When I became a teacher in 1993, I had never heard of autism.
Today it would be rare for me not to consider the possibility of autism in my psychological formulation in my work as an education psychologist.
The accumulation of research and practice-based evidence from both education and psychology, and the involvement of the autistic community in informing the evidence base, has led to a rich corpus of work.
This broadening of our understanding of autism is a plus.
Uta Frith and autism
It was within this context that I welcomed reading the perspective that Professor Uta Frith recently provided in Tes Magazine, explaining why she no longer thinks autism is a spectrum.
The concept of a spectrum, as proposed by Lorna Wing, has served its purpose well: it broadened our thinking and raised awareness that autism is more than the narrow DSM3 criteria, and it showed that not recognising this was to the detriment of children’s educational and wellbeing experiences.
Frith’s challenge to our collective thinking about the spectrum, and her views on describing subgroups to better understand the varied presentations in children and adults, makes sense to me.
However, Frith’s perspectives, based in a medical model, appear to seek a return to a narrow and pathologising diagnosis of autism, and with this, a concerning approach to the female presentation of autism.
In this article I set out why this is a cause for concern.
Is autism a spectrum?
Frith says the idea of a spectrum has “collapsed” and medical diagnosis has become “meaningless”. I’m not sure the latter is true.
I see the increased prevalence in diagnosis more in line with the paradigm shift away from autism as a pathology (ableist agenda) to autism as one part of our neurodiversity (inclusion agenda).
Frith’s challenge to the idea that there is something that unites all people who are autistic is a useful point of reflection, and I agree that subtypes could be a helpful guide to thinking when considering educational needs. Being diagnosis-led in the classroom, when the diagnosis doesn’t inform our understanding of varied presentations, risks rerouting a teacher’s natural intuitive understanding of a child to one that is too narrow.
Teachers need and want a reliable research base that allows them to practise in ways that help the actual children before them, rather than what a category or diagnosis tells them is in front of them.
Therefore, any diagnosis of autism must be sensitive to the population differences this diagnosis represents.
A socially constructed model
However, diagnosis is a medical term, with medical criteria. Autism is both a diagnosis and a construct.
A socially constructed way of thinking about autism involves culturally different perspectives on what autism is and means. Autism is not a set of diagnostic criteria to autistic people - it is how autistic people experience and process the world, and society can learn how autistic people are doing that by asking them, observing them, discussing with them and listening to their experiences.
This expands society’s thinking, and in education terms, it improves our identification of when the child-environment fit is a barrier to learning.
To only consider biological explanation in a diagnosis is limiting and “within child”. The biopsychosocial model of understanding human behaviour recognises the important interaction between all of these factors - we cannot ignore context or how we think and operate in various contexts.
So while I welcome Frith’s challenge on the idea of the spectrum, where that thinking takes me is a different place to where it takes her.
Girls and women with autism
On the issue of the female presentation of autism, the divide between Frith’s view and my own is more marked. Any stemming of the progress, already too slow in my mind, in how to identify the signs of autism in girls is worrying.
In my experience, this identification needs to be early enough to prevent later significant mental health crises.
Frith considers masking as something that we all do, and yes, social psychology research would agree with that. However, Frith seems to underestimate the very real impact of children imitating, all the time, what neurotypicals do.
This is not the same as putting on a performing self for a short period of time. It is a relentless performance with little respite until, in worst cases, a child reaches a functional collapse.
These children - frequently but not only girls - are captured on the Dynamic Support Register (DSR), a local authority health system set up to implement and monitor the support for children at risk of hospital admittance or readmittance for their mental health.
Mental health and SEND
I believe Frith’s view that masking is not harmful is reductionist. If we consider what persistent masking can lead to - that is, a loss of self or a lack of circumstances conducive to developing a sense of self, such as “Who am I?”, “What do I like?”, “What do I think?”, known to correlate with later mental health issues - then it is undeniably harmful.
What is helpful about the construct of masking is that it gives, by its very definition, guidance to teacher understanding (ie, you will not see it).
Understanding this and giving validity to masking, as a concept to concern ourselves with immediately, provides the rationale for a different identification approach.
We listen to parents more. We notice more. We know our children more. We act earlier.
Equating the “exhaustion” of such children with the general idea of exhaustion suggests a normalisation, which, again, I think can be detrimental to understanding children who are gradually losing cognitive function.
Masking and safeguarding
Frith uses “hypersensitivity” as a term, and I think this is worth exploring further, but associating hypersensitivity with the construct of resilience is dangerous because it implies that children are not trying hard enough or are not tough enough.
This misses the point. These children are trying too hard to be like others all the time, every day.
Research shows that autistic girls have a stronger drive for social engagement and a heightened response to social rejection, and, with that, a “natural” propensity to fit in, or mask.
Minimising the importance of understanding the drive for masking is, therefore, dangerous.
Girls and women who have not been able to develop a secure sense of self, an understanding and comfort with their own preferred ways of being, are at risk of increased vulnerability to control by others.
This is a safeguarding matter. It may be, as Frith notes, that the research points to a lower ratio of females being autistic than males, but we also know that research has historically underrepresented female populations in studies.
The female autistic presentation requires our greatest attention and curiosity, and any rethinking of diagnosis - as proposed by Frith - must be sensitive to this or we risk autistic girls being misunderstood in the classroom.
Dr Sue Franklin is a principal educational psychologist in London
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