6 Obscure Signs Of Autism That Psychiatrists Secretly Look For | Dr Amber Sadiq

0:01Dr Fareeha Amber Sadiq:Comcast reaches more than 65 million homes and businesses with the nation's most intelligent network, powered by AI and designed to optimize every connection in real time. And that really matters when millions are tuning in for the biggest live events. With ultra-low latency and the capacity to handle massive demand, Comcast helps deliver every moment in stunning 4K, so viewers stay close to the action without missing a minute. Learn more at ComcastCorporation.com slash network. Autistic people, they like watching the same film over and over again, listening to the same song. Does that predictability give them comfort?

0:37There are sensory differences, being hypo or hyper reactive to sensory aspects. That's why a decision that feels so small, like picking socks out of a whole sock drawer, can feel extremely difficult. If they don't have that awareness, can that person just believe that they are too sensitive? Autism or not, you often believe what you're told. you are too sensitive, too much, too mouthy, too defensive. People start to believe those external voices and they internalise that. What's the autistic person scared of? Is it perfectionism or is it something deeper? There's so many aspects to this. So one is...

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1:37Dr. Amber, most people probably think that they know what autism looks like, or at least the signs of it. Difficulty making eye contact, sensory sensitivities, wanting routine. but you as a consultant psychiatrist who've seen thousands of neurodivergent individuals. So today we're going to explore the six signs that a psychiatrist will look for in an assessment that might not be the obvious ones. But before you begin, you said something fascinating of camera to me, and that's that there's one sentence that people say during an assessment that makes you as a psychiatrist think this person has autism.

2:18But we're going to come back to that a little bit later, because I truly believe that that is going to shock people. So today, let's start with the first sign. And that's when every decision feels enormous. One thing someone with autism said to me was that they can spend 20 minutes deciding on what pair of socks to wear in the morning, for example. And it's not because they don't care. It's because to them, every single decision feels immensely important. That kind of thing, is that something you hear often in autism assessments? Autistic individuals often describe the decision-making process as being really difficult at times, often more than not.

3:01And it's because, like you said, Alex, that every decision has multiple variables, multiple inputs, and so many outcomes as well. and for people that are autistic they care so deeply they process deeply they're looking at you know that that question or that dilemma or that decision as as being a very important one and therefore because they process deeply it can also take them longer to process so whereas somebody who isn't autistic might be able to make that decision very very quickly someone who's autistic will take longer and they might find that process really laborious, really tricky, because they're looking at all the different possible questions around, let's say, picking something from a menu.

3:54That can be one of the most common things that I see in my clinic. It's people that say, you know what, when I go into a restaurant, first of all, I have to deal with the noise, the sensory input. I have to deal with the people. So I don't know what's going to happen next. people that are autistic, they prefer predictability. And therefore, maybe going to a restaurant where you know what to expect, what the menu is going to look like, maybe you've whittled down to a few options, feels a lot easier than having a whole menu where you're having to weigh up the pros and cons and what it might taste like.

4:29And is this going to be as good as the last macaroni cheese that I had? And that can be, you know, very, very difficult and very cognitively demanding. what I mean by that is that it uses up a lot of energy. So if you can imagine in an average day, an autistic person has to make so many decisions. They're kind of having to, you know, make an opinion on not just what they're going to eat, but are they going to leave the house, you know, managing their day-to-day structure as well. But that actually involves a lot of energy in the first place, but also then that additional part of transitions and moving from one thing to another.

5:11So often, you know, what I see in clinical practice as a psychiatrist is that decision making can feel very, very painful. And it looks different from what we might see with other neurodivergent conditions as well. So interesting, Dr. Amber. So if we focus in on the decision paralysis for a moment, and the lovely example you said, go to a new restaurant and oh my gosh, I have to choose what to eat. I mean, that's terrifying. What's the autistic person scared of? Is it perfectionism or is it something deeper? There's so many aspects to this. So one is not knowing what to expect because the autistic brain likes to know what's going to happen next.

5:51And if they've never ate in that restaurant before, they don't quite know what that dish is going to be like, how it's going to look, how it's going to be presented. The smell as well can be an additional factor. And then if you're thinking about making the wrong decision as well, because often autistic people are kind of weighing up the pros and cons, they're kind of, every decision feels like a new, a new dilemma, a new problem. And that's often what's described to me in the clinic. And that's why it feels so hard. And that's why, you know, I always use the analogy of being in a restaurant and how you can then put adaptations in place to make it a bit easier for them.

6:34So is it that autistic people, they get huge comfort from knowing the outcome, i.e. they like predictability, they like watching the same film over and over again, or they like listening to the same song over and over again because they know how it starts, they know how it makes them feel they know how it ends does that predictability give them comfort it's really important for autistic people of course i want to add just now alex that one autistic person has a very different experience from another autistic person but generally you know there are things like sensory differences which we know can impact so either being hypo or hyper reactive to sensory aspects in your environment and really appreciating and having a preference for that consistency and knowing what's going to happen next and being prepared for that.

7:31And that's why, you know, in my opinion, actually a decision that feels so small, like picking socks out of a whole sock drawer or picking something that you're going to eat when you're out in a restaurant with your loved ones can feel extremely difficult. What happens when an autistic person is forced to make a decision? They're put under pressure. Is that overlapping between sort of shutdown and overwhelm? So there are overlaps. There are overlaps between, you know, how autistic people make decisions and what that experience is like for them. And also autistic people generally need space and time to make decisions.

8:13They need time to process because if we think about what autism is, it's a difference in processing information and processing the world around you. So if you're somebody that just needs that little bit more time and maybe some scaffolding around that decision making, then if you put an additional stress or if you ask that person another question on top of that, that just can be so difficult for that person to manage. Because it's unpredictable. They've not expected it's kind of come from nowhere. B, they've possibly not prepared for it as well. So it's kind of something that's kind of, again, you know, come out of the blue.

8:56It's moving from one problem to then moving to another problem. And we know that for many autistic people that they struggle with transitions. So moving from one thing to another thing can feel really, really difficult. So actually, yes, when we talk about shutdowns and meltdowns, there is an overlap. because if someone who's autistic is faced with multiple things to have to make decisions about, that can impact on their energy and their cognition. There was another sign, Amber, that felt like somebody had had a camera hidden in my flat and was spying on me. And that's when unfairness feels impossible to ignore, when you feel like you should just be able to let something go, but you can't.

9:44and I think an example that happened to me recently I was in a coffee shop and queuing up to get my coffee and someone just walked in walked to the front of the queue ordered their coffee and the person behind the counter served them and they walked out and and off they went and no one said anything well I didn't say anything but it was it really stuck with me all day like how could that person not stick to the rules like why did no one say I didn't say anything but that justice sensitivity is that something that you see come up in assessments something that i ask about in all of my assessments when i'm looking at neurodivergence and in particular autism is that strong moral compass that strong sense of justice so it's really interesting what you describe alex because that feeling of that didn't feel right you know how did that happen you know it's it kind of jars you, doesn't it?

10:37It kind of that experience, it just doesn't feel ethical. And if you've got a preference for rules, which many autistic people have, which I think is, is wonderful in many ways, but you're also somebody who has to make sense of a situation. And if a situation has kind of gone in a way that you think is really unfair for yourself, for somebody else, for somebody in your workplace, then you might be more likely to call that out. And that is something that many of my autistic human beings that I see and families describe. They say, look, I've really felt this injustice and I can't let go of it. You know, it's just like sitting there and I just, it's just, I keep mulling over it because I think there's a sense of, unless you can find an explanation for it, unless you can kind of make it right, or unless you can get the other viewpoint of why did that happen?

11:34How did that happen? Often many autistic people describe themselves as being very good problem solvers. So if you're not able to solve that problem, and if someone has violated the rules, then you can really see how that could almost become an area of focus for somebody who's autistic. Could, following on from that, could that cause problems in the workplace? If an autistic person who has massive justice sensitivity, and perhaps they witness somebody get a promotion, for example, and in the autistic person's mind, they can tell that the reason that person got the promotion is because they might be just more chummy with the boss, not because they are necessarily there through merit.

12:16And therefore, if that justice sensitivity is so overwhelming and it bubbles up, it Could it cause problems where the autistic person feels like they have to say something, even though if that saying something is going to put them in a position that could cause the rest of the office to think that they're awkward or being difficult? Again, there's different ways that autistic people will respond to that situation. Some people will suppress what they notice and what they feel and that radar for noticing injustice or that something doesn't feel right or this doesn't feel fair. you know they may suppress it and they might mask and they might just say look um they might really feel it inside if that makes sense other people autistic people may call it out and I would hope that somebody in that situation has a supportive line manager or somebody that can explain why because often you know we will make some interpretations or we'll find you know in that kind of that person got a promotion and I didn't and this is why and these are all the reasons why often making that autistic person feel less than or worthless which often then fits into maybe negative experiences that they've had in the past as well it really fits into that low self-confidence that low self-esteem why that person why not me I'm really hoping that in that situation that person has you know someone supportive that they can go to and say very candidly how did this happen and that they can get an explanation for it as well because often what I find with my autistic clients is that when they have an explanation for something and it makes sense it can really help them through and then if they've got some practical things that they can do to help improve their situation.

14:09And if they feel heard and witnessed for what they experience internally and cognitively, then that can really help. So interesting. If the person is feeling intense justice sensitivity and they have that overwhelming bubbling up of emotional response when they witness something that they perceive as unfair, if they don't have that awareness of autism and justice sensitivity can that person just believe that they are too sensitive you often believe what you're told so if you're told as a human being autism or not that you are too sensitive that you're too much that you're too mouthy that you're too defensive that you always have a strong opinion about things, then I truly believe that people start to believe those external voices and they internalize that as well.

15:06And they might think, especially if they get further feedback from others, that they are too sensitive. And then that then fits into that negative construct that they might have about themselves. I just want to zoom in and get a bit geeky just for a moment on this particular point of justice sensitivity. Are autistic people naturally more wired to be sensitive to unfairness? Or is it the environment that has made them more sensitive to unfairness? In my view, and from my experience, and having worked with autistic individuals across the lifespan, so that's kind of from adults all the way, if you think, down to children and families, most of my autistic clients have got a natural brain wiring for justice, for integrity, for saying it how it is, reducing that need for ambiguity, you know, cutting out, I'm sorry about my language, the bullshit, which I think is actually really refreshing, you know, as you get kind of get to know people that are autistic and get to know how their brains are wired up.

16:14So I would say that from my opinion and from my clinical experience, It's very much there's a preference for having a strong moral compass, for having a strong sense of what feels right. I suppose the other side of the coin would be thinking about flexibility to other perspectives. so for many of my autistic younger people younger adults when they've not had any support or they've not been able to kind of think through their profile what can really help is to kind of have some space to think about what might other people think about this you know and to kind of do some coaching around that not to change their opinion but to get them to just generate new thinking and new ways of, I suppose, living in the world.

17:08Because actually living in the world where you notice and you've got that sensitivity for injustice can feel really hard. And I don't think there's any surprise that, you know, many people who feel strongly about things go into the kind of activist space. They'll go in to fight for their passions. They'll go in to, you know, they'll develop these kind of special interests around injustice and unfairness. And they can do really well through that. But I also feel that that can come at a cost as well. What would that cost be? I always talk to my clients about looking after their energy because energy is such a powerful, important resource.

17:54The energy when you're making a decision, the energy when you're moving from one task to another. the energy that you utilize when you're fighting passionately and giving so much and making sure that you don't empty your cup to the point of depletion. And that cost then would be looking at things like meltdowns, shutdowns, emotional dysregulation. Many people that I work with who are autistic often come into the clinical space, not necessarily because they're looking for an autism diagnosis but because they've experienced additional mental health difficulties like anxiety depression we might see substance misuse we might see adhd we might see ocd there's kind of like other routes or they might have a child that comes into the clinic for an assessment and then as that adult is listening and hearing the questions and and things that you know kind of pattern recognition skills are kind of being played out and they're kind of thinking, oh, that sounds like me as well.

19:04That I think can be really valuable because I think as people go through that process of learning about who they are, how their brain is wired up, how they manage their energy, they also recognize that there are times where they just find it really hard to function and sometimes that can get misinterpreted as depression or something else but actually it could be indeed part of the the autism i'm so pleased you mentioned adhd just briefly there because i think that leads us nicely onto the next sign and for me this one is the one i relate to the most and i think it's the one that can cause feelings of being misunderstood to the greatest extent.

19:48And that's almost having like an inability to start sometimes, but also having an inability to stop. And I hear some people with autism say they just can't start a task. And other times I hear the same person saying, I can't stop something. How can both be true at the same time? It's incredible, isn't it? It's almost like a bit of a contradiction when you think about it. So if we think about kind of the starting of a task, you know, we've talked about kind of that inertia that can happen or that sense of it's too complicated to make a decision to start a task. The environment needs to feel right.

20:25You know, there can be too much visual clutter. There can be a lot of sensory stimuli. Where to start first? You know, do you start with this bit of the problem? Do you start with that bit of the problem, that bit of the task? It can feel really overwhelming to the nervous system. And then what we find is that when some people, some autistic people start a task, then it's almost like they can't finish it, right? So they continue and to the point where someone has to tell them or they have to recognize in themselves that they've not eaten, they've not been to the toilet, they've not drank water, and that can be really challenging.

21:03So I would say that kind of with the starting a task, that can be linked to transition that can be linked to starting something that perhaps perhaps they're not interested in if you think about you know autism like ADHD it's linked to having an interest-based brain so you're more likely to be able to do something that feels manageable that's enjoyable that fits in with your life purpose so funny really does this explain why some people they might drive somewhere and then they have to sit in the car for say 20 minutes before they can walk into the place that they're going because this is something I struggle with I can start a particular task which might be get in the car get ready and go but then I almost have to have this like 20 minute 25 minute transitional period where I'm just sat in the car and I don't know if that's related to this inertia I I'm still in the mindset of finishing this task am I preparing my mask for starting the new task because that's going to be involving meeting new people is that experience common like just having to have this transitional period where you might just stop yourself from going into another environment i think it's really helpful that that you've got that insight and and really valuable that you're recognizing the important of importance of that time in between tasks i think often the challenge is when people don't build that in to their schedule so they're moving from one thing to another thing to another thing and actually that transitioning becomes way too much because it leads to anxiety and it leads to that sense of unpredictability and nervous system system dysregulation so actually that sense of kind of like needing time in the car just kind of quiet time you know I think many people will be able to to relate to that as well it's almost time for your nervous system to catch up on itself to allow you to prepare for the next stage, to get your mind and your body into the right space.

23:09And I suppose what I would be really interested in is during that transition phase, what else could people do to help them regulate themselves? I think actually it's really important that autistic people recognize the importance of having extra transitions and building in some self-regulation time I think that can be really valuable yeah so interesting Amber one of the biggest lies I used to tell myself was that I could book two appointments back to back and be okay afterwards and I tried to do that in the past like zoom meeting zoom meeting zoom meeting and I was drinking in the evening and I didn't understand why yeah yeah but that's so interesting so in the breaks that we create for ourselves what could an autistic person do to make the best use of that time?

23:57Being intentional about making sure, you know, have they drank? Have they drank water? Have they had something to eat? Have they peed? Have they been to the toilet? You know, just making sure that their basic bodily functions have been attended to because many autistic people, when they get into that flow or they, we call it monotropism, where you're kind of so into a task and you can't finish it, you know, it's that leading to that kind of can't stop scenario that often because autistic people can struggle with noticing their bodily cues sometimes they don't know when they're hungry they don't know when they're thirsty they can get so caught up in something that kind of hyper fixation that they don't have their needs met and that makes it even more likely that they can become more dysregulated so just kind of like having your basic needs met using breath work so kind of taking a pause taking you know inhalation, exhalation, stimming, you know, thinking about kind of using that opportunity to unmask as well, because often people are performing so much in today's world that they don't have opportunities to unmask and just to be and just to like listen to their favorite song on the radio or, you know, watch something that they enjoy, you know, because they kind of lose sense of who they are in day to day life.

25:18And I think just things like that can be really valuable. Obviously, each person is going to be very different in how they want to use that time. But I think it's so valuable to build in that time and almost like block it in your diary as well. So if you notice that you're moving from one task to another and on that particular day, there's a heavy cognitive load and you're going to be making lots of decisions about things. it's giving yourself some grace and some respite and all of that and also recognizing that perhaps in the days following that you might need to do a bit less as well i think autistic people struggle with what this behavior looks like from the perspective of other people like if you picture the scene i'm sat in the car for 25 minutes i'm doing the exercises you suggested or i'm at home and I'm lying on the sofa for 15 minutes between my Zoom meetings.

26:13Why do you think these transitional periods can look like laziness? Because they're not the dominant narrative about, you know, for most people who are not neurodivergent, moving from one task to another isn't as challenging. It doesn't come with the same level of anxiety. It doesn't come with the same level of decision making. You don't have to manage the sensory stimuli. you're not having to think about all the different combinations and algorithms and you know that chat gpt in your head you know you're not kind of going through every single possibility actually you can use as somebody who's not autistic you can use prior learned knowledge to be able to help you make a decision which is a different way of processing a problem but for someone that's autistic because you are a deeper processor actually it feels it can be more exhausting actually for them to be able to live a life where they're having to make these decisions.

27:12And so for the person on the outside, they'll be looking at Johnny or Amelia, just making up these names. They'll be looking at those people thinking, actually, why are they just lying down? What's going on? They should be doing more. Come on, work harder. Come on, let's go for a run. But actually, what I would say for somebody who's autistic and for their loved ones is, actually allow somebody to build in that restorative practice, ensure that it's almost like it's a habit, it's a non-negotiable, it's something that they build into their week, into their daily practice, because that's what's going to help them in the longer run as well.

27:56I want to move on to the sign of autism that I think probably causes the most damage if it's not spoken about. And that's the shutdown that nobody notices. We mentioned briefly earlier meltdowns, but I think nobody talks about shutdowns quite so much. What is the difference between a meltdown and a shutdown? Meltdowns and shutdowns, in my experience, often come from a similar root cause. They come from a sense of being overwhelmed. They come from an experience of your resources not quite meeting the demands that are being placed on you or the activities that you're having to engage with. Also managing sensory stimuli, which can be extremely difficult, managing social interactions, some which are predicted and some which are not.

28:49And a meltdown is more of like, if you think about someone who's meltdown, having a meltdown, it's more of a dysregulation on the outside so you know somebody who becomes very upset who becomes very distressed um you know there there might it's it's it seems like it's more of a problem but actually i see people who go inwards so they experience the same level of anxiety and nervous system dysregulation But actually, the way that they respond to that can look quite different, where, again, the autistic experience is so varied. You've got autistic people that are nonverbal. You've got autistic people that are verbal.

29:32Often in the clients who I see who are verbal, the majority of them, they describe losing their ability to speak. They just don't know where this comes from. And I always ask about it. they lose their ability to engage in everyday activities this could be things that they can actually do really well on a normal day but they just can't do it anymore you know even getting out of bed can be really challenging or they might almost kind of appear fine but they're not processing in the way that they normally do and in my opinion and from my experience that's coming from a real sense of overwhelm and a real sense of protection actually it's at that point it's like an acute episode that that person goes into in order to help them cope with a situation so interesting you said you could go non-verbal if you aren't otherwise non-verbal and I think I think of my own story a little bit here.

30:39I mean, if I have a conversation with one person, I enjoy that. I'm able to monitor their reactions. I'm able to listen to them. I'm able to have a good conversation. I think if there's more than one person, it's a significant struggle. If it's three or more people, for example, if I'm in a restaurant with a group of people that I don't know very well I go non-verbal to the point because I'm it's too much to pay attention to it's too many different people to observe their patterns and understand what everyone wants to talk about and I just go into what I would describe now as non-verbal though to the point where in the past people have said Alex why have you gone so quiet Alex why are you so awkward and for me internally it feels like everyone is looking at me judging me thinking I am weird because the Alex who turned up half an hour ago was like good posture, very confident, shaking hands.

31:32And now I'm at the table not saying a word because I don't know who to focus on, what to say, what's going to get the most praise from the group. There's too much going on. Absolutely. So much stimuli, isn't there? You're kind of talking about maybe the brain not being able to filter out all that information. So there's the words that people are using. There's their facial expressions. There's the noise of the restaurant. there's the unpredictable you know the friends that then come into the conversation and thinking oh how do I manage this and it's really interesting that you talk about kind of losing your speech I think it's one of those things that a lot of people don't understand and I think it's absolutely fascinating because it comes up in so many of my assessments where people say I literally don't know what to say you know I feel like and especially if you're put into a pressurized situation where there's so much visual clutter and there's so much sensory stimuli it's that sense of But I would know what to say in a different situation, in a different context.

32:31But I feel that that's a moment of dysregulation. So often for autistic people, being regulated and being able to thrive as a regulated human being, having your sensory differences appreciated, supported, being accepted, having your communication needs met as well, and having that predictability around a situation can really help someone to thrive. But if you're kind of thrown into a situation that for many people would be very manageable, it's not surprising that the body will communicate or not communicate, you know, lose its speech. Some people describe anxiety symptoms in that situation as well, where they will look like they're not reactive, so they're shut down.

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