Rev J Autism Dev Disord (2015) 2:287–299

DOI 10.1007/s40489-015-0052-y

REVIEW PAPER

The Effects of Psychological Trauma on Children with Autism

Spectrum Disorders: a Research Review
Daniel W. Hoover 1

Received: 13 May 2015 / Accepted: 18 June 2015 / Published online: 9 July 2015
# Springer Science+Business Media New York 2015

Abstract Traumatic events such as abuse, bullying, and ex- experiences include death and separation from loved ones,
posure to violence are commonplace among typically devel- witnessing domestic violence or other community violence,
oping children and occur at least as often among those with verbal and physical bullying by peers, exposure to natural and
autism spectrum disorder (ASD). Children with ASD are vul- man-made disasters, and painful medical interventions,
nerable to traumatization due to their deficits in social com- among others (National Child Traumatic Stress Network
munication and emotion regulation. Research on posttraumat- 2012).
ic symptoms among children with ASD is reviewed. Bullying A recent survey of child maltreatment such as physical
has received much attention while there is a paucity of re- abuse and neglect reported a trauma incidence rate of 9.1 per
search on other types of trauma. Anxiety, social isolation, 1,000 children in the USA in 2013 (US Department of Health
and developmental regression are associated with trauma. Fur- and Human Services Department of Health and Human Ser-
ther research is needed to clarify the symptom presentation vices, Administration for Children and Families, Administra-
and frequency of PTSD. Sensitive self-report measures are tion on Children, Youth and Families, Children’s Bureau
needed as well as validation of existing measures for assessing 2015). In a nationally representative study, 68 % percent of
trauma in this population. youth were found to have experienced a potentially traumatic
event by the age of 16. Less than one half of 1 % of the
Keywords Autism spectrum disorder . Posttraumatic stress . children and youth were subsequently diagnosed with post-
Child maltreatment traumatic stress disorder (PTSD) but for those who experi-
enced more than one traumatic event the rate of PTSD was
nearly 50 %. Other trauma-related problems such as academic,
Children with autism are exposed to traumatic events at least emotional, and somatic difficulties were present in more than
as often as their typically developing peers but the effects in 20 % of the exposed children (Copeland et al. 2007).
this group are not well understood (Sullivan 2009; Turner Posttraumatic stress disorder is described in the DSM-5 as
et al. 2011). Child maltreatment and other potentially traumat- a syndrome arising from witnessing, directly experiencing, or
ic experiences of youth are a major national health problem being otherwise exposed to serious physical or sexual vio-
and frequently cited priority for research and intervention lence, threats to bodily integrity, or death of family members
(Fairbank 2008). Traumatic experiences include childhood (American Psychiatric Association 2013). The central symp-
maltreatment such as physical and sexual abuse, emotional tom pattern is as follows: (a) re-experiencing of traumatic
abuse, and physical neglect. Other types of traumatic thoughts or images through memories, dreams, or intrusive
thoughts; (b) negative cognitive and mood states related to
* Daniel W. Hoover the trauma; and (c) alteration of physical arousal related to
[email protected] the trauma. Other types of adjustment difficulties, including
impairment of relationships and attachment, avoidance of
1
The Center for Child and Family Traumatic Stress at Kennedy
traumatic reminders, and behavior and emotional problems
Krieger Institute, 1750 East Fairmount Ave. 2nd Floor, are labeled Btrauma related symptoms^ while they may not
Baltimore, MD 21231, USA meet full criteria for PTSD (Goenjian et al. 1995; Perkonigg
288 Rev J Autism Dev Disord (2015) 2:287–299

et al. 2005). Trauma effects children differently at each stage factors (Simonoff 2012). ASDs are characterized by pervasive
of development and can interfere with the acquisition of de- developmental deficits in social communication and interac-
velopmental milestones (Lieberman et al. 2011; Trickett et al. tion as well as rigid, repetitive patterns of behavior, interests,
2011). Males and females are exposed to violence and abuse at or activities. The DSM-5 groups those diagnosed into three
about the same rate (US Department of Health and Human severity levels based on functional behavior. At the lower-
Services Department of Health and Human Services, Admin- functioning end of the spectrum are those who require Bvery
istration for Children and Families, Administration on Chil- substantial support^ due to severe deficits in verbal and non-
dren, Youth and Families, Children’s Bureau 2015). However, verbal communication and often display markedly impairing
there are gender differences in the expression of trauma- rigidity and repetitive behavior. At the higher-functioning end
related symptoms. Males on average tend to display more are individuals who show difficulty initiating and maintaining
externalizing behavior and females tend to display more inter- successful social contact, may be quite inflexible in behavior
nalizing behavior with heightened susceptibility to PTSD es- and routines, and have difficulty organizing and transitioning
pecially following sexual abuse (Darves-Bornoz et al. 1998; between activities (American Psychiatric Association 2013).
Evans et al. 2008; Walker et al. 2004). Broad and long-lasting Outside of the growing literature on bullying which com-
negative health effects have been found in those exposed to prises the majority of studies of potential trauma in children
trauma in childhood (Felitti et al. 1998). with ASD, there is little clear information about the rate or
Given the high percentage of traumatic exposures among effects of traumatization in this population. The purposes of
youth, it is likely that a significant proportion of those with this article are to review the literature regarding the types of
autism spectrum disorder (ASD) have been exposed to trauma traumatic exposure and symptoms occurring in children with
with resulting mental health symptoms. Several factors may ASD, address measurement problems arising in the assess-
set them up for traumatization. They are more socially isolat- ment of this population, and to make recommendations for
ed, less accepted and liked by peers, and more often excluded further investigation efforts.
and ridiculed (Carter 2009; Rotheram-Fuller et al.2010). Chil-
dren with ASD lack the social support networks that have
been shown to protect or buffer children from the effects of
peer bullying (Bauminger and Kasari 2000; Estell et al. 2009). Trauma in Children with ASD
Children with ASD have been shown to become more angry
and upset in response to bullying than typically developing For the purposes of this review, Psychinfo and PubMed were
children, which could lead to more targeted aggression direct- searched using the following autism related keywords: autism,
ed toward them (Rieffe et al. 2012). Language delays may get Asperger, PDD, and PDD-NOS in combination with trauma-
in the way of reporting abuse or expressing reactions to trauma related keywords: posttraumatic/post-traumatic, PTSD, child
(Cook et al. 1993). Verbal expression and processing form a abuse, child neglect, interpersonal violence, child
key part of most therapies for trauma in children but may be maltreatment, domestic violence, peer victimization, and
difficult or impossible for children with autism (Howlin and bullying. Reference lists in the identified articles were also
Clements 1995). Perhaps because of these developmental vul- searched for relevant articles.
nerabilities they show high rates of co-morbid anxiety and Articles were selected for review if they were: (a) empirical
other emotional and behavioral problems (Konst and Matson research published in a peer-reviewed journal of any date up to
2014; Vasa et al. 2014). They may therefore be expected to the current issue; (b) non-dissertation; (c) reported in English;
have more severe emotional reactions to traumatic events. (d) clearly identified ASD in children and youth; and (e) re-
As with childhood trauma, ASD is being increasingly di- ported a quantifiable assessment of PTSD or specified emo-
agnosed, a trend that gained momentum with the labeling of a tional, behavioral, and/or functional problems associated with
wider range of symptoms as pertaining to autism in the DSM- potentially traumatic experiences. Case studies, purely theo-
IV (American Psychiatric Association 1994). Recent CDC retical, position, or clinical papers without quantitative data
estimates in the USA indicate a prevalence rate of 1 in 68 were excluded from this research review.
children being identified with ASD in 2010 based on national There is a clear divide in the literature between studies of
survey data, whereas similar surveillance methods identified a bullying (used interchangeably here with peer victimization)
rate of 1 in 150 children in 2002 (Centers for Disease Control and studies of child trauma, abuse, and other maltreatment.
and Prevention 2014). Estimates vary based on method of This distinction was followed in presenting articles for this
assessment, country or region studied, and definition of review. Twenty-two studies of bullying were found that met
ASD but have shown a general trend of increasing prevalence criteria A–D above. Of these, 11 also met criterion E by
that may be starting to level off (Tsai 2014). The increased reporting measured emotional, behavioral, or functional out-
prevalence rate is most likely due to changes in diagnostic comes of bullying, the central purpose of the review. These 11
criteria but may also reflect genetic and/or environmental were selected for inclusion. Of the 10 bullying studies that did
Rev J Autism Dev Disord (2015) 2:287–299 289

not meet criterion E, most focused on predictors of bullying victimization. There was a greater tendency for anxiety, hy-
rather than outcomes. per-sensitivity, self-injury, stereotypies, and hyperactivity in
The literature search revealed eight studies of non-bullying children who experienced the most frequent victimization.
child trauma in children with ASD that met criteria A–C In a sociometric study conducted among school children in
above. Two of these studies were excluded from formal re- northern UK, students were asked to rate their classmates on a
view as they did not adequately identify autism as separate continuum from most to least liked (Symes and Humphrey
from other developmental disabilities and did not report on 2010). Reports of bullying frequency, perceived social stand-
emotional or behavioral outcomes of trauma. Given the rela- ing, and social support were obtained from students with and
tive paucity of studies and wide differences in methodology, without ASD diagnosis. Along with being more often bullied
no quantitative analysis of reviewed articles was attempted. than the comparison groups of children with dyslexia and
those without special education needs, youth with ASD re-
Peer Victimization ported more feelings of isolation and lack of peer support
(Symes and Humphrey 2010). Similarly, Twyman et al.
Peer victimization/bullying studies account for the majority of (2010) obtained ratings from ASD-identified youth with vic-
empirical articles about potential traumatization of children timization histories, suggesting increased feelings of being left
with ASD. Two recent reviews summarize much of the avail- out and ostracized.
able research on incidence, causal and contributory factors, Bitsika and Sharpley (2014) administered a semi-structured
and recommendations for prevention and intervention prac- interview to boys with ASD and their parents, asking about
tices (Schroeder et al. 2014; Sreckovic et al. 2014). frequency and types of bullying experiences as well as the
Prevalence estimates vary depending on time frames and children’s responses to the bullying. Eighty-one percent of
reporters but by all reports, children with ASD are bullied the children said that they had been bullied (83 % of parents),
more often than peers with other disabilities and more often with daily bullying being reported by 41.7 % of the children
than non-disabled peers (Sreckovic et al. 2014), those with (39.6 % of parents). The boys most frequently reported
intellectual disabilities alone (Zeedyk et al. 2014), and their experiencing the following types of bullying: BMake mean
typically developing siblings (Nowell et al. 2014). One esti- jokes and laugh at me;^ BCall me mean names and swear at
mate summarizing data from a variety of studies (Storch et al. me;^ BBeing hit, pushed, or kicked;^ and BHave ganged up on
2012) indicates that broad-scale parent and children surveys me.^ They reported having both emotional and physiological
report 44–77 % of ASD children being bullied within a 1- reactions including BAngry,^ BSad,^ BLonely,^ BNervous,^
month period, as compared to a rate of 2–17 % in self-report BStomach Butterflies,^ and BHeadaches.^
surveys of typically developing children (van Roekel Rieffe et al. (2012) found that adolescents with ASD expe-
et al.2010). Another estimate based on a large parent survey rienced and expressed more anger when bullied than typically
suggests that as many as 94 % of children with ASDs and non- developing peers who were bullied. The authors suggest that
verbal learning disorders are bullied at some point in the past this is consistent with the emotional reactivity and upset com-
year as rated by mothers (Little 2002). monly observed in children with ASD that in turn may lead to
As trauma symptoms are the central focus of this review, more bullying (Sofronoff et al. 2007; Volker et al. 2010).
the studies summarized in Table 1 specifically assessed func- Storch et al. (2012) showed that bullied children with ASD
tional and mental health impacts of bullying. and their parents reported that they had symptoms consistent
The following comprises a review of the studies listed in with panic disorder, major depression, loneliness, and social
Table 1. Cappadocia et al. (2012) conducted a survey of 192 anxiety.
parents of children diagnosed with ASD, contacted through As part of a large survey of parents reporting that their child
autism support websites and snowball sampling. Types of vic- had a Bcurrent ASD diagnosis from a medical professional,^
timization included physical, social, verbal, and cyber-bully- Zablotsky et al. (2013, p. 2) administered a questionnaire to
ing. Sixty-seven percent of the sample reported that their child parents regarding their children’s victimization experiences.
had experienced physical, social, verbal, and/or cyber- Results of the survey confirmed the high rate of bullying re-
bullying in the previous month. Of that group, 46 % were ported elsewhere by children with ASD (Cappadocia et al.
reported to have experienced frequent peer victimization one 2012). The children were reported to have internalizing symp-
time per week or more. Sixty-eight percent experienced more toms connected with the bullying, including increased ner-
than one type of bullying. Social ostracism and verbal teasing vousness, fearfulness, and anxiety. Comparisons were made
were the most frequently reported types. Parent report mea- between children with ASD who bullied others, those who
sures were used to assess for mental health problems among were victims, and those who were both victims and bullied
the subjects. Higher levels of victimization, i.e., one or more others. The latter group was most likely to have co-morbid
episodes per week, were associated with relatively more emo- disruptive behavior and diagnoses including attention-deficit/
tional and behavioral concerns than lower levels of hyperactivity disorder, conduct disorder, and oppositional
Table 1 Summary of research studies examining youth with autism spectrum disorders and effects of peer victimization
290

Author (year) Age range Number ASD subtypes Post-bullying Symptom measures
(mean) symptoms

Adams et al. (2014) 10.39–17.99 (14.62) 54 Asperger PDD-NOS Internalizing symptoms Self-/Parent Report of Peer Victimization
Autism (Schwartz et al. 2002); CBCL Internalizing
Problems Scale Youth Self-Report/Parent Report
(Achenbach 2001); Children’s Depression Inventorya
(Kovacs 1992); Social Responsiveness Scalea
(Constantino and Gruber 2005); Repetitive Behavior
Scale-Revisedb (Bodfish et al. 2000).
Bitsika and Sharpley (2014) 7–12 (9.9) 48 ASD, Asperger, BAngry,^ BSad,^ BLonely,^ Authors’ semi-structured interview of five topic areas: (1)
PDD-NOS anxiety, somatic complaints friendships and social interactions at school, (2)
recognition of specific bullying behavior,( 3) strategies
for reporting bullying, (4) responses to being bullied, (5)
emotional and physiological impacts of being bullieda
Cappadocia et al. (2012) 5–21 (11.71) 192 Asperger PDD-NOS Increased anxiety, hyperactivity, Kessler 6-Item Psychological Distress Scaleb (Kessler et al. 2003);
Autism self-injury, stereotypies, Nisonger Child Behavior Rating Formb (Aman et al. 1996)
sensitivities
Mayes et al. (2013) 1–16 (6.6) 791 High Functioning, Low Suicide ideation or attempts Pediatric Behavior Scaleb (Lindgren and Koeppl 1987)
Functioning Autism
Mikami et al. (2009) 14–19 (17.1) 12 Autism Spectrum PDD-NOS Suicide attempts/ideation Chart review, diagnoses, suicide attempts/ideation history
Rieffe et al. (2012) 9.4–14.75 (11.75) 64 High functioning ASD Significant anger The Bully/Victim Questionnaire a (Olweus 1997); The Mood
Questionnairea (Rieffe et al. 2004); Maladaptive and
Adaptive Scalesa (Ferguson et al. 2000)
Shtayermman (2007) (19.7) 10 ASD Suicidal ideation Social Experience Questionnairea (Crick and Grotpeter 1996);
Patient Health Questionnaire for Adolescentsa
(Johnson et al. 2002); Suicidal Ideation Questionnairea
(Reynolds 1991).
Storch et al. (2012) 11–14 (12.2) 60 Asperger, PDD-NOS, Reputational victimization; Revised Peer Experiences Questionnairea (Prinstein et al. 2001);
Autism loneliness; panic disorder Asher Loneliness Scalea (Asher et al. 1984);
symptoms; major depressive Child Behavior Checklist b(Achenbach 1994); Columbia
symptoms; generalized Impairment Scaleb (Bird et al. 1993); Revised Children’s
anxiety disorder symptoms Anxiety and Depression Scalea (Chorpita et al. 2005); Social
Responsiveness Scaleb (Constantino and Gruber 2005)
Symes and Humphrey (2010) (13.75) 40 Not reported Isolation, lower levels Social Inclusion Surveya (Frederickson and Furham 1998);
of social support My Life in School Checklist a (Arora and Thompson 1987);
Social Support Scale for Childrena (Harter 1985)
Twyman et al. (2010) 8–17 (11.0) 32 Not reported Social ostracism Reynolds Bully-Victimization Scalea (Reynolds 2003);
Bully and Ostracism Student Screena (Twyman et al. 2010)
Zablotsky et al. (2013) (10.57) 1221 Asperger, Other ASD Internalizing symptoms, i.e., Bullying and School Experiences of Children with ASD Surveyb
Autism nervous, withdrawn, sad, (Zablotsky et al. 2013)
fearful; bullying behavior

a
Self-report
b
Parent-report
Rev J Autism Dev Disord (2015) 2:287–299
Rev J Autism Dev Disord (2015) 2:287–299 291

defiant disorder. They were found to show higher rates of more prone to false positives when they had been extensively
impulsivity and emotional regulation problems. Children bullied. Their accuracy in defining bullying also depended on
who were victimized most frequently displayed the most ner- their level of Theory of Mind (TOM; Baron-Cohen 2000).
vousness, withdrawal, sadness, and fearfulness. Those with less well-developed TOM gave more false nega-
Several studies have examined the effects of bullying on tives. Teachers in this special education setting reported more
suicide attempts and ideation in children who have ASD, fol- bullying than peers or the target youth themselves reported.
lowing from the literature on suicide and bullying in samples Adams et al. (2014) found that parents reported greater
of typically developing children (Borowsky et al. 2013; frequency of bullying than their teens with ASD but teens’
Litwiller and Brausch 2013; Pan and Spittal 2013). Mayes self-reports of victimization were closely associated with the
et al. (2013) found that while mood dysregulation and depres- youths’ internalizing symptoms. Parent reports of their chil-
sion were the strongest co-morbid predictors of suicidality, dren’s bullying experiences were associated with internalizing
youth who were teased were three times more likely than symptoms only in the case of physical victimization. This
non-teased youth with ASD to report suicidal ideation or to study highlights the importance of self-report information as
make an attempt. In a small retrospective study of psychiatri- a unique contribution to assessment that captures the experi-
cally hospitalized children in Japan, Mikami et al. (2009) ence in ways that are lacking in parent reports alone.
identified a group of youth diagnosed with ASD who had Shtayermman (2007) demonstrated in a self-report study,
attempted suicide. These authors found in their review of de- that children and teens with ASD reported more victimization
mographics and risk factors, that in 9 of the 12 youth, self- at higher-functioning levels than at lower-functioning levels.
reported bullying and interpersonal conflict were the primary Rowley et al. (2012) reported similar results. Children with
precipitating factors of suicide attempts. Shtayermman (2007) higher-functioning ASD both reported more depth of relation-
also found in a small group of adolescents and young adults, ships and more bullying. These authors concluded that chil-
that self-reported peer victimization was strongly correlated dren with ASD may be more attuned to social rejection and
suicidal ideation. victimization because they are higher functioning and because
they are more likely to socialize often in groups of peers with-
Perceptions of Bullying Given their unique styles of process- out ASD.
ing social information, one might ask how accurately children Overall, it appears that higher-functioning youth with ASD
with ASD perceive or recognize bullying and other traumatic are quite sensitive to bullying and are generally cognitively
situations. Some researchers have called into question their capable of discriminating between social victimization and
ability to pick up on the socially inappropriate behavior of non-bullying. It is possible that they report being bullied to a
others, especially in complex interpersonal situations. For greater extent because they are more attuned to it than lower-
example, Rieffe et al. (2012) suggested that children with functioning youth. Less is known about the perceptions and
ASD may not be so much affected by negative relational mes- reactions of lower-functioning youth on the autism spectrum,
sages from their peers but that their style of social disconnec- when they are bullied. The quality of perception in target
tion impedes full recognition of the implications of such mes- youth can be a powerful factor as it determines whether the
sages. In their sample, levels of overt reputational and rela- target child suffers negative effects, and may lead to over-
tional victimization effects were not beyond what is found reaction (Rieffe et al. 2012), bullying behavior by the victim
among typically developing children. (Cappadocia et al. 2012), and possible over-identification (van
Roekel et al. 2010) of being teased when in interactions with
In one study, scenes of verbal and non-verbal interactions other youth.
were video recorded and youth with and without ASD were
asked to rate the scenes for social appropriateness (Loveland Abuse, Neglect, and Other Traumatic Events
et al. 2001). While the ASD and non-ASD groups were equal-
ly able to identify inappropriate behavior (e.g., hitting some- Studies of potentially traumatic experiences other than bully-
one, destroying property) from the scenarios, youth diagnosed ing are summarized in Table 2.
with ASD missed more verbal inappropriateness (e.g., insults, Bleil Walters et al. (2013) examined a group of youth ad-
talking loudly in a quiet environment) than typically develop- judicated with sexual offenses residing in a state-operated
ing youth did. When asked to explain their answers, develop- sexual offender residential program. Of the 43 youth studied,
mentally typical youth relied on social norms while their 27 were identified as having an autism spectrum disorder. The
counterparts with ASD showed fewer reasonable explanations authors found only minor differences between youth with and
for their answers. without ASD in terms of the severity or frequency of abuse
Similarly, van Roekel et al. (2010) demonstrated that teens and neglect. However, youth with ASD in this sample scored
with higher-functioning ASD were just as accurate in identi- higher than their typically developing peers on a measure of
fying bullying from videotaped scenarios as typical peers, but depressive symptoms. Unlike other sub-groups in this sample,
292 Rev J Autism Dev Disord (2015) 2:287–299

Table 2 Summary of studies examining autism spectrum disorders and trauma-related symptoms (non-peer victimization)

Authors Age (years) Number ASD Co-morbid Types of Setting Trauma/diagnostic

(year) subtypes symptoms trauma measures

Bleil Walters 11–20 27 ASD Depression Physical, State sex offender Childhood Trauma Questionnairea
et al. 2013 sexual, program (Bernstein and Fink 1997); Beck
emotional Depression Inventory, 2nd Editiona
abuse; (Beck et al. 1996)
physical
neglect
De Bruin 6–12 94 Asperger PTSD Not reported Outpatient psychiatry, DISC-IV Parent Reportb (Ferdinand
et al. PDD- Netherlands and van der Ende 1998)
(2007) NOS
Autism
Mandell 8.3 (ave.) 125 Asperger Not reported Physical, Community mental Not reported
et al. Autism sexual health
(2005) abuse; centers
domestic
violence
Mehtar and 6–18 20 Asperger PTSD Accidents, Outpatient psychiatry, K-SADS-PL PTSD Scaleb (Kaufman
Mukaddes PDD- violence, Turkey et al. 1997); Aberrant Behavior
(2011) NOS sexual Checklistc (Aman et al. 1985);
Autism abuse, Trauma Symptoms Investigation
multiple Form in Autism Spectrum
trauma Disordersc (Mehtar and Mukaddes
2011)
Storch et al. 7–16 6 Asperger PTSD, Suicidal Not reported Anxiety treatment ADIS-IV Child/Parent (Silverman and
(2013) PDD- thoughts study group Albano 1996); CBCL Parent/Youth
NOS Self-Report (Achenbach 1994);
Autism Multidimensional Anxiety Scale for
Children -Parent Form (March 1998);
Columbia Impairment Scaleb (Bird
et al. 1996)
Valenti et al. Children, 50 ASD Not assessed Earthquake Semi-residential Vineland Adaptive Behavior
(2012) adolescents rehabilitation Scalesb (Sparrow et al. 2008)
centers, Italy

a
Self-report
b
Parent-report
c
Clinician/research-rated scale

a strong positive association was found in the ASD group identified six subjects with co-occurring ASD and PTSD
between severity of abuse and level of depression, suggesting (Storch et al. 2013). These youth showed increased propensity
that the youth with ASD showed increased sensitivity to trau- for suicidal thoughts over those without PTSD. This is similar
matic events. to research previously cited on youth with ASD who have
Several studies tracked the incidence of various traumatic been bullied with subsequent suicidal thoughts and actions
experiences and their psychological effects. Valenti et al. (Mayes et al. 2013; Mikami et al. 2009).
(2012) compared students with ASD in a semi-residential Ital- In a Dutch study that looked at the prevalence of co-morbid
ian training school before and after a 2009 earthquake. Chil- diagnoses among children with ASD, none of the sample of
dren and adolescents (defined as medically post-puberty) who 94 children ages 6 to 12 who met research criteria for perva-
directly experienced the earthquake showed significant de- sive developmental disorder, not otherwise specified (PDD-
clines in the Communication, Daily Living, Socialization, NOS) were identified as having PTSD (de Bruin et al. 2007).
and Motor Skills scores on the Vineland Adaptive Behavior These findings stand in marked contrast to the results of a
Scales (VABS; Sparrow et al. 2005; Sparrow et al. 2008) at 6 Turkish study conducted in a children’s autism clinic (Mehtar
and 12 month intervals following the earthquake. Students at and Mukaddes 2011). In this study, 18 of the participating
the same age levels at institutions outside of the earthquake sample of 69 patients with ASD were reported to have been
zone did not show VABS declines during the same time exposed to significant traumatic experiences. Twelve of these
period. patients (69 %) were judged to meet DSM-IV criteria for
A study that focused on suicidal thoughts and actions in a PTSD. Of the three patients exposed to multiple traumas
sample of youth with ASD and co-morbid anxiety disorders (i.e., combinations of physical violence, accidents, sexual
Rev J Autism Dev Disord (2015) 2:287–299 293

abuse), all met criteria for diagnosis with PTSD. In addition to for this purpose (Mahan and Matson 2011). The assess-
having PTSD features of re-experiencing, hyper-arousal, and ment literature provides much evidence that even parents
avoidance, the traumatized patients in this study showed a of typically developing, emotionally expressive children
higher frequency of disruptive behaviors than those patients often rate them much differently than children rate them-
who did not have notable PTSD symptoms, as measured by selves on a variety of measures (Renk and Phares 2004).
the Aberrant Behavior Checklist—Turkish Version (Aman In order to satisfy the reasonable suggestion that children
et al. 1985). They also showed deterioration in their social be evaluated by multiple observers using multiple tech-
functioning including verbal and non-verbal communication niques (Achenbach et al. 1987), a reliable self-report for-
and imitation as well as increased motor mannerisms and mat is needed to assess the child’s experience. The self-
increased stereotypical interests. reports of children and adolescents have been shown to
While in the Mehtar and Mukaddes (2011) sample, the rate add significantly to the diagnostic picture in ways that are
of exposure to potentially traumatizing events (26 %) was less unique and not accounted for by observer reports (Becker
than is usually reported in typically developing samples et al. 2004). For example, Adams et al. (2014) found that
(Fairbank 2008), the proportion of individuals diagnosable internalizing symptoms in children with ASD who had
with trauma-related symptoms was considerably higher than been bullied were highly correlated with the children’s
the 20 % range usually reported in the trauma literature (e.g., self-reports of victimization and largely uncorrelated with
Copeland et al. 2007); as high as 100 % among those who parent reports of victimization.
were multiply traumatized. The authors conclude that children
with ASD may be more sensitive to the effects of traumatizing Psychometric Properties of Co-morbid Symptom Mea-
situations than other groups. sures While it appears that children with ASD have relatively
Overall, these 17 studies of peer- and non-peer related vic- high rates of co-morbid behavioral and emotional symptoms
timization constitute the entire existing empirical base for un- (Mannion and Leader 2013), appropriately validated assess-
derstanding the effects of trauma on children with ASD. The ment instruments are lacking (Konst and Matson 2014). A few
list is even shorter if one includes only studies that measured instruments have been developed for co-morbid diagnosis in
the full PTSD syndrome including exposure, re-experiencing, ASD, which have shown acceptable psychometric qualities,
alterations in cognition and mood, and arousal (de Bruin et al. but none of these directly assess trauma symptoms (Matson
2007; Mehtar and Mukaddes 2011; Storch et al. 2013). De- et al. 2009).
spite the limitations of the aforementioned studies, including
inconsistently reported and sometimes inadequate identifica- One solution is to evaluate the application of symptom
tion of ASD (Cappadocia et al. 2012; Mikami et al. 2009; measures developed for non-ASD groups. Mazefsky et al.
Shtayermman 2007; Symes and Humphrey 2010), small sam- (2011) assessed the validity of several commonly used self-
ple sizes (Storch et al. 2013), and no agreed-upon means for report rating scales including the Revised Child Manifest
assessing trauma in the children, there is enough early infor- Anxiety Scale (RCMAS; Reynolds and Richmond 1985),
mation to suggest that many children with ASD exposed to the Children’s Depression Inventory—Short Scale (CDI—S;
trauma develop symptoms of post-traumatic stress. Craighead et al. 1998; Kovacs 1992), and the Conners-Wells
Adolescent Self-Report Scale—Short Edition (CASS—S;
Assessment of Trauma in ASD Children Conners 1997; Conners et al. 1997). All of these measures
have been found to have significant clinical utility with typi-
If the goal is to ascertain whether children exposed to trauma cally developing children. However, when administered to
develop post-traumatic or related symptoms, measurement children with ASD, high false negative and false positive rates
becomes a key issue. Several central factors must be taken resulted. The authors recommend caution in using these self-
into account including: (a) raters as sources of information; report measures for children with ASD.
(b) the sensitivity and specificity of measures for children with Another well-validated and widely used measure, the Be-
ASD, and (c) the content validity or coverage of the intended havioral Assessment System for Children—2nd Edition
dimensions being measured. (BASC-2; Reynolds and Kamphaus 2004) has been shown
to produce characteristically different pattern types when ap-
Sources of Information—Who Are the Best Reporters? plied to children on the autism spectrum (Goldin et al. 2014;
Due to their core deficits in communication, emotional Mahan and Matson 2011). These differences likely reflect and
understanding, and expression, children with ASD are of- are sensitive to the unique behavioral tendencies of the popu-
ten poor reporters of their own psychological symptoms lation but must be interpreted with these differences in mind.
and under-report problems on symptom rating scales All of these measures are likely sensitive to trauma-
(Mazefsky et al. 2011; White et al. 2012). Clinicians have associated anxiety, mood, and behavior difficulties, but they
come to rely on the reports of parents or other observers are not specific to PTSD assessment.
294 Rev J Autism Dev Disord (2015) 2:287–299

Content Assessment—Trauma Perhaps the most researched 2010; Twyman et al. 2010) as well as a host of internalizing
and reliable measure for assessing PTSD in a population of problems (Adams et al. 2014; Cappadocia et al. 2012;
children with ASD at this point is the Anxiety Disorders In- Zablotsky et al. 2013) and suicidality as a direct of result of being
terview Schedule—Parent and Child Report (ADIS-IV—C/P; teased and bullied (Mayes et al. 2013; Mikami et al. 2009;
Silverman et al. 2008). The measure has shown very strong Shtayermman 2007). This is especially concerning as there is
inter-rater reliability for the PTSD subscale for use with chil- evidence to suggest that children and youth with ASD are bullied
dren on the autism spectrum (Ung et al. 2014). The ADIS-IV even more often than their peers without ASD (Cappadocia et al.
has been used widely for assessing co-morbid anxiety disor- 2012). As most of these individuals show internalizing emotion-
ders (Chalfant et al. 2007; Reaven et al. 2012; Storch et al. al symptoms in response to bullying and are not necessarily good
2013). The ADIS-IV has also demonstrated validity and reli- at verbally or non-verbally expressing emotion, their distress
a b i l i t y f o r a s s e ss i n g t r e a t m e n t c h a n g e s i n n o n - may be missed by teachers and caregivers (Adams et al. 2014).
pharmacotherapy intervention studies of anxiety with children These findings are potentially beneficial for informing interven-
who have been diagnosed with ASD (White et al. 2013). It has tion and policy in schools and communities (Schroeder et al.
the benefit of having both parent and child report scales, 2014).
allowing comparisons between different reporters on the same Posttraumatic stress as a co-morbid symptom pattern in au-
instrument. tism needs more study, much as do other co-morbid conditions
(Konst and Matson 2014; Mannion and Leader 2013). It remains
However, while the ADIS-IV has shown sound psychometric unclear whether children with ASD exhibit classical features of
properties overall, it has been employed in only one study of PTSD in the same or similar manner shown by their typically
traumatized children with ASD (Storch et al. 2013). In another developing peers. The studies presented here provide initial ev-
study, only one subject was identified who met PTSD criteria on idence that these children experience mental health symptoms in
the scale (White et al. 2013). response to potentially traumatic events such as various kinds of
Another promising avenue is assessment of functional and abuse (Bleil Walters et al. 2013; Mandell et al. 2005; Mehtar and
adaptive competencies in association with trauma. Mehtar and Mukaddes 2011) and natural disasters (Valenti et al. 2012). They
Mukaddes (2011) found trauma-related declines in appetite show resulting symptoms including anxiety, regression in adap-
and eating, self-care abilities, and regression in social tive behavior, increased behavior problems (Mehtar and
interactions using their own Trauma Symptoms Investigation Mukaddes 2011), in some cases suicidal ideation (Storch et al.
Form. 2013).
In their study of children with ASD exposed to a natural However, it is not known whether children with ASD ex-
disaster, Valenti et al. (2012) employed the Vineland Adaptive perience the characteristic PTSD syndrome of re-experienc-
Behavior Scales (Sparrow et al. 2005; 2008) to assess func- ing, arousal, avoidance, and trauma-related alteration in cog-
tional changes on the Communication, Daily Living, Sociali- nition and mood (American Psychiatric Association 2013).
zation, and Motor Skills domains at 6 months and 1 year fol- Results have varied when structured interviews are employed
lowing the earthquake. They found 30 % average decreases in using DSM criteria to identify PTSD in children with ASD.
Vineland scores in the first months after the trauma across all These have ranged from a lack of PTSD-diagnosed cases in
domains studied, and a 15 % decline compared to baseline one one study (de Bruin et al. 2007) to a larger proportion than the
year following the trauma. The comparison ASD group unex- typical population in another study (Mehtar and Mukaddes
posed to the traumatic event showed no such declines in adap- 2011). Of the available studies, only Mehtar and Mukaddes
tive behavior. (2011) reported data on individual PTSD symptom endorse-
ment. It is recommended that future studies closely track and
report on symptom patterns present in children with ASD
Discussion following traumatic events.
In order to address diagnostic and other questions, more
This review has attempted to summarize the existing research accurate assessment of trauma reactions in ASD will be nec-
about childhood trauma and its implications for children with essary. Communication differences, difficulty expressing
ASD. Several trends are suggested. First, the research on PTSD emotion and responding in a straightforward manner to stan-
in autism is in its infancy but studies of bullying constitute a dard rating scales and measures complicate the task of assess-
major initial thrust of inquiry. It does seem clear from the existing ment even for children with higher-functioning autism
bullying literature that children with ASD are sensitive to peer (Mazefsky et al. 2011). To further complicate matters, children
victimization and suffer deleterious effects much as has been with ASDs show wide variations in verbal and conceptual
found in typically developing children (Borowsky et al. 2013; abilities ranging from those who are non-verbal with signifi-
Reijntjes et al. 2010). They report social concerns such as ostra- cant intellectual disability, to those with sophisticated lan-
cism and loneliness (Storch et al. 2012; Symes and Humphrey guage and processing skills. Executive functions including
Rev J Autism Dev Disord (2015) 2:287–299 295

planning and flexibility are often delayed in ASD and vary in treatment or learning activities in ways that may be more
with age and intellectual function (Happe’ et al. 2006; difficult otherwise (Kagohara et al. 2013). There are indications
Robinson et al. 2009). Regular achievement of developmental that children attend better to electronic, screen-based devices
milestones can be disrupted or delayed by challenging behav- than to traditional means of teaching or presentation (van der
iors, repetitive behavior and preoccupations, intellectual im- Meer et al. 2012). Use of electronic devices has potential limita-
pairment, and weaknesses in executive functions (Matson tions, however. Devices themselves are prone to breaking and
et al. 2011). Also, as with typically developing children, those becoming obsolete, and the programming can be expensive.
with ASD will likely manifest trauma symptoms differently at Also, the wide range of functioning in children with ASDs
different ages (National Child Traumatic Stress Network would likely require more than one program to meet the needs
2012; Trickett et al. 2011). of users at different ages and verbal abilities.
Gender may also play a role in the expression of both ASD A tablet-based trauma assessment instrument may adapt al-
and PTSD symptoms. Overall, there is a 4:1 ratio of ASD diag- ready existing rating scales or take the form of games or other
nosis in boys as compared to girls. However, on the higher end interactive activities. One example is the Kid Trauma® (Markus
of the spectrum, this discrepancy changes to 10:1 males vs. Landolt, University Children’s Hospital Zurich) assessment
females, with a 2:1 ratio of males to females at lower- available as an Apple iOS application or through www.
functioning levels (Fombonne 2009). While males and females kidtrauma.com. It provides a self-report questionnaire for chil-
with moderate to severe intellectual disabilities tend to show dren over 6 and a parent questionnaire for younger children in a
similar symptom patterns, diagnosis can be more difficult in standard rating scale format. The software includes brief infor-
higher-functioning females. It may be that females show rela- mation about childhood trauma and links for obtaining treatment
tively better developed social communication and emotional ex- services.
pression than males (Dworzynski et al. 2012). Given this differ- A standard of care in assessing trauma in typically developing
ence, it has been suggested that gender bias exists in the diagno- children is to combine validated structured interviews such as the
sis of higher-functioning females, essentially denying them of Diagnostic Infant and Preschool Assessment (DIPA; Scheeringa
needed services based on assessment techniques developed and Haslett 2010), K-SADS (Kaufman et al. 1997) or other
mainly for boys (Constantino and Charman 2012). It has been similar instruments with parent- and self-report rating scales.
noted that males and females, while experiencing trauma at es- The UCLA PTSD Reaction Index (Pynoos and Steinberg
sentially similar rates, may show different patterns of symptom 2013) and the Trauma Symptom Checklist (Briere 1996) are
expression (Darves-Bornoz et al. 1998; Evans et al. 2008; Walk- examples of frequently used and validated trauma measures that
er et al. 2004). give a well-rounded, multi-informant view of both traumatic
Sensitive assessment tools must take into account these dif- events and their effects. These measures and others should be
ferences in age, gender, and developmental level. Further, given tested with children on the autism spectrum to determine their
findings suggesting that self-report data provide a unique and psychometric properties and to determine whether they can be of
important source of assessment data (Adams et al. 2014; Becker help for initial assessment and ongoing treatment and research.
et al. 2004), more work needs to be done to develop valid in- An understanding of the unique effects of trauma on chil-
struments that incorporate self-report data from children with dren with ASD, combined with valid and reliable assessment
ASD (Mazefsky et al. 2011). This may be a relatively straight- tools should contribute much to developing effective treatment
forward task for verbal children with normal intellectual func- strategies. Accommodations to standard therapy approaches
tioning but more difficult with non-verbal or lower-functioning are often required to treat children and youth with ASD and
children. Suitable measures will need to be sensitive to symp- co-morbid anxiety disorders (Scarpa et al. 2013). Some recom-
toms and changes, specific to trauma, understandable, and psy- mendations have been made to adjust evidence-based practices
chologically accessible to children on the autism spectrum. for trauma treatment for children with ASD (Grosso 2012) but
Particularly lacking are well-validated self-report measures this endeavor is in its infancy. More information about trauma
that can capture these children’s unique experience and reactions and its evaluation in children with ASD can guide clinicians in
to trauma. Such measures would optimally be appealing, engag- their choice of approaches and assessment of outcomes.
ing, able to hold children’s attention, and present material
through more than one modality (e.g., visual, auditory, touch)
to allow accessibility by individuals at different functional levels. Compliance with Ethical Standards The author declares that he has
Electronic devices such as tablets may provide a format for this no conflict of interest.
kind of appeal and flexibility. Treatment providers and educators
have increasingly turned to electronic platforms including Ethical Approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
iPads®, iPods ® and other similar devices to present material
institutional and/or national research committee and with the 1964 Hel-
to children with ASD ( Neely et al. 2013). Some of these pro- sinki declaration and its later amendments or comparable ethical
grams have been shown to effectively engage children with ASD standards.
296 Rev J Autism Dev Disord (2015) 2:287–299

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