Anxiety Disorders in Children and Adolescents with Autistic Spectrum Disorders: A Meta-Analysis

“Publication bias is typically assessed via visual inspection of funnel plots (Munafò et al. 2004), tests of funnel plot asymmetry (Egger et al. 1997), or rank correlation methods (Begg and Mazumdar 1994).”

“Publication bias is typically assessed via visual inspection of funnel plots (Munafò et al. 2004), tests of funnel plot asymmetry (Egger et al. 1997), or rank correlation methods (Begg and Mazumdar 1994).”

“To our knowledge, this is the first meta-analysis of anxiety disorders in young people with ASD and the first to evaluate factors influencing the observed heterogeneity for rates of anxiety reported in the literature.”

“The interrater reliability, internal consistency, and test–retest reliability as well as diagnostic validity of the ADOS-G were found excellent (Lord et al. 2000).”

“It is widely known that parents tend to underestimate the frequency of internalizing symptoms in their own children (e.g., Muris et al. 1999; Cosi et al.2010) and that child‐parent agreement for internalizing problems is generally lower compared with the child‐parent agreement of externalizing problems (e.g., Achenbac…”

“2008) or training interviewers to distinguish anxiety from ASD (Simonoff et al. 2008).”

“These results should therefore be interpreted with caution as effects found in the fixed effect model only allow for inferences based on the studies included in the meta-analysis and limits the generalizability to other (future) studies (see Hedges and Vevea 1998 for a detailed discussion).”

“…which is a modified version of the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; Ambrosini 2000) and was used in the study of Leyfer et al. (2006) and Mazefsky et al. (2011), and (2) the questionnaires used by Davis et al. (2011), namely the Baby and Infant Screen for…”

“Other instruments that were used to assess anxiety in children with ASD, and which are also commonly used to assess anxiety (or psychopathology in general) in typically developing children, include the Diagnostic Interview Schedule for Children (DISC; Shaffer et al. 1996), the Kiddie Schedule for Affective Disorders a…”

“The validity of these methods, however, decreases when the number of studies under investigation is small (Rothstein et al. 1996).”

“However, there are also studies (Kim et al. 2000; Pearson et al. 2006; Gadow et al. 2004; Sukhodolsky et al. 2008) that found no differences in anxiety levels between ASD subtypes.”

“…non-anxiety-disordered children in typically developing populations with good sensitivity and specificity (e.g., Beidel et al. 1996; Nauta et al. 2004; Bodden et al. 2009), and (3) the sample size of the meta-analysis was too small to run analyses separately for interviews and…”

“Studies that reported Table 2 Assessment of ASD and anxiety in the selected studies First author (Year) Assessment of anxiety with ASD diagnosis obtained/confirmed by Ando (1979) Maladaptive behavior scale Child psychiatrists Bellini (2004) Social Anxiety Scale for Adolescents (SAS-A) Qualified mental health professio…”

“…the Diagnostic Interview Schedule for Children (DISC; Shaffer et al. 1996), the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; Ambrosini 2000), the Child Behavior CheckList (CBCL; Achenbach 1991), the Spence Children’s Anxiety Scale (SCAS; Spence 1997), and the Social Phobia…”

“The validity of these methods, however, decreases when the number of studies under investigation is small ( Rothstein et al. 1996 ).”

“…whether or not comorbid symptoms of anxiety may be seen as part of the broader ASD-phenotype, such comorbidity contributes to functional impairment over and above the functional deficits of ASD with important implications for treatment and care of the young person (Matson and Nebel-Schwalm 2007).”

“Some studies (Kuusikko et al. 2008; Lecavalier 2006) found older ASD children more likely to report anxiety, while others reported no age differences (Ando and Yoshimura 1979; Pearson et al. 2006; Meyer et al. 2006; Sukhodolsky et al. 2008; White and RobersonNay 2009).”

“Some studies (Kuusikko et al. 2008; Lecavalier 2006) found older ASD children more likely to report anxiety, while others reported no age differences (Ando and Yoshimura 1979; Pearson et al. 2006; Meyer et al. 2006; Sukhodolsky et al. 2008; White and RobersonNay 2009).”

“DSM-V (APA 2011) attempts to deal with such issues at least with respect to social anxiety disorder; the proposed changes make an additional diagnosis of social anxiety disorder in children with ASD more easy (Bögels et al. 2010).”

“…author (Year) Assessment of anxiety with ASD diagnosis obtained/confirmed by Ando (1979) Maladaptive behavior scale Child psychiatrists Bellini (2004) Social Anxiety Scale for Adolescents (SAS-A) Qualified mental health professionals Bradley (2004) Diagnostic Assessment of the…”

“Indeed anxiety is viewed as sufficiently inherent to ASD that additional diagnoses of certain conditions are required ‘‘to be not better accounted for by the ASD itself’’ (i.e., separation anxiety disorder, social anxiety disorder, and generalized anxiety disorder).”

“However, whether or not comorbid symptoms of anxiety may be seen as part of the broader ASD-phenotype, such comorbidity contributes to functional impairment over and above the functional deficits of ASD with important implications for treatment and care of the young person ( Matson and Nebel-Schwalm 2007 ).”

“Some studies (Kuusikko et al. 2008; Lecavalier 2006) found older ASD children more likely to report anxiety, while others reported no age differences (Ando and Yoshimura 1979; Pearson et al. 2006; Meyer et al. 2006; Sukhodolsky et al. 2008; White and RobersonNay 2009).”

“…anxiety disorders observed in children with an autistic spectrum disorder are more than two times higher than in typically developing children (Costello et al. 2005), and higher than found in children seeking treatment for ADHD (Gau et al. 2010) and learning difficulties (Dekker and Koot 2003).”

“This finding warrants further investigation as earlier studies point to both positive (Sukhodolsky et al. 2008; Weisbrot et al. 2005; Witwer and Lecavalier 2010) and negative correlations (White and Roberson-Nay 2009) between anxiety and IQ in this population.”

“Also, the sample assessed by Gadow et al. (2004) was included in a later study by the same group but with additional subjects and with different anxiety disorders (Gadow et al. 2005).”

“Finally, a possible distinction is that the interest in engaging in social situations may be different between the two groups ( Bellini 2006 ), whereas individuals with social anxiety disorder generally have an interest in engaging in social situations, this interest could be less in individuals with ASD.”

“There is some evidence that younger children with ASD have more restricted, repetitive behaviors compared with older children with ASD ( Ebensen et al. 2008 ) and that children with ASD ‘‘improve’’ in the ritualistic/repetitive behavior domain as they grow older (Piven et al. 1996).”

“In further support, treatment studies revealed that the symptoms of anxiety, and anxiety disorders, in autism can be decreased (e.g., Sofronoff et al. 2005 ;C halfant et al.2007; Reaven et al. 2009), while the core symptoms of autism are found to be rather persistent (e.g. Billstedt et al. 2007 ).”

“Also, the sample assessed by Gadow et al. (2004) was included in a later study by the same group but with additional subjects and with different anxiety disorders (Gadow et al. 2005).”

“The few studies that have compared anxiety levels across ASD subtypes suggest that anxiety varies with ASD severity: children with less severe ASD symptoms would endorse more anxiety (MacNeil et al. 2009).”

“We know that anxiety disorders in typically developing children significantly interfere with everyday functioning—particularly school attendance (DSM-IV; APA 2001), negatively impact quality of life ( Bastiaansen et al. 2004 ) and are associated with higher health care usage and other social costs (Bodden et al. 2008).”

“compulsive disorder. However, it is worth noting that (1) in the study of Piven et al. (1996) , symptoms in the social and communication domain decreased significantly more over time compared with the symptoms in the ritualistic/repetitive domain; (2) other studies found no association between severity scores of repet…”

“the study of Piven et al. (1996), symptoms in the social and communication domain decreased significantly more over time compared with the symptoms in the ritualistic/repetitive domain; (2) other studies found no association between severity scores of repetitive behavior and age (e.”

“As subjects with PDD-NOS are less likely to present with severely restricted, repetitive, and stereotyped patterns of behavior (Szatmari et al. 1995; Buitelaar et al. 1999; Starr et al. 2003), the possibility of ‘‘misdiagnosis’’ of obsessive–compulsive disorder in children across the ASD spectrum needs to be considere…”

“In support of such changes are studies that suggest that anxiety disorders experienced by children with ASD are more similar than different in topography as those experienced by typically developing children with anxiety disorders (Russell and Sofronoff 2005; Farrugia and Hudson, 2006).”

“In addition, Baron-Cohen and Wheelwright (1999) compared the obsessions of children with ASD and those with Tourette’s syndrome.”

“As subjects with PDD-NOS are less likely to present with severely restricted, repetitive, and stereotyped patterns of behavior (Szatmari et al. 1995; Buitelaar et al. 1999; Starr et al. 2003), the possibility of ‘‘misdiagnosis’’ of obsessive‐compulsive disorder in children across the ASD spectrum needs to be considere…”

“Some studies (Kuusikko et al. 2008; Lecavalier 2006) found older ASD children more likely to report anxiety, while others reported no age differences (Ando and Yoshimura 1979; Pearson et al. 2006; Meyer et al. 2006; Sukhodolsky et al. 2008; White and Roberson-Nay 2009).”

“…anxiety disorders observed in children with an autistic spectrum disorder are more than two times higher than in typically developing children (Costello et al. 2005), and higher than found in children seeking treatment for ADHD (Gau et al. 2010) and learning difficulties (Dekker and Koot 2003).”

“Publication bias is typically assessed via visual inspection of funnel plots (Munafò et al. 2004), tests of funnel plot asymmetry (Egger et al. 1997), or rank correlation methods (Begg and Mazumdar 1994).”

“De Bruin et al. (2007) found no cases of post-traumatic stress disorder in their sample of 94 children with ASD, while Mehtar and Mukaddes (2011) found 17.4% of 69 children with ASD to be suffering from post-traumatic stress disorder.”

“One study (Wozniak et al. 1997) reported the percentage of participants with two or more anxiety disorders.”

“... and studies that used screening cutoffs of questionnaires was the following: (1) screening for anxiety disorders with questionnaires has predictive value at least in typically developing children (e.g., Simon and Bo ¨gels 2009), (2) questionnaires seem to have the ability to discriminate between anxiety-disordered…”

“For example, Mandell et al. (2006) found that children with ASD had health care expenditures ten times higher than those without ASD.”

“To our knowledge, this is the first meta-analysis of anxiety disorders in young people with ASD and the first to evaluate factors influencing the observed heterogeneity for rates of anxiety reported in the literature.”

“To our knowledge, this is the first meta-analysis of anxiety disorders in young people with ASD and the first to evaluate factors influencing the observed heterogeneity for rates of anxiety reported in the literature.”

“Indeed, Ruta and colleagues (Ruta et al. 2010) found different patterns of symptoms between the children with Asperger’s syndrome and children with OCD.”

“This finding warrants further investigation as earlier studies point to both positive (Sukhodolsky et al. 2008; Weisbrot et al. 2005; Witwer and Lecavalier 2010) and negative correlations (White and Roberson-Nay 2009) between anxiety and IQ in this population.”

“Some studies (Kuusikko et al. 2008; Lecavalier 2006) found older ASD children more likely to report anxiety, while others reported no age differences (Ando and Yoshimura 1979; Pearson et al. 2006; Meyer et al. 2006; Sukhodolsky et al. 2008; White and RobersonNay 2009).”

“After contacting the author, data from one presentation abstract (Herguner and Motavalli 2009) were found to display considerable overlap with the data from the published article of Mukaddes et al. (2010), and this abstract was therefore excluded.”

“As subjects with PDD-NOS are less likely to present with severely restricted, repetitive, and stereotyped patterns of behavior (Szatmari et al. 1995; Buitelaar et al. 1999; Starr et al. 2003), the possibility of ‘‘misdiagnosis’’ of obsessive–compulsive disorder in children across the ASD spectrum needs to be considere…”

“When the standardized Z score falls outside the confidence interval bounded by -3.3 and ?3.3, then the observation is possibly an outlier ( Tabachnick and Fidell 2001 ).”

“…disorders (generally) increase with age (Ford et al.2003); (2) rates of generalized anxiety disorder (specifically) increase with age (Frala et al. 2010; Tracey et al. 1997); and (3) rates of separation anxiety disorder are associated with a lower mean age (Kearney et al. 2003; Last et al. 1992).”

“…following: (1) screening for anxiety disorders with questionnaires has predictive value at least in typically developing children (e.g., Simon and Bögels 2009), (2) questionnaires seem to have the ability to discriminate between anxiety-disordered and non-anxiety-disordered children in…”

“…disorders in typically developing children significantly interfere with everyday functioning—particularly school attendance (DSM-IV; APA 2001), negatively impact quality of life (Bastiaansen et al. 2004) and are associated with higher health care usage and other social costs (Bodden et al. 2008).”

“In partial support, Kristensen and Torgersen (2008) found that in a population-based screening sample of typically developing children, those diagnosed with social anxiety disorder, as compared to those having other disorders or no disorders, verbal IQ was more reduced.”

“After contacting the author, data from one presentation abstract (Herguner and Motavalli 2009) were found to display considerable overlap with the data from the published article of Mukaddes et al. (2010), and this abstract was therefore excluded.”

“Consistent with estimates from childhood (van Steensel et al ., 2011), we found that specific anxiety disorders, particularly social phobia and OCD, were more commonly present in adults with ASD.”