Aggression is likely the most problematic of all issues that may accompany autism spectrum conditions in terms of separating individuals from the mainstream and significantly affecting many aspects of quality of life. For children and adults alike, problems with aggression can sabotage life direction in significant ways. Social distancing is an obvious consequence as others avoid involvement with an individual who is unpredictably aggressive, and with distancing comes decreased ability to develop relationships, as well as the danger of losing existing ones. For students, aggression can mean loss of inclusion in mainstream education, severely limiting options for academic stimulation and educational achievement. For adults, aggression can result in job loss, which for individuals on the spectrum is often tenuous anyhow. For children, adolescents, and adults physical aggression can lead straight to psychiatric admission and treatment, and in some circumstances arrest and legal proceedings.
When we consider aggression, we need to think about all types and how they manifest. Herein lies the rub for those on the spectrum. Aggression is really a natural part of life that is more or less accepted when it is expressed within socially acceptable circumstances, but clearly understanding these specifics can elude those on the spectrum. There are many kinds of aggression (Nelson et al., 2008) and each has its rules for expression. They include:
- Direct physical aggression that causes overt physical harm.
- Indirect physical aggression that covertly or inadvertently causes physical harm or damages property.
- Verbal aggression including verbal intimidation or disparagement such as insulting, slandering, or verbally attacking.
- Passive aggression designed to cause harm but shield the perpetrator, such as undermining.
- Non-verbal aggression that purposefully avoids or excludes, such as gestural expressions of disdain.
- Direct relational aggression including confrontational or direct behaviors that cause harm by damaging relationships or group inclusion.
- Indirect relational aggression including covert behaviors that damage reputation or group inclusion, such as gossiping.
In reviewing all these types of aggression, one is struck by the fact that those on the spectrum are frequently the victims or targets of such behaviors, yet they are the ones who often are in trouble for “aggression.” Clearly a key element of aggression is the social appropriateness of its expression.
The use of aggression is part of social-emotional development. Physical aggression generally emerges early in life and comes under self-control as a child learns alternate ways of managing behavior. As communication capabilities increase it is generally replaced by verbal aggression. As an individual matures, relational aggression emerges and sophistication in its uses increases with age. Early adolescence marks an increase of many types of aggression as social roles emerge and the world of play is left behind. Yet for those on the spectrum, the development of social communication and understanding may be delayed or different, retarding the emergence of the skilled use of aggression. It is the developmentally inappropriate use of aggression that causes the problems individuals on the spectrum so often encounter. While we accept that a two-year-old can have a tantrum, a ten year old may find himself suspended from school for such behavior. Similarly, those who resort to uncontrolled verbal aggression at an age where self-control is expected may find themselves fired from their job. Meanwhile, such individuals are often themselves victims of covert aggression in the form of bullying, gossiping, and group exclusion and have no real ability to handle these behaviors. Sometimes the mere knowledge that an individual on the spectrum has no defense will encourage covert aggression toward them. There are many other factors in the expression of aggression that will next be considered in an attempt to understand all the influences that can cause expression of inappropriate aggression that can endanger living in the mainstream and the achievement of an acceptable quality of life.
Some of the very characteristics of autism spectrum conditions can be contributory in the expression of aggression. The inflexibility of thinking and resistance to deviations in expectancy can cause an individual to become quite anxious and upset without the skills necessary to communicate distress. The difficulty with transitions that youngsters may have or the anxiety adults may experience in periods of life change can also lead to a response of some type of aggression if other skills to manage themselves have not been developed.
Sensory issues can also cause a feeling of overwhelm that may lead to socially inappropriate behavior, including aggression. A person may feel so assaulted by sensation that any escape is sought. In addition, the discomfort that sensory hypersensitivity causes can make one more vulnerable to increased anxiety. So, someone may be exhibiting inappropriately aggressive behavior arising from any number of sensations not obvious to others, but very overwhelming to the individual so affected.
Many individuals on the spectrum manifest difficulties with information processing because they are doing so in much slower time than is typical and needed to keep up with neurotypical interplay. For example, a child may be confused because he is still processing the directions for an assignment when everyone else is getting up to leave the room. Later, there may be a demand based on those incompletely processed directions. Children who have impaired processing speed may feel perpetually confused over expectations, transitions, instructions, or other’s intentions causing them to feel perpetually stressed from lack of understanding.
Emotional dysregulation occurs when judgment and management strategies are overwhelmed by the strength of an emotion and coping resources cannot be marshaled. As the executive functions that underlie this ability are often less mature for individuals on the spectrum than for those with neurotypical development, many find themselves less able to handle emotional challenges than their age mates. Thus age-inappropriate emotional expression can occur with the resulting disdain of peers and alarm of teachers. Sometimes what may look like overreaction may be the inability to handle the rush of fear and anxiety that may result from an unanticipated transition, the interruption of a focused interest, or the anticipation of potential trauma on the bus, lunchroom, or gym.
Aggression of all types may be exacerbated by the social limitations inherent to those on the spectrum. An individual may be unaware of particular social rules or their nuanced application. They may have had limited opportunity to experience relational controls typically developed through frequent peer interaction. They may misconstrue others’ behavior as confrontational or misunderstand social intent because of their theory of mind limitations. The rather common experience of being bullied or teased may cause increased fear in school or work settings.
In addition to a spectrum condition, many individuals may also have an additional diagnosed or undiagnosed disorder. Individuals who have double challenges from a co-morbid condition are likely to find demanding situations even more difficult and may be unable to manage their behavior. Mood disorders, including bipolar disorder or depression, are themselves issues that can affect self-control, so the additionally vulnerable individual with an autism condition may be at sea in self-management. Individuals on the spectrum may have attentional issues that are typically associated with ADHD that may manifest as problems in activity level, impulsivity, or attentional focus. These factors can make following instructions and classroom demands even more difficult. A response of frustration can look like an aggressive action on first consideration. Before the student realizes the inappropriateness, a cascade of events has occurred. Most individuals on the spectrum struggle with anxiety, but many experience it so severely that an additional diagnosis on the anxiety spectrum could be made. For such individuals, the very intensity of their anxiety may create the impression of intended aggression or their desperate escape behaviors may result in inadvertent harm to others.
Sometimes the treatment for comorbid disorders can itself exacerbate physical or verbal aggression. A stimulant can cause a “crash” as it wears off. SSRIs can cause overactivation, especially during dosage increases. Benzodiazapines can cause agitation and aggression under certain circumstances. Some anticonvulsants can have activating effects. So even the agents used to help can sometimes be the culprits in an aggressive episode.
If direct and indirect physical, verbal, and relational aggression can be viewed in a very different framework, with etiology being carefully considered, we are much more likely to be able to help individuals on the spectrum develop effective coping techniques for the additional challenges they face. We need to be able to:
- Make an objective assessment of their behavior in context
- Consider their neurobiological assets and vulnerabilities
- Consider their social history and opportunity for opportunity to learn interactional strategies
- Assess additional mental health issues
- Develop a sophisticated understanding of triggers, precursors, cognitive differences, and individual situational stressors
With this assessment and knowledge, can blame be removed from the equation and can alternative behaviors be developed and incorporated into the individual’s repertoire? Often the mere understanding of the causative elements can help those around them make effective environmental changes.
We are in a state of knowledge explosion concerning general neurobiological understanding, including that particular issues that affect those on the spectrum. The systematic evaluation of treatments is less well developed. Nevertheless, there are evidence-based interventions that can be utilized effectively to address many of the aforementioned issues.
For the central characteristics of the autism spectrum, we know that visual schedules, preparation for changes and pre-teaching can diminish the anxiety many children experience during the school day. Social stories (Thiemann & Goldstein, 2001; Gray, 2000, 2010) have been an effective anxiety reducer as they help the individual understand what is happening next and what their response could be. Cognitive behavior therapy has been utilized effectively for children and adults (Attwood & Nielson, 2008; Gaus, 2007) to help them handle their unusual thinking, anxiety, or distorted belief systems and communicate more effectively about their experiences.
For sensory issues, it is vital to educate those around them, teach individual self-awareness and management, and encourage self-advocacy from a young age (Williams & Shellenberger, 1996; Paradiz, 2009). When the individual and those in their environment realize the extent to which sensory overwhelm can lead to aggression, everyone can help diminish these kinds of stressors to beneficial result.
Likewise, processing problems can be supportively addressed through a combination of individual awareness and helpful supports. It is useful to assess when confusions occur, to clarify directions and check for understanding, and to assess executive functions through neuropsychological evaluation in order to develop an understanding of personal executive function challenges. From this consideration arises the application of helpful, individualized coping techniques (Metzler, 2010; Buron & Curtis, 2004).
Emotional dysregulation has many contributors including executive function problems, lack of relational experiences, poor problem solving abilities, and social misperception regarding others’ intentions. Ladd & Troop-Gordon (2003) emphasize that adverse peer experiences have long-term consequences concerning a child’s self-belief and skill development. Therefore, systematic efforts to develop relationships in and out of school can help children have experiences that improve personal control and social function (Common Connections at www.aspergercenter.com/articles.html). An understanding of an individual’s cognitive processes informs the individual and important others about coping strategies for emotional dysregulation that might be particularly useful in challenging situations. Difficulties with shifting set, inhibition, or initiation imply different intervention approaches, so a thorough assessment of these aspects through neuropsychological assessment can be very useful.
As impaired social function is a defining characteristic of spectrum conditions and can have a causative effect of the expression of all types of aggression, it is critical that interventions and supports in this area be evidence-based and faithfully executed. General social skills interventions can seem like a good idea, but then may have no real effect. Instruction in social cognition has been shown to be effective for typical issues including handling the unexpected, appropriate social initiating, and social problem solving (Crooke, Hendrix & Rachman, 2008). The many books of Michelle Garcia Winner offer effective curricula for teaching social thinking.
Another factor in inappropriate social behavior, including aggression of all types, is impairment in empathy. Empathic skills vary widely among those on the spectrum, but for those severely affected in this dimension, there can be frequent misreading of others’ intent, opinion, or needs. This type of misunderstanding can be significantly diminished through instruction in empathic skills. Research tells us that such instruction can be effective (Pecukonis, 1990; Long et al., 1999) and there are curricula for school aged children that can be helpful in changing this kind of perception and thinking (Caselman, 2007). There are also some bullying prevention programs that include empathic thinking in their approach. However, large-scale bullying programs have had varying success (Rahey & Craig, 2002), so we need to also address bullying with the children who experience it or engage in it in a more individual way.
Finally, the issue of comorbid mental health issues and their treatment needs also to be integrated into any plan developed to address aggression. Professionals who have real knowledge of the special cognitive characteristics of those on the spectrum and how they may affect mental health can be valuable in dissecting the complicated factors in the expression of aggression and the development of individualized intervention plans. It is always important to ask potential treating clinicians what kind of experience they have in working with complex children and adults with spectrum conditions before engaging in assessment or treatment.
There is no quick solution to understanding and treating aggression of any type, but it is clearly a more complex problem than can be easily modified by behavioral techniques alone. A sophisticated understanding of the underlying and highly variable neurodevelopmental issues is critical to successful outcome. Knowledge of both the types of issues that may be generally germane must be paired with a thorough assessment of the individual’s unique neurodevelopmental profile, psychosocial history, and environmental challenges. An approach that seeks explanation rather than assignment of blame is critical to an effective intervention plan. Because aggression is one of the biggest challenges for individuals on the spectrum and may have the most profound effects on quality of life, we owe them our thoughtful, informed, and cooperative best practices.