Screening and treatment of trauma-related symptoms in youth with autism spectrum disorder among community providers in the United States

An Investigation of Dissociative Symptoms and Related Factors in Autistic Adolescents

Despite exposure to trauma and adverse life events being frequently reported in Autism Spectrum Disorder (ASD), few studies have examined the relationship between these factors and dissociative symptoms in the autistic population. The aim of the study is to investigate symptoms of dissociation in autistic adolescents, and to explore factors that could be associated with dissociative symptoms in ASD. This cross-sectional study involved 59 autistic adolescents between 12 and 18 years old, with the mean age of 14.3 ± 1.8. Dissociation, autism characteristics, childhood traumas, peer bullying, and Post-Traumatic Stress Disorder (PTSD) symptoms were assessed using the Adolescent Dissociative Experiences Scale (ADES), the Childhood Autism Rating Scale (CARS), the Childhood Trauma Questionnaire (CTQ), the Nine-Item Child-Adolescent Bullying Screen (CABS-9), and the Child Posttraumatic Stress Reaction Index (CPTS-RI), respectively. Results from the ADES revealed that 12.5% of the participants scored above the threshold for dissociative disorders. In the linear regression model constructed to evaluate factors associated with dissociative symptoms, an increase in dissociative symptoms was statistically significantly associated with an increase in the total CTQ score (p = 0.002) and age (p = 0.006). The findings of the study indicate that dissociative symptoms may occur in autistic adolescents. It is suggested that dissociative symptoms observed in autistic adolescents may particularly be associated with childhood traumas and increasing age. Further research into dissociative symptoms in ASD is warranted, requiring larger sample sizes, specialized measurement scales, and structured interviews.

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.

Using EMDR with autistic individuals: A Delphi survey with EMDR therapists

LAY ABSTRACT

Eye Movement Desensitisation and Reprocessing (EMDR) is a psychological therapy that can help people process memories and distress about past events, so they have less impact on their daily lives. EMDR can be effective for treating symptoms of post-traumatic stress disorder, including nightmares and anxiety. Psychological therapies usually require adaptation so they are more accessible and effective for autistic people, but minimal research has focused on how best EMDR can be adapted. In this online survey study, we asked 103 EMDR therapists about barriers they think autistic people face when trying to have EMDR and what adaptations they use in their everyday practice. Four barriers were highlighted: client-related characteristics, therapist-related characteristics, differences in the therapeutic relationship and broader issues. Therapists identified a range of adaptations that can potentially be useful for autistic people, relating to being flexible, communicating clearly and having an awareness of individual differences. Many therapists emphasised the importance of not making assumptions about a person based on their autism diagnosis. Overall, the study findings suggest adaptations to EMDR are likely to be useful, but how relevant they are depends on each person.

Expert consensus regarding indicators of a traumatic reaction in autistic youth: a Delphi survey

OBJECTIVE

It has been suggested that the sequelae of trauma are under-recognized in youth on the autism spectrum. We aimed to generate expert consensus regarding important trauma indicators, including but not limited to traumatic stress symptoms, in autistic youth.

METHODS

We recruited 72 experts in autism and/or childhood trauma. Via a 2-round Delphi survey, experts commented on and rated the importance of 48 potential indicators, drawn from PTSD criteria and a broader literature on traumatic sequelae in autism. A revised list of 51 indicators, 18 clinical guidelines developed from expert comments, and summaries of expert qualifications and ratings from Round 1 were submitted to a second round (n = 66; 92% retention) of expert review and rating.

RESULTS

Twenty-two indicators reached consensus (>75% round 2 endorsement). Many, but not all, reflected PTSD criteria, including intrusions (e.g., trauma re-enactments in perseverative play/speech), avoidance of trauma-reminders, and negative alterations in mood/cognition (e.g., diminished interest in activities) and in arousal/reactivity (e.g., exaggerated startle). Experts also identified increased reliance on others, adaptive and language regressions, self-injurious behavior, and non-suicidal self-injury as important indicators. Consensus guidelines emphasized the need for tailored measures, developmentally informed criteria, and multiple informants to increase diagnostic accuracy.

CONCLUSIONS

Expert consensus emphasizes and informs a need for tailored diagnostic guidelines and measures to more sensitively assess traumatic reactions in autistic youth.

Using eye movement desensitisation and reprocessing (EMDR) with autistic individuals: A qualitative interview study with EMDR therapists

OBJECTIVES

Eye Movement Desensitisation and Reprocessing (EMDR) is an evidence-based psychological therapy that targets distress associated with trauma and affective disturbance. Few studies have examined EMDR for autistic individuals who have co-occurring mental health conditions, but there is preliminary evidence of effectiveness. The current study explored EMDR therapists' experiences of working with autistic individuals, and adaptations incorporated into clinical practice to make this more accessible and effective.

DESIGN

A qualitative interview design was used. Data were thematically analysed.

METHOD

Twenty-three UK-based EMDR therapists attended one-off semi-structured qualitative interviews.

RESULTS

Four main themes emerged: (1) the experience of being autistic; (2) factors around accessing EMDR; (3) adapting EMDR; and (4) supervision and support for EMDR therapists. Participants described offering a nuanced and tailored approach; one that retained the integral components of the eight phases of EMDR, while also being flexible and responsive to each client.

CONCLUSIONS

Findings reinforce the importance of offering formulation-based psychological therapy that flexes in an evidence-informed way, according to the preferences and needs of autistic individuals. Further research should establish factors influencing accessibility and effectiveness of EMDR for autistic individuals, and the impact of autism-relevant training on the knowledge, skills and confidence of EMDR therapists and clinical supervisors working with this client group.

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.

Intergenerational trauma: Parental PTSD and parent-reported child abuse subtypes differentially relate to admission characteristics in the autism inpatient collection

Autistic youth experience high rates of maltreatment. Little research has considered how distinct abuse dimensions differentially relate to meaningful outcomes, nor taken an intergenerational approach to consider how caregiver trauma and child maltreatment are related. This study sought to identify how parent-reported child abuse subtypes and parent posttraumatic stress disorder (PTSD) relate to each other and to admission characteristics upon inpatient service entry. Autistic youth (N = 527; 79% White, 21.3% girls, mean age = 12.94 years) participated in the autism inpatient collection. Parents reported on child abuse subtypes (physical, sexual, emotional) and their own PTSD, child behavior and emergency services, and parenting stress. Youth of parents with PTSD were nearly three times more likely to have parent-reported physical and emotional abuse. Autistic girls were more likely to experience parent-reported sexual abuse and a higher number of subtypes. Lower income related to higher rates of parent-reported child emotional abuse and parent PTSD. Emotional abuse associated with child behavior whereas both child physical and emotional abuse related to emergency services. Reported parent PTSD associated with child behavior and parental distress. When considered jointly, parent PTSD and number of parent-reported child abuse subtypes differentially related to child behavior and interacted to predict psychiatric hospitalizations. Intergenerational continuity of trauma is important to consider among autistic youth, and both parent-reported child abuse and parent PTSD relate to admission characteristics. Critical limitations include reliance on binary parent reports of child abuse and parent PTSD and the low representation of youth of minoritized identities. Implications for trauma-informed care are discussed.

Trauma, intellectual and/or developmental disability, and multiple, complex needs: A scoping review of the literature

BACKGROUND

Trauma is a significant underlying factor in the multimorbidity of people with Intellectual and/or Development Disabilities (IDD). This relationship is further complicated by a growing recognition of a subset of multiply stigmatized individuals with an IDD and complex, intersecting health and social needs.

AIM

The aim of this review was to examine what is known about trauma and people with an IDD and complex needs, as defined by Community Living British Columbia's (CLBC) Multiple, Complex Needs (MCN) framework, through a broad review of relevant literature.

METHOD AND PROCEDURES

We conducted a scoping review of the peer-reviewed (9 disability journals; 7 academic databases) and grey (2 grey literature databases) on IDD and trauma through an inclusive approach that used search criteria drawn from the defining features of CLBC's MCN Framework.

OUTCOMES AND RESULTS

Apart from there being a limited amount of research on trauma and IDD, two key findings emerged. Through differing approaches that get at issues of trauma in different ways (i.e., through adverse life events or experiences of abuse), the first finding is that the research related to trauma and IDD is not cleanly linked together. The second is the focus on treatment services or interventions and not on what's happening at the organizational or system level.

CONCLUSION AND IMPLICATIONS

There is limited research on trauma and IDD making it even more important to unify the evidence that exists. However, the literature is not integrated across different theoretical and disciplinary perspectives. In addition, the focus of trauma-related research that is occurring is interventions at the individual versus system level. Also needed are studies that explore trauma-informed practice from an organizational or top-down perspective.

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.

Direct and Inverse Correlates of Post-Traumatic Stress Disorder among School-Age Autistic Boys

Young people with autism are often bullied at school, a potential direct correlate of Post-Traumatic Stress Disorder (PTSD). This may be compounded by their difficulties in social interaction. Alternately, some of these young people may develop ‘coping strategies’ against bullying that may have an inverse association with PTSD. As a vulnerable population for PTSD, a sample of 71 young males with autism were surveyed for their self-reported experiences of being bullied at school, their coping strategies for dealing with this bullying, and their own evaluations of the severity of two of the key diagnostic criteria for PTSD. Their mothers also provided a rating of the severity of the three major diagnostic criteria for autism for these boys. Over 80% of this sample had been bullied, and there was a significant direct correlation between this and PTSD score, and between their mother-rated severity of the boys’ social interaction difficulties, but also a significant inverse correlation between their coping strategies and PTSD score. There were differences in these relationships according to whether the boys attended elementary or secondary school. These findings hold implications for the identification, assessment and support of autistic youth at risk of PTSD.

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

BACKGROUND

Individuals with Autism Spectrum Disorder (ASD) are known to be at increased risk of exposure to traumas such as maltreatment and abuse, however less is known about possible susceptibility towards the development of Posttraumatic Stress Disorder (PTSD) and associated risk factors.

AIMS

This study investigated the rates of trauma exposure and PTSD, and the role of cumulative trauma exposure and memory as risk factors for PTSD in adults who self-reported having received an ASD diagnosis, compared to a typically developing (TD) comparison group.

METHODS

Questionnaires assessing self-reported frequency of trauma exposure (LEC), PTSD symptomology (PCL-S) and memory (EMQ- R and BRIEF-A) were completed online by 38 ASD adults and 44 TD adults.

RESULTS

Rates of trauma exposure and PTSD symptomatology were significantly higher in the ASD group, compared to the TD group, with deficits in working memory and everyday memory mediating this association. Interestingly, a cumulative effect of trauma exposure on PTSD symptom severity was only found in the ASD group.

CONCLUSIONS

High rates of trauma and probable PTSD in ASD adults highlight the importance of routine screening. Cumulative trauma exposure and memory deficits may act to increase risk of PTSD in ASD; longitudinal research is called for.

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.

Unrelenting Depression and Suicidality in Women with Autistic Traits

Understanding the cognitive and emotional mechanisms that link autistic traits and risk for suicide is a vital next step for research and clinical practice. This study included a broad sample of adult women (n = 74) who report finding social situations confusing and/or exhausting, and who score high on measures of autistic traits. Regardless of autism diagnostic status, these women reported high rates of suicidal thoughts and behaviors. Depression symptoms were more associated with suicidality than were autistic trait measures of social communication. Measures of neurotypical "imagination" and of repetitive behavior likewise were associated with suicidality risk. Simultaneously feeling sad and feeling stuck or unable to imagine alternate strategies, may uniquely increase suicide risk in autism.

Potentially traumatic experiences and behavioural symptoms in adults with autism and intellectual disability referred for psychiatric assessment

BACKGROUND

Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) more frequently experience potentially traumatic events (PTEs), and may be more vulnerable to trauma-related symptoms. However, it is unclear how such symptoms are captured on tools used for behavioural and psychiatric assessment in this population.

AIMS

To explore whether and how PTEs are associated with symptom reports in adults with ASD and ID.

METHODS AND PROCEDURES

Associations and group differences for death of a close relative and serious disease/injury in a close relative/caregiver/friend were explored in a clinical sample of 171 adults with ASD and ID referred for psychiatric assessment. Symptoms were measured using Aberrant Behavior Checklist (ABC) and Psychopathology in Autism Checklist (PAC).

OUTCOMES AND RESULTS

Disease/injury was associated with higher scores on ABC irritability, ABC hyperactivity and self-injurious behaviour. Death was associated with lower scores on ABC lethargy and ABC stereotypic behaviour. Some associations reached significance only when controlling for ASD, ID, or verbal language skills, but the identified associations were not robust. No associations were found for PAC.

CONCLUSIONS AND IMPLICATIONS

There is a risk of under-appreciating the impact of PTEs in this population unless ASD, ID and verbal language skills are taken into account.

"If we do not look for it, we do not see it": Clinicians' experiences and understanding of identifying post-traumatic stress disorder in adults with autism and intellectual disability

BACKGROUND

Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) are at increased risk of potentially traumatic events and may be at increased risk of post-traumatic stress disorder (PTSD). However, knowledge regarding identification of PTSD in this population is limited. The aim of this study was to investigate clinical experience regarding PTSD and trauma assessment in individuals with co-occurring ASD and ID.

METHOD

Interpretative phenomenological analysis was used to explore experiences of identifying PTSD in this population among 18 mental health clinicians working with ASD and ID.

RESULTS

Informants viewed PTSD in individuals with ASD and ID as equivalent to PTSD in the general population, but with causes and expressions potentially differing. Several factors were described to contribute to challenges in identification.

CONCLUSIONS

Trauma may have severe impact in individuals with ASD and ID. Multidimensional, individualized assessment strategies seem necessary to recognize PTSD or trauma-related symptoms in this population.