Anxiety is one of the most prevalent co-occurring symptoms for individuals with autism spectrum disorder (ASD). Individuals with ASD and anxiety present with complex behaviors that interfere with the ability to communicate effectively and respond appropriately. In addition to skill deficits, auditory processing issues, and motor speech disorders, anxiety is one of the greatest barriers to communication in individuals with ASD. Anxiety and communication form a negative feedback loop where one may bring about the other.
Anxiety disorders exacerbate the existing social and communication difficulties individuals with ASD possess such as deficits in social use of language and the inability to sustain a conversation; breakdowns in communication due to an increase in anxiety may also result in a disruption in verbal fluency. Effective therapeutic interventions are necessary to address the clinical needs of individuals with this comorbid presentation.
There are many treatment options available depending on the level of functioning of the individual with ASD as well as to what degree of anxiety the individual is experiencing.
Cognitive Behavioral Therapy
- Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that aims to solve problems concerning dysfunctional emotions, behaviors, and cognitions through a goal-oriented, systematic procedure.
- Modified CBT (MCBT) is better suited for those who have increased communication skills and are motivated to change. MCBT may be administered individually or in a group and typically includes parental involvement. Strategies such as affective education, cognitive restructuring, reduction of avoidance behaviors, relaxation, modeling, and exposure to feared stimuli are implemented. CBT adaptations that help students with ASD understand cognitive and emotional concepts are: visual supports (thermometers, emotional faces), concrete language, written materials (schedules, lists, social rules or vignettes, opportunities for repetition and practice, incorporation of special interests, video modeling, etc.) These techniques are often adapted for self-help applications.
- Many individuals with ASD are well aware of their communication and socialization deficits; therefore, when confronted with opportunities for social interaction, their anxiety will typically increase. When implemented correctly and practiced consistently, CBT has been found to significantly reduce anxiety in many individuals with ASD. The pressure to communicate may be reduced as the individuals begin to possess some of the necessary tools for a successful communicative interaction.
Social Skills Interventions
- Social Stories by Carol Gray as well as instructor-written stories about actual events in the individual’s life may be very helpful in alleviating anxiety, particularly about a social situation the individual is having difficulty with. The individual and/or instructor reads and discusses the story and may rehearse the social situation as needed. Comic Strip Conversations, also by Carol Gray, incorporate the use of simple drawings and color to illustrate an ongoing communication.
Practicing and rehearsing real life social situations in the individual’s life affords practice and opportunities for role-playing various social scenarios. This may decrease anxiety when the actual social situation occurs as the individual has practiced the words, phrases, etc., and they are part of his or her lexical repertoire. Of course, there will always be novel social situations that have not been rehearsed; however, if proper instruction and support are provided, such as increasing existing vocabulary and practicing a variety of social scenarios, the individual may be able to use those tools and apply them to novel social situations.
- Power Cards by Elisa Gagnon present short scenarios of how a child’s hero solves a problem and is written in the first person. Along with a picture of the hero or special interest, the child is presented with a power card that tells how he/she can use the same strategy as their hero. Three to five cards, with one step per card, are typically used with one card introduced at a time. The cards may be carried in a pocket or wallet and are easily accessible by the child at all times. Once the child has internalized the first skill, he or she can be given new cards.
- Textual and audio scripts, which are often used to increase initiating skills, may also help decrease anxiety in many individuals on the autism spectrum. Textual scripts comprise written cues; audio scripts comprise auditory cues. Both are designed to promote verbal exchanges. Providing individuals with scripts in various social situations when they are unsure of what to say may help to reduce anxiety.
Anxiety can significantly interfere in an individual’s ability to communicate effectively and appropriately. Using therapy, interventions, and, in some cases, medication to reduce anxiety can make it possible for children with ASD to learn communication and other skills more easily and quickly, ultimately leading to improved quality of life now and in the future.
Jan Downey is the director of speech-language and communication services for Eden II/Genesis Programs and an adjunct professor in the Communication Sciences Department at L.I. University/C.W. Post in Greenvale, N.Y. She is a licensed speech-language pathologist in New York State and holds a certificate of clinical competence from the American Speech-Language and Hearing Association. She serves on the Parent Partners Project Advisory Board at Winthrop University Hospital’s Department of Behavioral Pediatrics in Mineola, N.Y. She is the mother of two sons with autism spectrum disorder.