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

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.