Social Functioning And Anxiety In Autistic Children

Anxiety is significantly more prevalent among autistic individuals compared to the general population. This heightened prevalence may be due to various factors, including sensory sensitivities, difficulties with social communication, and challenges in adapting to change.

A key concept in understanding anxiety in autism is Theory of Mind (ToM) – the ability to understand others’ thoughts, feelings, and intentions.

Impaired ToM, often observed in autism, can lead to social difficulties and misunderstandings, potentially contributing to anxiety.

Anxiety in autism can present in both typical and atypical ways, ranging from excessive worry to increased repetitive behaviors or meltdowns.

Recognizing and addressing anxiety, while considering ToM abilities, is crucial for improving overall quality of life for autistic individuals.

Hunsche, M. C., Cervin, M., Storch, E. A., Kendall, P. C., Wood, J. J., & Kerns, C. M. (2022). Social functioning and the presentation of anxiety in children on the autism spectrum: A multimethod, multiinformant analysis. Journal of Psychopathology and Clinical Science, 131(2), 198–208. https://doi.org/10.1037/abn0000724

Key Points

• Social motivation and theory of mind (ToM) emerged as central factors in the social functioning of autistic children with co-occurring anxiety disorders.
• Bullying experiences were independently associated with having multiple anxiety disorders in autistic children.
• Autistic children with distinct social fears (not related to fear of negative evaluation) showed more difficulty with ToM compared to those with traditional social anxiety disorder.
• The study found two distinct communities of social functioning: one related to social ability (ToM, social motivation, friendship quality) and another related to social integration (bullying, interpersonal difficulties).
• Limitations include the cross-sectional design, reliance on parent report for most measures, and a treatment-seeking sample with relatively higher IQ.
• The findings suggest incorporating ToM and social skills training into anxiety interventions for autistic youth may be beneficial, especially for those with distinct social anxiety presentations.

Rationale

Autistic children often experience significant challenges in social functioning, including difficulties with social communication, understanding others’ perspectives, and developing positive peer relationships (Chevallier et al., 2012; Kimhi, 2014).

These social challenges are often compounded by co-occurring anxiety disorders, which occur at above-population rates in autistic youth (Kerns et al., 2021; Simonoff et al., 2008).

While previous research has found associations between anxiety symptoms and various aspects of social functioning in autistic children, findings have been mixed and limited by methodological issues such as reliance on single, broad measures of social functioning and single-informant approaches (Chang et al., 2012; Duvekot et al., 2018; McVey et al., 2018).

This study aimed to address these limitations by employing a multimethod, multi-informant approach to examine how different facets of social functioning relate to anxiety severity and comorbidity in autistic children.

The researchers were particularly interested in identifying which aspects of social functioning are most strongly associated with anxiety and with each other, as this information could help inform more targeted interventions.

Additionally, the study sought to explore how social functioning profiles may relate to distinct presentations of social anxiety in autistic youth, an area that has received limited attention in previous research.

Method

The study used a multimethod, multi-informant approach to assess various aspects of social functioning and anxiety in a sample of autistic children with co-occurring anxiety disorders.

Procedure

Participants completed a phone screen, followed by diagnostic intake interviews for those meeting eligibility criteria.

Assessments included measures of anxiety, autism symptoms, cognitive functioning, and other socioemotional difficulties. Interviews were conducted by trained clinicians and doctoral students.

Sample

The final sample included 191 autistic children (ages 7-13) with co-occurring anxiety disorders and their caregivers.

Participants were predominantly male (79.1%) and White (76.7%), with varied autism and anxiety symptom severity and mildly impaired to superior intellectual functioning.

Measures

1. Anxiety Disorders Interview Schedule with Autism Spectrum Addendum (ADIS/ASA): A semi-structured interview that assesses DSM-IV anxiety disorders and includes additional items to differentiate autism vs. anxiety symptoms and capture anxiety expressions unique to autism.
2. Pediatric Anxiety Rating Scale (PARS): A clinician-rated scale that measures the overall severity and interference of anxiety symptoms in children.
3. Autism Diagnostic Observation Schedule-2 (ADOS-2): A semi-structured observational assessment that evaluates social interaction, communication, play, and restricted and repetitive behaviors associated with autism.
4. Childhood Autism Rating Scale-2 (CARS-2HF): A 15-item rating scale that helps identify children with autism and determines symptom severity through quantifiable ratings based on direct observation.
5. Wechsler Intelligence Scale for Children-IV (WISC-IV): A comprehensive clinical instrument for assessing the cognitive ability of children aged 6 to 16 years.
6. Child Behavior Checklist (CBCL): A parent-report measure that assesses various behavioral and emotional problems in children, including a subscale for social problems.
7. Social Responsiveness Scale-2 (SRS-2): A 65-item rating scale that measures the severity of autism spectrum symptoms as they occur in natural social settings, including aspects like social awareness, social cognition, and social communication.

Statistical measures

The study employed Bayesian network analytics using the R package BGGM. This approach allowed for examining unique associations among specific elements of social functioning while controlling for other variables in the model.

Pairwise comparisons of edges between nodes were conducted to identify the strongest relationships. Binary logistic regressions were used to examine how social functioning related to different presentations of social anxiety.

Results

1. Social motivation emerged as the most influential factor in the network, showing strong associations with other aspects of social ability (ToM, friendship quality, social affect).
2. ToM was the most interconnected variable in the network, demonstrating significant associations with four of the six social nodes.
3. Bullying experiences were independently associated with having multiple anxiety disorders.
4. Two distinct communities of social functioning emerged: one related to social ability (ToM, social motivation, friendship quality) and another related to social integration (bullying, interpersonal difficulties).
5. Autistic children with distinct social fears (not related to fear of negative evaluation) showed more difficulty with ToM compared to those with traditional social anxiety disorder.

Insight

This study provides a nuanced understanding of how different aspects of social functioning relate to each other and to anxiety in autistic children.

The emergence of social motivation as a central factor suggests that interventions focusing on increasing children’s interest in social interactions may have cascading positive effects on other areas of social functioning.

The finding that ToM was highly interconnected with other social variables highlights its potential importance in social skill development and peer relationships for autistic youth with anxiety.

The distinct communities of social functioning identified in the network analysis suggest that difficulties in one area of social functioning (e.g., social communication) may be closely linked to challenges in related areas (e.g., friendship quality).

This underscores the potential value of comprehensive social skills interventions that address multiple facets of social functioning simultaneously.

The association between bullying experiences and multiple anxiety disorders highlights the need for targeted interventions to address peer victimization in autistic youth. Future research could explore the effectiveness of anti-bullying programs specifically tailored for autistic children in reducing anxiety symptoms.

The finding that autistic children with distinct social fears (not related to fear of negative evaluation) showed more difficulty with ToM compared to those with traditional social anxiety disorder suggests that different mechanisms may underlie various presentations of social anxiety in autism.

This has implications for tailoring anxiety interventions to address the specific cognitive processes involved in an individual’s anxiety presentation.

Strengths

This study had several methodological strengths, including:

1. Use of a multimethod, multi-informant approach to assess social functioning
2. Inclusion of both standard and autism-specific measures
3. Large sample size of treatment-seeking autistic children with co-occurring anxiety
4. Advanced statistical techniques (Bayesian network analysis) allowing for nuanced examination of relationships among variables
5. Consideration of both traditional and distinct presentations of social anxiety in autism

Limitations

This study also had several methodological limitations, including:

1. Cross-sectional design limits ability to determine causal relationships or developmental trajectories
2. Reliance on parent report for most measures, which may not fully capture children’s social experiences
3. Treatment-seeking sample with relatively higher IQ may limit generalizability to broader autism population
4. Predominantly male and White sample may not represent the full diversity of autistic individuals
5. Small sample size for the group with distinct social fears (n=26) may have limited power to detect group differences

Implications

The findings have several important implications for clinical practice and future research:

1. Interventions targeting social motivation and ToM may be particularly beneficial for improving overall social functioning in autistic children with anxiety.
2. Comprehensive social skills programs that address multiple facets of social functioning simultaneously may be more effective than those focusing on isolated skills.
3. Anxiety interventions for autistic youth should incorporate strategies to address and prevent bullying experiences.
4. Clinicians should be aware of the potential for distinct presentations of social anxiety in autism and tailor interventions accordingly, potentially incorporating ToM training for those with atypical social fears.
5. Future longitudinal research is needed to clarify the developmental trajectories and causal relationships between social functioning and anxiety in autism.
6. Interventions should be developed and evaluated that specifically target the unique social-cognitive profiles associated with different presentations of anxiety in autism.

References

Primary reference

Hunsche, M. C., Cervin, M., Storch, E. A., Kendall, P. C., Wood, J. J., & Kerns, C. M. (2022). Social functioning and the presentation of anxiety in children on the autism spectrum: A multimethod, multiinformant analysis. Journal of Psychopathology and Clinical Science, 131(2), 198–208. https://doi.org/10.1037/abn0000724

Other references

Chang, Y. C., Quan, J., & Wood, J. J. (2012). Effects of anxiety disorder severity on social functioning in children with autism spectrum disorders. Journal of Developmental and Physical Disabilities, 24, 235-245. https://doi.org/10.1007/s10882-012-9268-2

Chevallier, C., Kohls, G., Troiani, V., Brodkin, E. S., & Schultz, R. T. (2012). The social motivation theory of autism. Trends in cognitive sciences, 16(4), 231-239. https://doi.org/10.1016/j.tics.2012.02.007

Duvekot, J., van der Ende, J., Verhulst, F. C., & Greaves‐Lord, K. (2018). Examining bidirectional effects between the autism spectrum disorder (ASD) core symptom domains and anxiety in children with ASD. Journal of Child Psychology and Psychiatry, 59(3), 277-284. https://doi.org/10.1111/jcpp.12829

Kerns, C. M., Rast, J. E., & Shattuck, P. T. (2020). Prevalence and correlates of caregiver-reported mental health conditions in youth with autism spectrum disorder in the United States. The journal of clinical psychiatry, 82(1), 11637.

Kimhi, Y. (2014). Theory of mind abilities and deficits in autism spectrum disorders. Topics in Language Disorders, 34(4), 329-343.

McVey, A. J., Schiltz, H. K., Haendel, A. D., Dolan, B. K., Willar, K. S., Pleiss, S. S., … & Van Hecke, A. V. (2018). Social difficulties in youth with autism with and without anxiety and ADHD symptoms. Autism Research, 11(12), 1679-1689. https://doi.org/10.1002/aur.2039

Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child & Adolescent Psychiatry, 47(8), 921-929. https://doi.org/10.1097/CHI.0b013e318179964f

Keep Learning

1. How might the relationship between social motivation and other aspects of social functioning differ in autistic individuals without co-occurring anxiety disorders?
2. What are some potential explanations for the negative association found between ADOS social affect scores and bullying experiences when controlling for ToM?
3. How might cultural factors influence the presentation of social anxiety and social functioning in autistic children from diverse backgrounds?
4. What ethical considerations should be taken into account when developing interventions targeting social motivation in autistic individuals?
5. How might the findings of this study inform the development of peer support programs for autistic youth in school settings?