PERSPECTIVE

published: 25 March 2022

doi: 10.3389/fpsyt.2022.873121

Vulnerability to
Ideologically-Motivated Violence
Among Individuals With Autism
Spectrum Disorder
Marc R. Woodbury-Smith 1*, Rachel Loftin 2 , Alexander Westphal 3 and Fred R. Volkmar 4
1
Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom, 2 Department of Psychiatry and
Behavioral Sciences, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States, 3 Division of Law and
Psychiatry, Department of Psychiatry and Child Study Center, Yale University, New Haven, CT, United States, 4 Child Study
Center, Yale University and Southern Connecticut State University, New Haven, CT, United States

People with autism spectrum disorder (ASD) are represented among those who
espouse extremist thought and have committed violent acts associated with their
beliefs. Media often highlight a perpetrator’s psychiatric diagnosis following acts of mass
violence, which in some instances has included ASD. ASD may itself not provide useful
information for understanding motivations. Instead, understanding specific traits and
neuropsychological and other vulnerabilities may offer an opportunity to make sense of
these very complex events.
Edited by:
Jeffrey C. Glennon, Keywords: autism spectrum disorder, extremism, terrorism, vulnerability, mental health, incels, forensic
University College Dublin, Ireland
Reviewed by:
Darren William Roddy, INTRODUCTION
Trinity College Dublin, Ireland
Through the media we are often made aware of the mental health of individuals who have engaged
*Correspondence:
Marc R. Woodbury-Smith
in high profile acts of either mass violence or inexplicable acts of violence toward others (1, 2).
marc.woodbury-smith@ Mental disorders such as schizophrenia and mood disorders are often cited as increasing the risk
newcastle.ac.uk of unlawful behavior, although it is also recognized that this increased risk is modest (3, 4). More
recent studies have also investigated mental disorders among people who have engaged in violence
Specialty section: in the context of holding extremist beliefs. These indicate that among violent extremists between
This article was submitted to 10 and 17% have one or more mental disorders, with a range of psychiatric diagnoses represented,
Autism, with mood disorder and schizophrenia the most frequent (5, 6). In recent years, the media has
a section of the journal drawn attention to perpetrators who have been formally diagnosed with autism spectrum disorder
Frontiers in Psychiatry
(ASD) (2). Examples include the Toronto Van Attack and the Sandy Hook shootings, where, in
Received: 10 February 2022 both instances, the perpetrator had an established diagnosis of ASD. Similarly, among those who
Accepted: 04 March 2022 are drawn to extremist ideologies or outgroup affiliations, such as incels (involuntary celibates)
Published: 25 March 2022
(7), we are aware that a significant minority either have ASD or self-identify with this label (8).
Citation: The perpetrator of the Toronto Van Attack is one such individual. Other examples do exist in the
Woodbury-Smith MR, Loftin R,
literature in which an ASD diagnosis is suggested (9, 10), but such highly-speculative cases will not
Westphal A and Volkmar FR (2022)
Vulnerability to Ideologically-Motivated
be discussed further, particularly given the lack of formal diagnosis and other inherent biases in the
Violence Among Individuals With approach taken (11).
Autism Spectrum Disorder. It is important to understand the nature of any apparent relationship between diagnosis and
Front. Psychiatry 13:873121. behavior in such instances given that it may reflect aspects of vulnerability that characterize ASD
doi: 10.3389/fpsyt.2022.873121 and that may be amenable to intervention. Moreover, given that ASD as currently conceptualized

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Woodbury-Smith et al. Ideologically-Motivated Violence in ASD

has evolved into a relatively prevalent condition [more than rise in diagnosis among those who function in the normal range
1:54 people, and with a year-on-year rise in prevalence of of intelligence (i.e., an IQ of 70–75 or above) (12). Beyond the
nearly 10%, (12)] it is increasingly important to understand the broadening of criteria, factors such as better recognition of the
nature of this risk, including its implication for forensic mental diagnosis and greater awareness among families and healthcare,
health services and the criminal justice system. We set out to social care, and education, explain this increase to a large extent.
critically examine the evidence base concerning the relationship However, this is surely an under-estimate of actual prevalence,
between ASD and acts of violence that are mediated by extremist given that there will be other individuals who are unable to
beliefs. The relationship is, of course, complex, but, as discussed pursue a diagnostic assessment for health insurance reasons,
subsequently, red flags can be identified and, as such, it is crucial and others who may live far from diagnostic availability. The
for mental health and criminal justice professionals to be alert to data also support the fact that certain ethnic groups are under-
the possibility of ASD and its potential relevance. represented (16). Additionally, those who do not identify with
the illness model will never feature in healthcare statistics. This is
important as there may be some individuals whose diagnosis does
ASD AS A DIAGNOSTIC ENTITY not become apparent until the occurrence of some event, such as
alleged unlawful behavior.
ASD is an early onset, lifelong disorder impacting the core
domains of social interaction and communication, and,
by definition, is associated with concomitant functional ASD AND UNLAWFUL BEHAVIOR
impairment. ASD’s social and communication vulnerabilities
A number of previous studies have identified the risk of violence
manifest in different ways and include difficulties such as
and other unlawful behavior among some people with ASD, and
initiating and maintaining social interaction with others,
have expounded on some of the possible mechanisms (17). This
understanding non-literal aspects of communication such as
is particularly true among the single case studies and case series
irony and sarcasm, and cognitive difficulties in domains such
that offer detailed investigation of relevant risk factors. There
as face and emotion processing, and planning, predicting, and
are a number of themes that seem to emerge consistently from
problem solving. While poor problem solving and emotional
this research, including a naïve understanding of relationships
regulation may predispose an individual to behave in a violent
and jealousy of others or anger and frustration at their own
manner, a lack of empathy and interpersonal connection with
experiences; being coerced into unlawful behavior by dominant
others may increase the possibility that violent thoughts are
others; and the obsessional pursuit of a particular interest (18).
enacted if there is a failure to conceptualize others as people who
Other studies have also suggested that people with ASD are over-
become victims. Much has been written about such mechanisms
represented in secure psychiatric hospitals (19–21) and in prisons
in the context of psychopathy (13). At a clinical level, of course,
(22). Although such studies have suggested that as many as 5% of
there are significant differences between ASD and psychopathy,
these populations are diagnosed with ASD, they are by no means
but at a cognitive level there is some evidence of overlap (14, 15),
robust in their methodology.
so similar vulnerabilities may be relevant.
A number of other related symptoms also occur under the
umbrella of rigidity of thought and behavior. These comprise ASD AND EXTREMISM
strongly held beliefs and “black and white” thinking. Such beliefs
can sometimes be abnormal or inappropriate in focus, and it is Extremism is characterized by beliefs that are held with
in this context that they may be deemed “extremist” in nature. conviction and with inherent hate and anger toward others.
Extremist thought may also appeal to those with a tendency As such, those holding such extremist beliefs generally accept
toward black and white thinking because it can present a clear the possibility of a violent solution, which is normalized and
means of organizing an overwhelming and chaotic world. Belief justified as a means to an end (23, 24). Given the disruption that
that people can be readily classified by gender, race, or other such groups inflict on society, there is a strong motivation to
features may make the world feel more manageable to someone understand their behavior, including from the point of view of
who struggles to understand or follow social conventions. (It is their psychological motivation and mental health. The literature
worth noting that in the vast majority of people with ASD this has largely argued that those who engage in terrorism are
tendency may have a very prosocial impact by encouraging rule- psychologically stable and lack any enrichment for particular
following.) personality traits or specific mental disorders (25), although
ASD has evolved into a broadly defined disorder whose in individual cases the evidence can be substantial. On the
margin relative to the “tail end” of population-level social other hand, research that has focused specifically on lone-wolf
and communication skills is somewhat blurred. Perhaps this terrorism has identified a significant increase in depression,
distinction between those who formally meet diagnostic criteria anxiety and specific personality disorders (26). In the context
and those who show traits but not the full clinical picture is not of the current article, many are loners who have very few if
important, but that being the case, definitions will need to be any social relationships, and some identify with or have been
adjusted accordingly. The prevalence of formally diagnosed ASD formally diagnosed with ASD. Of course, the episodic nature of
has seen an almost 10% year-on-year increase over the last 20 or disorders such as depression and schizophrenia means that the
so years (12). This increase is largely explained by a significant risk may come and go, as symptoms deteriorate and improve. The

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Woodbury-Smith et al. Ideologically-Motivated Violence in ASD

fluctuation in risk associated with these disorders will also relate resulting in violence. For others, however, these beliefs can be
to contact with services for support and monitoring. acted out in the form of violence (31).
One notable study examined the prevalence of specific mental What may be more important than particular interests or
health disorders among group (N = 158) and lone-actor (N = rigidly held beliefs is the social exclusion and bullying that are
119) terrorists using retrospective data comprising reports from both common among adolescents with ASD, and which can fuel
a variety of sources (26). Cases were not directly evaluated and resentment and hate toward their peers. The adolescent years
so at best the “diagnoses” are speculative. Nonetheless, 3% of place particular emphasis on social performance as a metric
the lone actor terrorists were labeled ASD, compared to the for “worthiness,” and can be brutal for someone who struggles
population prevalence of 1.5%. One illustrative example is Sandy to understand interpersonal behavior. Numerous first-person
Hook in Connecticut where a 20-year-old murdered 26 people by narrative accounts of individuals with ASD describe the sense of
shooting, among whom were 20 children. At the age of 13 years hopelessness imbued by the observation that the most socially
the perpetrator was diagnosed with Asperger Syndrome (now competent individuals are always the most popular, not only
recognized under the umbrella term ASD) and a year later also among peers but also teachers [for example (32)]. Children
with obsessive compulsive disorder (OCD). He was described as and adolescents with ASD are often the victims of bullying
socially aloof, awkward and emotionally disengaged even from (33), sometimes over a long period of time. This may result in
family. He developed political interests and opinions that he feelings of anger toward others, particularly victimizers and their
argued with authority and arrogance (27). His OCD manifested affiliates, even among those without ASD but who have engaged
in a typical repetitive and ritualistic manner, driven by sensory in mass violence. The exact relationship between bullying and
overload and fear of contamination, as was his anxiety and panic mass violence is unclear however: some evidence suggests that
attacks. Even given this small amount of clinical information 87% of school shooters had described of being victims of bulling
it would be very difficult to argue against the relevance of his (34), whereas a more detailed examination of school shooters
diagnoses, which has been discussed in detail elsewhere (27). found no such evidence (35).
In some cases, diagnosis is made post offense, often in On the one hand, therefore, extremism-mediated violence
the context of Court-directed psychiatric and psychological among those with ASD may not be so much about ASD
assessment. Even now it is not unusual for diagnosis of ASD per se, but instead relate to how others treat them because
to be delayed into adulthood, and so this is not particularly of their vulnerabilities. The appeal of belonging, such as by
indicative of their symptoms being relatively “milder” than those associating with an outgroup, may be stronger in people who
diagnosed when younger. As many extremists who carry out do not experience a sense of community and belonging in other
terrorist activities ultimately also kill themselves, or are killed contexts. Of course, other factors that have not been well-studied,
by law enforcement, diagnosis is also sometimes based on an such as poor empathy or mentalizing, may also mediate violence
indirect means (9, 10), such as interview with family, friends and through their impact on mechanisms that inhibit violence (13,
documentation from diaries or blogs rather than through direct 36). Research has also shown that a history of trauma can impact
assessment. These “diagnoses” must be approached with a degree the same biological mechanisms and may in itself be associated
of skepticism. with an increased risk of violence (37). However, trauma as a
precursor to poor outcomes among people with ASD has not
been well-studied, and hence the role of childhood sexual and
RELEVANT RISK FACTORS physical abuse and neglect on the risk of violence specifically in
ASD is unknown (38).
Vulnerability to extremist patterns of thinking may be related
to ASD’s rigidity and otherwise ritualistic and constrained
patterns of belief and behavior. The manifestation may vary from INFORMATION SEEKING AND ANXIETY
individual to individual, for some manifesting as circumscribed REDUCTION
interests that are pursued with intensity. The focus of interests
vary, but information gathering on particular topics is frequent. Individuals with ASD are at higher risk for anxiety disorders
It is recognized that there may be an association between and difficulties (39–41). This is also a population where
circumscribed interests and violence (28–30), although the focus familiarity with computers and the internet is common and
of interests themselves is not a good marker of risk: for example, indeed frequently seen as a life-line with great fluency with
a fixation on military or law enforcement may be confined purely web based resources (42, 43). This fluency has both positive
to an academic interest. and negative effects (44). For example, there is potential
For some, patterns of thinking may be rigid, with fixed, for anxiety reduction through information gathering, but,
firmly held beliefs. This may be an extension of a particular conversely, internet searching can become obsessive and the
interest, but may also relate to a personal experience. Although potential for internet addiction is high (45, 46). One of the
people more generally may become emotionally involved with great risks is that lack of good social judgment and supportive
particular topics, for an autistic person this may become all peers (who can provide an important balance to disinformation)
encompassing, and, importantly, held without consideration of makes individuals with ASD more vulnerable as targets for
counterarguments. In clinical practice, such rigidly held beliefs misinformation (47).
are not uncommon, and for the most part result in further Instances of terrorism may lead individuals with Asperger’s
alienation, compounding any depression or anxiety, but not or ASD who are cyberfluent to seek information initially to

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Woodbury-Smith et al. Ideologically-Motivated Violence in ASD

manage their anxiety. However, repeated internet searches on extremism and terrorism/mass violence has drawn focus from
topics related to terrorism (e.g., building bombs or information different academic disciplines as well as legislators, policy makers
on terrorist groups) may be noticed by government agencies even and security experts. What is striking is the broad-based expertise
if the individual involved is merely curious. On the other hand, that characterize those working in this area. Although this carries
sometimes the lack of social sophistication, critical thinking, the option of a fruitful exchange of information, more often
and poor judgment can act to seemingly or actually radicalize than not true cross-fertilization of knowledge is confounded by
individuals with ASD (48). It is important that supporters little opportunity to work together, or other agendas, political,
and family members help provide good information on safe or otherwise.
internet use and that government agencies be aware of these
potential vulnerabilities. DISCUSSION
ASSESSMENT The motivation for an individual to hold extremist beliefs and
the risk of violence represent the interplay between a number
There is much to be gained from developing a better of factors, both well-defined and those that are stochastic
understanding of the relative roles of these various factors in and unpredictable. We have considered risk from a mental
the etiology of violence among individuals with ASD, crucially health perspective, and specifically in relation to ASD. People
to inform prevention and treatment. Assessment of individual with ASD are certainly represented among those who are
motivation is often performed by suitably trained professionals affiliated with extremist groups, and some have engaged in
as expert witnesses in order to inform decisions of culpability. extremist-related violent acts. Whether this is more frequent
In this way, the whole gamut of possibly relevant etiological than those with other neurodevelopmental disorders, or those
factors can be considered along with other stochastic events and with other mental health problems, is unclear. We expect
decisions the defendant may have made along the way. The that the relationship is not strong, but at the same time,
expert who considers individual level risk has the opportunity as articulated above, there are reasons to believe that the
to pull together these multiple threads into a rich, detailed diagnosis will be relevant. In order to be able to approach
understanding that surpasses the generic, descriptive actuarial these difficult clinical questions, what is needed is suitably large-
risk. It is not enough to say that ASD is or is not relevant; reducing scale research that draws on expertise across disciplines and
risk in this simplistic way will for certain undermine the ability to that goes beyond the level of diagnosis to explore trait and
understand the nature of risk and how best to manage that risk. neuropsychological risk factors, both current and historical.
The actual assessment itself requires the use of standardized Although case studies are informative, they do not allow
instruments both in the diagnostic assessment itself but also hypotheses concerning, for example, risk and protective factors
in relation to measuring additional relevant traits and behavior to be tested. Moreover, given the multitude of mental disorders
such as acquiescence/suggestibility, mental health-comorbidity, raised in the extant literature, and the strong possibility of
and theory of mind/empathy. Assessments are widely available, individuals displaying co-morbidity, there needs to be careful
a discussion of which is out of the scope of this current article. attention to characterizing the clinical phenotype. Good clinical
However, it is important to bear in mind that none of the ASD practice dictates that at every stage of the criminal justice
diagnostic assessments were developed to be used in a forensic process ASD and other neurodevelopmental diagnoses are
population, and may not be sensitive to differentiate between, for given appropriate consideration when formulating cases with
example, social impairments that are largely trauma related from reference to culpability, criminal intent and other aspects of
those that may be indicative of ASD. Given that adult assessments criminal responsibility.
place a greater emphasis on adult adjustment rather than
development, this may be particularly problematic. Similarly, DATA AVAILABILITY STATEMENT
screening assessments were developed for community use, and
the questions posed are biased toward particular experiences that The original contributions presented in the study are included
may not reflect those who have had less opportunities. in the article/supplementary material, further inquiries can be
One potential drawback of focusing on diagnosis is that in the directed to the corresponding author/s.
search for mental health “explanations” the true complexity of
human behavior may be missed. As indicated above, there is a ETHICS STATEMENT
need to understand extremism and extremist-related behavior,
but it is often the case that in doing so explanations offered Written informed consent was not obtained from the
become pallid and rather simplistic. Moreover, by simply looking individual(s) for the publication of any potentially identifiable
for diagnostic labels, there is a chance that such reductionist images or data included in this article.
tendencies merely identify “red herrings” rather than true
risk factors. A related issue is the tendency to apportion AUTHOR CONTRIBUTIONS
“responsibility” for behavior to a particular diagnostic label, when
in fact the role it plays maybe really quite small and peripheral. MW-S wrote the first draft and all authors subsequently
One reason this may happen is that experts are trained to focus on contributed to revisions. All authors contributed to the original
specific dimensions of risk, whether psychiatric, psychological, conception of the idea, contributed to the article, and approved
social, environmental, or economic. Indeed, understanding the submitted version.

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Woodbury-Smith et al. Ideologically-Motivated Violence in ASD

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sample with autism spectrum disorder and/or attention-deficit hyperactivity potential conflict of interest.
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46. Jordan CJ, Caldwell-Harris CL. Understanding differences in and do not necessarily represent those of their affiliated organizations, or those of
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Frontiers in Psychiatry | www.frontiersin.org 6 March 2022 | Volume 13 | Article 873121