Can ABA Therapy Help with Anxiety? In Many Cases, Yes

Nearly 91% of children with autism have a co-occurring condition, such as epilepsy, ADHD, anxiety disorders, OCD, intellectual disability, etc. In this article, we are going to focus on anxiety, which estimates predict is present in 11%-84% of children and adolescents with autism.

In a study using parental reports, most parents felt that their autistic child’s anxiety impacted the child’s ability to engage in enjoyable activities, interact with peers, their classroom performance, as well as parents’ ability to attend events, and their careers. Another study reported that autistic children who exhibit higher levels of anxiety are less likely to participate in both home and community-based activities, showing how debilitating the condition can be.

Applied behavior analysis (ABA) therapy is an evidence-based intervention that examines why certain behaviors occur and teaches functional alternatives. ABA therapy can help to reduce anxiety by examining what triggers the anxiety, how to reduce the likelihood of these triggers occurring, and teaching coping strategies to help manage the feelings associated with anxiety.

Understanding Anxiety in Autistic Children

Due to the difficulties autistic children exhibit with communication, symptoms of anxiety are usually recognized and described by caregivers.

There is currently a debate about whether typical anxiety tests miss out on diagnosing children with autism due to communication challenges or because the anxiety may present differently. One study that aimed to bridge this gap asked parents of autistic children about their child’s anxiety using a combination of tools, including standardized measures, open-ended questions, and closed-ended questions. Parents were asked about their child’s anxiety at home, in school, and in the community. 89% of parents reported that their child exhibited anxiety in at least one of the settings, while 43% reported anxiety across all three. There was variation in how and which symptoms of anxiety were present in each setting. For example, in the home, parents reported that children appeared preoccupied, worried, and scared, shouting rapid vocalizations, and engaging in repetitive behaviors. In the school setting, children were more likely to hide and shut down, cry, and experience non-compliance. In the community, children would ask for or want a specific person, engage in repetitive behaviors or movements, and show sensory sensitivities.

Core symptoms of ASD include a preference for routines and sameness, including ritualistic behaviors, daily schedules, restricted interests, and difficulties with change and flexible thinking. On top of this fear of uncertainty, there are communication challenges that prevent or complicate the child’s ability to ask questions or express their needs. These two challenges together create a high sense of stress and anxiety for autistic children. Furthermore, with more socially aware autistic children, social challenges can cause bullying and teasing as well as loneliness, which can fuel social anxiety disorder.

What is ABA Therapy?

ABA therapy is an evidence-based intervention that examines what causes certain behaviors to occur in specific situations and teaches functional alternatives. ABA therapy can occur both in home, school, community, and clinic settings and heavily relies on parent training to help the skills learned generalize across people and places. During ABA therapy, the child will learn a variety of functional skills that are important and applicable to that specific child, including communication, play and socialization, daily living, and academic and self-regulation goals. Furthermore, ABA therapy will also target some maladaptive behaviors to reduce and replace, such as tantrums, hitting, grabbing, etc.

An ABA therapy team is comprised of a Board Certified Behavior Analyst (BCBA) who will assess your child and write a treatment program that is specifically tailored to their needs and learning style. The assessment will include observations, rating scales, and caregiver interviews. Once the caregivers have approved the treatment goals, a therapist will begin to work with your child on the goals written by the BCBA. The therapist and BCBA train caregivers on how to implement goals and use strategies to help manage symptoms of autism.

ABA Therapy’s Approach to Anxiety

ABA is heavily reliant on collecting data on observable events to identify what is triggering certain behaviors. Initially, the BCBA will start by defining what anxiety means to that specific child in observable, objective language. For example, anxiety might be exhibited by hand wringing, screaming, pacing, freezing, skin picking, etc. The BCBA will then observe and take data on what is occurring before the “anxious behaviors” to identify the triggers.

Once the triggers to the anxiety have been identified, BCBAs implement several techniques to help reduce the anxious symptoms. Here, we will go into detail about some commonly used methods:

Cognitive restructuring

Cognitive restructuring involves changing stress-producing thoughts with calmer thoughts that produce less stress. Initially, the child is asked to record their thoughts, followed by selecting one stress-inducing thought. Once this thought has been selected, the next step involves finding a different point of view and formulating a new statement to replace the previously held thought. This approach can help reduce anxiety for children with autism who have strong language and language comprehension skills.

Desensitization

Desensitization techniques can be a helpful tool for decreasing stress responses in children who may not be receptive or able to fully participate in cognitive restructuring. This technique gradually exposes the child to stressful stimuli systematically and only increases the exposure once the child is fully calm with the stimuli. Once the child is calm, a more intrusive type of stimuli is introduced. For example, if a child has anxiety about dogs, initially, a child will just be shown a picture of a dog. Once the child is calm with this picture, a video will be introduced, and so on, until the child is calmly able to interact with a real dog.

Teaching coping strategies and relaxation techniques

In the process of teaching replacement behaviors to autistic children, coping strategies and relaxation techniques are often taught. These are usually simple and easy-to-follow methods, such as counting to 10, deep breathing exercises, having some quiet time, engaging in a relaxing activity such as coloring, listening to music, using a fidget toy, etc.

Benefits of ABA Therapy for Anxiety in Autistic Children

During my work as a BCBA, I used desensitization procedures frequently to help decrease anxiety for my students. For example, one student struggled with changes in routines and required a written schedule at all times of the day. Using systematic desensitization, the student was taught to tolerate and be calm with changes. Initially, small schedule changes were made after the student had been thoroughly warned and had been taught some self-regulation techniques. By the end of the intervention, therapists were able to make last-minute changes to their schedule, including moving around times related to their favorite activities and decreasing their overall dependence on schedules.

Another student was unable to allow adults to cut his nails due to anxiety and fear. Desensitization steps were created, allowing the student to hold the nail clipper, feel the clipper on his hand, on his nail, and then finally allow the instructor to cut the nail.

Studies have shown ABA can be an effective tool to decrease social anxiety by teaching social skills. ABA was shown to be more effective than other therapies for children with autism as the language is more direct than abstract, utilizes more visuals, and implements rewards to improve the child’s participation in therapy.

ABA has also been shown to help reduce anxiety in classroom and school settings, by teaching both proactive and reactive skills. Another study also supported the ABA approach of highly individualized treatment plans and using graduated exposure, such as desensitization paired with reinforcement to help reduce anxiety symptoms.

Participación de los padres en la terapia ABA

Parental or caregiver involvement in ABA sessions is paramount to the success of the program. While therapists become a big part of the child’s life, no one can replace the amount of time and impact that parents have on their child’s life. When parents are involved and learn to run the goals the ABA team is working on, the child can learn the skills quicker and is also able to generalize with more ease. In the context of anxiety, this means the child will feel more comfortable and calm faster and utilize their newly learned self-regulation techniques in a variety of settings and with different caregivers.

As part of ABA therapy, parents should be receiving parent training with the BCBA about once a month, as well as during the ABA session. Here, parents are taught how to run the goals with their child in front of the child’s therapist. As a parent, this is your time to make the most use of the therapist’s expertise in the field. If you show you are open and ask questions about how you are running the programs and ask about areas for improvement, you will create a strong training relationship with the therapist as they will feel more confident to train you. If the program is unclear or you feel like you are missing information, just ask. Your team should be there for you and be able to provide answers. If you feel that parent training and support are not offered after repeated requests or you feel unsupported, you can switch providers and find a team that works better for you.

Elegir al proveedor de ABA adecuado

When selecting an ABA therapist, as with any provider, it is useful to know their expertise and background. Inquire about the therapists’ previous experience treating anxiety and ask for specific examples of how they helped a child, including names of approaches so you can follow up with your research on your own time.

Another important question to ask is how the therapist will ensure your child’s discomfort is kept to a minimum, and how they will pivot and modify the treatment plan if they do show signs of distress. Finally, I would ask questions regarding the alternative skills that will be taught to your child to be able to monitor and cope with their anxiety.

Desafíos y consideraciones potenciales

Using ABA for anxiety can be effective as long as certain factors are considered. For example, each treatment plan needs to be individualized and tailored specifically to meet the needs of that child and the environment they are in. For example, the plan should consider the child’s learning style, language ability, stress tolerance, etc.

During the treatment, there should be a balance between pushing the child and monitoring for signs of distress or discomfort. If done correctly, the child should not be in a situation of distress as the intensity of the treatment will move along once the child is calm and desensitized in the current plan.

The child should have a method of requesting breaks and time out for the treatment for them to be able to regulate and successfully participate in the treatment. If the child is requesting a break, these requests should be honored and treatment resumed after a suitable break.

Alternative and Complementary Therapies

Various other therapies can be combined with ABA to help reduce anxiety. For example, behavior therapists can collaborate with other healthcare providers, such as speech therapists and occupational therapists.

As autism affects communication, speech therapy can be included as part of a child’s treatment plan, which targets verbal, non-verbal, and social communication. Therapists can help give language to children to help them process their emotions around their anxiety-provoking stimuli as well as help them communicate their needs.

Occupational therapy can also be a useful component, focusing on self-regulation and soothing techniques. These skills can then be used by the child, both proactively to stay calm and reactively to come back to a regulated state.

If these strategies and therapies are not proving helpful in reducing anxiety, medication can also be considered as an option. When considering this option, ask plenty of questions about potential side effects, including what they are, how severe, and how long they will last. Ideally, if you choose medication, keeping up with non-medical interventions like the ones mentioned is helpful to teach coping skills so that, eventually, the medication can fade.

Conclusión

If your child is experiencing high levels of anxiety and stress, there are options available to help. ABA therapy, paired with different therapies such as speech and OT can teach you and your child valuable tools to help minimize anxiety-producing situations and deal with the feelings of anxiety when they occur. These approaches are evidence-based and effective, offering a safe method to help reduce your child’s anxiety.

When you feel ready, discuss your concerns and goals with different members of your treatment team. For the different options suggested to you, find out the efficacy and evidence base, what are the side effects of each, and chose the option which will work best for your child and you. If at any point you feel uncomfortable, voice your concerns. If you do not feel they have been adequately addressed, you are free to change approaches and/or providers to find the right treatment fit.

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