Brain differences and Relationships Series – Part 2: Autism

In the previous article, we looked at ADHD and the role that executive function plays in how people focus, organize, and regulate their thoughts and actions. Many of those same brain processes also show up in autism, which is one reason the two conditions are often discussed together and sometimes overlap. But while ADHD mainly affects attention and self-regulation, autism includes a broader set of differences that often involve social understanding, sensory experiences, and patterns of thinking. Because autism is frequently described as a “spectrum,” it can look very different from one person to another. In this next part of the series, we’ll take a closer look at what autism actually means, how the idea of the spectrum developed, and what people often experience at the more subtle end of the range.
Perhaps the first thing to say about autism is that it is described as a spectrum disorder (formally Autism Spectrum Disorder) and it is a huge spectrum! However, many if not most diagnostic categories are now being recognized as falling on spectrums, even if not so designated in their titles. The previous official DSM-4 diagnosis was divided into four to five categories (depending on what you count), including what was known then as Asperger’s Disorder. Asperger’s was named after the eponymous German doctor who first identified the syndrome of what has also been generally referred to as “high-functioning autism.” Hans Asperger fell into disrepute after revelations that he was involved with the Nazis, resulting in the elimination of that diagnostic category and disparagement of the term.
Around the same time, all the other previous categories were determined to be unreliable and so were collapsed into one broad spectrum. However, this creates another kind of confusion as the general terms “autistic” or “ASD” can now refer to an extreme range. At one end are folks who have no language and engage in severe self-stimulating behaviors such as banging their heads against hard surfaces. At the other end are brilliant and successful entrepreneurs, CEO’s, authors, and artists (among others).

The high/low functioning descriptors have also come under criticism for oversimplifying and being potentially misleading or able-ist. As discussed with ADHD, each individual will have their own weightings within the various features of the diagnosis. And even “high functioning” ASD folks likely will need certain kinds of support. The current diagnostic scheme in the DSM-5 describes three levels of need for support, with Level 1 needing the least support (what might have formerly been called “high functioning”), and Level 3 needing the most.

Many people with Level 1 autism had previously identified with the term Asperger’s, often referring to themselves as “Aspies.” They developed identities and communities around those terms. While some may still relate to that nomenclature, most people that I’ve encountered with autism simply prefer to identify themselves as autistic (though one should always check with the individual about what their preferred designation is, if any).

As with any clinical designation, there is a range of acceptance among individuals who are so diagnosed. The value of diagnosis lies in providing a handle for a set of characteristics, which can then help with understanding, self-compassion, and strategies for getting along in a world where divergence is often not properly cared for. The downside, of course, can be stereotyping, stigmatizing, and discrimination, which are prime reasons why people sometimes don’t want to be identified with a diagnosis and may feel shame around it.< br />On the other hand, many are relieved to find out that they have ADHD or autism. They incorporate it into their identities, and are quite open about it. Affirming the diagnosis helps them make sense of their experiences and can connect them to like-minded souls.

Here I will be addressing Level 1 autism: what used to be called “high-functioning,” and the part of the range clinicians who mostly see “neurotypicals” are apt to encounter. Virtually all people with autism will also have some ADHD features, since a key component of autism is EF differences, just like ADHD. Some autistic folks may also be diagnosed with ADHD, but technically ADHD is only supposed to be diagnosed when it’s not accounted for by another diagnosis. There is also an informal term called AuDHD that attempts to combine the two.

But technically, autism should encompass the ADHD findings and not have the extra diagnosis tacked on. One can assume that someone with autism will have ADHD characteristics (such as problems with self-monitoring, working memory, shifting attention, planning and organization, etc.), and that executive function is the overlapping aspect between the two syndromes.

If I have a significant suspicion that a client is on the spectrum I will usually ask if they have ever considered it. Often they or others in their immediate circle will have had the idea, and they may have lightheartedly joked about the possibility. If they are at all open to it I usually suggest they do some research on their own (e.g., Wikipedia, reliable AI sources, etc.) and see if they think it fits. Different levels of assessment are available if they want to pursue a formal diagnosis further, from relatively informal, publicly available, research-based tests, to extremely thorough neuropsychological testing costing up to $10,000 or more.

For those who are not open to it, I let it go and just refer to the collection of symptoms as they come up in their relationships or daily lives. A colleague suggested that for people who are in engineering-related fields, calling it an “engineering mindset” can work.

The main differentiators that suggest or confirm ASD are lumped into two categories: social intuition, and inflexibility. People with autism often describe a difficulty “reading people,” or “reading the room.” As one autistic man explained, they seem to lack the ability to absorb the rules of social engagement through osmosis as neurotypicals do. Instead they find many social engagements puzzling and stressful. While this may apply to some extent for some neurotypicals, it is more severe for those with autism and often from an early age. Interestingly, as with neurotypicals, there is a range of introversion and extroversion with ASD folks, with some being very extroverted and gregarious, despite their frequent social bewilderment.

A related idea is that autistic people have weakness in what is referred to as “theory of mind,” or “mindsight.” These are roughly the abilities of being able to put oneself in another’s shoes or entertain alternative perspectives. Compounding this, reduced EF in the areas of impulse control and self-monitoring can create problems with conversational turn-taking, leading to such things as talking-over, and over-talking. Although complex, being able to see things from another person’s perspective requires a certain amount of cognitive flexibility, which brings us to our second major differentiator for autism: cognitive inflexibility.

Cognitive inflexibility can show up in a variety of ways, and as mentioned it also can be a facet of ADHD. However, ADHDers are usually more flexible overall; the inflexibility in autism tends to be more pronounced. In the diagnostic criteria this lack of flexibility is described as “restricted, repetitive, and inflexible patterns of behavior,” which again can span a range on any of those descriptors.

At the more severe end inflexibility can show up as OCD, which may be diagnosed concurrently. With OCD, people get very attached to having things be ordered in certain ways, and/or they can get stuck on certain thoughts (obsessions) or behaviors (compulsions). Examples of compulsions include checking behavior (like having to check the locks of the dwelling many times) or excessive handwashing. Generally, these are thought of as overactive safety-related behaviors, fueled by anxiety, which have become frozen into compulsive routines.

Lesser levels of inflexibility can manifest as difficulty with transitions or context-switching (one of the traits most commonly shared with ADHD), or overly-literal thinking. Literal thinking can be another contributor to social impairment, in that folks with autism may have difficulty recognizing sarcasm, for instance.

Interestingly, despite these areas of inflexibility, at the higher ends of the intelligence gamut ADHD-ers and people with autism are often able to think “outside the box,” in part accounting for all the inventors and often exceptionally creative people with those diagnoses. As with diminished impulse control, both groups of people may refer to themselves–or be seen–as being “unfiltered.” While reduced filtering can present problems socially, it may also open up access to non-linear or divergent thinking that, in the right context, can be a remarkable virtue.

Effects of reduced filtering can come across as odd or eccentric to neurotypicals. While this may be true of ADHD-ers, autistic folks are more likely to manifest behavioral characteristics that stand out as unusual. Some of these may have to do with socially awkward actions, such as excessive pacing while waiting, or difficulty negotiating interpersonal space smoothly. Others may over-articulate their speech in a distinctive way, or have noticeably different posture or gait. However, bear in mind that there are also neurotypical people who appear eccentric as well, so it’s important not to jump to conclusions based on particular elements.

Another attribute related to filtering that tends to co-occur in autism is sensory sensitivity. This reflects problems with modulating sensory inputs. Some examples might include intolerance of itchy clothing or labels in clothing, misophonia (strong reactions to certain kinds of sounds), various kinds of light sensitivity, etc. Sensory sensitivity is not unique to autism but can be another suggestive aspect, in combination with the more prominent criteria.

Interestingly, the rates of secure attachment with autism are not that different from those in the neurotypical population. Estimates in the general population are around 2 out of 3 securely attached, while estimates in Level 1 populations tend to be around 50%.

Simon Baron-Cohen—one of the foremost thinkers and researchers about autism—theorizes that autism is a kind of “extreme male” paradigm. In his research he has shown that in general, men tend more towards what he calls “systemizing,” while women tend more towards empathizing. Systemizing is essentially what it sounds like: emphasizing things like systems, categorization, and abstract thinking. Informally, this can be observed in stereotypical male-male conversations about things like sports statistics, cars, and devices, vs. stereotypical female conversations which more likely to center on relationships and family.

Along the same lines, people with autism almost always are high systemizers. This is the process that produces what is often described as “special interests,” which usually involve lots of categorized and organized information. It also explains why many ASD folks find work in fields like law, engineering, and music which are very structured. And on the other hand, they have difficulty with empathy, as reflected in the mind-blindness and social differences discussed earlier. Simon Baron-Cohen has some corresponding theories about the role of testosterone in-utero, but I’ll leave those for the adventurous reader to pursue on your own. Anecdotally–and admittedly based on a very limited sample–the autistic women I’ve known have been a little warmer and more capable of empathy than the men, but still struggle with social conventions.

In terms of strengths, this systemizing ability can be very impressive, with the extreme being what are referred to as “savant” abilities, such as being able to remember exact autobiographical dates (more common) through things like Raymond’s ability to instantly know the number of matches dropped on the floor in the movie Rain Man. The latter is less common, and the character of Raymond would probably be considered Level 2 Autism, needing a higher level of support than the Level 1 we’ve been discussing. Autistic folks are often quite charming in their own ways, and part of this is their directness and extreme honesty (which, of course, can also get them in trouble at times).

Stepping back from all of this, the most important takeaway is that autism and ADHD are not simply about behavior, motivation, or effort—they reflect real differences in how the brain works, especially in areas related to executive function. What may look like forgetfulness, selfishness, or a short-fuse from the outside is often the result of challenges with memory, mindblindness, or switching contexts. At the same time, these differences often come with unique strengths such as creativity, deep focus, honesty, and strong problem-solving abilities. Understanding this can help partners, families, and individuals move away from blame and toward curiosity, patience, and practical solutions. In the last article, we’ll look at some simple, real-world strategies that can help support executive function and make daily life—and relationships—run more smoothly.

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