Autism and Anxiety: What’s Really Driving the Behavior?

Many autistic children struggle with anxiety, but it doesn’t always look the way parents expect.

Sometimes anxiety looks like constant worrying. Sometimes it looks like school refusal, perfectionism, meltdowns, rigidity, reassurance seeking, avoidance, or a child who needs to know exactly what’s going to happen next.

In this episode of Beneath the Behavior, Dr. Mark Bowers explores the complex relationship between autism and anxiety and helps parents understand why so many autistic children experience intense stress around uncertainty, change, social situations, and daily demands.

We discuss:

 • Why anxiety is so common in autistic children
 • The connection between autism, uncertainty, and the need for predictability
 • School anxiety and school refusal
 • Social anxiety and friendship challenges
 • Perfectionism and fear of making mistakes
 • Reassurance seeking and constant questioning
 • When anxiety looks like behavior problems
 • Why meltdowns can be driven by fear and overwhelm
 • The difference between support and avoidance
 • Therapy considerations for autistic children with anxiety
 • What meaningful progress actually looks like

If you've ever wondered whether your child's behavior is really anxiety underneath, this episode will help you understand what may be happening beneath the surface and how to support your child with greater clarity and compassion.

Transcript

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Hi, I'm Dr. Mark Bowers. I'm a licensed pediatric psychologist and I specialize in working with neurodivergent kids and their families. This podcast is for parents and caregivers who feel like parenting has been harder than they expected and who want understanding instead of blame. Here we slow things down and look beneath behavior so we can make sense of what's actually going on from a brain and nervous system perspective and support neurodivergent kids with science, not shame. Now, before we get started, a quick note. This podcast is for education and understanding. It isn't therapy and it isn't a substitute for working with your own provider. I won't be giving individual advice, but I hope these conversations help you think more clearly and compassionately about your child. Now in today's episode, we're continuing our Now What series after an autism diagnosis. And today we're talking about anxiety. Specifically, one of the questions I hear all the time: is this autism? Is this anxiety? Or is this both? And honestly, by the time many families get to my office, they're exhausted trying to answer that question. Because they don't necessarily see anxiety. What they see is behavior. They see the child who refuses school. The child who asks the same question 20 times. The child who melts down when plans change. The child who won't try new things. The child who argues. Child who needs constant reassurance or who has stomach aches every morning? The child who seems to worry about everything. And often what happens is that adults start focusing on the behavior itself. How do we stop the arguing? How do we stop the refusal? How do we stop reassurance seeking? How do we stop the meltdowns? But as you probably heard me say before, behavior is often the last thing I'm interested in. Because behavior is usually the visible part. What I want to understand is what's driving it. And when we slow down and look beneath behavior, anxiety is often a much bigger part of the picture than families realize. So today we're going to talk about why anxiety is so common in autism. Why it doesn't always look the way people expect. Why some autistic children seem to live in a constant state of anticipation. How anxiety shows up at school, at home, and socially, when accommodations help, when accommodations can accidentally feed anxiety, and what meaningful support actually looks like. Because if anxiety is driving a lot of what you're seeing, understanding that changes everything. One of the first things I explain to families is that autism and anxiety often travel together. Not always, but very often. And when you really think about it, it makes sense. Imagine trying to navigate a world that often feels unpredictable. Social situations don't always make sense. Sensory experiences can be overwhelming. Transitions can feel abrupt. People say one thing yet mean another. Rules seem to change depending on the situation. Expectations aren't always clear. And many autistic children spend a lot of energy trying to figure out what's going to happen next. Because predictability feels safe. Uncertainty does not. Let me introduce you to Liam. Liam is eight. His parents describe him as a constant worrier. Before leaving the house, he asks, Where are we going? Who's going to be there? How long will we stay? What if it rains? What if it's closed? What if we get lost? What if I don't like it? And honestly, by the 10th question, his parents are exhausted. Sometimes they tell Liam, You already asked that. Or it's okay, stop worrying. Or everything will be fine. But here's what I want you to notice. Liam isn't asking because he enjoys worrying. He's asking because the uncertainty feels uncomfortable. Every answer helps him temporarily feel safer, at least for a few minutes. And that's one of the things anxiety does. It keeps searching for certainty. The problem is that certainty is impossible. So the anxiety keeps looking. One of the reasons anxiety gets missed in autistic children is because it doesn't always look anxious. Sometimes it looks angry. Sometimes it looks oppositional. Sometimes it looks controlling. It looks like behavior. Let's talk about Noah. Noah's 13. His parents describe him as rigid. If plans change unexpectedly, things fall apart. A trip gets canceled, a restaurant changes, a substitute teacher shows up, somebody moves his belongings, and suddenly Noah's yelling, arguing, refusing, escalating. From the outside, it can and often looks like he's trying to control everyone. But when we slow it down, a different picture emerges. Noah isn't trying to control people. He's trying to control uncertainty. Those are very different things because uncertainty feels threatening to the nervous system. And if we only focus on the outward behavior, we miss what's actually happening underneath. I think this is one of the biggest shifts that parents make after they begin understanding anxiety. They stop asking, why is my child trying to control everything? And they start asking, what feels unsafe right now? Very different question. And it often leads to very different solutions. Now, this is one of the areas where autism and anxiety often overlap. Many autistic children rely heavily on predictability. Not because they're stubborn, not because they're difficult, but because predictability reduces uncertainty. And uncertainty creates stress. Think about your own life for a moment. Most adults use predictability too. Calendars, schedules, routines, GPS, reminders. We all create systems that make life feel more manageable. Now imagine that uncertainty feels amplified. Imagine your nervous system responds strongly to the unexpected. Imagine changes feel bigger, harder, more disruptive. Maybe you already experienced it yourself, but that's often what many autistic children are experiencing as well. And this is why comments like just go with the flow can be incredibly frustrating because the child, I'm sure, would love to go with the flow. The problem is that the flow feels unpredictable, and unpredictable feels unsafe. So it's logical, right? They seek reassurance, they ask questions, they create routines, they need warnings, they prefer sameness. And adults sometimes interpret those behaviors as inflexibility when there actually attempts to manage anxiety. That doesn't mean that we never work on flexibility. We absolutely do. But understanding the function matters because flexibility is taught differently than compliance. Let's talk about one of the biggest anxiety triggers for many children. School. Meet Ava. Ava's eleven. Every Sunday afternoon, her mood changes. By Sunday evening, she's irritable. By Monday morning, she has a stomach ache. Sometimes a headache, sometimes nausea, sometimes tears, sometimes complete refusal. The school focuses on attendance. The parents focus on getting her through the door. Everyone is focused on behavior, but nobody is asking the most important question. Why does school feel so hard? Sometimes the answer is academic stress. Sometimes it's sensory overload. Sometimes it's social anxiety. Maybe it's masking. Sometimes it's bullying. Sometimes it's exhaustion. And sometimes it's several of those things at once. One of the mistakes I see adults make is assuming that the school refusal means a child doesn't value their education. Quite often the opposite is true. Many children who refuse school care deeply about it. They're overwhelmed, they're anxious, they're exhausted, and their nervous system has started associating school with distress. That doesn't mean we start eliminating expectations, but it does mean that we need to understand the source of the anxiety. Because attendance and access are not the same thing. A child can physically attend school and still not be accessing learning effectively. Those are very important distinctions. Now, this portion connects directly to our friendship episode that you may have previously listened to. Because for some autistic children, social situations are not just confusing, they're anxiety-provoking. Imagine trying to navigate conversations when you're not always sure what people mean. Imagine worrying about saying the wrong thing, missing a joke, misreading a social cue, being left out, being embarrassed, being rejected. For some children, every social interaction starts to feel like a test. And eventually anxiety starts influencing behavior. They stop initiating, stop participating, avoid social opportunities, decline invitations, not because they don't want connection, but because the risk starts feeling too high. This is why I think parents need to be careful about assuming that avoidance always means lack of interest. Sometimes avoidance is protection, protection from discomfort, protection from uncertainty, protection from rejection. So once again, understanding the function that matters. Now, this is one of the most overlooked forms of anxiety, perfectionism. I've worked with plenty of autistic children who would rather not start than risk making a mistake. They erase repeatedly, they ask for reassurance constantly. They get upset when work isn't perfect. They avoid difficult tasks, refuse to try new things. And adults sometimes interpret this as stubbornness, but often it's fear. Fear of failure. Perfectionism gives the illusion of safety. If I can do it perfectly, maybe I can avoid mistakes. Problem is, perfection is impossible. So the anxiety never really gets satisfied. Just like we can never be certain about anything. That's not possible either. So the anxiety will just keep demanding more and more and more as far as certainty and as far as perfection. And that's why we get stuck in these anxious loops often with our anxious kids. So let's talk about support because accommodations can be incredibly helpful when they're done thoughtfully. Accommodations reduce barriers, they create access, they help nervous systems function more effectively. Things like visual schedules, advance warnings, sensory supports, predictable routines, written instructions, break opportunities, clear expectations. These supports are not about removing all discomfort. They're about reducing the unnecessary stress. When anxiety is already high, reducing unnecessary stress with accommodations can free up energy for growth. And now we need to talk about something more nuanced. Because sometimes anxiety wants one thing more than anything else: escape. Avoidance feels pretty good in the short term. If I'm afraid of something and I don't have to do it, my anxiety goes down immediately. Problem is the brain ends up learning avoidance worked. And so the next time the anxiety often gets bigger. And this is why support can become tricky because we want to help kids, but we don't want anxiety making all the decisions. The goal is not to never feel anxious, the goal is to learn that you can handle anxiety. It's very different. Sometimes support means reducing demands. Sometimes support means building skills. Often it means finding a balance between the two. When families ask about therapy for anxiety, one of the first things that I think about is fit. Because anxiety treatment has to account for autism. The most effective therapy isn't simply stop worrying, it's helping children understand their nervous system to recognize anxiety and build coping skills so that flexibility can be gradually increased. And hopefully, over time, learn that uncertainty can be tolerated. Trust matters, relationship matters, and exposure when used needs to be thoughtful. The goal with anxiety treatment is not to shock and surprise and overwhelm children. It's to be very careful, very strategic, very deliberate in helping these kids build confidence through manageable, uncomfortable experiences. Because confidence doesn't come from eliminating anxiety, it comes from learning that anxiety can be tolerated and it can be handled. So let's end with this. Progress does not mean anxiety disappears. Every human experiences anxiety. The goal is not zero anxiety. The goal is that anxiety stops running the show. Progress might look like trying something new, tolerating a change in plans, asking fewer reassurance questions, recovering more quickly after uncertainty, attending school more consistently, participating socially despite discomfort, trying despite imperfection. These things all count, and often they're much more meaningful than parents realize because confidence grows one experience at a time. So if you're listening and thinking, this sounds exactly like my child, and I need help figuring out how to apply it, I want you to know that you don't have to do that alone. If and when you're ready for ongoing neurodivergent-specific support, the Neurodivergent Parenting Collective was created for parents who want practical tools, real clarity, and a community where their child's needs don't have to be explained or defended. You can find more information in the episode description and explore it at your own pace. You deserve support too. Before we wrap up, I want to leave you with one thought. Anxious children are often trying very hard to feel safe in a world that doesn't always feel predictable. And when we understand that, we stop seeing anxiety as simply a collection of behaviors. And we start seeing a nervous system working overtime to prevent something from going wrong. It doesn't mean we remove every challenge, but it means we support children in building confidence while understanding what they're carrying. Because confidence doesn't come from a world that never feels uncertain. Confidence comes from learning that you can handle uncertainty when it shows up. Here we focus on supporting neurodivergent kids with science, not shame. You're not failing your child, you're learning how to understand them. And that matters. So let's keep going.