Anxiety Prevalence in Youth with Autism: A Systematic Review and Meta-analysis of Methodological and Sample Moderators



Anxiety is a common mental health problem that affects many children and adolescents with autism spectrum disorder (ASD). However, the exact prevalence of anxiety in this population is unclear, as different studies have used different methods and samples to measure it. A recent systematic review and meta-analysis aimed to address this gap by synthesizing the findings from 15 community studies that assessed anxiety in youth with ASD.


What did they do?


The authors searched three databases (Embase, PubMed, and PsycINFO) for studies published between 1970 and 2023 that reported the prevalence of anxiety symptoms or disorders in children and adolescents with ASD from community samples. Community samples are those that are not recruited from clinical settings, such as schools or general population surveys. The authors included studies that used either self-report measures (such as questionnaires) or diagnostic interviews (such as the Anxiety Disorders Interview Schedule) to assess anxiety. They also extracted information on the characteristics of the participants (such as age, gender, and IQ) and the studies (such as sample size, country, and year of publication).


What did they find?


The authors identified 15 studies that met their inclusion criteria, with a total of 4459 participants with ASD aged between 4 and 18 years. They calculated the pooled prevalence of anxiety symptoms and disorders across the studies, as well as the effect of potential moderators (such as IQ and gender) on the prevalence estimates.


The main findings were:

  • The pooled prevalence of anxiety symptoms was 33% (95% confidence interval [CI] = 25 to 40%) based on self-report measures, and 19% (95% CI = 7 to 40%) based on diagnostic interviews. This means that about one-third of youth with ASD reported experiencing anxiety symptoms, and about one-fifth met the criteria for an anxiety disorder, according to the studies included in the review.
  • The pooled prevalence of specific anxiety disorders varied depending on the type of disorder and the method of assessment. For example, the prevalence of social anxiety disorder was 11% (95% CI = 5 to 20%) based on self-report measures, and 6% (95% CI = 2 to 14%) based on diagnostic interviews. The prevalence of generalized anxiety disorder was 8% (95% CI = 4 to 14%) based on self-report measures, and 4% (95% CI = 1 to 11%) based on diagnostic interviews.
  • Higher IQ and male gender were associated with higher prevalence of anxiety symptoms and disorders, based on both self-report measures and diagnostic interviews. However, the authors cautioned that these results may reflect sampling biases, as most of the studies included participants with higher IQ and more males than females.
  • There was no significant effect of age, country, or year of publication on the prevalence estimates.


What does it mean?


The review provides a comprehensive and updated overview of the prevalence of anxiety in youth with ASD from community samples. The findings suggest that anxiety is a common and significant problem for this population, regardless of the method of assessment. The authors highlight the need for routine screening of anxiety in youth with ASD, using multiple informants (such as parents and teachers) and validated measures. They also call for improved sampling methods that are more representative of the diversity of the ASD population in terms of IQ, gender, and other characteristics.


The review also points to some limitations and gaps in the existing literature, such as the lack of studies on the prevalence of anxiety in low- and middle-income countries, the lack of longitudinal studies on the development and course of anxiety in youth with ASD, and the lack of studies on the impact of anxiety on the quality of life and functioning of youth with ASD. The authors suggest that future research should address these issues, as well as explore the causes and consequences of anxiety in youth with ASD, and evaluate the effectiveness of interventions to prevent and treat anxiety in this population.



What is the difference between anxiety symptoms and anxiety disorders?


Anxiety symptoms are the signs of anxiety, such as nervousness, worry, fear, or physical reactions. Anxiety disorders are the clinical diagnoses of anxiety, such as generalized anxiety disorder, social anxiety disorder, or specific phobias. Anxiety disorders are defined by the severity, frequency, and impact of the anxiety symptoms on the person’s life.


How can I tell if my child with autism has anxiety?


Anxiety can be hard to detect in children with autism, as some of the symptoms may overlap with the symptoms of autism. For example, both autism and anxiety can cause repetitive behaviors, avoidance of social situations, or difficulty with changes. However, anxiety may also cause additional symptoms, such as excessive worry, panic attacks, or physical complaints. The best way to find out if your child has anxiety is to consult a professional who can assess your child using multiple sources of information, such as interviews, questionnaires, observations, and standardized tests.


What are the signs of anxiety in toddlers and preschoolers with autism?


Anxiety can manifest differently in toddlers and preschoolers with autism, compared to older children and adults. Some of the signs of anxiety in young children with autism are:

  • Increased or excessive tantrums, meltdowns, or crying
  • Increased or excessive clinginess, separation anxiety, or fear of strangers
  • Increased or excessive avoidance, escape, or refusal of situations, places, or people
  • Increased or excessive repetitive behaviors, rituals, or routines
  • Increased or excessive sensory sensitivities or aversions
  • Increased or excessive physical symptoms, such as stomachaches, headaches, or sleep problems



What are the causes of anxiety in youth with autism?


There is no single cause of anxiety in youth with autism, as anxiety is influenced by a complex interaction of biological, psychological, and environmental factors. Some possible factors that may contribute to anxiety in youth with autism are:

  • Genetic predisposition: Anxiety may run in families, and some genes may increase the risk of both autism and anxiety.
  • Neurological differences: Autism may affect the brain structures and functions that are involved in regulating emotions, such as the amygdala, the hippocampus, and the prefrontal cortex. These differences may make youth with autism more sensitive to stress and less able to cope with uncertainty or ambiguity.
  • Cognitive style: Youth with autism may have a tendency to focus on details, perceive threats, or overestimate risks. They may also have difficulty understanding social cues, predicting outcomes, or taking others’ perspectives. These cognitive styles may increase the likelihood of experiencing anxiety in various situations.
  • Life experiences: Youth with autism may face many challenges and stressors in their daily lives, such as bullying, discrimination, isolation, or transitions. They may also have a history of trauma, abuse, or neglect. These experiences may trigger or worsen anxiety in youth with autism.


How can anxiety affect the quality of life and functioning of youth with autism?


Anxiety can have a negative impact on the well-being and development of youth with autism. Anxiety can interfere with their academic performance, social skills, self-esteem, and independence. Anxiety can also increase the risk of other mental health problems, such as depression, substance abuse, or suicidal thoughts. Anxiety can also affect the family and caregivers of youth with autism, as they may experience more stress, burden, or conflict.


What are the best treatments for anxiety in youth with autism?


There is no one-size-fits-all treatment for anxiety in youth with autism, as each person may have different needs, preferences, and goals. However, some of the evidence-based treatments that have been shown to be effective for anxiety in youth with autism are:

  • Cognitive-behavioral therapy (CBT): CBT is a type of psychotherapy that helps people identify and challenge their negative thoughts and beliefs, and learn coping skills to manage their emotions and behaviors. CBT can be adapted to suit the cognitive and developmental level of youth with autism, and can involve parents, teachers, or peers as co-therapists or supporters.
  • Medication: Medication can be used to reduce the severity of anxiety symptoms, such as selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines. Medication should be prescribed by a qualified professional, and should be monitored for side effects and effectiveness. Medication should be used in combination with other interventions, such as psychotherapy or behavioral strategies.
  • Behavioral interventions: Behavioral interventions are based on the principles of learning and reinforcement, and aim to modify the behavior of youth with autism and their environment. Behavioral interventions can include exposure therapy, which involves gradually exposing the person to the feared stimulus or situation, while providing positive reinforcement and coping skills. Behavioral interventions can also include relaxation training, social skills training, or parent training.


How can I support my child with autism and anxiety?


As a parent or caregiver, you can play a vital role in helping your child with autism and anxiety. Some of the ways you can support your child are:

  • Seek professional help: If you suspect that your child has anxiety, or if you notice that their anxiety is affecting their daily functioning, you should consult a professional who can assess, diagnose, and treat your child’s anxiety. You can also ask for referrals to specialists, such as psychologists, psychiatrists, or therapists, who have experience and expertise in working with youth with autism and anxiety.
  • Educate yourself: You can learn more about autism and anxiety, and how they affect your child, by reading books, articles, or websites, or by attending workshops, seminars, or support groups. You can also ask questions and seek advice from the professionals who work with your child, or from other parents or caregivers who have similar experiences.
  • Be supportive and empathetic: You can show your child that you care and understand their feelings, by listening to them, validating their emotions, and praising their efforts. You can also help your child cope with their anxiety, by providing a safe and predictable environment, encouraging them to face their fears, and teaching them relaxation and problem-solving skills. You can also model positive and healthy behaviors, such as seeking help when needed, expressing emotions appropriately, and coping with stress.


How can I prevent anxiety in my child with autism?


While anxiety may not be completely preventable, there are some strategies that may help reduce the risk or severity of anxiety in your child with autism. Some of these strategies are:

  • Provide a supportive and nurturing environment: You can create a safe and comfortable space for your child, where they can express their feelings, needs, and preferences. You can also provide positive and consistent feedback, guidance, and encouragement for your child, and celebrate their strengths and achievements.
  • Promote a healthy lifestyle: You can help your child adopt a healthy lifestyle, by ensuring that they have a balanced diet, adequate sleep, regular exercise, and limited screen time. You can also help your child avoid or limit substances that may trigger or worsen anxiety, such as caffeine, alcohol, or drugs.
  • Expose your child to new and challenging situations gradually: You can help your child overcome their fears and anxieties, by exposing them to new and challenging situations gradually and systematically. You can start with the least feared or difficult situation, and move up to the most feared or difficult situation, as your child becomes more comfortable and confident. You can also provide your child with coping skills, support, and rewards, as they face their fears.



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