Anxious Imagery in Children with Autism Spectrum Disorder

Thursday, May 14, 2015: 11:30 AM-1:30 PM
Imperial Ballroom (Grand America Hotel)
A. Ozsivadjian1, M. J. Hollocks2, M. Absoud3, J. Southcott4 and E. Holmes5, (1)Guy's Hospital, London, United Kingdom, (2)Denmark Hill, King's College London, London, United Kingdom, (3)Children's Neurosciences Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom, (4)Children's Neurosciences Centre, Guy's and St Thomas' NHS foundation trust, London, United Kingdom, (5)Cognition and Brain Sciences Unit, Cambridge University, Cambridge, United Kingdom

Anxiety disorders occur in ~40% of children with ASD (van Steensel et al, 2011), compared to 2-3% in the general population. Reasons for this increased rate are currently speculative although a small body of research is emerging investigating cognitive and physiological pathways to anxiety in ASD (Hollocks et al, 2013). In the typically developing (TD) adult population, research has suggested mental imagery may play a role in the aetiology and maintenance of anxiety disorders. Images can be extremely vivid, intrusive and more emotionally-laden than verbal thoughts; despite this, the latter have tended to be the focus of most cognitive behavioural research. Given that individuals with ASD are often thought of as being ‘visual thinkers’ (Kunda and Goel, 2011), we sought to examine the role anxious imagery might play in the development and maintenance of anxiety in this population.


This is an exploratory cross sectional cohort study investigating anxious imagery in children with ASD with both high and low anxiety, compared to TD children with both high and low anxiety.


78 participants (29 ASD high anxiety; 14 ASD low anxiety; 17 TD high anxiety; 18 TD low anxiety) aged 8-16 (69% male) matched for IQ took part in a semi-structured interview that provided both quantitative  and qualitative data on the features of images experienced, and the meaning attached to them. Participants completed four questionnaires examining anxiety, depression, spontaneous use of imagery in daily life, and emotional regulation. Parents completed anxiety, depression, and the Social Communication Questionnaire. Nominal data were compared using χ2or Fisher’s exact tests. Parametric or nonparametric tests were used for continuous measurements as appropriate given normality. For the binary logistic regression a backward elimination approach was used using predictor variables with presence of anxiety as the dependent variable.


Children with ASD and anxiety reported the highest number of anxious images, followed by children with ASD and low anxiety, TD children with anxiety, and finally TD children with low anxiety (χ2=22.7; p<0.001). Children with anxiety regardless of ASD diagnosis had images that were more frequent (χ2=9.1; p=0.028); more vivid (t=-2.7; p=0.012), and had more emotional valence (t=-2.8; p=0.007). Examples of anxious intrusive imagery included ‘the eyes emanating from the television’; ‘the nothing thing – a shadowy creature’; ‘the sound of the teacher shouting at my classmate’ ‘standing alone at the school gates with no one to pick me up’; ‘the smell of blood from my arteries popping’. Logistic regression revealed that anxiety in all groups was predicted by vividness of images(OR=3.6, p=0.011). 


Children with ASD and anxiety experience anxious imagery that causes them distress. These images may play a significant role in the high rates of anxiety seen in ASD. This finding also has treatment implications for the delivery of CBT in anxiety disorders in this group, which may be more effective if imagery modification/restructuring as well as verbal cognitions are addressed in therapy.