Early Identification of Repetitive Behavior in Autism

Early Identification of Repetitive Behavior

The DSM-5 criteria for autism spectrum disorder (ASD) include restricted and repetitive patterns of behavior (RRB) as a core diagnostic feature, together with the domain of social communication and social interaction deficits. Recent evidence suggests that restricted and repetitive behaviors may differentiate children who develop autism spectrum disorder (ASD) by late infancy. A study published in the Journal of Child Psychiatry and Psychology found that children who show several repetitive behaviors at their first birthday have nearly four times the risk of autism of children who don’t show repetitive behaviors.

Researchers collected parent-report data (Repetitive Behavior Scales-Revised) for 190 high-risk toddlers and 60 low-risk controls from 12 to 24 months of age. Forty-one high-risk children were classified with ASD at age 2. Profiles of repetitive behavior were compared between groups. The study found that the profiles for children diagnosed with ASD differed significantly from high- and low-risk children without the disorder on all measures of repetitive behavior. Toddlers with ASD showed significantly higher rates of repetitive behavior across at the 12-month time point. Repetitive behaviors were significantly associated with adaptive behavior and socialization scores among children with ASD at 24 months of age, but were largely unrelated to measures of general cognitive ability.

These findings suggest that as early as 12 months of age, a broad range of repetitive behaviors are highly elevated in children who go on to develop ASD. While some degree of repetitive behavior is essential to typical early development, the extent of these behaviors among children who develop ASD appears highly atypical. The study supports earlier findings that repetitive behaviors may be among the earliest-emerging signs of autism. It also points to new avenues of inquiry. While the search for early social deficits has received substantial attention from researchers, ritualistic, repetitive behaviors have largely been neglected. This is unfortunate because repetitive behaviors are often easier for a parent to notice than the absence of a social behavior. Parents of individuals with ASD also report that restricted and repetitive behaviors are one of the most challenging features of ASD due to their significant interference with daily life. Likewise, they can impede learning and socialization by decreasing the likelihood of positive interactions with peers and adults. 

Implications

Given the importance of restricted and repetitive (RRB) behavior, clinicians and practitioners should give increased attention to the assessment and presence of this behavior in screening and assessment as an early indicator and consider their impact on the psychological well-being of individuals with ASD. Restricted and Repetitive behavior (RRB) should be included as a core domain in a comprehensive developmental assessment. Although broad-based measures such as the Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri, 2010) and the Social Responsiveness Scale (SRS-2; Constantino & Gruber, 2012) incorporate scales and treatment clusters assessing stereotypical behaviors, sensory sensitivity, and highly restricted interests, there are parent/caregiver questionnaires that focus solely on restricted and repetitive behaviors and provide a more complete understanding of the impact of RRB on adaptive functioning. The most commonly used are the Repetitive Behavior Scale-Revised (RBS-R; Bodfish, Symons, Parker, & Lewis, 2000) and the Repetitive Behavior Questionnaire-2 (RBQ-2; Leekam et al., 2007). Both cover a wide range of repetitive behaviors and were designed as a quantitative index of RRB. Individuals who have marked deficits in social communication, but whose symptoms do not meet the RRB criteria for ASD, may be evaluated for social (pragmatic) communication disorder (SCD).

Adapted from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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Wolff JJ, Botteron KN, Dager SR, Elison JT, Estes AM, Gu H, Hazlett HC, Pandey J, Paterson SJ, Schultz RT, Zwaigenbaum L, Piven J. Longitudinal patterns of repetitive behavior in toddlers with autism. J Child Psychol Psychiatry. 2014 Feb 19. doi: 10.1111/jcpp.12207. [Epub ahead of print]

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).