Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-020-04632-y

ORIGINAL PAPER

The Gap Between Cognition and Adaptive Behavior in Students

with Autism Spectrum Disorder: Implications for Social Anxiety
and the Moderating Effect of Autism Traits
Gil Zukerman1   · Gili Yahav1 · Esther Ben‑Itzchak2

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
The gap between cognitive ability and adaptive behavior has been thought to enhance psychopathology among people with
autism, particularly among those without intellectual disability. We examined this association by exploring the gap between
cognitive understanding of social behavior and socially adaptive behavior, and its impact on social anxiety symptoms,
obsessive–compulsive symptoms, and depressive symptoms, among 53 university students with autism (without intellectual
disability). A higher cognition—social adaptation discrepancy was associated with more social anxiety, but this effect was
moderated by autistic trait (AT) levels; a greater gap was associated with more avoidance symptoms of social anxiety only
among students with high AT. Cognitive flexibility and prosocial behavior may mitigate the effects of AT. Potential implica-
tions and interventions are discussed.

Keywords  Cognitive ability · Adaptive behavior · Autism traits · Social anxiety · Autism

Individuals diagnosed with autism spectrum disorder exhibit
a wide range of cognitive and verbal impairments (Ben-
Itzchak et al. 2008, 2014; Boucher 2012; Grzadzinski et al.
2013; Lord and Pickles 2006; Tager-Flusberg et al. 2005).
Along with these, adaptive behavior, which is essential for
independent living and includes daily living skills, social
skills, and communication abilities (Harrison and Oakland
2005), is reduced among this population (Lee and Park
2007; Liss et al. 2001; Matthews et al. 2015; Pugliese et al.
2015). This reduction appears even among individuals with
autism and without intellectual disability (Kraper et al. 2017;
Zukerman et al. 2019a).
* Gil Zukerman
gilzu@ariel.ac.il
Gili Yahav
giliyhv@gmail.com
Esther Ben‑Itzchak
benitze@ariel.ac.il
1 (Tassé et al. 2016); although associated, the two constructs
Department of Communication Disorders, School of Health
Sciences, Ariel University, Ariel, Israel
2 One of the Wechsler Adult Intelligence Scale (WAIS,
Bruckner Center for Research in Autism Spectrum Disorder,
Department of Communication Disorders, School of Health
Sciences, Ariel University, Ariel, Israel
In a typically developing population, adaptive skills are
positively associated with cognitive ability (Harrison and
Oakland 2000; Sparrow et al. 1984). However, among indi-
viduals with autism a different trajectory has been reported,
indicating a gap between cognitive and adaptive abilities
in toddlers that increases through adolescence (Bradshaw
et al. 2019; Volkmar 1987; Volkmar et al. 1993). This gap
is more evident among those without intellectual disability
(Fenton et al. 2003; Kanne et al. 2011; Myers et al. 2018;
Perry et al. 2009; Pugliese et al. 2015; Salomone et al. 2018;
Szatmari et al. 2009).
The associations between adaptive behavior and intel-
lectual ability have theoretical and clinical implications
(Fisher et al. 2016). The two abilities are tapped into differ-
ently—unlike intellectual ability that is measured through
meticulous examination under controlled conditions (IQ
testing), adaptive behavior is measured by a series of ques-
tions regarding everyday functioning. It has been suggested
that there is a correlational, but not causational, relation-
ship between intellectual functioning and adaptive behavior
may be independent and reflect distinct domains of abilities.
Wechsler 2008) subtests, the Comprehension subtest, is
considered to tap into verbal IQ. The individual is asked

13
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18 questions about social and other situations that focus on
“why we do things” or “how things work” in our society.
The subtest also includes two proverbs and demands intact
language ability, verbal expression, and flexibility (Kauf-
man and Lichtenberger 2006), as well as executive func-
tion (Arffa 2007; Thoma et al. 2009). Notably, individuals
with ASD (with and without intellectual disability) typically
perform worse on the Comprehension subtest than on other
WAIS subtests, even those that tap into verbal comprehen-
sion (Goldstein and Saklofaske 2010; Holdnack et al. 2011;
Koyama et al. 2006; Koyama et al. 2007; Mayes and Cal-
houn 2003; Nader et al. 2015; Oliveras-Rentas et al. 2012;
Rabiee et al. 2019; Wechsler 2003). Indeed, the Comprehen-
sion subtest contains unique features that combine demands
for language comprehension as well as abstract thinking; this
may constitute a significant obstacle for people with autism.
Due to the social context of its various items, this subtest has
been associated with knowledge, as well as understanding,
of abstract social norms/conventions (Kaufman and Lichten-
berger 2006; Nestor et al. 2010; Suchy and Holdnack 2013)
and was conceptualized to tap into social intelligence or
social competence (Sipps et al. 1987). Among individuals
with ASD without intellectual disability, a significant cor-
relation between performance on this subtest and the ADOS
Reciprocal Social Interaction domain (representing social
disability; Lord et al. 1999) was reported, leading the authors
to suggest that performance on this subtest relies, at least
in part, on knowledge of community and social norms as
well as the ability to elaborate a socially related action to
a specific situation (Oliveras-Rentas et al. 2012). However,
it is possible that due to its unique features, performance of
individuals with ASD without intellectual disability on this
subtest indicates a more cognitive (scholastic) understand-
ing of social behavior and less general IQ. This supposition
is supported by previous suggestions that high performance
on this subtest does not necessarily indicate social adjust-
ment and should be corroborated by other measures, such as
adaptive behavior inventories, in case of clinical evaluation
(Kaufman and Lichtenberger 2006).
Previous ASD research has reported a positive associa-
tion between full scale IQ scores and measures of anxi-
ety and depression, although verbal IQ was more strongly
associated with this psychopathology (Mayes et al. 2011;
Mazurek and Kanne 2010). Research has also suggested that,
among individuals with ASD without intellectual disability,
higher cognitive ability is associated with more awareness
and social comparison, which may result in more awareness
of impairments in social performance and therefore lead
to more anxiety and depression. Hedley and Young (2006)
reported that depressive symptoms were indeed associated
with higher levels of social comparison in this population.
An additional study reported that depression was associated
with greater self-perception of autism-related impairment,
13
Journal of Autism and Developmental Disorders
even when controlling for adaptive behavior levels (Gotham
et al. 2014). Among children with autism (without intel-
lectual disability), higher full scale IQ predicted lower
self-perceived social competence, which, in turn, predicted
higher levels of depressive symptomatology (Vickerstaff
et al. 2006). Recently, a positive association between a full
scale IQ—adaptive behavior gap and levels of depression
and anxiety was reported among those with autism and with-
out intellectual disability (Kraper et al. 2017), although this
finding was not replicated in a recent study of individuals
with autism including those with intellectual disability (Till-
mann et al. 2019). Although mostly conducted using a full
scale IQ assessment, indicating a broad array of intellec-
tual abilities, this finding may possibly suggest that, among
people with autism, the perceived gap between cognitive
ability, including understanding of social behavior (Compre-
hension subtest score) and adaptive behavior (social adaptive
behavior, in particular) might also lead to the development
of depression and anxiety. Other conceptualizations could
be suggested to account for the association between cogni-
tion—adaptive behavior discrepancy and psychopathology.
Previous research has suggested that some individuals with
autism tend to conceal their social communication difficul-
ties by a conscious effort to use learned social communi-
cative behavior (imitations, gestures) while internal social
communicative understanding is still impaired (Lai et al.
2011). This process, referred to as camouflaging (Hull et al.
2017), is more evident among women (Lai et al. 2017) and
was conceptualized as the discrepancy between the person’s
external behavioral presentation in social-interpersonal
contexts and the person’s internal status (social cognitive
capacity). It was suggested that a constant effort to mimic
conventional behaviors and “pretend to be neurotypical (nor-
mal)” may lead to exhaustion, elevated anxiety, and elevated
depression (Lai et al. 2011, 2017). Accordingly, depression
and anxiety may be the result of constant effort to conceal
autistic features by employing socially acceptable behaviors
(and not a direct consequence of elevated awareness of one’s
social disabilities).
The level of Autism traits could be associated with impor-
tant capabilities that may impact the ability to cope with a
cognition/adaptive behavior discrepancy and its effects on
one’s mental state and functioning. In neurotypical samples,
autism traits were negativity associated with higher order
cognitive abilities such as cognitive flexibility (i.e., the abil-
ity to disengage from one situation, orientation, or task and
shift to another in order to adapt to a new situation; Albein-
Urios et al. 2018; Geurts et al. 2009). Cognitive flexibility
has been reported to be reduced among individuals with
autism (Granader et al. 2014; Wallace et al. 2016). Accord-
ingly, one hypothesis is that this reduction, associated with an
autism-related impairment in executive function (Kenworthy
et al. 2008), may impair the ability to effectively cope with a
Journal of Autism and Developmental Disorders
cognition/adaptive behavior discrepancy. Various social situ-
ations may require adaptation to different ways of behaving
and those with low cognitive flexibility may stick to few rigid
ways of responding, in spite of intact intellectual understand-
ing. This may lead to more frustration and enhance the devel-
opment of psychopathology.
The current study was designed to assess the association
between cognition/adaptive behavior gaps and psychopathol-
ogy among university students with autism and without intel-
lectual disability. A focus on the adaptation of young adults
with autism to post-secondary education has drawn much
attention in recent years, although actual research in this field
is scarce and usually includes small numbers of participants or
case reports (Gelbar et al. 2014). Even in more recent studies,
a moderate sample size (N = 30–50) has been reported (Bol-
ourain et al. 2018; Hillier et al. 2018). Additionally, research
in people with autism in general (and with university students
in particular) has encountered a number of methodological
issues; researchers tend to use a cross-sectional, and, in many
cases, a single-case design (Gelbar et al. 2014). Most studies
use a factorial comparison when experimental manipulation
is tested; however, since people with autism are characterized
by high individual variability in performance, this approach
may be misleading (Bertollo et al. 2019). Previous research has
also suggested that people with autism are more compliant on
both self-report and experimental tasks (Chandler et al. 2019)
which can also affect research findings.
Among university students with autism and without intel-
lectual disability, high academic demands and on-campus liv-
ing may accentuate “gap awareness.” In this study, we were
specifically interested to find out whether the gap between
cognitive understanding of social behavior (as measured by
the Comprehension subtest score) and social adaptive behavior
(e.g., everyday behaviors such as initiating and organizing joint
activities with a group of friends, listening to a friend talking
about their problems, etc.) would be associated with internal-
ized psychopathology: anxiety (social anxiety, in particular)
and depression. An additional study aim was to examine the
effect of the level of autistic traits on the severity of psycho-
pathological symptoms of this cohort. Based on previous
research, we hypothesized that, among university students, the
discrepancy between cognitive understanding of social behav-
ior and adaptive social behavior would be positively associated
with psychopathology indices (anxiety/depression). In addi-
tion, we postulated that among students with higher levels of
autism traits, this association would be more robust.
Methods
Participants
The study population included 53 first degree (Bachelor’s)
students diagnosed with ASD) 4 females; Mage = 23.53,
SD = 2.81), that were studying in a medium size (15,000
students) public university. Inclusion criteria for the study
involved being a full-time university student, a diagno-
sis of ASD from a licensed neurologist or psychiatrist,
and a score ≥ 32 on the Autism Spectrum Quotient (AQ;
Baron-Cohen et al. 2001). This score has been associated
with clinically significant levels of autistic traits and is
used as a screening tool for autism spectrum conditions
among the general population (Baron-Cohen et al. 2001).
Participants were attending the university’s “integration
program” that guides students with autism through their
academic studies. All students had met the formal aca-
demic entry requirements of the university department into
which he/she applied and had been pre-interviewed by the
university’s integration program to ensure their potential
to adjust to on-campus living. Among the recruited cohort,
two participants received a marginal score on the AQ [29
and 31, respectively—lower than the suggested cutoff by
Baron-Cohen et al. (2001) but higher than 26, the cutoff
score suggested by others (Woodbury-Smith et al. 2005)
and accordingly were reassessed using the Social Com-
munication Questionnaire- SCQ (Berument et al. 1999).
Based on their high scores on the SCQ (19 and 21, respec-
tively), they were included in the study; a score of 15 on
the SCQ is the commonly-used cutoff criterion for ASD
(Barnard-Brak et al. 2016). Two additional participants
were excluded due to low AQ scores. Sixty-six percent
of the students in the current sample were affiliated with
the “exact sciences” fields of study (e.g., engineering and
architecture), 24.5% with humanities, and about 9.5% with
life/health sciences or other programs.
Measures
Adaptive Behavior Assessment System (ABAS‑II)
The ABAS-II (Harrison and Oakland 2003) provides
information on skills and adaptive behavior in the areas
of Communication, Community Use, Functional Academ-
ics, Home Living, Health/Safety, Leisure, Self-Direction,
Social (skills), and Work (for those who work). Scores in
different areas are presented as norm–referenced scaled
scores (M = 10; SD = 3). A General Adaptive Compos-
ite score (GAC) that taps into all domains of adaptive
behavior is calculated. Additionally, composite scores are
13

produced relating to the three main facets of functioning:
Conceptual (CON; Communication, Functional Academ-
ics, Self-Direction), Social (SOC; Leisure, Social), and
Practical (PR; Community Use, Home Living, Health/
Safety, Self-Care). The composite scores are trans-
formed into a norm-referenced standard score (M = 100,
SD = 15). The adult self-report version was used. High
internal consistency, high test–retest reliability, and high
convergence validity with the Vineland Adaptive Behav-
ior Scale (VABS) has been reported (Harrison and Oak-
land 2003). The ABAS-II has been used in several studies
that examined adaptive behavior among individuals with
ASD, indicating correlation between the ABAS-II GAC
and ASD symptomatology (Kenworthy et al. 2010; Lopata
et al. 2013). Among the current sample, the three ABAS-II
composite scores were in the 16th percentile reflecting low
average performance (Harrison and Oakland 2000) and
significantly lower than among a control group of typically
developing students matched for academic field affiliation,
as reported in a previous study (Zukerman et al. 2019a).
Autism Spectrum Quotient (AQ)
The AQ is a self-report questionnaire that quantifies autistic
traits among adults with average IQs (Baron-Cohen et al.
2001). Scores range from 0 to 50; the higher the score, the
more autistic traits a person possesses. Participants rate to
what extent they agree with statements on a 4-point Likert
scale. Relatively good internal consistency was reported
(Baron-Cohen et al. 2001). In this study, as in previous stud-
ies (Golan et al. 2006), the criteria for participation included
AQ scores ≥ 32 (associated with clinically significant levels
of autistic traits (Baron-Cohen et al. 2001) along with a for-
mal ASD diagnosis.
Comprehension Subtest of the WAIS‑III
This subtest measures apprehension of conventional rules of
behavior and social norms, and is associated with verbal IQ
(Wechsler 1997, 2008). Previous research has suggested that
performance on this subtest might be also associated with
language comprehension, abstract thinking. and executive
function (Arffa 2007). Acceptable split-half and test–retest
reliabilities were reported (0.84 and 0.81 respectively, Kauf-
man and Lichtenberger 1999). In the current study, the Com-
prehension subtest was taken from the WAIS–III, which has
excellent psychometric properties, particularly in terms of its
standardization and reliability (Kaufman and Lichtenberger
1999). Scaled scores for WAIS-III Comprehension subtest
were transformed into IQ standard scores (M = 100, SD = 15)
using the Norm Scale Calculator (Lenhard and Lenhard
2014) and in accordance with the expected procedure for
13
Journal of Autism and Developmental Disorders
clinical and experimental use (Dehm 2010; Lenhard and
Lenhard 2014; Wright and Wright 2006).
Liebowitz Social Anxiety Scale (LSAS)
The LSAS assesses social interaction and social perfor-
mance anxiety and includes 24 Likert scale items (0–3) that
are each rated for the experienced level of fear and avoidance
(Beard et al. 2011; Liebowitz 1987). A total score and fear
and avoidance subscale scores are produced (Beard et al.
2011). A total score of 35 in the self-report version of the
questionnaire is considered an optimal cutoff point for social
phobia/Social Anxiety Disorder (SAD; DSM-5, APA 2013)
(Rytwinski et al. 2009; Santos et al. 2015; von Glischinski
et al. 2018). High reliability and validity were reported for
the self-report version used in this study (Baker et al. 2002).
Beck Depression Inventory‑II (BDI‑II)
The BDI-II is a 21-item self-report measure assessing cogni-
tive, affective, and behavioral outcomes of depression (Beck
et al. 1996). The BDI-II is widely used and has high reli-
ability and validity (Beck et al. 1996). A cutoff score of 13
was previously suggested to indicate at least mild dysphoria
(Dozois et al. 1998).
Yale‑Brown Obsessive Compulsive Scale‑ Second Edition
(Y‑BOCS‑II)
The Y-BOCS-II measures symptom severity in obses-
sive–compulsive disorder (OCD) (Goodman et al. 1989).
The scale yields a total score (range 0–40) as well as sub-
scale scores for obsessions and compulsions (range 0–20
for each). Scores in the 0–13 range have been postulated to
indicate absent to mild symptoms, while scores of at least
14 to indicate moderate or greater symptomatology (Storch
et al. 2015). Previous research has demonstrated moderate
to high reliability and significant correlations with other
scales of clinical symptoms related to OCD (Deacon and
Abramowitz 2005).
Procedure
University Ethics Committee approval was obtained prior
to study onset. Participants gave signed informed consent
to participate (including permission to access information
regarding their academic program affiliation. The self-
reported version of the ABAS-II, LSAS, BDI-II, and AQ
were completed by the students themselves; a research
assistant was available, as necessary. The Comprehension
subtest of the WAIS-III and the Y-BOCS-II were adminis-
tered by a licensed clinical psychologist. Data was collected
from all 53 participants for the ABAS-II, LSAS, AQ, and
Journal of Autism and Developmental Disorders

Y-BOCS-II, from 47 participants for the WAIS-III Com- adaptive behavior gap (C-SOC) and level of autistic traits
prehension subtest, and from 42 participants for the BDI-II. (high/low AQ index) to the variance in severity of LSAS
(Distress and Avoidance), BDI-II, and Y-BOCS-II scores.
Data Analysis Regressions were conducted according to Dawson (2014).
Age was entered in the first step, the discrepancy between
Analyses were conducted using SPSS version 25 (Ark- Comprehension and social adaptive behavior (C-SOC) and
monk, N.Y.; IBM Corp., 2013). Missing data were com- the index level of autistic traits (high/low AQ index) in the
pleted for the ABAS-II, LSAS, and Y-BOCS-II. Imputation second step, and the interaction term C-SOC * AQ index
was conducted only when ≤ 20% of the data was missing, in the third step. The interaction was entered in a stepwise
used the “expectation maximization” technique, and only method.
when data was missing completely at random, by utilizing In addition, moderation was tested using computational
Little’s “missing completely at random” (MCAR) test. Nor- procedures for probing interaction as described by Hayes
mal distribution for each of the continuous dependent study and Matthes (2009). We investigated whether the associa-
variables was tested for skewness and kurtosis according tion between C-SOC and social anxiety is moderated by
to Kim (2013). A repeated measures analysis of variance autism traits (AQ index below/above median). Additionally,
was used to examine differences for the Comprehension we explored whether the association between C-SOC and
subtest and adaptive behavior domains across all partici- the level of autism traits (AQ score) would be moderated
pants. Pearson correlation analysis was conducted in order by anxiety (social anxiety index- LSAS score below/above
to examine the association of ABAS-II subdomain scores median).
(Conceptual [CON(], Social [SOC(], Practical [PR]) and the
psychopathology measures (LSAS, BDI-II, and Y-BOCS-II
scores). In addition, Pearson correlations were performed on Results
the difference between the WAIS-III Comprehension subtest
score and the scores of each of the three ABAS-II domains Skewness and kurtosis values indicated a normal distri-
of adaptive behavior (the gaps between these scores; there- bution of all continuous dependent variables (Z; p > 0.05;
fore, they are heretofore referred to as C-CON, C-SOC, and Kim 2013). Table 1 presents the characteristics of the study
C-PRA) and psychopathology. We also examined the cor- population. Low average scores on the Comprehension
relation between the AQ score and psychopathology indices subtest ­(19th percentile) as well as on the three domains
(LSAS, Y-BOCS-II, BDI-II). False Discovery Rate analysis
(FDR; Benjamini and Hochberg 1995) was used for correc-
tions of multiple correlations between those variables. Table 1  Characteristics of the study population
In order to study the effects of the gap between Com- Mean (SD) Range N
prehension and social adaptive behavior (C-SOC) and
autistic features (AQ) on psychopathology (LSAS/BDI- Age (years) 23.53 (2.81) 18–34 53
II/Y-BOCS-II), participants were divided according to ABAS
their median levels of: 1. AQ index (AQ < 46 = low AQ,  Conceptual 85.79 (14.43) 57–120 53
n = 26; AQ ≥ 46 = high AQ, n = 27); and 2. WAIS-III  Social 86.06 (16.62) 58–116 53
Comprehension score and social adaptive behavior index  Practical 85.16 (15.91) 48–120 53
gap (C-SOC < 5 = low gap, n = 23; C-COS ≥ 5 = high gap,  WAIS comprehension 87.97 (9.18) 70–120 47
n = 24). A 2 X 2 MANOVA (2 high/low AQ index X 2 high/  WAIS Comprehension—con- 3.70 (14.83) (–30)–37 47
ceptual
low C-SOC index) and follow-up ANOVAs with distress and
 WAIS Comprehension—social 2.81 (17.86) (–36)–48 47
avoidance LSAS subscales scores as dependent variables
 WAIS Comprehension—practi- 4.19 (16.50) (–34)–42.00 47
were then conducted. Additional 2 X 2 ANOVAs (2 high/low cal
AQ index X 2 high/low C-SOC index) were conducted with AQ 43.79 (4.50) 29–49 53
either depression level (BDI-II score) or obsessive–com- LSAS 44.64 (23.07) 3–108 53
pulsive symptom level (Y-BOCS-II score) as outcome vari- BDI II 9.59 (8.06) 0–28 42
ables. Greenhouse–Geisser corrections were applied as nec- YBOCS II 13.67 (5.87) 2–26 53
essary for violations of sphericity, and partial eta square ( 𝜂p2 )
served as an estimate for effect size of the ANOVAs. In all ABAS II Adaptive Behavior Assessment System II, AQ Autism Spec-
trum Quotient, Comprehension Comprehension subtest WAIS (III).
the analyses, Bonferroni post-hoc tests were used to examine
LSAS Liebowitz Social Anxiety Scale (LSAS), BDI II Beck Depres-
group differences. sion Inventory-II, YBOCS II Yale-Brown Obsessive Compulsive
Four linear regression analyses were conducted in order Scale II
to examine the contribution of the Comprehension/social Scores for the ABAS and Comprehension subtest are standard scores

13

of adaptive behavior (16–18th percentiles) were observed.
Comparison of standard scores revealed no significant dif-
ferences between the Comprehension subtest score and
adaptive behavior scores (or between adaptive behavior
domain scores themselves) (p = 0.21). The average reported
levels of social anxiety were beyond the cutoff point used
to differentiate individuals with and without Social Anxiety
Disorder—SAD (35), while a subclinical level of depres-
sion (BDI-II < 13) and a threshold level of OCD symptoms
(Y-BOCS-II < 14) were observed.
A correlation analysis indicted that ABAS-II Social and
Practical composite scores were negatively correlated with
the LSAS (social anxiety) total score, while C-SOC and
C-PRA (comprehension Social/Practical behavior gaps)
were positively correlated with the LSAS (social anxi-
ety) total score (Table 2). No significant correlations were
observed between the AQ score and any of the psychopa-
thology indices (LSAS, Y-BOCS II, BDI-II).
Next, we compared scores on the psychopathology indi-
ces (LSAS, BDI-II, Y-BOCS-II) between the groups des-
ignated according to their AQ index (Low/High AQ index)
and C-SOC index (Low/High C-SOC index) using a 2 X 2
MANOVA. For the LSAS scores, a significant C-SOC index
group effect was noted [Hotelling’s Trace; F(2, 42) = 4.70,
p = 0.01, 𝜂p2 = 0.18]. Univariate analysis revealed that the
High C-SOC group reported a higher level of avoidance
Table 2  Pearson correlations between ABAS-II composite scores,
Comprehension-ABAS-II composite scores, and psychopathology
indices
LSAS BDI-II Y-BOCS-II
r (n) r (n) r (n)
CON ABAS-II − .18 (53) − .01 (42) − .27* (53)
SOC ABAS-II − .42**† (53) − .12 (42) − .22 (53)
PRA ABAS-II − .37*† (53) − .11 (42) − .24* (53)
C-CON .19 (47) − .05 (39) .12 (47)
C-SOC .40**† (47) − .10 (39) .04 (47)
C-PRA .35**† (47) − .02 (39) .06 (47)
ABAS-II Adaptive Behavior Assessment System II, BDI-II Beck
Depression Inventory II, Comprehension Comprehension subtest
of the WAIS-III, CON ABAS-II Conceptual composite score of the
Adaptive Behavior Assessment System II, SOC ABAS-II Social com-
posite score of the Adaptive Behavior Assessment System II, PRA
ABAS-II Practical composite score of the Adaptive Behavior Assess-
ment System II, C-CON Comprehension subtest score of the WAIS-
III minus the Conceptual composite score of the ABAS-II, C-SOC
Comprehension subtest score of the WAIS-III minus the Social com-
posite score of the ABAS-II, C-PRA Comprehension subtest score
of the WAIS-III minus the Practical composite score of the ABAS-
II, LSAS Liebowitz Social Anxiety Scale, Y-BOCS-II Yale-Brown
Obsessive Compulsive Scale II
*p ≤ 0.05
**p ≤ 0.01
†
 Survived FDR correction q < 0.05
13
Journal of Autism and Developmental Disorders
Low C-SOC
High C-SOC
35
LSAS Avoidance score
30
25
20
15
10
5
Low AQ High AQ
Fig. 1  LSAS Avoidance scores as function of the discrepancy
between cognition (WAIS-III Comprehension subtest score) and
adaptive social behavior (ABAS-II Social composite score) below/
above the median, and autistic features (AQ scores below/above the
median). Standard errors are represented by the error bars attached to
each column. C-SOC Comprehension subtest score of the WAIS-III
minus the Social composite score of the Adaptive Behavior Assess-
ment System II, AQ Autism Spectrum Quotient, LSAS Liebowitz
Social Anxiety Scale
(Fig. 1) compared to the Low C-SOC group (F(1, 43) = 7.71,
p = 0.00, 𝜂p2 = 0.15). In addition, a significant interaction of
the C-SOC index and AQ index was observed [Hotelling’s
Trace; F(2, 42) = 3.85, p = 0.03, 𝜂p2 = 0.16]. Univariate anal-
ysis indicated that this interaction was significant for the
LSAS Avoidance score (F(1, 41) = 4.50, p = 0.04, 𝜂p2 = 0.09].
As presented in Fig. 1, among the High AQ group, those
with a high C-SOC gap reported greater Avoidance com-
pared to those with low C-SOC gap. This pattern was not
found among those with low AQ scores. Since both BDI-II
(depression) and Y-BOCS-II (obsessive–compulsive symp-
toms) scores were at subclinical or subthreshold levels in all
the designated groups, we did not compare group differences
for these psychopathology indices.
We then searched for predictors of the severity of social
anxiety (fear and avoidance subscales), depression, and
obsessive–compulsive symptoms, using linear regression
models. Only the model with LSAS Avoidance as a depend-
ent variable was significant (Table 3) and explained 32% of
the variance. The C-SOC gap and AQ index scores in the
second step added 24% to the explained variance; however,
only the C-SOC gap correlated positively and significantly
with severity of LSAS Avoidance. The interaction of C-SOC
* AQ scores in the third step added 8% to the explained
variance and was the only significant factor; among partici-
pants with a high AQ index, C-SOC levels predicted LSAS
Avoidance symptoms, while among those with a low AQ
index, this pattern was less robust. Using Hayes and Matthes
(2009) procedure, a significant moderation of autism traits
on the association between C-SOC and avoidance symptoms
of social anxiety (LSAS avoidance) was observed (p = 0.03).
However, the level of social anxiety (avoidance symptoms)
Journal of Autism and Developmental Disorders

Table 3  Linear regression Step Variable B SE β p R2 p R2Δ p

analysis for social anxiety
avoidance symptoms (LSAS 1 Age .18 .56 .04 .75 .00
Avoidance score, n = 47)
2 Age .20 .50 .05 .69 .24** .00 .24** .00
C-SOC 5.43** 1.48 .49 .00
AQind − 1.64 2.96 − .08 .58
3 Age .12 .48 .03 .80 .32** .00 .08* .03
C-SOC 1.77 2.21 .16 .43
AQind − 1.44 2.84 − .06 .61
C-SOC*AQind 6.30* 2.90 .43 .036

AQind Autism Spectrum Quotient by median (AQ < 46, AQ ≥ 46), C-SOC Comprehension subtest score
of the WAIS-III minus the Social composite score of the Adaptive Behavior Assessment System II; LSAS
Liebowitz Social Anxiety Scale
*p ≤ 0.05 **p ≤ 0.01

did not moderate the association between S-COC and AQ
score (p = 0.43).
Discussion
Among a cohort of university students with autism and
without intellectual disability, performance on the WAIS-
III Comprehension subtest (representing, among other con-
structs, cognitive understanding of social behavior) was
at the low-average range and comparable to the scores in
all domains of self-reported adaptive behavior (ABAS-II).
Importantly, while previous research reported an average
full scale IQ among autistic individuals without intellectual
disability (Chiang et al. 2014; Kraper et al. 2017) that might
relate to a broad array of intellectual abilities; our findings,
indicating lower than average performance on the Compre-
hension subtest (which is associated more with cognitive
understanding of social behavior than with IQ), are cor-
roborated by previous reports of impaired performance on
this subtest among people with autism without intellectual
disability (Goldstein and Saklofaske 2010; Holdnack et al.
2011). The below average performance may be explained
by the demands for intact executive function (problem solv-
ing, judgment) that completion of the comprehension subtest
imposes. In the current study, the discrepancy between this
subtest score (cognitive understanding of social behavior)
and functional social adaptive social behavior was positively
associated with avoidance of social situations. This finding
corroborates our first hypothesis, albeit confined to only one
area of psychopathology—social anxiety.
A closer look at the instruments used to measure social
function and anxiety may be useful to further understand
the findings. In the current study, we used the ABAS-II to
measure social functioning. Many of its items assess passive
or receptive social behavior such as "Avoids saying things
that might hurt or embarrass others," "Listens to friends/
family members that need to speak about their problems,"
and "Shows sympathy when others are sad or depressed."
In contrast, the LSAS, which measures social anxiety, uses
many items that tap into proactive social behavior that might
lead to rejection or conflict such as "To express disagree-
ment with someone," "To appear in front of an audience,"
and "To initiate a meeting with someone for romantic or
sexual purposes." Accordingly, one possible interpretation
of these findings is that awareness or acknowledgement of
one’s failure to translate academic understanding of social
behavior into everyday conventional social functioning
leads to restriction of proactive social behaviors that might
elicit negative reactions or rejection. Social anxiety, which
includes concerns about potential negative evaluation and
scrutiny by others (DSM 5, APA 2013), has been reported as
the most frequently occurring anxiety disorder among adults
and children with autism and without intellectual disability
(Bellini 2004; Cholemkery et al. 2014; Kuusikko et al. 2008;
Spain et al. 2016).
Interestingly, although all the students in our study exhib-
ited clinically significant levels of autistic traits, the positive
association between the cognition-adaptive behavior gap and
severity of social anxiety symptoms was evident only among
those with higher (above median) levels of autistic features.
Several explanations can be suggested for this novel finding.
One possible explanation is that relatively high/low autistic
traits are associated with different ways of coping with a
cognition/adaptive behavior discrepancy among people with
autism without intellectual disabilities. This difference in
coping might be related to cognitive flexibility, defined as
the ability to disengage from one task and to shift to another
in order to adapt to a new situation (Geurts et al. 2009). Cog-
nitive flexibility may be associated with social adaptation by
enabling implementation of different behaviors depending
on the social context, and consequently leading to better
adjustment. Cognitive flexibility has also been negatively
associated with autistic features (Albein-Urios et al. 2018).

13

Thus, one postulation is that, among autistic people without
intellectual disability and relatively elevated autistic traits
(including cognitive inflexibility), their intact academic
understanding of social behavior combined with awareness
of their social dysfunctionality may activate a rigid scenario
that includes anticipation of rejection and scrutiny from oth-
ers, and consequently lead to avoidance of social interac-
tions. Those with lesser autistic features (and, presumably,
greater cognitive flexibility) might be able to conceive of
more alternatives (negative as well as positive) for manag-
ing a social situation, in spite of their social skill inferior-
ity. These hypotheses are corroborated by previous research
findings indicating a significant association between cogni-
tive inflexibility and anxiety among individuals with autism
(Lawson et al. 2015; Wallace et al. 2016).
Another possible explanation, derived from the social
motivation hypothesis, postulates that high levels of autistic
traits may lead to a reduction in positive rewards associated
with social behavior and social interactions (Chevallier et al.
2012). Previous research has demonstrated that high levels
of autistic traits attenuated the extent to which reward learn-
ing for social stimuli (i.e., the association between reward
and social stimuli) is transferred into prosocial behav-
ior (Panasiti et al. 2016). Other researchers have reported
reduced activation of brain reward networks among people
with autism (Cox et al. 2015; Gossen et al. 2014). Among
neurotypical individuals in academic settings, more social
interaction and broader social networks has been associ-
ated with greater psychological gains (social and emotional
support) and academic gains (participating in collaborative
learning) (Blansky et al. 2013; Crosnoe et al. 2003; Goguen
et al. 2010) leading to better academic achievements (Brook
and Willoughby 2015). However, such rewarding outcomes
may be less stimulating for people with autism, a population
that is also characterized by diminished interest in collabora-
tive activities, social anhedonia, and more restricted social
networks, leading, possibly, to lower academic achievements
(Chevallier et al. 2012; van Asselt-Goverts et al. 2015; Zuk-
erman et al. 2019b). Accordingly, it is possible that, among
students with greater autistic features, social interactions are
not perceived as likely to achieve favorable outcomes, and a
larger gap between cognitive understanding of social behav-
ior and actual social behavior elicits more social avoidance.
In contrast, among students with relatively lesser autistic
features, more social motivation and, possibly more antici-
pation of positive outcomes associated with social interac-
tion, may lead to less avoidance of social situations, despite
awareness of social skill disparity. Another possibility is
that among those with high levels of autistic features, the
discrepancy between cognitive understanding of social
behavior and actual adaptive behavior leads to more pressure
to camouflage one’s behavior and thus, to more stress and
avoidance (Lai et al. 2017). Further studies should examine
13
Journal of Autism and Developmental Disorders
these possible explanations. Moreover, it is important to note
that although we divided the study population into those
with high and low levels of autistic traits, participants in
both groups reported high (> 29) AQ scores. Nevertheless,
according to the AQ norms for individuals with ASD estab-
lished by Baron-Cohen et al. (2001; M = 35.08, SD = 6.5),
the two groups’ standard scores represent the 7­ 4th and the
­96th percentile. We believe that such significant differences
in the levels of autistic traits (AQ score) may be expressed
in different ways of coping and, consequently, effect differ-
ently the development of internalized psychopathology. This
possibility should be taken into consideration when devising
university programs for integration of young students with
autism and without intellectual disability.
The current study is novel in its attempt to understand the
mental processes of young students with autism and with-
out intellectual disability who are acclimating to independ-
ent living and to campus life. Unlike previous research that
assessed full scale IQ and overall adaptive skills (Kraper
et al. 2017), the current study measured the gap between
cognitive understanding of social behavior (utilizing a spe-
cific IQ subtest—Comprehension) and real-world socially
adaptive skills. We also used standardized instruments that
tap into socially adaptive behavior. Previously, it has been
suggested that intact self-awareness among people with
autism without intellectual disability leads to focusing on
the oftentimes frustrating gap between cognition and adap-
tive ability, and therefore to more depression and anxiety
(Hedley and Young 2006; Vickerstaff et al. 2007). In the cur-
rent sample, the levels of depression and obsessive–compul-
sive symptoms were in the sub-clinical range, suggesting no
significant distress relating to these comorbidities. Instead,
the identified cognition/adaptive skill gaps were associated
with avoidance, but not distress, symptoms of social anxiety.
Thus, our finding does not support the hypothesis that such
gaps are associated with generally elevated internalized psy-
chopathology; rather, it suggests a more specific effect, cen-
tered around the anxiety elicited by actual social situations.
The current study has important potential clinical impli-
cations. The high prevalence of anxiety disorders among
people with autism (estimated to be as high as 50%; Spain
et al. 2018) requires scientific exploration aimed at under-
standing its genesis, course, and treatment (including con-
struction of intervention programs). Recently, it has been
asserted that the impact of a pre-existing impairment in
the ability to behave in a flexible manner, among people
with autism, may be magnified by an inherent tendency
to avoid anxiety-provoking situations such as social inter-
actions (Rodgers and Ofield 2018). The current findings,
indicating that the highest levels of social avoidance were
observed among those with more autistic features (and,
perhaps, less cognitive flexibility), also suggest a recipro-
cal association between those factors. Previous research
Journal of Autism and Developmental Disorders
has demonstrated the efficacy of Cognitive Behavioral
Therapy (CBT) in reduction of anxiety among individuals
with ASD (Ung et al. 2015), especially when such inter-
vention incorporates strategies for improving social inter-
actions, such as enhancing social skills, theory of mind,
and the ability to identify emotions in others (Attwood
2004; Luxford et al. 2016). Although we did not directly
measure cognitive flexibility, one possible suggestion,
considering the current findings, is that teaching students
with autism and without intellectual disability to think
about social situations in a more flexible and diverse man-
ner may reduce avoidance and facilitate better integration
into the social settings of post-secondary education. A
possible line of intervention among this population would
be to increase awareness of viable options to successfully
manage interactions with, and appropriately respond to,
others, within social situations, as is frequently done when
implementing CBT (Niles et al. 2014).
Notwithstanding its strengths, the study findings are
limited by the fact that the indices of measuring psycho-
pathology (social anxiety, depressive symptoms, obsessive
compulsive symptoms), and adaptive behavior are based on
self-report questionnaires. Moreover, the Comprehension
subtest, conceptualized in the current study to tap into the
understanding of social behavior, is also associated with
other important abilities such as language comprehension,
abstract thinking, and executive function; this may have
impacted our findings. Additionally, the male to female ratio
in the current study (4 females of 53 participants) is lower
than the typically estimated prevalence ratio of 4:1 (Fom-
bonne et al. 2011). Several studies have shown that ratio of
males to females is higher among autistic people without
intellectual ability (Scott et al. 2002; Lai et al. 2015), but
this was not supported in other studies (Idring et al. 2012;
Mattila et al. 2011). Accordingly, our finding might be more
applicable to men than to women. Future studies should
attempt to use a more balanced male/female sample. Finally,
the relatively modest sample size of our cohort, although
typical of similar studies of this subpopulation, recommends
caution when interpreting the current finding. Eventually,
the participants did not undergo a full psychological assess-
ment. Future research should attempt to address these issues.
The current study was a pioneering attempt to exam-
ine adaption to university life among young autistic adults
without intellectual disability. As such, the study findings
provide a platform for new hypotheses to understand the
relationship between gaps in cognitive and adaptive abilities
and the adaptation of autistic students without intellectual
disability to everyday functioning, particularly in the social
domain. The current findings suggest that a cognitive/behav-
ioral discrepancy leads to increased social avoidance among
those with more autistic features. Cognitive flexibility and
prosocial behavior have been suggested as possible factors
underlying the association between autism and social avoid-
ance and should be explored in future research.
Author Contributions  GZ and EBY and GY planned and
conceived the study. GY conducted the application of ques-
tioners to the study participants. GZ and EBYconducted the
statistical analysis as well as reviewed the paper. All authors
have approved the current version of the manuscript.
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