Anxiety And Autism Research Paper
Autism and Anxiety
Autism is a developmental disorder that usually appears within the first three years of a child’s life and affects approximately four times as many boys as girls (Levy, Mandell & Schultz, 2009). Autism spectrum disorders are characterized by deficits in social interaction, communication and stereotyped or repetitive behaviours, and the range of severity varies (Levy et al., 2009). Anxiety disorders are one of the most common disorders in childhood, and although precise statistics vary, anxiety disorders are especially present among individuals with autism (Reaven, 2009). Estimates show that the prevalence of anxiety in individuals with Autism Spectrum Disorders (ASD) ranges from 11-84% (White et al., as cited in Lang, Regester, Lauderdale, Ashbaugh and Haring, 2010). Studies indicate that anxiety …show more content…
disorders are more common among children with autism than typically developing children (Lang et al., 2010). Anxiety is a concern because it can interfere with a child’s participation across many different settings and disrupt educational opportunities (Reaven, 2009).
Symptoms
According to APA (2000), anxiety disorders is an umbrella term for a number of different disorders, which are all characterized by inappropriate or abnormal anxiety. Everyone experiences symptoms of anxiety, but anxiety becomes a problem when symptoms are experienced without the presence of a stimulus evoking them or the stimulus evoking the symptoms should not lead to such an extreme reaction (APA, 2000). Different types of anxiety disorders include generalized anxiety disorder, specific phobias, social phobia, separation anxiety disorder, obsessive-compulsive disorder, and post traumatic stress disorder (APA, 2000). Common symptoms of anxiety include: “difficulties separating from parents, marked and excessive fearful responses to objects or events, excessive avoidance, somatic complaints, presence of distressing thoughts, concentration difficulties, restlessness, fatigue, irritability, sleep disturbance, and psychological over reactivity” (DSM as cited in Reaven, 2009). Reaven, 2009 states that it may be difficult to determine whether a child is experiencing normal anxiety symptoms, or anxiety symptoms that are abnormal and warrant a diagnosis. If the symptoms of anxiety stop over time and are justifiable in context, they are probably normal, but if the symptoms are long lasting and unreasonable in context, the symptoms may warrant the diagnosis of an anxiety disorder (Chansky, 2004 as cited in Reaven, 2009).
Assessment
Most research on assessment techniques for anxiety has been conducted on typically developing children (Hagopian & Jennett, 2008). The assessment of anxiety for typically developing children includes: interviews, rating scales, direct observations and self-monitoring (Silverman & Ollendick, 2005). According to Silverman et al., (2005) interviews can be structured or semi-structured, and they help aid in the development of rating scales. Based on the information obtained from interviews, clinicians can develop rating scales to rate the severity anxiety. Although there are limits to interviews such as subjectivity, interviews are often used in conjunction with other assessment techniques. Direct observations are mainly used for looking at the impact of the family context on anxiety, and self-monitoring is used more frequently than direct observation. Self-monitoring is often used to evaluate treatment outcome, but it is also used during the assessment phase (Silverman et al., 2005). Since most assessment techniques are created for use with typically developing children, they may not be appropriate for children with autism (Reaven, 2009). According to Reaven (2009), because of deficits in cognition or communication, individuals with autism may not be able to communicate their symptoms to a clinician. Modifications have been made to assessment tools in order to make the applicable to children with autism. Information usually collected via interviewing the child has been administered to the parents of children with autism instead. Although the modification of assessment techniques is still emerging, reports indicate that revised assessment techniques have been effectively applied to children with autism (Reaven, 2009). Wood et al., (2009) states that clinicians must be careful not to confuse behaviours found in children with autism as being signs of anxiety. Children with autism often display stereotyped or repetitive behaviours, which must not be confused with compulsions found in obsessive-compulsive disorder.
Etiology
Research indicates that here may be a relation between the social deficits that are found in autism and anxiety (White, Ollendick, Scahill, Oswald & Albano, 2009). Bellini (2006) conducted a study to examine the relation between social deficits, physiological arousal and anxiety. Results of the study indicated that the combination of social deficits and physiological arousal contributes to anxiety in individuals with autism. The researcher did not tease out social deficits and physiological arousal separately, so it is difficult to say whether social deficits, physiological arousal, or the combination of both was responsible for the anxiety. It is possible that social deficits or physiological arousal alone was responsible for the increased levels of anxiety. White and Roberson-Nay (2009) conducted a study to examine the connection between social skills impairment, anxiety and loneliness in individuals with autism. Results of the study indicated that there was a connection between level of anxiety and reports of social loneliness. Individuals with high anxiety scores scored higher on reports of loneliness than individuals with less anxiety. Information about social deficits, depression and withdrawal were obtained via parent report, and results indicated that there was a relationship between the parents’ reports of withdrawal and depression and social deficits. Anxiety disorders present themselves later in autism than in typically developing children (White et al., 2009). This may be because of the fact that as an individual gets older, they become more aware of their social impairments, and as the reach teenage years, they may want to form social relationships but recognize that they do not have the skills necessary to do so (White et al., 2009). Overall, research suggests that social skills deficits may be a contributing factor to anxiety in individuals with autism (White, et al., 2009; Bellini, 2006; White & Roberson-Nay, 2009). When looking at the relation between social deficits and anxiety, it is important to keep in mind that correlation does not equal causation and conclusions cannot be made that social deficits cause anxiety. It is also possible that increased levels of anxiety cause social deficits. If a child is anxious, they may be missing out on opportunities that lead to the development of social skills (Myles, 2003 as cited in White & Roberson-Nay, 2009). Other researchers propose that anxiety in autism is due to abnormalities in the amygdala (Juranek, Filipek, Berenji, Modahl, Osann & Spence, 2006; Schumann, Bauman & Amaral, 2011). Schumann et al., (2011) states that the amygdala differences are present in many developmental disorders, leading them to be characterized by either increased anxiety ore increased risk. Juranek et al., (2006) conducted a study to examine the association between amygdala volume and anxiety scores in children with autism. Anxiety scores were obtained via the Child Behaviour Checklist and information about amygdala volume was obtained from MRIs. Results of the study indicated that symptoms of anxiety were related to increased volume in the amygdala.
Treatment
Cognitive Behaviour Therapy (CBT) is a treatment that is often used for children with autism and anxiety (White et al., 2010, White et al., 2009; Lang et al., 2009; Wood, et al., 2008). Aspects of CBT treatment vary, but generally a treatment package includes: externalizing the symptoms, becoming aware of behaviour problems caused by the anxiety, listing anxiety stimulating contexts and teaching coping behaviours (Lang et al., 2009). According to White et al., (2009) adaptations have been made to CBT to make it more useful for individuals with autism. Adaptations include increased structure, visual supports, and increased parent involvement (White et al., 2009). Chalfant, Rapee and Carroll (2006) took a CBT intervention designed for typically developing children and adapted it for children with autism. The treatment used was called the “Cool Kids” program and it was used as a group treatment program. Adaptations included a longer time period, increased visual support and structured worksheets. One aspect of this program was to make children become aware of their anxious feelings. It also involved coping strategies, self-talk, relaxation strategies and exposure to anxiety provoking situations or stimuli. Four sessions were designated to teaching skills, and the rest of the sessions were spent practicing the skills. White et al., (2009) conducted a study in which CBT was used to treat anxiety in four individuals with ASD. Treatment involved CBT with additional parent education and social skills training. Results of the study indicated that treatment was successful in decreasing anxiety in three of the participants and social skills improved for all four participants. Wood et al., (2008) also conducted a study, which supports the effectiveness of CBT as an intervention for anxiety in children with autism. This study was conducted on forty children ages 7-11. In this study, the researchers adapted a CBT program normally used for typically developing children, and made it appropriate for children with autism. Adaptations were made to account for the social and adaptive skill impairments in children with autism. Results of this study showed that the CBT treatment package was effective at decreasing anxiety in participants with autism. Lang et al., (2009) reviewed nine studies, which used CBT to treat anxiety in individuals with autism. Strict inclusion criteria were used to decide which studies were included in this review. Inclusion criteria were based around the participants, treatment procedures, dependent variables, and results of intervention and certainty of the evidence. A review of these studies indicated that CBT is an effective treatment for anxiety in children with high functioning autism, but studies involving lower functioning individuals are limited.
Controversy
According to White and Roberson-Nay (2009) there are problems around the assessment of anxiety in individuals with autism. One problem is the fact that anxiety symptoms may be expressed differently in children with autism than in typically developing children. Also, because of communication impairments, it may be difficult for children with autism to self-report symptoms of anxiety (White & Roberson-Nay, 2009). Although estimates have been made with regards to the percentage of children with autism who also have anxiety, calculations may be confounded by the difficulties experienced in assessment. It might also be the case that many instances of anxiety are not assessed because the child is unable to communicate their anxiety symptoms to a parent or other individuals who might refer them to assessment. An adult might also confuse symptoms of anxiety as being symptoms of autism. Another problem with regards to autism and anxiety is the fact that standard CBT techniques many not be appropriate for children with autism who have particular deficits. Introspection is a technique commonly used in CBT, which requires the ability to recognize thoughts and feelings, and children with autism have difficulty doing so (Lang et al., 2010). Although modifications have been made to standard CBT techniques, research in this area is limited (Lang et al., 2010). Most research on anxiety has been conducted on typically developing children, and research around anxiety and autism is limited. Future research is needed to establish the effectiveness of assessment techniques and interventions for individuals with autism and anxiety. Although current research is limited, high numbers of individuals with autism also experience anxiety, and the importance of research in this area has been recognized (Reaven, 2009).
References
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders-fourth edition, text revision. Washington, DC: American Psychiatric Association.
Bellini, S. (2006). The development of social anxiety in adolescents with autism spectrum disorders. Focus on Autism & Other Developmental Disabilities, 21(3), 138-145.
Chalfant, A., Rapee, R., & Carroll, L. (2007). Treating anxiety disorders in children with high functioning autism spectrum disorders: A controlled trial. Journal of Autism & Developmental Disorders, 37(10), 1842-1857.
Hagopian, L. P., & Jennett, H. K. (2008). Behavioral assessment and treatment of anxiety in individuals with intellectual disabilities and autism. Journal of Developmental & Physical Disabilities, 20(5), 467-483.
Juranek, J., Filipek, P. A., Berenji, G. R., Modahl, C., Osann, K., & Spence, M. (2006). Association between amygdala volume and anxiety level: Magnetic resonance imaging (MRI) study in autistic children. Journal of Child Neurology, 21(12)
Lang, R., Regester, A., Lauderdale, S., Ashbaugh, K., & Haring, A. (2010). Treatment of anxiety in autism spectrum disorders using cognitive behaviour therapy: A systematic review. Developmental Neurorehabilitation, 13(1), 53-63.
Levy, S., Mandell, D., & Schultz, R.
(2009). Autism. Lancet, 374(9701), 1627-1638.
Reaven, J. A. (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.
Schumann, C. M., Bauman, M. D., & Amaral, D. G. (2011). Abnormal structure or function of the amygdala is a common component of neurodevelopmental disorders. Neuropsychologia, 49(4), 745-759.
Silverman, W. K., & Ollendick, T. H. (2005). Evidence-based assessment of anxiety and its disorders in children and adolescents. Journal of Clinical Child & Adolescent Psychology, 34(3), 380-411.
White, S. W., Ollendick, T., Scahill, L., Oswald, D., & Albano, A. (2009). Preliminary efficacy of a cognitive-behavioral treatment program for anxious youth with autism spectrum disorders. Journal of Autism & Developmental Disorders, 39(12), 1652-1662.
White, S. W., & Roberson-Nay, R. (2009). Anxiety, social deficits, and loneliness in youth with autism spectrum disorders. Journal of Autism & Developmental Disorders, 39(7),
1006-1013
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 & Psychiatry, 50(3), 224-234.
Autism is a developmental disorder that usually appears within the first three years of a child’s life and affects approximately four times as many boys as girls (Levy, Mandell & Schultz, 2009). Autism spectrum disorders are characterized by deficits in social interaction, communication and stereotyped or repetitive behaviours, and the range of severity varies (Levy et al., 2009). Anxiety disorders are one of the most common disorders in childhood, and although precise statistics vary, anxiety disorders are especially present among individuals with autism (Reaven, 2009). Estimates show that the prevalence of anxiety in individuals with Autism Spectrum Disorders (ASD) ranges from 11-84% (White et al., as cited in Lang, Regester, Lauderdale, Ashbaugh and Haring, 2010). Studies indicate that anxiety …show more content…
disorders are more common among children with autism than typically developing children (Lang et al., 2010). Anxiety is a concern because it can interfere with a child’s participation across many different settings and disrupt educational opportunities (Reaven, 2009).
Symptoms
According to APA (2000), anxiety disorders is an umbrella term for a number of different disorders, which are all characterized by inappropriate or abnormal anxiety. Everyone experiences symptoms of anxiety, but anxiety becomes a problem when symptoms are experienced without the presence of a stimulus evoking them or the stimulus evoking the symptoms should not lead to such an extreme reaction (APA, 2000). Different types of anxiety disorders include generalized anxiety disorder, specific phobias, social phobia, separation anxiety disorder, obsessive-compulsive disorder, and post traumatic stress disorder (APA, 2000). Common symptoms of anxiety include: “difficulties separating from parents, marked and excessive fearful responses to objects or events, excessive avoidance, somatic complaints, presence of distressing thoughts, concentration difficulties, restlessness, fatigue, irritability, sleep disturbance, and psychological over reactivity” (DSM as cited in Reaven, 2009). Reaven, 2009 states that it may be difficult to determine whether a child is experiencing normal anxiety symptoms, or anxiety symptoms that are abnormal and warrant a diagnosis. If the symptoms of anxiety stop over time and are justifiable in context, they are probably normal, but if the symptoms are long lasting and unreasonable in context, the symptoms may warrant the diagnosis of an anxiety disorder (Chansky, 2004 as cited in Reaven, 2009).
Assessment
Most research on assessment techniques for anxiety has been conducted on typically developing children (Hagopian & Jennett, 2008). The assessment of anxiety for typically developing children includes: interviews, rating scales, direct observations and self-monitoring (Silverman & Ollendick, 2005). According to Silverman et al., (2005) interviews can be structured or semi-structured, and they help aid in the development of rating scales. Based on the information obtained from interviews, clinicians can develop rating scales to rate the severity anxiety. Although there are limits to interviews such as subjectivity, interviews are often used in conjunction with other assessment techniques. Direct observations are mainly used for looking at the impact of the family context on anxiety, and self-monitoring is used more frequently than direct observation. Self-monitoring is often used to evaluate treatment outcome, but it is also used during the assessment phase (Silverman et al., 2005). Since most assessment techniques are created for use with typically developing children, they may not be appropriate for children with autism (Reaven, 2009). According to Reaven (2009), because of deficits in cognition or communication, individuals with autism may not be able to communicate their symptoms to a clinician. Modifications have been made to assessment tools in order to make the applicable to children with autism. Information usually collected via interviewing the child has been administered to the parents of children with autism instead. Although the modification of assessment techniques is still emerging, reports indicate that revised assessment techniques have been effectively applied to children with autism (Reaven, 2009). Wood et al., (2009) states that clinicians must be careful not to confuse behaviours found in children with autism as being signs of anxiety. Children with autism often display stereotyped or repetitive behaviours, which must not be confused with compulsions found in obsessive-compulsive disorder.
Etiology
Research indicates that here may be a relation between the social deficits that are found in autism and anxiety (White, Ollendick, Scahill, Oswald & Albano, 2009). Bellini (2006) conducted a study to examine the relation between social deficits, physiological arousal and anxiety. Results of the study indicated that the combination of social deficits and physiological arousal contributes to anxiety in individuals with autism. The researcher did not tease out social deficits and physiological arousal separately, so it is difficult to say whether social deficits, physiological arousal, or the combination of both was responsible for the anxiety. It is possible that social deficits or physiological arousal alone was responsible for the increased levels of anxiety. White and Roberson-Nay (2009) conducted a study to examine the connection between social skills impairment, anxiety and loneliness in individuals with autism. Results of the study indicated that there was a connection between level of anxiety and reports of social loneliness. Individuals with high anxiety scores scored higher on reports of loneliness than individuals with less anxiety. Information about social deficits, depression and withdrawal were obtained via parent report, and results indicated that there was a relationship between the parents’ reports of withdrawal and depression and social deficits. Anxiety disorders present themselves later in autism than in typically developing children (White et al., 2009). This may be because of the fact that as an individual gets older, they become more aware of their social impairments, and as the reach teenage years, they may want to form social relationships but recognize that they do not have the skills necessary to do so (White et al., 2009). Overall, research suggests that social skills deficits may be a contributing factor to anxiety in individuals with autism (White, et al., 2009; Bellini, 2006; White & Roberson-Nay, 2009). When looking at the relation between social deficits and anxiety, it is important to keep in mind that correlation does not equal causation and conclusions cannot be made that social deficits cause anxiety. It is also possible that increased levels of anxiety cause social deficits. If a child is anxious, they may be missing out on opportunities that lead to the development of social skills (Myles, 2003 as cited in White & Roberson-Nay, 2009). Other researchers propose that anxiety in autism is due to abnormalities in the amygdala (Juranek, Filipek, Berenji, Modahl, Osann & Spence, 2006; Schumann, Bauman & Amaral, 2011). Schumann et al., (2011) states that the amygdala differences are present in many developmental disorders, leading them to be characterized by either increased anxiety ore increased risk. Juranek et al., (2006) conducted a study to examine the association between amygdala volume and anxiety scores in children with autism. Anxiety scores were obtained via the Child Behaviour Checklist and information about amygdala volume was obtained from MRIs. Results of the study indicated that symptoms of anxiety were related to increased volume in the amygdala.
Treatment
Cognitive Behaviour Therapy (CBT) is a treatment that is often used for children with autism and anxiety (White et al., 2010, White et al., 2009; Lang et al., 2009; Wood, et al., 2008). Aspects of CBT treatment vary, but generally a treatment package includes: externalizing the symptoms, becoming aware of behaviour problems caused by the anxiety, listing anxiety stimulating contexts and teaching coping behaviours (Lang et al., 2009). According to White et al., (2009) adaptations have been made to CBT to make it more useful for individuals with autism. Adaptations include increased structure, visual supports, and increased parent involvement (White et al., 2009). Chalfant, Rapee and Carroll (2006) took a CBT intervention designed for typically developing children and adapted it for children with autism. The treatment used was called the “Cool Kids” program and it was used as a group treatment program. Adaptations included a longer time period, increased visual support and structured worksheets. One aspect of this program was to make children become aware of their anxious feelings. It also involved coping strategies, self-talk, relaxation strategies and exposure to anxiety provoking situations or stimuli. Four sessions were designated to teaching skills, and the rest of the sessions were spent practicing the skills. White et al., (2009) conducted a study in which CBT was used to treat anxiety in four individuals with ASD. Treatment involved CBT with additional parent education and social skills training. Results of the study indicated that treatment was successful in decreasing anxiety in three of the participants and social skills improved for all four participants. Wood et al., (2008) also conducted a study, which supports the effectiveness of CBT as an intervention for anxiety in children with autism. This study was conducted on forty children ages 7-11. In this study, the researchers adapted a CBT program normally used for typically developing children, and made it appropriate for children with autism. Adaptations were made to account for the social and adaptive skill impairments in children with autism. Results of this study showed that the CBT treatment package was effective at decreasing anxiety in participants with autism. Lang et al., (2009) reviewed nine studies, which used CBT to treat anxiety in individuals with autism. Strict inclusion criteria were used to decide which studies were included in this review. Inclusion criteria were based around the participants, treatment procedures, dependent variables, and results of intervention and certainty of the evidence. A review of these studies indicated that CBT is an effective treatment for anxiety in children with high functioning autism, but studies involving lower functioning individuals are limited.
Controversy
According to White and Roberson-Nay (2009) there are problems around the assessment of anxiety in individuals with autism. One problem is the fact that anxiety symptoms may be expressed differently in children with autism than in typically developing children. Also, because of communication impairments, it may be difficult for children with autism to self-report symptoms of anxiety (White & Roberson-Nay, 2009). Although estimates have been made with regards to the percentage of children with autism who also have anxiety, calculations may be confounded by the difficulties experienced in assessment. It might also be the case that many instances of anxiety are not assessed because the child is unable to communicate their anxiety symptoms to a parent or other individuals who might refer them to assessment. An adult might also confuse symptoms of anxiety as being symptoms of autism. Another problem with regards to autism and anxiety is the fact that standard CBT techniques many not be appropriate for children with autism who have particular deficits. Introspection is a technique commonly used in CBT, which requires the ability to recognize thoughts and feelings, and children with autism have difficulty doing so (Lang et al., 2010). Although modifications have been made to standard CBT techniques, research in this area is limited (Lang et al., 2010). Most research on anxiety has been conducted on typically developing children, and research around anxiety and autism is limited. Future research is needed to establish the effectiveness of assessment techniques and interventions for individuals with autism and anxiety. Although current research is limited, high numbers of individuals with autism also experience anxiety, and the importance of research in this area has been recognized (Reaven, 2009).
References
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders-fourth edition, text revision. Washington, DC: American Psychiatric Association.
Bellini, S. (2006). The development of social anxiety in adolescents with autism spectrum disorders. Focus on Autism & Other Developmental Disabilities, 21(3), 138-145.
Chalfant, A., Rapee, R., & Carroll, L. (2007). Treating anxiety disorders in children with high functioning autism spectrum disorders: A controlled trial. Journal of Autism & Developmental Disorders, 37(10), 1842-1857.
Hagopian, L. P., & Jennett, H. K. (2008). Behavioral assessment and treatment of anxiety in individuals with intellectual disabilities and autism. Journal of Developmental & Physical Disabilities, 20(5), 467-483.
Juranek, J., Filipek, P. A., Berenji, G. R., Modahl, C., Osann, K., & Spence, M. (2006). Association between amygdala volume and anxiety level: Magnetic resonance imaging (MRI) study in autistic children. Journal of Child Neurology, 21(12)
Lang, R., Regester, A., Lauderdale, S., Ashbaugh, K., & Haring, A. (2010). Treatment of anxiety in autism spectrum disorders using cognitive behaviour therapy: A systematic review. Developmental Neurorehabilitation, 13(1), 53-63.
Levy, S., Mandell, D., & Schultz, R.
(2009). Autism. Lancet, 374(9701), 1627-1638.
Reaven, J. A. (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.
Schumann, C. M., Bauman, M. D., & Amaral, D. G. (2011). Abnormal structure or function of the amygdala is a common component of neurodevelopmental disorders. Neuropsychologia, 49(4), 745-759.
Silverman, W. K., & Ollendick, T. H. (2005). Evidence-based assessment of anxiety and its disorders in children and adolescents. Journal of Clinical Child & Adolescent Psychology, 34(3), 380-411.
White, S. W., Ollendick, T., Scahill, L., Oswald, D., & Albano, A. (2009). Preliminary efficacy of a cognitive-behavioral treatment program for anxious youth with autism spectrum disorders. Journal of Autism & Developmental Disorders, 39(12), 1652-1662.
White, S. W., & Roberson-Nay, R. (2009). Anxiety, social deficits, and loneliness in youth with autism spectrum disorders. Journal of Autism & Developmental Disorders, 39(7),
1006-1013
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 & Psychiatry, 50(3), 224-234.