Autism and anxiety: how they overlap in children, and what helps

"He just refuses." Won't go into the hall, won't try the new food, won't start the worksheet with the different layout. For many autistic children, a flat no is read as stubbornness or as part of being autistic. Sometimes it's something else that can be helped: anxiety. This guide covers how common it is, what it can look like, why it gets missed, and what the evidence says helps.

How common is it?

A 2011 review pooled 31 studies of 2,121 autistic children and teenagers. About 40% had at least one anxiety disorder. The most common were specific phobias (around 30%), such as an intense fear of dogs, loud noises or the dark, then obsessive-compulsive disorder (around 17%) and social anxiety (around 17%). The figures varied with the children's age, their IQ, and how anxiety was measured, and many of the children came from clinics, so the rate among all autistic children may be different. Even so, anxiety is not a rare extra. It's one of the most common things to come with autism.

What it can look like

Anxiety in an autistic child doesn't always look like worry. Things parents often describe include:

• Refusal and avoidance: the flat no to a place, a food, a lesson or a change of plan.
• Lots of questions about what will happen: the same question again and again, needing the plan repeated.
• Holding on tighter to routines: more upset than usual when something changes.
• Meltdowns or shutdowns before or after something new or loud.
• Body complaints: tummy aches or headaches before school.
• Trouble sleeping.

None of these on its own means anxiety, and many overlap with autism itself. That's exactly why it gets missed.

Why it gets missed

When a child's behaviour can be explained by autism, it often is, and the anxiety underneath goes unasked about. Many autistic children also find it hard to name what they feel, so "I'm scared" comes out as "No." And girls, who are more likely to mask their autism, may hold it together all day at school and fall apart at home.

A question that helps you tell

Next time it's a flat no, try asking "What's the worst bit?" and then waiting, longer than feels comfortable. A child who is being stubborn usually tells you what they want instead. A frightened child often names a specific thing: the hand dryer, not knowing where to sit, the teacher who shouts. That specific thing is something you can plan around.

What helps

The most studied treatment is cognitive behavioural therapy (CBT) adapted for autistic children. A 2021 review of 19 randomised trials, with 833 young people, found it reduced anxiety by the end of treatment. The effect was largest when clinicians rated anxiety and smaller, but still real, when parents and children rated it. Few trials followed children up for long, so it isn't yet clear how long the benefits last.

At home and at school, these are reasonable things to try alongside professional help:

• Preview changes. Say what's different tomorrow, today. A photo of a new place helps.
• Plan for the scary part. Ear defenders for the loud hall, a set seat, a way to leave.
• Agree an exit signal your child can use in class without having to explain.
• Keep the predictable parts predictable, so there's energy left for the new part.

When to ask for help

If fear is stopping your child doing everyday things, such as going to school, eating, sleeping or seeing friends, talk to your doctor and to the school's special educational needs staff (the SENCO in the UK; in Singapore, often the Allied Educator for learning and behavioural support). Ask specifically about anxiety, and whether an assessment or adapted CBT is available. You know your child's flat no better than anyone. Saying "I think some of this is fear" is a good place to start.

Related reading: autistic burnout in children, sensory overload, explained, and test anxiety. If school study feels overwhelming, our free study rooms can be set up as a private room with chat switched off.

References

• van Steensel, F. J. A., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clinical Child and Family Psychology Review, 14(3), 302-317.
• Sharma, S., Hucker, A., Matthews, T., Grohmann, D., & Laws, K. R. (2021). Cognitive behavioural therapy for anxiety in children and young people on the autism spectrum: a systematic review and meta-analysis. BMC Psychology, 9, 151.