As a young child, decades before a diagnosis of autism, I remember wondering how other children made friends so easily, chattered happily, and made sense of their world. I, on the other hand, would stay quiet and alone, or wait for a glimpse of my older sister at the railings between the nursery and primary school. This led to internalised anxiety, stomach aches, and a need for solitude to recover from a noisy day.
I never spoke of these feelings, but I felt ashamed, as if I were somehow deficient and alien. Adults assumed I was a “quiet child” or “lacked confidence”. At age three, at the reception for my mother’s second wedding, the noise made me clench my teeth, and I bit through the rim of a drinking glass. As my mother checked that all the shards were gone from my mouth, I was told I was “seeking attention”. I was finally diagnosed with autism at age 46.
Now, a new study has shown that I was far from alone in internalising anxiety. Researchers at Seattle Pacific University have found that young autistic children internalise anxiety to a far greater extent than their typically developing peers. They studied 159 children aged three to seven years, including 61 with a diagnosis of autism, and their teachers.
Greater expectations lead to internalised anxiety symptoms
The research found that while all young children internalise anxiety symptoms to some extent, neurotypical children begin to cope better with these feelings as they reach the end of pre-school and start school, from age four to nine months.
However, autistic children internalise these feelings at an earlier age and continue to do so as they grow older. The researchers suspect this is due to increased structure and expectations during this transition period, when children are learning many new skills to prepare for school life. This developmental phase entails greater expectations for social interaction, new routines and more academic engagement.
It seems that while typically developing children can navigate this well, autistic children continue to internalise these anxieties as the demands of school life increase.
The researchers suggest that this is a crucial time for intervention and support to address these “unique challenges” during the early years.
They also point to other research that shows internalising symptoms of anxiety or depression can exacerbate their social and developmental difficulties, such as being bullied, difficulties making friends and lower self-esteem.
Autism and anxiety
The researchers say this highlights the (obvious) importance of early identification of these anxiety-induced behaviours, so targeted strategies to support the “emotional wellbeing and social adjustment” of autistic children to help them, as these pressures invariably increase as they progress through school.
The study relied on teachers’ assessments, emphasising the importance of teachers knowing what to look for and getting to know each child well. They should also maintain accurate records of each child’s social and emotional development to identify those who may warrant concern.
In a reception class of up to 30 children, where some are almost five and others barely four, this can be a challenge, given the developmental differences at this age. This is even more reason for Early Years teachers to have the training to understand how autism can manifest in young children and, in particular, when they may be internalising these feelings, or trying to “mask” as a strategy to fit in.
Support for autistic children with anxiety
The researchers emphasise the use of evidence-based interventions, a practice that England’s Department for Education is now working to advance by creating collections of good practice.
Organisations such as NASEN’s Whole School SEND also offer a growing range of free online training and interventions to help teachers develop strategies for supporting children with SEND or emerging symptoms of neurodivergence.
As the study alludes, without this support early enough, children may develop greater mental health struggles, including with school attendance. This certainly happened to me and many others who were not diagnosed until well after their school years.
Lack of intervention can lead to crisis
Not fitting in socially and being bullied for it are ever greater concerns, given the prevalence of smartphones, meaning the bullying doesn’t stop at the school gates. Often, it’s only when a young person reaches a crisis level that adults begin to ask whether something deeper is occurring.
The study’s limitations included that the children were verbal, mostly white, and relatively affluent. In addition, it didn’t include parental observations or how well the teachers knew the children. These are all potential areas for future research studies, particularly looking at what happens when parents who raise concerns about their child with class teachers are fobbed off with, “We don’t see that here,” (even if a child has an autism diagnosis).
This is despite the statutory SEND Code of Practice 2015 saying parental concerns should be listened to:
“All those who work with young children should be alert to emerging difficulties and respond early. In particular, parents know their children best and it is important that all practitioners listen and understand when parents express concerns about their child’s development. They should also listen to and address any concerns raised by children themselves.”
SEND Code of Practice 5.5
Missed diagnosis, lost potential
Although this study was limited to children with a diagnosis, physical manifestations of internalised anxiety, including depression, toilet phobia, tummy troubles, and reluctance to go to school, can be the first signs that something is amiss. However, these signs can be easily missed or misinterpreted.
Linking these symptoms to anxiety for a child who’s undiagnosed isn’t easy. That’s even more the case when you are not from a white, affluent background.
Research by Special Needs Jungle in 2022 into race and SEND shows how children and their parents from ethnic and marginalised communities can be misunderstood, mischaracterised, or dismissed through bias and a lack of understanding of cultural differences. This means a child may go unsupported, and as difficulties grow, the child can develop more severe mental health problems, school avoidance (written off as truancy), behavioural difficulties, and exclusion.
Further research in this area is vital to ensure that additional needs are not missed or misinterpreted and that a child’s potential is not lost.
Symptom subtlety means a lack of curiosity by schools
As the study focused on children diagnosed before the age of seven, there will likely be one or more in the class who will later go on to be diagnosed with autism. Therefore, it’s important for teachers to also consider subtle and new signs in children who are not diagnosed, but who may heretofore have been “successfully” internalising anxiety. Some children can be hiding a lot of worries until something happens that’s more than they can handle.
In the UK, the law states that a diagnosis isn’t required for support, but in some schools, it’s the first time any action is taken if a child is otherwise untroublesome. By then, the benefits of early intervention have long been missed.
In older autistic girls in particular, the signs can be very subtle as they are more likely to start to use “masking” to cope. Masking is common in autistic girls in an unfriendly world, employed to keep the emotional distress of internalised anxiety at bay.
This can mean it’s harder to see that they are internalising anxiety and worry, but may display it by avoiding social interactions, perfectionism, headaches and eating problems.
Masking and autistic girls
Girls, more than boys, learn to mimic what others do, although it may never come off as quite natural, leaving them more open to bullying. They may, on the surface—though at great cost to themselves—seem to be managing well until they get to Year 7 and beyond. Then, when the stresses of transition to secondary education and being in a much wider, more impersonal environment can trigger an explosion of anxiety, they can no longer hide.
When set out like this, it’s easy to see how the threads of early internalised anxiety can grow into mental health problems in secondary school. But when faced with a small child with a persistent tummy ache, anxiety isn’t the first thought.
Nevertheless, it still serves to raise awareness of how far back anxiety of children with ASD is rooted, and the importance of watching carefully to reduce the potential for developing a future anxiety-related or depressive disorder that persists into adulthood.
References
- Quinnett C, Drafton KM, Wilson BJ, et al. Internalizing Symptoms in 3- to 6-Year-Old Children With Autism Spectrum Disorder. Focus on Autism and Other Developmental Disabilities 2025, 40(4), 200-207. https://doi.org/10.1177/10883576251353507
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Tania Tirraoro, Co-Director, Special Needs Jungle
