E-Speaks Newsletter
Recognizing and treating anxiety in children and teens who have autism
As a group, people with autism have high rates of anxiety disorders. Anxiety also tends to have different causes and symptoms among those with autism compared to the general population. For these reasons, the Autism Speaks Autism Treatment Network (ATN) developed the first evaluation and treatment guidelines for anxiety in autism. In this two-part series, the guideline's lead author discusses insights and strategies. This work was made possible through the ATN's role as the Autism Intervention Research Network on Physical Health.
Your ATN@Work: Treating anxiety in children and teens with autism
Part 2 of our Q&A with the lead author of new guidelines for diagnosing and treating anxiety in children and adolescents with autism
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 ithere.)
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.
* Learn more about the Autism Speaks Autism Treatment Network here.
* Explore our archive of ATN expert-advice blogs and news stories here.
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The Autism Speaks blog features opinions from people throughout the autism community. Each blog represents the point of view of the author and does not necessarily reflect Autism Speaks' beliefs or point of view.
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Easing separation anxiety in a preschooler who has autism
Answers and perspective from a child psychologist in the Autism Speaks Autism Treatment Network.
Easing separation anxiety in a 4 year old with autism
“When my aunt is at work, I take care of my 4-year-old cousin who has autism. Her doctor says that developmentally she’s like an 18 month old. I’m writing because she has really bad separation anxiety. Every few minutes she asks when her mommy is coming. Do you have any suggestions on how I can help her feel more comfortable?”
Easing separation anxiety in a preschooler who has autism
Answers and perspective from a child psychologist in the Autism Speaks Autism Treatment Network.
Easing separation anxiety in a 4 year old with autism
“When my aunt is at work, I take care of my 4-year-old cousin who has autism. Her doctor says that developmentally she’s like an 18 month old. I’m writing because she has really bad separation anxiety. Every few minutes she asks when her mommy is coming. Do you have any suggestions on how I can help her feel more comfortable?”
This week’s “Got Questions?” answer is from child psychologist Michelle Spader, of Ohio’s Nationwide Children’s Hospital, a member of the Autism Speaks Autism Treatment Network.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.
Thanks for your question. It’s helpful to know that your cousin is developmentally like an 18 to 24 month old. Children at this stage often have separation anxiety. So your cousin seems to be going through something that’s both common and normal. Sometimes separation anxiety eases over time. Meanwhile, here are some suggestions to help her through the day:
Talk with her autism therapy team
Hopefully your young cousin is receiving autism-related therapy. So first and foremost, I encourage you and your aunt to enlist the members of her therapy team in addressing her separation anxiety. A speech therapist, for example, can help her learn language related to understanding past, present and future. An understanding of “future,” in particular, can help her grasp that her mommy will come for her. Her behavioral therapist or psychologist can help your young cousin develop coping strategies.
Say it with pictures and stories
Children with autism or other developmental delays often do better with visual supports than repeated verbal explanations. For example, you can create a “Where is Mommy?” page. On the paper, paste a picture of her mom at her workplace. Next to it, have a picture of your young cousin with you in your home. When she asks if her mommy is coming, point to the picture of her mom and say, “Mommy is at work right now.” Then point to the picture of the two of you in your home and say, “She’s coming here to pick you up this evening.” (Learn more about visual supports and download the AS-ATN/AIR-P Visual Supports Guide here.)
Similarly, you might try writing and illustrating a simple social story. Social stories are short narratives designed to help those with autism understand a situation. Your social story might be about a little girl who goes to stay with her older cousin while her mother is at work. Have it illustrate how the little girl misses her mother but comes to understand that her mom always comes to get her at the end of the day. (Click here for an example of a simple social story. Click here for more detailed directions for writing social stories.)
Create a daily schedule
Many individuals with autism crave predictable routines. Consider making a daily schedule that illustrates the order of your young cousin’s day. Start with the first thing that happens – perhaps “Say goodbye to mommy. Give her a kiss.” Include a photo or drawing.
The next picture should illustrate what she does next while in your care. Eat breakfast? Watch Sesame Street? Continue, in order, with the day’s predictable events (a snack, going outside to play, going to the store, etc.) The last picture will be of her mother walking into the door.
Now when your little cousin asks when mommy is coming, you can show her in the context of the day’s events.
Establish a separation routine
When your aunt leaves in the morning, it may help if she and her daughter have a simple, consistent and cheerful routine. This might be a kiss and saying, “See you later. I love you!” Please caution your aunt against sneaking out of the house when her daughter isn’t looking. In the short term, that may avoid tears. But it can backfire by causing greater anxiety.
I hope these tips prove helpful. Please let us know at GotQuestions@autismspeaks.org.
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Autism & anxiety: Help for a grade-schooler's extreme reaction to loud noise
Their son's noise-triggered anxiety attacks are so intense that this family ends up in the emergency room on a regular basis. We have advice from an expert studying cognitive-behavioral therapy for anxiety in children and adolescents who have autism.
Autism & Anxiety: Parents seek help for extreme reaction to loud noise
Our 12-year-old son has autism, mild intellectual disability and anxiety attacks so severe that we end up in the emergency room. Loud noises are the worst – for example the school fire alarm, thunderstorms, a balloon popping, fireworks. Any help would be greatly appreciated.
Autism & anxiety: Help for a grade-schooler's extreme reaction to loud noise
Their son's noise-triggered anxiety attacks are so intense that this family ends up in the emergency room on a regular basis. We have advice from an expert studying cognitive-behavioral therapy for anxiety in children and adolescents who have autism.
Autism & Anxiety: Parents seek help for extreme reaction to loud noise
Our 12-year-old son has autism, mild intellectual disability and anxiety attacks so severe that we end up in the emergency room. Loud noises are the worst – for example the school fire alarm, thunderstorms, a balloon popping, fireworks. Any help would be greatly appreciated.
This week’s “Got Questions?” answer is by Judy Reaven, a clinical psychologist and associate professor of psychiatry and pediatrics at the University of Colorado School of Medicine and Children’s Hospital Colorado, in Denver. Dr. Reaven’s conducted research on the effectiveness of cognitive-behavioral therapy for anxiety in adolescents with autism, with the support of an Autism Speaks research grant.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.
Thanks for the great question. It certainly sounds like your family is experiencing a very difficult situation. Anxiety symptoms and reactions are very common in individuals with autism spectrum disorder (ASD). They can interfere with functioning across home, community and school settings.
Although your son’s reaction sounds more severe than most, many people with autism struggle with a range of fears, phobias and worries. These can range from a debilitating fear of, say, spiders or the dark to chronic anxiety about making mistakes or being late.
Fortunately, recent research suggests that anxiety in children and adults who have autism is quite treatable. Often, these individuals are helped by the same or similar strategies that work well in treating anxiety in the general population.
These approaches include cognitive behavior therapy, or CBT. Cognitive-behavioral approaches are well-established, evidenced-based treatments that have become the gold standard of psychosocial treatments for anxiety. My own research and that of my colleagues has demonstrated the helpfulness of modifying cognitive-behavioral approaches to address the special needs of those who have autism.
Where to begin?
You describe a number of fears that may be related to sensory sensitivities. I recommend that you begin by consulting an occupational therapist who can assess whether your son’s extreme sensitivities to noises are part of a broader sensory processing disorder. If this is the case, and if your son’s fears are exclusively triggered by sensory stimuli, then his symptoms may be best addressed by a sensory-focused intervention. Many occupational therapists who specialize in autism receive special training in this area.
It’s common for children with ASD and anxiety to become extremely frightened in response to sensory stimuli. Perhaps – like many individuals with autism – your son also has difficulty telling you what’s scaring him. Instead, he may show his fear with extreme avoidance of a situation.
For example, he might refuse to go to school after a fire drill. He might become fearful of birthday parties after being frightened by a balloon that popped unexpectedly. Other signs of extreme distress can include yelling, crying, clinging and general agitation. Because your son may have difficulty communicating, it’s important to observe his behavior for these signs of distress. This can help you determine what’s triggering his fears.
Avoidance versus learning to cope
Many parents go to great pains to protect their children by avoiding agitating situations. This approach is sometimes appropriate and even necessary. However, it denies individuals the opportunity to learn how to manage anxiety-provoking situations on their own.
By helping your son learn to manage his fear, you can prepare him for an unpredictable world so that he can participate in it to the maximum extent possible.
Given the severity of your son’s anxiety symptoms, I suggest that you seek professional support in addition to the strategies offered here. Families whose children have milder symptoms of anxiety can try these strategies on their own – seeking professional help if symptoms worsen.
Tackling one fear at a time
I suggest making a list of your child’s major fears and worries. Try to rank order them from mild to severe. To encourage success, I’d start with a mild-to-moderate fear before taking on his extreme reaction to loud noises.
Key components of a cognitive behavioral approach include introducing coping strategies such as deep breathing and “helpful thoughts” that can help a person manage fearful reactions.
For example, you can teach your son to take deep slow breaths to help manage his body’s physical anxiety reactions.
“Helpful thoughts” are statements that your son can say to himself when faced with a situation that makes him anxious. For example, you can coach to your son to say, “This is a loud noise. I don’t like it, but I can handle it.”
To help your son to learn these strategies, I suggest you model taking deep breaths while repeating a “helpful thought” out loud.
Graded exposure
The most important step is to help your son face his fears a little at a time. We call this “graded exposure.” For example, explain to your son that the two of you are going to listen to a recording of thunder. The first time, you might play the recording at a soft volume, then gradually increase the volume over time as he demonstrates increased comfort with the sounds
Or you might try watching a video of a balloon pop – perhaps with the volume off the first time. Then he can watch a real balloon pop while standing some distance away. Over time, he can move closer and closer to the balloon.
After such exercises, you can present him with small rewards for being brave and “facing fears.” Remember that even a small act of bravery – such as listening to a recording of thunder for 10 seconds – represents an important step toward handling fears. It deserves to be acknowledged.
Although graded exposure may seem counterintuitive, research indicates that this strategy is the single most effective strategy for getting over a particular fear.
I wish you and your son the very best. Please let us know how you’re doing with an email to GotQuestions@autismspeaks.org.
Editor’s note: Also see these related “Got Questions?” blog posts from our archives …
Managing Anxiety in Children with Autism
What behavioral therapies can help someone with autism and severe anxiety?
Reducing Anxiety in the ER
How common are anxiety disorders in people with autism? Are there effective treatments?
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Autism and social phobia: Help for an anxious teen
Expert advice on easing the social anxiety that has kept this teenage girl largely housebound, from a leading expert in treating anxiety in those on the autism spectrum.
Autism and school phobia: Parents seek help for anxious teen
Autism and social phobia: Help for an anxious teen
Expert advice on easing the social anxiety that has kept this teenage girl largely housebound, from a leading expert in treating anxiety in those on the autism spectrum.
Autism and school phobia: Parents seek help for anxious teen
My teen daughter has Asperger’s and extreme social anxiety. It started to get worse at 13, resulting in refusing school. It has progressed to hardly leaving the house at all and no education as such for 2 years. She is 15 now, and no one seems to be able to help. I am at a loss too. How do I get her through
this?
This week’s “Got Questions?” answer comes from Jeffrey Wood, PhD, a psychologist at the University of California, Los Angeles. Three Autism Speaks research grants support Dr. Wood’s work on adapting cognitive behavioral treatments for children and teens with autism.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.
Thanks for the question. Unfortunately, anxiety – including social anxiety – is very common among children and teens on the autism spectrum. Many of these kids have a particular problem going to school. In fact, the problem is so common that we have a term for it: school phobia, or school refusal. Sometimes, school phobia involves the broader fear of leaving the house, also known as agoraphobia.
Sometimes these phobias stem from a specific fear such as a fear of having a panic attack in public. In other cases, it reflects more general social anxieties and fears around embarrassment or humiliation in public.
We’ve found great success easing both school phobia and agoraphobia with cognitive behavioral treatment (CBT) approaches, which I’ve described in previous posts to this column.
Cognitive behavioral therapy is a widely accepted psychological approach for breaking severe cycles of anxiety. Through extensive research, our group and others have shown that modified forms of cognitive-behavioral therapy can work particularly well with children and teens who have autism.
The first step in this process involves helping the child or teen identify the root of his or her fears. In second step involves taking small, incremental steps to approaching the feared situation and becoming more comfortable, or “habituated,”with the situation.
In your daughter’s case that would mean working with a cognitive behavioral therapist on gradually re-entering school. For instance, the therapist might begin by having your daughter simply step out the front door for a few minutes – or even seconds. In this way, your daughter would begin the process of habituation, and build up from there.
Next, the therapist might work with you and your daughter on briefly visiting the parking lot of the school, then the entryway of the school, the office and so on. Each small step in the right direction warrants praise and reward. Shaming is never a part of the process.
The therapist is likely to take the same or similar approach with social interactions: developing a list of easy to hard social situations and coaching your daughter through each until her anxiety is reduced to a reasonable level before moving to the next level.
Patience is important. After a long time out of public situations, most people are very cautious and avoidant. They need to take it slowly. A good cognitive-behavioral therapist can guide progress through this delicate early phase of treatment.
A good resource for finding a cognitive behavioral therapist is the Association for Behavioral and Cognitive Therapy. You can find local therapists through the associations “Therapist Finder” here.
You may be able to access these services free of charge through your local school system’s Individualized Education Plan (IEP) for your daughter. I would encourage you to work with the school system to evaluate your daughter’s needs and develop a comprehensive educational plan that supports her re-entry. What school placement, grade level and accommodations does she need? A qualified psychologist can perform the needed testing to guide you and the school on providing the appropriate educational environment to support a successful transition back to school.
Meanwhile, if you haven’t already, I encourage you to work with your school district to meet your daughter’s current educational needs, perhaps with in-home services.
In addition, your child’s physician and/or your health insurer may be able to provide a referral to an expert in child anxiety who practices cognitive behavioral therapy and is experienced working with children who have autism.
In other posts to this advice column, my colleagues and I have written extensively about anxiety and autism – particularly on the effectiveness of cognitive behavioral treatments. I think you’ll find them relevant to your issue:
Thanks again for your question. Please let us know how you and your daughter are doing by writing us again at gotquestions@autismspeaks.org.
Readers: Got more questions? Send them to GotQuestions@AutismSpeaks.org.
You can also contact the Autism Speaks Autism Response Team (ART). ART members are trained to connect families with information, resources and opportunities. They are available to answer calls and emails from 9am to 1pm local time.
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Research yields tips for easing anxiety in nonverbal kids with autism
This Autism Speaks Weatherstone fellow and his mentor are adapting a highly effective anxiety therapy to meet the needs of those severely affected by autism with intellectual disability.
Research yields tips for easing anxiety in nonverbal kids with autism
“I have a nonverbal 6-year-old grandson with severe autism. Going to the lake had been his one great love. He would wade for hours. But on the last of many boat rides, he suddenly reacted badly to the sound of the engine. Since then, he’s become extremely frightened of any boat engine noise and won’t go near the shore. As soon as he hears even the faintest boat sound (miles away), he dashes to the cottage or car where he feels safe. What can we do to help?”
This week’s “Got Questions” response is by psychologist Jeffrey Wood, of the University of California, Los Angeles (above left), and Autism Speaks Weatherstone Fellow John Danial. An Autism Speaks research grant helped support Dr. Wood’s pioneering work on developing behavioral treatments for school children with autism and anxiety. Under Dr. Wood’s guidance, Dr. Danial’sWeatherstone research project involves adapting these highly effective anxiety therapy techniques for children severely affected by autism complicated by intellectual disability.
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.
Thank you for your question. It reflects many that we have heard concerning new fears that have put an end to once-beloved activities such as watching trains or airplanes or even birds. Research has confirmed that anxiety is very common among children – and adults – who have autism.
Research yields tips for easing anxiety in nonverbal kids with autism
This Autism Speaks Weatherstone fellow and his mentor are adapting a highly effective anxiety therapy to meet the needs of those severely affected by autism with intellectual disability.
Research yields tips for easing anxiety in nonverbal kids with autism
“I have a nonverbal 6-year-old grandson with severe autism. Going to the lake had been his one great love. He would wade for hours. But on the last of many boat rides, he suddenly reacted badly to the sound of the engine. Since then, he’s become extremely frightened of any boat engine noise and won’t go near the shore. As soon as he hears even the faintest boat sound (miles away), he dashes to the cottage or car where he feels safe. What can we do to help?”
This week’s “Got Questions” response is by psychologist Jeffrey Wood, of the University of California, Los Angeles (above left), and Autism Speaks Weatherstone Fellow John Danial. An Autism Speaks research grant helped support Dr. Wood’s pioneering work on developing behavioral treatments for school children with autism and anxiety. Under Dr. Wood’s guidance, Dr. Danial’sWeatherstone research project involves adapting these highly effective anxiety therapy techniques for children severely affected by autism complicated by intellectual disability.
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.
Thank you for your question. It reflects many that we have heard concerning new fears that have put an end to once-beloved activities such as watching trains or airplanes or even birds. Research has confirmed that anxiety is very common among children – and adults – who have autism.
Many children – and adults – with autism struggle with extreme anxieties and phobias. Nonverbal individuals, in particular, can have difficulty explaining their fears.This is true regardless of where a child may be on the autism spectrum. But no doubt being nonverbal can add to the challenge because the child may feel unable to communicate what’s making him or her anxious.Naturally, this can likewise be extremely frustrating for family members and other caregivers who want to help the child. We know it’s difficult to see your grandchild struggle with fear and anxiety without being able to effectively communicate with him.
Unfortunately, there have not been many treatment options to help minimally verbal children with autism and severe anxiety.
With the support of John’s Autism Speaks Dennis Weatherstone Fellowship, we are developing and evaluating a treatment program that incorporates strategies designed to help children with communication difficulties cope with anxiety and phobias.
Six children with severe autism and anxiety have now completed the intervention. With further refinement and scientific evaluation, we hope this program will help many children and their families.
Meanwhile, we have been presenting and discussing our program at professional meetings and are glad to share some of its strategies with you today.
1. Enlist professional help is available
It’s important to note that the strategies we developed are considered experimental when used with minimally verbal children who have autism. They are adaptations of strategies proven to help children and adults on the less-severe end of the autism spectrum.
They’ve shown themselves helpful in the hands of trained therapists, and we believe parents, grandparents and other care-givers can likely use them to help children as well. In fact, there are many books on the market about how to help anxious children face their fears.
That said, we encourage you to involve a behavioral therapist who is familiar with autism as well as your grandson’s pediatrician or other primary care physician. In this way you can reduce the likelihood of inadvertently making the problem worse or otherwise causing undue stress.
A beloved toy or video character can help you and your child play act the frightening situation. Flickr photo courtesy Daniel Go.2. Approach the anxiety-producing situation in a playful way using beloved characters
In our program, we use a child’s special interests to talk about the scary situation. Does your grandson have a favorite cartoon, TV or movie character? For example, one might use an Elmo stuffed animal to “act out” the scary situation.
Let’s use the example of a child who is scared of birds. In this play scenario, you or your grandson might have Elmo happily wade into a pretend lake. One of you could then have a toy bird approach. Elmo might hide his eyes or run away.
We find it’s important for the child to actively participate in the story. So encourage your grandson to hold and move Elmo and/or the toy bird as you act out the scene. If he’s not ready for that, try asking him to point at the bird or Elmo for starters.
3. Help the child recognize emotions
As part of this play-based approach, we can gently help a child learn to identify his or her emotions. This process can be as simple as pointing to a picture of a “scared” face when Elmo sees the bird and saying “Elmo feels scared.” As you may know, being nonverbal or minimally verbal doesn’t mean a child doesn’t understand language.
Recognizing emotions can be an important first step in developing coping strategies. Using a character to model anxiety helps many children calmly think about what’s been frightening them – while making the connection between the situation and feeling scared.
Editor’s note: Visual supports help many nonverbal and minimally verbal children communicate.
In our program, we use a child’s special interests to talk about the scary situation. Does your grandson have a favorite cartoon, TV or movie character? For example, one might use an Elmo stuffed animal to “act out” the scary situation.
Let’s use the example of a child who is scared of birds. In this play scenario, you or your grandson might have Elmo happily wade into a pretend lake. One of you could then have a toy bird approach. Elmo might hide his eyes or run away.
We find it’s important for the child to actively participate in the story. So encourage your grandson to hold and move Elmo and/or the toy bird as you act out the scene. If he’s not ready for that, try asking him to point at the bird or Elmo for starters.
3. Help the child recognize emotions
As part of this play-based approach, we can gently help a child learn to identify his or her emotions. This process can be as simple as pointing to a picture of a “scared” face when Elmo sees the bird and saying “Elmo feels scared.” As you may know, being nonverbal or minimally verbal doesn’t mean a child doesn’t understand language.
Recognizing emotions can be an important first step in developing coping strategies. Using a character to model anxiety helps many children calmly think about what’s been frightening them – while making the connection between the situation and feeling scared.
Editor’s note: Visual supports help many nonverbal and minimally verbal children communicate.
Learn more about visual supports and download the Autism Speaks ATN/AIR-P visual supports tool kit here.4. Develop a soothing phrase, or “mantra”
We’ve found that repeating a short reassuring phrase, or “mantra,” helps many children with autism face a feared situation. For example, that phrase for the child overcoming a fear of birds might be: “Birds are buddies.” For a fear of airplane noise, it might be: “Airplanes are awesome.”
Some minimally verbal children can repeat a short phrase they’ve just heard. Some will repeat the same phrase or phrases over and over. For children who have no language, a caregiver can repeat the phrase. In fact, we’ve found that with some children, hearing the phrase is particularly helpful.
Next, we put these steps together:
5. Replay the pretend scenario with the new mantra.
Once a child has practiced identifying his toy character’s fearful response, you can begin to alter the narrative of the story. Instead of Elmo running away, for example, he may wait in the water and watch the bird fly by. He might listen to the bird’s call and say, “Wow that’s loud!” while staying in the water. Then the caregiver and/or child can repeat that reassuring mantra.
As mentioned earlier, we found it’s particularly important to encourage the child to participate in the play scenario. So encourage your grandson to hold one of the props or at least point to them as you move them at first.
Another key, we found, is to make sure the game is playful and positive. In other words, lighten up and have fun!
In our program, we play-acted the scenario at least several times before beginning what we call the “exposure” phase, which we describe below.
6. Building experience in a slow, safe and gradual way
After play acting scenarios involving the feared situation, animal or object, your child may be ready to watch some related videos – perhaps with the sound muted at first.This is by far the most important step for easing the symptoms of anxiety symptoms. It is important to remember a key finding from anxiety research: Feared situations must be presented very gradually and with reassurance.For a child who is afraid of a type of an animal, for example, we might start by watching an online video of the animal. We might keep the volume muted at first to further reduce any associated stress. At the same time, we’re repeating the reassuring mantra and encouraging the child to do so as well.
In the fear-of-birds scenario, we might use a variety of videos with different types of birds. This helps promote what we call “generalization.” It’s the ability to apply learning to different situations. In this case, we want the child to experience different types of birds approaching in different ways, with different sounds and in different environments.
Here again gradual is the key word to remember. We might have a child watch one short, muted video clip per day for the first week. An important part of this phase of therapy is to reward the child with praise and/or a treat each time he or she completes a video clip. This treat might be a favorite activity or snack.
Future steps can include watching video clips with the volume turned a little higher – again using that reassuring mantra.
When a video of the situation no longer provokes anxiety, see if the child is ready for a very gradual approach in the real world – in this case, observing a boat in the distance. Photo courtesy AlexFreeStockVideo.7. Stepping out into the real worldWhen watching a video clip no longer produces anxiety, the next step might be to watch an actual bird at a distance. In subsequent tries, we might come a bit closer. The grand finale might be a trip to a zoo or sanctuary to see birds up close.
While we’ve been focused on birds here, the same therapy approach is used for many different feared objects and situations.
In every case, these steps must be selected carefully based on the child’s needs. Our program emphasizes that every child should feel in control and never too scared.
It’s equally important that the child show willingness to try each subsequent step in the process.
Habituation
The goal is for the child to become “habituated.” This is a form of learning where someone stops reacting to a situation after repeated exposures. In the case of an anxiety-inducing situation, the fear is reduced considerably, at least under certain supportive circumstances.
We hope these strategies will prove helpful to you and the larger autism community and that they may contribute, ultimately, to a lessening of anxiety problems for people across the autism spectrum. We hope you and other readers will let us know how you are doing in the comment section below. Or email us again at
Readers: Got Questions for our behavioral and medical experts? Send them to GotQuestions@AutismSpeaks.org.
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