The Spectrum of Regulation: Why the DSM is Failing Our Neurodivergent Clients

There is a quiet revolution happening in the world of mental health, but if you look closely at the paperwork, it feels more like a bureaucratic traffic jam.

As a neurodivergent specialist, I look at my caseload and notice something undeniable: we are seeing a larger percentage of the population identifying as neurodivergent than perhaps at any point in human history. We see it in the profound wave of women finally receiving validation with ADHD diagnoses in their late 30s and 40s. We see it in the steady rise of young boys diagnosed with autism. Yet, the closer I look at these diagnoses, the more I find myself bumping up against the rigid boundaries of our current diagnostic bible, the DSM-5. In our clinical rush to put everyone into a neatly labeled box, are we actually doing our clients a disservice?

The legendary Temple Grandin once remarked that changing autism to a single, monolithic "spectrum" did people a disservice. There is a popular saying in our field: "If you’ve met one person with autism, you’ve met one person with autism." I believe that; but only to a point. The current DSM criteria for Autism Spectrum Disorder (ASD) have become so generic, (focusing broadly on communication issues, socialization challenges, and repetitive behaviors) that they can occasionally feel like a horoscope. Under a broad enough lens, these traits can apply to almost anyone experiencing developmental or modern life stress. By grouping Level 1, 2, and 3 needs under a single umbrella, the DSM flattens the nuance of human experience. It fails to distinguish between vastly different neurological realities, leaving us with a system that feels both overly broad and clinically restrictive.

Consider a child I recently observed in my practice. At home, he whines constantly at night, keeping both his mom and dad awake. Yet, when I shadowed him at school, he was remarkably, intensely quiet. If we look through a purely DSM-focused lens, it is easy to check the boxes: Is he masking his neurodivergence at school? Possibly. Is he experiencing social overwhelm? Maybe. Is he showing rigid behavioral patterns at home? It looks like it.

But when we step back and look at this child from a holistic mental health and developmental perspective, other possibilities emerge. Could this simply be severe anxiety? Could it be a deeply introverted child hitting a wall of sensory fatigue? Or is it a developmental difference that will naturally rectify and smooth out as his nervous system matures?

Instead of pathologizing him with a lifelong label, we implemented a practical, non-restrictive support system. We gave him a visual morning choice board so he has autonomy over his breakfast and activities, lowering his transition anxiety. We introduced playful social skills training. Most importantly, we focused on caregiver environmental modifications: training his parents to regulate their tone of voice, validate his intense emotions, and offer steady confidence statements. (This is where Applied Behavior Analysis (ABA) is extremely helpful; matching the functions of his behaviors, teaching him skills, creating systems of support. ) Yet, what it also means is matching his internal state of hyperarousal or hypoarousal, his hypersensitivity or hyposensitivity.Gradually, he is improving. He has started being more talkative at school, even though he still gives his parents a hard time at home. But am I expecting him to completely change? No. I want his personality to shine through.

What I have noticed continuously when I work both as a counselor and in neurodivergence is that to find the true common denominator across ADHD, Autism, AuDHD, and even generalized anxiety, we have to look to the field where Occupational Therapists (OTs) have excelled for decades: Sensory Regulation. OTs look at the world through the lens of hypo-sensitivity (under-responsiveness) and hyper-sensitivity (over-responsiveness). Of all the diagnostic criteria that overlap across various labels, I often think that sensory processing is the one true thread that connects them all.

Our current system struggles immensely with overlapping traits. Take the massive rise in people identifying with AuDHD (the unofficial, colloquial term for co-occurring Autism and ADHD). The DSM-5 only allowed doctors to dual-diagnose these two conditions starting in 2013. Before that, they were viewed as mutually exclusive. This brings up a fascinating question that I hope to research deeply in a future PhD: Why are so many more people feeling neurodivergent right now? And why are there so many overlapping traits? Why are people with ADHD more likely to have anxiety and eating disorders? Why are people with autism more likely to have sensory processing differences? Individuals with both Autism and ADHD often live in a state of internal contradiction: the ADHD side of their brain desperately craves novelty, dopamine, and change, while the autistic side mandates rigid routines, predictability, and order.

A number of years ago, Dr. Gabor Maté profoundly challenged the traditional medical model on this very topic. In his book on ADHD, Scattered Minds, Maté argues that ADHD is not a purely unchangeable genetic disease, but rather a product of our environment and early experiences. He notes that when an infant or young child experiences chronic stress, instability, or a lack of emotional attunement from caregivers, it can essentially "trap" the development of the prefrontal cortex and disrupt critical brain circuitry. Because the human brain develops its self-regulation systems through early relationships, environmental conditions can literally alter our neurobiology.

[ Early Environmental Stress ] 
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[ Disrupted Prefrontal Cortex Development ]
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[ Acquired Executive Dysfunction / ADHD Traits ]

While more research must be done about it, this supports my high suspicion that a perfect storm of modern technology, social media, and attention addictions are compounding these vulnerabilities, actively rewriting our neurobiology in real time. Perhaps we must begin distinguishing between true neurodivergence from birth (inborn structural differences) versus acquired neurodivergence—changes in brain chemistry developed later in life due to chronic overstimulation and changing environmental conditions. If we treat almost every severe mental health condition with high-level SSRIs and neuromodulators, it proves that all mental health struggles have elements of neurodivergence. The line between a psychiatric disorder and a neurodevelopmental one is incredibly thin.

If the DSM is too rigid, what is the alternative? While the ICD-10 (and ICD-11) offers more nuanced developmental framing, the reality is that health insurance companies; the true, silent directors of modern healthcare; remain anchored to DSM billing codes.

Perhaps the diagnostic spectrum shouldn't belong to just "Autism" at all. What if we mapped human psychology onto a Sensory Regulation Spectrum? Imagine a diagnostic model where we don't label a child as "disordered," but rather place them on a universal sensory spectrum. We all land somewhere on it. Some of us need high stimulation to function; others require a quiet, muted environment to avoid a total system crash. But perhaps some, like Dr Grandin, would disagree. Because, by opening up the spectrum, we are limiting it, once again.

I do wish we could focus on shifting the focus from rigid, behavioral checklists to the underlying nervous system. I hope we can stop forcing children into lifelong diagnostic boxes, but the world changes and its needs are constantly changing. I hope that instead, that health care becomes more supportive to interventions and supportive environmental modifications children (and adults) actually need to thrive.