Work

Historical diagnostic failure, not conceptual collapse: A response to Frith

Year: 2026

Type: article

Abstract: We disagree that the autism spectrum has lost its meaning, that cultural factors have driven diagnostic inflation, or that differences between early-and late-diagnosed individuals now justify division into separate categories (Frith, 2026).These claims conflate several distinct problems and risk real-world harm.Autistic Doctors International (ADI) numbers over 1,500 autistic medical doctors worldwide, demonstrating that autism is not incompatible with a medical career.Some were diagnosed as young as 3 years (Shaw et al., 2023), meeting Frith's criteria for the core group, yet by their professional profile are indistinguishable from colleagues she places in the other.Her taxonomy cannot accommodate this.Some had childhoods where differences were conspicuous; others built careers of apparently effortless competence while quietly managing demands their neurotypical colleagues never had to consider.Yet across differing profiles they find commonalitiessensory differences, pattern recognition, and the exhaustion of life among a non-autistic majorityacross what Frith frames as an unbridgeable divide.That common phenomenology extends further still.A published exchange between one of us and a nonspeaking autistic undergraduate who communicates by independent typing found the experience of being perceived as a fraud spontaneously recognized across profiles Frith's framework would separate (Doherty, 2026a).The extent of this shared phenomenology deserves rigorous investigation, not premature taxonomic foreclosure.Frith insists on 'disorder', presented as scientific precision.This is a value-laden choice with consequences.An ADI membership survey found members viewing autism as a disorder were almost three times more likely to have attempted suicide than those who did not (Shaw et al., 2023).Autistic shamethe internalized sense of defectiveness arising from lifelong exposure to neuronormative expectations, where difference is misread as deficitis a barrier to disclosure among autistic psychiatrists (Doherty, 2026b).This matters beyond the individual.Where shame impacts self-recognition or disclosureincluding among researchers and cliniciansit shapes science: the questions asked, the experiences centered, the expertise recognized.How we name, frame, and shame these difficulties has consequences reaching well beyond diagnostic manuals, into consulting rooms, classrooms, and workplaces where autistic people spend our lives (Doherty et al., 2026).What Frith characterizes as loosening of criteria is the correction of a systematic bias.For decades, diagnostic criteria reflected white male presentations, often with co-occurring intellectual disabilitythus excluding most autistic people.The category was never a pure one later contaminated; it was always incomplete.Late diagnoses among women and people without intellectual disability are evidence of historical diagnostic failure: people rendered invisible by narrow criteria, not invented by wider ones.Many spent decades misdiagnosed with depression, bipolar disorder, schizophrenia, or personality disorders, treated with pharmacotherapy that never addressed the underlying neurodevelopmental reality.The most substantive point Frith offers rests on the finding that polygenic profiles differ between early-and late-diagnosed autistic people (Zhang et al., 2025), the later-diagnosed group showing stronger genetic correlation with ADHD, major depressive disorder, and PTSD.She reads this as misclassification, an inference requiring scrutiny.Polygenic correlations do not establish the direction or mechanism of association: they are also consistent with these conditions being downstream consequences of unrecognized autism.Frith rejects the concept of masking, yet it is robustly associated with elevated anxiety, burnout, depression, and suicidality, and the genetic profiles of masking and compensation have not been examined.A large-scale integrative study found elevated depression and ADHD polygenic scores across autistic people without intellectual disability generally, not only late-diagnosed subgroups (Fleury et al., 2025).Zhang's findings cannot bear the weight of misclassification, Frith asserts.

Source: Psychological Medicine

DOI: 10.1017/s0033291726105996