The quick-moving, high-stress practice of emergency medicine means health care professionals need to be prepared for anything. Among emergency physicians’ diverse patient populations, neurodivergent individuals represent a unique group with distinct challenges and requirements. Neurodivergence is an umbrella term that refers to a variety of neurological differences (not deficits), including autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and dyslexia, among others.²

These conditions are prevalent and frequently misunderstood, leading to gaps in care and communication.

Why is this important to emergency physicians? First, research suggests a higher number of emergency department visits among individuals with ASD. About 30 percent of children with ASD need treatment in an emergency department, and this number increases to nearly 70 percent for those aged 15–18.⁷ Second, diagnosed adults have twice the number of emergency department encounters compared to those without these diagnoses.⁷ Thus, understanding neurodivergence is crucial for emergency physicians, who often serve as the first point of contact for these patients when they are in crisis. Knowing how to recognize and respond appropriately can significantly impact the quality of care provided, ensuring that all patients receive compassionate and effective care.

But what exactly are neurodivergence and neurodiversity? Neurodivergence refers to the unique way in which an individual’s brain processes and responds to certain information, differing from the typical or average brain.⁹ Neurodiversity refers to the diversity in human brain functioning and encompasses a range of neurological differences that affect how individuals think, learn, and interact with the world.⁹ As Stowers points out in his article debunking neurodiversity myths: Consider that some individuals are auditory learners, while others prefer visual methods.¹² Each person has their unique approach to learning and understanding, and we adapt and use techniques that suit us best. So, it shouldn’t be surprising that people perceive the world in diverse ways too and that their thinking, learning processes, and traits don’t conform to a one-size-fits-all model.¹² The term “neurodiversity” represents a shift from viewing these conditions as “deficits” or “abnormalities” to recognizing them as human thinking and behavior variations.⁹ Here are some of the key conditions that are considered neurodivergent and that emergency physicians are likely to encounter:

1. Autism Spectrum Disorder (ASD): Although the definition of autism has changed over time, in general, it refers to a group of complex developmental brain disorders.^3,4 The spectrum nature of autism means that symptoms and their severity can vary widely among individuals. Some people with ASD may have exceptional abilities in specific areas, such as math or art; others may need considerable support in daily living tasks.^2,3,4,6
2. Attention Deficit Hyperactivity Disorder (ADHD): ADHD is a neurodevelopmental disorder marked by more severe patterns of inattention, hyperactivity, and impulsivity than are typically observed in individuals at a similar developmental level. Individuals with ADHD may struggle with organizing tasks, following instructions, or remaining still for extended periods, leading to difficulties in various settings, including the fast-paced environment of an emergency department.¹
3. Dyslexia: Dyslexia is a specific learning condition that primarily affects reading and language processing. People with dyslexia often struggle with phonological processing, spelling, and quick verbal responses; however, many of them have strong problem-solving skills and creative thinking abilities.¹⁴
4. A variety of others: Dyscalculia, dys praxia, sensory processing disorder, and Tourette’s are some of the other diagnoses that belong under the neurodiversity umbrella.⁶

According to a 2022 survey of 1,000 people across multiple organizations, 91 percent of respondents do not know how common neurodivergent conditions are.¹³ In fact, many people are working alongside or interacting with neurodivergent individuals regularly and may not know it.¹³ According to the Centers for Disease Control and Prevention, approximately one in 35 children in the United States is diagnosed with ASD. ADHD affects around seven million children aged three to 17 years, and dyslexia impacts approximately 15–20 percent of the population.^3,14 These statistics highlight the importance of emergency physicians being prepared to encounter and support neurodivergent individuals.

Several myths and misconceptions about neurodivergence can affect care in emergency settings. One common myth is that neurodivergent individuals are intellectually disabled or incapable of understanding complex information. But many individuals with neurodivergence are knowledgeable and capable when given the appropriate support.² As previously stated, given that there is no one “right way” to think or learn, neurodivergence is just a difference—not a deficit.²

Another misconception is that neurodivergent behaviors are always disruptive or intentional. For example, a person with ADHD may appear restless, fidgety, or inattentive, but this is often not due to defiance or disrespect. These behaviors spring from differences in their brain that are part of the condition.¹⁵ Understanding these nuances is critical for emergency physicians, enabling them to approach neurodivergent patients with empathy and tailored strategies that accommodate their unique needs. Emergency physicians can significantly enhance the quality of care they provide by dispelling myths and adopting an informed perspective on neurodivergence.

Effective Communication Strategies to Aid in the ED

When working with neurodivergent patients, emergency physicians can use the following communication strategies to create a positive and respectful experience:

1. Active Listening: Take the time to listen to the patient’s concerns and needs. Show empathy and understanding for their experiences. It’s also important to include caregivers, as they may notice changes and subtle differences in the patient’s behavior.⁵
2. Clear and Concise Language: Use clear and straightforward language when providing information or instructions. Avoid jargon or ambiguous terms that may confuse or overwhelm the patient (e.g., “bandwidth” and “deep dive”). Also avoid using idioms and metaphors, as these are often misunderstood (e.g., “a piece of cake” or “feeling down in the dumps”).^8,11
3. Visual Aids: Use diagrams, charts, or illustrations to improve communication and help those who understand information better through visuals. One simple visual aid, a “now and next board,” is a board with the word “now” on the left and the word “next” on the right. Below those words is space for words, pictures, or even symbols that will let patients know what is going to happen.⁸ Using a board like this in the emergency department can create trust and decrease fear in neurodivergent patients.
4. Create a Calmer Environment: The emergency department can be overwhelming due to noise, crowds, and unfamiliar surroundings.⁸ To help alleviate stress:
   1. Identify specific triggers: Ask the patient what makes them feel uncomfortable or anxious. This could be loud noises, crowds, or certain types of lighting.⁸ Knowing this information can help clinicians and staff tailor the environment to the specific needs of that patient.
   2. Provide a quiet space: If possible, offer a quieter area for patients to wait.
   3. Consider noise-canceling devices: Keeping some ear defenders (noise reduction earmuffs) on hand that can be lent out can significantly reduce noise-related distress.⁸
   4. Adjust lighting: Be mindful of lighting preferences. Some patients may require bright lighting, while others may prefer a darker environment.⁸
5. Allow for Processing Time: Understand that neurodivergent individuals may need extra time to process information and respond. Be patient and give them pauses during the conversation.⁵
6. Pain Assessment: Keep an open mind when assessing pain, especially in children with complex needs. Just because a child can’t express their pain verbally doesn’t mean they aren’t experiencing it. Use a pain assessment tool that considers their developmental stage, parents’ observations of pain, and any information from the child.⁸

Ultimately, emergency physicians can improve care for neurodivergent patients and create a welcoming environment to all seeking medical assistance by implementing effective communication strategies while promoting acceptance and respect. Every patient deserves care that meets their individual needs, and by embracing neurodiversity, emergency physicians can provide truly patient-centered care in the emergency department.

Dr. Kendall is the chief of clinician engagement at US Acute Care Solutions and has 15 years of emergency department leadership experience. She is the chair of the USACS diversity, equity, and inclusion committee, the social issues and equity in medicine committee co-chair, and leads physician leadership development for USACS.

References

1. Austerman J. ADHD and behavioral disorders: assessment, management, and an update from DSM-5. Cleve Clin J Med. 2015;82(11 Suppl 1):S2-S7. 
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3. Maenner MJ, Warren Z, Williams AR, et al. Centers for Disease Control and Prevention. Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020. https://www.cdc.gov/mmwr/volumes/72/ss/ss7202a1.htm?s_cid=ss7202a1_w. Published March 24, 2023. Accessed October 17, 2024.
4. Cleveland Clinic. Neurodivergent. https://my.clevelandclinic.org/health/symptoms/23154-neurodivergent. Accessed October 17, 2024.
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7. International Board of Credentialing and Continuing Education Standards. Autism and the emergency department (ED): why it’s important. https://ibcces.org/blog/2020/06/05/autism-and-the-emergency-department-ed-why-its-important/. Published June 12, 2020. Accessed October 17, 2024.
8. Kam J, Herrieven L. Autism spectrum condition in the ed. RCEMLearning. https://www.rcemlearning.co.uk/foamed/autism-spectrum-condition-in-the-ed/. Published October 31, 2023. Accessed October 17, 2024.
9. Khaliq R. A guide to neurodivergence and types of neurodiversity. MEDvidi. https://medvidi.com/blog/types-of-neurodiversity. Updated August 18, 2023. Accessed October 17, 2024.
10. Mi Training. Dispelling common myths about neurodiversity. https://mitraining.edu.au/blog/dispelling-common-myths-about-neurodiversity/. Published November 16, 2023. Accessed October 17, 2024.
11. Prospect Therapy. 5 Ways to improve communication with your neurodivergent partner. https://www.prospecttherapy.com/blog/2022/11/30/5-ways-to-improve-communication-with-your-neurodivergent-partner. Published December 3, 2022. Accessed October 17, 2024.
12. Stowers S. Debunking the myths: why everything you know about neurodiverse learners is wrong. eLearning Industry. Available at https://elearningindustry.com/debunking-the-myths-why-everything-you-know-about-neurodiverse-learners-is-wrong. Published February 1, 2023. Accessed October 17, 2024.
13. Texthelp. New industry survey highlights state of neurodiversity and inclusivity in U.S. companies. https://www.texthelp.com/about/press-release/new-industry-survey-highlights-state-of-neurodiversity-and-inclusivity-in-us-companies/. Published August 30, 2022. Accessed October 17, 2024.
14. Yale Center for Dyslexia & Creativity. Dyslexia FAQ. https://dyslexia.yale.edu/dyslexia/dyslexia-faq/. Accessed October 17, 2024.
15. Williams P. What are the 3 types of ADHD?. ADDitude. https://www.additudemag.com/3-types-of-adhd/. Published September 1, 2019. Accessed October 17, 2024.