Ask the Expert: Heather Dukes-Murray, PhD: Anxiety, Autism and Interventions

Posted on 09/24/18 in School by Milestones

Anxiety, Autism, and Interventions: Playing to One’s Strengths and Supports
Anxiety can be a part of daily life for many individuals with autism. Rates of clinically significant comorbid anxiety in autism have varied widely, with some estimates as high as 40%. Regardless of verbal abilities, cognitive abilities, or developmental level, signs of anxiety present similarly. Stress reactions termed “Fight, Flight, or Freeze” are common. “Fight” can look like irritability, meltdowns, explosions, aggression, or yelling. “Flight” can look like leaving a situation, eloping, or refusing to go to a stressful environment. “Freeze” can look like non-responding, putting one’s head down, or ignoring others. All of these are signs of high anxiety. Cognitive Behavioral Therapy (CBT) is one of the most effective therapeutic techniques to reduce anxiety. However, CBT can be a verbal-heavy, somewhat abstract intervention. It is important to identify your child’s learning strengths and weaknesses, then adapt the CBT techniques to fit your child.

Know triggers (and make sure your child and those involved with your child know them too!) - For a week, document when your child demonstrates anxiety symptoms, what happened before and during, what you and your child each did. Look for patterns and minimize anxiety triggers. Ideally, work with your child and their therapist to make a plan to overcome the anxiety associated with that trigger. For example, if your child is anxious in social situations and large groups are a trigger, work with a therapist to build a plan to engage in increasingly social situations while practicing coping skills. Diffusing a trigger is empowering and helps build confidence to take on other anxiety triggers.

Know the “rumblings” of anxiety (and, again, communicate these to others!) - Individuals on the spectrum may not always demonstrate anxiety through worried statements (such as “I’m worried that…”), but may be more likely to demonstrate physical signs, such as increased restlessness, fidgeting, irritability, as well as seek out more reassurance during times of high anxiety. If we pick up on these small signs that anxiety is rising, we may be able to intervene to avoid a meltdown. Know the “rumblings”, help your child become aware of their physical signs (such as picking their nails), and communicate these signs to teachers and others involved in your child’s life. Recognize these signs as a cue to engage in a well-established coping skill.

Identify coping skills (and practice when calm) - No one learns anything new when upset. We all know this, but frequently forget it and try to prompt someone to “take deep breaths” when they have never done that before. An anxious state is not a good time to suggest a new coping skill. The anxiety symptoms are much better established than the new coping skill and the anxiety will win and undermine the coping skill. Instead, get in front of this problem through practice. Model and help your child practice a couple preferred coping skills regularly, when calm. This establishes the skill and makes it an alternative to other well-established, less-desirable behaviors. Set a time to practice every day. Practice in the car, after school, before bed

Coping skills that calm the body and distract the brain can be very helpful in decreasing anxiety. Some of these include:

- Physical activity, as simple as walking, jumping on a trampoline, bouncing on a yoga ball, to more complex activities to build into your routine, such as swimming or horseback riding. Physical activity is an excellent tool to help manage anxiety. Help your child choose an activity that they enjoy then schedule practices.

- Distractors such as playing with a favorite toy, reading a favorite book, drawing, listening to music, playing a game are valuable to stopping the ruminative anxious thoughts. Help your child identify activities they enjoy, engage in those activities as practice and identify how your child can access those activities when they recognize their anxiety “rumbling”.

- Sensory input can be anxiety-provoking or calming, depending on an individual’s sensory profile. Consult with your child’s OT to discuss ways that you can use sensory input to help reduce anxiety.

- Calming body activities such as meditation or deep breathing can be very helpful. However, getting a person to “buy-in” can be increasingly difficult as they get older. Apps are available that can help, but if you want to avoid screens, an easy activity to remember and follow is this 54321 grounding exercise.

Visuals! - Processing speed, expressive-receptive language, social situations – all these factors can impact how a person with autism engages in a conversation about a problem. These factors can make discussing an anxiety-riddled situation even more anxiety-provoking. Visuals provide added support and reduce the heavy reliance on verbal interactions. A visual can be helpful to prompt an individual to engage in a coping skill. Coping skill cards are one example of how to prompt a coping skill without conversation. When discussing anxiety, a visual such as a thermometer the child references to rate their anxiety can be helpful in making the idea of anxiety reduction more concrete. As previously stated, CBT can be abstract, working with a therapist who builds visuals into interventions can make the interventions more concrete.

There are so many other ways to help decrease anxiety that I can’t cover in one brief post. Dr. Barlow and I recently spoke at Lawrence School about anxiety and how to support children at home and at school. A recording of that talk will be posted on the Meghan Barlow & Associates website soon, along with other podcasts and videos regarding anxiety. Feel free to reach out with any questions or for guidance. Anxiety and autism can seem like they go hand in hand – but there are tools to reduce the impact of anxiety on your child’s life.

Heather Dukes-Murray is a clinical psychologist who specializes in the assessment and treatment of autism spectrum disorder, ADHD, learning differences, and mood and anxiety disorders in children and adolescents. She is in private practice at Meghan Barlow & Associates and is the Clinical Director of MBA's Early Identification of Autism Clinic. She is also the consulting psychologist at Lawrence Upper School.