Developmental Disorders

Neurodevelopmental Disorders

Neurodevelopmental disorders are disabilities that are present from birth or early childhood which affect how individuals perceive, make sense of, and interact with the world. Neurodevelopmental disorders can impact personal, social, academic, and vocational functioning in various ways and are highly comorbid with each other, mental health conditions, and physical health conditions. Notably, individuals with neurodevelopmental disorders have a higher risk of experiencing trauma, including multiple complex interpersonal victimizations across the lifespan, and there is increasing evidence that developmental disorders increase the risk of posttraumatic stress disorder (PTSD). This may have important implications for vulnerability to dissociation.

This is an emerging area of academic research, but the topic has in recent years been of increasing interest to individuals with neurodevelopmental disorders, their clinicians, and their friends and family. Autistic adults in particular self-report high rates of trauma, posttraumatic stress, and dissociation, and there have been repeated requests for accessible information on this topic. Although in-depth coverage of this complex issue is not possible here, major points are summarized below. 

Neurodevelopmental Disorders and Trauma

Neurodevelopmental disorders increase the risk or impact of a variety of traumas, including injuries, medical symptoms or procedures, and witnessing violence (Ko et al., 2015). Interpersonal victimization is also a major risk, including the chronic child maltreatment most often associated with dissociative identity disorder (DID). Children with neurodevelopmental disorders are more likely to lack secure attachment to their caregivers, who often report high levels of caregiving stress and difficulties accessing sufficient support. This, combined with anti-disability discrimination and challenging child behaviors, can lead to high rates of child abuse and neglect. Stigma and discrimination can also lead to peer harassment, rejection, or abuse, as can the social differences inherent to many neurodevelopmental disorders. Additionally, individuals with autism and intellectual disability are perceived as more vulnerable, may have difficulties recognizing warning signs of danger, and are often not given age-appropriate education on romantic or sexual relationships, all of which increase the risk for sexual violence and intimate partner victimization. Difficulties communicating can also increase the risk of victimization and make it difficult for victims to get help and support (for review, see Reuben & Parish, 2022).

Accordingly, reported and confirmed victimization rates are very high. Baladerian et al. (2013) found that 62.5% of individuals with a neurodevelopmental disorder had experienced abuse, including 34.2% sexual abuse. When specifically examining ADHD, other studies found child maltreatment rates ranging from 22.9% to 51%, including 6.4% to 51% for neglect, 12.9% to 43.5% for physical abuse, and 6.6% to 33.7% for sexual abuse (Fuller-Thomson et al., 2015; Guendelman et al., 2016; Hellstrom, 2019; Ouyang et al., 2008). When examining autism, 50.4% to 80% report any form of child maltreatment, including 62.2% to 79% emotional or verbal abuse, 18.5% to 57.8% physical abuse, and 2.8% to 30% sexual abuse (Baladerian et al., 2013; Chan et al., 2018; Griffiths et al., 2019; Hellstrom, 2019; Mandell et al., 2005; McDonnell et al., 2019; Pfeffer, 2016). Victimization often extends into adulthood and includes intimate partner victimization, physical assault, and sexual assault, all of which can further complicate and worsen dissociative responses. One study of autistic adults (Reuben et al., 2021) found that the majority reported having experienced physical assault or sexual violence, and these experiences were associated with both posttraumatic stress and dissociation.

In addition to higher rates of interpersonal victimization, many factors increase the risk that individuals with neurodevelopmental disorders will develop PTSD, including executive dysfunction, uneven cognitive profiles, lack of social support, and disability-related stressors (for review, see Reuben & Parish, 2022). This is under-studied, and the frequency at which specific neurodevelopmental disorders and PTSD co-occur is largely unknown. Dissociation is even less often recognized, let alone studied. However, there is some research on PTSD and dissociation in ADHD and autism spectrum disorders. 

ADHD, Posttraumatic Stress, and Dissociation

There is a growing body of research showing that ADHD can be caused, exacerbated, or mimicked by childhood maltreatment. Although ADHD is known to be strongly heritable, there is evidence that genetic vulnerability interacts with an adverse family environment to increase the risk of ADHD (Laucht et al., 2007). Among those with childhood-diagnosed ADHD, the majority will not meet full ADHD criteria in adulthood, but childhood adversity increases the likelihood of continuing symptoms (Fuller-Thomson et al., 2015). Child maltreatment is strongly associated with symptoms also found in ADHD, including inattention, impulsivity, difficulties managing anger, extreme passivity, peer rejection, poor academic functioning, and cognitive delays (Briscoe-Smith & Hinshaw, 2006; Guendelman et al., 2016), and childhood physical abuse is so strongly associated with ADHD that some studies have found that ADHD is more likely to result from physical abuse than any other disorder, including PTSD (Sugaya et al., 2013). Most notably, ADHD symptoms are conceptualized as one of the clusters of symptoms associated with developmental trauma disorder, a proposed diagnosis meant to capture the extremely wide-reaching effects of severe childhood neglect and abuse (D’Andrea et al., 2012). 

Developmental trauma disorder also draws a connection between ADHD symptoms and dissociation (D’Andrea et al., 2012). Other researchers have also confirmed an association between child maltreatment and dissociation, including parts-based dissociative disorders, for individuals with ADHD (Endo et al., 2006; Matsumoto & Imamura, 2007). On the other hand, studies have found that those with ADHD but no trauma history or PTSD dissociate at equivalent levels to the general population (Endo et al., 2006; Kilic et al., 2017; Zoroglu et al., 2002). It is also possible for dissociation to mimic inattentive ADHD symptoms such that individuals with posttraumatic externalizing symptoms and a dissociative disorder are misdiagnosed with ADHD (Bozkurt et al., 2014; Endo et al., 2006; Schenk, 2002). There is professional discussion about the differences and overlap between posttraumatic ADHD symptoms versus ADHD as a neurodevelopmental disorder, and research around this complex topic is ongoing. 

    Autism, Posttraumatic Stress, and Dissociation

    Autistic children have worse posttraumatic stress than children without autism (Paul et al., 2018; Mehtar & Mukaddes, 2011), and autistic traits predict posttraumatic stress (Haruvi-Lamdan et al., 2020; Roberts et al., 2015). The few prevalence studies on autism and PTSD show that 32% to 60% of autistic adults screen positive for PTSD (Haruvi-Lamdan et al., 2020; Reuben et al., 2021; Rumball et al., 2020). Additionally, PTSD rates might be higher in autistic adults who are women or gender minorities in addition to those with more complex trauma histories (Reuben et al., 2022). However, PTSD is drastically under-diagnosed, with only 16% to 20% of autistic adults reporting a professional PTSD diagnosis (Griffiths et al., 2019; Reuben et al., 2022). 

    Interpersonal victimization, meeting the DSM-5 criteria for PTSD, and having a professional diagnosis of PTSD all predict higher levels of dissociation in autistic adults. This is highlighted in studies by Reuben et al. (2021, 2022). However, even baseline dissociation rates are very high in autistic samples. Of the autistic adults that Reuben et al. (2021) surveyed, 94% reported at least one clinically elevated type of psychoform dissociation. This included emotional disengagement (85%), depersonalization (72%), emotional constriction (60%), derealization (59%), memory-related dissociation (53%), and identity disturbances (26%). Additionally, 32% reported elevated somatoform dissociation. These findings are further borne out by research by Storch et al. (2012), who found that 18% of autistic youth experience anxiety-related dissociation. Additionally, somatic dissociation has been found by other research groups to be elevated in autistic children (Mahan & Matson, 2011; Sukhodolsky et al., 2008) and adults (Zdankiewicz-Ścigała et al., 2021). 

    Even non-traumatized autistic individuals may have an increased risk of experiencing dissociation. Anxiety is very common in autism and has also been linked to depersonalization and derealization. Alexithymia and difficulties with interoception may make it difficult for autistic people to understand their internal experiences and so make it more appealing to try to ignore these entirely. Some autistic people use fantasy or media to cope with stress, which may encourage disconnection from the external world. Many report having overwhelming or painful sensory experiences which are downplayed or denied by others, which may encourage disconnection from oneself and one's environment. Similarly, exposure to stigma and discrimination may cause dissociation through shame and self-alienation. Pressure to "mask" as neurotypical (i.e., hide autistic traits and pretend to be someone the autistic person is not) may cause identity confusion and, when combined with childhood trauma, encourage the formation of dissociated identities. Finally, early attachment disruptions are common in autistic populations and may increase the risk of dissociation even in the absence of overt maltreatment (for review, see Reuben & Parish, 2022). 

    Autistic people self-report a wide variety of dissociative experiences. Some of these reports occur through informal mediums such as blogs, social media discussions, and forum posts. The most notable example of an autistic person describing their dissociation is the works of Polly Samuels (“Donna Williams”), one of the first autistic self-advocates. When surveyed by researchers, autistic adults have described everything from depersonalization and derealization to dissociative amnesia and alternating between dissociated self-states. Many associate these experiences with childhood trauma, adult stressors, overwhelming sensory and emotional experiences, a perceived inability to meet social demands, and being shamed for having visible traits of autism (see Reuben & Parish, 2022).

      Elevated Dissociation According to Trauma History and Posttraumatic Stress. From a study of 687 autistic adults by Reuben et al. (2021).

      Image description: A table titled "Elevated Dissociation According to Trauma History and Posttraumatic Stress." It's from the dataset used in Reuben et al. (2021), which surveyed 687 autistic adults. It shows the prevalence of elevated levels of each type of dissociation measured (disengagement; depersonalization; derealization; emotional constriction; memory disturbance; identity dissociation; somatization) for the full sample and for the subsamples that endorsed interpersonal victimization, screened positive for PTSD, and reported a professional PTSD diagnosis. Each subsample has higher dissociation rates than the full sample.


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