Social anxiety and autism

Social anxiety and autism often go hand in hand. It can be debilitating to not be able to participate in social situations, especially if you might want to but just can’t.

Here’s a story of one incident of social anxiety for a primary school girl with autism. She got invited to a birthday party. It’s a pretty rare occurrence to get a party invite, given how misunderstood she is at school, and her small friendship group. This invite was for a structured activity, and she was excited to go. She’d picked out a present, using her empathy to think about what the birthday child would like to play with. She’d chosen an outfit and was happy on the journey to the party location. However when she got there, she suffered incapacitating shyness and anxiety. Not knowing many of the other children, she couldn’t move towards them. She stuck to mum’s leg and started crying. She couldn’t even look at the other children and nothing could incentivise her to join in. And that was the end of the party for her.

What is social anxiety?

Social anxiety is a fear of social situations. This phobia may cause feelings of anxiety and fear or embarrassment and self-consciousness. Everyday social interactions can cause anxiety and fear around being judged, being embarrassed or worry about doing the wrong things and offending someone. It is more than just shyness or being introverted.

Signs and symptoms of social anxiety, according to the Mayo Clinic, include:

  • Fear of situations in which you may be judged negatively
  • Worry about embarrassing or humiliating yourself
  • Intense fear of interacting or talking with strangers
  • Fear that others will notice that you look anxious
  • Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling or having a shaky voice
  • Avoidance of doing things or speaking to people out of fear of embarrassment
  • Avoidance of situations where you might be the center of attention
  • Anxiety in anticipation of a feared activity or event
  • Intense fear or anxiety during social situations
  • Analysis of your performance and identification of flaws in your interactions after a social situation
  • Expectation of the worst possible consequences from a negative experience during a social situation
  • Physical symptoms such as blushing, fast heartbeat, trembling, sweating, nausea, dizziness, or a feeling that your mind has gone blank.

How is social anxiety related to autism?

Social anxiety often co-occurs with autism, according to Spain et al. They may be connected because common autistic difficulties around understanding social situations and cues relate to social skills. If an individual has poor social skills, then can lead to social anxiety.

Social skills include skills in communication, social motivation, and social thinking. Autistic individuals may have difficulties with:

  • eye contact, which may be expected in some social situations to be considered polite and engaged.
  • understanding non-literal speech, such as sarcasm or idioms. This can make engaging in conversation challenging and confusing.
  • paying attention to non verbal language and environmental cues. Without an awareness of other communication clues (social clues), it can be difficult to fully understand what is going on.
  • understanding what others may be thinking and feeling.
  • reading facial expressions to understand feelings.
  • being expressive of their own emotions such as through tone of voice, and facial expressions.
  • flexible speech. Autistic people may have stereotyped or idiosyncratic speech or repetitive behaviours (repeating words or phrases, repetitive body or hand movements)
  • motivation to be social and engage in conversation around topics or activities that don’t interest them, if they have restricted or obsessive interests.
  • understanding social interactions such as saying “how are you” and always responding with “fine”. This can lead to mental rehearsal and memorising “social scripts” in order to mask or fit in with expected social norms.
  • sensory sensitivity, that is often present in social situations such as loud noises, lights, heat at parties etc.

These challenges in social interaction can lead to negative social experiences (including bullying, teasing, misunderstandings, embarrassment). This can then lead to negative thoughts, fear, withdrawal, avoidance and social anxiety.

How to tell the difference between autism and social anxiety?

Social Anxiety TraitsAutism Traits
Blush, sweat, or shake as a sign of anxiety.
Experience a fast heart rate.
Feel their “mind going blank”.
Feel nauseous.
Speak with an overly soft voice.
Find it difficult to make eye contact, be around people they don’t know, or talk to people in social situations, even when they want to.
Feel self-consciousness or fear that people will judge them negatively.
Avoid places where there are other people.
Avoids or doesn’t give eye contact
Has obsessive or restrictive interests that make sharing conversations with others difficult
Has limited or repetitive phrases or movements, repeating the same words over and over
Anxiety, stress or excessive worry
Strong emotional reactions
Dislike of new or strange situations
Struggle to understand non literal language

How many autistic children have social anxiety?

In typically developing children, the prevalence of social anxiety is estimated at 7-13%. Yet for children with autism, this could be as high as 49%, particularly for children without an intellectual disability. This is a huge increase for autistic populations. However, there are some issues around how reliably data can be collected in many of the studies. A meta-analysis review of 31 studies found that on average, the prevalence was likely around 17% for general autistic populations, as reported in Briot et al.

There are many overlapping symptoms between autism and social anxiety. This can make a diagnosis difficult, as they can be confused. Because of the overlap, people with autism may not get recognition of social anxiety, as symptoms may be explained by the ASD. Additionally, autistic children may have difficulty with interoception and self-reporting their internal states. This can make a diagnosis and measurement of social anxiety challenging.

How do you treat social anxiety in autistic children?

Psychologists talk about protective factors. These protective factors help reduce or prevent all kinds of anxiety, including social anxiety.

Protective factors include:

  • being able to cope with stress. Having regulation skills, a positive outlook on life and problem-solving skills are part of building resilience.
  • having good physical health, nutrition and physical activity. Being healthy in your body can help boost your mental health.
  • having strong, positive relationships with parents, family, friends, cultural groups and/or social clubs. Having a relational support network such as good connections to parents is a big protective factor.

Interventions or treatments may include psychology therapy, such as CBT (cognitive behaviour therapy). This treatment for social anxiety might include working with the autistic child on:

  • learning about the brain, emotions and anxiety
  • developing emotional awareness
  • providing exposure to situations that are anxious, and working through them together
  • talking about coping skills and emotional regulation, along with strategies for positive mental health
  • teaching problem solving skills
  • learning and practicing social skills and social thinking for communication skills

The Australian Government recommends the Cool Kids program as one such program that can reduce anxiety in children.

References

Briot Kellen, Jean François, Jouni Ali, Geoffray Marie-Maude, Ly-Le Moal Myriam, Umbricht Daniel, Chatham Christopher, Murtagh Lorraine, Delorme Richard, Bouvard Manuel, Leboyer Marion, Amestoy Anouck. (2020). Social Anxiety in Children and Adolescents With Autism Spectrum Disorders Contribute to Impairments in Social Communication and Social Motivation. Frontiers in Psychiatry. 11. DOI=10.3389/fpsyt.2020.00710

Spain, Debbie & Sin, Jacqueline & Linder, Kai & McMahon, Johanna & Happe, Francesca. (2018). Social anxiety in autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders. 52. 51-68. 10.1016/j.rasd.2018.04.007.

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