Anxiety and autism disorders
Approximately 40 percent of children with an autism spectrum disorder (ASD) also have an anxiety disorder (Steensel, Bögels, & Perrin, 2011). Anxiety can exacerbate symptoms of ASD making communication and social interactions increasingly difficult.
Helping a child with autism learn practical skills to manage his/her anxiety can improve quality of life by making self-regulation, forming friendships, and assessing and tending to his/her own needs more manageable. A combination of cognitive-behavioral therapy, medications, and exposure therapy has been proven beneficial for many children with comorbid ASD and anxiety.
What is anxiety?
The word anxious is typically used in relation to an imminent event or occurrence. People who experience intermittent or heightened nervousness are likely able to pinpoint the cause of their feelings of unrest when they expect that feeling to go away, or make a plan of action to reduce these feelings. While this can be possible for people with anxiety disorders, it might take a combination of therapy, behavioral changes, or medication to gain this level of insight. Some people with anxiety might even experience the emotional weight and physical feelings of anxiety while no obvious stressors are present.
Common symptoms of anxiety in autism
It can be difficult to discern symptoms of ASD from anxiety. If you suspect your child is experiencing an anxiety disorder, it is important to identify which behaviors stem from anxiety versus his/her ASD. You will likely find that your child’s anxiety-motivated behaviors exist separately from behaviors related to autism.
According to a 2011 study by Professor Joshua Nadeau (et al.), “patients with ASDs and comorbid anxiety are at increased risk for displaying externalizing behavior problems, social avoidance, difficulties establishing/maintaining peer relationships, sleep problems, and disruptions in family functioning…Youths with ASD often also display repetitive behaviors with some phenotypic resemblance to behaviors performed with youth with certain anxiety disorders [e.g., compulsions]…In both populations, these rituals may be performed to exert greater control over the environment and reduce anxiety or may be performed for intrinsic reasons” (Nadeau, et al., 2011).
Every child’s anxiety will manifest differently, but common behaviors include counting, checking, repeating, tapping, rigid adherence to routines, and repeatedly reinstating certain words, facts, or expressions (Nadeau, et al., 2011).
How anxiety affects children with autism
Children with ASD can show symptoms of a comorbid anxiety disorder from their early years. A 2011 meta-analysis of anxiety disorders in children with autism found that approximately 40 percent of children diagnosed with autism also met criteria for an anxiety disorder (Steensel, Bögels, & Perrin, 2011).
There are multiple types of anxiety disorders, but six are most commonly found in children with ASD: specific phobia(s), social anxiety disorder/agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, separation anxiety disorder, and panic disorder.
The Indiana Resource Center for Autism at the Indiana University Bloomington has found these types of anxiety disorders to occur at the following rates in children with both anxiety and ASD (Merrill, Anxiety and Autism Spectrum Disorders):
- Specific phobia(s): 30%
- Obsessive-compulsive disorder: 17%
- Social anxiety disorder/agoraphobia: 17%
- Generalized anxiety disorder: 15%
- Separation anxiety disorder: 9%
- Panic disorder: 2%
According to the Mayo Clinic, specific phobias are characterized by “major anxiety when you’re exposed to a specific object or situation and a desire to avoid it. Phobias provoke panic attacks in some people” (Anxiety Disorders, 2018). Specific phobias are often developed after traumatic experiences or negative associations. Some phobias are more common in children, both with ASD and those who are neurotypical, such as dark rooms, insects, dogs, or doctors.
Some children with ASD experience phobias of less common things such as toilets, trains, busses, or rainstorms. Phobias can be broad categories of things (e.g., animals) or very specific (e.g., orange trains). Phobias, especially those with no obvious root, can be hard to understand and even frustrating for parents and caregivers of children with ASD. It is important to be patient with your child and understand that while a phobia may pose no true threat to his/her wellbeing, the fear is extraordinarily real to the child.
Obsessive-compulsive disorder (OCD) is an anxiety-driven disorder in which someone experiences intrusive thoughts and fears or obsession that can cause repetitive behaviors and rituals, or compulsions. OCD is sometimes treated with varying behavioral interventions and medications, but its nature is rooted in anxiety. OCD and autism can present similarly (stimming, comfort in a highly regimented schedule, lining up of objects, etc.); however, the mental processes are different.
A child diagnosed with autism may enjoy routine and creating patterns while a child with OCD and autism may feel like he/she needs to create a pattern or a disruption of routine will cause something catastrophic to happen. For children with OCD, compulsions are a way of quelling their obsessive thoughts. Children with an autism diagnosis might enjoy repetitive behavior. Identifying whether your child has OCD in addition to autism is critical to ensure he/she receives appropriate treatments to help him/her experience the best quality of life possible.
Social anxiety and agoraphobia are anxiety disorders centered around a fear of social situations and judgment. Children with social anxiety fear social situations due to perceived judgment and intense self-consciousness. Agoraphobia is similar in that it can cause children to avoid social situations, but it also extends to any place or situation that could cause the child to feel judged, helpless, or embarrassed. Children, with Asperger’s syndrome, especially girls, are often misdiagnosed with social anxiety or agoraphobia.
The two can exist as comorbid conditions, but like OCD and autism, the mental processes are different. children with autism may avoid social situations because they deem them unnecessary, do not feel like they can communicate effectively, or because they simply have no interest in participating in them. People with social anxiety or agoraphobia might be able to discern some benefit from social situations such as working or building friendships and even desire socialization but feel unable to do so due to high levels of anxiety.
Generalized anxiety disorder
Generalized anxiety disorder (GAD) is categorized as “persistent and excessive anxiety and worry about activities or events—even ordinary, routine issues. The worry is out of proportion to the actual circumstance, is difficult to control and affects how you feel physically. It often occurs along with other anxiety disorders or depression” (Anxiety Disorders, 2018). Children with autism who are diagnosed with GAD might experience panic attacks, sleep disruptions, appetite changes, irritability, or a decrease in functioning. GAD tends to affect most areas of someone’s life without a clear trigger.
Separation anxiety disorder
Separation anxiety disorder primarily exists only in childhood. Children with separation anxiety have a harder time being away from their parents or caregivers than is typical for their age and developmental level. The anxiety might be related to fears of abandonment, fears that something bad will happen to them or their parent while they are separated, or a fear that the child’s needs will not be met without the parent present. Many children outgrow separation anxiety, but it is important to address the underlying cause to avoid the anxiety shifting from one anxiety disorder to another.
Children with panic disorder experience repeated panic attacks and take great measures to avoid anything that they think will trigger a panic attack. Panic attacks look different for every child, but they commonly consist of “feelings of impending doom, shortness of breath, chest pain, or heart palpitations” (Anxiety Disorders, 2018). These symptoms reach their peak within minutes and result in a panic attack.
What triggers anxiety in autism?
Helping your child to identify what triggers his/her anxiety is an important first step in helping him/her manage symptoms. Some children struggle with anxiety as a result of a traumatic event while others experience anxiety as a constant in their lives. Anxiety, especially OCD, might be a response to feeling out of control. Social anxiety might stem from a deeply embarrassing social situation or a child’s awareness that he/she struggle to communicate effectively.
Panic disorders might develop after trauma and be triggered by smells, sights, sounds, tastes, or touch associated with the trauma. A child who struggles with GAD might find daily life overwhelming. No matter what triggers your child’s anxiety, being present and open-minded to triggers will help you to understand him/her better and allow you to help your child develop healthy coping skills.
What can you do about anxiety?
Anxiety does not have to be unmanageable or impede on daily living. Each person’s experience with anxiety is different, and it exists on a spectrum much like autism. However, most people are able to find a combination of coping skills and support people to reduce their symptoms. People with anxiety often find seeing a psychologist helpful. Child psychologists are safe people for children to explore their anxiety and identify triggers and coping skills.
Many child psychologists will offer family therapy sessions so those who interact with your child most often can be supportive of treatment. If therapy is not sufficient, a psychiatrist can prescribe anti-anxiety medications. Alternative therapies such as art therapy, music therapy, hippotherapy, or sports therapy are options you can discuss with your child’s team to support psychotherapy. Anxiety cannot be cured, but treatments are available to help your child manage his/her symptoms and increase his/her quality of life.
How to deal with anxiety and autism and strategies to help your child cope
Making a plan to manage your child’s anxiety might include medication and therapy as well as changes to your child’s routine at home and school. Including planned relaxation times in your child’s schedule will help promote his/her emotional wellbeing and encourage him/her to prioritize mental health. Implementing time for yoga, reading a favorite book, going for a walk, or taking a handful of deep breaths can be helpful. During these brain breaks, it is important to make sure your child’s triggers are not present to the best of your ability. For example, a child with social anxiety would not find a crowded yoga class relaxing, but creating a comfortable space in your home for him/her to stretch and take deep breaths might help.
Check-in times where your child can let you know how he/she is feeling with no judgment might be helpful. This might look like a short verbal exchange, a thumbs up or thumbs down, a picture is drawn, or any way your child prefers to communicate.
Above all, when you are making a plan to help children deal with anxiety, meet them where they are. Do not expect them to respond to treatments at any particular pace. Allow your child time to figure out what works for him/her. Anxiety and its triggers can seem trivial or downright strange to others but are very real for the person suffering. Patience and encouragement are key to supporting your child.
Autism and depression and self-injurious behavior – when to seek professional help
When your child’s symptoms begin to interfere with day to day life, it is time to see a doctor. Anxiety can cause regression in some children making it near impossible for them to progress academically, in other therapies, and socially. While depression and anxiety are different medical issues, it’s important to monitor children for depression as causes and symptoms can overlap. If you notice your child engaging in self-injurious and aggressive behavior or withdrawing from activities or people they previously enjoyed, a psychiatric evaluation can help you identify the best course of action for your child.
Behavioral treatment to help anxiety
Cognitive-behavioral therapy (CBT) is beneficial for many children with autism, particularly Asperger’s syndrome, and anxiety. CBT combines talk therapy with behavioral therapy and is facilitated by a psychologist. Children who participate in CBT will identify their triggers and develop an understanding of why these triggers exist. Next, your child’s therapist will help him/her become aware of emotions and thoughts surrounding triggers. Your child will then practice “thought stopping” or not allowing negative thoughts to spiral, and replace negative thoughts with more realistic and positive ones. Finally, your child will learn skills to face his/her triggers in the real world and develop coping skills to deal with moments of anxiety or panic.
According to an article in Developmental Neurorehabilitation, “Positive outcomes were ubiquitous, suggesting CBT is an effective treatment for anxiety in individuals with Asperger’s…CBT has been modified for individuals with ASD by adding intervention components typically associated with applied behavioral analysis (e.g., systematic prompting and differential reinforcement)”(Lang, 2010).
Medications and treatments to ease anxiety in autism
Medication can be a great option to help children with autism manage their anxiety. If you suspect that your child’s anxiety is not sufficiently well-controlled by behavioral interventions, you can ask your child’s pediatrician or psychologist for a referral to a pediatric psychiatrist. Working with a pediatric psychiatrist is crucial to ensuring that your child is taking appropriate medications for his/her condition and age. Psychologists and psychiatrists work closely to observe your child’s behavior and assess his/her symptoms to develop a medication regimen that will best help.
If your child has a seizure disorder, he/she may already be taking an anti-anxiety medication commonly used off-label to control epilepsy. Such medications include Xanax, Niravam, Buspar, Ativan, Vivitrol, Valium, but there are many more suited for anxiety disorders that your child could try if the aforementioned ones have not offered him/her relief.
Your role as a parent of a child with autism
Your role as the parent of a child with autism and anxiety is to identify resources to help your child work through his/her anxiety and to exercise patience and love with your child even if you do not understand the struggles. You are your child’s greatest support and your dedication to his/her wellbeing is so important. As your child begins the hard work of unpacking his/her anxiety, the triggers, and practicing coping skills, he/she will need someone who is a safe and calming presence.
Take the time to ask questions and listen with an open mind. If you don’t understand why something triggers your child, that’s okay. Anxiety is perplexing, and often the person managing anxiety won’t have all the answers either. Showing up, validating your child, helping him/her to challenge his/her fears, and encouraging him/her to persist in the hard work involved with therapy is an invaluable gift.
Anxiety Disorders. (2018, May 04). Retrieved from https://www.mayoclinic.org/diseases-conditions/anxiety/symptoms-causes/syc-20350961
Merrill, A. (n.d.). Anxiety and Autism Spectrum Disorders. Retrieved from https://www.iidc.indiana.edu/pages/anxiety-and-autism-spectrum-disorders
Nadeau, J., Sulkowski, M. L., Ung, D., Wood, J. J., Lewin, A. B., Murphy, T. K., . . . Storch, E. A. (2011, December). Treatment of comorbid anxiety and autism spectrum disorders. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809000/
Russell Lang, April Regester, Stacy Lauderdale, Kristen Ashbaugh & Anna Haring (2010) Treatment of anxiety in autism spectrum disorders using cognitive behavior therapy: A systematic review, Developmental Neurorehabilitation, 13:1, 53-63, DOI: 10.3109/17518420903236288
Van Steensel, F.J.A., Bogels, S.M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review, 14, 302-317.
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