Anxiety is one of the most common and impactful experiences reported by autistic people. Across the lifespan, studies report estimates of approximately 40% to 80% for elevated anxiety symptoms or anxiety disorders, although rates vary according to age, sample characteristics, measurement methods and whether research examines symptoms or formal diagnoses (Kent & Simonoff, 2017; Zaboski & Storch, 2018).
Persistent anxiety can affect education, employment, relationships, sleep, everyday participation and quality of life. Yet anxiety may not always be recognised accurately. Some autistic people do not describe distress primarily through words such as “worried”, “afraid” or “anxious”, and most measures may overlook other ways anxiety is experienced or communicated.
Cognitive behavioural therapy, usually abbreviated to CBT, is the most extensively researched psychological therapy for anxiety in autistic people. Evidence suggests that it can help some autistic people, particularly when adapted. However, it is not universally effective or automatically the best option for every highly anxious autistic person.
Some autistic people experience recognised anxiety disorders, including generalised anxiety disorder, social anxiety disorder, panic disorder, separation anxiety disorder and specific phobias. These conditions have established diagnostic criteria within classification systems such as the DSM-5-TR and ICD-11.
Some autistic people also experience obsessive-compulsive disorder, or OCD. Although anxiety is often central to OCD, the DSM-5-TR classifies it separately from anxiety disorders. Distinguishing OCD compulsions from autistic routines or repetitive behaviours requires attention to their meaning, function and relationship with distress.
In our clinical practice, we use the term autistic anxiety to describe anxiety closely connected to autistic neurology and lived experience, while recognising that it is not a formal diagnosis. This may include anxiety associated with:
Halim et al. (2018) found that autistic young adults described anxiety experiences that aligned with DSM criteria alongside experiences more closely connected to autism, including sensory distress and meltdowns or shutdowns. Their findings support considering both conventional anxiety symptoms and the autistic person’s broader experience of distress.
However, autistic anxiety remains a developing clinical concept rather than a separate, universally accepted diagnosis. Recognising what is contributing to the anxiety is important because CBT, or any psychotherapy, is unlikely to help if therapy targets the wrong source of distress.
Many anxiety experiences are shared by autistic and non-autistic people. However, some autistic people may communicate anxiety less through explicit descriptions of worry and more through bodily distress, changes in communication or functioning, increased reliance on predictability, withdrawal, repetitive behaviour, meltdowns or shutdowns. Hallett et al. (2013) found that parent-rated restlessness, tension and sleep difficulties were more commonly identified than verbally expressed worry among autistic children.
Research with autistic adults similarly suggests that the broad content of worry may be familiar, but its intensity and triggers can differ, with uncertainty and concerns about social missteps sometimes overlooked by standard measures (Black et al., 2024). Recognising these presentations matters because CBT is less likely to help when the therapist has not accurately identified what is driving the person’s anxiety.
CBT is a structured therapy that can help people recognise their signs of anxiety, understand connections among thoughts, emotions, bodily experiences and behaviour, develop coping strategies, and gradually approach feared situations when appropriate.
Research suggests that CBT can reduce anxiety for some autistic children and adolescents, although results vary according to how outcomes are measured and who reports them. Clinician ratings have generally shown larger improvements than parent ratings, while autistic young people’s self-reported improvements have often been smaller. Evidence about whether benefits continue after therapy is mixed (Sharma et al., 2021; Roberts & Rankin, 2025).
A systematic review found that some forms of CBT may reduce anxiety among autistic children and adults compared with no additional intervention. However, the included studies examined varied interventions, the certainty of the evidence was low or very low, and the researchers could not determine that one intervention or form of CBT was more effective than another (Linden et al., 2023). Potential harms and acceptability were also poorly reported, limiting conclusions about how often CBT may be unhelpful or distressing.
A recent adult-specific review reached a similar conclusion: CBT may reduce anxiety for some autistic adults, but the evidence remains too uncertain to draw firm conclusions (Perez-Castilla et al., 2026).
Overall, CBT is a promising option, particularly for some autistic children and adolescents, but the limited quality and comparative evidence does not establish it as the best therapy for every highly anxious autistic person.
Most autism-adapted CBT research has involved children and younger adolescents who use spoken language and do not have intellectual disability (Linden et al., 2023). Far less is known about its effectiveness for autistic adults, people with intellectual disability, minimally speaking people and those whose anxiety is communicated mainly through changes in behaviour or functioning. The smaller adult evidence base does not demonstrate that CBT is less effective in adulthood, only that fewer studies have included autistic adults.
CBT may also be less accessible when it depends heavily on verbal reasoning, emotional labelling or written monitoring. Difficulty describing internal experiences does not necessarily mean that someone is less anxious or unable to benefit from therapy. It may instead indicate that the assessment or therapy does not match how they communicate and process information.
CBT may suit some autistic people because it can be structured, explicit and practical, providing a predictable framework for understanding anxiety and developing strategies. It may be particularly helpful when it:
Emotional literacy does not need to be a prerequisite for CBT. It can be developed within therapy using words, visual scales, body maps, written communication or other methods that suit the person.
CBT is not the only psychological approach being explored for autistic people. Research has also examined mindfulness, acceptance and self-compassion-based approaches. Preliminary studies suggest that these approaches may improve stress, emotion regulation, wellbeing and, in some cases, anxiety symptoms among autistic adults, although the evidence remains limited and some participants have reported adverse experiences (Pahnke et al., 2023; Hartley et al., 2022; Cai et al., 2024).
In our clinical practice, autism-adapted CBT is not a fixed model. Depending on the person’s needs and goals, it may incorporate relevant principles from mindfulness, acceptance-based, and compassion-focused approaches.
To explore autistic anxiety in greater depth, including how it may present, the factors that can contribute to it and how to provide neurodiversity-affirming support, join our upcoming webcast, Autistic Anxiety, on 18 September 2026. The session will also examine anxiety and trauma in autism and ADHD, practical accommodations, and how to respond to meltdowns and shutdowns.
Black, M. H., Greenwood, D. L., Hwa, J. C. C., Pivac, J., Tang, J., & Clarke, P. J. (2024). What are you worried about? Content and extent of worry in autistic adults. Journal of Autism and Developmental Disorders, 54(5), 2040-2054.
Ru Ying Cai, Chris Edwards, Abigail M. A. Love, Lydia Brown, & Vicki Gibbs. (2024). Self-Compassion Improves Emotion Regulation and Mental Health Outcomes: A Pilot Study of an Online Self-Compassion Program for Autistic Adults. Autism: The International Journal of Research and Practice, 28(10), 2572–2585.
Halim, A.T., Richdale, A L., & Uljarević, M. (2018). Exploring the nature of anxiety in young adults on the autism spectrum: A qualitative study. Research in Autism Spectrum Disorders, 55, 25–37. doi: 10.1016/j.rasd.2018.07.006
Hallett, V., Lecavalier, L., Sukhodolsky, D.G. et al. Exploring the Manifestations of Anxiety in Children with Autism Spectrum Disorders. J Autism Dev Disord 43, 2341–2352 (2013).
Hartley, M., Due, C., & Dorstyn, D. (2022). Barriers and facilitators to engaging individuals and families with autism spectrum disorder in mindfulness and acceptance-based therapies: a meta-synthesis. Disability and Rehabilitation, 44(17), 4590-4601.
Kent, R., & Simonoff, E. (2017). Prevalence of anxiety in autism spectrum disorders. In C. M. Kerns, P. Renno, E. A. Storch, P. C. Kendall, & J. J. Wood (Eds.), Anxiety in children and adolescents with autism spectrum disorder (pp. 5–32). Academic Press. https://doi.org/10.1016/B978 0-12-805122-1.00002-8
Linden A, Best L, Elise F, Roberts D, Branagan A, Tay YBE, Crane L, Cusack J, Davidson B, Davidson I, Hearst C, Mandy W, Rai D, Smith E, Gurusamy K. Benefits and harms of interventions to improve anxiety, depression, and other mental health outcomes for autistic people: A systematic review and network meta-analysis of randomised controlled trials. Autism. 2023 Jan;27(1):7-30. doi: 10.1177/13623613221117931. Epub 2022 Aug 11. PMID: 35957523; PMCID: PMC9806485.
Pahnke, J., Jansson-Fröjmark, M., Andersson, G., Bjureberg, J., Jokinen, J., Bohman, B., & Lundgren, T. (2023). Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting. Autism, 27(5), 1461-1476.
Perez-Castilla, J., Contreras-Pizarro, C. H., Valdivieso-Jiménez, G., Munoz-Figueroa, A., Sifuentes Montalvo, A. V., Taype-Rondan, A., & Brañez-Condorena, A. (2026). Effects of Cognitive Behavioral Therapy in Autistic Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Autism in Adulthood.
Roberts, K., & Rankin, P. M. (2025). A cognitive help or hindrance? A systematic review of cognitive behavioural therapy to treat anxiety in young people with autism spectrum disorder. Clinical Child Psychology and Psychiatry, 30(2), 419-435.
Sharma, S., Hucker, A., Matthews, T. et al. Cognitive behavioural therapy for anxiety in children and young people on the autism spectrum: a systematic review and meta-analysis. BMC Psychol 9, 151 (2021).
Zaboski, B. A., & Storch, E. A. (2018). Comorbid Autism Spectrum Disorder and Anxiety Disorders: A Brief Review. Future Neurology, 13(1), 31–37. https://doi.org/10.2217/fnl-2017-0030
