Dual diagnosis is not an uncommon thing for individuals on the Autism spectrum. For many kiddos with Autism Spectrum Disorder (ASD), they oftentimes have symptoms of anxiety. In a 2008 study from the American Academy of Child & Adolescent Psychiatry, over seventy percent of kiddos who had been diagnosed with ASD had a dual diagnosis. Dual diagnosis, which is the existence of two separate diagnoses, can also be called "comorbid diagnosis." Furthermore, one of the most frequent comorbid diagnoses for children with autism were anxiety related.
So if you are a parent of a child with ASD and anxiety, you are not alone.
What's the breakdown?
A 2011 article published in Clinical Child and Family Psychology review outlines the following statistics and correlations.
"¦A systematic review of the literature identified 31 studies involving 2,121 young people (aged <18 years) with ASD, and where the presence of anxiety disorder was assessed using standardized questionnaires or diagnostic interviews. Across studies, 39.6% of young people with ASD had at least one comorbid DSM-IV anxiety disorder, the most frequent being specific phobia (29.8%) followed by OCD (17.4%) and social anxiety disorder (16.6%). Associations were found between the specific anxiety disorders and ASD subtype, age, IQ, and assessment method (questionnaire versus interview).
To answer the question as to what the actual connection between Autism and anxiety is not one that is easy. It's certainly correlated together, as evidenced by the aforementioned clinical study. It's tough to pin down exactly which regions of the brain are affected by ASD, just as it is incredibly difficult to nail down the neurology of anxiety. That being said, there is a lot of clinical research studies available that can provide a lot of insight as to exactly the correlated connection is between autism and anxiety.
To fully understand ASD and anxiety, we want to start by simply explaining and providing you with the clinical definitions of the two diagnoses.
On one hand, "Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and restricted repetitive behaviors (RRBs)," as it is identified in a 2015 article entitled "Characteristics of Brains in Autism Spectrum Disorder: Structure, Function and Connectivity across the Lifespan," published online by Experimental Neurobiology. The article continues to identify the symptoms of ASD change over time with the age and development of the individual. ASD is different for every individual, which makes the definition relatively fluid. However. there are many hallmark characteristics, like difficulty socializing and repetitive behaviors. For many individuals on the spectrum, these can be more or less pronounced. Diagnosis of autism should always be left to a medical professional, specifically a child psychologist, pediatrician, or psychiatrist.
The various symptoms of anxiety go as follows (list adapted from the Mayo Clinic)
- Feeling nervous, restless or tense
- The sense of impending danger, panic or doom
- Increased heart rate
- Breathing rapidly (hyperventilation)
- Sweating
- Trembling
- Feeling weak or tired
- Trouble concentrating or thinking about anything other than the present worry
- Difficulty with falling or staying asleep
- Gastrointestinal (GI) problems or irritable bowel syndrome (IBS)
- Difficulty with self-soothing worries or calming fears
While the above list is a great place to start identifying if your loved one with autism may have anxiety, it is not meant to serve as a means of diagnosis. Anxiety and its related disorders are different for everyone that has them, and the diagnosis of such should be left to a medical professional.
On the other hand,
Mood and tdisorders are characterized by a variety of neuroendocrine, neurotransmitter, and neuroanatomical disruptions. Identifying the most functionally relevant differences is complicated by the high degree of interconnectivity between neurotransmitter- and neuropeptide-containing circuits in limbic, brain stem, and higher cortical brain areas. Furthermore, a primary alteration in brain structure or function or in neurotransmitter signaling may result from environmental experiences and underlying genetic predisposition"¦
As it is defined by Psychiatric Clinics of North America, Volume 32, Issue 3, in 2009. Anxiety, like autism, manifests differently in every individual it affects. For many people, anxiety is a behavioral response to external stimuli. Anxiety can seem like a feeling of fear and worries, can manifest as a meltdown, panic attack, hives, and various other physical and emotional responses. The diagnosis of anxiety should be left to a medical professional. However, it can be easy to understand and identify anxious tendencies in anyone.
Anxiety disorders, whether it's OCD, social anxiety, phobias, or just plain old generalized anxiety disorder (GAD) are far ingrained into the brain's synapses and can be caused by genetics or environment, or both.
Here's the real breakdown of beginning to understand ASD and anxiety as a dual diagnosis. Another research study and article from 2018, published in Future Neurology attempts to provide ideas as to the prevalence of comorbid anxiety and ASD.
Comorbid anxiety complicates assessment due to the presence of core ASD symptoms, such as social communication deficits, and the potential for symptom overlap (e.g., repetitive behaviors in OCD; communication deficits due to social anxiety) provided specific assessment recommendations for this comorbid presentation by synthesizing expertise from members of the USA and Canada's Autism Intervention Research Network on Physical Health Anxiety Workgroup to provide a "useful starting point for clinicians to develop a standardized approach to the assessment and treatment of anxiety in youth with ASD". Clinicians must consider that assessing individuals with ASD requires the consideration of several unique factors. For instance, individuals with ASD are more likely to experience cognitive deficits and may communicate nonverbally or struggle to articulate internal experiences, which may impair a child's ability to articulate her inner experience of anxiety. Use of parent and teacher reports may also mask the prevalence of anxiety if raters confuse behaviors associated with anxiety as symptoms of ASD (e.g., rituals vs repetitive behaviors).
A speculated reason as to why anxiety and autism exist comorbidly so often is due to the similarity of the behaviors in the two neurological experiences. Anxiety and some of the ways that autism expresses itself behaviorally are oftentimes similar, which can perhaps provide insight as to why the two are so often diagnosed together.
It is imperative to understand, however, that Autism and anxiety are not mutually exclusive, and while studies show a positive correlation between the two, that does not mean that they are causation.
What's going on in the brain?
Just to add another "A" to the mix, let's talk about the amygdala, autism, and anxiety. The amygdala is the part of the brain that is largely responsible for processing emotions and emotional responses, like fear and the flight or fight response.
In an article from the Interactive Autism Network, published in 2018,
The amygdala has often been called a "danger detector"; and is crucial for the survival of the individual and the species. Many neuroscientists have speculated that abnormal activity of the amygdala may lead to anxiety or a sense of fear when there is no danger present. Given the link of anxiety to autism, it should not be surprising that there is substantial evidence that the structure and function of the amygdala in autism is altered.
In short, there's quite a lot of speculation that surrounds the neurological activity in the amygdala, autism, and anxiety. It is hypothesized that the reason that the two go hand-in-hand is because of the fact that the structure of the amygdala in an individual with autism is altered, and since the amygdala is also responsible for emotional processing and assessing fears, anxiety might be a direct result.
In addition, another study found that the size of the amygdala in individuals with autism and anxiety had size differences. The following information is from a 2019 article by Alana J. McVey, published in the journal from the International Society for Autism Research.
Results showed that anxiety and depression were positively correlated with total and right, but not left, amygdala volume. Results from the second study of youth with autism, which examined both structural and fMRI, found that social anxiety was negatively linked with right amygdala volume.
The study identifies that neurotypical children and adults with anxiety oftentimes have an enlarged amygdala, and "both enlarged and reduced amygdala volumes have been found in comparison to children without psychiatric disorders."
The amygdala, which is responsible for emotion processing and fear receptors in the brain, has size variances for individuals with anxiety and individuals with the comorbid diagnosis of ASD and anxiety.
What helps?
Everyone with autism is different, and the way that anxiety manifests in people varies from individual to individual. That being said, here are some great tips from our Occupational Therapist, Emily Martin.
- Keep track of it.
Keeping a calendar of when your kiddo has anxiety moments, panic attacks, meltdowns, or breakdowns can be a great way of identifying the triggers of their anxiety.
- Try weighted items
Using weighted items, like vests, blankets, and lap pads can all help decrease anxiety by administering calming proprioceptive feedback. Some kids prefer weight, and some do not, so be mindful of your child's preferences.
- Guided imagery
Before your kiddo drifts off, give them a helpful guided imagery. One of the things that our OT Emily likes is this:
https://www.youtube.com/watch?v=g69cyia-aKI
- Decreasing screen time
- Improving hygiene
- Daily organizational skills
For many individuals on the spectrum, task planning can sometimes induce anxiety. However, using task sequencing, a smartwatch, or visual schedules can encourage daily organizational skills and consequently decrease daily anxiety.
- Journaling worries with a follow-up with the family
If your kiddo is having anxiety, have them write it out. Work through it together. Don't diminish their fears, but rather help work through them and seek resolution.
- Clothing organizer
Taking away the stresses of daily life and routines by having a clothing organizer can help relieve anxiety about the school day and increase the predictability of what kiddos will wear.
- Sleep hygiene
Helping your kiddo get the recommended hours of sleep for their age bracket can severely decrease anxiety moments, meltdowns, or panic attacks. Consult your pediatrian if you need extra help getting your little one to stay asleep, as they might suggest various oral supplements in low dosages that could help them drift off to dreamland. It might be a great idea to try a weighted blanket for them, too!
- Finding balance for stress
The problem with anxiety is that it usually manifests as inhibiting fear that can manifest as unproductivity. That's the tough part about anxiety. Finding ways to balance stress, time manage, and prepare can help decrease overall anxiety.
- Cognitive Behavioral Therapy or behavioral modifications
Cognitive Behavioral Therapy (CBT) is a solution-oriented therapy for individuals with anxiety. The therapy seeks to alter the negative thoughts of an individual by identifying them and replacing them with positive behaviors. A psychologist or psychiatrist may be able to help you with this.
