Daily living skill support for autistic people through a neurodiversity‐affirming practice lens

Abstract

Introduction

Supporting daily living skill (DLS) development for autistic people is a component of occupational therapy practice. DLSs are essential for an increased quality of life (QoL), independent living, and community participation. Autistic young people experience poorer outcomes in terms of QoL and independent living than non‐autistic peers. Finding a balance between targeted DLS support to maximise independent living and improve QoL, while avoiding attempts to ‘normalise’ or ‘change’ autistic people, presents as a dilemma for therapists striving to align with neurodiversity‐affirming practice.

Methods

This theoretical paper explored literature pertaining to DLS and the neurodiversity movement in the context of occupational therapy values and the Canadian Model of Occupational Participation. Consideration of whether targeted DLS support is neurodiversity‐affirming or whether occupational therapists are compelling autistic people to mimic behavioural norms perceived by society was discussed.

Results

DLSs are an important factor for maximising QoL, regardless of neurotype. Occupational therapy values align with the core tenets of the neurodiversity movement, and occupational therapists are equipped with the values and skills to support the development of DLSs utilising affirming practice.

Conclusion

Occupational therapists should critically reflect on their practice to ensure alignment with the professions core values and recent occupational therapy models, to ensure affirming practice. Further research investigating DLS and neurodiversity‐affirming practice would benefit occupational therapists striving to align with neurodiversity‐affirming practice.

Consumer and Community Involvement

No consumer or community involvement. Consumers have been considered throughout the development of this paper through their representation in the literature. This involved a process of reviewing the literature and considering it in the scope of the questions and how occupational therapy sits within the neurodiversity movement.

PLAIN LANGUAGE SUMMARY

It is important to help autistic people to learn to do everyday things. Everyday things include activities like showering, cleaning, and cooking. These things are important so that autistic people can live on their own. It has shown that autistic young people are less likely to be able to do everyday activities on their own. It is important that therapists help autistic people learn how to do everyday things; however, do not try and change who they are. This is because completing everyday activities is an important part of QoL for all people.

Key Points for Occupational Therapy.

• DLSs are a core component of QoL, regardless of neurotype.

• Occupational therapists have a role in supporting autistic people to develop their daily living skills.

• The core values of occupational therapy are entirely consistent with the neurodiversity movement. Thus, practitioners should critically reflect on their practice's alignment with occupational therapy values and recent occupational therapy models.

1. INTRODUCTION

From a medical model perspective, autism spectrum disorder (ASD) is a complex neurodevelopmental condition, which is characterised by persistent challenges in the areas of social communication and interaction and behaviours and thinking that are considered maladaptive, repetitive, and/or rigid (American Psychiatric Association, 2013). Rigidity is a characteristic of autism that involves different facets, such as fixed interests, insistence on sameness, inflexible adherence to routines, black‐and‐white mentality, intolerance of uncertainty, and ritualised patterns of verbal and non‐verbal behaviour (Petrolini et al., 2023). A neurodiversity‐affirming perspective describes autism as a unique way of thinking, sensing, moving, communicating, and socialising (Autism Self Advocacy Network, n.d). Whether the medical model or neurodiversity‐affirming perspective is adopted, autistic advocates have identified that having an autistic neurotype can often be challenging in a society dominated by typical thinkers (Pearson & Rose, 2021).

Autism diagnosis rates in Australia have increased by 25.1% between the years 2015 and 2018 (Australian Bureau of Statistics, 2018). This has also been noted worldwide with an estimated 62 in 10,000 diagnosed in 2012, to 1 in 100 in 2022 (Zeidan et al., 2022). Over the years, the growth of autistic self‐advocacy coupled with the neurodiversity movement has brought about new ethical, theoretical, and ideological debates within autism theory, research, and practice (Leadbitter et al., 2021). The neurodiversity movement functions with two aims. These being advocacy for the rights and interests of neurodiverse people and de‐pathologising autism (Shields & Beversdorf, 2021). The Diagnostic and Statistical Manual of Mental Disorders Text Revision (American Psychiatric Association, 2022) classifies autism as a disorder, which has been argued by neurodiversity advocates to precipitate an alignment with a deficit‐focused framework (Cherewick & Matergia, 2023). For example, it has been argued that if we continue to define autism as a disorder, we are suggesting therapeutic practice should aim to extinguish autistic characteristics and, therefore, not value autistic strengths (Cherewick & Matergia, 2023). The language used to describe, define, and talk about autism has influential implications for research, practice, and autistic people. The neurodiversity movement seeks a change to this classification to promote that autism is rather a difference reflecting natural variations in the human brain and rightfully, autistic people should be embraced and celebrated as part of human diversity (Cherewick & Matergia, 2023). Neurodiversity activists reject practice that attempts to enforce a normative agenda and opposes support which promotes conforming or masking. In other words, activists oppose support aimed to ‘normalise’ autistic people (Happé & Frith, 2020). Neurodiversity framed as a social justice and civil rights movement is proposed to intersect with the broader disability and civil rights movement, with the aim to re‐structure society in ways that will support autistic individuals to live meaningful, thriving lives as equally worthy members of society (Leadbitter et al., 2021). Not all autistic authors agree with this framing. Sonya Freeman Loftis, an autistic author, summed this up when she wrote;

Some use the example of homosexuality being removed from the DSM, as though they hope that autism will also be de‐pathologised in a similar way. But LGBTQ people can fly on a plane by themselves and eat more than twelve foods. I'm not poking fun at anyone else's autistic impairments; I'm just using some of my own examples (Loftis, 2015, pp. 8).

It must also be noted that the neurodiversity movement is not a unified movement. While neurodiversity was initially conceived as an inherently inclusive notion (e.g. Singer, 1998), Dekker (2019) proposed that it has now moved beyond the ideas around advocating for equal rights for neurodivergent people to a prescriptive movement that involve social practices that some autistic people have found traumatising and have later reflected may mirror the nature of the disability inherent in autism.

Health‐care and allied health disciplines, such as occupational therapy, have been encouraged to move towards more neurodiversity‐affirming practices when engaging with autistic individuals (Dallman et al., 2022). Ongoing debates regarding the neurodiversity movement and neurodiversity‐affirming practice have caused tension with some in the autism community and among health professionals, researchers, and families (Leadbitter et al., 2021). Occupational therapy is an allied health profession which provides services to autistic people through the National Disability Insurance Scheme (NDIS). The NDIS is a funding mechanism to enable occupational therapy practice and other health service access in Australia. Occupational therapy aims to work alongside clients to advocate for and provide a range of needed resources and services that support the individuals' ability to participate fully in daily life (Mack et al., 2023). Occupational therapy aims to utilise a person‐centred approach to optimise individual well‐being through supporting people to participate in the things they need to and want to do (OTA, 2023). Providing services to support autistic people to develop independence in daily living skills (DLSs) is a core focus of occupational therapy practice. DLSs are defined as behaviours necessary for independence and encompass three subdomains including personal (caring for oneself), domestic (maintaining a home), and community skills (school/community living) (Sparrow et al., 2016). There is a variety of approaches utilised by occupational therapists to support DLS. These include video modelling, low‐tech picture prompts and sequences, backwards chaining, and the use of adaptive equipment (Auld et al., 2022).

An ethical issue for the occupational therapy profession is ensuring a shift to neurodiversity‐affirming practice. (Dallman et al., 2022). Neurodiversity‐affirming practice takes person centred care to the next level moving beyond what people think (individual values, wants, and needs) to include how people think (Cashin, 2020). Valuing the viewpoint that autism is a form of neurodiversity and that autistic people themselves have a rich and meaningful existence are not in themselves novel notions in occupational therapy (Dallman et al., 2022). However, it has not been analysed as to whether targeted DLS support is neurodiversity affirming or whether occupational therapy practitioners are compelling autistic people to mimic behavioural norms perceived by society. As mentioned, DLSs are a collection of activities that have been defined and established from a neuro‐normative standpoint. How and whether these align with a neurodivergent person's experience, preferences, and desires is not understood within the literature. In addition, how DLSs fit within a neurodiversity‐affirming approach has not been explored. The limited research available creates a dilemma for occupational therapists striving to align with neurodiversity‐affirming practice. This paper aimed to explore this phenomenon through discussion of the current evidence to provide some practical guidance for therapists. Further current practice predicaments are highlighted that require further consideration and research exploration.

1.1. Positionality statement

The first author is a PhD candidate at Southern Cross University in the process of writing her thesis. She is an occupational therapist with 8 years' experience working with autistic youth. This paper represents a stage of the process. The next stages of her research involve consulting with consumers. The second and third authors are her university supervisors. The second author is a Nurse and Professor of Autism and Intellectual Disability at Southern Cross University. The third author is an Occupational Therapist and Senior Lecturer at Southern Cross University. As this paper is a theoretical paper, it does not require ethical approval.

2. OCCUPATIONAL THERAPY CORE VALUES

Occupational therapists strive to deliver quality services that are occupation‐based, client‐centred, safe, interactive, culturally sensitive, evidence‐based, and consistent with the profession's values and philosophies (AOTA, 2020). In 1985, the American Occupational Therapy Association (AOTA) funded a study to delineate the entry‐level practice of occupational therapists and occupational therapy assistants (Aguilar et al., 2012). From this study, seven core values were identified which now underpin the occupational therapy profession. The AOTA functions with a focus on a globally connected workforce, as reflected in their Centennial Vision that states ‘we envision that occupational therapy is a powerful, widely recognized, science‐driven, and evidence‐based profession with a globally connected and diverse workforce meeting society's occupational needs’ (AOTA, 2007, pp. 613).

Therefore, these core values are drawn upon by therapists worldwide. They are further reflected in the competency standards in the Occupational Therapy Board of Australia (OTBA, 2018). In the absence of established Australian occupational therapy values and the overlap between the OTBA competency standards and the core values, the seven values established by the AOTA provide the foundation for ethical practice in Australia (Aguilar et al., 2014). Australia's professional association for occupational therapy, Occupational Therapy Australia (OTA), integrated these values through fostering evidence‐based practice and lifelong learning of therapists in Australia (OTA, 2023).

The AOTA provides a code of ethics with these seven core values embedded to guide occupational therapy personnel towards ethical courses of action in professional and volunteer roles (AOTA, 1993). These are represented in Table 1 and include altruism, equality, freedom, justice, dignity, truth, and prudence (AOTA, 1993). The seven core values underpin the way in which occupational therapists plan and conduct support, structure sessions, goal set, and how they interact and engage with their autistic clients. There has been no identified research exploring the alignment of the core values with neurodiversity‐affirming practice. To analyse and understand the alignment of occupational therapy DLS support and neurodiversity‐affirming practice, it must first be explored whether these grounding values that underpin practice align with the neurodiversity movement.

TABLE 1.

Occupational therapy core values and their alignment with neurodiversity‐affirming practice.

Core value	Definition	Neurodiversity‐affirming practice
Altruism	Altruism indicates demonstration of unselfish concern for the welfare of others. Occupational therapy personnel reflect this concept in actions and attitudes of commitment, caring, dedication, responsiveness, and understanding.	A primary concern of neurodiversity advocates is the welfare of autistic and other neurodivergent individuals (Hughes, 2021). They are concerned with promoting and preserving the health, happiness, and fulfilment of neurodiverse people (Leadbitter et al., 2021). Aligned with this notion is the occupational value of ‘altruism,’ which guides practitioners to demonstrate concern, commitment, and responsive action towards the welfare of their consumers and clients.
Equality	Equality indicates that all persons have fundamental human rights and the right to the same opportunities. Occupational therapy personnel demonstrate this value by maintaining an attitude of fairness and impartiality and treating all persons in a way that is free of bias. Personnel should recognise their own biases and respect all persons, keeping in mind that others may have values, beliefs, or lifestyles that differ from their own. Equality applies to the professional arena as well as to recipients of occupational therapy services.	The neurodiversity movement is concerned with equality of opportunity, choice, and control for neurodivergent people (Runswick‐Cole, 2014). Equality is an occupational therapy value that is additionally integral to the neurodiversity movement.
Freedom	Freedom indicates valuing each person's right to exercise autonomy and demonstrate independence, initiative, and self‐direction. A person's occupations play a major role in their development of self‐direction, initiative, interdependence, and ability to adapt and relate to the world. Occupational therapy personnel affirm the autonomy of each individual to pursue goals that have personal and social meaning. Occupational therapy personnel value the service recipient's right and desire to guide supports.	Neurodiversity activists advocate for the right of neurodivergent individuals to exercise autonomy and choice, including the freedom to make one's own choices (Lollini, 2018). A dignified life for all people can only be achieved when an individual has the freedom to pursue goals that have meaning to them (Dallman et al., 2022). This is a consistent belief within the occupational therapy profession through its value of ‘freedom’
Justice	Justice indicates that occupational therapy personnel provide occupational therapy services for all persons in need of these services and maintain a goal‐directed and objective relationship with recipients of service. Justice places value on upholding moral and legal principles and on having knowledge of and respect for the legal rights of recipients of service. Occupational therapy personnel must understand and abide by local, state, and federal laws governing professional practice. Justice is the pursuit of a state in which diverse communities are inclusive and are organised and structured so that all members can function, flourish, and live a satisfactory life regardless of age, gender identity, sexual orientation, race, religion, origin, socioeconomic status, degree of ability, or any other status or attributes. Occupational therapy personnel, by virtue of the specific nature of the practice of occupational therapy, have a vested interest in social justice: addressing unjust inequities that limit opportunities for participation in society. They also exhibit attitudes and actions consistent with occupational justice: full inclusion in everyday meaningful occupations for persons, groups, or populations.	Neurodiversity, as a social justice and civil rights movement, has the objective to re‐structure society in ways that will support neurodivergent individuals to live meaningful, thriving lives as equally worthy members of society (Leadbitter et al., 2021). Occupational therapy personnel, as reflected in the core value of ‘justice’, have a vested interest in social justice and addressing unjust inequities that limit opportunities for participation in society (AOTA, 2020). Justice is consistent across the occupational therapy values and the neurodiversity movement.
Dignity	Dignity indicates the importance of valuing, promoting, and preserving the inherent worth and uniqueness of each person. This value includes respecting the person's social and cultural heritage and life experiences. Exhibiting attitudes and actions of dignity requires occupational therapy personnel to act in ways consistent with cultural sensitivity, humility, and agility.	The notion of neurodiversity evolved in response to felt oppression and stigmatisation, with supporters advocating for the rights of people who were different to be valued and accepted with dignity, rather than pathologised (Carr‐Fanning, 2020). These are social rights issues. Dignity is the basis for social rights and is a shared value across the occupational therapy profession and the neurodiversity movement (Carr‐Fanning, 2020).
Truth	Truth indicates that occupational therapy personnel in all situations should be faithful to facts and reality. Truthfulness, or veracity, is demonstrated by being accountable, honest, forthright, accurate, and authentic in attitudes and actions. Occupational therapy personnel have an obligation to be truthful with themselves, recipients of service, colleagues, and society. Truth includes maintaining and upgrading professional competence and being truthful in oral, written, and electronic communications.	The act of being truthful has been suggested to be associated with respect, as it values clients as people capable of making their own decisions (Zolkefli, 2018). Without knowledge of the truth, it would be uncertain whether clients can make informed decisions and could be considered failure on behalf of the occupational therapist to respect them as autonomous individuals (Zolkefli, 2018). Thus, the value of truth is synonymous with the objectives of the neurodiversity movement and its promotion of respect for the capacities, values, and perspectives of neurodivergent people.
Prudence	Prudence is synonymous with judgement, underlining one's ability to govern and discipline themselves through the use of reason. Occupational therapists and OTAs must act with prudence—in other words, with discretion, moderation, care, and judiciousness. They must be able to make judgements soundly and respond on the basis of intelligence, evidence, and rational thought.	The value of ‘prudence’ requires therapists to obtain, understand, and utilise their client's experiences and individual values throughout the therapeutic process, to align with evidence‐based practice (Hoffman et al., 2023). This links with the neurodiversity movement's objective for health‐care professionals to actively listen and understand the autistic person's priorities, and to include them in decision‐making around their care (Leadbitter et al., 2021).

2.1. Occupational therapy core values and neurodiversity‐affirming practice

A definition and description of each core value is provided in Table 1 (AOTA, 2020, pp 2–4). Table 1 also includes important insights when determining how DLS support is consistent through the lens of neurodiversity‐affirming practice. As aforementioned, the neurodiversity movement strives for autism to be recognised and accepted as a form of human diversity. The movement advocates for autistic people to have equitable rights to individual care and for therapists to recognise, value, and capitalise on the unique strengths of autistic people (Cherewick, 2024). When considering these principles in relation to the occupational therapy core values, there is evidence of a correlation between the two.

When reviewing the core values of occupational therapy, links with the neurodiversity movement can be noted within the first two values ‘altruism’ and ‘equality’ (Table 1). Altruism represents the unselfish concern for the welfare of others, whereas equality represents fundamental human rights and the right of consumers and clients of occupational therapists to access the same opportunities as their peers (AOTA, 2020). The term ‘neurodiversity’ was created by Judy Singer, an Australian sociologist, and was based on her own experiences as an autistic woman and mother (Singer, 1998). Singer (1998) coined the term to promote equality, welfare, and inclusion of neurological minorities. The drive for equality and autistic welfare continues to be an integral component of the neurodiversity movement. Within the occupational therapy core values, equality and altruism are explicitly listed, demonstrating alignment between the neurodiversity movement and the occupational therapy profession.

The values of ‘freedom,’ ‘truth,’ and ‘prudence’ further demonstrate alignment between the occupational therapy core values and the neurodiversity movement (Table 1). Freedom denotes that practitioners are to value each person's right to exercise autonomy and demonstrate independence, initiative, and self‐direction (AOTA, 2020). This directly relates to the objective of the neurodiversity movement to support individual autonomy, including the freedom to make one's own choices (Lollini, 2018). Prudence guides occupational therapy practitioners to comply with evidence‐based practice and deliver services in line with the best available evidence. Evidence‐based practice involves the integration of the best research evidence, clinical expertise, and the client's values and circumstances to support provision of the most meaningful support (Hoffman et al., 2023). Bringing a clear and focused importance to the client's values and circumstances, as part of evidence‐based practice, provides an avenue for occupational therapists to ensure their services are neurodiversity affirming.

Prudence and freedom require therapists to listen and understand their client's experiences and values, and to actively partner with their clients to inform the therapeutic process (AOTA, 2020). This is in alignment with the aim of the neurodiversity movements to value autistic people as equally worthy members of society and ensure they have an active role in decision‐making around their care. In further support of this, therapists must uphold the value of ‘truth.’ The provision of truthful information is one way to enable autistic people to make informed decisions regarding their support. It demonstrates respect and values the person as a capable individual able to make their own choices (Zolkefli, 2018). When analysed against the objectives of the neurodiversity movement, the combination of freedom, truth, and prudence can be considered neurodiversity affirming as they respect, value, and affirm neurodivergent ways of being by enabling choice, control, and autonomy of the autistic person (Leadbitter et al., 2021).

The final two values, ‘justice’ and ‘dignity,’ provide further evidence of the occupational therapy values supporting the aims of the neurodiversity movement. The notion of neurodiversity evolved in response to perceived oppression and stigmatisation, with supporters advocating for the rights of people who were different to be valued and accepted with dignity, rather than pathologised (Carr‐Fanning, 2020). Justice and dignity are essential to social rights, which is a fundamental objective of the neurodiversity movement. These two values demonstrate unity between the neurodiversity movement and the occupational therapy professional values, as they demonstrate the profession's vested interest in social justice and addressing any unjust inequities that limit opportunities for participation in society (AOTA, 2020).

Within the occupational therapy profession, these core values underpin theories, models, and frameworks that provide the foundation for occupational therapy education, research, and clinical practice (Hoyt et al., 2023). The Canadian Association of Occupational Therapists (CAOT) has been a leading organisation in developing and advancing models of practice within the occupational therapy profession. In 2022, CAOT released a new model that has evolved from the previous Canadian Model of Occupational Performance and Engagement (CMOP‐E). The updated model, the Canadian Model of Occupational Participation (CanMOP), provides an advanced critical framework for gathering and considering information to meaningfully explore valued occupations and enhance occupational possibilities through addressing micro, meso, and macro contexts (Egan & Restall, 2023). Within occupational therapy, occupations refer to ‘the everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to, and are expected to do’ (WFOT, 2024, About Occupation, para 2).

As demonstrated in this definition of occupation, the term encompasses DLS. The previous version of the CanMOP, the CMOP‐E, categorised occupations into three categories including self‐care, productivity, and leisure. DLSs are considered to spread across self‐care and productivity. There is no comprehensive list that captures all meaningful occupations. The revised CanMOP has evolved to acknowledge this by removing the discussed categories and becoming a relationship focussed model (Egan & Restall, 2023). This evolution of the model demonstrates alignment with neurodiversity‐affirming practice as it recognises and acknowledges the differences in experiences and individual values of each person. Categorisation can lead to imposing personal and professional values and meanings and does not value or affirm neurodivergent ways of being. It is recognised within neurodiversity‐affirming practice and within the CanMOP that people experience different ways of being and thus, define, experience, and value occupations differently. The evolution and introduction of the CanMOP demonstrate the occupational therapy profession's commitment to its values and continued alignment with neurodiversity‐affirming practice (Egan & Restall, 2022).

Occupational therapy values promote advocacy for equality, concern for the welfare of the clients of occupational therapy personnel, and strive for practitioners to provide services that offers freedom, choice, and autonomy to support all people irrespective of neurotype to function, flourish, and live meaningful lives in society. These core values and the recently evolved CanMOP provide examples of the occupational therapy profession's alignment with neurodiversity advocates who strive for the de‐pathologising of autism and advocate for each person to be valued as equally worthy members of society. The seven occupational therapy values are entirely consistent with this objective; therefore, occupational therapy practice should align with neurodiversity‐affirming practices that value neurodivergent experiences and ways of being. With this understanding, we can begin to explore DLS support, whether it fits from a neurodiversity‐affirming lens.

(AOTA, 2020, pp. 2–4).

3. NEURODIVERSITY‐AFFIRMING PRACTICE AND DLS

3.1. DLS and quality of life (QoL) of autistic people

A significant aim of occupational therapy and the neurodiversity movement is to promote the QoL of autistic people, and other neurodivergent people, to lead thriving, meaningful lives. It can be argued that this could be achieved through supporting DLS; therefore, this intersection was explored.

QoL is defined by the World Health Organisation (WHO) as ‘a subjective evaluation of one's perception of their reality relative to their goals as observed through the lens of their culture and value system (WHO, 2012, pp. 11).’ This definition is similar to the description of QoL provided in a scoping review focussed on exploring QoL in occupational therapy intervention research (Baron et al., 2019). There is no single agreed‐upon definition of QoL from the autism or neurodiversity literature; therefore, the WHO definition of QoL will be utilised in this paper.

There are various methods and tools utilised to measure QoL. Not all assessments referenced in the literature have been evidenced as reliable and valid measures of QoL for the autistic population. WHO developed an international assessment tool titled the ‘WHOQoL‐100’ and the ‘WHOQoL‐BREF’. The WHOQoL‐BREF is a shortened version of the WHOQoL‐100 (WHO, 2012). The WHOQoL‐BREF has been determined as a reliable and valid tool for measuring QoL with autistic people (Mason et al., 2022). Mason et al. (2022) explored the validity and reliability of the WHOQoL‐BREF in their study that included 352 autistic adults aged 18–80 years. Structural validity was explored by an exploratory factor analysis of WHOQoL‐BREF data, and qualitative data were derived from four discussion groups (n = 20 autistic people) that explored the face validity of the items. The study limitations include the participant sample as 81% of the participants independently participated, without requiring support. Including the participants with a diverse range of personal characteristics and skill levels would have strengthened the results. The study findings indicate that the WHOQoL‐BREF has suitable validity and reliability for use with autistic adults; however, assessors may need to provide further explanation throughout the social domain as these were found to be interpreted differently by some of the autistic participants (Mason et al., 2022). Given the validity of the tool for use across both the neurotypical and autistic population, it may be concluded that factors that contribute to optimal QoL for the general population are also relevant for the autistic population.

The WHOQoL‐BREF has been one of the most common tools used to measure QoL by occupational therapists (Baron et al., 2019). Studies utilising the WHOQoL‐BREF have reported lower QoL of autistic people. Domain III of the WHOQoL‐100 is titled ‘Level of Independence’ and facet two is titled ‘Activities of Daily Living’. This facet investigates an individual's proficiency in performing self‐care and domestic tasks, with the focus on the person's capacity to perform tasks which they are likely to need to perform on a day‐to‐day basis (WHO, 2012). Within the shortened WHOQoL‐BREF, this domain is collapsed and reflected in items 9, 17, 23, and 25 and listed in Table 2. These items explicitly seek the subjective evaluation of a person's satisfaction with aspects of their daily life, such as the health of their environment, independent living capacity, and ability to perform DLS.

TABLE 2.

WHO‐QoL‐BREF and relevance to DLS.

Item no.	Question	Relevance to DLS
9	How healthy is your physical environment?	Domestic skills are significant DLSs that include the skills required to maintain a healthy home and physical environment (Sparrow et al., 2016).
17	How satisfied are you with your ability to perform your daily living activities?	Daily living activities, or activities of daily living (ADL), comprise the actions that involve caring for one's self and body, including personal care, mobility, and eating (Mlinac & Feng, 2016).
23	How satisfied are you with the conditions of your living place?	This again, relates to domestic skills that are required to maintain a home that is healthy and functional (Sparrow et al., 2016).
25	How satisfied are you with your transport?	Transport is an important community skill. Dependence on others may result in reduced community participation, work, training, and social opportunities (Kersten et al., 2020).

Note: WHO (2012).

A key point can be highlighted here. The ‘Activities of Daily Living’ facet of the WHOQoL‐100 and continued inclusion of DLS within the WHOQoL‐BREF demonstrate the influential impact DLS have on QoL for all people, regardless of neurotype. Therefore, QoL can be considered central for everyone. Regardless of a person's race, age, gender, identity, or neurotype, while QoL is rather subjective, the desire to experience optimal QoL is not particular to neurotypical people. Neurodiversity advocates acknowledge that autistic people similarly seek to live a thriving and meaningful life through maximising QoL (Schuck et al., 2022).

Maximising QoL is desirable regardless of neurotype, and DLSs form a critical component of optimal QoL. A scoping review identified that independent living is a desired outcome for autistic people; however, achieving this is not common for autistic people compared to the general population (Auld et al., 2022). Difficulties were identified in varying areas of DLS, such as self‐care, home maintenance, community skills, meal preparation, and financial autonomy. Auld et al. (2022) ascertained that many autistic people maintain dependency on caregivers to perform DLS throughout their lives, although desire the skills to perform them themselves. Given the role DLSs play in QoL and the lower levels of QoL experienced by autistic people, these findings suggest that the low levels of independence in DLS may be associated with autistic people's overall QoL.

A unanimous concern and underpinning value of both the neurodiversity movement and the occupational therapy profession are equality and altruistic practice, with advocates and practitioners guided to take responsive action towards the promotion of health, happiness, and equal opportunities for neurodiverse people. Considering this, and research indicating low QoL for autistic people, it could be reasoned an ethical responsibility for occupational therapists to align with their values by addressing barriers to QoL through moral and just support. This would further align with neurodiversity‐affirming practice. If DLSs are not particular to a neurotype, then it could be hypothesised that the drive to develop living skills is a standard feature of human existence, independent of variance in thinking. When considering this in the context of occupational therapy, this suggests that targeted DLS support differs from compelling or pressuring autistic people to change or alter themselves to fit in socially. If DLS support for autistic people is driven by the autistic person's desire to increase independence, access, and autonomy, then alignment can be drawn with the values in Table 1 and neurodiversity‐affirming practice.

3.2. DLS support and the neurodiversity movement

The discussion regarding QoL and DLS provides important insights when determining how DLS support corresponds with the neurodiversity movement. DLSs are a natural aspect of humanity, and thus, DLS acquisition is desired and expected of all people. Differences in sensory, social, motor, and other areas can impact the capacity of autistic people to complete DLS and function in today's society (Dallman et al., 2022). Some autistic people, researchers, families, and health professionals agree and suggest that there are aspects of autism that negatively impact an individual's QoL and independence in DLS (Dallman et al., 2022). Professional support has therefore been suggested to be essential in supporting autistic people to thrive (Pantazakos, 2023).

Repetitive patterns of behaviour and special interests are common characteristics of autism (Grove et al., 2018). These have been identified as strengths of autistic people when they support participation in daily life, such as employment (Cope & Remington, 2022). However, some autistic people are prone to becoming locked into special interests and repetitive patterns of thought and behaviour, which prevents them from completing important life tasks, such as DLS (Cashin & Yorke, 2018). In such cases, the result can be a loss of behavioural flexibility, which can impair the ability to adapt to life challenges (Cashin & Yorke, 2016). A survey study explored the relationship between special interests and well‐being (Grove et al., 2018). An encouraging finding was that special interests had a positive impact on autistic adults and were associated with higher subjective well‐being and satisfaction across specific life domains, such as social contact and leisure (Grove et al., 2018). However, a very high intensity of engagement in special interests was negatively related to well‐being. This hyper‐fixation on a passionate interest was subjectively described as harmful to the degree of neglecting self‐care (Grove et al., 2018). The study's limitations include relying on self‐report measures. Special interests induce pleasurable ‘flow states’ for autistic people; thus, participants may be less likely to consider these activities as negative influencers (Leadbitter et al., 2021). Therefore, it could be reasoned that the actual influence of special interests may be impacting more greatly then described by some of the participants as valued more highly than activities they displace. The study findings suggest that special interests are important for autistic people, when balanced within their daily life. However, a hyper‐fixation may hinder an autistic person's capacity to complete DLS and live a fulfilled, meaningful life. Occupational therapists are well positioned to support autistic people to achieve a balance between DLS and special interest participation.

Occupational therapy supporting DLS with autistic people needs to align with the values of the profession to subsequently align with neurodiversity‐affirming practice. Person‐centred care and respectful, dignified support are essential. A core component of the occupational therapy values and the neurodiversity movement is the value of freedom, which signifies the advocacy of the rights of neurodivergent individuals to exercise autonomy and choice, including the freedom to make one's own choices (Lollini, 2018). This is often championed by neurodiversity advocates as therapists handing the reins of support over to their autistic clients (Pantazakos, 2023). This would amount to the therapist following their client's testimony as to which of their behavioural, cognitive, and emotional modes belong to their core autistic self and which are open to change through supports (Pantazakos, 2023). While well‐intentioned, the most severe normalisation costs do not stem from acknowledging disabilities and their ethical complexities. Additionally, it is likely the case that at least some autistic clients would identify goals and seek therapeutic outcomes in the opposite direction of neurodiversity‐affirming practice, such as learning how to socially engage in a neurotypical way (Pantazakos, 2023). It could be argued that supporting clients to achieve neurotypical goals because it is the focus of the client. However, the tension remains between balancing choice and control with therapy that does not compromise an autistic person's identity or QoL. It is difficult to see which parts of ourselves could be accommodated, optimised, and explored to enhance our lives. Professional support to identify these areas is what makes therapy valuable. Every human being, the neurodivergent included, follows an at least partly habitual and unexamined modus operandi (Pantazakos, 2023). The role of occupational therapists is to uncover the default mode when it leads to an unfulfilling or disempowered life. Thus, helping a client can require taking them seriously, not literally and obediently (Pantazakos, 2023).

Embracing neurodiversity and celebrating variance in neurotypes and different ways of being do not mitigate the need for individual accommodations. Within our socio‐cultural context, some minds need supports and/or accommodations to enhance a person's capacity to function and participate in their daily community. Autistic self‐advocates frequently describe how their innate differences contribute to a sense of identity in being autistic (Pearson & Rose, 2021). Simultaneously, they acknowledge that being autistic in a neurotypical society can lead to challenges with sensory overload, autistic burnout from the load of masking and hiding natural forms of self‐regulation to avoid stigmatisation and alienation (Botha & Gillespie‐Lynch, 2022). Masking is a term used by neurodiversity advocates to describe the suppression of aspects of self and identity so that an individual appears ‘normal’, using conscious or unconscious means (Miller et al., 2021). Neurodiversity advocates proclaim that any support provided by health professionals aimed to change autistic people according to neurotypical norms is wrong and compels masking behaviours. Masking can have serious consequences for autistic people, yet, removing the act of masking is complex and can contribute to burnout through sudden exposure to increased levels of discrimination and stigma (Mantzalas et al., 2022).

Autistic burnout can be the result of masking and can have detrimental impacts on the mental health, QoL, and self‐worth of autistic people (Mantzalas et al., 2022). An online survey study by Miller et al. (2021) explored experiences and views of masking in autistic people (n = 144), neurodivergent people without an autism diagnosis (n = 49), and neurotypical people (n = 45). Thematic analysis revealed that while some aspects of masking appear to be specific to the autistic experience (i.e. suppressing stims), others are shared across autistic and neurotypical people. For example, using mimicry of others as a social strategy and the feeling of exhaustion from persistent masking to avoid stigmatisation. While study limitations include the self‐selecting nature of online research and the limited range of experiences (i.e. such as nonspeaking people), the study findings suggest that aspects of masking are experienced across neurotypes. This is often driven by stigma avoidance. Stigmatisation is an experience not particular to a single neurotype and leads to detrimental outcomes for marginalised individuals, such as bullying and/or physical violence (Labrum et al., 2018).

Masking, like other autistic behaviours are not always detrimental, can be related to seeking social acceptance and connection (Cook et al., 2018). Health professionals, such as occupational therapists, have a role in supporting autistic people to find balance to participate in daily life. Mitigating or replacing behaviours that interfere with basic health and safety can benefit autistic people (Leadbitter et al., 2021). The inability to complete DLS can lead to unsafe conditions and poor QoL for all people (Edemekong et al., 2023). Thus, providing support to autistic clients to enhance their capacity to participate in daily life is an ethical mandate for occupational therapy practitioners (Dallman et al., 2022). DLS support should uphold the occupational therapy value of dignity, while also demonstrating altruistic concern for the autistic clients to align with both the values of the profession and neurodiversity‐affirming practice. Variations in neurology, corporeality, and culture drive humans to participate, think, and experience in vastly and beautifully different ways. Neurodiversity is a valuable lens for occupational therapy practice to support people who have neurological differences to acquire DLS and enhance QoL, well‐being, and their capacity to live thriving, meaningful lives.

4. CONCLUSION

QoL is a core goal for occupational therapists and neurodiversity advocates, and DLSs are a core component of QoL for all people, regardless of neurotype. The seven occupational therapy values when applied to supporting autistic people in the context of DLS are entirely consistent with the goals of the neurodiversity movement. Occupational therapists should critically reflect on their practice to ensure alignment with the professions core values, to ensure affirming practice. The discussions within this paper further highlighted how significant independence is to autistic adults and how much they value being able to make choices and have control in their daily lives. As this is the first known paper to the authors investigating DLS and neurodiversity‐affirming practice, further research investigating the phenomenon would benefit occupational therapists striving to align with neurodiversity‐affirming practice.

AUTHOR CONTRIBUTIONS

The first author, Chelsea Morrison, explored the literature, extracted information, and interpreted the results. All authors reviewed and shaped the discussion and prepared a draft. All authors reviewed and approved the final version of the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors have no conflict of interest to declare.

Morrison, C. , Cashin, A. , & Foley, K.‐R. (2025). Daily living skill support for autistic people through a neurodiversity‐affirming practice lens. Australian Occupational Therapy Journal, 72(2), e13002. 10.1111/1440-1630.13002

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.