Positive Approaches Journal, Volume 13, Issue 2
Beck | 23-32
Volume 13 ► Issue 2 ► September 2024
Trauma and Social Adversity in Autism: Considerations and Directions for Clinicians and Researchers
Kelly B. Beck
Keywords: Autism, trauma, post-traumatic stress disorder (PTSD), minority stress, trauma-informed care, assessment
Autism spectrum disorder is a neurodevelopmental disability characterized by differences in social communication and behaviors that is associated with lifelong challenges in social relationships, independence, and emotional well-being. In particular, autistic people have very high rates of lifetime mental health diagnoses, with two to ten times higher rates of co-occurring mental health diagnoses compared to non-autistic people. Death by suicide is the leading cause of premature mortality among autistic adults without intellectual disability.1,2 These negative trajectories start early, with some autistic children first attempting suicide as young as seven years old.3 1,4 Despite these alarming statistics, autistic people are frequently denied or removed from care due to the complexity of their psychiatric challenges, and some adults have reported that the lack of appropriate mental health supports has led them to consider suicide.5,6 As such, autism has been described as the “blind spot in mental healthcare”.7
Only recently has autism research begun to consider the powerful influence of the environment on mental health outcomes among autistic people. Published prevalence estimates of traumatic events (i.e. exposure to actual or threatened death, serious injury, sexual violence8) vary but are uniformly high in autism.9–11 Autistic youth are two to three times more likely to experience peer victimization, violence, and neglect than non-autistic peers.9,12 Specifically, autistic children are bullied and approximately 40% experience sexual victimization.10 Among adults, one recent study found that 75% of autistic adults reported having experienced physical or sexual abuse in their lifetime, and another study found that 84% of autistic people experience multiple forms of adverse childhood experiences, such as abuse and victimization.11 Reasons for this heightened risk are not well understood, but several mechanisms have been suggested. Differences in communication and social behaviors likely increases vulnerability for peer victimization by non-autistic peers and/or caregivers.10,13,14 Further, many autistic youth have clinically elevated emotion dysregulation (i.e. difficulty managing emotions) that is associated with the need for crisis services, involuntary hospitalizations, and police interactions, ultimately creating more opportunities to experience traumatic events.15
Autistic people also experience reoccurring social adversity (e.g. social contextual stressors, including excess stress people from marginalized groups experience, as a result of their inferior social status16), which may further compound the impact of exposure to potentially traumatic events.17–19 Examples of social adversity include experiences of discrimination, prejudice and stigma, invalidation, and social rejection.17 Inherent to autism is difficulty adhering to social and communication norms set by the neurotypical majority. Given this, it is not surprising that autistic youth and adults report to frequently experiencing social adversity in the form of stigma, discrimination, invalidation, and social rejection because of their autistic traits and lower social status.19,20 Discrimination and stigma among autistic people is significantly associated with more emotion dysregulation, higher suicidality, lower self-esteem, and lower quality of life.18,21 In a recent study with autistic adults, discrimination was a key contributor to emotion dysregulation, which led to some potentially traumatic events of involuntary sedation, termination of healthcare services, and police involvement.22 Another recent study found that reoccurring trauma and social adversity exposure had a cumulative effect on trauma symptom presentation among autistic people, demonstrating the importance of considering the additive nature of social adversity experienced by autistic people.23,24 Further, many autistic people cope with social adversity by attempting to mask or hide their autistic traits in order to meet neurotypical social norms, which we know to be predictive of worse mental health outcomes and heightened risk for suicide.25–28 Taken together, autistic people are both at heightened risk for traumatic exposure and experience reoccurring social adversity, which likely contributes to their alarming rates of suicidal thoughts and behaviors.
Despite these disparities in exposure to trauma and social adversity, it remains unclear how many autistic people develop post-traumatic stress disorder (PTSD).13,29,30 Some recent research suggests that autistic people are more likely to develop PTSD following adverse childhood experiences and traumatic events than neurotypical peers, though the research is still emerging and mechanisms why that may occur are unknown.13,14 Recent work suggests an overlap in symptoms and neurobiological networks impacted by both autism and PTSD.31,32 Others posit that challenges with neurocognitive and affective processes (e.g. working memory, cognitive inflexibility, rumination) and social perception common in autism increases vulnerability for both PTSD and suicidality following trauma and adversity.24,33–35 Further, autistic people appear to have reduced resiliency to the impact of adverse childhood experiences and traumatic events due to restricted social networks and difficulty maintaining relationships.
Assessment remains a key barrier to identifying and treating PTSD among autistic people. Differential diagnosis is challenging, as several key symptoms of PTSD overlap with core autistic features, and autism traits impact the presentation of trauma symptoms.14 For example, decreased attachment, flattened affect, repetitive play or speech, and withdrawal are all symptoms of PTSD and common social behaviors among autistic children and adults.14,36 Autistic adults without intellectual disability most commonly report symptoms of re-experiencing and hyper-vigilance.14 Yet symptom identification among autistic people with co-occurring intellectual disability remains difficult due to communication challenges, with aggressive behavior and running away being the most common responses following sexual trauma.29,30 While the field lacks validated tools for differential diagnosis, providers can refer to recently published tools and checklists by Michna and colleagues.23 Upon intake, clinicians should explore histories of exposure to traumatic events and ongoing social adversity, given that exposure to traumatic events and discrimination heightens risk for both PTSD and suicidal thoughts and behaviors.37 Providers are encouraged to assess the timing of symptom presentation (i.e. following a traumatic event or during a developmental period) and consider any sudden regression of skills that an autistic child or adult previously had (e.g. sudden loss of communication or increased withdrawal or aggression).23,30 In a recent study by Kerns and colleagues, ten key indicators of PTSD in autism were identified, including: physiological reactivity after trauma reminders, avoidance of trauma reminders, involuntary or intrusive memories, increase in emotion dysregulation, persistent avoidance, increased irritability or aggression, persistent trauma related emotions, increased suicidality, and new or worsened sleep disturbance.36
Trauma-informed care for autistic people remains a critical area for further exploration among clinicians and researchers alike. While intervention research on trauma in autism is still emerging, trauma-focused cognitive behavioral therapy and mindfulness interventions have growing evidence as appropriate options for autistic people with trauma histories or symptoms.38,39 Providers should individualize these interventions to meet the unique cognitive, sensory, and communication needs of each autistic client, as some of those treatments were not designed for neurodivergent needs.38,40 Further, several transdiagnostic treatments focusing on emotion regulation were designed specifically for autistic people and their caregivers.41 While these interventions have yet to be tested for PTSD symptom reduction specifically, there is strong evidence that these interventions improve shared symptomology.41 Thus, autism specific emotion regulation interventions are likely a good fit for autistic people that are experiencing social adversity and have trauma histories. In regard to social adversity, clinicians should also consider focusing on practical and realistic ways for autistic people to manage ongoing social adversity. For example, working with autistic people to identify and advocate for easily accessible safe places (e.g. quiet, sensory friendly space to go when dysregulated, feeling sensory overwhelm, or to use coping methods) and supporting people in all contexts of their daily living.22 Clinicians may also consider working with autistic people to identify internal signals of increasing distress, needing to safely cope and seek support.22 Finally, social connectedness and belonging are robust protective factors for trauma, social adversity, and suicidality in other populations.42–44 Supporting autistic clients to find autism-affirming social spaces, and form safe, social relationships online or in person should be a focus, regardless of therapeutic approaches.
In sum, it is imperative for clinicians and researchers to consider the impact of trauma and social adversity among children and youth on the spectrum, and related implications on their social and emotional wellbeing.
This manuscript was supported by the NICHD under Award Number L30HD109969, NIH under Award Numbers 1 P50 MH130957-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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Biographies
Kelly Beck, Ph.D., LPC, CRC, is an Assistant Professor of Psychiatry at the University of Pittsburgh. She is a rehabilitation scientist and Licensed Professional Counselor that works clinically with individuals with disabilities across the lifespan. Her specialty is using participatory research methods to design and test mental health interventions for autistic people. Dr. Beck is a co-developer of the Emotion Awareness and Skills Enhancement Program (EASE), a mindfulness-based intervention for autistic adolescents and young adults with and without co-occurring intellectual disability. She studies the impact of social adversity and trauma on mental health outcomes among autistic people. Dr. Beck is the Director of the Pittsburgh Adult Autism Research Community Collaborative for the Pitt Autism Center of Excellence that focuses on understanding mental health and suicide risk in autistic adults. She also leads the Schools Unified in Neurodiversity project, a community research project that designed a training program on fostering inclusive public-school environments for neurodivergent children. Dr. Beck received her Ph.D. in Rehabilitation Science from the University of Pittsburgh.
Contact Information
Kelly B. Beck, Ph.D.
Department of Psychiatry
School of Medicine
University of Pittsburgh
406 Sterling Plaza
201 North Craig Street
Pittsburgh, PA 15213
Phone: 1-412-383-6727
Email: kellybeck@pitt.edu