Often, when we talk about autism as a disability, conversations both within and outside of the autistic community focus primarily on discussing autism as a mental health disability, rather than a physical one. It often makes sense to do this, many of the more unique features of autism that set it aside from other disabilities are internally experienced sensory, routine processing, and social communication differences. This focus however often leads to us not discussing the ways that autism is often a physically experienced disability, with impacts that can be outwardly measured.
So today, on Access-Ability, I want to take some time to talk about autism as a physical disability, rather than exclusively a mental health disability. While I won’t be talking about specific video games this week, I do believe that expanding the conversation around what autism is and how it impacts people in this way is an important part of advancing how we view autistic player accessibility in the gaming space.
Gastrointestinal Issues
Around ⅓ of autistic people experience lifelong physical gastrointestinal issues, not explained by other more specific diagnoses. These can range from chronic constipation and abdominal pain to bowel inflammation, chronic diarrhoea, and gastrointestinal reflux issues.
As an autistic individual I’ve lived with multiple of these throughout my life, which have worsened in impact over time. For me this looks like living with a chronic upset stomach similar in presentation to some experiences of IBS (Irritable Bowel Syndrome), and experiencing acid reflux during sleep that can wake me up in coughing fits, occasionally resulting in vomiting during the night.
Ehlers-Danlos Syndrome
The gastrointestinal issues experienced commonly by autistic people may in some cases be tied to a comorbid diagnosis common alongside autism – EDS, Ehlers-Danlos Syndrome, which 30-40% of autistic adults meet the diagnostic criteria for.
EDS is a connective tissue disorder that comes in many forms, but in its most common form (Hypermobile EDS) results in fatigue, joints that over extend in their sockets risking dislocation and pain, and other associated physical issues.
EDS can cause issues with pain, fatigue, muscle weakness, but can also impact connective tissue inside of the body in numerous ways, such as causing numerous gastrointestinal system issues. A lot of research suggests the common autistic experiences with gastrointestinal issues may be in part EDS experiences, with connective tissue in the stomach, throat, and gut not properly functioning.
Seizures
Epilepsy and other seizure conditions are also more common than normal in autistic adults, with around 10% of adults diagnosed autistic also meeting the criteria for a seizure condition.
Issues Caused by Poor Interroception
70% of autistic children and around 60% of autistic adults present with something called Atypical Eating Behaviours. In many cases this is referring to food selectivity (a broad category discussing sensory sensitivities and need for predictability that can lead to eating a heavily restricted diet of “safe foods”), but it can also present as an increased prevalence of eating disorders and unsafe eating behaviours.
Interroception is the brain’s built-in system for keeping track of the body’s signals for what it needs, and translating those signals into something actionable. If you find yourself feeling hungry, that’s a result of your body in the background keeping an eye on a web of sensory data and alerting you that enough signals have lined up that you should act on them and eat some food. In autistic people interoception can often fail to properly track these signals, either not keeping a good eye on them in the background or producing the wrong resulting answer from the data that is collected.
With regards to eating issues, a lack of proper interoception can lead to an autistic individual over or under eating, due to feeling full too early or too late. This lack of interoception can also lead autistic individuals to not feeling the physical signs that are designed to tell them when they need to use the bathroom, if their body is too hot or too cold, or that they’re experiencing the physical symptoms that highlight a change in emotional mood.
Often autistic people physically can’t feel the signs that their mood is changing, the way that someone else might feel themselves welling up or becoming tight in the stomache when angry, that might initially clue them in to a coming change of emotional state.
This is also thought to be linked to increased rates of Pica in the autistic community, a condition where individuals compulsively crave consuming non food items. Interoception when functioning properly plays a role in helping a person to understand what their body is craving to consume, and in individuals with poor interoception this can manifest as craving non food items, because the signals in their body have been falsely interpreted to suggest that that’s what they need to eat.
While interoception is not directly a physical manifestation of autism, it impacts physical systems in a way that feels relevant to this type of discussion.
Anxiety
26% of autistic adults also have a diagnosed anxiety disorder. This should intuitively make sense, autistic people are living life with a nervous system triggered negatively by a wider range of sensory stimuli than the general public, and experience more severe swings of fight or flight response than most people.
As easy as it is to consider this not a physical aspect of autism, long term heightened anxiety physically strains the body, leading to chronic issues such as high blood pressure, heart disease, the previously discussed gastrointestinal issues, weakened immunity, chronic pain (in the form of things like headaches or muscle tension), and sleep disorders such as insomnia and more.
Hearing Issues
While still a fairly new area of research, there is ample evidence out there to suggest that autistic individuals experience a statistically significant likelihood of being born with a physical abnormality impacting one of their ears.
This tends to manifest in a few notable ways – being more prone to ear infections on the impacted ear, higher rates of experiencing “Glue Ear” (a fluid buildup behind the eardrum causing muffled hearing), and higher rates of needing to have a Grommet fitted (A tiny tube that is inserted into the ear surgically to reduce the prevalence of some of the previously discussed issues).
Access-Ability is at its heart a show about video game accessibility, and I suspect some of you who have made it this far may be wondering what relevance some of this has to making video games more accessible for autistic players.
As a video game accessibility consultant, I have been reached out to on multiple occassions by game developers who want their games to be more playable by autistic players. Often, what they present to me for feedback on is ideas they have for making their video game more sensory friendly – ways to prevent spikes in audio or visual intensity that might be distressing for an autistic individual. If I’m lucky they may have also been experimenting with social complexity tools, such as including tone tags on closed captions to convey non verbal subtext.
What developers who have brought me in to talk about autistic player accessibility often aren’t prepared for is me talking to them about aspects of being autistic that were not on their radar as being connected to autism.
If I explain to a developer that I need a game to be able to be paused, because I may suddenly need to use the bathroom on short notice due to poor interoception or EDS and Anxiety related GI issues, it’s not uncommon to get baffled expressions from the developer in response.
I want people who are trying to consider the needs of autistic players in their game design to understand that autistic players’ experiences are often more broad than just the internal sensory, structure, routine, and social understanding issues that tend to be the unique signifiers of the diagnosis.
An autism diagnosis is often also tied to a whole lot of other symptoms that might at a glance seem unrelated, but at the end of the day cannot be separated from the discussion if your end goal is to make a game that is broadly accessible for a wide range of autistic players.