Ep. 144: Professor Tony Attwood - The Asperger’s Syndrome

 Sucheta Kamath: Welcome to another episode of Full PreFrontal, my mission is to help people understand that their brain's prefrontal cortex, at its best acts as an orchestra conductor, directing actions, guiding emotions, tweaking responses and calibrating decisions in order to create a beautiful, harmonious symphony of well lived life. And the glue that holds it all together is your social skills, your ability to form relationships, your ability to reciprocate your ability to understand the minds of others, and your ability to resolve conflicts. But some of us are more gifted in that area than the others. And it's it really important that we engage in conversations so that we can uncover the key components that drive and propel the prefrontal cortex to regulate itself and lead to better and more meaningful relationships. And that's why you are always waiting for eagerly for my guests. And today we have a special treat. Because we have one of my favorites, which is Professor Tony Attwood, who is a clinical psychologist who has explored autism for nearly 50 years, which is kind of fooled by that by his looks, because he could not have been working in the field for 50 years. When he looks he's barely 50. So that's another note, Tony wrote Asperger's Syndrome: A guide for parents and professionals, which has been translated into 27 languages. And that's been my North Star dealing with Asperger's. I really, sincerely thank him. And he is a practitioner, practicing clinician with a clinic for ASD, which is Asperger's Syndrome disorder in Brisbane, Australia, and has contributed to over 30 research articles and written over 10 books on this topic. Welcome to the show. Tony, how are you?

Tony Attwood: Thank you, Sucheta. And thank you for that introduction, you have now set me up that the audience is anticipating this fantastic presentation, I'll see what I can do. 

Sucheta Kamath: And they will never be disappointed because I personally have gained from your your humor, your talent, your wit and your sharp observation of human potential. So thank you. Okay, I'm going to start with this question, which I often ask my audiences, since you specialize in Asperger's, social skills, and this ability to understand minds of others, and you're a hardcore neuropsychologist. How would you describe your own skills in those areas when you were a child? Did Were you really great with it? Did you struggle with it? What brought you closer to this field?

Tony Attwood: When it comes to social skills, I was very good at it. And it was when I met autistic children who aren't that I realized how complicated it is. I mean, in terms of social skills, I never knew my parents together, I was a baby when they separated. And when I was six years old, my mother remarried an engineer. Today would diagnosed with Asperger syndrome,

Sucheta Kamath: I see. 

Tony Attwood: But in that setting, I didn't feel welcome at home. So my escape was the homes of friends. And friendship was very important for me as an opportunity to be true to my real self, and engage in reciprocity and facial expressions and humor and so on, in friendship, which was my, shall we say, coping mechanisms. But it also meant from the age of six with my stepfather. I observed him and felt you're different. The you, you really don't understand. And so when you say I began in this area, officially 50 years ago, actually sort of 60 years, because my stepfather enabled me to understand Asperger-ese, so I'm bilingual. From an early age. And so that's why when I met those autistic children, it wasn't so strange to me, because I've been brought up in an aspie household.

Sucheta Kamath: You know, you say this, this reminds me of my personal journey when I was a young child and a young person. Many outsiders are outliers were socially unacceptable. unaccepted or unacceptable, always drew to me. And I maybe I don't know, maybe my. I wouldn't paint in a grand ways, but I was much more patient tolerant and inviting. And I was raised with great social skills and etiquette to always be inclusive. But it annoyed me inside because these unpopular people would bring down my social capital. Because they would always be odd and they were blurt out things that were not kosher, or they would not have the veil or pretense that gives you social cream, you know, greed. So anyway, but I am so grateful for for a bringing I had because that really tuned me into a lot of people who had social skills problem. I had an uncle, my, my mother's sister's husband, who would classically be diagnosed as Asperger's. And he collected clocks. So anyway, we can we're going to talk more about that. But I really appreciate that. So sounds like, can you help define for our audience? What is Asperger syndrome and since DSM-5, for those who may not know, but it's a psychological, I guess, categorization or evaluative process, which has gotten rid of the term and it has embedded back into Autism Spectrum Disorder,

Tony Attwood: Okay, there are the official, okay, the official DSM-5 diagnostic criteria. I have some very good points. But I have my own, not definition, description. And when I'm doing a diagnosis, I call it a discovery, rather than that I. And I say, it's a different way of perceiving, thinking, learning and relating it, you found something more interesting in life than socializing. It's a different form of perception. You notice detail sounds, pattern systems far more effectively than others. So it's a different form of perception. It's a different form of thinking. Often, it's not an internal conversation, it's visualization. It's finding solutions, not understanding why but inspirational. It's a different way of thinking. Now, unfortunately, it's a different way of learning. Most school education is in a social conversational context. That's not the autistic way. And so it's a different way of learning. And when you accommodate their cognitive profile, then you will find abilities that are really quite entrancing. But it's also a different way of relating in terms of how the person perceives social cues, social regulation, reads facial expressions and social context, and is able to engage socially and some are very competent socially. But it's exhausting, because it's an intellectual process. And then frontal lobe comes in, because it's processing time, etc. And so that can be success, but it is unfortunately, at the cost of exhaustion. Now, DSM-5 is it on the whole, I'm, I do think it has many positive aspects. But I do think that it is most unfortunate that the United States, in terms of its psychologists, psychiatrists, and professionals, have a perception of autism that Leo Kanner produced in terms of the silent, aloof, autistic child. And hopefully, we have yet to have someone other than Fred Wagner. In the United States, who champions, the far end of the spectrum, I call it it's like visual impairment. There are those who are blind, oh, very obvious. But there are those like me, I am visually impaired, but I'm not blind. And I see the social dimension of autism like visual impairment. And we need to accept and support those who in the terms of the social development can do reasonably well to a certain point and DSM-5 in section. To a certain extent, the section that refers to camouflaging and compensating, I think DSM-5 is right in that. But the American view is one of a disability, primarily for financial reasons. And DSM-5 is for money. It's basically so that the person can be given insurance company funding, it is sufficiently severe to warrant that we've got to go beyond the finance and look at the individual and realize this person has major social needs. And we need to accommodate that and approach it from the autism perception. So this is a problem we have with girls and women, the United States does not have a champion for the girls and women, or those that I call it the upper end of the spectrum. And so in Europe, Australia and other countries, they have been in far in advance in terms of both research and therapy for such individuals compared to the USA. Sorry, but that's my perception. 

Sucheta Kamath: No, I'm so glad you. First of all, I think laid out the foundation and two thoughts come to mind about what you just said about that. inclusivity as we widen the circle of inclusivity, and more important gain value we gain is lack of stigma, I think that is so important because it's not only comes from something lacking, but something that is strengthening you if you have a language that you speak. I mean, to me, people with autism are multilingual. They speak visual spatial language that many people are impaired. You know what I mean? And the point though, I think the analogy that you gave with with the visual impairment with glasses or no glasses, one thing is the reason maybe there was quicker acceptability of you needed correction, in spite of your visual impairment versus autism, it doesn't involve other people. Because, you know, imagine like, if you bumped into people as part of your visual impairment, then you will be a bigger nuisance, not you, but your disability. So there is that interdependence on social skills where lack of somebody's ability to socially relate appropriately interferes with other's ability to interact with them, do you think that has to do with the way we approach autism? And particularly Asperger's and the stigma that goes with it?

Tony Attwood: Yeah, but but can I transfer that to how other children would perceive the child? They know they're different before they have a diagnostic assess? Yes, they have a different way of relating talking perception, and other kids know, they're different. Now, that means that the other kids sometimes see them, as I'm afraid to say this, not human. And that means that you have no guilt for bullying and teasing. And so a lot of my clinical work, is actually trying to repair the damage done by neurotypicals. I don't mind austism, autism is fine. Yeah, you have that you're different. That's all right thing. But I am concerned about neurotypicals. And how they will relate to someone who by definition is different. And that will bring out either compassion or cruelty. And that cruelty can lead to trauma and despair, that we spend a lot of effort trying to undo what neurotypicals did. It's not the autism, it's often the result of neurotypicals.

Sucheta Kamath: And, you know, I really My heart aches, as I hear you speak about this, that there are two paths. One is cruelty or compassion. And what is what is up with us as neurotypicals Why is there such a compulsion to to assimilate, and particularly children, you know, they don't want to be different. And then anybody who is different, who is dehumanizing that, I will tell you a quick story. I had a second grader. A mom was giving her bath and she noticed that she had long, long red streaks on her back, not one or two, there were like seven long streaks. It looked like somebody had crawled their nails on her back. Mom was panicked. And she called the teacher that night, immediately. Next day, she showed up at school the everybody gathered. And they said, No, nobody has touched her. Nobody has interacted with her. And so they tracked everything what had happened. So this is the only time we have seen her do is this. This was before even she got the diagnosis. She does something very unique. They said not weird. But they said she sits in the corner of the playground gathering pine cones. And so we wonder and so once they started talking, and I got involved, it turned out, this girl did not know how to engage these kids. So she would invent these games. And she had of course trouble but she would invent invite them to slide the pine cones back her back. So the kids did it a couple of times. They thought it was weird, but funny, you know, not fun. And she got their engagement. And of course, that was the way the reason she got the back. The streaks on her back. The challenge there is everybody went to protect her, but she didn't understand anything like why this is not a good way to engage. But also the other kids did not. not do that. You see what I mean? They readily engaged with that. And that's pretty aching, these are normal kids. These were decent kids. These were not harmful, or, or weird or bullies. They were just went along. 

Tony Attwood: I think when we just expanding on this a little bit farther. You asked the original question was about my own childhood. I strongly suspect that on my father's side, there are signs of autism. And I think there are those who are neurotypical are born with the neural structures, genetically to understand autism and I I think you'll find that there are some people who understand that if they never had any training, they just get it. And when you ask, Are you just like, my dad is just like my uncle. My granddad was like that, or my grandma was like that. And then I think it's not just observation of that person. I think the neural structures are there, genetically, to get it very easily, but there are a minority.

Sucheta Kamath: I see. Oh, wow. So let's talk a little bit more about this. What are the symptoms of somebody? How do you diagnose them? And what are the typical concerns or what age group parents become very concerned?

Tony Attwood: Okay, I think there are certain essential components and DSM-5 is absolutely correct in the term reciprocity, it's the balance. And it can either be the aloof, autistic person who really is on the periphery doesn't want to engage lack of eye contact is being alone, not lonely. But I also know of the extrovert as opposed to introvert. Now, the extrovert wants to socialize, wants to engage a little bit like that girl you were just describing. And the extrovert splits into two groups, one I call Italian drivers, they don't read the signals. Now, your face as you smiled, it's like traffic lights, green light, keep talking. If you your eyebrows went down, and you looked a bit puzzled with your head to one side, amber light, slow down and explain, if you burst into tears, red light, I'd stop. So they don't see the no tailgating signs, the Men at Work signs and keep interrupting you. And they break the codes. And they can't understand what did I do wrong. But they have a lack of theory of mind that is the ability to perceive nonverbal communication. But over the last five to 10 years, we found that there's another group of extroverts that, pull back, observe, analyze, and imitate. In autism, you're very good at looking at systems and patterns, especially pattern breaks, but patterns. And if you're not good at social, you say, Okay, I'm going to watch, I'm going to look for patterns, what are the social rules, and when I get them, I will be the rule policeman. And I'll become very upset if somebody breaks the rules, and it's not fair. So this is an individual who observes the patterns, analyzes the interplay. It's a complex intellectual process, and then creates a mask to camouflage and compensate in various ways for their social confusion. It's a script. And what I say is, this was from a friend and colleague, Maya again, who said, the person should be awarded an Oscar every day for their performance as neuroatypical Wow. And so what I've got to look at is in the diagnostic assessment, the degree of withdrawal? Do they read the signals? Do they give me the signals, what you got to do is create an opportunity of reciprocity and engagement. Okay, and you just check what's going on? You try and do this as naturally as possible. But then there are those that, for example, have in ADOS, it's an absence of social gestures. But you have the girl who goes, and I don't know. And then I don't know. And then I don't know. And it's stylized. It is an imitation, it's the right gesture, but it's a borrowed gesture. So what you have is a realization that this person has learned the script, they sometimes I will notice, they are duplicating my facial expressions and gestures. So it's a qualitative analysis that needs to be explored. And this is the subtleties in an ADOS may not pick up the subtleties of what's occurring. So it is a degree of engagement. It's also other areas, for example, some of the things I picked up is with adults, I'll say, I don't really know you. Tell me very simple question, but I'd like to know your answer. Who are you? And neurotypicals will answer very quickly, and define themselves by their social network, or a complex vocabulary of personality types. Here. The person defines the self by what they do, and No. Oh, wow. I can't answer that.

Sucheta Kamath: Yes. Oh, sorry. Do you know the show called Boston Legal?

Tony Attwood: I heard of it. Yeah. 

Sucheta Kamath: Oh, that's. So this is my theory. So I came from India, and I'm not very well versed with American television. And I saw, I've been here now for 25 years. And one of the things I saw a transformation, before my time, there was a show called Mork and Mindy. And all the odd behaviors of Robin Williams were because he was an alien. Then there came a show that was actually called third Rock from the Sun. Oh, yes, I know. And, and so the whole family was an alien family trying to assimilate. So they were not like Mork and Mindy, he was like a little alien. They were alien, in the body of a simulated humans doing the running into full pass. Then, fast forward, you have shows like, you know, Sheldon, The Big Bang Theory, and then the surgeon or were actually full blown. People with spectrum disorder are actually depicted. But they are now dominating the scene, they're saying we won't change our behaviors. And all the adjustment is done by others. So I see a cultural transformation. As I look at the way we have begun to understand before we made fun of them, now we laugh with them. And now as time progresses, there's even more revering them for their unique qualities.

Tony Attwood: Can I take that up, because what is occurring is respect. When I talked to the kids, one of the things they lack at school is respect.

Sucheta Kamath: Yes.

Tony Attwood: They talk about it yearning for acceptance and respect. And they're dealing with a group that, in fact, are very intolerant of anyone who's different. But respect is important. Society is changing. But there is a problem that's occurring in high schools. And today, if a student makes a social error, the derogatory comment is, what's the matter with you? Are you autistic, or something? Oh, wow. And so the term autistic has become a derogatory term for anyone who doesn't read the social cues. So you've got to be very careful to avoid distraction. That's one of the reasons why many teenagers reject the diagnosis, not because they don't agree with it. But they know what their peer group will think, when that's confirmed, it's viewed as someone again, in a derogatory way.

Sucheta Kamath: And you know, to your point, I do see there's a greater recognition of their unique qualities and contribution to society, for example, like you said, engineers, or talented, IT professionals, but they to me, there is a some attitude of using them, using their talents and discarding their place in social interactions. I'm circling back and finishing my thought about Boston Legal. I was taken aback this this show is I think, 2010, or maybe seven, something like that. But they actually had a lawyer who had a who was, I mean, he was a person with Asperger's, and had all the quirks and almost placed in the plot as a human human source of humor. So I cringed because that was laughing, because of his idiosyncrasies, but not really having compassion for his suffering. And I just didn't like that at all.

Tony Attwood: What I've done is I've actually talked to TV producers, and I say that this person clearly has autism? They said, We can't say that. Because then people wouldn't love. Yes, you can't laugh at disability. So we can't say they have autism.

Sucheta Kamath: Oh, my goodness. But then we have a problem there. Because then they we are also saying that all the oopsies and faux pas are only worth laughing at or

Tony Attwood: All they want is the audience to laugh. And that's their goal, as script writers and producers, is to make the audience laugh. But we can't say that they're autistic. Because what people would say no, that's not fair. Now, can I take you back on something you want us that among to go on careers in it? Yes, you're absolutely right. But that's only a third. Because when I looked at the careers, there are those with autism who have alexithymia we've only been exploring this in autism in the last five or 10 years. Although it was originally known in the 1970s as a part of psychoanalysis, whereby the person has difficulty converting thoughts and emotion to speech. So when you ask them, What are you feeling now? I don't know. Come on. What do you feeling? You can tell me every Dinosaur in the Jurassic period? What do you think? I don't know. I will now complete the sentence. I don't know how to grasp one of the many thoughts and feelings swirling in my mind, hold it, identify it, and explain it in speech, so that you will understand. So the conversion of thought and emotion into speech is impaired. However, if you ask that teenager, can you create the playlist of music that describes your feelings? Can you go to Google Images type in what you think is the feeling and choose 10 images that represent that you are a great fan of Harry Potter, choose me a part of a movie or a paragraph in a Harry Potter book that perfectly describes your inner thoughts and feelings. Play me some music on the piano. And this is where many with autism with their difficulty converting thought and emotion into speech are in the arts, fine art, music, may sing in perfect pitch. They become conductors spotting the errors of the orchestra. They have an attention to detail, perception and color in the arts, Vincent van Gogh and Andy Warhol, that we need to recognize that the arts is a career. The third is the person has observed and analyzed people and became a psychologist at three years old. And they graduate with a PhD in psychology in their 20s. And they become very effective clinical psychologists and psychiatrists.

Sucheta Kamath: I know so many of them. And other people also mentioned the whole field of medicine. Because again, it's a content heavy, very cluttered. Do you see that as well?

Tony Attwood: Yeah, research has shown my clinical experience confirms that the career with the highest level of autistic kids is medicine.

Sucheta Kamath: Wow. And so I'm glad that you mentioned that because I think that's another you pointed out my stereotyping or only focusing on technology and information processing. So tell us a little bit about I had this question about their, their social emotional makeup. So you have said that people with Asperger syndrome may lead an emotionally reclusive life. And in your book, you talk about one example of Lily Anna, I think, one of the adult patients who eagerly explained I don't have emotional skin to or protection we are exposed. And that is why we hide, I love that you captured that in your book. What does that mean?

Tony Attwood: Okay. First of all, when you do formal testing of the ability to read facial expressions, body language, what we call theory of mind, and you show that person with autism or face or expression, what's this person feeling they go? Either I don't know, or five seconds later, they cognitively worked it out by process of elimination. And checking back with previous images in their mind, it's a retrieval process, they can actually get it. And so often, in a formal setting, the person has difficulty reading, nonverbal communication. The other problem is it is so fast processing time executive functioning means that they are often missing it and out of sync. So that can be one of the problems that occur, however, in the autobiographies. And in the conversations, especially with women on the spectrum. They describe a sixth sense perception of emotion in others. And I will talk to somebody and they'll say, I'm feeling sad today. Really sad. I said, oh, what's happened to make you sad? What eventually occurred? Nothing. Oh, I, I had a chat with Rebecca. Rebecca is feeling sad. She infected me with her sadness. And this is why the sometimes the child becomes very upset if the teacher in correcting them is irritated, disappoint, even to a minor degree, the child finds that very aversive. And so sometimes social withdrawal is not purely because of social immaturity and confusion. It's a protection mechanism, from emotionality in others. And when I asked, Where did this come from, they say, I don't know. But I can just sense negativity, and I'm infected by it. Now if you go to this father in law Unfortunately, they're not easily infected by happiness and euphoria. There'll be very quickly infected by disappointment, irritation, anxiety, anger, for example, and they're very reactive to it and amplified. But if you try to jolly them up, or use affection and those sorts of things, No, it doesn't. It's like a filter system or to say, a plumbing system, the valve will only allow through negative emotions, but not positive.

Sucheta Kamath: You know, and it's really disheartening, I have an adult person, an adult I work with, and she, she, she's very sensitive to changes in mood of others. And one of the filters she has developed is what did I do to make you feel this way? So her immediate self blame comes in? And so we were doing like just the CBT approach, but doing a lot of perspective taking? Is it possible for others to have certain experiences that is influencing their emotions, and they are not in relationship to you? And it takes a lot of cognitive effort, as you know, to go walk yourself through that it's not me, it's you. It's not me, it's you.

Tony Attwood: Right? Okay. But you've also identified there another autistic characteristic of self-blame. And when I explore this further, this doesn't come from parents. This doesn't come from teachers or peers, it's self-imposed. And that self-blame that self-doubt, it's a fear of being judged, actually, in general. They don't like people judging them. But also the component is their tendency to be self-critical to personalize in their cognitive, should we say thinking distortion is what did I do wrong in that situation without realizing the perception of others their motivations, and if you can't understand the motives of others, your first reaction is going to be what did I do wrong? Because I can understand that, but I can't understand your motives. And it's that difficulty of understanding the motives can lead to cognitive, I suppose to a certain extent, it is ruminating on why people would tease me why people would do that, because you can't find an answer. You can't have closure. And that causes a lot of problems.

Sucheta Kamath: Yeah. And this reminds me of Hannah Gatsby, the comedian from Australia, who came on the stage, broke on the stage with great was so well received, that the next show she did, she came out as having autism spectrum. And I have heard now a lot of her interviews, which she she talks about, not knowing there was anything wrong with her in a way in a way, but never always getting excluded. And that she wasn't even aware that she was being excluded. Her lack of awareness kind of acted as a protection until she became a teenager. And then it the social world opened up a little bit only to realize you're not part of it. And yeah, right.

Tony Attwood: Okay, can I take your pause on that? Yes, please. as a clinician, this is why the girls are often not diagnosed until the teenage years when the wall wheels fall off. Yeah, when there's a degree of insight and complexity of what's going on. Because if you're imitating and it's relatively simple, you can create this facade of inclusion and success, superficially, and somebody externally observing. But it's in the teenage years, when it becomes far more subtle and internal. That's when the person starts to realize it's not working. And that's when they can go off the rails, in terms of personality disorders, eating disorders, a whole range of things. And so they're first diagnosed with borderline personality disorder, or anorexia nervosa, or gender dysphoria, not as a diagnosis but as a description. And that means that when a developmental history is taken, for the first time, the pattern of autism is identified, but for many of the girls and women, it is in the teenage years when they either they become either what I call a goody two shoes, puritanical nun, and they do everything and the teacher thinks they're wonderful, but you wait till they get home. And they've suppressed it. Because in autism and you either suppress it or you're avoiding it, okay, you don't cognitvely process it, but at home, you're a different character, or they go to the dark side. And in teenage life for those with autism, it's needing connection. They're seeking connection. And the thing is they may get connection in a group that is tolerant of a width of diversity, but may not be encouraging, like anorexia nervosa and so on. Strategies for coping, which we would recommend.

Sucheta Kamath: You know, the Hannah Gatsby's interviewing, she says that I would struggle all day, I would keep it bottled up, then I would come home, and I would have a massive meltdown. And then my parents would turn around and say, she's just being hormonal, she's a teenager, and she never received any diagnosis until you know, later in life, because all her oddities were either chopped off as Oh, that's just Hannah, or get over it, like you're not trying to get over it.

Tony Attwood: Yeah. And to certain extent, it's not necessarily severe enough to bring in expertise. And the general public wouldn't necessarily know because the general public's have a view of the male description. But one of the interesting things we're finding is that some males will do the same of observe, analyze and imitate. And so they're also now being identified, we've picked it up with the girls first, because they tend to write the autobiographies, boys and men don't tend to write autobiographies, unless they're famous. And so we're now finding that this process occurs with the males as well. And that means that the true level of autism spectrum disorder could be mentioned is much higher. And what the Centers for Disease Control does is assess the number of eight year olds in a particular geographic area. That's great. That's lovely. But you're missing the girls, because they won't be picked up till they're 13-14. So it's still a conservative estimate.

Sucheta Kamath: Wow. So could you speak to this contradiction in people with Asperger's Syndrome, what they lack in their interpersonal relationships, or social reciprocity is made up by the remarkable ability in a chosen area of expertise or interest maybe, and often called in our field, like special interest. And what I see is that they tend to know a lot of facts and details about certain topics, they seem to be collecting objects, they have very, very, very hyper focused interest. And what they bring to the conversation is conversation about the stuff and not people.

Tony Attwood: Okay, and this is where I find roundabout from age nine onwards, you tend to get autistic friendships with those who share the same interests. Now, obviously, it's some Minecraft and a whole range of things too. But what the person will do is search for someone who shares the same interest. And that's one of our common grounds. For friendships, it may be Lego, it could be a whole range of things that are of similar interest. It's Comic Con, and cosplay. It's, it's the Harry Potter group, or the Star Wars, appreciation, society, Star Trek conventions, etc. And so you will find someone and the basis of friendship is similar experiences. And so sometimes the greatest friendships, but also the greatest wisdom comes not from professionals. It comes from those on the spectrum themselves. So when I'm running groups, and somebody presents a problem to the group, I can maybe come in with a suggestion my colleague, Michelle, but if the suggestion comes from somebody else on the spectrum, it has far more credibility, yes, because they've experienced it. And so what I'm trying to do is put those with autism in touch with those with autism, so that they can share that experience and that that's what I did with Craig Evans and Anita Lesko in the book have been there done that try this, where we did a survey 300 people, what are your biggest challenges? The greatest challenge was anxiety. Right? We got various people, Stephen shore, Temple Grandin, and others, to write a brief essay on as mature people on the spectrum, what they would recommend for the younger ones that worked for them. And that becomes a treasure trove of information. Which has the credibility and the description, which is heartbreaking at times. But then those with autism say are, I will try that, because somebody who's experienced it found it worked.

Sucheta Kamath: You know, I had Elizabeth Laugeson, she is the clinical psychologist from UCLA who is the director of the PEERS program that does parent assisted social skills training. And one of the things we were talking about is this challenge with people with our autism and are on the spectrum, who fall on the darker side of social disconnection. Can you comment a little bit about the the percentage of children or young adult young adolescents who join white supremacist groups or those who engage in bullying in virtual space, many of them struggle with with the spectrum disorder, and not understanding the full ramification of other impact of their behaviors, particularly, lack of face to face interactions, but really not seeing or whatever treatment they have received. They tend to respond to that in a way that maybe not so savory, but also not understanding the impact. What is your experience in that?

Tony Attwood: Okay, several things is that many of the teenagers are seeking connection. They're not necessarily being accepted and connecting with the conventional teenagers, young adults. But what they're looking for is acceptance. But a characteristic of autism can be black and white thinking no gray areas. Yeah. When you get to fundamentalist religions and political groups, it's black and white. It is a very clear what's allowed or not allowed, and that rigidity, that sense of certainty, of following a script, the Bible, the Quran, gives you no need to, to think and make a philosophical, moral interpretation. It's there in black and white. It's usually in Christian terms. It's an Old Testament God of retribution, not a New Testament, Jesus Christ, compassion. And so that person is then intoxicated by feeling this is my home. This is my new family. This is a group of people that are encouraging me in my beliefs. And so the risk can be that they start to become manipulable by those who will see them as we use in Britain, the term cannon fodder for the cause. And that can be a problem.

Sucheta Kamath: So do we have data to know how many people who join cults or extremists activism or it's not even collectivism, I guess, what percentage of that population tends to be?

Tony Attwood: No, it is very difficult to go up to these organisms, okay, excuse me, can I want to administer to every person in your group, the autism quotient, because I want to know how many are autistic, they're not going to do that.

Sucheta Kamath: Tony, if anybody can be persuaded it will be you,

Tony Attwood: persuading them, I would have to persuade it in a way that it's to their advantage. But it does mean it's a problem for parents, who can feel that they're starting to lose their son or daughter. Another component that will occur in the teenage years is the teenager will discover the cure to autism. And there is a cure. There is a way of dissolving all the diagnostic criteria in DSM-4 and DSM-5, it's very easy. You go into your bedroom, and close the door, and you're cured. Because you can't have a deficit in social emotional reciprocity in reading nonverbal communication, and maintaining friendships and relationships. All Section A of DSM-5, got Section B, you can flap, you can rock, you can live in an environment where there are no sensory intrusions, you are able to engage in your special interest and nobody tells you to stop it. And your routines and rituals are to cope with anxiety. You're not anxious anymore, you're cured. And so for many teenagers they become a recluse in their bedroom, on the computer. They may change day night cycle. And they say to Mom and Dad, what's the problem, I don't cost you much. All I do is at midnight, raid the fridge, go back to my room, lock it. And I'll put all my laundry once a month, outside the door, and just put it in a pile when it's done. And so they found the cure, because you're not going to be bullied, you're not going to be teased, you don't have to stress yourself by social emotional situations. So they found the cure the cure of autism is solitude. Now, especially solitude in your bedroom, on nature, and you have behind you an autism friendly environment, its nature is natural sounds, it slows accelerating thoughts. It's a sense of peace and tranquility. You can't get in social urban life.

Sucheta Kamath: Yes. You know, and plus, also, I think there is stability in nature where it takes a long time for change to happen. So if if I mean, unless you have like a rain when it was sunny, that not that kind of thing. But the landscape, you know, there is some anchoring effect there. When you have a mountain that doesn't go away, you have trees that always give shade. That's like some sense of reliability you have, and you don't have to interpret what they're doing with you.

Tony Attwood: And you don't have suprises.

Sucheta Kamath: No surprises, yes.

Tony Attwood: So you can understand that if I am looking at the sense of well being of an autistic person, it's encouraging time in nature as much as we can. Because that is the restorative it is the natural environment of someone on the spectrum is to be in nature, with animals in particular, because animals except you animals are kind, you get animals, they again, you

Sucheta Kamath: And they love you no matter whether you have great eye contact or not.

Tony Attwood: No, they just adore you. So as long as you feed them, it means that what we're having to do is look at not behavior modification, but environmental modification, because many of the autistic behaviors are coping mechanisms for stress, because of the intense social environment they are in you have a different person in a different environment.

Sucheta Kamath: So so you already touched upon this, but does does treatment. Is treatment, the right word, when we talk about is there. Is the word intervention of better word or is the when, like you said, environmental modification, but empowering individuals to recognize the nature and scope of their diagnosis and understanding what is you can you know, the kind of people like dealing with acceptance, I do a lot of self advocacy work, and teaching, how to understand you, you can stay different, you don't need to learn all the social skills, because you it will only take you to a point where you're imitating as you mentioned, or there is always going to be a place where you are going to be like, Oh my god, I this is way beyond my paygrade. So what will be? No, how do you structure intervention? 

Tony Attwood: Okay,you said, one of the key words, acceptance be a first rate Aspie not a second rate neurotypical?

Sucheta Kamath: Oh, I love that.

Tony Attwood: Okay, it is, accept who you are. But explain, don't change, explain. I'm the sort of person who I'm the sort of person who tends to look away when you're talking helps me concentrate on what you're saying, I'm not being disrespectful. I'm the sort of person who loves talking about Russian T-34 tanks. Unfortunately, this is boring for other people. If I'm boring you, I'm not good at reading the signals, let me know. And I'll stop. I'm not good at reading the signals. So rather than teach, it's explained, and then the neurotypical goes, oh I've noticed that now I know why I understand and accept. So if I'm looking at a treatment, I am also working on acting When in Rome do as Romans do. So when you are at work or in various situations. This is your role. This is your script. It's the artificial you when the curtain opens and you're on stage. This is what you do. However, when the curtain closes and you go home, Be true to yourself, but to get the job you want. You've got to learn the night that is the script and so on. If I do look at treatment, yes, absolutely. But it's not for autism. It's for anxiety, depression and emotion management. And that's not in the diagnostic criteria. But there is treatment, but it's because of problems. expressing and managing and regulating emotions.

Sucheta Kamath: I love that I had your colleague from Australia, Dr. Ron Rapee, who studies anxiety or provides interventions. And and I think that that was the same point. I think what he was saying to that anxiety may be a response to the amount of stress you're feeling, it may not be the original diagnosis, but any treatment you're providing is the toolset to manage it. So last question I have about and then don't forget social skill development were ending. No, no, I, I am a speech pathologist. So we do pragmatic interventions, which is actually understanding the setting and and the protocol of each setting and understanding needs of others and expressing or checking in with others and providing them that emotional support in the best capacity you can so that they also knowing that they have goals, desires, needs, and emotional requirements. So So the last question I had was about being duped. One of the one of the challenges with somebody with Asperger's is this inability to understand intent correctly, and being taken advantage of they become very susceptible to scams and emotional manipulations or exploitation at workplace never giving them promotions, keeping them longer than a lot longer hours, never really, because they don't understand the nuances or the politics. Is this something you work with our experience? What are your suggestions for tackling those challenges?

Tony Attwood: Okay, you've, you've gone through one dimension of that, which is the naive or degullibility, generosity and kindness and taking people by what they say not what they mean, and assume everyone is as kind as they are. Which means that employers may take advantage of them. And so, however, I want to go to a darker side, particularly for the teenage girls and young women. And the sexual predators. Yes. And they don't read the intentions. They don't have a group of friends to go out with for protection. They don't have a group of friends to say, I wouldn't trust this guy. In their, naiveity and should we say euphoria? Yeah, I'll go to the bar. Yep. I've never had vodka before, etc. And they are intoxicated by the intention of attention, but not aware that the intentions are not honorable. And so there are a couple of books one by well, Debbie Brown wrote one and Leann Holiday Willie wrote another because of their own experiences, they don't want others with autism, to experience that. So what Leann does, is or did was that if somebody new comes into their circle of contacts, she has a group of friends who are very good at character judgments, and she ensures that they see them and indirectly assess them. And if they say, Leann, you're not very good at this. She's okay. Okay, that's it no more, or they say no, early on, I think that's okay. But slowly, carefully, because there can be an intensity in autism, there's a problem with intensity. Yeah. And of taking it too fast and being too excited, and intoxicated by the situation. So I do have to explain to parents and teenage girls and young women with the young women, when I talk to them, there are frequent descriptions of date rape, there's abuse, that is financial, emotional, physical and sexual abuse. That's because there's low self esteem, I'm not worth anything more than this. And they tend sometimes to be attracted to lame dogs who are not good in potential relationship qualities. And so sometimes that can be a problem of it's like, either a moth to a flame, and they shouldn't go there. Or the predators will spot their naivety, insecurity, lack of support network, and to be taken advantage of, again, the problem is neurotypicals, not autistic people.

Sucheta Kamath: Yeah, and I think that's the sad part that you know, the bystander effect you need society to be looking out. For those who appear a drunk girl who came alone or is now going with a guy when she's actually not even walking. He's holding her up. That should be an alarming But I think we have become very, I don't know. I don't want to call it any different, but people are just so cautious about what their role is. You know what I mean?

Tony Attwood: This is a function I think of high density populations. If you live in a village, people will step in. Yeah. But people cope with high density living by creating a bubble or barrier is their only way of coping. So if they're on the metro, or a bus, they won't look at each other. Because it's too crowded. Yes, if you've got a bus, in a village community, oh, they're all chatting. And they aren't socially engaged, but responsible for each other.

Sucheta Kamath: I love that. 

Tony Attwood: I can tell you the loneliest place can be where the most number of people.

Sucheta Kamath: And with one quick story, I had a client once, who had a lot of difficulty, understanding she was about 19. And so Was she a toy? I am a guy called her a guy who was an acquaintance, not even a boyfriend or any such thing and asked her, would you come and visit me, I'm feeling lonely. And she said he was lonely, you know. And so she went, and of course, it was a booty call us, as we call it in America. And it was a very delicate situation, because it was clear example of exploitation. But myself and the therapist, we were working together with her parents, it was very delicate situation, because if you tell her she just got used, that would have devastating effect. But then how do you, you know, we had to really craft as a collective strategy about how to create those confidence by whom you run this decision.

Tony Attwood: Okay. And this is some of the new work that I'm doing, again, with my friend and colleague, Michelle Garnett, is building resilience, a concept of self. And so this is perhaps the fourth wave of cognitive behavior therapy is, who are you? And it's building up a strength of character, your qualities in personality and abilities. And by having that self-confidence and resilience, you are less likely to follow through with the predators because they're looking for somebody who doesn't have that resilience.

Sucheta Kamath: I love that. So you're talking about identity that I am the person who doesn't? I am the person who does in my family. Yeah,

Tony Attwood: Yeah, we have some some interesting things. Like, if you were an animal, what animal would you be? And then we say, Okay, well, some people are a snake. Some people are a wolf in sheep's clothing. Okay, so that's a way of characterization. Another one we'll do is to create a collage. And in that collage are important people to you, real and fictional, your favorite photos and mementos, things that are important to you. And we spend some time creating all the content of this collage, and then putting it all together and where they put things in the connections can be absolutely fascinating.

Sucheta Kamath: I will share one last thing, sorry, there's going on my sharing, but I do concentric circles have connections with them, which is the same concept. But these are concentric circles, and who goes in the center of it, which is the closest people to you, and then peripheral. And then of course, we have objects interest and people in concentric circles. And then we have rules for each circle. So further away from the concentric circle in the center, less freedom of giving them decision making power or giving them for you know, and talk, we talk about coming to the stop sign. So who came first to the stop sign. So the last person who came has to wait so they don't get so last person in the circle doesn't get your attention. So that kind of, we talked about that visualizing the concept relationship.

Tony Attwood: I use that and I color coded like a rainbow. So you have red in the center and blue. So I say this person is in the green circle. Now this person is in the orange circle. And just using that color coding can speak volumes.

Sucheta Kamath: Okay, so I don't color code. That's a fantastic idea. Well, Tony, I have taken up a lot of your time. And we obviously can talk for hours, not just one hour, days days. Yes. Well, as we close, I wanted to see if you had you already have given a lot of recommendations about the expertise in this area. But do you have books that influenced you as a person or a person and as a thinker and as learner that you think every person should explore?

Tony Attwood: Oh, it's a tricky one because sometimes that reading can either be professionally or for pleasure, whichever. Okay, um Oh, Good question. Where did I begin? Lorna Wing in the I first became officially interested in autism in 1971, when it was childhood schizophrenia or childhood psychosis. And she wrote an excellent book not only as a psychiatrist, but a mother of Susan. And her book, which is now ancient. It's on my shelf, and I haven't looked at it. But what I found was that it was so prophetic in its understanding, which was remarkable. So I think Lorna Wing, and her anything Lorna Wing did she died a few years ago. I have with great respect, she was the one who first used the term Asperger's syndrome.

Sucheta Kamath: Isn't she the one who actually challenged the, not challenge, but came up with the label as well as the different approach to it, right? 

Tony Attwood: Yeah, she did. She, at the time, the view was, if you can find if you finding a pattern, you search, has anybody else found this before you and she did, Hans Asperger. And so as the protocol was then she called it Asperger's Syndrome, because they in the 1940s, he described very accurately because that was his training, accurate description, a group of people that she said Asperger's Syndrome, but she's British. And this is where I say the Americans have never really understood Asperger's, because it wasn't discovered by an American. Sorry.

Sucheta Kamath: I know the whole neuro tribal history there.

Tony Attwood: Okay. Right. So I think that's a very, very important book.

Sucheta Kamath: That Beyond the Silence?

Tony Attwood: I'm not sure I'd have to find a few moments. It's, it's in one of my far in my library, in the far corners of the library.

Sucheta Kamath: Listed so people have in our show notes so people can actually look it up. Thank you. And which other second book you were thinking about?

Tony Attwood: This is going to be strange.

Sucheta Kamath: Go for strange. You're British? No, I'm just kidding.

Tony Attwood: No, no, it's my own book. And

Sucheta Kamath: I love it.

Tony Attwood: Because I will look at it. And I will go back. And I think, that was good. Oh, I like that phrase. And, and I keep thinking, did I actually write this? Is this me? Oh, that was really good. Oh, that was insightful. Who wrote it was me.

Sucheta Kamath: Complete Guide, because that's my favorite. One of my favorite books.

Tony Attwood: Yeah. So in a way, it's, it's looking back at how my perception of autism has changed. And what I saw. So many years ago, I find as a clinician, academics are about 10 to 20 years behind clinicians. Yes. And I read, I have to read, I'm a professor, I have to read journal articles. And they'll say we've discovered this, I knew that 20 years ago, but you only this only accept it now. Because you have got data for it. There is wisdom, which is more important than data. Because in academia, data is what the more data you have the higher status. I say wisdom, wisdom is more important.

Sucheta Kamath: Well, Tony, you are amazing. And I'm again, just I am moving to Australia so that I can spend not moving maybe I'll one week in the pandemic, so not to scare you, but thank you for being with us and sharing your wisdom. Again, I think yes, you are not wrong to admire some of the writings because sometimes the there is a lot of poetry to your writing. And there's a lot of compassion. And and I think as you look back, you can wonder but just know that every person who reads your books feels the same way. There is a sense of Wow, that is so beautifully said. It is bring a hope for us.

Tony Attwood: Thank you. It means that as they watch this, they will now have a face and a voice to what they've read. And they will know that what they read is my voice.

Sucheta Kamath: Yes, yes. Well, folks, if you enjoyed what you heard today, please share with your friends subscribe to our podcast newsletter and like or leave a comment we are sure to read any questions you post and thank you for staying connected and always always sending good wishes our way. Once again this is Sucheta and I look forward to getting together again on the next podcast. Thank you, Tony.

Tony Attwood: Okay, thank you.