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The AuDHD Psych Podcast.

Transcript

SPEAKER_00 0:09

Hello friends, welcome back to the Audi HD Psych Podcast. I'm Aaron Howard, Clinical Psychologist, and gentlemen who matches their clothes to their rosacea. Well, welcome back again. Thank you to everyone as always for your comments and feedback. Um, I really want to say thank you to everybody who's been commenting and rating us on Spotify and Apple Podcasts. Um, if you like what we do, please get out there, like, follow, subscribe, rate us, um, and give us some feedback. Uh, we're open to positive and negative feedback. We'd love it because it helps us improve and know what we're doing well. So uh a quick note just on episode eight, I'll be re-recording that shortly, just because the sound on the uploaded copy was not amazing. Um I would like to describe it as the insight of a newborn snappy, but we'll be correcting that shortly and I'll be uploading a little monologue that covers most of the information contained in that episode. So uh what was next on my little note here? Um, yeah, I just wanted to thank everybody. We have moved so quickly into podcast. Um, we've reached our Instagram followers over 4,000 followers. So thank you all. And our downloads are up towards 3,200 downloads now. And in three and a half months, and this is just unbelievable for an independent, self-funded, self-produced podcast. So we really appreciate all of your support, and I cannot say that enough. Thank you, thank you, thank you. Um well, I think you're asking what are we chatting about today? Today I just wanted to have a little bit of a chat about late diagnosis and diagnostic levels. I know many of you out there will have received late diagnoses of autism and ADHD for your ADHD diagnosis or your neurodivergent diagnoses uh regardless. And might be wondering how it was missed for so long, certainly as I did when I finally realized that I was ADHD and a delightful autist. And I guess there's a lot goes into that. And I'll start with talking about the diagnostic criteria. So speaking solely about autism and ADHD, our diagnostic criteria have been developed over the last century or so around externalizing presentations, often in children rather than adults. So when I say externalizing presentations, what I mean is uh expressions of our characteristics that are visible from the outside or observable from the outside. So, you know, I've used the example before when I was growing up in the 70s and 80s, the stereotypes of ADHD were a naughty little boy in a classroom yelling and throwing chairs. And I wasn't that. So I wasn't the obvious ADHD. That's an externalizing presentation. That's a young child who has an impulse to do something and doesn't control that impulse, doesn't keep it inside, doesn't internalize it. Um they externalize it, they behave in a certain way, they come to the teacher's attention, and then maybe a psychologist or a psychiatrist's attention. So that's an example of how a diagnostic criteria have been developed. When we look at the criteria of ADHD, for example, it's you know the inattentive one, often daybreeding that can be seen from the outside, uh, often fails to pay close attention to tests or things like that. And the impulsivity might be verbal impulsivity when I cut you off, or it might be obvious impatience and waiting at a cure or in traffic. These are things that can be seen from the outside. So they're external expressions of my characteristics. For autism, it might be the really obvious meltdown that I have I might have in public as a young child or as an adult. Uh, it may be my difficulty in holding a conversation with new people, you know. I have a very, very static script that I have in um public settings where I don't know people. And it's pretty much I start conversations by this conversation. Uh oh, nice to meet you. How do you know the host? Um, oh, what do you do for a living? And if I have some context for that job, I'm like, oh, I thought about being an architect once, but my attention to detail is terrible. Uh-huh. And that's how I flow that scripted conversation because I just don't know how to start a conversation with a stranger otherwise. That's visible from the outside. Um, in terms of those restricted and repetitive patterns of thought, behavior, and use of objects. You know, we have the stereotypes of the child lining up the toys. Or I actually like to color code and hang my clothes by t-shirts and then long sleeved shirts, uh, buttoned down or not. Uh cats, shorts, and then color-coded. That's what I like to do. That is a restricted and repetitive pattern of behavior that others can see. But a lot of my characteristics I internalize, so I'm not that little boy in a classroom. Uh I am very impulsive. I make decisions quickly, and I, idiot optimist, I assume they're going to work really well, so I act on them. Sometimes they do, and that's a great privilege. Sometimes they don't, and there's a great privilege in the learning from those for me. But a lot of us, particularly biological females and a lot of internalizing males, uh in my case, it was probably anxiety that led to me becoming primarily an internalizer. But for a lot of biological females in Western cultures, we teach our daughters and our MB biological females. Uh, young ladies don't act like that. So those externalizing expressions of our characteristics, we're taught, we're teaching our biological females, our daughters, early in life that that's not appropriate and there are social repercussions for doing that. So many, many, many, many women are have internalized, and many internalizing guys have internalized. And what we see there is much more anxiety, much more depression. And in a lot of people, a lot of safety-related concerns, suicidality, self-harm. But also, because the diagnostic criteria have been built on an externalizing presentation, they often don't cover what an internalizing presentation actually looks like. And I allow to use borderline personality disorder, which many, many neurodivergent people, particularly Audi HDers, have previously been diagnosed with. And now borderline personality disorder does exist. It can co-occur with autism and ADHD. But when we actually look at the diagnostic criteria for BPD, we actually see that it's underpinned by impulsivity, as is ADHD. And when we consider the often social exclusion that autistic people and ADHD is experience, either because I don't understand the social rules or because I impulsively say the first thing that comes to mind and offend people, we experience exclusion that leads to rejection sensitivity that we see across meritivergent people and often a lot of other minority stresses, which can lead us to really want to connect with people, but always fear that we're going to be rejected. And that's a really central thing that we see in the borderline. You can actually go through the borderline uh personality diagnostic criteria. And when viewed through the right lens and through the lens of minority stresses and uh autistic lack of theory of mind, for example, other characteristics, you can actually track an Audi HD presentation with a specific set of early life dormates or interpersonal trauma across to the borderline characteristics. Why did I spend so much time talking about that? Because this is how some people are not diagnosed with Audie HD or as Audi HD is earlier in life, because it can look very much like borderline personality disorder or other personality differences as well. And if I'm given a diagnosis that I can clearly see in the diagnostic criteria, people are unlikely, clinicians like myself, are unlikely to go, oh, it could be something that's not covered in the diagnostic criteria for this other thing. So we end up with a lot of mood difficulties. We end up with other diagnoses. Another one that uh we often see crosses over with neurodivergence is OCD. Um, autistic stims look very much like compulsions in OCD. The main difference there is that in autism, my stim can provide a sense of safety when I'm really, really stressed. But often there's no real use to it. It just feels nice. I will listen to the same song over and over and over again. That is an audio stim for me. It doesn't manage any distress that I'm experiencing, but it improves my mood when I do it. OCD, on the other hand, the compulsions must neutralize some anxiety caused by a thought, usually an impressive thought, and often a thought that is misaligned with our actual values. But if I don't know OCD and autism, and I don't know or I only know the externalized expressions of ADHD and autism, I'm more likely to lean into your STEM being an OCD characteristic if I see that it actually neutralizes an anxiety for you. Why does that matter? Because then you end up with an OCD diagnosis, which is an anxiety disorder, but not the neurodevelopmental, the neurodivergent diagnosis of being an Audi HD or an ADHD or a beautiful Ortiz. So I think I've waxed lyrical about that long enough. So our diagnostic criteria are built on externalizing presentations, which means that so many of us have internalizing presentations and so were missed until relatively recently when the research has started to catch up with the fact that it's not just what can be viewed from the outside. Now, let me have a little look at my notes and see what the next point was that I was going to make. We talked about the diagnostic criteria. We talked about it being visible to others, and we talked about it not being internalized. Another thing that can really mask a diagnosis in the neurodivergent space, particularly ADHD and autism, is higher than average intellect. So if you have above average intellect or higher, it's more likely that you'll be able to compensate for those cognitive differences that we have as neurodivergent people. And I should go and say that all of those behavioral and verbal expressions of our neurodivergent characteristics are expressions of and are underpinned by cognitive characteristics. In autism, we talk about cognitive rigidity. In ADHD, we talk about impulsivity or low impulse control or inattention, pardon me, or ease of distraction. These are all our mental mechanics, if you will, that make up all of the characteristics that we have internally of our minds, that we then express behaviorally and be seen by other people. So if you're a professional university educated, it's highly likely that you have intellect that means that you've learned to compensate or you've been able to compensate for some of your neurodebutment characteristics when they're expressed in an unhelpful way. And that means you're more likely to be missed in diagnosis. But there's also, as I mentioned before, we teach our daughters, particularly young ladies don't like that, or even our young, our young biological males, oh, good boys don't behave that way. And so we learn to internalize and win. There are cultural differences. If I come from a non-Western society and I'm being assessed by a Western practitioner, I'm more likely to miss your characteristics that are culturally outside of the norm, but in a diagnostic sense, they fall within the Western normal. And I'm sure you all know that I love the word novel. I don't really. So why does that matter? Because if I'm an internalizer and I have differences of mood, or I have more mood difficulties than the average person, and I'm being missed for what's actually underpinning some of the difficulties that I may be having, assuming my characteristics are expressed in unhelpful ways, that mood and my cognitive characteristic, they interact. The more anxious I am, the harder it's going to be for me to pay attention to a single thing. My attention is going to bounce around looking for all of the threats. And if I'm inattentive already and struggle to keep my attention on the non-interesting stars, then that's going to amplify my ADHD characteristic. The flip side is that if I'm depressed, for example, if I have a lot of self-esteem issues because maybe I failed lots of tests, um, maybe I've felt that social exclusion and I experience depression, my processing speed, the speed at which I process information will be slower. This is something that clinically I see in a lot of autistic people that I do diagnostic assessments on, compared to their personal other characteristics. Often, certainly not always, um, processing speed is lower than the other characteristics, the other baseline characteristics. And that can be perhaps a structural thing where it actually doesn't move as quickly. Or it can be that it's tied up with other things. Same with working memory in ADHD. It may be, we honestly don't know. It may be that my working memory is actually smaller than my language skills or my visuospatial skills. Um, or it may be that I just always have, to use that language that many of you all know, many tabs open in my brain at once. So I don't, I actually didn't think I was that person, but I was talking to the lovely Uma recently, who was just saying, yeah, we were talking about that the other day. You always seem to have three tabs open in your head that you can draw on any any given point in time. So thank you for highlighting that to me, Uma. But if that's the case, and I've got three files open, and my working memory of my desk is only big enough for two files, I'm gonna see those inatemplate characteristics. Not what I was talking about. Let me get back on track. So my intellect can mask a diagnosis. Cultural and social influences can mask a diagnosis, biases towards externalizing presentations in an assessor can mask a diagnosis. We spoke about anxiety and we spoke about depression and how that can impact my cognitive characteristics. Um, but also if uh I have what I like to think of as a real Audi HD mind, and that's a mind that's underpinned by an autistic details orientation, but also has an ADHD tangentiality, the ability to jump to not necessarily unrelated, but certainly only vaguely related uh items of interest as it may be viewed by others, then I'm probably trying to hold more information in mind. And when I jump to the new thing, I'm probably data dumping the old thing, which we often do see. You know, when I have a conversation, I often start a conversation and then deviate and never quite finish that. I'd like to thank a friend of mine who kept track of them and maybe make all of my points at the end of one night. So when I'm doing that, that's impacting my cognitive function as well. If I have multiple tabs open, I have less cognitive energy to apply to using the appropriate social skills or communicating in the appropriate way for the average person, or paying attention to the really not very interesting thing. Um and that can really amplify the difficulties that I have. As I'm cognitively overwhelmed all the time, my emotions are more likely to have difficulties as well. And they feed back into one another. What was the next thing I was about to chat about? Uh attention. So again, the more anxious I am, the harder it is for me to pay attention. The more I'm likely to look anxious, uh, even if half of my inability to pay attention in that situation is actually ADHD inattention. Um and when I'm obviously anxious, but an internalizer and masking a lot of those other visible characteristics of ADHD, a clinician is more likely to diagnose me with generalized anxiety disorder, for example, than they are with ADHD. Or generalized anxiety disorder. I really see that in that Audi HD sort of state of mind also. We want all the details. So we're looking at all of the risks everywhere. And if I'm already anxious and I have that brain, I don't find the threats and the risks when I look for it. Um, Ori postponement for anybody out there who has a generalized anxiety disorder diagnosis or has that Audi HD state of mind that looks and finds all of the difficulties. Uh, Ori Post Piment is a great strategy to help manage that. And I will put a link somewhere to a page on our website that talks about Wari Postplayment, how it works, and how to use it. So why did I talk about all of that in terms of um late diagnosis? Because that's how we end up with late diagnosis or not being diagnosed earlier in life. Um, because we're missed for many reasons, the ones that I've mentioned, and there are many, many more that I just don't have time to go into right now. But it links into levels of impairment. So those of us with I beg your pardon, those of us with ADHD diagnoses, we will have had a severity uh assigned to that. ADHD combined type, inattentive type, or hyperactive type, uh mild, moderate, or severe. And with autism, we have levels of support required. And that will be level one, two, and three, with one being the lower of the support needs and three being the higher of the support needs. Those levels are not static. You are not born with level three support needs or level two support needs or moderate or severe ADHD. That is an environmental interaction, or better language, is a contextual interaction because my context is internal also. If I'm really stressed, uh, as I said before, really anxious, my inattention will be much more obvious and much more impactful when I don't want it to be. That can push me up into severe ADHD diagnosis. If I'm in a world where my autism expresses as being nonverbal, whether that's uh the development of those skills at all, or for those many of us who the more stressed we get, the less we're able to frame conversation, that can change by context, by my confidence in being able to speak, by the context that I'm in and the demands to speak, and to whom I have to speak, that can change. So the support need for my ability to communicate will change based on the environmental expectation for me to communicate and my confidence in communicating in a way that the people around me or the context around me needs or requires. So those levels of impairment, there's the there's the environmental demand that leads to those, but there's also that internal, there's internal confidence. Um, I talked already about how mood impacts cognitive functioning. If I am stressed and anxious and starting to lose my capacity to speak to the people around me, that's probably going to increase my anxiety. My anxiety is then going to impair my cognitive functioning, making it harder again for me to actually communicate. And this is just obviously one example. Um, and my stress gets higher again, my cognitive function gets poorer, my mood gets worse, and it becomes a self-sustaining cycle. If I have enough of those experiences, it can become a self-fulfilling prophecy. When I go to go into social settings, I might work myself up into a state that I either can't go there, or when I do go there, I can't bring myself to speed. But if I can change that thought process first, change the level of support I require in that imaginary setting. So I'm just looking up my timer and I have monologued a lot. Didn't I get to all the points? Um actually so there was a note there that I couldn't quite read. It looked like strebbers, but it was other stresses. Um it's a broader interaction than that. Um if I'm having difficulties with my family, that's going to increase my stress, decrease my ability to apply those cognitive functions that are. Let the stronger or weaker in neurodivergent people. And then that maintenance cycle comes back around again. So I guess in closing for today, really what I wanted to point out was that your neurodivergence is there and it's beautiful. And I've spoken specifically about diagnosis, so I've been framing in quite an unhelpful expression of our characteristics context today. But so everywhere that we have a characteristic that is expressed in a way that's unhelpful to us, I believe that we can find ways that they're actually expressed in really helpful ways. Also, those diagnoses, the reason that we're often missed is because we internalize, or because there are cultural differences between us and the person assessing, or because the diagnostic criteria just don't account for our particular expression of those characteristics that underpin the diagnosis. And the levels of impairment are not static. We are not born broken or not broken, and we are not born at a level of broken or not broken. We're born with characteristics and our context and our environmental. Let me try again. We are born with characteristics, and our context and our environment interact with those characteristics to yield a level of difficulty. And that's what we look at with our levels of severity and levels of impairment in diagnosis. Well, I hope today was helpful, friends. Uh, if you have any feedback, please feel free to comment on Instagram, on Apple Podcasts, on Spotify, all of the things. Please like, follow, and subscribe. And again, if you enjoy our content and our information, please give us a rating on your streaming app. It really helps us get the word out there. And we look forward to, well, we I look forward to chatting to you again for episode 10. Thanks again, friends. See ya. Moist