Pharmacy’s neuro-affirming approach to autism

Case scenario

During peak hour, 19-year-old Enzo and his mother arrive to collect a new prescription for melatonin MR 2 mg. The pharmacy is highly stimulating: background music blares, customers converse loudly nearby, staff assist others in a cramped space, and general noise amplifies the chaos. While processing Enzo’s prescription and attempting to deliver verbal instructions, you observe Enzo avoiding eye contact, fidgeting intensely, and appearing overwhelmed, with reduced capacity to process verbal or non-verbal cues due to sensory overload.

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Introduction

Neurodevelopmental disorders (NDDs) arise from differences in brain development and typically affect cognition, communication, behaviour and occupational functioning. Common NDDs include attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), referred to as autism in this article, and intellectual developmental disorder (IDD).¹ Autism is characterised by persistent social interaction and communication difficulties and restricted behavioural patterns.² Symptoms begin in early childhood; however, diagnosis can occur at any age.³ Autism affects how the brain processes information, shaping how autistic people see, understand and respond to the world around them, with marked variability in presentation, day-to-day functioning and support needs.^3,4

In Australia, autism prevalence has increased due to evolving diagnostic practices and awareness,⁵ meaning pharmacists now routinely engage with autistic individuals as part of everyday practice. 

The challenge and opportunity for pharmacy is to shift from a medical model of crisis response, treatments and cures to a neuro-affirming social model that helps autistic individuals thrive, not just survive.

A neuro-affirming social model conceptualises neurodevelopmental differences as natural variations within human diversity and rejects deficit-based assumptions that frame these differences as disorders.⁶ Rather than ‘correcting’ individual traits, this approach provides reasonable adjustments while supporting autonomy, community participation and wellbeing, alongside awareness of diagnostic criteria, comorbidities, communication styles, lived realities and the impact of misinformation.⁶ The shift to a neuro-affirming social model calls for reducing systemic and environmental barriers, while still addressing health needs.^6,7  

For pharmacists, it means making practice adjustments in the way that the profession engages with and provides support for autistic individuals.

Epidemiology

According to the Australian Bureau of Statistics, approximately 290,900 Australians (1.1%) are reported to have had an autism diagnosis in 2022.⁵ A recent estimate by Autism Spectrum Australia (Aspect) suggested at least 1 in 40 Australians are autistic.⁷

Rising prevalence reflects improved awareness and diagnostic practices rather than a true increase in incidence, including better recognition in historically underdiagnosed groups such as females and older adults.⁷ Autism prevalence peaks in children and adolescents, particularly those aged 10–14 years, and is markedly lower in adults, acknowledging limited adult data.^5,8,9 

Autism prevalence rates may appear to vary among ethnic and cultural
groups, reflecting inequities such as access to healthcare, effective communication, diagnostic practices and cultural perceptions.¹⁰

Prevalence remains higher in males than females, with 1.6% of males identified compared with 0.7% of females, and the greatest disparity is seen in children aged 5–9 years.⁵ Autism in females is frequently underdiagnosed, as characteristics may manifest differently, be masked (e.g. forced eye contact, rehearsed social scripts, suppressing stimming or copying peers), or fail to align with historically male-centred diagnostic criteria, leading to misdiagnosis as mood or personality disorders.^11,12 Masking may occur due to a desire to fit in, fear of stigma or bullying, previous negative reactions to autistic behaviours, and expectations of how females are ‘supposed’ to behave.¹² Increasing awareness of the under-recognition of autism in females and gender-diverse individuals, and the social drivers of masking, is anticipated to influence future prevalence estimates.^4,5,11

Aetiology

There is no single cause of autism, and despite extensive research, aetiology remains incompletely understood. Current evidence indicates autism arises from a complex interaction between genetic susceptibility and environmental influences on neurodevelopment.¹³

Family history is one of the strongest predictors of autism.^13,14 Researchers have identified hundreds of genes, with approximately 10–20% of cases associated with rare genetic variants arising from mutations in sperm or egg cells.¹⁴ Autism is considered polygenic, meaning overall risk typically reflects the cumulative effect of multiple inherited variants, each contributing a small effect.¹⁴

The expression of genetic susceptibility is known to be influenced by prenatal, perinatal and postnatal environmental factors.¹³ Environmental factors appear most relevant during the prenatal period.¹⁴ Modest associations have been reported between autism likelihood and maternal factors such as hypertension, gestational diabetes, obesity, alcohol and substance use, poor antenatal care, and infection or fever during pregnancy.¹⁵

Imprecise and inconsistent associations have been reported for folate status, exposure to some air pollutants, and the use of some medicines.^15–17 Importantly, these findings are largely derived from observational studies and are subject to confounding. While some prenatal medicine exposures show more consistent associations with autism, there is no clear   evidence that associations between autism and other environmental and medicine exposures represent a causal relationship, and any contribution to autism risk remains limited and uncertain.^14,17  

Diagnosis

Autism is diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria: ‘persistent deficits in social communication and social interaction across multiple contexts’, with the presence of ‘restricted, repetitive patterns of behaviour, interests or activities’.²

‘Symptoms must be present in the early development period’, although they may only become fully apparent later in life.

‘Symptoms cause clinically significant impairment in social, occupational or other important areas of functioning’ and ‘these disturbances are not better explained by IDD’ although both can co-occur.² The DSM-5-TR also specifies severity levels (1–3) to indicate the degree of support required.²

In Australia, individuals may pursue an autism diagnosis through public or private pathways.¹⁸ Both are typically lengthy and necessitate a degree of health literacy and English proficiency. Diagnostic assessments may be conducted by a multidisciplinary team, including paediatricians, psychiatrists, psychologists, speech pathologists and occupational therapists.⁴ Multiple appointments may be needed, drawing on input from family, carers or teachers.^18,19

Barriers to diagnosis include limited awareness of early signs among caregivers and clinicians, long wait times and out-of-pocket costs for specialist assessment, socioeconomic and geographic disparities, and bias in recognising diverse presentations.^11,20,21 Limited health literacy and the complexity of navigating multidisciplinary assessments and National Disability Insurance Scheme requirements further impede access.²¹ In some communities, stigma, fear of labelling, and differing cultural interpretations of behaviour may delay help-seeking.²²

A best-practice diagnostic approach should promote cultural safety and sensitivity, acknowledge variations in health literacy, address socioeconomic barriers, and be grounded in person-centred care.

Autism is a spectrum, with each individual having a unique mix of strengths, challenges, interests, needs and way of interacting with the world. Autism advocate Dr Stephen Shore states, ‘If you have met one autistic person, you have met one autistic person’.²³

Beyond the core features

Comorbid NDDs, and psychiatric and medical conditions can create significant challenges for autistic individuals in relation to diagnosis, selection of appropriate interventions, medicines and support services.^1,24 

Comorbid NDDs among autistic individuals include ADHD, developmental coordination disorder (dyspraxia), IDD, and specific learning disorders such as dyslexia, dysgraphia and dyscalculia.²⁵ Psychiatric comorbidities are also prevalent, including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder.²⁶ These conditions can intensify social and sensory challenges, increase vulnerability to stress, and impair emotional regulation and executive functioning.

Autistic individuals experience higher rates and severity of mental and physical health comorbidities than neurotypical individuals. Neurodivergent mental health outcomes are influenced by the interaction between individual differences and environmental and societal factors.^25–28 Diagnostic overshadowing, whereby mental health symptoms are erroneously attributed to autism, should be avoided.²⁹ Comorbid conditions warrant assessment and treatment according to the same clinical standards applied to neurotypical individuals, with adaptations made to accommodate the communication, sensory and support needs of autistic people. Neurodivergent individuals experience the full range of medical comorbidities seen in the general population; however, research indicates higher prevalence of certain conditions, including gastrointestinal disorders (e.g. irritable bowel syndrome, chronic constipation), sleep disturbances, epilepsy, and immune or metabolic disorders.³⁰ These conditions may worsen fatigue, concentration and mood regulation, while motor difficulties may contribute to musculoskeletal pain, reduced physical activity and secondary health issues.³¹ 

Physical health conditions may be underdiagnosed when the clinical focus is limited to behavioural or psychological symptoms.²⁹

Recognising the complex interconnections between physical, psychiatric and NDD health is paramount. Pharmacists can play a vital role in this process. Effective care relies on health professionals working collaboratively to identify how comorbid conditions, treatment burden and medicines may influence behaviour, cognition and developmental outcomes.

Support and interventions   

Autism is a lifelong NDD for which there is no curative treatment.⁴ Clinical care focuses on supporting health, functioning and community participation, addressing comorbidities, and optimising quality of life, while recognising and respecting the individual strengths, capabilities and perspectives of autistic individuals.³

Non-pharmacological support

Supports and interventions are individualised and typically involve a multidisciplinary team to address evolving needs.¹⁰ Allied health professionals may include speech pathologists to support communication, occupational therapists to address sensory processing and daily living skills, and psychologists to support emotional regulation and mental health. Physiotherapists may support gross motor skills, while dietitians support feeding and nutritional adequacy, alongside specialist educational support and therapy (e.g. play therapy, art therapy).³ Effective management relies on coordinated care, regular goal review and clear communication between the autistic individual, families and carers, and the multidisciplinary team.²⁴

Pharmacological support

There is no evidence to support the use of medicines, exclusion diets or other biological treatment for the core features of autism.^32,33 To support comorbidities, psychotropic medicines, antiepileptics and sleep agents may be used short term and under specific circumstances. Off-label use is common and requires careful assessment of risk-benefit balance, adverse effects, formulation choice, monitoring, cumulative treatment
burden, and very careful consideration if the medicine is being prescribed as a
chemical restraint.⁴

Myths and misconceptions

Autism is subject to persistent myths that pharmacists may encounter. The most damaging is the long-debunked claim that vaccines cause autism.¹⁴ The retracted 1998 Lancet study by Andrew Wakefield that claimed a link between the measles, mumps, rubella (MMR) vaccine and autism was a small, flawed study (with only 12 participants) and was exposed for unethical processes, methodological misconduct, and undisclosed conflicts of interest.¹⁴ Despite retraction, its claims were (and continue to be) amplified, eroding trust in public health and fuelling vaccine hesitancy. A Cochrane review published in 2021 found no credible evidence of an association between MMR and MMRV vaccines and autism.³⁴

Two medicines made headlines in 2025: paracetamol and leucovorin (folinic acid or calcium folinate) claimed as a cause and treatment of autism respectively. Antenatal paracetamol exposure was alleged to increase autism and ADHD risk; however, major studies have not demonstrated a causal relationship.⁹ Stronger evidence from a large Swedish population-based cohort of 2,480,797 children born between 1995 and 2019 found no association between paracetamol use during pregnancy and autism, ADHD or IDD in sibling-controlled analysis.¹⁶ Cerebral folate deficiency (CFD) has been reported in a subset of autistic individuals, related to impaired folate transport into the brain, and may be associated with symptoms of speech difficulties, seizures and IDD, often within early childhood.^35,36 Leucovorin, a folinic acid derivative, has been investigated as a potential treatment for autistic children with CFD. Leucovorin can bypass impaired folate transport, increasing central nervous system folate availability.³⁶ Although some small-scale trials indicate potential minor behavioural improvements, supporting evidence remains limited, inconsistent, and not independently replicated.^15,37

As medicines experts, pharmacists are well placed to counter common myths. Responses should prioritise empathetic, respectful communication and the provision of clear, evidence-based information and resources.

Knowledge to practice

Accessibility, strong communication skills, medicines expertise, understanding of health system navigation and ability to synthesise information, position pharmacists to provide continuity of care for autistic individuals. Pharmacists can serve as an integrative link within multidisciplinary teams, supporting autistic individuals and their families across the healthcare continuum. 

Communication tips 

Effective communication underpins person-centred pharmacy practice. Pharmacists supporting autistic individuals should adapt both verbal and non-verbal communication to meet diverse needs.³⁸ Autism can influence communication and sensory processing in unique ways, with some individuals experiencing sensory sensitivities to sound, light, smell, touch and visual stimuli.^3,4,33 Some autistic individuals regulate sensory input through stimming (self-stimulatory behaviour), which may present as repetitive movements or sounds such as fidgeting, rocking or hand-flapping.³⁹ Flexibility, empathy and understanding of sensory needs ensure equitable access to healthcare and fosters the relationship between patient and pharmacist. Verbal communication with autistic individuals should be clear and structured. Pharmacists should use straightforward, unambiguous language and present information in small, logical steps, allowing time for processing and response. Offering a calm, quiet space can both minimise sensory overload and facilitate a more comfortable environment for communication.^38,40

Non-verbal communication requires equal attention. Eye contact, facial expressions and gestures can carry unintended meaning for autistic individuals. Some avoid eye contact
as a coping mechanism, not as disinterest.³⁸ Pharmacists should avoid assumptions and focus on open, calm body language and a reassuring tone. Visual supports can reinforce verbal explanations to provide ongoing reference, especially for individuals who process visual information more effectively than spoken language.⁴⁰

A person-centred approach requires pharmacists to recognise, respond and adapt to the communication preferences of each autistic individual. If a caregiver or support worker is present, collaboration should occur while directing communication towards the patient whenever possible.⁴⁰ Empathy, flexibility and inclusive communication techniques ensure care that is respectful and accessible and upholds an individual’s dignity and autonomy.

Conclusion

By adopting inclusive, neuro-affirming approaches, pharmacists strengthen equity, accessibility and person-centredness within healthcare. In doing so, they uphold the profession’s commitment to compassionate, evidence-based practice and help ensure autistic Australians receive the respect, understanding and tailored support needed to achieve optimal health and wellbeing.

Key points

• Shift to a neuro-affirming social model – pharmacists must transition to a social model that fosters neuro-affirming environments and services.
• Use clear and visual communication – use straightforward, unambiguous language, present information in small, logical steps, and utilise visual supports to reinforce verbal explanations.
• Ensure environmental accessibility – acknowledge sensory differences and offer calm, quiet spaces to reduce sensory overload.
• Pharmacists should act as an integrative care link within multidisciplinary teams – bridging care gaps for individuals and families.
• Manage comorbidity holistically – apply pharmacological expertise to manage physical, psychiatric and neurodevelopmental health.
• Correct misinformation – deliver evidence-based information, empathetically, compassionately and respectfully.

Assessment questions

Each question has only one correct answer.

1. The primary shift required of the pharmacy profession to effectively support autistic individuals is moving away from a medical model to a:

a. Crisis management model.

b. Social model that fosters neuro-affirming environments and services that help autistic individuals thrive.

c. Behavioural modification model.

d. A model that attributes psychiatric disorders to an individual’s autism diagnosis.

2. Recent data suggests the increasing prevalence of autism diagnoses in Australia is largely attributed to:

a. A true rise in the incidence of autism linked to specific environmental factors.

b. The historical lack of recognition among young adult males.

c. Increased awareness and enhancement in health professionals’ ability to recognise and diagnose, particularly among under-recognised groups.

d. Universal screening programs implemented across all Australian primary schools.

3. When providing medicines information about a sleep-aid to an autistic individual, which strategy is recommended to reduce the risk of information overload and ensure comprehension?

a. Use complex medical terminology to describe other comorbidities.

b. Move to a quiet area of the pharmacy that is cramped and cluttered with boxes.

c. Rely solely on non-verbal cues observed across the pharmacy counter.

d. Present information in small, logical steps, explaining dosage, timing and side effects separately, in a low-traffic area.

4. A young couple approaches the pharmacy counter expressing deep concern and hesitancy about giving their child the MMR vaccine, citing a claim that the vaccine causes autism. As a pharmacist, which of the following is the most appropriate, evidence-based and person-centred response?

a. State that, while there is insufficient evidence, it is important to remember that antenatal paracetamol use has also been claimed to increase autism risk.

b. Dismiss the concern immediately, insisting that the source of the claim (the 1998 Lancet study) was unethical and therefore irrelevant.

c. Empathetically and respectfully discuss the 2021 Cochrane review that found no credible evidence linking MMR or MMRV vaccinations to autism.

d. Explain that autism is caused by rare genetic variants, which are the only known predictors.

Our author

Yvette Anderson (she/her)

BPharm, MPS, CredPharm (MMR), ANZCAP (MentalHth, Paeds), CPGx, GradCert Autism

is an accredited clinical pharmacist with over 20 years’ experience across aged care, consultancy, community pharmacy and hospital pharmacy. In 2020, she launched The Spectrum Pharmacist to increase awareness, promote inclusion, and provide education and support for neurodevelopmental disorders.

Our Reviewer

Victor Senescall (he/him)

BPharm (Hons)