It has become increasingly common for patients to arrive for diagnostic evaluations referencing TikTok and social media depictions of their symptoms. They may even show a video to the clinician, indicating that this content creator’s representation of attention-deficit/hyperactivity disorder (ADHD) or of autism mirrors their own. While many clinicians may balk at this social media-driven trend, an alternative way to view these encounters is as an opportunity to identify and validate distress and impairment. At the same time, clinicians must contend with both sensationalized fears around a pandemic of neurodivergence diagnoses leading to a reduced workforce and their own relative skepticism of the increased rate of questions coming from their patients about different “fad” diagnoses. For patients struggling with academic, social, and occupational functioning throughout their lives the necessity of seeking help persists. For clinicians encountering neurodivergence routinely, could ADHD and Autism diagnoses help explain more patient difficulties than initially thought? Here we examine ways in which clinicians can improve inclusion of neurodiverse diagnoses for our patients.
Psychologists providing psychological testing and diagnostic clarification services have a unique role in their ability to set the tone of such evaluations. The nomothetic classification of neurodevelopmental conditions means that these categories are not new, only the concept is new. DSM-5 furthers the broadening of neurodevelopmental disorders through the concept of a “spectrum,” as well as our movement as a psychological field toward dimensional models, away from discrete categorical diagnosis (APA, 2022). As the gate-keepers of clinical diagnoses, we have been trained to look for distress and impairment and to find the line at which it warrants a clinical label.
Executive dysfunction is a perfect place to start the conversation around these categories. Almost every human has experienced episodes of executive dysfunction, yet the diagnosis of ADHD is made only when this impairment is sustained, developmental in nature, and occurs across multiple domains. Our prototype for ADHD, the hyperactive little boy, falls short of the true variety of presentations, particularly among girls and women (Young et al., 2020). As clinicians, we have the difficult job of identifying individuals who have been missed and told their distress and impairment is invalid, while also being careful not to cast the net too wide. Research suggests that neurodivergence plays a role in ADHD, and that differential diagnosis should carefully consider the potential for autism spectrum disorder when evaluating for ADHD (Fuca et al., 2023). Most at risk of being overlooked are individuals without impaired speech or intellectual functioning (Knott et al, 2024). One way to improve inclusion of neurodiverse diagnoses in our differential diagnoses is to actively consider it as potentially concealable through learned behaviors and masking. Typically, clinical focus is on mental health diagnostic criteria alone and would benefit from a broader look for neurodevelopmental concerns through careful review of social, educational, and occupational histories (e.g., by means of self-report or report through other medical providers or educators).
Use of Psychological Assessment
For evaluations that question independent functioning or ability to function independently, one could include more intensive cognitive and adaptive functioning measures (e.g., WAIS, Woodcock Johnson, Adaptive Behavior Scales, Vineland). Assessment could specifically address impairments reported, such as auditory learning and short-term memory through the CVLT. Continuous performance tasks can help with understanding complaints of sustained attention, inattention, and impulsivity. Standardized questionnaires can be used to assess executive functioning, autism spectrum symptoms, and a broad range of clinical concerns, some of which include collateral reports. Measures that include assessment of engagement, effort, and potential malingering are also useful. When significant questions about autism spectrum are raised, a structured interview, such as the MIGDAS, ADOS, among others are helpful in identifying criteria through different clinical experiences, such as use of humor or sarcasm, conversational turn-taking, and areas of interest; however, one must also be cautious of cultural biases or over-stereotyped views of autistic presentations when using specific measures. There are autism spectrum questionnaires that provide standardized scores based on age and gender (e.g., CAARS, SRS-2) and others in the public domain that have typically been used for research (e.g., the RAADS-R, the Pure Alexithymia Questionnaire, and the Repetitive Behavior Questionnaire).
Given the broad nature and complexities of neurodiversity, it is helpful to provide psychoeducation related to ADHD and autism spectrum diagnoses with patients. New research, transdiagnostic and dimensional models, and political concerns show the evolving nature of these diagnostic categories (Michelini et al, 2024). It is validating and powerful to own the limits of scientific knowledge and emphasize that while symptoms create distress and impairment in our society, neurodivergence is not inherently disabling. Time spent highlighting the strengths individuals with autism spectrum characteristics bring to the world is important.
A recipe for a good conversation is to validate patient distress and impairment, apply a psychological theory as to why distress and impairment is present, and ground these assertions with assessment findings. Feedback is a conversation, not a judgement of the clinician alone. While clinicians are experts on the diagnostic criteria and the assessments, the patient is the expert on themselves. Together we create a shared understanding. If there is a true disagreement with the patient, agreement may be reached through conceptualization and an order of treatment options to try.
If the clinician is concerned about patient malingering, one can continue to be therapeutic and validating of the individual’s experience. There is strength in an approach that clearly defines occupational impairment and creates a discussion of what would be an ideal lifestyle for the individual. Those who are truly feigning symptoms will separate from those with the lifelong, developmental throughline of these neurodivergent difficulties. Just because an individual has completed educational degrees or successfully worked a job does not inherently suggest ongoing functioning. As DSM-5 moved away from the Asperger’s eponym and toward a spectrum-based approach, it overtly describes that the levels of severity cannot fully map on to need for services. Higher functioning individuals may encounter more barriers in some contexts, suggesting an idiographic approach to services based on individual goals.
It is the experience of the author that patients wondering about autism diagnoses have felt unheard and invalidated by many providers, both medical and psychological. Especially when struggling in occupational settings, they have been told they are lazy, exaggerating problems, and wrong about their own experience. They burn out quickly in work environments, finding themselves experiencing severe mental and medical concerns when working a 40-hour work week. The majority would happily work half-time, finding work helpful and rewarding, but struggling greatly to live on half-time pay and must balance qualifying for Medicaid with working as much as they are allowed. Current social expectations keep them stuck in a loop of failure, struggling to survive.
Validating the distress experienced while emphasizing a non-pathologizing approach can help guide a conversation away from inherent disability, to identify specific areas of desired support. There are many interesting approaches, both tangible and theoretical to understanding our current American situation and encourage patient-led research and supports (Benevides et al., 2020; Chapman, 2023). Outcomes suggest empathy, understanding, and respect are at the top of the needs list to improve resiliency and functioning, something that should be inherent in the therapeutic psychological relationship. It is the author’s clinical observation that individuals feel safe knowing the goal is not to become neurotypical and are excited to build off their many strengths. As part of feedback from an evaluation, it is important to discuss the goals of treatment (e.g., medication, occupational therapy, and psychological therapy) as building independent functioning, interpersonal skill, and executive functioning skills, while learning to cope with stress more efficiently and effectively. There are many different approaches to individual and group interventions related to skill building; one such example is Autism Working (2021) by Attwood and Garnett.
When referring neurodivergent individuals for therapy, providers will often state that they do not provide therapy for ADHD or autism in adolescents and adults, as it is not within their scope. Given the discussion above, it is highly likely that therapists are already treating neurodivergent individuals. Continuing education in this area would likely improve treatment outcomes for their many patients currently being seen for their mental health symptoms. Ongoing education in neurodiversity should be seen as addressing the whole of patients we encounter, much like we have come to acknowledge treatment of issues related to race, gender, and sexuality dynamics. These areas can be specialized practice but also should be expected skills within the general wheelhouse of most providers to appreciate the uniqueness of the patient and their life experiences. It is my hope that more clinicians will consider additional training and consultation related to neurodiversity with measured curiosity about its role in existing patient panels and incoming patient evaluations.
References
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787
Benevides, T. W., Shore, S. M., Palmer, K., Duncan, P., Plank, A., Andresen, M.-L., Caplan, R., Cook, B., Gassner, D., Hector, B. L., Morgan, L., Nebeker, L., Purkis, Y., Rankowski, B., Wittig, K., & Coughlin, S. S. (2020). Listening to the autistic voice: Mental health priorities to guide research and practice in autism from a stakeholder-driven project. Autism, 24(4), 822-833. https://doi.org/10.1177/1362361320908410
Chapman, R. (2023). Empire of Normality: Neurodiversity and Capitalism (1st ed.). Pluto Press. https://doi.org/10.2307/jj.8501594
Fucà, E., Guerrera, S., Valeri, G., Casula, L., Novello, R. L., Menghini, D., & Vicari, S. (2023). Psychiatric Comorbidities in Children and Adolescents with High-Functioning Autism Spectrum Disorder: A Study on Prevalence, Distribution and Clinical Features in an Italian Sample. Journal of clinical medicine, 12(2), 677. https://doi.org/10.3390/jcm12020677
Garnett, M. , & Attwood, T. (2022). Autism Working: A Seven-Stage Plan to Thriving at Work. London: Jessica Kingsley Publishers. http://dx.doi.org/10.5040/9781805015642
Knott, R., Mellahn, O. J., Tiego, J., Kallady, K., Brown, L. E., Coghill, D., Williams, K., Bellgrove, M. A., & Johnson, B. P. (2024). Age at diagnosis and diagnostic delay across attention-deficit hyperactivity and autism spectrums. The Australian and New Zealand journal of psychiatry, 58(2), 142–151. https://doi.org/10.1177/00048674231206997
Michelini, G., Carlisi, C. O., Eaton, N. R., Elison, J. T., Haltigan, J. D., Kotov, R., Krueger, R. F., Latzman, R. D., Li, J. J., Levin-Aspenson, H. F., Salum, G. A., South, S. C., Stanton, K., Waldman, I. D., & Wilson, S. (2024). Where do neurodevelopmental conditions fit in transdiagnostic psychiatric frameworks? Incorporating a new neurodevelopmental spectrum. World psychiatry: official journal of the World Psychiatric Association (WPA), 23(3), 333–357. https://doi.org/10.1002/wps.21225
Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., Tierney, K., … Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC psychiatry, 20(1), 404. https://doi.org/10.1186/s12888-020-02707-9
Jo Ellison, PhD, ABPP
Board Certified in Clinical Psychology
Correspondence: jo.ellison@ellisonmentalhealth.com