Is the Concept of Neurodiversity Useful?

Focus on Workplace Applications by Andres Fonseca 

The neurodiversity movement advocates for viewing neurodevelopmental differences not as deficits but as natural human variations. This is quite reasonable, but it is also where problems start. It is true that if you look at a checklist of symptoms of neurodivergence you will probably meet quite a few of them. Different people will meet different ones, but I don’t think there will be anyone who does not meet at least one of them, particularly because the definitions of these criteria are not strictly operationalised.

If you are confronted with one of these checklists you are already primed to try to see if and how you might fit these criteria. This may well result in you concluding that you are neurodivergent. Since there is no clear definition of what this actually means, you will very likely be right.

One of my friend’s sons has a PhD in physics. When he recently came to visit he asked me who he could see to ‘get a diagnosis of ADHD’, as he thought he could have it. When I asked him why, he said that he believes himself to be inattentive, forgetful, and prone to procrastination. He also said he was clumsy, suggesting a degree of dyspraxia. Furthermore, he stated that he can experience mood swings, and difficulty managing stress and coping with change. He said that he can feel overwhelmed in social situations and that he had challenges sometimes maintaining conversations. He had gone through a checklist to determine this. The checklist in itself was quite a reasonable instrument. Since there is no clear definition of neurodivergence and that it is a spectrum, he could very well be neurodivergent. However, this is a young man who has achieved the highest academic accolade in a field that requires diligence, attention to detail, perseverance, hard work, and great capacity to maintain sustained mental effort.

I believe the neurodivergent movement has broadened awareness of these potential differences, perhaps promoting a more inclusive society. However, my concern as a psychiatrist is that it dilutes the concept of neurodevelopmental disorders. To me, this creates a tension between clinical definitions that identify disorders based on impairment and a socio-cultural model that emphasises diversity and inclusion. The confusion leads to things like advocating for specialist neurodivergent services for workers. In reality, this creates more problems than it solves. Individuals with neurodevelopmental disorders will need specialist services that cannot be hoped to be provided by an employer. I would strongly argue that neurodivergent individuals that do not meet the criteria for a neurodevelopmental disorder are perfectly well catered for by mainstream services and that doing otherwise will create problems for them and those affected by neurodevelopmental disorders.

Impact on Clinical Definitions

Clinical definitions are based on specific criteria that include functional impairment, severe distress or risk (or a combination of these). Broadening of the spectrum, especially in conditions like autism, means that more individuals, including those with subtle manifestations that are part of the variation of the general population, are labelled as being on the autistic spectrum. This expansion is a double-edged sword. Arguably this may have increased awareness (although I am not sure it has increased understanding). This may lead to earlier intervention and support in cases of neurodevelopmental disorders. It will also lead to raised concerns about over-diagnosis or the minimisation and misunderstanding of challenges faced by those at the more severe end of the spectrum.

Self-Identification

The ease of self-identification with traits on the spectrum has helped many to gain an understanding and seek the support they previously lacked. However, this self-identification without formal diagnosis can lead to misunderstandings about the nature of these conditions and their impact on daily functioning.

I believe that this has downstream effects on the availability of resources for those at the more severe end of the spectrum. There is a limited supply of specialist clinicians in this area and if non-clinical presentations attract considerable resources then those professionals may be incentivised to take on less complex, subclinical, more lucrative presentations depriving those with neurodevelopmental disorders of professional expertise and driving up the price of clinical care.

The Role of the Healthcare Industry

The medico-pharmacological-industrial complex is well poised and incentivised to pathologise normal variations in the population. Many now advocate for special funding dedicated to supporting neurodiverse individuals in the workplace as they stand to gain financially from this trend. This highlights the potential conflicts of interest within the healthcare industry, particularly regarding the diagnosis of ADHD and the prescription of medication. I know from personal clinical experience that over-diagnosis is a valid concern as is over-medicalisation, influenced by the interests of the pharmaceutical industry but also, I am sorry to say, some clinicians.

Paradoxically, under-diagnosis is also a concern in complex difficult-to-treat cases that present with multiple comorbidities. Increasing the spectrum and enabling clinicians and the industry to treat those with subjective or minimal symptoms again pulls resources away from those that are impacted the most.

Addressing the neurodiversity challenge in the workplace

The neurodiversity movement has contributed positively to the acceptance of individuals with neurodevelopmental differences. It has attempted to promote a better understanding of cognitive and behavioural diversity. However, the challenges associated with broadening diagnostic criteria, self-identification, and the influence of the healthcare industry on diagnosis and treatment decisions are not always a net positive. For employers, this means a new set of demands and for employees a new set of ways in which they can have greater needs than other colleagues.

This phenomenon of overidentification of neurodevelopmental conditions effectively pathologising the general population and what are normal variations of human development I believe is absolutely contrary to the original goals of the neurodiversity movement. Instead of acceptance and the recognition that the traits of neurodevelopmental conditions are present in the population at large in mild form, we have more medicalisation and more labelling of individuals than ever before.

Because neurodiversity is present in the general population, it does not require specialist services. It does require services that are well-informed and able to look at individuals based on their personal characteristics and needs, rather than look at them through the lens of neurodiversity only.

My advice to employers is to offer high-quality mainstream mental health services for their employees capable of catering to normal variations which may be understood under the umbrella of neurodiversity and also detect the presence of a condition that crosses the threshold into an established neurodevelopmental disorder. The role of the service would then become supporting the individual to reach the right specialist service and obtain appropriate treatment which would be well beyond the scope of what an employer can reasonably provide. As the employee receives support from the specialist service, the employer can think about reasonable adjustments working together with the specialist provider and the employee.