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This article proposes a link between autistic people being misperceived by the neurotypical majority and their being at risk of poor mental health and wellbeing. We present a transactional account of development in which the misperceptions (and consequent behaviour) of the neurotypical majority influences the perceptions and behaviour of autistic people such that they become increasingly separate and indeed isolated from mainstream society. This jeopardises their mental health and prevents autistic people from developing to full potential. The situation is not only problematical for the development of autistic people but is also to the detriment of wider society, in so far as autistic people are effectively prevented from contributing fully. This account assumes that some (not necessarily all) autistic people yearn to be included, to be productive and to be useful. It thus directly opposes accounts that view autism as an extreme case of diminished social motivation.
British Journal of Developmental Psychology (2021), 39, 1–18
©2021 The Authors. British Journal of Developmental Psychology
published by John Wiley & Sons Ltd on behalf of British Psychological Society
Invited Article
Autism and the double empathy problem:
Implications for development and mental health
Peter Mitchell
*, Elizabeth Sheppard
and Sarah Cassidy
School of Psychology, University of Nottingham, UK
School of Psychology, University of Bradford, UK
This article proposes a link between autistic people being misperceived by the
neurotypical majority and their being at risk of poor mental health and well-being. We
present a transactional account of development in which the misperceptions (and
consequent behaviour) of the neurotypical majority influences the perceptions and
behaviour of autistic people such that they become increasingly separate and indeed
isolated from mainstream society. This jeopardizes their mental health and prevents
autistic people from developing to full potential. The situation is not only problematical for
the development of autistic people but is also to the detriment of wider society, in so far as
autistic people are effectively prevented from contributing fully. This account assumes
that some (not necessarily all) autistic people yearn to be included, to be productive and
to be useful. It thus directly opposes accounts that view autism as an extreme case of
diminished social motivation.
This article explores how the experience of living in a largely neurotypical society could
hinder development of abilities which allow smooth interactions between autistic
neurotypical people. Autism is classified as a lifelong developmental condition marked by
difficulties with social communication coupled with a restricted range of interests (DSM-
5; APA, 2013). However, a particular aim of the article is to explore how being
misunderstood or misperceived by other people could create a barrier to participation in
social experiences for the minorityautistic people. We argue that this barrier acts to
prevent both groups (autistic and non-autistic people) from having otherwise valuable
opportunities to learn about each other’s social behaviour and about how to interpret
signals emanating from the other group. These signals can be informative about inner
states (like what the person is thinking or how they feele.g. Valanides et al, 2017) and
traits (such as whether the person is kind, trustworthy, shy, calm, etc.e.g. Wu et al,
2016, 2019).
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
Correspondence should be addressed to Peter Mitchell, School of Psychology, University of Bradford, Bradford, BD7 1DP, UK
We use the term “autistic people” in this paper rather than “people with autism”, as this terminology is preferred by a majority of
autistic people (Kenny et al, 2016).
A further aim is to explore the developmental consequences of this barrier for each
group (autistic and neurotypical). Autistic people, who are in the minority, might respond
by trying to hide or camouflage their autism-specific style of social interaction and attempt
to emulate the social interaction style of the neurotypical majority (Hull et al, 2019). This
strategy could enable a degree of access to neurotypical social experiences and indeed a
degree of acceptability therein, but at psychological cost owing to the effort that has to be
exerted (Hull et al, 2017), coupled with the stress associated with the risk of being ‘found
out’ (Cage & Troxell-Whitman, 2019). Worryingly, research is identifying a strong
association between camouflaging autistic traits, with poor mental health, well-being, and
high rates of suicidal thoughts and behaviours in autistic people (Cassidy et al., 2018;
Cassidy et al, 2019). We urgently need to further understand the risks to mental health
arising from the stress associated with this camouflaging behaviour, coupled with the
sense of isolation, and consequent feelings of loneliness. Our aim is to explore whether
such experiences could lead the individual to feel not valued and unwanted, perhaps
leading to a fatal outcome if the individual feels they are a burden on society and that the
world would be better off without them, with suicide perceived as the only available
option. We propose a new model in order to understand how this process may come
about, and how it may be empirically tested in future research.
On the face of it, the consequences of the misperception for neurotypical people, who
are the majority group in society, are less damaging. Nevertheless, we argue that exclusion
of autistic people from society likely serves to prevent opportunities for neurotypical
people to learn from cross-neurological social interactions, and maintains or even
increases division within society. This in turn means that society does not fully benefit
from the valuable contribution that autistic people could make in many spheres of life,
including innovation, the workforce, and culture, to name but a few (Silberman, 2015).
We adopt an approach that recognizes autism as a developmental disability (where
development is the operative word) situated in a social contexta context that is
powerful in shaping development. We aim to contrast this approach with a medical model
of autism. Our starting point, then, is to compare and contrast the medical model with a
socialdevelopmental account that embraces the ‘double empathy’ view of autism, as
defined below.
The medical model versus a socialdevelopmental account
The medical model assumes that autism exists in the individual as part of their essence,
condition or constitution, a viewthat is likely shared by individuals so diagnosed (Silberman,
2015);that ifwe couldtreatthiscondition(witha kindofmedicalortherapeuticintervention)
togetridofit,thenthe individualwouldbe cured and continuelifethereafterasaneurotypical
person.Our first challenge,then, should be tounderstandthehistoricalcontext that explains
how the medical model came intoexistence. Both Leo Kanner and Hans Asperger, the two
medical doctors credited with discovering autism, understandably subscribed to medical
models of disorders. Indeed, according to Czech (2018), Asperger wassituated in a historical
context where political imperative (favouring eugenics) encouraged an approach that
classified certain ‘defects’ in order to isolate those affected individuals to prevent them
‘contaminating’the widerpopulation.Tothisend,aprogrammeofeuthanasiawas pursuedin
Nazi Austria, the nation in which Asperger worked.
Various cognitive theories of autism (Rajendran & Mitchell, 2007) that came into
prominence over recent decades implicitly subscribed to a medical model of autism, the
2Peter Mitchell et al.
theory of mind hypothesis being a case in point (Baron-Cohen et al, 1985). A particular
version of the theory of mind hypothesis, championed by Leslie (1987), viewed autism as a
defective module that in a neurotypical person enables one to make calculations of what
other people are thinking. This account seemed to imply that if the part of the brain that
hosted the affected module could be fixed, then the individual would be ‘cured’ of their
autism. This account was met with an insightful critique from Hobson (1990): He argued
that in adopting a modular approach the theory of mind hypothesis is a, ‘nondevelop-
mental, nonsocial, and restrictively cognitive account alternative thesis is proposed:
A young child’s knowledge about people is grounded in the experience of ...
interpersonal relations’. (P114). We concur, adding that not only a young child’s but
everybody’s knowledge about people is grounded in the experience of interpersonal
relations. That said, we are not intending to deny that an aspect of autism has an innate
basis, perhaps relating to attentional preferences or priorities. For example, autistic
people may have an innate preference for aspects of the physical over the social world,
unlike typically developing people (e.g. Freeth et al, 2010); and this might explain the
development of heightened visuospatial abilities in autism (Mitchell, 2017).
In contrast to the medical model, a socialdevelopmental account of autism assumes
development is shaped by the kind of responses and reactions we experience when
encountering others. This is a transactional account of development (Mitchell, 2017)
that assumes your behaviour influences how others perceive you which in turn
determines how they behave towards you which then impacts on how you behave which
further influences how others perceive you and so onFigure 1. The transactional model
embraces the view expressed by Karmiloff-Smith (1998), who argued that development
itself is key to understanding developmental disorders. L
opez (2015) concurs, noting that
social experiences critically influence the way autism develops over the lifespan.
A key priority, then, is to understand how autistic people are perceived and
understood by others. Surprisingly, we know little about this, though considerable
research effort has been devoted to demonstrating that autistic people have an under-
developed ability to perceive and understand other (non-autistic) people (e.g. Pillai et al,
2014). This research imbalance is probably driven by the medical model, perhaps with the
implicit belief that if we can identify the nature of impairment in autistic people then we
will be well-placed to reduce or even cure it.
A great volume of research has documented the difficulties autistic people face in
inferring other people’s inner states (Baron-Cohen, 1995). These difficulties are offered as
an explanation for why autistic people experience challenges in social contexts (Frith,
2003). More recently, though, a few researchers have turned the question on its head to
enquire how neurotypical people fare in understanding autistic people, especially in
inferring their inner states (e.g. Edey et al, 2016). Accordingly, Milton (2012) articulated
the ‘double empathy problem’, suggesting that autistic people have difficulty fitting into
society not just because they misunderstand others but also because they are
misunderstood by others. Hence, considering how autistic and neurotypical people fare
in perceiving and understanding each other, there could be a failure of empathy in both
How are autistic people (mis)perceived by neurotypical people?
This is a highly pertinent question but one that is extremely difficult to answer (though not
impossiblesee below). Specifically, it is hard to determine how accurately people infer
Double empathy problem and mental health 3
the inner states of any people, including those who are autistic. The problem concerns the
criterion against which we should compare inferences to determine if they are accurate.
But surely, we could simply ask the person (the target) what their inner state is and then
observe whether another person’s (the perceiver’s) inference tallies with this (Ickes,
2003). The trouble is that what a target declares as their inner state is not a reliable source
of information, as we cannot be certain of the value of introspection in this matter (Wu
et al, 2019): Implicitly, we would be assuming that the target knows their own inner state
through introspection and we would therefore effectively be assuming that introspection
is a valid source of information.
Edey et al (2016) sought an objective measure of mind-reading accuracy by asking
targets to manipulate geometric shapes to enact interactions (between the geometric
shapes) that involved interpersonal emotions, such as coaxing, mocking, seducing, and
surprising. The movements of the shapes were video recorded and then shown to
perceivers who were asked to infer which interpersonal emotions were being depicted
(even though they could not actually see the person who was doing the manipulating).
Neurotypical perceivers were considerably more accurate in their inferences when the
shapes were manipulated by neurotypical targets than when manipulated by autistic
targets. The authors concluded on the strength of this that the inner states of autistic
people are more difficult for neurotypical people to infer than are the inner states of
neurotypical people. Such a conclusion is limited, though, considering that perceivers
were not actually asked to infer inner states of targets but rather were asked to interpret the
movements of geometrical shapes by selecting from a set of interpersonal emotion terms.
Our research, in comparison, invites perceivers to interpret signals in the behaviour of
targets to infer things such as what a person said to the target (Cassidy, Ropar, et al, 2014,
Figure 1. HowPersonA behavesimpactson how theyare perceivedby others,whichinfluenceshow others
behave, behaviour which is interpreted by Person A, which in turn influe ncehow A behaves. This is an example
of the transactional model of development. [Colour figure can be viewed at]
4Peter Mitchell et al.
2015), what the target is looking at (e.g. a facial expression or a positive/negative image
Kang et al, 2018; Teoh et al, 2017), what the target is thinking (Valanides et al, 2017), and
the status of the target’s social context (whether they are accompanied or aloneTeoh
et al, 2017)see Wu et al (2019) for a summary. These inferences qualify as ‘retrodictive
mind reading’ (Gallese & Goldman, 1998), which refers to the process of interpreting
signals in another person’s behaviour to infer their inner state (the proximal cause of their
behaviour) and perhaps the event in the world that triggered the inner state (the distal
cause of their behaviour, Teoh et al, 2017; Wu et al, 2019). For example, on observing a
person in a bar behaving in a gregarious and uninhibited manner we might infer that they
feel cheerful and tipsy, perhaps, we further infer, because they imbibed some intoxicating
beverages. When perceivers make an inference, usually by selecting among plausible
alternatives, we the researchers can know with complete certainty whether or not the
inference is accurate, as we know factually what the target is reacting to (a particular
stimulus, a cue word, what another person said to them, etc). Hence, if the perceiver
makes an accurate inference, then it is fair to assume that the event the target is reacting to
is signalled in their behavioura signal that is readable to the perceiver.
Granted, one might say that inferring what a target is reacting to does not amount to
inferring the target’s inner states: Perhaps perceivers are able to make inferences from
signals in a target’s behaviour to make direct inferences of the worldly event that caused
the target reaction without giving any consideration to the target’s inner states. However,
an EEG study conducted by Kang et al (2018) suggests that the cortical processing
involved in a retrodictive inference is entirely consistent with the involvement of
mentalistic processing, suggesting that on viewing signals in a target’s behaviour,
perceivers make an inference about the causal worldly event via an intermediary inference
of the target’s inner state (see Wu et al, 2019, for further discussion).
The value of retrodictive inference methodology as described above is manifold. It uses
spontaneous, natural and unguarded behaviour as the target stimuli that perceivers are
invited to interpret. Consequently, it enables us to measure the ability of perceivers to
make inferences about the kind of stimuli they are likely to have to work with in everyday
life. Second, the method outputs a graded measure of the perceiver’s performance,
depending on how many accurate inferences they succeed in making. Third, the task is
intuitively highly accessible, so much so that it can be presented to young children (Kang
et al, 2017) who, like older participants, also demonstrate significantly accurate
In addition, a key value of this method is that accurate inferences depend not only on
the ability of the perceiver to interpret signals but also on the quality of signal emanating
from the target. It stands to reason that some targets will be more readable than others and
this is measurable as the proportion of perceivers who make an accurate inference on
what a particular target is reacting to. It is then possible to rank targets in ascending order
of their readability, as in Figure 2. The figure is based on pilot work in which targets were
observed by multiple perceivers, each of whom made a judgement on what the target was
experiencing in a four-way forced choice task. The data appear as standard scores in the
figure such that chance is zero. If most targets are readable, as we expect, then the majority
will have positive values. If signals emanating from autistic targets are difficult to read,
then they will tend to populate the bottom half of the figure, as we see with the thin lines
(bold lines represent neurotypical targets). Please note that this figure is for illustrative
purposes only and the data depicted have not been submitted to peer review.
Sheppard et al (2016) are credited with the first published article to use a retrodictive
mind-reading paradigm to demonstrate that autistic people (targets) are less readable than
Double empathy problem and mental health 5
neurotypical people by neurotypical others. In this version of the task, the experimenter
greeted the target in one of four ways when they arrived to participate in an activity they
had signed up to do. The targets’ reactions to the experimenter’s greeting were video
recorded. These videos were then shown to neurotypical perceivers, who were tasked
with inferring (based on the target’s reaction) how the experimenter had greeted them.
Neurotypical perceivers were significantly more accurate in making such an inference
when viewing neurotypical than autistic targets, suggesting the signal emanating from
autistic targets was difficult for neurotypical perceivers to read. Note that perceivers were
not informed at any time that some of the targets were autistic.
Is this because the strength or the quality of the signal was different in autistic
compared with neurotypical targets? To find out, Sheppard et al asked a different group of
neurotypical perceivers to rate the expressiveness of targets (without being informed that
some were autistic), and in at least two of the scenarios (in which autistic targets were less
readable than neurotypical targets), autistic targets were adjudged to be equally as
expressive as their neurotypical counterparts. By implication, then, the signal emanating
from autistic targets is not weaker in strength but is of a different quality, compared with
neurotypical targets.
The medical model argues that autistic people experience social communication
impairments, and predicts that these deficits would be amplified in autisticautistic
interactions. In contrast, the double empathy problem argues that autistic and non-autistic
people have different social communication styles, with each group having difficulty
empathising with the other. Therefore, the double empathy problem would predict that
mixed autisticnon-autistic interactions would experience the most difficulty in social
communication, whereas autisticautistic peer communication would be significantly
more efficient in comparison. Research has started to explore these hypotheses. Heasman
and Gillespie (2019a) investigated interactions between two autistic people playing a
video game. Results showed unique aspects of interaction between autistic people.
Figure 2. It is possible to assign a readability value to each target, depending on how accurately multiple
perceivers are able to interpret that target’s behaviour. It is then possible to rank targets from most to
least readable, whilst encoding who is autistic (thin lines) and who is neurotypical (thick lines). Note that
this figure is for illustration purposes. [Colour figure can be viewed at]
6Peter Mitchell et al.
Generous assumptions of common ground and low demand for coordination helped build
rapid rapport, even when there were frequent interruptions in the flow of conversation.
This suggests a different quality to autistic peer interactions, which does not impede
ability to communicate or achieve a common goal. Crompton et al (2019) compared the
quality of a set of instructions to complete a simple task, communicated through a
diffusion chain of participants across three conditionswhere the chain consisted
entirely of autistic people, entirely of non-autistic people, or a mixed chain of non-autistic
autisticnon-autistic people. Results showed that the quality of the instructions, and
successful completion of the task, was significantly higher in the all autistic compared to
the mixed diffusion chain. Together, the evidence suggests that, contrary to the
predictions of the medical model, and consistent with the double empathy problem
model, autistic people have a unique interaction style which is significantly more readable
by other autistic people, compared to non-autistic people.
The research conducted by Sheppard et al (2016), on how the behaviour of autistic
people is interpreted by non-autistic people, is complemented by research by Sasson et al
(2017) on how the behaviour of autistic people is evaluated by neurotypical people. Non-
autistic perceivers watched short videos of targets (some of whom were autistic)
performing a brief audition and then rated how much they favoured each target. Although
the perceivers were not informed that some targets were autistic, their favourability
ratings effectively discriminated between those targets who were autistic and those who
were neurotypical. Specifically, autistic targets tended to be rated negatively. Given that
we generally like people whose behaviour we can interpret, more so than those whose
behaviour we struggle to interpret (Anders et al, 2016), it is reasonable to enquire whether
there is an association between being difficult to interpret for neurotypical people and
being rated unfavourably by this group. Alkhaldi et al (2019) presented the target videos
used by Sheppard et al to a new group of neurotypical perceivers who rated each target on
an adaptation of Sasson et al’s social favourability scales. The findings replicated Sasson
et al in demonstrating that autistic targets were rated less favourable than neurotypical
targets by neurotypical perceivers. Moreover, the findings supported the prediction that
targets who were difficult to interpret also tended to be rated unfavourably. Hence, the
behaviour of many autistic targets was difficult for neurotypical perceivers to interpret
and they also tended to be rated unfavourably by (a different group of) neurotypical
perceivers. Interestingly, though, further statistical analysis revealed that this association
between interpretability (or readability) and social favourability maintained indepen-
dently of clinical diagnosis. In short, the finding is consistent with the possibility that
autistic targets tended to be rated unfavourably by non-autistic others in a way that is not
specifically associated with their being autistic but in a way that is associated with their
behaviour being difficult to interpret.
This begs the question whether autistic people tend to rate other autistic people more
favourably than non-autistic people, given that autistic people’s behaviour appears to be
easier for other autistic people to read (Crompton et al., 2019), and evidence of a unique
shared social communication style (Heasman & Gillespie, 2019a). Two recent studies
have explored this question. Grossman et al. (2019) and Debrabander et al. (2019) both
compared how autistic and non-autistic people rated other autistic and non-autistic peers.
Results in both studies showed that autistic people rated other autistic people as less
socially favourable compared to non-autistic people (similarly to non-autistic raters).
However, in Debrabander et al. (2019), autistic people’s ratings were not perceived as an
impediment to future social interaction (unlike non-autistic raters).
Double empathy problem and mental health 7
How does being misperceived impact on development?
Autistic people have a unique social communication style, which tends to be
misinterpreted by neurotypical people, and are associated with neurotypical people
perceiving autistic people unfavourably. Neurotypical people thus seem to lack the
capacity to empathize with autistic people, just as it is claimed that autistic people lack
capacity to empathize with neurotypical people. In this respect, the condition of autism
should be understood as a bidirectional failure of empathyhence, the double empathy
problem (Milton, 2012). Consistent with this theory, and contrary to the predictions of the
medical model, autistic people communicate more efficiently with other autistic people
than they do with non-autistic people.
How do these misperceptions impact on development for each group? Some
speculation is involved in answering this question and Figure 3 provides a starting point.
We propose that how the behaviour of autistic people is perceived by neurotypical others
(negatively), influences how they behave towards autistic people (unwelcoming), which
is then perceived by autistic people (that they are not welcome), which then impacts on
the behaviour of autistic people (perhaps wariness, mistrust, low self-esteem, lack of
social ability due to lack of positive and rewarding social experience). This in turn will
impact on how autistic people are perceived by neurotypical others (negatively), and so
on. Meanwhile, perhaps neurotypical people tend to perceive autistic people
unfavourably because they struggle to interpret signals in their behaviour; or perhaps
on perceiving autistic people unfavourably, neurotypical people lack empathy and put
little effort into interpreting signals in their behaviour. Either way, because neurotypical
people are unwelcoming towards autistic people and exclude them socially, they do not
learn to interpret their autism-specific style of social interaction, which might serve to
further perpetuate their misunderstanding and misperception.
Figure 3. Hypothesized associations between readability, social favourability, and suicidality. The
proposed association between lack of social favourability with suicidality is mediated by social
camouflaging and thwarted belongingness. Social motivation moderates the association between lack of
social favourability and social camouflaging. Insight into one’s own difficulties moderates the association
between social camouflaging behaviour with feelings of thwarted belongingness.
8Peter Mitchell et al.
Hence, we envisage that early-emerging, or even innate, social interaction differences
between autistic and non-autistic people act as a starting point for a transactional
developmental process across the lifespan, the outcome of which is two ever more
distinct groups, each with their own social interaction styles, which do not understand or
empathize with each other particularly well. This means that both groups miss
opportunities to learn from each other, not just about each other’s’ style of social
engagement, but also fail to benefit from each other’s’ unique skills and abilities. Although
we propose this to be a bidirectional issue, it is plausible that, as suggested by Milton
(2012; see also Chown, 2014), neurotypical people might fail to empathize more than
autistic people, as autistic people probably have greater opportunity (and need) to
interact with and understand neurotypical others than the revers e, because the majority of
society is neurotypical.
The argument above raises the interesting possibility that, if increased cross-
neurological social interaction and inclusion were to occur from an early point in
development, this could alter the developmental course for both autistic and neurotypical
people. Fewer misunderstandings might occur, more favourable cross-group impressions
could be formed, and ultimately perhaps a distinctive cross-neurological social interaction
style could emerge.
One area of evidence which could begin to address our proposed model is to explore
whether people who regularly interact with autistic people over the course of
development, such as family members and siblings, are better able to interpret autistic
people’s behaviours, and also rate their behaviour as more favourable. To our knowledge,
no research has directly addressed this question, although one previous study has
investigated misunderstandings between autistic individuals and their family members
(Heasman & Gillespie, 2018). This research asked autistic participants and their family
members to rate themselves and each other on various characteristics, as well as to predict
how the other would rate themself. It was found that, although both groups perce ived that
the other group would misunderstand them (i.e. differed in their own rating of self and
predicted rating of self by other), neither group experienced significant actual
misunderstanding (i.e. did not differ in predicted and actual ratings of self by other).
This implies that there is a degree of understanding between autistic people and their
family members but, as comparisons with non-family members were not part of this study,
it is not clear what role familiarity had in the findings. There is also initial evidence that
disclosure of autism diagnosis increases non-autistic people’s favourability ratings of
autistic people (Sasson & Morrison, 2019), but this may not translate into meaningful and
positive behaviour change (Heasman & Gillespie, 2019b).
Consequences for mental health of being misperceived
Being socially isolated is likely to have adverse consequences for mental health (H
2019), as is being perceived negatively by others along with the associated damage to self-
esteem (Henriksen et al, 2017). At the time of writing, a link between how autistic people
are perceived and the status of their mental health has yet to be established empirically.
Nevertheless, as there is reason to believe such a link does exist, we can expect to find that
issues of mental health will be elevated in autism. Sadly, the findings of recent research are
entirely as expected. A majority of autistic adults (up to 79%) meet criteria for a psychiatric
condition (Lever & Guerts, 2016) and up to 72% experience suicidal desire (Cassidy,
Bradley, et al, 2014; Cassidy et al, 2018). Autistic people are at significantly increased risk
Double empathy problem and mental health 9
of dying by suicide than the general population, with suicide a leading cause of early
death in this group (Hirvikoski et al, 2016; Kirby et al, 2019, and Cassidy, 2020 for a
Humans have an innate desire to be accepted by others, and to establish meaningful
social connectionsa sense of belonging. Suicide theories developed for the general
population, such as the Interpersonal Psychological theory of Suicide (ITS, Van Orden
et al, 2010) posit that a sense of social belonging is a crucial protective factor against
mental health difficulties, and desire for suicide. Autism research has been plagued by the
unhelpful assumption that autistic people are socially unmotivated (Chevallier et al,
2012), contrary to the testimony of autistic people (Jaswal & Akhtar, 2019; Mitchell,
Cassidy & Sheppard, 2019). This has led to little research exploring how autistic people
may experience constructs like thwarted belonging, and the consequent impact on
mental health through the lens of suicide models such as the ITS. Our participatory
research suggests, however, that autistic people painfully feel the consequences of social
rejection and isolation, with consequent negative impact on mental health.
Autistic people describe belonging as a crucial aspect of their well-being (Camm-
Crosbie et al, 2019; Milton & Sims, 2016), and those who are more likely to report external
indicators of thwarted belonging, such as loneliness (Hedley, Uljarevi
c, Wilmot, et al,
2018), lack of social support (Hedley et al, 2017), dissatisfaction with social support
(Cassidy et al, 2018; Hedley, Uljarevi
c, Foley, et al, 2018), and lack of acceptance in society
(Cage et al, 2018), are also more likely to experience depression and suicidal desire.
Pelton et al, (2020a) explored whether autistic people were more likely to experience
thwarted belonging than neurotypical people, and whether there were similar associa-
tions between thwarted belonging and suicidal desire in both groupsas predicted by the
ITS. Results showed that autistic people reported significantly higher levels of thwarted
belonging than non-autistic people. In fact, thwarted belonging was normally distributed
in autistic people, whereas this experience is typically rare, resulting in a skewed
distribution in the neurotypical group. Thwarted belonging is thus a far more common
everyday experience for autistic people than it is for neurotypical people. Thwarted
belonging was also associated with suicidal desire in both autistic and non-autistic people,
as predicted by the ITS. However, the associations were significantly attenuated in the
autistic compared to the neurotypical group (Pelton et al, 2020a). This could reflect the
fact that the measures designed to capture thwarted belonging in non-autistic people, do
not similarly capture this construct in autistic people (Pelton et al, 2020b).
What other constructs may be relevant to understanding why thwarted belonging is
associated with poor mental health in autistic people? Research has recently identified
that many autistic people try to mask or compensate for their autistic traits in social
situations, in an attempt to ‘fit in’ better with neurotypical people and wider society
(Allely, 2019; Cage & Troxell-Whitman, 2019; Hull et al, 2017; Lai et al, 2017; Livingston
et al, 2019). Autistic people report that camouflaging is exhausting and stressful (Hull
et al, 2017). In co-designed research, autistic people described experiences of trying to
camouflage their autistic characteristics in social situations, but as a consequence their
‘true self’ was not accepted, leading to increased feelings of thwarted belonging, and
consequently the high rates of poor mental health, suicidal thoughts and behaviours.
Consistent with this, the co-produced research showed that camouflaging autistic traits
significantly predicted suicidal thoughts and behaviours, even after controlling for a
number of other risk factors (Cassidy et al, 2018). Cassidy et al (2019) also found support
for a serial mediation effect, where high autistic traits were associated with increased
tendency to camouflage these traits, high levels of thwarted belonging, and suicidal
10 Peter Mitchell et al.
thoughts and behaviours in non-autistic people. The testimony of autistic people,
reflected in research findings, suggest that people who attempt to camouflage their
autistic traits are more likely to experience thwarted belonging and consequently
experience suicidal thoughts and behaviours (Cassidy et al, 2019).
It is important to acknowledge that these proposed associations between readability
and social favourability, camouflaging, thwarted belonging, and poor mental health are
likely a transdiagnostic pathway, present regardless of autism diagnosis (Figure 3).
Indeed, the association between readability and social favourability was present
regardless of autism diagnosis (Alkahaldi et al, 2019), and associations between autistic
traits with camouflaging, thwarted belonging, suicidal thoughts, and behaviours were
found in the general population (Cassidy et al, 2019; Pelton & Cassidy, 2017). However,
given that autistic people are the minority in society, they appear to be at significantly
greater risk of being difficult to read and being perceived unfavourably by the neurotypical
majority, which may lead to increased attempts to camouflage their autism to fit in, giving
rise to increased feelings of thwarted belonging and suicidality.
It is important to consider what could moderate the associations in our proposed
model (Figure 3). The desire to camouflage one’s autism in social situations in order to fit
in, and subsequent feelings of thwarted belonging that ensue, likely require social
motivation and insight into one’s own difficulties, including into how one is perceived by
others (Cassidy et al, 2018; Chevallier et al, 2012). Specifically, one must desire social
connections (i.e. be socially motivated) in order to camouflage in an attempt to be socially
accepted. One must also have insight into one’s own difficulties in achieving these
meaningful connections with others, despite attempts to camouflage, in order to
experience thwarted belonging and associated mental health difficulties. Hence, the
associations between variables in the model will likely be present or stronger in those with
high levels of social motivation and insight. Notably, the presence of such abilities in
autism would stand in contrast to widely held views that autistic people lack social
motivation and insight into other minds (Baron-Cohen et al, 1985; Chevallier et al, 2012).
Following Jaswal and Akhtar (2019), we propose that both social motivation and insight
are likely to vary among autistic people, who are a very diverse group, much as they
presumably do in the neurotypical population. If empirical support is found for the model,
it would reveal a complex, sophisticated, and nuanced profile of social behaviour in
autism, further challenging ‘social deficit’ models.
The hypothesized moderating effects of social motivation and insight have not yet
been tested in our proposed model. However, associations between social difficulties and
mental health in autism are supported by research. For example, (Smith & White, 2020)
proposed a model of depression in autistic people on the basis of a systematic review of
the available literature in this area. In this model, depression is more likely to develop in
autistic people who are socially motivated, alongside pronounced social and communi-
cation difficulties that prevent development of meaningful social relationships. Consis-
tent with this model, Gotham et al (2014) report that autistic people who had insight into
their difficulties were more likely to experience depression. Social motivation and insight
are therefore likely to be important moderator variables in the later stages of the model,
influencing whether autistic people attempt to camouflage their autistic characteristics in
an attempt to fit in, experience increased feelings of thwarted belonging, and thus poor
mental health.
Double empathy problem and mental health 11
How should society change?
In considering how society should change, we begin by identifying societal features that
currently prevail. A chief feature of society is the dominance of the medical model which
implicitly views autism as a maladaptive condition that needs to be cured. This view
locates the problems of autism within the individual, with the assumption that the
individual must be treated to effect change in order to make the problem go away.
Common approaches have been to apply behaviour techniques, to administer medica-
tion, implementing programmes of therapy and offering dedicated teaching on how to
understand other people’s minds (see Medavarapu et al, 2019, for a review). Such
interventions are likely to cause autistic people to feel they are defective and that they
need to change in order to fit into society. Being subjected to these interventions could
lead to a sense of thwarted belonging (‘If you can’t change then you are not welcome!’)
and, associated with that, a desire to camouflage autistic features. If so, ironically, and
despite all good intentions, these interventions might put the individual at risk of mental
health issues and even increased risk of suicide.
The view we espouse, in agreement with Milton (2012), locates challenges associated
with autism at the interface between autistic and neurotypical people, with the
implication that this is where change is needed in the interest of improving quality of life
for all. This interface is problematical in that autistic people are liable to be misperceived
by neurotypical people, as detailed above. In summary, neurotypical people are likely to
misinterpret signals emanating from autistic people, preventing them from accurately
inferring thoughts, feelings and intentions. Connected with this, neurotypical people are
liable to perceive autistic people unfavourably.
As with neurotypical people, some autistic people have well-developed self-insight
(Mitchell & O’Keefe, 2008) and some are socially motivated (Jaswal & Akhtar, 2019), and
these individuals in particular might experience a sense of thwarted belonging coupled
with a tendency to camouflage with consequent risk to mental health. Society should
change, therefore, to be more accepting of diversity; in so doing, an opportunity would
arise for neurotypical people to understand, value, and learn from autistic people. It would
thus be highly productive if neurotypical people could be enlightened as to the different
kinds of code that are signalled in the behaviour of autistic people, enabling them to
interpret the signals more informatively and more positively.
Note, however, that it would not be helpful for society to impose social experiences
upon autistic people. As with neurotypical people, presumably autistic people vary in
how socially motivated they feel. Perhaps not all autistic people want to socialize and
perhaps neither do they necessarily need to socialize in order to maintain good mental
health (see Fletcher-Watson & Crompton, 2019). Hence, we are keen to respect diversity
among autistic people and we recognize the importance of not imposing unwanted
experiences on autistic people.
Questions for future research
There are a number of questions remaining for future research to address, to further
understand and tackle the implications of the double empathy problem. In doing so, the
aim is to increase autistic people’s inclusion in society and prevent the high rates of mental
health problems and risk of suicide in this group.
First, there is limited but promising evidence for higher empathy between autistic
peers (with similar neurotype and interaction style), in comparison with autisticnon-
12 Peter Mitchell et al.
autistic peers (with different neurotypes and interactions styles), consistent with the
predictions of the double empathy problem. However, the only research to explore
whether autistic people are significantly more accurate at interpreting the behaviour of
other autistic people (compared to non-autistic people) used a method in which the
sample of behaviour was quite different from what one experiences in everyday life (Edey
et al, 2016).
Second, there is limited evidence regarding whether increased interaction with
autistic people, particularly throughout development, is associated with increased
empathy with autistic people. One study showed that non-autistic people with increased
knowledge of autism also tended to rate autistic people as more socially favourable
(Sasson & Morrison, 2019). However, further studies are needed in different groups,
including siblings of autistic people (who have increased interaction with autistic people
throughout their development), non-autistic pupils in schools including autistic peers,
late-diagnosed adults who might not have had many opportunities to interact with other
autistic people, parents of autistic children (who are not autistic themselves), and those
who support autistic people (e.g. clinicians, support workers).
Third, each autistic person has unique strengths and difficulties. According to the
medical model, autistic people are categorized on a spectrum from severely to less
severely affected, and these internal aspects of the individual determine that person’s
outcomes. However, according to the transactional account of development, and social
models of disability, how an autistic person is able to access and participate in society
depends on the interaction between the autistic person with others in their environment.
Further research is needed to determine these implications for the transactional model we
outline here. Is it that autistic individuals who inhabit a milieu that is inclusive and tolerant
of diversity can expect a more positive developmental outcome? Conversely, is it that
individuals who are perceived by neurotypical others to have ‘mild’ autistic features are
more likely to be accepted and included such that their developmental outcome is more
positive? How do features of the self and social environment interact to determine
Fourth, autistic people change and develop over the course of their lives. How does
being misperceived affect autistic individuals at different points in their development? Is
the impact uniform across development or does being misperceived impact differently as
one grows up and matures?
We are not denying that autism has an innate basis and we accept the evidence on
heritability along with its implication for a broader phenotype (Pickles et al, 1995).
However, it is also very important to recognize and understand how the behaviour of
autistic people is misperceived by the neurotypical majority in society and how this
misperception could have far-reaching negative consequences for the development of
autistic individuals. This misperception could result in autistic people being excluded
from the social world to a degree which is detrimental to both autistic and non-autistic
groups, as both are denied opportunities to benefit from each others’ skills and abilities.
Moreover, social exclusion could impact negatively on mental health, leading the
individual to camouflage and pretend to be other than they are, leading to low esteem and
a sense of thwarted belonging. In some cases, this could lead to suicidal thoughts.
Double empathy problem and mental health 13
The way forward is not to seek a way of changing autistic people to make them ‘fit in’
but to change society to make all of us more tolerant of diversity. Doing so will not only
improve the quality of life and the productivity of autistic people but will make society a
better and more functional place for everyone.
This article makes a start in outlining the issues; it is not an end point. There is much to
discover, such as how the experience of living with autistic people improves one’s ability
to interpret behaviour more accurately and evaluate behaviour more positively. We also
do not yet know how the severity of autism impacts on how the individual is perceived by
the neurotypical majority; and we do not know how others’ perceptions affect autistic
individuals differently as they grow and mature. These and other questions are waiting to
be explored and the information we gather will surely make society better for all.
Conflict of interests
All authors declare no conflict of interest.
Author contribution
Peter Mitchell (Conceptualization; Methodology; Visualization; Writing original draft;
Writing review & editing) Elizabeth Sheppard (Conceptualization; Methodology;
Visualization; Writing original draft; Writing review & editing) Sarah Cassidy
(Conceptualization; Methodology; Visualization; Writing original draft; Writing review
& editing).
Data availability statement
Data sharing is not applicable to this article as no new data were created or analysed in this
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18 Peter Mitchell et al.
... Autism, in particular, characterized by the problematic social communication and interaction (e.g., persistent sociopragmatic inadequacy or poor interactive communication) and by repetitive and stereotyped behavior (American Psychiatric Association, 2013), provides the robust evidence for decoding the discrepancies between the core and complementary properties of human language, and the divergences on language use and acquisition as well as language proper among various linguistic or philosophical perspectives. Without doubt, these vital investigations could also be helpful for clarifying autism as a condition that is "both biologically and socially derived when considering the double empathy problem" (DEP) 1 (Milton, 2012, p. 886;Mitchell et al., 2021). ...
... In other words, DEP would bring about a breakdown in reciprocity and mutual understanding that can happen among both autistic and non-autistic people with very differing ways of experiencing the world (López, 2022;Milton, 2012). Recently, Mitchell et al. (2021) attributed autistic poor social interactions with non-autistic people to DEP. 6 "Module" is defined as highly independent system of knowledge, each with its distinct properties; the principles of a module define its content as a system of knowledge. They also enter into the processes of acquisition of this knowledge and of its use (Fodor, 1983;Kasher, 1991). ...
Full-text available
The unique linguistic profile of autistic people urges linguists to address the divergences in human language, its acquisition and use among major linguistic perspec- tives. Fitting with the dual roles of language (thought and communication), this paper adopts an internal pragmatic competence (IPC) and a (similar) pragmatic competence for external communication (PCEC) to elucidate how autistic linguistic profile discloses the divergences between nativism and constructionism on language use and acquisi- tion (ultimately language proper). IPC justifies why autis- tic people resort not to mind-reading but to self-sufficient mental interactions among organism-internal submodules or nearly intact grammatical subsystems when abstractly processing linguistic and communicative needs, contra constructionists' assumption of sole intersubjective language use. PCEC, required for facilitating the authentic intersubjective language use, explains how the dysfunction of modular interactions and their interactions with outside contexts leads to autistics' sociopragmatic impairment and the double empathy gap. In this way, the divergences, along with the possible reconciliation between the two perspec- tives, can be expounded.
... This view has been referred to as 'double empathy problem' (Milton, 2012), which states that empathy problem in ASD should be seen as a bidirectional lack of empathy. In line with this idea and in contrast to the traditional medical models, individuals with autism communicate more effectively with other individuals having autism as compared to neurotypical individuals (Mitchell et al., 2021). In fact, the testaments of individuals with autism often speak of hyper-empathic experience in contrast to the prevalent deficit focused view of empathy (Bollen, 2023). ...
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Research has consistently shown that individuals with Autism Spectrum Disorder (ASD) exhibit Empathy deficits. The aim of this study was to systematically review and meta-analyze the research conducted in the domain of cognitive and affective Empathy in Autism. The author also attempted to see the influence of moderators, such as age, culture, and measure-used, on the effect sizes. To fulfill the objective, the meta-analysis was performed on 35 studies that fulfilled the inclusion criteria with the help of the Meta-essentials, which is a free excel meta-analysis tool that facilitates the integration of effect sizes from various studies. The results indicated that the ASD group differs significantly from typically developing (TD) group in both cognitive and affective empathy. The effect size for cognitive empathy was very large (1.26), whereas, for affective empathy, the effect size was medium (0.58). Further, there was a significant moderating effect of the type of measure used on cognitive empathy. However, there are a few limitations of the present meta-analysis. Firstly, it does not shed light on how symptom severity in Autism influences empathy. Secondly, all the possible moderating variables influencing empathy could not be considered. Lastly, the generalizability of the findings may be limited owing to the limitations present in the included studies themselves. The present meta-analysis has implications for conceptualizing cognitive and affective empathy appropriately, and developing appropriate measures to assess empathy in the Autism population.
... Other concerns involve putative long-term harm from the application of ABA therapy to autistic clients (e.g., posttraumatic stress disorder; Kupferstein, 2018; but cf. Leaf et al., 2018) and even suicidality (Mitchell et al., 2021;Ne'eman, 2021). These concerns largely revolve around the ways in which ABA interventions for autistic clients are implemented. ...
The behavior analytic literature on neurodiversity remains limited. This article aims to begin filling the lacuna. We will introduce the neurodiversity perspective and demonstrate an important congruence between the behavior analytic and neurodiversity perspectives on autism. Despite this congruence, applied behavior analysis is often targeted for criticism by proponents of the neurodiversity perspective. A central concern raises questions about the aims of behavior analytic interventions for clients with autism. Is it appropriate to teach clients with autism to behave as if they were neurotypical? Concerns about the aims of behavior analytic interventions mirror concerns that have been raised about the aims of language education in schools. Drawing on the literature regarding linguistically diverse classrooms, we will critically evaluate the abolitionist neurodiversity critique of ABA. We conclude by considering both concrete and theoretical implications for the ethics of behavior analytic work with autistic clients.
... This section will illustrate several socio-sexual problems faced by autistic people and conclude with ways BDSM could alleviate those problems. According to the theory of the double empathy problem, allistic people do not accurately understand autistic people while autistic people also struggle to understand allistic people and social norms (Mitchell, 2021). The distinct autistic patterns of moving, thinking, focusing attention and behaving described earlier in this article result in coercion, rejection, discrimination and predation by those enacting or taking advantage of neuronormative standards. ...
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... In relation to the ability of empathy in people with ASD, it is also acknowledged the explanation of the double empathy problem (L opez 2022, Milton 2012, Mitchell et al. 2021. This theory states that interpersonal communication of people with ASD is complex when it occurs with their peers without ASD, but it is efficient when interactions occur between people with ASD. ...
Background: Callous-unemotional traits (CUT) are an antisocial personality trait, which can be present in people with autism spectrum disorder (ASD), especially in relation to difficulties in empathy. These traits are related to challenging behaviors, such as aggressive behavior, which may occur in people with ASD. Method: This study aimed to expand the understanding of the role of CUT in adults with ASD and intellectual disability (ID). Eighty-three adults with a diagnosis of ASD and ID participated in the study. Results: Mediation analyses found that CUT indirectly mediated the relationship between ASD symptomatology and the frequency of self-injuries and stereotypies, but not aggression. Conclusions: It is considered that CUT may have a protective effect on the presence of individual challenging behaviors in adults with ASD and ID. The apparent relationship between CUT and executive functioning was discussed. CUT traits may be considered as a variable to contemplate in relation to interventions in challenging behaviors in the ASD population, especially in those individuals who show aggression-related behaviors and who have a higher executive level.
Based on the mind-blindness hypothesis, a large number of studies have shown that individuals with autism-spectrum disorder (ASD) and autistic traits have empathy deficits. However, the recent double empathy theory contradicts the mind-blindness hypothesis and suggests that individuals with ASD and autistic traits do not necessarily lack empathy. Thus, the presence of empathy deficits in individuals with ASD and autistic traits is still controversial. We recruited 56 adolescents (28 high autistic traits, 28 low autistic traits, 14-17 years old) in this study to explore the relationship between empathy and autistic traits. The study participants were required to undertake the pain empathy task, during which the electroencephalograph (EEG) activities were recorded. Our results show that empathy was negatively associated with autistic traits at the questionnaire, behavioral, and EEG levels. Our results also suggested that empathy deficits in adolescents with autistic traits may be manifested mainly in the late stages of cognitive control processing.
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Abstract Introduction: Suicidal in teenagers has increased. Although uncommon, the use of sodium nitrate has also increased, stimulated by online information of unpainful death and easy acquisition. It is an oxidant that converts hemoglobin into methemoglobin, causing asphyxia, vasodilation and hypotension, with high mortality when consumed in high doses. There is effective therapy, if early initiated. Clinical case: This is a case of sodium nitrate voluntary ingestion, bought online as a fertilizer, in a previously healthy 17-year-old boy. The boy called 911 due to vomiting and lower limb paresthesia. At the arrival of the rescuers, the boy was dizzy, reactive, hypotensive, tachycardic, hypoxemic and cyanotic. During transportation, he entered cardiorespiratory arrest and basic life support was initiated. In emergency room he was intubated and ventilated effectively (PaO2 293 mmol/L), maintaining exuberant cyanotic extremities. The initial rhythm was electrical activity without pulse, followed by ventricular fibrillation, with approach following the algorithms. The Antivenom Information Center was contacted and methylene blue was started. He did not recover spontaneous circulation after 35 minutes of resuscitation. His sister was evaluated by the Hospital Organization for Child and Youth Risk Management and started having pedopsychiatric appointments, due to suicidal ideation.
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Abstract Background: SARS-CoV-2 pandemic has led to socioeconomic and family changes. During lockdown, due to increased intrafamily conflict and lack of contact with other protective adults, there was an increased risk of child physical abuse. Concomitantly, with school closures, there was a decrease in the risk of physical aggression at school. Objective: To compare pediatric emergency admissions due to physical abuse at the beginning of the school year before and during SARS-CoV-2 pandemic. Methods: Retrospective and descriptive study. Children observed in the emergency department due to physical abuse between September and November of four consecutive years (2018 to 2021) were included. Results: Included 169 emergency admissions (102 pre-pandemic vs. 67 during the pandemic). In 33% (n=56) there was a previous history of physical abuse. School aggression was the main form of aggression (46% vs. 40%), followed by family aggression (30% vs. 31%) and delinquency (23,5% vs. 28% during). The episodes were considered moderate to severe in 17% before the pandemic versus 27% during the pandemic. During the pandemic, there was a greater referral to the Hospital Center for Children and Teenagers at Risk (p=0.011), a greater number of children/teenagers referred to an institution (p=0.013) and to the Public Ministry (p=0.023). Conclusions: There was a decrease in emergency admissions due to physical abuse during the pandemic. There was a decrease in school aggression and an increase in cases of delinquency. There was no increase in intrafamilial physical abuse. There is greater awareness of health care professionals of these cases, with more referral.
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Lay abstract: Sharing information with other people relies on the ability to communicate well. Autism is defined clinically by deficits in social communication. It may therefore be expected that autistic people find it difficult to share information with other people. We wanted to find out whether this was the case, and whether it was different when autistic people were sharing information with other autistic people or with non-autistic people. We recruited nine groups, each with eight people. In three of the groups, everyone was autistic; in three of the groups, everyone was non-autistic; and three of the groups were mixed groups where half the group was autistic and half the group was non-autistic. We told one person in each group a story and asked them to share it with another person, and for that person to share it again and so on, until everyone in the group had heard the story. We then looked at how many details of the story had been shared at each stage. We found that autistic people share information with other autistic people as well as non-autistic people do with other non-autistic people. However, when there are mixed groups of autistic and non-autistic people, much less information is shared. Participants were also asked how they felt they had got on with the other person in the interaction. The people in the mixed groups also experienced lower rapport with the person they were sharing the story with. This finding is important as it shows that autistic people have the skills to share information well with one another and experience good rapport, and that there are selective problems when autistic and non-autistic people are interacting.
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Background: Autistic adults are more likely to engage in suicidal thoughts and behaviours but there is little research to explore the underlying reasons. It is unclear whether self-report suicide scales that have been designed for non-autistic people accurately measure suicide risk constructs in autistic people. Therefore, this study explored, for the first time, whether the measurement properties of the self- report scales of the Interpersonal Theory of Suicide are equivalent in autistic and non-autistic adults. Methods: In this study, responses from 342 autistic and 353 non-autistic people on the Interpersonal Needs Questionnaire-10 (INQ-10) and Acquired Capability for Suicide Scale Fearlessness About Death (ACSS-FAD) were compared using measurement invariance analysis. Data were gathered through an online cross-sectional survey of the self-report measures. Results: Results suggest that measurement properties of the INQ-10 were different in autistic people. Autistic characteristics, such as different theory of mind and preference for concrete language, may have led the scale items to load differently on the factors in the autistic group than in the non- autistic group. The measurement properties of the ACSS-FAD were invariant between autistic and non-autistic people. Conclusions: Scores on the INQ-10 cannot be meaningfully compared between autistic and non-autistic people due to different measurement properties. Future research could explore how autistic people experience the concepts of burdensomeness and belonging, to consider how measures could accurately capture this. This would allow researchers to explore the role of these constructs in the development of suicidal thoughts and behaviours in autistic people. Clinicians should be aware that suicide risk factors may present differently in autistic people. Scores on the ACSS-FAD can be meaningfully compared but the negatively worded scale items may pose similar response difficulties to autistic and non-autistic people.
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This study explored whether the Interpersonal Theory of suicide informs our understanding of high rates of suicidality in autistic adults. Autistic and non-autistic adults (n = 695, mean age 41.7 years, 58% female) completed an online survey of self-reported thwarted belonging, perceived burden, autistic traits, suicidal capability, trauma, and lifetime suicidality. Autistic people reported stronger feelings of perceived burden, thwarted belonging and more lifetime trauma than non-autistic people. The hypothesised interaction between burdensomeness and thwarted belonging were observed in the non-autistic group but not in the autistic group. In both groups autistic traits influenced suicidality through burdensomeness/thwarted belonging. Promoting self-worth and social inclusion are important for suicide prevention and future research should explore how these are experienced and expressed by autistic people.
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The current study explored whether people who camouflage autistic traits are more likely to experience thwarted belongingness and suicidality, as predicted by the Interpersonal Psychological Theory of Suicide (IPTS). 160 UK undergraduate students (86.9% female, 18-23 years) completed a cross-sectional online survey from 8th February-30th May 2019 including self-report measures of thwarted belongingness and perceived burdensomeness (INQ-15), autistic traits (AQ-S), depression (PHQ-9), anxiety (GAD-7), camouflaging autistic traits (CAT-Q), and lifetime suicidality (SBQ-R). Results suggest that camouflaging autistic traits is associated with increased risk of experiencing thwarted belongingness and lifetime suicidality. It is important for suicide theories such as the IPTS to include variables relevant to the broader autism phenotype, to increase applicability of models to both autistic and non-autistic people.
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Co-occurring psychiatric conditions are extremely common among people who have autism spectrum disorder (ASD). The Oxford Handbook of Autism and Co-Occurring Psychiatric Conditions presents a compilation of the latest research in this area, summarized by internationally renowned experts. Each chapter presents an overview of the problem or disorder including information on prevalence in ASD and in the general public and a synthesis of the research on etiology, diagnostic best practices, and evidence-based intervention approaches. Case studies bring these concepts to life, and each chapter concludes with suggestions for future research directions in order to further develop our scientific and clinical understanding of the particular comorbidity. Given the fact that comorbidity is often a chronic and pervasive concern, this Handbook takes a lifespan approach, with each chapter touching on developmental aspects of the targeted problem, from early childhood through adulthood. The concluding section of the Handbook is comprised of content on clinical considerations and research approaches, including chapters on medications commonly used to treat co-occurring conditions, strategies for managing crisis situations in this clinical population, and community partnerships within an implementation science framework.
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[This corrects the article DOI: 10.1371/journal.pone.0219663.].
Lay abstract: Many adolescents and adults with autism spectrum disorder experience difficulty with symptoms of depression. These symptoms can contribute to poor quality of life and lack of independence for adolescents and adults. To better understand these symptoms, we conducted a review of articles that examined the presentation of depression specific to autism spectrum disorder. Our goals in conducting this study were (1) to examine whether depression may be associated with symptoms that are common among people with autism spectrum disorder, such as loneliness or poor social motivation; (2) to determine whether people with autism spectrum disorder experience depression in a different way than the general population; and (3) to add to other recent studies that have examined how common depression is in autism spectrum disorder and how it is typically measured. Our study reviewed 48 papers on this topic. Results showed that a substantial proportion of people with autism spectrum disorder experience significant symptoms of depression. We related our results to social factors commonly studied in this field (i.e. social motivation) and proposed a new model for the development of depression in this population.
In this article, we propose a new framework for investigating how accurately and by what process people read others' minds—a process that requires perceivers to make a retrodictive inference. In this context, we discuss the value of a novel methodological approach that complements the conceptual framework. This framework is formulated on the basis of a series of empirical articles emerging over the past few years in which the ideas appear in nascent form. Retrodiction is the process in which, on observing a person's behavior (often but not exclusively a facial expression), people are equipped not only to sense the underlying inner state but also to infer the event that caused that inner state. Indeed, the goal of mindreading need not always be to identify an inner state explicitly but to infer the event that caused the inner state. Doing so is adaptive in that it permits access to a more expansive view of the world through the lens of another mind. This view of mindreading naturally leads to a reconsideration of methods that are fit for purpose and leads to testable hypotheses.
Background: Autistic adults receive unfavorable first impressions from typically developing (TD) adults, but these impressions improve when TD adults are made aware of their diagnosis. It remains unclear, however, how autistic adults form first impressions of other autistic adults, and whether their impressions are similarly affected by diagnostic awareness. Methods: In this study, 32 autistic and 32 TD adults viewed brief videos of 20 TD and 20 autistic adults presented either with or without their diagnostic status and rated them on character traits and their interest in interacting with them in the future. Results: Findings indicated that autistic raters shared the TD tendency to evaluate autistic adults less favorably than TD adults, but these judgments did not reduce their social interest for interacting with autistic adults as they did for TD raters. Furthermore, informing raters of the diagnostic status of autistic adults did not improve first impressions for autistic raters as they did for TD raters, suggesting that autistic raters either already inferred their autism status when no diagnosis was provided or their impression formation is less affected by awareness of a person's diagnosis. Conclusions: Collectively, these results demonstrate that autistic observers make trait inferences about autistic adults comparable with those made by TD observers-suggesting a similar sensitivity to perceiving and interpreting social signifiers that differ between TD and autistic presentation styles-but unlike their TD counterparts, these trait judgments are not perceived as an impediment to subsequent social interaction and are relatively consistent regardless of diagnostic disclosure.
In arguing that autistic people are socially motivated, Jaswal & Akhtar miss the opportunity to puncture the notion that social motivation is a prerequisite for humanity. Instead, we contend that some autistic people may indeed find social interactions to be unmotivating and that this doesn't have to be seen as a problem.