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 (2019) 6:294–324
https://doi.org/10.1007/s40489-018-0133-9
REVIEW PAPER
A Systematic Review of the Assessment and Treatment of Posttraumatic

Stress Disorder in Individuals with Autism Spectrum Disorders
Freya Rumball 1,2
Received: 14 August 2017 / Accepted: 20 March 2018 / Published online: 18 April 2018
# The Author(s) 2018
Abstract
Individual differences are known to influence the risk of trauma exposure and development of posttraumatic stress disorder
(PTSD). It has been suggested that features of autism spectrum disorder (ASD) may confer such risk. This article provides a
systematic review of the assessment and treatment of PTSD in individuals with ASD, in addition to summarising the rates and
presentation of PTSD within this population. Twenty-four studies met eligibility criteria. PTSD in children and adolescents was
found to co-occur at a similar or greater rate compared to general population estimates, although current estimates come
predominantly from treatment-seeking samples. Preliminary findings from case reports suggest traditional assessments and
treatments for PTSD can be effective, although there is a shortage of well-controlled research.
Keywords Posttraumatic stress disorder . Autism spectrum disorder . Trauma . Assessment . Prevalence . Treatment
Autism spectrum disorders (ASD) are a group of predispose individuals to the development of clinical anxiety.
neurodevelopmental conditions characterised by impairment This risk is influenced by both mediating factors which are
in reciprocal social interaction, communication and repetitive intrinsic to ASD and moderating effects of individual differ-
and stereotyped behaviours (American Psychiatric Association ences (Wood and Gadow 2010; White et al. 2014; South and
2013). Prevalence of co-occurring anxiety disorders for chil- Rodgers 2017). These models hold ASD-related stressful
dren and adolescents with ASD has been estimated to be around events as key in the vulnerability towards clinical anxiety, with
40% (van Steensel et al. 2011), with rates in adults ranging from reviews highlighting the high rates of peer victimisation within
34% to 50% (Bakken et al. 2010; Hofvander et al. 2009). this population (Humphrey and Hebron 2015; Sreckovic et al.
Anxiety in ASD presents an increased symptom burden over 2014).
and above that associated with ASD, with the potential to ex- Whilst peer victimisation in ASD has been studied in great
acerbate core ASD features and to increase social withdrawal detail, research examining the prevalence of other traumatic or
and behavioural problems (for a review see Wood and Gadow stressful life experience is lacking. It has been proposed that
2010). Preliminary evidence suggests that anxiety in ASD pre- certain features of ASD symptomatology may predispose this
sents itself in both Btraditional^ and Batypical^ forms (Kerns population to an increased risk of trauma exposure and subse-
et al. 2014). Models of anxiety development in ASD posit that quent development of posttraumatic stress disorder (PTSD)
cognitive, genetic and neurobiological features of ASD presen- (Kerns et al. 2015; Hoover 2015; Haruvi-Lamdan et al.
tation, together with socio-environmental stressors, act to 2017). The experience of traumatic life events for children
and adolescents with ASD has been found to increase ASD-
related deficits in communication, daily living motor skills
and socialisation, measured at 6 and 12 months post-trauma
* Freya Rumball (Valenti et al. 2012). Following trauma exposure, it is clear
freya.1.rumball@kcl.ac.uk
that PTSD can and does develop in certain individuals with
1
King’s College London, Department of Psychology PO78,
ASD (Mehtar and Mukaddes 2011), with PTSD diagnosis
Institute of Psychiatry, Psychology & Neuroscience, found to be associated with suicidal thoughts and actions with-
De Crespigny Park, London SE5 8AF, UK in this population (Storch et al. 2013).
2
South London and Maudsley NHS Foundation Trust, Bethlem Royal The current DSM-5 classification of PTSD resides within a
Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK new category of Btrauma- and stressor- related disorders^,
Rev J Autism Dev Disord (2019) 6:294–324 295
highlighting the importance of the prerequisite trigger as ex- 1. How is PTSD being assessed in individuals with ASD?
posure to Bdeath, threatened death, actual or threatened serious 2. What is the presentation of PTSD in populations with
injury, or actual or threatened sexual violence^ (Criterion A; ASD?
American Psychiatric Association 2013). However, the previ- 3. What are the rates of PTSD in individuals with ASD?
ous conceptualisation of PTSD within DSM-IV was nested 4. What psychological and psychosocial treatments have
within the Banxiety disorders^ category—emphasising the been implemented, and what outcomes have been report-
close links between PTSD and anxiety symptomatology. A ed, for individuals with PTSD and ASD?
large body of literature has now explored the co-occurrence
of anxiety and other mental health difficulties in ASD (Kerns The objective of this review was to outline the current
and Kendall 2012), and modified treatments for anxiety have state of the field of research into PTSD in ASD, highlighting
been developed (Vasa et al. 2014). Despite the symptomatol- limitations and gaps in the literature and providing recom-
ogy of PTSD being characterised by altered arousal, in addi- mendations regarding future research directions. Studies of
tion to trauma re-experiencing, avoidance and negative alter- all designs across any age group were considered relevant,
ations in cognition and mood (American Psychiatric given the scarcity of literature on PTSD in ASD. Whilst it
Association 2013), this disorder has been noticeably neglected has been posited that a broader or differential range of ex-
in studies exploring mental health difficulties in individuals periences may be perceived as traumatic by individuals with
with ASD. The omission of PTSD assessment and diagnosis ASD (Kerns et al. 2015; Haruvi-Lamdan et al. 2017), this
within the bulk of ASD literature is particularly surprising in review focuses on Btraditional^ traumatic events as defined
light of the abundance of literature, outlined above, detailing within criterion A of the DSM-5 criteria for PTSD
the association between ASD and anxiety. (American Psychiatric Association 2013).
Associations between known risk factors for PTSD devel-
opment in the general population and features inherent to
ASD suggest that individuals with ASD may be at increased
risk of PTSD development. Cognitive models of PTSD in the Methods
general population (e.g. Brewin et al. 1996; Brewin 2001;
Ehlers and Clark 2000) hold that deficits in trauma processing Protocol and Reporting
and memory are key to the aetiology of the disorder. Sensory-
based (Bvisuospatial^) processing of the traumatic event re- A systematic review protocol was developed and registered
sults in the formation of poorly contextualised and disjointed with Prospero (https://www.crd.york.ac.uk/PROSPERO;
trauma memories, leading to the development of intrusive registration number: CRD42017071131) prior to data
trauma memories and subsequent PTSD symptomatology extraction. The systematic review was conducted and
(Halligan et al. 2002). Maladaptive emotion regulation strate- reported in accordance with the preferred reporting
gies, such as suppression and behavioural avoidance, then act guidelines for systematic reviews and meta-analysis
to maintain PTSD symptomatology by blocking opportunities (Moher et al. 2009).
to consolidate and adaptively process the trauma memories
(Davis and Clark 1998). Theoretical papers exploring the as-
sociation between ASD and PTSD suggest that the socio- Search Strategy
cognitive features of ASD, including deficits in theory of
mind, executive functioning, global processing, emotional in- A systematic search of databases including: Web of Science,
sight and cognitive flexibility, may impact peri-traumatic and Medline, Psychinfo, Pubmed, Embase and PILOTS (a data-
post-traumatic processing, and appraisals of traumatic memo- base of PTSD literature) was completed. Two search group-
ries and their sequelae, thus increasing risk of PTSD develop- ings were created and used across all database searches, the
ment (King 2010; Kerns et al. 2015). Although theoretical first covered terms pertaining to ASD including: autis* OR
articles have outlined the possible links between ASD, trauma Asperger* OR BPervasive developmental disorder^ OR
exposure and post-trauma outcomes (Kerns et al. 2015; PDD-NOS OR Bchildhood disintegrative disorder^, the sec-
Hoover 2015; Haruvi-Lamdan et al. 2017), to date no system- ond covered terms pertaining to PTSD including:
atic review of the literature has been conducted to collate BPosttraumatic stress disorder^ OR Bpost-traumatic stress
current knowledge regarding the assessment or treatment of disorder^ OR Bpost traumatic stress disorder^ OR PTSD
PTSD in individuals with ASD. This paper seeks to extend the OR Bacute stress disorder^ OR Bacute stress reaction^ OR
literature by providing a comprehensive and systematic re- traum*. The reference lists of all included papers and all
view of published original studies investigating PTSD in in- prior reviews of anxiety disorders, PTSD or trauma in pop-
dividuals with ASD. In this review, the following research ulations with ASD, developmental disabilities or intellectu-
questions are addressed: al disability were also reviewed.
296 Rev J Autism Dev Disord (2019) 6:294–324
Selection of Articles quantitative study designs (The EPHPP quality assessment

tool for quantitative studies, Effective Public Health Practice
A systematic search was completed for English language Project; available at www.ephpp.ca/tools.html) and another
publications, published between 1980 (the year PTSD for- for case study or case report designs (Checklist for Case
mally entered the psychiatric nosology) and May 2017, Reports, The Joanna Briggs Institute 2016; available at
which reported data pertaining to PTSD within individuals joannabriggs.org/research/critical-appraisal-tools.html).
of any age with a confirmed diagnosis of an autism spectrum Data were extracted regarding (I) study and sample char-
disorder (ASD), including Asperger’s syndrome, high func- acteristics (e.g. sample size, study design, recruitment process,
tioning autism, childhood autism, atypical autism, sample source, demographics, IQ, ASD diagnosis, comorbid-
Pervasive Developmental Disorder Not Otherwise ities, trauma types), (II) the rates of PTSD reported in samples
Specified (PDD-NOS) and childhood disintegrative disor- of individuals with ASD, PTSD assessment measures, details
der. Any studies employing a randomised control trial, qua- of PTSD presentation (i.e. symptomatology), details of inter-
si-experimental, cross-sectional, longitudinal, case series or vention(s) for PTSD and outcomes of interventions addressing
case study were considered for inclusion if they reported PTSD and (III) aspects relating to the quality of the study,
data pertaining to either: based on the tools listed above. Data were summarised using
a narrative synthesis approach, due to the heterogeneity of the
& The assessment of PTSD in one or more individuals with literature and study designs. Rates of PTSD were calculated
ASD based on studies with a sample size of ≥ 30.
& The rates of PTSD in ASD
& The treatment of PTSD in one or more individuals with
ASD. Results
Grey literature (e.g. thesis, conference abstracts, confer- Study Selection

ence proceedings, book chapters), letters to the editor and
theoretical/opinion papers which did not report any relevant The titles and abstracts of all returns from the search strate-
case studies were excluded. Studies were excluded if they did gy were reviewed, 1198 were excluded as not meeting the
not explicitly specify either (I) the assessment of PTSD, (II) criteria. Reasons for exclusion included the returns being
the rate of PTSD within a sample of ≥ 30 individuals with grey literature (book chapters, book reviews, conference
ASD or (III) treatment aimed at addressing PTSD, in individ- proceedings, commentaries, editorials and thesis) or letters
uals or groups. In addition, for publications outlining either to the editor, papers not including new data (reviews and
(II) the rates or (III) treatment of PTSD in ASD, papers were theoretical papers), studies being in populations other than
excluded if participants did not have a diagnosis of PTSD humans with clinically diagnosed ASD (animal models,
confirmed by a psychiatrist, psychologist or other trained cli- ADHD, psychosis, depression, traumatic brain injury, epi-
nician, or clinically significant scores on a standardised diag- lepsy, Parkinson’s, mental health of parents of children with
nostic measure of PTSD symptomatology. ASD, neurotypicals with no mental health difficulties), pa-
An initial screening of all titles and abstracts was complet- pers not written in English language and studies not
ed, with full text screening carried out for any hits which did reporting the assessment or treatment of PTSD in ASD or
not obviously fit within the exclusion criteria. Any ambiguous psychodynamic papers reporting trauma as a primary cause
papers were discussed with a second reviewer to reach con- of ASD development. In total, 130 full text articles were
sensus. In addition, a second reviewer reviewed all the articles retrieved and assessed for eligibility, with 24 meeting the
that were judged to meet the review eligibility criteria and criteria for inclusion in this systematic review. Reasons for
10% of all abstracts, chosen at random. Inter-rater agreement exclusion at the full-text screening stage included the
was very good (Kappa = .092; SE = .045; CI = .083–1) and returns being grey literature (conference proceedings; the-
any discrepancies were discussed between the coders until a sis), studies being in populations other than humans with
consensus was reached. clinically diagnosed ASD (investigating mixed develop-
mental disorders, ASD-traits or mental health of the parents
Data Extraction and Quality Assessment of children with ASD), papers not written in English lan-
guage, and studies not reporting assessment or treatment of
Details regarding the study characteristics, design, outcomes PTSD in ASD (psychodynamic papers reporting trauma as
and quality were extracted. Personalised data extraction forms cause of ASD development, no clinical diagnosis or
were used to collate data pertaining to characteristics, design standardised measure of PTSD reported or data on anxiety
and outcomes. Data relating to the quality of the studies was disorders not sub-divided by PTSD). The full study selec-
extracted using an adapted quality assessment tool for tion process is depicted in Fig. 1.
Fig. 1 PRISMA flow diagram of Titles and abstracts

study selection process id ed through
databases
n = 2062
Records screened for eligibility Excluded

duplicates removed n = 1275 n = 1198
Full copies retrieved and assessed

for eligibility
n = 77
Full copies retrieved and

assessed for eligibility,
id ed from other
sources:
Searching in reference list

n = 18
Searching relevant Excluded

reviews n = 35 n = 106
Publi ons mee ng

inclusion criteria
Case studies n = 10
Quan ve studies n = 14
Assessment of PTSD in People with ASD report (Weiss and Lunsky 2010) detailed clients who had
been referred to clinical services for specialist assessment
All of the 24 papers which met the eligibility criteria reported and/or treatment. For a full summary of demographic char-
information regarding the assessment of PTSD in individuals acteristics, see Table 1.
with ASD. The following section provides an expanded over- The most common traumatic event was experiencing
view of the results regarding assessment of PTSD in individ- abuse or assault, which occurred in 8 cases (Table 1).
uals with ASD, to supplement the information presented in PTSD was most often assessed via information gathered
Tables 1, 2 ,3, and 4. from multiple informants and sources including self-report
and/or parent report, standardised questionnaire measures
Case Studies or semi-structured interview, clinical observation, informa-
tion from staff and reports regarding historical diagnosis
Ten papers reported case studies and case series outlining (Table 2). PTSD symptom presentation was detailed in all
the assessment of PTSD in individuals with ASD, across a studies where PTSD was formally diagnosed (Table 2). Five
total sample of seven females and 15 males. The age range of the studies explicitly specified that diagnosis of PTSD
of the patients was between 6 and 45 years of age, with four according to DSM or ICD criteria was possible (Ryan
papers reporting data in children (Cook et al. 1993; Trelles 1994; Cook et al. 1993; Weiss and Lunsky 2010; Carrigan
Thorne et al. 2015; Harley et al. 2014; Mevissen et al. 2011) and Allez 2017; Mevissen et al. 2011). Clients were able to
and six in adults (Ryan 1994; Carvill and Marston 2002; report events, symptoms and emotional states and expressed
Weiss and Lunsky 2010; Kosatka and Ona 2014; Carrigan a comparable symptom profile to that seen in the typical
and Allez 2017; Barol and Seubert 2010). All but one case developing population. However, for two cases presented
Table 1
298
Sample characteristics of the studies included in the review
First author Study type Reason for referral ASD participants Comparison Mean age in Female % ASD method of Level of Trauma types
(year) (Case reports) or group years (range) or gender diagnosis functioning
sampling technique
(Group studies)
Barol and Case Series Recruited via purposive N = 4 (Autism) None 25 (20) 50% (2/4) ASD diagnosis prior to 2/4 mild ID; 1/4 Bullying at school
Seubert sampling of individuals study moderate ID; and home
(2010)1 with PTSD symptoms 1/4 severe ID (n = 1); death of
from a residential mother aged 12
facility and snowball (n = 1); serious
sampling via referrals illness (n = 1);
from clinical homicide of
advertisement brother and
suicide of
father(n = 1)
Carrigan and Case report Referral by his GP to the N = 1 (ASD, None 26 Male Childhood diagnosis of Mild learning Sexual assault
Allez (2017) Community Learning PTSD) ASD disability; IQ
1,3
Disabilities Team. not specified
Carvill and Case series Referrals to South N = 8 (atypical None 30.5 12.5% (1/8) Clinical assessment using 2/8 Moderate ID; Past recurrent
Marston Birmingham ASD, sensory ICD-10 criteria, using 6/8 Severe ID; abuse (n = 1);
(2002)1 Psychiatry of ID impairments) information systemati- IQ not specified Several moves
service between 1996 cally gathered from (n = 1)
and 1999 staff, families and
medical records.
Behaviour monitored
for 4–6 weeks.
Cook et al. Case report Referred psychiatric N = 1 (autistic None 12 Male Psychiatrists evaluation Severe delays in Physical abuse
(1993)1,3 clinic because of disorder, PTSD) using DSM-III-R language and
persistent, severe criteria, Autistic marked
delays in language, Diagnostic Interview b limitations in
poor social (ADI; Le Couteur et al. ability to
relatedness, and 1989) algorithm, and communicate—
stereotypes behaviours Childhood Autism although verbal;
c
(e.g. spinning and Rating Scale (CARS; IQ not specified
hand flapping) Schopler et al. 2002)
de Bruin et al. Cross sectional All consecutive referrals PDD-NOS None 8.5 (6–12) 11.7% Multidisciplinary team IQ, M = 91.22 Not reported
(2007)1,2 to an outpatient (N = 94) obtained consensus for (range =
treatment clinic final DSM-IV 55– 120)
between July 2002 and classification, using
September 2004, semi-structured inter-
screened for views with parents,
PDD-NOS and asked psychiatric observation
to participate via opt-in. of child and review of
school and medical re-
cords. ADOS-G c
completed in 93.6% of
the sample, but 42.1%
did not meet criteria on
this. Rated according
to the PDD-NOS re-
search criteria
(Buitelaar et al. 1999).
Harley et al. Case report Referred to a clinical None 6 Male Diagnosed at age of Not specified Exposure to
(2014)1,3 service because of 2 years old and domestic
Rev J Autism Dev Disord (2019) 6:294–324
Table 1 (continued)
sampling technique
(Group studies)
trauma history and N = 1 (Autism, confirmed via a violence and

difficulties with DBD-NOS, psychological experiencing
cognitive, behavioural PTSD) assessment during physical and
and social functioning treatment. emotional
abuse.
Hofvander et al. Cross sectional Consecutively referred Autism (N = 5) AS None Median = 29 33% Clinical diagnosis of ASD Specified as having Not reported
(2009)1,2 adults with normal (N = 67) PDD (16–60) (DSM-IV), confirmed Bnormal
intellectual NOS (N = 50) by clinicians in the intelligence^
functioning, with study. 87% of the

possible sample completed the
childhood-onset neuro- Asperger Syndrome
psychiatric disabilities Diagnostic Interview b
a hospital in Paris and a (ASDI; Gillberg et al.
hospital in 2001). Diagnosis
Gothenburg, who sub- assigned according to
sequently met criteria DSM-IV and the
for ASD. Gillberg & Gillberg
(1989) criteria
Hollocks et al. Cross sectional ASD: Recruited from ASD (n = 55) Typically (10–16) 0% Diagnosis by local IQ and reading Not reported
(2016)1,2 NHS treatment clinics developing clinicians. Confirmed level ≥ 70
Controls: recruited controls (n = 28) for 30/55 cases using
from local schools and ADOS-G c and/or
public advertisement, ADI-R b, remaining
no history of participants confirmed
psychiatric or using score of > 15 on
neurological problems the Social
Communication
Questionnaire a (SCQ;
Rutter et al. 2003).
Kosatka and Ona Case report Referred to a clinical N = 1 (AS, PTSD) None 21 Female Diagnosed by Average IQ, Abuse by peers in
(2014)1,3 service for psychiatric psychological testing spelling 1SD school.
evaluation because of at 18 years of age below average
impairing symptoms.
Mattila et al. Cross-sectional Recruited from both a AS/HFA (n = 50) No TD group; 12 (9–16) 24% Clinical diagnosis prior to IQ > 75 Not reported
(2010) 1 community based compared clinic the study. Confirmed
sample (n = 18) and a and community by Finnish versions of
clinic sample (n = 32) based samples the Autism Spectrum
with ASD Screening
Questionnaire a
(ASSQ; Ehlers et al.
1999), the Autism
Diagnostic
Interview-Revised b
(ADI-R; Lord et al.
1994), and the Autism
Diagnostic
Observation Schedule
(ADOS-G; Lord et al.
2000).
McConachie RCT Recruited via clinician ASD (n = 32) No TD group; 11 (9–13) 12.5% Clinical diagnosis prior to IQ, M = 100 Not reported
et al. approach to parents compared the study. Confirmed
299
300
Table 1 (continued)
sampling technique
(Group studies)
(2014)1,2 using CAMHS immediate using score of > 15 on

services, via opt-in. treatment and the Social
Excluded children with delayed Communication
untreated ADHD or treatment groups Questionnaire a (94%)
oppositional with ASD (SCQ; Rutter et al.
behaviour. 2003) and/or over
Treatment-seeking threshold on the
sample. Recruited to ADOS d (84%).
have at least one anxi-
ety disorder.
Mehtar and Cross-sectional All regular attendants of Autism (n = 59) AS No TD comparison 11.7 (6–18) 23% Diagnosis according to Borderline – Witnessing or
Mukaddes the Autism Clinic at (n = 5) group; data DSM-IV criteria. normal range being victim of
(2011)1,2 Istanbul School of PDD-NOS compared Re-confirmed by study (n = 19; 27.5%); an accident or
Medicine. Recruited (n = 5) between team. Mild LD (n = 5; disaster (n = 9);
during follow up individuals with 7.2%); Witnessing or
appointment, via and without Moderate LD being victim of
opt-in. Followed up trauma histories (n = 27; 39.1%); violence,
over a period of Severe LD physical or
1–12 years. (n = 18; 26.1%) sexual abuse
(n = 9); multiple
traumas (n = 3)
Mevissen et al. Case series Referred for specialist N = 1 (Autism, None 7 Female Diagnosed with Borderline Witnessed sudden
(2011) 1,3 assessment and OCD, PTSD) childhood disorder (IQ = 71) death of family
treatment. NOS age 6; diagnosed member, learned
with multiple complex about father’s
developmental best friend being
disorder age 7 due to found with stab
disturbing thoughts; wounds and
post-therapy diagnosis seeing pictures
changed to autistic of classmate in
disorder, as traumas hospital with life
had been identified threatening
which explained illness.
disturbing thoughts.
Reinvall et al. Cross sectional Unclear whether AS and no major No neurological ASD: 11.6 ASD: 20% TD: Clinical diagnosis ASD: No learning Not reported
(2016)1,2 self-referral permitted. genetic or disorders, (6.5–16.7) 22% (ICD-10) prior to disability
ASD: recruited from a neurological learning TD: 11.1 study; confirmed via (M = 105.5)
b
hospital in Helsinki disorders difficulties, (6.9–16.2) ADI-R in the study Comparison: IQ
and a private medical (N = 60) psychiatric not tested but
centre, via opt-in. TD: disorders or attending
recruited from main- ASD based on mainstream
stream school in same parent report school.
borough as hospital, (N = 60)
via opt-in.
Ryan (1994)1,3 Case Example Referral to developmental N = 1 (autism, None 21 Female Diagnosis was present Profound Physical and sexual
disorders service for PTSD) since childhood and intellectual abuse
consultation and author states it was disability and no
evaluation of abrupt Bcorrectly diagnosed^ spoken
shrieking, drawing up language; IQ not
of legs and scratching specified
legs and abdomen.
Table 1 (continued)
sampling technique
(Group studies)
Storch et al. Cross-sectional Treatment-seeking Autism (n = 28) AS No TD comparison 10.55 (7–16) 23% Clinical diagnosis prior to IQ ≥ 70 Not reported
(2013)1,2 sample. Recruited to (n = 39) group; data study. Confirmed by
have an anxiety PDD-NOS compared ADOS c and ADI-R b,
disorder. Recruitment (n = 35) between and a psychologist ac-
strategy not specified. individuals with cording to
and without DSM-IV-TR criteria d.
suicidal
thoughts/ behav-
iours
Taylor and Cross-sectional Recruited through local ASD (n = 36) None 18.7 (17–22) 16.7% Clinical diagnosis prior to Mean not specified Full range of
Gotham treatment clinics, other study. Confirmed via (IQ, traumatic life
(2016)1,2 autism studies, local ADOS-G c and ADI-R range = events endorsed,
b
support groups, service in the study 40–137). 27.8% including
providers and autism IQ ≤ 70 11.1% witnessing
organisations. IQ 71–85 27.1% abuse. 56%
IQ 86–100 experienced
33.3% IQ > 100 death of
someone close
to them, 50% a
life-threatening
injury or illness
of someone in
the home, 31%
parental divorce.
Trelles Thorne Case report Referred to a clinical N = 1 (ASD, None 9 Male Diagnosed with Borderline Physical and
et al. (2015) service due to ADHD, PTSD) PDD-NOS at intellectual emotional abuse
1,3
worsening aggressive 18 months and con- functioning; and exposure to
and self-injurious be- firmed by author using IQ = 79 domestic
haviour and multiple Autism Mental Status violence
c
behavioural problems Examination
(Grodberg et al. 2012)
Ung et al. Cross sectional Recruited via clinical Autism (N = 23) None 11 (7–16) 16% ASD diagnosis prior to Full scale IQ ≥ 70 Not reported
(2014)1 referrals, flyers, AS (n = 32) study; confirmed via
c
brochures and PDD-NOS ADOS-G and ADI-R
b
organisations. (n = 15) in the study
Treatment-seeking
sample. Recruited to
ety disorder.
Weiss and Case series Clinic referral or N = 3 (AS) [N = 1 None Mid 40’s [PTSD 66.6% (1/3) Diagnosis confirmed by a IQ > 85 Several sexual
Lunsky self-referral for clinical with PTSD] case: Mid [PTSD case: physician or assaults (n = 1)
(2010)1 trial of a manualised 30’s] Female] psychologist and using
CBT treatment for the Adult Asperger
mood and anxiety dis- Assessment a
orders in ASD (Baron-Cohen et a.
2005)
White et al. Cross-sectional Recruited via specialist AS (N = 16) None 14.58 (12–17) 23% ASD diagnosis prior to No diagnosis of Not reported
(2012)1,2 ASD clinic and flyers Autism (N = 10) study; ADOS-G c intellectual
sent out local services, PDD-NOS (Lord et al. 2000) and disability; verbal
school and media (N = 4) ADI-R b IQ > 70 (Verbal
advertising. (Lord et al. 1994) IQ, M = 97)
301
302
Table 1 (continued)
sampling technique
(Group studies)
Treatment-seeking completed during

sample. Recruited to study, but not specified
have at least one anxi- if all subjects crossed
ety disorder. thresholds for ASD
White et al. RCT Recruited through Autism (n = 10) No TD comparison 15 (12–17) 23% Clinical diagnosis prior to IQ, M = 97.07 Not reported
(2013)1,2 university-affiliated PDD-NOS group; data the study. Confirmed
autism centres, refer- (n = 4) AS compared across by ADOS-G c in the
rals from local (n = 16) the intention to study.
clinicians, clinics, treat and waitlist
schools and media ad- groups.
vertisements.
Treatment-seeking
ety disorder.
Wood et al. RCT Recruited from an autism Autism (n = 20) No TD comparison 9 (7–11) 33% Diagnosis based on IQ ≥ 70 Not reported
(2009)1,2 clinic in a medical PDD-NOS group; data ADI-R b scores,
c
centre, regional (n = 17) AS compared across ADOS-G scores, a
centres, parent support (n = 3) the intention to parent-report checklist
groups and schools. treat and waitlist pertaining to children’s
Treatment-seeking groups. circumscribed interest
b
sample. Recruited to and a review of med-
have at least one anxi- ical records. An algo-
ety disorder. rithm was used to de-
termine between ASD
subtypes (Klin et al.
2005)
Wood et al. RCT Recruited through two Autism (n = 22) No TD comparison 12.3 (11–15) 33% Clinical diagnosis prior to IQ ≥ 85 Not reported
(2015)1,2 university-affiliated PDD-NOS group; data study participation.
autism centres in (n = 3) AS compared across Confirmed by
America via opt-in and (n = 8) the intention to ADOS-G c and ADI-R
b
self-referrals. treat and waitlist in the study.
Treatment-seeking groups.
ety disorder.
Note: Case reports/series indicated as italicised font. Study meets criteria for inclusion based on: 1 assessment; 2 rates of PTSD; 3 treatment. Measures: a self-report; b parent/carer report; c clinician rating scale
AS Asperger’s disorder, ASD autism spectrum disorder, HFA high functioning autism, DBD disruptive behaviour disorder, OCD obsessive-compulsive disorder, LD learning disability
Table 2 Outcomes of the studies included in the review
Assessment, prevalence and presentation of PTSD Treatment of PTSD
First author PTSD method of Proportion of Outcome of assessment: PTSD treatment Treatment Treatment outcome Outcome of treatment
(year) diagnosis (interview or PTSD cases in symptom presentation method outcome measure assessed at
questionnaire) ASD sample (%) and/or comparisons (n sessions)
across groups
Barol and Seubert Assessment battery made N/A Not specified N/A N/A N/A N/A
(2010)1 up of: List of the 19
DSM IV PTSD
symptoms; 59 items
from the Psychiatric
Questionnaire, an
adaptive checklist of
psychiatric symptoms;
and a generic list of 32
possible indicators of
PTSD in this
population. Combined
with self-reporting,
caregiver observations
and ongoing in-session
response scores using
SUD and VOC scales.
Carrigan and Allez Clinician lead assessment N/A Patient was able to 12 weeks of CBT for PTSD symptom 6 and 8 months Post-therapy CRIES-8
(2017)1,3 of symptomatology describe what he PTSD using Ehlers reduction self-report score re-
(according to ICD-10 experienced mentally et al. (2005) approach, according to duced to 11. Patient
criteria) via patient and emotionally such with time spent CRIES-8 self-- and parent reported
self-report; Revised that it was clear he was adapting language and report, com- symptom reduction. At
Child Impact of Events suffering from PTSD explaining metaphors bined with pa- 6-month follow-up
Scale a (CRIES-8; according to ICD-10 to help with tient self-report gains were reported as
Perrin et al. 2005) criteria; CRIES-8 engagement. One hour and parent re- maintained, but
score of 32 (well above sessions. Few of the port of CRIES-8 not adminis-
recommended cut off of procedures of the symptoms. tered. Patient no lon-
17) supporting PTSD cognitive therapy for ger experienced
diagnosis. Symptoms PTSD, apart from flashbacks, had im-
over the last 3 years language and greater proved sleep, no longer
included: arguments explanation of argued with parents or
with parents, angry metaphors, had to be had outbursts, was
outbursts in the com- adapted for the more affectionate with
munity (where he de- patients ID or ASD, his siblings and
scribed feeling and cognitive nephew, no longer had
threatened), belief that restructuring was nightmares, felt more
people are out to get possible, showing the in control of his mem-
him and not to be patient was able to ories of the attack, no
trusted, blaming him- engage in the longer avoided places
self for the trauma, re- metacognitive he had before.
duced time spent out- processes required for
side the house, cognitive therapy.
avoiding walking to the
shops alone, difficulty
falling and staying
asleep, remaining alert
for threat, avoiding the
location where the at-
tack happened,
303
Table 2 (continued)
304
across groups
difficulties concentrat-
ing on TV programmes
or books, suppressing
trauma memories, ru-
minating about what
he could have done to
prevent the trauma,
flashbacks of the
trauma, concern that
trauma symptoms were
a sign of madness.
Carvill and Clinical assessment of N/A It was not possible to N/A N/A N/A N/A
Marston (2002)1 symptoms suggestive of assign accurate and
ICD-10 criteria via reliable ICD-10 diag-
information from staff, nosis for 2 patients due
families and previous to their unusual be-
psychiatric concerns. havioural presenta-
Behaviour monitored tion. In two of these
for 4–6 weeks. cases where accurate
diagnosis could not be
made, a Bprobable dif-
ferential diagnosis^ of
BPTSD or depressive
illness^ and BAnxiety
disorder or PTSD^
was made.
Cook et al. Psychiatrists evaluation N/A Patient initially reported Individual psychotherapy, Psychiatrists Follow-up over 4 years Reduced anxiety
(1993)1,3 using direct interview the abuse to his with additional assessment post-trauma. symptoms including no
techniques with the parents, who noticed a support for parents. emotional distress on
patient, diagnosis number of changes in Therapist and parents talking about the
made according to his behaviour around enabled patient to school (trauma setting)
DSM-III-R criteria this time. During ventilate his feelings and reduced frequency
psychiatrists interview, and reassured him of reexperiencing
the patient was able to regarding current and symptoms. Increased
report the events of future safety (n anxiety continued to
abuse and his related sessions not reported) occur towards
emotional state. PTSD environmental trauma
was diagnosed reminders
according to (anniversaries and
DSM-III-R criteria. visiting similar
buildings). 4 years
later the client
continued to show
increased anxiety to
trauma reminders but
frequency of
reexperiencing
symptoms reduced.
Table 2 (continued)
across groups
de Bruin et al. Dutch version of the 0/94 (0%) 19.1% had no N/A N/A N/A N/A
(2007)1,2 DISC-IV b (Ferdinand co-morbidities, 13.8%
& van der Ende 1998; met criteria for mood
Shaffer et al. 1993) disorders, 55.3% met
criteria for an anxiety
disorder, 19.1% had

internalising disorders,
21.3% disruptive
behaviour disorders,
40.5% internalising
and disruptive
behaviour disorders.
No PTSD cases.
Harley et al. Trauma Symptom N/A Clinically significant Child-parent Trauma Symptom Post-treatment Substantial improvement
(2014)1,3 Checklist for young symptoms of psychotherapy (CPP). Checklist for in PTSD symptoms on
children b (TSCYC; avoidance, arousal, 60-min weekly young children TSCYC scores, with
Briere 2005); Life anger and aggression sessions, held with (TSCYC) b; only the avoidance
events measured by - on TSCTC. Total score father and aunt, Family Impact scale remaining
Traumatic Events on TSCTC for PTSD together with child. 8 of Childhood clinically significant
Screening Inventory b was clinically session assessment and Disability Scale and overall profile no
(TESI-PRR; significant but in engagement phase. 27 (FCID) b; longer suggestive of
Ghosh-Ippen et al. normal range for session intervention Parenting Stress PTSD. Father
2002) and Life Stressor intrusions sub-scale. phase working with all Index-Short endorsed more positive
Checklist Revised family and using play Form (PSI-SF - consequences of
b
(Wolfee et al. 1993). with the child. measure of pa- having a child with a
Occupational therapist rental distress) disability on the FCID,
b
brought in as ; qualitative although continued to
co-therapist half way exit interview report some negative
through to aid engage- with father and consequences. Father
ment. Building safe re- aunt. also continued to
lationships and bonds. experience high levels
8 session Termination of stress in parent-child
phase. dysfunctional interac-
tion and difficult child
sub-scales. No longer
met criteria for
Disruptive Behaviour
Disorder NOS. Eye
contact and social
overtures had
increased
Hofvander et al. Structured Clinical 2/122 (1.6%) Lifetime DSM-IV ratings: N/A N/A N/A N/A
(2009)1,2 Interview for DSM-IV 43% met criteria for
- Axis I disorders a ADHD, 14% met
(SCID; First et al. criteria for dyslexia,
1997) n = 63; all other 12% met criteria for a
participants had psychotic disorder,
DSM-IV-based 53% for lifetime mood
305
Table 2 (continued)
306
across groups
structured clinical in- disorder, 8% for bipo-

terviews including a lar disorder,16% met
lifetime DSM-IV criteria for substance
symptoms checklist misuse, 62% for a per-
with individual criteria sonality disorder, 1.6%
or symptom definitions for PTSD.
for all Axis I disorders.
Axis II disorders
assessed in 96% of the
sample, using either
the SCID-II (n = 95) or
a clinical interview.
Hollocks et al. The Child and Adolescent 0/55 0% 21 of the ASD group did N/A N/A N/A N/A
(2016)1,2 Psychiatric not meet criteria for
Assessment b (CAPA; any anxiety disorder.
Angold and Costello 76% of those that did
2000) meet anxiety criteria
had more than one
co-occurring anxiety
disorder. No partici-
pants met criteria for
PTSD.
Kosatka and Ona Psychiatrists assessment N/A Avoidance of strangers, Zoloft 100 mg PO daily PTSD checklist a Post-treatment and Post-intervention PCL
(2014)1,3 and diagnosis. difficulties sleeping and EMDR treatment (PCL; DSM-IV; 8 months follow-up score reduced from 60
Diagnosis changed and anhedonia. administered according Weathers et al. to 23. Two of worst
from anxiety disorder to standard procedures 1994) traumas reduced from
NOS to PTSD. with eye movement for 10/10 SUDS to 0/10
BLS. Events targeted SUDS. At follow-up,
from least to most PCL score was 21.
traumatic to avoid Happy in mood and no
overwhelming patient. hand wringing or hair
Mother present during twirling seen. Still tak-
all sessions as ing Zoloft 100 mg PO
requested by client. 3 daily and Trazodone
sessions a week on 50 mg PO qhs for
Monday, Wednesday, sleep. Improvements in
Friday (n = 9 sessions). social life.
Some difficulty putting
emotions into words
during assessment
phase of EMDR Client
able to tolerate EMDR
using eye movements,
only side effect was
vivid dreams.
Mattila et al. K-SADS-PL a b Not reported Not reported N/A N/A N/A N/A
(2010) 1 (Kaufman et al.1997)
assessing current and
lifetime episodes
Table 2 (continued)
across groups
according to DSM-IV
criteria. Not including
the exclusionary rules
in DSM-IV regarding
Autism.
McConachie et al. ADIS-IV-C/P (Silverman 1/32 (3.1%) The most common N/A N/A N/A N/A
(2014)1,2 & Albano, 1996). anxiety disorders
Child version is included generalised
specified, however the anxiety disorder
paper also states Bthe (GAD) (n = 26; 81%),
trained interviewer specific phobia
elicited parent’s obser- (n = 27; 84%) and so-
vations of the child’s cial anxiety disorder
behaviours and severi- (n = 22; 69%).
ty of impact on family
life and recorded a
clinical severity
rating^. a or b - unclear
Mehtar and K-SADS-PL, PTSD scale 12/69 (17.4%) Mean duration of PTSD N/A N/A N/A N/A
ab
Mukaddes (Kaufman et al. 12/18 with trau- symptoms was 18.75
(2011)1,2 1997). Current and ma history (range = 1.5–50
lifetime episodes using (66.7%) months). The trauma
DSM-IV criteria; com- history group had
pleted with child only showed significantly
where possible. more disruptive
behaviour on the
Turkish version of the
ABC, than those
without trauma
exposure. Those with
trauma also showed
deterioration in ASD
symptoms, aggression
and agitation, sleep and
appetite disturbance,
self-harm and in-
creased activity levels.
Mevissen et al. Interview with parents N/A Met criteria for PTSD EMDR treatment using Interview with Post-intervention and Disturbing thoughts
(2011)1,3 and caregivers according to DSM-IV the story telling method parents and 7 weeks and 3 months disappeared, sustained
according to DSM-IV and DM-ID. For (due to poor caregivers follow-up. improvements at
and DM-ID DSM--IV: Parents un- communication and according to 7 weeks follow-up.
able to report criterion reluctance to follow DSM-IV and More positive mood
A2 as concealed emo- instructions) and DM-ID and decrease in anger;
tional impact of event buzzers in hands for more relaxed
from caregivers. BLS. (4 sessions = 1 generally. Depressive
Criterion B for preparation and 3 symptoms decreased.
(re-experiencing) able treatment sessions). No longer met criteria
307
Table 2 (continued)
308
across groups
to report (disturbing Treatment had to be for PTSD according to

thoughts). Criterion C adapted for cognitive DSM-IV or DM-ID. At
relies too strongly on and emotional level. 3 months results were
verbal, subjective maintained.
reporting for clients
with ID. Criterion D
only reported anger
outbursts, but unclear
if other symptoms not
noted by caregivers.
Symptoms included:
Fears, Compulsive
behaviours, outbursts
of anger, frequent
mood changes,
disturbing thoughts
about illness/knives/-
death.
Reinvall et al. Development and ASD: 1/60 (1.7%) No significant differences N/A N/A N/A N/A
(2016)1,2 Well-Being TD: 0/60 (0%) between rates of PTSD
Assessment b in ASD and TD
(DAWBA; Goodman samples, or between
et al. 2000). Diagnosis the current ASD
according to DSM-IV sample and the
and ICD-10 made by prevalence rates for TD
an experienced child children and
psychiatrist based on adolescence (0.1%)
the DAWBA from a larger scale
(N = 10,438) study
using the DAWBA
(Ford et al. 2003)
Ryan (1994)1,3 Functional analysis to N/A Symptoms included Psychopharmacological: None specified Not specified Not specified.
rule out any gains, dissociative Carbamezepine to
observation, review of events/flashbacks of address dissociation,
videotapes of being scalded and sex- tapering and
behaviours in several ual abused, triggered discontinuation of beta
settings and interview by hearing water run- blockers and
with mother of patient ning. Ongoing sleep neuroleptics.
disturbance (waking Behavioural therapy:
screaming), erratic Systematic
appetite, hypersensitiv- desensitisation to
ity to touch, absence of water Staff: Retraining
any sexual behaviour. staff to reduce the
Crouching in the cor- number of
ner of the clinic room dissociations and to
with a terrified facial assist patient in
expression, moaning, reorienting when
hypervigilant, frequent dissociating and
self-scratching, supporting patient to
Table 2 (continued)
across groups
defensive covering of find ways to help

chest, lower legs and herself when becoming
genital area, shrieking, frightened.
drawing up her legs
and a lack of recogni-
tion of familiar staff.

PTSD was diagnosed
according to
DSM-III-R criteria.
Storch et al. Anxiety Disorder 6/102 (5.9%) Comorbid diagnosis of N/A N/A N/A N/A
(2013)1,2 Interview Schedule – major depressive
Child and Parent disorder/dysthymia
versions ab and PTSD significantly
(ADIS-IV-C/P; predicted suicidal
Silverman and Albano thoughts and behav-
1996). Interviews iours. Demographic
conducted separately variables and ASD di-
with child and agnosis did not predict
caregiver. suicidal thoughts or
behaviours, but chil-
dren with Autism were
more likely to have
suicidal thoughts and
behaviours than those
with Asperger’s disor-
der.
Taylor and Gotham Schedule of Affective 0/36 (0%) 25% met clinical criteria N/A N/A N/A N/A
(2016)1,2 Disorders and for a mood disorder
Schizophrenia for and 25% for an anxiety
School Aged Children disorder. Mood and
b
(K-SADS-PL; anxiety disorders were
Kaufman et al. 1997). not associated with the
Current and lifetime number of traumatic
episodes using events experienced.
DSM-IV criteria. 90% of youth with a
Parent report of disor- mood disorder had
der diagnosed by an- experienced a trauma;
other medical provider. this association was
significant even when
accounting for IQ and
sex.
Trelles Thorne Psychiatrists diagnosis N/A Symptoms included Guanfacine (0.5 mg Psychiatrists Not specified for School assistance
et al. (20151,3 via interview with nightmares, waking orally twice day, assessment and psychological reduced the frequency
client and with his multiple times in the titrated to 1 mg over monitoring. interventions; of tantrums and
mother night, wetting the bed, month, increased to Pharmacological aggression. Outcomes
309
Table 2 (continued)
310
across groups
fear of a strange man 1.5 mg after sadness, interventions for psychological and
coming into his room sleep problems and monitored over psychoeducational
and harming the anxiety increased) to 6 months whilst treatments not
family, becoming treat anxiety, medication changed specified. Authors
emotionally hyperarousal, and reviewed. summarises that
dysregulated when aggression, irritability Bchildren with complex
abuse mentioned. and poor sleep. clinical pictures and
Sadness and Sertraline (10 mg comorbidity often do
withdrawal from orally daily) to treat best in multi-modal
family over last year. PTSD symptoms, but treatment^.
Aggressive and stopped due to side Guanfacine showed
self-injurious effects. Aripiprazole good response in short
behaviour, behavioural (1 mg daily, increased period. Developed
problems at home and to 2 mg after 3 weeks manic symptoms on
school, frequent and and to 3 mg during Sertraline, which re-
severe temper period of worsening mitted within a week of
tantrums, including irritability and poor stopping. Aripiprazole
throwing things and sleep) to treat resulted in worsening
biting and kicking aggression and mood symptoms at
others, requiring A&E irritability, self-injury, dosage above 2 mg,
visit. Easily frustrated hyperactivity and but this stabilised over
and oppositional, de- stereotypic behaviours. time on low dose.
clining academic per- Psychotherapeutic
formance and hyper- interventions in
activity and combination with
impulsivity. parental support and
therapy, increased
frequency of services in
school setting
(paraprofessional
assigned).
Ung et al. (2014)1 ADIS-C/P ab (Silverman Not specified Not specified N/A N/A N/A N/A
and Albano 1996) ad-
ministered separately
to children and parents.
Diagnosis determined
by clinician after con-
sidering child and par-
ent responses on
ADIS-C/P.
Weiss and Lunsky Structured Clinical N/A Meet criteria for Past N/A N/A N/A N/A
(2010)1 Interview of Major Depressive
DSM-VI-TR Axis 1 Episode which
disorders a (SCID-I/P; occurred earlier that
First et al. 1997) year, post-ASD
diagnosis. Met criteria
for substance
dependence
Table 2 (continued)
across groups
(Marijuana use almost

daily, but agreed not to
use before groups).
PTSD was diagnosed
according to
DSM-VI-TR criteria.
Reported feeling
trapped and angry and
tried to put it out of her
mind. She experienced
intrusive memories and
flashbacks. She de-
scribed often feeling
angry, as she had dur-
ing the traumas and
having intense distress
to trauma reminders.
White et al. Anxiety Disorders 1/30 (3.3) Not specified N/A N/A N/A N/A
(2012)1,2 Interview Schedule for
Children/Parents ab
(ADIS-C/P; Silverman
and Albano 1996)
jointly administered to
children and parents.
Severity rating
assigned by interview-
er based on symptom
scores, severity scores
and clinical
observation, careful
not to double-code
ASD features as anxi-
ety symptoms.
White et al. ADIS-IV-C/P a b 1/30 (3.3%) Primary diagnosis N/A N/A N/A N/A
(2013)1,2 (Silverman & Albano included social anxiety
1996), conducted disorder (n = 23),
jointly with child and separation anxiety
caregiver. (n = 1), specific phobia
(n = 16) obsessive
compulsive disorder
(n = 4) and generalised
anxiety disorder
(n = 19), panic disorder
with agoraphobia
(n = 1). Only one
participant met criteria
for PTSD
311
Table 2 (continued)
312
across groups
Wood et al. ADIS-IV-C/P –Parent 1/40 (2.5%) Primary diagnosis N/A N/A N/A N/A
(2009)1,2 versions b (Silverman included social anxiety
& Albano 1996). disorder (n = 35),
separation anxiety
(n = 24), obsessive
compulsive disorder
(n = 17) and
generalised anxiety
disorder (n = 19). Only
one participant met
criteria for PTSD
Wood et al. ADIS-IV-C/P a b 1/33 (3%) Primary diagnosis N/A N/A N/A N/A
(2015)1,2 (Silverman & Albano included social anxiety
1996), conducted sep- disorder (n = 14),
arately with child and separation anxiety
caregiver. (n = 7), obsessive
compulsive disorder
(n = 3) and generalised
anxiety disorder
(n = 9). Only one
participant met criteria
for PTSD
Note: Case reports/series indicated as italicised font. Study meets criteria for inclusion based on: 1 assessment; 2 rates of PTSD; 3 treatment. Measures: a self-report; b parent/carer report; c clinician rating scale
AS Asperger’s disorder, ASD autism spectrum disorder, HFA high functioning autism, DBD disruptive behaviour disorder, OCD obsessive-compulsive disorder, LD learning disability
Table 3 Quality assessment of methodology for included studies using a case report or case series design: Checklist for Case Reports (Johanna Briggs Institute 2016; http://joannabriggs.org/
research/critical-appraisal-tools.html)
First author Clear Clear description Clear description Clear description Clear description Clear description Were any adverse Does the case report
(year) description patient’s history current clinical diagnostic tests or of the intervention post-intervention reactions, unanticipated provide takeaway
demographics and timeline conditions assessment methods or treatment clinical conditions events or necessary lessons regarding
and result of these procedure modifications described assessment and
treatment of PTSD
in ASD
Barol and Seubert (2010) 1 Yes Yes No—ASD and PTSD Yes—assessment Yes Yes—descriptively Yes—specifies Yes
presentation and PTSD No—assessment No—diagnostically none present
DSM criteria ASD & PTSD
assessment outcome
Carrigan and Allez (2017) 1,3 Yes Yes Yes Yes—PTSD Yes Yes Yes Yes
No—ASD
1
Carvill and Marston (2002) Yes No Yes Yes Yes No Yes Yes
Cook et al. (1993) 1,3 Yes No—prior history Yes Yes Yes—psychopharmacology Yes—psychopharmacology Yes—psychopharmacology Yes—Assessment and
Yes—post-assessment No—psychotherapy No—psychotherapy No—psychotherapy systemic issues
No—Treatment
Harley et al. (2014)1,3 Yes Yes No—PTSD symptoms Yes Yes Yes Yes Yes
Yes—other conditions
1,3
Kosatka and Ona (2014) Yes Yes No—limited description Yes Yes Yes Yes Yes
of PTSD symptoms
1,3
Mevissen et al. (2011) Yes Yes—traumas and Yes Yes—PTSD Yes Yes Yes Yes
ASD No—school, No—ASD
home life, health
Ryan (1994) 1,3 Yes No Yes No Yes No No Yes—Assessment
No—Treatment
Trelles Thorne et al. (2015 1,3 Yes Yes Yes Yes Yes—pharmacology No Yes—pharmacology No—Assessment
No—psychological No—psychological Yes—Treatment
and school interventions and school
Weiss and Lunsky (2010) 1 Yes Yes Yes Yes Yes No—PTSD Yes— Yes No—Assessment
depression Yes—Treatment
and anxiety
Note: Study meets criteria for inclusion based on 1 assessment; 2 rates of PTSD; 3 treatment
313
Table 4 Quality assessment of methodology for included studies using a quantitative design: EPHPP quality assessment tool for quantitative studies (Effective Public Health Practice Project; www.ephpp.
2 (moderate)
2 (moderate)
2 (moderate)
2 (moderate)
2 (moderate)
2 (moderate)
2 (moderate)
by Carvill and Marston (2002) PTSD could not be reliably
3 (weak)
3 (weak)
3 (weak)
3 (weak)
3 (weak)
3 (weak)
3 (weak)
Global
diagnosed according to ICD-10 criteria due to the clients’
rating
unusual behavioural presentation and in a further case of a
appropriate client with LD the caregiver was unable to report the client’s
emotional state (Mevissen et al. 2011).
Statistics
Anger, arguments, aggressive and oppositional behaviour
N/A
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
at home and school or temper tantrums/outbursts, with parents
and people in the community, were also reported in three
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
analysis
children (Trelles Thorne et al. 2015; Harley et al. 2014;

Unit
Mevissen et al. 2011) and two adults (Weiss and Lunsky
Note: 7a cross-sectional within groups; 7b cross-sectional between groups. Study meets criteria for inclusion based on: 1 assessment; 2 rates of PTSD; 3 treatment
2010; Carrigan and Allez 2017). Symptoms which are sug-
collection
gestive of additional impacts on mood included reporting sad-

method
Rating
Data
ness and withdrawal (Trelles Thorne et al. 2015), anhedonia

1
1
1
1
3
3
3
3
3
1
3
1
1
(Kosatka and Ona 2014), frequent mood changes (Mevissen
reliable
et al. 2011) an erratic appetite, lost interest in activities (Weiss

Tool
and Lunsky 2010), absence of sexual behaviour and self-

1
1
1
1
3
3
3
3
3
1
3
1
1
harm. Additional symptoms which may be indicative of an

Tools
valid
exacerbation of ASD features and additional functional im-

3
3
3
3
1
3
1
1
1
1
3
1
1
pairments included increased hypersensitivity to touch, com-

blinding
pulsive behaviours, declining academic performance, hyper-

Rating
activity and impulsivity. Substance dependence was reported

3
3
3
3
3
3
3
3
3
3
3
3
3
3
in one case (Weiss and Lunsky 2010).

research
Anxiety
Aware
Group Studies
Q re
1
1
1
1
1
1
3
1
3
1
1
1
1
1
A total of 823 cases were reported across the 14 included

Rating
design
Study
papers. Sample size varied from 30 to 122, with a median of

2
2
2
2
1
2
2
2
2
2
2
1
1
1
52.5. The majority of studies recruited children and adoles-

Randomised
cents (White et al. 2012; Ung et al. 2014; Reinvall et al. 2016;
de Bruin et al. 2007; Storch et al. 2013; Hollocks et al. 2016)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
with a mean age of 11.69 years. Only three studies also in-
Yes
Yes
Yes
Yes
cluded individuals aged 18 and over (Hofvander et al. 2009;

design
Study
Taylor and Gotham 2016; Mehtar and Mukaddes 2011). One

7a
7b
7b
7b
7a
7a
7a
7a
7a
7a
paper was based on a sample of males (Taylor and Gotham

1
1
1
1
2016), whilst all other articles were based on mixed-gender

Selection
samples. The highest proportion of females recruited was

Rating
bias
33%, which occurred within three studies (Hofvander et al.

2
2
2
1
2
2
2
2
1
2
2
2
2
2
2009; Wood et al. 2009; Wood et al. 2015), the median was
participate
23.5% female participants. Six of the studies selectively ad-

agreed
vertised for or recruited individuals with an anxiety disorder

%
(White et al. 2012; Ung et al. 2014; Storch et al. 2013; Wood
1
1
5
1
1
1
5
5
5
5
5
4
5
4
et al. 2009; Wood et al. 2015; White et al. 2013). For a full
Representative
summary of demographic characteristics, see Table 1.

The traumatic experiences of the samples were not spec-
of ASD
ified in 12 articles. In the two studies that reported their

2
2
2
1
2
2
2
2
1
2
2
2
2
2
participants had been victims of mixed traumas (Taylor

Taylor and Gotham (2016)1,2
and Gotham 2016; Mehtar and Mukaddes 2011). A range

McConachie et al. (2014)1,2
Hofvander et al. (2009)1,2
de Bruin et al. (20077)1,2
Hollocks et al. (2016)1,2
of assessment measures and informants was used across the

Reinvall et al. (2016)1,2
Mehtar and Mukaddes
Storch et al. (2013)1,2
White et al. (2012)1,2

White et al. (2013)1,2
Wood et al. (2009)1,2
Wood et al. (2015)1,2
Mattila et al. (2010)1
studies, see Table 2. All articles employed a standardised

Ung et al. (2014)1
ca/tools.html)
semi-structured interview to assess PTSD symptomatology,

(2011)1,2
with the most common being the Anxiety Disorders

author
(year)
Interview Schedule for Children and Parents (ADIS C/P;

First
Silverman and Albano 1996) which used in six studies

(White et al. 2012; Ung et al. 2014; Storch et al. 2013; Wood individuals with anxiety disorders (White et al. 2012; Storch
et al. 2009; Wood et al. 2015; White et al. 2013). Only Ung et al. 2013; Wood et al. 2009; Wood et al. 2015; White et al.
et al. (2014) tested the inter-rater reliability of the assess- 2013; McConchie 2014; Ung et al. 2014); with this being a
ment measure (ADIS C/P) for PTSD diagnosis in youth with necessary prerequisite for access treatment it is possible that
ASD. They found the ADIS C/P to have excellent inter-rater individuals may have had an incentive to artificially inflate
reliability (kappa = 1.0); however, the rates of PTSD were their symptom reports thus biasing the overall rates of PTSD
not reported. Only three papers specified that the inter- within the samples. Rates of PTSD occurrence were substan-
viewers were careful to take into account the behavioural tially higher across the aforementioned studies (3.52%) com-
overlaps between symptoms of anxiety and ASD when cod- pared to the two studies that measured current PTSD in child
ing (White et al. 2012; White et al. 2013; Hollocks et al. and adolescent samples that were not recruited based on any
2016). characteristic other than ASD status (0.85%; Reinvall et al.
PTSD symptom presentations were not reported within any 2016; Hollocks et al. 2016). Across the literature, three studies
of the papers. However, Storch et al. (2013) found that co- found no cases that meet criteria for PTSD (de Bruin et al.
occurring ASD, mood disorder and PTSD significantly pre- 2007; Taylor and Gotham 2016; Hollocks et al. 2016). These
dicted suicidal thoughts and behaviours, with other individual three papers, with the lowest rates of PTSD, also contained
differences or psychopathology not predicting suicidal idea- some of the highest proportion of males within their samples
tion or behaviours. (88.3–100%), although all studies reporting rates of PTSD
contained predominantly male samples (median 77%, mean
Rates of PTSD Diagnosis in People with ASD 79%).
Of the group studies reviewed above, all but two (Ung et al. Treatment of PTSD in People with ASD
2014; Mattila et al. 2010) reported information regarding the
occurrence of current (i.e. last month) or lifetime PTSD in a Seven papers met eligibility criteria for inclusion in the treat-
group of individuals with ASD. However, none of these were ment synthesis, reporting additional information regarding the
large-scale well-controlled population-based studies assessing treatment of PTSD in individuals with ASD. All included
prevalence. Within these 12 studies, rates of PTSD were re- papers were case presentations, with no cross-sectional or
ported across a total of 703 cases. The mean sample size of RCT studies reporting treatment outcomes separately for indi-
studies reporting rates of PTSD was 58.58 (range 30–122). viduals with PTSD and ASD. The following section provides
Although all but one study (Hollocks et al. 2016) recruited a an expanded overview of the results regarding the treatment of
mixed-gender sample, no articles reported the rates of PTSD PTSD in individuals with ASD, supplementing the informa-
in ASD separately for men and women. tion in Tables 1, 2, and 3.
The rates of PTSD reported across the literature to date are Cases ranged from 6 to 26 years of age, with the median
presented in Table 5; PTSD rates have been subdivided ac- being 12. Ability levels varied drastically across the cases, as
cording to the age of the sample (children/adolescents and outlined within Table 1. All cases were referred for assessment
adult) and the rating period used for diagnosis (current, life- or treatment within a specialist clinical service. Multiple treat-
time and 12 months). Studies were included in the child/ ment interventions, combining pharmacological and talking
adolescent or the adult category according to the mean age therapies, were employed in the treatment of three cases.
of their sample being under or over 18 years of age, respec- Three cases received psychotherapy (Cook et al. 1993;
tively. Seven of the studies assessing current PTSD in children Trelles Thorne et al. 2015; Harley et al. 2014), one received
and adolescents selectively advertised for and/or recruited individual CBT therapy using the Ehlers and Clark (2000)
Table 5 Rates of PTSD in individuals with ASD
Age group and rating period for PTSD diagnosis N: total Mean rate Mean age (range) Mean %
(Studies Included) sample of PTSD Females
Children and Adolescents: Current PTSD (White et al. 2012; 382 2.85% 12.13 (6.5–17) 21%
Reinvall et al. 2016; Storch et al. 2013; Hollocks et al. 2016; Wood et al. 2009;
Wood et al. 2015; White et al. 2013; McConachie et al. 2014)
Children and Adolescents: Lifetime PTSD (Mehtar and Mukaddes 2011) 691 17.4%1 11.7 (6–18) 1 23%1
Children and Adolescents: 12-month PTSD (De Bruin 2007) 941 0%1 8.5 (6–12) 1 11.7%1
Adults: Lifetime PTSD (Hofvander et al. 2009; Taylor and Gotham 2016) 158 0.8% 23.85 (16–60) 25%
1
These statistics are gained from one paper and are not an average
approach (Carrigan and Allez 2017), one received behavioural across the quantitative studies. As all group studies only
therapy using systematic desensitisation (Ryan 1994), and two qualified for inclusion within the assessment and preva-
received EMDR (Kosatka and Ona 2014; Mevissen et al. lence aspects of this review, the tool was modified to only
2011). The number of sessions ranged from 4 (EMDR) to 43 include relevant items in addressing the risk of bias in as-
(child-parent psychotherapy), with a median of 10.5 sessions; sessment and prevalence of PTSD in ASD; the study ratings
three articles did not report the number of sessions, length of are presented in Table 4. Seven of the studies received a
treatment or duration of each therapy session (Ryan 1994; moderate global rating and the remainder received a weak
Cook et al. 1993; Trelles Thorne et al. 2015). rating. Only two studies were scored as strong with regards
Six cases provided information regarding treatment out- to selection bias (Taylor and Gotham 2016; Mattila et al.
come (Carrigan and Allez 2017; Kosatka and Ona 2014; 2010). Taylor and Gotham (2016) recruited from a wide
Mevissen et al. 2011; Cook et al. 1993; Harley et al. 2014; variety of sources and including individuals across the
Trelles Thorne et al. 2015). Follow up periods, reported in spectrum, and Mattila et al. (2010) used a clinical sample
five articles, varied from immediately post-intervention— combined with a community sample that were gathered by
4 years post-intervention, with the median being 6 months approaching all 8-year-olds across an entire geographical
post-treatment. Post-treatment symptom reduction was re- region. All other studies were rated as moderately represen-
ported in all six cases, with all but one (Trelles Thorne et al. tative, either recruiting based on a particular characteristic
2015) reporting a reduction in PTSD symptomatology spe- such as anxiety as outlined above, or lack of a characteristic,
cifically, in addition to reductions in anger, aggression, tan- such as no history of psychiatric or neurological problems
trums, disturbing thoughts, anxiety and depressive symp- (Hollocks et al. 2016) or untreated ADHD or oppositional
toms reported in some cases. Improved quality of life (in disorder (McConachie et al. 2014), or recruiting solely from
regards to relationships and school), improvement in posi- one clinical service (Reinvall et al. 2016; Hofvander et al.
tive parental view of their child and improvements in ASD 2009; de Bruin et al. 2007; Mehtar and Mukaddes 2011).
symptoms such as eye contact and social overtures were The most common design was cross-sectional, which was
also reported. Symptoms that were reported not to remit in given a moderate quality rating; with four studies employing a
some cases included PTSD avoidance symptoms and paren- randomised control trial (RCT) design and rated as strong.
tal stress following child-psychotherapy and anxiety to- Whilst RCTs offer a superior experimental design and have
wards environmental trauma reminders, such as buildings been rated accordingly in the quality assessment ratings, it
and anniversaries, following psychotherapy. It was reported should be noted that none of these studies sufficiently broke
in two articles that slight modifications to therapy were down their results so as to detail the treatment findings spe-
needed to support features of ASD (Kosatka and Ona cifically for those with PTSD. As a result, the quality of the
2014; Carrigan and Allez 2017). study design becomes less relevant to the conclusions regard-
ing assessment and prevalence as such data precedes
Risk of Bias randomisation and allocation. Seven studies were rated as
strong with regard to their data collection method; all of these
Case Studies studies employed the ADIS C/P (Silverman and Albano
1996). The ADIS/CP is the only measure employed within
Single-case or case series designs are inherently limited in the studies included in this review which has been shown to
their ability to contribute to the efficacy literature. The arti- be valid and reliable for use with individuals with ASD, al-
cles reviewed here presented a detailed description of the though internal consistency and content validity have yet to be
assessment and presentation of PTSD symptoms within an tested (Wigham and McConachie 2014).
ASD client group; however, generalisation of the findings
to the wider population of individuals with ASD is limited
by the restricted sample size, lack of comparison group and Discussion
the impact of possible confounds not being accounted for.
The methodological quality of these studies was assessed The current review has provided an overview of the current
using a checklist for case reports (The Joanna Briggs state of the field of research into PTSD in ASD, including a
Institute 2016), see Table 3. total of 24 studies, 10 being case reports/series and 14 quan-
titative studies. All of the included studies contained informa-
Group Studies tion regarding the assessment of PTSD in individuals with
ASD; however, details regarding the assessment, outcome
A modified version of the EPHPP quality assessment tool and PTSD symptom presentation were extremely limited
for quantitative studies was employed to assess the risk of within cross-sectional and RCT studies, with two studies fail-
bias in selection, study design, blinding and data collection ing even to report the rates of PTSD found within their sample
(Ung et al. 2014; Mattila et al. 2010). Whilst case reports measures in diagnosing PTSD in ASD (Ung et al. 2014),
predominantly relied on the judgement of the clinician in di- using the ADIS C/P. Whilst excellent inter-rater agreement
agnosing PTSD, usually following a multiple informant infor- was reported for PTSD diagnosis using the ADIS C/P, the
mation gathering process, quantitative studies consistently authors failed to specify anywhere in the article what the
employed standardised assessment tools to aid diagnosis. rates of PTSD were in the sample, thus limiting the conclu-
The most commonly used assessment tool was the ADIS sions that can be drawn from this finding.
C/P, with other tools including the DISC, CAPA, K-SADS Although the ADIS C/P has been shown to be a prom-
and SCID. Importantly, the ADIS C/P is the only measure ising tool for assessing anxiety and PTSD in ASD, the
used to assess PTSD in ASD that has received preliminary development and addition of an ADIS/ASA PTSD adden-
support for its validity and reliability in ASD populations dum specifying ASD-specific considerations may encour-
(Wigham and McConachie 2014; Ung et al. 2014), meaning age clinicians to consider ASD symptom overlap in greater
the remaining quantitative studies employed diagnostic tools detail and aid in the accurate assessment of PTSD in ASD.
whose psychometric properties have yet to be evaluated for Kerns et al. (2015) provide a summary of the key charac-
use within this population (Reinvall et al. 2016; de Bruin et al. teristics and considerations in designing new measures of
2007; Hollocks et al. 2016; Taylor and Gotham 2016; Mehtar PTSD symptomatology and sequelae, for individuals with
and Mukaddes 2011; Hofvander et al. 2009). Certain mea- developmental disabilities. Measures need to (1) assess
sures of anxiety in ASD, such as the Multidimensional prevalence of trauma exposure and post-trauma symptom-
Anxiety Scale for Children, parent-report (MASC-P; March atology, (2) detect risk factors, (3) track the influence of
et al. 1997), have been found not to measure identical con- trauma on wider social and functional outcomes, (4) iden-
structs in anxious individuals with and without ASD (White tify when symptom expression is severe enough to require
et al. 2015), so although tools such as the DISC, CAPA, K- treatment and (5) measure symptom change and assess
SADS and SCID have been shown to be robust within the treatment outcomes. Beginning with the adaptation of
general population, it is unknown whether they are appropri- existing trauma/PTSD measures may be a first step in this
ate for use within ASD populations. Whist a review by process, however ultimately the design of new ASD-
Wigham and McConachie (2014) found the Spence specific PTSD assessment measures (both clinician-led
Children’s Anxiety Scale- revised (SCAS; Spence 1998) and and self/informant-report tools), that are developed to suit
the Screen for Children’s Anxiety Related Emotional Disorders the needs of this population and carefully account for
(SCARED; Birmaher et al. 1997) are the most robust measure- overlapping symptomatology, would be preferential. Mehtar
ment tools for assessing anxiety in ASD, unfortunately neither and Mukaddes (2011) developed a new measure called the
of these measures assess PTSD symptomatology. Trauma Symptoms Investigation Form in ASD (TIF-ASD)
A key issue in assessing anxiety-related symptomatology which measures the impact of trauma exposure on core symp-
in ASD is that of differentiating between traditional co- toms of ASD and associated behavioural disturbances (but not
occurring anxiety and Banxiety-like^ presentations that PTSD). The use of the TIF-ASD within this sample provided a
may either be a manifestation of ASD features or an ASD- rich data set; however, its reliability and validity have yet to be
specific presentation of anxiety (for a review of this issue tested. The expansion of such a measure to include PTSD
see Kerns 2012 and Wood and Gadow 2010). A new ASD symptom expression may aid in exploring any possible over-
addendum to the ADIS has been developed to allow for lap in symptomatology between ASD and PTSD and delineate
clearer differentiation between traditional anxiety and these from Batypical/PTSD-like^ symptoms.
symptoms which may be better explained as ASD-related PTSD symptom presentation was described in eight cases
anxiety or features of ASD (Kerns et al. 2017). The ADIS/ studies, with a comparable PTSD symptom profile found in
ASA can reliably measure comorbid and Banxiety-like^ individuals with ASD to that of Btraditional^ PTSD, providing
symptoms in ASD; it has been shown to be valid for the initial evidence that PTSD does develop in individuals with
assessment of traditional anxiety symptoms and partially ASD and can be diagnosed according to DSM-5 and ICD-10
valid for assessing Banxiety-like^ symptoms in ASD; how- criteria. Within two cases, standardised PTSD self-report
ever, unfortunately, the PTSD module was not administered questionnaires designed to assess DSM-IV PTSD symptom-
or adapted by Kerns et al. (2017). Issues pertaining to the atology were used to measure symptom expression (Kosatka
assessment and differentiation of comorbid PTSD from and Ona 2014; Harley et al. 2014), adding further support to
BPTSD-like^ symptoms or features inherent to ASD also the view that traditional PTSD presentation can and does oc-
need to be teased apart in the diagnosis of PTSD in ASD; cur in ASD. This finding unequivocally answers the query
therefore, tool development and the controlled study of raised in past theoretical papers as to whether individuals with
symptom presentation is vital to enhance understanding ASD can experience the classic symptoms of PTSD (Hoover
and treatment of PTSD in ASD. Within this review, only 2015, p.294). Only in one article were two cases of an atypical
one paper assessed the inter-rater reliability of assessment post-trauma behavioural presentation described (Carvill and
Marston 2002). The two individuals with ASD and trauma increased risk of physical and sexual abuse (Mandell et al.
histories were noted as having unusual behavioural presenta- 2005) and peer victimisation (Cappadocia et al. 2012; Blake
tions which did not neatly fit into a diagnostic category, al- et al. 2012), or (II) the experience of abuse results in an increased
though Bpossible PTSD^ was considered. Taken together, symptom burden that is more likely to require assessment and
these findings illustrate that whilst there is evidence to suggest treatment (as all cases were using clinical services), in line with
that traditional PTSD can develop in ASD, it is possible that research in the general population showing that childhood phys-
for some individuals a BPTSD-like^ presentation may occur. ical (Springer et al. 2007) and sexual (Spataro et al. 2004) abuse
This BPTSD-like^ presentation may be best explained as ei- predicts an array of mental health difficulties and increased
ther an ASD-specific variant of PTSD or a manifestation of treatment seeking. Large-scale epidemiological studies compar-
core ASD diathesis; however, further research is needed to ing patterns and effects of trauma exposure in individuals with
determine the different presentations and possible variants of ASD are required to fully address such a question.
PTSD in ASD and provide clear differentiation between Within the current review studies were classed as eligible
PTSD and ASD symptomatology. for inclusion in summation of reported rates of PTSD diag-
An additional post-trauma symptom presentation of anger nosis if the ASD sample size was ≥ 30. Of the 12 studies
and disruptive, aggressive and oppositional behaviours was meeting this criterion, the majority measured current PTSD
described across six papers (five case studies: Trelles Thorne diagnosis, with the remainder measuring PTSD over the pre-
et al. 2015; Harley et al. 2014; Mevissen et al. 2011; Weiss and vious 12 months or lifetime (including current) (Table 5). As
Lunsky 2010; Carrigan and Allez 2017; and 1 cross-sectional would be expected, merged estimates of the rates of PTSD in
study: Mehtar and Mukaddes 2011), suggesting that trauma childhood and adolescence with ASD were higher when
and/or PTSD development may have an additional negative comparing lifetime diagnosis (17.4%) to current diagnosis
impact on emotional and behavioural characteristics for some (2.9%). However, studies assessing the rates of PTSD in
individuals. Worryingly PTSD diagnosis (with co-occurring children over a 12-month period found no cases with PTSD
major depressive disorder/dysthymia) in ASD was also found and the rates were very low (0.8%) in studies assessing life-
to be associated with suicidal thoughts and behaviours, in a time PTSD in adults. The majority of studies recruited their
cross-sectional study of 102 children and adolescents with samples from treatment seeking settings, which may include
ASD (Storch et al. 2013); however, this was based on a sample more severe and comorbid presentations (Du Fort et al.
of only six individuals with PTSD and ASD, so requires rep- 1993); as such, the overall rates of PTSD occurrence outlined
lication. Interestingly, whilst no papers reported the specific here are more representative of those which may be expected
deterioration of socio-communicative features of ASD as as- in treatment-seeking clinical samples. Overall, the rates of
sociated with the onset or development of PTSD, Harley et al. current PTSD were found to be higher in treatment-seeking
(2014) reports an improvement in frequency of eye contact samples when compared to studies assessing current PTSD
and social overtures post-treatment. This finding raises the in non-treatment-seeking samples. Interestingly, however,
question as to whether trauma exposure or co-occurring three studies that recruited treatment-seeking subjects found
PTSD may result in the exacerbation of ASD features, which no cases of PTSD within their samples (de Bruin et al. 2007;
can then be alleviated by PTSD treatment. Indeed, research Taylor and Gotham 2016; Hollocks et al. 2016). A large-
completed by Valenti et al. (2000) into outcomes for individ- scale population study in England found the rates of current
uals with ASD following an earthquake in Italy found that PTSD in adulthood to be 3% (McManus et al. 2009); how-
trauma exposure resulted in an exacerbation of ASD features. ever, no studies have assessed the rates of current PTSD in
Studies exploring the psychiatric, behavioural and functional adults with ASD. The rate of current PTSD in typically de-
impairments associated with trauma exposure, comparing veloping adolescent populations has been found to be lower
groups with trauma exposure and PTSD, trauma exposure than that in adulthood, at 1.6% (Kessler et al. 2012); given
without PTSD and non-trauma exposed individuals with that the mean age of the studies assessing current PTSD in
ASD, are needed to examine the unique contribution of trau- childhood and adolescence with ASD was 12.13, the merged
ma and PTSD to symptom expression in ASD. rates of PTSD in children and adolescents with ASD found
The most commonly reported traumatic experience for in- within this review (2.9%) appear to be somewhat higher than
dividuals with ASD was abuse, which occurred in over 60% those found for adolescents within the general population
of the trauma-exposed case examples, as well as being spec- (1.6%). However, as mentioned previously, the studies in
ified as occurring within both the cross-sectional studies that children and adolescents with ASD outlined here recruited
identified the types of traumatic events experienced by their predominantly treatment-seeking populations and to date
participants (Taylor and Gotham 2016; Mehtar and Mukaddes there have not been any large scale well-controlled popula-
2011). This finding suggests that either, (I) individuals with tion-based prevalence studies in individuals with ASD, so
ASD may be particularly vulnerable to abuse, in line with further research is needed before any clear comparisons or
previous research showing that individuals with ASD are at conclusions can be drawn.
Interestingly, general population rates have been found to Within the one study that reported rates of trauma exposure
vary according to gender (McManus et al. 2009), with trauma within their sample (Mehtar and Mukaddes 2011), the condi-
exposure more prevalent in men and the rate of PTSD higher tional probability of (lifetime) PTSD following trauma-
in females (3.3% women, 2.6% men). A preponderance of exposure was extremely high (66.7%); an important caveat
male participants were included within the cross-sectional to this finding is that the rates of trauma exposure are incon-
studies assessing rates of PTSD in ASD, and rates of PTSD sistently reported between the text and tables of that paper
were unfortunately not split by gender within the results. (p.542), meaning this may be a slight overestimate. General
However, the studies reporting the lowest rates of PTSD (de population rates of PTSD within samples exposed to abuse are
Bruin et al. 2007; Taylor and Gotham 2016; Hollocks et al. lower than those found by Mehtar and Mukaddes (2011),
2016) also had some of the lowest proportions of females ranging from 43.9% (Mcleer et al. 1992) to 48.4% (Mcleer
within their samples, tentatively suggesting that gender may et al. 1988) in childhood and 30.6–37.5% in adulthood
also play a role in risk of PTSD development in ASD. As ASD (Widom 1999). Further research is needed in trauma exposed
is more prevalent in males (Baio 2012), it will be important for samples with ASD in order to confirm whether individuals
future research to recruit a more balanced distribution of males with ASD are at increased risk of PTSD development follow-
and females to assess whether the same association between ing exposure to traumatic life events.
gender and PTSD risk holds for individuals with ASD or Another factor found to be associated with an inflated risk
whether characteristics of ASD are more important than gen- of trauma exposure and PTSD development in the general
der in predicting vulnerability to PTSD. This will allow for a population is lower IQ (Breslau et al. 2006). The majority of
more accurate comparison of PTSD prevalence rates between cross-sectional studies recruited individuals with an IQ > 70;
those with ASD and general population statistics. however, three studies included individuals across a range of
As children age, there is more opportunity for exposure to IQ scores (de Bruin et al. 2007; Taylor and Gotham 2016;
traumatic life events, both in terms of the breadth of events Mehtar and Mukaddes 2011). Whilst two of these studies
and the likelihood that they will have experienced at least one reported no cases with PTSD in a total of 130 individuals
traumatic event across their lifetime. This means that studies with ASD (de Bruin et al. 2007; Taylor and Gotham 2016),
assessing lifetime rates of PTSD in adulthood (5.6% in the the highest rates of PTSD across all studies (17.7%) were
general population; Rimmo et al. 2005) should have an in- reported by Mehtar and Mukaddes (2011) where 72.5% of
herently higher chance of finding cases with trauma expo- the sample had a mild-severe learning disability.
sure (which may act as a catalyst for PTSD development) Interestingly, although both Mehtar and Mukaddes (2011)
than studies assessing lifetime prevalence of PTSD in chil- and Taylor and Gotham (2016) used the same assessment
dren and adolescents, with general population rates ranging tool to measure lifetime PTSD and relied on parent-report
from 3 to 15% in girls and 1–6% in boys (Carr 2004). (K-SADS), their findings differ drastically; it is possible that
Research has also shown that PTSD presentation may differ the sole use of a treatment-seeking sample and reliance on a
in children (particularly those 6 years of age and under), sample predominantly diagnosed with a learning disability
affecting the ability to identify the condition (Scheeringa inflated the rates of PTSD found by Mehtar and Mukaddes
et al. 2011). Interestingly, however, the study with the largest (2011). Further research is needed to clarify the association
age range (Hofvander et al. 2009) did not report the highest between IQ and communication difficulties, and trauma ex-
occurrence rates across the present articles, with the highest posure and PTSD development in individuals with ASD
rates instead found within a study that used a predominantly across both community and clinical samples. Exploring the
child and adolescent sample (Mehtar and Mukaddes 2011). individual differences that confer risk of PTSD in ASD
The lifetime occurrence of 17.4% reported by Mehtar and would aid in the identification of at risk groups and allow
Mukaddes (2011) across a predominantly male sample is for tailored early interventions to be developed.
greater than the higher end of both the male and female Unfortunately, none of the treatments employed within
neurotypical estimates for lifetime PTSD prevalence in chil- cross-sectional or RCT studies were designed to treat
dren and adolescents (Carr, 2004) and greater than the adult PTSD per se and outcomes were not reported separately
prevalence rates in the general population of 6.8% (Kessler for those with co-occurring PTSD, meaning that conclu-
et al. 2005). As it is known that in the general population the sions regarding this question are limited to the findings
rates of current and lifetime PTSD are greater in adulthood, it collated from case examples. In the majority of cases, treat-
is surprising that the lifetime rates of PTSD were lower in ment was sought for PTSD resulting from exposure to
adult samples than child/adolescent samples (Table 5). The emotional, physical or sexual abuse, with one case seeking
majority of studies included in this review investigated treatment following exposure to traumatic deaths of close
PTSD in children and adolescents with ASD and more re- family members (Mevissen et al. 2011). This finding adds
search is needed to clarify the incidence of PTSD in a gender support to the proposition that abuse is associated with
balanced sample of adults with ASD. treatment seeking in ASD, as is the case in the general
population (Spataro et al. 2004). Prescription of psychoac- overview of the literature to date across all ASD diagnoses, it
tive drugs Carbamexepine (Ryan 1994), Zoloft (Kosatka affected the ability to collectively synthesise the data meaning
and Ona 2014) and Guanfacine with Sertrailne (Trelles that sub-group comparisons had to be made on a number of
Thorne et al. 2015) was always combined with psycholog- levels (e.g. case/group designs and child/adult samples). There
ical therapy, however these articles reported very limited was a preponderance of male participants across the studies,
details regarding the adjacent psychological therapy pro- which inherently produces a gender biased set of results.
vided. Whist it is beyond the scope of this article to provide Further bias in sample characteristics is produced by seven
a full overview of the use of psychopharmacology in ASD, studies having advertised for participants with anxiety symp-
the reader is referred to McPheeters et al. (2011) for a toms or disorders. Results regarding PTSD symptom profiles
review of this topic. and treatment relied on information collated from case reports,
NICE guidance suggests 8–12 weekly sessions of trauma- severely limiting the generalisability of the findings.
focused psychological therapy as the first-line treatment for None of the included quantitative articles achieved a strong
both children and adults with PTSD, where symptoms have rating within the risk of bias assessment, with a number of
been present for more than 3 months post-trauma, with fami- studies advertising for individuals with anxiety disorders and
lies involved where appropriate in the treatment of PTSD in recruiting predominantly from clinical services. Whilst six
children and adolescents (NICE 2005). A variety of psycho- studies used a measure that has received at least some support
logical therapies and treatment lengths (range 4–43-h-long for its use in ASD populations, the remaining 5 studies did not
sessions) were employed in the treatment of PTSD in ASD, (Reinvall et al. 2016; de Bruin et al. 2007; Hollocks et al.
with the most common therapy being psychotherapy (Cook 2016; Taylor and Gotham 2016; Mehtar and Mukaddes
et al. 1993; Trelles Thorne et al. 2015; Harley et al. 2014). 2011; Hofvander et al. 2009) limiting the validity and reliabil-
Modifications were reported within EMDR (Kosatka and Ona ity of their results and conclusions.
2014) and CBT (Carrigan and Allez 2017) PTSD treatments; The inclusion criteria for this review specified that studies
however, in most treatment cases, standard procedures were must be written in English and no grey literature was included,
employed and it was noted in one case that the patient was which may have resulted in studies published in other lan-
Bable to engage in the metacognitive processes required for guages or non-peer reviewed formats being missed.
therapy^ (Carrigan and Allez 2017). Reduced PTSD symp- Additional inclusion criteria for prevalence estimates speci-
tomatology was found following trauma-focused CBT treat- fied that studies must include a minimum sample size of 30;
ment using the Ehlers and Clark approach (Carrigan and however, if a more conservative cut off of n = 50 had been
Allez), EMDR treatment (Kosatka and Ona 2014; Mevissen employed, as was used in a recent review exploring preva-
et al. 2011) and psychotherapy with some trauma focus (Cook lence of anxiety in children and adolescents with ASD
et al. 1993; Harley et al. 2014). The effectiveness of trauma- (Reardon et al. 2015), then six of the studies would have been
focused therapies in treating PTSD in ASD is in line with the excluded. Finally, this paper set out to systematically review
NICE guidelines for PTSD treatment in the general popula- the literature pertaining to PTSD in ASD across all age
tion. The findings of this review suggest that, at least for indi- groups. Whilst allowing for a more representative and expan-
viduals that present with Btraditional^ PTSD symptoms, sive summary of the state of the field, DSM-5 criteria for
existing PTSD treatments may be effective in alleviating PTSD specify that presentation may differ in under 7’s
symptom burden with modifications to support features of (Scheeringa et al. 2011). Three studies outlining assessment
ASD, such as allowing longer session durations or more ses- and presentation (Reinvall et al. 2016; de Bruin et al. 2007;
sions to give individuals time to process and verbalise their Mehtar and Mukaddes 2011) and one study outlining treat-
experiences (Kosatka and Ona 2014), simplifying language ment (Harley et al. 2014) included 6-year-olds at the lower
and reducing the use of metaphors (Carrigan and Allez end of their sampling age range, which may have influenced
2017). Such modifications to the treatment of comorbidities the overall conclusions drawn from the pooled data.
in ASD are also supported by NICE guidelines (CG170, 2013,
p.22), although a recent review suggests that in practice addi- Clinical Implications and Future Research Directions
tional modifications over and above those recommended by
NICE are often enlisted in the treatment of comorbidities in Given the limited research that has been completed in the field
ASD (Walters et al. 2016). of PTSD in ASD, only tentative clinical conclusions can be
drawn from the literature to date. However, a number of ave-
Limitations nues for further research have been identified as a result of this
narrative review.
A limitation of the current systematic review was the large It is clear from this review of the literature that PTSD does
heterogeneity of the study designs, methodology and partici- occur in individuals with ASD, possibly with a similar or
pant characteristics. Whilst such heterogeneity provided a full elevated prevalence in childhood and adolescents to that
found within the general population. The vast majority of (with appropriate modifications), although cohort studies
literature exploring co-occurring mental health diagnoses in and clinical trials are required before any firm conclusions
individuals with ASD has neglected to assess and/or report the can be drawn about which therapies are effective in treating
incidence of PTSD. Given that rates of other anxiety-related comorbid PTSD in ASD.
conditions are known to be inflated in individuals with ASD,
it is crucial that clinicians and researchers begin routinely
screening for trauma exposure and conduct appropriate as- Conclusions
sessments for PTSD symptomatology within this at risk pop-
ulation. The case studies included in this review provide pre- The findings of this systematic review highlight that although
liminary evidence that Btraditional^ PTSD symptom presen- there is a shortage of well-controlled studies investigating the
tations can occur in ASD and can be diagnosed according to assessment, prevalence and treatment of PTSD in individuals
DSM-5 and ICD-10 criteria. However, further research is with ASD, preliminary data in children and adolescents with
needed in larger samples where the influence of individual ASD suggests that PTSD co-occurs at a similar or heightened
differences such as gender, intellectual functioning and fea- rate to that in the general population, and PTSD in ASD can be
tures of ASD can be investigated and Btypical^ and Batypical^ assessed according to current DSM-5 and ICD-10 PTSD
PTSD presentations can be disentangled. symptom criteria. Trauma exposure and associated PTSD
The ADIS/CP was used to assess PTSD in the majority of symptomatology should be routinely assessed in individuals
cross-sectional and RCT designs and at present it is the only with ASD who present to clinical services. Preliminary evi-
measure assessing PTSD in ASD to have received preliminary dence was found for the effectiveness of PTSD treatments
evidence of its validity and reliability in diagnosing anxiety recommended within the NICE guidelines, with appropriate
disorders (Wingham and McConachie 2014) and PTSD (Ung modifications for ASD. Research is needed to develop tools
et al. 2014) in ASD. As such the ADIS/CP would be the that can appropriately distinguish between symptoms of ASD
recommended tool for diagnosis of PTSD in children and and PTSD and assess the efficacy of PTSD treatments within
adolescence with ASD until further research has examined the ASD population.
the measurement properties of a broader range of PTSD as-
sessment tools in individuals with ASD; no tools have yet to Compliance with Ethical Standards
be validated for the assessment of PTSD in adults with ASD.
The clinical field would also benefit from research assessing Conflict of Interest The author declares that there is no conflict of
interest.
the measurement properties of PTSD-specific assessment
tools that have been shown to be reliable within the general Open Access This article is distributed under the terms of the Creative
population, including clinician administered measures such as Commons Attribution 4.0 International License (http://
the Clinician-Administered PTSD Scale for DSM-5, adult creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appro-
(CAPS-5; Weathers et al. 2013a) and child version (Pynoos priate credit to the original author(s) and the source, provide a link to the
et al. 2015), and self-report measures such as the PTSD Creative Commons license, and indicate if changes were made.
Checklist of DSM-5 (PCL-5; Weathers et al. 2013b) and the
Child PTSD Symptom Scale (CPSS; Foa et al. 2001). There
are, however, difficulties relying on a single informant for
assessment of PTSD in ASD, with self-reporting in ASD pos- References
sibly affected by problems mentalising (Brent et al. 2004) and
parent-reporting also being problematic in the assessment of References marked with an asterisk indicate studies included
internal experiences associated with PTSD (e.g. re- in the systematic review
experiencing symptoms and confidently attributing symptoms
as being associated to a particular traumatic event). As such, American Psychiatric Association. (2013). Diagnostic and statistical
multi-informant approaches are recommended in the assess- manual of mental disorders (5th ed.). Arlington, VA: American
ment of psychiatric disorders in ASD (MacNeil et al. 2009). Psychiatric Publishing.
Angold, A., & Costello, E.J. (2000). The child and adolescent psychiatric
The evidence collated within this review relating to the
assessment (CAPA). Journal of the American Academy of Child and
treatment of PTSD in ASD comes solely from case study Adolescent Psyciatry, 39, 39-48.
designs, as such they provide only an indication of the types Baio, J. (2012). Prevalence of autism spectrum disorders: autism and
of therapies which may be effective for individuals with developmental disabilities monitoring network, 14 Sites, United
PTSD and ASD and do not form the basis of definitive States, 2008. Morbidity and Mortality Weekly Report.
Surveillance Summaries. Volume 61, Number 3. Centers for
clinical recommendations. This preliminary evidence sug- Disease Control and Prevention.
gests that NICE recommended treatments for PTSD may Bakken, T. L., Helverschou, S. B., Eilertsen, D. E., Heggelund, T.,
also be effective for at least some individuals with ASD Myrbakk, E., & Martinsen, H. (2010). Psychiatric disorders in
adolescents and adults with autism and intellectual disability: a rep- Effective Public Health Practice Project. Quality assessment tool for quan-
resentative study in one county in Norway. Research in titative studies. www.ephpp.ca/tools.html. Accessed 15 April 2017.
Developmental Disabilities, 31(6), 1669–1677. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic
*Barol, B. I., and Seubert, A. (2010). Stepping stones: EMDR treatment stress disorder. Behaviour Research and Therapy, 38(4), 319–345.
of individuals with intellectual and developmental disabilities and Ehlers, S., Gillberg, C., & Wing, L. (1999). A screening questionnaire for
challenging behavior. Journal of EMDR Practice and Research, Asperger syndrome and other high-functioning autism spectrum
4(4), 156-169. disorders in school age children. Journal of autism and developmen-
Baron-Cohen, S., Wheelwright, S., Robinson, J., & Woodbury-Smith, M. tal disorders, 29(2), 129-141.
(2005). The adult Asperger assessment (AAA): a diagnostic method. Ferdinand, R.F., and Van der Ende, J. (1998). Diagnostic Interview
Journal of Autism and Developmental Disorders, 35(6), 807. Schedule for Children IV. Parent-Version. Rotterdam, the
Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., Netherlands: Erasmus University, Department of Child and
& Neer, S. M. (1997). The screen for child anxiety related emotional Adolescent Psychiatry.
disorders (SCARED): scale construction and psychometric charac- First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1997).
teristics. Journal of the American Academy of Child and Adolescent Structured clinical interview for DSM-IV clinical version (SCID-I/
Psychiatry, 36(4), 545–553. CV). American Psychiatric Press.
Blake, J. J., Lund, E. M., Zhou, Q., Kwok, O. M., & Benz, M. R. (2012). Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. H. (2001).
National prevalence rates of bully victimization among students The Child PTSD Symptom Scale: a preliminary examination of its
with disabilities in the United States. School Psychology psychometric properties. Journal of Clinical Child Psychology, 30,
Quarterly, 27(4), 210. 376–384.
Brent, E., Rios, P., Happé, F., & Charman, T. (2004). Performance of Ford, T., Goodman, R., & Meltzer, H. (2003). The British child and
children with autism spectrum disorder on advanced theory of mind adolescent mental health survey 1999: the prevalence of DSM-IV
tasks. Autism, 8(3), 283–299. disorders. Journal of the American Academy of Child and
Breslau, N., Lucia, V. C., & Alvarado, G. F. (2006). Intelligence and other Adolescent Psychiatry, 42(10), 1203–1211.
predisposing factors in exposure to trauma and posttraumatic stress Ghosh-Ippen, C., Ford, J., Racusin, R., Acker, M., Bosquet, K., Rogers,
disorder: a follow-up study at age 17 years. Archives of General C., & Edwards, J. (2002). Trauma events screening inventory-parent
Psychiatry, 63(11), 1238–1245. report revised. San Francisco: The Child Trauma Research Project
Brewin, C. R. (2001). A cognitive neuroscience account of posttraumatic of the Early Trauma Network and The National Center for PTSD
stress disorder and its treatment. Behaviour Research and Therapy, Dartmouth Child Trauma Research Group.
39(4), 373–393. Gillberg, C., Gillberg, C., Råstam, M., & Wentz, E. (2001). The Asperger
Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation syndrome (and high-functioning autism) diagnostic interview
theory of posttraumatic stress disorder. Psychological Review, (ASDI): a preliminary study of a new structured clinical interview.
103(4), 670. Autism, 5(1), 57–66.
Briere, J. (2005). Trauma symptom checklist for young children (TSCYC). Gillberg, I. C., & Gillberg, C. (1989). Asperger syndrome—some epide-
Odessa, FL: Psychological Assessment Resources. miological considerations: a research note. Journal of Child
Buitelaar, J. K., Van der Gaag, R., Klin, A., & Volkmar, F. (1999). Psychology and Psychiatry, 30(4), 631–638.
Exploring the boundaries of pervasive developmental disorder not Goodman, R., Ford, T., & Richards, H. (2000). The Development and
otherwise specified: analyses of data from the DSM-IV autistic dis- Well-Being Assessment: description and initial validation of an in-
order field trial. Journal of Autism and Developmental Disorders, tegrated assessment of child and adolescent psychopathology.
29(1), 33–43. Journal of Child Psychology and Psychiatry and Applied
Cappadocia, M. C., Weiss, J. A., & Pepler, D. (2012). Bullying experi- Disciplines, 41, 645–655.
ences among children and youth with autism spectrum disorders. Grodberg, D., Weinger, P. M., Kolevzon, A., Soorya, L., & Buxbaum, J.
Journal of Autism and Developmental Disorders, 42(2), 266–277. D. (2012). Brief report: the autism mental status examination: de-
Carr, A. (2004). Interventions for post-traumatic stress disorder in chil- velopment of a brief autism-focused exam. Journal of Autism and
dren and adolescents. Pediatric Rehabilitation, 7(4), 231–244. Developmental Disorders, 42(3), 455–459.
*Carrigan, N., and Allez, K. (2017). Cognitive behaviour therapy for Halligan, S. L., Clark, D. M., & Ehlers, A. (2002). Cognitive processing,
post-traumatic stress disorder in a person with an autism spectrum memory, and the development of PTSD symptoms: two experimen-
condition and intellectual disability: a case study. Journal of Applied tal analogue studies. Journal of Behavior Therapy and Experimental
Research in Intellectual Disabilities, 30(2), 326-335. Psychiatry, 33(2), 73–89.
*Carvill, S., and Marston, G. (2002). People with intellectual disability, *Harley, E. K., Williams, M. E., Zamora, I., and Lakatos, P. P. (2014).
sensory impairments and behaviour disorder: a case series. Journal Trauma treatment in young children with developmental disabilities:
of Intellectual Disability Research, 46(3), 264-272. applications of the child-parent psychotherapy (CPP) model to the
*Cook, E. H., Kieffer, J. E., Charak, D. A., and Leventhal, B. L. (1993). cases of" James" and" Juan". Pragmatic Case Studies in
Autistic disorder and post-traumatic stress disorder. Journal of the Psychotherapy, 10(3), 156-195.
American Academy of Child and Adolescent Psychiatry, 32(6), Haruvi-Lamdan, N., Horesh, D., & Golan, O. (2017). PTSD and autism
1292-1294. spectrum disorder: co-morbidity, gaps in research, and potential
Davis, M. I., & Clark, D. M. (1998). Predictors of analogue post- shared mechanisms. Psychological trauma: theory, research, prac-
traumatic intrusive cognitions. Behavioural and Cognitive tice and policy. https://doi.org/10.1037/tra0000298.
Psychotherapy, 26(4), 303–314. *Hofvander, B., Delorme, R., Chaste, P., Nydén, A., Wentz, E., Ståhlberg,
*de Bruin, E. I., Ferdinand, R. F., Meester, S., de Nijs, P. F., and Verheij, O., et al. (2009). Psychiatric and psychosocial problems in adults
F. (2007). High rates of psychiatric co-morbidity in PDD-NOS. with normal-intelligence autism spectrum disorders. BMC
Journal of Autism and Developmental Disorders, 37(5), 877-886. Psychiatry, 9(1), 35.
Du Fort, G. G., Newman, S. C., & Bland, R. C. (1993). Psychiatric *Hollocks, M. J., Pickles, A., Howlin, P., and Simonoff, E. (2016). Dual
comorbidity and treatment seeking: sources of selection bias in the cognitive and biological correlates of anxiety in autism spectrum
study of clinical populations. The Journal of Nervous and Mental disorders. Journal of Autism and Developmental Disorders,
Disease, 181(8), 467–474. 46(10), 3295-3307.
Hoover, D. W. (2015). The Effects of Psychological Trauma on Children *Mattila, M. L., Hurtig, T., Haapsamo, H., Jussila, K., Kuusikko-Gauffin,
with Autism Spectrum Disorders: a Research Review. Review S., Kielinen, M., et al. (2010). Comorbid psychiatric disorders asso-
Journal of Autism and Developmental Disorders, 2(3), 287-299. ciated with Asperger syndrome/high-functioning autism: a
Humphrey, N., & Hebron, J. (2015). Bullying of children and adolescents community-and clinic-based study. Journal of Autism and
with autism spectrum conditions: a ‘state of the field’review. Developmental Disorders, 40(9), 1080-1093.
International Journal of Inclusive Education, 19(8), 845–862. *Mcconachie, H., McLaughlin, E., Grahame, V., Taylor, H., Honey, E.,
Kaufman, J., Birmaher, B., Brent, D., Rao, U. M. A., Flynn, C., Moreci, Tavernor, L., et al. (2014). Group therapy for anxiety in children
P., et al. (1997). Schedule for affective disorders and schizophrenia with autism spectrum disorder. Autism, 18(6), 723-732.
for school-age children-present and lifetime version (K-SADS-PL): Mcleer, S. V., Deblinger, E., Atkins, M. S., Foa, E. B., & Ralphe, D. L.
initial reliability and validity data. Journal of the American Academy (1988). Post-traumatic stress disorder in sexually abused children.
of Child and Adolescent Psychiatry, 36(7), 980–988. Journal of the American Academy of Child and Adolescent
Kerns, C. M., & Kendall, P. C. (2012). The presentation and classification Psychiatry, 27(5), 650–654.
of anxiety in autism spectrum disorder. Clinical Psychology: Mcleer, S. V., Deblinger, E., Henry, D., & Orvaschel, H. (1992). Sexually
Science and Practice, 19(4), 323–347. abused children at high risk for post-traumatic stress disorder.
Kerns, C. M., Kendall, P. C., Berry, L., Souders, M. C., Franklin, M. E., Journal of the American Academy of Child and Adolescent
Schultz, R. T., et al. (2014). Traditional and atypical presentations of Psychiatry, 31(5), 875–879.
anxiety in youth with autism spectrum disorder. Journal of Autism McManus, S., Meltzer, H., Brugha, T. S., Bebbington, P. E., and Jenkins,
and Developmental Disorders, 44(11), 2851–2861. R. (2009). Adult psychiatric morbidity in England, 2007: Results of
Kerns, C. M., Newschaffer, C. J., & Berkowitz, S. J. (2015). Traumatic a household survey. The NHS Information Centre for health and
childhood events and autism spectrum disorder. Journal of Autism social care.
and Developmental Disorders, 45(11), 3475–3486. McPheeters, M. L., Warren, Z., Sathe, N., Bruzek, J. L., Krishnaswami,
Kerns, C. M., Renno, P., Kendall, P. C., Wood, J. J., & Storch, E. A. S., Jerome, R. N., & Veenstra-Vanderweele, J. (2011). A systematic
(2017). Anxiety disorders interview schedule–autism addendum: review of medical treatments for children with autism spectrum
reliability and validity in children with autism spectrum disorder. disorders. Pediatrics, 127(5), e1312–e1321.
Journal of Clinical Child and Adolescent Psychology, 46(1), 88– *Mehtar, M., and Mukaddes, N. M. (2011). Posttraumatic stress disorder
100. in individuals with diagnosis of autistic spectrum disorders.
Kessler, R. C., Avenevoli, S., Costello, E. J., Georgiades, K., Green, J. G., Research in Autism Spectrum Disorders, 5(1), 539-546.
Gruber, M. J., et al. (2012). Prevalence, persistence, and *Mevissen, L., Lievegoed, R., and De Jongh, A. (2011). EMDR treat-
sociodemographic correlates of DSM-IV disorders in the National ment in people with mild ID and PTSD: 4 cases. Psychiatric
Comorbidity Survey Replication Adolescent Supplement. Archives Quarterly, 82(1), 43-57.
of General Psychiatry, 69(4), 372–380. Moher, D., Liberati, A., Tetzlaff, J., Altman, D., & The PRISMA Group.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & (2009). Preferred reporting items for systematic reviews and meta-
Walters, E. E. (2005). Lifetime prevalence and age-of-onset distri- analyses: the PRISMA statement. PLoS Medicine, 6(7), e1000097.
butions of DSM-IV disorders in the National Comorbidity Survey https://doi.org/10.1371/journal.pmed1000097.
Replication. Archives of General Psychiatry, 62(6), 593–602. Perrin, S., Meiser-Stedman, R., & Smith, P. (2005). The Children's
King, R. (2010). Commentary: complex post-traumatic stress disorder: Revised Impact of Event Scale (CRIES): validity as a screening
implications for individuals with autism spectrum disorders – part I. instrument for PTSD. Behavioural and Cognitive Psychotherapy,
Journal on Developmental Disabilities, 16(3), 91-100. 33(4), 487–498.
Klin, A., Pauls, D., Schultz, R., & Volkmar, F. (2005). Three diagnostic Pynoos, R. S., Weathers, F. W., Steinberg, A. M., Marx, B. P., Layne, C.
approaches to Asperger syndrome: implications for research. M., Kaloupek, D. G., Schnurr, P. P., Keane, T. M., Blake, D. D.,
Journal of autism and developmental disorders, 35(2), 221-234. Newman, E., Nader, K. O., and Kriegler, J. A. (2015). Clinician-
*Kosatka, D., and Ona, C. (2014). Eye movement desensitization and Administered PTSD Scale for DSM-5—child/adolescent version.
reprocessing in a patient with Asperger’s disorder: case report. Scale available from the National Center for PTSD at www.ptsd.
Journal of EMDR Practice and Research, 8(1), 13-18. va.gov.
Le Couteur, A., Rutter, M., Lord, C., Rios, P., Robertson, S., Holdgrafer, Reardon, T. C., Gray, K. M., & Melvin, G. A. (2015). Anxiety disorders
M., & McLennan, J. (1989). Autism diagnostic interview: a stan- in children and adolescents with intellectual disability: prevalence
dardized investigator-based instrument. Journal of autism and de- and assessment. Research in Developmental Disabilities, 36, 175–
velopmental disorders, 19(3), 363-387. 190.
Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism Diagnostic *Reinvall, O., Moisio, A. L., Lahti-Nuuttila, P., Voutilainen, A.,
Interview-Revised: a revised version of a diagnostic interview for Laasonen, M., and Kujala, T. (2016). Psychiatric symptoms in chil-
caregivers of individuals with possible pervasive developmental dis- dren and adolescents with higher functioning autism spectrum dis-
orders. Journal of autism and developmental disorders, 24(5), 659– orders on the Development and Well-Being Assessment. Research
685. in Autism Spectrum Disorders, 25, 47-57.
Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L., Dilavore, Rutter, M., Bailey, A., and Lord, C. (2003). The social communication
P. C., et al. (2000). The Autism Diagnostic Observation Schedule— questionnaire: Manual. Western Psychological Services.
Generic: a standard measure of social and communication deficits *Ryan, R. (1994). Posttraumatic stress disorder in persons with develop-
associated with the spectrum of autism. Journal of Autism and mental disabilities. Community Mental Health Journal, 30(1), 45-
Developmental Disorders, 30(3), 205–223. 54.
Mandell, D. S., Walrath, C. M., Manteuffel, B., Sgro, G., & Pinto-Martin, Scheeringa, M. S., Zeanah, C. H., & Cohen, J. A. (2011). PTSD in
J. A. (2005). The prevalence and correlates of abuse among children children and adolescents: toward an empirically based algorithm.
with autism served in comprehensive community-based mental Depression and Anxiety, 28(9), 770–782.
health settings. Child Abuse and Neglect, 29(12), 1359–1372. Schopler, E., Reichler, R. J., & Renner, B. R. (2002). The childhood
March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Conners, C. K. autism rating scale (CARS). Los Angeles, CA: Western
(1997). The Multidimensional Anxiety Scale for Children (MASC): Psychological Services.
factor structure, reliability, and validity. Journal of the American Shaffer, D., Schwab-Stone, M. E., Fisher, P., Cohen, P., Piacentini, J.,
Academy of Child and Adolescent Psychiatry, 36(4), 554–565. Davies, M., et al. (1993). The Diagnostic Interview Schedule for
Children-Revised Version (DISC-R): I. Preparation, field testig, people with autism spectrum disorders. Review Journal of Autism
interrater reliability, and acceptability. Journal of the American and Developmental Disorders, 3(2), 137–153.
Academy of Child and Adolescent Psychiatry, 39, 28–38. Weathers, F. W., Litz, B. T., Herman, D., Huska, J., & Keane, T. (1994).
Silverman, W. K., & Albano, A. M. (1996). The anxiety disorders inter- The PTSD checklist-civilian version (PCL-C). Boston, MA:
view schedule for children for DSM-IV: clinician manual (child and National Center for PTSD.
parent versions). San Antonio, TX: Psychological Corporation. Weathers, F.W., Blake, D.D., Schnurr, P.P., Kaloupek, D.G., Marx, B.P.,
South, M., & Rodgers, J. (2017). Sensory, emotional and cognitive con- and Keane, T.M. (2013a). The Clinician-Administered PTSD Scale
tributions to anxiety in autism spectrum disorders. Frontiers in for DSM-5 (CAPS-5). Interview available from the National Center
Human Neuroscience, 11, 1–6. for PTSD at www.ptsd.va.gov.
Spataro, J., Mullen, P. E., Burgess, P. M., Wells, D. L., & Moss, S. A. Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., and
(2004). Impact of child sexual abuse on mental health. The British Schnurr, P.P. (2013b). The PTSD checklist for DSM-5 (PCL-5).
Journal of Psychiatry, 184(5), 416–421. Scale available from the National Center for PTSD at www.ptsd.
Spence, S. H. (1998). A measure of anxiety symptoms among children. va.gov.
Behaviour Research and Therapy, 36(5), 545–566. *Weiss, J. A., and Lunsky, Y. (2010). Group cognitive behaviour therapy
Springer, K. W., Sheridan, J., Kuo, D., & Carnes, M. (2007). Long-term for adults with Asperger syndrome and anxiety or mood disorder: a
physical and mental health consequences of childhood physical case series. Clinical psychology and psychotherapy, 17(5), 438-446.
abuse: results from a large population-based sample of men and
White, S. W., Lerner, M. D., McLeod, B. D., Wood, J. J., Ginsburg, G. S.,
women. Child Abuse and Neglect, 31(5), 517–530.
Kerns, C., et al. (2015). Anxiety in youth with and without autism
Sreckovic, M. A., Brunsting, N. C., & Able, H. (2014). Victimization of
spectrum disorder: examination of factorial equivalence. Behavior
students with autism spectrum disorder: a review of prevalence and
Therapy, 46(1), 40–53.
risk factors. Research in Autism Spectrum Disorders, 8(9), 1155–
1172. White, S. W., Mazefsky, C. A., Dichter, G. S., Chiu, P. H., Richey, J. A.,
*Storch, E. A., Sulkowski, M. L., Nadeau, J., Lewin, A. B., Arnold, E. B., & Ollendick, T. H. (2014). Social-cognitive, physiological, and neu-
Mutch, P. J., et al. (2013). The phenomenology and clinical corre- ral mechanisms underlying emotion regulation impairments: under-
lates of suicidal thoughts and behaviors in youth with autism spec- standing anxiety in autism spectrum disorder. International Journal
trum disorders. Journal of Autism and Developmental Disorders, of Developmental Neuroscience, 39, 22–36.
43(10), 2450-2459. *White, S. W., Ollendick, T., Albano, A. M., Oswald, D., Johnson, C.,
*Taylor, J. L., and Gotham, K. O. (2016). Cumulative life events, trau- Southam-Gerow, M. A., et al. (2013). Randomized controlled trial:
matic experiences, and psychiatric symptomatology in transition- multimodal anxiety and social skill intervention for adolescents with
aged youth with autism spectrum disorder. Journal of autism spectrum disorder. Journal of Autism and Developmental
Neurodevelopmental Disorders, 8(1), 28. Disorders, 43(2), 382-394.
The Joanna Briggs Institute. (2016). Checklist for Case Reports. http:// *White, S. W., Schry, A. R., and Maddox, B. B. (2012). Brief report: the
joannabriggs.org/research/critical-appraisal-tools.html. Accessed 15 assessment of anxiety in high-functioning adolescents with autism
April 2017. spectrum disorder. Journal of Autism and Developmental Disorders,
*Trelles Thorne, M.P., Khinda, N., Discussant:, and Coffey, B. J. (2015). 42(6), 1138-1145.
Posttraumatic stress disorder in a child with autism spectrum disor- Widom, C. S. (1999). Posttraumatic stress disorder in abused and
der: challenges in management. Journal of Child and Adolescent neglected children grown up. American Journal of Psychiatry,
Psychopharmacology, 25(6), 514-517. 156(8), 1223–1229.
*Ung, D., Arnold, E. B., De Nadai, A. S., Lewin, A. B., Phares, V., Wigham, S., & Mcconachie, H. (2014). Systematic review of the proper-
Murphy, T. K., and Storch, E. A. (2014). Inter-rater reliability of ties of tools used to measure outcomes in anxiety intervention stud-
the anxiety disorders interview schedule for DSM-IV in high- ies for children with autism spectrum disorders. PLoS One, 9(1),
functioning youth with autism spectrum disorder. Journal of e85268.
Developmental and Physical Disabilities, 26(1), 53-65. Wolfe, J., Kimerling, R., Brown, P., & Chrestman, K. (1993). The life
Valenti, M., Ciprietti, T., Di Egidio, C., Gabrielli, M., Masedu, F., stressor checklist. Boston: National Center for PTSD, Boston VA
Tomassini, A. R., & Sorge, G. (2012). Adaptive response of children Medical Center.
and adolescents with autism to the 2009 earthquake in L’Aquila, Wood, J. J., & Gadow, K. D. (2010). Exploring the nature and function of
Italy. Journal of Autism and Developmental Disorders, 42(6), anxiety in youth with autism spectrum disorders. Clinical
954–960. Psychology: Science and Practice, 17(4), 281–292.
van Steensel, F. J., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders *Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., and Langer, D. A.
in children and adolescents with autistic spectrum disorders: a meta- (2009). Cognitive behavioral therapy for anxiety in children with
analysis. Clinical Child and Family Psychology Review, 14(3), 302. autism spectrum disorders: a randomized, controlled trial. Journal
Vasa, R. A., Carroll, L. M., Nozzolillo, A. A., Mahajan, R., Mazurek, M. of Child Psychology and Psychiatry, 50(3), 224-234.
O., Bennett, A. E., et al. (2014). A systematic review of treatments *Wood, J. J., Ehrenreich-May, J., Alessandri, M., Fujii, C., Renno, P.,
for anxiety in youth with autism spectrum disorders. Journal of Laugeson, E., et al. (2015). Cognitive behavioral therapy for early
Autism and Developmental Disorders, 44(12), 3215–3229. adolescents with autism spectrum disorders and clinical anxiety: a
Walters, S., Loades, M., & Russell, A. (2016). A systematic review of randomized, controlled trial. Behavior Therapy, 46(1), 7-19.
effective modifications to cognitive behavioural therapy for young

A Systematic Review of The Assessment and Treatment of Posttraumatic Stress Disorder in Individuals With Autism Spectrum Disorders

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Review Journal of Autism and Developmental Disorders (2019) 6:294–324

A Systematic Review of the Assessment and Treatment of Posttraumatic

Selection of Articles quantitative study designs (The EPHPP quality assessment

Grey literature (e.g. thesis, conference abstracts, confer- Study Selection

Fig. 1 PRISMA flow diagram of Titles and abstracts

Records screened for eligibility Excluded

Full copies retrieved and assessed

Full copies retrieved and

Searching in reference list

Searching relevant Excluded

Publi ons mee ng

Sample characteristics of the studies included in the review

trauma history and N = 1 (Autism, confirmed via a violence and

functioning, with study. 87% of the

(2014)1,2 using CAMHS immediate using score of > 15 on

Treatment-seeking completed during

Assessment, prevalence and presentation of PTSD Treatment of PTSD

Assessment, prevalence and presentation of PTSD Treatment of PTSD

Assessment, prevalence and presentation of PTSD Treatment of PTSD

disorder, 19.1% had

Assessment, prevalence and presentation of PTSD Treatment of PTSD

structured clinical in- disorder, 8% for bipo-

Assessment, prevalence and presentation of PTSD Treatment of PTSD

Assessment, prevalence and presentation of PTSD Treatment of PTSD

to report (disturbing Treatment had to be for PTSD according to

Assessment, prevalence and presentation of PTSD Treatment of PTSD

defensive covering of find ways to help

tion of familiar staff.

Assessment, prevalence and presentation of PTSD Treatment of PTSD

Assessment, prevalence and presentation of PTSD Treatment of PTSD

(Marijuana use almost

Assessment, prevalence and presentation of PTSD Treatment of PTSD

Anger, arguments, aggressive and oppositional behaviour

children (Trelles Thorne et al. 2015; Harley et al. 2014;

Mevissen et al. 2011) and two adults (Weiss and Lunsky

gestive of additional impacts on mood included reporting sad-

ness and withdrawal (Trelles Thorne et al. 2015), anhedonia

et al. 2011) an erratic appetite, lost interest in activities (Weiss

and Lunsky 2010), absence of sexual behaviour and self-

harm. Additional symptoms which may be indicative of an

exacerbation of ASD features and additional functional im-

pairments included increased hypersensitivity to touch, com-

pulsive behaviours, declining academic performance, hyper-

activity and impulsivity. Substance dependence was reported

in one case (Weiss and Lunsky 2010).

A total of 823 cases were reported across the 14 included

papers. Sample size varied from 30 to 122, with a median of

52.5. The majority of studies recruited children and adoles-

cluded individuals aged 18 and over (Hofvander et al. 2009;

Taylor and Gotham 2016; Mehtar and Mukaddes 2011). One

paper was based on a sample of males (Taylor and Gotham

2016), whilst all other articles were based on mixed-gender

samples. The highest proportion of females recruited was

33%, which occurred within three studies (Hofvander et al.

23.5% female participants. Six of the studies selectively ad-

vertised for or recruited individuals with an anxiety disorder

summary of demographic characteristics, see Table 1.

ified in 12 articles. In the two studies that reported their

participants had been victims of mixed traumas (Taylor

and Gotham 2016; Mehtar and Mukaddes 2011). A range

Hollocks et al. (2016)1,2

of assessment measures and informants was used across the

Storch et al. (2013)1,2