ADHD and Autism in Children and Adults: The Missed Diagnosis with Thomas E. Brown, Ph.D.

hello everyone and welcome to attitude magazine's adhd experts broadcast we are pleased to have dr thomas brown here to talk about adhd and autism in smart kids and adults before we get started let me note a couple of housekeeping items those of you tuned into the live webinar may download the slides now by clicking on the event resources section of your webinar screen and if you are interested in the certificate of attendance option look for instructions in the email you receive around an hour after the live broadcast for those of you listening in replay or podcast mode you can visit attitudemag.com and search podcast 356 to access the slides the webinar replay and the certificate of attendance option and we'd like to just say if you support the work we're doing here at attitude to strengthen the adhd community we encourage you to visit attitudemag.com subscribe and sign up for attitude magazine for your family or to share with a teacher or a loved one who could benefit from greater understanding of adhd and today's sponsor of the webinar is landmark college landmark college online dual enrollment program preparing students for their college transition their unique approach to online dual enrollment courses is personalized and highly supported enabling your student to develop and hone critical academic skills explore their interests and earn college credits during their junior and senior years of high school or during a gap year experience their model uses universal design and a guided scaffolding approach to executive function skill building for more information please visit them at www.landmark.edu duel d-u-a-l or email them at online at landmark.edu attitude wants to thank our sponsors for supporting our webinars sponsorship has no influence on speaker selection or webinar content now for today's topic when very smart kids or adults chronically underperform in school work or social interactions it is often assumed that they are bored lazy or uncaring parents teachers and employers of those who are obviously bright but floundering may not recognize two challenges that often co-occur adhd and autism including signs formally associated with asperger's syndrome asperger syndrome was removed from the dsm in 2013 in favor in favor of the umbrella diagnosis of autism spectrum disorder which many researchers and clinicians see as a mistake in this webinar dr brown will describe his work with high iq students and adults who did very well in their earlier school years but who had increasing difficulty academically and socially as they navigated middle school high school college and or employment dr brown is a yale trained clinical psychologist who specializes in assessment and treatment of adhd and related problems in children adolescents and adults after serving on the clinical faculty of yale medical school for 25 years he has relocated to manhattan beach california to open his new brown clinic for attention and related disorders he is also an adjunct clinical associate professor of psychiatry and behavioral sciences at the keck school of medicine of the university of southern california you can ask questions of dr brown during his presentation and we will try to get to as many of them as we can after he is finished now without further ado let's introduce dr brown and so happy you could be here today thanks wayne i'm delighted to be here it's an honor to be with you uh let me begin by by saying that i think that the topic announcement as uh the misdiagnosis is is a good thing to to put up because it it calls attention to a diagnosis which is often not recognized and part of the problem with that is that it's a missing diagnosis you know as wayne mentioned uh in his comments uh this diagnosis which was uh put over 20 years ago into the diagnostic manual the dsm-4 was removed in 2013 and just all lumped in together with all the other versions of autism spectrum now that makes some sense in some ways but on the other hand uh it's a little difficult it'd be sort of like they if we had the dsm uh you know and uh of all the they've got 157 different diagnoses and if we said okay let's just put all the anxiety disorders together and just call them anxiety disorders and we won't distinguish between separation anxiety and phobic anxiety and social anxiety and panic disorder and agrophobia and generalized anxieties you know i think that it was a mistake for them to pull that out uh because the fact is it's important to be able to to recognize the characteristics that go with these various diagnoses and so i tend in our clinic we still use the the term asperger syndrome and i've uh you know got a new book coming out talking about adhd and asperger's syndrome recognizing that officially it's still simply part of the autism spectrum but i think there's some value in recognizing that it has its unique characteristics that it's a good idea to pay attention to so in this presentation i want to talk a little bit about the various different kinds of smarts because we're talking about smart kids and adults but keep in mind that there's not just one kind of smarts i'm going to offer a few case examples from my new book talk a little bit about them in some are younger and some are older people uh fully adult and then i'm going to talk a little bit about asperger's syndrome you'll notice i've removed the apostrophe s because i'm not so concerned with with the attribution to hence asperger's who was the first one to write about it but i do think that the term is useful for us still in spite of the dsm's having made the changes they did and i'm interested in how that overlaps with adhd and then talk uh eventually i'll talk a little bit about treatment what can we do to help people in this situation now as to the various kinds of smarts uh if you think about it you know we often say oh he's so smart she's so smart but if you think about it there are many different ways of being smart you know there uh this is something that's taken from howard gardner's uh book published years ago where you talked about well there's language intelligence oral and written communication then that's different from musical intelligence and that's different from logical and math intelligence with the calculating and logical reasoning and then there's scientific technological intelligence like the commuter tech stuff uh visual and spatial the kind of things that's involved in architecture bodily kinesthetic you know like dance and then the two that are most relevant to what we're talking about today are what he calls personal intelligence being able to understand one's own feelings and oneself and interpersonal intelligence being able to understand where other people are coming from and it's these two kinds of intelligence which tend to be a bigger problem for those people that used to be called officially aspire syndrome and now it's it's you know officially in the in the book as simply one aspect of the uh the autism spectrum however i think there's still value as i said in recognizing this separately these are just a couple of stereotypes that you see in the media jim parsons on the big bang theory and leonard nimoy the vulcan science officer of the uss enterprise and those are caricatures but they talk about some of the strengths and difficulties of people like that and here are a few more well-known things you might if you watch saturday night live you might remember a couple of weeks ago elon musk was hosting and introduced himself as what he thought was the first person with asperger's to be hosting that show anthony hopkins the actor young greta thundberg who's done a lot for environmental activism jerry seinfeld a comedian jim taylor musician isaac asimov the science fiction writer and susan boyle the singer these are just a few of people who have come out and said look i've got aspergers now the cdc uh estimates prevalence of the various disorders uh that they're important keeping track of for us and when you look at how they're doing it for the autism spectrum those data on prevalence data are based solely on kids eight years old and do not differentiate between the various subtypes but when you take a look at the breakout there's a wide range of intelligence differences from one part of that spectrum to another you know about 31 percent of the uh you know people diagnosed with autism on the autism spectrum have iqs below 70. about a quarter of them are in the seven in the low average uh range 71 to 85. and look at this where the arrow is 44 percent have iqs 86 130 and above and uh when we talk about asperger's syndrome we're really talking about people who are within that range where uh you know anything that's average or and sometimes they go way high and you know the fact is that about 85 percent of the kids who are diagnosed with autism spectrum are recognized before they're three years old as having this difficulty however for those who have higher iq often it's not picked up and diagnosed until considerably later and as a result they tend to be a population of people who tend to be quite vulnerable i'd like to introduce you to some patients that i've worked with of various ages uh whom i've also described in more detail in a new book that's coming out this summer joshua 11 years old came in to see me with his parents and he said you know i'm in school to work ahead i want to get to college faster where i can be around others who are very smart like i am and who will share my interests in music and in theoretical physics i don't have many friends at this school i'm lonely there the other kids are not like me but at least i'm not getting bullied like i was at my last school i used to be pretty depressed and had thoughts of suicide it's been better recently but i do still worry you know think about the the reference to the bullying those kids who have these difficulties with asperger's you know are very often mixed in with the general population of kids in the school they some may have special education services but most of them are in mainstream classes and in social interactions and often they get recognized as really different in ways that other people tend to other kids tend to make fun of you know and you know this is this is what uh joshua said to me in the first conversation he said you know i'm a nerd who's in school just to work ahead i get along a lot better with grown-ups and with older kids than with kids my age i don't have any friends at school i'm lonely there i want to get into high school as fast as i can and then get into college where i'll be with other people who are smart like i am when i get there i want to major in theoretical physics a minor in law or business he didn't know much of anything about theoretical physics i've always had trouble focusing on anything for long think about add and i've always had depression and some thoughts of suicide i also have migraines i'm germaphobic i wash my hands until they're red and raw i also fidget a lot he's presenting all these symptoms to me in the first part of the first conversation but two years prior to the time that he came with his parents to see me when he was in third grade in a mainstream school they did a neuropsych evaluation and one of the things that the psychologist did in that they sent me a copy of the the report was he gave him a sentence completion task and when he presented that to joshua he said other kids and then finish the sentence for me please and joshua's response was other kids are mean to me they annoy me i can't understand why kids are so mean to me my mother thinks i'm very nice and special my father thinks i'm very nice and special and then they asked him well what would you wish for if you could wish for things he said i would wish for everybody to be nicer to me that i'll be able to fly and i'd be able to do anything now you know i think what that reflects is the the fact that this boy was growing up in a family where everything this was his he was their only child and the parents were very proud of him and they kept talking with him about how right he is and how smart he is and uh didn't recognize some of the difficulties that he had and as a result he came across in a way that sort of turned off other kids they were always praising him as gifted and highly intelligent much smarter than other kids and when he would come home complaining that other kids were teasing him and hassling him they said oh they're just yellow just jealous of you when the fact is carol dweck a psychologist who was with me in graduate school at yale has done a lot of very good work on the issue of when kids are repeatedly praised for their intelligence they're likely to have difficulties because they tend to give up too quickly if they get confronted with something that they can't master right away you know and the fact is that that it works much better if parents respond to the strengths of their kids by acknowledging their hard work and reminding them that it's not the grades that are most important but how hard they're trying that usually will enhance their learning and also allow them to stick with the issues that they need to be working on that don't come so easily to them you know one of the struggles that many kids with the i would call asperger's syndrome is that they really struggle when uh they're with other kids particularly if they have gotten the idea that they can do things that nobody else can do and that everybody else is beneath them uh after we had uh done some work we figured i talked with the the parents and he was in a school where this was a very private school where each kid was in his own little cubicle and there was no social interaction and they were lucky enough that and worked hard to find a school placement for him where he would do he was a great musician and uh where he could be working with other kids who have been a particular gifts in the arts but it was a long bus along with band right so he got in the van the first day and uh it was kind of crowded he went to squeeze into the back of the van and this one african afro-american boy said to him uh you're a little pudgy can you fit in back there and impulsively joshua responds well at least i'm not black and he said he realized immediately after those words came out of his mouth that was not right the right thing to say and nobody talked with him for the rest of that ride but then we did work together in therapy to uh to talk about uh how he was going to go back because i saw him that very day and uh so when he went back the next day he said to the to this kid who had made that comment sorry about what i said yesterday i'm not really a racist i was just really uptight about my first day of school and fortunately the other boy said no problem i remember how i felt my first day we get used to is here we roast each other once in a while but we can still be friends and i think it's important to to look at this as an example of the difficulties that many of these kids who are very bright who have answers one their lack of interpersonal intelligence and sometimes their lack of experience interacting with other kids their own age leaves them handicapped you know in their uh being able to do it a little later on the uh you know he did soon after joshua had been there for a few weeks uh he was participating in class and was doing well but he he wasn't going to the lunchroom he'd go eat his lunch by himself and he said that uh you know you know those kids they're always gossiping and looking at instagram together this is about lunch i can't understand much of what they're talking about it's like that calvin and hobbes cartoon saying we're both speaking english but we're not speaking the same language you see a lot of what kids learn about how to get along with other kids does not come from parents it comes rather from their interaction with other kids and very often uh kids in the group we're talking about have a lot of difficulty in being able to to learn the idioms the the sort of ways of conversing with other kids because there's a lot judith harris has written about the role of parents and in helping to shape social skills and emphasizes it's the peer interaction that really shaped these things and her research uh shows that uh but one day after uh he had been there for a couple of weeks joshua came in and he said you know the other kids there are not talented in every way each one is just talented in a particular way they're just like normal kids that was a very important insight for him because he had this notion of himself as super above everybody else his age and now uh as he was having a chance to hang out more with other kids his own age who also were good at art and with various arts he had a chance to see that they're kids and that each one had their own strengths and their own difficulties but let's look at another case this is bella 13 year old girl and her mother uh brought her in she'd been seen by another psychologist or psychiatrist actually three years before she came to see me and the description written in the report was that she's a very bright and talented girl who suffers from significant difficulties with executive function and meets diagnostic criteria for adhd they tried her on a regiment of medication which didn't prove helpful and it wasn't adjusted and they sort of gave up on that and so her mother brought her into my office and uh was reporting that the kid had been increasingly moody and had a lot of episodes of anger she was stressed out lashing out her mother yelling sulking crying restlessness on a daily basis and started talking what's the point of living i'm just going to kill myself although she never engaged in any kind of self-harm behaviors or violence but she was very isolated and the diagnosis that had been given to her just before she came to me was just generalized anxiety disorder they put her on some medicine for anxiety which didn't do very much but the thing that i was struck by is when she came into the office she has a large stuffed animal with her and uh she was very good about talking about the difficulties that she was having in school and then she said and next year there's a high school the juxtaposition of the things that were going on in terms of of her situation at school and the tone and his whole clutching that animal i think was a clue to some of the struggle that she was going because she was quite socially isolated i asked her mom to get uh the teachers each each of her several teachers in middle school to write a little bit of a note about it and here's what i got uh once teacher wrote belly interacts with her classmates in classes she's focus on things she finds interesting at times i find her writing a notebook or reading during class discussion she may focus on what's being discussed or she may just ask a question that's off topic she seems to lack a filter in public sense her classmates have come to accept her quirky and somewhat offbeat personality another teacher said bella's ability to grasp the subtleties and nuances of the french language is impressive her passion isn't refreshing her patience and attention to detail goes way beyond her years but at times she falls behind and loses interest in her work she constantly has a book in front of her her interaction with other students seems quite limited and the receptions of other students to her seems to be somewhat guarded she has her own agenda and she makes it a parent one more teacher bella chooses not to interact with the other kids when bella is in put into groups she moves her table away from the other students and reads her book she doesn't participate in any one-to-one conversation or even in group conversations she'll purposely call out sometimes in class causing a distraction sometimes the purpose is to make students laugh other times they'll just do a little elicit a different kind of reaction you know and you know the teachers are generally saying she doesn't interact much with other kids but she's got a lot of academic strengths at home her mother said she was typically playing video games for four to six hours every night and had very little interaction with other kids although she was a pretty impressive kid in some ways i did some testing on her and i asked her to do it one of the things i did was a test for her ability to written expression and so she had 10 minutes to write a a some short essay in which she was asked to say tell me about your favorite game and give three reasons why you like it here's what she started with picture a universe with infinite possibilities only restrained by the bounds of your imagination where there are no rules no predetermined objectives aside from those you choose that my presumably skeptical friend is minecraft with savannas dotted with bushes and acacias to plateaus that cut through the clouds the diverse landscapes are a sight to behold that's pretty sophisticated language for a 13 year old and it's an as an example of her strengths but it also shows you something about how she's working in a way that doesn't make much room for other for other interactions with other kids and she needed some help with this and before i gave any uh further response to the evaluation she handed me a note and this is what she said some reasons not excuses in parenthesis but reasons why i struggle in school adhd even with the medication i still have a tendency to doze off and get distracted and procrastinate can't help it's the way i've always been sometimes i get called on out of the blue to answer a question i didn't even hear and it's a lot of work i just got spooked and hide from it but believe it or not i legitimately care i'm not stupid i'm not unintelligent yes i procrastinate but this is not the work of a lazy adolescent pretty articulate for a kid her age so this is another piece and you can see the difficulties that she had to deal with and with medication uh she had been put on vivants which often is very helpful and in cursed case that didn't work out we had to switch over to adderall i'll talk more a little bit about medications a little bit later but let's look at somebody else now this is anthony i saw him first when he was in high school and the his mom gave me a note she said you know in many ways anthony has always been an easy parent but he's a child parent he's very sweet and kind he's not a demanding person other parents and teachers often raise a rave about him what a nice boy he is and find him interesting he always seems he could learn things easily he has an incredible memory is great with trivia facts wants to be an engineer and even in this area he love in which he excels his ability to get things done on time is a problem his mother then went on he has no organizational skills and his homework is now a marathon taking twice as long as his teachers say it would writing is excruciating and he'll often say things to people that are just slightly inappropriate they just don't fit he misses nonverbal clues so you get a picture here of the academic strengths but some of the difficulties with social interaction that are typical for the population we're talking about and when he came in and this was after he had been uh i'd seen him initially while he was in high school we started some medicine he was doing better and he was followed by his pediatrician and then a year and a half later he uh after he had graduated he came back with his parents because he'd been away at college and it had not worked out well you can see from what he said here he said i was doing pretty well since i came home from that out of state college i was going to my grades in this local college are not perfect but he now came back was living at home but they're pretty good i was feeling proud that i had finally found a girlfriend and went out with her a couple of times and suddenly she broke it off and didn't want to see me i texted her and tried a bunch of times to see her but she said no and i got a restraining order against me and then i met her in the parking lot at school so i could ask her what happened i had no idea that i'd get arrested and put in jail for that you know you can see there the desperation that he felt to be able to have a girlfriend and at the same time his inability to understand or as some of the workers in this field say mind read take the point of view of somebody else to see why it was that after the date and uh she was not interested to make it clear she wasn't interested in pursuing it that all he could think about was that he had to to get her to explain it and hopefully talk her out of it and these social interactions can make a big difference in terms of of the strengths or also the misery that many of these kids that i'm calling asperger's have and he needed quite a bit of help to eventually he described when he back when he was away at that school for a year and a half he said he wanted to get to know other kids but he felt so awkward and out of in the social situations he didn't get some of their jokes and didn't feel like he could uh join them for him meals he often was eating his meals alone and spent time alone in his in his room uh and uh it just was felt so out of it and needed a lot of help to be able to learn how to organize study groups with a couple of other people and he also had a lot of difficulty with ocd where he had great difficulty in being you know and that was a secret for him for example he had a walk up two steps at a time anytime he's going up the staircase if he lost count while he was doing he had to go down and try again and that sort of thing had not come up earlier in his conversation but let's take a look at another richard when i graduated the top of my class in a very competitive college by the way and then got hired in a big law firm i felt good he'd already passed the bar but they terminated me in less than a year for reasons that were never clear then i got a job in another law firm and got fired from there because i was late in completing a couple of projects and didn't communicate enough with my supervising partner my girlfriend with whom he was living says i'm smart and i work hard but i have difficulty reading where other people are coming from now i'm looking for another job but it's not going to be easy you know this is a very bright guy who not only passed the bar exam but was tutoring some people to earn some money by tutoring some people for the bar exam but the problem was that socially he was clueless in his interactions with other people that he was working with and one of the things that happened was that that uh he had a situation where he was wanting to to get himself ingratiated with the lawyer that he was working with who had given him assignment and he ended up doing a very thorough job on the assignment and but the lawyer said i have to meet with the this client in three days since i gave him the date and he was a half an hour late to getting to the meeting with his report not realizing at all how that left the attorney you know in a difficult situation another story that he presented was that he there were several other courts when he was working with one of the judges as part of his training in his courtship and uh he just gave him a cold shoulder he wasn't particularly interested in them and the secretary that they often chatted with he wasn't paying any attention to her well it turns out he found out eventually that there had been a call coming into the office that that secretary got or somebody wanted to get a reference for him and was thinking about hiring him and the secretary said uh don't hire him he's not good at getting along with other people that was the result of his never having been able to make the connections with these people you know and i think it illustrates the importance of uh people being able to learn how to get along in social interactions that that kind of intelligence you know is really vital in terms of success and work regardless of what kind of work you're doing as well as in getting along with the people that are working with you okay there are many different types of personalities not like anybody with asperger's is always the same as everybody else i've got some of them listed here that some are just kind of shy and and very dependent in clinic and others come across as sort of arrogant know-it-alls and and uh some of them are very driven high achievers uh and are looking for intimacy at a distance i had one guy who one girl who said that yes he had a boyfriend uh but that he was living three thousand miles away and they were very rarely in touch with each other it's not that all these people are exactly the same and in fact the milder forms of autism are more common and often they're not picked up you know for the higher iq people on the autism spectrum often they're not recognized and diagnosed with autism or i would say asperger's until they're adolescents or adulthood which means they're not getting any help you know simon baron cohen who's head of the asperger's program at cambridge university in the uk uh has studied a lot of adults with asperger's and he said that some of the things you see about him is they tend to be loners they often don't know how to interact with their peers they much prefer talking with other with adults rather than playing with or talking with other kids often they're not invited to play at classmates homes or birthday parties they're not into pretend play they stick to very factual more scientific stuff non-fiction reading uh and they often have areas in which they really specialize and are quite knowledgeable but often they don't get their schoolwork done and as a result they've got problems in terms of academics so how many children with autism spectrum have adhd well if you're looking at community samples the studies depending on how they're defining it are anywhere between 13 and 50 percent but when you look at clinical samples people who are identified as having an autism spectrum disorder the prevalence of adhd in that population is between 20 and up to 80 percent and the better studies are on the higher end not the lower end unfortunately sometimes you end up this study was done at harvard they had 140 kids ages 6 to 17 who were brought into their specialty clinic for autism spectrum and all of these kids had iqs of 70 of 85 or better and had an autism spectrum diagnosis they evaluated all of them for adhd what they found was 76 percent of those with autism spectrum in that clinic group fully met adhd diagnosis and 41 of those who had autism spectrum and adhd had received no diagnosis or previous treatment for their adhd which is a problem talk more about that later but some basic facts about adhd you know we think about this not just as a behavior problem often it's not that big a behavior problem but the impairments of executive functions of the brain all these are problems everybody has sometimes it's people they have a lot more trouble it's inherited uh one out of every four people with adhd has a parent who's got it but the thing that puzzles a lot of people is this bottom bullet everybody i've ever seen who has add and that's a lot of people has a few tasks or activities in which they have no trouble exercising executive functions that are quite problematic for them in most other situations because it then makes it look like that's a problem with willpower when in fact it's not it's that the the brain of somebody with adhd turns on and functions much better in its executive functions if whatever they're dealing with is something that really interests them or they're afraid that if they don't take care of this something very unpleasant is going to happen fast this is a model that i've published and talked about quite a bit i'm not going to take a lot of time to labor it you can see it on my website the details of it but just as a reminder that that the elements of executive function you can write an equation that says adhd equals developmentally impairment exec of executive function and these executive functions include organizing and being able to prioritize and get started being able to focus and shift focus when you need to be able to regulate alertness and keep up the effort to finish things and do reasonably fast processing speed dsm has nothing to say about managing emotions but that's a big part of adhd utilizing short-term working memory sometimes there are people with add their memory is amazing for long-term stuff but they can't remember what happened just a couple of minutes ago or what they just read and then monitoring and self-regulating action these are little separate compartments but the fact is all these things are dynamic and they interact with each other so what can you do about it if we're talking about with somebody who has this asperger's syndrome and adhd one of the things that's most important is for the individual and the family and the teachers to have information about adhd and also about asperger's syndrome as they need it provide adequate scaffolding and personal support particularly with new situations which are especially difficult for these kids and then intensive psychotherapy is not likely to be very helpful for many of them but to learn to be able to teach use the teachable moments to help them understand why it is that sometimes they get into difficulties with other people where they just don't recognize what's happening and then the importance of fine-tuned and emphasize fine-tuned medications to alleviate their adhd symptoms and if needed for related problems because adhd is fundamentally a chemical problem the most effective treatment is to change the chemistry with medication for eight out of ten people who have adhd medications can be helpful if those medications are adjusted but the amount that is needed the dosing doesn't go by how old you are how much you weigh or how severe the symptoms are it's how sensitive is your body to it there's a picture just describing you know what the medicines do this is one uh this is the sending side of one neuron there's a hundred billion neurons in everybody's mind brain these are about three-fifths the diameter of human hair um and then here's the opposing side and what this cartoon is is showing us is that the electric charge comes when a message is coming through the brain and it has to release micro dots of a chemical most often dopamine but sometimes others that's what's involved in the medicines we use and hits these receptors on the other side it hits enough of the receptors fast enough the zip goes on moves the message and gets things done but then you've got to also get it cleaned out and these shapes here are the uh functions the function is the reuptake and they suck back up this chemical that's been released because otherwise you're locked open you're not going to be able to get anything else through you know the the importance of of this in meditation is important but the other thing that's important is for people with autism spectrum particularly with with asperger's many of them have very sensitive body chemistry that's what the sbc stands for and so you want to start with small doses and then gradually taper it up to find that sweet spot between too little and too much for the adhd symptoms usually we start with stimulants and possibly some guanfacine which isn't so good for focus but it does help to calm down some of the other things atomoxetine is our third line usually it works well for some people when nothing else will work but usually the stimulants work considerably better but sometimes we also need to add other medicines for the exact excessive anxiety or ocd mood problems fluoxetine and search lean being a couple widely used and then for excessive hyperactivity and impulsivity and aggression uh usually we use guanfacine first often in combination with the stimulant and then if necessary we could use a very small dose of abilify or risperidone both of which are approved for this population but i'd like to just mention to you the importance of monitoring the response this this diagram is one that i think is important if a person's taking a medication for adhd and let's say it's kick in here it could be a half an hour to an hour and a half depending on which version and then it works for whatever length of time it's going to work and then it comes down if during this time the person taking is is feeling too wired like they had way too many cups of coffee or too crabby where every little thing is pissing them off way more than it would normally or too serious where they sort of lose their sparkle their spontaneity if that's happening during the time the medicines in and then goes down when the medicine wears off the dose is too high or it's not the right medicine for them however if these things are not happening when the medicine is active but they do start happening as the medicine is wearing off that's a completely different problem that's a rebound and what it means is not the dose is too high because that you would have seen here it means it's dropping too fast and you're crashing and so usually you can fix it easily with a small dose of the same medicine that we're doing as a stimulant so that kind of fine-tuning is is critical for being able to get adhd medicines to work for anybody and about 70 to 90 percent of kids in adolescents and adults respond well that the symptom improvement for some it's huge how much it helps them for others substantial but not huge usually the adverse effects are not very significant this is a statement by the people who did that study at harvard that i wrote mentioned to you a few minutes ago and they're talking about the importance of recognizing adhd in people with asperger's syndrome and i'm quoting here failure to recognize adhd especially in intellectually capable youth with autism spectrum disorder can seriously undermine their educational and social functioning worsening and already compromised social performance and can predispose these kids to increased risk for disruptive behavior disorders mood dysregulation and substance disorders there's a list of some resources the the one this is my commercial here uh this is a book that adhd and asperger's syndrome and smart kids and adults which will be released this summer it's already available on amazon and then the earlier book on outside the box and smart but stuck but john robertson's book on look me in the eye it's very important liz loggeson's science of making friends and then tony atwood's complete guide to asperger's syndrome all of which i would recommend and then these are some of my other books and this is the new one that's going to be coming out hopefully within the next couple of months so let me stop at this point and see if wayne has any questions that are ready for us yes we have loads of questions that was excellent um really an excellent presentation thank you um a lot of people want some practical information what sort of treatment do you recommend for a seven-year-old with asperger's to address improvement in social interaction okay one thing i'd want to do is to find out if what what that's going on in terms of behavioral problems because if if this particular kid happens to be acting in ways that are too restless or too aggressive or disruptive in school that's going to get him in trouble on two or three different counts and so i want to look and see do we have adhd symptoms that need to be treated with the usual medications although starting low doses and then gradually tapering up uh is this somebody who's likely to need a little bit of additional medication uh if there's too much restlessness and then to work with parents to try to help them to learn how to use the teachable moments stay in touch with the teachers and observe the child in interaction even these very young kids can learn a lot but it needs to be taught in terms of very specific situations you know when this kid did this and you did that that's a problem a better way of doing it would be this other alternative several questions about how do we find therapists and psychologists and psychiatrists who understand these kids with both asperger's and adhd um that's a good question because the the reality is most psychologists most psychiatrists uh are not trained to deal with the difficulties on the autism spectrum and that's an an area where your best bet is to talk with other people who have kids with similar needs and see what what's available in the neighborhood to look at information that's available on the chad list of resources or attitude magazines list of resources and see which people are identified as offering these services see who's published books on it and try to to get a word and then just ask the local pediatricians sometimes we'll be able to tell you oh yeah this uh there's this psychologist or this psychiatrist who we had good luck with with that kind of thing but i don't want to make it sound as though it's easy because it's not because they're not a lot of people in those various helping professions who have this specialty yeah because a lot of people have brought up that um and sadly so that the asperger's was missed the adhd was diagnosed the asperger's was missed and it sort of sent them on a path that wasn't the best for their child exactly yeah i think that that's the risk that often what gets picked up is what's most obvious and what more people are familiar with and it's very important to try to you know get in touch with other with pediatrician or other parents who have some kids with similar concerns and autism now has done a good job and there's the autism parenting magazine which has a lot of articles about this and you can get information about this in your own magazine right in attitude and often that you will lead you to people you can get in touch with uh who may be able to help if not face to face and possibly um zoom um several people want to know uh the effect of adhd medication and i think you might have touched on this um on asperger's well adhd medicine can be very helpful with people who have aspergers however what i've tried to emphasize is that many of them have very sensitive body chemistries right and i've had many patients brought into my clinic uh where they the parents will say oh yeah we've tried in the name of you know three or four or five different medicines often used for adhd and when i ask about the dose i find that they were start that the kid was started on a dose that was really too high for them and they didn't back it down they just jumped to a different medication the fine-tuning is very important and you know so it's better to start with these kids many of them have very sensitive body chemistries and you want to start with a minimal dose and but don't do don't leave it there if it's not doing the job and gradually titrate just sort of take it up a little bit at a time looking for that sweet spot between too little and too much if you have too little it doesn't do a damn thing you might as well be taking breath mints but if you have too much uh then you're gonna get that jittery or real crabby or too serious and those are things that can usually be adjusted by dosing and changing the time in which it's being done uh some people are caught up in the terminology are asperger's high functioning autism and level one asd the same okay um most people with asperger's would be that i would call asperger's uh are you know officially now diagnosed as autism spectrum disorder level one but there the fact is that that they uh i think the diagnosis i think that diagnosis should be back in the book and uh it makes it a little bit easier to do it i'm sorry there were three things you mentioned and i i got just two of them oh okay i'm i'm on to another question um there are three different things are espers disorder similar to what and what oh high functioning autism and then just asd okay the term high functioning autism is is not being used as much in the literature these days and the reason is that people were thinking that if you had a high iq that means your high functioning autism and the reality is that the research shows that often the people with high iq are not high functioning in terms of day-to-day activity and iq does not equal high functioning there are a lot of reasons why people on the spectrum uh you know with high iqs often just do not get the help they need and the support they need early enough to be able to help them deal with what they have to deal with before they've been to to give up on trying to deal these these things and interacting with other people several of the attendees have asked about is asperger's diagnosed less diagnosed in women and people of color um yes but that's not the same thing as is it less present there is a predominance of of males in the population of people with aspergers uh but the fact is that there also are many uh girls and women who have some similar problems and there's a whole literature on what's called camouflaging uh because many of the the girls and women uh work a little bit harder than many of the boys do who have these difficulties to try and cover it up and to try and do what they see other people doing and sometimes it works but sometimes it does not but i would say yeah probably more males than females that seems pretty clear but it is not absent in in girls and in women unfortunately it's often ignored in them or just not recognized right okay here's a blunt question why did the american psychiatric association change asperger's definition and had and do you agree with them well i'll take the last part first i disagree with the decision i think it was a mistake right you know in and as i mentioned at the beginning you know i think there are good reasons why we have a lot of different types of anxiety disorders separation anxiety phobias social anxiety panic disorder because each one has its own particular needs and ability to respond to particular treatments and when you lump all these things together uh you know it doesn't offer if there are no diagnostic criteria stipulated in dsm-5 for asperger's syndrome you know all we've got is the the three there are different levels uh which tell us very little about uh you know how to recognize this so i think that it'd be good idea to get it back in there and the diagnostic criteria we had in dsm-4 were not all that bad uh it's a good place to begin however uh it's also true that the reason that they uh you know decided the committee decided they were going to do it all as autism spectrum is that genetically there there are a lot of similarities across these various diagnoses uh with the diagnostic subtypes in what now are included in autism spectrum so it becomes a matter of whether you're a lumper or a splitter that's a good explanation um i don't know if you know about this but what are the differences between nonverbal learning disorder and asperger syndrome i am a pediatrician with a son who's been diagnosed with nvld who has adhd he fits autism more than nvld so and probably the autism fits of in most cases like that nonverbal non-verbal learning disorder is is a category that is not really all that helpful and it's not widely recognized uh you get some psychologists who are likely to do it but basically it just tells you that their their strengths are not you know in the verbal domain but the fact is uh if asperger's fits then there's probably good reason to find somebody who knows what it looks like and who can help you with that the fact that it's coming from a physician also is an example of the fact that there's not much information out there you know i taught in a pretty decent medical school on their clinical faculty for more than 20 years and [Music] even there there was not that much attention being paid to the education of physicians about adhd and about asperger's syndrome [Music] several people have talked about this one mom has mentioned that uh i have a smart kid who missed the asd diagnosis just because of her adhd they use the ah the adhd and an eccentric personality to explain away the autism but she wants to know how um i guess she's 17 now she wants to know how to get back on track how to deal with the asperger syndrome so um let's say this diagnosis comes late which seems like it often does it often does come late that's absolutely true excuse me however uh the other thing that may have been point at play in this is that uh years ago the dsm ruled out the use of adhd diagnosis for anybody who was having autism characteristics that you're just not supposed to make an adhd diagnosis if somebody's on the autism spectrum now that got corrected uh when the dsm-5 came out that was one of the good things they did in that version uh but previously in dsm-4 you know there was reason why clinicians were discouraged from making the diagnosis of autism spectrum and adhd at the same time so we've caught up on that but i think in losing the adhd or the option for asperger's syndrome that created a problem in itself but what what to do about it you have to ask around and um it's not that easy to find people the list i mentioned before in attitude magazine and chad can provide some help autism now uh and autism parenting magazine has some resources there but it's important to be able to find other parents who've been struggling with these things and then continue uh to work with somebody who actually understands it and you know realize that there are a lot of very good doctors and good psychologists and psychiatrists who just have not had much training to deal with these things right one mom wants to know how to treat extreme anxiety that comes along with the asperger's i mean what how would how should she approach them well it depends on the nature of the anxiety that usually i would be uh inclined to avoid using uh short acting benzoates you know like xanax or valium um except for just a particular dis you know for example if a kid freaks out and have to get on an airplane uh that short-term use can be you know useful for that but for chronic anxiety which is a very real problem with a lot of people with adhd and then an even bigger problem with a lot of people with asperger's syndrome usually one of the first things that we'll generally try is an ssri uh and the ones that have been best tested for use with uh with kids uh in that category are prozac and uh sertraline uh oxetine and sergioline the zoloft and prozac but again dosing is important and you want to go in with a relatively small dose and then gradually take it up in order to get something that makes a difference uh i mentioned guanfacine the extended release not the short acting but the extended release version often can work along with a stimulant uh when it's first started you don't notice much of improvement if you it tends to make people a little sleepy first week or two particularly if the doses started too high and the dosing range on on the guanfacine is narrow you know you were usually talking about one two or three max four milligrams for a daily dose but that along with the stimulant can help to take the edge off the anxiety are there any therapies that can help um with asperger symptoms beyond the medication well i think the medication i always think you know change change the medication the body chemistry first because that's the thing which is most likely to be effective uh but uh there's a kind of um what i leave to told before is a kind of pedagogical approach or didactic approach that i see my role when i'm dealing with people who have asperger's uh syndrome is there's a lot of just sort of teaching them to get them to tell me about the situations that have been frustrating that they've had with family or they've had with with teachers or classmates or employers and then learn about what where the trouble is and then talk with them about different ways they can deal with it you know provide uh strategies you know so then the didactic thing you know many people think that psychotherapy always has to be just sort of you know digging in and helping people to express their underlying feelings and so forth and for many kinds of problems that's helpful but you know when you're dealing with somebody who's bumping up against other people in their social interactions frequently it's often more helpful to be able to see how you can avoid some of these collisions learning sort of what kinds of things you can say in this sort of situation or what you know how to ask a question that might be helpful or when to back off and shut up uh when people are obviously uh you know having difficulty you know continuing what whatever you're doing or talking about but i think it's it i think it's almost like a coaching function uh but the the trick to it is being able to learn how to think about the way this person is seeing the situation right and you have to to not only talk to them but to listen to them and um i'm thinking for example about a a kid that was complaining that other kids were often uh beating him up in uh verbally and that one day uh the uh three kids were walking you know across together and you know bumped into him in the hall and knocked his and he knocked his all his books and notebooks and everything hit the floor um and what they said as they were leaving was you carry too much book too many books and uh you think you're so high and muddy the the the notion of of sometimes people who are very good at answering questions in class have their hand up all the time and uh or this particular kid the thing that had happened the day before they knocked all the books out of his hand was that those three kids were talking with each other about how this test they had just taken was way harder than they thought it was going to be and they didn't know if they had had passed it and the kid's comment to him was i don't see what you're complaining about i didn't study at all for it and i thought it was easy i got all the questions you can imagine what the impact that kind of a comment is right and as far as he was concerned it there was nothing wrong with it because he was just telling him the truth and it's it's that difficulty in sort of understanding how other people are likely to hear it yes then is it true or is it not true right well i think the hour's up tom thanks so much for being here and sharing your expertise very insightful i appreciate the you you're setting it up for us and i appreciate the questions people have offered great hope to have you back thank you um and thanks to all of the attendees for joining us please join us next week on june 2nd when ann dolan will talk about learning loss how to make up for lost ground during the summer break make sure you don't miss future attitude webinars adhd expert articles or important research updates by signing up to receive our free email newsletters at attitudemag.com newsletters thanks everyone for being here and have a great day thank you

Channel: ADDitude Magazine

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Length: 63min 3sec (3783 seconds)

Published: Thu Feb 03 2022