Examining Adverse and Benevolent Childhood Experiences and Associated Psychosocial Outcomes Among Autistic Adults

Abstract

Background:

Autistic youth experience high rates of adverse childhood experiences (ACEs), although it is critical to extend this work by further identifying the ACEs most commonly reported by Autistic adults. We know less about rates of benevolent childhood experiences (BCEs) among Autistic adults and how they are associated with ACEs and psychosocial outcomes. The current study aimed to (1) identify rates of ACEs and BCEs, (2) evaluate how they are related for Autistic and non-autistic adults, and (3) evaluate how ACEs and BCEs are associated with psychosocial outcomes (i.e., trauma symptoms, resilience, treatment utilization, vulnerable life experiences [VLE]) across Autistic and non-autistic adults.

Methods:

A total of 276 Autistic adults (M_age = 29 years, M_income = 34,935 U.S. dollars, 46.4% cisgender men, 74.3% White) and 361 non-autistic adults (M_age = 45.69 years, M_income = 56,753 U.S. dollars, 49.9% cisgender women, 66.2% White) completed an online survey. Participants provided information about demographic and treatment history characteristics (age, income, gender, race/ethnicity, treatment use), and completed checklist measures of ACEs and BCEs and self-report scales assessing posttraumatic stress disorder (PTSD) symptoms (Posttraumatic Symptom Checklist for DSM-5, PCL-5), resilience (Brief Resilience Scale), and broader trauma-related and service experiences (VLE scale).

Results:

Autistic adults reported more ACEs and fewer BCEs than non-autistic adults, even when accounting for demographic differences. ACEs and BCEs were weakly to moderately associated to a similar degree across groups. ACEs and BCEs differentially associated with psychosocial outcomes among Autistic and non-autistic adults. Child maltreatment ACEs related to higher PTSD symptoms, VLEs, and use of services. BCEs related to lower VLEs and use of services.

Conclusion:

Autistic adults differentially experience ACEs and BCEs, and trauma-focused supports should seek to facilitate and improve positive experiences among Autistic youth. Future research should identify potential protective factors for Autistic individuals.

Community Brief

Why is this an important issue?

Autistic people experience more stressful experiences, such as adverse childhood experiences, than non-autistic people. Less information is known about positive childhood experiences among Autistic adults and how they relate to mental health and life experiences.

What was the purpose of the study?

This study aimed to identify rates of stressful and positive experiences and examine how they are related for Autistic and non-autistic adults. This study also examined how stressful and positive experiences relate to mental health (trauma symptoms, resilience) and life experiences (using mental health care, negative life experiences).

What did the researchers do?

Researchers collected data from an online survey platform. A total of 276 Autistic and 361 non-autistic adults gave information about their demographic backgrounds, mental health care backgrounds, stressful and positive experiences from childhood, mental health (trauma symptoms, resilience), and other negative life experiences (such as encounters with police or emergency room visits).

What were the results of the study?

Autistic adults experienced more stressful events (e.g., emotional abuse, suicide in the home, emotional neglect, parent divorce, substance use in the home) and fewer positive events (e.g., liking themselves, liking school, having one supportive adult, having good neighbors, having beliefs that give comfort) during childhood than non-autistic adults. Stressful and positive events were weakly to moderately related, which may mean that experiencing lots of stressful childhood events does not mean an individual only experiences few positive experiences (i.e., a person can experience lots of stressful and positive experiences, or few positive and stressful experiences). Experiencing stressful events was related to more trauma symptoms, more negative life experiences, and more use of mental health care. Positive events were related to fewer negative life experiences and less use of mental health care, including less use of mental health therapy for trauma among non-autistic adults, but not Autistic adults. This means that Autistic adults may need more supports for trauma and stress, even when they have experienced positive childhood events.

What do these findings add to what was already known?

These findings support that Autistic adults experience more stressful and fewer positive experiences in childhood than non-autistic adults. Both stressful and positive childhood experiences relate to mental health and other life experiences.

What are potential weaknesses in the study?

This study used a short measure of stressful experiences, which did not ask about broader types of stress such as racial or community stressors, nor autism-specific stressors such as sensory trauma. The measure of positive childhood experiences also has not been used before with Autistic people, so it may not include a wide enough range of positive experiences that Autistic people experience.

How will these findings help Autistic adults now or in the future?

These results emphasize the need for more support in creating positive childhood experiences for Autistic adults and helping Autistic adults heal from stressful or traumatic childhood experiences.

Introduction

Adverse childhood experiences (ACEs) are potentially traumatic or stressful events occurring in childhood and adolescence that are commonly grouped into domains of childhood maltreatment (CM physical emotional and sexual abuse and physical and emotional neglect) and household dysfunction (HD parental divorce witnessing violence in the home incarceration substance use and mental health concerns).¹ Consistent with multidimensional models of adversity it is important to consider both CM and HD experiences for specifying how different domains of ACEs may differentially relate to outcomes.^2,3 For example Autistic people may disproportionately experience CM which may involve direct experiences of victimization and/or HD which may reflect broader disparities in stressful and negative childhood experiences.⁴

ACEs relate to a multitude of poor physical and mental health-related outcomes, through mechanisms at multiple levels of analysis (e.g., psychological changes in stress response system; social processes relating to decreased access to health care).^5–7 However, benevolent childhood experiences (BCEs), a set of psychosocial events associated with positive outcomes, may buffer negative effects of adversity.^8–10 Strikingly, little research has examined how ACEs and BCEs together relate to meaningful psychosocial outcomes in adulthood, particularly for Autistic adults in the United States.

Autism and Adversity

Autistic individuals more frequently experience stressful, adverse, or traumatic events, including higher rates of ACEs, compared with their non-autistic peers, and they may also experience more negative outcomes after traumatic or stressful event exposure.^11–14 Regarding CM ACEs, Autistic youth experience high rates of all maltreatment subtypes, including abuse and neglect, reported to child protective services.^15,16 Autistic adults experience high rates of sexual abuse and violence.¹⁷ Autistic adults also report high rates of physical and emotional abuse, with much of this research occurring in Western countries.¹⁸ Autistic people also experience broader interpersonal stressors such as peer victimization (e.g., bullying), although this is not always routinely assessed as an ACE.⁴

Autistic individuals also are more likely to experience HD ACEs,¹⁹ which reflect a broader range of child adversities beyond CM, although there is a high co-occurrence of CM and HD ACEs among youth.^18,20,21 For example, Autistic people have high rates of exposure to parent mental health difficulties, an HD ACE.^4,22 It is important to consider how Autistic adults experience both CM and HD ACEs, because these domains may differentially relate to outcomes and benefit from different types of prevention and support strategies.

The disparities in trauma, adversity, and physical and mental health outcomes experienced by Autistic individuals, compared with non-autistic individuals, may be understood through a minority stress model.^23,24 This model posits that individuals with a minoritized identity may disproportionately experience adversity and its negative effects due to systemic factors (e.g., societal bias and stigma, inaccessible community supports) that increase both (1) the likelihood of exposure to stressors and (2) the likelihood of experiencing negative mental health effects after adversity exposure (e.g., greater physiological and psychological disparities due to experiencing increased stress related to having a minoritized identity, decreased access to supports).²⁴ Botha and Frost applied this model to Autistic individuals,²³ who are marginalized in society and thus experience high rates of community stigma and bias, high rates of trauma and social stressors (e.g., rejection), combined with often inaccessible mental health supports. Therefore, the minority stress framework explains why Autistic individuals disproportionately experience ACEs, and it is consistent with socioecological theories emphasizing the systemic factors that contribute to high rates of adversity in marginalized communities.^25–27

BCEs Among Autistic Adults

While much research has examined the long-term effects of exposure to early adversity, other research has examined the benefits of early positive experiences and whether they may foster resilience or buffer the effects of adversity.^28,29 The BCE scale was developed to compile a list of positive early life experiences concerning perceived safety, security, and support, as well as predictability and positivity of life (e.g., having at least one caregiver with whom you feel safe, having at least one good friend).²⁹ The BCE measure may capture two different dimensions of positive experiences, including experiences of perceived safety and support (PSS; e.g., having at least one caregiver with whom you feel safe) and internal and environmental motivation (IEM; e.g., having a predictable home routine).³⁰ It is important to assess multiple dimensions of BCEs to better understand the multidimensional nature of how positive childhood experiences may confer resilience.³¹ BCEs have not yet been examined among Autistic adults, a critical priority for understanding potential strengths-promoting factors.

Moreover, it remains unclear whether ACEs and BCEs are separate constructs or opposing dimensions of the same construct for Autistic adults. Several studies among non-autistic adults have reported moderate inverse associations between ACE and BCE composite scores,^29,32,33 which may reflect that these constructs are separate but related. Clarifying the extent to which they are related to one another would advance our understanding of the construct of BCEs, especially as they may be experienced by Autistic adults.

Psychosocial Outcomes Associated with ACEs and BCEs in Autistic Individuals

ACEs negatively impact a variety of mental health outcomes due to their impact on stress response system changes, and broader psychological processes (e.g., emotion regulation, coping).³⁴ Among Autistic adults, experiencing high rates of ACEs relates to higher mental health symptoms, such as posttraumatic stress disorder (PTSD) symptoms and other mental health symptoms (e.g., depression, anxiety).^11,13 Relatedly, high rates of ACEs relate to lower levels of resilience on various trait resilience measures among non-autistic individuals,³⁵ indicating lower levels of an individual’s ability to overcome or adapt to stressors. However, some research suggests that among Autistic youth specifically, higher rates of ACEs are not necessarily associated with lower resilience scores.³⁶

Apart from these psychological impacts, ACEs may also impact social and behavioral outcomes related to service access and/or usage (including use of health care and treatment services).^5,37 For example, high levels of ACEs are associated with a higher likelihood of involvement with the criminal legal system or law enforcement among Autistic adolescents in the United States.¹¹ Similarly, high rates of ACEs are associated with overall greater difficulties accessing health care among families with Autistic children,⁵ or less use of health care services (e.g., not using some health care services, more no-show or late appointments).³⁸ It is important to clarify these patterns of health care service and treatment use for Autistic adults.

It is also important to identify how BCEs relate to these outcomes among Autistic adults. In the general population, high rates of BCEs relate to lower levels of PTSD symptoms²⁹ and more positive psychological outcomes that may counteract the negative impact of adverse experiences.^9,10,39 However, other findings suggest that BCEs may not predict reductions in certain psychological symptoms (e.g., suicidal ideation, perceived stress) when accounting for ACEs, and may not “counteract” all ACEs or impacts of ACEs.^29,32,40

Goals of the Current Study

This study aimed to (1) identify rates of ACEs and BCEs among Autistic relative to non-autistic adults, at the total score, subscale, and individual item level, (2) identify how ACE and BCE dimensions are interrelated for both groups, and (3) evaluate the associations between ACEs, BCEs, and various psychosocial outcomes across Autistic and non-autistic adults. We hypothesized that Autistic adults would report experiencing higher ACEs and fewer BCEs than their non-autistic peers, based on prior research documenting high rates of adversity among Autistic individuals.¹¹ We also anticipated that ACEs and BCEs would be only moderately negatively intercorrelated, due to research suggesting that individuals can report high rates of both experiences. Specifically, adverse and positive experiences may occur together in environments, as evidenced by research reflecting high rates of both adverse and positive experiences among various research samples.^29,33 Neither environment (adverse, positive) excludes either type of experience from occurring, and this has been hypothesized as one explanation for prior research demonstrating that these are independent constructs that are only moderately associated.^29,33

Regarding aim 3, we predicted that higher ACEs would be associated with higher trauma symptom scores, lower resilience scores, less likelihood of participation in psychiatric treatments, and higher rates of trauma-related experiences more broadly. Due to research suggesting that Autistic adults report worse psychosocial outcomes following traumatic or stressful events than non-autistic adults,^5,11,13,38 we specifically predicted that these results would be stronger among Autistic adults than non-autistic adults. Lastly, we anticipated that BCEs would be associated with these outcomes in the opposite direction, even when accounting for the effect of ACEs.^9,10,39 The prediction for whether this association would be stronger or weaker for Autistic compared with non-autistic adults was exploratory, given the lack of prior research on BCEs in Autistic adults.

Method

Participants

Autistic (n = 276) and non-autistic adults (n = 361) from the United States participated in this study. Autistic adults were significantly younger than non-autistic adults (M = 45.69 years, SD = 16.12; t[606.66] = 16.15, p < 0.001), and reported a significantly lower average household income (t[588.13] = 4.99, p < 0.001). There were significant differences for gender identity (χ² [2, n = 637] = 56.91, p < 0.001) and race/ethnicity (χ² [2, n = 637] = 15.38, p < 0.001) across groups of Autistic and non-autistic adults, such that there were more non-autistic cisgender women (49.9% relative to 33.7% in the Autistic group), more Autistic transgender and nonbinary individuals (19.9% relative to 2.5% in the non-autistic group), and fewer Black Autistic individuals (5.1% relative to 14.7% in the non-autistic group). The majority of participants identified as White/non-Hispanic among Autistic (74.3%, n = 205) and non-autistic (66.2%, n = 239) adults. We present descriptive and demographic characteristics across groups in Table 1.

Table 1.

Demographic Characteristics of the Sample and Group Demographic Differences

	Autistic	Non-autistic	Group differences
	M (SD)		t	Df	p	Cohen’s d
AQ-Short score	78.61 (11.28)	64.47 (10.72)	−15.91	617	<.001^*	−1.29
Age (years)	29.00 (9.80)	45.69 (16.12)	16.15	606.66	<.001^*	1.21
Income (USD)	34,935 (40, 194)	56,753 (68,042)	4.99	588.13	<.001^*	.38

	n, %		χ ²	Df	p
Gender			56.91	2	<.001^*
Cisgender woman	93, 33.7%	180, 49.9%
Cisgender man	128, 46.4%	172, 47.6%
Transgender/Nonbinary	55, 19.9%	9, 2.5%
Race/Ethnicity			15.38	2	<.001^*
White	205, 74.3%	239, 66.2%
Black/African American	14, 5.1%	53, 14.7%
Other/non-White	57, 20.7%	69, 19.1%

	M (SD)		t	Df	p	Cohen’s d
ACEs
CM (0–5)	1.72 (1.54)	.97 (1.33)	−6.44	543.16	<.001^*	−.53
HD (0–5)	1.67 (1.41)	1.01 (1.24)	−6.12	548.17	<.001^*	−.50
Total (0–10)	3.40 (2.40)	1.99 (2.26)	−7.51	621	<.001^*	−.61
BCEs
PSS (0–5)	3.61 (1.33)	4.35 (1.02)	7.63	499.01	<.001^*	.63
IEM (0–5)	2.92 (1.42)	3.93 (1.30)	9.32	632	<.001^*	.75
Total (0–10)	6.51 (2.40)	8.27 (2.04)	9.75	533.24	<.001^*	.80

ACE and BCE total scores ranged from 0 to 10, while CM, HD, PSS, and IEM scores ranged from 0 to 5. Gender was coded in a three-part variable due to small numbers of transgender and/or nonbinary adults, which included any adults identifying as agender, transgender, nonbinary, or another not listed gender. Race/ethnicity was similarly coded in a three-part variable due to low numbers of adults in most non-White, non-Black racial, and/or ethnic groups.

p < 0.001.

AQ-Short, Autism Spectrum Quotient-Short; USD, US dollars; ACEs, adverse childhood experiences; CM, childhood maltreatment; HD, household dysfunction; BCEs, benevolent childhood experiences; PSS, perceived safety and support; IEM, internal and environmental motivation.

Among the Autistic group, adults indicated if they received a formal autism diagnosis from a professional (n = 214) or self-identified as Autistic without having received a formal diagnosis from a professional (n = 62). Specifically, we asked participants, “Have you ever been diagnosed (e.g., told by a professional) with autism spectrum disorder (including ASD, autism, autistic disorder, Asperger’s disorder, pervasive developmental disorder, PDD-NOS)?” Participants could indicate yes—they have received a formal diagnosis from a provider, no—but they self-identify as being on the autism spectrum, or no. Those who indicated that they received a formal diagnosis reported the year in which they received their diagnosis (range 1974–2020) and the age in years at which they received their diagnosis (M = 16.97, mode = 5, median = 15). They also reported the type of provider who gave the diagnosis (i.e., medical doctor (16.5%), psychiatrist (38.2%), psychologist (33%), social worker (4.2%), other (8%)) and specific diagnosis that they received (i.e., autism (28%), Asperger’s (62.3%), PDD not otherwise specified (4.2%), or other autism diagnosis (4.7%)).

We recruited participants from the online survey platform Prolific Academic. Prolific is a research platform similar to Amazon’s Mechanical Turk that allows advertising of studies to specific groups of participants and typically produces higher quality data than other platforms, includes greater diversity of participants, and requires an ethical level of minimum payment for each participant.^41,42 To recruit the non-autistic comparison group, we used Prolific’s tool for stratifying the sample, which allowed the sample to be nationally representative of the United States in terms of age, sex, and ethnicity. Prolific describes that this added, optional feature of their platform recruits a sample with subgroups (of age, sex, and ethnicity) with the same approximate proportion as the U.S. population according to U.S. Census Bureau data.

Inclusion criteria required that participants were adults (i.e., 18 years or older) who were comfortable reading and answering questions in the English language. We grouped together participants who received a diagnosis or self-identified as Autistic to be inclusive of those who may not have had access to a diagnosis,⁴³ as there were no significant differences between groups in levels of autistic traits (as measured by the Autism-Spectrum Quotient-Short (AQ-Short)⁴⁴; t(269) = 0.09, p = 0.929), age (t[274] = −1.21, p = 0.228), average household income (t[265] = 0.22, p = 0.829), gender identity (χ² [2, n = 276] = 0.02, p = 0.992), nor race/ethnicity (χ² = 0.57 [2, n = 276], p = 0.753). Autistic adults have used Prolific and produced high-quality data.^45–48 Prolific allows for recruitment among a wider range of locations and may be particularly beneficial among Autistic people, as participants can complete studies online rather than in-person.^42,45–48

Procedure

Participants provided informed consent before proceeding to complete an online questionnaire. We did not describe some specifics of the study aims in the title or initial advertisement of the study to avoid desirable responding (e.g., to avoid participants falsely endorsing that they have an autism diagnosis to access the survey). To further verify autism-related information, we removed data from any participant whose autism-related information in the complete study did not match that which they provided in Prolific’s prescreening survey (n = 109). Throughout the questionnaire, participants completed several attention-check items (e.g., being asked to enter a specific response in an open-ended box, or being directed to a specific answer choice) to ensure that participant responses were valid. The current dataset consisted of only participants who fully passed all attention checks, to more cautiously ensure valid responding given the online nature of this study (n = 39 were removed for failing attention checks). We further ensured data validity by inspecting response times to confirm that all participants spent a meaningful amount of time on the survey (the minimum time spent was 20 minutes). In addition, we required reCAPTCHA verification and enabled the “prevent ballot box stuffing” feature to prevent repeat responders. Prolific also verifies participant identities when they sign up for the platform, to ensure that each individual can only access the survey once. Upon completion of the measures, participants received debriefing materials and general resources for mental health support and were compensated for their participation. This study received institutional review board approval from Virginia Tech (IRB #20–860).

Measures

ACE questionnaire

The ACE questionnaire is a widely used 10-item self-report measure in which participants responded yes/no to the following adverse childhood events (i.e., occurring before the age of 18): physical abuse, emotional abuse, sexual abuse, physical neglect, emotional neglect, parental divorce, witnessing partner violence, incarceration of a household member, mental illness of a household member, or substance use of a household member.¹ We summed “Yes” responses for a total ACE score (alpha = 0.73 for the Autistic group, 0.78 for the non-autistic group), which can range from 0 to 10, as well as for the CM (alpha = 0.71 for the Autistic group, 0.72 for the non-autistic group) and HD domain scores (alpha = 0.64 for the Autistic group, 0.64 for the non-autistic group). Although the ACE questionnaire and BCE scale described below are used to collect evidence of adversity-related risk and positive experiences and primarily function as checklists, we included reliability alphas for each measure (total scores and domains). We did this to increase transparency about the psychometric properties of the ACE questionnaire and BCE scale, which aligns with recommendations for improving adversity research.^49,50 The ACE questionnaire has been used reliably and validly in a range of populations, including among autistic samples.^4,5,13

BCE scale

The BCE measure is a yes/no self-report 10-item questionnaire of positive early life experiences occurring between ages 0 and 18 years.^{9,10,29,32,33} Items describe events pertaining to perceived safety, security, and support (e.g., at least one safe caregiver, at least one good friend,) and internal and environmental motivation (e.g., school enjoyment, having a predictable daily routine). We summed “Yes” responses for a total BCE score (alpha = 0.72 for the Autistic group, 0.75 for the non-autistic group), ranging from 0 to 10, as well as for PSS (alpha = 0.59 for the Autistic group, 0.60 for the non-autistic group) and IEM (alpha = 0.58 for the Autistic group, 0.65 for the non-autistic group) domain scores. The BCE scale has been used reliably and validly across a range of populations (reported Cronbach’s alphas ranging from 0.69 to 0.70, and test–retest reliability of r = 0.80) but has not yet been used among Autistic samples.^{9,10,29,32,33,51,52}

Autism Spectrum Quotient-Short

The Autism Spectrum Quotient-Short (AQ-Short) is a 28-item abbreviated self-report measure of autistic traits.⁴⁴ Participants rate items on a 4-point scale (“Definitely Agree” to “Definitely Disagree”). We summed items into a total score ranging from 28 to 112. Higher scores indicate higher levels of characteristics associated with autism. Among the samples in the current study, Cronbach’s alphas were 0.83 for the Autistic group and 0.82 for the non-autistic group.

Posttraumatic Stress Disorder Checklist for DSM-5

The Posttraumatic Symptom Checklist for DSM-5 (PCL-5) is a 20-item self-report measure assessing for symptoms of PTSD that correspond to DSM-5 symptom criteria and which has been used among Autistic adults.^53–55 Participants rated each item on a 5-point scale (“Not at all” to “Extremely”) for how much they have been bothered by each symptom. We summed items for a total score of PTSD symptoms (alpha = 0.96 for the Autistic group, 0.97 for the non-autistic group), with higher scores reflecting higher levels of symptoms.

Brief Resilience Scale

The Brief Resilience Scale (BRS) is a 6-item self-report measure used to assess how well an individual perceives their ability to recover from stressful events (e.g., “I tend to bounce back quickly after hard times”).⁵⁶ Participants rated each item on a 5-point scale (“Strongly disagree” to “Strongly agree”). We summed responses and divided by the number of items completed for a total score ranging from 1 to 5 (alpha = 0.91 for the Autistic group, 0.92 for the non-autistic group). Higher scores reflected higher levels of self-reported resilience. The BRS has been used among Autistic individuals.⁵⁷

Treatment use and vulnerable life experiences

Participants reported on whether they have any current or history of any medication or therapy for psychological concerns, and whether they have ever received any therapy for trauma-related concerns. Regarding broader trauma and service-related experiences, participants indicated which of the following they have experienced: emergency room visit for mental health, inpatient hospitalization for mental health, police visit to the home for mental health, having a criminal record, being charged with a criminal offense, being cautioned by police, spending time in prison or a juvenile detention center, being arrested by police, and being bullied as a child. We drew these items from the Vulnerability Experiences Quotient, a measure of stressful life experiences that has been developed for Autistic adults.⁵⁸ We summed the responses to these items (rated as 1 for present or 0 as absent) to generate an overall measure of the number of different events endorsed (ranging from 0 to 9), which was referred to as vulnerable life experiences (VLEs; alpha = 0.71 for the Autistic group, 0.66 for the non-autistic group).

Analytic plan

For the first aim, we presented and compared rates of ACEs and BCEs across Autistic and non-autistic participants. We evaluated differences in ACEs and BCEs total and domain scores via independent-samples t-tests (effect sizes included as Cohen’s d), and we used chi-square analyses to evaluate differences in individual ACEs and BCEs. Follow-up multivariate analyses of covariance (MANCOVA) evaluated whether group differences in ACEs or BCEs were maintained (1) when accounting for group differences in demographic variables (age, income, race/ethnicity, and gender), and (2) when considering differences between autistic individuals with a diagnosis, those who self-identify without a diagnosis, and non-autistic individuals. Effect sizes are presented as partial eta-squared (0.01 = small, 0.06 = medium, 0.14 = large).^59–61 For the second aim, Pearson correlations examined how ACEs and BCEs related to each other among autistic adults and non-autistic adults separately. Correlations were interpreted as weak (|0-.3|), moderate (|.4-.6|), or strong (>|.7|).^62,63 We used Pearson’s R to Z comparison to evaluate correlation strengths across groups to consider whether associations were statistically different across groups.

For the third aim (i.e., evaluating how ACEs and BCEs are associated with psychosocial outcomes), we performed a series of moderated multiple regression analyses to evaluate how ACEs and BCEs associated with core psychosocial outcomes (PTSD total symptom score, BRS score, and VLE variables). We used logistic regression analyses for dichotomous dependent variables (medication use, any therapy use, and trauma therapy use). Autism group (Autistic vs. non-autistic) and the ACE and BCE subscales were independent variables, and core demographic variables (age, gender, race/ethnicity, income) were covariates. To consider whether these associations differed across groups (Autistic vs. non-autistic), we examined whether the autism group moderated the association between ACEs and BCEs with the outcome variables. We applied a Bonferroni correction to reduce the chance of type I error resulting from the six regression models; only p values less than 0.0083 (alpha level 0.05/6 regression models) were considered statistically significant. We plotted significant interactions using the InterActive data visualization tool.⁶⁴

Results

Rates of ACEs and BCEs

We present descriptive statistics for ACEs and BCEs (total and subscales) in Table 1 along with group difference statistics. Autistic adults reported significantly higher rates of CM ACEs, HD ACEs, and total ACEs than non-autistic adults, with moderate effect sizes. Similarly, Autistic adults reported significantly lower rates of PSS BCEs, IEM BCEs, and total BCEs than non-autistic adults, with moderate-to-large effect sizes.

Autistic and non-autistic adults also significantly differed in their reports of individual ACEs and BCEs (see Table 2 for chi-square analyses). Autistic adults reported significantly higher rates of all individual ACEs except for witnessing home violence. They most frequently reported experiencing emotional abuse (52.2%), household suicide (51.4%), emotional neglect (50.4%), parent separation/divorce (49.3%), and substance use in the home (40.2%). Autistic adults reported significantly lower rates of all individual BCEs, and they least frequently reported experiencing the BCEs of liking themselves (37.1%), liking school (44.0%), having one supportive adult (57.2%), having good neighbors (57.8%), and having beliefs that provide comfort (58.7%).

Table 2.

Individual ACEs and BCEs and Correlations Among Autistic and Non-Autistic Adults

	Autistic	Non-autistic	Group differences
	%		χ²	df	p
Individual ACEs
Emotional abuse	52.2	30.5	30.73	1	<.001^***
Physical abuse	27.2	16.4	10.93	1	.001^**
Sexual abuse	23.6	15.0	7.42	1	.008^**
Emotional neglect	50.4	29.1	29.95	1	<.001^***
Physical neglect	19.2	7.5	19.34	1	<.001^***
Parents separated/divorced	49.3	33.2	16.67	1	<.001^***
Witness home violence	15.3	10.3	3.57	1	.069
Substance use in home	40.2	27.6	11.26	1	<.001^***
Household suicide	51.4	25.0	47.17	1	<.001^***
Household incarceration	10.5	4.7	7.74	1	.008^**
Individual BCEs
Safe caregiver	77.9	89.8	16.88	1	<.001^***
Good friend	83.7	93.6	16.19	1	<.001^***
Comforting beliefs	58.7	81.4	39.52	1	<.001^***
Like school	44.0	69.5	41.90	1	<.001^***
Caring teacher	79.3	85.9	4.73	1	.033^*
Good neighbors	57.8	82.5	46.63	1	<.001^***
Supportive adult	57.2	74.7	21.63	1	<.001^***
Good opportunities	84.4	94.2	16.50	1	<.001^***
Like self	37.1	67.3	57.44	1	<.001^***
Home routine	73.8	88.4	22.45	1	<.001^***

Correlations among ACEs and BCEs across groups
	ACE CM	ACE HD	ACE total	BCE PSS	BCE IEM	BCE total
ACE CM	—	.32^{*** +}	.83^{*** +}	−.42^***	−.35^***	−.44^***
ACE HD	.54^{*** +}	—	.79^{*** +}	−.23^***	−.19^**	−.25^***
ACE Total	.89^{*** +}	.87^{*** +}	—	−.40^***	−.34^***	−.43^***
BCE PSS	−.36^***	−.22^***	−.34^***	—	.51^***	.86^***
BCE IEM	−.42^***	−.28^***	−.41^***	.54^***	—	.88^***
BCE Total	−.45^***	−.29^***	−.43^***	.85^***	.91^***	—

Valid percent frequencies and group difference chi-squares are reported. For the correlations, values above the dashed cells correspond to associations among the Autism group. Values falling below the dashed cells correspond to associations among the non-autism group. Correlations between ACEs and BCEs are shaded gray.

p < 0.05.

^**

p < 0.01.

^***

p < 0.001.

⁺

Indicates significant differences in correlations across groups as calculated using Pearson’s R to Z comparison tool.

ACEs, adverse childhood experiences; CM, childhood maltreatment; HD, household dysfunction; BCEs, benevolent childhood experiences; PSS, perceived safety and support; IEM, internal and environmental motivation.

As a follow-up analysis, we used MANCOVA to evaluate whether group differences between Autistic and non-autistic adults were maintained when adjusting for demographic differences across groups, and when considering possible differences between Autistic adults with and without a diagnosis. Thus, we considered the autism group variable as a three-part variable for these analyses (i.e., adults who have a formal diagnosis of autism (n = 203), adults who self-identify as Autistic ([n = 61], and non-autistic adults [n = 340]). When accounting for main effects of gender (F [8, 1184] = 4.33, p < 0.001, partial eta-squared = 0.028), race/ethnicity (F [8, 1184] = 2.23, p < 0.05, partial eta-squared = 0.015), age (F [4, 592] = 3.74, p < 0.01, partial eta-squared = 0.025), and income (F [4, 592] = 3.85, p < 0.01, partial eta-squared = 0.025), the overall multivariate test for autism group remained significant (F (8, 1184) = 7.33, p < 0.001, partial eta-squared = 0.047). The between-subjects effect for autism group remained significant for all dependent variables (see Supplementary Table S1). Post hoc Bonferroni-corrected comparisons (see Supplementary Table S2) indicated that both the formally diagnosed Autistic group and the self-identified Autistic group had higher scores on ACEs, CM ACEs, and HD ACEs, and lower scores on BCEs, PSS BCEs, and IEM BCEs, compared with the non-autistic group. Moreover, the self-identified Autistic group also had higher ACEs and CM ACEs, and lower BCEs, PSS BCEs, and IEM BCEs, than the formally diagnosed Autistic group. There was no significant difference between formally diagnosed and self-identified Autistic adults on HD ACEs.

Interrelations among ACE and BCE domains

We present associations between ACEs and BCEs in the Autistic and non-autistic groups in Table 2. Across both Autistic and non-autistic adults, ACE CM and HD domains significantly positively correlated with each other (moderately), and with ACE total scores (strongly). BCE PSS and IEM domains significantly positively correlated with each other (moderately) and BCE total scores (strongly). As expected, ACEs (total and domains) significantly negatively correlated with BCEs (totals and domains); most correlations were weak to moderate (ranging from −0.19 to −0.45). The magnitudes of only three correlations significantly differed between Autistic and non-autistic adults based on Pearson’s R to Z comparisons: ACE CM and HD (z = −3.26, p = 0.001; r = 0.32 for Autistic adults, r = 0.54 for non-autistic adults), ACE CM and Total (z = −2.55, p = 0.011, r = 0.83 for Autistic adults, r = 0.89 for non-autistic adults), and ACE HD and Total (z = −2.99, p = 0.003, r = 0.79 for Autistic adults, r = 0.87 for non-autistic adults). Each of these associations was significantly weaker for Autistic than non-autistic adults.

ACEs, BCEs, and psychosocial outcomes

Moderated multiple regressions (with Bonferroni correction for interpretation of coefficients) evaluated how ACE and BCE domains associated with PTSD symptom scores, BRS scores, VLE scores, and the categorical treatment use variables (any medication, any therapy, any trauma therapy, evaluated via logistic regression). We present regression coefficients for continuous dependent variables in Table 3. Regarding PTSD symptom scores, the overall regression model was significant (R² = 0.387, F [15, 581] = 24.46, p < 0.001). While accounting for core demographic variables, the main effect of CM ACEs relating to higher PTSD symptoms was significant, although this was not moderated by autism group. Regarding BRS scores, the overall model was significant (R² = 0.251, F [15, 584] = 13.053, p < 0.001). However, none of the coefficients for ACE or BCE values was significant. Lastly, regarding VLE scores, the overall model was significant (R² = 0.227, F [15, 588] = 11.496, p < 0.001). After accounting for demographic variables and applying the Bonferroni correction, there were significant main effects of CM ACEs relating to higher scores and IEM BCEs to lower scores.

Table 3.

Linear Regression Associations Between ACEs, BCEs, Demographic Variables, and Psychosocial Outcomes

	PCL total scores R² = 0.39^***		BRS total scores R² = 0.25^***		VLE total scores R² = 0.23^***
	B (SE)	β	B (SE)	β	B (SE)	β
Age	−3.12 (0.93)	−0.14 ^***	0.20 (0.05)	0.20 ^***	0.03 (0.07)	0.02
Income	−0.60 (0.78)	−0.03	0.07 (0.04)	0.07	−0.16 (0.06)	−0.11 ^**
Woman	4.20 (1.62)	0.09^*	−0.16 (0.08)	−0.08^*	−0.08 (0.12)	−0.03
Transgender/Nonbinary	10.05 (2.80)	0.13 ^***	−0.12 (0.14)	−0.04	−0.16 (0.20)	−0.03
Black/African American	0.14 (2.53)	0.00	0.26 (0.12)	0.08^*	0.15 (0.18)	0.03
Other non-White Race/Ethnicity	5.32 (1.99)	0.09 ^**	−0.07 (0.10)	−0.03	0.16 (0.14)	0.04
Autism identity	3.60 (1.93)	0.08	−0.34 (0.09)	−0.17 ^***	0.72 (0.14)	0.24 ^***
ACE CM	9.59 (1.41)	0.42 ^***	−0.02 (0.07)	−0.02	0.39 (0.10)	0.27 ^***
ACE HD	0.31 (1.29)	0.01	−0.12 (0.06)	−0.12	−0.02 (0.09)	−0.01
BCE PSS	−1.28 (1.46)	−0.06	0.10 (0.07)	0.10	0.24 (0.11)	0.16^*
BCE IEM	−2.11 (1.39)	−0.09	0.09 (0.07)	0.09	−0.33 (0.10)	−0.23 ^***
ACEsCM*Autism	−1.73 (1.89)	−0.05	0.05 (0.09)	0.04	−0.10 (0.14)	−0.05
ACEsHD*Autism	0.54 (1.73)	0.02	0.19 (0.08)	0.13^*	0.11 (0.13)	0.05
BCEsPSS*Autism	1.28 (1.93)	0.04	−0.02 (0.09)	−0.02	−0.36 (0.14)	−0.18^**
BCEsIEM*Autism	−0.64 (1.94)	−0.02	0.09 (0.09)	0.06	0.34 (0.14)	0.15^*

Interaction terms are terms with an asterisk (e.g., ACEsCM*Autism). Significant associations (applying the Bonferroni correction for multiple tests) are bolded and significant ACE and/or BCE associations are also shaded.

p < 0.05.

^**

p < 0.01.

^***

p < 0.001.

PCL, Posttraumatic Stress Disorder Checklist for DSM-5; BRS, Brief Resilience Scale; VLE, vulnerable life experiences; ACEs, adverse childhood experiences; CM, childhood maltreatment; HD, household dysfunction; BCEs, benevolent childhood experiences; PSS, perceived safety and support; IEM, internal and environmental motivation.

All logistic regression overall models were significant (medication use: χ²(15) = 172.337, p < 0.001; any therapy: χ²(15) = 219.800, p < 0.001; trauma therapy: χ²(15) = 123.550, p < 0.001; see Table 4). While accounting for demographic variables, there was a significant main effect of CM ACEs associated with higher rates of any therapy use and a significant main effect of IEM BCEs associated with lower rates of trauma therapy use. There was a significant interaction between IEM BCEs and autism identity such that more IEM BCEs related to less use of trauma therapy among non-autistic adults (simple slope b = −0.08), and there was a nonsignificant association among Autistic adults (simple slope b = 0.05; see Supplementary Fig. S1).

Table 4.

Logistic Regression Associations Between ACEs, BCEs, Demographic Variables, and Treatment Use Outcomes

	Medication χ² = 172.34^***		Any therapy χ² = 219.80^***		Trauma therapy χ² = 123.55^***
	B (SE)	O. R.	B (SE)	O. R.	B (SE)	O. R.
Age	−0.20 (0.11)	0.817	−0.23 (0.12)	0.794	−0.02 (0.14)	0.979
Income	−0.09 (0.11)	0.914	−0.03 (0.11)	0.966	0.14 (0.10)	1.150
Woman	0.34 (0.21)	1.402	0.58^** (0.22)	1.792	0.91 ^*** (0.24)	2.494
Transgender/Nonbinary	0.94^* (0.47)	2.551	0.86 (0.55)	2.372	1.50 ^*** (0.35)	4.462
Black/African American	−0.74^* (0.32)	0.480	−0.05 (0.33)	0.955	0.14 (0.37)	1.151
Other non-White Race/Ethnicity	−0.17 (0.26)	0.846	−0.67^* (0.28)	0.510	0.07 (0.28)	1.071
Autism identity	1.35 ^*** (0.24)	3.837	1.94 ^*** (0.29)	6.963	0.76 ^** (0.28)	2.144
ACE CM	0.37^* (0.16)	1.442	0.67 ^*** (0.17)	1.947	0.28 (0.19)	1.324
ACE HD	0.24 (0.15)	1.273	0.08 (0.15)	1.079	0.36^* (0.18)	1.435
BCE PSS	0.22 (0.18)	1.245	0.14 (0.18)	1.151	0.26 (0.21)	1.293
BCE IEM	−0.40^* (0.16)	0.672	−0.35^* (0.17)	0.706	−0.58 ^** (0.20)	.559
ACEsCM*Autism	−0.45 (0.24)	0.639	−0.68^* (0.29)	0.506	0.25 (0.25)	1.283
ACEsHD*Autism	−0.23 (0.23)	0.795	−0.22 (0.27)	0.803	−0.04 (0.23)	0.963
BCEsPSS*Autism	−0.21 (0.26)	0.808	0.02 (0.30)	1.018	−0.35 (0.26)	0.702
BCEsIEM*Autism	0.06 (0.26)	1.065	−0.25 (0.32)	0.780	0.85 ^** (0.26)	2.332

Interaction terms are terms with an asterisk (e.g., ACEsCM*Autism). Significant associations (post-Bonferroni correction for multiple tests) are bolded and significant ACE and/or BCE associations are also shaded.

p < 0.05.

^**

p < 0.01.

^***

p < 0.001.

Discussion

The results of the current study expand existing literature by examining differences in ACEs and BCEs across Autistic and non-autistic adults. First, Autistic adults reported higher levels of ACEs and lower levels of BCEs, at the total score, subscale, and individual item level. There were significant differences in ACEs and BCEs across groups when accounting for demographic differences between Autistic and non-autistic adults. CM ACEs related to higher PTSD symptoms, higher vulnerable life experiences, and higher use of any therapy, and these associations were not moderated across groups. BCEs related to lower vulnerable life experiences (not moderated across groups) and lower use of trauma therapy (with this association being different across Autistic and non-autistic adults). These findings show how ACEs and BCEs differentially associate with psychosocial outcomes among Autistic adults.

Rates of ACEs and BCEs across Autistic and non-autistic adults

Autistic adults reported significantly more ACEs than non-autistic adults, consistent with prior work.⁴ Autistic children and adolescents disproportionately experience ACEs, such as maltreatment, peer victimization, and overall early adversity.^11–13 Autistic adults frequently experience interpersonal victimization, including emotional abuse.⁶⁵ Similarly, prior work has aimed to support Autistic people after losing loved ones to suicide, which is consistent with our finding of frequent reports of household suicide among Autistic adults.⁶⁶ Notably, most ACE research among Autistic samples has focused on measuring ACEs via caregiver report or records, or among child or adolescent samples (who may not yet be the age of 18, which is the maximum age that many adversity measures use to anchor individuals in their report of ACEs). The current study is among early research to obtain self-reported adversity data among Autistic adults, which ensures that ACEs can span the full developmental period (up to age 18) as indicated by the ACE measure.

Autistic individuals also had lower rates of BCEs among Autistic individuals, which has not yet been directly observed in existing BCE research. Our findings are consistent with prior work showing that Autistic adults report lower levels of overall self-esteem than non-autistic adults, and that Autistic youth experience a variety of school difficulties throughout childhood (e.g., experiencing bullying by peers, receiving inadequate supports, or unequal treatment from teachers or school staff).^67,68 Although little work has examined relationships among Autistic youth and noncaregiver adults, social support has been implicated in relating to the quality of life of autistic people,⁶⁹ which suggests that this is an important future research area to develop.

Formally identified and self-identified Autistic adults both experienced higher ACEs and lower BCEs relative to non-autistic adults. However, among Autistic adults, self-identified individuals had higher ACEs and lower BCEs than formally diagnosed Autistic individuals (except for HD ACEs, which did not differ across groups). Self-identified individuals in this sample may have experienced particularly high rates of child maltreatment and low levels of positive childhood experiences, perhaps because Autistic individuals without a diagnosis may lack access to supports and resources.⁷⁰ Future research should be inclusive of self-identified individuals,⁷¹ particularly for understanding childhood experiences of adversity and resilience.

Associations between ACEs and BCEs

ACEs and BCEs significantly correlated with each other in expected directions among both groups. The magnitude of the relationships among ACEs and BCEs ranged from −0.19 to −0.44 in the Autistic group and −0.22 to −0.45 in the non-autistic group. None of these magnitudes significantly differed across groups (e.g., there were no significant Pearson’s R to Z differences in the strength of the ACE-BCE correlations across groups), suggesting that ACEs and BCEs relate to each other similarly across Autistic and non-autistic adults. This supports existing research that BCEs and ACEs are two distinct but related constructs as opposed to opposite ends of the same underlying construct, and that individuals may experience high rates of both ACEs and BCEs.²⁹ Understanding these constructs as separate but related can guide future research and inform prevention and intervention strategies relating to goals of decreasing ACE exposure, and/or increasing BCEs. In other words, it is possible to support BCEs even among individuals with high rates of negative and ACEs.

Correlations within ACE domains significantly differed in strength across Autistic and non-autistic adults. The magnitudes of all intercorrelations between the ACE total score and domain scores (CM and HD) were significantly weaker for Autistic adults than for non-autistic adults. ACE domains may not be as closely linked among Autistic adults, perhaps due to higher rates of adversity that may include stressors not captured within the 10-item ACEs (e.g., peer victimization).^13,23

ACEs, BCEs, and psychosocial outcomes

CM ACEs related to higher PTSD symptoms and negative life experiences, whereas higher BCEs related to lower negative life experiences among both Autistic and non-autistic adults. High rates of IEM BCEs specifically related to less use of current or past trauma therapy among non-autistic adults but were unrelated to trauma therapy among Autistic adults. Positive experiences (i.e., IEM BCEs) may more uniquely promote positive outcomes and reduce the need for trauma-related therapies among non-autistic adults, whereas the association between IEM BCEs and trauma treatment use is less clear among Autistic adults. This could suggest that the possibly protective impact of BCEs on some outcomes is less strong for Autistic adults while considering the impact of ACEs, which supports research indicating that BCEs may counteract the negative impact of ACEs in most cases, except for when some psychological outcomes (e.g., perceived stress, suicidality, depression symptoms) of adversity may be too strong.^29,32,40 Alternatively, this may also reflect that the current BCE measure does not capture the types of experiences that are meaningful for Autistic people.

Limitations and future directions

There were several important limitations to the current study. Regarding methodology and measurement, some variations of ACE questionnaires have been expanded to include community-level stressors (e.g., witnessing neighborhood violence, experiencing racism) as potentially adverse events.^72,73 Expanded ACE measures may provide more insight to stressors experienced among marginalized communities that may not be fully captured on the 10-item ACE measure.⁷³ Our 10-item ACE and BCE measures also had lower reliability alphas for some subscales (e.g., PSS and IEM BCEs), which should be noted as an additional limitation. Furthermore, Autistic youth may experience a wider range of stressors than are traditionally assessed via ACE measures or other tools for adversity and trauma exposure (e.g., sensory traumas).^55,74 The ACE measure that we used in the current study did not include items related to peer victimization, despite this being a commonly reported stressor among Autistic individuals.⁴ Similarly, the current BCE measure may not fully capture the full range of positive experiences that Autistic adults have described as important for overcoming adversity (e.g., adjusting societal attitudes and social expectations).⁷⁵ Future work should modify or expand existing ACE and BCE tools to assess for a wider range of stressful and positive events, respectively, among Autistic individuals. Moreover, dimensional response formats or interview-style follow-up administrations of these measures rather than a binary item rating (i.e., yes/no) may better capture data about how Autistic individuals experience ACEs and BCEs. Relatedly, we measured self-reported symptoms of PTSD and did not confirm symptoms with a more extensive PTSD interview.

We also recognize that the Autistic group of participants in our study consisted of adults who were capable of consenting to research online. Our sample may not have included a large proportion of adults with high support needs (although this was not directly assessed in our study), and our Autistic group comprised a large number of women and White individuals. Therefore, our study results are limited in generalizability and additional research should seek to understand adverse and benevolent experiences among Autistic adults with a broader range of demographic characteristics. There were significant differences in ACEs and BCEs between Autistic and non-autistic adults while covarying for demographic differences. Yet, it should still be noted that our Autistic and non-autistic groups significantly differed in age, income level, race/ethnicity, and gender. Future work should replicate results among groups that do not significantly differ in these characteristics to strengthen these findings. Furthermore, future work should clarify how multiple intersecting demographic identities may relate to adverse and positive experiences (e.g., future work should directly compare ACEs and BCEs across groups of Autistic adults with different diverse racial/ethnic and gender identities). Moreover, it will be critical for future work to consider ACEs and BCEs in a wider range of contexts, especially low- and middle-income countries and other international, global contexts.⁷⁶

In addition, although there were significant associations between ACE and BCE domains among Autistic and non-autistic adults, future work should further evaluate the relations among these constructs using more advanced analytic techniques. In particular, a range of multivariate approaches have been applied to the study of child adversity exposure, including data-driven approaches (e.g., principal component analysis, canonical correlation analysis) and prediction-based approaches (e.g., tree-based models, neural networks).⁷⁷

Finally, the current study was not codesigned with Autistic people, which should be a central priority for future work in this area.⁷⁸ Researching adversity and benevolent experiences for Autistic adults may fill this gap by including Autistic voices and the needs of the Autistic community in research, while also generally serving to build resilience and improve well-being among Autistic adults. Prior research has examined resilience among Autistic adults,^75,79 although it is not entirely clear how Autistic and non-autistic adults differentially experience and understand resilience. Future work in this area may highlight how Autistic adults uniquely experience resilience, which may inform strategies for fostering resilience among Autistic individuals across the lifespan.

Footnotes

Authorship Confirmation Statement

Conceptualization: T.A. and C.G.M. Formal analysis: T.A. and C.G.M. Investigation: C.G.M. Writing—original draft: T.A. Writing—review and editing: C.G.M. The article has been submitted solely to Autism in Adulthood.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The authors did not receive any funding for this study.

Supplementary Material

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