Delivering effective psychological therapies and interventions for autistic and otherwise neurodivergent people
Language and terminology statement: As understanding about neurodiversity develops, it is natural that the language used to describe it will evolve, and it is important that we adapt our language to reflect these changes as they occur. We will continue to listen to neurodivergent people and take their lead on this. This is consistent with a Human Right’s based approach now enshrined in Scottish law and in policy, e.g., the Children & Young People – National Neurodevelopmental Specification: Principles and Standards of Care, 2021, as well as the Scottish Government Learning Disability, Autism and Neurodiversity (LDAN) Bill consultation, 2023. While we do refer to specific neurodevelopmental diagnoses in this document, primarily to highlight the evidence-base for intervention and supports, our goal is to use a broad neurodiversity-affirming lens.
Language about identity is, by its nature, a personal choice, and individuals have preferences about how to describe themselves, e.g., neurodivergent, autistic person (identity first) vs person with autism (person first) etc. Checking with people in an open and straightforward way is good clinical practice, as is understanding that their preferences about language may change over time. Recent research and consultations suggest a preference for “identity first” language in the Autistic community so we have used this throughout the present document (Kapp et al., 2013).
As humans, we all have different ways of thinking and experiencing the world - no two brains function the same; this benefits us all, in the same way as diversity benefits any ecosystem. The term, ‘neurodivergence,’ describes individuals for whom elements of cognition and function are out-with the typical for the population (often referred to as neurotypical or ‘neuro-majority’) e.g., social communication, social interaction, emotion regulation, sensory processing, attention, language processing and use, motor development, executive and cognitive functioning.
We understand the term ‘neurodivergence’ to be broader than specific diagnoses such as Autism or Attention Deficit Hyperactivity Disorder (ADHD). Some individuals might meet criteria for a diagnosis while others may not, but still have a neurodivergent profile; others might meet criteria for more than one condition because co-occurrence is the norm. For example, in Autistic children, studies suggest between 37-85% have co-morbid features of ADHD (Rao & Landa, 2013).
Whether neurodivergence leads to difficulties with wellbeing and mental health depends on a range of factors. Aspects of neurodivergence may confer advantages, e.g., the ability to ‘hyper-focus’ on tasks or special interests can lead to expertise in a particular field, excellent attention to, and memory for, detail as well as creativity, lateral thinking, and compassion. On the other hand, neurodivergent individuals can be at higher risk of experiencing stress and overwhelm and vulnerability to these varies according to environmental factors and life stages. It is important that services are aware of potentially helpful environmental accommodations and that vulnerabilities at different life stages are anticipated and supported, e.g., the sensitivity of those who have ADHD to hormonal fluctuations, such as puberty, menstrual cycles, and menopause. Finally, neurodivergence can occur alongside any level of intellectual ability and can include those who have a Learning / Intellectual Disability (LD / ID). There are additional evidence reviews and practice guides for people with learning / intellectual disabilities and these can be considered alongside this guidance.
It is recommended that services operate in a neurodiversity-affirming way demonstrating awareness and acceptance of neurodivergence, without stigma or stereotype and seeking to highlight strengths and talents in the neurodivergent population, as well as recognise and support challenges. Services should adapt their service delivery to reduce barriers and allow equity of access to support, including to psychological interventions, while recognising that everyone is an individual and approaches should be tailored to suit presenting needs.
Adaptation of psychological therapies and interventions for people who are neurodivergent – Rationale and Context:
Access to evidence based psychological therapies and interventions is important because coexisting mental health problems, particularly anxiety and depression, are more prevalent in the neurodivergent population. Around 70% of autistic people meet criteria for one mental health condition that impairs functioning (NICE, 2017) and ADHD is a risk factor for several mental health conditions (Meisinger and Freuer, 2023). Neurodivergent CYP (Children & Young People) are more likely to be bullied / rejected by their peers and to experience adverse childhood experiences (Hoover and Kaufman, 2018) and maltreatment (Dinkler et al., 2017). They are at higher risk of exposure to traumatic events overall (Ford et al., 2009) and may be at increased risk of developing post-traumatic stress disorder following a traumatic event (Adler et al., 2004 and Gurvits, et al., 2000). It is important to remember that how an event is experienced may be different for neurodivergent people who can have intense emotional reactions to events that others may not experience as typically traumatic. Services should adopt Trauma Informed approaches, see the NES National Trauma Training Programme for more on this. Lifetime experience of suicidal ideation may be nine times higher for neurodivergent compared to neurotypical people (Cassidy et al., 2014). NICE suicide prevention guidance recognises autistic people as being among those at highest risk of suicide (2019). People with ADHD are also at higher risk of suicidal thoughts, plans and suicide attempts (Septier et al., 2019).
Many individuals report a need to mask their neurodivergent traits, e.g., supressing natural actions and responses or using ways of regulating sometimes described as ‘stimming’, tolerating environments that they find challenging, socialising more than they want to and in general working hard to ‘look’ neurotypical.
Psychological assessments and interventions should provide an environment which is supportive, understanding and accepting of difference and can provide a space to encourage people to understand, and celebrate, themselves as they are.
Finally, neurodivergent individuals can present their mental health difficulties differently to neurotypical people, for example, Autistic CYP can find it hard to recognise and talk about their anxiety and present instead with dysregulated behaviour, which can impede access to evidence-based psychological interventions (Ozsivadjian and Knott, 2011).
Adaptation of psychological therapies and interventions for people who are neurodivergent - Principles
Suggested adaptations, based on the literature, are summarised in a table available HERE, and follow two main principles:
- Environmental adaptations should be considered initially post diagnosis, along with psychoeducation (RC Psych CR235, 2023). Psychoeducation and post diagnostic support are key to develop understanding about how best to adapt the physical and interpersonal environment, and in most cases should be offered to all CYP and adults who receive a ND diagnosis (NICE 2017/2019). This may positively impact mental health and wellbeing and negate the need for further psychological intervention or therapy.
- The psychological therapies literature often focuses on adaptations to CBT (Cognitive Behavioural Therapy) and there is growing evidence that adapting talking therapies increases their effectiveness for autistic people (Walters et al., 2016). Where neurotypical individuals would be offered specific therapies based on their presentation (as described in evidence tables in The Matrix), this should be replicated for neurodivergent people, and adapted to the needs of the individual. A diagnosis of a neurodevelopmental condition is not a reason to withhold therapies, and intervention should not be postponed until diagnostic assessments are completed (SIGN 2016).
Clinicians should be mindful that referral to psychological therapies may not come from the individual themselves, and this can have a significant, and understandable, negative impact on engagement (RCP, 2023).
Neurodivergent-affirming report writing
When writing reports avoid deficit-based language and remain focussed on an individual’s strengths as well as their difficulties (e.g., instead of “poor eye contact” say, “listens best when not making direct eye contact”). There are some other suggestions in Divergent Perspectives. When diagnostic criteria are included in a report, the rationale for using deficit-based language should be explicit, e.g., for ADHD the symptoms must impair functioning for the diagnosis to be given, but the rest of the report should use neurodivergence-affirming language wherever possible.
Clinical guidelines and additional resources:
SIGN (Scottish Intercollegiate Guidelines Network)
SIGN 145 (2016): Assessment, Diagnosis and interventions for autism spectrum disorders.
NICE (National Institute for Health and Care Excellence)
The following clinical guidelines from NICE are relevant for neurodevelopmental disorders.
Autism spectrum disorder in under 19s: recognition, referral and diagnosis (2017)
Autism spectrum disorder in under 19s: support and management (2021)
Autism spectrum disorder in adults: diagnosis and management (2016)
Attention deficit hyperactivity disorder: diagnosis and management (2019)
Royal College Psychiatrists:
Attention deficit hyperactivity (ADHD) in adults: Good practice guidelines (2023)
Scottish Government:
NHS Education for Scotland (NES):
Further resources about Autism and Neurodiversity Across the Lifespan can be found on TURAS here.
Authentisitic Research Collective (2021):
Psychological Therapy for Autistic Adults (1st digital ed.).
National Autistic Society (NAS):
The National Autistic Society (NAS, 2020) & Mind co-produced (with Autistic people and their families) an excellent Good Practice Guide for those who deliver talking therapies.
Wider work developed by the media and Scottish Government is also helpful in developing greater understanding and acceptance of neurodiversity in society and some helpful examples include: Inside Our Autistic Minds / My Autism and Me, Different minds, One Scotland.
Acknowledgements
Technical group: Dr Kimberley Ross, Dr Suzy O’Connor, Dr Jill Jones, Dr Doug McConachie, Fiona Young.
Advisors: Dr Joshua Muggleton, Dr Marion Rutherford.
Table: Taking account of neurodivergent thinking styles and preferences to increase access to psychological therapies
This table includes elements of the ‘Autistic SPACE’ framework (SPACE – Sensory, Predictability, Acceptance, Communication and Empathy) (Doherty, et al 2023). While this is a model often used for autistic individuals, it may be helpful for all neurodivergent and neurotypical individuals. The table also includes literature from NICE guidelines (both for autism and ADHD) as well as the National Autistic Society’s (NAS) Good Practice Guide for delivering talking therapies to autistic adults and children (see clinical guidelines section for references).
This guide suggests a range of possible adjustments, but all neurodivergent people are different, and adaptations must be discussed and agreed collaboratively.