Understanding and Treating
Anxiety
in Individuals with
Autism Spectrum Disorders
Doreen Granpeesheh, Ph.D., BCBA
Center for Autism and Related Disorders, Inc
Todays Lecture:
Exploring Anxiety in ourselves
What is Anxiety?
What are the signs of Anxiety in ASD?
Some ways to assess Anxiety in ASD
Incidence Rates of Anxiety in ASD
Treatments for Anxiety in Individuals with
ASD
Exploring Anxiety in Ourselves
How do we define Anxiety?
 Anxiety is a normal reaction to stress. It helps
one deal with a tense situation in the office,
study harder for an exam, keep focused on an
important speech. In general, it helps one cope.
But when anxiety becomes an excessive,
irrational dread of everyday situations, it has
become a disabling disorder. (NIMH)
Symptoms we call Anxiety
When I’m Anxious, I …
worry
am afraid
don’t sleep
don’t eat
eat too much
obsess about things
have racing thoughts
have heart palpitations
have Irritable bowel syndrome
feel dizzy
How do I deal with Anxiety?
I distract myself
I keep myself busy
I talk to my friends/gain reassurance
I pray
I take medications to help me
I exercise
I breath, meditate, do yoga
I practice positive self talk
I try to change my beliefs
I avoid what’s making me anxious
I take drugs/alcohol/other addictions
I try to change what is causing me anxiety
From a behavioral perspective…
Everything we do is to
 Get something good, or avoid something bad!
Feeling Anxious is something bad!
Sometimes we avoid all situations that may
bring on anxiety
And if we cant avoid the situation, we do
things to help us cope.
Some of the things we do are good, other
things are bad!
How do I deal with Anxiety?
Good Coping Strategies
I distract myself
I keep myself busy
I talk to my friends/gain
reassurance
I pray
I take medications to help
me
I exercise
I breath, meditate, do yoga
I practice positive self talk
I try to change my beliefs
Bad Coping Strategies
I avoid what’s making me
anxious
I take drugs/alcohol/other
addictions
I try to change what is
causing me anxiety
With all these coping strategies,
what are we trying to gain?
Avoid or reduce the anxiety
Find other things that are rewarding so they
replace the anxiety
Gain better understanding of what’s causing
us anxiety
Change our perceptions and beliefs so we
have less anxiety
If our children with ASD felt anxious,

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
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Would we know it?
How would they show us?
What ways do they have to cope?
What techniques do they know to calm
themselves?
 Can we help reduce what causes them anxiety
to begin with?
Our goal is to…
Recognize anxiety in our children
Help them recognize what makes them
anxious
Help them find good coping strategies
Help them feel confident enough to
approach situations they feel anxious about
Help them overcome their anxieties
Help them find ways to reward themselves
What is Anxiety
Panic Disorder
Separation Anxiety Disorder
Specific Phobia
Social Phobia
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Generalized Anxiety Disorder
DSM IV definitions of Anxiety
Panic Disorder: Recurrent and unexpected
panic attacks.
Separation Anxiety Disorder:
Developmentally inappropriate and
excessive anxiety surrounding separation
from home or from significant attachment
figures
Specific Phobia: a significant anxiety
provoked by exposure to a feared object,
often leads to avoidance
DSM IV definitions of Anxiety
Social Phobia: a significant anxiety
provoked by exposure to social or
performance situations, which often leads to
avoidance
Obsessive Compulsive Disorder: obsessions
that cause marked distress and/or
compulsions which are performed to
neutralize anxiety
DSM IV definitions of Anxiety
Post Traumatic Stress Disorder: the reexperiencing of an extremely traumatic
event accompanied by increased arousal and
avoidance of stimuli related to the trauma
Generalized Anxiety Disorder: At least 6
months of persistent and excessive anxiety
and worry
How many of these do individuals with
ASD experience?
What is ASD?
Autism
 Delays in Communication
 Delays in Social Skills
 Stereotyped Repetitive Behaviors
Asperger’s Syndrome
 No Delays in Communication
Pervasive Developmental Disorder NOS
 Same as Autism but fewer than 6 symptoms
Why would individuals with ASD have
Anxiety?
Symptoms of ASD lead directly to anxiety:
 Not understanding what’s going on around
them
 Not being able to attend to important things
 Fear of failure
 Feeling like they don’t fit in
 Not knowing how to handle social situations
 Not understanding what is expected of them
Underlying reasons in ASD lead to Anxiety:
 Not getting enough sleep
 Not feeling well due to underlying GI issues
 Sensory overload
 Being on medications that can agitate or cause a
sensation of anxiety
 Receiving treatments that can increase anxiety
 Imbalances in neurotransmitters
 Abnormal activity levels in certain parts of the
brain
Signs of Anxiety in ASD
Ritualistic Behavior
 Obsessive Compulsive Behavior
• Lining up objects (control of the environment)
• Hoarding (safety)
• Body Rocking (parasympathetic activation)
 Physiological Responses
• No sleep
• Irritable bowel or other GI issues
• Hives
 Avoidant Behaviors
•
•
•
•
Self isolation
No eye contact
Social avoidance
Self stimulatory behaviors
Anxiety and avoidance in infants and toddlers
with autism spectrum disorders: Evidence
for differing symptom severity and
presentation
Thompson E Davis III, Jill C. Fodstad,
Whitney S. Jenkins, Julie A. Hess, Brittany N.
Moree, Tim Dempsey, Johnny L. Matson
Research in Autism Spectrum Disorders 4 (2010) 305-313
Results: Toddlers with AD had more severe anxious
and avoidant symptoms than those with PDD NOS
or with controls (other developmental disorders)
Avoidance Behavior
Item Description
Autism
(n=159),
M (SD)
PDDNOS
(n=
154),
M (SD)
Control
(n
=200),
M (SD)
Fear of being around others in
school, at home, or in social
situations
0.27
0.16
0.07
Avoids specific situations,
people, or events
0.36
0.12
0.02
Unreasonable fear of
approaching or touching
specific objects, people, or
items
0.39
0.23
0.09
Withdraws or removes him/her
self from social situations
0.75
0.28
0.07
20
Avoidance Behavior
Item Description
Autism
(n=159),
M (SD)
PDDNOS (n=
154),
M (SD)
Control
(n
=200),
M (SD)
Avoids specific objects, persons,
or situations causing interference
with his/her normal routine
0.23
0.06
0.02
Persistent fear that is not age
appropriate
0.13
.012
0.02
Exposure to specific
0.26
objects/situations provokes
immediate distress that is not age
appropriate
0.12
0.02
Presentation of a specific object
or situation results in loss of
control, panic, or fainting
0.11
0.06
0.01
Trembles or shakes in the
presence of specific objects or
situations
0.94
0.08
0.06
21
Anxiety/Repetitive Behavior
Item Description
Autism
(n=159),
F (%)
PDDNOS
(n=
154),
F (%)
Control
(n=200)
,
F (%)
Engages in repetitive mental
acts for no apparent reason
0.06
0.05
0.02
Sudden, rapid, repetitive
movement or vocalization that
occur for no apparent reason
0.28
0.08
0.01
Repetition of actions or words to
reduce stress
0.31
0.21
0.05
Sudden, rapid, repetitive
movements or vocalization that
are not associated with a
disability
0.21
0.05
0.03
22
Anxiety/Repetitive Behavior
Item Description
Autism
(n=159),
F (%)
PDDNOS
(n=
154),
F (%)
Control
(n=200),
F (%)
Ordering of objects for no
apparent reason or to reduce
stress
0.22
0.08
0.01
Persistent or recurring impulses
that interfere with activities
0.25
0.12
0.03
Engages in repetitive behaviors
for no apparent reason or to
reduce stress
0.44
0.12
0.35
Checking on play objects
obsessively
0.19
0.07
0.03
Trembles or shakes in the
presence of specific objects or
situations
0.94
0.08
0.06
Has difficulty organizing tasks,
activities, and belongings
0.23
0.10
0.02
23
Summary of research findings
Studies show that individuals with ASD
experience greater levels of anxiety than
community populations, regardless of their
age!
Individuals with ASD show greater levels
of anxiety than individuals within other
clinical groups (DD, ADHD, MR)
Individuals with ASD show similar levels
of anxiety when compared to individuals
with a diagnosis of clinical Anxiety!!
Co-morbidity incidence rates of
Anxiety and ASD
Prevalence of Anxiety in ASD ranges from
11% to 84%!!
Most studies estimate prevalence of about
40-50%
Children with more severe ASD have more
anxiety than those less affected.
Why is it hard to dx Anxiety in
Individuals with ASD?
Diagnostic Overshadowing
 We attribute the anxiety to the autism
 We ignore the co-morbid issues because the
main diagnosis of autism is more debilitating
Anxiety is often misunderstood as a
behavior problem
The symptoms get mixed up…is he having
avoiding the situation because of his autism,
or is it anxiety?
Recommended ways to assess
for Anxiety
Clinical Interview (may only be possible
with higher functioning individuals)
 Young children with ASD cant identify
emotions well so we need to give them concrete
examples, and teach them about emotions
 Give forced choice, rather than open ended
questions
 Use many visual aids such as pictures of
emotions, emotional thermometer (Atwood)
Recommended ways to assess
for Anxiety
Anxiety Rating Scales
 Stress Survey Schedule for Persons with
Autism and Developmental Disabilities
(Gorden et. al 2001)
 The Autism Co-Morbidity Interview: a semi
structured parent interview
(Leyfer et al 2006)
Recommended ways to assess
for Anxiety
Direct Observations of Anxiety
A Functional Behavior Assessment (FBA)
looks at what happened before and after a
behavior that may be a sign of anxiety
Time for School….Joe Tantrums….Gets sent home
A challenging behavior (tantrum) may begin due to
anxiety, but then become learned due to reinforcement!!!
Noisy Environment....Tom lines up toys….Tom Avoids
Is it ok to let Tom avoid the social setting, or is it better to help
him cope with the noisy environment?
Three part contingency
In behavioral theory, every behavior can be
changed if we change the antecedents (what
happened before the behavior) and the
consequences (what happened right after the
behavior!
If we change the antecedents and
consequences, can we reduce the anxiety?
Can we reduce the anxiety without
rewarding challenging behaviors?
Treatments for Anxiety
Psychopharmacology
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SSRI’s
SNRI’s
Azaspirones
Benzodiazepines
Tricyclics
Monoamine Oxidase Inhibitors
All these medications influence our
neurotransmitters and control our ability to
feel anxious
Treatments for Anxiety
Medications that may improve underlying
causes of Anxiety
 GI meds to calm gastrointestinal distress
 Sleep medications to help alleviate sleep
deprivation
Treatments for Anxiety
Cognitive Behavior Therapy
 Aims to create new coping templates by using
behavioral techniques such as
• Modeling
• Exposure
• Relaxation Training
 And teaches cognitive techniques to reduce
cognitive distortions and deficiencies
4 Components of CBT
Assessment
Psychoeducation
Restructuring
Exposure
CBT: Assessment
Need to determine what is causing the
anxiety (real or imagined, concrete or
abstract)
Need to determine when it is occurring
(what are the environmental triggers or
antecedents?)
Need to determine how it is being
maintained (consequences)
Need to establish a hierarchy from most
anxiety provoking to least.
CBT: Psychoeducation
Teaching New Skills
Skills that help us cope with Anxiety
 Relaxation exercises/ deep breathing
 Guided Meditation
 Contingency Management
Skills that help us understand better so we
do not experience Anxiety
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Social skills training
Cognitive reasoning
Planning
Perspective Taking
CBT: Cognitive Restructuring
Identifying our negative thoughts
Identifying anxious self talk
Identifying perceived threats
Identifying negative self evaluation
Understanding that our thoughts influence
our feelings!
CBT: Exposure
Eliciting the anxiety provoking thought (or
situation) while practicing extinction of
avoidance behavior and habituation to
excessive or maladaptive physiological
responses!!
Which means: Facing the Fear!
Exposure
Systematic Desensitization
 3 components
• Exposure to a hierarchy of anxiety provoking
images or experiences
• Relaxation, imagery and breathing
• Pairing
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Begin with lowest item on hierarchy
Begin with imagination not in vivo
Pair with relaxation until mastered
Go up the hierarchy gradually until all mastered
Then do in vivo
Copy Cat Workbook (Kendall 1992)
5 sessions assessment and psychoeducation
 Building rapport
 Orienting to treatment
 Explaining, in child language, the nature of the problem
 Identifying anxious feelings and responses
 Teaching child relaxation techniques
5 sessions on cognitive restructuring
 Identifying anxious self talk
 Identifying challenging thoughts
 Teaching Self evaluation
 Teaching Self reward
5 sessions of graduated exposure
1 session on generalization
Applying CBT to Autism
With more affected individuals, the
preferred order is




Exposure
Relaxation
Cognitive Restructuring
Modeling
Along with
 Social skills training
 Goal setting
 Parent Psychoeducation
CBT Modifications for ASD
Pay attention to the deficits caused by the
ASD
 If the individual doesn’t have social skills,
teach them
 If the individual would be less anxious with
better adaptive skills, teach them
 If the individual would be less anxious with
better regulation of sensory input, work on this
CBT Modifications for ASD
Use many Visual stimuli
 Toolbox (can hold strategies)
 Written Schedules (reduce anxiety of not knowing what
is coming next)
 Narratives (I am the boss, anxiety is not the boss)
 Stories
 Role Play
 Choice Lists
 Drawings (thought bubbles, cartoons)
 Visual Worksheets with response lists
 Rules lists of emotion to coping
 Rules lists of what’s normal and what’s excessive
CBT Modifications for ASD
Use concepts that the individual likes or is
interested in
 Astronauts exploring a new planet
 Harrison Ford obsession: what would he do/Star wars cartoons
Use Self Stimulatory behavior as a way to reward/self
calm: The Premack Principle
 Allow non preferred activities to reward preferred activities
Develop socially acceptable compulsions
 Organizing
Finally…
Parent Anxiety perpetuates Child Anxiety!
Heal yourselves
Stress is when we don’t agree with reality!
 Our minds find a way to obsess over how
reality is different from what we wanted
 Our minds find a way to obsess about how
present reality can lead to a worse reality in the
future!
We all have something we are afraid of!!
What is Fear?
Fear only comes when we allow our past
experiences to color our perceptions of the
present, and produce apprehension about
the future!
Question the beliefs you have. You will
find that the universe has a plan for you.
One that is far greater than what you had
imagined.
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