ASD Child

07/05/2025

The concept of interception is important to understand some of the difficulties in autism.

07/05/2025

Stimming as an important behaviour for self regulation.

07/05/2025

An important contribution for our understanding of repetive behaviour in autism.

20/11/2024

This is an important topic. The discussion gives some important insights to depression in autistic adolescents.

Understanding Depression in Autistic Children and Adolescents

Depression is a significant mental health concern affecting many individuals worldwide. In autistic children and adolescents, it presents unique challenges. This blog explores the challenges of depression within this population, exploring its prevalence, presentations, underlying causes, and support ideas for depression.

◾️ Prevalence of Depression in Autistic Youth

Depression is notably prevalent among autistic individuals, with approximately one in three adolescents experiencing at least one episode of depression (Hollocks et al., 2019). This rate is alarmingly higher compared to their neurotypical peers, emphasising the need for timely and targeted mental health support and intervention, including accurate diagnosis and the prompt provision of appropriate support services.

◾️ What is Depression?

Major Depressive Disorder (MDD) is characterised by a persistent feeling of sadness or loss of interest in previously enjoyed activities, impairing daily functioning. According to the DSM-5-TR (APA, 2022), a diagnosis requires the presence of at least five symptoms over a two-week period, including changes in appetite, sleep disturbances, fatigue, feelings of worthlessness or guilt, difficulty concentrating, and recurrent thoughts of death or su***de.

◾️ Challenges in Diagnosing Depression in Autistic Youth

Recognising depression in autistic children and adolescents is challenging due to the overlapping of autism characteristics and depression symptoms. Characteristics such as social withdrawal, sleep disturbances, and changes in appetite can be attributed to either condition, leading to potential misdiagnosis or underdiagnosis. This phenomenon, known as diagnostic overshadowing, often results in depressive symptoms being mistaken for autistic behaviour (Oakley et al., 2021).

◾️ Presentations of Depression in Autistic Youth

While many depressive symptoms are similar across different populations, autistic children and adolescents may express and experience these symptoms differently. In addition to the DSM-5-TR symptoms for depression, other presentations may be experienced:

🔹Changes from Personal Baseline: Any changes from an individual's usual behaviour or baseline should not be solely attributed to the dynamic nature of autism; they might signal underlying mental health issues.

🔹Irritability and Frustration: Increased irritability or frustration, especially when finding it difficult to articulate their feelings or when overwhelmed.

🔹Loss of Interest in Special Interests: Changes in the frequency or topic of special interests are common, including reduced engagement and motivation or shifts to new, often more negative topics. Some may maintain or increase special interests out of a sense of obligation or routine, despite a loss of genuine enjoyment.

🔹Changes in Autistic Characteristics: Increased self-soothing behaviours such as stimming during periods of stress or depression. Additionally, there is often a heightened need for routine and structure to cope.

🔹Social Withdrawal and Camouflaging: Some individuals may feel an increased need to mask both autistic characteristics and signs of depression to fit in or to lessen the perceived burden on others. This can lead to significant mental and physical exhaustion, necessitating withdrawal from social interactions to cope and reduce sensory input. For many, the ability to mask diminishes during depressive episodes, which can further exacerbate depressive symptoms due to increased vulnerability and exposure of their authentic selves without the usual protective barriers of masking.

🔹Physical Symptoms: Emotional distress can often present as physical complaints, including headaches, body pains, and stomach aches.

🔹Emotional Dyskinesia: A reduced range of emotional expression in the face and body language, which can result in their feelings being overlooked. This lack of recognition can lead to feelings of alienation and increased depression.

🔹Externalised Agitated Depression: Depression can present as agitation and blame directed towards others. This may appear as aggressive behaviour but often stems from low self-worth and underlying depression.

🔹Suppression of Emotions: Suppressing painful emotions can hide depressive symptoms, leading to a lack of recognition and support. This suppression can intensify depressive episodes and create intermittent 'depression attacks.' The effort to mask true emotions can lead to chronic feelings of alienation and personal defectiveness, significantly contributing to depression.

🔹Functional Use of Anger: Using anger functionally to achieve solitude.

🔹Depression Attacks: Intense episodes where suicidal ideation rapidly intensifies, marked by a deep, out-of-control feeling and a dangerous urgency to act on impulses. These attacks can be overwhelming and require immediate attention and support.

◾️ Underlying Causes of Depression in Autistic Youth

Several factors contribute to the heightened risk of depression among autistic children and adolescents:

🔹Social Isolation and Loneliness: Difficulties in social interaction often led to feelings of isolation, unheard, and loneliness, significantly impacting mental health.

🔹Peer Rejection and Bullying: Repeated negative social experiences can erode self-esteem and lead to a persistent sense of worthlessness.

🔹Mental Exhaustion: The continuous effort to analyse and navigate social interactions can be mentally draining, leading to depression.

🔹Internalising Criticism: Frequent bullying and negative feedback can result in internalised negative beliefs about oneself, perpetuating depressive feelings.

🔹Cognitive Patterns: Autistic individuals may tend to focus on errors and potential problems, contributing to a negative self-image and hopelessness about the future.

🔹Family History: A higher incidence of mood disorders in the families of autistic individuals suggests a genetic predisposition to depression.

🔹Autistic Burnout: Many autistic individuals experience autistic burnout, characterised by extreme mental, physical, and emotional exhaustion, often due to prolonged periods of stress and masking autistic characteristics. If left untreated, autistic burnout can lead to the development of depression.

🔹Hyperarousal of Emotional Empathy: Intense affective empathy can lead to self-imposed social isolation to protect one's mental health.

🔹Alexithymia: Many autistic individuals also experience alexithymia, a condition characterised by difficulty in identifying and describing emotions. Alexithymia can mask depressive symptoms, making it harder for individuals to recognise and communicate their distress. This can lead to underreporting of symptoms and delays in receiving appropriate treatment, thereby increasing the risk and severity of depression.


◾️Interventions and Support Strategies

Effective interventions require a multi-faceted approach tailored to the unique needs of autistic children and adolescents. Each intervention should be individually tailored and person-centered, considering the person's sensory profile, cognitive needs, history, and other personal characteristics. It's important to recognise that not all programs will be suitable for every individual, and flexibility in approach is crucial to provide effective support:

🔹Early Recognition and Diagnosis: Improving awareness and training among healthcare professionals to accurately recognise and diagnose depression in autistic youth.

🔹Therapeutic Interventions:

Cognitive-Behavioural Therapy (CBT): Adapted for autistic individuals, CBT can help address depressive symptoms and improve coping strategies by focusing on changing negative thought patterns and behaviours.

Dialectical Behaviour Therapy (DBT): This therapy can be beneficial for managing intense emotions and improving interpersonal effectiveness and distress tolerance.

Acceptance and Commitment Therapy (ACT): ACT focuses on helping individuals accept their thoughts and feelings rather than fighting them, encouraging them to commit to personal values and take action towards a meaningful life.

🔹Behavioural Activation: This strategy involves encouraging engagement in enjoyable or meaningful activities to counteract the withdrawal and inactivity common in depression. However, this might not be suitable during periods of autistic burnout due to the additional mental and physical exhaustion.

🔹Mindfulness and Relaxation Techniques: can help manage stress and improve emotional regulation. Techniques include mindfulness meditation, deep breathing exercises, and progressive muscle relaxation.

🔹Social Skills Training: Programs designed to enhance social interaction skills can reduce feelings of isolation and improve self-esteem. These can be particularly effective when tailored to the specific needs of autistic individuals.

🔹Parental and Caregiver Support: Providing resources and support to caregivers can help them better understand and support their child's mental health needs. This includes psychoeducation, support groups, and respite care to alleviate caregiver stress.

🔹Creating Inclusive Environments: Schools and communities should foster inclusive environments that promote acceptance and understanding of autistic individuals. Reducing the risk of social isolation and bullying can significantly improve mental health outcomes.

🔹Monitoring and Addressing Autistic Burnout: Recognising the signs of autistic burnout and implementing strategies to manage it, such as reducing demands, increasing downtime, and providing supportive environments, can prevent the progression to depression.



💡Where to From Here?

We have created a brand new event to assist clinicians who see adolescents to increase their knowledge and skill in recognising autism and distinguishing autism from other conditions, such as ADHD and depression, and in the provision of support and therapy for autistic teenagers who are often suffering with mental health issues. Our event comprises two days, Masterclass Day 1: Diagnosis for Autistic Teenagers and Masterclass Day 2: Support and Therapy for Autistic Teenagers. The events will be help live in London, and can be attended live via webcast and watched later for 60 days after the event.

https://attwoodandgarnettevents.com/product/webcast-event-and-live-in-london-day1-diagnosis-for-autistic-teenagers-16-january-2025/

https://attwoodandgarnettevents.com/product/webcast-event-and-live-in-london-masterclass-day-2-support-and-therapy-for-autistic-teenagers-17-january-2025/

📚References

American Psychiatric Association [APA]. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).

Cassidy, Sarah, Au-Yeung, Sheena, Robertson, Ashley, Cogger-Ward, Heather, Richards, Gareth, Allison, Carrie, Bradley, Louise, Kenny, Rebecca, O'Connor, Rory, & Mosse, David. (2022). Autism and autistic traits in those who died by su***de in England. The British Journal of Psychiatry, 221(5), 683-691. https://doi.org/https://doi.org/10.1192/bjp.2022.21

Cassidy, S. A., Bradley, L., Bowen, E., Wigham, S., & Rodgers, J. (2018). Measurement properties of tools used to assess depression in adults with and without autism spectrum conditions: A systematic review. Autism Research, 11(5), 738-754.

Chandrasekhar, T., & Sikich, L. (2015). Challenges in the diagnosis and treatment of depression in autism spectrum disorders across the lifespan. Dialogues in clinical neuroscience, 17(2), 219-227.
Hedley, D., Uljarević, M., Wilmot, M., Richdale, A., & Dissanayake, C. (2017). Brief report: Social support, depression and suicidal ideation in adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47, 3669-3677

Hedley, D., Uljarević, M., Foley, K. R., Richdale, A., & Trollor, J. (2018). Risk and protective factors underlying depression and suicidal ideation in Autism Spectrum Disorder. Depress Anxiety, 35(7), 648-657. https://doi.org/10.1002/da.22759

Hollocks, M. J., Lerh, J. W., Magiati, I., Meiser-Stedman, R., & Brugha, T. S. (2019). Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis. Psychological Medicine, 49(4), 559-572. https://doi.org/10.1017/s0033291718002283

Kinnaird, E., Stewart, C., & Tchanturia, K. (2019). Investigating alexithymia in autism: A systematic review and meta-analysis. European Psychiatry, 55, 80–89.

Oakley, B., Loth, E., & Murphy, D. G. (2021). Autism and mood disorders. Int Rev Psychiatry, 33(3), 280–299. https://doi.org/10.1080/09540261.2021.1872506

Rhodes, S. M., Eaton, C. B., Oldridge, J., Rodgers, J., Chan, S., Skouta, E., McKechanie, A. G., Mackie, L., & Stewart, T. M. (2023). Lived experiences of depression in autistic children and adolescents: A qualitative study on child and parent perspectives. Res Dev Disabil, 138, 104516. https://doi.org/10.1016/j.ridd.2023.104516

20/11/2024

See a podcast from Prof Atwood.

04/11/2024

Some thoughts about camouflaging

Camouflaging can help autistic adolescents blend in, but it's important to remember that survival doesn't always mean thriving. True support means recognising the cost behind the mask. - Dr Michelle Garnett, AuDHDer and Clinical Psychologist


When I talk about camouflaging, I think about the effort autistic adolescents put into blending in with their peers. It's a survival mechanism—a way to avoid bullying, rejection, and misunderstandings. But while camouflaging can offer temporary safety, it often comes with significant emotional and cognitive costs. It's exhausting, and over time, it can erode one's sense of identity and well-being. As a psychologist, I believe our role isn't about helping these young people fit in but to help them thrive—to understand the toll that camouflaging takes and to create environments where they can be their authentic selves without fear.

Learn more about supporting autistic teens:
On Friday, January 17th, 2025, Tony and I will present Day 2 of our Masterclass on Autistic Teenagers. The course equips professionals with neurodiversity-affirming strategies and therapeutic techniques to support autistic adolescents, focusing on best practices for addressing depression, anxiety, social connections, and self-identity through adaptations informed by current research and clinical expertise. The full day will be webcast live from London, so the timing will suit people in the Northern Hemisphere best, but participants will have 60 days to access the event.

https://attwoodandgarnettevents.com/product/webcast-event-and-live-in-london-masterclass-day-2-support-and-therapy-for-autistic-teenagers-17-january-2025/

02/11/2024

Autism and challenges in families

02/11/2024

Autism and Parenting

Autism, Custody and Access Issues

There is a popular belief that having an Autistic child causes so much parental stress and discord that the divorce rate is at least 80%. However, this is a myth, as research on over 900 families who have an Autistic child has found no evidence to suggest a greater risk of divorce (Freedman et al. 2012). The study found that 64% of Autistic children had married parents, compared to 65% of non-autistic children. If divorce occurred, the level of support needed was not a factor. Instead, results showed that divorce was more likely when the Autistic child was young. In the first few years after diagnosis, there can be stress associated with acceptance of the diagnosis and the effects on the relationship of intensive early intervention. Over time, many families adapt, and stress levels stabilise. Research shows that parents of Autistic children experience higher rates of depression, anxiety, stress and burnout than parents of nonautistic children (Chen et al., 2024). The rates of depression are often higher in mothers than in fathers, likely due to mothers often taking on a more prominent caregiving role. Each of these factors can impact marital satisfaction (Freedman et al. 2012).

When divorce occurs, there can be legal issues regarding custody and access, and the Autistic child’s specific needs are often a specific consideration. Here are some common issues that may arise:

- Best Interests of the Child
Courts will prioritise the child’s best interests when making custody and access decisions. For an Autistic child, their best interests often require particular attention to their developmental and emotional needs.
Judges may ask for expert evaluations (e.g., from psychologists or developmental specialists) to better understand the child’s specific needs to make decisions regarding custody and access.

- Parenting Ability and Capacity
The ability of each parent to understand and accommodate the needs of the autistic child is a critical factor in custody decisions. This may include:
* Acceptance of the diagnosis of autism.
* Ability to provide emotional and practical support.
* Knowledge of the child’s therapeutic and educational requirements.
* Capacity to manage the child’s routines and behaviours effectively.
* Willingness to cooperate with professionals involved in the child’s care.
Parents might have different levels of ability or understanding regarding how to meet the child’s unique needs and be effective advocates with relevant agencies.

- Consistency and Structure
Many Autistic children thrive on routine, consistency and structure. A disruption in their daily routine (e.g., due to changing homes frequently between parents) can be particularly distressing for them.
Courts may prefer arrangements that maintain consistency for an Autistic child, such as having a primary residence with one parent and specific, structured visitation with the other.

- Therapeutic and Support Needs
Autistic children often have specialised therapeutic and support needs (e.g., speech therapy, occupational therapy, and behavioural interventions), which are time-consuming. Parents will be expected to engage and liaise with and coordinate support and therapy services.
The court may consider how much each parent educates themselves in the various therapy and support services.
Both parents may be required to ensure that the child has access to necessary support and therapy. Custody arrangements may be influenced if one parent fails to follow therapeutic and support plans.
Decisions on therapy, treatment options and support to ensure consistency might require mediation or court intervention, especially in high-conflict divorce proceedings.

- Educational Requirements
Autistic children may require specific school placements, which can vary between geographical locations. The parent/s with custody may have significant input in selecting schools or managing Individualized Education Programs (IEPs).
Frequent school changes can be detrimental, so stability in educational placement is often prioritised.

- Communication and Collaboration Between Parents
Co-parenting an autistic child often requires a high level of cooperation and communication. Parents must coordinate appointments, therapy sessions, and schooling and remain consistent in behaviour management approaches.
Courts may recommend joint parenting plans, but one parent may be given more decision-making authority if communication is poor.
The prevention by one parent of another’s meaningful involvement in therapy will impede positive outcomes for an Autistic child. The court would perceive it as contrary to the child’s best interests.

- Sensory Sensitivities and Environment
Autistic children can have specific sensory sensitivities that need to be considered in custody decisions. The child’s environment in each parent’s home must be accommodating, calm, and suited to their needs.
A home that is overly stimulating or lacks accommodations for autism may not be appropriate for the child.

- Sibling Relationships
The relationship between the autistic child and their siblings can be important in custody arrangements. Courts might consider whether a separation of siblings could negatively affect the Autistic child, especially if they rely on their siblings for emotional support or routines.

- Access Schedules
Traditional access schedules (e.g., alternating weekends or overnight visits) may need to be adjusted for an Autistic child. The schedule must be tailored to the child’s unique behavioural and developmental abilities.
Some Autistic children may struggle with transitions between homes, so minimising the frequency of transitions could be beneficial to their well-being.

- Child Advocate
A court may appoint a child advocate to represent the best interests of the Autistic child during the custody proceedings. The advocate’s role is to make recommendations based on the child’s needs and ensure the court recognises their preferences.

- Financial Considerations
There may be additional financial responsibilities (e.g., therapy, resources, or medical expenses). Parents may need to negotiate how these costs will be shared in a custody arrangement.
Child support payments might be adjusted to account for the child’s long-term needs, especially if they are likely to continue needing support beyond the age of majority.

- Impact on Long-Term Care
Some Autistic children may require care and support beyond the age of 18. This could impact long-term custody and financial arrangements, including who will be responsible for decisions regarding the child’s future care, education and support, and living arrangements.

- Practical Steps for Parents:
* Obtain expert evaluations: Consider getting professional assessments to outline the child’s specific needs.
* Build an ‘umbrella’ over the Autistic child: Regardless of the level of tension or acrimony in the relationship, as much as it is possible to do so, protect your child from these feelings.
* Develop a comprehensive parenting plan: The plan should address all aspects of the child’s care, including schooling, therapy, support and medical needs, and transitions between homes.
* Be flexible: Understand that the child’s needs may change over time, so the custody arrangement may need to evolve.
* Consider mediation or counselling: These can help parents resolve disputes and improve communication, ensuring that the child’s needs remain the priority.
* Be aware that the characteristics of Autism may be different in each household.
* Being present during conflict and acrimony between parents will be distressing for an Autistic child, who is likely to be very sensitive to either parent’s distress. A court may make an order regarding avoiding arguments in the presence of the Autistic child or third-party supervision during times associated with expressed agitation.
* An Autistic child will need to be adequately prepared before access visits and supported when those visits end.


Where to from here?
Tony and Michelle will present a webinar, Autism in the Family, on the 15th of November, 2024. The webinar will help participants understand the effects of Autism on family dynamics and appropriate ways of accommodating Autism within the family.

WEBCAST EVENT: Autism in the Family – 15 November 2024

https://attwoodandgarnettevents.com/product/webcast-event-autism-in-the-family-15-november-2024/

References
Chen et al. (2024) Factors predicting depressive symptoms in parents of children with autism spectrum disorder in eastern China. BMC Public Health. 2024 Jan 18;24(1):226. doi: 10.1186/s12889-024-17731-7.

Freedman, B. H., Kalb, L. G., Zablotsky, B., & Stuart, E. A. (2012). Relationship status among parents of children with autism spectrum disorders: A population-based study. Journal of Autism and Developmental Disorders, 42, 539-548.

02/11/2024

19/10/2024

This is an important topic which has received limited attention.