Autism Spectrum Disorders: Excessive Anger & Anxiety


Children and adults with Autism Spectrum Disorder (ASD) struggle with a serious disorder.  The growing body of knowledge and research about ASD shows that excessive anger and anxiety are highly comorbid (present with) in this disorder. Forgiveness therapy is effective in diminishing the anger and anxiety present in many of those with ASD.
The criteria for making the diagnosis of Autism Spectrum Disorders are qualitative impairment in social interaction, qualitative impairment in communication and restricted and repetitive and stereotyped patterns of behavior.   The severity levels are based on the amount of support needed, due to challenges with social communication, restricted interests and repetitive behaviors. For example, in the DSM-5 a person might be diagnosed with Autism Spectrum Disorder, Level 1, Level 2, or Level 3. 
Autism spectrum disorders (ASD) are recognized to occur in up to 1% of the population and to be a major public health concern because of their early onset, lifelong persistence, and high levels of associated impairment.  A growing literature is demonstrating the common comorbidity of ASD with anxiety disorders and oppositional defiant disorder with its excessive active and passive-aggressive anger.   In one study seventy percent of participants had at least one comorbid disorder and 41% had two or more. The most common diagnoses were social anxiety disorder (29.2%), attention-deficit/hyperactivity disorder (28.2%), and oppositional defiant disorder (28.1%, Simonoff, et al., 2012). A  meta-analysis of 31 studies involving 2,121 young people revealed that 39.6% of young people with ASD had at least one comorbid DSM-IV anxiety disorder, the most frequent being specific phobia (29.8%) followed by OCD (17.4%) and social anxiety disorder (16.6%, van Steensel, et al., 2011).  Cognitive-behavioral therapy has been demonstrated to be effective in treating the anxiety in children with ASD (Sofronoff, et al., 2005).
A significant percentage of children with ASD exhibit the symptoms of oppositional defiant disorder (ODD).  Two studies found that the percentage of 3- to 5- and 6- to 12-year-olds with ASD meeting the criteria for ODD, according to their parents, was 13 and 27%, respectively, and the rates for teachers were 21 and 25%, respectively (Gadow, et al., 2004; Gadow & DeVincent, 2005).   These symptom prevalence rates for ODD in children with ASD are comparable to the rates for ODD in non-ASD children referred for child psychiatric outpatient clinic evaluation.  Both disorders are characterized by difficulties in social interaction with parents, siblings and peers.   Youth with angry/irritable symptoms (AIS) vs. noncompliant symptoms or passive aggressive symptoms of ODD evidenced the most severe ASD symptoms (Gadow & Drabick, 2012).  Also, for both children with and without ASD, the most common co-occurring psychiatric disorder with ODD is attention-deficit hyperactivity disorder (Gadow, et al., 2008).   
In a 2007 report of CBT intervention for anger management in children with Asperger’s syndrome, parent reports indicated a significant decrease in episodes of anger following intervention and a significant increase in their own confidence in managing anger in their children (Sofronoff, et al., 2007).  In another study of parent’s perspective of anger in 121 children with ASD,  they were angry frequently with aggressive behaviors, their anger was target and context specific, and they could not control their own behaviors during their angry episodes but some were apologetic afterward. These behaviors impacted the whole family, their parents, their siblings and the children with ASD. These episodes were influenced by their being physically or emotionally unwell, and antecedents included inaccessibility to preferred items, and changes in routines/environments (Ho, et al., 2012).
Children and adults with ASD vary greatly with regard to the severity of their excessive anger with disruptive behaviors, anxiety, and mood symptoms.  Little is known about behavioral syndromes change over time or differentiate into other disorders in children with ASD. 
Systematic assessment of the comorbid behavioral and emotional disturbances should occur because they will have important implications for medical interventions, school placement, and family life. Assessment of the family is also essential since ASD has been shown to be positively associated with maternal emotional disorder (Totsika, Hastings, Emerson, Lancaster & Berridge, 2011) and that while early behavior problems are not a risk factor for later maternal well-being, maternal psychological distress, physical health limitations, and lower life satisfaction are risk factors for later child behavior problems (Totsika, et. al, 2013). In addition, family poverty, low maternal warmth and household chaos are risk factors for externalizing problems in children with ASD (Mihouhas, et al., 2013). Prospective examination of co-occurring symptoms in children with ASD could contribute to an understanding of how comorbid conditions may impact the onset and course of ASD and response to treatment.  Although co-occurring symptoms have many components, clinical work with children and adults with ASD should include the examination the history of the degree of secure attachment with each parent and siblings, the degree of anxiety and anger in the family, parental characteristics and family dynamics.
Forgiveness therapy has been demonstrated to be effective in treating both ODD with its excessive anger and anxiety in youth as cited earlier in this chapter.  Angry/irritable symptoms of ODD have been shown to be correlated with the most severe ASD symptoms.  Teaching an autistic youth to learn to master his/her anger by the use of forgiveness may help diminish ASD symptoms.  We recommend that FT be incorporated into the treatment protocols of the comorbid ODD and anxiety disorders in many of those ASD and be included in research studies of the treatment of ASD.


      Ronald was seven year old boy who also demonstrated serious difficulties with social communication, restricted interests and repetitive behaviors, primarily in the home.   In the home he distanced himself from his parents, did not make good eye contact with them and regularly failed to respond to their reasonable requests.  Family members and friends were struck what appeared to them to be abnormal behaviors. They even expressed to his parents the concern that he might have ASD.   His parents identified the following ODD symptoms related to the more passive-aggressive expression of anger of refusing to comply reasonable parental request, performing actions to deliberately annoy others, being easily annoyed and blaming others for his mistakes.   He regularly acted in what has been described as noncompliant or headstrong manner that has been considered by some researchers as a subtype of ODD (Gadow, 2012). 

However, at school he did not demonstrate these ASD symptoms with his peers.  Instead, he communicated in a friendly manner and participated in many activities with them.  Also, teachers did not identify him as noncompliant or headstrong.  The ratings of his parents versus those of the teachers differed significantly as the parents identified him as manifesting numerous symptoms of passive-aggressive anger on our childhood anger checklist while teachers identified few angry behaviors.
Family sessions revealed that Ronald had demonstrated a  headstrong, determined personality from early in his life that resulting in his attempting to control his parents and other. Subsequently, he had great difficulty in responding to their reasonable requests.  When he could not have his own way, he manifested his anger by giving his parents and others the silent treatment in which he ignored them.  The family dynamics demonstrated that the father had a permissive parenting style and rarely corrected Robert’s angry and disrespectful behaviors, particularly toward his mother.  
Forgiveness therapy was initiated after many of his ODD behaviors were interpreted as his having a major problem with overreacting in anger in the home, in part because of his headstrong refusal to be obedient.  The father agreed to correct their son’s anger regularly and to coach him in the use of forgiveness exercises as a way to master his excessive anger.  He discovered the need to forgive his mother, in particular, for asking him to be responsible, less selfish and more loyal to the family.  Slowly, his angry, headstrong and controlling behaviors diminished and with them also his ASD symptoms.  He opened himself up more to his parents and became more cooperative with their requests rather than distancing himself from his family members.


      Marietta was forty year old married woman and mother of two teenagers who demonstrated serious difficulties with social communication, restricted interests and repetitive behaviors.   She was seen in marital and in family therapy because of the great difficulty she had in communicating with and being present to her husband, daughter and son.  She had severe social anxiety with no personal friendships and regularly overreacted in anger blaming her husband exclusively for her unhappiness.  A diagnosis of Asperger’s was made after she was unable to participate in helping her daughter prepare for her junior prom. 

Her husband and one of her siblings believed that she never developed a secure, loving relationship with either parent, both of whom had busy professional lives and treated her from an early age as though she should be independent.  She was a latch key child and prepared her own dinner from an early age.   For a significant amount of time she denied how much her ability to trust others had been hurt by her childhood experiences with her parents.  She reluctantly agreed to consider employing forgiveness therapy for the lack of closeness to her parents because she was troubled and guilty primarily about her distant relationship with her adolescent children.  
A note was given to on which she was asked to think of herself as a girl and a teenager and reflect, “Mom and Dad, I want to try to forgive you for not being present to me when young and for giving me more warmth, affection and words of praise.”  As she worked on forgiveness therapy (FT) daily, the unconscious conflicts with her parents emerged and then she did feel strong anger toward each of them, but particularly her mother.  The forgiveness process coupled with a cognitive decision to try to trust her husband and children more, diminished her fears, anger and difficulty in giving herself.   Subsequently, her relationship with her husband and children slowly improved over the course of several years.

While atypical anti psychotics have been used to treat the excessive anger and aggression in youth with ASD, other approaches to this anger need to be considered in view of the 2013 report of serious side effects from their use. Specifically, a retrospective cohort study of youth in the Tennessee Medicaid program showed that the users of anti psychotics had a 3-fold increased risk for type 2 diabetes that increased with cumulative dose (Bobo, et al., 2013).

There are reasons to be hopeful that ASD symptoms could diminish through the use of forgiveness therapy for the excessive anger associated with this serious disorder.

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