The privilege of working with Autistic Athletes

'Celebrating Neurodiversity and the unique privilege of working with an athlete with diagnosed or suspected autism spectrum condition'

By Dr Caz Nahman

On this page:

• An introduction to Dr Caz Nahman

• Katie - an anecdotal story

• What is Autism?

• Autism & athletes - the overlap

• Katie's relationship with her coach

• What would help?

• Other considerations...

• References

An introduction to Dr Caz Nahman

👋 "Hi, my name is Caz Nahman. I'm a child and adolescent psychiatrist with interests in Autism, eating disorders, compulsive exercise and athlete mental health. I have a small athlete clinic, but work mainly within a community adolescent eating disorders team, where up to 1/3 of my patients do competitive sport, and up to 1/2 of my patients present with Autism traits. I am the teaching lead for child and adolescent psychiatry, for undergraduate medical students at Oxford University."

Caz: "The following story is based on real life scenarios from my work with several athletes with autism but does not refer to one particular athlete and any resemblance to a known athlete is co-incidental."

Katie is a 19-year-old university swimmer competing at regional and national levels. Until transitioning to university she had had the same coach for almost ten years. Andy, the coach of her new university team, is struggling to understand her.

Recently, after a session, the physiotherapist spoke to Andy about Katie's badly bruised tendon – Andy wasn't sure why Katie didn’t tell him herself. Katie believes she did tell him, but Andy can't recall a conversation. Andy can’t tell when Katie is in pain by looking at her because she doesn’t show it.

During her first week at training, Katie had gotten dizzy and bumped her head hard – when the physiotherapist booked her off sessions due to head injury policies, she burst into tears and shouted at both Andy and the physio. Andy thought she was both childish and decided she was 'badly' behaved.

Katie asks “why” a lot when asked to do things, and Andy suspects she doesn't trust him. He feels he has bent over backwards trying to answer her questions, and yet she never seems to thank him or appreciate how much he is trying. She does work hard, but she doesn't smile much and rarely joins in team banter.

Katie has a psychologist she is working with regarding anxiety, and the psychologist (with Katie’s permission) has asked to meet with Andy. Andy is surprised as this seems to have come out of the blue – Katie is doing okay as an athlete... although he finds her frustrating to work with.

The psychologist told Andy that Katie was diagnosed with Autism at the age of 14. She has always been anxious. She loves her sport – this is her main interest, and the rest of her life will revolve around sport. Katie is somebody who is desperate to get things right and to follow the rules, but right now she isn’t sure what the rules are or when she's getting things right or wrong.

She loves to understand the facts, science, and biomechanics behind her training and likes detail focused and specific corrections. Her belief is that if she isn’t being corrected; the coach isn’t interested. The incident where Katie was dizzy and bumped her head followed a “pep talk” by the coach, during which he told the entire training squad that "nobody was trying". Katie therefore pushed herself to exhaustion. On finding this out, Andy was surprised – everyone knows Katie is a hard worker. She doesn't chit chat or gossip during training sessions... surely, she would know his remark didn’t apply to her?

Katie is struggling with sleep, the changes and demands of university, and managing nutrition around her academics and training. The psychologist explained that Katie becomes distressed if she isn't able to swim or if she has to miss any sessions, and that this can become overwhelming for her.

When he was told of Katie's diagnosis, Andy’s first thoughts were – "she doesn’t look Autistic" – yes, she’s difficult, really quiet, doesn’t show what she's feeling... but she’s intelligent, dedicated and in some ways pretty normal...

What is Autism?

Autism is a lifelong neurodevelopmental condition, whereby the individual shows differences in social skills, communication and often intense and restricted interests. Individuals with Autism, or Autistic individuals (if person-first language is preferred) are very different from one another, and intellectual levels vary greatly; from profoundly learning disabled up to academically gifted. So – be aware that because you’ve met one person with Autism, it doesn’t mean that everybody with Autism will look or seem the same... In females, Autism often shows itself very subtly. Females with Autism are often missed because they can work hard to fit in and hide their differences. Individuals with Autism have a higher prevalence of some specific learning disabilities like Dyslexia or Dyspraxia, as well as ADHD.

Autism & athletes - the overlap

If one thinks about the qualities of an athlete, some of these include perseverance, detailed focus, and commitment to sport and training; well known Autistic strengths. Individuals with Autism often have intense interests and will hyperfocus, persist and engage with one area of interest for a very long time. They are able to do seemingly quite repetitive tasks over and over again with little boredom.

There is very little research regarding Autism and sport, and it seems to have been the assumption that athletes are unlikely to have Autism, or that Autistic individuals are unlikely to be athletes. Most research is confined to disabled athletes and suggests the presence of motor skill difficulties.

Anecdotal evidence suggests that Autistic individuals are able to perform predictable, repetitive movements to a high level of skill, with practise... most evidence at this moment in time is anecdotal e.g. practitioners with knowledge and experience having worked with elite athletes and seen the signs and overlaps.

Grant (2008), assessed students in higher education, and noted higher than expected levels of athletic achievement in students with Dyslexia or a combination of Dyslexia and Dyspraxia. The athletes in this study often preferred individual sports, but not exclusively so.

It appears that Autism and neurodivergence in sport are areas that warrant further research.

Katie's relationship with her coach

• Katie has had a significant transition to a new, potentially frightening and unpredictable environment. It can be hard for her to understand and pick up the unwritten social rules within a new situation, so she is trying hard to understand this within a number of new environments at once; her new sporting environment, academic environment, and university accommodation.

• Unless Katie knows somebody well, she can take a while to pick up other people’s nonverbal cues (body language and facial expressions) and intentions. So, if a coach shouts at their athletes, she might interpret this as anger or that she is personally doing something wrong. She might not say this to others, but will feel incredibly anxious about making mistakes.

• When the coach tells the entire training squad that "nobody is trying", how could Katie be expected to know this might not include her? She was told “nobody is trying”, which surely means everybody needs to work harder - including her...

• Katie might not show many visible reactions to being anxious, stressed or in pain until the situation reaches a certain point. Her reaction might appear as a meltdown that's come from nowhere. It hasn't come from nowhere.

What would help?

• Katie and her coach Andy should get to know each other as individuals. Autism comes with many strengths – strengths like determination, persistence, focus, attention to detail, self-reliance, motivation, problem solving, enhanced memory. Other strengths (that can be misinterpreted) include being critical, questioning, logical, and curious. Andy needs to understand the strengths behind being questioned.

• Andy should help Katie to understand the implicit “rules”, expectations and exceptions surrounding their relationship. He would also benefit from understanding his own emotional responses to Katie’s behaviour.

• Andy should be careful to avoid making sweeping statements about the team, such as “nobody is trying” or “we’re going to throw all of you off the squad”. Some athletes benefit from negative coaching strategies like these, but many - including neurotypical athletes - don’t.

• Andy should be explicit about training goals session expectations. For example, Katie might need to be explicitly told “trying hard does not always equal maximum effort”. Helping her to understand the rationale behind training and reminding her of the focus for each session would enable Katie to better gauge and monitor her own effort - making consistent improvement rather than gradual burn out a more likely outcome.

• Perfectionism should be respected as it can very easily become unhealthy in an Autistic athlete – there is a fine line between striving to achieve goals and rigid, self-critical expectations. Consistently setting, adapting and communicating smart and realistic training goals is critically important...

Other considerations...

• There is an overlap between hypermobility and Autism. The currently limited research suggests a possible increase in injury risk.

• Pain thresholds can vary among Autistic athletes, but due to sensory perception differences, some Autistic athletes will have unusually high pain thresholds. They may not notice when they're in pain or injured.

• There is an overlap between Autism, picky eating and poor “interoceptive” awareness (e.g. a lack of sensitivity to tiredness and hunger cues). The use of wearable and other technologies (e.g. heart rate monitoring, monitoring of training load), as well as utilising and communicating 'the facts' behind the feelings, can prove incredibly helpful for Autistic athletes.

References:

• Bonete S, Molinero C, Ruisanchez D (2023) Emotional dysfunction and interoceptive challenges in adults with ASD. Behavioural sciences 13: 312

• Cederlof M, Lawson H, Lichtenstein P (2016) Nationwide population-based cohort study of psychiatric disorder in individuals with Ehlers-Danlos syndrome in Hypermobility Syndrome and their siblings. BMC Psychiatry 16:207

• Grant D (2008) Sport Preferences and achievements of Dyslexic and Dyspraxic Sports Men and Women: Lessons for London 2012? Dyslexia Review 20(1) 31-34

• Greenway R, Howlin P (2010) Dysfunctional attitudes and Perfectionism and their relationship to Anxiety and Depression in Boys with autism spectrum disorders J Autism Dev Disord 40: 1179 - 1187

• Hill AP, Hall HK, Appleton PR (2010) A comparative examination of the correlates of self-oriented perfectionism and conscientious achievement striving in male cricket academy players Psychol of Sport & Exercise 11: 162-168

• Kimber A, Burns J, Murphy (2021) It’s all about knowing the young person: Best practice in coaching autistic athletes Sports Coaching Review 1-21

• Simcoe SM, Gilmour J, Garnett M (2022) Are there Gender-based variations in the presentation of autism amongst male and female children. J of autism and developmental disorders.

• Solomon M, Miller M, et al (2011) Autism Symptoms and Internalizing Psychopathology in Girls and Boys with Autism Spectrum Disorders J of Autism and Dev disorders 42(48-59)

• Vetri L, Rocella M (2020) On the playing field to improve: a goal for autism – review Medicine 56:585

• Wood-Downie, H., Wong, B., Kovshoff, H. et al. Sex/Gender Differences in Camouflaging in Children and Adolescents with Autism. J Autism Dev Disord 51, 1353–1364 (2021). https://doi.org/10.1007/s10803-020-04615-z

🙏 Thank you Caz for writing such a well resourced and informative article 🙏