Autism and Anxiety in the Classroom

Abstract

It is well documented that Generalized Anxiety Disorder (GAD) and Autism Spectrum Disorder (ASD) are often comorbid conditions, but it is not well-known amongst educators and parents of children diagnosed on the autism spectrum. The cause of ASD is still undetermined; therefore, possible genetic and environmental factors will be presented. Differences in the expression of anxiety based on age will also be discussed. This literature review discusses the current treatment options for children in both classroom and home settings that struggle with these conditions. It might be determined if expressions of anxiety might be minimized by specific interventions or treatment options as children enter social independence and adolescence by analyzing existing research. Another focus of this research paper is to determine the outcomes of current treatment methods. Finally, educator awareness of comorbidities and their correlation with more prosocial behaviors in the classroom will be presented.

Keywords: autism, anxiety, comorbid, treatment, classroom

Autism and Anxiety in the Classroom

In recent years, Autism Spectrum Disorder (ASD) has been diagnosed more frequently as awareness of the disorder becomes more prevalent. Formerly three or more separate diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM), Autism is now considered one diagnosis on a spectrum: one disorder with many expressions and no known cause. Parents of children with ASD and educators teaching children with ASD have minimal resources and information to utilize when serving these children; the doctors are sometimes at a loss. ASD includes a diagnostic list of criteria that seem common to most children on the spectrum, although pathology from case to case may vary significantly.

ASD diagnoses require a significant deficit in social communication and interaction across multiple contexts (American Psychiatric Association, 2013). These individuals struggle in several areas of day-to-day relational interaction, such as the back and forth in conversation, situational awareness, reading of nonverbal cues, inappropriate social interactions, and maintaining relationships (American Psychiatric Association, 2013). Individuals on the autism spectrum also battle the restrictive urge to repeat movements, adhere to rigid schedules, control their environment and understand the rules (American Psychiatric Association, 2013). Often, children on the spectrum battle sensory input differences and cannot censor or restrict external stimuli as neurotypical children can do. Some children are sensory seekers, meaning they seek external stimuli and often become fixated on one fascinating feeling, taste, or smell, such as jumping up and down or switching lights on and off. Other children are sensory avoiders who try, without success, to quiet the constant barrage of ticking clocks, tapping pencils, buzzing lights, strong smells, strange textures, and consistent changes of every day.

When considering the social difficulty, requirement for sameness, and sensory differences that autistic people battle against, children on the autism spectrum often develop the comorbid condition of anxiety at some point in their childhood or adolescence. It is estimated that approximately 43% of children diagnosed with ASD also present with clinical symptoms of either Generalized Anxiety Disorder (GAD) or Social Anxiety Disorder (SAD) (Morie et al., 2019). Individuals on the spectrum are seemingly programmed to be opposed to our culture's social structures; therefore, they develop comorbid conditions, only complicating an already debilitating disorder.

More parents and teachers need an explanation of this phenomenon and how to adapt the child's environment to create a world more suited to their needs. This literature review strives to 1.) Provide parents and educators the available knowledge concerning the epidemiology of autism, 2.) Examine possible factors, like alexithymia, which complicate the issue for individuals with ASD, 3.) Discuss the differences in anxiety expression in a child with autism and how those expressions change as the child matures, 4.) Offer teachers insight into the unique needs of individuals with ASD to provide a learning environment to suit their needs.

Literature Review
Epidemiology

Newschaffer et al. (2007) provide an extensive empirical review based on the available body of research concerning ASD. As awareness grows, more and more children are being diagnosed with ASD, but doctors and educators lack a unified criterion of how and when to suggest screening for diagnosis; therefore, it is essential to highlight current information. Boys are at greater risk for ASD than girls; however, differences according to ethnicity are unknown. There is also differing information concerning the socioeconomic status and the likelihood of diagnosis. Paternal age is likely a factor in developing ASD, although more research is needed (Newschaffer et al., 2007).

It is believed, and research supports the theory, that there are genetic components of ASD. For example, if a sibling is diagnosed with ASD, there is a 2-6% likelihood that another sibling will also have the disorder. The likelihood jumps as high as 14% of the diagnosed sibling is a female (Newschaffer et al., 2007). The study also explores research that identifies possible genetic factors such as the possibility that a gene is linked with the heritability of ASD located on chromosome 7q (Newschaffer et al., 2007). There is also evidence of a link between ASD and immunologic components. Again, there is a lack of information on how these are connected, but there is evidence of immune system differences consistent with chronic inflammatory processes (Newschaffer et al., 2007).
Age Differentiation of Expression

Varela et al. (2020) focused on how anxiety expression changes in children diagnosed with ASD as they mature. Information from clinical visits and archival data for a ten-year timespan was used to determine the results. Two hundred ninety-four children aged 6-11 and 60 adolescents aged 12-18 were used for the study. There were 284 males and 70 females represented in the study. The mean IQ for the sample was 76.87, with a standard deviation of 19.55 (SD = 19.55). The sole basis for inclusion in the study was a clinical diagnosis of either autistic disorder, Asperger’s disorder, Pervasive Developmental Delay – Non-Specified (PDD- NOS), or ASD, dependent on the DSM criteria at the diagnosis time (Varela et al., 2020). Overall, the data showed a difference in the expression of anxiety symptoms for different age groups. The younger age group showed more generalized anxiety disorder (GAD) symptoms, whereas the older group reported symptoms that better described social anxiety (SAD).

The study relied solely on existing data and testing measures that the authors admit lack in depth, specifically for those children and adolescents struggling with these comorbid conditions. The authors also draw attention to self-reporting and that, for the 6–11-year-old group, children were not personally interviewed, but instead, their parent filled out the form on their behalf.

Autism, Mood Disorders and Alexithymia

Morie et al. (2019) hypothesize that both of these conditions may be treated at once by treating the underlying characteristic of ASD and Alexithymia (Morie et al., 2019). In other words, the study posits that the underlying cause for many of the mood disorders that children with ASD suffer from stems from the inability to recognize and describe their own emotions and, therefore, are unable to recognize emotions in others and respond appropriately.
This study's independent variable was Autism Spectrum Disorder, and the dependent variables were the levels of anxiety and alexithymia reported by participants. Participants completed several questionnaires online: the 20 Item Toronto Alexithymia Scale (TAS-20) (Bagby et al., 1994), the Depression Anxiety and Stress Scale (DASS) (Lovibond & Lovibond, 1995), Difficulties in Emotion Regulation Scale (DERS) (Gratz & Roemer, 2004), the finally, the Social Responsiveness Scale, Second Edition (SRS 2) (Constantino & Gruber 2012). Questionnaires were scored, and the total scores were synthesize using SPSS PROCESS.

Data analysis supported the research hypothesis regarding the interplay between autism, depression, anxiety, and alexithymia; these conditions feed on each other to create a complex cycle for the autistic person to break without intervention. This research study helps to clarify the relationship between well-known comorbid conditions, endeavoring to enhance the pool of knowledge regarding these issues.

A weakness in the research design is that over 70% of the participants were female; this creates a possibility that the data may be skewed since hereditary factors and sex differences of ASD is unknown. The study also had a minimal sample size (N = 64), hardly representative of the more significant population. Finally, the entire study was based online and relied on self- reporting. None of the individuals were confirmed to have ASD by a clinician; this too was self- reported. Implications from the study point to treatment options for people with ASD, which are focused on identifying and naming the emotion, recognizing emotion in others, and learning socially acceptable techniques for coping with emotions.

Autism and Anxiety in Classroom Settings

Syriopoulou-Delli et al. (2019) aimed to explore teachers' attitudes toward children with ASD when they exhibit symptoms of anxiety in the classroom. The study also endeavored to find new strategies to help children succeed in the classroom when anxiety inevitably arises. The School Anxiety Scale – Teacher Report (SAS-TR) (Lyneham et al., 2008) was completed by 291 special education teachers and 118 general education teachers to provide information regarding the children's behavior in their classroom. Data was then collected and synthesized. Reliability analysis was executed for the data instrument, which indicated high levels of consistency.

The questionnaire results showed that in children with ASD, a higher IQ was weakly correlated with higher levels of anxiety. Children with ASD that had better verbal skills reported higher levels of anxiety than their peers. The study also reported that teachers play an integral role in the success of their students with ASD. Many suggestions were made to reduce anxiety levels in children with ASD, which mainly pertained to consistency in the schedule and adapting communication methods to their needs.

In terms of validity, the SAS-TR appeared unsatisfactory for gaging a student with ASD's anxiety level because the 16-questions relied heavily on symptoms related to social anxiety rather than generalized anxiety. The SAS-TR was developed to gauge anxiety for neurotypical students, but children with ASD do not feel anxious for the same reasons as their neurotypical peers. For example, the questionnaire mainly focused on feeling anxiety due to speaking or being asked a question in front of the class. Children with ASD tend to feel more anxiety over a schedule or environmental change and external stimuli. The SAS-TR needs to be adapted for children with ASD to be a valid testing resource for anxiety in children with ASD in school settings.

Discussion

When it comes to the epidemiology of ASD, researchers seem to be grasping at straws. In addition to the information shared by Newschaffer et al. (2007), the relationship between maternal obstetrics, exposure to mercury and other metals, and exposure to smoking, alcohol, and illicit drugs were also discussed as possible contributing factors. In short, there have been incredible strides in understanding the epidemiology of ASD, but there is much which is still a mystery to researchers. If we cannot understand the genesis of one disorder, it will be difficult discover the pathology of its comorbid conditions. For these reasons, parents and educators must focus now on treating the symptoms as there is still no hope of treating the disorder itself.

With this in mind, Varela et al. (2020) give a detailed account of how children with autism present anxiety symptoms, at which developmental milestones they may arise, and how these expressions will potentially differ as the child matures through adolescence. This information is invaluable for parents and educators alike. If the neurotypical adults responsible for the environment adapt that environment to diminish potential anxiety triggers, there is a real possibility of minimizing the effect of this comorbid condition. Parents and educators can also use the knowledge provided by Varela et al. (2020) to prepare the child for the social exchanges which will inevitably occur in adolescence. Social stories and social-emotional coaching would be appropriate methods for preparing these children for the next phase in social development.

As previously mentioned, Morie et al. (2019) focus on the effect alexithymia, the inability to recognize and label one's own emotions, has on the individual with ASD. Many curriculums exist which focus on the importance of social-emotional awareness and would be helpful for these purposes. These resources would also be advantageous for adolescents who may be lower functioning and have lesser IQ scores. These proposed techniques would be easy to introduce during the early developmental stages of childhood and would benefit all children, whether they are diagnosed with ASD or not.

Syriopoulou-Delli et al. (2019) highlighted the teacher's importance in identifying and treating ASD. Second, only to the parent, the educator can potentially impact the child for the better. The research proved that when the teacher is aware of the struggles specific to the child on the autism spectrum, the teacher facilitates interactions which result in greater social inclusion for the child and less anxiety in the classroom.

Conclusion

Much is still unknown about ASD and how anxiety symptoms develop in conjunction with it, but using the information provided by the research community, parents and educators can minimize the impact specific stressors have on children and adolescents with ASD. Using preventative and treatment strategies, parents and educators can assist the student by filling in the gaps of social awareness through intentional teaching of social-emotional positive behaviors, relational give and take, and conversational back and forth. Although these are behaviors that neurotypical people glean through everyday interactions, parents and educators have the opportunity to open the social world to children and adolescents with ASD by teaching them these social concepts.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Bagby, R. M., Parker, J. D., & Taylor, G. J. (1994). The twenty-item Toronto alexithymia scale– I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research,38(1), 23–32.

Constantino, J. N., & Gruber, C. P. (2012). Social responsiveness scale-second edition (SRS-2). Torrance: Western Psychological Services.

Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment,26(1), 41–54.

Lovibond, S. H., & Lovibond, P. F. (1995). Manual for The Depression Anxiety Stress Scales. Sydney: Psychology Foundation.

Lyneham H.J., Street A.K., Abbott M.J., Rapee RM (2008) Psychometric properties of the school anxiety scale- teacher report (SAS–TR). Journal of Anxiety Disorders, 22:292– 300.

Morie, K. P., Jackson, S., Zhai, Z. W., Potenza, M. N., & Dritschel, B. (2019). Mood disorders in high-functioning autism: the importance of alexithymia and emotional regulation. Journal of Autism & Developmental Disorders, 49(7), 2935–2945. https://doi- org.proxy.ccis.edu/10.1007/s10803-019-04020-1

Newschaffer, C. J., Croen, L. A., Daniels, J., Giarelli, E., Grether, J. K., Levy, S. E., et al. (2007). The epidemiology of autism spectrum disorders. Annu. Rev. Public Health, 28, 235–58. doi:10.1146/annurev.publhealth.28.021406.144007

Syriopoulou-Delli, C. K., Polychronopoulou, S. A., Kolaitis, G. A., & Antoniou, A.-S. G. (2019). Views of teachers on anxiety symptoms in students with autism spectrum disorder. Journal of Autism & Developmental Disorders, 49(2), 704–720. https://doi- org.proxy.ccis.edu/10.1007/s10803-018-3752-1

Varela, R. E., DuPont, R., Kamps, J. L., Weems, C. F., Niditch, L., Beaton, E. A., & Pucci, G. (2020). Age differences in expression of generalized and social anxiety among youth with autism spectrum disorder. Journal of Autism & Developmental Disorders, 50(3), 730–740. https://doi-org.proxy.ccis.edu/10.1007/s10803-019-04289-2