Children with ASD exhibit deficits in social interaction and communication, and restricted and repetitive behaviors. Epidemiological studies reveal a high prevalence of EBPs, including anxiety, depression, hyperactivity, inattention, and aggression, in this population. Understanding the specific associations between autism symptoms and EBPs is crucial for effective intervention planning. While some studies have explored these relationships, results concerning the effects of autism symptoms on emotional symptoms have been inconsistent, with some finding positive correlations, others showing no association, and some even finding a negative correlation between autism severity and anxiety/depression. In contrast, the association between autism symptoms and behavioral problems has been consistently positive. However, existing research has limitations: broad or narrow age ranges hinder the understanding of developmental stage-specific associations, and few studies have considered both professional and caregiver perspectives, which might lead to different perceptions of symptom severity and associations with EBPs. This study addresses these gaps by focusing on children aged 3–12 years (divided into preschool and school-aged groups) and employing assessments from both professional (Childhood Autism Rating Scale, CARS) and caregiver (Social Responsiveness Scale, SRS-2) perspectives.

Previous research investigating the relationship between autism symptoms and emotional and behavioral problems in children with ASD has yielded mixed results. Studies on the link between autism symptom severity and emotional symptoms like depression and anxiety have shown inconsistencies, with some reporting positive correlations, others showing no significant associations, and some even suggesting negative correlations. In contrast, studies consistently found positive associations between autism symptom severity and behavioral problems, such as challenging behaviors, aggression, and hyperactivity. However, methodological limitations, including broad or narrow age ranges and reliance on a single perspective (either professional or caregiver), have hindered a comprehensive understanding of these associations. The inconsistent findings highlight the need for further research employing more rigorous methodologies and considering multiple perspectives.

This study recruited 108 children with ASD (58 preschool, 50 school-aged) from five hospitals and pediatric rehabilitation clinics in Taiwan. Inclusion criteria were a diagnosis of ASD and age between 3 and 12 years. Caregivers who could not communicate in Mandarin or read Chinese were excluded. Autism symptoms were assessed using the CARS (clinician perspective) and the SRS-2 (caregiver perspective). EBPs were assessed using the Strengths and Difficulties Questionnaire (SDQ). The CARS uses a 15-item scale rated on a 4-point scale; in this study, a two-cut-off points were adopted to identify ASD, using 30 for children with IQs below 80 and 25.5 for children with IQs of 80 or higher. The SRS-2, a 65-item caregiver-report measure, assesses social functioning, and this study used its four-factor structure: general features, autistic mannerisms, social awareness, and social emotion. The SDQ assesses emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behaviors. Descriptive analyses characterized participant demographics, autism symptoms, and EBPs. Pearson correlations examined correlations within and between the CARS, SRS-2, and SDQ. Multiple stepwise regression models examined the effects of autism symptoms (CARS and SRS-2 subscales) on EBPs (SDQ subscales), controlling for age, gender, and verbal comprehension index (VCI). All analyses used SPSS 18.0 and significance was set at α = 0.05.

The study revealed three main findings. First, similar correlation patterns between autism symptoms and EBPs were observed in both preschool and school-aged children. Second, clinician and caregiver perspectives yielded different association patterns. Clinicians primarily linked repetitive behaviors to hyperactivity and inattention, while caregivers linked all autism symptoms to a wider range of EBPs. Third, different autism symptoms showed distinct associations with different EBPs. Specifically, the CARS subscale of social interaction showed no significant association with any SDQ subscale except hyperactivity and inattention in the school-aged group. The CARS subscale of restricted and repetitive behaviors was associated with hyperactivity and inattention and peer relationship problems. Analysis of the SRS-2 revealed that general features and autistic mannerisms were associated with emotional symptoms, hyperactivity/inattention, and peer relationship problems. Social awareness showed variable associations across age groups. Social emotion was consistently linked to emotional symptoms, hyperactivity/inattention, and peer relationship problems. Regression analysis showed that restricted and repetitive behaviors were positively associated with hyperactivity and inattention. Social emotion significantly predicted emotional symptoms. General features (from SRS-2) were associated with hyperactivity, inattention, and peer relationship problems, and social awareness was also significantly associated with hyperactivity and inattention. In the regression models, the association between social emotion and peer problems was negative while the correlation was positive, highlighting the need for caution in interpreting complex associations.

The findings highlight the importance of considering both professional and caregiver perspectives when assessing autism symptoms and their associations with EBPs. The discrepancy in perceived associations may stem from differing observational contexts and focuses. Clinicians’ assessments might concentrate on observable behaviors during brief encounters, whereas caregivers have more extensive exposure to the child’s behavior across various settings, leading to a broader perception of associated problems. The study's results align with previous research indicating the connection between repetitive behaviors and hyperactivity, and the overlap between ASD and ADHD. The strong association between social emotion and emotional symptoms suggests the importance of targeting emotional regulation skills in interventions. The association between general features of autism and peer problems indicates challenges in social interaction and communication impacting peer relationships. The study also emphasizes the influence of different autism symptom domains on specific EBPs, informing targeted interventions.

This study demonstrates that different assessment methods and perspectives (clinician vs. caregiver) reveal distinct associations between autism symptoms and EBPs in children with ASD. These findings underscore the need for a comprehensive approach to assessment, incorporating multiple informants and focusing on specific symptom domains to develop targeted interventions. Future research employing longitudinal designs and more comprehensive assessment tools could further clarify causal relationships and refine intervention strategies.

This study has several limitations. The use of relatively brief assessment tools (SDQ, CARS) may have limited the depth of EBP and autism symptom assessment. The sample predominantly comprised children with mild to moderate ASD, limiting generalizability to children with severe ASD. The cross-sectional design prevented the establishment of causal relationships between autism symptoms and EBPs. Future research should address these limitations by employing more comprehensive assessment tools, including a wider range of ASD severity, and longitudinal designs to establish causality.