Exploring insistence on sameness may help us treat anxiety in children with Autism Spectrum Disorder

Children with Autism Spectrum Disorder (ASD) are more prone to anxiety symptoms and also have a strong desire for consistency, or “sameness” in their lives. This recent paper explores the patterns and relations that anxiety and sameness behaviours share, and what parents and care providers can do to help prevent these challenges from becoming severe and affecting wellbeing later in life.

Dr. Meng-Chuan Lai interviewed lead author Dr. Danielle Baribeau to learn more.

DB: ASD is a disorder of brain development; in addition to difficulties recognizing or understanding social cues, individuals on the spectrum often prefer ‘sameness’ in their activities and interests. In young children, insistence on sameness (sometimes called ‘sticky’ or ‘rigid’ behaviours) can take a number of forms, including insistence on wearing the same specific type of clothing, eating the same foods, or playing with the same toys all the time. They might have very specific rituals and routines that they insist be followed, and transitions or changes can be a significant source of stress.

High levels of anxiety and anxiety disorders are also very common in ASD; about 40% of kids on the autism spectrum may meet criteria for an anxiety disorder during childhood. However, the symptoms of anxiety can present differently in kids with autism, making it easy to miss. For example, they may be more likely to have unusual specific fears or phobias, and may be less likely to describe feeling ‘worried.’

ML: What motivated this research?

DB: Anxiety disorders are usually diagnosed in grade school, whereas autism is most often identified during preschool. Outside of cognitive behavioural therapy, we also don’t have a lot of good treatments for anxiety disorders in kids with ASD. So it made sense to study early identification and prevention of anxiety. In particular, we wondered whether there were any early behavioural signs that might signal increased risk for anxiety problems down the road. A previous study we performed showed that high insistence on sameness behaviours in preschool may be associated with increased rates of future anxiety. We wanted to know more about the typical patterns that anxiety and insistence on sameness behaviours follow in children with ASD, and how they might be related.

ML: What did you find regarding insistence on sameness and anxiety in children with ASD?

DB: We studied a large research cohort of kids with autism (421 in total) who were followed from preschool until age 11. We found that there were many different patterns of change (or ‘trajectories’) of anxiety and insistence on sameness behaviour in ASD over time, not one uniform pattern. Approximately one third of study participants had clinically elevated anxiety by age 11; for most of these kids, they had moderate or greater anxiety levels in preschool that then worsened as they aged. This presents a great opportunity to intervene early; to identify and treat anxiety before it becomes severe. Children with intense sameness behaviours in preschool were at especially high risk for elevated anxiety when they were school-aged; almost all were clinically anxious by age 11. About two thirds of the time, anxiety symptoms and sameness behaviours followed similar trajectories (i.e., both worsened, or both improved), as children aged.

ML: How will this finding change care and support for children with ASD and their families?

DB: The main take home point of the paper is that it is worth thinking about and potentially screening for anxiety symptoms (and mental health symptoms more broadly), very early on in kids with ASD, even from the time of first diagnosis. Severe insistence on sameness behaviour may be a unique manifestation of anxiety in preschoolers with autism, or a sign of future difficulties to come. There is evidence that cognitive behavioural therapy (CBT) can help with anxiety in kids with ASD. Performing more research and increasing the availability of CBT could help us treat or even prevent anxiety disorders for children with ASD.

ML: What are the next research steps?

DB: Next, we are planning to look at the different ways that insistence on sameness behaviour may lead to anxiety in ASD (i.e., is it a way of coping, a sign of mental inflexibility, or a reaction to the environment?) and vice versa. This will help guide the best way to intervene early.

ML: What are the major take home messages for children with ASD and their parents?

DB: Anxiety can manifest differently in kids with ASD which can make it hard to recognize. For very young children, severe levels of insistence on sameness (‘sticky‘ or ‘rigid’ behaviour) might be a sign of anxiety, and can help identify kids at elevated risk for future anxiety problems. Clinicians should consider assessing anxiety and sameness behaviours at the same time, as they tend to be related. Talk to your doctor or therapist early about anxiety symptoms, because there are programs and therapies that can help.

IMPACT Committee includes Krista Lanctôt, Alastair Flint, Meng-Chuan Lai and Simone Vigod. 

Co-occurring trajectories of anxiety and insistence on sameness behaviour in autism spectrum disorder. The British Journal of Psychiatry (2020)
doi: 10.1192/bjp.2020.127

Danielle A. Baribeau, Simone Vigod, Eleanor Pullenayegum, Connor M. Kerns, Pat Mirenda, Isabel M. Smith, Tracy Vaillancourt, Joanne Volden, Charlotte Waddell, Lonnie Zwaigenbaum, Teresa Bennett, Eric Duku, Mayada Elsabbagh, Stelios Georgiades, Wendy J. Ungar, Anat Zaidman Zait and Peter Szatmari.