In November 2022, I presented on the topic "Identifying Autism in Undiagnosed Women" at the National Art Therapy Conference. I'm sharing here the abstract I submitted to the conference prior to being accepted as a speaker. This abstract is not my traditional writing style, but I think the information is relevant to autistics and therapists alike.
When most therapists diagnose autism, they rely on the symptoms listed in the DSM-5 for Autism Spectrum Disorder, such as difficulty with socializing, repetitive behaviors, and low eye contact (American Psychiatric Association, 2013). The DSM-5 symptoms are primarily derived from observations and studies of cis-white-heternormative boys and do not reflect the general autistic population (Nerenberg, 2020). Many autistic girls go undiagnosed because their symptoms do not match what is listed in the DSM-5 (Haney, 2016).
Neurodiversity offers a new framework that sees autism as a difference in brain functioning, processing, and learning (Haney, 2018). These differences are not seen as pathological, but simply different from the average individual, referred to as “neurotypicals” (Clarke & van Amerom, 2008).
The intense world theory (Markarm, Rinaldi, & Markram, 2007) suggests that autistic individuals have a greater amount of neural connections that likely fire more rapidly in conjunction with other neural pathways. This difference leads to higher sensitivity in the five senses, greater intensity of emotions, and a higher volume of quick, connected thoughts (Markram, Rinaldi, & Markram, 2007).
The high input of information can be beneficial (such as having better hearing, delighting in small things, and creative brainstorming), but it can also become overwhelming. When overwhelmed, autistic individuals rely on different coping mechanisms. While boys tend to cope in ways that are externally visible (i.e. stimming), research shows that autistic girls tend to cope internally (Haney, 2016). Girls externally mask the discomfort they are feeling, often leading to depression and anxiety (Nerenberg, 2020). They also overcompensate by finding areas in which they excel, such as academics and creative endeavors. Their academic excellence helps them to fly under the radar (de Giambattista, Ventura, Trerotoli, Margari, & Margari, 2020).
By the time an undiagnosed girl reaches adulthood, she often knows there is something different about her. This is often converted into self-judgment, wondering what is “wrong” with her (Nerenberg, 2020). When she seeks therapy, her autism is not recognized by therapists who rely on the DSM-5 criteria (de Giambattista, Ventura, Trerotoli, Margari, & Margari, 2020).
A therapist with a neurodivergent lens can identify autism by watching for clusters of traits related to perception, communication, relationships, social functioning, and talents (Ekblad, 2013). Therapists can be aware of how these manifest in women. For example, most autistic women’s special interests are in the social/arts realm, such as psychology, art, and music (Nerenber, 2020). Autistic women are often exceptionally empathetic, observant, and understanding (Nerenberg, 2020). They see things as they are and want to communicate them as such. They often struggle in social situations when others do not communicate directly (such as hiding one’s true feelings to save face) or speak in unkind ways (gossip, sarcasm, manipulative behavior, etc.) (Toeps, 2019). They often need breaks from out-of-home activities due to the exhaustion of navigating social situations and constant high levels of input (Toeps, 2019). Due to these challenges, autistic individuals often like to anticipate where they are going, what they will be doing, and what will be expected of them (Toeps, 2019).
When an autistic woman knows she is neurodivergent, she can begin to understand and accept how her brain functions. She can release self-judgment and learn to work with her brain. She can learn how to capitalize on its strengths, develop strategies to slow input, and learn skills to cope when overloaded (Nerenberg, 2020).
The author of this paper learned she was autistic in her 30’s and now works with neurodivergent clients. She will share research, client artwork, and personal vignettes to illustrate how to identify autism in undiagnosed women.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi-org.ezproxy.frederick.edu/10.1176/appi.books.9780890425596
Clarke, J., & van Amerom, G. (2008). Asperger’s syndrome: Differences between parents’ understanding and those diagnosed. Social Work in Health Care, 46(3), 85–106. doi:10.1300/j010v46n03_05
de Giambattista, C., Ventura, P., Trerotoli, P., Margari, F., & Margari, L. (2021) Sex differences in autism spectrum disorder: focus on high functioning children and adolescents. Frontiers in Psychiatry. 12.
Ekblad, L. (2013). Autism, personality, and human diversity: defining neurodiversity in an iterative process using aspie quiz. SAGE open. 3 ( 2158244013497722). http://sgo.sagepub.com/content/3/3/2158244013497722.abstract
Haney, J. (2016). Autism, females, and the DSM-5: Gender bias in autism diagnosis, Social Work in Mental Health, 14 (4). 396-407, DOI: 10.1080/15332985.2015.1031858
Haney, J. (2018) Reconceptualizing Autism: An Alternative Paradigm for Social Work Practice. Journal of Progressive Human Services. 29 (1), 61-80.
Markram, H., Rinaldi, T., & Markram, K. (2007). The intense world syndrome—An alternative hypothesis for autism. Frontiers in Neuroscience, 1(77-96).
Nerenberg, J. (2020). Divergent Mind. Harper Collins.
Toeps, B. (2019). But you don’t look autistic at all. Blossom Books.