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ORIGINAL RESEARCH

Relationship Among Sensory Over-Responsivity,

Problem Behaviors, and Anxiety in Emerging
Adults with Autism Spectrum Disorder
This article was published in the following Dove Press journal:
Neuropsychiatric Disease and Treatment

Ya-Cing Syu 1 Introduction: Despite the highly prevailing rate of sensory over-responsivity, problem
Pai-Chuan Huang 1 behaviors, and anxiety among emerging adults with autism spectrum disorder (ASD), little
Tsui-Ying Wang 1 is known about the nature of their experiences. While previous studies have indicated
Yen-Ching Chang 1 potential relationships among these conditions, their connections still need to be clarified.
This study aimed to examine the relationships between sensory over-responsivity, problem
Ling-Yi Lin 1,2
behaviors, and anxiety.
1
Department of Occupational Therapy, Methods: Fifty-seven emerging adults with ASD (Mage = 21.4, SD = 2.5; males = 80.7%)
College of Medicine, National Cheng
Kung University, Tainan, Taiwan; 2Institute were recruited. The Adult Sensory Profile – Chinese version, Problem Behavior Scale of
of Allied Health Sciences, College of Scales of Independent Behavior – Revised, and Generalized Anxiety Disorder-7 – Chinese
Medicine, National Cheng Kung
version (GAD-7) were used.
University, Tainan, Taiwan
Results: The percentage of emerging adults with ASD who scored more than most people in
the two quadrants were sensation sensitivity = 33.3% and sensation avoiding = 26.3%.
Approximately 66.7%, 27.5%, and 50.9% of participants had internalizing behaviors, exter­
nalizing behaviors, and asocial behaviors, respectively. Approximately, 64.9% of the parti­
cipants scored on or above the cut-off score of 6 on the GAD-7. Sensation sensitivity and
sensation avoiding were significantly correlated to problem behaviors; and anxiety was
a mediating variable that accounts for the relationships between sensory over-responsivity
and problem behaviors.
Conclusion: These results indicated that emerging adults with ASD showing problem
behaviors might also report more exaggerated responses toward sensory inputs and experi­
ence more anxiety symptoms. The results indicate that sensory over-responsivity, problem
behaviors, and anxiety may have common underlying mechanisms. Findings can be useful to
understand the impacts of such difficulties for emerging adults with ASD.
Keywords: autism spectrum disorder, sensory over-responsivity, anxiety, problem behaviors

Introduction
Autism spectrum disorder (ASD) is a lifelong developmental disability that often
presents persistent deficits in social communication and interaction problems,
restricted or repetitive patterns of behavior and interests, and hyper- or hypo-
reactivity to sensory input or unusual interests.1 A growing number of children
diagnosed with ASD are aging into adolescence and toward adulthood. The transi­
Correspondence: Ling-Yi Lin tion from adolescence to adulthood is a critical stage in which youth experience
Tel +886-6-235-3535 ext. 5917 changes in contextual and social roles, begin to take responsibility for their own
Fax +886-6-237-6604
Email [email protected] choices, and learn and train for their occupation of choice. Research for adults with

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http://doi.org/10.2147/NDT.S270308
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ASD is urgently warranted at the beginning of adulthood.2 over-responsivity is common in individuals with ASD and
Emerging adulthood (ages 18–25 years) is a period is linked to sleep problems, lower levels of social skills
wherein youth may pursue further education, prepare to and adaptive behaviors, and increased anxiety; moreover,
enter the workforce, participate in the community, or when combined with anxiety, it predicts an increasing
achieve a certain degree of independent living based on level of gastrointestinal problems.18–21 Among the few
their level of functioning.3 Considering the cultural differ­ studies that included adults with ASD, the results have
ences between Western and Eastern societies, evidence shown that sensory over-responsivity persists into
suggests that Chinese emerging adults may feel more adulthood.22–24 Sensory over-responsivity can affect an
obligated or responsible to their families and the society.4 individual’s emotional states, education participation,
Nevertheless, the core characteristics of ASD could greatly social life, and work performance.22,23 Previous studies
impact several aspects of their lives, including the ability have also suggested that over-responsiveness to sensory
to relate to things, events, and people. Emerging adults stimuli may negatively impact on psychological well-
with ASD often face the responsibility of making their being in children.18,19,21,25 However, little is known
own decisions while not completely understanding their regarding this issue in emerging adults with ASD, thus
abilities or challenges, and they often feel alienated from indicating the need for further investigation.
their peer group.5 Clinical experiences suggest that pro­ Sensory over-responsivity might correlate with pro­
blem behaviors and sensory over-responsivity are highly blem behaviors. However, thus far, only three studies
prevalent in individuals with ASD.6 These behaviors are have examined the relationship between sensory proces­
barriers to employment, residential living, social opportu­ sing dysfunction, emotion, and behavior problems in chil­
nity, and community-based services.7 dren with ASD. Tseng et al26 found that sensation
Problem behaviors (or maladaptive behaviors) are avoiding and sensory sensitivity were significantly asso­
behaviors that interfere with everyday activities, including ciated with internalizing and externalizing problem beha­
self-injurious behavior, withdrawal, uncooperative beha­ viors in 67 children with ASD aged 48–84 months.
vior, aggression, disruptive behavior, and destruction of O’Donnell et al27 found that preschool children had higher
property.8 Problem behaviors have been widely documen­ levels of sensory processing difficulties are more likely to
ted in studies on individuals with ASD and include a range present problem behaviors, including irritability, lethargy,
of emotional and behavior problems including internaliz­ stereotypic behaviors, hyperactivity/noncompliance, and
ing and externalizing behaviors.8–10 In a longitudinal study inappropriate speech. Similarly, Dellapiazza et al28 found
that was conducted for 24 years, the negative effects of that irritability is related to avoiding-sensation behaviors,
problem behaviors persisted when not treated and were while hyperactivity/noncompliance is related to seeking-
associated with poor adult outcomes.11 Recent longitudinal sensation behaviors and sensory-sensitivity behaviors.
autism research has observed an overall decline in problem Atypical sensory processing also explains a significant
behaviors over time among adults with ASD.8,12,13 part of the variance of problem behaviors (from 16% to
However, several studies have shown a high prevalence 39%) after controlling age and IQ. The results indicated
rate and high symptom stability of problem behaviors in that children with ASD having higher levels of sensory
adolescences and adults with ASD.12,13 In addition, pro­ processing difficulties were more likely to present with
blem behaviors are associated with vocational indepen­ problem behaviors, including irritability, lethargy, stereo­
dence and activities of daily living, lower feelings of typic behaviors, hyperactivity, and inappropriate speech.
parent–child closeness, and a decreased sense of Yet, none has considered the relationship between sensory
autonomy.14,15 over-responsivity and problem behaviors in adults
Sensory processing refers to the ability to manage the with ASD.
sensory information received from the surroundings and Anxiety is another co-occurring condition that has been
from the body.16,17 Sensory over-responsivity is a sensory proposed as being relevant to both problem behaviors and
processing difficulty, which implies exaggerated or nega­ sensory over-responsivity. According to a review regard­
tive responses to sensory stimuli.18 Sensory over- ing the comorbid psychiatric symptoms of ASD, anxiety
responsivity reflects two behavior patterns according to disorders are the most detected disorders in individuals
Dunn’s model: sensation sensitivity and sensation with ASD, with the rates of 5–35% generalized anxiety
avoiding.16,17 Some research findings suggest that sensory reported in previous studies.29 Studies have shown that

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individuals with ASD who have higher levels of anxiety Participants

symptoms will also experience greater levels of difficulty Fifty-seven adults with ASD (46 males/11 females) aged
with over-responsivity.18,19,21,30 However, the reviewed between 18 and 25 enrolled in the present study, giving
studies were limited because they (a) examined in children a mean age of 21.4 years. All participants reported that
or adolescents with ASD but not in adults, and (b) used they were diagnosed with ASD by a registered psychia­
different measurements for anxiety which may cover sev­ trist according to the Diagnostic and Statistical Manual
eral types of anxiety disorders, such as generalized anxi­ V (DSM-5) criteria.1 The severity levels the psychiatrist
ety, separation anxiety, or social anxiety. Compared to assigns depend on the severity of the symptoms and the
children with ASD who reported lower scores on anxiety, levels of support. A diagnosis on the autism spectrum
children with ASD with more severe anxiety and mood was confirmed with a disability identification card. The
problems had more aggressive behaviors.31 Storch et al32 disability identification card was issued by a health and
found that children and adolescents with ASD who had co- welfare agency of the Taiwanese government after pro­
occurring behavior problems experienced higher levels of cesses of evaluation and assessment by the committee
anxiety than youth with anxiety and ASD alone. In the few composed of professionals from medicine, social work,
studies that have been conducted, youth with ASD demon­ special education and employment counseling.
strated higher levels of anxiety also have more disruptive Participants with moderate and severe intellectual dis­
behaviors and are more likely to use antipsychotic ability were excluded. Nine participants had an intelli­
medication.31,32 Though clinical experiences show that gence quotient between 53 and 69 (mild intellectual
individuals with ASD often exhibit both anxiety and pro­ disability), three participants had an intelligence quoti­
blem behaviors, the relationship has rarely been studied in ent between 73 and 85 (borderline intellectual function­
adults. ing), and 45 participants had an intelligence quotient
Given the high prevalence of problem behaviors, anxi­ between 86 and 150. Table 1 provides sample character­
ety, and sensory over-responsivity, it thereby highlights the istics of the participants with ASD.
need for further research on the relationships among pro­
blem behaviors, sensory processing, and anxiety in emer­ Measurements
ging adults with ASD. Regarding the core symptoms of Demographic Information
ASD, a change in the physical and social environments Caregivers of participants with ASD provided background
may relate to anxiety, resulting in the emergence of pro­ information, including age, gender, medical history (eg,
blem behaviors. Despite the importance of understanding diagnosis, comorbid psychiatric conditions, psychiatric
the potential relationships among these factors in emerging medication, disability identification card), residential liv­
adults with ASD, no study has addressed these issues. ing, access to spoken language (formulate echolalia,
Thus, the present study aimed to explore the relationships words, phrases, sentences), the intellectual quotient, edu­
between sensory over-responsivity, problem behaviors, cational level, occupational status.
and anxiety in emerging adults with ASD. We, therefore,
tested the following hypotheses: (1) Sensation sensitivity Adult Sensory Profile – Chinese Version (ASP)
and sensation avoiding are associated with problem beha­ The ASP is a 60-item questionnaire, which assesses beha­
viors in emerging adults with ASD, (2) sensation sensitiv­ vior response to sensory processing experience in every­
ity and sensation avoiding are associated with anxiety, and day life.33 The scale is designed for adolescents and adults
(3) anxiety is associated with problem behaviors. aged 11 to 65 years. The questionnaire is based on Dunn’s
sensory processing theory, which addresses neurological
thresholds and behavioral responses. The scale consists of
Materials and Methods four quadrants: sensation sensitivity (shows over-response
Ethics Statement reactions with sensation but does not actively avoid them),
The study protocol has been proved by the Institutional sensation avoiding (engages in behaviors of avoidance or
Review Board of National Cheng Kung University reduces everyday sensory events), low registration (fails to
Hospital (B-ER-107-076) and followed the Declaration notice sensory stimuli and may act indifferent to the sur­
of Helsinki Ethical Principles for Medical Research roundings), and sensation seeking (actively seeks or craves
Involving Human Subjects. sensory stimuli). The scale uses a 5-point scale to rate the

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Table 1 Sample Characteristics (n = 57) The Problem Behavior Scale of Scales of Independent
Characteristics Mean ± SD or Behavior – Revised (SIB-R)
n (%) The SIB-R evaluates the level of functioning in main behavior
areas across settings, such as the home, school, workplace, and
Gender
Male 46 (80.7%) community.35 The scale contains 14 areas of adaptive behavior
Female 11 (19.3%) and eight areas of problem behavior. To fit the study purpose,
the present study used only the problem behavior scale to
Age (years), mean ± SD 21.4 ± 2.5
measure the frequency and severity of participants’ problem
Severity levels of autism according to Disability behavior over 6 months. The scale consists of eight problem
Identification Card
behaviors, which are divided into three domains: internalizing
Mild (require support) 38 (66.7%)
Moderate (require substantial support) 15 (26.3%)
(eg, self-injury, stereotyped, withdrawn), externalizing (eg,
Severe (require very substantial support) 4 (7.0%) disruptive, destructive, hurts others), and asocial (eg, socially
offensive, uncooperative). The SIB-R uses a scale of 1 to 5 to
Educational level
determine the level of severity of the problem behaviors, ran­
High school and below 33 (57.9%)
College and above 24 (42.1%) ging from 1 (“not a problem”) to 5 (“a critical problem”). The
frequency of problem behaviors was assessed using a 5-point
Occupational role
scale, ranging from 1 (“never”) to 5 (“1 or more times
Student 18 (31.6%)
Employee 14 (24.5%) an hour”). The raw scores were converted into standard scores
Unemployed 25 (43.9%) and maladaptive index scores. Standard scores with a mean of
100 and a standard deviation of 15 were utilized; higher scores
Comorbid psychiatric diagnosis
Mild intellectual disability 6 (10.5%)
imply a more severe problem behavior.35 The Taiwanese ver­
Attention deficit hyperactivity disorder 18 (31.6%) sion of the SIB-R shows a good test–retest reliability
Anxiety disorders 12 (21.1%) (Cronbach’s alpha = 0.70), compared to the test–retest relia­
Depressive disorder 9 (15.8%) bility of the English version, which is 0.80.35,36 Alpha relia­
Bipolar disorder 5 (8.8%) bility was 0.79 for the sample in the present study, indicating an
Schizophrenia 2 (3.5%)
acceptable internal consistency.
Taking medicine 24 (42.1%)

Residence
Generalized Anxiety Disorder-7 – Chinese Version
Living with families 49 (86.0%)
(GAD-7)
Living alone 3 (5.3%) The GAD-7 measures the frequency of seven symptoms of
Living in dormitory 5 (8.8%) anxiety by asking participants to rate how often they have been
bothered by the symptoms in the last 2 weeks on a 4-point scale
ranging from 0 (“not at all”) to 3 (“nearly every day”).37 The
frequency of the sensory experience, ranging from 1 higher the sum score of the scale, the higher the level of
(“almost never”) to 5 (“almost always”), leading to anxiety. On the Taiwanese version of GAD-7, a cut-off score
a total score for each quadrant of 15 to 75; higher scores of 9 is used to determine a possible clinically significant con­
indicate a higher frequency of certain sensory processing dition of anxiety. The Chinese version of GAD-7 shows good
patterns. The study used the quadrants of sensation sensi­ reliability (Cronbach’s alpha = 0.89).38 Alpha reliability was
tivity and sensation avoiding. The cut-off scores that are 0.95 for the sample in the present study, indicating an excellent
similar to most people in the two quadrants are sensation internal consistency.
sensitivity (31–45) and sensation avoiding (33–47) based
on the Taiwanese norms of the test.34 Scores above the Procedure
cut-off scores would be categorized as more than most The principal investigator contacted and posted the advertise­
people. The internal consistency of the four quadrants is ment via Facebook Groups, Foundations or Associations for
between 0.71 and 0.80, indicating acceptable internal con­ Individuals with ASD, Resource Classrooms of Universities,
sistency of the Chinese version of the ASP.34 Alpha relia­ and the hospitals. Data were collected using printed question­
bility was 0.93 for the sample in the present study, naires and Google Online Forms. A written consent informa­
indicating an excellent internal consistency. tion was presented to the participants before they begin the

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questionnaires. After the participants have read the consent off value of 100. Approximately 57.9%, 66.7%, 27.5%,
information and agree to participate, they filled in the informed and 50.9% of participants scored above 100 for overall
consent online. Then, they would be directed to the research problem behaviors, internalizing behaviors, externalizing
questionnaires. The participants who have voluntarily agreed behaviors, and asocial behaviors, respectively. Regarding
to participate in this study were asked to complete the demo­ the types of problem behaviors experienced, 28.1% had no
graphic information, the problem behavior scale of the ASP, specific problem behaviors, 24.6% had at least one type,
the SIB-R, and the GAD-7. Completing the questionnaires 31.6% had at least two types, and 15.8% had all three
took approximately 20 to 25 minutes on average. specific types. The mean score of the GAD-7 was 8.9
(6.7), and approximately 64.9% (n = 37) of the participants
Data Analysis scored on or above the cut-off score of 6 on the GAD-7.
Data were analyzed using the IBM SPSS 22.0, with two-tailed Table 3 presents the Pearson correlation coefficients
p < 0.05 to identify statistically significant coefficients. between the two sensory quadrants and problem behaviors.
Descriptive statistics were examined to ensure the basic prop­ Sensation sensitivity was found to correlate significantly with
erties of the demographic data. Pearson correlations were used sensation avoiding (r = 0.737, p < 0.001), overall problem
to clarify the relationships between the outcome variables. behaviors (r = 0.380, p = 0.004), internalizing behaviors (r =
Multivariate regression analysis was computed to identify sig­ 0.360, p = 0.006), and asocial behaviors (r = 0.390, p = 0.003).
nificant relationships among all variables. Sensation avoiding was found to significantly correlate with
overall problem behaviors (r = 0.356, p = 0.007), externalizing
Results behaviors (r = 0.270, p = 0.042), and asocial behaviors (r =
Table 2 shows the scores for the sensory over-responsivity, 0.366, p = 0.005). Given that higher sensory quadrants scores
problem behaviors, and anxiety levels of the participants. indicate greater levels of difficulty with over-responsivity, this
The mean scores (standard deviation [SD]) of the two positive correlation supported our first hypothesis.
sensory quadrants were sensation sensitivity = 41.4 (9.8) Pearson’s correlations were conducted to investigate the
and sensation avoiding = 42.1 (11.8), which were similar relationship between the two sensory quadrants and anxiety.
to most people from a large normative sample of the Anxiety was found to robustly and significantly correlate with
sensory quadrants. The percentage of those who scored sensation sensitivity (r = 0.458, p < 0.001) and sensation
more than most people in the two quadrants were sensa­ avoiding (r = 0.342, p = 0.009), suggesting that participants
tion sensitivity = 33.3% (n = 19) and sensation avoiding = experienced greater anxiety when they more frequently
26.3% (n = 15). The mean scores for the problem behavior reported being overwhelmed by sensation. Table 3 also pre­
scale and three subscales were as follows: overall problem sents the results of Pearson’s correlations to examine the rela­
behaviors = 104.3 (SD = 9.4, range = 96–145); internaliz­ tionship between anxiety and problem behaviors. Anxiety was
ing behaviors = 107.5 (SD = 11.1, range = 96–135); found to be significantly associated with the overall problem
externalizing behaviors = 94.3 (SD = 7.5, range = behaviors (r = 0.568, p < 0.001), internalizing behaviors (r =
90–133); and asocial behaviors = 102.4 (SD = 11.2, 0.495, p < 0.001), externalizing symptoms (r = 0.335, p =
range = 92–131). Analyses were also made using a cut- 0.011), and asocial behaviors (r = 0.693, p < 0.001). The result
indicates that the higher the level of reported anxiety, the
greater the frequency of problem behaviors.
Table 2 Scores of Problem Behaviors, Sensory Over-Responsivity,
and Anxiety (n = 57) Partial correlation analysis was employed to detect possible
effects of the co-occurrence of psychiatric disorders on the
Variables Mean ± SD Range
relationship between sensory quadrants, problem behaviors,
Sensory sensitivity 41.4 ± 9.8 23–62 and anxiety. The correlations between the sensation sensitivity,
Sensation avoiding 42.1 ± 11.8 15–69 sensation avoiding, the overall problem behaviors, and anxiety
remained significant after partialling the effects of psycho­
Overall problem behaviors 104.3 ± 9.4 96–145
pathological co-occurrence (Table 3).
Internalizing behaviors 107.5 ± 11.1 96–135
Externalizing behaviors 94.3 ± 7.5 90–133 The method outlined by Hayes39 was followed to examine
Asocial behaviors 102.4 ± 11.2 92–131 whether anxiety was a mediating variable that accounts for the
relationship between sensation avoiding and problem beha­
Anxiety 8.9 ± 6.7 0–21
viors. This hypothesis was tested by a series of regression

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Table 3 Intercorrelations of Sensory Over-Responsivity, Problem Behaviors, and Anxiety (n = 57)

Variables Sensation Sensation Overall Problem Internalizing Externalizing Asocial Anxiety
Sensitivity Avoiding Behaviors Behaviors Behaviors Behaviors

Sensory –
sensitivity

Sensation 0.737*** –
avoiding (0.751***)

Overall problem 0.380** 0.356** –

behaviors (0.291*) (0.330*)

Internalizing 0.360** (0.257) 0.248 (0.213) 0.819*** (0.798***) –

behaviors

Externalizing 0.245 (0.200) 0.270* 0.854*** (0.858***) 0.509*** –

behaviors (0.253) (0.490***)

Asocial behaviors 0.390** 0.366** 0.874*** (0.860***) 0.651*** 0.615*** –

(0.284*) (0.340*) (0.602***) (0.606***)

Anxiety 0.458*** 0.342** 0.568*** (0.507***) 0.495*** 0.335* (0.300*) 0.693*** –

(0.344*) (0.313*) (0.412**) (0.638***)
Notes: *p < 0.05, **p < 0.01, ***p < 0.001. Partial correlation controlling for the co-occurrence of psychiatric disorders (in parentheses).

analyses. Sensation avoiding was significantly associated with behaviors was reduced or became nonsignificant. A mediation
problem behaviors and anxiety (Table 3). After controlling the effect would be supported. Figure 1 shows that anxiety was
relation between the problem behaviors and anxiety, the sig­ a mediator that accounts for the relationship between sensation
nificant relationship between sensation avoiding and problem avoiding and problem behaviors. Analyses using Sobel’s test40

Figure 1 Results of testing for mediation by anxiety on relationship between sensation avoiding and problem behaviors.

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Table 4 Analysis Results of Mediation Effect Taiwanese emerging adults with ASD. The current study
Models β Standard Sobel’s adds to the existing literature of adults with ASD by
Error Test z exploring the relationship between these two common
conditions with problem behaviors. This research pro­
Regression 1
Sensation avoiding–Overall 0.356** 0.101 vides the following three findings: (1) sensation sensitiv­
problem behaviors ity and sensation avoiding are associated with problem
behaviors in emerging adults with ASD; (2) sensation
Regression 2
Sensation avoiding–Anxiety 0.342** 0.072 sensitivity and sensation avoiding are associated with
anxiety; and (3) anxiety is associated with problem
Regression 3
behaviors.
Anxiety–Overall problem 0.568*** 0.156
behaviors
One of the core ASD symptoms includes a range of
symptoms potentially related to sensory processing
Regression 4 2.473*
difficulties.1 In this sample, more than 25% of partici­
Sensation avoiding–Overall 0.183 0.093
problem behaviors
pants scored more than most people in the sensation
Anxiety–Overall problem 0.506*** 0.164 sensitivity and sensation avoiding quadrants. This result
behaviors is consistent with those of a study by Clince et al.22
Consistent with previous studies, emerging adults with
Regression 1
Sensation sensitivity– 0.380** 0.120 ASD who exhibit more severe overall problem beha­
Overall problem behaviors viors also have more exaggerated responses to sensory
stimuli.41,42 Atypical sensory processing is a strong pre­
Regression 2
Sensation sensitivity– 0.458*** 0.082 dictor of self-injury behaviors within a large ASD sam­
Anxiety ple during childhood and adolescence.42 Our findings
support the results of another study that used caregiver-
Regression 3
Anxiety–Overall problem 0.568*** 0.156
reported data of high-functioning autism and found that
behaviors the presence of stereotyped behaviors, a type of inter­
nalizing behavior, correlated with sensory processing
Regression 4 2.896**
Sensation sensitivity– 0.151 0.119
issues.41 Our findings were also in line with those of
Overall problem behaviors Tseng et al26 who showed that a significant correlation
Anxiety–Overall problem 0.499*** 0.175 exists between sensation sensitivity and internalizing
behaviors behaviors and between sensation avoiding and externa­
Notes: *p < 0.05, **p < 0.01, ***p < 0.001. β = Standardized coefficient. lizing behaviors. Furthermore, our findings extend the
findings from preschool children to emerging adults
with ASD.
indicated that the mediation effect was supported. This figure Consistent with our hypotheses, individuals with pro­
indicates that the greater problem behaviors in participants blem behaviors evidenced higher levels of both sensory
with greater sensation avoiding were mediating by their higher over-responsivity and anxiety. Consistent with prior
level of anxiety. A similar result was obtained in sensation studies,18,21 this study found that sensation sensitivity, sen­
sensitivity with a significant Sobel’s test (z = 2.896, p = 0.038). sation avoiding, and anxiety are highly correlated, suggest­
Table 4 presents the results of mediating effect. ing that adults with ASD who have higher levels of anxiety
more frequently respond to sensory inputs with exaggerat­
Discussion ing response. In line with the studies of Kim et al32 and
Sensory processing difficulty is a prevalent condition in Storch et al31 the results of this study show that individuals
adults with ASD, but its association with their psycholo­ with ASD having higher levels of anxiety present greater
gical well-being and behaviors has not been well and more frequent problem behaviors, including internaliz­
explored. While previous studies have suggested some ing, externalizing, and asocial behaviors. Little attention
associations between sensory over-responsivity, problem has been given to the presence of problem behaviors within
behaviors, and anxiety, the present study is the first to use the context of anxiety among individuals with ASD.
a cross-sectional design to examine all three conditions in Nevertheless, the data support that clinicians should

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concern clients’ comorbid anxiety symptoms which may be Conclusions

related to their problem behaviors; however, more research The current study is the first to examine the relationships
is needed to support this relationship. among sensory over-responsivity, problem behaviors, and
Notably, significant relationships were found between aso­ anxiety in emerging adults with ASD in Taiwan. These
cial behaviors and sensory over-responsivity as well as anxiety. findings indicate that emerging adults with ASD who
Miller et al43 indicated that children who are sensation avoid­ experience problem behaviors may also have difficulties
ing may present with asocial behaviors. Kring et al44 reported modulating their sensory input; their sensory over-
that adolescents and adults with ASD having a co-morbid responsivity was associated with their anxiety. Sensory
psychiatric disorder (eg, schizophrenia, bipolar disorder, over-responsivity was found to be associated with greater
major depression, anxiety disorder, or obsessive-compulsive problem behaviors indirectly through elevated levels of
disorder) are more likely to have higher levels of asocial anxiety. Given the unique symptoms of adults with ASD,
behaviors. However, no existing studies have been undertaken a comprehensive intervention might be required for chan­
to determine the relationships between asocial behaviors and ging the modulation of sensory inputs, emotional regula­
sensory over-responsivity or anxiety directly. Future longitu­ tion, and problem behaviors. Directions for future research
dinal studies with more representative samples are needed to may further investigate the underlying mechanisms and
fully address these issues. form an integrated treatment for these three conditions.
The study examined the bivariate relationships among
the three conditions of interest. It is critical to consider the Acknowledgment
impacts of problem behaviors for emerging adults with Support for this study was provided by grants MOST 107-
ASD, who also have problems regulating their response 2410-H-006-091 from the Ministry of Science and
to sensory inputs and emotions. The results of this study Technology in Taiwan.
provide insights into the associations among sensory over-
responsivity, problem behaviors, and anxiety in emerging Disclosure
adults with ASD. The lack of strategies for dealing with The authors declare that they have no conflicts of interest
sensory over-responsivity could also affect their emotional for this work.
status and may lead to them exhibiting more severe pro­
blem behaviors. However, these three conditions might References
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