Restricted, repetitive
and stereotyped
patterns of behaviour,
interest and activities
Dr. Avril V. Brereton
Part One:
Managing special interests in
children with autism
“Obsessions”, “circumscribed interests”, “special
interests”, “routines”, “rituals” , “preoccupations”
are some of the terms used when describing the
behaviour of children with autism. These
behaviours belong to one of the three core areas
of impairment in children with autism. To put
these behaviours in perspective it is helpful to go
back to diagnostic criteria and consider the three
core areas affected in children with autism.
According to DSM-IV-TR (2000) these are:
1.
2.
Qualitative impairment in social interaction
Qualitative impairments in communication
And the area this fact sheet is concerned with3.
Restricted, repetitive and stereotyped
patterns of behaviour, interest and activities,
as manifested by at least one of the
following:
a. encompassing preoccupation with one or
more stereotyped and
restricted
patterns of interest that is abnormal
either in intensity or focus.
b. apparently inflexible adherence to
specific non-functional routines or
rituals.
c. stereotyped
and
repetitive
motor
mannerisms e.g.: hand or finger flapping
or twisting, or complex whole-body
movements.
d. persistent preoccupation with parts of
objects.
Special interests or obsessions fit into this third
area of “restricted, repetitive and stereotyped
patterns of behaviour, interest and activities”.
Children must have at least one of the symptoms
from this area of impairment, together with
symptoms from the other two areas for a
diagnosis of autism to be made. So young children
with autism may have preoccupations, and/or
non-functional routines or rituals and/or motor
mannerisms and/or preoccupations with parts of
objects. Some children with autism may present
with all of the symptoms in this core area while
others may have only one or two. Recent research
suggests that these symptoms are more likely to
occur after about three years of age. Because
autism is a developmental disorder, symptoms
will change over time and with age and
development.
What is important is that with each of these
symptoms, there is a descriptive word used to
emphasise that we are not talking about
occasional odd interests or odd movements.
These are “encompassing” preoccupations,
“apparently inflexible adherence” to routines and
rituals, “repetitive” motor mannerisms, and
finally, “persistent” preoccupation with parts of
objects. All young children can have favourite
toys and activities, and favourite topics of
conversation, but for the child with autism, these
interests become intense and focussed to a
degree that exceeds what is expected in typically
developing young children. Some children will
move from one obsession to another and the
obsession may last for weeks or months before it
changes. Others may develop an interest, for
example, in trains and Thomas the Tank Engine in
early childhood and continue with this interest
through adolescence and into adulthood. Below is
an illustration by a teenager with autism who at
three years of age would only play with his
Thomas trains and only wear Thomas clothes. You
can see that the train obsession has continued
and he now draws complex pictures of railway
sidings, trains and railway crossings.
Autism Friendly Learning: Restricted, repetitive and stereotyped patterns of behaviour, interest and
activities
1


Attending
Visual thinking.
What can we do to manage special
interests and obsessions?
Why do children with autism develop
special interests and obsessions?
Recent research is helping us to understand how
children with autism think and learn. The findings
of brain imaging studies are pointing to problems
in several areas of the brain. For example:
increased brain volume but decreased grey
matter in the limbic system (social cognition and
emotions); Reduced neurons in cerebellum
(motor)
and
parietal
lobes
(attention);
Abnormalities in prefrontal cortex (executive
function) and fMRI decreased activity in fronto
striatal circuits (executive function).
These brain anomalies affect emotions and
behaviour. For example, we know that some
children with autism have difficulty moving from
one task or activity to the next. They are unable
to move the focus of their attention – they get
stuck and cannot shift their attention easily. This
might be perceived as being obsessed with an
activity or thought but may also be explained by
problems with weak central coherence (inability
to integrate detail into the whole). Poor executive
function (the ability to plan, time, adapt
behaviour to act appropriately and with relevance
to a situation) may explain why some children are
rigid and inflexible and would prefer to follow
strict routines. These behaviours may also occur
when children are excited or anxious.
Some of the problems children with autism have
with thinking and learning






Difficulty seeing cause and effect
relationships
Focus on details
Difficulty sequencing
Difficulties with understanding of time
Compulsiveness
Distractibility
When discussing obsessions in autism, the term
'obsessions' is used narrowly, to indicate strong,
repetitive interests. First there needs to be some
thought as to how much of a problem the
obsession or special interest is for the child and
also the family and others such as teachers or
therapists. The rule of thumb when making
decisions about whether or not to intervene or
change behaviour (including special interests or
obsessions) is to ask yourself:




Does the behaviour endanger the child or
others?
Does the behaviour increase the likelihood of
social rejection or isolation?
Does the behaviour interfere with or
preclude participation in enjoyable activities
and an education programme?
Will the behaviour be acceptable in 5 years
time?
In young children with autism, obsessive and
special interests are most likely to be judged
inappropriate because they fall into the third
scenario and interfere with learning new skills
and participating in educational programmes.
Removal of obsessions is unwise and rarely
successful. Take an existing obsession away and a
new one will appear that may be worse than the
one you removed so care needs to be taken. Early
intervention and response to obsessional
activities is recommended because the longer an
obsession continues, the more entrenched it
becomes and more difficult to reduce.
Management, limitation and control
These are better than trying to remove
obsessions. Gradual change will also be less
distressing for the child. This should be done
gradually with an emphasis on teaching new skills
or play activities.
Time
Set clear consistent rules about when and where
obsessional activity is allowed and when is it not.
Photographs or simple behaviour scripts,
timetables and first-then strategies can be
helpful. An oven timer that shows time passing
can be used when setting limits on the time spent
Autism Friendly Learning: Restricted, repetitive and stereotyped patterns of behaviour,
interest and activities
2
talking about
topic/activity.
or
playing
with
a
favourite
Object
Limit the amount of a preferred object the child
may have. For example: Leave the Thomas trains
in the school bag; Rock collection stays in the car
when Mum drops child at school.
Shared activities
You may find that you can develop some shared
activities that utilize obsessions and special
interests. For example, play trains together for a
set time during the day or evening before bed; go
to the library together to find books about the
special topic of interests and look at them
together.
Consistency
You must be consistent across settings and
people when introducing management of
obsessions. It is very confusing for a young child
with autism if limits are different depending on
where and with whom he/she is.
References
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSMIV-TR), (2000) American Psychiatric Association.
Marjorie H. Charlop-Christy and Linda K.
Haymes (2004) Using Objects of Obsession as
Token Reinforcers for Children with Autism.
Journal of Autism and Developmental Disorders,
28, 189-198.
Ami Klin, Judith H. Danovitch, Amanda B. Merz,
Fred R. Volkmar (2007) Circumscribed Interests
in Higher Functioning Individuals With Autism
Spectrum Disorders: An Exploratory Study.
Research and Practice for Persons with Severe
Disabilities, 32, 89-100
National Autistic Society UK “Obsessions,
repetitive
behaviours
and
routines”
http://www.nas.org.uk/nas/jsp/polopoly.jsp?d=
1071 anda=7103
Remember obsessions can be used as
rewards to increase new behaviours and
teach new skills
There is an “upside” to obsessions and special
interests. They can be used as rewards and
motivators to teach new skills and behaviours.
Studies over the past twenty years have been
reporting the successful use of objects of
obsession rather than only using the more usual
reinforcers such as stickers, food and stars to
reward on task performance, and to decrease
inappropriate behaviours during work and play
sessions. Some special interests also provide a
source of enjoyment for young children who have
limited play skills.
If the obsession is not dangerous, to the child or
others, intruding on learning opportunities or
excluding the child from social opportunities it’s
probably OK to let it go.
Autism Friendly Learning: Restricted, repetitive and stereotyped patterns of behaviour,
interest and activities
3
Part Two:
Managing routines, rituals and
repetitive motor mannerisms
“Obsessions”, “circumscribed interests”, “special
interests”, “routines”, “rituals”, “preoccupations”
are some of the terms used when describing the
behaviour of children with autism. These
behaviours belong to one of the three core areas
of impairment in children with autism. To put
these behaviours in perspective it is helpful to go
back to diagnostic criteria and consider the three
core areas affected in children with autism.
According to DSM-IV-TR (2000) these are:
4.
5.
Qualitative impairment in social interaction
Qualitative impairments in communication
And the area this fact sheet is concerned with6.
Restricted, repetitive and stereotyped
patterns of behaviour, interest and activities,
as manifested by at least one of the
following:
a. encompassing preoccupation with one or
more stereotyped and
restricted
patterns of interest that is abnormal
either in intensity or focus.
b. apparently inflexible adherence to
specific non-functional routines or
rituals.
c. stereotyped
and
repetitive
motor
mannerisms e.g.: hand or finger flapping
or twisting, or complex whole-body
movements.
d. persistent preoccupation with parts of
objects.
Adherence to non-functional routine or rituals
and
stereotyped
and
repetitive
motor
mannerisms fit into this third area of “restricted,
repetitive and stereotyped patterns of behaviour,
interest and activities”. Children must have at
least one of the symptoms from this area of
impairment, together with symptoms from the
other two areas for a diagnosis of autism to be
made. So young children with autism may have
preoccupations, and/or non-functional routines
or rituals and/or motor mannerisms and/or
preoccupations with parts of objects. Some
children with autism may present with all of the
symptoms in this core area while others may have
only one or two. Recent research suggests that
these symptoms are more likely to occur after
about three years of age. Because autism is a
developmental disorder, symptoms will change
over time and with age and development.
Why do children with autism do these
things?
Some young children with autism develop a
resistance to, or fear of, change that then
involves being rigid in their approach to their
surroundings. Insistence on sameness, routines
and rituals begin. Certain items must be placed in
particular places and not moved. Objects may be
stacked or lined up in a repetitive manner.
Certain routes must be followed to and from
familiar places. Particular cutlery and crockery
must be used or the child refuses to eat or drink.
Perhaps confusion coping in a world that is
overwhelming is the cause of this behaviour, so
the young child with autism responds to this
uncertainty by being in control of what they
can...usually their immediate environment, the
objects in that environment and also the people
in it. Repetitive motor mannerisms may occur
when some children are excited, anxious, or
worried. For others, sensory sensitivities and
physical enjoyment may drive repetitive jumping,
arm flapping, twiddling of fingers in front of their
eyes and covering ears and eyes with their hands.
It
must
be
said
that
repetitive
behaviours/mannerisms in autism is a somewhat
neglected area of research. In the past, these
behaviours were associated with lower levels of
functioning and repetitive motor mannerisms are
also seen in children with intellectual disability
who do not have autism, so we cannot say they
are particular to children with autism. These
behaviours were also thought to increase during
the preschool years. There is now some evidence
that repetitive motor mannerisms develop
differently to insistence on sameness and these
behaviours follow different trajectories over time.
Richler et al, (2008) concluded that restricted and
repetitive behaviours “show different patterns of
stability in children with ASD, based partly on the
‘subtype’ they belong to. Young children with low
NVIQ (non verbal IQ) scores often have persistent
RSM behaviours (motor mannerisms). However,
these behaviours often improved in children with
higher nonverbal IQ (NVIQ) scores. Many children
who did not have IS behaviours (insistence on
sameness) at a young age acquired them as they
got older, whereas children who had these
Autism Friendly Learning: Restricted, repetitive and stereotyped patterns of behaviour,
interest and activities
4
behaviours sometimes lost them. Trajectories of
IS behaviours were not closely related to
diagnosis and NVIQ.”
What should we do about routines,
rituals, and repetitive motor mannerisms?
First ask yourself the question “How much of a
problem is it?” and ”Who for?” The answer is
often that these behaviours are a problem for
parents/carers, teachers and therapists rather
than the child him/herself, who is quite happy to
be preoccupied in these ways. Therefore, it is
unlikely that the child will want to change his/her
behaviour! The rules of thumb when making
decisions about whether or not to intervene or
change behaviour are to ask yourself:

Does the behaviour endanger the child or
others?
 Does the behaviour increase the likelihood of
social rejection or isolation?
 Does the behaviour interfere with or
preclude participation in enjoyable activities
and an education programme?
 Will the behaviour be acceptable in five
years time?
In young children with autism, adherence to nonfunctional routines and rituals and displaying
repetitive motor mannerisms may be judged
inappropriate because they fall into one or more
of these categories, or may be tolerated by the
family and others and are not seen as
problematic.
Let me give some examples:
Behaviour - Repetitive pacing
“Andrew” (5 years) paces the fence line in the back
yard of his home for about one hour every time he
arrives home from school. This is the only time he
paces like this and he was able to tell his parents
that it makes him “feel good” when he does this. He
is able to come inside and get on with the rest of his
day after this pacing. For “Andrew” it seems that
this repetitive pacing is necessary for him to calm
himself after the social demands of attending the
busy school environment. His family decided that
this was OK and felt they did not need to stop the
behaviour because it occurs in the privacy of his
own home and does not interfere with anyone else.
Behaviour - Repetitive pacing
“Billy” (6 years) was constantly flicking his ears with
his fingertips. He has made them bleed with the
frequency of the flicking. He did not seem distressed
about this, but his family and others were. It was
unclear as to why “Billy” was doing this and he
generally under reacted to pain so it was not
thought to be a sensory issue. A general assessment
of his learning, communication and play skills
revealed that he had a developmental delay, no
functional speech and very few play interests.
Observation over one week found an association
between “Billy” wanting something and the ear
flicking. He would stand beside an adult and flick his
ears. Management included slowly introducing
some photographs of desired objects (usually food).
“Billy” learned to use these to make requests and as
this communication skill increased, the ear flicking
decreased.
Behaviour - Rituals and routines (Shopping
aisles)
“Tamsyn” (4 years) enjoyed shopping in the
supermarket with her parents and always wanted to
go on this outing. However, when they arrived she
would scream if her parents did not go down every
aisle in the supermarket starting with aisle number
1. She would read the number and then direct her
parents down that aisle. At first the family thought
it was “cute” that she could read numbers but this
behaviour became very problematic when the
shopping trip extended into a very long activity.
They could not skip the aisles they did not need to
buy anything in or “Tamsyn” would throw herself on
the ground and scream. Other shoppers pointed and
stared or told the parents “She needs a good
smack.” It was decided that change would be
introduced gradually to decrease this routine. At
first, shopping was limited to going to buy one item.
Before going out, it was explained to “Tamsyn” that
mum would be buying “milk today”. She was shown
a photograph of the type of milk that would be
bought and “Tamsyn” knew the aisle number for
that item. A simple behaviour script with
photographs was prepared and read before the
shopping trip. “Car, shop, milk, home”. Tamsyn”
also took this with her. Very simple instructions,
consistency, use of a reward for “good shopping”
and a gradual increase in items to be bought worked
to change this rigid routine. (While this was
happening, mum and dad did most of the shopping
when “Tamsyn” was at child care!)
Before developing a response or management
plan to deal with restricted, stereotype
behaviours it is essential to gather the following
information about the child’s:
Autism Friendly Learning: Restricted, repetitive and stereotyped patterns of behaviour,
interest and activities
5





current profile of autism symptoms,
developmental level,
communication skills,
preferred activities (possible use of these as
rewards), and
Careful observation of the child to find out
when and where restricted, stereotype
behaviours occur and whether there are any
triggers to the behaviour.
Further reading
Emma Honey, Helen McConachie, Val Randle,
Heather Shearer and Ann S. Le Couteur (2008)
One-year change in repetitive behaviours in
young children with communication disorders
including autism. Journal of Autism and
Developmental Disorders , 38, 1439-1450
Richler, J., la Huerta, M., Somer L., Bishop, D. &
Lord, C. Stability of Individual Restricted and
Repetitive Behaviors in Children with Autism
Spectrum Disorders. The International Meeting
for Autism Research (London, May 15-17, 2008)
Autism Friendly Learning: Restricted, repetitive and stereotyped patterns of behaviour,
interest and activities
6