High-Functioning Autism in Adults

A Mayo Clinic approach to adults with autism

STUDY: Bostwick JM et al, Mayo Clin Proc 2026;101(5):846–853

STUDY TYPE: Concise review

FUNDING: Independent

Background

Since DSM-5 collapsed four autism diagnoses into one in 2013, its prevalence has nearly doubled, with around 1 in 45 adults carrying the diagnosis. Many were missed in childhood because they had fluent language, intact intellect, and well-developed coping strategies, including deliberate “masking” of autistic traits to appear neurotypical.

Making the Diagnosis

Here are tips on assessing the core domains of the DSM and ICD criteria. Ask about how these played out in childhood as well:

Social communication

• How do they initiate conversation or respond to others?
• Is there back-and-forth dialogue?
• How is their nonverbal communication: facial expression, eye contact, and body language?
• Do they understand nonverbals from others?

Relationships

• How much do they desire relationships?
• How well do they understand relationships? Enough to build and maintain them?

Restricted or repetitive patterns

• Motor activity. Do they engage in stereotypies like rocking, hand flapping, pacing, rubbing, or repeating words or phrases?
• Inflexible routines. Rituals such as a sameness in food eaten, routes taken, and greetings made (or not). Do even small deviations from the predictable cause great distress? Are transitions especially hard?
• Restricted interests. Are their hobbies or interests narrow, fixated, and intense to the point of preoccupation or perseveration?
• Sensory. Do they have extreme responses to sensory input, either highly responsive or not responsive at all? Examples include indifference to pain, fascination with smelling or touching objects (or people) around them, and exquisite sensitivity to clothing or food textures.

Severity

How much of a problem do the symptoms cause? In what areas of life do they require assistance?

• Level 1 (mild): Inflexibility and behaviors interfers enough to compromise independence in one or more areas. For example, trouble switching activities; rigidly organized surroundings, but still able to complete college, gain employment, and live independently.
• Level 2 (moderate): The symptoms interfere in several contexts. They may be able to participate in special education classes or supervised work-shops and live with some degree of oversight.
• Level 3 (severe): The inflexibility, repetitive behaviors, and restricted interests cause problems in almost any sphere. They usually require the round-the-clock support or institutionalization.

Further Tips

Adults with high-functioning autism typically meet criteria through subtle impairments in social-emotional reciprocity, nonverbal communication, and peer relationships, combined with rigid routines, narrow fixated interests, and sensory sensitivities. Masking — common in women — often delays diagnosis.

The comorbidity burden is substantial:

• ADHD in 28%, 4 times the general rate
• Depression in 20%, 3 times the general rate
• Anxiety disorders in 11%, double the general rate
• Gender dysphoria is 11 times more prevalent than in the general population

Treatment

No medications target core autism deficits. Aripiprazole and risperidone have FDA indications for irritability in youth and may help adults off-label (Dr. Aiken’s note: These have major risks. Best reserved for short term use of severe aggression, not mild irritability). Skill-based therapies — cognitive-behavioral therapy, dialectical behavioral therapy, mindfulness — are favored over insight-oriented approaches. Employment support, occupational therapy, and social skills groups round out care.

Practice Implications

• The patient who’s been fired from three jobs, can’t sustain friendships, and is showing up for anxiety or depression may have undiagnosed autism spectrum disorder.
• Screen with the Autism Spectrum Quotient (AQ-10) or Autism Symptom Dimensions Questionnaire, and treat the comorbidities that are impairing function right now.