Insights from the Couch - Mental Health at Midlife

Ep.35: Diagnosing Autism Spectrum Disorder in Women and Girls

• Colette Fehr, Laura Bowman • Season 3 • Episode 35

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Autism Spectrum Disorder (ASD) has long been misunderstood, especially in women and girls. In this episode, we’re joined by Dr. Brady Bradshaw and Dr. Allison Brazendale, two experts in adolescent and adult mental health, to break down why ASD is often underdiagnosed in females. We dive into pink flags, the subtle signs that might indicate ASD, and discuss why so many girls and women go undiagnosed for years. Plus, we explore the overlap between ASD and ADHD, the role of sensory sensitivities, and how understanding ASD can lead to greater self-acceptance and connection.

 

Episode Highlights:

[00:03] – Welcome back! Introducing our expert guests, Dr. Brady Bradshaw and Dr. Allison Brazendale, and today’s topic: ASD in women and girls.

[01:55] – Why is autism so often underdiagnosed in females? Breaking down outdated stereotypes and the challenges of diagnosis.

[04:18] – Pink flags: The subtle early signs of ASD in girls that are often overlooked.

[06:50] – The effortful nature of social interactions and why masking can be exhausting.

[09:56] – How girls on the spectrum struggle with friendships and group dynamics.

[12:36] – The overlap between ADHD and autism—how to tell the difference.

[14:45] – What’s happening in the brain? Understanding the neurobiological differences of ASD.

[23:37] – Sensory sensitivities: Why environments like grocery stores can feel overwhelming.

[26:25] – Breaking the stigma: How the conversation around ASD is shifting, and why some are resistant to the diagnosis.

[33:13] – Signs of ASD in adult women—what to look for if you suspect you or someone you know might be on the spectrum.

[38:45] – ASD and relationships: Challenges in communication, perspective-taking, and emotional connection.

[47:55] – The strengths of ASD: Deep focus, intelligence, and unique ways of seeing the world.

 

Resources:

Dr. Brady Bradshaw’s website: https://www.bradybradshawmd.com/ 

Book: Is This Autism? https://www.amazon.com/This-Autism-Donna-Henderson/dp/103215022X/ref=asc_df_103215022X?mcid=c3343feccc2d380f97695f5d35 

 

For more on this topic visit our website insightsfromthecouch.org If you have questions please email us at info@insightsfromthecouch.org we would love to hear from you!

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Laura Bowman:

Hi everybody. Welcome back to another episode of insights from the couch. We are welcoming back Dr Brady Bradshaw to the podcast. She was on our ADHD episode. If you do remember, she is the owner of Bradshaw and Associates in Baldwin Park. Dr Bradshaw is double board certified psychiatrist in both adult psychiatry and Child Adolescent Psychiatry. And also joining us is Dr Allison brazendale, a licensed clinical psychologist specializing in child assessment and therapy. Dr brazendale works with children with ADHD learning differences and Autism Spectrum Disorder. Dr brazendale is based Bradshaw and Associates. Also Welcome guys. I'm so excited to have you guys to talk about ASD autism spectrum disorder in women and girls. This is a huge new thing, right? Like this is something that women are now being identified at record numbers. So talk to us. What are you seeing?

Brady Bradshaw, M.D.:

We are definitely diagnosing more, and I know in my practice, I'm hearing more parents coming in and bringing their daughters with a concern for autism, or even adult patients coming in and saying that they think that they have autism. So I think there's more of an awareness, and people are starting to present with that question a little bit more frequently, maybe than we saw in the past. There is still a huge under diagnosis in women and girls with autism, so especially for what we would call like high functioning or high camouflaging, higher IQ patients, a huge under diagnosis is still is still there, but we are seeing it more, which is good.

Colette Fehr:

Can you guys explain a little bit about why this is so often under diagnosed, misdiagnosed in women and girls in particular.

Dr. Allison Brazendale:

Yeah. So I think that, you know, especially when I was getting my doctorate, I think autism was, you know, thinking about those kids who don't make eye contact and are having self injurious behaviors, or are non vocal, non verbal, but what we have found is that actually, you know, the diagnosis is so much more vast than that, and it's really about a different variation in the way that they think, right? And just because you don't make eye contact doesn't mean you don't have autism. And I think that's one of the main things that I see. Is when a parent comes in, they're like, oh well, they make eye contact with me. So it just can't be autism, right? But the diagnosis is there's seven different criteria that you have to meet in order to be diagnosed with autism, and eye contact is part of what we call a two which is non verbal difficulties, and that can include anything from eye contact, how close you stand to other kids understanding non verbals, perspective, taking non verbally so it's just so much bigger than that. So I think that in the past, maybe these girls were diagnosed with oftentimes, I know Dr Bradshaw and I see a lot oppositional defiant disorder because they're really strong willed, or ADHD because they're so impulsive. But that doesn't explain everything, and so what I feel like we do as a practice is really go deep into the history and looking for what Dr Donna Henderson, who's an expert in diagnosis of high functioning autism, specifically in girls, these pink flags from their history, that kind of explains some of these behaviors as they get older. And as they get older, the gap gets wider, and so I think that's often when they come into us, and parents are like, you know, they were diagnosed with ADHD, but it's just not explaining everything. There's something else there. And when we do that deeper dive, we can see it,

Laura Bowman:

Ooh, what's a pink flag?

Colette Fehr:

Yeah, what are some of the pink flags? That's what I want to know.

Dr. Allison Brazendale:

Some of those pink flags are, you know, often we see emotional dysregulation when they're younger. So that's something that I pick up on a lot. And of course, that can mean many things, right, anxiety, you know, ADHD, some mood stuff, right? But when I see that, I'm kind of like, okay, but meaning,

Colette Fehr:

meaning, like, for the listener, that their emotions are kind of all over the place, and they struggle to regulate themselves when they get emotional.

Dr. Allison Brazendale:

Yes, and big behavioral outbursts. You know, big behavioral outbursts, we say big reactions to maybe small problems. Well, we would define as small problems, also difficulties with personal space. Sometimes they're like, oh well, they never really knew a stranger. They would go and hug kids. At the park, or adults that they had just met. And of course, that can be typical too, but it's something that you know, as the data, I like to sit in my data, and as the data is coming together, that's definitely something that I pick up on as well.

Brady Bradshaw, M.D.:

Interesting I was going to just add to back to the question of, why are we missing it in girls, or why is there an under diagnosis in general? And this is true for autism, and people who are not autistic, females tend to have more internalizing symptoms. And so our diagnostic criteria for autism, similar to ADHD, are really focused on external symptoms or things that we can see. And so, you know, you can see a child flapping, and it's like, okay, they're having a repetitive movement. That's a criteria. That's like, you know, a check box. But if you have, especially a girl, their their symptoms are more likely to be internalized. So they might have struggles with relationships, socially. They might know when I meet somebody I'm supposed to make eye contact, but it's not intuitive, right? So it takes a lot of effort that they have to put in to say, Okay, I'm meeting someone. I'm supposed to make eye contact. I'm supposed to say, I have one little girl every time she sees me, I like your shoes. She just like says, I like your shoes, so

Colette Fehr:

something socially lubricating, right? Effort. It's

Brady Bradshaw, M.D.:

not intuitive, and they it requires some effort. And I think that that also sort of hints at, or sort of suggests that it can be an internal struggle, and like, very draining for these kids. Even if they can present on the outside like they have it together, it's a lot of effort to make it look like that on the outside. And

Dr. Allison Brazendale:

speaking of effortful too, and that's a really good point. A lot of those things that you know, even having reciprocal conversation, they can absolutely specifically on things that they really enjoy and their interests, but they know by watching TV and watching other people that you are supposed to ask questions. But again, can be very effortful. And when I am testing and you know an adolescent female who is on the spectrum, and I ask them about that, they say it's very taxing. It takes a lot of effort. It's not natural for them to do that, but they know they should. And so that experience can be really exhausting. And, you know, just it doesn't feel it doesn't feel good. So that, yes, I totally agree that was

Colette Fehr:

it takes a lot of effort. And then are these, like, let's say I'm a mom of a girl, and I'm not sure if some of this is applying, is one of the things I might see that's perhaps a pink flag really struggling with social friendships and maintaining those social friendships in a fluid way.

Brady Bradshaw, M.D.:

Yeah, yeah. So that is some that is part of the history that we get and the detail that we go into when we're doing a diagnostic evaluation on like a teenager, so who was their friend in first grade? Who was their friend in second grade? Not that directly, but we're listening for that. Can they maintain friendships? Sometimes the girls on the spectrum are more able to make a friend, but they struggle to keep the friend because of their rigidity socially, so they might, you know, if a third person comes in that throws them off, and they can't, you know, tolerate that, and so they, they struggle to maintain friendships. We can hear that a lot of times in their history. So relationships is a big one,

Colette Fehr:

and it's a rigidity. Brady, like it's a rigidity around friendships, is it also difficulty picking up on social cues,

Brady Bradshaw, M.D.:

all of those things. It's all of those things. Yeah, so it's the rigidity, it's the black and white thinking, you know, in the younger girls with autism, if you're my friend, then you can't be her friend because you're my friend, you know, or they just aren't sure how to navigate that. I mean, navigating three people in a friendship can be hard for girls who aren't on the spectrum, but the the nuance and the non verbal communication and being able to tolerate maybe feelings like you're being maybe not as favorite as the other friend, they it's just it's too much, it's overwhelming, and they struggle with navigating that. It's very difficult for them to maintain friendships.

Laura Bowman:

Wow. It's so interesting, though too. It's like the language of girls is so intricate, like, if you watch girls, you know that are playing, like on a cheer team or a volleyball team. There's so much language and so much behavior that is intuitive and instinctual, and if you can't play along, if you can't roll with it, you get, like, kicked out pretty quickly. So I'm assuming, like, are girls on the spectrum? Are they not particularly successful in group dynamics? Yes,

Brady Bradshaw, M.D.:

that's true. They might be able to play along. Young like, do the act of like, okay, I make eye contact. Oh, I laugh when she says something, yeah. But they might then also miss other people's non verbal. So it's not just, can I put out the non verbal? Can I read the non verbal too? So not realizing, like, the shifts that are non verbal, that would be really, that would be really a hard, a hard thing for them to

Colette Fehr:

know, and I can see why this would require a lot of effort and emotional energy, because these are things that some people are doing subconsciously, intuitively. They're not giving any energy to it. They're not thinking about it. You know, I just think about myself. Navigating a social situation requires nothing, whereas I'm thinking about it like if I got into a piece of machinery that I had to learn how to operate, and I read the manual, and I'm like, Okay, now I need to do this. Or when I first learned to drive a stick shift car, right when the RPMs are here, I need to downshift, and then I need to put the clutch in. So you're really having to be so conscious and intentional, and then I would imagine maybe the experience of often feeling like, despite that effort, you're getting it wrong, and that must be so hard.

Dr. Allison Brazendale:

And that is how it's described. Often when I'm doing diagnostics, thinking about group dynamics, one of the things that I try to help them navigate is, what are you interested in? Because typically, there's the double empathy theory, which is like, you know, people who are alike tend to obviously connect more. And so figuring out what exactly are you interested in and what might be a good group dynamic for you to be involved in. So whether that's, you know, a lot of kids are into dungeons and dragons or anime or arts, or, you know, there's like a few like coding so there's some coding classes. So those type of things, I think that they have a better experience because it's of their interests, and they feel really comfortable in that space. And then also, there are other kids that are probably similar to them in that same setting. That makes so

Colette Fehr:

much sense. It gives you a shared interest that you can maybe more easily bond and engage Exactly.

Laura Bowman:

Let me ask you, I'm assuming that some that some of these diagnoses just really cross over and it's hard to pull them apart, like ADHD and autism, how many of these things kind of fly together? And what do you see in kind of like a cluster, or where people come in and they're confused, like, is this autism, or is this this other thing? And how do you decide if it's like autism?

Brady Bradshaw, M.D.:

There is a lot of overlap, that's for sure, and there's a lot of comorbidity. So people with autism do have higher rates of ADHD, think it's like 70% they also have higher rates of anxiety. So there is a lot of overlapping symptoms, especially between ADHD and autism. One of the main differentiators that I feel and then Dr brazendale, please take it from here. But one of the main things that I notice and feel pretty quickly is the rigidity that people on the spectrum can have. Because people with ADHD can be very flexible by nature, you know, they can kind of roll with it. They can be impulsive, you know? They can sort of go with things, but the rigidity that you can feel with someone on the spectrum is very intense, and it can be like, one example I'm thinking of is I had an adult patient who wouldn't go out in the rain because of that sensory experience of getting rain done was so uncomfortable that, like, she needed to go to the grocery store, and She wouldn't go because it was raining. So, you know, me introducing this idea, like, well, could you just get an umbrella? Like, and it was like, not like, no. I mean, it hadn't occurred to her, first of all, and second of all, she was like, Are you crazy? Like, it's raining, you know. So the rigidity, that's an that's an extreme example, but the rigidity is, like, palpable. It feels really intense, especially if you're working with someone therapeutically, or you're a parent trying to coach a kid to go do something that they don't want to do. That rigidity is very intense. It's not easily swayed. Like, oh well, we'll go to Target afterwards. If you can come with us to this restaurant. It's like, right? No dice, you know.

Colette Fehr:

Okay, so I have a question, as we're talking about a lot of the symptoms and how this can present, can you explain just a little bit, even for the average person, what is going on in the brain that leads to this? Is this? Is this a difference in brain functioning, or is it something else altogether, because I don't really know much about the etiology or how it manifests internally.

Dr. Allison Brazendale:

Yeah, so it is a neurobiological disorder, and so it is about like the way that the brain functions, the way that I like to think of it, is really a variation of the way that a neurotypical individual would think. You know, in general. All the way that they experience the world is just really different, or not really different, but it is different from neurotypical individuals, and that is part of the rigidity. And they tend to see things more in black and white and less in the gray. And I think that is the way that they are, that they think, and that's what we know. And what Dr Bradshaw was saying is probably one of the biggest differences, is that rigidity. And the other thing I wanted to say too is I also think the stereotypes are repetitive. Motor movements is another thing that really differentiates it for me, because commonly, a child with ADHD, let's say may do something repetitively, like, you know, they like to play with a certain thing, or, you know, a certain way, or, you know, maybe they have some very specific interest. Or a gifted ADHD kid might really hyper focus on one thing, but once they master it, they kind of move on. Typically with autism, you'll see more of those repetitive motor behaviors like flapping or pacing or visual stimming, like looking at something as it's going around, like wheels on a car, lining up, and then these very focused interests that typically are on things that maybe are a little bit different for their age. Like I had a seven year old who was very interested in the mechanics of roller coasters. Knew everything about roller coasters, how they functioned, how they were built. It's amazing. Like, the interest they have and the amount of I mean, it's such a gift, in my opinion. I think it's awesome. Like that part of it is so cool. So I think that those are the two things that differentiate it. And yes, I do believe that the brain and the way that their brain functions is more in this kind of very structured predictability is very comforting to them. These motor behaviors are very comforting. Knowing everything about something is very comforting, and that feels good to them, versus, you know, with ADHD, it might be a different story. It might be just something that they're super they want to go on a deep dive, and then they're done. And it's

Brady Bradshaw, M.D.:

genetic. There's a heritability to it as well, which I think is another indicator for us, the neurobiological way that this is inherited. So it's often genetic. Sometimes there's a parent further back, or a grandparent that had, you know, was different, or, you know, didn't leave their house, or whatever, you know, you can kind of hear it in the family history. So it is genetic. We think it's related to mirror neurons. We don't totally understand the entire story, but there's some involvement of mirror neurons, which are probably part of that social handbook that we were all born with that they didn't get, you know, and so that's some of the theory, like most of psychiatry, a lot of it is theory that we're trying to understand better that

Colette Fehr:

makes a lot of sense, though, mirror neurons, because you end up connecting with someone, because your nervous systems kind of sync up and replicate without any conscious effort due to those mirror neurons. So I could see that making sense, but interesting to know that it is different, and yet maybe it's not fully understood why or how, but it's inherited. Tends to be inherited, and then when you get somebody coming into you, let's say with a daughter, are they typically coming in saying, I suspect my daughter may be on the ASD spectrum, or are they coming in for something else? And then they're surprised that this is maybe what it is. I mean, I'm sure you see everything. But what's the typical scenario, or the most common scenario

Brady Bradshaw, M.D.:

that's I'm laughing because Dr brazendale, I feel like, has a reputation in the community now, and so we're often seeing people who have been seen by three or four people before they've been seen by us. Interesting, and there's still some lingering questions, or like Dr brazendale was saying some things that are still not explained by ADHD or anxiety, and the parent still has this feeling like I'm not we're not being totally understood here. That's

Dr. Allison Brazendale:

exactly why I was smiling and laughing, because I feel like by the time they come, usually it's because of that they've had a previous evaluation, and there's still some stuff missing. And also I feel like I have a good relationship with a lot of the schools around here. And they'll, they'll kind of send me a text and say, hey, you know, we're not really sure, but we think, you know, we want to send them to you. And then I'm kind of, you know, in my mind, like, okay, you know, this may be more complex, and I like the more complex cases, to be honest, and part of my evaluation actually, because I do find high functioning autistic individuals like we were talking about before, they tend to mask really well, and they do really well with adults. So when, you know, commonly, a lot of psychologists, when they do their diagnostic testing, they meet with the kids one or two times. Times in their office, and, you know, I'll read past reports, and they're like, oh, they did really well. They made good eye contact, they asked me a lot of questions. That's not the full picture, right? Because I'm not a peer, so I'm not I'm not stressful for them, because I, I don't have any expectations for them socially, right? Versus when they're with their peers. It commonly looks very different. So actually, a requirement when I do diagnostic testing is I go in and observe the child in their natural environment with their peers, before they know who I am. And so if I'm doing an autism diagnosis or diagnostic assessment, I will go to the school and I will do an an observation, not in the classroom, because I if it's a dual diagnosis, maybe ADHD, I'll do half and half classroom. But where I really want to see them is in that naturalistic peer environment, lunch, pe recess, those environments, I want to see what they look like when they have to socialize on their own with their peers. Well, not sitting next to someone that they had to write. I also want to see what happens when they get excited on the playground. Are they flapping? Are they posturing when they run? Are they asking peers to do something over and over again? Are they stimming? Are they talking to themselves? Are they talking to others? So that's a super important part of my evaluation, and I think that gives me a lot of data. Yes, we get both, but commonly they're coming to me because they haven't had answers. And that piece of data collection is the most valuable thing that I can do in these diagnostic assessments

Colette Fehr:

that makes so much sense. Okay, two quick questions. I don't know. I hear this all the time. I don't know what stimming is. Stimming

Dr. Allison Brazendale:

can be a lot of different things. Stimming can be things like we all stim, right? It's a repetitive movement and behavior. So my stim is, I, I bite the inside of my mouth that if I don't know it's an anxiety stim, I It makes me feel calmer. Some people pick their nails. That's a stem. People can bounce their legs. That can be considered a stem. Or, commonly in autism, it may look like flapping. Or they may take an object, like I said, and look at it from different angles. That's a visual stem. So it's

Colette Fehr:

a repetitive kind of unconscious behavior that is just constantly happening. I'm trying to think of what I do as a stem.

Brady Bradshaw, M.D.:

It's usually in an effort to soothe. So it usually happens when they're over stimulated. So like, if they're excited or they're in an overstimulating environment, it's a way that they're able to soothe their nervous system is to have these repetitive movements. So sometimes it's even just like little finger movements that they're doing with their hands in their lap. So it's not very obvious, could be vocal stems?

Colette Fehr:

What's a vocal stem? What might be a vocal stem? So it could

Dr. Allison Brazendale:

be like grunting repetitively or saying specific noises, or just making noises repetitively with their mouths. So oftentimes it can look like a tick too. And so teasing that apart is also can be challenging. Same with OCD, okay? And this is a way

Colette Fehr:

to, like, down regulate your nervous system, seek comfort, self soothe. So then over stimulation is also a part of this, often getting easily over stimulated by social environments or so that's

Brady Bradshaw, M.D.:

the sensory piece that we see. That's part of the diagnostic criteria for autism, that they tend to be either hypo or hyper sensitive to different sensory experiences, so loud noises or bright lights or the grocery stores like hell for these kids, you know so or you know, too much chaos in a classroom or something that's really, really exciting. So I think a lot of people in the common knowledge about sensory experience can be like tags and clothes, or that socks don't feel right, or shoes don't feel right, jeans textures of fabrics, you know. So there's a lot of sensory challenges, and we see more sensory issues in girls, and so that can be another pink flag. Compared to boys, they tend to be much more sensory sensitive. Smells are a big one. They can be very sensitive to different smells, and that can contribute to a feeling of being over stimulated, and that might be when you see some of that stemming behavior.

Dr. Allison Brazendale:

Sorry, I was just going to say food, eating. Oh, right, rituals and sensory differences related to food or rigidity around eating, yeah,

Laura Bowman:

like certain foods, really, yeah. I mean, I'll just disclose this, like my father is probably. On the autism spectrum, and was never, you know, back in the day, was not diagnosed. He was just kind of a introverted chemical engineer, right? And then I married probably the most ADHD human on the face of the earth, and we reproduced. So you can imagine what my kids are like. It's just I have two that are probably ADHD ASD combined, very high functioning, very high masking. But I live with all of this stuff, and it's fascinating to watch the genetic coil kind of unravel in retrospect, like even because my my one cousin's son is fully on the autism spectrum, and I even watch him in meetings, and he'll grunt, he'll go, and I'm just looking at all of us, and I'm just like, I see it now so clearly, but I didn't see it. You know, when you're living it forwards, it's hard to understand what you're looking at. But now I do understand. One of the things I wanted to ask about is the stigma. Are people coming in, like, afraid of this diagnosis, not wanting it, especially if they have high masking kids where, like, by all intents and purposes, they're doing well in school, they're they're pretty well, you know, everything's fine, you know, but it's not fine, but it's fine. Are they wanting this diagnosis? Are they pushing against it?

Dr. Allison Brazendale:

So I see a little bit of both. I will say that as there's been more highly successful individuals coming forward, and, you know, saying that they're on the autism spectrum, and, you know, with this kind of neuro affirmative push more the social model versus medical which I, you know, really believe in. And I also have been doing this for, you know, 15 years or so, and I feel like autistic people are my favorite people. I just find them really amazing and awesome. I also have several family members on the autism spectrum who did not get diagnosed until much later, my uncle, my cousin, and there's a lot of phenotype in my family too. But anyway, I feel like there, there is both. And you know, oftentimes, Dr Bradshaw and I will recommend this book, the book that you know Donna Henderson wrote. It's called, is this autism, and it is a very neuro affirmative book about high functioning autism, and it takes the voices of autistic people and it puts it in the book, and they explain from their voice how each of the diagnostic criteria feels within them. And I think it's a very positive experience for parents to read that, especially when that's on the table. And I try to during an intake, I do a two hour very thorough intake, if I do hear these pink flags that is an like a homework assignment, I assign to the parents say, hey, you know, I want you to read this book, and I want you to see what resonates with you, because that kind of sets up the neuro affirmative process for this diagnosis. And I think it does feel comforting and good to read about. You know, these, like chemical engineers and CEOs of large companies, surgeons, you know, these very focused, very successful individuals in their craft and how they're so successful and also on the autism spectrum. So I do feel like the stigma is less, but it's definitely still there. But I do think there's, there's a big push. I know on Tiktok, there's a lot of teenagers they I forget what they call it, but I don't have Tiktok, but maybe Dr Bradshaw would know better than me, but I know that they call it something where they want to be on the autism spectrum, because it's part of a community, which I think is cool. I

Colette Fehr:

think it's become kind of en vogue among younger people, particularly right now. So I'm curious, as you say this, I have a client who comes to mind, who's an adult female, and obviously this is not something I know a lot about hence my questions. I can think of clients who probably fit some of this, but it's not something I'm super plugged into, and this particular female client was recently diagnosed being ASD. I never in a million years would have guessed that by any way she behaved or presented, just with my kind of very average, rudimentary, probably stereotypical, you know, other than taking psychopathology and like the brief dive into it in the DSM, this is not really something I've thought about much since then, you know, 1520, years ago. So what is it look like in an adult woman who maybe hasn't been diagnosed, and I'm sure there's variability, but let's say a high functioning adult woman who may be ASD and not realize or have suspicions.

Brady Bradshaw, M.D.:

I think that's such a wonderful perspective that your brain. Being because what I was thinking of when you were describing her, the banner issue I feel for for folks on the spectrum, when they present to a therapist, is feeling misunderstood. Yeah, so you don't need to be knowledgeable in autism to help someone feel understood. And so for if I had an adult present with autism as a therapist, and I was kind of working with them, I would really want to be so curious and hold space for her. Tell me, what does that mean for you? Like, what? How does that look for you? And really empathizing with my God, how much you have been through how much effort you must have made to pull this off to be able to get this far and not get diagnosed. I mean, you might, I mean, how exhausting these social experiences were, how invalidating, you know, was your home life when you were made to take a shower, even though it was so sensory overload painful for you, you know? I mean, I think we can come with a perspective of help me understand absolutely not because I want you to teach me that's not your job, but because that, I think, is the work of therapy, and really therapeutic for someone who feels like they've been misunderstood their entire life, I think when they present to you, They might look neurotypical and look like there's no autism underlying but if you give them permission to open up about their experience, you might see more as they become more comfortable with you, that you're a safe place. And like, if they need to stem, they can stem if they I have somebody who sits in different colored lighting now, you know, you know. So it's almost like giving permission to sort of, you don't have to camouflage here if you need to turn your camera off because my eye contact is freaking you out. That's okay, you know. But just sort of asking, What does this look like for you? And, you know, being really sensitive to their experience and their inner experience,

Colette Fehr:

I mean, that all makes perfect sense. And I just wonder if there are typical things that are part of the process, because some of the things, and I know this is like, everything, right? When you're a therapist, a psychologist, you're you're learning about disorders, you find like, 10 things in the DSM that you're like, oh my god, I'm kind of this, or I'm kind of that, right? I mean, some of the things you described, I don't think that in any way, that I'm probably ASD, but, you know, I have tactile issues. I'm impulsive. I There's a million things. So I guess I'm just wondering too, because even this client I'm describing, you know, I have a wonderful rapport with her, and she was and she has a lot of complex PTSD, so there's like, a lot going on there that I don't think she had any clue that any of this applied to her. So I would imagine there may be women out there in middle age who don't realize that this could be a thing, like, what could they look for? What might be some of the signs that there's high functioning autism present in an adult female?

Brady Bradshaw, M.D.:

So the rigidity, like we talked about, the rigidity, is one thing. So having, like, a really strong insistence on it being this way, or it has to be this way, there can be a concrete use of language. So that's another way in the therapy office that they might look different. So not understand, you know, not being able to understand jokes is the extreme example of it. But they can be very concrete in how they interpret language. Concrete,

Colette Fehr:

okay? So like somebody, I'm just thinking, sorry to interrupt you, but if somebody who in my office, we have these two pictures in the waiting room, this is so funny, actually, and telling and how I don't pay attention to certain things. So I bought them as a set. I thought they like went together. Well, it's actually the same exact picture. It's like an abstract I bought the same picture twice, and I hung them up. They're still out there as like, here's this set. One of my ASD clients was waiting for me one day, and she was like, Do you know that's the exact same picture? I said, No, no, they're they're a set. And she's like, No, look, this is the same as this. And I was like, wait, what? And I'm like, Oh, my God, I bought two of the same picture and tried to make it like an artistic moment. In a million years, I wouldn't notice that. I'm just like, oh, this is pretty here. Grab it, right? But like, she had zoomed in on it and, like, found this thing. And was like, these are the same, right? So is that some of the like honing in on things and,

Laura Bowman:

yeah, so interesting. And is it, can I also say, is it just a little bit of a felt sense? I mean, I know we all have our diagnostic criterias and we have our checklists, and we have to ask, we have to do a lot of good. Um. Information taking and history taking. But is there a felt sense, you know, just like a little bit of space between beats, a little bit of, like, woodenness, or that you're just like, oh, or am I making that up?

Dr. Allison Brazendale:

Yeah, no, that's part of the diagnostic process for autism. Is what I use is something called the ADOS. It's the autism diagnostic observation schedule. It's been coined kind of like the gold standard of autism testing, although it does miss many girls. So there's a lot of controversy kind of surrounding that, but I do find it a helpful measure. But one of the things that you code on in the ADOS is reciprocal communication. And then, you know, kind of this, like, social initiation, or overtures, like, how does it feel? And so kind of what you're saying, you know, if I'm dropping a bid, and I'll say something like, Oh, I'm going on vacation next week, right? You would expect, where are you going? Yeah. So if there's a little bit of like, and then there's that awkward silence, and then it's, Oh, where are you going? Or, you know, Dr Bradshaw and I had a child that we were sharing, and we like to co treat as well, because it's really helpful to be able to bounce ideas off each other, especially when there are these more complex, high functioning cases. And she seemed very social, but then lacked depth. And so that's something that you would just expect a little bit more from. So in that way, it is a shared experience, right? Like you're answering the questions, but there's not like more to it as we're peeling away the onion kind of so yes, that is definitely something that I look at. I drop a lot of bids to see what's picked up, like bread crumbs, you know.

Brady Bradshaw, M.D.:

And I think for adults, if we're thinking about adults, especially the concreteness, when you're especially trying to do therapy, where you're asking about, well, you know, some kind of deeper meaning, or, like, their inner experience, and it's gets brought back quickly to whatever the concrete facts are. And it can have a feeling to someone who's not on the spectrum and in the room with you therapy, I'm kind of like, why are we back here? Like, wait, no, I'm trying to connect a meaning here, you know. So that depth and meaning piece, I think, can, it can feel harder to get to sometimes, because they're so focused on, like, the black and white, like data points of like, well, but this is the reality my, you know, I can't pay my mortgage, or whatever it is, and it just keeps coming back to that, and it feels like you're hitting a wall almost.

Colette Fehr:

I bump into that in couples therapy, for sure, especially with the type of couples therapy I do Emotionally Focused, that is a lot about exploring your inner world and nuance, and what does that mean to you? And you know, having a lot of people from like Lockheed and engineers and surgeons, and they just don't have and some of them, ASD may be a part of it, they just don't have much there. And the last thing I want to do is, you know, pursue someone for something that isn't in their natural repertoire, but that can be a challenging connection. So I feel like I would be remiss to not ask you a little bit about the relationship front here, because I would imagine that it may be challenging to be in a relationship someone who's more classically neurotypical with someone ASD Do you see that that can be a struggle? Because I feel like that's probably showing up in my office, probably even more than I realize.

Dr. Allison Brazendale:

Yeah, I do. I think that, you know, going back to, you know, the friendship and relationship piece, it can be hard to navigate and, you know, look at perspective taking right? So how does someone else feel in this situation and that concreteness of like, well, no, because that doesn't feel good for me, or I don't want to do that. And so the answer is no versus like, okay, the answer is no, but and I can maybe be flexible and try to think about it a different way. I think that is something that can be more challenging. I

Brady Bradshaw, M.D.:

think that we can hear for couples, sometimes they can feel a little narcissistic and ASD partner, because they have that struggle with perspective taking. So I'm not really always aware of my own inner world. And now you want me to try to be aware of someone else's inner world experience. It's like, wow, that's a big leap, you know? And so I would guess I'm not a couple's therapist. You can correct me, but I would guess that the effort is to understand the ASD individuals experience in the relationship, and what are they capable of? Because they have a great sense of empathy, and they can sense that something's up. They just might not be sure what the meaning is. Yeah. So you're mad at me, but what? Actually, maybe they're like, stressed about something that happened at work, you know? So there can be an effort to understand on both sides that it can work. It's not doomed, but it's just, it's not, maybe, as intuitive the understanding,

Colette Fehr:

yeah, I think it's really important. I've had multiple people when their partner or spouse has been diagnosed ASD say it's such a relief, because now at least I may not take certain things as personally. You know, sometimes people who are really emotionally fluent and attuned, they're coming in going, what is this response like, What the fuck is wrong with you? I say this heartfelt thing, and then you look at me with a blank stare, like, fuck you. You know they're so offended and hurt by it. And if this is at least part of what's at play, and there are a host of other things that can be factors too, of course, but if ASD is part of it, then it's like, Oh, okay. You know you're not not caring. You show caring differently, and let's work on this as a team so that we can understand each other with a little more explicitness and grace.

Laura Bowman:

To that end, I'm wondering, what is it? Because I'm thinking about it, even the work I do with my own children in my house is the role of the therapist with a client, and what, what people on the spectrum can really get out of therapy? Because I do a lot of you know, I have very black and white thinking children right and wrong. And I'm doing, I'm lending out a lot of my gray brain, you know, of let's think about it this way. Can you take this particular perspective? Can we what kind of meaning I'm, you know, I'm making this meaning. What meaning are you making? I'm doing a lot of that work all the time, naturally. Is that something that people with ASD can work a lot on in a therapeutic relationship and have somebody to sort of bounce that off of?

Dr. Allison Brazendale:

Yeah, absolutely. I think those are all, you know, things that I do in my own practice. A lot of what you're saying. I also think that, you know, I feel like back in the day, when we were first, you know, diagnosing, or before we had a lot of knowledge, there was a lot of push to change autistic individuals to look neurotypical, and that is no longer, at least how I do therapy. I know at our practice, we don't do that because ultimately, sometimes it's a them problem, like, if it feels uncomfortable for you that your child isn't making eye contact with you, what? Why is that uncomfortable for you? Right? Because if it feels so uncomfortable for them, and that's not part of how they like to experience the world. Why are we making them make eye contact, you know? And so I think a lot of what I do, too, is like perspective taking like, yeah, look, if eye contact doesn't feel good for you, don't make eye contact. Or if stimming feels great for you, stim. However, here's how other people might interpret that, and so you just think about that as you're doing it. Because that's, that's the the knowledge I feel is, you know, you need to do what feels good for you, just like we would do for anything, right? So someone who's having a panic attack, if you're having a panic attack, and you're having a panic attack in front of a lot of people, here's what it's going to look like to the outside world, even though this is your internal experience, it's kind of the same thing. So how do we do that differently or not? But then it kind of accepting that this is what feels good for you, and feeling fine about it, right? So I think that's a big part of what I do, too, you know? But I think flexibility teaching is important because, yeah, like, we do a lot about a lot of work around cognitive flexibility, and I think that's good for anyone and how for everyone, yeah, and how, if you are black and white, here's how other people are going to experience that. Yeah, yeah, no,

Colette Fehr:

oh, God. I'm married to someone who is like the king of black and white, concrete and rigidity, whatever the heck. In fact, I'm thinking, maybe I need to have him come see you guys and take a little test. To that end, Sorry, Steve, you'll be hearing this live on YouTube. Nothing new. I'm pretty outspoken about every thought that crosses my mind. But To that end, what is the process for, let's say, an adult. Do they make an appointment with you guys, or someone like you guys, and are there they take some tests like, how do you if you're an adult and you suspect this may be a factor, how do you go about figuring that out?

Brady Bradshaw, M.D.:

So it is a clinical diagnosis similar to ADHD. So there can be, you know, a psychologist or a neuropsychologist who might do formal testing for autism. You could also see a psychiatrist, an MD, who specializes in diagnosing adults with autism. Usually, that means they have some background in adult psychiatry and child psychiatry. Tree, because it's neuro developmental so the child psychiatrists tend to get a little more training in that background, but you certainly if you were seeking to understand more or you suspected some type of neurodivergence, you would want to make sure that the person you're making an appointment with has experience and a reputation for knowing how to diagnose adults with autism, because it's not every psychiatrist and every psychologist, it definitely can be missed,

Colette Fehr:

okay, and that is something you all do correct, not just children, but also adult diagnoses. I do,

Brady Bradshaw, M.D.:

Dr brazenda Does it? Okay? Yeah,

Dr. Allison Brazendale:

I do up to 18 typically, is where I feel the most comfortable, but I have other colleagues that are psychologists that do it, and then Dr Bradshaw does it as well,

Colette Fehr:

right? And Dr Bradshaw, you have that dual board certification, right? Child psychiatry, adult psychiatry, so that's that important criteria. You want to really make sure, like so many of these things with therapy too, right? You don't want to go to someone, well, I was going to say something, but some people may not like that. You don't want to go with someone with a cert if they don't have trauma experience. Let's just, let's just leave it at that, if you have complex PTSD. So it's really important to find the right professional. And it

Brady Bradshaw, M.D.:

takes time. And it does take times. I don't you know if I'm doing an evaluation like this, it's an hour, and then I might be seeing you at another hour, and it might take me to hour three or hour four before, not that that's all part of the evaluation, but I'm getting to know the person, and then I'm then I'm seeing, like, okay, there's like, a super you know, either there's a concreteness that we're not getting past, or, like, there's a sort of non verbal issues I'm picking up on that, like, weren't just anxiety about a first visit. So it takes time. It's, it's, there's a lot of overlapping symptoms with other disorders like we mentioned. You know, I'm glad that there's more out there on social media, on Tiktok and all of that. And so when patients bring it to me and say, you know, I saw this on Instagram, and now I think I have it, I take that really seriously. It's not like, I'm gonna say, Oh, well, if Instagram said it, then you do. But I'm like, okay, like, what is that resonating with? Because I may not be seeing it all. I might not be seeing inside what's going on for you. So tell me about why that resonated. What did you notice? So it can take some time to get to know someone to make the diagnosis. Also, sometimes for women, especially if they have a history of multiple diagnoses. So this doctor told me I had borderline personality. This doctor told me I had oppositional define as a kid. This doctor told me I had bipolar, you know. So if I start to hear multiple diagnoses, that's another thing that I'm like, okay, maybe we've missed one, you know, underlying unifying diagnosis here with autism,

Laura Bowman:

that's fascinating. And just to, just to, kind of like, end on more of a positive note, like, what are some of the really cool things about people that have ASD and especially some of the unique things you see their abilities or strengths?

Dr. Allison Brazendale:

I mean, like I mentioned before, the fund of knowledge that they have about things that they're interested in is, I mean, it's just absolutely incredible. And the way that they can interpret the world, I think, is also pretty amazing. I also, I say this often, because oftentimes they know when to be like, No, I don't want to be in this social situation, which I think a lot of times. I mean, even for myself, I'll push myself into situations where I'm like, Oh, well, I need to go talk to these parents, or I need to go to this birthday. Go to this birthday party where I would rather just be at home and recharge. And I think they have a, honestly, like, a better handle on that. And I think that's a really admirable thing. They're extremely intelligent, and I think that the way that they can focus on a craft is, you know, unmatched. It's very, very cool. Wow.

Brady Bradshaw, M.D.:

You can definitely see like a giftedness in certain areas and different people. And it depends on the individual. Of course, that is stunning. And, you know, can bring tears to my eyes sometimes, when I'm hearing them talk about something that they've come up with, it's usually Uniquely Creative and just blows you out of water.

Laura Bowman:

Yes, I've seen that too, and I think it's this fine dance between learning how to be in a world full of neurotypical people and also really honoring your own the way your brain works and the way you need your environment set up and moving between those two things. But I'm glad we're talking about it, and I'm glad it's out there more and that people are being able to understand themselves, because there's nothing worse than like, being diagnosed with like, four different things and going, what the hell is going on with me? And

Colette Fehr:

like you all said, the experience that. Being misunderstood is so painful and so isolating. So I think it is really important that we all understand it better and make space for everyone to feel more understood and have permission to be who you are, right, and if other people don't like it, tough shit.

Dr. Allison Brazendale:

Yeah, exactly perfect

Colette Fehr:

way to end our time together. Ladies, thank you so much. I have learned a tremendous amount. It's fascinating. It's so important to understand, and I know our listeners will have to we're so grateful to you for your time and expertise. And of course, if people who are local or in Florida, right, can make appointments with you all if they would like to. I mean, I know you don't have a ton of free space, but is that something that it's okay to say?

Dr. Allison Brazendale:

Yeah,

Brady Bradshaw, M.D.:

I'm really do. We are both very passionate about raising awareness around this topic, so we appreciate you guys giving the time to it and letting us talk about it. Yeah,

Colette Fehr:

I think it's really important. And we'll link to how to get in touch with you in the show notes and everyone listening. Thank you so much. If you have questions for us, please reach out to us at info, at insights from the couch.org. We hope you got some valuable insights from our couch today, and we will see you next time. Bye guys. You.