Understanding Anxiety in Autism Spectrum Disorder

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  • Published On: 2-12-2023

Autism Spectrum Disorder (ASD) is referred to as a complex developmental disorder that includes persistent challenges regarding verbal and non-verbal communication, social interaction and restricted behaviour. The impact of ASD and its severity is different in all person (Grove et al., 2019). The emotional well-being of the people with ASD is important because it allows them to have a stable mental state which helps them in recognising and managing their emotions to effectively understand and respond socially to the people. Moreover, the emotional well-being of autistic individuals helps them to feel energised and develop better focus to think and act effectively without exhaustion (Danker et al., 2019). In this study, the overview of typical anxiety and anxiety in Autism Spectrum Disorder (ASD) individuals are to be discussed and the way they are differently represented in each population is to be explained. Moreover, psychological theories and risk factors along with symptoms related to anxiety in Autism Spectrum Disorder (ASD) is to be discussed. Further, the diagnostic tools and assessment for anxiety in AD and implications of emotional well-being in ASD is to be discussed.

Overview of Anxiety

Anxiety is referred to as an emotional condition in which people develops recurring intrusive thoughts and concerns regarding actions in life and are seen to avoid social situation out of being worried. Anxiety mainly develops as a natural response to any emotional stress suffered by the individual (Leichsenring and Leweke, 2017). The symptoms of anxiety disorder include racing thoughts, difficulty to concentrate, uncontrolled and over-thinking, heightened alertness, development of problem with sleeping pattern, change in appetite and others (Rodebaugh et al., 2018). The development of anxiety causes a human body to trigger their flight-or-fight stress response that leads to the release of increased amount of chemicals and hormones like adrenalin in the body. This increase within the body response leads the person to develop increased pulse and breathing rate along with experience lack of reach of oxygen to the brain that affects their emotional control and behaviour (Mossman et al., 2017).


In the global condition as well as in the UK, anxiety disorder is one of the key mental health issues found mostly among young people and people suffering from any mental or emotional disorder (mhfaengland.org, 2019). In 2017, 5.8% people between 5-15 year of age in the UK are found to be suffering from anxiety which was only 3.9% in 2004 (mhfaengland.org, 2019). In 2018-19, it is reported that 1 in 6 workers are seen to suffer from anxiety or depression due to work-related stress and nearly 602,000 adult people in the UK are suffering from anxiety or depression due to stress in life (mhfaengland.org, 2019). Moreover, in the world, in 2017 it is mentioned that nearly 284 million people are mentioned to be suffering from anxiety disorder (ourworldindata.org, 2018). This indicates that anxiety is highly prevalent in the UK as well as globally.

In the study by Vasa and Mazurek (2015), it is mentioned that anxiety is a co-occurring disorder in people with ASD. It is informed that 22-84% of the people with ASD usually suffer from anxiety. In another study by Ung et al. (2013), it is mentioned that out of the 108 high-functioning AD individuals who are mainly children recruited in the study, nearly 91.6% of them are seen to suffer from anxiety disorder. This indicates that presence of anxiety as mood disorder is quite prevalent globally as well as in the UK in normal individual as well as people suffering from ASD. Thus, the current study regarding anxiety in AD individuals is of greater importance understand the way it affects them AD individuals and way to diagnose as well as overcome the condition.

Difference between typical anxiety and anxiety in Autism Spectrum Disorder (ASD)

The presence of typical anxiety in normal individuals and anxiety in people with ASD are caused due to different reason and expressed differentially. The typical anxiety in normal individuals are able to be easily detected due to specific expression of symptoms regarding the mood disorder that can be differentiated from normal mood and emotional activity. This is evident as normal individuals remain socially active and express no challenges with behaviour but with the expression of anxiety they develop and express hindered social behavioural, withdrawal from society and others that are entirely different from the way they normally interact. The sudden change in behaviour is easily detected which leads to early identification and intervention for typical anxiety in normal individuals (Hartwright et al., 2018). However, in case of people with Autism Spectrum Disorder (ASD), it is seen that they express hindered social behaviour and cognitive function already as a result of their mental health condition. The expression of anxiety in this case are often unable to detected properly as they overlap with the symptoms of ASD (Ventola et al., 2017). For example, people with ASD are seen to show repetitive behaviour and with anxiety they may express added insistence to further repeat the same behaviour which is hard to be differentiated (South and Rodgers, 2017).

The presence of typical anxiety in normal individuals is mainly caused due to stress at work, failure in education, executing complicated activities and others (van Steensel and Heeman, 2017). For example, typical anxiety is raised in common people out of stress regarding complex activities at work or studies (van Steensel and Heeman, 2017). However, in case of people with ASD, it is seen that anxiety is raised due to presence of a socially demanding environment where the ASD individuals cannot function effectively out of their hindered social cognition caused by the disorder (South et al., 2017). For instance, the communication impairment in ASD individual leads them to develop anxiety out of the fear of being mocked and abused by others for not being able to meet the social expectations (Smith et al., 2019). The anxiety in people with ASD are also often raised due to presence of specific phobia, obsessive compulsive disorder, separation anxiety and others (Zaboski and Storch, 2018). For instance, ASD people are often seen to be closely related with their parents more intricately compared to normal individuals. This is because the disorder makes them dependent on their parents for making decision regarding their care. In this condition, the separation of ASD individuals from their parents may lead them to become anxious out of fear regarding none to trust in the society whereas normal individual due to their enhanced thinking and cognition capability can overcome the hindrance with separation and avoid showing anxiety (Kerns et al., 2020).

Psychological theories of Autism Spectrum Disorder (ASD)

The psychological theories provide framework regarding the way human thoughts, behaviours and emotions are to be understood (Dieleman et al., 2018). One of the psychological theories regarding Autism Spectrum Disorder (ASD) is social motivation theory. The social motivation theory of autism mentions that presence of early impairment in the mesocorticolimbic reward circuit of the brain in children with autism causes reduction of their motivation regarding social experience. It lowers their ability to experience control over social interaction and the way they pay attention to any social information as they consider them not to be rewarding (Burnside et al., 2017). This set them in a motion of developmental process which deprive them of adequate opportunities regarding social learning that further affects the brain to show hindered behavioural development (Livingston et al., 2019). Thus, the theory explains that lack of prioritisation of the social information in people with ASD from the early stage due to the damaged brain functioning creates cascading effect on them to show hindered social interaction in making communication with other. However, the theory fails to explain and understand the way motivation deficit within the social domain is responsible for expression of anxiety and repetitive behaviour in individuals with ASD (Clements et al., 2018). Thus, in this respect, the Theory of Mind is been explored.

The theory of mind (ToM) in case of ASD individuals mention that autistic children expressed delayed ability to put oneself in the shoes of another to imagine their feelings, attitude and thoughts (Livingston et al., 2019). The normal people who are able to read minds by being other’s shoes are seen to make sense of one’s behaviour as well as imagine set of mental state that can predict the way the other person is going to act towards them (Mazza et al., 2017). However, the inability of the autistic children and individuals to understand one’s action by being in their shoes makes them to develop anxiety. This is because they are unable to understand the cause of action of the other individuals in the society toward them or predict the way the person may react towards them. It leads the children and individuals with ASD remain always uncertain and be anxious due to fear of harm from others as a result of mind blindness of their own (Livingston et al., 2019). For example, deception can be easily understood by a normal 4-year old child (Yang et al., 2017). However, the children with ASD are seen to assume that everyone is telling truth and would appear to get shocked as well as anxious that by the idea that other may not always say what they mean due to their mindblindness caused by the mental disorder (Đorđević et al., 2020).

The strength of ToM for ASD is that it provides effective information regarding the way social anxiety and communication hindrances are raised in individual with ASD. However, the limitation of theory is that it fails to explain regarding the way non-social features affects the people with ASD to express symptoms of the disorder along with anxiety (Livingston et al., 2019). The other psychological theory that explains development of anxiety in ASD individuals is Stress-Transaction theory. The Stress-Transaction theory mentions that psychological stress or anxiety is a certain relationship between person and the environment that is praised by them. The stress or anxiety is developed when the demands of the person exceeds the personal and social resources of the individuals which they are able to mobilise or control (Biggs et al., 2017). In case of individuals with ADS, it is seen that they have limited ability and resource to personally control any social situation because of their hindered social cognition ability. This leads them to develop anxiety as their ability to socially manage situation is found to exceed their personal resources (Biggs et al., 2017). For example, when a normal person feels stressed or anxious regarding a situation, they talk with their relatives or access therapy to overcome the situation. However, in case of individuals with ASD, on facing anxiety regarding any situation they are seen unable to access help or inform regarding the condition because of their hindered communication and cognition ability. It leads them to have lack of resources that exceeds their demands of accessing help from avoiding anxiety (Biggs et al., 2017).

Risk factors and symptoms of Autism Spectrum Disorder (ASD)

One of the risk factors related to Autism Spectrum Disorder (ASD) which poses vulnerability of anxiety for the ASD individuals is lack of friendship in the social environment. This is because lack of friendship leads the ASD child or individual to feel lonely and unwanted in the society which links with their development of anxiety in social situations. It is evident as without friendship the autistic individual become socially isolated which lead them to have limited opportunity in making new friends or understanding the way to react in social situation by overcoming their hindrance in communicating with others (Campisi et al., 2018). This fact can be related to Stress-Transaction Theory regarding autism where it is mentioned that autistic individuals develop stress or anxiety when their personal resources exceed their environmental needs (Biggs et al., 2017). In this case, the presence of friendship or supportive social relation for the ASD child may acted as a personal resource to be used as an experience for overcoming social anxiety in the environment. However, the lack of resource exceeds the autistic individual’s ability to overcome the language skill barrier and understating what other say, in turn, making them develop anxiety and failure in making social connections (Sharma et al., 2018).

The other vulnerability faced by people with ASD is that they show hindered ability to adapt to any settings or change their daily activities which leads them to retain their repetitive behaviour and experience hindrance in learning new information or adapt to new environment. This is evident as autistic individuals are seen not to show positive response toward avoiding repetitive movement like hand flapping, rocking and twirling and other (Bölte et al., 2019). The condition can be linked with the theorical explanation made through social motivation theory. This is because according to the theory the ASD individuals due to lack of reward feeling regarding changing repeated action or daily activities avoids changing them (Burnside et al., 2017). Thus, due to lack of development of motivation in the mind that avoiding rocking and hand flapping action, or other daily activities would help them in making better social interaction with others leads the autistic children and individuals to remain same. The children and individuals with ASD are seen to show rejection toward making physical contact with others as well as avoid making direct eye contact while speaking with others. This is because such actions are considered stressful or uncomfortable by them (Bölte et al., 2019). This aspect can be explained by linking to the theory of mind (ToM) framework according to which the autistic individual due to their hindered brain functioning fail to understand the cause and importance of physical touch or making direct eye contact during communication (Livingston et al., 2019). Thus, it leads them to retain their rejection toward such activities.

Diagnostic and assessment tools for anxiety evaluation in Autism Spectrum Disorder (ASD)

There are currently no specific diagnostic or assessment tools present for detecting and evaluating specified anxiety in people with Autism Spectrum Disorder (ASD). The psychiatrist mainly through psychological assessment of the mood and expression of thoughts based on the symptoms of anxiety in ASD individual detect anxiety in them and develop evaluation to understand the source of the problem through communication with the child or individual and their family members (Hollocks et al., 2019). The key signs considered during evaluation that informs that the ASD child or individual may have anxiety are their instance of making increased repetitive actions, expressing trouble toward sleeping, emotional outbursts, social withdrawal, relying on obsessive actions and others (Hollocks et al., 2019). The hindrance with use of physical assessment in detecting anxiety in ASD children or individuals is that actual level of anxiousness as detected in case of general anxiety assessment could not be reached or detected. This lead the physicians unable to understand the severity of the anxiety in the ASD individuals and nature immediate actions to be required in priority (Hollocks et al., 2019).

Implication for emotional well-being of individuals with Autism Spectrum Disorder (ASD)

There are wide strategies that are able to ensure emotional well-being of the individuals suffering from Autism Spectrum Disorder (ASD). One of the strategic implications for emotional well-being of ASD individual is delivery of mindfulness-based cognitive therapy (MBCT). In MBCT, the mindfulness strategies and cognitive behavioural techniques are combined together to help individuals develop better understanding and management of their thoughts and emotions to achieve relive from stress and anxiety. In this therapy, the individuals are taught regarding the way to perform mindfulness mediation based on the principle of cognitive therapy to let the people get educated regarding the way they are to consciously pay attention to their feelings and thoughts without making any judgement (Adibi Sede et al., 2018).

The MBCT mainly helps the individuals with ASD to easily overcome stress and anxiety regarding any social situation that is hindering their progression toward making social interaction. This is evident from the study of Gaigg et al. (2020) where a pilot randomised control trail is been executed to understand the effectiveness of self-guided MBCT in reducing anxiety in autistic individual. For this purpose, 54 participants are included who were autistic and facing anxiety. The results revealed that 23 of the participants who were in the experimental group receiving MBCT for 3 and 6 months expressed significantly reduced anxiety that was maintained over 3-6 months compared to the control group who expressed no reduction in anxiety level. The fact is also supported by the study of Ridderinkhof et al. (2018) in which it was mentioned that application of MBCT to the children with autism did not make any change regarding the mindful awareness. However, their problems and tress with social communication and hindrance regarding functioning of emotional and behavioural functions were improved. This helped them to have better quality of life and emotional well-being.

The other therapeutic intervention to be made for individuals with ASD in helping them overcome social anxiety and stress is Cognitive-behaviour therapy (CBT). In this therapy, no mindfulness actions are to be implemented and it is mainly a talk therapy accompanied by behaviour therapy. In this action, the children or individuals with ASD are directly communicated to identify the triggers that led to their development of anxiety. The therapist by making aware of the triggers and helping the autistic individuals to develop “thought stopping” for the actions that leads to the anxiety controls their behaviour (Maskey et al., 2019). The study by Spain and Happé (2019) mentioned that the CBT to be delivered to the autistic individual in managing their anxiety are to be changed. The change should include adapting the therapy according to the neuropsychological impairments and ability of the individuals. Moreover, an individualised formulation-deprived approach is to be taken for successfully delivering CBT to the autistic individuals. According to NICE guidelines, the CBT to be delivered for helping autistic individual manage their anxiety are to include emotional recognition training, greater use of visual and verbal information and structured worksheet compared to non-verbal communication, simplified cognitive process, involvement of parent or carers in the process and others (NICE, 2013).

The general actions to be executed in helping people with ASD to overcome anxiety in social situation is by making them realise the situation prior to it occurrence through social stories, This is because the social stories would lead the individuals with ASD understand prior to be in the social situation about the incidence they may face and way to interact with others in the condition without free stressed out of not knowing how to react in the situation (Ghanouni et al., 2019). The use of social stories as positive support to overcome social anxiety and barriers in communication in autistic people is mentioned in the study of Manzari-Tavakoli et al. (2018). The study mentioned that social story use for the autism children helped in improving their motor skills and verbal communication to effectively remain in social situation without anxiety compared to the control group.

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The above discussion mentions that anxiety is a co-occurring symptom in people with Autism Spectrum Disorder (ASD). The symptoms mainly include for them increased sleeping hindrance, high social anxiety, increased repetitive behaviour and other. There are no specific tool present for assessing and diagnosing anxiety in AD individual and the physician mainly through physical and emotional assessment determines the presence of anxiety in AD individuals. The theory of mind (ToM) mentions that incapability of the autistic individual to adapt according to others leads them to face increased social anxiety. The use of Mindfulness-based cognitive therapy is regarded as key implication for overcome increased anxiety in ASD individual but the use of cognitive behaviour therapy and general actions are like social storytelling and also implication to be made for reducing anxiety in ASD individuals.

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