As a psychologist, neuroscientist, and neurodivergent individual, I adopt a neurodiversity-affirmative, person-centred approach. For me, that means respecting clients’ perceptions and focusing on their needs, regardless of how typical or atypical these perceptions and needs may seem. This can be achieved by employing neuroscience and healthcare knowledge while adopting an open-minded collaborative stance, co-creating the understanding with the client and finding the way forward together.
What is Neurodiversity and 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). Although this is not a clear-cut, distinct cathegories help structure a very complex landscape of traits. Common forms of neurodivergence include ADHD, autism, and dyslexia, accounting for 5–8%, 1–3%, and 5-10% of the population (2, 3). Notably, these intersect. For example, about half of autistic people also have ADHD.
Medical Model and Neurodiversity
Until recently, ADHD and autism were viewed exclusively through a medical lens, reflected by the terms attention deficit hyperactivity disorder and autism spectrum disorder in DSM-5 and ICD-11 classifications. 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.” These definitions illustrate two merging but notably distinct tendencies: an implicit idea of normality and a more contemporary functional focus on the mental and social wellbeing.
Recently, medical definitions were challenged from a social model of disability perspective (4). While society is often not accepting of people presenting differently, for example, not making eye contact or talking “too much”, this might indicate too rigid social norms of communication rather than a deficit within the neurodivergent individual. Thus, certain traits become disabling only in a social environment that is not accommodating to the diversity of humankind. This is what can be hopefully changed through neurodiversity advocacy and self-advocacy.
At the same time, other manifestations associated with autism and ADHD, such as difficulties initiating and completing tasks (executive dysfunction) or, as an extreme example, seizures, are commonly perceived as problematic by neurodivergent individuals themselves. Executive dysfunction can be helped both by environmental adaptations and ADHD medications, while seizures are life-threatening and require medical management. For me, being neurodiversity-affirmative does not mean underestimating the suffering or opposing any biological treatment. Rather, it means centring on what matters to the individual versus on what is traditionally regarded as normal or disordered and finding the most effective ways of meeting their needs.
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 hate 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 autistics is higher than within neurotypicals (5).
With such variability, does it make sense to use diagnostic categories? Probably 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. Studies show that 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 fewer 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 sequential, 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.
Why Psychotherapy?
Having said that, it would be a mistake to look at neurodivergence through rose-tinted glasses. Even without intellectual disability, it is linked to adverse mental health outcomes. Up to 80% of autistic and ADHD people have conditions such as depression, anxiety disorders, posttraumatic stress (PTSD), eating disorders or substance abuse (9, 10). ADHD and autism are associated with a 5-fold and 7-fold increased risk of suicide, respectively (11, 12). At the same time, neurodivergence is associated with resistance to both pharmacological and psychotherapeutic treatment (13). Even more, therapy that aims at “converting” a neurodivergent person to neurotypical, not respecting their way of being and failing to understand them, can become a traumatic experience. Importantly, common negative experiences with psychotherapy do not mean that it is not effective for neurodivergent individuals, but rather that approaches need to be adjusted.
🧠 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. Another common challenge of autistic people is alexithymia—difficulties recognising and labelling one’s own emotions. Alexithymia interferes with understanding and expressing needs, has a negative impact on relationships, and contributes to chronic stress. It is important not to underestimate the difficulties of neurodivergent people who seem 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 important 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 common in autistic females and non-binary people, but is not unfrequent in autistic males and those 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. This means accepting the way other people are and their limitations, but respecting your right to live a more authentic life.
🧠 Trauma
Mental health challenges of neurodivergent individuals are closely linked to trauma. Autistic and ADHD people have a 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 imagery rescripting in schema therapy. Often, neurodivergent people need a substantial amount of trauma-focused work to recover from depression and other chronic mental health conditions.
🧠 Relationships
Last but not least, neurodivergent people might need family and couples therapy. As a rule of thumb, autism, ADHD, and dyslexia can be found in several family members, both because they are genetically inherited and because neurodivergent people tend to build romantic relationships with folks of the same kind. In such neurodivergent families, brains might show more differences between the family members than in a neurotypical family, making it challenging to understand each other. In addition, high sensitivity, intensity of emotional experiences, limited energy resources, and alexithymia may get in the way towards a balanced relationship. Parents might experience burnout, and couples might face conflicts or disconnection. Couples and family therapy that takes into account the influence of neurodiversity can be highly beneficial in such cases.
References
(1) A detailed explanation of the neurodiversity 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.