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Abstract

Historically, educational and clinical practice with autistic children centred on developing their ability to ‘fit in’ and achieve neurotypical milestones. The neurodiversity movement aims to shift the focus from normalising behaviours to acceptance of the autistic child and inclusion with neurotypical peers while acknowledging differences. However, a review of how educators, and service providers can practice in a neurodiversity-affirming manner has not been conducted. This scoping review collated and synthesised the current literature on neurodiversity-affirming approaches in education, health and social care for autistic children. The authors searched eight databases up to July 2023. Qualitative content analysis guided data synthesis. Twenty-six studies were included, with 1,151 participants across the included studies. Results indicate that educators and service providers can practice in a neurodiversity-affirming manner through adapting the environment and changing their approach to interventions. Environmental adaptations can include integration of topics of interest to the autistic child, supporting acceptance of autistic children to peers, educators, and service providers, and a flexible classroom and curriculum. Interventions for autistic children should focus on their quality of life, value autistic communication, appreciate autism as part of human variation, and eliminate goals relating to ‘masking’.

Lay Abstract

Autistic children are commonly forced to ‘fit in’ to behave more like their neurotypical peers. This has been commonly seen in both education and clinical practice. For example, when autistic children go to the doctor, they will often be compared to their neurotypical peers to make sure milestones are being met, rather than seeing the autistic child as their own person. It is important that when professionals are providing any type of care for autistic children that they do so in a way that accepts their behaviours and supports the child to be their true self through inclusive strategies, such as changing the environment to meet the autistic child's interests, behaviours and needs. This is called neurodiversity-affirming care. The purpose of this article was to examine past research to better understand how neurodiversity-affirming care is being used or not being used in the areas of education, health and social care. This article describes ways that professionals can support neurodiversity-affirming care for autistic children such as through adapting the environment to include the interests of the autistic child, supporting neurotypical peers to interact with autistic children, and being flexible in how autistic children learn in classrooms. This article suggests that neurodiversity-affirming care interventions should include (1) focusing on the quality of life of the autistic child, (2) valuing autistic communication and (3) eliminating goals that are related to ‘masking’ autistic behaviours.

Keywords

Autism education health services interventions – psychosocial/behavioral

Introduction

Autistic children have the right to participate in all aspects of life that align with their values and identity (Office of the United Nations High Commissioner for Human Rights, 1990; United Nations, 2006). Despite the agreement across the field of disability studies on the rights of autistic children, a conceptual divide exists about the nature of being autistic, impacting the way that autistic people's rights are realised. The neurodiversity movement promotes acceptance of neurodivergence as a part of a person's identity; a difference rather than a deficit (Kapp, 2020). In contrast, other disability scholars maintain that the Social Model of Disability denies the impairment experience (Hickey & Wilson, 2017). The Capabilities Approach bridges some of this divide by exploring how the interactions between person's skills and impairments, the environment, and the available resources determine what they can do and be (Nussbaum, 2011). The central outcome is a person's set of capabilities; their choices in engaging in valued activities (Nussbaum, 2011). For example, if an autistic child has limited access to valued play opportunities, then they are denied the right to play, and there is a need to increase appropriate resources, modify environments or support skills (Sterman et al., 2018).

Being autistic in a neurotypical society without appropriate supports can lead to stress and burnout (Dallman et al., 2022; Taylor, 2022). Despite masking or camouflaging leading to increased depression and suicide among autistic people (Cassidy et al., 2018; Miller et al., 2021), many common clinical interventions continue to use behavioural intervention approaches to promote ‘preferred behaviours’ (Dallman et al., 2022; HM Government, 2021; Towle et al., 2020). The autistic community has shown a clear preference against behavioural interventions in favour of identity or neurodiversity-affirming approaches (Sterman et al., 2023). A recent survey indicates that although most occupational therapists continue to practice within a medical model focused on remediating impairments, there is a growing desire for occupational therapists and other clinicians working with autistic children to practice in a neurodiversity-affirming manner (Carlson-Giving, 2023b).

While there is no agreed upon definition of neurodiversity affirming care, in this scoping review we considered neurodiversity affirming approaches to be ways of providing health, education or social care services that affirm and support the identities of autistic children with a focus on modifying environments or tasks. This contrasts with deficit-focused approaches that seek to remediate perceived impairments associated with autistic traits, develop goals to have autistic children act in a more neurotypical manner, uses behavioural approaches drawing on the principles of applied behavioural analysis (ABA), or considers autism something inherently negative that should be prevented or treated (Najeeb & Quadt, 2024). To consider the full age spectrum of children and youth, this review followed the United Nations definition of children as anyone under the age of 18 years of age (Office of the United Nations High Commissioner for Human Rights, 1990).

Previous reviews have examined the trajectory of research, focusing on making the case for neurodiversity-affirming approaches (Pellicano & Houting, 2021). While neurodiversity affirming practice can be interpreted in many ways, for this study we conceptualised it as interventions that support autonomy, self-determination and wellbeing of autistic children and their families; remediate areas that cause discomfort, distress or risk to the autistic person or their family; and do not try to change nonharmful autistic traits such as stimming (Ne’eman & Pellicano, 2022). It is important to privilege autistic voices in the conceptualisation of neurodiversity affirming practice, and Ne’man is a cofounder of the autistic self-advocacy network (ASAN), the USA's leading autistic self-advocacy group. This definition supports a balanced consideration of practice, that acknowledges that autistic children have areas that they could benefit from interventions to address, such harmful actions or skill acquisition, while not trying to change core aspects of the autistic child. From the literature it is recommended that educators and service providers practice in a neurodiversity-affirming manner with autistic children; however, they need guidance on how to provide care that is neurodiversity-affirming, especially given the lag with knowledge translation (Doyle & McDowall, 2022). A review that collates how educators and service providers can provide care in a neurodiversity-affirming manner has not been conducted. This scoping review will therefore build on the literature base to better understand how to enact a neurodiversity-affirming approach. We sought to map and synthesise the peer-reviewed literature on how educators and service providers can promote neurodiversity-affirming values when working with autistic children. This scoping review aims to answer the question: What are the components, enablers and barriers of neurodiversity-affirming care for autistic children, and how can this inform education, healthcare and social care practice?

Autistic and Neurodivergent Input in Design

The autistic community values meaningful inclusion in research to maximise the potential for findings to be relevant to the communities of interest (Fletcher-Watson et al., 2019). The priorities of the research community are often at odds with the preferences of the autistic community (Pellicano et al., 2014), meaning that research into autism at present does not represent the people the research is supposed to be helping. To ensure that conclusions drawn are neurodiversity-affirming and supported by members of the autistic community, we integrated autistic knowledge and lived experiences at all levels of this review. The first author is autistic, and three additional authors are neurodivergent. One of the neurodivergent authors is also the parent of an autistic child.

Positionality statements enhance transparency and rigour by recognising authors’ worldviews and how the position they adopt influences their research (Darwin Holmes, 2020). The research team was comprised of five members who identify as: (1) an English speaking, nonbinary, autistic white female, early career psychology researcher; (2) an English speaking, white and minority ethnicity female, immigrant, is self identified as autistic, occupational therapist and academic with experience with scoping reviews; (3) an English speaking, white female, immigrant, ADHDer and school based occupational therapist, with experience in scoping reviews; (4) an English-speaking, white female, disabilities studies scholar, ADHDer with learning disabilities and experience in community-based research for people with intellectual disabilities and (5) an English-speaking, nondisabled, white female, disability ally, occupational therapist and mid-career academic with experience in scoping reviews.

Method

The scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews (Aromataris & Munn, 2020), with a protocol written following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance for Scoping Reviews (PRISMA-ScR). A published protocol does not exist for this scoping review.

Eligibility Criteria

Inclusion requirements were as follows: (a) experimental and quasi-experimental study designs, nonexperimental and review articles, (b) reporting of data addressing the inclusion of autistic children or embracing their identities as autistic people, (c) published in a peer-reviewed journal and (d) written in English or with a validated English translation. Studies were excluded if they (a) took non-neurodiversity-affirming approaches (e.g. promotion of ABA or behavioural approaches, encouraging masking or changing the autistic person), (b) did not include a description of how to promote inclusion or a neurodiversity-affirming approach for autistic children, or (c) did not include autistic participants or for nonempirical research was not focused on the needs of autistic children. No studies were excluded based on the date of publication. The authors engaged in ongoing dialoguing and reflexivity regarding the research approach, research questions, interpretations of the data and how they upheld or challenged tacit norms within the communities they belong (Hibbert et al., 2010). To provide a holistic understanding of a field where new research is quickly emerging, and to foster a more inclusive and comprehensive synthesis, studies of varying levels of methodological rigour were included.

Information Sources and Search

A systematic search of the peer-reviewed literature in eight databases (MEDLINE, PsychInfo, PsychArticles, PubMed, CINAHL, Scopus, Psychology and Behavioral Sciences Collection, and Web of Science) was conducted in May 2022 and updated in June 2023 using the search terms indicated in Table 1. The reference lists of the included articles were reviewed for possible additional articles to include, with no additional articles found that met the inclusion criteria. Three autism-focused journals (Autism, Research in Autism Spectrum Disorders, and Journal of Autism and Developmental Disorders) were hand-searched using the terms in lines 3 and 4 of Table 1 with 5 additional articles identified for inclusion. Grey literature was not searched as we focused on work published in peer-reviewed journals to understand the state of the scholarly field.

Table 1.

Search Strategy.

	Population	Area of interest
1	Autis* Identit* OR Autis* OR ASD OR Autistic Spectrum Disorder	Autism
2	Children OR Child OR P*diatric OR youth, OR adolescent	Children and youth
	Setting
3	Autis* Positive OR Positive Identity OR Confiden* OR Strength based OR strengths based OR strengths OR affirming OR inclusive OR inclusivity OR early intervention OR Holistic OR Person-Centred OR Person Centred OR person centered OR person-centred OR Neurodiv* OR Neurodiv* Indentit*	Neurodiversity-affirming approach
4	Autonomy OR Advocacy OR Self-Advocacy	Advocacy
	Implementation
5	1 AND 2	Children and youth
6	3 OR 4	Neurodiversity-affirming approach and advocacy
7	5 AND 6	Neurodiversity-affirming approach and advocacy for autistic children and youth

Screening

The first and the third authors independently screened articles for potential inclusion through Covidence (Covidence systematic review software, n.d.), with disagreements resolved through discussion. The two reviewers first completed a title and abstract screening, followed by a full-text review.

Data Extraction

Data from each study were extracted in Covidence by the first and third authors and collated in a Word document. Characteristic data (i.e. author name, year, country, sample size, methodology and population) and outcome data (i.e. themes and subthemes emerging from qualitative data, main outcomes of quantitative data, or main points of opinion pieces or literature reviews) were entered into tables. Characteristic data are presented in Table 2, while outcome data was used for the data synthesis. A critical appraisal of individual sources of evidence was not conducted for this review.

Table 2.

Characteristics of Included Studies.

Author (s)	Year	Sample size	Country	Aim	Data collection method	Sample population	Main findings
Cascio (2012)	2012	12	The United States of America	To describe the neurodiversity approach to autism, introducing it as a consideration for policies and practices that address parents of autistic children, such as the family-centred approach to care	Focus group and interviews	Members of support groups for parents of autistic children	There was often a focus on the negatives of autism in awareness groups Families sought to share the positives about their autistic children with others and help others understand their child Focus on embracing their child with their quirks, which applied behavioural analysis did not support
Chen et al. (2022)	2022	48	The United States of America	To explore (1) the experience and perceptions of students on the spectrum following their participation in the IDEAS Maker Program; (2) teachers’ perceived student outcomes and program impact; and (3) parents’ perceptions and perceived consequences of the IDEAS program following their children's participation	Focus group and interviews	Autistic students participating in IDEAS Maker Club, parents of participating autistic students, and teachers in the programme	Students had a positive experience and good engagement in the program Participants developed skills, an interest in STEM or related careers, and social relationships The autonomy supported participants to increase their confidence and self-determination
Chen et al. (2023)	2022	12	China	To observe the behaviour of autistic preschool children in three contexts: a fully ordinary kindergarten N, an inclusive education kindergarten C, and an ordinary kindergarten M with inclusive education	Interviews and observations	Autistic children, their parents, and preschool teachers	The children often felt very lonely Children's personality, temperament, motivation, ability and goals influenced their peer interactions The school environment influenced their attitudes and friendship management As autistic children can choose appropriate playmates, teachers should support environments to enable children to choose their own playmates
Chen and Patten (2021)	2021	-	The United States of America	To discuss how a shift of focus from individual deficits to environmental and other contextual barriers is necessary and beneficial in school-based occupational therapy	Opinion/Review article	N/A	Recommend considering autism and other neurocognitive conditions under the lens of human diversity Recommend modifying school environments rather than remediate individual deficits, including other's attitudes and knowledge and institutional policies and practices
Cohn et al. (2023)	2023	8	The United States of America	To examine the experiences of parents of autistic children regarding echolalia from a neurodiversity perspective	Interview	Mothers of autistic children with echolalia	Echolalia is part of the child's personality and identity and is enjoyable
Cost et al. (2021)	2021	112	Canada	To examine character traits identified by parents of autistic children at ages 3-4, 7-8 and 10-11. To examine the stability and evolution of parental trait endorsement over time and the associations between trait endorsement and autism symptom severity or behaviour problems	Qualitative survey	Parents of children aged between 2 and 5 years at time of an autism diagnosis	Parents first encounter autism from a negative lens through the diagnostic process, but have many good things to say about their children such as creativity, perseverance, kindness, friendliness, humour and enjoyment of interests A focus on the positive character traits for autistic children can support a strengths-based perspective that focused on resilience, motivation, and self-esteem and a better parent–child–provider working relationship
Crompton et al. (2023)	2023	13	The United Kingdom	To explore the experiences of young autistic people who have completed mainstream education (within the past 12 years), examining their perspectives on autistic peer support within the context of their school experience	Interview	Autistic adults aged 18-30 reflecting on their secondary school experience	Autistic peer support enabled inclusivity and should be based on accepted and encouraging difference Peer support needs to be flexible and reflect diverse needs and school environments Barriers included stigma associated with an autism diagnosis, and the need for non-autistic peers to understand and accept autistic people
Dallman et al. (2022)	2022	-	The United States of America	To provide background on neurodiversity and its movement and provide guidance on how occupational therapists can embrace a neurodiversity-affirming approach in their work.	Opinion/Review article	N/A	In a neurodiversity model, occupational therapists respect their client's unique processing, and understand behaviours as natural and valid responses to a specific situation given the skills, abilities, and preferences of the individual Occupational therapists should focus goals on emotional well-being and positive engagement, rather than changing core aspects of the autistic person Occupational therapists should support autonomy, agency, and honour all forms of communication.
(Dethorne & Searsmith, 2020)	2021	-	The United States of America	To address three common concerns associated with the neurodiversity paradigm, particularly as it pertains to school-based speech-language pathology, and to provide associated clinical implications.	Opinion/Review article	N/A	There is a misconception that the neurodiversity perspective (a) is incompatible with interventions and (b) denies the existence of disability Speech pathologists should consider environmental factors throughout the school day that are facilitating or inhibiting the autistic child's participation Interventions should not pressure children to fit in to avoid a negative social response Speech language pathologists could focus on facilitating interaction such as building interactions through shared interests, using multimodal communication, supporting sensory needs, respecting stimming and facilitating acceptance by neurotypical peers
Donaldson et al. (2017)	2017	-	The United States of America	To provide a brief introduction of the neurodiversity movement and its key principles for speech language patholoigsts who may be new to this viewpoint. To discuss how professionals might best partner with the autism community from a strengths-based perspective	Opinion/Review article	N/A	Important to identify the strengths of autistic people such as deeply focused thinking, passionate interests and motivation Presume competence for autistic people with limited or no spoken communication, support self-determination and modify the environment to support sensory needs Acknowledge the diversity of needs, perspectives and values of the autistic community
Falkmer et al. (2012)	2012	404	Sweden	To examine perceived participation in autistic students and their classmates in mainstream schools. To investigate correlations between what activities the students wanted to participate in and actually participated in.	Quantitative survey	Autistic students and typically developing classmates	Following the autistic children's interests, supporting positive self-knowledge and modifying activities to allow for breaks supported participation Autistic participants did not talk with, get help from, or help their classmates as often as their peers On 57% of the items, the autistic students perceived lower participation than their classmates Autistic students were more often misunderstood by their teachers than their neurotypical peers
Horgan et al. (2023)	2022	-	The United Kingdom	What are the lived experiences of autistic young people enrolled in mainstream postprimary schools?	Systematic review	N/A; systematic review	Smaller groups and class sizes supported inclusion and belonging The mainstream sensory environment was a barrier Students experienced high levels of stress related to school, and some had difficulty meeting the demands of the workloads
Jones et al. (2021)	2021	68	Australia	To identify the essential components of a strength-based technology club for autistic adolescents	Focus groups and interviews	Autistic adolescents (10-18 years), parents, and facilitators	Facilitators genuinely wanted to help and teach the autistic participants Facilitators identified participants’ skills and experiences with technology, and learning styles The club created a social environment of acceptance rather than explicitly learning skills Having shared interests and neurotypes supported friendship development
Leadbitter et al. (2021)	2021	-	The United Kingdom	Reflect on a psycho-social intervention program that aimed to improve young autistic children's cognitive, behavioural, emotional and correlational functioning	Literature review	N/A	Interventions should respect and enhance the things that bring happiness Early interventions should work with the child's developmental trajectory, as well as with their natural way of learning, taking consideration of internal drives and experiences Providers need to re-evaluate the goals of intervention to align with autistic priorities Communication support to enable autonomy are valid Future research should partner with autistic people and focus on goodness of environmental fit rather than impairments
Lee et al. (2020)	2020	52	Australia	To explore the principal components contributing to the success of a community-based strengths-based program and the outcomes for autistic students as a result of participating in the program as reported by their parents	Quantitative and qualitative survey	Parents of autistic children	Parents reported increased participant wellbeing and happiness, participation, skills and abilities, self-esteem, social skills, and feeling of acceptance Hypothesised to support future employment and outcomes into adulthood
Maciejewska (2020)	2020	4	Poland	To use discourse analysis to investigate a nondirective therapy, focusing on the autistic participants’ contributions and construing them as manifestations of their communicative and personal resources	Discourse analysis	Two autistic children	Communication strategies included using echolalia to maintain conversation, topic shifting to direct the conversation, using external objects to support communication, and mutual understanding with similar neurotypes or familiar communication partners It is important to recognise the strengths of autistic communication and acknowledge the compensatory adaptations in which they engage
Myles et al. (2019)	2019	8	The United Kingdom	To explore the social experiences and sense of belonging of autistic adolescent females in mainstream schooling	Interview	Autistic female adolescents	Participants felt happier with friends who accepted and valued them Participants sometimes felt like they were on the periphery and that others de-valued them and treated them like they were younger Managing hidden social rules and complex social dynamics was challenging for the participants
Neal and Frederickson (2016)	2016	6	The United Kingdom	How do autistic children experience transitions to secondary school that are identified as successful by school staff? Which strategies do such pupils identify as helping to manage their anxiety across the transition period?	Interview	Autistic adolescents in secondary school	Strategies include visiting the school and gathering practical information about their new school, understanding what secondary school will look like, booster classes, assemblies about transition, and support from family and friends
Nicolaidis (2012)	2012	-	The United States of America	To discuss the utility of neurodiversity in medicine	Opinion/Review article	N/A	Physicians are trained to think about autism using a deficit model, and perpetuate this through daily communication with patients and families Functioning labels deprive autistic people categorised as “low functioning” of their self-determination and opportunities to reach their potential, and people categorised as “high-functioning” of necessary supports and services There is a need to include autistic people in research as equal partners to strengthen the quality and validity of the research
Preece and Jordan (2010)	2010	14	The United Kingdom	To examine the experience and attitudes of families toward daily life and short breaks support	Interview	Autistic children	Autistic children did not understand the role of their social workers Bullying and negative auditory experiences were identified as problems at school The children valued solitary, physical and sensory-based leisure activities at short breaks Children disliked certain staff who placed demands on them, and the screaming, hitting and biting of peers
Sterman et al. (2023)	2023	10	The United Kingdom	To understand autistic adult perspectives on paediatric occupational therapy for autistic children	Podcast transcription and qualitative social media data	Autistic adults	Occupational therapists should Accept autistic children rather than trying to ‘fix’ them Change environments or tasks rather than using behavioural strategies Create goals that address self-advocacy and autonomy
Tesfaye et al. (2023)	2023	31	Canada	To identify key themes that arose from the autism voices interviews that were conducted with a group of autistic youth	Interview	Autistic young people	Consider interests in any planning process for autistic children, regardless of language or intellectual ability Making friends with other autistic youth facilitated forming safe friendships Adaptations supported a welcoming school environment while experience of bullying and lack of knowledge of how to support the autistic people negatively impacted their experience
Theodorou and Nind (2010)	2010	1	The United Kingdom	To use ethnography to better understand the play and inclusion of children with autism	Interview, video recordings and field observations	One autistic preschool child	The teacher modelled play for the autistic child through commenting, facilitating and mediating. The teacher did not over-interfere, and allowed free play to continue as much as possible
Waddington et al. (2023)	2023	326	New Zealand and Australia	To examine the reported priority-level and appropriateness of each type of support goal across participant groups, as well as participant's perception of early support	Survey	Autistic adults, parents of autistic children, and clinical professionals	The highest priority support goals related to adults changing or modifying their approach to better support the child, reduction or replacement of behaviours which cause hard to the child or others, and improving the child's quality of life Autistic and non-autistic participants prioritised neurodiversity-affirming goals
Wu et al. (2019)	2019	2	Canada	To explore the learning experiences of participating highly able autistic learners and provide insight into effective strategies and provisions that could better meet the unique learning and social-emotional needs of highly able autistic learners	Interview	‘Gifted’ autistic children	Recommended curriculum flexibility for including challenging content and supports Recommended strengths-based perspectives to support self-pacing, collaboration and sharing interests Recommend creating a safe environment that supports sensory regulation and positive peer and student–teacher relationships
Yi and Siu (2021)	2021	20	China	To understand the views of neurodevelopmental disabilities by neurotypical and autistic primary school students and understand the social environment of neurotypical and autistic interactions from the perspective of neurotypical children	Interview	Autistic primary school children and typically developing peers	The opportunity to initiate and develop friendships tended to be limited to teacher-led activities Neurotypical children had negative attitudes toward their autistic peers Exclusion of autistic children stated as due to their impairments and atypical behaviours

To ensure consistency, a pilot extraction exercise was performed between the two authors extracting data. Inter-rater agreement was excellent (91%) and no changes had to be made before full extraction commenced.

Data Synthesis

Qualitative content analysis (Mayring, 2014) guided data synthesis. A priori codes (e.g. components, enablers and barriers) and inductive codes (e.g. recommendations to promote positive autistic identities) were generated to analyse the extracted data. All of the extracted data was coded. These codes were then grouped into content categories (e.g. models of practice, focus on quality of life, and building off a child's interests), which were discussed and modified with the research team. Finally, the content categories were grouped into two major themes: Promoting an Environment of Inclusion, and Ways to Approach Intervention.

The authors engaged in discussion and reflection on ways that the findings from each of the themes and subthemes would support educators, and health and social care providers to be reflexive about their practice with autistic children. The authors drew from the findings, their knowledge of the neurodiversity movement, and their experience as occupational therapists, psychologists and disability scholars.

Results

Characteristics of Included Studies

Twenty-six studies were deemed eligible for inclusion in this scoping study (see Figure 1). Studies were conducted or authored in the following locations: the United Kingdom (8), the United States of America (8), Canada (3), Australia (3), China (2), Sweden (1), New Zealand (1) and Poland (1). One article collected data on participants residing in Australia and New Zealand (Waddington et al., 2023). Publication of included studies occurred between 2006 and 2023. Empirical studies had between 1 and 404 participants (m = 37, SD = 93.67) for a total of 1,151 participants across all studies.

Figure 1.

PRISMA Flow Diagram.

Studies predominantly used a qualitative methodology (15), survey (4), followed by opinion pieces (5), and systematic or literature reviews (2). Data collection methods included interviews (13), surveys, (4), focus groups (3), textual analysis or discourse analysis (2), and field observations (1). Nine of the studies gathered data from autistic children and two studies sought the perspectives of autistic adults reflecting on the needs of autistic children. The majority of studies (n = 7) that included autistic children as participants restricted their inclusion criteria to autistic children without intellectual disabilities. The ages of the children were predominately in late primary/elementary school to early high school. To support the inclusion of autistic children, studies provided visuals to accompany their interview questions (3) and were flexible in their data collection approaches (3). Flexible approaches included the use of focus group or individual interviews (Jones et al., 2021), or modifying some questions to be forced choice rather than open ended (Yi & Sui, 2021), and a pre-interview with parents, use of the child's preferred space for the interview, and use of picture cards to answer question (Tesfaye et al., 2023). Additional participants included: parents or caregiving family members of autistic children, autistic adults, teachers and healthcare professionals. Seven studies took the form of literature reviews or opinion pieces by professionals working with autistic children and as such did not recruit participants.

Theme 1: Promoting an Environment of Inclusion

The included articles discussed the social, physical and institutional environments around the autistic child. A majority of studies (n = 15) included in this scoping review described how the child's social and physical environment affected their inclusion.

Social

Studies included in this review supported the idea that inclusion and promotion of authentic autistic identities begin with the social environment. Supportive social environments that resisted negative perceptions of autistic children and promoted acceptance were vital to autistic children being included (Cascio, 2012; Horgan et al., 2023; Jones et al., 2021; Yi & Siu, 2021). In contrast, nonsupportive social environments where autistic children were infantilised or less understood led to fewer participation opportunities for the autistic child (Falkmer et al., 2012; Myles et al., 2019). Included articles described the need for autistic children to engage in activities that aligned with their interests to support social participation (Chen et al., 2022; Crompton et al., 2023; Lee et al., 2020; Sterman et al., 2023; Tesfaye et al., 2023). These studies demonstrated that inclusion and promotion of a neurodiversity-affirming approach begins with the social environment.

The need for support in social environments extended to peer interactions, where unsupportive relationships or interactions characterised by misunderstanding led to isolation of the autistic child (Cascio, 2012; Preece & Jordan, 2010; Yi & Siu, 2021). Bullying by neurotypical peers and its effect on social exclusion was reported in papers (Falkmer et al., 2012; Horgan et al., 2023). Study findings described a need for increased understanding and acceptance of autism from their neurotypical peers (Crompton et al., 2023). However, social inclusion with neurotypical peers led to engagement with education and a greater sense of belonging for the autistic child (Lee et al., 2020; Myles et al., 2019; Preece & Jordan, 2010). For some children, peer interaction between autistic children was more successful than between autistic and neurotypical children (Chen et al., 2023; Crompton et al., 2023; Tesfaye et al., 2023). To support neurotypical and autistic peer interactions, one study recommended teaching neurotypical peers how to interact with the autistic child rather than teach the autistic child neurotypical social skills or coping strategies (Yi & Siu, 2021). These recommendations included learning about neurocognitive disabilities, valuing diversity and developing positive social relationships (Yi & Siu, 2021).

Teachers and health professionals’ misunderstanding of autistic children and lack of positive relationships with the children reduced inclusion opportunities (Horgan et al., 2023). In contrast autistic children experienced greater inclusion when educators and service providers presumed competence and facilitated modelled interactions between autistic and neurotypical children (Donaldson et al., 2017; Theodorou & Nind, 2010). Recommendations for service providers to be effective in promoting a neurodiversity-affirming approach for autistic children include that they acknowledge that their own perception of behavioural norms may differ from the autistic child's way of being (Dallman et al., 2022). Studies described provider knowledge of the child's strengths and understanding of autism as key to inclusion of the autistic child (Falkmer et al., 2012; Jones et al., 2021; Preece & Jordan, 2010), while lack of awareness of the child's support needs led to exclusion (Chen & Patten, 2021).

Physical

The impact of the physical environment on inclusion was less commonly discussed in the included articles and tended to focus on the characteristics of physical spaces in schools. School physical environments enabled inclusion through flexible seating options and working patterns within classrooms that supported sensory needs (Crompton et al., 2023; Donaldson et al., 2017) organisational strategies (Preece & Jordan, 2010; Wu et al., 2019), and smaller class sizes that promoted collaborative working and incorporated safe spaces for autistic children to seek time alone (Horgan et al., 2023). In contrast, crowded or chaotic environments did not support autistic children's sensory needs, leading to exclusion (Horgan et al., 2023; Tesfaye et al., 2023).

Institutional

Curriculum design centred around expectations of neurotypical children, caused some autistic children to feel stressed, exhausted and isolated (Horgan et al., 2023; Preece & Jordan, 2010). Some participants in secondary school experienced challenges related to deadlines, the pace of lessons, and perception of the amount of class-based work and homework, while other participants thrived in a secondary environment where they could pursue their interests and have greater variety of learning (Horgan et al., 2023). Curricular recommendations for increased participation and wellbeing of autistic children included flexibility of the curriculum such as allowing students to pursue interests, more hands on activities, and using visual supports in learning (Falkmer et al., 2012; Horgan et al., 2023; Wu et al., 2019), and support in periods of transition, such as from primary to secondary school through practical advice about how expectations will differ in secondary school, involving family and friends, and school visits (Horgan et al., 2023; Myles et al., 2019; Neal & Frederickson, 2016).

Theme 2: Ways to Approach Intervention

Many studies (n = 17) included in this review gave recommendations for how to promote inclusivity and neurodiversity-affirming approaches while delivering interventions. No matter the intervention, researchers and practitioners should consult the autistic community (Dethorne & Searsmith, 2020; Leadbitter et al., 2021), prioritise the perspectives of the autistic child and autistic self-advocates rather than family members (Cohn et al., 2023; Dethorne & Searsmith, 2020; Nicolaidis, 2012), and involve autistic adults and children to ensure that the priorities of the autistic community are met (Cohn et al., 2023; Leadbitter et al., 2021; Nicolaidis, 2012).

Building on Interests and Focussing on Strengths

Building on the child's interests was identified as a valuable method of promoting social involvement (Chen et al., 2022; Donaldson et al., 2017; Jones et al., 2021; Lee et al., 2020), improving mental health and wellbeing (Lee et al., 2020), increasing inclusion in intervention activities (Falkmer et al., 2012; Leadbitter et al., 2021; Wu et al., 2019), and developing emotional regulation skills, confidence and pride (Chen et al., 2022). A common modality of building on strengths was the use of interest-based clubs, often with a science, engineering or technology focus (Chen et al., 2022; Jones et al., 2021; Lee et al., 2020).

Focusing on the child's strengths, including those related to autism, can improve others' perception of autism (Cascio, 2012; Cost et al., 2021). Strengths can be leveraged by identifying learning styles and positive qualities associated with autistic ways of being such as passion or ability to focus (Donaldson et al., 2017; Jones et al., 2021; Leadbitter et al., 2021).

Included articles in this review discussed that health and social care should aim to improve autistic quality of life (Cost et al., 2021; Nicolaidis, 2012; Waddington et al., 2023) through building on strengths (Donaldson et al., 2017), prioritising wellbeing over compliance (Dallman et al., 2022), reducing disability-based stigma for the autistic child (Crompton et al., 2023), and facilitating activities that bring the autistic child joy (Leadbitter et al., 2021).

A Part of Human Variation

Perceiving autistic behaviour as a part of human variation (Cascio, 2012; Chen & Patten, 2021; Dethorne & Searsmith, 2020), supports interventions to focus on wellbeing rather than changing the nature of the child (Dallman et al., 2022; Waddington et al., 2023). In addition to wellbeing, intervention and support should focus on autonomy (Leadbitter et al., 2021), with the autistic child having the right to physically move around, socialise, engage and disengage as they see fit (Dallman et al., 2022).

Deficit-oriented models of autism pose significant barriers to inclusion and carrying out neurodiversity-affirming care through de-humanising autistic people (Nicolaidis, 2012) and focusing on negative aspects of autism rather than acceptance (Chen & Patten, 2021; Cost et al., 2021; Nicolaidis, 2012). Similarly, behaviourist models of autism aim to change the way an autistic person interacts with their environment and prioritise ‘normalisation’ over individual meaningfulness (Dallman et al., 2022). Educators and service providers should critique their goals to reduce pressure on the child to ‘mask’ or adhere to societal standards that are counter to their self-expression (Cascio, 2012; Dallman et al., 2022; Dethorne & Searsmith, 2020).

Promote Autistic Communication

Educators and service providers seeking to create positive intervention environments should understand, value and promote autistic communication (Dethorne & Searsmith, 2020; Leadbitter et al., 2021). Both verbal and nonverbal communication styles (Dallman et al., 2022; Maciejewska, 2020), and autistic ways of socialising and self-expression should be valued and accepted (Dethorne & Searsmith, 2020). Meeting the autistic child in their preferred style of communication may involve following topic shifts, supporting object manipulation, and understanding the function of echolalia (Maciejewska, 2020). Parents of autistic children perceived echolalia as enjoyable for the child, intrinsic to their self, and not something that needed to be changed (Cohn et al., 2023). Autistic adults, parents of autistic children, and clinicians valued supporting autistic children's communication and daily living skills (Waddington et al., 2023).

Discussion

This scoping review examined: What are the components, enablers and barriers of neurodiversity-affirming care for autistic children, and how can this inform education, healthcare, and social care practice? Findings indicate that the key components that promote neurodiversity-affirming care for autistic children include supportive social, physical and institutional environments and interventions that build on a child's interests, focus on their strengths, support wellbeing and autonomy, and embrace autistic ways of being. To support children's rights, dignity and wellbeing, intervention outcomes should include valued choices or capabilities for autistic children (Nussbaum, 2011).

Given the current priorities of the neurodiversity movement including the need to prioritise the values of autistic stakeholders, this scoping review provides an important and novel contribution to the literature as it collates and synthesises the information on ways that educators and service providers can practice in a neurodiversity-affirming manner. This can act as a starting point for educators and service providers to reflect on their practice and consider ways they can support autistic children in a strengths-based and neurodiversity-affirming manner. Table 3 includes reflective questions for educators and service providers working with autistic children.

Table 3.

Reflective Questions for Educators and Service Providers.

Topic	Reflective Questions	Further Prompts
Overarching	In what ways can I be an advocate for working with autistic children in a neurodiversity-affirming manner within my workplace?	In what ways does my workplace already promote neurodiversity-affirming care?In what ways does it not?What could neurodiversity-affirming practice (e.g., strengths-based, promoting positive autistic identities) look like in my work?
Environment
Social	How do I support peer interactions between autistic and neurodivergent peers?	How do I advocate for embracing autistic ways of interacting?
Social	What neurotypical rules, norms or expectations govern the way that autistic children engage with others where I work (e.g., eye contact, stimming, turn taking, reading between the lines)?	How can I deconstruct my own expectations of social norms?How do I reduce pressure on the children I work with to mask?
Physical	How do I adapt the autistic child's physical environment to enable choice and participation?	How does the physical environment meet the child's sensory processing needs? What helps their attention?In what ways does the physical environment limit the autistic child's participation (e.g., seating, spacing, noise, lighting and other such factors)?
Institutional	What societal norms and ableist practices that seek to conform autistic children to a neurotypical standard govern the work I do?	Is there a focus on reducing behaviours (e.g., behavioural interventions) or supporting the needs the behaviours are identifying (e.g., providing safe methods of stimming, supporting sensory needs, trialingdiffering communication approaches to reduce the autistic child's frustration)?
Institutional	In what ways are the policies within my workplace neurodiversity-affirming?	How can I support my team to better understand neurodiversity-affirming policies in our workplace and how to implement them?
Interventions	In what ways do I prioritise the perspectives of autistic individuals?	Do I prioritise the perspectives of marginalised autistic individuals (e.g., BAME, LGBTQI+, nonspeaking)?
Interventions	What are the goals of the intervention?	Who benefits from the outcomes of myinterventions (e.g., Is it the autistic child? Or do others benefit from conforming the child to ‘normalised’ behaviours)?Are the goals written from a medical or remediation framework?
Building on interests and focusing on strengths	How do I use autistic children's interests within my practice?	In what ways are the autistic child's interests supported to improve wellbeing versus develop skills?
Building on interests and focusing on strengths	How does my approach to working with autistic children leverage their strengths?	Do I focus on building off their strengths or remediating deficits?
A part of human variation	How do I conceptualise the nature of autism (e.g., impairment to be remediated, disability to be supported, neurotype)?	Where does my conceptualisation of autism come from?What organisations provide that information? Do I seek out autistic voices?
	How do I explain autism to others?	What language do I use?What examples do I give? Does the language and examples include stereotypes?
	How do I support autistic children to understand the strengths and challenges of being autistic?	How do I support wellbeing as an outcome?How can I support autistic children to become their own advocate?
Promoting autistic communication	How do I support augmentative and alternative communication (AAC) or a total communication approach within my work with autistic children?	How can I support my team or workplace to understand the importance of different communication styles?
	How do I advocate for embracing autistic communication and self-expression within my team or workplace?	How do I value both verbal and non-verbal communication styles?
	How do I advocate for autistic children to interact authentically?	How can I build a culture in my workplace that allows autistic children to be their authentic selves?

Findings from this scoping review reveal a priority of valuing and supporting autistic ways of being, including autistic communication. Autistic children are often denied the choice of what to do and how to be by behavioural interventions that seek to conform them to a neurotypical standard. Prioritising the inclusion of autistic voices in how to approach education, healthcare and social care increases the set of capabilities autistic children have in how to do and be in everyday life. To increase their capability set, autistic children need educators and service providers to presume competence, support their disability-related impairments, modify the environment, and advocate for increased targeted resources. For example, River, an intermittently verbally speaking autistic child, can be supported to express their interests and create a set of capabilities through a total communication approach and honouring autistic styles of communication. Their parents, educators or service providers may need to advocate for increased resources for an augmentative and alternative communication device to support communication. River can then realise some of their capabilities and support their social participation through engaging in clubs based on their interests with like-minded peers.

Implications

Autistic children should be supported to develop an understanding of themselves, their strengths, and what brings them joy; leverage their strengths; develop skills related to their interests; and increase their autonomy. Autistic children may need support from parents, caregivers, educators or service providers to develop these skills. Children may desire to further specific skills related to their interests, wellbeing or autonomy. However, findings from this scoping review indicate that autistic children should not have to participate in fine motor, social skills or pragmatic language therapy simply because their skills are ‘behind’ those of their neurotypical peers (Donaldson et al., 2017; Jones et al., 2021; Leadbitter et al., 2021).

Educators and service providers can support wellbeing through modifying autistic children's environments to align with their needs. This can include creating an understanding and accepting environment (Cascio, 2012; Horgan et al., 2023; Jones et al., 2021; Yi & Siu, 2021), supporting neurotypical children to engage with autistic children (Lee et al., 2020; Myles et al., 2019; Preece & Jordan, 2010), building creative flexible spaces that support sensory needs (Crompton et al., 2023; Donaldson et al., 2017), and creating a curriculum that is flexible, supportive and has appropriate expectations (Falkmer et al., 2012; Horgan et al., 2023; Preece & Jordan, 2010; Wu et al., 2019).

Barriers to practicing in a neurodiversity-affirming manner with autistic children will inevitably arise and can be addressed through future research and development of clinical tools. Educators and service providers may benefit from a reflective tool that evaluates in which ways they are practicing in a neurodiversity-affirming manner, and in which ways they need to adjust. For example, as many educators and service providers continue to focus their evaluation and intervention on remediating deficits rather than building off strengths (Carlson-Giving, 2023a), evaluating if goals for autistic children focus on remediating impairments or building off strengths can support reflexivity and identification of areas for change. Educators and service providers may need examples of Individualised Education Plan goals that align with the neurodiversity paradigm, as they may be more used to writing goals within a medical model or remediation framework (Carlson-Giving, 2023a).

The literature included in this scoping review suggests that to support social participation, rather than administering social skills programmes for autistic children to behave in a neurotypical way, schools and communities should create inclusive social environments where autistic children are recognised and accepted (Jones et al., 2021; Lee et al., 2020; Myles et al., 2019; Preece & Jordan, 2010). Autistic participants described valuing peer interaction with other autistic children rather than neurotypical children (Crompton et al., 2023). This aligns with the literature that indicates that autistic to autistic interactions have higher rapport (Rifai et al., 2022) and information transfer (Crompton et al., 2020) than autistic to neurotypical interactions. One avenue for creating an inclusive environment that prioritises autistic ways of being is through interest-based clubs, which have demonstrated positive results in addressing student engagement, social relationships and self-determination (Chen et al., 2022; Lee et al., 2020; Patten, 2022). Additionally, to support inclusion and mutual understanding, it may be beneficial to design interventions where neurotypical children are taught about autistic communication and interaction styles (Yi & Siu, 2021). Previous studies have evaluated the effectiveness of disability awareness programmes on increasing positive attitudes of neurotypical peers towards children with disabilities (De Boer et al., 2014; Leigers & Myers, 2015). These interventions have shown some positive influence on attitudes towards children with disability, especially younger children (De Boer et al., 2014; Leigers & Myers, 2015). However, the focus of these studies has been attitudinal rather than behavioural change. The development of future interventions for neurotypical peers focused on increased social inclusion would support the desires of the autistic community to change social environments rather than try to teach autistic children neurotypical ways of being (Sterman et al., 2023).

Aligning with the neurodiversity movement requires researchers, educators and service providers to critically reflect on ways they may not be practicing in a neurodiversity-affirming manner, even when they thought they were engaged in best practice (Patten, 2022). Scoping reviews addressing interventions for children with disability often explore effectiveness, without consideration of the acceptability of the outcome measures or the approaches to the disability group. For example, a scoping review by Novak and Honan (2019), includes Applied Behavioural Analysis, token economies, and picture exchange communication system as ‘green light’ interventions for autistic children, approaches the autistic community is strongly against (Kupferstein, 2018). In contrast, Carlson-Giving (2023b) created a table to classify the acceptability of interventions from an autistic perspective based on dialogues with autistic educators, providers, researchers and advocates.

Educators and service providers may require mentoring to develop the skills, including reflexivity, to engage in a neurodiversity-affirming practice with autistic children. There is a growing number of educators, service providers and autistic advocates providing education and mentorship to support colleagues to align their practice with the values of the autistic community such as Autism Level-Up!, Learn Play Thrive, and The Lived Experience Educator (Ferrell, 2023; Laurent & Fede, 2023; Wise, 2019). Although educators and service providers engage in informal mentorship, they may require increased mentorship and skills to engage in a shift towards neurodiversity-affirming practice.

State of Current Literature and Future Directions

Although 11 of the articles included in this scoping review sought the perspectives of autistic people as part of the research, only one study (Tesfaye et al., 2023) actively included the perspective of autistic children with intellectual disabilities. To increase relevance and impact, future research should include perspectives from autistic people (Fletcher-Watson et al., 2019), especially people with intellectual disability, and similar to the current study, include autistic input throughout the design and implementation of research.

The included articles were predominately from high-income countries in the Global North. To support health and social care practice that is culturally and neurodiversity-affirming for autistic children, future research should explore how neurodiversity-affirming practice can and should be enacted within countries in the Global South, and among minoritised populations in the Global North.

There is a lack of understanding of the balance of how educators and service providers practice in a medical or remediation model or within a neurodiversity paradigm. Previous surveys of occupational therapists in Australia and the United States of America indicate a primary focus on remediating perceived deficits, rather than changing environments or leveraging skills (Carlson-Giving, 2023a; Spencer et al., 2006). To support a shift towards neurodiversity-affirming practice for autistic children, future research should seek to better map current practice.

The focus of the studies included in this scoping review was predominantly on school environments rather than clinics or homes. To better understand the components of neurodiversity-affirming practice across settings, future research should explore aspects of practice that are relevant within homes, communities and clinical settings.

The included articles were predominately qualitative research, surveys or opinion pieces. Due to the nature of the included studies, this scoping study cannot advise educators or service providers on specific interventions that they should be engaging in. Instead, this scoping study can support educators and service providers’ framing of their practice, and broad components that they can be addressing. Future research should address what components are essential in engaging in neurodiversity-affirming practice, and what specific interventions are effective to achieve neurodiversity-affirming and wellbeing focused outcomes.

Limitations

This scoping study was impacted by limitations based on selection and participation bias. The inclusion criteria of studies being written or translated into the English language inherently excludes any studies published in other languages. Given the evolving nature of the language and terminology within the neurodiversity movement, although the authors sought to have a broad search, key literature that used terminology that the authors are unfamiliar with may be absent. Similarly, articles that used strengths-based or neurodiversity-affirming approaches for autistic children but lacked identification in their titles, abstracts or keywords were not included in this scoping review.

Congruent with scoping review methodology (Aromataris & Munn, 2020), no critical appraisal of the included studies was conducted. Included in this review were opinion articles (e.g., Nicolaid, 2012), systematic reviews of the literature (e.g.,, Horgan et al., 2023) and empirical research with small (e.g., Wu et al., 2019) and large sample sizes (e.g., Chen et al., 2022). Content from the articles were included in the content analysis, irrespective of their design. While this is a limitation of scoping review methodology generally and this study in particular, inclusion of diverse sources also enabled the review to draw knowledge from all sources of evidence, which adds value in an emerging field.

Conclusion

The current literature highlights the importance of inclusion, setting goals that are significant to the child (rather than prioritising neurotypical developmental stages), and leveraging strengths to meet these goals. Educators and service providers must therefore centre these principles to promote a neurodiversity-affirming approach to care for autistic children. Using the child's preferred method of communication and integrating preferred activities or interests must be prioritised when designing interventions that value autistic quality of life, integrate feedback from the autistic community, and discard the idea of ‘normalisation’ of behaviour. When interventions are constructed using a neurodiversity-affirming model and the environment is adapted to the autistic child, rather than the child to the environment, the child can express their preferences and needs, leading to self-acceptance, and understanding of what the child needs to lead a fulfilling life.

Footnotes

ORCID iDs

Julia Sterman

Natasha Spassiani

Janet Njelesani

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this scoping review has been provided by Edinburgh Napier University School of Health and Social CareKnowledge Translation Grant.

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.

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Promoting Neurodiversity-Affirming Care for Autistic Children: A Scoping Review

Abstract

Lay Abstract

Keywords

Introduction

Autistic and Neurodivergent Input in Design

Method

Eligibility Criteria

Information Sources and Search

Screening

Data Extraction

Data Synthesis

Results

Characteristics of Included Studies

Theme 1: Promoting an Environment of Inclusion

Social

Physical

Institutional

Theme 2: Ways to Approach Intervention

Building on Interests and Focussing on Strengths

A Part of Human Variation

Promote Autistic Communication

Discussion

Implications

State of Current Literature and Future Directions

Limitations

Conclusion

Footnotes

ORCID iDs

Funding

Declaration of Conflicting Interests

References