Amy Keefer, Ph.D., dives into anxiety and autism. She characterizes anxiety, noting differences in anxiety typical during developmental stages and psychopathological anxiety that interferes with daily function over an extended period. The speaker discusses anxiety prevalence rates across populations, common anxiety disorders in autism, and contemporary research on ambiguous anxiety. Keefer considers how to identify anxiety in autism, underscoring the overlap of symptomology and genetics in autism and anxiety. The presenter explores treatment options, including medication, modified cognitive behavioral therapy (MCBT), and mindfulness-based treatments. She suggests collaborating with professionals who are knowledgeable about autism and provides resources before the Q&A.
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In this webinar:
0:00 – Speaker introduction and learning objectives
2:25 – What is anxiety?
4:00 – How do we know others are anxious?
9:45 – Impact of anxiety on autism functioning
11:33 – Prevalence of anxiety in autism
12:25 – Increased risk across development in autism
13:30 – Study: Subclinical vs clinical anxiety across age groups
15:43 – Intersection of autism and anxiety – DSM-5 definitions
20:40 – Ambiguous anxiety and contemporary research
26:15 – Study: Prevalence of ambiguous anxiety
28:10 – Identifying anxiety in autism
31:00 – Underlying causes of anxiety
32:15 – Behavioral observation questions
35:15 – First steps to treating anxiety in autism
38:00 – Classroom management strategies
41:00 – Medication management
42:05 – Psychological interventions – MCBT
43:45 – Psychoeducation
44:30 – Coping strategies
45:10 – Exposure and clinical creation of hierarchical exposure
47:13 – Cycle of parental/caretaker over-accommodation
49:08 – Mindfulness-based treatments
51:20 – Summary, acknowledgments, and resources
52:25 – Q&A
Anxiety in autism
Keefer lists emotional, physical, behavioral, and physiological characteristics of anxiety (2:25) and notes the difference between anxious excitement and clinical anxiety (3:40). The speaker discusses how to know when others are anxious and advises observable behaviors to look for in cases when an individual cannot describe how they feel or think (4:00). She highlights that anxiety is typical at points across development (6:09) and suggests viewers assess the interference of anxiety in daily functioning before pathologizing a patient or loved one (7:48). Keefer explains that anxiety becomes an issue when it lasts multiple weeks or months and interferes with an individual’s and/or family’s functioning in multiple areas (8:30).
Anxiety in individuals with autism is associated with exacerbated autism traits, treatment interference (too anxious to attend), depression, suicidality, and risk for long-term psychopathology (9:45). Studies up to 2019 revealed an anxiety prevalence rate of 40% in autistic children and adolescents and 50% in autistic adults. These rates are significantly higher than non-autistic individuals in both age groups (11:33). Keefer discusses the increased risk for anxiety across development stages in autism (12:25) and outlines a study on disparities in the prevalence of subclinical and clinical anxiety between school-age and adulthood (13:30).
The intersection of autism and anxiety
The speaker discusses the genetic and symptom overlap in autism and anxiety. She highlights this relationship and the lack of sufficient understanding, resources, and support for autism as driving factors in the prevalence of anxiety in autism (14:08). Keefer details DSM-5 anxiety disorders experienced by autistic people including separation, social, and generalized anxiety disorders as well specific phobias and unspecified anxiety disorder (16:20). Ambiguous anxiety, she continues, is a contemporary area of research focused on anxiety associated with or modified by autism traits/symptoms (20:40). These diagnoses do not fit neatly into the DSM-5 categories and include other social fear (21:50), idiosyncratic phobia (specific and unusual phobia), special interest fear (23:30), and fear of change (25:15). Keefer details a study on the prevalence of ambiguous anxiety compared to traditional (DSM-5) anxiety which found that 31% of autistic children surveyed had both presentations of anxiety simultaneously (26:15). She highlights that the prevalence rates discussed previously were taken from articles where ambiguous anxiety was not assessed and therefore posits that the rates are likely even higher (27:40).
Identifying anxiety in autism is difficult due to symptom overlap and the heterogeneity of presentation across individuals and developmental stages (28:10). It is, therefore, crucial to determine the underlying causes of behavior in autistic individuals via conversations or behavioral observations, especially in individuals with intellectual or communication difficulties (31:00). Keefer suggests questions to keep in mind during observation and urges viewers to collaborate with knowledgeable professionals, teachers, and caretakers for the most holistic understanding and treatment outcomes (32:15).
Treating anxiety in autism
To properly treat anxiety in autistic individuals, you must first discern if the anxiety is realistic – could they be experiencing anxiety for a very understandable reason (e.g., bullying, inappropriate expectations, other chronic stressors) (35:15)? If so, Keefer advises to let them know their anxiety is a normal reaction and to focus on problem-solving and coping, closing skill deficits, and providing environmental support and accommodations (36:50). The speaker touches on classroom management strategies for autistic children including visual schedules, social stories, timers, and possible educational accommodations (38:00).
Avenues of anxiety treatment for autistic people include medication management and psychological interventions (40:20). Keefer emphasizes the lack of data on medication management for anxiety in autism, noting the need for large-scale randomized control trials (41:00). Research on psychological interventions is much more robust and often focuses on modified cognitive behavioral therapy (MCBT) (42:05). The speaker discusses critical elements of MCBT including psychoeducation on anxiety and body cues (43:45), relaxation training, cognitive and behavioral coping strategies (44:30), and hierarchical exposure (45:10). She outlines the clinical creation of hierarchical exposure and provides examples (46:09). The speaker touches on the cycle of parental/caregiver over-accommodation and urgest caretakers to practice self-care and allow their loved ones to be in uncomfortable situations (47:13). Mindfulness-based treatments rooted in the principles of awareness and purposeful non-judgmental attention are also being investigated (49:08). Such treatments show significant benefits in the neurotypical populations and evidence of its usefulness in autism is emerging, especially for parents and caregivers of autistic individuals (50:40).
Keefer summarizes the presentation, reiterating the immense impacts of anxiety on autism function and presentation. Keefer notes that MCBT helps treat anxiety in school-age and adolescent autistic youth without significant language or cognitive delays and that other strategies are available for individuals who are not good candidates for MCBT. The speaker provides acknowledgments and resources before the Q&A, where she discusses how to find mindfulness practitioners, assessments for anxiety in autism, and more.
More Resources on Anxiety & Autism
- Read an interview transcript between ARI’s executive director Dr. Steve Edelson and Dr. June Groden, co-founder of the Groden Center, on stress and anxiety reduction in autism.
- Watch next: Behavioral Strategies for Anxiety in ASD
Dr. Amy Keefer is the supervising clinical psychologist within the Center for Autism and Related Disorders and coordinates the Post-Doctoral Residency in Clinical Child Psychology and Neurodevelopmental Disabilities in the Department of Neuropsychology and the Center for Autism and Related Disorders. She is an instructor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine. Dr. Keefer is a licensed psychologist and is board certified in cognitive and behavioral psychology. Dr. Keefer’s research interests focus on psychiatric comorbidities in individuals with autism spectrum disorder (ASD). Previous projects have investigated correlates of anxiety and predictors of response to anxiety treatment in youth with ASD. She is currently collaborating with researchers both within and outside Kennedy Krieger Institute to research mechanisms underlying anxiety and to develop novel, empirically validated treatments for emotional dysregulation.
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