Assessment and Understanding of Fear in Children with an ASD

Intense fears and phobias have been reported in up to 64% of children with an ASD (Muris Steerneman, Merckelbach, Holdrinet, & Meesters, 1998). In comparison, only 5% of typically developing children present with intense fears (Ollendick, King, & Muris, 2002). Children with an ASD also have an atypical presentation and express greater amounts of fear as compared to children with other developmental or intellectual disabilities (Evans, Canavera, Kleinpeter, Maccubbin & Taga, 2005; Rodgers, Riby, Janes, Connolly & McConachie, 2011). For example, children with an ASD express more fear of medical procedures and less fear of dangerous and harmful objects or situations than children without an ASD. It is interesting that given this lowered fear of dangerous and harmful objects or situations, research at the Institute for Child Development has indicated a threefold increase in unintentional injuries for children with an ASD compared to typically developing children (Calavari and Romanczyk, 2011). Although deficits in emotion perception, expression, and regulation in children with an ASD are well recognized, the understanding of specific emotional states, such as fear, is in its infancy.

Much of the current understanding of fear in children with an ASD has been through caregiver report, which is also common practice in the assessment of fear in typically developing children, along with self-report. Given that self-report can pose significant limitations for most children with an ASD, caregiver report has been the primary tool. However, interpreting emotional states in children with an ASD is a challenge for caregivers as well as service providers and researchers. Common deficits in ASD such as poor communication skills and difficulty with emotion identification and labeling, along with atypical reactions to the environment, limit the ability of even those that are closest to the child to accurately interpret the child’s behavior as fear-related. Children with an ASD often are not able to effectively identify or communicate their emotions or even dislike of an object or situation to their caregivers. Because of many of these challenges, there are currently no comprehensive, accurate, or standardized methods to assess fear in children with an ASD.


Comprehensive Assessment of Fear


Recent research at the Institute for Child Development utilized a comprehensive assessment method involving both caregiver report of children’s fear and direct observation of children’s fear responses. The purpose was in part to determine the correspondence between caregiver report of children’s fear and direct observation of children’s fear responses and to assess the utility of a comprehensive technique.

To directly assess children’s fear reactions, children viewed photographs of common natural stimuli (e.g., animals, car, boat, insects, medical procedures) on a 42-inch high definition monitor. Caregivers completed a questionnaire that assessed their knowledge of their child’s amount of fear (i.e., none, some, much) to the same stimuli that were viewed by the children. The photographs were presented gradually, such that the opacity of each, from absent to normal, increased in one-second intervals to attenuate possible startle responses. That is, the visual stimulus was gradually faded in to full view. If the child showed a fear response, the photograph was terminated and after a pause the next photograph was presented. Behaviors associated with fear were systematically observed as the children viewed each photograph (i.e., verbal complaints, looking away, body rigidity, fearful facial expression) as well as approach and positive behaviors. Notably, as the research literature does not present accepted parameters for assessing fear in children with an ASD, the current procedure was chosen to allow observation of the common fear responses expressed by typically developing children.

During the assessment, many children displayed positive affect (e.g., smiling), indicating the utility of many of the photographs to generate an emotional response from the children. Children also attended to the photographs, often labeling what they were presented on the monitor (e.g., “A car!”). In contrast, the data showed a limited utility of the photographs to evoke typical fear responses. The majority (i.e., 67%) of children with Autistic Disorder did not demonstrate a typical fear response to any of the photographs, whereas 100% of the children that did demonstrate typical fear responses had a diagnosis of PDD-NOS or Asperger’s Syndrome. However, to fully interpret these results it is important to consider the children’s ability to demonstrate a typical fear response. As many children with an ASD evince difficulties with affect and may be less likely to display emotions in a typical manner, the fear-related responses measured in this assessment may not be characteristic of children with an ASD. For example, research suggests that individuals with an ASD are generally less expressive and often show neutral or idiosyncratic expressions (Loveland, Tunali-Kotoski, Pearson, & Brelsford, 1994). Taken together, these findings highlight the complexity of assessing fear in children with an ASD and suggest that a more individualized assessment technique may be needed in identifying fear responses.

Results were interpreted that children with PDD-NOS or Asperger’s Syndrome may be more responsive than children with Autistic Disorder to non-invasive assessment procedures involving pictorial representations and measurement of the presence of typical fear responses. These results underscore the difficulty in making conclusions based on samples of children with an “ASD” (i.e. generic diagnostic descriptor). When considering the assessment and presentation of fear in children there are meaningful distinctions between the specific diagnostic groups that comprise the autism spectrum disorders.

With respect to correspondence between caregiver report and children’s reactions, overall correspondence was poor, with overlap on only 63% of photographs. Variation was seen among the three diagnostic groups that comprise the autism spectrum disorders. Specifically, average correspondence between caregivers and their children with PDD-NOS was 78%, whereas correspondence was 48% for children with Asperger’s Syndrome and 59% for children with Autistic Disorder. Of the children who did display typical fear responses, an even lower correspondence was seen with caregiver report, suggesting that, as would be expected, caregivers have difficulty interpreting the emotions and behaviors displayed by their child, illustrating the complexity of the relationships between display of affect, fear response, and caregiver interpretation.


Caregiver Modeling – Implications for Teaching Social-Emotional Skills


Social learning models have been used to explain the development of fear in typically developing children (Dubi, et al., 2008, Gerull & Rapee, 2002; Rachman, 1977). In fact, much research has shown that typically developing children quickly learn to fear various objects and situations via their mother’s reaction (Dubi, Rapee, Emerton & Schniering, 2008). Many typically developing children also present with similar fear and anxiety symptoms to those of their caregivers (Kendall, Ellsas, Kane, Kim, Kortlander, Ronan, et al., 1992; Silverman, Cerny, & Nelles, 1988; Windheuser, 1977).

However, additional recent research from the Institute suggests that caregiver’s report of their child’s fear and caregiver’s report of their own fears were not related. In other words, unlike typically developing children, children with an ASD are not modeling fear reactions (and appropriate coping responses) from their caregivers. This finding is understandable in light of the pervasive deficits in many social communication skills, such as eye contact, imitation, and the use and understanding of gestures and facial expressions, which are characteristic of individuals with an ASD. These skills are key factors in the ability to learn about emotions from others. More specifically, a lack of social comprehension skills may hinder the development of appropriate fears (e.g. strangers, harm) and spark the development of socially inappropriate fears (i.e. either in content or intensity) – which, described above, is a pattern often noted in the literature.

These results highlight the importance of direct instruction for teaching coping skills and emotion recognition, interpretation, expression, and regulation as part of a comprehensive service model for children with an ASD. Children must be directly taught the social coping skills needed to appropriately regulate and mitigate their expression of fear.




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