Autism and Trauma: How to Treat Trauma in Children with Autism

Nicole Palmer, MA, LPC, Certified Trauma Competent Professional

Chelsea Greenspon, PsyD, Assisting Clinical Director

Stephanie Miodus, MA, MEd

SPIN, Inc.

ABSTRACT

Trauma impacts many children in Philadelphia, including those with autism spectrum disorder (ASD) who experience higher rates of Adverse Childhood Experiences (ACEs; Berg et al., 2016). The approach to treating and explaining trauma to this population is different (D’Amico et al., 2022). This workshop will explore the impact of trauma and best practices for trauma treatment for children with ASD. There will be a brief review of trauma, ACEs pyramid, impact of trauma, and behavioral responses to trauma. We will discuss how children with ASD are uniquely affected by ACEs, specific approaches for working with this population, including adaptations to evidence-based treatments (e.g., Trauma Focused-Cognitive Behavioral Therapy), and addressing trauma with children with limited language skills.

KEY OBJECTIVES

This workshop will be provided by SPIN Inc, a Philadelphia Autism Center for Excellence. This workshop aims to give providers an understanding of how children with autism are impacted by trauma, and best practices for explaining and treating trauma within this population.

INTRODUCTION TO TRAUMA

  • Childhood trauma or Adverse Childhood Experiences (ACEs) are “stressful or traumatic events, including abuse and neglect. They may also include household challenges such as witnessing violence in the home or living with someone with a substance use disorder.” (CDC.gov)​

  • It also includes medical treatments, bullying, parental divorce and natural disasters as well as racial and sociocultural trauma. ​

  • Trauma can begin at the time of conception as anything that the mother experiences, the fetus experiences as well. ​

  • It can be something that happens once or something that happens often over time.​

INTRODUCTION TO AUTISM

TRAUMA & AUTISM

  • Kerns et al. (2015) discussed the possibility that “the core symptoms of ASD may predispose children to stressful experiences"​

  • Berg et al. (2016) & Rigles (2017) found children w/ ASD experience a greater number of ACEs​

    • Increased rates of income insufficiency, parental divorce, household mental health and/or substance use issues, and neighborhood violence (Berg et al., 2016)​

    • Bullied at a rate of 3-4X higher than the general population (Maiano et al., 2016)​

    • Similar rates of child maltreatment to the general population (Hall-Lande et al., 2015)​

    • More likely to be referred to child abuse hotline than general population but less likely for these to be screened further/acted upon (Fisher et al., 2018)

  • Rigles (2017) found that for children with ASD, a greater number of ACEs is related to worse health outcomes, but does not show any relationship with resiliency as it does in the general population and the population of children with other special health care needs​

  • Experience of ACEs related to longer time to diagnosis of ASD, as well as later entry into treatment/services (Berg et al., 2018)​

    • Impact: lost opportunity for early intervention, which has a significant clinical impact (Volkmar et al., 2014)

  • Individuals with ASD who have experienced a stressful or traumatic event may display behavioral responses to trauma that are often mistaken for an exacerbation of ASD symptoms instead of trauma responses, including: ​

    • aggressive outbursts​

    • distractibility​

    • social isolation

    • increased repetitive or stereotypic behavior ​

    • regression in daily living skills

IMPACT OF TRAUMA & RESPONSES

  • Trauma alters the brain. It becomes on “high alert” all the time and is sensitive to the tiniest of triggers. ​

    • It is always assessing for the next thing that might harm us, even after we are safe. ​

  • Can cause a disconnect between our mind and body.

  • We do not sense with our organs first, we sense first with our brain .​

    • Experiences a sight, sound, smell, taste or texture that reminds them (consciously or unconsciously) of the traumatic event​

    • Brain gives an action based on past experiences and current sensory experience. ​

  • The Triune or 3-part brain is a myth. ​

    • “Most successful and widespread errors in all of science.” Dr. Feldman-Barrett​

    • By the 1990s, experts completely rejected the theory based on updated analysis of the brain. ​

    • The brain instead reorganized itself as they evolved.​

    • Bad behavior is not due to our “inner beast” and good behavior is not due to being rational: "Instinct ,emotionality and rationality are not fighting each other. Emotions can be rational and sometimes thinking is not rational depending on the situation. " Dr. Feldman-Barret

  • Brain’s job is to keep us safe. ​

    • Therefore, it is rational for the body to release cortisol if it senses danger as this is needed for survival. ​

    • If there is a false alarm, the brain is continuing to protect you if it releases cortisol because the brain believes you need to be protected, even if now safe. ​

    • This means your brain has not adjusted yet to its new, safer environment, not that you are acting irrationally. ​

  • ​Amygdala, hippocampus, and brain stem work together. ​

    • If brain senses danger, will elicit stress response. Body goes into stress response to keep safe from danger.​

    • Not able to access language center of the brain. ​

    • Not able to use executive functioning skills. ​

DIFFERENTIAL DIAGNOSIS: TRAUMA VS. ASD

A Challenging Differential Diagnosis​:

​

  • Trauma reactions often look like symptoms of autism​

  • Decreased eye contact, flat affect, repetitive behaviors, sensory sensitivities, even developmental delays

TRAUMA ASSESSMENTS/INTERVIEWING FOR CHILDREN WITH ASD

  • No existing large-scale validated assessment/self-report tools assessing trauma specifically for children with ASD (Hoover & Kaufman, 2018), but a pilot study has shown promising initial results for an interactive self-report app to address this gap (Interactive Trauma Scale; Hoover & Romero, 2019)

  • Adapted from Modell Consulting Group, LLC - Forensic Interviewing for Individuals With Disabilities: https://modellconsultinggroup.com/find

    • Be aware of potential echolalia

      • Make sure endorsement of trauma is not a repetition of the question

      • Provide time for responses

      • Anxiety reduction strategies

    • Addressing perseveration

      • Clarity & predictability

      • Provide warnings before transitions

      • Redirection of responses

      • Reframing of questions

    • Anchoring: use the child's words to seek more details

      • You said _____. Tell me more about __________.

    • Avoid filling in the blanks for the child

    • High probability instructional sequence

      • Use if child struggling with the question or not oriented to responding

EXPLAINING TRAUMA TO CHILDREN WITH ASD

  • Hand brain models: upstairs and downstairs brain by Dan Siegel.​

  • For children who are concrete thinkers, teaching what each part of the brain does is helpful.​

  • For children who can think abstractly:​

    • Guard dog and Owl From Cosmic Kids Yoga video​

    • Thoughtful Turtle and Protective Porcupine- Whole Hearted School Counseling ​

    • Use preferred interests

  • Learn more about the hand brain model: https://drdansiegel.com/hand-model-of-the-brain/

BEST PRACTICES FOR TREATMENT

ECOSYSTEMIC ​STRUCTURAL ​FAMILY THERAPY (ESFT)

  • "ESFT is a treatment for children and families experiencing behavioral or relational challenges and is based on the theory that change in family structure contributes to change in the behavior of individual members."​

  • Works with both children and their families to coach family in changing negative relational patterns of interaction.​

  • Focuses on the strengths of the family.​

  • ACES: ​

    • Attachment between child and caregivers.​

    • Co-Caregiver Alliance​

    • Executive Functioning​

    • Self-regulation (co-regulation with caregivers).

  • Bowlby defines attachment as the “lasting psychological connectedness between human beings.” When there is damage done to a child’s attachment to their caregivers (i.e. needs not being met, lack of connection, abuse) this will impact their relationships with others throughout their lives if not addressed. ​

  • The more healthy relationships a child has, the more likely they will be to recover from trauma and thrive. Relationships are the agents of change and the most powerful therapy is human love.” - Bruce Perry, MD, PhD

  • Secure Attachment is when a parent/caregiver:

    • Responds appropriately to the child’s needs.​

    • Creates a safe and supportive environment.​

    • Will be easy to develop a relationship with.

  • Co-Caregiver Alliance

    • Strong alliance is needed, no one person can do it all on their own.​

    • Caregivers working together to share responsibilities of raising child.​

    • Important as it models for kids healthy interactions such as compromise and forgiveness.​

    • Helps to create structure and consistency in the family.

  • Executive Functioning:

    • Be consistent and predictable. ​

    • Model desired behaviors.​

    • Set healthy boundaries in relationship and minimize toxic conditions.​

    • Have clear expectations for behaviors.​

    • Set limits & follow through with reasonable consequences.​

    • Use praise and focus on positive behaviors.​

    • Create family routines.

  • Co-regulation:

    • Self-regulation is the ability to manage feelings, thoughts and actions. ​

    • Develops through interactions with caregivers, such as parents and teachers. ​

    • Needs predictable and supportive environments to develop.​

    • "Co-regulation is the supportive process between caring adults and children, youth, or young adults that fosters self-regulation development" (Rosanbalm & Murray, 2017)

    • Caregivers must:​

      • Be aware of their own feelings and reactions .​

      • Be aware of their own thoughts or beliefs about other's behaviors. ​

      • Use coping skills to stay calm.​

      • Respond calmly and model use of skills.

  • Co-regulation activities:

    • Grounding exercises ​

      • “I spy”​

      • Rainbow Grounding​

      • 5-4-3-2-1​

    • Deep breathing​

    • Dancing / moving to music​

    • Yoga​

    • Progressive muscle relaxation​

    • Shaking out energy

TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY (TF-CBT)

  • Evidence-based treatment for children who have experienced trauma and their caregivers​

  • Incorporates both CBT and family therapy approaches​

  • PRACTICE:​

    • Psychoeducation & Parenting​

    • Relaxation​

    • Affective/Emotion Regulation​

    • Cognitive Coping (Thoughts)​

    • Trauma Narrative​

    • In Vivo Practice​

    • Conjoint Sessions​

    • Enhancing the Future

  • Research shows that experience working with children with autism/developmental disabilities matters for whether therapists make adaptations to treatment (D'Amico et al., 2022)

  • Recommendations for adaptations for children with autism (D'Amico et al., 2022):

    • Treatment length/pacing of sessions (shorter sessions)

    • Increase caregiver involvement

    • Increase time on concerns not related to the trauma

    • Provide teaching materials with psychoeducation on autism

    • Adapt materials (e.g., more visuals, videos, apps, activities)

    • Adapt structure of sessions

    • Incorporate preferred interests

REFERENCES

  • Adverse Childhood Experiences (ACEs). (n.d.). Retrieved from https://www.cdc.gov/violenceprevention/aces/index.html

  • Barrett, L. (2021). Seven and a Half Lessons About the Brain. Mariner Books.​​

  • Berg, K. L., Acharya, K., Shiu, C. S., & Msall, M. E. (2018). Delayed diagnosis and treatment among children with autism who experience adversity. Journal of Autism and Developmental Disorders, 48(1), 45-54. https://doi.org/10.1007/s10803-017-3294-y

  • Cozolino, L. (2014). The Neuroscience of Human Relationships. New York, NY: W.W. Norton & Company, Inc.​

  • Cozolino, L. (2017). The Neuroscience of Psychotherapy. New York, NY: W.W. Norton & Company, Inc.​

  • D’Amico, P. J., Vogel, J. M., Mannarino, A. P., Hoffman, D. L., Briggs, E. C., Tunno, A. M., Smith, C. C., Hoover, D., & Schwartz, R. M. (2022). Tailoring trauma-focused cognitive behavioral therapy (TF-CBT) for youth with intellectual and developmental disabilities: A survey of nationally certified TF-CBT therapists. Evidence-Based Practice in Child and Adolescent Mental Health, 7(1), 112-124. https://doi.org/10.1080/23794925.2021.1955639

  • Eliot, L. (1999). What’s Going On In There? How the Brain and Mind Develop In the First Five Years of Life. New York, NY: Bantam Books.​

  • EPIC. (2015, September). Ecosystemic Structural Family Therapy (ESFT). Evidence-Based Practice and Innovation Center. Retrieved July 5, 2022, from https://dbhids.org/wp-content/uploads/2015/09/EPIC-ESFT.pdf​

  • Fisher, M. H., Epstein, R. A., Urbano, R. C., Vehorn, A., Cull, M. J., & Warren, Z. (2019). A population-based examination of maltreatment referrals and substantiation for children with autism spectrum disorder. Autism, 23(5), 1335-1340. https://doi.org/10.1177/1362361318813998

  • Fuld S. (2018). Autism Spectrum Disorder: The Impact of Stressful and Traumatic Life Events and Implications for Clinical Practice. Clinical Social Work Journal, 46(3), 210–219. https://doi.org/10.1007/s10615-018-0649-6 ​

  • Hall-Lande, J., Hewitt, A., Mishra, S., Piescher, K., & LaLiberte, T. (2015). Involvement of children with autism spectrum disorder (ASD) in the child protection system. Focus on Autism and Other Developmental Disabilities, 30(4), 237-248. https://doi.org/10.1177/1088357614539834

  • Hoover, D. W., & Kaufman, J. (2018). Adverse childhood experiences in children with autism spectrum disorder. Current Opinion in Psychiatry, 31(2), 128-132. https://doi.org/10.1097/YCO.0000000000000390

  • Hoover, D. W., & Romero, E. M. (2019). The Interactive Trauma Scale: a web-based measure for children with autism. Journal of Autism and Developmental Disorders, 49(4), 1686-1692. https://doi.org/10.1007/s10803-018-03864-3

  • 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

  • Levine, P. & Kline, M. (2007). Trauma Through A Child’s Eyes. Berkeley, CA: North Atlantic Books. ​

  • Maiano, C., Normand, C. L., Salvas, M. C., Moullec, G., & Aimé, A. (2016). Prevalence of school bullying among youth with autism spectrum disorders: A systematic review and meta‐analysis. Autism Research, 9(6), 601-615. https://doi.org/10.1002/aur.1568

  • Perry, B. & Szalavitz, M. (2006). The Boy Who Was Raised As a Dog. New York, NY: Hachette Books.​

  • Rigles, B. (2017). The relationship between adverse childhood events, resiliency and health among children with autism. Journal of Autism and Developmental Disorders, 47(1), 187-202. https://doi.org/10.1007/s10803-016-2905-3

  • Rosanbalm, K.D., & Murray, D.W. (2017). Caregiver Co-regulation Across Development: A Practice Brief. OPRE Brief #2017-80. Washington, DC: Office of Planning, Research, and Evaluation, Administration for Children and Families, US. Department of Health and Human Services.​

  • Siegel, D. & Bryson, T. (2011) The Whole-Brain Child. New York: NY: Bantam Books.

  • Teachers Pay Teachers. (n.d.). WholeHearted School Counseling. https://www.teacherspayteachers.com/Store/Wholehearted-School-Counseling

  • The Owl and the Guard Dog | Cosmic Kids Zen Den - Mindfulness for kids. (2016, October 17). YouTube. https://www.youtube.com/watch?v=so8QN9an3t8​

  • Volkmar, F., Siegel, M., Woodbury-Smith, M., King, B., McCracken, J., & State, M. (2014). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 53(2), 237-257. https://doi.org/10.1016/j.jaac.2013.10.013

CONTACT INFORMATION

For more information on this presentation, please contact:

Nicole Palmer, MA, LPC, Certified Trauma Competent Professional at npalmer@spininc.org

Chelsea Greenspon, PsyD, Assisting Clinical Director at cgreenspon@spininc.org

Stephanie Miodus, MA, MEd at smiodus@spininc.org or stephaniemiodus@gmail.com