Opinion: Highly Sensitive Person (HSP) and Female Autism Are the Same In Some Cases

Sorry, Elaine Aron, but you could be wrong about this one.

Elaine Aron coined the term “Highly Sensitive Person” or HSP to describe someone with a unique cluster of emotional, physical, and sensory sensitivities.

Her description has led many to wonder about the similarities between HSPs and those on the autism spectrum. Aron’s responses appear to consider autism as it is traditionally portrayed, but do not show awareness of autism as it presents in women (aka the female autism phenotype) or in those who present in less obvious ways.

In fact, the description of someone who is Highly Sensitive sounds a lot like the description of what was formerly known as “high functioning autism” or “Asperger syndrome”. For this reason, the spread of information about HSPs could be one of several factors responsible for delayed diagnosis.

If someone believes they are an HSP or believes their child is an HSC (Highly Sensitive Child), they will assume that certain difficulties or problematic behaviours are related to the HSP trait and will be less likely to search for other answers — namely, an autism diagnosis.

According to Aron, those who are Highly Sensitive are more aware of subtleties in their surroundings, are easily overwhelmed, and are usually more comfortable alone than in large groups or crowds.

The “Are You Highly Sensitive?” checklist on Aron’s website includes items such as:

1. I am easily overwhelmed by strong sensory input.
2. Other people’s moods affect me.
3. I find myself needing to withdraw during busy days, into bed or into a darkened room or any place where I can have some privacy and relief from stimulation.
4. I am particularly sensitive to the effects of caffeine.
5. I am easily overwhelmed by things like bright lights, strong smells, coarse fabrics, or sirens close by.
6. I am deeply moved by the arts or music.
7. My nervous system sometimes feels so frazzled that I just have to go off by myself.
8. I get rattled when I have a lot to do in a short amount of time.
9. I am annoyed when people try to get me to do too many things at once.
10. I become unpleasantly aroused when a lot is going on around me.
11. Changes in my life shake me up.
12. I make it a high priority to arrange my life to avoid upsetting or overwhelming situations.

The checklists for women on the spectrum (see here and here) overlap on every single one of the 27 HSP checklist items.

The Invisible End of the Spectrum

Aron has clearly received a lot of questions, comments, and concerns about the similarities between the Highly Sensitive Person trait and autism spectrum disorder, including, she says, from “concerned parents” who suspect that their Highly Sensitive children might actually be autistic. She has written a FAQ section for this specific topic, where she seeks to explain reasons for the confusion:

Both HSCs and those with the [autism spectrum] disorder are bothered by overstimulation. Plus both may withdraw from social activities and stay in their rooms on the computers, watching movies, and so forth.

She then lists two autism symptoms from the DSM that are not, she claims, part of being Highly Sensitive: 1) highly restricted, fixated interests, and 2) hyper- or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment.

To present these symptoms in apparent contrast with HSP, she describes more classical or stereotypical presentations of autism — presentations that are decidedly more male. Autistic females or afabs (assigned female at birth) tend not to have as highly restricted or fixated interests as males. They tend to have broader interests that can come and go, and can include what most think of as regular or mainstream interests, like makeup, fine art, fashion, or celebrities.

At one point, Aron writes, “HSPs have intense imaginations and varied interests rather than narrow preoccupations” — a distinction that betrays an overused, outdated, and cliched view of autism.

“It is a gross misconception that people with Aspergers have no imagination,” writes Rudy Simone, the autistic author of Aspergirls. “A great number of writers, directors, artists, more inventive engineers are on the spectrum. … Psychologists who have observed kids with AS have labelled them as unimaginative, simply because they were not playing as society expects to see children play and have subsequently misunderstood what they’ve observed.”

Regarding hyper- or hypo-reactivity and the interpretation of social cues, Aron writes:

So those on the autistic spectrum have hyper reactivity, but also hypo reactivity at other times or in other situations. This is due to problems in properly processing information social and otherwise. They fail to sort it out, so it is all there, all the time, or totally shut out. In contrast, HSPs and HSCs process information very carefully. We can become overstimulated if there is too much for too long, but we do not become fixated in an extreme way or unable to shift to other stimuli according to the needs of the moment. Above all, we can read social cues, unless we are overaroused in the moment by being overstimulated. … Those with an ASD are always processing the wrong things and always experiencing chaos unless they are able to shut themselves off from the world entirely.

Autistic females tend to process social information more accurately than men on the spectrum, or at least they can become quite adept at navigating social situations, so again Aron is describing an outdated or classical male presentation of autism, and failing to address the full autism spectrum.

And as Tony Attwood, one of the world’s foremost autism experts, explains (after describing the top two ways that children with Asperger syndrome respond in social situations):

There’s a third group that’s not in the diagnostic criteria, which is how the girls [with Asperger syndrome] cope. … What she does is observe, analyze, and imitate — to fake it till you make it. She has a mask, a facade, that makes her highly successful in what she does [socially]…

This imitation is not done to purposely dupe or deceive, but is done as a means of fitting in. And since the girl begins this behaviour at a very young age, long before she is ever aware of autism or of the distinction between “neurodiverse” and “neurotypical,” she may assume that this is what all children must do to fit in.

This is what it must mean to belong. She may eventually learn that she is different somehow, but this will make her try even harder to “get it right.” So might begin a lifelong trend of pretending to be normal, of suppressing her true self, for fear that others will judge her as not one of them.

The Stereotypical View of Autism

Elaine Aron’s discussion of her grand-nephews, whom she misdiagnosed with HSP but later turned out to be autistic, is even more telling:

No one who loves a child or their parents would want to think about autism, even when the child in question will eat only exactly three kinds of food or is happy for twenty minutes merely watching a bicycle wheel spinning.

Aron’s conception of autism, at least as evidenced in the FAQ section of her website, does not reach beyond outdated, incomplete, and stereotypical views of autism (which also happen to be what most people think of when they think of autism).

Very few of those diagnosed with level 1 autism could relate to Aron’s description of her grand-nephews. Many “level 1” folks have behaviours and tendencies that are so close to “normal” that they are often misdiagnosed or undiagnosed for much of their lives. This is a particularly common experience for women on the spectrum.

In fact, it was once thought that the ratio of males to females with autism was 4:1. New research has shown that it’s actually closer to 2:1. The numbers may turn out to be more equal than that.

Elaine Aron succeeds in detailing the difference between the Highly Sensitive Person trait and what the DSM 5 would call level 2 or level 3 autism spectrum disorder (Note: the word “disorder” is quickly falling out of use, to be replaced formally in the future), but she neglects to consider that the HSP trait that she coined may describe elements of level 1 autism (formerly known as “high functioning” autism or “Asperger syndrome”).

Aron’s mistake is an understandable one, since research on the female autism phenotype is still in its infancy.