Why Accurate Autism and ADHD Assessments Are an Ethical Issue

Accurate assessment of autism and ADHD is critical. These assessments ensure individuals receive the support, accommodations, and interventions they need. Despite wider awareness, many people—particularly women, AFAB (assigned female at birth) individuals, and those from diverse backgrounds—continue to be misdiagnosed or overlooked.

The Importance of Accurate Identification

Identifying autism accurately positively affects mental health and overall wellbeing (Kelly et al., 2022; Stagg & Belcher, 2019). Early diagnosis reduces the risk of developing various psychiatric conditions. On the other hand, delays in diagnosis are linked to heightened psychiatric comorbidity (Rim et al., 2023). Those diagnosed later in life often experience higher rates of depression, self-harm, and suicidality (Hosozawa et al., 2020).

This highlights that early and correct identification of autism—and other forms of neurodivergence—is vital. It serves as a protective factor. When we cannot recognise these neurotypes, the potential harm is significant. We, as psychologists, must ensure our assessments are evidence-based, culturally sensitive, and attuned to the diverse presentations of autism and ADHD. Misidentification or failure to identify can lead to inappropriate treatments, increased distress, and lost access to essential supports.

For those looking to improve their diagnostic skills, ADHD and autism assessment training is necessary for thorough, affirming assessments aligned with the latest research.

Understanding Misdiagnosis and Underdiagnosis

The most pressing ethical issue in autism and ADHD assessments is not overdiagnosis, but misdiagnosis and underdiagnosis. Many individuals receive incorrect labels. Some common misdiagnoses include:

• Anxiety disorders: mistaken when sensory overload is the underlying issue.

• Personality disorders: often misinterpret lifelong traits of autism or ADHD, particularly in trauma backgrounds.

• Bipolar disorder: mood shifts linked to emotional dysregulation in ADHD are overlooked.

• Oppositional Defiant Disorder (ODD): issues with transitions or authority may stem from executive dysfunction, sensory challenges, or the need for consistency.

  
  

Underdiagnosis disproportionately affects certain groups:

• Women and AFAB individuals: Often mask their struggles, making them go unnoticed.

• Individuals with high IQs: May compensate for executive dysfunction in structured settings.

• Culturally diverse individuals: Traits might be misinterpreted due to different social norms.

  
  

The Ethical Responsibility of Psychologists in Assessments

Psychologists play a crucial role in accurate identification and support for neurodivergent individuals. Ethical assessment practices should prioritise:

1. Emphasising a Neurodiversity-Affirming Framework

A neurodiversity-affirming framework recognises that autism and ADHD are natural variations in human experience. These are not deficits or disorders needing “fixing.” In this approach, assessment focuses on identifying both needs and strengths that support well-being.

From late 2025, AHPRA will introduce new competencies for psychologists. Competency 7 requires practice from a neurodiversity-affirming perspective. This will no longer be optional; it's foundational for ethical psychological practice.

What does this assessment look like?

• Avoiding pathologising language: Frame autism and ADHD as differences rather than disorders, moving away from negative descriptors.

• Recognising strengths alongside challenges: A neutral stance acknowledges both disabling aspects and the individual’s strengths.

• Prioritising internal experience: Assessments often prioritise observable behaviour. It’s essential to consider feelings, thoughts, and internal experiences.

• Taking a collaborative approach: The client is the expert on their life. Their input honors their experience and prevents clinician bias.

• Creating supportive environments: Adjustments for sensory needs—such as low lighting and movement breaks—should be standard to reduce cognitive load.

  
  

2. Utilising Comprehensive, Evidence-Based Assessment Methods

A complete assessment should integrate both quantitative and qualitative data. Key components include:

• In-depth clinical interviews: Structured tools, like the DIVA-5 for ADHD and MIGDAS-2 for autism, should be adaptable for nuanced presentations.

• Developmental history: Early behaviours, sensory sensitivities, and communication styles must be considered. Often, traits hide over time and emerge through deeper exploration.

• Input from multiple sources: Family, friends, and teachers can provide valuable context, but third-party input should not gatekeep diagnosis, especially for adults.

• Qualitative data collection: Sensory profiles, executive functioning assessments, and open-ended interviews reveal unique experiences.

  
  

Standardised assessments often miss individuals with internalised or atypical autism and ADHD presentations. Incorporating qualitative data is essential for a comprehensive diagnosis.

💡 If you provide single-service assessments, implement a robust intake process. I recommend using intake questionnaires informed by current research to capture nuance effectively.

You can explore my intake forms—they are editable, easy to use, and focused on nuanced assessments.

Autism Diagnostic Intake Questionnaire Bundle

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ADHD Diagnostic Intake Questionnaire Bundle

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3. Avoiding Bias in the Diagnostic Process

Ethical assessment requires psychologists to recognise and minimise bias. Remember to:

• Acknowledge diagnostic limitations: Many criteria are normed on primarily white, young males, leading to under-diagnosis of women and CALD communities.

• Avoid outdated markers: Traits like the presence or absence of eye contact, or your client appearing socially capable are not reliable indicators.

• Challenge confirmation bias: Stay open—a diagnosis shouldn't be ruled out based on your observations alone.

  
  

Our understanding of autism and ADHD, especially in high-masking individuals, has evolved. As clinicians, our ethical duty is to remain updated with the latest research and frameworks. If you haven't reviewed your approach recently, now is the time.

4. Accessibility and Cultural Sensitivity

Neurodiversity-affirming assessments must be accessible and culturally sensitive.

• Adapt tools for language and communication styles.

• Utilise clear, literal language to explain diagnostic procedures.

• Consider intersectionality: A client’s neurodivergent experience will be influenced by various factors, including race, gender, and socioeconomic status.

  
  

When assessments honor neurodivergence and individual experiences, they create safer paths for identification and support.

How ADHD and Autism Assessment Training Can Improve Ethical Practice

To enhance diagnostic accuracy and integrity, psychologists must prioritise quality training.

ADHD and autism assessment training should cover topics such as:

• Distinguishing autism from ADHD and related conditions.

• Recognising masked or internalised presentations.

• Using neurodiversity-affirming language.

• Navigating diagnostic nuances for high-IQ individuals.

• Conducting culturally responsive assessments.

• Building comprehensive, flexible diagnostic processes.

  
  

My Autism and ADHD Assessment Training equips clinicians with the tools to accurately identify neurodivergence, reduce bias, and uphold ethical standards.

Final Thoughts

Misdiagnosis and underdiagnosis of ADHD and autism pose ongoing ethical challenges in clinical practice. Psychologists must proactively refine their assessment skills, ensuring everyone receives an accurate and affirming diagnosis.

For clinicians eager to enhance their skills, autism and ADHD assessment training is essential.

Ready to refine your assessment approach? Explore my Autism and ADHD Assessment Training here and elevate your practice to new heights.

References

• Hosozawa, M., Sacker, A., & Cable, N. (2021). Timing of diagnosis, depression and self-harm in adolescents with autism spectrum disorder. Autism, 25(1), 70–78. https://doi.org/10.1177/1362361320945540

• Kelly, C., Sharma, S., Jieman, A. T., & Ramon, S. (2022). Sense-making narratives of autistic women diagnosed in adulthood: A systematic review of the qualitative research. Disability & Society, 39(3), 663–695. https://doi.org/10.1080/09687599.2022.2076582

• Rim, S. J., Kwak, K., & Park, S. (2023). Risk of psychiatric comorbidity with autism spectrum disorder and its association with diagnosis timing using a nationally representative cohort. Research in Autism Spectrum Disorders, 104, 102134. https://doi.org/10.1016/j.rasd.2023.102134

• Stagg, S. D., & Belcher, H. (2019). Living with autism without knowing: Receiving a diagnosis in later life. Health Psychology and Behavioral Medicine, 7(1), 348–361. https://doi.org/10.1080/21642850.2019.1684920