What is Spectrum?: The Importance of Pattern

Autism in the Adult

Join Dr. Regan for an episode about what "spectrum" means and why the pattern of neurologic characteristics in each individual is so important to understand.

Dr. Regan's Resources

New Course for Clinicians - Interventions in Autism: Helping Clients Stay Centered, Connect with Others, and Engage in Life

New Course for Clinicians: ASD Differential Diagnoses and Associated Characteristics

Book: Understanding Autism in Adults and Aging Adults, 2nd ed

Audiobook

Book: Understanding Autistic Behaviors

Autism in the Adult website homepage

Website Resources for Clinicians

Read the episode transcript:

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Hello and welcome.

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This is Dr Theresa Regan,

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your host for this podcast,

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autism in the adult.

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I am a neuropsychologist,

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a certified autism specialist,

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the parent of an autistic teenager and the director of an adult diagnostic autism clinic in central Illinois.

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I am happy that you're joining me today for our episode about spectrum.

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What does that mean?

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And Why is pattern important?

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So let me explain a little bit of background as far as where I'm coming from with spectrum and pattern.

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So as a neuropsychologist,

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I specialize in understanding how brain pathways and brain health impact things like thinking,

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skills but also emotions,

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personality and behavior by looking at how someone's brain is able to process verbal information or learn new information,

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pay attention how they're able to balance emotions or plan for the future.

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The neuropsychologist can make conclusions about the health of the brain or specific ways that the brain has connected informed pathways across different locations.

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So we know that the brain is divided up into various areas and the locations can have specific functions specific jobs.

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So the left hemisphere versus the right hemisphere or the center of the brain versus the outside.

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There are also specific nuclei in the center of the brain and there are lobes that we talk about the frontal lobe,

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the parietal lobe,

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etcetera.

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So the brain is really special in that the neurology is patterned and localized and there's a function to it.

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So one of the ways that a neuropsychologist makes conclusions about those patterns and what's going on in the brain is by looking at the way that the brain behaves.

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So how does it do with reading?

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How does it do with um staying calm and centered?

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And that gives um revelation about the connections,

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the anatomy,

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how the brain is wired.

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So a huge focus of what neuropsychologist analyze is.

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Not any one score.

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Like let's say we give a memory task and a reading task and we look at something called praxis,

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we're not gonna look at any one score.

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What did this person get correct?

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What did they get wrong?

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Um No,

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we're looking for this data to fall into a pattern.

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It's the pattern that is really where the revelation is.

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And once we get a significant amount of data from a checkup,

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we look for how these pieces of data hang together.

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So the pattern should be consistent with the way that the brain is organized anatomically.

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So in the same way that a neurologist would check your vision or reflexes your walking patterns to make conclusions about the health and functioning of the brain.

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A neuropsychologist also uses information um about patterns.

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So we look at cognitive scores,

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we make behavioral observations and we uh make conclusions about how the brain is functioning.

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Different types of situations will have different patterns because various pathways might be impacted uh in a sequence that's really kind of unique.

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For example,

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if someone has a traumatic brain injury with a left sided brain bleed and a diffuse axonal injury ... that has a different neuropsychological pattern than someone who presents with the Parkinson's condition and because of this neuropsychologist are very practiced at looking for pattern and understanding how important pattern is and understanding the neurology of the individual.

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In the case of the autism spectrum.

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Certain neurologic characteristics hang together in one person because of differences in the development of the nervous system.

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The characteristics hang together behaviourally because they fall within specific pathways.

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They cluster together anatomically in some way because scientists have noted that these neurologic characteristics sometimes hang together and one person they say oh we should call this cluster of neurology something so that we can start talking about it and learning more about it and then it's been decided that we'll call this clustering the autism spectrum.

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So when do we actually call that neurology autism.

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So what the scientific community has done is determined seven diagnostic criteria to look at in the assessment process.

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And they've also developed general guidelines and as with any of um the diagnostic conditions that we have in the D.

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S.

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M.

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Five,

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the diagnostic and statistical manual fifth edition.

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You know there are committees that get together and they look through research and our current understanding and they determine then what the criteria are.

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But there are always discussions and disagreements about uh when do we call this autism when do we call this depression when do we call this dyslexia whatever the state is that they're trying to describe.

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So one thing is to know that there are seven diagnostic criteria.

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And then there are also uh,

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disagreements and discussions about whether other things should be included,

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um,

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etcetera.

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But for our purpose,

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what I want to emphasize is that there's this structure,

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these criteria and the first three are social in nature and all three of those must be met.

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The last four criteria are grouped into what's called repetitive and restricted behaviors,

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and only two of the four must be met.

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So one type of pattern that we see in autism is that individuals may have unique patterns of which specific criteria are met in order to get this to meet this diagnostic threshold.

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And that can mean that individuals on the spectrum can really present differently.

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So one person may meet all seven criteria.

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Another may meet five or six criteria,

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depending on how many of that last grouping they present with.

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Think about this.

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There could be two people who both meet five criteria,

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but they meet different groupings of the criteria and therefore they present with somewhat different characteristics.

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So they may meet all three of the social criteria.

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And then two of the last four.

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But which two?

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And that brings this uniqueness of what the features are for these individuals.

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So the combination of which criteria are met will create a pattern for that individual.

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And this is part of what I consider.

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When I'm thinking about spectrum?

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What does spectrum mean?

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Well,

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to me,

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it's pattern and that the pattern in one person versus another person who meets criteria for the threshold of diagnosis,

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that's gonna have some unique flavors to it.

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So the neurologic foundation,

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the criteria are met in both individuals,

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but they can be met with a different pattern of features.

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It is not true that individuals with seven criteria met have more significant impact in their daily life than someone where five criteria are met.

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This does not have to do with how much someone is impacted.

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It just has to do with the breadth of the neurologic features.

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Um,

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some of which will really be beneficial to that individual.

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They'll help in their daily life and other things that will be challenges.

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But the number of criteria,

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those do not determine,

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uh,

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what some people call quote severity,

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um,

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of autism.

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A lot of people who come for a diagnosis want information about,

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about severity.

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And that's not what we're talking about.

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We're talking about pattern because,

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you know,

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it's so important to understand each person as an individual and it's not enough to go for a diagnosis and then be told,

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well,

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yes or no,

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you fit the criteria or you don't really,

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what you're coming for is revelation of this pattern.

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Well,

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what does this look like in me?

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How does this impact my daily life?

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What are my strengths and challenges within this neural neurologic pattern.

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And that's where the gold is.

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That's where the spectrum is.

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That's where self awareness and understanding lie in this revelation of pattern.

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In addition to the pattern across the seven criteria,

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we also want to look at the pattern within each criteria.

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So there are different layers of pattern.

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Let's say someone meets the same five criteria that another person meets,

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but they can still meet each individual criteria with unique features.

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So let's take this and talk about it.

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For example,

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let's take the first criteria.

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And this has to do with difficulty in the area of social approach social reciprocity and the back and forth flow of conversation during social interactions.

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And usually this criteria is called the social reciprocity criteria.

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And reciprocity means exchange.

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Um so what we're looking for here is not whether someone can exchange information about topics and facts,

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but whether they lean toward being able to exchange information for social purposes for emotional purposes and to take turns.

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So there's kind of an equal exchange um in connecting with another person,

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one autistic individual may meet this criteria because he rarely approaches others at all for any kind of social exchange.

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So this approach,

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piece of the criteria may be very limited when he does approach,

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he really only wants answers to questions directly asked.

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Um or he will uh answer a question if somebody else asks it,

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but he basically exchanges facts and data,

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but he doesn't really fully engage in exchanging social and emotional information?

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For example,

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if someone is explaining why they're looking forward to christmas,

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this autistic individual may say something like uh huh rather than really fully engaging in that social peace um or saying something like I've always loved christmas too.

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What's your favorite christmas tradition?

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In contrast to the autistic individual who does not tend to approach or engage socially,

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another individual may do so to really an extreme level a level that does not create good social exchange because it's done too frequently.

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This individual may respond to the Christmas comment by talking in a monologue for 15 minutes about the differences in Christmas traditions across the world and the impact of Pagan practices and celebrations on current Christmas traditions.

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Now the first and the second individual both struggle to appropriately exchange the social piece of interaction,

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one because of infrequent exchange and the other because of too much approach and exchange and too much talking,

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not taking turns and asking for the other person's input.

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Um and really allowing there to be the social emotional piece instead of uh kind of a large exchange of factual information.

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So this is an example of the pattern within a criteria.

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Um so it can look unique from person to person on the spectrum.

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Another example of an internal pattern within a criteria would be the 7th criteria,

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which is about sensory processing.

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Now this criteria does not have to be present for a diagnosis,

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but when it is present,

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the pattern may be one of high levels of reactivity to sensory information.

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So this could be,

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for example,

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someone that's really very sensitive to touch or light.

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It could be a pattern of under reactivity to sensory information.

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So when they experience something from the sensory environment,

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they just don't notice it as much as other people would.

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And it could also include an unusual fascination with sensory aspects of the environment.

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So really loving to watch visual movement or to smell certain objects,

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that this sensation,

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this part of the environment is really fascinating.

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So one autistic individual may show extreme sensitivity to sound,

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a very narrow range of food textures in their diet and an extreme need for high levels of movement.

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This vestibular sensory process,

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but a second individual may show a different pattern within sensory processing.

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So they might show a very high pain tolerance that they don't even notice that their finger was broken until they realized they couldn't hold a pencil to complete a form even though the injury occurred the day before.

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Ah This person may also be highly sensitive to movement to the point where they'd rather sit still and do table work than moving around or playing sports or going outside.

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So even though people meet the same criteria,

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they certainly may meet those in different ways.

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And that individual pattern is really important.

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Given these examples of patterns across the criteria,

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for example,

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how many are met,

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what pattern of criteria are met.

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and also within each criteria.

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What do the specific sensory differences look like for this individual?

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For example,

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you can get a sense of what spectrum can look like.

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So this is how I view the term spectrum,

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I really don't find it useful uh as any kind of um continuum of what people would call severity.

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Um but rather spectrum is a way of knowing that the same neurologic criteria are met for all of these individuals,

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but the specific neurologic manifestations,

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the way that this neurology manifests will vary from person to person and that level of individual insight with people that's so important to um kind of reveal that it's not enough just to have a global uh term that we're going to call things,

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we really want to know people on an individual level,

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it makes more sense to look at how much struggle someone's having based on a pattern rather than the number of characteristics or to analyze how they are so gifted in this particular academic subject or this particular part of work or life um life skills and ways that that is a manifestation of their unique neurology.

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So whether we're looking at struggles or gifts,

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challenges or strengths,

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we like to know the pattern this person has both and in a unique pattern that's different than this next person that we see on the spectrum.

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When we're able to examine what the pattern of neurologic features are for one specific person,

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then we can work towards increased self awareness of pattern for that individual,

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maybe for family around them,

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who want to understand better but feel confused and to focus on strategies that may specifically address um,

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the strengths and challenges of this person.

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You know,

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how can we amplify the things that they're just so strong in and how can we help with things that are challenges or things that are draining and really making some of life more difficult than we wanted to be?

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Part of.

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What I think is most valuable about the diagnostic process.

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Is this kind of feedback from the clinician to the individual about not just yes or no,

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Is there a diagnosis,

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but what does autism look like in me?

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How is that manifest?

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And oftentimes people coming in for a diagnosis will know some of that,

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but the clinician should be skilled enough to say.

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And I also see this in you.

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I see that this pattern in your nervous system likes this and I'm wondering about this issue here so that there's more revelation about pattern.

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It's more um identified.

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It's more specific.

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It's clearer.

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Um and that is part of what makes the assessment process so valuable.

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Let's end with a few more examples just to highlight what I mean by pattern and differences between two individuals on the spectrum.

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So let's take Julio who is a 50 year old male.

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He's working as a structural engineer for a local company,

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he's married to Mona,

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they have three daughters and the last of their daughters has just moved out to attend college.

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So they are in this early empty nest season.

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Life is changing and Mona really starts to spend quite a bit of time alone with Julio when he's not at work and she brings him in to see a psychologist because she feels that Julio is depressed.

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Mona notes that with her Children gone,

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she's really struck by how limited Julio converses with her at home.

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It's very quiet now and she can't really get much out of him.

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He's likely to come home after work,

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eat dinner,

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go to the basement to work on his tabletop Battle replicas most recently highlighting the Battle of the Bulge,

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a famous battle from World War Two.

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Now when she invites him to watch a tv show with her after dinner instead he'll sit in the rocking chair and watch the show but does not like to talk or a visit during the program.

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His facial expressions and tone of voice is either serious or really kind of flat or empty of emotion and she has a hard time gauging what he's thinking.

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She's used to the more energetic conversations that she would have with her daughters and she concludes that Julio is depressed during this life season of change.

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He's thinking about uh Retirement in the next 10 years.

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He is with Mona now in an empty nest.

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And she hypothesizes since he doesn't talk very much that his thought process has to do with depressed mood.

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Now.

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We didn't talk about all the autistic characteristics in Julio,

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but you can get a flavor of how this is manifest in their home.

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In contrast,

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let's take Maddie who was a 27 year old,

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single female.

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She has no Children and she has always loved to be the center of attention.

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She's put on plays and music performances for her family as a child and then she focused on magic tricks.

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When she was in middle school.

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She really wanted to wow everyone.

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And what became apparent is that she really liked to have the role of an entertainer and she liked to have an audience.

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Um that could see all of her gifts and talents.

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She also liked to take control of the topics of conversation,

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so making sure that it's something she's really interested in,

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like greek mythology or sewing costumes for theater or cosplay events.

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She has a hard time understanding how she impacts others.

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What does this person need from me during the interaction and some people feel like maybe she's really controlling because she likes things to go her own way and doesn't care about other people.

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But this is really a misunderstanding.

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She feels comfortable in a specific social role and she also likes to know what's going to happen next.

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So she likes to choose the activities that they do together or the topics that they're talking about.

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She over plans,

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vacations with family and will hand out a schedule of activities to everyone.

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She'll leave the room of someone who wants to talk about their own interests.

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And even though she talks successively,

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she also complains about noises that other people make when they talk.

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Uh,

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so she wants people to be quiet and people around her are very confused,

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like how can you talk so much and also want us to be quiet.

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But that's a very common phenomenon and sensory processing that the person is much more upset by surrounding noise than their own noise.

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She wears noise,

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canceling headphones around others and people feel because of this pattern that she's very self absorbed.

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They really,

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she's misunderstood essentially.

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Um,

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she doesn't ask other people how they're doing or what they need,

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how their weakened was she often corrects others when they make errors of detail,

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like saying something cost $50 when it actually cost 50-37.

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So both of these people did not realize their diagnosis.

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Uh,

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and then at a certain age in life,

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they were given a diagnosis and the information about their neurology helped them understand and those around them what,

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how the neurology manifest both in things,

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they were really good at the things that were gifts that were strengths and also things that were characteristics that they didn't intend to isolate themselves from anyone or hurt anyone's feelings,

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but they really just had different needs socially and with this increased awareness.

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People were able to understand and interact in a more satisfying way.

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So both individuals struggled to socially connect with others.

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But while Julio was under engaged with his wife,

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Maddy ended up being over engaged in her social exchanges and she wasn't as attentive to the needs of others.

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Being aware of why two autistic individuals can both meet criteria but look quote so different on casual observation can help us connect with the concept of spectrum.

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We also can become more aware of why one autistic individual may benefit from one thing as a recommendation while another needs something different that we have this unique patterning and that part is very important.

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There are the same neurologic foundations but with different specifics in the characteristics.

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So whether we're talking about an autistic individual who is really self aware,

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who has strategies that really help them during rough spots and who is able to focus and use their strengths to great advantage and to um really meet their goals and to help others or if we're talking about someone who is not diagnosed or newly diagnosed and still learning this concept of the individual pattern,

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The individual spectrum of qualities really is an important revelation to focus on understanding each individual because that's where the power is right.

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I see you,

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I hear you,

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I get you better.

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I think we can connect more.

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Um,

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that's really the magic about thinking about pattern within the spectrum.

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I am really glad you joined me to hear about pattern and spectrum today within autism.

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And next time we'll be starting a new series and we're going to focus on misdiagnosis on the autism spectrum.

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In addition to those who are on the spectrum who don't carry any diagnosis,

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many others carry a misdiagnosis or several,

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um,

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diagnoses that really are not correct.

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And often this is within areas of mental health.

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So we're going to start by talking about why this occurs on the spectrum.

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And then we're going to review various conditions that are common culprits for misdiagnosis such as borderline personality disorder,

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bipolar disorder,

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attention deficit and more.

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I hope you'll join me for our next series on misdiagnosis.

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And thanks for tuning in.