By Dr. Michelle Garnett and Professor Tony Attwood
Differentiating between trauma and autism can be challenging because both can present with overlapping behaviours, such as social withdrawal, communication difficulties, and sensory sensitivities. However, there are key differences in their origins, external signs, and patterns that can help in distinguishing between the two. Understanding the differences between trauma and autism can help in identifying the most appropriate support and interventions.
In this blog we provide a general guide to help you understand the distinctions. There is also the possibility that the person is both autistic and has trauma. Autistic people have been found to have an increased risk of experiencing potentially traumatic events throughout their lives (Christofferson, 2022; Quinton et al, 2024; Rumball, 2019) and to be more likely to develop post-traumatic stress disorder (PTSD; Haruvi-Lamdan et al 2020; Rumball et al 2021).
*The term ‘trauma’ can refer to the traumatic event/s that led to a trauma disorder, or to the trauma disorder itself. In this blog we use trauma to refer to disorders emerging after traumatic events. Specifically, these may include reactive attachment disorder, disinhibited social engagement disorder, post-traumatic stress disorder, complex- post traumatic stress disorder, acute stress disorder and the dissociative disorders.
History and Onset
Trauma:
Signs of trauma emerge after a specific event or series of events, such as abuse, neglect, loss, or a significant life change. In complex trauma, the triggering events are prolonged, repetitive and difficult to escape from (WHO, 2018; Karatzias et al, 2018). In autism the traumatic events causing trauma symptoms may be any of those mentioned, but commonly involve negative interpersonal events such as adverse childhood events and violence and sexual abuse (Christofferson, 2022; Gibbs et al, 2021, 2023; Rumball, 2019; Rumball et al 2021). Autistic people commonly experience trauma symptoms following events not currently defined as being traumatic by DSM-5 (APA, 2022) including bullying, social exclusion and sensory trauma (Kerns et al 2022; Lobregt-van Buuren et al 2018; Rumball, et al 2021).
Autism:
Autism is known to be the result of differences in neurology present from birth, though external signs might not be recognized until early childhood for an externalised (non-camouflaged) presentation and much later, for example in adolescence or adulthood, for an internalised (camouflaged) presentation. There is no specific triggering event. Trauma does not cause autism.
Observable Patterns of Behaviour
Trauma:
Trauma-related behaviours include hypervigilance, avoidance, visible distress/anxiety, nightmares, and strong emotional reactions to reminders of the traumatic event. These signs can be inconsistent, with some periods where the person seems fine and others where they exhibit distress. In complex trauma, in addition to the core observable symptoms of PTSD as described, there are also problems of a negative self-concept, emotion dysregulation and difficulties sustaining interpersonal relationships.
Autism:
Observable and internal presentations of autism are consistent and predictable across settings. Common observable patterns can include repetitive behaviours (e.g., hand-flapping, rocking), insistence on sameness, and following specific routines. Social and communication challenges are persistent and not linked to specific events. An autistic person who camouflages will have the same autistic features but has learned to suppress, mask and camouflage these over time. However, they can describe their own methods of suppression, masking and camouflaging and can usually pinpoint when these began.
Social Interaction
Trauma:
A traumatised person will withdraw from social interactions due to fear, distrust, and anxiety. There is a noticeable change in their social behaviour after a traumatic event. Interpersonal trauma is very often associated with deep feelings of distrust toward others.
Autism:
Social challenges in autism are intrinsic and long-standing, including difficulties with understanding neuro normative social communication, including nonverbal communication and unwritten social rules, building friendships and relationships. These difficulties are consistent and experienced due to a different neurology. Certain conditions may worsen these challenges for autistic people including living in a society not designed for autistic people and the impact of stigma due to being autistic (O’Connor et al 2023).
Communication
Trauma:
The person may regress in their communication abilities, showing a decrease in verbal skills or reluctance to speak, particularly about the trauma. They may also experience situational mutism (only having the capacity to speak in certain situations or to certain people) and/or selective mutism (only choosing to speak in certain situations or to certain people). Selective mutism is categorised as an anxiety disorder in that can be diagnosed alongside other anxiety disorders in DSM-5-TR (APA, 2022).
Autism:
Social communication difficulties are experienced from an early age and may include delayed speech development, difficulty with conversational skills, and challenges in understanding figurative language. Non-verbal communication might also be affected (e.g., limited eye contact, difficulty reading body language, facial expression and tone of voice). Selective and situational mutism has commonly been reported by and observed in autistic people. One research study (Steffenburg et al. 2018) found that 63% of a sample of four and 18 years old with a confirmed selective mutism diagnosis also met the diagnostic criteria for autism. For many reasons, including very high levels of anxiety/fear, mutism is common in autism. Because of this DSM-5-TR disallows a separate diagnosis of situational mutism if the mutism occurs within the context of autism.
Sensory Sensitivities:
Trauma:
Sensory issues might develop as a response to the trauma, particularly if the trauma involved sensory experiences (e.g., loud noises, bright lights). These sensitivities may appear after the traumatic event.
Autism:
Sensory sensitivities are a core feature and are present consistently, not tied to specific events. Autistic people may be hyper- or hypo-sensitive to external sensory input like sounds, lights, textures, or smells, and internal sensory input such as body sensations (interoception), where the body is in space (proprioception) and information from the inner ear that guide balance and body coordination (vestibular input).
Emotional Responses:
Trauma:
Emotional responses are often tied to specific triggers that remind the person of the trauma/s they have experienced. There may be intense fear, anger, or sadness associated with certain situations or memories.
Autism:
Intense emotional experiences are common in autism, especially anxiety, stress, being overwhelmed, and depression, to the extent that some clinicians may see these emotions as inherent in being autistic (Kildahl and Helverschou, 2024). Sometimes these emotions may seem atypical or disconnected from the situation. For example, the person laughs when crying may be expected, or the trigger for the emotion seems too small for the intensity of the emotion, or there may be no discernible trigger. Autistic people may have difficulty expressing emotions if they also have intellectual disabilities (Deb et al 2022) or alexithymia (Garnett & Attwood, 2023).
Response to Intervention
Trauma:
Healing from and resolving trauma can occur within the context of emotional support, a safe environment, and therapeutic intervention. A recommended approach for attachment-based trauma in children is parent-child attunement work (NICE, 2015). The World Health Organisation (WHO, 2018) recommends therapeutic approaches like eye movement desensitisation reprocessing (EMDR) and trauma-focused cognitive-behavioural therapy (TF-CBT) for resolving specific trauma. Dialectical Behaviour Therapy (DBT) and EMDR are known to be efficacious for adolescents and adults experiencing complex trauma (c-PTSD).
Autism:
Autism is no longer seen as a condition that necessarily requires intervention if there is only autism. However, there are often co-occurring conditions that require support and therapy. For example, young autistic children often benefit from speech therapy, and occupational therapy to assist with any speech and language delay, pragmatic language issues, and problems with motor skill development and sensory perception differences. Progress is typically gradual and focuses on building skills over time. A person with profound autism (autism co-occurring with severe language delay and /or intellectual impairment) will benefit from a multidisciplinary team approach for early intervention and beyond. Autistic people experiencing mental health conditions often benefit from therapy developed for the specific mental health condition, provided by a neurodiversity affirming therapist who can adapt the therapy for autism. Dialectical Behaviour Therapy (DBT) and EMDR have emerging research efficacy for adolescents and adults with trauma conditions (Fisher et al 2023, Lobregt-van Buuren 2019).
Professional Evaluation
If you are unsure, we highly recommend seeking a comprehensive evaluation from a professional trained to assess autism and trauma. These professionals are usually psychologists, paediatricians and psychiatrists, but not always. Check the person’s specialisations and training before booking an appointment. The trained professional can differentiate between trauma and autism through detailed assessments, observations, and understanding the person’s history.
Where to From Here?
To further understand the association of autism with trauma we have developed two brand new events: Trauma and Autistic Children and Teens and Trauma and Autistic Adults. Within these events you will learn:
- why the effects of trauma can be missed in autistic people and autism can be missed in traumatised people
- about the types of events that can cause trauma for autistic people
- the recent research on the association of trauma and autism.
- the similarities and differences between autism and trauma
- the impacts of trauma for an autistic person.
- strategies that can help the person, their partner and/or family
- when to seek professional help and the types of assistance available to help resolve and heal from trauma/s.
Whilst the themes and content description for these events are similar, please note that we have divided the content by age because the research, case examples, impacts, types of support and strategies for each age group differ. As a result, the events are quite different from each other.
References
American Psychiatric Association (2022), Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR, 5th ed. Text Revision, American Psychiatric Publishing, Washington, DC, D.C.
Garnett, M.S. & Attwood, T. (2023). Autism and Trauma. Retrieved from, available at: https://attwoodandgarnettevents.com/autism-and-trauma/
Christoffersen, M.N. (2022), “Sexual crime against schoolchildren with disabilities: a nationwide prospective birth cohort study”, Journal of Interpersonal Violence, Vol. 37 Nos 3/4, pp. NP2177-NP2205.
Fisher, N., van Diest, C., Leoni, M., & Spain, D. (2023). Using EMDR with autistic individuals: A Delphi survey with EMDR therapists. Autism, 27(1), 43-53.
Flackhill, Charlotte & James, Sarah & Milton, Karen & Soppitt, Richard. (2017). The Coventry Grid Interview (CGI): exploring autism & attachment difficulties. Good Autism Practice, 18, 1, 62-80. Good Autism Practice. 18. 62-80.
Gibbs, V., Hudson, J. and Pellicano, E. (2023), “The extent and nature of autistic people’s violence experiences during adulthood: a cross-sectional study of victimization”, Journal of Autism and Developmental Disorders, Vol. 53 No. 9, pp. 3509-3524.
Gibbs, V., Hudson, J., Hwang, Y.I.J., Arnold, S., Trollor, J. and Pellicano, E. (2021), “Experiences of physical and sexual violence as reported by autistic adults without intellectual disability: rate, gender patterns and clinical correlates”, Research in Autism Spectrum Disorders, Vol. 89, p. 101866.
Haruvi-Lamdan, N., Horesh, D., Zohar, S., Kraus, M. and Golan, O. (2020), “Autism spectrum disorder and post-traumatic stress disorder: an unexplored co-occurrence of conditions”, Autism, Vol. 24 No. 4, pp. 884-898.
Karatzias T, Cloitre M, Maercker A, Kazlauskas E, Shevlin M, Hyland P, Bisson JI, Roberts NP, Brewin CR. (2018). PTSD and Complex PTSD: ICD-11 updates on concept and measurement in the UK, USA, Germany and Lithuania. Eur J Psychotraumatol.; 8(sup7):1418103. doi: 10.1080/20008198.2017.1418103. PMID: 29372010; PMCID: PMC5774423.
Kerns, C.M., Lankenau, S., Shattuck, P.T., Robins, D.L., Newschaffer, C.J. and Berkowitz, S.J. (2022), “Exploring potential sources of childhood trauma: a qualitative study with autistic adults and caregivers”, Autism, Vol. 26 No. 8, pp. 1987-1998.
Kildahl, A.N. and Helverschou, S.B. (2024), “Post-traumatic stress disorder and experiences involving violence or sexual abuse in a clinical sample of autistic adults with intellectual disabilities: prevalence and clinical correlates”, Autism, Vol. 28 No. 5, pp. 1075–1089.
Lobregt-van Buuren E, Sizoo B, Mevissen L, de Jongh A. (2019). Eye Movement Desensitization and Reprocessing (EMDR) Therapy as a Feasible and Potential Effective Treatment for Adults with Autism Spectrum Disorder (ASD) and a History of Adverse Events. J Autism Dev Disord;49(1):151-164. doi: 10.1007/s10803-018-3687-6. PMID: 30047096.
NICE guideline [NG26] ( 2015) Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care London: NICE
Quinton, A.M.G., Ali, D., Danese, A., Happé, F. and Rumball, F. (2024), “The assessment and treatment of post-traumatic stress disorder in autistic people: a systematic review”, Review Journal of Autism and Developmental Disorders.
Rumball, F. (2019), “A systematic review of the assessment and treatment of posttraumatic stress disorder in individuals with autism spectrum disorders”, Review Journal of Autism and Developmental Disorders, Vol. 6 No. 3, pp. 294-324.
Rumball, F., Brook, L., Happé, F. and Karl, A. (2021), “Heightened risk of posttraumatic stress disorder in adults with autism spectrum disorder: the role of cumulative trauma and memory deficits”, Research in Developmental Disabilities, Vol. 110, p. 103848.
Steffenburg H, Steffenburg S, Gillberg C, Billstedt E. (2018). Children with autism spectrum disorders and selective mutism [published correction appears in Neuropsychiatr Dis Treat. 2018 Sep 06;14:2305]. Neuropsychiatr Dis Treat. 2018;14:1163-1169. Published 2018 May 7. doi:10.2147/NDT.S154966
World Health Organization (2018), “International classification of diseases for mortality and morbidity statistics, 11th revision (ICD-11)”, Retrieved from, available at: https://icd.who.int/browse11/l-m/en
