Neurolight Series — Part IV
Why Assessment Systems Protect Themselves Instead of People
Abstract
Beyond individual clinician bias, adult autism diagnosis is shaped by administrative systems that prioritize throughput, liability management, and procedural compliance over epistemic care. This article argues that many harms experienced by autistic adults arise not from misinterpretation alone, but from administrative violence—the cumulative psychological and material harm caused by rigid processes, inaccessible communication, complaint suppression, and unaccountable discharge practices. It examines how paperwork, timelines, and institutional power dynamics erase complexity, silence dissent, and convert uncertainty into denial.
1. Diagnosis Is Not Just Clinical — It Is Bureaucratic
Autism diagnosis is often framed as a purely clinical act.
In reality, it is also an administrative one.
Decisions about:
- appointment length
- documentation format
- evidence thresholds
- follow-up availability
- complaint handling
shape outcomes as much as diagnostic criteria.
When systems are optimized for speed and risk management, complexity becomes a liability.
2. From Care to Throughput
Many adult assessment services operate under intense pressure:
- long waiting lists
- limited clinician time
- performance targets
- funding constraints
These pressures incentivize:
- brief assessments
- checklist reasoning
- binary outcomes
- rapid discharge
Nuance slows systems down.
So nuance is filtered out.
3. Paperwork as Power
Clinical reports do not merely describe reality — they produce it.
Once written:
- reports override lived experience
- language hardens into record
- contradictions become “facts”
- future care is shaped by past phrasing
Phrases such as:
- “no evidence”
- “appears to cope”
- “good insight”
carry institutional weight far beyond their evidentiary basis.
Paper becomes authority.
4. The Complaint That Goes Nowhere
Many patients attempt to challenge flawed assessments through formal complaints.
Common outcomes include:
- non-response
- procedural deflection
- prolonged delays
- silent closure
This creates a secondary harm:
- emotional exhaustion
- learned helplessness
- withdrawal from care
The system interprets silence as resolution.
5. Discharge as Containment
Discharge is often framed as neutral closure.
In practice, it can function as:
- containment of complexity
- removal of liability
- termination of dialogue
Once discharged:
- access to revision disappears
- new referrals restart the clock
- responsibility shifts back to the patient
The burden of repair is externalized.
6. Credibility Is Not Evenly Distributed
Adult autism assessment is shaped by credibility hierarchies.
Credibility is often granted to:
- clinicians over patients
- documentation over narrative
- fluency over struggle
- calmness over distress
Autistic adults who are:
- articulate
- reflective
- ethically careful
are often perceived as less credible witnesses to their own difficulty.
This is not neutrality.
It is structural bias.
7. Risk Management Disguised as Clinical Judgment
Administrative systems are designed to minimize institutional risk.
This encourages:
- conservative diagnosis
- avoidance of complexity
- preference for exclusion over inclusion
False negatives are institutionally safer than false positives.
The cost is borne by patients, not systems.
8. Intersectional Amplification of Harm
Administrative violence disproportionately affects:
- trans and gender-diverse people
- late-diagnosed adults
- people with ADHD
- those without advocates
- individuals with trauma histories
Each layer of marginalization increases:
- disbelief
- delay
- procedural burden
Complexity multiplies risk.
9. What Accountability Would Look Like
Ethical diagnostic systems would:
- allow meaningful appeal
- separate assessment from discharge
- document uncertainty honestly
- treat narrative as evidence
- audit false negatives
- respond to complaints transparently
Without accountability, harm becomes routine.
Conclusion
When diagnosis is governed more by administration than understanding, care becomes containment.
The harm autistic adults experience is not always loud or dramatic.
It is quiet, procedural, and cumulative.
Until diagnostic systems are redesigned to hold complexity rather than expel it, many adults will continue to be erased — not by misdiagnosis alone, but by paperwork, silence, and power.
Listening must replace administration.
References
- NICE NG128 (2018). Autism spectrum disorder in adults.
- American Psychiatric Association. DSM-5-TR (2022).
- Livingston, L., & Happé, F. (2017). Compensation in autism.
- Crenshaw, K. (1989). Intersectionality and structural power (conceptual framework).