Social Anxiety or ASD?: Evidence-based treatments for social anxiety disorder

Social anxiety is categorized by a persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. While all individuals on the spectrum have unique experiences, many face similar challenges in regards to social communication and social interactions. These challenges may include difficulty with back and forth social exchanges, reduced sharing of interests, and increased difficulty interpreting others’ emotions. In addition, some individuals may struggle with nonverbal communication, including eye-contact, gestures, and reading nonverbal cues (American Psychiatric Association, 2013). These social challenges faced by individuals with ASD can sometimes come across as social anxiety, and in some cases, are also a form of social anxiety. This blog will differentiate the social challenges experienced by individuals with ASD from those experiencing social anxiety, and outline evidence based treatments for social anxiety disorders.

Social Anxiety Disorder (SAD)

Social Anxiety Disorder, or SAD, is a persistent fear of social situations. The individual fears that they will act in a way that will be embarrassing or humiliating, leading to an avoidance of social situations. Exposure to the feared situation may provoke anxiety, which may be seen in the form of avoidance, physiological symptoms, or even take the form of a panic attack.  

For an individual with social anxiety disorder, they recognize that the fear is unreasonable or excessive. Feared situations are avoided or endured with intense anxiety and distress. Avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, functioning, and relationships. There may also be marked distress about having the phobia.

Social Anxiety and ASD

The social communication challenges in ASD may come across as social anxiety, or may actually be related to a social anxiety disorder. These two conditions may present alone or together, and research actually suggests that 40% of individuals on the spectrum also struggle with an anxiety disorder. Comorbid anxiety disorders include social phobia with prevalence rates of 17–30%, specific phobias which affect 30–44% of the population, generalized anxiety disorder affecting 15–35%, separation anxiety disorder affecting 9–38%, and obsessive-compulsive disorder, or OCD, at 17–37%. Social anxiety in ASD may amplify the social skill deficits that are already present, change resistance, and repetitive behaviors. For individuals with ASD, this anxiety may present in sleep problems, self-injurious behavior, parental stress, insistence on sameness, and sensory concerns (Zaboski, 2018). 

Treatments

Research shows that cognitive behavioral therapy, or CBT, is an effective social anxiety treatment modality for the general population, but also for those on the autism spectrum.  Treatments work best when adequately accounting for social, familial and cognitive variables, and adding exposure therapy (Zabowski, 2018).

When supporting individuals with ASD specifically, CBT treatment is best when it includes the person’’s skill set, interests, and developmental capacity. This treatment can also include concrete behavior plans, and increased parental involvement. (Zabowski, 2018). 

Children 

The following are evidence-based treatment modalities where children can use coping skills to manage their anxiety:

• Sunfield recommends Coping Cat, a 16 week, evidence-based CBT intervention program aimed to help children recognize and analyze anxious feelings and develop strategies to cope with anxiety-provoking situations. This treatment is recommended for children aged 8-13 years of age. Research suggests Coping Cat participants had a clinically meaningful reduction in anxiety for clients with and without comorbid ASD. Most individuals demonstrated remission of clinically-significant anxiety symptoms.

• We also recommend Camp Cope-A-Lot, a 12-module online computer program based on the Coping Cat workbook. This program aims to provide cognitive behavioral therapy techniques and is recommended for children 7-13 years of age dealing with anxiety and stress. The first 6 sessions are designed for children to complete on their own, while the last 6 are designed for completion with a parent or therapist. This module comes with videos and a printable Go-To-Gadget child workbook. (copingcatparents.com) 

Adolescents 

Anxiety in individuals with ASD may derive from a lack of knowledge in how to engage in social situations, cause increased loneliness, and in turn result in fewer opportunities to practice social skills such as empathizing and considering other’s thoughts. Therefore, individuals with comorbid ASD and anxiety may benefit from both CBT and social skills training.

• We recommend the C.A.T. Project for adolescents ages 14-17, targeting anxiety-treatment. The C.A.T. Project is a modified version of Coping Cat which is recommended for children aged 8-13. The C.A.T. Project targets adolescent developmental needs by providing appropriate pictures and examples. The C.A.T. Project is a 16 week, evidence-based CBT intervention program aimed to help teens recognize and analyze anxious feelings and develop strategies to cope with anxiety-provoking situations. 
• We also recommend PEERS as an evidence-based protocol for social skills. PEERS targets anxiety in social situations due to uncertainty about how to behave. Social skills training occurs through habituation or disconfirming negative beliefs. Research studies have suggested that PEERS participants showed increased ability to empathize, positively engage in peer conflict resolution, romantic relationships, and manage friendships (Zabowski, 2018). PEERS treatment includes systematic training in non-verbal social skills (including increased eye contact), friendly attentive posture, and verbal social skills. Skills are identified and practiced through role plays in therapy sessions and homework assignments are assigned.

Adults
Studies found that the following treatment modalities and strategies are evidence-based practices for supporting adults with anxiety:

• Cognitive Behavioral Therapy (CBT) → evidence-based practice for treating stress and anxiety

• • CBT improves awareness and control of unhelpful thinking and behavioral patterns
  • CBT also encourages coping skills to ease emotional distress

• Mindfulness →  evidence-based approach focusing on emotional wellness 

• • Promotes relief from pain or distress
  • Non-judgmental and focused awareness of the present moment

• For adults, we recommend PEERS: Program for the Education and Enrichment of Relational Skills (PEERS®) 

• • PEERS is a research-based social skills training program to support social challenges
  • Strong evidence base for young adults with autism spectrum disorders
  • Appropriate for young adults with ADHD, anxiety, & depression 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC Autism Speaks. (2019). Social Skills and Autism.  https://www.autismspeaks.org/social-skills-and-autism  Bandelow B., Reitt M., Röver C., Michaelis S., Görlich Y., Wedekind D.   Efficacy of treatments for anxiety disorders: a meta-analysis. Int. Clin. Psychopharmacol. 2015;30(4):183–192. Kerns C. M., Kendall P. C., Zickgraf H., Franklin M. E., Miller J., Herrington J. Not to be overshadowed or overlooked: functional impairments associated  with comorbid anxiety disorders in youth with ASD. Behav. Ther. 2015;46(1):29–39.  Lidstone J., Uljarević M., Sullivan J., et al. Relations among restricted and repetitive behaviors, anxiety and sensory features in children with autism spectrum disorders. Res. Autism Spectr. Disord. 2014;8(2):82–92.  Mazurek M. O., Petroski G. F. Sleep problems in children with autism spectrum disorder: examining the contributions of sensory over-responsivity and anxiety. Sleep Med. 2015;16(2):270–279. van Steensel F. J., Bögels S. M., Perrin S. Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clin. Child Fam. Psychol. Rev. 2011;14(3):302–317. • Meta-analysis on Diagnostic and Statistical Manual of Mental Disorders criteria establishing high diagnostic overlap between autism spectrum disorder (ASD) and anxiety. van Steensel F. J., Zegers V. M., Bögels S. M. Predictors of treatment effectiveness for youth with ASD and comorbid anxiety disorders: it all depends on the family? J. Autism Dev. Disord. 2017;47(3):636–645. White S. W., Oswald D., Ollendick T., Scahill L. Anxiety in children and adolescents with autism spectrum disorders. Clin. Psychol. Rev. 2009;29(3):216–229. Wigham S., Rodgers J., South M., McConachie H., Freeston M. The interplay between sensory processing abnormalities, intolerance of uncertainty, anxiety and restricted and repetitive behaviours in autism spectrum disorder. J. Autism Dev. Disord. 2015;45(4):943–952. Wood J. J., Drahota A., Sze K., Har K., Chiu A., Langer D. A. Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial. J. Child Psychol. Psychiatry. 2009;50(3):224–234. Randomized controlled trial examining CBT for children with ASD. Zaboski, B. A., & Storch, E. A. (2018). Comorbid autism spectrum disorder and anxiety disorders: a brief review. Future neurology, 13(1), 31–37. doi:10.2217/fnl-2017-0030