Autism spectrum disorder (ASD) continues to spark debate—not only among clinicians but also within the autistic community. Is autism a disorder requiring treatment, a disability that calls for accommodations, or simply a different way of being in the world? This question touches on more than just labels. It affects how we understand the lived experiences of autistic individuals and how we approach the medical challenges they face.
Autism is characterized by difficulties in social interaction, communication, and repetitive behaviors, but these are only part of the picture. Autistic individuals often face a range of co-occurring conditions, including mental health disorders like anxiety and depression, attention-deficit/hyperactivity disorder (ADHD), epilepsy, and metabolic disorders such as obesity, diabetes, and cardiovascular disease. These health challenges, which significantly contribute to higher rates of premature mortality, demand attention—but not in a way that shames or pathologizes autistic people. Instead, we need to understand these medical issues holistically and explore innovative ways to treat them while respecting the autonomy, dignity, and rights of autistic individuals.
The Debate: Disorder, Disability, or Difference?
For some, autism is seen primarily as a disorder that needs treatment. From this perspective, the challenges it presents—especially in more severe forms—can severely limit communication, social engagement, and independence. In these cases, medical interventions and therapies are often necessary to improve quality of life and reduce difficulties.
Others view autism as a disability that requires societal adjustments and accommodations. The focus here is on supporting individuals by creating an inclusive environment, whether through specialized education programs, workplace accommodations, or social services. This perspective acknowledges the challenges of autism while emphasizing that autistic people can thrive when provided with the right support.
Others advocate for seeing autism not as a disorder or disability but as a natural variation in human neurobiology. Proponents argue that society should focus on celebrating and accommodating neurodivergence, emphasizing the strengths of autistic individuals, such as creativity, attention to detail, and problem-solving abilities. This view pushes back against medicalizing autism and instead encourages an embrace of neurological diversity.
Mitochondrial Dysfunction: A Key to Understanding Autism?
One area of research that offers new insights into autism and its related health conditions is mitochondrial dysfunction. Mitochondria, often referred to as the “powerhouses” of cells, are essential for energy production and myriad other cell functions. Many scientists now believe that mitochondrial dysfunction plays a key role in neurodevelopmental conditions, including autism.
Mitochondrial dysfunction can lead to impaired energy production in the brain, which may help explain the neurological and psychiatric symptoms that often accompany autism. For instance, conditions like anxiety, depression, and cognitive challenges can arise when the brain’s cells do not function optimally. Mitochondrial dysfunction is also implicated in epilepsy, a condition that affects up to one-third of autistic individuals. Understanding this underlying issue offers a new way to think about how these diverse conditions are connected, helping to unify the seemingly disparate symptoms seen in many autistic individuals.
Metabolic conditions, such as obesity, diabetes, and cardiovascular disease, are also thought to be linked to mitochondrial dysfunction. When the body’s energy systems are disrupted, metabolic regulation suffers, leading to the development of these chronic health issues. This connection helps us understand why autistic individuals are at higher risk for metabolic disorders and at least some of the reasons they experience premature mortality at higher rates.
Person-First vs. Identity-First Language
The language we use to describe autism is also a matter of debate. Some advocate for “person-first” language, such as “person with autism,” to emphasize that autism does not define the individual. Others prefer “identity-first” language, such as “autistic person,” asserting that autism is an integral part of who they are. Both perspectives have merit, and it’s important to respect individual preferences. What matters most is listening to people and allowing them to express their experiences in the language that feels right to them.
A Call to Action: Addressing Health While Respecting Dignity
How do we navigate the balance between addressing these health concerns and respecting the rights and autonomy of autistic individuals? We need a holistic approach that treats the medical issues autistic individuals face without reducing them to a diagnosis. This means creating more accessible healthcare environments, improving provider training, and offering treatments tailored to both mental and physical health.
At the same time, we must always respect the independence, autonomy, dignity, and preferences of individuals. Whether someone views autism as a disorder, disability, or simply a difference, their perspective matters. Healthcare and social services must be designed in a way that supports individuals without stigmatizing them or imposing unwanted interventions.
Understanding Autism in All Its Complexity
Autism is a multifaceted condition that resists simple categorization. The increasing recognition of mitochondrial function as a key factor in autism offers hope for a deeper understanding and more effective treatment of the many co-occurring conditions that affect this population. By addressing these medical challenges while respecting the dignity and autonomy of individuals, we can build a healthcare system that truly supports everyone in thriving.
Dr. Christopher Palmer is a Harvard psychiatrist and researcher working at the interface of metabolism and mental health. He is the Founder and Director of the Metabolic and Mental Health Program and the Director of the Department of Postgraduate and Continuing Education at McLean Hospital and an Assistant Professor of Psychiatry at Harvard Medical School. For almost 30 years, he has held administrative, educational, research, and clinical roles in psychiatry at McLean and Harvard. He has been pioneering the use of the medical ketogenic diet in the treatment of psychiatric disorders—conducting research in this area, treating patients, writing, and speaking around the world on this topic. Most recently, he has proposed that mental disorders can be understood as metabolic disorders affecting the brain, which has received widespread recognition in both national and international media outlets.
