- Therapists often miss signs of autism in clients with level 1 autism, previously known as Asperger's syndrome.
- Subtle communication symptoms may indicate to a therapist that a client is autistic.
- Anxiety, trauma, or mood disorders can manifest in similar ways, so therapists should proceed with caution.
Many therapists tell me that, with hindsight, they're sure that some of their past clients were autistic. These therapists often feel that they used to have preconceptions about how autistic people present socially, which meant they sometimes failed to notice potentially autistic traits in their clients.
It's of course important that therapists not jump to conclusions that someone is autistic just because they have one or two traits which might suggest autism, particularly given how the symptoms of autism may overlap with those of other conditions. The list below inevitably includes some behaviours that are not limited to autistic people and may point to, for example, a trauma history, anxiety, mood or personality disorders, or another condition.
That being said, being aware of certain communication patterns may provide a starting point for therapists trying to determine whether a particular client may be autistic. Because differences in social communication and interaction styles between autistic and neurotypical people have tended to be studied in isolation—as opposed to real-world social interaction situations1—and because research has historically focused primarily on autistic children (though that is changing in recent years), the following discussion draws heavily from my experience of observing autistic clients and anecdotal information from therapists working with autistic clients.
1. Speaking for excessive periods and providing considerable detail
Autistic people may talk excessively and for prolonged periods, including a high level of detail that can take conversations off on tangents. This may result from, for example, a desire to share information about their special interest or something they have recently become passionate about.
It may also result from difficulties in noticing communication cues from others. The Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R),2 one of the most widely used autism diagnostic screening tests, uses this type of communication as one potential indicator of autism. The term "infodumping" is sometimes used by people in the autistic community to describe this type of information sharing.
2. Eye contact
Many autistic people have problems making and maintaining eye contact.3 If you have a client who cannot make eye contact with you, who looks away or downwards for sustained periods or stares intently in a way that can feel uncomfortable, it could be a sign of autism.
It's important to keep in mind, however, that many autistic people, particularly women, "camouflage" their autistic symptoms and have various strategies to pass as less autistic. As part of camouflaging, many autistic people learn how to sustain eye contact in a way that looks natural—so while a lack of eye contact might indicate autism, natural-looking eye contact doesn't necessarily rule it out.
3. Slower verbal processing times
Research finds that autistic people may take longer to process verbal information.4 If you find your client frequently struggles to follow along when you explain more complex concepts or when you ask a multi-part question, despite being of average or above average intelligence, it could suggest autism.
4. Being "rude" or direct
In my experience, the communication challenges that autistic people must navigate can sometimes make them appear rude to other people.
Many of my clients tell me they prefer to communicate in a very direct manner and see social interaction as an opportunity to exchange information in the most simple, straightforward way possible. Because they may struggle to understand vague and metaphorical language,5 they tend to communicate how they prefer to be communicated with. Yet doing so may increase the likelihood that they come across as very blunt, even impolite.
5. Interrupting and talking over
The issues identified above—including knowing how much or how little detail to offer, struggles with figurative language, and difficulties picking up on social cues6—mean that it is often difficult for autistic people to know when to join a conversation. They may wait a long time for a chance to speak, either saying nothing or, finally, interrupting.
Interrupting may be less of a problem on a one-to-one basis, but you may find that your client interrupts at times that feel inappropriate or suggest they are not listening to you.
6. Talking loudly or softly, or having an unusual pitch, tone, or rhythm
One study on autistic children's communication suggested that autistic people may struggle to control their voices.7 This might manifest as someone talking very quietly or becoming loud, perhaps when they are excited about something. They may speak very rapidly, have little intonation, or have intonation in unusual places. Some clients might talk in a staccato manner; some may have voices which sound slightly computer-like.
7. Lack of facial expression
A lack of facial expression does not automatically suggest autism. However, many autistic people do not convey their emotions on their faces in the same way that neurotypical people do, according to one study of autistic children.8 Some may look excessively serious, regardless of the type of social situation they're in.
8. Change when talking about interests
Restricted interests are a core symptom of autism. Some autistic people find discussing anything other than their special interests difficult. Suppose you have a client who suddenly shifts from being bored, confused, or unengaged to, once their particular interest is brought up, suddenly coming to life and talking excessively. If combined with other symptoms on this list, it may indicate that they're autistic.
9. Finding it hard to talk at all during sessions
In contrast to clients who talk a lot, many autistic people find it hard to talk about themselves at all. Some autistic people find it very hard to articulate their thoughts or feelings. They may not be non-verbal, but they may still spend far less time than most people talking and face real struggles when asked questions. They may give short answers or appear highly uncomfortable during sessions.
10. Checking in
In my clinical experience, because of the communication issues they face, many autistic people check in regularly to see if they're "answering right" during a therapy session. This typically stems from a lack of confidence in their own abilities to communicate.
Gesturing—which includes hand, body, head, and arm movements—is important in communication. Autistic people may gesture unusually, or gesture significantly more or less than is typically expected.9
Some autistic people do not use non-verbal gestures at all. Some use gestures that are indicative of repetitive motor behaviours, rather than communication gestures. For instance, an autistic person may wave their hands while talking to "stim" (that is, engage in self-stimulating behaviors) rather than communicate.
How Therapists Should Proceed
For many previously undiagnosed autistic adults, learning that they’re autistic can be one of the most important, life-changing discoveries they’ll ever make. As their therapist, sharing your views could pave the way for them to finally understand themselves and receive the right type of support.
Yet if you think your client might be autistic, it’s critical that you proceed with caution. Unless you are qualified to diagnose, you need to make it clear to your client that you are not labeling them and that autism is simply one option they may want to explore. Sharing your thought process and pointing your client to a provider who can assess them for autism, if they're interested in investigating further, should be your first step.
1. Morrison, K. E., DeBrabander, K. M., Jones, D. R., Faso, D. J., Ackerman, R. A., & Sasson, N. J. (2020). Outcomes of real-world social interaction for autistic adults paired with autistic compared to typically developing partners. Autism, 24(5), 1067–1080. https://doi.org/10.1177/1362361319892701
2. Ritvo, R. A., Ritvo, E. R., Guthrie, D., Ritvo, M. J., Hufnagel, D. H., McMahon, W., Tonge, B., Mataix-Cols, D., Jassi, A., Attwood, T., & Eloff, J. (2011). The Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R): A scale to assist the diagnosis of autism spectrum disorder in adults: An international validation study. Journal of Autism and Developmental Disorders, 41(8), 1076–1089. https://doi.org/10.1007/s10803-010-1133-5
4. Haigh SM, Walsh JA, Mazefsky CA, Minshew NJ, Eack SM. Processing Speed is Impaired in Adults with Autism Spectrum Disorder, and Relates to Social Communication Abilities. J Autism Dev Disord. 2018 Aug;48(8):2653-2662. doi: 10.1007/s10803-018-3515-z. PMID: 29500756; PMCID: PMC6041130
5. Rundblad G., Annaz D. (2010). The atypical development of metaphor and metonymy comprehension in children with autism. Autism 1429–46 10.1177/1362361309340667
6. Sturrock, A., Chilton, H., Foy, K., Freed, J., & Adams, C. (2022). In their own words: The impact of subtle language and communication difficulties as described by autistic girls and boys without intellectual disability. Autism, 26(2), 332–345. https://doi.org/10.1177/13623613211002047
7. Bonneh YS, Levanon Y, Dean-Pardo O, Lossos L, Adini Y. Abnormal speech spectrum and increased pitch variability in young autistic children. Front Hum Neurosci. 2011 Jan 19;4:237. doi: 10.3389/fnhum.2010.00237. PMID: 21267429; PMCID: PMC3024839.
8. Grossard C, Dapogny A, Cohen D, Bernheim S, Juillet E, Hamel F, Hun S, Bourgeois J, Pellerin H, Serret S, Bailly K, Chaby L. Children with autism spectrum disorder produce more ambiguous and less socially meaningful facial expressions: an experimental study using random forest classifiers. Mol Autism. 2020 Jan 13;11(1):5. doi: 10.1186/s13229-020-0312-2. PMID: 31956394; PMCID: PMC6958757.
9. de Marchena A, Kim ES, Bagdasarov A, Parish-Morris J, Maddox BB, Brodkin ES, Schultz RT. Atypicalities of Gesture Form and Function in Autistic Adults. J Autism Dev Disord. 2019 Apr;49(4):1438-1454. doi: 10.1007/s10803-018-3829-x. PMID: 30523479; PMCID: PMC6451661.