Could you talk about why autistic children are at risk of experiencing anxiety?
First, it’s important to know there can be many pathways for anxiety. Some people may have had scary experiences in the past that can lead to anxiety. Other research suggests that there may be a biological vulnerability for anxiety. Anxiety can run in families, so it is very common for anxious parents to have anxious children.
What is autism?
A neurodevelopment condition, autism is characterized by differences and difficulties in social interaction and reciprocity, sensory processing, alongside restricted and repetitive behaviors and focused interests. It’s also a spectrum, with each autistic person having unique presentations and support needs.
Autistic and non-autistic children may be similar when it comes to their experiences of anxiety, but the social and communication differences that autistic youth frequently display may make them particularly vulnerable to developing anxiety. Additional areas of difficulty, including emotion regulation and planning and organizational differences, may also contribute to anxiety, particularly in school settings. The contextual mismatch of being autistic in a world that was not designed for autistic thinking, may partially explain why autistic youth experience anxiety at high rates.
Could you explain the psychoeducation aspect of the Facing Your Fears in Schools (FYF-S) program?
Similar to many CBT programs for anxiety, FYF-S has two primary components – psychoeducation and graded exposure.
Psychoeducation includes the following: helping youth identify what situations or circumstances make them anxious, learn to identify what's happening physically in their bodies when they feel anxious, and recognize the negative self-talk that so many of us experience when anxious, which can sound like: “This is so scary.” “I can't do it.” “This is terrible.” “Something bad is going to happen.”
We want autistic kids to recognize these parts of an “active mind” and encourage them to identify “helpful thoughts” instead. For example, if they’re afraid of a dog at the park and saying to themselves in an active-mind way: “That dog is so ferocious, I’m sure it’s going to get off-leash and bite me. I better leave the park”. That’s an active-mind unhelpful thought. Instead, we’ll work with our autistic kids to use reason and facts. They might then say: “That dog is on a leash, “That dog is sitting,” “That dog is listening to its owner,” “The owner is following the on-leash rules and I'm over here, and so it's unlikely to get off its leash. I want to play at the park, so I will stay even though there is a dog over there.”
We’ll then combine the self-talk or cognitive portions of the program with somatic management – which is coming up with strategies to manage the uncomfortable feelings in your body when feeling anxious or upset. Sometimes we do deep breathing. Sometimes we encourage youth to do other relaxing activities. Sometimes we encourage them to think about a mindful activity. Schools are great at thinking about all the different ways a student can calm themselves down and take a minute.
That’s simplifying the approach – it includes more detail than what I outlined. We want our kids to put it all together to manage their emotions by first recognizing the intensity of their emotions and then using a pre-planned strategy for how to calm themselves down when anxious or upset.
Ultimately, what we’re doing is teaching our kids how to recognize when they become escalated and then figure out how to calm their system back down. It may not be something that comes naturally to a lot of our autistic students (or non-autistic students for that matter), so we want to give them specific strategies for how to do that.
And the second part of treatment is graded exposure?
Correct. We define graded exposure as facing your fears a little at a time. In other words, helping autistic youth identify their fear and then do the thing that they are afraid of in school.
For example, if they’re afraid of talking to their teacher, we make a plan to help them talk to their teacher. Or if they’re afraid of going to recess because there might be insects on the grassy areas and they’re afraid of bugs, we help them go outside, even on the grassy areas.
It is important to note that we don’t make kids do things they don't want to do. This is all about what things the students themselves identify as getting in their way. And if this is something that they want to conquer it, and feel like they want to try being brave, that's what we go with.
All brains are beautiful
Reaven notes that while the current Diagnostic and Statistical Manual of Mental Disorders – published by the American Psychiatric Association – uses words like “impairments, deficits and disorders” when discussing autism, there is a shift, driven by the autistic community, to be more affirming in how autistic traits are described. Instead, words like “difficulties” and “differences” help to better characterize autistic traits. Additionally, a move toward using “autistic/autistic person” over “person with autism” helps to place autism as an identity that is just part of who they are. Reaven does add that it is a complex and evolving conversation and is unique to each individual.
We have to help our kids identify that what's getting in their way is something they can actually manage and do something different about. Lots of our kids just accept anxiety as part of their life. We are here to poke holes in it saying, “Actually, your life can be a little bit better if you get a handle on this thing.”
Were you encouraged by your most recent findings studying Facing Your Fears in Schools in Colorado?
Very much so. We found that kids who participated in the Facing Your Fears program saw their overall anxiety improve relative to those who didn’t participate.
It’s potentially a huge deal, because the school based FYF was based on our clinic model, which is 14 sessions of 90 minutes each time delivered only by psychologists or graduate students in psychology. Compare that to FYF-S which was 12 sessions, 40 minutes each lesson, delivered by interdisciplinary school providers, rather than mental health providers alone.
That’s half the dosage between the two programs for similar levels of results, with the added flexibility of being able to be done in a setting a student is familiar with versus a clinical setting.
I think it’s really great and bodes well for our school providers to be able to deliver a mental health-based program regardless of provider background. Importantly, all providers received specific training in FYF-S so we don’t know how well providers could deliver the program without training.
What are some of the barriers to implementing this approach?
Time for the training and time to deliver and learn a new program – given all the other responsibilities and priorities school providers have and need to manage throughout their day. Support from district administration is essential.
When thinking about the FYF-S specifically, we have learned that the psychoeducation portion of FYF-S is pretty straightforward, and schools do a really good job with these activities. Some of our school providers can get tripped up on doing the exposure half of the training – which is key to kids getting better with anxiety. That’s a barrier we see in a lot of exposure-based programs, both in and out of schools. We’re actively trying to figure out how we help schools with training and sustainability of FYF-S.
Do you have any tips for parents of autistic kids on anxiety?
As part of FYF-S, we include weekly handouts following each lesson with specific tips on how parents can support students with the content of each lesson. Doing these and understanding the basics of the program – especially psychoeducation and graded exposure – can be a big help.
Supporting their child’s use of coping strategies and encouraging their child’s brave behaviors goes a long way. We also encourage parents to model their own brave behaviors and coping strategies so their kids can see these strategies in action. Parents are valuable partners in supporting their children to successfully manage anxiety.
For more information on the Face Your Fears programs, visit their site.
