A new era in understanding neurodivergence: A conversation with Dr. Megan Anna Neff.

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Dr. Megan Anna Neff is a clinical psychologist, researcher, and author of the book, Self-care for Autistic People: 100+ Ways to Recharge, De-stress, and Unmask. Dr. Neff is also the author of Violet’s newest Neurodiversity collection, as part of our Clinical Quality Educational Interventions (CQEI). We sat down to speak to her about her own personal experience with neurodivergence and the evolving mental health care landscape.

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Violet: Can you share a bit about your personal journey with neurodivergence and how it has influenced your professional work?

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Dr. Neff: My journey with neurodivergence began when I was diagnosed with autism at 37, shortly after one of my children received a similar diagnosis. This revelation came just three weeks before I was to graduate with a Doctorate in Clinical Psychology. Additionally, I later discovered I had ADHD and mild dyslexia. This period marked a significant turning point, requiring me to reevaluate and unlearn many of my preconceived notions about neurodivergence, especially its manifestation in girls and women.

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After seeing this in myself and my child, and realizing that my lifelong mental health struggles were more accurately framed within the context of ADHD and autism, it ignited a profound passion in me. I became deeply committed to increasing awareness about the non-stereotypical presentations of autism and ADHD. Recognizing that those of us who remain undiagnosed often have significant mental health support needs and face a much higher risk of suicide, I've come to believe strongly in the necessity for more comprehensive training in neurodivergence for both mental health and medical professionals. This realization has not only been a turning point in my professional journey but has also marked a deeply personal commitment to this cause birthed from my personal experiences. 

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Violet: What are some common misconceptions or stereotypes about autism and ADHD within the mental health field, and how do you work to challenge and broaden these perceptions?

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Dr. Neff: Historically, the diagnosis of autism and ADHD has leaned heavily on observable behavioral traits and checkboxes, rooted in research predominantly focused on a narrow demographic: affluent, white, cisgender boys with externalizing behaviors. This approach has inadvertently established a feedback loop, reinforcing a limited view of what autism or ADHD "should" look like based on the most represented groups in research. This cycle has solidified stereotypes and misconceptions, overshadowing the diverse presentations of neurodivergence across different populations.

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Many assume, for instance, that individuals with autism cannot make eye contact or engage in small talk, or that those with ADHD cannot be successful or organized. These stereotypes overlook the reality of individuals who, through significant effort, repress their innate instincts and adopt performative strategies to meet societal expectations, often at a great personal cost to their energy and mental health.

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Another widespread misconception is that autism and ADHD are conditions exclusive to boys and are always identified in childhood. Recent studies, such as one suggesting the true ratio of autism may be closer to 4 girls for every 3 boys, challenge this view (McCrossin, 2022). There's also a considerable number of adults with undiagnosed ADHD and autism, seeking mental health services without recognition of their neurodivergence.

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Another assumption I often encounter is the belief that mental health professionals can intuitively identify someone as Autistic or with ADHD—or more precisely, will confidently conclude they are not Autistic or have ADHD because they can do x (insert outdated stereotype here). This overlooks the complexities of masking, varying intellectual levels, and the propensity for internalization. In my work, I strive to challenge and broaden these perceptions by advocating for a nuanced understanding of autism and ADHD that centers on the subjective experience of the individual. This approach highlights the diversity within these conditions and underscores the importance of considering the internal experiences and struggles of each person. This involves pushing for wider recognition of the varied presentations of these conditions and the need for mental health professionals to adopt a more inclusive and comprehensive approach to diagnosis and support.

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Violet: How do you approach the intersectionality of neurodivergence with other identities, such as race, gender, or socioeconomic status, in your work?

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Dr. Neff: It's a critical observation that many disability spaces struggle with intersectionality, and similarly, numerous racial justice spaces fall short in addressing disability. This insight is greatly influenced by Tiff Hammond, a Black Autistic advocate, who frequently discusses the importance of intersectionality and disability. Neurodivergence doesn't exist in a vacuum; it intersects with all other facets of identity, like race, gender, and socioeconomic status, influencing how individuals experience the world.

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In my own work, for example, I have several privileged identities that, in some ways, shield me from the full brunt of challenges my neurodivergent identity might otherwise pose. It's clear that my journey as an Autistic person differs significantly from those facing multiple, intersecting marginalizations. I believe it’s really important we situate ourselves when engaging in advocacy, as we’re never talking about autism alone. 

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It's vital to acknowledge that BIPOC individuals have historically been underdiagnosed or misdiagnosed regarding neurodivergence. Moreover, the additional pressures for those who mask and code-switch can be immense. And there are other dire considerations such as how Black and Brown Autistic boys face a heightened risk of violence when their behaviors are misunderstood—a stark reality that must be addressed within discussions on neurodivergence.

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Furthermore, the neurodivergent community includes a higher proportion of queer and genderqueer individuals compared to the general population. The medical skepticism towards the self-reported gender identities of Autistic individuals is deeply troubling and something we need to challenge.

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Hence, considering neurodivergence through an intersectional lens is not just important—it's imperative for addressing the multi-layered experiences of stress and discrimination that come with navigating multiple identities.

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Violet: Your upcoming book focuses on Autistic Burnout. What are some key insights or coping strategies you've found helpful in managing burnout as an individual with autism?

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Dr. Neff: In my upcoming book, I emphasize the importance of understanding and regulating one's sensory environment as a cornerstone of managing burnout. Recognizing and seriously addressing my sensory needs led me to significantly reorganize my life to avoid constant sensory dysregulation, which can be a precursor to burnout—since burnout is essentially a burnout of the nervous system.

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Part of restructuring our lives to prevent burnout includes establishing accommodations, both formal, like those provided by educational institutions or workplaces, and informal, which we implement ourselves. For instance, I often wear beanies because the proprioceptive pressure on my head aids in sensory regulation. While beanies might not be deemed professional attire, they serve as a personal accommodation that contributes to my sensory well-being.

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Yet, when discussing the reorganization of our lives to prevent burnout, acknowledging privilege is essential. The capacity to adjust or transform our lives, including obtaining a diagnosis and accessing accommodations, frequently depends on one's socioeconomic and social privileges, highlighting once more the role of intersectionality in discussions of neurodivergence. 

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Additional strategies that have proven beneficial include supporting my sensitive nervous system and getting more comfortable with boundaries. This latter point often requires confronting and working through neurodivergent shame, internalized ableism, and a tendency towards people-pleasing that many of us carry, so we have to be patient with that process! 

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Furthermore, embracing neurodivergent strengths and seeking out community have been crucial in buffering against burnout. The sense of belonging and connection with others who share these experiences can be incredibly impactful.

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Violet: Could you share some practical tips or strategies for health care providers to improve their cultural competence in serving neurodivergent patients?

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Dr. Neff: The very first suggestion I have is to always entertain the possibility of neurodivergence. Neurodivergent adults often present with significant mental and physical health needs, making their presence in health care settings common, yet many remain undiagnosed. Recognizing the potential for conditions like autism and ADHD is crucial, as these often go unnoticed with providers instead defaulting to diagnoses such as bipolar disorder, personality disorders, or trauma. While these conditions may coexist with neurodivergence, their identification should not preclude the consideration of autism or ADHD, which are frequently overshadowed.

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Another strategy is to adopt sensory-friendly practices during visits. This can involve modifying the environmental factors like lighting, sound, and scent, alongside offering flexible scheduling and telehealth options to accommodate diverse sensory needs. A deeper understanding of sensory regulation among health care providers is also essential. Often, emotional regulation strategies are recommended without addressing underlying sensory dysregulation, rendering these interventions less effective.

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Lastly, I encourage providers to familiarize themselves with the concept of the double empathy problem, introduced by Autistic sociologist Damian Milton. This theory suggests that communication breakdowns occur not because of deficits in Autistic individuals, but due to mismatches in cognitive styles between different neurotypes, akin to cross-cultural misunderstandings. Empirical studies have supported this theory, indicating that neurotype compatibility, rather than autism itself, influences rapport. Understanding this could lead providers to approach cross-neurotype interactions with the same humility and openness as cross-cultural engagements, fostering better communication and reducing the impulse to "fix" neurodivergent individuals.

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Violet: How can health plans and provider organizations better support the needs of neurodivergent individuals within their systems and services?

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Dr. Neff: While not an exhaustive list, here are a few ideas that come to mind: 

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• Increase access to flexible health care options. Providing more adaptable health care services, such as telehealth, can make a significant difference for those who struggle with traditional in-person visits due to sensory sensitivities or limited energy. 
• Extend the length of visits. Recognizing the complexity of conditions that neurodivergent individuals often face, longer appointment times can ensure a thorough discussion of their health concerns without feeling rushed, which will help with more  accurate diagnoses and treatment plans.
• Reduce barriers to navigating health care. Considering the executive functioning challenges that many neurodivergent people experience, simplifying the health care navigation process is crucial. This could involve clearer communication, streamlined appointment scheduling, and assistance with managing health care logistics.

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Violet: The integration of spirituality into psychotherapy is an intriguing aspect of your work. How do you see spirituality intersecting with neurodivergence, and what role can it play in fostering resilience and well-being among neurodivergent individuals?

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Dr. Neff: Indeed, much of Western psychology tends to overlook the concept of the transcendent self, which is regrettable. This omission not only results in a less holistic approach to care but also reinforces the Eurocentric myth of hyper-independence. As my relationship with spirituality has transitioned from a religious framework to a broader spiritual viewpoint, this shift has significantly enriched my comprehension of spirituality's impact on neurodivergent individuals.

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Many neurodivergent people are profoundly value-driven, embodying their values and interests to an extent that they become inseparable from their identity. This concept is beautifully articulated by Autistic advocate Terra Vance, suggesting that for Autistic individuals, "We don’t just have values; we are our values." This intrinsic alignment with deeply held values resonates with my definition of spirituality, which I see as transcending oneself and connecting with a purpose or energy greater than oneself.

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This spiritual connection, when aligned with personal values, can be a powerful source of pleasure, flourishing, and meaning for neurodivergent individuals. It not only benefits the individual by fostering resilience and well-being but also has the potential to contribute positively to the world. The characteristics often associated with neurodivergence—such as intense focus, justice sensitivity, and passionate engagement—can drive significant social and environmental advocacy. I view this alignment of values and advocacy as a spiritual practice, one that highlights the profound impact neurodivergent individuals can have when their voices are harnessed and valued.

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Violet: What would you say influenced the current spike in neurodiversity interest and what do you hope will come from more clinicians being educated on the topic? 

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Dr. Neff: The surge in interest towards neurodiversity, in my view, stems from a conflation of several factors. I’ll try to break them down: 

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• The pandemic: This period of global pause allowed many to step back from the sensory-intense rhythms of daily life, offering insights into their baseline states. Personally, I noticed a significant reduction in chronic fatigue once the constant sensory overload was no longer present—a connection I might not have made without this forced hiatus. For many with ADHD, the removal of structured work environments highlighted executive functioning challenges more starkly than before.
• Social media: Despite my ambivalence towards social media, I will always appreciate its pivotal role in elevating the voices of underrepresented groups, including neurodivergent individuals. It has facilitated a platform where lived experiences can be shared and seen, helping many to see reflections of themselves. While there's a cautionary note about self-identification based on limited information, recent studies suggest that a majority of those who self-identify as Autistic indeed are Autistic, lending credibility to these shared narratives.
• Cultural timing: We are in a moment of collective awakening, making it a fitting time to expand our understanding of neurodivergence beyond the stereotypical cis, white, boy narrative. The increasing visibility of neurodivergent individuals from diverse backgrounds, including people of color, women, those facing economic disadvantages, and genderqueer people, is not only challenging outdated norms but also actively encouraging a more inclusive perspective. As a culture, we’re moving on from the 1950s and the traditional focus on the cisgender, white male as the standard for defining all experiences is increasingly recognized as inadequate. We see this in many places, neurodivergence just being one example of this expanded awareness.

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From this growing awareness and education on neurodiversity, I hope for a future where clinicians are better equipped to recognize, understand, and support the wide spectrum of neurodivergent experiences. 

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To learn more about Violet’s clinical education, request a demo.

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References

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McCrossin, R. (2022). Finding the True Number of Females with Autistic Spectrum Disorder by Estimating the Biases in Initial Recognition and Clinical Diagnosis. Children, 9(2), 272. https://doi.org/10.3390/children9020272

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