Associations Between Symptoms of Autism and Emotional and Behavioral Problems in Children With Autism Spectrum Disorder

Children with ASD show two core symptom domains: deficits in social interaction/communication and restricted, repetitive behaviors. Beyond these, they often exhibit elevated emotional and behavioral problems (EBPs) such as anxiety, depression, hyperactivity/inattention, and aggression. Prior studies have reported mixed findings regarding how autism symptom severity relates to emotional symptoms, while associations with behavioral problems are more consistently positive. Two gaps motivated this study: (1) broad or narrow age ranges in prior work limit developmental specificity; and (2) few studies simultaneously compare clinician- versus caregiver-based assessments of autism symptoms, which may yield different perspectives and associations. The study therefore examined, in children aged 3–12 years (analyzed as preschool and school-aged groups), how clinician-rated (CARS) and caregiver-rated (SRS-2) autism symptom dimensions relate to EBPs (SDQ).

Evidence on autism symptoms and emotional symptoms is inconsistent. Some studies (e.g., Lindsey et al., n=129, ages 4–10) found ASD symptom severity positively correlated with internalizing and externalizing at multiple time points. Others reported that greater ASD severity was associated with fewer anxiety/depression symptoms (Mazurek & Kanne, n=1,202) or that less social impairment and higher cognition related to more depressive symptoms (Sterling et al.). Several studies (Kim et al.; Strang et al.) found no significant associations between ASD symptoms and depressive symptoms, suggesting more research is needed. In contrast, links between autism symptoms and behavioral problems are consistently positive: repetitive/restrictive behaviors relate to challenging behavior and aggression (Matson; Jang; Kanne et al., n=1,380), and ASD increases odds of hyperactivity, conduct problems, and emotional symptoms even after controlling for confounders (Totsika et al.). Methodological issues include heterogeneous age ranges and reliance on single-perspective assessments (either clinician- or caregiver-reported), with only a few studies incorporating both perspectives, which may explain discrepant findings.

Design: Cross-sectional, multicenter study examining associations between autism symptoms and emotional/behavioral problems in children with ASD, analyzed separately for preschool (3–6 years) and school-aged (7–12 years) groups. Participants: 108 children with ASD recruited from five hospitals and pediatric rehabilitation clinics in Taiwan: 58 preschool (mean age 65.67 months, SD 12.49) and 50 school-aged (mean age 99.28 months, SD 21.54); male 84.5% and 90.0% respectively. Caregivers unable to communicate in Mandarin or read Chinese were excluded. Measures: - Childhood Autism Rating Scale (CARS): 15-item clinician-administered measure (4-point scale). Chinese version Cronbach’s alpha 0.735; items correlate 0.569–0.935 with total. ASD cutoffs: 30 if IQ<80; 25.5 if IQ≥80. Two-factor model used: (1) social communication and interaction; (2) restricted and repetitive behaviors (RRB). Subscale sums used. - Social Responsiveness Scale, Second Edition (SRS-2), Chinese version (caregiver report, school-age version, 65 items). Four-factor structure: general features, autistic mannerisms, social awareness, social emotion. Good test–retest reliability (ICC 0.75–0.85) and internal consistency (α 0.94–0.95). - Strengths and Difficulties Questionnaire (SDQ), Chinese version: five domains (emotional symptoms, hyperactivity/inattention, conduct problems, peer problems, prosocial). Reliability ICC 0.71–0.85; internal consistency α 0.40–0.86; good validity. - Cognitive: Verbal Comprehension Index (VCI) from WPPSI-IV or WISC-IV as IQ proxy; used to determine CARS cutoff and as covariate. Procedures: Clinician conducted semi-structured caregiver interview and observation to administer CARS; child assessed for VCI; caregivers completed demographics, SDQ, and SRS-2 concurrently. Missing data were followed up by phone. Statistical analysis: Descriptive statistics; Pearson correlations among CARS and SRS-2 subscales and between SDQ subscales and autism measures, computed separately for preschool and school-aged groups. Multiple stepwise regressions predicted each SDQ subscale from age, sex, VCI, and autism subscales (CARS or SRS-2), analyzed separately by measure and age group. Due to high collinearity between SRS-2 general features and autistic mannerisms (r≈0.92), only general features was entered among these two. Alpha=0.05; SPSS 18.0 used. Ethics: Approved by IRBs of Kaohsiung Municipal Kai-Syuan Psychiatric Hospital and Chi-Mei Hospital; informed consent obtained; procedures followed relevant guidelines.

Sample: N=108 (preschool n=58; school-aged n=50). CARS total: preschool mean 29.40 (SD 3.34), school-aged mean 31.12 (SD 3.76). SRS-2 total: preschool mean 88.12 (SD 24.10), school-aged mean 95.10 (SD 28.15). SDQ total difficulties: preschool mean 18.55 (SD 5.32), school-aged mean 18.68 (SD 6.16). Correlations within autism measures: - CARS subscales moderately correlated (r=0.36 preschool; r=0.55 school-aged). - SRS-2: general features strongly correlated with autistic mannerisms (r=0.90 preschool; r=0.93 school-aged); both correlated strongly with social emotion (r=0.77–0.79) and weakly to moderately with social awareness (r=0.13 preschool; r=0.47 school-aged). Associations between autism symptoms and EBPs (SDQ): - Clinician perspective (CARS): Social interaction showed no significant associations with SDQ subscales, except a correlation with hyperactivity/inattention in school-aged (r=0.56). Restricted and repetitive behaviors correlated with hyperactivity/inattention (r=0.42 preschool; r=0.31 school-aged) and peer problems (r=0.26; r=0.28). - Caregiver perspective (SRS-2): General features and autistic mannerisms correlated with emotional symptoms (r=0.26–0.46), hyperactivity/inattention (r=0.43–0.53), and peer problems (r=0.41–0.62) in both groups; also with conduct problems in school-aged (r=0.32–0.34). Social awareness correlated with hyperactivity/inattention (r=0.34 preschool; r=0.53 school-aged), prosocial behaviors (r=−0.32 preschool), and with most SDQ subscales in school-aged (r from −0.42 to 0.53). Social emotion correlated with emotional symptoms (r=0.40–0.61), hyperactivity/inattention (r=0.36–0.42), peer problems (r=0.32–0.43), and conduct problems in school-aged (r=0.37). Regression (controlling age, sex, VCI): - CARS: Only hyperactivity/inattention was significantly predicted by restricted and repetitive behaviors (β=0.45 preschool; β=0.54 school-aged). CARS social interaction was not a significant predictor. - SRS-2: Emotional symptoms predicted by social emotion (β=0.53 preschool; β=0.55 school-aged). Conduct problems model was significant but only VCI contributed; no SRS-2 subscale predictors. Hyperactivity/inattention predicted by general features (β=0.61) and social awareness (β=0.27) in preschool; by social awareness (β=0.50) in school-aged. Peer problems predicted by general features (β=0.84 preschool; β=0.54 school-aged) and by social emotion in preschool (β=−0.40). Prosocial behaviors had no significant models. Overall patterns: Similar across age groups; clinician- and caregiver-based assessments yielded different association patterns; specific autism symptoms linked to specific EBPs (e.g., RRBs with hyperactivity/inattention; social emotion with emotional symptoms; general features with peer problems).

Findings address the research question by demonstrating that associations between autism symptom domains and EBPs depend on both developmental stage and the perspective of assessment. Clinician-rated CARS emphasized restricted and repetitive behaviors as the key correlate of hyperactivity/inattention, aligning with literature linking RRBs to externalizing behaviors. Caregiver-rated SRS-2 revealed broader associations: social emotion captured emotional aspects of social behavior predicting emotional symptoms, general autistic features predicted peer relationship problems, and social awareness related to hyperactivity/inattention, consistent with known ASD–ADHD overlap. The divergent patterns between clinician and caregiver measures highlight that different tools and perspectives capture distinct aspects of symptomatology, which has practical implications for assessment and intervention planning. Results suggest targeted interventions: managing RRBs may help reduce hyperactivity/inattention; addressing social-emotional skills may mitigate emotional symptoms; and broader autistic features relate to peer difficulties, suggesting social skills and peer interaction supports are needed.

This study showed that in children with ASD, associations between autism symptoms and emotional/behavioral problems are broadly similar across preschool and school-aged groups but differ by assessment perspective. Clinician-rated restricted and repetitive behaviors were specifically linked to hyperactivity/inattention, while caregiver-rated social emotion predicted emotional symptoms and general autistic features predicted peer problems. These insights can guide tailored intervention planning that targets specific EBPs associated with particular autism symptom dimensions. Future research should employ more comprehensive diagnostic and behavioral assessments, include children with a broader range of ASD severity, and use longitudinal designs to clarify causal relationships.

Measures prioritized brevity and ease of administration (SDQ, CARS, SRS-2, VCI only), limiting depth compared to comprehensive instruments (e.g., CBCL, ADOS/ADI-R, full-scale IQ). The sample largely comprised children with mild to moderate ASD, limiting generalizability to severe ASD. Cross-sectional design precludes causal inferences; longitudinal studies are needed.