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Focus on Anxiety at the Annual Conference

Dr. Patrick Friman, who has more than 30 years of experience as a licensed psychologist, opened the Autism Society of North Carolina’s annual conference with “Anxiety and Sleep: Addressing Life’s Challenges.” For those who were not able to attend his presentation in Charlotte, we are sharing highlights of the anxiety portion here.

Dr. Friman began by explaining that common misconceptions about anxiety prevent us from combatting it. “Anxiety is not something that you have. … like a cold, or flu, or cancer. You are anxious. All that means is you’re afraid,” he said. “Then the question becomes pretty straightforward. What are you afraid of?”

When someone is afraid, their brain narrows their choices to fight or flight, Dr. Friman explained. This is when inappropriate behavior occurs. He said that we don’t have to get over fear or get rid of it. We have to learn how to behave in the presence of fear.


Clinical anxiety

Some anxiety does have benefits, he said: it motivates us to get things done. But too much of anything is a bad thing, and so the key is balance. At least 30 percent of people have suffered from an anxiety disorder, Dr. Friman said. Among individuals on the autism spectrum, the rate is about 40 percent.

Signs of clinical anxiety include:

  • Excessive fear-based avoidance of benign objects or events: He did note that not all avoidance is fear-based. Avoidance is the cardinal behavioral component of anxiety and also of autism. Avoidance by individuals with autism may be linked to sensory issues, he said.
  • Excessive emotional reaction
  • Excessive need for control: For example, if a person feels calmer when they are driving a vehicle, that is fine. But if they are so afraid of others driving that they cannot ride with someone, that is clinical anxiety.
  • Constantly coming up with worst-case scenarios
  • Being unresponsive to reason
  • High frequency of episodes


Threat-based stress response

When someone feels threatened, they experience a stress response that prepares their body for action. Their body releases stress hormones and metabolism increases, which uses up oxygen in their body. Once they are worked up, it doesn’t help to tell them it’s over nothing, he said, because it is a physical response. You have to get the body settled down.

Dr. Friman recommended the 4x4x4 method used by the military. Have the individual breathe in, hold, and breathe out, each for a count of four, for a total of four minutes.


Signs of clinical anxiety in kids

In children, anxiety may come out in certain behaviors, Dr. Friman said. They cannot always tell us that they are anxious.

  • Excessive need for control
    • Arranging, ordering, movement of objects
    • Scripting
    • Correcting
    • Bargaining
    • Frustration at unexpected shifts in play
    • Interrupting the play of others
    • Avoiding play altogether
  • Social confusion
  • Dependence on adults


Unintentional parent and caregiver anxiety signals

Dr. Friman explained that parents can unintentionally create or reinforce anxiety in children. He shared some common actions to avoid.

  • Questioning and checking: “Are you OK honey?” is not neutral and makes the child question whether they are or should be OK.
  • Overprotection and reduced independence: Keeping a child’s world small makes them afraid of what is outside of it.
  • Enabling avoidance: This may help a child feel better in the moment but it does not help them grow in the long term.
  • Attention to fear: Noting when they are brave is much more productive, he said.
  • Low distress tolerance: Be able to tolerate stress and upset by the child so they can stretch themselves. Don’t solve problems for them. Let them struggle.


Strategies for parents and caregivers

Dr. Friman then shared some ways that parents can decrease their children’s anxiety.

  • Praise and attend to brave behavior.
  • Model brave behavior and use role reversal. Be honest with them and let them see your own apprehension about something but that you act anyway. It doesn’t help to say they have nothing to be afraid of; acknowledge fear and show how to work through it.
  • Allocate responsibility, encourage independence, and allow mistakes. Let them act on their own, even if they fail a few times. That is how people grow and learn, he said.
  • Set reachable goals
  • Create opportunities for change. For example, Dr. Friman said he has clients who do not like change, so he rearranges his furniture before their appointments. Over time, they learn that change will not hurt them.
  • Schedule worry time. This is especially effective for young children. Set a time when they are allowed to sit and think about the worst thing that could happen. Setting the period during a time when they would rather be doing something else, such as watching a favorite show, makes them less likely to do it. But it will reassure them that they can worry if they really want to.
  • Incorporate intense or unusual interests such as rocking and flapping. Why take away something they love, Dr. Friman asked. Let them do it after they’ve done something you want them to do. You can let them do it privately and for a certain period, so it doesn’t take up too much of their day. Trying to eliminate such behaviors increases anxiety.
  • Exposure and desensitization over time
  • Teach relaxation exercises, such as the 4x4x4 method previously mentioned, progressive muscle relaxation, focused breathing, or mindfulness.


Dr. Patrick Friman, PhD, ABPP, is Director of Clinical Services at Boys Town and Vice President of Outpatient Behavioral Health Services and Clinical Professor in the Department of Pediatrics at the University of Nebraska School of Medicine. He has more than 30 years of experience as a licensed psychologist and has been the principal investigator and published numerous research articles. Dr. Friman also is a past president of the Association for Behavior Analysis and is a member of the Advisory Board of the Little Star Autism Center in Indianapolis.


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