By Professor Tony Attwood and Dr Michelle Garnett
Autistic children appear vulnerable to feeling anxious for much of their school day, often experiencing extreme anxiety in anticipation of, or in response to, specific events, such as the sound of the school bell, making a mistake, or having a replacement teacher for the day. Richard Maguire, an autistic adult, explained, “I call anxiety the permanent emotional state for autistic people… anxiety is my constant companion. Much of my life and strength have been used up on anxiety.” Sometimes, the level of anxiety may be perceived as more disabling than the diagnostic characteristics of autism.
There can be qualitative differences in the presentation of anxiety in autistic children when compared with typical children. Phobias may develop as a response to specific autistic characteristics. For example, extreme auditory sensitivity to specific sounds – such as thunder, electric appliances, and someone shouting– may elicit heightened, actually painful, responses, with a resultant phobia of these sounds and related situations. Fear of being laughed at (gelotophobia) may result from impairments in Theory of Mind and the difficulties determining the thoughts and motivations of peers. Typical children know intuitively that some forms of laughter are benevolent, and that laughter can be expressed in friendship as a sign of mutual happiness, not always derision.
An assessment of the circumstances associated with, or that create, heightened anxiety levels can indicate an intolerance of uncertainty and a fear of making a mistake or performance anxiety. There can be a fear of being targeted for bullying, teasing, rejection, and humiliation, and anxiety associated with changes in routine or expectations but socializing with peers is perhaps the most significant source of anxiety.
Anxiety can frequently be associated with specific social situations, such as those circumstances where there are no clear or previously experienced social rules or where other children deliberately break social codes or conventions. There can be anxiety associated with complex and possibly novel social situations, such as birthday parties, and performance anxiety in terms of being able to apply learned social responses and behaviour in real-life social settings. The high level of anxiety experienced in social situations, such as the classroom or playground, may result in the child’s use of coping strategies that lead to a diagnosis of Separation Anxiety, where the child genuinely needs guidance and reassurance from a parent; and Situational Mutism (in terms of the flight, fight and freeze response to anxiety), where the child ‘freezes’ and is unable to speak in the classroom, but is verbally fluent when relaxed at home.
Signs of Anxiety in the Classroom
In typical children, there are many familiar signs that we associate with high levels of anxiety: restlessness and a genuine difficulty keeping still as the child tries to burn up the emotional energy created by anxiety; fiddling with an object as a soothing activity; a lack of self-confidence and continual seeking of reassurance; the imposition of rituals; reduced attention and rigid thinking; social withdrawal; racing thoughts; and in extreme situations, emotional meltdown. Medical signs can include changes in appetite and sleep and disturbances of the gastrointestinal system, leading to constipation or diarrhea. While all of these signs may be present for an autistic child, in autism anxiety can present differently to typically developing children.
The parents of an autistic child have often identified specific behaviours, actions, and comments that indicate increasing anxiety. Some may be unique to the child, such as talking about a particularly ferocious dinosaur or repeating fragments of conversation associated with the first time they experienced a particular expression of anxiety. These parents may find it valuable, once they recognize both their child’s conventional and unique signs of expressing increasing anxiety, to create a ‘foreign phrase’ dictionary that translates the behaviour to identify the nature, type, and depth of emotion and pass this information on to the child’s class teacher.
Anxiety can also increase the core characteristics of autism, and some of the diagnostic features of autism may be an attempt to manage anxiety. Restricted, repetitive, and ritualistic behaviours may be soothing and function as a means of reducing anxiety. Insistence on sameness prevents experiencing situations that could create anxiety. Special interests have many functions, including distraction and blocking anxious thoughts. Anxiety may also amplify other behaviour problems, such as aggression, especially when the child’s attempts to reduce high stress and anxiety are thwarted. Anxiety can also explain other behavioural characteristics associated with autism, such as acting as the ‘class policeman’: the child’s attempt to reduce chaos and uncertainty and impose order.
Triggers for Anxiety
Sometimes, the teacher must be a detective or scientist, observing, collecting, and analyzing the data or evidence regarding which situations and events can precipitate intense anxiety. Such situations may include:
- disruptions to established routines
- circumstances where the child is expected to behave in a certain way but doesn’t know how
- times when the child is prevented from carrying out certain expected activities or routines
- instances where there are too many demands and expectations on the child
- the experience of classroom and playground rules being broken.
- having a change imposed when the child is not ready for it. An autistic child often has considerable difficulty creating an internal representation of a new plan and, as a result, can be very anxious during unforeseen changes to daily routines and expectations. Thus, there can be an insistence on sameness: variety is not the spice of life
- having to wait or hurry up
- experiencing or observing social injustice
- fear of making a mistake or that schoolwork is not perfect
- being considered or called stupid by peers
Coping strategies for high levels of anxiety
There are many strategies that a typical child would use to manage high levels of anxiety, and autistic children will use some of the same strategies but also some that are specifically associated with autism. Increases in any of the following behaviours in an autistic child may mean that their underlying anxiety levels are high and anxiety management strategies are needed.
Controlling and oppositional behaviour
A means of avoiding anxiety-provoking situations is developing behaviours perceived as controlling. An anxious child may develop strategies to control everyday experiences that have the potential to trigger more significant anxiety or even panic. Such strategies can include defiantly refusing to engage in a particular activity, especially using emotional blackmail, such as threats to damage something or hurt someone, to escape having to comply with a teacher or parent’s request, or with the expectation to participate in an activity that has previously been, or is anticipated to be, a cause of intense anxiety. These behaviours may lead to a recognition of the characteristics of Pathological Demand Avoidance (PDA).
Repetitive actions, rituals, and routines
These are actions and behaviours that are soothing, relaxing, and calming. They range from simple, repetitive, manual activities, such as rotating an eraser or twisting hair, to performing a sequence of activities in a particular order. Familiar objects and routines are perceived as comforting, creating a feeling of safety and control. The rituals are extensions of the superstitious behaviour undertaken by typical people to reduce uncertainty or anxiety, for example, the action to ‘touch wood.’ These strategies may be effective in relieving the emotional tension, but the routines and rituals can become excessively prolonged and complex and interfere with engaging in other activities. There can also be extreme distress and anger if the routines and rituals are interrupted, occur out of sequence, or are prevented altogether.
A way of blocking anxious thoughts is to engage in a special interest, such as reading about dinosaurs. The autistic child appears mesmerized, seemingly enjoying their detachment from their surroundings. The special interest can be so engrossing and enjoyable that no anxious thought can intrude. By engaging in special interests, an autistic child also avoids social situations, one of the most significant causes of their anxiety. The enjoyment and escape from anxiety achieved by engaging in a special interest can sometimes lead to an irresistible compulsion.
Sometimes, a special interest in superheroes and fantasy literature can be a way of coping with fears, with the child wanting the qualities of a superhero to become brave. The origins of the special interest may also be a way of overcoming anxiety. For example, a child who feared spiders decided to overcome her anxiety by reading about spiders: knowledge to overcome fear. The more she learned, the more she started to admire spiders. Arachnophobia gradually became Arachnophilia as she began to search for, observe and collect spiders, developing expertise that adults greatly respected.
When the level of anxiety is increasing and becoming intolerable, one option for an autistic child is to ‘shut down’ to self-protect from being overwhelmed. Considerable intellectual and emotional energy has probably been consumed trying to contain and suppress anxiety during the day. As described by an autistic adult, “When I am emotionally depleted, I need to be disconnected to look after myself.” The child desperately needs a coping strategy. An effective strategy is to become psychologically isolated, perhaps adopting the foetal position and choosing not to communicate or engage with anyone.
An Emotional Explosion or Meltdown
In evolutionary terms, anxiety is a valued emotion for survival. Anxiety alerts the body to potential danger and enables survival by releasing physical energy for ‘fight’ or ‘flight.’ A coping mechanism for high anxiety levels can be a quick, destructive release of emotional energy. Three autistic children explained how the explosion “cleanses the system”’, “clears the air” or “reboots the emotion computer”. As an autistic adult explained, “It’s a bit like wanting to vomit and knowing you will feel ill until you actually throw up. You get it over and done with and feel better. Getting it out of your system”. However, such destructive actions may alleviate the high anxiety levels of the child but will have inevitable consequences, such as punishments for arguing, fighting, and being destructive, and result in the child being labelled as aggressive.
An autistic child may suppress their anxiety at school but release the restrained emotional energy and despair when they return home. The child is almost a ‘Dr. Jekyll and Mr. Hyde’ in terms of being subdued and compliant at school but incredibly agitated at home. This is not an indication of maladaptive emotion management strategies used by parents but due to the autistic child’s feeling of being free to express suppressed negative emotions at home.
Autistic teenagers who are anxious may self-medicate using alcohol and marijuana. At low levels of consumption, alcohol is a relaxant and a tempting means of reducing anxiety. However, consumption of alcohol below a permitted age is illegal and can lead to addiction. Marijuana can very effectively alleviate anxiety and create a feeling of isolation from the negative experiences associated with the social world; thus, it may be a very tempting option for autistic teenagers. However, such emotion management strategies are potentially addictive, reduce motivation and intellectual capacity, and are illegal depending on where the adolescent lives.
If you are a parent or teacher of an anxious autistic child or a health professional who works with anxious autistic children, we recommend that you attend our upcoming event, Support and Therapy for Autistic Children & Adolescents. In this presentation we will discuss in more depth the many reasons for high anxiety in autism, and the strategies we have found that are helpful.