Assessment and Treatment of Anxiety in Youth With Autism Spectrum Disorders

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Assessment and Treatment of
                                      Anxiety in Youth With Autism
                                      Spectrum Disorders
                                      Roma A. Vasa, MD,a Micah O. Mazurek, PhD,b Rajneesh Mahajan, MD,a Amanda E. Bennett, MD,c Maria
                                      Pilar Bernal, MD,d Alixandra A. Nozzolillo, MS,e L. Eugene Arnold, MD,f Daniel L. Coury, MDg

OBJECTIVES: Anxiety is one of the most prevalent co-occurring symptoms in youth with autism                                                                abstract
spectrum disorder (ASD). The assessment and treatment recommendations proposed here
are intended to help primary care providers with the assessment and treatment of anxiety
in ASD.
METHODS: The Autism Speaks Autism Treatment Network/Autism Intervention Research on
Physical Health Anxiety Workgroup, a multidisciplinary team of clinicians and researchers
with expertise in ASD, developed the clinical recommendations. The recommendations were
based on available scientific evidence regarding anxiety treatments, both in youth with ASD
and typically developing youth, and clinical consensus of the workgroup where data were
lacking.
RESULTS: Assessment of anxiety requires a systematic approach to evaluating symptoms
and potential contributing factors across various developmental levels. Treatment
recommendations include psychoeducation, coordination of care, and modified cognitive-
behavioral therapy, particularly for children and adolescents with high-functioning ASD.
Due to the limited evidence base in ASD, medications for anxiety should be prescribed
cautiously with close monitoring of potential benefits and side effects.
CONCLUSIONS: Assessment and treatment of clinical anxiety in youth with ASD require a
standardized approach to improve outcomes for youth with ASD. Although this approach
provides a framework for clinicians, clinical judgment is recommended when making
decisions about individual patients.

aKennedy Krieger Institute and Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine, Baltimore, Maryland; bDepartment of Health

Psychology at the University of Missouri and Thompson Center for Autism and Neurodevelopmental Disorders, Columbia, Missouri; cDivision of Developmental and Behavioral Pediatrics, The
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; dChildren’s Health Council, Palo Alto, California; eCenter for Child and Adolescent Health Research and Policy, Massachusetts
General Hospital for Children and Harvard Medical School, Boston, Massachusetts; and fNisonger Center of Excellence in Developmental Disabilities and gDepartment of Developmental and
Behavioral Pediatrics, The Ohio State University, Columbus, Ohio

Drs Vasa, Mazurek, Mahajan, Bennett, and Arnold contributed to the conception and design, analysis and interpretation of data, and drafting and revising the
manuscript; Drs Bernal and Coury contributed to the conception and design, interpretation of the data, and revising the manuscript; Ms Nozzolillo contributed to the
conception and design and revising the manuscript; and all authors approved the final manuscript as submitted.
DOI: 10.1542/peds.2015-2851J
Accepted for publication Nov 9, 2015
Address correspondence to Roma A. Vasa, MD, Center for Autism and Related Disorders, Kennedy Krieger Institute, 3901 Greenspring Ave, Baltimore, MD 21211.
E-mail: vasa@kennedykrieger.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

  To cite: Vasa RA, Mazurek MO, Mahajan R, et al. Assessment and Treatment of Anxiety in Youth With Autism Spectrum Disorders. Pediatrics. 2016;137(S2):e20152851J

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PEDIATRICS Volume 137, Number S2, February 2016:e20152851                                                                                               SUPPLEMENT ARTICLE
Anxiety is one of the most prevalent        care providers use in their clinical             treatment of anxiety in TD youth.
and impairing co-occurring                  practice. The workgroup was                      Both assessment and treatment
conditions in youth with autism             composed of 7 authors of this article.           recommendations were informed by
spectrum disorder (ASD).1–3 A               The goal was to help clinicians                  clinical consensus when data were
recent meta-analysis indicated that         develop a systematic approach to                 lacking. For each recommendation,
39.6% of youth with ASD have at             the assessment of anxiety in this                clinical consensus was achieved
least 1 anxiety disorder.4 Despite          population, to provide treatment                 through an iterative process. After
this burden, youth with ASD face            recommendations, and to help                     extensive discussion, a written
barriers in accessing timely and            clinicians decide when to refer to a             draft of each recommendation
appropriate mental health treatment,        mental health specialist.                        was circulated to all members for
which places increasing demands on                                                           feedback. Recommended changes
primary care providers to manage                                                             were discussed during subsequent
anxiety in these children.5                 METHODS                                          conference calls, incorporated into
                                                                                             the written draft, and redistributed to
Diagnosing anxiety in youth with            The ATN/Autism Intervention
                                                                                             the workgroup members for further
ASD can be more challenging than            Research Network on Physical Health
                                                                                             review. The process continued until
in typically developing (TD) youth          Anxiety Workgroup developed the
                                                                                             all workgroup members reached
because of cognitive and language           current assessment and treatment
                                                                                             consensus with the final revision.
impairments, compromised reporting          approach through a systematic multi-
of emotions, overlapping symptoms           iterative process. The ATN/Autism
between anxiety and ASD, and unique         Intervention Research Network                    RESULTS AND DISCUSSION
behavioral expressions of anxiety           on Physical Health is a consortium
in the ASD population. In addition          of 14 ASD centers throughout the                 Assessment of Anxiety
to challenges with assessment, the          United States and Canada focused on
                                                                                             The recommendations below
field is faced with limited proven          improving the clinical care of youth
                                                                                             present a systematic process to
treatments to target anxiety in youth       with ASD. The Anxiety Workgroup
                                                                                             assess anxiety. Conducting a full
with ASD. The Autism Speaks Autism          is composed of a multidisciplinary
                                                                                             assessment may take a prolonged
Treatment Network (ATN) Anxiety             group of clinicians and researchers
                                                                                             visit or multiple visits. Practitioners
Workgroup recently authored a               (child psychiatrists, developmental
                                                                                             whose schedule does not allow
systematic review of pharmacologic          pediatricians, and a clinical
                                                                                             adequate time may wish to delegate
and nonpharmacologic anxiety                psychologist) with extensive clinical
                                                                                             this assessment to a mental health
treatment studies in ASD that were          experience in working with this
                                                                                             professional. The recommendations
published through June 2013.6               population.
                                                                                             below correspond to Fig 1.
These results showed modest
                                            The workgroup held a series of
evidence for the efficacy of cognitive-                                                      Recommendation 1: Perform a
                                            conference calls from April 2014
behavioral therapy (CBT) and lack                                                            Developmentally Appropriate
                                            to November 2014 to discuss best
of randomized placebo-controlled                                                             Multi-Informant and Multi-Method
                                            practices for both assessment and
trials investigating pharmacologic                                                           Assessment of Anxiety
                                            treatment of anxiety in youth with
treatments for anxiety in youth with
                                            ASD. The group reviewed relevant                 Current evidence recommends the
ASD. The few existing studies that
                                            studies pertaining to anxiety and                use of multiple assessment modalities
focus on anxiety are open-label or
                                            ASD and discussed clinical practice              and informants when assessing
retrospective chart reviews. This
                                            patterns. For the assessment                     anxiety in children with ASD.11,12 This
finding is in contrast to data in TD
                                            process, evidence was gleaned from               process includes data from clinical
youth, which support the use of both
                                            manuscripts on the topic indexed                 interviews and rating scales gathered
medications and therapy.7–9
                                            in PubMed and/or PsychINFO,                      from multiple informants (eg, child,
Most primary care providers lack            clinically relevant articles that                parent, and teachers) as well as
specific training in managing               were not indexed in PubMed or                    behavioral observations whenever
youth with ASD and co-occurring             PsychINFO, and book chapters that                possible. Assessment of anxiety
psychiatric conditions.10 On the basis      were published between 2000 and                  in this population can be more
of this finding, coupled with the           2014. Treatment recommendations                  laborious than in TD youth because
lack of anxiety treatments for youth        were based on findings from the                  of potentially compromised language
with ASD, the Anxiety Workgroup             systematic review conducted by                   and cognitive functions in the child
sought to develop a systematic              Vasa et al,6 anxiety treatment studies           and the presence of multiple complex
approach to the assessment and              in ASD published from June 2013                  co-occurring conditions that overlap
treatment of anxiety that primary           to January 2015, and studies on                  with anxiety. It is also important to

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S116                                                                                                                         VASA et al
explanations of these emotional
                                                                                                   terms when needed.14 Some children
                                                                                                   may respond better to forced choice
                                                                                                   responses (ie, those requiring a “yes”
                                                                                                   or “no” response) than open-ended
                                                                                                   questions. Other children may be able
                                                                                                   to provide responses using visual
                                                                                                   analog scales rather than through
                                                                                                   verbal response. If emotional insight
                                                                                                   is compromised, results must be
                                                                                                   interpreted cautiously.
                                                                                                   Parent report and other caregiver
                                                                                                   information. Clinicians must rely
                                                                                                   on accurate reporting of children’s
                                                                                                   anxiety symptoms by parents and
                                                                                                   other caregivers. If child self-report
                                                                                                   is compromised, the evaluation
                                                                                                   must rely on reported observed
                                                                                                   behaviors.15 These may include
                                                                                                   avoidance and crying in response
                                                                                                   to specific stimuli or contexts,
                                                                                                   freezing behavior, fearful affect,
                                                                                                   clinginess, and increased repetitive
                                                                                                   behaviors and/or vocalizations.
                                                                                                   Irritability, tantrums, disruptive
                                                                                                   behavior, aggression, worsening
                                                                                                   sleep problems, and self-injury may
                                                                                                   also suggest the presence of anxiety.
                                                                                                   Parents who have an anxiety disorder
                                                                                                   may have enhanced perceptions of
                                                                                                   anxiety in their child.16 Sometimes,
                                                                                                   there may be disagreement between
                                                                                                   parent and child reports.17 It is
                                                                                                   therefore important for clinicians to
                                                                                                   collect collateral information from
                                                                                                   school staff and other caregivers in
                                                                                                   the form of narratives and behavior
                                                                                                   reports to supplement their findings.
                                                                                                   Anxiety instruments. There are few
                                                                                                   well-validated tools for assessing
                                                                                                   anxiety in youth with ASD, and
                                                                                                   as such, clinicians often depend
                                                                                                   on measures used in TD children
                                                                                                   when assessing anxiety in ASD.
FIGURE 1
Assessment of anxiety in youth with ASD.                                                           Some scales such as the Screen for
                                                                                                   Child Anxiety Related Emotional
                                                                                                   Disorders (SCARED)18 show
evaluate the anxiety symptoms in the             capable of providing self-report, it
                                                                                                   comparable psychometric properties
context of child and family stressors.           is important to assess the child’s
                                                                                                   between youth with ASD and TD
Child self-report. Children with ASD             ability to understand and express                 youth, whereas others, such as the
may differ in their ability to self-             emotions (eg, “Do you know what I                 Multidimensional Anxiety Scale
report symptoms of anxiety due to                mean by nervous or scared?” “Tell me              for Children (MASC),19 show factor
age, verbal fluency, and cognitive               a time when you were nervous”) and                structures that differ between the
ability.13 If the child appears to be            provide developmentally appropriate               2 groups. Preliminary data on the

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PEDIATRICS Volume 137, number S2, February 2016                                                                                      S117
Spence Children’s Anxiety Scale            Recommendation 2: Assess for                     asking about behavioral signs of
(SCAS) indicate that it may serve          Specific Anxiety Disorders and                    anxiety that may accompany the
as an effective anxiety-screening          Anxiety Symptoms Related to the Core             symptom in question (eg, is the social
tool in youth with ASD.20 Data             Symptoms of ASD                                  avoidance associated with fearful
from 2 systematic reviews indicate         Many youth with ASD meet criteria                affect, irritability, or physiologic
some support for the use of the            for anxiety disorders according                  symptoms?). It is also important
following additional anxiety scales        to the Diagnostic and Statistical                to assess baseline ASD symptoms
in children with ASD: the Revised          Manual, Fifth Edition (DSM-5).24                 to differentiate preexisting ASD
Child Anxiety and Depression Scale         The most common DSM-5 anxiety                    characteristics from new-onset
(RCADS), the Child and Adolescent          disorders are social anxiety disorder,           anxiety symptoms (eg, has the child
Symptom Inventory, Fourth Edition          generalized anxiety disorder, and                always avoided crowds or is this a
                                           specific phobia.2 A substantial                  new behavior?). Other questions to
(CASI-4R), and the Pediatric Anxiety
                                           number of children with ASD also                 ask include whether ASD symptoms
Rating Scale (PARS).21,22 However,
                                           exhibit atypical anxiety symptoms                have intensified (eg, has the
both reviews noted measurement
                                           that are connected to the core                   frequency of repetitive behaviors
limitations across these scales.
                                           symptoms of ASD and may not fit                  increased recently?) and whether
Furthermore, a recent study reported
                                           neatly into DSM-5 categories.25                  there is a relationship between
that some of these scales may not
                                           Examples of atypical anxiety                     exposure to specific stimuli and
detect atypical fears.23 In summary,                                                        anxiety symptoms.
                                           symptoms include anxiety about
data from anxiety instruments used
                                           sensory stimuli, transitions, or social
in TD children should be interpreted                                                        Recommendation 3: Assess and
                                           situations without accompanying                  Treat Other Psychiatric and Medical
cautiously when applied to youth
                                           fear of negative evaluation. Thus, the           Conditions That May Cause or
with ASD.
                                           assessment of anxiety in children                Aggravate Anxiety
                                           with ASD should include a focus
Examination. In the office, clinicians                                                      Youth with ASD may present with
                                           on both categorical and atypical
should conduct a physical and                                                               other types of psychiatric symptoms
                                           symptoms.
mental status examination when                                                              such as inattention, hyperactivity,
                                           Anxiety and ASD symptoms can                     irritability, aggression, self-injury,
evaluating for anxiety. Elevated
                                           overlap. For example, social                     and tantrums.1,2 These symptoms
heart rate or blood pressure may
                                           avoidance may represent behavioral               may be a manifestation of anxiety
reflect situational anxiety related
                                           avoidance of feared stimuli, which               (eg, children who are anxious about
to the medical procedure or office
                                           suggests social anxiety, or social               schoolwork may exhibit irritability at
visit. Other signs of anxiety include      indifference, which is a core                    school) or may be related to another
tremors, nail biting, bald spots           feature of ASD.26 Ritualistic and                disorder that is triggering the
secondary to hair pulling, and             repetitive behaviors are core ASD                anxiety (eg, symptoms of attention-
skin lesions due to skin picking. A        symptoms and are also present in                 deficit/hyperactivity disorder
palpable thyroid, fine skin or hair,       certain anxiety disorders, including             at school may lead to academic
and/or brisk tendon reflexes suggest       obsessive-compulsive disorder,                   struggles and subsequent anxiety
checking the thyroid status as a           generalized anxiety disorder, and                about schoolwork). Treating other
possible cause of anxiety symptoms.        separation anxiety disorder.24 These             conditions that may exacerbate
Mental status examination may              rituals may serve to reduce anxiety or           anxiety should therefore be part of
reveal poor eye contact, negative          may be a preferred activity unrelated            the treatment plan and should be
affect (eg, fear, irritability), and       to negative affect.27 Clinicians should          considered before treating anxiety
changes in communication (eg,              therefore inquire about the function             directly.
stuttering, increased vocalizations,       of the ritualistic behaviors. A referral
                                                                                            Co-occurring medical disorders are
decreased verbal exchanges). The           to a behavioral psychologist, who
                                                                                            prevalent in youth with ASD but may
presence of disruptive behaviors           can conduct a functional behavioral
                                                                                            also reflect the presence of anxiety.
may reflect anxiety; however, these        analysis, may help differentiate these
                                                                                            For example, gastrointestinal28
behaviors may also reflect a desire        etiologies.
                                                                                            and sleep problems29may cause
to escape from the situation and           Clinicians can also ask questions to             or aggravate anxiety, particularly
therefore require careful assessment.      help tease out whether overlapping               if symptoms are more frequent or
Some children may not exhibit signs        symptoms are explained solely                    severe or may be caused by anxiety.
of anxiety on examination even             by ASD or are consistent with a                  Complex partial seizures can
though they experience anxiety in          co-occurring anxiety disorder.                   present with anxiety-like symptoms,
other settings.                            Some of these questions include                  including fear, misperceptions, and

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S118                                                                                                                       VASA et al
irritability.30 Some medications (eg,            for increased services at school),                first step. Other points to discuss
psychostimulants, bronchodilators,               suggest strategies to stabilize the               include delineating specific and
allergy medications) can also cause              home environment (eg, increasing                  measurable treatment outcomes
anxiety and may need to be changed.              structure and predictability),                    (eg, decreased avoidance of
Any medical issues affecting anxiety             accessing resources (eg, behavioral               feared stimuli, more responsive to
therefore warrant treatment.                     therapy, respite care), and promoting             psychosocial interventions when
                                                 parental self-care (eg, taking breaks,            anxious, sleeping in own room every
Recommendation 4: Address                        seeking personal mental health and                night). Coordinating the treatment
Psychosocial Stressors or Suboptimal             medical treatments). The child’s                  plan with parents and care providers
Behavioral and Educational Supports
                                                 anxiety level should be reassessed                (eg, therapists, school staff) is
That May Be Contributing to Anxiety
                                                 to determine if symptoms have                     recommended to track progress.
Many children with ASD have a                    decreased after modifying these
strong need for sameness and prefer              stressors.                                        Recommendation 2: Anxiety Can Be
predictable routines and schedules.26                                                              Treated With Modified CBT Techniques
Changes in the environment can                   Recommendation 5: Assess the Degree
                                                 of Anxiety-Related Impairment                     Preliminary data suggest that
therefore cause significant distress                                                               modified CBT (MCBT) is an
and anxiety. These changes can be                After collecting all of the data, the             efficacious treatment of children and
minor (eg, desks are moved in class)             clinician should assess if anxiety-               adolescents with high-functioning
or substantial (eg, new school, loss             related impairment is present (eg,                ASD and DSM-5 anxiety disorders.35
of a one-to-one aide, loss of in-home            How much does anxiety interfere                   MCBT can be administered
behavioral support services, change              with daily functioning? Is impaired               individually or in a group and often
in a parent’s job schedule).                     functioning present across 1 or                   includes parental involvement.
Anxiety may also result from a                   multiple settings?). Assessing the
                                                 contribution of anxiety symptoms                  CBT in TD youth involves many
mismatch between the child’s needs
                                                 (eg, schoolwork avoidance or                      components, including affective
and the types of supports in place
                                                 behavioral challenges at school and               education, cognitive restructuring,
in his/her daily life. For example,
                                                 home) to the overall impairment and               reducing avoidance behaviors,
inadequate educational supports
                                                 functioning of the child with ASD will            relaxation, modeling, and exposure
or high academic expectations
                                                 help to prioritize treatment.                     to the feared stimuli (with response
may cause increased stress due to
                                                                                                   prevention). Some youth with high-
academic challenges.31 Unrecognized              Treatment of Anxiety                              functioning ASD can understand
learning, gross or fine motor, or
                                                 If clinical anxiety persists despite              basic cognitive concepts of CBT and
speech and language difficulties may
                                                 relieving potential sources of anxiety            therefore may be responsive to both
aggravate such stress. Many children
                                                 or if stressors cannot be immediately             the cognitive and the behavioral
with ASD experience bullying and
                                                 modified, then treatment is                       elements of MCBT.36 In ASD, special
peer victimization in school, which
                                                 recommended. Clinicians and parents               CBT adaptations are needed to
may lead to significant anxiety.32
                                                 must decide together what the best                facilitate understanding of cognitive
Stressors in the family environment              treatment approach will be. Potential             and emotional concepts. These
must also be evaluated. Parents of               treatment barriers should be explored             include the use of visual supports and
youth with ASD experience greater                (eg, insurance constraints, parent                concrete language, the use of written
stress than parents of children with             work schedules, access to providers,              materials and lists, opportunities for
Down syndrome and TD children.33                 and transportation issues). Due to                repetition and practice, incorporating
Stressors can include caregiver burden,          limited treatment data in ASD, a                  special interests, video modeling,
lack of sleep, limited social and                specific treatment algorithm is not               and more active parent engagement
community engagement, and worries                offered but rather various treatment              in therapy.35 Behavioral therapy
about the future.34 Parental anxiety             recommendations are presented with                with exposure may be particularly
may contribute to anxiety in children,           the caveat that clinicians tailor treat-          useful for youth who have language
through modeling of anxious and                  ment on the basis of child and family             and cognitive difficulties, thereby
overprotective parenting behaviors.15            circumstances and clinical judgment.              precluding participation in the
Inquiring about recent stressors and                                                               cognitive components of treatment.37
working with parents to alleviate                Recommendation 1: Psychoeducation                 Some families may have limited
                                                 and Coordination of Care Are the First            access to mental health professionals
these stressors is critical. Clinicians
                                                 Steps of Treatment
can help with educational advocacy                                                                 with expertise in ASD and MCBT
(eg, talking to school staff or                  Educating youth and families about                protocols, in which case medications
writing letters indicating the need              anxiety symptoms is an important                  may be an option. Sometimes, a child

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PEDIATRICS Volume 137, number S2, February 2016                                                                                      S119
may be resistant or severely anxious         TABLE 1 Summary of Medications for the Treatment of Anxiety in Youth With ASD
during therapy (eg, exposure to a            Symptomsa                   Medicationb                        Dose Rangeb                                  References
feared stimulus results in severe                                                               Starting Dose             Maximum Dose
tantrums). In these situations,              Core anxiety               Sertralinec              12.5 mg daily              200 mg daily         Reviews in typically
parents and clinicians must decide             symptoms                 Fluoxetinec             2.5–5 mg daily               60 mg daily           developing youth:
together whether medication should                                      Citalopramc             2.5–5 mg daily               40 mg daily           Mohatt et al (2013),
be tried to facilitate engagement in                                    Escitalopramc          1.25–2.5 mg daily             20 mg daily           Strawn et al (2014)
                                             Specific anxiety
                                               symptomsd
therapy.                                       Sleep                    Melatonin                    2 mg hs                 10 mg hs            Guenoe et al (2011)
                                                  disturbance           Clonidine                  0.05 mg hs                0.2 mg hs
                                                                                                                                                 Nguyen et al (2014)
                                                                        Trazodonee               12.5–25 mg hs               100 mg hs
Recommendation 3: Certain                       Physiologic             Clonidinef              0.05 mg hs for 1           0.1 mg tid-qid        No data in TD
                                                  symptomsf                                     week then bid-qid                                  or ASD youth;
Medications Can Be Considered for the                                   Guanfacinef             0.05 mg hs for 1               1 mg tid            recommendations
Treatment of Anxiety                                                                            week then bid-qid                                  based on clinical
                                                                        Clonidine ERf          0.1 mg hs or qam            0.2 mg hs or            consensus
Table 1 presents a summary of                                                                                                   qamg
medications that could potentially                                      Guanfacine              1 mg hs or qam              4 mg hs or
                                                                           ERf                                                  qamg
be considered for the treatment                                         Propanolol           10 mg bid-tid or prn            30 mg tid
of anxiety in youth with ASD.                   Behavioral              Clonidine               0.05 mg hs for 1           0.1 mg tid-qid        Reviews by: Mahajan
Because these medications have not                dysregulationf                                week then bid-qid                                  et al (2012), Ji and
been rigorously studied in youth                                        Clonidine ER              0.1 mg daily            0.2–0.3 mg daily         Findling (2014)
                                                                        Guanfacine           0.5 mg hs for 1 week             1 mg tid
with ASD, the doses presented in                                                                    then bid tid
Table 1 are based on data in TD                                         Guanfacine                  1 mg hsg              4 mg hs or qam
children and adolescents. The                                             ER
recommendations, however, are to                Situational             Lorazepam               0.25–0.5 mg prn               2 mg prn           No data in TD
                                                   anxietyg                                                                                        or ASD youth;
start medications at low doses and                                                                                                                 recommendation
titrate slowly with close monitoring                                                                                                               based on clinical
(eg, monthly office visits) of both                                                                                                                consensus
benefits and adverse effects. Most                                      Propanolol                5–10 mg prn                 20 mg prn
important, we recommend that                 bid, twice daily; ER, extended-release; hs, bedtime; prn, as needed; qam, each morning; qid, 4 times per day; tid, 3 times
                                             per day.
primary care providers have a low            a Specific anxiety symptoms refer to individual or limited symptoms of anxiety, whereas core anxiety symptoms refer to

threshold for seeking consultation           the entire syndrome of cognitive, affective, and physiologic changes associated with anxiety.
                                             b Maximum doses are based on data in TD children and adolescents. Higher doses in this table should only be used in
from a developmental/behavioral
                                             consultation with a specialist versed in their use, such as a child psychiatrist or developmental-behavioral pediatrician
pediatrician or child psychiatrist           c Discuss side effects including risk of behavioral activation. Higher doses may be needed for fast metabolizers. Slow

when prescribing psychotropic                metabolizers may need lower doses.
                                             d Behavioral dysregulation refers to symptoms of irritability, aggression, property destruction, and self-injury. For severe
medications. Consultation could be           behavioral dysregulation, refer to a mental health specialist or follow the ATN pathway for treatment of irritability and
requested either before starting the         problem behaviors.
                                             e There are no data to support the use of trazodone. It is only recommended in children aged >8 years. The risk of priapism
medication or during the titration
                                             should be discussed with the family.
process, especially if higher doses          f For short and ER clonidine and guanfacine preparations, monitor blood pressure and heart rate at each visit. Check for

are used. Mental health professionals        orthostatic hypotension if dizziness, light-headedness, or falls are reported. Guanfacine ER can be started in the evening
                                             initially due to the possibility of sedation and then switched to morning, if needed. Alternatively, it can be started directly in
can assist pediatricians with titration      the morning if tolerated by the patient. Guanfacine is preferred over clonidine during daytime hours because of its longer
and safety monitoring, and help tease        half-life and lower potential for sedation.
                                             g Lorazepam is a short-acting benzodiazepine (6–8 hours). For situational anxiety, it should be given 30 min before the
out the complex developmental,
                                             event. There are no data on the use of propranolol in children and adolescents, but it is used by some experts for the
psychosocial, and medical issues that        treatment of situational anxiety.
can affect treatment outcomes. If
medications are ineffective or poorly        the efficacy of selective serotonin                                 although benefits may not be seen
tolerated, gradual discontinuation is        reuptake inhibitors (SSRIs) for                                     for several weeks after treatment
recommended. Liquid preparations             the treatment of anxiety disorders                                  initiation.
are available for slower titration or if     (separation anxiety, generalized
pills cannot be swallowed.                   anxiety, and social phobia) in TD                                   SSRIs are frequently prescribed in
Medications with efficacy in TD              youth.7 Indeed, SSRIs are the most                                  youth with ASD38; yet, there is a lack of
children can be tried for anxiety            effective pharmacologic treatments                                  double-blind placebo-controlled trials
in ASD. Robust evidence supports             for anxiety disorders in TD youth,                                  supporting their efficacy for anxiety

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S120                                                                                                                                                              VASA et al
in this population.6 Data from SSRI                   anxiety may exhibit significant                        response to medications should be
trials in youth with ASD report high                  physiologic arousal symptoms                           referred to an ASD mental health
rates of behavioral activation, which                 including increased heart rate, blood                  clinician (eg, a child psychiatrist,
manifests as increased activity level,                pressure, sweating, and muscle                         developmental pediatrician,
impulsivity, insomnia, or disinhibition               tension. Although no data are                          psychologist, and others). If the
without manic symptoms.39                             available, α-agonists and propranolol                  child’s anxiety triggers self-injury
Thisbehavioral activation typically                   could be considered to reduce such                     and/or lopement, treating clinicians
occurs at the beginning of SSRI                       physiologic symptoms.                                  should initiate appropriate
treatment or with dose increase and                   Anxiety can also result in                             interventions to keep the child
resolves with reducing the dose or                    behavioral dysregulation, which                        safe. Appropriate intervention may
discontinuing the medication. Other                   can be characterized by irritability,                  include a referral to an inpatient or
prescribing considerations include                    aggression, property destruction,                      partial hospitalization program.
a family history of bipolar disorder,                 and self-injury. α-Agonists (clonidine,
drug interactions, and the black box                  guanfacine, guanfacine extended
warning of suicidal ideation. Given                                                                          SUMMARY
                                                      release), which improve symptoms
these factors, certain SSRIs (shown in                of attention-deficit/hyperactivity                     The proposed assessment and
Table 1) are preferred over others. In                disorder in youth with ASD, may                        treatment strategies provide a
summary, SSRIs should be prescribed                   potentially reduce some of these                       useful starting point for clinicians
cautiously in youth with ASD, with                    behaviors.42–44 The ATN pathway                        to develop a standardized approach
close monitoring.                                     for the treatment of accompanying                      to the assessment and treatment of
Medications can be used to treat                      irritability and problem behaviors                     anxiety in youth with ASD. These
specific anxiety-associated symptoms                  can also be followed to manage these                   recommendations can be updated
based on evidence in ASD as well as                   behaviors.45                                           and specific treatment algorithms
expert clinical consensus. Several                                                                           can be developed as research on
                                                      Youth with ASD frequently                              the phenomenology, risk factors,
studies discuss the management                        experience situational anxiety such
of sleep disturbance in youth with                                                                           and treatments for anxiety becomes
                                                      as during family events, holiday                       available.
anxiety and ASD.40,41 Insomnia                        time, blood draws, and other
secondary to anxiety can be treated                   medical procedures. There are no
initially with melatonin, and if                      data on pharmacologic treatments
ineffective, there is preliminary                     for situational anxiety. Short-acting
evidence indicating that clonidine,                   benzodiazepines (eg, lorazepam)                          ABBREVIATIONS
a short-acting α-agonist, may help                    or a β-blocker (eg, propranolol)                         ASD: autism spectrum disorder
with insomnia. Although no data are                   can be considered temporarily                            ATN: Autism Treatment Network
available, low-dose trazodone can                     with close attention to sedation,                        CBT: cognitive behavioral
also be considered. Antihistamines                    cognitive impairment, and behavioral                           therapy
with anticholinergic effects (eg,                     activation.                                              DSM-5: Diagnostic and Statistical
diphenhydramine) should be avoided
                                                                                                                        Manual, Fifth Edition
for chronic sleep difficulties due                    Recommendation 4: Refer to a Mental
                                                      Health Clinician if Anxiety Is Extremely                 MCBT: modified cognitive
to the potential for delirium and
                                                      Impairing or Is Not Responding to                                behavior therapy
constipation. Referral to a sleep
                                                      Interventions                                            SSRI: selective serotonin
specialist should be considered as
                                                                                                                      reuptake inhibitor
necessary if these interventions                      Children with complex
                                                                                                               TD: typically developing
are ineffective. Some children with                   presentations or partial or no

Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr. Arnold has received research funding from Curemark, Forest, Lilly, Neuropharm, Novartis, Noven, Shire, Young Living, NIH, and
Autism Speaks. Dr. Arnold has consulted with or been on advisory boards for Gowlings, Neuropharm, Novartis, Noven, Organon, Otsuka, Pfizer, Roche, Seaside
Therapeutics, Sigma Tau, Shire, and Tris Pharma and has received travel support from Noven. Dr. Coury has research grants from Autism Speaks and SynapDx.
He is on the advisory board for Cognoa and on the Data Safety Monitoring Board for Neuren Pharmaceuticals. He is also on the Speaker’s Bureau for Abbott Labs.
Dr. Vasa has a grant from Autism Speaks. Dr. Bennett has had research funding from Seaside Therapeutics, Shire, Neurim pharmaceuticals, NIH, and Autism
Speaks. The remaining authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This research activity was supported by a cooperative agreement UA3 MC11054 through the US Department of Health and Human Services, Health
Resources and Services Administration, Maternal and Child Health Research Program to the Massachusetts General Hospital. This work was conducted through
the Autism Speaks Autism Treatment Network serving as the Autism Intervention Research Network on Physical Health.

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PEDIATRICS Volume 137, number S2, February 2016                                                                                                           S121
POTENTIAL CONFLICT OF INTEREST: Dr Arnold has received research funding from Curemark, Forest, Lilly, Neuropharm, Novartis, Noven, Shire, Young Living, the
National Institutes of Health, and Autism Speaks; he has consulted with or been on advisory boards for Gowlings, Neuropharm, Novartis, Noven, Organon, Otsuka,
Pfizer, Roche, Seaside Therapeutics, Sigma-Tau, Shire, and Tris Pharma and has received travel support from Noven; Dr Coury has research grants from Autism
Speaks and SynapDx; he is on the advisory board for Cognoa and on the Data Safety Monitoring Board for Neuren Pharmaceuticals as well as on the Speaker’s
Bureau for Abbott Laboratories; Dr Vasa has a grant from Autism Speaks; Dr Bennett has had research funding from Seaside Therapeutics, Shire, Neurim
Pharmaceuticals, the National Institutes of Health, and Autism Speaks; Drs Mahajan and Mazurek and Ms Nozzolillo have indicated they do not have any potential
conflicts of interest to disclose.
The views expressed in this article do not necessarily reflect the views of Autism Speaks or the Health Resources and Services Administration.

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PEDIATRICS Volume 137, number S2, February 2016                                                                                              S123
Assessment and Treatment of Anxiety in Youth With Autism Spectrum
                                  Disorders
Roma A. Vasa, Micah O. Mazurek, Rajneesh Mahajan, Amanda E. Bennett, Maria
 Pilar Bernal, Alixandra A. Nozzolillo, L. Eugene Arnold and Daniel L. Coury
                           Pediatrics 2016;137;S115
                        DOI: 10.1542/peds.2015-2851J

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Assessment and Treatment of Anxiety in Youth With Autism Spectrum
                                  Disorders
Roma A. Vasa, Micah O. Mazurek, Rajneesh Mahajan, Amanda E. Bennett, Maria
 Pilar Bernal, Alixandra A. Nozzolillo, L. Eugene Arnold and Daniel L. Coury
                           Pediatrics 2016;137;S115
                        DOI: 10.1542/peds.2015-2851J

The online version of this article, along with updated information and services, is
                       located on the World Wide Web at:
     http://pediatrics.aappublications.org/content/137/Supplement_2/S115

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