Identifying both observable and less obvious signs of anxiety in Autistic children, Estelle Pretorius highlights the importance of understanding a child’s preferences and sensitivities, and the use of sensory-based activities and visual supports. 

Anxiety is becoming one of the most diagnosed conditions in young children (Field et al., 2011). Anxiety can be described as feelings of worry, stress or fear that affect how the body and mind operate. For children, these feelings may interfere with their ability to participate in daily activities, such as routines of self-care or participation in family and community gatherings. Anxiety can trigger emotions and children can experience a feeling of being overwhelmed. Anxiety manifests differently in each child: different expressions, actions, emotions, and ability to engage. Research suggests that there is a high prevalence of Autistic children who also experience anxiety (Lai et al., 2019; Middletown Centre for Autism, 2020). Also, while Autistic children may feel and experience many of the same worries and fears as neurotypical children, they might feel anxious or worry about things that matter less to their neurotypical peers. Sensory sensitivities, uncertainty and change, negotiating social expectations and interpreting emotional responses are common anxiety triggers in Autistic children. 

Sensory sensitivities 

Sensory processing is the ability to integrate signals from various sources, such as visual, auditory, taste, smell, tactile, proprioceptive, vestibular and interoceptive signals. When sensory integration works effectively, children can participate and engage with their environment meaningfully by taking an interest, communicating their ideas, and responding to spoken or non-spoken messages. However, Autistic children often experience and process sound, touch, smell, movement and internal body signals differently than their neurotypical peers. Some examples of these differences include heightened reactivity to sound, touch or movement or heightened responses to sensory information that is new or unexpected. These responses can trigger heightened emotional responses, impulsivity or avoidance and resistance. For example, a noisy kindergarten environment or a loud shopping mall can trigger worry or fear responses in the child and these can escalate quickly.

Uncertainty and change 

Another common trigger for anxiety in Autistic children is small disruptions to regular and predictable routines, for example, when a favourite routine or activity is delayed or changed. Uncertainty and change are often unavoidable and can overwhelm and confuse children. Young children often mitigate change and manage emotions during these periods of uncertainty, with the usual support from caregivers. However, this might not be the case with Autistic children, as emotions of overwhelm and confusion may not be so obvious and are often misinterpreted by carers. Similarly, for Autistic children, unplanned or unsupported transitions between activities can often trigger periods of emotional distress. 

Understanding and responding to social expectations 

Autistic children can become overwhelmed and anxious when there is an expectation to interact, connect and share in a specific / expected way; however, the rules of social engagement may have not been made explicit or explained to them. Young children are usually introduced to unspoken social rules of engagement early on in their development, through peer-to-peer play and sometimes explicit instruction from adults. However, when these social cues from others are not interpreted or explained, Autistic children might feel overwhelmed when others do not understand them, or they might not understand why others act in a certain way. 

Presentation of anxiety in Autistic children 

While anxiety is something we all experience in varied ways, most of us are adept at using strategies and tools to manage our emotions and successfully navigate situations. For example, some people chew their nails when nervous, while others repeatedly flick a pen while thinking or sitting a test. More stressful situations usually require more cognitive or emotional competence, and we actively seek to understand, communicate or describe our experiences. Anxiety presents itself differently in Autistic children compared to non-Autistic children. For some, anxiety shows up in obvious or observable actions; for others, it can be less noticeable that they are experiencing worry, uncertainty, fear or upset feelings. 

Observable, obvious clues that may indicate that a child is anxious: 

• Physiological responses include sweating, tension, fatigue, nausea, or headaches. 
• Sensory seeking or avoiding actions, such as covering the ears to block a particular sound. 
• Intense emotional responses, including being angry, irritable or upset, defiant or out of control. 

 Not-so-obvious clues that may indicate that a child is anxious: 

• A lack of engagement or wandering around aimlessly. 
• Communicative responses such as being unusually quiet or overly chatty. 
• Avoiding or withdrawing from situations. 

Responding to anxiety 

Anxiety communicates, whether explicitly or not. Caregivers of Autistic children often intuitively know what triggers their child’s anxious responses, but communicating these to other carers, whānau or friends can be challenging. Children respond differently in different settings and a helpful approach is to start with understanding the child’s preferences, interests and strengths. 

• Practise observing the child regularly in a range of activities and across settings. Pay attention to how the environment impacts the child’s involvement in activities, routines and ongoing play. Consider what the child needs or enjoys in order to be present and actively engaged. What does ‘actively engaged’ look like for this child? Does the child have access to preferred activities? How does the child typically show you what they want or need? Are there alternative ways for the child to communicate their intentions, for example, picture boards, communication devices? 
• Learn about the child’s sensitivities. What does the child typically respond to? What do they seek out? Which sensory experiences do they avoid? 
• Consider planning and implementing a sensory diet. This means creating an individualised range of sensory-based activities that can be performed regularly to give the body the sensory feedback it craves. 
• Teach the child a practical skill so they can contribute actively to routines in whatever manner works for them. For example, supporting a child to have responsibility for setting the table for family meals might ease their anxiety around the timing and transition to the mealtime routine. Engaging children in everyday routines and activities can reduce anxiety and positively impact their emotional wellbeing. 
• Find a visual support system that works for this child. Consider a visual system that makes routines and expectations explicit and participation easy. Build in regular breaks and offer options or choices; make these choices explicit and accessible. Anxiety can be significantly reduced when a child knows what is available and how to access it when needed. 
• Relaxation techniques are helpful and effective in easing anxiety; however, they must be demonstrated and practised. Use fun games throughout the day to introduce a range of relaxation activities such as breathing, bear hugs, listening to music or favourite and preferred activities that are calming to the child. 
• Relaxation or calming spaces can be set up anywhere at home or in the early learning centre. Consider colour, texture, sound, light and movement when creating a space for the child to go to calm or relax. Consider the child’s interests, preferences and sensory sensitivities when creating this space. Think about ways the child can access this space independently; will they have a way to communicate if they need a break? 
• Feelings of anxiety can prompt children to act impulsively or react unsafely. Suggest or provide alternative ways or places where you know the child will experience calm and become more regulated. Model affirmation and calm wherever possible. 

Estelle Pretorius (MSLT), an advisor for Altogether Autism, is currently doing doctoral research and is an experienced speech-language therapist. She wrote this article for the 2023 edition of the Altogether Autism Journal. Read More.

References 

Field, A. P., & Silverman, W. K. (2011). Anxiety disorders in children and adolescents (2nd ed.). Cambridge University Press. https://doi.org/10.1017/CBO9780511994920 

Lai, M.-C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., Szatmari, P., & Ameis, S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: A systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 819–829. https://doi.org/10.1016/S2215-0366(19)30289-5 

Middletown Centre for Autism, (Ed.). (2020). Autism and Managing Anxiety: Practical Strategies for Working with Children and Young People (1st ed.). Routledge. https://doi-org /10.4324/9780429285653