Advances in Autism – 10-3 – Meeting the trauma needs of Autistic people
1. Morris D. Guest editorial: Rising to the challenge: meeting the trauma needs of autistic people. Advances in Autism;2024;10(3):101-103.
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2. Webb E, Lupattelli Gencarelli B, Keaveney G, Morris D. Is trauma research neglecting neurodiverse populations? A systematic review and meta-analysis of the prevalence ACEs in adults with autistic traits. Advances in Autism;2024;10(3):104-119.
Purpose The prevalence of exposure to adversity is elevated in autistic populations, compared to neurotypical peers. Despite this, the frequency and nature of early adverse experiences are not well understood in autistic adults, with several underlying methodological limitations in the available literature. The purpose of this study is to systematically synthesise and analyse the prevalence of childhood adversity in this marginalised population, in accordance with the adverse childhood experiences (ACEs) framework. Design/methodology/approach Peer-reviewed empirical research articles were systematically searched for from electronic databases and screened against established inclusion criteria. Pooled prevalence rates for individual ACE types were calculated. Findings Four papers were included (N = 732), all of which used a predominantly or exclusively female sample. Only sexual abuse was reported in all papers, with a pooled prevalence rate of 38%. Physical abuse and emotional abuse were less frequently explored, with two papers reporting on these ACEs, though obtained comparable and higher pooled prevalence rates (39% and 49%, respectively). Pooled prevalence rates could be calculated for neither neglect nor “household” ACEs because of insufficient data. The limited state of the evidence, in conjunction with high levels of heterogeneity and poor sample representativeness found, positions the ACEs of autistic adults as a critical research priority. Originality/value To the best of the authors’ knowledge, this study is the first to systematically synthesise the prevalence of early childhood adversities, as conceptualised in accordance with the ACEs framework, in adults with autistic traits.
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3. Al-Attar Z, Worthington R. Trauma or autism? – understanding how the effects of trauma and disrupted attachment can be mistaken for autism. Advances in Autism;2024;10(3):120-134.
Purpose Early bio-psycho-social experiences can dramatically impact all aspects of development. Both autism and traumagenic histories can lead to trans-diagnostic behavioural features that can be confused with one another during diagnostic assessment, unless an in-depth differential diagnostic evaluation is conducted that considers the developmental aetiology and underpinning experiences and triggers to trans-diagnostic behaviours. Design/methodology/approach This paper will explore the ways in which biological, cognitive, emotional and social sequelae of early trauma and attachment challenges, can look very similar to a range of neurodevelopmental disorders, including autism. Relevant literature and theory will be considered and synthesised with clinical knowledge of trauma and autism. Findings Recommendations are made for how the overlap between features of autism and trauma can be considered during assessments alongside consideration for interventions to enable people to access the most appropriate support for their needs. Originality/value Many features of the behaviours of individuals who have experienced early childhood trauma and disrupted or maladaptive attachments, may look similar to the behaviours associated with autism and hence diagnostic assessments of autism need to carefully differentiate traumagenic causes, to either dual diagnose (if both are present) or exclude autism, if it is not present. This has for long been recognised in child and adolescent autism specialist services but is less well developed in adult autism specialist services.
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4. Kildahl AN, Storvik K, Wächter EC, Jensen T, Ro A, Haugen IB. Distinguishing between autism and the consequences of early traumatisation during diagnostic assessment: a clinical case study. Advances in Autism;2024;10(3):135-148.
Purpose Distinguishing between autism characteristics and trauma-related symptoms may be clinically challenging, particularly in individuals who have experienced early traumatisation. Previous studies have described a risk that trauma-related symptoms are misinterpreted and/or misattributed to autism. This study aims to describe and explore assessment strategies to distinguish autism and early traumatisation in the case of a young woman with mild intellectual disability. Design/methodology/approach A clinical case study outlining assessment strategies, diagnostic decision-making and initial intervention. Findings A multi-informant interdisciplinary assessment using multiple assessment tools, together with a comprehensive review of records from previous assessments and contacts with various services, was helpful in distinguishing between autism and trauma. This included specific assessment tools for autism and trauma. Autism characteristics and trauma-related symptoms appeared to interact, not merely co-occur. Originality/value The current case demonstrates that diagnostic overshadowing may occur for autism in the context of early trauma. The case further highlights the importance of not ascribing trauma-related symptoms to autism, as service provision and treatment need to take account of both. Overlooking autism in individuals who have experienced early traumatisation may result in a risk that intervention and care are not appropriately adapted, which may involve a risk of exacerbating trauma symptoms.
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5. Allman M, Kerr S, Roldan CI, Harris GM, Harris GE. Comorbid autism spectrum disorder and borderline personality disorder: case conceptualization and treatment implications. Advances in Autism;2024;10(3):149-162.
Purpose Autism spectrum disorder (ASD) and borderline personality disorder (BPD) are complex disorders characterized by pervasive symptoms of rigidity, emotion dysregulation and social cognitive difficulties. Comorbid ASD and BPD are recognized emerging clinical problem that may be challenging to treat. Design/methodology/approach The authors present a case study of a young person in the authors’ assessment clinic diagnosed with BPD and ASD who had received standard dialectical behavior therapy (DBT) with modest effects. The authors provide ASD-informed recommendations for continued DBT treatment. Findings The de-identified patient described in this case report met full criteria for ASD and BPD. The patient’s cognitive, behavioral, social and personality functioning are described in detail. Practical implications Other practitioners seeking to treat this complex comorbidity may make use of the authors’ treatment recommendations for their patients. The authors underscore the importance of individualized treatment planning and hope the authors’ exemplar will be useful to others. Originality/value Several evidence-based treatments exist for ASD and BPD symptom reduction. However, to the best of the authors’ knowledge, no current treatments exist for comorbid ASD and BPD to target emotion dysregulation in individuals with restricted and repetitive interests and behaviors and disturbances in social and communication domains.
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6. Rumball F, Parker R, Madigan AE, Happe F, Spain D. Elucidating the presentation and identification of PTSD in autistic adults: a modified Delphi study. Advances in Autism;2024;10(3):163-184.
Purpose Autistic individuals are at increased risk of trauma exposure and post-traumatic stress disorder (PTSD). Diagnostic overshadowing, however, often results in PTSD symptoms being mislabelled as autistic traits. This study aims to develop professional consensus on the identification and assessment of co-occurring PTSD in autistic adults. Design/methodology/approach An online modified Delphi design was used to gather professionals’ perspectives on key aspects of the identification and assessment of PTSD in autistic adults. Data were gathered qualitatively in Round 1 and then synthesised using content analysis into a list of statements that were rated in Round 2. Statements reaching 60–79% consensus and additional suggestions were sent out for rating in Round 3. Consensus for the final statement list was set at 80% agreement. Findings Overall, 108 statements reached consensus. These form the basis of professional-informed recommendations to facilitate the identification and assessment of PTSD symptoms in autistic adults. Practical implications The final Delphi statements provide a framework to assist with the assessment and recognition of traumatic stress reactions in autistic adults presenting to mental health, diagnostic or social services. Originality/value To the best of the authors’ knowledge, this is the first study to explore the presentation and identification of PTSD in autistic adults (with and without intellectual disability), using a bottom-up approach informed by professional consensus.
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7. Phillips MD, Parham R, Hunt K, Camp J. Dialectical behaviour therapy outcomes for adolescents with autism spectrum conditions compared to those without: findings from a seven-year service evaluation. Advances in Autism;2024;10(3):185-199.
Purpose Autism spectrum conditions (ASC) and borderline personality disorder (BPD) have overlapping symptom profiles. Dialectical behaviour therapy (DBT) is an established treatment for self-harm and BPD, but little research has investigated the outcomes of DBT for ASC populations. This exploratory service evaluation aims to investigate the outcomes of a comprehensive DBT programme for adolescents with a diagnosis of emerging BPD and a co-occurring ASC diagnosis as compared to those without an ASC diagnosis. Design/methodology/approach Differences from the start to end of treatment in the frequency of self-harming behaviours, BPD symptoms, emotion dysregulation, depression, anxiety, the number of A&E attendances and inpatient bed days, education and work status, and treatment non-completion rates were analysed for those with an ASC diagnosis, and compared between those with an ASC diagnosis and those without. Findings Significant medium to large reductions in self-harming behaviours, BPD symptoms, emotion dysregulation and inpatient bed days were found for those with an ASC diagnosis by the end of treatment. There were no significant differences between those with an ASC and those without in any outcome or in non-completion rates. These findings indicate that DBT may be a useful treatment model for those with an ASC diagnosis, though all results are preliminary and require replication. Originality/value To the best of the authors’ knowledge, this is the first study to report the outcomes of a comprehensive DBT programme for adolescents with an ASC diagnosis, and to compare the changes in outcomes between those with a diagnosis and those without.
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8. Al-Attar Z, Worthington R. Moral distress and moral injury in the context of autism. Advances in Autism;2024;10(3):200-219.
Purpose Clinically, it is often observed that autistic people may have a heightened need for rules and may find rule violations very distressing. It is clinically plausible that autistic individuals may be prone to hyper-morality and greater reactivity and adverse experiences arising from moral threats and violations. Such adverse experiences may, in some instances, lead to moral distress (MD) or in more extreme cases moral injury. Thus, this study aims to examine how MD can operate in the context of autism. Design/methodology/approach The authors explore clinical hypotheses on how MD can intersect with different features of autism by drawing on clinical and research knowledge of autism spectrum disorder and how it contextualises experiences of morality. Findings Based on a review of the literature and theory, the authors hypothesise that autistic individuals may be more prone to MD where they have a lower threshold for MD. As a result of this lower threshold, they may have more frequent exposure to MD, experience more immediate and intense subjective reactions to moral transgressions, for more protracted periods. Also, they may find it more difficult to over-ride and neutralise moral outrage. As a result, they may be more susceptible to mental health sequelae and impaired social and occupational functioning. Practical recommendations are made for clinicians supporting people with autism with a propensity for MD or moral injury, to improve their quality of life. Practical implications Practical recommendations are made for clinicians supporting people with autism with a propensity for MD or moral injury, to improve their quality of life. Originality/value Understanding MD in an autistic context is important for detecting and treating the adverse impacts of MD on autistic individuals. Importantly, erroneous preconceptions about moral reasoning in autism need to be mitigated to fully understand the moral experiences and harness the many strengths of people with autism.
