Are You Missing the Signs of Autism in Adults?
- Amanda Moses Psychology
- 2 days ago
- 5 min read
Subtle signs of autism, internalised traits, and the indicators every psychologist should know
If you have ever worked with a client and thought, “Something deeper is going on, but it does not quite fit the picture,” you are not alone.
Autism in adults often looks very different from what most of us were taught in textbooks. This is especially true for clients who mask their traits, internalise distress, or have received several inaccurate diagnoses over the years.
For many clinicians, it can feel like something is being overlooked. You might sense autism, but your standard assessment tools do not fully explain what you are observing.
Let’s explore why adult autism is so often missed, why traditional assessments fall short, and how frameworks such as the MIGDAS (Monteiro Interview Guidelines for Diagnosing the Autism Spectrum) can help us identify autism more accurately.
Why So Many Adults Go Undiagnosed
A growing body of research shows that many autistic adults, particularly women and those assigned female at birth (AFAB), are often missed by traditional diagnostic systems. This happens for several reasons. Most diagnostic frameworks were developed for children, often focusing on observable behaviours rather than internal experiences. Adults who have learned to adapt to social expectations may present very differently from the stereotypical profile.
Many describe a lifelong sense of difference, yet they have developed compensatory strategies that conceal their traits. They might appear highly articulate or successful, but underneath there is often exhaustion, social confusion, and self-doubt.
Common experiences include:
Learning to mask social communication differences by copying others
Receiving multiple misdiagnoses such as anxiety, depression, or borderline personality disorder
Experiencing burnout or emotional fatigue during major life transitions
When autism remains unidentified, clients can spend years blaming themselves for not fitting in. As clinicians, we miss the opportunity to help them understand their neurotype and access support that actually fits.
“Missing autism is not just a diagnostic gap. It is a missed opportunity for understanding, validation, and support.”
Why Traditional Autism Assessments Miss Adults
Standardised autism tools such as the ADOS-2 and ADI-R were designed for use with children. While valuable, they often fail to capture the complexity of adult presentations, or those with internalised presentations.
Adults may have learned social scripts that mask communication challenges. They may experience sensory sensitivities that are not outwardly visible. Some have high levels of intellectual insight but limited interoceptive awareness.
Because traditional assessments focus heavily on observable behaviour, they can miss internal experiences that are equally significant. The result is that many adults do not meet diagnostic thresholds despite clear autistic traits.
The best approach is to combine structured tools with neurodiversity-affirming assessment frameworks that explore lived experience, and the person's internal world.
The Role of the MIGDAS in Autism Assessment
The MIGDAS is a qualitative, sensory-based interview framework that brings the client’s voice to the forefront.
Instead of relying purely on checklists, the MIGDAS helps clinicians:
Explore the sensory and emotional world of the client
Engage in collaborative conversation rather than relying only on what is observable
Identify strengths, coping mechanisms, and patterns that may mask autistic traits
Honour the client’s own words, metaphors, and self-understanding
MIGDAS training gives clinicians the skills to recognise subtle and internalised autism presentations that traditional tools overlook. It aligns naturally with neurodiversity-affirming practice, allowing psychologists to assess clients in a way that feels validating rather than pathologising.
Clinicians who complete MIGDAS training often describe a shift in how they conceptualise autism, moving away from a deficit-based model toward a strengths-focused understanding of autism.
Commonly Missed Signs of Autism in Adults
When conducting an autism assessment, it is essential to look beyond surface behaviours. Internal experiences often hold the clearest clues.
Some signs of autism that may indicate an overlooked or internalised presentation include:
Rehearsing conversations in advance to manage social anxiety
Adapting personality or communication style to fit different environments
Feeling exhausted after socialising, even when it appears to go well
Engaging in subtle self-regulatory behaviours such as tapping, skin rubbing, or mental stimming
Describing lifelong feedback of being “too sensitive,” “intense,” or “overreactive”
A long list of previous diagnoses that never felt accurate
Indicators That May Suggest Missed or Masked Autism
Some clients may not fit the classic image of autism yet show consistent patterns that point to an underlying difference. Look for:
Multiple diagnoses across different stages of life that don't quite fit
Burnout or periods of shutdowns linked to stress or life transitions
Difficulty identifying or expressing emotions (alexithymia)
A strong tendency to intellectualise feelings
'Treatment-resistant' anxiety or depression
A history of sensory overload or social fatigue that lacks a clear cause
These clients often report that therapy and medication have not helped as expected. In such cases, an unrecognised autistic profile may be the missing piece.
A Case Example: When Anxiety Wasn’t the Whole Story
Consider Sarah (name and details changed), a 32-year-old professional who sought therapy for anxiety and burnout. She described feeling “on edge” in social situations and needing long periods of recovery after work.
Despite years of therapy, her anxiety never truly improved. During her assessment, we explored her sensory experiences, her tendency to rehearse conversations, and her exhaustion after social contact.
Eventually, when these experiences were reframed through an autistic lens, the picture became clear. Her anxiety was not the core issue. It was the result of chronic masking and sensory overload. Understanding this allowed Sarah to build self-awareness, make sensory adjustments, and engage in therapy that finally addressed her real needs.
Building Confidence in Adult Autism Assessment
Recognising autism in adults requires curiosity, humility, and a willingness to look beyond labels. Start by prioritising the client’s lived experience rather than focusing exclusively on DSM criteria. Ask open-ended questions such as:
“What does socialising feel like for you?”
“Do you find certain environments more draining than others?”
“How do you usually recover after a big day?”
These types of questions invite reflection and help uncover patterns that structured assessments might overlook.
Gaining confidence in identifying internalised presentations takes both practice and training. Frameworks like the MIGDAS can help clinicians refine their approach and increase diagnostic accuracy.
Why Neurodiversity-Affirming Assessment Matters
A neurodiversity-affirming approach recognises autism as a natural variation in human neurology, not a disorder that needs to be fixed. It seeks to understand the individual in context, exploring how the environment interacts with their strengths and challenges.
When clinicians adopt this perspective, the diagnostic process becomes empowering rather than stigmatising.
For many adults, receiving an autism diagnosis later in life can be life-changing. It provides language for self-understanding and helps them access support that aligns with who they are.
Final Thoughts
You do not need to have all the answers in your first session. What matters most is curiosity.
When we take time to listen deeply, explore the client's internal experiences, and apply the right assessment frameworks, we begin to see clients who have been overlooked for far too long.
The more we understand internalised autism, the fewer people fall through the cracks.
Want to Learn More?
Autism & ADHD Diagnostic Assessment Training My Autism & ADHD Diagnostic Assessment Training is designed for clinicians working with adults and adolescents. It covers:
How to identify internalised and masked presentations
How to differentiate co-occurring conditions
How to use neurodiversity-affirming approaches in assessment and formulation
MIGDAS training
You will also learn how to integrate practical tools such as the MIGDAS, DIVA-5, and in a way that fits real-world practice. The training is grounded in current research and designed to help you assess confidently and compassionately.
