Approaching Autism: Clinical Skills and Resources for Working with People on the Spectrum

Emily Grills | May 1, 2022 | 25 min read


The article provides a comprehensive exploration of autism spectrum disorder. Emily's insight and expertise into this often-overlooked condition by the behavioral health community is illuminating. I am honored to share her article on this platform.

Identifying Autism

General Autistic tendencies include an overall deficit social communication and interaction, and usually a lack of emotional intelligence. For example, people with Autism may struggle to notice or understand their emotional reactions as well as others'. Some people may not notice changes in tone of voice, body language, or facial expressions when someone is upset, and may not change those features when feeling upset.

Autism Spectrum Disorder presents in a wide array of symptoms which range from an inability to speak, which would be considered a sever experience, to lesser concerns such as a lack of social-emotional intelligence.

Autistic symptoms are almost always prevalent in children between the years one and two, yet the average age for diagnosis is still well over four years (Young, et. al, 2020). Delayed diagnosis prevents many children from receiving the most effective treatment possible, as the toddler years are when a child's brain is considered to be most "plastic" in that the brain is most susceptible to learning new things. The older a person with Autism gets before receiving treatment, the more likely they are to have lifelong social challenges that may affect their ability to engage in friendships, romantic relationships, and obtain and maintain employment.

People with Autism may struggle to understand many general social cues, such as personal space. People with Autism may stand uncomfortably close to a stranger, talk very loudly in a quiet space, sing or hum in a manner that is disruptive to others, or touch others in seemingly inappropriate manners. For example, if a person is wearing ripped jeans, a person or child with Autism may touch the exposed skin that protrudes from the jeans.

Autism can be mistaken for Narcissism, as people with Autism tend to struggle with taking interests in others' hobbies or passions. A person with Autism may appear to monopolize conversation, dictate usually cooperative events such a decorating a room, or setting a schedule. People with Autism do not intend to harm others, or hurt others for personal benefit. They are simply struggling to understand the emotional process of others, and therefore often appear to be very self-centered.


In the year 2000, about one in 150 children (aged 3-17) were diagnosed with Autism. In 2016, that number reached one in 54 American children. The increased prevalence appears to demonstrate a 200% increase in people living with Autism in less than two decades; however, it is possible that data gathering is far more efficient than ever, and that the actual increase of children born on the spectrum has not been operating at such a staggering speed.

Males are 4.3 times more likely to be on the spectrum than females. There are a few studied possibilities that may explain the disparity between the sexes. For one, male brains tend vary more often in intelligence and cognitions, as represented in IQ scores. This variability seems to increase vulnerability to atypical development, and some researchers believe Autism is the result of overdevelopment of the male brain. There has also been considerable research into the male X chromosome. A mutation on the chromosome has been observed in many males with Autism. This may account for the imbalance of male susceptibility.

Autism has been linked to a number of events. Research supports the idea that mothers who drink and/or smoke during pregnancy increase the chances of their child being born with some sort of developmental disability, including Autism. Some developmental biologists believe that twins are more likely to have Autism, as growing two fetuses at once can be straining on a mother's body, and any number of issues can result from having twins. Finally, new research suggests that mothers who eat highly processed foods, often found in America, are more likely to give birth to a child with a developmental disability.


There are various symptom combinations of people with Autism. Remember that people who are "high functioning" may only display one behavior of each section, and this is still an experience of Autism. Challenges in social communication and interaction in various settings:

  • Inhibitions in social-emotional abilities
  • Struggling in normal back and forth conversations
  • Flat affect or lack of emotional investment in communication *This can also look like uninterrupted happiness or an "unbothered" personality.
  • Failure to initiate conversation or social interaction.
  • Struggling to understand or interpret nonverbal behavior such as body language or facial expressions.
  • Struggling to appropriately use nonverbal cues to communicate effectively.
  • Issues with making eye contact.
  • Challenges to understand and maintain personal relationships, romantic or otherwise.
  • Failure to adjust behavior and/or appearance to suit a social context.
  • Rigid patterns of behavior and interests
  • Repetitive motor movements
  • Using sameness in speech, singing, and interacting with others.
  • Insistence on consistency in routines, schedules, and sometimes clothes and food.
  • Perseverative interests considered to be abnormally intense.
  • Hyper or hypo reactivity to sensor input: this can look like an indifference to pain, a considerably low pain tolerance, a need for sensory input such as weighted blankets or hugs during crisis, and/or a sensitivity to sounds, visuals, and competing sensory input.

These symptoms must be present in the early developmental period, 12-18 months, but not may not become obvious until social demands in middle childhood expose limited capacities. These symptoms should not be better explained by an intellectual disability.

Behavioral Tendencies


Both children and adults with Autism have an increased vulnerability to experiencing trauma because they tend to struggle with communication, have increased likelihood for social isolation, and tend to experience high levels of familial stress. People who endure a trauma may develop PTSD or Complex-PTSD. People with Autism who experience trauma are more likely to develop PTSD or CPTSD because they are less likely to receive trauma treatment.

People who develop PTSD or CPTSD are also more likely to experience anxiety, depression, medical issues, addiction behaviors, and relationship issues. These additional disorders are often treated with medication such as antidepressants and antianxiety. When medication for Autism is discussed, the medication is not intended to address core Autistic symptoms, rather, the medication is intended to decrease supplemental symptoms.

People who have been exposed to trauma usually leads to increased stress on the amygdala, especially for children, which often results in conditioned fear responses. So, people with Autism who have been exposed to trauma often experience increased perceptions of threat, which usually dysregulates emotional function. People with Autism who have been exposed to trauma often engage in self-injurious behavior because of increased perceptions of threat and lack of defense mechanisms.

Self-Injurious Behavior

Some research suggests that the sudden onset of self-injurious behavior (SIB) may due to trauma exposure. Symptoms of traumatic stress and ASD are closely related, and sometimes diagnosis overlaps between the two. Discerning between trauma and Autism can be difficult. To be clear, the issue is that people with Autism often cannot report trauma. Therefore, it can be difficult to uncover whether a person with Autism endured a traumatic event, not whether a person who has endured trauma has Autism.

Many people with Autism have trouble communicating effectively or speaking at all. When a person with Autism cannot explain their needs, they may turn to self-injurious behaviors such as head-banging, biting, teeth grinding, or scratching. These behaviors often occur as a result of an unmet need. For example: a person with Autism wants cheddar cheese. The person is refused cheddar cheese because they are lactose intolerant. The person has an unmet need and feels frustrated. The person may turn to self-injurious behavior in order to gain the desired item.

Self-injurious behavior is not common in people who experience low symptoms of Autism. Usually, people who have severe symptoms of Autism, such as an inability to speak, engage in self-injurious behavior. Return to the cheddar cheese example. While counselors usually do not endure issues around food, the cheddar cheese may be metaphorical for a number of desires. Replaced needs may be met with replaced behaviors. An alternative for cheese may be fulfilling, and self-injurious behavior may decrease when a person feels they are being heard.


People with Autism are capable of consensual, positive sex lives. Some social implications may need to be broached or reminded as a person engages in safe sexual behaviors. Reminders and appropriate conversations about sex may include hygiene and grooming, changing bodies and their functions, reproductive health, contraception, socially transmitted infections, sexual behaviors, and awareness of the disparity between media-portrayed sex and sex in the real world (Peloquin, 2013).

People with Autism are at a higher risk for sexual abuse and assault because of communication barriers and understanding norms in safety (Peloquin, 2013). Especially for children and adolescents with Autism, reiterated explanation of safe and dignified sexual behaviors may be important. People with Autism may benefit from explanations of consent, cyber dangers, sexual aggression, and abusive relationships. An open conversation about interests, orientation, and exploration may also benefit a person with Autism.

Depending on the severity, clinicians may also consider explaining boundaries for the benefit of others. Morals and social responsibility are important parameters. Touching, masturbation and sexual acts are only appropriate in privacy, with consenting others or the self. Explaining privacy may be necessary (Peloquin, 2013).

Some people with Autism spend extensive time using video games or other technological pass times. These forms of media tend to display sex in aggressive, sexist, unsafe manners. Have conversations with your patient about their understanding of sex and what they believe to be normal. Promoting safety and consent is vital.

Sensory Considerations

Sensory concerns are commonly overlooked for accommodating Autism. Many studies show that young adults (college students) with Autism are less likely to receive a college degree because of unmet needs.

People with Autism have many sensory needs including sight and sound overwhelm, adversity to touch, and issues eating foods with certain textures. When working in a counseling room with a person with Autism, consider the lighting and noise level of the environment.

  • Overhead lighting may be too harsh for the patient to focus well. Lighting the room with lamps and warm light may improve the environment and therefore the quality of counseling sessions.
  • Most counseling rooms have noise machines sitting outside the door. Patients may benefit from a simple explanation of the purpose of the noise machine. Patients may also appreciate turning the noise machine down or off. Patients may also struggle with voices and people passing outside the counseling room. Practitioners should be patient with allowing patients to turn their focus back to the conversation once noise distractions have passed.
  • Voice volume is an important factor of building rapport with patients with Autism. Practitioners who present themselves as calm and comfortable may improve the comfortability of their patients.

Multicultural Implications

Diagnosing Autism in the United States tend to occur more easily than in countries where certain social norms differ. For example, eye contact is a strong indicator of Autism in young children. Most healthy infants begin making eye contact around three months. Some children with Autism may meet this milestone but begin to lose social skills such as eye contact or speech in the toddler years. This regression is sometimes interpreted as a child "learning respect" if their culture discourages eye contact between generations. Unfortunately, this phenomenon may be the first of many Autistic symptoms however may often go unnoticed if not interpreted as different behavior.

Statistics show that African American children are often undiagnosed or diagnosed late because of cultural misconceptions and often socio-economic status. Some parents living in poverty may notice odd behaviors in their child but may not have the resources to have their child assessed. Other parents may also experience shame and embarrassment for having a child who is different and may therefore be hesitant to get confirmation of their child's issues.

As mentioned, males are four times more likely to receive an Autism diagnosis than females. While this statistic is consistent with prevalence, females are at a higher risk for late or under-diagnosis because many clinicians do not consider Autism when the patient in question is female.

Female Autistic symptoms can present differently than male. Females often exhibit improved social skills compared to their male counterparts. Females tend to intimate social emotional intelligence more readily than males because they learn from a young age that social emotional skills are often more generally expected in females.

Common Relevant Presenting Concerns

Anxiety can be a common presenting concern of a person with Autism. This is not to say that every person with anxiety is Autistic, but many people with Autism are likely experiencing anxiety because of felt disconnection from others.

People with possible Autism may benefit from probing questions about emotions surrounding anxiety. A person with Autism may be unable to name the emotions or name one secondary emotion consistently such as frustration or disappointment. Anxiety coupled with an emotional disconnection could indicate Autism.

Communication concerns are common for people with Autism. A patient might comment "I don't understand sarcasm" or feel disconnected from people who use slang or informal language. Formal language tends to be more objective, which may be more readily understood by a person with Autism.

Emotional intelligence is commonly a concern for people with Autism. Many high functioning adults will notice differences in their experiences compared to others, but may not necessarily understand how to connect, therefore questioning their emotional intelligence. People with Autism feel emotions typically but may not always relate emotions to actions or behaviors. For instance, a married male with Autism may understand that his spouse is angry with him however may not connect that the anger is a result of his staying at work late every night.


Medications will not improve the core symptoms of Autism, which are social and emotional disconnections and deficits. Medications may, however, improve anxiety or depression that can occur in a person with Autism. Curbing additional issues or symptoms usually benefits a person with Autism.

Antipsychotics haloperidol and risperidone have been researched and shown to improve behavioral symptoms of people with Autism. They can occasionally lead to reduction of aggression and irritability.

Note: this research has been primarily if not exclusively conducted on children, and there is little research to support administering antipsychotics to adults to treat Autism. Additionally, haloperidol and risperidone have significant side effects, including weight gain, tardive dyskinesia, and hyperprolactinemia.

Common Misdiagnoses

Many males with Autism have been misdiagnosed with Schizophrenia based on their general "oddness" or detachment from society. It is important to discern whether a person with overlapping symptoms of Autism and schizophrenia is experiencing psychosis. If there is no psychosis, consider Autism.

Many mood disorders such as hypomania and Bipolar I and II have been mistakenly diagnosed instead of Autism. Impulsivity, irritability, and some inconsistent behavior are all symptoms of Autism. It is important to obtain patient's family history when diagnosing. If a person has a blood relative with Autism, it is more likely they are on the spectrum than experiencing a stand-alone mood disorder.


Stereotypic movement disorder can both be misdiagnosed for Autism as well as co-occur The diagnoses are considered comorbid when the motor movements are self-injurious and become the treatment focus.

Attention deficit/hyperactivity disorder (ADHD) can also be misdiagnosed or comorbid. ADHD can be appropriately diagnosed instead of Autism when attention and hyperactivity are the sole concerns of the individual, and these concerns exceed typical behavior of the development age. ADHD and Autism are considered comorbid when attention abnormalities seem to coincide with social inhibitions and/or motor movement concerns and/or sensory needs.

A General Guide to a Productive Relationship

While counseling is often rooted in insight and relation, psychoeducational techniques tend to be more useful to people on the spectrum. Conversations focused on emotion are often experienced as hypothetical and can be difficult to comprehend for people who engage in the world rather literally.

For example, instead of focusing solely on a person's feelings about abandonment, psychoeducation about effects of abandonment on a person's behavior may be more appropriate. A person with Autism may gain more insight to understanding that they to fear confrontation based on fear of abandonment than focusing simply on the emotion of fear itself.

Counseling people with Autism often looks like coaching. Goals are specific tangible, and usually relevant to adjusting routines or obtaining successes such as employment. For example, CHP has experienced some people with Autism come to counseling for the goal of successfully completing a job interview to secure employment.

One person was tasked to bring in interview questions for three sessions in a row. The client addressed interview questions that were abstract or overwhelming to him such as "Tell us about yourself" or "Why are you a unique applicant?". The client was interested in breaking down these questions to understand their root. He reported concerns about "uniqueness" because no one is completely different from everyone else. The counselor explained "unique" as a term used to describe to a trait someone has that perhaps only 10 or 20% of people have. The client came to understand the employers were looking for rare, not 1 in a million, skills.

Following these "breakdown" sessions, the client attended a mock interview in which he practiced answering typical questions that would be expected for a candidate in this field. During the interview, the client dressed appropriately (shirt & tie) to make the artificial environment as realistic as possible. These preparatory sessions allowed the client to calm his nerves and discomfort with a trusted person.

Common and Productive Goals in Counseling


  • Job security: obtaining or maintaining employment through interview skills improved social skills in the workplace.
  • Substance use reduction: Many people with Autism cope with their differences by drinking or using drugs. People with Autism often respond to a reduction approach instead of quitting cold turkey. For example, learn how often a person is drinking a day, and begin with reducing that amount by one drink. Gradual reduction may be more sustainable.
  • Driving: Autism can impact a person's hand-eye coordination, as well as result in a person experiencing intrusive thoughts. Some people with Autism may never be able to drive, but some may simply need support in developing the skill. Discern whether the person is interested and capable of driving before encouraging this skills set.
  • Academic success: Many people with Autism are highly skilled in academic settings, however, may struggle with overwhelm of assignments or managing the classroom environment (See Neurodiverse Environments).


Marital/Relationship connection: Communication skills are a core symptom of Autism and can impact their ability to engage healthily in romantic relationships. Clients with Autism most often benefit from developing signs or signals to let their partner know they need or are currently incapable of something.

Emotional concerns can also be involved when a client decides to disclose their diagnosis to friends, family, or professional peers. Support may look like normalizing the diagnosis as about 1 in 8 Americans are on the spectrum. Clients may also find support in learning how their diagnosis is a benefit to them. Diagnosis can help a person better understand their own needs to function more effectively in the world.

Neurodiverse Environments

Just as college campuses and staff have been expected to adapt to neurodiversity, so should counseling and medical personnel. Neurodiversity is not meant to single out people who are "different" as most all brains function somewhat uniquely. Neurodiverse environments are an important factor in equity in healthcare. Consider the waiting room and/or counseling and medical offices. People with Autism who walk into the hustle and bustle of a busy non-profit may be overwhelmed by the bright, fluorescent lights, the distracting sounds of people on phones, pens on paper, or even jeans on seat cushions. They may find any smell of perfume, cologne, or air freshener to be intrusive. Loud voices, intensive eye-contact, or unanticipated touching may considerably uncomfortable.

Because a patient's neurodiversity cannot be immediately broken down, consider these neurodiverse environmental improvements:

  • Using lamps or indirect lighting,
  • Being conscious of your speech volume, speed, and tone,
  • Wearing light or no perfume or cologne
  • Using intermittent eye contact
  • Closing doors when talking on the phone
  • Keeping co-worker conversations confined to employee-only spaces
  • Avoiding eating or drinking in front of patients
  • Using language that is direct and unambiguous (no sarcasm)

More drastic changes for a neurodiverse environment might look like:

  • Using only furniture that does not create an uncomfortable sound when colliding with clothing
  • Using only sound machines that offer interpretable sounds (ocean waves, rain falling) as compared to white noise
  • Providing a large or multiple waiting rooms for comfortability when waiting for a clinician, and avoiding competing noises when in the waiting room or exam/counseling room such a radio competing with a sound machine competing with a person's phone call

Applied Behavior Analysis

Applied behavior analysis, or ABA, is the most used therapeutic approach to Autism. ABA is generally conducted after the completion of a functional behavior analysis (FBA) which is the process of discerning the motivation for a specific behavior.

For instance, a therapist may be asked to work a person with Autism who is constantly engaging in self-injurious behavior by hitting their head on walls, floors, or other solid objects. The therapist may discern, through the FBA, that the self-injurious behavior is performed when the person with Autism is not receiving attention. The motivation for the behavior is attention.

Once motivation has been established, the therapist may intervene in a number of modalities. A common treatment in ABA is replacement behavior. Through discreet trials (repeated attempts), the therapist may teach the person with Autism to request attention through speech, a speech aid, or gesture. The original behavior was self-injury for attention. The replacement behavior ensures the same response (attention), but the reinforcement is earned through a safe, respectful manner for both parties.

Self-injurious behavior (SIB) can be a difficult issue to address. While counselors are unlikely to encounter a person with persistent self-injurious behavior (they most likely would not perform the behavior in front of the counselor) they may noticed evidence of SIB in session. Medical personnel may witness a person demonstrate SIB when the patient is uncomfortable, angry, or afraid. For instance, a person may hit their head against a wall when a medical professional attempts to give them a shot or even discusses the need for a shot. If self-injurious behavior ensues, remember the safety of the medical professional is just as important as the safety of the patient. Attempt to the calm the person by talking about some of the patients' interests, talking about yourself, or any other relatable topic. Avoiding questions may be important as questions can be an additional stress for a person displaying SIB.


An Autism diagnosis should not occur based on the results of one assessment. Observing and interacting with a patient multiple times before diagnosing is important for accuracy and confidence of the clinician as well as a strong rapport with the client. The following assessments are tools to be used supplementary to one-on-one clinician-patient interaction.

AQ-10 (Autism Spectrum Quotient 10)

The AQ-10 is a 10-question self-assessment that can be completed by adults and older children. The assessment most all concerns for ASD in simple vernacular. The AQ-10 is likely the most appropriate assessment for clinical sites like Community Health Partners. The assessment is also available in Spanish. Patients may need up 15 minutes to complete the questions.

ADOS (Autism Diagnostic Observation Schedule)

The ADOS is a largely extensive interactive assessment intended for children who are suspected to be experiencing developmental delays, though the assessment may be used to diagnosis adults. A clinician must administer the assessment, which may last anywhere from 40 minutes to one hour. The assessment consists mostly of clinical observation of a patient. The ADOS is available in English and most European languages. Please be advised, the ADOS is a considerably expensive tool.

Sex-Bias in Assessments

Unfortunately, many American mental health assessments were created based on the data of Caucasian males between the ages of 20 and 45. Autism assessments are no exception as most people with Autism are male. The AQ-10 and the ADOS are considered valid assessments but are biased toward the male experience.


Many females with Autism engage in camouflaging or pretending to behave in a socially acceptable manner. Camouflaging can include forcing oneself to make eye contact during conversation or in situations where eye contact is expected, preparing jokes, phrases, or stories prior to social situation, mimicking the social behavior of others, and imitating gestures and expressions.

Autism is commonly diagnosed based on abnormal or muted social skills. Females with Autism may not present with these symptoms because of camouflaging. Females with Autism may be better identified by both assessment from the AQ-10 as well as clarifying and gender-specific questions such as:

  • I feel pressure to act the way other girls (kids) in my class/office/on my social media.
  • I practice making small talk to myself or in the mirror before going into a social situation.
  • I engage in sexual activity out of felt obligation more than interest.
  • I hug people or let people hug me even though I do not prefer to be touched.
  • I often force myself to make eye contact in personal or professional settings or when I think people want me to look at them.

Emily Grills is a clinical counselor who works with underserved populations at a federally qualified health center. As a colleague I have learned a considerable amount from her. She has really opened my eyes to the importance of identifying and treating autism spectrum disorder especially with high functioning adult populations.


  • Many, if not all individuals with Autism are protected under the Americans with Disabilities Act (ADA). If your patient seems to be abused or mistreated, contact Child/Adult Protective Services (CPS/APS) and, if necessary, the ADA. Americans with Disabilities Act: 1- 800-514-0301
  • Child Abuse Hotline: (866) 820-5437 (toll free, 24 hours) TTY-hearing-impaired Child Abuse Hotline: Dial 711; when prompted dial 1-866-820-5437
  • South Central Region III (Gallatin, Park, Sweet Grass, Carbon, Stillwater and Yellowstone) Jason Larson, Regional Administrator 2525 4th Avenue North, Suite 309 Billings, MT 59101 (406) 657-3120 (406) 657-3178 Fax
  • Family Service Department: 406-585-9984



American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Anderberg, E. Cox, J.Tass, E. Neeley, E. Gabrielsen, D. Warren, T. Jared, S. Cline, J. Petersen, D. South, M. (2017). Sticking with it: Psychotherapy outcomes for adults with autism spectrum disorder in a university counseling center setting. Autism Research., 10(12), 2048-2055.

Center for Disease Control and Prevention (2020). Autism spectrum disorder. Center for Disease Control and Prevention. Link

Coghill, E., & Coghill, J. (2021). Supporting neurodiverse college student success. Roman & Littlefield: Lanham, MD.

Graetz, J. (2010). Autism grows up: Opportunities for adults with autism. Disability & Society.,25(1), 33-47.

Matson, J., & Lo Vullo, S. (2008). A review of behavioral treatments for self-injurious behaviors of persons with autism spectrum disorders. Behavior Modification, 32(1) 61-76. doi: 10.1177/0145445507304581

Peloquin, L. (2013). Autism spectrum disorders and sexuality. Presentation. Profectum.

Posey, D. Erickson, C. & McDougle, C. (2008) Antipsychotics in the treatment of autism. Journal of Clinical Investigation. 118(1), 6-14.

Sarrett, J. (2018). Autism and accommodations in higher education: Insights from the autism community. Journal of Autism and Developmental Disorders. 48:3, 679-693.

Stack, A. & Lucyshyn, J. (2018) Autism spectrum disorder and the experience of traumatic events: Review of the current literature to inform modifications to a treatment model for children with autism. Journal of Autism and Development Disorders, 49 1613-1625.

VanBergeijk, D. Klin, B. & Volkmar, H. (2008). Therapeutic relationships with individuals on the autism spectrum. Presentation. IBHC.

Young, G. Constantino, J. Dvorak, S. Belding, A. Gangi, D. Hill, A. & Ozonoff, S. (2020). A video-based measure to identify autism risk in infancy.Journal of Child Psychology and Psychiatry, 61(1), 88-94. doi:Link

©2024 Behavioral Health Consulting Solutions

All rights reserved