10 things to keep in mind when working with adults with ASD

Adults with Autism Spectrum Disorder (ASD) represent a diverse spectrum of individuals with various functioning levels, from working and married with children, to living in a highly supervised setting and having all basic needs met by a caretaker. The level of functioning will affect the approach one takes when evaluating an adult with ASD. Mental health professionals may encounter adults with ASD in a variety of settings, and it’s important to understand how to work and communicate with this population in order to best set them up for success. Here are 10 considerations when treating adults with ASD.

Individuals with severe ASD who are lower/low functioning:

1. Collateral informants are important. Because individuals in this category will have significant problems relaying a history, if they are able to at all, collateral informants are very important. More than one (from different settings) can be particularly helpful.

2. Be cognizant of changes in behaviors. Often, patients with severe ASD are brought in for evaluation due to a change in behaviors, including:

changes in routines, including sleeping and eating;
increased agitation and aggression; and
self-injurious behaviors (SIB).

3. A good medical evaluation with lab work is a critical first step in order to rule out any medical conditions, including:

dental problems;
pain, including headaches;
ear infections or earaches;
abdominal conditions, including constipation; and
other medical conditions

4. Ask about any recent changes in routine, as individuals with ASD are very sensitive to this.

changes in routine can cause a change in the person’s behavior; and
this includes changes in caregiver, whether the individual is living in a group home, supported setting or living at home.

5. Individuals with ASD should be evaluated for different psychiatric syndromes, which can be recognized when doing a thorough evaluation of the whole picture, including:

mood changes – level of happiness, crying, irritability;
changes in vital sense, such as appetite, energy, distractibility, sleeping, sexual activity, and interest in activities, etc.;
group homes / residential settings will sometimes track sleeping and eating habits in charts or logs; and
apparent attending to hallucinations, though this can be very difficult to identify for certain, since one cannot directly examine the person’s mental state.

6. Be sensitive to the possibility of abuse, although this is not usually the case.

Individuals with ASD who are higher functioning and have better communication skills:

7. Collateral informants are still important. In this situation, the person may be coming in on own their own or at the behest of a family member or friend. Usually, one can obtain a useful history directly from the patient, but collateral information is always important and helpful, if the patient consents.

8. A good medical evaluation is still important to rule out medical problems.

9. High functioning individuals with ASD may also have trouble describing their mood states.

Because of the difficulties in interpersonal abilities and affect recognition for a person with ASD, one may need to consider vital sense and other symptoms and behavioral manifestations of affective states, including a loss of interest in activities when considering different diagnoses.

10. Be careful in questioning. Some individuals who are fairly high functioning can be somewhat concrete in questioning and have trouble understanding metaphor. Be careful how you ask about hallucinations and delusions, for example.

Robert Wisner-Carlson, MD, joined the Neuropsychiatry Program at Sheppard Pratt in 2007. A graduate of University of Michigan Medical School, he trained in psychiatry at The Henry Phipps Psychiatric Clinic at Johns Hopkins Hospital and at Maudsley Hospital in London. He holds specialty certification in Behavioral Neurology and Neuropsychiatry from the United Council for Neurologic Subspecialties. As well as leading The Developmental Neuropsychiatry Clinic, Wisner-Carlson is also service chief for the Adult Neuropsychiatric unit at Sheppard Pratt Health System. His areas of scholarly interest include comorbid behavioral and neuropsychiatric problems in individuals with intellectual disability and autism spectrum disorder, the young adult transition in ASD, and genetic disorders in developmental neuropsychiatry.