Guest editorial: Rising to the challenge: meeting the trauma needs of autistic people

Citation

Morris, D. (2024), "Guest editorial: Rising to the challenge: meeting the trauma needs of autistic people", Advances in Autism, Vol. 10 No. 3, pp. 101-103. https://doi.org/10.1108/AIA-07-2024-079

A very warm welcome to this special edition. I am delighted to introduce a volume comprising of papers offering practice guidance, exploring challenging diagnostic questions, empirically evaluating treatments and expanding the theoretical lens for improving our understanding of trauma in autistic people.

An increasingly robust body of evidence suggests that autistic people are more likely to experience adversity, across the lifespan (Hartley et al., 2023; Stewart et al., 2022). Yet, autistic people represent a heterogeneous community and currently we have limited understanding as to whether there are differential trauma experiences and needs within this population. As such, our research and clinical approaches would benefit from exploring assumptions of homogeneity. Relatedly, it is critical that we move beyond acknowledging the increased likelihood of exposure to adversity, and develop an understanding of which types of childhood adversity are more prevalent and impactful, which is necessary for developing nuanced preventative and management approaches.

As such, the special edition opens with Webb et al. (2024) reporting a systematic review and meta-analysis for exposure to different types of childhood adversity in people with autistic traits. Critically, Webb et al. (2024) identify that research exploring childhood adversity in this population could be considerably strengthened. Firstly, current studies need to be more inclusive of different autistic populations and tackle assumptions of symmetry of experiences. Currently, the experiences of males, gender-diverse groups and individuals outside of high-income countries are excluded from the literature. As such, design limitations in current studies impact on our ability to understand these experiences in autistic people, from an intersectional lens. The lack of inclusivity in the autistic trauma literature mirrors the populations who are also typically omitted or minimally present in the neurotypical trauma evidence base, representing a key shortcoming to address more generally. Webb et al. (2024) also remind us of the importance of exploring a wider range of adversities in future studies, with consideration of the ACEs framework as a whole, as well as consideration of additional adversities experienced by autistic people, to ensure we have effective prevention and intervention frameworks in place.

Exposure to adversity can, for neurodiverse and neurotypical populations, manifest in highly idiosyncratic ways and attract different formulations of need, including developmental difference, including delay and a range of mental health diagnoses, including trauma (e.g. post-traumatic stress disorder [PTSD]) and personality disorder. The nature and language of diagnoses can have profound implications for an individual’s sense of self and identity, social stigma and marginalisation, as well as determining clinical treatment pathways. Accordingly, clinicians are increasingly required to formulate diagnoses in the context of competing diagnostic frameworks and it is vital, going forward, that we develop our understanding of the factors that lead to differential diagnoses, including shortcomings or biases in assessment processes, as experienced by autistic people.

Central to these debates are the complex relationships between autism, trauma and personality disorder. Challenges include misdiagnosis, diagnostic overshadowing and mimicking, as well as diagnostic primacy and co-existence. This is an area of practice in much need of clinical guidance, grounded in evidence from clinical, academic and lived experience perspectives. These challenges, with practice guidance solutions, are explored in four papers in this volume.

The challenges of navigating competing autism and trauma diagnostic nosology are explored by Worthington and Al-attar (2024), who explore how biological, cognitive, emotional, relational and social sequelae of exposure to adversity and potentially traumatic events can mirror core features of autism. Through discussion of core and extended features of autism and their relationship with trauma presentations, Worthington and Al-atter provide accessible guidance for clinicians navigating assessment processes.

In their invited paper, Kildahl et al. (2024) draw on their extensive clinical experience of working with people with trauma and developmental difference, to present a case study navigating clinical experiences of disentangling trauma and autism in the context of intellectual disability. Similarly, Harris (2024) explore the challenges of formulating need in the context of possible borderline personality disorder and autism, in a gender minority young person. Acknowledging the limitations of the current evidence base for this population, their review of the literature and practice guidance provides a valuable consideration of the similarities and differences of the two diagnostic systems in the context of an underrepresented population.

Case studies play a critical role in demonstrating individual service user experiences and demonstrate clinical dilemmas and learning points that can inform clinical practice. At the same time, empirically derived clinical practice guidance to inform assessment and diagnostic processes for trauma needs in autistic people are critically absent, and represent a key clinical priority, especially in the area of differential diagnoses. In the absence of empirically driven guidance, consensus expert views provide interim “holding” for services and service users.

In recognition of this important need, Rumble et al. (2024) report on a modified Delphi study to establish consensus-derived expert guidance to support the process of making differential diagnoses of trauma and autism, and to support the assessment process itself. Their guidance stresses consideration of the differential experiences, clinical profiles and impacts of traumatic events for autistic people. Recommending 108 points of clinical guidance, their study highlights the key role of individualised and collaborative approaches to assessment processes and offers clinicians’ practical steps to embed evidence into clinical assessment activities.

Moving from assessment to treatment, Phillips et al. (2024) provide an essential empirical evaluation of Dialectical Behaviour Therapy for autistic adolescents with comorbid emerging personality needs. Critically, their evaluation draws on a wide range of outcome measures, extending beyond the traditional focus on symptom changes to include service user valued outcomes such as functioning, encompassing work and employment status and length of admission in their framework.

The final paper in this volume brings a much welcomed and exciting expansion of trauma frameworks to inform our understanding of the adversities experienced by autistic people. Current trauma models predominantly focus on an individual’s fear response and appraisals of an event considered life-threatening. Yet, refocusing our attention to the potential interaction of core characteristics of autism with the social world of autistic people may provide a key area of theory development and innovations in trauma, beyond traditional fear conceptualisations.

The concept of “moral injury” is gaining increasing traction in the health-care literature as a trauma response distinct from PTSD. A moral injury arises as a result of transgressions or betrayals of deeply held moral values and beliefs, and can result in significant and enduring psychological distress, typically anger, shame and disgust. In neurotypical populations, moral injury has been associated with negative biopsychosocial outcomes and poorer outcomes of treatment in a range of populations including military personnel, first responders, health-care professionals and service users.

Worthington and Al-attar (2024) offer an innovative paper that explores different aspects of moral injury and how this may provide a framework to account for enduring emotional responses to “transgressions” experienced by autistic people. Through exploring trauma responses through a moral injury framework, Worthington and Al-atter provide the field with a rich area for future investigation that could provide a much needed additional framework for understanding trauma responses in this population.

Finally, a huge thank you to Verity Chester, general editor, for suggesting this special edition and inviting me to take on the temporary stewardship of this wonderful journal. Her support has been critical to the success of this edition. Emerald journals play a key role in supporting researchers and clinicians to reduce the gap between research and clinical practice and promote accessible papers that can lead to practice improvements for the betterment of the people we support. Their dedication to supporting clinicians and researchers is much needed in an ever changing academic and clinical landscape.