Reducing Anxiety Among Those with Autism Spectrum Disorder

by Corinne G. Catalano, Ph.D. and Eileen McKeating, Ph.D., Montclair State University Center for Autism and Early Childhood Mental Health

As many as 84% of children diagnosed with Autism Spectrum Disorder (ASD) are reported to also present with significant symptoms of anxiety (White et al., 2009) despite the fact that anxiety is not part of the diagnostic criteria for ASD. The diagnosis of ASD is based on observations of behavior which may be impacted by anxiety and stress responses that are the result of differences in the brain and the neurosensory system. The COVID-19 pandemic elicits fear and apprehension in all of us and presents an opportunity to gain insight into how anxiety affects human behavior. Heightened anxiety is the everyday lived experience of a majority of children with ASD, impacting behavior and warranting our attention.

ASD is a neurodevelopmental disorder characterized by challenges with social communication and social interaction, restricted, repetitive patterns of behavior, interests, or activities, and sensory sensitivities (APA, 2013). When this diagnostic criteria of autism was released, Thomas Insel, the director of the National Institute of Mental Health at the time, questioned the continued use of a behavioral symptom-based diagnosis that does not account for emerging findings in the field of neurobiology (Insel, 2013). Since the diagnosis of ASD is predicated only on observations of a child’s behavior, the diagnosis tells us nothing about what might be causing a child to exhibit such behaviors. Insel pointed out, as we are learning more about the possible underlying causes of a child’s behavior, we need to shift our lens from viewing ASD as a behavioral disorder to understanding it as a neurodevelopmental condition. This not only calls for new ways of diagnosing this condition but also new ways of intervening and teaching that move beyond simply managing, shaping, or extinguishing behaviors (Markham & Markham, 2010; Mintz, 2015, Singletary, 2015).

What are we learning about children who receive an ASD diagnosis?

The limbic system and amygdala, in particular, are known to process emotions, including fear. Perceived or real threats activate the limbic system sending messages to the autonomic nervous system (ANS) in humans, which controls involuntary functions such as heart rate and breathing, inducing fight, flight or freeze reactions. Due to significant differences in how children diagnosed with ASD perceive the world through their senses, the environment may seem louder, brighter, and more threatening to them (Tomcheck & Dunn, 2007). For example, a child with auditory hyper-sensitivity may experience buzzing fluorescent lights in the classroom as threatening. He might lash out, run away, or withdraw. This connection between anxiety and sensory hypersensitivity in children with autism has been supported by empirical research for more than a decade. For example, Pfieffer and colleagues (2005) found a significant correlation between sensory defensiveness and anxiety in children between the ages of 6 and 17 diagnosed with Asperger’s disorder, a condition that was formerly part of the autism diagnosis.

Another growing body of research has hypothesized that children with ASD have difficulty accessing memories of prior experiences; in other words, they see most events as novel. Their lack of ability to predict what will happen next results in heightened anxiety and a need for control (Neil et al., 2016; Pellicano & Burr, 2012). This explains behaviors commonly observed in children with ASD, such as repeatedly lining up their blocks in a particular order.

Restricted and repetitive behaviors are a common feature of ASD and are included in the current diagnostic criteria. Researchers have reported that higher levels of anxiety have been associated with restricted and repetitive behaviors (RRB) in ASD (Gotham et al., 2013; Lidstone et al., 2014; Rodgers et al., 2012). Some suggest that RRB—more specifically insistence on sameness including routines, rituals, and unusual interests—may be a coping mechanism used to reduce anxiety (Rodgers et al., 2012). Numerous first-person accounts (e.g., Fleishmann & Fleischmann, 2012; Grandin, 2011; Williams, 1994) emphasize the reliance on RRB to foster calm and reduce feelings of anxiousness.

This research helps us to understand children’s reactions when overwhelmed by sensory stimuli or presented with something unfamiliar, not simply as task avoidance or misbehavior, but possibly as stress behavior resulting from what is perceived by them as threatening stimuli (Shanker, 2016).

How does this information inform interventions?

When challenging behaviors often associated with children diagnosed with ASD are reframed and seen through the lens of stress and anxiety, the focus of intervention shifts to interventions that serve to help children feel calm and safe. Efforts should be aimed at soothing the child’s reactive nervous systems and reducing unpredictability by providing consistent, predictable routines and relationships (Neil et al., 2016; Perry & Hambrick, 2008). While alleviating stress is not the primary focus of visual support strategies (i.e., photos, icons, schedules, graphic organizers), research indicates that these strategies support social communication and reduce challenging behaviors among children and adolescents diagnosed with ASD (Wong et al., 2013). When the intent of such strategies is to organize learning environments, provide cues or supports, and/or establish routines, educators’ use of visual supports may foster a sense of safety and predictability.

Interventions such as mindfulness, including breathwork and body scans, are specifically focused on calming the nervous system and have been studied with children and adolescents diagnosed with ASD. The findings are promising and suggest that mindfulness training can reduce anxiety and challenging behavior in children diagnosed with ASD as well as decrease aggression and increase social responsiveness in adolescents with this diagnosis (Cachia et al., 2016; Hwang & Kearney, 2013).

What happens when this information is shared with educators?

Educators believe that understanding the specific needs of each child diagnosed with ASD is essential to successfully teach and support them (Adams et al., 2019; Lindsay et al., 2013). Together with our colleagues, we have been studying a teacher preparation course developed by our team at the Center for Autism and Early Childhood Mental Health that engages pre-service and in-service teachers in examining the nature of sensory processing, self-regulation, motor planning, social engagement, and language development, as related to ASD. The majority of pre-service teachers who participated in our study reported that they experienced change in their thinking of children diagnosed with ASD, and for many, this change was related to looking for reasons behind the challenges associated with behavior.

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Teaching this course, we have had the opportunity to see how engaging teachers and other school-based professionals in wondering about the individual profile of each child with an ASD diagnosis can inform and change their pedagogy. We are constantly struck by the reactions of teachers and paraprofessionals, especially those assigned to classrooms using strict behavior modification techniques, when they read first-person narratives by individuals with an ASD diagnosis or make a connection to how they, personally, respond to an adverse sensory experience or stimulus. Many feel guilty when they learn that a child with this diagnosis might understand what is being said about them even though that child is unable to speak or that a child’s perseverative behavior may be a way of him coping with an uncomfortable classroom environment. Others inquire if they could be contributing to a child’s outbursts by making a child comply with a mandatory fine-motor task or an unannounced change to their routine. While this new insight into ASD may be uncomfortable at times, our research found that it also increases teachers’ confidence to work with children with this diagnosis.

Rooted in advances in science and verified by self-advocates, the evidence of the neurobiological basis of ASD and connection to anxiety must be taken into account when working with children and adolescents with this diagnosis. Shifting our lens from viewing ASD as a disorder of behavior to seeing ASD as a neurobiological disorder of early brain development is critical if our goal is to uncover each child’s strengths and challenges so that every child can be best understood, taught, and supported.