From risk to resilience: a narrative overview of modifiable factors influencing anxiety in children with autism spectrum disorder (part II)

Abstract

Background Anxiety disorders are highly prevalent in children and adolescents with Autism Spectrum Disorder (ASD) and contribute substantially to functional impairment and reduced quality of life (QoL). Objective This paper represents the second part of a two-part narrative overview addressing internalizing symptoms in ASD. Complementing the first paper focused on depression, the present work examines anxiety, emphasizing shared and distinct modifiable risk and protective factors within a unified conceptual framework. Methods A structured narrative overview was conducted, synthesizing evidence from systematic reviews, meta-analyses, and robust clinical studies. Studies were selected based on relevance and scientific rigor, and findings were organized across biological, psychological, and environmental domains. Results Anxiety in ASD is associated with multiple interacting factors, including sensory hypersensitivity, intolerance of uncertainty (IU), social challenges, and neurobiological vulnerability. Protective factors such as cognitive-behavioral therapy (CBT), structured physical activity, and supportive environments may mitigate anxiety symptoms and promote adaptive functioning. Nevertheless, variability in study design and population characteristics limits generalizability. Conclusions Addressing anxiety in ASD requires a comprehensive, multidisciplinary strategy that integrates risk reduction with resilience-building interventions. Together with the first part of this overview, these findings support transdiagnostic and personalized approach to mental health in children and adolescents.