All procedures in this study were consistent with the guidelines for humans of the National Institute of Health and approved by the Ethical Committee of the Baqiyatallah University of Medical Sciences, Tehran, Iran (IR.BMSU.REC.1399.512).
Fifty-three children with ASD (42 males/11 females) aged between 6 and 12 years (M = 8.51, SD = 2.51) enrolled in the study. The race of all the participating children was white, and all of them were monolingual Persian speakers and residents of Tehran. All questionnaires were completed by the mothers of these children. The mothers ranged in age from 23 to 45 years (M = 32.7, SD = 5.9). Their education level was as follows: seven had a high school education, 18 had a high school diploma, 20 had a bachelor’s degree, and eight had master’s or doctoral degrees. According to the Diagnostic and Statistical Manual V (DSM-5) criteria, all subjects were diagnosed with ASD by a professional psychiatrist, which was extracted from the participant’s medical records. To confirm this diagnosis, the authors also used the Persian version of the Gilliam Autism Rating Scale-3 (GARS-3) for all participants. All participants in this scale scored above the cutoff point of 54 . The severity of autism was determined based on the DSM-5 categorization. The mild, moderate, and severe ASD are defined as severity level 1, severity level 2, and severity level 3, respectively . All participants of this study had severity level 2 of ASD. Children whose anxiety has not been treated and who have not received any treatment in the past year were included. In addition, participants with visual impairment, hearing loss, epilepsy, and other neurological difficulties such as cerebral palsy were excluded.
Short Sensory Profile (SSP)
The Short Sensory Profile (SSP) is a shortened version of the Dunn’s Sensory Profile Caregiver Questionnaire . The SSP with 38 items is a standardized assessment instrument for measuring sensory features in children and students in the classroom, school, and preschool settings. The subscales of the SSP are tactile sensitivity, taste/smell sensitivity, movement sensitivity, under-responsive/seeks sensation, auditory filtering, low energy/weak, and visual/auditory sensitivity. In addition to these subscales, four basic patterns of sensory processing are extracted from the SSP. These sub-types are sensation seeking, including the representation of high thresholds and an active self-regulation strategy; sensation avoiding, including low thresholds and an active self-regulation strategy; sensation sensitivity, including low thresholds and a passive self-regulation strategy; and low registration, including representation of high thresholds and a passive self-regulation strategy. This questionnaire can be used for the age range of 3 to 11 years and 11 months. The questionnaire is designed based on Likert’s scale of five points always = 1, often = 2, sometimes = 3, rarely = 4, and never = 5. Cronbach’s alpha for the subscales of the original version of the SSP was reported as 0.74, 0.93, 0.74, 0.74, 0.78, 0.93, and 0.72 . The construct validity of the Persian version of this questionnaire for 384 children and students aged 3 to 12 years was confirmed through confirmatory factor analysis (P < 0.001). In addition, the reliability of the Persian version of the SSP, based on Cronbach’s alpha, for the whole questionnaire was equal to 0.88, and for low registration, sensation seeking, sensation sensitivity, and sensation avoiding were reported as 0.82, 0.88, 0.82, and 0.81 respectively . In this study, the online version of the SSP was used for sampling. Internal reliability of the online version ranges from 0.65 to 0.92 (Cronbach’s alpha for the SSP subscales was 0.71, 0.81, 0.71, 0.70, 0.74, 0.92, and 0.65, respectively). In this study, based on the division of Watson et al. , the sum scores of sensory seeking and low registration patterns were considered as the score of hyporesponsiveness, and the sum scores of the patterns of sensation avoiding and sensation sensitivity were considered as the score of hyperresponsiveness. Higher scores indicate normal sensory processing, and lower scores indicate sensory disturbances. The SSP cutoff scores include a score of less than 141 indicating a definite difference and a score between 142 and 154 indicating a possible difference in sensory processing. A score greater than 155 is considered normal performance .
The Spence Children’s Anxiety Scale (SCAS)
The Spence Children’s Anxiety Scale (SCAS) is designed to evaluate anxiety in children aged 6 to 12, based on the APA (DSM-IV, 1994) classification system. The scale includes six correlated factors: panic disorder, social phobia, separation anxiety, generalized anxiety, obsessive–compulsive disorder, and fear of physical injury. The scale has 38 questions, and Cronbach’s alpha for the subscales of the original version of the SCAS was reported as 0.82, 0.70, 0.70, 0.60, 0.73, and 0.73, respectively. The construct validity of the Persian version of the SCAS was confirmed using confirmatory factor analysis (P < 0.001). In addition, its reliability based on Cronbach’s alpha for the whole questionnaire was 0.89, and the subscales of the Persian version of the SCAS were reported as 0.82, 0.70, 0.70, 0.60, 0.73, and 0.73, respectively . In this study, the online version of the SCAS was used for sampling. Internal reliability of the online version ranges from 0.55 to 0.83 (Cronbach’s alpha for the SCAS subscales was 0.83, 0.68, 0.66, 0.62, 0.55, and 0.64, respectively.)
Children’s Communication Checklist (CCC)
The Children’s Communication Checklist (CCC) was created to identify the areas of communication disability not effectively assessed by current standardized language assessments . It is normally completed by a parent or other caregiver; however, teachers or other professionals who are familiar with the child might provide helpful information. It takes 5 to 15 min to complete and consists of 70 questions and 9 subscales of (A) speech, (B) syntax, (C) inappropriate initiation, (D) coherence, (E) stereotyped language, (F) use of context, (G) rapport, (H) social relationships, and (I) interests. The Pragmatic Composite Score (PCS) is the sum of the scores of five pragmatic subscales, C to G. Lower scores on this questionnaire indicate more difficulties. Internal reliability for the subscales of the original version of the CCC was reported as 0.86, 0.78, 0.80, 0.86, 0.87, 0.84, 0.87, 0.88, and 0.84, respectively . The checklist has been verified in Iran for children aged 6 to 11 years, with a Cronbach’s coefficient of 0.82 . In this study, the online version of the CCC was used for sampling. Internal reliability of online version ranges from 0.53 to 0.82 (Cronbach’s alpha for the CCC subscales was 0.78, 0.53, 0.77, 0.71, 0.82, 0.57, 0.54, 0.71, and 0.67, respectively).
The subjects were selected from three medical centers and two private clinics in Tehran based on the inclusion criteria. First, the examiner (first author) explained the objectives of the present study individually to the parents. To each parent who volunteered, the examiner immediately sent a link to the three questionnaires. While completing these questionnaires, the first author was available to answer any questions from the parents. A written consent was obtained from all participants. All three questionnaires were completed online by parents in the clinic waiting room. Completing all the questionnaires would take about 20 to 25 min. The sampling of this research, which was available as a sample, was done in the winter of 2021. In other words, we only sampled these centers and clinics for 3 months, and during this period, only 53 children met the inclusion criteria.
The data were analyzed using IBM SPSS 16.0 with a two-tailed p = 0.05. Pearson correlation was used to analyze the data to examine the relationship between research variables and research hypotheses.