Autism: A New Introduction to Psychological Theory and Current Debate - Tiffany Watt Smith 2019

The impact of cognitive models on autism understanding and practice

IN THIS BOOK, we have focused on attempts to describe autism at the cognitive level. This is the largely hidden, conceptual layer between directly observable behaviour and biology. We have grouped psychological theories of autism into primary deficit models, developmental accounts and cognitive difference models. While each account has experimental evidence in its favour, none of them is universally accepted as an adequate way to describe how autism differs from the neurotypical cognitive experience.

There is another way to examine the validity of these psychological models, however, which is to consider to what extent they — individually or as a collection — have had an impact on society. Here we consider the prevalence and success of approaches to supporting autistic people, grounded in psychological theory. We also review how psychological theory has shifted attitudes to autism, including the important question of autistic people’s perceptions of these theoretical models.

Before launching into this investigation, it is crucial to make a statement about the role that an evidence-based support might have in the life of an autistic person. There is no doubt that large swathes of the literature have described interventions with therapeutic goals that can be summed up as a drive to make autistic people less autistic. In some cases, this amounts to little more than rote training in behaving like a neurotypical person. This isn’t to say, however, that evidence-based interventions (when used in psychological research, the word ’intervention’ merely describes anything that a person doesn’t already routinely do) cannot align with a progressive agenda. There are numerous ways in which psychological theory and robust scientific methods can be leveraged to deliver genuine benefits to the autistic community, without undermining an individual’s identity and self-esteem. For example, an intervention might target specific aspects of common autistic profiles which are agreed to be disadvantageous, like supporting children with autism to develop their communication — whether this focuses on speaking or alternative and augmented communication aids. We might also create autism-enabling versions of generic mental health supports, like cognitive behavioural therapy. Or drugs might be developed to allow an autistic individual to dampen their sensory responses at will — in the same way someone with allergies might take medication before visiting a friend with a pet cat.

1. What does it mean to be evidence based?

There are two ways that a specific approach to supporting autistic people might have a basis in psychological evidence. First, they may have been evaluated using an appropriate scientific method. The ’gold standard’ for building an evidence base is a double-blind randomised controlled trial (RCT) and, where multiple trials have been completed on the same or similar approaches, systematic reviews and meta-analyses of these. There are numerous excellent texts describing these methods properly (e.g. Petticrew & Roberts, 2008; Boutron et al., 2017), so we will limit ourselves to just one or two key observations.

It is essential to understand that trial and meta-analytic methods were developed with reference to investigations of drug efficacy. Drug trials nearly always have a specific, objectively measurable target (e.g. lowering blood pressure) which is known to have clinical relevance. It is straightforward to measure and compare things like dosage (how much you’re meant to take) and adherence (how much you did take) across trials, you can easily have a placebo condition and no-one, including the patients, their family and the trial doctors, needs to know who is taking active drugs and who is getting placebo. For psychological and educational interventions, none of these things is straightforward, some are downright impossible, and all are expensive to achieve. This makes RCTs and meta-analyses of psycho-behavioural supports rare and, often when judged against standard criteria for quality of evidence, poorly rated.

Thus, for psychology-derived supports, these types of evidence may not always be the most appropriate options. It may well be more informative to do a high-quality observational or interview study than to do a low-quality RCT, even if the results are technically less robust. But even if you could design and deliver an excellent RCT, that might not be the right type of evidence for your question — perhaps you’re just not interested in the type of outcome-focused data that this produces. Take the example of ’conversation clubs’ for autistic people. While we might choose an objective, measurable outcome, such as scores on a self-report questionnaire of well-being, in some ways, what we want to capture is the process, not just the outcome. What is the experience of being in the club? Is everyone having a good time? If not, why not, and what could we change to fix this? In the USA a wide-ranging research project on transitions for youth with autism identified a need for greater focus on systems-level factors and population-based outcomes to develop and evaluate measures to improve transitions (Shattuck et al., 2018). Thus, when considering the evidence for or against a specific practical approach, we should not merely apply standard metrics for judging quality of evidence, but also consider whether the evidence is relevant to the claims being made and to the context in which the support is being used.

The second way in which evidence may be brought to bear on practical questions, is that approaches may be grounded in robust theory. In this case, there may be no direct test of the intervention itself, but if it is founded on a theory that in turn is strongly supported by empirical data, then we can say it is evidence-based. An example would be advising families to use explicit and literal language to describe their thoughts and feelings to avoid confusion resulting from difficulty tracking a speaker’s intentions. Or using technology to motivate learning in a student who shows reduced response to social rewards. Or creating a low-impact sensory environment to avoid processing delays and prevent information overload. In these cases, the approach may not have been rigorously evaluated, but the underlying theory has and, to the extent that you endorse that theory, you might also endorse the practical approaches derived from it.

There is no doubt that, from a scientific standpoint, the second type of evidence base is inferior, but also more realistic, especially for things like everyday classroom practices or new technologies. We simply can’t expect an RCT of everything, and we could wait a long time for such studies to get funded. Under these circumstances, an important aspect to consider when evaluating the evidence base for a particular guideline or approach is to reflect on the potential benefits but also harms of that approach. Harms come in many guises. The most obvious is when the novel aspect of the intervention is actively harmful — for example, when a drug has negative side-effects. But just as important to weigh in the balance are economic harms; how much money is being spent on this approach that could otherwise be invested elsewhere? Other resources will also be assigned: time for teacher training and family activities or communal space may be given over to a therapeutic system. If it does not deliver benefit, or even enough benefit, this can be characterised as harmful. Parents can feel under enormous pressure to try any new intervention, at great personal and family cost, both economic and emotional. Another key factor, especially pertinent in the case of autism, is to consider how experiencing some kinds of specialist support might affect self-confidence and self-esteem. We must be sure that any attempts to develop skills or provide opportunities to autistic people are not at the expense of their self-belief and well-being.

Under the circumstances outlined earlier, decisions about the weight of evidence and appropriateness of any particular approach to supporting people with autism, must be made on a case by case basis. As well as considering the issues described, it is also essential to be on the lookout for pseudoscience. Key markers have been developed and published for this, and one example list is reproduced in Table 9.1 (Finn et al., 2005). Sadly, pseudoscience is rife in the autism intervention world and we advise readers to be alert to signs of pseudoscience and to exercise critical judgement when making decisions and recommendations. Parents, in particular, are often bombarded with interventions that have little by way of evidence base; even the most discerning and sceptical mum or dad may feel they have to try these, asking themselves ’what if’ this is the thing that makes a real difference to their child’s well-being.

2. Impact in homes, schools, clinics and assisted living

Many specific approaches to supporting autistic people are delivered in family, educational, clinical or community settings. Delivery can be led by a range of professionals including psychologists, speech and language therapists, teachers, doctors and care professionals in the third sector. The same groups of professionals may also deliver structured training or informal guidance to parents, who then try to implement autism support practices in the home. Crucially, within any of these groups, individuals will have very different levels of autism-specific knowledge and training.

If there is one cognitive theory that all autism training probably covers, it is Theory of Mind (ToM). Talk about ToM is often at the heart of any kind of introduction to autism. Regardless of what we might consider to be the evidence in favour of, or against, this theoretical model, learning that an autistic person may not automatically, accurately or confidently represent the mental states of other people is a very useful ’handle’ for a novice. It reminds practitioners to make information more explicit and encourages them to be patient when an autistic person in their care doesn’t behave quite as expected by neurotypical social norms. Despite this positive role for ToM models in guiding practice, the theory has not led to effective therapeutic approaches to date (Fletcher-Watson et al., 2014). In particular, specifically teaching ToM skills does not produce change in areas that extend beyond the taught skill. The clinical impact of ToM is also limited in terms of diagnostic tools or prognostic indicators. This exemplifies the gap that can exist between a theory’s ’informal’ impact on practice — shaping how people talk and think about autism — versus its ’formal’ impact on things like diagnosis and post-diagnostic support.

Developmental theories have had some successful influence on the design and delivery of supports for very young autistic children. Interventions based on these models can sometimes lead to downstream effects — for example, by developing early joint attention, communication and play skills we can see better language outcomes a year later (e.g. Kasari et al., 2008). Some groups have tested training of parents of infants who are not diagnosed, but do have a higher likelihood of later getting an autism diagnosis, in their play and communication skills. These interventions have also shown downstream effects on later, broader social and communication abilities (Green et al., 2017).

However, this “developmental cascade” model — in which attention to an early pivotal skill is expected to deliver later, generalised, developmental change — is not always successful (e.g. Kaale et al., 2014). This kind of approach may require many hours of intensive intervention, which is a cost to the families involved. Although there is some evidence that earlier intervention relates to greater gains (Kasari et al., 2012), there is no research that directly compares how intervention at different ages yields benefit. Given the lack of a robust evidence base (Green & Garg, 2018), we must remember that the current drive for ’early intervention’ at all costs can be very stressful for parents. For those whose child is diagnosed later, they may be led to believe they have ’missed the boat’ in terms of providing meaningful help to their child. When the child receives a diagnosis early in life, parents’ ability to adapt to, and accept, the diagnosis may be impeded by a desperate scramble to get some kind of intervention in place before it is too late. If intervention for ’high-likelihood’ infants is rolled out, we need to consider the ethics of intervention prior to diagnosis. Finally, and crucially, we need to question whether by intervening in an attempt to enable autistic children to achieve normative developmental milestones we could be denying their right to follow their own, autistic, learning trajectory.

Developmental theories have also been applied to the quest for earlier diagnosis but, as for ToM, no markers have adequate diagnostic precision to support a change in clinical practice. In fact, as noted in Chapter 7, the most consistent early markers seem to come from non-social paradigms, which is at odds with socially focused theoretical accounts. Furthermore, the reliance on neurotypical comparison groups in these studies means that any application to differential diagnosis (i.e. distinguishing autism from other neurodevelopmental disorders, rather than just from typical development) is still far in the future.

There is relatively little to say on the role of information processing accounts in practice. A good educational or home setting will recognise the need, sometimes, to strip down information for an autistic person. There are some manualised educational frameworks which promote this concept — e.g. TEACCH (Virués-Ortega et al., 2017). Detail-focused cognitive style is a notion that teachers and parents find helpful in thinking about how autistic and neurotypical thinking styles may differ (Noens & Berckalaer-Onnes, 2005). However, few formal interventions have resulted from these theories as yet, and they have no role in diagnosis at present. Instead, information processing accounts may have had a greater impact on societal perceptions of autism, and these will be considered next.

3. Societal impact

One of the most marked distinctions between the academic literature and accounts of autism in the mainstream media is the prominence given to theories which we have grouped under the umbrella of “information processing” (see Chapter 8). One example is the so-called extreme male brain theory, characterised in psychological terms by the constructs of systemising and empathising. This account is frequently evoked when considering, for example, how to increase rates of employment among autistic people. Many employment programs aim to channel autistic people into industries characterised by a need for systemising — such as computer and data sciences, finance and risk analysis or engineering. This is all well and good provided that we do not make the mistake of treating autistic people as a homogenous group whose diverse career goals and personal preferences can be met by a one-size-fits-all employment scheme. Furthermore, quite apart from the fit of individual to industry, we also need to consider how autistic people are welcomed into, managed and supported in the workplace.

The influence of information processing models is also apparent in representations of autism in TV and film, where sensory sensitivities, learning disability and ’systemising’ type skills are often apparent. For a long time, the film Rain Man was the bane of many families’ lives, due to its compelling portrayal of an autistic man with minimal independent living skills but also a prodigious memory and mathematical ability. There was nothing inaccurate about the characterisation — in fact, the role was largely based on a real man with autism, Kim Peek, as well as many other talented autistic individuals — but of course, no single media representation can be accurate on its own. Nonetheless, in a recent analysis of representations of autism on screen, Nordahl- Hansen and colleagues (2018) identified that about 50% of autistic characters in popular films and TV shows had some kind of savant skill — much higher than estimates from the literature. They propose that this is probably driven by a creative need for characters with interesting features that can drive the plot of a movie or TV show. However, the same paper also reported that, savant skills aside, on-screen representations of autism are not, on the whole, inaccurate. Rather, they fit the diagnostic criteria almost too closely, resulting in a series of archetypal at best, stereotypic at worst, depictions of autism in the mainstream media. Thankfully, now there are increasing representations of autism and the diversity of the community is starting to be represented on screen (e.g. The Bridge), on stage (e.g. Curious Incident of the Dog in the Night-Time) and in print (e.g. Rubbernecker, The Rosie Project). In addition, autistic characters are starting to be played by autistic actors, as in the new BBC show for children, Pablo. We look forward to this trend continuing, so that characterisations of autism in entertainment can become more authentic to the enormous variability of autistic experiences.

4. Personal impact

Developmental theories can have a positive influence on the experience of autistic people and especially their parents, because they emphasise that autism is present in the individual from infancy (or even before). This may contribute to the validity of the autistic identity and help to discount theories that falsely invoke a causal role for vaccines or other childhood experiences. But at the same time, emphasis on developmental factors prior to diagnosis may suggest a role for the parent in the ’onset’ of autism. Recent UK headlines describing parents who had taken part in a parent-training intervention to help autistic children develop social and communication skills as “super parents” are dangerously close to inferring that autism (or disadvantageous accompaniments to autism, such as language disorders) results from inferior parenting. We should avoid undue pressure on families to ’get it right’ and counter the false notion that autism can, or even should, be prevented with the right environmental influences.

The systematising/empathising account, with its suggestion of reduced empathy, can lead to inaccurate conceptualisations of autistic people as cruel or heartless. The media have hypothesised about the autism status of people who have committed horrific crimes and recently discussed whether autistic people might be more likely to be terrorists. By contrast, the ToM account makes it clear that only a circumscribed set of social representations is likely to be different in autism. We can break the steps required to display empathy down into four parts. First, one must notice someone else’s emotional signals. Second, one must accurately interpret the internal mental state from the outward signals — is this person crying from sadness, happiness, pain or shock? Third, one must be motivated to respond by feeling empathy. And, finally, one must respond in the ’appropriate’ way. A few autistic people might fall at the first hurdle, but many will only struggle with steps two and four. A difficulty extrapolating mental states from visible signs, and working out what is the normative way to respond, should never be confused with not caring. Attachment, empathy and affection are not reduced in autism — although they may not easily recognise another’s thoughts, autistic people are no more likely to be callous than non-autistic people.

Information processing models that emphasise autistic strengths can be great, but these also risk pigeonholing autistic people. Increasingly, we are seeing a community of autistic artists and people in creative industries coming to the fore, though research on this aspect of autism remains lacking. Their talents contrast with the predictions and assumptions from many information processing models. For example, theoretical arguments about reduced generativity in autism are contradicted by the prolific and expansive nature of a lot of autistic art. These contrasts remind us that, even if autism were to be definitively characterised at a cognitive level, a wide variety of behavioural profiles may result.

5. Other ways to think about autism

In this book, we have referenced biological, cognitive and behavioural levels of explanation. These three levels are at the core of psychological studies in autism and beyond — in our efforts to comprehend and describe cognitive processes we must examine observations, derived from biological and behavioural data, which provide the input and output to the ’black box’ of cognition. However, there are also ways to comprehend autism that operate outside this framework — namely social models (see Figure 9.1).

Social models of autism align with the wider social model of disability, which emphasises the disabling effect of the environment, including other people’s negative attitudes. For example, deaf people might point out that hearing impairment is a disability primarily because not everyone is fluent in sign language. In the context of autism, one influential theory based on a social model, is the double empathy problem (Milton, 2012). This account makes the deceptively simple point that a successful social interaction requires the participation of two people. Where interactions between people with and without autism are unsatisfactory, both parties should take mutual responsibility for this situation. Specifically, in relation to empathy, Milton points out how little empathy neurotypical people routinely show for autistic people in their community. This is manifest in our failure to create autism-enabling environments or to adapt our behaviour — e.g. enforcing social norms like eye contact and hand shaking — to the autistic person’s interaction style. This observation, however, should not be construed as suggesting that those who work and live with autistic people fail to accommodate their needs. There are myriad — formal and informal — ways in which parents, siblings and other family members, as well as many under-resourced professionals attempt to adjust their behaviour to accommodate the needs of the autistic people in their lives. The existence of a range of bespoke voice-output apps is just one case in point, where deep understanding of autism and of the essential role of communication for autonomy has been enabling to many autistic people (Fletcher-Watson, 2016).

Figure 9.1 A four-level framework for understanding neurodevelopment

Although this model is not primarily a psychological theory, instead describing autism at the behavioural level, it can be tested experimentally. A number of pieces of evidence have recently emerged that support this model. Sasson and colleagues showed neurotypical raters “thin slices” of information — photographs and short video or audio clips — from autistic and non-autistic contributors (Sasson et al., 2017). They rated autistic people as more awkward and said they were less likely to become friends with them, despite judging both groups as equally trustworthy and intelligent. These judgements show how disadvantaged autistic people may be, as negative first impressions take hold incredibly quickly. Importantly, there was no difference when raters were given just a transcript of the original clips, showing that autistic people were saying all the right things, but just presenting themselves differently. More recently, Sasson has published follow-up work which reveals that disclosing the diagnostic status of the autistic people, and especially increasing the knowledge of autism in the rater, improves first impressions (Sasson & Morrison, 2017). This indicates that interventions in the neurotypical community could play a role in improving the social experiences of autistic people — and that disclosing diagnostic status may be an important part of that.

At the same time, Heasman (Heasman & Gillespie, 2017) showed that the self-ratings of people with autism for abilities like “handling criticism” and “making decisions” were higher than ratings provided by their family members. Autistic participants were well aware of these perceptions, correctly predicting low-ratings from their family. Conversely, neurotypical family members were less accurate at predicting how they would be rated by their autistic relatives. Objective measures of the rated skills were not included, but the patterns of disagreement between ratings of self, other and predicted-other reveal considerable complexity in the relationships of autistic and non-autistic people even within a family unit.

Further evidence comes from the finding (reported in Chapters 6 and 8) that neurotypical judges (and sometimes autistic judges; Brewer et al., 2016) struggle to identify the emotional expressions of autistic people, or interpret their expressions of mental states (Edey et al., 2016; Sheppard et al., 2016). Gernsbacher and colleagues modified a widely used measure of autism traits, the Autism Quotient (AQ), creating versions which emphasised in-group or out-group status (Gernsbacher et al., 2017). For example, items might say I often understand what autistic people are thinking, or I often understand what non-autistic people are thinking rather than the original: I often understand what other people are thinking. The authors found that for both autistic and non-autistic respondents, their self-reported autism quotient increased when given the version of the measure that emphasised their out-group and went down for the in-group version. All of these studies, in different ways, highlight that the neurotypical majority play a significant role in the interactive experiences of the autistic minority. Given this insight, it may be time to re-consider our three-level framework, which positioned environmental influences as a parallel ’stream’ (Morton & Frith, 1995), and instead consider a four-level model for investigating neurodevelopment and neurodivergence.

6. The social model and learning disability

One common objection raised to the social model of disability, and to the neurodiversity movement that arose from that framework, is that they deny the very real challenges faced by some people with autism — especially those with a learning disability. Many feel that the focus on the rights of autistic people is at odds with a recognition of needs, including the needs of the families and supporters of autistic people. The previously substantial overlap between autism and learning disability is now diminishing (though they are still co-present for a significant minority) as diagnostic criteria change. One risk in this transition is that the difficulties faced by those with autism plus learning disability will be solely attributed to their learning disability, without any attempt to understand what part their autism may be contributing. Recognition that autism is partly disabling because of the ’baggage’ that often accompanies it, should not be taken as a reason to disregard the need for autism understanding and accommodations. There is no doubt that a top priority for the field, and for society as a whole, is to develop more ways to allow people with autism and a learning disability to express themselves and achieve greater autonomy and influence (Long et al., 2017). However, while this goal remains elusive, effective and critical engagement with the neurodiversity movement ought to yield benefits for autistic people of all abilities.

There are three reasons to be optimistic about the potential for positive outcomes for learning disabled people as a part of the autistic rights agenda. First, vocal and effective advocates are drawing attention to autism, raising awareness and the level of public understanding and debate. Listening to their perspectives provides insights that may be relevant to other people in the constellation, even when they seem very different. For example, hearing why an autistic woman ’stims’ and how she feels when she does so might help the brother of an autistic child be more accepting of his sister’s flapping and spinning. Second, many autistic advocates have autistic siblings or children, choose to work in autism support settings, or simply meet other autistic people within their community. To presume that an autistic person only has experience of their own ’profile’ denies the realities of a vibrant and engaged autistic community. Moreover, many autistic adults who come across now as fluent and autonomous describe having a very different presentation in childhood — Temple Grandin is one famous case in point. Autistic people have been some of the most powerful advocates for increased understanding of, and attention to, the viewpoints of people with learning disabilities (e.g. Milton & Martin, 2016, 2017). Finally, it is hard to imagine how someone who does not display respect towards autistic people who are articulate self-advocates can claim to be respectful towards other people in the autism constellation. Ultimately, regardless of differences in presentation or lived experience, any attempt to understand and support autistic people cannot pick and choose whose viewpoint we want to hear.

7. Current debates

Summary

Psychologists have been concerned with attempts to describe autism at the cognitive level for more than 30 years. These attempts can be organised into three categories of psychological model: primary deficit models, developmental accounts, information processing models. In every case, there is, at best, fairly limited evidence of specifically designed and evaluated supports for autistic people derived from these accounts. However, each of these has had an impact on practice, public understanding and the autistic experience, sometimes via their integration into training and awareness- raising programmes or via their infiltration of public narratives about autism in the mainstream media. Some of the results of this influence may be positive but in other circumstances, a little knowledge of a psychological theory of autism can be applied in a damaging way. Social models of autism, and of disability more generally, offer a positive way to conceptualise autism, important for public awareness and understanding. Experimental evidence in support of these models is growing and should inform social change.

Big questions

What will be the role of psychological theory in the future, especially in relation to accounts grounded in a social model of disability? How can we leverage the power of experimental methods to yield meaningful benefits to people on the autism spectrum?

What should be the goals of psychology-derived supports for autism? How can we translate perspectives from the autistic adult community into the development of supports for young children? Can we develop measures that reflect autistic lived experiences while also having robust psychometric properties and theoretical relevance? Is there a risk that by stepping in to change something in early development we have a negative effect on a child’s autistic strengths, identity, self-esteem or general well-being?

Is there a risk that growing up as an autistic child means every activity is branded as an intervention: trampolining becomes “rebound therapy”, horse-riding becomes “equine therapy”. Regardless of the quality and benefits of these individual approaches, a childhood crammed with therapeutic experiences could be stressful for both the individual and their family.

Do simplified versions of basic theories — such as the ToM model — have value in the context of providing a quick and easy handle on what autism is? Is it acceptable to boil the complexity and richness of autism down to a few sentences, and if not, how can we disseminate difficult ideas and debates to professionals, like teachers, with limited time and resources?

COMMUNITY CONTRIBUTION: FERGUS MURRAY — TEACHER AND CO-FOUNDER OF THE AUTISTIC MUTUAL AID SOCIETY, EDINBURGH (AMASE). THEY WRITE ON THE INTERNET UNDER THE NAME OOLONG

I have always found it odd how much about autistic experience is left untouched by most theories about autism. Executive dysfunction is a useful term to describe aspects of autistic thinking, but says nothing about perceptual differences and barely addresses social difficulties. Thinking in terms of ToM may provide a useful handle for novices, but it does nothing to help people to understand problems relating to inertia or, again, perceptual differences. The ’extreme male brain’ theory leaves similar gaps. The enhanced perceptual functioning hypothesis, mentioned in Chapter 7, does deal with perceptual differences but is less convincing in providing an account of differences in social interactions and attentional control.

Scientific theories are useful to the extent they have explanatory and predictive power. From my perspective as an autistic adult and a science teacher, none of the theories presented in this chapter are altogether satisfactory on this front. Even within the domains of autistic experience that they do address, I have misgivings.

Theory of Mind deficit does little to explain communication difficulties resulting from literal-mindedness, or from neurotypicals having just as much difficulty understanding autistic minds as vice versa. As such, it is a weak explanation for observed social difficulties; worse, focusing on social manifestations of autism has evidently been a factor in the under-diagnosis of female autists, and others who blend in better (Lai et al., 2017). It also backfires when people wrongly assume autistics don’t understand other people’s perspectives (Heasman & Gillespie, 2018) and that problems in communication all stem from the autistic side.

The category of ’executive functions’ includes several different cognitive abilities, and many other conditions also affect some of these in different ways, so distinguishing their role in autism requires considerable elaboration. The lack of parsimony here limits the usefulness of the idea in understanding autism; it needs breaking down into components before it really starts to explain anything. In my experience, the biggest factor in autistic executive dysfunction is inertia; thinking in those terms provides a much tighter explanation than ’executive dysfunction’ for most (but not all) of these difficulties.

The only theory I’m aware of that seems to make a decent stab at explaining the many seemingly disparate features of autistic psychology — from inertia to communication problems to hyperfocus and spiky profiles — is monotropism. However, this theory (formulated by autistics who aren’t professional psychologists) has received relatively little attention from psychologists and awaits direct empirical verification.

Recommended reading

Boucher, J. (2008). The autistic spectrum: Characteristics, causes and practical issues. London, UK: SAGE Publications Ltd.

Gernsbacher, M. A., Stevenson, J. L., & Dern, S. (2017). Specificity, contexts, and reference groups matter when assessing autistic traits. PloS One, 12(2), e0171931.

Milton, D. E. (2012). On the ontological status of autism: The ’double empathy problem’. Disability & Society, 27(6), 883—887.