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What does autism look like in women and girls as opposed to men and boys? What are three things every therapist should know about how autism presents in women? How do you know whether to test for autism in a client?
In this podcast episode, Joe Sanok speaks with Wendela Whitcomb Marsh about how to recognize autism in women and girls.
- Three things every therapist should know about autism in women and girls
- How to know if you should consider autism as a diagnosis for your client
- Providing treatment
- Wendela’s advice to private practitioners
Three things every therapist should know about autism in women and girls
1 – It’s going to look different
Don’t go in with a closed mind thinking, “If they don’t look autistic then that can’t be it”. Have an open mind and be willing to say, “Oh, maybe you are autistic”. (Wendela Whitcomb Marsh)
Autism looks different in women and girls.
A common trait of autism is if a patient is often flapping their hands, but in women and girls, the equivalent of this could be to twirl their hair.
It’s still a repetitive behavior but they have tried to make it more socially acceptable when they notice people looking at them funny. (Wendela Whitcomb Marsh)
2 – Women and girls are more socially aware of how their autism presents in public.
Common traits may include:
- Twirling hair
- Bouncing a leg
- Biting the inside of the cheek
3 – They teach themselves things that are natural to other children and adults
For example, looking at people in the eye, making the appropriate facial expressions, and learning how long to leave a pause in a conversation before starting to talk.
How to know if you should consider autism as a diagnosis for your client
- Social communication: ask your clients about how comfortable they are with their social interactions.
- Physical self-regulation: are there ways that the client moves their body to self-regulate or soothe themselves? It could be fiddling with an object that is nearby or rocking back and forth.
- Have these symptoms always been present?
The social responsiveness scale (SRS) 2 is primarily used to diagnose people with autism. However, when the SRS 2 test gives a severe score, it does not mean that the person has severe autism but that there is a greater likelihood that they have autism.
Adults who seek treatment for autism are often not going to have a high score on the SRS 2 test because they went through most of their lives not presenting their autism.
Furthermore, many women are only diagnosed as autistic in adulthood because the scales and symptoms have been designed for men and boys in the past.
Therefore, many women have been “masking” their autism for most of their lives, and it is exhausting.
Remember to listen openly [to your clients] … sometimes neurotypical people think, “you don’t look autistic so you’re not autistic” is a compliment which seems to imply that autism is bad, and it’s not. There’s nothing wrong with being autistic, just like there’s nothing wrong with being lefthanded. (Wendela Whitcomb Marsh)
Wendela’s advice to private practitioners
You are doing a terrific job! You have come into a line of work to help other people and you should acknowledge that. Take care of yourself as well.
Books mentioned in this episode:
Useful Links mentioned in this episode:
- Slow Down School sign up now!
- Group Practice Launch
- Visit Wendela Marsh’s website and see also Autism PIPS.
- Connect with Wendela on Facebook and LinkedIn.
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- Apply to work with us — a decision-making matrix for your next steps
Meet Joe Sanok
Joe Sanok helps counselors to create thriving practices that are the envy of other counselors. He has helped counselors to grow their businesses by 50-500% and is proud of all the private practice owners that are growing their income, influence, and impact on the world. Click here to explore consulting with Joe.
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This is the Practice of the Practice podcast with Joe Sanok, session number 717.
[JOE] I’m Joe Sanok, your host, and welcome to the Practice of the Practice podcast. If you missed it, we have had some amazing shows this month already. We talked about what is Slow Down School, we did the Ask Joes’, we also talked about how to hire in this market. LaToya’s been taking over some of the shows as well on Fridays this month. We also talked about how Christine left her full-time job and has a 23-person group practice now. So a lot of really just interesting shows this month. We are doing four shows every single week, so rocking out a ton of shows, interviewing a ton of really just interesting people. We know that you love the clinical issues as well.
Being a single dad, I have 7- and 10-year-old daughters to just notice how much research is done around boys and not always inclusive around girls and women, I’m so, so, so excited to have wend marsh today on the Practice of the Practice podcast. Wendela is an award-winning author and board-certified behavior analyst specializing in autism. After a career, working with children on the spectrum, she took early retirement to write books and to promote autism assessments for adults. Her most recent book, Recognizing Autism in Women and Girls was written to help therapists to look behind the mask, to identify the subtle feminine characteristics of autism that are so well hidden. Wendela, welcome to the Practice of the Practice podcast. I’m so glad that you are here with us today.
[WENDELA WHITCOMB MARSH] I am so happy to be here, Joe. It great to be here.
[JOE] Yes, well it’s always interesting to hear how people get into the field that they’re in. So you practice in the field of helping people with autism, helping children. Tell us a little bit about how you got into that career and then when you took early retirement, a lot of people would just stop working. Why why’d you start writing?
[WENDELA] Well, that’s a good question. I’ll give you a little thumbnail sketch. For 20 years I was a special ed teacher and worked with all kinds of kids and loved it. For 20 years I was a school psychologist and loved that aspect and then became a board-certified behavior analyst and a licensed educational psychologist and got my religious studies doctorate in pastoral counseling specific to autism. Then after I got all those letters after my name, gathered all the letters I wanted, I took early retirement so that I could basically do what I want and it turned out what I wanted was to still work, just not for other people. So I started writing books and the one that’s coming out May 2nd is my fifth book all about autism, one for teachers, one for parents, one for homeschooling. One for independent living for adults with autism was my one that won the biggest award and now recognizing autism and women and girls.
I also started a solo private practice, which I’m in the process of moving to a group practice and I do adult autism assessment. While I was working with kids. I didn’t realize that my late husband and two of our three children, now grown, were actually on the autism spectrum because they looked different from the kinds of kids that I worked with. But the fact was I was living with a majority autism household. So I’ve come to really appreciate the adults on the spectrum and the fact that it can be difficult to get a diagnosis if you don’t look like the classic little boy with autism.
So the more I’ve worked with adults, the more I find people have come to me and said that they’re pretty sure that they’re autistic, but when they went to their doctor or their therapist and said, I think I might be autistic they have been left at, they’ve been told, oh, you can’t possibly be autistic because you made eye contact with me or because you’re married or because you wouldn’t even be talking to me about this if you were actually autistic. It can be so hard for anyone, but especially for autistic people to self-advocate and to get the courage it takes to go to your therapist and say, I think I’m autistic. If they get left at, or just told, no, no, no, you’re not autistic, it’s hard for them to ever reach out again.
I work with people who really want to know. All I do anymore is adult autism assessment, and Joe, I want to thank you for something I learned on one of your podcasts if I could mention that at the moment. I was listening to one where you were offering advice to a woman and because I listened in the car, I didn’t write down her name, but something she said really spoke to you and you said you should get that as your domain, see if that’s available as a domain. I was doing autism assessment, but with a domain name that didn’t really make sense anymore, pipsforautism.com for Promoting Independence in Problem Solving and I thought, “I wonder if adult autism assessment is available.”
It just says what I do and it was available. So now, yes, thanks to you I now own adult autismassessment.com and I’m in the Group Practice Launch, transitioning from trying to do it all myself, to having a group where I’m going to be training people and how to assess adults with autism, because there is a mask. And most of these people have not necessarily consciously chosen to mask. It’s a survival strategy in childhood when they realize people keep saying, look at me, look at me. Then they teach themselves how to make or fake eye contact. Maybe they look at the eyebrows.
Typical babies, you’ve got kids, you never teach them how to look at your eyes. It’s natural in a neurotypical baby, but a neuro divergent or autistic person that might not be their natural way to communicate with people. They still interact and have loving relationships with their parents but looking at the eyeballs is weird for them, for many of them. When I say them, whether I’m talking about neurotypicals or neuro divergent people just believe that what I really mean is many, but not all, because we can never say that there’s a them. You know what I mean.
[JOE] Well, I think it’s interesting because I think about, I graduated in 2004 from grad school and if I were to jump into practice. I sold my practice in 2019 but if I had someone in my office, I think about, there’s so many things to try to keep up with, out in the field of emerging research, like what would you hope people would know right now if they’re in private practice in regards to autism, in adults, particularly in women and girls, because I know that’s the specialty of this book? If we had all of say next level practice or a bunch of our audience just sitting here, like teach us, what should we know, what are the maybe five things or so that are really important for people to know right now about women and girls in regards to autism?
[WENDELA] Very good question. Number one, it’s going to look different. Don’t go in with a closed mind thinking they don’t look autistic, so that can’t be it. Have an open mind and be willing to say, oh, maybe you are autistic. The mannerisms that we see in autistic kids, you see kids flopping their hands or rocking, many women and girls have transitioned to something that’s very minor like twirling their hair instead of flopping their hands or jiggling their leg, instead of actually rocking back and forth. It’s still a repetitive behavior, but they have tried to make it more socially acceptable when they notice people looking at them funny. Girls can be more socially aware, so they try to change. They want to fit in with others. Some of them will go into the bathroom and then just rock as hard as they can or flop their hands as hard as they can to get that out of their system and self-regulate. Those movements really help with self-regulation but many of them have chosen something else. Like a lot of women I talked to bite the insides of their cheeks. That’s their repetitive mannerism.
Another thing is to find out if they have taught themselves things that are natural to other kids like, did you teach yourself to make or fake eye contact? One woman I interviewed had said, oh, my eye contact was great all through childhood. Then she said, or she had no problems with eye contact through her childhood but then in interviewing her further and asking follow up questions, I found out that it wasn’t a problem in childhood because she just didn’t do it. But in grad school studying to become a counselor herself, she taught herself to make eye contact because she learned in grad school that that was important.
Sometimes they’ve had to teach themselves how to make facial expressions. Often in a group conversation it just goes a little faster. Neurotypicals tend to have a wave of how long is there a pause between the next person jumping in and saying things. That’s narrow. Most autistic people I know are looking for a wider opening so they’ll know if it’s their turn to talk and that never happens. If they’re talking to a group of neurotypical people, the chat just keeps bouncing around. So the two ways that they respond is either to just not say anything or to interrupt, because they’ve learned if I don’t say it now, then the topic will change and I won’t be able to say anything. So let’s see. I don’t know if I’ve said five things yet.
[JOE] Yes, no, you tore through it. That was great. So I’m just picturing a typical therapist in the office interviewing someone that maybe is having trouble with socialization. This client may not identify themselves as being on the autism spectrum, but what are things that clinician, would they run through that list that you just said of like asking them questions? Of course, we want to use assessments. We want to use validated measures, but what are things that they could pick up on that would at least get them to think in that way? Because I think that sometimes someone, they may be just a quirky person and we don’t want to necessarily just label people, but then also we want, sometimes diagnoses can really help with, oh, I’m naming something that I didn’t realize was named and it can give someone a sense of security or direction, or even treatment. So what would the typical therapist in their office, what could they do in their intake, or even if they’ve been with clients for a really long time, what can they be thinking or doing in regards to identifying or narrowing down whether autism should even be on the radar for their clients?
[WENDELA] Good idea. Good question. The main things, number one would be social communication. Ask how comfortable they are with their social interactions and just see if they can freeform-talk about that and ask them if there are ways that they, as far as restricted repetitive behaviors, if there are ways that they move their bodies, that help them regulate like mannerisms or habits. It might be using objects like having to always pick up a paperclip and fiddle with it or whatever is nearby. Have these things always been present? If somebody is suddenly struggling with their social relationships, but it didn’t start until the pandemic, for instance, and their childhood was fine, they made friends, they made, I mean, who even thinks about eye contact?
If you’re neurotypical, it’s like a fish thinking about water. It’s just so natural that we don’t teach ourselves. A lot of people I work with have a lot of thought around eye contact. You could ask, do you ever wonder which eye am I supposed to look at? Do you ever keep track of how long you’re looking at the eyes, then glance away for a certain number of seconds, then glance back? That consciousness to the eye contact. Have they struggled to make and keep friends to the point that sometimes they cannot understand why they’ve lost friends? The whole social aspect of somebody got their feelings hurt and now I have no idea what to do or how to repair it. So let’s just burn that bridge and never go back. These are the kinds of things that they might experience
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At Slow Down School you’ll be in Traverse City, Michigan on the beautiful shores of Lake Michigan, July 24th, through 30th, 2022. At Slow Down School we’re going to spend a few days slowing down, hiking. I’ll bring in massage therapists and yoga teachers and healthy food and time on the beaches with sunsets and just connecting with other folks like you. Then we’re going to run full tilt towards your business, towards your big ideas, towards your private practice, using all of the skills of Killin’It Camp, sprint types of being able to get so much done in a short period of time. We’ve seen so, so many businesses grow and expand and launch as a result of Slow Down School and I would love to join you in that process. Slow Down School tickets are on sale now. Make sure you grab them before the early bird. If you get them after the early bird, that’s totally fine, too but we’d love to have you involved with Slow Down School, July 24th through 30th, 2022. Head on over to slowdownschool.com to grab your ticket today. I can’t wait to see you in Northern Michigan.
[JOE SANOK] So when someone identified as that there’s potential there for treatment or for assessment, what are some of the measures that you go to and then what do you look for in those measures typically?
[WENDELA] Okay, good question. I use the SRS, the Social Responsiveness Scale second edition. It gives a good likelihood. Now when it gives a severe score, what I have found is that that does not mean that the person has severe autism. That means there’s a severe probability that they have autism. But the people who come to me as adults are not going to be severely autistic because they’ve gotten through their whole life until now so they’re going to be at level one. I do like to point out level one says requiring support, not requiring significant or substantial support, but it doesn’t say level one, you’re smart so you get nothing. Level one, just continue to mask. Masking is exhausting for these people and many of them are just done. They’re burned out. So I do like the SRS two.
I’ve tried many other tests and I buy them, I go through the whole thing, but so many of them are written for children and so many of them, as you mentioned, are normed on a predominantly male sample. I know why they would do that because there’s a belief that four out of five, approximately autistic people are going to be male, but that skews it against the women. There are a lot of articles in the literature showing how women are missed and misdiagnosed. I’ve actually written some tests myself that I use that align with the DSM five TR, the Text Revision is only slightly different, but it’s a little different. I haven’t published them at this point, but I’m planning to start an autism assessment training for adult autism assessment.
Sometimes they might want to just pull out the DSM with their client and talk about the different things and say, does this particular thing speak to you, this point, whether it’s A one or whatever? I don’t have a lot of other tests to recommend, although I’m always looking. I’m sure there are more out there, but I do use the SRS two, and then my own tests.
[JOE] That’s great. That’s really great. Now when it comes to, when you’re working with clients and helping them identify in maybe their daughters, how is that different? How is it similar? Even just having daughters and also they have lots of friends, not that I’m going to be going around diagnosing their friends, but what should therapists keep in mind in regards to the ways that like autism in girls looks differently than autism in boys?
[WENDELA] Well, it can be easily mistaken for a number of things like shyness or OC D, or ADD without the hyperactive component, just inattentiveness. In my book, Recognizing Autism in Women and Girls I’ve made up seven fictional characters. They’re not based on real life, but each one of them has something else, whether it’s ADHD or shyness, or OCD. There’s seven of them and each one has characteristics that people say, oh, it’s just that and they did not get diagnosed until they were adults. I think having those stories, little pieces of fiction can help us get a handle on what we might be looking for. So like a shy baby, if you’re in a grocery store, you might see a baby in the cart ahead of you online. A lot of babies are just going to be looking at your eyes and cooing at you and or toddlers trying to get your attention.
A shy baby might look at you and then immediately put her face against her mom’s shoulder or something, and then peek out at you. Maybe if you smile at it, she’ll jump back behind her mom and then peek out again and do a little peek-ka-boo shyly. A person the same age who has autism might, number one, not notice that you’re even there. You might be trying to flirt and smile at the baby, and they don’t notice. They might be more interested in a ceiling fan than in a person’s face. If they find out that you’re trying to get their attention and turn their face to their mother, they are not going to look back at you with that little shy peek-ka-boo game, because you are other, they do not want to interact with. So that’s one way to see a difference.
[JOE] So if there’s that history there for that child in regards to throughout their childhood, oh, that’s so great. Well when people are developing specialties, any other advice or tips you have around autism, women with autism, like girls, or just general things that you’ve discovered that you think is really important to make sure we hit on before we get to our last question?
[WENDELA] Yes, getting behind that mask. Well, first, and I know your people are already good as your listeners, because I’ve been one of them. I think I am your listeners. They’re already good at listening to their people being open to them and responsive to them because if they weren’t, they probably wouldn’t be going to podcasts to learn more. So I already have a high opinion of your people, but to just remember, to listen openly and to not think, sometimes neurotypical people think, oh no, you don’t look autistic. You’re not autistic. It’s like a compliment, which seems to imply that autism is bad and it’s not.
There’s nothing wrong with being autistic just like there’s nothing wrong with being lefthanded but if you walk into a store and you want to buy a pair of scissors, you might feel like you’re in the minority. All the scissors on the shelf are going to be right-handed and being autistic is like that. There’s nothing wrong with an autistic brain. It’s just a different brain and the world is majority neurotypical. So to just be open and respectful and not try to dissuade them, as if that’s a compliment, oh no, I’m sure you’re not autistic. I’m sure you’re fine because autism is fine. So that’s what I would say, just be open to them and be the listener that I know that they already are.
[JOE] The last question I always ask is if every private practitioner in the world we’re listening right now, what would you want them to know?
[WENDELA] I think you are doing a terrific job. All you, every practitioner in the world, you’ve come into a line of work that allows you to reach out and help other people. I want to really acknowledge you for that. You’re doing great. Remember to take care of yourself, even as you’re taking care of your other people and do be aware of people that might come to you and say, I think I’m autistic and be there for them. Thanks for the job that you do.
[JOE] Well, if people want to get your book, if they want to follow your work check out your website, where can they do that?
[WENDELA] Yep, it’s adultautismassessment.com.
[JOE] And the book is Recognizing Autism in Women and Girls. So when this releases that will already be out. Wendela, thank you so much for being on the Practice of the Practice podcast?
[WENDELA] Oh, and I’ve got something for your listeners. I’ve created a checklist, PDF. I can put that on the website and we’ll figure out how to get that to your people.
[JOE] Perfect. We’ll have links to that in the show notes as well. Thank you so much for being on the Practice of the Practice podcast. We’ll talk with you soon.
[WENDELA] You’re welcome. Thank you for having me. This has been lovely.
[JOE] I just love when people take, whether it’s their career or their practice, the thing that they’re working on and they go even beyond it. It’s so great to see when there’s just so much knowledge and it goes beyond just being in the practice, which I say just in the practice and that somehow diminishes doing solo practice work. That’s not my intent at all. But you all are so brilliant. I mean, 8% of the US gets a master’s degree, so that means in any room of a hundred people, statistically, you’re going to be the only person with a master’s in counseling, social work, psychology, and go beyond that. If you’re a doctoral level, holy cow. So the day you graduate, you are top tier and have so much knowledge that the world needs. So I just love when people like Wendela are going out into the world and taking this knowledge and sharing it through books and teaching and podcasts to go beyond just the practice and that she is in Group Practice Launch, so expanding her practice into having more clinicians, helping more people, so awesome.
Even just taking the action to go buy that URL. I remember when I bought michigancounselorsupervision.com just because it was available. I still own it. At some point, maybe I’ll develop it or sell it or who knows? I’ll buy websites if I have the idea and think that it’s an interesting website. So go out there, get some things done. Do some action. We don’t do our best work though when we are totally stressed out and maxed out. It’s when we slow down, focus, reflect and take that time away. That’s exactly what Slow Down School is all about. Slow Down School is the event that we put on every single summer. We did not do it in 2020 or in 2021, but it’s back in 2022.
It’s going to be July 24th through 30th here in Northern Michigan. You fly into the teeny tiny Traverse City airport. It’s not two terminals. It is two doors, one for Delta, for American. So I mean you can get through security and everything in 22 minutes. So it’s this cute little airport you fly into up here. We pick you up, we take you out to a place on the water. It’s right on Lake Michigan. If you’ve never seen one of the great lakes, so many people look at it and they’re just like, this is a lake? I thought I could see Wisconsin. No, it looks like the ocean. So we watch sunsets there, we have massage therapists come, yoga teachers. We really just spend time slowing down for those first two days. Then on Wednesday, Thursday, and then Friday morning, we run full tilt towards your group practice or your big idea.
So people like Wendela that are growing a group practice or launching things like books, we’re going to be digging in, take sprinting and getting a ton and ton done at Slow Down School. If that sounds interesting to you head on over to slowdownschool.com and schedule a time to meet with me. I meet with every person that’s comings, really 20 people. We want to see if it’ll be a fit for you, a fit for the group. We’re all at similar phases to get a huge return on investment for taking a week in the summer off to come hang out at Slow Down School. I mean, things that have been launched from. There are businesses like Simplified SEO, I’m Sorry simplified SEO Consultants. We have all sorts of other businesses that are launched from there. It’s just really cool to see. So slowdownschool.com, sponsor for today’s podcast.
Thanks so much for letting us into your ears and into your brain. Have an amazing day. Talk to you soon.
Special thanks to the band Silence is Sexy for your intro music.
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