What are 4 key take home treatment strategies that SLPs and OTs can apply.

I believe that it is important to first ask some questions regarding the repetitive behaviors including: Does the obsession, routine or repetitive behavior restrict the person's opportunities, cause distress or discomfort or negatively impact the individual's learning, participation or interaction? I would question if the behavior needs to be addressed if the answers to the above questions are NO. From the literature that I have read from adults with autism, it is evident that there is a benefit to SOME of the repetitive behaviors utilized in order to reorganize, regroup and de-stress. AND… What function does the repetitive behavior, routine or obsession have for the individual? Completing an FBA to try to determine the purpose/reason/cause of the repetitive behavior will likely provide necessary information to guide intervention strategies based on the function. All of that being said, some take home treatment strategies may include…


Contingency Modification Procedures are based on the premise that repetitive behaviors are learned and maintained by operant contingencies; there are studies that indicate this is an effective approach to reducing repetitive behaviors including verbal perseverations (Rehfeldt & Chambers, 2003). There are 2 types of procedures that can be utilized under this approach to reduce repetitive behaviors; 1.) contingent – utilized in response to a target behavior and may include punishment, 2.) noncontingent – utilized when a behavior is not exhibited for a period of time, reward for not engaging in the behavior. This would include differential reinforcement of other behaviors (DRO) or differential reinforcement of incompatible behaviors (DRI). Care needs to be taken when utilizing these approaches as obviously, the contingent approach can be viewed as punishment and not well viewed in many settings. I am not recommending this type of intervention but felt compelled to review it as it is listed as an effective approach in the literature.

Teaching and Prompting Alternative Activities – this is in direct contrast to those techniques in which the main purpose is to reduce the behavioral repertoire of individuals with autism; this approach seeks to expand the individual’s behavioral options.

One such example would be to provide social skills training which has been shown to decrease repetitive motor behaviors. A study conducted by Loftin et al., (2008), found that social interaction is incompatible with repetitive motor behavior. They hypothesize that because social interaction does not come easily to the individual with autism, the individual likely has to provide his/her full attention to engage in the social interaction. By providing training in social skills as well as the communication skills required for increased social interaction, and utilizing the necessary strategies and supports for the individual’s needs, the individual will be more competent and better able to engage in social interactions. We have learned of the difficulties that an individual with autism has in regard to social interactions and communication abilities, so care needs to be taken to address the areas of need to enhance the ability to participate in appropriate social and communicative interactions.

To address the issue that many individuals participate in repetitive behaviors to modify or alter arousal levels - monitor the sensory/arousal levels of the individual and incorporate strategies to neutralize the arousal state (environmental modifications, use of visuals, provide intervention strategies that will teach the individual alternative methods or strategies to achieve self regulation). I believe this starts at a very young age. Beginning to identify how a child is “feeling” either verbally or pictorially – utilizing concepts of self regulation (engine speeds). Developing strategies and teaching how to ask for assistance or seek the strategy independently by again using words or pictures. And I believe a huge first step is validating what the individual is feeling and teaching others in the lives of the individual that what he or she is “feeling” or perceiving on a sensory level is very REAL to them. I have seen this change in approach to an individual, even a very young child, make a huge difference. The idea is that by neutralizing the arousal level of an individual, there will be a decrease in the repetitive behaviors utilized by the individual in an attempt to self-regulate or block further sensory input. A study conducted by Gabriels et al, found that decreasing visual distractions in the learning environment reduces restrictive, repetitive and stereotyped behaviors, interests and activities (RBs) and increased on task behaviors. This study further indicates that reinforcing the environmental modifications to minimize visual distractors and increase regular opportunities for tactile and deep pressure/heavy work input helps to decrease RBs. This certainly is an implication for those of us who support children with autism in typical classroom environments where there are numerous visual distractors especially in preschools.

Teaching skills in general has been shown to decrease repetitive behaviors (motor, play, speech), in that skill development provides options for further choices and interactions. This will reduce the likelihood that an individual with autism will have only one option to carry out the same behavior over and over again (Turner, 1999).

Some literature encourages individual’s working with or interacting with individuals with autism, to join in the repetitive behavior. There is supportive information of the positive interactions that are elicited when the repetitive behavior is mimicked and joined. A relationship of sorts is established from which the behaviors can begin to be reshaped or expanded. As a way to first establish a relationship, then slowly expand behaviors in order to teach new skills.

As posed in an earlier post: review of the literature indicates that the perseverative nature of ASD individuals, while most often viewed as a weakness, can be regarded as a possible strength. Byrna Siegel reminds us as interventionists, that the perseverative tendencies may be utilized to influence motivation in a child who may otherwise be non-motivated. She challenges us to be creative and utilize the goal directed motivation (which can be seen when a “stim” or “stimming toy” is present) to achieve new learning.

Obsessions may be positively channeled to increase skills and areas of interest, promote self-esteem, and expand an individual's social group. Looking creatively at a particular obsession or repetition and thinking of ways of developing it into something more functional for the individual can be a very effective way of managing the behavior.

In summary
 Intervene early by setting boundaries around repetitive behaviors and obsessions from a young age and as they emerge.
 Increase environmental structure by using visual cues (eg timetables, daily planners), social stories, and pre-planning strategies to prepare for stressful events or change.
 Provide skill development opportunities including social skills training, relaxation and emotions identification training and skills to assist the individual better cope with change.
 Increase social, recreational and vocational opportunities for the person.
 Set clear and consistent boundaries around the behavior by rationing the object, the time or the place - remember to start small and go slowly.
 Explore alternative, more appropriate activities that have the same function as the repetitive behavior.
 Use obsessions to motivate and reward, develop skills, increase social opportunities and improve self-esteem.

Hope these posts have been informative and helpful. I have enjoyed reading others' special topics as well.


"Angela loved to rummage in the dustbins. Rather than stop the behavior, she was given the regular job of sorting the rubbish for recycling (bottles/paper/plastic) and ensuring rubbish was placed in the appropriate bins. Regular time was scheduled every day for this activity. A condition of this job was that she wears disposable gloves whilst sorting the rubbish and always wash her hands afterwards." (Clements & Zarkowska, 2000, p. 162)

The National Autistic Society, Obsessions, repetitive behaviors and routines, 2008

Turner, Michelle. "Annotation: Repetitive Behaviour in Autism: A Review of
Psychological Research." Journal of Child Psychology and Psychiatry 40.6
(1999): 839-849.

Loftin, Rachel, Samuel Odom, and Johanna Lantz. "Social Interaction and
Repetitive Motor Behaviors." Journal of Autism and Developmental Disorders
38 (2008): 1124-1135.

Rehfeldt, Ruth Anne, and Mark R. Chambers. "Functional Analysis and Treatment of Verbal Perseverations Displayed by an Adult with Autism."
Journal of Applied Behavioral Analysis 36 (2003): 259-261.

http://www.bbbautism.com/pdf/article_57_restricted_repertoires_in_autism.pdf

http://www.autismtreatmentcenter.org/contents/reviews_and_articles/research-social_interraction.php

Describe the Role of Stress Upon Repetition, Perseveration, and Self-Injury

The idea that repetitive behavior serves to decrease chronically high arousal levels (stress) in ASD has been prevalent for over three decades (Hutt and Hutt, 1970; Deitz & Singh, 1992). It has been hypothesized that “nonspecific activity of the ascending reticular activating system is at a chronically high level in individuals with autism, and that the individual strives to lower this by engaging in simple stereotypies that serve as displacement activities to block further sensory input relating to the arousing situation.” It has also been hypothesized that novel activities/situations can be arousing, resulting in the individual with autism to avoid novel interactions and prefer sameness. The overarousal hypothesis is based on the notion, that as situations increase in novelty, arousal levels will increase, as will repetitive behaviors. The opposite would then be proposed, that as more routine situations/interactions are encountered, anxiety will be reduced and the frequency of repetitive behaviors will decrease (Baron, Groden, Groden, Lipsitt, 149). Charop (1986) compared the rates of echolalia in children with autism when they were presented with an unfamiliar task by both a familiar and unfamiliar person. The highest rates of echolalia were observed when the children were presented the unfamiliar task by the unfamiliar person.

As reviewed by Baron, Groden, Groden, Lipsitt in their book entitled, Stress and Coping in Autism, stereotypies occur not only in individuals with ASD but also in typically developing individuals and animals. Stereotypies can arise spontaneously in captive animals and are usually indicators of stress as such behaviors often occur in environments that are considered boring or uncomfortable and where the potential for stress is high. Some studies indicate that repetitive behaviors are a coping mechanism as they have been found to reduce heart rate such as leg swinging in children, during crib-biting in horses and during stereotypic behaviors in pigs (Baron, Groden, Groden, Lipsitt, pg.150). There are also studies that indicate a lower level of baseline cortisol levels in stereotyping animals than that of similiar animals that are nonstereotyping. This suggests that stereotypy helps animals cope better with their captive environments. Some data from populations without autism suggests stereotypies are a means of self-soothing in aversive situations as changes in plasma endorphin levels are noted. These stereotypies may develop as an effective method of self soothing initially by increasing the levels of endorphins but the role of the endorphins may change over time as the ability of medications to block endorphins and block the repetitive behaviors diminishes as the behaviors become more a part of the behavioral repertoire.

A quote from an adult with Autism, pretty thought provoking….
"Reality to an autistic person is a confusing, interacting mass of events, people, places, sounds and sights. There seem to be no clear boundaries, order or meaning to anything. A large part of my life is spent trying to work out the pattern behind everything. Set routines, times, particular routes and rituals all help to get order into an unbearably chaotic life. Trying to keep everything the same reduces some of the terrible fear." (Jolliffe, 1992 in Howlin, 1998, pp. 201-202)


Baron, Grace, et al. Stress and Coping in Autism. N.p.: Published by Oxford
University Press US, 2006.

Turner, Michelle. "Annotation: Repetitive Behaviour in Autism: A Review of
Psychological Research." Journal of Child Psychology and Psychiatry 40.6
(1999): 839-849.

Lewis, Mark, and James Bodfish. "Repetitive Behavior Disorders in Autism ."
Mental Retardation and Developmental Disabilities 4 (1998): 80-89.

Summarize articles that discuss executive function and decision-making skills as they may contribute to repetitive behaviors.

‘Executive function’ is an umbrella term for functions such as planning, working memory, impulse control, inhibition and mental flexibility, as well as for the initiation and monitoring of action. A study conducted by Shafritz et al.,(2008) indicates that individuals with autism have lower activity in some brain regions compared with controls. The repetitive behaviors that are observed in individuals with autism are associated with this abnormal activity in the ‘executive’ brain system, which is responsible for attention, planning and for inhibiting inappropriate behaviors. A study conducted by Dalton et al., (2005) indicate that approximately 80% of adults with autism have some form of repetitive behaviors.

Only a few studies have tested repetitive behaviors using imaging. For this study, Shafritz had the participants lie inside the fMRI machine, holding a button in each hand. They were required to press the button in the corresponding hand for a specific geometric shape. 97% of the time, the shape was consistent but occasionally a different shape would appear and the participants had to press the other button. This test was designed to tap into the cognitive processes underlying the repetitive behaviors without making movements (in order to lie still during the scanning). Pressing the second button meant that the individuals had to change a previously repeated behavior. Shafritz found that compared with controls, adults with autism have more trouble switching to the new button for the target shapes.
The fMRI scans show that during these tasks, those with autism have lower brain activity compared with controls in three brain regions: the dorsolateral prefrontal cortex; the posterior parietal cortex; and the basal ganglia, deep within the brain. These areas are components of the brain’s executive functioning circuitry. Individual’s whose test results were higher for restricted and repetitive behaviors demonstrated lower brain activity in two smaller regions of the circuit: the anterior cingulate cortex and the intraparietal sulcus. This indicates that the circuit is less active which would imply a barrier to inhibiting over-learned responses, a “failure in the frontal ‘brake’ mechanism”.

Functionally, a deficit in the executive functioning impedes an individual’s ability to generate, plan, attend, and inhibit inappropriate behaviors. Turner hypothesizes that without the ability to regulate behavior appropriately or inhibit the repetitive behaviors, the autistic individual may only be able to carry out the same behavior in a repetitive fashion as if becoming “locked into” one line of thought or behavior. She also looks at the possibility of the repetitive behavior as a difficulty in generating novel behavior. We have learned of the many challenges that are faced by autistic individuals (motor planning, face processing, sensory processing, global to local processing, etc, etc, ) which would further impede the ability to inhibit repetitive behaviors or generate novel behaviors during play, self-care routines, social interactions, leisure activities, work, and other areas of the autistic individual’s life.

I found one article that briefly discussed the conventional behavioral approaches to autism, such as ABA or RDI, focusing on distraction and substitute behavior with suggestions for recovering the executive functions by increasing blood flow to the specific brain regions. Brief reference was made to hyperbaric oxygen therapy (HBOT) which would increase blood flow to the specific brain regions helping to improve brain function which was stated, in turn, would facilitate the ability to exert self-control in order to limit or eradicate repetitive behavior. More information regarding hyperbaric treatment with autistic individuals can be found searching the web or library. I have attached a link to a research article specific to autism and hyperbaric oxygen treatment.

http://www.hbotalabama.com/scripts/content/documents/PDF01%20-%20HBOT%20and%20Autism%20-%20Rossignol%202006.pdf

Shafritz, Keith, et al. "The Neural Circuitry Mediating Shifts in Behavioural
Response and Cognitive Set in Autism ." Journal of Biological Psychiatry
63.10 (2008): 974-980.
Turner, Michelle. "Annotation: Repetitive Behaviour in Autism: A Review of
Psychological Research." Journal of Child Psychology and Psychiatry 40.6
(1999): 839-849

Summarize at least 3 articles which explore play patterns, perseveration, and self injurious behaviors.

Play Patterns
Wolfberg (1995) defines play as an activity that is pleasurable, intrinsically motivated, flexible, non-literal, voluntary, and involves active engagement. In contrast, children with autism spectrum disorders often engage in inflexible, repetitive play patterns and may not exhibit symbolic or pretend behavior. Individuals with this disorder tend to view the world as concrete and literal; thereby displaying difficulty with abstract concepts and imaginative behavior. It is common for individuals with this disability to have restricted and unusual interests, so they may be resistant to explore play themes with others. The autistic child’s repetitive behaviors and lack of ability to understand a peer’s perspective may leave the peer not understanding how to effectively engage the ASD child in play and may result in the peer excluding a child with ASD.


Repetitive behaviors are characteristic of ASD but not exclusive to ASD as they are also seen in typically developing children and in children with other diagnoses. Repetitive behaviors are often present in typically developing children from infancy until approximately 4 years of age when there is a decline in these behaviors due to increased skills in the areas of emotional understanding and social communication. Children with ASD exhibit longer duration and more repetitive behaviors that tend to continue with age. There is evidence to support an association between repetitive behaviors and imagination in children with ASD. Studies reviewed by Honey et al (2006), have found that children with ASD demonstrate impairments in symbolic play and non symbolic play. It has also been reported that ASD children demonstrate less functional play and less elaborate functional play than their typically developing peers and peers with learning difficulties (Jarrold et al, 1996). Again, there are discrepancies in the research but the study conducted by Honey et al, found a correlation between repetitive behaviors and play in children with ASD between the ages of 2 and 8. This indicates that ASD children who exhibit fewer repetitive behaviors engaged in more play activities than ASD children who engaged in repetitive behaviors more frequently. It is interesting to note that typically developing children’s play abilities (2-4 years of age) were found to be predicted by expressive language but for the same age children with ASD, play was also predicted by repetitive behaviors. This information is in agreement with Wing and Gould (1979) indicating a three-way association between repetitive behavior, imagination and communication.

Honey, Emma, et al. "Repetitive Behaviour and Play in Typically Developing
Children and Children with Autism Spectrum DIsorders." Journal Of Autism
and Developmental Disorders 37 (2007): 1107-1115.

Perseveration
The study conducted by Watt et al (2008), examined repetitive stereotyped behaviors (RSB) in children between 18-24 months of age diagnosed with ASD and matched groups of children with developmental delays (DD) and typical development (TD). This study found that children with ASD demonstrated significantly higher frequency and longer duration of RSB with objects and RSB with body (moderate to large effect sizes) and sensory behaviors (small effects), compared to the DD and TD groups. A subset of RSB with objects was found to distinguish the ASD group – repetitively banging or tapping objects on a surface, rocking or flipping objects back and forth, swiping objects away repetitively, spinning, wobbling or rolling objects, moving or placing objects in a stereotyped manner or place and clutching objects for longer than expected. RSB with body that distinguished the ASD group included more repetitive banging of the table surface, rubbing the body and stiffening or posturing of the hands and fingers. This study did not find that sensory behaviors were related to repetitive behaviors with objects or body; however other studies have made this correlation (Gabriels et al).

This study also drew conclusions regarding a significant negative correlation between RSB with objects (but not body) with developmental level. Bishop et al. (2006) suggests that prolonged engagement in RSB over the developmental span of the 2nd and 3rd year of life may interfere with the ability to learn other skills impacting developmental outcomes/levels. This study also drew correlations between RSB with objects and social symptoms indicating that prolonged engagement in RSB with objects could impede social skill development over the 3rd year of life. In this larger study, early RSB was predictive of the severity of symptoms in ASD in the 3rd year of life and may be early red flags of autism in observational measures of children between 18-24 months. This study did not consider the potential functions of RSB but many other research studies have, with consideration given to stress reduction, sensory stimulation, reward, amelioration of an impoverished environment (Lewis and Bodfish, 1998), learned or operant behavior, cognitive impairment, weak “central coherence”, and executive dysfunction (Turner,1999).

Interesting video on youtube - with some good music! :) Just another perspective
http://www.youtube.com/watch?v=f15JexiQt4U


Watt, Nola, et al. "Repetitive and Stereotyped Behaviors in Children with Autism
Spectrum Disorders in the Second Year of Life." Journal of Child Psychology
and Psychiatry 49.8 (2008): 826–837.

Turner, Michelle. "Annotation: Repetitive Behaviour in Autism: A Review of
Psychological Research." Journal of Child Psychology and Psychiatry 40.6
(1999): 839-849.
Lewis, Mark, and James Bodfish. "Repetitive Behavior Disorders in Autism ."
Mental Retardation and Developmental Disabilities 4 (1998): 80-89.

Self-Injurious Behaviors
Self-injurious behavior often refers to any behavior that can cause tissue damage with two major theories providing possible functions of the behavior, physiological and social. Physiological reasons for self-injurious behavior may be biochemical. Some research suggests that the levels of certain neurotransmitters are associated with self-injurious behaviors. Beta endorphins produce an opiate like response and self-injury may increase the production or release of endorphins possibly increasing a euphoric-like feeling in the individual. Some studies have found drugs that block the binding at opiate receptor sites can successfully reduce self-injurious behaviors (Herman et al., 1989). Studies on laboratory animals have indicated that low levels of serotonin or high levels of dopamine are associated with self-injury as found by an increase in self-injurious and aggressive behaviors when medications were given to either reduce serotonin levels or increased dopamine levels (Mueller et al., 1982). Review of the literature indicates some research and anecdotal reports of decreased self-injurious behaviors after medical intervention including drugs to increase serotonin levels or decrease dopamine levels, as well as vitamin supplements (B6), calcium supplements, and changes to diet. A study conducted by Hollander et al (2003), found that the administration of oxytocin, decreased the severity and the number of different types of repetitive behaviors in autistic individuals confirming their hypothesis that deficits in oxytocin peptide processing plays a role in the severity of compulsive/repetitive and even self-injurious behaviors. Research also indicates the possibility of self-injurious behavior occurring as a result of seizures, genetic disorders, pain, frustration, arousal and sensory. The arousal theory suggests that self-injury may increase or decrease one’s arousal level. Self-injury to increase arousal level may be considered an extreme form of self-stimulation and self-injury to decrease arousal level may release tension/anxiety.

Possible social causes of self-injurious behavior may include poor communication skills leading to frustration. Social attention – Lovaas (1965), demonstrated self-injurious behaviors increasing when given positive attention or positive reinforcement whereas ignoring the behavior decreased the frequency of the self-injurious behaviors (extinction); extreme care needs to be given to consistency as the behavior will continue and even become more extreme if intermittently reinforced. Other individuals may engage in self-injurious behaviors as a way to obtain something they want such as an object or event (Durand, 1986). Another possible social cause is to avoid or escape an “aversive” social encounter. An individual may engage in self-injurious behavior prior to a social interaction in order to avoid the interaction or may engage in the self-injurious behavior to escape a social interaction that has already begun.

The concluding information from the Together For Autism website, reminds one that there are many possible reasons for an individual to engage in self-injurious behaviors. Edelson et al. (1983) observed three different forms of self-injury by the same individual. This individual banged his head against his knee and then received attention; pinched his stomach after the staff asked him to do something; and bit his wrist after he asked for something but did not receive it.

It is noted that when self-injurious behaviors occur, a functional analysis of the behavior should be conducted in order to obtain detailed information including a description of the behavior and the relationships between the behavior and physical and social environment. However, when self-injurious behavior is the result of a biochemical abnormality, there may be little or no relationship between the person’s physical/social environment and self-injury. The functional analysis would prove to be a valuable tool in trying to identify the cause of the self-injurious behavior to assist with implementing the correct intervention strategy as the various physiological and social possibilities as causes for self-injurious behaviors would have different interventions to address the underlying cause.

Edelson, Stephen. TogetherForAutism.org. 2009. 21 Mar. 2009
.

Hollander, Eric, et al. "Oxytocin Infusion Reduces Repetitive Behaviors in
Adults with Autistic and Asperger's Disorders." Neuropsychopharmacology 28
(2003): 193-198

How do skills/abilities and cognition impact perseverative play/repetitive play? How do play patterns/self-injurious behaviors impact daily function?

There are conflicting findings in the literature that examines the relationship between repetitive and stereotyped behaviors (RSB) and developmental levels in children with autism. Some studies, as reviewed by Watt et al. (2008) indicate a lack of association between RSBs and developmental levels (language stages and mental ages). However, other studies have found that RSBs and developmental levels were significantly related. Variabilities in age and the measures used to assess language stages and mental ages may have accounted for the discrepancies in the various studies.

One study by Bishop et al. (2006), examined 830 children with ASD and found that as the children got older there was a strong correlation between developmental levels and RSBs (lower developmental levels and increased RSBs – specifically resistance to change, compulsions/rituals, repetitive use of objects, unusual attachments, stereotyped speech and self-injury). With increased RSBs in terms of type and frequency, the obvious impact on play and daily function would be a decrease in functional abilities and/or acquisition of new skills. It has been found that early RSBs have a significant impact on the acquisition of a number of skills during interventions (Boppe et al. 2005). This study showed that preschool children with fewer RSBs at the onset of intervention showed more progress in social skill development over 2 years. It was also found that children who showed a decrease in RSBs within 6 months to 1 year of intervention demonstrated greater gains in language, ADLs and IQ scores over 2 years. Both findings demonstrate the significant need to work on decreasing the number and frequency of RSBs during the preschool years. It could be hypothesized that prolonged RSBs across the crucial developmental period of the 2nd and 3rd years of life may interfere with learning opportunities and may have a cumulative impact on developmental outcomes over time.

A point to ponder, review of the literature also indicates that the perseverative nature of ASD individuals, while most often viewed as a weakness, can be regarded as a possible strength. It could be considered that if a child prefers repetition, this type of task may produce more focused and sustained attention than tasks requiring flexibility and dynamic problem solving. On the negative side, of course, perseverative behavior can be regarded as mental “downtime” during which no new stimulation is being received. Byrna Siegel reminds us as interventionists, that the perseverative tendencies may be utilized to influence motivation in a child who may otherwise be non motivated. She challenges us to be creative and utilize the goal directed motivation (which can be seen when a “stim” or “stimming toy” is present) to achieve new learning.

Please view this PDF on play – http://www.thehelpgroup.org/pdf/Handout13.pdf

Watt, Nola, et al. "Repetitive and Stereotyped Behaviors in Children with Autism Spectrum Disorders in the Second Year of Life." Journal of Child Psychology and Psychiatry 49.8 (2008): 826–837.
Siegel, Byrna. Helping CHildren with Autism Learn: Treatment Approaches for Parents and Professionals. N.p.: Oxford University Press, 2003.