[Music] welcome to the attention deficit disorder expert podcast series by attitude [Music] magazine hi everyone I'm Carol Fleck and on behalf of the attitude team I'm so pleased to welcome you to today's ADHD experts presentation titled why autism is so difficult to diagnose in women and girls with ADHD leading today's presentation is Dr Karen saparo Dr saparo is a licensed clinical psychologist who has been in private practice for over 20 years her interest and Specialty is in working with children and adults with ADHD and autism spectrum disorder she's passionate about educating others on the different presentations of neurodevelopmental disorders in girls and women Dr SA is a member of the American professional Society of ADHD and Related Disorders and she serves on its adult ADHD guidelines committee and its diversity committee ADHD is believed to be highly comorbid with autism yet it wasn't until 2013 that the DSM allowed for ADHD and autism to be diagnosed in the same person while our understanding of this dual diagnosis has evolved D we still don't have an evidence-based standardized approach for diagnosing and treating co-occurring autism and ADHD in today's webinar Dr saparo will talk about the overlap of symptoms in ADHD and autism and why these diagnoses are so easily missed in women and girls she'll also provide us with tips for working with our health care provider to get an accurate diagnosis so without further do I'm so pleased to welcome Dr Karen saparo thank you so much for joining us today and for leading this discussion thank you Carol I really appreciate attitude magazine for having me and this is super important information I think to get out there and have more dialogue about so I appreciate the what you're doing on your website and uh being here today uh I'd like to discuss uh the overlap with autism and ADHD and why it's been so difficult to uh find people to diagnose you or your child uh or your loved ones or to why it's so difficult to diagnose if you're a clinician who's attending uh and they're complex issues uh I want to be able to explain um sorry I'm doing my SL okay I want to be able to explain some basic things first though um when we're diagnosing any condition or issue in anyone uh everybody is an individual and everybody's different and this is particularly so when we're talking about ADHD and autism there's lots of people that have those sayings where you say you know if you've met one person with ADHD you've met one person with ADHD same thing for autism um so we only know I think uh in terms of science and research and testing and diagnosis and treatment and support I think we only know a lot about a small segment of the population so if you think about those Iceberg pictures where we know the tip of the iceberg I specialize in people who are under that tip of the iceberg and generally are harder to see but need to be seen um so I want you to just try and keep in mind as I speak that everything that I talk about is not going to apply to yourself or the person that you're thinking about as I discuss uh everything we're going to talk about today both ADHD and autism are multi-dimensional complex conditions and some people have parts of some traits and behaviors and some people have lots and some people don't have those aspects and if you've been online on attitude mag or online anywhere you see lots of vend diagrams and different charts and overlapping everywhere and they're all different and every time I see what I'm like agreeing with parts and disagreeing with other parts but we really um aren't that specific yet about how to uh separate and bring together all of these issues so just remember that everything doesn't have to apply to whoever you're thinking about to have a diagnosis or qualify for one uh I also want people to understand that when we're talking about scientific research and medical and mental health treatment everything is rapidly changing and evolving especially in the field of neurodevelopmental disorders uh the internet has been a wonderful resource for people to communicate with each other and I think it's pushing science along quickly but when we're talking about going from say a clinical observation and when I say clinical I mean interacting with a client or a patient uh when we're going from Clinical observation where you see the same thing or pattern of behaviors or symptoms or traits occurring in a whole bunch of people then you know there's ideas for research then you have to go to research and see is this a specific pattern or is it just anecdotal based on my bias or whatever my experience and what I'm bringing to my opinion or is this something that we can demonstrate across settings uh that stands on its own statistically so we know it's a a an issue that we can generalize across people so that takes a lot of time and money and probably a lot of people on the internet see things a lot differently and maybe from a broader perspective so some of the things that I'm going to talk about today people are going to disagree with uh I generally go Rogue on a lot of things because I've done this for so long and I have a lot of observations and there haven't been a lot of Standards with uh what I do so I've been able to learn and grow in my field as I go so there's going to be things that people um see differently and that's fine and by the time I am done this webinar there's probably going to be different terminology and vocabulary based on people's experience in communication online and scientific experience so just keep in mind that this is a moving Target and we're continuing to grow and learn as we go I want to uh Define some things so gender and sex uh is important to understand in terms of the differences because they're very different and I think a lot of people really don't uh understand so gender is a social construct gender is uh are roles that Society creates and expectations uh like feminine Behavior or masculine Behavior Uh sex is a signed of birth based on somebody's physiology so generally historically it's you know assigned male at Birth assigned female at Birth or intersex what we now are starting to understand and I'm just saying starting because we are just starting to understand uh gender diversity and a gender Spectrum um is that people experience their own gender in different ways and are learning to understand that as they uh grow and develop and so allowing people to uh figure out who they are is important and listening to people is important because we have to learn from everybody that we work with um in terms of our research and clinical work all of our research and uh clinical work in terms of testing and diagnosis is based on binary gender any forms that anybody fills out say male or female um or man or woman or you know girl or boy we have to change that and we've barely begun to recognize that so some states will recognize I live in New Jersey and we have I think on driers license they have a law now that that allows for other gender uh labels um that is uh very forward thinking and unfortunately uh but we're we're learning and we have to pay attention to this and we have to push the envelope in terms of redoing our research and the way we approach things um I'll talk more about that in a little bit um the reason that I want to talk about this is also because neurod Divergence ADHD autism neurodevelopmental conditions um neurod Divergence is occurs at much higher frequencies in a gender diverse population this is something that is just newly we're newly aware of I remember looking this up because I just you know in my CL in my practice uh anybody that I was seeing uh and this is a a biased sample because they came to me for specific uh evaluations but so many people that I was seeing that were gender diverse I was seeing a lot of autistic traits and maybe five years ago I tried to look in the literature I talked to the local gender clinic and people weren't recognizing this but now they do and so now we do have some data saying that you know uh we have to pay attention and look for neurod Divergence in people that are gender diverse uh the importance of this is also uh I'm going to get to in a little while as well because this is a high-risk population really needing support uh a little a few more definitions uh neurod Divergence uh relatively new term maybe not for most of you uh just means that people are you know would qualify for a label or find themselves in the neurodevelopmental disorders category of the DSM the DSM is the diagnostic and statistical manual for psychiatric disorders and you many of you may know that and we have a lot of different uh additions uh where in 2013 the dsm5 and then uh text revision came a little later that changed some of these and I'm going to talk about that as well but uh neurod Divergence I always think about ADHD and autism in an overlapping way uh and that's what I refer to but it can learning disorders and and uh I tick disorders is in this category and language disorders so uh there's a good number of people that land in this category person first language I think is important and from you know people that I work with and things that I read uh it makes a lot of sense to me that people most of the time want to be referred to as autistic versus having autism ADHD I I'm just hearing people say I have ADHD uh I think that people should label themselves however they want to but I'm defining what person first language is because a whole lot of people really would prefer to be labeled as Autistic or label themselves versus having something um it's not a disease uh I know it's labeled a disorder but I I think we have to you know talk about our language and how we uh how we understand these issues because it's really just a processing system how our brain works um stakeholders is also an important word I think because people with lived experience people who have ADHD or Autism uh really need to be a part of what we're doing we in when I say we I mean clinicians I mean medical and mental health providers uh caregivers anybody who is you know related in any way need to understand that stakeholders are people we need to listen to um I also really want to give credit to everybody that I've worked with because I have specialized in Pediatrics on up through you know older adults over the course of my career and you know there was a big push for diagnosing and supporting and treating kids who were Autistic or had ADHD and uh you know only in recent years have we really recognized that uh these are these issues don't go away they occur across the lifespan it's just how your brain works so I everything that I have learned has been from working with people I've worked with it wasn't from learning in books I didn't wasn't trained in ADH year autism until my pre-doctoral internship so I went through my whole PhD program and that was the first time that anybody taught me anything about autism or ADHD and it was in children I did a pediatric internship at a hospital uh I had great training and I'm so grateful for that uh but because I had that pediatric training and then worked with uh people across the developmental lifespan I it allowed me to see uh traits of autism and ADHD in adults um at this point I specialize in that because there's fewer people that specialize in it and we need we need everybody we can get but the only way that I've learned anything is from the people that I work with listening and really participating doing evaluations and treatment and that's what we need in order to make the field go where it needs to go in terms of understanding and supporting people uh I touched on this so ADHD and autism um diagnos diagnostic changes in recent years uh what Carol said is really astounding is that when we got to dsm5 in 2013 that's the first time that we were allowed to diagnose ADHD in somebody that we were giving an Autism diagnosis before that um it was you know uh it was you could only diagnose autism in someone and when I and that's how it was when I was trained and it really helped me to understand that most of the people that I have worked with uh and seen children or adults who are autistic would qualify for a diagnosis of ADHD if you look deep enough and peel back the layers um it's important to recognize that this is such a recent change because I I think it has really uh had effects on clinical work and research separating these disorders somewhat artificially where this is where I'm going to go Rogue a little bit I really believe that when you know being immersed in in working with people in these areas for so long I really think that they're the same Spectrum I think they overlap a lot that does not mean that I think everybody that has ADHD is autistic but I think that you know we do have some data when we're looking closely that people you know probably more than half of people with ADHD have autistic traits and I'm going to get to why um not I don't know about the why but I'll get to describing what that means so I do think that these are very much overlapping categories and I think they're both Spectrum issues um and I'm using issues and conditions because we also have to talk about our language um these are psychiatric diagnoses in a diagnostic category of disorders and we have to pay attention to medicalized and pathologized language while still retaining the idea that these are people you know people that need specific kinds of support a lot of people that have uh traits and behaviors in common but when we're talking about symptoms when we're talking about disorders we have to pay attention to functioning and distress if something's interfering with functioning or somebody's distressed about something then we can support them but the medical terminology uh artificially makes these categories sound like illnesses and disease and they shouldn't and that interferes with somebody accepting themselves and people accepting the diagnosis of loved ones so I think that we're seeing a paradigm shift sh towards neurot types and the acceptance and embracing of neurod Divergence and neurodiversity in general is uh a wave that's happened I think because of the internet um in terms of autism terminology uh in dsm5 everything changed to autism spectrum disorder this is important because even um medical and mental health care providers that don't specialize or do specialize in these areas even if they specialize in ADHD a lot of people don't understand that the diagnoses and labels that uh H were in place before 2013 uh all collapsed into an Autism Spectrum Disorder category so anybody who was diagnosed previously with high functioning autism or Aspergers disorder or pervasive developmental disorder noos PDD NOS people say um all would qualify for a diagnosis of autism spectrum disorder once it shifted um the shift had I think beneficial and negative effects on and it just depends on the people and I always tell people you can call yourself whatever you want um but I think that uh that confused a lot of people and providers and I get a lot of evaluations for people that don't think that they have had an Autism diagnosis even though they'd had an Asperger's diagnosis when they were a child or a young adult so sometimes just an explanation of no this is that's you had this diagnosis it's just a new name now um I've been talking a lot about autism and I'm going to continue to talk a lot about autism as we go I want to also just recognize that I think this is a pretty well educated audience if you're here at attitude so I I am going to assume some basic understanding especially about ADHD um where autism comes in I think there's a lot less understanding especially in the field of ADH and I think that that is you know an artifact of the changes in DSM so people clinicians specialize in one or the other or they specialize in kids or adults so it's uh bringing it all together is important but you know people can ask questions as much as they want to if I'm not explaining something well in terms of changes for ADHD there was you know a change in the age requirement for onset or observing symptoms is was before 12 uh in for dsm5 it was I think it was eight before then and it's the reason for some of those changes uh and this is not an exhaustive list of changes but the reason for that is that we it was a we were able to capture more girls and women uh and more adults and the recognition that these aren't just childhood issues uh has happened uh pretty recently uh I would say you know in the last 20 years in particular recognizing that adults can have ADHD has been a new thing and both autism and ADHD have been considered a childhood uh issue before that um I also want to say before I go to the next slide is that uh most providers uh as including myself are not trained in ADHD or Autism unless they seek it out uh there are new programs coming uh you know and in existence now just in the last 5 years there's been uh an explosion of awareness uh but there are still not a lot of clinicians that do these diagnoses especially in the adult population it takes a really long time to train people and um and there's not a lot of evidence based yet so be patient things are changing and hopefully for for the better but uh it's it is hard to find people that specialize in either of them much less both and much less doing diagnosis and treatment because they're very separate things and they're complex um I'm going to move on to evaluation and diagnosis um I think that this is a basic idea who can diagnose ADHD and autism uh there's a lot of confusion here uh you have to be a licensed medical or mental health provider but there aren't specific requirements for who is allowed to these are clinical diagnoses they're based on behavioral observations and whether or not somebody meets the criteria uh so if you're trained and have experience and you're a licensed provider you can do a diagnosis and uh treatment or support uh there's lots of providers that can do this uh pediatricians can do ADHD diagnosis they can certainly do screening for autism I think it's a very complex evaluation so pediatricians usually are not going to have the time or training to do a whole autism diagnosis um but absolutely can do screening and I think that's become uh very common uh thankfully developmental pediatricians a lot of people don't know what they are but they're pediatricians that uh generally stay with somebody until they're an adult and help with changes in someone's needs and kind of uh coordinate care much like a regular pediatrician but specializing in developmental issues and treatments like um you know School accommodations and letters and occupational and physical therapy and Medical Treatments and ref referrals it's like a a developmental Hub that coordinates care um and is important if somebody is autistic and has had that label because they may have more support needs people with ADHD absolutely as well it just depends on the individual but psychiatrist neurologist psychologists neuros pychology there's a lot of other physician assistant nurse practitioners licensed clinical social workers all of these people could diagnose if they were licensed if they're licensed and trained and have experience in ADHD or Autism and uh able to take the time to do it so I think that it's just as important to talk about who can't diagnose ADHD and autism and I'll try and explain why um without getting emotional about it but uh a lot of opinions are out there and there's a lot of medical and mental health providers and Educators who have predetermined beliefs biases stereotypes of understanding about what ADHD and autism are both ADHD and autism are the diagnostic categories were based on young boys with specific kinds of presentations more observable or externalizing traits and that stereotype uh and it's a stereotype but it also does reflect a part of the population uh but that remains in the minds of people and uh affects whether or not people get referrals and D diagnoses or whether or not people endorse symptoms or observe them so this is important to U recognize um I also should you know I didn't say that I'm when I'm talking today I'm talking about especially when I'm talking about autism I'm talking about people without intellectual development disorder so people of average or higher intelligence is the population that I'm speaking about so it's harder to see these issues in people uh in this population in terms of why I'm saying who can't do this diagnosis I have been I've been evaluating and supporting people in who are neurod Divergent for over 20 years 25 years and I have countless stories about Primary Care Providers neurologists psychiatrists kindergarten teachers lots of people family members um who disagree with my diagnosis or saw somebody and said you're not yeah I saw somebody came in with their parent they were a young adult this is so many years ago and said yeah we saw a neurologist but they said I'm not autistic because I have empathy so later on I'll rant about that a little bit and talk about myths and myth misinformation but it's really super important that people recognize that they may not understand this category and these categories and when you tell people you're not Autistic or you don't have ADHD it often derails people from a path that would allow them to get a label understand themselves and be supported in whatever way they need to be supported and that's a very risky Endeavor there because there's a lot of risk of you know psychiatric co-occurring issues like depression anxiety self harm suicide uh it's very very risky to not uh get the support that you need in in a neurod Divergence population so social media and the internet um I know that a lot of medical and mental health providers say is this a tick tock diagnosis um I really think that it's important to be grateful for the internet and for social media because you especially during covid people connected with people online around the world and that has allowed the transmission of information and understanding and the creation of social attachments and support and communities out there that never would have existed so making blanket statements about social media diagnoses I think is irresponsible and jumping to conclusions I think there's a ton of valid information out there online on lots of different websites including attitude mag um I think that social media has a lot of good information and people talking about what their experience has been whether or not they've been diagnosed and then other people can relate and they hear themselves in other people's experiences and that creates communities and understanding and it helps people to refer themselves so I say you know let's not jump to conclusions and say that the internet is wacky I do understand that there's a lot of misinformation out there uh especially in the last several years with all of the uh Co issues and questioning about what is science what who do we trust um so I I know it's important to be cynical sometimes but I do think that we can't rule out the information that we see online and you know medical and mental health providers aren't the holders of all of the information that is valid I do think it's important to be a little bit cynical and pay attention to what believe when you're hearing people and just a couple of things that I try and think about is that when people are presenting their own experience on social media that is their own experience and because everybody is different and has different biology and medical history and and understanding of things it's important that people get that that's one person's understanding and some of their information May generalize or apply to other people too but not everybody so be careful when you hear All or Nothing statements about this is how everybody is or be careful when you hear about like some cure and I'm saying cure with quotes because we don't want we don't need to cure ADHD and autism that would change who everybody is and not be a good thing what we need to do is understand how to support people so you know just keeping in mind that if you take food die out that's not going to change whether or not somebody has ADHD or their behavior I think nutrition and sleep and all kinds of supplements and behavior approaches are super important but one thing isn't going to fix or change everything so just be a little cynical when you're looking at um individual Reports online if they don't feel like they apply to you um again you know I've I've talked about this already a lot of people have a lot of opinions about these things I hear clinicians that don't specialize in ADHD or Autism or specialize in one or the other say all kinds of stuff you know middle-aged White women are telling themselves that they're autistic and there's all these people being mislabeled there's a lot of ridiculousness and you have to understand that if you're not specializing in things you shouldn't be talking about them to people unless you're asking and listening um stay in your lane it causes harm if you tell people things that maybe medically or mental healthwise are not true because it's your opinion um and it makes people doubt themselves so if they've gotten a diagnosis and somebody's saying oh that's not true um it makes people doubt the providers who are supporting them it makes people doubt themselves and it's hard to know who to believe and it just leaves people confused and further behind in their acceptance and understanding and embracing of themselves so I put if you don't know um just ask how you can support or be curious ask questions and educate yourself don't necessarily ask people who are Autistic or have DHD to educate you but people can if they want to um but listening to people's experience and being respectful that their experience may not be something you understand or have encountered so um I just think it's important for people to not think you know things that you don't uh which is hard to know what you don't know but try um okay this is uh complicated how ADC and autism are diagnosed but there is a lot of parallel and when we're talking about these categories it's just whether or not somebody meets the diagnostic criteria and has met these criteria across development since childhood um there you know issues and symptoms behaviors and traits uh wax and Wayne across development they're very contextually based so fit with environment is important uh so sometimes things present themselves more than others and uh typically people don't really grow out of how their brain works they just may have better coping skills or understanding of themselves and know what they need in their environment so they're adapting better and supported the way they need to be these evaluations though are not there's no biomarkers okay there's no uh there's lots of people out there wanting to um do a diagnosis based on like a a you know an fmri or blood work or genetics and there's a lot of really good information and a lot of it is populationbased like if you look at metadata when you look at a lot of data together you can see a statistical significance in you know uh maybe it's brain volume uh from people who are not neurodivergent or neurotypical and people who are neurode Divergent but on an individual basis we're not at a place where we can use biomar markers to do diagnosis they are information uh and medically uh appr as used medically appropriately uh they're great and hopefully we'll get there and I think there's a lot of fantastic research going on in in a lot of biomarker areas so just stay tuned but try not to spend thousands of dollars to get you know uh a diagnosis I mean many thousands of dollars to get a diagnosis uh when it's just premature in terms of the nuts and bolts of these kinds of evaluations and adult versus pediatric um a lot of them are interview based when it's pediatric it's based on parent report teacher report uh observations of the clinician uh checklists about whether or not people are observing these behaviors or traits in different situations it's uh seeing these uh behaviors and traits and symptoms across settings uh in pediatric evaluations there might be more educational testing because kids are in school and being able to support different kinds of Learners is important and because people who are neurod Divergent have higher rates of specific learning disord so they may need to learn in different ways and supporting them appropriately so that they are able to be successful in school and a having strength-based approaches um it's helped by having specific testing testing is also required in some areas uh sometimes the government requires testing or colleges require testing ing for accommodations uh whether or not that uh actually is a gold standard or uh absolutely necessary for this kind of diagnosis probably not but it adds a lot of information when it is helpful uh but in terms of adult evaluations a lot of it is self-report so filling out checklist and diagnostic interview with a clinician who's able to do a full differential diagnosis a differential diagnosis means that you have to do a full evaluation psychiatric history developmental history family history their educational history how they've done in work how they've done in relationships you really have to look at everything because they you know especially when adults are coming in and maybe are getting a late diagnosis they're more likely to have psychiatric issues like uh uh depression and anxiety uh different things from self-esteem issues from trauma from not being able to be supported and understand themselves across a lifespan so we have to do a full evaluation so we know how to approach uh supporting and treating someone uh so it takes time to do these and these are um you know ADHD evaluations can be I think can be done faster than autism evaluations uh but we really have to not just give a checklist to people we have to get to know people I do them across several sessions depending on uh who the person is how complex their history is when I'm working with an adult kids it might it's more uh it might be done in chunks so that you can get the testing done and you can get them going on what kinds of support they need uh adults can get accommodations in the workplace and disability benefits and things like that so test testing can be helpful as well there is not one di one test that can diagnose autism or ADHD and that's not sufficient for a diagnosis it is information that can supplement but it's clinical judgment and observation of these issues across settings and lifespan that has to happen self- diagnosis I'm going to try to go pretty quickly through this I think it's a conversation that needs to be had hasn't been had enough um I think that a lot of people doubt uh information on the internet and a lot of people are skeptical especially in the medical and mental health communities but I think that we do need to talk about this because there's not enough people that do diagnosis uh it's there's there's not enough equity in terms of access to evaluations access to health insurance access to treatment so if somebody is learning about themselves online and they're hearing themselves in these issues and they're educating themselves it can be helpful I mean understanding yourself and seeing where you fit in the world having like-minded people around you supporting you and embracing and uh celebrating your uniqueness is transformative in your life so I think it's super important that we listen to um people talk about self- diagnosis and the benefits of it I have seen in the research literature um recently that when they're looking at autistic traits in people or looking at autism that there uh researchers are starting to include people who are self-diagnosed in that category and we're learning more so it's important important to understand that these are relatively new diagnostic categories and we don't know a lot about everybody under the tip of the iceberg so we still have to listen and learn and it's crucial that we do so and don't think that we know everything we need to know or that we're experts and it's done it is continuing to evolve so self- diagnosis may have a role um medical and mental health diagnosis is also important because we have to be able to support people and give accommodations and have the resources for that so there is a role for the importance of doing a good differential diagnosis and and seeing an expert it just it depends upon the person and their needs uh I know this is autism and ADHD overlap is one of the biggest reasons people are here today and talking about gender so I'm going to try and dive in a little bit here um I wrote clinically observed overlap because uh I'm a clinician I see uh clients uh all the time I'm not a researcher I do participate in and you know more and working with colleagues and training and having dialogue about what I learn because researchers and clinicians need to uh join together and help each other and educate so the field is expanded um but when we're looking at overlap and ADHD and autism symptoms and traits uh we're if you look at ADHD symptoms uh in attentiveness uh hyperactivity impulsivity executive dysfunction and that's like organization and time management most people that I see that are Autistic or have autistic traits have those traits as well so if you take the traits of ADHD and you apply them in autism uh you're going to see that but they're not spelled out in the autism diagnostic criteria the same goes for autism Di notic criteria being applied to ADHD so when we're talking about um autistic traits I I evaluate everybody the same way in autistic symptoms in the diagnostic criteria are differences for example in sensory processing people being hypo or hyper sensitive to different sensory stimuli 99% of the people that I evaluate for ADHD will report those symptoms uh or traits when you ask when you dig deep enough same with social skills or social relationship issues or social communication these are um crit diagnostic criteria and autism but if they're not uh they're not spelled out in the diagnostic criteria for ADHD but they're seen clinically in people with ADHD lot so frequently um autistic traits like difficulty with change uh anxiety with uh um uncertainty occurs all the time in people with ADHD anxiety um social anxiety self-esteem issues are not knowing exactly what to do um that happens I mean I see that in almost everybody I see with ADHD in this population so it's important that we ask about the criteria but also the the behaviors and Trad that we know clinically exist in both of these categories and just apply them to each category and we will see how much overlap there is um as we uh learn and grow I think that the criteria are going to change and we have to talk about gender uh so let's go there um I talk about I have girls and women I have females in various places in my slides and part of that is that all of our data that we have all the research and testing is based on binary gender so the facts that we have that we have proven in terms of research are based on girls and women but I don't want to leave anyone out and that's important and that's why we have to make changes and how we do this but I'm going to talk about girls and women and when I talk about females I mean females assigned at Birth uh so or or sex assigned at Birth and because those are the things that we know and we'll talk I'll talk about some things that we don't know but we do know that girls and women are more likely to fit in they are more likely to to want to fit in and mimic or mask and to be much more socially observant and have much more social motivation that's motivation to understand and connect with people motivation to be in relationship with people so some of the myths and misdiagnoses and misunderstanding of autism and ADHD are that but especially autism are that they are not social don't have empathy or compassion and that's it's kind of the opposite in most of the people that I see is that there's so much empathy and compassion and so much feeling and so much fear of getting it wrong which is perfectionism and dichotomus all or nothing thinking uh and fear of rejection again ADHD kind of Realm applied to autism um so females are more motivated and pay more attention and may be more uh detail oriented and perfectionistic and can mimic better and it's important because as girls grow in female roles um gender roles we're supposed to be good at talking about emotions and verbalizing our feelings and we connect by talking to each other and processing things and a lot of girls and women who are Autistic or have ADHD struggle with having words in the moment or being able to report something as they're experiencing it or labeling their feelings but when you make those mistakes or you're not really good at that stuff rejection is super hard in when you're a girl and rejection sensitivity is profoundly painful in anybody who is Autistic or has ADHD so the motivation to get it right is there and I see that in almost all of the adults that I see and very much uh more so in females is that people study patterns in in how people interact to try to get it right and predict and figure out what they're supposed to do and it's harder to see because when they try to fit in more and there's more subtle issues like more internalizing or internally experienced issues you don't see that externally and then they may have trouble verbalizing it they may not get out exactly what they're experiencing and what they need help with so it's important that we understand the things on this slide that you know special interests in people girls and Fe women who are autistic are much more likely to be typical or expected in terms of gender roles um so we have to look more deeply we have to dig into relationships and peel back the layers of how they're experiencing relationships uh and how good they feel at being in relationships and making friends and maintaining them um we also have to pay attention to girls and women being diagnosed later uh and girls and and and their behaviors being interpreted in a more normalized way so if you have a girl and a boy or an adult you know woman or a man expressing the same behavior girls and women's behavior is much more likely to be interp interpreted in a more normalized way and then they get missed but this is also because of masking and shame so that drive to fit in the drive to you know be a good girl or be feminine or whatever the ex social expectations are really pushes girls and women to mask and there's lots of words for masking but that interferes with referrals with people's understanding about what people's you know their experiences are what people's self understanding of their own experiences are and it can cause a lot of medical and mental health issues it's exhausting for people to constantly mask and that means trying to figure out what others are expecting of you and to mold yourself into that in any given moment trying to play a role but doing that all the time means that people end up not being in tune with their own needs and emotions and understanding and just trying to be what other people want them to be so then there's exhaustion there may be medical illnesses that happen over time with chronic stress but also it interferes with people really being in um true emotionally intimate relationships because they're not truly being themselves and it's hard to know when people are masking and whether they're not when your own masking is happening um I'm going to try and get pretty quickly through the end of this but we really need to pay attention to the gender diverse population and non-conform gender non-conforming there's lots of uh terms that we have to pay attention to but the reason is that this is a very high-risk population there's a lot of trauma and bullying and misunderstanding and rejection by families and communities uh it's pride month uh we just had a big party in my local town and it was super important because some people didn't want even Pride Flags to be up on Main Street so this community is at much higher risk of suicidal behavior and self harm and depression and anxiety and being disconnected from their community and themselves and it's super super important that we prioritize paying attention to and understanding people who are gender diverse um again I'm going kind of quickly what do we need to do in terms of people who are gender diverse we need to do better research we need to have different categories on forms aside from male and female we need to listen and have uh people who are stakeholders participate in our clinical work and our research and educate us on what we need to do and what their needs are um and we need to continuously monitor monitor our own selves and our views about biases racial biases cultural biases gender biases stereotypes it has to be an ongoing daily practice for the rest of our lives because we don't know what everybody else who's different from us wants or needs we have to listen we cannot assume and that needs to be a continuous monitoring and that's just a self-evaluation that happens that needs to happen um and again be curious listen to people but we also need to protect people we need to legally protect people we need to protect people from bullying from bias from harassment we need to protect people from being excluded from communities and we need to I we put this in italics because we need to practice using gender diverse pronouns we need to ask people what their pronouns are not what their preferred pronouns are what their pronouns are and we have to practice I have had people that work for me practice with me practice in the mirror because it was something that they needed to get used to and it's respectful and it helps people feel seen and heard and so it's super important I'm G to real quickly go through my myth and misinformation because anytime I can say this I will autistic people have lots of empathy and compassion and feelings there's a whole wide range of emotional functioning in any any population so it's you know not true that people don't have feelings that people don't want friends or aren't interested in friends often they do desperately and don't know how to connect or maintain connections um internet friends I've heard so many parents and clinicians think oh they are just people they play games with but they're just on the internet these are people that people spend time with and talk to and they have real connections with and it's important to value that and acknowledge it autistic people are very funny and have lots of sense of humor and get lots of jokes and sometimes need people to explain things but everybody does nobody gets everything all the time we have to really understand that everybody's an individual eye contact people are trained to make eye contact eye contact can be harmful and stressful people can't focus when they make eye contact making eye contact briefly or in a different way or looking at somebody's farhead okay I know it facilitates social interactions but forcing people to make eye contact is not okay but also understanding that eye contact is in lots of different ways um I work with people who are autistic and have ADHD who are uh independent and living on their own in all kinds of levels of functioning so we have to acknowledge that I have to wrap up I do have an advocacy slide about how to establish care just respect yourself educate yourself expect that from your care providers if somebody makes you feel uncomfortable move on collaborate Network help each other take care of your own stress when you're looking for somebody to help you or your child um and just you know expect to be respected so I'm going to pass it back to you uh Carol thank you C uh Dr saparo I we appreciate um that informative discussion before we start the Q&A I'd like to share the final results from today's poll question we asked were you or your child misdiagnosed before receiving an accurate diagnosis of ADHD Andor autism 43% said yes 39% said no and 19% said they weren't sure now let's get to your questions um the first one is as a high functioning successful late ADHD diagnosed woman who suspects and displays autistic Tendencies is it worth pursuing a diagnosis are there advantages well I love that question and I work with so many people um that applies to too I always think that it's relevant and important to get a diagnosis uh but it depends on access and privilege you know if you have health insurance if there's somebody around that can do it um but understanding yourself is transformative it removes shame uh understanding that these are developmental issues they're biologically based uh and knowing how to support yourself it it's never too late for that so understanding your own needs having coping skills skills removing shame and accepting and embracing yourself for who you are is there's never a too late for that everybody has a journey over the course of their lives and is evolving so information that helps you to understand yourself and feel understood and celebrated is absolutely I think it's beneficial um someone writes how do I communicate to a clinician so that they won't take it as a personal insult on their intelligent on their intelligence that I'm smart and I read the same materials they do therefore I know I'm autistic I simply require the diagnosis a diagnosis for the support that I need so how do you recommend talking to a physician or clinician um I you know that's a really complex question and it's super important I think that it's important for all of us to come into situations um with an open mind and so I think whenever in my experience whenever I meet somebody with respect they relax and that includes going to your clinician if you feel disrespected again um it's hard not to be upset about that um I think it depends on the level of not listening and if somebody's really not listening then you know maybe it's move on but try not to come in with um defensiveness because they May learn and they may know things and they may have to go through a process to give you that label and that process may feel like a waste of time because you're well educated but there may be something that you can learn and you know there may be things that you can show them or teach them so just really um trying to be present and as much as you can calm and respectful of each other is the best approach but if you feel disrespected or if people are cynical and not listening to your answ or they're not acting in a collaborative teamwork kind of way then you know you can say thank you and move on it's it's just hard to find people so I don't think that it should be an elite uh thing where you know medical providers I'm going to be the expert um we are to some degree and we have a lot of uh power to help people but we have to collaborate so you know there's not an easy answer for that because feeling disrespected is a common thing and a lot of people who are neurode Divergent have been disrespected and felt um unheard so it's really hard to sit with that and feel patronized so I always try and think okay where might they be coming from and why and just try and listen with Curiosity on both sides um I certainly myself have uh reset and thanked some somebody for correcting me for things and I think that that's been really transformative for the person I was working with too um and and I've learned from it so I mean it's not a concise answer for you but uh an approach um someone else writes can you talk about emotional disregulation and autism and are girls with autism more likely to have OD um I don't think that we have uh a like numbers or data about girls being more likely to have OD I think that people we have data that people who are who have ADHD are you know a lot uh what 40% or something may have OD I think it's not diagnosed in girls as much um emotional disregulation I didn't get to talk about that because I had too much stuff uh but emotional disregulation is uh not part of the diagnostic criteria for ADHD or Autism but are is very much uh can be very impairing the rejection sensitivity and um going from 0 to 60 with whatever emotions or kind of thoughts or topics spiraling uh very much impairs somebody's functioning and ability to interact and hear and listen so um it's important for everybody I mean I teach everybody that I work with uh how to how to breathe about the fight flight or freeze response how to uh stimulate your Vagas nerve by calming down and relaxing your muscles and breathing so that you can think more clearly uh so it's very impairing it's very much a part of ADHD and autism it's often hard to see if somebody is you know girls are not supposed to get upset we're not supposed to be angry so you know socially so um can be rejected a lot and so people hold it in and when you hold it in so much it explodes like a teapot you know so um being able to understand your emotions and know when you need to step out know when you need to breathe being able to practice and do that when you're not upset so that you can use it when you're upset that's all super important because nobody whatever human being there is can think clearly when they're having a fight flight or freeze response and people who are neurode Divergent have way more overactive amygdalas and that shuts down reasoning and recall and and you know the ability to pause and think before you want to do something so it's a very relevant issue in both areas um when a person has ADHD and autism which one gets treated as the main one someone asks uh I think I don't think that there's an answer for that I think it depends on the person and I don't think that you can tease it out that much it depends on what's the most impairing thing so um there aren't medications for autism as and because you don't want to make it go away there's medications to help support mood and reactivity there's medications in terms of ADHD and attention and impulsivity hyperactivity so you know if there's something that medication can address and fine-tuning that that's important um but I think approach really is the same is looking at somebody's distress and impairment in functioning and whatever gets in the way the most first just having a kind of a symptom based or presentation based approach is important and you can over time peel back the layers it just depends on the person okay um what are the common misdiagnoses given to girls and women with ADHD and autism great questions thank you because I didn't get to all this stuff um so uh women girls and women with ADHD and autism are often diagnosed with baline personality disorder which is a really difficult differential diagnosis and I question a lot because you've got dichotomous thinking and emotional reactivity and fear of rejection and abandonment um you know which is it uh you've got people get misdiagnosed with uh you know bipolar disorder with OCD is a common one because a lot of people who are neurode Divergent just like repetitiveness or like to systematize things and have trouble interrupting a sequence but it doesn't necessarily mean it's OCD um and and we're talking about misdiagnosis but there's also co-occurring issues so sometimes it is necessary to diagnose more than one thing um a lot of people who are gender diverse have experienced diagnostic overshadowing which is the idea that um they may be presenting with emotional and behavioral issues like girls often get diagnosed to your question U with a anxiety and depression way more frequently or first before they get to any of the neuro Divergent diagnoses that they need uh but people who are trans say or or gender diverse they uh it's harder from my experience and listening to we don't have a lot of data about but it's harder to get down to the okay is ADHD your autism present here because people get so wrapped up in you know gender identity and and the emotional um Fallout of not understanding yourself or being bullied or having trauma so a lot of those issues just um take up space in the beginning and it takes time to get to them um I hope that answered because it's kind of um our last question is in general what kind of advice would you give a neurotypical person on how to best support their partner who has ADHD and autism I love that question um I mean I would ask and I would try and understand um there's a lot of good information I think on the on your website about this but I think you have to try and understand that everybody is different and so you know I don't even what is neurotypical anyway like everybody's everybody's different people who are you know not autistic and have ADHD often have traits if they are attracted to their partner because they just there's a vibe there so often there's traits going on and um even if there aren't like everybody has their own issues so the label um pathologizes things and shames and blames a little too much sometimes but so educating yourself and listening to the person and helping when they're asking for specific help with things and understanding that you need help as well so you know I've seen people come in uh for couples treatment and I don't specialize in couples but occasionally I will work with people if it's to educate them about these issues and so it's just like listening and learning about and respecting each other and understanding that everybody's got issues and whatever they are and everybody has needs and just hearing each other and being Mutual about support um and intentional about educating yourselves everybody is different I love that um so thank you so much Dr saparo for joining us today and for sharing your expertise with our ADHD Community we really appreciate it I appreciate being here thank you and thank you to today's listeners if you would like to access the event resources visit attitudemag dcom and search podcast number 511 the slides and recording are posted a few hours after each live webinar if you're listening in replay mode simply click on the episode description please know that our full library of attitude webinars is available as a podcast it's called the ADHD experts podcast and it's available on all streaming platforms make sure you don't miss future attitude webinars articles or research updates by signing up to receive our free email newsletters at attitud mag.com newsletters thanks everyone have a great [Music] day for more attitude podcast and information on living well with attention deficit visit attitudemag tocom that's addit t d m a.com [Music]