"Currently, there is no evidence based practice for the treatment of trauma [for autistic individuals]".
Those are words from a recent paper looking at ideas for how to help autistic children who have experienced traumatic events. The paper, by Slack and Lucyshyn (2018), can be found at https://link.springer.com/article/10.1007%2Fs10803-018-3854-9
I must admit that when I read this, I didn't know quite what to say.
We know that autistic children experience high levels of bullying. We know that they are seen as a target by predators. We know that many show distress behaviour, and many express a wish to end their own lives.
We know there is likely to be an autistic child in every classroom, from the most recent research into numbers of autistic individuals.
But no-one knows how to help an autistic child who shows signs of trauma (for example Post Traumatic Stress Disorder or complex Post Traumatic Stress Disorder (PTSD, cPTSD)?).
What are PTSD and cPTSD?
From an online article linked to in the paragraphs below, "PTSD usually develops after someone sees or experiences a terrifying or life-threatening event. After that initial episode, any reminder of it can trigger panic, extreme startle reflexes and flashbacks. Beyond that, however, there’s a wide variety in the way PTSD manifests: It can lead to hypervigilance and anger; it can cause recurring nightmares and other sleep issues; or it can lead to depression, persistent fear, aggression, irritability or difficulty concentrating and remembering things." cPTSD happens for some after enduring multiple traumatic events or one really long traumatic event, from which there is no escape, for example.
There's more information on PTSD and cPTSD at https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/complex-ptsd/#.XLlvvOhKjIU
What does PTSD or cPTSD look like, in an autistic child? We don't know. No, really, we don't know. This is explored in this article, which also lists some of the common ways that PTSD is experienced. https://www.spectrumnews.org/features/deep-dive/intersection-autism-trauma/
Why don't we know what PTSD looks like in autistic children? Why don't we have a clear idea how many are experiencing it? I sense that this is because of the deeply problematic core belief in society that autistic distress is a 'problem behaviour' that is to be trained out of us. Looking at that list, anger, depression, aggression, irritability, panic, hypervigilance.... I'm mindful of how many behavioural-intervention checklists I see where those items are listed as 'autism symptoms' and the individual is relentlessly trained and rewarded for making their internal terror invisible to outsiders.
In a quest to find something, anything, helpful, I followed a link to Shaffer et al's recent paper (2018) proposing a new treatment regime (in part ABA based) for emotional regulation, which some believe is a way to treat trauma. The link is here https://link.springer.com/article/10.1007%2Fs10803-018-3727-2
It looked at 34 children with combinations of diagnoses of autism, or ADHD, or conduct disorders, or depression. In other words, so varied that any results would have been impossible to unpick, I suspect. 26 male, 8 female. Age 8-12. The parents were asked about the child's angry or defiant behaviour, and the parents were asked about their own quality of life. Then an intervention was done, and the parents were asked to rate the child's behaviour and whether it improved the parent's own quality of life. A brief clinical improvement score was also given (the CGI-I). We are not told whether the clinicians had any deep modern understanding of autism. The CGI-I's general use is discussed here : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880930/ It's a basic measure designed mostly for illness, and is around 'is the patient better than last week'? No mention of sensory needs or adaptations, just behavioural and psychological interventions. One could question whether a medical checklist is appropriate for a neurodiversity, also. Better than what? From whose perspective? If we train gay people to act straight, are they 'better' than they were last week?
Can anyone see the problems here?
Everything is related to a caregiver's or professional's observation of external behaviour, and how happy the caregiver is, not the child. It's irrelevant to hear the child expressing whether it's worked as a therapy or not. The actual feelings, experiences and self-determined outcomes of the child aren't evaluated, it appears. I'm pretty shocked, if so.
If the child learns not to show their distress, hey, the therapy's worked...? Really?
As a professional in the field of autism, I am deeply concerned about all of this. It appears that we are not even off the proverbial starting-blocks in the race to understand autism and trauma, with children. We don't know what it looks like, we don't know how to treat it, and we are told by behaviourists that a quiet child means a happy child?
I do not agree. From personal perspective of 20 years in autism work, I sense that by encouraging traumatised children to never show how they feel, then not even asking them, we are internalising the trauma and potentially setting the children up for very bad outcomes indeed.
I am not a therapist. I would very much like the therapeutic communities to do some work on this, because clearly this is a desperate situation for autistic people of all ages. It's not just children who experience traumatic events. We see an increasing number of autistic adults who are being diagnosed with PTSD or cPTSD, and an increasing number of therapists desperate for some clues, some strategies.
What would my advice be, right now, as a professional who specialises in autism training, enablement of autistic lives, safeguarding, and cultural interpretation?
- That we get excellent modern training on autism, from autistic specialists and allies. Training that acknowledges the humanity and difference of autism, rather than framing it as deficit and disorder. The books of Dr Luke Beardon are an excellent start for this, for example. So is the work of Dr Damian Milton on double empathy.
- That we stop seeing all 'behaviour' as defiance, or as 'autism'. Think - could this be trauma?
- That we stop assuming that all distressed autistic people will show 'challenging' behaviours.
- That we stop interpreting quietness as a success or as a sign of happiness.
- That we acknowledge that repeated deprivation of sensory and other needs for autistic children may be traumatising, and that we investigate and take seriously the endless personal accounts of those needs, by autistic individuals. It should not be routine to take everything autistic children need away from them, to 'normalise' them.
- That we start asking autistic children and young people about their actual experiences. Yes, some do not use spoken language. This is where working with autistic specialists as interpreters, and working with the individual using different communication methods, is important. Good SALT teams are allies here. It is not enough to say, "Well it was too hard." Our job is to communicate effectively with people, not just ask others for their opinion on them. That's not a proper evaluation.
- That we commission balanced, autistic-informed and led research into all of this, as a matter of priority, and look at ways to fund the resulting therapies properly and fully.
- And mostly, that we acknowledge the damage done to too many autistic children, and indeed adults. Whether accidentally or deliberately. Instead of blaming autistic people for every single thing they do or say and calling it a 'deficit', we need to acknowledge the deep humanity and integrity of most autistic people, and acknowledge the potential for trauma to be at the heart of their distress responses.
This is a topic that needs to be on every key organisation's agenda, putting together the best of the best. We need to be working with the autistic professionals and general autistic population at every level, finding out how to identify trauma in autistic people, how to safeguard against it, and how to improve the lives of those enduring it in ways meaningful to the person.
Autistic people deserve lives of safety, of thriving, and of caring, enabled to be their authentic autistic selves. That is a set of societal and therapeutic outcomes we should all be seeking.
Thank you for reading.