What Does Neurodiversity actually mean?
What exactly does Neurodiversity actually mean? Human language is so up and coming now and so often misdiagnosed or overlooked for appropriate care due to Neurodiversity describes the idea that people experience and interact with the world around them in many different ways; there is no one "right" way of thinking, learning, and behaving, and differences are not viewed as deficits, which I personally love. The word neurodiversity refers to the diversity of all people, but it is often used in the context of autism spectrum disorder (ASD), as well as other neurological or developmental conditions such as ADHD or learning disabilities. The neurodiversity movement emerged during the 1990s, aiming to increase acceptance and inclusion of all people while embracing neurological differences. Through online platforms, more and more autistic people were able to connect and form a self-advocacy movement. At the same time, Judy Singer, an Australian sociologist, coined the term neurodiversity to promote equality and inclusion of "neurological minorities." While it is primarily a social justice movement, neurodiversity research and education is increasingly important in how clinicians view and address certain disabilities and neurological conditions. There are so many people conscious and aware of their differences now, that we have nuances and diagnosis that correlate with the symptoms. For many of you, you understand the person is way more than a diagnosis, however for treatment planning and effective treatment, this can be helpful to flesh out the nuances.
Words matter
Neurodiversity advocates encourage inclusive, nonjudgmental language. While many disability advocacy organizations prefer person-first language ("a person with autism," "a person with Down syndrome"), some research has found that the majority of the autistic community prefers identity-first language ("an autistic person"). Therefore, rather than making assumptions, it is best to ask directly about a person's preferred language, and how they want to be addressed. Knowledge about neurodiversity and respectful language is also important for clinicians, so they can address the mental and physical health of people with neurodevelopmental differences.
Neurodiversity and autism spectrum disorder
Autism spectrum disorder (ASD) is associated with differences in communication, learning, and behavior, though it can look different from person to person. People with ASD may have a wide range of strengths, abilities, needs, and challenges. For example, some autistic people are able to communicate verbally, have a normal or above average IQ, and live independently. Others might not be able to communicate their needs or feelings, may struggle with impairing and harmful behaviors that impact their safety and well-being, and may be dependent on support in all areas of their life. Additionally, for some people with autism, differences may not cause any suffering to the person themself. Instead, the suffering may result from the barriers imposed by societal norms, causing social exclusion and inequity.
Medical evaluation and treatment is important for individuals with ASD. For example, establishing a formal diagnosis may enable access to social and medical services if needed. A diagnostic explanation may help the individual or their family understand their differences better and enable community connections. Additionally, neurodevelopmental conditions may also be associated with other health issues that require extra monitoring or treatment. It is important that people who need and desire behavioral supports or interventions to promote communication, social, academic, and daily living skills have access to those services in order to maximize their quality of life and developmental potential. However, approaches to interventions cannot be one-size-fits-all, as all individuals will have different goals, desires, and needs.
Neurodiversity can range from ASD, to dyslexia,dyspraxia, dyscalculia, ADHD, OCD, Tourettes and various other types of disorders. For this blog, we will be focusing on ADHD, Autism, and OCD.
Some theorists say that Neurodiversity can also present as someone with antisocial personality or avoidant or dependent personality disorder, without context they would assume that with initial presentation potentially.
Attention Deficit disorder Hyperactive (ADHD)
ADHD is a neurodevelopmental disability that stands for attention deficit hyperactivity disorder. There are three types of ADHD a person can be diagnosed with; predominantly inattentive presentation, predominantly hyperactive/impulsive presentation or combined presentation (inattentive and hyperactive/impulsive). There are some great visuals by some other providers, researchers, and writers that I will be giving credit for making. These are helpful for breaking this down, however it’s only helpful for clinical presentations, conceptualization, and treatment planning as it helps to know where the problem stems from orginally to treat it.
ADHD impacts 6% of US Population per a 2023 survey, most likely more by this point. An estimated 7 million (11.4%) U.S. children aged 3–17 years have ever been diagnosed with ADHD, according to a national survey of parents using data from 2022. According to a national 2022 parent survey, nearly 78% of children with ADHD had at least one other co-occurring condition. We’ll look more at how ADHD may look like OCD, then look at all three together.
Autism
Autism is a neurodevelopmental condition / disability that is characterized by differences in way a person’s nervous system is wired, differences in the way a person experiences the world, acts, thinks, and socializes, etc. You’ve made your way to this blog, so I assume that you have some more foundational knowledge about Autism, or are expanding your knowledge now. Here is a terrific blog post, with alternatives for more affirming language (next to original DSM, deficit based language). Socialization, communication, repetitive behaviors or restrictive sensory processing dynamics, intense and narrow interests that may consume a good bit of their time, limited ability to engage in back and forth dialogue which impacts relationships. Additionally, here are some very helpful resources for sensory processing challenges they face.
Obsessive Compulsive Disorder (OCD)
OCD stands for Obsessive Compulsive Disorder, it is a mental health condition in the diagnostic and statistical manual for mental disorder by the American Psychiatric Association. Unless you feel called to look up the full criteria, I’ll provide you the Cliff’s Notes: OCD is characterized by obsessions and compulsions that cause distress, and impact a person’s life significantly. Obsessions are recurrent and persistent thoughts, urges or images that intrude on a person’s mind, are unwanted and cause distress. Compulsions are acts (physical, mental, etc.) that a person does in response to their obsessions, in an effort to reduce their distress, or prevent a feared outcome from happening.
OCD affects about 1-3% of the global population per one study, another source estimates about 1 in 100 adults, or between 2-3 million adults in the U.S.A; and 1 in 200 kids and teens, or around 500,000 in the U.S.A. OCD can be incredibly debilitating, in fact, according to digging that the OCD-UK did, “OCD was once ranked by the World Health Organization in the top 10 of the most disabling illnesses by lost income and decreased quality of life.”
Each person with OCD will have a different experience from another person with OCD. People who live with OCD have different content of their intrusive thoughts / obsessional doubt, sometimes referred to as “themes,” One theme of OCD is commonly referred to “harm OCD,” in which a person has intrusive thoughts / obsessional doubts about harming others and/or themselves, which is not consistent with who they are and their values in life.
Remember that everyone has worries, and everyone experiences intrusive thoughts. The difference between worries that exist outside of OCD and OCD is the worries happen continuously, tend to revolve around the same or similar topics, cause a great deal of distress, and a person makes efforts to ignore or suppress thoughts, or neutralize them with another thought or action.
The type of worries within OCD are repetitive. Like throughout the day, throughout the week, etc.
Some examples of obsessions include:
Worry that you might hurt yourself or someone else, on impulse, without a desire to do so, for example; “what if I stab my loved one,” “what if I accidentally drive off that bridge?” or “what if I harm someone because I wasn’t careful enough.” (harm OCD theme)
Worry that you are actually are a p*dophile, for example; “what if I get a groinal response when I’m babysitting,” “what if I (P*dophilia OCD, or POCD)
Continuous doubt and worry about your romantic relationship, for example, “is this person right for me,” “what if there is someone better out there,” or “do I really love them?” (Relationship OCD).
Concern with morality. For example, “what If I offended God / Allah / Universe, and I’m going to hell / purgatory?” or “I think I committed blasphemy, what if God hates me?” (scrupulosity / religious OCD)
Worry about making mistakes, or if things are not “just right.” For example, “what if I make a typo in this email, and people think I’m incompetent and I get fired for it?” or “I don’t feel right the way I’m cutting this apple, that must mean that I’m doing it wrong, and something awful could happen if I don’t cut it another way.” (Perfectionism OCD or “just right OCD”).
As mentioned earlier, compulsions can be overt, subtle or mental acts that a person does in an attempt to reduce their distress, or prevent the feared outcome from happening.
Compulsions can be:
Physical acts or cover acts, such as: switching a light switch on and off until it feels right, excessively washing your hands.
Reassurance seeking: asking someone to reassure you that a feared outcome will not happen. For example: asking people repeatedly if they think you’re straight, or a bad person.
Subtle Acts: re-writing or rereading something to check for mistakes
Mental compulsions (4): reassuring yourself (for example, repeatedly asking yourself if you want to push that person in front a train), mental review (replaying conversations in your head to answer a question, gain certainty, or reassure yourself), worry (for example, thinking over and over again about something that might happen, and making a plan for a hypothetical situation), and rumination (thinking about something over and over again to gain certainty or answer an unanswerable question).
Avoidance of situations, people, places, things that may trigger obsessions, or avoidance of situations, people, places, things, behaviors because OCD tells you avoiding it is the only way to prevent the bad outcome. For example: avoiding using sharp objects (harm OCD), avoiding children (POCD), avoiding touching surfaces for fear of germs (contamination OCD).
There are a number of other challenges that co-occur with OCD, if you’re interested, you can learn more here. Interestingly, in my research, I also found that 90% of individuals with OCD met the criteria for at least one other psychiatric condition.
Similarities, differences, and co-occurrences
So now that you’ve, hopefully, got a basic understanding of OCD, ADHD and Autism. Let’s explore where OCD may differ, be similar and overlap between ADHD and/or Autism.
As you may be able to tell by now from the sources, and footnotes, I appreciate the work of Dr. Megan Anna Neff, she has a blog post about this very topic. Let’s give immense gratitude to Dr. Megan Anna Neff and all the work they do educating folks. I reference it for this part of the post, and also encourage you to check it out. The beautiful visual comes from her blog post!
That said, let’s discuss the term comorbidity / co-occurrence, this is used in the mental health, and likely physical health field, to describe when a person has one or more condition. For example, an Autistic person may also have PTSD. There are comorbidities / co-occurrences that are common; such as Autism & ADHD; Autism & PTSD. And you guessed it, Autism and OCD; and ADHD and OCD. The symptoms can occur like a vin diagram and be a sprectrum.
ADHD and OCD
Impacts on working memory
Challenges with attention and focus
Compulsive checking
Intrusive thoughts
Sensory differences
How these similarities may differ:
Working memory impacted:
With ADHD, this is due to a this being a symptom of ADHD
With OCD, this could be due to a variety of reasons; some of them possibly be the amount of mental activity that a person with OCD may be engaged in as a result of managing their OCD symptoms impacts their working memory.
Attention and focus difficulties
With ADHD, this will exist with or without intrusive thoughts and managing compulsions (including mental compulsions).
With OCD, this will be a result of managing intrusive thoughts and compulsion (including mental compulsions).
Compulsive checking:
With ADHD, this may be due to forgetting whether or not you performed an action.
With OCD, this is due to doubting whether or not you did when, if you relied on your sense data, you would be able to conclude that you did. For example, “I touched the lock on my car key, and I heard the car beep when it locked, but what if I am just imagining that I did that. What if I really didn’t lock it, even though I felt the sensation and heard with my ears?”
If an ADHDer tends to forget things, it is possible that they may develop OCD as a way to “mask” or compensate for ways their ADHD impacts their life.
We’ve explored what OCD is, the similarities and differences between OCD & Autism, and OCD & ADHD; let’s now look at all three (woot woot)!
ADHD, Autism & OCD
Similarities
Insomnia
Skin-picking and hair pulling
Intrusive thoughts
High rate of: depression, anxiety, eating disorder, self-harm and substance abuse
Executive functioning difficulties
Sensory differences
GI issues
Differences: I’m not going to cover the differences that were already covered.
Skin picking and hair pulling:
ADHD and Autism: this is usually done as a way to stim and self-regulate
While body-focused-repetitive-behaviors (BFRBs) (5) such as trichotillomania (the fancy, diagnostic term for hair pulling) or excoriation (the fancy, diagnostic term for skin picking) are not necessarily OCD compulsions, BFRBs co-occur with OCD (6), and BFRBs often feel compulsive.
That said, let’s discuss the term comorbidity / co-occurrence, this is used in the mental health, and likely physical health field, to describe when a person has one or more condition. For example, an Autistic person may also have PTSD. There are comorbidities / co-occurrences that are common; such as Autism & ADHD; Autism & PTSD. And you guessed it, Autism and OCD.
OCD vs Autism? Could be Both?
Similarities:
Repetitive thoughts and behaviors
Difficulty managing or tolerating uncertainty
Preference for routine / rituals and similarity
May avoid taking risks
Rumination / perseveration
Mentally rehearsing / scripting social interactions
Intrusive thoughts
Challenges with executive functioning
Sensory differences
How these similarities may differ:
Repetitive behaviors and thoughts:
When it comes to Autism, usually are congruent with a person’s desires, preferences, wishes, and may bring them joy (for the most part).
Witn OCD repetitive behaviors are usually performed to reduce anxiety, distress, bring certainty, or prevent a feared outcome.
Preference for routine / rituals: I
In order to understand if it’s more related to Autism or OCD, we want to understand the “why” behind the action, if the “why" is related to fear, then it can be due to OCD, though, with this one, fear may arise when an Autistic person, without OCD is unable to do things in the way they are used to / prefer, because changes in routine can cause nervous system disruption. As a therapist, I might explore the fear more deeply; asking something such as “what would happen if x happened?” and then “what would you worry about happening then?” and “what would that mean if that (second thing) happened? Would there be any additional worries?”
If a person puts their items away in a certain way, because it brings them joy, or because it helps keep things familiar, predictable, and automates habits, it’s usually and indication this is a result of Autism (if they are Autistic, or suspect they are).
If a person puts their items away in a certain way, because they fear that if they do not, that means they’ll get sick, then it’s likely OCD related.
Difficulty managing uncertainty: this one is a bit trickier to parse out, because usually this one there is a fear that may arise when there is uncertainty with both OCD and Autism. We’d want to again, explore the why the fear, and continue asking “why.” Even then, I find that as a therapist, if an Autistic client also has OCD, it may be challenging to determine if the difficulty managing uncertainty is more related to their Autism or their OCD.
Repetitive behaviors:
If the behaviors soothe a person, bring them comfort, or joy, it can be related to Autism.
If someone does a repetitive behavior out of fear of what might happen if they don’t, that’s likely due to OCD.
Scripting social interactions or mentally rehearsing them.
With OCD this is usually done out of fear, fear either due to uncertainty, to prevent a feared outcome, or because it “feels right,” and they need to find the “right” word.
With Autism, this can be both a coping skill, and a form of masking, and is usually done because a person may have difficulties managing social interactions, and may desire to feel prepared, to have an idea of topics they could discuss, or phrases / responses they could give.
Sensory differences.
A person with OCD may have trouble when they hear a sound, and may fixate on it; and take measures to make the room completely silent for sleep, because they fear that if they don’t they may not sleep (even if they are generally not a light sleeper).
With Autism, a person may have a reaction in their nervous system that causes distress, and/or misophonia, that, because of how our brain is wired, we take in more sensory data (3, 4, 5, 6, 7, 8), and we have a much more difficult time tuning out / ignoring sensory input. So if an Autistic person is hyper focused on sound, and worried that it may make it challenging to focus on studying or work, that’s very likely because it will make it challenging, and can cause nervous system disruptions and sensory overload.
The difference being with OCD, the worry is usually hypothetical, and not based on consistent lived experience (i.e. if someone is usually able to ignore sounds, and once in a while, when stressed or anxious has a harder time ignoring. That said, let’s say they are in a cafe studying, and have been here for 30 minutes, and once they settled in, got into a grove, easily able to ignore sounds, sights and other sensory stimuli. The next minute, their OCD is telling them, “but what if that sound of the espresso machine interrupts your concentration, and you miss an important term, and that’s the one question that would have gotten you an A vs. a B on the test?” and they think, “oh, that’d be bad, I need to make sure that doesn’t happen!” and now each time they hear the sound of the espresso machine, they mentally check if they retained what they just read, living in possibility land, trying to control for uncertainty, and living the fear of their the OCD story. In this example, they are not relying on their sense data to tell them that they’ve been able to actually focus, and their trust in themselves to go back if they got distracted. They are focused on engaging in a compulsion to prevent the bad outcome from happening.
That list is not exhaustive, and not all inclusive. As you can see, depending on the behavior, distress, or symptom, there are some cases where it’s more clear cut which may be which, and other cases where it’s pretty challenging to parse out. Perhaps as I continue to gain more experience treating OCD and working with Autistic clients, who may or may not also have OCD, then it could become more clear. Footnotes:
Co-occurrences
So now let’s talk about how there can be differences, and similarities between OCD and Autism.
People with OCD are four times more likely to be diagnosed as Autistic (Meier et al., 2015).
Nearly half of folks with OCD show significant Autistic traits, and over a quarter meet the criteria (Wikramanayake et al., 2018).
Autistic individuals have twice the risk of being diagnosed with OCD later in life (Meier et al., 2015).
So now let’s talk about how there can be differences, and similarities between OCD and ADHD.
According to Brem, 2014, up to 30% of individual with OCD are also ADHDers.
Among ADHDers, 17% to 25% show signs of OCD (Masi, et. al, 2010).
One in five children with OCD also had ADHD (Abramovitch and Mittelman; 2013).
Now let’s look at the overlaps and differences between ADHD and OCD below.
Personal Thoughts
If you have, or think you may have OCD, along with ADHD and/or Autism, it’s important to work with a provider who is neurodiversity affirming, informed and who is trained in treating OCD by using ERP, I-CBT or ACT. The risk of working with a provider who is not, they may ask you to do exposures for things that are upsetting to your nervous system, which could lead to sensory overload, sensory meltdowns, and burnout. For example, if you experience distress in social situations, and socializing with folks you need to mask around, doing an exposure around socializing is not going to have the opposite effect (granted, if a person’s social needs are not being met, then exploring exposures that are affirming, and that may reduce the chances of burnout / sensory overload may be worthwhile). Are you working with a provider who treats OCD already? Consider educating them on the overlaps and differences (i.e. send them this blog post and/or the resources linked in the footnotes), advocate for yourself when you feel that they’re encouraging you to do an exposure that may actually be harmful for you due to your Autism and/or ADHD. If you feel that you want to find a better fit, feel free to reach out for a free consultation here!
