Autism spectrum disorder and anxiety disorders can be co-occurring disorders in youth who are high functioning and aware of their different social disability. The reviewed research conducted on anxiety in children and adolescents diagnosed with Autism spectrum disorder reviewed aims to sum up the empirical research on the treatment, occurrence and presentation of anxiety in children and adolescents with Autism Spectrum Disorder. This review hopes to provide the guidance to what should be the next step in clinical research in this area. In reviewing these studies the authors provide recommendations based on the understanding anxiety and youth with Autism Spectrum Disorder.
Research articles were identified by two criteria; that the target population included children or adolescents diagnosed with ASD, and that their symptoms of anxiety assessed with direct evaluation, observation or report from parent, teacher or child. The identified research, based on the primary research question, was then classified into three categories prevalence, phenomenology, or treatment.
Results in the studies reviewed specify that between 11% and 84% of children with ASD experience anxiety impairment in some extent, with a 42% overall anxiety disorder diagnosis rate. It was also noted that many anxiety disorders, such as social phobia and obsessive-compulsive disorder, are rarely diagnosed in those with ASD, due to a consensus that the symptoms are more thoroughly explained by ASD itself. The evaluation of the treatment of anxiety in youth with ASD finds that there are no empirically supported treatments that target behavioral and emotional concerns presented by youth with ASD and anxiety. The findings of the studies reviewed that focused on the phenomenology of anxiety; verify that anxiety is not a rare incidence in children with ASD. Age and IQ affect the presentation of anxiety in children with ASD. In general, the higher functioning and the older the child with ASD, the more anxiety they will experience.
In conclusion, the conceptualization of anxiety in patients with ASD is complex. Clinicians are faced with determining if anxiety problems are representative of the ASD disorder, or if anxiety is a secondary disorder.
The authors recommend that future research further examine the need to identify the risk factors for anxiety in ASD. It is also recommended that since the number of children diagnosed with ASD grows the need for precise assessment tools and effective treatment approaches of both anxiety and ASD.
White, Susan, & Roberson-Nay, Roxanne (2009). Anxiety, Social Deficits, and Loneliness in Youth with Autism Spectrum Disorders. Journal of Autism & Developmental Disorders, 39 (7), 1006-1013.
The analysis of the growing need to assess and treat co-occurring psychiatric condition in youth with ASD was the basis for this study. The limited data on anxiety, loneliness and social deficits of youth with ASD and limited guidelines on how to assess for these areas determined the qualifications of this study. The aim was to examine self reported experiences of anxiety in youth with ASD. The study hypothesized that more severely socially disabled youth would report high symptoms of anxiety, and that with higher self-reported anxiety, their report of loneliness would also increase, more so then less anxious peers.
A sample of 20 children and adolescents receiving outpatient services for ASD was used. The age range of the participants was seven to fourteen years old and 90% of the sample groups were male. The sample group was assessed by several diagnostic measures and questionnaires, including: Autism Diagnostic Observation Schedule, Social Communication Questionnaire, Social Responsiveness Scale, Social Competence Inventory, Multidimensional Anxiety Scale for Children, Child Behavior Checklist, and Loneliness Questionnaire.
The hypothesis that youth who self-report greater anxiety will have more social disability was not supported by the data. No significant correlation between anxiety and loneliness was found. There was however, a difference in reported loneliness, when divided into normal and above average anxiety scores.
In conclusion, the study found that the effectiveness of commonly used self-report measures of anxiety in youth with ASD are reliable tools, although some of the children may have had trouble understanding the questions or responded randomly. It was also found that youth with ASD who reported experiencing elevated anxiety also experienced more social loneliness, as reported by self-report, but not emotional loneliness.
The authors recommend that future research should examine larger, more diversified samples of youth with ASD. It is also recommended that future studies determine if anxiety measures are performed equally across youth with ASD and youth without ASD.
Wood, J.J, Drahota, A, Sze, K., Har, K, Chiu, A., & Langer, D. A. (2009). Cognitive Behavioral Therapy for Anxiety in Children with Autism Spectrum Disorders: a Randomized, Controlled Trial. Journal of Child Psychology and Psychiatry , 50(3), 224-234.
Children with ASD frequently present with anxiety disorders that cause significant impairment in functioning. Intervention programs have been developed for youth with typical development who experience anxiety disorders. The issues found are that the cognitive, social characteristics and linguistics of ASD may make the standard treatment for typical children with anxiety disorders less effective for children with ASD. In this study a randomized, controlled trial tested a cognitive behavior therapy modified for children with ASD and anxiety disorders.
The study sample included 40 children, 7 to 11 years old, with a dual diagnosis of ASD and Anxiety disorder. The modified Building confidence CBT program for children with ASD was implemented by therapists working with families for 16 weekly sessions of 90 minutes each. Families were assessed blindly by a third party unaware of the intervention condition of the families, using diagnostic interviews before and immediately after intervention.
The study results showed that the majority of participants in treatment showed positive treatment response, compared to those who were not provided the treatment. Those who received post-treatment were identified as Anxiety free, and no significant difference was found between post-treatment and follow-up.
In conclusion the study finds that children treated with a modified CBT showed significant anxiety reduction, although self-reported anxiety did not show improvement with therapy. The modified CBT program is the first modification of an evidence based program for children with ASD.
Recommendations for future research state that a larger more diverse sample size would provide more evidence based results of change in anxiety level in youth with ASD. Another recommendation is that the modifications of these interventions should be performed by an independent resource to validate the results and modifications, and that future research should measure family adherence to the intervention methods.
White, S., Albano, A., Johnson, C., Kasari, C., Ollendick, T., Klin, A., Oswald, D., & Scahill, L. (2010). Development of a Cognitive-Behavioral Intervention Program to Treat Anxiety and Social Deficits in Teens with High-Functioning Autism. Clinical Child and Family Psychological Review, 13, 77-90
Anxiety may be compounding the social deficits of young people with ASD. This study focuses on the development of a manual-based, cognitive-behavioral treatment program targeting anxiety symptoms, as well as social skill deficits, in adolescents with ASD. At present behavioral treatment program targets both core social deficits, and problems associated with anxiety which frequently occur in adolescents with ASD.
The Multimodal Anxiety and Social Skills Intervention (MASSI) are based on the CBT principles. It addresses the areas of the individual’s feelings, actions, and thoughts, as well as interactions in three domains to bring about change. The program consists of four individual therapy modules. These core modules are delivered consecutively for every participant as a basis for the program. A fifth module, in the final session, serves as a review and wrap-up of all that has been taught. The treatment modules selected are based on the needs and skill deficits of the individual. Sessions of treatment last 50 to 75 minutes and are devoted to only one module.
MASSI results show that the intervention program focuses on social development and anxiety reduction only. It should not be used to treat youth with co-occurring problems requiring immediate and intensive treatment.
The findings of the MASSI intervention conclude that the multiple modalities of the treatment add to its utility in aspects of the intervention. Since only four children were tested on this developed intervention, the findings cannot be generalized, but does provide support for the effectiveness of the program implementation.
The development of this program represents the next step in the development of treatment of children with ASD and anxiety. Future research will determine efficacy and feasibility. It is also suggested that more programs be researched and developed based on the data represented by this program since it demonstrates that children with ASD may be responsive to intervention programs for anxiety.
Reaven, Judith. (2009). Children with High-Functioning Autism Spectrum Disorders and Co- occurring Anxiety Symptoms: Implications for Assessment and Treatment. Journal for Specialists in Pediatric Nursing, 14(3), 192-199.
Children with ASD are at an increased risk for developing anxiety disorders. These anxiety disorders manifest in symptoms that can impact school performance, family functioning and peer relationships. Research has demonstrated that there is potential for the positive impact of modified cognitive behavioral therapy to reduce anxiety in children with ASD.
The assessment of anxiety symptoms identified these as the most prevalent: separating from parents difficulties, fearful responses to objects or events, unwarranted avoidance, somatic complaints, presence of stressful thoughts, difficulties with concentration, fatigue, irritability, disturbance, sleep, and restlessness. Using anxiety symptoms assessments developed for typical peers can be difficult to use with children with ASD. Since these assessments were not created with children with ASD in mind, it is recommended that children with ASD be assessed using modified assessment tools. The Autism Co-Morbidity Interview-Present and Lifetime Version (ACI-PL) was found to provide accurate results when tested.
Treatment plans have been found to be effective when based on the CBT behavior intervention plan. The CBT intervention addresses both physiological and cognitive associations with anxiety, which when implement accurately show changes in the anxiety level of children with ASD.
In conclusion, the study shows that it is necessary to use appropriate assessments and treatment plans for children with ASD and anxiety in order to help children overcome and deal with anxiety appropriately. In application the ability to apply and adapt these assessments and treatments to individuals with ASD and their specific needs and skills is necessary.
Recommendation for future research includes the development of more appropriate assessments and treatments for children with ASD and anxiety disorders. It is also suggested that research be completed on the accurate implementation of the assessments and treatments to support accurate findings and outcomes.
A review of the literature on Anxiety disorders and children with ASD shows that modifications and the implementation of CBT techniques are shown to provide the most effective relief of anxiety in children with ASD. Issues arise because there are not many empirically validated and based treatment plans or interventions available for children with ASD and anxiety disorders. The only currently available treatment plans are ones modified from empirically based interventions created for typical peers with typical development. The few developed intervention show some research supporting positive outcomes, but as of yet there is not enough evidence to support the outcomes from these interventions.
The research providing evidence that children with ASD can have a co-occurring anxiety disorder provides a basis for professionals and parents to request assessment and services for their children. To understand the relationship between ASD and anxiety, it is important to be aware that it is not unusual for some anxiety to be based on the misunderstanding of social interactions between peers, because of the child’s inability to understand the social implications of these interactions.
In conclusion, all of the research and reviews show that anxiety and ASD can be co-occurring disorders. Although diagnosis of these disorders co-occurring is difficult, it is necessary to assess the level and types of anxiety present in the child’s life in order to provide an appropriate intervention program. The ability of an individual with ASD to understand that anxiety is a normal part of growing, and that some anxiety is normal in social interactions for all individual with and without ASD’s key.