Hello everyone and welcome. I'm very pleased to have Dr. Allison kawase. My guest today. Dr. Kawa is a licensed clinical psychologist and the clinical director at the Los Angeles center for integrated assessment. She specializes in the evaluation of children, adolescence and emerging adults. Her approach to assessment is informed by decades of work with individuals with neurodevelopmental disorders, formal training in object relations theory and cutting edge research in the field of interpersonal neurobiology. With more than a decade in private practice, she has honed her expertise in the diagnosis and treatment planning for individuals challenged by learning and processing differences, attention disorders, autism and anxiety or mood issues. Dr. Carla's areas of sub specialty include language based learning differences, pre verbal and medical trauma, adoption issues, and substance related issues in emerging adults. Welcome, Alison. And thank you so much for joining me today to discuss the important work that you do. Oh, Gilda,
thank you so very much for having me. I'm super excited to come on and talk about all this stuff.
Thank you, Alison. And so to begin with, how do you describe or define Autism Spectrum Disorder, which is often referred to as a SD? And why is there such a big range of abilities, functioning level, verbal skills, and so on.
So I think that the autism spectrum disorder is best conceptualized as this umbrella term. And under this umbrella, we are going to have a ton of individuals that have some things in common, and that are wildly divergent in other ways. So the things that they have in common are deficits or difficulties with social communication. So that's your social use of language. And that includes having reciprocal exchanges and reciprocal relationships. So whether it's friendships and younger children, or romantic relationships, and adolescents and adults. And then there's also the presence of interests that are either overly intense or unusual, or behaviors that are stereotyped, like the jumping and flapping would be an example lining things up would be another example. And then difficulties with sensory processing. And I think that the question about why do we see so many different levels of ability and so on and so forth? Is the million dollar question. It is one of the reasons why we have so much research going on right now, we don't understand the brain, the way that we understand other organs in the body. We're very much in our infancy in terms of understanding autism spectrum disorders. And so you will absolutely have a broad range of functioning from the nonverbal individuals who are cognitively delayed to the extremely high functioning individuals who are off inventing electric cars.
Well, what about other terms like Asperger's, and PDD, and iOS, and also what other kinds of things can co occur with ASD.
So the other terms, the Asperger's, and the PDD. On iOS, literally, it depends on what book you look in. So we use the Diagnostic and Statistical Manual, we're in our fifth edition, it's basically a book to make sure that all the doctors are talking about the same thing. And it defines all of the different diagnostic labels that we have. So in the fifth edition, it we only have one choice Autism Spectrum Disorder. In the fourth edition, there were more choices. There was Asperger's, there was PDD ns there was autistic disorder. What they found is that the clinicians were not very good at distinguishing between high functioning autism, Asperger's PDD on iOS, and a lot of what was determining diagnosis was actually geographical area. So people that were being seen in the clinic where ami Klin was working, for example, and he's one of the leading authors on Asperger's, you had a higher chance of being diagnosed with Asperger's versus at UCLA where I actually had worked and you had a 0% chance of being diagnosed with Asperger's. And part of the reason was Because of California, Asperger's did not qualify you for any services. And so, you know, the doctors weren't that great at discriminating if we kind of can't tell anyway. And we know that one labels going to disqualify you for things that you absolutely need. And yet, you know, so doctors were not so good at figuring out who was who, and they sort of came together the scientific community, and said, Well, if we can't figure it out, is there really a difference? And they decided no. And so that's where we have that, in terms of what else can occur with autism spectrum disorders, there's a lot. ADHD is a super common one. So about half of people who have ASD will also have ADHD. epilepsy is about a third of people will have Yeah, it's very, very common. gastrointestinal issues is another, like gut stuff is another very common issue. Anxiety is very, very prevalent. Depression, especially among high functioning adults, is a very common comorbid issue as well. And then you have the levels of intellectual functioning. And so we would define an intellectual disability as somebody whose cognitive abilities and their adaptive skills, so their ability to kind of take care of themselves and function independently falls below 70. So like kind of the bottom 2%. And about 40% of individuals with ASD are in that range. 40% are in the sort of, quote unquote, normal IQ range, and then the other 20% are in the middle, we call that borderline intellectual functioning,
will then tell me At what age is ASD usually diagnosed, and is there a different saying how autism presents in males versus females.
So we can reliably diagnose autism in toddlers 18 months to two years old, is sort of the lower end of when we can diagnose little guys. Unfortunately, the kids that are more mildly affected, often are not diagnosed when they're two years old. And so those children are much more likely to be diagnosed when they're like four or five years old. The very, very high functioning kids are sometimes not diagnosed until well into Elementary School. fourth, fifth grade is a very common time because there's this really big social jump that happens. A lot of the girls that I am seeing are not being diagnosed until Middle School. And then as the kind of diagnostic community is getting more versed on the difference in how autism presents between girls and boys or men and women, we are starting to diagnose a lot more adolescent, adult women. And so that goes into your second part of your question about does it look different and 100%? It does. Girls are much less likely to have those restricted interests and stereotyped behaviors. When they do have them their interests are usually age appropriate, and sort of gender appropriate. And so they go unnoticed. So you might have girls that are really into horses, or dogs, or unicorns, right, lots of little girls are super into those things. And it's when you really start to dig into it and you realize well, but they're interested in these things to the exclusion of other interests. And it's getting in their way because of their friend wants to play restaurant, all they want to play is my little pony. And then there's a conflict there. As the kids get older, a lot of the super common ones are hair, makeup, clothing, fashion. Kpop and anime are also two big areas that I see quite often. And again, totally normal for a pre adolescent adolescent girl to be interested in any or all of those things. It just becomes a question of how intense is that interest? And is it getting in the way of other things. Girls also tend to be a lot more socially adept than their male counterparts. And part of that has to do with the way that we socialize girls. They're taught very early on to be polite and to make eye contact. And girls tend to be socially motivated. It's a misconception that boys or girls on the spectrum don't want to connect with others don't want to have friends, many, many of them are very searchable and really, really wants to connect and have friends. And what a lot of girls do is they will look at Tick Tock videos or TV shows or you know, something they find online. Maybe they'll observe the popular girls at school, and they'll try to sort of mimic the social behaviors, and it allows them to blend in, it's called camouflaging. And in that way, it can be very subtle, and it can be very difficult to detect, because they're acting as if, which is, as you can imagine, exhausting. And really something that is impossible to maintain without being completely draining. And eventually, you start to feel really inauthentic. But it is something that makes it super, you know, sneaky and difficult for clinicians to spot.
Well, you may have already touched on this next question that I have, in fact, I you did, but I'm going to ask it anyway. So on the topic that girls with ASD are often overlooked or miss diagnosed. Can you go into a little more detail as to exactly why?
Yeah, absolutely. So there's a few different things that place number one is we have these diagnostic tools that are basically calibrated to pick up boy autism. So what a lot of people will tell you is that the A das is which is a structured kind of interview is like a gold standard measure for identifying kids with autism or people who are on the autism spectrum. However, that particular measure, not so great at picking up on these girls that are camouflaging because we're rating your eye contact, we're rating your ability to volley a conversation, we're determining whether you ask us follow up questions, if we start talking about ourselves. These are skills that these girls have learned. And they are performing beautifully in this 45 minute to one hour time that they're spending. And so they really aren't showing the full measure of their difficulties. Similarly, the rating scales that we have parents and teachers filling out they're really looking for a lot of these repetitive behaviors, the restricted interests, things that are kind of loud and easy to spot. And that just isn't the way that it presents in girls. A lot of girls and women are mis diagnosed, or they have something that is co morbid, that gets diagnosed. And that can delay an autism diagnosis and it kind of muddies the water. So not unusual to have a girl diagnosed with ADHD, for example, because sometimes kids with ADHD have social issues, they're impulsive, they blurt things out, they're interrupting all the time. Right? They can do things that might be a little off putting they can be a little immature at times. And so you say, oh, here's a girl, she's got ADHD. That's why she's got these social issues, when in reality, she has both. And but the ADHD is easier to see. And so that is what gets diagnosed is called diagnosis, overshadowing when you have a lot of anxiety, right? A lot of girls who are doing all this work with the camouflaging, they have social anxiety. And so that social anxiety gets big and loud. And that's what you see, and then you miss. And a lot of the evaluation process is around the subjective experience that the individual is having with their social skills. So I can tell you I have 100% been in the room with girls and adolescents who have ASD and look to me pretty good. They're making great eye contact, they're carrying or conversation. They're charming and delightful and having a lovely time. And then you ask them, what's it like for you to make eye contact? And they're like, oh, man, can I stop doing that? Because it is just really uncomfortable for me, but I don't want to be rude. You know? And so that's where it's really important to have a good understanding of not only what are the observable behaviors, but what is their experience of engaging in those behaviors.
So Staying on the topic of girls with eggs, ASD for a moment, females tend to struggle more or not more, but in different ways than their male counterparts. They both struggle, but females struggle in different ways. Can you go into a little more detail in terms of the differences of those struggles? And also, why is it so important to diagnose the higher functioning girls and women with ASD.
So, girls are a lot more at risk for indiscriminate social behavior. And what I mean by that is, they will make bad choices in order to curry favor with their peers, they are so eager to connect, they might make unsafe internet choices. You have a higher incidence of anorexia, with girls on the spectrum and at when they become adolescents and women, that perfectionism, the rigidity, the kind of restriction that goes along with anorexia can become really a medical issue. And you're also a lot more likely to have bullying going on self esteem issues are pretty prevalent with girls and women and then you start getting into self harm types of behaviors, possibly substance abuse as a self medicating kind of coping mechanism. And it's important to get an accurate diagnosis because in the absence of an accurate diagnosis, often you will get a pretty severe misdiagnosis. borderline personality disorder is one that comes up a lot when you have an undiagnosed a woman who is potentially you know, doing some self harming and has instability in her relationships, and has some emotional lability right, or mood swings and such. And we go, we call that person borderline personality, we put them into a DBT group. And now they're getting the complete wrong kind of therapy for them. They're getting no symptom relief. And we don't know why. Right, they're just difficult. Similarly, if you have a girl or adolescent or woman, then they are diagnosed with ADHD. But truly their issues are rooted in ASD, stimulant medication isn't going to work, it's not going to help them it's not going to be effective, or it might be a little bit helpful, but it's not going to really move the needle the way that it would. For somebody who has more garden variety ADHD. You can also get a misdiagnosis of bipolar disorder. Again, because of those mood swings and the mood lability. And then you start getting prescribed some pretty intense medications. People with ASD tend to have kind of sensitive neurological systems. And that goes for the way that they metabolize medications as well. And so you can really get into a bad situation with medication. If you aren't, if you don't know what you're treating, and you're treating the wrong thing. And the goal is always with any you know, person that you're trying to treat is you want them to be able to harness their strengths, bootstrap them, and do whatever it is that is their path to happiness. And if you are not able to identify what is going on with a person, and you are thinking that this is a personality disorder or you know, a chemical imbalance in their brain, and you're not giving them the support for social skills, and more importantly, the self understanding of having an accurate diagnosis. It's it's very, very challenging to go out and be a functioning adult.
You've made some excellent, excellent points, Ellison and at this stage of the discussion, I wanted to ask you, is there something that we haven't covered that you think is important to mention, or the one important takeaway that you want to make sure is discussed before we conclude and also how can our listeners reach you if they have questions or if they want to know more?
So I will say that in my work with families, the autism diagnosis is kind of a big scary one. It is very often the one that parents are like, Oh, God, just don't say that one, you know, and my experience in talking to people about their diagnosis and getting supports into place is that it is such a relief. It is such a relief to have somebody who gets it, who understands what's going on with you, who understands why you do the things you do, what is it that we need to help you feel more contained, to help you to be your best self, and to help make you the best you that you can be. And whenever a kiddo comes in, or an adult or an adolescent, they're the same person after we've made a diagnosis as they were before, right? It's not like they change all we have is more information. And just like we had all those name changes from the DSM four to the DSM five. It's that just shows you how much our understanding of the way that the brain works is evolving. And there's absolutely nothing about an autism diagnosis that needs to be completely limiting. Oftentimes, when I'm telling families is like this is not doors shutting on your kid, this is me giving you a key to open doors that are ready, shut. And so I believe that information is really powerful. And that it's important to really have an accurate understanding no matter what's going on, in order to put the right supports into place because we all need support. Sometimes. The best way to reach me or to get more information would be to check out my website. It's www.lasica.org. So it's la dash ci a dot o RG.
Well, thank you so much, Alison, for your time, and for giving us some truly wonderful information today.
It was truly a pleasure. And thank you for putting this together and for making such a great resource for all the families out there that are trying to, you know, put together some information so they understand what's going on,
much appreciated. And I also want to thank our listeners for spending a part of their day with us. I'm Gilda Evans reminding you to take care of yourself and that special person in your life
