Neurodiversity-Affirming Practice

Editor’s note: This text-based course is a transcript of the webinar, Neurodiversity-Affirming Practice, presented by Virginia Spielmann, PhD, OTR/L.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

• After this course, participants will be able to identify key concepts and terminology related to neurodiversity and neurodiversity-affirming practices.
• After this course, participants will be able to identify the importance of individualized and strengths-based approaches in supporting neurodivergent clients.
• After this course, participants will be able to list practical strategies for creating inclusive environments that respect and honor neurological differences.

Introduction/Terms

This topic is so important and dear to my heart. I have a lot of information to share, so let's start with some terms.

In discussions surrounding neurodiversity, it's crucial to acknowledge and celebrate the inherent differences in how individuals process and experience the world. While the majority may fall within the central range of the bell curve, those who diverge from this norm, often referred to as neurodivergent, contribute to the rich tapestry of human cognition.

The term "neurokin" encapsulates the shared identity among neurodivergent individuals, emphasizing cultural connections and mutual understanding. While neurodivergent populations encompass a wide array of diagnoses beyond autism and ADHD, much of the literature and discourse focuses primarily on autism. However, it's imperative to extend these principles of person-centeredness and affirmation across all neurodiverse communities.

Drawing from personal experience as a parent, I discern a clear distinction between neurodivergence and conditions requiring medical intervention. My eldest child, who possesses multiple neurodivergent diagnoses, illustrates the complex nature of neurodiversity. In contrast, my other children grapple with type one diabetes, a medical condition necessitating ongoing management and, ideally, a cure. This juxtaposition underscores the importance of delineating between inherent neurodivergent traits and medical ailments.

Unfortunately, societal norms often conflate childhood differences with illnesses, perpetuating the misconception that neurodivergence requires "fixing." By aligning developmental variances with medical conditions, we risk stigmatizing neurodivergent individuals and overshadowing their unique strengths and perspectives.

Central to this discourse is the concept of autistic pride, akin to the empowerment movement within deaf culture. Just as deaf individuals championed their distinctive mode of communication and demanded inclusion and respect, neurodivergent individuals advocate for the acknowledgment of their inherent value and dignity.

The notion of "neuronormativity" underscores the problematic agenda of seeking to normalize neurodivergent individuals, often through therapeutic interventions aimed at eradicating autistic traits. However, emerging narratives highlight the unintended consequences of such efforts, as individuals who undergo intensive therapy may later grapple with heightened anxiety and other mental health challenges. This raises profound questions about the authenticity of one's identity and the inherent validity of being neurodivergent.

As we navigate these complexities, it's essential to foster an environment that celebrates neurodiversity, recognizing the multifaceted nature of the disability experience and affirming the autonomy and agency of neurodivergent individuals. By reframing our discourse and practices, we can cultivate a more inclusive and supportive society for all.

Ableism, deeply ingrained within society, manifests externally and internally, perpetuating the notion that a singular standard exists for humanity and physical embodiment. This narrow framework dictates what is considered "normal" or "acceptable," relegating deviations as abnormal or strange. The pervasive belief in the superiority of able-bodiedness marginalizes those whose bodies and ways of navigating the world differ from the norm, reinforcing harmful stereotypes and expectations.

Diagnostic overshadowing, a concept critical to understanding neurodiversity-affirming practices, refers to the tendency to attribute symptoms solely to a pre-existing diagnosis, thereby overlooking or dismissing other potential health concerns. This phenomenon is particularly prevalent in medical settings, where individuals with neurodivergent traits may have their diverse needs and experiences overshadowed by their primary diagnosis. This practice hinders accurate diagnosis and treatment and reinforces systemic biases and inequities within healthcare systems.

Re-traumatization, another essential principle in neurodiversity-affirming practice, underscores the inadvertent repetition of sensory, social, emotional, or environmental experiences that elicit stress reactions in neurodivergent individuals. Despite well-meaning intentions, such encounters can exacerbate existing traumas and reinforce negative neural pathways, perpetuating cycles of distress and disempowerment. In healthcare settings, where sensory stimuli and social interactions abound, practitioners must exercise sensitivity and mindfulness to avoid inadvertently re-traumatizing their neurodivergent clients.

By acknowledging and addressing these concepts, practitioners can cultivate environments prioritizing the holistic well-being and autonomy of neurodivergent individuals, fostering greater inclusivity, understanding, and respect within healthcare and broader societal contexts.

Neurodiversity lite refers to the appropriation of the neurodiversity movement, wherein individuals or organizations may superficially align themselves with neurodiversity principles without genuinely incorporating the perspectives and insights of neurodivergent individuals. This appropriation can stem from well-intentioned efforts or deliberate attempts to capitalize on the movement for personal gain. However, the key distinction lies in the lack of authentic consultation with those who possess lived experiences of neurodivergence, particularly autistic individuals. Such token gestures fail to uphold the core values of neurodiversity, undermining its true essence and impact.

Performative neurodiversity represents another facet of appropriation, characterized by superficial displays or gestures prioritizing image and perception over genuine inclusivity and understanding. In these instances, individuals or entities may espouse neurodiversity-affirming language or symbols as a means of virtue signaling or avoiding criticism rather than fostering meaningful engagement or enacting substantive change.

These terms shed light on the complexities of engaging with neurodiversity and underscore the importance of genuine collaboration, respect, and empowerment of neurodivergent voices in shaping inclusive practices and discourse.

Agency encompasses the experience of exerting control over one's actions to influence both social and physical environments, thereby causing an effect. It entails navigating and shaping one's surroundings in alignment with personal goals and intentions. Autonomy, closely intertwined with agency, denotes the capacity to exercise free will and make decisions independently, including the ability to provide or withhold consent freely.

Prioritizing both agency and autonomy is paramount in fostering neurodiversity-affirming practices. This approach emphasizes empowering individuals to actively participate in decision-making and assert their preferences and boundaries. By promoting a philosophy that values and respects individuals' capacity to control their actions and make autonomous choices, practitioners can create environments that honor the diversity of cognitive experiences and promote self-determination.

The double empathy problem, coined by Dr. Damian Milton, highlights the mutual incomprehension that can occur between autistic and non-autistic individuals. While autistic individuals may exert considerable effort to communicate with their non-autistic counterparts, misinterpretations and judgmental attitudes often hinder effective understanding. This phenomenon underscores the need for increased empathy and mutual respect in interpersonal interactions, recognizing the validity of diverse perspectives and communication styles.

Dr. Dinah Murray introduced the concept of monotropism, which elucidates the focused attention and intense concentration experienced by autistic individuals. This attentional tunneling phenomenon can lead to exceptional productivity and flow in tasks of interest, yet it may also result in difficulties attending to external stimuli, social cues, or basic self-care needs. Understanding monotropism sheds light on the unique cognitive processing styles of autistic individuals and underscores the importance of accommodating and supporting their diverse needs within various contexts.

Masking is a coping mechanism often encouraged, whether intentionally or unintentionally, within societal norms. It involves concealing or suppressing one's neurodivergent traits or behaviors to appear more typical or "normal" according to prevailing social expectations. This pressure to conform can be particularly pronounced for autistic individuals and others with neurodivergent traits, leading to a sense of discomfort or inauthenticity as they navigate social interactions and environments.

The promotion of masking reflects a broader societal discomfort with visible manifestations of neurodivergence, such as verbal tics in individuals with Tourette's syndrome. This discomfort may prompt efforts to suppress or extinguish such behaviors, ultimately marginalizing neurodivergent individuals and undermining their mental health and well-being.

Camouflaging expands upon the concept of masking, encompassing the pervasive adaptation of behavior to navigate various social contexts. Individuals may engage in camouflage to blend in or fit seamlessly into neurotypical environments, even at the expense of their own comfort or authenticity. This phenomenon is particularly evident when neurodivergent individuals navigate spaces where their differences are not fully accepted or accommodated, such as workplaces discouraging stimming or other forms of neurodivergent expression.

The notion of belonging versus fitting in, as highlighted by Brene Brown, underscores the importance of authenticity and acceptance in fostering genuine connections and inclusion. Internalized ableism, stemming from societal norms and expectations, can exacerbate feelings of inadequacy or self-doubt among neurodivergent individuals, perpetuating harmful beliefs about what it means to be "normal" or "acceptable."

In navigating these complexities, it's essential to recognize the potential impact of masking and camouflage on individuals' mental health and self-esteem. By promoting acceptance, understanding, and accommodation, we can create environments that embrace neurodiversity and foster a sense of belonging for all individuals, regardless of their cognitive differences.

I have given you many resources and slides today, and I will not read all of them. I have given them to you to refer back to later. However, I will read this quote in its entirety.

Alfie Kohn Quote

This is a quote from Alfie Cohen that I find so impactful.

“There is a time to admire the grace and persuasive power of an influential idea, and there is a time to fear its hold over us. The time to worry is when the idea is so widely shared that we no longer even notice it when it is so deeply rooted that it feels to us like plain common sense. At the point when objections are not answered anymore because they are no longer even raised, we are not in control: we do not have the idea; it has us.”

Kohn, Alfie. Punished By Rewards: Twenty-Fifth Anniversary Edition (p. 3). HarperCollins. Kindle Edition.

A Brief History

The pervasive influence of the medical model and behaviorism is evident in various societal frameworks and conceptualizations, including Maslow's hierarchy of needs. These frameworks often prioritize individualism and pathologize deviations from perceived norms, perpetuating a narrow understanding of human diversity and well-being.

By critically reflecting on these entrenched ideologies, we can begin to challenge their assumptions and explore more inclusive and holistic approaches to understanding human experiences and needs. Neurodiversity-affirming practice aligns synergistically with the principles outlined in the occupational therapy code of ethics, emphasizing respect for individual autonomy, dignity, and diversity.

Moreover, this approach resonates with the origins of medicine, which, despite its imperfections, initially aimed to understand and address the diverse needs of individuals within their social and environmental contexts. By embracing neurodiversity-affirming practices, we can uphold the moral imperative of promoting equity, justice, and empowerment for all individuals, regardless of their cognitive differences.

Origins of Medicine

Hippocrates, the father of medicine, discussed the interconnectedness of body, mind, and environment, the importance of diet, the importance of lifestyle, and even natural healing processes. He wanted to see more and more people taught what was evidence-based or best practice at the time. It was very holistic in nature.

The Medical Model

Various factors, including advancements in medical science, the rise of specialization, the development of technologies, and the Industrial Revolution, have influenced the shift toward the modern medical model. This transformation has led to a more specialized approach to healthcare, emphasizing the diagnostic process and the treatment of specific ailments. While this focus is crucial for addressing acute medical needs and emergencies, it has also contributed to a deficit-focused and pathology-oriented mindset within healthcare systems.

Historically, medicine has often prioritized identifying and treating diseases or disorders, overlooking the broader context of an individual's health and well-being. This narrow focus on pathology and symptom management has been reinforced by institutional structures and societal expectations, leading to a reductionist approach to healthcare.

However, it's important to recognize that this emphasis on diagnosis and treatment has its place within the healthcare system, particularly in addressing acute medical conditions and emergencies. Yet, when applied indiscriminately to all aspects of healthcare, it can overshadow the importance of considering individuals' holistic needs and experiences.

Historical Evolution

The anatomical theater serves as a striking example of historical medical practices that underscored the dehumanization of patients and prioritized the study of pathology over individual well-being. In these theaters, students observed surgeries and autopsies as part of their medical education, often without the explicit consent of the individuals involved. This lack of consent, coupled with power imbalances and societal norms, contributed to an environment where patients were objectified, and their bodies were reduced to mere subjects of study.

The Medical Gaze

Michel Foucault referred to this as the medical gaze, in which the biomedical paradigm stripped away holistic and client-centered thinking. We also filtered out all the other elements of a person's story. The tendency to categorize all differences as pathology or disease perpetuates harmful stereotypes and stigmatizes individuals who diverge from societal norms.

Application to Disability

This paradigm reinforces the notion that disability is solely the fault of the disabled person, framing differences as indicators of malfunctioning or maladaptation. By pathologizing diversity, society communicates to these populations that they are inherently devalued and burdensome, further marginalizing them and eroding their sense of worth and belonging.

Criticisms and Limitations of The Medical Model of Disability

This dehumanizing perspective is compounded by societal discomfort with visible differences, leading to the suppression or hiding away of individuals who do not conform to perceived norms. There is a pervasive desire to "fix" or cure disability for individuals to conform to societal expectations and appear "normal." This pressure to assimilate communicates to neurodivergent and disabled individuals that their true selves are unacceptable and must be concealed or corrected.

By challenging these deeply ingrained beliefs and embracing a more inclusive understanding of human diversity, we can work towards creating a society that values and celebrates the unique strengths and perspectives of all individuals, regardless of their differences. This involves shifting away from a deficit-focused lens and towards a framework that recognizes the inherent worth and dignity of every human being, irrespective of their abilities or differences.

What Does the World Health Authority Say?

The World Health Authority is not a big fan of the medical model, and they have lots of resources about the medical model and the social model of disability.

Hollywood and the Moral Model

The moral model of disability subtly infiltrates media and cultural representations, perpetuating harmful stereotypes and misconceptions. This model insinuates that disability is somehow deserved or the result of past actions, akin to a form of karma or moral judgment. While rarely articulated explicitly, these underlying beliefs contribute to stigma, discrimination, and victim-blaming attitudes toward individuals with disabilities and their families.

In popular media, examples of the moral model of disability can be seen in the portrayal of disabled characters as villains or as overly angelic and passive recipients of charity. Tokenism, another aspect of this model, involves including disabled characters or individuals in media or organizations merely for the sake of appearance without genuinely incorporating their perspectives or experiences.

For instance, in the Wonder Woman movie, Doctor Poison was portrayed as a villain with facial disfigurement, perpetuating the harmful stereotype that physical differences are associated with villainy or moral depravity. Such portrayals reinforce negative perceptions of disability and contribute to a culture that marginalizes and devalues individuals who look different or have disabilities.

By challenging these stereotypes and promoting more nuanced and authentic representations of disability in media and culture, we can combat the insidious influence of the moral model and work towards a more inclusive and equitable society that celebrates diversity and respects the dignity and humanity of all individuals.

Behaviorism

Behaviorism is applied behavior analysis in its most commonly understood form or modality. Many OTs are trained as BCBAs (Board Certified Behavior Analyst®). Occupational therapy is provided in many contexts, and a BCBA psychologist is the boss.

As Alfie Kohn discusses in "Punished by Rewards," behaviorism encompasses using rewards and punishment to shape behavior, a concept rooted in operant conditioning.

Operant Conditioning

In operant conditioning, behaviors are reinforced or punished, increasing or decreasing the likelihood of those behaviors recurring. The classic examples, such as Pavlov's dogs or the mouse pressing a lever for cheese, illustrate how behaviors can be conditioned through associations with stimuli.

However, applying behaviorist principles to individuals with disabilities can perpetuate harmful narratives and reinforce ableist attitudes. The notion of shaping a disabled person to become more "abled" aligns with societal expectations and norms, perpetuating the belief that there is a singular template for the "right" way to be human. This approach fails to recognize the inherent value and diversity of human experiences and abilities and overlooks the importance of embracing neurodiversity and disability as integral aspects of human variation.

What is Ableism?

Shaping is pushing a person to be "normal." When we discuss ableism and the push for normalization, it's crucial to recognize the oppressive nature of such endeavors. The foundation of our approach should be a fusion of evidence-based practice, clinical wisdom, and the voices of the communities we aim to support. This trifecta ensures a comprehensive understanding and response to their needs and experiences. 

Consider the autistic population, for instance. Their lived experiences provide invaluable insights into the challenges they face, including feelings of inadequacy and the alarming prevalence of mental health conditions. This community's stark reality of shortened life expectancy via suicide and co-occurrent heath disparities underscore the urgency of addressing systemic barriers and stigma.

Despite the wealth of information at our disposal, the echoes of oppression persist. Suicide rates among autistic individuals serve as a poignant reminder of the urgent need for change.

The Social Model of Disability

The social model of disability shifts the responsibility for disability away from the individual and onto the community, emphasizing the importance of addressing systemic barriers to full participation and inclusion. This approach resonates with occupational therapy's core philosophy and paradigm, prioritizing empowerment and accessibility for all individuals.

Intersectionality and Diversity

A popular, illustrative example of the social model's principles is the image of three people of varying heights trying to watch a baseball game over a fence. Instead of focusing on individual solutions, such as providing different-sized steps or platforms, the emphasis is on removing the barrier by removing the fence altogether. This concept embodies health equity, where each person has the opportunity to fully engage and participate, and inclusion, where systemic barriers are eradicated to create an environment where everyone can thrive.

Universal design plays a pivotal role in realizing these principles by creating environments and products that are accessible to all, regardless of ability. For example, installing ramps instead of stairs benefits everyone, not just individuals with mobility impairments, thereby promoting inclusivity and accessibility for all.

I love that Audre Lorde says, "There is no hierarchy of oppression." Many of our frames of reference or models for thinking and supporting our clinical reasoning can be seen as neurodiversity-affirming.

Occupational Therapy

As practitioners, a significant part of our journey involves unlearning our own ableism, engaging in reflective practice, and addressing the systemic biases and barriers within our professional spheres. It's essential to recognize that occupational therapy, in its origins, emerged from a subversive impulse—a response to the dissatisfaction with the status quo of institutionalized care, where individuals were relegated to passive recipients of basic necessities rather than being empowered to engage in meaningful activities and contribute to society.

Occupational therapy pioneers challenged this paradigm by asserting that engagement in purposeful activities was essential for healing and well-being. This ethos of empowerment and advocacy for meaningful occupation aligns closely with the principles of neurodiversity-affirming practice, which prioritize recognizing and celebrating the unique strengths and perspectives of neurodivergent individuals.

Neurodiversity-Affirming Practice

In this context, models such as Wilcock's "doing, being, becoming, and belonging" occupational model of health and Kielhofner's Model of Human Occupation offer frameworks that seamlessly integrate with neurodiversity-affirming principles. The MOHO emphasizes the importance of volition—the intrinsic motivation and desire to engage in personally meaningful occupations aligned with one's values and goals. By centering the individual's autonomy and agency in the therapeutic process, practitioners can support neurodivergent individuals in identifying and pursuing activities that promote their well-being and fulfillment.

When practicing neurodiversity-affirming approaches, it's essential to ensure equitable support and opportunities for all individuals, including those who are neurodivergent. This means challenging preconceived notions and creating inclusive spaces for celebrating growth and diversity.

For instance, in educational settings, if a neurodivergent student exhibits behaviors such as fidgeting, leaning on friends, or making noises, it's crucial to recognize that these behaviors may not be inherently problematic but rather expressions of individual differences. By reframing our understanding of these behaviors and providing support and resources as needed, we can create environments where all students, regardless of neurodivergence, can thrive.

Moreover, fostering social success involves teaching and supporting neurodivergent and neurotypical students. It requires unlearning internalized assumptions and biases, including ableism, and committing to trauma-informed and sensory-informed practices. By prioritizing the self-actualization and agency of each individual, we can help students engage in meaningful activities rather than focusing solely on non-preferred activities.

In pediatric occupational therapy, there is often an overemphasis on independence, neglecting the importance of interdependence and play as meaningful occupations. By embracing interdependence and recognizing play as both a means and an end, practitioners can create more holistic and inclusive interventions that promote the well-being and development of all children.

Ultimately, the goal is to cultivate environments where individuals feel empowered to be themselves and engage in activities that bring them joy and fulfillment. By shifting our focus from conformity to celebrating diversity, we can create spaces where all individuals are valued and supported in reaching their full potential.

Presuming Competence

The concept of presuming competence is a fundamental principle in neurodiversity-affirming practice that emphasizes believing in individuals' inherent abilities and potential, regardless of their neurodivergence. It challenges the notion of setting predetermined benchmarks for individuals' capabilities and instead encourages viewing each person's potential as boundless.

Presuming competence means recognizing that individuals with neurodivergent traits are at least as capable as their neurotypical peers and deserve access to the same opportunities for growth and development. It involves shifting away from paternalistic attitudes and patronizing language towards a stance of genuine belief in individuals' abilities to learn and succeed.

In pediatric occupational therapy, presuming competence requires practitioners to approach each child, believing they can learn and progress, regardless of perceived limitations. This mindset encourages practitioners to focus on identifying and supporting each child's strengths and abilities rather than dwelling on deficits or predetermined expectations.

Moreover, presuming competence challenges practitioners to reconsider traditional methods of assessing intellect and cognition, especially for non-speaking clients. Instead of relying solely on motor outputs or standardized assessments, practitioners should prioritize finding effective communication options that allow individuals to express themselves and demonstrate their capabilities.

By presuming competence, practitioners can create environments where all individuals feel valued, respected, and empowered to reach their full potential. It is a mindset that celebrates diversity, fosters inclusion, and promotes meaningful engagement for individuals across the neurodiversity spectrum.

The Least Dangerous Assumption

“In the absence of CONCLUSIVE data, educational decisions should be based on assumptions which, if incorrect, will have the least dangerous effect on the student.”

Anne M. Donnellan

The concept of the least dangerous assumption, proposed by Anne Donnellan, emphasizes the importance of making decisions based on assumptions with the least harmful consequences if they are incorrect. While Donnellan initially discussed this concept in the context of education, its applicability extends to various settings, including healthcare, social services, and beyond.

At its core, the least dangerous assumption encourages practitioners to prioritize individuals' well-being and autonomy by choosing assumptions that are least likely to limit their opportunities or negatively impact their lives. This means avoiding assumptions that underestimate individuals' abilities or potential, as these can lead to missed opportunities for growth and development.

Instead, practitioners should strive to make inclusive, empowering, and respectful assumptions of individuals' diverse strengths and capabilities. By adopting a curiosity, openness, and humility mindset, practitioners can create environments where individuals feel valued, supported, and empowered to achieve their goals and aspirations.

Vignettes

The least dangerous assumption would be to presume competence and provide alternative communication methods and opportunities for students to develop their knowledge and skills. Doing so creates a supportive environment that respects the individual's abilities and provides them with the necessary support to succeed.

On the other hand, underestimating the students' abilities and providing them with content for a developmental age attributed to them risks limiting their opportunities to demonstrate their true capabilities. This approach may lead to missed opportunities for growth and development, potentially harming the students by perpetuating low expectations and underestimating their potential.

Similarly, the least dangerous assumption in healthcare settings is presuming competence and involving the patient in decision-making. This approach respects the patient's autonomy and ensures that decisions are made collaboratively rather than on their behalf without their input. Failing to involve the patient and making assumptions about their abilities based on physical presentation or medical history can lead to significant harm and may result in legal repercussions if the patient's rights are violated.

In employment settings, presuming competence and providing equal opportunities for individuals who use communication devices to excel in their roles fosters an environment that values diversity and promotes inclusion. Restricting their job roles based on assumptions about their abilities can limit their potential contributions to the organization and perpetuate discrimination.

The least dangerous assumption is to presume competence and provide individuals with the necessary support and opportunities to thrive rather than making assumptions that underestimate their abilities and potential. This approach promotes dignity, respect, and equity and creates environments where all individuals can reach their full potential.

Client-Centered

We're presuming and facilitating competence and prioritizing volition. We must do this so the client is central to our goal-setting and clinical reasoning. This is never more precarious than in pediatrics, where we tend to make many decisions on behalf of the client and prioritize the parents' and teachers' goals over everything else.

Growth vs. Change/Recipe for Brain Growth

We want to support their idea of growth on their own terms so that they can self-determine. Ryan and Dechi's self-determination theory is a really beautiful resource for you to look at. At Star Institute for Sensory Processing, our approach centers around empowering individuals to become their favorite authentic selves. We aim to support individuals on their journey toward personal growth and fulfillment without attempting to change or normalize them.

Our therapeutic environment prioritizes creating a space where individuals feel regulated, integrated, and empowered to control their experiences. We strongly emphasize consent and collaboration in therapeutic services, ensuring individuals actively participate in their care.

Operating in a Space of Tension

Our ultimate goal is to promote flourishing and well-being, recognizing the profound impact that the environment can have on an individual's disability experience. Although some individuals may confront significant physical challenges, which can be inherently disabling, we are dedicated to providing support and resources that enable them to navigate these obstacles with dignity and autonomy. Our approach is firmly grounded in the belief that everyone deserves the opportunity to define and pursue their own unique path toward fulfillment and authenticity.

Autistic Play

Danny Witte's blog, "Danny with Words," offers profound insights into the experiences of disability, sharing both successes and challenges in a deeply moving manner. Through their writings, Witte sheds light on the pervasive issue of ableism in our society, challenging the notion that certain autistic behaviors, such as systemizing or lining up cars, are inherently wrong and in need of correction.

It's important to recognize that what society often deems inappropriate or abnormal play behaviors can hold value and significance for individuals with autism. For instance, lining up cars may bring a sense of order, satisfaction, and aesthetic pleasure. It's a reminder that what may seem unconventional to some is, in fact, a source of joy and engagement for others.

I like to remind people that every weekend around the world, adults pay money and show up to line up their cars at automobile fairs and carnivals. There's something very pleasing about these lines and lines of cars at these fairs, but looking at toy cars on carpeting is not. Many also like going to craft shops and looking at items such as shiny glassware.

By reframing our perspective and embracing diverse forms of play and expression, we can cultivate a more inclusive and accepting environment for individuals with autism. After all, the same behaviors dismissed as "wrong" in one context may be celebrated and appreciated in another.

An Affirming Approach

Celebrating our clients' authentic interests and play is paramount. Moving away from approaches focused on shaping, conditioning, and extinguishing behaviors and curing agendas requires deep self-reflection and a commitment to understanding and respecting neurodiversity.

Sensory integration and processing training can be invaluable, even for occupational therapists who may not specialize in sensory integration therapy. Understanding and addressing sensory needs is fundamental to promoting well-being and participation for individuals across the neurodiversity spectrum. It's akin to acknowledging the significance of respiration in sustaining life—it's an essential aspect of human functioning that cannot be ignored.

Sensory integration is a neural process, and recognizing its significance is crucial for providing effective care, especially for neurodivergent populations. For example, individuals in eating disorder clinics may have specific sensory needs that must be addressed to support their attunement to their bodies and their ability to pick up cues of satiety and hunger. These individuals may require movement and specific sensory experiences, such as heavy work, to feel grounded and connected to their bodies.

However, traditional approaches in such settings often take a one-size-fits-all approach, focusing primarily on calorie deficit-based interventions that may not align with the sensory needs of neurodivergent individuals. A sensory-informed approach can transform the therapeutic experience by acknowledging and accommodating these unique sensory needs.

Additionally, an affirming approach involves being open to the possibility of making mistakes and being willing to apologize when necessary. Acknowledging that therapists are also continuously learning and evolving fosters a sense of trust and understanding between the therapist and the client. This willingness to apologize and learn from mistakes demonstrates humility and models resilience and growth, contributing to the overall well-being of both the therapist and the client.

Neurodiversity-Affirming Practice: Social Skills

We also want to avoid traditional social skills training to align with social role valorization. 

Social Role Valorization (SRV) indeed aims to enhance the social roles of individuals with disabilities by emphasizing the importance of socially valued roles in society. However, there is a risk of inadvertently reinforcing ableism and perpetuating the notion of "normalcy" by focusing solely on conforming to socially valued roles.

While the intention behind SRV is often well-meaning and altruistic, it's essential to recognize that true inclusion and equity require more than just teaching individuals to fit into predefined social roles. Addressing structural inequities and cultural barriers is crucial for creating a truly inclusive society where diversity is celebrated and valued.

By challenging ableism and advocating for systemic change, we can work towards dismantling barriers to inclusion and promoting a more equitable society where individuals of all abilities have the opportunity to thrive in roles that are meaningful to them.

Deficit Model

When we standardize social skills training and expect individuals to conform to predetermined rules, we overlook the diversity and nuances in social interactions. It's essential to recognize that social interactions vary greatly from person to person and from situation to situation. By focusing solely on teaching individuals with autism or other neurodivergent conditions to adhere to neurotypical social norms, we may unintentionally reinforce the double empathy problem. This problem arises when there's a mutual incomprehension between autistic individuals and neurotypical individuals, with the burden often disproportionately falling on the autistic individual to adapt and conform. Instead of imposing rigid social skills training programs, we must adopt a more flexible and inclusive approach that acknowledges and respects the diverse ways individuals communicate and interact. This involves fostering understanding and acceptance of neurodiversity, promoting empathy and mutual respect, and creating environments where all individuals feel valued and included.

Diane Parnam Quote

"Let us juxtapose behavior modification with sensory integrative treatment methods. Behavior modification typically centers on systematically administering rewards and punishments by agents outside the child, such as parents or therapists. Implicit in this treatment is a valuing of controls on behavior that are external to the child. Conversely, sensory integration focuses on the degree to which the child can organize his or her behavior. The role of the therapist is to organize the environment to maximize the likelihood of success and increase complexity in child-directed activities. Thus, there is an implicit valuing of internal, within-child controls on behavior." 

Parham, D. L. (1987). Toward professionalism: the reflective therapist. American Journal of Occupational Therapy, 41(9), 555–561. https://doi.org/10.5014/ajot.41.9.555

This 1987 article by Dr. Parham resonates deeply with me, particularly its focus on the reflective therapist and the importance of supporting individuals to organize their own behavior. Dr. Parham highlights the distinction between externally organizing someone's behavior and valuing controls on behavior versus empowering individuals to self-organize. This philosophy closely aligns with occupational therapy principles, such as Jean Ayre's goal of fostering a self-organized child. This concept directly relates to self-actualization and self-determination, allowing individuals to define who they want to be on their own terms and engage in activities because they genuinely want to, not because they feel compelled to by external forces.

Neurodiversity-Affirming Practice: Adulthood

We strive for sincerity and authenticity in client interactions, always respecting their consent and honoring their spirit. This means celebrating them as intentional occupational beings, even if they engage in behaviors like "info dumping" or stimming, which are often misunderstood. Info dumping, for example, is a way for autistic individuals to express care and excitement by sharing their special interests, not just a social deficit to be corrected. Stimming serves various functions and shouldn't be automatically extinguished. Instead, we should work on what's necessary and support clients to be successful while creating shared meaning and joy.

You can contact me, and I can send you a "stimming" flow chart I have co-developed.

The Double Empathy Problem and Attunement

It's important to divide the labor rather than placing all the burden on the neurodivergent individual. This approach challenges myths perpetuated by theories like Simon Baron-Cohen's triad of autism deficits, particularly the idea that autistic individuals lack empathy or are solely focused on inanimate objects. In reality, many autistic individuals are highly empathic, and such misconceptions can be harmful.

Non-Autistic Perspective

We aim to promote an understanding among our non-autistic colleagues and classmates that diverse communication styles should be celebrated and accommodated. By embracing and respecting different communication styles, we can foster a shared culture and create safe spaces where everyone feels valued and included. 

Misconceptions About Empathy in Autism

It's crucial to challenge pervasive misconceptions, often perpetuated by movies and media, about autism and other neurodivergent conditions.

Impact on Mental Health and Well-being

It's important to be in spaces in affirming ways. We also need to embrace the concept of different, not less. 

Reciprocity in Social Interactions

Earlier, we discussed reciprocity, the mutual exchange of social cues, and the double empathy problem.

Noah Sasson's Key Findings

Noah Sasson has also researched the above concepts and found that non-autistic people are quicker to judge, dismiss, and disengage from autistic people. Meanwhile, autistic individuals often try harder but may not succeed as well due to the differences in social communication styles.

Autistic-to-Autistic Interactions

In autistic-to-autistic interactions, there tends to be better rapport and shared understanding. This highlights the importance of autistic culture and the significance of helping autistic individuals find their community. Doing so can be incredibly affirming, healing, and valuable for their well-being.

Enhancing Social Inclusion

Creating safe and inclusive social spaces, such as autistic hangouts led by autistic individuals, is essential for fostering a sense of belonging and community.

Therapeutic Supports

In this regard, corrective recapitulation involves replacing negative experiences with positive ones through repetition, safety, and co-regulation. This process aligns closely with occupational therapy principles, promoting healing through meaningful and positive co-occupations.

What Next?

Engaging with neurodivergent voices on social media and seeking out educational resources and webinars led by neurodivergent individuals can contribute to continuous learning and reflection. Platforms like YouTube and websites such as Neuroclastic offer valuable resources.

Therapeutic Use of Self

As you reflect critically, consider addressing the double empathy problem by achieving mutual understanding and empathy. Reflect on any biases or assumptions you may need to unlearn to create more inclusive and affirming environments for neurodivergent individuals.

Environmental Accommodations

Implementing environmental accommodations is crucial for promoting inclusivity and accessibility. Instead of normalizing people, we should normalize accommodations to create dynamic and inclusive spaces like classrooms. Universal design principles can guide us in creating environments that benefit everyone, regardless of their neurodivergent status.

Key Points

• Listening doesn’t have a look
• Communication is key (provide options)
• Presume competence
• Respect body autonomy
• Strength-based language in every conversation and all documentation
• Avoid power struggles – that is YOUR red flag
• Avoid tolerating, non-preferred, extinguishing, extinction, etc.
• Minimize positive reinforcement
• Never use time out or restraint

"Listening doesn't have a look" is a powerful reminder that effective listening can take many forms and doesn't always involve traditional behaviors like eye contact or stillness. Recognizing and accommodating diverse listening styles is essential to ensure that individuals can fully engage and access the curriculum. This concept aligns with students' legal rights in educational settings, emphasizing the importance of creating inclusive environments that support diverse learning needs.

ND Affirming Practice: Respects and Understands

Embracing the social nature of autistic and neurodivergent populations is crucial. It's essential to recognize that they are interested in social connections and belonging, just like anyone else. Access to various communication options allows them to express themselves authentically and discover their identity. Additionally, supporting their regulation, sensory integration, and processing needs is vital for their overall well-being. Occupational therapists are key in addressing these aspects and helping individuals thrive in social settings.

Allyship

Being an ally is crucial, especially for those with more social power and privilege. Allies can use their influence to advocate for marginalized communities and work towards creating more inclusive environments. Occupational therapists, committed to helping individuals achieve their full potential, have always been positioned to be agents of social change and advocates for diversity and inclusion.

Ottawa Charter for Health Promotion/World Health Organization

"To achieve complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations."

Affirming Client-centered Care

It's important to make space for mischief and non-compliance in the lives of neurodivergent clients, especially in pediatric settings where childhood experiences are often sanitized. Allowing room for harmless mischief and occasional non-compliance can contribute to developing self-awareness and understanding of consequences. Occupational therapists can support their development by helping clients assess risk and make accurate predictions about their actions, starting with sensory integration and extending to abstract thought.

Furthermore, when clients ask for support on their own terms, therapists can assist in developing skills to navigate existing societal paradigms, such as preparing for job interviews and addressing concerns about potential dismissal.

Example

Let's talk about what you can do in the first five or 10 minutes. Here is an example.

"Hi. My name's Virginia. I find making eye contact difficult. So, I'm making eye contact with you now to explain myself. I hope it's okay with you if I don't make it so much as our conversation continues." We're teaching cultural competence and how to navigate a neurotypical world, but we're not teaching masking or camouflaging.

The Power We Hold

Advocacy and neurodiversity-affirming practices should permeate every aspect of occupational therapy, including documentation. It's essential that every document produced by my team serves as advocacy, demonstrating our unwavering support for neurodivergent individuals. Even if a child reads these documents as an adult, I want them to see that we were genuinely on their side in every situation, advocating for their needs and affirming their neurodiversity.

J. L. Eberhardt

"Bias, even when we are not conscious of it, has consequences that we need to understand and mitigate. The stereotypic associations we carry in our heads can affect what we perceive, how we think, and the actions we take."

Eberhardt, J.L., (2019) Biased: Uncovering the hidden prejudice that shapes what we see, think, and do. Penguin Books

It is crucial to fully comprehend the repercussions of our subconscious assumptions and biases. Embracing diversity entails becoming at ease with individuals who possess different experiences and viewpoints. While this journey may present challenges, it also offers personal growth opportunities, expanding one's horizons and confronting concealed biases. We've covered a lot of ground, and I hope it has been illuminating.

Summary

Let's now go to the exam poll to wrap everything up.

Exam Poll

We are going to do an exam poll now.

1) What is a TRUE statement about neurodiversity?

A. All brains are different.

B. Divergent ways of processing and experiencing the world are natural and to be celebrated.

C. We are all neurodiverse.

D. All of the above are true.   Correct Answer

Brilliant. You all got this one correct. The answer is D.

2)What is masking?

A. A social strategy, often employed unconsciously, where neurodistinct individuals alter their behavior and mannerisms to conform to social expectations, often at the cost of natural identity.   Correct Answer

B. A term coined by Dr. Damian Milton to explain the phenomenon of mutual incomprehension between autistic and non-autistic communication partners.

C. An individual’s ability to exert their free will and act on their own volition or on their own terms. Includes the ability to give and withdraw consent freely.

D. An individual's capacity for intentionally causing change. The ability of an individual to make things happen, and to be the author of my own actions.

Yes, 95% of you got that right. Excellent. It is a social strategy often employed unconsciously when neurodistinct individuals alter their behavior and mannerisms to conform to social expectations. 

3) A neurodiversity-affirming practice includes ALL of the following characteristics EXCEPT:

A. Gives power to the client

B. Does not challenge systemic barriers   Correct Answer

C. Is sensory informed

D. Growth versus change

Neurodiversity-affirming practice gives power to the client, is sensory-informed, and prioritizes growth over change. It challenges the barriers and systems preventing participation, so B is the correct answer.

4) Experiences needed for brain growth require:

A. Regulation

B. Motivation

C. Novelty and intensity

D. All of the above   Correct Answer

The correct answer is all of the above, as brain growth needs all of these things.

5)Which is NOT an example of therapeutic support?

A. Opportunities for social flourishing

B. Inclusive design

C. Using the deficit model   Correct Answer

D. Family and caregiver support

We oppose the deficit model when being neurodiversity-affirming, so C is the correct answer.  

Please stay in touch. I work for Star Institute, which is a 501 nonprofit. We'd love to hear from you. 

• www.sensoryhealth.org
• virginia.spielmann@sensoryhealth.org

Questions and Answers

What are your views on Applied Behavior Analysis (ABA) therapy for autistic individuals?

It's noteworthy to highlight that a significant majority of autistic individuals who have undergone ABA interventions report experiencing harm. This sentiment is not only reflected in research and literature but also in numerous polls. While there may be exceptions, such as autistic individuals who become Board Certified Behavior Analysts (BCBAs), the prevalence of negative experiences suggests a deeper issue with the underlying philosophy of behaviorism itself. The concept of "helping people be normal" inherent in behaviorism bears resemblance to conversion therapy, a practice widely acknowledged as harmful and detrimental to one's sense of self. In contrast, the core values of occupational therapy, which prioritize supporting individuals' volition, meaningful engagement in occupations, self-actualization, and agency, are more aligned with affirming and empowering approaches within our field.

References