I have written a letter which I intend to email to the ASC Diagnostic Team tomorrow for the attention of the Speech & Language Therapist and Clinical Psychologist I saw. The majority of it is below, modified for clarity in the context of this blog:
I feel that perhaps enough wasn’t taken seriously or discussed with me in depth from my written questionnaire; you both said that “the person in the room was different from the person in the questionnaire”. I think this is because I have had to “put this mask on so much that it has become my face” and that my most truthful self is the one written about in my questionnaire; it’s too painful for me to reveal that person in a room with complete strangers, though perhaps it would have been better to do so because of the outcome of the two appointments.
I feel that I was discredited because I’m too sociable. I feel that, despite my indicating early on in the first session that my American-ness may work against me here, this was disregarded. Also, being the firstborn in my family could also be an indicator as to why I am outgoing, but being outgoing is not a contra-indicator of ASC; being outgoing is a big feature of being from America – if we don’t take initiative and present as “confident”, we’re classified as “weird”. In England, one is allowed to be quiet and more reserved. I don’t believe that the reality of how I was taught to be was fully taken into account, and certainly, my more ASC-type traits did not come out in just seven hours of observation.
Watch Jennifer Cook O’Toole on YouTube (https://www.youtube.com/user/AsperkidsVideos) – remind you of anyone? She is a well-known writer with ASC and is very American and outgoing, and probably would have been undiagnosed in the UK.
I have related my experience to a fellow female expat who is a writer and public speaker with ASC (I will refer to her as G); I have been chatting with her periodically online since meeting at the Autism Show in Birmingham last summer. She indicated that I may need a longer than average assessment and this would be in keeping with the Equality Act of 2010, which would argue that reasonable adjustments need to be made so that I am not inadvertently discriminated against because I am from a different culture. She said a longer assessment would be totally reasonable to ask for as 50% of the diagnosis rests on how I interact socially and I’m from another country where social interaction is reinforced differently (remember that I was 23 when I moved to the UK, so beyond my formative years). This is especially true if your service is considering denying the diagnosis based on my social presentation. As you know, women with ASC are good at hiding their traits, and American women will be exceptionally good at hiding them. G’s first diagnostic appointment resulted in her being told that she did not have ASC, but following further appointments for a second opinion, she was eventually diagnosed. I did not think that I would have to go through the same uphill struggle that she has; she is also the one who shared the YouTube link above.
Not much was discussed regarding how I felt about being on the periphery of my social group at school, despite me explaining how traumatic it was finishing high school and just completely obliterating my relationships; that is not typical behaviour, especially since I couldn’t identify a particular incident or altercation which caused it. G also read the extended version of my questionnaire and said the following (this was via email communication):
You mentioned feeling like you were on the periphery of your social group at school. You mentioned being bullied and taking times away from people. There was some detail but try to dig out more. It may be hard to do with you not being able to recognise and retell the specifics of what transpired or what went wrong. It’s hard to know at which moment you were “being weird” if you don’t know when you’re “being weird”.
A person on the spectrum would be bad at explaining exactly when they “got it wrong” socially, why they didn’t click with the group as well as others. I imagine this is the most difficult part for you to dissect, but this also is the part that your “outgoing” personality masks the most. They aren’t seeing the social disconnect in the room, so you need to dissect past social exchanges and explain where it has happened.
It’s hard for me to recall back this far, as the high school fallout occurred 12 years ago and my memory is patchy at best. The only things I seem to recall in clear detail are things that had very strong emotions attached, usually of guilt or shame, which I have worked hard to cast from my mind because they are so debilitating. When I think about finishing high school, I can only remember feeling very anxious, uncertain and out of control. I think I cast away my friendships from the past 4-7 years [middle school into high school] at that point because that gave me some semblance of control, despite it completely isolating me between graduation and starting afresh at university in the dorms. I did very little that summer break because all my friends must have grown weary of trying to engage me and dealing with my flat-out refusal. Like I indicated on my questionnaire, I’ve “virtually reconnected” with most of these friends, but we have not spoken of what occurred at the end of high school, and while they are on my Facebook friends list, we do not talk like friends do. We may exchange birthday greetings, but that’s about it – how much more superficial can this be?? We have reconnected as “someone that I used to know” but that’s about it. Does that help?? Just because I appeared on the surface to get along with them all fine in my early years, doesn’t what happened in adolescence obscure that somewhat?
G also indicated that I wrote a lot about rigidity and a need for sameness and routine in my life in ways that have nothing to do with my sensory issues, and she said, “I don’t know how anyone can dismiss these.”
She indicated certain points from my questionnaire under Current Difficulties which jumped out at her:
- needing sameness when living with Paul’s mother
- I hate answering the phone, especially at work
- I struggle being in overcrowded spaces where personal space can be an issue, especially any store which becomes crowded with shoppers prompts me to leave
- social blindness when out in public
- group conversations, especially being interrupted and unable to finish my thought or story – present in childhood and adulthood.
- I can understand sarcasm, but only when context is given
- perfectionism, which I had always attributed to being a “typical first born”, which can explain why I am so outgoing
- as a child, I was very particular about keeping my toys in order and in pristine condition; my dad’s questionnaire probably didn’t say anything about this and he would probably have put it down to having taught me to respect my belongings… it was much more than that.
- I preferred playing alone a lot of the time and didn’t regularly have friends over; I also did not (and still do not) initiating interactions and prefer someone else taking the lead and joining in when appropriate. I do not feel confident in initiating but will only do so when no one else will because I’m frustrated and want to get on with whatever the task is because I can’t take the awkward silence anymore.
- you had me talk in detail about the bullying that I endured; I thought surely this would have mattered more strongly – again, just because my dad didn’t pick up on it does not mean it didn’t happen; I was quite private and didn’t tell my parents everything or would just tell them things were fine
- particular about colour-coding things, especially in a ‘rainbow’ order
- need for symmetry and matching
- borderline ritualistic about numbers – I even described how Paul’s and my wedding date was “pleasant” – no one else I know has done that
- resorting to putting on the same movies or TV series that I’ve seen multiple times to have on in the background – I can’t even begin to guess how many times I’ve watched and re-watched Daria on my Amazon Fire TV box or on my Fire Tablet when getting ready (for work or going out)
- parking space at work and parking near an edge so I can find my car again
- gauging the speed of fast-moving objects
- handwriting and drawing – having an awkward grip and not ever being picked up on for it
- problems with hormonal birth control – although others might not register this, but she agrees this demonstrates a fragile chemistry and I felt was quite compelling
G also attached some PowerPoint slides called Missed Diagnosis or Misdiagnosis? Girls and Women in the Autism Spectrum from Dr Judith Gould, Director of the NAS Lorna Wing Centre for Autism. I will attach it with this letter but I am going to highlight some of the stronger points here:
- Historically there has been a strong gender bias of more males than females; as a result, professionals are less likely to diagnose girls/women even when symptoms and behaviours are evident
- Asperger (1944) suggested autistic traits in females become evident only after puberty
- My dad moved out of the family home when I was 13 years old and only saw me once every two weeks for several years, so he would not have necessarily noticed these traits and would assume my stroppiness whenever he came to visit was because of being a teenager rather than anything else presenting differently to my peers. I would agree that difficulties became more present after moving up through middle school into high school, culminating in the friendship breakdown at the end of my senior year of high school.
- There is still a strong gender bias towards diagnosing boys (linked with descriptions in the International Classification Systems)
- Social Interaction
- Girls more able to follow social actions by delayed imitation; they observe children and copy them – masks symptoms
- They are on the periphery of social activities [which I highlighted]
- Girls more aware and feel a need to interact socially
- When involved in social play are often led by peers rather than initiating contact [I agree with this – I rarely initiate because I don’t feel confident enough to do so.]
- Girls more socially immature and passive than typically developing peers
- In primary school more likely to be ‘mothered’ by other girls but bullied in secondary school [YES to the second part for sure; I can’t remember being ‘mothered’ in elementary school.]
- Social Communication
- Little difference in acquiring speech in girls and boys
- Girls generally have superior linguistic abilities to boys of a similar cognitive level
- In society, girls are expected to be social in their communication but they do not “do social chit-chat or make meaningless comments to facilitate social communication” [when I do make social chit-chat, it’s to quell the awkward feelings when not much is being said… that’s more unbearable for me than sitting in complete silence when there’s a lull in the conversation.]
- Social Imagination
- When involved in solitary doll play, they have a ‘script’ and may reproduce a real event or a scene from a book or film [I vaguely recall playing with my Barbies with an almost soap opera-like script, as when I was at home with my mother, she would regularly watch The Young & The Restless.]
- There is a lack of reciprocity in their social play and can be controlling or domineering [I would get cross if my little brother wasn’t playing the way I wanted him to, which would lead to him and I bickering and fighting, which was probably minimised to sibling interaction.]
- Special Interests and Routines
- The male stereotype of autism has clouded the issue of diagnosis
- Girls are more passive and collect information on people rather than things
- The interests of girls in the spectrum are similar to those of other girls
- Perfectionism is frequently seen in girls [Ding! Ding! Ding!]
- It is not the special interests that differentiate them from their peers but it is the quality and intensity of these interests [I minimised the intensity of my areas of interests in the appointments because I have enough social wherewithal to know when it is and is not appropriate to talk about them in great detail, but that doesn’t mean that they are not there. Again, something not touched on much in my two appointments.]
- The Diagnostic Criteria
- The current systems do not give examples of types of difficulties shown in girls
- There is a need for a wider perspective regarding social, communication and imaginative dimensions in addition to special interests and rigidity of behaviour
- There is a need to ask the right questions and make appropriate observations
- Over- and under-reaction to sensory input is an important feature for all on the autism spectrum and is common in females
- The Importance of Diagnosis
- A diagnosis is the starting point in providing appropriate support
- A timely diagnosis can avoid the difficulties women experience throughout their lives
- Diagnosis can lead to assessment of needs in employment (amongst other areas)
- Dale Yaull-Smith, NAS Communication, 2008 – “The fact that girls with undiagnosed autism are painstakingly copying some behaviour is not being picked up on and therefore any social and communication problems they may be having are also overlooked. This effort of mimicking and repressing their autistic behaviour is exhausting, perhaps resulting in the high statistics of women with mental health problems.”
I don’t dispute that there may be an element of Sensory Processing Disorder on my part and look forward to meeting with the Occupational Therapist to discuss this further. I have also purchased Too Loud, Too Bright, Too Fast, Too Tight to investigate things further (like I have done with Aspergirls and the other ASC books I have read) in the meantime whilst I’m awaiting the appointment to be made. However, I still feel that my diagnostic process was too short and inconclusive. I’ve been doing my best to keep myself back from the edge of completely shutting down and being signed off work until this is resolved, mostly because I cannot afford to be off work long-term and I know myself enough that if I were to cave in and stay at home in bed, it will be infinitely harder to pull myself out of that funk and get back into work than just persevering with it, no matter how much it emotionally drains me.
You want to see the real me? Please read between the lines of my questionnaire again. Read between the lines of this letter. Yet again in my life, I feel like I’ve been misunderstood and it hurts me to my core that I have to practically beg for this to be understood. The thought of going into work today and facing people was too much to bear, so I’m working from home. I feel like raw nerve endings – on edge, anxious, unsettled, unsoothed – even a nice shower didn’t alleviate my anxiety this morning. Is this what you needed to see? This is the person that is in the questionnaire; I’m sorry you didn’t get to see her in those two short appointments, but considering that I’ve had 31 years of adapting my behaviour to appear “normal”, I think it takes a bit more than six hours to get to see her, especially since she knows how to behave in a clinical setting.