Valerie Boles, OTR/L, Clinical Director   •   October 16, 2026

The most common question people ask me about my job is “Why does everyone have autism now?” 

There are dramatically more children being diagnosed with autism than there were twenty or thirty years ago. People who have worked with children for a long time notice it. Parents notice it.

The increase is real. What is much less clear is what the increase means.

We Learned More about Autism

Some of it is almost certainly because we got better at recognizing autism.

When I was growing up, the public picture of autism was fairly narrow. A bright, verbal child who did well academically and wanted friends could go a long time without anyone considering autism.

I work with adolescents who can answer every question on a formal social test correctly. Show them two people having a conflict and ask what everyone should do next. They know.

Then you talk to their mothers.

She may tell you that she has spent fifteen years explicitly teaching her daughter those answers. She passed the tissues every time her daughter got laughed at for a poorly planned joke.

Knowing the social rule does not tell us how the child learned it. A skill that is automatic and a skill that has been consciously practiced for years can look remarkably similar during an evaluation.

Autistic adults have also described things like masking in ways that have changed how clinicians think about outwardly competent social behavior. Clinicians now recognize subtler presentations. 

The DSM Changed

The diagnostic categories changed too. Some kids who would have been previously identified as having Asperger's and other diagnoses are now labeled with Autism Spectrum Disorder. 

DMS changes and clinician understanding has resulted in some people receiving an autism diagnosis that probably would not have received one thirty years ago.

Yet, hat still does not explain everything. There are a variety of social and societal factors which have changed.

A Diagnosis Changes Things

An autism diagnosis is not just a description of a child.

It affects what happens next.

I learned this early in outpatient occupational therapy. Two children could have essentially the same functional problem and very different access to treatment depending on the diagnosis attached to the claim. Autism can unlock substantially more therapy than another developmental diagnosis. 

It is also much easier for a child to qualify for school services with a medical diagnosis of autism rather than the vague “Developmental Delay” identification which expires at the age of ten. 

Those policies exist for good reason. Autistic children need treatment, and families have historically had to fight for it.

Nonetheless, we have created incentives to diagnose autism. 

Imagine you’re the evaluator and you’re on the fence about a diagnosis. The child is three years old. You know that time of the essence in the first few years of life.  You know “developmental delay” gets 10 visits a year. You know “autism” gets a child multiple appointments a week.  You can see why someone would choose to write autism at the bottom of their evaluation.

Looking Like Autism Is Not the Same as Being Autistic

We do not have a blood test or brain scan for autism. In the absence of obvious physical evidence, someone needs to make a clinical interpretation.

I once worked with a young girl whose referral clearly presented her as autistic. She had substantial developmental difficulties and several behaviors that could reasonably be associated with autism.

I started treating her using the kinds of developmental approaches I often used with autistic children.

Nothing worked.

When a child cannot manage a developmental skill, I usually go backward. If taking turns is too difficult, I sit beside the child and play. I make an interesting noise. Does she look at me? Can we establish shared attention?  I go looking for an earlier social skill that is intact?

With this child, I kept moving backward and could not get anywhere.

Eventually I went through over a hundred pages of her medical records and discovered that she had suffered a stroke associated with serious complications around birth. 

She wasn’t looking at me but it had nothing to do with her comfort or desire to make eye contact. She couldn’t use her ocular muscles because of an injury. No amount of social developmental intervention would have helped because I needed to focus on her neuromuscular system.

She had a speech delay for the same reason. She had repetitive movements, but it was because her muscles could only move in a couple different ways.

I changed my treatment approach, addressed her motor skills instead of her play skills and we started making progress.

She had been playing pretend all along and once she had the skills to show us, we finally saw it.

Nobody had been wrong that the child had unusual social behavior, they were wrong about why.

This comes up often with trauma.

A child who grows up in a chronically threatening environment may become extremely aware of what is happening around him. He may respond strongly to noise or unexpected movement. His social development can suffer because a great deal of his attention has been devoted to managing a difficult environment rather than learning how to be a kid with other kids. Maybe rocking himself was soothing when soothing adults were inconsistent. By the time I meet him, he may have sensory differences and significant social problems. He rocks and keeps to himself. 

But he doesn’t necessarily have autism

This is why recognizing a behavior is only the beginning of an evaluation. We can’t use a checklist alone. We still have to understand when it developed, what was happening around the child and whether autism actually explains the larger developmental pattern.

Sometimes the Kid Knows Exactly What He Is Doing

Observing social behavior creates another version of the same problem.

There is a tendency to interpret inappropriate social behavior as evidence that the child does not understand the social situation.

Sometimes that is true. Other times, understanding is not the problem.

A child may know that yelling, “You throw like my sister!” will make the other kid angry. That’s why he said it. Maybe the other kid leaves, now he’s the best player on the field. This insult could be a sophisticated way to gain control.

That is clinically very different from a child who was just observing both his friend and his sister are left-handed. 

We cannot assume bad behavior is a lack of social understanding. Both neurotypical and autistic kids are capable of making decisions. They are capable of deciing to  pvocative and hurtful.

As much as it is important to teach the skill to a child who is confused or embarrassed that he hurt someone’s feelings, it is also important not to excuse every challenging behavior as a lack of understanding simply because it exists. 

Assessing people is wildly complicated and involves history and behavior patterns over time. It requires you to observe, consider and maintain curiosity throughout the process.

The Problem With Testing

This is also why I am cautious about how much authority we give formal testing.

Neuropsychological evaluations can be extremely useful. I find them particularly valuable when I am trying to understand learning differences or a child's cognitive profile.

I am much less confident in the weight we  give an autism diagnosis simply because it came from a neuropsychological evaluation.

I have repeatedly seen children arrive at Direction with an autism diagnosis from neuropsych testing who, after months of evaluation by a multidisciplinary team, very clearly do not appear autistic to us.

After weeks of becoming more comfortable, kids become engaged and gregarious. They are no longer timid and awkward. In fact, some kids have incredible social skills that was hidden beneath a veil of anxiety. 

Another teenager may correctly explain what two people in a picture should do after a disagreement during a formal assessment.

Then somebody insults her at lunch.

Now she has to understand what the other person meant while she is also angry. She has to read the situation, decide what to do and respond while the interaction is still happening.

Those are not the same task.

At Direction, we have the advantage of seeing children for hours at a time, several days a week, often over months. We get to see what happens when social interaction is not being administered as a test.

That information does not look as scientific as a standardized score but more accurately parallels her life outside the clinic.

A good neuropsychologist may tell me things about a child's learning and cognition that I could never determine from ordinary clinical observation. Many neuropsychologists perform observations in natural settings to complete their assessments.

I think the problem comes when reports and test scores start to carry more authority than the child.

So Why Are There So Many More Diagnoses?

We are clearly identifying autistic people we used to miss. The diagnostic system has changed.

 The systems surrounding the diagnosis have changed.

But experienced teachers will tell you that something is getting genuinely harder, it’s not just the labels. There are more meltdowns. There is less eye contact. Kids are moving clumsily. They are picky eaters. 

Childhood does not look the way it did thirty years ago. Children move differently, play differently and interact with the world differently. We have good reason to believe that some of those changes affect development.

Maybe its iPads, maybe parenting, maybe air pollution, maybe gut microbes. We have a lot of guesses, but we don’t have a real answer

So no, everyone does not have autism now but it’s an increasingly reasonable question. 

I don't think there is going to be one dramatic discovery that explains the whole increase.

Until the day this is all sorted out, clinicians and parents alike need to stay focused on the bigger picture: teach kids to navigate the world that’s too fast, too complicated and too loud. Whatever we call it.