Industry Voice: Repatriating neurodiverse clients

Illustration of a character in a persons hand

Dr Adrian Hyzler, Chief Medical Officer for Crisis24, discusses how medical assistance companies can approach the repatriation of people with neurological differences to ensure as safe and comfortable a journey for the patient as possible

Neurodiversity is not a term that everyone will be familiar with, as it has only been understood as a collective for a relatively short period. During the 1990s, the neurodiversity movement emerged with the aim of increasing acceptance and inclusion of all people while embracing neurological differences. If we try to unpack the meaning of ‘neurodiversity’ (ND), we come across a broad spectrum of neurological conditions. These reflect that our brains work in unique ways and that people interact with and experience the world in different ways – it is important that this is not misinterpreted as a deficit.

What is neurodiversity?

The range of ND conditions includes, but is not limited to, the following:

  • Autism spectrum disorder (ASD): individuals who have challenges with social interactions and sensory processing and who demonstrate repetitive behaviours; these individuals often have a wide range of strengths, abilities, needs, and challenges
  • Attention deficit hyperactivity disorder (ADHD): individuals who have difficulties with attention span, hyperactive behaviour and impulsive actions
  • Tourette syndrome: individuals with tics and involuntary vocalisations
  • Learning difficulties: individuals who have challenges with information processing, which would also include those with dyslexia, which affects fluency, and dyspraxia, which affects motor skills
  • Down’s syndrome: individuals often have a range of behavioural and emotional challenges similar to those above
  • Long Covid: there is a vast range of symptoms associated with long Covid – too many to go into here – but some of the psychological effects, often described as ‘brain fog’, mimic ND conditions.

Medical assistance and the neurodiverse traveller

There are several scenarios in which a medical assistance company may become involved in the management and repatriation of people with ND conditions. They may be patients with an unrelated condition but with the added complication of their individual challenges. They may rarely be admitted as a direct result of their ND condition with, for example, an acute anxiety attack. Alternatively, their relative/companion/carer may need medical assistance themselves, leaving the potentially vulnerable individual without essential support.

Our brains work in unique ways and that people interact with and experience the world in different ways – it is important that this is not misinterpreted as a deficit

Once the attention shifts to repatriation considerations, plenty of considerations need to be discussed. There will have been a regular discourse throughout the process and plans for the eventual return home will have been forming with a view to a safe and comfortable journey.

Firstly, a joint decision will be reached with the local treating medical team as to what requirements the patient or travelling companion will require, ranging from simple transport arrangements with wheelchair assistance at the airport to possibly flying out a non-medical escort or the provision of medical escort(s) to facilitate the repatriation. This decision is made by the medical team, taking into account the clinical condition and airline regulations, alongside a discussion with the patient and any travelling companion. We will focus here on the aspects of repatriation that involve a medical team, which could be a doctor, a registered nurse escort, or a combination of escorts.

Understanding individual needs: tailoring the repatriation experience

Each individual on the ND spectrum experiences the world in a unique way. Preparation is key; therefore, planning a medical repatriation necessitates an individualised approach that recognises the specific needs and sensitivities of the neurodiverse person. Involving the individual in planning discussions, understanding their preferences and concerns, and tailoring the repatriation process are crucial. Of course, remember that we may have no prior knowledge of an ND person and that there may be absolutely no special considerations necessary in many cases. Potential key considerations include:

  • Escort selection: while all medical professionals who undertake repatriations will have the necessary medical skills and must fulfil strict registration and revalidation criteria, not all will have had the experience to manage a patient/companion with ND-related difficulties. The ideal escort would be ND trained, have an appropriate understanding of ND, and be confident in supporting the individual. On occasion, it may also be necessary to include a non-medical escort who is known to and trusted by the individual – they can provide emotional support, assist with communication, help manage sensory overload, and advocate for the individual’s needs
  • Communication hurdles: on the pre-flight assessment call, it becomes even more important to run through the repatriation protocol in as much detail as possible and even to email an itinerary. At the first meeting between the medical escort and the ND person, it is important to determine how individuals prefer to be addressed and how they want to be referred to when speaking to others. This is an invaluable time to build trust and allow for open questions that can reassure the person. It also helps to discuss whether there is a preference for direct and concise communication or more explanation and reassurance. For some, it may be appropriate to have a pad and pen or alternative visual aids to enable necessary communication. Understanding preferred communication styles will ensure effective information exchange and reduce potential anxieties
  • Airport protocols and security: airports can be stressful to navigate for even the most seasoned of travellers, and extra consideration can lighten this challenge – for example, use of priority desks, wheelchair assistance where necessary, taking careful precautions to ensure that bags are clear
    of restricted items before passing through security scanners, and caring assistance from airport personnel. Using airport lounges can minimise unnecessary interactions and provide dedicated quiet spaces for comfort. Offering pre-boarding allows for familiarisation with the crew and fellow passengers and for gradual acclimatisation to the environment, easing social anxieties
  • Sensory overload: commercial flights can be overwhelming. The unfamiliar social environment of an airplane cabin, with its close proximity to strangers and constant interactions, loud or repetitive noises, overhead announcements, and bright lighting, can be highly stressful. Individuals with ASD or sensory processing disorders may benefit from noise-cancelling headphones, dimmed lighting, and designated quiet areas – cabin upgrades can be justified to minimise these difficulties
  • Routine and predictability: disruption of routines can be very distressing for individuals with neurodivergent conditions. Maintaining familiar routines as much as possible, having clear printed itineraries and tickets in hand, keeping to defined sleep schedules, and pre-booking preferred meals can provide comfort and a sense of control
  • Home support: it is crucial that careful consideration is taken to plan for the return home. There will need to be close collaboration with the support network in order to care for someone likely to be mentally and physically exhausted, overloaded with sensory stimulation, and needing the familiarity of people and places. The medical escort(s) should be encouraged to provide opportunities for the individual and their caregiver to debrief and address any emotional or psychological challenges arising from the experience to help with long-term adjustment.
    The majority of ND conditions are not immediately apparent to others

What more can be done

While significant progress has been made in understanding and accommodating ND passengers, there is still room for improvement. Some airlines have implemented ND training programmes for their staff, and offer designated quiet zones, sensory-friendly amenity kits, inclusive in-flight entertainment options, and pre-boarding assistance. Researching airlines with a proven track record of supporting ND passengers significantly contributes to a smooth and comfortable repatriation experience.

The majority of ND conditions are not immediately apparent to others. This can make it hard for some people to understand and believe that someone with a non-visible condition genuinely needs support. You may have seen the ‘Hidden Disabilities Sunflower’ on your travels. It is a simple tool that allows a person to share voluntarily that they have a hidden disability in the hope that it will encourage inclusivity, acceptance, and understanding.

Everyone has the right to travel, and everyone involved in the travel industry should create an environment where people with invisible disabilities can travel independently with confidence in the knowledge that at every stage of their journey, there is support should they need it.