Autism diagnosis debate turns on how broad the spectrum should be

A long-running debate over how autism should be defined has sharpened after psychologist Uta Frith argued that the term is becoming too broad to remain clinically precise.

Writing in Psychological Medicine in August, Frith said autism risked changing from a “precise, clinical” term into a “vague, culturally amplified identity category”. She said the autistic spectrum had become increasingly accommodating and had “come to its collapse”.

Frith also acknowledged uncertainty, saying she might be wrong. Her position is part of a wider disagreement about rising diagnosis rates, changing diagnostic concepts and whether people with very different experiences should share one broad category.

Why diagnosis rates are part of the debate

The source reports that UK autism diagnoses increased by 787% between 1998 and 2018, with a greater rise among women than men and the largest increase among adults. American statistics showed a 175% increase across the whole population between 2011 and 2022, with the largest rise among 26- to 34-year-olds. Childhood rates also increased in both countries.

These figures describe changes in diagnosis, not by themselves the underlying prevalence of autism. A government-commissioned review attributed the increases to socio-cultural changes in awareness and recognition, as well as broadened diagnostic concepts.

The review said that, if current trends continued, the balance of risks could shift towards greater misdiagnosis and overdiagnosis. It recommended closer monitoring of privately run autism and ADHD diagnostic clinics, while also stating that it could not conclude that overdiagnosis was occurring at scale.

A disagreement about who the spectrum includes

Frith now argues that many adults diagnosed later in life differ substantially from autistic people whose condition becomes evident in early childhood and who have learning disabilities. She believes most of the former group do not merit the label “autistic”.

She suggested that some people may be influenced by social media because an autism diagnosis can appear to offer an explanation for difficulties. She also described another subgroup as people formerly called neurotic, including people with anxiety and hypersensitivity.

Frith said, in her opinion, that broadcaster Chris Packham could not be autistic because his ability to communicate brilliantly was a “blatant contraindication”. Packham was diagnosed at 44 with what was then called Asperger’s syndrome.

Those views are contested within the broader debate about masking, adult diagnosis and the range of ways autism can present. The source does not resolve whether the people Frith describes should be included or excluded from the spectrum.

How the single spectrum developed

Research by Lorna Wing and Judith Gould in the 1970s concluded that autism was more widespread and complex than previously thought and was best understood as a continuum, later called a spectrum. They identified a “Triad of Impairments” involving difficulties with social skills, reciprocal language and social imagination.

Wing later created the category of Asperger syndrome in 1981 for autistic people without language issues or learning disabilities. The category entered the Diagnostic and Statistical Manual of Mental Disorders in 1994 and was removed in 2013, when autism spectrum disorder became a single broad category with three support levels: requiring support, requiring substantial support and requiring very substantial support.

Autism is now also understood to commonly involve sensory differences, including heightened or reduced sensitivity to sound, light, texture, heat and cold.

Frith helped develop influential ideas about autism while working at London’s Institute of Psychiatry, connected to the Maudsley hospital. Her experiments found that autistic minds tended to be more responsive to visual cues than to words. In 1989, she proposed the theory of Weak Central Coherence, which holds that autistic people tend to focus on details rather than overarching stories and themes.

Why the argument matters for support

Frith’s central concern is that the needs of more intensely autistic children and adults could be forgotten as so-called high-functioning people shape popular understanding of autism.

That concern is also raised in The Age of Diagnosis, in which neurologist Suzanne O’Sullivan argues that autistic people with the greatest needs are becoming invisible and questions whether some diagnoses may cause “more harm than good”.

The stakes are personal and social. The writer describes having a 20-year-old autistic son with learning disabilities, exceptional musical talent and a place at a specialist further education college. The source also notes that autistic people face a greatly increased risk of suicide, citing the case of autistic Cambridge professor Jason Arday, who died by suicide after coverage of allegedly specious claims about his life story and achievements.

As governments and health systems respond to changing diagnosis patterns, the unresolved challenge is how to improve recognition without losing sight of support needs. The current evidence presented here supports debate about diagnostic practice, but does not establish that one group’s experiences are more valid than another’s or settle the question of where the spectrum should end.

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