When I say … neurodiversity paradigm

Abstract

New paradigms require new language. The term ‘neurodiversity’ is often misunderstood and used interchangeably with neurodivergence. Instead, neurodiversity describes the infinite, natural variation of neurocognitive functioning in human minds.¹ ‘Neurodiverse’ is, therefore, a societal descriptor, outlining this variation across the population. By contrast, ‘neurodivergent’ refers to those who differ from societally perceived norms of brain or mind function—or from the majority, who are sometimes described as ‘neurotypical’. Neurodiversity should not be thought of as a single or even static concept. This raises the question what do people mean when they say ‘neurodiversity’? On the one hand, we might consider the biological fact that all human brains differ to varying degrees. This is not, however, what we are referring to. Next, we might consider the neurodiversity movement, grounded in the disability rights movement—the on the ground advocacy driving forwards justice for neurodivergent people culturally, socially and politically.¹ This may indeed be what some refer to when discussing ‘neurodiversity’ as an undifferentiated term. Here, however, we shall discuss the neurodiversity paradigm. This refers to the conceptual beliefs, or worldview, underpinning the assertion that a neurodiverse society is made up of neurotypical and neurodivergent people—and that being neurodivergent is no less worthy than being neurotypical.

Diversity of thought, perspective and experience adds to the rich nuance required to understand the complexity of medical practice and education. A diverse medical workforce also benefits the general population. For example, neurodivergent doctors may help to alleviate barriers to healthcare access for neurodivergent patients.² Medical education is, however, failing neurodivergent learners, who continue to face significant challenges, despite efforts to promote student support and accessibility.^{3, 4} Why are our current approaches insufficient, and what needs to change? In this ‘When I say …’ article, we leverage our unique lived experiences to offer a diversity of perspectives on current understandings in this area. We argue that medical education will fundamentally fail in its mission to support neurodivergent learners unless we undergo a significant transformation in how we value different ways of thinking and learning. We conceptualise this philosophical transformation as a shift towards the neurodiversity paradigm.

First and foremost, the neurodiversity paradigm concerns itself with social justice. Drawing on the concept of power, this paradigm promotes critical thinking around things we have previously passively accepted as real. This considers the influence of power on how we constructed such historical ‘truths’ and how these are then maintained as part of the wider status quo. Prior to this, traditional understandings of neurodivergence were created and maintained by the neurotypical majority. This led to external perspectives of people being disordered. For example, Autistic people were previously—and erroneously—thought to feel no empathy because they displayed empathy in ways that fell outside of normative societal expectations, which went unrecognised by medical professionals and researchers. This led to a ‘fallacy of misplaced concreteness’, where a perspective about the way neurodivergent people are, developed through decades of research from a deficit perspective, was mistaken for reality and continually reinforced. In that sense, it may be easy to ‘prove’ something if we do not reflect critically on its philosophical underpinnings. The neurodiversity paradigm brings a critical perspective to this area.

Paradigms are sets of ideas through which people engage with reality and form knowledge, which are determined by our ontological and epistemological beliefs.⁵ Ontology considers the nature of reality—what something is. This might consider one objective truth (‘realism’, where we believe there is a single reality that is separate to those experiencing or perceiving it) or that reality is more subjective (‘relativism’, where reality may instead be different for different people). For example, if two people attend an event and experience it very differently, is one of them correct and the other wrong, or might the reality be dependent on the person perceiving it? Epistemology then considers how we create knowledge, entwined with our ontological beliefs.⁵ For example, might the best approach be objective and free of bias, or subjective and embracing human experience? Digging deeper, this could also consider our aims in making knowledge, such as seeking to improve human existence or promoting social justice. In that sense, it asks what knowledge is meaningful and how we can best create it.

Ontologically, the neurodiversity paradigm argues that neurodivergent people are different—not flawed, impaired, or disordered. Difference does not entail inherent lack of worth, regardless of whether difference is personally experienced as an impairment, a disability, or an advantage. Societal factors can contextually disable neurodivergent people due to a mismatch between their differences and any given expectations. Such factors might be historical, political, cultural, social or environmental in nature. This is different from a strengths-based perspective, which promotes a focus on celebrating strengths. This accidental conflation of these has attracted criticism over the years, with people thinking the neurodiversity paradigm did not account for disablement or that it asserted that neurodivergent people had inherent ‘superpowers’. Instead, this paradigm argues that strengths and weaknesses are both contextual, depending on the aforementioned mismatch between our differences and the given situation, systems, structures and expectations.

Epistemologically, the neurodiversity paradigm argues that neurodivergent people should be central to the creation of knowledge around neurodivergence. Research should be grounded in neurodivergent community perspectives and should seek to advance social justice. In essence, the minority-group status of neurodivergent people led to them having no meaningful voice in the academic world for many years. This was an example of an ‘epistemic injustice’—an injustice in the way we have created knowledge, which has systematically led to misunderstanding and one-sided perspectives.³ The lack of neurodivergent voices shaping our discourse has led to flawed practices. One such example is policies to screen for neurodivergence following exam failures. Such policies remain commonplace in both undergraduate and postgraduate medical education in the UK. While well intended, this practice draws on a deficit-based view of neurodivergence and reinforces associations with failure and thus promotes on-going stigma. Small changes, such as offering optional screening to all students on admission to their courses, could help to break the association with failure in this example.

Sebastian Charles Keith Shaw: Conceptualization; writing—original draft; writing—review and editing. Megan E. L. Brown: Conceptualization; writing—review and editing. Neera R. Jain: Conceptualization; writing—review and editing. Riya Elizabeth George: Conceptualization; writing—review and editing. Sarah Bernard: Conceptualization; writing—review and editing. Megan Godfrey-Harris: Conceptualization; writing—review and editing. Mary Doherty: Conceptualization; writing—review and editing.