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Table of Contents

Part One

Chapter 1 - Our framework: The current diagnostic criteria

Chapter 1 describes the diagnostic criteria as presented in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR, 2022) and in the International Classification of Disease (ICD-11, 2019).

The criteria are divided into two major areas: (A) social and communication challenges, and (B) repetitive and restricted behaviors (RRBs).


Social and communication challenges include (1) social/emotional reciprocity, (2) nonverbal communication, and (3) relationship management.


Repetitive and restricted behaviors include (1) repetitive or idiosyncratic behavior, (2) inflexibility, (3) restricted interests that are intense or atypical, and (4) sensory differences.


A person must show differences in all three of the social/communication differences, as well as two of the four repetitive/restricted behaviors in order to qualify for a diagnosis of autism. Individuals can meet criteria on both groups either currently or by history. The chapter closes with a description of the differences and similarities between the DSM-5-TR and ICD-11.

Chapter 2 - Reciprocity

Chapter 2 begins by describing the features of reciprocal interactions between non-autistic individuals, including co-regulation, building on what the other person says, sharing experiences, showing curiosity about others, and seeing the world from another person’s perspective. Autistic people can have different ways of interacting in any of these domains, struggling with skills such as how to greet people, expressing curiosity about others, sharing experiences, maintaining back-and-forth flow during interactions, seeing a comment or situation from another person’s point of view, and/or misunderstanding other people’s intentions. 

Readers will learn about empathic disequilibrium, and the different types of empathy — cognitive, affective, and compassionate. The authors explain that autistic girls and women are more likely to follow the implicit non-autistic norms of reciprocity by explicitly thinking through every interaction, even those that seem simple to non-autistics. This camouflaging (a.k.a. masking) is exhausting and stressful. Navigating race, gender, and ethnic/societal/cultural expectations renders it even more so because the social rules around communication, turn-taking, interrupting, and humor are culturally-bound. The authors also discuss the difficulty of navigating romantic interests and dating, with particular attention to the impact of being a person of color.

Chapter 3 - Nonverbal communication

Chapter 3 first describes the double empathy problem — in which people who have very different experiences of the world may struggle to understand and empathize with each other. This is particularly evident in how autistics and non-autistics use nonverbal communication to augment and clarify their message through both receptive (understanding what the other person is communicating) and expressive (communicating your message to others) channels. The areas of nonverbal communication in which autistic and non-autistic people have different experiences include body positioning, personal space, eye contact and gaze, prosody (including volume, tone of voice, and inflection), facial expressions, and gestures. Speakers must integrate these behaviors with the spoken words, and the listener must decode what each of these behaviors mean in context. Culture can have an impact too, with high-context cultures demanding more facility using and interpreting nonverbal cues than low-context cultures. The authors note that autistic females tend to have more expressive nonverbal communication than autistic males, though they are not necessarily better than males at understanding other people’s nonverbal communication.

Chapter 4 - Relationships

Autistic people often understand, build, and maintain their relationships differently than non-autistic people. This can cause challenges and misunderstandings, particularly in relationships between autistics and non-autistics. This chapter explores relationship management differences, and it distinguishes between social motivation (the desire for connection) and challenges with making, deepening and maintaining friendships. The authors describe differences that include time spent nurturing relationships, understanding different kinds of relationships, attending to social hierarchies, social flexibility, and conflict management. They also discuss the difference between social motivation and social energy.

This chapter also reviews gender-specific differences in relationship management. One reason autistic women and girls have not been recognized as frequently as autistic boys and men is because they are more likely to engage in pretend play, less likely to be loners, and less likely to be overtly rejected by their peers. They tend to have higher social motivation than autistic males, report higher quality friendships, and manage interpersonal conflicts differently. The importance of understanding cultural differences in dating and marriage norms is also discussed.

Chapter 5 - Repetitive or idiosyncratic behavior

Behaviors that meet criteria for the first category of repetitive and restricted behaviors (RRBs) refer to behavior that is either repetitive or idiosyncratic. These “stims” (self-stimulating behaviors) can include motor movements, speech, or use of objects. Movements are not limited to flapping, flicking hands and fingers, spinning, rocking, or toe walking. They also include pacing, tapping, swaying, scratching, persistent skin picking, playing with hair, rhythmic self-harm, and an endless variety of other patterned idiosyncratic movements. Repetitive use of objects is not limited to lining up or organizing things, taking objects apart, opening and closing doors, or turning lights on and off, but can also include behaviors like repeatedly reading the same book or watching the same show, making lists, etc. Likewise, repetitive speech or language may include repeating words and phrases — questions, answers, songs, passages from a book, or movie dialogue — pronoun reversal, unusual use of words, palilalia, humming, or other noises. The repetitive behavior of females tends to be more subtle. These so-called “purposeless” behaviors are calming, promote focus, and provide stress relief. Autistic people report that when they are prevented from doing them, they can become dysregulated.

Chapter 6 - Flexibility

While some autistic people are overtly rigid in many ways, others can be highly flexible in some contexts and highly inflexible in others. Rather than looking for ubiquitous inflexibility, we find it helpful to look for islands of rigidity, which can take many different forms. These can include routines and rituals, difficulty with change, trouble transitioning from one activity to another, black and white thinking, obsessive thinking, having an unusually strong moral compass, rigid rule following, interpreting language literally, and difficulty parting with seemingly useless objects. Autistic people offer logical explanations for their preferences for predictability and sameness, such as difficulty with executive functioning, desire for efficiency, avoiding the extra work required to prepare for something different, providing a stable foundation from which to explore new things, minimizing sensory overwhelm, and finding comfort in knowing what to expect. Autistic females may internalize their discomfort with change and are thus highly vulnerable to being obsessive and perfectionistic in their thinking and approach to tasks, and this often manifests with persistently high stress levels and anxiety.

Chapter 7 - Intense or atypical interests

“Restricted or fixated interests that are abnormal in intensity or focus” can mean different things to different people. In this chapter, the authors note that “restricted” does not necessarily imply that the interest eclipses all other considerations in a person’s life. Additionally, “intense” can manifest in different ways, including frequency of thought or intensity of emotions. Intensity and atypicality of interests must also be considered in the context of the person’s developmental level and culture; for example, an interest that is atypical in one culture may be typical in another, and an interest that is typical for one age may be atypical for another. The interests of autistic women and girls are more likely to be intense than atypical and often center on people, animals, reading, and pop culture, rather than objects or data. Daydreaming is an intense interest that can be positive or can become problematic when a person becomes so immersed in thinking about a fantasy world that they fail to notice their environment or meet basic expectations for work or school (referred to as maladaptive daydreaming). Because many autistic people have learned to hide their intense or atypical interests from others, it is important to ask them about their experiences.

Chapter 8 - Sensory differences

The DSM-5-TR notes that autistic people can have hyper- and hypo-reactivity to sensory input – also called over- or under-responsivity, hyper- or hypo-sensitivity. They can also have an unusual interest in sensory aspects of the environment, which may include sensory-craving. In this chapter, readers learn about the five senses everyone knows (hearing, touch, vision, taste, and smell), as well as proprioception (information about body position and movement), vestibular information (about the position and motion of the head and body), and interoception (internal bodily sensations), and how these senses are integrated. Over-responsivity (also called sensory sensitivity or sensory defensiveness) can lead to extreme discomfort or reactions to any of these sensations. Under-responsivity occurs when an individual shows little to no response to external stimuli or to internal sensations. Many autistic people also report other unusual sensory experiences, such as synesthesia and misophonia. Sensory differences often change over time and can have an overwhelming impact on an autistic person’s ability to function.

Part Two

Chapter 9 - Co-occurring challenges that are not part of the diagnostic criteria

This chapter describes co-occurring challenges that occur frequently in autistic people and can have an enormous impact on their functioning and/or well-being. Furthermore, they occur more frequently in autistic cohorts than in non-autistics, and can therefore also serve as potential “pink flags” for considering whether autism is part of the individual’s profile. Co-occurring emotional challenges described include anxiety, obsessive-compulsive disorder (OCD), depression, autistic burnout, emotional intensity and lability, neuro-crash, extreme empathy (and emotional disequilibrium), rejection sensitive dysphoria, bipolar disorder, self-injury, suicide, trauma, alexithymia, and pathological demand avoidance/ pervasive drive for autonomy (PDA). The authors then describe cognitive differences that include attention, executive functioning, a high need for explicit context (and/or weak central coherence), spoken language, academics, slow processing speed, prosopagnosia, and giftedness. Medical/health concerns described include sleep, eating, gastrointestinal issues, dental issues, atypical reactions to medications, obesity, menstruation, menopause, motor skills (fine motor, gross motor, hypotonia), tic disorders and Tourette syndrome, seizures, migraines, autoimmune conditions, connective tissue disorders, dysautonomia/POTS, and genetic disorders. Last but not least, the chapter describes differences autistic people may experience in adaptive functioning, gender, and attraction.

Chapter 10 - Autistic strengths

In this chapter, the authors consider the talents, skills, character, and other strengths that are frequently seen in autistic people. The authors describe seven areas in which autistic people show substantial strengths. These include (a) sensory differences, (b) cognition – including attention to and memory for detailed information, facility making associations, a narrow and intense focus of attention, less distractability, systemizing, and logically reasoning through problems, (c) intense interests with a deep desire to learn, an intensity of focus, and the energy and memory to develop an encyclopedic understanding of a topic through intense, self-directed study, (d) consistency, (e) social communication skills including a direct, straightforward, and honest communication style, a strong sense of integrity, less susceptibility to peer pressure, accepting of difference, and keen attunement to the emotions of others, (f) a sense of humor that can involve wordplay or irreverence, and (g) resilience and perseverance that can best be understood as grit. These strengths show the positive side of autistic traits. These traits allow autistic people to contribute to society and the world in unique and valuable ways.

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