SPEAKER_01 0:00

Today's podcast is called The Missing Piece. So we're going to be talking about incorporating assessments for autism and ADHD in community mental health settings because we think that's a very important part of mental health. And so who are we? My name is Sonia Kuma, and I'm a psychiatrist in youth mental health service called Yes in Western Sydney. And I'm Ed.

SPEAKER_02 0:32

I'm a psychologist. I work with Dr. Sonia Kumar in the Youth Enhanced Support Service of Western Sydney.

SPEAKER_01 0:38

Okay, so just to start with an overview of the podcast. So we're going to be running through a few different topics today. I guess we're going to be presenting a view that it's very important to be able to assess neurodevelopmental disorders, including ADHD and autism, in community mental health. And we're going to be providing a real-world example of how we did this in the Yes service, a little bit of a background about yes. We're going to cover how to do autism and ADHD assessments, or at least how we do them. Some prevalence and comorbidity statistics as well, looking at the comorbidity of ADHD and autism with all of the common mental disorders, including trauma-based disorders. And then we're going to present some of our file audit data, discussing the value of using file audits as well to improve clinical practice. We're going to cover diagnostic dilemmas such as how do you discriminate between complex trauma and neurodevelopmental disorders. And then we're going to talk a little bit about adapting our clinical practice for people with neurodiversity. So I'm going to start by asking Ed, what is the Yes service?

SPEAKER_02 2:03

Well, Yes Western Sydney or the Youth in the Hands Support Service, we're a mental health program that works with young people aged 12 to 25 with severe and complex mental health issues. We work with them for 12 months. And in that 12 months, we can offer psychiatry, we can offer therapy, case management, and we try and provide wraparound care, really intensive, like weekly sessions, groups and individual therapy, so that by the end of that 12 months, the young people are feeling a bit more prepared to tackle life and hopefully move on to your private practice or GP and are hopefully in a much better spot. Working in the enhanced space for youth mental health, our service was designed to capture people who were falling through the gaps. And over the course of our experiences working with young people, one of those gaps, it turns out, is neurodivergence. We have young people who have had long-term therapy, and at no point was it ever raised that autism or ADHD was even on the radar, or maybe it was, and they just didn't have the resources to financially in order to pursue that. And so that formed a core gap that we have tried to fill. Because it turns out when someone is neurodivergent, their experience of therapy of intervention is different compared to what we might be expecting. And until we were able to recognize that, we weren't really providing targeted care and intervention for them.

SPEAKER_01 4:34

And can you tell us also about what kind of therapies we do at yes? Because we're lucky enough to have three psychologists who know a lot a lot of different therapies.

SPEAKER_02 4:44

Yeah. So in terms of therapies, we started with classic cognitive behavioral therapy, CBT. And then over time we've branched out to offer dialectic behavior therapy, including sort of individual and groups. Then we kind of further specialized into radically open dialectic behavior therapy. That was a really helpful therapy to roll out for us. And we've done that both in individual sessions and in group, or I guess we call it a class in RODBT. Most recently, we've also started to do EMDR and schematherapy as well. I recently received training in that. And I believe one of our psychologists is also trained in trauma-focused CBT.

SPEAKER_01 5:23

So we're lucky. We're able to offer such a great range of therapies. And so my next question for Ed is to maybe explain some of the terms and the difference between neurodiversity, neurodivergence, and neurodevelopmental disorders.

SPEAKER_02 5:44

Right. Well, that that is a pretty important distinction. And uh for for this podcast, you know, we'll try and use the terms correctly as much as we can. Uh, but we're we're still learning. So I'll start with uh neurodiversity. A neurodiversity is it's just a it's a concept uh and a movement. The idea is that everyone's brain is different, everyone's way of experiencing the world, their way of interacting with others. All of that is different based on their individual circumstances and you know their individual personalities and everything that goes into what makes someone unique. So everyone by default is neurodiverse. When we talk about the idea of neurodivergent, that's where we draw more into that sociopolitical lens where neurodivergent is this idea that you diverge from what they consider to be the neuronormative way of existing, coping. A lot of that is sort of informed by your cultural lens, economic lens. Um, it comes from a very you know capitalist perspective of this is how you need to function. Um, and people who don't fit into that box of neuronormative are considered neurodivergent or can sort of identify as neurodivergent.

SPEAKER_01 7:01

And this is this is where we also get uh people referring to the term neurotypical as well, as if there's some sort of norm of the you know classic neurotypical person who is not neurodivergent in any way. But I suppose the more we look into these things, we realise that that category gets smaller and smaller. Um so what's the difference with in terms of our presentation, we're talking about more about disorders, so we're talking about ASD and ADHD as neurodevelopmental disorders. So what's the distinction there?

SPEAKER_02 7:36

Well, the that is a really important distinction because when you are neurodivergent, it doesn't just mean you have autism or you have ADHD. Anyone with, for example, traumatic brain injury can be considered or can identify as neurodivergent. When we're talking in that lens of disorders or mental health conditions or neurodevelopmental conditions, there's specific labels. So someone who is autistic can identify as neurodivergent. Being autistic isn't the only qualifier for being a neurodivergent.

SPEAKER_01 8:07

Yeah. So in terms of our presentation, our service, and the assessments that we do, we are considering you know these as mental disorders, so associated with some level of impairment. I'm just going to go over, for those of you who haven't been working much in this area, I'm going to go over the main features of autism and ADHD. So autism spectrum disorders, I think, have two main components in terms of the symptoms or characteristics. So the first category is in social communication and social interaction. So this is where we see some unusual communication styles. We might see an absence or atypical non-verbal communication, and we may see different preferences for social interaction. So people who prefer to interact around a specific topic or interest, or people who have a preference for online interaction, or people who become very tired by social interaction. And these characteristics are, by definition, pervasive across the person's lifetime. And the second category of symptoms is in terms of the restricted and repetitive behaviours that people can have. So this could be a preference for routines, a preference for eating the same foods, a preference for doing things in the same way and leading to distress when their plans are disrupted or changed. This could include, you know, hobbies or special interests, and within our team we've got very good at identifying people's, you know, highly passionate interests, which again could be a strength in somebody with autism. So the two main categories that we assess are the social communication and interactions, and then restricted and repetitive behaviours, and it's important to assess those throughout the lifespan. And the other aspect of autism spectrum disorder is the levels. So we classify that according to how much support the person needs. So level one requiring support, level two requires substantial support, and level three very substantial support. And I'm also just going to give a refresher on the main features of ADHD as well. So we've got the three main symptom clusters for ADHD. So we have deficits in attention, which can impact on someone's ability to concentrate, but also organization skills, time management, and planning and affecting, you know, a number of different domains in the person's life. And then we have the hyperactivity component, which is most obvious in terms of physical hyperactivity, but might also include verbal or mental hyperactivity, people with very busy brains and racing thoughts. The other component which is considered to be strongly aligned with the hyperactivity is impulsivity features, so being spontaneous or impatient. And so the subtypes of ADHD, we have predominantly inattentive symptoms, predominantly hyperactive or combined types. And the other thing that's important to always keep in mind, this is also neurodevelopmental. So we for DSM criteria, we have to have at least some evidence that these issues were present before the age of 12, which is an extra level of difficulty in terms of the assessments. But now I'm going to go back to Ed and we're going to talk about what we did at Yes in Western Sydney to include these assessments in our process.

SPEAKER_02 11:56

All right, thanks, Sonia. Uh so these assessments we know in out in the community in private practice they can be very expensive. So we were very excited to introduce those assessments and offer them to our clients and our young people. We started in 2023 when we were fortunate enough for Sonia to come on board and help with assessing and prescribing ADHD. And we developed a bit of a process there through gathering examples of symptoms, the accounts of young people throughout their life. And we hear that through our individual sessions. And after we rule out things like sleep disorders, other mental health issues like depression, we bring them to Sonya. And when we bring them to Sonya, uh, we also then come along with screeners, you know, from parent ratings or parent observations to self-reports. Uh, so we're using things like the Diva, the diagnostic interview for autism for ADHD, I should say. So, because of how complex uh these neurodevelopmental assessments are, we've been able to actually take advantage of the 12 months that we have with the young people that we work with in order to really get to know them. So during that 12 month, from the very first time we're meeting that young person, we're looking at and observing for differences in their communication style, differences in how they're coping with life, the different strategies that they've used to get by. And we also have the opportunity to observe them not just in our individual sessions, but also in sessions with other professionals, such as in their psychiatry reviews, and also in group therapy. So that gives us a range of different contexts to see differences in their interactions, differences in how they're understanding things. And on top of that, during that 12-month period, we also get to understand how their different symptoms are interacting. We get to observe for things like difficulties with sleep, drug and alcohol use, and we often have opportunities to try and work on that to make these assessments for autism and ADHD a bit more clear-cut. So it's a very thorough process. And the types of young people that we work with, as I said earlier, complex mental health presentations. We typically exclude referrals that are primarily just for ADHD, for example, to get ADHD medication. We also decline referrals for things like psychosis because there are already existing early psychosis services in in our area. But once you make it through that referral process, we do an initial biosocial assessment and an initial psychiatry assessment, all within the first sort of three months, within three months ideally. And then during that 12-month therapy program, we've got regular psychiatry reviews. And it's only after we've seen them for a bit of time, usually around three to six months, that's when we start to consider uh will we do an autism or ADHD assessment.

SPEAKER_01 14:54

All right. So I'm just gonna go over some general principles of these assessments based on our experiences over the last few years and also our experiences working in different services as well. So the first thing is that ADHD and autism are clinical diagnosis, so it's not something that can be done with a psychometric screener at all, you know, alone. And there is no ADHD or autism assessment without a general mental health assessment. So we need the general psychiatry assessment to know what else is going on for that person and what their comorbidities are, and we need a medical assessment and assessment of functioning. So, according to the APS guidelines for autism assessment, the medical assessment and assessment of functioning is an important thing to do before proceeding with the full assessment. And the other thing that is commonly discussed among psychiatrists, all psychiatric conditions can cause impairments in attention and concentration. So we know that common disorders make it very hard to concentrate. The rating scales are used. We do have a lot of psychometric scales which provide very information, but not the clinical diagnosis. And with these neurodevelopmental disorders, the childhood symptoms are really essential. So we have to have a pretty good idea of the person's early development. And for that, ideally, we need to be able to speak to a parent. So that's the an important difference, I suppose, with these assessments to your usual mental health assessment. And we do run into difficulties sometimes if the person does not have contact with their parents, or in fact, there's an abuse history, it may be dangerous to involve the parent. And there are ways around that, so we can find siblings or family friends, but we go to quite an effort to find someone that knew that person as a child. People do not really remember, you know, aren't really able to self-assess their childhood symptoms, and other things to be aware of are just the potential for bias. So in these assessments, there's a potential for self-selection bias. Often the client really has a specific agenda, they want a diagnosis that's quite unique in psychiatry, that doesn't happen in other areas of psychiatry. There's also recall bias, which affects parents as well as children, and some parents will be heavily invested in not having their kids diagnosed, and some will be the reverse, and also just to be aware of clinician biases as well, as particularly if you're very passionate in this area or you're very passionately against this area as well. Um, and we've found just through our experience that the best assessment really comes from knowing a person over an extended period of time, which we have the luxury to do because we've got a whole 12 months. So now I'm going to ask Ed to give a bit more detail about what is an autism assessment.

SPEAKER_02 18:04

Well, um, so an autism assessment uh with Yes Western Sydney is is based on the gold standard clinical guidelines released by Autism CRC a couple of years ago. And we primarily focus on first ruling out other disorders like mood disorders, anxiety disorders, and also screening for symptoms of autism, which we've started to learn more around from hearing clients count their experiences. We've started to observe patterns, and that allows us to start to fine-tune who we have that discussion with, and in general, we try to be really open and welcoming about the idea that we're we want to be able to look into that. It's not a topic that we're afraid to discuss, and it's not a topic that we're going to be judgmental about either. Uh, we'd also, of course, rule out physical health issues, sleep disorders, other medical conditions, and we also look at potential family history. If there are preexisting diagnoses of autism, that often is an indicator that the person might be at risk. And also then we look at functioning. How is their symptoms or differences impacting the way that they live? And so to get into the nitty-gritty of the actual process, we always start with screeners. We'll use things like the AQ, the autism quotient, uh, or the RADs. And if they're scoring above threshold for those screeners, that's when we refer them to our assessment stream. Once they they come up for assessment, so we use a number of gold standard um autism standardized assessments. These include the ADIR and the ADOS 2. Uh the ADIR looks at parents' perspective, and it's a you know an a diagnostic interview that involves looking at how this person was different from childhood. Where did the problems start to occur? When did they occur? And it's a very retrospective look. And how does that compare to now? The ADOS is an interview with the younger person, and basically it involves getting them to do some tasks, getting them to explain stories, movements, things like that, and we use that as a way of getting observational data for things like repetitive behaviors and getting a sense of how they're interacting with the interviewer. Alongside those two main assessments, we also use the ACIA or the autism clinical interview for adults. That's quite useful because it is one that is informed by the actual young person, and that can be very helpful in situations where talking to parents isn't as safe, especially when there's trauma and domestic violence. And we also started to use the MiGDAS2, which is one of the newer, more neuroaffirming autism assessments, and it focuses more around meeting the person where they're at, communicating at the level that they're happy and safe to communicate at in order to do our assessments. Alongside those, we also look at school reports. Sometimes we find that there are comments around how they're interacting with other students, and that can be very helpful in providing that developmental information, past psychological reports, can also note some previous suspicions of a neurodevelopmental condition like autism, and that allows us to just catalog information across the lifespan. So once we've done all of those formal assessments and collected that information, we then look at their adaptive functioning. Typically, we use the vinylin 3 or the ABAS 3, and that identifies areas where this person might be having a lot of difficulties or might need extra support. And those areas usually map on quite neatly to what we would expect for someone with autism. And occasionally we might also do cognitive assessments. So that's the whisk or the waste. And the idea is that sometimes a person might have a very high cognitive potential or Intellectual potential, but their adaptive functioning doesn't match that. And that usually indicates that something is getting in the way from for this person to reach that potential and to show it in how they're functioning.

SPEAKER_01 22:12

Okay, so we're putting together from our own uh assessments and the structured psychological interviews, plus or minus cognitive assessment. And I'm just going to very quickly run through how we do our ADHD assessment. I know that there'll be a lot of other information on that, but our process is to we start with the first psychiatry assessment in the first couple of months, which does not focus on ADHD particularly, but it's more about their presenting issues and um setting up a treatment plan. Then there'll be a there'll be sort of a second psychiatry interview uh a few months later. And to prepare for that interview, the clinicians have done some screeners. So we use the ASRS Adult ADHD screener and we use the Wendy Utah Observer Scale for a parent to complete regarding the childhood symptoms. We also do a clinician interview based on the Diva 5 interview, and we're very keen on trying to find primary school reports. Some of these primary school reports can show very clear evidence of ADHD. The more you know time you spend looking at school reports, the better you get at discriminating that out. So that's our basic process. We really, you know, emphasize having collateral from a parent and school source as well. And now I think just so that we're gonna have enough time for everything, I'm just gonna do the section about the file audit. So what did we find? There has been large population studies looking at comorbidity, so that's what obviously we're very interested in in comorbidity, and what proportion of these people have ADHD and autism, and and is it does it correlate with anything else? So we've done a clinical file audit looking at a 12-month period in 2025, and so we audited 70 of the files, and this is just routinely collected data. So the diagnosis was based on you know psychiatry and psychology assessments, and we didn't use standardized interview scales or anything like that. So the first set of results is just in regards to the diagnosis that we found, and so looking at you know percentage with each diagnosis, the highest um percentage was that was actually for PTSD, and bearing in mind that we we have a sort of a broad definition of PTSD, and and most of those people are complex PTSD with large number of adverse childhood experiences and adult experiences of trauma, and so that over 60% of the population had PTSD symptoms, anxiety around 40%, ADHD, depression, OCD, substance abuse, roughly equivalent, about 30%, and ASD was 20% in our population. And then we looked at the comorbidity. So to look at comorbidity, we just used a correlation, Pearson's correlation statistic, looking at exposures and outcomes. So because we are actually have a small sample size, not all of those reached significance, but the I guess the outstanding ones there was a high overlap between ADHD and autism, and a strong overlap between PTSD and substance use, and a strong overlap between depression and anxiety. And some of the more unusual findings, for example, very low correlations. So depression and ADHD was one that was quite a low correlation, which was slightly surprising. And if we sort of try to compare that to the larger population studies, so in the, for example, the World Mental Health Survey in Japan used a logistic regression method with over 2,000 participants with autism and found elevated odds ratios for social anxiety around two or three, but substance abuse, the odds ratio was five. So very high risk of substance abuse for people with autism, but also social anxiety, which you would expect. And in the same population study, again, it's over 2,000 participants with ADHD. The odds ratios were very high for generalized anxiety disorder, panic, social anxiety, and agrophobia. So all of the anxiety disorders very high in the ADHD population. And obviously, you know, there there's a lot of prevalence and comorbidity studies. So we were interested in trying to generate our own data and and look at what the local data is telling us. We then had a look at our outcome measures, so the 12-month period of therapy, what actually changed. And because of our sort of organization, Uniting collects K-10 as the preferred outcome measure. So everyone has to complete these K-10s. Wouldn't be my preferred option. I think I'd probably like to use a DAS.

SPEAKER_02 27:45

I believe that's a government.

SPEAKER_01 27:47

It's government, yeah, it's a government uh requirement. We have to collect K-10s, but I think um I would definitely prefer to be using a different outcome measure there. And so, yes, for the future that would be a better thing. So when we looked at the the change in K-10s, we stacked that up by diagnosis, and it was it was interesting to us because the people with the neurodevelopmental condition, so autism and ADHD, had the largest change in K-10 around six, six to seven. And what was also interesting and kind of surprising was that people with depression had the smallest change in in K-10s and then the other disorders in between. I think our bipolar and OCD also did pretty well.

SPEAKER_02 28:34

Yeah, and I'll just clarify by change. I mean, they went down people. Um, yeah, they they've experienced a lot less distress uh by the end of their time with us. And the top benefiters, I suppose, were our young people with autism and ADHD, which is really cool to see.

SPEAKER_01 28:52

Yeah, that's an important point. Yes. Though they were um improvements in in the K10s. So yeah, I'm going to ask Ed to talk a little bit about therapy because we do you know a range of different clinical therapies: DBT, RODBT, EMDR, CBT. So I'm gonna ask Ed to talk about how we adapt our clinical care and how we adapt our therapy for people with neurodiversity.

SPEAKER_02 29:22

All right. So as always, you know, we we try and adapt our interventions and how we interact with our young people based on the individual. But I think one thing that has been actually quite helpful is as we've done more of these assessments, it's actually allowed us to learn more about how best to tailor these interventions to young people with autism or with ADHD or both. And well, I always like to go back to that idea of you have to understand a person, you have to listen to their story, listen to their experiences. And so when we're working with young people who have these neurodevelopmental conditions, the best thing I could say is that just ask them. Just ask them what works best. Uh, oftentimes they're used to being told they have to do things in a certain way, uh, or they've had these experiences where they're being forced to conform to this neuronormative approach to mental health and to interventions, and we might even carry those biases with us. But one thing that I've learned is it always helps to just take a step back and just ask, hear them out, give them the opportunity and show that it is safe for them to advocate for themselves. And through that, I guess from my own experiences, I've learned a lot when we're talking about how DBT, for example, often it's used for to help young people with emotional dysregulation. But when you actually talk to a young person, you try and understand what is it that's causing that dysregulation, sometimes it's not what you expect. For example, you know, someone could get quite seemingly dysregulated for something completely, you know, not on your radar, where, you know, there was a disruption to something they were anticipating. And you would actually treat that very differently, wouldn't you? You would look at that and go, okay, where is it because they're dysregulated just in general and their emotions all over the place? Or is there something specific about having those plans disrupted that really hurt for them? Is there something different about how they're experiencing those disruptions? And I'd like to think over time we've developed a bit of a library of different features or I guess common experiences for our young people, and that's helped us then fine-tune our therapy to and our delivery of interventions to better suit uh their needs. So things like having lots of sensory toys. As much as we can, we try and make sure that our therapy rooms are have access to that. We try and keep in mind that a lot of young people are using those sensory toys to regulate. And, you know, they might not be concentrating or seemingly not concentrating on what you're saying. It doesn't mean they're not listening. You know, we we find that there's similarities in how people experience the world. Different coping strategies tend to come up quite frequently. For example, masking, learning scripts for different situations, having a set of responses to different situations or questions that are almost like it's just like having having a toolbox in your back pocket.

SPEAKER_01 32:20

How about um, you know, I mean, I think we've also learned quite a lot about people's communication preferences. Do you want to talk about that?

SPEAKER_02 32:28

Yeah, the well, everyone has these different communication differences. And actually, what what's interesting is that over time they've started to look more into those differences and how they might manifest. A classic example of that would be the double empathy problem, which was, I think, coined by Milton in 2012, and that where there's a breakdown in mutual communication between any two people, but it often occurs when there's people of different dispositions. And a classic example of that would be someone who's you know neurotypical and someone who's autistic. And so learning to navigate those differences in you know, when when we deliver an intervention, when we give a strategy or a suggestion, how is that person interpreting it? Checking in with them to see whether that their interpretation of it is the same or not, checking in to see if we have the same goals. Is our goal for them to have a full-time job and we're holding that bias in when in reality that young person actually doesn't want that, that's not how they want to live their life. And are we being judgmental about it?

SPEAKER_01 33:30

Yeah, I think that one of the things that we've learned or or noticed also is how you know people with autism or ADHD enjoy being in each other's company as well. And they they sort of gravitate towards each other because some of those communication styles are compatible. So they actually like to form interest groups and social groups. And that's that's something that I wouldn't have known before we did all of this. I just wanted to take a little bit of time to talk about complex PTSD and cognition, because I think this is one of the diagnostic dilemmas that we're really having to thought through, which is the question: how do you tell if someone ha has a lot of trauma and complex PTSD? How do you tell whether they've got ADHD or autism, or is it all just the effects of trauma? So looking at sort of studies of people with autism, I guess, people with autism are more likely to experience traumatic events, and they're also maybe more likely to perceive the same event as being traumatic. So, you know, if you look at sort of uh school bullying as an example, somebody who's autistic, you know, maybe more traumatized by that event than a more neurotypical person. So in systematic review, there's um increased prevalence rates of PTSD of people, you know, who have autism. So I think one of the issues that comes up in these autism assessments is that some clinicians in the community may ascribe people's symptoms to complex trauma and giving us the impression that, you know, because somebody has complex trauma, they don't have ADHD. Or because they have trauma, they don't have autism. And I've heard this being said, and and my argument is that that's actually a bit of a logical fallacy that you know people with ADHD and autism can definitely have trauma, and vice versa. So there is associations, obviously, with comp complex PTSD and brain functioning. So, for example, in in systematic reviews of large numbers of people with childhood trauma, you know, it it has been associated with significant deficits in attention and working memory. So we need to keep that in mind because not all of our complex PTSD patients with attention problems, you know, really do have ADHD. So that's why you're really needing to do your comprehensive assessment over a long period of time and emphasizing the childhood symptoms. But the the difficulty comes when there's a lot of trauma happening in the early developmental period, and sometimes we simply say that we don't know, and it's okay to recognise that you don't know as well. So, what did we learn from all of this, or what are the implications of what we've been doing? I think you know, the main message here is that really autism and ADHD are a missing piece, and that it's there's a lot of unrecognized, you know, undiagnosed autism and ADHD, particularly in a population like ours, and that services are not available, and it's very difficult to access assessments. Funding is obviously required for these disorders in the missing middle population, which is where we work. And early access to comprehensive assessments and support services, you know, may actually prevent comorbidity. So it's a prevention approach, potential improvements for the burden of disease, and really improvements for people's social and occupational outcomes if they're able to receive an assessment early in life. And really, it's also about breaking down the silos of clinical practice and increasing awareness in our colleagues, psychiatrists and psychologists. You know, we're really advocating that all psychiatrists should do some training on how to do an autism and ADHD assessment, and all psychologists, like people in the public sector, private sector, you know, we all really need to have this training. And also thinking that what we're really about is reducing the impact of socioeconomic inequities on mental health. So, in terms of future research, I guess you know, our projects in the future will definitely include improved outcome measurement, different rating scales, specific PTSD scales, Y Box. And I'd really like to look into the effective specific therapy modalities, such as particularly the RO, DBT, and the EMDR role of medications, you know, what difference does the medication make in this context? And it's just this sort of principle of using your routinely collected data to derive information and knowledge that you can then feed back into your service and cause, you know, for service improvements, quality improvement.

SPEAKER_00 38:47

So I was just wondering if Ed could tell us a little bit about RODBT.

SPEAKER_02 38:54

Yeah, no worries. RODBT or radically open dialectic behavior therapy is a newer modality that is focusing on individuals who rather than experience what they conceptualize as emotional under control, actually lean more on the opposite end of the spectrum where their strategies revolve around exerting more control, or as we would describe it, maladaptive over control. What that means is that when these individuals are interacting with the world, they focus a lot on controlling their behaviors, their reactions, and often it's to preserve or protect their relationships, to preserve or protect their reputation. And there's a lot of functional benefit to it. However, when we talk about maladaptive over control, it means that those strategies are actually having negative impacts on things like their relationships, and it leads people to feel more isolated and alone. Where RODBT steps in is it focuses on the idea of social signaling. Social signals are anything that you do in front of another person that can be perceived. So, for example, something that you might do at home where no one is looking and no one can see it, that doesn't count. But if you were to, for example, pull a funny face in front of another person, that would be interpreted as a social signal. Where our autistic young people have found a lot of benefit in RODBT is helping them understand how their social signaling might be impacting their relationships. We know from the research that autistic people might appear more flat, and that is something that is not necessarily their intent or their fault, and yet it also impacts their relationships. Why is that? Because other people are seeing a flat affect, so to speak, and interpreting it as a social signal. They might interpret it as a signal that this person might not like them, and that causes a lot of miscommunication. And so by drawing attention to social signaling and using what we call the RODBT skills class to help enhance those signals, to build skills and to give them a framework for understanding all of this through things like worksheets, group exercises, and discussions alongside peers and helping them grow together. Our autistic young people have given quite good feedback about the experience and have really gained a lot, at least from what they're reporting to us.

SPEAKER_00 41:38

Thanks, Ed. And we're now coming towards the end of the podcast.

SPEAKER_02 41:43

Yeah, so thank you for listening to The Missing Piece, where we hope we've provided a solid real-world example of how to incorporate autism and ADHD assessments into a youth mental health setting. So here are some take-home messages from our experiences that we hope you can learn from.

SPEAKER_00 42:04

So, in terms of the data that we looked at now, the main findings were that we had much higher prevalence rates of autism and ADHD, which are around 30% compared with the expected population prevalences, which would be around 2% of autism and 6 to 8% for ADHD.

SPEAKER_02 42:30

We also found through doing these assessments that getting to know a client in a team setting over an extended period of time has been very helpful for diagnostic clarification because we've been able to observe them across settings with different clinicians, in group settings, in medical reviews, and even in their sessions with peer workers. And we can collect all of that data and observations to inform our understanding.

SPEAKER_00 42:59

And when we looked at the existing population research, another thing that we found was that research often doesn't adequately cover prevalence of autism and ADHD in clinical populations and, for example, in large population mental health studies. So that would be an exciting area for future research.

SPEAKER_02 43:23

And from a clinician perspective, me personally, I've found that learning more about autism and ADHD has really improved my understanding of young people. And also it's allowed me to develop my and grow my empathy. I'm able to now understand better where someone might be coming from when they're, for example, an autistic person might not be understanding the content or understanding what we're teaching and you know from a worksheet or from you know your your usual manuals. And instead, rather than trying to force the understanding, it's allowed me to be more aware of finding creative ways to connect to neurodivergent young people using mediums that are more relevant to them. For example, using analogies that draw on their special interests rather than trying to apply basic everyday example to help them understand. And that has been really effective. And now I feel as though my ability to build rapport with neurodivergent young people has also really improved, and my connection with them has also felt really good.

SPEAKER_00 44:31

We also found that young people with neurodivergent traits usually relate very well to these concepts as well. So they certainly welcomed the assessments and talking about neurodivergent and when we were able to engage them in the understood, and you know, they intended to become more open about their experiences and also more likely to engage with mental health services for the future.

SPEAKER_02 45:04

And so going forward, I believe, and Sonia as well, we both believe that it is important for psychiatrists, psychologists, and other mental health clinicians to receive training and experience related to autism and ADHD to improve our ability to recognize these conditions. There's lots of options for training. We know, for example, that the Autism Clinical Interview for Adults or ACIA is available through the University of Newcastle in the UK. And that's a pretty low-cost option for getting training in autism assessments. There's also the ADOS and ADIR, which are the two gold standard autism assessments. There is also the MIGDAS, which is one of the newer autism assessments that focuses more on differences rather than deficits.

SPEAKER_00 46:00

So we hope this has been useful for everyone listening and that you may have some of these options in the future.