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Creating truly radical change in autism research: A response to Frith and Mottron
Running Title: Response to Frith and Mottron
Amy Pearson¹, Richard Woods², Hayley Morgan³ and Monique Botha
¹School of Psychology, Faculty of Health and Wellbeing, University of Sunderland, Sunderland, UK.
²School of Law and Social Sciences. London South Bank University. 103 Borough Road. London.
SE1 0AA, UK. ORCID: 0000-0002-8292-632X
³Faculty of Medicine, Health and Life Science, Swansea University
⁴Division of Psychology, University of Stirling, Stirling, FK9 4LA, Scotland. ORCID: 000-0002-5935-
Amy Pearson
School of Psychology
Faculty of Health Sciences and Wellbeing
University of Sunderland
City Campus
Tel: 0191 515 2279
ORCID ID: 0000-0001-7089-6103
Keywords: Subtypes (of ASD), Developmental Psychology, Social Cognition and
Theory of Mind
Frith (2021) and Mottron (2021) recently called for a backwards shift in autism research towards
identifying cognitive deficit and ‘prototypes’, to remedy a more heterogeneous diagnostic criteria. Frith
argues that our current conceptualisations of autism have shifted too far away from the idea of
‘disorder’. Likewise Mottron argues that autism has been ‘trivialised’, diluted by the inclusion of the
merely quirky. Whilst there is much to critique in the suggestion that research into the mechanisms of
autism should be prioritised over the identification (and associated support) of autistic people, here we
focus on two key points: autism as a discrete variable, and cognitive deficits as a core feature of
The initial introduction of autism as a diagnostic category in the 1940s was grounded in early 20th
century conceptualisations of normality and productivity (Evans 2014). These conceptualisations were
reified in the stratification of autism into ‘classic’ (or ‘Kanner’s’) autism, and Asperger Syndrome,
which were later collapsed with acknowledgement that it provided little insight into the support needs
of autistic people, and was stigmatising (Woods, Waldock, Keates and Morgan, 2019). Mottron
acknowledges that attempts to identify a singular genetic marker for autism has failed, as have
attempts to divide autism with biomarkers, and it is now recognised these endeavours are unlikely to
succeed. Frith acknowledges that theories of cognitive deficit are foiled by heterogeneity. The most
parsimonious explanation here does not require a narrowing to prototype, but an acknowledgement of
human error.
Multiple co-occurring diagnoses are common in both autistic adults and children, and attempts to
distill ‘pure’ autism have proved futile so far. ‘Autism’ may currently represent a particular clustering of
characteristics within the wider umbrella of developmental differences (Astle et al. 2021), or may
reflect more broadly the psychiatric othering endemic in the 20th century. As we debate the nature of
autism, autistic people continue to experience poorer mental and physical health outcomes,
victimisation, and stigma which is often grounded in cognitive deficit views of autistic people as
mindblind and lacking empathy. Differences at the cognitive level fail to translate to real world social
skill (Morrison, Pinkham, Kelsven, Ludwig, Penn and Sasson, 2019) whereas advances in theory
about autistic social style (Milton, 2012) have been confirmed in robust and ecologically valid social
research (Crompton, Ropar, Evans-Williams, Flynn, and Fletcher-Watson, 2020). These findings
suggest that it is indeed better theory we need, and not simply smaller, more stratified groups of
autistic people.
From birth our cognition is shaped by our interaction with the outside world, just like our behaviour.
Perhaps it is time to acknowledge that separating humans into smaller categories based upon their
perceived difference from normative expectations is unhelpful. Whilst a desire to understand the link
between brain, mind, and behaviour is a basic impetus in Psychology, this cannot be separated from
the social context (or ‘extraneous variables’) that has underpinned our knowledge. A truly radical
approach would be research that aims to understand autistic people, instead of the entity we call
Astle, D.E., Holmes, J., Kievit, R. and Gathercole, S.E. (2021), Annual Research Review: The
transdiagnostic revolution in neurodevelopmental disorders. J Child Psychol Psychiatr.
Crompton, C. J., Ropar, D., Evans-Williams, C. V., Flynn, E. G., & Fletcher-Watson, S. (2020).
Autistic peer-to-peer information transfer is highly effective. Autism, 24(7), 17041712.
Evans B. (2014). The foundations of autism: the law concerning psychotic, schizophrenic, and autistic
children in 1950s and 1960s britain. Bulletin of the history of medicine, 88(2), 253285.
Frith, U. (2021), When diagnosis hampers research. Autism Research. Online ahead of print.
Milton, D.E.M. (2012) On the ontological status of autism: the ‘double empathy problem’, Disability &
Society, 27:6, 883-887, DOI: 10.1080/09687599.2012.710008
Mottron, L. (2021). A radical change in our autism research strategy is needed: Back to prototypes.
Autism Research. Online ahead of print.
Sasson, N. J., Morrison, K. E., Kelsven, S., & Pinkham, A. E. (2020). Social cognition as a predictor of
functional and social skills in autistic adults without intellectual disability. Autism Research, 13(2), 259-
Woods, R., Waldock, K., Keates, N., & Morgan, H. (2019). Empathy and a Personalised Approach in
Autism. Journal of Autism and Developmental Disorders. DOI:
... The title used the term: ''A rising tide.,'' in relation to Autistic people: immediately provoking comparison with the term autism epidemic, 3 which negatively references the increasing identification of Autistic people. Similar narratives are rife in academia, highlighted by the response of Pearson et al. 4 to Mottron's 5 and Frith's 6 assertations that academia is wrongly pulling away from the notion of ''disorder'' and that the narrative of autism is somehow becoming diluted by overrepresentation of groups that these academics consider ''mild'' or ''least affected.' ' We therefore argue that the term: ''the rising tide'' is loaded, insinuating that increasing identification of Autistic people is problematic; and given the current narratives around climate change, an implied analogy to rising water levels and indications of doom and potential danger is hugely damaging. ...
A response to the authors citing opposition to the term 'Genrontautism' and picking apart the narratives around both it and wider issues with autism research.
Purpose of review: Sex/gender-related factors contribute to contextual issues influencing the recognition of autism and attention-deficit/hyperactivity disorder (ADHD), and modulate how neurodevelopmental characteristics are manifested. This review summarizes the empirical literature to provide directions for improving clinical diagnostic practices. Recent findings: Timing of autism and/or ADHD diagnosis, particularly in girls/women, is related to the individual's developmental characteristics and co-occurring diagnoses, and expectancy, alongside gender stereotype biases, of referral sources and clinicians. This is further compounded by sex and gender modulations of behavioural presentations. The emerging 'female autism phenotype' concept may serve as a helpful illustration of nuanced autism phenotypes, but should not be viewed as essential features of autism in a particular sex or gender. These nuanced phenotypes that can present across sexes and genders include heightened attention to socially salient stimuli, friendship and social groups, richness in language expression, and more reciprocal behaviours. The nuanced female-predominant ADHD phenotypes are characterized by subtle expressions in hyperactivity-impulsivity (e.g., hyper-verbal behaviours). Optimizing neurodevelopmental diagnoses across sexes and genders also requires an understanding of sex-related and gender-related variations in developmental trajectories, including compensation/masking efforts, and the influences of co-occurring conditions on clinical presentations. Summary: Equitable diagnoses across sexes and genders for autism and ADHD require understanding of the nuanced presentations and the Gestalt clinical-developmental profiles, and addressing contextual biases that influence diagnostic practices.
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Practitioners frequently use diagnostic criteria to identify children with neurodevelopmental disorders and to guide intervention decisions. These criteria also provide the organising framework for much of the research focussing on these disorders. Study design, recruitment, analysis and theory are largely built on the assumption that diagnostic criteria reflect an underlying reality. However, there is growing concern that this assumption may not be a valid and that an alternative transdiagnostic approach may better serve our understanding of this large heterogeneous population of young people. This review draws on important developments over the past decade that have set the stage for much‐needed breakthroughs in understanding neurodevelopmental disorders. We evaluate contemporary approaches to study design and recruitment, review the use of data‐driven methods to characterise cognition, behaviour and neurobiology, and consider what alternative transdiagnostic models could mean for children and families. This review concludes that an overreliance on ill‐fitting diagnostic criteria is impeding progress towards identifying the barriers that children encounter, understanding underpinning mechanisms and finding the best route to supporting them.
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The evolution of autism diagnosis, from its discovery to its current delineation using standardized instruments, has been paralleled by a steady increase in its prevalence and heterogeneity. In clinical settings, the diagnosis of autism is now too vague to specify the type of support required by the concerned individuals. In research, the inclusion of individuals categorically defined by over-inclusive, polythetic criteria in autism cohorts results in a population whose heterogeneity runs contrary to the advancement of scientific progress. Investigating individuals sharing only a trivial resemblance produces a large-scale type-2 error (not finding differences between autistic and dominant population) rather than detecting mechanistic differences to explain their phenotypic divergences. The dimensional approach of autism proposed to cure the disease of its categorical diagnosis is plagued by the arbitrariness of the dimensions under study. Here, we argue that an emphasis on the reliability rather than specificity of diagnostic criteria and the misuse of diagnostic instruments, which ignore the recognition of a prototype, leads to confound autism with the entire range of neurodevelopmental conditions and personality variants. We propose centering research on cohorts in which individuals are selected based on their expert judged prototypicality to advance the theoretical and practical pervasive issues pertaining to autism diagnostic thresholds. Reversing the current research strategy by giving more weight to specificity than reliability should increase our ability to discover the mechanisms of autism. Lay Summary Scientific research into the causes of autism and its mechanisms is carried out on large cohorts of people who are less and less different from the general population. This historical trend may explain the poor harvest of results obtained. Services and intervention are provided according to a diagnosis that now encompasses extremely different individuals. Last, we accept as a biological reality the constant increase over the years in the proportion of autistic people among the general population. These drifts are made possible by the attribution of a diagnosis of autism to people who meet vague criteria, rather than to people who experienced clinicians recognize as autistic. We propose to change our research strategy by focusing on the study of the latter, fewer in number, but more representative of the “prototype” of autism. To do this, it is necessary to clearly distinguish the population on which the research is carried out from that to which we provide support. People must receive services according to their needs, and not according to the clarity of their diagnosis.
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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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There is no abstract to this. I will note I insisted on using person first language to avoid antagnoising JADAD reviewers or editors. I used Pathological Demand Avoidance instead of Demand Avoidance Phenomena to ensure the article would appear in searches for PDA, while lowering word count.
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Although social cognition is frequently identified as a target in clinical trials and psychosocial interventions for adults with autism spectrum disorder (ASD), these efforts are hampered by a lack of consensus and validation of social cognitive measures. The current study provides psychometric evaluation of 11 frequently used measures encompassing different subdomains of social cognition. Adults with autism (N = 103) and typically developing controls (N = 95) completed 11 commonly used social cognitive tasks spanning the domains of emotion processing, social perception, and mentalizing/theory of mind. We examined each measure's internal reliability and sensitivity to group differences, how performance related to general intellectual ability, and alignment of measures with a proposed two‐factor structure of social cognition in ASD. Controls outperformed the ASD group on 8 of the 11 social cognitive tasks, with the largest group differences occurring on two mentalizing measures, The awareness of social inference task (TASIT) and hinting task. In ASD, all tasks demonstrated strong internal consistency and avoided ceiling and floor effects. Social cognitive performance was also related to, but not redundant with, intellectual functioning. We also found support for a two‐factor structure of social cognition, with basic social perception and emotional processing aligning into a lower‐order social perception factor, while mentalizing tasks aligned into a higher‐order social appraisal factor. In sum, eight tasks showed adequate to strong psychometric properties. The psychometric data, effect size estimates, and correlations between measures reported here can be used for study planning for social cognitive interventions in autism. Autism Res 2019, 999: 1–13. © 2019 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals, Inc. Lay Summary We examined 11 tasks that measure how adults with autism perceive and interpret social information. Eight of the tasks were reliable and showed lower performance in adults with autism compared to typically‐developing controls. Task performance was related to but distinguishable from IQ. These measures evaluated here may be useful in assessing the effectiveness of interventions and treatments to improve social abilities in adults with autism.
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While the origins of child psychiatry in Britain can be traced to the interwar period, contemporary concepts and methodological approaches to pathological mental development in children were not created until the 1950s and 1960s. It was at this time that one of the most salient and lasting diagnoses in child psychiatry, autism, was established through a network of intellectual, institutional, and legal changes in Britain. This article argues that the work of child psychiatrists at the Maudsley Hospital was central in driving these changes and uses archival sources from this hospital, along with other legal and intellectual sources, to explore attempts to conceptualize pathological thought in infants in the 1950s and 1960s. When the first epidemiological study of autism was published in 1966, this finally established the autistic child as a scientific, demographic, and social reality in Britain.
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In recent decades there has been much debate over the ontological status of autism and other neurological ‘disorders', diagnosed by behavioural indicators, and theorised primarily within the field of cognitive neuroscience and psychological paradigms. Such cognitive-behavioural discourses abstain from acknowledging the universal issue of relationality and interaction in the formation of a contested and constantly reconstructed social reality, produced through the agency of its ‘actors'. The nature of these contested interactions will be explored in this current issues piece through the use of the term the ‘double empathy problem', and how such a rendition produces a critique of autism being defined as a deficit in ‘theory of mind', re-framing such issues as a question of reciprocity and mutuality. In keeping with other autistic self-advocates, this piece will refer to ‘autistic people', and ‘those who identify as on the autism spectrum', rather than ‘people with autism'.
Autistic adults, including those without intellectual disability, commonly experience poor social and functional outcomes. Although reduced social cognitive ability in autism is often theorized as a mechanism of these poor outcomes, there has been surprisingly little empirical work testing this assumption. Here, 103 autistic adults without intellectual disability completed a comprehensive battery that included eight social cognitive tasks psychometrically validated for use with this population (e.g., emotion recognition and theory of mind), five tasks assessing neurocognitive abilities (e.g., processing speed and working memory), performance‐based measures of their functional skills, and a standardized assessment of their social skills. Collectively, the combination of demographic variables, IQ, neurocognitive performance, and social cognitive performance accounted for 49% of the variance in functional skills and 33% of the variance in social skills. For functional skills, demographic variables, and general and neurocognition independently accounted for a significant portion of the variance, but social cognition did not. Social cognition did, however, significantly mediate the effect of neurocognition on functional skills. Social cognition also accounted for significant proportion in the variance in social skills above and beyond the relatively large contribution of neurocognition. Taken together, findings indicate that social cognitive ability contributes to functional and social skills in autistic adults without intellectual disability, but this contribution may be more limited and indirect than commonly assumed. Autism Res 2019. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. Many social programs for autistic adults presume that improving social cognition will translate to better life outcomes. In this study of 103 autistic adults without intellectual disability, we found that social cognitive abilities do contribute to real‐world social and daily living skills, but this contribution is small and indirect once general‐cognitive abilities are taken into account. Although results substantiate social cognition as an independent cognitive capacity in autism spectrum disorder, its unique contribution to functional and social outcomes may be more limited than previously assumed.
Online ahead of print
Autism Research. Online ahead of print.