Autism training lead Matt Trerise presents effective strategies for supporting autistic people in mainstream healthcare settings.
1 Establish a preferred method of communication
We cannot assume that having a verbal interaction is the preferred method of communication, or that it is the most effective way of interacting with autistic people. Many autistic people describe having difficulties communicating and interacting with medical professionals, especially when there is time pressure in appointments or they are experiencing high levels of anxiety. If someone has difficulty articulating what they need support with, suggest alternative methods of communicating, such as written or pictorial rather than verbal.
2 Use clear, concise and precise language
It is important to use clear, concise, plain English when communicating with autistic people – avoid the use of metaphors, idioms, irony and sarcasm. Say exactly what you mean, as people with autism interpret language literally. Using too much language can be overwhelming for people to process, and many find it difficult to retain verbal information. If you are having long conversations, discussing multiple topics or passing on important information, provide a written summary of the conversation, with key points highlighted.
3 Avoid open questions
When assessing the needs of autistic people, avoid open questions; ask closed, specific questions instead. This can be challenging for professionals as many will have been trained to ask open questions. However, closed, process-of-elimination-type questions are much more effective for autistic people.
4 Allow sufficient time to process questions
If there is a delay in response when you have asked an autistic person a question, wait 30 seconds to a minute if they have not responded before saying anything else. Some people experience a processing delay with verbal communication, which can lead to professionals assuming the person has not understood. Repeating or changing the question could overload people if they are thinking of the best way to respond. If the question made sense, the person will probably respond. If you are unsure, ask the person if they understood the question.
5 Visual aids and scales can be helpful
If someone is having difficulty articulating the severity of a problem, scales can be helpful. For example, ‘I experience anxiety in social situations: 0 (disagree) to 10 (agree)’. If someone has difficulty understanding what you are saying, or the information you are providing, consider using pictures or diagrams – many autistic people find it easier to process visual information. Providing written summaries of the outcomes from the appointment can be hugely beneficial to assist with the retention of information.
6 Be aware of diagnostic overshadowing and provide mental health support
It is important not to assume that everything a person experiences is simply because they are autistic. Many people do not receive appropriate support or treatment for comorbid mental health difficulties because professionals misinterpret symptoms as part of their autism. Autism is not a mental health difficulty, but there are increased rates of anxiety, depression and suicide in autistic adults who do not have additional learning disability compared with the general population.
If someone has autism and additional mental health difficulties, it is important to treat the comorbid psychiatric condition, but:
• Communicate in an ‘autism-friendly’ way and structure your services accordingly.
• Adapt therapies that are specially designed for autistic people.Consider autism in patients with long-term mental health difficulties when:
• A patient does not respond to treatment for a condition they are diagnosed with, or has adverse reactions to antipsychotics.
• Early developmental history indicates a lifelong problem rather than late onset.
7 Be aware of sensory differences
While this is not relevant to everyone, many autistic people experience differences across the eight sensory systems in the body:
• Visual (sight).
• Auditory (hearing).
• Olfactory (smell).•
• Tactile (touch).
• Vestibular (balance, movement).
• Proprioceptive (body positioning and spatial awareness).
• Interoceptive (internal monitoring of pain, hunger, thirst, bladder).
People with autism often experience hypersensitivity or hyposensitivity in one or multiple senses, and if someone experiences differences in multiple senses, they are likely to experience the world differently from other people. If someone is hypersensitive, they may experience significant discomfort or ‘overload’ from sensory input and be sensation avoidant, whereas if they are hyposensitive, they may not be receiving sufficient sensory input and be sensation seeking. People with hyposensitive tactile or interoceptive systems may have a high pain threshold, or find it difficult to identify physical health problems.
8 Be as precise as possible with timings
Try to give precise or concrete times and avoid vague timescales. Many autistic people have difficulty in predicting future scenarios, or if/when things will occur, which can increase anxiety significantly. If you have said you will do something at a specific time but can no longer facilitate it, it is important to tell the person before the pre-agreed time; for example, display how late appointments are running in reception, or agree a new time with the person in advance.
9 Be aware of diversity in autism
Many people still have very stereotypical ideas about what autism is, or how an autistic person may present. There is, however, just as much diversity in autistic people as in everyone else, with the same range of intelligence and abilities as everyone else. Historically, autism has been thought of as a predominantly male condition. There has, however, been a significant increase in females seeking and receiving a diagnosis in recent years. Many autistic people have developed sophisticated strategies to mask or camouflage their difficulties, which can lead to people not getting their needs met or receiving support.However articulate or intelligent someone may appear to be, never underestimate how much extra processing they might be doing to navigate social interactions. What works for one person may not work for everyone. It is important to ask people what they need individually and encourage people to inform you of any adaptations that would improve access to services.
10 ‘Autism-friendly’ services benefit everyone
Although autism is complex, many of the adjustments autistic people find beneficial are simple and straightforward, and often benefit everyone. Developing clear communication systems, providing structure in services, and considering the impact of the sensory environment is just good practice. If you embed these strategies into everyday practice, there will be less need to make specific adaptations for autistic people and everyone will have a better experience when accessing your services.
Matthew Trerise is the training and liaison lead for Bristol Autism Spectrum Service, Avon and Wiltshire Mental Health Partnership NHS Trust.
If you are supporting a person in crisis, the following approaches are often the most effective:
• Demand reduction – don’t overload the person with questions or demands on them.
• Reducing environmentally arousing stimuli – consider whether you can reduce light and sound input and be aware that the person may not be able to ask you to do this.
• Awareness of your own non-verbal communication – if you are stressed, your behaviour might escalate the situation. Try to remain calm and composed.
• Diversionary tactics – try engaging with the person’s interests or switching to a more positive topic.
• Challenging staff assumptions about the individual’s control of their behaviour – unusual or challenging behaviour during a crisis does not mean the person is ‘acting out’ or not in control.
Further reading and resources
• A Systematic Review of What Barriers and Facilitators Prevent and Enable Physical Healthcare Services Access for Autistic Adults
• Silberman S. NeuroTribes: The Legacy of Autism and the Future of Neurodiversity
• Bristol Autism Spectrum Service awp.nhs.uk/services/specialist/autism-spectrum/