Autism and Managing Anxiety

Practical Strategies for Working with Children and Young People

Middletown Centre for Autism

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781000195422
• Edition: 1
• Topic: Education
• Subtopic: Education General

This easy-to-use resource is a compilation of theoretical background and concrete approaches designed to increase understanding and outline strategies to support autistic children and young people who experience anxiety in the school environment. This resource also has practical application for parents, carers and professionals across a range of educational and community-based settings.

Using real life examples and case studies, the book explains and explores the different forms of anxiety and their impact across the school environment. Each chapter offers practical information and strategies that may help reduce the negative symptoms of anxiety and help support emotional resilience across home and school environments.

Key features of this book include:

• Chapters aimed at enhancing the understanding of anxiety in autism, considering potential triggers of anxiety, discussion on cognitive theories, social communication and means of assessing anxiety.
• A wealth of downloadable anxiety management strategies and resources that can be adapted and used by a teacher, parent or other professional.

This resource has been developed by the multidisciplinary team at Middletown Centre for Autism, and is a useful resource for the busy parent, teacher and other professionals who wish to provide individualised support strategies for anxiety across a range of settings.

1. Autism and anxiety

Introduction

Anxiety is a common response to stressors experienced throughout life, such as starting a new school, taking examinations or moving house. In some circumstances, anxiety can be helpful as it triggers adrenaline responses which help the brain and body to cope with the stressors. These adrenaline responses help individuals to run from danger, enhance cognitive functioning in an examination or improve motivation to complete a challenging task. Prolonged and frequent anxiety, however, is physically and emotionally damaging as the body needs time to recover and repair after adrenaline releases. A person who has persistent and pervasive anxiety does not have the opportunity to recover and the impact on mental health can be significant.

Anxiety is a prevalent problem for autistic children (White and Roberson-Nay, 2009; Ozsivadjian and Knott, 2011), affecting at least 40% of individuals who have a diagnosis of autism (Van Steensel et al., 2011). The impact of anxiety on school-age children with autism is significant, adversely affecting school attendance, educational attainment, family quality of life and parental stress (Dabrowska and Pisula, 2010; Carter et al., 2013).

Table 1.1 Diagnostic features of autism

Deficits in social communication and interaction May not initiate or respond to social interactions Lack of reciprocity in conversations Unusual eye contact and body language Difficulties understanding gestures May not adjust behaviour appropriately to context Lack of engagement in imaginative play Difficulty in forming and maintaining friendships

Restricted and repetitive interests and behaviours Stereotypes or repetitive movements and/or speech Insistence on sameness Strict adherence to routines Anxiety in response to small changes Strong attachment to favourite objects Extremely fixated and restricted interest on a topic, activity or object Hyper-reactivity or hypo-reactivity to sensory input, or an unusual preoccupation with specific sensory input

Autism

Autism is characterised by a spectrum of differences categorised in diagnostic criteria as difficulties in social communication, and restricted, repetitive interests and behaviours (American Psychiatric Association (APA), 2013; World Health Organisation (WHO), 2018). The Diagnostic and Statistical Manual (5th edition) (DSM-5) (APA, 2013) provides criteria for a diagnosis of autism and lists examples of how these criteria may be observed. Examples of the criteria are provided in Table 1.1.

The criteria set out in DSM 5 (APA, 2013) and in the International Classification of Diseases (11th edition) (ICD-11) (WHO, 2018) also highlight that for a diagnosis to be confirmed, autistic features must have been present in early development and significantly impact current functioning.

These autistic features can often become predisposing factors for anxiety, placing autistic children at a higher risk of developing anxiety.

Point to remember

Every autistic child will have a unique set of differences and strengths and they will all be affected by their autism in different ways. A flexible approach to their specific needs and skills is therefore essential.

Prevalence of anxiety in autism

Anxiety is cited as one of the main co-existing difficulties for autistic children (Smith Myles, 2003; White and Roberson-Nay, 2009; Kent and Simonoff, 2017) with up to 84% experiencing anxiety at some time (Ozsivadjian and Knott, 2011). The earliest observations of autism, made by Kanner in 1943 and Asperger in 1944, described autistic children presenting with high levels of worry, obsessions and fear of social encounters (Frith, 1991).

A study by Van Steensel et al. (2011) found that approximately 40% of autistic children have been diagnosed with at least one co-existing anxiety disorder, with the following prevalence rates:

• Specific Phobia: 30%
• Obsessive–Compulsive Disorder: 17%
• Social Anxiety Disorder/Agoraphobia: 17%
• Generalised Anxiety Disorder: 15%
• Separation Anxiety Disorder: 9 %
• Panic Disorder: 2%

The prevalence of anxiety in autism suggests that there is a correlational relationship between them, but causality is still unclear. Kerns and Kendall (2012) suggest that anxiety is both influential to autism and influenced by autism. There are a number of core autistic characteristics which may predispose a child to developing anxiety.

Causes of anxiety in autism

People with autism may be more prone to experiencing anxiety due to biological differences in brain structure and function and due to the core characteristics.

1. Social communication differences

Differences in both expressive and receptive language skills can create high levels of confusion and frustration for autistic children. Interpreting non-verbal cues alongside complex language can be overwhelming, while difficulties in communicating fluently and coherently can lead to anxiety in social interactions. This creates a cycle of negative social communicative experiences, which creates anxiety thought patterns which then further confound communication difficulties.

Events and people may be perceived as threatening, which exacerbates the anxiety and can lead to withdrawal and isolation.

Case example

Becky is a 14-year-old girl with high-functioning autism. She has an extensive vocabulary and her teachers report that she is able to express herself coherently when asked questions in class. Becky, however, finds it difficult to interact with her peers at break and lunchtimes. She cannot process information when several people are speaking at once and cannot easily contribute to conversations about music, movies and fashion. She has now become anxious at these times and withdraws to a quiet classroom to sit alone.

2. Insistence on sameness

Many autistic children have a strong preference for predictable routines and familiar places and objects. When inevitable disruptions occur, or when introduced to new situations, anxiety often increases. This anxiety can then create an even greater drive for sameness and routine.

3. Intolerance of uncertainty

Intolerance of uncertainty is explained as the ‘tendency to react negatively on an emotional, cognitive, and behavioural level to uncertain situations and events’ (Buhr and Dugas, 2009, p. 216). People with autism are thought to have a higher degree of intolerance to uncertainty (Neil et al., 2016) and can find uncertain situations, environments or events stressful, which causes negative thinking and can trigger episodes of intense anxiety.

4. Sensory processing differences

Negative reactions to sensory input are common in autistic children. Hyper-reactivity, or over-sensitivity, to sensory input is frequently correlated with anxiety. Many noises, smells, lights, touch and movement are received at a greater intensity by the autistic child, which can lead to sensory overload and anxiety. Unpredictable input, such as a car horn or fire alarm, is particularly stressful. Memories of sensory experiences are stored and affect emotional responses to similar input in the future. The memory of a negative sensory experience is stored and will influence responses to sensory experiences in the future.

5. Executive dysfunction

Executive functions include planning, focusing and shifting attention, initiating activity, self-regulation and impulse control. Some autistic children have difficulty with executive functions and demonstrate functions including impulsivity, disinhibition and difficulty controlling emotions (Ozonoff et al., 1991; Ozonoff and Jensen, 1999; Leung et al., 2015). It will also affect the ability to organise themselves and their belongings. This can limit success in daily activities, such as getting dressed or catching a bus, which can fuel negative thinking patterns and contribute to anxieties. Difficulties in executive functioning also impact on the ability to select and utilise emotionally regulating strategies in stressful situations.

Point to remember

The key features of autism are dually causes and outcomes of anxiety. Differences in communication, sensory processing, executive functioning and a need for predictability can create feelings of anxiety. The anxiety then exacerbates these core differences.

These key characteristics of autism create a world which is confusing and chaotic for an autistic child, and this is further confounded by difficulties in recognising and communicating when they feel anxious, or knowing how to ask for help. The factors listed above predispose an autistic child to developing anxiety, but then there are certain events which can trigger anxiety at any time.

Triggers for anxiety in autism

A trigger is something that causes an individual to feel uncomfortable within their environment, which then creates a feeling of anxiety and subsequent behavioural responses. Major life events like adolescence, illness and death of a loved one can trigger anxiety. Significant changes, such as moving house or starting a new job can also be triggers. Autistic children, however, experience many more triggers, and often on a daily basis. Examples of such triggers may include:

• Transitions: Daily transitions, such as going from home to school, or moving from one ­activity to another, are often stressful for autistic children. Anxiety is exacerbated if the transition is poorly managed and has not been communicated to the child in advance.
• Unexpected changes to routine: Unpredictability is a significant stressor for many with autism. A substitute teacher in the classroom, the bus arriving late or an activity being cancelled are all examples of changes which can trigger anxiety.
• Unstructured times: When there is no structure in an activity or environment, it feels chaotic and confusing to an autistic child. They cannot make sense of the situation and do not know what is expected of them. Places, such as the school playground or a soft play centre, and activities such as waiting for a bus or free play, tend to increase anxiety.
• Unfamiliar places and people: Autistic children will often become fearful when going to a new place or meeting new people. New toys, clothes and household objects can even cause upset, as there is usually a strong preference for sameness and for familiar objects and places.
• Sensory stimuli: Anxiety may be triggered by specific stimuli which the child dislikes or finds intolerable, or anxiety may be triggered by multiple overwhelming stimuli, which can be ­experienced in busy and crowded environments. Sensory input can cause even more stress when sudden and unpredictable (e.g. a car horn, a fire alarm).
• Social demands: An expectation to answer a question or to interact with others will often trigger anxiety in autism. This can happen in multiple scenarios throughout the day, including a teacher asking a question in the classroom, participating in a group discussion in school, chatting with friends at a youth club or asking for an item in a shop. The challenges in social communication mean that all social situations can provoke anxiety in autistic children.
• School specific anxieties: The school day presents specific challenges for autistic children. Alongside the typical stressors of exams and homework, there are triggers such as getting to the correct classroom on time, bringing the correct books and submitting homework to a deadline. These demands are particularly challenging for those with autism if they have executive functioning difficulties as any task which requires planning and organisation is stressful. The social communication difficulties associated with autism can also create challenges in the school context as the student may have difficulty processing verbal instructions for a task and doe...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of tables
• List of resources
• List of contributors
• Colour coding for visual supports
• Preface
• 1. Autism and anxiety
• 2. Social communication, autism and anxiety
• 3. Cognitive theories, learning style, autism and anxiety
• 4. Sensory processing, ­autism and anxiety
• 5. Assessment of anxiety
• 6. Anxiety ­management strategies for ­autistic children and young people
• Resources
• Index