A Framework for Neurodiversity-Affirming Interventions for Autistic Individuals

In recent years, scholars at the vanguard of clinical psychology have moved towards more explicitly embracing intervention frameworks for traditionally marginalized groups who have historically had a great stake, but little say, in how interventions for themselves have been designed, developed, and focused (e.g., transgender-affirming care; healing racial trauma; Anderson & Stevenson, 2019; Austin & Craig, 2015). Despite being targets of intervention practice and research for over 60 years, autistic people have been left out of the conversation. Until recently, nearly no research or implementation work has sought the input of autistic people in regard to the design of interventions and, more importantly, how the goals for such interventions are prioritized and determined. As such, the very interventionists who are most invested in the autism community are increasingly often furthest from the discussions needed to advance autism interventions that maintain standards of ecological validity, community engagement, and methodological rigor. As a result, large schisms have formed around some of the most widely-used approaches.

Resolving such gaps in other traditionally marginalized populations has historically involved embracing broader frameworks that reconceptualize the nature of the challenges a given population faces. Such frameworks are characterized by an appreciation of the fact that, in such groups, the presence of mental health challenges is often a product of – and inextricable from - existing in an environment that devalues core aspects of an individual’s identity, and that the context in which one exists (social, academic, professional, family) is often a more amenable and appropriate target for intervention.

Such a framework has already arisen in the autism field, in the form of neurodiversity. While there are many competing approaches to conceptualizing neurodiversity, the core principles usually involve embracing diversity through the lens of different neurological ways of being. The neurodiversity movement aims to shift how autistic experience is viewed in educational, clinical, research, and societal settings. This is, instead, framed as a distinct way of being in the world, as worthy as any other – regardless of an individual’s patterns of ability and aspects of disability. Thus, autism and other forms of neurodiversity are considered identities with social dynamics that are similar to other forms of marginalization.

This reframe has profound implications for autism-focused interventions and research, most of which have aimed to reduce or eliminate autism symptoms, with variable empirical support (Bottema-Beutel, 2023). These outcomes are practically and ethically incompatible with a neurodiversity perspective. Most prominently, applied behavior analysis (ABA), which was the first intervention approach widely applied to autistic people, has come under increasing scrutiny and criticism for failing to include autistic people the design of intervention elements and consideration of goals; moreover, autistic people are increasingly identifying iatrogenic effects they have experienced when receiving ABA (Bottema-Beutel), with these concerns often being met with minimization rather than an endorsement of their validity and willingness to hear them out. Thus, there is a pressing need for a neurodiversity-affirming interventions (NAI) framework for autism.

What should a NAI framework prioritize? Dawson et al. (2022) recently highlighted that neurodiversity challenges autism researchers to think more deeply about which outcomes really matter, and which procedures (e.g., inclusion of autistic people across all stages) can uplift neurodiverse perspectives in early intervention. Interventions exist for autistic individuals across the lifespan, and a NAI framework should follow suit.

Neurodiversity entails appreciating the unique profile of each individual. Thus, NAIs should reframe the goals of interventions to focus on supporting the strengths - including the social strengths - of autistic individuals, and creating environments that foster them. This can mean teaching peers how to include people with a range of differences, empowering individuals to identify and value their own sense of purpose and meaning, affirming autistic-led and -focused contexts as inherently productive settings, and training clinicians, educators, and leaders to make the settings in which they work more affirming to autistic people.

However, crucially, the aim of NAIs should not be to ignore or downplay the challenges that autistic people face – and practitioners should be mindful of the risk that purely “strengths-based” approaches may do precisely this – but, instead, identify venues, approaches, and tools that allow those strengths to be more evident even in the face of these challenges. They also should aim to do this in ways that do not unduly or disproportionately burden the autistic person cognitively or emotionally. Importantly, there is a nascent body of interventions that do precisely this, which have begun to show an intriguing pattern of empirical results. They positively impact those selfsame challenge domains that are traditionally targeted (e.g., difficulties with social connection), but without explicitly doing so (i.e., without trying to teach rules for “correct” behavior; McDonald et al., 2022). In this way, they are often incidentally achieving the same goals that have long been targeted, while explicitly focusing on goals that have often been ignored, and engaging a different (and perhaps more humane) set of mechanisms and contingencies. Most centrally, they exemplify a NAI priority of not trying to increase normalization and compliance as outcomes.

If NAIs do not prioritize normative social behavior, what should they prioritize? We contend that NAIs should focus on facilitating interdependence across the lifespan. This is ideally how nondisabled persons are taught: to collaborate and engage with people with a range of strengths and challenges to achieve common social goals. Traditionally, interventions aimed at addressing challenges faced by autistic people have sought to reduce behavioral or cognitive challenges that interfere with independent functioning. However, this approach risks creating unrealistic expectations, and standards to which neurotypical individuals are not held: most individuals aim to live fulfilling lives enmeshed in a supportive environment with others on whom they can rely for support and vice versa; autistic individuals are no different. Indeed, what is social success, if not the ability to offer reciprocal benefit and support to one’s family and community? Interdependence exemplifies such success.

In practice, NAIs must contend with the aforementioned history of lack of choice in the intervention process. Autistic people have often not had a say in whether they receive a given intervention, or what the goals and practices of that intervention are. While this issue is endemic to the ethical discussion about intervention practices for various populations (e.g., children do not typically self-refer; clinicians are bound by Tarasoff and similar statutory guidelines when a client indicates likelihood of imminent harm to self or others), its application in autism is often overly-broad. Autistic people are often perfectly competent and capable to effect self-determination when given appropriate tools and supports, regardless of expressive language ability. The lack of choice they are given in interventions belies this fact. Autistic people should be given the opportunity to make informed choices about what their interventions are, what they do, and what they target. NAIs must prioritize this opportunity in both research and practice, particularly through the use of participatory approaches.

Finally, given that NAIs draw from frameworks designed to uplift traditionally marginalized groups, it is valuable to ensure they are framed and explicitly prioritize the intersectional identities of individuals who will inevitably experience them (e.g., Black, Brown, and transgender autistic people; Lopez et al., 2022; White et al., 2023). Crucially, the NAI framework is not meant to be limited to oral communicators with average-or-above measured IQ and few support needs; rather, it must be applied, understood, and studied across the spectrum of ages, cognitive and verbal ability, and full complexity of autistic life. Ethically, it is incumbent upon researchers and practitioners to advance methods to ensure these perspectives can be validly included. Indeed, it is these identities and populations for whom an NAI framework is perhaps most urgently needed, as they are at the highest risk – and have the longest history – of not having their communicative intent regarding, and their experiences affirmed. The field of autism interventions is vast, and has already seen the beginning of a shift towards considering neurodiverse perspectives (Dawson et al., 2022). With the establishment of an NAI framework, future research and practice can have a guidepost against which to adjudicate not only efficacy and effectiveness, but also alignment with the values, goals, interests, and experiences of the people these interventions aim to help.