Reducing anxiety in students with autism

Anxiety is a common problem in school-aged children with autism spectrum disorder (ASD). School may present students with ASD particular cognitive, social and behavioural challenges that increase levels of anxiety, which in turn can impair school-functioning.

Anxiety interventions

Interventions and programs that aim to address anxiety and the challenges that school-aged children with ASD face in educational environments may improve their overall school-functioning and later life-outcomes. Cognitive behavioural therapy (CBT) is a relatively popular alternative to pharmacological intervention for anxiety symptoms that targets, as the name suggests, cognitions or thoughts and how these may contribute to or alleviate anxiety, and behaviour or how a person might respond to a situation or experience that may trigger anxiety, as well as how these cognitions and behaviour interact. 

A CBT-based intervention for young people with ASD and anxiety commonly includes educational sessions for the young people, and possibly their parents, about negative thought patterns and cognitive distortions such as ‘catastrophising’ and how these contribute to anxiety, and how to challenge these thought patterns. These sessions might also be combined with other types of intervention like supported exposure to situations that the young people have previously found anxiety-provoking, with coaching sessions on how to monitor their thoughts, and to recognise and control physical reactions to stress and anxiety.

Some characteristics of CBT, such as its highly-structured, pragmatic focus on current problems may align with features of ASD such as increased need for structure and order, while other aspects such as reliance on verbal communication with the therapist, insight in one’s own thoughts, feeling and actions, and recognition of emotions in oneself and others, may prove challenging for some clients with ASD.

Teachers and clinicians working in the education sector therefore have significant responsibility for implementing interventions that are evidence-based and tailored to the needs of the child. But the sheer volume of published research, and the different aims, foci and methodology of those studies, makes evidence-based practice difficult.

Reviewing the evidence

In order to examine the effectiveness of interventions for school-aged children with ASD and anxiety, ACER joined Campbell Systematic Reviews in collating evidence from 24 studies involving 931 children with clinical anxiety and ASD, but without co-occurring intellectual disability. The studies spanned the period 2005 to 2018 and were mostly carried out in Australia, the UK and the USA.

Twenty-two of the studies used a CBT intervention, with some developed specifically for use with participants with ASD. While interventions ranged across clinical, school-based or home-based settings, most involved parents or caregivers and most were conducted face-to-face.

Overall, the effects of interventions on anxiety were statistically significant and of moderate to high effectiveness, compared to waitlist and treatment-as-usual control conditions at post-treatment.

However, effects differ depending on who reports on the student’s anxiety. Clinician reports indicate very high effectiveness, parent reports indicate high effectiveness, and self-reports indicate only moderate effectiveness on the reduction of anxiety in students with ASD.

Larger effects were found for treatments that involve parents than for student-only interventions. Effects are also larger for one-on-one interventions compared to treatments delivered in a group context with peers.

The evidence collated suggests that children who participate in interventions based on CBT, whether modified specifically for those with ASD or not, may make significant gains in terms of reduction of anxiety symptoms, in some cases no longer meeting criteria for a primary anxiety diagnosis or comorbid diagnoses of other anxiety disorders.

However, further studies are required to (a) identify the characteristics that contribute to the effectiveness of these interventions and (b) identify the characteristics of participants who are more likely to respond to such interventions.

Read the full report:

Hillman, K., Dix, K., Ahmed, K., Lietz, P., Trevitt, J., O’Grady, E., Uljarević, M., Vivanti, G., & Hedley, D. (2020). Interventions for anxiety in school-aged children with Autism spectrum disorder (ASD): A systematic review. Campbell Systematic Reviews. DOI: 10.1002/cl2.1086