ASD and Social Anxiety

It is estimated that up to 80% of ASD level 1 (high functioning autistic) kids also experience intense anxiety symptoms. Anxiety Disorders (e.g., Obsessive Compulsive Disorder, Social Anxiety, Generalized Anxiety Disorder) commonly co-occur with ASD. When anxiety symptoms are untreated, they can further interfere with a youngster’s quality of life. 
Kids with both autism and Anxiety Disorders experience a more limited social world than kids with only one disorder. They may have difficulty (a) adapting at home and in school, (b) making friends and joining in social activities, and (c) breaking their usual rituals to try something new.

Although little is known about what anxiety symptoms look like in autistic kids, the following symptoms, which overlap with Anxiety Disorders, indicate anxiety:

• Withdrawal from social situations
• Somatic complaints
• Irritability
• Avoidance of new situations

Another set of anxiety symptoms may be seen and may be unique to ASD kids:

• Becoming "silly"
• Becoming explosive easily (e.g., anger outbursts)
• Increased insistence on routines and sameness
• Increased preference for rules and rigidity
• Increased repetitive behavior
• Increased special interest

Social anxiety is a condition in which the child has an excessive and unreasonable fear of social situations. Anxiety (intense nervousness) and self-consciousness arise from a fear of being closely watched, judged, and criticized by others. The fear may be made worse by a lack of social skills.

ASD children with social anxiety may be afraid of a specific situation. However, most kids with social anxiety fear more than one social situation. Other situations that commonly provoke anxiety include:

• Answering questions
• Asking questions
• Attending family get-togethers (e.g., Christmas)
• Attending parties
• Being called on in class
• Being teased or criticized
• Being the center of attention
• Being watched while doing something
• Dating
• Eating or drinking in front of others
• Giving reports in groups
• Going to school
• Interacting with people
• Making phone calls
• Making small talk
• Meeting new people
• Performing on stage
• Public speaking
• Taking exams
• Talking on the telephone
• Talking with “important” people or authority figures
• Using public bathrooms
• Writing or working in front of others

Psychological symptoms of social anxiety include:
  • Avoidance of social situations to a degree that limits activities or disrupts life
  • Clinging to the parent
  • Crying
  • Excessive self-consciousness and anxiety in everyday social situations
  • Extreme fear of being watched or judged by others, especially people you don’t know
  • Fear that others will notice that you’re nervous
  • Fear that you’ll act in ways that that will be embarrassing or humiliating
  • Having a meltdowns
  • Intense worry for days, weeks, or even months before an upcoming social situation
  • Refusing to go to school
  • Throwing a tantrum

Physical symptoms of social anxiety include:

• Blushing
• Clammy hands
• Confusion
• Diarrhea
• Dizziness, feeling faint
• Dry mouth
• Muscle tension
• Pounding heart or tight chest
• Rapid breathing
• Shaking
• Trembling voice
• Sweating or hot flashes
• Twitching
• Upset stomach, nausea


Cognitive behavioral therapy, a time-limited approach designed to change thoughts, emotions, and behaviors, has been shown to be successful in treating social anxiety in these children. Cognitive-behavioral therapy for social anxiety typically involves:
  • Challenging negative, unhelpful thoughts that trigger and fuel social anxiety, replacing them with more balanced views.
  • Facing the social situations you fear in a gradual, systematic way, rather than avoiding them.
  • Learning how to control the physical symptoms of anxiety through relaxation techniques and breathing exercises.

Modifications designed to address the cognitive, social, and emotional difficulties include:

1. "Individualizing" anxiety symptoms—Kids should be helped by the therapist to identify what their own anxiety symptoms look like as anxiety symptoms may present differently.

2. Behavioral management—Addition of a reward and consequence system maintains structure and prevents anger outbursts.

3. Combining visual and verbal materials—Use of worksheets, written schedules of therapy activities, and drawings can be added to increase structure in therapy sessions.

4. Games and fun physical activities are important to include in group therapy to promote social interactions.

5. Greater parent involvement—To build on the attachment between parent and child, it is important to have moms and dads learn the techniques and coach kids to use them at home.

6. More education on emotions—Activities such as feeling dictionaries (i.e., a list of different words for anxiety) and emotional charades (i.e., guessing people's emotions depending on faces) are helpful in developing emotional self-awareness.

Three types of medication are also used in the treatment of social anxiety:

• Antidepressants – Antidepressants can be helpful when social anxiety disorder is severe and debilitating. Three specific antidepressants—Paxil, Effexor, and Zoloft—have been approved by the U.S. Food and Drug Administration for the treatment of social phobia.

• Benzodiazepines – Benzodiazepines are fast-acting anti-anxiety medications. However, they are sedating and addictive, so they are typically prescribed only when other medications for social phobia have not worked.

• Beta blockers – Beta blockers are used for relieving performance anxiety. They work by blocking the flow of adrenaline that occurs when you’re anxious. While beta blockers don’t affect the emotional symptoms of anxiety, they can control physical symptoms such as shaking hands or voice, sweating, and rapid heartbeat.

Practicing breathing exercises can help the child decrease the physical symptoms of anxiety and stay calm. Parents and teachers can coach the child on the following techniques:
  • Sit comfortably with the back straight and the shoulders relaxed. Put one hand on the chest and the other on the stomach.
  • Inhale slowly and deeply through the nose for 4 seconds. The hand on the stomach should rise, while the hand on the chest should move very little.
  • Hold the breath for 2 seconds.
  • Exhale slowly through the mouth for 6 seconds, pushing out as much air as possible. The hand on the stomach should move in when exhaling, but the other hand should move very little.
  • Continue to breathe in through the nose and out through the mouth. Focus on keeping a slow and steady breathing pattern of 4-in, 2-hold, and 6-out.

Resources for parents of children and teens on the autism spectrum:

==> Videos for Parents of Children and Teens with ASD

Resources for Neurodiverse Couples:

==> Online Group Therapy for Men with ASD

==> Online Group Therapy for NT Wives

==> Living with ASD: eBook and Audio Instruction for Neurodiverse Couples 

==> One-on-One Counseling for Struggling Individuals & Couples Affected by ASD

==> Online Group Therapy for Couples Affected by Autism Spectrum Disorder

 ==> Cassandra Syndrome Recovery for NT Wives

==> ASD Men's MasterClass: Social-Skills Training and Emotional-Literacy Development

==> Pressed for time? Watch these "less-than-one-minute" videos for on the go.




Anonymous said...

I have no idea what to do in social situations, so they make me nervous. People would try to force me to interact. I tell them I don't know what to do. They don't believe me and push me on. I make a mistake, they laugh and I'm afraid to try it again. Or, I try, make a mistake and someone yells at me,”You just don't say that!" I ask why not. They think I'm being sarcastic, refuse to answer and alienate me more. Eventually, they just give up on me which leads to further isolation. The only way I can avoid what they do, and the tension it causes, is to avoid them. They ask me why I avoid them. I tell them it’s because they yell at me. They tell me,”Well, if you would just say the right thing." I tell them I don't know what that is. They still don't believe me and think I'm making up lame excuses. Most people I know can't handle my AS traits. It frustrates them too much. That pushes even more of them away.

Anonymous said...

I was shy as a child and also what I call "socially tone deaf," which made me awkward in many of my interactions with other kids, but even at that early age I would say I didn't have social anxiety as much as I had social indifference...I was simply happier spending time alone than with others. That is still true today, even though years of life experience have greatly improved my social skills. I am animated, outgoing and sociable at work and with a few friends whose homes I visit, but I only go to actual social "events" two or three times a year, not because I am anxious but because I just can't be bothered and very much prefer quiet evenings alone at home. When I do go out, I am OK for 2 or 3 hours, but then I begin to feel bored or crowded and am ready to leave. I do think I am happiest and healthiest living alone...it's easier to be around people all day if I have my solitude to look forward to.

Anonymous said...

That is interesting and good to read... I have put off saying I think I'm Aspie like because there are times I can appear 'out-going' - but usually it is when I am talking about an interest of mine in a situation where I am sharing with people who I trust to accept me. I have had people tell me that it's like a switch turns on and I light up and it's amazing to watch. If I think about that at the moment, I get self-conscious and stammer... so I try not to think about it. Like you I can usually do something socially demanding for about 3 hours before I start to shut down and need to go rest. Holiday parties with family and all the kids and chatty conversation can be the most exhausting thing for me... I end up finding some place quiet to hang out before I can rejoin. I don't live alone, but I stay at home while the kids go to school, which gives me my peace. During the summer though, I get grumpier and grumpier until Mommy needs a time out. Thank God for DVD's!

Anonymous said...

That sounds just like me! I love to talk and can actually be the "life of the party," especially when talking about a subject I love and know well. What I find so tiring about socializing is sitting through 2 or 3 hours, in which I may spend only 5 or 10 minutes talking this way and the rest of the time sitting around, waiting a polite length of time to go home, longing to be online...

Anonymous said...

For me during social anxiety it felt like I knew what to say but when that was treated I still didn't know what to say. I do ok with one person but in a group situation I have nothing to say. I don't have anxiety anymore because when I realize I'm not saying anything I just look for something else to occupy my mind with. I do repetitive things like try to straighten objects on a table. It still sounds like anxiety but I don't get those racing thoughts in my head, so in a way it's better. If you want to get treated for social anxiety you can't do it on your own. See a therapist/ psychologist and if you need it take medication. Also, look for books or ways to treat social anxiety online. My way works for me, but may not work for everybody.

Anonymous said...

I have both. I thought social anxiety/phobia was my single issue for most of my life up until recently. It is probably more prominent than my autism. My diagnosticians said that my social anxiety likely primarily arose due the hindrance in my ability to understand people and social norms, but also because of sensory issues. Early on, my psychologists/iatrists tried social situation exposure in an effort to get over it. This was while on SSRIs. That's the classical method, but it never really worked with me. It probably would be more successful on someone who doesn't also have autism.

Anonymous said...

My solution has been finding the right medication: Lexapro. This has helped me a lot, but I still have difficulties.

Anonymous said...

I used to be quite extraverted, but I turned very introverted after years of embarrassing mistakes and failings. And now my social anxiety is pretty bad, and if you took that away I'd probably do well socially.

Anonymous said...

I was placed on antidepressants after a lifetime of dysthymia and bouts of clinical depression. They relieved my social anxiety to some degree, which I was not expecting. I still avoid social situations but I am merely shy now rather than paralyzed. Now I am more likely to blurt something out or ramble on about my particular area of interest. I think my social anxiety masked my possible Aspie traits. (self dx'd).

Anonymous said...

I only have one of the two. Social anxiety disorder. I'm glad I can actually relate to some people since joining this website as an NT xD. I know how to respond in any situation on the spot, I don't even have to think about it. The anxiety symptoms can make it difficult sometimes, but I seem to be getting over some of them now.

Anonymous said...

That is very much my child. At this point, she is taking medication to help her at bedtime.

That article is very helpful.

Anonymous said...

Not sure if my 25 year old has Asperger's. He goes to college for Physical Therapy, but not sure what he wants to be. Doesn't have a job, but had one up till about a year ago. Doesn't want to look for one. Has social anxiety. Doesn't like me, his mom. Doesn't like to be told what to do.

Anonymous said...

Hi Mark,

My 15 year old son has a phobia about going into shops and buying even an ice cream for himself. I think this has developed because we haven’t taken him out enough or ever made him buy anything by himself. I have sat down and talked to him about why it is so important because when he has his own home he will have to do his own shopping.(he seemed to agree with this)
I have explained to him that we will be going shopping together about 2 times a week and 2 times a week he has to go into a shop and pay for his own ice-cream. What happens if he refuses to go into the shop because he is so anxious, do I need to say if he refuses that he will have a consequence and loose his iPod until he carries through with my request. How should I handle this phobia.

We have been following your programme for 1 week now and I have notice a huge improvement in his behaviour and our relationship. Thanks so much.

Mark said...

Re: What happens if he refuses to go into the shop because he is so anxious, do I need to say if he refuses that he will have a consequence and loose his iPod until he carries through with my request. How should I handle this phobia.

This is a wonderful task that you are giving him!!!

I would go in small steps... perhaps something like:

1st time- You go in the shop with him and pay
2nd time- You go in the shop with him - he pays
3rd time- You go in the shop with him - he pays - you stand at the door (as far away as possible) and watch
4th time- Same as 3rd, but you stand right outside the door (out of view, but when he comes out, you are right there)

Also, rehearse all of this at home before attempting (role play ...you are the cashier).

I would caution against punishing him for not following through as this will just raise the anxiety level.

Anonymous said...

One time I was invited to a birthday party. I was so anxious the week before that, kept thinking bout it and how I didn't have a present yet, if I had the time right and other stuff like that.
Then, a day before the party I was doing some stupid stuff with my friend, to keep my mind off of it. Long story short, I got injured, enough that they called in a helicopter. Only two things were going through my mind at that point, one was the pain and the other one was relief at not having to attend that birthday party the next day.

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