Anxiety and Autism Spectrum Disorders

Many children with autism spectrum disorders (ASD) will receive another diagnosis at some point in their development.   In a 2008 study, seventy percent of a sample of children with ASD ages 10 to 14, had also been diagnosed with another disorder.  Forty-one percent had been diagnosed with two or more additional disorders (Simonoff, et al).  These additional disorders, or comorbid diagnoses, can at times be extremely debilitating for individuals with autism spectrum disorders.  The most common types of diagnoses are those related to anxiety.

Recently researchers at The University of Amsterdam reviewed 31 studies that focused on the presence of anxiety disorders in children under 18 years old with ASD.  Upon review of these studies, researchers concluded that about 40% of children with ASD had at least one comorbid diagnosed anxiety disorder (van Steensel et al., 2011). Psychologists include numerous diagnoses under the heading of Anxiety Disorders, but the debilitating force behind them all is the presence of excessive worry and fear. The prevalence of specific anxiety disorders in youth with ASD were found at the following rates:

• Specific Phobia: 30%
• Obsessive-Compulsive Disorder: 17%
• Social Anxiety Disorder/Agoraphobia: 17%
• Generalized Anxiety Disorder: 15%
• Separation Anxiety Disorder: 9 %
• Panic Disorder: 2%

This study and others have shown that children with ASD have more severe symptoms of phobias, obsessions, compulsions, motor and vocal tics, and social phobia than other groups of children.  Even without an official diagnosis, anxiety is an important factor in the everyday lives of many children and teens with ASD.  For example, anxiety can make it extremely difficult for children with ASD to do everything from making friends, to going shopping, to taking public transportation. 

Anxiety and Autism

There are many common behaviors seen in children with ASD that overlap with symptoms seen in varying anxiety disorders.  For example, the obsessions and compulsions of Obsessive-Compulsive Disorder may look similar to repetitive and stereotyped behaviors in children with ASD.  For this reason, there is speculation as to what psychologists should consider symptom overlap and what is a distinctly different disorder (van Steensel et al., 2011).  One group of children on the spectrum that are more likely to receive a diagnosis of an anxiety disorder seems to be adolescents that have been diagnosed with Asperger’s Syndrome or high functioning autism.  Many researchers speculate that this could be because teenagers with fairly high cognitive functioning may have a heightened awareness of their environment and the way they are perceived by others.  As children with ASD enter into adolescence, the difference between themselves and their peers may become more pronounced (Alfano, et al., 2006).  Alternatively, a child with more intellectual impairment may experience less anxiety or simply have a harder time reporting their anxieties in a way that lends itself to formal diagnosis. 
Children and teens with ASD, in general, will have a much harder time self-reporting their anxious symptoms – many of which may only occur internally (i.e., consistent worry).  These limitations make it difficult for individuals with ASD to be diagnosed because of the difficulties with self-report.  There are some who argue that we may need to develop different ways of measuring anxiety in individuals with ASD.  For example, a better way to possibly assess levels of anxiety is to interview adults that interact on a regular basis with the individual.  However, reports from adults are not necessarily consistent.  For example, Gadow and colleagues (2005) found that teachers reported significantly higher levels of anxious behavior than parents.  This could be because parents and/or teachers are not reliable in reporting these behaviors, or it’s possible that anxious symptoms are more likely to occur in school than at home.  Therefore, there is obviously room for improvement in the measurement of anxiety in children and teens with ASD.

Cognitive-Behavioral Therapy as Treatment

The most effective treatment for anxiety disorders is cognitive-behavioral therapy (CBT).  Cognitive-behavioral therapy uses graded exposure, or taking small steps toward facing anxiety-inducing situations, as well as teaching modes of relaxation.  It also uses cognitive restructuring, or identifying and working to change irrational thought patterns, and modeling appropriate thinking.  CBT is based on the premise that working to change maladaptive thinking, such as magnifying negatives or overgeneralizing, can lead to a change in maladaptive behavior.  To think about it in another way, CBT seeks to train an individual to reconceptualize the way they process the world and then acquire skills that will allow them to apply this new way of looking at things. 
There are certainly some possible issues using traditional CBT with children and adolescents with ASD.  CBT is very verbally-based and often quite abstract.  In order to deal with these issues, Moree and Davis (2010) find that incorporating more concrete visuals and child specific interests, as well as parent involvement, are all extremely important.  Some suggest that CBT may not work as well for children with ASD due to their impairments in theory of mind (a capacity necessary to engage in CBT strategies), but psychologists have shown improvement in high-functioning children with ASD after CBT (Wood et al, 2009). 

Parents have an integral role in helping to treat anxiety in children with ASD.  In fact, many agree that parents can not only be parents, but must be coaches, therapists, and friends as well.  The following recommendations are part of the “Face Your Fears” intervention developed by Judy Reaven and colleagues:

1. Encourage and reward your child for his or her effort and engagement in brave behaviors
2. Ignore excessive displays of anxiety
3. Distinguish between realistic and unrealistic fears so that an appropriate treatment direction can be established
4. Convey confidence in the child's ability to handle his or her worry and anxiety
5. Model courageous behaviors
6. Work together with your spouse or partner to develop a plan for facing fears
7. Discuss how to share coping skills and the creation of exposure hierarchies with other professionals so that gains in one setting can be generalized to other settings.

Parents can play a critical role in the treatment of anxiety in their child with ASD.  As the parent, you know more about your child than just about anyone else.  Being aware of anxiety triggers for your child is another important step in working to improve and anticipate stress and anxiety.  Common triggers may include change in routine, lack of sleep, and highly social situations.  For more ideas about anxiety triggers see Kim Davis’ article on anxiety on this website:  Anxiety and Panic Struggles.

Resources for Parents

Looking for more information? Check out these books, websites, and mobile applications about anxiety and ASD:

Books
Chalfant, A.M.  (2011).  Managing Anxiety in People with Autism: A Treatment Guide for Parents, Teachers and Mental Health Professionals.  Bethesda, MD: Woodbine House.
Baron , M.G., Groden, J., & Lipsitt, L.P.  (2006).  Stress and Coping in Autism.  New York, NY: Oxford University Press. 
Lipsky, D.  (2011).  From Anxiety to Meltdown: How Individuals on the Autistic Spectrum Deal with Anxiety, Experience Meltdowns, Manifest Tantrums, and How You Can Intervene Effectively.  Philadelphia, PA: Jessica Kingsley Publishers.
Buron, K.D.  (2006).  When My Worries Get Too Big! A Relaxation Book for Children Who Live with Anxiety.  Shawnee Mission, KS: Autism Asperger Publishing Company.

Websites
http://www.autism-help.org/points-june-groden-stress.htm
https://www.sensory-processing-disorder.com/autism-anxiety-overload.html

APPS
The Social Navigator: http://www.socialnavigatorapp.com/social_navigator.php
The Autism 5-Point Scale EP: https://itunes.apple.com/app/autism-5-point-scale-ep/id467303313?mt=8

References

Merrill, A.(2016). Anxiety and autism spectrum disorders. Retrieved from anxiety-and-autism-spectrum-disorders.