Key Points:
- With autism comes a high level of comorbid anxiety due to characteristics of ASD that contribute to anxiety such as sensory sensitivities and difficulty with unpredictability.
- The most successful way to help support anxiety in individuals with autism includes a multifaceted approach considering all sensory, emotional, and cognitive needs.
- Psychoeducation, exposures, cognitive restructuring, and relaxation techniques can all be utilized to help manage anxiety with the support of caregivers.
Autism spectrum disorder is a neurodevelopmental disorder characterized by impaired social interaction and restricted or repetitive interests/behaviors. An individual diagnosed with autism exhibits difficulties with social communication and social interactions across settings, beginning early in development (American Psychiatric Association, 2013). Anxiety is an emotion that is characterized by worried thoughts and physical side effects, such as increased heart rate. Anxiety is a normal and important reaction that is rooted in our evolutionary past (Nesse, 2022). However, anxiety is diagnosed as a mental health condition when it begins to impact our day-to-day functioning (American Psychiatric Association, 2013).
Up to 40% of individuals diagnosed with autism are diagnosed with clinically significant anxiety. This leads to unique challenges and increases already present difficulties surrounding social skills and rigid behaviors (Zaboski & Storch, 2018). Increased anxiety in individuals with autism may present as increased repetitive behaviors (e.g., rocking), avoidance/shutting down to escape a situation or physical symptoms such as sleep difficulties or complaints of illness. There are several interactions between anxiety and characteristics of autism that contribute to high levels of comorbidity, like sensory sensitivities and difficulty with unpredictability (Neilson & Bond, 2023).
There are several ways to support those with autism manage anxiety. It is essential to consider the various sensory, cognitive, and emotional needs, and because each person with autism experiences anxiety differently, a tailored approach to find the right combination of strategies is required. For example, with unpredictability and routine change being a trigger for individuals with autism (Neilson & Bond, 2023), being able to establish predictability wherever possible will help to mitigate the aversive experience associated with change. Some ways to help establish predictability include using visual schedules or written plans to outline daily routines. Writing out what is expected for the day or week will help individuals know what is coming up and be able to better prepare their day-to-day. When changes do occur, provide advanced notice or share the change right away to help minimize uncertainty. Being able to practice flexibility and change in smaller and controlled doses can also help support individuals in responding to change more adaptively when advanced notice is not possible. For instance, playing a game and announcing that every few rounds, the rules will change, and each person will get to pick a new rule to implement, or taking a new way home from work or school and stopping to get a treat or engage in a preferred activity. These examples can help individuals see that change does not always have to be aversive. It also helps to be able to practice dealing with change in a controlled environment where you can help individuals engage in coping strategies to help adjust to the presented change.
Several controlled trials indicate that cognitive behavioral therapy (CBT) is an effective treatment modality for reducing anxiety in individuals with autism (Zaboski & Storch, 2018). Using cognitive behavioral strategies helps teach individuals to work through anxiety-inducing situations. CBT for individuals with autism is most effective when focusing on psychoeducation, exposure to feared triggers, and cognitive restructuring (Zaboski & Storch, 2018). It is important to note that a key element of CBT is helping individuals distinguish between thoughts, feelings, and behaviors as separate concepts. Each person should be assessed to determine whether this approach is suitable for managing anxiety. If this concept is not well understood by the individual, treatment may need to be adjusted, or the information presented in a more concrete manner (Lickel, MacLean, Blakeley-Smith, & Hepburn, 2012).
Regarding psychoeducation, identifying cognitive and physiological reactions to anxiety, along with accommodations and treatment for anxiety, are important topics. Helping individuals identify what happens to their body and thoughts when feeling anxious can help them identify when coping strategies should be implemented. Additionally, parents commonly report accommodating anxiety by avoiding activities rather than allowing individuals to experience the anxiety-provoking activity on their own. Data shows that decreasing family accommodation is associated with decreases in anxiety pre and post-treatment (Zaboski & Storch, 2018). With the avoidance of anxiety-inducing situations entirely, there is limited opportunity to build skills or tolerance. On the other hand, being able to confront the feared situation in controlled doses results in a temporary increase in anxiety, but with the use and practice of coping skills, anxiety reduces to a manageable level and results in an individual’s belief in their ability to control their fear responses.
Exposure to feared triggers means the creation of a fear hierarchy. This is a graded list of exposures that address specific fears (e.g., sit on the edge of the pool with a parent, stand in the shallow end with a parent, swim in the shallow end with floaties and a parent, etc.) While engaging in these graded fears, it’s helpful to use any special interests to reinforce approaching the fears and encourage individuals to cope with these challenging situations (Zaboski & Storch, 2018). The aforementioned examples of practicing change with games and new routes home are other ways to engage in exposures around routine change.
Cognitive restructuring or “talking back to worries” can help fight against maladaptive thinking in feared situations. With anxiety, individuals often focus on worst-case scenarios and what could go wrong rather than what is actually occurring or what is most likely to occur. Teaching individuals to be “detectives” of their thoughts can help fight against them. For example, asking, “What is the evidence for this belief?” or “Could there be any other explanations?” can help individuals fight back their “what ifs” with facts.
Relaxation strategies are also helpful in reducing anxiety by counteracting the fight or flight response that is triggered by stress and anxiety. These can be used while engaging in graded exposures or when an individual is experiencing physiological symptoms of anxiety at any time. Diaphragmatic breathing, also known as “belly breathing,” can be an amazing way to promote relaxation and reduce anxiety. Evidence from studies on diaphragmatic breathing suggests a large reduction in anxiety after several weeks of practice (Chen et al., 2016). This can be practiced sitting up or lying down. Have the individual place a hand or light object (e.g., stuffed animal if lying down) on their stomach. The practicing individual should then take a deep breath through their nose while allowing their stomach to expand, evidenced by their hand or the chosen object rising. Once they have taken a slow, deep breath in through their nose, they should exhale slowly through their mouth, shaping it like they are blowing through a straw, causing the object or hand to lower. Strategies that engage the senses can also be effective in promoting relaxation. For instance, using noise-canceling headphones to manage sensory sensitivities, listening to calming music or sounds, fidget toys, soft textures, or soothing scents can all help reduce feelings of overwhelm and encourage a sense of calm. Creating a designated relaxation space at home or assembling a portable kit with comforting sensory items can provide support in stressful situations, helping to reduce anxiety and improve coping abilities when encountering overwhelming environments.
The overlap of autism and anxiety presents unique challenges, but with the right approach and support, individuals with autism can learn to manage anxiety effectively. It is important to note that with all these coping strategies, it is likely that the individual with autism in your life will need support in implementing these in their day-to-day life. The ultimate goal is independence in utilizing these strategies, but offering immediate support as needed will help reinforce coping skills and build a lasting habit.
Amanda Trovato, PsyD, is a Licensed Clinical Psychologist at the Els for Autism Foundation®. Learn more at www.elsforautism.org.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Association.
Chen, Y. F., Huang, X. Y., Chien, C. H., & Cheng, J. F. (2016). The effectiveness of diaphragmatic breathing relaxation training for reducing anxiety. Perspectives in Psychiatric Care, 53, 329-336. https://doi.org/10.1111/ppc.12184
Lickel, A., MacLean W.E. Jr., Blakeley-Smith A., Hepburn S. (2012). Assessment of the prerequisite skills for cognitive behavioral therapy in children with and without autism spectrum disorders. Journal of Autism & Developmental Disorders, 42(6), 992-1000. doi: 10.1007/s10803-011-1330-x
Neilson, C., & Bond, C., (2023). The experience of anxiety for autistic children and young people: A thematic synthesis review. Research in Autism Spectrum Disorders, 109. https://doi.org/10.1016/j.rasd.2023.102274
Nesse, R.M. (2022). Anxiety disorders in evolutionary perspective. Evolutional psychiatry: current perspectives on evolution and mental health, 101-116. Cambridge University Press
Zaboski, B. A., & Storch, E. A. (2018). Comorbid autism spectrum disorder and anxiety disorders: a brief review. Future neurology, 13(1), 31–37. https://doi.org/10.2217/fnl-2017-0030
