Heightened risk of posttraumatic stress disorder in adults with autism spectrum disorder: The role of cumulative trauma and memory deficits

Experiences of interpersonal victimization and abuse among autistic people

LAY ABSTRACT

What do we already know?Autistic people are more likely to have negative life experiences than non-autistic people, from bullying and ostracization, to being victims of crime, to unemployment and homelessness. This includes being victims of intimate partner violence, sexual assault and domestic abuse. Quantitative work has suggested that as many as 90% of autistic people experience these forms of abuse in some form during their lives, but there is little work asking them to talk about harmful relationships in their own words.What does this article add?This article reports on interviews with 24 autistic adults about their experiences of being victims of intimate partner violence, sexual assault and/or domestic abuse. Some of the themes which came from these interviews are shared with non-autistic victims, but others appeared unique to autistic people. One of these was evidence for unique autism-related vulnerabilities, as well as the impact the abuse had on their relationships long term. Participants also talked about how the sex and relationship education they had received had inadequately prepared them for adult relationships, and how this had contributed to their struggle to recognize and react to abusive behaviour.Implications for practice, research and policyPolicies around intimate partner violence and sexual assault need to be updated to account for the different ways in which neurodivergent people (people whose brains process information differently from the majority) may discuss their experiences, rather than looking for 'standard narratives' as an indicator of a need for support. Relationship and sex education should be tailored for autistic young people to help them recognize abusive behaviours, and include how to respond to these safely. We recommend that future research tries to focus specifically on the abuse experiences of autistic men, non-binary and trans people, who have been under-represented in studies to date. In addition, much less is known about the abuse experiences of autistic people of colour or autistic people with intellectual disabilities, who also need to be actively included in these discussions.

Adverse Childhood Experiences and Autism: A Meta-Analysis

Evidence suggests that autistic children have a higher probability of experiencing adverse childhood experiences (ACEs) compared to their non-autistic peers. This meta-analysis (PROSPERO: CRD42022262635) aimed to quantify the association of autism and ACEs. Eight databases and Google Scholar were searched for studies that reported dichotomous outcomes regarding the associations between ACEs and autistic individuals, compared to non-autistic individuals. A random-effects model was used to calculate the average Odds Ratio (OR) of the relationship between a diagnosis of autism and ACEs. A total of 40 studies with 5,619,584 participants were included, generating an overall average OR 2.11 (CI 1.61, 2.77). Significant differences in the magnitude of association were found across studies with regards to the type of ACEs studied, comparison groups, and population type. Overall, moderate certainty evidence (downgraded for bias) indicates that autistic individuals are at greater risk of experiencing ACEs, compared to non-autistic individuals. Appropriate support for autistic individuals and their families are required to prevent ACEs and treat the impact of ACEs.

Parvalbumin interneuron activity in autism underlies susceptibility to PTSD-like memory formation

A rising concern in autism spectrum disorder (ASD) is the heightened sensitivity to trauma, the potential consequences of which have been overlooked, particularly upon the severity of the ASD traits. We first demonstrate a reciprocal relationship between ASD and post-traumatic stress disorder (PTSD) and reveal that exposure to a mildly stressful event induces PTSD-like memory in four mouse models of ASD. We also establish an unanticipated consequence of stress, as the formation of PTSD-like memory leads to the aggravation of core autistic traits. Such a susceptibility to developing PTSD-like memory in ASD stems from hyperactivation of the prefrontal cortex and altered fine-tuning of parvalbumin interneuron firing. Traumatic memory can be treated by recontextualization, reducing the deleterious effects on the core symptoms of ASD in the Cntnap2 KO mouse model. This study provides a neurobiological and psychological framework for future examination of the impact of PTSD-like memory in autism.

Post-traumatic stress disorder and experiences involving violence or sexual abuse in a clinical sample of autistic adults with intellectual disabilities: Prevalence and clinical correlates

LAY ABSTRACT

Post-traumatic stress disorder is a mental health disorder that may be triggered by the experience of events perceived as terrifying or overwhelming. Examples of such events include being the victim of violence or sexual abuse. Compared with other people, autistic people have increased risk of being exposed to violence or sexual abuse. In addition, autistic people may be more vulnerable to developing post-traumatic stress disorder following such exposure. However, knowledge is limited concerning the prevalence of experiences involving violence and sexual abuse, and post-traumatic stress disorder, in autistic people with co-occurring intellectual disabilities. Detection of these experiences, and identification of post-traumatic stress disorder, may be challenging in these individuals, and previous research indicates that post-traumatic stress disorder symptoms may be overlooked or misinterpreted. In this study, we examined prevalence of post-traumatic stress disorder, violence and sexual abuse in a clinical sample of 88 autistic adults with intellectual disabilities referred for mental health assessment. Only 3.4% were diagnosed with post-traumatic stress disorder, even if experiences involving violence (34.1%) or sexual abuse (17.0%) were common. Anxiety and affective disorders were common diagnoses among participants with these experiences. Controlling for autism characteristics, level of intellectual disability and communication skills, experiences of violence/sexual abuse were found to be associated with a measure of 'challenging' behaviours. These results indicate that potentially traumatic experiences are common in autistic adults with intellectual disabilities referred for mental health assessment, and that post-traumatic stress disorder may be under-recognised. The findings highlight the importance of trauma screening and post-traumatic stress disorder assessment, as well as the importance of trauma-informed care, in this population.

Measuring and validating autistic burnout

Researchers have begun to explore the characteristics and risk factors for autistic burnout, but assessment tools are lacking. Our study comprehensively examined and compared the psychometric properties of the unpublished 27-item AASPIRE Autistic Burnout Measure (ABM), and personal and work scales of the Copenhagen Burnout Inventory (CBI) to evaluate their efficacy as screening measures for autistic burnout, with a group of 238 autistic adults. Exploratory factor analyses (EFA) revealed a 4-factor structure for the ABM and a 2-factor structure for the CBI personal scale (CBI-P). Factorial validity and dimensionality were examined with four exploratory models which indicated a unidimensional structure for the ABM with an overarching 'Autistic Burnout' construct, and multidimensional CBI-P structure comprising two subscales and overarching 'Personal Burnout' construct. Other reliability and validity indicators included Spearman correlations, analysis of variance, receiver operating characteristics, sensitivity, specificity, and intra-class correlations (ICC). The ABM and CBI-P were strongly correlated with depression, anxiety, stress, and fatigue. Unexpectedly, correlations between the burnout measures and camouflaging, and wellbeing measures were moderate. Potential overlap between burnout and depression and fatigue was examined through EFA, which supported convergent validity of the ABM and depression measure, while correlations and ICC analyses revealed mixed results. We concluded that the ABM and the CBI-P Emotional Exhaustion subscale were valid preliminary screening tools for autistic burnout. Testing with larger and more diverse autistic samples is required to further examine the psychometric properties of the ABM, and to understand the relationships between autistic burnout and depression, and masking.

Increased risk of acute stress disorder and post-traumatic stress disorder in children and adolescents with autism spectrum disorder: a nation-wide cohort study in Taiwan

Introduction

Children and adolescents with autism spectrum disorder (ASD) may be particularly vulnerable to the impact of traumatic events, yet the association between ASD and the risk of developing acute stress disorder and post-traumatic stress disorder (PTSD) remains uncertain. This study aims to investigate this association, addressing the gap in large-scale evidence on the subject.

Methods

Conducted as a retrospective and matched cohort study, data was sourced from the National Health Insurance Research Database (NHIRD) in Taiwan, spanning from January 1, 2000, to December 31, 2015. The study included patients aged 18 years or under newly diagnosed with ASD (n=15,200) and compared them with a matched control group (n=45,600). The Cox proportional regression model was employed to assess the risk of acute stress disorder and PTSD.

Results

Over the 15-year follow-up period, a total of 132 participants developed either acute stress disorder or PTSD. Among them, 105 cases (0.691% or 64.90 per 100,000 person-years) were in the ASD group, while 27 cases (0.059% or 5.38 per 100,000 person-years) were in the control group. The adjusted hazard ratio for the ASD group was significantly higher compared to the control group (25.661 with 95% CI = 15.913-41.232; P < .001).

Discussion

This study provides compelling evidence that individuals with ASD face an elevated risk of developing acute stress disorder and PTSD. The findings underscore the importance of clinicians recognizing and addressing this vulnerability in ASD individuals exposed to traumatic events. This emphasizes the need for heightened attention to the risk of PTSD and acute stress disorder in the ASD population.

A call for trauma-informed dental care for individuals with intellectual disabilities

People with intellectual disabilities are at increased risk of dental anxiety and poor oral health. In addition, people with intellectual disabilities are at increased risk of potentially traumatic experiences, such as violence and sexual abuse, and appear to be more vulnerable to developing trauma-related disorders following such experiences. While psychological trauma is associated with poor oral health and dental anxiety in the general population, the potential link between dental anxiety, poor oral health and psychological trauma is yet to be explored in people with intellectual disabilities. In this conceptual paper, we provide an overview of recent findings concerning the relationships between oral health and intellectual disabilities, psychological trauma and intellectual disabilities, as well as between psychological trauma and oral health, and discuss the relevance of these findings related to dental care for people with intellectual disabilities. We conclude that psychological trauma is likely to contribute to dental anxiety and poor oral health also in people with intellectual disabilities. Implications include an urgent need for research exploring how trauma affects oral health and experiences of dental care for people with intellectual disabilities, as well as the importance of individualized and trauma-informed dental care for these individuals.

Promoting Quality of Life: Suggestions for Mental Health Care Providers Working with Young Autistic Adults

There is a growing population of autistic adults in need of supports from a service delivery system that, at present, fails to accommodate their needs adequately and equitably. Unfortunately, there is a shortage of trained behavioral health service providers to meet the needs of young autistic adults. Quality of life (QoL), or one's perception of, and satisfaction with, life in relation to held goals and expectations, has been identified as a key outcome of interest by autistic self-advocates. By supporting autistic clients to hone their strengths and interests, integrate various aspects of their identity, identify goals, and connect to appropriate resources, providers can promote clients' self-knowledge and self-determination, in the service of improving QoL. In this Perspectives article, we offer concrete recommendations to mental health providers, including those who do not specialize in autism, with the goal of supporting implementation of evidence-based strategies that improve QoL and promote self-determination among young autistic clients.

Prevalence of Victimisation in Autistic Individuals: A Systematic Review and Meta-Analysis

Autistic individuals are at an increased risk of experiencing victimisation. Previous reviews have focussed specific types of victimisation. Thus, a clearer picture considering the range of victimisation experiences autistic people face is required. This systematic review aims to identify the prevalence of victimisation in autistic individuals considering a variety of victimisation types (e.g., bulling, sexual victimisation, and crime) in both adults and children from clinical and community settings. Through systematic searches of relevant databases, 291 studies met the criteria for review. Of those, 34 studies met the inclusion criteria: a) quantitative studies, b) involving autistic individuals, c) reporting prevalence rates of victimisation. Meta-analysis found a pooled prevalence rate of victimisation of 44% in autistic individuals. Subgroup analysis examined moderating factors as high heterogeneity was present. This found the pooled prevalence rates for bullying to be 47%, 16% for child abuse, 40% for sexual victimisation, 13% for cyberbullying, and 84% for multiple forms of victimisation in autistic individuals, though heterogeneity remained. Correction for participants' age, reporter used, and the population which the sample was recruited from did not reduce heterogeneity. Although heterogeneity impedes the definitive interpretation of the findings, this review illustrates the need for strategies and interventions to reduce the incidence of victimisation.

Association of adverse childhood experiences and cortical neurite density alterations with posttraumatic stress disorder symptoms in autism spectrum disorder

Background

Posttraumatic stress disorder (PTSD) can be a source of significant social and daily distress in autism spectrum disorder (ASD). Compared to typically developed (TD) individuals, people with ASD are at an increased risk of adverse childhood experiences (ACEs), which can result in abnormal neuronal development. However, whether or how ACEs influence abnormal neural development and PTSD symptoms in ASD has not been fully elucidated.

Methods

Thirty-nine TD individuals and 41 individuals with ASD underwent T1-weighted magnetic resonance imaging and neurite orientation dispersion and density imaging (NODDI), with axonal and dendritic densities assessed in terms of the orientation dispersion index and neurite density index (NDI), respectively. Voxel-based analyses were performed to explore the brain regions associated with PTSD symptoms, and the relationships between the severity of ACEs and PTSD symptoms and NODDI parameters in the extracted brain regions were examined.

Results

There was a significant positive association between PTSD symptom severity and NDI in the bilateral supplementary motor area; right superior frontal, left supramarginal, and right superior temporal gyrus; and right precuneus in the ASD group, but not in the TD group. ACE severity was significantly associated with NDI in the right superior frontal and left supramarginal gyrus and right precuneus in the ASD group. Moreover, NDI in the right precuneus mainly predicted the severity of PTSD symptoms in the ASD group, but not the TD group.

Conclusion

These results suggest that ACE-associated higher neurite density is of clinical importance in the pathophysiology of PTSD symptoms in ASD.

Exploring the Efficacy of an Online Intervention in Processing Experiences of Heterosexism Among Autistic-LGBQ + Individuals

This experimental study explored the use of online expressive writing interventions to cope with distress from heterosexist events among a sample of autistic-LBGQ + individuals. This study included an open writing condition and an emotion focused therapy guided writing condition. Over 89% of the participants indicated that the writing exercises were helpful in processing the event, with significant decreases for measures of depressive and trauma/stressor symptoms. A thematic analysis identified specific aspects of each condition that were helpful for participants in coping with heterosexist distress, such as the development of insight through the emotion-focused exercises. This low-demand exercise is promising as a solo exercise or as a therapy homework assignment, especially given the accessibility of this online intervention for autistic-LGBQ + people.

Exploring the different cognitive, emotional and imaginative experiences of autistic and non-autistic adult readers when contemplating serious literature as compared to non-fiction

Introduction

Recent research has demonstrated how reflections on serious literature can challenge dominant social-deficit views of autism. This method enables autistic readers to explore social realities more slowly and carefully, encouraging detail-focused considerations. Previous research has also shown that autistic and non-autistic readers reflecting on serious literature together are able to achieve mutuality in a way that enables them to overcome the double empathy problem. However, the advantages of reading aloud designs have yet to be explored with autistic and non-autistic readers due to previous concerns amongst autistic people on the issue of being read aloud to. The present study aimed to explore how an adapted shared reading design that compared serious literature and non-fiction would enable autistic and non-autistic readers to imaginatively engage in the reading experience.

Methods

Seven autistic and six non-autistic participants read 8 short text extracts alone while listening to pre-recorded audio of an experienced reader reading each text aloud. Participants completed a reflective questionnaire for each text and a follow-up interview where moving parts of the text were then re-read aloud before discussion. Half of these texts were serious literature, while the other half were non-fiction. Similarly, half of the texts explored fictional social realities that depicted a lack of mutuality, or non-fiction accounts of autism; while the other half explored broader emotional experiences.

Results

Thematic and literary analysis of participant reflections and follow-up interviews revealed three main themes: (1) From Surface Reading to Intuitive Engagement, (2) Imaginative Feeling and (3) Going Forward from the Reading Experience.

Discussion

The findings showed that autistic readers were better able to hold onto the detailed complexity of serious literature, while non-autistic readers tended to reduce information down to key ideas and understandings for later generalization. Findings are discussed in relation to future shared reading designs.

Looking through rainbow-rimmed glasses: Taking neurodiversity perspective is related to subjective well-being of autistic adults

Finding new ways of supporting the well-being of autistic adults is an essential goal for research and practice. We tested the predictive value of attitudes towards autism (as neurodiversity or as a disorder) and identification with other autistic people, on the psychological distress and self-esteem of autistic adults ( n = 109). Adopting a neurodiversity attitude not only predicted higher self-esteem but also served as a protective factor against the negative impact of identification with other autistic people on psychological distress. These findings show that clinicians should be sensitive to the way autistic people understand autism and the extent to which they identify with the autism community, as these factors relate to their well-being.

Lay abstract

Autistic adults experience a high level of distress. Finding new ways to support their well-being is an important goal for researchers and clinicians. We assessed the way autistic adults view their autism, as a disorder or as a type of mind (neurodiversity), and the level they integrate with other autistic people, and we checked how those factors contribute to their well-being. People who see autism rather as a type of mind than as a disorder had higher self-esteem. People who view themselves as more similar to other autistic people felt more stressed, but this result was not accurate for people who view autism as a type of mind. Clinicians should be sensitive to the way autistic people understand autism and to what extent they identify with the autism community, because it may relate to their well-being.

A Qualitative Study of Self and Caregiver Perspectives on How Autistic Individuals Cope With Trauma

Background

Coping can moderate the relationship between trauma exposure and trauma symptoms. There are many conceptualisations of coping in the general population, but limited research has considered how autistic individuals cope, despite their above-average rates of traumatic exposure.

Objectives

To describe the range of coping strategies autistic individuals use following traumatic events.

Methods

Fourteen autistic adults and 15 caregivers of autistic individuals, recruited via stratified purposive sampling, completed semi-structured interviews. Participants were asked to describe how they/their child attempted to cope with events they perceived as traumatic. Using an existing theoretical framework and reflexive thematic analysis, coping strategies were identified, described, and organized into themes.

Results

Coping strategies used by autistic individuals could be organized into 3 main themes: (1) Engaging with Trauma, (2) Disengaging from Trauma, and (3) Self-Regulatory Coping. After the three main themes were developed, a fourth integrative theme, Diagnostic Overshadowing, was created to capture participants' reports of the overlap or confusion between coping and autism-related behaviors.

Conclusions

Autistic individuals use many strategies to cope with trauma, many of which are traditionally recognized as coping, but some of which may be less easily recognized given their overlap with autism-related behaviors. Findings highlight considerations for conceptualizing coping in autism, including factors influencing how individuals cope with trauma, and how aspects of autism may shape or overlap with coping behavior. Research building on these findings may inform a more nuanced understanding of how autistic people respond to adversity, and how to support coping strategies that promote recovery from trauma.

Investigating the relationships between resilience, autism-related quantitative traits, and mental health outcomes among adults during the COVID-19 pandemic

Resilience is a dynamic process through which people adjust to adversity and buffer anxiety and depression. The COVID-19 global pandemic has introduced a shared source of adversity for people across the world, with detrimental implications for mental health. Despite the pronounced vulnerability of autistic adults to anxiety and depression during the COVID-19 pandemic, relationships among autism-related quantitative traits, resilience, and mental health outcomes have not been examined. As such, we aimed to describe the relationships between these traits in a sample enriched in autism spectrum-related quantitative traits during the COVID-19 pandemic. We also aimed to investigate the impact of demographic and social factors on these relationships. Across three independent samples of adults, we assessed resilience factors, autism-related quantitative traits, anxiety symptoms, and depression symptoms during the COVID-19 pandemic. One sample (recruited via the Autism Spectrum Program of Excellence, n = 201) was enriched for autism traits while the other two (recruited via Amazon Mechanical Turk, n = 624 and Facebook, n = 929) drew from the general population. We found resilience factors and quantitative autism-related traits to be inversely related, regardless of the resilience measure used. Additionally, we found that resilience factors moderate the relationship between autism-related quantitative traits and depression symptoms such that resilience appears to be protective. Across the neurodiversity spectrum, resilience factors may be targets to improve mental health outcomes. This approach may be especially important during the ongoing COVID-19 pandemic and in its aftermath.

Anxiety and Trauma-Related Disorders in Children on the Autism Spectrum

PURPOSE OF REVIEW

To summarize recent findings regarding anxiety and trauma-related disorders in children diagnosed with autism spectrum disorder (autism), focusing on the distinct ways in which these conditions may be expressed, as well as advances in evidence-based assessment and treatment.

RECENT FINDINGS

Current findings suggest both anxiety and trauma-related disorders may be more prevalent, yet more complicated to address in autistic relative to non-autistic children. Overlapping symptoms and distinct manifestations of these disorders pose challenges for the accurate identification, assessment, and treatment of anxiety and trauma-related disorders in autistic children. Emerging evidence recommends adapting traditional assessment and treatment approaches to better meet the needs of autistic children. Recent research suggests autism-centered conceptualizations, which accommodate complexity in how anxiety and trauma-related disorders are experienced and expressed by autistic people, are needed to enhance the psychiatric care of this population.

Exploring potential sources of childhood trauma: A qualitative study with autistic adults and caregivers

The stressors autistic individuals encounter and experience as traumatic may vary from non-autistics. We conducted a qualitative study to identify potential sources of trauma for autistic individuals and evaluate correspondence with a standard measure. We enrolled autistic adults (N = 14) and caregivers (N= 15) with varied adversities, levels of functioning, and socio-demographics. Participants completed standard measures of autism, traumatic exposures and stress, and qualitative interviews, which were submitted to thematic analysis. A wide range of experiences were described as traumatic. Whereas some reflected traditional traumas (e.g. maltreatment) and forms of social marginalization, others reflected conflicts between autistic characteristics and the environment (e.g. sensory trauma). All adults and caregivers described sources of trauma in interviews not captured by standardized measures. Varied stressful experiences, many not detected by a standardized measure, may have a traumatic effect on autistic individuals. Whereas some reflect commonly recognized trauma sources, others may reflect particular vulnerabilities for autistic individuals. Results have implications for assessing traumatic events and understanding their contribution to mental health inequities in the autistic population.

The comorbidity between autism spectrum disorder and post-traumatic stress disorder is mediated by brooding rumination

LAY ABSTRACT

Autism spectrum disorder is a neurodevelopmental condition characterized by social communication difficulties and restricted repetitive behaviors. Individuals with autism spectrum disorder are often diagnosed with other psychiatric conditions, including attention deficit hyperactivity disorder, anxiety, and depression. However, research on post-traumatic stress disorder among individuals with autism spectrum disorder is scarce. Nonetheless, studies have shown that those with autism spectrum disorder may face an increased risk of exposure to traumatic events. Separate lines of research in autism spectrum disorder and post-traumatic stress disorder have shown that the two may share several vulnerability factors. One of those is ruminative thinking, that is, one's tendency to re-hash thoughts and ideas, in a repetitive manner. This article examined the role of two rumination types as potential factors connecting autism spectrum disorder and post-traumatic stress disorder: brooding (continuously comparing one's current condition to one's desired condition) and reflection (an introspective effort to cognitively solve one's problems). A total of 34 adults with autism spectrum disorder (with no intellectual impairment) and 66 typically developing adults completed questionnaires assessing post-traumatic stress disorder symptoms and rumination. The results showed increased post-traumatic stress disorder symptoms in adults with autism spectrum disorder, compared to typically developing adults. Brooding rumination was also higher among those with autism spectrum disorder. Finally, brooding, but not reflection, served as a mechanism connecting autism spectrum disorder and post-traumatic stress disorder, that is, those with autism spectrum disorder showed increased brooding, which in turn predicted more post-traumatic stress disorder symptoms. This study has potential clinical implications. Rumination and cognitive inflexibility, which are common in autism spectrum disorder, could exacerbate post-traumatic symptoms among individuals with autism spectrum disorder who experience traumatic events. Interventions targeting brooding rumination and cognitive flexibility may assist in alleviating post-traumatic symptoms in individuals with autism spectrum disorder.

Co-occurring mental health symptoms and cognitive processes in trauma-exposed ASD adults

BACKGROUND

Mental health problems are common amongst adults with an Autism Spectrum Disorder (ASD). Stressful and traumatic life events can trigger or exacerbate symptoms of anxiety, depression and PTSD. In the general population, transdiagnostic processes such as suppression and perseverative thinking are associated with responses to trauma and mental health symptoms.

AIMS

This study explored the relationships between thought suppression, perseverative thinking and symptoms of depression, anxiety and PTSD in ASD adults who reported exposure to a range of DSM-5 and non-DSM-5 traumatic events.

METHODS

59 ASD adults completed a series of online self-report questionnaires measuring trauma, transdiagnostic cognitive processes, and mental health symptoms.

RESULTS

Probable PTSD rarely occurred in isolation and was associated with depression and anxiety symptoms in trauma-exposed ASD adults. All cognitive processes and mental health symptoms were positively associated with one another, regardless of whether the trauma met DSM-5 PTSD Criterion A. When accounting for both cognitive processes, only thought suppression significantly predicted PTSD and anxiety symptoms, while only perseverative thinking significantly predicted depression symptoms.

CONCLUSIONS AND IMPLICATIONS

These preliminary results suggest that different cognitive processes more strongly affect anxiety/PTSD versus depression symptom severity in trauma-exposed ASD adults, although co-occurring symptoms are common. Implications for assessment, treatment and future research are discussed.