Anxiety in Autism Spectrum Disorders
By Holly Bortfeld
From time to time, everyone has anxiety. Public speaking, work, health scares, relationships and money are the top causes of anxiety in typical adults. Sometimes anxiety turns into full-blown panic attacks, but most of the time, it doesn’t.
Anxiety disorders affect approximately 40 million American adults per year, which is about 18 percent of the country's population. Anxiety in children is less studied but it’s estimated that 25% of kids 13-18 have anxiety but about 6% have severe anxiety that requires treatment.
Statistics on Anxiety in ASD
For children with ASD, the research varies widely, from 11% for more affected individuals up to 84% for those with high functioning autism or Asperger’s.
A recent study showed 38% of adults with autism have depression and anxiety.
Presentation and Symptoms of Anxiety in ASD
The DSM (IV and V) criteria for ASD includes symptoms and traits of anxiety:
Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:
1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).
3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).
Anxiety can lead to disruptive behaviors like fighting, screaming, temper tantrums and result in children getting suspended from school, or worse.
Physical symptoms can include a racing heart, headache, muscular tensions, sweating, erratic movement and behaviors, problems catching their breath (not asthma), nausea, diarrhea, sensory disturbances, dilated pupils, stomachache, and talking to themselves out loud as if to calm themselves down or reason out of a situation.
Intense anxiety can result in repetitive behaviors that appear to serve no function, such as pacing, stimming and/or shredding paper or clothing.
Anxiety can result in insomnia, difficulty concentrating, negative thinking, refusing to attend school, extreme shyness and isolation, fear of failure, helplessness, defensiveness, hypochondria and, if left untreated, suicidal thoughts and actions. In short, while common in people with ASD, anxiety should not be dismissed or untreated.
There are also different types of anxiety – PTSD, OCD, Panic attacks, Social Anxiety, Generalized Anxiety Disorder and specific phobias.
Causes of Anxiety
Because ASD is diagnosed by behaviors rather than cause or a blood test and people with ASD may not be able to explain to doctors fully the reasons for their anxiety, we don’t have a full definitive list of causes, but some of the proven causes include PANDAS, OCD, excitotoxins, autonomic dysfunction, chemical imbalance, foods with soy and neurotransmitter dysfunction.
The NIMH says: “Mental illnesses are complex and probably result from a combination of genetic, environmental, psychological, and developmental factors.”
Pain, in particular, untreated gastrointestinal pain, in people with autism is also a trigger for anxiety. Read up on common GI issues in ASD on TACA's Poop Page.
Prevention and Treatments
The gold-standard treatment for anxiety is CBT – Cognitive Behavioral Therapy (e.g. talking to a therapist). Group CBT has shown to be effective for teens and adults. Many insurance companies don’t like to cover this long term, but it’s what works and parents should fight to get and keep this as long as needed either through insurance or in the school system.
Other ways to head off depression and anxiety are exercise, stress management skills, coping skills, social and lifeskills, meditation, yoga, consuming no foods with soy or excitoxins like MSG and homeschooling (to lessen pressure of perfection and social phobias).
Staying in the present
According to the Anxiety and Depression Association of America, most professionals have the patient focus on the here and now during therapy-based treatment as opposed to reflecting on what has occurred in the past. Studies have also found that practicing being present through mindfulness meditation can help reduce levels of anxiety and mental stress.
A lot of children with anxiety measure themselves against an impossible ideal of “perfection”. Imperfection is life. Teach your kids that perfect doesn’t exist and they need to deal with themselves, rather than compare themselves to everyone else.
Natural vs Prescription Treatments
According to the NIMH, medications do not cure anxiety, they can only reduce symptoms while you seek other treatments.
Please note that there are no FDA-approved medications expressly for the treatment of anxiety in children, adolescents or adults with autism, but doctors still prescribe SSRI drugs like Prozac or Zoloft off-label, even though research shows they don’t have the same efficacy for people with ASD. This should be a cause for concern and further consideration for parents when handed a prescription for medications rather than CBT or other treatments that are less invasive or have less potential for side effects.
It is possible that the biological root of autism-associated anxiety may differ that of anxiety in the general population. If this proves to be true, individuals with autism may respond best to tailored treatments.
rTMS - Repetitive transcranial magnetic stimulation may help anxiety. Although it's new, it's shown promise when studied on people with autism specifically.
Natural treatments that require a prescription include nasal Oxytocin and medicinal marijuana.
Study states that gut bacteria (Clostridia’s HPHPA) can cause anxiety.
“And now, scientists think there may be a link between what's in your gut and what's in your head, suggesting that bacteria may play a role in disorders such as anxiety, schizophrenia and autism. In some patients, the strep bacterium has been linked to OCD in a condition known as PANDAS.”
Natural treatments that don’t require a prescription include cardiovascular exercise, biomedical treatments, Acupuncture, neurotransmitter calmers like 5HTP, kava kava, GABA, taurine, EFAs, B6, inositol, Magnesium, l-theanine among others. Your doctor can order a neurotransmitters panel lab test to see what your child may need.
What can you as a parent do to help your child?
- Obtain CBT for your child
- Get Organic Acid, PANDAS, neurotransmitter and allergy panels pulled by your doctor
- Teach Self-Regulation
- Work the “Face Your Fears” steps
- Teach self-esteem and self-advocacy skills
Calming techniques to help your child include:
- A sensory diet to include things like sensory breaks throughout the day with a quiet place to decompress; weighted vest, deep pressure massage, swinging, bouncing, and use of the Wilbarger Protocol. More Sensory Diet ideas
- Using visual or written schedules to help them know what is going to happen during their day.
- Epsom salts baths
- Supplements like GABA, taurine, EFAs, B6, inositol, 5HTP, Magnesium, l-theanine and others that slow neurotransmitters.
- Removing the offenders like food colorings and preservatives, excitotoxins like MSG and aspartame and caffeine.
- If your child is able to participate in therapy, such as with a counselor or psychologist, it may help for them to talk it out and get advice on how to deal with the situations they are having problems coping with or understanding.
- Tai Chi or Yoga
- Cardio exercise
- 1-5 scale of frustration
The following recommendations are part of the “Face Your Fears” intervention developed by Judy Reaven and colleagues:
- Encourage and reward your child for his or her effort and engagement in brave behaviors
- Ignore excessive displays of anxiety
- Distinguish between realistic and unrealistic fears so that an appropriate treatment direction can be established
- Convey confidence in the child's ability to handle his or her worry and anxiety
- Model courageous behaviors
- Work together with your spouse or partner to develop a plan for facing fears
- 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
Dealing with Aggression in ASD
Facts about Asperger's Syndrome
What are Life Skills?
What are Social Skills?
Teens and Social Skills
Teens with ASD: Self Advocacy and Self-Esteem
ARI's Webinar on Anxiety
Books on Cognitive Behavioral Therapy
Social Navigator App
What triggers anxiety for kids with ASD
Tips to Reduce your Child's Stress and Anxiety
Many families report that the impact of the mental health problems can be as or more impairing than the autism spectrum difficulties themselves.
The Other Public Health Crisis: Suicide Prevention by Sallie Bernard, excerpted from the Autism File Magazine
Suicide ideation and attempts in children with autism
Anxiety is highly prevalent in HF ASD but is too often misdiagnosed
Lack of Efficacy of Citalopram in Children With Autism Spectrum Disorders and High Levels of Repetitive Behavior
SSRI Benefit in Autism May be Overstated
More Research Needed on SSRIs for Treating Autism Disorders “This research made it clear that the effects of SSRI treatment in ASD are considerably overrated because of publication bias,” they wrote. “In addition, our search strategy uncovered as many completed SSRI trials in ASD with unpublished results as have been published, further supporting the influence of potential publication bias on effect estimates.”