingsabout people that have ASD and
especially some of the uniquethings you see their abilities
or strengths?
Dr. Allison Brazendale (48:13):
I mean, like I mentioned before, the
fund of knowledge that they haveabout things that they're
interested in is, I mean, it'sjust absolutely incredible. And
the way that they can interpretthe world, I think, is also
pretty amazing. I also, I saythis often, because oftentimes
they know when to be like, No, Idon't want to be in this social
(48:34):
situation, which I think a lotof times. I mean, even for
myself, I'll push myself intosituations where I'm like, Oh,
well, I need to go talk to theseparents, or I need to go to this
birthday. Go to this birthdayparty where I would rather just
be at home and recharge. And Ithink they have a, honestly,
like, a better handle on that.
And I think that's a reallyadmirable thing. They're
extremely intelligent, and Ithink that the way that they can
(48:56):
focus on a craft is, you know,unmatched. It's very, very cool.
Wow.
Brady Bradshaw, M.D. (49:03):
You can definitely see like a giftedness
in certain areas and differentpeople. And it depends on the
individual. Of course, that isstunning. And, you know, can
bring tears to my eyessometimes, when I'm hearing them
talk about something thatthey've come up with, it's
usually Uniquely Creative andjust blows you out of water.
Laura Bowman (49:25):
Yes, I've seen that too, and I think it's this
fine dance between learning howto be in a world full of
neurotypical people and alsoreally honoring your own the way
your brain works and the way youneed your environment set up and
moving between those two things.
But I'm glad we're talking aboutit, and I'm glad it's out there
(49:45):
more and that people are beingable to understand themselves,
because there's nothing worsethan like, being diagnosed with
like, four different things andgoing, what the hell is going on
with me? And
Colette Fehr (49:58):
like you all said, the experience that. Being
misunderstood is so painful andso isolating. So I think it is
really important that we allunderstand it better and make
space for everyone to feel moreunderstood and have permission
to be who you are, right, and ifother people don't like it,
tough shit.
Dr. Allison Brazendale (50:19):
Yeah, exactly perfect
Colette Fehr (50:22):
way to end our time together. Ladies, thank you
so much. I have learned atremendous amount. It's
fascinating. It's so importantto understand, and I know our
listeners will have to we're sograteful to you for your time
and expertise. And of course, ifpeople who are local or in
(50:43):
Florida, right, can makeappointments with you all if
they would like to. I mean, Iknow you don't have a ton of
free space, but is thatsomething that it's okay to say?
Dr. Allison Brazendale (50:54):
Yeah,
Brady Bradshaw, M.D. (50:57):
I'm really do. We are both very passionate
about raising awareness aroundthis topic, so we appreciate you
guys giving the time to it andletting us talk about it. Yeah,
Colette Fehr (51:07):
I think it's really important. And we'll link
to how to get in touch with youin the show notes and everyone
listening. Thank you so much. Ifyou have questions for us,
please reach out to us at info,at insights from the couch.org.
We hope you got some valuableinsights from our couch today,
and we will see you next time.
Bye guys. You.
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