How Assessments Fail High-Masking Adults

It’s 8 p.m. on a Friday night, and my phone’s “ding” announces an email from Kristy, a former client. “You have to watch Janet McNamara’s stand-up act on YouTube. Right now. Trust me.”

Janet’s new special, recorded live at The Gutter Comedy Club in Brooklyn, is called Not Smart Enough. It opens with a clip of her seated at a desk in the accounting firm where she works, clicking fiercely at her keyboard, her mouth hanging slightly open. A faceless coworker leans in. “Hey, Janet. How was your weekend?” Janet gazes up at the ceiling and sighs, the way a lot of Autistic employees do when they’re on the receiving end of small talk. Then she puts her AirPods in and gets back to work.

The scene cuts to Janet on stage. She says she’s been tested for autism three times, because “people keep asking me.” The first psychologist who evaluated her 15 years ago for Asperger’s said she wasn’t autistic on the grounds that “people with Asperger’s generally have above-average IQs.” The crowd is already laughing before the joke lands. “So, apparently, I’m not smart enough to be mildly autistic. That’s what that doctor told me.”

As a therapist who specializes in working with late-diagnosed, high-masking adults, watching Janet methodically work through her bit starts setting off familiar bells. My specialization isn’t an accident. I went most of my life without a diagnosis, collecting explanations for why I was too much or not enough. I spent years in therapy chasing answers and feeling broken. And I’m not a rare case. My practice is full of adults living this reality: people like Janet, who were evaluated, sometimes repeatedly, and given something other than the answers that would have helped them.

Janet’s eyes dart past the audience to three fixed positions as she delivers her jokes. The punchline always landing at “12:00.” Her voice is monotone, her presentation deadpan. Her left pointer fingernail digs repeatedly into her thumb in a subtle, yet persistent stim. I know these moves all too well. If Janet were sitting across from me during an intake, I’d already have questions. If she were sitting next to me at a party, I’d know neither of us wanted to be there, and I’m fairly certain we’d get along.

Ding. Another email from Kristy: “Kory, I’m laughing so hard. She’s new on the scene. I bet she’d do your podcast if you asked.”

I DM Janet’s manager that night. A month later, Janet’s a guest on my podcast on neurodivergent adults. She’s wearing a well-worn, tie-dyed hoodie and the undecorated white wall behind her gives no clues that this apartment has housed her for 20 years. She launches immediately into a comfortable monologue about her life. Beyond the jokes, the story isn’t funny at all. Tears well up in her eyes as she recounts all the professionals she’d turned to for help who failed to see the obvious traits of neurodivergence in front of them. And ultimately failed to help her.

Janet doesn’t actually have a low IQ. That first psychologist she went to was probably looking for the autism that comes with the word savant attached. In the 1980s, this was the only autism professionals were trained to look for. Today we know this presentation is a narrow slice of the whole story. High- masking autistic adults have expanded what the diagnosis looks like. Our clinical approaches haven’t yet caught up.

The next clinician Janet saw for an assessment ruled her out for being too coordinated. Janet had been a lifelong athlete whose sports career had brought her the kind of positive attention and self-esteem that school hadn’t. But having mainstream special interests, like sports or reading, doesn’t mean you’re not autistic. Often, it just means that people are more likely to overlook what you’re struggling with underneath. Plenty of my clients excelled on the field and then hit adulthood entirely unprepared to make friends outside a structured roster or navigate an office with no rule book. “Soccer player” comes with rules, routines, and built-in support. “New accountant” does not.

A third clinician ruled Janet out for making “appropriate facial expressions” and having “an understanding of what a friendship is.” High masking adults are well versed in learning the expectations of non-verbal communication. We also have friends, often other adults who are wired similarly. These clinical observations are no longer enough to rule out autism. In 2026, they are an indicator to dig deeper beyond traits that can be observed.

This is the paradox of being Autistic. We’re frequently capable of overcoming things that would break most people, and we struggle with things most people never have to think twice about. Janet’s neurodivergence didn’t cancel out her talent, it produced it, the kind of talent that gets you standing gigs at iconic comedy clubs. But long before that dream took shape, years of misdiagnosis left her deep in burnout: anxious, miserable, reprimanded by bosses, sometimes unable to work, and cycling through increasingly higher levels of psychiatric care.

None of those identified disqualifiers should have precluded Janet from getting support for what was actually overwhelming her: sensory stressors, being continually pulled out of hyperfocus, office politics and bullying that altered the shape of her career. High-masking autism shows up regularly in all sorts of sectors: medicine, law, tech, and a range of creative arts—anywhere that intense and brilliant brains get to shine, or should get to shine. But all too frequently, my Autistic clients, especially ones who were undiagnosed for much of their life, are met with trauma rather than career growth, because they don’t get the support they need to shine.

Janet is a public case study of what happens when professionals don’t understand high-masking autism. Fortunately, Janet found her way to a comedy club stage. But many of my clients instead land in unemployment, disability, and the kind of burnout that doesn’t get better without neuro-affirming care.

That’s why I’m so passionate about sitting with my clients long enough to ask the right follow-up questions to see what’s actually there rather than what fits a checklist.

The Problem with Checklists

The tools we’ve been handing clients to assess for autism are a little like X-rays. They may catch big, obvious “breaks.” But they miss what’s happening in those of us whose struggles exist in the “soft tissue” of life.

Do you maintain eye contact? Always, sometimes, or never.

This question trips up high-masking Autistic adults because the answer is complicated. Eye contact comes easily on the couch with a partner. It disappears entirely in an unfamiliar conference room. At the grocery store eye contact depends on the day, the lighting, how many decisions you’ve had to make that day. Did your mom and teachers shame you into eye contact for years as a kid? Did you learn it through repetition and correction, the way you learn things that don’t come naturally? By adulthood, many high-masking autistic people make eye contact so reliably that it reads as effortless. It’s not. It’s labor that has been so thoroughly automated that even the people doing it forget they’re doing it. There’s no room for that nuance on a standardized test.

Do you have difficulty making friends? Always, sometimes, or never.

When? Where? Work is work and home is home. High-masking folks are often unsure of how to answer this question. Where’s the option that lets them say something like: Neurotypicals don’t usually like me, so I don’t try with them. With other autistic people who share my special interests? That usually goes well for about six months, and then it’s not so easy keeping those friends. I have a couple of group chats going with people who share my special interest. I’ll go out on occasion. Friendship is complicated when we’re comparing the kind we prefer to the kind that’s dictated by neurotypical standards. Often our brain yearns for connection, while our bodies are exhausted by the expectations that come bundled with the realities of friendship.

A standardized test can’t accurately measure the kinds of nuances you see in high-masking people. Still, the assessment process for autism, even in 2026, is observable, binary, scoreable. Check the box, print the report, and tell the test taker that unfortunately, they “just didn’t meet the criteria.”

I understand the appeal of that assessment. I’m not arguing that these systems should disappear. Standardized measures are built to provide consistency in care. They can reduce the impact of the assessor’s bias, and for clinicians without a strong background in the autistic population, they provide a springboard for a deeper level of understanding. This isn’t an indictment of practitioners who begin with a standardized measure, but rather a plea to consider the limitations when these tools become the final word. Clinical judgement is uniquely critical for this population in ways that are specific to the traits we’re looking to understand in our clients. A tool used as one piece of the picture is useful. The problem is that what these assessments actually measure is a surface presentation. And for a population that’s spent their entire lives learning how to pass as the evaluator’s version of normal, surface presentation is unreliable.

Think about every other diagnostic label we hand out in this field. When a client reports depression, we don’t need a number on a scale. We ask what happened and how it lives in the body now. We ask how long it lasted and what helps. We talk and listen. We’re certainly not asking them to rate their depression against a bell curve.

Even in the medical field, if a client tells a doctor that he has erectile dysfunction, does the doctor ask him to rate the dysfunction on a scale of 1 to 10? Or does the doctor believe him, ask what’s changed, and inquire what the issue is doing to his intimate relationships? We don’t demand ratings for social anxiety, or separation anxiety, or phobias. We ask, listen, and treat what’s in front of us. We certainly do not ask for a second opinion from a family member in order to confirm a diagnosis.

The standardized instrument doesn’t make the diagnostic process more scientific. It gives the illusion that a deviation from the norm makes the treatment path clear. A client account of their own lived experience is data. Observing what they eat, what they wear, what shuts them down—that’s data, too, not a lesser form of evidence that requires validation from a checklist.

Many of the Autistic adults in my office have spent thousands of dollars to mask their way through an assessment built to catch when someone isn’t performing as constantly as they are. They walk out with a report that says they don’t meet the criteria. No diagnosis. No care. No answer for the thing that brought them into the room in the first place. Often, the assumption is, “It must just be anxiety.”

If a missed or wrong diagnosis here meant sending someone into chemotherapy, I’d understand insisting on an airtight, heavily quantified process first. That standard exists for a reason elsewhere in medicine. But we’re talking about therapy, delivered by someone who understands autism, for a person who needs it. Get it right, and the cost is nothing. Get it wrong, and the cost is years of the wrong treatment and a client who has learned, once again, not to trust the process. When provider after provider tells you the reason you’re not improving is you, that causes trauma.

Misdiagnosis is not a neutral outcome. It causes real, documented, lasting harm. And it misses women, people of color, anyone without thousands of dollars to get a second opinion, anyone who learned early that masking was survival. It sends people into treatment rooms with clinicians who are working from wrong information. And when it misses them, far too often, we just move on, delaying appropriate support by years or even decades.

More and more misdiagnosed autistic adults are leaving messages in my inbox, asking to be added to my waiting list, commenting on every post I put up about late diagnosis and recognizing themselves in language no evaluator ever used with them. They’re in their 40s and 50s, finally getting closer to the answer that would have changed the trajectory of their lives if someone had asked better questions decades ago.

Systems are extraordinarily resistant to change, especially when the change requires clinicians to slow down and sit with ambiguity rather than scores. As a result, we’re still using forms designed decades ago, scored against criteria that were developed primarily from observations of a narrow slice of the autistic population—white men—and calling it the “best” way to get diagnosed. The forms have been slightly updated, and the scoring is more refined, but the fundamental approach—observable behavior checklist, norm comparison, and threshold decision—remains largely intact.

The Narrative Alternative

Do you want to know if someone has sensory sensitivities? Skip the checklist and just ask them. And then, importantly, ask follow-up questions. Don’t ask, “Do seams in your socks bother you?” and accept yes or no. Ask what happens in their nervous system when they feel those seams, whether they’ve spent years happily paying 14 dollars for seamless socks from one very particular brand because it’s the only thing that works. When we identify someone as Autistic through a narrative assessment, the treatment that follows is surprisingly ordinary: the client receives therapy focused on their neurodivergence, guidance on accommodations, help understanding their own nervous system and their own sensory needs and building a life around the brain they actually have instead of the one they were taught to perform. It’s the same therapy I’d give anyone, just tailored more precisely to their concerns.

We already have clinical training for this kind of conversation. We have the science that tells us how the autistic nervous system processes sensory input differently and generates responses Autistic people often try to mask until they burn out and can’t mask any longer. We can show our clients how their Apple Watch can alert them to a nervous system crash more reliably than their own body, and see that it’s the grocery store, the chaos of parenting, and the transition from work to home that spikes their overwhelm. None of that belongs to generalized anxiety, BPD, bipolar, or anything else our clients are wrongly told they are. It’s predictable with a level of precision the field claims to want from a checklist.

Comedian Janet McNamara knows what happens when that precision is missing. She wasn’t “smart enough” for one evaluator, she was “too coordinated” for another, and she was “too good at performing neurotypical facial expressions” for a third. Now, in her show, she’s showing people, rather than telling them, that Autistic people are unique, creative, and probably not what you learned about in grad school. When I suggested that she’s changing the stigma of what autism looks like, Janet said, “I can’t really educate somebody on autism at this point. I just know what I’m going through.”

I’m not Janet’s therapist. But I spent a few hours with her, and I heard a lot of my own struggles in hers. I walked away smiling—partly because she’s hilarious and partly because she’s a neurodivergent person who’s learned to lean into a life built for her, and it’s working. She’s built her special interest into a way to stay employed, found neurodivergent friends who “get her,” and taken real, proactive steps to manage her health.

If I’d been the first diagnostician who evaluated her 15 years ago, rather than handing her an incorrect assessment and a bag of medication, I would’ve advised her to get comfortable saying no and find a schedule that worked for her body, a therapist who understood autism, and friendships that felt right to her. Janet was left to figure that out on her own.

A lot of us now are assessing for autism through narrative interviews. We focus on knowing the questions to ask, and when to ask more. A negative, standardized result is one data point, not the final word. A narrative assessment is what happens when someone with real expertise asks the next question and presses on the spot that actually hurts instead of drawing a definitive conclusion from an X-ray that supposedly came back clean.

Janet’s humor pokes fun at the way the system failed her, but there’s real trauma underneath it. Telling her she “didn’t meet the criteria” because she didn’t offer up sensory challenges unprompted was a missed opportunity, not a clean result. Someone could have asked about the rotation of three baggy shirts she wears, or her drawer of identical Bombas socks, or the fact that she can’t tolerate being touched on her arms or legs. Instead, they accepted “I don’t have any sensory issues” and moved on.

You don’t have to be an Autistic therapist to assess for autism and you don’t need to rely on a standardized test. But it does take someone who looks beyond checklists at the bigger picture. People talk a lot these days about the rising number of autism diagnoses as if it’s evidence of something wrong: a trend, overdiagnosis. I see it differently. If the numbers are climbing, maybe it’s because generations of people are finally getting help they should have gotten decades ago.

For now, I’ll keep assessing people through detailed interviews, asking what it feels like inside their nervous system when the lights are bright and the tags haven’t been cut out of their shirts. I’ll keep reading past every box checked “no” on reports that say, “does not meet threshold,” and finding the person who was there all along.

Not enough people in our mental health system have been willing to say “I trust you” to the clients who need to hear it most. I built my entire practice on trusting what people say about their own experience.