A Neurodiversity Paradigm Breakdown of the DSM-5 Criteria for Autism
From the perspective of a trauma-informed positive autistic identity
Reader’s Note: Quotes from the DSM-5 appear in regular text. The neurodiversity paradigm perspective appears in italic text written by autistic trauma specialist Janae Elisabeth. The medical model of autism presented in the DSM may be particularly disturbing for autistics to read. If you begin to feel dysregulated, it’s ok to stop and come back to this later when you’re feeling more resourced.
Diagnostic Criteria for 299.00 Autism Spectrum Disorder*
*This is not the full criteria. It is a representative selection from the full text
All of the following should be understood as a speculative story from a dominant cultural group about a minority cultural group presented with deep bias and without any attempt to understand how that minority cultural group perceives their differences.
To meet diagnostic criteria for ASD according to DSM-5, a child must have persistent deficits in each of three areas of social communication and interaction (A) plus at least two of four types of restricted, repetitive behaviors (B).
A. Persistent deficits in social communication and social interaction:
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
All of these apparent “deficits” are either stress or trauma responses or perfectly functional neurodivergent social interactions. A stressed or traumatized autistic person will not feel safe to hold conversation, share interests, or initiate social interactions because of the trauma associated with past attempts.
In addition, the expectation of back and forth conversation, sharing of emotions, and initiating social interaction is uniquely neurotypical. Autistic people do not need to speak to share emotional information, we have different cultural conversation patterns, and we often prefer to let others initiate socialization so that we can be sure they are participating willingly.
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
All of these apparent “deficits” are either stress responses or perfectly functional neurodivergent communication differences. When an autistic person is overwhelmed by a sensory or social aspect of their environment, their body starts to shut down and the communication parts of the brain go offline. This is a normal response to stress which should prompt an inventory of potential stressors rather than the assumption that the person who is having a stress response is dysfunctional. The idea that autistic stress responses are deficits or the result of “faulty neuroception” is deeply emotionally damaging to autistic people.
Additionally, autistic people communicate with nonverbals very differently from neurotypical people to such an extent that neurotypical researchers would not be able to comprehend or recognize functional autistic nonverbal communication. Differences in eye contact and body language are also attributable to cultural differences. Eye contact and direct gaze can result in an overwhelming level of information input to autistic people, so we keep each other safe during social interactions by averting our gaze and not making eye contact.
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
All of these apparent “deficits” are either trauma responses or perfectly functional neurodivergent social behaviors. Difficulty in developing and maintaining relationships is primarily due to misunderstandings between the autistic person and neurotypical peers which result in the autistic person being excluded, bullies, or punished for their differences.
Difficulty in understanding neurotypical relationship expectations is due to cultural differences and goes both ways — neurotypicals have just as much difficulty understanding autistic relationship expectations. Since NTs are the ones in power, they have determined that these relational differences should be pathologized and eradicated.
Autistic people have no lack of interest in their peers and have no difficulty making friends with other autistic people. It is healthy and natural to not desire connection with people who don’t understand us or who regularly respond violently to our differences. [Link: Autistic People Do Want to Socialize They May Just Show It Differently]
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:
Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
Repetitive movements and “motor stereotypes” are perfectly normal expressions of mammalian nervous systems. Everyone does them to some extent. Autistic people do them more than others, but there is no reason to pathologize repetitive or stereotypical motor behaviors. The unique forms of autistic expression, movement, play, and echolalia are celebrated in the autistic community.
Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
Insistence on sameness is one of the primary ways autistic people cope with the day to day overwhelm of living with neuronal hypersensitivities and hyper-plasticity. The intense world theory of autism explains why routines and rituals help autistic people. Neurotypicals also rely on routines and have difficulty with transitions in times of extreme stress.
Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
One could not offer a clearer picture of neurotypical cultural supremacy than the pathologizing of “preoccupation with unusual objects or excessively narrow and obsessive interests.” By whose standard do we judge something “unusual” or “excessive”? We can be sure no one asked autistic people about the function of their special interests or strong affiliation with objects. Special interests and personification of objects are frequently an expression of the autistic social engagement system / ventral vagus state.
Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
In the neurodiversity paradigm, hyper- and hypo-reactivity to sensory input is among the defining traits of the autistic neurotype. Hyper-reactivity is the natural effect of heritable neuronal hyper-sensitivity and hyper-plasticity. Hypo-reactivity is a common response to sensory trauma. Complex PTSD can mimic this heritable autistic trait. If someone’s hypersensitivity disappears after successfully integrating past trauma, that person is not autistic. When autistic people integrate past trauma, they experience a shift in their threshold for sensory overwhelm along with increased sensory input as hypo-reactive sensory systems resume function. Healing trauma may actually cause an increase in disability and perceived dysfunction as the autistic person becomes more internally authentic.
Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
In a book that is supposedly about mental health, masking is barely mentioned. It’s a major oversight considering, masking (suppressing natural biological responses in order to appear socially acceptable) is the leading cause of depression and suicide in autistic people. Unfortunately, the effect of a diagnostic list like this one is to enforce masking. When an autistic person’s natural behavior is deemed pathological by neurotypical experts and when educators and therapists seek to train children into behaving in ways that are not innate to their divergent bio-social nervous systems, the end result is trauma. When the trauma of forced masking is ignored by mental health professionals, the result is a systemic gaslighting of autistic people. [Link: New research sheds light on why suicide is more common in autistic people]
Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
In modern western societies, being autistic is a disability. This does not mean our innate traits cause impairment; it means that society has failed to adapt to our differences in functioning. Social and occupational impairments that exist in a capitalist society are not viewed as impairments in interdependent indigenous cultures. Autistic people with high support needs should not be pathologized for being dependent on others for help with social or occupational functions. Many autistic people with low support needs have extreme difficulty getting their support needs met because masking prevents professionals and educators from recognizing our need for support. We must destigmatize the need for support of all kinds. Needing support does not mean a person is dysfunctional. [Link: Indigenous Perspectives of Disability by Minerva Rivas Velarde (Faculty of Medicine, University of Geneva)]
Janae Elisabeth is an autistic researcher, educator, and neurodiversity advocate who believes free neuroscience education will change the world.
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