As a psychologist, neuroscientist, and neurodivergent individual, I adhere to the neuroaffirmative, non-pathologising therapeutic approach. I also believe that while working with ADHD, autism, other neurodevelopmental conditions, and brain injury, it is essential to adjust psychotherapy based on the growing body of research data. In this long read, I attempted to briefly outline my view on neurodivergence and why and how neurodivergent people can benefit from psychological support.
What is Neurodivergence?
All people have different brains, and the way our neural networks are wired has a profound impact on how we think, feel and communicate. The neurodiversity of humankind makes it interesting to meet people who are not like us and helps us complement each other’s strengths and difficulties, thus being effective as a team.
While all people are neurodiverse, some people are also neurodivergent, meaning their brains significantly differ from those of the neuromajority (1). The most common forms of neurodivergence are ADHD and autism, accounting for 5–8% and 1–2.5% of the population (2, 3). Notably, about half of autistic people also have ADHD. Other types of neurodivergence are dyslexia, dysgraphia, dyspraxia and acquired brain injury. In this article, I will focus on ADHD and autism, but in many aspects, the same can be applied to other types of neurodivergence.
Neuroaffirmative Approach vs. Deficit Discourse
Until recently, ADHD and autism were viewed through a deficit lens, reflected by the terms attention deficit hyperactivity disorder and autism spectrum disorder and still dominating in medical classifications such as DSM-5 and ICD-11. Autism is defined as “persistent deficits in the ability to initiate and to sustain reciprocal social interaction and social communication, and by a range of restricted, repetitive, and inflexible patterns of behaviour.” To be diagnosed with ADHD, one should demonstrate “a persistent pattern of inattention and/or hyperactivity-impulsivity that has a direct negative impact on academic, occupational, or social functioning.”
More recently, it became evident that neurodivergence is a genetically inherited difference rather than a deficit or disease (4). While society might not be accepting of people presenting differently, for example not making eye contact or talking “too much”, it does not mean that this way of being is not valid. Of note, even if thought of in terms of social adaptation, autism and ADHD might both disable or enable, depending on the environment. Neuroaffirmative approach aims to recognise and celebrate differences rather than pathologising them while providing individuals with tailored support.
Neuroscience of Neurodivergence
Neurodivergent people are a very diverse group. Some autistic folks experience communication difficulties while others appear as very sociable people, some love math and easily write code while others have problems dealing with their own smartphones. ADHD people might struggle to organise themselves to buy groceries or might effectively manage big teams, being praised for their abilities to multitask by social recognition. Some ADHD people don’t mind their attention at all but rather present with emotional dysregulation as their main complaint. In neuroscience, there is a term idiosyncrasy, reflecting the fact that no two autistic brains are the same, the diversity of neural connectivity within the “ASD” group is much higher than within the neurotypical group (5).
With such variability, does it make sense to use diagnostic categories? Yes, because it is not the appearance but the inner mechanisms that matter. Autistic people are not the ones who fail to communicate in the “socially appropriate” way, but those whose brains perceive and integrate information differently. To make a long story short, autistic brains tend to intake all the incoming information rather than filter out what is considered irrelevant (6). This spongy behaviour leads to some unpleasant consequences such as sensory overload when a person can be easily stressed out by a noisy environment or even by a cloth not fitting well enough. However, when autistic people succeed in dealing with this heightened amount of information, they can show exceptional analytic skills and create works of art.
Similarly in ADHD, the frontal lobes show less top-down connections to the lower-order cortical and subcortical areas, making the brain less regulated and more flexible (7). As a result, ADHD attention is less ordered and successive, but rather multidimensional, multitasking and creative. It is a challenge to deal with such complexity, but it is more than a deficit. People with ADHD can be very creative, and, surprisingly, can be effective managers in non-standard settings, where there is a need to think outside the box, to be flexible rather than rigid (8). On a parallel track, ADHDers tend to have intense emotions and might be especially sensitive to rejection (RSD, rejection sensitive dysphoria)—another consequence of having their subcortical structures less regulated.
If It Is Not a Disease, Then Why Therapy?
Having said that, it would be a mistake to only reassure neurodivergent people that they are OK without offering them help. Up to 80% of autistic and ADHD people have mental conditions such as depression, anxiety disorders, posttraumatic stress (PTSD), eating disorders or substance abuse (9, 10). ADHD and autism are with a 5-fold and 7-fold increased risk of suicide, respectively (11, 12). Neurodivergence is associated with resistance to both pharmacological and psychotherapeutic treatment (13). The often-present negative experience with psychotherapy is related to the unfortunate fact that usually treatment is not adjusted for people whose brains work differently. Even more, the therapy might not be neuroaffirmative, meaning that it aims at “converting” a neurodivergent person to neurotypical, not respecting their way of being and in fact being a traumatic experience. So, why do neurodivergent people struggle and how a psychologist can help?
🧠 Not a Disease, But a Disability
Social, learning and emotional disability are not a rule but often accompany ADHD and autism. According to the social model of disability, it is not about the disabled person being broken, but about the environment not matching their needs. For example, autistic people usually find the typical urban environment too sensory noisy, and for many ADHDers learning or working conditions don’t offer enough novelty to engage their brains and are too restrictive for their wild attention. Fortunately, there is some flexibility in this world, and the goal of therapy is to help neurodivergent people understand themselves, connect to their needs and build their lives in the best way possible. This work is quite complex and requires mapping out the neurobiology of a particular idiosyncratic brain rather than only using stereotypical knowledge about autism and ADHD. The goal is to build the connection between brain functioning, strengths and difficulties, accepting the way it is, developing an individual support toolbox, and advocating for your needs in the community.
🧠 Spiky Profiles of Strengths and Weaknesses
Neurodivergent people tend to have spiky profiles of strengths and weaknesses, meaning that they might be very effective in some spheres while being disabled in others (14). For example, an ADHD person might be smart at creative work but helpless when faced with boring housework. Often, autistic people can do well cognitively but struggle to deal with their own bodies, displaying rapid shifts between too-low and too-high arousal and requiring a lot of care just to function. Another common difficulty of autistic people is alexithymia—difficulties recognising and labelling your own emotions. Alexithymia makes it more challenging to understand and express your needs and thus has a negative impact on the quality of relationship and contributes to chronic stress. It is important not to underestimate the difficulties of neurodivergent people who are well-adapted and not to mix disability with laziness. Thus, a person who generally does well might still need therapy to support the troughs of their profile.
🧠 Masking and Mental Health
Another reason why not only disabled neurodivergent people need support is that, as mentioned previously, it is of importance how it works inside rather than how it looks from the outside. Many autistic and ADHD people can mask their differences, following the neurotypical social conventions of communication (15). Masking might help in terms of career, but it is related to devastating mental consequences, including feeling non-authentic, disconnected from yourself and other people, being depressed and even thinking about suicide (16). Hiding and suppressing yourself to fit in is a very traumatic experience. Masking is especially typical for autistic females and non-binary people but is not unfrequented in autistic males and people with ADHD. When it comes to masking, the goal of the therapy is to develop self-understanding and invent more flexible, balanced ways of dealing with social demands, accepting the way other people are but respecting your right to live a more authentic life.
🧠 Trauma
While some difficulties come from the neurodivergence itself, others originate from trauma. Autistic and ADHD people have dramatically heightened risk of adverse childhood experiences, including but not limited to bullying, parental divorce, income insufficiency, and sexual abuse (17, 18). In addition to easily noticeable traumatic events, neurodivergent people might suffer from background feelings of being rejected because of the way they are, failing to fit in, trying hard but not succeeding, and other. Trauma has a profound impact on psychological wellbeing and thus needs to be addressed by special therapy techniques such as EMDR or rescripting in schema therapy. Often, neurodivergent people need a substantial amount of trauma-focused work to recover from depression and other chronic medical conditions.
🧠 Relationships
Last but not least, neurodivergent people might need family and couple therapy. As a rule of thumb, autism and ADHD can be found in several family members, both because they are genetically inherited and because neurodivergent people tend to find folks like them to be of more interest for a romantic relationship. In such neurodivergent families, brains might show more differences between the family members than in a neurotypical family, making it more challenging to understand each other. In addition, high sensitivity, intensity of emotional experiences, limited energy resources and sometimes alexithymia may get in the way towards a balanced relationship. Parents might experience burnout, and couples might face conflicts or disconnection. Couple and family therapy taking into account the influence of neurodivergence can be highly beneficial in such cases.
References
(1) A detailed guide on neuroaffirmative language can be found here.
(2) E. Abdelnour, M. Jansen, J. Gold. ADHD Diagnostic Trends: Increased Recognition or Overdiagnosis?
(3) R. Sacco et al. The Prevalence of Autism Spectrum Disorder in Europe.
(4) See, for example, an explanation by NHS: “Being autistic does not mean you have an illness or disease. It means your brain works in a different way from other people.”
(5) O. Benkarim et al. Connectivity alterations in autism reflect functional idiosyncrasy.
(6) E. Pellicano, D. Burr. When the world becomes ‘too real’: a Bayesian explanation of autistic perception.
(7) K. Rubia. Cognitive Neuroscience of Attention Deficit Hyperactivity Disorder (ADHD) and Its Clinical Translation.
(8) L. Schippers et al. A qualitative and quantitative study of self-reported positive characteristics of individuals with ADHD.
(9) M.Hossain et al. Prevalence of comorbid psychiatric disorders among people with autism spectrum disorder: An umbrella review of systematic reviews and meta-analyses.
(10) M. Katzman et al. Adult ADHD and comorbid disorders: clinical implications of a dimensional approach.
(11) C. Fitzgerald et al. Suicidal behaviour among persons with attention-deficit hyperactivity disorder.
(12) T. Hirvikoski et al. Premature mortality in autism spectrum disorder.
(14) N. Doyle. Neurodiversity at work: a biopsychosocial model and the impact on working adults.
(15) You can find a self-assessment masking questionnaire here.
(16) S. Cassidy et al. Is Camouflaging Autistic Traits Associated with Suicidal Thoughts and Behaviours? Expanding the Interpersonal Psychological Theory of Suicide in an Undergraduate Student Sample.
(17) N. Brown et al. Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.
(18) D. Hoover, J. Kaufman. Adverse childhood experiences in children with autism spectrum disorder.