Understanding and Managing Anxiety in Students with Autism Spectrum Disorder (Part One)
Definitions & Prevalence
Anxiety, a natural response to a stressor or threat, is a prevalent problem in students with autism spectrum disorder (ASD). It is an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure¹. Some anxiety is perfectly normal, e.g., taking a test, losing a job, severe illness of someone you care a lot about, etc. Anxiety at times can help the individual muster strength, wisdom and resources to deal with the difficult tasks or hardships s/he is facing. However, some children and adults may have excessive or unreasonable worry that is beyond the normal extent and is unnecessary. When is anxiety a problem for a student with ASD? It will not be a problem unless it lasts multiple weeks or months and it interferes with the student’s and/or his/her family’s typical functioning in multiple areas³.
Recent research indicated that approximately 40 percent of children and youth with ASD had at least one comorbid diagnosed anxiety disorder, and as many as 84 percent experienced some degree of impairing anxiety⁴,⁵. Anxiety is more prevalent in students with ASD than in typically developing students and those with other developmental disabilities. It is likely that there are many characteristics inherent to autism—such as the need to insist on sameness, sensory sensitivities, difficulties in communication, social interaction and understanding other people’s actions and intentions—that predispose individuals with ASD to be more anxious than those without ASD, or that can predispose them to stressful experiences that lead to anxiety⁶.
There are many common behaviors seen in children with ASD that overlap with symptoms of varying anxiety disorders. This causes one of the most difficult aspects of diagnosing anxiety in students with ASD. For example, pacing, saying or doing the same thing over and over again, and avoiding social interaction are actions that would look like anxiety in a typically developing person. They could be symptoms of certain anxiety disorders such as social anxiety disorder and obsessive-compulsive disorder. In some cases, those behaviors are responses to anxiety; while in other cases they do not seem to relate to anxiety and are simply a part of being autistic7. Research reported that when they are feeling anxious, students and adults may become more repetitive in their actions and more insistent on routines, perhaps as a way of dealing with uncertainty, fear of failure, and sensory input⁸, ⁹ One group of students on the spectrum that are more likely to receive a diagnosis of an anxiety disorder seems to be adolescents who are high functioning autism given that they are more likely to have a heightened awareness of their environment and the way they are perceived by others¹⁰. On the other hand, a child with more intellectual impairment may experience less anxiety or simply have a harder time reporting their emotions or anxieties in a way that lends itself to formal diagnosis¹¹.
Possible Causes/Triggers
Anything that causes any child anxiety can cause anxiety in students with ASD, e.g., academic stress, peer pressure, bullying, family problems, etc. In addition, they face other factors that are more related to ASD itself. Lynch (2019) called the additional factors that might cause anxiety in students with ASD “five prime suspects” and provided strategies dealing with them respectively¹², ¹³.
Prime suspect #1: Cognitive rigidity
Difficulty adjusting to change
Strategies:
Try to prevent too many changes from occurring within a short period of time.
Prepare the child for upcoming changes that may occur and allow her to have some input into how things will change when possible.
Include manageable changes in your daily schedule that the child is not expecting and encourage your children to embrace those changes as “surprises.”
Don’t provide information about a change until you are nearly certain that it is definite.
Give praise when change is handled well.
Difficulty coping with transition
Strategies:
Give reminders or “warnings” before a transition occurs.
Use visual aids and other strategies to help with the understanding of time.
Use structure to help keep events predictable.
Organize the child’s physical environment.
Use visual supports to guide a child through a transition.
Provide praise when transitions are handled well.
Inflexibility
Strategies:
Help your child see the bigger picture.
Highlight how inflexible thinking can cause problems.
Be a flexible role model.
Provide praise when you see your child being flexible.
Fixed routines
Strategies:
Prevent routines from developing in the first place.
If a routine is fixed, break it gradually.
Help your child understand the value of breaking from routine and doing different things.
Restricted interests
Strategies:
Encourage your child to broaden interests.
Help the child be aware of the social consequences of having restricted interests.
Give praise for talking about or doing new things.
Prime suspect #2: Sensory sensitivities
Noise
Strategies:
Prevent or minimize exposure to loud or distressing sounds.
Help the child anticipate situations that will have loud or unpleasant noise.
Smell and taste
Strategies:
Prevent or minimize exposure to aversive smells or tastes.
Help the child anticipate difficult situations.
Gradually expose the child to new tastes and smells.
Allow your child to participate in meal planning, food shopping, ad meal prep.
Touch (Tactile)
Strategies:
Avoid or minimize the impact of difficult situations involving the tactile sense.
Help the child anticipate and cope with difficult situations.
Set limits on sensory-seeking behaviors.
Sight
Strategies:
Adjust lighting.
Address problems due to visual fascination.
Vestibular/Proprioceptive
Strategies:
Minimize distressing sensations.
Set limits and provide acceptable alternatives to fulfill sensory needs.
Help the child anticipate and cope with difficult situations.
Prime suspect #3: Social demands
Strategies:
Develop confidence through role modeling and practice.
Teach social cognition.
Approach social challenges gradually.
Support the child in real-life situations.
Prime suspect #4: Language demands
Strategies:
Use of visual supports.
To explain rules and guidelines for behavior.
To remind a child of consequences for behaviors.
To explain instructions.
To remind a child of available coping strategies.
To help a child to get used to a new situation.
Allow additional time and summarize information.
Use reduced language.
Give means for expressing frustration and anxiety.
Prime suspect #5: Task frustration
Strategies:
Be aware of learning differences or impairments.
Provide a balance of challenging and easy tasks.
Teach who, when, and how to ask for help.
Highlight the child’s strengths.
References
American Psychological Association (n.d.). Anxiety. Retrieved from https://www.apa.org/topics/anxiety
Moskowitz, L. J. & Jeffay, M. (2021) Assessing and treating anxiety in individuals with autism spectrum disorder. In S. M. Edelson, and J. B. Johnson (Eds.), Understanding and Treating Anxiety in Autism. London and Philadelphia: Jessica Kingsley Publishers. 199-240.
Keefer, A. (2019). Anxiety in children with autism spectrum disorder. Presented at Autism Research Institute webinar on March 6, 2019. Retrieved from https://www.youtube.com/watch?v=wkM6z-4WWQs
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.
White, S. W., Oswald, D., Ollendick, T., and Scahill, L. (2009). Anxiety in children and adolescents with autism spectrum disorders. Clinical Psychology Review, 29, 216-229.
Moskowitz, L. J. & Edelson, S. M. (2021). Introduction. In S. M. Edelson, and J. B. Johnson (Eds.), Understanding and Treating Anxiety in Autism. London and Philadelphia: Jessica Kingsley Publishers. 14-22.
Rudy, L. J. (2022). Helping people with autism manage anxiety. Retrieved from https://www.verywellhealth.com/anxiety-and-autism-4428086?print
Joyce, C., Honey, E., Leekam, S. R., Barrett, S. L., and Rodgers, J. (2017). Anxiety, intolerance of uncertainty and restricted and repetitive behavior: Insights directly from young people with ASD. Journal of Autism and Developmental Disorders, 47, 3789-3802.
Rodgers, J. (2018). Anxiety in autistic people. Retrieved from https://www.autism.org.uk/advice-and-guidance/professional-practice/anxiety-autism
Alfano, C. A., Beidel, D. C., & Turner, S. M. (2006). Cognitive correlates of social phobia among children and adolescents. Journal of Abnormal Child Psychology, 34(2), 182-194.
Merrill, A. (n.d.). Anxiety and autism spectrum disorders. Retrieved from https://www.printfriendly.com/p/g/XwDsjV
Lynch, C. (2019). Anxiety management for kids on the autism spectrum: Your guide to preventing meltdowns and unlocking potential. Arlington, TX: Future Horizons Inc.
Lynch, C. (2020). Anxiety, autism, and the five prime suspects. Presented at Autism Research Institute webinar on March 25, 2020. Retrieved from https://www.google.com/search?client=firefox-b-1-d&q=Christopher+Lynch%3A+Anxiety%2C+Autism%3A+Five+Prime+Suspects#fpstate=ive&vld=cid:b5d24ec6,vid:fkA5zhRp4pM
Alicia Li, Ed.D
Professor
Department of Special Education & Communication Sciences and Disorders
Eastern Michigan University
Ypsilanti, MI 48197
tli@emich.edu