Journal of Autism and Developmental Disorders

, Volume 48, Issue 11, pp 3831–3845 | Cite as

Treatment for Higher-Order Restricted Repetitive Behaviors (H-RRB) in Children with Autism Spectrum Disorder

  • C. Enjey LinEmail author
  • Robert Koegel
Original Paper


Restricted repetitive behaviors (RRB) are one of the core symptoms of autism spectrum disorder (ASD). Evidence suggests that higher-order RRB (H-RRB) are particularly challenging and can negatively impact family functioning (e.g., insistence on sameness, following idiosyncratic routines). The study examined the effects of a parent-implemented behavior intervention using a multiple baseline single case experimental design in three young children with ASD. The intervention involved self-management procedures and included principles of pivotal response treatment during which parents provided bids for children to vary from H-RRB and children obtained points for engaging in these other interests and activities. Results showed improvements in child behavior, parent and child affect and interactions, children’s engagement in family activities, and overall parent ratings of RRB.


Autism spectrum disorder Restrictive repetitive behaviors Repetitive behaviors Intervention Restricted interests Insistence on sameness 



The authors would like to thank the families who participated in the study and undergraduate assistants who aided with data management. The study was funded in part by the Ray E. Hosford Fellowship Research Grant and the Eli Broad Foundation.

Author Contributions

CEL conceived of the study, implemented the design of the study, collected data, conducted data analyses, interpreted the data and drafted the manuscript. RK participated in the conception of the study, design of the study, data analyses, and reviewed the manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.


  1. Albin, R. W., & Horner, R. H. (1988). Generalization with precision. In R. H. Horner, G. Dunlap & R. L. Koegel (Eds.), Generalization and maintenance: Life-style changes in applied settings (pp. 99–120). Baltimore, MD: Paul H. Brookes Publishing.Google Scholar
  2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.Google Scholar
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., DSM-5). Arlington, VA: American Psychiatric Association.Google Scholar
  4. Attwood, T. (2003). Understanding and managing circumscribed interests. New York: Guilford Press.Google Scholar
  5. Baker, M. J. (2000). Incorporating the thematic ritualistic behaviors of children with autism into games: Increasing social play interactions with siblings. Journal of Positive Behavior Interventions, 2(2), 66–84.CrossRefGoogle Scholar
  6. Bandura, A. (1978). The self system in reciprocal determinism. American Psychologist, 33(4), 344–358.CrossRefGoogle Scholar
  7. Barlow, D. H., & Hersen, M. (1984). Single case experimental design: Strategies for studying behavior change (2nd ed.). New York: Pergamon.Google Scholar
  8. Bishop, S. L., Richler, J., & Lord, C. (2006). Association between restricted and repetitive behaviors and nonverbal IQ in children with autism spectrum disorders. Child Neuropsychology, 12(4–5), 247–267.PubMedCrossRefGoogle Scholar
  9. Boyd, B. A., Woodard, C. R., & Bodfish, J. W. (2011). Feasibility of exposure response prevention to treat repetitive behaviors of children with autism and intellectual disabilities: A brief report. Autism, 0, 1–9.Google Scholar
  10. Campbell, D. T., & Stanley, J. C. (1963). Experimental and quasi-experimental designs for research. Chicago: Rand McNally & Company.Google Scholar
  11. Carcani-Rathwell, I., Rabe-Hasketh, S., & Santosh, P. J. (2006). Repetitive and stereotyped behaviours in pervasive developmental disorders. Journal of Child Psychology and Psychiatry, 47(6), 573–581.PubMedCrossRefGoogle Scholar
  12. Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 20, 37–46.CrossRefGoogle Scholar
  13. Cuccaro, M. L., Shao, Y., Grubber, J., Slifer, M., Wolpert, C. M., Donnelly, S. L., et al. (2003). Factor analysis of restricted and repetitive behaviors in autism using the autism diagnostic interview-R. Child Psychiatry & Human Development, 34(1), 3–17.CrossRefGoogle Scholar
  14. Evans, D. W., Leckman, J. F., Carter, A., Reznick, J. S., Henshaw, D., King, R. A., & Pauls, D. (1997). Ritual, habit, and perfectionism: The prevalence and development of compulsive-like behavior in normal young children. Child Development, 68(1), 56–68.CrossRefGoogle Scholar
  15. Fenstermaker, S. (1996). The dynamics of time use: Context and meaning. Journal of Family and Economic Issues, 17(3/4), 231–242.CrossRefGoogle Scholar
  16. Fiese, B. H., Tomcho, T. J., Douglas, M., Josephs, K., Poltrock, S., & Baker, T. (2002). A review of 50 years of research on naturally occurring family routines and rituals: Cause for celebration? Journal of Family Psychology, 16(4), 381–390.CrossRefPubMedGoogle Scholar
  17. Gabriels, R. L., Cuccaro, M. L., Hill, D. E., Ivers, B. J., & Goldson, E. (2005). Repetitive behaviors in autism: Relationships with associated clinical features. Research in Developmental Disabilities, 26(2), 169–181.CrossRefPubMedGoogle Scholar
  18. Green, V. A., Sigafoos, J., Pituch, K. A., Itchon, J., O’Reilly, M., & Lancioni, G. E. (2006). Assessing behavioral flexibility in individuals with developmental disabilities. Focus on Autism and Other Developmental Disabilities, 21(4), 230–236.CrossRefGoogle Scholar
  19. Harrop, C. (2015). Evidence-based, parent-mediated interventions for young children with autism spectrum disorder: The case of restricted and repetitive behaviors. Autism, 19(6), 662–672. Scholar
  20. Harrower, J. K., & Dunlap, G. (2001). Including children with autism in general education classrooms: A review of effective strategies. Behavior Modification.Special Issue: Autism, Part 1, 25(5), 762–784.CrossRefGoogle Scholar
  21. Hofferth, S. L., & Sandberg, J. F. (2001). How american children spend their time. Journal of Marriage & the Family, 63(2), 295–308.CrossRefGoogle Scholar
  22. Kazdin, A. E. (1974). Reactive self-monitoring: The effects of response desirability, goal setting, and feedback. Journal of Consulting and Clinical Psychology, 42(5), 704–716. Scholar
  23. Klin, A., Danovitch, J. H., Merz, A. B., & Volkmar, F. (2007). Circumscribed interests in higher functioning individuals with autism spectrum disorders: An exploratory study. Research & Practice for Persons with Severe Disabilities, 32(2), 89–100.CrossRefGoogle Scholar
  24. Klinger, L. G., Dawson, G., & Renner, P. (2003). Autistic disorder. New York: Guilford Press.Google Scholar
  25. Koegel, L. K., Koegel, R. L., Hurley, C., & Frea, W. D. (1992). Improving social skills and disruptive behavior in children with autism through self-management. Journal of Applied Behavior Analysis, 25(2), 341–353.PubMedPubMedCentralCrossRefGoogle Scholar
  26. Koegel, L. K., Koegel, R. L., & Parks, D. R. (1992). How to teach self-management to people with severe disabilities: A training manual. Santa Barbara, CA: University of California.Google Scholar
  27. Koegel, R. L., Bimbela, A., & Schreibman, L. (1996). Collateral effects of parent training on family interactions. Journal of Autism and Developmental Disorders, 26(3), 347–359.PubMedCrossRefGoogle Scholar
  28. Koegel, R. L., & Egel, A. L. (1979). Motivating autistic children. Journal of Abnormal Psychology, 88(4), 418–426.PubMedCrossRefGoogle Scholar
  29. Koegel, R. L., Koegel, L. K., & McNerney, E. K. (2001). Pivotal areas in intervention for autism. Journal of Clinical Child Psychology, 30(1), 19–32.PubMedCrossRefGoogle Scholar
  30. Korotitsch, W. J., & Nelson-Gray, R. O. (1999). An overview of self-monitoring research in assessment and treatment. Psychological Assessment, 11(4), 415–425.CrossRefGoogle Scholar
  31. Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159–174.CrossRefPubMedGoogle Scholar
  32. Lecavalier, L., Leone, S., & Wiltz, J. (2006). The impact of behaviour problems on caregiver stress in young people with autism spectrum disorders. Journal of Intellectual Disability Research, 50(3), 172–183.PubMedCrossRefGoogle Scholar
  33. Lee, S., Simpson, R. L., & Shogren, K. A. (2007). Effects and implications of self-management for students with autism: A meta-analysis. Focus on Autism and Other Developmental Disabilities, 22(1), 2–13.CrossRefGoogle Scholar
  34. Lovaas, O. I., Koegel, R., Simmons, J. Q., & Long, J. S. (1973). Some generalization and follow-up measures on autistic children in behavior therapy. Journal of Applied Behavior Analysis, 6(1), 131–166.PubMedPubMedCentralCrossRefGoogle Scholar
  35. Mahoney, M. J. (1972). Research issues in self-management. Behavior Therapy, 3(1), 45–63.CrossRefGoogle Scholar
  36. Mancina, C., Tankersley, M., Kamps, D., Kravits, T., & Parrett, J. (2000). Reduction of inappropriate vocalizations for a child with autism using a self-management treatment program. Journal of Autism and Developmental Disorders, 30(6), 599–606.PubMedCrossRefGoogle Scholar
  37. McConachie, H., & Diggle, T. (2007). Parent implemented early intervention for young children with autism spectrum disorder: A systematic review. Journal of Evaluation in Clinical Practice, 13(1), 120–129.PubMedPubMedCentralCrossRefGoogle Scholar
  38. Mercier, C., Mottron, L., & Belleville, S. (2000). A psychosocial study on restricted interests in high-functioning persons with pervasive developmental disorders. Autism, 4(4), 406–425.CrossRefGoogle Scholar
  39. Militerni, R., Bravaccio, C., Falco, C., Fico, C., & Palermo, M. T. (2002). Repetitive behaviors in autistic disorder. European Child & Adolescent Psychiatry, 11(5), 210–218.CrossRefGoogle Scholar
  40. Mischel, W. (1973). Toward a cognitive social learning reconceptualization of personality. Psychological Review, 80(4), 252–283.PubMedCrossRefGoogle Scholar
  41. Newman, B., Reinecke, D. R., & Meinberg, D. L. (2000). Self-management of varied responding in three students with autism. Behavioral Interventions, 15(2), 145–151.CrossRefGoogle Scholar
  42. Palmen, A., Didden, R., & Arts, M. (2008). Improving question asking in high-functioning adolescents with autism spectrum disorders: Effectiveness of small-group training. Autism, 12(1), 83–98.PubMedCrossRefGoogle Scholar
  43. Pierce, K. L., & Schreibman, L. (1994). Teaching daily living skills to children with autism in unsupervised settings through pictorial self-management. Journal of Applied Behavior Analysis, 27(3), 471–481.PubMedPubMedCentralCrossRefGoogle Scholar
  44. Richler, J., Bishop, S. L., Kleinke, J. R., & Lord, C. (2007). Restricted and repetitive behaviors in young children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37(1), 73–85.PubMedCrossRefGoogle Scholar
  45. Scahill, L., Aman, M. G., Lecavalier, L., Halladay, A. K., Bishop, S. L., Bodfish, J. W., et al. (2015). Measuring repetitive behaviors as a treatment endpoint in youth with autism spectrum disorder. Autism, 19(1), 38–52. Scholar
  46. Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., et al. (2015). Naturalistic developmental behavioral interventions: Empirically validated treatments for autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(8), 2411–2428. Scholar
  47. Schreibman, L., Kaneko, W. M., & Koegel, R. L. (1991). Positive affect of parents of autistic children: A comparison across two teaching techniques. Behavior Therapy, 22(4), 479–490.CrossRefGoogle Scholar
  48. South, M., Ozonoff, S., & McMahon, W. M. (2005). Repetitive behavior profiles in asperger syndrome and high-functioning autism. Journal of Autism and Developmental Disorders, 35(2), 145–158.PubMedCrossRefGoogle Scholar
  49. Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland adaptive behavior scales (2nd ed.). Circle Pines, MN: American Guidance Service.Google Scholar
  50. Stahmer, A. C., & Gist, K. (2001). The effects of an accelerated parent education program on technique mastery and child outcome. Journal of Positive Behavior Interventions, 3(2), 75–82.CrossRefGoogle Scholar
  51. Sytsma, S. E., Kelley, M. L., & Wymer, J. H. (2001). Development and initial validation of the child routines inventory. Journal of Psychopathology and Behavioral Assessment, 23(4), 241–251.CrossRefGoogle Scholar
  52. Troyb, E., Knoch, K., Herlihy, L., Stevens, M. C., Chen, C., Barton, M., et al. (2016). Restricted and repetitive behaviors as predictors of outcome in autism spectrum disorders. Journal of Autism and Developmental Disorders, 46(4), 1282–1296. Scholar
  53. Turner, M. (1999). Repetitive behaviour in autism: A review of psychological research. Journal of Child Psychology and Psychiatry, 40(6), 839–849.PubMedCrossRefGoogle Scholar
  54. Turner-Brown, L., Lam, K. S. L., Holtzclaw, T. N., Dichter, G. S., & Bodfish, J. W. (2011). Phenomenology and measurement of circumscribed interests in autism spectrum disorders. Autism, 15(4), 437–456. Scholar
  55. Ventola, P. E., Yang, D., Abdullahi, S. M., Paisley, C. A., Braconnier, M. L., & Sukhodolsky, D. G. (2016). Brief report: Reduced restricted and repetitive behaviors after pivotal response treatment. Journal of Autism and Developmental Disorders, 46(8), 2813–2820. Scholar
  56. Zaborskis, A., Zemaitiene, N., Borup, I., Kuntsche, E., & Moreno, C. (2007). Family joint activities in a cross-national perspective. BMC Public Health, 7(94), 1–14.Google Scholar
  57. Zandt, F., Prior, M., & Kyrios, M. (2007). Repetitive behaviour in children with high functioning autism and obsessive compulsive disorder. Journal of Autism and Developmental Disorders, 37(2), 251–259.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.University of California, San FranciscoSan FranciscoUSA
  2. 2.Stanford University School of MedicinePalo AltoUSA

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