b. Repetitious Behavior –
Raulston & Machalicek (2017) point out that within the repetitive behavior literature, there are generally two categories described – Lower-order: involving motor stereotypy like hand flapping, rocking, lining up toys, or flipping pages of a book; usually found in those very young children. Higher order: including obsessive preoccupation with odd interests and excessive question asking; usually found in those with advanced language skills.
Also, telling us that the latest edition of the Diagnostic & Statistical Manual of Mental Disorders – DSM-5, describes four areas of Restrictive & Repetitive Behaviors (RRB) to include:
- Stereotypy – repetitively tapping or banging an object on a surface; clutching, spinning, rolling, moving, or placing objects in a stereotypical manner.
- Insistence on sameness – inflexible adherence to routines or ritualized patterns of verbal (echolalia) or non-verbal behavior.
- Perseverative interests – uncontrollable repetition of a word, phrase or gesture despite the absence or cessation of a stimulus. Insisting to continue an act or activity without purpose.
- Hyper or hypo activity to sensory input or unusual interest in sensory aspects of the environment
< My Thoughts > “…four areas of Restrictive & Repetitive Behaviors in the newer DSM-5.”
One of the reasons clinicians say this is an important part of the newer DSM-5 is because it changes how they arrive at an accurate diagnosis for persons with autism.
The Centers for Disease Control & Prevention (CDC) put it this way –
- Stereotyped or repetitive motor movements
- Insistence on sameness, inflexible patterns.
- Highly restricted & fixated interests of abnormal intensity
- HYPO (under) or HYPER (over) activity to sensory input
In an Overview of Repetitive Behaviors in Autism, expert and parent, Lisa Jo Rudy tells us that repetitive, purposeless behaviors, like lining up toys, spinning objects, or opening and closing drawers or doors can become a problem when getting in the way of ordinary daily activities.
She tells us that the DSM-5 lists abnormal, intense focus on repetitive motor movement of objects, speech and highly restricted fixated interests, or preoccupation with unusual objects. Focus on such things as – ritualized patterns of verbal or nonverbal behavior, flipping objects, echolalia, and/or idiosyncratic phrases. As well as, insistence on sameness; or, inflexible adherence to routines, and extreme distress at small changes. Above text by Lisa Jo Rudy; retrieved from: https://www.verywellhealth.com/repetitive-behaviors-in-autism-260582
< My Thoughts > “…focusing on things…”
Sonny is nonverbal, he makes sounds and laughs, but no language, so all of his repetitive behavior is nonverbal. We purposely give him ‘interactive’ toys so that he can engage in ‘purposeless behaviors’. “Wait, what?” My reasoning is that, much like the autistic child or adult who repeats video scripts as a type of communication, Sonny can use his ‘See and Say’ toy. Of course, this is where the perseverance comes in.
“Someone poisoned the waterhole!” “Someone poisoned the waterhole!” “Someone poisoned the waterhole!”… (Courtesy of Tom Hanks’ voice, Toy Story 3) Sometimes accompanied by Sonny’s laughter… and sometimes by his sounds of frustration if his juice cup is empty.
Pushing the same button, over and over and over, for no apparent reason, can make the listener crazy. But, we have taken a cue from Sonny’s playbook, and just tune out what we don’t want to hear. Or, in the case of some really irritating sounds or phrases we just make a slight adjustment to that ‘See and Say’ button. Sometimes, I laugh, move him over and start hitting the button that yells “HELP MEEEE! HELP MEEEE! Smiles.
What perseverating may look like would be for the child to continue to have an adverse reaction to a noise, an action, or some undesirable stimuli… long after that stimuli has ceased. They may be unable to bring themselves out of prolonged stimming, even though the stimming isn’t calming them.
Zafer Elcik created Otsimo, a mobil education platform for his brother with autism. He tells us that outbursts or prolonged sessions of repetitive behavior can be signs of distress, joy, pleasure, or relaxation, as well as trying to attract attention. Hoping to help his brother and others gain speaking skills, he designed this app to reduce the need for unconventional perseverant speech and incessant question asking, i.e., echolalia.
Elcik believes that the prolonged duration of echolalia means not developing skills and socializing. And, that with speech therapies and trainings, echolalia can be reduced to effective acceptance, or even eliminated completely. Above text by Zafer Elcik; retrieved from: https://otsimo.com/en/avoid-repetitive-behaviors-autism/
Stokes (2018) says that children with autism have echolalia in greater frequency and is longer lasting when they have significant difficulty developing spontaneous generative language skills. She continues that many children with autism even repeat sophisticated utterances without an understanding of their meaning, or without any purpose at all. Some may have certain phrases they repeat when upset. One example she gives is the child who blurts out… “Everyone find a seat and start eating!” Or, another may answer questions by repeating the question back to you… “Want to go swing?”
< My Thoughts > “…speech therapies, trainings, and echolalia …”
Early in the late 1990’s, psychologists seem to assume that because those with autism did NOT have, or could NOT find the words to express what they were thinking, that they weren’t thinking at all. Sobel, Capps, & Gopnik (2005), explored the research to see if children with mental delay were more likely to perseverate than others. This study they found used the task of showing a single interpretation of an ambiguous figure of a rabbit/duck (see picture below), , to see if children were successful with ‘theory of mind’ tasks. ‘Theory of mind’ tasks (thinking that everyone is having the same ‘sensory experience’ that you are) seeming to be have been the gold standard assessment of the day.
They found a study where researchers of early social-cognition wanted to determine which children tended to perseverate on a single interpretation; children with autism, or those without. In that study, typically developing 5 year olds were said to have certain internal mental states such as beliefs, desires, intentions and emotions, with which children with autism may have difficulty.
< My Thoughts > “…children with autism and those without.”
At this point, the researchers ‘assumed’ that children with autism were delayed in their social-cognition. That they didn’t have the same ability for ‘elevated performance’ or ‘theory of mind’ which was expected from their peers without autism.
One of the proposed tasks in the research Sobel, et al. discussed was to ask the child to look at a picture and tell the person what they saw. The picture in this case was an ambiguous drawing of what could be interpreted as either a duck, or a rabbit, or both.
If the child spontaneously sees both, it was thought that s/he had the ability for higher order social functioning. If they only saw one or the other, then that was noted. At the end, there was an opportunity for that child to learn that the drawing could reveal another animal, other than the one they first identified.
After the learning opportunity, if the child sees the additional animal, then it was noted that they possibly had ‘executive functioning’ and/or ‘theory of mind’ abilities. But, if the child refused to believe that there was the ‘other’ animal, then they were noted to be ‘perseverating’ on the first animal they identified. Thus, they were thought to be ‘restricted’ in their task behavior.
Considered in the study was the possibility that the participating child just didn’t have the appropriate verbal skills to give the expected response. Also, that the child’s mental-state somehow equated with the child’s ability for awareness and learning.
< My Thoughts > “…child’s ability for awareness and learning.”
With Sonny and others, in the classroom setting, it’s always such a nice surprise to find out how powerful ‘awareness’ can be. That when showing a child another way to see something, understand something, or learn something… they often greet it with delight. They seem to know that they have just ‘learned’ something they didn’t know a minute ago. This is when ‘autism’ becomes ever a greater mystery as the teacher learns something about the autistic child that they didn’t know a minute ago. Smiles.
Raulston & Machalicek (2018) remind us that lack of screening and accurate assessment measures means that children with ASD are NOT likely to receive evidence-based practices. Therefore, there will be NO positive changes in the child’s developing nervous system and/or neuromuscular maturation. This means the child will continue with stereotypy behavior, insistence on sameness, and continued repeated ritualistic behavior.
< My Thoughts > “…continue with stereotypy behavior…”
Reading the above authors also reminded me of two of my favorite psychologists – Piaget & Vygotsky. Their approaches resonated with me because they believed that all children learn through stages of self-discovery, self-reflection, and autonomy. And of course there’s Vygotsky’s “zone of proximal development”, which is to say… the child has to be in the ‘zone’ before they can learn what you are trying to teach them. So therein lies the key… how do you get the child in the ‘zone’ in order to get them out of the ‘loop’ of restrictive, repetitive behavior? Smiles.
Garcia-Villamisar & Rojhn (2015) want us to know that there are ‘comorbid’ disorders which possibly moderate the relationship between Autism Spectrum Disorder and Repetitive and Restricted Behaviors (RRBs). Some of these simultaneous chronic conditions are: stress, anxiety, depressive mood, communication difficulties.
Their study of adults with autism also considered an impaired ‘executive function’ as being related to the severity of RRB. That is the brain’s ‘executive function’ allows the brain to carry out a sub-set of functions such as – the ability to make, attend to, and effectively perform goal-directed plans. Also, the ability to self-monitor and inhibit certain undesirable or inappropriate behaviors was considered. In the end, they ruled out impaired executive function as a contributing factor.
Mostert-Kerckhoffs, M., Staal, W., et al. (2015) did however, find a study which explored the processes which play a role in RRB in an attempt to detangle the influences of ‘response inhibition’ and ‘attentional flexibility’. The results of which seem to suggest that both ‘executive function’ brain processes are highly correlated and both play a role in RRB behavior in daily life.
They found in this study that autistic individuals, both children, adolescent, and adults, showed significantly more control dysfunctions than typically developing study participants. These difficulties were found to extend to auditory and visual flexibility tasks. In conclusion, they offered a suggestion to at least consider these things when working with students, and/or clients.
< My Thoughts > “…at least consider these things…”
Hundley, et al. (2016) would like us to consider another possibility which might well be part of the mix, and that is ‘sleep disturbances’ as associated with daytime behavioral problems. They add that poor sleepers were rated by their parents as showing more ritualistic and compulsive behavior in their children with ASD. Also mentioned by parents was the influence of nocturnal awakenings, sleep-onset delays and/or shortened overall sleep duration on their child’s anxiety and over-responsivity levels.
REFERENCES used here are:
Garcia-Villamisar, D. & Rojhn, J. (2015). Comorbid psychopathology & stress mediate the relationship between autistic traits & RRB in adult with autism; Journal of Intellectual Disability Research; V59, p116-124.
Hundley,R., Shui, A., et al. (2016). Relationship Between Subtypes of RRB & Sleep Disturbance in ASD; Journal of Autism & Developmental Discord; V46, p3448-3457.
Mostert-Kerckhoffs, M., Staal, W., et al. (2015). Stop & Change: Inhibition & Flexibility Skills Are Related to Repetitive Behavior in Children & Young Adults with ASD; Journal of Autism & Developmental Discord; V45, p3148-3158.
Raulston, T. & Machalicek, W. (2018). Early Intervention for Repetitive Behavior in Autism Spectrum Disorder: a Conceptual Model; Journal of Autism & Developmental Discord; V30, p89-109.
Sobel, Capps, & Gopnik (2005). Ambiguous figure perception and theory of mind understand in children with autistic spectrum disorders; British Journal of Developmental Psychology, V23, p159-174.
Stokes, S. (2018). Increasing Expressive Skills for Verbal Children with Autism; National Association of Special Education Teachers, https://www.naset.org/index.php?id=2771.
< My Thoughts > What I am offering here is a powerful story which may capture in a moment, what it is like to have this experience. (Echolalia)
No You Don’t – Essays from an Unstrange Mind by Sparrow Rose Jones, eBook Edition 2013; with < My Thoughts > by Sara Luker (Echolalia)
Focused Excerpts from the book (14% indicates location in the Kindle version of the book, instead of page numbers.)
14% I get hung up on words or phrases. There are words that are so funny to me that I can’t say them without fits of laughter. So often, they are ordinary words but they sound so hilarious to me that I almost choke on them. Other words have a disgusting, oily feel to me and I don’t like to say them. Saying one of those words is a horrible sensory experience I try to avoid.
Ever since I was a child, I get stuck on a word and begin repeating it over and over, tasting how odd it feels in my ears. I have a strange relationship with language anyway. Sometimes my partner lovingly teases me by calling me “Data,” after the android character on Star Trek: The Next Generation, because, like Data, my use of language is formal, almost to the point of being stilted, but I consciously insert colloquialisms I have collected from listening to others speak.
I admire a musical turn of phrase and have been known to cobbie together slang from a wide variety of sources in my speech. (I have also gotten in trouble with others more than once for using the wrong slang in the wrong place.)
< My Thoughts > “…I get stuck on a word and begin repeating it over and over…”
Here is a transcript that I ran across from You-Tube, that I (Sara Luker) would like to share with you:
Why Do Autistic People Repeat Words & Phrases? What’s Echolalia? An Autistic Perspective by Christa Holmans – Neurodivergent Rebel; September 2018.
First I will explain what ‘echolalia’ is for me. So, often…someone will say something to me or I will hear something and I will repeat it back. Most of the time, I will repeat it back with the same rhythm and tonality that I heard this in… So it can be a spoken word or two; it can be a whole sentence; it can be a sound that I like sometimes.
Uh…and (chuckles) the problem sometimes is people think I’m mocking them. And there’re usually two reasons I’ll actually do this so I think it’s a good thing to explain so people know that I’m not mocking you—nobody! I’m not mocking anyone and I don’t think anyone is trying to mock anyone else when they do this. (laughs) So, I’ll unpack the misunderstanding there.
But, I mean, just how this places in to my daily life and my everyday life is, you know, when I’m relaxed and with people I’m close to—I’ve got, you know, a few close friends and family—I… typically just randomly use song—sounds and…in conversations, make funny noises, and I will burst into song (laughs). “I often quote movie clips and other catchy one or two-word phrases.”
Once someone said to me – before I was diagnosed – they said, “You just like the sound of your own voice, don’t you?” I do kind of…like the sound of my own voice, but not in the way I think they intended.
You know, I like—I guess I’m seeker—I seek sounds. I like sounds; I like music. And it’s just something that I seek and I can stimulate my senses with my own voice by making funny sounds and funny voices and I enjoy the heck out of it. (shrugs and claps) And…that’s just my…very… plain English personal experience, uh explanation, of echolalia.
Transcript from – https://neurodivergentrebel.com/2018/07/04/why-do-autistic-people-repeat-words-phrases-whats-echolalia-an-autistic-perspective/ Includes You-Tube
What I am offering here is a powerful story which may capture in a moment, what it is like to have this experience. (Incessant Questions)
< My Thoughts > Autism repetitive behaviors definition from dailyhealthlifestyles.com relays that repetitive behaviors in autism can vary radically from person to person. For some people, it involves saying or talking about the same things over and over again (for example, listing all of Marvel's Avengers and their powers, reciting scripts from TV, or asking the same question many times in a row).
I Wish I Were Engulfed in Flames: My Insane Life Raising Two Boys with Autism by Jane Decker; eBooks 2011 edition with < My Thoughts > by Sara Luker (Incessant Questions)
Focused Excerpts from the book (2% indicates location in the Kindle version of the book, instead of page numbers.)
2% Jaxson is my second son. Jake is my first son, who also has autism. Jake also can’t tell a lie. Whenever he does something bad, he tells me about it immediately. For this reason, I think all people should have a touch of autism. Truth in advertising – you know what you’re getting.
3% I straddle Jaxson, holding his wrists down, hoping he’ll calm down enough so that I can get off him. I need an Ibuprofen. He’s in the middle of one of his tantrums and he’s all over the place – one moment kicking me in the stomach, the next moment patting me on the head.
6% I headed off to find out what was broken in the other room, hoping Jaxson didn’t need stitches.
“Mom, who is more irritating, me or Jaxson?” I stood over a broken Christmas bulb on the kitchen floor.
“You both have your moments,” I told Jake. “What do I do that’s as bad as his fits?”
“You ask a lot of questions. Questions, questions, questions. Questions are good, but sometimes when they’re coming as fast and furious as you ask them…it feels like getting hit with one of your brother’s little fists. Or a stun gun.”
“I guess I’m just bi-curious,” said Jake. I smiled. “Where did you hear that word?” “On TV somewhere,” Jake said as he picked up a few shards of red glass.
< My Thoughts > “Questions, questions, questions.”
I’m going out on a limb here, but having been around many verbal students with autism, my ‘semi-educated’ guess about the constant question asking is as follows –
Autistic children often are stuck with thoughts that won’t go away. Saying repetitive words or sing-songy words, or continually checking on something becomes their daily mantra or comforting ritual. Perhaps there is comfort in communicating and connecting with the adults in their world, by asking never-ending questions. After all it’s a way to get into the adult conversation game when they have not yet learned the social skills of an appropriate back-and-forth conversation.
< My Thoughts > What I am offering here is a powerful story which may capture in a moment, what it is like to have this experience. (Perseverate on perceived injustice). I offer this story here because while Sonny is non-verbal, due to the way his brain was formed, there are those who choose to be mute at times. This condition isn't often covered in the professional literature, so I wanted to include it here. Smiles.
The Aspie Parent, the First Two Years A Collection of Posts from the Aspie Parent Blog by Liz Cademy, eBook 2013 Edition; an Extended Review with < My Thoughts > by Sara Luker
Focused Excerpts from the book (26% indicates location in the Kindle version of the book, instead of page numbers.)
26% Writing from the blog – My son hates injustice and hates to be misunderstood; this can incite anger and rage. He is prone to temper or crying meltdowns, even in public, sometimes over small things. He’s even prone to ‘mutism’ when stressed or upset… or speaking in a raspy voice or monotone at times when stressed of sad. Strong sensory issues, like sounds, sights, smells, and touch bring on overload; even bouts of depression.
< My Thoughts > “…prone to ‘mutism’ when stressed or upset…”
Muris & Ollendick (2015) say selective mutism (SM) is a relatively rare childhood disorder characterized by a consistent failure to speak in specific settings (school, &/or social situations) despite speaking normally in other settings (at home). To establish the diagnosis the DSM-5 specifies that the absence of speech (SM) should be present for at least one month.
Furthermore, the DSM-5 states it NOT be attributable to lack of knowledge or discomfort with, the spoken language. And finally, that it should be an interference with daily functioning in those chosen settings (school, &/or social situations).
Clinicians noted that these persons also showed comorbid symptoms of anxiety-related behaviors simultaneously, such as shyness, withdrawal, and avoidance. Behavioral inhibition and SM seem to be linked, although they found no empirical support for that relationship.
One investigation, they say, showed a small percentage of children who met the full criteria for Oppositional Defiant Disorder (ODD). Parents reported them to be stubborn, sullen, irritable, and shy. They mentioned ‘situational anxiety’ and possible anxiety when separated from parents; although these actually being comorbid symptoms being experienced simultaneously was debated here by experts.
A suggestion was that psychologists, psychiatrists, and other mental health professionals consider remaining alert to the multifaceted nature of this disorder. And, to individually addressing, any of the other difficulties they find; such as problems with audio functioning, cognitive, speech/language development and other debilitating problems.
REFERENCES used here are:
Muris, P. & Ollendick, T. (2015). Children Who are Anxious in Silence: A Review on Selective Mutism, the New Anxiety Disorder in DSM-5; Clinical Child & Family Psychology Review, V18, p151 – 169.