This article first appeared as a discussion post in PSY303, Abnormal Psychology, at the University of Arizona Global Campus, January 21,2022.
Comparing Autism Spectrum Disorder and Conduct Disorder
Disclaimer: I am autistic and also have ADHD, GAD, and MDD. Six of my eight children are also autistic, each in their own way, ranging from “I had no idea he was autistic” to non-verbal and developmentally delayed. As a lived experience, autism is completely different from what is read in the DSM-V. If you are planning on working with autistic people as a course of your professional (or personal) life, I strongly encourage you to get to know us directly before deciding what we are and how to deal with us.
Autism Spectrum Disorder
Autism is a neurodevelopmental condition that is defined in the DSM-V as having persistent social and communication difficulties; repetitive behaviors and routines; restricted and fixated interests; and altered sensory reception (hyper- or hyposensitivity to environmental stimuli) (American Psychiatric Association, 2013). Affecting approximately 1 in 57 children, it is typically observable from early childhood on and does not resolve with age, though it does evolve in presentation. Autism is clinically diagnosed according to the level of support that an individual requires, from basic to very substantial support. Autistic individuals may exhibit a wide range of communication behaviors, from non-verbal to echolalic to independently novel speech, and their intellectual capacity may range from impaired to extraordinary, though they tend to have areas of specialized knowledge and uneven distribution of competencies.
Recent research has cast enormous doubt on a number of clinical assumptions regarding autism. One in particular is the theory of mind (ToM) approach, suggesting that people with autism are incapable of empathy, relating to another person’s perspective (Getzfeld, 2018); this is patently false. There is no empirical proof that such a claim is true (Gernsbacher & Yergeau, 2019), and as Holt et al. point out (2021), this supposition is based on motivated observation and not in any way on phenomenological studies or insider perspectives – as in, input from actual autistic people. This lack of involvement of autistics in autism research is not uncommon: Simon Baren-Cohen developed the Autism Quotient (AQ) test, one of the most widely used tools for clinical assessment, but it has shown questionable validity and application (English et al., 2020; Fusar-Poli et al., 2020). Its weakness is obvious from the poor wording and overly generalized questions – critical failures of a tool meant to measure people prone to being literal-minded and favoring semantic specificity (Vance, 2020). Keep these considerations in mind as you explore the diagnosis and support options for autism.
Conduct Disorder (Antisocial Personality Disorder for Kids)
Mostly simply, the DSM-V describes conduct disorder (CD) as a minor-aged person engaging in antisocial behaviors (violence, disregard for rules and guidelines, violation of others’ persons or property) without demonstrating remorse or regret (American Psychiatric Association, 2013). CD affects around 3% of children, has a high comorbidity rate with ADHD, and seems to have diasthesis-stress etiology with both genetic and environmental factors affecting its development and long-term prognosis. Notable structural neurological impairments are also common, including reduced grey matter in the limbic regions; abnormalities in circuits relating to emotional processing and regulation; and hyporeactivity to stress in autonomic systems (Bayard et al., 2020; Fairchild et al., 2019). Lower socioeconomic status, being a minority, and experiencing abuse or neglect as a child all contribute to significantly higher rates of diagnosis as well as extending the diagnosis into antisocial personality disorder as an adult (Patel et al., 2018; Sagar et al., 2019).
What is the difference between a kid who’s acting out from stress and a kid who legitimately warrants a CD diagnosis? Neurology is the largest component, though the full etiology paints a highly complex picture. Paternal psychiatric disorders and low SES are highly predictive of CD (Salmanian et al., 2021), as are early childhood environments rife with harsh punishment, both from parents and schools (Goulter et al., 2020). People with PTSD derived from multiple events or circumstances also show a higher prevalence of CD (Bernhard et al., 2018). Without sufficient intervention, CD also predisposes a child or adolescent to have earlier and more severe criminal behavior patterns, especially violent crimes (DeLisi et al., 2018; Whipp et al., 2019), and PTSD is also notable comorbidity in prison populations (Facer-Irwin et al., 2019). We can surmise from this that CD is a neurodevelopmental potentiality that is a triggered by high-stress and traumatic events, which suggests that neurochemical, psychotherapeutic, and social service support all together might provide relief with early interventions.
Comparing Autism and Conduct Disorder
I chose to examine these two presentations to illustrate that observation alone is absolute rubbish in terms of clinical validity, and additionally that the preference for behaviorism as a basis for diagnosis and treatment is often deleterious to the individual. Specifically, each of these diagnoses is marked by “a lack of empathy for others,” but only one of them is based on empirical and demonstrable evidence to support that statement. Even at that, the term “lack of empathy” belies the complexity of what empathy is or could be. In a 2019 discussion, experts pointed out that using the term “empathy” in a clinical setting is more often than not misleading. Ideas like “compassion” were far more appropriate in many circumstance, and a critical differentiation has to be made between affective empathy (experiencing someone else’s emotional state) and cognitive empathy (recognizing intellectually what their emotional state is). Compassion was described as a form of cognitive empathy that triggered a motivation to soothe, and this is something that autistic people actually tend to excel at (Nicolaidis et al., 2019).
The more salient point that I’d like to make is that “lack of empathy” is often confounded with “refusal to empathize,” confusing practical inability with conscious decision. As I’ve already stated multiple times, the greatest weaknesses of psychological diagnostic programmes are the purely subjective application of observational criteria and the underlying moralistic judgment against “abnormal” presentations.
As Promised: the Soapbox
First, Autism Speaks does NOT speak for us (Hughes, 2015; Willingham, 2013). They are an exploitative organization that ignores the agency and capacity of autistic people, and their focus on a “cure” and “awareness” – but not acceptance or practical research – is a constant reminder of how little regard they have for us (Henkel, 2016; Luterman, 2020). Having an autistic child can be rough, no doubt, but it’s not a tragedy to be bemoaned and mourned (Jackson, 2021). It’s not a life sentence of hell, and it’s not the end of the world. You know what makes raising an autistic kid hard? People who think you’re tragic and treat you with pity instead of compassion.
Next, applied behavior analysis (ABA) is literal torture. It’s dehumanizing, degrading, and traumatizing (Kupferstein, 2019). If you are unaware, in its most basic format, ABA focuses on “training” autistics out of “socially unacceptable” behaviors, such as stimming and redirected attention, using a system of reward and denial. Because the focus is exclusively on behaviors and not at all on the inner process of the mind, the functional value of stimming is lost and autistics are forced to engage in behavior that is unnatural to them and thus enormously distressing (“Problematic and Traumatic,” 2020). Adult autistics are speaking out in droves at how much damage ABA has done, and even with recent attempts to improve on it, the premise is still insulting (McGill & Robinson, 2020; Meyer, 2020; Restless Hands, 2021). Autistic people are far more prone to develop PTSD because of how we’re wired (Rumball et al., 2020), and ABA is evidenced to create a completely unnecessary traumatic opportunity (Kupferstein, 2018) that we not only have to live with for the rest of our lives but is objectively harder to treat, leading to a higher prevalence of addictive and long-term psychiatric disorders, including substance abuse and suicidality (Anderson & Catallozzi, 2021; Castellanos et al., 2020; Khan et al., 2019; Kunreuther, 2021). There are current reviews into the bioethics of ABA, and it’s not looking good (Wilkenfeld & McCarthy, 2020).
Here’s the bottom line about ABA: it’s applied behavior analysis to a problem that isn’t a behavior. Autism is a neurodevelopmental variation that can express itself in a wide range of ways. The behaviors that are observed are not a means of external communication as they are with neurotypical people (especially children); they are not derived from modeling and emulation. They are the physical expression of purely internal experiences. More importantly, most of the behaviors that autistics exhibit are adaptive and beneficial. As examples:
- Humming moderates auditory processing sensitivity.
- Tapping and flapping moderates excessive neural feedback sensations.
- Echolalia and using quotes substitutes for original phrasing when experiencing language dysfunction.
- Organizing things into systems (lining up cars, arranging things on shelves) provides a point of reference to make sense of disordered visual stimulation.
When these things become extreme – headbanging instead of flapping, screaming instead of humming, etc. – it’s because emotions, external stimuli, or mental processes are exceeding their capacity to regulate with regular stimming activity. Intervention should include dispelling the sensory overload (deep-body squeezes, a hiding under a dark blanket, etc.) according to the overloaded person’s signals. You know what doesn’t work to help an autistic through that moment? Taking away the iPad. Withholding a treat. Ignoring them until they “behave.”
ABA is a huge industry right now, but its foundation is fundamentally flawed and bigoted. It stems from the same kind of prejudice that inspired Whats-his-name to suggest that vaccines cause autism. That is to say, autism is so poorly understood and so vilified as an “othering” condition that people who buy into this kind of toxic rhetoric would rather have a dead kid than an autistic one, or a quiet-yet-traumatized child than a happy-but-weird one. It’s not about the kid being happy in the long run or having a successful life, because if it was, they would have asked us what makes us happy. We’ve been left out of our own equation, and we would very much like that to stop, please.
Finally, we are not puzzles or mysteries. We’re humans who see things and experience things differently – sometimes very differently. That doesn’t make us less-than or more-than, it’s just different. And there’s nothing wrong with that.
Yes, people with extreme autism presentations need extra support and help, and even so-called “high functioning” auties often require a different environment than neurotypicals in order to thrive. However, there are lots of excellent support systems and excellent therapies that aren’t ABA. Always start with getting to know your autie for themselves instead of merely as their diagnosis. When you’ve met one autistic person, you’ve met one autistic person. Even in our shared diagnosis, we have a brilliant diversity to explore.
American Psychiatric Association. (2013). Disruptive, impulse-control, and conduct disorders. In Diagnostic and statistical manual of mental disorders (5th ed., pp. 495–514). American Psychiatric Pub. https://doi.org/10.1176/appi.books.9780890425596
American Psychiatric Association. (2013). Neurodevelopmental disorders. In Diagnostic and statistical manual of mental disorders (5th ed., pp. 69–124). American Psychiatric Pub. https://doi.org/10.1176/appi.books.9780890425596
Anderson, S. A. R., & Catallozzi, M. (2021). Autism spectrum disorder and the risk of substance use disorder: A call for targeted screening and prevention in adolescents. JAMA Pediatrics, 175(2), e205376. https://doi.org/10.1001/jamapediatrics.2020.5376
Bayard, F., Nymberg Thunell, C., Abé, C., Almeida, R., Banaschewski, T., Barker, G., Bokde, A. L. W., Bromberg, U., Büchel, C., Quinlan, E. B., Desrivières, S., Flor, H., Frouin, V., Garavan, H., Gowland, P., Heinz, A., Ittermann, B., Martinot, J.-L., Martinot, M.-L. P., … Petrovic, P. (2020). Distinct brain structure and behavior related to ADHD and conduct disorder traits. Molecular Psychiatry, 25(11), 3020–3033. https://doi.org/10.1038/s41380-018-0202-6
Bernhard, A., Martinelli, A., Ackermann, K., Saure, D., & Freitag, C. M. (2018). Association of trauma, Posttraumatic Stress Disorder and Conduct Disorder: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 91, 153–169. https://doi.org/10.1016/j.neubiorev.2016.12.019
Castellanos, D., Carcache, L., & Ng, C. (2020). Substance use in youth with autism spectrum disorder. Addictive Disorders & Their Treatment, 19(2), 118–122. https://doi.org/10.1097/ADT.0000000000000192
DeLisi, M., Drury, A. J., Caropreso, D., Heinrichs, T., Tahja, K. N., & Elbert, M. J. (2018). Antisocial personality disorder with or without antecedent conduct disorder: The differences are psychiatric and paraphilic. Criminal Justice and Behavior, 45(6), 902–917. https://doi.org/10.1177/0093854818765593
English, M. C. W., Gignac, G. E., Visser, T. A. W., Whitehouse, A. J. O., & Maybery, M. T. (2020). A comprehensive psychometric analysis of autism-spectrum quotient factor models using two large samples: Model recommendations and the influence of divergent traits on total-scale scores. Autism Research, 13(1), 45–60. https://doi.org/10.1002/aur.2198
Facer-Irwin, E., Blackwood, N. J., Bird, A., Dickson, H., McGlade, D., Alves-Costa, F., & MacManus, D. (2019). PTSD in prison settings: A systematic review and meta-analysis of comorbid mental disorders and problematic behaviours. PLOS ONE, 14(9), e0222407. https://doi.org/10.1371/journal.pone.0222407
Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., Freitag, C. M., & De Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 1–25. https://doi.org/10.1038/s41572-019-0095-y
Fusar-Poli, L., Ciancio, A., Gabbiadini, A., Meo, V., Patania, F., Rodolico, A., Saitta, G., Vozza, L., Petralia, A., Signorelli, M. S., & Aguglia, E. (2020). Self-reported autistic traits using the AQ: A comparison between individuals with ASD, psychosis, and non-clinical controls. Brain Sciences, 10(5), 291. https://doi.org/10.3390/brainsci10050291
Gernsbacher, M. A., & Yergeau, M. (2019). Empirical failures of the claim that autistic people lack a theory of mind. Archives of Scientific Psychology, 7(1), 102–118. https://doi.org/10.1037/arc0000067
Getzfeld, A. R. (2018). 11: Neurodevelopmental disorders. In Abnormal psychology (2nd ed.). Bridgepoint Education.
Goulter, N., McMahon, R. J., Pasalich, D. S., & Dodge, K. A. (2020). Indirect effects of early parenting on adult antisocial outcomes via adolescent conduct disorder symptoms and callous-unemotional traits. Journal of Clinical Child & Adolescent Psychology, 49(6), 930–942. https://doi.org/10.1080/15374416.2019.1613999
Henkel, D. (2016, April 5). 7 Reasons To Not Support Autism Speaks. The Odyssey Online. http://theodysseyonline.com/pitt/7-reasons-not-support-autism-speaks/385861
Holt, A., Bounekhla, K., Welch, C., & Polatajko, H. (2021). “Unheard minds, again and again”: Autistic insider perspectives and theory of mind. Disability and Rehabilitation, 0(0), 1–11. https://doi.org/10.1080/09638288.2021.1949052
Hughes, V. (2015, February 23). Autistic people spark twitter fight against Autism Speaks. BuzzFeed News. https://www.buzzfeednews.com/article/virginiahughes/autistic-people-spark-twitter-fight-against-autism-speaks
Jackson, J. (2021, April 19). Autism ‘awareness’ and Autism Speaks are misleading. The Scribe UCCS Student Newspaper. https://scribe.uccs.edu/opinion-autism-awareness-and-autism-speaks-are-misleading/
Khan, S., Qayyum, R., & Iqbal, J. (2019). Prevalence of autism spectrum disorders (ASD) and attention deficit hyperactivity disorders (ADHD) among adult psych. PAFMJ, 69(2), 419–423. https://pafmj.org/index.php/PAFMJ/article/view/2766
Kunreuther, E. (2021). Autism spectrum disorder and substance use disorder: A dual diagnosis hiding in plain sight. Psychiatric Clinics, 44(1), 35–49. https://doi.org/10.1016/j.psc.2020.11.004
Kupferstein, H. (2018). Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis. Advances in Autism, 4(1), 19–29. https://doi.org/10.1108/AIA-08-2017-0016
Kupferstein, H. (2019). Why caregivers discontinue applied behavior analysis (ABA) and choose communication-based autism interventions. Advances in Autism, 6(1), 72–80. https://doi.org/10.1108/AIA-02-2019-0004
Luterman, S. (2020, February 14). Perspective | The biggest autism advocacy group is still failing too many autistic people. Washington Post. https://www.washingtonpost.com/outlook/2020/02/14/biggest-autism-advocacy-group-is-still-failing-too-many-autistic-people/
McGill, O., & Robinson, A. (2020). “Recalling hidden harms”: Autistic experiences of childhood applied behavioural analysis (ABA). Advances in Autism. https://doi.org/10.1108/AIA-04-2020-0025
Meyer, S. (2020, August 31). Another post: What’s wrong with modern ABA? Medium. https://sara-meyer-1989.medium.com/another-post-whats-wrong-with-modern-aba-ae3712f7d37
Nicolaidis, C., Milton, D., Sasson, N. J., Sheppard, E. (Lizzy), & Yergeau, M. (2019). An expert discussion on autism and empathy. Autism in Adulthood, 1(1), 4–11. https://doi.org/10.1089/aut.2018.29000.cjn
Patel, R. S., Amaravadi, N., Bhullar, H., Lekireddy, J., & Win, H. (2018). Understanding the demographic predictors and associated comorbidities in children hospitalized with conduct disorder. Behavioral Sciences, 8(9), 80. https://doi.org/10.3390/bs8090080
Problematic and traumatic: Why nobody needs ABA. (2020, April 14). Autistic Self-Advocates Against ABA. https://autisticselfadvocatesagainstaba.wordpress.com/2020/04/13/problematic-and-traumatic-why-nobody-needs-aba/
Restless Hands. (2021, October 29). What’s wrong with “better” ABA? Restless Hands. https://restlesshands42.wordpress.com/2021/10/29/whats-wrong-with-better-aba/
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
Sagar, R., Patra, B. N., & Patil, V. (2019). Clinical Practice Guidelines for the management of conduct disorder. Indian Journal of Psychiatry, 61(Suppl 2), 270–276. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_539_18
Salmanian, M., Mohammadi, M. R., Hooshyari, Z., Ahmadi, N., Khaleghi, A., & Alavi, S. S. (2021). The relationship between conduct disorder and parents’ psychiatric disorders, social capital, lifestyle, and comorbid disorders: A structural equation modeling study. Current Psychology. https://doi.org/10.1007/s12144-021-02229-x
Vance, T. (2020, May 10). Autistic people react to the Autism Spectrum Quotient (AQ) test. NeuroClastic. https://neuroclastic.com/autistic-people-react-to-the-autism-spectrum-quotient-aq-test/
Whipp, A. M., Korhonen, T., Raevuori, A., Heikkilä, K., Pulkkinen, L., Rose, R. J., Kaprio, J., & Vuoksimaa, E. (2019). Early adolescent aggression predicts antisocial personality disorder in young adults: A population-based study. European Child & Adolescent Psychiatry, 28(3), 341–350. https://doi.org/10.1007/s00787-018-1198-9
Wilkenfeld, D. A., & McCarthy, A. M. (2020). Ethical Concerns with Applied Behavior Analysis for Autism Spectrum “Disorder.” Kennedy Institute of Ethics Journal, 30(1), 31–69. https://doi.org/10.1353/ken.2020.0000
Willingham, E. (2013, November 13). Why Autism Speaks doesn’t speak for me. Forbes. https://www.forbes.com/sites/emilywillingham/2013/11/13/why-autism-speaks-doesnt-speak-for-me/