Adult autism diagnosis

[Shiori]

One of my favorite parts of consultation training is hearing how other psychologists say things. That, or hearing how they interpret one of my well-worn phrases.

---

Members don't see this ad.

 

[psychma]

This is what I put in my reports "While Rambo exhibits some symptoms that could be considered consistent with ASD (e.g., difficulty making friends, behavioral rigidity, sensory processing differences, etc.), he doesn’t demonstrate the pervasive deficits in the areas of social interactions, communication, and restricted/repetitive behaviors and interests that characterize ASD. In particular, Rambo showed a number of age-appropriate social skills during the assessment, including shared enjoyment, directed facial expressions, well-modulated eye contact, use of gestures, frequent social overtures, ability to easily establish rapport, interest in the examiner, and frequent sharing of information. His teacher/parents also reported appropriate gesture use, eye contact, and average frequencies of autism related symptoms on rating scales.

Nonetheless, Rambo exhibits a number of significant challenges in the areas of behavior, emotion regulation, and social skills. (elaborate with what's really going on here."

It's ridiculous how boilerplate and little tailoring that paragraph usually needs

This is good. Thanks. I like seeing how different clinicians phrase things.

 

[borne_before]

This is good. Thanks. I like seeing how different clinicians phrase things.

I totally stole that or some version from a report.

 

[borne_before]

One of my favorite parts of consultation training is hearing how other psychologists say things. That, or hearing how they interpret one of my well-worn phrases.

I script a lot - but I have a dysgraphia; not autism.

 

[borne_before]

Here is my mild intellectual disability script:

Psychologist: "Because Rambo's intellectual functioning and adaptive skills are here (show them normal curve drawing), they meet the diagnostic criteria for an intellectual disability."

Them: ???

Psychologist: An intellectual disability used to be called "mental ******ation."

Them: ooooh!

Here's the main points I try to hit:

• (Needing to get in front of the parents) I say " when I say mental ******ation, what do you think about? (rhetorical question) - " most people think about Down syndrome. Most people with Down syndrome have a moderate to severe intellectual disabiliy. There are 10 times as many people with a mild intellectual disability than there are with a moderate level of an intellectual disability. In fact, 2% of the population has a mild intellectual disability. You run into these people all the time. They often hold jobs, get married, have kids, etc. There is nothing outwardly different about them, but they could come off as slightly immature."
• Let me put this into perspective a little bit. Those with a moderate level of intellectual disability need a lot of extra help and can generally read at the kindergartner level by the time of 20 years old. In contrast, most individuals with a mild intellectual disability will be able to read at the 2nd-4th grade level by the time of 20. To put that into more contacts, the average newspaper or magazine is written at the 3rd-4th grade level. So they can get by pretty okay.
• Most kids with mild intellectual disabilities look pretty normal until school, then school is absolute hell for them, unless they get schoolwork at their level, then they graduate and get a more basic job. Many live pretty independently, can drive a car, etc. They might need some support here and there to be fully independent. They might struggle with some problem solving skills, budgeting, and being socially naïve.
• That's why i think we need to focus on school right now - to help Rambo be more independent and develop their life skills, because we just know that algebra is going to kill their self-esteem and not be used by them.

 

[smalltownpsych]

Here is my mild intellectual disability script:

Psychologist: "Because Rambo's intellectual functioning and adaptive skills are here (show them normal curve drawing), they meet the diagnostic criteria for an intellectual disability."

Them: ???

Psychologist: An intellectual disability used to be called "mental ******ation."

Them: ooooh!

Here's the main points I try to hit:

• (Needing to get in front of the parents) I say " when I say mental ******ation, what do you think about? (rhetorical question) - " most people think about Down syndrome. Most people with Down syndrome have a moderate to severe intellectual disabiliy. There are 10 times as many people with a mild intellectual disability than there are with a moderate level of an intellectual disability. In fact, 2% of the population has a mild intellectual disability. You run into these people all the time. They often hold jobs, get married, have kids, etc. There is nothing outwardly different about them, but they could come off as slightly immature."
• Let me put this into perspective a little bit. Those with a moderate level of intellectual disability need a lot of extra help and can generally read at the kindergartner level by the time of 20 years old. In contrast, most individuals with a mild intellectual disability will be able to read at the 2nd-4th grade level by the time of 20. To put that into more contacts, the average newspaper or magazine is written at the 3rd-4th grade level. So they can get by pretty okay.
• Most kids with mild intellectual disabilities look pretty normal until school, then school is absolute hell for them, unless they get schoolwork at their level, then they graduate and get a more basic job. Many live pretty independently, can drive a car, etc. They might need some support here and there to be fully independent. They might struggle with some problem solving skills, budgeting, and being socially naïve.
• That's why i think we need to focus on school right now - to help Rambo be more independent and develop their life skills, because we just know that algebra is going to kill their self-esteem and not be used by them.

Too bad everyone lives in Lake Wobegon where everyone is above average. On a different note, why do we have to have a “disability” in order to receive reasonable accommodations when often it is just the lower end of a normal distribution? I mean that question sort of rhetorically as I understand the history of the ADA and how that was broadened to help people with intellectual or emotional difficulties and that was probably a good thing, but I think it has had some negative side effects such as over-pathologizing and reinforcement of that.

 

[WisNeuro]

Too bad everyone lives in Lake Wobegon where everyone is above average. On a different note, why do we have to have a “disability” in order to receive reasonable accommodations when often it is just the lower end of a normal distribution? I mean that question sort of rhetorically as I understand the history of the ADA and how that was broadened to help people with intellectual or emotional difficulties and that was probably a good thing, but I think it has had some negative side effects such as over-pathologizing and reinforcement of that.

When it comes to schools, answer is probably resources. Every year, schools and teachers forced to do more with less. I'd hate to be a teacher who gets more and more students every year, and having to help manage several dozen IEPs or similar situations. Also, depends on the definition of reasonable here. There are some ridiculous accommodation requests out these days in work and school settings. Even when I used to teach I rejected some on reasonable grounds.

 

[Sanman]

Too bad everyone lives in Lake Wobegon where everyone is above average. On a different note, why do we have to have a “disability” in order to receive reasonable accommodations when often it is just the lower end of a normal distribution? I mean that question sort of rhetorically as I understand the history of the ADA and how that was broadened to help people with intellectual or emotional difficulties and that was probably a good thing, but I think it has had some negative side effects such as over-pathologizing and reinforcement of that.

Because at the end of the day someone has to come out at the bottom. Each of us is just trying to make sure that it is not our kid that ends up there. Capitalism's cannon fodder as it were.

 

[borne_before]

Too bad everyone lives in Lake Wobegon where everyone is above average. On a different note, why do we have to have a “disability” in order to receive reasonable accommodations when often it is just the lower end of a normal distribution? I mean that question sort of rhetorically as I understand the history of the ADA and how that was broadened to help people with intellectual or emotional difficulties and that was probably a good thing, but I think it has had some negative side effects such as over-pathologizing and reinforcement of that.

I dunno - but, I hate that the traditional definition of ID is 70ish or below. In a modern American economy and school - you're gonna be severely disadvantaged with a 70-80 IQ, regardless of adaptive functioning.

But, I think you're kind of touching on the philosophy of a disability. To answer that question, we need to agree on what a disability is. Is it like porn? You know it when you see it? It's disabling, but a lot of the disabling part has to do with an interaction and the difference in an individual with environment. Take a person who uses a wheelchair - they get around pretty most of the time, until they have to use stairs - then I would argue that's when the disability is apparent.

I think in a kinder world, we'd just recognize that people on the lower end of the distribution do need a lil more help and compassion. But, we also can't try to make everyone have equal outcomes.

When it comes to schools, answer is probably resources. Every year, schools and teachers forced to do more with less. I'd hate to be a teacher who gets more and more students every year, and having to help manage several dozen IEPs or similar situations. Also, depends on the definition of reasonable here. There are some ridiculous accommodation requests out these days in work and school settings. Even when I used to teach I rejected some on reasonable grounds.

I think you must have been a school psychologist in a past life, dude. Now throw in things like no child left behind for people with an 80 IQ, their parents, organizational demands, blank slatism, etc. Schools often have an impossible task - especially public schools.

 

[WisNeuro]

I dunno - but, I hate that the traditional definition of ID is 70ish or below. In a modern American economy and school - you're gonna be severely disadvantaged with a 70-80 IQ, regardless of adaptive functioning.

But, I think you're kind of touching on the philosophy of a disability. To answer that question, we need to agree on what a disability is. Is it like porn? You know it when you see it? It's disabling, but a lot of the disabling part has to do with an interaction and the difference in an individual with environment. Take a person who uses a wheelchair - they get around pretty most of the time, until they have to use stairs - then I would argue that's when the disability is apparent.

I think in a kinder world, we'd just recognize that people on the lower end of the distribution do need a lil more help and compassion. But, we also can't try to make everyone have equal outcomes.

I think you must have been a school psychologist in a past life, dude.

That'd be tough. I pretty much despise most kids aside from my own. Though, a lot of that stems from parents of those children doing nothing to parent their children.

 

[Sanman]

When it comes to schools, answer is probably resources. Every year, schools and teachers forced to do more with less. I'd hate to be a teacher who gets more and more students every year, and having to help manage several dozen IEPs or similar situations. Also, depends on the definition of reasonable here. There are some ridiculous accommodation requests out these days in work and school settings. Even when I used to teach I rejected some on reasonable grounds.

When it comes to anything in life, especially in the U.S., it is a question of resources. You know that is the key to quality of life on the other end of the spectrum (old folks) as well as I. The difference between a dementia patient living with dignity until their natural end vs being medicated into oblivion is money and manpower. Kids, at least, get a little more consideration.

 

[WisNeuro]

When it comes to anything in life, especially in the U.S., it is a question of resources. You know that is the key to quality of life on the other end of the spectrum (old folks) as well as I. The difference between a dementia patient living with dignity until their natural end vs being medicated into oblivion is money and manpower. Kids, at least, get a little more consideration.

I'm just hoping that as I get older, we relax our attitudes towards medically assisted methods of that end for certain conditions.

 

[borne_before]

That'd be tough. I pretty much despise most kids aside from my own. Though, a lot of that stems from parents of those children doing nothing to parent their children.

It rough, man. Schools are literally always asked to fix society's problems - from integration to navigating dynamic trans issues and dealing with existential concerns about science education from sputnik/cold war and malnutrition.

But it's also holy. Schools often are the most stable environment for kids. The most steady place where they get a meal. But the problem is, schools try to do too much these days for all students - too many competing demands. Lest we forget that the space race was won by many who went to school in single room classrooms!

One huge issue is the liberalism of the college of educations who have gotten bored teaching teachers how to teach reading and instead focus on identity issues over fundamentals.

 

[Sanman]

I'm just hoping that as I get older, we relax our attitudes towards medically assisted methods of that end for certain conditions.

We have a long way to go in that area in medicine as a whole. As someone that is passionate about palliative care and quality of life, I would be glad if we just stop torturing old people for a buck. Ever met an 85 year old with h/o moderate dementia, post-craniotomy from a meningioma, with uncontrollable/unmanageable behaviors in short-term rehab? I have. What an undeserving way to live out your last days. That family was not educated on compassionate care.

 

[WisNeuro]

It rough, man. Schools are literally always asked to fix society's problems - from integration to navigating dynamic trans issues and dealing with existential concerns about science education from sputnik/cold war and malnutrition.

But it's also holy. Schools often are the most stable environment for kids. The most steady place where they get a meal. But the problem is, schools try to do too much these days for all students - too many competing demands. Lest we forget that the space race was won by many who went to school in single room classrooms!

One huge issue is the liberalism of the college of educations who have gotten bored teaching teachers how to teach reading and instead focus on identity issues over fundamentals.

I think a bigger issue is state governments, and federal to a lesser extent, continually eroding teacher pay and benefits, making the profession incredibly undesirable. Pile on the right wanting to put schools in the middle of the culture wars, and I can't imagine any sane and competent person wanting to go into that profession.

We have a long way to go in that area in medicine as a whole. As someone that is passionate about palliative care and quality of life, I would be glad if we just stop torturing old people for a buck. Ever met an 85 year old with h/o moderate dementia, post-craniotomy from a meningioma, with uncontrollable/unmanageable behaviors in short-term rehab? I have. What an undeserving way to live out your last days. That family was not educated on compassionate care.

Yeah, I have seen some things in the inpatient units that convinces me that there are certainly a lot of ways that I would not care to spend the end of my life. And, I've done plenty of medical decision making evals, where the patient knew that they were essentially going home to die, and did not want to spend their last days in a hospital, gorked out on meds/treatment, that may temporarily extend their life, but decrease QoL. The desire to extend life at all costs is real in medicine.

 

[smalltownpsych]

Increased resources is part of the issue, but if we just spend more money doing things that aren’t working, then I doubt that would help. I have worked in schools both public and private and I have seen dramatic effects of paradigm shifts in these environments.
One of the most effective schools I was involved with had academic classes three days a week for about four hours a day. The rest of the time they were involved in vocational and artistic pursuits. Taking care of animals, cooking, painting, drama, chopping wood, etc. The vocational stuff wasn’t academitized if you know what I mean if was purely hands on and experiential and not really graded. Very small classes as well. Half of the kids had ADHD diagnoses and about half of those were able to discontinue their medications altogether and about 80% reduced the dosages. Also, standardized testing on PSAT improved by 200 points. Other confounds as well, such as lots of psychotherapy, but the academic outcomes were clearly impressive.
Other schools I have worked in that have had great teachers accomplishings great things would be moving in similar directions and a key point is that these people aways had to work around or against the system. I really think that most of what I have seen of the direction of education in my lifetime has been misguided and going in the wrong direction. As I always like to say, the only thing worse than our problem is our solution. It’s like my patients that can’t shift their paradigm and they need to shift it in order to change. That’s why I pose questions about how we view and treat disabilities. i don’t have answers but one of the problems we have in our society, especially politically, is that if we don’t have answers then we shut down the questions.

 

[cara susanna]

I do think that our system is too one size fits all, although I don't know how to fix it. People with ADHD seem to manage pretty well when they're able to move around and do more hands-on things.

 

[smalltownpsych]

I do think that our system is too one size fits all, although I don't know how to fix it. People with ADHD seem to manage pretty well when they're able to move around and do more hands-on things.

Every time we try to fix it, we emphasize the non-hands on stuff. Also, I think that the neurotypical are just better at tolerating or more resilient to an unhealthy system. The outliers are like the canaries in the coal mine.

 

[romanticscience]

It's funny you start this thread. I had one today. I've been starting to consider "autism" as any other disorder which can lie on a dissociative spectrum (cogiform--factitious) and consider the underlying personality dynamics. For instance, in someone with narcissism, this "factitious autism" may provide a defense against shame (You're upset with me? My autism made me do it!"), the same as pain or conversion symptoms have a dynamic utility. Just my $0.02

I'm moving past the apparent conflict, giving into a battle in "accepting the diagnosis," and appreciating the vulnerability. That is, managing the countertransference that comes from my opinion as a doctor being devalued.

Now, if it's ADHD and stimulants are at stake, that's another story!

Ouch! This patient just ended up leaving me a bad review because I *questioned* her adult autism self-diagnosis.