The AuDHD Psych Podcast

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🎙️ Episode 31: Neurodivergent Experience - Male/Female Vs Internalising/Externalising Presentations & Late Diagnosis
"When we talk about male and female presentations, we're really talking about internalising and externalising presentations."
Summary:
In this episode of The AuDHD Psych Podcast, clinical psychologist and AuDHDer Aaron Howearth asks why more boys and men are diagnosed with autism and ADHD than girls and women. He argues that what we call male and female presentations is better described as internalising and externalising. An internalising presentation suppresses the impulse and works hard to fit the social rules, while an externalising presentation acts on it and is visible to everyone in the room. He links that split to how we still raise sons and daughters differently, and to how diagnostic criteria are built from what clinicians and researchers could observe. Because externalising presentations are the observable ones, they are the ones encoded in slow-moving manuals like the DSM and ICD, while quieter internalising presentations are less likely to be noticed or referred on.
He then traces the cost of being missed. Internalising presentations more commonly come with anxiety, depression, self-harm and suicidality, difficulties with self-esteem and self-concept, and a greater likelihood of a personality disorder diagnosis. Externalising presentations more often attract conduct diagnoses, defiance and aggression, but they also tend to bring earlier recognition and the relief of seeing yourself reflected in peers with the same label. Without that recognition, "I'm different" quietly becomes "I'm not enough". He closes on late diagnosis: masking eventually meets a threshold it cannot hold, and for many neurodivergent women that arrives at perimenopause, when falling oestrogen affects GABA, serotonin and dopamine and brain fog, inattention and sensory gating become harder to hide.
Key Themes & Takeaways
Internalising vs Externalising – What we often call male and female presentations may be better described as suppressing the impulse versus acting on it.
Culture May Contribute to Teaching Us Our Presentation – "Boys will be boys" permits externalising, while girls are taught to be pro-social, so masking is learned earlier.
How Criteria Get Built – Manuals encode what clinicians could observe, so externalising is captured and quieter presentations are missed.
Masks, Scripts And Stress – An internal compendium of social rules, with a script for each situation, works but can be a costly constant effort.
Patterns of Difficulties Differ – Internalisers more often meet criteria for anxiety, depression and personality disorders; externalisers for conduct and aggression.
Self-Concept Is A Deeper Injury – Without a name for what you are, self-understanding drifts from who you actually are.
Community Repairs The Picture – Seeing your strengths and struggles in others replaces being a bad person with being a different one.
Perimenopause And Late Diagnosis – A real Female-Male difference may be the reduced effects of oestrogen on GABA, serotonin and dopamine, amplifying brain fog, inattention and sensory gating.
The Double Mask – People approaching burnout often mask the burnout too, which can push diagnosis even later and burnout deeper.
Referenced Concepts
Internalising and externalising presentations of autism and ADHD
How diagnostic criteria are constructed in the DSM and ICD
Personality disorder diagnoses in internalising presentations
Self-concept and identity after late diagnosis
Perimenopause, oestrogen, GABA, serotonin and dopamine
Sensory gating, attention and autistic burnout
See Eps 10, 20 & 24 for related diagnosis/late diagnosis content.
If this episode raises difficult feelings, support is available in Australia: Lifeline 13 11 14, 13YARN 13 92 76, or Beyond Blue 1300 22 4636.
We are different, not defective.
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Keywords: AuDHD podcast, autism and ADHD, neurodivergent psychologist, neurodiversity affirming, Howearth Psychology, queer psychologist, autism diagnosis, ADHD awareness, lived experience, neurodivergent mental health, clinical psychology podcast

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🎙️ Episode 30: AuDHD Experience - Autistic Burnout & Recovery
"Downtime is a necessity, not a nice to have."
Summary:
In this episode of The AuDHD Psych Podcast, clinical psychologist and AuDHDer Aaron Howearth takes on two questions: what is autistic or neurodivergent burnout, and what can we actually do to protect ourselves from it? He begins by being clear about where the evidence sits. Autistic burnout has been described within community since around 2008 but only reached academic publication in 2020, when Raymaker and colleagues offered a description, followed by Higgins and colleagues the year after. There is no specific research on ADHD burnout — that literature is about occupational burnout in ADHDers — and no research at all on combined AuDHD burnout, so this episode draws on the autistic burnout literature and says so plainly.
Aaron works through the characteristics the two descriptions broadly agree on: debilitating exhaustion that leaves people drained and depleted, a loss of existing skills that increases disability, and, in Higgins' description, withdrawal. He makes the skill loss concrete — heightened sensory sensitivity, more emotional difficulty, reduced cognition, memory, speech and executive function, and increased difficulty with the activities of daily living like showering, cooking, cleaning and getting to work. He also complicates the three-month timeframe commonly quoted from Raymaker and colleagues, noting that the lived experience research mostly doesn't specify a duration at all: for some people it is days, for others months or years, and some don't fully recover.
Drawing on a recent systematic review synthesising the lived experience literature, Aaron maps the consequences across three domains: adverse health and wellbeing impacts, our place within the community, and our capacity to stay hopeful about the future and about ourselves. That includes longer-lasting disability and continued fatigue, difficulty expressing our intelligence and feeling like we come across as silly, the sense of having lost part of ourselves, anxiety, depression, increased meltdowns, self-injury and somatic distress; reduced capacity to engage in education and work, with homelessness, inpatient admission and lost independence reported by some participants; and lowered self-esteem, self-criticism, hopelessness and increased suicidality — where, for some people, the wish is not to die but to escape the feeling of being burnt out.
Aaron then turns to what feeds burnout and what protects against it. He handles camouflaging carefully: much of the lived experience research points to masking as a contributor while some follow-up research hasn't shown a significant influence, and his own argument is that what matters is our relationship with masking and whether the benefits genuinely outweigh the costs. He names ignorance, stigma, disbelief and unaccommodating environments as exhausting in their own right, before closing on the protective themes from the review — the power of knowledge, the power of taking care of our own needs for rest, solitude and sensory relief, and the power of others. He finishes by inviting listeners to choose one thing over the coming week that lowers the cost of their days, while noting that sometimes the thing to do is nothing at all.
Key Themes & Takeaways
 • Three Very Different Evidence Bases — Autistic burnout has descriptive academic research from 2020 onwards, the ADHD literature is really occupational burnout in ADHDers, and combined AuDHD burnout has no research at all.
 • Exhaustion, Skill Loss & Withdrawal — The agreed characteristics are debilitating exhaustion and a loss of existing skills that increases disability, with withdrawal included in Higgins' description.
 • Skill Loss Is Concrete, Not Abstract — It shows up as heightened sensory sensitivity, more emotional difficulty, reduced cognition, memory, speech and executive function, and difficulty with basic activities of daily living.
 • No Fixed Timeframe — The frequently quoted three months is not a rule; the lived experience research describes days, weeks, months or years, and incomplete recovery for some people.
 • Burnout Reaches Across Life — Impacts span physical and mental health, education and employment, housing and independence, and our hope about the future and about ourselves.
 • Masking Is Associated, Not Proven Causal — Lived experience research points to camouflaging as a contributor while some follow-up research does not; what likely matters is our relationship with masking and whether it earns more than it costs.
 • Ignorance & Stigma Are Exhausting — Sensory-harsh environments, unmet accommodations, being told we're overreacting, and disbelief in our autism or our distress all carry their own cost across healthcare, education, employment and family.
 • Self-Knowledge Is Protective — Being unaware means our support needs stay hidden and self-concept difficulties are more likely; understanding our own patterns makes life more manageable and replaces "I'm broken" with "I'm doing things differently."
 • Rest, Solitude & Sensory Relief — Pacing, permission to leave early, managed expectations in both directions, working from home, deliberate solitude and protected low-demand time are necessities rather than luxuries.
 • The Power of Others — Being trusted, accepted and seen, in accommodating environments that account for a disability they can't see, is both preventative and restorative; community is where we stop feeling broken.

References:

Ali, D., Bougoure, M., Cooper, B., Quinton, A. M. G., Tan, D., Brett, J., Mandy, W., Maybery, M., Magiati, I., & Happé, F. (2025). Burnout as experienced by autistic people: A systematic review. Clinical Psychology Review, 122, 102669. https://doi.org/10.1016/j.cpr.2025.102669 
Clarey, M. M., Abel, S., Ireland, M. J., & Brownlow, C. (2026). Autistic burnout on Reddit: A Sisyphean struggle with daily tasks. Journal of Autism and Developmental Disorders, 56(7), 2790–2802. https://doi.org/10.1007/s10803-025-06765-4 
Higgins, J. M., Arnold, S. R. C., Weise, J., Pellicano, E., & Trollor, J. N. (2021). Defining autistic burnout through experts by lived experience: Suggested data-based model and consensus method. Autism, 25(8), 2356–2369. https://doi.org/10.1177/13623613211019858

Raymaker, D. M., Teo, A. R., Steckler, N. A., Lentz, B., Scharer, M., Delos Santos, A., Kapp, S. K., Hunter, M., Joyce, A., & Nicolaidis, C. (2020). "Having all of your internal resources exhausted beyond measure and being left with no clean-up crew": Defining autistic burnout. Autism in Adulthood, 2(2), 132–143. https://doi.org/10.1089/aut.2019.0079

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Keywords: AuDHD podcast, autism and ADHD, neurodivergent psychologist, neurodiversity affirming, Howearth Psychology, queer psychologist, autism diagnosis, ADHD awareness, lived experience, neurodivergent mental health, clinical psychology podcast

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🎙️ Episode 29 — Work, Burnout & Ableism: Why So Many of Us Aren't Employed

Episode Summary

If we are different and not defective, why are so many of us unemployed, underemployed, or exhausted at work? In this episode, Aaron Howearth (Clinical Psychologist) works through the employment gap for neurodivergent people — and makes the case that it is structural, not a matter of effort or willingness.
We start with the numbers. Around three in ten autistic adults are employed in UK research, roughly half in Australia, and in the Netherlands the most common employment trajectory across thousands of autistic people was long-term unemployment. ADHD sits differently in the data, with productivity loss, injury, and time off carrying much of the cost. What ties it together is a person-environment mismatch — and the uncomfortable finding that most interventions still try to change the person rather than the workplace, even though environmental change is what actually shifts employment outcomes.
From there we get into burnout as a mechanism. We work through what autistic burnout actually is — chronic exhaustion, skills loss, reduced tolerance for sensory and cognitive demands, nonlinear and often long-term — how it must be differentiated from depression, anxiety, trauma responses and personality differences without excluding them, and why the withdrawal looks different (recovery, not amotivation). We are careful with masking: it is associated with burnout and likely a leading mechanism, but the causal evidence isn't there yet. We also name the thin ground honestly — ADHD burnout is a clinical and community idea without a defining study, and AuDHD burnout has almost no academic literature at all.
Then we turn upstream to ableism: the assumption that able-bodied and typical means right, normal, and appropriate, and that anything else is deficient. That shows up bluntly (employers who say they would not hire an autistic person under any circumstances) and subtly (be quiet, slow down, be more cheerful) — and both feed masking, stress, and burnout. We extend the double empathy problem to triple empathy in professional settings, where the mismatch is with colleagues and managers too, not just clients. Finally, we get practical: what accommodations actually cost, why everyone already uses accommodations, what to ask for, and how to plan recovery before you run out of spoons.

In This Episode (Chapters)

(00:00) Different, not defective — so why aren't so many of us employed?
(01:00) The employment gap is real and structural: UK, Australia, US, Netherlands
(03:30) ADHD and work: productivity loss, injury, and time off
(04:30) Barriers are structural, not effort-related
(05:30) Why interventions change the person instead of the environment
(07:00) Autistic burnout: Raymaker, Higgins, and what it actually looks like
(09:00) Differentiating burnout from depression, anxiety and trauma responses
(10:30) Why late diagnosis changes the presentation
(11:30) Masking and burnout: associated, not proven causal
(13:30) Recovery withdrawal vs depressive withdrawal
(15:00) ADHD burnout: a clinical idea without a defining study
(16:00) AuDHD burnout: almost no evidence base at all
(17:00) Who is most at risk: gender, and co-occurring conditions
(18:00) What ableism is, and why it drives everything upstream
(20:00) Over half of employers say they wouldn't hire an autistic person
(21:30) The subtle version: "be quiet", "slow down", "be more cheerful"
(24:00) Minority stress, cumulative feedback, and why our masking is safety-related
(26:00) Double empathy at work — and the triple empathy problem for professionals
(28:30) "Why should you get accommodations?" — the stairs and the lift
(30:00) What accommodations actually cost: mostly free, average around USD $300
(31:30) Practical accommodations: headphones, quiet spaces, breaks, stimming, routine
(33:30) Supported work models and work-person fit
(35:30) Disclosure: entirely your call, and how to open the conversation
(37:30) What employers can do to make disclosure less frightening
(38:30) Planning recovery before you run out of spoons — closing reflection

Key Takeaways

The employment gap is structural, not motivational. Roughly three in ten autistic adults are employed in UK research, about half in Australia, and long-term unemployment was the most common trajectory in a large Netherlands study. Nobody is sitting at home deciding they can't be bothered.
ADHD shows up differently in the data — around 21 to 22 extra days of lost productive work a year, plus higher rates of injury and time off — rather than as outright exclusion.
Most employment interventions try to change the person. The research points the other way: changing the work environment substantially increases neurodivergent employment.
Autistic burnout is chronic exhaustion, skills loss, and reduced tolerance for sensory, social and cognitive demands, arising from unsupported person-environment mismatch. It is debilitating, nonlinear, and often long-term with spikes.
It must be differentiated from depression, anxiety, trauma responses and personality differences — but the presence of those does not exclude autism, ADHD or AuDHD. Burnout withdrawal is recovery-seeking; depressive withdrawal is amotivation and hopelessness.
Masking is associated with burnout and is likely a leading mechanism, but the causal evidence is not there yet. It's said plainly in the episode: the relationship is real, the causal claim isn't earned.
ADHD burnout is an idea in clinical, community and advocacy circles without a defining study, and AuDHD burnout has almost no academic literature. That gap is named rather than papered over.
Ableism is the upstream driver: the assumption that typical ability is right and normal, and difference is deficient. Over half of employers in one study said they would not employ an autistic person under any circumstances.
The subtle version does the quiet damage — "be quiet", "slow down", be more expressive, be more cheerful — accumulating as minority stress, which drives masking, which drives burnout.
Double empathy extends into the workplace as triple empathy: research on young GPs found communication difficulty with colleagues and managers, not only with clients.
Everyone already uses accommodations. Stairs, lifts and escalators are accommodations for capacities humans don't have. We are just further from the middle of the human road, so we need a few more.
Accommodations are cheap — most are free, averaging around USD $300 — and quiet spaces, headphones, redistributed breaks, permitted stimming, clear routines and flexible or online work all support engagement.
Neurodiversity-affirming does not mean nobody has support needs. Some of us need considerably more support than others, and that has to stay visible.
Disclosure is entirely personal and case by case. Where it feels safe, framing it as a shared problem to solve makes it a win for both sides — and employers can make those conversations normal so disclosure stops being frightening.
Plan recovery before you need it. Build restoration into the day, week or month rather than waiting until the spoons are gone.

A Note on the Evidence

Today's discussion draws on a mix of peer-reviewed research (strongest for autistic employment outcomes, autistic burnout, and accommodations), thinner and largely non-definitive material on ADHD burnout, and clinical and lived-experience observation where the literature does not yet reach — particularly for AuDHD burnout, where academic evidence is close to absent. Where a claim is associational rather than causal, or clinical rather than trial-based, that's named clearly in the episode.

Disclaimer

This episode is general educational and advocacy information only. It is not individualised or tailored therapy, assessment, advice, or employment or legal guidance. If you need support, please speak with your GP or a registered practitioner in your area.
Thanks for listening, and remember — we are different, not defective.
Support the show
Keywords: AuDHD podcast, autism and ADHD, neurodivergent psychologist, neurodiversity affirming, Howearth Psychology, queer psychologist, autism diagnosis, ADHD awareness, lived experience, neurodivergent mental health, clinical psychology podcast

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 🎙️ Ep 28 — Relationships: Friendship, Loneliness & Intimacy Across Neurotypes
"It's not meeting my needs. It's not meeting your needs. It's meeting our needs in the best balance for us"

⚠️ Content note: this episode includes brief discussion of trauma, including sexual trauma.
If we're different and not defective, why do so many of us find relationships hard? In this episode, Aaron Howearth (Clinical Psychologist) sits with that question and works through friendship, loneliness, and intimacy across neurotypes — not as evidence of a deficit inside us, but as something that lives in the space between us and the people we're trying to connect with.
We start with what the research bears out: on average, autistic people report being lonelier and having fewer, lower-quality friendships — though this varies enormously from person to person, and many of us genuinely prefer smaller, higher-quality networks. From there we get into the double empathy problem: the idea that communication difficulties aren't a one-sided skills deficit, but a two-way mismatch, like speaking the same language in a slightly different dialect. When neurotype-matched pairs communicate, that difficulty largely disappears — which tells us it's a language barrier, not a broken person. We look at why community is protective, why masking costs us, and why the evidence is stronger for autism than ADHD, with only grey-literature hints that double empathy extends to ADHD too.
We then turn to intimacy across neurotypes — comparable desire for connection, but real barriers around sensory sensitivity, communication style, and a statistically higher likelihood of trauma. Finally, we bring in Gottman's work on partner responsiveness (turning towards vs turning away) and a warm-hug framing of attachment styles, landing on the most practical lever of all: understanding how you and your partner work, and meeting needs in the balance that's right for your context.

In This Episode (Chapters)

(00:00) Different, not defective — so why are relationships hard?
(00:45) Friendship and loneliness: what the research bears out
(02:00) Fewer but higher-quality friends — and why that's often a preference
(02:45) A spectrum of understanding, not a skills deficit
(03:30) Same language, different dialect: where nuance gets lost
(04:15) The thin evidence base for ADHD and friendship
(05:00) Masking costs us; community is protective
(06:00) The double empathy problem, and how it was tested
(08:00) Why it's a language barrier, not a broken person
(09:00) Does double empathy extend to ADHD? A pragmatic argument
(10:30) Intimacy across neurotypes: comparable desire, real barriers
(11:30) Sensory sensitivity, communication, and trauma (content note)
(13:00) It's not always "because I'm autistic" — stress and history matter
(14:00) Gottman, turning towards vs turning away, and bids for connection
(17:00) Partner responsiveness: the strongest lever we can pull
(18:30) Attachment as a big warm hug: secure, avoidant, anxious, disorganised
(21:00) ADHD, conflict, and satisfaction — statistical, not deterministic
(23:00) The push-pull cycle of anxious and avoidant partners
(25:00) Higher risk of interpersonal stress and how it shapes attachment
(26:30) What we can do: naming our style, our needs, and our part
(28:00) Boundaries as meeting our needs in balance — closing reflection

Key Takeaways

The difficulty usually isn't in us — it lives in the interaction. Relational difficulty is a mismatch between communication styles, not an inherent deficit.
On average, autistic people report more loneliness and fewer, lower-quality friendships — but this varies widely, and many of us genuinely prefer small, high-quality networks. Loneliness drops with better friends, not necessarily more of them.
The double empathy problem reframes "social deficits" as social differences: neurotype-matched pairs communicate without significant impairment; the difficulty arises when different neurotypes meet. It's a contested idea, but a simple, elegant one.
Masking costs us — it raises stress. Being around community is protective because our communication styles align more closely, so we feel heard, understood, and connected.
The evidence base is strongest for autism; ADHD friendship research is thin, mostly in children and college students. Double empathy probably extends to ADHD (a pragmatic, clinical argument), via verbal impulsivity rather than filtering.
Intimacy: desire for connection is comparable to the general community, but barriers around sensory sensitivity, communication, and a higher likelihood of trauma can get in the way — often it's stress or history amplifying the dynamic, not the neurotype itself.
Partner responsiveness is the single strongest determinant of healthy neurodivergent relationships. Turning towards small bids for connection — even a "mm-hmm, yes dear" — builds trust; consistently turning away erodes it.
Attachment is about trusting that our needs will be met. Secure, avoidant, anxious, and disorganised (anxious-avoidant) styles play out in a push-pull cycle — and our higher risk of interpersonal stress and trauma can push us toward insecure attachment.
The practical work: ask what my attachment and relational style are, what I expect, what I might be doing that makes my partner pull away — and the reverse. Then have the conversation. Boundaries aren't about my needs or your needs; they're about meeting our needs in the best balance for our context.

A Note on the Evidence

Today's discussion draws on a mix of peer-reviewed research (strongest for autism, and for the double empathy work), grey literature (particularly for any extension to ADHD), and lived-experience and clinical observation. Where the ADHD-and-friendship evidence is thin, or where the argument is pragmatic rather than trial-based, that's named clearly in the episode.

Disclaimer

This episode is general educational and advocacy information only. It is not individualised or tailored therapy, assessment, or advice. Aaron does not provide relationship counselling. If you need support, please speak with your GP or a registered practitioner in your area.
Thanks for listening, and remember — we are different, not defective. 
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Keywords: AuDHD podcast, autism and ADHD, neurodivergent psychologist, neurodiversity affirming, Howearth Psychology, queer psychologist, autism diagnosis, ADHD awareness, lived experience, neurodivergent mental health, clinical psychology podcast

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🎙️ Ep 27: AuDHD Experience - Therapy Adaptations for Neurodivergent Folk (AuDHD, ADHD & Autism)  — What's the Point?
"Barriers aren't a 'you' problem — they're an 'us' problem to manage together."
Hi friends. If neurodivergent people are already showing up to therapy, why do affirming adaptations even matter? In this solo episode I work through that question from my own clinical experience and lived experience as an AuDHD psychologist. We map the barriers that keep neurodivergent people out of the therapy room — physical, psychological, emotional, sensory, and cognitive — and then walk back through the same five to look at small, practical, often low-cost changes that make care genuinely accessible. From externalising working memory and body doubling, to trauma-informed safety, non-fluorescent lighting, situational mutism, and a cushion instead of new chairs, this one is for neurodivergent listeners deciding what to ask for, and for clinicians wanting to do better.
A note on the evidence: I'm speaking mostly from clinical and lived experience here, not a deep RCT base. Where I mention that neurodivergent people "endorse" adapted approaches as helpful, that's about acceptability and client-rated helpfulness — how much people value these adaptations — not proven treatment efficacy or effect sizes. The main study behind that point is Paynter, Sommer & Cook (2025), who asked autistic adults to rate the helpfulness of specific therapy adaptations. The passage on perimenopause and sensory gating is an emerging, still-contested area, not settled science — hold it lightly.
Takeaways:
• There's no single "neurodivergent barrier" — physical, psychological, emotional, sensory, and cognitive access all matter, and they stack.
• Affirming therapy is trauma-informed by default; many of us carry complex stress and iatrogenic harm from past care.
• Speech is never a choice — situational mutism is overwhelm, not defiance.
• Meltdowns are overwhelm, and what looks like social anxiety or agoraphobia is often sensory-cognitive overload.
• Most adaptations are cheap: in-session alarms, chunking information, body doubling, dimmable lights, a cushion, starting on time.
• Clients: you're allowed to ask for a reasonable accommodation. Clinicians: mostly, just ask.
If this was useful, please share it with a clinician who needs to hear it — that's the single best way to get affirming care to more people.
📚 Reference: Paynter, J., Sommer, K., & Cook, A. (2025). How can we make therapy better for autistic adults? Autistic adults' ratings of helpfulness of adaptations to therapy. Autism. https://journals.sagepub.com/doi/10.1177/13623613251313569
Educational content only — this is not therapy or personalised clinical advice.
We are different, not defective.
Keywords: neurodivergent therapy, AuDHD, autism, ADHD, affirming practice, therapy adaptations, accessibility, situational mutism, sensory overwhelm, trauma-informed care, clinical psychology
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Keywords: AuDHD podcast, autism and ADHD, neurodivergent psychologist, neurodiversity affirming, Howearth Psychology, queer psychologist, autism diagnosis, ADHD awareness, lived experience, neurodivergent mental health, clinical psychology podcast