Issues in Mental Health Nursing, 35:664–671, 2014
Copyright © 2014 Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840.2014.894158
The Need to Support Students with Autism at University
Ann M. Mulder, PhD, and Andrew Cashin, PhD
Southern Cross University, School of Health and Human Sciences, Lismore, Australia
Publicity surrounds the increased prevalence of autism. How-
ever, in contrast to support in primary and secondary schools,
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there exists little focus on supporting students with autism at uni-
versity. Mental health nurses are well placed to facilitate support
programmes for students with autism who have the capacity for
higher education. This article examines the international literature
around the support needs for these students and discusses opportu-
nities that exist to support these students, their families, and higher
education staff. Research is urgently needed to evaluate the success
of such interventions, particularly in light of the low participation
rates in study and work for people with autism.
Autism is a spectrum disorder made up of the diag-
For personal use only.
nostic constructs of Autistic Disorder, Asperger’s Disorder,
Childhood Disintegrative Disorder, and Pervasive Development
Disorder not otherwise specified (PDD-NOS). In this paper
“autism” is used to refer to all four disorders as classified in
the recent DSM-V (American Psychiatric Association [APA],
2013).
Autism first entered the scientific literature in 1943 (Kanner,
1943). In the first two editions of the Diagnostic and Statistical
Manual of Mental Disorders (DSM; APA, 1952, 1968), chil-
dren with autistic-like symptoms were classified as “childhood
schizophrenic.” In the third edition (APA, 1980), autism was
included as a distinct category although the only form was “in-
fantile autism.” In 1994, the fourth edition (APA, 1994) included
Autistic Disorder, Asperger’s Disorder, Childhood Disintegra-
tive Disorder, and PDD-NOS as separate diagnoses. Since the
introduction of Asperger’s Disorder in 1994, there has been a
dramatic rise in the number of people diagnosed with autism.
This is largely related to changes in clinician diagnostic prac-
tice and the recognition of autism in those without intellectual
disability; individuals with Asperger’s Disorder do not exhibit a
clinically significant delay in language or cognitive development
Currently the prevalence of autism is between 0.6% and 2.6% of
the population: 2.6% in Korea (Kim et al., 2011); 1.6% in Britain
(Baron-Cohen et al., 2009); 1.2% in Sweden (Idring et al., 2012)
Address correspondence to Ann M. Mulder, School of Health and
Human Sciences, Southern Cross University, PO Box 157, Lismore,
2480 Australia. E-mail: ann.mulder@scu.edu.au
664
and Iceland (Saemundsen, Magnusson, Georgsdottir, Egilsson,
& Rafnsson, 2013); 0.7% in the US (Centers for Disease Control
and Prevention, 2007); and 0.6% in Norway (Suren et al., 2013),
the Canary Islands (Fortea Sevilla, Escandell Bermudez, & Cas-
tro Sanchez, 2013), and Israel (Davidovitch, Hemo, Manning-
Courtney, & Fombonne, 2013). Additionally, prevalence rates
are 0.6% for full-term births, 1.3% for late preterm births, and
2.2% for early preterm births in Taiwan (Hwang, Weng, Cho, &
Tsai, 2103).
It is now 19 years since the inclusion of Asperger’s Disorder
in the DSM and approaching rapidly is an increased wave of stu-
dents with autism needing to access post-secondary education.
While student-centred learning is a widely embraced concept
internationally, universities are only beginning to realise that
practicing this for students who are not neurotypical requires
identification and increased support. Through consultation and
faculty practice, nursing faculty are ideally placed to take an ac-
tive role in supporting university services for those with autism.
Mental health nurses, with their understanding of thinking and
information processing, when combined with the pedagogical
expertise possessed by nursing faculty, are ideally equipped to
consult on reasonable adaptations to curricula and teaching for
people with autism. Mental health nurses also are well-equipped
to consult on individual support needs of students related to dis-
tress and anxiety and to provide direct support as part of faculty
practice.
AUTISM DEFINED
Autism is a behavioural diagnosis defined by a triad of im-
paired communication, social skills, and behavioural flexibility
expressed through restricted and repetitive interests, activities,
and behaviours (APA, 2000). Impairment also can be viewed at
the cognitive level resulting in impaired linguistic processing,
theory of mind, and abstraction.
Elements of both the behavioural and cognitive process-
ing triads in autism are relational and not mutually exclusive
(Cashin, Sci, & Barker, 2009). The combination of the elements
is not additive, but rather together they compound to result in
the expression of autism. However, it is fruitful to discuss them
individually.
 STUDENTS WITH AUTISM AT UNIVERSITY
Communication
Impaired communication is one identified element in the triad
of impairment. This is at the level of generating meaningful com-
municative messages (Kanner, 1943). Prior to the development
of speech, those with autism have less communicative intent
than neurotypical people (Duffy & Healy, 2011). The impair-
ment in communication is at the linguistic and para-linguistic
level. In addition to the difficulty of using words to communi-
cate, intonation and facial expression, both learnt traits, also are
impaired. The age at which speech is acquired does not correlate
with later development in people with autism and no comorbid
intellectual delay (Howlin, 2003). It follows that the impair-
ment is not a communication delay but a difference. The beha-
vioural elements of communication are underpinned by the
difference in cognitive processing. People with autism have im-
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paired linguistic processing of information (Cashin et al., 2009);
they have a relative strength in visual processing (Sacks, 1986).
Social Skills
Impaired social skills found in those with autism are un-
derpinned by impaired theory of mind. Theory of mind is the
ability to understand that others have beliefs and desires that are
different from one’s own. It is the ability to put oneself in an-
other’s shoes, which supports an understanding of empathy and
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is an essential element of social communication (Howlin, 2004;
Senju, 2012). For some on the spectrum, there is no inclination
to become socially involved. However for those who do wish to
be engaged socially with others, impaired theory of mind often
results in the constant tripping over of social conventions and
being mystified by the unwritten rules and etiquette of social
contact (Wing, 1996).
Behavioural Flexibility
Restrictive and repetitive interests, activities, and behaviours,
or impaired behavioural flexibility, is underpinned by impaired
abstraction. People with autism have been described as having
weak central coherence; at the base of which is impaired abstrac-
tion and the ability to determine like, or similar. This results in
an impaired ability to categorise and see links between ideas
and information. People with autism have been described as
having a spotlight focus as opposed to the gestalt of big picture
thinking. The term “executive dysfunction” has been used to
describe impairment in frontal lobe mediated behaviour where
the person with autism has trouble locating where activities and
information fit into the big picture. This results in difficulty in
organising and sequencing activities, impulse control, working
memory, and mental flexibility (Happé & Frith, 2006).
PARTICIPATION IN WORK AND STUDY
Autism and Education in Australia
The most recently available data from the Australian Bureau
of Statistics (ABS) (2009b), reported that more than 95% of
665
children with autism attended school. Just over half of those
who attended school were in mainstream classes. However, the
majority of these children reported difficulty at school; partic-
ularly with communication, learning, and social engagement.
The remainder needed to attend either a special class in a main-
stream school or a special school that is better able to meet
their needs. Generally, children with autism need a high level
of support to attend school, with around a half requiring the
services of a counsellor, disability support person, or special
tuition. Data suggests that the difficulties students with autism
experience in the education system continue after school. For
example, of people with autism who had finished school, three
quarters (77%) had not completed a post-school qualification;
a rate well above both people with disability (50%) and people
with no disability (43%) (Australian Bureau of Statistics [ABS],
2009b).
Autism and the Labour Force in Australia
People with autism also encounter difficulties participating
in the labour force. In 2009, the labour force participation rate in
Australia for people with autism was 34%, compared with 54%
for people with other disabilities, and 83% for people without
disabilities. These figures, the ABS suggest, indicate significant
implications for the economic security of people with autism,
as without jobs, and therefore sufficient income, they lack the
financial freedom to make decisions about their lives. Further,
they miss out on other beneficial aspects of working, such as the
social networks that develop through workforce participation
(ABS, 2009b). As a function of the restrictive and repetitive
behaviours, there exists a drive in many individuals with autism
to a shrinking world; so if not participating in study or work,
they can become extremely isolated in their homes (Cashin &
Waters, 2006).
One of the key goals of both the National Disability Strat-
egy and National Disability Agreement is to increase the eco-
nomic and social participation of people living with disabil-
ities. The Australian National Disability Strategy notes that,
“work is essential to an individual’s economic security and
is important to achieving social inclusion. Employment con-
tributes to mental health, personal well-being and a sense of
identity” (Commonwealth of Australia, 2011, p. 42). People
with autism struggle with social engagement, and in 2009 the
data indicate they also were struggling with economic participa-
tion and had lower levels of post-school qualifications and labour
force participation compared to people with other disabilities
(ABS, 2009b).
While primary and secondary schools in Australia are pro-
viding support to children and young people with autism, 2009
data indicate that more needs to be done to help them into ter-
tiary education and the labour force (ABS, 2009b). We identified
no formal transition programmes between secondary school and
university for people with autism in Australia. Transition pro-
grammes, if they existed, would allow study skills learnt during
 666 A. M. MULDER AND A. CASHIN
secondary school to be more effectively transferred to university
study, resulting in more effective transitioning and identification
of students needing support, along with a history of the support
found to be of most use (Janiga & Costenbader, 2002). Such
programmes would help mitigate the added stress and anxiety
of university study (Hart, Grigal, & Weir, 2010; Stallman, 2010).
Autism and Participation in Work and Tertiary Study
Internationally
Congruent with the 2009 Australian figures reported above,
outcomes from a US study using 2007–2008 data from the Na-
tional Longitudinal Transition Study 2, a ten-year prospective
study of youth receiving special education services, found that
youth with autism had the highest risk of being completely
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disengaged from any kind of post-secondary education or em-
ployment (Shattuck et al. 2012). The risk is particularly high in
the two years following high school, pointing to potential gaps
in transition planning in youth with autism. The study exam-
ined data from youth aged 19–23 years with autism (n = 680),
speech/language impairment (SLI; n = 470), learning disability
(LD; n = 460), and mental retardation (MR; n = 430). They re-
ported that in youth with autism, 55% had had paid employment
since high school, 28% had attended a 2-year college, 12% had
attended a 4-year college, and 9% had attended a vocational or
For personal use only.
technical education program; 35% had not participated in any
post-secondary employment or school. Higher family income
and youth with higher functional skills were associated with
higher odds of participation in paid employment and education.
Compared with other disabilities, youth with autism had the
lowest rates of employment and education participation. The
paid employment rate for youth differed based on the youths’
diagnoses: the rate of paid employment for those with autism
was 55%; for those with MR, it was 69%; for those with a SLI,
it was 86%; and for individuals with a LD, the rate of paid em-
ployment was 94%. In contrast, the rates of no participation in
either paid employment or education was 3% for youth with a
LD, 7% for youth with a SLI, 26% in youth with MR, and 35%
in those diagnosed with autism (Shattuck et al., 2012).
In Sweden, a prospective follow-up study, minimum five-
year post-diagnosis, of adults with Asperger’s Syndrome (AS;
n = 70) and autism (n = 70), found that only 27% of participants
with AS were assessed as having good social, communication,
and functioning outcomes. A good outcome entailed being (a)
employed, or in education or vocational training, and (b), if
23 years of age or older, living independently or, if 22 years or
younger, having two or more friends and/or a steady relation-
ship. The largest percentage (47%) had a fair outcome; (a) or
(b) but not both. However 26% had a restricted outcome; neither
(a) nor (b); that is, they undertook no education or occupation
and had no friends. Outcomes for participants with autism were
worse, with 76% assessed as having either poor (20%) or very
poor (56%) outcomes; a poor outcome entailed having an obvi-
ous, severe handicap, but with some clear verbal or non-verbal
communicative skills, and a very poor outcome entailed hav-
ing an obvious, very severe handicap, being unable to lead any
kind of independent existence, and no clear verbal or non-verbal
communication; it is worth noting that only 7% of participants
with autism were assessed as having normal intellectual ability
(Cederlund, Hagberg, Billstedt, Gillberg, & Gillberg, 2008).
Similarly, a Canadian study of young adults with ASD (n =
48, mean age = 24 years), reported outcomes based on occu-
pation, friendships, and independent living. They assessed only
4% as having a very good outcome, 17% as having good, 32%
as having fair, and 46% as having poor outcomes. A very good
outcome entailed achieving a high level of independence, having
some friends, and holding a job. A good outcome was generally
used to describe someone who was working, but required some
support in daily living and who had some friends/acquaintances.
A fair outcome entailed having some degree of independence
and not needing specialist residential provisions and having no
close friends but some acquaintances. A poor outcome entailed
needing special residential provisions or a high level of support
and not having friends outside of the residence. The highest lev-
els of unmet needs reported by families of these young people
with ASD were social programs/outlets (31%), work (29%), and
friends (25%) (Eaves & Ho, 2008).
AUTISM AND UNIVERSITY
Increasingly, inclusion in mainstream primary and secondary
(K-12) education is being embraced for students with autism. In
contrast, higher education facilities, such as universities and col-
leges, can exhibit an elitist environment where only students who
meet certain admission requirements are accepted and educated.
Consideration of the implications of student-centred learning in
a university environment that promotes inclusion is only now
beginning to be considered. For students who are outside the
norm, current practise often suggest that these students do not
belong. However, the inclusiveness of K-12 schooling with its
high academic expectations is challenging these assumptions
about who belongs and can benefit from a university education
(Hart et al., 2010). Shattuck (Shattuck et al. 2012) identified that
12% of students from the USA with autism attended a four-year
degree programme; no Australian data is available. However if
we apply to a conservative 1% of the population estimate of
autism, the numbers potentially already attending university in
Australia are large. While figures that allow estimate of numbers
in the range likely to attend university are not available, using
the ABS’ (ABS, 2013) population estimate of 23,004,776 for
April 28, 2013, we get 27,606 Australians with autism (12%
of the 1% population estimate) who may at some point in their
life attended, have aspirations to attend, or be attending univer-
sity. International evidence indicates that the number of students
with autism who have entered higher education is increasing. In
the UK, the Higher Educational Statistical Agency (HESA) data
indicate that 80 students with Asperger’s Syndrome entered in
the 2003–04 school year, 295 students entered in 2004–05, and
 STUDENTS WITH AUTISM AT UNIVERSITY
475 students entered in the 2005–2006 school year (Madriaga
& Goodley, 2010).
There are many compelling arguments that support access
to university education for students with autism. These include
the argument that participation in post-secondary education is
a natural development growing from ever-expanding inclusive
opportunities in the K-12 system, a system that has demon-
strated that with appropriate support, students with autism can
succeed both socially and academically. In addition, people with
autism benefit from participating in valued social roles (such as
being a university student), making it more likely that they will
have a good quality of life and less marginalisation. For many
students with autism, their intellectual capabilities may become
a critically important domain essential to their feelings of self-
worth. Participation in advanced education programs becomes a
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significant source of self-esteem (Camarena & Sarigiani, 2009).
It is important however that inclusion is structured to cre-
ate legitimate university status; pretending does not have the
same value as true participation. There are strong positive
relationships among a university education, employment out-
comes and lifetime earnings (ABS, 2009a). A positive univer-
sity education is not just measured by academic grades but also
by increased learning, independence, self-determination, and
positive social experiences. Internationally, universities, simi-
lar to K-12 schools, are finding that students with autism are
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having a positive impact, not only on other students without
autism, but on the university community as a whole (Hart et al.,
2010). Faculty members at a New Hampshire College stated
that:
. . . we have found ourselves to be more understanding and apprecia-
tive of both our differences and our similarities, we regard students
with AS or autism as having a great deal to contribute both to our own
learning, as well as to our college community as a whole. Spending
time with and befriending these students is not just about delivering
an essential clinical service, but about what kind of people we want
to be and what kind of communities we want to create. (Welkowitz
& Baker, 2005, p. 186)
Mental health nurses with a strong tradition of person-centred
practice (more recently expressed through a recovery focus) and
who work within complex systems to promote integration are
ideally placed to support the broader university staff’s under-
standing of, and efficacy in, working with students with autism.
Mental Health Nurses are suitably qualified to be employed
on learning support teams. The context of supporting students
with autism also provides an opportunity for nursing faculty ser-
vice to the university community through consultation or direct
support of students. In Australia, community service is often a
component of academic workload models.
Currently significant differences exist between K-12 and
post-secondary education for students with autism. In K-12
schooling, students are supported with individualised education
programs that provide a comprehensive structure for support
services and accommodations. These are typically determined
collaboratively in an Individual Education Plan through con-
667
versations among the student, parents, the school counsellor,
teachers, and other school personnel that relieve the student
from negotiating educational services or academic accommo-
dations. Teachers are typically able, due to smaller class sizes,
to provide support for socially inappropriate behaviours, pro-
vide guidance for gaining perspective, and assist students when
experiencing sensory overload. This support, however, does not
generally occur in post-secondary education. Instead, the stu-
dent must navigate their own challenges, such as understanding
the perspective of others, integrating multiple streams of envi-
ronmental stimuli, and the complexities of social interactions.
This is often a greater challenge when students have become
accustomed to support in primary and secondary education and
is compounded by the fact that university/college personnel typ-
ically have neither the resources nor guidelines for best practise
when working with students with autism (Pillay & Bhat, 2012).
A survey of students with disability in one UK university
(n = 173) found that virtually no students declaring “unseen
disabilities” was either in contact with the Disability Coordina-
tor or in receipt of Disabled Students Allowance (Fuller, Healey,
Bradley, & Hall, 2004). The onus is usually on the student to ask
for support. This onus was not present in secondary education,
as parents played a greater role and school staffs were proac-
tive. Adapting to the new demand may require a degree of or-
ganisation and social competence not present. Support services
may need to be ready to either anticipate or identify problems
(MacLeod & Green, 2009).
In Australian universities, in order to obtain student support,
the student with autism is required to self-identify and submit
medical documentation that verifies the diagnosis while register-
ing with Disability Services. Ideally the student discloses their
autism diagnosis to Disability Services and this enables roles
played by a variety of other university personnel. These include
university counsellors, academic faculty, residential staff, and
peer mentors. Nursing faculty are ideally positioned to sup-
port counsellors, or in the form of faculty practice, to become
counsellors. Counsellors often have the most significant impact
and involvement with students with autism, due to their inti-
mate involvement with behavioural interventions. If prepared
and supported, counsellors may detect early warning signs of a
student they suspect may have autism and have failed to pro-
vide documentation or is without previous diagnosis, as well
as provide guidance regarding the benefits of disclosure. Gen-
erally, they work with Disability Services to liaise with faculty
to deliver suitable academic accommodations and can work
as a student’s advocate. Counsellors also may assist students
in developing strategies to compensate for impaired executive
functioning, such as time management; they can discuss strate-
gies or alternative behaviours to cope with sensory overload
and implement spaces such as safe zones where students can
retreat and de-escalate in times of overload. Counsellors may
discuss strategies that support better social behaviours and in-
crease self-advocacy and assertiveness skills. They may need
to educate students to recognise discrimination or harassment
 668 A. M. MULDER AND A. CASHIN
and teach them how to respond appropriately. Counsellors also
may support collaboration among the student, parents, Disabil-
ity Services, residential services, and faculty. When issues arise
between the student and faculty, counsellors may be able to
develop strategies that support the continued inclusion within
class and the development of new routines of behaviour by the
student if required, resulting in positive changes and a win-win
situation (Pillay & Bhat, 2012).
While academic faculty often do not automatically know
what accommodations a student requires, it is important that they
consult and collaborate with Disability Services to ensure that an
inclusive academic environment exists for students with autism.
It is important to note, though, that faculty must be assured that
they do not have to compromise the fundamental requirements,
standards, or essential functions of a course in a way that confers
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unfair advantage to a student or poses an undue burden on the
institution (Australian Government Attorney General’s Dept,
2005).
Residential staff are other university personnel who may be
invaluable for students with autism if given the appropriate ed-
ucation and support. While living at home can provide security,
it does not often support full engagement in university life. On
the other hand, residential life can be akin to constant exposure
to the worst aspects of high school, such as bullying, ridicule, or
social exclusion. Residential staff with appropriate knowledge
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about autism, and confidence in ways to assist students with
autism, are more likely to be understanding and to connect and
empathise with these students rather than judge their behaviours
(Pillay & Bhat, 2012).
University Accommodations
The support needs associated with autism are complex,
highly idiosyncratic, and often at odds with the individual’s
apparent capability. Sainsbury (2000) noted that in Asperger’s
original 1944 paper on Asperger Syndrome “one of his patients
had not only studied theoretical astronomy at university, but
also proved a mathematical error in Newton’s work” (p. 122).
However, the profile of abilities can be very uneven (Cashin
et al., 2009) and individuals can be emotionally immature and
lacking in practical skills expected of young adults. University
support services therefore face the challenge of being ready and
willing to adapt their existing systems so that they can respond
effectively to the individual needs of their students with autism.
In Australia, nursing faculty are well placed to support and re-
source Disability Services. This has the potential to provide
opportunities for faculty practice as well as better outcomes for
people with autism. Faculty practice could be through consul-
tation or direct service provision.
A vast range of accommodations are available at univer-
sity for students with disabilities, including those with autism.
These include academic support, counselling referral and spe-
cial advising, modified course load, priority registration, early
registration, or course substitute for a “required” course. Ac-
commodations associated with lectures and tutorials include the
use of a peer note taker, laptop computer, spell checker and
grammar checker, e-reader, read and write software, textbooks
on tape, screen reader, screen enlarger, listening device, and
priority seating, as well as access to notes from the lecturer,
tape-recorded lectures, course materials available in alternative
form, and advanced receipt of syllabus and course handouts.
Finally, examination accommodations include using a separate
room with minimal distractions, having access to priority seat-
ing, having extended time for the exam, having breaks during
the exam or having the exam administered in several sessions,
prioritising a specific time of day that is best for the student, us-
ing a reader to read directions and questions, receiving an oral
exam, dictating answers to a scribe or tape recorder, allowing a
student to mark responses on the test rather than on a Scantron
answer sheet, increasing the size of answer sheet bubbles, using
larger type, and using a word processor for written responses
(Hart et al., 2010; Pillay & Bhat, 2012; Roberts, 2010).
For students with autism who have sensory impairments, cop-
ing with the stress of overstimulating environments may mean
their safe spaces may need to be free from auditory and visual
overstimulation. Considering the sights, sounds, and crowds of
student facilities such as pubs and cafes, a safe space may be
the silence of the library (although this, too, has been found to
be too noisy for some students) or their own student accommo-
dation. However if there is a consistent lack of accessibility to
more appropriate social venues within the university, that may
be a cause for concern as it can socially and spatially constrain
the lives of students with autism. A UK study of 237 adults with
Asperger Syndrome found that for 77% of them social situations
were either extremely or very stressful (Beardon & Edmonds,
2007); it also has been recognised that living in a shrunken social
world can lead an individual with autism towards depression.
Students with autism who are not part of a social network can
be disadvantaged as they are less able to catch up on missed lec-
tures or seek clarification from other students (Taylor & Knott,
2007).
However, what also must be considered is the range of diver-
sity that exists underneath the diagnosis of autism. While some
people with autism crave being alone, others crave social inter-
action. Whatever the preference, students with autism should be
able to enter a variety of university spaces without confronting
triggers to hypersensitivities or anxieties, while still increasing
opportunities to socially engage in university life. Some suggest
that universities should provide alternative spaces for students
with autism to limit the risk of sensory overload, such as al-
ternative places to eat, and space to avoid noisy places. While
pragmatic, these suggestions also raise questions of concern re-
garding inclusivity and the marginalisation from conventional
university spaces because of these students’ impairment.
Having segregated eateries similar to segregated exams reaf-
firms the ghettoisation of an already excluded group of people.
Whether they eat in their own room or a designated eating place
they are alone and set apart from others; Madriaga (2010) says
 STUDENTS WITH AUTISM AT UNIVERSITY
this type of thinking reflects the dominant thinking of disabled
student support provisions within the UK higher education insti-
tutions. It is a base-level thinking, requiring minimum provision
for disabled students as opposed to best practice. To address this
issue, disability support practitioners should work with disabil-
ity student union representatives in planning alternative ways to
engage disabled students in student-led societies. For example
while many students with autism found orientation week very
stressful due to the noise and crowds, they should have the op-
portunity to attend a similar event without the noise and crowds
or have a choice of having mentoring support or a personal as-
sistant in attending such events. Having to exclude oneself from
university spaces due to the university’s misrecognition of im-
pairments is not reflective of inclusive practice. Achieving best
practice requires exploration and discussion with people to high-
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light examples of good practice, including social alternatives
that offset the effects of isolation and depression (Madriaga,
2010).
A UK study (Beardon, Martin, & Woolsey, 2009) of students
who self-disclosed Asperger’s Syndrome or high-functioning
autism (HFA) and who identified challenges at university (n =
135), explored their perceptions about challenges and support
at university. Note that not all the students had a formal diag-
nosis; 72% had been diagnosed with AS, 8% with HFA, and
the remaining 20% had not gone through a formal diagnosis.
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Forty percent of the students reported difficulties with social
interaction, including challenges relating to the need to com-
municate with others, such as in group work. Support involved
understanding neurotypical behaviour, and it was suggested that
since understanding is a two-way process, an understanding of
autism for neurotypicals could be of benefit. Twenty-one percent
of the students identified challenges in the social environment,
challenges arising from expectations, activities, and the pres-
ence of others (e.g., physical proximity and sensory distraction).
Twenty-six percent of students identified challenges with course
structure or curriculum demands. These related to practical ac-
tivities, rigid assessment criteria, organisational requirements,
and flexible programs of study. Twenty-four percent of students
identified challenges related to their own or other peoples’ un-
derstanding of AS/HFA (Beardon et al., 2009).
Another study involving comments by eight students in the
UK with Asperger’s Syndrome, reported a variety of impedi-
ments to learning in higher education, which included: barriers
in lectures related to understanding; barriers participating in
group work; and issues with assessment, including doing as-
signments and taking exams. Conclusions of the study were that
higher education institutions need to conjure creative and more
inclusive ways of engaging students with AS in learning and as-
sessment. While well-intentioned, adoption of minimum levels
of provision for students with disability, such as not assigning
group work or constructing separate catering outlets for students
with AS, may actually perpetuate marginalisation (Madriaga &
Goodley, 2010).
669
Integration of Students with Autism into University
In order to further understand peer responsiveness to stu-
dents with autism, a US study (n = 652) examined college
students’ openness toward peers who demonstrated behaviours
characteristic of autism (Nevill & White, 2011). It was identi-
fied that students who reported having a first-degree relative with
autism obtained significantly higher openness scores, perhaps as
a function of increased exposure and understanding of autism.
In terms of college major, engineering students indicated the
most comfort yet, incongruently, also the most fear about being
around peers with autism. Physical sciences students (biology
and mathematics) indicated the highest willingness to spend
their free time with a peer with autism and the strongest belief
that the person would be likeable and possess an equal level of
intelligence to them. Social science students (psychology and
sociology) received the lowest fearfulness score and indicated
the least concern about having peers with autism living in the
hall of residence. This is possibly due to the curriculum em-
phasis on the understanding of diversity and varying personality
attributes in the building of social environment. As a result,
these students showed the most acceptance of others regardless
of their background. Those from the “other major” category had
the highest belief that students with autism were different from
themselves. These results suggest that greater awareness and
education about autism and its increased prevalence within the
university population could improve peer responsiveness toward
students with autism.
Further education and awareness could be undertaken, partic-
ularly during World Autism Awareness Month in April, aimed
at academic faculty and peers. Education of university staff
and providing information on the perspective of a student with
autism and steps that support success in the classroom would be
prudent. In addition, information on autism could be included in
appropriate academic courses such as Introductory Psychology,
which would greatly enhance understanding and openness. Peer
mentoring programs could be implemented to help students de-
velop social, academic, and daily living skills, all of which may
be impaired in those with autism, and peer support groups for
students with autism could be established to enable students
with similar experiences to connect (Nevill & White, 2011).
CONCLUSION
Increased diagnosis and, therefore, prevalence of autism
means there will be an ever-increasing number of students enter-
ing university in Australia and elsewhere with additional support
needs specifically tailored to autism. In addition the Disability
Discrimination Act and the Australian Disability Standards for
Education have placed responsibility with institutions to pro-
mote access to inclusive education. Mental health nurses are
well-placed to lead and evaluate the development of transi-
tion programmes from school to university to support access,
and to work with university staff to promote accommodations
 670 A. M. MULDER AND A. CASHIN
conducive to inclusiveness. This could include both consultation
and direct service provision. Research is urgently needed to eval-
uate the success of such interventions, particularly in light of the
low participation rates of people with autism in study and work.
Declaration of Interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the paper.
REFERENCES
American Psychiatric Association. (1952). Diagnostic and statistical manual of
mental disorders. Washington, DC: Author.
American Psychiatric Association. (1968). Diagnostic and statistical manual of
mental disorders (2nd ed.). Washington, DC: Author.
American Psychiatric Association. (1980). Diagnostic and statistical manual of
mental disorders (3rd ed.). Arlington, VA: Author.
Issues Ment Health Nurs Downloaded from informahealthcare.com by Gazi Univ. on 05/01/15
American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of
mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Asperger, H. (1944). Die autistischen psychopathen im kindesalter (The
autistic psychopathology of childhood). Archiv fur Psychiatrie und Ner-
venkrankheiten (Archives of Psychiatric and Nervous Dieases), 117,
76–136.
Australian Bureau of Statistics. (2009a). Australian Social Trends, cat. no.
4102.0. Canberra, Australia: Author.
For personal use only.
Australian Bureau of Statistics. (2009b). Autism in Australia, cat. no. 4428.0.
Canberra, Australia: Author.
Australian Bureau of Statistics. (2013). Population Clock. Retrieved from
www.abs.gov.au
Australian Government. (2005). Disability Standards for Education 2005.
Attorney-General’s Department, Department of Education, Science and
Training.
Baron-Cohen, S., Scott, F. J., Allison, C., Williams, J., Bolton, P., Matthews,
F. E., & Brayne, C. (2009). Prevalence of autism-spectrum conditions:
UK school-based population study. British Journal of Psychiatry, 194(6),
500–509. doi: 10.1192/bjp.bp.108.059345
Beardon, L., & Edmonds, G. (2007). ASPECT consultancy report: A national re-
port on the needs of adults with Asperger Syndrome. Sheffield, UK: Asperger
Syndrome People Contributing for Themselves (ASPECT).
Beardon, L., Martin, N., & Woolsey, I. (2009). What do students with Asperger
syndrome or high-functioning autism want at college and university (in their
own words). Good Autism Practice, 10(2), 35–43.
Camarena, P. M., & Sarigiani, P. A. (2009). Postsecondary educational aspi-
rations of high-functioning adolescents with autism spectrum disorders and
their parents. Focus on Autism and Other Developmental Disabilities, 24(2),
115–128. doi: 10.1177/1088357609332675
Cashin, A., Sci, D. A., & Barker, P. (2009). The triad of impairment in autism re-
visited. Journal of Child and Adolescent Psychiatric Nursing, 22(4), 189–193.
doi: 10.1111/j.1744–6171.2009.00198.x
Cashin, A., & Waters, C. (2006). The undervalued role of over-regulation
in autism: Chaos theory as a metaphor and beyond. Journal of Child
and Adolescent Psychiatric Nursing, 19(4), 224–230. doi: 10.1111/j.
1744-6171.2006.00075.x
Cederlund, M., Hagberg, B., Billstedt, B., Gillberg, I., & Gillberg, C. (2008).
Asperger syndrome and autism: A comparative longitudinal follow-up study
more than 5 years after original diagnosis. Journal of Autism and Develop-
mental Disorders, 38, 72–85. doi: 10.1007/s10803-007-0364-6
Centers for Disease Control and Prevention. (2007). Prevalence of autism spec-
trum disorders—autism and developmental disabilities monitoring network.
14 sites, United States, 2002, surveillance summaries. Morbidity and Mor-
tality Weekly Report, 56(SS-1), 12–28.
Commonwealth of Australia. (2011). National disability strategy. Canberra,
Australia: Author.
Davidovitch, M., Hemo, B., Manning-Courtney, P., & Fombonne, E. (2013).
Prevalence and incidence of autism spectrum disorder in an Israeli popula-
tion Journal of Autism and Developmental Disorders, 43(4), 785–793. doi:
10.1007/s10803-012-1611-z
Duffy, C., & Healy, O. (2011). Spontaneous communication in autism spectrum
disorder: A review of topographies and interventions. Research in Autism
Spectrum Disorders, 5(3), 977–983. doi: 10.1016/j.rasd.2010.12.005
Eaves, L., & Ho, H. (2008). Young adult outcome of autism spectrum disor-
ders. Journal of Autism and Developmental Disorders, 38, 739–747. doi:
10.1007/s10803-007-0441-x
Fortea Sevilla, M., Escandell Bermudez, M., & Castro Sanchez, J. J. (2013).
Estimated prevalence of autism spectrum disorders in the Canary Islands.
Anales de pediatria, 79(6), 352–359. doi: 10.1016/j.anpedi.2013.04.022
Fuller, M., Healey, M., Bradley, A., & Hall, T. (2004). Barriers to learn-
ing: A systematic study of the experience of disabled students in one
university. Studies in Higher Education, 29(3), 303–317. doi: 10.1080/
03075070410001682592
Happé, F., & Frith, U. (2006). The weak coherence account: Detail-focused
cognitive style in autism spectrum disorders. Journal of Autism and Devel-
opmental Disorders, 36(1), 5–25. doi: 10.1007/s10803-005-0039-0
Hart, D., Grigal, M., & Weir, C. (2010). Expanding the paradigm: Postsecondary
education options for individuals with autism spectrum disorder and intel-
lectual disabilities. Focus on Autism and Other Developmental Disabilities,
25(3), 134–150. doi: 10.1177/1088357610373759
Howlin, P. (2003). Outcome in high functioning adults with autism with and
without early language delays: Implications for the differentiation between
autism and Asperger syndrome. Journal of Autism and Developmental Dis-
orders, 33, 3–13. doi: 10.1023/A:1022270118899
Howlin, P. (2004). Autism and Asperger syndrome: Preparing for adulthood.
London, UK: Routledge.
Hwang, Y., Weng, S., Cho, C., & Tsai, W. (2103). Higher prevalence of
autism in Taiwanese children born prematurely: A nationwide population-
based study. Research in Developmental Disabilities, 34(9), 2462–2468. doi:
10.1016/j.ridd.2013.05.019
Idring, S., Rai, D., Dal, H., Dalman, C., Sturm, H., Zander, E., . . . Magnusson, C.
(2012). Autism spectrum disorders in the Stockholm Youth Cohort: Design,
prevalence and validity. Plos One, 7(7). doi: 10.1371/journal.pone.0041280
Janiga, S., & Costenbader, V. (2002). The transition from high school to post-
secondary education for students with learning disabilities: A survey of
college service coordinators. Journal of Learning Disabilities, 35(5), 462–
468.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2,
217–250.
Kim, Y., Leventhal, B., Koh, Y., Fombonne, E., Laska, E., Lim, E., . . .
Grinker, R. (2011). Prevalence of autism spectrum disorders in a total
population sample. American Journal of Psychiatry, 168(9), 904–912. doi:
10.1176/appi.ajp.2011.10101532
MacLeod, A., & Green, S. (2009). Beyond the books: Case study of
a collaborative and holistic support model for university students with
Asperger syndrome. Studies in Higher Education, 34(6), 631–646. doi:
10.1080/03075070802590643
Madriaga, M. (2010). “I avoid pubs and the student union like the plague’:
Students with Asperger syndrome and their negotiation of university spaces.
Children’s Geographies, 8(1), 23–34. doi: 10.1080/14733280903500166
Madriaga, M., & Goodley, D. (2010). Moving beyond the minimum: So-
cially just pedagogies and Asperger’s syndrome in UK higher educa-
tion. International Journal of Inclusive Education, 14(2), 115–131. doi:
10.1080/13603110802504168
Nevill, R. E. A., & White, S. W. (2011). College students’ openness
toward autism spectrum disorders: Improving peer acceptance. Journal
 STUDENTS WITH AUTISM AT UNIVERSITY
of Autism and Developmental Disorders, 41(12), 1619–1628. doi: 10.1007/
s10803-011-1189-x
Pillay, Y., & Bhat, C. (2012). Facilitating support for students with As-
perger’s syndrome. Journal of College Student Psychotherapy, 26, 140–
154.
Roberts, K. (2010). Topic areas to consider when planning transition from
high school to postsecondary education for students with autism spectrum
disorders. Focus on Autism and Other Developmental Disabilities, 25(3),
158–162. doi: 10.1177/1088357610371476
Sacks, O. (1986). The man who mistook his wife for a hat. London, UK: Picador.
Saemundsen, E., Magnusson, P., Georgsdottir, I., Egilsson, E., & Rafnsson, V.
(2013). Prevalence of autism spectrum disorders in an Icelandic birth cohort.
BMJ, 3(6). doi: 10.1136/bmjopen-2013–002748
Sainsbury, C. (2000). Martian in the playground. Bristol: UK: Lucky Duck
Publishing.
Senju, A. (2012). Spontaneous theory of mind and its absence in autism spectrum
disorders. Neuroscientist, 18(2), 108–113. doi: 10.1177/1073858410397208
Shattuck, P., Narendorf, S., Cooper, B., Sterzing, P., Wagner, M., & Tay-
Issues Ment Health Nurs Downloaded from informahealthcare.com by Gazi Univ. on 05/01/15
lor, J. (2012). Postsecondary education and employment among youth
For personal use only.
671
with an autism spectrum disorder. Pediatrics, 129(6), 1042–1049. doi:
10.1542/peds.2011–2864
Stallman, H. M. (2010). Psychological distress in university students: A compar-
ison with general population data. Australian Psychologist, 45(4), 249–257.
doi: 10.1080/00050067.2010.482109
Suren, P., Bakken, I., Lie, K., Schjolberg, S., Aase, H., Reichborn-Kjennerud, T.,
. . . Stoltenberg, C. (2013). Differences across counties in the registered preva-
lence of autism, ADHD, epilepsy and cerebral palsy in Norway. Tidsskrift for
den Norske lageforening: Tidsskrift for Praktisk Medicin, ny Rakke, 133(18),
1929–1934. doi: 10.4045/tidsskr.13.0050
Taylor, A., & Knott, F. (2007). Developing a diagnostic and support service for
students with Asperger syndrome at university. Good Autism Practice, 8(2),
9–16.
Welkowitz, L., & Baker, L. (2005). Supporting college students with Asperger’s
syndrome. In L. Welkowitz & L. Baker (Eds.), Asperger’s syndrome: Inter-
vening in schools, clinics, and communities (pp. 173–187). Mahwah, NJ:
Laurence Erlbaum.
Wing, L. (1996). The autistic spectrum: A guide for parents and professionals.
London, UK: Constable.