Beyond the Buzz

Allessandra Farrar
2 days ago
11 min read

What Does Neurodiversity-Affirming Therapy Really Mean?

If your social media algorithms are anything like ours, you may have heard words like “neurodiversity” and “neurodiversity-affirming” floating around. You may have also seen these words as part of our practice’s mission statement. While more and more people, both within and without the disability community, have been discussing these terms and ideas over the past few years, it can be tricky to figure out what it actually means to be neurodiversity-affirming.

Let’s take a look at some key terminology:

Neurodiversity: Neurodiversity is the idea that everyone's brains are different. Therefore, people may act, think, or experience the world differently.

Neurotypical: Neurotypical individuals are those who behave or process the world in a way that aligns with society's standard for what is "normal."

Neurodivergent: Neurodivergent individuals are those who don't process or interact in a way that has been classified as "typical."

The neurodivergent umbrella includes individuals who are Autistic as well as those diagnosed with ADHD, dyslexia, stuttering disorders, and more. Neurodivergent individuals may…

Communicate in a different way
Behave in ways that differ from the norm
Interact differently within societal expectations

Masking: Masking is a term used to describe how neurotypical people learn or are taught to hide their inherent traits in order to appear more neurotypical. This might include making forced eye contact, speaking in a certain way to sound more neurotypical, or hiding signs of burnout or overwhelm.

Double Empathy Problem: The Double Empathy Problem is a theory proposed by Dr. Damian Milton explaining that, while autistic people may have difficulty understanding and interpreting the perspectives of non-autistic (or allistic) people, allistic people have similar difficulties understanding the perspectives of autistic people. This theory promotes the idea that the burden for more effective communication should not be placed solely on autistic people, but that communication and understanding is a two-way street and is the responsibility of all people across neurotypes.

Disability Models

It’s important to note that people have differing views on whether to frame neurodiversity as difference, disorder, and/or disability. You may already be asking the question:

Are all neurodivergent people disabled?

As SLPs, we operate within a medical system with clearly defined disability categories -- you may see an evaluation report or therapy bill designating "Autistic disorder" as the diagnostic code. However, we can combine features of different disability models to best serve our clients. Let’s take a closer look…

The moral model can serve to acknowledge the challenges overcome by disabled people and their families and can celebrate strength and dedication. At the same time, the moral model may influence some people to view disability status as a reflection of a moral failing or a reason to shame families. For example, the debunked belief that autism is caused by vaccines, medications, or food additives can place blame on mothers and families.

The medical model helps individuals access necessary services and support. Oftentimes, children diagnosed with autism or ADHD are automatically granted access to school-based services and insurance-funded care. However, focusing on deficits and framing all differences as disordered can prevent those with disabilities from being accepted for who they are. Those operating under this model may view neurotypical people as “experts” who are needed to “correct” neurodivergent traits.

The social model places the responsibility for change outside of the disabled person and views disability as a natural part of human diversity. However, our world is not built for neurodivergent people, and it’s important that disabled people get access to support in addition to efforts to change the environment around them.

The neurodiversity movement seeks to shift society’s view of disability toward the social model. Its aim is to highlight the ways in which our society is not set up to be accessible or inclusive to all people and to remove those barriers. At the same time, the movement values accessing support to build skills for neurodivergent people so that they can better navigate the world around them.

Neurodiversity-Affirming Care

When it comes to the field of speech-language pathology (and the related services fields as a whole), being neurodiversity-affirming means that we are in a constant state of listening to and learning from the voices of those in the Autistic and neurodivergent communities and using what we learn to re-evaluate our practices and biases. It’s an ongoing process -- nobody is perfect, but we strive to be as affirming as we can be.

"Do the best you can until you know better. Then when you know better, do better" - Maya Angelou

As the landscape of neurodiversity-affirming care has changed and grown, many parents, therapists, and others in the disability space have had to re-examine their own perspectives and practices when relating to neurodivergent individuals. In my seven years as an SLP, I have learned so much about autism, Autistic experiences, and how to be more neuro-affirming. As I’ve learned, I’ve abandoned some popular strategies (First, Then boards, anyone?) and adopted new ones. It’s okay if you’re a parent or therapist who has made mistakes or used language, strategies, or approaches that aren’t neurodiversity-affirming. What’s important is that we do our best to listen to Autistic and neurodivergent voices and make changes when they need to be made.

Neurodiversity-affirming therapists are so important in the care and support of children with neurodivergent profiles. These therapists prioritize fostering your child's confidence and authenticity while building on their strengths to support their growth.

Neurodiversity-affirming therapy embraces the following principles:

Why is neurodiversity-affirming therapy so important?

Participating in therapy that is not neurodiversity-affirming - especially therapy that promotes masking by encouraging people to hide or change their neurodivergent traits - can have serious life-long consequences. Masking can lead to higher rates of depression and anxiety, cause autistic burnout, and lead to feelings of isolation and loneliness (Pantazakos T and Vanaken G-J, 2023). The language used to describe, evaluate, and treat neurodivergent people should never imply that their natural way of being, even if it differs from the “norm,” is inherently bad or something that needs to be changed. Instead, the focus of therapy should be to help neurodivergent people learn about themselves and their communication and feel empowered to be themselves in a world that is designed to suit neurotypical people.

Evaluation & Treatment

As SLPs, we diagnose and treat communication disorders. As a pediatric outpatient clinic, some of our most common diagnoses include receptive and expressive language disorders, speech production disorders, pragmatic communication disorders, and fluency disorders. While these disorders can, and often do, exist in isolation (meaning that a child is not diagnosed with any additional disabilities or disorders), we often evaluate children who are also diagnosed with autism spectrum disorder, ADHD, learning disabilities, or intellectual disabilities. All this to say - we are very often working with neurodivergent children!

It’s important that we ensure that our diagnoses and treatment plants differentiate between a true deficit or area of need and simple differences. While this is true across communication domains, this mindset is particularly impactful when we’re discussing social skills.

Evaluations

At Talk Time, we strive to approach evaluations from a strengths-based lens. Rather than focusing only on what a child can’t do, we also place a lot of emphasis on what the child can do. For example, an Autistic child might have difficulty expressing their emotions, especially when they are upset or dysregulated. But, that same child might be really great at remembering episodes from their favorite TV show. Take a look at these examples:

Deficits-Based Report:

"During a classroom observation, Bella became upset during a transition to the playground. She did not express her emotions at that moment, and instead engaged in repetitive scripting from an episode of Daniel Tiger. Intervention should prioritize the use of feelings vocabulary to express her emotions."

Strengths-Based Report:

"During a classroom observation, Bella became upset during a transition to the playground. When asked to put on her jacket, Bella used a script from an episode of Daniel Tiger: “Grr, I want to be the engineer!” to express that she was upset. Given wait time, access to a comfort item (i.e., her favorite stuffy), and a visual schedule indicating that the class would return to the classroom after playing on the playground, Bella successfully transitioned to the playground and enjoyed using the swing. Bella would benefit from access to an increased range of language to express different feelings."

How do we decide what's difference and what's disorder?

When evaluating for the presence of a social communication disorder, we often make subjective conclusions about what is “appropriate” or “expected.” One common method of evaluating perspective-taking skills is showing a picture to a child and asking them to determine how the people are feeling or what they’re thinking.

(SLTD-E: NU, WPS)

The example above is taken from the Multiple Interpretations subtest of the Social Language Development Test, an assessment designed to evaluate the ability of elementary-aged kids to use visual clues to determine what others might be thinking or feeling. The expected, "correct" responses to this prompt are that the child is listening to music or yawning. So what happens if a child’s response is different?

I recently had a child respond to this prompt by saying that the girl was feeling frustrated and that she was thinking "It's too loud in here." Although I was not able to score this response as correct according to the test instructions, I could easily see why my client had thought this way.

The child I was evaluating was, in fact, using visual cues to help draw an appropriate conclusion. I knew that this child had her own sensory sensitivities, and that she often used headphones similar to the ones in the photo to block out bothersome noise.

This is just one example of how a child’s performance may not fit our expectations, but that doesn’t necessarily mean that they lack a skill. We can acknowledge a different way of thinking without automatically labeling it as disordered. At the same time, we can highlight true areas of need that do need to be supported. This mindset carries us through to neurodiversity-affirming therapy as well. Part of our job as diagnosticians working within a medical system is to label the clients that we evaluate and treat. However, using a neurodiversity-affirming model of care means that just because we know the diagnosis (whether it’s communication-specific or not) doesn’t mean that we know what’s best for that child. We treat each client as an individual and ensure that we establish a basis of trust.

Particularly when we’re determining social communication goals for neurodivergent clients, there are a few things we must consider:

What social communication skills will be most meaningful for this child? Are they hoping to make more friends? Are they struggling to advocate for their needs in the classroom?
How can we spread the responsibility of effective communication across both our client and their communication partners? Can they learn about their own unique communication style and use that to connect with others?

Treatment

Speech and language therapy can, and should, look different for every client. While some kids thrive in more structured settings, others do best when we use a more play-based, child-led approach. For many of our neurodivergent clients, this means following their lead to figure out what works for them.

Let’s take a look at some examples:

Play-Based Sessions for a Young Gestalt Language Processor
Hailey is a four-year old Autistic girl who has been identified as a gestalt language processor. She absolutely loves all things Disney and she enjoys listening to music, looking in mirrors, and doing gymnastics.

Her current communication goals include expanding her use of language for different

communicative functions (e.g., asking for her favorite activities, protesting when she

doesn’t like something, asking for help), increasing her awareness and attention on

communication partners, and expressing her feelings during moments of frustration.

Hailey’s sessions take place at home, with her dad participating in each session. Hailey’s

SLP uses a play-based, child-led approach, allowing Hailey to choose each activity.

Hailey’s dad writes a list of potentially-meaningful phrases from Hailey’s favorite Disney

movies and shows, which the clinician shows how to model for Hailey. Recently, she’s

started using the line “This is amazing!” from Frozen on her own to share when she’s

excited! The clinician also coaches Hailey’s dad on how to use motivating people-play to

increase Hailey’s joint attention. Lately, their favorite activity has been making funny

faces in the mirror together.

Community-Based, Functional Sessions for a Teenage AAC User
Ben is a sixteen year old Autistic AAC user. He has expressed that he’d like to work part-time at his favorite toy store and is working with his SLP to develop functional communication skills.

Ben’s home-based sessions are used to practice expanding his AAC-related skills to

ensure that he has access to functional communication across settings. The clinician

incorporates Ben’s interests by bringing books about superheroes, playing video games,

and listening to music during his sessions. Ben often asks for short breaks during home

sessions, and these are always honored.

Ben also attends monthly sessions in the community, going on trips to local libraries,

coffee shops, and the mall. Here, Ben practices engaging in functional conversations

with community members, such as asking for directions or ordering food. These

interactions help Ben feel more comfortable communicating with a variety of people, a

skill that will help him be successful at work.

Structured, Sensory-Minded Sessions for an Elementary Schooler with ADHD
Jasmine is an eight year old diagnosed with ADHD and social communication disorder. She attends weekly speech therapy sessions to support her ability to build social communication skills in order to make and maintain friendships.

Jasmine’s SLP has learned that Jasmine thrives in a more structured environment, but they

make sure to incorporate activities that are motivating for Jasmine. Recently, they’ve been

making friendship bracelets while practicing social communication skills in order to keep

Jasmine’s hands engaged and to provide tactile input (a recommendation from Jasmine's

occupational therapist).

Using a neurodiversity-affirming approach, Jasmine’s clinician supports her perspective

-taking and problem-solving skills and frequently collaborates with Jasmine’s parents and

teachers so that they can discuss real-life situations during therapy.

While all of these therapy sessions may look different, the underlying principles of neurodiversity-affirming therapy hold true. None of these clients are encouraged to change their inherent way of being. Client loves looking in the mirror but isn’t so into “traditional” toys? No problem! Client has access to speech but needs AAC when language is hard to access? Let’s build up that AAC competency! Client’s perspective-taking difficulties make it hard to make friends? Let’s build those skills without shaming or invalidating their own perspectives!

Another way to ensure that treatment is neurodiversity-affirming is to take a look at the messaging used when targeting social skills. Let’s look at two examples:

These two posters are an older and newer version of a ‘Listening Larry’ poster developed by Social Thinking and Everyday Regulation. Both posters serve to teach children all the ways that their body helps them listen, especially during group lessons or conversations.

However, the messaging conveyed by each poster is different, and is especially notable when we consider the implications for neurodivergent children.

In the first example (green), children are directed in how to use their body to show others that they are listening. The role of each body part is stated as fact - “Eyes look at the person talking to you,” “Hands are quiet in your lap, pockets, or by your side.” These statements don’t allow for personal differences in how children look or act when they’re listening. Many of these statements are particularly concerning in consideration of neurodivergent children - many Autistic people report that eye contact is uncomfortable or even painful, and children with sensory differences or ADHD may have a hard time keeping their hands still.

In response to feedback echoing these sentiments, the new (purple) poster was created. In the new version, 'Listening Larry' invites children to explore how their bodies help them listen. By leaving blank spaces, children can share their own unique way of listening. It allows for all sorts of differences - from sensory needs, attention differences, physical limitations, and more!

Beyond the Session

As SLPs, our focus is often on our sessions with clients. However, as part of the larger neurodiversity-affirming movement we have a responsibility to influence change beyond the session.

Supporting Clients
We can take what we know about using affirming language, validating unique perspectives, and embracing strengths-based therapy in our interactions with our clients. We should choose assessments and therapy materials with care to promote an environment of acceptance.
Collaborating with Families, Teachers, and Professionals
Through educating and learning from families, sharing our knowledge with teachers, and working closely with professionals like occupational therapists, we can ensure that our clients' entire support systems operate within a neurodiversity-affirming framework.
Influencing the Wider Community
As we've discussed, the mission of the neurodiversity-affirming movement is to move toward the social model of disability. This means creating change in our communities to make the world a more accepting and accessible place for everybody. Sharing information via social media, community events, and political campaigns are some of the ways that SLPs (and everyone!) can influence the community.

At Talk Time, we strive to foster a community of families and clinicians who respect, accept, and support neurodivergent kids. We know that parenting children who are neurodivergent can be hard at times, and we hope to be a place that families can come to for support and guidance.