From Pathology to Identity: Why the DSM Must Evolve to Reflect Neurodivergent Realities
Bridgette Hamstead
For decades, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has served as the primary framework for how neurodivergence is classified and understood in the fields of psychology and psychiatry. Autism, ADHD, dyslexia, and other neurodivergent conditions have historically been framed as disorders—pathological deviations from a supposed norm, rather than natural variations in human cognition. This deficit-based model has profoundly shaped how neurodivergent individuals are diagnosed, treated, and perceived by society. However, the DSM’s continued reliance on outdated and stigmatizing language fails to reflect the lived realities of neurodivergent people. If the DSM is to remain relevant in an evolving discourse on neurodiversity, it must undergo fundamental changes to align with a strengths-based, identity-affirming approach that respects neurodivergent ways of being.
The Historical Roots of Pathologization
The DSM, first published in 1952, was designed as a classification system for mental disorders, drawing clear distinctions between what was considered "normal" and "abnormal" cognition and behavior. Over the years, the DSM has undergone multiple revisions, with shifting definitions of various neurodivergent conditions. Autism, for example, was once falsely attributed to poor parenting (“refrigerator mother” theory), and ADHD was often dismissed as a behavioral problem rather than a legitimate cognitive difference.
Though scientific understanding of neurodivergence has progressed, the DSM remains largely rooted in a pathology-based framework. The latest edition, the DSM-5-TR, continues to define autism and ADHD in terms of deficits—social communication deficits, executive function impairments, and maladaptive behaviors—rather than as natural cognitive differences that come with both strengths and challenges. This language reinforces a deficit mindset, which in turn influences public perception, education policies, employment accommodations, and access to healthcare services. Instead of helping neurodivergent individuals receive appropriate support, the DSM’s framing often contributes to stigma, discrimination, and unnecessary medicalization of neurodivergent experiences.
The Harmful Impact of the DSM’s Deficit-Based Model
The DSM’s deficit-based classification has real-world consequences. When neurodivergence is framed as a disorder rather than a legitimate cognitive identity, it influences everything from clinical treatment to social policies, often creating more harm than good.
Misdiagnosis and Underdiagnosis Many neurodivergent individuals, especially women, nonbinary people, and people of color, remain undiagnosed or misdiagnosed due to the DSM’s rigid criteria. The clinical presentation of autism and ADHD has historically been based on studies conducted on white cisgender boys, which has resulted in narrow diagnostic criteria that do not account for the diverse ways neurodivergence manifests. Women and people of color are often dismissed, their symptoms misunderstood as anxiety, depression, or behavioral issues rather than recognized as traits of autism or ADHD. Because the DSM describes neurodivergence in terms of observable deficits rather than underlying cognitive differences, clinicians often overlook individuals who do not fit the stereotypical presentation.
Barrier to Accommodations and Support Many legal and institutional frameworks rely on DSM diagnoses to determine whether a person is eligible for accommodations in school, the workplace, or healthcare settings. Because the DSM presents neurodivergence as a medical disorder rather than an identity, neurodivergent individuals often have to "prove" that they are disabled enough to deserve support. This results in gatekeeping that prevents many from accessing the help they need, particularly those who are highly masking or those with inconsistent levels of support needs.
Reinforcing Stigma and Internalized Ableism The DSM’s medicalized descriptions of neurodivergence contribute to the broader societal perception that being autistic or ADHD is inherently negative. Many neurodivergent individuals grow up feeling broken or defective because their cognitive styles are framed as disorders rather than as valid, diverse ways of thinking. This can lead to significant mental health struggles, including internalized ableism, anxiety, depression, and feelings of isolation. Shifting away from deficit-based language toward a more neutral and affirming framework can help neurodivergent individuals build a healthier sense of identity and self-worth.
What Needs to Change in the DSM
For the DSM to truly serve neurodivergent individuals rather than pathologizing them, it must undergo fundamental structural changes. These reforms should be guided by neurodivergent voices and based on the principles of the neurodiversity paradigm, which recognizes neurodivergence as part of human diversity rather than as a set of disorders that need fixing.
Reframing Neurodivergence as an Identity, Not a Disorder The DSM should shift its framing from disorder-based definitions to identity-affirming descriptions that acknowledge both the strengths and challenges of neurodivergence. Instead of listing only impairments, diagnostic criteria should describe the cognitive differences that define autism, ADHD, and other forms of neurodivergence, emphasizing how these differences interact with environmental barriers rather than positioning them as inherent deficits.
Incorporating a Social Model of Disability The DSM currently operates under a medical model of disability, which sees neurodivergence as something to be diagnosed and treated. Instead, it should adopt aspects of the social model of disability, which recognizes that much of the distress neurodivergent individuals experience is due to societal barriers rather than inherent flaws. If diagnostic criteria reflected the role of systemic inaccessibility—such as sensory-unfriendly environments, rigid social expectations, and lack of workplace accommodations—more holistic and affirming support could be developed.
Expanding and Diversifying Diagnostic Criteria The DSM must revise its criteria to include a broader and more inclusive understanding of neurodivergence. This means incorporating research on how autism and ADHD manifest in different genders, racial backgrounds, and cultural contexts. It also means listening to neurodivergent individuals and using their lived experiences to refine and expand diagnostic language, rather than relying solely on clinical observations made by neurotypical professionals.
Moving Away from Cure-Based Thinking Many interventions for autism and ADHD still operate under the assumption that the goal is to make neurodivergent individuals function more like their neurotypical peers. This is a direct result of the DSM’s pathology-based framework. Shifting away from cure-based thinking toward affirming, supportive interventions—such as teaching self-advocacy, providing assistive technologies, and making environments more accessible—should be the priority for mental health professionals moving forward.
Conclusion: A DSM That Reflects Neurodivergent Realities
The DSM, as it stands, is failing neurodivergent individuals by reinforcing outdated deficit-based models of diagnosis and treatment. If we truly want to support autistic, ADHD, and other neurodivergent people, we must move away from a framework that treats them as broken and in need of fixing. The future of neurodiversity advocacy depends on dismantling ableist medical models and replacing them with identity-affirming frameworks that recognize neurodivergence as a natural, valuable part of human diversity.
A DSM that reflects neurodivergent realities would not only improve the accuracy and accessibility of diagnoses but also empower neurodivergent individuals to embrace their identities without stigma. By centering neurodivergent voices, incorporating social and cultural perspectives, and rejecting the pathology-based approach, we can build a mental health system that truly serves the needs of neurodivergent people, rather than marginalizing them.