Authors: Caroline Cannistra and Sabrina Lin
Editors: Jae Kuhn and Joe Albrecht
Introduction
In this report we will talk about the intersection between neurodiversity and mental health; the prevalence of mental health disorders among neurodiverse individuals; the struggles neurodivergent individuals face in accessing mental health care; the relationship between neurodiversity, gender, and mental health; and how we can support each other in the future.
We will explore the relationship between contributing factors of mental health and neurodiverse conditions, specifically social stigma and a lack of institutional support. Hopefully, as the neurodiversity paradigm gets more popular and people are more aware of the needs of neurodivergent people, mental health outcomes will improve for this population.
For the purposes of this report, we will focus on autism and ADHD, but we do acknowledge the need for mental health research on other neurodiverse conditions.
Background Information
Autism and ADHD both have comorbid mental illnesses, including depression, anxiety, substance abuse disorder (SUD), bipolar disorder, obsessive compulsive disorder (OCD), eating disorders, personality disorders, and more.
The Social Model approach explains that the profound connection between mental health and neurodiverse conditions stem from external systemic factors that are out of the neurodiverse individual’s control (Cage et al., 2018). For example, an employers’ internal biases and attitudes may make it difficult for an autistic individual to find employment, even if they are qualified for the position (Cage et al., 2018). It is important to note that these larger systemic factors stem from oppressive structures that mitigate the growth of marginalized communities, and that individual characteristic traits and identities are not attributable to lack of social growth and success in society.
For the majority of mental health disorders, the prevalence of mental illness is greater among the U.S. autism population than neurotypical population. In the U.S. autism population, there is a 28% prevalence for ADHD, a 20% prevalence for anxiety disorders, a 13% prevalence for sleep–wake disorders, a 11% prevalence for depressive disorders, a 9% prevalence for obsessive-compulsive disorder, a 5% prevalence for bipolar disorders, and a 4% prevalence for schizophrenia spectrum disorders (Lai, 2019). According to a study published by the Journal of Developmental and Physical Disabilities, anxiety is present in the majority of autistic children ages 1-17 and depression is present in about 50% of these children, which is also much higher than the neurotypical population (Mayes, 2011). On top of the higher prevalence of mental health in the autistic population, “co-occurring mental health conditions are [also] more prevalent in the autism population than in the general population” (Lai, 2019).
Comorbid mental health conditions are also very common for people with ADHD. As many as 80% of adults with ADHD are estimated to have a comorbid mental disorder, with the most common being bipolar disorder (5-47%), depression (19-53%), anxiety (about 50%), and substance abuse disorders (about 2 times as likely to occur compared to the general population).These conditions are not mutually exclusive and can co-occur (Katzman et al., 2017).
Drivers of Mental Illness in Neurodivergent People
Some characteristics of autism and ADHD can be distressing or difficult to manage, which can negatively affect a person’s mental health. A common example of this can be found in neurodivergent people with SUD. The link between ADHD and abuse of alcohol, nicotine, and marijuana has been well-established in the literature. Preliminary research suggests that autistic people may also be more likely to abuse substances than their neurotypical peers. In an interview-based study of autistic and ADHD patients in treatment for SUD, patients with ADHD discuss using substances to suppress their overactive minds, and autistic patients discuss using alcohol to cope with difficult social situations. In the long term, substance use impaired functioning in both groups by taking away needed structure (Kronenberg et al., 2014).
Although there are internal drivers of mental illness in neurodivergent people, we cannot discount external drivers, especially social stigma against neurodivergence. Throughout their lives, neurodivergent people are often isolated from their peers, punished for being different from “normal,” and taught that they are inferior because of their neurotype. They learn to hide their condition to avoid stigma; yet, this compounds the effect by masking their true self and supporting inferior ideation. External and personal self-acceptance have been shown to correlate negatively with depression and stress in autistic people, with people who report masking also reporting higher levels of depression (Cage et al, 2018). This demonstrates the relevance of the Social Model approach in treating mental illness; sometimes, the most important thing you can do for a neurodivergent person’s mental health is improve their social support network, their environment, and their self-image.
Gender, Neurodiversity, and Mental Health
In a study from the Advances in Autism Journal, researchers found that “autistic people are more likely to have anxiety and depression than non-autistic people of all genders” (Sedgewick et al., 2020). Thus, anxiety and depression are severe issues for those with autism and can be attributable to the drivers and influencers spoken about previously in this report. Additionally, they found that gender minorities like women and non-binary people with autism experience higher rates of mental health issues than men and “at similar rates to each other” (Sedgewick et al., 2020). Oppressive structures that instill implicit biases against gender minorities is prevalent in the mental health of both the neurotypical and the autistic community. This intersectionality of marginalized identities is incredibly important to understand in order to take steps towards autism acceptance, especially for gender minorities with autism. Along with anxiety and depressive disorders, researchers from the Advances in Autism Journal found that autistic people were two times more likely to develop any eating disorder compared to non-autistic people (Sedgewick et al., 2020). As clearly evident, autistic people are disproportionately affected by nearly all mental health and eating disorders.
Before 2020, there was no published research investigating the relationships between being mental health outcomes from those with autism or identify as transgender (Sedgewick et al., 2020). Then, in 2021, researchers published “In Addition to Stigma: Cognitive and Autism-Related Predictors of Mental Health in Transgender Adolescents” in the Journal of Child and Adolescent Psychology. Here, they investigated mental health among autistic transgender adolescents by assessing “mental health, IQ, LGBT stigma, ASD-related social symptoms, executive functioning (EF), and EF-related barriers to achieving gender-related needs” (Strang et al., 2021). For reference, executive functioning refers to the mental processes that allow humans to plan, focus attention, remember instructions, and multi-task (“Executive Function & Self-Regulation”, 2020).
The study of the associations between transgender autistic individuals and mental health outcomes is still a very new topic. Researchers looked into mental health among autistic transgender adolescents, non-autistic (allistic) transgender adolescents, and autistic cisgender adolescents (Strang et al., 2021). They found that “autism spectrum disorder (ASD) is significantly over-represented among transgender adolescents” and that “autistic-transgender adolescents experienced significantly greater internalizing symptoms,” which includes symptoms of depressive disorders, eating too little or too much, and abusing substances (Strang et al., 2021; Fraser-Thill, 2021). They also found that worse mental health outcomes were associated with “social symptoms and EF gender barriers with greater internalizing… [and] EF problems and EF gender barriers with greater suicidality” (Strang et al., 2021). This research study is just another example of how the intersectionality of marginalized gender identities and neurodiverse status largely influence negative mental health outcomes in these populations.
Getting Treatment
Barriers to accessing proper treatment for mental illness exist on many different levels for neurodivergent people. One of these is at the diagnosis stage; many mental illnesses share symptoms with autism and ADHD, and thus may be hard to differentiate. For example, bipolar disorder and ADHD both feature “restlessness, talkativeness, distractibility, and fidgeting” (Katzman et al., 2017). A psychiatrist with more experience with bipolar disorder might treat these as bipolar symptoms and pass the patient over for ADHD evaluation, leading to the patient not getting the type of support they need. This seems to especially be a problem with comorbid ADHD and depression. One study found that 34% of a cohort of patients with treatment resistant depression had undiagnosed ADHD (Sternat et al, 2018). Outcomes for these patients could be improved by treating both their ADHD symptoms and their depression symptoms at the same time (Katzman et al., 2017).
Lack of education and stigma from mental health professionals is also a potential barrier to accessing treatment. Many medical/psychiatric professionals do not know a lot about autism or ADHD, and do not know how to provide proper care for their patients. In other cases, they may not be willing to listen to a neurodivergent patient, viewing them as incompetent. This makes it harder for neurodivergent people to get the treatment they need, and creates a hostile environment that makes them less likely to seek out treatment in the first place. Autistic activist Amythest Schaber discusses this in detail in her essay “Autistic Navigation of Chronic Illness, Mental Illness, and Healthcare,” from the anthology Knowing Why published by the Autistic Self-Advocacy Network.
Some mental health providers underestimate the abilities of autistic people, particularly nonverbal autistic people. Some providers are resistant to helping autistic people with communication difficulties access alternative methods of communication, even though communication is a basic right, and every autistic person should have access to and instruction in methods of communication that work best for them.
Some mental health providers believe that autistic people don’t desire social interactions or need relationships. That autistic people don’t feel emotion or experience the same range of feelings as non-autistic people do. That we lack empathy. That we can’t love. These ideas are common and harmful, and impede our access to mental health services and our ability to open up when we need to. How can we trust a therapist who believes that we aren’t whole people, that we’re emotionless and empty– or that if we do have emotions and relationships, we can’t be autistic? (Knowing Why, p.98-99).
This brings us to the topic of mental health interventions that can make a neurodivergent person’s mental health crisis worse. Some sites of mental health care, like the emergency room, are overwhelming sensory environments, which can be distressing for neurodivergent people. An Australian study found that neurodivergent children and adolescents are often brought to the emergency room for “acute severe behavioral disturbance,” which can be aggravated by a stressful environment like an emergency room. These patients are often treated with methods such as seclusion and restraint, which is highly distressing for anyone, but especially for neurodivergent people. The study’s authors recommend treating these patients in sensory-friendly spaces, developing de-escalation methods that work for neurodivergent patients, and limiting seclusion and restraint as much as possible (Bourke 2021).
It is also worth noting that many neurodivergent people might not have access to any treatment because of their living situation. For example, an estimated 25% of the US’s incarcerated population has ADHD, and American prisons tend to have very limited access to mental healthcare (Young et al., 2015). Cost may also be a limiting factor for neurodivergent people with low income and/or no health insurance, which is common in the neurodiverse population.
Interventions
There are several things neurodiverse individuals and neurotypical allies can do to decrease the prevalence of the mental health-neurodiversity comorbidity and the disproportionate mental health outcomes in the neurodiverse population.
It is important for neurodiverse individuals to have the opportunity to engage with others who are like-minded and to develop one’s sense of belonging through neurodiverse community-building (Cage et al., 2018). While it is important to gain support within the neurodiverse community, it is also important to gain support between communities. More contact between people with and without autism, as well as supportive family and friends can help increase autism acceptance and decrease mental health prevalence among these communities (Cage et al., 2018).
Autistic individuals can also take steps to combat the mental health comorbidity by increasing self-acceptance (Cage et al., 2018). Research has shown that if they self-identify more strongly with the concept of neurodiversity, they tend to view autism itself more positively (Cage et al., 2018).
There are also ways to combat systemic barriers that prevent autistic individuals from getting proper mental health support, accomodations, and care. Education on neurodiversity for medical professionals would lead to accommodations in mental healthcare sites, as well as clinical approaches to encourage positive Autism identities (Bourke et al., 2021; Cooper et al., 2017). Additionally, “careful assessment of mental health” would lead to less misdiagnoses, giving autistic individuals the opportunity to seek help with the proper diagnoses (Lai, 2019). This would ultimately help us improve care for neurodivergent patients by educating ourselves and prioritizing patient wellbeing and agency.
Autism acceptance and neurodiversity education are two main ways we can break down the mental health-neurodiversity comorbidity and more towards social and health equity.
Conclusion
Autistic people are much more likely to be diagnosed with mental health disorders like anxiety and depression, especially among gender minorities and those with a lack of support and community.
It is incredibly important for the public, regardless of neurodiversity status, to take steps towards more acceptance/awareness of the struggles neurodiverse individuals face, as well as breaking down the systemic barriers and oppressive structures that put these individuals in difficult positions.
If you or a loved one are feeling depressive symptoms and/or would like professional help, please utilize the information below:
National suicide prevention hotline: 800-273-8255
National suicide prevention lifeline website: https://suicidepreventionlifeline.org/
References
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