Motivation and emotion/Book/2025/Neurodivergence and trauma

Case study Mitchell, a seventh-grader student who experiences difficulties coping with stress and demand of high school. He constantly suffers from headache and physical tenderness. He has many fears, inclusive of failing, not being liked by other students and being seen as 'different'. He becomes very self-conscious whenever he presents as he worries about being judged by others for his difference. He has never had close friends and is often the target of bullying and ridicule at school. He finds it difficult to understand and thus trust people in his new environment. His anxiety becomes so intense, alongside with excessive feelings of guilt and shame, that he cannot eat and sleep well therefore misses classes and school work.

This chapter lays the foundation for better understanding and behaviour change. You will find out what neurodivergence and trauma actually are and how they can significantly impair one’s life. You will also be able to identify trauma-related behaviours you would like to move forward and make a positive change.

Focus questions What is neurodivergence? What is trauma? How might the relationship between common neurodivergent conditions and associated traumas be? What approaches would you rely on in terms of treatments and supporting strategies? Are there specific interventions you think work best? If so, in what ways?

Neurodivergence is a non-medical term, referring to the variations in how human brains function, process information and behave. These neurological differences are made of a range of mental health conditions diverging from the societal norms and what is considered as typical (Butcher & Lane, 2024 ; Wilson et al., 2024). And that, certain mental health diagnoses, which fall into neurodivergent classification, include Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), learning disabilities (e.g., dyslexia, dyspraxia) and Obsessive Compulsive Disorder (OCD).

An emotional response to a single or a series of distressing, harmful or even life-threatening event/s that overwhelm one's ability to cope at the time and and function life normally. Trauma can take many forms and affects not only those to whom it is directly exposed but also those who are living around.

Autism or ASD is a lifelong developmental disorder characterised by abnormalities in human brain development and functioning. Those affected show various patterns of difficulties including in, but not limiting to socialisation (how to interact with others), communication (ability to understand verbal/non-verbal language in social contexts) and engaging in repetitive behaviours or activities (APA, 2013). Due to the differences in how information is processed in the autistic brain, the child can strongly respond to different external stimuli, be extremely emotional but does not seek comfort, avoid eye contact and play with others, or even engage in prolonged periods of self-soothing activities. They also tend to dive into own imagination and manipulate objects to make play, get fixated on specific (cartoon) characters and preferred routines or express themselves through the repetitive use of expressions and symbols. Therefore, environment change can become problematic and a source of tantrum and challenging behaviour. This variation in symptomatic patterns makes autism one of the most difficult conditions for understanding and treatment.

Theory of mind and ASD

The current Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) suggests the differential diagnoses of language disorders and social (pragmatic) communication in the absence of the restricted range of interests or behaviour (APA, 2013). The weak areas of communication and socialisation skills in those with an ASD can be identified as theory of mind (ToM) and pragmatic language (PL) deficits. ToM refers to the ability to understand/recognise humans’ different “minds” in terms of beliefs or intentions and relating to those in order to empathise for what they are doing/feeling. PL, meanwhile, refers to the ability to effectively apply practical language in reciprocal communication – knowing the back-and-forth conversational context, when it is appropriate to initiate a conversation, what to say and how to take turns. Accordingly, pragmatic effectiveness requires working ToM to figure out what the other person know/think to predict their intents/actions (Duval et al., 2023). With impaired pragmatic and ToM skills (see Table 1), the child’s perception of the world around them is severely altered, restricting their ability to not only realise own feelings and needs, but also recognise and empathise with the other mind. Thus, autistic individuals continue to find difficulties in achieving meaningful conversations, resulting in disinterest in social interactions and having no sense of companionship.

Table 1.

ASD and ToM vs. PL skills

Adapted from Duval et al. (2023)

The DSM-5 identifies ADHD as two distinct inattention and/or hyperactivity-impulsivity types. Of those, three subtypes of ADHD were specified: (1) ADHD-I as predominantly inattentive, (2) ADHD-H as predominantly hyperactive/impulsive and (3) the most common form of ADHD-C as combined inattentive and hyperactive/impulsive. In reality, children with ADHD are often found to be constantly irritated and unable to concentrate on tasks especially of little interest. They tend to display disruptive behaviours and act out of control across contexts as a result of an inability to inhibition (see Table 2).

The prefrontal cortex (PFC), as part of the large frontal lobes in our brain, is considered as an inhibitory centre allowing us ample time to process contextual and sensory inputs to decide where we are, where we want to go then take purposeful and controllable actions in order to get there. Thus, the ability to inhibit is of great importance in executive function including planning and self-regulatory skills. However, the impaired connection between the PFC and other parts of the brain hinders abilities to filter incoming stimuli to prioritise (basal ganglia), to determine appropriately emotional reactions (limbic system) and to manage the sense of time (cerebellum). These deficiencies, resulting from an under-functioning PFC, can lead to other executive dysfunctions – leaving ADHDers with classic symptoms of disorganisation, poor time management, lack of foresight and reaction without consideration of all available options.

Additionally, it appears in ADHD that when the specific neurotransmitter dopamine is released into the synapse, the altered dopamine signalling prevents it from reaching the target neuron on the other side of the synapse. This leaves the brain with less dopamine than it requires to function properly and thus causes the disrupted flow of information between the frontal lobes and other parts of the brain in order to inhibit other brain activities for self-directed regulation. In turn, the abnormally low levels of dopamine across the brain regions directly impact on higher functions of concentration, problem-solving and decision-making, which relates to symptoms of inattention and impulsivity.

Table 2.

Difficulties associated with ADHD

Adapted from APA (2013).

The DSM-5 classified OCD as one of the anxiety-related disorders with the presence of either obsessions or compulsions or both. Obsessions are unwanted and nonsense but intrusive thoughts, mental images or urges often arisen from periods of anxiety or distress. Accordingly, compulsions are performed as repetitive behaviours (hand washing in response to fear of contamination, rechecking in prevention of harm) or mental acts (counting, silently repeating words/phrases and the need for symmetry) in attempts to decrease the level of anxiety caused by obsessions (APA, 2013) following rigid rules. These behaviours must become clearly excessive, unreasonable, unrealistic and time-consumed (1 – 3 hours per day) to the extent that cause severe distress and impair general life functioning before a diagnosis can be considered. Once confirmed, additional attention should be paid for tics of approximately 30% at lifetime risk and other possible related disorders such as body dysmorphic disorder, skin picking disorder and trichotillomania. Functional imagining studies in OCD have shown it specifically linked to structural abnormalities in various brain regions including the orbitofrontal cortex (OFC), anterior cingulate cortex (ACC), striatum and thalamus (see Table 3) (Huey et al., 2008).

Table 3.

OCD and the brain

Adapted from Huey et al. (2008)

Research indicates the interconnection between trauma and neurodivergence due to overlapping symptoms, with both impacting brain development and function resulting in altering behaviours (AI-Attar & Worthington, 2024). Comorbidities thus exist between neurodivergences and trauma- and stressor-related disorders. Comparing to the neurotypical population, there is a great tendency for neurodivergent individuals, with a history of traumatic experiences, to develop associated traumas such as childhood trauma, interpersonal trauma or post-traumatic stress disorder (PTSD). In fact, Gajwani and Minnis (2022) found that childhood trauma or adverse childhood experiences (ACEs) of childhood maltreatment in particular and the term they coined as “neurodevelopmental conditions” (consisting of ADHD, ASD) are unlikely to occur in isolation, creating a double jeopardy of long-term negative health impacts associated with potent risks of stress responses and maladaptive coping behaviours (Wilson et al., 2024).

A further study, aiming to investigate the relationship between NDs and ACEs, was conducted by Wilson (2024) and colleagues of 5,395 English residents aged 18 years and above using 1-item ND and 9-item ACEs self-reports to measure their general health and mental wellbeing. Findings indicated that comparing to a nearly half of neurotypical (NT) people, almost three quarters of ND people had experienced at least one ACE (or interpersonal trauma), defined as physical or sexual abuse; physical or emotional neglect; and other familial stressors including being raised by a single parent, witnessing domestic violence; having a household member who was illegally arrested, mentally ill or suicidal, or abusing alcohol and/or other drugs (also see Kalisch et al., 2025).

Importantly, the research team also found that comparing to the NT sample population, ND individuals, consisting of all those with an official diagnosis; being self-diagnosed and suspecting, were significantly likely at 4.9 times to experience more than 4 ACEs, at twice to experience 2 – 3 ACEs and 1.6 times to experience 1 ACE. Thus, these findings suggested the higher prevalence of ACEs amongst ND individuals, the greater impacts on their overall health and wellbeing over the course of life. In other words, ACEs can predict a wide range of serious health problems into adulthood such as depression, obesity, alcohol and/or other drugs abuse, impaired life functioning (including education and employment), childhood or developmental trauma and dissociation. And that, the more ACEs, the greater the likelihood of developing these health-related problems later in life (see Figure 2).

As John Bowlby, the British psychologist, developed his attachment theory, he saw attachment as a secure base that explained the early emotional bonds between infants and caregivers. This primary attachment bond is considered vital for survival and social/emotional development as it helps shape relationships throughout life (Khadka, 2022). Accordingly, the more responsive the adult is to the child, the stronger the attachment and the more likely the child will develop healthy ways in response to the world around him. Bowlby’s (1969) original work was intensively expanded later on by Mary Ainsworth (1978), who conducted the “strange situation” experiment aiming to assess how the 12- to 18-month-old children responded to brief periods of separations then reunions with their caregivers and identifying four different attachment styles of secure, anxious-ambivalent, avoidant and disorganised.

Secure attachment tends to develop if the caregiver shows consistent nurturing behaviours with delicate levels of physical interactions (e.g., holding their babies) and “affect attunement” (e.g., making them feel understood and their needs met) (also see Newman et al., 2015). As these children grow into adulthood, histories of responsive and reliable interactions from early life, in turn, form a foundation of “internal working models” for emotional security as part of a formula for relationships (AI-Attar & Worthington, 2024). On the contrary, children with insecure (anxious-ambivalent or avoidant) and disorganised attachment styles – perhaps resulted by experiencing abuse and neglect – often become very defensive, hypervigilant to the surroundings and sensitive to slight changes to the extent that they may overreact to situations, easily be withdrawn or lose control of impulses.

It is believed that these children may grow up with frequent moments of misattunement in the transition between affective states, which not only ruptures the attachment bond but hinders the development of self-regulation skill (Khadka, 2022). Such disrupted attachment to a primary caregiver (e.g., a neglectful parent who failed to provide unconditional love and bond to a child because s/he was mentally ill or traumatised) can be counted towards some forms of abuse and neglect (Cross et al., 2017). Other early experiences, linked to the interpersonal trauma, might include bullying and domestic violence outside of home (e.g., school, neighbourhood or local communities) (Kalisch et al., 2025). While single-event PTSD is quite straightforward, prolonged and repeated exposure to these multiple forms of interpersonal traumas can consequently results in complex trauma or PTSD (Kliethermes et al., 2014; Maercker et al., 2022).

Humans are vulnerable and that anyone of us can get PTSD upon exposure to traumatic events. However, certain factors can heighten the risk of developing PTSD and one of which is the long lasting consequences of disorganised attachment patterns (Khadka, 2022; Kliethermes et al., 2014). It is particularly important to explore ACEs in the high-risk population of NDs (e.g., ADHD, OCD and especially ASD), in which multiple ACEs can highly be identified (AI-Attar & Worthington, 2024). Having said that, combined factors such as the exposure frequency (repeated, long-term) and exposure outcomes (affected emotional and behavioural dysregulation, altered self-perception and relationship/attachment issues) are commonly known in complex trauma, indicating the diversity and severity of trauma symptoms as well as involving the requirement for longer duration and combination of treatment modalities (AI-Attar & Worthington, 2024; Kliethermes et al., 2014). The impact of complex trauma tends to worsen amongst the population of children and adolescence following their critical developmental periods, which disrupts the identity formation as a result.

Complex trauma or PTSD is sometimes misdiagnosed as neurodivergent conditions. Thus, another view holds that complex trauma significantly impairs one’s self-concept, psychological wellbeing, attachment capabilities (e.g., bonding, intimate relationships) and social interaction, which necessitate a comprehensive assessment considering differential diagnoses for trauma to be ruled out of its greatly associated conditions in order to provide properly individualised treatment and care plans (Gajwani & Minnis, 2022). According to Miller and Brock (2017), trauma victims may be at high risk for OCD with obsessive thoughts, negative feelings and restricted or repetitive behaviours, perhaps resulting from ACEs, to prevent them from reoccurring; these symptoms can, in turn, be accompanied with excessive worry, phobias, panic attacks and compulsive behaviours (as cited in AI-Attar & Worthington, 2024). For example, a victim of rape or sexually abuse compulsively washes herself in response to obsessive feelings of being contaminated and become inbound or avoid public places. Affected dysregulation such as difficulties in regulating emotions, controlling impulses and seeking attention (e.g., emotional outbursts, aggression, rule breaking, restlessness) can easily be labeled as ADHD. Other trauma-related symptoms include misunderstanding of social cues or intentions, inability to identify emotions, (sensory) sensitivity, hypervigilance (e.g., sustained scanning for threats) and dissociation due to feeling unsafe, which can be mistaken for typically autistic processing deficits especially in relation to ToM/PL skills.

The increasing prevalence of ND individuals, identified as having ASD with comorbid ADHD (25 – 28%) and OCD (7 – 10%) can become a source of stress for caregivers (Deb, Roy & Limbu, 2023). The nature of these conditions may be seen as being anxious or depressed, underlying challenging behaviours as the results of cognitive and psychosocial functioning difficulties. This has led to the significant rise (64% as at 2014) in the use of medication (e.g., psychotropics and mood stabilisers) as preferred treatment within the population of children and adolescents. For example, stimulants improve aggression in developing children with ADHD and reduce anxiety when ADHD with comorbid anxiety disorder (e.g., OCD). However, there is a call for alternative practices in place to avoid overmedication due to concerns around pharmacological intervention, which involve long-term, severe side effects and conflicting findings whether it cures the conditions (Deb, Roy & Limby, 2023). Pharmacotherapy alone do not cure PTSD and is highly unlikely to be recommended for young children with PTSD. However, in some cases, relieving symptoms of depression and anxiety can help facilitate other forms of treatment for success (Maercker et al., 2022).

Mindfulness

Mindfulness practice is referred as the ability to intentionally shift focus and intention on feelings, thoughts and bodily experiences in the present moment (Cross et al., 2017). For individuals with neurodivergent conditions such as ADHD and/or ASD (neurodevelopmental disorders associated with altered brain structures and cognitive/behavioural functioning difficulties) as well as those with complex trauma, mindfulness can be considered a useful tool for stress release and emotional self-regulation (Cross et al., 2017; Patilima, 2025). Without any mental efforts for change or control, individuals are reaching self-awareness and a greater understanding of their inner experiences in a nonjudgemental and accepting perspective.

Attachment-based family therapy (ABFT)

Considering the learning aspects of attachment theory, the ABFT has recently been adjusted as transdiagnostic treatment for various disorders including attachment-related traumas and emotions (Van Vlierberghe et al., 2023). While this approach does not directly focus on neurodivergences, it does focus on addressing the foundation of emotional and attachment insecurities, underlying difficult behaviours, affected regulation and maladaptive coping strategies. With attachment-focused parenting through its core, the 16-session family intervention, incorporating five therapeutic tasks, aims to assist parents in rebuilding a secure base for their 8- to 12 year-old children to redevelop a safe relationship based on unconditional love and acceptance.

Under ABFT, much more attention is given to what is happening beneath the behaviour and within the family. Thus, families are required to alternatively complete child-only, parent-only and parent-child tasks. Child- (Task 2) and parent-only (Task 3) sessions not only give the therapist opportunities to build strong therapeutic relationships with individuals but also help with identifying emotional needs and life stressors which affect parenting styles and contribute to attachment insecurities. Most importantly, other parent-child together sessions are central to the therapy in terms of both attachment and familial relationship repair. Other potential interventions in clinical settings, which utilise the attachment needs and caregiving practices are listed in Newman et al. (2015) as Circle of Security, Watch, Wait and Wonder, and Video Interaction Guidance.

Trauma-focused therapies

Results from a multi-level meta-analysis, conducted by Hoogsteder (2022) and colleagues, indicated that both Eye movement desensitisation and reprocessing (EMDR) and Trauma-focused cognitive behavioural therapy (TF-CBT) can be significantly effective (large effect d = 1.123) in the reduction of trauma symptoms (especially those of PTSD in older adolescents). However, the comparative efficacy between EMDR and TF-CBT requires further investigation with the inclusion of larger amounts of studies especially for EMDR (Hoogsteder et al., 2022).

Originally employed by Dr. Francine Shapiro in 1987 for survivors of war, rape and molestation, EMDR has now becoming an eight-phase comprehensive treatment plan for diverse traumatic experiences across ages. The rhythmic set of (bilateral) eye movements, whilst processing traumatic memory, is believed to lessen the emotional impact of upsetting experiences. Consequently, negative images, thoughts and feelings identified as trauma symptoms, will be either reduced, eliminated or replaced with positive responses. This is because rapid eye movements stimulate electrical connections and activate parts of brain regions that process memories. Also, a focus on eye movement provides distraction from the pain of intrusive memories while processing them with adaptive cognitions.

TF-CBT is an evidence-based treatment recommended for children aged 5 and above experiencing interpersonal and complex trauma (Kalisch et al., 2025; Maercker et al., 2022). TF-CBT treatment plan usually involves both individual child sessions and joint sessions with a non-offending caregiver. It incorporates essential components of cognitive behavioural techniques and trauma-sensitive interventions (e.g., psychoeducation, relaxation techniques, cognitive processing and narrative exposure). Research shows TF-CBT significantly improve core symptoms of PTSD with a moderate to large effect size (Maercker et al., 2022).

As hypothalamic-pituitary-adrenal (HPA) axis dysfunction is not present in all individuals experiencing trauma, especially those found neurobiologically resilient, Cross et al. (2017) recommended some protective factors to make any environments sensorily safe for them. These recommendations include offering opportunities for supportive relationships (e.g., friends, carers, partners or other significant others) as buffers while stress is happening or during stressful events (Kalisch et al., 2025). It can also be useful for mental healthcare professionals to take into consideration the environments, in which individuals live and spend most of their time (e.g., home, school, local communities) with ongoing trauma exposure and received threats, may impede interventions (Cross et al., 2017).

Modifications that apply trauma-informed educational practices, such as individualised learning plans, universal design for learning, flexible (seating) and sensory-friendly classroom arrangements (sensorily safe space, visual aids, checklists/planners, relaxation strategies), can help reduce anxious, dissociative behaviours, promote learning and engagement in classroom contexts, and therefore improve academic outcomes (Patilima, 2025). Additionally, early access to mental health networks for families of neurodivergent children experiencing trauma, have positive conversations around diversity and acceptance and participate in peer mentoring programs can provide these students with support and guidance to navigate social situations with confidence and build interpersonal skills overtime (Cross et al., 2017; Patilima, 2025).

==Conclusion== but This chapter recognises the interplay between neurodivergence and trauma. It also shows possible directions to follow in the selection of methods and trying them out in order to address individual needs of each child for effective support and healing. Trauma can cause alterations in brain structure and function involving the hippocampus, prefrontal cortex and amygdala, which result in neurodivergent traits such as heightened anxiety, sensitivity, sensory, emotional and cognitive processing dysfunction (Cross et al., 2017). Reversely, neurodivergent individuals can highly likely be susceptible to experiencing trauma, as the results of misunderstanding, mislabeling, underrepresentation and possible societal stigma. This can then create a cycle where trauma symptoms and neurodivergent traits exacerbate each other, making it vital to identify and address them both in any treatment plan. The type and intensity of selected treatment should depend on the type and severity of NDCs and traumatic experiences. However, any intervention and support strategies should not aim to change these individuals, but rather to help them cope with their problems and learn to function life matters in healthier ways.

• Attachment theory (Wikipedia)
• DSM-5 (Wikipedia)
• Evidence-based assessment/Rx4DxTx of PTSD (Wikiversity)
• Psychological trauma (Wikipedia)
• Trauma-informed education (Book chapter, 2024)

• Post-traumatic stress disorder (World Health Organization)
• We can prevent ACEs (Youtube)
• What is attachment theory? (Verywell Mind)
• What is EMDR Therapy? (Verywell Mind)
• Understand the Effects of Childhood Trauma (Verywell Mind)