In a recent article,[1] the CDC examined the extreme diversity in Autism Spectrum Disorders (ASD), commenting on the difficulty this creates in addressing the needs of this community and planning for the future and encouraging an increased focus on what the authors refer to as “profound autism.” Profound autism, they explain, has been overlooked in the literature as the diagnosis continues to expand to include greater numbers of less severely affected people, and they encourage greater focus on this portion of the Autism spectrum among clinicians and researchers alike.
This supports recent work that I and others have published on the topic of Autism, neurodiversity, and psychiatric overreach.[2] In particular, it addresses the claims of the neurodiversity movement’s argument that ASD is not a genuine disorder along with the disturbing rise of ASD diagnoses in the United States.
Neurodiversity
Neurodiversity refers to a cluster of claims and an associated movement contending that various conditions currently considered psychiatric disorders are in fact normal-range differences in mental functioning. That is: autism is not a disorder but simply a different way of thinking, relating, and emoting. If Autism is not a disorder but simply a different way of being it would stand to reason that it might be much more prevalent than we had previously thought; increased prevalence rates might simply be us “catching up” to the near ubiquity of Autism or autistic traits in the general population.
The neurodiversity movement represents a valuable corrective to the rampant overdiagnosis occurring in mental health. However, as I have argued in print, in arguing that ASD is not a real disorder, neurodiversity advocates have failed to appreciate the heterogeneity of the autism spectrum potentially causing many people with serious impairments without access to services they deserve.
Neurodiversity, Diagnosis, and Justice
One reason why neurodiversity advocates argue that autism (and other neurodiverse conditions) ought to be depathologized is that it removes a reason for these people to be discriminated against. My coauthors and I find this a worrisome motivation because it suggests that those with disorders may have their rights curtailed. As we wrote in our 2020 article:[3]
"Disorder status is often used as an excuse to curtail the rights of stigmatized groups. It is, however, a poor excuse; issues of justice and of diagnostic status are largely separable. It is risky for the neurodiversity movement to link depathologization with justice and respect too closely. If emerging etiological evidence supports a disorder attribution for some subset of autists, the implication might then be that continued injustice and inadequate respect are acceptable. That would be a terrible, utterly mistaken conclusion to draw from neurodiversity arguments. A vigorous movement has long fought to defend and expand the rights of people with recognized psychiatric disorders. Among its achievements are strong presumptions against institutionalization and enforced treatment, and a strong presumption of decision-making capacity for people with psychiatric disorders. To protect and advance this progress, claims about disorder and justice should be kept distinct. "
An Expanding Diagnostic Category
The precipitous rise in ASD diagnoses in the United States (some studies indicating that it has risen three-fold in the past two decades)[4] has invited the question of whether ASD is more easily identified due to more sophisticated diagnostic instruments or if there is rampant overdiagnosis.[5] Neurodiversity advocates argue for the latter, adding that autism, and many other conditions are not disorders at all but normal-range differences thinking, emoting, and relating. According to neurodiversity advocates, Autism is not merely overdiagnosed, it shouldn’t be a diagnosis at all because it is simply a different way of being in the world.
One of the changes made in the DSM-5 was to eliminate Aspergers Syndrome and officially expand “Autistic disorder” into “Autism Spectrum Disorder.” ASD now varies along a dimension of severity from “high-” to “low-functioning.” Studies suggest that it is within the high-functioning subcategory that increased prevalence rates are mostly occurring.[6]
A Neurodiversity Spectrum
Although in many circles the image of Autism is shaped by depictions of ASD in popular culture (such as Max Braverman [Parenthood], Sheldon Lee Cooper [Big Bang Theory], and Abed Nadir [Community]), as well as perhaps a friend who has been diagnosed with “high-functioning” Autism, this is not representative of many people on the Autism spectrum. These encounters with ASD can give the impression that Autism generally causes difficulty recognizing social cues and expressing emotions while also conferring greater computational and logical skills.
However, ASD also encompasses those discussed in the CDC article who struggle with activities of daily life, are nonverbal, and need significant supports throughout life. Failing to recognize this severe end of the Autism spectrum, the neurodiversity movement’s attempts to eliminate the ASD diagnoses as a whole threatens to restrict the resources that those with “profound autism” deserve. Just as there is a danger in such overdiagnosis, there is a danger in underdiagnosis as well. Eliminating the ASD category all together would leave many people who have significant impairments in social development and communication and who are harmed thereby without a valid justification for receiving educational and at-home resources that they deserve. As the CDC observes,[7] it is important that we appreciate that ASD includes those with “profound autism.”
For this reason neurodiversity arguments are best thought of as lying on a spectrum. What my coauthors and I have called “weak neurodiversity” refers to the claim that we should cease expanding the ASD category. So called “strong neurodiversity” includes the claim that the entire Autism category, including those severely affected, ought to be eliminated. In the middle – and the position we endorse – is “moderate neurodiversity”: the claim that the DSM-5 has unjustly expanded the autism category to include nondisordered individuals but that in its severe form Autism is a genuine psychiatric disability.
Autism, Neurodiversity, and Treatment
Regardless of where one falls on the Autism spectrum, psychotherapy can be an invaluable tool for leading a more fulfilling life. As I have argued elsewhere, one needn’t have a disorder to benefit from psychotherapy. Whether or not you are diagnosed with ASD, having satisfying interpersonal relationships, functioning effectively as part of a team, and overcoming social anxiety are very real parts of life that therapy can help with.
[1] Hughes, M. M., Shaw, K. A., DiRienzo, M., Durkin, M. S., Esler, A., Hall-Lande, J., Wiggins, L., … Maenner, M. J. (2023). The prevalence and characteristics of children with profound autism, 15 sites, United States, 2000-2016. Public Health Reports, 1-10. [2] Conrad, J. A. & Wakefield, J. C. (Forthcoming). The implications of DSM category evolutionary heterogeneity. In L. Al-Shawaf & T. K. Shackelford (Eds.), Oxford Handbook of Evolution and the Emotions. Oxford: Oxford University Press.;Wakefield, J. C., Wasserman, D., & Conrad, J. A. (2020). Neurodiversity, autism, and psychiatric disability: The harmful dysfunction perspective. In A. Cureton & D. Wasserman (Eds.), Oxford Handbook of Philosophy and Disability (pp. 501-521). Oxford: Oxford University Press. [3] Wakefield, J. C., Wasserman, D., & Conrad, J. A. (2020). Neurodiversity, autism, and psychiatric disability: The harmful dysfunction perspective. In A. Cureton & D. Wasserman (Eds.), Oxford Handbook of Philosophy and Disability (pp. 501-521). Oxford: Oxford University Press. [4] Shenouda, J., Barrett, E., Davidow, A., Sidwell, K., Lescott, C., Halperin, W., Silenzio, V. M. B., Zahorodny, W. (2023). Prevalence and disparities in the detection of Autism without intellectual disability. Pediatrics, 151(2): e2022056594. [5] Gerrand, R. B. (2022, Feb. 10). There’s no Autism epidemic. But there is an Autism diagnosis epidemic. Statnews. Retrieved from: https://www.statnews.com/2022/02/10/theres-no-autism-epidemic-but-there-is-an-autism-diagnosis-epidemic/ [6] Baio, Jon, Lisa Wiggins, Deborah L Christensen, Matthew J Maenner, Julie Daniels, Zachary Warren, Margaret Kurzius-Spencer, … Nicole F Dowling. 2018. “Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years – Autism and Developmental Disabilities Monitoring network, 11 Sites, United States, 2014.” The Morbidity and Mortality Weekly Report Surveillance Summery 67: 1-23.; Dave, Dhaval M., and Jose M. Fernandez. 2015. “Rising Autism Prevalence: Real or Displacing Other Mental Disorders? Evidence from Demand for Auxiliary Healthcare Workers in California.” Economic Inquiry 53, no. 1: 448–468. [7] Hughes, M. M., Shaw, K. A., DiRienzo, M., Durkin, M. S., Esler, A., Hall-Lande, J., Wiggins, L., … Maenner, M. J. (2023). The prevalence and characteristics of children with profound autism, 15 sites, United States, 2000-2016. Public Health Reports, 1-10.
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