When Autism And Other Mental Disorders Converge: Recognizing And Responding

Editor's note: This text-based course is a transcript of the webinar, When Autism and Other Mental Disorders Converge: Recognizing and Responding, presented by Debora Davidson, PhD, OTR/L.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

• After this course, participants will be able to differentiate diagnostic features of autism spectrum disorder from those of four commonly co-occurring mental illnesses.
• After this course, participants will be able to analyze ways that co-occurring mental disorders may affect clients’ participation in therapy, education, work, and home life.
• After this course, participants will be able to analyze ways to screen and refer clients to mental health services and educate clients and families on how to access crisis services as needed.

Introduction

Thank you for the kind words of introduction. I’ve worked with individuals across various mental health and educational settings. These days, I maintain a small independent practice that serves young adults who are neurodivergent and striving to achieve their goals for independent living, education, and meaningful careers. I also mentor occupational therapists interested in developing a practice similar to mine.

I’m glad you’re here, because the odds are overwhelming that you have worked—and will work—with clients, patients, and family members who are experiencing symptoms of one or more mental disorders. 

Before We Jump In...

Before we jump in, I’d like to take a moment to explain how I’m framing today’s talk. I want to go on the record by saying that not all individuals who meet the diagnostic criteria for mental disorders automatically require therapeutic intervention. Many people self-identify as neurodivergent and do not need continuous—or even occasional—therapeutic services for mental health reasons.

Today, we’re focusing on our roles as occupational therapy practitioners and physical therapists, specifically on how we can be helpful to our clients and patients experiencing functional and emotional distress. These are individuals who may be dealing with a mental disorder that does require attention, and our work can be an essential part of supporting their well-being and participation in daily life.

Quick Facts

Here are some compelling facts to consider. Forty-six percent of Americans will meet the diagnostic criteria for a mental condition at some point in their lives. In any given year, 20% of Americans will experience a diagnosable mental health condition. Additionally, individuals with autism spectrum disorders—referred to as ASD for the sake of brevity—are at an increased risk for a variety of co-occurring mental disorders.

Now let’s think about the prevalence of ASD as we currently understand it. This has been something of a moving target over time. When I began practicing in the 1980s, the prevalence rate of ASD was believed to be about 1 in 10,000 children. That number has changed significantly.

As you’re probably aware, the most recent estimates show that approximately 2.8% of 8-year-old children in the United States are identified as having ASD. That’s a substantial increase from the numbers we worked with decades ago. Why the rise? One explanation is that the diagnostic criteria have become broader, sensitive, and nuanced. Educators, pediatricians, and other professionals who interact regularly with children have also become more attuned to the presentation of ASD, which leads to more frequent referrals. And while those factors certainly contribute to the increase, it’s also possible that there has been an actual rise in incidence, though that remains definitively established.

Prevalence of ASD

ASD is more prevalent among boys than girls by a significant margin. However, this remains a work in progress, as there's growing interest and research focused on how ASD presents in girls and women. Emerging evidence suggests that the presentation may differ in subtle but important ways, meaning the current prevalence estimate of around 1.1% for girls may be underrepresented. This is an evolving area of study that continues to refine our understanding.

Lastly, it’s important to note that ASD is reported to occur across all racial, ethnic, and socioeconomic groups. It is a worldwide phenomenon, not limited to any region or population, further underscoring the need for broad, inclusive awareness and understanding.

Etiology of ASD

What causes ASD? The truth is, we don’t know for sure. While some strong indicators point to contributing factors, the exact reasons why some individuals have ASD remain not fully established.

Identifiable genetic patterns appear to play a role. Research has shown a strong familial component when we examine siblings, twins, and offspring. Some specific genotypes that may be associated with ASD have been identified. In addition, neuroanatomical differences have been found—certain areas of the brain may be more or less developed in individuals diagnosed with ASD. Some neurophysiological features seem to serve as potential markers.

Despite these findings, we still cannot definitively say what causes ASD. However, one thing that research has established is that parenting styles do not cause ASD. Decades ago, there was a damaging hypothesis that cold or unloving mothers were to blame for their child’s autism. That has been thoroughly debunked. Likewise, there is a robust body of scientific literature confirming that vaccinations do not cause ASD. These conclusions are essential not only for guiding research but also for reducing stigma and misinformation.

Presentation

How does autism present? What does it look like? I’ve paraphrased the main features listed in the DSM—the Diagnostic and Statistical Manual of Mental Disorders—to provide a clearer picture.

The first key feature is a persistent deficit in social communication and social interaction across multiple settings. In other words, the individual experiences some difficulty engaging with others. It’s important to remember that autism exists on a spectrum, and the way it presents can range from very subtle to very noticeable signs and behaviors. This variability is reflected in some case examples we’ll discuss later.

The second major feature involves a restricted, repetitive pattern of behavior, interests, and/or activities. A person with ASD may value their routines more than most people. They may prefer to focus on topics or activities they find particularly interesting and might talk about those interests with a level of detail or frequency that’s unexpected in typical social interactions. Changes in routine or environment may be very upsetting or difficult for them to manage.

These symptoms typically present in the early developmental period, though they might not always be diagnosed at that time, especially now that we recognize a broader spectrum of autistic features. We generally understand that these characteristics are present from birth and shape how the person grows and interacts with the world.

Finally, to meet the diagnostic criteria, these symptoms must cause significant impairment in social, occupational, or other important areas of daily functioning. Because ASD is a wide spectrum, many people—whether or not they identify as neurodivergent or as having autism—might share some of these traits. However, the distinction lies in how these characteristics interfere with day-to-day life, overall happiness, and functional independence.

Prevalence of Mental Disorders: General vs. ASD

This is where things get very interesting for me, and it forms the backbone of our discussion today. What we’re looking at is a comparison of the prevalence of several well-known mental disorders between the general population—the lower, gray bar on the chart—and individuals with Autism Spectrum Disorder.

As you can see, across the board, people with ASD are more at risk for experiencing a range of mental health conditions. This includes anxiety, depression, obsessive-compulsive disorder, catatonia, schizophrenia, bipolar disorder, and sleep disorders.

This data highlights a crucial point: individuals with ASD represent a group at significantly higher risk of experiencing mental disorders. Understanding this increased vulnerability is essential to how we think about our roles as therapists—how we assess, support, and intervene in meaningful and sensitive ways that address both the core features of autism and the co-occurring emotional or psychiatric challenges that may arise.

Why are those with ASD more likely to experience mental disorders?

There are a few significant reasons. First, we know that there are genetic overlaps between some of the gene differences associated with ASD and those related to other mental disorders. For example, there is a strong correlation and shared genetic underpinnings between Attention Deficit Disorder and ASD. Similarly, substantial overlap has been found between Obsessive-Compulsive Disorder and ASD. These conditions often seem to “hold hands,” appearing together or sharing features that suggest a biological connection.

Another critical factor is the frequency and severity of stress experiences among people with ASD. This is one of the ways a diagnosis may initially come to light—through visible distress in response to everyday situations. Although not listed as a formal diagnostic criterion in the DSM, the accompanying text acknowledges that many individuals with ASD experience sensory processing differences. This means their nervous systems may respond more strongly to stimuli others might not even register as challenging. Loud, visually overwhelming, or socially complex environments can trigger intense reactions.

Their nervous systems may become triggered more easily and stay in that heightened, overwhelmed state for extended periods. From my experience working with many individuals who have ASD, I can say that this heightened sensitivity is a standard part of the package. These people are more prone to stress and have to cope with difficult or uncomfortable situations from a very young age.

On top of that—and very unjustly—individuals with ASD often endure traumatizing life experiences simply because of how society is structured. The rates of bullying among children and adolescents with ASD are incredibly high. The literature is unequivocal on this. Many people with ASD experience exclusion, teasing, and mistreatment. They often struggle in relationships with authority figures—teachers, sometimes parents, and indeed community members—who may not understand or tolerate their behaviors and needs. This lack of acceptance and understanding leads to repeated social injuries that accumulate over time and further increase their vulnerability to mental health challenges.

Why Should Practitioners Know This?

Why is it important for us to know this information? I’m very aware that most of the people attending this workshop probably don’t work in primarily mental health settings. That’s why I’m delighted you’re here—because your presence shows that you’re among the more open-minded professionals who recognize the relevance of mental health, even if it’s not your primary area of practice.

We all need to understand these issues because sometimes our client behaves in irrational, unexpected, or confusing ways. When that happens, it can throw you off and disrupt the flow of your session. But if you can pause and consider that the person in front of you may be dealing with a mental or cognitive difference, and if you can briefly shift your frame of reference to explore what might be happening beneath the surface, that understanding can change everything.

You’ll be a better therapist for it. This perspective can help you disengage from feeling locked in a power struggle with your client. Instead of becoming frustrated or discouraged, ask yourself, “What’s different here? What might I be missing?” You will likely feel more compassionate and centered if you can make that shift. That shift in mindset not only benefits your clients, it can also help reduce your stress on the job.

Another critical reason to be informed is that you may be the first—and possibly the only—to recognize that someone needs mental health support. And that carries real responsibility.

Here’s a sobering fact: In the United States, 55% of adults with a diagnosable mental disorder will never receive a mental health evaluation or treatment in their lifetimes. There are several reasons for this. One is the shortage of mental health practitioners and the limited access to services in many areas. Another is stigma. Many people are afraid to seek help because acknowledging a mental disorder is not culturally encouraged—it’s often associated with shame or weakness, and it can be incredibly distressing to confront. And then there’s the issue of cost and coverage; for many people, insurance doesn’t adequately support the care they need.

So you might be it. Your awareness, sensitivity, and willingness to see beyond the surface can make a meaningful difference in someone’s life, sometimes even life-saving.

Effective Screening & Referral Can Improve and Save Lives

So it’s important that all of us, whether we work primarily in a mental health setting or other environments, are ready and willing to be screeners. We do have the potential to save lives, and we will talk more about that today.

As an occupational therapist, I see myself in a particularly strong position to serve in this role. When I work with clients, they are often at ease. Our sessions are typically engaging, even enjoyable, and because of that, people may feel less guarded with me than they would with their physician. They may not feel the same need to be defensive or protective of themselves. I also get to see clients repeatedly—across different sessions, over time, in various settings, and engaging in a variety of activities with different people. That continuity gives me the opportunity to observe a wide range of behaviors and emotional states. I get to see them when they’re doing well and when they’re under stress, and that provides a rich perspective for screening.

In my role as an OT, I consider myself to be skilled at recognizing the key features that warrant attention. I’m trained to observe subtle behavioral cues—things a doctor might not have the time or context to catch in a 10- or 15-minute exam room visit. This kind of detailed, person-centered observation is one of the strengths of our profession.

And I’m deeply motivated to screen and help people get connected to appropriate care. Unlike autism, which is a neurodevelopmental condition with few medical “fixes,” many of the co-occurring mental illnesses we’re going to talk about today do have effective medical and therapeutic treatments. It’s powerful to think that by recognizing and responding to these issues early, we could help relieve suffering. We could help someone experience more joy, more ease, and more ability to be their full, authentic self. That’s a compelling reason to do this work—and to do it well.

Problems With Accessing Diagnosis and Intervention

There are many barriers when it comes to accessing diagnosis and intervention, and unfortunately, we do not currently have a robust or well-integrated mental health system in our country. This reality makes it even more critical for health and therapeutic professionals to be aware and proactive.

Another challenge is that when someone carries a diagnosis of a developmental disorder—such as autism or another syndrome—there is a tendency for everything they do to be interpreted through that lens. Every behavior, every challenge, every emotional expression can get dismissed or explained away with, “Oh, well, that’s because they have autism.” But that approach is limiting and, quite frankly, inaccurate. The mental illnesses we’ll be discussing today—depression, anxiety, bipolar disorder, obsessive-compulsive disorder, and others—are not autism. They are separate conditions. They can coexist with autism, they can overlap in presentation, and they can complicate someone’s life, but they are not the same. And we mustn’t overlook or dismiss these conditions just because someone has a developmental diagnosis.

This isn’t always easy. Many of the traits we associate with ASD resemble, or are variants of, traits we see in other mental illnesses. That’s part of what makes this work complex. It can be hard to tease apart where one set of symptoms ends and another begins. But the good news is that we can improve at this. Through observation, reflection, and good screening practices, we can improve our ability to recognize what our clients are experiencing—and help them get the support they need.

Costs of Unidentified MH Needs

What happens when we don’t help people access the mental health care they need? They suffer. To live with symptoms of mental illness is often to live in a state of ongoing anguish. People feel broken. They know they’re not functioning at their full potential, and that awareness can be incredibly frustrating. They may know what they’re capable of, but can’t seem to access it. This leads to feelings of shame and isolation—feelings that are not necessary if the right kind of help is made available.

From a prognostic standpoint, symptoms can worsen over time if left untreated. Mental health conditions can become more entrenched and more severe. People begin to lose the ability to fulfill their roles in life and participate in their occupations in the ways they would want to—and in many cases, the ways they inherently can do. Their potential gets blocked.

When I’m working with someone who is highly symptomatic, the therapeutic process becomes much less effective. It’s hard to absorb new learning or engage meaningfully in therapy when depression, anxiety, or other symptoms are dominating their mental space. It’s like trying to build something on a foundation that is constantly shifting beneath you.

As a result, people face decreased opportunities in their daily lives. They can’t consistently show up as their best selves, and this affects not only their progress but also their overall sense of well-being. Families suffer too. Support systems become strained and, in some cases, completely burn out. I’ve had clients who were turned out of their family homes—not because they weren’t loved, but because their symptoms had made day-to-day life so difficult that it became unbearable for everyone involved. And the tragedy is, much of that could be helped.

There are effective medical and therapeutic treatments available. And yet, when care isn’t accessed, the consequences can be devastating. People with severe and chronic mental illness also tend to have shorter lifespans. Sometimes that’s due to suicide, but even when suicide isn’t part of the picture, they still face reduced life expectancy because of the way mental illness intersects with other health conditions. The cumulative toll on both physical and emotional health is very real. And it's avoidable—with the proper support.

Ways to Discern Signs of Mental Health Disorders

Today, we’re going to focus on how to recognize some of the signs of various mental disorders and how these might present during your sessions. We’ll talk about how these signs might look in real time—how they show up in interaction, participation, and response to activity. And just as importantly, we’ll explore how to begin teasing apart which behaviors may stem from autism spectrum disorder and which ones might point to something more, something co-occurring that deserves separate attention.

This is nuanced work. It requires us to be observant, reflective, and willing to reconsider our initial impressions. But by sharpening our skills in this area, we can become more effective in recognizing our clients' distress and more attuned to how best to support them, both as therapists and as potential gateways to further care.

Verynice Rehabilitation & Wellness Clinic

In addition to everything we’ve already covered, I invite you to join me in imagining a new setting—a new job. We're all going to work together at a place I’ve called the Very Nice Rehabilitation and Wellness Clinic. It’s a beautiful facility, a large and welcoming building where we have access to an ideal range of services and professionals. Picture this: occupational therapy, physical therapy, speech-language pathology, clinical nurse practitioners, Ph.D.-level psychologists, medical doctors, master’s-level social workers, and licensed clinical social workers—all working side by side in this interdisciplinary environment.

I’ve created this setting for us because I want to use it to illustrate ideal conditions. I know that most of us don’t work in environments like this—myself included—but starting from this idealized framework helps us explore what’s possible. From there, we can shift our focus to the more common reality: how we adapt and continue to do good work in settings that may lack these kinds of integrated supports.

At Very Nice, we provide outpatient services for children, adolescents, and adults, and our approach is truly interdisciplinary. We collaborate, communicate, and share expertise across disciplines to meet the broad range of physical and mental needs that our clients bring to us.

To explore these ideas more concretely, I like to use case stories. I’ve found case stories to be one of the most effective ways to share information. After all, that’s how we work. People don’t walk into our clinics with bullet points listing their challenges. They come in as full, complex individuals—shaped by families, experiences, and lives that are as layered as they are unique. And often, these individuals present with both neurodivergent traits and mental health concerns. Through case stories, we can develop a more realistic and compassionate understanding of what it looks like to support someone navigating both.

Case Story: Andrew

Andrew is 30 years old and identifies as he/him. He was diagnosed in early childhood with autism spectrum disorder, and later on with Attention Deficit Disorder. Throughout his school years, he received supportive services that helped him navigate academic and social challenges. As a child, he was very bright—he completed high school alongside his peers in his age group and even went on to college. He spent a few years in college and was doing well, but things started getting difficult.

Andrew decided to leave college to return after gaining some work experience. He held various jobs over the years—he's worked in delivery services, retail, and most recently, a library. He enjoyed his career at the library and had even started to consider pursuing a master’s degree in library science.

But in 2020, everything changed. Like many others, Andrew was laid off due to the COVID-19 pandemic. At that point, he returned to his parents’ home, and since then, he hasn’t been able to relaunch—he hasn’t returned to work or school. Despite his abilities and aspirations, he’s felt stuck, unable to regain momentum.

He’s coming to Very Nice Rehabilitation and Wellness Clinic for physical therapy. He’s been dealing with significant knee and ankle pain, and he’s looking for help with that. That’s what brought him through the door today, but as we know, there may be more layers to explore as we get to know Andrew and understand the broader context of his life and challenges.

Andrew's Care at Verynice Rehabilitation

Andrew’s referral reads, “Please evaluate and treat for bilateral knee pain.” This is my favorite kind of referral, honestly, because it leaves space to make thoughtful decisions based on what we learn through the process. I should mention that I’m not a physical therapist, so some of you will catch that as we go along. I’m doing my best from an OT perspective, so thank you for bearing with me.

During the intake evaluation, the physical therapist observes that Andrew has been experiencing severe knee pain and inflammation for at least three weeks. In the interview, Andrew shares that this pain has become unmanageable, despite his efforts to manage it on his own. Importantly, he arrived at the clinic independently—he drove himself, came in alone, and was able to respond to all questions appropriately. He is quiet and reserved, making only fleeting eye contact, and seems shy.

Interestingly, if the ASD diagnosis hadn’t been documented in his chart, the PT might not have suspected it. Andrew presents as a low-key, independent 30-year-old. There’s nothing immediately striking that would point to autism or ADD based on surface-level interaction.

As the PT continues the interview, a clearer picture begins to emerge. Andrew shares that he has been running more than 10 miles daily, every day, for over four years. He does not just run—he runs while carrying a 50-pound weighted backpack. He’s had some intermittent issues with pain throughout that time, but has always managed to bounce back with self-care measures like heat and cold packs. This time, though, the pain has escalated beyond his ability to manage, and that’s what’s brought him in.

When the PT gently challenges him about the intensity of his routine, Andrew acknowledges that it’s probably more than what most people do. But he also explains that running, especially with the weight, helps him relax. It gives him a sense of control and achievement, and he’s proud of it. It’s not just exercise for him; it’s a way to regulate his emotions and feel competent in his body.

This detail is significant because it opens a window into how Andrew navigates his life, especially post-COVID, after losing his job and structure. It starts to raise questions for us, not just about physical overuse injuries, but about the role this intense routine might be playing in his emotional regulation, his mental health, and how he’s trying to cope with the challenges he’s facing.

Andrew's Very Bad Day: PT Evaluation

So we move into the evaluation, and Andrew reports that his pain levels are consistently present—he rates it as a 5 out of 10 at rest, a 6 when walking, and an 8 when running. He describes the pain as constant, without any true relief. His active and passive range of motion is decreased bilaterally, due to joint swelling and inflammation. He’s been trying to manage it himself, using cold packs, heat, and Tylenol, but this time, those strategies haven’t brought any improvement.

The physical therapist administers the IKDC Subjective Knee Evaluation, and Andrew scores a 30, which is clinically significant and indicates substantial functional limitation.

Then comes the stair climb test. The PT explains the task, guiding Andrew over to the stairs. The moment the instructions start, Andrew interrupts, saying he needs to use the bathroom—and then he leaves. But he doesn’t come back.

At first, the PT waits, assuming Andrew will return shortly. The bathroom isn’t far, and it’s not unusual for clients to step away briefly. But the minutes pass, and then a colleague enters and says, “Hey, I think you need to come out here—I think this is your patient.”

Stepping into the hallway, the PT finds Andrew not in the bathroom, but wedged into the recessed niche in the wall where the drinking fountain is. Andrew is visibly distressed—tears are streaming down his face, his entire body is trembling, and he’s gently rocking, moving his head from side to side, bumping it softly against the wall behind him. Through the tears, he repeats, “I’m useless, I’m useless. I wish I were dead. I’m useless.”

This is not our typical session. This moment takes us far beyond orthopedic evaluation. It reveals the intense emotional distress that’s been simmering beneath the surface. It challenges us to step outside the structured flow of the physical therapy assessment and confront the reality of someone who is in deep psychological pain—pain that has been hidden beneath a quiet, cooperative demeanor until now.

What we see isn’t just the product of inflamed joints or physical overexertion. It’s a crisis point—a combination of prolonged emotional burden, self-perception, and likely undiagnosed or untreated mental health issues that have reached a breaking point. And this is where our broader clinical lens becomes essential.

Is Crisis Intervention Needed?

So we’re going to step away for just a moment into what I like to call a clinical reasoning moment. This is the time to center yourself, not to panic or let fear take over. Take a deep breath. You see a patient in deep distress, coming on suddenly and unexpectedly. These moments can feel disorienting, especially when they fall so far outside the usual rhythm of our sessions. But this is precisely where clear thinking and compassionate clinical judgment are essential.

In a moment like this, I ask myself a few grounding questions. First: Is the patient in acute distress? In this case, the answer is absolutely yes. It’s not typical for a 30-year-old man to have this kind of emotional episode in a public place, certainly not in a hallway niche in a clinic or at home. This behavior is a strong indicator that something serious is going on internally.

Next: Is the patient an immediate danger to themselves or others? From what we’re seeing here, the answer is probably not. Yes, Andrew is bumping his head, but it’s not forceful. He’s not trying to injure himself severely, nor is he threatening others. What we’re witnessing is vulnerability, not violence. He’s overwhelmed, not aggressive.

Then I ask: Is there a risk that they could become a danger to themselves, others, or property? And here, I have to be honest—I don’t know. Right now, it doesn’t seem like it. But things can escalate quickly, especially when someone is in such a heightened emotional state. So I keep that question open and continue to monitor, being ready to respond if the situation shifts.

Once I’ve answered those safety questions, I move to the next essential step: What could be happening here, and how can I help? That’s the heart of clinical reasoning. You step back, ground yourself in what you know about this person, and begin to piece together what might have led to this moment. Then, you start to consider how to support them effectively and compassionately because this is a human being who is not only in physical pain but also emotionally unraveling.

These situations are rare, but they’re powerful. How we respond can shape that session and the trust, recovery, and dignity of the person we’re trying to help.

ASD vs. Anxiety

• ASD
  • Avoid situations/ demands that have resulted in discomfort
  • Overwhelmed and confused by strong emotions
  • Have “meltdowns”
  • Engage in self-soothing/ “stimming”
  • At risk of running away or aggression
  • May self-medicate
  • In DSM-5, social anxiety is a diagnostic hallmark of ASD
• Anxiety
  • Avoid situations/demands that may trigger symptoms
  • Experience feelings of panic or extreme upset
  • May cry, flush, tremble, increase activity, perspire, withdraw, act angry
  • May abruptly exit stress-causing places, people, and demands
  • May self-medicate

We’re going to come back to helping Andrew in just a moment, but first, let’s take a step back and explore some crucial clinical understanding, specifically, the relationship between Autism Spectrum Disorder and anxiety. One of the thoughts that crossed my mind during Andrew’s episode is that he may have been experiencing an anxiety or panic attack. It’s hard to be certain in the moment, and even harder to tease out when the presentation is subtle. In Andrew’s case, it stood out because it was such a significant, intense shift from how he appeared earlier in the session. But in general, ASD and anxiety are closely linked—and unfortunately, they are very common companions.

These two conditions share a lot of overlapping features. For example, both individuals with ASD and those with anxiety often avoid situations or demands that cause discomfort. That’s something we all do to some degree, but for people with ASD, the range of things that provoke discomfort is often broader and more deeply felt. So the avoidance behavior may be more pervasive or pronounced.

People with ASD may also become extremely overwhelmed or confused by strong emotions. Similarly, people with anxiety disorders may experience moments or more extended periods of heightened emotional states—panic, dread, and intense upset. In ASD, we often refer to these moments of complete overwhelm as “meltdowns.” During a meltdown, the individual’s neurological and emotional systems are so overloaded that their functioning ability essentially shuts down. Anxiety or panic attacks can look similar: crying, flushed skin, sweating, activation of the autonomic nervous system. Sometimes, individuals may appear angry or reactive when, in fact, the underlying emotion is fear or anxiety.

Another point of overlap is self-stimulatory behavior, or “stimming,” in individuals with ASD. These are often repetitive movements or actions—body rocking, hand flapping, vocalizations, or tactile engagement—that can occur throughout the day. Sometimes, stimming is done for self-soothing, pleasure, or regulation, and it’s often harmless. With anxiety, on the other hand, we may observe repetitive movements too, but these are usually performed under duress, not for pleasure but for relief or to reduce acute distress.

Both individuals with ASD and those with anxiety may abruptly leave a room or situation if something becomes too uncomfortable. And both groups are also at increased risk of attempting self-medication with substances like alcohol, cannabis, or other drugs—an attempt to blunt the emotional overwhelm they experience regularly.

So my working theory, based on what we saw with Andrew, is that he was probably experiencing anxiety in that moment. As a clinician, I’m tuning in with my eyes and ears—observing and listening for those signs. His sudden departure and hiding behavior are clear red flags. But there are more subtle cues I also watch for in clients who may be struggling with anxiety outside of an acute crisis. For example, a person might say things like, “I can’t do this,” or “I’m not good at this,” or “This is impossible for me.” That kind of self-deprecating language, especially when it becomes a theme, can point toward chronic anxiety.

I’ve also had clients who frequently missed or were very late for appointments—not because they didn’t care, but because the anxiety made it incredibly hard for them to get out the door. I remember one client I worked with while practicing cooking skills in his home. He appeared relatively composed on the surface—his facial expression was neutral and he didn’t seem upset—but the perspiration was dripping from his hair, and his hands trembled. The anxiety he was experiencing was intense, even though it wasn’t outwardly verbalized. Just being in that space with me, doing an activity where he didn’t feel entirely competent, triggered that response.

Now, while we’re on the topic of comorbidities, I want to mention another pairing that’s important to keep in mind: ASD and depression. These two also frequently co-occur. Whether that’s something we’ll see with Andrew remains to be seen, but it’s on my radar to consider as we continue to work with him.

You can see how complex this all gets. The diagnostic features of ASD are already nuanced, and when layered with conditions like anxiety or depression, it becomes a careful balancing act of observation, interpretation, and compassion. Understanding these overlaps helps us provide more responsive, supportive care, especially when things don’t go according to plan.

ASD vs. Depression

• ASD
  • Narrow but intense interests
  • Limited social interaction
  • Affect and mood are difficult to read, may seem flat
  • Vocal tone flat/monotone or stilted
  • Self-care may not be valued
  • Sleep issues
• Depression
  • Interest and pleasure diminished
  • Reduced social interaction
  • Affect and mood: blunted, irritable, sad, tearful
  • Vocal tone flat
  • Decreased self-care
  • Sleeping patterns changed
  • Pessimism, Hopelessness
  • Self-depreciation

Let’s take a deeper look at how Autism Spectrum Disorder and depression can appear both similarly and differently, because this can inform our clinical reasoning, especially when working with clients like Andrew.

With ASD, we often see a narrow but intense focus on particular interests. Social interaction is typically limited, and affect and mood can be challenging to read. A person with ASD may seem emotionally flat, not because they lack emotion, but because their expression is more subdued or atypical. Their vocal tone may be monotone or stilted, and self-care may not be a high priority. Sleep issues are also common—difficulty falling, staying, or maintaining a consistent sleep cycle.

Depression, on the other hand, also brings diminished interest and reduced social engagement, but it comes with a different emotional and physiological texture. In depression, there is an apparent diminishment in the joy and pleasure people derive from things they usually enjoy. As an OT, I often ask clients, “What kinds of things do you like to do?” And what I hear is telling. They might list hobbies or interests, but it becomes clear they haven’t engaged in them in quite some time. A person might say, “I’ve always been a reader,” followed by, “but I haven’t been able to focus enough to read lately.” Or, “I used to play guitar,” and when I ask when they last played, the answer is often, “a few years ago.” The spark is gone, and the connection to these once-enjoyed activities has faded.

Social interaction often declines even further. While a person with ASD might already have a quieter social life, what I notice in depression is a change—a pulling back from even their typical baseline. The absence of contact with friends or family becomes a red flag for someone who's usually sociable.

Affect and mood in depression are also distinct. Affect is what we see—the visible expression of emotion. Mood is the internal emotional climate. In depression, affect is often blunted or flat, but it can also swing toward irritability, anger, sadness, or just a hollow numbness. In session, I may observe tearfulness or sudden flashes of irritation that weren’t typical for that person before. These are signs that call for closer observation and possibly screening.

Vocal tone is another tricky area. For someone with ASD, a flat vocal tone may be typical. But if a client who usually has a bit more animation in their speech suddenly sounds very flat, that’s something to note.

Changes in self-care are also common in depression. A client may arrive looking less groomed than usual—clothing is wrinkled or mismatched, hair unkempt, or they may even have body odor or signs of not bathing. Again, the key is noticing a change from their usual level of self-care.

Sleep changes are also critical to monitor. As mentioned earlier, people with ASD often have long-standing sleep challenges. But in depression, we look for changes, either sleeping less or more than usual. Insomnia can show up as trouble falling asleep or, more often in depression, waking up in the early morning hours and being unable to fall back asleep, frequently accompanied by a flood of anxious thoughts. On the other hand, some people with depression sleep excessively, napping through the day, feeling chronically fatigued no matter how much rest they get. In session, this might show up as constant yawning, sluggishness, and trouble with initiation.

Then come the cognitive and emotional themes: pessimism, hopelessness, helplessness. I often hear clients say things like, “This won’t work,” “There’s no point,” or “I’ll never be able to do this.” They might speak about themselves in harsh, self-critical ways: “I’m not capable,” “I’m stupid,” “I can’t do anything right.” These are deeply painful beliefs, and they are central to understanding the emotional burden the person is carrying.

One more feature not listed on the slide worth noting is appetite changes. During depression, some people lose their appetite altogether, while others may overeat, often reaching for comfort foods and eating less nutritiously than they might otherwise prefer.

All of these signs matter. We don’t necessarily jump to a diagnosis when we notice them, but we do take note. We listen. We observe. We begin to connect the dots. These clues may explain why therapy has stalled and guide us toward steps that support the client’s recovery more holistically. Our awareness and sensitivity to these details can make a meaningful difference in treatment outcomes and overall quality of life.

Next Steps

So, back to Andrew. He’s tucked into the niche by the drinking fountain. He’s crying, he’s shaking, and he’s clearly in deep emotional pain. He’s verbalizing feelings of worthlessness—he’s overwhelmed and vulnerable. So, what do we do?

First, we provide comfort and space. The goal is gently enticing him out of that niche without rushing or pressuring him. Bring him some tissues, offer a soft voice, and tell him it’s okay to cry here—that he’s not alone and his feelings are valid. A clinic can be a hard place for a person in distress, so if possible, I would try to relocate him to a quieter, more private space. Maybe it’s a conference room or an office where he doesn’t have to be confronted by the stairway that likely triggered or contributed to the meltdown.

Let him know there’s no hurry to “pull it together.” He can take the necessary time, and you’ll be there. This is also a moment when it may be appropriate to involve a team member or family member if one is available. That kind of support could be stabilizing; practically speaking, you may need help. You may have another patient scheduled or waiting already, so this becomes a moment of juggling—balancing the needs of others while staying present and steady for Andrew.

Once he’s calmer, I’d consider scheduling a follow-up session with Andrew and one or both of his parents. It’s important to talk through what happened, how it felt, and whether this emotional overwhelm is showing up in other areas of his life. That conversation may lead to the need for further support. If he already has a therapist, counselor, or psychiatrist, this could be the time to reconnect him with that provider and help facilitate the conversation about what he’s going through. As an OT, I often like to be part of those meetings when I can—it allows me to support the client holistically and strengthen the interdisciplinary team’s response.

If Andrew doesn’t already have a mental health provider, this is a clear opportunity to refer him for evaluation and support. Because let’s be honest—the behaviors we’ve observed, like the intense, ritualized running with a weighted pack despite pain, point to deeper emotional needs. These aren’t isolated orthopedic issues; they have roots in his mental and emotional health. And so, I consider it part of his PT plan—part of his overall care—to help him connect with the right mental health resources.

Lastly, I would want to document everything clearly and thoroughly—what happened, how he presented, what support was provided, and what the follow-up steps are—not just for legal or procedural reasons but to make sure that everyone on the team understands the seriousness of what occurred and that Andrew receives consistent, compassionate support from now on. This isn’t a side note to his care—it’s central.

Who Can Diagnose Mental Disorders?

As always, let’s step back and think about who’s on our team. I’ve set us up at Very Nice Rehabilitation and Wellness Clinic, where we benefit from an interdisciplinary team, including professionals specifically trained to address mental health needs. So when a client presents with possible signs of a mental disorder, we’re not expected to take on the full weight of diagnosis or treatment planning for that issue ourselves. And that’s good news—the onus is not on us.

As occupational therapy practitioners and physical therapists, our role is not to diagnose mental health conditions. That responsibility lies with specialists in the field. Psychiatrists—medical doctors with a specialty in mental health—are licensed to diagnose and prescribe treatment. Clinical psychologists, psychiatric clinical nurse practitioners, and licensed clinical social workers (LCSWs) are also trained to evaluate and diagnose mental disorders. Some licensed mental health counselors (LMHCs) and master’s-level social workers (MSWs) can also, though that often depends on state-specific licensure laws. It’s worth being familiar with your state’s statutes to know who has that authority in your local context.

The key takeaway is that we don’t have to figure this out alone. However, we play an essential role in recognizing when something seems off and knowing when to advocate for further evaluation. When I begin to suspect that a client may be struggling with anxiety, depression, or another mental health condition that is interfering with their daily function, I want to make sure that someone on the team—someone qualified to do a complete mental health evaluation—is brought in.

When we were talking about Andrew, for example, I was thinking about anxiety and depression, and how both of those conditions can be treated effectively. Some medications can dial down the overwhelming symptoms, and there are therapeutic interventions that can provide coping strategies and emotional relief. Helping a client connect to that kind of support is meaningful and creates space for the rest of their treatment to move forward.

Once a client feels more grounded—once their emotional pain has been acknowledged and addressed—the work we do in occupational or physical therapy can become more productive, goal-directed, and empowering. So, being aware of who’s on our team and what they bring to the table is not just helpful—it’s essential to providing the kind of integrated, compassionate care our clients deserve.

Case Story: Olive

Here’s another case story—this time about Olive.

Olive comes in with a dual diagnosis of Down syndrome and Autism Spectrum Disorder. That combination is relatively uncommon and immediately suggests a more complex developmental and behavioral profile. She’s lived with her parents her entire life, and you’re the occupational therapist on the case. The referral you receive says, “Please evaluate and treat for problems with ADLs.” A solid, straightforward referral—and honestly, one I’m always glad to accept. I enjoy working with people in their daily activities. It’s where we often see the most meaningful and empowering changes.

At intake, Olive presents with some concerning features. She’s not smiling. Her facial expression is flat, and she seems disengaged. The way she walks into the room is unusual—her knees and hips are slightly flexed, and she’s moving sideways rather than straight ahead. She’s holding her mother’s hand tightly, using her as an anchor, and she scoots with this odd gait pattern. Her body language suggests discomfort, insecurity, or possibly pain. Right away, it’s clear that Olive will need some support—not just with physical movement, but emotional regulation, communication, and the deeper layers of occupational engagement.

We know Olive has not been coming in to fine-tune basic ADLs from the start. Her presentation tells us a lot is going on beneath the surface. The way she moves, the way she connects—or doesn’t—and the expression on her face all point to potential challenges that span physical, emotional, sensory, and relational domains. This is where our skill set as OTPs shines: observing, decoding, and supporting the whole person.

As we begin to work with Olive, we’ll need to consider how her diagnoses interact. What role might sensory sensitivities play in her movement patterns or social presentation? Is she experiencing discomfort or anxiety that makes her reluctant to engage? Does she understand why she’s here and what we’re asking her to do? How can we meet her in a way that feels safe and builds trust?

This is the beginning of a much larger therapeutic process that requires patience, creativity, and collaboration with her family. Olive’s initial presentation may be quiet and withdrawn, but with the proper support, she can make meaningful progress in her daily living skills and overall quality of life.

Intake

From Olive’s history, you know that her measured IQ is around 45, placing her in the moderately impaired intellectual range. That sets a general framework for her developmental baseline, but doesn’t explain the sharp decline you’re seeing now. During your intake, Olive sits quietly. She doesn’t speak, and her facial expression remains flat. Her mom does most of the talking, and what she shares is concerning.

Mom tells you, “We don’t know why she’s lost what she could do. She used to be independent. All I had to do was make sure she had what she needed in the bathroom and in her closet and dresser, maybe remind her it was time to get dressed. But she would go in and get dressed—she liked being cute. She’d choose her outfits. She washed her hair and brushed her teeth. She’s been toilet-trained since preschool. And now? Now she needs reminders—or else she urinates on herself.”

Then Mom’s voice softens and cracks a little as she continues. “Olive was a little ball of fire. She volunteered at the animal shelter and the food bank at our church. She bowled. She made crafts. She loved family events and parties. She has a job at the sheltered workshop but hasn’t gone in for at least two months. She’s always been easy. She talked to us and was shy with strangers, but at home, she was the life of the party. Now I have to help her with everything. I feel like we’ve gone back to when she was a toddler. Only now, she’s sad. She wasn’t sad when she was a toddler. I want our Oll back.”

This is where your clinical red flags should go up. You’re hearing about an acute decline. This isn’t a slow regression or a plateau that would be typical for someone with a lifelong developmental disability. This is a marked and sudden deterioration in function, mood, and personality over about two months. That is not typical for Down syndrome, nor for autism, and not even for the combination of the two. This change points toward something more that needs to be investigated urgently.

As her OTP, your next step is clear: you go back to her medical record and begin a full review. You need to know—has she had a recent illness? Has there been a change in medication? Are there any documented pain issues, sleep disruptions, behavioral incidents, or infections? Has she been seen by her primary care provider recently? Have there been any labs? Imaging? Has there been a psychiatric evaluation?

Because this is not a behavioral problem or a permanent developmental plateau, it’s something new. Something is going on that has dramatically affected Olive’s ability to function, her emotional regulation, and her engagement with daily life. That kind of sudden regression is not just unsettling—it’s “creepy,” as you noted. And it needs to be treated as a red-flag presentation for underlying medical or psychiatric pathology.

You're in a powerful position to initiate that deeper look, to advocate for Olive, to document this sudden functional decline, and to push for a coordinated medical workup. She deserves to be seen, thoroughly and compassionately, so that the people who love her can begin to understand what’s happening—and she can start to get the help she so clearly needs.

OT Evaluation

Olive has had a thorough medical and neurological workup, and nothing appears out of the ordinary—no seizures, no brain tumor, no acute medical crisis. That’s good news, of course, but also frustrating, because something has clearly changed in a profound and distressing way. When you observe her, you notice some subtle but telling behaviors. Sometimes she sits blankly, but other times she pulls her lips back tightly over her teeth and squints her eyes—a grimace that suggests discomfort, fear, or internal strain. Her gait is unusual: she takes small, sideways steps, knees and hips slightly flexed, as if she’s trying to widen her base of support, maybe to maintain balance or avoid falling. Her muscle tone is low-normal, consistent with Down syndrome. Still, when you attempt active or passive range of motion, she stiffens, not in a typical spastic way, but in a kind of protective resistance that raises your clinical curiosity.

During OT sessions, you set out familiar objects—things that invite grasping, reaching, manipulating. But Olive doesn’t engage. She just sits and looks. Even with verbal cues, she doesn’t respond. You have to offer gentle physical prompts to get her started. When she’s not being cued or directly engaged, you begin to see something else—patterned, repetitive hand and finger movements that aren’t purposeful or functional. They’re unusual, and they don’t serve an apparent task. Then you notice something else—marks on her hands.

Her mother explains: Olive has started biting herself at home. She also shares something deeper. “We’ve always built our lives around Olive,” she says. “She’s such an important part of our family. But now she’s all we do. Somebody has to be with her constantly. We have to help her with everything to ensure she stays safe and even just cared for.”

What do you do? You trust your instincts. You see that this is not a child who simply lost skills because of disuse or boredom or a plateau. Something happened. Something that cannot be explained by IQ, developmental disability, or even autism alone. This looks like trauma—whether psychological, emotional, or sensory in origin. Olive is communicating through her behavior, her withdrawal, her shutdown. Her motor resistance, her altered gait, her sensory defensiveness, and her self-injury are telling a story that hasn’t yet been put into words.

Your job, then, is not just to reteach skills, but to rebuild connection, familiarity, and safety. So you begin gently. You focus on sensory and functional motor activities that mirror daily life but do not overwhelm. You start with brushing hair in front of a mirror—talking about what you see, how it feels, what looks nice. You try toothbrushing, utensil use, hand washing. You bring in button boards, zipper boards—things that echo real tasks but in a low-pressure, play-like context. You might offer garments she can put on and fasten herself to re-engage her hands in something functional and rhythmic.

And because she seems so disconnected from her body—walking cautiously, avoiding movement, seeming afraid of gravity—you take a sensory integration approach. You introduce swinging on sensory equipment to help her reconnect with vestibular input in a safe, controlled way. You offer tactile exploration—maybe a bucket filled with rice and small hidden objects that invite her fingers to search, explore, and find surprises. You meet her at the intersection of function and sensory comfort, always gently, always at her pace.

And just as importantly, you support her mother. You recognize that this family is in crisis. You validate that what’s happening is real, serious, and complex. You offer hope through consistent, gentle interventions. You remind them that Olive’s story isn’t over—that people can come back from these kinds of regressions. That healing, while not always linear, is possible.

You don’t need to solve everything at once. What you’re doing is holding space—for trust to rebuild, for skills to re-emerge, and for Olive to begin to feel safe in her body and in her world again. It’s slow work. But it’s the kind of work that matters most.

Olive's Very Bad Moment- OT Intervention

Then, during session number three, Olive arrived with her mother, and we continued with the familiar routine, engaging in tabletop tasks and sensory-based activities. She appeared somewhat more responsive and seemed increasingly comfortable with both me and the therapeutic environment. I was beginning to feel encouraged, as if we were gaining some traction in our work together.

However, without warning, the tone of the session shifted dramatically. Olive abruptly stood up, adopting a very upright posture, and began moving rapidly through the clinic. She navigated between treatment tables quickly and suddenly began swiping objects off tabletops. Her actions were abrupt and startling. Her facial expression remained flat and impassive—she did not appear visibly upset or distressed.

As I approached to redirect her and positioned myself between Olive and the next area she was headed toward, she unexpectedly reached out and struck me across the face with a strong, sweeping motion. The slap was forceful and entirely unanticipated. The session instantly transitioned from one of quiet progress to one marked by significant behavioral dysregulation.

This unexpected escalation signaled a profound shift in Olive’s presentation and raised immediate concerns regarding her emotional and neurological regulation. It was a clear departure from her previous behavior and indicated a need for reassessment, safety planning, and further interdisciplinary consultation.

Is Crisis Intervention Needed?

Is crisis intervention needed? Is this patient in acute distress? She has certainly demonstrated an abrupt and significant shift in behavior. Is she an immediate danger to herself or others? At this point, she presents a threat to property. There is uncertainty about where this is heading. This is not typical behavior, and it is concerning. What steps should I take next?

Next Steps

Here we return to crisis management and support. At this point, I believe bringing Olive’s mother into the session is necessary. I’ll ask a team member to please locate and escort her in, and if possible, I’ll also request that another colleague join me in the room for additional support.

The goal now is to safely guide Olive into a less cluttered space—somewhere with fewer objects that she could potentially use to harm herself or others or damage property. Our immediate priority is to de-escalate the environment. I’ll work to reduce the sensory load by lowering the lighting, minimizing noise, and removing excess stimuli from the space.

Once her mother arrives, we’ll begin a conversation to gather context. I’ll ask if she’s seen this type of behavior before. Her mother will likely respond, “Yes, actually,” even though she may not have mentioned it previously. She may explain that Olive has occasionally exhibited sudden episodes resembling rage, even though her facial expression doesn’t appear angry, and that she has struck family members in those moments.

Catatonia With ASD

Now I’d like to introduce the topic of catatonia, so that you have it in your clinical repertoire to consider when working with specific individuals. Catatonia is not widely discussed in many professional circles, and often when it is mentioned, it’s only in passing or with limited context. However, in the past five to ten years, catatonia has become an increasingly important area of study, especially concerning individuals with Autism Spectrum Disorder (ASD). While it’s not exclusive to that population, we now recognize it more frequently where it may have been overlooked or misattributed.

Catatonia is a neuropsychological syndrome, and importantly, it has an acute onset. Given her sudden decline, these two checkboxes already seem relevant in Olive’s case.

From a motor standpoint, individuals with catatonia may exhibit either marked slowing or episodes of agitation. Some individuals become nearly motionless for extended periods—this may include a phenomenon called “waxy flexibility,” where the person remains in a fixed posture, even if someone else moves their limb into that position. For example, if a practitioner raises their arm, they may hold it there for an inordinate amount of time, much like a wax figure.

At the other extreme, catatonia can involve sudden bursts of psychomotor agitation, such as fleeing from school, home, or even jumping out of a car. In Olive’s case, she exhibited similar agitation while moving rapidly through the OT clinic. Posturing is also typical. This might include holding unusual positions or assuming abnormal limb placements for extended durations. Additionally, stereotypical movements—such as repetitive body rocking, head movement, or hand motions—may be observed, often without functional purpose aside from sensory input.

In terms of speech and language, many individuals experiencing catatonia become mute. Others may display echolalia, repeating phrases they’ve just heard, often multiple times. For instance, if you say, “Please sit down now,” they might echo back, “Please sit down now,” repeatedly.

Emotionally, affect is often difficult to read. Expressions may remain neutral or blank, although you might observe a grimace. It’s unclear whether this facial expression reflects affective experience, sensory input, or internal distress.

Aggressive behaviors may occur—either toward self or others. In Olive’s case, we’ve already seen examples of both: self-biting at home and striking others during sessions. There can also be signs of negativism, which may appear as resistance or doing the opposite of what’s requested. For example, if you ask someone to sit, they may stand or move away instead. This isn’t necessarily willful opposition, but rather a neurobehavioral feature of the syndrome.

Catatonia is often associated with trauma. While trauma can mean a significant event like a car accident or physical assault, it can also include less visible emotional traumas or sensory overwhelm. I’ve known clients who developed catatonia following traumatic events, including one young woman who required hospitalization after becoming catatonic in the aftermath of sexual assault.

The peak age of onset is typically between 15 and 19 years old, though it can occur outside of this range. Research shows that catatonia affects approximately 10.5% of individuals with ASD at some point, with higher prevalence among males—though we also know ASD is more commonly diagnosed in males overall.

There is also a form of catatonia called malignant catatonia, which constitutes a medical emergency. It involves dysregulation of the autonomic nervous system. In such cases, individuals may experience fever, tachycardia, rapid breathing, or disruptions in temperature regulation. These symptoms require immediate intervention in an emergency department.

Fortunately, catatonia is treatable. The most commonly used and effective treatment is antipsychotic medication, which can help individuals recover from catatonic episodes. In some cases, benzodiazepines have also been used with success, though the evidence is not as strong. Electroconvulsive therapy (ECT), typically associated with treatment-resistant depression, has also been shown to help individuals with catatonia. There appears to be some overlap in how ECT supports both conditions.

We must recognize catatonia when we see it. Many well-trained, competent clinicians are unfamiliar with it, which is why I wanted to take the time to bring it to your attention. You may encounter individuals in your practice who are referred for OT or PT for motor difficulties or regression in ADLs, when the root issue may actually be catatonia or a related neuropsychiatric syndrome.

As clinicians, we must be equipped not only to provide therapy but to recognize when a person may need something else—specifically, urgent or ongoing mental health care. Identifying catatonia or even suspecting it could be life-changing for the client and their family.

Clinician's Tool Kit

We need to have a strong understanding of Autism Spectrum Disorder, as well as sensory dysfunction—how they appear, how they relate, and importantly, how they differ. Recognizing the signs of catatonia is also essential now. In each of these cases—ASD, sensory processing challenges, and catatonia—we benefit greatly from having a clear reference point. That means knowing the person’s baseline: who they were before the symptoms appeared. This helps us detect what’s truly changed, what may be layered on top of their pre-existing condition or personality, and what might be treatable. Baseline knowledge provides the context we need to identify new or concerning developments accurately.

It’s also essential that we bring to our practice our therapeutic use of self and refined communication skills. Establishing a connection with someone who is experiencing significant psychiatric symptoms is a skill in and of itself. It requires the ability to be warm but not intrusive, to listen attentively while keeping our clinical curiosity active, and to hold space for ideas and observations that may not align with our usual caseload or expectations. This flexibility allows us to consider explanations that are less obvious or outside the typical scope of our practice.

Staying current with crisis management and safety training is equally important. While not every clinical setting offers this standard, I firmly believe that all practitioners should seek it out. It builds both competence and confidence in the moment we need it most.

We must also cultivate strong observation skills. Rather than getting caught up emotionally in a moment of client dysregulation, we can practice stepping back to assess: What is this behavior telling me? For example, instead of reacting with, “Oh no, what am I going to do?” we can shift our mindset to, “This person is agitated. This person is overwhelmed. What can I observe, and how can I respond?” This detachment doesn’t mean emotional coldness—it means clinical clarity.

Our judgment is key in these moments. We need to assess quickly: Is there a safety risk? What level of risk? What are my options to manage it effectively at this moment? Crucially, who can I bring in to support this situation?

Although I work independently in my practice, I still believe in the power of teamwork. I make it a point to connect with other professionals—to build a network before I actually need one. I meet people, form relationships, and maintain those connections so that when a complex situation arises, I have a team to lean on—even if we don’t share the same building.

When we work with individuals who have complex needs, the work becomes deeper, more layered, and, in many ways, more meaningful. It can also be more rewarding and, yes, more fun when we collaborate, think creatively, and build partnerships around care.

ASD vs. OCD

• ASD
  • Specific and intense interests
  • Adherence to patterns of routine and environment
  • Emotional attachment to specific objects or ideas
• OCD
  • Obsessional thoughts: distressing ideas, images, or impulses that enter a person's mind repeatedly and are often perceived to be senseless.
  • Compulsive acts or rituals: stereotyped behaviors that are not enjoyable or functional and are repeated over and over; actions are perceived to prevent an event that is in reality unlikely to occur.

Although I love case-based learning, I will briefly examine the case model because I think we can also approach these topics from a broader clinical perspective.

Approximately 9% of individuals with Autism Spectrum Disorder exhibit symptoms of Obsessive-Compulsive Disorder (OCD). The good news is that OCD symptoms can often be effectively treated with medication. The most commonly used medications are antidepressants, although others may also be prescribed depending on the individual’s needs. While it’s not within my scope as an occupational therapist to diagnose or prescribe, it is within my scope to screen and refer appropriately.

Let’s look at the overlap between ASD and OCD, as well as the key differences.

In ASD, individuals often have specific and intense interests that they frequently return to in thought and activity. They tend to find comfort and function in routine and familiar environments. Emotional attachment to specific objects, ideas, or rituals is common, and when these are disrupted, distress often follows.

OCD can resemble this, but it typically presents with some distinct characteristics. Individuals with OCD experience intrusive thoughts—obsessions—that can include distressing ideas, mental images, or impulses. These thoughts are often repetitive and unwanted. Unlike ASD, where rituals or patterns can be enjoyable or comforting, OCD thoughts are usually unpleasant and anxiety-inducing.

To manage this internal anxiety, the person may perform compulsive acts or rituals. These behaviors are not typically enjoyable or functional, and in severe cases, can consume a large portion of a person’s day—sometimes four to eight hours or more—draining their energy and disrupting daily function. These compulsions are meant to neutralize or prevent the feared outcomes linked to their intrusive thoughts, even if there is no logical connection between the two.

It's also worth noting that, like many neuropsychiatric conditions, OCD can exist on a spectrum. Some people have mild traits—quirky behaviors, personal rituals—that don’t interfere with daily life. But for others, the compulsions become debilitating.

What might OCD look like in a therapy session? You might observe a client who is unusually inflexible about scheduling, who insists on meeting at the exact same time or with the same therapist every session. This might extend to the structure of the session—they may become upset if the sequence of activities changes or if certain items (like a beanbag chair) are unavailable. I’ve worked with children who had to follow a particular ritual upon entering the room before they could transition into any other task. If that ritual was interrupted, they became significantly distressed.

You may also observe ritualistic and repetitive actions, such as frequent, excessive handwashing. A client might leave the session repeatedly to wash their hands, even if they appear clean and there’s no clear trigger. Some clients may repeatedly bring up the same topic or express ongoing fears, often unrelated to the context of the session.

One client I worked with had OCD that was triggered after a neighbor's house was broken into. Though the family talked about the incident calmly, it affected him deeply. He developed a ritual that involved avoiding the front door. Each time I came to pick him up, he would answer the front door, say, “I’ll be right out,” then close and lock it—only to emerge five to ten minutes later from the back of the house. His family tried to reason with him, but he remained locked into this new routine.

In other cases, you might see clients hyper-focused on order and cleanliness, who need the room arranged a certain way or can’t begin until the space is “just right.” Others might insist on using the same objects or performing tasks the same way every time.

These behaviors aren’t always harmful but can become barriers to participation, independence, and well-being. For example, one child I worked with in a therapeutic school setting, who had both ASD and a history of behavioral outbursts, had developed a strong interest in stickers. Initially, it was a minor preference—he liked to look at or collect them. But over time, this interest consumed the session. He couldn’t focus on anything else. Eventually, his medical provider prescribed medication for OCD symptoms, and it made a significant difference. The compulsive energy around stickers faded, and his range of interests returned. That moment was a massive relief because it opened the door for broader therapeutic work.

So, what should we do? We observe and document carefully. We approach clients with compassion and understanding, never shaming or invalidating their behaviors. We don’t say, “You can’t do that.” Instead, we engage the client and their family in a conversation: Is this happening in other settings? Is it interfering with daily life? Is it distressing to the client?

If yes, we can offer a referral to an appropriate provider and explain that effective treatments exist. We let the family know that there are medications that can help reduce the volume of repetitive, distressing thoughts. The goal is not to eliminate personality or preference, but to relieve the person of the internal suffering that drives the compulsive behavior. And in doing so, we help them re-engage with their broader life, interests, and goals.

Psychosis

Psychosis is a diagnosis, but it's also a subset of behaviors and experiences that people have neurobehaviorally. It can be a symptom of schizophrenia or bipolar disorder, sometimes of severe depression, and sometimes related to substance use. Psychosis is when a person has thoughts and experiences that are not based in our physical reality.

People may have delusions, which are irrational thoughts and beliefs that are often unpleasant. Sometimes, they’re pleasant—people may have delusions of grandiosity and feel very powerful, which can be enjoyable. But more often, delusions are fear-based, like believing someone is trying to poison them, that someone is listening to their thoughts, or that something is wrong inside their body, such as believing that something has invaded it.

Hallucinations are sensory experiences that are not based on external stimuli. A person might hear voices that are not there—voices talking to them, telling them what to do, or criticizing them. Hallucinations might be somatic, where the person feels like their organs are moving around in their body, or they might be visual. Visual hallucinations can happen in mental illness but are more often associated with the effects of drugs. Seeing things that are not visible to others would be an example.

Psychosis is severe, as you can imagine. That said, there is a subset of people who have auditory hallucinations that are not particularly distressing and who function pretty well. You would never guess that this is their experience unless they chose to share it. So it's important not to assume extreme pathology in every case.

You might observe that a client describes experiences or concerns that don’t make sense or don’t seem possible. I had a client tell me that someone had come into his condo, taken a prized watch his father gave him, embedded it into the wall, and that he could hear it ticking inside. He was punching holes in the wall to try to find it. Another client told me they believed someone was putting poison in their vitamin supplements. Someone else felt that when they parked their car in front of their house at night, someone would come, take the top off, move things around inside, and put it back on, believing they were being fooled but still insisting they knew it was happening. That’s a delusion.

You might observe people responding to experiences you cannot perceive. A person might look up at a spot in the room and smile, as if someone is speaking to them. They might speak aloud in response to voices, or reach out and appear to take things from the air. In those moments, it’s okay to ask gently, “What’s funny right now?” or “What’s going on?” to see if they’ll share what they’re experiencing.

You don’t want to play along. I don’t say, “What is he saying now?” Instead, I might say, “That sounds confusing, that someone is talking to you while I’m also talking. That must be hard to process.” Or, “That sounds scary, that you’re feeling like someone is taking the top off your car.” I try to remain grounded and supportive: “It’s confusing to hear that, but I want to understand how you’re feeling.”

Then, as always, assess: is the person in crisis, or is this just their experience? Are they open to a mental health evaluation? This is important, because psychosis is treatable. There are many medications available now—better than ever—that can help reduce or eliminate the distressing thoughts and voices.

Sleep: A Common Denominator of Wellness

Let’s talk about sleep. Sleep is the common denominator of wellness—it just is. Without adequate sleep, we can’t function for long, physically, emotionally, or cognitively. And for individuals with neurodivergence, especially those with Autism Spectrum Disorder, sleep problems are pervasive.

Many people with ASD have difficulty falling asleep. Others may fall asleep but struggle to maintain sleep for a sufficient duration. Even when they do sleep, the quality is often diminished. They may not cycle through all the normal sleep stages as expected and often have reduced REM sleep—the dreaming phase, which is critical for brain processing. REM sleep plays a vital role in learning, memory consolidation, emotional regulation, and the brain’s overall housekeeping functions. Without adequate sleep, engaging with the world socially, emotionally, and physically becomes significantly harder.

I’ve worked with several clients who have completely flipped day-night cycles. This is particularly common in individuals with ASD, often for complex reasons. For some, staying awake at night allows them to avoid daytime life's social demands and pressures. They find comfort and solitude in nighttime activities—video gaming, watching shows, or simply being in a quieter and less demanding world. Unlike the daytime routines often filled with expectations and sensory overload, these activities feel safe and self-directed.

That’s why it’s so important that we screen for and address sleep issues when working with clients who have ASD. I always begin with an interview, asking, “How is your sleep?” I don’t just leave it there—I dig deeper. I ask them to describe their typical day. I use what I call a “day line,” where I walk through their day with them, starting from when they usually get up.

Right away, I often get clues. If a client says, “It depends on the day… sometimes I wake up at 11 a.m., sometimes at 4 p.m.,” that tells me a lot. We’re likely dealing with a disrupted circadian rhythm, and that has far-reaching effects—not just on energy and alertness but also on motivation, mood, participation, and the person’s ability to engage meaningfully in therapy and life.

Sleep isn’t a side topic. It’s foundational. If we don’t explore it, we may miss a critical factor impacting everything else.

Sleep Screening & Referral

Some useful structured self-report tools are available. The Fabry article, which outlines several approaches, is included in your references and resources. You can also use a simple paper-and-pencil checklist with clients to help them describe their sleep patterns more clearly.

I always incorporate teaching about sleep hygiene strategies into my sessions. I share handouts—some that I’ve created myself, others that I’ve found online—to support clients in understanding how to improve their sleep. I won’t spend too much time reviewing the details of sleep hygiene, since most of us are already familiar with the basics.

That includes helping people go to bed consistently, keeping their bedroom dark and quiet, and avoiding multitasking in that space—using it only for sleep and dressing, not for work, entertainment, or other stimulating activities. Developing good sleep hygiene takes time and commitment. As therapists, a large part of our role can involve helping clients understand these strategies and stay motivated and supported long enough to implement them and see meaningful changes.

If needed, some clients may benefit from a referral to a sleep clinic, especially if there are signs of sleep apnea or if they are open to medical evaluation and support. That kind of referral can be very appropriate and valuable. Sleep is such a foundational occupation that addressing it can make a meaningful difference in many areas of life.

I want to add one more critical point. Although I haven’t focused on bipolar disorder in this presentation, sleep-related discussions can sometimes reveal symptoms of mania. If a client says something like, “I don’t need to sleep,” or describes staying awake for long periods—days at a time—that’s a red flag. If this is accompanied by other signs, such as grandiosity (“I can do anything—I’m amazing at everything”) or pressured, disorganized speech, that’s cause for serious concern. In those cases, I strongly recommend a referral to a psychiatrist.

Manic episodes are highly treatable with the proper medical support. People deserve relief and shouldn’t have to live with that kind of distress. However, they can be very painful for the person experiencing them and those around them.

Suicide Screening & Prevention

I'm going to transition now to talking about the most dangerous kind of mental health crisis, which is suicidality, and I feel passionate about this topic. I am a volunteer for a suicide prevention crisis text line, and I encourage all of my colleagues who are so inclined to consider volunteering for this kind of work. It's incredibly meaningful, and the training you receive can strengthen your clinical skills in significant ways.

We can save lives. It's not often that an occupational therapist gets to say, “I’ve saved a life,” but I know I have—by helping people through moments when they were seriously considering ending their own lives. The current literature indicates that individuals with autism spectrum disorder are two to eight times more likely to attempt or die by suicide than those in the general population. This is a very relevant topic for any practitioner working with clients who have ASD.

Clients with ASD are believed to be more prone to suicidal thoughts and behaviors due to a few key factors. Many experience intense emotional dysregulation that can be extremely uncomfortable and difficult to manage. In addition, individuals with ASD often report feeling like a burden to their families or society, especially given the higher rates of unemployment and undereducation within this population, even among those with significant potential.

When should you screen for suicide risk? You should do so if the person expresses a wish or intention to die. Think back to Andrew, who was tucked into the niche by the drinking fountain, crying, shaking, and saying, “I wish I were dead.” That counts. When someone says something like, “I just wish I weren’t here,” you should consider that an indicator of possible suicidal ideation. If the person expresses despair, statements like “Nothing can help,” or “I can’t do this” are signs. If they are visibly agitated and unable to calm down, that’s another reason to screen. If they have a history of self-harming behaviors such as cutting or choking, or if they’ve previously attempted suicide, the risk increases significantly. Exposure to someone else's suicide, especially if it was someone they knew well or identified with, is also a serious risk factor.

You don’t need to be a mental health expert to screen for suicide risk and offer some support. One tool I recommend is the Ask Suicide-Screening Questions (ASQ), available online through the National Institute of Mental Health. It’s a brief, four- to seven-question screener for primary care and other non-mental-health settings. It’s appropriate for youth through adulthood and consists of straightforward yes/no questions.

Here are the four basic questions:

1. In the past few weeks, have you wished you were dead?

2. In the past few weeks, have you felt that you or your family would be better off if you were dead?

3. In the past week, have you been having thoughts of killing yourself?

4. Have you ever tried to kill yourself?

If the answer to any of these is “yes,” you follow up with the acuity question: Are you having thoughts of killing yourself right now?

These are sensitive and tender questions, and I recommend starting with a softener. I usually say, “I'm concerned about your safety, and I need to ask you a few routine questions, okay?” That helps to frame the questions as standard practice. You’d be surprised how many people are relieved to have someone bring it up. Talking about it directly with someone willing to listen without judgment is often a relief.

So what happens if they say yes? That’s where many of us feel uncertain. It's hard to open a can if you're unsure what to do with what's inside. But you don’t have all the answers—you need to know how to get them to the next step.

Ideally, I would walk the person across the hall to a trusted colleague such as a social worker, psychologist, psychiatrist, or licensed counselor. But many of us don’t work at “Verynice Rehabilitation & Wellness Clinic,” and may not have available mental health colleagues. If you’re in a school setting, you might bring in the school counselor or nurse if they are equipped to speak with a student about suicidal thoughts. But in other settings, support may be harder to access immediately.

One important option you can always offer is access to suicide prevention services. There are several types: phone hotlines, text lines, and online chat options. The easiest way to connect is through 988—the national Suicide & Crisis Lifeline. Clients can call or text 988 or go online to 988lifeline.org. They will be connected to a trained volunteer (like me) or a mental health professional. That person will help guide them through their immediate distress, assess risk, and offer referrals and follow-up resources to connect them with local support.

Another essential action you can take is building a network of trusted local mental health providers in advance. I highly recommend this. It takes a little time and effort, but it’s well worth the investment. Contact social workers, psychologists, school counselors, psychiatrists, licensed professional counselors, or psychiatric nurse practitioners. Attend NAMI meetings or events—NAMI stands for the National Alliance on Mental Illness. It’s a great organization with public-facing resources and local chapters. Mental Health America is another excellent group to connect with. Get to know the professionals in your area and let them know about your work and your desire to be able to refer clients who are in crisis.

You can also explore Psychology Today’s online directory, which many clinicians use to list their practice and describe their client specialties. For example, if I search in Denver and use “Autism Spectrum Disorder” as a keyword, I can find professionals who enjoy working with neurodivergent clients. I want to know who they are, and I want to help my clients and their families find the right match.

Suicide is a very real and very preventable problem. And I can't think of anything more important—or more empowering—than helping someone survive one of the darkest periods in their life.

Summary

We’re coming up on the end of our time together. People with ASD can and do experience co-occurring mental illness—conditions that can cause significant emotional distress and interfere with daily functioning. As occupational and physical therapy practitioners, we are uniquely positioned to screen for these concerns and to make timely referrals—if we prepare ourselves to do so. I strongly encourage you to build that readiness into your practice.

Occupational therapy, in particular, has the training to evaluate and actively participate in mental health intervention teams. In many states, OTPs are licensed mental health providers. Even in states where that’s not the case, we can still partner closely with those who offer practical, hands-on support to ensure that mental health recommendations are implemented in the client’s everyday life. We serve as vital boots on the ground, bridging the gap between clinical insight and real-world application.

We are in a position to meet clients’ needs in ways that are both unique and life-changing. I know you’re already doing that every day at work. I hope that after today, you feel equipped with just a few more tools, a little more insight, and a more profound sense of empowerment to support those clients whose needs may not always be immediately visible, but are certainly not rare. As you’ve seen, these situations aren’t the exception—they’re relatively routine.

Exam Poll

1)What is the estimated prevalence of Autism Spectrum Disorder (ASD) among 8-year-old children across eleven CDC surveillance sites in the U.S., as of 2020?

A. 1.1%

B. 2.8%   Correct Answer

C. 3.8%

D. 4.3%

2)Populations with ASD are at increased risk of co-occurring mental disorders because...

A. They have had inadequate parenting.

B. They tend to isolate themselves from social and family support systems.

C. They suffer frequent trauma and have heightened stress responses.   Correct Answer

D. They typically refuse mental health care.

3)What was a notable behavior exhibited by Andrew during the Stair Climb Test at Verynice Rehabilitation that suggested a possible mental health component?

A. Refused to climb stairs due to knee pain

B. Performed test with high scores despite pain

C. Fled the evaluation due to emotional overwhelm   Correct Answer

D. Demonstrated aggressive behavior toward staff

4)Recognizing the possibility that Olive may have catatonia allows the OT practitioner to help this patient by:

A. Correctly diagnosing and treating this mental disorder

B. Referring her for psychiatric evaluation and intervention   Correct Answer

C. Initiating intensive sensory integration therapy

D. Educating family on ways to support ADLs at home

5)Which of the following observations is more characteristic of Obsessive-Compulsive Disorder (OCD) than Autism Spectrum Disorder (ASD)?

A. Emotional attachment to specific objects

B. Repetitive and nonfunctional thoughts and actions   Correct Answer

C. Inflexibility in routines and sessions

D. Specific and intense interests

References

See additional handout.