Tuesday 21 July 2020

Autism: Are you a GP or other Clinician? Quick tips.

A blonde woman with medium length hair, wearing a jacket. She looks quizzical and there are two question marks near her head

Are you a GP or other Clinician?

Are you desperately short of time and resources?

Worried about how to provide the right care for the 1 in 30 autistic people in your Practice lists?

Firstly, this isn't formal training.  For that, you'll have to go through the usual channels.  This is a quick primer, to get you up to speed on the latest stuff in a few minutes. 
I have a fabulous GP, and I work with many more across the country, in various roles.  Yours is a difficult job, and not made any easier by the current Covid-19 crisis. 

Personal interest: I'm autistic, and a Mum of an autistic adult.  I'm a patient. I train a lot of Clinicians on autism, working within teams, and have done for years.

OK, here we go.
References can be found at 

It's 1 in 30 of your patients (and colleagues, and staff, and neighbours, and probably friends & wider family...).

It's probably not far off equal numbers of males and females, but many have other genders such as Non-Binary.  Lots of diversity of sexuality also.

It's all ages.

It's all cultures and ethnicities.

It's all IQs.

It's a genuinely different social communication system, not a broken one.

It's a strong need for routine and predictability.

It's a very different way of processing sensory signals, which can mean that incoming sensory stuff is utterly overwhelming.  Especially background noise or flickering overhead lighting.  Fluorescent lighting is a particular peril for many. This may help.  A personal example.  The level of exhaustion from being in such a space, for some of us, is overwhelming.

In terms of current healthcare outcomes, it's not good.  Yet of course autism isn't a disease. There isn't a clinical reason for poor outcomes.
may be helpful for some background info and top tips.
https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/asd-toolkit.aspx is more useful info, though some of it may need an upgrade on language and very latest research.  

Broadly, autistic people are dying way too early. Our suicide rates are breathtaking.  We end up with all manner of mental health situations because of relentless bullying, ostracism, defrauding, violence and sundry other horrors.

So...making it possible for us to get a GP's opinion on our health, or a steer towards good autism diagnosis, is vital.  We're now into virtual world possibilities, which may make it easier for some.  But be aware that many find telephones especially impossible.  Be prepared to offer the thing that works for them, instead.

Watch out for myths.
Yes, we can appear to make eye contact.
Yes, we can smile and joke (often when in great pain)
Yes, we can be well dressed and seeming to be socially 'competent'.  That's called 'masking' and the strain of disguising our autism is strongly linked to really poor outcomes for too many.
Nearly all of us do not want a 'cure' (whatever that would be).  We would mostly like life to be doable, and have access to the same human rights as everyone else.
Most of us have lots of empathy for others.

So, make it OK to be ourselves.
Put up stuff about autism-acceptance.
Refer generally to autistic people as autistic people, but ask the person what their own preference is.
Make it OK to wait somewhere doable, for an appointment that is more or less on time.  Otherwise, your patient will likely flee, unable to take the sensory overwhelm any more.
Be gentle and explain what you're about to do.
Be accurate.  If you say, "Just wait five minutes" but you actually mean, "...well, maybe more than 20", that's a nightmare for us.  Be vague if you can't be specific. "Some time in the next 20 mins or I'll let you know there's a further delay", etc.
Be kind.

Goodness me, we live in a world that is so utterly unkind to us so very very often - that kindness and clarity is vital.

Be aware that our internal 'signalling' is often dodgy, so we may not know how much pain we're in...or where the pain is.  But if someone autistic has turned up at your Surgery, something's wrong.  It's not something we'd do for fun.  Investigate.  
A member of my family played Rugby for weeks with a broken foot.  He had no idea it was broken.  It didn't really hurt.  Even the Physio was sure it was just a bruise, because it wasn't hurting.  It's very deceptive.  Another member of my family was complaining of vague discomfort, but their mannerism was strange, so the team though it was a mental health incident.  They were dead soon thereafter. It was their heart.  None of the signs and symptoms may match what you're expecting.  Expect the unexpected.

Use visuals as well as spoken questions.  Wait patiently for an answer.  It can help to ensure that people have a double length appointment, to allow for extra time.  Allow an advocate or family member to explain if the person cannot, or if they would prefer the other person to do so.

Be aware of how many autistic people also may have hypermobility syndromes, ADHD, sleep problems, PTSD, or epilepsy (amongst other possibilities). Many end up with quite a list of mental health condition possibilities, none of which match, because no-one has considered autism.  Especially the case for autistic females or those from BAME communities.

Get good training, working with autistic team leaders to ensure it's authentic.  Get to know us as people.  And remember...1 in 30 GPs is likely to be autistic, so whatever language you're using around 'disorder' and 'deficit' isn't appropriate, no matter what it says in a manual.  This is a neurodiversity, and a genuine set of differences.  Start from that knowledge, and good things have a much better chance of occurring. 

Thank you for reading.  And thank you for all you are doing to improve our lives.

Saturday 4 July 2020

Autism, Bullying, Post Traumatic Stress Disorder and Behaviour. The links?

A woman with dark hair sitting on the floor, her arms around her head, seeming very afraid. In front of her, an open laptop computer.
An important study was done by Freya Rumball , Francesca HappĂ©, and Nick Grey, published in 2020.  The link to it is here ,  - warning for medicalised language and discussion around traumatic situations.  

It's about Post Traumatic Stress Disorder ("PTSD").  This is a brain response to extreme trauma, for example a near-death experience, terrible injury, being present in some major disaster.  There's a tick-box list of things that are alleged to cause it.  If it's not in the tick-box list, often no-one is supposed to diagnose it as PTSD, even if the person is clearly traumatised.  Strange but true.

That has failed an awful lot of autistic people, in my view.  

So, this new research happened.  The team found 59 autistic adults to take part in this study.  The team wanted to find out what sort of traumatic things they had experienced, in their view, and whether the people now had symptoms suggesting they had PTSD.

This is one of the pictures from the research. It shows how many of the autistic people had experienced these things, finding them traumatic.  This list is the usual things that cause PTSD (according to the medical lists).

But, the autistic people also listed these as also causing trauma, and these aren't on the usual lists for PTSD:

Many of them experienced bullying as causing immense trauma, for example.  The team did a lot of deep thought about their findings.  This is what they have written:

"A broader range of life events appear to be experienced as traumatic and may act as a catalyst for Post Traumatic Stress Disorder development in autistic adults. Assessment of trauma and PTSD... should consider possible non-DSM-5 traumas in this population, and PTSD diagnosis and treatment should not be withheld simply due to the atypicality of the experienced traumatic event."

In other words, autistic people are indeed traumatised by a wider range of things than the teams were expecting.  And diagnostic teams should be considering PTSD after a wider list of possible triggering events.

"The rate of probable PTSD in our ASD participants following DSM-5 or non-DSM-5 traumas was similar, ranging from 43% to 45%"

So, nearly half of those in this study exposed to bullying/awful social exclusion etc may have PTSD.

Let's think about symptoms of PTSD.  This isn't a full list, and people don't have to have every bit of it.  If you want to look at the full diagnostic lists, this is one here

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
2. Recurrent distressing dreams about the events.
3. Flashbacks to what happened.
4. Panic at anything resembling a part of what happened.
5. Avoiding thinking about what happened.
6. Avoiding being near people or places that remind them of what happened.
7. Brain blanks out some detail of what happened.
8. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
9. Possible irritable behaviour and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
10. Possible reckless or self-destructive behaviour.
11. Hypervigilance (always ultra-watchful for anything resembling what happened)
12. Exaggerated startle response.

Think about the autistic people around you. 
Think about how many are subjected to awful things.  There's good research on that.  See the 'vital research links' blog at 
http://annsautism.blogspot.com/2019/01/autism-some-vital-research-links.html for a list of some of the main ones. (And a lot of modern info on autism.  Gee whizz, did we ever have this wrong, eh?) 
Think about how much we talk about 'challenging behaviour' or 'attention seeking'. 

Is it?

Think about how often we employ behaviour-control teams to ensure that the autistic people never ever show their internal trauma to anyone.  Never run.  Never hide.  Never self-soothe.  Never scream.  Never cry.  Never fail to concentrate.  The belief-set that all of those responses are just ways to avoid working or being pleasant to others.

What are we doing?

I leave you with this question.

Thank you for reading.

If you would like support, after reading this post, the following organisations may be able to help in the UK:
 https://youngminds.org.uk/find-help/get-urgent-help/#are-you-a-young-person-in-crisis?  for young people

https://www.samaritans.org/how-we-can-help/contact-samaritan/  for adults

https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/about-ptsd/  about PTSD and links to support

In the USA, this may be a starting point for information and links to support