1. Effects of Mindfulness Based Stress Reduction Techniques on Anxiety in Children with Autism
Spectrum Disorder: A Literature Review
Stephanie Wilman
December 19, 2016
Psych 621
Cara Knoeppel & Lawrence Tello

2. Autism Spectrum Disorder (ASD) is a wide range, or “spectrum”, of defined serious
neurodevelopmental disorders characterized by both symptoms and severity of impairments in
verbal and nonverbal communication, social interaction, and repetitive behaviors (James, et al.,
2006; “Diseases and Conditions,” 2014; “Autism Spectrum Disorder: Definition,” 2016).
According to the CDC (2016), ASD is a relatively common disorder, affecting about 1 in 68
children. The effects and severity of ASD differs in each person. People with autism have a
spectrum of severity from mildly to severely impaired (“Autism Spectrum Disorder: Definition,”
2016). ASD is an umbrella diagnosis of multiple disorders, encompassing the once distinct
subtypes, including autistic disorder, childhood disintegrative disorder, pervasive developmental
disorder, and Asperger syndrome (“What is Autism?”, 2016). The term “Asperger’s syndrome” is
no longer used in the DSM-5 but is still generally used to describe the mild end of the autism
spectrum (“Diseases and Conditions,” 2014). ASD is recognized as having a complex etiology that
involves both genetic and environmental factors influencing early brain development (“What is
Autism?”, 2016; James, et al., 2006; Dalton, et al., 2005).
It is evident that anxiety is a problem for many people with ASD. Many children with ASD
will receive at least one other diagnosis at some point in their lifetime; the most common being
disorders relating to anxiety (Merrill, 2016; van Steensel, et al., 2011). Even without clinical
diagnosis, anxiety for children with ASD can make even the simplest of tasks extremely difficult
(Merrill, 2016). Acknowledging anxiety in children with ASD is not new. Kanner (1943) describes
eleven autistic children case studies and notes that many have severe anxiety problems, derived
from a desire of things to maintain the same, a dislike of spontaneous activity, poor social
relationships, and an overall tense and uneasy expression. However, the evaluation and treatment
of anxiety disorders in this population has only relatively recently received empirical attention

3. (White, et al., 2009). Van Steensel et al. (2011) show results that indicate a high comorbidity rate
that nearly 40 percent of children with ASD are estimated to have clinically elevated levels of
anxiety or at least one anxiety disorder, a consistent finding with previous work done by White, et
al. (2009). There has been a considerable amount of research attention on anxiety in typically
developing children and empirically supported treatment options available. Costello, et al. (2005)
found that typically developing children have an occurrence rate range between 2.2 to 27 percent
for anxiety disorders. This shows a significant difference between children with ASD (around 40
percent [van Steensel, et al., 2011]) and typically developing children (2.2 to 27 percent [Costello,
et al., 2005]). Specifically, van Steensel, et al. (2011) found “specific phobia was most common
at nearly 30%, followed by obsessive–compulsive disorder in 17%, social anxiety disorder and
agoraphobia in nearly 17%, generalized anxiety disorder in 15%, separation anxiety disorder in
nearly 9%, and panic disorder in nearly 2%.” It is important to note that children with ASD often
do not show age typical symptoms of anxiety (White, et al., 2009). Groden (1996) suggests that
individuals with ASD are more likely to experience stress in their life than those individuals with
good communication skills because stress is often associated with not being able to assert oneself
and communicate what one needs or wants. Thus, children with ASD who have communicative
impairments are at an increased risk for stress. A reverse reaction is also proposed by White, et al.
(2009) that a comorbid social anxiety disorder and ASD would compound the overall social
impairment of the child. This suggests that anxiety has a bidirectional effect on children with social
impairments caused by their ASD. For children on the higher end of the autism spectrum, it is
possible that their higher levels of cognitive functioning and awareness of their social disability
contribute towards their perceived stress or anxiety (Merrill, 2016; White, et al., 2009).

4. Mindfulness-based stress reduction (MBSR) is a therapeutic meditation practice that
focuses on paying attention to breathing and the present moment (Garey, 2016). MBSR techniques
can be effective in helping treat psychological and physical symptoms (Shapiro, Carlson, Astin, &
Freedman, 2006). Meditation is a scaffolding technique, involving mindful sitting and mindful
breathing, used to develop the state of being mindful (Shapiro, et al., 2006). Mindfulness teaches
one to calm the mind, relax the body, and to concentrate on the present situation (Stantorelli, 2014).
Being mindful can improve an individual’s psychological well-being (Brown, et al., 2003). MBSR
requires effort through consistent practice to learn how to develop reliable calmness and relaxation
techniques when presented with an unpleasant situation (Stantorelli, 2014). Practicing MBSR
produces long-term effects, such as declines in stress and mood disturbances in some populations
(Stantorelli, 2014; Brown, et al., 2003). MBSR teaches an awareness and acceptance of the
situation at hand (Stantorelli, 2014). There are many ways to structure MBSR programs that
depend on environmental and personal factors.
There is no single best treatment method for people with ASD (“Autism Spectrum
Disorder: Definition,” 2016). Everyone with ASD is unique, therefore each intervention/ treatment
program is unique (“What is Autism?”, 2016). With treatments and services, symptoms of ASD
decrease and their ability to function normally increases (“Autism Spectrum Disorder: Definition,”
2016). There is no cure for ASD, however, intensive and early treatment programs and
interventions can make crucial differences in the lives of many children with ASD (“Diseases and
Conditions,” 2014). Groden (1996) suggests that early intervention programs help young children
with ASD to reach similar achievement levels as those in typically developing children.
Individuals with ASD implicate relaxation procedures with regularly scheduled practice sessions
where the individual learns to tighten and relax different parts of the body without tensing and to

5. do deep breathing (Groden, 1996). Applied Behavior Analysis (ABA) therapies are used as
treatment programs with individuals with ASD, including prompting and reinforcement (Lang,
Regester, Lauderdale, Ashbaugh, & Haring, 2010). Some clinics, such as Mindful ABA in
California, continue to use the science of ABA therapies, while integrating a focus on “soul
nurturing, slow and peaceful care” (“What is Autism?”, 2016). Relaxation procedures used in
addition to ABA therapies have shown to be affective in stress reduction (Groden, 1996). Certain
relaxation techniques aim to train the individual “to reconceptualize the way they process the world
and then acquire skills that will allow them to apply this new way of looking at things” (Merrill,
2016). Certain medications can help control the symptoms of ASD, including antidepressants
prescribed for anxiety, antipsychotic drugs prescribed for severe behavioral problems, and
medications prescribed for hyperactivity, but medications cannot cure ASD (“Diseases and
Conditions,” 2014). Apps have been designed to help ASD individuals understand their thinking
processes and the emotions they feel that influence their behavior (“What is Autism?”, 2016).
There is currently no empirically supported treatment that targets both the behavioral and
emotional symptoms presented in children with ASD (White, et al., 2009). Individuals with
comorbid ASD with an anxiety disorder are likely to receive health care treatment, which leads to
the growing amount of health care services as treatment/intervention programs for children with
ASD (van Steensel, et al., 2011). Levels of stress, hyperactivity and emotional distressed can be
reduced using MBSR treatment programs with children with ASD (Pahnke, et al., 2013). Per
Groden (1996), children with ASD who use relaxation techniques can go from not interacting with
other children at school and having a slow language development to being able to relax
immediately every time they become anxious, turning previous uncomfortable events into
comfortable ones, and even implementing relaxation techniques on their own, without prodding

6. from aides or parents, which can lead to feelings of accomplishment for the child. MBSR programs
can lead children to be less emotionally unstable and can allow them to handle daily challenges
and to choose their behaviors (Garey, 2016). MBSR can allow the child to graduate from any
special services and move on to attending regular schooling programs, as they can increase
prosocial behavior (Groden, 1996; Pahnke, et al., 2013).
MBSR intervention programs can target children with ASD more effectively by adapting
to fit their needs (White, et al., 2009). MBSR techniques must be non-forced because
implementing forced relaxation can produce more tension and frustration on the individual dealing
with the situation (Stantorelli, 2014; Shapiro, et al., 2006). White, et al. (2009) note that many
people with ASD are aware of their social “disconnectedness” and do appear to wish it to improve.
Therefore, Stantorelli (2014) suggests setting personal goals of what would like to be changed and
being motivated to practice mindfulness is fundamental for achieving change in patterns of
behaviors and emotions.
Wells (1990) examined the differences of the effects between using autogenic training, like
meditation, and externally attentional focused training on anxiety symptoms. Wells (1990) found
that additional self-directed attention interventions enhanced anxiety intensity and the prevalence
of panic attacks while evoking external attentional focuses resulted in eliminating panic attacks,
suggesting that MBSR might not be the best option for obtaining relaxation in children with ASD.
Raising a child with ASD is different than raising a typically developing child. It can be
physically exhausting and emotionally draining (“Diseases and Conditions,” 2014). Parents are
suggested to receive counseling on how to handle individuals with ASD, anxiety triggers, what to
look for, what types of problems could occur, and how to handle them (Groden, 1996; Merrill,
2016). Parents of children with ASD are suggested to take time for themselves (“Diseases and

7. Conditions,” 2014). By implementing MBSR programs with parents of children with ASD, their
well-being and long-term caregiving to their children can benefit (Dykens, et al., 2014).
The relationship between anxiety and ASD is not fully understood at this time. Some results
have shown correlations of MBSR techniques with ASD diagnostic sub-type Asperger’s, but
results relating stress reduction techniques to other diagnostic sub-types are limited (Lang, et al.,
2010). New components could be added to ABA therapy to reduce anxiety in individuals with
ASD, which would ultimately lead to more efficient and effective intervention programs (Lang, et
al., 2010). Further research on specific etiologies of ASD are needed to determine how to prevent
and treat ASD properly (James, et al., 2006). There is an overlap of common behaviors seen in
children with ASD and symptoms seen in varying anxiety disorders, so Merrill (2016) suggests
psychologists should consider what is distinctly a different disorder. This diagnostic overlap of
symptoms of ASD and symptoms of anxiety disorders is specifically unclear between ASD and
obsessive compulsive disorder, due to repetitive behaviors in individuals with ASD, and between
ASD and social anxiety disorder, due to impairments in social interaction and both nonverbal and
verbal communication in those with ASD (van Steensel, et al., 2011). Larger studies should also
be evaluated to further evaluate the benefits of stress reduction therapies (Pahnke, et al., 2013).
There is little clarity on how to best measure anxiety symptoms in the ASD population.
Shapiro et al. (2006) suggest developing clearer empirical examinations and methods for
measuring severity of anxiety. Much work has been done to study higher functioning children with
ASD but not with lower functioning children with ASD due to difficulties in testing. Because
individuals with lower functioning ASD often have trouble self-reporting internal feelings of
anxiety due to profound impairments in communication abilities, different ways to measure
anxiety should be further developed that do not rely on parent or child self-reports of perceived

8. anxiety but instead something more concrete (Merrill, 2016; van Steensel, et al., 2011). Using a
combination of different measurements of anxiety would yield a better analysis of the severity of
anxiety in individuals with ASD (van Steensel, et al., 2011). Only after a better clarification on
anxiety in ASD individuals, it will be easier to determine the best line of treatment.

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