Individuals with Asperger’s Syndrome (AS) and high functioning autism (HFA) often report being bullied at some point in their lives. Many describe in great detail the experience of being bullied, and some appear traumatized by the experience. In my clinical experience, individuals with AS and HFA appear to develop post-traumatic stress symptoms as a consequence of bullying. Parents, teachers, and clinicians should be alert to this possibility.
What is Bullying?
The pioneer of bullying research, Dan Olweus (1993), has defined bullying as the experience of being exposed, repeatedly and over time, to negative actions by one or more other persons, and having difficulty defending oneself. Olweus described nine types of bullying behavior including verbal and physical aggression, isolation, lies, false rumors, threats, and racial, sexual and cyber bullying. Bullying may be overt or subtle but in all cases involves an interaction where there is an imbalance of power.
Bullies generally victimize individuals who appear or act different from the group. Individuals with AS and HFA are particularly vulnerable in school and work settings, given their social and communication challenges. Their behavior may be viewed as unusual, annoying or socially clumsy. If they show anxiety, this may be perceived as a weakness that can be exploited. Individuals with AS and HFA may be socially isolated, and lack the supports that would protect them from being bullied.
Unfortunately, individuals with AS and HFA may not recognize bullying when it occurs. Baron-Cohen et al., (1985) have described how autism spectrum disorders are associated with deficits in “theory of mind” abilities, namely they have difficulty attributing mental states (beliefs, intents, desires, and feelings) to themselves and others, and understanding that other people have mental states that are different from their own. This makes it challenging to recognize and interpret subtle social cues and social signals of threat and sarcasm. Credulity and gullibility are important factors in our understanding of why individuals with AS and HFA are often victims of bullying (Sofronoff et al., 2011).
Credulity is defined as the ability to determine whether something is believable; gullibility refers to the experience of being vulnerable to being tricked or manipulated. Individuals with AS and HFA tend to interpret verbal exchanges and social cues literally, and may therefore be more vulnerable to bullying, and have fewer resources to combat the bullying when it occurs.
The Effects and the Neurobiology of Bullying
Victims of bullying have been shown to be at risk for depression and suicidal thoughts. In addition, we should consider the possibility that individuals with AS and HFA who have experienced bullying may be at risk for developing Post-Traumatic Stress Disorder (PTSD). As a result of the bullying they may develop traumatic memories that are sufficiently intense to lead to the re-experiencing of the trauma, avoidance of situations that bring up these memories, and a chronic state of hyper-arousal.
Studies on the neurobiology of AS and HFA have provided clues to why individuals with these conditions may be more prone to developing PTSD after being bullied. Neuroimaging studies have found differences in the structure and function of the amygdala and prefrontal cortex in the brains of individuals with AS and HFA, as compared to typically developing individuals. The amygdala is the area of the brain that is involved in the detection of threat and the formation of fear responses to a threat. These responses, also known as “fight or flight” responses, are mostly automatic/instinctive and are critically important for survival. The amygdala is activated when a threat is identified and rapidly activates different brain regions to prepare the mind and body for action. At the same time the prefrontal cortex assesses whether an action needs to be taken, and therefore has a modulating effect on the amygdala and the fight-flight response.
Individuals with AS and HFA have been shown to have an overly active amygdala that acts semi-autonomously due to under-developed connections with key regions of the prefrontal cortex. This may lead to exaggerated fear responses to events and, through the amygdala’s effect on the memory circuits of the brain, the formation of intense fear-based memories of these events. The overly active amygdala also increases the stress hormone response to such events, leading to hypervigilance and hyperarousal. This neurobiological model helps explain why intense experiences such as bullying may cause post-traumatic stress symptoms in individuals with AS and HFA.
Building on neuroscience research findings, Markram and Markram (2010) have articulated the “Intense World Theory of Autism,” which may have relevance to the experience of bullying in individuals with AS and HFA. The theory describes psychological and brain functioning in individuals on the autism spectrum that places them at heightened risk of developing exaggerated responses to environmental stressors. The model proposes that individuals with autism spectrum disorders experience sensory inputs in an exaggerated form, hyper-focus on certain aspects of the environment, form clear and intense memories of the events that unfold, and have heightened emotional and fear responses. This leads to changes in neural circuits that “cements” the negative experience of the initiating sensory event.
As a clinician, I find this model helpful in understanding how painful traumatic memories in individuals with AS and HFA form, and how bullying may lead to post-traumatic symptoms.
What Can We Do About Bullying?
Educators, clinicians, and caregivers should take seriously the issue of bullying among individuals with AS and HFA, especially since these individuals are frequently the victims of bullying and may be at risk of developing intense traumatic memories as a result. In the event that bullying has occurred, caregivers and professionals must ensure the bullying stops and, in addition, be alert to signs of post-traumatic stress so that a therapeutic intervention can be initiated.
Clinical studies with typically developing individuals have found that cognitive behavioral therapy is effective in the treatment of PTSD, and includes psycho-education, gradual exposure, and the teaching of relaxation strategies. However, these therapeutic approaches (which are frequently manualized) need to be modified to meet the needs of individuals with AS and HFA who have PTSD.
Markram and Markram (2010) propose a therapeutic approach for individuals with autism spectrum disorders that would include progressive systematic desensitization to stimuli that have evoked heightened fear responses and intense memories. Their proposed treatment model is described as an extinction-based rehabilitation, with a cognitive behavioral component. Its success depends on the creation of a sense of safety, both with the clinician and in the environment more generally.
It is clearly important to recognize and treat any distressing and potentially disabling symptoms caused by bullying. However, this is insufficient. Strong policies must be established in schools, workplaces, and communities, to prevent the victimization and bullying of individuals with AS and HFA. Recent legislation in states like New Jersey aim to reduce bullying by implementing state-wide bullying prevention programs (Schroeder et al., 2011). However, much work needs to be done to ensure that policies are implemented and enforced so that all individuals, including those with AS and HFA, are safe from bullying.
Charles Cartwright, M.D., is Director of the YAI Autism Center and Chief of the Premier HealthCare Autism Research and Treatment Institute. Victoria Bein, M.A., M.S., is Coordinator at the Premier HealthCare Autism Research and Treatment Institute. Premier HealthCare is a member of the YAI Network. For more information about the YAI Autism Center visit yai.org/autism or call 1-888-YAI-Autism. For additional information about Premier HealthCare and other services available through the YAI Network, visit yai.org or call 1-866-2-YAI-LINK.