Assessment and Treatment of Anxiety in Youth With Autism Spectrum Disorders

Abstract

OBJECTIVES: Anxiety is one of the most prevalent co-occurring symptoms in youth with autism spectrum disorder (ASD). The assessment and treatment recommendations proposed here are intended to help primary care providers with the assessment and treatment of anxiety in ASD. METHODS: The Autism Speaks Autism Treatment Network/Autism Intervention Research on Physical Health Anxiety Workgroup, a multidisciplinary team of clinicians and researchers with expertise in ASD, developed the clinical recommendations. The recommendations were based on available scientific evidence regarding anxiety treatments, both in youth with ASD and typically developing youth, and clinical consensus of the workgroup where data were lacking. RESULTS: Assessment of anxiety requires a systematic approach to evaluating symptoms and potential contributing factors across various developmental levels. Treatment recommendations include psychoeducation, coordination of care, and modified cognitive-behavioral therapy, particularly for children and adolescents with high-functioning ASD. Due to the limited evidence base in ASD, medications for anxiety should be prescribed cautiously with close monitoring of potential benefits and side effects. CONCLUSIONS: Assessment and treatment of clinical anxiety in youth with ASD require a standardized approach to improve outcomes for youth with ASD. Although this approach provides a framework for clinicians, clinical judgment is recommended when making decisions about individual patients.

The measurement properties of the spence children's anxiety scale‐parent version in a large international pooled sample of young people with autism spectrum disorder

“…Following further replication, the SCAS‐P appears to be a reasonably good choice as a freely available first line screening tool for typical DSM‐derived anxiety in ASD, provided that it is employed alongside other multi‐informant and multi‐method information gathering approaches (i.e., using the ASC‐ASD by Rodgers et al, to also examine more ASD‐related anxiety difficulties; or the ADIS C/P ASD addendum clinical interview by Kerns and colleagues, 2014; see also Vasa et al, ). If the original SCAS‐P is used, we recommend the use of the total score as a general screen for anxiety, and not of the separate subscales, as the underlying subscale/factor structure remains inconsistent and unclear and requires further exploration.…”

Identification, Evaluation, and Management of Children With Autism Spectrum Disorder

“…458,459 Anxiety disorders are most commonly identified in children with ASD and typical cognitive and language abilities. 468,469 Symptoms may be present in early childhood and manifest as behavioral challenges, such as overreactivity. Biological predisposition to both ASD and anxiety may be attributable to common genetic factors and/or altered neurophysiologic responses to stress.…”

“…• Behavioral rigidity, insistence on sameness Anticonvulsants (valproic acid and divalproex sodium) 613,621,622 Modest improvement has been reported with divalproex sodium treatment May have improvement with topiramate as a second agent with risperidone Most antiseizure drugs have potential for sedation, cognitive adverse events SSRI (fluoxetine, fluvoxamine) 480,509,611,612,[623][624][625][626][627] Studies to date have not revealed effectiveness of SSRI medications for repetitive behaviors related to ASD, although they may diminish anxiety SSRIs may be effective for reducing symptoms of OCD and of anxiety when included in a comprehensive approach to treatment Need comprehensive behavioral approaches to minimize repetitive behaviors Anxiety, depression SSRIs 469,628 Anxiety relief has been reported in trials of citalopram and buspirone, with fluvoxamine revealing some effect in female patients with ASD; documented utility in children and youth without ASD a-adrenergic (clonidine, guanfacine)…”

“…Hyperactivation is an adverse effect of SSRIs in children and youth with ASD that may result in stopping the medication The anxiety disorders most amenable to treatment are generalized anxiety disorder, separation anxiety disorder, and social phobias Atypical (second generation) antipsychotics 469,620 If a mood dysregulation disorder is identified, treatment with a mood stabilizer and/or a second-generation antipsychotic is recommended, although an SSRI may be used to treat comorbid anxiety, OCD, or depression; behavioral activation with hypomanic or manic switches has been reported First-line treatment is a program of cognitive behavioral therapy to reduce symptoms [472][473][474][475] Few studies have examined the specific effects for these symptoms; clinicians may consider use of these agents; although SSRIs, SNRIs, and/or buspirone may be effective for the treatment of anxiety in children with ASD, they have not been rigorously evaluated for this purpose 507,626,627,629,630 Medications to consider include sertraline, fluoxetine, citalopram, or escitalopram for symptoms of anxiety and a-2 agonists (eg, guanfacine and clonidine and b-blockers such as propranolol), which may be useful for anxietyrelated physiologic symptoms and behavioral dysregulation, and a short-acting benzodiazepine, such as lorazepam, could be considered for event related anxiety As in children and youth with typical development, assessment of depression and other mood disorders must include family history, history of environmental stressors, the potential for toxic ingestions, and evaluation for comorbid conditions. Interventions for depression include supportive therapy, cognitive behavioral therapy, and medication, if indicated, as coordinated interventions (see Table 11 for medication use).…”

“…480 Medication recommendations are based on data from the general pediatric population and expert consensus. 469 The DSM-5 criteria for bipolar illness include changes in activity, energy, and mood. It may be difficult to make a diagnosis in people with ASD with limited language.…”