Tag: medical model

Neurominorities, Spiky Profiles, and the Biopsychosocial Model at Work

I’m making my way through my second read of the very interesting ”Neurodiversity at work: a biopsychosocial model and the impact on working adults”. There is a lot to digest. It offers:

  • definitions of neurotypical and neurodivergent based on spiky versus flat profiles
  • a taxonomy and timeline of neurominorities
  • an evolutionary critique of the psychomedical model
  • a biopsychosocial model for work
  • occupational considerations of neurodiversity
  • work-related difficulties and strengths attributed to neurominorities

I recommend this to all DEI and HR workers. Selected quotes:

There is consensus regarding some neurodevelopmental conditions being classed as neurominorities, with a ‘spiky profile’ of executive functions difficulties juxtaposed against neurocognitive strengths as a defining characteristic.

An evolutionary critique of the psychomedical model

Given the extent of overlap between the conditions, the under-diagnosis of females who instead present with anxiety, depression or eating disorders, and the estimated prevalence of each condition, a reasonable estimate of all neurominorities within the population is around 15-20%, i.e. a significant minority. Research supports a genetic component to most conditions which, when considered with combined prevalence rates, suggests an evolutionary critique of the medical model: if neurodivergence is essentially disablement, why do we keep replicating the gene pool? The less extensive, yet persistent, body of work indicating specialist strengths within neurodiversity, supports the hypothesis that the evolutionary purpose of divergence is ‘specialist thinking skills’ to balance ‘generalist’ thinking skills (as per the ‘spiky profile’). The evolutionary perspective is congruent with the Neurodiversity movement and essential to understanding the occupational talent management perspective that is currently in vogue.

The psychomedical histories outlined in Table 2 speak to the evolutionary critique for two reasons. Firstly, they demonstrate the consistency of the ‘specific’ rather than ‘general’ nature of impairment (the spiky profile) across all four conditions over time, irrespective of the changing nature of causal theories. The conditions are named and identified according to their most prominent deficits, which are themselves contextualized within our normative educational social history. Dyslexia is discovered around the same time as literacy becomes mainstream through education; ADHD becomes more prevalent with the increasing sedentary lifestyles from the industrial revolution; autism increases in line with modern frequency of social communication and sensory stimulation and DCD as our day-to-day need for motor control of complex tools and machinery becomes embedded. The evolutionary critique of neurodevelopmental disorders is that their perceived pathology is related to what we consider normal in modern times, as opposed to what is normal development within the human species.3,7,53–55 Secondly of interest from the timeline in Table 2 is the final column, wherein we see that, despite consistent observation of similar neurobiological differences, we lack a single unifying theory for any condition.

Towards a biopsychosocial model

The spiky profile may well emerge as the definitive expression of neurominority, within which there are symptom clusters that we currently call autism, ADHD, dyslexia and DCD

Within the biopsychosocial model of neurodiversity, understanding work-related intervention and treatment becomes more about adjusting the fit between the person and their environment than about treating a disorder. Critical review of the extant biopsychosocial research supports the social model proposition that the individual is not disabled, but the environment is disabling.

The legal status of neurodiversity

Disability status is predicated not on diagnosis of condition, but on the assessment of functional impairment, the extent to which the individual is inhibited and excluded.

Many neurominority employees find themselves in need of disability accommodation at work. Irrespective of legal protection, social and occupational exclusion are endemic for neurominorities.

Occupational considerations of neurodiversity

A reductive, medical paradigm of research is incongruent with the legal status of neurominorities as protected conditions in most developed countries, to which organizations must adjust.

Occupational symptomatology

At the functional level, there are similarities between neurominorities in terms of presentation. As alluded to in Table 2, executive functions are a common psychological complaint, resulting in difficulties with short-term and working memory, attention regulation, planning, prioritizing, organization and time management. Self-regulation of work performance is required in many modern employment contexts and therefore these issues present as the most disabling for individuals. There is also commonality among strengths, many related to higher order cognitive functioning reliant on comprehension and creativity.Table 3, adapted again from the British Psychological Society’s 2017 report, describes reported strengths and weaknesses associated with the four main neurominorities. The comparatively fewer references regarding strengths may reflect a research bias as opposed to an accurate representation of lived experience; it certainly is incongruent with the ‘talent’ narrative that is becoming dominant in workplaces.

Accommodations

The aim of occupational accommodations for neurominorities is to access the strengths of the spiky profile and palliate the struggles.

When assessment methods are more matched to the eventual job performance (for example observation of physical examination skills using role play patients) extra time becomes less important. This principle applies across education, recruitment and employment but is poorly understood by lay people or those without an understanding of cognitive functions and the antecedent components of job performance.

Following Diagnosis

Once a condition or conditions have been identified, an individual may feel vindicated, and experience catharsis. Psychology practitioners report their clients’ mental shift following correct diagnosis at the identity level and warn that, done badly, it can lead to disempowerment.12 However, done well, understanding one’s strengths and weaknesses can lead to breaking down barriers and removing self-reproach.

Accessing adjustments

Adjustments tend to be provided as a compliance activity per individual, with few businesses looking systemically at Universal Design for neurominorities as would be recommended in the United Nations Convention on disability. Access to accommodations is thus predicated on individual disclosure, typically occurring following a conflict or episode of poor performance. Individuals are reluctant to voluntarily disclose in advance as they fear discrimination (with some justification) and therefore the aims of the disability legislation programs worldwide are not yet having the intended effect on inclusion.

Accommodations in providing medical treatment

Differences in sensory perception have been reported as a hallmark of neurominority internal experience, which may affect pain management, sleep patterns and increase routine-change difficulties during in-patient care.

Conclusions

From within an emerging paradigm, clinicians and researchers must appreciate the shift in discourse regarding neurodiversity from an active, vocal stake- holder group and embrace new avenues for study and practice that address practical concerns regarding education, training, work and inclusion. This article has provided an overview of the neurodiversity employment picture; namely high percentages of exclusion juxtaposed against a narrative of talent and hope. Understanding the importance of nomenclature, sensory sensitivity and the lasting psychological effects of intersectional social exclusion is key for physicians wanting to interact confidently and positively with neurominorities. The proposed biopsychosocial model allows us to provide therapeutic intervention (medical model) and recommend structural accommodation (legislative obligation) without pathologization (social model). In other words, we can deal pragmatically with the individuals who approach us and strive for the best outcomes, given their profile and environment.

Source: Neurodiversity at work: a biopsychosocial model and the impact on working adults | British Medical Bulletin | Oxford Academic

Via:

Psychological models of autism tend to work on the cognitive level of explanation, with some attempting to make links to biological and neurological data. In order to produce cognitive models, all of them rely on accounts of behaviour to make inferences from. A major criticism of these models, is that they are formed (with the exception of monotropism theory, see section 2.5) from a perspective of a cognitive psychology overly restricted by its total adherence to scientific method as the gold standard, which do not value the input of ‘autistic voices’, or that of sociological viewpoints on autism. This has come about for a number of reasons, one of which being the splitting of levels of explanation into subject ‘silos’ (Arnold, 2010). Another was the triumphant victory that biomedical explanations earned at the expense of Bettleheim’s theory of the ‘refrigerator mother’. This victory would not just produce a rejection of this theory however, but it seems a total rejection of psycho-sociological reflection upon what it is to be autistic, a fatal flaw that only alienated the voices of autistic people further. The victory spared the mother, yet lay the blame at the neurology of the ‘autistic person’ themselves, in the sense that there was something medically deficient about the ‘autistic person’, and if one could only find the site of the ‘lesion’ one could find a ‘cure’ (Happe, 1994a). Assumptions of what autism is are enshrined in the diagnostic criteria of the DSM-IV (1994) and ICD-10 (1992) and based upon interpretations of observed behavioural traits. All the psychological theories base their models within this criterion of behaviour led framework, although in the monotropism theory (see section 2.5), this is thankfully balanced by the accounts of lived experience of ‘autistic people’ themselves, including one of the authors of the paper, Wendy Lawson.

The current psychological models seem somewhat inadequate at drawing the links between biology and behaviour, but even more so, between biology and the lived experience of autistic subjectivity, often attempting to obscure the ‘autistic voice’ or ignore it, in an attempt to reduce autistic behaviours to definable objective criteria. The theory of monotropism, is a welcome departure from this theoretical dominance however, largely basing its account in subjective accounts. In so doing, this theory is more applicable to the vast array of subjective differences experienced by autistic people, although perhaps not all. Unfortunately, it does not seem to have achieved the widespread recognition enjoyed by the other theories.

“…right from the start, from the time someone came up with the word ‘autism’, the condition has been judged from the outside, by its appearances, and not from the inside according to how it is experienced.” (Williams, 1996: 14).

Source:  So what exactly is autism? 

Had a nice chat this afternoon with Boston Children’s Hospital’s inpatient neuroscience folks on autism, the social model of disability, identity first language, and designing for pluralism. The best hospital onboarding I’ve experienced.

Society insists on making education, healthcare etc into a sensory hell, and we have to navigate it. Headphones, sunglasses, different clothing, etc can make a big difference. That’s really cheap to achieve for a lot of us, with a small budget from a provider. Hold that thought….that it’s really cheap to achieve for a lot of us ….because it is. If you know what you’re doing. If you ask the autistic person what helps, after having autism training from autistic people, so you know your subject.

Source: Ann’s Autism Blog: Let’s look at why “Autism is the most expensive disability” is untrue.

I use many healthcare portals for fetching med records & contacting docs. They’re all frustrating & buggy. Threshold flow is uniformly bad w/ archaic & unspecified password rules. I often can’t sign up at all, requiring phone calls. Med model flow is high friction & high stress.

Our medical insurance id has an O in it (rather than a 0). This means regularly receiving bills for hundreds and thousands of dollars because of errant data entry. Each one requires phone calls to resolve.

Beach and her research colleagues found that physicians-in-training who read the stigmatizing patient chart notes were significantly more likely to have a negative attitude toward the patient than those who read the chart containing more neutral language.”

And not only did their attitudes change—so did their treatment plans. Those physicians-in-training who had read the stigmatizing chart note decided to treat the patient’s pain less aggressively.

Source: Stigmatizing Language in Medical Records Affects Patient Care – Mad In America

“To be defined as abnormal in society is often conflated with being perceived as ‘pathological’ in some way and to be socially stigmatised, shunned and sanctioned. Then, if there is a breakdown in interaction, or indeed a failed attempt to align toward expressions of meaning, a person who sees their interactions as ‘normal’ and ‘correct’ can denigrate those who act or are perceived as ‘different’ (Tajfeel & Turner, 1979). If one can apply a label on the ‘other’ locating the problem in them, it also resolves the applier of the label’s ‘natural attitude’ of responsibility in their own perceptions and the breach is healed perceptually, but not for the person who has been ‘bothered’ (Said, 1978).”

Source: A Mismatch of Salience | Pavilion Publishing and Media