Innovations of the ICD-11 in the Field of Autism Spectrum Disorder: A Psychological Approach

Abstract

Background
This article aims to explain and elaborate upon the recently released ICD-11 criteria for Autism Spectrum Disorder (ASD, World Health Organization), which endorse a medical model.

Method
We integrate insights from several disciplines (e.g., psychology, linguistics, sociology and lived experiences) to reflect the scientific and ethical insights derived from the biopsychosocial, neurodiversity perspective on autism.

Results
First, we describe the core domains of ASD’s behavioural characteristics and then the lifetime, developmental perspective on the manifestations of these behaviours. Subsequently, we discuss potential underlying neuropsychology, related behaviours (i.e. associated features/conditions) and we consider some similarities and differences with the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM 5, American Psychological Association).

Conclusions
Recommendations for clinical application are provided. For instance, diagnostic classification in clinical practise should be a means to provide proper, suitable care, and therefore all diagnostic assessments should be used to tailor interventions and/or care to the capacities and genuine needs of the people that ask for professional help.

Full text

Scientiic Update and Overview
Innovations of the ICD-11 in the Field of Autism
Spectrum Disorder: A Psychological Approach
Kirstin Greaves-Lord1,2 , David Skuse3,4 , William Mandy 4
[1]Department of Psychology, Clinical Psychology and Experimental Psychopathology unit, University of Groningen,
Groningen, The Netherlands. [2]Autism Team North-Netherlands, Jonx, Lentis Psychiatric Institute, Groningen, The
Netherlands. [3]Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.
[4]Research Department of Clinical, Educational, & Health Psychology, University College London, London, United
Kingdom.
Clinical Psychology in Europe, 2022, Vol. 4(Special Issue), Article e10005, https://doi.org/10.32872/cpe.10005
Received: 2022-08-01 •Accepted: 2022-11-03 •Published (VoR): 2022-12-15
Handling Editor: Andreas Maercker, University of Zurich, Zurich, Switzerland
Corresponding Author: Kirstin Greaves-Lord, Department of Psychology, Clinical Psychology and Experimental
Psychopathology unit, University of Groningen, Grote Kruisstraat 2/1 9712 TS Groningen, The Netherlands. E-mail:
k.greaves-lord@rug.nl
Related: This article is part of the CPE Special Issue “Innovations in ICD-11”, Guest Editor: Andreas Maercker,
Clinical Psychology in Europe, 4(Special Issue), https://doi.org/10.32872/10.32872/cpe.v4.si
Abstract
Background: This article aims to explain and elaborate upon the recently released ICD-11 criteria
for Autism Spectrum Disorder (ASD, World Health Organization), which endorse a medical model.
Method: We integrate insights from several disciplines (e.g., psychology, linguistics, sociology and
lived experiences) to relect the scientiic and ethical insights derived from the biopsychosocial,
neurodiversity perspective on autism.
Results: First, we describe the core domains of ASD’s behavioural characteristics and then the
lifetime, developmental perspective on the manifestations of these behaviours. Subsequently, we
discuss potential underlying neuropsychology, related behaviours (i.e. associated features/
conditions) and we consider some similarities and differences with the Diagnostic and Statistical
Manual of Mental Disorders Fifth Edition (DSM 5, American Psychological Association).
Conclusions: Recommendations for clinical application are provided. For instance, diagnostic
classiication in clinical practise should be a means to provide proper, suitable care, and therefore
all diagnostic assessments should be used to tailor interventions and/or care to the capacities and
genuine needs of the people that ask for professional help.
This is an open access article distributed under the terms of the Creative Commons
Attribution 4.0 International License, CC BY 4.0, which permits unrestricted use,
distribution, and reproduction, provided the original work is properly cited.

Keywords
Autism Spectrum Disorder, ICD-11, diagnostic process policies
Highlights
• Atypical responses to sensory stimuli are included as part of the diagnostic
requirements in ICD-11, in contrast to ICD-10, where unusual sensory processing was
not yet considered a core (diagnostic) feature.
• In ICD-11 it is recognized that some individuals with Autism Spectrum Disorder start
to experience distress, impairment and overt social challenges once societal demands
increase (e.g., during adolescence or adulthood).
• Unlike DSM-5, ICD-11 does not emphasize the criteria related to Disorders of
Intellectual Development (ID; such as lipping objects, strong attachment or
preoccupation with unusual objects, excessive smelling or touching of objects,
echolalia, stimming).
Current ICD-11 Definition, Criteria and
Conceptualisations of Autism Spectrum Disorder
According to the current International system for the Classiication of Diseases 11th
Revision (ICD-11) diagnostic requirements, in order to receive a classiication of Autism
Spectrum Disorder (ASD), a person’s behaviour should be characterised by three essen
tial features. First, “persistent deicits in the ability to initiate and sustain reciprocal so
cial interaction and social communication” (World Health Organization, 2019a). Second,
by “a range of restricted, repetitive, and inlexible patterns of behaviour, interests or
activities that are clearly atypical or excessive for the individual’s age and sociocultural
context”. Atypical responses to sensory stimuli are now included in this domain, unlike
ICD-10, where unusual sensory processing was not considered a core (diagnostic) fea
ture. Third, “symptoms should result in signiicant impairment in personal, family, social,
educational, occupational or other important areas of functioning” and, as in previous
deinitions, the onset should have been during early development. Yet, some individuals
with ASD can function in many contexts through exceptional effort, such that their
autistic characteristics are not apparent to others during childhood. ICD-11 recognises
that overt symptoms are sometimes only fully manifest later, in adolescence or even
adulthood, when social demands exceed capacities. Consequently, the condition can
present clinically at all ages. ASD is a “lifelong condition, of which the manifestations
and impact are likely to vary according to age [developmental stage], intellectual and
language abilities, co-occurring conditions and environmental context”.
The ICD-11 is an international system for the Classiication of Diseases. As such,
it endorses a medical model, conceptualising Autism Spectrum Disorder as a medical
condition with an inborn, for a substantial part, genetically inherited nature, while
ASD in ICD-11: A Psychological Approach 2
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

acknowledging that gene-environment interactions also play a pivotal role in neurode
velopment (classifying this category in the over-arching category of Neurodevelopmental
Disorders). Although most people agree with this conceptualisation of neuro-biological
aetiology, amongst a variety of stakeholders, the preference for a biopsychosocial model
with more emphasis on how social factors affect functioning and wellbeing, is increasing
(Bolis et al., 2017; Greaves-Lord et al., 2022). In such integrative accounts of ASD, an au
tistic person’s dificulties are not seen as simply caused by individual deicits; but rather
are understood as arising from a poor it between, on the one hand, the individual’s
characteristics and, on the other hand, the demands placed on them by their environment
(Mandy, 2022). According to this perspective, autistic symptoms are seen as a form
of neurodiversity, and emphasis is placed on promoting functioning and wellbeing via
environmental modiications that can improve person-environment it.
In this article, we were invited to describe and relect upon the recently released
ICD-11 criteria, therefore, this will be the focus of the paper. Yet, in doing so, we will
try to integrate insights from several disciplines (e.g., medical, psychological, linguistic,
sociological and lived experiences), to relect the scientiic and ethical insights derived
from the biopsychosocial, neurodiversity perspective on autism. We will irst go into the
core domains of ASD’s behavioural characteristics. Then we will emphasize the lifetime,
developmental perspective on the manifestations of these core behaviours. Subsequently,
we briely discuss theories on the underlying neuropsychological mechanisms driving
the core behaviours. Finally, we discuss related behaviours (i.e. associated features/condi
tions), consider similarities and differences with the Diagnostic and Statistical Manual
of Mental Disorders Fifth Edition (DSM 5, American Psychiatric Association, 2013) and
make some inal remarks for clinical application.
Social Communication
Individuals on the autism spectrum display the full range of intellectual functioning and
language abilities; nowadays, especially in high-income countries, an ASD diagnostic
classiication is increasingly made in individuals who have normal-range verbal and
non-verbal intellectual abilities (e.g., Lord et al., 2022; Zeidan et al., 2022).
The key features of an ASD comprise persistent deviations from the norms of social
behaviour shown by most non-autistic people, including dificulties with initiating and
sustaining social communication and reciprocal social interactions, and responding in a
manner considered typical (conventional). Whilst there is a normal distribution of such
abilities in the general population, people with an ASD are “outside the expected range
of typical functioning”, when an individual’s age and level of intellectual development
are considered (World Health Organization, 2019a). “Speciic manifestations will vary
according to the individual’s chronological age, verbal and intellectual ability”, and
the overall proile of their autistic characteristics (World Health Organization, 2019a).
Greaves-Lord, Skuse, & Mandy 3
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

There are, however, a number of key characteristics of interpersonal behaviour that
are the essence of the condition. First and foremost, is the dificulty of spontaneously
understanding the verbal or non-verbal social communications of other people, together
with the tendency not to respond typically (conventionally) to those communications. It
should be noted that autistic people and professionals are increasingly aware that many
of the social dificulties ascribed to autistic people as simply relecting their impairments,
are better understood as relecting the challenges of ‘cross-neurotype’ interactions (Chen
et al., 2021). Autistic people may struggle to understand non-autistic people, but also,
non-autistic people frequently struggle to empathise with autistic people. People with an
ASD diagnosis vary in terms of their social motivation, although ICD-11 states that there
is a tendency for them, compared to non-autistic people, to show less interest in social
interactions, and be less likely to pay attention to other people’s verbal and non-verbal
social cues. An important nuance to make here, is that although some autistic people
show less involvement in social interaction, this might not necessarily be the result of
lower social motivation, but rather it may be a consequence of exhaustion from trying
to emulate a typical non-autistic style of interaction, known sometimes as camoulaging
(e.g., Cook et al., 2021; Livingston et al., 2019). Moreover, there is a critical role of early
communicative experiences in the development of individuals’ attention towards other
people’s verbal and non-verbal social communication cues (Vernetti et al., 2018).
“Children vary widely in the age at which they irst acquire spoken language and
the pace at which their speech and language become irmly established” (World Health
Organization, 2019a). Most children with early language delay eventually acquire similar
language skills to their same-aged peers. Early language delay alone is not strongly
indicative of ASD, unless there is also evidence of limited motivation to engage in social
communication and of atypical social interaction skills (World Health Organization,
2019a).
An essential feature of ASD is persistent atypicality in how language is used and
understood for social communication. People with an ASD typically do not follow
non-autistic norms (conventions) in how they integrate their spoken language with
complementary non-verbal cues, such as (considered) appropriate eye-contact, gestures,
facial expressions, nodding in agreement, or other demonstrations of acknowledgement.
Compared to non-autistic people, they are less likely to use body language to share a
perspective, such as pointing to express interest in a distant object, or sharing attention
in some external event or object. There is usually reduced tendency to initiate, join, or
to sustain a conventional back-and-forth social conversation, which has its origins in
early childhood. In general, people with an ASD have dificulty understanding and using
language in social contexts that are dominated by non-autistic people, and are less likely
to initiate and sustain reciprocal, purely social conversations (especially ‘chat’). The
pragmatic language dificulties that are typical of ASD can manifest as misunderstand
ings of others’ language due to literal interpretations, together with speech that lacks
ASD in ICD-11: A Psychological Approach 4
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

‘normal’ (i.e., non-autistic) prosody and emotional expressiveness, sometimes with a
distinctly monotonous tone of voice, or contrastingly, with exaggerative expressiveness.
Some autistic people are unaware that, to non-autistic people, their use of language
sounds atypical, and may talk with such precision that it is considered pedantic, together
with the use of an arcane vocabulary. In isolation, atypical language of this nature is only
indicative; the diagnostic classiication of an ASD requires there to be broad range of
additional social reciprocity dificulties, as well as tendency towards inlexible behaviour
and sensory sensitivities (see below).
In the context of social relationships with non-autistic people, especially with unfa
miliar individuals, there can be limited social awareness, which can lead to behaviour
that is not appropriately modulated according to the social context. Although people
with ASD are often characterised as ‘lacking empathy’, the evidence for diminished
empathic capacity in typical ASD is not strong. Some research shows altered affective
empathy (e.g., Mazza et al., 2014), but, especially in cognitively able individuals, cognitive
empathy can usually be present, although there may be an altered processing speed (i.e.
due to a local rather than a global processing style, information is processed somewhat
slower, but in more detail; Bölte et al., 2007). According to clinical observations of
autistic adults, the empathic response may be over-developed (i.e., the tendency to expe
rience high levels of emotional contagion). Moreover, whilst someone with ASD may
not obviously be conventionally responsive to a non-autistic person’s feelings, autistic
adults often explain their atypical reaction relects a state of anxious confusion and/or
indecision, rather than unawareness or disinterest.
Compared to non-autistic people, those with ASD are less likely to spontaneously
share their interests with others, and may assume that others do spontaneously share
their own interests and point of view (without the need to explicitly ask them). Given
that in social life, non-autistic people are often highly intolerant of even small devia
tions from social norms, this can lead to challenges making and sustaining typical peer
relationships. The impact of such peer problems changes from early childhood to adoles
cence. Intimate friendships with peers become more signiicant during adolescence, and
dificulties building such relationships often become more overt at that time (e.g., Mandy,
2022). Isolation from or rejection by peers will usually have secondary consequences in
terms of impaired mental health (e.g. social anxiety, depression or even trauma). Genuine
pervasive lack of interest in making peer relationships is rare. Clinically, it is important
to be aware that a young person’s withdrawal from social interactions may relect social
anxiety, and could be the result of persistent lack of acceptance by a peer majority
non-autistic group. Furthermore, peer victimisation is a common experience for autistic
people, and clinical assessment should always explore whether bullying is occurring,
how it can be stopped, and its impact on the individual.
Also, non-autistic individuals “vary in the pace and extent to which they acquire and
master skills of reciprocal social interaction and social communication” (World Health
Greaves-Lord, Skuse, & Mandy 5
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

Organization, 2019a). A diagnosis of ASD should only be considered if there is marked
and persistent difference from the expected range of abilities and behaviours in these
domains given the individual’s age, level of intellectual functioning, and sociocultural
context. Some individuals may exhibit limited/altered social interaction due to shyness
(i.e., feelings of awkwardness or fear in new situations or with unfamiliar people, due
to anxiety about negative social judgement), behavioural inhibition (i.e., being slow to
approach or to ‘warm up’ to new people and situations) or behavioural disinhibition (i.e.
impulsiveness). Limited social interactions in shy or behaviourally (dis)inhibited children,
adolescents, or adults are not indicative of ASD. Shyness is differentiated from ASD by
evidence of typical, non-autistic social communication behaviours in familiar situations
(World Health Organization, 2019a).
Repetitive, Stereotyped Behaviours and
SensoryInterests
“Many children go through phases of repetitive play and highly focused interests as a
part of typical development. Unless there is also evidence of impaired reciprocal social
interaction and social communication, patterns of behaviour characterized by repetition,
routine, or restricted interests are not by themselves indicative of Autism Spectrum
Disorder” (World Health Organization, 2019a). Clinically signiicant evidence requires
persistent “restricted, repetitive, and inlexible patterns of behaviour, interests, or activ
ities that are clearly atypical and excessive for the individual’s age and sociocultural
context” (World Health Organization, 2019a).
Typically, children with ASD are slower and/or less able to adapt to new experiences
and circumstances. Strong reactions (often one of acute anxiety, distress and/or anger)
can be evoked by changes to a familiar environment that, to non-autistic people, seem
trivial, or in response to unanticipated events. Characteristic of the response to such
unwelcome change and uncertainty is extreme discomfort which manifests in childhood
as acute distress. This resistance to change also commonly manifests as the tendency
to strongly adhere to particular routines. These may be geographic, such as the need to
follow familiar routes, or may require precise timing, such as during mealtimes or when
travelling. The tendency to engage in restricted and repetitive behaviours persists over
time, although its frequency and overtness may diminish during adolescence. In contrast,
insistence on ‘sameness’, can become more prominent in later life. Other aspects of this
underlying need for consistency and predictability can be observed in terms of unusually
strong adherence to rules (e.g., when playing games), as well as marked “and persistent
ritualized patterns of behaviour (e.g., a preoccupation with lining up or sorting objects in
a particular way” (World Health Organization, 2019a) or analysing/systemizing all sorts
of information). Historically, such behaviours have been dismissed by non-autistic people
as serving no apparent external purpose, but recent qualitative research with verbally
ASD in ICD-11: A Psychological Approach 6
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

luent autistic individuals has revealed that the actions of organizing and systemizing can
serve to regulate arousal. Thus, as their internal tension builds up, (e.g., in response to
increasing social demands) an autistic person might start organizing or performing some
systemic routine, in order to calm down (Greaves-Lord et al., 2022).
Speciic repetitive or stereotyped behaviours will differ according to the developmen
tal stage of the individual, but the tendency is usually life-long. In contrast, “repetitive
and stereotyped motor movements, such as whole-body movements (e.g., rocking), atyp
ical gait (e.g., walking on tiptoes), unusual hand or inger movements and posturing”
(World Health Organization, 2019a), are more likely to be observed during childhood
and are seen in situations of distress and excitement (i.e. hyperaoursal, see below).
Such behaviours can also persist into adulthood, especially in autistic people with a
co-occurring Intellectual Disability (abbreviated: ID).
Many individuals with an ASD develop fascinations with speciic topics, objects or
activities. In ICD-11, these are characterised as persistent preoccupations “with one or
more special interests, parts of objects, or speciic types of stimuli (including media),
or an unusually strong attachment to particular objects (excluding typical comforters)”
(World Health Organization, 2019a). The range of special interests is wide, and they may
change from time to time during development. A key feature of the intensity of the
special interests that are typical of ASD, is their pervasiveness and the fact that they
disrupt an individual’s ability to conform to conventional norms within a social setting,
to some extent. For example, everyday life may be adversely inluenced by the need to
pursue those interests. In childhood, this could have a negative impact on the family, as
could the intense attachment to favoured objects (e.g., because of the distress engendered
by their being left behind or lost). Nevertheless, it is important to recognise that these
fascinations often enrich autistic peoples’ lives, with positive effects on identity and
mood. Furthermore, such fascinations can engender skill and expertise that is valued in
wider society.
The most recent addition to the diagnostic rubric of ASD symptoms (i.e., a change
from ICD 10 to ICD 11) is the presence of lifelong strong and persistent hypersensitivi
ty and/or hyposensitivity to sensory stimuli. Sensory sensitivities can include unusual
interests in certain sensory stimuli, which may include sounds, light, textures (especially
clothing and food), odours and tastes. Although a strong interest in spinning objects
is often illustrated in assessment tool as characteristic of ASD, this clear exemplar of
autistic behaviour is mainly observed in individuals with ID and delayed social-emotion
al development. A positive interest in sensory stimuli is less common than negative
reactions to such stimuli, but a strong negative reaction to everyday sensory stimuli can
be upsetting for the autistic person and also disruptive of family life. These typically
include sensitivities to sounds, especially white noise such as hand dryers or vacuum
cleaners. The sounds may not be especially loud; these reactions are most frequently
observed in childhood. Other negative reactions can be observed to bright lights, certain
Greaves-Lord, Skuse, & Mandy 7
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

clothing textures including labels, and especially food textures. Negative reactions to
textures in food typically include the avoidance of mixed textures, requiring strict food
separation. Although such behaviours are not exclusively observed in ASD, their severity
and persistence, together with the consequent impact on everyday life, are more typical
of ASD.
Life-Course Perspective and Advice
onAssessment
When individuals with suspected ASD present in adolescence or in adulthood, it is
essential to perform an interview on developmental history, and not to rely exclusive
ly on self-report or observations of current behaviour, however well-structured the
observation. This is because one prerequisite for the diagnostic classiication (although
deliberately formulated in a nuanced way) is evidence that the onset of the atypical
behaviours occurred during the early developmental period, typically toddlerhood/child
hood (i.e., pre-school/primary school).
In contrast to ICD-10, in ICD-11 there is no longer the requirement of history of
delayed onset of language, or clear evidence of autistic symptoms before/around the
age of four to ive years. This change relects in part the fact that Asperger syndrome
has been discontinued as a valid diagnosis; typically, individuals with normal-range
verbal intelligence do not have delayed onset of language and they have been subsumed
into the ASD diagnostic rubric. Also, it is now recognized that some individuals with
ASD start to experience distress, impairment and overt social challenges once societal
demands increase (during adolescence or adulthood).
Late onset symptoms of ASD and their differential diagnosis from personality disor
ders in adulthood are still a complex and controversial issue. Dificulties in inter-personal
functioning (i.e., with understanding others’ perspectives, intimacy and self-regulation)
are also characteristic of personality disorders. As we do not conventionally diagnose
personality disorder in childhood, clear history of early (preschool) social communica
tion dificulties, could be a differentiating feature. Enquiries should attempt to deine
exactly when the atypical social behaviours started to occur, but more importantly, under
what circumstances. Early signs and predictors of later manifest ASD, such as a lack
of/altered attention to eyes (Jones & Klin, 2013) and limited facial recognition (Eussen et
al., 2015)/limited use of facial expressions, should be investigated.
At the time our conventional diagnostic instruments were developed, most clinically
recognised children with autism were also experiencing generalized developmental delay
(i.e., ID). Plateauing of social communication and language skills and lack of progress
in their development characterises many such children. Yet the minority had a period
of normal development (sometimes including age-typical language skills), but then lost
their previously acquired skills, often in the second year of life. Such regression can be
ASD in ICD-11: A Psychological Approach 8
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

rapid, over a period of days or weeks, and usually leads to impaired language and social
responsiveness. “Loss of previously acquired skills is rarely (spontaneously) observed
after 3 years of age” (World Health Organization, 2019a), but can occur in acquired
conditions such as encephalitis. If it occurs after age 3, it is more likely to involve a
more generalized loss of cognitive and adaptive skills (including the loss of bowel and
bladder control, and impaired sleep), as well as regression of language and social abilities
(World Health Organization, 2019a). In rare cases of spontaneous regression, recovery
takes place. This is usually slow (over months or years), and usually requires intensive
interdisciplinary care that focusses on restoring the lost skills, including support for
the development of speech/conversational, adaptive and regulatory skills. Asking and
clarifying concrete examples of atypical development is therefore key when performing
an interview on developmental history, and especially challenging when done only
once the individual and caregivers involved are already older. Therefore, training such
interviewing skills is essential when educating mental health professionals.
In preschool children, indicators of an ASD “often include avoidance of mutual eye
contact, resistance to (conventional expressions o) physical affection, lack of social
imaginary play, language that is delayed in onset, or is precocious” (World Health
Organization, 2019a), but not used for conventional back-and-forth social conversation;
social withdrawal, marked fascinations with topics that are sometimes notably unusu
al, and lack of age-typical social interaction with non-autistic peers, characterized by
parallel play or apparent disinterest. “Sensory sensitivities to everyday sounds, or to
foods, may overshadow the underlying social communication deicits” (World Health
Organization, 2019a). These social characteristics are often irst reported by a nursery or
other preschool placement where the child’s behaviour is observed to differ signiicantly
from the majority. Therefore, obtaining information from such sources (e.g., reports from
infant care agencies/pre-school) can be of important additional value when charting the
developmental history, especially in older cases.
In children with ASD without a Disorder of Intellectual Development (or general
developmental delay), "social adjustment dificulties outside the home may not be detec
ted until school entry or adolescence", when atypical social communication all-too-com
monly leads to peer rejection, bullying and social isolation (World Health Organization,
2019a). "Resistance to engage in unfamiliar experiences and marked reactions to even
minor change in routines is typical" (World Health Organization, 2019a). Furthermore,
a strikingly strong "focus on detail as well as rigidity of behaviour and thinking" may
be present. Secondary mental health problems are common, and symptoms of anxiety
(i.e. social/speciic phobia; e.g. Verheij et al., 2015) may become evident at this stage of
development (World Health Organization, 2019a).
By adolescence, the capacity to cope with increasing social complexity in peer
relationships at a period of ever-more demanding academic expectations is often over
whelmed. In some autistic individuals, their underlying social communication dificulties
Greaves-Lord, Skuse, & Mandy 9
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

may be overshadowed by the symptoms of co-occurring mental and behavioural disor
ders. Depressive or anxiety symptoms are often a presenting feature (World Health
Organization, 2019a), and restrictive eating disorders (including anorexia nervosa) be
come increasingly common in autistic girls at this age. Thus, clinicians should be aware
of potential underlying ASD when performing diagnostic assessment in mental health
settings.
In adulthood, the capacity for those with ASD to cope with complex and luid
cross-neurotype “social relationships can become increasingly challenged, and clinical
presentation may occur when social demands overwhelm the capacity to compensate.
Presenting problems in adulthood may represent reactions to (victimisation and) social
isolation” (World Health Organization, 2019a). Also, they may relect the challenges
of planning and organising one’s professional and personal life, and regulating emo
tions, with less support than was received in childhood and adolescence. Compensation
strategies may be suficient to sustain dyadic relationships, but usually come under ex
cessive strain in more complex group situations. “Special interests, and focused attention,
may beneit some individuals in education and employment. Work environments may
have to be tailored to the capacities (and sensitivities) of the individual. A irst diagnosis
in adulthood may be precipitated by a breakdown in domestic or work relationships”
(World Health Organization, 2019a). As mentioned, if the individual is autistic, there is
always history of at least some atypical signs in early childhood social communication
and relationships, although this may only become apparent, or interpreted as such, in
retrospect.
Because it is now recognised that ASD represents a more intense manifestation of
the wide range of behaviours that are observed in the general population, it is critical
to consider the impact of those symptoms on everyday life, before making a diagnosis.
Diagnostic criteria, as outlined above, stipulate that autistic characteristics should “result
in signiicant impairment in personal, family, social, educational, occupational or other
important areas of functioning” (World Health Organization, 2019a; e.g., emotional/phys
ical wellbeing). Some individuals with ASD can function well in many contexts, often
through exceptional effort on their part, such that their autistic characteristics are ‘cam
oulaged’ and are not apparent to others. A diagnosis of ASD is still appropriate in such
cases, especially when such exceptional effort is no longer achievable due to aging or
changing social circumstances, during which the autistic characteristics might become
more apparent to others over time. Camoulaging is commonly described by autistic
people as exhausting and is associated with elevated risk for anxiety, depression and
suicidality (Cook et al., 2021).
ASD in ICD-11: A Psychological Approach 10
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

Hypothesised Neuropsychological Mechanisms
Driving the Core Behaviours Defining ASD
Although ASD is deined based on behavioural features, several theories exist on the
neuropsychological mechanisms hypothetically underlying these behaviours. Classically,
three main theoretical frameworks explaining underlying neuropsychological function
ing were presented; Theory of Mind (ToM; e.g., Andreou & Skrimpa, 2020), Executive
Functioning (EF; e.g., Demetriou et al., 2019) and Central Coherence (CC; e.g., López et
al., 2008). Over time, nuances were made on how these theories each explain particular
behavioural aspects of autism (e.g., Happé et al., 2006). More recently, theories have been
proposed that combine, integrate and extend these theories, e.g. the Predictive Coding
account (PC; e.g., Van de Cruys et al., 2014) and the Polyvagal Theory (PT; e.g., Brown,
2020). Given the scope of this article, we cannot go into detail on all these accounts,
nor can we mention the abundant literature. However, we will briely explain these
theories and illustrate them with examples of behaviours seen in autistic people, so
that clinical psychologists can a) better understand what mechanisms might be driving
certain behaviours, and b) use this to increase the understanding of autistic people they
support.
Firstly, ToM refers to the ability to formulate hypotheses on how other people feel,
think and thus behave; i.e. mentalizing. Autistic people might sometimes respond differ
ently than conventionally would be expected. Such responses can however be better
understood, when being aware that - depending on the circumstances - the response
might be either mostly to the verbal information that was primarily processed, or to the
visual information that was mainly processed (e.g., Chung et al., 2014).
Secondly, EF refers to a set of capacities used to consciously plan ahead, meet goals,
display self-control, etc. Speculatively, more unconscious, automatically driven cognitive
distortions might appear in case of cognitive overload in autistic people (e.g., Autistica,
2021). Sometimes, autistic people show the tendency to categorize things or people
as all good or all bad, all right or all wrong (sometimes referred to as 'dichotomous
thinking'), rather than - at that instance - being able to consciously notice the possibilities
in between, sometimes referred to dichotomous thinking.
Weak CC refers to dificulties in ‘seeing the bigger picture’, but rather an associative,
non-linear thinking style in autistic people (e.g., Grandin, 2009). Simply put, some people
might mainly have a global (bigger picture) processing style, while other (autistic) people
might mainly have a local (detail-focussed) processing style (Bölte et al., 2007).
The idea of CC was taken further in PC theory. This theory of brain function
stipulates that the brain is constantly generating and updating a mental model of the
environment (e.g., Pellicano & Burr, 2012). This model is used to generate predictions
of sensory input that are compared to actual sensory input. This comparison results in
prediction errors that are then used to update and revise the mental model. An autistic
person might be focussed more on the actual sensory input and their brain might be con
Greaves-Lord, Skuse, & Mandy 11
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

stantly working to minimize the gap between the prediction and actual sensory input.
As such, this theory might explain why some autistic people have more intolerance of
uncertainty, given the larger prediction errors and the cognitive resources it takes to
try and solve these. Finally, although the PT (Porges, 1995) is not yet well substantiated
empirically, it’s popularity is growing amongst some clinical practitioners and autistic
people, as it is relatable. Therefore, we discuss it briely. Polyvagal theory takes its name
from the vagus, a cranial nerve that is the primary component of the parasympathetic
nervous system. The autonomic nervous system (ANS) has two parts; the sympathetic
nervous system, which is mostly activating (“ight or light”), and the parasympathetic
nervous system, which exists of two distinct branches: a "ventral vagal system" which
supports social engagement, and a "dorsal vagal system" which supports immobilisation
behaviours, both “rest and digest” and defensive immobilisation or “shutdown”. Behav
ioural responses that derive from the hybrid state of activation and calming are key to
the ability to adaptively socially engage. It is speculated that in autistic people, the ANS
might (at times) be dysregulated, which could explain emotional melt downs or shut
downs in autistic people. Again, we emphasize that in this section we did not provide
an extensive explanation of all neuropsychological concepts. Rather, we illustrated some
behaviours seen in autistic people and tried to stimulate readers to think about their
assumed neurobiological origins. In clinical practice, for most autistic people it is key
to connect abstract, neuropsychological concepts to very concrete day-to-day personal
experiences, to ‘digest’ these explanations fully (e.g., Gordon et al., 2015). Thus, in psy
cho-education, it is essential to help autistic people make these translational connections.
Further Features and Disorders
Some individuals with an ASD experience delay in the development of their intellectual
abilities, and qualify for a diagnosis of ID. In countries with well-established facilities for
the assessment of autistic symptoms, and with experience in the manifestations of the
condition among individuals with good verbal skills, individuals with ID are a minority
of those diagnosed with ASD. By contrast, in more under-served areas, those with ID
constitute the majority people diagnosed with ASD. “If present, a separate diagnosis of
Disorder of Intellectual Development should be assigned, using the appropriate category
to designate severity (i.e., Mild, Moderate, Severe, Profound, Provisional). Because social
dificulties are a core feature of Autism Spectrum Disorder, the assessment of adaptive
behaviour as a part of the diagnosis of a co-occurring Disorder of Intellectual Devel
opment should place greater emphasis on the intellectual, conceptual, and practical do
mains of adaptive functioning than on social skills” (World Health Organization, 2019a).
Self-injurious behaviours (e.g., hitting one’s face, head banging) occur more often in
autistic people with co-occurring Disorder of Intellectual Development, perhaps because
ASD in ICD-11: A Psychological Approach 12
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

they represent attempts to express and communicate painful feelings, in the absence of
verbal means.
Even among individuals with normal-range intellectual abilities, proiles of speciic
cognitive skills in ASD as measured by standardized assessments, may show striking and
unusual patterns of strengths and weaknesses that are highly variable from individual to
individual. Clinical experience teaches that such a ‘spikey proile’ of cognitive strengths
and dificulties can affect learning and adaptive functioning to greater extent than would
be predicted from the overall scores on measures of verbal and non-verbal intelligence,
yet more research on this matter is needed to substantiate such clinical claims. Isolated
dificulties in intellectual functioning that are associated with ASD include slow/different
processing speed/style (Bölte et al., 2007) and limited verbal or non-verbal working
memory, which may occur in the presence of strong verbal and/or visuospatial skills in
other domains.
"The degree of impairment in functional language (spoken or signed) should be
designated with a second qualiier. Functional language refers to the capacity of the
individual to use language for instrumental purposes (e.g., to express personal needs
and desires). This qualiier is intended to relect primarily the verbal and non-verbal
expressive language [dificulties] present in some individuals with Autism Spectrum
Disorder” (World Health Organization, 2019a), and not the atypical pragmatic language
that is a core feature of the condition. ICD-11 requires the assessment of whether the
individual has a degree of functional language impairment (spoken or signed) relative to
their age in the following terms: i) with mild or no impairment of functional language; ii)
with impaired functional language (i.e., not able to use more than single words or simple
phrases); iii) with complete, or almost complete, absence of functional language (World
Health Organization, 2019a).
It is important to note that the observable manifestation of ASD will be different
at different developmental stages (as discussed above), as well as in different groups
(e.g., males versus females versus gender-diverse individuals, or those with and without
ID). For instance, parental or caregiver concerns about intellectual or other develop
mental delays (e.g., problems in language and motor coordination) often characterise
the presentation in young children during the preschool period. When there is no
signiicant impairment of intellectual functioning, the presentation to clinical services
is often prompted by staff at nursery school, who have observed unusual social or other
behaviour. In middle childhood, there may be prominent symptoms of anxiety, including
social anxiety disorder, school refusal, and speciic phobia (Verheij et al., 2015). During
adolescence and adulthood, depressive disorders are a common presenting feature. For
women, a restrictive eating disorder can drive engagement with mental health services,
with their underlying ASD and/or associated social trauma only being identiied later
(Bentz et al., 2022). Across all ages, there is strong co-occurrence with attention dei
cit/hyperactivity disorder, and in males impulsive and disruptive behaviour often prompt
Greaves-Lord, Skuse, & Mandy 13
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

referral (especially in middle childhood), although in females the symptoms are more
likely to be related to attention dificulties, rather than impulsivity or hyperactivity.
Consequently, it is important to be aware that ASD commonly co-occurs with other
mental, behavioural or neurodevelopmental disorders across the lifespan. In a substantial
proportion of cases, particularly in adolescence and adulthood, it is the co-occurring
disorder that irst brings the autistic individual to clinical attention. Some people with
ASD are capable of functioning even in environments that are poorly adapted to accom
modate them, by making an exceptional effort to compensate for their symptoms during
childhood, adolescence or adulthood (i.e., ‘camoulaging’). Such camoulaging requires
sustained effort, is more typical of females (although it is common in all genders), and
can have deleterious impact on mental health and well-being (Cook et al., 2021).
“Some young individuals with Autism Spectrum Disorder, especially those with a co-
occurring Disorder of Intellectual Development, develop epilepsy or seizures during early
childhood with a second increase in prevalence during adolescence. Catatonic states
have also been described. A number of medical disorders such as Tuberous Sclerosis,
chromosomal abnormalities including Fragile X Syndrome, Cerebral Palsy, early onset
epileptic encephalopathies, and Neuroibromatosis” are associated with an ASD diagnosis
(World Health Organization, 2019a), with or without a co-occurring Disorder of Intellec
tual Development. Genomic deletions, duplications and other genetic abnormalities are
increasingly described in individuals with ASD, some of which may be important for
genetic counselling. Prenatal exposure to valproate is also associated with an increased
risk of ASD (World Health Organization, 2019a).
Recently, there is growing recognition of the fact that people with ASD more fre
quently develop more severe physical illnesses, in the worst case resulting in relatively
early death, as compared to other people from the general population. Potentially, this
might relect the fact that autistic people experience high levels of stress, due to having
to live in environments that are poorly designed to accommodate them, with consequent
elevated levels of mental health, suicidality and substance use problems. Poor physical
health outcomes could relect a combination of two underlying causes. First, autistic
people might have a limited capacity to sense and recognize early physical symptoms.
This might be due to limited interoception, i.e. hypo-sensitivity or a limited inclination
to direct their attention towards internal stimuli of the body (e.g. Garinkel et al., 2016).
Secondly, they might be reluctant to communicate any concerns they have about their
physical health to professionals. This might result in their initially not seeking access
to medical services, as well as limiting their action in following up any subsequent
referral to medical specialists. Research on this topic is still ongoing. Nevertheless, it is
important that mental health professionals are aware that there is potentially limited
somatic awareness in autistic clients. They should therefore pro-actively bring up the
topic of their client’s physical health. Psychologists should consider referral to a medical
specialist when an autistic client complains about somatic symptoms, and should be
ASD in ICD-11: A Psychological Approach 14
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

aware of their potential professional biases. Faced with an autistic client who has somatic
symptoms they should not automatically assume a psychological explanation, but be
aware that an alternative physical condition could be present, and that condition should
be adequately investigated. The prevalence of premature mortality affecting people on
the autism spectrum, which is excessive, could be attributable at least in part from these
risk factors.
Comparison Between ICD-11 and DSM-5
Both systems of diagnosis differ substantially from previous versions (ICD-10 and DSM-
IV and DSM IV TR). There are differences in their conceptualization of ASD as a broad
category comprising many different conditions (not yet identiied, the 'autisms'), and in
terms of speciic phenotype requirements. Hence the agreed term ASD, relecting the
heterogeneity of those conditions. Both systems recognize that ASD is a set of symptoms
that exist on a continuum that blends into normal variation, and they also consider the
fact that at one extreme end there is a subset of conditions that are associated with
identiiable biological substrates (largely genetic, but also some environmentally induced
risks). The greatest difference between the ICD-11 and DSM 5 diagnostic systems is not
in the social communication aspects of the condition, but in the patterns of restrictive,
repetitive, and inlexible patterns of behaviour that are regarded as atypical.
The blurry boundaries between ID and ASD bedevils research. Experts who are look
ing at genetic risk factors continue to have a heated debate about whether certain genetic
anomalies increase risk for ASD or ID or both. ICD-11 criteria are cognizant of the fact
that nowadays most diagnoses of ASD are made in individuals who are of normal-range
intelligence. Accordingly, B-scale symptoms are deined in a way that relects behaviours
that are seen in those individuals (more broadly ranging than is discussed in DSM-5).
Unlike DSM-5, ICD-11 does not emphasize the ID-related criteria (such as lipping
objects, strong attachment or preoccupation with unusual objects, excessive smelling
or touching of objects, echolalia, stimming; WHO, 2019b). The associated limited enquiry
about symptoms of Repetitive, Restricted and Stereotyped behaviour (RRSB) is one of the
reasons why there was, under the former DSM-IV TR criteria, such high prevalence of
Pervasive Developmental Disorder – Not Otherwise Speciied ('PDD-NOS'). By broaden
ing the criteria and introducing concepts such as 'Lack of adaptability to new experiences
and circumstances...' ICD-11 has aimed to reduce the perceived lack of sensitivity of the
DSM-5 criteria to cognitively able and older individuals.
Intellectual disability is conceptualized as a homogeneous condition in DSM-5. It is
said that ASD may be dificult to differentiate from ID in very young children (under the
heading Differential Diagnosis), but this statement exempliies the problem that in the
USA the terms are much closer aligned than the developers of ICD-11 considered to be
appropriate. DSM-5 does not make distinctions between levels of intellectual impairment.
Greaves-Lord, Skuse, & Mandy 15
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

In ICD-11, as discussed, there is the possibility to record an associated Disorder of
Intellectual Development, and this should be assigned a degree of severity.
DSM-5 criteria state that, to make an ASD diagnosis, the atypical social communi
cation should be more marked than would be anticipated from the individual's develop
mental level when any associated ID is considered. In ICD-11 a similar statement is
made. Both diagnostic systems acknowledge that it is important to distinguish the lack
of adaptive behaviours that are indicative of generalized learning disabilities from the
speciic dificulties that are experienced by individuals with ASD. The difference in
emphasis between the systems relects the expectation in the US that it is important to
identify ASD symptomatology in those with ID, whereas in ICD-11 the emphasis is on
the importance of identifying intellectual impairment in those with a primary diagnosis
of ASD.
In DSM-5 a differential diagnosis is made between ASD and Social (Pragmatic) Com
munication Disorder, a condition that does not exist in ICD-11. The developers of ICD-11
criteria were not convinced that a speciic disorder of this nature could be differentiated
clearly from atypical social communication that is associated with ASD, nor from vari
eties of Speciic Language Impairment (Mandy et al., 2017). ICD-11 records the degree
of impairment of functional language at three levels, but this distinction is not treated
as a differential diagnosis. That decision, to record three levels of impairment appears
to be similar, but more structured, than the DSM-5 stipulation to use the speciier 'with
or without accompanying language impairment' with an injunction to assess the current
level of language and describe it. The choice of three levels relected the need to be more
explicit for clinical purposes, and the ICD-11 developer’s estimate that this distinction
could be made reliably.
Both systems of diagnosis require the recording of loss of skills. In ICD-11 there is a
qualiier that records whether there is loss of previously acquired skills, or not. DSM-5
discusses loss of skills in the context of Development and Course and distinguishes social
from loss of other skills (such as toileting or motor skills). ICD-11 acknowledges that the
pattern of skill loss will be different at different stages of development.
DSM-5 has a section on differential diagnosis which implies that it is possible that
ASD could be confused with other diagnoses, such as selective mutism or ADHD. ICD-11
has taken a different approach, recognizing that these conditions can (and frequently do)
co-occur. Hence, in ICD-11 they are included in a section that uses the term 'Boundaries
with Other Disorders and Conditions’. The guidelines in ICD-11 provide greater detail
than DSM-5 about the distinction between conditions that may present with an autism-
like phenotype.
ASD in ICD-11: A Psychological Approach 16
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

Towards Intervention to Improve Quality of Life
and Functioning
In our view, the diagnostic classiication of ASD should always inform and serve proper,
suitable interventions and support aimed at improving the wellbeing and functioning
of the autistic person. Thus, clinical psychologists should remain aware that diagnostic
classiication is not a purpose in itself. Therefore, as part of the diagnostic assessment
process, clinicians should perform assessments with a purpose in mind. If the goal is
to primarily acquire new insights for scientiic/applied research and/or related mental
health care innovations, that purpose of potential additional assessments should be
transparently communicated to all involved. Diagnostic classiication in clinical practise
should be a means to provide proper, suitable care, and therefore all diagnostic assess
ments should be used to tailor the interventions and/or care to the capacities and
genuine needs of the people that ask for professional help. Even though ASD is concep
tualized as predominantly inborn, so genetically determined condition, the interaction
with social factors is more and more recognized both in society as well as in research. As
such, interventions to help autistic people should not simply focus on effecting change
in the individual, but should also include steps to improve person-environment it by
making adaptations to the environment. Furthermore, intervention targets should be
identiied collaboratively with the client and their family, and will often concern improv
ing wellbeing, mental health and societal functioning. Whilst practice may need to be
adapted to promote access and inclusion for autistic clients, mental health care providers
are in a good position to use their clinical skills to offer effective help. There is growing
evidence-base for psychological treatment procedures and social support interventions.
Recommendations regarding suitable methods for treatment and support with suficient
evidence as well as preference base will be provided in a future follow up article.
Funding: The authors have no funding to report.
Acknowledgments: We want to thank Gillian Baird and Graccielle Rodrigues da Cunha who were involved in
writing a related book chapter. Also, gratitude goes out to Annemiek Landlust, Inge van Balkom and Sigrid Piening
who at the Autism Team North-Netherlands provide an excellent environment in which much can be learned about
ASD, conceptually as well as practically. Finally, a large thank you to all members of the Academic Workplace
Autism, the Volante workgroup and Autism Europe who enlarged our perception and conception of what ASD entails
when experienced at a daily basis.
Competing Interests: All authors were involved in the development and evaluation of the Developmental,
Dimensional and Diagnostic interview (3Di), a semi-structured interview that can be used to clarify the
developmental history as part of the diagnostic assessment process concerning Autism Spectrum Disorder.
Greaves-Lord, Skuse, & Mandy 17
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). https://doi.org/10.1176/appi.books.9780890425596
Andreou, M., & Skrimpa, V. (2020). Theory of mind deicits and neurophysiological operations in
autism spectrum disorders: A review. Brain Sciences, 10(6), Article 393.
https://doi.org/10.3390/brainsci10060393
Autistica. (2021). Unhelpful thinking styles.
https://www.autistica.org.uk/what-is-autism/anxiety-and-autism-hub/unhelpful-thinking-
styles
Bentz, M., Holm Pedersen, S., & Moslet, U. (2022). Case series of family-based treatment for
restrictive-type eating disorders and comorbid autism: What can we learn? A brief report.
European Eating Disorders Review, 30(5), 641–647. https://doi.org/10.1002/erv.2938
Bolis, D., Balsters, J., Wenderoth, N., Becchio, C., & Schilbach, L. (2017). Beyond autism: Introducing
the dialectical misattunement hypothesis and a Bayesian account of intersubjectivity.
Psychopathology, 50(6), 355–372. https://doi.org/10.1159/000484353
Bölte, S., Holtmann, M., Poustka, F., Scheurich, A., & Schmidt, L. (2007). Gestalt perception and
local-global processing in high-functioning autism. Journal of Autism and Developmental
Disorders, 37(8), 1493–1504. https://doi.org/10.1007/s10803-006-0231-x
Brown, D. (2020). Polyvagal theory and regulating our bodily state. Affect Autism.
https://affectautism.com/2020/08/24/polyvagal/
Chen, Y.-L., Senande, L. L., Thorsen, M., & Patten, K. (2021). Peer preferences and characteristics of
same-group and cross-group social interactions among autistic and non-autistic adolescents.
Autism, 25(7), 1885–1900. https://doi.org/10.1177/13623613211005918
Chung, Y. S., Barch, D., & Strube, M. (2014). A meta-analysis of mentalizing impairments in adults
with schizophrenia and autism spectrum disorder. Schizophrenia Bulletin, 40(3), 602–616.
https://doi.org/10.1093/schbul/sbt048
Cook, J., Hull, L., Crane, L., & Mandy, W. (2021). Camoulaging in autism: A systematic review.
Clinical Psychology Review, 89, Article 102080. https://doi.org/10.1016/j.cpr.2021.102080
Demetriou, E. A., DeMayo, M. M., & Guastella, A. J. (2019). Executive function in autism spectrum
disorder: History, theoretical models, empirical indings, and potential as an endophenotype.
Frontiers in Psychiatry, 10, Article 753. https://doi.org/10.3389/fpsyt.2019.00753
Eussen, M. L., Louwerse, A., Herba, C. M., Van Gool, A. R., Verheij, F., Verhulst, F. C., & Greaves-
Lord, K. (2015). Childhood facial recognition predicts adolescent symptom severity in autism
spectrum disorder. Autism Research, 8(3), 261–271. https://doi.org/10.1002/aur.1443
Garinkel, S. N., Tiley, C., O’Keeffe, S., Harrison, N. A., Seth, A. K., & Critchley, H. D. (2016).
Discrepancies between dimensions of interoception in autism: Implications for emotion and
anxiety. Biological Psychology, 114, 117–126. https://doi.org/10.1016/j.biopsycho.2015.12.003
Gordon, K., Murin, M., Baykaner, O., Roughan, L., Livermore-Hardy, V., Skuse, D., & Mandy, W.
(2015). A randomised controlled trial of PEGASUS, a psychoeducational programme for young
ASD in ICD-11: A Psychological Approach 18
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

people with high-functioning autism spectrum disorder. Journal of Child Psychology and
Psychiatry, and Allied Disciplines, 56(4), 468–476. https://doi.org/10.1111/jcpp.12304
Grandin, T. (2009). How does visual thinking work in the mind of a person with autism? A
personal account. Philosophical Transactions of the Royal Society of London: Series B. Biological
Sciences, 364(1522), 1437–1442. https://doi.org/10.1098/rstb.2008.0297
Greaves-Lord, K., Kruizinga, I., Landsman, J., van Daalen, E., Landlust, A., & van Balkom, I. D. C.
(2022). Factors associated with behavioural problems in ASD. Wetenschappelijk Tijdschrift
Autisme, 2, 2–25. https://doi.org/10.36254/WTA.2022.201
Happé, F., Ronald, A., & Plomin, R. (2006). Time to give up on a single explanation for autism.
Nature Neuroscience, 9(10), 1218–1220. https://doi.org/10.1038/nn1770
Jones, W., & Klin, A. (2013). Attention to eyes is present but in decline in 2–6-month-old infants
later diagnosed with autism. Nature, 504, 427–431. https://doi.org/10.1038/nature12715
Livingston, L. A., Shah, P., & Happé, F. (2019). Compensation in autism is not consistent with social
motivation theory. Behavioral and Brain Sciences, 42, Article E99.
https://doi.org/10.1017/S0140525X18002388
López, B., Leekam, S. R., & Arts, G. R. (2008). How central is central coherence? Preliminary
evidence on the link between conceptual and perceptual processing in children with autism.
Autism, 12(2), 159–171. https://doi.org/10.1177/1362361307086662
Lord, C., Charman, T., Havdahl, A., Carbone, P., Anagnostou, E., Boyd, B., Carr, T., de Vries, P. J.,
Dissanayake, C., Divan, G., Freitag, C. M., Gotelli, M. M., Kasari, C., Knapp, M., Mundy, P.,
Plank, A., Scahill, L., Servili, C., Shattuck, P., . . . McCauley, J. B. (2022). The Lancet Commission
on the future of care and clinical research in autism. Lancet, 399(10321), 271–334.
https://doi.org/10.1016/S0140-6736(21)01541-5
Mandy, W. (2022). Six ideas about how to address the autism mental health crisis. Autism, 26(2),
289–292. https://doi.org/10.1177/13623613211067928
Mandy, W., Wang, A., Lee, I., & Skuse, D. (2017). Evaluating social (pragmatic) communication
disorder. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 58(10), 1166–1175.
https://doi.org/10.1111/jcpp.12785
Mazza, M., Pino, M. C., Mariano, M., Tempesta, D., Ferrara, M., De Berardis, D., Masedu, F., &
Valenti, M. (2014). Affective and cognitive empathy in adolescents with autism spectrum
disorder. Frontiers in Human Neuroscience, 8, Article 791.
https://doi.org/10.3389/fnhum.2014.00791
Pellicano, E., & Burr, D. (2012). When the world becomes ‘too real’: A Bayesian explanation of
autistic perception. Trends in Cognitive Sciences, 16(10), 504–510.
https://doi.org/10.1016/j.tics.2012.08.009
Porges, S. W. (1995). Orienting in a defensive world: Mammalian modiications of our evolutionary
heritage. A Polyvagal theory. Psychophysiology, 32(4), 301–318.
https://doi.org/10.1111/j.1469-8986.1995.tb01213.x
Greaves-Lord, Skuse, & Mandy 19
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005

Van de Cruys, S., Evers, K., Van der Hallen, R., Van Eylen, L., Boets, B., de-Wit, L., & Wagemans, J.
(2014). Precise minds in uncertain worlds: Predictive coding in autism. Psychological Review,
121(4), 649–675. https://doi.org/10.1037/a0037665
Verheij, C., Louwerse, A., van der Ende, J., Eussen, M. L., Van Gool, A. R., Verheij, F., Verhulst, F. C.,
& Greaves-Lord, K. (2015). The stability of comorbid psychiatric disorders: A 7 year follow up
of children with pervasive developmental disorder-not otherwise speciied. Journal of Autism
and Developmental Disorders, 45(12), 3939–3948. https://doi.org/10.1007/s10803-015-2592-5
Vernetti, A., Ganea, N., Tucker, L., Charman, T., Johnson, M. H., & Senju, A. (2018). Infant neural
sensitivity to eye gaze depends on early experience of gaze communication. Developmental
Cognitive Neuroscience, 34, 1–6. [N.B. corrected version published in March 2019].
https://doi.org/10.1016/j.dcn.2018.05.007
World Health Organization. (2019a). 6A02 Autism spectrum disorder. In International statistical
classification of diseases and related health problems (11th ed.).
https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/437815624
World Health Organization. (2019b). 6A00 Disorders of intellectual development. In International
statistical classification of diseases and related health problems (11th ed.).
https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/605267007
Zeidan, J., Fombonne, E., Scorah, J., Ibrahim, A., Durkin, M. S., Saxena, S., Yusuf, A., Shih, A., &
Elsabbagh, M. (2022). Global prevalence of autism: A systematic review update. Autism
Research, 15(5), 778–790. https://doi.org/10.1002/aur.2696
Clinical Psychology in Europe (CPE)
is the oficial journal of the
European Association of Clinical
Psychology and Psychological
Treatment (EACLIPT).
PsychOpen GOLD is a publishing
service by Leibniz Institute for
Psychology (ZPID), Germany.
ASD in ICD-11: A Psychological Approach 20
Clinical Psychology in Europe
2022, Vol. 4(Special Issue), Article e10005
https://doi.org/10.32872/cpe.10005