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Anxiety in Autism Spectrum Disorders. Todd Levine MD, FAAP Assistant Professor in Psychiatry and Human Behavior Brown Center for the Study of Children at Risk Warren Alpert Medical School of Brown University, Providence, RI . Disclosures. No financial relationships or conflicts of interest

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anxiety in autism spectrum disorders

Anxiety in Autism Spectrum Disorders

Todd Levine MD, FAAP

Assistant Professor in Psychiatry and Human Behavior

Brown Center for the Study of Children at Risk

Warren Alpert Medical School of Brown University, Providence, RI

  • No financial relationships or conflicts of interest
  • Many of these treatments are “off label”, non-Food and Drug Administration approved
learning objectives
Learning Objectives
  • Investigate the relationship between symptoms of Autism Spectrum Disorders (ASDs) and those of anxiety disorders
  • Understand common anxiety symptoms assessed and treated in ASDs
  • Understand how mechanisms of arousal and stress may differ in children with ASDs
diagnostic considerations
Diagnostic Considerations

Core deficits in socialization and communication can lead to difficulties with:

  • Connecting with one’s own feelings and those of others
  • Interpretation of motivations behind behaviors
  • Contextualizing behaviors
dsm iv considerations
DSM-IV Considerations

Some diagnoses exclude/modify for Pervasive Developmental Disorders:

  • Social Phobia (Social Anxiety Disorder)
  • Separation Anxiety Disorder
  • Selective Mutism
  • Generalized Anxiety Disorder
  • ADHD
  • Pica
  • Rumination Disorder
  • Schizophrenia (Delusions/Hallucinations present)
  • Schizoid Personality Disorder
  • Schizotypal Personality Disorder
with this in mind
With this in Mind…
  • Children and adults with Autism Spectrum Disorders (ASDs) are at higher risk for anxiety1, depression2, and ADHD3
  • Psychiatric medications are likely to be prescribed to those with ASDs4
  • Psychotherapies have been adapted for children with ASDs and anxiety5

1Gillot et al. Autism (2001), 2Ghaziuddin et al. J Autism DevDisord. (2002), 3Ghaziuddin et al.J Intellect Disabil Res (1998), 4Mandell et al. Pediatrics. 2008,

5Chalfant et al.J Autism DevDisord (2007)

possible explanations
Possible Explanations
  • Some children with ASD may be overstimulated due to a hyperactive nervous system1
  • Children with ASD may have difficulty with emotional processing2
  • Deficits in socialization and communication may cause vulnerability to anxiety and depressive symptoms

1Hirstein et al. Proc Biol Sci (2001) 2Losh and Capps. Dev Psyc (2006)

other factors in anxiety in asds
Other Factors in Anxiety in ASDs

Eussen et al. Autism (2012), Lane et al. Am J OccupTher(2012),

Ozsuvadjian et al. Autism (2012)

  • Intelligence?
  • Social Functioning Difficulties: May be worsened by higher anxiety
  • Sensory sensitivities
  • Changes in routine
  • Avoidance of non-preferred tasks
  • Lack of expressive language
psychotropic prescribing in asd
Psychotropic Prescribing in ASD

Martin et al. JAACAP. 1999

psychotropic prescribing in asd1
Psychotropic Prescribing in ASD
  • In a sample of 60,641 children with ASDs, 56% used at least 1 psychotropic medication
  • 20% were prescribed 3 medications concurrently
  • Use was common even in children aged 0 to 2 years (18%) and 3 to 5 years (32%)
  • Neuroleptic drugs were the most common psychotropic class (31%), followed by antidepressants (25%) and stimulants (22%)

Mandell et al. Pediatrics. 2008

obsessive compulsive disorder vs repetitive interests in asds
Obsessive Compulsive Disorder vs. Repetitive Interests in ASDs
  • Obsessions are “recurrent and persistent thoughts, impulses, or images that…cause marked anxiety or distress” (DSM-IV)
  • Compulsions are acts designed to counteract those thoughts, impulses, or images
  • Are either consistent with “restricted repetitive and stereotyped patterns of behavior, interests, and activities” in ASDs?
  • “Insistence on Sameness” different from anxiety in study. Gotham et al. Autism Research (2013)
when does generalized anxiety occur in as
When Does Generalized Anxiety Occur in AS?
  • Persistent worries about scheduling can occur in those with ASDs
  • Generalized Anxiety (GAD) includes being “keyed up”, sleep difficulties, and muscle tension
  • As in OCD, dysphoric thoughts and feelings delineate problematic anxiety
considering ptsd in as
Considering PTSD in AS
  • Is trauma processed differently in those with ASD?
  • The symptoms of hyperarousal and social withdrawl can be difficult to delineate in people with ASDs
  • Is there a case for chronic trauma affecting those with ASDs?
  • Considerations for group therapy
can someone with as be socially anxious
Can Someone with AS be Socially Anxious?
  • Excluded from Social Anxiety Disorder diagnosis
  • Socially anxious people are fearful of humiliation and opinions of others
    • People with ASDs can be aware of these factors
  • Many with ASDs appear dysphoric or anxious in groups of people, but is this anxiety?
  • Cognitive behavior strategies have been applied
the elusive inner state
The Elusive “Inner State”
  • How reliable/valid are self-reports in adults and children with ASDs?
  • Can parents tell us more about their kids with ASDs than the kids?
  • Can we look at more concrete, biological markers of emotional response to help understand psychiatric reporting?
  • There are few psychiatric measures for those with ASDs
the study of social anxiety in asperger s disorder
The Study of Social Anxiety in Asperger’s Disorder
  • Compares children ages 8-12 years old with Asperger’s Disorder (AD, n=19) to those without (n=12) during a social stressor
  • Protocol involves parent and child reports of anxiety (MASC and SPAI-C), child self-report of anxiety during the events, and measurement of psychophysiology:
    • Salivary cortisol reactivity
    • Electrodermal reactivity (EDR)
    • Heart rate variability, “vagal tone” (VT)


Vagal Tone

brief summary of study results
Brief Summary of Study Results
  • Children with Asperger’s were twice as likely to be cortisol non-responders than controls (p=0.056)
  • There were no between group differences on EDR and VT across time
  • EDR positively correlated with parent reports of arousal on the MASC in controls, but not the Asperger’s group
trends in medication treatment studies in as asd
Trends in Medication Treatment Studies in AS/ASD
  • Most studies focus on specific behaviors vs. diagnostic criteria
  • Specific behavioral measures have been created or modified for AS patients
  • Successful strategies in “neurotypical” children have been applied to children and adults with AS and similar behaviors
problem behaviors targeted by psychotropic medications

Lack of Attention







Repetitive Behavior

Compulsive Behavior





Problem Behaviors Targeted by Psychotropic Medications
side effects of psychotropic medications

Lack of Attention





Side Effects of Psychotropic Medications
  • Agitation
  • Repetitive Behavior
  • Compulsive Behavior
  • Hyperarousal
  • Irritability
  • Tics
  • Serotonin Specific Re-uptake Inhibitors (SSRIs) have evidence for use in children and adolescents with anxiety and depression
  • U.S. FDA Black Box warning spurned controversy over use of SSRIs
  • Applicability to AS behaviors has been explored: repetitive behaviors and anxiety
  • Recent research has changed previous conceptions about SSRI use in ASDs
sertraline for perseverative anxiety
Sertraline for Perseverative Anxiety
  • Based on clinical experience
  • Useful for overly-repetitive concerns or “anti-Zen” states
  • Low doses can work very well
  • Don’t have to wait too long for results
  • Low side effect profile
  • Cheap
citalopram for repetitive behaviors
Citalopram for Repetitive Behaviors

King et al. (2009) Arch Gen Psychiatry

risperidone for irritability
Risperidone for Irritability

McCracken et al. (2002) NEJM

  • Family includes benzodiazepines, and antihistamines
  • These medications can cause disinhibition and irritability
  • Sometimes used in conjunction with antidepressants
  • Sometimes used in children
my home
My Home

Autism Spectrum Disorders Clinic

Child Psychiatry Consultation Service

Brown Center for the Study of Children at Risk

Women and Infants’ Hospital

(401)274-1122 x 8935