Autism Spectrum Disorder (ASD) is a developmental disorder characterized by deficits

in social interaction, communication, stereotyped behaviors and restricted interests (Selles, &

Storch, 2012). Many people with autism also have clinically significant anxiety. Anxiety is

defined as a disproportionate fear reaction to a relatively benign environmental stimuli (Lang,

Mahoney, Zein, Delaune, & Amidon, 2011).

There are a variety of different percentages describing the co-morbidity of autism and

anxiety. According to a study of forty articles published between 1990 and 2008, anywhere from

11% to 84% of people with ASD have elevated levels of anxiety. A separate study concluded

that 39.6% of children and adolescents with ASD had at least one anxiety disorder (Scattone, &

Mong, 2013). Anxiety is more common for children with autism then in children with language

disorders, chronic medical conditions, conduct disorder, severe mental retardation or epilepsy

(Puleo, & Kendall, 2010). According to Wood, anxiety is the second most cited problem by

parents of children with autism (Wood, et.al, 2009). Additionally, increases in anxiety have been

associated with decreased participation in social activities and a lower quality of life (Selles, &

Storch, 2012) (Steensel, Dirksen, & Bögels, 2014).

People with autism often have difficultly interpreting thoughts, beliefs and intentions of

others in addition to poor pragmatic skills. As a result, maintaining long term social relationships

may be challenging for individuals with autism (Scattone, & Mong, 2013). These difficulties can

lead to increased stress or anxiety for some individuals, particularly those who have high

functioning autism, as they “are aware of their social deficits and likelihood a failure yet

maintain a desire for peer approval” (Selles, & Storch, 2012).

For school age children and adolescents with comorbid autism and anxiety, anxiety may

be most frequently encountered during the school day and can interfere with learning in the
classroom. In order to allow this population to succeed both academically and socially, anxiety

reducing interventions are needed.

Several of these interventions, require external strategies involving a change in the

environment or other people (Hare, Wood, Wastell, & Skirrow, 2014). Many such intervention

strategies involve exercise or relaxation. Examples include taking a walk outside the classroom

or progressive muscle relaxation, which involves laying down and gently tensing and relaxing

each part of the body (Chalfant, 2011). Still other strategies may require going to talk to a school

social worker or special educator. All of these examples require the student to leave the

classroom which can not only make them appear different to peers but can also result in

significant loss of class time. Therefore, having the ability to remain in the classroom while

reducing anxiety is a critical component of any anxiety management procedure to be used during

the school day.

Self-management is another key element when looking at interventions to manage

anxiety in the classroom. For example, in one strategy, the teacher would come over to the

anxious individual and remind him or her to take deep breaths or use another strategy. However,

White notes “Intervening directly with the child in his or her classroom while peers are present

… is intrusive and usually not feasible” (White, et al., 2010). This draws attention to the

individual with anxiety. This strategy also requires the teacher to stop instructing the entire class

for a moment. This can happen several times during one period. In addition, many students with

anxiety and autism have hopes and plans of becoming more independent. These plans often

postsecondary education or employment, where being able to self-manage their anxiety will be

crucial.

There are anxiety self-management procedures helpful in the classroom for school age
children and adolescents with autism. Before students with autism can learn self-management

procedures for anxiety, they need to be able to recognize emotions and when they are feeling

anxious. In Managing Anxiety in People with Autism, Chalfant discusses using a worry scale

thermometer, which is part of the Cool Kids Child Anxiety Program: Autism Spectrum Disorders

Adaptation. The worry scale thermometer looks like a mercury thermometer with numbers

ranging from zero to ten with cartoon images of children representing different levels of anxiety.

Zero is labeled as very relaxed while ten is extremely worried. For individuals who require a

more concrete scale, traffic lights can be used, with green representing no or minimal worry and

red representing a high level of worry (Chalfant, 2011). Both of these tools allow an individual

with autism to identify emotions and know when they need to use an anxiety reducing strategy.

Once students are able to accurately recognize their anxiety, they can be taught ways to

self-manage these feelings in the classroom. There are many self-management procedures

helpful in the classroom for school age children with autism. However, treatment of anxiety in

people with comorbid autism is more complex than treatment of anxious people with

neurotypical development. Some features of autism including limited communication abilities

and cognition as well social deficits, can render typical psychosocial treatments for anxiety less

effective (Selles, & Storch, 2012). As a result many types of psychosocial therapy traditionally

used for people with anxiety need to be modified in some way to be effective for individuals

with comorbid anxiety and autism.

Traditional treatment for anxiety, in people without autism, uses Cognitive Behavioral

Therapy (CBT) in which people are taught to challenge and then change unhelpful thoughts or

behavior along with learning coping strategies. Many studies were conducted in which

traditional CBT was changed. Sofronoff conducted a study in which CBT was changed by
including emotional recognition and cognitive restructuring (Wood, et.al, 2009). Sofronoff used

fictional scenarios found in ‘James and the Math Test’ to help children develop ways of

managing their own anxiety. In this program, the clinician would explain different anxiety

inducing situations which James faced and the child would have to name as many strategies as he

or she could. By completing this program, children with comorbid autism and anxiety were able

to develop strategies that they could do independently to self-manage anxiety both inside and

outside the classroom. (Lang, Regester, Lauderdale, Ashbaugh, & Haring, 2010). Parents

reported significant reductions in symptoms on both the Spence Children’s Anxiety Scale for

Parents and the Social Worries Questionnaire- Parent Version. This study was determined to be

capable of providing preponderance level of evidence (Lang, Regester, Lauderdale, Ashbaugh, &

Haring, 2010). While an experimental design was used, therapists involved in the study

conducted the post-treatment diagnostic reviews instead of independent evaluators. Additionally,

fidelity of treatment was not evaluated (Wood, et.al, 2009).

Wood saw that others had adapted traditional CBT and decided to substantially expande

on the program. In what became known as modular CBT, Wood addressed common problems

for people with ASD through a separate study. The problems Wood focused on included: poor

social skills and perspective taking, poor adaptive skills and circumscribed interests and

stereotypies. Wood incorporated the Building Confidence CBT program in the study which

includes coping skills training and in vivo exposure. Study participants were taught affect

recognition and cognitive restructuring along with the principle of exposure, resulting in self-

independence skills to manage anxiety (Wood, et.al, 2009). It is hypothesized that many of the

skills, particularly cognitive restructuring, learned through the Building Confidence program

could be used as self-management in the classroom. Upon completion of the study 92.9% of
participants in the treatment group meet criteria for positive treatment according to the Clinical

Global Impressions Scale compared to 9.1% of the control group. The study was the only study

as of 2010 to be considered capable of providing conclusive level of evidence due to the use of

experimental design, blinding, random assignment, control group, treatment fidelity, inter-

observer agreement, and the control for alternative explanation of treatment gains (Lang,

Regester, Lauderdale, Ashbaugh, & Haring, 2010).

In another study, the Coping Cat Program, which was originally developed for typically

developing individuals with anxiety, was used with children with comorbid autism and anxiety.

The Coping Cat program is based on teaching behavioral and cognitive strategies. Additionally,

participants were also taught that they could influence the way they were feeling through the

FEAR plan. FEAR is an acronym for Feeling frightened? Expecting bad things to happen?

Attitudes and Action that can help and Results and Rewards (Podell, Mychailyszyn, Edmunds,

Puleo, & Kendall, 2010). While the study involving participants with autism and anxiety had

positive results, the results do not provide a conclusive level of evidence. The study had a small

sample size of twenty-two and results were based off parent report, which resulted in no

blinding.

There are also several other specific strategies that can potentially enable an individual to

self-mange anxiety in the classroom. However, it is not clear if these strategies have been tested

using the certainty of evidence. Several strategies are listed in Chalfant’s Managing Anxiety in

People with Autism, including controlled breathing, muscle relaxation and the coping strategies

toolbox (Chalfant, 2011).

While both the studies by Sofronoff and Wood were evidence based and had positive

results, it is impossible to determine which specific components of the interventions were

successful. Each specific component was not “measured for [it’s] incremental validity in

treatment outcomes, and therefore little is known about their effectiveness or importance in

treatment.” For example in the study conducted by Wood, several modules were used. However,

only cumulative results were reported. It is unknown which parts were effective or if all parts

were needed for success (Selles, & Storch, 2012).

While CBT has been shown to be effective in treating anxiety for individuals with

autism, many individual and their families feel that this therapy is ineffective or unavailable. In a

small study by Scattone, two participants had a positive response to CBT based intervention.

However, they did not continue therapy after the study ended because they “had a difficult time

finding a therapist who was skilled in CBT, knowledgeable about [Asperger’s syndrome] and

affordable” (Scattone, & Mong, 2013). There are people with comorbid anxiety and autism who

would like to participate in CBT programs but believe these programs are unavailable to them.

Additionally, most studies looking at anxiety in autism used a similar homogenous group

of participants. Most were high-functioning males between seven and thirteen years old (Selles,

& Storch, 2012). Autism is known to be a spectrum affect a wide range of individuals in many

different ways. Further research involving other subsets of individuals with autism, such as those

with lower cognitive abilities as well as younger children, older adolescents and adults (Lei,

Sukhodolsky, Abdullahi, Braconnier, & Ventola, 2017).

In order to enable all children with comorbid autism and anxiety to lead independent and

fulfilling lives, they must have strategies to self-manage anxiety in the classroom and throughout

their daily lives. These strategies exist, are scientifically based and effective. However, they need

to be made a more available in order to help a larger proportion of those effected. Additionally,
more research needs to be done to identify specific strategies and also to include a wider range of

individuals.