School environment plays a role in the occurrence of "child victimization": mainstreaming vs specialised provision examined

As the schools here in Blighty begin to open their doors for another year of education, I thought it timely to talk about schools and schooling in the context of autism...

With that being said, I don't want to get too heavily into the whole 'mainsteam school vs. specialised provision' in this post, but the findings reported by Ko Ling Chan and colleagues [1] do seem quite important. I was particularly struck by one of their observations: "Children attending special schools were at lower risks of victimization, while children with disabilities who had been placed in ordinary schools for inclusive education were at higher risks of most types of victimization when compared to children without disabilities."

I've previously covered the idea that, whilst the sentiments of 'mainstreaming' (placing students with additional educational needs in a general education setting) are noble ones, the reality is that mainstreaming can bring about its own challenges (see here). Indeed, the current focus here in the UK on the rise of mainstream school exclusions (expulsions) where certain diagnostic labels are mentioned (see here), is probably not entirely unrelated to this 'policy' of inclusive education functioning in a world of seemingly dwindling financial resources devoted to educational establishments and the individuals they serve. That said, things might be changing in this area (see here) if recent judgements are taken into account...

Chan et al set out to examine "the associations between disabilities and child victimization" as a function of school environment (i.e. mainstream vs. specialised educational provision). They looked at a cohort of over 4000 children aged between 6-18 years who "were receiving primary or secondary education in Hong Kong in 2016-2017." They assessed for "7 types of victimization in the past year" as a function of various diagnostic labels being received or not.

Findings: it's probably no surprise to anyone that: "Children with ADHD [attention-deficit hyperactivity disorder], internalizing disorder, autistic spectrum disorder, and restrictions in body movement were at higher risks of victimization while other types of disabilities were not." I say this on the basis that victimisation (a.k.a bullying) is no stranger to behavioural labels such as autism for example (see here and see here). The additional observation that school environment (type) might be some kind of moderating variable for the presence of such victimisation has already been mentioned. Authors add that: "When placed in a protective environment, children with disabilities could even be less vulnerable to victimization than those without disabilities."

There are a couple of implications from such findings. The first one is a fairly obvious one in that, although there are benefits to be had from mainstream school in the context of disability (hopefully with additional provisions tailored to the individual) insofar as interacting with peers and not being 'singled out' in an educational sense, there are potential downsides too. I know that we would all love for school to be a place that everyone enjoys and thrives in, but the reality is that they're not such a place for every child. Kids can be cruel. 'Bad kids' can be cruel and 'good kids' can be just as cruel; and it's often the perception of 'differences' (particularly differences in 'power') that starts and perpetuates the bullying process in a number of contexts. I know all that sounds harsh and a little apocalyptic, but fluffy clouds and unicorn thinking about 'everyone holding hands and getting along' is not going to help everyone.

Second, bullying hurts. It really hurts. Bullying also has many effects both in the short- and longer-term [2]. We can um-and-ah about the psychology of bullying and provide some psychobabble reason for why bullying has the effect it has, but the long-and-short of it is that bullying hurts. Bullying doesn't solely just impact on the child either. And whilst on the topic of bullying in the context of autism, the recent paper by Zoe Hodgins and colleagues [3] observing that "male adolescents with ASD [autism spectrum disorder] understand bullying differently than their TD [typically developing] peers" is perhaps also relevant to the content of this post.

Finally I go back to that statement from the authors about how 'protective environments' may help some children "be less vulnerable to victimization." It would be easy to suggest that as and when a diagnosis of something like autism is received, a child should have the right to attend a specialised facility that, among other things, potentially 'protects' them against bullying. Ah yes, in an ideal world. The reality however is that such 'protective environments' are not necessarily as protective as one might imagine. I say this on the basis that if even the nearest and dearest of kids with autism are not always the shoulder to cry on (see here) why would anyone assume that every child placed in such a protective environment would be immune to being a bully or being bullied? And without wishing to equate 'negative impressions' with bullying, a recent paper by Ruth Grossman and colleagues [4] *could* be relevant to such an argument: "adolescents with autism spectrum disorder form negative first impressions of autistic adolescents that are similar to, or lower than, those formed by neurotypical peers" (see here for my take). I repeat: specialised educational settings are not going to be immune to bullying behaviour. Added to all that is another issue: does placement in a 'protective environment' provide a false impression of the world at large? Y'know, children don't stay in school forever...

I would have loved to end this post with some all-encompassing answer to solving the issue of school environment and victimisation (bullying) behaviour in the context of various diagnostic labels. Unfortunately I can't. Yes, the data suggest that specialised educational provision *might* be a better option when it comes to reducing the risk of victimisation/bullying perhaps also alongside other important issues [5], but in the real-world where such provisions are seemingly not able to keep up with demand, there are often great difficulties in accessing such places. I also wouldn't want to give any sweeping generalised position statement about such resources being worry-free either. They aren't.

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[1] Chan KL. et al. Associating disabilities, school environments, and child victimization. Child Abuse Negl. 2018 Jul 5;83:21-30.

[2] Novin S. et al. Bidirectional relationships between bullying, victimization and emotion experience in boys with and without autism. Autism. 2018 Aug 3:1362361318787446.

[3] Hodgins Z. et al. Brief Report: Do You See What I See? The Perception of Bullying in Male Adolescents with Autism Spectrum Disorder. J Autism Dev Disord. 2018. Aug 31.

[4] Grossman RB. et al. Perceptions of self and other: Social judgments and gaze patterns to videos of adolescents with and without autism spectrum disorder. Autism. 2018. July 17.

[5] Adams D. et al. School-related anxiety symptomatology in a community sample of primary-school-aged children on the autism spectrum. Journal of School Psychology. 2018; 70: 64-73.

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ALSPAC says... "Social communication impairments had the strongest association with a depression diagnosis at age 18 years"

ALSPAC mentioned in the title of this post refers to The Avon Longitudinal Study of Parents and Children, one of the premier research initiatives here in Blighty, that has provided all-manner of interesting and important research associations. With autism in mind, ALSPAC has opined on various different research questions (see here and see here for examples) including the issue of a possible 'real' increase in the numbers of children presenting with autistic traits (see here).

On this particular research occasion, ALSPAC was the source data for the findings reported by Dheeraj Rai and colleagues [1] who set out to "compare trajectories of depressive symptoms from ages 10 to 18 years for children with or without ASD [autism spectrum disorder] and autistic traits, to assess associations between ASD and autistic traits and an International Statistical Classification of Diseases, 10th Revision (ICD-10) depression diagnosis at age 18 years, and to explore the importance of genetic confounding and bullying." I might add that some of this authorship group are making some real research waves when it comes to investigations using population registries with autism in mind (see here).

The starting point this time around was the notion that a diagnosis of autism is in no way protective when it comes to a diagnosis of depression and/or the expression of depressive signs and symptoms. Again, it's a topic that has cropped up before on this blog (see here) and is perhaps one of the longer term associations that have been made down the years. The idea that depression or depressive symptoms *might* be something much more than just 'comorbid' in the context of at least 'some' autism is something else that has been banded around the peer-reviewed research literature before (see here) but the evidence base is not particularly big or strong in this area at the moment.

There were a few different research questions asked by Rai et al, including looking at children "with or without ASD or high scores on autistic trait measures" and any relationship(s) with depression and depressive traits. They report findings for over 6000 children ("maximum sample with complete data") where questionnaire items on bullying were also included ("Relational and overt bullying was assessed as separate yes or no items at ages 8, 10, and 13 years using the modified Bullying and Friendship Interview Schedule") alongside various other potentially confounding variables.

Results: "children with ASD and those with higher scores on all autistic trait measures had more depressive symptoms at age 10 years than the general population, and these remained elevated in an upward trajectory until age 18 years." I don't think there's anything too novel in such findings, aside from the observation that depression / depressive symptoms may start quite early on in childhood. I can remember when I started out in autism research a couple of decades ago hearing about depression being typically linked to the onset of adulthood in the context of autism. This current data suggests otherwise.

Next: "Social communication impairments had the strongest association with a depression diagnosis at age 18 years. Findings were robust to adjustment for a range of confounders, including maternal depression and anxiety and the child’s polygenic risk for autism." This is important. What it suggests is that there may something 'more than just comorbid' about depression or depressive symptoms appearing alongside autism or at least in connection to certain autistic traits. I know some people have already taken exception to this possibility alongside the use of the word 'impairment' by the authors. But much like other research on an important bedfellow to depression - anxiety - one may have to entertain the possibility that there may be some enhanced 'predisposition' to something like depression alongside the presentation of autistic traits (see here and see here) perhaps mediated by factors such as rumination and perseveration for example [2]. This doesn't mean that depression is solely a product of autistic traits; merely that certain traits may potentially form an important vulnerability factor. I'm similarly minded to bring in other work from the ALSPAC initiative [3] (including Rai and colleagues as authors) where related findings were mentioned: "Social communication impairments are an important autistic trait in relation to suicidality." This on the basis that depression and suicidality show an important association.

Also: "We found evidence of a substantial role of bullying in contributing to and explaining a higher risk of depression in individuals with ASD and autistic symptoms." Bullying in the context of autism is another long-standing topic (see here). Bullying covers a lot of ground in terms of behaviour and also source (see here). The authors opine that: "Previous work has shown strong links between the experience of bullying and later depression... although confounding could have a role, the association is considered to be at least partially causal." It's also important to note that social-communication 'issues' were reported to be potentially predictive of being bullied according to the authors. The model that then appears hints that the appearance of depression *might* be linked to "reduced self-esteem or social isolation after the bullying" accepting that causality is not established and also not accounting for other variables: "other relevant characteristics, including comorbidities with neurodevelopmental conditions (eg, attention-deficit/hyperactivity disorder) and classroom placement could be important in this association within or outside the context of bullying." That last point is important in the context that autism rarely exists in some sort of diagnostic vacuum (see here).

There are a few caveats attached to the Rai findings that need to be kept in mind outside of any 'correlation does not necessarily equal causation' sentiments. So: "atypical presentations of depression are common in ASD, and our study has the potential for outcome measurement error because we used scales... that have not been adapted for autism." Indeed. I've previously talked about how bipolar disorder for example, might not follow a typical pattern when present in the context of autism (see here). I daresay that this could also hold for other types/forms of depression too. I'm also minded to reiterate that depression, as well as being a heterogeneous condition, also seemingly has many pathways to it. Some of those pathways will include psychological and social variables such as bullying and perhaps even more extremes of 'trauma'; where a diagnosis of PTSD is for example, no stranger to autism (see here). 'Happiness' and perceived quality of life (see here) are also likely to exert an important effect too.

Other pathways to depression seem to be more biologically defined as per depression in the context of physical ailments (see here) that may have a *link* to some autism (see here) or following the use of seemingly common medicines according to recent news reports (see here). I'll also mention that things like physical activity and exercise *seem* to show an important relationship with depression (see here). This could also be pertinent to the data suggesting that physical activity levels are typically not optimal where and when autism is diagnosed (see here). Other factors (fatigue, sleep, etc) also need to be mentioned in the context of depression. In short, there are lots and lots of potential variables to consider [4].

Outside of the important messages from the Rai findings on how depression is over-represented in relation to autism and how social factors like bullying seem to be linked  to it and thus are subsequently 'modifiable', there is another important point to consider: depression is typically treatable. Minus any medical or clinical advice being given or intended, the first step in managing/treating depression is identifying it. Perhaps the Rai findings might serve as a further call to action for preferential screening in the context of autism...

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[1] Rai D. et al. Association of Autistic Traits With Depression From Childhood to Age 18 Years. JAMA Psychiatry. 2018 Jun 13.

[2] Patel S. et al. Association between anger rumination and autism symptom severity, depression symptoms, aggression, and general dysregulation in adolescents with autism spectrum disorder. Autism. 2017 Feb;21(2):181-189.

[3] Culpin I. et al. Autistic Traits and Suicidal Thoughts, Plans, and Self-Harm in Late Adolescence: Population-Based Cohort Study. J Am Acad Child Adolesc Psychiatry. 2018 May;57(5):313-320.e6.

[4] Köhler CA. et al. Mapping risk factors for depression across the lifespan: An umbrella review of evidence from meta-analyses and Mendelian randomization studies. J Psychiatr Res. 2018 May 25;103:189-207.

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Bullying and autism: not always originating from where you might expect...

There is something rather uncomfortable about the findings reported by Imar Toseeb and colleagues [1] but, at the same time, they do raise an important issue that needs to be openly discussed. Specifically their findings on: "sibling bullying, and the associated psychopathological adversities, in children with and without ASD [autism spectrum disorder]" deserve some airtime.

Bullying and autism is quite a regular talking point in the peer-reviewed research literature (see here) and beyond. Although a diagnosis of autism is by no means protective of someone becoming a bully or being involved in what could be considered bullying behaviour, it is far more typical that those with autism are going to be a victim of bullying rather than perpetrator (see here). Indeed, I reluctantly use the word 'vulnerable' yet again on this occasion but...

When one thinks about bullying in any context including that with autism in mind I would imagine that the school bully who name calls or becomes physical aggressive towards someone - usually smaller and quieter than them - probably first springs to mind. Siblings by contrast, conjure up an image of being caring, supportive and again, with autism in mind, often very protective of their brother(s) and/or sister(s) given their important role, present and probably future. And indeed, many, many siblings are just that (see here).

But real life is rarely so clear-cut or 'homogeneous' as many parents, whether with children diagnosed with autism or not, will attest. Siblings argue, fight and probably because of how well they 'know each other', often know all the right buttons to press to get their required reaction. And yes, behaviour sometimes can spill over to what would be considered bullying under any other circumstance...

Toseeb et al started with the hypothesis that: "children with ASD (child has ASD but their sibling does not) would experience higher levels of sibling bullying compared to those without ASD (child and sibling do not have ASD)." They arrived at this hypothesis on the basis of various factors such as a role for the social-communicative issues that follow autism, the possible effect of the 'broader autism phenotype' (BAP) on siblings, and issues such as a greater frequency of aggression - "reactive aggression" - accompanying particularly boys with autism.

They relied on data from the Millennium Cohort Study (MCS) (a resource that has been mentioned before on this blog) and eventually included data from nearly 500 children with autism alongside over 13,000 not-autism controls. The question(s) on sibling bullying were asked at 11 years of age and went: "he/she was asked to respond to two questions on a six-point scale (never, less often, every few months, approximately once a month, approximately once a week, most days): “how often do your brothers or sisters hurt you or pick on you on purpose?” (victimization) and “how often do you hurt or pick on your brothers or sisters on purpose?” (perpetration)." Responses were coded according to who did what and how often. Various other measures were also examined as part of the MCS and used in the Toseeb paper: socio-demographic data (single parent status, birth order, number of siblings, household incomes), parenting style, psychopathology and cognition.

Results: children diagnosed with autism or ASD were more likely to be bullied by their non-autistic sibling compared with those who did not have autism. This finding held "even after controlling for socio-demographic and family level variables" and "was associated with adverse psychopathologies." Further: "having ASD, being a girl, of White ethnicity, having more siblings, and experiencing harsher parenting were all associated with increased odds of being bullied by a sibling." Whilst we're on the topic of 'adverse psychopathologies, it's perhaps pertinent to mention the findings reported by Dantchev and colleagues [2] observing a possible connection between sibling bullying receipt and psychotic disorder. Yes, it is quite an extreme example, but nonetheless demonstrates the effects bullying can have long-term. I might also refer you back to some discussion arising from the ICF core sets development with autism in mind too (see here).

I digress. I note also that authors discuss sibling bullying as a two-way street: "Our findings indicate that children with ASD are specifically at increased risk of sibling victimization as a bully-victim."

As I said at the beginning of this post, this all makes for uncomfortable reading. If it's not bad enough that a child may be being bullied at school to also then potentially learn that there is little respite from such behaviour at home, makes for an uncomfortable (intolerable?) situation all-round. The question then arises minus any sweeping generalisations: what can be done about sibling bullying for the good of all concerned? And please, don't just solely suggest 'coping strategies' for the bullying victim either.

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[1] Toseeb U. et al. The Prevalence and Psychopathological Correlates of Sibling Bullying in Children with and without Autism Spectrum Disorder. J Autism Dev Disord. 2018 Feb 8.

[2] Dantchev S. et al. Sibling bullying in middle childhood and psychotic disorder at 18 years: a prospective cohort study. Psychological Medicine. 2018. Feb 12.

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The ICF core sets for autism in action

The findings reported by Soheil Mahdi and colleagues [1] (open-access available here) reiterate that 2018 looks like being the year of the ICF core sets for autism.

Having covered this topic yet again only recently (see here), I'm back to talking about the core sets and, once again, get to use the beautiful word 'melange' with reference to the "complex melange of functioning experiences beyond the diagnosis" of autism.

This time around it was about trying to "capture aspects of functioning and contextual factors pertaining to individuals with ASD [autism spectrum disorder] as assessed by the ICF-CY [International Classification of Functioning, Disability and Health (ICF, and Children and Youth version, ICF-CY)] in a clinical practice setting." I must admit to making a cold shudder when seeing the words: "The ICF-CY is grounded on an interactive bio-psycho-social model of functioning" in light of what the biopsychosocial model has 'done' to other conditions (see here). But in this case, I'm willing to give it the benefit of the doubt... at least for now.

So, from a starting participant group of 126 children, adolescents and adults with ASD (even though researchers used the children and youth version of the ICF), this number was slightly whittled down to some 122 who completed the study. It was a worldwide effort, as participants were drawn from 10 countries and, perhaps notably, the United States and United Kingdom were not among the countries taking part on this occasion. I was pleased to read that inclusion criteria for the study was a diagnosis of autism of course, but also did not exclude participants who also presented with "any given common co-morbidity." This, in light of 'autism plus' perhaps being more 'realistic' than autism appearing in some sort of diagnostic vacuum (see here).

Results: "In total, 139 of 161 ICF-CY categories assessed met the cut-off in at least 10% of the participants." The authors observed that this included "64 categories in the activities and participation component, 40 body functions and 35 environmental factors." Although you can look for yourself what issues/factors are included under those headings, I might point out a few of interest including the handling stress and other psychological demands, sensory functions and pain, functions of the digestive, metabolic and endocrine systems and the role of immediate family.

Continuing: "Examples of supportive personal factors included high IQ, acceptance towards own diagnosis and specific interests (e.g., art, sports)." These are also interesting. The role of 'acceptance towards own diagnosis' is something that has cropped up before in the peer-reviewed literature (see here). On that research occasion, the authors leaned towards a role for 'others' (external sources) accepting a person with a diagnosis of autism as being potentially 'positive' when it came to good mental health in the context of autism. I was perhaps more sceptical of the primacy of this 'other' influence - based as it was on rating statements such as "over the past week, I have felt accepted by society as an autistic person/person with autism" on a 5-point scale - insofar as 'personal acceptance' potentially being the more important variable. The Mahdi data seems to agree. The other 'supportive' variable, talking about having specific interests such as art or a sport, also tallies with a lot of other independent research findings (see here for an example, also using a certain WHO tool relevant to the ICF core sets for autism).

Onwards: "Past traumatic life events (e.g., getting bullied at school) were mentioned as a hampering personal factor, as it affected the individual’s self-esteem and self-worth." This, alongside various other routes to stress that "exacerbate ASD symptoms", provides some useful information about what could be done to mitigate such negative influences. I'm not sure that it is possible to completely eradicate issues such as perfectionism, but I daresay that it could be minimised through certain talking interventions for example, thus potentially improving quality of life. Insofar as the role bullying might play, well, probably quite a bit (see here) and any efforts to reduce things like bullying at school should be welcomed.

I do want to pass one final comment on the Mahdi data going back to the issue of comorbidity appearing alongside autism. As I've mentioned, this was a study that did not shy away from comorbidity being central to quite a few people diagnosed on the autism spectrum. The types of comorbidity reported included old friends such as attention-deficit hyperactivity disorder (ADHD), present in about a quarter of participants, and intellectual (learning) disability, present in about 15%. Whilst part of the clinical picture for quite a few, there is always the possibility that some of factors discussed in relation to the ICF core sets for autism *may* be more directly influenced by such comorbidity than by the 'core features' of autism themselves. I guess it doesn't matter if said comorbidity is part of the clinical picture, but if it's not, there may be some assumptions being incorrectly generalised...

And it appears that autism is not alone in its receipt of the ICF core sets treatment [2]...

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[1] Mahdi S. et al. An International Clinical Study of Ability and Disability in Autism Spectrum Disorder Using the WHO-ICF Framework. J Autism Dev Disord. 2018 Feb 8.

[2] Mahdi S. et al. An international clinical study of ability and disability in ADHD using the WHO-ICF framework. Eur Child Adolesc Psychiatry. 2018 Feb 17.

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On treating psychosis in the context of autism

"This report describes the successful improvement in symptoms and quality of life in a young man with psychosis and ASD [autism spectrum disorder], who had previously tried numerous medical interventions."

So said the findings published by Victoria Bell and colleagues [1] (open-access available here) providing some discussion not only about how a diagnosis of autism is seemingly not protective against the development of something like psychosis (see here) but also how psychosis in this context can be successfully managed with a little bit of [clinical] thought. I'll also draw your attention to some other quite recent research that has conversely talked about how difficult it can be to treat psychosis when an autism diagnosis is also in the frame (see here).

Bell et al discuss a case report of a young man (HP) who came to clinical attention in his mid-teens. School examinations seemed to be a possible trigger for episodes of vomiting after eating, leading to hospitalisation. Other symptoms also appeared - "a lowering of mood and poor sleep, and weight loss" - leading to more clinical contact. Bullying was also a feature; as we are told that: "a group of boys had made videos of him, including him being flash mobbed, which had been placed on YouTube; they had also made a persecutory Facebook page." I can think of a few choice words to describe such boys and their antics but won't.

As time progressed, he had "an in-patient admission to a Child and Adolescent Mental Health Services ward, for over a year" where a diagnosis of Asperger syndrome was made alongside "dissociative disorder, and a severe depressive episode with psychotic features." Lots more followed including him becoming "increasingly non-communicative and episodically aggressive toward his parents" culminating in him returning to an in-patient setting.

What is rather refreshing to see is the clinical work-up that this young man received. So: "magnetic resonance imaging (MRI) scans, electroencephalograms (EEGs), anti-NMDA antibodies, as well as B12, folate and thyroid function tests were repeatedly normal." Some critical thinking eventually led clinicians to discount the idea that his symptoms 'were just part of his autism' - "differentiating between psychotic catatonia and autism-related catatonia" - and instead look to a comorbid diagnosis of psychosis. Further: "this was adopted as our working diagnosis for treatment."

Treatment came in the form of various pharmacotherapy and some 'psychological input' bearing in mind "HP remained selectively mute throughout his admission." His clinical management wasn't exactly helped by the fact that another 'very disruptive patient' was admitted at the same time as HP and, on more than one occasion, physically attacked him. But eventually the 'number of days out' increased and symptoms such as vomiting, incontinence and aggression decreased as the "symptom-based approach" adopted seemed to work.

What lessons can be learned from this case report? Well, several. Not least that as well as not existing in some sort of diagnostic vacuum (see here), a diagnosis of autism can and does raise the risk of various psychiatric comorbidity potentially appearing. And sometimes it's hard to see where autism ends and said comorbidity starts (see here for example); assuming that is, that you see comorbidity as comorbidity and not something rather more core.

There is also a positive message from the Bell findings in relation to the 'treatability' of various comorbidity over-represented alongside autism. Yes, it takes time and resources to diagnose and rule things in or out, but quality of life can be improved for the person and those around them. Indeed the authors add: "The level of violence upon admission concerned our team and his parents... if psychotic symptoms were ignored, violence may have continued and led to long-term placements in a more secure environment." Indeed.

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[1] Bell V. et al. A symptom-based approach to treatment of psychosis in autism spectrum disorder in October 2017. BJPsych Open. 2018 Jan;4(1):1-4.

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Bullying and autism: stating the bleedin' obvious...

A short post today to reiterate the 'bleedin' obvious': children diagnosed as being on the autism spectrum are far more likely to be the victim of bullying than perpetrator (see here for a previous blog post on this topic).

This conclusion comes from the paper by Hwang and colleagues [1] based on responses to the Behavior Assessment System for Children: Second Edition (BASC-2) (parental report version). The authors initially reported that "children with ASD [autism spectrum disorder] showed significantly increased risk for bullying involvement compared to community children" potentially indicating that a diagnosis of autism does not somehow shield someone from either being bullied or indeed, participating in bullying behaviour (perpetrator). But... "after controlling for comorbid psychopathology and other demographic factors, increased risks for being perpetrators or victim-perpetrators disappeared while risk for being bullied/teased continued to be significantly elevated." Said 'comorbid psychopathology' included aggression and conduct problems as well as the signs and symptoms of depression potentially accompanying a diagnosis of autism. Indeed, aggression was pretty much linked to every type of bullying behaviour in both autism and control groups...

What's more to say on this topic? Well, further recognition that school in particular, can be a significant source of stress and anxiety for children on the autism spectrum is one thing (and potentially contributory to the stats on school refusal in the context of autism). Indeed, without trying to armchair diagnose nor artificially inflating the seriousness of bullying, I wonder whether quite a few more children on the autism spectrum need to be screened for possible post-traumatic stress disorder (PTSD) in the context of how traumatic bullying can be for a person (see here). In relation also to the point made about aggression being a common variable predicting bullying across the Hwang cohort, I wonder whether more needs to be done more generally in relation to reducing aggression in places like school and thus potentially reducing bullying behaviour more generally?

And whilst on the topic of bullying, it appears that some of the longer term effects of bullying for some might be countered by some kind of resilience (whatever 'resilience' might mean)...

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[1] Hwang S. et al. Autism Spectrum Disorder and School Bullying: Who is the Victim? Who is the Perpetrator? J Autism Dev Disord. 2017 Sep 21.

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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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Autism awareness among the young is actually quite good

The message of 'increasing awareness of autism' is still a strong one in modern times despite the label of autism officially entering medical texts some 80+ years ago. We have a World Autism Awareness Week and a World Autism Awareness Day and lots more in-between to raise awareness of autism and what the label [differentially] means to many, many people.

The findings reported by Karola Dillenburger and colleagues [1] seem to suggest that, particularly among children and young adults, the autism awareness message is getting through as they observed: "Children and young people have good levels of awareness and knowledge about autism and reported positive attitudes towards peers with autism." Even further: "A higher than expected number of children and young people self-reported being on the autism spectrum."

Based on analysis of "two large-scale surveys: the Kids Life and Times survey for 11-year olds and the Young Life and Times survey for 16-year olds" yielding some 3300 children and young adults, researchers posed various questions including those pertinent to autism awareness. The results suggested that some 80% of teenagers had some knowledge about autism compared with about 50% of younger children. Most participants held positive attitudes towards autism including recognition that bullying is an issue that some on the autism spectrum are particularly at risk of. Further: "Self-reported prevalence of autism was 3.1% for teenagers and 2.7% for the younger children." That last point was based on the study population being based in Northern Ireland (which interestingly, has recently reported a rather large upswing in the number of formally-diagnosed cases of autism too).

These are rather positive results insofar as the recognition of autism and indeed, how common it is in modern times. It is perhaps not unexpected that some of these authors have some research form in this area [2]. The authors frame the result in terms of boding well for "peer-mediated support strategies for inclusive education" but I think they go much further than that. Assuming that awareness covers the entire spectrum of autism (see here) and not just a part/branch of it, I'd like to think these findings go some way to supporting efforts to 'make autism more visible' and onward, ensuring that the wants and needs of those on the spectrum are more readily expressed and addressed. Media and culture probably has a lot to do with such findings (see here for example) but the fact that many classrooms and schools do now cater for students on the autism spectrum no doubt played an important role in these findings.

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[1] Dillenburger K. et al. Autism awareness in children and young people: surveys of two populations. J Intellect Disabil Res. 2017 Jun 7.

[2] Dillenburger K. et al. Creating an Inclusive Society… How Close are We in Relation to Autism Spectrum Disorder? A General Population Survey. J Appl Res Intellect Disabil. 2015 Jul;28(4):330-40.

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I am not condoning violence...

Mr Bruce Lee @ Wikipedia 

Name calling, spreading rumours, excluding from social groups, hitting, kicking and taking belongings. Bullying (definition courtesy of the UK National Autistic Society) covers quite a lot of ground.

I don't actually know if I had a bully or not at school. I mean, there was this one kid at school who always seemed to have it in for me until that is, one day I snapped (yes, we English are not all watercress sandwiches and afternoon tea) after which the kid in question didn't tend to come near me again. I never actually thought however that this kid was a bully per se; just someone who I didn't seem to get along with.

That was then. Nowadays the media is awash with news about cyber-bullying and the various new fangled ways that some kids use / have used to cause misery to other kids (albeit with questions about prevalence). I have to say that I'm kinda glad that I'm not a teenager in the Internet or cameraphone age after reading all this.

In this post I want to talk about the paper by Paul Sterzing and colleagues* reporting on the experiences of school year bullying (and bullying perpetration) in teens with an autism spectrum disorder (ASD). On purpose I've left it a while before I get to this paper in order to let the dust settle around this quite emotive topic before I stuck my oar in with this quite long post.

Needless to say that this study has from the initial press release and author profile created quite a few column inches as per headlines like this one: School bullies prey on children with autism and this one: Why autistic kids make easy targets for school bullies no doubt alongside hitting some really raw nerves for many people. I tread carefully.

A quick summary first:

• This was a survey study which asked parents (N=920) (and teachers) of teens with an autism spectrum disorder about the bullying (both victim and perpetrator) experiences of their children.
• Coming up to almost half of all teens with autism were reported to be the victims of bullying (46%) whilst 15% were perpetrators of bullying and about 10% combined bullying victims and perpetrators.
• Various factors correlated with bullying victim status including lower social skills, some level of conversational ability and a comorbid ADHD diagnosis. Being in mainstream education was also mentioned as a correlate.
• On the other hand, the presence of ADHD was also associated with being a bullying perpetrator alongside having some kind of friendship base.

This is not the first time that bullying has been studied with autism in mind. This paper from van Roekel and colleagues** (open-access) looked at bullying specifically within the special education school system, again reporting a figure of 46% on the prevalence of bullying and victimisation. Indeed not dissimilar from the findings from a recent UK report on the school experience and autism (see here).

I was also interested in the findings reported by Montes & Halterman*** on the influence of ADHD comorbidity, where dual presentation (autism & ADHD) seemed to confer the greatest risk for bullying behaviours. Not a million miles away from the Sterzing conclusions. As an aside, I do also wonder whether the paper by Susan Dickerson Mayes and colleagues**** on suicide ideation and attempts in cases of autism might also reflect a potential effect from bullying in some extreme cases.

I'm not an expert on bullying but I might add a few points potentially tied into these findings. Stick with me on this one.

Although there are probably lots of reason for bullying behaviour, I've always believed that, from the bully's point of view, it all eventually comes down to exerting power over another person/s. It's a two-stage process so please hear me out: (i) a bully, whether because of issues in their own life, at home, at school, at anywhere, either has lost some degree of 'power' over their own life and wants to recoup it over others perceived as less powerful, or in some cases, has an insatiable desire for power not readily satisfied by their current life. That's how (I think) it starts, accepting that other factors such as prejudice, jealousy, socio-economic status (see here) and popularity among peers also might carry influence. The second stage (ii) is all about maintaining a bullying control over someone; something where the more social side of things comes into play. Peer groups based on that bullying power, some degree of showing off to those peers and the notion of 'getting away with it' all contribute to keeping the cycle of bullying going.

Then there is the 'victim' perspective. As per the discussion above, victims generally have to be perceived by bullies as someone who is less powerful than them. This could take the form of being less physically powerful than the bully as per this study by Bejerot and colleagues***** on how poor performance in physical education classes might be a risk factor for being bullied or this study by Wildhaber and colleagues****** discussing asthma-related bullying. It could also be someone who 'stands out' from the crowd as discussed in this study by Kukaswadia and colleagues******* on obesity being a determinant of bullying. As per this editorial, "the symptoms of the disorder are the exact reasons that make young people with autism vulnerable". With that in mind, have a think about the suggestion of hyper vs. hypo-theory of mind (see here) with bullying and autism in mind.

Without trying to cherry-pick the evidence, other research on some of the hows and whys of bullying, victims and their behaviour (as per studies like this one and this one and this one) to some degree correlate with my view including this very interesting piece from the American Psychological Association.

I know some people might read all this psycho-babble and ask questions like 'why can't society be kinder?' and 'who would pick on a child with autism?'. I too ask those questions. The simple fact however is that children, like adults, whether with or without autism or other labels, are complicated and the way society like schools are set-up combined with that human nature means that bullying is probably always going to be present to some degree. Where there is social structure, there's always going to be people who want to be top dog. Where there are differences, there will probably always be some degree of prejudice. These aren't nice thoughts, but unfortunately it is current reality.

But that's not to say that something can't be done to moderate those bully and victim characteristics. Quite a few people seem to be talking about bullying prevention and interference strategies and I believe that when they work, they can work very well. So little things like bullying victims being able to tell someone about their experiences, through to proactive processes and policies at a school and even at a societal level designed to educate and stop would-be bullies from starting their 'give me your dinner money' ways. There are some obvious issues with some of these suggestions when applied to some cases of autism and the characteristic presentation of the condition but I don't really have the space in this post to go into specifics now.

If you're still reading this, I would perhaps also offer another tool in the anti-bullying arsenal: self-defence skills. As per the title of this post, I am not condoning violence in any way, shape or form by saying this and realise that bullying covers so much more than just physical action. But let's face it, with all the will in the world and support from parents, schools, whoever, there are always going to be situations where a child is on their own and potentially faced with a bully or bullies. Particularly when bullying turns from words and phrases to 'sticks and stones' is where perhaps some degree of self-defence might come in handy. Note the stress on defence before any charges of incitement to violence are levelled at me. And I'm not the only one suggesting this by the way.

Searching the literature on the use of martial arts / self-defence for people with autism, there are some interesting pieces of research to note. This poster presentation by Palermo and colleagues******** talks about how karate is not only a skill that can be taught to children with autism, but also a skill which might (in some cases) actually have some value-added benefits outside of just being able to 'take care of yourself'. Indeed other studies, whilst limited in quantity, have indicated similar potential gains from taking up martial arts as per this study by Bahrami and colleagues*********. If one takes the martial arts path to its natural progression in terms of the mental and physical discipline required and related concepts like mindfulness, you can perhaps see other potential benefits which might also accompany the various moves outside of just increasing self-confidence and physical empowerment.

I'll reiterate that I'm not suggesting that every child with autism trains up to be some kind of Keanu Reeves "I know Kung-Fu" warrior. And once again I am totally understanding of the voices of 'why would someone bully a kid with autism?' sentiments and the need to try and alter attitudes whether through education or indeed legislation. The trouble is that we live in a world where kids, some kids, can be very cruel and whether through ignorance or other factors, bullying is pretty much always going to be on the periphery of growing up just as it can, and often does, carry forward to the adult workplace. Having autism it seems, does not confer immunity to that premise. With all that in mind, does taking a wide ranging approach to managing bullying including an element of teaching self-defence really sound so un-PC?

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* Sterzing PR. et al. Bullying involvement and autism spectrum disorders: prevalence and correlates of bullying involvement among adolescents with an autism spectrum disorder. Archives of Pediatrics & Adolescent Medicine. September 2012.

** van Roekel E. et al. Bullying among adolescents with autism spectrum disorders: prevalence and perception. JADD. 2010; 40: 63-73.

*** Montes G. & Halterman JS. Bullying among children with autism and the influence of comorbidity with ADHD: a population-based study. Ambulatory Pediatrics. 2007; 7: 253-257.

**** Dickerson Mayes S. et al. Suicide ideation and attempts in children with autism. Research in Autism Spectrum Disorders. 2013; 7: 109-119.

***** Bejerot S. et al. Poor performance in physical education - a risk factor for bully victimization. A case-control study. Acta Paediatrica. 2011; 100: 413-419.

****** Wildhaber J. et al. Global impact of asthma on children and adolescents' daily lives: the room to breathe survey. Pediatric Pulmonology. 2012; 47: 346-357.

******* Kukaswadia A. et al. Obesity as a determinant of two forms of bullying in Ontario youth: a short report. Obesity Facts. 2011; 4: 469-472.

******** Palermo MT. et al. Karate and autism spectrum disorders: sports as treatment for social cognition deficits. Archives of Disease in Childhood. 2008; 93: ps540.

********* Bahrami F. et al. Kata techniques training consistently decreases stereotypy in children with autism spectrum disorder. Research in Developmental Disabilities. 2012; 33: 1183-1193.

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Sterzing PR, Shattuck PT, Narendorf SC, Wagner M, & Cooper BP (2012). Bullying Involvement and Autism Spectrum Disorders: Prevalence and Correlates of Bullying Involvement Among Adolescents With an Autism Spectrum Disorder. Archives of pediatrics & adolescent medicine, 1-7 PMID: 22945284