Repetitive Behavior Severity as an Early Indicator of Risk for Elevated Anxiety Symptoms in Autism Spectrum Disorder

Danielle A. Baribeau, Simone Vigod, Eleanor Pullenayegum, Connor M. Kerns, Pat Mirenda, Isabel M. Smith, Tracy Vaillancourt, Joanne Volden, Charlotte Waddell, Lonnie Zwaigenbaum, Teresa Bennett, Eric Duku, Mayada Elsabbagh, Stelios Georgiades, Wendy J. Ungar, Anat Zaidman-Zait, Peter Szatmari

Research output: Contribution to journalArticlepeer-review


Objective: A significant proportion of children with autism spectrum disorder (ASD) will develop an anxiety disorder during childhood. Restricted and repetitive behavior severity in ASD positively correlates with anxiety severity in cross-sectional surveys. The longitudinal relationship between restricted/repetitive behavior and future anxiety symptoms is unclear. Method: In a longitudinal cohort of children with ASD (n = 421), restricted/repetitive behavior severity at enrollment (age 2−5 years) was categorized as “mild,” “moderate,” or “severe” using the Autism Diagnostic Interview−Revised. Elevated anxiety symptoms were defined by a Child Behavior Checklist (parent report) Anxiety subscale T-score of >65 at ages 8 to 11 years. Multivariable logistic regression with multiple imputation for missing data was used to examine the association between restricted/repetitive behavior severity and elevated anxiety symptoms while adjusting for age, sex, adaptive functioning, baseline anxiety, income, and parenting stress, generating adjusted odds ratios (aORs) and 95% CIs. Results: Approximately 58% of children with severe restricted/repetitive behavior at enrollment had elevated anxiety symptoms by age 11, compared to 41% of those with moderate, and 20% of those with mild restricted/repetitive behavior, respectively. Moderate and severe restricted/repetitive behavior were both associated with increased odds of elevated anxiety (moderate aOR: 2.5 [1.2−5.3]; severe aOR: 3.2 (1.4−7.5]). Conclusion: Restricted/repetitive behavior severity at time of ASD diagnosis indicates risk for future anxiety symptoms. This finding increases our understanding of which children with ASD will develop anxiety disorders and may guide research concerning early interventions and etiological mechanisms.

Original languageEnglish
Pages (from-to)890-899.e3
JournalJournal of the American Academy of Child and Adolescent Psychiatry
Issue number7
StatePublished - Jul 2020


  • anxiety
  • autistic disorder
  • stereotyped behavior


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