Neurodiversity in Recovery Education in the UK: A Protocol for the N.I.R.E Guidelines

Rationale for guidelines regarding neurodiversity in recovery education

The need to develop a set of guidelines to support neurodivergent individuals in recovery colleges stems from an increasing prevalence of neurodiversity among those with mental health challenges^6,7. For example, autism and ADHD, which are often accompanied by higher rates of anxiety and depression^8,9. In addition, to coincide with the N.I.R.E study, since those who are neurodiverse are more likely to engage in recovery education for their mental well-being than the lay population, the need for guidance has been recognised as crucial in order to support recovery colleges and their staff in engaging with and creating a conducive learning environment for the neurodiverse community that engages in such education. As such, developing a set of guidelines will aid fostering of a neuro-inclusive environment within such spaces, thereby enhancing staff readiness, whilst also ensuring that, in so far as is possible, recovery based outcomes can be achieved for neurodivergent students in a holistic manner.

Aim and objectives of the guidelines

As such, the aim of this protocol is to highlight the process of developing guidelines for recovery college staff, in order to create a more neuro-inclusive environment within this space that ultimately empowers recovery college staff and facilitators to effectively support neurodivergent students in their mental health recovery and personal development. In order to achieve this aim, the following objectives need to be achieved:

By achieving these aims, the guidelines proposed here aspire to build a recovery education framework that values neurodiversity and provides tailored, evidence-based supports for all stakeholders involved in neuro-inclusive recovery education across the UK.

Target population

These guidelines are being developed to address an identified gap in practice thus far. It is well documented that due to the close connections between the concepts of mental health and neurodiversity^8,9,12, that often an individual can identify as being both a service user and a person with neurodivergency. As a result, in the UK as well as elsewhere, such individuals are likely to engage with recovery education services to enhance their own mental well-being³. However, The N.I.R.E Study was conceptualised in 2023 based on the idea that recovery colleges need to be better equipped to support their neurodivergent staff and students in recovery through the creation of a neuro-inclusive environment within recovery colleges³. As a result, these guidelines will be created as a result of the work of The N.I.R.E Study will primarily affect service users who also identify to be neurodivergent and who are seeking to enhance their mental well-being through recovery education. Please note, we as a working group are aware of the language fluidity for terms like service user and as such wish to clarify that when we refer to service user in this paper and within the subsequent guidance document that we mean individuals with lived experiences of mental distress and/or recovery who may or may not have used mental health services but have had times of significant mental distress and wo utilise the recovery education services to enhance their own mental wellbeing.

End users and settings

These guidelines are to be implemented within recovery colleges situated in the United Kingdom. Recovery colleges are centres which provide educational based information, networking and skills development to support the management of mental health and well-being on a daily basis¹³. Within such recovery colleges, the primary user of the proposed guidelines will be recovery college staff and management. This is inclusive of the individuals that manage recovery colleges as well as its facilitators, administration staff and peer and staff volunteers. The secondary users of these proposed guidelines will be ImROC [Implementing Recovery through Organisational Change] who has the capacity to share these guidelines across the UK and beyond through their extensive networks list. Finally, the tertiary users of these proposed guidelines will be those who engage in research in this area of scholarship, so that their work can build on what has been achieved here.

Guideline development group

The guideline development group has yet to be formally convened. However, it will consist of the following stakeholders and personnel:

Mr. Michael John Norton. Mrs Olga Zilberberg, Mr. William Gillani-Poole and Mrs Lydia Little will be involved in the quality assessment of the articles included in the scoping review proposed for the N.I.R.E study¹⁴. Mr. Norton will carry out a delphi exercise with the guideline development group based on the findings of the scoping review, and of each work package. Once a draft guideline has been prepared and the guideline development group has signed off on same, the guidelines will undergo a process of external review by the recovery education community. Mrs Zilberberg will be in charge of coordinating the external reviews which will take place in person at the Refocus in Recovery international conference in 2027. Amendments will be made to the guidelines once this external review ends and then will go through design and handed to ImROC to distribute amongst the recovery education community.

Evidence

To help inform the proposed guideline, a gathering of evidence is necessary. To do just that, the below will document the process by which a research/review question was constructed and the use of a systematic methodology to gather and appraise evidence. Such detail will be discussed below.

Research questions

Formulating a research question for review is a crucial first step in any scientific inquiry¹⁵. As such, the use of a research question generator is an important first step. There are multiple examples of research question generators available to support clinicians and researchers in generating a research question. Examples include SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research Type), PIRT (Population, Index Test, Reference Standard, Target Population), AND PICO (Population, Intervention, Comparison, Outcome)¹⁶. However, for this review, we will utilise the method as per our scoping review protocol: PICO¹⁴. As such, based on the already published protocol for this aspect of guideline development the research questions for investigation are: what is the current evidence that neurodiversity is fairly represented in recovery colleges? What is the current evidence that recovery colleges successfully support student’s recovery and well-being?¹⁴

Systematic review

Within the RIGHT-P guidelines¹¹, a systematic review should be conducted to explore in-depth the evidence presented. However, as noted above, this project aims to conduct a scoping review and not a systematic review¹⁴. As the protocol for this particular review is already published and peer reviewed, the review team will continue with a scoping review but will deviate from the already established protocol by implementing Levac and colleagues¹⁷ updated guidelines which permits us to both quality appraise and synthesize the evidence gathered from this extensive search of the literature. As a result, this will allow the research team to honour both the existing protocol and this paper for the purposes of guideline development.

Quality assessment

Since the scoping review will take any peer reviewed and/or grey literature sourced study into neurodiversity in recovery education, the MMAT (Mixed Methods Appraisal Tool) tool will be used for the quality appraisal of included studies¹⁸. The MMAT was designed to support researchers in the quality appraisal of individual studies given the heterogeneity of the research designs within these studies¹⁹.

Recommendations development

Once the evidence is gathered and analysed, a set of recommendations will be constructed by MJN, based on the evidence analysed and the preliminary results of work packages 1 and 2. After which, the next step will be to convene a group of relevant stakeholders to review the recommendations for the guidelines based on evidence. The stakeholders involved in the core co-design group will consist of members of the guidelines development group. This process will be an iterative process involving multiple rounds of refinement and adjustment until a final set of recommendations are finally constructed. At this point, the guidelines development group will engage in a process of further co-design to co-produce the guidance document. Co-design, otherwise known as co-production, has been defined by Norton²⁰ as: “the creation and continuous development of a dialogical space where all stakeholders … enter a collaborative partnership” in order to produce a product that positively impacts the organisation and/or community in which the activity occurs²¹.

Predicted economic and resource implications

Resource implications will not be considered as part of the co-production of the recommendations and subsequent guidelines. The authors of this paper do not envisage that any recommendations will have a cost implication as becoming neuro-inclusive requires a change in organisational behaviour, not necessarily a change in infrastructure.

Decision pathway

The decision pathway associated with the co-design of the N.I.R.E guidelines is visually expressed in Figure 1 below.

Figure 1. This figure depicts a process map of the proposed stages required to co-design the N.I.R.E guidelines based on the RIGHT Guidelines.

Independent review

Once the guidelines have been fully developed and have passed initial scrutiny from the guidelines development group, they will then undergo independent review as per Figure 1 above. To do this independent review, the guidelines will be presented to delegates of the Refocus in Recovery International Conference 2027 where delegates will vote on the inclusion/exclusion of recommendations made in the guidelines. If delegates of this conference agree with all the recommendations and associated guidance, the guidelines will be published by the N.I.R.E Guidelines Development Group. If delegates propose amendments, these will be conducted after the conference with a revised version of the recommendation being circulated to delegates for final approval. Once final approval is received, the N.I.R.E Guidelines will be formally published.

Institutional review board statement

Ethical approval was sought and awarded by University College Cork’s Social Research Ethics Committee [REC No. 2024-215]. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.