1. Introduction

Autism, is indeed a phenomenon that can no more be ignored. Whether it is “a global health crisis that knows no borders”[^1], or it is just “a variation in functioning and a different way of being”^[2], autistic people need to receive full support and to fulfil their needs to achieve a happy, meaningful life^[3]. This involves equal and fair opportunities in employment, housing, education, healthcare and more.^[2,4]

Autistic people also have the right for social inclusion. Online interaction helps autistic people develop social relationships through, blogs, online communities, social networks and e-mails. It gives them the opportunity to interact with each other and interact with other people. However, online-only relationships cannot allow autistic individuals to take part in shared activities and recreation. Thus, providing autistic people with the help and support they need to engage in face-to-face social interaction is essential.^[5,6] This can be done through developing programs that would assist autistic people get involved in the physical social world, arranging social events and activities that would encourage them to interact or finally, planning tourism trips that would enhance their chances to interact socially with others during their vacations while providing them with all the support they would need to make these trips an enjoyable positive experience.

Most scientific researches that discuss autism focus on it from the medical point of view, investigating its causes, prevention, treatments and cure. Only few articles in the academic literature focus on the real-life of autistic people and the concerns that affect them. Enhancing the quality of life of autistic people needs that academic researchers shift their focus to the specific barriers autistic people experience and concentrate more on their social life and needs. Besides that, the majority of researches in the autism field focus on children, only few researches are concerned with the challenges facing autistic adults. Furthermore, researchers in the autism field still depend mostly, for gaining the information they need, on parents, caregivers and education experts to explore the needs and problems confronting the autistic individuals. Very few studies have tried to involve the autistic individuals themselves to discuss and explain their own problems. Thus, a very important part of these people’s lives is still vague for others. How they experience the world, what their priorities are, how they are affected by social inclusion and many other issues.^[2,7,8]

The same problems exist in the field of investigating how autistic people deal with travel and tourism issues. Travelling and having a tourism trip for an autistic person can be overwhelming as it involves changes in routine, anxiety and dealing with sensory issues. A very little research evidence shows how to best prepare an autistic person for travel. The majority of what is published on travel is concerned with children with physical or significant cognitive disabilities and is not specific to autism. Other articles are written by professionals in the autism field or parents according to what they believe to be true from their experience with autistic people.^[9]

The current research focuses on one of the areas affecting autistic people’s life. It highlights the role of tourism trips and activities in enhancing the autistic individual’s social inclusion and improving his quality of life. It suggests that tourism components and activities should be manipulated and tailored according to the autistic tourist’s needs, desires and capabilities. In addition, it recommends that tourism trips for autistic people would be planned and carried out by travel companies to ensure the availability of support, assistance and safety the autistic tourist needs during the trip. Moreover, the study proposes a method for travel companies to gain the information it would need about its autistic customer before planning the trip. This method involves a hypothetical model for a questionnaire that travel companies can follow. Furthermore, it recommends some strategic tips that can help travel companies in planning and implementing tourism trips for autistic people.

The importance of the current research and the difference between it and the previous researches concerned with autism is that it deals with one of the social aspects that affect autistic people’s real life. In addition, it is concerned specifically with autistic adults. Finally, it depends in the study section mainly on the autistic individuals own opinions, regarding the proposed questionnaire model and the strategic tips, and it did not only rely on family members and professionals’ experiences and thoughts.

2. Literature Review

This section explains the nature of autism from various aspects and reveals its prevalence worldwide.

2.1. What is Autism?

As people have become more aware of autism in recent years, a great debate has emerged around whether to deal with it as a serious health condition or as a variation of the human brain and a diverse way of brain functioning. The group who believes that autism is an epidemic sickness adopts what is known by “the medical model” or “the recovery movement”.^[2] On the other hand, the group embracing “the neurodiversity movement” appeared promoting to the idea that autism should be accepted as a variation in functioning rather than a mental disability. ^{[2,6,7,10,11]}

The following section discusses autism as a phenomenon presenting the viewpoint of both movements.

2.1.1. Autism from the Medical Model Perspective

Clinicians and specialists adopting this model view autism or autism spectrum disorders[ASD] as a developmental brain disorder. Their main goal is to find the route or the main cause of autism and defeat it. This path is known by “the recovery movement”^[2]

Autism from this perspective falls under a broader category known as pervasive developmental disorders[PDD]. PDD can cause delays in several areas of childhood development. PDDs involve: Autism spectrum disorder [ASD], Asperger’s Syndrome, Rett’s Syndrome, childhood disintegrative disorder and Pervasive developmental disorder not otherwise specified[PDD-NOS] ^{[12,13,14,15]}

All five PDDs have common characteristics in spite of their difference and that is why ordinary people and non-specialists mix them up and usually refer to any of them by using the term {autism}.

Yet, Autism specifically is defined according to the medical model as a complex developmental disability that results from a neurological disorder which affects the normal functioning of the brain. It significantly impacts communicative, social and behavioural development, often accompanied by abnormalities in cognitive functioning, learning, attention and sensory processing. The symptoms typically appear during the first three years of life. People affected by this disorder usually have poor eye contact, language delay and exhibit stereotyped or repetitive behavior. They ignore others, as they are unable to successfully communicate and interact with them, and often seem to be self-absorbed in their own private world.[^{1,14,15,16,17]} This has been the main reason for using The word autism to refer to this disorder which has got its origin from the Greek word “autos”, which means “self”.^[17]

Autism is often referred to as a spectrum disorder[ASD], meaning that the symptoms and characteristics of autism can reveal themselves in a wide variety of combinations and ranges from mild to severe. At one end of the spectrum of autism, individuals tend to have many challenging behaviours. At the other end individuals generally have greater cognitive abilities and can communicate relatively well with spoken language.

Thus, symptoms will present in each individual differently. Two individuals both with a diagnosis of autism can act very differently from one another. It is said that “if you know one person with autism; you know one person with autism.”^{[1,13,14,15,17,18]}

Causes for autism

The vast majority of cases of autism are “idiopathic” which means the cause is unknown.^[14] Arguments and theories around its causes go back to the year 1943 when it was first described by Dr. Leo Kanner, the psychiatrist as a unique condition. He believed that it was caused by rigid mothers. Dr. Bruno Bettelheim later adopted the same misleading interpretation of autism. During this period, autism was diagnosed as a psychological disorder and was classified under schizophrenia; the childhood type.^[2,8]

In the 1960s and 1970s, Dr. Bernard Rimland, the father of an autistic son, who later founded the Autism Society of America and the Autism Research institute, helped the medical society understand that the main cause for autism is not entirely social or psychological, but it is rather biological.^[14,19]

Specialists adopting the “medical model”^[2] started searching for the medical or biological cause for autism. Some suggest that medical problems, such as inflammation, gastro-intestinal or metabolic problems, may cause autism symptoms to manifest in the child’s brain. Others believe that autism is a genetic disorder.

Additionally, some researches took the path of investigating the relationship between the immune system and the behaviours related to autism. They assume that due to the weakness of immunity, the body systems get overloaded with environmental toxins, such as chemicals, bacteria and viruses, causing the autism symptoms to appear.

Moreover, many psychologists now consider sensory processing to be a major factor in ASD.^[2,13,14,20]

The best scientific evidence provided by the medical model so far suggests a potential for various combinations of factors causing autism: “Multiple genetic components may cause autism on their own or possibly when combined with exposure to certain environmental factors. Timing of exposure during the child’s development may also play a role in the development or final presentation of the disorder.”^[14]

Although autism is usually a life-long condition and its cause and cure are still anonymous, the symptoms may lessen over time and the long term outcome is highly variable. Some individuals may drop their diagnosis over time, while others may remain severely affected. The earlier the disorder is diagnosed and appropriate treatment interventions is offered to the child, the sooner a child can develop life skills to better perform and function more independently.^[14,21,22]

2.1.2. Autism from the Nuerodiversity Model Perspective

In recent years, the neurodiversity model has gained more acceptance as an alternative to the medical model. It has driven the interest of an increasing number of academic researchers to develop studies examining autism and autistic people from this perspective.^[5,7]

Autism from the neurodiversity perspective is considered as a form of human diversity and a different way of being that has its strengths and difficulties. Unlike the medical model, that describes autism as a neuro-developmental deficit or disorder, the neurodiversity model describes autism as a diverse way of brain functioning and atypical pattern of development other than the common developmental pattern that people are familiar with and hence call it “normal”. It argues that although neurotypical is the dominant neurological configuration, this does not mean that it is the only normal or best pattern as Blume (1998) suggests that Cybernetics and computer culture, for example, may favour a somewhat autistic mind.^[2,6,7]

Neurodiversity in this model is viewed as crucial and important for the human race as biodiversity for life in general. Furthermore, it has been reinforced by the idea of being similar to socio-diversity associated with the society’s acceptance and embrace of diversity in culture, ethnicity, religion, gender and nationality.^[7]

The neurodiversity model criticizes the medical model in the following aspects:

a) Portraying autistic people as individuals with a severe neurological disorder. The neurodiversity model describes them as individuals possessing cognitive strengths and weaknesses in these areas: “Language, communication and social interaction; sensory processing; motor skill execution and finally, goal-oriented, reflexive thinking, planning and self-regulation.”^[7]

b) The persistent focus on autistic people's weaknesses disregarding that living in a society designed for non-autistic people increases the challenges and barriers confronting autistic individuals, leading to more emphasis on their weaknesses.

c) The constant disregard of the autistic people’s cognitive strengths and talents, such as detailed thinking, expansive long-term memory, comfort with rules and the devotion for analysing complex patterns in the social and physical worlds, ignoring that these strengths allow autistic individuals to excel and even surpass the neurotypical people in certain fields such as information technology, math, science and even art and music.^[7,23]

All this has led to the emergence and growth of what is known by “the neurodiversity movement”, a social movement developed in the 1990s by groups of autistic people, caregivers, autism activists and advocates opposing the recovery movement. The movement later was associated with civil rights and was known by the autism right movement[ARM] .^[5,6]

“Nothing About Us Without Us” expresses the main theme of this movement.^[24]

What persuaded and reinforced this principle were autistic people who were able to express themselves and transfer their opinion to the nuerotypicals’ world. They transferred the idea that autism may be a disability or a disorder but for them it is just a different way of being. They also emphasized that autism is more challenging for neurotypical people rather than it is for autistic individuals as neurotypicals are the ones who doesn’t know how to deal with it , while, autistic people view it as a gift taking the form of a dilemma” .^[2]

The adopters of the neurodiversity movement believe in the equality of all mental states and refuse the medical model’s regard to learning and functioning differences as being a disorder or a dysfunction.^[10] The main goal of this movement is to achieve greater acceptance and full enclosure of autistic people in the society and to redirect the communities’ main focus and concern from searching for a cure for autism to finding ways to embrace autistic people in the society and help them achieve a happy and meaningful life that cope with their capabilities, interests and motivations.^{[ 6,25]}

2.2. Autism Prevalence

Autism emerges everywhere. It is not associated with a certain ethnicity, geographic area, social or economical level.

The World Health Organization (WHO) does not maintain global statistics on autism prevalence. The reason for this is that ASDs can occur along with other disabilities. In addition, autism diagnosis depends on behavioural observation rather than medical assessment, thus, obtaining accurate numbers on it is challenging.^[1,26]

However, some resources have succeeded in revealing estimates related to the ASD prevalence worldwide and in certain regions.

“Worldwide, population-based studies conducted before 1985 identified the prevalence of autism and related conditions among children under 18 years old to be approximately 0.5 per 1,000 children. The U.S. Centers for Disease Control and Prevention[CDC] most recent studies suggest that children meeting the autistic disorder criteria range in numbers up to 12 per 1,000 children” .^[1]

The prevalence is much higher among boys than among girls.^[14,15,27]

In this regard, there is an argument whether the reason for the significant rise in autism prevalence is only related to the increase in the population of autistic children or it is also associated with the better detection and the increase in diagnoses. Some recent studies suggest that autism prevalence has always been under estimated as the diagnostic criteria used for identifying it were much more immature in comparison with what is being used today.^{[ 4, 26]}

Other resources estimate that Approximately 67 million people are affected by autism around the world.^[1]

In the USA, According to the CDC’s most recent released numbers in April 2012 based on 2008 data, about one in 88 children has been diagnosed with ASD. The prevalence is 5 times more common among boys than among girls which means that 1 in every 54 boys and 1 in every 252 girls have an ASD diagnose.^{[3,4, 27]}

In addition, experts estimate that 11. 3 children per 1,000 have autism .^{[ 27]}

In Europe, studies have identified approximate prevalence rate of children diagnosed with ASD in certain countries such as Denmark 9 in 1000, Sweden 1in 188 and Finland 1 in 833. Studies in the UK estimate the prevalence to be 1% of their population.^[1]

In Asia, studies have revealed as well the approximate prevalence in some countries such as India 1 in 250, china 1.1 in 1000 and Japan 3 in 1000.^[1]

Furthermore, a recent study in South Korea reported a prevalence of 2.6% of their population. Prevalence in other regions is: Australia 6.25 in 1000, Canada 1 in 154 and Mexico 2 to 6 in 1000.^{[ 27]}

3. Autistic Right to Practice Tourism

Whether they are considered disabled or neurodiverse, autistic people have the right to maintain high quality of life. Researchers have identified eight core domains for the quality of life and their underlying indicators for people with disabilities and autistic individuals. Among these core domains are: Social inclusion that involves the engagement in community activities. Emotional well being that is based essentially on happiness, contentment and freedom from stress. Interpersonal relations which encompass interactions, friendships and support. Physical well-being that includes recreation and leisure.^[7,28,29]

Tourism can accomplish the four core domains and their indicators mentioned above as it is considered to be a human and social experience that comprises a group of activities which provide leisure, recreation and social interaction leading to the sensation of happiness, contentment and freedom of stress. Accordingly, tourism can be considered one of the autistic people’s rights and one of the main tools that can be utilized to enhance the quality of life of autistic people.

Furthermore, autistic people have the right to get the amount and kind of help they need to fully participate in all major aspects of life in the society. This requires manipulating the society in a way that would assist these people to be active members in it. To achieve this goal, a lot of restructuring is needed in the field of education, training, social support, public communication, transportation facilities, public recreation and many other services.^[23,30]

Tourism is one of these services that need to be restructured or re-organized with all its components, transportation, accommodation, sightseeing, recreation and other tourist activities, to suit and meet the autistic tourist’s needs and desires.

The following section demonstrates the challenges that can face the autistic tourist during a tourism trip.

4. The Challenges Facing the Autistic Tourist during the Tourism Trip

As mentioned before, there are great variations among autistic individuals. Thus, the specific services, accommodations, and support requirements needed for each autistic tourist depend on his own needs, challenges and preferences. Yet, there are several common challenges that usually present major obstacles for almost all autistic people in their daily life. These challenges are addressed in the following section.

4.1. Sensory Demands

Many autistic people process sensory informational input, received from vision, hearing, smell, taste, touch, balance and muscular feedback, differently from how non-autistic people do. The senses of an autistic individual can be hypersensitive to stimuli, presented in the person’s inability to tolerate certain ordinary sounds, textures, tastes and smells, or hyposensitive to stimuli, which might be apparent in the person’s increased tolerance for pain or his persistent need for sensory stimulation.^{[6,7,14,21,31,32]}

These sensory challenges can lead autistic people to feel overwhelmed during the tourism trip. The level and nature of sensory sensitivity may vary greatly under different circumstances and in different situations, depending on the autistic individual's level of stress, emotional state, and surroundings.^[6]

4.2. Stereotyped or Repetitive Behavior

Many autistic people reveal repetitive body movements or repetitive movement of objects. This behavior is common in many individuals with developmental disabilities; however, it is more apparent in autistic individuals. Some of them repeatedly flap their arms, flick their fingers, grind their teeth, walk on toes or rock their body back and forth while sitting. Some of them might spend hours lining up objects in a certain way, rather than using them for a purposeful task. These behaviors are usually referred to as[stimming] which is shorthand for[self-stimulation] .^[33,34] Repetitive behavior sometimes takes the form of a persistent, intense preoccupation or a strong interest in something. This strong interest may be unusual because of its attribute, such as being interested in fans or doors, or because of the intensity of the interest, such as being extremely interested in detailed information about vacuum cleaners or train schedules or having a great interest in numbers, letters, symbols, dates or science topics.^[14]

Repetitive behavior or stimming may increase during the trip due to routine change and getting overwhelmed or confused in new places.

4.3. Change in Routine

A tourism trip is typically based on going to a new place and having a change in ones routine. On the contrary, autistic people usually need consistency in their environment, a change in ones daily routine can be disturbing.^[14,21]

Thus, this issue should be taken into consideration while planning a tourism trip for an autistic person.

4.4. Communication Challenges

Autistic people have verbal and non-verbal challenges that affect their communication skills. Some of them remain mute throughout their lives, others may develop language as late as age five to nine. Even those who do speak, they often use language in an unusual way.^[21,35]

Without using an adequate means of communication, it is not possible to sufficiently express the individual wants, needs and preferences. In the meantime, assistive technology service provides the solution for autistic people to communicate throughout their daily routine. “Assistive technology service is any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device”.^[36]

Typically, autistic people process visual information easier than auditory information. Thus, assistive technology devices focus on giving the information visually, using various visual systems such as real objects, photographs, drawings and written words. These visual means can be used with various modes of technology, depending on which visual representation the autistic individual can comprehend. Furthermore, the systematic, logical, and detailed-oriented nature of assistive technologies, such as computers and other information technologies, makes them a natural fit for many autistic people. Information technologies can assist autistic people to plan and organize their lives, connect socially with other people, and participate in local communities.^[7,18,21,32]

Using assistive technologies can help minimize the communication challenge through the trip.

4.5. Social Interaction and Inclusion Difficulties

Social interaction difficulty is one of the challenges that can affect the autistic individual during the trip. As mentioned previously, an autistic individual may have a difficulty developing or maintaining an eye contact with others. He may resist attention and avoid people. He may not understand what others think or feel and may not understand their social cues, gestures and facial expressions. Thus, he is unable to predict or comprehend other people’s actions and reactions. This lack of understanding between the autistic individual and other people confuses him and may lead to an increase in his desire to be left alone or an increase in his repetitive behavior as a way of escape from his confusion”.^{[ 6,14,21,35]}

This choice of isolation converts the trip from an enjoyable experience to a negative experience.

4.6. Sleeping Problems

Some autistic people have trouble getting to sleep or sleeping through the night. This problem may get worse during the tourism trip as a result of the change in place and routine. Sleeping problems can form a challenge during the trip as it may drive the person’s bad mood leading to an increase in stimming, stress or lose of control”.^[14,21]

4.7. Medical Problems

Many autistic people have medical problems such as seizures and gastrointestinal disorders. About 39% of autistic people have seizure disorders”.^[14]

In addition, a very high percent of autistic individuals suffer from gastrointestinal (GI) problems such as chronic constipation, diarrhea or vomiting. The reason for some of these GI issues is allergy to certain food, such as milk, eggs, nuts and gluten or the intolerance to certain food textures”. ^[14,21]

Other autistic individuals have medical problems related to mental health such as depression, bipolar disorder, anxiety and schizophrenia”.^[7] These mental health-related conditions can affect their daily living and social activity. Thus, medical problems can form a challenge during the trip.

5. The Study

The key to a successful trip in general is preparation. Preparation for the autistic tourist differs from what is expected for others. An autistic person may require more assistance than others with planning and organizing his tourism trip”.^[37,38,39]

This planning can be related to choosing the suitable destination, means of transportation, accommodation, sightseeing, leisure activities and all other services. All these aspects should be chosen carefully and manipulated in the way that would suit the autistic tourist desires, needs and capabilities. Furthermore, the autistic tourist may also require assistance in prioritizing and scheduling the tourist activities included in the trip. Besides, his needs for more help and support with his daily activities during the trip.

Accordingly, planning and implementing the tourism trip through travel companies for autistic tourists might be the best option to ensure their gaining of assistance they need and ensure their safety.

In this case, the travel company needs to know all the information about its autistic customer that can assist it in tailoring and carrying out the tourism trip according to his own preferences. This could be done by providing the customer with a questionnaire to be filled out before planning the trip. This questionnaire should include all the inquiries the travel company would need to plan him the desired supported trip. Consequently, the travel company should plan and carry out the tourism trip according to a strategy that is designed specifically to meet its autistic customer’s needs, desires, capabilities and tolerances.

This study focuses on both the questionnaire the travel company should send to the autistic tourist before planning the trip and the strategy the travel company should plan and implement the trip according to it.

5.1. Methodology

The study encompasses two phases. The first phase involves designing a questionnaire as a hypothetical model for the questionnaire a travel company should send the autistic tourist to complete before planning the trip. It includes the suggested inquiries that the travel company would ask about to be able to plan and tailor the trip according to the autistic tourist’s responses.

“Nothing about us without us!”^[24] is the famous statement widely used by the international autistic self-advocacy communities to let everybody know that autistic people can take control of their lives. Thus, they have the right to get involved and to take part in all issues and aspects that concern them. Responding to this message, this study was keen to involve autistic individuals in it.

This is done through conducting a qualitative study that employs in-depth interviews with autistic adults to explore their opinions and recommendations about the questionnaire model. The main aim for this study is to investigate whether the inquiries included in the questionnaire model are sufficient to provide the travel company with all the information it should need or there are other things that should be added to make the questionnaire more inclusive from the autistic person’s perspective.

The study is conducted mainly through the online discussion forums of four online communities that are dedicated to autistic people. These online communities are: Wrongplanet.net, Talkaboutautism.org, Autismweb.com and Aspiesforfreedom.com. In addition, e-mail and direct correspondence is utilized to interview two autistic participants.

Regarding the second phase, it involves proposing strategic tips that would assist the travel company in planning and carrying out a supported tourism trip for its autistic customer. These strategic tips are composed according to previous readings of researches and articles written by researchers, autistic people or by a family member of an autistic person, in addition to the suggestions and preferences gathered from the autistic individuals participating in the first phase of the study.

Face to face in-depth interviews are conducted, in the United States of America, with professionals in the autism field and family members of autistic individuals to investigate their opinions concerning both the proposed questionnaire model and the strategic tips. In addition, the opinion of an Egyptian tourism expert in the travel companies’ business is taken concerning the general idea of planning and implementing tourism trips for autistic people through travel companies, the questionnaire model and the applicability of the recommended strategic tips.

5.2. Findings

Encouraging autistic adults to participate in the first phase of the study is considered a challenge that has confronted this research. Ten autistic adults accepted to participate by giving their opinions and suggestions concerning the questionnaire model. Five of them have even answered the questions mentioned in the questionnaire model giving the study more opportunity to explore their own preferences while being in a trip. All the responses received have been very useful. All the participants have agreed that the questionnaire model seems to ask all the right questions and cover all the inquiries that a travel company should know about its autistic customer to plan and implement the trip according to his needs and preferences. Some participants commented on the idea itself of planning and implementing the tourism trips through travel companies by stating that this would be the best way to guarantee a good experience for the autistic tourist as he will be always escorted by a tour leader and a tour guide that will tell him what to expect, how to be prepared and will always be there for help and assistance, especially, in foreign destinations where the autistic tourist does not know the language of the country.

In addition, some of them added some suggestions that were used in modifying the questionnaire and composing the strategic tips.

Four of the participants were from the same online discussion forum: Wrongplanet.net which is the most popular among autistic individuals and also the most well-known for non-autistic people. The fifth, sixth and seventh participants were from Aspies for Freedom.com. The eighth was from Talkaboutautism.org. And finally, the ninth and tenth participants responded via e-mail and direct correspondence.

The difficulty in obtaining responses from the autistic individuals in the first phase is the cause of choosing to only involve the experts and family members of the autistic individuals in the second phase, relying on their direct connection and experience with autistic people.

Two professionals in the autism field, a behavioral health consultant and a physical therapy specialist, and the members of two families of autistic individuals participated in the second phase of the study by giving their opinions and suggestions concerning the questionnaire model and the strategic tips.

The professionals in the autism field, the family members of the autistic individuals and the tourism expert, all declared that the questionnaire model is clear, concise, easy to follow and complete. In addition, it seems relevant to persons of any age, gender, sex or ethnicity and it covers all the topics needed to assist an autistic person and those accompanying him in a tourism trip. Concerning the strategic tips, they all agreed on its validity and relevancy and added that it has weight and significance.

The questionnaire model illustrated in table (1) and the strategic tips presented in this paper have been refined to take their final structure according to the suggestions and recommendations of the autistic participants, the autism professionals and the autistic family members.

5.3. The Strategic Tips for Planning Tourism Trips for the Autistic Tourist

This section proposes some strategic tips that can help travel companies in planning and implementing a tourism trip for the autistic individuals. However, it should be taken into consideration that autistic individuals are different from one another. Hence, what is considered to be good practice for one may not necessarily suit the other.

5.3.1. Identifying the Core Problem Areas of the Autistic Tourist

Arranging a trip for an autistic tourist should start with an understanding of his core problem issues^[38,39] such as sensory issues, sleep problems, health problems, verbal or non-verbal, food allergies and all other problems discussed in the previous section of the challenges that could face the autistic tourist during the trip. Being familiar with these problems will facilitate designing the trip to meet the autistic tourist needs and capabilities and help in preventing places and activities that can arouse these problems. Besides that, the travel company should identify the autistic individual’s interests and favorite activities to take this in to consideration while planning the trip.

The travel company should get this information before starting to arrange the trip. This could be done by providing the autistic tourist or his family with a questionnaire to fill it out, similar to the questionnaire model demonstrated in table (1) in this study. This questionnaire should include inquiries covering all the issues mentioned above.^[40,41]

It would also be preferable if the travel company send its autistic customer along with the questionnaire a deceleration stating that the customer’s information will remain confidential.

5.3.2. Choosing the Appropriate Destination

According to the information gathered from the questionnaire, the travel company can recommend the suitable tourism destination, type of trip and activities to the autistic tourist. Certain places might be more appropriate than others. It might also be better to avoid going to certain places that can trigger the autistic tourist problem issues. It all depends on the autistic individual’s needs, capabilities, level of exposure to outside activities and sensory tolerance .^[42] For example, the beach is typically a tourist favorite but could be an issue for an autistic individual if he has hyper-sensitive sensory problems. He might not tolerate one or more of the following: the sound of the waves, feeling of sand, wind, humidity, the taste of the water and the bright sun.^{[37,38,39,42,43]}

One of the autistic participants in the first phase of this study, among those who have chosen to answer the questions mentioned in the questionnaire model, declared that he cannot tolerate these issues. In such case, the beach should not be included in the tourist trip. On the other hand, if the autistic tourist has hypo-sensitive sensory issues and love the sensation of water and sand, then the beach should be on top of the recommendation list as it will offer the autistic tourist all his sensory needs and satisfy his desires. Another example, theme parks might be overwhelming for an autistic tourist who cannot bare noise, crowd or has sensory problems related to motion and balance. One of the autistic participants in this study declared that he avoids theme parks. However, it could be the perfect place for another autistic tourist who craves for more light, noise and motion sensation .^[44]

5.3.3. Choosing the Components of the Tourism Trip

After choosing the destination, comes the choice and arrangement of the components of the tourism trip. This includes: transportation, accommodation and tourist activities. All these components should be chosen and tailored carefully according to the information provided in the autistic tourist’s questionnaire to meet the tourist’s needs, desires and capabilities. Furthermore, the autistic tourist should be prepared in advance for what he may experience while going through each component.

The following paragraphs illustrate these components and suggest some tips for choosing them.

5.3.3.1. Transportation

This includes the main mode of transportation used for transferring the tourist from the origin to the destination, by air, sea or land. This paper will focus only on air as an example. Transportation also includes the mean used to transfer the tourist from a place to another within the destination such as cars and buses.

a) Travelling by air: Travelling by air may cause a great deal of stress to the autistic tourist along with every procedure that it involves; checking bags, navigating through airport security, waiting time before boarding, long queues for boarding and the boredom of the flight, especially, if it is his first time to travel by air.^[45,46]

The travel company can help minimize this stress by informing the airport and the airlines in advance about the tourist condition in order to provide him special services that might assist in making the experience as comfortable and stress-free as possible. This may involve a person to meet him, checking bag assistance, waiting in a special quiet spot in the airport, priority boarding and seating and special care and assistance during the flight.^[37,42,47]

Some airlines such as Northwest Airlines offer adult and needy passengers an assistance program for an extra fee. The program offers personal assistance through the crucial security checkpoints, check-in, boarding and through the destination airport.^[48] In addition, giving the tourist a visualization of what to expect at airport security can help prevent stress and lose of control. The travel company can provide that through information, images or videos sent to the tourist before the trip to give him an idea of what to expect and tips that can make this experience passes smoothly, such as advising the tourist not to wear belts with metal buckles or have coins in his pockets to help pass the security points quickly and easily or recommending wearing comfortable loose clothes during the flight. Moreover, if possible, the travel company can arrange with the airport a pre-visit for the autistic tourist as an orientation to air travel and go through a mock travel scenario including going through security points and even boarding an airplane. Some airports in the USA already offer this service for autistic individuals such Newark Liberty International, Columbus and Cincinnati airports.^[9,45,49]

Two of the autistic participants in this study stated that they have travelled frequently by air. In such case, the travel company would not need to prepare the autistic tourist for the airport experience.

Some of the air travel tips mentioned above can also be applied in sea and land travel.

b) Transportation within the destination: This can be by bus, mini-bus or limousine. Choosing this mean of transportation depends on the number of travellers with the autistic tourist and on his tolerance. For example, some autistic individuals cannot tolerate big buses because of sensory issues such as noise and motion sickness. In such case, mini buses or limousines are preferable. The autistic respondents to the questionnaire model declared that they prefer limousine on bus. One of them admitted that his cause for this is the noise that is often associated with bus trips.

In addition, regardless of which mean of transportation is used within the destination, it should be considered keeping the driving distance between the places visited on the same day to the minimum to avoid stress and exhaustion.^[42]

5.3.3.2. Accommodation

This component also needs to be selected carefully according to the information provided in the autistic tourist questionnaire. Accommodation can be an all inclusive resort, a hotel, a motel, a rental chalet or condo or even a cruise ship. This depends on the tourist budget, type of the trip and above all the tourist’s needs and tolerances. In general, most autistic individuals prefer quiet, uncrowded places.

Renting a condo can be an appropriate choice that relieves a lot of the potential stress. It allows the autistic tourist and his family to customize the rooms in the way that would comfort him and prepare his food within the facility. However, if the choice is a resort, a hotel or a cruise ship it is preferable to select smaller ones, less than 250 rooms in capacity.^[42,43,45]

The autistic respondents to the questionnaire model agreed on preferring small hotels and motels as they do not feel comfortable in big resorts and big hotels.

The travel company should arrange in advance with the accommodation facility the services needed for hosting the autistic tourist. Among these services are fast checking in, selecting the rooms located in quieter areas, reserving quieter spaces in the dining area during meals, faster service during meals, preparing special meals in case of food allergies or texture intolerance, providing a fridge or even a kitchenette in the room if eating there is a better option to avoid food allergy risks or overwhelming situations during meal times.^{[37,42,45,46]}

The autistic respondents have also agreed on preferring to have a bed and breakfast accommodation and they would be responsible for the rest of their meals. However, one of them stated that he would take a full board accommodation if the accommodation facility responds to his special needs in meals.

Greater autism awareness led some hotels especially in the USA to offer “autism-friendly accommodation”. Amοng thе services that they offer for autistic guests are autism-friendly rooms, specially trained staff, and special gluten аnd casein free meal options .^[46]

Moreover, some cruises offer individualized services for autistic guests. This includes an experienced cruise staff, priority boarding and disembarkation, private dining, special gifts and a pre-cruise questionnaire to help the onboard counselors, professional physicians and nurses.^[41]

5.3.3.3. Tourist Activities

Tourist activities involve leisure, adventure and sightseeing.^[45]

The tourism trip can include all these types or just one of them depending on the autistic tourist needs and tolerances.

A trip to the beach is a good choice for recreation and leisure and can be relaxing and enjoyable. Nature and Scenic areas is also a good option for some autistic people if it would meet their needs and tolerance level to the outside atmospheric conditions. Most of the autistic respondents to the questionnaire model declared that scenic areas offer them a calming and peaceful experience and that they love taking photographs for nature scenes.

On the other hand, theme parks offer a variety of recreational options that suit autistic individuals who crave for sensory activities. However, it also depends on the tourist’s needs, tolerance and the pre-arrangements that the travel company can settle with the administration staff before the visit to provide the tourist with the special services he need.^[38]

The adventure activities involve great deal of action. It may encompass visiting ranches, riding horses, safari, hiking and snow or sand skiing. Choosing whether to plan for an adventure activity for the autistic tourist or not and selecting the appropriate adventure activity also depends on his desires and capabilities. One of the autistic respondents stated that she loves adventure, especially, horse riding.

Regarding sightseeing; this involves visiting historical and cultural sites, museums, aquariums and art galleries. Sightseeing trips may suit many autistic people as they are passionate learners.

Most of the autistic respondents agreed on enjoying visiting cultural and historical sites.

It only needs preparing the autistic tourist, as everything else, for the experience. Visual guidebooks and photo books describing the site or illustrating the exhibits can help in this.^[50]

Some museums have started realizing this potential tourist and have dedicated some of its exhibits for serving him. The Metropolitan Museum of Art in New York City is one of these “Autism-Friendly Museums” as it offers small-scale gallery tours encouraging autistic individuals to use all their senses to discover the world of fine art.^[50]

However, if the site is not yet autism friendly, the travel company should arrange for the visit in advance with the administration to try to create a suitable atmosphere for the autistic tourist, such as planning for the visit to be at the off time, or early morning before the crowd.^[50]

The study also revealed that special interest tourism can be a good choice for some autistic tourists as two of the autistic respondents declared that they love bird watching and living the cultural atmosphere of certain places, in addition to trying their regional dishes.

In general, the travel company should consider the following tips while choosing and planning the tourist activities of the trip. First, it is preferable not to crowd the trip with too many activities and to keep it simple. In addition, limit the number of activities that will be done on the same day to a few number and consider keeping the driving distance between the places or the sites that will be visited on the same day to the minimum. Furthermore, if possible, arrange the autistic tourist’s visit to a certain place in off times: low season, early morning, late afternoon or the off day of the place, to prevent the crowded periods. Finally, allow plenty of relax time or “downtime” at the accommodation facility during the day.^[45] Applying these rules can help in preventing the trip from being overwhelming or exhausting for the autistic tourist.^{[37,42,45,49,51,52]}

5.3.4. Introducing the tourism trip to the tourist

As mentioned before, preparation is very important in the case of dealing with an autistic tourist. One of the areas that need preparation is preparing the tourist himself for the experience and the place he will spend his vacation in. This step is essential to prevent the autistic tourist’s confusion in the new place and avoid the problems that can result from the change in his routine. Introducing the destination and the tourism trip to the tourist could be done by offering him a video, brochure or book of the destination to prepare him for what he will be seeing and what to expect during the trip. This should be done within a sufficient time before the trip to give the autistic tourist the chance to grasp the details.^{[43,45,47,52,53]}

5.3.5. Avoiding Stress during the Trip

Despite, choosing the appropriate components for the trip that go with the autistic tourist needs and tolerances, other procedures should be done to make these components even more autism-friendly. For example, one of the autistic respondents declared that crowds, noises and bright lights can be very confusing, especially, in new places. Hence, making some adjustments to the surrounding physical environment to decrease the overload resulting from sensory issues is essential. These adjustments may include but not limited to modifications in the accommodation facility such as dimming or removing fluorescent lights from the hotel room. Another example is the use of compensatory sensory-assistive tools that some autistic individuals may need, such as sunglasses to reduce visual glare indoors and headphones that filter out background noise while still permitting them to listen to conversations.^[6,39,44]

One of the respondents explained that using these tools during the trip is a very good idea to reduce the sensory challenges.

Another tip that can prevent overwhelming situations is avoiding long lines and queues in tourist sites. This could be done through arranging in advance with the guest service of these places to provide the autistic tourist with a special “guest assistance card” that could allow him not to wait in queues for entering the site or enjoying any of its sections. Disney World and many other theme parks apply this policy.^{[ 39,44,45,,52]} Moreover, in restaurants during meal times, it is useful to pre-arrange for priority seating and to have the autistic tourist table near an exit or a window.^{[ 44]}

All the adjustments mentioned above are helpful for decreasing the sensory challenges during the trip. However, an autistic tourist may still experience overload from his sensory system at certain times. Hence, the trip should include the option of having short free times that can be spent in a clam space to reduce one’s stress when a period of sensory overload occurs.^{[ 6,44,49,,51]}

5.3.6. Controlling the Impacts of Change in Routine

Change in the autistic person’s routine can lead to his confusion, increase in stimming or lose of control during the trip. This can be prevented by arranging the tourism components encompassed in each day in the form of a routine that the autistic tourist would follow throughout the day.^{[ 54]}

This routine even includes organizing free time. Furthermore, using tools that would help introduce the description and timing of every component included in the trip can help maintain order and stability in the autistic tourist’s day. These tools include brochures, showing every place that will be seen or visited during the trip and even the routes and modes of transportation, demonstrated by photos, visual schedules, day-planners, calendars, tasks lists, organizers, checklists and maps.^{[ 6,9,49]}

Videos could also be used for preparing the autistic tourist for what he will be seeing and what to expect during the trip. This tool can be used, as mentioned above, initially before starting the trip for describing the entire trip. It can be used again daily before leaving the accommodation facility to inform the tourist about the tour of the day. Furthermore, it could be used while transferring the tourist from a place to the other, to describe the place that he is heading to before seeing it. Two of the respondents mentioned that they would appreciate using such tools as they would always need to know what is going to happen next during the trip.

5.3.7. Encouraging Communication and Social Interaction

The travel company can organize certain events; excursions, short picnics or even a night dedicated specifically for encouraging the autistic tourist to interact socially with the staff members of the company or the accommodation facility, giving him a sense of accomplishment and reinforcing his desire to communicate with others in general. These events may involve social play, group discussion, sensory activities, sports, photography, arts and crafts and even assisting in preparing meals. This can be applied under the supervision of professionals or therapists in physical, occupational, speech, art or music fields.^{[ 44,55]}

On the other hand, both the autistic respondents in this study and previous papers agreed that using assistive technology devices, such as travel dry erase board, sticky notes with simple language on each, a typing program on a phone, tablet, laptop or a notebook, can help encourage the autistic tourist to communicate his basic needs, emotions and opinions during these events in particular and through the whole trip in general.^{[ 7,21,49]}

5.3.8. Managing Sleeping Problems

To try to manage this problem during the trip, “sleep –hygiene”^[14] should be taken into consideration while planning the trip. This involves limiting the amount of sleep during the day. Breaks and free or off times during the day are very important for the autistic tourist to self-regulate and cope with his environment. However, it could be utilized for spending quiet time or practicing a sensory activity rather than taking a nap. It may also be helpful to maintain the regular bedtime routine of the autistic individual during the trip to minimize the effects of the sleeping problems.^{[ 14,45,51]}

5.3.9. Dealing with Medical Problems

This needs preventive steps to avoid its occurrence and emergency readiness to face it if it happens.

Concerning the preventive steps; the travel company has to have all the information concerning the autistic tourist medical problem, medications and doses before starting the trip. In addition, it has to ensure that the autistic tourist who has seizures or a mental health problem brings his medications with him during the trip. On the other hand, pre-arrangements should be made for the autistic tourist who has food problems. This involves the special meals needed for the tourist with certain food allergies such as dairy-free meals and gluten-free meals and the special meals needed for the tourist who cannot tolerate certain food texture such as purees, yogurt and jello. Another option is to give the autistic tourist the facility of preparing his food by himself or through his family in his room.^{[ 39]}

Regarding the emergency readiness; this includes making pre-arrangements with a specialist or a nurse practitioner to be ready for dealing with unexpected medical emergencies, such as unexpected seizure fits or unpredicted sickness, by taking all necessary safety procedures and being always prepared with the needed rescue medications. In case of hospitalization, the travel agency needs to provide the hospital with all the information related to the tourist’s medical problem.^{[ 40]}

5.3.10. Planning for Other Safety Issues

Undesirable coincidences might happen during the trip such as losing contact between the tourist and the travel company’s representative or the tour leader in any place. Certain precautions should be arranged to prevent that. The travel company should prepare an identification card with the tourist’s name, recent photo, diagnosis, hotel address and phone number to contact and anything else a person might need to know to keep him safe and calm until the travel company gets him back safely. This ID card should be carried with the autistic tourist all the time whether he is verbal or non- verbal. The telephone number of the tour leader should be pre-programmed into the autistic tourist phone as a speed dial number. The tour leader should also carry a recent photo of the autistic tourist all the time during the trip.^{[ 9,45,47,48]}

One of the respondents stressed on the importance of these precautions for his safety during the trip.

5.3.11. Considering Flexibility through the Whole Trip

Even the best laid plans can go out of control in certain points, especially with an autistic person. This can happen due to a medical emergency, fatigue, over stimulation or any other reason. Hence, while tailoring the trip, the travel company should consider a great deal of flexibility and alternative plans to be prepared for dealing with any risks or unexpected changes during the trip.^{[ 43]}

Taking these tips into consideration while planning the trip, enhances the autistic tourist’s chances for enjoying a positive tourist experience.

Table (1). A hypothetical model for the questionnaire provided by the travel company to the autistic tourist

6. Conclusions

This study has shown the importance of engaging autistic people in the tourism activity. It has suggested that travel companies would plan and carryout tourism trips for the autistic individuals, manipulating all the components of the trip to suit and meet the autistic tourist’s desires, needs, capabilities and tolerances.

As mentioned previously, the study has presented a hypothetical model for a questionnaire that can be used by the travel companies as a method for gaining all the information that it would need from the autistic customer to plan his trip according to his own needs and preferences.

In addition, the study has proposed some strategic tips that can help the travel companies in planning and implementing tourism trips for the autistic individuals.

Both the questionnaire model and the strategic tips have gained approval and support from autistic adults, professionals in the autism field, family members of autistic individuals and the tourism professional.

ACKNOWLEDGMENTS

The author would like to acknowledge Mrs. Kathryn Towsley, Behavioral Health Consultant; Mrs. Valerie Spoerl, Physical Therapy Specialist and Mr. Mohamed Hamed, Tourism Expert, for participating in the study with their precious opinions. The author would also like to thank all the autistic participants in this study that due to confidentiality their names cannot be mentioned.

Endnotes

1. It was chosen in this paper to use “identity-first” language in referring to “autistic people” rather than calling them “people with autism” using “person-first” language since identity-first language is widely preferred by the international autistic self-advocacy community .^{[ 6,7]}

2. In this paper Travel companies refer to both tour operators and travel agencies.