Tuesday, November 5, 2019

Adverse Childhood Experiences (ACEs) in Autism


Adverse Childhood Experiences (ACEs) and Trauma

Research is advancing our understanding of the nature of childhood stress and trauma in autistic individuals and its subsequent impact on mental health and wellbeing. The DSM-5 notes that psychological distress associated with stress and trauma is varied and may include anxiety or fear-based reactions, changes in mood, anger, irritability, aggression or dissociation. Although there is a specific diagnostic category for trauma and stressor-related disorders, stress and trauma are identified as risk factors for several other disorders including depression and anxiety.

An important development in understanding the impact of stress and trauma on mental health in the general population has been the adverse childhood experience (ACE) studies. Adverse childhood experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and well-being. The more adversities an individual has experienced, the higher the likelihood that individual will have serious mental and physical health problems later in life. ACEs include all types of abuse, neglect, and other stressful and traumatic experiences (e.g., bullying, peer rejection, neighborhood violence, poverty, financial hardship, parental divorce, incarceration, death, domestic violence, household substance abuse problems, and family mental health concerns).

There is mounting evidence for stress and trauma as a risk factor for comorbidity and the worsening of the core symptoms in ASD. These findings are consistent with research on the psychological consequences of adverse childhood experiences (ACEs) in the general population. A recent study to identify rates of ACEs in children with ASD found that a diagnosis of ASD was significantly associated with a higher probability of reporting one or more ACEs. The number of children with ASD who were exposed to four or more ACEs was twice as high compared to their typically developing peers.

The core symptoms of ASD may themselves predispose children to stressful and traumatic situations. For example, difficulty with socialization could lead to increased social anxiety or peer rejection. Experiences known to be distressing for autistic individuals such as unexpected schedule changes, the prevention or discouragement of repetitive or preferred behaviors, and sensory sensitivities, could be perceived as traumatic particularly when such distress occurs on a consistent basis, adding to the potential for comorbidity. These core symptoms would make  every day social situations and new or unexpected experiences highly stressful for someone with ASD. It is possible that consistent rumination on stressful or traumatic experiences could lead to co-occurring symptoms of depression, anxiety or even PTSD if a significant traumatic event has taken place.

 Implications

Research suggests that autistic individuals may be at high risk for experiencing stressful and traumatic life events, the consequences of which can negatively impact mental health through the development of comorbid disorders (e.g., anxiety, depression) and/or worsening of the core symptoms of ASD. Exposure to stressful and potentially traumatic events may manifest as symptoms of aggression, difficulty concentrating, social isolation, increased relational difficulties, regression in daily living skills, and increased repetitive or stereotypic behavior. As many of these symptoms are commonly associated with ASD, the stress and/or trauma underlying these symptoms may go untreated. Stressful and traumatic life events should be considered by mental health professionals when conducting assessments and determining appropriate treatment plans for autistic individuals experiencing comorbid symptomatology and or/an exacerbation of core ASD symptoms to help ensure that underlying causes of these symptoms are not overlooked. Formal screening and identification of ACEs can lead to trauma-informed interventions and treatment goals that can help to mitigate negative outcomes while promoting an environment that is supportive and affirmative of the experience of having ASD.
 
Key Resources and Further Reading

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders ( 5th ed.). Washington, DC: American Psychiatric Association.

Beck, J. (2011). Cognitive behavior therapy: Basics and beyond ( 2nd ed.). New York: Guilford Press.

Berg, K. L., Shiu, C. S., Acharya, K., Stolbach, B. C., & Msall, M. E. (2016). Disparities in adversity among children with autism spectrum disorder: A population based study. Developmental Medicine & Child Neurology, 58, 1124–1131. https://doi.org/10.1111/ dmcn.13161.

Bishop Fitzpatrick, L., Mazefsky, C. A., Minshew, N. J., & Eack, S. M. (2015). The relationship between stress and social functioning in adults with autism spectrum disorder and without intellectual disability. Autism Research, 8(2), 164–173.

Doepke, K. J., Banks, B. M., Mays, J. F., Toby, L. M., & Landau, S. (2014). Co-occurring emotional and behavior problems in children with Autism Spectrum Disorders. In L. Wilkinson (Ed.), Autism Spectrum Disorders in Children and Adolescence: Evidence-based Assessment and Intervention in Schools (pp. 125-148). Washington, DC: American Psychological Association.

Earl, R.K., Peterson, J., Wallace, A.S., Fox, E., Ma, R., Pepper, M., & Haidar, G. (2017. Trauma and autism spectrum disorder: A reference guide. Bernier Lab, Center for Human Development and Disability, University of Washington. bernierlab.uw.edu

Fuld, S (2018). Autism spectrum disorder: The impact of stressful and traumatic life events and implications for clinical practice. Clinical Social Work Journal, 46, 210-219.

García Villamisar, D., & Rojahn, J. (2015). Comorbid psychopathology and stress mediate the relationship between autistic traits and repetitive behaviours in adults with autism. Journal of Intellectual Disability Research, 59(2), 116–124. https://doi.org/10.1111/jir.12083.

Harvey, K. (2012). Trauma-informed behavioral intervention: What works and what doesn’t. Washington D.C.: American Association on Intellectual and Developmental Disabilities.

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), 3475–3486. https://doi.org/10.1007/s10803-015-2392-y.

Kerns, C. M., Rump, K., Worley, J., Kratz, H., McVey, A., Herrington, J., & Miller, J. (2016). The differential diagnosis of anxiety disorders in cognitively-able youth with autism. Cognitive and Behavioral Practice, 23(4), 530–547.

Mannion, A., Brahm, M., & Leader, G. (2014). Comorbid psychopathology in autism spectrum disorder. Review Journal of Autism and Developmental Disorders, 1(2), 124–134. https://doi.org/10.1007/s40489-014-0012-y.

Matson, J. L., & Williams, L. W. (2014). Depression and mood disorders
among persons with autism spectrum disorders. Research in Developmental Disabilities, 35, 2003–2007. https://doi.org/10.1016/j.ridd.2014.04.020

Mayes, S. D., Gorman, A. A., Hillwig-Garcia, J., & Syed, E. (2013). Suicide ideation and attempts in children with autism. Research in Autism Spectrum Disorders, 7(1), 109–119. https://doi.org/10.1016/j.rasd.2012.07.009.

Mehtar, M., & Mukaddes, N. M. (2011). Posttraumatic stress disorder in individuals with diagnosis of autistic spectrum disorders. Research in Autism Spectrum Disorders, 5(1), 539–546. https://doi.org/10.1016/j.rasd.2010.06.020.

Reinvall, O., Moisio, A. L., Lahti-Nuuttila, P., Voutilainen, A., Laasonen, M., & 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. https://doi.org/10.1016/j.rasd.2016.01.009.

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.

Schilling, E. A., Aseltine, R. H., & Gore, S. (2007). Adverse childhood experiences and mental health in young adults: A longitudinal survey. BMC Public Health, 7(1), 30.

Spratt, E. G., Nicholas, J. S., Brady, K. T., Carpenter, L. A., Hatcher, C. R., Meekins, K. A., … & Charles, J. M. (2012). Enhanced cortisol response to stress in children in autism. Journal of Autism and Developmental Disorders, 42(1), 75–81. https://doi.org/10.1007/s10803-011-1214-0.

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. https://doi.org/10.1186/s11689-016-9160-y.

Wilkinson, L. A. (2015). Overcoming Anxiety on the Autism Spectrum: A Self-Help Guide Using CBT. London and Philadelphia: Jessica Kingsley Publishers.

Wilkinson, L. A. (2017).  A best practice guide to assessment and intervention for autism spectrum disorder in schools (2nd ed.). London & Philadelphia: Jessica Kingsley Publishers.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk,
S., … Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental
Disorders, 45(7), 1951–1966. https://doi.org/10.1007/ s10803-014-2351-z.


Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorder. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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