"his sudden interest in changing gender may have been another of his autistic obsessions"

A recent (online) newspaper report from here in Blighty included the quote used in the title of this post: "his sudden interest in changing gender may have been another of his autistic obsessions" (see here).

The report describes how a male - born biologically male - teenager diagnosed with autism expressed an opinion that "he believed he was female" and how his opinion was received by his parents and other professionals. Differences in the reception and perception of that opinion eventually led to some 'frustration' and, worryingly, the eventual intervention of social (child) services.

I decided to blog about this report primarily because (a) it ties in with some important peer-reviewed science discussions about gender identity and autism (see here and see here), and (b) there is a distinct possibility that the headline accompanying the report - "Social services threaten to take autistic boy into care after his parents refuse to let doctors give him powerful sex-change drugs" - is likely to be replicated again. Such a headline also taps into some wider debates about an increasing number of children talking about their gender and the decision-making rights and abilities of children both on and off the autism spectrum.

First things first, I know there are lots of strong opinions about sex and gender and 'what's right for children' these days. I don't offer an opinion either way nor do I claim to be an expert on issues such as gender dysphoria - "where a person experiences discomfort or distress because there's a mismatch between their biological sex and gender identity" - or gender reassignment or related issues. As mentioned, I'm interested in the science behind such discussions because autism has been discussed, on more than one occasion, as being potentially 'over-represented' among those with gender dysphoria [1] and/or wanting to/going through gender reassignment services. I say 'potentially over-represented' but wouldn't want anyone to think that any scientific debates have been settled at the current time: they haven't [2] (see here). I'm also interested in this topic because, aside from any gender reassignment issues, autism not so long ago was faced with something called the 'Lupron protocol'. Then leuprorelin, a drug sometimes used to 'delay puberty', was touted as something important to autism for very, very different reasons. I might add that the story of such a 'protocol' did not end well, as words like 'chemical castration' were banded around (see here).

I selected the quote that heads this post because it strikes me that there are some 'unique' issues that arise in the context of autism being mentioned alongside gender dysphoria and/or reassignment. Issues that don't seem to have been properly considered at the time of writing. Indeed, when I first tweeted about the source article for this post, a couple of response summed up the positions taken. First: "That child is not a boy. She is a girl and she needs the medical transition that will treat her dysphoria and allow her to live her best life." Another response was from someone who is themselves autistic and mentioned an important word: 'impulsivity'. Indeed, the article itself also mentions some similarly important phrases which require consideration. So: "they [his parents] suspected his abrupt decision to change sex was a result of his autism" and "All we were doing was trying to get him to pause and think about his actions" and "The school and social workers took what our child said as gospel. But considering he has autism, his perception of social scenarios is seen through an autism lens." An autism lens?

As you can see, a lot of those quotes/opinions focus on the idea that the traits that stem from or follow autism are potentially important to this debate. Minus any 'pity me' sentiments, they imply for example, that autism confers some specific 'vulnerability' that cannot simply be brushed under the carpet particularly when a person makes, or wants to make, important, potentially life-changing, decisions. I've talked about the issue of vulnerability and autism before on this blog (see here and see here) with some equally life-changing issues in mind. The topics differ but the sentiments remain the same. It's highly likely that the parents discussed in that news report know a little a bit about such vulnerability and autism purely in the context of raising their offspring.

Such vulnerability does however have to be balanced with individual rights; that is the rights of an individual to make important decisions that affect them. Such decisions might not always be 'the correct ones' or the ones that significant others necessarily want them to make but nonetheless, still need to be valued particularly within the context of assumed competence (see here). Indeed I get the impression that it's the possibility that the child has expressed an opinion with future consequences - "My biggest worry as a mum is my child gets pushed down this route, becomes a woman, goes through the surgery, then gets to 25 and says, “I’ve made a mistake.”" - that seems to worry the parents in the news report more than anything else. The use of the word 'surgery', implying the degree of 'invasiveness' needed and potentially also inferring 'irreversibility', is perhaps also an important part of their response.

What else? Well, without heading too far into scientifically unexplored territory I think there are other issues that come into play in such a scenario. Going back to the comment on impulsivity and the 'abrupt decision' talked about in the article, another important (and contentious) issue is potentially introduced: rapid-onset gender dysphoria (ROGD) [3]. ROGD is something that is not well-liked in some quarters (see here) and still remains a topic of some (heated) discussion (see here). It defines a state whereby "teens and young adults who did not have symptoms of gender dysphoria during childhood but who were observed by their parents to rapidly develop gender dysphoria symptoms over days, weeks or months during or after puberty." I don't make any comment on the rights or wrongs of something like ROGD but would encourage further study. Specifically with autism in mind and on the basis of the case being reported, questions like: 'how abrupt was the decision?' (or was the decision taken many moons ago but just communicated recently?) are important. Whether those who are diagnosed with autism or present with significant autistic traits are 'over-represented' among cases of ROGD is another research question that perhaps needs considering. And then there's the possible question of why?

Ultimately there are no easy answers to the issue described in today's post despite some significant strength of feeling. What will help however, is research; good quality research that is not afraid to test difficult hypotheses. And whilst individuals should always be empowered to make decisions for themselves, there should always be an appreciation that decision-making typically does not occur in a vacuum...

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[1] Janssen A. et al. Gender Variance Among Youth with Autism Spectrum Disorders: A Retrospective Chart Review. Transgend Health. 2016 Feb 1;1(1):63-68.

[2] Nobili A. et al. Autistic Traits in Treatment-Seeking Transgender Adults. J Autism Dev Disord. 2018. April 13.

[3] Littman L. Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PLoS One. 2018 Aug 16;13(8):e0202330.

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Risk of coercive sexual victimization *associated* with neurodevelopmental disorders

The paper by Vide Ohlsson Gotby and colleagues [1] represents an important contribution to the idea that 'vulnerability' is very much part and parcel of various childhood neurodevelopmental disorders (NDDs), and such vulnerability can have some pretty serious outcomes.

Relying on data from the Child and Adolescent Twin Study in Sweden (CATSS) - an initiative that is no stranger to discussions on this blog (see here for example) - researchers set about looking at any *association* between NDD status and risk of "being sexually victimized." Sexual victimisation was defined as "lifetime experiences of coercive sexual touching and/or coercive sex." Importantly, the Ohlsson Gotby results only covered "coercive sexual victimization up to age 18".

Their findings are worrying; as per one example: "In females, ASD [autism spectrum disorder] was associated with an almost threefolded increased risk of coercive sexual victimization." Following further analysis on whether "the association is driven by a general NDD phenotype versus specific diagnoses" authors concluded that: "General NDD symptom load, rather than specific ASD or ADHD [attention-deficit hyperactivity disorder] symptoms, seems to be a moderate vulnerability factor for coercive sexual victimization."

I appreciate that this is an uncomfortable topic. In light of all the talk about 'female autism' (see here) and issues such as camouflaging and the like (see here) potentially impacting on the rates of autism in girls and women, added to the age limit imposed by authors, it's highly likely that the Ohlsson Gotby findings are only the tip of the iceberg. Further investigation is required to see how prevalent such issues are across a lifetime, and importantly, what protective factors there might be against such a vulnerability. Whether also, minus any sweeping generalisations, there may be an intergenerational 'effect' (see here) is also an important question to answer. And having mentioned the word 'vulnerability' quite a bit already, more evidence is emerging on this topic [2].

Another important point to mention about the data derived from Ohlsson Gotby et al is their focus on boys as well as girls. They discuss how the [statistical] magnitude of the results obtained looking at males was not the same as with girls, but I'm inclined to again suggest that there may be some under-reporting of such issues. Being male and being diagnosed with autism and/or ADHD is not likely to be a protective factor against sexual victimisation.

And finally something rather shocking from the authors: "We speculate that an evocative gene-environment correlation might account for this observation [general NDD symptom load being related to sexual victimisation], such that sexual perpetrators actively target NDD individuals." Parents, caregivers and others with a vested interest in the care of those with NDD need to be particularly vigilant it seems.

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[1] Ohlsson Gotby V. et al. Childhood neurodevelopmental disorders and risk of coercive sexual victimization in childhood and adolescence - a population-based prospective twin study. J Child Psychol Psychiatry. 2018 Mar 23.

[2] Williams DM. et al. Can you spot a liar? Deception, mindreading, and the case of autism spectrum disorder. Autism Res. 2018 Apr 27.

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Euthanasia and assisted suicide mentioning autism: inadequate safeguards and 'vulnerability'

By discussing the paper by Irene Tuffrey-Wijne and colleagues [1] (open-access), I'm once again returning to the complex topic of euthanasia and assisted suicide (EAS) where autism is mentioned (see here and see here).

As per my previous blogging entries on some of the peer-reviewed science on this subject, I'll reiterate how sensitive and contentious this topic is. On the one hand is the primary human freedom to choose. On the other, is another human right: the right to live and the sanctity of life. The two viewpoints collide on this topic (see here).

Tuffrey-Wijne et al follow on from the work of Kim and colleagues [2] by focusing on the Netherlands, where EAS is legal. Legal that is, "provided that statutory due care criteria are met, including: (a) voluntary and well-considered request; (b) unbearable suffering without prospect of improvement; (c) informing the patient; (d) lack of a reasonable alternative; (e) independent second physician’s opinion." The authors searched the records of regional review committees (RTE) who provide oversight on "whether the requirements of 'due care' had been observed" in cases of EAS, looking for any mention of intellectual (learning) disability and/or autism spectrum disorder (ASD). They found a small number of people (N=9) who met these diagnostic criteria and set about analysing whether "the EAS due care criteria are applied." Their conclusions: "The Dutch EAS due care criteria are not easily applied to people with intellectual disabilities and/or autism spectrum disorder, and do not appear to act as adequate safeguards."

Authors provide details on the nine cases, including "selected quotes with regards to the patients’ stated characteristics, diagnosis, and due care criteria." I was particularly struck by some of the reports included under the heading 'unbearable suffering without prospect of improvement' which provides not only insight into how lives can be so totally affected by a diagnosis, but also a reflection of how we (society) continue to fail so many people on so many different levels. I know to use the word 'suffering' in the context of autism for example, has the ability to furrow brows in some quarters. But for these nine people there did seem to be genuine misery and suffering. To quote: "For two patients, for whom various psychiatric and somatic conditions were described, the stated suffering appeared to stem from characteristics of autism spectrum disorder itself, rather than from acquired medical conditions." Factors such as a 'loss of control' and the manifestation of issues stemming from autism "that may not be directly understandable to others" are also detailed.

The authors conclude: "particular caution [is required] in cases of EAS requests from people with intellectual disabilities and/or autism spectrum disorder, with the onus on both physicians and the RTE to demonstrate much more clearly how all due care criteria were met." In other words, countries that have legalised EAS need to do quite a bit more to ensure that vulnerable groups are not unfairly disadvantaged and are supported as much as possible when it comes to making such an extreme decision. I'll also say again (see here), vulnerability is too often seen as a 'dirty word' when it comes to autism, despite there being ample evidence that vulnerability manifests widely across many areas of daily living for those diagnosed. I can think of no more 'final' outcome than EAS where the (supposed implied) recognition of vulnerability needs to be paramount to any decision being made.

As per the opening paragraph to this blog entry, there is a balance to be struck between the sanctity of life and personal choice in this area. But that 'choice' needs to be an informed choice; with the requirement to ensure that any "such [EAS] legislation includes sufficient safeguards to protect vulnerable patient groups."

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[1] Tuffrey-Wijne I. et al. Euthanasia and assisted suicide for people with an intellectual disability and/or autism spectrum disorder: an examination of nine relevant euthanasia cases in the Netherlands (2012–2016). BMC Medical Ethics. 2018; 19: 17.

[2] Kim SY. et al. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016 Apr;73(4):362-8.

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"A greater understanding of ASD-related violence risk is needed to combat stigma"

This is another one of my long posts, so please, bear with me.

The topic of violence is always an emotional one. I know that even to mention the word 'violence' in the context of any label/diagnosis/condition/group carries the risk of making some people believe that there is some sort of generalisable connection. No smoke without fire eh? And one only needs to look at another label to see how a link with violence and by inference, 'dangerousness' has left a deep and long-lasting mark (see here) that continues today. So we're stuck between a rock and hard place: to talk about something and the risks attached in doing so, or just leave it, let people make their own judgements...

I've discussed quite a few uncomfortable topics on this blog down the years in light of various peer-reviewed research publications. I'm not one for shying away from calm and proportionate discussion where science - peer-reviewed science - has some vitally important input. In that context, I continue my discussions on the topic of violence and autism (see here). By doing so, I'm not making any sweeping generalisations. I'm not making any wild claims. I don't offer any brilliant insights into this topic. I'm just following the science and keeping emotions as far away from such cold, objective science as possible.

But there is a message before I continue. A message to those who might, in light of various media headlines, make some snap judgements about some of the people in your community. The message is simple: violence, in all it's forms, is not inherent to any one group. No-one is violent because of generalisations about who they are, whether on the basis of age, race, socio-economic circumstances or anything else. There are typically reasons for violence, and in many cases they're complicated. By saying all that, I'm not trying to talk down the very real effects that violence can have on individuals, families and society in general and the strong need for justice and more importantly, prevention. Just that seemingly apparent correlations and simple answers rarely provide an accurate insight into the particular hows-and-whys of violence and violent acts...

So today I'm talking about the paper published by Jill Del Pozzo and colleagues [1] who "provide a comprehensive review of the literature bearing on the relationship between ASD [autism spectrum disorder] and violent behavior." This is a timely publication because I'm sure many people have seen the word 'autism' being used among the coverage of a quite horrendous act recently. Indeed, even Del Pozzo et al allude to other similar attention: "Over the last decade, there has been increased media attention focused on the relationship between ASD [autism spectrum disorder] and violent behavior due to a number of school shootings and high-profile criminal cases involving offenders with alleged ASD diagnoses."

Perhaps I need to mention that the word/description 'violence' covers a lot of ground. It of course covers violence against others, whether on an individual or collective basis, but importantly, also covers violence in many other forms including against oneself in the form of self-injury and/or self-abuse. Most media coverage of violence covers violence against others. But I'd wager that violence against oneself is the predominant form of violence in many circumstances minus any big headlines...

Del Pozzo et al set about providing a "comprehensive review of the literature" on autism and violence. Following their surveying of the current peer-reviewed research literature in this area, the authors concluded that whilst a diagnosis of autism is by no means protective of someone committing a violent act, there is generally more peer-reviewed scientific support for the idea that "ASD does not cause violence" over and above the sometimes negative media portrayals of the label in this context (see here). A welcome conclusion it has to be said, and one that needs to be circulated widely; but again, minus any sweeping generalisations and bearing in mind that science is all about probability not absolutes.

There are caveats to the statement that 'ASD does not cause violence' insofar as the multiple observations that autism typically does not exist in a diagnostic or social vacuum (see here), and how various factors (environment, psychiatric comorbidity, criminality) can potentially elevate the risk of violence for some people. All of this is not about passing the diagnostic buck (see here) as some people quite unceremoniously have decided to do, but needs to be mentioned; particularly in light of these days where 'autism plus' [2] is more typically the norm (see here) over and above the label of autism existing as some sort of stand-alone diagnosis. The pertinent question therefore may not necessarily be one of 'does autism cause violence?' but rather what role autism may or may not play [3] when it comes to violence, taking into account an often very complicated, very individual clinical picture. I say this also acknowledging that a diagnosis of autism is not some 'magical status' automatically reserved only for 'good people' (see here); just as any other behavioural/psychiatric label does not similarly distinguish between 'good' and 'bad' people.

As per the title of this post utilising a quote from Del Pozzo and colleagues - "A greater understanding of ASD-related violence risk is needed to combat stigma" - there is a pressing need to further understand how and why violence can/does occur for some alongside the label of autism or rather autism plus. Whether as part of the often nebulous term that is 'challenging behaviours' (see here) or in other related contexts (importantly also including that self-aggression angle), trying to answer such how/why questions can only be of benefit to all concerned. Indeed, alongside another quite sweeping generalisation made by Del Pozzo et al that: "Violence results from undetected or untreated third variables (e.g. psychosis)" and "Individuals with ASD have an elevated risk of psychosis", various lessons continue to be learned [4] (see here also) albeit stressing how complicated any relationship is likely to be [5]. As I mentioned before, easy answers are not likely to forthcoming.

Finally, I want end by again introducing the concept of 'vulnerability' in the context of autism into proceedings. I'm not specifically talking about vulnerability to various comorbidity that 'probably' influence the presentation of violence in the context of autism, but rather vulnerability in more general terms (see here). The writings of Tom Berney [6] provide some particularly insightful details on such vulnerability in relation to violent and other offending acts within the context of some autism or rather some 'autism plus'. Such vulnerability issues stress how, minus hype or sensationalism or indeed any calls for censorship in this most delicate area, investigations need to continue and sensitively continue without stigmatising and without further disadvantaging an already quite disadvantaged community...

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[1] Del Pozzo J. et al. Violent behavior in autism spectrum disorders: Who's at risk? Aggression and Violent Behavior. 2018. Jan 31.

[2] Gillberg C. & Fernell E. Autism plus versus autism pure. J Autism Dev Disord. 2014 Dec;44(12):3274-6.

[3] Allely CS. et al. Violence is Rare in Autism: When It Does Occur, Is It Sometimes Extreme? J Psychol. 2017 Jan 2;151(1):49-68.

[4] Långström N. et al. Risk factors for violent offending in autism spectrum disorder: a national study of hospitalized individuals. J Interpers Violence. 2009 Aug;24(8):1358-70.

[5] 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.

[6] Berney T. Asperger syndrome from childhood into adulthood. Brit Journal Psych Advances. 2044; 10: 341-351.

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On the "co-occurrence of autism and delinquency": no association for the majority

"The extant research shows that for most people with ASD [autism spectrum disorder] there is no association between ASD and delinquent behavior."

That was one of the primary conclusions reached in the literature review published by Alexa Rutten and colleagues [1] (open-access) looking at the collected peer-reviewed science from 1990 to 2015 on this topic. Boiling down the literature to 12 papers "five of which report the prevalence of delinquency in patients with ASD and seven the prevalence of ASD in a forensic population", authors reported on quite a lot of variability when it came to delinquency and offending behaviours but overall, offending behaviour was "lower in people with ASD than in the general population."

This is welcomed research. It reiterates what many people have already known/suspected, in that the label 'autism' for many is not typically associated with intentional delinquency or offending behaviour. As Rutten et al note: "many people with ASD have an overactive sense of right and wrong and are usually conscientious and unwilling to break the law." I should also point out that a diagnosis of autism is not however necessarily some kind of 'shield' when it comes to offending behaviour (see here and see here for a more recent example) or indeed, potential 'vulnerability' to becoming involved in specific offences (see here). But serious 'intentional' delinquency is not the norm; even that is, in the context of something like greater likelihood of contact with law enforcement agencies (see here).

There are still lessons to learn in this area of research and practice. Certain 'over-represented' comorbidity appearing alongside autism is still something to potentially consider [2] as per other findings (see here and see here). I say that without 'trying to pass the [diagnostic] buck'. Bearing in mind also how wide the autism spectrum is, specific diagnoses on the spectrum might also require further study as per the authors comments: "The prevalence of ASD diagnoses, particularly Asperger’s syndrome, in forensic settings is remarkable because it is much higher than the prevalence of ASD diagnoses in the general population." At this point I'll also refer you once again to the comprehensive review paper by Tom Berney [3] that mentions some of the potential how-and-whys of offending in the specific context of Asperger syndrome, again minus any sweeping generalisations. Recent media attention on previously undiagnosed Asperger syndrome in a prison context also makes for important and relevant reading too (see here) particularly where substance abuse is prominently mentioned (see here).

I would however question one rather sweeping statement made by Rutten and colleagues: "It is important to diagnose ASD carefully and to differentiate autism symptoms such as a lack of empathy from psychopathic traits". Lack of empathy and autism? Hmm, sounds a bit old hat to me...

I will again close with the point made that for the majority of people on the autism spectrum, the label is much more likely to be associated with law abiding rather than law breaking.

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[1] Rutten AX. et al. Autism in adult and juvenile delinquents: a literature review. Child and Adolescent Psychiatry and Mental Health. 2017; 11: 45.

[2] Newman SS. & Ghaziuddin M. Violent crime in Asperger syndrome: the role of psychiatric comorbidity. J Autism Dev Disord. 2008 Nov;38(10):1848-52.

[3] Berney T. Asperger syndrome from childhood into adulthood. Advances in Psychiatric Treatment. 2004. 10; 341-351.

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'Vulnerability' to radicalisation and autism or autistic traits: tread carefully

I was more than a little hesitant to post this entry given the sensitivity of the material it covers. I opted to publish this post because peer-reviewed science is peer-reviewed science...

In a recent piece for The Conversation, Dr Clare Allely asked a very difficult but potentially important question: "Are autistic people at greater risk of being radicalised?"

Based on her own research [1] and in light of several high profile cases where an autism diagnosis has been mentioned in the same breath as various terrorist-related offences, some with a potential radicalisation element to them (see here and see here) it is indeed timely that such a question is posed.

This is a sensitive area. Yes, I very much appreciate that people commit crimes, not their diagnostic labels (see here) and sweeping generalisations are not required, but "it is crucial to consider how the diagnosis of autism may have presented as a contextual vulnerability" when it comes to such issues.

There are various sensitivities to consider before it comes to even examining any possible link between vulnerability to radicalisation and autism or autistic traits. One needs only look at the effects of years and years of sweeping generalisations about schizophrenia and 'dangerousness' for example (see here) to see how stigma can build up quickly and how damaging it can be on a personal and societal level. Science and clinical practice need to tread very carefully indeed, whilst also not shying away from any uncomfortable results.

The Allely piece for the The Conversation touches however on several important points pertinent to the idea that 'vulnerability' to radicalisation may be perhaps elevated in relation to a diagnosis of autism for various reasons. I've stressed the word 'vulnerability' for several reasons...

First off, use of the word 'vulnerable' - "unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation" - in the context of autism is, I think, under-used. I don't say that in any 'pity me' fashion but rather that many people on the autism spectrum are/should be classed as 'vulnerable' despite any [typically sweeping] notions about being 'high' or 'low' functioning or other description of their positioning on the autism spectrum. There are several other examples of this vulnerability in action in the peer-reviewed literature [2] and indeed, autistic commentators have themselves noted various other scenarios (see here) specifically where enhanced victim risk of coercion and bullying is part and parcel of such vulnerability. With such vulnerability comes inevitable heightened risks for all manner of potential adverse outcomes.

Dr Allely also talks about how: "Searching for a “need to matter” or social connection and support for someone who is alienated or without friends may also present as risk factors" when it comes to enhanced risk for radicalisation. I think again, this may be something of an important point when it comes to parts of the autism spectrum. The idea for example, that those on the autism spectrum do not want (or need) friends is an unfortunate side-effect of years and years of further sweeping generalisations when it comes to trying to define the spectrum. The whole 'lacking in empathy' thing (myth?) has, I think, played a big part in perpetuating the idea that difficulties in forming relationships with peers for example, has sometimes been misinterpreted as not wanting relationships with others. Obviously one has to guard against making counter sweeping generalisations that everyone with autism wants lots and lots of friends around them all of the time, but what seems to be true is that autistic people do in the most part want significant others around them at certain points and want the benefits that friendships and belonging bring under their own terms. The vacuum created by not belonging to a social circle or not having that 'need to matter' to others is something faced by at least some on the autism spectrum and could therefore be considered a risk factor for vulnerability to issues like radicalisation especially when others with an ulterior motive come forward with a seemingly welcoming face and message. Indeed, one might also see evidence of this when one talks about hacking or cyber-terrorism in the context of a diagnosis of autism...

"Autistic special interests such as fantasy, obsessiveness (extreme compulsiveness), the need for routine/predictability and social/communication difficulties can all increase the vulnerability of an person with ASD [autism spectrum disorder] to going down the pathway to terrorism." I'm not in total agreement with everything said in that sentence but some of it could ring true. As difficult as this may be to face, forensic examination of cases where autism has been cited alongside terrorist activities has noted obsessions in particular, to be a potentially important variable. As a case in point: "The court heard Smith had been interested in making bombs since the age of 10 and said it was "something to do when he was bored"". A long interest in 'making bombs' at any age is not something typical; let alone when starting such an interest as a 10-year old. The source of such interests is likely to be complex but, with all the media attention paid these days to terrorism and talk of the objects of terrorism and the like easily found on the internet and other media, it's not difficult to find a context for why someone might become utterly engrossed and/or obsessed with such material for years and years.

What's missing from the Allely article? Well, I'd like to see quite a few more resources dedicated to the idea that comorbidity around a diagnosis of autism might also play an important role in both risk of radicalisation and any onward decisions to actually implement acts of terrorism. Again, minus sweeping generalisations or passing the buck from one label to another, quite a few diagnostic labels with a psychiatric element to them do seem to be over-represented when it comes to autism (see here) and services are not necessarily suited to picking them up or managing them for everyone (see here). This applies particularly to those conditions characterised by an altered sense of reality (see here) - I assume, a potentially important point for some when it comes to for example, transitioning from ideas to acts.

Another issue that ties in with some factors already mentioned is the idea that "everyday young people in social transition, on the margins of society, or amidst a crisis of identity" may be over-represented among some parts of radicalised terrorism. Minus any psychobabble, it wouldn't be difficult to fit some on the autism spectrum into some of those categories on the basis for example, of being marginalised or being 'amidst a crisis of identity'. Obviously one could argue that such issues are not autism-specific; quite a few young (and old) people probably feel disenfranchised particularly in today's modern society and hence a diagnosis of autism per se is not the defining variable. But again, we come back to that issue of vulnerability...

Reiterating that any talk about a link between autism and vulnerability to radicalisation in the context of terrorism is fraught with difficulties and risks, there is a need for further scientific investigation into this area. Radicalisation is a complicated process (see here); the risk of which is not something that can be just laid at the door of labels like autism or autistic traits. One needs to be mindful not to stigmatise whole swathes of the population on the basis of a few, very high-profile cases. Yes, people want quick and easy answers to the questions of 'how and why' but I doubt there are any simple or universal answers to issues such as radicalisation and further.

The fact however, that the Allely article was published at all highlights how this issue is starting to come into the public consciousness. If indeed some of the facets of autism or the issues created by a diagnosis of autism are found to be a variable in some cases of radicalisation and beyond, resources aplenty need to be poured into what can be done to educate against and mitigate any excess risk both inside and outside the context of a diagnosis of autism or autistic traits. All this however needs to be done carefully minus further stigmatisation and any scaremongering (that includes sensationalised newspaper headlines) but always realising that science should not being afraid to try and find answers to difficult questions in as many different quarters as are required.

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[1] Faccini L. & Allely CS. Rare instances of individuals with autism supporting or engaging in terrorism. Journal of Intellectual Disabilities and Offending Behaviour. 2017; 8: 70-82.

[2] Brown-Lavoie SM. et al. Sexual knowledge and victimization in adults with autism spectrum disorders. J Autism Dev Disord. 2014 Sep;44(9):2185-96.

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