Hi, all. Over the last year I have noticed that I am routinely getting more people presenting to be evaluated for Autism. They are all adults, who graduated at least high school, and frequently college, with full time jobs. Are they looking for an excuse/reason for their behavior? Is it just social media pushing these individuals to be evaluated? How are you handling these patients?
Adult Autism Evaluations? Is everyone else getting these?
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Staff refer these to psychologists.
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I get referrals for depression or anxiety + "concerns for autism", which invariably means patient thinks they have autism for some reason. I do a standard psych eval. Most of the time it's an anxiety disorder with social stressors that the patient thinks they shouldn't have to experience. Occasionally it's undiagnosed ADHD or OCD. I've had a couple of BPD patients identity seeking as well. Rarely it's legit autism (have seen one who was mild but obvious autism).
I just explain what I think is really going on and that even if they have autism the only thing I'm going to do is refer them for therapy. If they show resistance you can directly ask them why an autism diagnosis matters to them. Usually they just want an explanation for their perceived deficits and sometimes they just want to put a name to their experience. Regardless, I let them know that I'll address what we can and then send them back to their PCP once they more stable.
I just explain what I think is really going on and that even if they have autism the only thing I'm going to do is refer them for therapy. If they show resistance you can directly ask them why an autism diagnosis matters to them. Usually they just want an explanation for their perceived deficits and sometimes they just want to put a name to their experience. Regardless, I let them know that I'll address what we can and then send them back to their PCP once they more stable.
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I have a long blurp I say. Here are some highlights:
-capable of diagnosing autism but won't
-there are specialty clinics that can do such a review
-but why, what will change if you get the Dx?
-Likely will continue to piece together objectives /changes with therapist, does it really need autism Dx?
-Because I haven't been doing these evals I may be outdated, and could be value to actually getting a consult for autism specifically and may be particular therapy modalities I'm not aware of, if you really want to...
90% plus are like yeah, you're right. No need to get another diagnosis. Then are able to treat depression, anxiety, whatever per routine.
But yes, so many are coming in with 'Oh, and I wonder if I have autism?'
-capable of diagnosing autism but won't
-there are specialty clinics that can do such a review
-but why, what will change if you get the Dx?
-Likely will continue to piece together objectives /changes with therapist, does it really need autism Dx?
-Because I haven't been doing these evals I may be outdated, and could be value to actually getting a consult for autism specifically and may be particular therapy modalities I'm not aware of, if you really want to...
90% plus are like yeah, you're right. No need to get another diagnosis. Then are able to treat depression, anxiety, whatever per routine.
But yes, so many are coming in with 'Oh, and I wonder if I have autism?'
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I don’t have people asking me to diagnose them but I have many people being diagnosed with autism. I have a few psychologists in my area that seem to diagnose most people they evaluate with adhd, autism or both.
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Both ASD and ADHD are frequently diagnoses that my existing patients return to me saying their therapist told them they should ask me about. They frequently do not have those diagnoses.
Sometimes we get primary ASD evals. I'm trying to think whether I've seen a case yet where the patient does not have a preexisting (from childhood) ASD diagnosis, comes in seeking an ASD eval, and actually also has legit ASD. All of my legit ASD patients have been diagnosed since childhood, all are male, and all of them live with their parents.
Like the new ADHD presentations, often the new ASD patients have various suboptimal behavioral patterns and are looking for an "excuse/reason." ADHD is often an excuse for suboptimal performance with an obvious fantasized solution (stimulants.) ASD is an excuse with an inappropriate fantasized solution (accommodations so everyone at work has to treat them exactly they way they want to be treated and they don't have to make any adjustments to their behavior--yes I have head this multiple times.)
Many of these ASD-dx-seeking patients pitch a royal fit if you directly tell them they don't have it. I've taken to telling some of these patients "I'm a psychiatrist, I can determine whether you have clinically significant ASD and, based on my evaluation today, you did not report sufficient symptoms or show behavioral signs required to make the clinical diagnosis. That doesn't mean you don't have some traits on the spectrum, it just means that I am not able to diagnose you with ASD as it's defined in the DSM."
Sometimes we get primary ASD evals. I'm trying to think whether I've seen a case yet where the patient does not have a preexisting (from childhood) ASD diagnosis, comes in seeking an ASD eval, and actually also has legit ASD. All of my legit ASD patients have been diagnosed since childhood, all are male, and all of them live with their parents.
Like the new ADHD presentations, often the new ASD patients have various suboptimal behavioral patterns and are looking for an "excuse/reason." ADHD is often an excuse for suboptimal performance with an obvious fantasized solution (stimulants.) ASD is an excuse with an inappropriate fantasized solution (accommodations so everyone at work has to treat them exactly they way they want to be treated and they don't have to make any adjustments to their behavior--yes I have head this multiple times.)
Many of these ASD-dx-seeking patients pitch a royal fit if you directly tell them they don't have it. I've taken to telling some of these patients "I'm a psychiatrist, I can determine whether you have clinically significant ASD and, based on my evaluation today, you did not report sufficient symptoms or show behavioral signs required to make the clinical diagnosis. That doesn't mean you don't have some traits on the spectrum, it just means that I am not able to diagnose you with ASD as it's defined in the DSM."
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I've seen one that was a new diagnosis with very relevant functional impairment. It was a guy that was living with his mom in his late 30's and all he does is work out and play video games because he couldn't hold down jobs at Wal-Mart/Home Depot/insert 2-3 other warehouse stores. Was referred to me for depression and and autism eval. The ASD was painfully obvious but he never got diagnosed because he was always homeschooled.
Other than him I have had 2-3 others who I do think are probably mildly on the spectrum and would have previously been diagnosed with Asperger's, but definitely wasn't severe enough to warrant any intervention other than discussion social skills and emotional processing with a therapist.
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I don't offer clinical autism evals (I do autism evals on the forensic side) but it does come up quite a bit in my patient population. Interestingly, one of my recent consults was so obviously autistic I knew it before I met him and confirmed it within minutes and he was adamant that he was NOT autistic.
I think it is good to have a healthy skepticism and bear in mind that the majority of autistic individuals can't work full time or live independently nor do they marry or have a longterm romantic relationship. At the same time, there is a wide range of outcomes and a significant minority of autistic people won't meet criteria for an ASD diagnosis as adults.
Differential for these consults includes patients with borderline, narcissistic, avoidant, schizoid, obsessive-compulsive personalities, PTSD and complex developmental trauma, social anxiety disorder, schizotypal disorder, highly sensitive persons.
Other things to note is that a lot of people do have autistic like traits but won't meet criteria for ASD (either because of lack of any language impairment or because their traits don't cause significant impairment in social and occupational functioning).
Patients can definitely be correctly diagnosed for the first time as adults. This can the case if they had other problems as children that meant the autism was overlooked, their parents were neglectful, they were from a different culture/country with less access to this kind of care, they were able to compensate to some degree, and many women present somewhat differently. I had one patient who had significant intellectual disability and an interesting neurogenetic diagnosis with autism. No genetic testing was ever done and the autism was completely missed. This patient was unable to live alone, work, and had textbook worthy brain imaging and was in their 5th decade of life before the ASD dx or genetic testing offered by me.
We also see patients with ASD presenting to memory clinics for evaluation of bvFTD even though their behaviors are not new and they've always been socially inappropriate and weird.
In my forensic work, I also see people who weren't diagnosed with ASD as children. There is a lot of BS with autism as moral exculpation for bad behavior, and most of them time they don't have autism, but we definitely genuine autism first diagnosed at the time. Of course, the courts rightly look more suspiciously at de novo diagnoses.
My main pet peeve is that the ADOS is NOT the "gold standard" for autism evaluation and should not be used as a standalone tool to diagnose autism. The "gold standard" is a clinical evaluation with access to collateral sources for developmental history by an expert in autism who might be a developmental pediatrician, psychologist, psychiatrist or neurologist. The ADOS was never intended to be used as a clinical diagnostic tool and while it is certainly useful, it is neither necessary nor sufficient for an ASD diagnosis.
As an aside, doing autism evaluations can be potentially very lucrative in the right setting. Bonus points if you speak Mandarin.
I think it is good to have a healthy skepticism and bear in mind that the majority of autistic individuals can't work full time or live independently nor do they marry or have a longterm romantic relationship. At the same time, there is a wide range of outcomes and a significant minority of autistic people won't meet criteria for an ASD diagnosis as adults.
Differential for these consults includes patients with borderline, narcissistic, avoidant, schizoid, obsessive-compulsive personalities, PTSD and complex developmental trauma, social anxiety disorder, schizotypal disorder, highly sensitive persons.
Other things to note is that a lot of people do have autistic like traits but won't meet criteria for ASD (either because of lack of any language impairment or because their traits don't cause significant impairment in social and occupational functioning).
Patients can definitely be correctly diagnosed for the first time as adults. This can the case if they had other problems as children that meant the autism was overlooked, their parents were neglectful, they were from a different culture/country with less access to this kind of care, they were able to compensate to some degree, and many women present somewhat differently. I had one patient who had significant intellectual disability and an interesting neurogenetic diagnosis with autism. No genetic testing was ever done and the autism was completely missed. This patient was unable to live alone, work, and had textbook worthy brain imaging and was in their 5th decade of life before the ASD dx or genetic testing offered by me.
We also see patients with ASD presenting to memory clinics for evaluation of bvFTD even though their behaviors are not new and they've always been socially inappropriate and weird.
In my forensic work, I also see people who weren't diagnosed with ASD as children. There is a lot of BS with autism as moral exculpation for bad behavior, and most of them time they don't have autism, but we definitely genuine autism first diagnosed at the time. Of course, the courts rightly look more suspiciously at de novo diagnoses.
My main pet peeve is that the ADOS is NOT the "gold standard" for autism evaluation and should not be used as a standalone tool to diagnose autism. The "gold standard" is a clinical evaluation with access to collateral sources for developmental history by an expert in autism who might be a developmental pediatrician, psychologist, psychiatrist or neurologist. The ADOS was never intended to be used as a clinical diagnostic tool and while it is certainly useful, it is neither necessary nor sufficient for an ASD diagnosis.
As an aside, doing autism evaluations can be potentially very lucrative in the right setting. Bonus points if you speak Mandarin.
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Sadly, now you have just earned an extra punitive google review, and the ARNP down the street will say clearly is Autism, and ADHD, etc.
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I have noticed this too. My best guess is that it is a kind of "Neurotribes" effect. People are viewing traits like social awkwardness, introversion, sensory sensitivity, aversion to eye contact, etc. as being something akin to a form of "neurodiversity" that is actually beneficial. For example, in the Neurotribes book the author reviews various brilliant, accomplished people who seem to have had autism or at least many of the traits. I think many people who in the past would have been called a "nerd" are now being shunted into an "autism spectrum" category that is far different from the much more severe autism most of us were trained to recognize as a mental disorder.
Interestingly I think one point of the neurodiversity movement was to recognize that we all have brain differences and that these quirks of personality and thinking can actually strengthen society as a whole. I think it is getting at least partially translated, though, as seeing people as being "on the spectrum" (disordered) rather than "quirky."
I also think that for some people (for example borderline patients) who have very severe interpersonal deficits, it is less shaming and more socially accepted to explain bad social behavior with "I have autism" than "I have a personality disorder."
Interestingly I think one point of the neurodiversity movement was to recognize that we all have brain differences and that these quirks of personality and thinking can actually strengthen society as a whole. I think it is getting at least partially translated, though, as seeing people as being "on the spectrum" (disordered) rather than "quirky."
I also think that for some people (for example borderline patients) who have very severe interpersonal deficits, it is less shaming and more socially accepted to explain bad social behavior with "I have autism" than "I have a personality disorder."
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The problem is I feel like that is where so much fauxtism is suggested to people or validated.
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I think one issue is people are seeing it as another way to differentiate themselves and be "special," or as an excuse for wherever they are lacking social skill or experiencing difficulty.
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How do you "un-diagnose" these people when it is the issue?
I literally just saw paperwork where someone is taking out a restraining order, and the order has extra checkboxing, and presumably protections, for people with disabilities, and they are claiming autism. On questioning, it is undiagnosed autism. I'm not sure it will be a question from a judge or if they will ask or it will matter
There are real consequences to this diagnosis people are looking for just to have an excuse or be special (not all, obviously).
Some people just need explanation and education, obviously. Not all bad actors.
Just wondering how you divorce people from it in any case.
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Sure ADOS is essentially a structured observational assessment tool that was initially designed for research work but it is certainly intended at this point to be used as a clinical diagnostic aid along with an appropriate developmental history and consideration of other diagnoses.
Totally agree with the “gold standard” thing and also agree nobody should be doing any kind of autism assessment without appropriate collateral, I don’t see a ton of local psychologists doing an ADOS without a developmental history though. There are certainly other structured assessment tools that can be really helpful.
I have a little problem with this thinking not from you but that I’ve seen this argument from less trained people or people who are giving pretty soft or pay to play “autism” diagnoses who don’t do an ADOS because it’s “biased” or something.
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I mean yeah, I see it. How could we not all be seeing it with the prevalence of it as a topic on social media? In terms of how you deal with it, you check for other/alternative diagnoses. If there's a diagnosis that is treatable within your specific clinical setting, eg with 15-30 minute med management every 1-3 months, you do so. Beyond that, if the person is having primarily interpersonal relationship challenges for any reason, including possible autism, they need to generally be seeing a therapist for weekly hour long visits, which statistically (although certainly not universally), is not a psychiatrist. So, you refer out. Now the therapists described above who are for some reason telling patients to go ask their psychiatrist if they have autism, that I haven't seen, but I'd certainly be calling the therapist right up and asking how exactly my involvement in this diagnosis one way or the other would affect their course of treatment since it wouldn't be affecting my course of treatment. I very much agree with the concept because of "I could diagnosis this, but I don't" with the corollary being because it doesn't affect my course of treatment. The ADOS is great and I do agree that I don't see people administering it without a thorough history. However, regardless of the results on the ADOS, it doesn't change how I treat a specific patient. In terms of legal paperwork, I'd advise the person that that is outside my area of expertise and recommend they have a subspecialist (generally well outside psychiatry) fill out any specific paperwork.
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"You obviously are someone who feels like they have a lot of trouble fitting in with other people and your social skills are no the best from what you've told me. You often seem to come at things from a very different perspective than most people and you are interested in things that a lot of people think are strange to be interested in. You're not happy about this and it causes a lot of pain for you.
If I had a magical crystal ball, and could look into it, and tell you, 100% for sure no exceptions, that no, you are just an eccentric or odd person but you're not autistic, what would you do about those problems? What would you do differently if the crystal ball told you you were autistic instead?"
If I had a magical crystal ball, and could look into it, and tell you, 100% for sure no exceptions, that no, you are just an eccentric or odd person but you're not autistic, what would you do about those problems? What would you do differently if the crystal ball told you you were autistic instead?"
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I haven’t undiagnosed anyone with autism. My understanding is the treatment of autism is not pharmacological so I just kind of step aside and point towards psychological interventions. These people are usually very invested in their diagnosis and I don’t find disputing it ever gets anywhere.
ADHD is much trickier but getting a uds and not prescribing to those using cannabis screens out many people.
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FWIW, I've told folks they don't have ADHD fairly often. IMHO, A good ADHD evaluation involves a thorough clinical interview that is often structured, knowledge of the ADHD literature, collateral (I've used narrow band measures and interviews), and the ability to tolerate inevitable patient anger when they are told that procrastination + interrupting their partner during a fight + boredom while completing TPS reports does not equal ADHD. The social disability "model" that many therapists and psychologists are taught in school is not helping the overdiagnosis problem nor is academics writing that subthreshold impairing symptoms still need treatment (if they mean stimulants). I think there's a lot of noise out there that contributes to this problem, and yes, it's too easy for us psychologists to punt to you guys since in many states we don't hold the prescription pad.
I have this conversation regularly with people, and many times, it's satisfying enough for them to avoid seeking out a further evaluation. I've paired it with a RAADS-R before many as a way to chat about what they notice, how they "mask", and then make suggestions in how to cope. Most of the time, I'm doing some mix of reframing and social skills training.
Have been getting these referrals for years and turning down a lot of them, but the reasons driving this are specific to our Australian system.
Someone in government decided that Autism Level 2 would enable automatic access to the National Disability Insurance Scheme, which can result in tens of thousands of dollars in annual funding for a range of things including support workers, cleaners, gardeners etc.
For some reason there’s very little medical oversight with this process, and frankly I’m not interested in getting involved after having had patients with schizophrenia and bipolar being knocked back by some faceless bureaucrat without the intellectual capacity to process a medical report.
Now I don’t have an issue with severe cases getting on, but adults in relationships, full time work and clearly have no language impairment? Nah. At best they are high functioning ASD, so there’s no point in writing a report which will get knocked back. If they are still insist on pursuing it, I send them off to look for a psychologist. A lot of psychologists are making good coin by charging thousands for questionable assessments – if they want to make that decision it’s up to then.
Someone in government decided that Autism Level 2 would enable automatic access to the National Disability Insurance Scheme, which can result in tens of thousands of dollars in annual funding for a range of things including support workers, cleaners, gardeners etc.
For some reason there’s very little medical oversight with this process, and frankly I’m not interested in getting involved after having had patients with schizophrenia and bipolar being knocked back by some faceless bureaucrat without the intellectual capacity to process a medical report.
Now I don’t have an issue with severe cases getting on, but adults in relationships, full time work and clearly have no language impairment? Nah. At best they are high functioning ASD, so there’s no point in writing a report which will get knocked back. If they are still insist on pursuing it, I send them off to look for a psychologist. A lot of psychologists are making good coin by charging thousands for questionable assessments – if they want to make that decision it’s up to then.
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Similar things seem to be happening in the United States. Although it’s not likely to get disability there is some secondary gain.
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I think the inflection point for the increase in requests for de novo assessment of ADHD and ASD in adults was a couple of years before the pandemic. I don't have data to back up that claim, though, just thinking about how our attendings were somewhat unprepared to handle the notable increase in low-symptoms patients asking about these diagnoses when I was in my last two years of residency. Then it really took off with everyone being far too online (subreddits, social media, and other "neurodivergent community" forums) in the first couple of years post-pandemic.
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Perhaps the inflection point was the majority of people at once with interest in obtaining the diagnosis, sought it, got whatever they wanted out of it, and are now basically the folks running around with fauxtism, and they're not really darkening the mental health system's door the same way.
Because once they establish "my therapist thinks I'm ADHSD or whatever letters" or "I'm undiagnosed because the system sucks and doesn't "see" us" then they've gotten what they want and back to whatever circle this has benefit for them. There's nothing more anyone can do for them.
This makes sense and would be consistent with the observations here that it isn't rampant in what you see. Ironic there are some forms of "crazy" that doesn't end up on the office a bunch. Nope, just making someone else's life more difficult.
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I rarely have people who get diagnosed with autism and say "wow thank you so much! i feel so much better now." It's usually on to the next diagnosis they can use to distance themselves from meaningfully reflecting upon their experiences or blame for their problems instead of owning up to them.
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I think this is particularly the case when someone comes in announcing what diagnosis they believe they have and asking for confirmation.
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I think you're describing a real thing (these people don't always re-present after they "get my diagnosis") but TBH I was referring to an upward inflection point--I (have and still) see this stuff often, although I wouldn't say there seems to be an acceleration in rates of people presenting like this the way there was 5ish years ago. I do think all those people getting lazy diagnoses and then returning to their therapists may serve as a reinforcing factor for therapists thinking they're uncovering all of these "undiagnosed/hidden" ADHD/ASD problems.
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100%
My entire company is focused on helping people improve functioning regardless of diagnosis. We have plenty of patients with social difficulties for a wide variety of reasons and the diagnosis is not really that relevant. What is more important is how to use psychological interventions to identify problematic patterns of behavior and thinking and come up with strategies to mitigate and/or improve those.
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Yes in a way it’s easier than a person with an incorrect bipolar diagnosis because those people are pushing for medications. With an incorrect autism diagnosis at least we can point them towards psychological interventions that may help.
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Yep getting a lot who watch a YouTube video and think they have autism. Or they think their “neurodivergence” is an actual diagnosis of autism when they’re just a mildly socially awkward individual. I just refer to psychologist.
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I send them for formal psychological testing if they believe they have ASD. I will diagnose ADHD based on clinical interview.
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Do you complete an ADOS for your forensic evals? Completely agree that doing them in isolation is not the move for ASD diagnosis.
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Hipster psychiatrist got these Evals before they were cool
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Not meant for adults
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Yes meant for adults.
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Yeah, ADOS-2 can be used with adults. I imagine some of the confusion may come from the fact that many/most people evaluating children are probably not also seeing adults. And many people actually evaluating adults are doing so without measures like the ADOS (or maybe any measures at all).
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I stand corrected. Apologies ! I have never heard of nor seen it being used in adults. An 18 year old? Maybe. A 55 year old? Never seen it. I guess you can administer ADOS to an adult but is it valid and reliable in this population ? Always, always have learned and only seen it used in children. I guess because ten years ago 40 year olds weren’t wondering if they all of a sudden have autism , unlike now, with tik tok and social media pushing the diagnosis on young and older millennials.
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Very interesting ! 😭
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Yep, I suspect this is a major contributing factor.
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Module 4 can be used with adults. It's effectively an interview.
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I use it. I'm an adult psychiatrist who got certified to use the ADOS through the WPS video program. I had to slog through the other modules, knowing I'd only use this part. Much of Module 4 compares to a semi-structured personality assessment. I use the SCID-AMPD, and many areas overlap (e.g., What annoys you about people? What is a friend? How is work going?).
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Ah yes module 4. Very helpful thanks guys !
