Patty Kikos interviews Dr Fiona Aldridge for part 1 of this interview series. Fiona is a clinical psychologist who joined ‘Autism Spectrum Australia’, also known as ‘Aspect’, in 2008 and is currently the manager of Aspects Assessments. She shares how the DSM 5 criteria helps define autism around social and social communication skills, along with the presence of restricted and repetitive behaviours. . Part 2 will be available soon.
Fiona Aldridge:
The 2nd area under that behavioral criteria, is around routines and rituals, and I guess we're talking about nonfunctional routines and rituals here. So being very insistent on doing something in a certain way and struggling to cope if that has had to change. So if mum normally drives a specific way to school, and for some reason that changes, there's bad traffic or there's a problem.
Patty Kikos:
Or lo and behold, you have to change car seats for today, yeah?
Fiona Aldridge:
That's it! Or you need to stop and get some milk on the way home, or whatever is going on.. So, finding that very difficult and not being able to go with that flow.
And to be honest, I think all of us probably naturally operate on some level of routine.
Yeah, but I guess it's about not coping well if that routine changes, like If there's a different teacher, or you need to make a detour on the way home if, or it rained, so you can't go to the park.
Patty Kikos:
Like at a scheduled time, yeah?
Fiona Aldridge:
Yes that’s right, and really not being able to cope with that, and finding it all quite distressing.
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Billy:
From the Carer Gateway at the Benevolent Society, we welcome you to, Carer Conversations with your host Patty Kikos.
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This podcast is where we share interviews with guests that have specialized knowledge to help support carers to look after their emotional, mental and physical well-being.
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Patty Kikos:
Hello and welcome everyone. Today, I'm particularly excited to share Part 1, of a 2 part interview, with Doctor Fiona Aldridge. Now I have a sense that you might get sick of me, saying that this guest is very special. But she is because she's my first guest.
Fiona is a clinical psychologist who joined ‘Autism Spectrum Australia’, also known as ‘Aspect’, in 2008 and is currently the manager of Aspects Assessments. She holds full registration as a psychologist with AHPRA, and has specialty area endorsement in clinical psychology.
Fiona has worked with children and adolescents for many years in a range of contexts, and specialises in the assessment, diagnosis and provision of support for Autism Spectrum Disorder, (also known as ASD), Intellectual Disabilities, Developmental Disabilities and Learning Difficulties.
I'm sure you're going to love this interview with her as much as I did.
When it comes to defining autism, I often like to use the analogy of comparing a Mac computer with a Windows version.
Now both are different, and while they may not necessarily do and see things the same way, both are unique and amazing in their own way.
And when it comes to human interaction, I'd like to think that we're sophisticated enough to learn how we can collaborate and thrive together, irrespective of whether we are neurotypical or neurodiverse.
So Fiona, I guess that's my first question to you. What is autism? How would you define it for our carers and our listeners?
Fiona Aldridge:
So really, I think autism is a condition or a way of being, that affects how someone sees, thinks, feels, interacts with other people and experiences the world, so it's their way of perceiving, their way of interacting with those around them and the world around them.
When it comes to a formal diagnosis of autism, however, there is a set of specific criteria or symptoms that we would look for.
And the criteria that we use in Australia are outlined in the diagnosis, diagnostic and statistical manual 5th Edition.
Patty Kikos:
Can you tell us a little bit more about what that means, exactly? Because I know that it's usually referred to as the DSM 5.
Fiona Aldridge:
So the DSM 5 is a book published by the American Psychiatric Association. I think the EPA that outlines a set of criteria for a whole range of conditions that either neurodevelopmental or developmental conditions or mental health conditions and it contains the recipe or the criteria for each of those conditions, and in Australia it is the set of criteria that we use for Autism Spectrum Disorder.
Patty Kikos:
OK, and can you tell us a little bit more about the the more formal criteria that is potentially used to diagnose autism?
Fiona Aldridge:
So when we're doing an assessment for autism, we do use those DSM 5 criteria. They define autism or autism spectrum disorder as it's called in the DSM five as meaning that someone has differences or difficulties in two main areas.
So the first area is around social and social communication skills and the second area is around the presence of restricted and repetitive behaviours. So there's a a social element to it, and a behavioural element as well. And we look for both of those when we're making a diagnosis.
Patty Kikos:
And can you tell us of a couple of examples of of the range of that spectrum? Because I was literally today years old when I discovered that Asperger's Syndrome is part of the autistic spectrum, and previously I thought it was actually a separate condition.
Fiona Aldridge:
Yeah, so I think that's a really common misbelief I guess. Or misconception and I think that it's a bit historical, if you like, there's a bit of a historical back story here, so the DSM 5, the 5th edition that we use now came into being in 2013 and it changed the way that autism was described and classified so prior to that, in the DSM 4, we had the autism spectrum disorders that included three different diagnosis autistic disorder, Asperger's disorder, and a condition called pervasive developmental disorder not otherwise specified or PDNOS, and they were all considered forms of autism.
They were kind of similar but different, but what research showed is that actually, they are all more similar than they were different and trying to separate them out into these different category was not that helpful. It didn't tell us about how a person was going to function or what their prognosis was, and so to reflect that research and increased knowledge with the 5th edition, the DSM 5 just has one kind of category autism spectrum disorder that includes, Autistic disorder, Asperger's disorder and PDD Nos. So yeah, Aspergers has always been kind of part of the spectrum, but it did sit as a separate diagnosis, whereas now that is not so much the case.
Patty Kikos:
OK, and this is something that is lifelong. It's a lifelong neurodevelopmental difference and like everything in life, it comes with strengths and weaknesses, right?
Fiona Aldridge:
Exactly, so it is considered to be a neuro developmental difference, which means a brain difference. It's a difference in the way that someone’s neurobiology works and is kind of wired up just like we have differences in terms of some people are great at reading and some people find reading a lot harder.
Some people are very musical and that comes more naturally to them. These are all kind of brain differences and autism I guess is a a group of specific differences that when they occur together, and they are having some impact on a person’s life, I guess that we call that autism.
Patty Kikos:
Yeah, like some people can easily assemble IKEA furniture and can easily program an Excel spreadsheet. I happen to not have those super strengths.
Fiona Aldridge:
Also, not my special abilities , and I think you know the thing is, as you said, there are strengths and their weaknesses associated with autism spectrum disorder and, you know, I think that's important to remember. I think, particularly when someone is going through a diagnostic assessment or a diagnostic process, and tried to apply for funding and different things like that. The process, I guess necessarily focuses on the deficits that someone has.
Because in part that's what the DSM 5 does, when we're looking at the criteria out there, we're looking at things like difficulties, forming friendships and relationships, difficulties making eye contact. Difficulties doing a whole range of things in order to determine whether someone meets the criteria, but that's just part of the person, right?
So even though that's what the diagnostic criteria might focus on and applications for the NDIS or other supports, look at that to determine eligibility, I think it's really important to remember that there are strengths. It's not the whole a deficit is not the whole person.
Patty Kikos:
Yeah, you're absolutely right, and you've also brought up an incredibly important point about the NDIS, and it's a topic in and of itself that we'll be covering on a separate podcast simply because we won't have time today. I want to pick your brain about certain other things and one in particular is what are some of the early indicators that parents, or carers might notice?
Fiona Aldridge:
So maybe in order to give a bit more context for that question or to help answer that question, I might if it's OK, just outline a little bit more of what the the DSM 5 criteria are. So I think I mentioned a moment ago that there's kind of two main areas of difference that we look at. We look at the social communication and then the more behavioural or restricted and repetitive area, and there are three kinds of symptom groups, if you like under the social communication area and for symptom groups under the behavioural area.
Patty Kikos:
And what are they?
Fiona Aldridge:
So in the social area, the three things that we're looking at the 1st one is around reciprocity, which is just a fancy way of saying how does someone go having backwards and forwards kind of interactions with other people.
So do they respond when someone smiles at them, or when someone starts a conversation or when someone greets them, do they initiate those kind of social greetings and interactions and cues?
Will they offer comfort to other people? Can they have a backwards and forwards kind of ping pong conversation? Or is it all one sided? So it's looking at that nature of interactions and relationships.
The 2nd area is it see if it’s more nonverbal communication. So how does someone use eye contact gesture, facial expression? Vocal quality, body posture, to aid their communication. To give a richer kind of communication.
Patty Kikos:
What would be an example of body posture?
Fiona Aldridge:
Yeah, so things like if we're really interested in something, we might sit forward in our chair to show our interest. If we're not interested, we might move back, or turn away and that is kind of appropriate use of body posture. But someone who struggles with that might not know that in some situations, it's appropriate to be close or to move in or what the meaning of those kind of different movements of the body are.
And then the final area is around developing and maintaining friendships and interactions. So this is things like forming and maintaining friendships, but also being able to read social cues. Understanding how the way the world works.
Knowing that you know, maybe if someone Looks away in the middle of a conversation, they're not that interested, or reading that kind of social cue. Knowing when to join a conversation, when to join in play, or when you're not welcome in play. Being able to take the perspective of someone else, putting yourself in their shoes.
Patty Kikos:
And having that camaraderie that seems to be natural, not interrupting at inappropriate times as well, I'm imagining
Fiona Aldridge:
That's it, that's all social cues. So knowing kind of yeah when it's appropriate to interrupt when it's not. I think it kind of quite good example is that you know kids learn when they're growing up that it's OK to swear in the playground and to kind of carry on, but they know not to swear in the classroom or in front of the school principal. That's a social norm and a social cue, and no one really teaches us that. We just pick it up yet. But people have difficulties in thatin this area.
And so that's the kind of a Social area, so then the second area is restricted and repetitive behaviours, or the more behavioural area.
There are 4 kinds of symptom groups in this one and the 1st one is around repetitive body movements. Repetitive use of speech, so this is things like, I guess some of the classic signs people might associate with autism like hand flapping or walking on tip toes or speaking in a very stereotyped or repetitive way up lining up toys, playing in that kind of restricted way.
Patty Kikos:
And would there be a reason for those predispositions, for example, the walking on tip toes, or the lining up toys in a particular way, is there a reason that drives that kind of behaviour?
Fiona Aldridge:
No, I suspect it varies for different people. At some some level, but I think it is just thought to be part of what autism is and the the neurological differences.
Patty Kikos:
So it would help people self regulate?
Fiona Aldridge:
Definitely, I think maybe it’s also pleasurable for them and they get enjoyment from doing it in in that way and or they might get some feedback from the movement, but I do think it probably varies a little bit for different people.
The 2nd area under that behavioural kind of criteria is around routines and rituals, and I guess we're talking about nonfunctional routines and rituals here. So being very insistent on doing something in a certain way and struggling to cope if that has had to change. So if mum normally drives a specific way to school. And for some reason that changes, there's bad traffic or there's a problem.
Patty Kikos:
Or lo and behold, you have to change car seats for today.
Fiona Aldridge:
Yeah! That's it or you need to stop and get some milk on the way home. Or whatever is going on. So finding that very difficult and not being able to go with that flow. I think all of us probably naturally operate on some level of routine, but I guess it's about coping as well. If that routine changes. If there's a different teacher, or you need to make a detour on the way home. If it it rains so you can't go to the park at a scheduled time.
Really not being able to cope with that finding that quite distressing. Or being prevented from doing something in a certain way, like if you always pour the milk into the cereal bowl before putting the cereal in. But someone stops you for whatever reason, not being able to roll with that kind of situation.
Patty Kikos:
Or going to that scheduled swimming class after you see your grandparents as opposed to before. Yeah little things like that, yeah?
Fiona Aldridge:
Yes. Or skipping bath that night because you are out and running late, Yep, that kind of quite little change I guess, but finding that difficult to manage and to to cope with or finding it distressing.
The 3rd area then is around forming very strong and persistent interests, so this is like sometimes called obsessions or passions, so things that someone focuses on, I guess to the exclusion of other activities. And again, it's not uncommon for people to do this, we all have our preferred topics, but I guess it comes down to the level of intensity and the interference. Potentially, whether it's preventing people from doing other things, so stopping them from joining social activities, because they would much prefer to engage in that interests.
Patty Kikos:
Yeah, like going to a family dinner at an uncle or aunty’s house for example or a sibling having a play date and you're interrupted.
Fiona Aldridge:
That's it.
Patty Kikos:
Can you give some examples of that fixation and behaviours around what can potentially happen when that gets interrupted?
Fiona Aldridge:
Yeah, so again, I think because someone who's autistic is still a person., there's a great range of variation, and really what someone can be interested in, and at a very strong level, is pretty much as big as the imagination. So sometimes it is just being really interested in typical age-appropriate things, but at a strong level, so your trains, PJ masks or Bluey or whatever kind of latest thing or for older kids, maybe Minecraft or Pokémon.
So the normal kind of activities, but at a stronger level to the point where that's all they want to do. Not having a range of different interests, through to things that are quite unusual for someone of that age to be interested in, so like little kids are really into fans or garbage truck, or the kind of topics that you wouldn't normally expect someone that age to kind of be fixated or interested.
And I guess the kind of things you might see if they were not able to access that might be, throwing a tantrum for whatever better word or becoming very distressed and upset, or it just throwing them off.
Patty Kikos:
And a tantrum that might take a little bit of time to de escalate.
Fiona Aldridge:
Yeah, that's it. It might be a more intense experience, I guess.
Patty Kikos:
Which happens, yeah, which happens in in in many instances anyway, regardless.
Fiona Aldridge:
Of course.
And then the final one is around sensory needs and sensory behaviours, and this kind of has two sides. I guess it has the sensory seeking side of things, so this is seeking out certain things. Maybe holding things up close to the eyes to have a good look at them or dropping down to a certain level to look at things in a certain way or from a certain angle. Rubbing and touching different textures, fabrics, the wall, or different things to get that input and really people can seek input for any of the senses.
The flip side is then that sensory sensitivity, so things like being very sensitive to noises and putting hands over ears or moving away from certain sounds or being sensitive to fluorescent lights or the feel of certain fabrics against their skin, or their teeth being brushed, or hair being cut.
Patty Kikos:
And certain textures in foods as well?
Fiona Aldridge:
Exactly, yes.
Patty Kikos:
And I mean the majority of us can experience this when we go shopping and we go into a store that has blaring music and we think “Oh my goodness, I'm starting to lose the will to live". It's almost like it's penetrating our amygdala? Yeah, so is this another level?
Fiona Aldridge:
Yeah, it's at a higher level and I think that's a really important point that you make that we can all probably identify with bits of these symptoms or indicators, (is probably a better term), than I've talked about. But it's about the overall pattern and also the level of impairment or the impact that's having on someone’s day-to-day life.
And when we look at making a diagnosis, we look at those 7areas. The 3 social and the 4 behavioural. And to say that someone meets the criteria for a diagnosis of Autism, you need to be able to say they have significant difficulties in all 3 of the social areas and at least 2 of the 4 behavioural areas.
Patty Kikos:
Yeah, that's important to note, isn't it? Because children will often display maybe 1, or 2 of these anyway, won’t they?
Fiona Aldridge:
Yeah, , I think most people of any age. I think I can certainly look at that list and say “Oh well, I'm a bit particular about how things are placed” or even different things, but it's that overall pattern, that's really important. And so I guess that's a little bit of a long answer.
Patty Kikos:
No that's a very thorough, very thorough explanation. Thank you for that.
Fiona Aldridge:
But I guess in terms of maybe to go back to indicators in very young children or those very early indicators. A lot of nonverbal behaviours, the nonverbal social behaviours that you would see early on.
So things like not making a lot of eye contact with other people not watching other people faces or not using gestures to communicate, quite small babies will wave goodbye and use those pre language kind of skills to communicate. So not seeing that can be an indicator.
Patty Kikos:
And then the adequate facial expressions for different emotions that correspond to that.
Fiona Aldridge:
That's it, I'm matching. I guess the matching of the facial expressions that there's not a mismatch. Things like not necessarily responding when their name is being called or not being aware of the people stuff happening around, when people walk in and out of a door, or when grandma comes or things like not being aware of things like that.
Perhaps a preference for solitary play, maybe not joining in with play times or story time at childcare but preferring to avoid those kinds of situations can be a little bit of an indicator as well as well as any of that kind of sensory behaviours or other behavioural indicators we were just chatting about.
Patty Kikos:
About and if parents or carers are concerned, what is your advice? Should they consult their GP or their early childhood nurse or pediatrician in the first instance? Is that what you think?
Fiona Aldridge:
Yeah, so I think I think I would say to parents to that to listen to your gut, You are the expert in your child, you know them better and spend more time with them than anyone else, so if you are worried it is important to see someone and to check in with someone. And I think that the local early childhood centre and the nurses there, or a GP is a really good place to start.
And then if they were concerned, they might refer on to a pediatrician, or an assessment service for a more thorough assessment. Or they might say, you know, “maybe we'll have a look at a speech assessment first, or we'll check hearing, or we'll do some things to get the the ball started”.
Patty Kikos:
OK. I think it might be time for some rapid fire wrap up questions. Are you ready?
Fiona Aldridge:
Ready
Patty Kikos:
OK, What's your favourite colour?
Fiona Aldridge:
My favourite colour is blue.
Patty Kikos:
Oooh what sort of blue like an ocean blue?
Fiona Aldridge:
All shades of blue, but particularly like a duck egg blue.
Patty Kikos:
Oh lovely, now if there's one book that you would recommend all parents read to their children, what would it be?
Fiona Aldridge:
I'm going to be a bit cheeky. I actually have two.
I really think reading is one of the great joys that you can do with your kids.
And for really little kids, I absolutely love ‘10 little fingers and 10 little toes’ by Mem Fox, because I just think it shows us how we're all different, but we're all the same and it's got such a lovely rhythm.
And then for slightly older kids, I love the book ‘Our Babies’ by Martin Waddell which I just think is such a real story that both parents and kids can identify with of separating and coming together again and the joy that that can be.
Patty Kikos:
So folks, we're going to leave it there for now and in a few weeks, we'll share Part 2 of this fabulous interview where we can dive further into assessment tools, how they might differ for adult, as opposed to children, and how common it is to have Autism, as well as other behaviours.
Patty Kikos:
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Billy:
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