A Critical Realist Approach on Autism: Ontological and Epistemological Implications for Knowledge Production in Autism Research

The ontological status of autism has been a subject of considerable debate and philosophical approaches of it have been recent and sparse. On the one hand, from its conception, autism has been historically heavily located in the fields of psychiatry, psychology and neuroscience, which often assume access to an “objective,” neutral and infallible reality that is external to the research process and is based on the autistic person’s biology and behavioural characteristics, which can be scientifically observed and studied. On the other, proponents of the neurodiversity movement argue against medicalised and pathologising approaches to autism and toward approaches that consider social constructions of autism and relations of power. The Critical Realist philosophy can help reconcile the two positions. Critical Realism conceptualises objectivity as a statement about an object, rather than a neutral and infallible reality. Consequently, Critical Realism suggests that access to reality can only occur through fallible theories. It also suggests that effective theorising goes beyond appearances and phenomena and may even contradict them, which can help challenge dominant behaviourist approaches on autism. I then explore how the tenets of Critical Realism can help strengthen autistic-led theories of autism, the arguments they make, as well as how they support the importance of community autism knowledge. Finally, I present how Critical Realism’s approach to knowledge itself as well as the process of knowledge creation can strengthen autistic theorising, autistic participation in autism research and autistic emancipation. In the last part of the article, I explore how the concepts of Critical Realism apply to autistic sociability. I start with the debate between structure and agency, how Critical Realism reconciles this debate and the implications for autistic emancipation and autism research. I then present Critical Realism’s process of critique and explanation, how they connect to human emancipation and how they can lead to impactful change in autism research by requiring clear links from research to practice, enhancing practices with strong theoretical underpinnings and thus aiding the aims of emancipatory autism research.

Remembering Dr Li-Ching Lee, a pioneer of global autism research

The field of global autism research lost a pioneer, champion, and innovator with the passing of Dr Li-Ching Lee in May 2021. Dr Lee served as the editor for a special issue in Autism on global autism research (2017, Volume 21, Issue 5) and her substantial impact on autism research and autistic individuals and their families in low- and middle-income countries warrants a place in this special issue. While a giant in the professional arena, her large impact on science is minor compared to the compassion, kindness, and love she brought to her family, friends, and her professional communities at Johns Hopkins, across institutions, her native Taiwan, and the areas in which she conducted her research. Dr Lee was immensely humble and intensely focused on harnessing epidemiology to positively impact the lives of people with autism and developmental disabilities. Her humility and professional dedication was coupled with a desire to keep her own challenges and triumphs private including her courageous efforts to stave off cancer while accomplishing so much in support of others.

A blind spot in mental healthcare? Psychotherapists lack education and expertise for the support of adults on the autism spectrum

Most adults on the autism spectrum have co-occurring mental health conditions, creating a high demand for mental health services – including psychotherapy – in autistic adults. However, autistic adults have difficulties accessing mental health services. The most-reported barriers to accessing treatment are therapists’ lack of knowledge and expertise surrounding autism, as well as unwillingness to treat autistic individuals. This study was conducted by a participatory autism research group and examined 498 adult-patient psychotherapists on knowledge about autism and self-perceived competency to diagnose and treat autistic patients without intellectual disability compared to patients with other diagnoses. Psychotherapists rated their education about autism in formal training, and competency in the diagnosis and treatment of patients with autism, lowest compared to patients with all other diagnoses surveyed in the study, including those with comparable prevalence rates. Many therapists had misconceptions and outdated beliefs about autism. Few had completed additional training on autism, but the majority were interested in receiving it. Greater knowledge about autism was positively linked to openness to accept autistic patients. The results point to an alarming gap in knowledge necessary for adequate mental health care for individuals with autism. Lay abstract Most autistic adults experience mental health problems. There is a great demand for psychotherapeutic support that addresses the specific needs of autistic individuals. However, people with autism encounter difficulties trying to access diagnostic and therapeutic services. This study was conducted by a participatory autism research group: a group in which autistic individuals and scientists collaborate. The group developed a questionnaire for psychotherapists in Germany to assess their knowledge about autism. Psychotherapists also rated their ability to diagnose and treat autistic patients without intellectual disability, and patients with other psychological diagnoses. Many of the 498 psychotherapists that responded reported little knowledge and outdated beliefs about autism, as well as little training on treating patients with autism. Their expertise about other psychological conditions was more comprehensive. However, many psychotherapists were interested in professional training on autism. Those with more knowledge were also more open to treating autistic patients. In conclusion, psychotherapists’ lack of knowledge and expertise seem to be a major barrier for adults with autism to receiving helpful psychotherapeutic support. The results demonstrate the need for an advancement in autism education during psychotherapists’ training and in continuous education.

The meaning of significant mean group differences for biomarker discovery

Over the past decade, biomarker discovery has become a key goal in psychiatry to aid in the more reliable diagnosis and prognosis of heterogeneous psychiatric conditions and the development of tailored therapies. Nevertheless, the prevailing statistical approach is still the mean group comparison between “cases” and “controls,” which tends to ignore within-group variability. In this educational article, we used empirical data simulations to investigate how effect size, sample size, and the shape of distributions impact the interpretation of mean group differences for biomarker discovery. We then applied these statistical criteria to evaluate biomarker discovery in one area of psychiatric research—autism research. Across the most influential areas of autism research, effect size estimates ranged from small (d = 0.21, anatomical structure) to medium (d = 0.36 electrophysiology, d = 0.5, eye-tracking) to large (d = 1.1 theory of mind). We show that in normal distributions, this translates to approximately 45% to 63% of cases performing within 1 standard deviation (SD) of the typical range, i.e., they do not have a deficit/atypicality in a statistical sense. For a measure to have diagnostic utility as defined by 80% sensitivity and 80% specificity, Cohen’s d of 1.66 is required, with still 40% of cases falling within 1 SD. However, in both normal and nonnormal distributions, 1 (skewness) or 2 (platykurtic, bimodal) biologically plausible subgroups may exist despite small or even nonsignificant mean group differences. This conclusion drastically contrasts the way mean group differences are frequently reported. Over 95% of studies omitted the “on average” when summarising their findings in their abstracts (“autistic people have deficits in X”), which can be misleading as it implies that the group-level difference applies to all individuals in that group. We outline practical approaches and steps for researchers to explore mean group comparisons for the discovery of stratification biomarkers.