Understanding the Overlap Between ADHD and Autism with Dr. Celine Saulnier
This week on The ADHD Podcast, Pete and Nikki sit down with Dr. Celine Saulnier, a specialist in diagnostic assessment and research on autism spectrum disorders. The conversation delves into the complex relationship between ADHD and autism, shedding light on the often misunderstood overlap between these two neurodevelopmental conditions.
Dr. Saulnier explains the evolving diagnostic criteria for autism spectrum disorder (ASD) and how changes in the DSM-5 have allowed for the co-occurring diagnosis of ADHD and autism. She explores the similarities and differences between the two conditions, including the shared challenges with executive functioning and the distinct underlying causes of apparently similar behaviors.
The discussion also touches on the unique challenges faced by females with autism, who often fly under the diagnostic radar due to their ability to mask or camouflage their symptoms. Dr. Saulnier emphasizes the importance of comprehensive evaluations by clinicians with expertise in both ADHD and autism to ensure accurate diagnoses and appropriate treatment plans.
They navigate the nuances of neurodiversity, the divide within the autism community, and the need for increased awareness and acceptance of neurodiverse individuals. This conversation offers insights for anyone seeking to better understand the complexities of ADHD, autism, and their intersection.
Links & Notes
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Pete Wright:
Hello everybody and welcome to Taking Control: The ADHD Podcast on TruStory FM. I'm Pete Wright and I'm here with Nikki Kinzer.
Nikki Kinzer:
Hello everyone. Hello, Pete Wright.
Pete Wright:
How are you doing Nikki?
Nikki Kinzer:
I'm doing pretty good. How about you?
Pete Wright:
I'm good. This is one of those shows where I think ... Stop me when I start lying. I think I'm speaking for both of us. We're coming into a world that we know precious little about.
Nikki Kinzer:
Yes. It's true.
Pete Wright:
I don't know that I have much to contribute apart from just rabid curiosity. Because it seems like this issue when we talk about the Venn diagram of these conditions, we're hearing more and more questions about this. So we have a fantastic guest who's going to talk to us all about ... It's going to be an intro for you and me. It's really great. I'm very excited about this. We're talking about ADHD and autism today. Before we jump into the show proper, you know what to do. Head over to takecontroladhd.com, get to know us a little bit better. Find us on Facebook and Instagram and Pinterest at Take Control ADHD. But really what you need to do, if you really want to talk about this autism ADHD thing, that conversation's going to be happening over in our Discord server. You can get in there at takecontroladhd.com/discord.
You'll be whisked over to the general invitation and login page. If you're looking for a little more, and we sure hope that you're looking for a little more, head over to patreon.com/theadhdpodcast. Patreon is listener-supported podcasting. With a few dollars a month you can help guarantee we continue to grow the show and add new features, invest more heavily in our community, and unlock a whole bunch of super secret Discord channels where a lot of really fantastic conversation and events are happening behind the scenes. Visit patreon.com/theadhdpodcast to learn more.
Dr. Celine Saulnier specializes in diagnostic assessment as well as teaching and training for autism spectrum and related disorders. She has published over 50 articles, written two books, and she's an author on the Vineland Adaptive Behavior Scales Third Edition. She's here to give us a primer on the relationship between autism and ADHD. Dr. Saulnier, welcome to the ADHD Podcast.
Dr. Celine Saulnier:
Thank you so much and it's so nice to meet both of you and it's a pleasure to be here and I really appreciate you having me on.
Pete Wright:
Well, we're really excited to learn. That's actually a great place to start. Nikki, can we get a sense from your perspective as a coach, what are you seeing in your work in terms of people asking more and more of these questions?
Nikki Kinzer:
Yes. Well, the trend that I'm seeing, which I'm really interested to hear what you have to say about this is women, I would say probably in their late-20s, maybe early-30s, are getting this later diagnosis with ADHD. So they were probably diagnosed with ADHD first, but then now they're also getting this diagnosis of being on the spectrum of autism. And just a really interesting pattern that I've noticed. So I don't know if that's something that you're seeing as something that's happening or-
Dr. Celine Saulnier:
Without a doubt. I have my own clinic in Decatur, Georgia, and I opened it in 2018, and over the past six or so years, the majority of my clients are adolescent, adult females. What we're learning about the female presentation of autism is it's very different than prototypical autism in males, and so they get missed. And what happens is they get missed. They have enough social ability, so to say that they get by on a surface level, but they're struggling tremendously internally with anxiety, which leads to depression. They probably are diagnosed with ADHD among other things. Borderline personality disorder because of the most emotional dysregulation and then eventually are getting the appropriate diagnosis of autism.
Nikki Kinzer:
Wow.
Pete Wright:
So what does it look like? I hear autism. I think I have a broad understanding of it. Give me the clinical definition. What do I need to know about autism to have this conversation?
Dr. Celine Saulnier:
It is such a broad spectrum, probably too broad in my view in this day and age. There are two hallmark areas of impairment or delay or vulnerabilities. Those are first and foremost the social communication interaction vulnerabilities because it's a social disability first and foremost. And then secondly, the presence of what we call restricted, repetitive and stereotype behaviors. There are so many of these. There are a need for sameness and routine, not liking changes in routine or transitions. There's the repetitive motor mannerisms, hand flapping, rocking back and forth, spinning, jumping. There's intense interests on objects or things or topics over people, and those interests become all intrusive and really get in the way of social interactions. And then there are the sensory processing impairments. Hypersensitivities to sound, touch, taste, a lot of food selectivity or there could be seeking out sensory input. As you can imagine, any individual can have an array of so many different restricted and repetitive behaviors as well as gradations of their social impairments, but you still have to have both of those areas to meet criteria for the disorder.
Pete Wright:
It sounds like we've been talking a lot about other comorbidities and some of the trigger words you are using in describing autism seem like the same trigger words we use to describe some of the OCD demonstrations. I can imagine missing this if you don't necessarily present, I guess obviously.
Dr. Celine Saulnier:
Yes. And the overlap between OCD would be the ritualized behaviors.
Pete Wright:
Exactly.
Dr. Celine Saulnier:
And then the obsessive thoughts. So on surface level they look exactly the same, but they're coming from very different places. Obsessive thoughts and OCD are negative in connotation, which leads to the repetitive behaviors. In autism, the obsessive thoughts are enjoyable. The individuals do not want you to take away those thoughts. They're soothing and relaxing to them to learn, learn, learn or fixate. It's similarly with ADHD. Just about every individual on the spectrum has some form of impulsivity, attention deficits and hyperactivity.
Nikki Kinzer:
So I'm curious to learn more about the spectrum because I have a friend whose son was diagnosed. And I understand that this may not be a diagnosis anymore. With Asperger's. Is that still a diagnosis?
Dr. Celine Saulnier:
It's not. So in the DSM-4 there was a category under which autism fell that was called pervasive developmental disorders. Autistic disorder was one, Asperger's was one, and then the PDDNOS, pervasive developmental disorders not otherwise specified. And then two rare disorders that aren't prototypical. In the DSM-5, they did away with all subtypes because there was no research to back up that Asperger's and autism per se were qualitatively different. They're both social disabilities, they both have the restricted and repetitive behaviors. So it just got subsumed under ASD.
The thing is in the DSM-4 if we really want to get technical and historically prior to that the diagnostic criteria for autism required a history of a speech delay. And Asperger's syndrome actually had no history of a speech delay so that was a distinction between the two. And then the majority of autistic individuals, maybe 20 years ago, had intellectual disability co-occurring with the autism. But in this day and age, it's the complete opposite. Only 33% of the spectrum has co-occurring intellectual disability. So the diagnostic criteria for Asperger's syndrome also had no history of cognitive impairment. So people started calling it just high functioning autism, which I hate that term. High functioning just means high cognitive or high language or both. When we get into saying "high functioning", we're assuming that someone's not struggling and many high cognitive, high language autistic individuals struggle throughout their entire life.
Nikki Kinzer:
The spectrum then. Going back to that spectrum. Because her son was diagnosed at a very, very young age and it was very apparent that something was going on with some of the symptoms that you were saying. With the hand clapping and very fixated on certain things. And so I'm curious how someone like that can be diagnosed at three or four and then somebody else doesn't get diagnosed until they're in their late 20s. How does that happen?
Pete Wright:
Yeah. That was my question. Amazing.
Dr. Celine Saulnier:
First and foremost, it's because we keep changing the diagnostic criteria and as we change diagnostic criteria, we're making it more broad. So when we cast a broader net, someone who's now 20, when they were three or four, wouldn't have met the criteria at that time, especially the females. And then we get into because the spectrum is so broad as far as individuals with co-occurring intellectual disability and language disorders, those are the individuals that are getting caught early because they're more prototypical, classically impaired and affected. The individuals who have the social disability and the restricted and repetitive behaviors but have intact cognition and language, they usually fare well in highly structured environments like school. They're the ones that are doing very well academically, even excelling academically so they fall through the cracks. No one's really picking up on the social vulnerabilities. That's all happening at home. Or they're keeping to themselves and they're suffering quietly.
They call autism the invisible disability for that reason. You can't see the impairments. Whereas in other disabilities ... ADHD, it all depends. If someone only has inattentive type, you can't really see it either. But if you see the pronounced impulsivity and hyperactivity, you can tell. Then we get into the female presentation of if you have enough foundational social skills to monitor your social environment, you can pick up on cues enough to fake it. And that's called masking or camouflaging. And females ... Sorry Pete, but females just come into the world more social than males and-
Pete Wright:
We're doing our best. Okay.
Dr. Celine Saulnier:
And they can pick up on these cues, they can study characters and they can mask and pretend as if they're trying to get along with somebody, and yet it's not working for them. And what happens is it works probably through the elementary school years, then they get into those awful tween and teenagers years where these are the sleepovers. It's all verbal interactions. Reading between the lines. We're saying things we don't mean and meaning things we don't say. And that goes all over the heads of autistic females or autistic individuals in general. And they just ... They suffer.
Nikki Kinzer:
I can imagine. With social media especially, I can't even ... Text messages. Like how you can misread those. Oh my gosh. Without a doubt.
Pete Wright:
So many of our social cues are built on irony and sarcasm, and those I imagine are two hot button issues.
Dr. Celine Saulnier:
Exactly. Not to mention figures of speech. Autism is so concrete and literal that some individuals, regardless of their cognition, can be so literal that ... I always use this example of a client many, many years ago is like, I'm going to fly on a plane, and the person melted down and started crying. "No, I'm not flying on a plane. No, I'm not flying on a plane." But you just told me you were going on a trip and flying on a plane. "No, I'm flying in the plane." So something that concrete could trip them up. So now you understand that neurotypical kids pick up on this in a split second and then it just makes them ripe for getting teased and ostracized and manipulated, and that just adds to the social stressors. Yes. Bullying is huge in autism.
Pete Wright:
Can you talk a little bit more about the sensory experience? Because some of the questions I've heard are like, is autism the thing that attaches to my photophobia, my sensitivity to the environment or textures or sounds?
Dr. Celine Saulnier:
Interestingly, I did my dissertation on sensory processing impairments and autism before these were even criteria in the DSM. Sensory processing impairments were first and foremost researched with learning disabilities, ADHD language disorders. They were not specific to autism. Just as they became more and more pronounced in autism, there was a push to include them in the diagnostic criteria. But they are certainly not specific to autism. It's just the high prevalence. You'll see the hypersensitivity to sounds. Misophonia. Not wanting to hear anyone chew. Mouth noises in general. And the food selectivity that certain taste, textures, even sight of foods. Two foods can't touch each other on a plate for example. Highly behavioral restricted eating to the point where now they have ARFID in the DSM-5 which is the avoidant restricted food intake disorder.
Nikki Kinzer:
Yeah. We talked about that with our eating disorder show.
Pete Wright:
Just last week.
Nikki Kinzer:
Just last week.
Dr. Celine Saulnier:
Nice.
Nikki Kinzer:
Yeah.
Pete Wright:
All right. Now I feel like I have a baseline. Let's move into the AuDHD part, the overlapping part. Because that's where I think a lot of eyes are being opened right now in just treatment culture. So what do we need to know? How really common is this comorbid diagnosis with ADHD?
Dr. Celine Saulnier:
Now you're going to test my stats knowledge.
Pete Wright:
Oh, good. Yes.
Dr. Celine Saulnier:
Let me give you your listeners a history lesson first. Prior to the DSM-5, you were not allowed to give co-occurring diagnoses of both ADHD and autism.
Pete Wright:
Not allowed?
Dr. Celine Saulnier:
You were not. It was actually a stipulation in the criteria that you cannot have both because autism is just subsumed ... ADHD, rather, the symptoms are subsumed under autism. Like I was saying, most individuals will present with some degree of behavioral dysregulation, impulsivity, attention deficit.
Pete Wright:
Your executive functioning system is compromised anyway.
Dr. Celine Saulnier:
Exactly.
Nikki Kinzer:
Right. Yeah.
Dr. Celine Saulnier:
And then you get into executive functioning. So every individual with ADHD, for example, has executive functioning deficits to some degree. Not everybody with autism does, but a vast majority of them do. And there's the overlap. And remind me if I don't circle back to executive functioning, to get back to one differentiation. So the DSM-4 and prior, there were many of us that still gave both diagnoses, but we technically were not supposed to. Now the DSM-5 was the first time it actually allows you to say in the criterion that you can have an additional neurodevelopmental disorder of ADHD in addition to the autism. How do you even tell that apart?
Pete Wright:
Yeah.
Dr. Celine Saulnier:
There are some studies that still go by, no, if you get to the point where you have autism and all of the criteria of ADHD are met, you're probably just talking about severe autism and not two distinct disorders. Or you have the camp of research that says, no, these are two distinct neurodevelopmental disorders. They overlap quite a bit, but there are underlying differences. So for example, inattention in ADHD. I don't want to oversimplify because I know over-focused attention occurs in ADHD. But inattention is I'm not paying attention. I have a difficulty focusing on someone or something. The appearance of inattention and autism is the social disability. I'm not attending to you, to the teacher, to my parents, not because I'm inattentive, it's because you're not salient or meaningful to me because I have a social disability and I'm so overly focused on these objects and things that could even be intrinsic. My thoughts. So I'm focused on those and not paying attention to your bids for interaction. That's qualitatively different, even though it appears on face value is inattention.
And then impulsivity in ADHD, again, oversimplifying is I lack impulse control to not say or do something that comes across as inappropriate, odd, aggressive, et cetera. In autism, you're going to have lack of social awareness and lack of perspective taking that you have different thoughts, other people have different thoughts, experiences, feelings than me, which comes across as a lack of empathy, but it's not. It's not understanding even what empathy is. So if I think you look ugly today or that's an ugly shirt or you smell or whatever, I'm just going to say it. And that come across as impulsive.
Pete Wright:
That presents just like lack of impulse control.
Dr. Celine Saulnier:
Exactly. But it's coming from a different place. There is no medication that is going to impact either of those behaviors in autism the way they be-
Pete Wright:
Okay. And on ADHD, when we have meds, we can close the window on those thoughts to some degree.
Dr. Celine Saulnier:
Yeah.
Pete Wright:
As part of a comorbidity series, so many of our conversations are how do you begin to address one or the other of the conditions that we're talking about to again, close the window on some of these behaviors and help you figure out what systems you need to live your life and adapt and those kinds of things? How do you begin to do that with ADHD and or autism when so many of the symptoms and experiences overlap, but come from a completely different engine?
Dr. Celine Saulnier:
It starts with the evaluation. So you hope that the evaluation is comprehensive enough with clinicians who have expertise, a modicum of expertise in both to assess for those differences. And then programming really goes to the underlying cause. The autism is you have to teach the skill explicitly, and usually that's through repetition and using reinforcement sometimes if that intrinsic motivation's not there. And teach the skill and then teach how to apply it in a meaningful social way in the real world.
ADHD is providing accommodations. And that's why when I do just an autism evaluation, I'm also doing a screener for executive functioning because I'm going to be recommending those accommodations in the school, in the workplace, wherever, even at home for executive functioning deficits versus the explicit teaching for the autism symptoms. And they're not necessarily diagnostic label based. It's symptom based. So I could be making those recommendations for someone who solely has autism, just the way I could make those same recommendations for someone who solely has ADHD. Because as you know, any individual with ADHD has social sequelae, so they will have social delays, they might have social impairments in some contexts. The difference is it's not the underlying nature of the disability. Their foundational social skills are intact, especially social communication skills and ADHD are intact. Those individuals know how to make eye contact and integrate facial expressions and gestures with their speech and make requests and joint attention and shared engagement. Those skills are there where those are the ones that are deficient and vulnerable in autism.
Pete Wright:
Talking about masking again.
Dr. Celine Saulnier:
Right.
Pete Wright:
Right. Whatever's going on in my brain, the fireworks in my brain, I can learn how not to show you those all the time.
Nikki Kinzer:
Right. So when you're treating someone with autism and you're talking about those social cues and things like that, are they aware? Are they understanding the concept that this is important like they want this to be different or does it not connect? I'm just curious if you're having these social issues and if I have autism, am I even going to know that I have these social issues? And if I am told do I care?
Dr. Celine Saulnier:
It depends on the individual. That's a great question. And we assess that as well, level of insight and awareness into social emotional experiences. There are several factors that go into that including age, cognition, language level, but literally just awareness. And it's almost like the autistic individuals who lack that awareness are buffered in a way because all of their struggles are ... To them, they're not internalizing. The more awareness someone has, the more they're internalizing the negativity, the failed experiences, and there's the anxiety and depression and even suicidality. So you really want to assess that level of awareness so that when you're doing the intervention, you can teach.
Nikki Kinzer:
You can ... Yeah.
Dr. Celine Saulnier:
There are some individuals who ... And ADHD is neurodiverse too. Adolescents and adults who self-identify as neurodiverse sometimes are of the thought that there's nothing wrong with me. I'm different, not disordered, so you shouldn't cure me or change me. The world should be modifying the environment. Which absolutely, that should be the case. We should be more accepting of neurodiversity just as any diversity we should be accepting of. However, we live in a social world that demands a modicum of social ability. And if these individuals are going to struggle in basic social interactions at the grocery store, in the workplace, wherever they are, they need to learn these foundational skills or they need to self-advocate and say, I'm neurodiverse, I have autism, whatever. And I might not look you in the eye, but that doesn't mean I'm being rude or not paying attention to you, or I'm disrespecting you it's because I'm neurodiverse and it's painful or whatever is the reason. And I think just raising awareness of all of these different disabilities is important so people understand that. And not to just the neurodiverse community, to assume that the world should just understand it and change. We're not there yet.
Pete Wright:
That is such an interesting, I'll say contrast, to the other comorbid conversations that we've been having because this is the first one where there is a culture that is broad and divided on this particular topic. Nobody says, "I don't want you to heal my eating disorder." Nobody says, "I really am happy living with depression and anxiety. Please let me keep my depression." But here's the thing that says, don't try to cure me. This is who I am and I'm with you. Obviously, this is who we are. Let's celebrate who we are. And yet, to your point in culture, a spirit of adaptation when it's required.
Dr. Celine Saulnier:
Exactly. And now think of the parents on the other end of the spectrum and family members of individuals who are non-verbal or minimally verbal, banging their head against the wall, biting through their arms and they want a cure and they're still using person first language. My child with autism, not autistic child. And we are absolutely divided as a field to the point where the Lancet Commission just about a year and a half ago agreed to have another subtype called severe and profound autism to differentiate that from the neurodiverse that is the gray area, the blurred area between neurotypical and having autism and saying that we have much different needs. These individuals require lifelong care 24/7.
That's a very different disorder. And how are we calling this the same thing? And that's when we get back to is it too broad? Are we talking about one disability or multiple disabilities? And I as a clinician am only giving this diagnostic label to someone who by the criterion, their symptoms are impairing to their life in multiple contexts. I am not giving this label to someone who has a quirky personality. And believe me, that's about 30 or 40% of my clientele when they come in seeking a diagnosis for autism, and I don't give one. They get very upset.
Pete Wright:
I feel like I understand so much more about my own, the bias that I brought into this conversation, right? My experience so far has been working on projects or documenting individuals with severe and profound autism. Kids who are in homes where they have to put iron gates in the kitchen because overnight the kid would get out of the room and go destroy the kitchen. And kiddos who are profoundly impacted, and to your point, the parents who are just doing their best to advocate for their kids to get the resource they want. And that looks so profoundly different than the neurodiverse. It's as a layperson living with ADHD, unrecognizably different.
Dr. Celine Saulnier:
Right. And yet the common thread is this constellation of symptoms of the social communication interaction, vulnerabilities in the neurodiverse. They're not deficits by any stretch. And the presence of these restricted and repetitive behaviors. Interestingly, in the neurodiverse end of the spectrum, you can see pretty pronounced restricted and repetitive behaviors that are very intrusive.
Pete Wright:
Again, confusing set of behaviors to figure out how to label, how to give yourself definition to talk about what you're experiencing, I can imagine is very complicated. And so how do we get into figuring out a path toward ... I don't know. If we're a coaching show, we're talking about building life skills to help you figure out your life for those who are sitting here saying-
Dr. Celine Saulnier:
That's my wheelhouse. Adaptive behavior.
Pete Wright:
Yeah. Let's talk about that. Where do you start with building a scaffold for adaptive behavior when you're in that? And maybe this is an opportunity for you to come back around on the executive functioning loophole you wanted to close.
Dr. Celine Saulnier:
The adaptive skills are critical because we want to foster as much self-sufficiency and independence as possible. If you look at the research in autism, on the autism side, I don't know on the ADHD side, the vast majority, 70 to 80% of autistic adults who have no cognitive impairment fail to hold down jobs, live independently or have successful, meaningful relationships. 70 plus percent.
Nikki Kinzer:
70%.
Dr. Celine Saulnier:
And that's-
Nikki Kinzer:
I'm sorry. When you said neurodivergent, so that's the side, I guess you would say less severe than the people that are non-verbal that need-
Dr. Celine Saulnier:
That's 60% of the spectrum. 60% of the spectrum have no cognitive impairment.
Nikki Kinzer:
Wow.
Dr. Celine Saulnier:
And yet the adult outcome research is abysmal. Therefore, the adaptive skills, when you look at it, they're the biggest predictor of that failure. Because we historically thought, well, you have to have intact cognition and intact language. And now we're seeing that that end of the spectrum is not successful, therefore we have to build those adaptive skills. That's coaching. Life coaching, job coaching, executive functioning coaching. Teaching in vivo, how to use the skills. So you teach it, you practice it, then you apply it. It's more than therapy because what happens in a therapeutic environment is these individuals learn the skills, but they don't naturally walk out the door and apply them. A coach will take the individual into the grocery store, will take them into the restaurant, will help them in their relationships. And that's what the social skills groups do. They're working in vivo on relationships.
And then circling back to the executive functioning, I wish I looked up the article before I came on here. I meant to. I didn't have time to tell you the author. But one study showing the overlap in individuals who have both ADHD and autism, and then comparing it to distinct autism and ADHD. They all have executive functioning impairments. They share inability to sustain working memory, inability to get going on tasks, inability to plan, organize, you name it. All of those are in both disorders. What's most distinctive of ADHD is response inhibition, that impulsivity, and what's most distinct in autism is sticky attention, inability to shift attention flexibly across tasks, transitions.
Nikki Kinzer:
Transitions.
Pete Wright:
And transitions even in ADHD is the thing we talk about all the time as being context shifting is very, very difficult.
Dr. Celine Saulnier:
Yeah. But it's more pronounced in autism.
Pete Wright:
More pronounced in autism.
Nikki Kinzer:
Well, and I think it's a different response sometimes too. I could be wrong. I'm just thinking of my friend and her son, and I know that the transition would turn into a meltdown. And loud and hard, really hard as a parent and as a child with these issues. And so I think with ADHD it looks a little different. You could still want to not do it, and it's still hard, but you don't necessarily go into this real meltdown or real frustration that somebody with ... That's how I'm perceiving it. I don't know if I'm looking at that right.
Pete Wright:
Yeah. Where does that come from? Is it an emotional response? Is that the risk? When we use the word meltdown or frustration, where's that coming from in autism?
Dr. Celine Saulnier:
It's emotional dysregulation and in some cases sensory dysregulation.
Pete Wright:
Sensory. Yeah.
Dr. Celine Saulnier:
If you think of classroom environments, so overwhelming. And so it's almost an autistic individual, maybe even ADHD, their compensatory strategy to over fixate to calm themself down, to tune out all of that overstimulation and then for someone to abruptly take you out of that and switch without predictability. And so we always recommend for autism, visual schedules, visual timers, advanced notice and predictability and routine as much as you can make things predictable. But then also once someone gets into routines, teaching flexibility that routines can shift unexpectedly. Social stories, for example, are huge in autism. Write out either in picture form, word form, or both what the sequence of events are. And fire drills, for example, are cruel and unusual punishment because they are unpredictable, they're loud and they cause chaos. There are social stories where it goes through the exact schedule of what will happen in the fire drill. And then the accommodation is that the autistic individual is informed of when the drills are. Obviously if it's a real fire drill, that's not predictable.
Nikki Kinzer:
Not much ... Yeah.
Dr. Celine Saulnier:
But prepping them ahead of time. Prepping them ahead of time for transitions of new schools, prepping them ahead of time if you're going to take a day off to go to a doctor. But it's Tuesday, I go to school. And that can be very dysregulating. And these strategies are going to be exactly the same that we would recommend in ADHD as well.
Pete Wright:
If we circle back to where we started and Nikki's sort of opening, setting the table statement that when you have these people who are becoming aware of the possibility that they might be on a different path as well as ADHD, how do you start that journey as an adult? What does the scaffolding look like that you need to build to work toward a diagnosis? What are your recommendations for those exploring who are curious about the way their brains are working toward autism?
Dr. Celine Saulnier:
Sure. Well, first and foremost, when autism is missed in childhood, the ADHD is usually diagnosed first. When autism is caught in early childhood, we can reliably diagnose autism by 18 to 24 months, the autism is diagnosed first. In these individuals, it's usually not just ADHD. It's anxiety, it's depression, it's a litany of labels that these individuals have acquired because they've probably been hospitalized a couple times or near hospitalization. They've been from therapists to psychiatrists to different physicians. And there's a huge history. And what usually brings someone to me is not the autism symptoms. It's they are so anxious and depressed that their therapists have tried everything they possibly have in their toolkit for the anxiety, depression, ADHD, and everything has failed. And they're trying to figure out what is the missing piece here and that's when autism comes up. So I would say to those listeners, if that resonates with you, that you've just been through doctor to doctor to doctor, and you've tried all the supports and nothing is helping, what is underlying that hasn't been detected yet? And it could be the social vulnerabilities.
Pete Wright:
You worked on an actual diagnostic tool.
Dr. Celine Saulnier:
The Vineland Adaptive Behavior scales is an assessment of adaptive behavior and adaptive behavior in the diagnostic criteria for intellectual disability, you have to have delays in both cognition and adaptive behavior. So you're doing IQ tests, but also standardized adaptive behavior measures. So the Vineland is just one of the most common measures for that kind of like the Wechsler scales for IQ.
Pete Wright:
Okay. Okay.
Dr. Celine Saulnier:
In autism, because adaptive deficits are so striking, you have an intellectual disability, someone's cognition is lower than their mental age, so you expect their adaptive skills to also be lower than chronological age, but they're going to be on par with mental age. So if a 10-year-old is functioning at a seven-year-old level, cognitively, their adaptive skills are probably at a seven-year-old level. If a 10-year-old with autism also has cognitive delays and functioning at a seven-year-old level, their adaptive skills, especially their functional social skills, are probably at a three-year level, maybe even lower. Because they don't have those initiation joint attention, these foundational skills that toddlers possess, even infants. And that's the gap.
Pete Wright:
Does that gap work in parallel through life? Does it ever close as they get older?
Dr. Celine Saulnier:
It widens. Without intervention, it widens. Which means that the adaptive skill acquisition is not keeping pace with chronological development and even cognitive development. In ADHD, you can also see that, but the profiles are different.
Pete Wright:
There's definitely an ADHD cognitive ... Yeah. Right.
Dr. Celine Saulnier:
But there are differences like the socialization, interpersonal relationship skills will not be the lowest in ADHD. Receptive communication will be. Following instructions, right? And autism, interpersonal relationship and coping skills will be the lowest. So there are patterns of adaptive behavior. So one of my books is just on adaptive behavior profiles and neurodevelopmental disorders to show the overlap and the differences.
Pete Wright:
My mind is blown.
Nikki Kinzer:
I know. And I feel like what I'm getting out of this is the diagnosis is really important to get if you have it and the adaptive skills are really important to implement and find that support group. Because I want to go back because there are people that I know are listening that have autism themselves or have children who have ADHD and autism. And when I hear the statistic of 70% have issues as adults, that scares me. So how can we bring some hope in that?
Pete Wright:
Right. We talk about building that scaffolding for kids. What does that look like as an adult? What are those life skills that-
Dr. Celine Saulnier:
So adaptive skills, the wonderful thing about adaptive skills is you can change them very quickly.
Pete Wright:
It's in the name.
Dr. Celine Saulnier:
They're modifiable.
Pete Wright:
Adaptive skill.
Dr. Celine Saulnier:
IQ is more stable, right?
Pete Wright:
Yeah.
Dr. Celine Saulnier:
It's harder to move an IQ point, but it's very easy. If you don't know how to brush your teeth and someone explicitly teaches you how to brush your teeth, now you can brush your teeth. And so that's why adaptive measures like the Vineland are very useful outcome measures for treatment and clinical trials because you can see in 12 weeks that adaptive skills can move. And so it's very optimistic. It just means life coaching, executive functioning coaching, all of that stuff is successful. And there's a reason why in applied behavior analysis, which gets a really bad rap in some areas of the autism world, because historically there were some negative associations with this particular intervention of discrete trial therapy. Teaching through repetition, repetition. And there used to being consequences and punishment, which there isn't anymore. There should not be anymore.
But applied behavior analysis is so broad. We all shape behavior. Anybody shapes behavior. If you have an infant, you're shaping behavior, you're shaping language, you're shaping development. Everyone is a behaviorist. So ABA, to say we can't have anything affiliated with ABA, ABA is the devil, that's erroneous and it's ill-informed. So that's why ABA works, because it's skill acquisition. So if there's a deficit, it teaches the skill and teaches how to apply the skill. Most of the neurodiverse individuals have the skills, the foundational skills in their repertoire. That's cognition. They have the ability, the capacity to perform the skill. They don't. That's the adaptive deficit. So now they just need to be taught to apply it. They don't need to be taught the skill. They just need to be taught to apply it and how to apply it. And if you think about how we have learned most of our adaptive skills in life, we learned from birth by watching other people. Just watch my siblings brush their teeth. And that's how I learned how to brush my teeth. No one sat down and taught me the sequence of brushing my teeth. Yet if you have a social disability and you are not monitoring other people, you don't have imitation skills-
Pete Wright:
You're not learning.
Dr. Celine Saulnier:
You're not learning. And people just assume because the individual's so bright and verbal, they don't need to be explicitly taught, but they do. They have to be explicitly taught some of these skills and to apply it.
Pete Wright:
It seems like what you're describing are two different things so check me when I misunderstood. That on one end of the spectrum, you have an increased deficit in skill acquisition and on the other end you have an increased deficit in skill execution.
Dr. Celine Saulnier:
If you have the skill deficit in acquisition, you will also have the deficit in application. So you have to teach and then you have to teach how to apply. But on the higher cognitive end, they have the capacity to do pretty much any adaptive skill. You just have to explicitly teach them how to apply it and that's the coaching.
Pete Wright:
How to apply it. Because it's almost the same thing. Just because they know how to do the skill, they don't have a model for how to apply it successfully, and they need to be taught that.
Dr. Celine Saulnier:
And think of it to give an example of a conversational skill that someone who's really bright and verbal, and I hate to throw this out, but Elon Musk can say some really inappropriate things and talk at you, not with you, and be just completely maladaptive in communication and social interaction. So coaching on, you already have the language. I don't have to teach you the speech skills. But here's how you initiate a conversation about someone else's interest, not your own. Here's how you think about their perspective so you don't hurt their feelings when you bluntly say something. You don't always have to say what you're thinking. Those things.
Pete Wright:
Here's how to turn off your computer for a little while.
Nikki Kinzer:
It's so interesting because I just watched a movie, it's called The Accountant, and it has been Ben Affleck in it. And he has autism.
Dr. Celine Saulnier:
I was asked to consult on that movie and I was busy. I was busy when they were filming in Atlanta so I gave the opportunity to my colleagues who have credit to the movie.
Nikki Kinzer:
Okay, okay.
Pete Wright:
That's awesome.
Nikki Kinzer:
Well, because it's so interesting what you're saying because if you watch the movie, that's exactly ... He learns this from an inmate, but the inmate is teaching him how to pick up on how someone's feeling. So throughout the movie he'll say, "Oh, you're upset right now. I can tell you're really upset." And then he's just really stone cold. But you can tell that he's learned to pick up what that person is feeling, being taught by somebody else.
Dr. Celine Saulnier:
And that's exactly the intervention. I just diagnosed a two-and-a-half-year-old this morning, and that's the strategy. You map the language for them. He didn't know even how to make a request and say, I want. You show him that language. Oh, I want juice. And use his language from his perspective. I want the juice. Here you go. And that's exactly what the inmate was doing.
Pete Wright:
Well, and on the emotional side, here's what it looks like when somebody is angry. Here are the social cues that you're missing that you're not picking up intuitively. But when you say create the map, that really rings to me. This is what the face is going to look like. Let's look at a face when it's angry. And now when you see another face that looks like that-
Dr. Celine Saulnier:
That's exactly what the intervention looks like.
Pete Wright:
Yeah. You'll be able to map that. And that's why Ben Affleck knows what angry looks like.
Dr. Celine Saulnier:
And for some kids, they're so impaired that if you use a stick figure, it won't register. You have to use actual pictures-
Nikki Kinzer:
Of a person?
Dr. Celine Saulnier:
People in their life. Yep. And Comic Strip Conversations by Carol Gray is one intervention source where you literally draw the stick figures. Here's Sally, here's Johnny. Sally's interests are coming out of her head. Your interests are ... Here are the two that are the same. Look, you both like pizza, but it's different. She likes pepperoni. You like cheese. You have to make it that explicit to some.
Nikki Kinzer:
Which I think is why the awareness piece is so important that we understand that that's what's happening so that we don't get frustrated.
Dr. Celine Saulnier:
You see a meltdown in a grocery store and you're just like, "Oh, get your kid out of here. Why would you bring your kid here?" And not having any understanding that he's heard the humming of the fluorescent lights and that sent them into a tantrum or anything. It could be anything.
Nikki Kinzer:
That awareness is just really important.
Pete Wright:
This has been fascinating. I feel like we've opened the door on something I have a lot to learn about. Thank you so much for hanging out with us today.
Dr. Celine Saulnier:
Of course, of course.
Nikki Kinzer:
Great.
Pete Wright:
Where do you want us to send folks to learn more about you and your work?
Dr. Celine Saulnier:
My website is www.nacsatl.com, and that stands for my company, which is a mouthful, Neuro-Developmental Assessment and Consulting Services. And the ATL is Atlanta. So nacsatl.com.
Nikki Kinzer:
And we'll put that in the show notes too.
Pete Wright:
Definitely put it in the show. You don't have to memorize it. It'll be in the link. It'll be a link. You can just click it.
Nikki Kinzer:
If you can send us the article, we'll make sure that we put that in the show notes too, that you referenced earlier in the show.
Dr. Celine Saulnier:
Okay. I'll send several because-
Pete Wright:
Great.
Dr. Celine Saulnier:
There's a lot. And people that you should know about are ... Megan Miller is a researcher at The Mind Institute at University of California-San Diego. And she in the autism field is the expert in the overlap between autism and ADHD. And she's looking at the earliest divisive markers in children under the age of five. And her research is really phenomenal of the overlap that you're seeing in two and three year olds, but also the subtle differences that diverge in these kids.
Pete Wright:
Fascinating. Thank you for the referral. All right. Everybody, hey, thank you for hanging out with us today. We appreciate you downloading, we appreciate you listening, and thank you for your time and your attention. Don't forget if you have something to contribute to the conversation, we're heading over to the Show Talk channel in the Discord server, and you can join us right there by becoming a supporting member at the deluxe level or better. On behalf of Nikki Kinzer and Dr. Celine Saulnier, I'm Pete Wright, and we'll see you right back here next week on Taking Control: The ADHD Podcast.
