Understanding and Treating Anxiety

in Individuals with

Autism Spectrum Disorders

Center for Autism and Related Disorders, Inc

Doreen Granpeesheh, Ph.D., BCBA

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, 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 AnxietyPanic 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 AnxietySocial 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 AnxietyPost Traumatic Stress Disorder: the re-experiencing 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 ASDRitualistic 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)

20

Avoidance Behavior

Item Description Autism (n=159),M (SD)

PDD-NOS (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

21

Avoidance Behavior

Item Description Autism (n=159),M (SD)

PDD-NOS (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 objects/situations provokes immediate distress that is not age appropriate

0.26 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

22

Anxiety/Repetitive BehaviorItem Description Autism

(n=159),F (%)

PDD-NOS(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

23

Anxiety/Repetitive BehaviorItem Description Autism

(n=159),F (%)

PDD-NOS (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

Summary of research findingsStudies 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 homeA 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 AnxietyPsychopharmacology 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: PsychoeducationTeaching 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 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!

ExposureSystematic Desensitization 3 components

• Exposure to a hierarchy of anxiety provoking images or experiences

• Relaxation, imagery and breathing • Pairing

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 ASDUse 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 ASDUse 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.