Anxiety

Anxiety and autism

Anxiety and autism go hand in hand and it is more prevalent in children with autism because they have difficulty making sense of the world around them and understanding social rules, and tend to be more rigid. There are lots of different possible causes of anxiety, which makes it very difficult for parents to know what to do or how to react.

We all experience anxiety, it is part of our everyday life and we all react to stressful situations in a way which is personal to us, but the symptoms of anxiety are often similar. Think of a time when you have felt anxious, you may have experienced feelings such as being scared, panic, increased heart rate, sweating, sickness, not knowing where to turn or what to do next, loss of confidence etc. These are unpleasant feelings and can impact our mood, energy levels and behaviour, so imagine what it must be like to feel anxious every day of your life but not understand why.

Reasons

Children with ASD experience anxiety for a variety of reasons, which can include:

• meeting strangers
• being given too many choices
• not being able to communicate their needs
• changes in routine
• new activities or places
• experiencing unpleasant sensations, for example, dog barking, flashing lights, crowded and noisy environments, overpowering smells (not being able to ‘filter out’ background sensory experiences)
• transitioning from one activity to another — even small transitions
• trauma - remembering unpleasant events, for example, having a haircut, seeing the dentist or doctor, which when being asked to repeat makes them anxious.

Reality for a child with autism

"Reality to an autistic person is a confusing, interacting mass of events, people, places, sounds and sights. There seem to be no clear boundaries, order or meaning to anything. A large part of my life is spent just trying to work out the pattern behind everything. Set routines, times, particular routes, and rituals all help to get order into an unbearably chaotic life. Trying to keep everything the same reduces some of the terrible fear."

(Terese Joliffe et al, 1992,  Jolliffe, T., Lansdown, R., Robinson, C., 1992. Autism: a personal account. Communication 26, 12– 19.)

Sometimes, children with ASD can be anxious about more than one thing at a time causing overload, which could then lead to extreme anxiety behaviours or behavioural outbursts.

Below is the analogy of a bucket overflowing. When levels of anxiety get too high it can result in  extreme anxiety and inappropriate behaviour.

Cognitive Behavioural Therapy (CBT)

Cognitive Behavioural Therapy (CBT) is a psychological intervention for mental health difficulties such as anxiety and depression. It is based on the idea that how we think, how we feel, and how we act, affect each other.

CBT uses techniques to help people become more aware of how they reason, so that they can change how they think and therefore how they behave.

CBT is likely to work only for those individuals who have both the capacity and the preference for monitoring and managing their own behaviour. It is therefore more likely to work for high-functioning individuals with autism or Asperger syndrome who are more than 8 years old without significant learning difficulties. There is good evidence to show that adapted CBT for anxiety can be helpful for anxious young people with ASD.

Top tips

• Always consider anxiety levels when deciding how to manage your child’s behaviour or when introducing them to change or new activities.
• Be empathetic - remember how it feels when you are anxious.
• Allow for the autism - be patient and tolerant.
• Maintain a neutral and calm tone of voice - your own anxiety, anger or frustration can make a child more anxious.
• Keep a diary of your child’s behaviour and you may be able to identify a trigger for their anxiety.
• Establish routines and stick to them. If you do need to change a routine, provide your child with as much notice that is possible. Explain what is going to happen instead. Visual supports to explanations useful.
• Small transitions can be a big deal to a child with ASD eg taking a bath and then cleaning teeth straight away might cause anxiety. Allow time between activities wherever you can.
• Give one instruction at a time.
• Give your child time to process information.
• ‘Fiddle toys’ such as stress balls, play dough, etc may help a child to lower their anxiety levels.
• If your child is upset, distressed or behaving in a challenging way, consider whether this is being caused by sensory issues. Sometimes it may be the fear of what might happen which will make them anxious.
• Identify a ‘safe place’ that your child can go to when they are feeling anxious, for example their bedroom. Provide your child with a time out mechanism for when things are getting too much. Use of a ‘time out’ or ‘break’ card can be useful or even coloured cards to relay how they feel. For example, red might mean time out now, green might mean okay for now. Alternatively, you could have a verbal code or hand gesture. If your child is older you could try teaching them an anxiety scale using numbers, for example, 1 = calm, 2 = very happy, 3 = feeling worried, 4 = very anxious, 5 = extreme anxiety behaviours.
• If your child has a way of calming themselves which you find difficult or annoying, be tolerant as your child is doing this to reduce the unpleasant feelings they are experiencing.
• Help your child to understand social rules. Social stories or visual structures can be helpful.