Anxiety, repetitive and restricted behaviors and interests, and social communication in autistic adults: an exploratory analysis of a phase 3, randomized clinical trial
In autistic adults, rising repetitive behaviors are a red flag for underlying anxiety that quietly drags down social communication.
01Research in Context
What this study did
Aponte et al. (2025) mined data from a phase-3 drug trial with 336 autistic adults . They ran simple correlations and mediation tests among three things: anxiety scores, repetitive/restricted behaviors (RRB), and social-communication scores. No new treatment was given; they just looked at baseline numbers.
What they found
Higher anxiety went hand-in-hand with more RRB and slightly lower social-communication scores. The new twist: RRB acted like a middle-man. Once RRB was in the model, anxiety no longer predicted social-communication problems. In plain words, anxiety shows up mostly as repetitive behaviors, not as social slips.
How this fits with other research
Storch et al. (2012) saw the same link in kids: kids who acted out their special interests in play had the highest anxiety. Aponte now shows the same bridge holds in adults, making the pattern lifelong. Adams et al. (2020) found 96 % of autistic children self-report anxiety but feel adults miss it at school; Aponte adds the adult side by showing what form that hidden anxiety takes—RRB. Adams et al. (2025) tracked adolescents and found anxiety best predicts school refusal years later. Aponte’s cross-sectional data fit that timeline: if RRB is the visible face of anxiety, spotting more RRB today could flag attendance risk tomorrow.
Why it matters
When an autistic adult shows new or stronger repetitive behaviors, screen for anxiety first instead of only teaching social skills. Targeting RRB with coping strategies (e.g., giving predictable break rituals) may indirectly ease social-communication strain. Quick anxiety care could also head off later problems like school or work refusal seen in the teen data.
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02At a glance
03Original abstract
Autistic adults are highly vulnerable to mental health problems and yet, our understanding of co-occurring psychiatric disorders in this population is limited. Anxiety is one of the most pervasive psychiatric disorders that affects autistic adults. Here, we investigated the association between anxiety, restricted and repeated behaviors and interests (RRB), and challenges in social communication and interaction (CSCI) as a post-hoc analysis of a large Phase 3 clinical trial (NCT03504917). The study enrolled 322 adults (64 females, age 27 ± 10) assessed at baseline and weeks 12, 24, 36, and 52, with the Hamilton Anxiety Rating Scale, the Repetitive Behaviors Scale – Revised, and the Vineland-II for CSCI. All analyses were blind to treatment assignment as the primary study analysis had found no treatment effects. Anxiety levels were significantly correlated with RRB and CSCI at baseline (RRB: r = 0.19, P < 10–3; CSCI=–0.13, P = 0.02) and across the entire study (RRB: r = 0.22, P < 10–3; CSCI=–0.16, P < 0.01). However, a mediation analysis revealed that the effect of CSCI on anxiety was fully explained by RRB (P = 0.17). While no causal relationship between both symptom domains has been established yet, our findings suggest that anxiety symptoms are associated with increased RRB, warranting further exploration of a potential causal association and implications for treatment. Clinical trial registration: The research presented is registered at ClinicalTrials.gov with the code NCT03504917. The online version contains supplementary material available at 10.1038/s41598-025-22659-y.
Scientific Reports, 2025 · doi:10.1038/s41598-025-22659-y