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Camera as a shield: Can Neurodiverse Affirming Practice via a Mindful Photography
Program Provide a Connection Back to School.
Keywords
Neurodivergence (ND), Neurotypical (NT), Neurodiverse (ND), Neurodiverse affirming,
Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD),
Sensory Processing Disorder, School refusal, Cognitive Behaviour Therapy (CBT),
Acceptance Commitment Therapy (ACT), Pathological Demand Avoidance (PDA),
Participatory photography, Therapeutic photography, Photovoice, Photo elicitation,
Participatory Photography
Introduction
School refusal is a term that describes students who have a high level of distress about
attending school. The neurodivergent community is represented at significantly higher rates
of school refusal due executive function challenges, anxiety, depression, emotional regulation
and higher rates of reported suicidality (Howe et al., 2020). Concurrently, rates of diagnosed
autism in the community are on the rise due to greater understanding of neuroscience and
changes in diagnosis (Russell et al., 2022). The Covid-19 pandemic has highlighted areas of
education that may need greater adjustments to ensure positive outcomes for students at risk
of permanent school refusal.
The likelihood of autistic students having experienced Applied Behaviour Analysis
(ABA) (Lovaas, 1987) therapy throughout their childhood may have added to the low
motivation and school non-compliance (Wilson et al., 2014). Neurodiverse self-advocates
describe past treatments for autistic individuals as non-affirming of autistic identity and some
go as far as labelling long term ABA therapy as abuse (Sandoval-Norton & Shkedy, 2019).
Novel ideas for bridging the gap between those who experience sensory processing
difficulties, social anxiety and relationship challenges are needed to re-engage students back
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into an education. A systematic review of the photovoice method, participatory photography,
hermeneutic photography and photo elicitation will inform future studies, incorporating
mindfulness-based practice with photography for school refusers. Further research is needed
to inform a future program that will include individual and group therapy using participatory
photography with school refusers in Australian primary and secondary schools.
Neurodiversity, neurodivergence, an affirming umbrella term
Neurodiversity is a term coined by Judy Singer combining the two words,
neurological and diversity. As an Australian sociologist who is autistic, she created this term
to encompass all neurotypes in the late 1990s (Singer, 1999). The umbrella term also known
as neurodivergent and neurodiverse includes Autism Spectrum Disorder (ASD), Pervasive
Developmental Disorder-Not Otherwise Specified (PDD-NOS), Attention Deficit
Hyperactivity Disorder (ADHD), Audio Processing Disorder (APD), Dyslexia, Dyscalculia,
Dyspraxia, Synaesthesia, Developmental Language Disorder, Developmental Co-ordination
Disorder, Intellectual Disability, Tic Disorder and other learning differences (Armstrong,
2015).
Neurodiversity in its many presentations, whether it be high needs autism or learning
differences of another type are on the rise. In 2020, the Centre for Disease Control identified
autism as one in 36 in the general population (Walensky et al., 2020). The research continues
to grow at higher rates and is predicted to continue (Russell et al., 2022). People who identify
as neurodivergent today may or may not include a formal diagnosis and the support needs are
vastly differing.
Sensory processing difficulties lie at the heart of school refusal
Dunn’s Theory of Sensory Processing, developed in 1997 developed to investigate
how individuals respond to sensory stimuli within an occupational therapy context (Dunn,
2007). Illustrated in four quadrants it describes self-regulation and strategy responses
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considering neurological thresholds on a continuum from high to low and responses in an
active or passive way, recognising that some individuals may identify more so in one
quadrant than another. The upper left quadrant, defined as low registration, describes an
individual that might look for higher levels of sensory stimuli to activate the sensory system
and be frequently sensory seeking as a strategy to self-regulate. Conversely the bottom left
quadrant describes a person who has a low threshold for sensory sensitivity who may actively
seek to avoid sensory stimuli to self-regulate. The latter of the two quadrants more
commonly describes neurodiverse individual and their experience of pain due to stimuli such
as light, sound, smell, taste and touch. A Canadian study highlighted the need for sensory
friendly zones as an imperative for autistic individuals (Clément et al., 2022). It noted
limited research in sensory processing in autistic individuals that could be considered
meaningful and suggested a sharper focus on sensory processing research via future
longitudinal studies is necessary to understand the impact of participation in education and
employment. Spaces such as educational institutions, shopping centres, workplaces can pose
great difficulties to those who require self-regulation at the sensory avoidant end of the
continuum. The context of Dunn’s model applying to the entire population and everyday life
situations, psychoeducation may assist with the wider appreciation of divergent ways of
processing senses.
The rise in school refusal across Australia and the link with neurodivergence
The link between school refusal and neurodivergence is complex and one that is
represented by a lack of inclusion and flexibility in the educational environment across
Australia (Totsika et al., 2023). Research demonstrated lockdowns in Melbourne, Australia,
have exacerbated school refusal in the neurodivergent population (Kouroupa et al., 2023).
Echoed around the globe during the pandemic, it appears that lockdowns increased school
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refusal numbers and the unmet needs of neurodivergent students in the school environment
(Connolly et al., 2023).
Senate inquiry into the national trend of school refusal
The senate inquiry into school refusal on October 27, 2022, investigated the
increasing national trend of “School Can’t” identified different to school truancy in primary
and secondary schools, since the Covid-19 pandemic, also encompassing the effects on
parents, carers and grandparents, economic and employment related difficulties (Australian
Senate Education & Employment References Committee, 2023) (See appendix A). It found
that students and their parents are best to advocates for their lived experience and education
system inflexibility requires change to be more inclusive and adaptive. The lack of support
from the National Disability and Insurance Scheme (NDIS) and the disproportionate number
of neurodivergent students who are affected by school refusal requires further investigation
into future funding for support for advocacy groups. With numbers as high as one in three
students reported school refusal in the past 12 months, the recognition of a growing problem
needs a different approach to the disciplined approach of the past. Anxiety and stress are
often what lies beneath school refusal for the neurodiverse community and the issue is much
more complex than previously thought given that trend has been rising over the past 10 years
(Clark, 2023).
Senate inquiry into assessment and support services for people with ADHD
On November 6, 2023, the Australian Government released the findings of a Senate
Inquiry into Attention Deficit Hyperactivity Disorder (ADHD) (Australian Senate
Community Affairs References Committee, 2023) (See Appendix B). The terms of reference
of the inquiry investigated access to timely diagnosis, support, workplace flexibility, gender
bias in assessment, access and cost of medication, the National Disability Insurance Scheme
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(NDIS) role and responsibilities for ADHD, funding for research, social and economic cost
and Australian and international best practice for professionals among other questions.
The inclusive nature of inquiry has been widely supported by those with lived experience,
professionals and academics who agree with the need for a national framework for ADHD
and the 15 recommendations in the response (see Appendix B). The recommendations will
support the ADHD community and lessen the stigma around deficit-based language.
Considering ADHD as a variation in the cognitive profile that offers strengths and
weaknesses like any other, awareness in the wider community about embracing differences
rather than stifling them, will assist with inclusion and may reduce school refusal.
For those with differences in learning needs, the mainstream school system can be a
place of high anxiety, difficult relationships and sensory overstimulation. This hyper aroused
state reduces the capacity of learning often leading to long term school refusal (Connolly et
al., 2023). Some schools provide accommodations for quiet spaces and sensory rooms to
assist with regulation of emotions for autistic individuals, whilst most schools offer such
spaces within a wellbeing setting with counselling staff to keep the individual participating.
Where students are given appropriate accommodations for their needs (Clément et al., 2022).
Polyvagal Theory (Porges, 2011) suggests that mindfulness can increase the window of
tolerance and develop greater resilience and self-regulation.
Neurodiversity treatments and interventions
Embracing differences with curiosity and respect for the individual is the cornerstone
of contemporary therapies in counselling although this hasn’t always been the case for the
neurodivergent community. Therapeutic treatments for those who need greater support have
been scientifically researched over decades and many, now maligned, therapies were born out
of a need to move away from the institutionalisation of autistic people and “normalise” them
into society (Skinner, 1963; Lovaas, 1987). Autonomy for those who needed higher levels of
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support was not a consideration within these practices and due to the non-verbal nature of for
some autistic groups, it is likely that their inner world needs were not met.
Of all developmental disorders under this umbrella, Autism Spectrum Disorder (ASD)
requires greater support at one end of the continuum. The National Guideline for supporting
the learning, participation, and wellbeing of autistic children and their families in Australia
published in February 2023, makes 84 recommendations to ensure treatments for autistic
children, notable are that they must be strength based, child and family centred,
individualised, holistic, ethical, culturally safe, respecting of first nations people, evidence
based and incorporated informed consent for the parents and the autistic individual with their
expression of approval to be sought and respected (Trembath et al., 2022)
Applied Behaviour Analysis as early intervention for Autism Spectrum Disorder
In the past such early interventions included up to 40 hours a week of Applied
Behaviour Analysis (ABA). As a component of the wider area of study known as behavioural
science, ABA was the gold standard for early intervention for newly diagnosed autistic
toddlers. The grandfather of behaviourism, Burrhus Frederic Skinner founded the theory of
operant conditioning, finding that behaviours are conditioned through reinforcement
(Skinner, 1963). With origins in animal behaviour to understand human behaviour, his theory
that behaviours occur in response to environmental stimuli are congruous with current
neurodivergent ideals. Sadly, his theory suggesting that behaviour change occurs as a result
of punishment of reinforcement has left a trail of trauma in its wake (Dillenburger+&+
Keenan,+2023).
Many autism advocates speak negatively about ABA therapy and the stereotypes of
treatments that included aversion and punishments such as electric stimulation (shock) for
behaviour modification in its earlier days. Their historic foundations still remind us that there
can be a human cost in psychological research. Recent research shows that ABA can lead to a
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violation in autonomy when it may be a primary drive such as hunger or toileting (Wilkenfeld
& McCarthy, 2020). ABA practice enforces restraint of self-stimulation activities (stimming
that assists with self-regulation), compliance in all aspects of their lives and often results in
prompt dependency and low intrinsic motivation (Wilson et al., 2014). Brain differences in
the autistic individuals (Pitskel, 2014) showed that weaker connections between the
amygdala and the prefrontal cortex suggests emotional regulation doing complex tasks can be
difficult and making accommodations for this may assist with positive learning outcomes. An
Australian survey of ABA practitioners in 2020 noted that there was no national standard or
professional qualification required to be an ABA practitioner and that lack of regulation puts
a vulnerable population at risk of out date or unethical standards of practice (Leif et al.,
2020).
Evolution of Behavioural Therapy: Acceptance Commitment Therapy (ACT)
The evolution into contextual behaviour analysis, Acceptance Commitment Therapy
(ACT) (Hayes et al., 2011) and Relational Frame Theory (RFT) broaden the scope of
behaviourism rather than reduce it as the scientific model of the ABA. Incorporating ACTr
(ACT training) into ABA may go some way into adapting this maligned treatment into the
future. With research in the behavioural world focusing on the individual role in process-
based therapy, the movement away from the expert/patient scenario, may be well received by
autistic advocates (Hayes et al., 2019). Considering biopsychosocial aspects to individuals
undergoing ABA therapy, changes to this therapy from a more contextual position (Ong et
al., 2022) and the individual having a greater role in the process may improve its palatability.
The psycho-educational structures of ACT offer a wealth of opportunities for the
neurodiverse community for developing psychological flexibility (Hayes et al., 2011).
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Treatments for ADHD
Evidence based therapies such as Cognitive Behaviour Therapy (CBT) (Beck, 2020)
Acceptance Commitment Therapy (ACT) (Hayes et al., 2011)) and Dialectical Behaviour
Therapy (DBT) (Linehan,2015) have all been researched widely for this cohort and
treatments. CBT has been found to increase the efficacy of stimulant medication in reducing
in impairment and symptom severity and support recommendations that medication along
with this therapeutic intervention as best practice (Emilsson et al., 2011).
A recent pilot study called “Less Stress” (Oerbeck et al., 2021) incorporated a
customised CBT psychoeducation program for ASD/ADHD adolescents in Norway set out to
improve the coping strategies and reducing anxiety. Although not its main aim, the result of
improved school attendance showed the need for tailored programs to re-engage students.
Although a very small pilot study, the implications of the need to tailor programs toward
students who have higher levels of anxiety and depression requires accommodations within
the settings for sensory challenges.
What is Neurodiverse Affirming Practice
Affirming practice approaches include autonomy, respecting the rights of the
individual to express their traits and honouring the differences. Some researchers suggest it is
a moral imperative to evolve treatments to be inclusive of differences (Dallman et al., 2022).
In 2023, the need for inclusive approaches to treatment, greater acceptance of the support
needs and accommodations are needed more than ever before due to higher levels of anxiety
across the community post pandemic. The necessity to improve outcomes for children who
are more at risk of school refusal, lower life expectance and suicide (Connolly et al., 2023;
McClemont et al., 2021) is becoming more evident.
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Changes in the Australian Health Practitioner Regulation guidelines
Further changes in the Australian Health Practitioner Regulation (AHPRA) guidelines
and Australian school pedagogy support the Positive Behaviour Support model, working in
consultation with neurodiverse individuals within their communities to engage. Such changes
provide meaningful support via professions with planned progress support under Australia’s
National Disability Insurance Scheme (NDIS) and support with assistance without the
historic restrictive practices.
Neurodiverse affirming Inclusion in Education for all
Learning differences and 21st Century education
Not only Autism and ADHD are challenges in the 21st century education system.
Dyslexia, Dyspraxia, Dyscalculia, other differences can impede learning in the current school
environment often leading to poor self-worth and confidence in ability to achieve an
education successfully (McArthur et al., 2016). The deficit driven language around these
differences also impedes students positive learning identity. Changes in language would
assist with challenging the notion that brain differences are less capable, instead creating an
awareness of strengths in other areas that may be advantageous with the change to the old
3Rs of education to become Relevance, Relationships and Real for experiential learning
(Bialeschki, 2007).
The influence of teaching methods and how they inform current curriculum
Differences in learning styles have been researched over the past century with many
still supporting and influencing our current education system. Piaget’s stages of cognitive
development (Huitt, Hummel, 2003), Stiener’s theory of autonomy in education (Steiner,
(1999), Montessori’s fostering of independence (Lillard & Else-Quest, 2006) all show that
the importance of student directed learning.
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One to one learning programs and current pedagogy and neurodivergence
Many past theories inform our one-to-one learning programs of today supporting
diversity in our current national curriculum. Built on the “Four C’s super skills” (Kivunja,
2015) of Communication, Collaboration, Creative thinking and Critical thinking, the current
national curriculum suggesting that students require a learning framework that is consistent
with skills they will need in the 21st century careers (Kivunja, 2015). With the “Four C’s
super skills” focus change away from the traditional methods and utilising technological
advances to ensure they are ready for the careers of tomorrow (Kelly et al., 2008). As the
curriculum continues to evolve into the 21st century, it will be important to consider how the
changes impact those who are more at risk of school refusal and build in scaffolds for
pathways back. Current pedagogy practice for the four C super skills through a lens of
Bruner’s 5E’s (Engage, Explore, Explain, Elaborate, Evaluate) (Bruner, 1961) suggests
current curriculum offers high levels of customisation, flexibility and inclusion for learning
experiences for all. Why is it then than many neurodivergent students are disengaging?
Programs to promote inclusion and improve school engagement
Programs to improve engagement in school for the neurodiverse community often
include a creative arts process such as music, art and photography. Contrary to the movie and
televisions representation of autism suggesting that they often work in maths, physics or
engineering, often areas of interest in the neurodivergent community are much broader and
include arts, animals, literature and much more. Programs that provide an appreciation for the
specialities that come with neurodiverse brains and encourage greater awareness in the
community as a positive point of difference may provide further inclusion. For example, the
experience of synaesthesia, an experience for some neurodiverse individuals where senses
combine, can enhance an artistic endeavour. (Van Leeuwen et al., 2019). Synaesthetes have
an atypical experience of their environment with greater attention to detail. The experience of
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synaesthesia is common amongst autistic individuals (Van Leeuwen et al., 2019) and more
research is needed to identify if this is a potential subtype of autism. The research also
suggested that the awareness of sensory differences may assist with the acceptance of the
challenges for the individual as well as providing meaningful understanding in the
community.
Systematic Review
Photovoice, participatory photography, photo elicitation and mindful photography
The systematic review of photovoice and photo elicitation research will inform a pilot
program of Mindful Photography in 2024 working with neurodiverse individuals who are at
risk of long-term school refusal. Incorporating methods such as mindfulness (Kabat-Zin,
2015) Mindful Self-Compassion (MSC)(Germer & Neff, 2019) in the pilot program along
with participatory photography, photovoice and photo elicitation.
Of the 36 peer reviewed articles researched on photography as a therapy tool in
mental health, only eight included articles that dealt with neurodiverse individuals, and two
of those that had been completed post Covid-19 Pandemic. The gap in research for this as a
tool to reduce school refusal in the post Covid-19 may ensure future refusal is ameliorated.
Photovoice and photo elicitation as tool for research interviewing
Photo voice and photo elicitation are not new techniques in research. The use of
photography in both film and digital forms have been used for storytelling over the past
century for its ability to explore beyond language. Photo elicitation in a research context was
first developed in 1957 by anthropologist John Collier (Collier, 1957). Photo elicitation
utilizes photos that may have been taken by others shared in a research context to elicit a
response. The level of self-reflection may be more limited by the selection of photographs
available to choose from.
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In contrast, photovoice as a research method allows participants autonomy to take
photos to express their responses to research questions and has been used widely in the
disability sector as it allows inclusivity to those who may have difficulty with
communication.
Empowering Voices via photovoice
Photovoice offers a tool to illustrate what may need to be changed within a
community setting and can be influential in provoking a response from policymakers. In
1997, health researchers developed the concept of photovoice to empower women in the
Chinese province of Yunnan in participatory research where women were not formally
educated (Wang & Burris, 1997). The outcome of this research has been widely cited as a
methodological guide encompassing a multistage needs assessment, analysis and the ethical
dilemmas they experienced in a multilayered hierarchy. Their approach reflected the needs of
the community with contextual analysis with the participants and codified the needs of the
community. This research echoes experiences neurodiverse individuals experience on a daily
basis due to bias and social difficulties.
Using photovoice to explore their needs, Yunnan participants demonstrated their
experiences at a more intrinsic level. The extrinsic elements of the photo along with their
experience offered a wider view for researchers to explore beyond the usual constraints of
fitting into a predetermined model (Wang & Burris, 1997) and avoids distortion of researcher
bias, providing a voice for those who are less likely to be heard.
This influence of this photovoice research and how it can be used for participatory
needs assessment (Wang & Burris, 1997) has generated a wide body of research in
marginalised groups such as men’s mental health(Reid & Alonso, 2018), adolescent mental
health (Jackson et al., 2022; Vélez-Grau, 2019) disability (Agarwal et al., 2015; Povee et al.,
2014), LGBTQI+(McGarvey, 2023) and autism (Do et al., 2021; Ha & Whittaker, 2016).
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Meta synthesis of Photovoice in research
In 2021, a meta synthesis of photovoice was conducted by Deakin University and the
University of Waikato researching the efficacy of participatory photography with autistic
individuals who may have difficulties in communication that may limit their participation in
research. Of the 94 papers, 11 met the inclusion requirements for the review over a period of
2010-2020 to investigate the perspectives of people on the autism spectrum. Identifying the
need for future research to authenticate responses using verbal and visual stimulus to support
communication, the results of this research provide a method to ensure autistic voices are
being reflected accurately and meaningfully in the research.
Each of these studies incorporated approaches including participatory research,
ethnography, phenomenology, case study, grounded, socio ecological theories to support a
wide range of qualitative research demonstrating the rigour of this study.
The meta synthesis found that the inclusive nature of photography as a method to
clarify responses in research offered a tool for the broad range of the autism spectrum. The
potential for even greater inclusivity due to the advancement of imaging products and the
ubiquitous access to smartphones, photovoice, as a method to assist and demonstrate the lived
experience of autism may lead to greater awareness of the support needs in wider community.
Discussion
Considering the tensions around the Covid-19 pandemic and school lockdowns over
the past three years have exaggerated the challenges that were already there for autistic
individuals, it is unsurprising school refusal is escalating. When teachers are leaving the
profession in large numbers due to burnout, compassion fatigue and traumatic stress, the need
for trauma specific training and support is necessary for the wellbeing teachers and students
alike (Oberg et al., 2023). This study suggests further research is needed to support the
cumulative trauma in the student body and retaining teachers in the profession requires
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trauma informed training and practice for their own wellbeing. A closer look at the trauma
informed practice tenets in a group therapy environment may offer an awareness of
inclusions for reluctant students. Offering empowerment of voice and choice for their
individual needs, safety, trust, transparency, collaboration, and an awareness of issues
surrounding cultural, neurodiversity and gender issues (Giacomucci, 2023) may offer
protective factors for continued school attendance.
Perception, experiential focusing and hermeneutic phenomenological photography
Existential philosophers, medical and psychological scientists have suggested the
inner world and the mind interacts to create self-awareness (Sitvast & Springer, 2020).
Interoceptive awareness for neurodiverse individuals can be muted and bodily sensations can
be more difficult to discern. Students who school refuse often have difficulties in awareness
of sensory challenges and may appear to go from homeostasis to complete dysregulation
within a very short time. Alexithymia, a condition common amongst the neurodivergent
population, is described as difficulty with identifying and expressing emotions. With its
literal definition as no words for feelings (Luminet et al., 2021), this sub clinical cognitive
affective impairment is categorised by challenges with connecting language and emotion and
sits across multiple conditions. When individuals are unable to express emotions due to
alexithymia, emotional dysregulation occurs due to the multiple processes of language,
attention, memory and behaviour, the body and mind are impacted (Luminet et al., 2021).
As qualitative studies that look at the internal world of the individual, the benefits of
using photography as a therapy tool can offer insight for all stakeholders. With the use of
Gendlin’s Focusing to access a felt sense (Gendlin, 1981) students may become aware of the
visual perceptual experience that photography offers and develop their bodily awareness
through this mindful practice. The visual experience of walking down the same path and
seeing something new each time you experience it tells us that the conscious awareness does
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not always include the cognitive, it is only once you review the image that the cognitive
comes to light. Cognitions of the photo can reveal a wealth of information about the inner
world of the individual’s perception in the moment. Like music therapy, visual therapy via
photography allows the visual perception of the mood of the feeling to be exposed (Sitvast &
Springer, 2020). In this process it is only once it is exposed that the reflexive cognitive
awareness come to the fore. This mindful awareness of the moment and the feeling of what
comes forward in the visual perceptual field, may allow a student to find meaning in what
they are experiencing.
Using this strengths based practice, photographs can mirror perception and help to
make meaning of experiences in the moment, offering the mindfulness component to this
activity. The neural integration that comes from using language to express emotion (Siegel,
2010) may assist students with their own awareness of self-regulation. Similar to photovoice,
hermeneutic photography applied by mental health nursing staff in the 1970s (Hagedorn,
1994) demonstrates that the use of photography has been used as a support structure that
creates awareness of experience and conscious mind (Sitvast & Springer, 2020), creating
meaning from the experience.
Mindfulness and creating meaning from sensory experiences is the basis for many
therapeutic interventions. Practicing mindful photography can differ from regular
photography. Consider the time lapse setting automatically taking one shot every minute,
this would not be deemed as mindful photography due to the automated camera that has no
operational intention (Diehl & Zauberman, 2022). Similarly, a photo taken with an external
perspective can distract engagement with the present moment when you consider how it
may look on social media. Mindful attention to the subject you are photographing and
awareness of surroundings, taking in the experience and fully engaging with the visual
sense can give way to emotional experiences that come to the fore.
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The development of self-awareness and meaning making across the photovoice
literature demonstrates the importance of accessing emotions through the image (Cheak-
Zamora et al., 2018) (Ha & Whittaker, 2016) (Do et al., 2021) and the therapeutic benefits of
the sense of common humanity in group work also creates a sense of inclusion and
community.
Conclusion
Rising school refusal rates demonstrate the need for change and advocacy for
neurodivergent individuals to ensure flexible engagement with education. Past practices in
treatment of neurodiversity, designed to offer an alternative to institutionalisation, have
evolved into neurodiverse affirming practice and greater inclusion in humanity.
Remembering the path travelled towards inclusion and embracing diversity may lead to
acceptance and appreciation of differences. Participatory photography, as a well researched,
strengths based method, may form connective tissue throughout school communities to
promote understanding, offering potential solutions to environmental adaptations within the
school environment to accommodate sensory difficulties. Further hermeneutic
phenomenological research is needed into photography as a tool to promote self-regulation in
the learning environment for the neurodiverse community. A future project proposal in late
2023 for a pilot program in 2024 to develop practice mindful photography through student
wellbeing staff will endeavour to investigate this method to re-engage neurodivergent
students back into the school environment.
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