Does the Study of Culture Enrich Our Understanding of Autism? A Cross-Cultural Exploration of Life on the Spectrum in Japan and the West

Autism spectrum condition is a neurodevelopmental condition in which people are characterized by their social differences. As such, autistic behaviors are often identified as deviating from what is considered normal or neurotypical ways of interacting with the world as dictated by a particular culture. This theoretical article explores a cultural model of disability concerning autism spectrum condition and how Western ideals of “normality” dominate autism-related discourses. To illustrate this point, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA]) descriptors are discussed concerning Western and, in contrast, Japanese cultural practices. Cross-cultural research from several domains reveals the subjectivity inherent to what is considered “normal” across cultures. In addition, research into the prevalence and lived experiences of autistic people and their families in Japan reveals the complexity of understanding neurodevelopmental conditions in non-Western countries. The article discusses autism in the context of culture and suggests further areas for cross-cultural research that can further build on the cultural model of disability.


キーワード 自閉症，日本，文化心理学，社会発達，ニューロダイバーシティ
Autism spectrum disorder (ASD) is a neurodevelopmental condition in which individuals display socio-communicative differences, restricted interests, and repetitive behaviors (American Psychiatric Association, 2013). Autism affects an estimated 2.5% of children, as reported by mothers in the United States (Kogan et al., 2018). Over the last decade, there have been significant shifts in how autism is conceptualized, diagnosed, and treated. The traditional medical model operated under the assumption that autism could be understood by identifying deficits and delays. It was then argued that rectifying such differences (that is, treatment which brought them more in line with neurotypicals) would "fix" the autistic person (as discussed by Pellicano & den Houting, 2021). However, some suggest that moving away from a deficit model and instead understanding autism as a condition (i.e., "ASC" rather than "ASD") is more in line with the idea that autism reflects natural variation in behavioral expression rather than aberrance (Baron-Cohen, 2017).
Specifically, in the last 30 years, a concerted effort has been made to move away from the medicalization of autism and toward the social model of disability. The social model of disability can be understood as a challenge to individualizing physical and mental health conditions (Shakespeare, 2006), and discourse around this model often borrows from the terminology of minority and civil rights groups (Hahn, 1988). Historically, disabilities have been explained in the context of moral failings or biological deficits, emphasizing the individual needing to conform to the needs and expectations of the dominant "typical" population. The social model instead seeks to explain disability in the context of social oppression, encultured prejudices, and environmental barriers that disable people in and of themselves (Shakespeare, 2006). Inherent to the social model is not only recognizing the intrinsic obstacles in society but also embracing neurodiversity and acknowledging that there is natural variation in body and brain types (Singer, 1999).
In the social model, difficulties autistic people face can be explained by failures to account for and abide by neurodivergent ways of living. As such, to improve the lives of autistic people, the environment needs to accommodate neurodivergent needs. Despite the social model becoming more widely used in disability discourse, autistic people are still more likely to develop mental health conditions as they age (Lever & Geurts, 2016), although recent research suggests that an earlier age of diagnosis may positively relate to better mental health and quality-of-life outcomes . Autistic individuals also experience social rejection and bullying at higher rates (Cappadocia et al., 2012) and struggle with employment (Shattuck et al., 2012) compared with neurotypical people. These inequalities suggest that despite a move to embrace neurodivergence, more may be needed to bridge the gap between autism awareness and autism acceptance.
One way to perhaps improve our understanding of autism is to develop the social model of disability further to include a cultural model of disability (Waldschmidt et al., 2017). Adding culture is necessary as the social model of disability often presents "society" as a monolith within which autistic people are necessarily "othered" (Anderson-Chavarria, 2022). However, what is critically missing from these models and may further enrich an appreciation of neurodiversity is the recognition that there is considerable cultural variation in what is considered "neurotypical." Indeed, the neurotypical world in which an autistic person is situated varies considerably depending on the cultural customs and values unique to the pocket of the world from which they originate. In this sense, it is more accurate, and indeed more interesting, to posit that one should adopt a sociocultural model of disability. In doing so, one considers how certain cultures interact with a neurodiverse individual and how particular cultural practices can magnify or diminish what are often incorrectly assumed to be objective differences. By culturally situating what it means to be "autistic," it becomes possible to examine how the values and customs embedded within particular cultures influence the way autism is perceived rather than assuming autistic people possess overarching, irrefutable differences that, as a rule, stand out.
This article aims to develop a rationale for integrating culture into the social model of disability. In the first sections of this article, the motivation for further developing a cultural model of autism is explored, along with examining the cultural origins of what is generally understood to constitute autistic characteristics. These sections discuss how without taking a culturally situated approach, autistic traits are somewhat arbitrary and biased toward pathologizing the lack of desirable attributes in the West, which may not be universal when accounting for different cultural contexts. Furthermore, these biases are embedded in diagnostic tools, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is a handbook used by professionals to diagnose mental health conditions. However, it has not necessarily been standardized across cultures and has been characterized as reflecting a decidedly Western definition of mental "health" (Gaines, 1992;Haroz et al., 2017;Nikelly, 1992).
To illustrate the extent that autism can be understood differently depending on the cultural setting, Japanese culture will be used as a lens to examine acceptance and appreciation for autistic ways of being. Japanese culture is discussed here as a representative of a context that is tighter and more scripted in general while retaining specific cultural norms and practices that may be particularly appealing to autistic people. However, by primarily discussing Japanese culture with a view of orienting toward a broader cultural dimensions framework, a culturally situated model of disability is proposed. This argument also draws on the double empathy paradigm (Milton, 2012) to illustrate how cultural biases must be accounted for when describing neurodiversity. It is suggested that such a model is critical for those undertaking global autism research and practicing with non-Western populations.

A Brief History
Autism comes from the Greek word "autos," meaning "self." The term autism was first coined by the psychiatrist Eugen Bleuler (1911Bleuler ( /1950Switzerland) to describe a child whose inner life was not readily accessible to others (Evans, 2013). The medicalized phrase "infantile autism" was then used by Leo Kanner (United States;1943) throughout a series of case studies. He described 12 children who displayed similar behaviors, including restricted interests, repetitive movements, delayed language, and limited social interest. Asperger (1944;Austria), only a few years later, but unknown to Kanner, then published a similar study of children who also showed these behaviors but had fewer difficulties with language.
With the publication of the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association [APA], 1980), Rutter (1978;United Kingdom) was responsible for creating the first inclusion of autism as a neurodevelopmental disorder that, at that time, was thought only to affect 3 in 10,000 children (Treffert, 1970). Conceptualized through a "triad of impairments" (Wing & Gould, 1979), children were diagnosed with autism if they showed difficulty with communication, imagination, and restricted, repetitive interests. With the publication of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994), autism was expanded to include several subtypes along with the "classic" form of autism. These subtypes included Asperger's syndrome, which did not include language delays, and Rett's syndrome, a rare form that mainly affected females with motor difficulties. It also included Pervasive Developmental Disorder Not Otherwise Specified, which was an even "milder" form of Asperger's, and Childhood Disintegrative Disorder which referred to a child who loses the language skills, motor skills, and social skills they had already learned after the age of four.
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) ushered in one of the most significant changes in the reconceptualization of autism. Relying on a panel of experts (whose home countries were the United States, Canada, and the United Kingdom; Kapp & Ne'eman, 2020), the new diagnostic category combined all the previous diagnoses under the umbrella term "autism spectrum disorder." Combining the subtypes into one diagnostic category allowed for improved diagnostic specificity and sensitivity and addressed research showing variability within and between diagnostic subgroups (for a review, see Rosen et al., 2021). Furthermore, the addition of the word "spectrum" referred to the considerable variation observed within the population concerning the presentation of specific traits. The autism spectrum refers to those with a clinical diagnosis and the subclinical expression of autistic traits that are elevated in autistic people's family members (Piven et al., 1997) and distributed throughout the general population (Wainer et al., 2011).

Purpose of Culturally Situating Autism
Although autism is often placed in a clinical, medical context, with regards to a discrete set of behaviors that can be codified and measured, autism is, at the same time, a condition that is socially constructed as a departure from an established norm. As Duffy and Dorner (2011) discuss Narratives of autism, in turn, are not simply descriptions of cognitive states of mind or behaviour. More, they are stories about a particular kind of people-autistic people-and their relationship to larger hierarchies, whether social, cultural, political or economic . . . So understood, the autism narrative is not merely a story; it is an expression of values. (p. 204) Social norms and values are specific to creating and maintaining a particular culture (Rakoczy & Schmidt, 2013). For instance, some theorize that the evolutionary purpose of social norms is to promote cooperation between group members and maximize differences between non-group members (Chudek & Henrich, 2011). Thus, it seems particularly relevant to conditions such as autism, identified through behaviors at odds with prevailing social norms and values, to examine how this may reflect dominating cultures and are thus subjective.
Thus, exploring and questioning the cultural origins of autism is essential for several reasons. (a) There is a practical need to understand how culture influences the perception of disabilities and strengths to maximize person-environment fit. (b) Recognizing mismatches between the individual and the pervading culture in which they are situated may encourage the exploration of subcultures or opportunities to interact with minority cultures. (c) More importantly, it may enhance one's ability to question cultural biases, presenting neurodiverse and neurotypical people with essential tools for change. The social model calls for one to examine how the environment may disable an individual and empower an autistic person to challenge biases embedded in social systems. It may be necessary to take this further and challenge specific cultural practices and preconceptions that may "disable" neurodiverse people. (b) Examining the cultural influences historically shaping how autism is understood is also an essential step toward reducing current healthcare inequalities. These inequalities stem from a misunderstanding or depreciation of the role of culture in creating diagnostic criteria, assessments, and interventions for conditions like ASD. Those from minority cultures are less likely to receive autism diagnoses (Angell et al., 2018). A study by Begeer et al. (2008) also found underrepresentation of minority children among those referred to autism institutions in the United States. Furthermore, they discovered that paediatricians were likelier to refer to autism when judging clinical vignettes of Western European versus non-European minority children, demonstrating how encultured views of autism can result in biased diagnostic decision-making. As these studies suggest, the existing models for conditions like ASD may not reflect other cultures' social customs and norms, which can lead to real-life implications for non-Western autistic people. (e) Without investigating how assessments and interventions derived from Western models may or may not reflect the values of non-Western cultures, there could be an ever-widening gap between successful intervention and acceptance, depending on the country of origin.

Autism in a Non-Western Context: The Case of Japan
To explore how the understanding of autism itself may be fused with particularly Western ideals, this article positions autistic traits in the context of Western values and then contrasts this with Japanese ways of being. Japan was chosen as it has a similar economic status compared with countries in Europe and the United States (Huber, 2019), with similarly advanced medical capabilities (Matsuda, 2019), while also possessing what could be characterized as distinctly Eastern values, traditions and customs (Hane, 2018). In the following section, we will present the DSM-5 criterion for the diagnosis of autism and situate them in a Japanese cultural context. We will explore how people from Western and Japanese cultures interpret these behaviors and traits. We will also explore the extent to which the pathologizing of autism may reflect a bias toward a certain encultured way of behaving.

Social and Communicative Differences
In the DSM-5, the first feature of the socio-communicative diagnostic criteria of autism is "deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions" (American Psychiatric Association, 2013, p. 299). While social reciprocity and cooperation are arguably fundamental to the human experience (Nowak, 2006), there are cultural manifestations of being socially reciprocal. In this sense, socially reciprocal behaviors may manifest differently between cultures.
In "looser" cultures such as the United States (Gelfand et al., 2011;Hofstede, 1984), social reciprocity and back-and-forth conversation are prized. Compared with Eastern speakers, Americans provide more personalized information, such as revealing more about themselves through self-disclosure or self-knowledge (Asai & Barnlund, 1998;Chen, 1995). Much of this stems from political value systems. Free speech and self-expression, for instance, are highly valued concepts in the United States and Europe and directly influence speech styles (H. S. Kim & Sherman, 2007). In European and European American societies, to speak is to think, unlike in Eastern cultures, where speech impairs rather than facilitates thinking (H. S. Kim, 2002). In the United States, fast speech is rated as more competent (Peng et al., 1993), again in line with the belief that speaking indicates thinking.
Autistic people are often judged more poorly when using Western standards of social reciprocity (C. Wood & Freeth, 2016). They may be less likely to speak (Ying Sng et al., 2018) and less likely to share personal information (Bang et al., 2013). Research suggests that autistic people take longer to process and produce social details. They, for instance, have differences in speech fluency, with studies showing more speech disfluency or pauses in the speech of autistic people in general (Lake et al., 2011) and fewer word utterances (Baixauli et al., 2016). This disfluency may be linked to difficulty processing language and interpreting the implicit information conveyed simultaneously through body language and facial expressions. Indeed, autistic people often report a preference for online communication as it allows for silences and pauses without having to quickly fill the gap (Gillespie-Lynch et al., 2014).
Autistic people report compensation for slower, less spontaneous speech through learning social scripts (Livingston et al., 2019), which may combat difficulties with uncertainty in communication and misunderstanding social situations (Boulter et al., 2014). This ties in with another feature of autism, insistence on sameness (Gotham et al., 2013). Autistic people can have difficulty communicating at the moment, and planned speech can help minimize moments when autistic people may not know what to say (Zisk & Dalton, 2019).
While a more scripted, less personal speaking style may stand out in the United States, this is more in line with East-Asian communication. For instance, in Japan, scripts are more heavily utilized in everyday life and are based on an understanding of social ranks, an autistic strength (Ogawa et al., 2019). Some of this stems from the concept of Kata, or the idea that there is a way of doing something, and it should follow a specific form, and the concept of Amae, or the idea that social affiliations should be delineated (De Mente, 2018). For instance, the context for speech in Japanese is at the group level and made evident in some ways by a person's age, familiarity, level of education, or job title. The goal is to minimize uncertainty (Duronto et al., 2005). Much of this may stem from what Hofstede (1984) refers to as "uncertainty avoidance," which he described as particularly pronounced in Japan. Uncertainty avoidance can be characterized by cultures made nervous by situations that can be viewed as unstructured, unclear, and unpredictable.
Compared with Western speech, Japanese speech acts are likelier to allow for silence and a slow, calculated response (Nishimura et al., 2008). In general, it is much more acceptable to leave silences in communication (Hasegawa & Gudykunst, 1998), with more recorded silences found in Japanese versus American instruction (King & Aono, 2017) and Japanese versus German conversation (Endrass et al., 2008). Some link this with the implicit association of silence with strength in Japan, in which to say too much is to appear unduly authoritative (Lebra, 1987). In this sense, a higher acceptance of silence and pauses may benefit individuals with processing difficulties.
Autistic people also experience difficulties integrating verbal language and non-verbal cues. The DSM-5 describes this as deficits in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
In the United States and Europe, eye contact is highly valued during communication, and compared with Eastern cultures, it is experienced more in daily life. Americans and Italians, for instance, ranked rules about maintaining eye contact more highly than Japanese and Hong Kong participants (Argyle et al., 1986). Canadians were more likely to look at eyes when thinking than Japanese participants (McCarthy et al., 2008), and Japanese managers made less eye contact during business meetings than Americans (Hawrysh & Zaichkowsky, 1990).
Perhaps the most well-known example of nonverbal communicative differences in autism lies in differences in eye contact, which autistic people report as uncomfortable (Trevisan et al., 2017). Some research suggests autistic people have gaze insensitivity or a reduced salience of eye contact, leading to less direct gaze (Kylliäinen et al., 2012;Moriuchi et al., 2016). Others suggest that autistic people's eye-gaze patterns reveal an increased discomfort and subsequent avoidance of direct eye gaze (Tanaka & Sung, 2016).
In Japan, there is an association between eye-contact avoidance and deference (Sue & Sue, 1977). Compared with Finnish adults, Japanese participants judge direct gaze faces as more angry, unapproachable, and unpleasant when making direct eye contact (Akechi et al., 2013). Compared with Westerners, Japanese people look at their eyes more during emotion recognition tasks. This increased contact when reading emotions may account for their decreased time spent looking at eyes in everyday life compared with the West (Uono & Hietanen, 2015). It is considered intrusive to spend too long making direct eye contact, and children are taught to gaze at the neck as it keeps eye contact in the periphery (Morsbach, 1973). This maps with autistic reports of heightened arousal when looking at eyes.
The DSM-5 also identifies autistic people as having "deficits in developing, maintaining, and understanding relationships." In Western studies, autistic people are more likely to experience exclusion and loneliness than their neurotypical peers (Kasari & Sterling, 2013;Mazurek, 2014). The Japanese report significantly less loneliness than individuals in the United States or the United Kingdom (9% compared to 22% and 23%; DiJulio et al., 2018). However, they also report significantly less time spent with other people than in the United States or United Kingdom, indicating that pathways to loneliness may differ for the Japanese compared with Westerners. It may also align with autistic perceptions of social contact, which could be fulfilled more through online communities (Brownlow et al., 2015) or smaller social networks (Sedgewick et al., 2019).

Highly Restricted, Fixated Interests That are Abnormal in Intensity or Focus
The majority of autistic people (as many as 85%) (Klin et al., 2007) possess restricted interests, or "highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests)." Research suggests that restricted interests in autistic people likely fall into specific categories, and some topics frequently occur within those categories. These include items relating to objects and cartoons (Anthony et al., 2013), particularly anime (Kuo et al., 2014), with some studies showing that animation is one of the most commonly represented restricted interests in children on the autism spectrum (Anthony et al., 2013;Klin et al., 2007;South et al., 2005;See Atherton & Cross, 2018 for a review of this relationship).
There are several reasons why autistic people may develop a specific interest in cartoon animation that is significantly elevated compared with neurotypicals, as research suggests (Anthony et al., 2013). The exaggeration inherent to anime (Liu et al., 2019) may make the emotional expression of characters particularly salient (Rozema, 2015), which autistic people may find helpful when decoding emotions Brosnan et al., 2015;Cross et al., 2022). For instance, anime faces have simplified shapes and a paucity of complex textures, which allow them to emphasize only the most salient aspects relevant to face identification with exaggerated expressions that powerfully convey meaning (Lu, 2009). In manga, comic books, and anime, a mark representing a specific emotional or sensory status is called "mampu (漫符)" and is frequently used to convey meaning succinctly. For instance, lines in a row on a face or background represent that the character with the mampu is shocked or feels bad, while a light bulb near a head demonstrates that the character conceives an idea (Wallestad, 2012). As autistic people are more responsive to exaggerated expressions (Carter et al., 2016), and use rules to decode facial expressions (Rutherford & McIntosh, 2007), anime may be a particularly engaging and valuable form of artistic expression and entertainment for autistic people (M. R. Lee, 2019;Lefler, 2018;Rozema, 2015). Anime may also be a useful medium for understanding the autistic experience (Foss, 2016).
Even the broader concept of anthropomorphism, or seeing the human as the non-human, is omnipresent in Japanese society and may be particularly pertinent to the autistic experience . The increased emphasis on anthropomorphism in Japanese culture may stem from the religious values of Shintoism, in which spirits or animism are thought to reside in things that are living or not, and the importance of Buddhism, a religion in which value is placed on all things whether or not they are human (M. Wood, 2019). The intersection between Shintoism and Japanese pop culture is perhaps most represented in the Kawaii or cute culture that creates the Yuru Kyara, or "soft wobbly" mascots represent a more childlike aesthetic that the Japanese relate to "healing" and innocence (Occhi, 2012).
Appreciation for anthropomorphism is also found in autistic populations. For instance, autistic people in the U.K. report elevated rates of personification (White & Remington, 2019), and autistic participants from the United Kingdom and the United States show an interest and aptitude for seeing the human in the non-human Atherton et al., , 2022Cross et al., 2019Cross et al., , 2022. A considerable body of research from Western and non-Western countries links anthropomorphism to autism (see , for a review). Social engagement with anthropomorphic characters may be helpful for autistic people's social lives, as evidenced by the high rates of autism among those who become involved in anthropomorphic fandoms (i.e., furry fandom, My Little Pony fandom; Pramaggiore, 2015;Reysen et al., 2018).
Subcultures that are comprised of "fans" of things that often include autistic restricted interests are found in Western and Japanese cultures, although Japan has arguably "normalized" fandom for much longer and to a greater degree (Freedman, 2015;McGray, 2002). Going back to the early train otaku, superfans of trains, to the more typical usage today, which primarily refers to anime fandom, the otaku are individuals characterized by their extreme interest in a particular area (Ito et al., 2012). Although they were first derided as people who were "extremely enthusiastic about specific areas [but] do not know how to deal with interpersonal relationships very well" (Shinmura, 1998), a popular Japanese newspaper shows that 62% of Japanese teens now identify as otaku (Baseel, 2018). As discussed, many autistic people have been shown to have restricted interests in cartoons, specifically anime (Harrop et al., 2019). Indeed, restricted interests are one of the most characteristic traits among autistic people (Uljarević et al., 2021). Restricted interests would be highly similar to the fandom observed in the otaku, meaning that they may find increased acceptance and shared interests in Japan.

Hyper-or Hyporeactivity to Sensory Input or Unusual Interest in Sensory Aspects of the Environment
Autistic people have several sensory differences, including either/both hyper or hyposensitivity, which can make certain smells, tastes, and sounds intolerable. The DSM-5 describes this as hyper-or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). p. 299) While this may be non-social in nature (i.e., aversion to strong smells or certain foods), this heightened reactivity also extends to physical displays of emotion and affection, which autistic people often find overwhelming and socially uncomfortable (Scheele et al., 2014). Social touch appears to be particularly affected, with autistic people showing irregular responses to physical and social contact (Baranek et al., 2006). Research suggests these differences appear early in development and are predictive of early autism diagnoses (Kadlaskar et al., 2019). They are also expressed in the general population, as autistic trait levels negatively predict the pleasantness of affective touch (Croy et al., 2016) and heterosexual interpersonal touch (Scheele et al., 2014). In general, autistic people may be more sensitive to touch, with higher physical pain and touch sensitivity (Riquelme et al., 2016).
The Japanese are, in some ways, more purposeful than their Western counterparts when it comes to experiencing the socio-sensory environment. For instance, they are less casually touchy-feely (Barnlund, 1975), and Japanese people experience more discomfort than their Western counterparts at strange touching from people (Suvilehto et al., 2019). Even greetings are performed without touching or bowing instead of shaking hands (Morsbach, 1988), and people rarely hug each other. However, that is not to say that the Japanese are touch averse, but rather that they appreciate the aspects of contact that can exist outside the body, such as the presence of another in your sphere or space (Sakiyama & Koch, 2003). This means that autistic hypersensitivity can perhaps be better controlled for and more generally understood in Japan.

Autism Rates and Trait Levels in Japan
Although by no means exhaustive, the previous sections described some aspects of the autistic phenotype that may be particularly in line with the Japanese way of life and how these traits are perhaps incompatible with Western standards of sociality. In this way, we can understand that there are aspects of autism that are culturally situated or particularly striking in particular cultural contexts while not being as noticeable in others. It is essential to investigate how autism is expressed and experienced in Japan.
There is evidence that autistic traits are elevated in the general Japanese population compared with the West. Using the Autism Quotient (AQ; Baron-Cohen et al., 2001), a 50-item scale that characterizes self-reported behaviors across five domains (social skills, attention switching, attention to detail, communication, and imagination), the average threshold of autistic traits was found to be elevated in Japan compared with the United Kingdom (Wakabayashi et al., 2006). Studies suggest that on a scale of 0 to 50, a Japanese person scores more than 4 points higher than those in the United Kingdom, although the clinical range for the AQ remains the same in both countries. This suggested that, on average, autistic traits were exhibited to a greater extent within the neurotypical Japanese population on existing measures. However, the authors of the article, who used this study to validate the AQ cross-culturally, wrote that "though some differences were seen on the AQ between the UK and Japan, we emphasize that there are more similarities than differences between the two cultures" (p. 269). Higher AQ scores in the general population have also been found in other Asian cultures, such as Malaysia (Chee et al., 2023) and Korea (Shim & Lee, 2019).
In another study on the discriminative ability of the AQ to identify autistic children, 27 items had high predictive power in the United Kingdom, while only 15 did in a Japanese sample (Carruthers et al., 2018). This also indicates that some behaviors considered "autistic" in a Western country like the United Kingdom may not be viewed as atypical in Japan. Differences in autism measures in Japanese samples were also revealed in a study by Porter et al. (2022). They surveyed 52 U.S. and 51 Japanese mothers of children with autism on standard measures of autism symptom severity, such as the Social Communication Questionnaire (Eaves et al., 2006) and the Social Responsivity Scale (Constantino & Gruber, 2002). The researchers found that Japanese mothers rated their children significantly lower on these symptoms than U.S. mothers, again indicating that behaviors that are labeled as "autistic" in Western cultures may be less salient to people in Japan. This same pattern was found on the Japanese AQ, in which parents from Japan rated their children as possessing fewer autistic traits than British parents rated their children (Wakabayashi et al., 2007), indicating that these characteristics are perhaps less noticeable to Japanese parents.
Indeed, some research suggests that possessing a high threshold of autistic traits in Japan relative to others in the general population may be advantageous. For instance, a recent study looked at the AQ short form and socioeconomic status (SES) among 2,075 Japanese factory workers (aged 23-65) who held various ranks. While high AQ scores were primarily associated with lower SES workers, the trait related to attention to detail and numbers was correlated with high SES workers (such as supervisors and managers). This relationship could be seen as evidence that certain aspects of autism are revered and lead to progression in the Japanese culture (Suzuki et al., 2018).
While Japan may have a higher trait threshold than Westerners, Japan does not appear to have a lower prevalence of autism. It is estimated that one in 55 children in Japan qualifies for an autism diagnosis (Saito et al., 2019). This is slightly less than Western countries like the United States (one in 44 children, Maenner et al., 2021) and Eastern countries like Korea (one in 38, Y. S. Kim et al., 2011) but higher than other Western countries like the United Kingdom (one in 100, National Institute of Health and Care Excellence, 2017), and other Eastern countries like China (one in 100, Sun et al., 2019). While numbers in Korea and Japan are relatively high, this may also reflect a growing recognition of autism among physicians. An increasingly sophisticated and widespread manner of early childhood assessment in Japan also contributes to this high number (Kawamura et al., 2008). In line with this, in Japan, the most common age for a child with autism is age three, with a trend toward increasingly early diagnoses (Kurasawa et al., 2018). In contrast, countries such as the United States and the United Kingdom have higher average ages of diagnoses (age 4 +; Brett et al., 2016;Zuckerman et al., 2021), which coincides with school entrance.
Recognizing the high rates of clinical and subclinical presentations of autism begs the inevitable question; is life easier for autistic people in Japan? Higher scores on tests such as the AQ indicate elevated trait levels within the general, non-clinical population. Elevated rates of diagnoses, in contrast, suggest that there remain aspects of autism that stand out in Japan and are widely recognized as "disabling." At the same time, while there may be aspects of autistic traits that are accepted more in Japan and aspects of autistic life that are more reflected in Japanese traditions, there are also aspects of Japanese culture that make neurodivergence less desirable.

A Collectivist and High-Context Culture
Difficulties in Japan as experienced by an autistic person may hearken back to one of the fundamental differences between Western and Eastern cultures; collectivism. Eastern cultures like Japan and Korea are collectivist, which, according to Gudykunst et al. (1987) means they "emphasise the goals, needs and views of the in-group over those of the individuals, and the social norms of the in-group rather than individual pleasure" (p. 296). There is an increased assumption in the East versus the West that the other is "like me," and thus, there is a starting belief of shared understanding. For instance, in the United States, a highly individualized society, it is less assumed that one's perspective is identical to another's, so more is said to be on the same page. A presumption of differences and an appreciation of the process of arriving at a place of mutuality may be more helpful for autistic people. Autistic people likely benefit from explicit communication about different perspectives as they may not be processing a situation similarly by virtue of their neurodivergence. Overcoming these issues would perhaps be more accessible when conversing using a more American communication style. In the United States, a conversation is typically less synchronized due to a greater appreciation for the speaker's differences in style and background when compared with the listener (Gudykunst et al., 1987).
Japan embodies a "high context" culture (Richardson & Smith, 2007), and the Japanese experience discomfort with individuals who "stand out" (Tafarodi et al., 2004;Weisz et al., 1984). As discussed, while aspects of Japanese speech styles may help provide a more explicit script' for how to converse, this does not mean that communication is entirely straightforward. Japan is considered a high-context culture, meaning that less may be overtly said, but much more is implicitly meant (Nishimura et al., 2008). Some aspects of this type of communication may be difficult for autistic people. For instance, in a high-context culture, people are expected to speak with brevity and assume that their meaning is universally understood. The Japanese may rely less on emotional expression to guide their communication, and their language reduces some aspects of lexical ambiguity. However, there are pragmatic aspects of the Japanese language that require an individual to continuously consider the context and implications of what is being said.
For instance, while there are typical instances where one uses polite or casual honorifics, Japanese speakers will deviate from these to make specific, implicit points accounted for by the speaker (Okamoto, 2011). For instance, a professor usually speaks to students more casually to reflect the students' lower hierarchy. When asking a favor, the professor may switch to a more formal mode of speech, which indicates the professor knows the request will be an imposition. Similarly, friends may regularly use a casual form of speech. However, when they switch to a more formal mode of communication, it is likely a deliberate signal that one friend wants to place more social distance between themselves and their friend.
These implicit signals within the Japanese use and interpretation of honorifics carry much weight in everyday life. For instance, honorific usage, specifically "misusage," plays a significant role in the "othering" of foreigners attempting to integrate into the Japanese workforce (Moody, 2017). Recent research suggests through electroencephalogram experimentation that Japanese honorifics are processed within the mindreading regions of the brain (Tokimoto et al., 2021), emphasizing the implicit social processing involved in honorific usage. To misinterpret or misuse them could place autistic people who struggle with implicit mindreading at a disadvantage. Indeed, autistic people have been found to struggle with spontaneous mindreading (Callenmark et al., 2014), which is key to implicit communication.
For instance, research into autistic versus neurotypical honorific use in Korea, which has similar speech conventions, shows that in a matched sample of 12 pairs of children, autistic children were significantly more challenged in honorific recognition (Lee et al., 2020). Interestingly, while neurotypical children were most skilled in non-honorific communication, autistic children showed the opposite pattern, meaning that while their honorific use was impaired, it was still a relative strength in the autistic sample (i.e., the two samples showed opposite patterns in honorific and non-honorific conversational strength). This indicates that while honorifics are likely challenging for autistic people compared with neurotypicals, they may still provide a "boost" in that they help structure speech.
The implicit understanding embedded in Japanese discourse is not limited to language. Japanese people pay more attention to emotional vocal tone than word content when listening to others' emotional speech (Ishii et al., 2003). In Western, low-context cultures (North America, Scandinavia, and Germanic countries, for instance, are low-context cultures; Hall & Hall, 1989), less attention is in some ways paid to the "details" as communication is more frequent. A person speaks more often, and there is more dialogue to ensure shared meaning (i.e., asking for clarification, repeating statements, and emphasizing points so that the purpose is clear). This means that if a person is not clear on what is said, it is appropriate to ask for clarification, and a back-andforth can transpire until there is a shared understanding (Nishimura et al., 2008). This low-context practice may be helpful to autistic people who may not initially understand what a person means, whereas asking these types of questions is less commonplace and acceptable in Japan.

Perceptions of Autism in Japan
While aspects of autism may match more closely with Japanese ideals, that is not to say that being a neurodivergent person in and of itself is easy in Japan. Take, for instance, the Hikikomori, or "hidden youth," who are primarily confined to their homes and communicate with the outside world online. The Hikikomori are perhaps best known in the context of Japan although they exist worldwide (Chan & Lo, 2014). Recent research suggests they exhibit high autistic traits (Shimono et al., 2022). Interestingly, some argue that their isolation is better understood through the culturally related external pressures of Japanese society rather than mental health conditions per se (Norasakkunkit & Uchida, 2014). This viewpoint, in some ways, runs parallel to how autism can also be conceptualized through societal rather than individual barriers, in line with the social model of disability (Kapp et al., 2013).
One study comparing Japanese and U.S. university students on autism knowledge and acceptance revealed that, compared with U.S. students, autism was significantly more stigmatized in Japan. Following an intervention, Japanese students still stigmatized those with the condition to a high extent, unlike U.S. students (Someki et al., 2018). This suggests that the aspects of autism that make a person "different" may be less appreciated in a more collectivist culture like Japan than in a more individualistic culture like the United States, where making differences explicit may be helpful. Indeed, one of the hallmarks of the neurodiversity movement is a celebration of individual differences, including autism, attention deficit hyperactivity disorder, and dyslexia, and dually recognizing the strengths and struggles stemming from these neural differences. In a society like Japan, which prefers homogeneity and can be uncomfortable when this assumption is violated, possessing a neurological difference and using this overtly to highlight strengths could be less appreciated. A recent study comparing Korean and U.S. autism stigma found that cultural tightness and a greater appreciation of hierarchies (i.e., greater vertical individualism and lesser horizontal collectivism) contributed to more significant autism stigma among Koreans (S. Y. Kim et al., 2021). It would be predicted that the Japanese culture, which shares many characteristics of the Korean culture, would also show a higher autism stigma relative to the West.
This increased stigma toward neurological differences may impact the lived experience of the autistic person and be difficult for families of autistic children in Japan. Porter and Loveland (2019) conducted a meta-analysis on parenting stress in parents of autistic children in Japan. Like other studies, they found that parents of autistic children exhibited more stress than parents of children without autism or with other disabilities. Interestingly, they also identified two studies that suggested that the autistic child's cognitive ability and parenting stress were positively correlated, meaning that parents were more stressed when raising autistic children who experienced less cognitive impairment (Mori et al., 2009;Suzumura, 2012). The authors posit that the emphasis in Japanese society on conformity and politeness may make "hidden" conditions like autism more stressful, particularly if their child is not immediately perceived as having a disability, as behavioral differences may present unexpectedly.
Indeed, a recent cross-cultural study found that Japanese parents of autistic parents experienced more stress than Italian parents (Giannotti et al., 2021). Porter et al. (2022) also found that although Japanese parents of autistic children rated their children lower on autism symptoms than U.S. parents, they experienced the same degree of parental stress. This indicates that perhaps social factors such as stigma, independent of symptom severity, impacts Japanese parent' experiences of stress.
The meta-analysis by Porter et al. (2022) also revealed a relationship between parenting stress in mothers, including low maternal efficacy and attachment difficulties. While such findings are not limited to Japanese populations, aspects of Japanese culture may exacerbate these issues. The Japanese mother-child bond is considered the cornerstone of Japanese social life (Behrens, 2004). The child depends entirely on the mother and uses this as their model for all future relationships, referred to as amae (Smith & Nomi, 2000). Japan is often considered to be one of the most quintessentially masculinized cultures (Hofstede, 1984;Nemoto, 2016), with women being considered the predominant caregivers of children and, therefore, responsible for the child's development (Holloway & Nagase, 2014). Research suggests that only 30% of Japanese mothers continue to work after having children (Nagase, 2006). Fathers are considerably more absent in Japan than in other Eastern countries, relating to Japan's strong sense of gender roles and male-dominated business culture (Ishii-Kuntz, 2013). In this sense, stigmatization among Japanese parents of autistic children, particularly mothers, may be more common than in other cultures.
Stigmatization, specifically regarding a lack of understanding and overt acceptance of autism in Japan, is a sentiment that Japanese autistic scholars have explicitly expressed. Miyazaki and DeChicchis (2013), two such authors, write that, in many ways, autistic people in Japan have similarities with foreigners who struggle to communicate and integrate into local communities. The authors describe how Japanese people understand the need for foreign job interviews to be conducted in English and signs posted in different languages on public transport, respecting how cultural differences may vary. They then wonder how "just as foreigners are so accommodated, we question whether Japanese 'neurotypical people' might also be able to accommodate the communication style of Autistic people, rather than forcing Autistic people to modify language that is intended for neurotypical people" (p. 32).
Research shows that children from collectivist versus individualistic cultures learn to appreciate certain values that may influence an appreciation for neurodiversity. Imada (2012), for instance, found that the importance of obedience, respectfulness, loyalty, and politeness were emphasized in Japanese storybooks. In contrast, children's stories from the United States feature more "self-centered" values relating to personal feelings, individual accomplishments, independence, courage, creativity, and humor were more frequently highlighted. Arguably both collectivist and individualistic value systems have room in the neurodiversity movement.

A Cultural Model of Disability: Implications for Autism, Neurodiversity, and Cross-Cultural Psychology
This article was not intended to be an exhaustive summary of autistic traits and relevant Japanese customs/practices. There are likely many examples that would benefit from further exploration, including a similar review using different cultural standards. Instead, this article aimed to introduce an addition to the social model of disability and to account for aspects of the cultural environment that disables individuals. To fully account for how an individual is disabled in their environment, a calculation of how their culture serves to disable them is necessary.
As discussed in the double empathy theory, autistic people are often disadvantaged by neurotypicals who fail to take the perspective of the autistic person, believing themselves to have the "right" interpretation of a situation or the correct behavior in a given context (Milton, 2012). Neurotypicals who fail to employ double empathy are not only ignoring autistic experiences, but they are not taking into account the cultural biases that shape their perceptions of what is "normal" or "typical." As evidenced, there are cultures in which neurotypicals process information, communicate, and interact with one another in ways that may align with what Westerners perceive as neurodivergent. While Japan was one example, there are likely many instances around the world where certain cultural practices align more closely with a neurodivergent person of a certain culture than their neurotypical counterpart.
Thus, a sociocultural model of disability would lead one to question the biases one has as to what constitutes neurotypical and neurodivergent behavior. Doing this may be especially helpful for rectifying power imbalances, as it places neurotypicals in a smaller cluster where they may no longer comprise a dominant group. After all, inherent in a sense to the phrase "neurotypical" is the idea that this brain is "typical" or "the same" as other neurotypicals. With an understanding that cultures dramatically shape brains and change the way the world is processed, the phrase "neurotypical" perhaps loses some of its meaning.
The sociocultural model of disability should be investigated further, and specific streams relative to this model warrant future investigation. For one, the DSM-5 states that Cultural differences will exist in norms for social interaction, nonverbal communication, and relationships, but individuals with autism spectrum disorder are markedly impaired against the norms for their cultural context. Cultural and socioeconomic factors may affect age at recognition or diagnosis; for example, in the United States, late or underdiagnosis of autism spectrum disorder among African American children may occur. (American Psychiatric Association, 2013, p. 50) This article calls this argument into the forefront of discussion. The DSM was written with a Western bias, and most autism research is conducted using Western samples and Western instruments. Assumptions regarding universal cognitive features of autism that would be expected to be present across cultures (such as a theory of mind deficit) should be tested across multiple cultural sites. For instance, quite a few studies have shown no theory of mind impairment in autistic adults (i.e., Cross et al., 2022), although many more do show a deficit (while of course, acknowledging that null findings are harder to publish; for a discussion see Gernsbacher & Yergeau, 2019). Thus, it may be that even these cognitive features of the condition present differently in different cultures, particularly given that most major autism cognitive tests (like the Sally Ann test for instance) were developed by Westerners and validated using Western samples (Baron-Cohen et al., 1985). It would be interesting to look at cultural variability on these measures and perhaps develop more culturally relevant measures for non-Western cultures.
Creating culturally relevant self-report, parent report, and observational tests of autistic behaviors/traits is perhaps even more vital, given the importance of such assessments in receiving a timely diagnosis and thus improving quality of life . This review reveals that aspects of what is commonly in the West considered to be "autistic" and thus appear as "markedly impaired" in the West, which may not be so "marked" in other cultures, such as Japan. For instance, some research suggests Japanese parents of autistic children experience relatively more stress than Western parents, and research on autistic stigma suggests that Japanese and Korean individuals are less accepting of autistic people. This suggests that there are aspects of autism that are perhaps "markedly impaired," but these marked impairments are not being identified on Western tests, which reveal higher levels of autistic traits in the general population, but a lower endorsement of autistic traits in the clinical population. Therefore, creating a more culturally specific instrument for autism would be of great interest and also reveal perhaps the aspects of particular cultures that are particularly "disabling." It may be that questions about autistic behaviors and traits need to be communicated differently to a non-Western audience. For instance, asking questions from an individualistic stance may be less helpful than asking them from a more collectivist stance in a country like Japan. Specifically, instead of asking parents to endorse questions about a child in an individual context (my child does x) ask them to think about their child's behavior in relation to other children (my child is the same as other children when doing x) could be more helpful at identifying or quantifying autism in Japanese culture. Likewise, there may be specific aspects of Japanese culture (and indeed every culture) in which autistic behaviors are exacerbated (such as specific cultural customs). Conducting qualitative data using multiple informants (parents, teachers, autism professionals, and autistic people) to examine a country's specific cultural practices and their intersection with autism would be particularly helpful.
As an extension to creating culturally specific measures, this article also emphasizes the need to reveal aspects of specific cultures that are particularly "disabling" toward individuals and mental health conditions. For instance, future research will want to separate the extent to which functionality for those on the spectrum is due to aspects that are specific to Japanese cultural norms and practices (e.g., social acceptance of engaging with manga, anime, and otaku culture well into the adult years) and to what extent this increased functionality is associated with cultural contexts that are tighter and more scripted in their language use in general. Examining the intersection of Hofstede's indices of tightness, looseness, and so on with disability or neurodiversity would be particularly helpful. It may reveal not only specific cultural practices that autistic people find beneficial to mental health and acceptance but also show the broader aspects of a culture that lead to autistic people becoming more accepted and having a higher quality of life. Similarly, a cross-cultural analysis of how neurodivergence in general and specific neurodivergent traits, in particular, are conceptualized by neurotypicals within specific cultures may help create culturally specific interventions to improve understanding and awareness of neurodiversity.
In close, this article set out to address the idea that neurodevelopmental conditions like autism are themselves not just socially constructed by those who are dominant neurologically (i.e., neurotypical) but also by particular cultures or regions that also dominate the research landscape. Thus, much that we consider being "autistic" and therefore "atypical" is not necessarily atypical when we consider the broader cultural landscape where customs and preferences may vary considerably. As illustrated through several examples, it is possible to unpack how particular cultural practices may disable an individual and, thus, how an individual may be empowered to question the cultural assumptions presumed to be standard.
Future research may want to specifically examine aspects of diagnostic criteria for several neurodevelopmental conditions and reflect on the cultural ideals that may disable an individual. Similar to Hofstede's (1984) seminal work on dimensions in national cultures, it may be that neurodivergent conditions can also be categorized through understanding how certain traits may be accepted and in line with the characteristics of particular cultures. Such work may be constructive in the context of promoting neurodiversity acceptance. It could reveal how neurodiverse individuals are disadvantaged by distinct cultural values and prescribe how neurotypical individuals in that culture can recognize the specific cultural biases that may lead them to be prejudiced or less accepting of neurodivergent ways of being.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.