The Relationship Between ASD and IPV

Journal of Child & Adolescent Trauma | 2024, p. 1-11 

The Convergence of Autism Spectrum Disorder and Intimate Partner Violence: Implications for Clinical Practice

Hannah Ruth Steinke; College of Social Work, The Ohio State University, 1947 North College Road, Columbus, OH 43210, USA

Trauma-specific care denotes best practice when working with individuals with histories of childhood abuse, maltreatment, or experiences of intimate partner violence. However, youth with autism spectrum disorder and exposure to intimate partner violence characterize a specific subpopulation of trauma-impacted individuals who present unique challenges for practitioners and researchers alike. The comorbidity of trauma and autism spectrum disorder raises a specific practice problem requiring an in-depth understanding of the complex interrelationship of childhood experiences of intimate partner violence, the associated traumatic sequelae, and the neurobiological characteristics of autism spectrum disorder. The current research on the intersectionality of intimate partner violence, trauma, and autism is limited. This paper draws attention to the practice implications of working with adolescent clients with both a history of trauma from childhood exposure to intimate partner violence and a diagnosis of autism spectrum disorder. The author utilizes a case study to contextualize presenting concerns, prioritize needs, and identify treatment outcomes. A systematic review is used to methodically review the literature on clinical interventions for youth with autism spectrum disorder and trauma. The aim is to draw attention to the gap in the literature as well as provide clinicians with a structured review of the literature on interventions for this unique population. Recommendations include research and tailored interventions to meet the developmental and concrete needs of the client in the present case study and perhaps others who are similarly situated. Clinical and research implications highlight the need for specialized care and further research to meet this underserved population.

Autism; ASD; intimate partner violence (IPV); child abuse; trauma

“The literature review explores the intersection of autism spectrum disorder (ASD), intimate partner violence (IPV), and trauma, emphasizing that "childhood exposure to IPV is deleterious when a child is aware of the violence or recognizes the potential threat of violence, even without explicitly witnessing violence." The author explains that "compared to neurotypical children, children with ASD have an increased risk of exposure to IPV" and other adverse childhood experiences. Furthermore, "there is an increased prevalence of trauma-related disorders among individuals with ASD," with some studies reporting that "rates of post-traumatic stress disorder (PTSD) prevalence in the ASD population to be ten times greater than that of the neurotypical population with similar traumas." The review highlights the complexity of ASD and trauma comorbidity, noting that "the neurobiological responses will often continue to remain active even after the threat no longer exists, leading to changes in neural structures and sensory processing systems." These factors complicate both the assessment and treatment of trauma in individuals with ASD, as they often present with "unconventional manifestations of trauma outside traditional diagnostic categories" (p. 1-3).

The paper aims to "draw attention to the gap in the literature as well as provide clinicians with a structured review of the literature on interventions for this unique population." The author presents a case study of "John (a pseudonym), a 16-year-old bi-racial boy diagnosed with ASD, PTSD, adjustment disorder, generalized anxiety, social anxiety, and major depression" who has a history of IPV exposure. Through a systematized review, the author applies the PICO (Patient, Intervention, Comparison, and Outcome) framework to identify "therapeutic modalities appropriate for youth similarly situated as John." The study’s methodology follows PRISMA guidelines to conduct "a search of the literature to determine a feasible treatment option for a specific population/problem." The literature search identified "177 articles after duplicates were removed," with the final review focusing on four key articles that explore ASD-specific adaptations to trauma-focused cognitive behavioral therapy (TF-CBT) and other therapeutic interventions (p. 3-4).

The discussion highlights that John’s "participation was minimal at best due to his social-communicative issues and difficulties identifying and labeling his emotions and feelings." His experience with traditional CBT was ineffective because "CBT, while an evidenced-based intervention for trauma-exposed clients, requires cognitive processing and communicative skills which John lacks when his brain reverts to a state of shutdown." The case study underscores the barriers that individuals with ASD face in accessing appropriate treatment, as "John was subsequently referred to an ASD-specific facility, but their policy included an exclusion criterion for individuals with suicidal ideations." The study identifies Stack and Lucyshyn’s (2019) model as the "most comprehensive treatment package that included not only adaptations to current evidence-based tools utilized in TF-CBT but also the incorporation of tools from Applied Behavioral Analysis (ABA) therapy" (p. 3, 7-8)

The findings emphasize the need for "a strengths-based, person-centered, trauma-specific perspective" for individuals with ASD and trauma histories. The study argues that "John would benefit from modalities that focus on soothing his nervous system while taking into consideration his very complex sensory processing issues." Additionally, intervention should include "functional behavior assessment (FBA), data monitoring and ongoing evaluations of outcomes, teaching emotional regulation and emotion recognition, utilizing graduated exposure, cognitive restructuring, and psychoeducation about trauma and trauma responses." The author concludes that "there is a significant gap in research and interventions related to ASD and trauma, specifically childhood exposure to IPV," calling for "specialized training for providers that focuses on the intersection of IPV, trauma, and ASD" (p. 7-8). 

“Stack and Lucyshyn’s (2019) model aligns with the research and evidence-based practices associated with the neurobiology of trauma, studies denoting the specific differences in the functional connectivity of the prefrontal cortex and amygdala in children/ youth with comorbidity of ASD and trauma exposure, and empirical evidence of TF-CBT with autism adaptations to treat the symptoms of anxiety in children with ASD. Furthermore, Stack and Lucyshyn’s treatment package could potentially address the practice needs of the client in the present case study, given his level of functioning and comorbidity of autism and trauma symptomology, including increased anxiety and suicidal ideations. The comprehensive nature of the model includes being able to treat trauma, ASD symptoms, and anxiety while also safety planning to protect against risk factors associated with suicidality. The ASD-specific adaptations of this trauma-informed program could help to meet the holistic needs of this client by recognizing and understanding the uniqueness of the clinical presentation when ASD and trauma converge. Further, this model emphasizes the need for family inclusion in the intervention process. Specific therapeutic practice recommendations for this case study include: 1) establishing a felt sense of safety and security for the client through the use of client-centered concrete tools to self-soothe and calm, 2) adapting tools and timeframes to meet the unique developmental needs of the client, 3) accommodating the client’s individual preferences surrounding rituals, rules, routines, and areas of interests, 4) building on ASD-specific strengths that may be present in the client (i.e., visual-spatial processing, rote memory, areas of exceptionality such as math, music, art, etc.), 5) addressing the unique sensory needs of the client utilizing principles from neurobiology and trauma healing, 6) incorporating parent/s in the therapeutic process for both family support and to address specific attachment needs, and 7) enhancing cognitive flexibility to promote resilience. Additionally, this case study, along with supporting literature, highlights the need for specialized training for providers that focuses on the intersection of IPV, trauma, and ASD” (p. 8-9).

“In addition to improved practices, research must be conducted to better understand the moderating and mediating factors associated with IPV and ASD. Current studies on IPV and developmental disabilities (DD) have noted a significant relationship between IPV and DD; however, current studies are limited by poor external validity, small sample sizes, and methodologies that prevent one from ascertaining directionality. Future studies are needed to not only study the relationship between IPV and ASD but to better understand how IPV differs in its impact on children/youth with ASD and DD compared to typically developed children/youth. While much ground has been gained by researchers focused on IPV and coercive control without physical violence as a deleterious form of violence against children, it is critical to study the impacts of coercive control on children/youth with ASD given the unique ways in which they perceive, process, and resolve trauma, as well as the predisposition to attachment disorders among this population. Additionally, an assessment forms the basis of any intervention, and yet there is a lack of available tools to screen for trauma and suicidality in children/youth with ASD. Finally, research must give attention to the development of ASD-specific trauma interventions to build protective factors in this vulnerable population. The primary prevention of IPV in subsequent generations demands a critical appraisal of how IPV is addressed with current youth with the convergence of ASD, IPV, and trauma. Trauma impacts children and youth with ASD at higher rates than typically developed children, while experiences of IPV among youth with ASD create additional neurobiological substrates of traumatic stress and trauma. Although there is a need for research focused on the convergence of ASD and IPV-related trauma, there is an even greater need for practitioners to understand the neurobiology of trauma and ASD and to be able to utilize recommendations in the literature. ASD-specific adaptations of evidence-based modalities provide a starting point for meeting the needs of this underserved population” (p. 9).