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Supporting a neurodiverse workforce

Supporting a neurodiverse workforce

In recent years, there has been a major shift in the recognition and awareness of neurodiversity. Conditions such as attention deficit hyperactivity disorder (ADHD) and autism can affect clinicians as much as our patients. This article explores some ways that we can understand and support neurodivergent health professionals within the workplace. You may also wish to refer to our associated articles:

• Neurodivergence: an umbrella approach.
• Attention deficit hyperactivity disorder (ADHD).
• Autism.
• Tourette’s syndrome and tics.

This article was reviewed in March 2024.

So, how might neurodiversity affect individual clinicians within primary care? Take a look at these two examples:

We hope you find some helpful ways to understand and support neurodivergent colleagues in the following article!

Neurodiversity refers to the many different ways that a person’s brain may process information. The term acknowledges that there is a wide range of normal variation in how we do this, and that there is no single or ‘right’ way to experience and interact with the world. As many as 15–20% of the population are estimated to be neurodivergent, and this is unrelated to race, gender or social class (InnovAiT 2023 0(0), 1–6).

From the perspective of neurodiversity, we can view neurodevelopmental conditions such as autism, ADHD, dyslexia, dyspraxia/developmental coordination disorder (DCD), Tourette’s syndrome, dyscalculia and dysgraphia as differences rather than as deficits. These conditions often co-occur and many symptoms overlap.

These differences may pose challenges or create areas of need that affect many areas of working life, particularly when attempting to fit into a largely neurotypical workplace, but they also include many strengths and areas of capability, such as in the following domains:

Neurodivergent clinicians will experience a unique pattern of personal characteristics across the different domains, and these can influence how we respond in different situations and how we function at work. Many neurodivergent individuals have a ‘spiky profile’, meaning they perform highly in some areas but markedly lower in others, or may have ‘hidden’ impairments. This disparity tends to be less pronounced in neurotypical individuals. Factors in the external environment can also have a major influence in how these characteristics affect a health professional in the workplace (Br Med Bull, 2020, 135(1): 108–125).

The precise number of neurodivergent health professionals is currently unknown. As high achievers who are often expert at ‘masking’, many clinicians may not realise they are neurodivergent until later life – perhaps when demands at home or work exceed their ability to compensate for differences. Women are particularly likely to be overlooked or misdiagnosed if they don’t display disruptive behaviours in childhood (CMAJ 2022; 194(27): E951).  Individuals from ethnic minority backgrounds may also be less likely to receive a formal diagnosis of neurodivergence (Autism Research 2020;13:464).

Even when recognised, a fear of stigma may make it difficult for neurodivergent clinicians to seek support. An editorial in the BJGP describes how many neurodivergent doctors remain undiagnosed and undercover for fear of disbelief or workplace discrimination, which can contribute to emotional distress and poor mental health outcomes (BJGP 2021; 71 (708): 294).

Neurodivergent individuals may spend a great deal of time and energy compensating for differences so they can succeed in settings that favour neurotypical behaviours. This ‘masking’ behaviour is aimed at avoiding negative reactions, rejection and stigma. However, it can be exhausting and anxiety-generating, and takes a major toll over time. Masking is associated with negative impacts on mental health, including anxiety, depression, burnout and increased suicidality (Medical Education 2023; 1-9).

In contrast, developing increased self-knowledge and awareness of underlying neurodiversity can ease feelings of anxiety or low mood, and create a sense of empowerment. A significant improvement in mental health can also occur when reasonable workplace adjustments that suit the individual’s needs are put in place.

Many neurodivergent conditions are considered a disability in the UK, as defined by the Equality Act 2010. The GMC defines a disability as “an impairment that has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities”, and refers specifically to autism, ADHD and specific learning difficulties such as dyslexia and dyspraxia (GMC - welcomed and valued guidance).

Employers have a legal duty to make reasonable adjustments to the way they operate in order to support an individual to do their job: by removing significant barriers that place them at a disadvantage because of their disability.

Some examples of reasonable adjustments that may support neurodivergent health professionals to work effectively are summarised below (Br Med Bull, 2020, 135(1): 108–125):

The Department for Work and Pensions offers an Access to Work grant which can be used to help pay for practical support with work that may be needed due to a physical or mental health condition or disability. Individuals can self-refer to the scheme. It is not means-tested, and is available for people in paid work or those due to start within 12 weeks. Note that Access to Work will not pay for reasonable adjustments, which must be provided by the employer, but can offer additional support such as coaching, transport or equipment.

Many individuals will not disclose (or even realise) that they are neurodivergent. Employers and workplaces should therefore take proactive steps to improve how we support and manage our teams across the board, not simply when neurodivergence has been highlighted as a potential issue.

The CIPD guide to neuroinclusion at work was developed to help employers create more inclusive workplaces where a diverse range of individuals are able to thrive and experience a sense of belonging. It identifies 7 key principles for creating a neuroinclusive organisation:

• Understand where you are now and commit to a long-term plan of action. Ensure that you act on this plan and demonstrate a lasting commitment to progress towards neuroinclusion.
• Create an open and supportive culture where people feel comfortable talking about neurodiversity.
• Proactively consider neurodiversity in how you manage your team on a daily basis. People should feel included, that they are treated with respect and that their contribution is valued. It may also be important to review policies and processes such as recruitment, training and staff development to ensure that they are neuroinclusive.
• Be guided by individuals about what they need to perform their best at work. There should be open and effective conversations about ways to improve support, communicate effectively, and make adjustments or increase flexibility within job roles that may help meet an individual’s needs.
• Embrace flexible working to enable everybody to thrive. Flexible working has been found to have a positive impact on employee engagement, wellbeing and performance (CIPD Neuroinclusion at work report 2024). This might be in relation to working hours, where you work, frequency of appointments, or other aspects of the role such as completion of admin tasks or attendance at meetings. The CIPD emphasises that making even small changes can have a big impact, and that some degree of flexibility is usually possible, even in frontline roles. Try to creatively explore ways to overcome any difficulties, for example by taking on additional or different roles and responsibilities that may better suit someone’s strengths.

• Practise ongoing attention to wellbeing. Managers should take time to regularly check in with their team and with individuals, giving people the opportunity to raise concerns and ask for support if needed.
• Empower neurodivergent voices. Your own team is often best placed to inform you how your organisation may be more neuroinclusive. Invite participation, but don’t expect it. Seek to improve opportunities for two-way communication and feedback, and do not assume that existing channels will be, or feel, accessible to everyone.

Other strategies that may help support a neurodiverse workforce include:

• Clarify organisational conventions: do you provide explicit information to new starters about organisational expectations and conventions, and any ‘unwritten rules’ and conventions of your practice, such as time at work, breaks, dress code, social events and other aspects of team working?
• Communicate tasks clearly: providing information in multiple formats (such as verbally, in writing or even video-recorded) can help different learning styles, enabling people to prioritise work and meet deadlines.
• Give structured positive feedback: ensure that you regularly provide positive feedback, along with a supportive space that allows the individual to discuss their needs and any challenges that are being experienced. Be aware that neurodivergent individuals may experience ‘rejection sensitivity dysphoria’, which can cause a strong emotional response to negative feedback or perceived criticism, and may trigger distressing emotions or feelings of rejection (PLoS ONE 2022;17(2):e0263366).
• Be sensitive when introducing change: giving clear communication about change and the reasons behind it in advance, and enabling everyone to participate in the process, can help individuals who find change stressful or difficult.
• Provide a calm space for decompression: in extreme circumstances, a neurodivergent person may experience a ‘meltdown’, defined as “an intense response to overwhelming situations” (Br Med Bull, 2020, 135(1): 108–125). Physical contact or verbal discussion in this context may exacerbate rather than alleviate the distress, and it is more helpful to provide a calm, quiet space for recovery and decompression.

Around 3% of adults are estimated to be autistic (PLoS One. 2023; 18(7): e028827). It is unclear how many clinicians are autistic, but it is increasingly recognised to be common among health professionals – although many remain undiagnosed (BJGP 2021; 71 (708): 294). A BJGP editorial (BJGP 2021; 71 (708): 294) reports that the majority of autistic health professionals are practising successfully, and only a minority are “in difficulty”. Problems involving clinical work or patient care – which are often task-focused and with a clearly-defined social role and expectations – are less likely to arise than when navigating unstructured, unpredictable and sometimes confusing interactions with colleagues and with the organisational hierarchy. Social conventions and norms may seem opaque, illogical or otherwise bewildering. This may mean that interactions with management, training or regulatory bodies can become fraught with misunderstanding.

The ’double empathy’ theory argues that autistic individuals are not lacking in empathy, but can communicate and empathise best with other autistic people. For example, communication may be improved between autistic clinicians and autistic patients (BJGP 2021; 71 (708): 294-295). This means that a two-way barrier may exist between autistic and non-autistic people, whereby each group finds it hard to understand and empathise with the experiences of the other.

Other workplace difficulties involve the experience of stigma. This can be fuelled by stereotypes about autism or by negative experiences with others who may discount the individual’s autistic identity. There may be a lack of support or contact with other autistic colleagues and peers, which can lead to a sense of isolation, depression and anxiety (Medical Education 2023; 1-9).

Some of the common strengths and challenges of autistic people are summarised below, although these differences can vary markedly between autistic individuals (Medical Education 2023; 1- 9 and InnovAiT 2023 0(0), 1–6).

Autistic SPACE is a framework that was developed to help meet the needs of autistic patients in healthcare settings, but it can also be a helpful way to consider the needs of autistic clinicians (Br J Hosp Med 2023 Apr 2;84(4):1-9):

The prevalence of ADHD is around 3% in adults. It is characterised by a persistent pattern of inattention and/or hyperactivity and impulsivity.  

The CIPD guide to neurodiversity in the workplace describes how a negative perspective of ADHD may be to view individuals as forgetful, absent-minded, easily distracted and easily bored. However, an individual with ADHD can have many strengths and areas of capability at work. They may be more comfortable taking calculated risks, living with uncertainty and pushing boundaries, reflected by an increased prevalence of ADHD among entrepreneurs.

Insight, creative thinking and problem-solving are also strengths often associated with ADHD. In addition, the ability to multitask, respond to changing environments and work demands, and remain calm and composed in high-pressure situations are highly-valuable traits that are extremely relevant in the current changing NHS landscape.

It is a myth that people with ADHD lack the ability to focus. Many have the ability to hyperfocus, and can become completely absorbed when engaging in a task that is sufficiently stimulating and interesting. However, it can sometimes be difficult to switch focus between tasks or stop once they have reached this state of ‘flow’.

People with ADHD may find themselves feeling restless, distracted and easily bored in a role or with work tasks that are not sufficiently stimulating or interesting. This can make it hard to complete routine admin or to engage with learning logs, reflections and appraisals.

It can be difficult to screen-out sensory input, meaning that an individual may be more easily distracted in a shared or open-space environment. It may also be challenging to maintain focus during long meetings. Organisation and time management can be challenging, and it may be difficult to organise thoughts when in conversation with others.

Common challenges in the workplace experienced by people with ADHD can be overcome by different types of support. This can range from coaching in communication skills to assistance with self-organisation, e.g. how to set goals, choose priorities and create to-do lists, and use of visual prompts and alarms as reminders to complete routine tasks.  Large or dual computer screens can allow more information to be visible at once and reduce the memory burden.

Many will benefit from a work structure that incorporates regular short breaks to enable physical movement and a change of environment. This can help to prevent boredom and can boost wellbeing and productivity. This is an adjustment that may be helpful for all staff, not just those who are neurodivergent.

People with ADHD are likely to thrive in a role where they are less likely to get bored. They may struggle more with roles that are very routine or predictable because this may not provide sufficient stimulation. Finding new challenges and utilising entrepreneurial skills can be a great way to maximise both wellbeing and improve outcomes for the practice.

Supporting a neurodiverse workforce As many as 20% of the population are estimated to be neurodivergent, and these figures also apply to clinicians and other staff working in primary care. Neurodivergent conditions often co-occur, and many symptoms can overlap. These can pose challenges or create areas of need that affect clinicians in many areas of working life, but also include many strengths and areas of capability. ‘Masking’ behaviours can be exhausting and takes a major toll on mental health over time. Recognising the impact of neurodiversity and taking proactive steps to improve how we support and manage our teams across the board can help create more neuroinclusive workplaces that enable every member of the team to thrive.