Investigating the Impacts of Anxiety in Children with Autism Spectrum Disorder (ASD)

Abstract

Children with autism spectrum disorder (ASD) often have various comorbid psychiatric conditions, but anxiety is one of the most prevalent. Therefore, this review focuses specifically on the unique impacts and challenges of anxiety and ASD. Data and results were analyzed from thirteen different studies, all of which were published within the last five years. The reviewed studies examined different aspects of anxiety in children with ASD and reported on various significant impacts. The most important impacts of anxiety on children with ASD are social ramifications and disparities in treatment due to psychiatric complexity and a lack of adequate personalized healthcare options. Current literature on the topic of anxiety in children with ASD demonstrates that further research must be conducted to improve the state of knowledge on this issue and to create effective solutions for mitigating negative impacts in these childrens’ lives. 

Introduction

ASD is a relatively common neurodevelopmental condition that affects about 1% of children worldwide [3,5,8,10] Children with autism have been shown to have a higher prevalence of comorbid psychiatric conditions, such as anxiety, ADHD, and depression [1,3,5,10,12]. Due to the complex nature of their conditions, children with ASD comorbid with anxiety face heightened health struggles that have significant impacts on their quality of life (QoL) [1,2]. Research indicates that some of these impacts include distinctive negative ramifications on social and family life [1-6]. Studies have also shown that disparities in treatment options for anxiety in children with ASD result from a lack of adequate research and scholarly agreement on this issue [3,5,7,9-13]. Another significant issue explored in this review is a lack of patient self-reporting, which may impede a comprehensive understanding of these conditions. Treating anxiety in children with ASD requires a greater focus on the complexities and challenges that each individual faces in their daily life. By understanding these challenges and impacts, physicians and other healthcare professionals will be able to treat anxiety in children with ASD more effectively. This paper consists of a comprehensive review of the impacts of anxiety in children with ASD and provides potential directions for future research that could aid in combating these disparities.

Social and Familial Ramifications

A noteworthy impact demonstrated in recent literature of anxiety in children with ASD is social and QoL ramifications [1,3-6]. Research indicates that children with ASD comorbid with anxiety face heightened emotional and behavioral challenges that limit participation in age-appropriate activities compared to children with ASD not comorbid with mental health conditions [4]. There has also been overwhelming evidence indicating that children with anxiety and autism face impacts on their social communication skills, including a decrease in aptitude for interactions with friends, social cue comprehension, and enjoyable activities [1,4-6]. Given the unique impacts on QoL resulting from the psychiatric complexities experienced by these children, poor social abilities are an important aspect to consider in the management of comorbid anxiety. Additional evidence has shown that school performance is also negatively impacted by anxiety in children with autism [2,3]. Personalized education, such as tailored lesson plans and adequate training of school staff, is another aspect that should be implemented to reduce the health disparities caused by anxiety in children with ASD [2,3]. 

Studies also indicate that anxiety in children with ASD contributes to significant impacts on family life and caregiver well-being [2,3,6]. One particular study found that, in contrast to neurotypical children with anxiety, children with anxiety and ASD rated the impact of anxiety to be greatest on family life². Research has also shown that many families and caregivers struggle to access adequate mental health support, which leads to consequences not only for the children, but for their caregivers as well [2,4,6]. One study found that mothers of children with autism face significant negative psychological impacts due to their struggles with managing their child’s comorbid mental health conditions [6]. Research has also shown that parents of these children face an inability to attend events or activities with their child, which can have negative impacts on their career and family dynamics [2,6]. Moreover, a large proportion of mothers felt alone, guilty, and traumatized in their struggles with healthcare professionals [6]. Due to this fragmented connection with mental health support, many families with children who experience autism comorbid with anxiety experience similar struggles in their daily lives that go unaddressed. Further research that aims to address these issues could play a role in improving the lived experiences and QoL for families of children who face these conditions. 

It is worth noting that many studies exploring the impacts on children with anxiety and ASD, especially those focusing on social and familial ramifications, are limited in their distinct lack of patient self-reporting [4-6]. These studies rely on family or caregiver insight to assess the symptoms and impacts of anxiety in these children. This may give rise to biased results, given that these individuals are directly involved with the children’s care, potentially creating an inaccurate representation of the true impacts of anxiety in children with ASD. To foster a more comprehensive understanding of this issue, additional research must be conducted that encourages patient self-reporting.

Furthermore, research has shown that children with ASD and anxiety require more personalized treatment options from medical professionals, teachers, and caregivers, including social skills programs that are better tailored to these specific conditions [1,3,5,6,11]. One study documented descriptions from children with ASD on how their anxiety affects their everyday life—over half of the children felt that others could not recognize their anxiety in school or in community settings [3]. The study therefore concluded that more personalized training can help adults recognize anxiety in children with ASD [3]. The children were also asked about the language they use to describe their anxiety, which resulted in a great deal of variability,³ suggesting that the experiences of these children are highly unique and not always consistent with one another. The researchers concluded that this highlights the importance of combining information from the children and their parents to develop a more personalized care plan for children with anxiety and ASD³. One particular group of researchers who recruited children through the Longitudinal Study for Australian Students with Autism (LASA) measured parent reports of their children’s anxiety symptoms on QoL [1]. Parents reported that their child’s autism characteristics impacted their interpretation of QoL questions, which resulted in the researchers concluding a need for further development of autism-specific measures [1]. A separate group of researchers concluded through parent-reporting that parents weren't able to adequately distinguish autism characteristics from anxiety symptoms². Similar to the results of the LASA based study, the researchers of the second study concluded that anxiety and ASD interact in complex ways that can skew a caregiver’s understanding of anxiety symptoms in children with ASD [2]. Given the distinctive impacts on QoL faced by children with autism comorbid with anxiety, further research should be done to establish adequate treatment that assesses all aspects of these issues.

Disparities in Treatment

When exploring current research on this issue, another significant impact associated with anxiety in children with ASD is disparities in treatment options [1,4-6,10-12].  Numerous studies have found that children with ASD have a greater prevalence of various comorbid psychiatric conditions, including anxiety, depression, attention-deficit/hyperactivity disorder, mood disorders, and other behavioral difficulties in comparison to children without ASD [3,5,10,12]. A limiting factor for assistance with these comorbidities in youth with autism is a lack of professional agreement on treatment or management options [3,5,7,9-13]. In terms of anxiety specifically, this largely stems from the unique and complex way the condition manifests in children with ASD [3,5,7,9-13]. Researchers maintain that there are significant knowledge gaps in measuring anxiety and promoting intervention, which impede clinical care for anxiety in children with ASD [11,12]. Studies have also shown that researchers have limited coordination in their studies concerning questions on this topic, which has further hindered the development of effective treatment strategies [5,12]. For instance, one study concluded that understanding how ASD symptoms affect treatment response, finding strategies for effective treatment implementation, and developing methods to separate the overlapping symptoms between ASD and anxiety are vital to improving treatment efficacy [12]. Given the prevalence of co-occurring conditions, researchers should investigate methods of effective anxiety diagnosis in children with ASD to prevent challenges arising from mis or absent diagnosis. The pressing nature of this issue and the apparent knowledge gaps uncovered in this study indicate that more research is needed to establish a focused understanding on the psychiatric complexities faced by youth with autism and co-occurring anxiety. 

Due to a lack of agreement, current literature suggests that there are conflicting opinions on treatment options for children with autism who are struggling with anxiety [7,9,10,13]. Researchers have stated that, due to the complexities of ASD and its comorbidities, the extent to which non-anxiety mental health conditions result from anxiety interventions is unknown [10]. Numerous studies have measured the effects of cognitive behavioral therapy (CBT) and medications for anxiety in children with ASD with varying outcomes [7,9,10,13]. One particular study that examined the effects of CBT in these children hypothesized that co-occurring psychiatric conditions, such as ADHD, would negatively impact treatment outcomes [1]. Though the researchers concluded that co-occurring conditions had no impact on anxiety-based treatment response [1], they discovered that there may have been overlap in the diagnoses of ADHD and anxiety. This might have skewed the results, indicating a reduction in symptoms of either condition following CBT [10]. This suggests that, prior to the administration of CBT, additional research is necessary to uncover ways in which anxiety can be effectively diagnosed in children with ASD, given their increased likelihood of multiple co-occurring psychiatric conditions. On the other hand, a placebo-controlled study found that mirtazapine, a commonly used antidepressant, reduces anxiety symptoms in youth with ASD to a clinically meaningful but not statistically significant extent [9]. However, this study consisted of a small, undiversified sample, and researchers stated that additional clinical investigation is needed to determine the definitive efficacy of this medication [9]. The variation in research focus present in each study could contribute to the existence of such disparities, indicating that further investigation is necessary to develop adequate treatment options. 

Conclusion 

Current research shows that children with ASD comorbid with anxiety face significant and unique impacts on their daily lives [1-13]. Studies have shown that these conditions result in distinct social and familial ramifications that are often unaddressed or poorly understood [1,3-6]. There is also an absence of patient self-reporting in research on these issues which contributes to a broader lack of understanding on how to manage anxiety in children with ASD^4-6. Additionally, recent literature lacks focused and comprehensive research on treatment options for these children [1,4-6,10-12]. This is due, in part, to the difficulties associated with addressing the complex nature in which psychiatric conditions manifest when comorbid with autism, as well as insufficient personalized care options [1,3,5,7,10,13]. Current literature provides conflicting and inadequate knowledge on this topic, which presses a need for further research. Researchers agree that this issue can be better understood with more focused studies and an increase in patient-reported data [4-6].

About the Author: Neha Ramesh

Neha is a third year Cell Biology major at UC Davis. She currently conducts research in the Hwang Lab at Davis studying pancreatic cancer metastasis as well as volunteers as the Emergency Department of the UC Davis Medical Center. She is interested in neurodevelopmental disorders as well as mental health conditions and chose to write this paper to learn more about the overlap between them.

Author's Note

I wrote this paper for a UWP104FY (Writing in Health Professions) class. The topic of anxiety and other mental health conditions in individuals with neurodivergence is one of personal and professional importance to me for a variety of reasons. In the future I hope to pursue a career in healthcare and am especially interested in understanding common healthcare inequities and steps that can be taken as a healthcare professional to address these barriers. I hope that this review can shed light on the lack of adequate treatment and care options available to children with comorbid anxiety and autism and raise awareness for the need for further research on this topic. 

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