نوع مقاله : مقاله پژوهشی

نویسندگان

• ذوالفقار عبدالمهدی لفته ¹
• خدامراد مومنی ²
• جهانگیر کرمی ³
• حیدر حاتم العچرش ⁴

¹ دانشجوی دکتری رشته روان‌شناسی، دانشگاه رازی، کرمانشاه، ایران

² استاد گروه روان‎شناسی، دانشگاه رازی، کرمانشاه، ایران

³ دانشیار گروه روان‎شناسی، دانشگاه رازی، کرمانشاه، ایران

⁴ استادیار گروه علوم اجتماعی، دانشگاه بابل، بابل، عراق

چکیده

این پژوهش باهدف تعیین رابطه پردازش حسی با مشکلات رفتاری و تعاملات اجتماعی در کودکان با اختلال طیف اتیسم با میانجیگری اضطراب انجام شد. روش پژوهش همبستگی از نوع مدل‌سازی معادلات ساختاری و جامعه آماری این پژوهش شامل تمامی کودکان با اختلال طیف اتیسم در سال 1402 در شهر کرمانشاه بودند که از میان آن‌ها 200 پدر و مادر با روش نمونه‌گیری در دسترس انتخاب شد‌ند و پرسشنامه‌های نمیرخ حسی دان (2014)، مهارت‌های اجتماعی بلینی و هوف (2007)، سیاهه رفتاری کودکان اخنباخ و رسکولار (2001) و اضطراب راجرز و همکاران (2016) پاسخ دادند. نتایج نشان داد که پردازش حسی از طریق اضطراب با مشکلات رفتاری رابطه منفی و معنی‌داری دارد. پردازش حسی با تعاملات اجتماعی رابطه مثبت و معنی‌داری دارد و متغیر اضطراب در هر دو رابطه می‌تواند نقش میانجی دارد، بنابراین مشکلات پردازش حسی در کودکان با اختلال طیف اتیسم به‌طور قابل‌توجهی با مهارت‌های ارتباطی و مشکلات رفتاری مرتبط است و اضطراب به‌عنوان یک واسطه بین آن‌ها عمل می‌کند. با توجه به ویژگی‌های خاص اتیسم، مداخله جامعی برای اصلاح تنظیم ورودی حسی، کنترل عاطفی و تفاوت‌های ارتباطی ضروری است.

کلیدواژه‌ها

• کلیدواژه‌ها: پردازش حسی
• مشکلات رفتاری
• تعاملات اجتماعی
• اضطراب
• طیف اتیسم. 

عنوان مقاله [English]

The Relationship Between Sensory Processing and Behavioral Problems/Social Interactions in Children with Autism Spectrum Disorder: The Mediating Role of Anxiety

نویسندگان [English]

• Dhulfiqar Abdul Mahdi Lafta ¹
• khodamorad momeni ²
• jahangir karami ³
• Haider Hatem Alijrish ⁴

¹ Ph.D. Student in Psychology, Razi University, Kermanshah, Iran

² Professor, Department of Psychology, Razi University, Kermanshah, Iran

³ Associate Professor, Department of Psychology, Razi University, Kermanshah, Iran

⁴ Assistant Professor, Department of Social Sceinces, University of Baylon, Babylon, Iraq

چکیده [English]

Abstract
This correlational study investigated the relationships between sensory processing, behavioral problems, and social interactions in children with autism spectrum disorder (ASD), examining anxiety as a mediating variable using structural equation modeling. Participants included 200 parents of children with ASD in Kermanshah (2023), selected through convenience sampling. Measures comprised the Dunn Sensory Profile (2014), Bellini and Hopf Social Skills Questionnaire (2007), Achenbach and Rescorla Child Behavior Checklist (2001), and Rogers Anxiety Scale (2016). Results revealed: (1) a significant negative relationship between sensory processing and behavioral problems mediated by anxiety (β = -., p <.01), and (2) a significant positive relationship between sensory processing and social interactions, again with anxiety mediation (β =., p <.01). These findings indicate that sensory processing difficulties substantially impact both communication skills and behavioral challenges in children with ASD through anxiety pathways. The study highlights the need for comprehensive interventions addressing sensory regulation, emotional control, and social communication differences in ASD populations.
Keywords: sensory processing, behavioral problems, social interactions, anxiety, autism spectrum
 
 
 
Extended Abstract

Introduction

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication and interaction, alongside restricted, repetitive patterns of behavior, interests, or activities (Siu et al., 2020). As one of the most prevalent neurodevelopmental disorders, ASD affects approximately 1 in 68 children worldwide (Agaz et al., 2018). Clinical presentations frequently include comorbid conditions such as intellectual disabilities (31%), epilepsy (20%), enuresis (15%), and attention-deficit/hyperactivity disorder (ADHD) in 30-50% of cases (Mohammadi et al., 2019). Core features typically manifest as atypical language comprehension, impaired social communication, and differences in nonverbal gestural interactions (O'Hearn et al., 2013).
Communication and language impairments represent core challenges in Autism Spectrum Disorder (ASD), with many children initially referred for evaluation due to parental concerns about delayed language development. Research emphasizes the critical importance of early language acquisition, particularly achieving functional communication skills by age five, as this significantly predicts long-term developmental outcomes (DiStefano et al., 2016; Eigsti et al., 2011). The DSM-5 delineates two diagnostic criteria for ASD: (1) persistent deficits in social communication and social interaction across multiple contexts, and (2) restricted, repetitive patterns of behavior, interests, or activities (American Psychiatric Association, 2013; Özért & Alikak, 2018). These communication difficulties manifest across various domains, including verbal and nonverbal expression, social reciprocity, and pragmatic language use.
Language development in children with ASD shows considerable heterogeneity in severity and progression. While some children acquire language without significant delays, approximately 25% fail to develop functional language skills over time (Klinger et al., 2003). These variations are clinically significant, as language concerns represent one of the most common reasons parents seek initial evaluations. Notably, early pragmatic language abilities - particularly the functional use of language in social contexts - serve as strong predictors of long-term developmental outcomes and adaptive functioning (Tager-Flusberg et al., 2005). Understanding this spectrum of language development is crucial for early identification and intervention planning.
Atypical sensory processing - including both hyper-responsiveness (over-sensitivity) and hypo-responsiveness (under-sensitivity) - is a common feature of ASD that significantly impacts multiple developmental domains (Feldman et al., 2020; Williams et al., 2018). This fundamental neurological process organizes sensory information from internal and external environments, enabling appropriate behavioral responses. Hyper-responsiveness, characterized by heightened or aversive reactions to sensory stimuli (Siu et al., 2020), often co-occurs with other clinical challenges. Research consistently links sensory processing differences in ASD with sleep disturbances, impaired social-communication skills, reduced adaptive functioning, and elevated anxiety symptoms (Ben-Sasson et al., 2009; Mazurek et al., 2013). These associations underscore the cascading effects of sensory dysregulation on daily functioning and quality of life.
According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ASD is characterized by two essential features: (a) persistent deficits in social communication and social interaction across multiple contexts, and (b) restricted, repetitive patterns of behavior. These characteristics typically appear early in childhood and result in challenges in daily life (Özçetin & Alıkak, 2018). Language development levels in children with ASD can vary greatly; while some children do not experience any language delays, functional language does not improve in 25% of cases (Klinger et al., 2003). Understanding the differences in language development in ASD is crucial, as parents often cite delayed language development as a primary concern. Additionally, early language pragmatics are closely tied to long-term outcomes (Tager-Flusberg et al., 2005).
Research Question:
Does anxiety mediate the relationship between sensory processing difficulties and (a) behavioral problems and (b) social interaction challenges in children with autism spectrum disorder?

Literature Review

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by challenges in social interaction and restricted, repetitive patterns of behavior, interests, or activities (Siu et al., 2020). As one of the most prevalent neurodevelopmental conditions, it affects approximately 1 in 68 children (Agaz et al., 2018). Research indicates that 86% of individuals with ASD experience at least one comorbid condition, including intellectual disability, epilepsy, enuresis, or attention-deficit/hyperactivity disorder (Mohammadi et al., 2019). Characteristic features include differences in language comprehension, social communication difficulties, and atypical gestural interactions (O'Hearn et al., 2013). The acquisition of functional language skills by age five represents a critical developmental milestone that significantly influences long-term outcomes (DiStefano et al., 2016; Eigsti et al., 2011). Additionally, sensory processing differences, particularly hyper-responsiveness and hypo-responsiveness to environmental stimuli, are commonly observed in ASD and may substantially affect adaptive functioning (Feldman et al., 2020).
Sensory processing difficulties in ASD are consistently associated with sleep disturbances, impaired social skills, reduced adaptive functioning, and elevated anxiety (Ben-Sasson et al., 2009; Mazurek et al., 2013). Existing research demonstrates that sensory challenges may adversely affect mental health outcomes, highlighting the need for further investigation in this domain (Ben-Sasson et al., 2009). Importantly, sensory differences show significant associations with both behavioral difficulties and anxiety symptoms, with evidence suggesting that sensory processing patterns and anxiety may mediate the relationship between core ASD symptoms and functional impairments (Green et al., 2012; Khaledi et al., 2022). The current study seeks to address critical gaps in the literature by examining the interrelationships among sensory processing, social interaction challenges, and behavioral problems, with particular emphasis on anxiety's mediating role in children with ASD.

Methodology

The present study is a descriptive-correlational investigation utilizing structural equation modeling (SEM). The statistical population includes all children with autism spectrum disorder (ASD) in Kermanshah in 2023, with a sample selected through convenience sampling. Accounting for a 10% dropout rate due to incomplete or damaged questionnaires, we distributed questionnaires to 200 participants. Sample size determination followed established guidelines: Stevens' analysis recommends 15 cases per predictor variable in regression analyses, while Loehlin suggests that models with 2-4 factors require at least 100 cases (preferably 200), confirming our sample's adequacy for path analysis (Momeni et al., 2022). Inclusion criteria were: (1) DSM-5 ASD diagnosis confirmed by a psychiatrist, (2) GARS-3 score >54, (3) parental consent, (4) untreated anxiety with no treatment in the past year. Exclusion criteria included visual impairment, hearing loss, and epilepsy. We administered four instruments: the Anxiety Scale for Children with ASD (ASC-ASD), Child Behavior Checklist (CBCL), Social Skills Inventory, and Sensory Profile 2.
After obtaining ethical approval and confirming the study proposal, questionnaires were distributed across ASD rehabilitation centers. Participants received detailed information about research objectives, confidentiality protocols, and data anonymity. Researchers verified inclusion criteria through preliminary screening questions and medical record reviews, with ASD diagnoses confirmed using the GARS-3 scale. Collected data were analyzed using SPSS-26 and Amos-24 software. Four standardized measures were employed: (1) the Anxiety Scale for Children with Autism Spectrum Disorder (ASC-ASD) for anxiety symptom assessment, (2) the Child Behavior Checklist (CBCL) for evaluating emotional/behavioral problems, (3) the Social Skills Inventory for measuring social behaviors, and (4) the Sensory Profile 2 for assessing sensory processing patterns. This methodological approach facilitated comprehensive data collection and analysis to examine relationships between sensory processing, behavioral challenges, and anxiety symptoms in children with ASD.

Results

Researchers evaluate model-data fit using goodness-of-fit indices, with the chi-square statistic (χ²) serving as the primary indicator of discrepancy between the hypothesized model's covariance matrix and the observed sample's matrix. The null hypothesis assumes perfect fit between model and data. However, χ²'s sensitivity to sample size necessitates supplemental indices: χ²/degrees of freedom (χ²/df) ratio, Goodness-of-Fit Index (GFI), Adjusted GFI (AGFI), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Standardized Root Mean Square Residual (SRMR), and Root Mean Square Error of Approximation (RMSEA). Acceptable model fit is typically indicated by RMSEA/SRMR values <0.08 and CFI/TLI values >0.90. Following initial analysis, we improved model fit by adding covariance relationships between error terms, resulting in final fit indices demonstrating acceptable model specification.
The path analysis revealed three key findings: First, sensory processing demonstrated a significant negative direct effect on anxiety (β = -0.056, p <.05) but no significant direct effect on behavioral problems (β = -0.032, ns). Second, sensory processing showed a significant positive direct effect on social interactions (β = 0.094, p <.05). Third, anxiety exhibited strong opposing effects - a significant negative impact on social interactions (β = -0.883, p <.001) and a significant positive effect on behavioral problems (β = 0.731, p <.001). Crucially, bootstrap analysis confirmed that sensory processing significantly influenced both behavioral problems (indirect effect = -0.041, 95% CI [-0.078, -0.012]) and social interactions (indirect effect = 0.049, 95% CI [0.018, 0.088]) through its mediation via anxiety, accounting for 56.2% and 34.3% of total effects respectively.

Discussion

This study examined anxiety's mediating role in relationships between sensory processing and both social skills and behavioral problems in children with ASD. Our results demonstrate that sensory processing influences behavioral and social outcomes primarily through anxiety pathways. These findings align with established literature, particularly regarding anxiety's mediation between sensory processing and social skills (Machado et al., 2024; Khaledi et al., 2022; Tsuji et al., 2022). Klynek et al. (2016) specifically found that children with ASD showing better sensory processing exhibited superior academic and communicative performance, with sensory scores positively correlating with most communication measures. Their work further revealed distinct sensory processing patterns in ASD that significantly correlate with communication impairments. Notably, social relationships showed strong positive associations with all sensory processing patterns, underscoring sensory processing's crucial role in shaping social communication abilities (Klynek et al., 2016). These collective findings, including supporting evidence from Watson et al. (2011) and Baker et al. (2008), substantiate that sensory processing patterns significantly contribute to ASD symptom severity profiles.
The findings suggest a potential shared mechanism between sensory processing difficulties and communication challenges in children with ASD. Consistent with previous research (Lane et al., 2010), sensory hypo-responsiveness was associated with poorer communication and social functioning. Our results revealed significant negative correlations between social relationship scores and all anxiety subscales, indicating a bidirectional relationship where anxiety reduction may improve social functioning and vice versa - a finding that aligns with Davis et al. (2011). Green et al. (2012) proposed that anxiety stems from maladaptive sensory processing patterns; specifically, sensory avoidance behaviors may limit participation in daily activities, while hyper-responsiveness can create barriers to engagement (Miller et al., 2007; Lane et al., 2012). Notably, communication skills demonstrate complex relationships with anxiety, where increased communication deficits may either alleviate or exacerbate anxiety depending on individual profiles. These findings underscore the clinical importance of addressing both sensory processing patterns and social relationship factors in ASD interventions (Khaledi et al., 2022).

Conclusion

The observed mediating role of anxiety in the sensory processing-behavioral problems relationship aligns with previous findings (Lane et al., 2012; Green et al., 2012; Wigham et al., 2015; Moore et al., 2021). Although behavioral problems frequently occur in children with ASD, their association with anxiety remains understudied. While existing research has established connections between behavioral problems, sensory difficulties, and anxiety in ASD populations, our study represents the first Iranian investigation employing cross-sectional methodology to examine these relationships. The characteristic link between sensory differences and behavioral problems - likely stemming from sensory processing challenges - constitutes a core feature of ASD (Siu et al., 2020). Our results demonstrated significant negative correlations between all sensory processing patterns/subscales and anxiety subscales, supporting Green et al.'s (2012) conclusion that sensory processing abnormalities directly contribute to anxiety development in this population.
These findings suggest that clinical interventions for anxiety in children with ASD should prioritize assessment and modification of sensory processing patterns. This approach is supported by Delapiazza et al. (2018), who demonstrated significant negative correlations between overall sensory scores and all anxiety subscales in ASD. The results indicate that heightened anxiety levels in children with ASD are associated with exaggerated responses to sensory stimuli. Importantly, these children manifest anxiety through diverse behavioral presentations, including internalizing, externalizing, and non-social behaviors - a phenomenon that remains understudied in ASD populations. This study investigated the interrelationships among communication differences, behavioral problems, sensory processing difficulties, and anxiety in children with ASD. The results indicate that children with ASD experiencing communication and behavioral challenges often demonstrate impaired sensory modulation, with sensory processing deficits showing significant associations with heightened anxiety. Importantly, anxiety mediated the relationship between sensory processing issues and both communication differences and behavioral problems. These findings highlight the need for multimodal interventions addressing sensory regulation, emotional control, and communication development in ASD.
Several study limitations warrant consideration. First, the exclusion of children receiving anxiety treatment limits generalizability to this population. Second, our reliance on volunteer participants with service access may not represent the broader ASD community. Third, the cross-sectional design precludes causal inferences about the observed relationships between sensory processing, anxiety, communication, and behavioral outcomes. Future longitudinal research could help establish temporal relationships and causal pathways among these factors.
Acknowledgments
The authors extend their deepest appreciation to the participating families for their invaluable contribution to this research. We are equally grateful to the collaborating rehabilitation centers for their support and to the clinical professionals who generously shared their expertise throughout this study.

کلیدواژه‌ها [English]

• Keywords: sensory processing
• behavioral problems
• social interactions
• anxiety
• autism spectrum