Restricted and repetitive behavior patterns in autism spectrum disorder

Repetitive and restricted behaviors (RRBs), a hallmark of autism spectrum disorder, are a broad category that can include unusual motor manners as well as one or more patterns of interest. Some interests, such as toy cars or vacuum cleaners, help individuals with ASD cope but could interfere with social relationships or self-care. However, scientists have increasingly adopted the view that taking away restrictive behaviors can do more harm than good.¹

Consider the case of Raya Shields, who is on the autism spectrum and has Tourette syndrome and obsessive-compulsive disorder. Now 28, she recalls rocking back and forth in school to cope with noisy environments—and still does.² When teachers scolded her for being disruptive, she began suppressing these behaviors (also called “stimming” or “self-stimulatory”). ² With no alternative, she resorted to snapping her fingers—to the point where it became too painful to write. As a result, her schoolwork suffered.²

When individuals like Raya experience stigma due to their RRBs, this can result in increased loneliness, poor academic outcomes, and the masking of autistic traits to fit into a neurotypical world—all of which can negatively impact their mental health.³ With an estimated 256,000 individuals on the autism spectrum in U.S. high schools, there is a call to provide them with more inclusive and supportive environments.^4,5

This post explores types of RRBs and their impact on quality of life, effective interventions at home and in school, and better ways to support individuals with ASD.

Types of RRBs

Repetitive behaviors and fixed interests constitute one of two criteria that define autism in the Diagnostic Manual for Psychiatry (DSM). Simply preferring a strict routine is not enough for an autism diagnosis.⁶

According to the DSM, the behavior must be “abnormal in intensity or focus,” and changes to these behaviors must cause "extreme distress.” ⁶

Repetitive behaviors may include:^6,7

• Motor: Repetitive movements of the body or objects, hand-flapping, body rocking, spinning objects, or finger-flicking
• Fixated Interests: Intense focus or preoccupation with specific topics, objects, or activities, often to the exclusion of other interests
• Compulsions: Rituals performed to alleviate anxiety or distress, such as counting or arranging objects
• Self-Injury: Actions that result in physical harm to oneself, such as head-banging, biting, or scratching

Course Connection: SPED 743: FUNCTIONAL BEHAVIOR ASSESSMENT

This course provides a problem-solving approach and the framework for teaching and assessment strategies to develop pro-social behavior in students with disabilities and their typical peers in classrooms and whole school contexts. Students assess problem behavior, discover the functions of problem behavior, and learn pro-social alternatives in home, school, and community settings.

Course Connection: SPED 843: ADVANCED METHODS AND ASSESSMENT

This course is designed to introduce educators and related service professionals to prevention and intervention related to a broad range of antisocial, aggressive, and behavioral problems. Approaches focus on understanding and addressing the precipitating factors related to inappropriate behavior, short-term approaches for immediate crises, and problem-solving strategies for longer-term change.

Prevalence and variability

The CDC reports more boys are diagnosed on the autism spectrum than girls: four boys for every autistic girl.⁸ Experts point to several factors to explain the gap.

ASD diagnosis criteria have been based on observations primarily made in boys, resulting in a skewed understanding of the disorder's presentation.⁸ Second, many higher-functioning autistic girls are often overlooked or misdiagnosed because they tend to mask repetitive behaviors.⁸

Here are some differences to look for:

• Girls: Present repetitive verbal behaviors, such as echolalia (or scripting), which involves repeating words or phrases from media or conversations. ⁸
• Boys: Display more overt and stereotypical repetitive behaviors, such as hand-flapping, rocking, or intense fixations on specific objects or topics. ⁸

Educators and clinicians need to consider diverse expressions of ASD in both girls and boys to ensure accurate diagnosis and appropriate support. When girls aren’t correctly diagnosed, they don’t have access to early interventions. Lack of support can increase the risk of depression, anxiety, and low self-esteem by the time they enter middle school or high school.

Understanding the function of RRBs

In 2014, journalist Ron Suskind published the book, “Life, Animated,” chronicling the struggles of his son, Owen, who was diagnosed with regressive autism at age three. The Suskinds chose to encourage their son’s special interest in Disney movies and characters, which helped him learn to speak and read again.² “Life, Animated” was later turned into a movie by the same name, shedding light on the positive side of RRBs.

Research studies are becoming more inclusive, focusing on the lived experiences of individuals with ASD. Many autistic adults report that pursuing their intense interests is rewarding and brings them happiness.² While these interests have been labeled restrictive, they provide a coping mechanism, enhance self-confidence, and sometimes facilitate connections with peers.²

In light of these studies, there has been “a major paradigm shift in perceptions of special interests,” notes psychologist Rachel Grove of the University of Technology Sydney.² Autism advocates and scientists argue for treatment approaches that respect the dignity and independence of individuals with ASD, including the need to build on special interests, rather than discouraging them.²

Course Connection: EPSY 715: UNDERSTANDING RESEARCH IN EDUCATION

This course introduces the concepts and skills involved in understanding and analyzing research in education and related areas. The course provides an overview of basic, general knowledge of various research methodologies used in the online master’s in autism spectrum disorder program.

Impact on daily functioning

While there are reported benefits of RRBs, individuals can also engage in disruptive or harmful behaviors. It’s important to pay attention to signs that these behaviors impair an individual’s daily functioning. Some parents may not know the severity of the repetitive behavior, such as hair pulling, until they find clumps of hair in the child’s bedroom. There are resources for parents and caregivers that may be helpful.

In addition, if an individual is neglecting self-care to the point of sacrificing sleep or forgetting to shower, then it’s time to seek support.¹⁰

These questions can serve as a starting point for professional evaluation:

• Is the student approaching the special interest with such intensity that they cannot stop when they need to?⁹

• Is the intense interest or repetitive behavior disrupting family life?⁹
• Is it interfering with the student’s enjoyment of other activities?⁹
• Is it resulting in the student harming themselves?⁹
• Is it interfering with the student’s academic success or social development?⁹

Before developing any treatment plan for a student with ASD, special education teachers and medical teams can use questionnaires and other assessments to evaluate the impact that RRBs have on academic success, socializing, and family dynamics. Then, they can include parents in critical decisions and recommend targeted interventions that can be implemented at home and in school.

Management and intervention

When repetitive behavior impairs an individual’s ability to function or poses a threat to family members, medication can seem like the only hope for managing problematic behaviors. Risperidone and Aripiprazole are the only FDA-approved drugs that can be prescribed to treat irritability in children with autism spectrum disorder, but they don’t work for all individuals with ASD.¹⁰ Glen Eliot, medical director of the Children’s Health Council encourages families to first try behavioral interventions, especially with very young children.¹¹

One alternative to medication is a cognitive-behavioral approach, which teaches students to use other coping mechanisms, problem-solving skills, and relaxation techniques so that they have the tools to self-manage anxiety and distress that triggers RRBs.

Another option is Applied Behavior Analysis (ABA) therapy, which uses positive reinforcement. Some research shows it has been effective in teaching life skills and reducing harmful behaviors.

However, a 2018 study found that ABA therapy, which involves intense repetition, can be grueling and put individuals with ASD at higher risk for developing post-traumatic stress disorder.¹²

Parents and advocates are critical of it because of these negative experiences.^12,13 In school settings, structured teaching such as the use of visual schedules, can promote greater independence in students with ASD.

Supporting individuals with RRBs

Creating structured environments involves establishing routines and predictable schedules to help individuals with RRBs feel supported. If the student has an Individualized Education Plan (IEP) or 504 plan, some accommodations could include allowing them to stim at their desk or leave the classroom and go to a quiet, calming space.¹⁴

Another way to support students with ASD is to integrate their special interests into the curriculum. New York teacher Jenny Licata, who teaches autistic students in a mainstream classroom, has found this approach has academic and behavioral benefits.² For example, one 6-year-old girl, who has an intense interest in outer space, routinely struggled with transitions.² So, Licata turned her folder into a spaceship. Then, she cues the student to put work into the folder and switch activities by saying, “blast-off in 10,” which makes transitions less stressful. ²

Depending on the student’s school placement, effective supports might include:

• Modified environments: Reduce sensory overload with soft lighting, eliminate visual clutter, and provide quiet spaces¹⁴
• Sensory-friendly strategies: Allow use of fidget toys, chewelry (jewelry designed for chewing), or stress balls¹⁴
• Visual supports: Provide visual schedules to help reduce anxiety and promote predictability to ease transitions during the school day¹⁴
• Social stories: Promote social skill development in settings, such as the supermarket, doctor’s surgery, and playground¹⁴

By drawing on evidence-based best practices, special education teachers can develop personalized accommodations and integrate the special interests of students with autism spectrum disorder.

These measures can go a long way toward reducing the impact of challenging behaviors, while fostering a greater sense of belonging.

Collaborating with families of children with ASD

Families are vital in supporting children with autism spectrum disorder (ASD) and restricted and repetitive behaviors (RRBs). Understanding these behaviors, like repetitive motor movements or ritualistic behavior, is crucial for effective home support.

Parents manage repetitive behaviors by creating supportive routines and advocating for services outlined in the diagnostic criteria. They offer emotional support, aiding their child's navigation of social and communication deficits.

Educators play an essential role as partners in the collaboration between schools, parents, and caregivers; they can help align strategies between home and school environments.

Through open communication channels, all stakeholders can share insights, enabling a holistic understanding of the child's needs, including those related to stereotyped behaviors, autism repetitive behaviors, and repetitive sensory motor behavior.

This collaborative approach ensures that interventions are tailored to the unique characteristics of children with ASD and autistic children, as outlined in the diagnostic criteria. Through this shared understanding, educators, parents, and caretakers can develop effective support plans that address the child's restricted interests and repetitive body movements, promoting success in both academic and social settings.

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*Master of Science in Education (M.S.E.) in special education with an emphasis in autism spectrum disorder (ASD)