When most people hear the term “post-traumatic stress disorder,” or PTSD, they probably picture adult war veterans, abuse survivors, or natural disaster victims. All of these things can cause PTSD, for sure, but sadly, many children face this condition, too―including children with autism spectrum disorder (ASD).
What is PTSD?
Post-traumatic stress disorder is exactly what it sounds like: a psychiatric disorder caused by experiencing traumatic events. Exposure to trauma doesn’t guarantee the development of PTSD. It’s estimated that about 70% of adults in the United States go through a traumatic situation at least once, and roughly 20% experience PTSD afterward.
Doctors in the United States diagnose and treat PTSD based on the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition, or the DSM-5. This book, published by the American Psychiatric Association, defines a wide range of mental health conditions.
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Under its standards, someone must have been exposed to “actual or threatened death, serious injury, or sexual violence” to qualify for a PTSD diagnosis. The person might have…
- Been threatened or harmed directly
- Witnessed others die or be threatened/harmed
- Found out that a loved one died or was threatened/harmed
- according to the DSM, if a loved one died, the “event(s) must have been violent or accidental” to cause PTSD
- Been exposed to details of traumatic events―for example, a social worker may develop PTSD after repeatedly handling severe abuse cases
- Exposure by photographs, television, movies, etc. doesn’t count, unless “this exposure is work-related”
Symptoms of PTSD
The criteria for PTSD states that symptoms should a) last longer than a month, b) cause significant problems with functioning socially, occupationally, and in other areas of life, and c) not be caused by another health condition or a substance like medication. These symptoms fall under four categories:
The person should show at least one of these symptoms:
- Frequent, distressing memories
- Frequent dreams related to the traumatic experience
- Children may have scary dreams without specifically trauma-related content
- Flashbacks, or the patient feeling/acting as if the event is happening again. In the most severe cases, he/she may lose awareness of his/her surroundings
- Children may revisit the situation through playing. For example, a boy who experienced a serious car crash might reenact it with toys during imaginative play
- Emotional and/or physical reactions to things that “resemble or symbolize” the experience. For example, a combat veteran may be distressed by fireworks that sound similar to gunfire
The person should show at least one of these symptoms:
- Avoiding thoughts, feelings, and memories associated with the trauma
- Avoiding places, activities, people, objects, etc. associated with the trauma
Changes in thoughts and mood
The person should show at least two of these symptoms:
- Inability to remember an important part of the event (but not because of drugs, alcohol, or head injury)
- Extremely negative beliefs about him/herself, others, and the world. For example, the person with PTSD may think, “Nobody can be trusted,” “Nowhere is safe,” “I deserve to have bad things happen to me,” etc.
- Unrealistic blaming of the event and/or its consequences on him/herself or others
- Prolonged negative emotional states, such as fear, anger, shame, etc.
- Lack of interest in previously enjoyable activities
- Feelings of estrangement or detachment from other people
- Inability to experience positive emotions (happiness, love, satisfaction, etc.)
Changes in “arousal and reactivity”
The person should also show at least two of these symptoms:
- Increased irritability, anger, and/or aggression
- Self-destructive or risk-taking behavior
- Hypervigilance, or constantly watching out for danger even in situations that are probably safe
- More intense reactions to being startled
- Trouble concentrating
- Trouble falling or staying asleep
Does autism raise the risk of PTSD?
As of now, there hasn’t been much research into the relationship between PTSD and autism. There’s some evidence that autistic people are at greater risk for PTSD, either because they aren’t as equipped to handle stress, they have higher chances of experiencing trauma, or because a wider range of events registers as trauma for them―or a combination thereof.
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Autistic children may be at higher risk of being abused by caregivers. A study of the Tennessee Child Abuse Hotline found that kids with ASD were reported to the hotline 2.5 times more than neurotypical children. This could be because children with ASD come into contact with more potential reporters, like therapists and educators, than neurotypical kids. But researchers suspect that “challenging behavior and complex cognitive and language impairments, increased caregiver stress, lower levels of family social support, and higher rates of caregiver isolation” play a major role.
A 1998 study found that rates of sexual abuse are twice as high for children with developmental disabilities compared to typically developing children. Neurodiverse kids could be vulnerable to predators because of loneliness, difficulty distinguishing between appropriate or inappropriate behavior, and/or being unable to report the abuse because of communication difficulties.
What counts as trauma?
There’s been a lot of debate among psychologists about whether the DSM’s definition of trauma is broad enough.
Although bullying (usually) doesn’t meet the DSM-5 criteria, some research shows that it can produce traits of PTSD in the general population as well as the autistic population. Harassment and bullying are big problems for children with ASD. A 2012 study of 1,200 kids on the spectrum revealed that 63% of them had been bullied by peers.
Individuals with autism often have higher stress responses to situations that don’t bother neurotypical people. For that reason, some professionals have considered whether things that are less extreme than death, serious injury, or sexual violence are enough to trigger PTSD symptoms in autistic people.
Rumball, Happé, and Grey (2020) surveyed 59 adults with autism, asking whether they had experienced trauma and whether they showed signs of PTSD afterward. A total of 35 participants said they had gone through a situation they considered traumatic, but wasn’t classified as such under the DSM’s standards. Some of the non-DSM traumas included:
- Parents’ divorce
- Death of a loved one (not by violence or accident)
- Death of a pet
- Social difficulties
- Police visit to house
- Abandonment by a family member
- Mental health issues
- Autism diagnostic process
A total of 22 of the 35 participants said they’d experienced PTSD symptoms, and 15 of those 22 said they currently experienced symptoms.
Right now, there aren’t definitive answers about how, why, or even if people with autism are truly more predisposed to PTSD. It’s also unclear whether rates of PTSD are significantly higher in autistic people than in the general population. Still, it’s definitely possible for someone to have both disorders, so you should keep an eye out for signs in your son or daughter.
What does PTSD look like in a child with autism?
PTSD is hard to diagnose in children with ASD because traits may overlap. In both conditions, you might find repetitive play, social withdrawal, intense anxiety, sleep issues, etc.
This is especially true in very young children, because PTSD is diagnosed based on changes in behavior after experiencing traumatic events. Some children may have suffered trauma at such a young age that it’s hard for parents to tell whether their behavior changed. Signs of autism also typically appear early in life, making the diagnosis process more complicated.
There’s still more to learn about how PTSD may manifest in people with autism specifically. But, along with the symptoms from the DSM, here are some hints your kid may show:
Regression is when an autistic person starts to lose skills―such as verbal, social, or motor skills―he/she had previously mastered. This sometimes happens at an early age, leading to a child’s autism diagnosis in the first place, but it can also happen later in life. Trauma is only one possible cause for regression. Sometimes, it’s just how one’s autism presents itself; it can also be due to a life change or to burnout.
Worsened sensory issues
Most kids with ASD are either hypersensitive or hyposensitive to stimuli like noises, lights, touch, etc. If someone has PTSD, he/she may be more prone to sensory overload and startle more easily.
It’s common for some autistic children to dislike being touched because of sensory issues. But be wary if one who used to like physical affection no longer does―especially if he/she now avoids a specific person or people.
Children who don’t have the words to describe their emotional state may complain of headaches, tummy aches, and other ailments when dealing with stress and anxiety.
Changes in stims
Stimming is a normal behavior for people on the spectrum, but watch out for changes. Autistic people might stim in order to reduce anxiety, so an increase in stimming could be a cause for concern. New self-harm behaviors, like head-banging or scratching, could also appear after trauma.
My child might have PTSD – what do I do?
First and foremost, it’s always best to consult professionals when it comes to your child’s mental health.
If you’re worried that your son or daughter is struggling with post-traumatic stress disorder, ask your healthcare provider about a PTSD screening. If you already know he/she has been through something serious, the screening could help determine whether that’s the cause of his/her behavior. Or you may see signs of potential trauma, but not know what could’ve caused it. Screenings typically include interviews to try and figure out if someone has had traumatic experiences.
If you discover that he/she has been the victim of a crime, it’s important to contact law enforcement. In most US states, professionals like therapists, teachers, and clinicians are mandatory reporters, meaning they’re required by law to report suspected/known child abuse. In 18 states and Puerto Rico, all adults are considered mandatory reporters.
Treatments for PTSD
Unfortunately, there hasn’t been much research about how to treat PTSD in people with autism. But typical treatments for children and adolescents with PTSD include:
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is one of the most evidence-backed treatments. Trauma-Focused CBT (TF-CBT) involves challenging distorted thoughts, learning calming techniques, and discussing the trauma.
The therapist uses play, such as games or drawings, to help children process their trauma. This method is mainly used with very young children.
In some cases, clinicians may decide that antidepressants are the best option for treating symptoms.
Some people find relief in a group of peers who have gone through similar struggles. A peer support group isn’t a substitute for counseling, but it can help survivors of trauma build connections and feel less alone.
Treating autism and PTSD
As we’ve seen throughout this article, there’s still a lot to learn about how autism spectrum disorder and post-traumatic stress disorder interact. That means there’s not much information about how typical treatment methods can or should be adjusted for patients with ASD.
TF-CBT is the most common technique, but it can be difficult for a) children with limited speech, and b) children who struggle to identify and understand emotions―issues many kids with autism deal with. Likewise, children on the spectrum might not get much out of support groups if they’re stressed by social situations.
King and Desaulnier (2011) looked at how typical therapies, particularly CBT, might be modified for people with autism or an intellectual disability. According to this article, a counselor could…
- Offer home-based services
- Use more visual aids, such as gradient scales to describe degrees of emotion
- Keep appointment times regular and predictable as much as possible
- Provide sensory toys or allow children to bring their own
- Emphasize the possibility of a “happy ending” after trauma―
“this correlates well with the documented effectiveness of social stories, narratives and role-playing in therapy involving individuals with ASD”
- Be mindful of how often society dismisses the emotions of autistic people
- Involve other trusted caregivers
…and more. Essentially, the therapist should keep the child’s unique strengths and limitations in mind at each step and be open to flexibility.
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Exploration into autism and PTSD is still in early stages. Do kids with ASD really have a greater risk for developing post-traumatic stress? What are the differences in how autistic people and neurotypical people experience and process trauma? How can clinicians best treat autistic patients? Unfortunately, we don’t yet have conclusive answers to these questions.
As a parent, there are ways you can help. Remember to…
- Not take behavior personally
- Remind your son or daughter that the trauma wasn’t his/her fault
- Be willing to listen without pressuring him/her to talk
- Identify possible triggers and help him/her avoid them
- Remain calm and understanding when he/she is emotional
- Let him/her make age-appropriate choices so he/she feels in control of his/her life
- Be patient. Recovery isn’t straightforward
Lastly, don’t neglect your own emotional health. It’s easy to feel guilty and overwhelmed when your loved one goes through something terrible. Seek your own mental healthcare if needed, and don’t be afraid to lean on family, friends, and other supporters. With the help of your child’s professional team, both of you can make it through.
Center for Substance Abuse Treatment (US). (2014). Trauma-Informed Care in Behavioral Health Services. Substance Abuse and Mental Health Services Administration (US).
Children’s Bureau. (n.d.). Parenting a Child Who Has Experienced Trauma. Child Welfare Information Gateway. https://www.childwelfare.gov/pubpdfs/child-trauma.pdf
Children’s Bureau. (2019, April). Mandatory Reporters of Child Abuse and Neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/pubPDFs/manda.pdf
Edelson, M. G. (2010). Sexual Abuse of Children with Autism: Factors that Increase Risk and Interfere with Recognition of Abuse. Disability Studies Quarterly, 30(1). https://dsq-sds.org/article/view/1058/1228
Hamblen, J., & Barnett, E. (2019). PTSD in Children and Adolescents. US Department of Veterans Affairs. https://www.ptsd.va.gov/professional/treat/specific/ptsd_child_teens.asp#two
Jaslow, R. (2012, March 30). Survey finds 63% of children with autism bullied. CBS News. https://www.cbsnews.com/news/survey-finds-63-of-children-with-autism-bullied/
King, R., & Desaulnier, C. L. (2011). Commentary: Complex Post-Traumatic Stress Disorder. Implications for Individuals with Autism Spectrum Disorders—Part II. Journal on Developmental Disabilities, 17(1), 47-59. https://oadd.org/wp-content/uploads/2011/01/41009_JoDD_17-1_47-59_KIng__Desaulnier.pdf
Rose, L. (2021, May 6). How to Identify Trauma in Autistic People. wikiHow. https://www.wikihow.health/Identify-Trauma-in-Autistic-People#aiinfo
Sidran Institute. (n.d.). Traumatic Stress Disorder Fact Sheet. Sidran Institute. https://www.sidran.org/wp-content/uploads/2018/11/Post-Traumatic-Stress-Disorder-Fact-Sheet-.pdf Vanderbilt University Medical Center. (2019, February 15). Children with autism more likely to face maltreatment, study finds. ScienceDaily. Retrieved from www.sciencedaily.com/releases/2019/02/190215135837.htm