What do we know about anxiety in autism and other developmental disabilities?

Anxiety is what we call an internalizing symptom, meaning that it occurs inside of our bodies as both physical feelings and anxious thoughts. For example, a child who is anxious about COVID-19 may have physical symptoms – upset stomach, racing heart – as well as negative thoughts – “What if I get the disease?” It is estimated that up to 40% of individuals with autism experience anxiety, and studies have reported similar rates in individuals with intellectual disabilities.


How do I know when my minimally verbal or nonverbal child is anxious?

Many children with developmental disabilities regardless of language level have difficulty communicating their thoughts or describing their physical feelings in their body. Look for changes in behaviors such as sleeping and eating habits that could be signs that your child is anxious or worried. Disruptive or aggressive behaviors may also be signs of anxiety or worry; you may notice that your child has been increasingly irritable or quick to react. These changes in behavior can give us clues into how the body is feeling.


Is there a treatment for anxiety for my child with special needs?

There have been several research studies looking at the best way to treat anxiety in developmental disabilities. These studies show that modifications to a behavioral treatment called Cognitive Behavioral Therapy (CBT) can be very helpful in decreasing anxiety symptoms. The basic idea behind CBT is that we can feel less anxious by changing our thoughts and calming down our physical body.


How can I help with my child’s anxiety?


Practice a calm body: Schedule times in the day for your child to practice calming his or her body. The simplest example is taking deep breaths. Try breathing in through your mouth for 3 full seconds, holding your breath for 1-2 seconds, then breathing out through your mouth for 3 full seconds. Using visuals may be helpful, such as this reminder of the steps of deep breathing or using bubbles to practice breathing in and blowing out. I also often teach full body relaxation, such as this video on muscle relaxation. The goal is to practice doing these activities even with the body is calm, so that when the body feels stressed or anxious, we can access these tools easily.


Teach brave thoughts: It is important to validate your child’s feelings of anxiety and fear, such as saying “I understand you are worried.” Saying things like “don’t worry” may make it seem like they should not be worried. However, feeling anxious or worried is very normal, especially under the current circumstances. What we want to do is challenge anxious thoughts with positive thoughts, such as giving facts. For example, to replace the negative thought “I may get sick”, your child can say “If I wash my hands and stay 6 feet away from people, I am keeping myself safe.” Similarly, practicing affirming thoughts can instill a sense of self-confidence, such as saying “I am brave” or “I can do this.” Create a list of positive thoughts with your child for them to look to in moments of high anxiety. You may even consider writing the negative thoughts and then replacing with positive thoughts or facts as is illustrated in this worksheet.


Take control of anxiety: One activity to help your child feel in control of their worry is to create a “worry bug” or “worry bully” — that is, a character that tries to bully your child into thinking negative thoughts. Then, encourage your child to create a superhero that can help to conquer the worry bug. When your child is anxious, you can remind him or her that their “worry bug” is taking over. Then, remind your child to use their superhero powers to defeat their “worry bug”, such as relaxing their body or thinking brave thoughts.


Maintain a routine: In my last post, I commented on the importance of developing a daily routine as best you can. Not only can a routine help develop a sense of normalcy for your child, it can also significantly decrease stress and anxiety by eliminating some of the “unknown” in their day.


Encourage physical activity: Daily physical activity, such as going for a walk or stretching your body, can help lower your overall stress level and has a positive impact on your mood. Make this a family activity by going for a walk around the neighborhood while maintaining physical distance from others or put on an exercise video to do in your home.


How do I know if I may need to seek professional help?

Keep in mind that anxiety is manifested in different ways, such as verbalizing fear or demonstrating changes in mood, behaviors, eating and sleeping habits. If you have concern that your child may be experiencing significant levels of distress, I advise you to seek support from a professional such as your child’s primary health care provider or a child therapist.


Do you have any suggestions of books or workbooks for more information?

I recommend the workbook What to Do When You Worry Too Much: A Kid’s Guide to Overcoming Anxiety by Dawn Huebner as an activity to do with your child. If you’re interested in reading more about anxiety treatment, I also recommend the book Freeing Your Child from Anxiety by Dr. Tamar Chansky. For more autism specific resources, consider programs such as Superflex: A Superhero Social Thinking Curriculum by Stephanie Madrigal and Michelle Garcia Winner as well as the group anxiety treatment program Facing Your Fears by Judy Reaven, Audrey Blakeley-Smith, Shana Nichols, and Susan Hepburn.


Click Here for Part 3 “Maintaining a Schedule.”


This post is part of a multi- part series of articles written by Dr. Jamie Barstein, child clinical psychologist at The Help Group with expertise in working with individuals with autism spectrum disorder and other developmental disabilities as well as their family members. 

Contributions to this series were made by Dr. Laurie Stephens, Director of Program Development at The Help Group.