Restricted & Repetitive Behavior (RRB) in Autism: Assessment & Future Directions

Restricted and Repetitive Behavior (RRB) in Autism

The DSM-5 criteria for autism spectrum disorder (ASD) include restricted and repetitive behavior (RRB) as a core diagnostic feature, together with the domain of social communication and social interaction deficits. RRBs include: (a) stereotyped or repetitive speech, motor movements, or use of objects; (b) excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (c) highly restricted, fixated interests that are abnormal in intensity or focus; and (d) hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (American Psychiatric Association, 2013). Studies of RRBs have identified two sub-groups; one comprising repetitive sensory and motor behaviors (RSMB), such as repetitive hand or finger movements and rocking, and the other consisting of behaviors such as narrow interests, rigid routines, and rituals routines, which are collectively referred to as insistence on sameness (IS) (Bishop et al., 2013; Bishop, Richler, & Lord, 2006; Richler, Huerta, Bishop, & Lord, 2010).

Research indicates that repetitive behaviors may be among the earliest-emerging signs of autism (Wolff et al., 2014). There is also evidence to suggest that different types of RRB may be predictive of co-occurring mental health problems. For example, autistic children who demonstrate high levels of ritualistic and sameness behavior have been found to show more severe symptoms of anxiety and depression (Stratis & Lecavalier, 2013). Parents of children and teens also report that RRBs are one of the most challenging features of autism due to their significant interference with daily life. They can significantly impede learning and socialization by decreasing the likelihood of positive interactions with peers and adults. Given the importance of RRBs as a core feature of ASD, professionals should give increased attention to the assessment and presence of these behaviors, and their impact on the adaptability and psychological well-being of children and youth with ASD (Stratis & Lecavalier, 2013).

                                                                           Assessment

Rating scales and questionnaires are the most frequently used methods of measuring RRBs. For example, measures such as the Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri, 2010) and Social Responsiveness Scale (SRS-2; Constantino & Gruber, 2012) incorporate scales and treatment clusters assessing stereotypical behaviors, sensory sensitivity, and highly restricted interests characteristic of ASD. There are also specialized parent/caregiver questionnaires available that focus solely on restricted and repetitive behaviors and provide a more complete understanding of the impact of RRB factors on adaptive functioning. Of these questionnaires, 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, rather than relying exclusively on the above referenced broad-based ASD measures to assess RRBs. 

The RBS-R is a parent report of repetitive behaviors in children, adolescents, and adults with ASD. It consists of 43 items and includes the following subscales: Stereotyped Behavior, Self-Injurious Behavior, Compulsive Behavior, Ritualistic Behavior, Sameness Behavior, and Restricted Behavior. For each subscale, the number of items endorsed is computed as well as the severity score for the subscale. On the last question, respondents are asked to consider all of the behaviors described in the questionnaire, and provide a global severity rating.  The RBS-R has been reported to have adequate psychometric properties, and acceptable reliability and validity for each subscale (Bodfish et al., 2000; Boyd et al., 2010; Esbensen, Seltzer, Lam, & Bodfish, 2009; Gabriels, Cuccaro, Hill, Ivers, & Goldson, 2005; Lam & Aman, 2007).

The RBQ-2 is also a parent-completed 20-item questionnaire suitable for children (with or without autism) of all ages. Item responses fall into four groups which correspond to four specific areas: Repetitive Motor Movements, Rigidity/Adherence to Routine, Preoccupation with Restricted Interests, and Unusual Sensory Interests. Questionnaire scores can be added to provide a Total Repetitive Behaviors Score. As with previous research on RRBs, two clusters can be identified: RSMB, which corresponds to repetitive motor movements and unusual sensory interests, and IS, which corresponds to adherence to routine and restricted interests. The reliability and validity of the RBQ-2 has been supported with children and adolescents (Lidstone et al., 2014).

Future Directions

Restricted and repetitive behavior (RRB) is a core diagnostic feature of autism. Although these behaviors present a major barrier to learning and social adaptation, most of the research on ASD has focused on social and communication deficits, with less attention given to the RRB symptom domain (Boyd, McDonough, & Bodfish, 2012; Leekam, Prior, & Uljarevic, 2011). Further research and is needed to better understand their development, expression, assessment, and related clinical features (e.g., cognitive ability, adaptive functioning, comorbid disorders) (Stratis & Lecavalier, 2013). For example, it is important to understand how RRBs in typical development vary across time in order to compare atypical trajectories in children with ASD across intellectual and adaptive levels. Future research should also be directed to understanding the RRB subtypes and their relationship to comorbid symptoms such as anxiety and depression. 

Compared to the relatively large number of evidence-based, behavioral interventions for the social communication and interaction symptoms of ASD, RRBs are less likely to be included in intervention planning. There is a need to develop evidence-based interventions that are effective in treating the continuum of repetitive behaviors in order to provide support in this domain and improve RRBs before these behaviors become well-established (Leekam et al., 2011). In terms of assessment, measures such as the RBS-R and RBQ-2 should be included in a comprehensive developmental assessment to provide a more complete understanding of specific RRBs and their impact on adaptive functioning, as well as inform intervention selection (see Wilkinson for a description of assessment domains and recommended measures). Lastly, it is important to provide parents with education and training on how to effectively address these inflexible and repetitive patterns of behaviors that affect their everyday lives.

Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.

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Key References and Further Reading

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.

Bishop, S.L., Hus, V., Duncan, A., Huerta, M., Gotham, K., Pickles, A., Kreiger, A., Buja, A., Lund, S., Lord, C. (2013). Subcategories of restricted and repetitive behaviors in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43, 1287-97. doi:  10.1007/s10803-012-1671-0

Bodfish, J.W., Symons, F.J., Parker, D.E., & Lewis, M.H. (2000). Varieties of repetitive behavior in autism: Comparisons to mental retardation. Journal of Autism and Developmental Disorders, 30, 237–243.

Boyd, B. A., McDonough, S. G., & and Bodfish, J. W. (2012). Evidence-based behavioral interventions for repetitive behaviors in autism. Journal of Autism and Developmental Disorders, 42(6), 1236-1248. doi:10.1007/s10803-011-1284-z

Esbensen, A. J., Seltzer, M., Lam, K., & Bodfish, J. W. (2009). Age-related differences in restricted repetitive behaviors in autism spectrum disorders. Journal of Autism and Developmental Disorders, 39, 57–66. doi:10.1007/s10803-008-0599-x

Lam, K. S. L. & M. G. Aman (2007). The Repetitive Behavior Scale-Revised: Independent validation in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37(5): 855-866.

Leekam, S, Tandos, J., McConachie, H., Meins, E., Parkinson, K., Wright, C…Le Couteur, A. (2007). Repetitive behaviours in typically developing 2-year-olds. Journal of Child Psychology and Psychiatry, 48, 11, 1131-1138.

Leekam, S. R., Prior, M. R., & Uljarevic, M. (2011). Restricted and repetitive behaviors in autism spectrum disorders: A review of research in the last decade. Psychological Bulletin, 137, 562–593. doi: 10.1037/a0023341

Stratis, E. A., & Lecavalier, L. (2013). Restricted and repetitive behaviors and psychiatric symptoms in youth with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 757–766.

Wolff, J.J., Botteron, K. N., Dager, S.R., Elison, J. T., Estes, A. M., Gu, H…Piven, J. (2014). Longitudinal patterns of repetitive behavior in toddlers with autism. Journal of Child Psychology and Psychiatry, 55, 945-53. doi: 10.1111/jcpp.12207

Lee A. Wilkinson, PhD, NCSP 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 best-selling 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).

© 2018 Lee A. Wilkinson, PhD

Sensory Processing in Autism: Assessment & Intervention Strategies

Sensory Processing in Autism: Assessment and Intervention

Unusual sensory responses (i.e., sensory over-responsivity, sensory under-responsivity, and sensory seeking) are relatively common in children with autism spectrum disorder (ASD). Sensory issues are included in the DSM-5 ASD symptom criteria for restricted, repetitive patterns of behavior, interests, or activities (RRB), and include hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment; such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects (American Psychiatric Association, 2013). When present, these problems can interfere with adaptability in many areas of life (communication, daily living, socialization, occupational). For example, sensory processing problems have been found to be associated with eating problems and physical aggression in children with ASD (Mazurek, Kanne, & Wodka, 2013; Nadon, Feldman, Dunn, & Gisel, 2011). 

Sensory issues are an important concern, but not a diagnosis in of themselves. It should be noted that although there is general agreement that some children  have serious sensory challenges associated with impairments in development, learning, and self-regulation, sensory processing disorder (SPD) is not recognized as a distinct diagnostic entity by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), Individuals with Disabilities Education Act (IDEA), or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Nevertheless, sensory-related difficulties in children should be evaluated and addressed to promote positive outcomes related to socialization, behavioral regulation, and attention.

 Assessment

Understanding that sensory features can have a negative impact on daily life skills of autistic children, efforts should be made to ensure early identification of these sensory features to improve their functional and psychosocial outcomes. Although measures such as the Autism Spectrum Rating Scales (ASRS), Social Responsiveness Scale-2nd Edition (SRS-2), and Childhood Autism Rating Scale-2nd Edition (CARS-2) include items that assess sensory sensitivity and unusual sensory interests, questionnaires are available that focus “solely” on the sensory processing domain. For example, the Sensory Profile, Second Edition (SP-2; Dunn, 2014) and the Sensory Processing Measure (SPM; Parham, Ecker, Miller Kuhaneck, Henry, & Glennon,, 2007) are both questionnaires that can be used to assess sensory processing and behaviors across various childhood environments (home and school). 

The SP-2 is a widely administered family of questionnaires which measure children’s responses to certain sensory processing, modulation, and behavioral/emotional events in the context of home, school, and community-based activities. Each form provides a combination of Sensory System (Auditory, Visual, Touch, Movement, Body Position, Oral), Behavior (Conduct, Social-Emotional, Attention), and Sensory Pattern (Seeking, Avoiding, Sensitivity, Registration) scores. A short version (Short Sensory Profile-2) is available for screening and can be completed in 5 to 10 minutes. The Sensory Profile School Companion-2, a school-based measure, is also available to evaluate a child’s sensory processing skills and their effect on classroom behavior. It can be used in conjunction with other SP-2 measures to provide a comprehensive evaluation of sensory behavior across home and school settings (Dunn 2001; Kern et al., 2007; Crane, Goddard, & Pring, 2009).

The SPM is a norm-referenced assessment that produces scores for two higher level integrative functions (praxis and social participation) and five sensory systems (visual, auditory, tactile, proprioceptive and vestibular functioning). Processing vulnerabilities within each system include under- and over-responsiveness, sensory-seeking behavior, and perceptual problems. Three forms comprise the SPM (Home Form, Main Classroom Form, and School Environments Form), which provide a comprehensive picture of children's sensory processing difficulties at home and school. Each requiring 15 to 20 minutes, the Home and Main Classroom Forms yield eight parallel standard scores: Social Participation; Vision; Hearing; Touch; Body Awareness (proprioception); Balance and Motion (vestibular function); Planning and Ideas (praxis); and Total Sensory Systems. An Environment Difference score allows direct comparison of the child’s sensory functioning at home and at school. Both the SP-2 and SPM have been used with children with autism and have utility in program planning and developing accommodations for unusual sensory responses. Regardless of the questionnaire used, practitioners should use several other sources of information when documenting sensory features in autistic children, including interviews with parents and teachers along with behavioral observations.

                                                               Intervention Strategies

Best practice guidelines indicate that when needed, comprehensive educational programs for children with autism should integrate an appropriately structured physical and sensory milieu in order to accommodate unique sensory processing patterns (Wilkinson, 2016). Students with autism frequently require accommodations and modifications to prevent the negative effects that school and community environments can have on their sensory systems. These include (a) reducing the amount of material posted on classroom wall for a student who has problems with excessive visual stimulation; (b) teaching the student to recognize the problem and ask in their mode of communication to leave the area; (c) providing a low distraction, visually clear area for work; (d) providing alternative seating and a quiet/calming space when students become overwhelmed; and (e) using headphones or similar device to minimize high noise levels. 

Practitioners employing sensory integration therapy (SIT) should use clinical reasoning, existing evidence, and outcomes to create a comprehensive, individualized program for each student, rather than utilizing isolated, specific sensory interventions. Parents and professionals should also be advised that the research regarding the effectiveness of SIT is limited and inconclusive. Accommodations, modifications, and support services needed to address sensory issues should be integrated into the student’s individualized educational program (IEP) and/or treatment plan. The collaboration of knowledgeable professionals (e.g., occupational therapists, speech/language therapists, physical therapists, adaptive physical educators) is necessary to provide guidance about supports and strategies for children whose sensory processing and/or motoric difficulties interfere with educational performance and access to the curriculum. 

                                                                 Concluding Comments

Unusual sensory responses (i.e., sensory over-responsivity, sensory under-responsivity, and sensory seeking) are relatively common in autistic children and when present, may interfere with performance in many developmental and functional domains across home and school contexts. Practitioners must be alert to the presence of certain sensory features specific to children with autism, including hyporeactive and sensory-seeking profiles, along with difficulties in the hearing, tactile, gustatory, olfactory, and proprioceptive domains (Dugas, Simard, Fombonne & Couture, 2018). The persistence of sensory features from an early age highlights the need for identification and management to improve functional and psychosocial outcomes. Because they are often overlooked in many assessment procedures, attention to sensory problems should be an integral component of a comprehensive developmental assessment as they are often a prominent and concerning feature of the individual’s behavioral profile (Dunn, 2001; Harrison & Hare, 2004). Interviews and observation schedules, together with an evaluation of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, atypical behaviors, and cognitive functioning are recommended best practice assessment procedures (Campbell, Ruble, & Hammond, 2014; National Research Council 2001; Ozonoff, Goodlin-Jones, & Solomon, 2007; Wilkinson, 2017). Because autism affects multiple areas of functioning, an interdisciplinary team approach is essential for establishing a developmental and psychosocial profile of the child to guide intervention planning. Further information on best practice guidelines for assessment and intervention is available from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools (Second Edition). London and Philadelphia: Jessica Kingsley Publishers.

                                                Key References and Further Reading

American Academy of Pediatrics, Section on Complementary and Integrative Medicine and Council on Children with Disabilities, Policy Statement (2012). Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics, 1186-1189. doi: 10.1542/peds.2012-0876. Available from http://pediatrics.aappublications.org/content/early/2012/05/23/peds.2012-0876.full.pdf+html

American Occupational Therapy Association. (2010). The scope of occupational therapy services for individuals with an autism spectrum disorder across the life course. American Journal of Occupational Therapy, 64 (Suppl.), S125–S136.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.

Baranek, G. T. (2002). Efficacy of sensory and motor interventions for children with autism. Journal of Autism and Developmental Disorders, 32, 397-422.

Campbell, J. M., Ruble, L. A., & Hammond, R. K. (2014). Comprehensive Developmental Approach Assessment Model. In L. A. Wilkinson (Ed.), Autism spectrum disorders in children and adolescents: Evidence-based assessment and intervention (pp. 51-73). Washington, DC: American Psychological Association.

Constantino, J. N., & Gruber, C. P. (2012). Social Responsiveness Scale (2nd ed.). Los Angeles, CA: Western Psychological Services.

Crane, L., Goddard, L., & Pring, L. (2009). Sensory processing in adults with autism spectrum disorders. Autism, 13, 215-228.

Dugas, C., Simard, M.-N., Fombonne, E., & Couture, M. (2018). Comparison of two tools to assess sensory features in children with autism spectrum disorder. American Journal of Occupational Therapy, 72, 7201195010. https://doi. org/10.5014/ajot.2018.024604

Dunn, W. (2014). Sensory Profile-2. San Antonio, TX: Pearson.

Goldstein, S., & Naglieri, J. A. (2010). Autism Spectrum Rating Scales. North Tonawanda, NY: Multi-Health Systems, Inc.

Kern, J. K., Trevidi, M. H., Grannemann, B. D., Garver, C. R., Johnson, D. G., Andrews, A. A… Schroeder, J. L. (2007). Sensory correlations in autism. Autism, 11, 123-134.

Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465.

Nadon, G., Feldman, D. E., Dunn, W., & Gisel, E. (2011). Association of sensory processing and eating problems in children with autism spectrum disorders. Autism Research and Treatment, Article ID 541926, 8 pages. doi:10.1155/2011/541926

National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. Available from: http://www.nationalautismcenter.org/national-standards-project/phase-2/

National Professional Development Center on Autism Spectrum Disorders. (2015). Evidence-Based Practices. Available from: http://autismpdc.fpg.unc.edu/evidence-based-practices

National Research Council (2001). Educating children with autism. Committee on Educational Interventions for Children with Autism. C. Lord & J. P. McGee (Eds). Division of Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

O’Neil, M. & Jones, R. S. (1997) Sensory-perceptual abnormalities in autism: A case for more research? Journal of Autism and Developmental Disorders, 3, 283–93.

Ozonoff, S., Goodlin-Jones, B. L., & Solomon, M. (2007). Autism spectrum disorders. In E. J. Mash & R. A. Barkley (Eds.). Assessment of childhood disorders (4th ed., pp. 487-525). New York: Guilford.

Parham, L., Ecker, C., Miller-Kuhanek, H., Henry, D. A., Glennon, T. J. (2007). Sensory Processing Measure. Torrance, CA: Western Psychological Services.

Perez Repetto, L., Jasmin, E., Fombonne, E., Gisel, E. and Couture, M. (2017). Longitudinal Study of Sensory Features in Children with Autism Spectrum Disorder. Autism Research and Treatment, 2017, pp.1-8. https://doi.org/10.1155/2017/1934701

Research Autism. Sensory Integration and Autism. Available from: http://researchautism.net/interventions/28/sensory-integrative-therapy-and-autism

Schopler, E, Van Bourgondien, M. E., Wellman, G. J., & Love, S. R. (2010). Childhood Autism Rating Scale (2nd ed.). Los Angeles, CA: Western Psychological Services.

Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.

Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk…Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45, 1951-66. doi: 10.1007/s10803-014-2351-z

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered 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 best-selling 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).

© 2018 Lee A. Wilkinson, PhD