Why is My Autistic Teenager Struggling So Much

There are many reasons why the teen years are a challenge for autistic adolescents and their parents. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR; APA, 2022), central characteristics of autism include an insistence on sameness, difficulties with transitions, and rigid thinking patterns (criterion B2). The teenage years are a time of natural changes in hormones, physique, emotions, friendships, and cognitive abilities. For many parents and autistic adolescents themselves, the problems of primary school seem relatively benign and manageable in comparison to the struggles of adolescence.

Onset of puberty and hormonal changes

Our clinical experience indicates that autism is associated with precocious puberty for males and females. We have known autistic girls as young as seven years old developing signs of puberty, confirmed by recent research (Hamdan, 2022; Moriuchi et al., 2023). A deluge of hormones naturally occurs in puberty, specifically the gonadotrophin-releasing hormone or GnRH, which triggers puberty and physical and emotional changes.

Autistic teenage girls are more likely than non-autistic teenage girls to experience premenstrual dysphoric disorder or PMDD (Groenman et al., 2022; Naik, 2023). They may also have heightened interoception of their period pain experiences (Gray & Durand, 2023).

Body changes

One of the changes that occur with the onset of puberty is increased sweating, which can lead to more pungent body odour. This can cause distress to parents and family members. However, an autistic adolescent may not appreciate the effect on others or feel they have time for regular washing and deodorant use, which can cause conflict within the family.

The gender-associated body changes could contribute to an autistic teenager feeling repulsed by those changes and may feel misaligned with their birth gender. The resultant dysphoria can be a profound source of depression and other mental health disorders, including, for example, seeking to be androgynous by developing an eating disorder.

Autistic individuals who have limited speech and high support needs may develop epilepsy during puberty, which is considered due to hormonal changes (Barloso, 2020).

Emotions

The hormonal changes for non-autistic teenage girls and boys can precipitate mood swings and increased negative emotions, especially anxiety, as so clearly illustrated in the recent film Inside Out 2. There can also be signs of greater emotional despair and frustration that lead to depression, self-harm and anger management issues.

As clinicians, we recognise that autistic teenagers will experience more intense negative emotions in adolescence, especially anxiety. However, our experience is that the depth of anxiety can be more significant for autistic teenagers. There can be waves of anxiety during puberty for non-autistic teenagers, but a tsunami for autistic teenagers.

Many autistic behaviours are coping mechanisms for anxiety and agitation. The repetitive motor movements and actions, such as rocking and lining up objects (DSM-5-TR B1) and rituals and routines (B2), can be soothing and calming. The unusual interest in intensity or focus (B3) has many functions, including being a thought blocker for anxious, depressed, or agitated thoughts. Thus, during the hormonal changes that increase the depth of emotions of autistic teenagers, there will be an increase in these autistic coping mechanisms.

Friendships

There are changes in friendship skills, social expectations, and social dynamics during adolescence. Autistic teenagers are less able to rely on intuitive abilities in social settings with their peers. They often find social interactions overwhelming and confusing, especially in group activities and often aversive in terms of bullying and rejection. They can be anxious about making a social mistake and being ridiculed. They recognise that they are not popular and blame themselves or being autistic for peer rejection. This affects self-esteem, self-identity, mood and their perception of autism. There can be a yearning for a sense of connection and acceptance but experiencing rejection from popular friendship groups. However, they may be accepted by marginalised teenagers who engage in activities and interests that cause concern for parents, such as alcohol and illicit drug consumption.

Adolescence can include an increase in camouflaging autism to be accepted by peers and to avoid being bullied for being different. Camouflaging involves consciously suppressing autistic characteristics, but unfortunately, this means not being able to engage in stress and anxiety-reducing autistic behaviours. The autistic adolescent observes, analyses and imitates their peers, creating a mask or artificial persona to achieve peer acceptance and to acquire friendships. The suppression is ended upon returning home, and parents will experience an autistic teenager who seems to have two personas: one at school who is socially and academically engaged and the home persona of a teenager who is short-tempered, critical and agitated—a Dr Jekyll and Mr Hyde. There is surface sociability at school but a lack of social identity or sense of authenticity. The stress from camouflaging can contribute to social anxiety, and the exhaustion contributes to autistic burnout and depression.

Cognitive abilities

The brain is ‘re-wired’ during puberty to achieve complex abstract thought. We describe this as ‘the brain being closed for renovation’. Our clinical experience is that for autistic teenagers, the closure may take longer, leading to a prolonged plateau in cognitive abilities before re-wiring is complete. This will affect academic abilities, especially school grades, self-esteem, and independence from parental guidance and support. Autistic and ADHD teenagers have issues with executive functioning, that is, organisational and planning abilities, prioritising and completing tasks, maintaining attention on tasks that are not intrinsically interesting and tracking time. A parent may need to be an ‘executive secretary’ and provide active support with homework and project management for high school assignments.

An answer to the question

There are many reasons why an autistic teenager struggles during adolescence. It is a time of change, and a characteristic of autism is to have difficulty coping with change. Physical, social, emotional and cognitive changes are the components of a psychological ‘perfect storm’ for an autistic teenager. The struggles are not due to bad parenting but factors beyond their control.

Our clinical experience is that around a third of autistic teenagers will ‘go off the rails’ with significant mental health issues and behavioural regression for the duration of adolescence. A third will struggle at times with mental health but recover within the teen years. However, we have recognised that around a third will have relatively few difficulties, and there can be a reduction in autistic characteristics. This reduction has been confirmed by Hamdan (2022), who interviewed the parents of autistic teenagers. Unfortunately, we cannot predict which will be the trajectory for an individual autistic teenager.

Where to From Here?

We have created a brand new event to assist clinicians who see adolescents, increasing their knowledge and skill in recognising autism and distinguishing autism from other conditions, such as ADHD and depression, and in the provision of support and therapy for autistic teenagers who are often suffering from mental health issues. Our event comprises two days: Masterclass Day 1: Diagnosis for Autistic Teenagers and Masterclass Day 2: Support and Therapy for Autistic Teenagers. The events will be held live in London and can be attended live via webcast and watched later for 60 days after the event. See Live Webcasts for further information.

https://www.attwoodandgarnettevents.com/products/webcast-event-masterclass-day-1-diagnosis-for-autistic-teenagers-16-january-2025

https://www.attwoodandgarnettevents.com/products/webcast-event-masterclass-day-2-support-and-therapy-for-autistic-teenagers-17-january-2025

References

• American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders. Fifth edition, Text Revision. Washington, DC

• Barloso (2020) Autism Parenting Magazine

• Gray and Durand 2023 BMC Women’s Health 23.

• Groenman et al. 2022 Autism

• Hamdan (2022) Dirasat: Educational Sciences 49

• Moriuchi et al. 2023 Cureus 15 (3)

• Naik (2023) Frontiers in Global Womens’ Health