Anxiety and ASD: Current Progress and Ongoing Challenges
J Autism Dev Disord
Anxiety and ASD: Current Progress and Ongoing Challenges
Mikle South 0 1 2
Jacqui Rodgers 0 1 2
Amy Van Hecke 0 1 2
0 Marquette University , Milwaukee , USA
1 Newcastle University , Newcastle upon Tyne , UK
2 Brigham Young University , Provo , USA
3 Jacqui Rodgers
Symptoms of anxiety add significant burden to many autistic individuals and their loved ones. There is an urgent need for better understanding of the unique underlying mechanisms of anxiety in ASD, and for the development of more specific assessment methods and treatment recommendations. This special issue brings together 24 articles grouped into three themes; mechanisms, measurement, and intervention. The result is a review of current anxiety research in ASD that is both broad and deep. Key themes include recognition of the importance individual differences in aetiology and presentation of anxiety in ASD, the need for a more nuanced understanding of the interactions between anxiety and characteristics of ASD and the need to develop appropriately adapted treatments. This special issue of the Journal of Autism and Developmental Disorders (JADD) aims to showcase the most recent research on anxiety in ASD. Around 50% of autistic individuals will experience anxiety that significantly impacts on their daily lives and the lives of their loved ones. When present, anxiety reduces quality of life and interferes with education, employment, and achievement of potential. The urgent need to address this pressing clinical issue was highlighted by the Autistica Priority Setting Partnership (2015), undertaken in collaboration with the autism community in the UK, which identified mental health concerns as the top priority for autism research with specific emphasis on the development of interventions to reduce anxiety identified as amongst the top five research priorities. The idea for this Special Issue arose as a consequence of discussions which took place at the Anxiety and ASD Special Interest Group at the International Meeting for Autism Research in 2015, with the call for papers issued in summer of 2015. We have been privileged to receive very many high quality submissions, all of which have been subjected to standard peer review processes. The outcome of this endeavour is this special issue, comprising 24 excellent papers from the leading international researchers in the field. Our aspiration was to present to JADD readership the most up-to-date scientific and methodological developments in the field. The papers included in this special issue fall into three broad themes: (1) mechanisms and correlates underpinning the development and maintenance of anxiety in ASD, (2) issues with measurement, assessment, and stability of anxiety in ASD, and (3) interventions for anxiety for autistic people.
The first theme concerns mechanisms and correlates of
anxiety in ASD. Herrington and colleagues identified decreased
right amygdala volume in a relatively large sample of
children diagnosed both with autism and an anxiety disorder,
compared to a group of autistic children with no anxiety
disorder. An important take-away from the study is that a
onesize-fits-all approach for treatment of anxiety and related
concerns is unlikely to be helpful. Turning to
physiological mechanisms and threat responsivity, South et al. found
that autistic children showed lower skin conductance
activity to a potentially threatening stranger; skin conductance
activity was related to anxiety symptom severity and also
to movement confounds, highlighting the need for
precision of measurement. A diminished threat response fits with
data presented by Grossman and colleagues, who examined
state versus trait anxiety in autistic adolescents, finding that
higher trait anxiety in ASD may contribute to dampened
physiological stress responses. Finally, research by
Milosavlejevic et al. found expected high levels of anxiety in autistic
children, but also found that threat sensitivity may present
more strongly in siblings of autistic children versus children
who meet criteria for ASD themselves, perhaps pointing to
a familial mechanism linking anxiety and ASD.
Studies of anxiety across neurodevelopmental conditions
are important for establishing areas of overlap and difference
that contribute to understanding of underlying cause and the
development of targeted intervention strategies. A group of
papers in this issue discuss the specificity of anxiety and
its relation to ASD versus other aetiologies: Crawford et al.
examine ASD and Fragile X, Cornelia de Lange, and
Rubinstein-Taybi syndromes; Roberts et al. examine ASD, Fragile
X, and anxiety in pre-schoolers; Factor et al. and Schiltz
et al. examine ASD and ADHD; and finally, Smith-Johnston
and colleagues consider clinical depression as a factor linked
to social competence in ASD. Royston et al. explicitly
examined the possible contribution of intellectual disability (ID)
to anxiety: their meta-analysis concluded that risk for
anxiety in Williams Syndrome was four times greater than the
risk arising from ID alone.
A final group of papers for this theme focus on correlated
symptoms and concerns that may contribute to anxiety in
ASD: Joyce et al. examine intolerance of uncertainty as both
an indicator and contributor to symptoms of ASD and
patterns of anxiety; Capriola et al. and Kleberg et al. focus on
social challenges, including fear of negative evaluation and
orienting to eyes, respectively, as mechanisms underlying
social anxiety in ASD; and, Oszivadjian and colleagues find
that anxious imagery is even more prevalent in ASD than in
children with anxiety alone. These papers collectively
reinforce the importance of considering very specific
mechanisms of anxiety in planning treatment across individuals.
Measurement, assessment, and stability make up the
second theme. Papers in this group include Glod et al.’s and
Jitlina et al.’s examination of psychometric properties of the
Spence Children’s Anxiety Scale, with both papers
suggesting areas of needed improvement. Finally, both Magiati et al.
and Schiltz et al. find stability over time for presentation
of anxiety symptoms in autism. As new measures of
anxiety that have been developed specifically for autism become
(for example, see Kerns et al. 2017; Rodgers et al.
it will be vital to sort out how typical and atypical
anxiety interact across neurodevelopmental conditions and
The final theme considers issues related to treatment of
anxiety in ASD. Clarke and colleagues, and Kovshoff and
colleagues, present promising results of randomized
controlled trials of
) Exploring Feelings
schoolbased cognitive behavioural therapy (CBT) for anxiety in
autistic children. Drmic and colleagues present similarly
promising results for a school-based adaptation of the
Facing Your Fears
(Reaven et al. 2012)
autistic adolescents.. Maddox et al. present impactful research
on the durability of CBT over time, as well as predictive
concomitants. Moskowitz and colleagues present a multiple
baseline trial of a positive behaviour and CBT intervention
for anxiety in autistic children with ID, showing promising
results on both behavioural and psychophysiological
measures. Keefer and colleagues examined how intolerance of
uncertainty (IU) poses additional challenges when delivering
adapted CBT: children with high IU scores at baseline
benefitted less from a standard approach. They suggest that
children with high levels of IU—with or without autism—may
benefit from targeted intervention as part of CBT. This idea
is supported by the innovative intervention developed by
Rodgers and colleagues, which specially focused on
assisting parents in handling challenges with IU in their autistic
Broader and Deeper: Blueprints for Future
We believe that the research presented here is an exciting
overview of the field. There remains, however, much still
to be done and many unanswered questions. Of note is the
paucity of research on anxiety in autistic adults, or those
with comorbid intellectual disability. Investigation of
potential gender differences in emotion awareness and coping
response will be critical for accumulating research on gender
differences in ASD symptom presentation, diagnosis, and
(McVey et al. 2017; Pisula et al. 2017)
One critical question not answered by existing studies is
how brain and physiological responses may be different for
autistic people who present with symptoms of anxiety that
do not fit traditional criteria for anxiety disorders, including
what Kerns and colleagues (2014) have labeled as
From a methodological standpoint, there has been a heavy
reliance on self or proxy report questionnaires, often
utilising tools which have not been developed for or validated
with autistic people. Understanding how questionnaire data
and physiological data can inform each other has been
difficult for anxiety researchers generally, perhaps because of
faulty conceptual frameworks
(LeDoux and Pine 2016)
may be an especially problematic task in the context of ASD.
The use of multi-trait, multi-method study designs is
essential, but so is the need for flexible, innovative frameworks of
how brain and behaviour interact in anxiety and ASD. Much
of the existing work is cross-sectional, significantly
impacting on our understanding of the developmental trajectory of
anxiety in autism.
The inclusion of atypical sensory processing in the
diagnostic criteria for autism is new with DSM-5, but has
a long history of clinical relevance
(Leekam et al. 2007;
O’Neill and Jones 1997)
. There is now growing evidence
for links between sensory function and anxiety along with
autism core symptoms including repetitive behaviour and
(Beaumont et al. 2015; South and
. Future research including questionnaire,
physiological and imaging paradigms will be useful for clarifying
underlying mechanisms that link these important constructs
together. Treatment regimens that integrate sensory
regulation, emotion regulation, and social skills training are an
important avenue for study.
We give thanks to the International Society for Autism
Research for sponsoring the IMFAR special interest group
that got this ball rolling, and to JADD editorial and
production staff for their support of the project. We hope that the
canon of work presented in this Special Issue of JADD will
serve as a further call to arms for current and future autism
researchers to continue to pursue these and other important
MS, JR and AVH contributed equally to all
aspects of this manuscript.
Compliance with Ethical Standards
Conflict of interest None of the authors have any conflicts of
Research Involving Human and Animal Participants This article
does not contain any studies with human participants or animals
performed by any of the authors.
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