Autism BPS

Working
with autism
Best practice guidelines
for psychologists
GUIDELINES
August 2021
CONTRIBUTORS
This guidance was prepared by the Autism Task and

Finish Group, under the auspices of the Practice Board.
A widespread consultation on a draft document was
conducted and the finalised guidance incorporates many
of the resulting revisions and suggested text. In keeping
with BPS policy, the document will undergo a light review
touch 2.5 years following publication and a full review
after 5 years.
The membership of the Task and Finish Group was:
Patricia Howlin (Chair) – Emeritus Professor Clinical

Child Psychology
Elisa Back – Developmental Psychologist
Andrew Bates – Forensic Psychologist
Kevin Conallen, Child and Adolescent Psychologist.
Jason Crabtree, Clinical Psychologist
Maria Daves-Hales, Counselling Psychologist
Sinead Hannan, Clinical Psychologist
Marie-Louise Hughes, Educational Psychologist
Katie Hunt, Clinical Psychologist
Barry Ingham, Clinical Psychologist
Glenys Jones, Educational Psychologist
Rita Jordan, Professor in Autism Studies
Tommy MacKay, Educational Psychologist
Lynda Meina, Clinical and Forensic Psychologist
Lindsay O’Dell, Developmental Psychologist
The Group would particularly like to thank those with lived

experience, parents and other professionals for their input
into the development of the guidelines.
BPS staff support was provided by: Lisa Morrison Coulthard

(Head of Research and Impact), Nigel Atter (Practice
Policy Advisor), Hannah Farndon (Manager: Practice Policy
Team) and Sunarika Sahota (Practice Officer).
© 2021 The British Psychological Society

ISBN 978-1-85433-795-5
All rights reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical,
including photocopy, recording or any information storage retrieval
system, without permission in writing from the publisher.
CONTENTS
WOR K ING WIT H AUT ISM

1. Introduction 6
1.1 Autism: An introduction 7
1.2 A diverse condition 7
1.3 A lack of service provision 7
2. Talking about autism 9

2.1 Person-first language 9
2.2 Diagnostic and Classification Changes 9
2.3 ‘Neurodiversity’: A new way to talk about autism? 10
3. Assessment, diagnosis and formulation 12

3.1 Assessment and diagnosis 12
3.1.1 Assessment Tools 12
3.2 Formulation 13
4. Autism in children and young people 15

4.1 Assessment and Diagnosis 15
4.1.1 Delayed Diagnosis 15
4.2 Limitations of diagnosis 17
4.2.1 Girls and Women 17
4.2.2 Ethnic minorities and cultural or religious groups 18
4.2.3 Looked-after children 18
4.2.4 Pathological Demand Avoidance (PDA) 18
4.3 Genetic, sensory, behavioural or other disorders 18
4.4 Autism and Education 19
4.4.1 Comprehensive assessment 19
4.4.2 Building capacity 20
4.4.3 Managing everyday transitions 20
4.4.4 Adjustments to the educational environment 20
4.4.5 Targeted approaches 20
4.4.6 Transition to further or higher education 20
4.4.7 Transition from education to employment 21
4.5 Co-existing conditions 22
4.5.1 Mental health 22
4.5.2 Autism and intellectual disability 22
4.6 Psychological interventions 23
4.7 Clinical guidelines 24
4.8 Counselling, psychology and social support services 25
4.9 Support for families and carers 25
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5. Autism in adults 27
WOR K ING WIT H AUT ISM 5.1 Diagnosis in adulthood 27
5.2 Mental health and autism 29
5.2.1 Prevalence of mental health problems 29
5.2.2 Diagnosing mental health conditions 29
5.2.3 Interventions 29
5.3 Physical health 31
5.4 Quality of life 32
5.5 Interventions for adults 32
5.6 Where people live 34
5.7 Older adults with autism 36
5.8 Support for families, carers and partners 37
6. Employment 39
6.1 Finding appropriate work 40
6.2 Maintaining employment 40
6.2.1 Education for employers 40
6.2.2 In-job support 40
7. Autism and the criminal justice system 43

7.1 Assessment 44
7.2 Intervention 44
7.3 Compulsory psychiatric treatment 45
8. Future directions for research and support 47
References 48
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CHAPTER 1
Introduction
WOR K ING WIT H AUT ISM 1. Introduction
This best practice guidance is for practitioner psychologists who work with people with autism
and their families and carers. Due to wide diversity within the autistic population (in terms of how
autism presents and the level of individual needs), the guidance has attempted to be as broad in
its application as possible. It does not support any particular theoretical or therapeutic approach.
It is, however, based on the current NICE (2016, 2017) guidance; similar guidance is also
contained in the Scottish Intercollegiate Guidelines Network (2016) Assessment, diagnosis and
interventions for autism spectrum disorders.
The NICE guidance recognises that autism is a highly complex condition for which the evidence
base for causation and treatment is continually developing. This BPS guidance is centred on
the importance of involving individuals with autism in the decision making process about their
assessment and the approaches taken. It recognises the importance of involving parents/carers
and indeed the whole family in this process and that family systems and dynamics can vary
greatly. It focuses on the role of psychologists as practitioners, in understanding these issues and
supporting others in adjusting what approaches are offered. The important role of psychologists as
drivers of change within a system or service, the commissioning processes and as contributors to
a multidisciplinary approach and to research, is also included.
The guidance covers the many different contexts in which psychologists work – including with
children and young people, with adults and older adults, in education, health, social care,
employment and in criminal justice settings. A short summary of best practice recommendations
is provided at the end of each section. Useful resources and further reading are also provided
throughout the guidance.
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1.1 AUTISM: AN INTRODUCTION

Autism is a lifelong developmental condition occurring in approximately one per cent of the
population. Autism is characterised by differences in social and communication skills, in ways
of thinking and in restricted and repetitive patterns of behaviour and interests. Many people
with autism experience over- or under-sensitivity to sensory inputs such as sounds, touch,
tastes, smells, light or colours, and may have issues with balance. Body awareness may also be
affected so that internal sensations such as pain, hunger, thirst and anxiety may be missed or
misinterpreted.
1.2 A DIVERSE CONDITION
Autism is a highly diverse condition covering a broad spectrum of skills and difficulties. It is
often associated with other co-occurring conditions. While all people with autism share certain
characteristics, their condition will affect them in different ways. A diagnosis of ‘autism’ alone is
not an adequate basis on which to judge someone’s ability, potential or needs.
Many individuals with autism develop ways of ‘fitting-in’ with social conventions and live full and
independent lives. However, for other people, autism is severely impairing and they may have
additional learning or other disabilities that require a lifetime of specialist support.
1.3 A LACK OF SERVICE PROVISION
Discrimination, lack of understanding, and failure to provide adequate provision can turn
difference into disability. Short, medium and long term outcomes depend not only on individual
characteristics but also on the support people receive. However, limited resources for clinical,
educational and social support mean that services for individuals with autism often fail to meet
their needs.
Support from education (including lifelong learning), employment, health and social care is
essential to provide individuals with appropriate resources and to help increase resilience.
Psychologists can play a key role in delivering this support, sharing evidence and best practice,
undertaking research, challenging stigma and discrimination and enhancing knowledge
and awareness.
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CHAPTER 2
Talking about autism
2. Talking about autism

Terminology is widely debated in the autism field. There is no single universal way for practitioners
to describe autism, apart from reference to the diagnostic criteria. Commonly used terms include
autism, autism spectrum disorder and autism spectrum condition. Some autistic people object to
being referred to as ‘disordered’ and see autism as a different way of being, while others feel that
autism seriously challenges their lives and wish to retain the term ‘disorder’ so that their needs are
recognised.
2.1 PERSON-FIRST LANGUAGE
Whether to use ‘person-first’ language is also debated, i.e. an ‘autistic person’ vs a ‘person with
autism’. In a 2015 study, autistic adults and their families preferred the term ‘autistic’ while
professionals tended to prefer the term ‘on the autism spectrum’ (Kenny et al., 2015). For some,
autism is a core part of their identity and they see themselves as autistic, rather than ‘someone
with autism’. Other individuals who do not see autism as central to their identity prefer the term
‘with autism’. It is important to clarify what language the individual would prefer, or if this is not
possible, to seek guidance from their parents, families or carers. In this guidance the terms are
used interchangeably to acknowledge different perspectives.
2 . 2 D I A G N O S T I C A N D C L A S S I F I C AT I O N C H A N G E S
Guidelines for the diagnosis of autism (e.g. NICE, 2016, 2017; SIGN, 2016) recommend that
this should be based on one of the two internationally-recognised classifications, the International
Classification of Diseases (ICD-10, World Health Organization, 1992, which will be replaced in
January 2022 by ICD-11, World Health Organization, 2018), or the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5, American Psychiatric Association, 2013). While both are
international, the former is the default classification generally used in the UK, although DSM-5 is
also used widely.
Until 2013, the DSM version in use was DSM-IV, which classified autism in terms of diagnostic
categories, these for the most part being autistic disorder, Asperger’s disorder and PDD-NOS
(pervasive developmental disorder, not otherwise specified). The version of ICD which will
remain in use until 2022, ICD-10, uses the broadly equivalent categories of childhood autism,
Asperger’s syndrome and atypical autism.
Both of the latest versions, DSM-5 and ICD-11 use the umbrella term ‘autism spectrum disorder’
for all forms of autism. However, in both systems, formal diagnosis requires specifying a sub-type
of autism spectrum disorder based on symptoms of autism and level of support required.
DSM-5 has additional specifiers related to other medical genetic, neurodevelopmental, mental or
behavioural disorders.
Although the former sub-groups of autism are removed under the new classifications, individuals
previously diagnosed using DSM-IV or ICD-10 will retain the diagnosis as given at that time. Thus,
for example, children and adults with an Asperger’s syndrome diagnosis will be described in that
way unless for any reason they have cause to undergo a diagnostic review. In addition, ICD-11
provides the classification ‘autism spectrum disorder without disorder of intellectual development
and with mild or no impairment of functional language’ as an equivalent to the previous diagnostic
category of Asperger’s syndrome.
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2 . 3 ‘ N E U R O D I V E R S I T Y ’ : A N E W WAY T O TA L K A B O U T A U T I S M ?
‘Neurodiversity’ describes a continuum of behaviours and differences in people’s skills, abilities
and understanding. Although the concept has mainly been used in advocacy discussions rather
than in clinical practice, the neurodiversity discourse has enabled people to talk positively about
autism and view it as a natural way of being, rather than a pathology (Brownlow & O’Dell, 2009).
Proponents of the framework of neurodiversity argue that it enables a shift in thinking from
positioning an individual as ‘impaired’ or ‘deficient’ to one where difficulties are acknowledged.
The difficulties are presented as alternative rather than lacking and the individual’s strengths
and difficulties identified as a basis for support. At the same time, for many people, autism is
a severely disabling condition and the extent and severity of their consequent disabilities must
also be recognised. Whatever perspective is taken it is essential that all people with autism are
viewed and respected on their own terms.
For more on the development of the concept of neurodiversity, see Blume (1998).
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CHAPTER 3
Assessment, diagnosis
and formulation
WOR K ING WIT H AUT ISM 3. Assessment, diagnosis and
formulation
Assessment, diagnosis and formulation are key parts of the work of practitioner psychologists.
A comprehensive assessment should bring together the views of individuals, families, and
professionals in order to reach a shared understanding of a person’s needs, difficulties, strengths
and protective factors (BPS, 2011). This assessment can then be used to formulate hypotheses
about the nature of problems and to guide an intervention plan that reflects and respects the
perspectives and wishes of the individual and the family.
3.1 ASSESSMENT AND DIAGNOSIS
The National Institute for Health and Care Excellence (NICE) guidelines provide comprehensive
recommendations for assessment and diagnosis of autism in children (NCG 128, 2017) and
adults (NCG142, 2016). Practitioner psychologists’ key role is to ensure that the assessment and
diagnostic process is psychologically informed. This involves:
• Ensuring that individuals and their families are central to the assessment process and included
at every stage.
• Promoting needs-based assessment.
• Promoting strengths-based assessment.
• Using different theoretical models to consider alternative understandings of client
presentations and differential diagnoses in the context of wider mental and physical health.
• Increasing understanding of contextual issues, including employment, housing and education.
• Conducting cognitive, neuropsychological and other assessments as required.
• Guiding the implementation of a formulation-based approach to the assessment and diagnostic
process that includes considerations of strengths and protective factors.
• Encouraging the use of language about autism that challenges stigma.
• Promoting a broad understanding of the bio-psychosocial model within the assessment and
diagnostic process.
• Providing consultation, supervision and clinical leadership in multidisciplinary teams.
• Working at different levels in an organisation to influence service delivery, service
developments, values and policy.
• Making recommendations in relation to ‘reasonable and personalised adjustments’ to include
individuals in services.
3.1.1 ASSESSMENT TOOLS
Although several well-validated and reliable screening, interview and observational assessments for
autism exist, none can be used alone to determine diagnosis (Charman & Gotham, 2013). Most
assessment tools were developed for children, so specificity and sensitivity for adults (especially
females) is often poor.
There are challenges in differentiating between autism and other mental health and other
neurodevelopmental differences due to the overlapping nature of symptoms. This is compounded
by the lack of mental health measures that can be reliably used in autism (Cassidy et al., 2018).
It is essential that standardised measures are interpreted in the light of clinical judgement and
in the context of a multidisciplinary team (NICE, 2016; 2017). In addition, when undertaking
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an assessment leading to a diagnosis, applied psychologists should consider other evidence,

including information from family members and carers and others who know the individual well
across contexts.
3 . 2 F O R M U L AT I O N
Formulation is one of the core skills and competencies for all applied psychologists. The British
Psychological Society produced in-depth guidance in its Good Practice Guidelines on the Use of
Psychological Formulation (BPS, 2011). Formulation provides a holistic and individually focused
understanding of a person’s difficulties, and leads to a person-centred and effective package of
interventions (Johnstone, 2017; Johnstone & Dallos, 2013).
A diagnosis of autism can be valuable because it provides information about the underlying
nature of the difficulties experienced, improves others’ understanding of why a person acts
and responds in a certain way, and indicates possible approaches to intervention. However,
given the heterogeneity of autism, diagnosis only provides limited information about an
individual’s strengths, difficulties and needs.
Formulation highlights the aspects of autism that are most prominent for the individual, and
when and under what circumstances they are problematic. Formulation helps to explore the
personal meaning and impact of the condition while including the wider interpersonal and
environmental context (BPS, 2011). Formulations can be developed by practitioner psychologists
or by multidisciplinary teams. Team-based formulations draw on the skills and experience of every
team member and can achieve cultural change in the service by promoting a better informed and
psychosocial perspective among all the disciplines involved (BPS, 2011; Johnstone, 2017) than
when working alone.
BEST PRACTICE GUIDANCE
Practitioner psychologists, wherever they are based, should work to:
• Promote a formulation approach to autism assessments and diagnostic processes.

• Ensure all autism assessments are comprehensive and, wherever possible, multidisciplinary.
• Ensure that all information is considered in the formulation, including historical and recent
life events and experiences.
• Ensure assessments and the resulting formulations consider a person’s strengths and
difficulties, extending beyond diagnostic categories and co-occurring conditions to look at
the whole person in context.
• Understand the limitations of standardised instruments used to identify autism and other
conditions (e.g. mental health conditions).
• Integrate assessment information from multiple sources when making a clinical judgement
on the appropriateness of a diagnosis of autism and possible co-occurring diagnoses.
• Promote the delivery of autism-informed psychological interventions based on the needs of
the child or adult as guided by the formulation.
• Construct positive diagnostic reports which focus on strengths and protective factors in
addition to identifying areas of need.
• Evaluate the emotional response of the person receiving the diagnosis and take any steps
necessary to address this.
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CHAPTER 4
Autism in children and

young people
4. Autism in children and young people

4.1 ASSESSMENT AND DIAGNOSIS
In the UK, the age children typically receive a diagnosis of autism varies from around 4.5 years
to 7 years or older (Brett et al., 2016; Crane et al., 2015). However, expert clinicians may make
a diagnosis as early as 24 months where an infant shows significant difficulties with social
interaction and communication (e.g. Steiner et al., 2012). Often children who are diagnosed early
are first seen for assessment by their family doctor, health visitor, paediatrician or by staff in infant
nurseries or early years settings. The US Center for Disease Control and Prevention (last review –
February 2019) lists characteristics that may be possible ‘red flags’ for autism in toddlers. These
are detailed in the table below:
• Not respond to their name by 12 months of age
• Not point at objects to show interest (point at an airplane flying over) by 14 months
• Not play ‘pretend’ games (pretend to ‘feed’ a doll) by 18 months
• Avoid eye contact and want to be alone
• Have trouble understanding other people’s feelings or talking about their own feelings
• Have delayed speech and language skills
• Repeat words or phrases over and over (echolalia)
• Give unrelated answers to questions
• Get upset by minor changes
• Have obsessive interests
• Flap their hands, rock their body, or spin in circles
• Have unusual reactions to the way things sound, smell, taste, look, or feel
4 . 1 . 1 D E L AY E D D I A G N O S I S
Many parents experience a significant delay, with an average wait of 3.6 years, between first
consulting a professional and receiving a final diagnosis (Crane et al., 2016). Diagnosis tends to
be more delayed in:
• Females;
• Children of higher IQ;
• Children with more subtle difficulties or relatively good language;
• Children with additional diagnoses (e.g. specific genetic conditions or ADHD).
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Some studies suggest that families from ethnic minorities are also more likely to experience delays
WOR K ING WIT H AUT ISM (Mandell et al., 2007; Rosenberg et al., 2011).
Many children may show no clear signs of autism until they attend nursery or enter formal
schooling. Frequently, however, these children have a history of developmental, social or
behavioural difficulties. These may be misdiagnosed as being due to developmental delay,
conduct disorder, or a variety of other conditions, or other factors, including poor parenting.
This misdiagnosis can lead to delays in a child receiving adequate intervention or education and
parents can feel criticised and unsupported.
For some, autism is not identified until adolescence, which can be a particularly difficult time for
any young person to cope with assessment or diagnostic processes (see e.g. Clarke & van Ameron,
2008; Hogue et al., 2008; Huws & Jones, 2008).
The main characteristics associated with possible autism in children from pre-school to secondary
school age children are summarised in NICE Clinical Guideline 128 (NICE, 2017). Practitioner
psychologists working with children should be familiar with these guidelines and refer children
and their families on for diagnosis if needed, and to appropriate support services.
Autism is a highly complex and diverse condition and characteristics can change markedly with
age and environment. Therefore, diagnosis should be carried out by a multi-professional team of
clinicians with training and experience in developmental disorders. This should include input from
medical (psychiatric or paediatric), psychological (appropriately trained practitioner psychologist)
and speech and language professionals, as well as any relevant inputs from other children and young
people’s services such as neurology, education, occupational therapy, physiotherapy. Diagnosis requires
direct individual assessment as well as information from parents or carers and others who play a role
in the child’s life (e.g. teaching staff). The diagnostic assessment should include a detailed clinical
history covering the child or young person’s developmental trajectory, medical history, and relevant
family and social factors. Assessments may be guided by standardised diagnostic instruments, but
final diagnosis is based on expert clinical judgement (Fuentes et al., 2020).
Practitioner psychologists should work to:
• Support all children and young people with suspected autism, and their families, to obtain
diagnosis and access appropriate support services as soon as possible.
• Recognise the particular needs of children and young people who fall outside the ‘typical’ age of
diagnosis and ensure that pre-school and secondary school age children and their families also
have access to diagnostic and additional appropriate support services as soon as possible.
• Increase their own and their colleagues’ understanding of the developmental demands in
adolescence and how these might be more complicated for young people with autism.
• Collaborate with other professionals, as part of a multidisciplinary team, to ensure an
accurate and appropriate diagnosis for children and young people.
• Provide teaching, training, supervision and consultation to education and care providers.
• Help parents and carers and other professionals to realise that needs can be identified and
appropriate support and provision given prior to a diagnostic assessment.
• Ensure that the timescales for review of the child/young person’s needs are appropriate to
the specific individual.
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4 . 2 L I M I TAT I O N S O F D I A G N O S I S

There are many circumstances in which standardised diagnostic instruments may be inadequate
or misleading, for example, when making a diagnosis in girls and women, ethnic minorities and
different cultural or religious groups, and looked after children.
4.2.1 GIRLS AND WOMEN
Research on the differences in presentation between males and females is in its infancy and much
of the current literature on this topic is anecdotal or based on small scale studies. Care needs
to be taken therefore, particularly in areas where such research indicates that differences exist.
Nevertheless, it is clear that there is a significant gender disparity in autism diagnoses (Green et
al., 2019). Average prevalence estimates in boys and men are three to four times higher than in
girls and women (Loomes et al., 2017). At the present time, it is suggested that many females with
autism tend to have better social integration skills than males. It may be the case that the special
interests of girls and women appear to be more age- or peer-appropriate (e.g. animals, celebrities,
make-up or fashion). In addition, they may show less evidence of repetitive, ritualistic behaviours or
unusual hand or body movements but these possible differences need to be further explored.
‘Masking’ behaviours, too, might be more common among females with autism (Dean et al., 2016;
Dworzynski et al., 2012; Kreiser & White, 2014; Lai et al., 2017; Mandy, 2019; Ratto et al.,
2018). It has been suggested that the effort involved in constant social mimicry and attempting to
repress their natural autistic behaviour can lead to a higher incidence of mental health difficulties
for these women. Many adolescents and young women with autism initially present to health
services because of secondary symptoms such as mental health issues (e.g. disordered eating,
anxiety, obsessive-compulsive disorder, depression or sleep disorders).
Research on autism in girls and women is relatively limited and many of the criteria currently
used to assess autism are predominantly derived from male participants. This means diagnosis of
autism in girls and women may be missed, leading to inappropriate treatment and management
(Kirkovski et al., 2013). Correct diagnosis relies on experienced clinicians who are able to see and
think beyond the typical male autism stereotype (Gould & Ashton-Smith, 2012).
• Promote better awareness of possible gender bias in:

– Existing screening and referral processes;
– The interpretation of current diagnostic criteria;
– Diagnostic assessments.
• Increase understanding of protective and compensatory factors in girls and women with
autism, and highlight differences in gender-specific autism profiles.
• Promote and provide diagnostic assessments that are informed by psychological knowledge
and experience of how women with autism present to services.
• Use training, consultation and supervision with colleagues across health, social and
educational settings, (particularly in schools and secondary mental health services, sexual
health services and maternity services) to highlight gender issues in autism and increase
understanding.
• Support colleagues to encourage girls and women with autism to help educate others on
their perspectives and lived experiences.
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4 . 2 . 2 E T H N I C M I N O R I T I E S A N D C U LT U R A L O R R E L I G I O U S G R O U P S
WOR K ING WIT H AUT ISM Current diagnostic instruments were developed mainly with participants from more affluent, ‘first
world’ countries (Scarpa et al., 2013) and there is relatively little information or research on their
appropriateness or validity for children from economically deprived, socially isolated, minority
ethnic or racial groups, or with individuals from very different cultural or religious backgrounds
(Mandell et al., 2009). The validity and appropriateness of standard diagnostic processes for these
groups requires further research.
4.2.3 LOOKED-AFTER CHILDREN
There are particular diagnostic challenges for looked-after children with autism. Many will have
experienced developmental trauma, such as abuse or neglect and there is a recognised overlap in
the behaviours of children with autism and those with attachment difficulties. The behaviour of
looked-after children with autism can be mistaken for attachment difficulties, with the result that
their autism goes unrecognised (see Moran, 2010; Flackhill et al., 2017).
• Increase understanding of the need for caution in interpretation of assessments

and diagnoses.
• Support other professionals through providing training on how the results of assessments
are communicated to and understood by families.
• Be aware of the impact of social and cultural differences which may lead to resistance to
accepting support and interventions (for example, in some cultures there may be a negative
impact on the marital prospects of other family members (Daley, 2013).
4 . 2 . 4 PAT H O L O G I C A L D E M A N D AV O I D A N C E ( P D A )
Pathological Demand Avoidance (PDA) is defined as an ‘obsessional avoidance of the

ordinary demands of everyday life,’ (Newson et al., 2003, p.596). PDA was first described
in the 1980s by Elizabeth Newson, a Consultant Child Psychologist who felt that some of
the children referred had features in common with, but were qualitatively different from,
autistic children. Since that time, there has been much debate and controversy about whether
PDA exists as a separate entity, whether it is specific to or part of the autism spectrum,
and whether children with other conditions also have a PDA profile (Egan et al., 2019;
Green et al., 2018; Ozsivadjian, 2020; Kildahl et al., 2021). There have been attempts to
design or modify tools to help clarify these questions (e.g. the Extreme Demand Avoidance
Questionnaire (EDA-Q) (O’Nions et al., 2014). Currently, there are no definitive answers and
PDA is not included in the two diagnostic manuals (DSM and ICD).
4 . 3 G E N E T I C , S E N S O R Y, B E H A V I O U R A L O R O T H E R D I S O R D E R S
The risk of autism is significantly increased in children and young people who have:
• Severe sensory problems such as profound deafness and congenital blindness

• Severe intellectual impairment
• A number of genetic conditions including Fragile X, Down’s syndrome, Rett Syndrome, Cornelia
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de Lange syndrome, Tuberous Sclerosis Complex, Angelman Syndrome, Neurofibromatosis Type

1, Noonan Syndrome, Williams Syndrome, 22q11.2 Deletion Syndrome (Richards et al., 2015)
• Obsessive compulsive disorder
Attention deficit hyperactivity disorder is also very common and although estimates of the overlap
vary widely, recent reviews suggest that between 40 to 70 per cent of individuals with autism have
co-occurring ADHD (Antshel & Russo, 2019).
For all children with co-existing conditions, standard autism assessments may be inadequate,
and their families frequently find it very difficult to obtain a diagnosis of autism as it is often
overshadowed by the primary medical diagnosis.
• Increase awareness of the significantly increased risk of autism in children with genetic,
sensory, behavioural or other disorders.
• Increase awareness of the need for assessments to go beyond the standard approaches in
recognition of the difficulties arising from co-existing and primary medical conditions.
4 . 4 A U T I S M A N D E D U C AT I O N
The diverse range of needs across the autism spectrum requires flexible and varied options
in educational provision. Psychologists play a key role in identifying appropriate educational
provision, which may precede formal identification of autism, and in contributing to the diagnostic
process. This includes:
1. Comprehensive assessment of need;
2. Building capacity (how best to support the individual to acquire and retain skills, knowledge
and other resources);
3. Managing everyday transitions;
4. Advising teaching and support staff on adjustments to the educational environment;
5. Advising teaching and support staff on targeted approaches;
6. Enhancing awareness of the peer group and fostering social inclusion;
7. Helping to prepare young people for transition to further and higher education;
8. Preparation and transition to employment.
4.4.1 COMPREHENSIVE ASSESSMENT
Whilst not all children with autism require a Statement of Special Education Needs (SEN)/
Statement of Additional Support Needs/an Education and Health Care Plan (EHCP)/Co-ordinated
Support Plan (CSP), psychological assessment of need is particularly important in the pre-school
and early years, at the transfer point from primary to secondary settings, and prior to the transition
to further or higher education or employment.
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4.4.2 BUILDING CAPACITY
WOR K ING WIT H AUT ISM Psychologists will be instrumental in advising on training and capacity-building within education
settings, and in advising education authorities on the development of a continuum of provision.
Practitioner psychologists have a role in developing the knowledge, skills and competencies of
staff and helping them to prepare for the needs of individual children with autism. This may
include training, interactive guidance, coaching and networking.
A number of competency frameworks have been developed:
• The Autism Toolbox: An Autism Resource for Scottish Schools

(http://www.autismtoolbox.co.uk);
• Evaluating Provision for Autistic Spectrum Disorders in Schools. (Bangor: Department of
Education Northern Ireland)
• The Autism Competency Framework (The Autism Education Trust commissioned by the
Department for Education in England).
4 . 4 . 3 M A N A G I N G E V E RY D AY T R A N S I T I O N S
Autism is frequently associated with difficulties with cognitive flexibility and sequencing and many
young people with autism struggle with change and transitions (Kuo et al., 2018; Nuske et al.,
2019). Small, everyday transitions or changes to the regular routine can be particularly difficult
as autistic people often find it very hard to predict what might happen. Anxiety increases when
things are uncertain and when individuals have little or no knowledge of a new place or activity or
situation. Providing clear details of the next place or task or setting (including the people who will
be involved) will be beneficial.
4 . 4 . 4 A D J U S T M E N T S T O T H E E D U C AT I O N A L E N V I R O N M E N T
Practitioner psychologists can advise on adaptations to the physical, social and sensory
environment in an education setting, as well as curriculum content and teaching methods. Many
useful and relevant resources can be downloaded free of charge from the Autism Education
Trust’s website (www.autismeducationtrust.org.uk) for Early Years, Schools and Post-16 settings.
4.4.5 TARGETED APPROACHES
Systematic and targeted teaching of core skills is a necessary part of a comprehensive educational
response for children and young people with autism. Interventions should draw on developmental,
behavioural and cognitive psychology. All interventions should be ‘autism-informed’ and centred
around the needs and strengths of individuals (see Jones et al., 2008). Embedding special
interests in curriculum content and delivery is often highly motivating (Davey, 2020).
4 . 4 . 6 T R A N S I T I O N T O F U R T H E R O R H I G H E R E D U C AT I O N
A key function of education is to prepare children and young people for life after they leave
school, college or university. Discussions with the young person and their family about the future
should start early in secondary school. It is vital that young people are given enough support and
information to choose study options that suit their interests and aptitudes and to enable them to
make well-informed decisions on the options available when leaving school (Elias & White, 2018;
Gelbar et al., 2014; Gillespie-Lynch et al., 2017; White et al., 2017).
Good information on local options is needed, together with guidance on opportunities for work
experience, apprenticeships and job training schemes, or university or college courses. For
those wishing to go on to further education and higher education, there is a need for sound
advice on different degree or training courses and discussions on how to apply. Many colleges
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and universities offer extra academic, practical or social support for autistic students, and

psychologists can be involved in identifying their likely areas of need in advance.
The location of a university/college placement in relation to home is also important. If autistic

students decide to study away from home, they may need preparation for this separation, which
might include short periods of experiencing staying away from the home.
4 . 4 . 7 T R A N S I T I O N F R O M E D U C AT I O N T O E M P L O Y M E N T
People with autism are more likely to achieve well in employment if their job is related to their
particular skills, interests, abilities and characteristics. Autistic people can prove a great asset to
employers and organisations across a wide range of both high- and low-skilled jobs, particularly
those jobs that tap into characteristics of their autism such as special interests, attention to
detail, visual memory or honesty. It is important to understand the nature of the social and sensory
demands of a job when seeking suitable employment.
A psychological assessment of a person’s skills, and the potential challenges of the workplace,
can be crucial in making suitable choices about employment. It is also important to ensure that
people have, or are able to develop, the skills necessary. Psychological input can help to develop
skills such as problem-solving and planning abilities, including time-management and on-task
behaviours. Psychological interventions can improve autistic people’s ability to work alongside
others, and promote acceptable ways of handling difficulties or conflict.
If an autistic person is at a disadvantage in employment because of the impact of autism,

that individual has certain entitlements under equality and disability legislation. This includes
entitlement to reasonable adjustments in the workplace, and eligibility to apply for funded support
from the Department for Work and Pensions. Details of how to apply for this can be found at:
https://www.gov.uk/access-to-work
Literature on employment issues and autism is increasing, and this evidence base can be helpful
in supporting people with autism into work (e.g. Kirby, 2014).
• Understand and incorporate relevant education legislation and policy in their practice.
• Familiarise themselves with published research and guidelines on good practice, and
understand the difference between ‘mainstreaming’ and true inclusion (Jones et al., 2008).
• Collaborate with colleagues, and young people themselves and their parents, to provide
support/shape the approach of the setting or service.
• Ensure that planning and discussions with young people with autism start early in their
school career and include study options and incorporate their wishes for the future on
leaving school.
• Advise staff on how they might understand the wishes and ambitions of young people
with autism.
• Recognise the multiple points of transition for children and young people with autism, the
importance of successful transitions and the potential barriers involved.
• Support colleagues to identify and address the likely needs of young people with autism
when they move to further or higher education or employment.
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4.5 CO-EXISTING CONDITIONS
Individuals with autism frequently experience a range of other problems, including ADHD,
irritability, behaviours that may appear challenging, self-injury, and sleeping, eating and
elimination difficulties. Epilepsy occurs in up to 20 per cent of cases (Pan et al., 2020), and
mental health conditions, particularly anxiety and depression are common (Hollocks et al., 2019;
Lord et al., 2018, 2021). Autistic individuals are also at increased risk of emotional, physical and
sexual abuse and other traumatic experiences (Hoover & Kaufman, 2018; Kerns et al., 2015).
Such problems can have a significant negative impact on functioning and quality of life, and
greatly increase stress for parents and carers.
4 . 5 . 1 M E N TA L H E A LT H
Emotional and behavioural difficulties are more common in children and young people with autism
than in the general population (Autism Speaks, 2018). Research indicates that up to 70 per cent
of 10 to 14 year olds with autism have at least one psychiatric disorder and 41 per cent have two
or more (Simonoff et al., 2008). However, it is often very difficult for children and young people
with autism and mental health problems to access adequate help from Child and Adolescent
Mental Health Services (CAMHS). Dedicated provision for this group is limited and very variable
across the UK, and staff often lack appropriate training. As a result, young people with autism and
their families frequently find services difficult to navigate, struggle to access support, and may not
find it helpful when they do (Crane et al., 2019).
• Ensure the inclusion of children with autism in CAMHS, when required.

• Be aware of the need to use adapted protocols when providing therapy to children and
young people with autism.
4.5.2 AUTISM AND INTELLECTUAL DISABILITY
Estimates of the proportion of individuals with autism who also have intellectual disability (ID)
have varied considerably. Earlier studies (Charman et al., 2011) suggested that around 55 per
cent of autistic children had an IQ<70 but a recent meta-analysis found that almost two-thirds of
people with autism were of average or above IQ; 20 per cent had moderate to severe ID and 13
per cent mild ID (MacKay et al., 2018).
An accurate assessment of intellectual ability is important in relation to autism. DSM-5 (2013)

already includes the need to specify the presence, or not, of intellectual impairment and ICD-11,
due for implementation from January 2022, requires an axial classification involving intellectual
function in every case. This is defined in terms of the dimensions of:
• Presence or absence of an intellectual disorder;

• Presence of absence of functional language;
• Whether there has been loss of previously acquired skills.
Level of intellectual disability is one of the most significant predictors of service needs, support
costs and long term outcome as demonstrated in a number of outcome, economic and other
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studies (Beadle-Brown et al., 2000, 2006; Fein et al., 2013; Howlin, 2004; Järbrink & Knapp,

2001; Knapp et al., 2009).
4.6 PSYCHOLOGICAL INTERVENTIONS
There is no ‘one size fits all’ approach to autism, and no single intervention will be appropriate
in all cases. What is important, is finding the right approach for each individual, and his or her
family, and enabling them to be active participants in decisions relating to their care and support.
The following best practice principles can help guide intervention (Barthelemy et al., 2019):
1. Early recognition and support can help to minimise the escalation of later problems. Thus,
even before a formal diagnosis is reached, a detailed developmental assessment can serve as
a baseline for planning and providing intervention, and for monitoring progress.
2. The views and perspective of the individual should be understood. The autistic person
should be at the centre of decisions made about intervention. Wherever possible, their
opinion should be sought directly on a regular basis, and their response to intervention
should be ascertained verbally or through their body language or from those who know them
well, and modifications to interventions should be made with this in mind.
3. Intervention should be provided in a natural and normal context. Treatment plans should
not be based on a pre-determined number of clinic-based therapy sessions. Instead all
possible opportunities during the day should be used to help minimise difficulties and foster
progress. The psychologist should not be the main, direct source of intervention but should
provide guidance, practical advice and monitoring of progress to those most directly involved
on a day-to-day basis, i.e. the person with autism, their parents, other family members,
carers and teaching staff.
4. Focus on individual strengths as well as limitations. Autism is characterised by a very

uneven profile of strengths and difficulties, and often the most effective way of fostering
progress is to help individuals use these strengths to circumvent or substitute for
weaker areas.
5. Intervention should be based on a ‘functional analysis’ of behaviour. This involves taking

account of all the factors that may be limiting an individual’s ability or impairing quality
of life, and developing testable hypotheses about the potential functions of observed
behaviours. It is important that the analysis of behaviour is ‘autism aware’. This makes it
possible to:
i. Identify potential underlying causes of difficulties;
ii. Help individuals acquire more effective/acceptable means of influencing their

environment; and
iii. Help develop the skills needed to improve quality of life.
6. The first line of intervention for behaviour that challenges should be psychosocial.
Pharmaceutical interventions for behaviour that seriously challenges self or others should be
considered only if psychosocial interventions are ineffective. If medication is used, it should
be reviewed after three to four weeks and discontinued if there is no indication of a clinically
important response within the recommended time (NICE, 2013). Medication should never
be used to manage the core characteristics of autism, although it may be needed for
co-occurring conditions such as epilepsy or severe anxiety and depression.
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7. Focus on making the social, physical and sensory environment comfortable for the individual.
WOR K ING WIT H AUT ISM Functional analysis should help to identify environmental factors that may be limiting functionality
and quality of life. Helping others to see the environment through the eyes of the person with
autism and designing ways to reduce environmental stress is crucial. Even very minor changes can
have major effects. Ensuring an informed balance between adapting environments and helping
individuals adapt their behaviour to fit the environment is particularly important.
8. Respect individual goals and dreams. Psychologists should help to empower people with
autism, and their families or carers, to defend their rights. They can support autistic people
to make informed life choices and to develop the skills or access the support they need to
achieve their goals.
9. Work collaboratively as part of a multidisciplinary team. The nature of multi-agency work will
depend on the specific individual’s needs but can be important in ensuring that individuals
with autism are supported to achieve independence in the community.
10. Finally, there are very many interventions that are claimed significantly to reduce symptoms
or even to cure autism. Many lack any evidence of effectiveness; some are a significant risk
to health (e.g. drinking bleach, stem cell replacement therapy, chelation, detoxification,
hyperbaric oxygen therapy etc); others show benefits for some children but not others.
As there are no universally effective interventions for autism the psychologist’s role is to help
parents navigate through the claims and counter claims, and decide on interventions that have
a robust evidence base, and are best suited to meet their needs and those of their child.
4.7 CLINICAL GUIDELINES
All psychologists working in the field of autism should be familiar with current NICE Guidelines
and Standards (NICE, 2013) and other guidelines (e.g. Scottish Intercollegiate Guidelines
Network, 2016; Autism Europe. 2019; European Society for Child and Adolescent Psychiatry,
2020; Lancet Commission on Future Care and Clinical Research in Autism, in press).
Recent reviews provide information on a number of evidence-based therapies that have been
shown to benefit young children (especially pre-school) with autism. These include early
social communication interventions that focus on joint attention, engagement and reciprocal
communication. Naturalistic, developmentally based interventions can also help to improve
learning and promote behavioural change (see Lord et al., 2020, 2021; Sandbank et al., 2020).
Although intensive ABA programmes have been found to have positive effects on IQ and adaptive
behaviour two years after intervention, there is no evidence that they reduce severity of autism or
improve longer-term outcomes (Rodgers et al., 2021).
NICE (2013) recommendations are based primarily on therapies for which there is moderate to
strong evidence from randomised control trials. However, relatively few interventions have been
rigorously tested in this way and in daily practice other approaches, albeit with a weaker evidence
base, are used. These interventions aim to minimise or circumvent areas of difficulty typically
experienced by individuals with autism. They include psycho-educational programmes to help
parents of young children develop effective strategies, such as non-verbally based strategies to
increase communication skills, and interventions to develop social understanding to facilitate peer
relationships, and cognitive behavioural programmes to improve mental health.
NICE (2013) concludes that many other ‘alternative treatments’ have no place in the management
of autism. These include approaches such as neurofeedback; facilitated communication; auditory
integration training; the use of Omega 3 fatty acids and secretin; chelation; hyperbaric oxygen
therapy, and exclusion diets.
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4.8 COUNSELLING, PSYCHOLOGY AND SOCIAL

SUPPORT SERVICES
Specialist counselling, psychology and social support can contribute to improved wellbeing and
quality of life for people with autism. Although some people with autism do not feel in need of
such support, and indeed view this as an unnecessary ‘pathologising and medicalising’ view of
autism (Clark & van Ameron, 2008), many others have difficult life experiences that give rise to
mental health problems. Individuals who need mental health services should be able to access
them and be provided with appropriate help by adequately trained staff. Where therapy is offered,
modifications are likely to be needed to approaches such as CBT or DBT when used in autism (e.g.
Attwood & Garnett, 2016; NICE, 2013).
4.9 SUPPORT FOR FAMILIES AND CARERS
NICE guidelines (2013) stress the importance of taking full account of the needs of the family
of the autistic child or young person. Their recommendations state that all family members,
including siblings and carers, should:
1. Receive verbal and written information about their right to:
• Short breaks and other respite care;

• Discretionary and other benefits;
• A formal carer’s assessment of their own needs and how to access these entitlements.
2. Have access to an assessment of their own needs, including:
• Personal, social and emotional support;

• Practical support in their caring role, including short breaks and emergency plans;
• A plan for future care for the child or young person, including transition to
adult services.
3. Have information about locally available help, advice, training and support,
especially if they:
• Need help with the personal, social or emotional care of the child or young person,
including age-related needs such as self-care, relationships, gender or sexuality;
• Are involved in the delivery of an intervention for the child or young person in
collaboration with health and social care professionals.
Practitioner psychologists designing or advising on service delivery, or delivering interventions,

should work to:
• Shape and inform services so that all interventions are commissioned, designed and
delivered based on the best psychological evidence.
• Advocate locally for a range of psychological services so that individuals, or their family,
can participate in choosing the method, modality and time for a psychological intervention
that suits them, or no intervention should they wish. It is important to note that although
services may be limited, psychologists can work to help/modify or make the best of what
is available.
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CHAPTER 5
Autism in adults
5. Autism in adults

Follow-up studies from child to adulthood generally indicate that the severity of core autism
characteristics decreases over time. Many people show improvements in social functioning and
communication as they grow older. The development of language and having a non-verbal IQ in
or around the average range are among the strongest predictors of a positive outcome for people
(Lord et al., 2018). In the most cognitively able group, there is a small number of adolescents
or young adults who are described as having an ‘optimal outcome’. This means they no longer
meet diagnostic criteria for autism, but they may continue to show subtle social, emotional and
behavioural difficulties (Orinstein et al., 2015).
The long-term prospects for most adults with autism known to services remain poor (Howlin &
Magiati, 2017). A lack of appropriate support and resources can lead to:
• Limited access to higher education and employment.

• Relatively few autistic people developing close, long-term relationships.
• Remaining dependent on families or government benefits for support.
• Mental health problems, especially related to anxiety and other mood disorders.
However, it is important to be aware that most information on outcomes in autism comes from
studies of clinical cohorts, often comprising individuals who were diagnosed as children because
of the severity of their difficulties. Therefore, existing data do not reflect outcomes for all
individuals with autism, who may have less severe issues. Many adults, especially those of average
or above intellectual ability, may never come to the attention of clinical or educational services,
and are able to live productive and fulfilling lives through their own skills and determination.
5 . 1 D I A G N O S I S I N A D U LT H O O D
Diagnosing autism in adults is a challenge as most reliable diagnostic instruments were developed
for children. In adulthood, it is more difficult to obtain early developmental data, and clinical
judgement usually relies on self-report or information from family members and friends. Autism
in adulthood may be less evident than in childhood, especially in more able individuals, as people
have learned ways of circumventing or disguising some of their difficulties. Additional mental
health conditions, such as depression or anxiety, and difficult life experiences further complicate
the clinical picture.
Some screening questionnaires, observational and interview measures have been adapted from
instruments based on children. NICE suggests a number of signs that are suggestive of autism in
adulthood in Clinical Guideline 142 (NICE, 2016):
• one or more of the following:

– persistent difficulties in social interaction
– persistent difficulties in social communication
– stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests,
and
• one or more of the following:

– problems in obtaining or sustaining employment or education
– difficulties in initiating or sustaining social relationships
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– previous or current contact with mental health or learning disability services
WOR K ING WIT H AUT ISM – a history of a neurodevelopmental condition (including learning disabilities and
attention deficit hyperactivity disorder) or mental disorder.
Information on any history of contact with child services, indications of earlier neurodevelopmental
difficulties, and assessment of current functioning (especially when functional ability is out of
synchrony with cognitive level) can also help to inform a diagnostic decision. Because of the
complexities involved in making a valid diagnosis of autism in adulthood it is important that,
wherever possible, diagnostic assessment is conducted by a specialised, multidisciplinary team.
Practitioner psychologists working with adults with autism should:
• Be aware of relevant guidelines, screening and other instruments that may aid
a diagnosis of autism.
• Conduct a detailed assessment of social understanding, cognitive functioning, sensory
experience and emotional difficulties to determine whether autism or another condition is
the likely cause of an individual’s difficulties.
• Recognise the role that access to a preferred, or even ‘obsessional’, activity may play in
helping individuals reduce their anxiety and regulate their behaviour, as well as helping
them to build new skills and develop coping strategies.
• Ascertain their ability to manage everyday living tasks (e.g. domestic tasks; paying
bills; shopping).
• Refer clients showing clear signs of autism to specialist diagnostic services when
appropriate.
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5 . 2 M E N TA L H E A LT H A N D A U T I S M

5 . 2 . 1 P R E VA L E N C E O F M E N TA L H E A LT H P R O B L E M S
The constant demands of ‘fitting in’ and the absence of appropriately structured support or daily
activities can contribute to high levels of stress, anxiety and depression in people with autism.
Recent systematic reviews suggest that the lifetime prevalence for anxiety disorders (including
panic disorders, phobias, obsessive compulsive disorder and post-traumatic stress disorder) in
people with autism is around 42 per cent, and lifetime prevalence for depressive disorders is 37
per cent (Hollocks et al., 2019). The occurrence of schizophrenia is lower at around six to seven
per cent (Lugo-Marin et al., 2019). Suicide is a significant cause of premature death in autistic
individuals of higher IQ (Hedley & Uljarević, 2018; Hirvikoski et al., 2016; Mandel, 2018).
Although high rates of substance abuse have been reported in some studies, the findings here are
very inconsistent (Helverschou et al., 2016).
5 . 2 . 2 D I A G N O S I N G M E N TA L H E A LT H C O N D I T I O N S
Accurate diagnosis of mental health conditions in people with autism presents many challenges.
These include:
• Atypical symptom presentation;

• An overlap of symptoms between autism and psychiatric disorders;
• Difficulties of many individuals in describing their own mental states;
• A lack of autism-specific psychiatric assessments;
• A lack of understanding of adult autism among psychiatrists (Brugha et al., 2015).
Any marked changes in behaviour, for example an exacerbation of existing problems, losing
established skills or the emergence of new difficulties, should be recognised as a possible
indication of the onset of mental health issues.
Further information on recognising, diagnosing and managing mental health problems in

autism can be found in the recent report from the Royal College of Psychiatrists The Psychiatric
Management of Autism in Adults (RCP, 2020)
5.2.3 INTERVENTIONS
The evidence base for interventions to improve mental health for people with autism is limited.
There is some evidence for the effectiveness of cognitive based therapies for anxiety and
depression, including CBT, mindfulness and other psychosocial therapies (Howlin & Magiati,
2017; Sizoo & Kuipers, 2017; Spain et al., 2018; White et al., 2017) although effect sizes are
generally modest. Adaptations to standard procedures are often required but at present there
are no empirically derived guidelines on how best to adapt standard practice. Spain and Happé
(2020) stress the importance of systematically assessing the views of autistic adults themselves
about what it is they hope to gain from CBT, and what aspects of treatment they find helpful.
Many of the difficulties experienced by people with autism can be related to environmental factors
or the stress of social demands. In such cases, careful assessment of possible causes, help
to develop more effective coping skills and appropriate modification to the sensory, social and
physical environment can have a more immediate and positive impact than interventions focusing
on the individual alone.
Recent guidelines from the British Association for Psychopharmacology (BAP, 2018), NICE
(2016) and the Royal College of Psychiatrists (RCP, 2020) stress that there is no justification for
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the routine use of medication in the management of the core symptoms of autism. The effects
WOR K ING WIT H AUT ISM of medication can be unpredictable as people with autism may show idiosyncratic responses
or greater sensitivity to side-effects. The risk of adverse effects means that medication should
only be considered on a case by case basis and, even then, should be only one component of
a multimodal approach that can include psychological therapies, education, and environmental
change. If medication is used it should commence at a low dose, be increased cautiously and with
careful monitoring, reviewed regularly, and withdrawn after a few weeks if no positive effects occur
(NICE, 2016; RCP, 2020).
BAP, NICE and RCP provide recommendations for medical interventions that can be used to
treat commonly co-occurring conditions such as sleep problems, epilepsy, and ADHD, when
appropriate.
Practitioner psychologists working with adults with autism should be:
• Aware of the high risk of mental health problems, especially related to anxiety and depression.
• Alert to changes in behaviour or mood that may indicate the onset of a mental
health disorder.
• Able to conduct a detailed analysis of behaviour to determine possible causes and
investigate the effectiveness of potential interventions.
• Able to advise carers and others about ways of reducing stress or improving
environmental factors.
• Aware of the need to use adapted protocols when providing therapy.
• Able to adapt their verbal and non-verbal communication to be more autism friendly and
therefore increase accessibility of talking therapies for autistic people.
• Should invite the autistic person to communicate their thoughts and feelings about the
sessions on a regular basis, in ways that are possible for them.
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5 . 3 P H Y S I C A L H E A LT H

Serious and chronic health disorders are significantly more common in people with autism than in the
general population (Cashin et al., 2018; Croen et al., 2015; Rydzewska et al., 2018). These include:
• Autoimmune conditions;
• Allergies;
• Gastro-intestinal disorders;
• Sleep disorders;
• Seizures;
• Hypertension;
• Diabetes or obesity;
• Thyroid disease;
• Vision and hearing impairments;
• Genetic disorders;
• Neurological disorders (including Parkinson’s disease and stroke).
Poor physical health is a major cause of premature mortality (Hirvikoski et al., 2016), which
is more common among people with autism than the general population (Barnard-Brak et al.,
2019). Autistic adults with intellectual disability and epilepsy are at particular risk of early
death (Hirvikoski et al., 2016). The need for treatment for chronic and acute medical conditions
contributes significantly to the high cost of adult care (Buescher et al., 2014; MacKay et al.,
2018). A recent US study (Zerbo et al., 2018) found that total annual mean healthcare costs for
adults with autism were double those of the general population.
The major barriers to effective health care remain lack of understanding of people with autism
among medical practitioners, and lack of autism-friendly healthcare facilities (Mason et al.,
2019; National Autistic Society; 2018). A website on autism for healthcare practitioners has been
developed by National Education Scotland (https://www.nes.scot.nhs.uk/education-and-training/
by-discipline/psychology/multiprofessional-psychology/autism.aspx).
Practitioner psychologists working with adults with autism should:
• Be aware of the high risk of serious health problems.

• Support assessments of physical health as it is common for people with autism to have
difficulties describing pain; pain thresholds may also be unusual or inconsistent (Failla
et al., 2020).
• Actively encourage people with autism, and those caring for them, to ensure they have
regular health checks with GP and other screening services.
• Promote better understanding of autism amongst all healthcare professionals (GPs,
pharmacists, in- and out-patient hospital staff).
• Offer practical advice to practitioners on how their services can become more
autism-friendly.
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5.4 QUALITY OF LIFE
There are few autism-specific measures of quality of life, although recent modifications have been
made to the WHOQOL-Brief (World Health Organisation Quality of Life – Brief version) following
detailed consultations with people with autism (McConachie et al., 2018; 2019). ‘Normative’
criteria such as living independently, being in work and having close social relationships, may not
always be associated with better physical or mental health in autistic adults. Not all individuals
can readily cope with living fully independently; similarly, not all may wish to work full-time, or
to engage in a wide social network. Judgements of what constitutes a good quality of life should
be based on the ‘goodness of fit’ between individuals and the environment in which they live
(Bishop-Fitzpatrick et al., 2016; Lai et al., 2020). Thus, improving quality of life can often mean
addressing the lack of support for semi/independent living, employment and leisure, as well as
supporting those living with family or in specialist residential settings.
Practitioner psychologists working with adults with autism should work to:
• Avoid imposing their own views of what constitutes a ‘good’ quality of life.
• Help adults with autism to acquire the necessary social, communication, emotional
regulation and self-help skills to live safely and without unnecessary stress.
• Encourage day-time programmes and accommodation that are appropriate for the
individual’s level of capacity and interests.
• Reflect the individual’s hopes, goals, and concerns in any plans for work, living and leisure.
• Engage with social and other local services to ensure that their autistic clients are provided
with suitable accommodation, adequate levels of support and all financial and other
entitlements.
5 . 5 I N T E R V E N T I O N S F O R A D U LT S
Practitioner psychologists working with adults with autism, in whatever capacity, should be
familiar with NICE guidelines CG 142: Autism spectrum disorder in adults: Diagnosis and
management (NICE, 2016).
Rates of social, behavioural and emotional difficulties in adults with autism are high but there
are no interventions that have been shown significantly to improve outcome. Most treatment
trials have focused on small samples and young adults, not older groups. The heterogeneity of
participants also limits the conclusions that can be drawn.
There are no specific adult interventions with a strong evidence base, but a number of
interventions show potentially positive effects:
• There is some evidence for interventions designed to improve social and communication
abilities, such as social skills groups, social and emotional awareness training (Ke et al., 2018;
Lorenc et al., 2018; Spain & Blainey, 2015) although effect sizes are moderate.
• Programmes to improve access to a wider range of recreational opportunities; help to
develop daily living skills, and increase access to employment also show positive benefits
(Bishop-Fitzpatrick et al., 2017; Hedley et al., 2017; Stacey et al., 2019).
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• There is some positive evidence for cognitive based strategies (e.g. CBT and mindfulness)

designed to reduce anxiety and improve mental health (Spain et al., 2018; White et al., 2018).
• Environmental modifications, such as improving others’ understanding of autism, avoiding or
reducing social, cognitive and sensory overload and other factors causing stress may also have
an impact, although research in this area is limited.
• There is an increasing role for the use of information technology as a communication or
problem-solving aid in autism (Van Der Aa et al., 2016).
Medication for mental health problems should be considered only if psychosocial or other
interventions have proved ineffective and only after a detailed functional analysis. (See also
Section 5.2.3).
Due to the limited evidence on adult interventions, practitioner psychologists should apply basic
psychological principles, adapted to the individual’s cognitive and social strengths and needs, to
help improve areas of difficulty, modify behaviours that reduce quality of life, and reduce mental
health and other difficulties.
• Take account of all the factors that may be limiting an individual’s ability or impairing
quality of life.
• Use psychological formulation to develop hypotheses about the source of difficulties in
the context of the individual’s relationships, social circumstances and life events, and the
sense that they have made of them (see Section 3.2 on formulation).
• Use autism-adapted applied behavioural science to identify potential ways of
ameliorating problems.
• Rigorously test the outcome of the strategies applied.
• Use the principles of functional analysis to identify the underlying causes and effects
of behaviours that challenge, and help individuals acquire more effective means of
influencing their environment.
• Use principles based on positive behaviour support to help individuals acquire the skills
needed to improve their quality of life.
• Make use of intervention programmes with some supporting evidence to develop skills or
minimise difficulties to reduce behaviours that challenge.
• Modify environmental factors that may be limiting functionality and reducing quality of life.
• Work closely with family, employers, carers, and health professionals to ensure they are
aware of how best to meet the needs of people with autism.
• Contribute to care plans for people with autism who receive a service from their
local authority.
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5.6 WHERE PEOPLE LIVE
Decisions regarding where people live should be person-centred, based on the support needs of
the individual, their preferences and the ability of their wider system to meet their needs. This
means that a broad range of living situations may be appropriate for people with autism, including
living in their own homes independently, with a partner or with a needs-led package of support,
with family (with or without a package of support), in individual or shared supported living, and in
residential care settings.
In each setting it is important that those providing support have a good overall understanding
of autism and the support needs of people with autism, together with understanding of the
individual’s likes and dislikes and more general support needs.
Decisions on where may be best for an individual to live need to consider a range of
possible factors:
• Individual choice and preferences.

• Impact of autism symptoms.
• Severity of learning disabilities.
• Social and communications skills.
• Sensory needs.
• Presence of mental health difficulties or behaviours that challenge.
• Distance from family.
• Skills and knowledge of support providers, including use of adaptive communication
approaches as used by the individual.
• Ability to tolerate living with others and numbers of others sharing the accommodation.
• Level of support for skills development.
Where an individual is cared for by others, the continuing development of independent living skills
should be considered integral to the support they receive. This is essential for facilitating a culture
of lifelong learning, active engagement and promoting a positive sense of wellbeing through skills
acquisition.
Particular attention should be paid to times of transition, for example changing from one place
of residence to another, or changes in staff or carers. Periods of change and transition can be
stressful and negatively affect psychological wellbeing. The best transitions are those that have
been well planned in advance, with new support teams having the opportunity to shadow existing
staff teams and carers, so that they are able to get to know the person with autism well before the
move takes place. Careful consideration, based on individual needs, should be given to how the
person is involved in the move, the extent to which the move is phased and the creative use of
photos, videos and other media to familiarise the individual with their new home, new people and
the local environment.
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Working with autism
In circumstances when individuals do not have capacity to make decisions about where they

live, it is particularly important that practitioner psychologists ensure that guidance on best
interests decision making about residential accommodation is followed. This is provided in the
Mental Capacity Act (2019)/Adults with Incapacity (Scotland) Act (2000)/Mental Capacity Act
(NI) (2019).
• Support assessment and person-centred decision making, when considering the

accommodation and support needs of people with autism.
• Play an active role in transition planning when an individual is being supported to move
from one place to another.
• Provide practical advice and consultation to residential staff on how to meet individual
needs depending on profiles of skills, difficulties and severity of autism.
• Help individuals with autism acquire the necessary self-help skills to live as safely and
independently as possible.
• Liaise with local services (including housing associations, housing department, Citizens
Advice Bureaus, leisure and community services) to ensure adults are provided with
suitable accommodation, adequate levels of support, and have access to all financial and
other entitlements.
• Ensure best practice guidelines regarding the relevant legislation on mental capacity and
best interests are followed when decisions are made about residential accommodation for
individuals who lack capacity to make such decisions for themselves.
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Working with autism
5 . 7 O L D E R A D U LT S W I T H A U T I S M
In an increasingly ageing population, the number of adults with autism who are aged over 60
years is steadily growing, bringing new challenges to health and social care services, to families,
and to individuals themselves. The prevalence of autism in elderly groups is likely to reflect that
in the general population (i.e. around one per cent), however many of these individuals may lack
a formal diagnosis and be previously unknown to services, having been supported mainly by family
members in the past.
Remarkably little is known about the lives of older people with autism. For example, although it
is recognised that premature mortality is increased in autism (DaWalt et al., 2019; Woolfenden et
al., 2012), we know relatively little about the physical health risks at an older age. Information on
mental health is also scarce, although there is some evidence that there may be less deterioration
in mental health and in overall quality of life in older adults with autism than in the general
elderly population (Van Heijst & Guerts, 2015). There is some indication, too, that the risks of
developing Alzheimer’s dementia may be lower than in the general population (Barnard-Brak et al.,
2019). Cognitive research also indicates that although verbal memory shows a similar decline to
that found in typical ageing, visual and working memory seem to be areas of relative preservation
or strength among older adults with autism (Roestorf & Bowler, 2016). As in younger adults with
autism, processing speed in older adults with autism appears to be an area of poorer performance
compared to typically developing older adults (Tse et al., 2019).
Practitioner psychologists working in services for older people should work to:
• Distinguish between older people with autism who have experienced difficulties in
social communication throughout their lives, and individuals experiencing age-related
deterioration in these areas. This is important for treatment and expectations
about prognosis.
• Continue to consider autism as a possible diagnosis in older adults who present with
a constellation of symptoms that map on to those indicative of autism.
• Arrange access to appropriate mental, physical and social services for elderly people with
autism in need of care.
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Working with autism
5.8 SUPPORT FOR FAMILIES, CARERS AND PARTNERS

Adults with autism living with families, partners, carers or in semi- or fully supported
accommodation can experience many challenges; families too can experience many challenges
in caring for them (Tint & Weiss, 2016). For example, living with increasingly elderly parents can
result in over-dependency on both sides, leading to tension and a lack of external activities. These
adults can be unknown to social care services, so if the home situation breaks down (typically due
to the death or illness of a parent), no alternative safe provision may be immediately available.
Siblings also face significant challenges (Moss et al., 2019; Shivers et al., 2019), and some may
fear or resent having to take on the responsibilities of being a carer. In many cases, partners of
people with autism were unaware of the condition when the relationship first began, and coming
to terms with the diagnosis and what it implies, can prove very difficult.
• Identify the potential strains on and difficulties for families/partners/carers, as well as for
the person with autism.
• Explain how the core characteristics of autism can impact on the relationship (e.g. rigidity;
inability to demonstrate affection; inability to empathise with others’ difficulties; inability
to understand parental frailty/illness, etc.)
• Advise on strategies to minimise friction and enhance independence of both the person
with autism and his or her partner or carers.
• Support families and carers to make plans for the future and consider the implications
of the death or serious illness of a parent or the need to move home (e.g. financial
arrangements, alternative living arrangements).
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Working with autism
CHAPTER 6
Employment
6. Employment

Several large scale studies have shown that adults with autism are less likely to be employed
than people with other developmental or intellectual disabilities (Roux et al., 2013; Shattuck
et al., 2012). It is estimated that only around 30 per cent of individuals diagnosed with autism
are in paid employment and their jobs are mostly unskilled, part-time or poorly paid (Howlin
& Magiati, 2017; Roux et al., 2014). However, it is not known how many undiagnosed adults
are in work.
Lack of employment is associated with substantial social and economic disadvantage, high
levels of dependency and increased rates of mental health conditions. The economic and social
disadvantages are significant in terms of potential waste of skills, loss of taxes and high costs of
welfare and social benefits (see MacKay et al., 2018).
Specialist supported employment programmes are designed to help autistic adults find and
maintain work, and to offer guidance to employers and colleagues to understand the needs and
positive assets of autistic employees. Such schemes have been shown to increase job retention,
job levels, pay, quality of life, and cost-effectiveness. (Hedley et al., 2017; Mavranezouli et al.,
2013). Although very few autistic adults have access to specialised interventions of this kind
there are several general factors that are related to successful employment (Autism Speaks, 2013;
National Autistic Society, 2016). These include:
• Adapting educational curricula to foster work related skills based on individual students’
interests and aptitudes.
• The provision of work experience during senior school and college years (see Section 4.4.6 on
transition).
• Matching the skills and needs of job seekers to job requirements.
• Education for employers.
• Adaptations to the work environment.
• Individual support in the workplace.
• Advocating for autistic people by explaining their rights under the Equality Act (2010) for
reasonable adaptations and encourage people to use schemes such as ‘Access to Work’
(https://www.gov.uk/government/publications/access-to-work-factsheet).
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Working with autism
6 . 1 F I N D I N G A P P R O P R I AT E W O R K
Cognitive ability or academic qualifications alone are not an adequate basis on which to make job
choices. Psychological assessment and guidance can be crucial in helping individuals with autism
to choose jobs that play to their strengths and match their intellectual, social and emotional
needs. Some individuals with autism find it easier and less stressful to work in jobs that are at
a lower level than their intellectual capability/educational attainments might indicate. Thus, they
may prefer, and be more comfortable in, work placements that are routine and predictable and
do not require extensive social contacts, rather than in jobs requiring the ability to cope with
complex social interactions, deal with unexpected events or make rapid decisions under pressure.
It is important, therefore that individuals’ social and emotional needs are taken into account in
advising about job placements and sometimes this may require exploring alternatives to full-time,
paid employment.
Practitioner psychologists working with autistic job seekers should be able to provide guidance on
how to explore possible job opportunities, and how (or whether) to disclose a diagnosis of autism
to potential employers. They should ensure that individuals are fully aware of, and are able to
claim their employment and benefit rights.
6.2 MAINTAINING EMPLOYMENT
Many people with autism fail to find and maintain work because of difficulties in understanding
the social demands of the job or because of a lack of understanding of autism among employers
and colleagues, and they can experience bullying in the workplace. This mutual lack of
understanding can be addressed in a number of different ways.
6 . 2 . 1 E D U C AT I O N F O R E M P L O Y E R S
Practitioner psychologists play an important role in educating potential employers about the skills
of individuals with autism and the benefits they can bring to the workplace. They should provide
guidance on how to comply with equality/disability legislation and on how to make ‘reasonable
adjustments’ to the work environment so that people with autism are not disadvantaged either
when applying for or when in work. This may include advising on how to:
• Adapt interview procedures to ensure that job seekers with autism can demonstrate their
relevant skills in an optimal way, for example by a prepared presentation rather than an
unstructured interview, or by-passing the interview and being assessed on the job.
• Address social and sensory issues that can affect an individual’s ability to function effectively
in the workplace (e.g. by modifying noise and lighting levels; changing proximity to other
workers; using non-verbal communication systems, such as text and email).
• Work with other employees and protect against bullying.
• Provide equal opportunity for promotion.
Psychological advice to managers and other staff can help them understand the importance of
consistency, predictability, clarity and unambiguous feedback for a colleague with autism.
6.2.2 IN-JOB SUPPORT
On-site, psychological support can help to ensure that the person with autism fully understands
and is able to meet the practical and social requirements of the job. Functional skills analysis and
psychological principles can be used to break down complex tasks into their component parts, and
cognitive and behavioural strategies can provide the employee with the skills needed to achieve
40
Working with autism
his or her work goals. Some autistic employees with more severe intellectual impairments may

need continuing support; for others, intensive intervention may be necessary only initially and
can then be steadily reduced. Regular, planned meetings with the employee and his or her line
manager can subsequently replace direct support. However, psychological advice should remain
available to the employer or employee as and when problems arise. Practitioner psychologists can
advise on third-party agencies that may be able to provide an appropriate mentor if they are not
able to provide support themselves, such as Department for Work and Pensions Access to Work
scheme or mentors from local and regional autistic societies.
The British Psychological Society’s Psychology at Work report covers neurodiversity in the
workplace in greater depth (BPS, 2018).
Practitioner psychologists working with adults seeking employment should work to:
• Provide assessments of individual skills and potential challenges to ensure that work is
appropriate for the job-seeker’s intellectual, social and emotional needs.
• Engage with employers to promote the skills of individuals with autism and advise on how
to adapt the work environment and job demands to the needs of the autistic employee.
• Help employees with autism to use cognitive and psychological strategies to cope with the
practical and social requirements of the job.
• Provide (or identify alternative sources of) in-work support for autistic employees as
necessary to ensure job success.
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Working with autism
CHAPTER 7
Autism and the criminal
justice system
7. Autism and the criminal

justice system
There is no consistent evidence that shows an association between autism and offending
behaviour. However, if crimes are committed by people with autism they can often be related to
lack of social understanding, rigid belief systems or obsessional interests (Helverschou et al.,
2018; King & Murphy, 2014). Without informed guidance and support, accurate risk assessment
and the management and treatment of people with autism who commit offences may cause
disproportionate challenges for criminal justice agencies.
Autistic individuals’ reactions after committing a crime may be idiosyncratic. Some fail to show
any remorse, insisting that their actions were justified. Others readily confess to offences, even
those they have not been charged with. People with autism can be vulnerable to the influence of
others whose approval, friendship or attention they crave and thus can become involved in crime
on the instigation of their peers, failing to understand the full implications of their actions. Some
people with autism report responding well to prison regimes where the clear structure and routine
appeals to them. Others find the prison environment deeply traumatic.
Psychologists can play an important role in identifying how the core characteristics of autism
can influence offending behaviours. Practitioner psychologists working in forensic settings can
contribute to ensuring that individuals with autism are treated in ways that take best account of
their condition. They may be able to provide guidance and training for front line services working
in police custody to understand the presentation of individuals with autism. In this respect, the
use of ‘Autism Alert Cards’ for those who may come into contact with police as a result of their
behaviour may be useful. Post-conviction, practitioner psychologists can advise about ‘reasonable
adjustments’ that may be required throughout police questioning and trial proceedings (Norris et
al., 2020), and for those serving prison or community sentences.
It is also important to consider the needs of victims and witnesses with autism who are
involved in the criminal justice process. Adaptions can be made in the way such individuals are
communicated with to take better account of their condition (Maras et al., 2020).
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Working with autism
7.1 ASSESSMENT
Some people are diagnosed with autism only when they come into contact with the Criminal
Justice System (CJS) (Helverschou et al., 2018). Ideally there might be greater screening for
autism undertaken in police custody settings to identify individuals who may be undiagnosed.
Even where autism is indicated in medical or other records, earlier diagnoses may have been
inconclusive, inconsistent or derived from non-standardised assessment methods. It may be
necessary to clarify previous diagnostic information to ensure it is accurate and relevant to the
criminal activity.
NICE Guidelines recommend that an autism diagnosis should include a detailed developmental
history from a parent, carer or close family member (NICE, 2016). However, individuals with
autism who become involved with the CJS may have problematic relationships with family
members, making access to this kind of background information not possible. Even where
there is access to family members, forensic psychological assessments often do not utilise this
source of information, although it should be encouraged where feasible. If a full developmental
history is unavailable, educational, social services or employment records may provide relevant
information. NICE suggestions for the identification of autism in adults can also be useful,
especially if supplemented by screening or other methods used to identify the presence of autistic
symptoms (see NICE, 2016; and Section 3 on diagnosis). In forensic hospital or custodial settings
accurate assessment can be enhanced by interviewing key staff involved with the individual
in the establishment (personal officer, primary nurse, education staff, occupational activities
coordinator etc.).
7.2 INTERVENTION
Incorrect or missed diagnoses can result in an individual with autism being treated in an
inappropriate or ineffective way within the CJS. Interventions that require offenders with autism
to demonstrate empathy or to take the victims’ perspective, or that involve group interactions,
for example non-adapted group work programmes or therapeutic communities, may be very
challenging for the individual and unlikely to be successful. Failure to respond to such
interventions can result in a harsher prison regime or parole being refused (Bates, 2016; Higgs &
Carter, 2015).
The evidence base for the effectiveness of interventions for offenders with autism is limited (King
& Murphy, 2013; Melvin et al., 2017). Practitioner psychologists therefore play an important
role in identifying how the core characteristics of autism can influence and explain offending
behaviours. They can also recommend methods of case management and intervention that suit
each individual case. Psycho-education may also help people with autism to understand more
about their condition and ways of avoiding situations that could lead to future offending.
Standard risk assessment protocols often prove inappropriate or inaccurate for offenders with
autism and adapted risk assessment protocols need to be devised and utilised (Westphal & Allely,
2019). Such methodologies are helpful to evaluate how autism might impact upon or explain the
risk of harm presented by the individual and ways in which this risk can be reduced. In addition,
psychologists can provide autism awareness training for staff working within the CJS. If possible it
is most inclusive to seek input from ‘experts by experience’ trainers who themselves have autism
and who have had experience of the CJS, either professionally or personally.
44
Working with autism
7 . 3 C O M P U L S O RY P S Y C H I AT R I C T R E AT M E N T

Part III of the Mental Health Act 2017 (in Scotland, refer to the Mental Health (Care and
Treatment) Scotland Act, 2003) allows ‘mentally disordered’ defendants (i.e. those with ‘any
disorder or disability of the mind’, including people with autism) to be diverted from the criminal
justice system into compulsory treatment by the healthcare system, either before or after
conviction. Treatment in a Medium Secure Unit or Special Hospital can be more appropriate than
prison sentences for people with autism who have committed serious offences, although there
are also challenges in accessing correct assessment and treatment approaches (Murphy, 2020).
Practitioner psychologists working in these settings can contribute to a multi-agency approach that
ensures that an individual’s needs are correctly identified and that appropriate treatment allows
the person to progress quickly through the secure mental health system. People with autism can
find it difficult to transfer learning from a hospital environment to the real world and practitioner
psychologists can assist in this transition.
Practitioner psychologists working in forensic settings should work to:
• Ensure appropriate assessment and, if necessary, facilitate diagnosis of offenders who may
have autism.
• Adapt treatment approaches to ensure that people with autism are not ‘set up to fail’
by being required to undertake interventions that are inherently challenging given
their condition.
• Support colleagues in the criminal justice system to take a more holistic view of individuals
with autism to understand their specific needs and behaviours.
• Where possible provide training in autism awareness and basic autism management skills
(assessment, recognition, interventions and care and support).
45
Working with autism
CHAPTER 8
Future directions for
research and support
8. Future directions for

research and support
Despite growing interest and research, the evidence base around how best to support people
with autism, or which interventions are most effective, needs to be improved. More research is
particularly needed on:
• The most effective models of care for people with autism at different stages of life or different
levels of autism, different abilities and diversity;
• How to reduce the vulnerability of autistic people to different mental and physical health
conditions;
• How to increase the general wellbeing of people with autism;
• The experiences of girls and women with autism; and
• Autism in older people.
Practitioner and research psychologists are already playing a key role in carrying out research to
build the scientific evidence base about what works best for people with autism at various stages
in their lives. Psychological science has been incorporated into national clinical guidance, such as
NICE (2016, 2017) and SIGN (2016), which all psychologists working with people with autism
should follow in their practice.
In any developing area of scientific physical or mental health research, as new evidence comes
to light and gaps in knowledge are filled, guidance must be updated accordingly. It is the role
of psychologists, research institutions and the BPS to ensure that the research base continues
to develop to fill gaps in knowledge and that emerging evidence is incorporated into national
guidelines.
47
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Working

This guidance was prepared by the Autism Task and

The membership of the Task and Finish Group was:

Patricia Howlin (Chair) – Emeritus Professor Clinical

Elisa Back – Developmental Psychologist

Andrew Bates – Forensic Psychologist

Kevin Conallen, Child and Adolescent Psychologist.

Jason Crabtree, Clinical Psychologist

Maria Daves-Hales, Counselling Psychologist

Sinead Hannan, Clinical Psychologist

Marie-Louise Hughes, Educational Psychologist

Katie Hunt, Clinical Psychologist

Barry Ingham, Clinical Psychologist

Glenys Jones, Educational Psychologist

Rita Jordan, Professor in Autism Studies

Tommy MacKay, Educational Psychologist

Lynda Meina, Clinical and Forensic Psychologist

Lindsay O’Dell, Developmental Psychologist

The Group would particularly like to thank those with lived

BPS staff support was provided by: Lisa Morrison Coulthard

© 2021 The British Psychological Society

WOR K ING WIT H AUT ISM

2. Talking about autism 9

3. Assessment, diagnosis and formulation 12

4. Autism in children and young people 15

7. Autism and the criminal justice system 43

8. Future directions for research and support 47

WOR K ING WIT H AUT ISM

1.2 A DIVERSE CONDITION

1.3 A LACK OF SERVICE PROVISION

WOR K ING WIT H AUT ISM

2.1 PERSON-FIRST LANGUAGE

3.1 ASSESSMENT AND DIAGNOSIS

3.1.1 ASSESSMENT TOOLS

WOR K ING WIT H AUT ISM

BEST PRACTICE GUIDANCE

Practitioner psychologists, wherever they are based, should work to:

• Promote a formulation approach to autism assessments and diagnostic processes.

Autism in children and

WOR K ING WIT H AUT ISM

• Not respond to their name by 12 months of age

• Not play ‘pretend’ games (pretend to ‘feed’ a doll) by 18 months

• Avoid eye contact and want to be alone

• Have delayed speech and language skills

• Repeat words or phrases over and over (echolalia)

• Give unrelated answers to questions

• Get upset by minor changes

• Have obsessive interests

• Flap their hands, rock their body, or spin in circles

BEST PRACTICE GUIDANCE

Practitioner psychologists should work to:

WOR K ING WIT H AUT ISM

4.2.1 GIRLS AND WOMEN

BEST PRACTICE GUIDANCE

Practitioner psychologists should work to:

• Promote better awareness of possible gender bias in:

4.2.3 LOOKED-AFTER CHILDREN

BEST PRACTICE GUIDANCE

Practitioner psychologists should work to: