Supplemental Information for Autism: Understanding Anxiety in Autistic Children

Anxiety Disorders and Core Symptoms

Common Anxiety Features in Autistic Children

Social Anxiety Disorder: anxiety about other people thinking badly of you, fear of being judged, fear of embarrassment, fear of rejection in social situations, and in autism, fear of not understanding how to act in social situations.

Autistic children can often be nervous in situations where they have to understand the social situation and use social skills to interact with others. Autistic children often do not understand social expectations, which can cause significant anxiety. They might also worry about being rejected by others because of how they are different.
Alternatively, autistic children may avoid or withdraw from social situations because they prefer to play alone. In this case, children are not fearful of social situations, but rather they are not interested in them. This is important to distinguish as we do not want to treat something that is a child's preference.

Specific Phobias: extreme fear and distress because of a specific object or situation.
Common fears: animals, natural environments (like storms), blood, injection, or injuries, situations like being somewhere high, or something else.

Autistic children can have uncommon fears like beards, toilets, or certain shapes.
They can also be afraid of loud noises or specific sounds. However, they may also avoid loud noises, not because they are afraid of them, but because they are very sensitive to those noises.

Separation Anxiety Disorder: anxiety about separation from loved one (usually the caregiver) and/or being away from the home.

Autistic children can be very rigid about family routines when they have separation anxiety, or feel like everything has to go the same with family every time (for example, if one parent has to take them to school every day).

Generalized Anxiety: uncontrollable negative thinking across a range of everyday topics happening over and over. Children with generalized anxiety are commonly afraid of making mistakes, getting in trouble, perfectionism.

Autistic children can have daily worries that often involve sticking to schedules and experience a lot of distress when they face new situations and changes to routine.
Their daily worries can also be tied to their special interests (for example, if they might not have enough time to do their favorite things).

Panic Fears: child experiences unexpected panic attacks over and over, which is when someone feels extremely scared very quickly. Some youth becomes anxious about the future attacks they might have. These fears are not too common in younger children.

Autistic children may have unique presenting features due to their sensory sensitivities or body-related self-soothing behaviors.

Selective Mutism: child cannot speak and respond to others in certain settings in which the child is expected to speak e.g., school (although the child is able to speak in other settings).

Sometimes selective mutism is caused by severe social anxiety- children might not speak because they worry what others will think of them or that they will say something wrong. In other cases, children may have trouble using words to communicate. In some cases, it can be a combination of both. Lots of autistic kids have trouble using words to communicate, so it can be difficult to figure out autism-related language and communication challenges, lack of social interest, selective mutism caused by social anxiety.

Agoraphobia: fear about situations where the child cannot easily escape or get help if needed (like in enclosed places or big crowds).

Autistic children may find it difficult to explain why they are afraid in these situations. They can have meltdowns/tantrums in these situations.

Autism-Specific Fears: In addition to these disorders described above, some fears may be specific to autism and do not usually occur in children without autism. They are listed to the right.

Some children may worry excessively only about their special interest. For example, they may worry about having enough time to engage in a special interest (for example, playing with trains), or fear losing something related to that special interest (for example, a toy train).
Other children may only fear changes in routine, even if they are very minor. For example, children may worry very much if a different caregiver picks them up from school, if they have to drive on a different route than their typical way, or if their caregiver wears contact lenses after usually wearing glasses.

Obsessive-Compulsive Disorder (OCD): child experiences unwanted thoughts (obsessions) and performs repetitive behaviors (compulsions) to relieve distress from the thoughts.
Common themes include contamination (fears of contamination and washing or cleaning behavior), harm (fears of harm and checking/reassurance-seeking), taboo thoughts (having "bad" thoughts and checking or reassurance-seeking behaviors), and/or symmetry (needing things to be "just-right" or even).

Many autistic children have repetitive behaviors, like playing a favorite game over and over, or think about a topic they enjoy over and over, but this might not mean they have OCD, which involve thoughts and behaviors that cause distress. The need for something to be "just-right" in OCD can overlap with repetitive autistic behaviors that lead to feelings of satisfaction. Similarly, sensory issues seen in autism can overlap with the disgust felt in OCD obsessions related to contamination.