The Mediating Effects of Alexithymia, Intolerance of Uncertainty, and Anxiety on the Relationship Between Sensory Processing Differences and Restricted and Repetitive Behaviours in Autistic Adults
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Distress caused by sensory processing differences for autistic individuals may be reduced by repetitive behaviours (RRB), including repetitive motor (RMB) and insistence on sameness (ISB) behaviours. Intolerance of uncertainty (IU) and anxiety mediate the relationship between sensory processing and RRB in autistic children. We replicated this model in autistic adults, extending it to include alexithymia. Serial mediation, using data from 426 autistic adults, identified significant direct effects from sensory processing to RMB and ISB, and indirect effects through alexithymia-IU-anxiety for RMB, and IU alone, and alexithymia-IU for ISB. Different mechanisms may underpin RMB and ISB. Alexithymia alongside, IU and anxiety, should be considered when understanding the relationship between sensory processing and RRB, and when offering interventions to support autistic people.
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These findings add support to the recommendation that for autistic individuals, an expectation of the possibility of one or more anxiety disorders and a focus on aspects of the autism profile (such as IU, sensory processing differences) need to be carefully considered in the assessment and treatment of anxiety symptoms and presentations.
“These findings add support to the recommendation that for autistic individuals, an expectation of the possibility of one or more anxiety disorders and a focus on aspects of the autism profile (such as IU, sensory processing differences) need to be carefully considered in the assessment and treatment of anxiety symptoms and presentations (e.g.,; Moore et al., 2021; South & Rodgers, 2017).”
From A Pilot Randomised Control Trial Exploring the Feasibility and Acceptability of Delivering a Personalised Modular Psychological Intervention for Anxiety Experienced by Autistic Adults: Personalised Anxiety Treatment-Autism (PAT-A) (2024) · cites this paper as Moore et al., 2021
The paper reports that anxiety is common among autistic people and links intolerance of uncertainty and sensory processing differences to anxiety (background section; page unavailable). Its Discussion recommends considering IU and emotional-processing difficulties in psychological interventions, and sensory differences in therapy formulation. It does not explicitly recommend anticipating one or more anxiety disorders or assessing and treating anxiety presentations in the terms stated here. (LLM, conf=0.83)
Experimental — accuracy not yet measuredAnxiety may interact with autistic traits.
“Since anxiety may interact with autistic traits (Moore et al., 2021; South & Rodgers, 2017)”
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Khaledi, H., Aghaz, A., Mohammadi, A., Dadgar, H., & Meftahi, G. H. (2022) · Middle East Current Psychiatry · doi:10.1186/s43045-022-00236-7 · Cited by 31 · see citing works
Moore, H. L., Cassidy, S., & Rodgers, J. (2023) · Autism Research · doi:10.1002/aur.3073 · Cited by 21 · see citing works
“As with previous research, our sample included individuals who self-identify as autistic (Brice et al., 2021; Cassidy et al., 2021; Mason et al., 2018; Moore et al., 2021).”
Self-citationLung, S. L. M., Picard, È., Soulières, I., & Bertone, A. (2024) · Research in Autism · doi:10.1016/j.rasd.2024.102458 · Cited by 24 · see citing works
Examining a model of anxiety in autistic adults
Riedelbauch, S., Gaigg, S. B., Thiel, T., Roessner, V., & Ring, M. (2024) · Autism · doi:10.1177/13623613231177777 · Cited by 19 · see citing works
“…suggestion has received support from a number of studies which have demonstrated that IU mediates the relationship between SPD and anxiety (Hwang et al., 2019; Wigham et al., 2015), as well as between ALX and anxiety (Moore et al., 2021; Ozsivadjian et al., 2021) in autism spectrum disorder (ASD).”
ResultBird, S., Moid, L. A. E., Jones, C. A., & Surtees, A. D. R. (2024) · Research in Autism · doi:10.1016/j.rasd.2024.102428 · Cited by 17 · see citing works
Rodgers, J., Brice, S., Welsh, P., Ingham, B., Wilson, C., Evans, G., Steele, K., Cropper, E., Le Couteur, A., Freeston, M., et al. (2024) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-023-06112-5 · Cited by 15 · see citing works
“Since anxiety may interact with autistic traits (Moore et al., 2021; South & Rodgers, 2017), autistic people may experience anxiety differently (Spain et al., 2017).”
BackgroundSelf-citationAuditory environments influence the link between Autistic traits and quality of life
Poulsen, R. E., Tan, D. W., Sowman, P. F., McAlpine, D., & Pellicano, E. (2025) · Scientific Reports · doi:10.1038/s41598-025-94585-y · Cited by 15 · see citing works
“Previous literature shows that hostile sensory environments can negatively affect non-social Autistic traits such as Cognitive Flexibility , Self-Regulating Repetitive Behaviors and Sensory Sensitivity (including other sensory modalities) 92–96 .”
Consoli, C., Turriziani, L., Antoci, M., Monaco, M. L., Ceraolo, G., Spoto, G., Nicotera, A. G., & Rosa, G. D. (2025) · Brain Sciences · doi:10.3390/brainsci16010053 · Cited by 13 · see citing works
“Neuroimaging evidence implicated amygdala structure and connectivity differences in sensory-driven anxiety, and early difficulties in sound tolerance or olfactory processing might act as early markers for anxious trajectories [184].”
Nwaordu, G., & Charlton, R. A. (2023) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-023-06133-0 · Cited by 12 · see citing works
Graham, J., Rodgers, J., & Cassidy, S. (2023) · Autism in Adulthood · doi:10.1089/aut.2023.0039 · Cited by 11 · see citing works
Self-citationRecio, P., Pozo, P., García‐López, C., & Sarriá, E. (2024) · Brain Sciences · doi:10.3390/brainsci14111088 · Cited by 10 · see citing works
Evers, K., Gijbels, E., Maljaars, J., Rumball, F., Spain, D., Happe, F. G. E., & Noens, I. L. J. (2022) · Autism · doi:10.1177/13623613221119749 · Cited by 10 · see citing works
Associations between the pupil light reflex and the broader autism phenotype in children and adults
Soker-Elimaliah, S., Lehrfield, A., Scarano, S. R., & Wagner, J. (2023) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2022.1052604 · Cited by 9 · see citing works
“that increased RRB are associated with difficulties in sensory processing in adults (Hwang et al., 2020; Moore et al., 2021) and children (Gabriels et al.”
BackgroundYu, M. H. M., Cao, Y., Fung, S. S. Y., Kwan, G. S. Y., Tse, Z. C. K., & Shum, D. H. K. (2025) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2025.102975 · Cited by 8 · see citing works
Self-Report of Restricted Repetitive Behaviors in Autistic Adults: A Systematic Review
Collis, E., Dark, E., Russell, A., & Brosnan, M. (2024) · Autism in Adulthood · doi:10.1089/aut.2023.0111 · Cited by 9 · see citing works
“Moore 39 found between-factor correlations, with a strong correlation between preferred interests and insistence on same-ness, and a strong to moderate relationships between sensory sensitivity and repetitive movements, and insistence on same-ness and sensory sensitivities.”
Keshavarz, S., & Esmaeilpour, K. (2025) · BMC Psychology · doi:10.1186/s40359-025-02369-w · Cited by 8 · see citing works
Jones, C. R. G., Livingston, L. A., Fretwell, C., Uljarević, M., Carrington, S. J., Shah, P., & Leekam, S. (2024) · Molecular Autism · doi:10.1186/s13229-024-00603-7 · Cited by 8 · see citing works
Lin, Y., Mason, D., Hirsch, C. R., & Happe, F. G. E. (2024) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-024-06310-9 · Cited by 6 · see citing works
“IU has also been shown to mediate the association between alexithymia and anxiety in autistic children and adults (Moore et al., 2022 ; Ozsivadjian et al., 2021 ).”
Josyfon, E., Spain, D., Blackmore, C. E., Murphy, D., & Oakley, B. F. M. (2023) · Healthcare · doi:10.3390/healthcare11243114 · Cited by 6 · see citing works
“…and repetitive behaviours are significantly associated with sensory processing differences (including through interrelationships with alexithymia [42], though please also see our previous work showing associations between alexithymia and anxiety symptoms in an autistic community sample after…”
BackgroundInfluentialJefferson, S. G., & Erp, L. S. (2022) · Child & Family Behavior Therapy · doi:10.1080/07317107.2022.2111750 · Cited by 6 · see citing works
Álvarez-Couto, M., García-Villamisar, D. A., & Armentia, A. D. P. (2024) · Journal of Mental Health Research in Intellectual Disabilities · doi:10.1080/19315864.2024.2333244 · Cited by 4 · see citing works
“However, anxiety derived from intolerance to uncertainty likely manifests through other non-self-JOURNAL injurious behaviors, such as repetitive behaviors, as indicated by previous studies (Bitsika & Sharpley, 2016; Glod et al., 2019; Moore et al., 2022).”
Moore, H. L., Freeston, M. H., Rodgers, J., & Cassidy, S. (2024) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-024-06260-2 · Cited by 4 · see citing works
Self-citationChallenging Behaviors in Adults with Intellectual Disabilities and ASD: Related Variables
Álvarez-Couto, M. (2024) · Springer eBooks · doi:10.1007/978-3-031-40858-8_63-1 · Cited by 5 · see citing works
Differences and Relationships Between Sensory Profile and Repetitive Behavior in Autism
López, M. D. C., & Ferrándo, M. (2025) · Children · doi:10.3390/children12040504 · Cited by 3 · see citing works
“Similarly, the study by Moore et al. [10] found a significant inverse correlation between age and motor repetitive behaviors in a sample of over 400 adults with ASD.”
Song, Z., Liang, S., Liu, S., Song, L., Zhang, Y., & Yu, Y. (2025) · Journal of Affective Disorders · doi:10.1016/j.jad.2025.120545 · Cited by 3 · see citing works
Merlo, E. M., Martino, G., Tutino, R., Myles, L. A. M., Hill, S., Alibrandi, A., Lia, M. C., & Minasi, D. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1667103 · Cited by 2 · see citing works
Diepman, M., & Brady, N. P. (2024) · Research in Autism · doi:10.1016/j.rasd.2024.102470 · Cited by 5 · see citing works
How auditory processing influences the autistic profile - a reviewPreprint
Poulsen, R. E., Williams, Z. J., Dwyer, P. S. R., Pellicano, E., Sowman, P. F., & McAlpine, D. (2024) · doi:10.31234/osf.io/a7kr5 · Cited by 2 · see citing works
Miller, P. K., Dewison, N., Bowden, S. L., Ingham, B., Thwaites, R., & Dagnan, D. (2025) · Neurodiversity · doi:10.1177/27546330251350037 · Cited by 1 · see citing works
Self-citationBrett, J. D., Jarvers, I., Uljarević, M., Whitehouse, A., Gross, J. J., Samson, A. C., & Preece, D. A. (2025) · Autism in Adulthood · doi:10.1177/25739581251371420 · Cited by 1 · see citing works
Moore, H. L., Brice, S., Spraggon, N., Ingham, B., Freeston, M. H., Parr, J. R., & Rodgers, J. (2025) · Autism Research · doi:10.1002/aur.70145 · Cited by 1 · see citing works
Self-citationPurposeless? Says Who? A Scoping Review of Potential Functions of Stimming in Autistic Adults
Camin, M., Hudry, K., Jellett, R., & Flower, R. L. (2026) · Autism in Adulthood · doi:10.1177/25739581261497840 · Cited by 1 · see citing works
Sensory Responsiveness and Alexithymia in Autistic ChildrenPreprint
Brady, N. P., & Diepman, M. (2023) · SSRN Electronic Journal · doi:10.31234/osf.io/aryhc · Cited by 1 · see citing works
Chen, Y.-C., Chien, Y., Chiu, Y., Tsai, W., & Gau, S. S. (2024) · Autism in Adulthood · doi:10.1089/aut.2023.0205
Using extended reality as a tool for creating activities for autistic students
Cerdán-Chacón, A., Lorenzo, G., & Meliá, S. (2025) · Health Education · doi:10.1108/he-06-2025-0079
Processes Associated with the Development of Depression in Autistic Individuals: A Narrative Review
Wallenberger, Y. H., Uljarević, M., Chetcuti, L., & Putnam, S. P. (2025) · Healthcare · doi:10.3390/healthcare13233112
“Although previous research demonstrates the clear separability of the SCI and RRB domains, and suggests that they have different genetic, neural, and cognitive origins [50], there are interrelations among SCI and RRB in prediction of outcomes [51].”
Jones, C. R. G., Livingston, L. A., Fretwell, C., Uljarević, M., Carrington, S. J., Shah, P., & Leekam, S. R. (2024) · Figshare · doi:10.6084/m9.figshare.25989201
Fujii, A., & Hirai, M. (2026) · Scientific Reports · doi:10.1038/s41598-026-47237-8
“This finding directly contradicts the model’s premise, which, based on prior findings that alexithymia acts as a source of IU 33,34 , predicts that lower AL would relate to higher IU.”
Correlates of Anxiety in Children and Adults With Moderate to Profound Intellectual Disability
Edwards, G., Tarver, J., Mingins, J. E., Oliver, C., Horton, I., & Waite, J. (2026) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-026-07539-2
- Authors
- Moore, H. L., Brice, S., Powell, L., Ingham, B., Freeston, M., Parr, J. R., & Rodgers, J.
- Affiliations
- Newcastle University (GB)
- Cumbria Northumberland Tyne and Wear NHS Foundation Trust (GB)
- Royal Victoria Infirmary (GB)
- Corresponding author
- Moore, Heather L.
- ORCID
- Venue
- Journal of Autism and Developmental Disorders
- Published
- 2021-10-13
- Volume
- 52
- Issue
- 10
- Pages
- 4384-4396
- ISSN
- 0162-3257 (ISSN-L)
- 1573-3432
- PMC
- PMC9508023
- OpenAlex
- W3205070028
- Cited by
- 42
- References
- 97
- Citations by year
- 2026: 3 · 2025: 12 · 2024: 14 · 2023: 10 · 2022: 3
- FWCI
- 3.55
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Journal of Autism and Developmental Disorders (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Newcastle University ePrints (Newcastle Univesity) (cc-by)
- Funders
- Autistica (7425)
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Keywords
- autism spectrum disorder, sensory processing differences, restricted and repetitive behaviors, insistence on sameness, alexithymia, intolerance of uncertainty, anxiety, autistic adults, serial mediation
- MeSH terms
- Autism Spectrum Disorder, Adult, Affective Symptoms, Anxiety, Autistic Disorder, Child, Humans, Perception, Uncertainty
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