Autism Spectrum Disorder Case Study

What is ASD?
Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that typically manifests before the age of three. Individuals with ASD have impairments in social interaction, communication, and behavior. This is referred to as the Triad of Impairments. Behavioral impairments include repetitive behaviors such as arm flapping or body rocking, being easily upset by minor changes to routine, and obsessive or ritualized behaviors and interests. Communication impairments include delayed speech, repetition of words or phrases, and unusual speech inflection. Social impairment is similar to communication impairment, but also includes having difficulty with interpreting communication, poor eye contact, flat affect, difficulties with playing

with others, and being resistant to physical contact.
Social deficits may play a significant role when it comes to violent and aggressive behaviors among individuals with ASD. Individuals with ASD’s social fears can manifest as compulsive behaviors and reactive violence and/or aggression (Reynolds & Dombeck, 2006). Social skills deficits may cause individuals with ASD to be more vulnerable to developing psychological distress because they have less access to the protective effects of social support due to their difficulty maintaining social relationships (Segrin, McNeils, & Swiatkowski, 2015). These social deficits may also play a role in aggression because of the frustration that these deficits cause. Living in a world that involves extensive social interaction may cause significant frustration for individuals with ASD who may have difficulty coping with this reality. This frustration could lead to compulsive aggressive behaviors if this frustration is not managed. These social deficits might also cause individuals with ASD to misinterpret the behaviors of others (Dodge & Crick, 1990). This could easily cause frustration in the individual who does not understand the reason behind someone else’s frustration at their actions. For instance, if someone cuts in line simply because they do not know that this behavior is socially inappropriate, the behavior might be interpreted as rude even though the individual did not intend it to be. Taken together, it is possible these social deficits could confer risk for aggressive behaviors. However, empirical evidence regarding the relation between social impairment in ASD and aggressive/violent behaviors is lacking.
Theory of Mind
Some researchers have proposed that deficits in theory of mind among individuals with ASD could confer risk for increased violent behaviors (Baron-Cohen, Leslie, & Frith, 1985; Leslie & Frith, 1987). As defined by Baron-Cohen (2001), theory of mind refers to “the full range of mental states (beliefs, desires, intentions, imagination, emotions, etc.) that cause action. In essence, theory of mind is a crucial component in understanding the underlying mental processes, intents, and motives of one’s self and others. For example, an individual with deficits in theory of mind may have more difficulty understanding the distress of an individual that lost a family member and may not understand the behaviors and social cues that accompany this distress. Lacking the ability to fully understand why an individual is experiencing distress in response to a negative life event may limit the ability of an individual to express empathy.
In this vein, researchers have examined if empathy and theory of mind are closely related and whether theory of mind is a critical component in the display of empathy. fMRI research indicates that neuronal networks activated for theory of mind partially overlap with neuronal networks activated for empathetic responses, particularly in the medial prefrontal cortex, temporoparietal junction, and temporal poles (Völlm et al., 2006). Given the overlap found in neuronal activation, particularly in the medial prefrontal cortex, it appears likely that higher order cognitive processes like executive function are required for both theory of mind and empathy. Research with ASD individuals indicates that executive function deficits, which involve regions of the prefrontal cortex, are associated with deficits in theory of mind (Ozonoff, Pennington, & Rogers, 1991). Thus, it may be possible that individuals with ASD, who are more likely to have deficits in executive function compared to the neurotypical population, experience deficits in theory of mind due to executive function deficits and not as as result of having ASD. However, additional research is required to determine the degree to which executive function deficits explain deficits in theory of mind compared to ASD-status (i.e. present vs. not present).
While research indicates that, on average, individuals with ASD have lower theory of mind compared to controls (Baron-Cohen, 2001; Baron-Cohen, Leslie, & Frith, 1985), extant research examining within-group variability of individuals with ASD indicates that theory of mind is likely not a significant predictor of violent behaviors. Woodbury-Smith and colleagues (2005) examined theory of mind in 21 individuals with ASD that had committed a violent crime and 23 individuals with ASD that had not committed a violent crime. Results indicate there was not a significant difference in theory of mind between these groups. While this may be attributable to low statistical power as a result of a small sample, individuals with ASD that had a violent history had a higher mean score for theory of mind compared to the individuals with ASD with no violent history. Thus, the extant empirical evidence does not support the notion that deficits in theory of mind increases risk for individuals with ASD to commit violent behaviors.
Types of Aggression
When examining aggression and violence exhibited by individuals with ASD, it is important to compare features of violent behavior in ASD with violent behaviors that appear more frequently in neurotypical populations. There are two primary forms of aggression: affective and predatory (Wuhland & Kristiansson, 2006). Affective aggression consists of acts that are reactive and instant. They are spontaneous and triggered by sympathetic activation of the autonomic nervous system. Affective aggression involves stimulus-driven “bottom-up” processes that do not significantly rely on executive function. Predatory aggression, on the other hand, involves minimal arousal and requires a capacity for controlled planning. Predatory aggression is characterized by “top-down” cognitive processes that require engagement of executive function and higher order cognitive processes (Wuhland & Kristiansson, 2006). As mentioned previously, ASD individuals are more likely to display deficits in executive function compared to neurotypical controls (Ozonoff, Pennington, & Rogers, 1991). Thus, individuals with ASD may be less likely to display predatory aggression, as executive function is a critical aspect of predatory aggression. In summary, affective aggression is characterized by “hot” cognitions and predatory aggression is characterized by “cold” cognitions, because affective aggression tends to be more driven by a reactive and emotional response while predatory aggression tends to be driven by higher order cognitive processes like executive function (Wuhland & Kristiansson, 2006).
Wuhland and Kristiansson (2006) examined different types of violence and aggression in people diagnosed with ASD and APD. They found that offenders with ASD were less likely to use guns and knives and, instead, were more likely to use methods that were less lethal. ASD offenders were typically younger than those with APD and displayed less planning and more odd motives (Wuhland & Kristiansson, 2006). This indicates that ASD offenders were more likely to exhibit affective aggression than predatory aggression, as the use of an unusual object likely signals less planning and less intent to kill. Predatory aggression is more likely to be indicative of school shootings and other incidences of planned violence and this form of aggression is uncommon among individuals with ASD.
Further, research shows that individuals with ASD are hypersensitive to stimuli (e.g., loud noise, certain textures, etc.; Bjørkly 2009).

This could explain the frustration that overwhelms individuals with ASD while in loud public areas and why they might react with violent behavior. Sensory hypersensitivity was found to be the second largest cause of violent behavior in people diagnosed with ASD (Bjørkly 2009). In one case study, a patient explained his violent behavior by saying that he felt compelled to physically stop a crying child and a barking dog because the frequency and loudness of the sounds were too much for him to handle. The patient believed that violence was the most effective way to end the significant discomfort he experienced (Mawson, Grounds, & Tantam, 1985). Regarding interpersonal communication, psychopaths are manipulative and cunning, while individuals with ASD tend to be more naive in their communication. When individuals with psychopathy are confronted about their violent activities, they are more likely to deny and lie about their violent act, whereas individuals with ASD are more likely to confess and be honest (Bjørkly 2009). This is important because it shows that when individuals with ASD are violent, it is typically not because they are malicious. Rather, it could be that individuals with ASD reacted too strongly to stimuli, engage in affective aggressive, do not fully understand the consequences, and potentially feel remorse for their

reaction.
Comorbidity Rate and Association with Autism Spectrum Disorder
With Autism Spectrum Disorder already ranging in a wide variety of symptoms that may be present in other disorders, it is easy to see the potential for overlap with other disorders they may be suffering from. ASD has a strong association with quite a few disorders and often times the person with ASD is also suffering from another one of these disorders. There are also many different rates and factors that someone suffering from ASD has a higher chance at also suffering from a comorbid disorder.
Someone who is suffering from Autism Spectrum Disorder tends to suffer more when being compared to the neurotypical population. Research shows that someone who has been diagnosed with ASD is three to four times more likely to suffer from a comorbid disorder (Wachtel et al., 2013). With this increased risk, it also seems likely that there will be a variety of possibilities that could come from this, and it has been proven that there are a few disorders that have a higher chance of affecting a person with ASD. With a chance rate of around 37%, it has been shown that someone who suffers from ASD may also be suffering from Obsessive Compulsive Disorder (Tsai 2015). OCD may have one of the highest chances, but there are also other disorders that occupy over a fourth of the people who suffer from ASD. ADHD (28.2%), Social Anxiety Disorder (29.2%), and Oppositional Defiant Disorder (28.2%), are the other disorders that are also highly prevalent in a comorbid relationship with ASD (Tsai 2015). ASD has shown that it is a highly susceptible disorder to comorbidity.
There are many common comorbidities that are found and associated with ASD, but there is also an increased risk factor and indicator that someone may be suffering from another disorder as well. It was discovered that someone suffering from ASD who had committed a crime had a 54% probable chance of suffering from comorbidity with 29.7% suffering from a definite comorbidity (Newman 2008). Along with this increased chance for comorbidity, people who suffer from a form of psychosis have a 49%-68% increased risk for violent behavior (Silverstein 2015). Psychosis may be an important factor in violence a lot of the violence that comes from people who suffer from ASD. In a study of 422 people with ASD and Aspergers, the patients who had ASD and were previously convicted for violence showed that 25.8% of them also suffered from either psychosis or schizophrenia (Wachtel 2009). Violence in patients with ASD and schizophrenia was found to be almost three times as high when compared to ASD patients who did not have schizophrenia (Wachtel 2009). Different forms of psychosis have proven to be possible explanation for the increase in violence that can be displayed by patients who suffer from ASD. People who suffer from ASD suffer differently with possibilities of different comorbidities arising that may lead to an increase in violent behavior. The association between ASD and comorbid disorders has proven to be a possible explanation to an increase in displayed violent behavior
Conclusion and Opinion
Although ASD may be associated with deficits in theory of mind, there is little research that supports the notion that ASD offenders exhibit a more significant deficit in theory of mind compared to ASD non-offenders (Woodbury-Smith et al., 2005).

In addition, the investigation of affective and predatory aggression in relation to ASD indicates that ASD is more strongly associated with affective aggression than predatory aggression (Wahlund & Kristiansson, 2006). Individuals with ASD are more likely to engage in violence that requires less planning and is carried out by more odd motives (Wahlund & Kristiansson, 2006). This indicates that ASD-status is likely not correlated with mass violence, which tends to be associated with predatory aggression which is indicated by conscious planning that engages higher order cognitive processes. Furthermore, the characteristics of violence in ASD individuals are differ from characteristics of violence in those with psychopathy. In reviewing literature on ASD, aggression, and associated comorbidities, we conclude that the link between ASD and violence could be better explained by the high comorbidity of ASD to various psychiatric disorders that are associated with violence if not properly managed (e.g., schizophrenia, ODD, CD). Although some features of ASD, such as social deficits, may increase the likelihood of violence, a conclusive link has not been found in the extant literature. In order to make any claims regarding the relation

between ASD and mass violence, there needs to be more extensive research conducted. Autistic individuals who are the perpetrators of mass violence are more likely than not to have experienced other biological, sociological, or psychological factors that could indeed confer risk to engaging in violent behaviors. Our review of the extant literature has affirmed our belief that there is not enough of a demonstrable link between ASD and instances of planned violence and that it is unjust to attach this negative stigma to the ASD population without the support of empirical evidence.