Author: Melissa Leggett

1.  Introduction

1.1.       Positionality

I identify as an autistic female, with immediate family members also identifying as autistic. I have nine years' experience in customer facing roles and 10 years in education. I am pro-social model and support the neurodiversity paradigm.

1.2.       Assignment Aims & Limitations

I will discuss the social and medical models of disability, due to their opposite views on disability. I will be critiquing three dominant theories of autism, Theory of Mind, Executive Function, and Central Coherence for their universality, uniqueness and specificity for autism. Due to the word count limitations, the Biopsychosocial Model (Engel, 1977), Neurodiversity Paradigm, and monotropism theory are beyond the scope of this paper.

2.  Terminology

There is a lack of consensus about the preferred terminology around autism (Botha, Hanlon & Williams, 2021). Yet person-first language (PFL) appears to be considered the most offensive (Bury et al., 2020; Kapp et al., 2013; Kenny et al., 2016) and follows the Medical Model of Disability (MMoD) as the person is placed first with the added noun, which is often associated with pathology or illness.

As the term ‘autistic’ is mostly used by autistic adults, along with their family and friends, whereas ‘person with autism’ is used by most professionals (Kenny et al, 2016), I will be referring to autism using identity-first language (IFL). As discussed later in this paper, the MMoD supports the notion that being autistic is a deficit and internal problem to the person. Before reading literature referenced within this paper, I originally had no preference. However, I can now see the negative connotations associated with PFL and I now align with IFL and is used within this paper.

To refer to the non-autistic population, ‘neurotypical’ has often been the term I would use before writing this paper. However, the word ‘typical’ can be synonymised with ‘normal’. Thus to not be normal, is to be abnormal, which could further stigmatise the autistic population. Instead, the term ‘predominant neurotype’ (PNT) will be used. Across the UK population, the PNT will be non-autistic (National Autistic Society, n.d.), although in a household, the PNT might be autistic – it varies, and I believe it is therefore affirming to both groups.

Autism can be referred to as a spectrum, but viewpoints on whether this should be considered a linear or multi-dimensional model is still debated. When I refer to autism, I align with Leatherland’s (2018) definition, as a communication difference. In my experience people I have spoken to may say a person is ‘very autistic’, which suggests a linear spectrum from ‘mild’ to ‘extreme’. However, this doesn’t account for the complexities around how a person may be able to access a task one day, but not in another or the impact of a support being removed (Hearst, n.d). For this reason, I support a multi-dimensional/constellation model is more appropriate.

Laing (1971:40) explains the etymology of the word as “Diagnosis is dia: through; gnosis: knowledge of”. Although the word can have negative connotations for neurological or biological differences due to the common practice that you receive a diagnosis from your GP when something is ‘wrong with you’, the meaning behind the word is more to do with gaining understanding and so isn’t necessarily a negative word to use in all contexts. When knowledge is being obtained, I think it is appropriate to use the term diagnosis. However, if a person has gained knowledge that they have a biological or neurological difference, from then on, the term should be identification.

3.  Models of disability and concepts of inclusion

3.1. The Autism Employment Gap & The Medical Model of Disability

The MMoD “is a set of procedures in which all doctors are trained [, in order to give diagnosis]” (Laing, 1971:39). Laing states that “Diagnosis is appropriate for social situations, if one understands it as seeing through the social scene” (Laing, 1971:40).

Although this model is useful in identifying ailments, history has shown us (as society) that using this model for neurological differences can be interpreted as the person being the ‘problem’ and they need to be fixed/cured to solve the problem, can lead to horrific examples of discrimination and inhumane treatment of autistic people (Kapp, 2020). I feel that Laing’s original essay (indeed terminology has been updated since that time) has been taken out of context to some degree, when presented in media, by those paraphrasing his accounts, without reading his full text. I interpret his account (Laing, 1971) as any person who enters a social situation must determine what is happening in the context.

Examples of direct discrimination happened during the 20th century (Kapp, 20:80) and indirect discrimination still occurs today, from what we see with the autism employment gap. Neurodivergent employment discrimination is institutionalised within society arguably due to the practises in the 1920s such as the Humm-Wadsworth Temperament Scale (HWTS), with the intent to rid the American workplace of ‘deviant’ personality types (Rosqvist et al., 2020: 54), which influenced the works of Aaron Rosanoff, “who claimed that human personality traits could be classified as hysteroid, manic, depressive, autistic, paranoid, or epileptoid (1921)” in (Rosqvist et al., 2020: 55). From Rosanoff’s work, the pseudo-theory that ‘everyone is a bit autistic’ developed because in his opinion, these traits appear in all people and the factor on determining if someone would be a good fit in the workplace, would be how they mask each of these characteristics. This potentially demonstrates why so many autistic people face such discrimination and stigmatism from the label (Turnock et al., 2022).

There are pragmatic advantages to the MMoD, albeit cautiously and in moderation to its implementation and interpretation. We cannot ignore that some impairments can lead to a person experiencing difficulties within their everyday lifestyle, such as pain and fatigue, which a physician is able to help treat, can benefit from some implementation of the MMoD. However, when this approach is applied to autism, a neurological difference, there is still research searching for a cure reflecting the “powerful belief that autism entails difficulties that are best avoided” (Rosqvist et al., 2020:77). This is emphasised further by the egg donor who was refused by four clinics due to one of her children being autistic (Keeler, 2009). “Whether intended or not, this message conveys a damning view about the value of autistic lives” (Rosqvist, Chown, Stenning, 2020:81).

3.2. The Autism Employment Gap & The Social Model of Disability

The Social Model of Disability (SMoD) originated to address the barriers that are constructed by society, which oppress the marginalised population of people with impairments (Oliver, 1983). It was an ethical (Goering, 2015), empowering and pragmatic attempt to equip professionals with helpful strategies to help their disabled clients and families (Oliver, 2013). Goering explains that providing if we (as humans) live long enough, we will all eventually have impairments. To accept this, it can help society shun the ‘them/us’ notion that has spawned as a likely result of the MMoD approach of impaired individuals being seen as inferior and parents of impaired children being told to forget their child had been born (Kapp, 2020:80) and instead acknowledge that being disabled is not the fault/problem of the impaired individual, but of the hegemony whose actions in society have provided a discriminatory platform for ableism (Mapp, 2016).

SMoD has received criticisms, often focusing on the notion that it doesn’t take all experiences of the individual (Crow, 1996) or the significant changes to the social context (Finkelstein, 2007), suggesting that the model is inadequate because disability is rarely just a social construct or difference (Shakespeare, 2014). Although Oliver (2013:1024) responds he did not “claim that the social model was an all-encompassing framework with which everything that happens to disabled people could be understood or explained”, it is clear when reading various media that author trepidation is apparent, due to the strong relationship between the model and the Disability Rights Movement and its significant progression since the model’s inception.

Leatherland’s (2018) definition for autism is a natural fit for the SMoD. The definition can be paraphrased within this model, as autism being an evolutionary neurological difference for some in the population and society has a responsibility to recognise the communication differences between the autistic and PNT population. By doing so, the environment can be made accessible for all neurotypes. In both my personal and professional perspective, often when a person is informed of a problem within the environment for an individual they work with, they want to implement strategies to make the environment more accessible and so supports the SMoD. The few occasions I have experienced barriers to the environment have either come from a desire to hold onto tradition: for example, inflexibilities with school uniform and the need to meet health and safety regulations. Each of these falls to the subjective nature of interpreting the phrase: ‘reasonable adjustments’, when “responses to impairment are seen as representing the interests of disabled people, [but] they are made largely by people with no direct experience of impairment, yet are presented as authoritative” (Crow, 1996:9). In my experience, the removal of these barriers are opposed based on the notion that most of the population are not affected by the barrier and so it does not need to change – instead the person should devise a way to cope and their feelings are invalidated – arguably, following the MMoD. Whereas, following the SMoD, autistic individuals are unlikely to be PNT in a population larger than their household and by denying the barrier to be removed is a form of oppression to the autistic population. Perhaps it is this interpretation of ‘reasonable adjustments’ that is a significant factor contributing to the autism employment gap. If decisions on what is a ‘legitimate’ barrier are being decided by the PNT, then the autistic perspectives are not being represented. There is a problem in that statement too, every human being will have their own individual perspectives and what is a barrier to one person may differ to another (Centers for Disease Control and Prevention, n.d). So for one person to decide on a barrier to another person, could mean that oppression still occurs. A realist may argue that some people may try to get out of completing tasks arguing that it is a barrier when they simply do not want to do the task. This model relies on honesty from all parties, which is unlikely to happen in a society, when many people are focused on getting only what benefits them.

In this scenario, I think job carving is essential rather than having non-negotiable job descriptions. Giving a person the opportunity to say “I find these situations are my strengths and these are my weaknesses” so that the employer can then find roles which meet their strengths, rather than adding distress for the person needing to find a way to cope with the weaker areas. This approach could yield a significantly higher job satisfaction rate, due to increased self-esteem and self-actualisation (Pichère & Cadiat, 2015), which could lead to decreased staff turnover.  

4.  A Critique for the Cognitive Theories Pertaining to Autism

Each theory I critique will be measured against four criteria: specificity, uniqueness, universality, and my lived experience.

4.1.  The Autism Employment Gap & Theory of Mind

The term ‘Theory of Mind’ (ToM) originated in Premack & Woodruff’s (1978) paper focusing on chimpanzees and whether they can consider another’s mental state. This concept was researched further and most notably (in my opinion) by Baron-Cohen, Leslie & Frith (1985). Despite the obvious MMoD tone to the paper, whereby frequent references to autistic people as having a “cognitive deficit” (Baron-Cohen et al., 1985:37-38), it is widely considered to be a dominant psychological theory in explaining autism, with similar conclusions being found in research (Sigman & Ungerer, 1981; Wing, et al,, 1977). Yet when critiqued against uniqueness, universality, specificity and the lived experience, there are significant flaws with this theory as a full account of autism.

The results from the small sample size of each of the three groups included in Baron-Cohen’s study is not representative of the full UK population in 1985, in terms of size, mental age, chronological age, or IQ (Macrotrends, n.d.). Although the methodology employed in Baron-Cohen’s study follows the suggested rules given in Dennett’s (1978) article on how to determine ToM, the methods implemented allow predictions to be made on participant performance based on their linguistic ability (Gernsbacher & Frymiare, 2005). Research has shown that family size can indicate participant performance to the False Belief tasks (Astington & Jenkins, 1995), however, these details are not presented in the procedure for Bohen-Cohen. It can be argued that the study and thus the theory is not valid, as it is not measuring ToM, but instead linguistic ability.

4/27 autistic participants passed the False Belief tasks. Although, there is a significant difference in performance compared to the PNT group having 23/27 and the Down Syndrome group having 12/14 pass the tasks, it cannot be a universal characteristic because there are some autistic participants that passed. Despite, Baron-Cohen claiming that a lack of ToM “is universal in applying to all individuals on the autistic spectrum” (Baron-Cohen, 2008:113; Baron-Cohen, 2009:70), Gernsbacher & Yergeau (2019:104) argue that “ ‘mindblindness’ cannot be a universal characteristic of autism”, because of how many autistic people can pass the task – if it were universal, then all autistic participants would fail. In addition to this “Belief tasks… [are] also prone to fail replication” (Gernbacher, 2019:107), as four research teams struggled to replicate Baron-Cohen’s findings, which “suggest that the theory-of-mind model has its limitations in explaining autism” (Dahlgren & Trillingsgaard, 1996:759,762).

ToM in any study discussed so far could not produce results that support uniqueness because PNT groups failed the False Belief tasks too. It cannot be denied that there is a significant difference between the autistic group result compared to the PNT. However, if autism involves a communication difference to those of the PNT, then it is to be expected that autistic participants would have a lower success rate (Gernsbacher, & Yergeau, 2019), if the test was designed by a PNT.

ToM does not address hyper-empathy, as autistic people can often have too much empathy, whereby “even the thought of anyone or anything suffering causes them intense emotional, psychological and often physical pain” (The Art of Autism, 2018). This cannot be explained using ToM alone, thus specificity criterion cannot be met.

Despite universality, uniqueness, and specificity, I have encountered autistic people that struggle to engage in lessons that involve empathising varying perspectives. For example, why a person may choose to believe in a deity in Religious Studies, or what the author, being studied in English, is trying to make the reader feel, or envisage as they read the text. For several pupils, this can be a trigger for a meltdown, because they cannot comprehend why someone would choose to be religious or vice versa. In English, I have been asked “why doesn’t the author just say that, rather than us trying to work it out”. Similarly, I have worked with people that are not autistic and have asked similar questions as well. Although I have needed to mask for a significant part of my life to navigate the social cues and etiquette in society, I can view things from varying perspectives and can feel physically and emotionally distressed if I am told something sad about a situation, even though I may not know the person(s) directly. It could be argued that from my extensive masking I have learnt to ‘hack’ ToM from observations during my lifetime (Frith, Happé & Siddons, 1994; Rajendran & Mitchell, 2007), but I would argue that every person does this through numerous observations during their lifetime, learning from their previous experiences – it is knowledge (Cambridge Advanced Learner’s Dictionary & Thesaurus, nd).

The ”claim that autistic people lack a ToM is empirically questionable and societally harmful” (Gernsbacher & Yergeau, 2019: 103) resonates deeply with me. Employers are required to show equality in all aspects of their employment practises (EOC, nd). However, if indirect discrimination is coming from a leading MMoD influenced theory of autism, with the foci being the person has the deficits, then it is no wonder there is an autism employment gap. Instead of celebrating what a person can do and contribute and accepting that all employees will have their own strengths and weaknesses, there is a systemic ‘them and us’ inherent conditioning between the PNT and autistic population. In my opinion, this is not intentional for many. If you are only presented with information coming from a monopoly of medical sources, then it can be argued why might someone challenge it further? If autism is always presented with negative connotations, such as having a “severe developmental disorder” preventing them coping with the environment (Baron-Cohen, Leslie & Frith, 1985: 37), then almost all organisations could argue all their job descriptions involve socialisation and an autistic person is not going to be appropriate for that role. This might be exacerbated in customer facing roles, often requiring the person to show empathy for the customer’s plight, if the leading thought for those in recruitment is that it is a disorder and could be damaging to their business, then it could explain the autism employment gap.

4.2. The Autism Employment Gap & Executive Functioning Deficits

A second theory, which follows the MMoD tone and tries to explain autism is Executive Function (EF) deficits (Ozonoff, Pennington & Rogers, 1991). EF involves the cognitive skills required to plan, focus, multitask, recall, and complete tasks (Center on the Developing Child Harvard University, nd), although the exact canopy for which EF covers is unclear, as sources can differ on what exactly it covers (University of California San Francisco Weill Institute for Neurosciences, nd). EF differences are associated with the brain’s frontal lobes, accounting for approximately 40% of the brain and is the last part of the brain to develop (University of California San Francisco Weill Institute for Neurosciences, nd).

It is proposed by Ozonoff et al., that EF deficits in their “sample suggests that it might be a primary deficit of autism” (1991:1099), however reflects on it being “simplistic to assume that all of autism can be explained” (Ozonoff et al., 1991:1101), so the specificity criterion cannot be met for this theory.

Indeed, Ozonoff et al. provided a comprehensive methodology to justify their findings, as they hypothesised that autism is not the result of one difference but multiple. It is worth noting that the Wisconsin Card Sorting Test (WCST) (Berg, 1948) is “among the most frequently administered neuropsychological tests” (Jodzio, Biechowska, 2010:267) and was used as part of the EF composite tests, however, the cards were ambiguous in their interpretation and since been modified to remove this problem. This modification is known as the Modified Card Sorting Test (MCST) (Nelson, 1976). This ambiguity could demonstrate why some of the autistic sample performed less favourably to the PNT group.

In terms of universality, 96% of autistic subjects performed worse than the control on the EF tasks. “Children aren’t born with these skills – they are born with the potential to develop them” (Center on the Developing Child Harvard University, nd). When considering this quotation with Ozonoff et al.’s results, it could be argued that the 4% that performed in-line/above the control group could have received support during their childhood to support them with these skills, whereas the 96% had not. Despite the overwhelming result and from other research (Rumsey, 1985; Rumsey & Hamburger, 1988), it cannot be universal to the autistic population if 4% did not perform in line with the rest of the autistic group.

In addition to this, it is not unique to the autistic population because “executive function deficits are not unique to autism” (Rajendran & Mitchell, 2007) because evidence from Ozonoff & Jensen (1999) found similar results in their Tourette and ADHD population. This might suggest that this theory could be unique to the neurodivergent population. In my experience, it is common for support to be put in place to help pupils in their organisation and processing of information, by providing scaffolds of the necessary data in manageable chunks. Every child that we oversee requires support in this respect, all to varying degrees. Further to this, our Autism Resource Base (ARB) provision in its earliest stages, involved plans on how we could reduce some of the anxiety for our pupils and involved techniques to support EF. If anxiety is to be considered to, then it could be worth investigation into samples involving those that require support with their mental health and EF, as “[M]ental health difficulties such as depression and anxiety occur at high rates in autistic people” (Hollocks et al., 2019:560).

Resulting from this theory, Buckle et al., (2021) obtained firsthand accounts from autistic visitors to the holiday destination, AutScape. They found accounts would commonly refer to what they called ‘autistic inertia’. This metaphor describes the difficulties in starting/stopping an activity, which links with EF as it focuses on planning and completing tasks. Often pupils I have worked with say, “I don’t know where to start”. Once the pupil has demonstrated understanding of the task and the content, writing frames or other scaffolds are often employed to help the pupil begin the task. They often report knowing what they want to say, but struggle with how to begin their response. Beardon’s (2017:11) “autism + environment = outcome” supports Buckle et al.’s summary of the internal and external descriptors and effects of ‘autistic inertia’. If autism is a life-long neurological difference, then to achieve better outcomes, the environment needs to change. Although society has dramatically improved since the 1940s view of autism, there are still significant adjustments that could be made to the environment that would be considered reasonable. This might include task analysis for recruitment and jobs during the person’s employment in the organisation. As EF differences follows the MMoD tone, the theory is still deficit driven. I believe most employers expect the successful applicant to be able to adjust to the needs of their ever-changing business. If inflexibility of thought, lack of planning and laziness are the connotations that come from this theory, combined with the previously discussed issues with ToM, then it can be argued further that due to the compounded indirect discrimination, it could be leading to less employers recruiting autistic applicants.

4.3. The Autism Employment Gap & Central Coherence

Weak Central Coherence (CC) is another MMoD inspired theory, with an aim to account for autistic participants that had passed the ToM tests in Baron-Cohen’s (1985) study. Morton & Frith (1991) claimed there was a need for autism specificity. The proposed answer was weak CC (Frith & Happé, 1994) and is partially supported by Pellicano et al., (2006). Frith (1989) proposed that autistic individuals outperform the PNT population on local processing (focusing on the details), but perform poorly on holistic processing (e.g., looking at the bigger picture), due to “this universal feature of human information processing [being] disturbed in autism” (Frith & Happé, 1994:121). Frith & Snowling (1983) claim their findings suggested that the autistic participants excelled at single word decoding, but performed poorly when context was required in the homograph tasks. However, the autistic participants performed consistently scoring 3/5 on both tasks, whereas the PNT group scored 5/5 and 2/5 on the two tasks, yet limited focus is given to the poorer performance of the PNT group. Weak CC cannot be unique to the autistic population, if the PNT population failed the tests as well.

It is difficult to provide support for the universal criterion, when the age of participants in studies are ranging between 4-18 years old and are mostly male (Pellicano et al., 2006; Frith & Happé, 1994) in sample sizes that are not representative of the entire population. It is worth noting that the ADI-R algorithm (Kim & Lord, 2012), widely used for identifying autism (AppliedBehaviorAnalysisEdu.org, nd) and used in Pellicano et al.,’s (2006) study with age ranging between 4-7 years old, is deemed accurate with older children, but inaccuracies have been found in young children (de Bildt et al., 2015). Moreover, Pellicano et al., (2006) excluded participants with co-occurring medical or neurodevelopmental conditions and those with verbal or non-verbal IQ below 80. Although I understand the need to limit the variables in an empirical study, it does however, limit the extent to which uniqueness or universality can truly be critiqued, when usually “[a]utism likes to bring a friend” (Jones, C., 2021:40).

In terms of specificity, weak CC is often considered to be just one contributor to autism due to relationships found between ToM, EF, and CC tasks (Frith & Happé, 1994; Pellicano et al., 2006). Attention to detail is something I find difficult, which does not conform to this theory. However, there are times when I can struggle to generalise and see the ‘bigger picture’. It could be argued that ‘it depends’ on the context, which supports Hearst (n.d.) Constellation model. Some pupils I have worked with are able to hyper focus on intricate details and excel with local processing tasks and need support in transitioning between tasks, while others are able to establish the ‘gist’ of the message being communicated as well. This appears to be the common theme throughout this paper, it depends.

In comparison to ToM and EF, CC at least proposes strengths to the autistic individual opposed to their PNT peer, in situations where local processing is advantageous. Autism is portrayed as a problem in ToM and EF, so to emphasise there are strengths is at least a start in trying to revert some of the societal damage that has been caused by these theories (Gernsbacher & Yergeau, 2019).

However, there is speculation as to the validity of CC theory as “several studies have failed to demonstrate superior performance by persons with autism on various tasks expected to favor local processing (e.g., Brian & Bryson, 1996; Ozonoff, Pennington & Rogers, 1991)” (Pellicano et al., 2006:78).

In terms of the autism employment gap, there are job roles that it could be advantageous to be able to focus on the details for the betterment of the organisation. However, the negative connotations that could be inferred to employers from this theory suggest narrow mindedness and lacking ingenuity, potentially leading organisations not to employ. Unfortunately, each theory discussed so far yields limited reasons why a person might want to disclose their autism identity to prospective employers, due to the potential discrimination they may endure during the recruitment process. I believe that the PNT population have limited experience in their intersectional identities being scrutinised to the extent that the neurodivergent have endured. The research I have read, emphasises the notion the autistic person is under a microscope as a foreign object, wanting to be understood for all its eccentricities and deficits. There appears to be limited research conducted by autistic researchers, yet are deemed to be the expert (Crow, 1996) on such matters and is negatively impacting society (Gernsbacher & Yergeau, 2019).

5.  Research Informed Personal Insights into Neurotype Differences: Inclusion and autism.

Figure 1: Explaining Neurological Differences Between PNT and Neurodivergence (Leggett)

von Neumann architecture (1993) is a computer architecture where memory and instructions shared the same space. The human brain can share similarities with computer systems, whereby the brain receives an input (a stimulus within the environment). This input is the same for all beings on the planet, but based on how the brain processes the input, is where our differences occur. I propose that the human brain will coordinate with its internal components including the amygdala in its immediate response to the input, while consulting with working, short- and long-term memory to determine what is being communicated. The result of this process yields a response (output) that may vary across the entire population.

Therefore, inclusion within the autism field, I believe should be focused on making the environment as accessible for all neurotypes, with the expectation for all human beings being ready to support their peers when interpretation of the environment has differed from the original intent. All human beings have their relative strengths and weaknesses, so if autism is a communication difference (Leatherland, 2018; Beardon, 2017) between the PNT and autistic population, then there needs to be more representation of the autistic population in all aspects of everyday life. This has started to appear with supermarkets offering sensory friendly operating hours during the day and increasing numbers in society are becoming aware of autism. The knowledge being shared might derive from a MMoD led theory, but I believe society is starting to shift towards seeing autism through a SMoD lens. Inclusion for autism will be when accommodations and options are accessible for all differences and not having to prove yourself with a formal “diagnosis” to be able to access support. In education, the current need for more specialist school provision (UKDHM, 2023) will decrease, because the expertise within these provisions is universally delivered to all teachers (both in service and training), so that difference is present and represented to pupils from an early age. Autism inclusion will mean that parents and learners won’t need to choose between segregation and understanding and acceptance in their school choices.

6.  Conclusion

The social and medical models of disability have been explored for their connotations in society. Dominant theories of autism including ToM, EF, and CC are each critiqued for their uniqueness, universality, specificity and lived experience. Models and theories have been discussed for their potential impacts on the autism employment gap. Despite these being dominant theories, not one of them was able to meet these criteria. One of the frequent issues that arose in each of these theories was intersectionality. It could be argued that people who do not identify as white cisgender males may find it more difficult to access autism identification, because the research mentioned within this paper do not necessarily represent their full identity.

Furthermore, it is unsurprising that there are negative connotations around autism, thus leading to an autism employment gap, when dominant theories discuss it as a significant deficit in the person and is something that needs to be cured/treated. When society can reach a point where we all acknowledge that everyone is unique and might interpret the world around us differently, then everyone can work to support those around us to interpret our perceptual differences (neurodivergent or PNT). To help reduce the employment gap, theories need to start adopting a SMoD perspective.

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