OARacle Newsletter

A huge industry exists to address the needs, activities, and preferences of older adults (65+) and those approaching older age (50+), a rapidly growing segment of our population. Autistic adults are among this growing population and, like everyone else, have emerging needs as they enter their 50s, 60s, and above. Some needs are like those of their non-autistic peers, and some are unique to the experiences of autism. Mental health providers who serve autistic adults are positioned to support them as they take steps to shape a healthy and meaningful life in their later years.

Defining a Model for Aging Well

In a recent review, Klein and Klinger drew from a current model of aging well for the general population and applied it to the lives of older autistic adults. Aging well for autistic adults means being healthy, active, and productive by taking steps to: 

• Preserve health and maintain activities of daily living
• Preserve cognitive and physical functioning, positive affect, and control (agency)
• Increase and maintain social participation and engagement

As a person who is considered older, I look at this list and say, “That looks very nice, but it is easier said than done.” Growing older and facing a decline in functioning is not a pleasant proposition for anyone. So, it is easy to imagine how the challenges faced by autistic people through every previous stage of life will make the latter years difficult as well. Mental health providers who serve older autistic adults can do a lot to help clients tap into their resiliency in the face of age-related challenges by using a strength-based approach and building coping skills. (See “Psychotherapy with older adults on the autism spectrum” in Autism Spectrum Disorder in Mid and Later Life)

Planning Treatment

The reason older autistic adults seek mental health treatment is often due to depression, anxiety, or PTSD, not for challenges related to autism. Many older autistic adults are still living with their parents or other family members, and they or their loved ones may seek help around caregiving concerns. For example, parents of an older autistic adult, who are quite old themselves, may come into therapy for help with anxiety about the future of their loved one. An older autistic adult will come into treatment because a family member who was instrumental in supporting them has passed away. In other cases, caregiver role reversal has occurred; an older autistic adult assumes the role of caregiver for an elderly parent. It is easy for families to let caregiving responsibilities fall onto that adult because they are more likely to remain unmarried and may already be living with or near the aging parent. In every case I have seen like this, the autistic adult is doing an excellent job caring for their loved one, while also suffering burnout because they are reluctant to ask others to help them.

Because cognitive behavioral therapy has an evidence base for treatment of depression, anxiety, and PTSD in the general and autistic population, it can help with older clients seeking help with stressful life circumstances, no matter what the diagnosis. Using an individualized approach, mental health providers can collaborate with older clients to make a treatment plan that will address the areas of life that each client finds most difficult.

Infusing positive psychology into this process means assessing for character strengths and resiliency factors that can be built upon. I have been struck by the courage and perseverance many of my older clients have demonstrated throughout their lives. Because educational and clinical supports were not as available back in the 1950s, 60s, and 70s, when they were young, they grew up having to find their own work-arounds and survival strategies. They have suffered and been traumatized, and that history must be respected, but they also have emerged with unique character strengths that I have not observed in their younger counterparts.

Promoting Healthy Habits

Mental health and physical health are interrelated, and perhaps this is more important than ever as one ages. So, mental health providers can help with promoting healthy habits and addressing barriers. Considering the model for aging well outlined above, mental health treatment plans may include goals such as the examples below. Note that these goals would be helpful for any older adult, not just autistic adults. However, each listed item has tips for designing goals with the unique needs of autistic adults and the barriers they may face in mind.

• Exercise regularly or be physically active, making adaptations for physical changes. Consider sensory issues and/or encourage unconventional ideas (repeatedly going up and down stairs, dancing in the living room) if the client doesn’t like traditional or popular exercises, such as jogging, pickle ball, gym memberships). Anything that reduces inactivity is beneficial (e.g., walking, hiking, swimming). Many activities can be done at home, if that is preferable. Yoga, strength training, gardening are good examples.
• Practice healthy eating. Consider food sensitivities and gastrointestinal issues; encourage connection with a good nutritionist or dietician who practices in a neuro-affirming way.
• Practice good sleep hygiene. Consider lifelong autism-related sleep problems and rule out sleep disorders, like sleep apnea, narcolepsy, or insomnia disorder. Encourage regular bedtime/wake time, using the bed only for sleep, and a wind-down hour before bedtime with no social media. The National Sleep Foundation maintains up-to-date guidance for sleep hygiene.
• Keep a routine for daily activities (bathing, dressing, grooming, household tasks), and make adaptations for physical changes to prolong independence. Consider executive function problems and design strategies with the client to match their learning style.
• Practice mentally stimulating activities that are enjoyable. Encourage pursuit of special interests and a variety of ways to engage in them. Guide the client through a values clarification exercise and do an inventory of activities that are aligned with their personal values and reinforce participation.
• Practice self-care for mental health. Teach some mindfulness-based strategies in session or refer the client to a secular mindfulness class. If a client has a faith practice, encourage them to continue.
• Enhance self-awareness and self-advocacy skills. Encourage pursuit of special interests and a variety of ways to engage in them. Problem-solving or creativity is one good way to engage. For someone has always loved math, suggest they join online math solution groups, for example. Or if they have a serious interest in botany, find online or in-person activities centering on botany.
• Engage in social and/or community activities. This may be done by working with the client to find activities that suit their preferences and interests. While popular activities for neurotypical older people may be enjoyed by some autistic people (e.g., golf outings, tennis games, book discussion groups), they are by far not the only ways to engage socially. There is social benefit from taking a class, volunteering at an animal shelter, or attending a workshop at the local public library, where interaction can be minimal and only surrounding a structured or prescribed set of activities.
• Incorporate activities that are personally meaningful. Guide the client through a values clarification exercise and do an inventory of activities that are aligned with their personal values. Then reinforce time spent in accordance with those values, such as connecting with nature, writing, creating, building or inventing. Values are individualized and personal, so it is important for a therapist to be led by the client in this area.
• Measure progress by looking at quality of life. Decreasing symptoms of depression and anxiety is not enough; increasing quality of life is the broader goal. At the beginning of treatment, use a quality of life measure, such as those found in the World Health Organization’s quality-of-life measures to assess the client’s satisfaction across a number of daily living domains (e.g., support, environment, relationships, physical well-being, etc). Include goals to enhance satisfaction and pursue lifestyle changes. LaPoint and colleagues offer specific ways to measure quality of life with autistic adults.

Growing older is not easy for anyone, and autistic adults face barriers as they have throughout their lives. But with the right kind of mental health support, autistic adults can go through the later chapters of life with strength, dignity, and hope.

Dr. Gaus is a psychologist, board certified in behavioral and cognitive psychology by the American Board of Professional Psychology. She has been a practicing psychotherapist since 1994. She consults at the University of North Carolina TEACCH program, Stanford University School of Medicine, and the Academy of Cognitive and Behavioral Therapies. She has written numerous articles, chapters and books, including Cognitive-Behavioral Therapy for Adults with Autism Spectrum Disorder, 2nd Edition, published in 2019 by Guilford Press and Living Well on the Spectrum: How to Use Your Strengths to Meet the Challenges of Asperger Syndrome/High Functioning Autism, published in 2011 by Guilford Press.