Reducing Anxiety

Anxiety is one of the most common challenges faced by autistic youth. As parents, when we see our children afraid or anxious, we naturally try to make them feel better. This includes allowing our children to avoid what makes them anxious or reassuring them that what they are afraid of will not happen.

Although this may reduce our child’s anxiety in the moment, it does not help them deal with anxiety in the long run; instead, this may inadvertently reinforce or maintain our child’s anxiety. When we avoid or escape what makes us anxious, we never learn we can handle it.

Gradual Exposure: The most critical part of treating anxiety is to face your fears, which is usually done in baby steps.

For example, if a child is afraid of pools, we would not force them to jump in; instead, we would encourage them (using strategies described later) to first dip their toes in the water, followed by their foot and, when they feel ready, their leg, up to their stomach, etc. The pool might feel cold at first but, after a while, it will not feel so cold anymore. 

The more you repeat an anxiety-provoking activity or stay in a feared situation rather than avoiding it, the more you get used to it, and the feeling of anxiety usually diminishes. More importantly, by facing our fears, we learn that we can tolerate or cope with fear and anxiety; we can do hard things!

Crucially, we never want to force a child to endure what makes them anxious. Instead, the child should always have the choice of whether to confront their anxiety. Too often, autistic individuals are not given any choice or control over their lives, which can be extremely anxiety-provoking. 

It is important to acknowledge that not every fear needs to be faced. Therefore, when deciding whether it is necessary for your child to face their fear, ask yourself: is it interfering with your child’s or family’s quality of life? If not, then it may not be worth targeting. 

That said, there are many cases in which it may not be desirable or possible to avoid the anxiety-provoking situation. This is where exposure comes in. 

However, since exposures can be incredibly challenging, here are several strategies to help children face their fears: 

Positive Reinforcement

Rather than forcing your child to face their fears, you should encourage or motivate them to do so by reinforcing or rewarding their brave behavior (e.g., petting a dog).

Usually, if a child is motivated enough, they will face their fears. However, the reinforcer for exposures must be more powerful than the relief from escaping/avoiding the feared situation. 

Additionally, the reward should be reserved exclusively for the exposure; if your child always has access to the reinforcer, it will lose its power. What does your child like the most? 

For example, if their favorite thing is Minions, you can allow them to watch a new Minions video or offer them a new Minions toy as a reinforcer for attempting exposures – but they cannot access that video or toy at other times. 

Although some parents do not like the idea of reinforcement, all of us need rewards to do things that are hard, and facing our fears is the hardest thing that we can possibly do. 

Incorporating Special Interests

Using your child’s intense or “special” interests as a reward or incorporating their special interests into the exposure itself can help them face their fears. 

For example, for a child with autism who was afraid of turning left/right while riding in the car, we paired this with his main special interest, Dr. Seuss. We made special audio recordings of Dr. Seuss’s books that he was only allowed to listen to during car rides.

Pairing the anxiety-provoking situation (left/right turns) with an even more powerful special interest (Dr. Seuss) appeared to counteract the aversiveness of the anxiety-provoking situation in a way that exposure alone may not have, or at least, may not have as quickly (Moskowitz et al., 2017). 

Although he still noticed the left/right turns, he no longer appeared distressed by them. 

Coping Self-Talk

While parents often try to reduce a child’s fear by downplaying its threats (e.g., “There’s nothing to be afraid of”), it is more effective to teach children they can cope with feared situations (e.g., “You can do it!”).

Cognitive restructuring, a specific technique which challenges anxious thoughts and replaces them with coping thoughts, can be adapted for autistic youth by simplifying it, using concrete visuals (e.g., pictures or videos), and incorporating special interests. 

For example, a child with a special interest in Star Wars might be encouraged to confront anxiety by naming it “Darth Vader,” and using coping self-talk or “boss back” talk with statements such as, “Back off, Darth Vader! I won’t listen to you!”

Providing Choices

We can provide the child with choices over how, when, or where to complete a disliked or anxiety-provoking activity, or over which rewards they want to receive for engaging in the activity. For example, an autistic individual who is afraid of a medical exam might be given a choice by the doctor such as, “Do you want me to check your ears or take your blood pressure first?” This gives the child some control over the situation.

Increasing Predictability

We all feel more at ease when we know what to expect. Autistic individuals, however, often need predictability to a greater extent than neurotypical individuals. There are several ways we can provide information proactively about what to expect to make things more predictable.

A visual schedule uses pictures or images to inform the child about the upcoming sequence of events. For example, if your child is anxious about transitioning in school (e.g., going from one classroom to another), create a schedule with velcroed pictures of each school activity. 

Throughout the school day, prompt them to remove each picture off the schedule after they have completed each transition. Priming involves previewing future events. 

A child can watch a videorecording of what it looks like transitioning from one classroom to another, and rehearse these transitions when school is not in session. 

Social Stories provide a personalized narrative that visually illustrates the sequence of events involved in a situation and how to behave in that situation. 

Lastly, Advanced Warnings, through verbal (countdowns) or visual cues (e.g., visual timer), give a child time to prepare for upcoming transitions. 

Reducing accommodation

Parents often take actions to reduce their child’s anxiety, such as speaking for a socially anxious child, adjusting routines to avoid triggers, or providing excessive reassurance. 

Although these accommodations seem to make your child feel better in the moment, they often reinforce and worsen anxiety in the long run. Therefore, a big part of treating your child’s anxiety is to eliminate (or at least reduce) accommodations.

Sources:

Facing Your Fears (designed for autistic youth; virtual groups available for autistic youth and their parents):

https://medschool.cuanschutz.edu/jfk-partners/clinical-services/facing-your-fears-program

Tips for Managing Anxiety (for people on the autism spectrum):

https://research.ncl.ac.uk/neurodisability/leafletsandmeasures/tipsformanaginganxiety/

Coping with Uncertainty (for people on the autism spectrum, but applicable to anyone):

https://research.ncl.ac.uk/neurodisability/leafletsandmeasures/copingwithuncertaintyeasyreadversion/

Mental Health in Autism: Support & Resources

https://sites.google.com/view/mentalhealthinautism/resources/support?authuser=0

Worrywisekids (designed for kids with anxiety, not kids with autism, but much of it still applicable to kids with autism):

https://www.worrywisekids.org/

The Child Anxiety Network designed for kids with anxiety, not kids with autism, but much of it still applicable to kids with autism):

http://www.childanxiety.net/

Parent Training Resources for Anxiety designed for kids with anxiety, not kids with autism, but much of it still applicable to kids with autism):

https://www.copingcatparents.com/

Meg Foundation for Pain (empowering families with strategies to manage pain and medical anxiety; designed for kids with anxiety, not kids with autism, but much of it still applicable to kids with autism):

https://www.megfoundationforpain.org/

UCLA Modular Evidence Based Practices for Youth with Autism (MEYA) Practitioner Training Program video set: features 16 videos illustrating the implementation of numerous positive evidence-based practices for youth with autism spectrum disorder that may useful as intervention tools for youth receiving services in outpatient settings:

https://www.youtube.com/@uclameyaautismintervention1480/videos