Dr. Jeremy Sharp (01:22)
Hey everybody, welcome back to the testing psychologist. I am hosting a return guest today. Dr. Sarah Woods is here with me to talk about ADHD, the combination of autism and ADHD, what that looks like, clinical presentation, diagnostic pitfalls, things that we might miss, and many other facets of this topic. So this is something that has been coming up more and more frequently, both
Out in the world and within the clinical realm as well. We were just talking about this as you’ll hear on the episode during one of our testing consultation meetings at my practice a few months ago. And I’m guessing that you have encountered this this construct as well if you’re doing clinical work with kids or adults. So let me see, I’ll tell you a little bit about Sarah. Sarah has been here before, and you may have caught her previous episode on autism, and that is a good one.
So go back and check it out if you haven’t listened to it. But Sarah’s a clinical psychologist at the University of Washington Autism Center. She’s in private practice at Discover Psychology as well.
She specializes in neurodiversity affirming differential diagnosis across the lifespan with expertise in autism and ADHD, of course. She also offers consultation and training to other professionals and community members.
So you’ll hear toward the end of the episode. Sarah is doing an upcoming training in October at the Chicago School or through the Chicago School of Professional Psychology. And she has a discount code for our listeners that’ll give you 15% off the training if you enjoy the content here in the podcast. So definitely go and check that out. like I said, we talked about the concept of Aud. So we do a definition there, what it is, how it’s different from
Autism and ADHD as separate diagnoses. We get into a discussion of whether it’s a a third diagnosis or presentation that we need to be aware of independent of those two diagnoses.
We talk about clinical presentation across the lifespan, and Sarah gives some examples at toddlerhood, childhood, adolescence, and adulthood.
We talk about how to assess questions that we might ask and things that we might be looking for in the data. And we close with a discussion I think that’s relevant for a lot of us right now, which is you know how to navigate differing thoughts on diagnosis when a client comes in either having self-identified as autistic or ADHD or ADHD, when the data or our clinical judgment doesn’t necessarily line up with that and how we navigate that.
So lots to take away from this conversation as usual. All right, let’s jump to this conversation with Dr. Sarah Woods.
Dr. Jeremy Sharp (04:22)
Sarah, hey, welcome back to the podcast.
Sara Woods (she/her) (04:25)
Hey, thanks for having me.
Dr. Jeremy Sharp (04:27)
Yeah, good to have you back as always. yeah, I’m excited to talk about this topic. like I said, before we started to record, this came up in our testing consultation meeting with our staff. And it’s a kind of a hot topic these days for many reasons. So
Sara Woods (she/her) (04:42)
Yeah, definitely.
Dr. Jeremy Sharp (04:44)
let me see. I’ll I’ll start with a question I always start with, which is of all the things to focus on within our field, what drew you to this topic in particular? Why put energy here?
Sara Woods (she/her) (04:55)
Sure. So I think traditionally we’ve talked about ADHD and autism as these kind of two separate diagnoses. And for a while, we were kind of forced to pick between one or the other in the DSM
Dr. Jeremy Sharp (05:06)
Mm-hmm.
Sara Woods (she/her) (05:07)
IV. And I started seeing more people talking about this concept of Aud, especially online, like in the autistic community. And then I started seeing emerging research suggesting that this concept of Aud is actually a little bit more.
Than just adding ADHD to autism. So I started exploring some of the research, and of course, there’s been lots of research in general on co-occurring autism and ADHD, but it seems like it’s been relatively recently, and the information has come from the community that this may actually be sort of a third thing that we have to consider. So instead of just looking
Dr. Jeremy Sharp (05:45)
Mm-hmm.
Sara Woods (she/her) (05:45)
at is there ADHD, is there autism?
Is there both? We should ask, is there ADHD? This other potential sort of neurotype that should be considered. And then as I thought about that, I asked, how exactly do we do that? What are the implications of that? What does that mean for us as clinicians who want to do rigorous, evidence-based work and also respect the opinions of the community and these emerging constructs?
Dr. Jeremy Sharp (06:13)
Mm. Yeah, well said. I feel like that I mean, that was a fantastic answer. That basically laid out the agenda for our entire conversation, which is fantastic. Thank you for that. but yeah,
Sara Woods (she/her) (06:24)
Come on.
Dr. Jeremy Sharp (06:25)
I don’t I don’t think you’re alone. I don’t think you’re alone. like I alluded to with our conversation and our consult meeting, this is something that’s coming up more and more.
I’m seeing it a lot like on the internet, you know, like where people are either self identifying as Audi H D or, you know, it’s coming up in clinical circles to some degree. so there’s a lot of lot of energy behind it. You know, I’m really curious to
Sara Woods (she/her) (06:48)
Yeah, definitely.
Dr. Jeremy Sharp (06:49)
to dig in.
Sara Woods (she/her) (06:50)
Yeah.
Dr. Jeremy Sharp (06:52)
So maybe we could do a a a little definition here and that will open up a couple related questions. So when just lay it out for folks, like when you say Audi HD, what what are we talking about exactly?
Sara Woods (she/her) (07:06)
Yeah, sure. So Aud essentially just means ADHD plus autism. This this construct of both of them together. And the implication that kind of goes along with the term Audi HD is the idea that this is a thing that should be considered on its own, in addition to just thinking of it as ADHD plus autism. So we
Dr. Jeremy Sharp (07:29)
Mm-hmm.
Sara Woods (she/her) (07:30)
see this as you mentioned in podcast culture in the community where people are identifying as Aud as this specific definition. And so I think we’re still figuring out what exactly does it mean when we say ADHD. Some of the qualitative that research that I did actually explored what do people in the community mean when they say Aud. So
Dr. Jeremy Sharp (07:53)
Mm.
Sara Woods (she/her) (07:54)
yeah, so I I did some research on Twitter and I specifically looked at the phrase
Aud is. And then I looked to see what people would say. And there was a huge range of different types of descriptions of how people were talking about Aud. So I really see
Dr. Jeremy Sharp (08:10)
Yeah.
Sara Woods (she/her) (08:11)
it as kind of an emerging construct that we’re still figuring out as a community, as a research community, and as a whole.
Dr. Jeremy Sharp (08:19)
Sure, sure. first of all, good for you for being brave enough to spend any time on Twitter. I feel like that’s
Sara Woods (she/her) (08:25)
Yeah.
Dr. Jeremy Sharp (08:27)
a complete chaos animal right now. so first of all, good good for you. second of all, can you do you have any of those responses handy, like you know, to get a sample of like how the community at large is describing Audi HT qualitatively?
Sara Woods (she/her) (08:41)
Yeah,
yeah, sure. So people talked about Audi HD as kind of a tension between two different themes. So that that was a theme that kept coming up. So a tension between like a quest for novelty and a need for routine, for example. and a a need for organization and then difficulty with organization and
Dr. Jeremy Sharp (09:05)
Mm.
Sara Woods (she/her) (09:06)
one one of my favorites was someone talking about Audi HD as cat dog. I don’t know if you remember that cartoon, the 1990s Nickelodeon cartoon, cat dog. It’s you remember that? It’s like this character
Dr. Jeremy Sharp (09:17)
Yeah, I do. Sadly, but
Sara Woods (she/her) (09:20)
that’s like made made up of a cat and a dog, and they’re kind of attached
Dr. Jeremy Sharp (09:23)
Mm-hmm.
Sara Woods (she/her) (09:24)
to each other. So so the person said, I think they said autism is like a cat and ADHD is like a dog, and Audi HD is like the 1990s Nickelodeon.
cat dog. So kind of these this two combination,
Dr. Jeremy Sharp (09:37)
Mm-hmm.
Sara Woods (she/her) (09:38)
this combination of two very different things, kind of being pulled in different directions. But also if they can cooperate, they can work really well together and and overcome obstacles and achieve goals and things like that. So the tension kept coming up. People kept talking about tension between two different things. People also talked a lot about pleasure actually associated with Aud, particularly around interests.
So
Dr. Jeremy Sharp (10:03)
Mm.
Sara Woods (she/her) (10:03)
that Audi HD really gave them a drive for curiosity, a desire to learn, a a tendency to sort of go down rabbit holes and experience great joy in going down those rabbit holes and and switching from one thing to another.
Dr. Jeremy Sharp (10:17)
Yeah.
Sara Woods (she/her) (10:17)
another thing that came up was executive functioning problems repeatedly. Aud HD was defined by people as consisting of pretty consist consistent executive functioning problems that were
in in many ways pretty debilitating. So I was interested to see that people were were talking about this tension, talking about positive aspects of it, but also definitely talking about the difficulties associated with it too.
Dr. Jeremy Sharp (10:43)
sure, sure. Yeah. I like how you phrase that. Yeah, that tension makes a lot of intuitive sense. And of all the of all those descriptions, somehow the cat dog actually makes the most sense and resonates with
Sara Woods (she/her) (10:53)
Yeah.
Dr. Jeremy Sharp (10:54)
you know with me the most. That’s great. That’s great. just to be clear though, I mean, this is not a clinical concept at this point. Like we don’t have it’s not a diagnosis or anything like that. Like the best we have is, you know, are these separate diagnoses of autism or
ADHD and then often there’s kind of a dual diagnostic presentation, but we don’t have anything diagnostically to capture both of them together, correct?
Sara Woods (she/her) (11:17)
Yeah,
yeah. I I I would describe it kind of as an emerging construct.
Dr. Jeremy Sharp (11:21)
Yeah.
Sara Woods (she/her) (11:22)
so yeah, so like if we think of autistic burnout, for example,
Dr. Jeremy Sharp (11:26)
Mm-hmm.
Sara Woods (she/her) (11:28)
I was talking to Zach Sadiq the other day, an autistic social worker and community organizer, and he was pointing out that autistic burnout has been a concept in the autistic community for like 10 years. And then
Dr. Jeremy Sharp (11:39)
Mm-hmm.
Sara Woods (she/her) (11:40)
it’s relatively recently that Ray Maker and some other autistic researchers
I’ve kind of brought it into the research world and said, hey, this is really a thing. Let’s define it. Let’s figure out what it is. And now it sort of gains credibility and people are starting to take it more seriously and consider it clinically. And I I kind of see Aud as similar. So of course, people
Dr. Jeremy Sharp (12:00)
Mm.
Sara Woods (she/her) (12:01)
in the research world have been talking about co-occurring ADHD and autism for a while. That’s not a new thing. But now the community is saying, hey, there’s this thing called Aud. And now there are researchers like Emocratic.
For example, who are doing some qualitative research and asking people, you know, what is what is this Audie HD experience? How do we kind of define it? What are the boundaries and stuff like that? So my prediction is that we’ll continue to see it kind of gaining more credibility. I don’t think it’s gonna turn out to be a separate diagnosis like in the DSM6 or anything like that, but I
Dr. Jeremy Sharp (12:35)
Mm, mm-hmm.
Sara Woods (she/her) (12:36)
think it’s it’s valid and it’s worth our consideration because I do think there are important implications.
For clinical work and research, in terms of considering that when we’re trying to figure out people’s experience, I think it does make sense to ask a little bit more than just whether ADHD is present and whether autism is present? I think it makes sense to consider there’s also this tension and this other thing that seems to happen when they’re both there.
Dr. Jeremy Sharp (13:02)
Yeah, I think that’s where I get stuck with it. And I’d love to spend a little time here and and try to try to sort through those because I mean full disclosure, like we were in this again, consultation meeting with all my clinicians and this question came up and I very confidently, you know, which is typical for me, I’ll be very confident and not necessarily know what I’m saying, but I was very confident and I was like, I don’t know that this is a separate thing.
I think it’s, you know,
Sara Woods (she/her) (13:26)
Yeah.
Dr. Jeremy Sharp (13:26)
it’s just it’s autism and it’s ADHD. And then, you know, you have both, and that’s that’s a sure, like that happens, but is it a separate
Sara Woods (she/her) (13:32)
Yeah. Right.
Dr. Jeremy Sharp (13:34)
third thing that we need
Sara Woods (she/her) (13:36)
Yeah.
Dr. Jeremy Sharp (13:37)
to define differently? And so I’m excited to get your perspective on this because it seems like you you do consider it a third thing. Like it is qualitatively different than just having autism plus ADHD. Is that right?
Sara Woods (she/her) (13:51)
Yeah, yeah. And I’d say that’s that’s based on my experience with clients, talking about what what it’s like to be Audi H, to have to be both autistic and have ADHD. And it does seem like there’s something about that interaction of traits that makes things a little bit more complicated. So I think
Dr. Jeremy Sharp (14:09)
Mm-hmm.
Sara Woods (she/her) (14:09)
there is there are some clinical implications of that. So for example,
Dr. Jeremy Sharp (14:13)
Mm-hmm.
Sara Woods (she/her) (14:14)
asking people, you know, do you ever feel like you sort of have two different parts of yourself?
That are in competition with each other. and
Dr. Jeremy Sharp (14:21)
Mm-hmm.
Sara Woods (she/her) (14:21)
then I even bring up the example of novelty and routine. And
Dr. Jeremy Sharp (14:25)
Mm-hmm.
Sara Woods (she/her) (14:25)
that just really resonates with people. They’ll just feel like, yeah, you totally get me. I’ve seen that happen with so many people. and then
Dr. Jeremy Sharp (14:32)
Mm-hmm. Mm-hmm.
Sara Woods (she/her) (14:34)
I think there is something to paying attention to what the community is talking about. So if we have all of this huge population saying, Hey, this odd is a thing, I’m defining myself this way. One person said,
Finding out I am AudieHD is the most important thing that’s ever happened to me in my life. That was the person’s tweet. So there was something really important about that label for that person. So I I think
Dr. Jeremy Sharp (15:00)
Mm-hmm.
Sara Woods (she/her) (15:01)
there’s when when the community is talking about that, I think it makes sense for clinicians to pay attention. there is some recent brain research showing that it seems like there’s some differences in gray matter in people who are
Aud as opposed to just being autistic or just having ADHD. Lou et al. in 2025 found that. And I think in terms of looking at future research, it makes sense now for us to think about looking at co-occurring autism and ADHD, looking at how people are using this term ADHD. As you know, traditionally when people do autism research, they’re like, let’s just make it as simple as possible. So let’s just get rid of like
All of the people who also have ADHD. Let’s just not include them in the study. That’s what some people do. But when we look at how how common it is, it’s like it could be more than 50%. Some researchers are finding like 70% of autistic people also have ADHD. So if we throw out all of those people with ADHD, like that’s a huge portion of the autistic population. So I think,
Dr. Jeremy Sharp (16:06)
Great point.
Sara Woods (she/her) (16:07)
yeah, I think it’s important for research. And then in terms of diagnosis,
We know that when someone is diagnosed with ADHD early on, it tends to to delay their autism diagnosis by two
Dr. Jeremy Sharp (16:19)
Mm-hmm.
Sara Woods (she/her) (16:20)
years, even longer for girls. Where because
Dr. Jeremy Sharp (16:23)
Mm-hmm.
Sara Woods (she/her) (16:24)
of this diagnostic overshadowing that happens where people are like, yeah, they have ADHD, so everything can be explained by the ADHD. If they have social difficulties, that’s probably just ADHD. And then they miss
Dr. Jeremy Sharp (16:34)
Mm-hmm.
Sara Woods (she/her) (16:35)
the autism component because they’re trying to explain it all away. So I feel like if we bring in like
yeah, there is something that happens when you have both that that could really inform our practices in terms of diagnosing people. and
Dr. Jeremy Sharp (16:49)
Mm-hmm.
Sara Woods (she/her) (16:49)
then of course for medication and treatment, they’re DHD people are very fun to interact with and also often very complex. So we don’t necessarily just wanna throw all the AHD treatments, all the treatments for autism at them and just hope that something works, right? I think it makes sense to
Dr. Jeremy Sharp (17:07)
Mm-hmm.
Sara Woods (she/her) (17:07)
figure out what works for this specific population including medication, but also other types of executive functioning interventions and supports for sensory processing differences and things like that. So did I bring you over? Okay. Yeah.
Dr. Jeremy Sharp (17:21)
Sure, sure. I I don’t know. I don’t know. I’m still I still wrestle with it.
I’m maybe maybe I’m just too concrete or something, but yeah, I still struggle with out
Sara Woods (she/her) (17:31)
Yeah. Yeah.
Dr. Jeremy Sharp (17:35)
with how how it’s a it’s a different construct. The but the most compelling thing is maybe the the functional research on the brain. You know, if we
Sara Woods (she/her) (17:44)
Yeah, yeah.
Dr. Jeremy Sharp (17:44)
are saying like, okay, this is this is a different
different presentation, you know, p physiologically than
Sara Woods (she/her) (17:51)
Yeah. Yeah.
Dr. Jeremy Sharp (17:52)
just having aut autism plus ADHD. yeah. Yeah, it’s go ahead.
Sara Woods (she/her) (17:56)
Yeah. And and yeah, sorry.
J just to be clear, I’m not suggesting that when we see people, we’ll say like you’re not autistic or ADHD, you’re Audi HD, which is this totally different thing. I’m not suggesting we do that. I’m just suggesting that when we’re looking at autism and ADHD, it makes sense to also consider some of these other elements of, you know, how how they interact. And if people have heard this construct in the community and said like, hey, I heard this Audi HD thing, what’s this about?
You know, kind of
Dr. Jeremy Sharp (18:25)
Mm-hmm.
Sara Woods (she/her) (18:25)
explaining that for them or even preemptively explaining that you may see this come up and here’s what it means.
Dr. Jeremy Sharp (18:32)
Mm-hmm. Mm-hmm. Yeah. So maybe I’m asking the wrong question, or maybe it’s a just a semantic difference or something. Like that it sounds like you’re saying like there is a a qualitative an experience when someone has been diagnosed with both autism and ADHD that is different than having either of them independent of one another, of course.
Sara Woods (she/her) (18:52)
Yeah.
Yeah, that’s what I’m saying.
Dr. Jeremy Sharp (18:54)
Yeah, yeah. So maybe I’m getting a little bit lost in that. Like I’m I’m trying to make a distinction between like again, is it like a a th a third a third element that we’re just not we just don’t understand enough yet? Like a like a separate diagnosis almost or a separate, you know, a separate thing that is somehow mashing together both sets of symptoms and it it is actually, you know, different than just having both diagnoses at
Sara Woods (she/her) (19:23)
Yeah.
Dr. Jeremy Sharp (19:23)
the same time.
Sara Woods (she/her) (19:24)
Yeah, exactly. Yeah. Emma
Dr. Jeremy Sharp (19:26)
Yeah.
Sara Woods (she/her) (19:26)
Cratic talks about it like as if it’s a different color. Like when you add red and blue, you get purple,
Dr. Jeremy Sharp (19:32)
Mm.
Sara Woods (she/her) (19:32)
which is like a totally different color. I I would say to me it’s a little bit more like tie dye, like red and blue tie dye. Like if you mix them together, you get some elements that are purple. So something that’s a little
Dr. Jeremy Sharp (19:42)
Mm-hmm.
Sara Woods (she/her) (19:43)
different. And then there’s also you retain parts of the ADHD. So you still see some of the red, your pink you retain parts of the
blue that goes along with autism so you
Dr. Jeremy Sharp (19:52)
Mm-hmm.
Sara Woods (she/her) (19:52)
just get this whole sort of pretty picture and sort of complicated picture of all these overlapping things happening and we want to pay attention to all of
Dr. Jeremy Sharp (20:01)
Mm-hmm. Yeah, that makes sense. Do you guys I I was thinking, like, why why is it these two diagnoses that have gotten so much attention and and gotten
Sara Woods (she/her) (20:12)
Yeah.
Dr. Jeremy Sharp (20:12)
their own portmanteau, I guess, like of Aud H D. Like like you know what I mean? Like why don’t we have why is there no like Andy H D or O C D H D or you know what I mean? Like why
Sara Woods (she/her) (20:23)
Yeah.
Dr. Jeremy Sharp (20:24)
why this versus anything else that is o that often co occurs w you know what I mean?
Sara Woods (she/her) (20:29)
Yeah,
I think that’s a really good question. I think we’re getting more attention lately on the strengths and the positive aspects that go along with autism and ADHD, more so than obviously other diagnoses like OC. So I think people are a little more inclined to be interested now in by being diagnosed in one or the other. I also think they’re they’re quite common, right? There’s some research that would suggest like,
About 10% of the population has ADHD, and maybe like 3% or so is autistic, or or two or three percent. So when you think about that, that’s pretty common. And and then about 20% or so of people with ADHD are are expected to also be autistic. So that’s a pretty huge portion of the population that would that would fall into that category. So I think it’s a combination of the fact that it’s genuinely common.
And also it’s getting more attention lately and particularly the positive aspects of these neurotypes are getting attention. So people are like, Hey, this might not be so bad if I get this diagnosis. And of course
Dr. Jeremy Sharp (21:33)
Mm.
Sara Woods (she/her) (21:33)
it opens supports and things like that and community too.
Dr. Jeremy Sharp (21:38)
Yeah, yeah. It seems like there is something about these two diagnoses that have a little more gravitas behind them or like more of a like a self-identified community or something, you know.
Sara Woods (she/her) (21:48)
Yeah, yeah, definitely.
Dr. Jeremy Sharp (21:50)
Yeah, yeah. I’m not sure if yeah, like anxiety and depression or OCD or even bipolar, you know, like I don’t get
Sara Woods (she/her) (21:57)
Who
Dr. Jeremy Sharp (21:58)
the sense that those diagnoses necessarily have the the the community aspect or the the
self identity that that autism and ADHD do. I’m I’m totally thinking out loud though. I could be wrong.
Sara Woods (she/her) (22:09)
Yeah. Yeah,
I totally agree with you. I think that makes a lot of sense. And and actually that’s one of the things that came up in my tweet research. A lot of people talked about the importance of community. One person talked about feeling like they they grew up as an orange on an apple tree. And then
Dr. Jeremy Sharp (22:25)
Hmm.
Sara Woods (she/her) (22:26)
being part of the Audi H D community helped them meet all of their other oranges and and allowed them to be part of people that that their neurokin, other people who they really related
Dr. Jeremy Sharp (22:36)
Mm.
Sara Woods (she/her) (22:36)
to. So
I definitely think the community piece is important. Yeah.
Dr. Jeremy Sharp (22:40)
Sure, sure.
Well maybe we move to a little bit more into clinical presentation. So you’ve touched on this a bit and it seems to be
Sara Woods (she/her) (22:46)
Yeah, sure. Mm-hmm. Mm-hmm.
Dr. Jeremy Sharp (22:49)
characterized by this tension, you know, and push pull. tell
Sara Woods (she/her) (22:51)
Mm-hmm. Yeah.
Dr. Jeremy Sharp (22:53)
us more about the clinical presentation.
Sara Woods (she/her) (22:56)
Yeah, sure. So I think in particular in little kids we’ll see a lot of what presents sort of as extroversion or hyperactivity. So the hyperactive impulsive traits are often more observable. And so we’ll see these kids that might sort of run around and seem super friendly. They might be willing to kind of talk to anybody and you know, really engage and and show a lot of joy in interacting, particularly in physical play.
Dr. Jeremy Sharp (23:23)
Mm-hmm.
Sara Woods (she/her) (23:24)
and then I think partly because they can often seem so friendly and energetic that the autism piece gets missed. So they’re getting that ADHD diagnosis pretty early on, and then people say, they’re so friendly, everybody knows their name. So, you know, they couldn’t be autistic. but then when we start to pay a little bit more attention to like how long are they actually engaging in back and forth play with other kids and how are their social communication skills actually working.
And we start to see things like there they might be getting in other children’s space. they might be able to sit for circle time when it’s time for their favorite song, but otherwise they’re having a really hard time sitting at circle time. So there’s more kind of subtle autistic features that might be present that are being missed because the ADHD seems so prominent.
Dr. Jeremy Sharp (24:14)
Mm. Mm-hmm. That’s a great example. Yes. I think of the kids, I could be generalizing, of course, but you know, we see a lot of kids or adults of course on the spectrum who are like very socially motivated, but not necessarily socially reciprocal. And it o that it brings that to mind, you know, as you describe.
Sara Woods (she/her) (24:30)
Yes, exactly. Yeah, yeah.
Right. Yeah. And and I think in adolescence we can see that too. And we we often start to see more masking showing up in adolescence. So I think people sometimes miss that where people will be adolescents will be able to engage particularly around their focused interests. And they might talk at length about their focused interests with people they’re comfortable with, for example.
but then when they they go to school, they might kind of really be putting a lot of thought into how they’re interacting, but they can’t completely be themselves because they’re constantly thinking, like, Am I making enough eye contact? And then at the same time, they have the executive functioning problems that can kind of get in the way of being successful academically, even though they might actually have the academic skills there. And so we start to see a lot of depression and anxiety emerge around adolescents.
people Aud adolescents or adolescents who are autistic with co-occurring ADHD are more likely to have co-occurring presentations than people with with just ADHD or just autism. So the depression, anxiety, sometimes OCD, other types of difficulties happening. the other thing that shows up that I think makes things particularly complicated is the sensory profile can often be kind of all over the place.
Dr. Jeremy Sharp (25:51)
Mm-hmm.
Sara Woods (she/her) (25:51)
So they’ll be really, really sensitive to certain types of sensory input. they’re even often more sensory avoidant than autistic people. but then they’re also very sensory seeking. So we’ll see these kids like running and banging and crashing into things on purpose or really enjoying music really loud, particularly if they choose it. And so
People, if you ask, if you just ask a parent, is your child sensitive to sounds, they might say, No, they they listen to their music like so loud in their bedroom. They’re not sensitive to sounds at all. But then if you ask a little bit more, like, yeah, the sound of the blender or the vacuum actually drives them insane. So we have to be careful about how we’re asking our questions and how specific we allow people to be in order to get a picture of what their experience is actually like.
Dr. Jeremy Sharp (26:43)
Yeah, yeah. This is helpful. So we talked about kids, adolescents. Is there what about adults? how are you seeing the clinical presentation in adults?
Sara Woods (she/her) (26:53)
Yeah, I think it varies quite a bit depending on whether they’re able to find their niche. So I’m seeing a lot of clients in private practice who’s who’ve been able to find their niche and really thrive in a lot of ways, particularly like software engineers and video game designers and things like that. If they have a really strong focused interest, they can often engage in that for hours and hours at a time and and not have any problems with attention.
But then when it comes time to organizing their space, their desk could be just a complete mess or they have trouble keeping up with chores or or basic kind of daily living types of activities. And in some cases, they have a spouse who’s super supportive and willing to kind of almost be their executive functioning. And that that can work out well for people in some cases, as long as they don’t rely too much on another person.
But I think they also ha have difficulty with social interaction in particular context. So for example, I’ve seen clients who really thrive if they’re going to trivia and there’s a particular activity that they’re doing. They get to show their fund of general knowledge. They absolutely love it. There’s a clear start time and end time. But then when they’re in a small talk situation and they have to sit around and just talk about whatever, they absolutely either fall apart or they put in so much work that they end up being exhausted and like can’t function for a couple of days afterwards because they’re so tired. So
I guess in adulthood there’s huge amounts of variability and I think it really depends on whether they’re able to find an environment that feels comfortable for them and that is really a good fit for their neurotype.
Dr. Jeremy Sharp (28:33)
Yeah, that makes sense. How do you have a sense of how the combination affects the concept or presentation of special interests or hyper focus? I see there’s kind of some overlap there. Yeah. Any thoughts on that?
Sara Woods (she/her) (28:46)
Yeah. Yeah, definitely.
Yeah, I’ve seen some sort of intense interests and then lots of switching. So like they’ll
Dr. Jeremy Sharp (28:56)
Mm-hmm.
Sara Woods (she/her) (28:56)
get really, really into a particular topic. It’s all they want to talk about. And then so that’s kind of the autistic part. And then the ADHD part comes in and has that need for novelty. So it’s like switching things up and all of a sudden they’re like out of nowhere, really, really into another interest all of a sudden.
or sometimes they’ll be able to combine their interests. some people talked about being able to sort of harness the ADHD part in a way that complements the autistic part. So they get really, really focused on an interest and then they’re able to sort of use that need for novelty to be able to pull themselves away and sort of switch it up and get into something else. the other thing that I think is really important for us to consider.
is socioeconomic status and how that interacts with the special interest piece. Because, like for example, in private practice, I’m seeing I tend to see more privileged people. So they’re in a situation where they often have been able to use their special interest in their work. So they’re spending 10 hours a day designing video games and they love video games, right? And that works out really well. But for
Dr. Jeremy Sharp (30:01)
Mm-hmm.
Sara Woods (she/her) (30:02)
other people, for example, I also see some people with Medicaid and
And people who are have lower incomes in other places. And they’re just not in a situation where they’re able to engage in their interests. So they would they would love to engage in their interests all day long, but they’re doing some other type of job that doesn’t allow for that, and then they might have other executive functioning demands that are directly related to their socioeconomic status, so having to figure out bus schedules, having to figure out
how to get access to different financial supports they needs and they need and all of those types of factors.
Dr. Jeremy Sharp (30:39)
I like that you bring up the socioeconomic differences. Yeah.
Sara Woods (she/her) (30:43)
Yeah.
Dr. Jeremy Sharp (30:43)
I think that I haven’t personally thought about special interests through that lens before. And that’s got me yeah, that’s really got the wheels turning and almost like the yeah, privilege, I suppose, of being able to
Sara Woods (she/her) (30:55)
Right.
Dr. Jeremy Sharp (30:56)
focus on your special interests. And that just leads to, I guess, less tension or friction in someone’s
Sara Woods (she/her) (31:02)
Mm-hmm.
Dr. Jeremy Sharp (31:02)
work life or, you know, work versus personal life.
Dr. Jeremy Sharp (32:25)
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Sara Woods (she/her) (33:30)
Yeah, exactly. And then if you have a lot of sensory needs but you’re pretty financially privileged, you can
Dr. Jeremy Sharp (33:35)
Mm-hmm.
Sara Woods (she/her) (33:36)
have quite a bit of control over your sensory environment. You know, I’ve had people who found a particular
Dr. Jeremy Sharp (33:40)
Mm-hmm.
Sara Woods (she/her) (33:42)
fabric that they love and so they just buy like a uniform of that fabric and wear that all the time. Or, you know, they
Dr. Jeremy Sharp (33:48)
Mm-hmm.
Sara Woods (she/her) (33:49)
they’re able to work from home and they’re able to set up the lighting in in a way that’s really comfortable for them and
Dr. Jeremy Sharp (33:55)
Mm-hmm.
Sara Woods (she/her) (33:56)
the temperature and
when they interact with people it’s very predictable. They have specific meetings, they know when it’s gonna happen. So all of those actually
Dr. Jeremy Sharp (34:04)
Mm-hmm.
Sara Woods (she/her) (34:05)
play a role, I think.
Dr. Jeremy Sharp (34:07)
Yeah, I wonder if we might pull on this thread for a little bit longer. this is
Sara Woods (she/her) (34:12)
Yeah.
Dr. Jeremy Sharp (34:12)
kind of interesting now that we’re getting down this path. Do you yeah, are there have you thought about other other ways that socioeconomic status or money or you know, privileges privilege, et cetera, like influences presentation of of these diagnoses?
Sara Woods (she/her) (34:28)
Yeah, I I think in terms of social interaction, I think it plays a role. You know, like if you’re working a low paying job and you have to work really long hours, it can be really hard to find time to meet people. And we know for Aud people and autistic people that special interests are often a great kind of bridge and way to connect with people. So if you
Dr. Jeremy Sharp (34:48)
Mm-hmm.
Sara Woods (she/her) (34:49)
can spend time engaging in a hobby, if you can
go skiing if you can do if you can buy all the supplies for your niche craft that you want to do and meet up with other women who are doing that craft, you know, you have lots of opportunities for those bridges. But if you’re working long hours, you don’t have a lot of extra money for hobbies, you don’t have a lot of extra time or maybe even energy for hobbies, I think it can be a lot more isolating for people.
Dr. Jeremy Sharp (35:16)
Mm. Mm-hmm. That’s a great point. I even think about maybe one step deeper and access to transportation whenever you need it and
Sara Woods (she/her) (35:21)
Yeah. Yeah, exactly. Right.
Dr. Jeremy Sharp (35:26)
ability to get to the places where these meetups might be happening and
Sara Woods (she/her) (35:30)
Mm-hmm.
Dr. Jeremy Sharp (35:31)
activities might be happening. Yeah, yeah. Yeah. This is that’s really got me got me thinking about this. yeah, I’m maybe disappointed in myself, you know, the haven’t really considered the implications before.
but it there’s a lot to lot to digest with that.
Sara Woods (she/her) (35:47)
Yeah, I think you have good insight into it. Yeah.
Dr. Jeremy Sharp (35:50)
Yeah,
yeah. I appreciate that. So
Sara Woods (she/her) (35:52)
Yeah.
Dr. Jeremy Sharp (35:53)
okay, so are there other aspects of the clinical presentation that feel important to mention before we transition to where we might get stuck as clinicians or miss things and you know, miss miss diagnoses and so forth.
Sara Woods (she/her) (36:06)
yeah, I think the main thing is is probably there’s just a huge amount of diversity. So it’s really hard to say, you know, this is specifically what Audi HD looks like at this age. so
Dr. Jeremy Sharp (36:17)
Mm-hmm.
Sara Woods (she/her) (36:18)
yeah, I think we we wanna be willing to consider that there are all other all different other factors that interact with the experience of being Audi H D and there’s there’s cultural considerations and of course there’s personality factors that play a role, like how introverted or extroverted someone is and
Dr. Jeremy Sharp (36:35)
Right.
Sara Woods (she/her) (36:36)
you know, what their family is like, what their what their community is like. So there’s not really kind of one size fits all in terms of what it looks like.
Dr. Jeremy Sharp (36:45)
What about gender differences? Do we know much in that realm?
Sara Woods (she/her) (36:49)
Yeah, I think that’s that’s definitely an important issue to consider. I think there is research to suggest that women tend to mask to a greater degree than men, in general, but there definitely are high masking men and I’ve definitely seen many of them. but I think women and girls are kind of socialized in general to think a lot about the influence you’re having on other people, make sure you’re coming across as nice and kind to other people.
So put a lot of thought into how you’re socializing. And I think women and girls tend to get a little bit more direct instruction in terms of how to socialize. And boys and men might be kind of left to to figure it out on their own a little bit more. And so there’s both advantages and disadvantages that go along with that. But I think that’s
Dr. Jeremy Sharp (37:32)
Mm.
Sara Woods (she/her) (37:32)
important to t keep in mind.
Dr. Jeremy Sharp (37:35)
Sure, sure.
So maybe we move to more of an explicit discussion around the diagnostic process and yeah, misconceptions, misinterpretations, things we might get tripped up on as clinicians in this diagnostic process. Yeah, you can take that wherever you’d
Sara Woods (she/her) (37:50)
Yeah, that sounds good.
Dr. Jeremy Sharp (37:51)
like.
Sara Woods (she/her) (37:52)
Yeah. so I think diagnostic overshadowing is a big thing to consider. And I I mostly sorry, go ahead. Yeah.
Dr. Jeremy Sharp (37:59)
And g can you define that for people just in case, you know, folks out there may not know what you’re talking about
Sara Woods (she/her) (38:04)
Yeah, so it’s kind of the idea that someone gets one diagnosis and then that becomes the explanation for everything.
Dr. Jeremy Sharp (38:11)
Mm-hmm.
Sara Woods (she/her) (38:11)
So I especially see that happening with ADHD. So someone’s labeled as having ADHD, and then when autistic features start to emerge or people start to notice autistic features, the autism itself gets missed because it gets explained by the ADHD. So we say like, this this child is having trouble with back and forth conversation and making friends.
And people dismiss that and say, yeah, well, people with ADHD have trouble with that too. So it’s probably just because of the ADHD. And just kind of not considering that, hey, not only is it possible that it could be both, but there’s research to suggest that it may might even be that most autistic people are both are both autistic and have ADHD. So it’s not at all unusual. So we definitely need to have that on our radar.
Dr. Jeremy Sharp (39:01)
Yeah, that’s important. I mean, what the statistic you gave earlier, the seventy percent of folks, autistic folks also have ADHD. I mean that that the math works out. Mm-hmm. Mm-hmm. Certainly. Yes.
Sara Woods (she/her) (39:08)
Yeah, yeah, some research suggests that for sure. Yeah.
Dr. Jeremy Sharp (39:13)
yeah. Anything else to say on yeah, diagnostic pitfalls. Sorry. as we move on to a kind of a broader discussion. Thanks for defining the diagnostic overshadowing.
Sara Woods (she/her) (39:22)
Yeah. Yeah, yeah, sure.
Dr. Jeremy Sharp (39:24)
Yeah.
Sara Woods (she/her) (39:25)
Yeah. I I think a lot of people miss masking and masking gets kind of a bad rap because I think people are concerned that there’s not enough research behind it. And I definitely agree that we need more research to figure out a little bit more about how to measure it and how to make sure
Dr. Jeremy Sharp (39:42)
Yes.
Sara Woods (she/her) (39:42)
that autistic masking, how we can make sure that when we’re measuring autistic masking.
It’s not just the masking that goes along with anxiety and stuff like that, how to kind of tease
Dr. Jeremy Sharp (39:51)
Mm-hmm.
Sara Woods (she/her) (39:51)
that apart. I totally agree with that. And at the same time, I don’t think that means that we throw out the concept of masking altogether. So I think it’s it’s definitely an important construct to consider. And so if people just give a bunch of quantitative questionnaires and they’re only looking at those standardized scores and they’re not kind of paying attention to the internal experience of what it’s like to be autistic, the work that the person is putting in, maybe how exhausted the person is, then they might really miss the whole picture of what what it might be like to be that person.
I had a client who was just extremely bright and an exceptional master. And he kind of cosplayed in this role as this really funny, outgoing guy. but when I when I talked to him about his experience,
He was putting in so much effort to play this role that he had kind of constructed over time that he was chronically depressed and often suicidal because he thought,
Dr. Jeremy Sharp (40:50)
Mm.
Sara Woods (she/her) (40:50)
well, everybody really likes me, but that’s not actually me. That’s this mask
Dr. Jeremy Sharp (40:54)
Mm-hmm.
Sara Woods (she/her) (40:55)
I put on. So I don’t even know what my real self is or peop if people really like myself. So I think it’s really important to ask questions about that. And w one tool for that would be the cat cue, the camouflaging autistic traits questionnaire.
We know that actually the research shows that Cat Q does not completely reliably differentiate masking that goes along with autism from masking that goes along with anxiety. So I use it both quantitatively and qualitatively. So I have people rate themselves on the statements, but I’ll also ask them for specifics about what’s going on in various scenarios. And that can be a lot more telling than just kind of looking and seeing: like, is this score in
Is it similar to how autistic women tenderweight themselves or that kind of thing?
Dr. Jeremy Sharp (41:41)
Yeah, yeah. I appreciate you making making that distinction and you know, keeping us honest, so to speak, with the cat cue that it’s yeah,
Sara Woods (she/her) (41:47)
Yeah. Yeah.
Dr. Jeremy Sharp (41:48)
I mean, we need more research for sure on that.
Sara Woods (she/her) (41:51)
Yeah, definitely.
Dr. Jeremy Sharp (41:53)
but yeah, I I think the qualitative experience is really helpful, right? And asking folks what they’re what
Sara Woods (she/her) (41:58)
Yeah, definitely. Yeah. And there
are some emerging measures of masking in children too. The I think it was Hall and all Hall et al who created the cat cue. I think they also recently came out with one for children that’s still being refined and probably will be clinically useful in the future for sure.
Dr. Jeremy Sharp (42:18)
Are there other pitfalls we might run into in this diagnostic process?
Sara Woods (she/her) (42:22)
Yeah, yeah, there’s two others I’d like to talk about. one is the the opposite of diagnostic overshadowing, which I like to call double counting. And that’s where yeah,
Dr. Jeremy Sharp (42:32)
yeah.
Sara Woods (she/her) (42:33)
you you see a trait and then you count it in both categories. So like a child is having, let’s say you have a child who actually has ADHD and they’re having trouble with back and forth conversation.
And maybe interrupting people, and you count the interrupting under the ADHD category, but you also count the having trouble with conversation under the autism category. You take the
Dr. Jeremy Sharp (42:56)
Mm-hmm.
Sara Woods (she/her) (42:56)
same symptom and you put it in both categories. And that’s fine to do a little bit here and there, but if you’re doing that for every single trait, then you might actually accidentally diagnose a person with both autism and ADHD when really it’s just ADHD. So
Dr. Jeremy Sharp (43:12)
Mm-hmm.
Sara Woods (she/her) (43:13)
you have to be careful of that one too.
Dr. Jeremy Sharp (43:15)
I appreciate you bringing that up. Yeah. That makes me think of a question that come up comes up a lot, I think, for for us, maybe for you and listeners as well. But kind of discerning what executive functioning challenges are to be expected with autistic individuals and what executive functioning challenges kind of go beyond that where we might you know, where it where it may
qualify for an ADHD diagnosis as well. Have you thought much about that?
Sara Woods (she/her) (43:43)
Yeah, that I would say that the research shows in general that people who are autistic and also have ADHD, so ADHD people, have a ton of executive functioning problems. So they they actually have executive functioning problems that are even worse in general than people who just have ADHD and also
Dr. Jeremy Sharp (44:03)
Mm-hmm.
Sara Woods (she/her) (44:03)
worse than people who are just autistic. That’s kind
Dr. Jeremy Sharp (44:06)
Mm-hmm.
Sara Woods (she/her) (44:06)
of the general trend.
but I and in particular we know that there are certain executive functioning problems that seem to go along with autism, like shift. So moving from one activity to another or switching your attention from one thing to another.
Dr. Jeremy Sharp (44:21)
Uh-huh.
Sara Woods (she/her) (44:22)
but I don’t think we have concrete research to show that if they show this many elevations on the brief, that means that it’s that it’s Audi HD as opposed to just autism.
So I would
Dr. Jeremy Sharp (44:34)
Yeah.
Sara Woods (she/her) (44:34)
look more at the diagnostic criteria. So I use things like the diva or the cars, I mean diva and the cars actually. And kind
Dr. Jeremy Sharp (44:42)
Mm-hmm, mm-hmm.
Sara Woods (she/her) (44:42)
of get do collateral interviews and kind of look at all the information together and just see if we can if we can check off the diagnostic criteria in a way that doesn’t involve just kind of using the same trait under both categories, if that makes sense.
Dr. Jeremy Sharp (44:58)
It does make sense. Yeah. Yeah. And even that discussion the that you touched on around like, yeah, individual autistic individuals might be more likely to have trouble with flexibility or
Sara Woods (she/her) (45:09)
Yeah.
Dr. Jeremy Sharp (45:09)
you know, rigidity, you know, kind of two sides of the same point. versus, you know, not all autistic folks are disorganized, for example, or, you know, impulsive unnecessarily.
Sara Woods (she/her) (45:17)
Right. Yeah.
Dr. Jeremy Sharp (45:20)
and th those things may, you know, be
red flag, so to speak, for an additional ADHD diagnosis. Sure, sure.
Sara Woods (she/her) (45:27)
Yeah, definitely. Yeah. And then
yeah. The the final thing and one of the most important things that I think people miss is forgetting to look for strengths. And
Dr. Jeremy Sharp (45:37)
Hmm.
Sara Woods (she/her) (45:38)
I think there’s good reason for that because you know, we’re taught to just look at autism and ADHD as a bunch of problems. We know now there’s emerging research that shows that autism is associated with lots of strengths. The research on ADHD is a little bit newer, but there’s definitely a lot of research.
To show that ADHD is associated with strengths like hyper curiosity, for example, the desire to learn, a desire for novelty that can be used in a positive
Dr. Jeremy Sharp (46:04)
Mm-hmm.
Sara Woods (she/her) (46:05)
way, and things like that. And so I’m excited to see more research on Audie HD strengths. What kind of strengths do we get when we combine these two things together? And so I think that we wanna be specifically asking people about strengths.
about their general strengths, but also exploring strengths that go along with one neurotype or the other and considering that as part of the broader picture.
Dr. Jeremy Sharp (46:28)
Yeah, yeah, yeah. I mean, have you been able to identify any specific strengths? I know everyone’s different, of course, but at least broad categories of of strengths that tend to go along with the Aud profile?
Sara Woods (she/her) (46:40)
Yeah, I was actually interviewing a colleague of mine, Dr. Lucas Harrington, who was sharing he he’s Audi HD, and he was sharing with me that his autism helps him get really, really into certain topics. And so he’s able to learn a lot about it and really retain a lot of information because he really enjoys it. But then the ADHD part of him sort of
acts almost like a little kid that says like let’s switch it up, let’s make it more interesting. And then
Dr. Jeremy Sharp (47:09)
Mm-hmm.
Sara Woods (she/her) (47:09)
so he takes his interest and then he’s motivated to sort of switch it up and learn something new, some something different. So he does 3D printing for example and he’s always coming up with cool 3D printing projects. And that little ADHD part of him said, Hey, let’s let’s start something new.
And so he decided to start making mouth models, you know, that SLPs use, speech language,
Dr. Jeremy Sharp (47:34)
Mm-hmm, mm-hmm.
Sara Woods (she/her) (47:36)
they use for helping children to figure out where to put their tongue when they’re speaking and stuff like that.
Dr. Jeremy Sharp (47:40)
Yeah.
Sara Woods (she/her) (47:41)
So he took an interest that he was already really super interested in, and then he said that he thinks it was the ADHD part of himself that said, Hey, let’s switch it up. We’ll still be engaging the interest, but we gotta try something new. And that that worked out really well for him. Yeah.
Dr. Jeremy Sharp (47:55)
Yeah, yeah, I
like that. That’s a great example. Yeah.
Sara Woods (she/her) (47:58)
Yeah.
Dr. Jeremy Sharp (47:59)
Nice. Okay. So we’ve talked about our pitfalls. anything else in that regard to chat about?
Sara Woods (she/her) (48:06)
I think the the main piece is just to really do a comprehensive assessment. So don’t over rely on SRS standard scores or Basque scores or even over rely on someone’s description of masking because you know, lots of people who experience anxiety will say that they always felt like they were different and that they have to put a ton of work into socializing. That doesn’t necessarily mean that they’re on DHD. So I think a really
a really accurate diagnosis is going to come from comprehensive, a lot of work, gathering a lot of different types of data and integrating it all together.
Dr. Jeremy Sharp (48:42)
Great. Yeah, that is a fantastic segue, I think, into the assessment process. And what what if anything looks different here? and you know, we could take it in terms of like interview strategies, testing, battery selection. yeah, either either of those will be great.
Sara Woods (she/her) (48:59)
Yeah, so I think the main thing I would do is take your autism battery, your battery that you use for autism, take your ADHD battery and use both of them. And then as you’re going through analyzing the data and talking to the person about their experience, consider that tension. So if you’re looking at their sensory experiences and they’re they’re talking about sensory avoidance, for example, considering
other aspects of their sensory experience too, like if they’re if they’re sensory seeking at the same time. Or like I said, if you just ask a simplistic question like, is your child bothered by sounds? And the parent says, no, they’re not, inquire a little bit more. Like what I I like some of the questions on the MiG disk, you know, like asking people about what sounds bother you and what sounds do you like. So getting a more comprehensive picture of of what their experience is.
So in general, I would include the autism battery, include the ADHD battery, put it all together. And as you’re looking at all those numbers, especially when they don’t line up nicely, ask yourself, could some of this be because of this tension between autism and ADHD? And then directly asking. So like I said, I’ll ask people, do you ever feel like there’s two parts of yourself kind of in conflict? Most people will say that they do in some way or another, right?
But then you explore, well, how do you see that? And bring up novelty versus routine and specific examples like that. Also asking parents, do you ever feel like there’s two different parts of your child? Like you see different parts of your child in different situations? How does that show up for you? And so kind of using some qualitative questions to get an idea about that tension. And I think one of the pieces that’s really important to consider is that this constructive ADHD.
as we’ve talked about, is really kind of an emerging construct. So I think we need more specific tools that we can use that capture this tension. And the research, as you know, takes a long time. So it’ll probably be a while before we have some Aud specific measures. But I’m excited to see what they’ll be over time.
Dr. Jeremy Sharp (51:06)
Mm, yeah, yeah. These are great ideas. I like the just the the idea of asking about tension and framing it that way or
Sara Woods (she/her) (51:14)
Yeah. Right.
Dr. Jeremy Sharp (51:16)
friction. Yeah. Yeah. I do wonder, you know, I’m always cautious, I guess, of leading the witness, so to speak, you know, and creating
Sara Woods (she/her) (51:23)
Yes.
Dr. Jeremy Sharp (51:24)
like a self-fulfilling prophecy, so to speak. Or, you know,
Sara Woods (she/her) (51:27)
Mm-hmm.
Dr. Jeremy Sharp (51:27)
people just agree with things because you give them an option. so I’ve got that in the back of my mind. and
Sara Woods (she/her) (51:31)
Yeah for sure. Yeah.
Yeah.
Dr. Jeremy Sharp (51:35)
No, you could apply that to any question we ask, I suppose.
Sara Woods (she/her) (51:38)
Yeah, definitely. So I I definitely think that’s partly why we don’t want to over rely on an answer to one particular question. We want to look at all
Dr. Jeremy Sharp (51:45)
Mm-hmm.
Sara Woods (she/her) (51:46)
the data and when we when we have an easy day, all the data lines up nicely. We have all the all the quantitative data
Dr. Jeremy Sharp (51:53)
Mm.
Sara Woods (she/her) (51:54)
and all the qualitative data make makes a nice easy picture. but it’s also fun to have a complex picture and that that ha happens often too, and then we have to do a bit of detective work to figure out what really makes sense here.
Dr. Jeremy Sharp (52:06)
Mm-hmm.
Sara Woods (she/her) (52:06)
And I do think we can be collaborative with people without kind of over-relying on them as their own expertise. I think it we can kind of balance the client’s expertise with our expertise as clinicians. So I do think there’s something to sort of giving them some information, getting feedback on their perception of the information and having a little bit of a back and forth that way without just deferring to whatever they think.
I do think some people think that neurodiversity affirming means just diagnosing everybody with autism or just confirming whatever the client already thinks. And I think that’s really doing people a disservice if we do that. But I do think there’s definitely room for collaboration and that that collaboration can actually lead to more accuracy.
Dr. Jeremy Sharp (52:52)
Yeah, I like that. I like that. I would I mean, I feel like we could do a whole conversation just on that topic, right? Like how to
Sara Woods (she/her) (52:58)
Yeah, for sure.
Dr. Jeremy Sharp (52:59)
how to collaborate without being blindly affirming. That’s huge. do
Sara Woods (she/her) (53:03)
Yes. Yes.
Dr. Jeremy Sharp (53:06)
you do you find any increased maybe pressure or difficulty with that dynamic?
Sara Woods (she/her) (53:14)
You know.
Dr. Jeremy Sharp (53:14)
with individuals, you know, in who might be in this?
Aud H D population.
Sara Woods (she/her) (53:19)
Yes, definitely. I think there’s a lot of pressure on clinicians in certain situations to diagnose to to assign a diagnosis that a person really relates to strongly.
Dr. Jeremy Sharp (53:31)
Yeah.
Sara Woods (she/her) (53:32)
yeah, because I think as you pointed out that there’s something specific about the Audi HD population that’s a little bit different than like anxiety or OCD. There’s there’s some kind of benefit to it and support that goes along with it that can make people really invested.
And I think there’s a few different things happening. One is I do think TikTok can be a good resource. And I will also say that I do think there’s research out there that says, or there’s there’s there’s videos out there that say that hey, if you do these 10 things, then you’re probably Audi HD. And it’s like things that like 70% of the population does. And so people
Dr. Jeremy Sharp (54:09)
Right.
Sara Woods (she/her) (54:10)
see these videos and they relate strongly to it, or you have the
questionnaires like the cat cue, right? Which can be really useful in the right context. But people think, they can go on the Embrace Autism website or other places and take these questionnaires. And it says they’ll get a result and it makes them think that they’re autistic. And there’s
Dr. Jeremy Sharp (54:29)
Mm-hmm.
Sara Woods (she/her) (54:29)
often not a lot of education out there about the fact that people can look autistic or have ADHD when they’re not. And so what I like to do is let people know all of that right from the beginning. I just be I’m just honest with people.
Right, I see it as part of the informed consent process because I think it can be really painful for people if they relate strongly to something and they feel they’re part of a certain community, and then we sort of take that rate away from them as a surprise at the end. So I let people
Dr. Jeremy Sharp (54:57)
Uh-huh, uh-huh.
Sara Woods (she/her) (54:58)
know right at the beginning, just as we’re talking about, I’m just honest with people, Aud and Autism are really complicated right now because we’re still kind of figuring out as a field how to define it.
And the way that the DSM describes it is not necessarily the way that it’s always described online. So it’s quite possible that you will feel really strongly that you’re autistic, we’ll go through this whole process, and then it’ll turn out that the data just don’t line up with the DSM definition. And I’ll ask people, what do you think that would be like for you? And just take
Dr. Jeremy Sharp (55:31)
Mm-hmm.
Sara Woods (she/her) (55:32)
a minute to let them process what that would mean for them. And then
Dr. Jeremy Sharp (55:36)
Mm-hmm.
Sara Woods (she/her) (55:36)
just kind of give them some time to think about that so they realize that’s a possibility and then go through the assessment and then if it comes out like that I’ll remind them. Remember we talked about it at the beginning. Autism really really complicated. Right now you’re what I’m seeing, I just don’t have enough evidence to assign a DSM diagnosis. and so unfortunately, you know, what you thought was your diagnosis is not. But let me help you understand yourself better.
Let me give you some tools and some information and also some community that will help you with next steps. Because really people are
Dr. Jeremy Sharp (56:10)
Mm.
Sara Woods (she/her) (56:11)
coming to us because they want support. So in the end, we
Dr. Jeremy Sharp (56:13)
Mm-hmm.
Sara Woods (she/her) (56:14)
just have to figure out a way to offer support to them. And in some cases, if people feel strongly that they’re autistic and I can’t assign a DSM diagnosis, but they’re already part of some autistic community online or something like that, I’m not going to tell them, you know, now you’re not allowed to be part of that community.
You’re kicked out because the the numbers didn’t work out and so now you’re kicked out. And I don’t say that to people.
Dr. Jeremy Sharp (56:38)
Mm-hmm.
Sara Woods (she/her) (56:38)
I I’m j when I say we’re still figuring out what autism and ADHD and Audi HD are, I’m genuine about that. I really think we are still figuring out what it how we’re going to define it and we’ll see what it’s going to look like in the DSM6. And so I I’ll say to people, I I’m not going to assign a medical diagnosis based on the criteria that I have right now, but in terms of how other people are dis deciding what autism is.
I’m not gonna take a a label away from you if you’re already part of the community. I’m not gonna kick you out of that community. So I think it’s it’s complicated. Is that
Dr. Jeremy Sharp (57:10)
Hmm. It is super complicated.
Sara Woods (she/her) (57:14)
is that how you handle it?
Dr. Jeremy Sharp (57:16)
Well, yeah, yeah, that’s the theoretically that’s how we handle it, you know? Like like on paper, that sounds great. and most of the time, I’m not I don’t know, I don’t want to exaggerate. Most of the time that goes over pretty well, right? Like we
Sara Woods (she/her) (57:30)
Yeah.
Dr. Jeremy Sharp (57:30)
inoculate people in the beginning and, you know, do the whole spiel. I think what I’m just I’m I’m I’m wrestling with the recency effect right now because I’m working with one individual where
that did not work and it’s it’s been
Sara Woods (she/her) (57:42)
Mm. Yeah.
Dr. Jeremy Sharp (57:44)
really tough going, you know,
Sara Woods (she/her) (57:46)
Yeah.
Dr. Jeremy Sharp (57:47)
as far as not affirming those diagnoses that this individual kinda came in with and was pretty identified with. And so
Sara Woods (she/her) (57:54)
Yeah.
Dr. Jeremy Sharp (57:55)
yeah, that’s why yeah, I’m trying to trying to step back and be objective here.
Sara Woods (she/her) (57:59)
Yeah, it can be reallInoculate I’ve had hard experiences like that too. I I
Dr. Jeremy Sharp (58:04)
Yeah.
Sara Woods (she/her) (58:04)
yeah, I I had one client who was just sobbing. She was so disappointed and that
Dr. Jeremy Sharp (58:09)
Yeah.
Sara Woods (she/her) (58:10)
but later she actually thanked me after she had some time to process it. And I I have actually had cases where I’ve done consults with people and
Dr. Jeremy Sharp (58:18)
Mm-hmm.
Sara Woods (she/her) (58:19)
they said, I’m I’m autistic and I just need you I just need the rubber stamp. I just need you
Dr. Jeremy Sharp (58:24)
Right.
Sara Woods (she/her) (58:24)
To confirm it and then that’s all I need. And then I’ll say, well, you know, I might not be able to assign an autism diagnosis and go through all that. What would that be like for you? And I’ve had people say that would be really hard. I I, you know, that would be so and I’ve actually said, I d I don’t think that we should necessarily go through this process. And I’ve I’ve actually turned people away if they said that, you know, they didn’t think they could really handle it if I didn’t confirm it. And
Dr. Jeremy Sharp (58:48)
Yeah. Yeah.
Sara Woods (she/her) (58:50)
I think it makes sense to do that in some cases.
Dr. Jeremy Sharp (58:53)
Yeah, that feels liberating. I like the the ability to turn people away if it doesn’t feel like it’s if it’s you know, if they’re open to other possibilities. Yeah.
Sara Woods (she/her) (59:01)
Yeah.
Dr. Jeremy Sharp (59:01)
Yeah. I think in this particular case that I’m talking about, it’s one of those places where it’s hard to it’s hard to argue against data in some cases, you know, like where especially self report data, like folks will come in and,
Sara Woods (she/her) (59:13)
Yeah.
Dr. Jeremy Sharp (59:14)
you know, endorse many things and the the data like
Theoretically supports an autism or ADHD diagnosis, but then
Sara Woods (she/her) (59:22)
Mm-hmm.
Dr. Jeremy Sharp (59:22)
developmental history doesn’t really support it. You know, parent collateral
Sara Woods (she/her) (59:26)
Yeah.
Dr. Jeremy Sharp (59:27)
interview doesn’t really support it. And then like clinical judgment doesn’t necessarily support it. But then you’re you’ve got
Sara Woods (she/her) (59:32)
Yeah, that makes it complicated.
Dr. Jeremy Sharp (59:33)
data to to integrate as well. So
Sara Woods (she/her) (59:36)
Yeah. Yeah, I
I agree with you. I think that’s why the collateral data is so important because we want it we want to get a comprehensive picture.
Dr. Jeremy Sharp (59:44)
Absolutely. Absolutely. Yeah. And even that, I mean, in this case, I’m just I’m gonna continue to go back to this one individual. But this has happened before. You know, this individual would
Sara Woods (she/her) (59:49)
Yeah, sure. Yeah.
Dr. Jeremy Sharp (59:52)
say, Well, my parents just didn’t understand or they didn’t see it. They were oblivious. They were checked out, like they didn’t know my inner my internal experience. That’s why they didn’t endorse any of these things like during childhood. And
Sara Woods (she/her) (1:00:00)
yeah, yeah. Mm-hmm. Yeah.
Dr. Jeremy Sharp (1:00:06)
you know, that’s it gets harder and harder to argue with and even using the term arguing, I’m aware,
brings a certain dynamic to it. It’s like we’re trying to convince
Sara Woods (she/her) (1:00:14)
Right.
Dr. Jeremy Sharp (1:00:14)
one another in one direction or the other and that doesn’t usually
Sara Woods (she/her) (1:00:17)
Yeah.
Dr. Jeremy Sharp (1:00:18)
work.
Sara Woods (she/her) (1:00:19)
Yeah. And and I think, you know, I all often you probably say this too, that p y you’re just going doing the best you can based on the information you have. And if you don’t agree, they’re welcome to get a second opinion, you know, you’re not the be all of end all and y you know, you’re just doing the best you can. That that’s that’s what I typically say to people. And I do think
Dr. Jeremy Sharp (1:00:36)
Mm-hmm. Yeah.
Sara Woods (she/her) (1:00:38)
there’s I I think you brought up an important point about the collateral information ’cause
I do like to gather a little bit of information from people about the validity of the reports. Like if people tell
Dr. Jeremy Sharp (1:00:49)
Hmm.
Sara Woods (she/her) (1:00:49)
me, you know, my parents are only gonna talk about positive things. and so I don’t think or like even in our culture, it’s not acceptable to talk about these types of issues, so they’re not gonna tell you that. I I take that into account when I’m interpreting what the people have to say and I also look for consistency.
Like if the person if the collateral is willing to describe some difficulties, but not others, that is more meaningful to me than if they just like I’ve had some where they just will not describe any kind of difficulties at all. They’ll only talk
Dr. Jeremy Sharp (1:01:21)
Yeah.
Sara Woods (she/her) (1:01:21)
about strengths. So yeah, I think I think
Dr. Jeremy Sharp (1:01:23)
Right. Right.
Sara Woods (she/her) (1:01:25)
it makes sense to evaluate the collaborators or the collateral.
Dr. Jeremy Sharp (1:01:28)
gosh. Yes. Yeah. It’s
complicated work that we’re doing here. Right. And
Sara Woods (she/her) (1:01:33)
Yeah, definitely.
Dr. Jeremy Sharp (1:01:34)
complicated to be human in general, right? And we’re all
Sara Woods (she/her) (1:01:36)
Yes, exactly.
Dr. Jeremy Sharp (1:01:38)
just trying to do our best, like you said.
Sara Woods (she/her) (1:01:40)
Yeah.
Dr. Jeremy Sharp (1:01:40)
Yeah. Well this has been a great conversation. What have we missed? Is there anything on your radar that you wanna make sure and mention before we wrap up?
Sara Woods (she/her) (1:01:49)
I wanted to mention that I am offering a training coming up
Dr. Jeremy Sharp (1:01:53)
Mm.
Sara Woods (she/her) (1:01:54)
on October 30th. And we’re gonna go through a bunch of cases in depth, and we’re gonna talk about these tricky cases. So, cases where the data does not line up, where some
Dr. Jeremy Sharp (1:02:06)
Mm-hmm.
Sara Woods (she/her) (1:02:07)
of the quantitative data might point to this, but the qualitative data points to that, and we’re gonna cover the whole lifespan.
it’s gonna be three hours and I’m offering a discount to listeners of your podcast and it’ll
Dr. Jeremy Sharp (1:02:19)
Amazing.
Sara Woods (she/her) (1:02:20)
be fifteen percent off and the code is testing psych15 and I can include a link if people want to check that out.
Dr. Jeremy Sharp (1:02:27)
Yeah, that’d be great. Let’s put a link to it in the show notes. And is that
Sara Woods (she/her) (1:02:30)
Okay.
Dr. Jeremy Sharp (1:02:30)
like self hosted or through another entity?
Sara Woods (she/her) (1:02:32)
That’s for the Chicago
School of Professional Psychology. Yeah.
Dr. Jeremy Sharp (1:02:36)
Okay. Okay. Fantastic.
Yeah. Yeah. This is a topic that people are super interested in. Like I said, it’s I mean it’s popping up everywhere, clinically and non
Sara Woods (she/her) (1:02:45)
Yeah.
Dr. Jeremy Sharp (1:02:45)
clinically. So I’m glad that you’re putting together some material for us. Yeah. And thanks again,
Sara Woods (she/her) (1:02:51)
Thank you. Thanks so much for talking.
Dr. Jeremy Sharp (1:02:53)
Sarah. I mean, it’s always fun to talk to you. I really appreciate you being here.
Sara Woods (she/her) (1:02:56)
Thank you, and appreciate the opportunity.
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