Separation Anxiety in Autistic Children and Children With Special Needs: What Helps

Separation anxiety is one of the hardest things a parent deals with, and it is harder when your child also has a disability. The morning routine stops working, drop-off becomes a scene, and you start turning down invitations and sleeping in your child’s room. For a child with autism, ADHD, a sensory processing difference or a speech and language delay, separation is rarely only about separation. It is separation plus a loud hallway, plus not knowing when you are coming back, plus not having the words to ask.

What is separation anxiety, and when does it become a disorder?

Separation anxiety is distress at being away from, or expecting to be away from, the people a child is attached to: crying, clinging, pleading, tantrums, physical complaints, refusing to sleep alone. It usually builds around 9 months, can start later in toddlers, and typically resolves by age 3 or 4; daily separation anxiety after the preschool years is rare.⁠^1,10

It becomes separation anxiety disorder when the fear is developmentally inappropriate and excessive, lasts at least 4 weeks in a child, and causes real distress or impairment. That affects roughly 4% to 5% of children and teens, and it is not only a childhood condition: across 18 countries and nearly 39,000 adults, 43.1% of lifetime onsets came after age 18.⁠^1,11

Why judge it against developmental age, not chronological age?

The diagnostic test is whether the fear is inappropriate to the child’s developmental level, not their birthday.⁠¹ For a child with a global developmental delay or intellectual disability, separation behavior that would be a red flag in a typical 6-year-old may be on track.

Developmental level does not explain everything, though. Followed yearly from age 5 to 9, children with moderate to borderline intellectual disability had more separation anxiety disorder at 5 and more clinical anxiety at 8 and 9 than typically developing children, were slower to show the usual fall in separation anxiety, and more often showed anxiety through behavior.⁠³ Psychiatric conditions tend to be underdiagnosed in people with intellectual disability, partly through diagnostic overshadowing, when symptoms are put down to the disability or its behaviors.⁠^13,14 If your instinct says this is more than developmental level, act on it; our orientation guide is the shortest route in.

How common is separation anxiety in autism and special needs?

The estimates depend on who was studied and how.

Why the autism numbers disagree. Samples drawn from clinics and treatment trials may overestimate how common anxiety is, and checklists built for the general population can miss how it shows in autistic children: an item such as “I worry about other people liking me” describes a fear that tends not to fit.⁠⁷

Is separation anxiety a sign of autism?

No. Autism is diagnosed from social communication differences plus at least two kinds of restricted, repetitive behavior, and separation anxiety is not one of them; a separation anxiety diagnosis in turn requires that the fear not be better explained by another condition, autism included.⁠^1,17 Autistic children do form attachments: in four samples, 53% of autistic children were securely attached, and the gap with other children disappeared at higher developmental levels.⁠¹⁸ What autism can add is extreme distress at small changes and difficulty with transitions, which makes a goodbye harder.⁠¹⁷

Why is separation harder for children with autism or special needs?

Working out which of these is driving your child’s distress matters, because each points to a different fix.

How does sensory over-responsivity feed anxiety?

A child already flooded by noise, light, smell and movement can have little left over for the work of separating. In 149 autistic toddlers followed for a year, sensory over-responsivity predicted later increases in anxiety, while anxiety did not predict changes in over-responsivity: the sensory problem came first.⁠⁸ In 117 children aged 8 to 12 with autism and other neurodevelopmental concerns, the over-responsive group had distinctly higher anxiety.⁠¹⁹ A psychiatrist walks through how sensory issues and anxiety overlap in more detail.

What does intolerance of uncertainty do?

Some children find not knowing what happens next genuinely aversive. In autistic children, intolerance of uncertainty is closely tied to anxiety and may be one route from autism to anxiety.⁠²⁰ Separation is an uncertainty problem: where is she going, when exactly does she come back, what if she does not.

How does the communication gap make separation harder?

A child who cannot ask “when are you coming back?” cannot get the reassurance that would settle the fear, and a child who cannot say “the hand dryer scares me” cannot get the trigger removed. That applies to children who are nonspeaking or minimally speaking, and to children whose understanding lags behind their speech, a gap speech therapy can work on directly, including AAC that lets a child express needs and feelings.⁠²¹

How do emotional regulation differences show up?

Getting upset is normal; coming back down is the skill. In the same study of 117 children, 39% met clinically concerning thresholds for emotion dysregulation, and every atypical sensory group had more of it, so a normal-sized upset can become a long one.⁠¹⁹

Why do change and transition load matter?

Autism’s criteria include insistence on sameness, with extreme distress at small changes and difficulty with transitions.⁠¹⁷ A new school year, a new aide, a substitute teacher or a different door can reset the anxiety, and separation anxiety symptoms often surface at school entry and again around ages 10 to 11.⁠¹

What is family accommodation, and why does it matter?

Family accommodation means the changes families make to spare a child distress: sleeping in their room, staying at the party, answering the same question forty times, avoiding the store, picking up early every day. It is a loving response, and it is also implicated in keeping childhood anxiety going.⁠⁵

In a randomized trial of 124 children aged 7 to 14 with anxiety disorders, 12 weekly parent-only sessions of SPACE (Supportive Parenting for Anxious Childhood Emotions), with no direct contact between child and therapist, did as well as 12 sessions of child CBT and reduced accommodation more.⁠⁵ For families whose child cannot or does not want to sit through therapy, that matters.

How does separation anxiety look in autism, ADHD and SPD?

What are the signs separation anxiety is more than a phase?

For a diagnosis, a child needs at least three of eight signs: excessive distress at separation or the thought of it, worry about harm coming to a parent or about events such as getting lost that could part them, reluctance to go out or to school, fear of being alone, refusing to sleep without a parent nearby, nightmares about separation, and physical complaints such as headache, stomachache or nausea when separation looms.⁠¹ At home, watch for:

• Distress that does not settle. Most children calm soon after a parent leaves; this child stays dysregulated for most of the day.⁠¹²
• Escalation, not habituation. Six weeks in and drop-off is worse than week one.
• Physical complaints that cluster on school mornings and vanish on Saturdays, often leading to medical workups first.⁠¹
• Spreading. It started at school; now it is bathrooms, other rooms, other caregivers.
• School refusal. See the school refusal section below.
• A new fear in an older child. Separation anxiety that appears out of the blue can point to another problem, such as bullying.⁠¹²
• A shrinking family life. You have stopped going places, one parent has cut work hours, siblings are affected.

What helps separation anxiety, ordered by strength of evidence?

What has the strongest evidence?

Graded, planned practice separations. Short, deliberately easy separations that get gradually longer: gradual exposure is a core part of CBT for separation anxiety, and pediatric guidance is to practice being apart before child care starts.⁠^10,22 Start absurdly short; thirty seconds in the next room counts.

Cognitive behavioral therapy. In the Cochrane review of 87 trials and 5,964 children, the 39 trials that reported remission found the main anxiety diagnosis had gone in 49.4% of children after CBT against 17.8% of those waiting or untreated. Results did not differ consistently between samples with and without autism, though evidence that CBT beats usual care was weak.⁠⁶

CBT adapted for autism. In a randomized trial of 167 anxious autistic children aged 7 to 13, CBT adapted for autism outperformed standard CBT and usual care.⁠⁴ A meta-analysis of 19 trials found large effects on clinician ratings but smaller ones on parent and child reports, and gains not maintained at follow-up, though few trials measured it.⁠²³ Ask for an adapted protocol, and plan for booster sessions.

Reducing family accommodation, with support. Parent-based treatment matched child CBT and reduced accommodation more, and it taught parents to respond in a way that acknowledges the child’s fear while conveying confidence that the child can cope.⁠⁵

Lowering sensory load at the point of separation. Over-responsivity predicted later anxiety in autistic toddlers, and the over-responsive group carried the most anxiety in older children, so arriving before the crowd, using a side entrance or skipping the assembly is a sensible part of the plan, though no trial has tested it for separation anxiety.⁠^8,19

Is medication used for separation anxiety?

Sometimes, for moderate to severe anxiety. The American Academy of Child and Adolescent Psychiatry’s 2020 guideline found considerable support for both CBT and SSRI medication as safe and effective short-term treatments for anxiety in children and teens.⁠²⁴ No medicine has an FDA-labeled indication for separation anxiety disorder itself; SSRIs are the usual first choice, sometimes combined with CBT, so ask the prescriber about benefits, side effects and the FDA’s boxed warning.⁠²²

What is clinically sound as part of a package?

Visual supports. They are an evidence-based practice for autistic children and youth.⁠²⁵ But a 2025 review found too little evidence that the visual schedule itself improves transitions, because schedules almost always come with other components that work.⁠²⁶ Use them as part of a plan, not as the whole plan.

Precise, concrete return information. A photo sequence of the day ending with your face, a first-then card, an object of reference: return times tied to events a child understands.⁠^10,12

AAC and communication supports. If your child is nonspeaking or minimally speaking, a way to ask about your return and to report problems goes straight at the mechanism. The worry that AAC delays speech is not supported: in the 27 most rigorously studied cases, none showed less speech after AAC, 11% showed no change and 89% showed gains, generally modest, and a review in autistic children reached the same conclusion.⁠^27,28

Consistent goodbye rituals. Pediatric guidance is a quick, loving goodbye ritual, the same each day, with your full attention.⁠^10,12

Which popular strategies have thinner evidence?

Weighted blankets. In a randomized, placebo-controlled crossover trial of 67 autistic children aged 5 to 16 with severe sleep problems, a weighted blanket did not help them sleep longer, fall asleep faster or wake less often than an identical-looking control blanket, though children and parents preferred it.⁠⁹ So: not a sleep treatment, possibly a comfort item your child likes. Follow current safety guidance on weight and age.

What is the five-minute drop-off routine?

A practice-based routine, built from pediatric guidance on goodbyes and the evidence on predictability and accommodation. Adapt it to your child.⁠^10,12

Which five things should you stop doing?

1. Sneaking out. Pediatric guidance is a short goodbye with your full attention, then leaving, then coming back when you said you would; following through is how a child learns they can manage the time apart.⁠^10,12
2. The long goodbye. If you linger, the transition lasts longer. With older children, running back in at every cry or canceling plans teaches them the tactic works.⁠^10,12
3. Bargaining and quizzing. “No crying and we get ice cream” makes the crying the subject. So does “are you going to be sad today?”
4. Treating a sensory problem as a behavior problem. If the trigger is hallway noise, no reward chart fixes it.
5. Letting accommodations grow silently. One skipped birthday party becomes no parties. List what you have adjusted over the last six months; it is the list a clinician can help you shrink.⁠⁵

What if separation anxiety shows up as school refusal?

For many families this stops being a drop-off problem and becomes an attendance problem. Separation anxiety frequently comes before school refusal, which affects roughly 1% to 5% of school-aged children.⁠¹ Among autistic students the picture is more severe: in a study of 486 children with a mean age of 11, students missed an average of 5 of 23 school days in a month, 43% had persistent absence, and school refusal accounted for 43% of absences, while truancy was almost nonexistent. This is distress, not defiance.⁠²⁹

• Treat attendance as a graded ladder, not a switch. Twenty minutes in the library counts. Build up.
• Put it in writing in the IEP or 504 plan: named greeter, arrival window, quiet entry point, sensory breaks, a check-in adult. Our classroom resources are written to be handed to the school.
• Audit the school day for the actual trigger. Hallways, lunch, recess and gym are worth checking as well as the classroom.
• Screen for bullying. In autistic children seen for school refusal, bullying was significantly linked to it in both boys and girls.⁠³⁰
• Involve the school psychologist early. Persistent absence is linked with poorer school and social outcomes.⁠¹

What about nonspeaking children, toddlers and bedtime?

What helps children who are nonspeaking or minimally speaking?

1. Give them a way to ask. A “when is mom coming?” button or symbol on their AAC device, programmed before you need it. The evidence does not support the fear that AAC suppresses speech.⁠^27,28
2. Give them a way to report. A pain, noise or “I need help” symbol means the environment can actually be fixed.
3. Choose a treatment that does not need the child to talk. The parent-based approach did as well as child CBT with no direct child-therapist contact, which makes it a serious option here.⁠⁵

What helps toddlers and preschoolers?

At this age some separation anxiety is expected development in toddlers and preschoolers. Focus on consistency and short practice separations rather than treatment, and talk to your pediatrician if daily separation anxiety continues past the preschool years or is clearly outside your child’s developmental range.⁠^10,12

What if sleep is the main battleground?

Bedtime is often the hardest separation: refusing to sleep without a parent nearby and nightmares about separation are both diagnostic signs.⁠¹ Treat sleep as a target in its own right rather than assuming it resolves when the daytime anxiety does; our guide to sensory processing and sleep problems in autism covers the sensory side.

When should you get a professional evaluation, and who does what?

Get an evaluation when separation fear has lasted 4 weeks or more and gets in the way of school, sleep, family life or development, or when daily separation anxiety continues past the preschool years.⁠^1,10

Most families end up with more than one of these. Ask them to talk to each other. You can browse providers by state to start.

What does treatment actually look like?

CBT usually takes 10 to 15 weekly sessions with practice at home between them, and the SPACE parent program ran 12 weekly sessions.⁠^5,22 Expect parent involvement, and a therapist who builds an exposure ladder with you rather than only talking about feelings. Questions worth asking a prospective provider:

• Do you use an anxiety protocol adapted for autistic or developmentally disabled children?
• How do you involve parents?
• Do you address family accommodation directly?
• How do you handle exposure work with a child who has limited expressive language?
• Do you consult with the school?

What should parents of an anxious child keep in mind?

Separation anxiety is exhausting in a way that is hard to explain to people who have not lived it. If you have been accommodating for a long time, that is not a failure of parenting; it is what a caring parent does when their child is frightened, and it is also one of the most changeable pieces of the whole picture.⁠⁵

In the trials that measured it, about half of children no longer met criteria for their main anxiety diagnosis after a course of CBT.⁠⁶ Your child’s world can get bigger again.

Sources

1. Bernstein BE; Pataki C, chief editor. Separation anxiety and school avoidance. Medscape Reference, updated March 23, 2026. Checked October 10, 2026.
   Show the passageHide the passage

   Background: separation anxiety disorder “is characterized by developmentally inappropriate and excessive fear or anxiety concerning separation from attachment figures,” and under DSM-5-TR “symptoms must persist for at least 4 weeks in children and adolescents and typically 6 months or longer in adults”; separation anxiety “is developmentally appropriate in infants and toddlers and typically resolves by age 3–4 years”; “Separation anxiety frequently precedes school refusal”; and common features include “reluctance to attend school or leave home, sleep disturbances, nightmares, and somatic symptoms such as abdominal pain or palpitations,” which “may lead to medical evaluation.” Diagnostic criteria: at least 3 of 8, including recurrent excessive distress when anticipating or experiencing separation, persistent worry about harm to attachment figures or about events that could lead to separation, reluctance to go out or to school because of fear of separation, fear of being alone, reluctance to sleep away from home or without an attachment figure nearby, repeated nightmares about separation, and repeated physical complaints “(eg, headache, abdominal pain, nausea) when separation occurs or is anticipated”; symptoms must cause clinically significant distress or impairment and “Not be better explained by another mental disorder (eg, autism spectrum disorder, psychotic disorders, agoraphobia, generalized anxiety disorder, illness anxiety disorder).” Epidemiology: “prevalence estimates of approximately 4–5% in children and adolescents”; “School refusal/avoidance behaviors occur in roughly 1–5% of school-aged children”; symptoms “often emerge at developmental transition points, particularly at school entry (ages 5–6 years) and again in later childhood (ages 10–11 years)”; and “Persistent school nonattendance is associated with adverse outcomes, including academic underachievement, social impairment ...”
2. van Steensel FJA, Bögels SM, Perrin S. Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clinical Child and Family Psychology Review. 2011;14(3):302–317. PMID 21735077. Checked October 10, 2026.
   Show the passageHide the passage

   The abstract: “31 studies involving 2,121 young people (aged <18 years) with ASD”; “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%)”; the full text (PubMed Central) adds “separation anxiety disorder in nearly 9%, and panic disorder in nearly 2%,” and that, except for panic disorder, the rates “are more than two times higher than in typically developing children.”
3. Green SA, Berkovits LD, Baker BL. Symptoms and development of anxiety in children with or without intellectual disability. Journal of Clinical Child and Adolescent Psychology. 2015;44(1):137–144. PMID 24528099. Checked October 10, 2026.
   Show the passageHide the passage

   The abstract: children with moderate to borderline intellectual disability (n=74) or typical development (n=116) were assessed “annually from ages 5 through 9”; “Children with ID had significantly higher rates of clinical levels of anxiety on the Child Behavior Checklist at ages 8 and 9 and higher rates of separation anxiety disorder at age 5”; they “were also more likely to have externalizing problems co-occurring with anxiety”; and “children with ID have both higher rates of anxiety across time and are delayed in showing typical decreases in separation anxiety in early childhood.”
4. Wood JJ, Kendall PC, Wood KS, Kerns CM, Seltzer M, Small BJ, Lewin AB, Storch EA. Cognitive behavioral treatments for anxiety in children with autism spectrum disorder: a randomized clinical trial. JAMA Psychiatry. 2020;77(5):474–483. PMID 31755906. Checked October 10, 2026.
   Show the passageHide the passage

   The abstract: children “(7-13 years) with ASD and maladaptive and interfering anxiety” were randomized to standard-of-practice CBT, CBT adapted for ASD or treatment as usual; “Of 214 children initially enrolled, 167 were randomized”; the adapted program “outperformed standard-of-practice CBT ... and TAU” on the Pediatric Anxiety Rating Scale; “Both CBT conditions achieved higher rates of positive treatment response than TAU (BIACA, 61 of 66 [92.4%]; Coping Cat, 47 of 58 [81.0%]; TAU, 2 of 18 [11.1%]”; and “It is recommended that clinicians providing psychological treatments to school-aged children with ASD consider developing CBT expertise.”
5. Lebowitz ER, Marin C, Martino A, Shimshoni Y, Silverman WK. Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: a randomized noninferiority study of Supportive Parenting for Anxious Childhood Emotions. Journal of the American Academy of Child and Adolescent Psychiatry. 2020;59(3):362–372. PMID 30851397. Checked October 10, 2026.
   Show the passageHide the passage

   The abstract: “Research implicates family accommodation in the maintenance and course of childhood anxiety”; children with primary anxiety disorders “(N = 124; 7-14 years of age)” were randomized to SPACE “with no direct child-therapist contact, or CBT”; “SPACE was noninferior, relative to CBT, on primary and secondary anxiety outcomes,” with “significantly greater reduction in family accommodation following SPACE.” The full text (PubMed Central) calls CBT “the best-established treatment for childhood anxiety with the strongest evidence base”; both arms had 12 weekly 60-minute sessions, and parents “were then taught supportive responses to child anxiety that acknowledge the child’s experience while also conveying confidence in the child’s ability to cope.”
6. James AC, Reardon T, Soler A, James G, Creswell C. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews. 2020;11(11):CD013162. PMID 33196111. Checked October 10, 2026.
   Show the passageHide the passage

   The abstract: “We included 87 studies and 5964 participants”; compared with waitlist or no treatment, “CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45 ...; n = 2697, 39 studies, moderate quality)”; “We did not find evidence of consistent differences in outcomes according to delivery formats ... or amongst samples with and without ASD”; and “We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments.”
7. Thiele-Swift HN, Dorstyn DS. Anxiety prevalence in youth with autism: a systematic review and meta-analysis of methodological and sample moderators. Review Journal of Autism and Developmental Disorders. 2026;13:76–89; published online January 18, 2024. Checked October 10, 2026.
   Show the passageHide the passage

   “We present the pooled findings from 15 community studies (N = 4459)”; “Equally high rates of anxiety symptoms and disorders were identified via self-report (33% ...) and diagnostic interview (19% ...)”; “Specific phobia was most common (41%), followed by social anxiety (28%), generalised anxiety (27%), and separation anxiety (14%)”; samples “from treatment trials or intervention settings ... may not only overestimate anxiety prevalence but can result in spurious associations”; and checklists designed for the general population may not capture anxiety in autistic youth, since an item such as “‘I worry about other people liking me’” reflects a fear “that tends not to be of concern in ASD populations.”
8. Green SA, Ben-Sasson A, Soto TW, Carter AS. Anxiety and sensory over-responsivity in toddlers with autism spectrum disorders: bidirectional effects across time. Journal of Autism and Developmental Disorders. 2012;42(6):1112–1119. PMID 21935727. Checked October 10, 2026.
   Show the passageHide the passage

   The abstract: “Participants were 149 toddlers with ASD and their mothers, assessed at 2 annual time points”; “SOR positively predicted changes in anxiety over and above child age, autism symptom severity, NVDQ, and maternal anxiety, but anxiety did not predict changes in SOR. Results suggest that SOR emerges earlier than anxiety, and predicts later development of anxiety.”
9. Gringras P, Green D, Wright B, Rush C, Sparrowhawk M, Pratt K, et al. Weighted blankets and sleep in autistic children: a randomized controlled trial. Pediatrics. 2014;134(2):298–306. PMID 25022743. Checked October 10, 2026.
   Show the passageHide the passage

   The abstract: a randomized, placebo-controlled crossover trial in children “aged between 5 years and 16 years 10 months, with a confirmed ASD diagnosis and severe sleep problems”; “Seventy-three children were randomized and analysis conducted on 67”; “The use of a weighted blanket did not help children with ASD sleep for a longer period of time, fall asleep significantly faster, or wake less often. However, the weighted blanket was favored by children and parents, and blankets were well tolerated over this period.”
10. Swanson WS; American Academy of Pediatrics. How to ease your child’s separation anxiety. HealthyChildren.org, last updated May 11, 2026. Checked October 10, 2026.
    Show the passageHide the passage

    Most children “develop more robust separation anxiety at around 9 months,” and many toddlers “start demonstrating challenges at 15 or 18 months of age”; tips: “Create quick goodbye rituals ... keep the goodbye short and sweet. If you linger, the transition time does too”; “Try to do the same drop-off with the same ritual at the same time each day”; “When separating, give your child full attention, be loving and provide affection. Then say goodbye quickly”; “Keep your promise” of return, since returning to visit after a hard transition extended the anxiety; “Be specific, child style ... say, ‘I’ll be back after nap time and before afternoon snack’”; “Practice being apart ... Before starting child care or preschool, practice going to school and your goodbye ritual”; and “It’s rare that separation anxiety persists on a daily basis after the preschool years. If you’re concerned ..., chat with the pediatrician.”
11. Silove D, Alonso J, Bromet E, Gruber M, Sampson N, Scott K, et al. Pediatric-onset and adult-onset separation anxiety disorder across countries in the World Mental Health Survey. American Journal of Psychiatry. 2015;172(7):647–656. PMID 26046337. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: “The sample included 38,993 adults in 18 countries”; “Lifetime separation anxiety disorder prevalence averaged 4.8% across countries ... with 43.1% of lifetime onsets occurring after age 18”; and twelve-month prevalence was 1.0%.
12. Nemours KidsHealth. Separation anxiety. Medically reviewed by Leah J. Orchinik, PhD; date reviewed March 2023. Checked October 10, 2026.
    Show the passageHide the passage

    “Create an exit ritual during which you say a pleasant, loving, and firm goodbye. Stay calm and show confidence in your child,” explaining your return “using concepts kids will understand (such as after lunch),” and “when you say you’re leaving, mean it; coming back will only make things worse”; return when you promised, because “this is how your child will develop the confidence that they can make it through the time apart”; “By the time you get to your car, your child is likely to have calmed down”; for older children, “If you run back into the room every time your child cries or cancel your plans, your child will continue to use this tactic to avoid separation”; “If separation anxiety appears out of the blue in an older child, there might be another problem, like bullying or abuse”; and if intense separation anxiety “lasts into preschool, elementary school, or beyond and interferes with daily activities, discuss it with your doctor.”
13. Manohar H, Subramanian K, Kandasamy P, Penchilaiya V, Arun A. Diagnostic masking and overshadowing in intellectual disability: how structured evaluation helps. Journal of Child and Adolescent Psychiatric Nursing. 2016;29(4):171–176. PMID 27901303. Checked October 10, 2026.
    Show the passageHide the passage

    A case report; the abstract: “Comorbid psychiatric diagnoses tend to be underdiagnosed in patients with intellectual disability,” and the case “highlights the need for a systematic assessment of patients with intellectual disability to arrive at reliable diagnoses.”
14. Perry BI, Cooray SE, Mendis J, Purandare K, Wijeratne A, Manjubhashini S, et al. Problem behaviours and psychotropic medication use in intellectual disability: a multinational cross-sectional survey. Journal of Intellectual Disability Research. 2018;62(2):140–149. PMID 29349928. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract, on 358 people with disorders of intellectual development: “We also found evidence of potential diagnostic-overshadowing, where symptoms of psychiatric co-morbidity may have been attributed to PBs” (problem behaviors).
15. Njardvik U, Wergeland GJ, Riise EN, Hannesdottir DK, Öst LG. Psychiatric comorbidity in children and adolescents with ADHD: a systematic review and meta-analysis. Clinical Psychology Review. 2025;118:102571. PMID 40245462. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: “In total 121 studies involving 39,894 children and adolescents with ADHD diagnosis were included. The most common comorbid disorders were Oppositional Defiant Disorder (34.7 %), Behavior Disorders (30.7 %), Anxiety Disorders (18.4 %), Specific phobias (11.0 %)”; and “All individual disorders studied had a higher prevalence among children and adolescents with ADHD than in the general population.”
16. Fodstad JC, Jones LB, Iticovici M, Russell RM, Bullington M, Meudt E. The state of anxiety treatments for adolescents and adults with Down syndrome: results from a scoping rapid review. Journal of Mood and Anxiety Disorders. 2024;6:100056. PMID 40655921. Checked October 10, 2026.
    Show the passageHide the passage

    From the full text (PubMed Central): “It is estimated that between 15–40% of adults with DS have a co-morbid neurobehavioral or psychiatric condition”; “while anxiety disorders may be equal to or less common in individuals with DS compared to individuals with other neurodevelopmental disabilities ..., anxiety disorders in the DS population are still common and may be equally as prevalent or more prevalent than in the general population”; the review found eleven articles, “primarily single case or case series,” and covered only people aged 13 and older.
17. Centers for Disease Control and Prevention. Clinical Testing and Diagnosis for Autism Spectrum Disorder. Page dated May 8, 2025. Checked October 10, 2026.
    Show the passageHide the passage

    “To meet diagnostic criteria for ASD according to DSM-5, a child must have persistent deficits in each of three areas of social communication and interaction ... plus at least two of four types of restricted, repetitive behaviors,” one of them “Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day)”; separation anxiety is not among the criteria.
18. Rutgers AH, Bakermans-Kranenburg MJ, van IJzendoorn MH, van Berckelaer-Onnes IA. Autism and attachment: a meta-analytic review. Journal of Child Psychology and Psychiatry. 2004;45(6):1123–1134. PMID 15257669. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: “Despite the impairments of children with autism in reciprocal social interaction, the majority of the studies found evidence for attachment behaviours in these children. In four samples using the Strange Situation procedure the average percentage of secure attachments amounted to 53% (n = 72)”; children with autism were less securely attached than comparison children, “but this difference disappeared in samples with children with higher mental development”; and “attachment security is compatible with autism.”
19. Brandes-Aitken A, Powers R, Wren J, Chu R, Shapiro KA, Steele M, Mukherjee P, Marco EJ. Sensory processing subtypes relate to distinct emotional and behavioral phenotypes in a mixed neurodevelopmental cohort. Scientific Reports. 2024;14:29326. PMID 39592662. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: “117 participants (8-12 years)” with neurodevelopmental concerns including autism, ADHD, anxiety and sensory processing differences; “39% of NDC children met clinically concerning thresholds for emotion dysregulation, 19% for anxiety, and 62% for ADHD”; “the Sensory Over-Responsive group exhibited distinctively elevated anxiety scores, while the Sensory Seeking and Sensory Under-Responsive groups showed heightened ADHD scores”; and all three atypical subgroups had elevated emotion dysregulation, “suggesting a potential shared mechanism.”
20. Boulter C, Freeston M, South M, Rodgers J. Intolerance of uncertainty as a framework for understanding anxiety in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders. 2014;44(6):1391–1402. PMID 24272526. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: “Results confirmed significant relationships between IU and anxiety in children with ASD,” and the results “were consistent with a causal model suggesting that IU mediates the relationship between ASD and anxiety.”
21. American Speech-Language-Hearing Association. Autism and Autism Spectrum Disorder. Practice Portal, undated. “AAC uses a variety of techniques and tools to help the individual express thoughts, ideas, wants, needs, and feelings”; and SLPs “can help mental health professionals work with AAC users, such as identifying and repairing communication breakdowns.” Checked October 10, 2026.
22. Feriante J, Torrico TJ, McArthur J, Bernstein B. Separation anxiety disorder. StatPearls, NCBI Bookshelf; last updated June 17, 2026. Checked October 10, 2026.
    Show the passageHide the passage

    “Developmentally appropriate separation anxiety typically emerges between 6 and 12 months of age” and “remains consistently observable until approximately age 3”; the 2020 AACAP guidelines “recommend selective serotonin reuptake inhibitors (SSRIs) for patients with separation anxiety disorder and support the use of cognitive behavioral therapy”; “CBT may be prioritized for mild symptoms, whereas SSRIs are an alternative first-line treatment in moderate to severe cases”; “No medications have an FDA-labeled indication for separation anxiety disorder”; “SSRIs are the first-line medication for the pediatric population” and carry an FDA boxed warning; and CBT “should include techniques involving psychoeducation, changing maladaptive thought patterns, and gradual exposure to anxiety-provoking situations. Effective CBT typically requires 10 to 15 outpatient sessions.”
23. Sharma S, Hucker A, Matthews T, Grohmann D, Laws KR. Cognitive behavioural therapy for anxiety in children and young people on the autism spectrum: a systematic review and meta-analysis. BMC Psychology. 2021;9:151. PMID 34598734. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: “A total of 19 RCTs met our inclusion criteria (833 participants)”; a large effect for clinician-rated symptoms and smaller but significant effects for parent and child reports; “These benefits were not however maintained at follow-up,” though “few studies have included this data”; and “CBT was more efficacious for younger children ... and when delivered as individual therapy.”
24. Walter HJ, Bukstein OG, Abright AR, Keable H, Ramtekkar U, Ripperger-Suhler J, Rockhill C. Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry. 2020;59(10):1107–1124. PMID 32439401. Checked October 10, 2026.
    Show the passageHide the passage

    The American Academy of Child and Adolescent Psychiatry guideline; the abstract: “both cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication have considerable empirical support as safe and effective short-term treatments for anxiety in children and adolescents. Serotonin norepinephrine reuptake inhibitor (SNRI) medication has some empirical support as an additional treatment option.”
25. Hume K, Steinbrenner JR, Odom SL, Morin KL, Nowell SW, Tomaszewski B, Szendrey S, McIntyre NS, Yücesoy-Özkan S, Savage MN. Evidence-based practices for children, youth, and young adults with autism: third generation review. Journal of Autism and Developmental Disorders. 2021;51(11):4013–4032. Published January 15, 2021. Checked October 10, 2026.
    Show the passageHide the passage

    The review by the National Clearinghouse on Autism Evidence and Practice: “A search initially yielded 31,779 articles ... 972 articles were synthesized, from which the authors found 28 focused intervention practices that met the criteria for evidence-based practice”; focused practices “are designed to address a single skill or goal” and “could be considered the building blocks of educational programs”; a practice qualified with “two high quality group design studies conducted by two different research groups,” five high-quality single-case studies by three groups with 20 participants, or a combination; “single case design studies made up 83% of the articles”; Table 2 lists the practices with their supporting studies, among them augmentative and alternative communication (44), cognitive behavioral/instructional strategies (50), exercise and movement (17), music-mediated intervention (7), naturalistic intervention (75), parent-implemented intervention (55), sensory integration (3), social skills training (74), task analysis and visual supports; “Sensory Integration refers explicitly to the classical sensory integration model developed by Jean Ayres (2005) and not to a variety of interventions that address sensory issues but have been found to be unsupported”; and the ten manualized interventions that met the criteria include PECS, JASPER, Pivotal Response Training, Project ImPACT, Social Stories and PEERS.
26. Mouzakes TN, Thompson RH. A closer examination of the visual schedule component of interventions to improve transitions. Behavioral Interventions. Published online August 20, 2025. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract, read in the publisher’s Crossref record: visual schedules “are often recommended with individuals with autism to improve transitions in educational settings based on the assumption that enhanced predictability will improve transitions”; “the included studies provided insufficient evidence that the VS component of the intervention contributed to improved transitions with individuals diagnosed with ASD”; and “VS are typically presented along with other treatment components with documented efficacy, and few component analyses have been conducted.”
27. Millar DC, Light JC, Schlosser RW. The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: a research review. Journal of Speech, Language, and Hearing Research. 2006;49(2):248–264. PMID 16671842. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: 23 studies of 67 individuals; “The remaining 6 studies, involving 27 cases, had sufficient methodological rigor for the ‘best evidence analysis’”; “None of the 27 cases demonstrated decreases in speech production as a result of AAC intervention, 11% showed no change, and the majority (89%) demonstrated gains in speech. For the most part, the gains observed were modest.”
28. Schlosser RW, Wendt O. Effects of augmentative and alternative communication intervention on speech production in children with autism: a systematic review. American Journal of Speech-Language Pathology. 2008;17(3):212–230. PMID 18663107. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: nine single-subject studies (27 participants) and two group studies (98 participants); “Although AAC interventions do not appear to impede speech production and may result in increased speech production, the modest gains observed require realistic expectations among clinicians and other stakeholders.”
29. Totsika V, Hastings RP, Dutton Y, Worsley A, Melvin G, Gray K, Tonge B, Heyne D. Types and correlates of school non-attendance in students with autism spectrum disorders. Autism. 2020;24(7):1639–1649. PMID 32419486. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract: “Parents of 486 students (mean age: 11 years) indicated which days their child had missed school (over a period of 1 month)”; “On average, students missed 5 days of school of a possible 23 days ... 43% of students experienced persistent absence”; “school refusal was the most frequent reason, accounting for 43% of absences”; and “Truancy was almost non-existent.”
30. Ochi M, Kawabe K, Ochi S, Miyama T, Horiuchi F, Ueno SI. School refusal and bullying in children with autism spectrum disorder. Child and Adolescent Psychiatry and Mental Health. 2020;14:17. PMID 32419839. Checked October 10, 2026.
    Show the passageHide the passage

    The abstract, comparing 94 outpatients with school refusal and ASD with 143 without ASD: “School refusal significantly occurred earlier in children with ASD than in those without. In addition, ‘bullying’ was significantly associated with school refusal in both boys and girls with ASD.”

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider about your child. It is not a substitute for evaluation by a qualified clinician who knows your child. If your child is in crisis, contact your pediatrician or local emergency services.