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Managing Anxiety in People with Autism

A Treatment Guide for Parents, Teachers, and Mental Health Professionals
Anne M. Chalfant, Psy.D.

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isbn# 978-1-60613-004-9
5½" x 8½"
275 pages

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Copyright controlled materials. Cannot be reprinted without permission of the publisher.

Sample from Managing Anxiety in People with Autism:

Chapter 2: Why Is Anxiety a Common Problem for People with ASD?

Chapter 2
Why is Anxiety a Common Problem for People with ASD?

Karl and the Potter Family
Mrs. Potter came to me with some concerns regarding her son, Karl, who has a diagnosis of atypical autism or pervasive developmental disability-not otherwise specified (PDD-NOS). Karl is ten years old and attends a local school where he is mainstreamed. His mother told me that this year Karl seemed to be spending much more time in the school library at recess and lunch time, away from his peers. Although the school reported to her that he seemed to be interacting with the other students in the library, for example playing chess or computer games, she expressed concern that he might be using the library as a means of avoiding social interaction on the playground. She further discussed that Karl had tried to make up health related excuses as to why he could not participate on the playground; e.g., that he was still recovering from a broken arm (that happened almost six months ago) or that he was feeling unwell and thought the library might be more relaxing in case it got too hot on the playground and he felt faint. He even complained about eye difficulties that might be exacerbated if he went outside in the sun. Naturally, Mrs. Potter had all of Karl’s possible medical and physical ailments ruled out by their family doctor and some specialists before coming to speak with me.

Mrs. Potter indicated that Karl seemed to catastrophize how bad the social experience on the playground was. She reported that Karl would come home and tell her that his day was 10 percent positive and 90 percent negative because of spending time outside with his peers at recess or lunch. When she asked him why, he talked about a brief and seemingly insignificant incident of another child throwing a ball in his direction and thinking that he was going to be hit by it and that the boy threw it at him on purpose.

I also spoke with the special educator at Karl’s school, who affirmed that Karl did seem to have a tendency to always see the worst in social situations even when they seemed harmless. She described one incident where Karl had misinterpreted and catastrophized someone’s move in a chess game with him as a deliberate attempt to cheat in order to make Karl unhappy. In general, the rigidity in Karl’s thinking and interpretations of social interaction was preventing him from engaging on the playground and feeling content at school.

Worries or “negative” thoughts are common in anxious children, whether or not they have an ASD. However, it is possible that children with an ASD are more predisposed to anxious thinking than other groups of children. Children with an ASD seem to have a natural thinking and learning style that is somewhat rigid or “black and white” (e.g., Rutter and Bailey, 1994). Interestingly, this is also the kind of thinking that we typically associate with a person who is anxious (e.g., Rapee & Heimberg, 1997).

How Does an Anxious Person Think?
Inflexible or “black and white” thinking has long been associated with the thinking styles of anxious individuals (e.g., Clark & Wells, 1995). It is argued that anxious people tend to process information in a restricted way. For example, researchers have shown that anxious children have a bias toward selectively attending to threat signals and, as a result, misinterpret ambiguous information as threatening because of a failure to consider the global context (Kendall, 1985).

Think of a flashlight. When you change the focus of the beam to hone in on an object, you can see a smaller area but you can see it in more detail. It is the same in the minds of anxious people. Typically developing anxious individuals tend to have a “narrow beam” that selectively illuminates what they feel anxious about in detail rather than also capturing information from the larger context that might reassure them that there is nothing to worry about. In other words, anxious people seem to have a bias for taking into account information that they consider threatening or fearful rather than taking other information into account as well (e.g., information about safety). For example, a typically developing child who fears getting injections, or shots, might have a bias toward thinking about all of the aspects of that situation that make him scared including the length of the needle, the possibility of pain during the injection, and the possibility of a foreign substance causing some harm in his blood stream. He is more likely to focus on this information alone rather than the fact that the needle is being delivered by an experienced nurse, that his parent is in the room with him for reassurance, that the shot won’t last very long, and that it is highly unlikely that he will become sick from the injection. It is the child’s tendency to over-focus on and over-interpret the “threatening” aspects of the situation that exacerbates his anxiety and doesn’t allow him to consider the broader context.

Anxious adults also tend to engage in more black and white thinking styles. For example, if I am driving to a meeting and begin to worry about being late, I might limit my focus to the signals that highlight the threat of running late, for example checking my watch and the car clock, the people driving ahead of me who I believe aren’t moving fast enough, and my over-interpretation that all of the traffic lights in the city are conspiring against me to turn red. I will probably not be thinking about the nonthreatening information such as how many times in the past I have driven the same route without running late, that the traffic is moving at a steady pace, that I am well prepared for the meeting, and that I can call ahead and let others know my status. Also, I might not remind myself that, if I am actually late, then the others whom I am meeting will more than likely understand as they know that traffic in the area is congested.

How Does a Person with Autism Think?
So, what is similar about the black and white thinking of anxious people and that of people with an ASD? Interestingly, like anxious people, individuals with autism have also been shown to have a “narrow beam” approach in terms of their thinking and learning styles. One prominent theory that helps explain this is the “weak central coherence” theory (Frith, 1989).

Central Coherence Theory
First proposed by Uta Frith (1989), central coherence theory refers to the idea that when we process information, we first explore the full or global context, and then we determine what out of that context is important to focus on in more detail. In other words, we use a wider beam on our “flashlights” to explore the bigger area, then we decide what information we want to adjust the beam over so as to explore more closely. Of course, these are decisions that are made in fragments of time. Thus we are unaware that we are going through that kind of thought process.

It is said that people with autism have “weak central coherence” (Happé & Frith, 2006; Frith, 1989). Specifically, people with an ASD have difficulty extracting meaning from a context due to a preference for processing local information first rather than global information (Happé, 1994; Happé & Frith, 2006). Instead of scanning the whole context in order to identify what is important to focus on, the person with an ASD is argued to be over-selective, focusing on small details and, therefore, less aware of other information in the environment (Happé & Frith, 2006; Frith, 1989). Going back to the analogy of the flashlight, people with an ASD seem to have a “narrow beam” focus on their flashlights, seeing less information but in greater detail. Therefore, some information remains out of sight since their flashlight beams are narrow and do not illuminate the bigger picture.

How often have you been speaking with a person with autism and heard him comment on a minute detail in a scene (real or in a picture) that you have missed completely and that does not seem particularly relevant to the overall image or point of discussion? For example, when I asked a client to discuss her day at school during our session she suddenly noticed and commented on the fact that she could see part of a cockroach’s leg above the alarm system in the top left hand corner of the room. It took me some time to actually see what she was referring to and to realize that it was indeed the leg of a cockroach, which later crawled up the wall from under the alarm box.

Do People with Autism Have a Predisposition to Anxiety?
Do you notice similarities between the thinking styles of those people with anxiety and those with autism as outlined above? Both groups seem to take in information based on a “narrow beam” approach rather than processing information from the larger picture. On this basis, it seems quite reasonable to argue that people with autism might have an underlying predisposition to anxiety because they think in a similar way to people who are anxious. In other words, it could be argued that the weak central coherence of people with ASD might make them particularly vulnerable to anxiety because they might have a natural tendency to focus on threat cues rather than first processing the bigger picture, which would include non-threat cues.

Consider the example of a handwriting task. A person with an ASD who is anxious about handwriting might already have an underlying predisposition to focus firstly on the details of the task he considers threatening because of his narrow beam thinking style. Therefore, when a writing task is introduced in the classroom, he might automatically focus on where to write his name or on the pencil he is using rather than first taking in broader information such as what the writing task is about, how long the task will take to complete, and that he might have free time when the task is complete. Focusing on the aspects of the writing task that seem threatening could exacerbate that person’s anxiety, making it harder for him to even start the task.

Similarly, in the case of Karl described at the beginning of this chapter, he seemed to have a bias toward focusing on certain details that he considered threatening and, therefore, to miss other important information in the “bigger picture.” For example, he focused mostly on the ball coming toward him on the playground rather than trying to consider more global information such as the look on the face of the person throwing the ball, the game that person was engaged in, or the other people who were near the ball and might have knocked it accidentally in his direction.

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