We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Hi, I'm Ruth Fine. I'm a speech and language therapist. Today, I'm going to be talking about autism, mental health, and communication. So understanding communication differences in assessment, diagnosis, and support for autistic children and young people. So a little bit about me. I'm a highly specialist speech and language therapist. I've been working for around 20 years across education, NHS, and independently. I work in diagnostic work nationally and I provide post-diagnostic support. I'm on ADOS-2 trainer in training. I've done a postgraduate certificate in autism. And I'm currently undertaking a diploma in autism and mental health. I'm the chair of the National Clinical Excellence Network for Speech and Language Therapists working in diagnostics and also co-creator of the Multidisciplinary Professional Network for all those working in diagnostics and post-diagnostic support. So I am massively passionate about autism, mental health communication and how it all interrelates into the work that we do and the support that we provide. So this session, I'm hoping to consider communication differences in autism, a brief overview of autism and mental health to consider the impact of communication differences on autism and mental health in terms of assessment, diagnosis, and support and input, and to provide some strategies and practical ideas. So it introduces the intersections between autism and communication, and also have a think about how understanding these differences is vital for accurate diagnosis, reducing distress, and building effective affirming support and pathways. It's important to highlight that this is a huge and really complex area. And this presentation is very much a whistle stop tour. So just for some key areas of consideration that I can just touch upon. So why does communication, autism, and mental health matter? So autistic children and adolescents face higher rates of anxiety, depression, and self-harm compared to their peers. Much of the distress comes not from autism, but from communication mismatches, stigma, and service barriers. Misinterpretation of communication differences can delay diagnosis and escalate distress. There can be myths and misdiagnosis. And certain studies show that common past diagnoses that were around intellectual disability, psychosis, personality disorders, and depression. And also an important point that there's a big lapse in time between an initial contact with a mental health support worker or evaluation and then actually being identified as autistic. There's also those difficulties in identifying and supporting mental health in autistic individuals effectively. And ultimately, neuro-affirming approaches improve outcomes. They can reduce risk and improve outcomes for all. So going on to communication differences, I want to cover diagnostic criteria going beyond the diagnostic criteria and how other experiences impact communication. So there are things we recognise as communication differences when looking at autism. We've got the DSM5 autism criteria, the diagnostic criteria, which shows differences in social communication. So things, such as different ways of conversing, different ways of sharing interests and emotions, differences in nonverbal communication, and differences in maintaining and understanding relationships. However, research and autistic voices have broadened our understanding of communication beyond the criteria. So autistic communication differences are diverse. So some young people rely on speech, but others rely on echolalia AAC, which is alternative and augmentative communication systems, they might rely on written communication or movement. Processing time is often longer often with a preference for visual information. And delayed responses should not be mistaken for lack of understanding. Monotropism has really deepened our understanding of attention focus and shows that autistic people can direct attention intensely towards a narrow set of interests creating an attention tunnel. And that makes it difficult to process information outside of that focus, as well as making it challenging to process simultaneous bits of information, such as processing verbal and nonverbal communication simultaneously. So there's a lot of information around masking and camouflage, which has really emerged over the last few years. And this is a really big issue around how autistic people are communicating because there has been such a pressure on camouflaging and masking and appearing to be different from how they truly are. So people camouflage or mask their difficulties to fit in. And while this may help in and to cope in the short-term, it significantly increases the risk of anxiety, depression, and suicidality. So masking is context-dependent. So clinicians should expect varied presentation across school, home, and clinic. So also sensory differences. These can lead to overwhelm and overload and shut down. Alexithymia, the difficulty in recognising, expressing, sourcing, and describing one's own emotions is really common in autistic young people. And this is also strongly linked to anxiety and depression. Interoceptive difficulties where children struggled to interpret their own body signals also contribute to distress and shutdowns. So it's so vital to understand these experiences when considering assessment, diagnosis and support. Autism and mental health, so what do we know? And how autistic traits and considered mental health presentations. So more than 7 in 10 young people have a co-occurring mental health condition. Anxiety and depression are the most common. And these are particularly linked to challenges at school and to masking. So 44% of parents report autistic children falling behind in schoolwork. 59% of parents report increased social isolation. And 75% feel that school doesn't meet their needs. There's a high incidence of loneliness, of self-harm, and suicide. And many young people don't receive the appropriate mental health care. And camouflaging stigma and invalidation increase the risk of all these issues. Often, assessments for autism and mental health are carried out separately. Unless someone is in a specialist or tertiary centre, often one has an autism diagnostic assessment and their mental health is evaluated separately. So there are pitfalls in clinicians recognising autism. So there are standardised assessments. But without sufficient knowledge and experience, there is under identification of autism and certain genders and in some racial groups. There are telehealth tools, which are fantastic, but they need validation. And also they have shown to miss certain elements of communication when you're not in the room with someone. Assessments must also consider cultural and linguistic differences, especially when it comes to communication. So do people understand an individual's nonverbal communication generally? Are they aware of cultural differences, let's say in the use of eye contact, recognising that in some cultures, it's disrespectful to make eye contact, or you don't make eye contact with certain genders? Do they know the use of language in actual words for autism, as well as cultural and religious perceptions of autism, mental health, or difference? Often there's not a holistic approach to an individual profile. Because of restrictions within services and processes often the question is, is someone autistic, yes or no? Are they meeting these standard assessment protocols, yes or no? There's also a big factor of clinician bias, which can lead to missed and misdiagnosis due to misunderstanding, preconceptions, and viewing a person through a particular lens. There are also pitfalls in assessments of emotions and mood in recognising mental health issues in autistic young people. So their nonverbal communication might not align with neurotypical assessment norms. So misinterpretation can happen. There may be open or vague questions, which lead to less useful answers. Distress levels may shift faster or slower than neurotypical people, which, again, affects people interpretation of people's responses. We mentioned alexithymia. Typical emotional language may be hard to access or interpret. Regulation dysregulation may be triggered by what seems to be atypical stimuli, perhaps not necessarily recognising sensory processing, or anxiety, or the need for predictability. Communication style might be detailed, precise, honest, efficient, highly focused, and not necessarily answering a question in an anticipated way. It's really common for young people to respond with I don't know, or agree quickly, or go silent when they're questioned. And this is not them being oppositional or difficult. It's genuinely not understanding what's expected of them or not knowing how to respond. There's also a high record of negative experiences that young people have with health care and pass negative health care experiences may have been minimised or dismissed and not recognising people's responses to how they're responding to those people now based on past trauma or experiences there. So there's a huge impact of communication on diagnosis. So as a speech and language therapist, I feel it's imperative to consider some key issues. So how do we unpick autism and mental health issues? But also, how do we consider, "is this selective mutism and/or autism?" So selective mutism is an anxiety disorder where a person is unable to speak in certain situations. It's distinct from autism, though they can co-occur. I mean, this was only quite recent with the ICD-11 recognising that selective mutism and autism can co-occur. But assessment needs to consider multiple informants and contexts, ensuring that support is individualised and adapted. There's excellent information on selective mutism from SMIRA, the Selective Mutism Information and Research Association and Libby Hill, who's an amazing speech and language therapist in this area. "Where does developmental language disorder fit in?" We talk about neurodiversity-affirming practise, but there are certain differences, which are often overlooked and not understood. So developmental language disorder is a persistent difficulty with understanding and/or recognising and using language not explained by another by medical condition. It affects around 7.6% of children more common than autism and often co-occurs with ADHD and dyslexia. DLD often goes unrecognised creating challenges for young people. It's been found that 81% of children with emotional and behavioural disorders have significant language difficulties, often unidentified. And 45% of young people referred to mental health services have communication difficulties. It's possible to have a language disorder associated with autism. And so it's so important to identify this in order for adequate and suitable support. There's also the issue that there's a reliance on language-based mental health support and how inaccessible this is for those with language difficulties. And "what about social communication disorder?" I'm often asked. So social communication disorder is a new addition. It's defined by persistent difficulties in using and understanding language in social contexts, such as interpreting humour or implied meaning, but without the restrictive and repetitive behaviours seen in autism. So it overlaps conceptually with autism and developmental language disorder, but its status is debated. So with some experts viewing pragmatic difficulties as part of a broader language disorder or difficulty. So there was a massive study, the catalysed study carried out around developmental language disorder to unify international ideas, diagnosis, and awareness of developmental language disorder. And they do not recommend that social communication disorder is a separate category. Instead, they feel it fits within a language disorder. Here are commonly considered mental health difficulties that are either diagnosed before autism is recognised or instead of autism or are later identified as being co-occurring. However, assessments which look at these mental health difficulties are not tailored for autistic people, hence the missed a misdiagnosis or autism diagnosis only occurring once young people are in crisis. So it's important to recognise that some autistic traits can be misinterpreted to either over or under diagnose mental health difficulties. So taking nonverbal differences, these differences may mean a failure to diagnose or incorrectly diagnosed mental health difficulties. So if we take something like depression, people might look at lack of eye contact or minimal facial affect. But these are differences that we do notice in autistic young people and yet they may be misinterpreted and not recognised as actually there being underlying depression. Alexithymia may mean it's very hard to describe feelings. So when people are being asked to describe their feeling, rate their feeling, compare their feelings, identify it, it's really, really hard, which can really affect the identification of mental health difficulties. Sensory processing can play a massive part in anxiety, in eating difficulties, and also with anxiety. Interoceptive issues may impact self-regulation with food. There's the need for consistency in autistic young people and also highly focused interests. But highly focused or intense, but positive behaviours could be framed as disordered or compulsive by others or periods of intense focus could be misread as manic episodes. So it's, therefore, so important to take an individualised and comprehensive approach to understanding someone's profile and not make assumptions based on preconceived ideas. A child or young person may just be autistic. They may just have mental health issues. However, a sole focus on autism can prevent identification of mental health issues or assume that difficulties are just part of being autistic, such as anxiety where people are often told that they're just anxious because they're autistic rather than identifying and supporting actual anxiety disorders. Similarly, solely looking at someone through a mental health lens can mean that identification of autism is missed and support services are ineffective or worse, they can have a negative and worsening impact on someone's mental health. So therefore, considering both aspects is imperative using a holistic approach and knowledge and experience of communication differences. So what is the impact of disconnected diagnosis? So mental health conditions may be underreported in autistic population or neurodiverse characteristics may lead to an unhelpful diagnosis. Many undiagnosed autistic people currently in a mental health system with predominantly neurotypical models. Autistic people are not accessing support because mental health presentation is being considered as part of autism. And lots of therapists are trained in models of therapy that have potential to be traumatic or damaging. So considering the impact of communication on support and input. So really thinking about the double empathy problem and considerations when adapting interventions. So the double empathy problem shifts the narrative from a deficit model to one of mutual understanding. It recognises that social communication challenges arise not just from autistic people, but from a mismatch between autistic and non-autistic communication and a mutual gap in understanding each other's perspective, experiences and communication styles. So this re-framing validates autistic experience and emphasises the need for reciprocity and adaptation and support. So there's a lot talk about adapting interventions. It's really interesting because there's a lot of debate about people feeling that some interventions are going to be some simply are not. There are evidence-based interventions like CBT and some people feel that they can be adapted for autistic young people by using concrete visual approaches, integrating special interests, and pacing sessions carefully. It is imperative that it is adapted. And it's vital that it is, in fact, relevant and suitable for the individual. Emotion education should focus on interoceptive awareness, as well as vocabulary. Interventions that include interoceptive education and body-based co-regulation can improve mental health outcomes. Clinicians must also recognise and support autistic burnout, incorporating rest, and recovery into treatment planning. There can be a limited awareness of autistic burnout when people are physically and mentally exhausted and struggling to function. It's thought to happen when autistic people have to spend a lot of time in environments that are not suited to them. So they may experience sensory overwhelm where they're invalidated or expect to mask their traits and where communication is not supported. So using a trauma-informed approach is a necessity. The team at the Anna Freud talk to this a lot. And in their training and in the book that was created on improving mental health therapies for autistic young people. So some recommended strategies. It's really important to look at neuro-affirming assessment, communication support for mental health, and re-framing the approach. There's lots of information on neurodiversity-affirming approach. There's actually the adult and child autism assessment handbooks and there are lots of books provided by neurodivergent people to help support this. Neuro-affirming assessment involves preparation, such as advanced questions, visual agendas, and sensory supports. During sessions, pace should be slowed, silence accepted, and literal communication prioritised. Afterwards, feedback should validate communication differences rather than pathologize them. And recommendations should be co-produced with the young person and the family. Communication support is mental health support. Predictable routines, visuals, and plain language reduce anxiety. Processing time and alternative response models may be respected. Strategies, such as interoceptive check-ins and co-created pause signals empower young people, and crisis plans should always include communication and sensory needs alongside clinical care. We were talking about increased risk of self-harm and suicide. However, there are no suicide prevention interventions which have been developed specifically for autistic people. So there has been work on autism adaptive safety plans. Developing personalised suicide prevention interventions with and for autistic people is a top research priority identified by the autistic community. Safety plans have been shown to reduce risk of self-harm, suicidal thoughts, and behaviours in a range of different groups. Re-framing the approach. So we've talked about communication, but it's vital to reframe our use of language, avoiding pathologizing language. It's easier said than done as within this presentation there are words, such as disorder used. However, further work is needed to use a strength-based approach and neurodiversity-affirming language, but without minimising difficulties, challenges, and barriers to success. We need to consider the context and environment for young people. School difficulties have only briefly been mentioned, but so much needs to be done on adapting schools to enable them to be more accessible and supportive. There's such an importance on routine and predictability. A concept that really resonated with me is re-framing "intolerance of uncertainty" to be safety and predictability. And that's written about by Ruth Moyse and Ellie Kolatsi in improving mental health therapies book. They say if we regard a response to uncertainty as rational rather than unreasonable, our attitude and our approach to support may both change. It shifts focus to the nature of uncertainty and interventions to removing or reducing the cause. Using all of the supports and reframes then has a massive impact on the development of relationship building and support with young people. So hopefully, the key takeaways from this session are the autistic difference will impact on how a person communicates their mental being at every level. It's vital to understand that person's differences in thinking to give them the best support. Systems and protocols are designed for the neuromajority. And we need to remove the barriers for accessing good support services for autistic people. Communication differences are central to autistic young people's mental health. Assessments must be context aware and sensitive to masking. Alexithymia and interoceptive challenges should be recognised in mental health support. And above all, neuro-affirming trauma-informed practise improves being and reduces the risk for autistic young people. Thank you so much. [MUSIC PLAYING]