Melbourne trauma psychotherapy

Neurodiversity definitions

Autism Spectrum Disorder (ASD) and Attention Deficit and Hyperactivity Disorder (ADHD) are two neurodivergent diagnoses that have gained increased social and clinical awareness over the last 5-10 years. ‘Neurodivergence’ is a term used to describe the idea that people’s brains can vary in their way of processing information, which can have subsequent impacts on an individual’s abilities, behaviours, strengths and struggles, and overall experience of the world. The term ‘neurodivergent’ refers to the way that some brains diverge from, or are different from, what is considered ‘neurotypical’ ways of processing information.

ASD and ADHD are diagnoses within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). To attract a diagnosis of ASD or ADHD, individuals have to meet certain criteria. For ADHD, this criteria revolves around the ability to sustain attention, and/or actions demonstrating hyper-activity or impulsiveness (see here for a list of diagnostic criteria). For ASD, the DSM uses highly pathologising language, but outlines criteria that revolves around difficulties in social and emotional understanding and communication, repetitive patterns of behaviour (e.g. stimming) or interests (i.e. special interests), and hyper- or hypo-reactivity to sensory stimuli (see here for a list of diagnostic criteria). I will discuss in some detail below (skip to section) that it has become apparent that these criteria are limited in identifying and diagnosing women and gender- and sexuality-diverse individuals.

Neurodiversity statistics

The global prevalence of Autism Spectrum Disorder (ASD) within the general population is reportedly under 1%, but this varies from country to country, with ranges from 0.2% in China and Italy, to 2.7% in South Korea, and 3.6% in Sweden (Salari et al., 2022). Australia’s prevalence sits at 1.7% (Salari et al., 2022). Global estimates of childhood ADHD within the general population hover around 5%, and despite previous beliefs that symptoms decreased for children as they grew into adulthood, further studies have attempted to capture the picture of adult ADHD and estimate that ‘persistent ADHD’ (i.e. where symptoms started in childhood and continued into adulthood) to be 2.5%, and symptomatic ADHD (i.e. symptoms started in adulthood) to be 6.7% (Song et al., 2021).

Prevalence studies with ‘psychiatric populations’ (i.e. individuals admitted to psychiatric wards, or receiving mental health support) rather than the ‘general population’ (i.e. all individuals within a population) reflect higher levels of neurodivergent prevalence, from 10% to 19% for ASD (Tromans et al., 2018; Nyrenius et al., 2021) and 15% to almost 40% for ADHD (Duran et al., 2013; Gerhand and Saville, 2021).

Under-recognition and under-diagnosis

There are obviously many difficulties with estimating the true prevalence of neurodivergent individuals, as social and clinical awareness and stigma will vary from country to country, and across age groups. For example, individuals in their 20s may have more education and knowledge about the symptoms of ADHD and ASD than individuals in their 60s and 70s, and thus under-reporting occurs for this age group, affecting prevalence statistics.

Additionally, in relation to autism, much of the research and clinical criteria was devised in observing and working with children who would meet criteria for a level 2 or level 3 diagnosis; individuals who require intensive support in school and within the home, and may have accompanying learning difficulties. Level 1 autism (what used to be known as ‘Aspergers syndrome’ or ‘high functioning autism’) has been researched less, and it is my experience that many psychiatrists and psychologists who have worked with autistic children do not fully understand how an adult with level 1 autism presents, thus missing many of these diagnoses.

However, one of the more significant reasons for under-recognition and under-diagnosis that is becoming apparent today, is the significant lack of research into how ASD and ADHD may present differently in women and gender- and sexuality-diverse populations, as opposed to how it presents in cisgendered, heterosexual boys and men. This has resulted in a significant disparity in diagnosis, with boys and men being diagnosed at much higher rates than girls, women and gender-diverse individuals. Previous rates of diagnosis within ASD were estimated to be 4 : 1 (boys/girls), but updated studies seem to indicate that a more accurate number is 2 : 1 (Rynkiewicz et al., 2018) and even 1.8 : 1 (Lockwood Estrin et al., 2020).

Professor Gina Rippon, Emeritus Professor of Cognitive Neuroimaging at the Aston Brain Centre, has written a book outlining the sexism historically inherent in ASD research and diagnosis, titled “The Lost Girls of Autism: The New Science of Neurodiversity in Women and Girls.” Text from a recent article she wrote for the New Scientist (“A revolutionary new understanding of autism in girls”) can be found here.

Differences between the ‘male model’ of autism, and how autism presents for women and gender- and sexuality-diverse individuals

In comparison to the ‘male’ model of autism, women and gender-diverse individuals have been observed to have less difficulties within social and emotional domains, and to use ‘masking’ or camouflaging strategies more in social situations than cisgendered autistic men (e.g. Head et al., 2014 and McQuaid et al., 2021). Masking is when an autistic person, either consciously or unconsciously, suppresses or hides their natural autistic behaviours and responses. Masking can include forcing eye contact, mimicking the behaviours, body language, or interests of others, hiding discomfort over sensory stimuli, or suppressing overstimulated/ anxiety responses (e.g. stimming).

Similarly, stereotypical understanding of ‘stimming’ in autism from research with boys has involved rocking and hand-flapping, but in girls and women more socially ‘acceptable’ stimming has been noticed, including hair-twirling, nail biting, and subtle skin picking.

It is thought that as a result of these masking behaviours, women and gender-diverse individuals with autism are not identified by family, teachers, and professionals, delaying or indeed preventing diagnosis and therefore support.

Delayed support, and misdiagnosis

Instead, many of the symptoms that autistic women and gender- and sexuality-diverse individuals experience are misidentified and misdiagnosed as other mental health difficulties. This misdiagnosis, for many of my clients, has meant that they have sought psychological support from various therapists over the years, but have found that while sometimes useful, they have not been able to address or shift core difficulties, and have experienced quite a lot of shame and distress believing these lack of changes reflect their own moral deficiencies (e.g. “I’m not trying hard enough”, “There’s something very wrong with me”, “I’m too lazy to change,” etc).

Some of the psychiatric diagnoses that individuals with autism get diagnosed with instead of recognising that these traits arise from ASD, include:

• Shyness, social anxiety/ awkwardness, need for alone time, post-social ruminations, general ruminations = anxiety disorders
• High emotionality, difficulty reading and following social cues, black and white thinking, diffuse sense of self, self-harm, suicidality = borderline personality disorder
• Preoccupation with order, following rules, perfectionism, and control = obsessive-compulsive personality disorder
• Limited interest in relationships, limited access to/ expression of emotions = schizoid personality disorder
• Difficulty reading social cues, understanding sub-text, difficulty with theory of mind, rejection sensitivity = paranoia/ paranoid personality disorder

It is also the case that individuals with ASD do have other mental health difficulties, but that these can be seen as expressions of the autistic neurotype. For example, autistic individuals are diagnosed with higher rates of obsessive-compulsive disorder (OCD; Martin et al., 2020), and eating disorders (Huke at al., 2013). Autistic individuals can also be diagnosed with depression, however this depression is often thought to be a manifestation of chronic over-stimulation and burnout, a different pathway to depression than what is understood to cause depression for neurotypical people (Benetov et al., 2024).

My clinical experience

My own previous under-recognition of neurodivergent individuals reflects that of the general mental health field, and lack of education within training programs regarding identification of ADHD and ASD in women and gender- and sexuality-diverse individuals. Some of my clients began exploring ADHD for themselves around five years ago, and receiving diagnoses, but before then, I would have interpreted their difficulties through the lens of trauma. While neurodivergent individuals have experienced higher rates of trauma and are diagnosed with PTSD at greater rates than the general population (Wendt et al., 2022; Lobregt-van Buuren et al., 2021), only using a trauma-lens with these individuals means that large chunks of their difficulties and experiences are misunderstood and misinterpreted.

The last few years has seen an increase in both clients referred to me with diagnoses of ASD and ADHD, and my own education around how these neurotypes present and are experienced by individuals. I now regularly raise neurodivergence with clients if I see neurodivergent patterns of thinking, living or experiencing the world.

My own experience would reflect the research that suggests neurodivergent processing is higher within populations of people seeking mental health support. Over 60% of my caseload are neurodivergent, with half of those clients being identified by me and referred for assessment over the last year, before receiving their diagnosis. The other half of those clients self-identify as neurodivergent, and some of these individuals are waiting to save up, or are on a waitlist to access a diagnosing practitioner. Because of the lack of research and lack of appropriate diagnostic tools for women and gender- and sexuality-diverse individuals who suspect that they may be neurodivergent, and the lack of training and awareness amongst many psychiatrists and clinical psychologists, many individuals are left to self-identify. While many diagnosing clinicians look unfavourably on self-identification, I would encourage clinicians and the field as a whole to move their attention away from pathologising individuals who self-identify, and direct that motivation and enthusiasm into conducting research that would help close the gap on the much needed knowledge and clinical information that will support neurodiverse individuals.

Questionnaires

When individuals are questioning whether they may be neurodivergent, they can find it helpful to complete some of the questionnaires freely available online that are often used by practitioners to diagnose neurodivergence. Here are a list of some of those questionnaires:

Autism Spectrum Disorder

Girls Questionnaire for Autism Spectrum (GQ-ASC): When applying a cutoff score of 57, the GQ-ASC correctly identified 80.0% of cases. The modified GQ-ASC is an effective and highly discriminant screening tool for use in adult autistic women (Brown et al., 2019).

Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R): This is a screening tool for the identification of autism in adults. On the RAADS-R, a score of 65 or higher is considered indicative of likely autism in adults.

The Camouflaging Autistic Traits Questionnaire (CAT-Q): A total score of 100 or above indicates the presence of camouflaging autistic traits.

The Adult Repetitive Behaviours Questionnaire (RBQ): On the RBQ, a score of 26 or higher is considered indicative of potential autism in adults, and most autistic adults score 36 or higher.

An Unofficial List: This list was put together by Samantha Craft, an autistic woman, and serves as a ‘springboard’ for discussion and awareness of how ASD presents in women.

The Highly Sensitive Person Test: Many individuals are now recognising that Elaine Aron, author of ‘The Highly Sensitive Person‘ was in fact identifying a phenotype of autistic individuals not otherwise captured in research on autism at the time.

Attention Deficit and Hyperactivity Disorder

The Adult ADHD Self-Report Scale (ASRS): Scores above four on Part A of the ASRS are considered ‘highly consistent’ with adult ADHD

Books

The following books have been helpful for some of my clients in exploring and understanding their own neurodiversity:

Spectrum Women: Walking to the Beat of Autism

Divergent Mind: Thriving in a World that Wasn’t Designed for You

Is this Autism?: A Guide for Clinicians and Everyone Else

Your Brain’s Not Broken: Strategies for Navigating Your Emotions and Life with ADHD

The Visual Thinker: The Hidden Gifts of People Who Think in Pictures, Patterns and Abstractions

Spectrums: Autistic Transgender People in Their Own Words

Neuroqueer Heresies