As per other occasions when the topic of child maltreatment and autism has been discussed on this blog (see here), this is a subject that is never going to make for great dinner party conversation. It's important however that, minus any sweeping generalisations, such issues are not just swept under the research or clinical carpet...
So it is then that the paper by Christina McDonnell and colleagues [1] is offered up for discussion, and once again minus any sweeping generalisations, how a diagnosis of autism spectrum disorder (ASD) with or without accompanying intellectual (learning) disability (ID) seems to increase the risk of maltreatment compared with not-autistic, not learning disabled population controls.
McDonnell et al discuss their cross-analysis of the records held at "the Department of Social Services (DSS) and the Autism and Developmental Disabilities Monitoring (ADDM) network" in parts of the United States (US). The ADDM has appeared before on this blog as part of those very important discussions about the (estimated) prevalence rate of autism in the US alongside related matters (see here). Researchers included quite a decent sized participant number - "ASD-only (n = 316), ASD and comorbid ID (ASD+ID; n = 291), ID-only (n = 1,280), and controls (n = 3,101)" - and set to work looking at the prevalence of maltreatment based on reported and substantiated cases.
So: "Controlling for demographic factors, this study found significantly higher odds of reported and substantiated maltreatment among children with ASD-only (odds ratio = 1.86 for reported, 1.51 for substantiated), ASD+ID (odds ratio = 2.35 for reported, 1.97 for substantiated), and ID-only (odds ratio = 2.45 for reported, 2.49 for substantiated) relative to a population control group." Specific maltreatment falling into the category 'physical neglect' was notable among the groups, but various other forms of abuse were also detailed as appearing. Researchers also observed that: "Maltreatment was associated with higher likelihood of aggression, hyperactivity, and tantrums for children with ASD."
In light of other independent evidence in this area [2] I don't think anyone should be too surprised by the McDonnell findings. I don't say that in a blasé manner; maltreatment is not something that any child should have to tolerate. I merely point out that the evidence is accumulating suggesting that a diagnosis of autism or learning disability does seem to increase the risk of such an issue occurring.
On the previous blogging occasion where this topic was discussed (see here) I went through some of the possible hows-and-whys of such behaviour(s). I'm not going to repeat myself here, aside from stressing that maltreatment probably has many different 'causes' or routes towards it and the more successful ways to tackle such issues are probably going to be multi-factorial.
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[1] McDonnell CG. et al. Child maltreatment in autism spectrum disorder and intellectual disability: results from a population-based sample. J Child Psychol Psychiatry. 2018 Oct 19.
[2] Duan G. et al. Physical maltreatment of children with autism in Henan province in China: A cross-sectional study. Child Abuse Negl. 2015 Oct;48:140-7.
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Showing posts with label abuse. Show all posts
Showing posts with label abuse. Show all posts
Monday, 26 November 2018
Saturday, 10 November 2018
"an association between maternal experience of childhood abuse and risk for ADHD in offspring"
As per the title of this post - "an association between maternal experience of childhood abuse and risk for ADHD [attention-deficit hyperactivity disorder] in offspring" - this is another entry about some uncomfortable but potentially important research [1]. Indeed, the findings reported by Andrea Roberts and colleagues continue a theme from this research group (see here and see here) on how maternal exposure to various forms of abuse both in childhood and adulthood *might* have some important repercussions for offspring psychological and developmental health and well being.
The authors begin with the premise that: "Children whose mothers experienced childhood abuse are more likely to suffer various neurodevelopmental deficits" based on quite a lot of their own previous findings [2]. Such abuse - which comes in many different forms - is, they observe, likely to impact various psychological and biological functions; some of those functions *could* also have an inter-generational effect.
So: "We examined the association of maternal experience of childhood abuse with ADHD in offspring, assessed by maternal report of diagnosis and validated with the ADHD Rating Scale-IV in a subsample, in the Nurses' Health Study II (n = 49,497 mothers, N offspring cases = 7,607, N offspring controls = 102,151)." The Nurses' Health Study II seems to be a favourite resource for these researchers, and continues to contribute to many areas of health science and research (see here). Alongside looking at maternal experience of abuse and ADHD diagnosis in offspring, researchers also looked for the presence of various other 'adverse circumstances' that might be important to any enhanced risk of offspring ADHD being diagnosed. This included exposure to tobacco smoking (see here) which has some pretty strong 'observational' evidence on a possible effect.
Results: "Exposure to abuse was associated with greater prevalence of ADHD in offspring." Although important, the nature of the relationship between abuse exposure and offspring ADHD was not exclusive, i.e. ADHD was present in both offspring of mums exposed to abuse and those not exposed to abuse. The percentage difference between abuse exposure vs. no exposure was statistically significant however, and importantly, remained significant even after adjustment for those other adverse circumstances mentioned previously. Ergo, maternal exposure to childhood abuse *might* have an important impact on offspring enhanced risk of a diagnosis of ADHD.
Although requiring further study, these are important findings. A case is made for further inspection of how such a relationship comes about covering important areas such as the effects of childhood abuse on maternal state and behaviour(s) [3] and indeed, whether adverse pregnancy factors such as tobacco smoking may also actually be related to such previous experiences of abuse [4]. I daresay that things are going to be complicated and not straight-forward when it comes to any relationship(s) and so no sweeping generalisations are required from me or anyone else.
The possibility of an 'inter-generational' aspect to the experience of childhood abuse and subsequent offspring ADHD risk is important. It provides evidence that the expression of some childhood developmental disorders may not necessarily be 'hard-wired' in a genetic sense (assuming that is, that exposure to childhood abuse is not able to 'modify' the structure/functioning of the genome [5] for example). It provides evidence for the idea that adverse life experiences may be able to manifest as physical issues (being careful how I use the term 'biopsychosocial' for example). It also might suggest that alongside the continuously important stress on preventing any form of childhood abuse, there may interventions that could eventually be put in place to 'undo' any biological effects that it causes to offspring... Eventually.
I do want to end by reiterating that whilst the experience of childhood abuse may be *associated* with a heightened risk of offspring ADHD, such a relationship does need to be treated with some caution. I'm particularly keen to 'nip in the bud' any idea that every diagnosis of ADHD is somehow an intergenerational product of abuse: it's not.
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[1] Roberts AL. et al. Association of Maternal Exposure to Childhood Abuse With Elevated Risk for Attention Deficit Hyperactivity Disorder in Offspring. Am J Epidemiol. 2018 May 14.
[2] Roberts AL. et al. Maternal exposure to intimate partner abuse before birth is associated with autism spectrum disorder in offspring. Autism. 2016 Jan;20(1):26-36.
[3] Chronis AM. et al. Maternal depression and early positive parenting predict future conduct problems in young children with attention-deficit/hyperactivity disorder. Dev Psychol. 2007 Jan;43(1):70-82.
[4] Pear VA. et al. The Role of Maternal Adverse Childhood Experiences and Race in Intergenerational High-Risk Smoking Behaviors. Nicotine Tob Res. 2017 May 1;19(5):623-630.
[5] Cecil CA. et al. Epigenetic signatures of childhood abuse and neglect: Implications for psychiatric vulnerability. J Psychiatr Res. 2016 Dec;83:184-194.
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The authors begin with the premise that: "Children whose mothers experienced childhood abuse are more likely to suffer various neurodevelopmental deficits" based on quite a lot of their own previous findings [2]. Such abuse - which comes in many different forms - is, they observe, likely to impact various psychological and biological functions; some of those functions *could* also have an inter-generational effect.
So: "We examined the association of maternal experience of childhood abuse with ADHD in offspring, assessed by maternal report of diagnosis and validated with the ADHD Rating Scale-IV in a subsample, in the Nurses' Health Study II (n = 49,497 mothers, N offspring cases = 7,607, N offspring controls = 102,151)." The Nurses' Health Study II seems to be a favourite resource for these researchers, and continues to contribute to many areas of health science and research (see here). Alongside looking at maternal experience of abuse and ADHD diagnosis in offspring, researchers also looked for the presence of various other 'adverse circumstances' that might be important to any enhanced risk of offspring ADHD being diagnosed. This included exposure to tobacco smoking (see here) which has some pretty strong 'observational' evidence on a possible effect.
Results: "Exposure to abuse was associated with greater prevalence of ADHD in offspring." Although important, the nature of the relationship between abuse exposure and offspring ADHD was not exclusive, i.e. ADHD was present in both offspring of mums exposed to abuse and those not exposed to abuse. The percentage difference between abuse exposure vs. no exposure was statistically significant however, and importantly, remained significant even after adjustment for those other adverse circumstances mentioned previously. Ergo, maternal exposure to childhood abuse *might* have an important impact on offspring enhanced risk of a diagnosis of ADHD.
Although requiring further study, these are important findings. A case is made for further inspection of how such a relationship comes about covering important areas such as the effects of childhood abuse on maternal state and behaviour(s) [3] and indeed, whether adverse pregnancy factors such as tobacco smoking may also actually be related to such previous experiences of abuse [4]. I daresay that things are going to be complicated and not straight-forward when it comes to any relationship(s) and so no sweeping generalisations are required from me or anyone else.
The possibility of an 'inter-generational' aspect to the experience of childhood abuse and subsequent offspring ADHD risk is important. It provides evidence that the expression of some childhood developmental disorders may not necessarily be 'hard-wired' in a genetic sense (assuming that is, that exposure to childhood abuse is not able to 'modify' the structure/functioning of the genome [5] for example). It provides evidence for the idea that adverse life experiences may be able to manifest as physical issues (being careful how I use the term 'biopsychosocial' for example). It also might suggest that alongside the continuously important stress on preventing any form of childhood abuse, there may interventions that could eventually be put in place to 'undo' any biological effects that it causes to offspring... Eventually.
I do want to end by reiterating that whilst the experience of childhood abuse may be *associated* with a heightened risk of offspring ADHD, such a relationship does need to be treated with some caution. I'm particularly keen to 'nip in the bud' any idea that every diagnosis of ADHD is somehow an intergenerational product of abuse: it's not.
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[1] Roberts AL. et al. Association of Maternal Exposure to Childhood Abuse With Elevated Risk for Attention Deficit Hyperactivity Disorder in Offspring. Am J Epidemiol. 2018 May 14.
[2] Roberts AL. et al. Maternal exposure to intimate partner abuse before birth is associated with autism spectrum disorder in offspring. Autism. 2016 Jan;20(1):26-36.
[3] Chronis AM. et al. Maternal depression and early positive parenting predict future conduct problems in young children with attention-deficit/hyperactivity disorder. Dev Psychol. 2007 Jan;43(1):70-82.
[4] Pear VA. et al. The Role of Maternal Adverse Childhood Experiences and Race in Intergenerational High-Risk Smoking Behaviors. Nicotine Tob Res. 2017 May 1;19(5):623-630.
[5] Cecil CA. et al. Epigenetic signatures of childhood abuse and neglect: Implications for psychiatric vulnerability. J Psychiatr Res. 2016 Dec;83:184-194.
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Monday, 28 August 2017
Post-traumatic stress disorder (PTSD) and autism (minus the psychobabble)
Quite a few years back, I talked about the idea that a diagnosis of autism or autism spectrum disorder (ASD) is seemingly not protective of other conditions/labels appearing alongside in the context of post-traumatic stress disorder (PTSD) (see here). Described as an 'anxiety disorder', PTSD is a complicated condition typically encompassing several key features: experiencing one or more traumatic events (natural disaster, victim of crime, experiencing various forms of abuse, etc) and subsequent re-experiencing of said events (flashbacks, nightmares, anxiety, etc) significantly impacting on day-to-day life.
The paper by Haruvi-Lamdan and colleagues [1] provides some further, welcomed, research interest in the relationship between PTSD and autism in the context that a "potentially unique perception of traumatic events, particularly from the social sphere" might predispose those diagnosed with autism to be more vulnerable to PTSD than other groups.
I've titled this post 'minus the psychobabble' because, unfortunately, there is still a body of thinking out there that tries to explain concepts like PTSD in terms of schools of thought such as the psychoanalytical for example. I don't want to get into the nitty-gritty of whether your 'ego balances the id' or whatnot (and how one would actually evidence such concepts), but I do want to keep autism away from psychoanalysis. I say all that in the context that Haruvi-Lamdan et al note: "While autism and trauma were often linked in psychoanalytic theory..." but go on to provide some slightly more evidence-based discussions.
Three important points are made by the authors as to how PTSD (and trauma in general) might be linked to autism.
"First, autism spectrum disorder (ASD) may serve as a vulnerability marker for posttraumatic stress disorder (PTSD), specifically by increasing the risk for exposure to traumatic events." Although not easy to say, a diagnosis of autism or the presence of clinically-relevant autistic traits does seemingly put someone at far greater risk for experiencing various traumatic events [2]. I speak of peer-reviewed research talking about being a victim of bullying in the context of autism (see here) for example; noting that bullying is not always 'just playground shenanigans'. I would also refer you to some other factors that don't make for great dinner-table conversation in the context of autism (see here). And if you think that such factors are typically present only in childhood, think again. This all on top of the more usual likelihood of experiencing trauma that we all face.
"Second, PTSD, once it has appeared, may exacerbate certain ASD symptoms, for example, through maladaptive coping strategies and reduced help-seeking." I'm not in total agreement with the idea of 'maladaptive coping strategies' in the context of autism because science/practice does not really know enough about coping strategies (and concepts such as resilience) either in general or in the specific context of autism. I don't doubt that individuals with and without autism might have their own way of 'coping' but there is no evidence of some 'one-size-fits-all' across the entire diagnosis or population. I do agree that there may be aspects of autism that can lead to 'reduced help-seeking' as per the issue of communication and/or language use for example, and also the strength of social circles, but that's about as far as we can reliably say at this point.
"Third, there may be shared underlying mechanisms for PTSD and ASD, including neurological abnormalities associated with both disorders, as well as cognitive and behavioral mechanisms, such as increased rumination, cognitive rigidity, avoidance, anger, and aggression." Again there are some quite sweeping generalisations included in the authors writings here - 'neurological abnormalities'? - but they do raise some important points. Rumination - a deep or considered thought about something - coupled to perseveration is something that I've covered before in the context of autism (see here). It boils down to a potential heightened risk of 'not letting go' of a topic and how, in the context of trauma and PTSD, this could be something over-represented in the context of autism or the presence of autistic traits. Added to other issues such as an intolerance of uncertainty (see here) and you can perhaps see how autism and PTSD might not necessarily be miles apart. I probably didn't need to say it but will anyway, anxiety in the context of autism seems to be both rife and in many cases, is absolutely disabling (see here).
Although there may be several inter-connecting variables that potentially unite autism and PTSD, I don't want to lose sight of the heterogeneity that is present alongside both labels. Even in the context of experiencing some truly awful acts, there are disparities in whether PTSD is diagnosed in the context of autism [3] similar to the not-autism population. Diagnosis of autism and/or clinically relevant autistic features are likely to be only part of the picture here. That being said, there does seem to be grounds for quite a bit more investigation in this area, and onward, whether screening for PTSD in the context of autism should be more widespread and also examination of how effective the intervention(s) currently in place for PTSD are in the context of autism + PTSD...
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[1] Haruvi-Lamdan N. et al. PTSD and Autism Spectrum Disorder: Co-morbidity, Gaps in Research, and Potential Shared Mechanisms. Psychol Trauma. 2017 Jul 20.
[2] Roberts AL. et al. Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse Negl. 2015 Jul;45:135-42.
[3] Brenner J. et al. Behavioral Symptoms of Reported Abuse in Children and Adolescents with Autism Spectrum Disorder in Inpatient Settings. J Autism Dev Disord. 2017 Jun 7.
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The paper by Haruvi-Lamdan and colleagues [1] provides some further, welcomed, research interest in the relationship between PTSD and autism in the context that a "potentially unique perception of traumatic events, particularly from the social sphere" might predispose those diagnosed with autism to be more vulnerable to PTSD than other groups.
I've titled this post 'minus the psychobabble' because, unfortunately, there is still a body of thinking out there that tries to explain concepts like PTSD in terms of schools of thought such as the psychoanalytical for example. I don't want to get into the nitty-gritty of whether your 'ego balances the id' or whatnot (and how one would actually evidence such concepts), but I do want to keep autism away from psychoanalysis. I say all that in the context that Haruvi-Lamdan et al note: "While autism and trauma were often linked in psychoanalytic theory..." but go on to provide some slightly more evidence-based discussions.
Three important points are made by the authors as to how PTSD (and trauma in general) might be linked to autism.
"First, autism spectrum disorder (ASD) may serve as a vulnerability marker for posttraumatic stress disorder (PTSD), specifically by increasing the risk for exposure to traumatic events." Although not easy to say, a diagnosis of autism or the presence of clinically-relevant autistic traits does seemingly put someone at far greater risk for experiencing various traumatic events [2]. I speak of peer-reviewed research talking about being a victim of bullying in the context of autism (see here) for example; noting that bullying is not always 'just playground shenanigans'. I would also refer you to some other factors that don't make for great dinner-table conversation in the context of autism (see here). And if you think that such factors are typically present only in childhood, think again. This all on top of the more usual likelihood of experiencing trauma that we all face.
"Second, PTSD, once it has appeared, may exacerbate certain ASD symptoms, for example, through maladaptive coping strategies and reduced help-seeking." I'm not in total agreement with the idea of 'maladaptive coping strategies' in the context of autism because science/practice does not really know enough about coping strategies (and concepts such as resilience) either in general or in the specific context of autism. I don't doubt that individuals with and without autism might have their own way of 'coping' but there is no evidence of some 'one-size-fits-all' across the entire diagnosis or population. I do agree that there may be aspects of autism that can lead to 'reduced help-seeking' as per the issue of communication and/or language use for example, and also the strength of social circles, but that's about as far as we can reliably say at this point.
"Third, there may be shared underlying mechanisms for PTSD and ASD, including neurological abnormalities associated with both disorders, as well as cognitive and behavioral mechanisms, such as increased rumination, cognitive rigidity, avoidance, anger, and aggression." Again there are some quite sweeping generalisations included in the authors writings here - 'neurological abnormalities'? - but they do raise some important points. Rumination - a deep or considered thought about something - coupled to perseveration is something that I've covered before in the context of autism (see here). It boils down to a potential heightened risk of 'not letting go' of a topic and how, in the context of trauma and PTSD, this could be something over-represented in the context of autism or the presence of autistic traits. Added to other issues such as an intolerance of uncertainty (see here) and you can perhaps see how autism and PTSD might not necessarily be miles apart. I probably didn't need to say it but will anyway, anxiety in the context of autism seems to be both rife and in many cases, is absolutely disabling (see here).
Although there may be several inter-connecting variables that potentially unite autism and PTSD, I don't want to lose sight of the heterogeneity that is present alongside both labels. Even in the context of experiencing some truly awful acts, there are disparities in whether PTSD is diagnosed in the context of autism [3] similar to the not-autism population. Diagnosis of autism and/or clinically relevant autistic features are likely to be only part of the picture here. That being said, there does seem to be grounds for quite a bit more investigation in this area, and onward, whether screening for PTSD in the context of autism should be more widespread and also examination of how effective the intervention(s) currently in place for PTSD are in the context of autism + PTSD...
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[1] Haruvi-Lamdan N. et al. PTSD and Autism Spectrum Disorder: Co-morbidity, Gaps in Research, and Potential Shared Mechanisms. Psychol Trauma. 2017 Jul 20.
[2] Roberts AL. et al. Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse Negl. 2015 Jul;45:135-42.
[3] Brenner J. et al. Behavioral Symptoms of Reported Abuse in Children and Adolescents with Autism Spectrum Disorder in Inpatient Settings. J Autism Dev Disord. 2017 Jun 7.
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Monday, 1 May 2017
On abuse exposure and mate selection
The paper by Andrea Roberts and colleagues [1] is offered up for brief discussion today, and a slightly uncomfortable but nonetheless potentially important set of results that "provide evidence that childhood abuse affects mate selection, with implications for offspring health."
I tread very carefully with this topic but was intrigued by the findings looking at whether 'offspring health' in the context of the presence of autism or autism spectrum disorder (ASD) might be at least sometimes mediated by the mate selection decisions made by women who "experienced childhood abuse." I might add that sweeping generalisations from this and related work from this authorship group (see here) are not required.
Some of the data for this study, I believe, once again comes from the Nurses’ Health Study II where initially autistic traits were measured using the Social Responsiveness Scale (SRS) for men and women. These results were stratified for various types and levels of abuse reported to be encountered during childhood. Using some statistical modelling, researchers observed that: "Maternal childhood abuse was strongly associated with high paternal autistic traits." In other words, it seemed like the experience of childhood abuse - particularly severe childhood abuse - encountered by women, seemed to correlate with later selection of partners who scored high when it came to the presence of autistic traits (as measured by the SRS). Results also took into account various potential confounding variables including socio-economic status (SES).
Bearing in mind previous discussions on assortative mating and autism [2] where "people who have certain “autistic” traits are increasingly meeting and marrying each other and having offspring who are more likely to be on the spectrum" the Roberts results potentially add an additional dimension. They suggest that early life experiences (particularly adverse experiences) may have quite a powerful effect when it comes to choices of mating partner. Whether this is driven by an active preference for the presence of autistic traits in a partner or is down to other factors such as 'availability' and/or 'accessibility' cannot be deduced from the current data. It is also important to add that looking at autistic traits alone does not necessarily mean that autistic traits drive any mating selection being undertaken. As I've mentioned before on this blog, various screens for autistic traits seem to have a generalisability issue (see here for example). I might also add that: "Maternal and paternal autistic traits accounted for 21% of the association between maternal abuse and offspring autism" so one has to be careful not to make too much of any single connection.
But still there is something rather interesting from these latest results from Roberts et al [with appropriate cautions] that requires further research inspection...
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[1] Roberts AL. et al. Maternal Exposure to Childhood Abuse is Associated with Mate Selection: Implications for Autism in Offspring. J Autism Dev Disord. 2017 Apr 9.
[2] Baron‐Cohen S. Two new theories of autism: hyper‐systemising and assortative mating. Archives of Disease in Childhood. 2006;91(1):2-5.
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Roberts AL, Lyall K, & Weisskopf MG (2017). Maternal Exposure to Childhood Abuse is Associated with Mate Selection: Implications for Autism in Offspring. Journal of autism and developmental disorders PMID: 28393290
I tread very carefully with this topic but was intrigued by the findings looking at whether 'offspring health' in the context of the presence of autism or autism spectrum disorder (ASD) might be at least sometimes mediated by the mate selection decisions made by women who "experienced childhood abuse." I might add that sweeping generalisations from this and related work from this authorship group (see here) are not required.
Some of the data for this study, I believe, once again comes from the Nurses’ Health Study II where initially autistic traits were measured using the Social Responsiveness Scale (SRS) for men and women. These results were stratified for various types and levels of abuse reported to be encountered during childhood. Using some statistical modelling, researchers observed that: "Maternal childhood abuse was strongly associated with high paternal autistic traits." In other words, it seemed like the experience of childhood abuse - particularly severe childhood abuse - encountered by women, seemed to correlate with later selection of partners who scored high when it came to the presence of autistic traits (as measured by the SRS). Results also took into account various potential confounding variables including socio-economic status (SES).
Bearing in mind previous discussions on assortative mating and autism [2] where "people who have certain “autistic” traits are increasingly meeting and marrying each other and having offspring who are more likely to be on the spectrum" the Roberts results potentially add an additional dimension. They suggest that early life experiences (particularly adverse experiences) may have quite a powerful effect when it comes to choices of mating partner. Whether this is driven by an active preference for the presence of autistic traits in a partner or is down to other factors such as 'availability' and/or 'accessibility' cannot be deduced from the current data. It is also important to add that looking at autistic traits alone does not necessarily mean that autistic traits drive any mating selection being undertaken. As I've mentioned before on this blog, various screens for autistic traits seem to have a generalisability issue (see here for example). I might also add that: "Maternal and paternal autistic traits accounted for 21% of the association between maternal abuse and offspring autism" so one has to be careful not to make too much of any single connection.
But still there is something rather interesting from these latest results from Roberts et al [with appropriate cautions] that requires further research inspection...
----------
[1] Roberts AL. et al. Maternal Exposure to Childhood Abuse is Associated with Mate Selection: Implications for Autism in Offspring. J Autism Dev Disord. 2017 Apr 9.
[2] Baron‐Cohen S. Two new theories of autism: hyper‐systemising and assortative mating. Archives of Disease in Childhood. 2006;91(1):2-5.
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Roberts AL, Lyall K, & Weisskopf MG (2017). Maternal Exposure to Childhood Abuse is Associated with Mate Selection: Implications for Autism in Offspring. Journal of autism and developmental disorders PMID: 28393290
Monday, 1 June 2015
The physical maltreatment of children with autism
As dramatic as the title of this post might seem, it is taken from the title of the paper by Guiqin Duan and colleagues [1] who reported that: "CPM [child physical maltreatment] is widespread in families of children with autism in Central China and more knowledge should be provided to parents of children with autism."
Given the subject matter of the Duan paper I will at this point affirm that this is a blog about science (peer-reviewed science in the most part) and my discussions on this topic are directed at the science. I am not trying to stigmatise, generalise or any other -ise the quite uncomfortable and potentially emotive topic of child maltreatment with autism in mind.
Based on an analysis of 180 reports from parents of children with autism, including assessment of the severity of offspring autism (based on CARS scores) and data on "parental CPM during the past 3 months", researchers built up a picture of how prevalent CPM might be and how age and severity of autism in offspring might 'intersect' with such practices. By saying that last sentence I am in no way trying to excuse CPM on the basis of autism presentation.
Results: "CPM was self-reported by 88% of the parents of children with autism." Most of these reports were described as minor although about a third of such reports fell into the 'severe' categorisation but were "unlikely to have caused injury." An analysis of CARS scores and age suggested that there may be more to see when it came to these correlates and the use of severe CPM is perhaps in line with the findings reported by Andrea Roberts and colleagues [2] following on from the idea that those with "high levels of autistic traits may be targeted for abuse."
As I initially indicated, the issue of maltreatment is generally an uncomfortable topic to discuss particularly when linked to the word 'child'. Add also the label of autism into the mix and this turns into a potentially very emotive issue especially in light of some of the extreme examples of where child maltreatment and autism have been reported with the most saddest of outcomes (see here). An additional side to this issue is also the strong requirement not to further stigmatise parents of children with autism with findings such as those from Duan et al accepting that no asymptomatic control group was included in their study. As per other discussions on intimate partner abuse and risk of offspring autism (see here) based on other research from Roberts et al [3], there is a balance to be struck between recognition of an issue whilst at the same time not over-generalising said issue to an entire group or population of people.
Insofar as what could be potentially done to minimise CPM and it's impact I don't want to adopt the 'holier than thou' position on this. Parenting, whilst rewarding, is a difficult business. Without making light of the topic, have a look at comedian Michael McIntyre's routine: 'parents with no kids don't know' on just how stressful parenting can become. The evidence on parenting a child with autism suggests that there are additional stress and strains that can accompany those of parenting in general (see here) that might also need to be considered.
Help, support and education are perhaps some of the most important tools that can be utilised. Within those concepts I'm talking about the rise and rise of parent education (without being condescending) on the ways and means that strategies could be adopted in times when the risk of CPM is high. I'd also like to think that important services such as respite care can be utilised as and when required so that parenting can go back to being parenting and not just coping / getting by as a scenario that can build up over time. All of these concepts are set against a backdrop of differing national policies on what is and is not socially acceptable when it comes to the use of smacking (spanking) for example as one facet of CPM.
The bottom line is that no child should be exposed to physical maltreatment. Over and above however just finger pointing, the provision of help, support and services where and when required to aid the parenting journey need to be more fully incorporated into action plans to reduce the likelihood of CPM occurring when autism is diagnosed.
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[1] Duan G. et al. Physical maltreatment of children with autism in Henan province in China: A cross-sectional study. Child Abuse Negl. 2015 May 6. pii: S0145-2134(15)00116-7.
[2] Roberts AL. et al. Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse Negl. 2015 May 5. pii: S0145-2134(15)00128-3.
[3] Roberts AL. et al. Maternal exposure to intimate partner abuse before birth is associated with autism spectrum disorder in offspring. Autism. 2015 Feb 6. pii: 1362361314566049.
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Duan, G., Chen, J., Zhang, W., Yu, B., Jin, Y., Wang, Y., & Yao, M. (2015). Physical maltreatment of children with autism in Henan province in China: A cross-sectional study Child Abuse & Neglect DOI: 10.1016/j.chiabu.2015.03.018
Given the subject matter of the Duan paper I will at this point affirm that this is a blog about science (peer-reviewed science in the most part) and my discussions on this topic are directed at the science. I am not trying to stigmatise, generalise or any other -ise the quite uncomfortable and potentially emotive topic of child maltreatment with autism in mind.
Based on an analysis of 180 reports from parents of children with autism, including assessment of the severity of offspring autism (based on CARS scores) and data on "parental CPM during the past 3 months", researchers built up a picture of how prevalent CPM might be and how age and severity of autism in offspring might 'intersect' with such practices. By saying that last sentence I am in no way trying to excuse CPM on the basis of autism presentation.
Results: "CPM was self-reported by 88% of the parents of children with autism." Most of these reports were described as minor although about a third of such reports fell into the 'severe' categorisation but were "unlikely to have caused injury." An analysis of CARS scores and age suggested that there may be more to see when it came to these correlates and the use of severe CPM is perhaps in line with the findings reported by Andrea Roberts and colleagues [2] following on from the idea that those with "high levels of autistic traits may be targeted for abuse."
As I initially indicated, the issue of maltreatment is generally an uncomfortable topic to discuss particularly when linked to the word 'child'. Add also the label of autism into the mix and this turns into a potentially very emotive issue especially in light of some of the extreme examples of where child maltreatment and autism have been reported with the most saddest of outcomes (see here). An additional side to this issue is also the strong requirement not to further stigmatise parents of children with autism with findings such as those from Duan et al accepting that no asymptomatic control group was included in their study. As per other discussions on intimate partner abuse and risk of offspring autism (see here) based on other research from Roberts et al [3], there is a balance to be struck between recognition of an issue whilst at the same time not over-generalising said issue to an entire group or population of people.
Insofar as what could be potentially done to minimise CPM and it's impact I don't want to adopt the 'holier than thou' position on this. Parenting, whilst rewarding, is a difficult business. Without making light of the topic, have a look at comedian Michael McIntyre's routine: 'parents with no kids don't know' on just how stressful parenting can become. The evidence on parenting a child with autism suggests that there are additional stress and strains that can accompany those of parenting in general (see here) that might also need to be considered.
Help, support and education are perhaps some of the most important tools that can be utilised. Within those concepts I'm talking about the rise and rise of parent education (without being condescending) on the ways and means that strategies could be adopted in times when the risk of CPM is high. I'd also like to think that important services such as respite care can be utilised as and when required so that parenting can go back to being parenting and not just coping / getting by as a scenario that can build up over time. All of these concepts are set against a backdrop of differing national policies on what is and is not socially acceptable when it comes to the use of smacking (spanking) for example as one facet of CPM.
The bottom line is that no child should be exposed to physical maltreatment. Over and above however just finger pointing, the provision of help, support and services where and when required to aid the parenting journey need to be more fully incorporated into action plans to reduce the likelihood of CPM occurring when autism is diagnosed.
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[1] Duan G. et al. Physical maltreatment of children with autism in Henan province in China: A cross-sectional study. Child Abuse Negl. 2015 May 6. pii: S0145-2134(15)00116-7.
[2] Roberts AL. et al. Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse Negl. 2015 May 5. pii: S0145-2134(15)00128-3.
[3] Roberts AL. et al. Maternal exposure to intimate partner abuse before birth is associated with autism spectrum disorder in offspring. Autism. 2015 Feb 6. pii: 1362361314566049.
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Duan, G., Chen, J., Zhang, W., Yu, B., Jin, Y., Wang, Y., & Yao, M. (2015). Physical maltreatment of children with autism in Henan province in China: A cross-sectional study Child Abuse & Neglect DOI: 10.1016/j.chiabu.2015.03.018
Wednesday, 11 March 2015
Intimate partner abuse and risk of offspring autism
I want to be slightly careful when discussing the conclusion reached in the paper by Andrea Roberts and colleagues [1] that: "autism spectrum disorder risk was increased in children of women who reported fear of partner or sexual, emotional, or physical abuse in the 2 years before the birth year."
Careful not only because correlation has an uncanny habit of being translated into causation for some people (they are not one and the same thing) and how this combines when one interprets the concept of 'risk', but also because the results potentially, yet again, increase the likelihood of stigmatising parents of children with autism. Refrigerator mums turning into domestic violence dads is a headline that I don't think anyone wants to see with autism in mind...
That being said, I don't want to downplay the findings from Roberts et al particularly given that this is not the first time that this team have reported results in this area [2] (open-access). On that previous occasion as on this, the implication was that past events that produce serious psychological (as well as physical) harm might have an "intergenerational" effect. Indeed, even more research from this group has hinted that maternal posttraumatic stress disorder (PTSD) might also affect offspring autism risk [3]. That is alongside the uncomfortable fact that having a child with autism seemingly does not protect mothers (or fathers) from being in abusive relationships.
The most recent study "calculated risk ratios for autism spectrum disorder associated with abuse in a population-based cohort of women and their children (54,512 controls, 451 cases)". They found that offspring risk of a diagnosis of autism spectrum disorder (ASD) was elevated for those mothers reporting "fear of partner or sexual, emotional, or physical abuse" sometime in the 2 years before the birth of their child, taking into account several other possible confounding variables. Interestingly, the risk of autism was not significantly elevated when it came to descriptions of "Physical harm from abuse during pregnancy" potentially indicating that any effect might be 'active' before conception.
This work potentially intersects with other research describing, for example, how parental experiences of trauma might have an intergenerational effect on future offspring. The paper by Duad and colleagues [4] suggesting that: "the children of tortured parents had more symptoms of anxiety, depression, post-traumatic stress, attention deficits and behavioural disorders" is not necessarily a direct comparator to the Roberts results but does provide a template for how parental experiences might have the ability to influence offspring outcomes. You could well suggest that the experiences of torture might have an effect on factors such as parenting style which could subsequently impact on offspring outcomes, but again it's difficult to prove causation. I might add that the Duad results focusing on "immigrant children whose parents have been tortured before coming to Sweden" may well also link in with other findings with an autism research slant (see here).
As to the mechanisms and without falling into any psychobabble explanations, I'm tempted to suggest that there may be quite a few areas requiring further investigation. Reiterating that correlation is not the same as causation and accepting that there may be as many different routes to a diagnosis of autism as there are 'autisms' [plural], I'm drawn to parallel these findings with other examples. I've mentioned the Dutch Hongerwinter before on this blog (see here) and how early nutrition might very well have an effect on later life health and wellbeing. Extending such effects to offspring of those subjected to the famine of 1944 (which also coincided with an unusually harsh winter) there is some evidence of a transgenerational effect for offspring in terms of the greater risk for being diagnosed with schizophrenia for example [5]. I'm not necessarily saying that abuse is the same as starvation; merely that there may be similar biological mechanisms at work in terms of their respective effects on stress and also the concept of resilience. This area of work also introduces the idea that epigenetics might play some kind of role in potentially 'programming' offspring development for something like autism. Just in case this might seem a little outlandish, I might refer you to some work coming from Project Ice Storm [6] and how DNA methylation patterns *might* be tied into maternal 'appraisal' [7].
In a previous post on this blog, I've also covered some interesting work suggesting that trauma and PTSD *might* elevate the risk of autoimmune disorders (see here). I know that again we have a 'correlation not necessarily being the same as causation' state of affairs in discussing such a possible link, but given the rising tide of research suggesting that there may be something more to see when it comes to autoimmunity and [some] autism (see here) with speculation a-plenty (see here) I wonder whether some additional questioning about autoimmune disorders appearing in medical records or more direct evidence of autoimmune biology might be indicated in further work in this area? I say this accepting that the process of autoimmunity still has the ability to invoke head-scratching (see here).
That being said, there are caveats to all this. The variables which did not seem to account for the recent Roberts results - "gestation length, birth weight, maternal smoking or alcohol consumption during pregnancy, gestational diabetes, preeclampsia, or history of induced abortion" - cannot and do not cover the multitude of other confounding variables that might affect risk. Familial predisposition to autism as per the broader autism phenotype (BAP) perhaps also needs some further inspection, accepting my slightly furrowed brow when it comes to the BAP being tied into something like postpartum depression for example (see here). I would however, like to know a little bit more about other potential psychopathology / psychiatric diagnoses of parents and whether this might affect risk of autism outside of the history of exposure to abuse. Again, not to generalise or stigmatise, I'll link to some of the work on schizophrenia and violence [8] with some further analysis (see here) for example, and some suggestion that certain parental psychiatric diagnoses might elevate the risk of offspring autism [9].
Finally, I want to end with a line or two about the societal implications to come from the Roberts results. Abuse comes in many forms and is unfortunately an all-too-common occurrence these days (see here). Aside from the suggestion of a link with offspring behavioural and developmental outcomes, I'd be minded to suggest that we really should be doing a lot more to reduce the numbers of those suffering such acts and dedicate further resources to helping those who have been abused to try and mitigate not just the potential intergenerational effect but what such events might mean for them as individuals also [10].
----------
[1] Roberts AL. et al. Maternal exposure to intimate partner abuse before birth is associated with autism spectrum disorder in offspring. Autism. 2015 Feb 6. pii: 1362361314566049.
[2] Roberts AL. et al. Association of maternal exposure to childhood abuse with elevated risk for autism in offspring. JAMA Psychiatry. 2013 May;70(5):508-15.
[3] Roberts AL. et al. Women's posttraumatic stress symptoms and autism spectrum disorder in their children. Res Autism Spectr Disord. 2014 Jun 1;8(6):608-616.
[4] Daud A. et al. Children in families of torture victims: transgenerational transmission of parents’ traumatic experiences to their children. International Journal of Social Welfare. 2005; 14: 23-32.
[5] Susser ES. & Lin SP. Schizophrenia after prenatal exposure to the Dutch Hunger Winter of 1944-1945. Arch Gen Psychiatry. 1992 Dec;49(12):983-8.
[6] Walder DJ. et al. Prenatal maternal stress predicts autism traits in 6½ year-old children: Project Ice Storm. Psychiatry Research. 2014; 219: 353-360.
[7] Cao-Lei L. et al. Pregnant women’s cognitive appraisal of a natural disaster affects DNA methylation in their children 13 years later: Project Ice Storm. Translational Psychiatry. 2015. Feb 24.
[8] Fleischman A. et al. Schizophrenia and violent crime: a population-based study. Psychol Med. 2014 Oct;44(14):3051-7.
[9] Daniels JL. et al. Parental psychiatric disorders associated with autism spectrum disorders in the offspring. Pediatrics. 2008 May;121(5):e1357-62.
[10] Dube SR. et al. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA. 2001 Dec 26;286(24):3089-96.
----------
Roberts AL, Lyall K, Rich-Edwards JW, Ascherio A, & Weisskopf MG (2015). Maternal exposure to intimate partner abuse before birth is associated with autism spectrum disorder in offspring. Autism : the international journal of research and practice PMID: 25662292
Careful not only because correlation has an uncanny habit of being translated into causation for some people (they are not one and the same thing) and how this combines when one interprets the concept of 'risk', but also because the results potentially, yet again, increase the likelihood of stigmatising parents of children with autism. Refrigerator mums turning into domestic violence dads is a headline that I don't think anyone wants to see with autism in mind...
That being said, I don't want to downplay the findings from Roberts et al particularly given that this is not the first time that this team have reported results in this area [2] (open-access). On that previous occasion as on this, the implication was that past events that produce serious psychological (as well as physical) harm might have an "intergenerational" effect. Indeed, even more research from this group has hinted that maternal posttraumatic stress disorder (PTSD) might also affect offspring autism risk [3]. That is alongside the uncomfortable fact that having a child with autism seemingly does not protect mothers (or fathers) from being in abusive relationships.
The most recent study "calculated risk ratios for autism spectrum disorder associated with abuse in a population-based cohort of women and their children (54,512 controls, 451 cases)". They found that offspring risk of a diagnosis of autism spectrum disorder (ASD) was elevated for those mothers reporting "fear of partner or sexual, emotional, or physical abuse" sometime in the 2 years before the birth of their child, taking into account several other possible confounding variables. Interestingly, the risk of autism was not significantly elevated when it came to descriptions of "Physical harm from abuse during pregnancy" potentially indicating that any effect might be 'active' before conception.
This work potentially intersects with other research describing, for example, how parental experiences of trauma might have an intergenerational effect on future offspring. The paper by Duad and colleagues [4] suggesting that: "the children of tortured parents had more symptoms of anxiety, depression, post-traumatic stress, attention deficits and behavioural disorders" is not necessarily a direct comparator to the Roberts results but does provide a template for how parental experiences might have the ability to influence offspring outcomes. You could well suggest that the experiences of torture might have an effect on factors such as parenting style which could subsequently impact on offspring outcomes, but again it's difficult to prove causation. I might add that the Duad results focusing on "immigrant children whose parents have been tortured before coming to Sweden" may well also link in with other findings with an autism research slant (see here).
As to the mechanisms and without falling into any psychobabble explanations, I'm tempted to suggest that there may be quite a few areas requiring further investigation. Reiterating that correlation is not the same as causation and accepting that there may be as many different routes to a diagnosis of autism as there are 'autisms' [plural], I'm drawn to parallel these findings with other examples. I've mentioned the Dutch Hongerwinter before on this blog (see here) and how early nutrition might very well have an effect on later life health and wellbeing. Extending such effects to offspring of those subjected to the famine of 1944 (which also coincided with an unusually harsh winter) there is some evidence of a transgenerational effect for offspring in terms of the greater risk for being diagnosed with schizophrenia for example [5]. I'm not necessarily saying that abuse is the same as starvation; merely that there may be similar biological mechanisms at work in terms of their respective effects on stress and also the concept of resilience. This area of work also introduces the idea that epigenetics might play some kind of role in potentially 'programming' offspring development for something like autism. Just in case this might seem a little outlandish, I might refer you to some work coming from Project Ice Storm [6] and how DNA methylation patterns *might* be tied into maternal 'appraisal' [7].
In a previous post on this blog, I've also covered some interesting work suggesting that trauma and PTSD *might* elevate the risk of autoimmune disorders (see here). I know that again we have a 'correlation not necessarily being the same as causation' state of affairs in discussing such a possible link, but given the rising tide of research suggesting that there may be something more to see when it comes to autoimmunity and [some] autism (see here) with speculation a-plenty (see here) I wonder whether some additional questioning about autoimmune disorders appearing in medical records or more direct evidence of autoimmune biology might be indicated in further work in this area? I say this accepting that the process of autoimmunity still has the ability to invoke head-scratching (see here).
That being said, there are caveats to all this. The variables which did not seem to account for the recent Roberts results - "gestation length, birth weight, maternal smoking or alcohol consumption during pregnancy, gestational diabetes, preeclampsia, or history of induced abortion" - cannot and do not cover the multitude of other confounding variables that might affect risk. Familial predisposition to autism as per the broader autism phenotype (BAP) perhaps also needs some further inspection, accepting my slightly furrowed brow when it comes to the BAP being tied into something like postpartum depression for example (see here). I would however, like to know a little bit more about other potential psychopathology / psychiatric diagnoses of parents and whether this might affect risk of autism outside of the history of exposure to abuse. Again, not to generalise or stigmatise, I'll link to some of the work on schizophrenia and violence [8] with some further analysis (see here) for example, and some suggestion that certain parental psychiatric diagnoses might elevate the risk of offspring autism [9].
Finally, I want to end with a line or two about the societal implications to come from the Roberts results. Abuse comes in many forms and is unfortunately an all-too-common occurrence these days (see here). Aside from the suggestion of a link with offspring behavioural and developmental outcomes, I'd be minded to suggest that we really should be doing a lot more to reduce the numbers of those suffering such acts and dedicate further resources to helping those who have been abused to try and mitigate not just the potential intergenerational effect but what such events might mean for them as individuals also [10].
----------
[1] Roberts AL. et al. Maternal exposure to intimate partner abuse before birth is associated with autism spectrum disorder in offspring. Autism. 2015 Feb 6. pii: 1362361314566049.
[2] Roberts AL. et al. Association of maternal exposure to childhood abuse with elevated risk for autism in offspring. JAMA Psychiatry. 2013 May;70(5):508-15.
[3] Roberts AL. et al. Women's posttraumatic stress symptoms and autism spectrum disorder in their children. Res Autism Spectr Disord. 2014 Jun 1;8(6):608-616.
[4] Daud A. et al. Children in families of torture victims: transgenerational transmission of parents’ traumatic experiences to their children. International Journal of Social Welfare. 2005; 14: 23-32.
[5] Susser ES. & Lin SP. Schizophrenia after prenatal exposure to the Dutch Hunger Winter of 1944-1945. Arch Gen Psychiatry. 1992 Dec;49(12):983-8.
[6] Walder DJ. et al. Prenatal maternal stress predicts autism traits in 6½ year-old children: Project Ice Storm. Psychiatry Research. 2014; 219: 353-360.
[7] Cao-Lei L. et al. Pregnant women’s cognitive appraisal of a natural disaster affects DNA methylation in their children 13 years later: Project Ice Storm. Translational Psychiatry. 2015. Feb 24.
[8] Fleischman A. et al. Schizophrenia and violent crime: a population-based study. Psychol Med. 2014 Oct;44(14):3051-7.
[9] Daniels JL. et al. Parental psychiatric disorders associated with autism spectrum disorders in the offspring. Pediatrics. 2008 May;121(5):e1357-62.
[10] Dube SR. et al. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA. 2001 Dec 26;286(24):3089-96.
----------
Roberts AL, Lyall K, Rich-Edwards JW, Ascherio A, & Weisskopf MG (2015). Maternal exposure to intimate partner abuse before birth is associated with autism spectrum disorder in offspring. Autism : the international journal of research and practice PMID: 25662292
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