“Both/And” - Neurodivergence as Culture: Why Autism, ADHD, and AuDHD Belong in Cultural Competence Frameworks

Allie Hoyt, LCMHCA

Let me be the first to say, I am no expert.

Throughout my time in this world and my time as a counselor in training, I have learned the importance of listening first. Of working to take off the glasses I see the world through as much as I can, and beginning to see the world that I have been entrusted to enter into through the client’s eyes.

Yes, I am an AuDHDer. And with that comes lived experience.

There is no question that being an AuDHD clinician comes into the room with me, as the way my brain works and sees the world is not something I turn off when I “clock in” as the counselor.

While, I ardently attempt to take my glasses off of what it means to be “Allie the AuDHDer” and work to learn about what it means to see the world through the client’s eyes, I know am not the expert of their life and experience, and that I can never truly 100% take off my own glasses. Through profound supervision, consultation, ethical decision making models, and self reflection I am able to recognize more when my glasses are still on, even as they are sliding down the bridge of my nose. 

In holding both truths, that is-being an AuDHD person and clinician, I have wrestled with which glasses I am wearing when I see the critical need for nuance in Neuro-Affirming care. While I don't have an exact breakdown of which lens each eye is looking through, I have been able to deduce that it can be a “both and”, that I see a gap-a critical need conceptualized by my lived experience and furthered through the clinical role I have worked in, cataloged by my time in academia, clinical practice, and life. 

Beyond Diagnosis: The Limits of a Diagnostic Lens

Autism, ADHD, and AuDHD are often introduced in academic settings, counselor education programs, and counseling departments through a diagnostic lens. Future clinicians may be trained in exploring DSM criteria, symptom clusters, differential diagnosis, diagnostic specifiers, as well as ways to implement evidence-based interventions and engage in profound self-reflection. These facets of counselor education are crucial, and are spaces where programs and counselors alike can truly excel.

And behind the diagnostic codes and case conceptualizations are people.

As conversations surrounding neurodiversity-affirming care and neurodiversity-informed counseling continue to grow, many clinicians are recognizing that diagnostic information may be insufficient on its own. Understanding Autism, ADHD, and AuDHD requires not only clinical knowledge, but also an appreciation for identity, culture, environment, and lived experience.

Autism, ADHD, and AuDHD are often introduced in academic settings and counseling departments through a diagnostic lens. Future clinicians may be trained in exploring the DSM criteria, symptom clusters, differential diagnosis, diagnostic specifiers, as well as ways to implement evidence-based interventions and engage in profound self reflection. These facets of counselor education are crucial, and are spaces where programs and counselors alike can truly excel. And, behind the diagnostic codes and case conceptualizations are people, and diagnostic information may be insufficient on its own. 

Neurodivergence as Identity, Culture, and Lived Experience

In truly listening to Autistic, ADHD, and AuDHD voices, time and time again the concept of identity comes up. Whether that be in academic journals or trainings or content creation or books or theoretical models, when we listen to the experts (that is the people we are wanting to advocate with and support), we learn that diagnostic criteria may not always be enough. For many, what it means to be Autistic, ADHD, and AuDHD is not limited to the newest iteration of the DSM, but also encompasses:

• A lived identity (Jones et al. ,2024) & (Fuld & McKelvie, 2024)

• A marginalized neurotype

• A cultural experience shaped by systems

• A group disproportionately impacted by trauma and suicide (Miller at al, 2021).

  
  

When these identities are treated solely as pathology, clinicians are trained to focus on symptom reduction rather than systemic context, identity development, or environmental impacts. This can narrow care, and can reinforce neuronormativity and compliance. When we hold one way of being, one neurotype, one brain structure, one “ideal” way to go through the world as the “best or better” way of being, whether that is overt or covert, intentional or unintentional, we reinforce the same harmful systems our profession has been tasked with undoing and rebuilding (Bolton, 2023) & (Chapman & Botha, 2023). 

Why Neurodivergence Belongs in Cultural Competence

Integrating Autistic, ADHD, and AuDHD identities into cultural competence frameworks is essential because:

1. Mental health disparities are well documented. 

Autistic and ADHD individuals experience elevated rates of suicidality and PTSD, with these outcomes not inherent to neurotype completely but also substantiated by chronic invalidation, masking pressure, and systemic exclusion (Miller at al., 2021); (Rumball et al., 2020); (Haruvi-Lamdan et al.,2020).

2. Cultural competence requires understanding power, privilege, and oppression. 

Neurodivergent individuals navigate systems designed for neurotypical processing. Educational, medical, and workplace environments can demand compliance over accommodation. This can often create cumulative stress and trauma exposure.

3. Clinical harm can occur unintentionally. 

When therapy centers normalization, behavior suppression, or compliance-based goals, it can replicate invalidating experiences clients have experienced elsewhere. Safety in the therapy room must be intentionally created.

4. Identity affirmation is protective.

 Research increasingly supports that identity-affirming care is associated with improved mental health outcomes, including reductions in depression and suicidality  (Kroll et al., 2024). 

At minimum, integrating this framework allows the clinician to engage in reflection-something clinicians alike have likely engaged with throughout their tenure in academia through countless reflection papers, prompts, and projects. Reflection on cultural experiences, implicit neuronormative assumptions, and expansion of conceptual flexibility. This is a chance for clinicians to flex a muscle, to stay active and intentional with the imperative we have of lifelong learning and of humility, knowing that we cannot and will not know everything, but that it is our responsibility to seek out and learn what we can. The impact of this reflection however, rarely stops there for clinicians and clients alike, as this framework can drastically improve positive outcomes, reduce shame, and increase belonging and connection. Truthfully, it has the potential to save lives. 

In other words, there is little clinical harm in approaching neuro-informed perspectives with humility, nuance, and structural/systemic awareness. There is, however, documented harm in failing to do so.

It is so critically important to acknowledge that as neurodiversity discourse becomes more visible, some narratives have been vastly amplified over than others. Conversations often center white, low-support-needs voices in cisgender bodies. That harm deserves attention and critique.

The solution is not to dismiss neuro-affirming practice; it is to broaden it. Cultural competence in neurodivergence must include:

• BIPOC neurodivergent experiences

• Individuals with higher support needs

• Non-speaking individuals

• Economically marginalized populations

• Intersectional identities and multiply marginalized individuals 

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When a population has elevated suicide risk, higher trauma exposure, and consistent reports of invalidating care, counselors are ethically obligated to respond.

This is about clinical ethics.

Integrating neurodivergence into cultural competence is not an abandonment of clinical rigor. It is an expansion of it.

It asks us to hold both, something clinicians are tasked with doing on a daily basis. To hold multiple truths, to infuse dialectics into practice, to recognize that the human experience may not be describable only by DSM criteria, severity scales, and ICD codes. This asks clinicians to do what mant of us may ask our clients to do in session, to switch “but” for “and”, and to hold both diagnostic knowledge and sociocultural/systemic awareness. 

It does not reject the medical model; it contextualizes it. And in a field that is often described as being one of “high context”, this has the possibility to support that definition. 

Ultimately, the question is not whether Autism, ADHD, and AuDHD “belongs” in cultural competence frameworks.

The question is whether we can ethically justify excluding folks with documented disparities from these frameworks, furthered by the substantial research breadth and literature to support increased client health and wellness when neuro-informed and neuro-affirming perspectives are integrated. 

Whether we can ethically justify excluding folks with documented harm from frameworks that not only reduce harm, but also increase health, wellness, and healing, 

Holistic care requires both evidence and empathy. Neuro-affirming practice offers the potential for both.

References

Bolton, M. J. (2023). De-centering neuronormativity is an imperative in humanistic psychotherapy: Towards a neurodiversity-informed, person-centered approach. The Person-Centered Journal. https://doi.org/10.31234/osf.io/q2t8h

Chapman, R., & Botha, M. (2023). Neurodivergence-informed therapy. Developmental Medicine and Child Neurology, 65(3), 310–317. https://doi.org/10.1111/dmcn.15384

Fuld, S., & McKelvie, M. R. (2024). A perspective on neurodivergent‐affirming relational practice: Exploration of identity and the healing process. Counselling and Psychotherapy Research. Advance online publication. https://doi.org/10.1002/capr.12792

Haruvi-Lamdan, N., Horesh, D., Zohar, S., Kraus, M., & Golan, O. (2020). Autism spectrum disorder and post-traumatic stress disorder: An unexplored co-occurrence of conditions. Autism, 24(4), 884–898. https://doi.org/10.1177/1362361320912143

Jones, F., Hamilton, J., & Kargas, N. (2024). Accessibility and affirmation in counselling: An exploration into neurodivergent clients’ experiences. Counselling and Psychotherapy Research. Advance online publication. https://doi.org/10.1002/capr.12742

Kroll, E., Lederman, M., Kohlmeier, J., Kumar, K., Ballard, J., Zant, I., & Fenkel, C. (2024). The positive impact of identity-affirming mental health treatment for neurodivergent individuals. Frontiers in Psychology, 15, Article 1403129. https://doi.org/10.3389/fpsyg.2024.1403129

Miller, D., Rees, J., & Pearson, A. (2021). “Masking is life”: Experiences of masking in autistic and nonautistic adults. Autism in adulthood, 3(4), 330–338. https://doi.org/10.1089/aut.2020.0083

Rumball, F., Happé, F., & Grey, N. (2020). Experience of trauma and PTSD symptoms in autistic adults: Risk of PTSD development following DSM-5 and non-DSM-5 traumatic life events. Autism Research, 13(12), 2122–2132. https://doi.org/10.1002/aur.2306