Introduction

There is considerable evidence demonstrating associations between childhood trauma, including physical, sexual and emotional abuse, with negative mental health, physical health and social outcomes, deficient communicative skills, antisocial behavior, substance abuse and, in particular, misuse of alcohol in a victim's later life; further details and references are in [1-3]. Detection of the abuse and exposure of perpetrators often depends on the victim. It is easy to expose a socially unprotected abuser, for example, an alcoholic or a mentally abnormal individual. Otherwise, different tools can be applied to prevent a disclosure: denial of facts and accusations of slander, threats, intimidation or subornation of the victim, appeals to preservation of honor and reputation of the family, nation, etc. It should be mentioned that over 99% of publications on child maltreatment have been based on research conducted in more developed countries [4]. While in less developed societies, child and elder abuse can persist without much publicity.

The prevalence of the substance use disorder among individuals with autism was reported to be relatively low [5] however, there may be an underestimation [6]. Persons with high-functioning autism without intellectual disability may drink alcohol to cope with anxiety, to maintain friendships and gain access to new relationships [6,7]. Furthermore, the youth with ASD were found to be at a higher risk of victimization and bullying [8-12]. Given the association of autistic traits in adults with the abuse in their childhood, studies identifying causal mechanisms can improve preventive efforts [13]. Here is presented a case illustrating a combination of the above-named symptoms and factors, followed by a discussion of putative mechanisms.

Case report

When Sergei (S.) was three years old, his parents were divorcing, while he was sent with a nanny to a suburb village. They spent there also two subsequent summers, having almost no contact with other children. The boy sat on a sofa or bench for a long time, which did not contribute to his physical development and communicative skills. At the age of about 6-7 years, S. was noticed to have autistic traits such as communication deficits, failure to develop peer relationships and motor clumsiness; at an age of about 10 years appeared fixated interests deemed unusual by some pedagogues: detailed study of history, later also of foreign languages. Some symptoms

Compatible with ADHD (Attention Deficit Hyperactivity Disorder) were observed as well: inattention, impulsivity and hyperactivity, the latter being more pronounced in a familiar environment. Appearance of the autistic symptoms coincided with the time when the socially unskilled child was exposed to bullying; the symptoms further aggravated in parallel with the physical abuse at home. Besides, it should be mentioned that S. has a relative macrocephaly (head circumference at an adult age approximately 60.5 cm), similarly to his mother and father, who both were professors. An increased prevalence of macrocephaly has been described in children with ASD [14,15]. While some researchers reported a higher level of functioning in children with ASD and macrocephaly in comparison to those with average head circumference [16]. Moderately expressed marfanoid features (long limbs, arachnodactyly, hypermobility of some joints, hiatal hernia in a later life) were noticed in S. and some maternal relatives. An association of macrocephaly, Marfan-like ligamentous laxity and Asperger's syndrome has been reported as well [17]. It should be mentioned without implying cause-effect relationships that Sergei’s maternal grandfather misused alcohol, paternal grandfather died of renal failure presumably in consequence of a professional poisoning by mercury, and maternal grandmother, a radiologist, died of cancer in her thirties.

When S. was 7 years old, his mother married a 13 years younger person. The following risk factors of the child maltreatment [18] were present: poor social support, presence of a younger child, family history of abuse - the abuser had been beaten by his father. The abuse was administered by slapping in the face and head as well as beating with a belt. The abuse was often administered under the pretext of punishment, but sometimes without any pretext. Episodes of violence went along with intimidation by gestures and grimaces as well as verbal abuse. There are statements in the literature that abusive encounters are heavily laden with emotion [19]. In this case, it could have been so in the beginning, but later the scenes of abuse became more theatrical and less emotional on the part of the perpetrator. Apparently, violence has become the abuser’s habit and obsession. The abuse sometimes occurred before spectators: the mother, relatives or friends. On rare occasions, the mother participated in battering, which is in agreement with the data that mothers tend to abuse their children at higher rates when their partners are not fathers of the victims [20]. A motive could have been squaring of accounts with the disloyal partner in the person of his son probably on the background of dissociation as the maternal affection was present and spontaneously returned during the earlier childhood. Apart from irregular nourishment now and again, an example of neglect was a deprivation of training clothes during the earlier school time. The boy was regularly sent to gymnastics lessons inappropriately dressed, so that his genitals could be seen during exercises, in spite of written reprimands from the teacher. This was one of the immediate causes of the bullying as well as delayed physical development: the teacher left the boy sitting on a bench during gymnastics lessons. An ethnic factor played a role: the abuser was of Jewish descent, while S. used to stress his Russian ethnicity. Having a Jewish stepfather, who even worked for some period at his school, S. was often treated by the social environment as a member of the ethnic minority. It was expressed by bullying, sometimes visibly inspired by adults including some teachers and other children’s relatives. It is known that bullying happens at schools, where children do not feel safe to report bullies [21]. The author does not intend to say that Jewish children were generally bullied at Soviet schools. Many of them were not, because they had been prepared by their families, did not deny their difference, and behaved adequately. On the contrary, S. behaved ambitiously, involuntarily provoking his environment. S. himself participated in bullying children from ethnic minorities; his role thus being classified as bully-victim, reportedly more at risk of substance use than pure bullies or victims [22].

As usual in such cases, S. was ashamed to tell to anybody about the abuse at home. Once he answered affirmatively a question of a teacher whether he had been physically punished; it had no consequences. Another teacher, surprised by xenophobic remarks made by S. at school, came with a home visit, which was followed by a discontinuance of the abuse for several months accompanied by an improvement of his progress in school studies. This is in agreement with the data that maltreated children are at risk for poor school functioning [23]. Apart from occasional participation in parties at home and drinking up to a bottle of beer with a schoolmate, S. did not consume alcohol till the age of 13. That summer he drank a 0.75 l bottle of fortified wine with an older boy. During the subsequent year, his alcohol consumption increased up to 250 ml of vodka with beer or a 0.75 l bottle of fortified wine at one sitting. An opportunity to stay away from domestic violence was provided by a drinking company of schoolmates including older boys inspiring alcohol purchase and consumption. During the following years, he was several times detained by the police (militia) and at least twice spent a night at a sobering-up station. At the age of 13.5 years, S. run away from the everyday’s violence first to his grandmother and then lived about 2 years in a small apartment together with the new family of his father. Thereafter he was manipulated to return to the mother’s flat. After the admission to a university, a separate room was rented for S. Next year, because of drunkenness and absenteeism, he was dismissed from the university and served 2 years with the army; his education was interrupted for 4 years. The immediate cause of the dismissal was as follows:

Having worked 2 months with a student construction brigade (stroyotriad), S. went to a Black Sea resort, where he, being 18 years old, was robbed and remained without money for a return ticket. Despite repeated telegrams and telephone calls, he received money with a delay, which resulted in about 2 weeks’ tardiness at the university. At the age of about 22.5 years, S. underwent an implantation of a disulphiram preparation Esperal, which was followed by a period of abstinence about 8 months long. After that he resumed alcohol consumption: 2-3 binges monthly with dosages as described above or occasionally higher. S. discontinued the alcohol misuse at the age of about 35 years, when it has become incompatible with his professional duties. Later he did not resume alcohol over-consumption in spite of provocations from the social environment. With time, subconscious motives of the alcohol intake have become clear: alcohol helped him to overcome communication barriers. It was, however, associated with risk: not possessing sufficient social skills, his rhetoric and acts under the impact of alcohol were sometimes precarious, which resulted e.g. in misdemeanors (minor hooliganism and public nuisance, petty larceny, drunk driving) and detentions by the police. This illustrates a mechanism contributing to the alcohol consumption not only in autistic persons: becoming "insider" through drinking with peers. This mechanism was exploited: in workers’, students’ and intelligentsia companies, the ringleaders were observed, who manipulated others towards alcohol intake, while non-drinkers were sometimes stigmatized [24].

To finish the case report on an optimistic note, it should be mentioned that S. made conscious efforts to forgive the abusers. Forgiveness was reported to be associated with improved alcohol-related outcomes [25]. Moreover, the mother and her partner cooperated with the author of this report in elucidation of the motives, of psychological, ethnic and social aspects of child abuse. In particular, according to the mother’s memory, behavioral and communication abnormalities during Sergei’s preschool time coincided with bullying on the playgrounds near their apartment house, which was apparently in some cases inspired by adults and tolerated by his nanny. During the same time, S. underwent tonsillectomy and adenoidectomy with inadequate local anesthesia and questionable indications. Later it has become clear that he had allergic rhinitis. Interestingly, larger head sizes were reported to be associated with allergic disorders in patients with autism [26].

Discussion

In the former Soviet Union, the child abuse and neglect has been rarely discussed. Public organizations and authorities sometimes did not react to known cases of domestic violence: for example, Sergei's grandmother wrote letters to the authorities about this case of abuse, which had no consequences. A part of the society seems to be opposed to a public discussion of violence in families. Dimensions of the problem are difficult to assess as there are no reliable statistics [27]. There is no generally agreed attitude to the problem and no consequent policy, which is complicated by a shortage of adequately educated personnel [28] and limited use of the foreign professional literature [29]. Scenes of violence and death are often shown on the Russian TV, apparently distracting the public attention from child and elder abuse. Violence towards children is sometimes discussed by the mass media as a norm. For example, the well-known filmmaker Nikita Mikhalkov said on 28 May 2014 from the TV screen without a trace of disapproval that his father Sergey Mikhalkov (https://en.wikipedia.org/wiki/Sergey_Mikhalkov), the writer of children's literature, slapped him in the face, which can cause additional cases of concussion in children. Celebrities are often copied. Note that a man’s hand is weighty. According to the laws of physics, by the given impulse, the damage would be above-average in cases of macrocephaly, which is associated with the ASD [15].

The ASD cases are often marked by symptoms consistent with ADHD [30-32]. In the case presented here, ADHD symptoms were observed especially during the early childhood: inattention, impulsivity and hyperactivity, the latter being more prominent in a familiar environment. Emergence and worsening of the autistic symptoms coincided with the time when the socially unskilled child was exposed to bullying and domestic violence. Interestingly, the avoidance of the eye contact, an ASD symptom, was not noticed till approximately 13 years, when a teacher told to Sergei’s mother that the boy had an “insolent gaze”; and the mother instructed him not to look into peoples’ eyes. Avoidance of the eye contact may have also resulted from intimidation. In the author’s opinion, physical abuse is an undervalued cause of autistic symptoms. Some children with autistic symptoms are probably battered ADHD children or initially healthy ones, possibly having unusual traits predisposing to the bullying. In the atmosphere of bullying and domestic violence, ADHD manifestations such as impulsivity and hyperactivity may be regularly punished. Abnormal behaviors seem to be a kind of adaptation in some cases, a consciously or subconsciously implemented strategy to avoid the trauma. Such behaviors might be compatible with the ASD e.g. abnormal social approach, failure to respond to social interactions, poorly integrated communication, abnormalities of eye contact, deficits of developing and maintaining relationships (DSM-5). Deranged relationship with parents such as the reduced sharing of emotions or interests can be also explained by the child abuse. Other features compatible with the ASD may be secondary to a deficit in relationships with peers and/or family members or result from sublimation as a defense mechanism against anxiety or psychological trauma [30]: fixated interests deemed abnormal e.g. study of special subjects beyond the school program.

According to the hypothesis discussed here, some ASD cases may be caused by intrinsic factors while others are ‘simulators’ induced or reinforced by environmental factors such as physical abuse and bullying. ADHD, ASD and social anxiety disorder have partly overlapping symptoms [31-34]. A differentiation may depend on external factors: in an environment permitting impulsivity and hyperactivity, the child would preserve ADHD symptoms or develop in a more typical way. In conditions of bullying and/or domestic violence, regularly punishing the impulsivity and hyperactivity, the child might be “educated” towards abnormal behaviors aimed at avoidance of trauma. It may be also hypothesized that children with macrocephaly are consciously or subconsciously more preoccupied with protection of their heads. On the other hand, macrocephaly, “giftedness”, marfanoid or other unusual features may predispose to the bullying. The cause-effect relationship may be bidirectional: autistic symptoms may enhance the risk of bullying while the bullying and domestic violence would induce or reinforce abnormal behaviors. In this connection, the heritability of the ASD may have a non-genetic explanation in certain cases. The child abuse is associated with inadequate parenting [35]; children of deviant parents may be more exposed to the maltreatment, as a result acquiring deviant features themselves. In conclusion, the child abuse and bullying may be causative factors of atypical behaviors more or less compatible with the ASD.

1. Springer KW, Sheridan J, Kuo D, Carnes M (2003) The long-term health outcomes of childhood abuse. An overview and a call to action. J Gen Intern Med 18: 864-870.
2. Jargin SV (2011) Child abuse and alcohol misuse in a victim. Alcohol and Alcoholism 46: 734-736.
3. Jargin SV (2013) Attention Deficit Hyperactivity (ADHD) and Autism Spectrum Disorder (ASD): on the role of alcohol and societal factors. Int J High Risk Behav Addict 1: 194-195.
4. Mikton C, Butchart A (2009) Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization 87: 353-361.
5. Ramos M, Boada L, Moreno C, Llorente C, Romo J, et al. (2013) Attitude and risk of substance use in adolescents diagnosed with Asperger syndrome. Drug and Alcohol Depend 133: 535-540.
6. Lalanne L, Weiner L, Trojak B, Berna F, Bertschy G (2015) Substance-use disorder in high-functioning autism: clinical and neurocognitive insights from two case reports. BMC Psychiatry 15: 149.
7. Rengit AC, Mc Kowen JW, O'Brien J, Howe YJ, McDougle CJ (2016) Brief report: Autism spectrum disorder and substance use disorder: A review and case study. J Autism Dev Disord 46: 2514-2519.
8. Zablotsky B, Bradshaw CP, Anderson CM, Law P (2014) Risk factors for bullying among children with autism spectrum disorders. Autism, 18: 419-427.
9. Hebron J, Oldfield J, Humphrey N (2016) Cumulative risk effects in the bullying of children and young people with autism spectrum conditions. Autism doi: 10.1177/1362361316636761
10. Maïano C, Normand CL, Salvas MC, Moullec G, Aimé A (2016) Prevalence of school bullying among youth with autism spectrum disorders: A systematic review and meta-analysis. Autism Research 9: 601-615.
11. Sterzing PR, Shattuck PT, Narendorf SC, Wagner M, Cooper BP (2012) Bullying involvement and autism spectrum disorders: prevalence and correlates of bullying involvement among adolescents with an autism spectrum disorder. Archives of Pediatrics Adolescent Medicine 166: 1058-1064.
12. Zeedyk SM, Rodriguez G, Tipton LA, Baker BL, Blacher J (2014) Bullying of youth with autism spectrum disorder, intellectual disability, or typical development: Victim and parent perspectives. Research in Autism Spectrum Disorders 8: 1173-1183.
13. Roberts AL, Koenen KC, Lyall K, Robinson EB, Weisskopf MG (2015) Association of autistic traits in adulthood with childhood abuse, interpersonal victimization, and posttraumatic stress. Child Abuse Negl 45: 135-142.
14. Aylward EH, Minshew NJ, Field K, Sparks BF, Singh N (2002) Effects of age on brain volume and head circumference in autism. Neurology 59: 175-183.
15. Sacco R, Gabriele S, Persico AM (2015) Head circumference and brain size in autism spectrum disorder: A systematic review and meta-analysis. Psychiatry Research 234: 239-251.
16. Zachor DA, Ben-Itzchak E (2016) Specific Medical Conditions Are Associated with Unique Behavioral Profiles in Autism Spectrum Disorders. Front Neurosci 10: 410.
17. Tantam D, Evered C, Hersov L (1990) Asperger's syndrome and ligamentous laxity. J Am Acad Child Adolesc Psychiatry 29: 892-896.
18.  Hindley N, Ramchandani PG, Jones DP (2006) Risk factors for recurrence of maltreatment: a systematic review. Arch Dis Child 91: 744-752.
19. Herbruck CC (1979) Breaking the Cycle of Child Abuse. Minneapolis: Winston Press.
20. Alexandre GC, Nadanovsky P, Moraes CL, Reichenheim M (2010) The presence of a stepfather and child physical abuse, as reported by a sample of Brazilian mothers in Rio de Janeiro. Child Abuse Negl 34: 959-966.
21. LePage P, Courey S. (2014) Teaching children with high-level autism. London: Routledge.
22. Radliff  KM, Wheaton JE, Robinson K, Morris J (2012) Illuminating the relationship between bullying and substance use among middle and high school youth. Addict Behav 37: 569-572.
23. Cicchetti D, Toth SL, Hennessy K (1995) Child maltreatment and school adaptation: Problems and promises (pp. 301-330) In: IE Sigel, D Cicchetti SL Toth (Eds) Advances in applied developmental psychology. Vol. 8. Child abuse, child development, and social policy. Norwood NJ: Ablex.
24. Jargin SV (2010) On the causes of alcoholism in the former Soviet Union. Alcohol and Alcoholism 45: 104-105.
25. Webb JR, Robinson EA, Brower KJ (2011) Mental health, not social support, mediates the forgiveness-alcohol outcome relationship. Psychol Addict Behav 25: 462-473.
26. Sacco R, Militerni R, Frolli A, Bravaccio C, Gritti A et al. (2007) Clinical, morphological, and biochemical correlates of head circumference in autism. Biological Psychiatry 62:1038-1047.
27. Nikulina EA (2006) Organizational and pedagogical prevention system of child abuse in families. Candidate Dissertation. Saratov: Saratov State University (in Russian)
28.  Besschetnova OV (2003) Social Work with Children - Victims of Abuse in Families (Analysis of Domestic and Foreign Experience) Balashov: Niklolaev (in Russian)
29.  Murphy J, Jargin S, Nadraga M (2017) International trends in health science librarianship. Part 20: Russia and the Ukraine. Health Information and Libraries Journal, doi: 10.1111/hir.12172.
30. Metzger JA (2014) Adaptive defense mechanisms: function and transcendence. J Clin Psychol 70: 478-488.
31.  Hartley SL, Sikora DM (2009) Which DSM-IV-TR criteria best differentiate high-functioning autism spectrum disorder from ADHD and anxiety disorders in older children?. Autism 13: 485-509.
32.  Mayes SD (2012) Checklist for Autism Spectrum Disorder. Chicago IL: Stoelting.
33.  Murray MJ (2010) Attention-deficit/Hyperactivity Disorder in the context of Autism spectrum disorders. Current Psychiatry Reports 12: 382-388.
34. Kleberg JL, Högström J, Nord M, Bölte S, Serlachius E, et al. (2016) Autistic traits and symptoms of social anxiety are differentially related to attention to others’ eyes in social anxiety disorder. J Autism Dev Disord doi: 10.1007/s10803-016-2978-z.
35. Gonzalez, A, MacMillan HL (2008) Preventing child maltreatment: an evidence-based update. J Postgrad Med 54: 280-286.