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Your ATN@Work: Treating anxiety in children and teens with autism

Last week we posted Part 1 in our Q&A with the lead author of the first guidelines for identifying and addressing anxiety in children and teens with autism. The guidelines came out of a study conducted through the Autism Speaks Autism Treatment Network (ATN) in its role as the Autism Intervention Research Network on Physical Health (AIR-P).

Research has long shown that people with autism have high rates of anxiety disorders. Research also suggests that anxiety tends to have different causes and symptoms in those affected by autism than it does in the general population. For these reasons, the Autism Speaks ATN prioritized the development of the diagnostic and treatment guidelines that became part of a special ATN/AIR-P supplement to the February issue of Pediatrics.

In last week’s Q&A, lead author Roma Vasa discussed the challenges involved in recognizing and diagnosing anxiety in children and teens with autism. This week, she discusses treatment options.

Child and adolescent psychiatrist Roma Vasa (shown above) practices at the Kennedy Krieger Institute, with a specialty in treating anxiety in children and adolescents with developmental disorders.

Editor’s note: The following information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional and/or behavioral therapist.

Autism Speaks: Who and what should be part of the treatment plan for anxiety in a child or teen who has autism?

Dr. Vasa: First and most important, treatment has to be customized to the developmental level of the child. This includes consideration of language level, any intellectual disability and other behavioral conditions. The treatment approach needs to be take all of these things into consideration.

Of course, it’s ideal if a child can be seen in a specialized center such as those in the Autism Speaks Autism Treatment Network. That can allow one-stop shopping for behavioral therapy, speech therapy, treatment for anxiety and meeting with psychiatrist all in one place. But getting to such a center is just not practical across much of this country.

If you don’t live near an autism specialty center, another option is to ask your child’s pediatrician for a referral to a child psychologist or psychiatrist who has experience working with kids on the autism spectrum. Teachers, special education staff and behavioral therapists can be another source of referral to services in the community.

I recommend asking: “Do you work with individuals on the spectrum. Are you familiar with some of the modified approaches using to treat anxiety in people on the spectrum?” It’s also important that a psychologist or psychiatrist coordinate care with your child’s pediatrician and behavioral therapists.

Autism Speaks: Your team’s guidelines strongly supports using a modified version of cognitive behavioral therapy for anxiety in children and teens who have autism without intellectual disability. Why is this type of therapy so effective?

Cognitive behavioral therapy, or CBT, has a long record of effectiveness among typically developing kids. In large treatment trials for anxiety disorders, two-thirds of kids responded to this approach.

CBT has two components. The first involves cognitive restructuring – changing your thoughts about situation you perceive as fearful. So you go through an interaction with a therapist to logically appraise the situation differently. The second piece is gradual exposure. The child and therapist together develop a list of situations that the child finds fearful. They rank them from least to most scary and then they develop a plan where child is slowly exposed to each situation.

The results of our research with CBT have been very positive and exciting. Some kids like CBT because it's logical. They learn about anxiety, identify things that make them anxious and learn ways to manage these things. We modify the CBT to make it more understandable and fun for kids with autism. In some situations, we de-emphasize the cognitive restructuring – because it involves a lot of mental flexibility and seeing things from different points of view. We also take into consideration each child’s learning style – for example, the tendency to be more visual. And of course, many kids with autism have special interests. It can be helpful to incorporate these interests into the treatment to keep them engaged. So far, we are seeing some really good results.

To date, most of our research on CBT for addressing anxiety in kids with autism focuses on children and teens who don’t have intellectual disability. We are in desperate need of more research on CBT for kids with intellectual disability. It’s wonderful to see this work starting. But there’s not much published yet. The research is still in its early stages.

Editor’s note: To learn about related Autism Speaks-funded research, also see
“Easing anxiety in kids with autism and limited verbal skills.”

Autism Speaks: What role can parents play in addressing anxiety in children who have autism?

Dr. Vasa: Parents can play a big role in figuring out whether a change in behavior is due to anxiety. This can involve making observations about when and where the behaviors occur and talking with teachers and therapists about what they notice. Are there clear situations or stimuli that put the child in a high state of arousal? Or does the anxious state seem to extend throughout the day?

Classic symptoms of anxiety can include an expression of fear or distress on the face. Another is that certain situations produce irritability, aggression or escape behaviors. These behaviors can mean that a child doesn’t have the coping skills to deal with the anxiety.

Autism Speaks: Would it be helpful for families to bring or send your Pediatrics report to their child’s physician?

Dr. Vasa: Absolutely. It can be a great springboard for discussion. I think it’s wonderful when families bring me something that we can review and discuss together. Going through these guidelines together can give the clinician and parents a common ground and structure. Remember this is about a collaborative model that involves working together. (Download it here.)

Autism Speaks: How did the Autism Speaks Autism Treatment Network make this research possible?

We received invaluable support from the Autism Speaks Autism Treatment Network leadership team. They knew that anxiety was a major problem in children and adolescents with autism and realized the importance of disseminating our knowledge to the public. The leadership team provided all the necessary resources for our workgroup to effectively conduct this research. I also want to take this opportunity to acknowledge my co-authors who work within the ATN at center sites across North America. They included Micah Mazurek, Rajneesh Mahajan, Amanda Bennett, Maria-Pilar Bernal, Alixandra Nozzolillo, Gene Arnold and ATN medical director Daniel Coury.

Autism Speaks: What’s next? What additional research and changes in healthcare do you want to see in the year and years ahead?

Dr. Vasa: I am hoping that our report appearing in a prominent journal like Pediatrics will call wide attention to the importance of evaluating for anxiety in kids with autism. This should be part of universal screening. As health care providers, we need to put this on our radar early and address it early. This is so important because anxiety can be easily overshadowed by other behavioral issues. But sometimes those same behavioral issues are, at their core, about anxiety.

We also need to make progress on the treatment front. We have no solid research on what medications might be helpful for anxiety in kids on the spectrum. What we know about anxiety medications for children is based on typically developing kids. But these medications may work differently in people who have autism. We urgently need more research on new medical treatments.

One last piece, I want to stress how important it is to provide safe learning environments for kids on the autism spectrum. We know that experiences in school can be a major source of anxiety. So we need methods and supports that meet the needs of each child consistently.