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Autism spectrum disorder (ASD) is a complex developmental condition that affects the way a person communicates and socializes. In 1943, Leo Kanner was the first psychiatrist who coined the term infantile autism to explain childrens obsession with objects and resistance to change (Baron-Cohen, 2015). The contributions of Steve Silberman and Hans Asperger cannot be ignored because they strengthened the field of autistic psychopathy. Since the middle of the 20th century, multiple studies and approaches have been developed to explain this disorder, analyze peoples behaviors, and predict autism-related complications.
Despite the fact that there is no definite cure for ASD, some researchers believe that this condition is treatable (not curable), and optimal outcomes and behavioral improvements can be obtained (Frye & Rossignol, 2016). Many comorbidities of autism exist, and parents are responsible for their control and prevalence. Anxiety is one of the possible complications, and its contributing factors have to be recognized (Orinstein et al., 2015). In this paper, the review of recent empirical studies about ASD and a comprehensive assessment of several research methodologies will be developed to identify the contributing factors of anxiety in children with autism.
What Is Autism Spectrum Disorder?
In the United States, as well as in many developed countries, attention is paid to the analysis of ASD as a growing problem. A number of hereditary and environmental factors may cause the emergence of behavioral, social, and communication challenges that are observed in autistic patients (van Steensel and Heeman, 2017). Restricted and repetitive behaviors are usually observed during the first five years of life, as it is a common period of a childs development when parents recognize the first signs of the disorder (Pritchard et al., 2016).
Many research projects of various evidence levels, including meta-analyses, randomized controlled trials, and prospective/cohort studies, were developed to explain the causes, treatment interventions, and control of autism in children. The role of parents, healthcare practitioners, and international experience has to be underlined to promote public awareness. Using the latest statistical data offered by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), researchers share similar numbers to prove the significance of the problem (Mahdi et al., 2018; Xu, Strathearn, Liu, & Bao, 2018). ASD is a condition that occurs in childhood and continues throughout the whole life.
Research about the Prevalence of Autism
Being one of the mental health disorders, autism has to be diagnosed using the Diagnostic and Statistical Manual of Mental Disorders (DSM), the fourth and fifth editions, that are characterized by broadening definitions and reducing symptoms. To gather enough information and make sure the chosen sources are credible, authors prefer to use multiple source methodology like records-based public health surveillance, case ascertainment, and prospective study cohorts (Atladottir et al., 2015; Hewitt et al., 2017; Idring et al., 2015). For example, overall ASD prevalence varied from 21 per 1000 cases in 2010 (Hewitt et al., 2017).
Today, about 1% of the global population is diagnosed with ASD (Baghdadli et al., 2019). In the United States, the number of cases varies from 13.1 to 29.3 in 1,000 8-year-old children, as the monitoring report by Baio et al. (2018) indicated. Secondary analysis of longitudinal studies by May, Sciberras, Brignell, and Williams (2017) introduced the prevalence and comparison of autism cases in Australia, proving the increase by approximately 3% from the 1990s to the 2000s. Parents, teachers, and non-profit organizations turned out to be the major sources of information in this type of research.
As a rule, the offered population sample is defined as the strength and the limitation of the chosen studies. The cohorts of children were properly identified and classified to mention the current state of affairs and compare the results obtained during different decades. Evidence on the prevalence of ASD in a particular region helps to estimate the number of problems in various racial/ethnic communities and consider ASD as a serious public health concern. However, the limitation of the data source quality cannot be ignored. More clinician-verified diagnoses are required to prove the appropriateness of the offered information.
There is a chance that the offered information system can miss patients with a relevant diagnosis, and a research team is not able to identify the scope of missing data (Atladottir et al., 2015). Incomplete sampling and low participation rates also provoke some restrictions on the multiple source methodologies (Idring et al., 2015). Therefore, research focused on the prevalence of ASD has found a connection with geographical or demographical aspects with a number of limitations.
Causes and Symptoms of Autism in Children
ASD is a neurodevelopmental condition that begins in childhood and causes a variety of problems with time. Social dysfunction is one of the evident symptoms of autism that is frequently discussed by scientists. As well as the absence of a particularly effective cure, this disorder does not have a list of clear causes, and researchers tend to define them as genetic or environmental ones in their reviews.
Genetic factors include the mutation of CHD8 genes or the other genes that confer risks of autism in children (Luo, Zhang, Jiang, & Brouwer, 2018). There are also systematic reviews of ASD records from multiple healthcare and education resources to examine environmental causes that are categorized into prenatal, natal, and postnatal exposures to air pollutants (Dickerson et al., 2015). Immediate family history of autism, metabolic imbalance, uncontrolled viral infections, as well as the use of medications may challenge children or their mothers (during the prenatal period).
The chosen methodologies have their strong and weak aspects of describing autism and its causes. For example, Dickerson et al. (2015) said about the importance of paying more attention to the individual level of the ecological study (environment). Luo et al. (208), on the other hand, required the recognition of the relationship between genes and their mutation as a personal factor for analysis.
Experiments are characterized by a limited sample and a small portion of events being covered. Meta-analysis and reviews contribute to a better understanding of the causes of autism and the possibility to combine findings and obtain common results, including both environmental and genealogical discussions. Recently published studies help to discover the challenges of autism and find out the interventions to deal with evident and hidden symptoms.
In this critical review, the analysis of symptoms of autism in children plays an important role because it enhances an understanding of anxiety as comorbidity, an outcome, or a sign of autism. There is a strong belief that first ASD symptoms are observed in children during the first five years of their development. This disorder challenges the neurological system in infancy, and children are not able to communicate and cooperate in the same way other children without autism can. Reduced eye contact, a lack of social-emotional response, and a poor understanding of human relationships are the diagnostic criteria that are used by clinicians (Trevisan, Roberts, Lin, & Birmingham, 2017).
Some evidence supports the idea that parents are responsible for identifying symptoms, as well as predicting autism and promoting healthy environments for child development (Trevisan et al., 2017). The success of early diagnosis is appreciated because parents can receive the necessary education and training about how to care for autistic children and learn how to deal with delays using available techniques, interventions, and medications.
Qualitative methodologies are necessary for discussing autism in modern children. Researchers focus on presenting rich and credible data about the necessary topic and describe practical implications from theoretical and educational perspectives. There are some limitations that are connected with the inability to verify diagnosis or extend sample (Trevisan et al., 2017). Qualitative studies based on secondary data introduce strong evidence on the topic and explain the development of autism-related problems, including eye contact or social isolation.
Anxiety in Children
Anxiety in children may be a normal reaction to danger or other conditions that deprive a person of comfort and control. Retrospective and prospective studies help to identify the reasons for anxiety in children and clarify the interventions that can be offered by parents, caregivers, and medical workers. According to Kandasamy, Girimaji, Seshadri, Srinath, and Kommu (2019), anxiety disorder is a frequent psychiatric condition that is prevalent in 2-24% of cases globally and 4-14% among the Indian population (the region of the prospective study). This study was based on a prospective design, which means that researchers gathered information about the population before the disease was developed or an outcome was achieved.
It was necessary to set particular criteria (age, socioeconomic status, race, or gender) and observed what changes, improvements, or challenges that could occur within the chosen perspective. In the majority of cases, anxiety turns out to be not the only disorder in pediatric children, proving the necessity to include as many resources as possible (van Steensel, Zegers, & Bögels, 2017). A retrospective study included the participants who already have anxiety in order to clarify the symptoms, development, and treatment.
Anxiety can be of different types, including the cases of phobias, fears, obsessions, or compulsions. Parents usually feel unease when their children are studied by unknown people, and multiple ethical approvals and considerations are required. In both retrospective and prospective studies, researchers prefer to cooperate directly with children and observe their behavioral and emotional changes. More than 40% of people globally experience significant levels of anxiety, and 20% of them are children (Kandasamy et al., 2019). Generalized anxiety is observed when children are anxious about everything that happens to them around and complaining of every fear, ache, or change (Jitlina et al., 2017).
Separation anxiety is characterized by an unwillingness to stay home alone or fears of being separated from regular caregivers. There are also cases of panic when anxiety touches upon the physical condition of a child, so he or she starts trembling, shaking, suffering from shortness of breath, or quick heart beating. As a rule, the discussion of anxiety is studied through meta-analysis or systematic reviews when evident facts and findings are gathered and supported by credible examples.
There are many other anxiety disorders that change the quality of life of children and their families. Therefore, it is expected from parents to report on each situation when obsession, compulsion, or post-traumatic stress disorder symptoms are observed (Jitlina et al., 2017). Such cooperation will promote the identification of factors that are associated with anxiety in social situations (meetings with strangers), daily routines (necessity to do something new), unpleasant situations (light flashes), or traumatic events (bullying).
Anxiety is not only a cause for children to shut down from society, cry, or run away. It is a significant contribution to new disorders and mental health problems that are hard to control with age. Empirical studies on anxiety in children are not numerous to find today because researchers prefer to evaluate the already maid achievements and investigate treatment plans and follow-up care, using communication with families and their past experiences.
In their intentions to investigate different aspects of anxiety in children, researchers invite parents to share their past experiences and predict their potential problems. The findings by De-la-Iglesia and Olivar (2017) indicated that children, who have at least one friend outside a family, face higher self-esteem and less anxiety. However, due to methodological limitations and the inability to use a variety of instruments within one study, the quality of information presented by De-la-Iglesia and Olivar (2017) requires additional peer-reviewed support and the findings of real-life observations. Researchers who prefer systematic reviews and analysis of the recent literature admit a number of drawbacks in their work, including the necessity to compare results with various sample characteristics and the inability to establish generalizations.
Anxiety and ASD
Today, there are many studies where researchers develop discussions about the relation that exists between autism and anxiety in pediatric patients. Randomized controlled trials and meta-analyses are preferred methodologies due to the possibility of avoiding various manipulations of results and creating reliable clinical guidelines for a particular population. Compared to randomized controlled trials, the strength of which is to define a basis for treatments and potential follow-ups, a meta-analysis is a quantitative tool where observational studies and trials are reviewed. The benefits of meta-analyses are the reduction of probable false results and an objective evidence appraisal. Van Steensel and Heeman (2017) found out that children with ASD could have higher anxiety levels in comparison with children who are typically developed.
This study enhanced the control of different variables that may influence anxious behaviors in autistic children. They include family factors (parental stress or neglect), genetic factors (mutation), environmental factors (bullying), and general factors like age or IQ (van Steensel & Heeman, 2017). In their analysis, researchers removed the variables that did not have a significant impact on anxious behaviors and defined those which could be helpful in the assessment.
The identification of contributing factors of anxiety is not an easy process. Van Steensel and Heeman (2017) introduced two main measures to assess anxiety and its relation to ASD, a total anxiety score and a questionnaire to measure a general problem, and developed the third measure that is a questionnaire to measure a total anxiety score of problematic behavior. On the one hand, the strength of this approach lies in the combination of different factors and the identification of the problem and its solution. The authors explained why new screening instruments are necessary for ASD pediatric patients and reviewed the opinions of different authors.
On the other hand, heterogeneity of the studies was defined as the main limitation of a meta-analysis, as the use of various samples or instruments. In addition, the contributing factors are defined on the basis of information offered by biased informants like parents or children. Van Steensel and Heeman (2017) underlined that ASD and anxiety symptoms are not always easy to identify. No one is confident that parents or children who fill in questionnaires recognize the symptom as the one inherent to anxiety or autism.
Autism is a complex condition that changes the development of the neurological system and causes new emotions, behaviors, and attitudes. Anxiety is frequently observed in ASD children, but not many researchers focus on the prevalence of risk factors of the chosen mental health problems in the identified population (Wijnhoven, Creemers, Vermulst, & Granic, 2018). It is recommended to combine the results of the prevalence overview and investigate the existing risk factors.
A randomized controlled trial is one of the most effective methods where researchers match people in groups as per their age, sex, race, and other necessary factors. Anxiety scales and psychiatric assessment tools were used to prove the presence of anxiety symptoms and the diagnosis of children (autism), respectively. Randomized controlled trials help to indicate symptoms, relying on the information obtained from patients records, as well as their own words and interpretations. In their study, Wijnhoven et al. (2018) also paid attention to the level of cognitive functioning because IQ was defined as an indicator of human behavior and childrens abilities.
There were 172 participants (children aged between 8 and 15 years) who got parental permission to participate in the project. Using the review of recent literature, the authors identified risk factors that could predict the development of anxiety. The path analysis was chosen to identify IQ, verbal IQ (VIQ), performance IQ (PIQ), age, and ASD subtype as the main predictors of anxiety types (social phobia, separation, total anxiety, etc.) (Wijnhoven et al., 2018). Despite the limited sample, positive results were achieved in examining anxiety levels in autistic children.
If the previous study is restricted due to the choice of the region (Dutch children), an understanding of the relation between anxiety and autism has to be promoted through the prism of other geographical locations. Randomized controlled studies introduce strong evidence, and the same research method was used by Kilburn et al. (2018). Compared to Wijnhoven et al. (2018), who focused on the discussion of anxiety prevalence in autistic children, Kilburn et al. (2018) aimed to analyze the effectiveness of cognitive-behavioral therapy as the main treatment method for mental health clinics patients.
The authors hypothesized that reduction skills are necessary to decrease the level of anxiety in ASD children and support better psychosocial development (Kilburn et al., 2018). The peculiar feature of this study is to identify the symptoms of anxiety and autism in children and develop an intervention that could help and control poor health outcomes. If autism is not curable, anxiety is a disease with a number of medications and therapies being used to remove symptoms and facilitate general health.
The evaluation of contributing factors of anxiety in ASD children covers a significant spectrum of tasks and expectations. Each study offered for analysis has its benefits and shortages, and they are connected not with the inability of authors to choose an appropriate research method but with the necessity to be bound within the offered scope. Autism is a serious public health problem, and anxiety increases the number of complications in patients. Jitlina et al. (2017) developed a longitudinal study to prove that the tools for treating anxiety can be effective for reducing the effects of autism on the childs behavior.
Randomized controlled trials by Kilburn et al. (2018) and Wijnhoven et al. (2018) introduced a solid background for ASD and autism signs and symptoms. Van Steensel and Heeman (2017) developed a meta-analysis to explain the impact of autism on children and describe the conditions that result in anxious behaviors. Separately, these empirical studies have a list of shortages and limitations that require additional research and experiments. Still, being combined within a critical review, these studies improve an understanding of anxiety-autism treatment for pediatric patients.
Interventions to Deal with Anxiety in ASD Children
Despite the existing variety of studies and approaches to investigate the impact of anxiety on autistic children, almost each of them concludes that treatment or, at least, facilitation of the conditions is possible. Develop a longitudinal, prospective, observational cohort study; Baghdadli et al. (2019) concluded that adequate care, effective support structures, and educative treatment could improve the quality of daily functioning and promote positive outcomes in children with autism.
A critical review with qualitative analysis by De-la-Iglesia and Olivar (2017) identified the importance of interventions to alleviate co-existing problems of ASD behaviors and anxiety, meaning that the contributing factors of anxiety remain the contributing factors of ASD. Using good evidence to analyze autism and anxiety, a number of underlying factors can be identified, including the need for routine and structured actions, attention to sensory sensitivity, and difficulties in controlling emotions. Parents, as well as therapists and other medical workers, must regularly observe the behaviors of children and report on each change or reaction as a part of a treatment process.
Many people who are not diagnosed with autism experience anxiety as a part of their behaviors and attitudes towards the outside and inside interferences. At the same time, the results of longitudinal studies prove that comorbid anxiety disorders are observed in 38% of ASD children, with anxiety symptoms being caused by the symptoms of ASD (Jitlina et al., 2017). When autistic children live in accordance with their regular schedules and cooperate with people they get used to meet, the chances to develop anxiety are controlled and reduced.
However, anxiety gets worse if unpredictable situations occur, like the appearance of a new person (a stranger), the necessity to do something new, or an obligation to move to a new location. Autistic people are not able to recognize the urgency of outside environmental factors and feel unpleasant sensations, which results in anxiety. As well as any mental health disorder, anxiety may be caused by different factors and lead to certain changes like the intention to shut down, stop any interactions, or avoid contact (either verbal or eye). Some children become aggressive and unintentionally choose self-injury as a response to the world outside.
Comorbidities of anxiety and ASD may vary, and treatment has to be focused on the prevention of new disorders (depression, generalized anxiety disorder, or obsessive-compulsive disorder). The authors of qualitative studies admitted that treatments should include both medications and psychosocial approaches (Mahdi et al., 2017; Orinstein et al., 2015; van Steensel et al., 2016). The exploration of predictors of treatment effectiveness was properly developed by van Steensel et al. (2016) through interpersonal interviews and defining cognitive-behavioral therapy (CBT) as one of the most frequent treatment methods. Parents and families may contribute to the development of anxiety or autism and are also explained as effective factors in the treatment of disorders.
Communication is a part of CBT for people to understand their problems, recognize their needs, and analyze different situations in their lives. However, in autism, communication impairment occurs, and the generation of helpful and unhelpful thoughts has to be regulated by a therapist (Kilburn et al., 2018). Randomized controlled trials are developed in real clinical settings and involve real staff with their real problems.
Along with the reality factor, this methodology is beneficial due to the possibility of using outcome measures for the analysis of information obtained from parents and children. Offered evidence and examples may be enough to provide the chosen population with effective interventions and treatments. Still, additional recommendations play a critical role in enhancing correct functioning and childrens behaviors.
Many departments of psychiatry and other related fields are interested in the development of new studies about how ASD patients may receive the necessary treatment. The complexity of relationships between anxiety and ASD is characterized by the necessity to establish prospective designs in order to clarify the nature of the condition and its pathophysiology. One of the good examples was introduced by Kandasamy et al. (2019) about pediatric ASDs and the modification of short-term outcomes for children who undergo usual treatment in clinical settings. The researchers invited 98 children, 78 of them met inclusion/exclusion criteria, and 64 families gave their informed consent for participation.
The choice of scales helped to control and assess behavioral changes, the quality of life, and remission status. The authors concluded that the initial treatment had to last 12 weeks, and then 24 weeks follow-up must be promoted (Kandasamy et al., 2019). These findings showed that treatment played a role in stabilizing the conditions of children with ASD and anxiety. Still, follow-ups have to be followed as well because they prevent the development of new symptoms.
Methodologies in ASD Research
As evidence shows, there are many classifications of research methodologies that can be applied to discuss and analyze the relationship between autism and anxiety in children. As a rule, the majority of research findings supported the chosen association and proved the possibility to achieve positive health outcomes. The absence of a cure for autism challenges many researchers because they realize that their attempts should be focused on the prediction of related complications (Frye & Rossignol, 2016). However, anxiety is a mental health disorder that can be diagnosed and treated at different stages, and pediatric patients have multiple chances to improve their health (Kandasamy et al., 2019). Researchers prefer to use different methods to develop their thoughts and check the appropriateness of interventions and treatment plans.
Qualitative vs. Quantitative Studies
There are qualitative and quantitative research designs that are based on certain hypotheses that should be generated or tested respectfully. For example, the authors of quantitative projects, Kilburn et al. (2018) or Wijnhoven et al. (2018), focused on testing the cognitive development of children through investigating age, gender, autism stage, and IQ levels as potential risk factors for anxiety.
Compared to them, qualitative researchers like Mahdi et al. (2017) and Orinstein et al. (2015) relied on the description of autistic behaviors and understanding of living experiences to facilitate interventions in regard to subthreshold symptoms. Despite a number of definite findings being discovered, both studies have some methodological challenges. Mahdi et al. (2017) had limited access to global generalization results, and Orinstein et al. (2015) defined retrospective data sources and a small sample as their limitations to obtain solid patients backgrounds. Communication with parents instead of testing pediatric patients directly is both a strength and weak aspect of qualitative studies.
Retrospective vs. Prospective Studies
In medical research, it is normal to use both retrospective and prospective methods because of the necessity to work with real patients but rely on the information obtained some time ago. The major distinctive feature of these study designs is the period when the data was gathered. Prospective studies are common longitudinal studies based on patient data that is collected through the period health changes occur. Birth cohort studies were chosen by Atladottir et al. (2014) and Idring et al. (2014) to follow a particular group of patients (similar age and disease). However, their limitations include the dependence on the information system and a chance to miss some facts that play a role in diagnosis or treatment. Biases and small sample sizes are still the methodological challenges for researchers to deal with in their projects.
Retrospective studies, in their turn, were developed on the information gathered from patients past. Interviews, meta-analyses, and multiple sources evaluation are the best examples of this type of study design. On the one hand, past events, historical cohort studies, and the already described circumstances enhance stability and reliability. De-la-Iglesia and Olivar (2015) use retrospective cohorts to underline diagnostic comorbidity of depression in autistic children. On the other hand, in their retrospective secondary analysis study, May et al. (2017) challenged their results because of the impossibility to use clinician-verified diagnoses but analyze the reports of patients parents and teachers. Theories and evident frameworks like those used by Trevisan et al. (2017) improve the results of retrospective studies.
For example, the mindblindness framework proved that autistic children are born with certain sharing attention states, and the information from eye contact determines necessary communication qualities and abilities (Trevisan et al., 2017). This theoretical perspective explains how behaviors in autistic people are developed but fail to recognize other symptoms that challenge patients. Such ambiguity enhances new limitations on retrospective and prospective studies.
Randomized Controlled Trials vs. Longitudinal Cohort Studies
The chosen sources for analysis factors of anxiety in autistic children may also be divided into those with randomized control trials (RCTs) and those with cohorts. Evidence obtained from these two types of designs is alike, with the main difference that RCTs contain interventions for analysis, and cohorts are based on naturally occurring events.
The effect of an anxiety intervention on ASD children was the goal of Wijnhoven et al.s (2018) research. In the RCT by Kilburn et al. (2018), social phobias and separation anxiety were proved as the major contributions to AST-related complications in children through the prism of treatment or a wait-list control condition. Both studies explained that anxiety might be controlled in children and prevent the development of negative or aggressive behaviors in autistic children. However, parental involvement, cognitive-behavioral therapies, and positive environments are recommended.
Longitudinal cohort studies did not introduce particular interventions, but these investigations create a solid basis for further follow-ups, intensive interventions, and long-term care (Atladottir et al., 2015; Baghdadli et al., 2019; Kandasamy et al., 2019). Meta-analyses and multiple sources reviews with statistical analyses like those presented by Dickerson et al. (2015), Hewitt et al. (2016), and van Steensel and Heeman (2017) highlighted the importance of additional research on the chosen topic. Cohorts by Luo et al. (2018) and Pritchard et al. (2016) proved developmental delays and the negative impact of anxiety in ASD children. RCTs by Wijnhoven et al. (2018) and Kilburn et al. (2018) introduced one of the possible solutions to deal with contributing factors of anxiety in ASD children. Each type of study complemented each other with the intention to discover new approaches to disease treatment.
Conclusion
Taking into consideration the results of this critical review of recent empirical studies, the field of autism and anxiety research undergoes a number of considerable changes and improvements. It was proved that anxiety influences the behaviors of autistic children, and it is a parental responsibility to report on health and behavioral changes (Pritchard et al., 2016). ASD is a condition that cannot be treated but may be enhanced by a variety of factors, including social phobias and separations as the types of anxiety disorders. Social support, medical treatment, cognitive-behavioral therapies, and stable environments are integral parts of an autistic childs life.
It is not enough to be diagnosed and replace all negative outside irritants from the childs routine. It is important to indicate all contributing factors and promote facilitation. Anxiety may be a related condition (comorbidity) in people with autism (De-la-Iglesia & Olivar, 2015; Mahdi et al., 2017). Sometimes, anxiety is a result of disturbance of regular activities or the presence of strangers in the room (Trevisan et al., 2017). In both cases, healthcare providers should focus on reducing the impact of anxiety on ASD childrens behaviors.
Using the offered systematic literature review, it is necessary to underline the existing differences and similarities in variables offered for the studies. The common factor in the majority of the articles is the age of patients.
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