ArticlePDF Available

Post-traumatic symptoms in adults with Autism Spectrum Disorder: An Unexplored Co-occurrence of Conditions

Authors:

Abstract and Figures

People with Autism Spectrum Disorder (ASD) show an increased risk of experiencing potentially traumatic events, particularly social victimization. However, ASD and PostTraumatic Stress Disorder (PTSD) co-occurrence was hardly studied. We examined exposure to potentially traumatic life events and PTSD symptoms (PTSS) in adults with ASD vs. typical adults (TA). Twenty-five (25) adults with ASD and 25 TA were matched on age and gender. Participants self-reported on potentially traumatic life events of social and non-social nature, and on PTSS related to their most distressing event. Results showed higher rates of probable-PTSD in the ASD group (32%) compared to the TA group (4%). Individuals with ASD reported more PTSS, particularly re-experiencing and hyperarousal, compared to TA, although the latter was elevated only in females with ASD. Participants with ASD, especially females, reported more negative life events, particularly social events, than TA. 60% of ASD participants, but only 20% of TA, chose a social event as their most distressing event. Individuals with ASD and probable-PTSD co-occurrence presented poorer social skills compared to those with ASD alone. Results indicate increased vulnerability of individuals with ASD to trauma and PTSD, especially due to social stressors. Females with ASD may be particularly vulnerable to PTSD.
Content may be subject to copyright.
Autism Spectrum Disorder and Post-Traumatic Stress Disorder
An Unexplored Co-Occurrence of Conditions
Nirit Haruvi-Lamdan1, Danny Horesh1,2,3, Shani Zohar1, Meital Kraus1, Ofer Golan1,3,4
1
Department of Psychology, Bar-Ilan University
2 School of Medicine, New York University
3Autism Research and Treatment Center, Association for Children at Risk
4Autism Research Centre, Department of Psychiatry, University of Cambridge
Corresponding author: Prof. Ofer Golan, Department of Psychology, Bar-Ilan
University, Ramat-Gan, 5290002, Israel. Tel. +972-3-5317941, E-mail:
ofer.golan@biu.ac.il
Published online ahead of print in Autism, The International Journal of Research and
Practice, special issue on Mental Health Across the Lifespan.
DOI 10.1177/1362361320912143.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Abstract
People with Autism Spectrum Disorder (ASD) show an increased risk of experiencing
potentially traumatic events, particularly social victimization. However, ASD and Post-
Traumatic Stress Disorder (PTSD) co-occurrence was hardly studied. We examined
exposure to potentially traumatic life events and PTSD symptoms (PTSS) in adults with
ASD vs. typical adults (TA).
Twenty-five (25) adults with ASD and 25 TA were comparable on age and gender.
Participants self-reported on potentially traumatic life events of social and non-social
nature, and on PTSS related to their most distressing event.
Results showed higher rates of probable-PTSD in the ASD group (32%) compared to
the TA group (4%). Individuals with ASD reported more PTSS, particularly re-
experiencing and hyperarousal, compared to TA, although the latter was elevated only
in females with ASD. Participants with ASD, especially females, reported more
negative life events, particularly social events, than TA. 60% of ASD participants, but
only 20% of TA, chose a social event as their most distressing event. Individuals with
ASD and probable-PTSD co-occurrence presented poorer social skills compared to
those with ASD alone.
Results indicate increased vulnerability of individuals with ASD to trauma and PTSD,
especially due to social stressors. Females with ASD may be particularly vulnerable to
PTSD.
Keywords: Post-Traumatic Stress Disorder, Autism Spectrum Disorder, Negative social
events, Traumatic life events, Gender differences.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Introduction
Autism Spectrum Disorder is a neurodevelopmental condition, characterized by
social communication deficits, and restricted, repetitive, behavior patterns (American
Psychiatric Association, 2013). It is well documented that individuals with ASD
experience high rates of psychiatric co-occurrence, with other conditions - ADHD,
anxiety, and depression being the most commonly diagnosed (Joshi et al., 2012).
Recently it has been suggested that individuals with ASD are at an increased risk of
experiencing potentially traumatic events and being significantly affected by them
(Haruvi-Lamdan, Horesh, & Golan, 2018; Kerns, Newschaffer, & Berkowitz, 2015).
The current study examined the association between ASD and symptoms of Post-
Traumatic Stress Disorder (PTSD).
PTSD is the most common chronic stress disorder resulting from exposure to
traumatic events. According to DSM-5 (APA, 2013), post-traumatic symptoms fall into
four main clusters: Re-experiencing symptoms (e.g., recurrent distressing memories or
dreams, flashbacks); Cognitive and behavioral avoidance of traumatic reminders;
Negative alterations in cognition and mood (e.g., inability to experience positive
emotions, negative beliefs or expectations); and Alterations in hyper-arousal (e.g.
startle responses, irritable behavior and anger, sleep disturbances). More than 80% of
individuals with PTSD have one or more co-occurring conditions, most commonly
depression, anxiety, and substance abuse disorders (Van Minnen, Zoellner, Harned, &
Mills, 2015). PTSD severity has been shown to worsen by high co-occurrence with
other psychiatric conditions (e.g., Kessler, 2000). While the vast majority of the
population is exposed to a potentially traumatic event at some point in life, only a small
percentage (5.6% lifetime prevalence; Koenen et al., 2017) will develop PTSD. Various
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
studies have attempted to identify different factors related to risk and maintenance of
PTSD (e.g., Marx & Gutner, 2015).
However, a surprisingly small number of studies have examined the
susceptibility to PTSD in individuals with neurodevelopmental conditions. Studies
suggest that youth with intellectual and developmental disabilities are 1.5 to over 3
times more likely to be maltreated (Hibbard & Desch, 2007; Reiter, Bryen, & Shachar,
2007) or to be exposed to trauma in general (Martorell & Tsakanikos, 2008), compared
to their typically developing peers. A few studies have shown that individuals with ASD
are exposed and strongly affected by traumatic events, especially abuse (e.g. Cook,
Kieffer, Charak, & Leventhal, 1993; Mandell et al., 2005; Taylor & Gotham, 2016).
However, these were either case studies or uncontrolled studies. Furthermore, most of
these studies focused on children and relied on parental report. Finally, the ASD
samples were highly heterogeneous in terms of intellectual abilities, and, most
importantly, PTSD symptoms were rarely measured as the outcome of exposure to
traumatic events. To the best of our knowledge, only one study focused on PTSD and
ASD, which examined it among children following various traumatic events, such as
accidents, natural disasters, violence and abuse (Mehtar & Mukaddes, 2011). This study
reported a PTSD prevalence of 17.4% in children with ASD. Four studies examined
PTSD rates as part of a general examination of psychiatric conditions co-occurring with
ASD; two examined it among children and adolescents and found a PTSD prevalence
of 1.7% (Reinvall et al., 2016) and 0% (de Bruin et al., 2007). Three studies examined
psychiatric symptomatology among adults with ASD and found PTSD rates of 7%
(Strunz, Dziobek, & Roepke, 2014), 1.6% (Hofvander et al., 2009), and 0% (Taylor &
Gotham, 2016). Four studies measured PTSD symptoms as part of research on anxiety
disorder treatment among children and adolescents and found PTSD rates of 2.5%
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
(Wood et al., 2009), 3.3% (White et al. 2013), 3.1% (McConachie et al., 2014), and 3%
(Wood et al. 2015). Another study by Storch and colleagues (2013) reported a PTSD
rate of 3% in an ASD sample, and PTSD was associated with suicidal thoughts and
behaviors. Finally, Hollocks and colleagues (2016) focused on cognitive and biological
correlates of anxiety in ASD and reported no co-occurrence with PTSD. It is therefore
hard to draw clear conclusions from those different findings. In addition, Kildahl and
colleagues (2019) reviewed studies that examined post-traumatic symptoms in
individuals with ASD and intellectual impairments. Their findings highlight the gaps
in the literature regarding the identification of PTSD in individuals with ASD. The
majority of reviewed studies did not include a standard measurement of PTSD
symptoms and studies varied in sample characteristics, methodology, and types of
traumatic events. Finally, a growing body of evidence suggests that, compared to those
with low levels of autistic traits (AT), individuals with higher levels of AT in the
general population, are more exposed to potentially traumatic events (Dell’Osso et al.,
2018; Kunihira, Senju, Dairoku, Wakabayashi, & Hasegawa, 2006), and suffer from
higher levels of PTSD symptoms following them (Haruvi-Lamdan, Lebendiger, Golan,
& Horesh, 2019; Roberts, Koenen, Lyall, Robinson, & Weisskopf, 2015).
Interestingly, PTSD and ASD show an opposite directionality of gender-related
vulnerability. PTSD is common approximately twice as more in females as in males
due to various risk factors (e.g., traumatic exposure, genetic and biological
vulnerability). Males and females with PTSD were also found to differ in terms of
symptom cluster manifestation (Farhood, Fares, & Hamady, 2018; Yehuda et al., 2015).
ASD, on the other hand, is more common in males than in females, with a male to
female ratio varying from 3:1 (Loomes, Hull, & Mandy, 2017) to 16:1 (Ferri, Abel, &
Brodkin, 2018). Previous studies suggested gender differences in core ASD symptoms
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
and raised the possibility of different male and female phenotypes (Hull, Mandy, &
Petrides, 2017; Lai, Lombardo, Auyeung, Chakrabarti, & Baron-Cohen, 2015). In both
research fields, studies attempt to shed further light on gender differences and
vulnerability. To the best of our knowledge, the levels of PTSD symptoms among
individuals with ASD have not been explored in relation to gender.
The definition of a traumatic event has changed throughout the years, since the
introduction of PTSD in DSM-III (APA, 1980). Although there is still an ongoing
debate regarding this definition (Larsen & Berenbaum, 2017), DSM-5 defines a
traumatic event as one which involves a direct or indirect exposure to actual or
threatened death, serious injury, or sexual violence (APA, 2013). This debate is highly
relevant when examining the unique experiences of individuals with
neurodevelopmental conditions. A review that examined trauma and PTSD among
adults with intellectual impairments discussed the difficulty to differentiate between
stressful life events and traumatic events, and argued for broadening the examination
of different types of events and experiences that may potentially be perceived as
traumatic (Martorell & Tsakanikos, 2008). Another review, by Kerns, Newschaffer, &
Berkowitz (2015), indicated that individuals with ASD may experience a variety of
stressful situations (e.g., intense sensory stimuli, changes in routine, medical ordeals)
as traumatic. Various characteristics of sensation, perception, social awareness, and
cognition, which are unique to individuals with ASD, may determine which events
would be experienced by them as traumatic. A recent paper discussed this issue and
focused on traumatic subjective perception of three groups of patients who are at risk
to developing PTSD, one being ASD (Brewin, Rumball, & Happé, 2019). The authors
argued that these groups’ PTSD symptoms are often overlooked and suggested adding
an "altered perception" subtype to PTSD criteria in the future. Specifically, it is possible
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
that social stressors are a significant source of vulnerability for individuals with ASD
(Haruvi-Lamdan, Horesh, & Golan, 2018; Hoover, 2015). Several studies suggest that
social demands are more often appraised as stressful by individuals with ASD
compared to typical individuals (Gillott & Standen, 2007; Jansen, Gispen-de Wied, van
der Gaag, & van Engeland, 2003). Individuals with ASD experience greater social
isolation and distress compared to their typical peers (Tani et al. 2012). Therefore, it is
reasonable to assume that some social interactions are experienced as particularly
stressful, and even traumatic, among this population. Furthermore, children and adults
with ASD are more often verbally, physically, and socially bullied, relative to the
general population (Bitsika & Sharpley, 2014; Schroeder, Cappadocia, Bebko, Pepler,
& Weiss, 2014; Falla & Ortega-Ruiz, 2019). Studies have shown that children with
ASD are bullied more often than peers with other disabilities (Sreckovic, Brunsting, &
Able, 2014; Zeedyk, Rodriguez, Tipton, Baker, & Blacher, 2014). However, PTSD
symptoms were not measured in any of these studies (Hoover, 2015), although previous
studies among the general population suggested bullying is a potential precursor of
PTSD (Idsoe, Dyregrov, & Idsoe, 2012; Nielsen, Tangen, Idsoe, Matthiesen, &
Magerøy, 2015).
The main aim of this study was to examine PTSD Symptoms (henceforth,
PTSS) among adults with ASD and typical adults (TA), following various potentially
traumatic life events, including a wide range of negative social events (such as
bullying and social exclusion), as well as events more commonly studied in relation to
PTSD (such as exposure to war or terror, serious accidents or injury). We aim to shed
light on the level of PTSS in adults with ASD, and to examine the moderating role of
gender. Moreover, we aim to understand which types of events are perceived as
traumatic for adults with ASD, and specifically whether negative social events are
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
more commonly associated with PTSS in this group. Finally, we aimed to assess
whether the existence of an ASD and probable PTSD co-occurrence exacerbates the
clinical picture of ASD.
Methods
Participants
Fifty adults, aged 18-35 (M=22.82, SD=3.57) participated in the study: 25 with
a formal diagnosis of ASD, and 25 TA. The groups were comparable on age and gender
(10 females in each group). Participants of both groups were invited to take part in a
life events study, using advertisements placed in internet forums and social networks.
Participants with ASD were also recruited through non-governmental organizations,
which operate community programs for adults with ASD in Israel. Inclusion criteria for
both groups were age of 18 and above, and Hebrew as a native tongue. Typical
participants were screened-out for ASD using the Autism-Spectrum Quotient (AQ;
Baron-Cohen, Wheelwright, Skinner, Martin, & Clubley, 2001), and all scored below
cutoff. Inclusion criteria for the ASD group was a formal diagnosis of ASD with no
intellectual impairment, from a clinical psychologist or psychiatrist, and recognition of
the diagnosis by the Israel Ministry of Welfare and the National Insurance service.
Individuals with a self-reported diagnosis of psychosis were excluded from the study
(n=1). Among males, the median age in which they were diagnosed with ASD was 4.5
while among females the median age for diagnosis was 14. Only two participants (8%)
with ASD had a legal guardian. The majority of participants were Jewish, single, and
born in Israel.
No differences were found between the groups regarding self-reported socio-
demographic characteristics or psychiatric co-occurring conditions. In the ASD group,
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
20% reported on co-occurring ADHD, 8% on depression and anxiety, and 4% on OCD.
In the TA group, 12% reported a current diagnosis of ADHD, and 4% reported a
diagnosis of depression and anxiety. An ASD-TA group difference in background
variables was found only for education 2(1)=13.60, p<.001), with more typical
participants reporting academic education (n=20, 80%), compared to participants with
ASD (n=7, 28%). Table 1 presents the sample's characteristics and group differences
on the study’s measures.
Procedure
Initially, a short telephone interview was conducted in order to assess
compatibility to the study, as well as to provide information on the study, and to
schedule a meeting. All participants and, when required, their legal guardians, provided
written informed consent. All participants completed self-report questionnaires during
a face to face meeting with a qualified member of the research team. Participants were
compensated for their time. The study received an official ethical approval from Bar-
Ilan University's institutional review board (IRB), where the study was conducted.
Measures
Socio-demographic background - Participants were presented with a variety of
background questions assessing socio-demographic factors, including date and place of
birth, family status, socio-economic status, religiosity, and psychiatric diagnoses.
Traumatic life events This measure includes a comprehensive list of
potentially traumatic life events, divided into two parts: The first part was based on the
Life Events Checklist for DSM-5 (LEC-5; Weathers, Blake et al., 2013). It included events
such as sexual assault, exposure to war or terror, a serious accident, and life-threatening
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
illness or injury. These events are compatible with the traumatic event definition
(Criterion A) in the DSM-5. Thus, we considered them as “PTSD criterion A events”
(APA, 2013). The second part comprised a list of negative inter-personal situations that
were based on a bullying questionnaire (Sourander et al., 2010). These included
exposure to various forms of bullying and cyberbullying, including physical (e.g.,
hitting, pushing), verbal (e.g., name-calling, threats), or psychological (e.g., social
exclusion, ostracism). In the current study, we considered them as “negative social
events”. Participants were asked to record stressful events, which they have
experienced during their lifetime. Next, they were asked to note which event caused
them the most significant distress from the entire list.
PTSD Checklist for DSM-5 (PCL-5), Specific Version (Weathers, Litz et al.,
2013) - The PCL-5 is a self-report questionnaire measuring PTSS in the preceding
month. Items correspond directly with the 20 symptoms of PTSD appearing in DSM-5
(APA, 2013). The PCL-5-S (specific) asks about symptoms in relation to an identified
stressful experience. Participants were asked to complete it while referring to the event,
which they marked as most distressing, from the potentially traumatic life events list
described above. The self-report rating scale is 0-4 for each symptom (from "Not at all"
to "Extremely"). The PCL-5 yields a total score, a score for each symptom cluster, and
a probable PTSD diagnosis according to a cutoff score of 38, which is commonly used
in trauma studies (Bovin et al., 2016). The PCL-5 has been shown to have very good
psychometric properties (Blevins, Weathers, Davis, Witte, & Domino, 2015). In the
current study, the instrument has shown excellent internal consistency (Cronbach’s
alpha=.94).
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Table 1: Sample Characteristics and Group Differences
Note: *p<.05, **p<.01, ***p<.001; PCL-5 PTSD Checklist for DSM-5; AQ Autism
spectrum Quotient.
The Autism-Spectrum Quotient (AQ; Baron- Cohen et al.,2001) - The AQ has been
used extensively as a self-report measure of autistic traits, and as a screener for ASD.
It comprises 50 items, grouped into five theory-driven clusters: social skill
difficulties, communication difficulties, attention switching difficulties, attention to
Background Variables
ASD
TA
Gender (M:F (
15:10
15:10
Country of birth (Israel:other)
24:1
22:3
Family status (Single: In a relationship)
21:4
24:1
Education (High School: Academic)
18:7
5:20
Religion (Jewish:other)
24:1
22:3
Income (Below Av.: Average: Above Av.)
2:10:13
5:5:15
Employment (Full:part:none)
5:9:11
4:12:9
Age Mean (SD)
22.88 (3.7)
22.76 (3.4)
Dependent Variable Means (SD)
Exposure: No. of negative social events
7.56 (3.85)
3.88 (3.85)
25.12***
No. of PTSD criterion A events
3.00 (1.41)
3.48 (2.53)
0.77
Total no. of events
10.56 (4.55)
7.36 (4.64)
11.06**
PCL-5: Re-experiencing
5.96 (4.41)
4.24 (2.96)
4.39*
Avoidance
2.92 (2.66)
2.72 (2.57)
0.27
Negative alterations in mood and
cognition
9.12 (6.65)
5.84 (5.86)
3.63
Hyper-arousal
8.24 (4.96)
3.44 (3.51)
20.27***
Total
26.24 (15.23)
16.24 (12.72)
7.56**
AQ: Social Skills
4.20 (2.29)
1.72 (1.54)
24.38 ***
Attention Switching
6.48 (2.08)
3.80 (1.78)
32.34 ***
Attention to Detail
6.56 (1.92)
5.56 (2.22)
3.66
Communication
5.04 (2.44)
1.48 (1.66)
33.67 ***
Imagination
4.40 (2.47)
2.92 (1.22)
5.76 *
Total
26.68 (8.07)
15.48 (5.47)
36.11 ***
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
details, and limited imagination. Participants rate to what extent they agree or disagree
with each statement on a 4-point Likert scale ranging from 1 ("definitely agree") to 4
("definitely disagree"). Using a binary scoring system (o or 1), scores range between
0-50, with a higher total score suggesting more autistic traits. AQ scores have been
shown to be stable cross-culturally (Hurst, Mitchell, Kimbrel, Kwapil, & Nelson-
Gray, 2007) and demonstrated good diagnostic validity (Baron-Cohen et al., 2001). In
the current study, the AQ has shown very good internal consistency (Cronbach’s
alpha=.89).
Results
Associations between ASD and PTSS
An examination of differences in probable PTSD rates revealed that the
proportion of participants in the ASD group reporting a probable PTSD diagnosis
according to the PCL cutoff score of 38 (n=8, 32%) was 8 times higher than in the
typical group (n=1, 4%; Fisher’s Exact Test p<.05). Pearson correlations revealed that
PCL total score (r=.58, p<.01), re-experiencing (r=.51, p<.01), negative alterations in
mood and cognition (r=.51, p<.01), and hyper-arousal (r=.48, p<.05) symptoms
significantly correlated with the social skills sub-scale of the AQ in the ASD group. In
the typical group, PTSS were significantly correlated with both the AQ subscales of
social skills and attention to details: The PCL total score (r=.40, p<.05), re-experiencing
(r=.44, p<.05), and negative alterations in mood and cognition (r=.53, p<.01) symptoms
were associated with social skills difficulties; PCL total score (r=.49, p<.05), re-
experiencing (r=.63, p<.01), and negative alterations in mood and cognition (r=.42,
p<.01) were associated with the AQs attention to details subscale.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Next, a Multivariate Analysis of Covariance (MANCOVA) was conducted,
with group and gender as the independent variables, and PCL scores (total score and
the four symptom cluster scores) as the dependent variables. Since the ASD and typical
groups differed on education level, this variable was added to the analysis as a
covariate. Table 2 presents descriptive PTSS scores by group and gender.
Table 2: Means (SD) of PTSD symptom scores by group and gender
ASD
TA
Male
Female
Male
Female
Re-experiencing
6.00 (4.65)
5.90 (4.25)
4.93 (3.01)
3.20 (2.69)
Avoidance
2.80 (2.56)
3.10 (2.92)
3.46 (2.72)
1.60 (1.95)
Negative alterations in
mood and cognition
9.20 (6.73)
9.00 (6.89)
7.13 (5.78)
3.9 (5.72)
Hyper-arousal
6.40 (4.57)
11.00 (4.37)
4.46 (3.97)
1.90 (1.96)
Total
24.40 (15.41)
29.00 (15.89)
20.00 (13.18)
10.60 (10.12)
The MANCOVA showed a significant main effect for group (F(4,42)=6.24,
p<.001,
2 =.37), and a significant group X gender interaction effect (F(4,42)=2.82,
p>.05,
2 =.21). Univariate analyses revealed that compared to typical participants,
those with ASD reported a significantly higher PCL total score (F(1,45)=7.56, p<.01,
2 =.14), as well as significantly higher levels of PTSS of re-experiencing
(F(1,45)=4.39, p<.05,
2 =.08) and hyper-arousal (F(1,45)=20.27, p<.001,
2 =.31). A
marginally significant difference was also found for negative alterations in mood and
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
0
1
2
3
4
5
6
7
8
9
10
11
Re-experiencing Avoidance Negative
alterations in
mood and
cognition
Hyper-arousal
PCL score
Figure 1: Groups differnces in PTSD symptoms
ASD
TA
cognition, with higher scores reported among participants with ASD, compared to TA
(F(1,45)=3.63, p=.063,
2 =.075). Figure 1 presents group differences in PTSS.
Note: ~p=.063, *p<.05, ***p<.001; PCL - PTSD Checklist for DSM-5.
A univariate interaction analysis revealed that the source of the multivariate
interaction effect was a significant interaction for hyper-arousal symptoms
(F(1,45)=9.65, p<.01,
2 =.18). A simple effects analysis showed that while the
difference in hyper-arousal symptoms between females with ASD and TA females was
significant, with the latter showing lower symptom levels (i-j= 9.27, s.e.= 1.90, p<.001),
no difference was found between males with ASD and typical males (i-j= 2.02, s.e.=
1.49, p=.18,). A marginally significant gender X group interaction was also found for
PCL total score (F(1,45)=3.14, p=.083,
2 =.065), again with females with ASD
reporting higher symptom levels than typical females.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
The severity of ASD symptoms as a function of co-occurrence with
probable PTSD
Next, we set out to examine whether the existence/non-existence of the co-
occurrence of ASD with probable PTSD is associated with greater ASD symptom
severity. Thus, we conducted a MANOVA comparing between those with ASD alone
(no co-occurring probable PTSD; n=17) and those with ASD-prob.PTSD (ASD and
probable PTSD; n=8) co-occurrence on AQ scores. The analysis showed a significant
main effect for ASD-prob.PTSD co-occurrence (F(5,19)=3.31, p<.05,
2 =.46).
Univariate analyses revealed that compared to those without a probable PTSD
diagnosis (i.e., ASD only), those with ASD-prob.PTSD co-occurrence reported a
significantly higher AQ score on the social skills sub-scale (F(1,23)=9.98, p<.05,
2=.303). Unfortunately, due to the very small number of participants with probable
PTSD from the TA group (n=1), we were unable to assess the same question regarding
PTSS severity.
Exposure to potentially traumatic life events
As noted earlier, in this study we chose to examine a wide variety of potentially
traumatic life events, including events clearly meeting the PTSD DSM-5 events
criterion (criterion A; e.g., war, sexual assault, traffic accidents) and social stressors,
such as bullying and ostracizing. A MANCOVA was conducted, with group and gender
as the independent variables, and number of potentially traumatic life events (total
count, number of negative social events and PTSD criterion A events) as the dependent
variables. Due to the between-group difference in education, the latter was added as a
covariate. The MANCOVA yielded main effects for group (F(2,44)=14.64, p<.001,
2
=.40), gender (F(2,44)=9.60, p<.001,
2 =.304), and the group X gender interaction
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
(F(2,44)=4.50, p<.05,
2=.17). Univariate analyses revealed that the source of the
multivariate group effect was a significant difference between the ASD and TA groups
in both the total number of potentially traumatic events (F(1,45)=11.06, p<.01,
2 =.20)
and the number of negative social events (F(1,45)=25.12, p<.001,
2 =.36), with
participants with ASD reporting higher exposure compared to typical participants. No
group difference was found regarding the number of PTSD criterion A events. Table 3
presents average numbers of potentially traumatic life events by group and gender.
Table 3: Mean numbers (SD) of potentially traumatic life events by group and gender
Males
Females
ASD
TA
ASD
TA
No. of negative social events
5.26
(3.19)
3.40
(3.33)
11.00
(1.33)
4.60
(3.62)
No. of PTSD criterion A events
2.53
(1.24)
3.93
(2.40)
3.70
(1.41)
2.80
(2.69)
Total No. of potentially
traumatic life events
7.80
(3.58)
7.33
(4.35)
14.70
(1.88)
7.40
(5.29)
In addition, significant gender differences were found regarding the total
number of potentially traumatic events (F(1,45)=9.40, p<.01,
2 =.17) and the number
of negative social events (F(1,45)=17.90, p<.001,
2 =.28), with females reporting
higher exposure compared to males. Additionally, a significant group by gender
interaction was found for the total number of potentially traumatic events
(F(1,45)=9.05, p<.01,
2 =.17). While the difference between females with ASD and
typical females was significant (i-j=7.70, s.e.=1.91, p<.001), the difference between
males with ASD and typical males was not (i-j=.66, s.e.=1.49, p=.66). A significant
interaction was also found for the number of negative social events (F(1,45)=7.95,
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
0
2
4
6
8
10
12
PTSD criterion A events Social events Total number of events
Number of events
Figure 2: Group differences in exposure to potentially traumatic life
events
ASD
TA
p<.01,
2 =.15). While the difference between females with ASD and typical females
was significant (i-j=7.21, s.e.=1.43, p<.001), the difference between males with ASD
and typical males was only marginally significant (i-j=2.25, s.e.=1.12, p=.051). Finally,
a marginally significant interaction was found regarding the number of PTSD criterion
A events (F(1,45)=3.18, p=.08,
2 =.07). While the difference between females with
ASD and typical females was not significant (i-j=.49, s.e.=.95, p=.61), the difference
between males with ASD and typical males was significant (i-j=1.60, s.e.=.74, p<.05).
The effects of exposure to potentially traumatic life events are illustrated in Figures 2
and 3.
Note: **p<.01, ***p<.001
**
***
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
0
2
4
6
8
10
12
14
Male Female
Number of events
Figure 3: Group X gender interaction regarding exposure to negative
social events
ASD
TA
Note: ~p=.065, ***p<.001
Finally, we examined which types of events were associated with PTSS in the
ASD and TA groups. Thus, Pearson correlations were calculated in order to examine
the association between PTSS and potentially traumatic exposure. As can be seen in
Table 4, a significant positive association between PTSS and number of negative social
events was found in the ASD group, but not in the TA group. In contrast, a significant
positive association was found between PTSS and PTSD criterion A events among the
TA group, but not in the ASD group. Looking at the PCL symptom clusters, the ASD
group showed significant positive associations only for hyper-arousal symptoms with
negative social events, and with total number of negative life events. In the TA group,
significant associations were found between all symptom clusters and PTSD criterion
A events, but no correlation was found for negative social events in this group.
***
~
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Table 4: Pearson correlations between number of potentially traumatic events and PCL
scores
Note: *p<.05,**p<.01
Finally, Sixty percent (60%; n=15) of participants with ASD chose a negative social
event as the event that caused them the most significant distress, compared to only 20%
(n=5) of typical participants 2(1)=8.33, p<.01). The events most frequently chosen by
ASD participants as the most distressing were shunning, physical, and verbal violence.
In the TA group, combat and exposure to terror were the events most commonly chosen
as most distressing.
Discussion
This is one of very few studies to have examined PTSS levels in adults with
ASD. So far, ASD-PTSD co-occurrence has received little empirical attention. Our
analysis reveals the increased vulnerability of adults with ASD (with no intellectual
impairment) to trauma and probable PTSD, and the role of gender as a moderator of the
PCL
Number
of events
Total score
Re-
experiencing
Avoidance
Negative
alterations in
mood and
cognition
Hyper-arousal
ASD
TA
ASD
TA
ASD
TA
ASD
TA
ASD
TA
Negative social
events
.41*
.31
.33
.23
-.09
.07
.35
.30
.53**
.38
PTSD criterion
A events
.15
.61*
-.05
.42*
.20
.46*
.04
.60**
.34
.52**
Total number
of life events
.39
.56**
.26
.40*
-.01
.30
.31
.55**
.56**
.56*
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
PTSS levels in adults with ASD. The results suggest that females with ASD are at a
greater risk for exposure to potentially traumatic events and for manifestation of PTSS.
Perhaps most importantly, our findings indicate that the social sphere in particular may
be potentially traumatic for individuals with ASD, especially for females. Additionally,
we found that individuals with ASD and probable PTSD co-occurrence present a more
severe clinical picture, compared to those endorsing ASD alone.
Our main finding revealed that individuals with ASD reported
significantly higher levels of PTSS, compared to typical participants. Looking at the
four PCL symptom clusters, individuals with ASD reported higher levels of re-
experiencing and hyper-arousal symptoms, as well as marginally significant higher
levels of negative alterations in mood and cognition. These findings are in line with a
previous study, which examined the association of PTSS and autistic traits (AT) in a
typical adult sample, revealing that those with the highest level of AT reported higher
levels of PTSS, particularly from the hyper-arousal cluster, compared to those with
lower AT (Haruvi-Lamdan et al., 2019).
One explanation for ASD and probable PTSD co-occurrence shown here may
be that ASD serves as a vulnerability factor for PTSD. Hirvikoski and Blomqvist (2015)
found that adults with ASD reported significantly higher subjective stress and poorer
ability to cope with stress in everyday life, compared to typical adults. One's subjective
perception of his or her ability to cope with a specific stressor is central in defining the
level of experienced distress (Karasek & Theorell, 1990). Individuals with ASD often
show executive functioning difficulties (Kenworthy, Yerys, & Anthony, 2008), which
may impede their choice of appropriate coping strategies. Another aspect related to
ASD that may affect individuals’ subjective distress level following trauma is sensory
hypersensitivity (e.g. Horder, Wilson, Mendez, & Murphy 2014), a factor that has been
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
associated with vulnerability to PTSD (Engel-Yeger, Palgy-Levin, & Lev-Wiesel,
2013). Additionally, communication difficulties and impaired social skills may get in
the way of reporting traumatic experiences and seeking help or treatment (Cook et al.,
1993). It is also possible that individuals with ASD receive less social support, which
is known as a major protective factor in the face of trauma (Wright, Kelsall, Sim,
Clarke, & Creamer, 2013). Importantly, ASD-PTSD co-occurrence could be attributed
to potential shared vulnerability mechanisms for both disorders, including emotion
regulation deficits, increased rumination, difficulties in autobiographical memory, and
impaired social cognition (Haruvi-Lamdan et al., 2018). This possibility of shared
mechanisms calls for future research.
Previous studies have shown mixed findings regarding the specific symptoms
characterizing individuals with ASD following trauma. In their review paper, Kildahl
and colleagues (2019) have shown that on the majority of studies examining response
to traumatic events among individuals with ASD and intellectual disability parents
reported symptoms of hyper-arousal and negative alterations in mood and cognition
following traumatic experiences. These symptoms were relatively more easily
identified, as opposed to intrusive memories and re-experiencing symptoms, which
cannot be fully captured using parental report. The few case studies that described re-
experiencing symptoms involved individuals with intact verbal abilities. Therefore,
they emphasized the importance of self-report measures that may capture the subjective
experience and symptomatology among traumatized individuals with ASD.
Additionally, previous studies have shown that children with ASD who experienced
frequent peer victimization reported increased arousal levels, including a stronger
tendency for anxiety, anger, hyper-sensitivity, self-injury, stereotypic behavior, and
hyperactivity (Bitsika & Sharpley, 2014; Cappadocia,Weiss, & Pepler, 2012). Looking
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
at the group differences in specific PTSS clusters, our results reveal the central role of
hyper-arousal and re-experiencing symptoms. The hyper-arousal cluster includes
several symptoms which may be considered "non-specific" to PTSD, including sleep
impairments, difficulty concentrating, agitation, and anger. This non-specific nature
may account for this cluster's association with other disorders co-occurring with PTSD
(Horesh et al., 2017). It is also possible that, at least in part, hyper-arousal is also related
to underlying symptoms of anxiety, which have been found to be elevated among those
with ASD (Zaboski, & Storch, 2018). While we did not specifically assess anxiety in
this study, this is a possible explanation. In addition, individuals with ASD have been
shown to experience sensory hyper-sensitivity, which in turn may cause them to feel
more agitated, hypervigilant, and generally aroused (Green, & Ben-Sasson, 2010). As
for re-experiencing, individuals with ASD were found to report high levels of
rumination and intrusive thoughts (Carne, Goddard, & Pring, 2013; Gothman et al.,
2014). This tendency to "rehash" mental and emotional content is at the core of the re-
experiencing cluster, and characterizes post-traumatic intrusions (e.g., constant
reminders of the trauma, flashbacks). Future qualitative inquiries may examine whether
the symptom clusters highlighted in our study fully capture the nature of the post-
traumatic experience in adults with ASD. Notably, there is also the possibility of the
increased hyperarousal symptoms resulting from an overlap between ASD symptoms
and PTSS, i.e., that some similarities between symptoms that are characteristic of both
conditions may inflate the level of PTSS reported by individuals with ASD. However,
symptom overlap is unlikely to explain the elevated re-experiencing PTSS found in the
current study.
In our sample, females with ASD reported marginally significant higher levels
of PTSS in general, and significantly higher levels of hyper-arousal symptoms,
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
compared to typical females. This difference was not found among males. A possible
explanation for this finding may be that the gender difference in PTSD rates in the
general population becomes even more profound among individuals with ASD. As
noted, in the general population females face a lifetime risk for PTSD that is twice as
high as males (Yehuda et al., 2015). Although gender differences in PTSS among
individuals with ASD were hardly ever studied before, one study did show that females
who experienced victimization and/or bullying reported more symptoms of anxiety
compared to males (Bouman et al., 2012). Our findings regarding PTSS gender
differences are particularly concerning considering the high prevalence of suicidal
thoughts and behaviors among individuals with ASD (Kirby et al., 2019), as well as
among women belonging to traumatized or abused minorities in society (Basile, Smith,
Fowler, Walters, & Hamburger, 2016). In fact, women with ASD were found to face a
particularly high risk of dying by suicide (Hirvikoski et al., 2016). Thus, traumatized
women with ASD may represent a particularly high-risk group, which possibly requires
special attention and treatment. Clearly, more studies are needed in order to elucidate
PTSD gender differences among individuals with ASD. We believe such an
examination is of particular importance in this era of personalized medicine.
Increased risk for traumatic exposure among individuals with ASD may also
serve as a vulnerability factor for PTSD (Haruvi-Lamdan et al., 2018). Indeed, our
findings indicate that individuals with ASD were significantly more exposed to
potentially traumatic life events compared to typical adults. In particular, participants
with ASD were more exposed to negative social events (e.g., bullying, ostracism), while
regarding PTSD criterion A events there was no group difference. Moreover, in our
sample, lifetime exposure to negative social events was related to PTSS in the ASD
group, but not in the TA group. In contrast, lifetime exposure to criterion A events was
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
related to PTSD symptoms among the TA group, but not the ASD group. In addition,
our results revealed that individuals with ASD showed a higher tendency to choose
negative social events as their most distressing experience, compared to typical adults.
This emphasizes the centrality of social stressors for individuals with ASD, compared
to events that are more commonly studied in trauma research. In this study, we included
a wide range of negative interpersonal experiences, from bullying, verbal insults,
humiliations, and social exclusion, to physical violence. These situations appear to be
perceived as more traumatic for individuals with ASD than for their typical peers. The
PTSD cognitive model by Ehlers and Clark (2000) emphasizes the importance of the
victim's subjective perception on the development and persistence of PTSD. The social
communication difficulties experienced by individuals with ASD may affect the
interpretations and meaning they assign to different situations. It is possible that they
encounter a social environment that is less accepting, and potentially more aggressive
towards them (White, Hillier, Frye, & Markrez, 2016). Moreover, at least for some
individuals with ASD, being aware of the difference between themselves and their
typical peers, as well as the way they are viewed by the latter, may be a source of
significant stress. The fact that individuals may be differentially vulnerable to certain
types of events is of key importance when attempting to understand the huge variability
in PTSD manifestation (Galatzer-Levy & Bryant, 2013). For those with ASD, negative
events occurring within the social realm seem to exert a unique influence in terms of
PTSS.
Importantly, our findings may indicate that for individuals with ASD, negative
social events exert a cumulative effect, as they are often experienced in a chronic,
continuous fashion. Spence and colleagues (2019) suggested that for many individuals
the traumatic event occurs within the context of other negative experiences, and that
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
one's emotional distress should be understood in light of this broader set of events. This
claim seems particularly relevant when it comes to ASD, as traumatic social events
often occur as part of ongoing, stress-inducing, inter-personal difficulties. For example,
bullying experiences are often recurrent, and tend to afflict socially vulnerable
individuals more than once (Sourander et al., 2010). Repeated and chronic traumatic
events have been shown to exert a powerful impact on one's inter-personal relationships
and core beliefs about the self and the world. Thus, it is quite possible that traumatized
individuals with ASD in fact experience chronic, complex trauma, as opposed to single
events, thereby yielding a broader, more severe clinical picture more akin to complex
PTSD (CPTSD; Brewin et al., 2017; Herman, 1992). To the best of our knowledge,
CPTSD has yet to be studied among adults with ASD (Taylor & Gotham, 2016), and
further studies in this area are needed.
Additionally, we have shown a gender by group interaction regarding trauma
exposure. Our findings indicate that females (but not males) with ASD face an
increased risk of experiencing potentially traumatic events compared to typical females.
One explanation for this finding may be that the ASD diagnosis for females usually
occurs later in life, compared to males. This may expose females to a longer period of
being misunderstood and potentially mistreated not only by their peers but also by
authority figures such as teachers or employers, with little appropriate support.
Furthermore, in recent years, findings about the tendency of females with ASD to
camouflage their characteristics (e.g., Dean, Harwood, & Kasari, 2017) suggests that
females may be exposed to traumatic experiences in the social realm, without being
properly noticed and supported. Camouflaging in females with ASD has been shown to
associate with more anxiety and depression (Brgiela, Steward, & Mandy, 2016; Lai, et
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
al., 2011). Future studies should examine if part of this clinical picture also includes
PTSD.
The final aim of this study was to examine whether ASD-probable PTSD co-
occurrence entails higher symptom severity. We have found that, compared to
individuals diagnosed only with ASD, those with ASD and probable-PTSD report
greater deficits in social skills. This is in line with previous studies, showing that having
two or more diagnoses was associated with worse functioning, specifically social
functioning: Chiang and Gau (2016) found among youth with ASD that co-occurring
psychiatric conditions (e.g., anxiety, depression) mediated the association between
autistic symptoms severity and social dysfunction. Zukerman and colleagues (2019)
found that adaptive behavior (e.g. social skills and communication) were negatively
correlated with social anxiety and OCD symptoms among students with ASD. In
contrast, Kerns, Kendall, Zickgraf, et al., (2015) have found that youth with co-
occurring ASD and anxiety disorders had better parent-reported functional
communication than youth with ASD alone. Therefore, further research is required. As
for PTSD, previous studies have similarly shown that the disorder's severity was
associated with the existence of co-occurring conditions, including depression and
substance abuse (e.g., Shah, Shah, & Links, 2012). To the best of our knowledge, this
is the first study to examine ASD-PTSD co-occurrence in this context. Our results
provide preliminary evidence that ASD and probable-PTSD co-occurrence exacerbates
at least some symptoms of ASD. Due to the small number of individuals meeting the
cutoff for probable PTSD in our sample, we were unable to examine this question for
PTSS severity as well. Thus, further studies are needed in this area, based on larger
samples.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
It is important to remember, however, that participants were labeled with a
probable PTSD diagnosis based on their self-report on the PCL. Whereas these reports
may indeed represent a co-occurrence of both conditions, reliance on self-report
measures that have not been adapted for the use of individuals with ASD may bias our
results in different ways: on one hand, they may be insufficiently sensitive to the unique
symptoms or the different manifestation of symptoms following trauma among
individuals with ASD. On the other hand, such measures may overpathologize
individuals with ASD given that some symptoms of ASD and related co-occurring
conditions (e.g., anxiety, depression) could resemble and elevate scores on a PTSD
measure erroneously (Cassidy et al., 2018). Hence, a clinical assessment for PTSD
among participants with ASD may be warranted. Noteworthy, even with a clinical
evaluation in place, the differential diagnosis between autistic and post-traumatic
symptoms may be complicated, especially with regards to socio-emotional functioning
and sensory experiences (Stavropoulos, Bolourian, & Blacher, 2018). Therefore, the
diagnosis of PTSD among individuals with ASD calls for the establishment of clear
clinical guidelines.
This study is limited by its focus on adults with ASD and no intellectual or
verbal impairments. Therefore, the generalization of findings to the wider autistic
spectrum may be limited. Our study was also based on a cross-sectional design, thus
excluding the possibility of establishing causal relationships between assessed factors.
It is therefore possible that some of the social difficulties attributed to the ASD
phenotype were actually PTSS. We recommend that future studies employ prospective,
longitudinal designs, in order to more accurately assess the temporal relationships
between specific events and their post-traumatic implications among individuals with
ASD. Finally, our sample size was quite modest, and thus statistical power was
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
sometimes insufficient to conduct certain analyses. This was especially apparent when
examining the probable PTSD diagnosis, as only few participants passed the PCL
threshold.
Nonetheless, this study is novel and important in several ways. Studies
examining PTSD among adults with ASD are very rare. These individuals are trying to
integrate and function in society, but often face significant challenges and hardships.
Future studies are encouraged to examine exposure to potentially traumatic events and
PTSD in different contexts, as well as among individuals with ASD in different age
groups, developmental and intellectual levels. Our findings indicate that there are
potentially traumatic events, most notably negative social events, that are not included
in standard trauma measures, and are central in the experience of individuals with ASD.
Therefore, further research is needed to create and validate measures of trauma
exposure, PTSD, and complex PTSD among children and adults with ASD. These
measures should also be sensitive to gender differences in symptom manifestation and
trauma exposure. These methodological complexities attest to the fact that the vast
majority of trauma studies to date have been conducted among typical individuals, thus
neglecting a wide variety of populations that may experience trauma differently and
carry unique post-traumatic scars. Finally, following the improved identification of
trauma and PTSD among males and females with ASD, future studies should focus on
developing novel interventions for treating trauma-exposed clients with ASD, and
assessing their effectiveness. While evidence-based psychotherapy has massively
developed for PTSD and ASD separately, we currently know only of case studies
describing psychotherapy for individuals who have co-occurring ASD and PTSD
(Rumball, 2018).
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
We conclude that individuals with ASD show increased vulnerability to trauma and
enhanced PTSS, particularly due to social stressors; that females with ASD may be at
an increased risk for trauma, and that adults with ASD may show a unique profile of
PTSS. This study is preliminary in nature, as it is based on a small sample, using self-
report measures. Its novel findings should be taken as a first step in this under-explored
area. There is a pressing need for future research based on larger samples and more
complex methodologies and study designs.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
References
American Psychiatric Association. (1980). Diagnostic and Statistical Manual of
Mental Disorders (3rd ed.). Washington, DC: American Psychiatric Publishing, Inc.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of
Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bargiela, S., Steward, R., & Mandy, W. (2016). The experiences of late-diagnosed
women with autism spectrum conditions: an investigation of the female autism
phenotype. Journal of Autism and Developmental Disorders, 46(10), 3281-3294.
Baron-Cohen, S., Wheelwright, S., Skinner, R., Martin, J., & Clubley, E. (2001). The
Autism-Spectrum Quotient (AQ): Evidence from Asperger Syndrome/High-
Functioning Autism, Males and Females, Scientists and Mathematicians. Journal of
Autism and Developmental Disorders, 31(1), 5-17.
Basile, K. C., Smith, S. G., Fowler, D. N., Walters, M. L., & Hamburger, M. E.
(2016). Sexual violence victimization and associations with health in a community
sample of African American women. Journal of Aggression, Maltreatment and
Trauma, 25, 231253. http://dx.doi.org/101080/10926771.2015.1079283
Blevins, C.A., Weathers, F.W., Davis, M.T., Witte, T.K., Domino, J.L. (2015). The
Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and
initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489-498.
Bitsika, V., & Sharpley, C. F. (2014). Understanding, experiences, and reactions to
bullying experiences in boys with an autism spectrum disorder. Journal of
Developmental and Physical Disabilities, 26, 747761.
Bouman, T., van der Meulen, M., Goossens, F. A., Olthof, T., Vermande, M. M., &
Aleva, E. A. (2012). Peer and self-reports of victimization and bullying: Their
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
differential association with internalizing problems and social adjustment. Journal
of school psychology, 50(6), 759-774.
Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr,
P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD checklist for
diagnostic and statistical manual of mental disordersfifth edition (PCL-5) in
veterans. Psychological Assessment, 28(11), 1379.
Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., . . .
Reed, G. M. (2017). A review of current evidence regarding the ICD-11 proposals
for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 1-15.
Brewin, C. Rumball, F., & Happé, F. (2019). Neglected causes of post-traumatic
stress disorder. The BMJ, 365, I2372.
Cappadocia, C. M., Weiss, J. A.,& Pepler, D. (2012). Bullying experiences among
children and youth with autism spectrum disorders. Journal of Autism and
Developmental Disorders, 42, 266277.
Carne, L., Goddard, L., & Pring, L. (2011). Autobiographical memory in adults with
autism spectrum disorder: The role of depressed mood, rumination, working
memory and theory of mind. Autism: The International Journal of Research and
Practice, 17, 205-219.
Cassidy, S. A., Bradley, L., Bowen, E., Wigham, S., & Rodgers, J. (2018).
Measurement properties of tools used to assess depression in adults with and
without autism spectrum conditions: a systematic review. Autism Research, 11(5),
738-754.
Chiang, H. L., & Gau, S. S. F. (2016). Comorbid psychiatric conditions as mediators
to predict later social adjustment in youths with autism spectrum disorder. Journal
of child psychology and psychiatry, 57(1), 103-111.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Cook, E. H., Kieffer, J. E., Charak, D. A., & Leventhal, B. L. (1993). Autistic
disorder and post-traumatic stress disorder. Journal of the American Academy of
Child and Adolescent Psychiatry, 32(6), 12921294.
Dean, M., Harwood, R., & Kasari, C. (2017). The art of camouflage: Gender
differences in the social behaviors of girls and boys with autism spectrum disorder.
Autism, 21(6), 678-689.
de Bruin, E.I., Ferdinand, R.F., Meester, D., de Nij, P.F.A., & Verheij, F. (2007).
High rates of psychiatric comorbidity in PDD-NOS. Journal of Autism and
Developmental Disorders, 37, 877-866.
Dell'Osso, L., Cremone, I.M., Carpita, B., Fagiolini, A., Massimetti, G., Bossini, L.,
Vita., A.,…Gesi, C. (2018). Correlates of autistic traits among patients with
borderline personality disorder. Comprehensive Psychiatry, 83, 7-11.
Ehlers, A., & Clark, M.C. (2000). A cognitive model of posttraumatic stress disorder.
Behavior Research and Therapy, 38, 319-345.
Engel-Yeger B, Palgy-Levin D and Lev-Wiesel R (2013) The relationship between
post traumatic stress disorder and sensory processing patterns. Occupational
Therapy in Mental Health, 29, 266278.
Falla, D., & Ortega-Ruiz, R. (2019). Los escolares diagnosticados con trastorno del
espectro autista y víctimas de acoso escolar: Una revisión sistemática [Students
diagnosed with autism spectrum disorder and victims of bullying: A systematic
review]. Psicología Educativa, 25(2), 77-90.
Farhood, L., Fares, S., & Hamady, C. (2018). Correction to: PTSD and gender: could
gender differences in war trauma types, symptom clusters and risk factors predict
gender differences in PTSD prevalence?. Archives of women's mental health, 21(6),
735-743.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Ferri, S. L., Abel, T., & Brodkin, E. S. (2018). Sex differences in autism spectrum
disorder: A review. Current psychiatry reports, 20(2), 9.
Galatzer-Levy, I. R., & Bryant, R. A. (2013). 636,120 ways to have posttraumatic
stress disorder. Perspectives on Psychological Science, 8(6), 651-662.
Gillott, A., & Standen, P.J. (2007). Levels of anxiety and sources of stress in adults
with autism. Journal of Intellectual Disabilities, 11 (4), 359-370.
Gotham, K., Bishop, S.L., Brunwasser, S., & Lord, C. (2014). Rumination and
perceived impairment associated with depressive symptoms in verbal adolescent-
adult ASD sample. Autism Research, 7, 381-391.
Green, S.A., & Ben-Sasson, A. (2010). Anxiety disorders and sensory over-
responsivity in children with autism spectrum disorders: Is there a causal
relationship? Journal of Autism and Developmental Disorders, 40(12), 1495-1504.
Haruvi-Lamdan, N., Horesh, D., & Golan, O. (2018). PTSD and autism spectrum
disorder: Co-morbidity, gaps in research and potential shared mechanisms.
Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 290299.
Haruvi-Lamdan, N., Lebendiger, S., Golan, O., & Horesh, D. (2019). Are PTSD and
autistic traits related? An examination among typically developing Israeli adults.
Comprehensive Psychiatry, 89, 22-27.
Herman, J. L. (1992). Trauma and recovery. New York, NY: Basic Books.
Hibbard, R. A., & Desch, L. W. (2007). Maltreatment of children with disabilities.
Pediatrics, 119, 10181025.
Hirvikoski, T., & Blomqvist, M. (2015). High self-perceived stress and poor coping in
intellectually able adults with autism spectrum disorder. Autism, 19(6), 752-757.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Lichtenstein, P., &
Bölte, S. (2016). Premature mortality in autism spectrum disorder. The British
Journal of Psychiatry, 208(3), 232-238.
Hofvander, B., Delorme, R., Chaste, P., Nydén, A., Wentz, E., Ståhlberg, O., et al.
(2009). Psychiatric and psychosocial problems in adults with normal-intelligence
autism spectrum disorders. BMC Psychiatry, 9(1), 35.
Hollocks, M. J., Pickles,Howlin, P., and Simonoff, E. (2016). Dual cognitive and
biological correlates of anxiety in autism spectrum disorders. Journal of Autism and
Developmental Disorders, 46(10), 3295-3307.
Horesh, D., Lowe, S.R., Galea, S., Aiello, A.E., Uddin, M., & Koenen, K.C. (2017).
An in-depth look into PTSD-depression comorbidity: A longitudinal study of
chronically-exposed Detroit resident. Journal of Affective Disorders, 208, 653-661.
Hoover, D.W. (2015). The effects of psychological trauma on children with autism
spectrum disorders: A research review. Review Journal of Autism and
Developmental Disorders, 2, 287299.
Horder, J., Wilson, C.E., Mendez, M.A., & Murphy, D.G. (2014). Autistic Traits and
Abnormal Sensory Experiences in Adults. Journal of Autism and Developmental
Disorders, 44, 14611469.
Hull, L., Mandy, W., & Petrides, K. V. (2017). Behavioral and cognitive sex/gender
differences in autism spectrum condition and typically developing males and
females. Autism, 21(6), 706-727.
Hurst, R. M., Mitchell, J. T., Kimbrel, N. A., Kwapil, T. K., & Nelson-Gray, R. O.
(2007). Examination of the reliability and factor structure of the Autism Spectrum
Quotient (AQ) in a non-clinical sample. Personality and Individual Differences,
43(7), 1938-1949.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Idsoe, T., Dyregrov, A., & Idsoe, E. C. (2012). Bullying and PTSD symptoms.
Journal of abnormal child psychology, 40(6), 901-911.
Jansen, L.M., Gispen-de Wied, C.C., van der Gaag, R.J., & van Engeland, H. (2003).
Differentiation between autism and multiple complex developmental disorder in
response to psychosocial stress. Neuropsychopharmacology, 28, 582590.
Joshi, G., Wozniak, J., Petty, C., Martelon, M. K., Fried, R., Bolfek, A.,...Biederman,
J. (2013). Psychiatric comorbidity and functioning in a clinically referred population
of adults with autism spectrum disorder: A comparative study. Journal of Autism
and Developmental Disorder, 43(6), 1314-1325.
Karasek, R.A. & Theorell, T. (1990). Healthy Work, Stress, Productivity, and the
Reconstruction of Working Life. New York: Basic Books.
Kenworthy, L., Yerys, B.E., Anthony, L.G., et al. (2008). Understanding executive
control in autism spectrum disorders in the lab and in the real world.
Neuropsychology Review, 18(4), 320338.
Kerns, C. M., Kendall, P. C., Zickgraf, H., Franklin, M. E., Miller, J., & Herrington, J.
(2015). Not to be overshadowed or overlooked: Functional impairments associated
with comorbid anxiety disorders in youth with ASD. Behavior therapy, 46(1), 29-
39.
Kerns, C. M., Newschaffer, C. J., & Berkowitz, S. J. (2015). Traumatic childhood
events and autism spectrum disorder. Journal of Autism and Developmental
Disorders, 45(11), 34753486.
Kessler, R. C. (2000). Posttraumatic stress disorder: The burden to the individual and
to society. Journal of Clinical Psychiatry, 61(5), 412.
Kildahl, A. N., Bakken, T. L., Iversen, T. E., & Helverschou, S. B. (2019).
Identification of Post-Traumatic Stress Disorder in Individuals with Autism
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Spectrum Disorder and Intellectual Disability: A Systematic Review. Journal of
Mental Health Research in Intellectual Disabilities, 12(1-2), 1-25.
Kirby, A. V., Bakian, A. V., Zhang, Y., Bilder, D. A., Keeshin, B. R., & Coon, H.
(2019). A 20 year study of suicide death in a statewide autism population. Autism
Research, 12(4), 658-666.
Koenen, K. C., Ratanatharathorn, A., Ng, L., McLaughlin, K. A., Bromet, E. J., Stein,
D. J., ... & Atwoli, L. (2017). Posttraumatic stress disorder in the world mental
health surveys. Psychological medicine, 47(13), 2260-2274.
Kunihira, Y. Senju, A., Dairoku., H., Wakabayashi, A., & Hasegawa, T. (2006).
‘Autistic’ traits in non-autistic Japanese population: Relationships with personality
traits and cognitive ability. Journal of Autism and Developmental Disorders, 36,
553-566.
Lai, M. C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S.
(2015). Sex/gender differences and autism: setting the scene for future research.
Journal of the American Academy of Child & Adolescent Psychiatry, 54(1), 11-24.
Lai, M. C., Lombardo, M. V., Pasco, G., Ruigrok, A. N., Wheelwright, S. J., Sadek,
S. A., ... & MRC AIMS Consortium. (2011). A behavioral comparison of male and
female adults with high functioning autism spectrum conditions. PloS one, 6(6),
e20835.
Larsen, S.E., & Berenbaum, H. (2017). Did DSM-5 improve the traumatic stressor
criterion?: Association of DSM-IV and DSM-5 criterion A with posttraumatic stress
disorder symptoms. Psychopathology, 50, 373-378.
Loomes, R., Hull, L., Mandy, W.P.L. (2017). What Is the Male-to-Female Ratio in
Autism Spectrum Disorder? A Systematic Review and Meta-Analysis. Journal of
the American Academy of Child & Adolescent Psychiatry, 56(6), 466-474.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Mandell, D.S., Walrath, C.M., Manteuffel, B., Sgro, G., & Pinto-Martin, J.A. (2005).
The prevalence and correlates of abuse among children with autism served in
comprehensive community-based mental health settings. Child Abuse and Neglect,
29, 13591372.
Martorell, A., & Tsakanikos, E. (2008) Traumatic experiences and life events in
people with intellectual disability. Current Opinion in Psychiatry, 5, 445-448.
Marx, B.P., & Gutner, C.A. (2015). Posttraumatic stress disorder: Patient interview,
clinical assessment, and diagnosis. In N.C. Bernardy & M.J. Friedman (Eds.), A
Practical Guide to PTSD Treatment: Pharmacological and Psychotherapeutic
Approaches (pp. 35-52). Washington, DC, US: American Psychological
Association.
McConachie, H., McLaughlin, E., Grahame, V., Taylor, H., Honey, E., Tavernor, L.,
et al. (2014). Group therapy for anxiety in children with autism spectrum disorder.
Autism, 18(6), 723-732.
Mehtar, M., & Mukaddes, N. M. (2011). Posttraumatic stress disorder in individuals
with diagnosis of autistic spectrum disorders. Research in Autism Spectrum
Disorders, 5, 539546.
Nielsen, M.B., Tangen,T., Idsoe, T., Matthiesen, S.B., MogerØy, N. (2015). Post-
traumatic stress disorder as a consequence of bullying at work and at school: A
literature review and meta-analysis. Aggression and violent Behavior, 21, 17-24.
Reinvall, O., Moisio, A. L., Lahti-Nuuttila, P., Voutilainen, A.,Laasonen, M., and
Kujala, T. (2016). Psychiatric symptoms in children and adolescents with higher
functioning autism spectrum disorders on the Development and Well-Being
Assessment. Research in Autism Spectrum Disorders, 25, 47-57.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Reiter, S., Bryen, D. N., & Shachar, I. (2007). Adolescents with intellectual
disabilities as victims of abuse. Journal of Intellectual Disabilities, 11, 371387.
Roberts, A.L., Koenen, K.C., Lyall, K., Robinson, E.B., & Weisskopf, M.G. (2015).
Association of autistic traits in adulthood with childhood abuse, interpersonal
victimization, and posttraumatic stress. Child Abuse & Neglect, 45, 135-142.
Rumball, F. (2018). A systematic review of the assessment and treatment of
posttraumatic stress disorder in individuals with autism spectrum disorders. Review
Journal of Autism and Developmental disorders, 6(3), 294324.
Schroeder, J. H., Cappadocia, M. C., Bebko, J. M., Pepler, D. J., & Weiss, J. A.
(2014). Shedding light on a pervasive problem: A review of research on bullying
experiences among children with autism spectrum disorders. Journal of Autism and
Developmental Disorders, 44(7), 1520-1534.
Shah, R. Shah, A. & Links, P. (2012). Post-traumatic stress disorder and depression
comorbidity: severity across different populations. Neuropsychiatry, 2(6), 521529.
Sourander, A., Brunstein K.A., Ikonen M., Lindroos J., Luntamo T., Koskelainen M.,
Ristkari T., & Helenius H. (2010). Psychosocial risk factors associated with
cyberbullying among adolescents: a population-based study. Archives of General
Psychiatry, 67 (7), 720-728.
Spence, R., Kagan, L., & Bifulco, A. (2019). A contextual approach to trauma
experience: lessons from life events research. Psychological medicine, 49(9), 1409-
1413.
Sreckovic, M., Brunsting, N. C., & Able, H. (2014). Victimization of students with
autism spectrum disorder: a review of prevalence and risk factors. Research in
Autism Spectrum Disorders, 8(9), 11551172.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Stavropoulos, K. K. M., Bolourian, Y., & Blacher, J. (2018). Differential diagnosis of
autism spectrum disorder and post traumatic stress disorder: two clinical cases.
Journal of clinical medicine, 7(4), 71.
Storch, E. A., Sulkowski, M. L., Nadeau, J., Lewin, A. B., Arnold, E.B., Mutch, P. J.,
& Murphy, T. K. (2013). The phenomenology and clinical correlates of suicidal
thoughts and behaviors in youth with autism spectrum disorders. Journal of Autism
and Developmental Disorders, 43, 24502459.
Strunz, S., Dziobek, I., & Roepke, S. (2014). Comorbid psychiatric disorders and
differential diagnosis of patients with autism spectrum disorder without intellectual
disability. Psychotherapie, Psychosomatik, Medizinische Psychologie, 64(6), 206-
213.
Tani, M., Kanai, C., Ota, H., Yamada, T., Watanabe, H., Yokoi, H., Takayama, Y.,
Ono, T., Hashimoto, R., Kato, N., & Iwanami, A. (2012). Mental and behavioral
symptoms of person’s with asperger’s syndrome: Relationship with social isolation
and handicaps. Research in Autism Spectrum Disorder, 6, 907-912.
Taylor, J. L., & Gotham, K. O. (2016). Cumulative life events, traumatic experiences,
and psychiatric symptomatology in transition-aged youth with autism spectrum
disorder. Journal of Neurodevelopmental Disorders, 8(1), 28.
Van Minnen, A., Zoellner, L. A., Harned, M. S., & Mills, K. (2015). Changes in
comorbid conditions after prolonged exposure for PTSD: a literature review.
Current psychiatry reports, 17(3), 17.
Weathers, F.W., Blake, D.D., Schnurr, P.P., Kaloupek, D.G., Marx, B.P., & Keane,
T.M. (2013). The Life Events Checklist for DSM-5 (LEC-5). Instrument available
from the National Center for PTSD at
http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P.
(2013). The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National
Center for PTSD at www.ptsd.va.gov.
White, D., Hillier, A., Frye, A., & Makrez, E. (2016). College students’ knowledge
and attitudes towards students on the autism spectrum. Journal of autism and
developmental disorders, 49(7), 2699-2705.
White, S. W., Ollendick, T., Albano, A. M., Oswald, D., Johnson, C., Southam-
Gerow, M. A., et al. (2013). Randomized controlled trial: multimodal anxiety and
social skill intervention for adolescents with autism spectrum disorder. Journal of
Autism and Developmental Disorders, 43(2), 382-394.
Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., and Langer, D. A.(2009).
Cognitive behavioral therapy for anxiety in children with autism spectrum
disorders: a randomized, controlled trial. Journal of Child Psychology and
Psychiatry, 50(3), 224-234.
Wood, J. J., Ehrenreich-May, J., Alessandri, M., Fujii, C., Renno, P., Laugeson, E., et
al. (2015). Cognitive behavioral therapy for early adolescents with autism spectrum
disorders and clinical anxiety: a randomized, controlled trial. Behavior Therapy,
46(1), 7-19.
Wright, B. K., Kelsall, H. L., Sim, M. R., Clarke, D. M., & Creamer, M. C. (2013).
Support mechanisms and vulnerabilities in relation to PTSD in veterans of the Gulf
War, Iraq War, and Afghanistan deployments: A systematic review. Journal of
Traumatic Stress, 26(3), 310-318. http://dx.doi.org/10.1002/jts.21809
Yehuda, R., Hoge, C.W, McFarlalne, A.C., Vermetten, E., Lanius, R.A., Nievergelt,
C.M., Hobfoll, S.E.,… Hyman, S.E. (2015). Post-traumatic stress disorder. Nature
Reviews Disease Primers, 8(1), 15057.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Zaboski, B. A., & Storch, E. A. (2018). Comorbid autism spectrum disorder and
anxiety disorders: a brief review. Future neurology, 13(1), 31-37.
Zeedyk, S. M., Rodriguez, G., Tipton, L., Baker, B. L., & Blacher, J. (2014). Bullying
of youth with autism spectrum disorder, intellectual disability, or typical
development: victim and parent perspectives. Research in Autism Spectrum
Disorders, 8(9), 11731183.
Zukerman, G., Yahav, G., & Ben-Itzchak, E. (2019). Increased psychiatric symptoms
in university students with autism spectrum disorder are associated with reduced
adaptive behavior. Psychiatry Research, 273, 732-738.
Haruvi-Lamdan et al. DOI 10.1177/1362361320912143
Conflict of interests
The authors declare that they have no conflicts of interests.
Ethics approval
All participants were informed about the study and provided written informed
consent before the study. The study was approved by the Institutional Review Board of
Bar-Ilan University.
Funding
Parts of this study were supported by a grant from the Autism Treatment and Research
Center, The Association for Children and Risk, Israel.
Article
Background Individuals with autism spectrum disorder (ASD) and high autistic traits (ATs) are at a higher risk of developing post-traumatic stress disorder (PTSD) following exposure to social traumatic events. However, the association between ATs and PTSD symptoms following exposure to pathogen threat-related traumatic situations, the role of sex differences in this association, and the mediating mechanism are yet unexplored. This study explored the effects of ATs, sex, and their interaction on COVID-19-related PTSD symptoms, as well as the possible mediating role of anxiety sensitivity (AS) between ATs and PTSD symptoms. Method In total, six hundred ninety-six valid participants (379 women) completed questionnaires assessing their ATs, COVID-19-related PTSD symptoms, and AS. Generalized linear model and mediation effects analyses were conducted. Results Our results showed higher levels of COVID-19-related PTSD symptoms in the high ATs group, especially in women with high AT, compared to the low ATs group. ATs also exerts a significant indirect effect on COVID-19-related PTSD symptom through AS. Conclusions The results indicate an increased vulnerability of individuals with high ATs (especially females) to COVID-19-related PTSD and the mediating mechanism of the co-occurrence of ATs-PTSD. These findings have implications for PTSD interventions for individuals with high ATs and ASD in the current COVID-19 pandemic.
Article
The Autism-Spectrum Quotient is a self-report scale, used to assess autistic traits. It was tested cross-culturally, and a short version was created to clinically refer adults for an autism assessment. This study aimed to examine the properties of the Hebrew version of the Autism-Spectrum Quotient and to create a short version suitable for Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Ninety-three clinically diagnosed autistic adults (24 females) aged 18–53, and 147 comparable controls (34 females) completed the Hebrew version of the Autism-Spectrum Quotient. Ten clinicians specializing in diagnosing autism in adults classified the Autism-Spectrum Quotient’s items according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria. The Hebrew version of the Autism-Spectrum Quotient showed good internal consistency (Kuder-Richardson 20 = 0.90). Based on the prevalence of autism among clinically referred adults (70%), receiver operating characteristic analysis yielded area under the curve of 0.94. A cutoff of 21 demonstrated high sensitivity (0.90), specificity (0.76), positive predictive value (0.90), and negative predictive value (0.77). The short version of the Hebrew Autism-Spectrum Quotient included five social communication and five restricted, repetitive behavior items, which represented two social communication and two restricted, repetitive behavior criteria of Diagnostic and Statistical Manual of Mental Disorders (5th ed.). It showed good internal consistency (Kuder-Richardson 20 = 0.86), and receiver operating characteristic analysis yielded area under the curve of 0.95. An optimal clinical cutoff of five showed high sensitivity (0.90), specificity (0.82), positive predictive value (0.92), and negative predictive value (0.78). The Hebrew version of the Autism-Spectrum Quotient and the short version of the Hebrew Autism-Spectrum Quotient can be effectively used to help screen for autism in clinically referred adults. Lay Abstract Despite the attempt to diagnose autism at an early age, there are still many individuals who would only get an autism diagnosis in adulthood. For these adults, a questionnaire that could assist in highlighting their need to seek diagnostic assessment is needed. The Autism-Spectrum Quotient is a self-report scale used to assess autistic traits. It was tested cross-culturally, and a short version was recommended to help identify adults who should be referred for an autism assessment. However, its relevance for the up-to-date diagnostic criteria, according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), has not been tested. This study aimed to examine the psychometric properties of the Hebrew version of the Autism-Spectrum Quotient and to create a short version of the Hebrew Autism-Spectrum Quotient, based on items which map on to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria. Ninety-three autistic adults (24 females), aged 18–51, clinically diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.), and 147 comparable controls (34 females) filled out the Hebrew version of the Autism-Spectrum Quotient. Ten clinicians who specialize in diagnosing autism in adults classified the Autism-Spectrum Quotient’s items according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria. The short version of the Hebrew Autism-Spectrum Quotient comprised items that best differentiated between adults with and without autism, five items representing each of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) diagnostic domains. The overall probability for participants to be correctly classified as autistic or neurotypical was 86% for the Hebrew version of the Autism-Spectrum Quotient and 88% for the short version of the Hebrew Autism-Spectrum Quotient. We conclude that both versions are reliable and sensitive instruments that can help referring adults for autism assessment.
Article
Full-text available
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.ResultsCoping 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.
Article
Few studies have examined self‐reported perceived stress in autistic adults. Existing studies have included relatively small, predominantly male samples and have not included older autistic adults. Using a large autistic sample (N = 713), enriched for individuals designated female at birth (59.3%), and spanning younger, middle, and older adulthood, we examined perceived stress and its associations with independence in activities of daily living and subjective quality of life (QoL). Perceived stress for autistic adults designated male or female at birth was compared to their same birth‐sex counterparts in a general population sample. In addition, within the autistic sample, effects of sex designated at birth, age, and their interaction were examined. Regression modeling examined associations between perceived stress and independence in activities of daily living and domains of subjective QoL in autistic adults, after controlling for age, sex designated at birth, and household income. Autistic adults reported significantly greater perceived stress than a general population comparison sample. Relative to autistic adults designated male at birth, those designated female at birth demonstrated significantly elevated perceived stress. Perceived stress contributed significantly to all regression models, with greater perceived stress associated with less independence in activities of daily living, and poorer subjective QoL across all domains—Physical, Psychological, Social, Environment, and Autism‐related QoL. Findings are contextualized within the literature documenting that autistic individuals experience elevated underemployment and unemployment, heightened rates of adverse life events, and increased exposure to minority stress. This study looked at self‐reported perceived stress in a large sample of autistic adults. Autistic adults reported more perceived stress than non‐autistic adults. Autistic individuals designated female at birth reported higher stress than autistic individuals designated male at birth. In autistic adults, greater perceived stress is related to less independence in activities of daily living and poorer subjective quality of life.
Article
Full-text available
Neurodivergent people are increasingly involved in postsecondary education, but they continue to face serious barriers and challenges on college campuses. These challenges are not only related to disability functional differences and accommodation needs, but also to stigma and prejudice toward neurodivergent people. Consequently, neurodivergent people are less successful than neurotypical peers; moreover, intersections between neurodivergence and other marginalized groups are associated with even greater inequities. This article was written by neurodivergent students and researchers, and their allies, who suggest a system-wide approach is needed to promote inclusion of neurodivergent students, staff, and faculty on postsecondary campuses. Specific recommendations, based on those the authors suggested to and that were endorsed by the University of California Academic Senate, are provided. These recommendations include diversity, equity, and inclusion (DEI)-oriented reforms (viewing neurodiversity through a DEI lens; establishing Disability Cultural Centers; providing campus-wide neurodiversity training; and fostering neurodivergent leadership in neurodiversity initiatives). Other recommendations address disability accommodations and supports (integrating disability accommodations in one place; making eligibility requirements less onerous; recognizing and accommodating sensory distress and distraction; establishing programs to facilitate transitions in and out of postsecondary; improving mental health support; and creating mechanisms to resolve issues where students are denied accommodations). Finally, further recommendations address accessibility of communication (respecting students’ decisions to involve support people; and offering neurodivergent people the option to choose accessible modalities for communicating with instructors and staff and for taking classes). Institutions that embrace these reforms have an opportunity to position themselves as neurodiversity inclusion leaders and destination campuses for neurodivergent people.
Article
Adolescence constitutes a period of vulnerability in the emergence of fear-related disorders (FRD), as a massive reorganization occurs in the amygdala-prefrontal cortex network, critical to regulate fear behavior. Genetic and environmental factors during development may predispose to the emergence of FRD at the adult age, but the underlying mechanisms are poorly understood. In the present study, we tested whether a partial knock-down of tuberous sclerosis complex 2 (Tsc2, Tuberin), a risk gene for neurodevelopmental disorders, in the basolateral amygdala (BLA) from adolescence could alter fear-network functionality and create a vulnerability ground to FRD appearance at adulthood. Using bilateral injection of a lentiviral vector expressing a miRNA against Tsc2 in the BLA of early (PN25) or late adolescent (PN50) rats, we show that alteration induced specifically from PN25 resulted in an increased c-Fos activity at adulthood in specific layers of the prelimbic cortex, a resistance to fear extinction and an overgeneralization of fear to a safe, novel stimulus. A developmental dysfunction of the amygdala could thus play a role in the vulnerability to FRD emergence at adulthood. We propose our methodology as an alternative to model the developmental vulnerability to FRD, especially in its comorbidity with TSC2-related autism syndrome.
Article
Full-text available
Post-traumatic stress (PTSD) is considered a clinical issue that influences numerous people from diverse trades all over the world. Numerous research scholars recorded diverse complexities to estimate the severity of the PTSD symptoms in the patients. But diagnosing PTSD and obtaining accurate diagnosing techniques becomes a more complicated task. Therefore, this paper develops a speech based post-traumatic stress disorder monitoring method and the significant objective of the proposed method is to determine if the patients are affected by PTSD. The proposed approach utilizes three different steps: pre-processing or pre-emphasis, feature extraction as well as classification to evaluate the patients affected by PTSD or not. The input speech signal is initially provided to the pre-processing phase where the speech gets segmented into frames. The speech frame is then extracted and classified using XGBoost based Teamwork optimization (XGB-TWO) algorithm. In addition to this, we utilized two different types of datasets namely TIMIT and FEMH to evaluate and classify the PSTD from the speech signals. Furthermore, based on the evaluation of the proposed model to diagnose PTSD patients, various evaluation metrics namely accuracy, specificity, sensitivity, and recall are evaluated. Finally, the experimental investigation and comparative analysis are carried out and the evaluation results demonstrated that the accuracy rate achieved for the proposed technique is 98.25%.
Chapter
Across schools, bullying under all of its forms (e.g., physical, verbal, relational, cyber) is a concerning phenomenon. Prevalence studies suggest that children with ASD are a particularly vulnerable population. Specifically, children with ASD are at a considerably higher risk of being bullied than their peers with other or no special educational needs. This chapter aims to examine in what way bullying occurs in ASD populations and what particular challenges individuals with ASD have to deal with. More specifically, the chapter describes and discusses key points in the existing literature on bullying and autism spectrum disorder, such as (1) types of bullying, (2) causes and determining factors, (3) risk and protective factors, (4) consequences of bullying, (5) prevention strategies and interventions where the transition to recommendations is made through thorough research specifically applied to this topic in order to provide theory and evidence-based practices for educators, teachers, school counselors, parents, and any other interested party.
Article
Full-text available
Background: Autistic adults with intellectual disabilities (ID) seem to be particularly vulnerable to potentially traumatic experiences and post-traumatic stress disorder (PTSD). Furthermore, this population may be at risk for a different set of traumatic experiences than the general population. However, knowledge is sparse concerning PTSD symptom manifestations in individuals with severe ID. Method: Exploration of PTSD symptom trajectories and manifestations in an adult, autistic man with severe ID. Results: Altered arousal/reactivity and problematic avoidance were the most easily observable symptoms. Avoidance seemed to become more generalised over time, and the impact of PTSD on behaviour, level of functioning, and quality of life was severe. Conclusions: Negligence and coercion in services for autistic adults with ID may involve a traumatic potential for these individuals. Increased awareness of this risk is needed in service providers and mental health professionals.
Article
Background Research has repeatedly demonstrated that people with disabilities, particularly intellectual disabilities, experience violence at higher rates compared to people without disabilities. There have been fewer studies of violence amongst Autistic people with most focused on abuse and peer victimisation during childhood. Many of these studies include large numbers of children with intellectual disability making it difficult to infer whether autistic traits confer any increased risk for violence. Method A cross-sectional survey design was employed to compare rates of reported childhood and recent physical and sexual violence, degree of traumatic impact, and tendency to confide in others amongst 245 Autistic adults without intellectual disability and 49 non-Autistic adults. We also examined whether autistic traits and emotion regulation were associated with experiences of reported violence. Results A higher proportion of Autistic adults reported experiencing sexual and physical violence during childhood. There was no difference in recent violence or traumatic impact, however Autistic adults were more likely to report they had never confided in anyone about their experience/s. Autistic traits (but not emotion regulation difficulties) were a significant predictor of experiencing violence. Conclusions The findings provide further evidence that Autistic people experience higher rates of physical and sexual violence and this cannot be attributed solely to the risk that is conferred by co-occurring intellectual disability. This information is important for policy makers and service providers so that steps can be taken to protect Autistic people from exposure to violence however further research is needed to better understand the extent and nature of violence experienced by Autistic people.
Article
Full-text available
Los escolares con trastorno del espectro autista (TEA) presentan dificultades en la interacción y comunicación social y rigidez cognitiva y de ejecución que los hace especialmente vulnerables al ,bullying,; sin embargo, la investigación ha sido menos profusa. El propósito del presente trabajo es revisar y considerar los estudios más recientes sobre TEA y acoso escolar. El método utilizado ha seguido las directrices de la declaración PRISMA. La muestra final la conforman 29 artículos que revelan que estos estudios se han realizado con muestras inferiores a 450 escolares con TEA. Asimismo, se señala que existen discrepancias sobre la comprensión que tienen del acoso y los factores que lo predicen, así como que la prevalencia de ,bullying, es superior a la publicada para los escolares normativos. Los resultados se discuten en comparación con revisiones previas y se plantean nuevos retos para el diseño de programas efectivos de intervención psicoeducativa específicos con este alumnado.
Article
Full-text available
Scientific Summary Growing concern about suicide risk among individuals with autism spectrum disorder (ASD) necessitates population‐based research to determine rates in representative samples and to inform appropriate prevention efforts. This study used existing surveillance data in Utah to determine incidence of suicide among individuals with ASD over a 20‐year period, and to characterize those who died. Between 1998 and 2017, 49 individuals with ASD died by suicide. Suicide cumulative incidence rates did not significantly differ between 1998 and 2012 across the ASD and non‐ASD populations. Between 2013 and 2017, the cumulative incidence of suicide in the ASD population was 0.17%, which was significantly higher than in the non‐ASD population (0.11%; P < 0.05). During this period, this difference was driven by suicide among females with ASD; suicide risk in females with ASD was over three times higher than in females without ASD (relative risk (RR): 3.42; P < 0.01). Among the individuals with ASD who died by suicide, average age at death and manner of death did not differ significantly between males and females. Ages at death by suicide ranged from 14 to 70 years (M[SD] = 32.41[15.98]). Individuals with ASD were significantly less likely to use firearms as a method of suicide (adjusted odds ratio: 0.33; P < 0.001). Study results expand understanding of suicide risk in ASD and point to the need for additional population‐based research into suicide attempts and ideation, as well as exploration of additional risk factors. Findings also suggest a need for further study of female suicide risk in ASD. Autism Research 2019. © 2019 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals, Inc. Lay Summary This study examined suicide risk among individuals with autism spectrum disorder (ASD) in Utah over a 20‐year period. Risk of suicide death in individuals with ASD was found to have increased over time and to be greater than in individuals without ASD between 2013 and 2017. Females with ASD were over three times as likely to die from suicide as females without ASD. Young people with ASD were at over twice the risk of suicide than young people without ASD. Individuals with ASD were less likely than others to die from firearm‐related suicides.
Article
Full-text available
The female-male ratio in the prevalence of post-traumatic stress disorder (PTSD) is approximately 2:1. Gender differences in experienced trauma types, PTSD symptom clusters, and PTSD risk factors are unclear. We aimed to address this gap using a cross-sectional design. A sample of 991 civilians (522 women, 469 men) from South Lebanon was randomly selected in 2007, after the 2006 war. Trauma types were grouped into disaster and accident, loss, chronic disease, non-malignant disease, and violence. PTSD symptom clusters involved re-experiencing, avoidance, negative cognitions and mood, and arousal. These were assessed using parts I and IVof the Arabic version of the Harvard Trauma Questionnaire (HTQ). Risk factors were assessed using data from a social support and life events questionnaire in multiple regression models. Females were twice as likely as males to score above PTSD threshold (24.3 vs. 10.4%, p ˂ 0.001). Total scores on all trauma types were similar across genders. Females scored higher on all symptom clusters (p < 0.001). Social support, social life events, witnessed traumas, and domestic violence significantly were associated with PTSD in both genders. Social support, social life events, witnessed traumas and domestic violence were significantly associated with PTSD in both genders. Conversely, gender difference in experienced traumas was not statistically significant. These findings accentuate the need to re-consider the role of gender in the assessment and treatment of PTSD.
Article
Full-text available
Individual differences are known to influence the risk of trauma exposure and development of posttraumatic stress disorder (PTSD). It has been suggested that features of autism spectrum disorder (ASD) may confer such risk. This article provides a systematic review of the assessment and treatment of PTSD in individuals with ASD, in addition to summarising the rates and presentation of PTSD within this population. Twenty-four studies met eligibility criteria. PTSD in children and adolescents was found to co-occur at a similar or greater rate compared to general population estimates, although current estimates come predominantly from treatment-seeking samples. Preliminary findings from case reports suggest traditional assessments and treatments for PTSD can be effective, although there is a shortage of well-controlled research.
Article
A contextual approach to trauma experience: lessons from life events research - Volume 49 Issue 9 - Ruth Spence, Lisa Kagan, Antonia Bifulco
Article
Introduction: autism spectrum disorder (ASD) and intellectual disability (ID) seem to influence the risk of and vulnerability to exposure to trauma and adverse events. While assessment of a psychiatric disorder in ASD and ID generally is challenging, identification of post-traumatic stress disorder (PTSD) seems particularly so, and knowledge does not seem easily accessible. Methods: This article provides a systematic review of studies describing trauma reactions in individuals with both ASD and ID, including studies involving any single case with the combination of ASD, ID, and PTSD. To systematically explore PTSD symptom presentation in the group, all reported symptoms from studies were assigned by DSM-5 criteria. Results: Eighteen studies met the inclusion criteria, eight group studies and 10 case studies. Assessment methodology in studies varied, as did the format of symptom report. DSM-5 criteria provided a useful framework for integrating findings across studies, indicating that PTSD may be identified in individuals with ASD and ID. However, symptoms involving alterations in arousal and negative alterations in thought and behavior seem more easily identified than symptoms of reexperiencing and avoidance. Conclusions: There is an urgent need to identify behavioral equivalents to PTSD symptoms in this group, making it possible to identify warning signs of trauma and abuse even if such incidents are not known to family or professional carers.
Article
High variability in adaptive behavior in cognitively-able adults with autism spectrum disorder has been previously reported, and may be caused by the high prevalence of psychiatric comorbidity in this population. This study's goals were to examine self-reported psychiatric symptoms in students with ASD, and to identify their relative contribution to the variance in adaptive behaviors. The study population included 95 students: 55 diagnosed with ASD (4 females; age range 18–34) who participated in a university integration program (ASD group), and 40 regularly matriculated students (non-ASD group, 7 females; age range 20–36). The ASD group showed a lower adaptive skill level than the non-ASD group as measured by the Adaptive Behavior Assessment System (GAC-ABAS). Significantly higher scores for the ASD group were found for social anxiety, trait anxiety, obsessive-compulsive symptoms, and depression symptoms. The level of adaptive skills correlated negatively and significantly with the severity of social anxiety symptoms in both groups and with severity of obsessive-compulsive symptoms only in the ASD group. Additionally, in a regression model, significant contributions of having an ASD diagnosis and severity of social anxiety explained 41.7% of the variance in adaptive skills. Adequate evaluation and treatment, if needed, are recommended in this population.
Article
Background and objectives: Previous research indicates that individuals with Autism Spectrum Disorder (ASD) face an increased risk of experiencing traumatic events. Autistic Traits (AT), characteristic of ASD, are continuously distributed across the general population. Our main objective was to examine the association between AT and PTSD (Post Traumatic Stress Disorder), a topic rarely assessed before. Methods: One hundred and three college students from 3 academic areas, previously found to be associated with different degrees of AT, completed self-report questionnaires tapping PTSD (the PCL-5; PTSD Checklist for DSM-5), AT (AQ; the Autism Spectrum Quotient), and traumatic life events. Results: AT were positively associated with all PTSD symptom clusters, except for avoidance. The association between imagination difficulties and PTSD was moderated by gender. Among participants meeting the PTSD cutoff, those with the highest AT levels reported a PTSD symptomatic profile with an increased dominance of hyper-arousal symptoms. Conclusions: The AT-PTSD association reported here may be attributed to several factors, including increased victimization associated with AT, as well as shared vulnerability factors for both conditions, including impairments in social cognition. Further research is needed in order to understand the associations between these two conditions, considering gender differences, and possible shared underlying mechanisms.