When Autism and Anxiety Overlap

As a pre-schooler, my daughter couldn’t wait to sleep over at friends’ houses. By the time she was seven, however, she could no longer make it through the night and called, weeping, begging to come home. She would grow increasingly tense whenever she was invited out, and she started having panic attacks.

Analysts estimate that around 40% of autistic children, like my daughter, have a co-occurring anxiety disorder. It’s important for caregivers to understand the related signs, symptoms and treatment approaches for effective parenting and support.

What is an anxiety disorder?

Everyone experiences anxiety at times, feeling fear, tension or worry in response to a real or perceived threat. Anxiety is healthy and can be protective. Our “fight, flight or freeze” response supplies our bodies with additional oxygen and blood to respond to danger. If your child’s everyday worries become intense, persistent and interfere with their daily functioning, however, an anxiety disorder may be present.

Anxiety disorders take different forms, and many children experience more than one type. According to Anxiety Canada, common anxiety disorders include:

• Generalized Anxiety Disorder: Excessive, uncontrollable worry about future events and minor matters, such as health, schoolwork and social situations
• Phobias: Intense, unreasonable fear of a specific object or situation not causing immediate danger

• Separation Anxiety Disorder: excessive fear when separated or anticipating separation from a loved one
• Social Anxiety Disorder: excessive nervousness meeting new people or in group situations

Other types include Selective Mutism, when a child stops speaking in certain situations, and Post-Traumatic Stress Disorder (PTSD) after exposure to a frightening, traumatic event.

Signs and symptoms of co-occurring autism and anxiety

Dr. Connor Kerns, Director of the Anxiety Stress and Autism Program (ASAP) at the University of British Columbia, explains that autistic children have many of the same worries as neurotypical children, but they can also feel particularly stressed about:

• Changes and disruptions to their routines or environments (desire for sameness)
• Social interactions and communication
• Sensory sensitivities
• Particular situations, activities or objects

It can be difficult to distinguish if behaviours are related more to a child’s autism or anxiety. Some autistic kids avoid social situations due to a fear of being rejected or teased; others become overwhelmed and yet others don’t enjoy social situations and prefer to be alone. Repetitive behaviours can be an expression of distress but can also be self-regulating and soothing. Many autistic children also have difficulty identifying and expressing their own thoughts and feelings.

Caregivers might notice:

• Physical symptoms, such as a racing heart, difficulty breathing, sleep problems, sweating and gastrointestinal problems
• Increased withdrawal from social situations
• More challenging behaviours and outbursts
• Signs of self-harm or withdrawal

In these cases, it’s wise to consult with an expert to explore the possibility of a mental health condition.

Causes and Risk Factors

While the causes of neither anxiety or autism are fully understood, a combination of genetic, biological and environmental factors contribute.

Dr. Kerns adds that a child’s cognitive ability is important in identifying their type of anxiety disorder, rather than determining whether they have one or not. Non-speaking children or those with co-occurring intellectual disabilities are unlikely to have generalized or social anxiety disorders, while certain phobias, obsessive-compulsive behaviours and separation anxiety are more evenly distributed across the spectrum.

How to support an autistic child with co-occurring anxiety

Dr. Kerns describes anxiety in autistic children as a “problem with a lot of promise”.

The critical first step is recognizing that a child may have a disorder. Doing so changes our mindsets and builds empathy and understanding. Certain fears are reasonable, however, and do not mean your child has an anxiety disorder—for example, if they’ve been bullied or excluded, anxiety about social encounters is understandable.

It’s not always easy to determine what is making your child anxious. Dr. Kerns often asks parents, “Are there scenarios where you think your child is afraid?” As she says, there’s an important distinction between “I don’t want to (because I’m afraid)” and “I don’t want to (because I don’t want to).”

The next step is to become educated. Caregivers often accommodate their child’s situational avoidance in an effort to soothe and calm them. This can potentially fuel the feelings, as avoidance provides temporary relief but perpetuates a cycle of fear and avoidance.

Dr. Kerns suggests that parents specifically ask for a comprehensive assessment that takes their child’s autism into account. Work with a qualified clinician who is willing to partner with you and teach you and your child appropriate coping strategies tailored to their needs. Then integrate these strategies into your daily lives.

Treatment options

Only a registered mental health professional can diagnose anxiety disorders. In addition to a diagnostic interview, they may use questionnaires to help inform their decision. Once there's a diagnosis, a clinician can recommend the best course of treatment, which may or may not include medication.

Cognitive behavioural therapy (CBT) helps identify the root cause of a child’s fears and teaches them to change their thinking in situations that make them anxious. They learn to progressively challenge their anxiety using exposure therapy, among other methods. A child who is afraid of being separated from her mother might initially learn to manage while being separated from her for just one minute, with longer periods gradually introduced over time.

Parental involvement is key to success. Dr. Kerns notes that caregiver participation is “firmly established” to improve CBT’s effectiveness and better support autistic children.

Depending on your child, modifications such as the use of visual supports and social stories, concise and concrete explanations and examples, and more interactive sessions can be helpful. A skilled clinician will incorporate your child’s preferred interests. Sessions may need to be shorter or more frequent, with more breaks.

Clinicians often treat autism behaviours and anxiety together. For example, they might teach a child strategies to address their social anxiety while teaching social skills at the same time.

Resources for parents and caregivers

Helpful resources include:

• National autism and anxiety organizations and helplines, such as Autism Speaks, the Anxiety and Depression Association of America and Anxiety Canada
• Autism service providers in your area, many of whom have anxiety-related parent support groups and forums as well as online courses and webinars.
• Dr. Kerns’ ASAP Lab, which has a resources page on its website
• The Association of Behavioural and Cognitive Therapies
• Your family doctor or other healthcare professionals

It’s comforting to know that anxiety disorders are highly treatable. The more we parents and caregivers learn about co-occurring autism and anxiety, the stronger position we are in to help our child and effectively advocate on their behalf. As Dr. Kerns says, “Once you recognize anxiety, it opens up a lot of avenues for effective treatment.”