Megan W 

So Okay, hi everybody. Welcome. Welcome to our clinical exchange series. We're so excited today to have Dr Iris Yusupov Rose with us. So I'll just take a second to introduce her before we get started, to hear all the wonderful things that she has to say today. So she's a clinical psychologist and neuropsychologist currently in supervised practice at Autism Wellness, which is a clinic dedicated to providing neurodiversity affirming services to neurodivergent individuals across the lifespan. She previously completed her PhD in Clinical Neuropsychology from York University, and has completed an accredited residency in clinical Neuropsychology at Baycrest hospital and Toronto Western Hospital. In more recent years, Dr Rose has combined her expertise in aging and cognitive health with her interests in autism, an emerging area of research and clinical practice, she is devoted to offering therapy and assessment services for both adults and older adults, focusing on the unique needs of those dealing with the intersection of autism, adulthood and cognitive aging. She also holds an MBA, and She currently teaches strategy and healthcare and advocates strongly for healthcare equity, and also as a mother, Dr rose understands the challenges of balancing motherhood, work and wellness, which deeply informs her empathetic approach to client care, supervision and training. So we're super excited to have her speak with us today. So Iris, I'll let you take it away. I'll monitor the chat, and we're so excited to listen to you today.

Dr. Iris Yusupov Rose 

Awesome. Thank you so much, Megan, for that super warm welcome nothing more awkward than listening to your own bio. But I'm very grateful and honored to be here today, and thank you for so many of you joining me. The title of my talk is the lifespan spectrum of autism from adulthood to older age. I was very ambitious when I picked this title to think that I could cover even half or even a little bit in an hour talk was very unrealistic. So what I basically did is I just went through and I thought of the most important themes that I've noticed in my clinical practice and the most practical information that would be useful to share with you today. And I picked this really beautiful picture of these leaves because the same way that we are reconceptualizing our understanding of autism, I hope I can be an advocate for also reconceptualizing how we think about aging as well. And so this picture really depicts the beauty and the change. And you know, when you traditionally look up pictures of lifespan or aging, there usually is like a decline trajectory or lots of negative age stereotypes with pictures of frail individuals or individuals that are receiving support from other other people. And this can be a whole talk on its own, but North America, unfortunately, has a lot of challenges within our healthcare system, within our long term care systems, and some deep rooted perceptions of how we view older adults in our society. And I'm not going to sugarcoat it, because the way that they are viewed, they're viewed as a burden. They're viewed as individuals that tax our healthcare system and that essentially need to be put in housing where they're separated from the community, whereas there's so many other countries that we can look up to in terms of this socio cultural shift that I really strongly advocate for, where older adults are really valued and where they are essentially kept as an integral part of their communities for their entire lives. And so I thought this picture was a really beautiful depiction of the beauty and change that comes with with aging. Okay, so you heard lots about me, so I won't go into too much detail about this, but one thing that I did want to talk about was this idea of nothing about us without us. So it's really important, when you're developing any service for a population, or you're offering any training on a certain population or a talk on a certain population, it's this idea that nothing about us without us, so something that should be really deeply ingrained within us. So as a disclaimer, I am not autistic. I do identify as an ADHD er, so I do understand lots of the traits that overlap between autism and ADHD, but you'll see throughout my presentation that I use a lot of quotes from qualitative research

Dr. Porthukaran 

because it's really important to me that all the information that I'm sharing is truly honoring the lived experience of autistic individuals, and I hope I do them justice by sharing my experiences that I'm honored to have with them throughout my personal life, family life, and clinical practice and research as well, but using qualitative research and quotes offers that little window into their lived experience, and that's essentially one of the objectives for today, is to spread awareness of the experiences of autistic adults and older adults. Second objective is to promote clinician understanding and support from a neurodiversity affirming lens, and we heard lots about that in the really wonderful talk last week. So I'm not going to repeat any of that kind of foundational, really important information. And I'm hoping to with this talk to build on that, and then to share tools and resources that you or your clients may find beneficial in the context of therapy and assessment. And so this was my vision for this talk. I'll walk you through nicely from point A to point B to point C, and a nice, beautiful path. This is my Instagram. And then my reality is that it's all over the place. So there were so many things that I wanted to dive into, so many different topics, lots of things that I'm going to talk about today could be its own topic on its own. So if there's any questions or you ever want to connect with me afterwards to learn more about anything that I mentioned, I would love to do that. So this is just a little warning that you're about to embark on this really wild journey with me across lots of different topics that I'm just really passionate about. And I'm going to start with emerging adulthood and make my way towards older, older adulthood.

Dr. Iris Yusupov Rose 

All right, so before I do that, in the spirit of being all over the place, I wanted to talk a little bit about inclusive language. So we learned about neurodiversity affirming language last week, so I won't touch on that, but I did want to talk about inclusive language when it comes to older adults and the older population. So as I mentioned, within a North American context, because we do have these negative associations, negative biases, negative stereotypes associated with the aging process and older adults. Some terms to avoid that have traditionally been associated with these negative age stereotypes are terms like the elderly, elderly people, seniors, senior citizens, you might be, you know, a little bit shocked by this. These are the APA guidelines, because even in our college, like the College of psychologists, when we declare our competencies in different populations, it's, you know, adults and then seniors. But we really want to move away from that kind of language. Of course, with any type of language, there are cultural differences, there are personal preferences you always want to honor whatever resonates for your client. But when it comes to our North American context, making promotional materials, making different developing different services, working with older adults. The suggested alternatives are older adults, older people, older persons, the older populations, persons 65 years and older. So these are the suggested, the suggested alternatives to use, and again, we want to avoid, you know, language that isn't inclusive or that has that negative, that negative connotation. For example, you might, you might have heard people say, you know, the silver tsunami, or this crisis associated with the aging population. Again, it's supporting that idea that older adults are a burden on our society, and we want to move away from that as a community and really as as a nation. So these are the suggested alternatives that you'll hear me use throughout the talk. So some very brief background, autism is equally as prevalent in children as it is in adults. So it is a myth if anyone believes or thinks that we outgrow autism. Autism is a neurodevelopmental condition. It's a brain style, and so it's long standing throughout one's life, there's this idea of the lost generation of autistic adults. So if you were born before the year 2000 you're much less likely to obtain an autism diagnosis before the age of 18 than people that are born after the year 2000s and so in my practice, and I know in several with it's the same with several of my colleagues is that we're seeing a lot of adults and older adults come to us asking about autism because they have had a younger family member, whether it's their child, their grandchild, nieces or nephews, that went through an autism assessment themselves, and then through this process or reading the report or answering questions about them, they notice that they're very similar. And so it's this idea that we've missed this entire generation of autistic adults and older adults. And so in my practice, I've, you know, done autism assessments for people as young as 18, and my oldest was 80. And so this is going to be an increasing trend that that we see. So the statistic that I saw from the talk last week was that one in 50 Canadians are autistic. I've seen some recent ones as well, about one in 34 but when it comes to clinical populations, the rate is one in five or more. And so this means that regardless of whether your practice focuses on working with autistic individuals or not, if you're working in a clinical setting, you are likely, more than likely, to come across an individual who's coming to see you for a different reason, maybe depression, substance use, eating disorders, and they're actually autistic. And so this is important for all of us across in the clinical field to to be aware of and and one reason why training on autism is so important, and so this brings us to the the question of why are so many autistic individuals missed? And it really there's so many reasons why. A couple of the reasons -  lack of clinician training. So if you are being trained to work with older adults or adults, you are not likely to come across training on autism or ADHD, compared to clinicians that are trained to work with children.

There's also outdated ways of thinking about autism. So if we look at the DSM and the way that the criteria are written, they're written, of course, you know the deficit model that we want to move away from, but it's really focused on the external, observable differences that we see in in autism, and we're just now understanding that the internal experience is really important for us to understand, and it's something that we wouldn't see unless we create that really safe environment to explore that inner, inner world and experience with with our clients. And so for this reason, a lot of our diagnostic tools and impressions, especially for strictly adhering to the DSM criteria, exclude a lot of Autistics who camouflage or who or who go through their life masking their autistic traits or using compensatory strategies.

You can imagine going through your life and feeling like you cannot be your authentic self like every day, having to put on this mask and feeling like you wouldn't be accepted and loved if you were your true self. It's very devastating, and leads to depression anxiety, and many people are coming seeking mental health support because of these reasons. And so diagnostic overshadowing, where there could be another diagnosis that shares similar traits with autism, for example, OCD and autism can be quite challenging to differentiate the compulsions from repetitive behaviors, and so it could be attributed to OCD, for example, that's diagnostic overshadowing or misdiagnosis. So so many people are misdiagnosed with OCD or borderline personality disorder or schizophrenia, and so that's another reason why so many,

Dr. Iris Yusupov Rose 

why we're missing so many. And then something for us to always be talking about, and this, this on its own, can be its own talk. Especially, you know, covid 19 really illuminated a lot of the disparities in health care and health outcomes among different racial and ethnic groups. It's something that is really important for us to to talk about as clinicians, because, for example, a white child is much more likely to obtain or receive an autism diagnosis than a black child for many different reasons, and it's important as a healthcare organization, as a healthcare clinician, that we are constantly having this dialog, and this this question of, what are we doing to. To promote health equity within our practice and within our communities. Some other reasons in North America include language barriers. So again, even though we want to shift to to really valuing the inner experience of autistic individuals, you can imagine how challenging that could be if there are language barriers. Cultural differences, so being aware in our cultural sensitivity the different perceptions of autism and different cultures. In certain cultures, there could be a stigma associated with neurodevelopmental conditions so that could prevent someone from even seeking or speaking about to a healthcare professional about that. And then, of course, financial barriers as well. So these are just some of the reasons why so many are being missed. Okay, so I urge you to join this paradigm shift in in your therapy and your assessment, it's really important to honor the lived experience of your client, so offering the opportunity for them to explore how they really feel underneath the mask, underneath, you know, all of the things that that you know they have to put up barriers to protect themselves in a society, you know, we don't treat autism, we don't fix or cure autism, but when you're doing therapy with an autistic individual, it's important to understand where their struggles come from, and often that comes from living in a world that's unfortunately not designed to support different brain styles. And so feeling like the world isn't made for you, feeling like you don't belong can lead to depression and anxiety. And so the the way that autism is such a spectrum of so many different traits, experiences, support, needs, strengths, each client is really so so unique, and it's important that we honor their lived experience. And it's also important to reflect on our own beliefs about autism. So you know, if we have this feeling as clinicians that autism is categorically a bad thing. We would be that would be our bias, that would change the way that we would see or not see autism in our clients. So it's really important to think about your own internal beliefs, implicit, explicit, what's underneath? Where did you first learn about autism? What do you know about it? How do you feel about it? Because if those perceptions or those beliefs are negative, we are probably going to be less likely to bring it up in therapy. We wouldn't want to offend someone, because we feel like, if autism is bad, we wouldn't want to bring it up or offend someone. It's coming from our own beliefs, and we'd be less likely to refer someone for an autism assessment. And receiving an autism assessment can be extremely empowering for lots of individuals for lots of different reasons. So it's important for us to really think about how we feel about autism and what our beliefs about autism are,

and then don't rely on your gut instinct either. So you know, it could get tempting as a clinician once you've seen several autistic individuals, to meet someone new and be like I didn't, I didn't get the sense that they were autistic. And you don't want to over rely on on that kind of instinct or that feeling just again, because thinking about that paradigm shift and reconceptualizing autism and really honoring the inner world of someone, as opposed to always letting your kind of gut or your observable experience guide your next steps, whether that's in therapy or in assessment. Okay,

Dr. Iris Yusupov Rose 

so let's talk about emerging adulthood and middle age. So there's so many things that we could talk about in this time. I'm going to talk about a few of these. So there are major life transitions that are really important or kind of really trends that I'm noticing in my therapy clients and throughout assessment. So a lot of my clients are coming to see me once they reach that major life transition of post secondary education. So it's a time where, you know, maybe high school was very routine. Classes were very small. They were able to get really great grades in high school, and then university or college is just such a jarring experience. Like, can you imagine, if you learn about what university and college is like from, like, all those movies about you know, you know what college is like in the States, and then you end up going to York University, York University, or U of T, and the experience is just totally different from the what you thought that happy experience would look like from TV and. So the social demands increase, the adaptive functioning demands increase, especially, especially if the individual is living on their own and moving out. So one thing that is common in autistic adults is a discrepancy between like high intelligence and adaptive functioning, where their adaptive functioning skills may may require some support. And so things like communication, self care, health and safety, that can be a huge demand on the individual, especially if they're moving out for the first time on their own, and so during this time, during post secondary, it's really important that individuals get the right assessment, the right supports and the right accommodations. And I always tell everyone about York University, because York University has the something called the autism mentorship program, and it's clinical psychology students that are paired with autistic students, and they offer them free mentorship, usually once every two weeks, throughout the whole year, and sometimes throughout the summer. And so lots of people Alberta too. That's amazing. Lots of people choose to go to York just because of that support. So I always recommend, if someone's considering going to a university that they do consider York University because of that support, another time that's that is a big major life transition is marriage and long term relationships. So I get a lot of requests to do couples therapy. If anyone does couples therapy that specializes in working with neurodivergent individuals, I'd love to connect with you, because this is an area of need. I actually just started last week to work on my couples competency, so I'm hoping I'll have that in the next year or so. But again, autism is not a deficit in social communication. It's a difference in social communication and social functioning. And so it's not just autistic people that have challenges communicating or interacting socially with non autistic people. It's also the non autistic people that have trouble sometimes communicating and socially interacting with autistic individuals. And so that's the double empathy problem. And so in marriages, especially if there's a mismatch in neurotypes or brain styles, there can be some challenges in terms of going through marriage and long term relationships. And you know, for everybody, marriage and relationships are hard, and so offering support to autistic individuals through a neurodiversity affirming lens is super important, because essentially, if you're not going through it from that lens, you might just be teaching them how to mask even better, or how to put aside their preferences, or their, you know, their needs for the needs of of their of their partners. And so that's another thing that I found really helpful when it comes to individuals

that are experiencing challenges in interpersonal functioning is screening for alexithymia. So alexithymia is a condition that many autistic and ADHD individuals have, and it's the difficulty in identifying

and describing their own emotions, and so for this, I use the task 20. It's a freely available questionnaire. It's called the Toronto alexithymia scale. I use it in my autism assessments because I find that if alexithymia is present, then it's a really helpful first step when it comes to what to work on in therapy, in terms of building emotional awareness. If that is a goal of the client, it's another nice way to identify a potential strength. So alexithymia  has three domains. The first one is difficulty identifying one's emotions. The second domain is difficulty describing one's emotions, and then the third domain is externally oriented in their thinking. And so what that means is that the individuals are kind of going through life, and in certain situations they they more so focus on external factors like facts in the environment, as opposed to using their internal experience to guide their decision making. And this can be a really, really strong autistic strength, because you can imagine someone that can make really sound, rational decisions without the bias of their emotions.

Dr. Iris Yusupov Rose 

Is a really important skill for for lots of jobs you can think of like policing or firefighting, high stake jobs where emotions can run high, but you have to be there to be calm and to be externally oriented in your thinking. And so ever, whenever I conceptualize alexithymia , I make sure that it's not just a negative aspect or condition, but there really is that opportunity to identify that, that strength in externally oriented thinking, okay, and then parenthood. So parenthood, I mean, again, challenging for everybody. It's important that we understand that the autistic experience can be different when it comes to pregnancy and childbirth. So one common symptom of pregnancy is like, what soon as you're pregnant, for lots of people, your sense of smell is like a superpower. But you can imagine if someone is autistic and they have sensory processing differences and they already have a really strong sense of smell that increase even more, so can be a real impact on quality of life. So that's just one example in terms of considering sensory processing differences when it comes to these major life transitions. And then having a child, having a child learning how to regulate your emotions, regulate their emotions, teach them emotion regulation, model it, and this is where alexithymia  and understanding it can also fit in um and trauma as well. So autistic, autistic adults are more likely to have traumatic experiences throughout their lives. There's a new study that just came out this year that they are more likely to develop PTSD as well compared to the general population, and if, if they've experienced trauma in childhood, going through parenting and essentially having a child and maybe giving the child something that you never had can be very hard. Can be it can bring up all of those experiences that that the autistic individual experienced when they were younger, and another strength of of autism is making those associations, like their their brains making these really wonderful associations and and often that association can still be very strong. And so taking a very trauma informed approach in therapy and in an assessment is really important, okay, and now I will talk about menopause, because a lot of my clients are really going through it, that are autistic and that are going through menopause, and menopause is something that we already don't talk about. And so I wanted to kind of zoom in on this one and start that conversation a little bit today. Okay, so menopause. So we're starting to do research on autistic the autistic experience through menopause, and we're noticing we're understanding, and I see this in my clinical practice, that menopause can be amplified in autistic people, and it's also important for us to kind of shift our maybe traditional understanding of menopause as being like 50, 50+ or 45

knowing that it can start even earlier than 38 so bringing back your conceptualization of menopause to 34-35-36

Dr. Iris Yusupov Rose 

perimenopause can start around that time, and those transitions, those hormonal changes, can really be a breaking point for a lot of autistic individuals, and could be the reason why they're seeking either Inpatient Care or mental health services, because they feel like they've been able to mask, they've been able to compensate. They've been and and the breaking point is the menopause. And then many of them hopefully realize that or are identified as as autistic. So here's a quote from one of the participants from the newest qualitative study on menopause and autistic individuals said, I think our society doesn't talk about, address, understand women, our age in general, very well. And so when you have the added dimension of autism, there is no resource, there is no font of wisdom to tell me how to handle that, and there's no room in society for it, either, because we don't talk about menopause, let alone autistic menopause. So I urge you all to have these conversations in your clinics and with with your clients, because that's the first thing that you can do. What can you do? You can ask about menopause and. And so starting as young as as seen clients, they don't have to be, you know, even near 50, they can be in their in their 30s. And so I always start out my assessment saying, you know, it's my job to make you feel as comfortable as possible. But if there's anything that you don't want to talk about, you can just say, I'd rather not go into that. And so they very May, they very well may not want to talk about menopause or hormones, and that's their choice, and we are always going to honor their experience and their decision, but we as clinicians cannot be scared to ask about menopause, to ask about hormones, to ask about their experience with their menstrual cycles, and to give them that opportunity to talk about that, and always in your feedbacks, to provide autistic informed information about menopause, about pregnancy, about menstrual periods. You know, when it comes to ADHD, we're finally doing research on women and understanding that their ADHD traits can change with their cycle and their hormones. And these are all very important things for us to be bringing to the attention of our clients, whether it's in therapy or an assessment. We also need to support advocacy within the healthcare system. So from this qualitative research, and I hear this with my clients all the time, is that they are being dismissed by healthcare professionals when they come to share their experience. And so supporting clients in terms of advocating within the healthcare system is really important because there's a lot of gatekeeping. There's a lot of problems with our healthcare system, and unfortunately, autistic individuals or neurodivergent individuals are often dismissed. They're often missed, they're not believed, and so many of them have experienced again and again healthcare trauma of being invalidated, and so you can imagine them being willing to come see you after having so many experiences like that throughout their life. I hear it time and time again, I thought I was autistic. I told my doctor, and he laughed and said, I'm too empathetic, you know, and so your clients coming to you, you have the opportunity to social, yeah, exactly, to be a corrective emotional experience for your clients and to validate their traumas from the healthcare system and experiences, and then to continue to tell them that you're going to have to keep advocating for yourself to make sure that your voice is heard, you're going to have to, you know, make sure that you get the services that you know you need and so a lot of that can be done in therapy together. This is probably my number one recommendation for anything but finding your people. So finding your people, whether that's people with shared interests. You know, neurodivergent people click with neurodivergent people, and having that sense of belonging is so important for your well being and overall quality of life and for your dementia risk. We'll talk about that in the next couple slides. And so finding your people is really important, and supporting your clients in ways to do that. And then we also want to support in adapting the environment to their sensory needs and preferences, particularly going through menopause, whether that's in the home, in the car, or in their workplace with accommodations. And then we want to talk, and then I'm going to talk about lead into talking about autistic burnout, because one common theme through all of these major life transitions is the risk of autistic burnout. And we don't really have prevalence rates on how many autistic people will have, will have or will experience autistic burnout, but it is a very common experience that I see over and over and over again in my therapy and assessment clients. So what is autistic burnout? So you can see the study here was done in 2021, so it's quite a new a new experience that we're starting to explore. So autistic burnout is a syndrome conceptualized as resulting from chronic life stress and a mismatch of expectations and abilities without adequate support. So typically, lasts more than three months, and it's characterized sorry by these three tiers That I'm going to walk walk you through. So the first one is chronic exhaustion. So that's the first in identifying autistic burnout. So here's a quote from one of the participants from the study. I've had people say to me many times over the years, but why are you so tired? What have you been doing? The brutal truth is that for an autistic person, simply existing in the world is nackering, never mind trying to hold down a job or have any sort of social life, and many of the standard recommendations for improving mental health, such as seeing more people in real life, spending less time on the internet, sitting still and being calm, simply make matters worse, we need a lot of downtime in order to recover from what, for most folks, are the ordinary things of life. So autistic burnout can lead to depression and suicidality, and so it's really important for us to be able to identify this in our assessments or in therapy, because, as you can see here, if we're stuck in that pattern of giving those generic mental health recommendations these you know, seeing more people in life spending less time on the internet, especially if that, if this is how they're accessing their special interest, can be harmful. The second one is a loss of skill. So it comes with a decline in executive function, loss of life skills or memory problems with speech. It's essentially a type of regression. So it's a loss of a previously of a previous skill, it could be in, really, in any domain, and then three a reduced tolerance to stimulus. So this means that the all the senses, all the information coming from from the world, just becomes too much to handle. So we see shutdowns, sensory overload. So you can see here very low sensory tolerance. Many routine noises have become quite painful, therefore very difficult and taxing to access public spaces, shopping, errands, parks and social gatherings, many artificial scents have started to make me mad, and I've had to make a handful of foods off limits due to texture. So you could see here that those sensory experiences can really be heightened to the point where it's really interfering with with quality of life. And so if we take a look at this conceptual model of autistic burnout, it can really help us understand where we can intervene as clinicians. So here we have  reducing the cumulative load. So if your client is in a constant state of masking, or is in constant environments where they have to mask, we know that that's going to be adding to their cumulative load and increasing their risk of autistic burnout, and then keeping in mind all those transitions that I talked about, all of those life changes and stresses add to that cumulative load. So you can ask yourself, as a clinician, how can we work together to reduce your cumulative load and then paired with an inability to obtain relief? So here, how can we remove barriers to support so this dismissal, right? You heard that in the in the first quote, where it's like, why are you even tired? People don't understand the internal experience. They're constantly being dismissed, both by people in their lives and also the healthcare system. And so we can support in advocating for boundaries, adding external resources and supports, or taking a break. And I have, I have in the past, been as directed with clients, to say, I strongly encourage you to take a leave of absence from work, because I'm genuinely concerned for your well being and then supporting them in terms of documentation, for for obtaining that that paid leave from work. And so when we have this increase in cumulative load, also with an inability to obtain any relief, the expectations of life and everything going on outweigh our abilities. That's where we see burnout. It's also really important to differentiate between autistic burnout and depression, again, for those reasons of making sure that we're providing the right recommendations. This is a misdiagnosis Monday. I love these. These are from Dr Neff, neurodivergent insights. Dr Neff is an autistic and ADHD psychologist, and I love sharing all of these infographics, lots of workbooks that clients find helpful, and this Venn diagram, everyone loves a good Venn diagram, or at least I do, but can be really helpful in seeing that there's a lot of overlap in depression and autistic burnout. For example, if it is depression, One common treatment could be behavioral activation, that could be really helpful in depression. But if it's autistic burnout, it could actually be. Harmful, and so it's really important to differentiate in your assessments and in in therapy, whether it's autistic burnout, whether it's depression or whether it's both, because your next steps will definitely depend on being able to correctly identify which one it is. Here's another infographic from neurodivergent insights. So what are some things that we can do, aside from reducing cumulative load and accessing more supports? Some good things are rest, so really taking time. Some sometimes I tell my my clients like, imagine you, you have the flu. You know, would you be pushing yourself to go out there and work and go see people, no you would be in bed, resting and taking care and nourishing your body, maybe incorporating sensory soothers or doing kind of a sensory detox. And so it's important when we consider sleep and rest, that we also provide recommendations on sleep hygiene that are personalized to autistic individuals, because there are differences in neurodivergent individuals and their sleep cycles and their sleep preferences,

other things, engage in rhythm. So I say, were there any things in childhood, like, any behaviors, any activities that that you really found soothing that we can kind of bring back to you right now. And a lot of people remember swinging on the swing set or swimming in the water, but swinging on a swing set to be really soothing, and it's that rhythmic back and forth, so engaging in rhythm that can be extremely soothing and regulating for the nervous system. Okay, here are a couple others, but for sake of time, I'm going to skip over this is a really nice guide that if I have identified autistic burnout in an assessment or in

Dr. Iris Yusupov Rose 

or a risk of it. It's a free guide by Jennifer Kemp, who's also wonderful ADHD and autistic psychologist, and it's a free workbook with lots of checklists, so it's very user friendly. And I attach this to my assessment as a resource for clients, and you may find it helpful as well. Okay, now for the last little bit, I'll talk about aging and cognition, or older adults. So by 2031 nearly one in four Canadians will be 65 plus, and so there's real demand for us to be offering services and supports to older adults. And want to just give a little bit of a background on the aging and cognition in general. So as we age, we experience what we call normal age related changes to our cognition. So some things, like our aspects of our memory, can decline, some aspects of attention,

lots of cognitive abilities stay stable, and lots of them improve, like wisdom, decision making, crystallized knowledge, financial literacy, and so that's what we consider the normal aging trajectory. And so normal aging is not associated with any cognitive decline on testing below what we would expect for their age, right? So when we test someone, we use age norms, so we compare them to other people their age, and there's no there's no functional decline. So they are independent. And all their activities of daily living, like cooking, cleaning, grooming and in their instrumental activities of daily living, instrumental activities of daily living are things like banking, managing finances, managing appointments, driving, managing medications, things like that. Then we have MCI, mild cognitive impairment. So this is a condition that many people in the aging world will just refer to as MCI. This is a time that is really important for us to be aware of in our clinical practice and in our personal lives, because about one in 10 or two in 10, it's between one to two people 65 plus have MCI. So what is MCI? MCI is an individual as a condition where the individual experiences a decline in their cognition more than what we would expect for their age. So if we did a neuropsych assessment, there would be one or more domains where they're performing below what we would expect compared to other people their age. However, that level of cognitive change is not affecting their functional independence, so they don't have any functional decline. They're still able to manage all of their activities of daily living on their own. So that's MCI. Why it's so important to be able to identify MCI is because.

As about one in three will continue and be stable throughout their lives, one in three individuals with MCI. So sorry, a third of individuals with MCI will improve over time, especially if we can identify MCI and really intervene with interventions to improve cognition, and then 1/3 of people with MCI will decline into dementia. And so dementia is an umbrella term for any neurodegenerative process that that affects cognition and functional independence. So cognition and Functional Independence declines over time. One of the most common types of dementia is Alzheimer's dementia. So that's a type of dementia, and dementia is just the umbrella term. And so here we move on to dementia, where we do see the cognitive decline,

Dr. Iris Yusupov Rose 

yes, and then the cognitive decline is enough to now interfere with the person's independence so they can no longer do some of the things that they were able to do independently, and that's how we move over into dementia territory. Okay, so very I'm going to walk through these very quickly for time's sake, but some themes on research on autism and older adulthood. If you look at all the research that has ever been done on autism that exists in the world, less than 1% focuses on older adults. And so this is really an emerging area of research. And so again, the same way that we don't want we want to reconceptualize autism. We don't want to perceive older adulthood as something that's purely negative. So we've seen the from the research that autistic older adults have had a lifetime of developing effective coping strategies and resiliency. They really find fulfillment from pursuing their passions. So some of the happiest clients that I have are autistic older adults that were able to take their interests, their passion, and make it their career. And that's often what I work on with a lot of autistic adults that are still trying to find their career path. Is, how do we incorporate your passions in life into your career? There's an opportunity for self acceptance and pride in autistic identity, so it can be quite a healing experience for the individual and for the family to understand and look back on their relationships now viewing themselves or their parent as being autistic, There's also important for us to consider that autistic older adults have higher rates of mental health conditions and chronic health conditions, and they also have some challenges accessing and benefiting from traditional healthcare services. There's research on differences in cognitive aging are currently inconclusive. So as of right now, we don't know if autistic older adults experience the same changes in their cognition as non autistic older adults do, so that's an emerging area of research, but we do know that autistic adults from this study were 2.6 times more likely to be diagnosed with dementia compared to the general population. There's lots of theories and lots of reasons as to why this is the case, but when it comes to working with older adults, it's important to consider brain health and how can we as clinicians be a part of education and reducing dementia risk. So in geriatric settings, for example, in Baycrest hospital, autism is only now starting to be considered as a differential diagnosis, and so you're going to see this coming up more and more, but there are lots of challenges in terms of differentiating neurodegenerative disease and neurodevelopmental conditions. So, for example, we had a client that came in. They were previously diagnosed. He was 65 years old, previously diagnosed, very recently, with late onset schizophrenia and adjustment disorder. And then he came to see us to see if there was actually a neurodegenerative process underneath. And the differential for him was whether he had Frontotemporal dementia. So Frontotemporal dementia is essentially characterized by behavior change, by personality change, by social disinhibition, people start to say things that are maybe not socially appropriate, or behaving in ways that are socially inappropriate. So you can imagine, you could see how autism could potentially be misconstrued or misdiagnosed as a frontal temporal presentation. And so with this client here, he. Had a perfect neuropsych profile. The key here was a developmental history. So some of the socially in a socially inappropriate things that he was doing was talking or bizarre things. Was talking about aliens and how they walk among us and and just talking over and over and over about that, which kind of makes the clinician, maybe that's why they thought schizophrenia or they had a rule out of psychotic disorder. But we did an interview with their family member, and we found, we found that this was his long standing passion and interest. And so the key here, we were able to say this is not a recent personality change or change in social behavior, which we would really need for a diagnosis of Frontotemporal dementia, but really it's it's his special interest, it's his long standing brain style difference. So we did not give any diagnoses, he had a really wonderful, strong neuropsychological profile, and we let him know that he was autistic. Another important consideration is ADHD. So whether it's at any stage in adulthood or older adulthood, ADHD is important to consider. So if you have a client with ADHD, you should think autism. If you have a client who's autistic, you should think ADHD. And so ADHD is important because there's new research coming out that undiagnosed ADHD in older adulthood actually increases risk of dementia. So that's another important consideration. And lastly, in the context of our autism assessments, whether that's in private practice or in an autism department, I encourage you to think about including a cognitive screener. So the cognitive screener that I use is called the Montreal cognitive assessment. You can go on their website, they have a free training if you're a student, and it's a really good tool to to have in your toolbox. And essentially, it's very sensitive to detecting MCI or mild cognitive impairment, so it can be really helpful in making sure that in this contact, in this contact that your client has with a healthcare professional, we're being as comprehensive as possible, and we're not missing anything, and we're taking an opportunity to provide psycho education about brain health and modifiable lifestyle factors that impact cognition, quality of life and well being. But it's really important that we provide psycho education on these lifestyle factors through a neurodiversity affirming lens. So when it comes to nutrition, we have to be considering their their their sensory preferences. When it comes to stress management, we're using techniques that are helpful for autistic individuals and for social engagement, we're not putting our own biases of what what strong or good social engagement looks like without considering their social preferences. And lastly, I'll leave you with this meta analysis that was done very recently the Landsat, with 1000s of individuals looking at modifiable risk of dementia. And so here, sorry if this a little bit small, but essentially this number in here is the percentage reduction in cases of dementia if this factor is eliminated. So if we eliminate or treat hearing loss, we can eliminate 7% of dementia cases. And so I don't have time to go into all of these here, but essentially, if we eliminate all of these 14 risk factors, we can potentially eliminate 45% of dementia cases, which is huge. So keeping these risk factors in midlife, that start in midlife and later in life in mind is really, really important when it comes to our assessments and and working with our clients. Okay, thank you. I'm racing the clock, but happy to take any questions, and thank you so much for for listening.

Megan W 

Thank you so so much. That was remarkable. I everybody in the chat is just Yeah, so So floored by everything you you had to say, Iris, thank you so so much. I know we did have a question that came up, I think, from Rob at one point, I know just in your discussion around, like, a lot of the overlapping diagnoses, like OCD and potentially having all these other diagnoses that could maybe better be explained by autism. But then. I think he's wondering, and maybe Rob, you can correct me if I'm misinterpreting, but he's wondering about the reverse, if the reverse is true sometimes as well. And and what you might think about that, like somebody coming in and you're thinking, Could this be autism that explains all of this? Does that happen? Maybe too much as well, right?

Rob 

Because I think I'm in this space, in my clinical journey, where I'm reading so much about autism, and I have clients who I believe are likely autistic, but of course, don't have the skills to diagnose that myself yet, and so I'm finding myself always asking, Is this autism? Is this autism? Is this autism? And I feel like I'm starting to sound like a broken record. And there's many clinicians of mine in my practice who are probably saying, oh god, he's going on about autism again. But, you know, I I wasn't aware of the one in five statistic until, until you mentioned it in this talk. So it's like, Oh, geez. Well, maybe I should be asking that as often as I am. I don't know. So, yeah, that was just my thing. Like, how do, how do you prevent yourself from kind of overreaching and saying, Oh, if this autism is it explains all these things and, you know, and kind of like checking your your expectations around that, in that it like overestimating how likely it might be popping up, but, and, yeah, that's kind of what I was wondering about.

Dr. Iris Yusupov Rose 

Thanks, Rob. I'm totally you too. I'm like, oh, autism. Oh, what about what about autism? So I, I'm doing that all the time too. I think it's just being mindful of that. And I mean, I do recommend it's a helpful thought exercise. You know, the way we work with clients we kind of have in our radar probably a couple things, right? Like, could be trauma, is it depression? Is it anxiety? I think just adding autism with every client is actually a helpful practice and and just looking for the evidence and being open to it, and testing your hypotheses and being collaborative with the client and asking them what they think, or if it's something that they've ever, ever considered, you might ask it, and you might be surprised that they thought, Well, yeah, I actually have this and this and this and this and this that I thought, you know, maybe that could be that, and they just reveal so much information to you. So I think about being transparent with your clients, and I'm always like, as honest as possible, and say, you know, this kind of makes me think, you know, maybe autism Is that something you've ever thought about, and just having just very transparent conversations with your clients is that's all we can do, I guess.

Rob 

Yeah, that's very validating. Thank you very much. Because I think there's, I have a lot of older clinicians in my practice, and they're always like, no, no, it can't. It can't be autism because this and because this and because this. And I'm like, but could it like, Are you sure? So that that does make me feel better about at least asking the question. So thank you very much.

Dr. Iris Yusupov Rose 

Keep doing that. That is so important. That's you literally being the paradigm shift like that's you questioning our traditional understanding of autism and having these dialogs. I think it's important to have these open dialogs and these debates. Well, it could be this or it could be that, but you know, this is a new autistic trait that we're coming to learn, and that's how people learn, and that's how people change their beliefs. So never stop asking, yeah,

Megan W 

I think the Yeah, everyone's just saying that it's been really insightful and really, really helpful. I think if there's any other questions, feel free to use the raise hand and Sarah can unmute you if needed.

Dr. Iris Yusupov Rose 

Sorry. Megan, I actually have a client at one.

Megan W 

Never mind.

Dr. Iris Yusupov Rose 

Can people email me?

Megan W 

Yes, we can definitely do that if people want to. Also the chat function will keep operating if someone wants to add questions there and then, maybe we can connect with you, Iris to to get some of those answers.  So thank you guys all so much for joining next week. Don't forget, we have Dr Kyla McDonald joining. She'll be talking about vulnerable and unseen, exploring youth homelessness and sexual exploitation. So we look forward to seeing you all next week. And thank you again Iris.

Dr. Iris Yusupov Rose 

 thank you for having me, and thank you all for your really wonderful comments and questions. And I'm here if you ever want to connect or need a consult or want to chat about autism, because I love talking about it, so I'm here. So thank you, and thank you Megan.