If you’re interested in ADHD and Autism therapy training, here are 8 top things to know. Read more to learn how to identify neurodiversity and how to offer neurodiversity-affirming, effective therapy.
- 1/5 of mental health clients are neurodivergent (*at least);
- Most will be undiagnosed;
- Identifying neurocomplexity can be life-changingly positive and essential for most effective therapy;
- How to identify ADHD and Autism;
- What looks like Depression, GAD, SA, OCD, BPD etc may actually be ND;
- ND is difference, not deficit. Take a neurodiversity-affirming approach;
- Identifying ND is not ‘labelling’, ‘trendy’ or an ‘excuse’;
- Assessments are accessible free & faster through Right to Choose than NHS (UK).
1. 1/5 of mental health clients are neurodivergent (*at least)
Research shows that 20% of clients presenting to mental health services are neurodivergent/neurocomplex (ND/NC). This may be an underestimate because of historical underdiagnosis. This means you probably have several ND clients in your caseload.
2. Most will be undiagnosed
For example, 80% of autistic women are not diagnosed at aged 18. 80%!
Historically, we only recognised stereotyped presentations (like Sheldon from the Big Bang Theory or naughty school boys), but many ND people look nothing like this. Teachers, parents and therapists have rarely been trained to screen for ND accurately (I wasn’t).
Many smart, objectively successful people have learned substantial coping strategies (‘masking’), so it may be quite hard to spot. Bill Gates and Simone Biles are ADHDers. Lionel Messi and Einstein are/were probably autistic.
Other key facts:
- ND people experience more trauma and daily social criticism and discrimination. E.g. 90% autistic women have experienced sexual assault. By aged 10, ADHD kids have received 20,000 more negative criticisms than their NT peers, that’s 5/day.
- Someone is most likely to be both ADHD and autistic due to neurobiological overlap. Someone is also more likely to be 2+ of ADHD, autistic, gifted, dyslexic, dyspraxic, or dyscalculic. So, when you recognise someone’s dyslexic, or either ADHD/autistic, keep an eye out for any others.
- 13% of males-assigned-at-birth are diagnosed ADHD and 4.2% of females-assigned-at-birth. However, females are just as likely to actually be ADHD – ‘good girls’ who daydream or internalise hyperactivity are much less likely to be recognised. Average age of male diagnosis is 7, female diagnosis is 36. Diagnosis of minorities is also worse.
- Autism is 85% heritable, and ADHD 70-90%.
- Life expectancy is 9-20 years shorter and suicide up to x9 higher.
- One theory is that a well-resourced neurocomplex person is identified as ‘gifted’. When they’re under-resourced and experiencing distress, it’s identified as ‘ADHD/autism’. Often, they were the gifted kids & high achievers, until life stressors maxed them out and that’s when they come to therapy. @method.creative.mpls
- ADHD and Autistic people have brains with denser neural connections and more electrical activity.
3. Identifying ND can be life-changingly positive and is essential for most effective therapy
After a lifetime of feeling somehow ‘different’ and ‘inadequate’, finally understanding oneself can be transformative. People can, at last, make sense of their experiences & history, start to develop self-acceptance, and find a way of life that suits them best. It also enables us to provide support and tailor therapy so that it is more effective.
Having said that, people have different levels of readiness and internalised ablism for this. Of course, we need to raise it sensitively and may need to support the process.
4. How to identify ADHD and Autism
a. ADHD
Someone may be ADHD if they have a highly creative, empathic brain that goes at 100mph, with a strong drive to do things and for new experiences. It can make ADHDers very successful. However, in modern society, it can also lead to cyclical boom/bust, exhaustion, anxiety/depression, dopamine-chasing and feeling inadequate.
‘Attention-deficit’ is a misnomer. ADHDers are interest-driven and can focus intensely on those interests. It’s more of an abundance of attention, with difficulty filtering out other stimuli or switching attention from interests, rather than attention deficit. It’s when things are under-stimulating that they can find it hard to concentrate. Hyperactivity can be external (i.e. moving a lot, obviously or subtly e.g. fiddling with pen/hair) or internal (wizzy brain). Rejection sensitivity dysphoria and executive functioning difficulties are common.
Biologically, ADHD is neural hyperconnectivity, monotropism, holotropic sensory gating, need for novelty, interest-driven dopamine system and varying processing styles (bottom-up & top-down (see here for more). ADHD involves executive functioning differences (planning/problem-solving, working memory, emotional regulation, self-awareness and self-inhibition).
The key ‘diagnostic features’ are attention differences, hyperactivity, impulsivity, and they’re arguing to add emotion dysregulation (outdatedly, defined by behaviours/deficits rather than neuropsychology). The 3 types are combined-ADHD, inattentive-ADHD, and hyperactive-ADHD. ‘Good girls’ with inattentive-ADHD are most likely to be late diagnosed. The term ‘ADD’ is no longer in use (that’s called inattentive-ADHD now).
b. Autism
Someone might be Autistic if they can have a different way of looking at things, are a logical thinker and great with patterns, systems & detail, develop excellent specialist knowledge in particular areas, and often have a strong sense of rules/justice. They might feel emotions, empathy and sensations intensely, or the opposite, have difficulty identifying their feelings.
Autists can also be very successful. Contrary to the stereotype, many autistic people like to be social and are empathic. Many of our clients will be on the lower end of the spectrum of support needs, without a co-occurring learning disability.
But again, for autistic people in modern society, social interactions can be exhausting/confusing. Autists might need routine and feel upset if something isn’t ‘right’. They might experience sensory sensitivity, or shutdowns/meltdowns. They might think they’re ‘weird’/’not good enough’.
Biologically, autism is neural hyperconnectivity, monotropism, and bottom-up processing. See here for more.
The key ‘diagnostic feature’ is social differences (in reciprocity, non-verbal communication and relationships), plus 2+ of repetitive behaviour (‘stimming’, e.g. nail picking, rocking), preference for familiarity/rules, deep ‘special interests’ (might be common interest e.g. psychology/sport), and sensory differences. Again, these define differences based on behaviours/deficits, what can be ‘inconvenient’ for others, rather than neuropsychology.
PDA (‘pervasive drive for autonomy’ or ‘pathological demand avoidance’) is a subtype of autism.
c. AuDHD
When someone is AuDHD (i.e. both), traits of one can camouflage the other, e.g. autistic systems hide the organisation challenges. Internally, it can feel like a battle between 2 sides. This can make it hardest to spot, despite it being most likely someone is both.
d. HSP
Identifying as HSP (‘highly sensitive person’) can be a distinct neurodivergence or it may be a stepping stone towards identifying ADHD or autism.
e. Screening Tools
- ADHD: The ASRS;
- Autism: CAT-Q (for masking, better at picking up non-stereotyped presentations), RAADS-R or AQ50;
- Note: These questionnaires are the best of an old fashioned bunch, biased towards stereotyped presentations. Use some clinical judgement about what they’re actually asking. E.g. for ‘I like to collect information about things such as trains’, think about whether someone likes to deep dive and learn everything they can about their interests in Taylor Swift or tech.
5. What looks like Depression, GAD, SA, OCD, BPD etc may actually be ND
Most neurocomplex people have been misdiagnosed with primary anxiety, depression, etc, prior to accurate diagnosis. Or, they might experience both, but the A/D is secondary.
Standard treatments might be less effective at best, and at worst exacerbate ND distress. Accurate recognition and treatment is essential and leads to best outcomes.
For example:
- ‘Depression’ may be autistic/ADHD burnout. Behavioural activation worsens burnout. ADHD/autistic burnout needs rest.
- ‘Worry’ (GAD) may be internal ADHD hyperactivity. ‘Reappraising worry’ will rarely slow hyperactivity down. It may be more helpful to use attention/hyperactivity regulation strategies (e.g. physical movement or mindfulness), develop compassionate acceptance, and harness/redirect capacity for rich thought.
- ‘Social Anxiety’ may be discomfort with neurotypical social communication norms. Teaching NT social communication reinforces “I’m inadequate/weird”. We need to embrace differences, find like-minded friends, and may need to process relational trauma.
- ‘OCD’ may be sensory differences or preference for order. Using OCD exposure on sensory sensitivity will not reduce sensitivity but will instead feel very painful. We may reduce some sensory sensitivity by reducing stress, but mostly we need to learn to accommodate these lifelong sensory needs.
- ‘Relationship difficulties’ or ‘emotional dysregulation’ (Borderline Personality Disorder) may be social/executive functioning differences or meltdowns/shutdowns. Teaching emotion regulation techniques may treat the symptom rather than the cause, and puts the social burden on the individual. Instead, we need to orient towards unmet needs and develop strategies to meet them.
6. ND is difference, not deficit. Take a Neurodiversity-Affirming approach.
Being neurodivergent is like being an iPhone; being neurotypical is like being an Android. Both are great, but if you try to use your iPhone with Android apps, it doesn’t work so well. Neurodivergence is a difference in wiring.
Actually, ND may have evolutionary advantages and lead to strengths. Some people call them ‘superpowers’. ADHDers are often the explorers and innovators. Autistic people often have a fresh way of looking at things and develop systems and deep knowledge. Personally, I think there can be both strengths and challenges.
They are ‘social disabilities’, i.e. made difficult by the way society is set up. It makes it difficult to have an iPhone if only Android apps are available. The DSM’s neuro-normative, pathologising language is due an overhaul. We need to develop neuro-diversity affirming language and practice.
Language: Most people prefer identify-first language (i.e. ‘I’m an ADHDer/I’m autistic’, not ‘I have ADHD/have autism’). It’s respectful to check with someone how they prefer to identify. It’s ‘high/low support needs’, not ‘high/low functioning’. They’re ‘traits’, not ‘symptoms’. Generally, avoid ‘ASD’, ‘ASC’, ‘Asperger’s’ (he was a Nazi), or ‘on the spectrum’. Some people like ‘Neurospicy’, ‘ADH(d)’, ‘ADH*’, or ‘Autist’.
(Note, disability may be compounded by issues of privilege, and it may be different for people with higher support needs or co-occurring learning disabilities. Some people love identifying their superpowers, others find this disrespectful of how challenging it feels.)
7. Identifying ND is not ‘labelling’, ‘trendy’ or an ‘excuse’
There is a wave of adults identifying their ND, just like there was a wave of left-handed people when teachers stopped hitting their hand with a ruler. Eventually the wave will level out. It’s also a positive thing to embrace this about someone. ‘Labelling’ would imply it’s a negative identification.
Instead of thinking it’s a ‘trend’, we should be thinking ‘how did we let so many people down?’
ND people are generally highly self-critical and try their absolute best – far from ‘lazy’ or looking for an ‘excuse’. People blame themselves for their challenges, having internalised negative messages. Overwhelm or lack of being taught skills may lead to behaviour paralysis or challenges.
Also, we’re all ‘neurodiverse’, but we are not all ‘neurodivergent’ or ‘a little bit ADHD’. Empathising and recognising how no-one really fits the standard ideas of how we ‘should’ think and feel is positive. We need more of this. However, there is a difference between occasionally forgetting things and it being a daily issue that causes distress, and we need to be respectful of others’ experiences and level of distress. Or maybe, someone actually ‘IS’ ADHD.
Instead, we’re developing more accurate understanding of people and their needs. This empowers everyone to take action that is actually helpful. This is a positive social movement.
8. Assessments are accessible free & faster through Right to Choose than NHS (UK)
Right to Choose assessments are private, but paid for by the NHS. People can choose their provider from a list, and waiting times are generally much shorter (varies depending on provider). The NHS waiting lists are often horrendous, so they have commissioned these assessments.
They are currently available for people in England, Wales and Northern Ireland (unfortunately not Scotland) and everyone has a legal right to one (if someone screens positive, GPs cannot refuse referral).
See here for more info on R2C on the ADHD UK website.
P.S. I offer one-off screening/guidance sessions & therapy for neurocomplex people and neurodiversity-informed clinical supervision for professionals.
Next steps: I encourage you to seek further training. Check out these brilliant books: ADHD 2.0, Is This Autism?, Unmasked and ADHD for Smart Ass Women: How to Fall in Live with your Neurodivergent Brain.