What Lies Beneath:
A former teacher observes similarities between trauma symptoms and symptoms of autism
While training as a psychotherapist I also worked as a teacher. Based in London schools, I taught many children who had arrived in the UK after fleeing conflict, political repression and dangerous everyday living situations in their home countries, or who were UK-born but had a comparable history in their family make-up. There were also pupils on-roll with extensive experiences of privation and deprivation, difficult family relationships, and insecure and chaotic home lives. I became concerned about the number of children classified as ‘naughty’ or ‘difficult’ by the behaviours they exhibited, and often felt that deeper exploration and understanding of what was causing their behaviours – and what they might be trying to communicate – was missing. I also noticed cases of children being somewhat dismissively referred to as ‘on the autistic spectrum’, without such diagnoses being confirmed.
Connecting what I was seeing in practice to theory I had studied as a trainee teacher, I began to make links between the presentations of children with known ASDs (autistic spectrum disorders) and autistic behavioural features, which research (Bennathan and Boxall, 2000; Rutter et al 1999) had shown could present in children who had experienced trauma and severe privation. Thus my motivation in writing this piece was to highlight similarities between trauma symptoms and the symptoms of autism, and to demonstrate the importance of the separation of these two presentations.
This article is an exploratory piece, in which I will look at how symptomatic presentations of autism and trauma may overlap and become blurred. I will draw on the fields of trauma and education and consider the role of traumatic experiences and early privation, where relational or situational trauma may or may not also be present. I will include two composite case examples, one taken from my experiences as a therapist, and one taken from my time as a teacher.
Early recognition of the symptomatic crossover of trauma and autism
In 1943 Leo Kanner was the first scientist to clearly define autism. Writing twenty years later he complained that “...it became a habit to dilute the original concept of infantile autism by diagnosing it in many disparate conditions which show one or another isolated symptom found as a part feature of the overall syndrome. Almost overnight, the country seemed to be populated by a multitude of autistic children” (Bishop, 1989).
As Kanner describes, diagnoses often become ‘fashionable’ within a society. This can result in the diminishing of their significance, as people who are displaying some – or many – of the symptoms of a syndrome may become immediately ‘diagnosed’. In a recent discussion with a colleague we wondered whether it was preferable to rely on the label of ‘autism’ when trauma may in fact be presenting as, with the aetiology of the syndrome rooted in biology, it is a more palatable classification that does not implicate parenting, society, an individual’s psychological inheritance or culture in the same manner as recognising early developmental trauma may do.
Research into the similarities between the symptoms of autism and the symptoms of trauma was pioneered by educational psychologist Majorie Boxall, in inner-London in the 1960s. It is important to situate the research within the context of its time, by highlighting that this was an era of increasing immigration to the city, developing Educational Psychology and the rolling out of a more progressive style of education in primary schools. This more child-led, free-flow style of education was based on the premise that children had already developed the skills necessary to enable them to employ a certain degree of personal organisation and autonomy. But, for children who lacked the skills of personal organisation necessary to cope with such an unstructured day, this approach had a detrimental effect on their development.
Boxall, writing in 2000 with her colleague Marion Bennathan, spoke of having identified a link between groups of children who were particularly at risk - those who were not securely attached and had experienced relational trauma - and those from immigrant families who had experienced trauma prior to arriving in London. From 1970 Boxall’s findings led to the formation of ‘nurture groups’ in a number of London schools. Such provision, which still exists today, was comprised of “short term, focused, intervention [strategies], which [addressed] barriers to learning arising from social, emotional and/or behavioural difficulties, in an inclusive, supportive manner” (www.nurturegroups.org). Attachment theory plays a key part in the philosophy of nurture groups, which aim to produce “educational attachments”, where children are “encouraged to develop trusting and caring relationships with adults, which are carefully focused on enabling children to learn” (Cooper and Whitebread, 2007). The cultural context that led to the formation of the early nurture groups was summarised in Bennathan and Kettelborough’s Response of the Nurture Group Network to the Primary Review (2007):
In the late 1960s a phrase, ‘West Indian autism’ had brief currency. It was racist, since it attributed to a particular culture a problem common to all children who are under-stimulated; that they are expressionless, unresponsive even when attempts are made to stimulate them, delayed in speech and motor skills and may end up stimulating themselves by repetitive behaviours such as rocking." (Bennathan and Boxall, 2000). Boxall saw the needs of many of the Jamaican children as the direct result of the harsh conditions under which many of them lived and that, having often had good early attachment experiences, they responded quickly to the help given in nurture groups. This was a transient problem; the proportion of children from ethnic minorities is now no greater than that of other groups.
‘Quasi-autism’ and its links to early privation
Rutter et al (1999) undertook research into the phenomenon of ‘quasi-autistic’ patterns of behaviour in children after experiences of severe early privation. The researchers considered 111 children from Romania who had been adopted into English families following a period of severe early privation, and found that 6% of the children demonstrated autistic-like patterns of behaviour, with a further 6% showing milder autistic features. The researchers considered these findings significant. A similar study was undertaken with children adopted within the UK, and such autistic characteristics were not found. That said, the research did show that children were most severely affected around 4 years of age, and were seen to be improving within a further two years.
As a result of their findings, Rutter et al highlighted the need to explore whether the syndrome these children were exhibiting was indeed childhood autism, or whether it was a different disorder that mimicked autism, resulting in ‘quasi-autistic features’. The authors state that, although prolonged institutional care was a factor in these cases (with some of this provision being categorised as very poor), they can only speculate on exactly what aspects of privation - eg psychological, nutritional, sensory, extreme stress or cognitive impairment - increased the risk of developing autistic features. However, they felt it was fair to infer adverse early experiences, and they do make links to the institutional rearing. Overall, the researchers concluded that: “the quasi-autistic pattern seemed to be associated with a prolonged experience of perceptual and experiential privation, with a lack of opportunity to develop attachment relationships, and with cognitive impairment” (Rutter et al, 1999). However, in conclusion, the researchers highlighted that there was a significant number of children who had experienced privation and did not show autistic-type features, which calls for further exploration again into why some children were affected in this way, while others were not, and what other factors were coming into play.
Some brief examples
As a teacher I repeatedly found that the number of children presenting with autistic-type features in a class of 30 to be higher than I expected. Presentations of autistic-type symptoms included difficulties in making and maintaining eye contact, underdeveloped social skills, echolalia and babbling, difficulties in managing transitions and change, obsessions with certain activities, extreme ritualistic play, an enhanced ability for a child to play on their own for an extended period of time combined with an inability – or unwillingness – to engage in reciprocal or shared play, a sense of being persecuted, and the sudden triggering of extreme behaviours such as lashing out or high-pitched, panic-stricken screaming, especially when over-stimulated, crowded or frustrated.
As a psychotherapist I have worked with a number of adult presentations where relational, developmental and situational trauma, or any combination of the three, have played a part in the client’s history. I have come to notice patterns in clients’ presentations, with clients who have experienced trauma in their past describing symptoms that may be more commonly thought of as being on the autistic spectrum. Clients have spoken of inhibited social skills, social anxieties and of a freeze response in relation to interacting with others or asking others for help and support. Clients have also reported ritualistic behaviours, hypersensitivity, paranoia, being easily-triggered, and a lack of awareness of danger. These symptoms may be easily recognised as trauma presentations when combined with the client’s narrative, but they could also be viewed as autistic-type symptoms and linked to the neurological condition, which might not be doing the client any favours. Of course, the reverse situation could also occur.
Case I – Child Z: relational and developmental trauma with related symptoms
Z was a young child who was difficult to manage in a classroom setting due to his temper outbursts, his inability to follow instructions, the sporadic, piercing shrieking he did when he felt distressed, his inability to form relationships and play with other children and his tendency to run away and hide when he felt threatened. Z was easily triggered and would often destroy other children’s games, or lessons that had been laid on for the class as a whole. That said, overall Z was a wonderful child and flourished when in the right environment, for example when he had one-to-one attention with a trusted adult, or when he was given responsibilities and the chance to ‘help’ adults.
Z displayed symptoms very similar to those typically seen in children on the autistic spectrum. However, there was an underlying quality to Z’s behaviour that I experienced as different to that which I noticed in children who were diagnosed with, or undergoing assessment for, autism. The detached presentation that I noticed in children who were on or suspected of being on the autistic spectrum was not present in Z, and his awareness of others appeared more enhanced than is typical in children presenting with autism at his age. Yet on more than one occasion I overheard Z being referred to as ‘autistic’, despite the fact that he was not diagnosed with or being assessed for the condition.
Z had had an extremely traumatic childhood thus far, involving rejection, abandonment and institutionalisation. He had recently moved to the UK and spoke no English. Z had no experience or understanding of the concepts of stability and security and had spent his early years fending for himself emotionally. He obviously felt unsafe in the classroom, and found it hard to trust in object constancy. Due to his history Z appeared hyper-vigilant, and was constantly on guard and ready to defend and fight for himself.
It is not my place to diagnose Z in any way. My intention is purely to draw attention to his autistic-type presentation, to highlight the presence of trauma in Z’s background, and to wonder about the potential links between the two in light of the research that I have cited thus far throughout this article. In my opinion Z was suffering from extreme relational and developmental trauma and was experiencing related symptoms. He had also devised ways to care for and manage himself, to the best of his developmental ability, which no doubt had been critical for his early survival. Over the course of his first year in school Z did begin to settle in and appeared to feel safer in his surroundings. Overall, his behaviour remained difficult to manage in a class setting, and his academic progress was hindered. Z has since been referred for play therapy.
Case II - Adult X: repetitiousness and the need for reparation
X was a woman in her early thirties presenting in the first instance with trauma symptoms including flashbacks, physical symptoms, hyper-vigilance and anxiety bordering on paranoia. She had a history of relational and situational trauma, and secondary symptoms uncovered throughout the course of therapy included social anxiety, enhanced self-reliance, hypersensitivity to lights, noise and movement and a sense of inner fragmentation.
X enjoyed ritualistic ‘play’, and found repetitive office toys, children’s train sets and abacus games soothing. During our work we discovered that smooth, repetitious movement had gone some way towards X managing her anxiety as a child. X had a tendency to create algorithms and word and number games in her head, or would obsessively recite times tables or her own idiosyncratic thought patterns mentally throughout the day. X was very literal, and needed structure and organisation in her life. She often found change and transitions difficult. X had lacked a sense of safety and security in her upbringing.
I am sure that in reading this the symptoms and signs of trauma, as well as their aetiology, have stood out. But in reading it minus a therapy hat, it may be easy to see how the presentation of symptoms alone could be taken as symptomatic of X being somewhere along the spectrum for autism or Asperger’s Syndrome. Techniques that have been developed to support those with autism may indeed be helpful and supportive for this particular client, for example in developing her social awareness and a sense of internal and external calm. But to have been classified as autistic could have done a disservice to the client’s needs as a whole if the label had taken away further investigation into her traumatic past and the need for subsequent reparative work.
Within this article I have highlighted the commonalities between the presentations of ASDs and the symptoms of trauma and PTSD, using theory from the fields of psychotherapy and education, and professional experiences from my work as a psychotherapist and a teacher. My intention is purely to draw attention to the similarities between the presentations of the two syndromes with the hope of opening up further realms of thinking and consideration around the presentation of both syndromes, when presenting either singularly or co-morbidly, within the psychotherapeutic community and beyond. This piece is not intended to imply that there has been an endemic of mis-diagnoses of ASDs in recent years, nor that those who have diagnoses of ASDs are in truth traumatised, or presenting co-morbidly, nor that ASDs cannot be present without trauma as a pre-requisite.
There are a number of further bodies of research and evidence within therapeutic literature on which I could draw in taking my article further, including research around the schizoid personality type, Dr Felicity de Zulueta’s work on the links between work attachment and early relational trauma and PTSD in adulthood, and research on the co-morbidity of autism and PTSD (Sinclair, 2002). There is not the space to explore all these links and connections here, although I feel it relevant to mention wider research and potential further reading relevant to the topic of discussion.
Beth Glanville holds a Counselling Diploma from The MInster Centre and is working towards the MA in Integrative Psychotherapy and Counselling. She works at The Grove Practice in Wimpole Street and is undertaking a counselling placement with Transport for London. Beth also works in private practice at The MInster Centre.
Bennathan, M., and Boxall, M. (1998) The Boxall Profile: Handbook for Teachers. London: The Nurture Group Network
Bennathan, M., and Boxall, M. (2000) Effective Intervention in Primary Schools: Nurture Groups. London: David Fulton Publishers Ltd.
Bishop, D. V. M. (1989) Autism, Asperger’s Syndrome and Semantic-Pragmatic Disorder: Where are the Boundaries?’ in British Journal of Disorders of Communication 24, pp107-121
Cook, E. H. J., Kieffer, J. E., Charak, D.A., and Leventhal, B. L. (1993) Autistic Disorder and Post-Traumatic Stress Disorder in Journal of the American Academy of Child and Adolescent Psychiatry 32(6), pp1292-1294
Cooper, P., and Whitebread, D. (2007) The Effectiveness of Nurture Groups on Student Progress: Evidence from a National Research Study in Emotional and Behavioural Difficulties 12(3) pp171-190
Glanville, E. (2008) Nurturing Provision: Supporting Children’s Learning. London: Unpublished
Rutter, M. Anderson-Wood, L. Beckett, C. Brendenkamp, D. Castle, J. Grootheus, C. Kreppner, J. Keaveney, L. Lord, C. O’Connor, T.G. (1999) Quasi-autistic Patterns Following Severe Early Global Privation in Journal of Child Psychology and Psychiatry 40(4) pp537-549
Sinclair, L.M. (2002) Consultation to a group home for a young autistic woman with a history of severe trauma in Journal of Developmental Disabilities 9(2)pp107-111
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