Restricted and repetitive behaviors and psychiatric symptoms in youth with autism spectrum disorders
Highlights
► Children with ASD experience high rates of co-occurring psychopathology. ► Restricted and repetitive behaviors (RRB) are predictive of psychiatric symptoms. ► Adaptive functioning moderates some of the RRB and psychopathology relationships. ► RRB may share etiologies with or be involved in the development of psychopathology.
Introduction
Autism spectrum disorders (ASD) are a group of neurodevelopmental disorders characterized by deficits in social and communication skills as well as the presence of restricted and repetitive behaviors (RRB). In contrast with the domains of social and communication skills, RRB have only recently begun to be systematically studied (Bishop et al., 2006, Carcani-Rathwell et al., 2006; Mirenda et al., 2010). RRB can cause significant challenges for both the individual with ASD and his or her family. RRB can additionally interfere with learning and socialization by decreasing the likelihood of positive interactions with peers (Nadig, Lee, Singh, Bosshart, & Ozonoff, 2010). Parents of individuals with ASD say that RRB are one of the most challenging aspects of ASD due to their significant interference with daily life (South, Ozonoff, & McMahon, 2005).
In the 4th edition of the Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association (APA), 2000), RRB are defined by the presence of at least one of the following: (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interests (“restricted interests”), (b) apparently inflexible adherence to specific nonfunctional routines or rituals (“ritualistic behavior” and “compulsive behavior”), (c) stereotyped and repetitive motor mannerisms (“stereotypic behavior”) and (d) persistent preoccupation with parts of objects. The proposal for the 5th edition of the DSM (DSM-5) indicates that RRB will remain a core feature of ASD, adding repetitive speech and sensory reactions to this domain (APA, 2012).
Individuals with ASD are more likely to be diagnosed with intellectual disability (ID) than the general population. In a review of 32 epidemiological studies, Fombonne (2003) concluded that 30 percent of individuals with autism have no intellectual impairment, 30 percent have mild to moderate ID and 40 percent have severe to profound ID. Level of functioning and chronological age impact the presentation of RRB in individuals with ASD. Lower-level RRB, including stereotypy, repetitive manipulation of objects and repetitive self-injurious behavior (SIB), are more common in younger individuals or individuals with lower intellectual functioning. Higher-level RRB, including object attachments, repetitive language and restricted interests, are more common in older individuals or individuals with higher intellectual functioning (Bishop et al., 2006, Carcani-Rathwell et al., 2006).
Individuals with ASD are at high risk of co-occurring psychiatric disorders including anxiety and mood disorders, attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). These psychiatric disorders that occur in individuals with ASD are phenotypically similar to disorders defined in the DSM-IV-TR (e.g., de Bruin et al., 2007, Gadow et al., 2008b; Leyfer et al., 2006). Research using semi-structured interviews such as the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) suggests that 70 to 80 percent of children with ASD meet diagnostic criteria for one or more co-occurring disorders and 40 to 50 percent meet criteria for two or more. Anxiety disorders (40–55%), ADHD (30–45%), ODD (10–30%) and mood disorders (5–15%) are the most common co-occurring disorders (e.g., de Bruin et al., 2007, Gjevik et al., 2011Leyfer et al., 2006, Mattila et al., 2010, Simonoff et al., 2008). Level of functioning is related to these co-occurring disorders in individuals with ASD. Higher functioning individuals are more likely to have anxiety and mood problems whereas lower functioning individuals are more likely to have symptoms of ADHD (Estes, Dawson, Sterling, & Munson, 2007; Gadow et al., 2008b). Psychopathology in individuals with ASD also has a large impact; for example, these symptoms are associated with increased caregiver stress (Lecavalier, Leone, & Wiltz, 2006).
Few studies have investigated the relationship between RRB and co-occurring psychiatric symptoms in individuals with ASD. All types of RRB, including stereotypic behavior, restricted interests, ritualistic behavior, compulsive behavior and SIB, are associated with parent-reported severity of anxiety, depression, ADHD, irritability and aggression (Lam, 2004) as well as parent-reported internalizing, externalizing and total problem scores on the Child Behavior Checklist (CBCL; Mirenda et al., 2010). Overall RRB are associated with parent reported hyperactivity as well as obsessions and compulsions (Lecavalier, Aman et al., 2006). However, most studies do not consider the impact of level of functioning, which is known to be associated with both RRB presentation as well as co-occurring psychiatric symptoms. In a small-scale study, Gabriels, Cuccaro, Hill, Ivers, & Goldson (2005) found that RRB are associated with irritability, hyperactivity and sleep problems. After controlling for nonverbal IQ, only hyperactivity remained significantly correlated with RRB.
The current study investigated the relationship of RRB and co-occurring psychiatric symptoms while controlling for level of functioning as indicated by parental report of conceptual adaptive behavior. A better understanding of the relationship between RRB and psychiatric symptoms has implications for genetic and neurobiological research as it could lead to refinement of ASD phenotypes and a better understanding of the pathogenesis of RRB. Additionally, understanding how co-occurring psychiatric symptoms impact the presentation of RRB (and vice versa) has implications for treatments and interventions designed to reduce the frequency and/or severity of RRB.
It was hypothesized that frequency and severity of RRB would positively correlate with specific psychiatric symptom domains. Specifically, it was predicted that anxiety symptoms would correlate most strongly with compulsive and ritualistic behaviors and that this relationship would be strongest for higher functioning individuals. Based on previous research, depressive symptoms were expected to correlate most strongly with repetitive SIB. Lastly, it was hypothesized that ADHD symptoms would correlate strongly with stereotypic behavior and that this relationship would be strongest for lower functioning individuals.
Section snippets
Participants
Participants were parents of children age 5 to 17 diagnosed with ASD. Participants were primarily recruited through school districts and autism schools in Central Ohio and additionally through programs and clinics in Central Ohio, national parent associations and an autism school in Providence, RI. Eligibility was based on parent reported ASD diagnosis, receipt of special education services and a score of 11 or higher on the Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003
Results
Zero-order correlations among the measures are presented in Table 2 and results of the hierarchical multiple regression analyses are presented in Table 3. The Conceptual domain of the ABAS-II did not emerge as a significant predictor of any psychiatric symptom domain. Ritualistic/Sameness Behavior was a significant positive predictor of Anxiety symptom severity. The Conceptual domain of the ABAS-II emerged as a moderator of the relationship between SIB and Anxiety symptom severity. The nature
Discussion
Consistent with previous research (e.g., Lam, 2004, Mirenda et al., 2010), zero-order correlations suggested relationships between most types of RRB and psychiatric symptoms. However, these relationships were further clarified using multiple regression to determine which domains of RRB were most predictive of psychiatric symptom severity. Inconsistent with prior research (e.g., Estes et al., 2007, Gadow et al., 2008a; Gadow et al., 2008b), all psychiatric symptom domains of the CSI-4 were
Conclusions
This study demonstrated relationships between several types of RRB and psychiatric symptom severity, further clarifying this relationship in individuals with ASD. Individuals with high levels of ritualistic and sameness behavior tend to show more severe symptoms of anxiety, depression and ODD. High levels of restricted interests are associated with less severe symptoms of depression, suggesting that restricted interests may be a protective factor against the development of depression in
Acknowledgment
This study was partially supported by the Nisonger Center Research Fund.
References (38)
- et al.
Repetitive behaviors in autism: Relationships with associated clinical features
Research in Developmental Disabilities
(2005) - et al.
Evidence for a relationship between cage stereotypies and behavioral disinhibition in laboratory rodents
Behavioural Brain Research
(2002) - et al.
Nonautistic motor stereotypies: Clinical features and longitudinal follow-up
Pediatric Neurology
(2008) - et al.
How does the topic of conversation affect verbal exchange and eye gaze? A comparison between typical development and high-functioning autism
Neuropsychologia
(2010) - et al.
Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample
Journal of the American Academy of Child and Adolescent Psychiatry
(2008) Diagnostic and statistical manual of mental disorders
(2000)- American Psychiatric Association. (2012). Autistic disorder: DSM-V proposed revision. Retrieved from...
- et al.
Association between restricted and repetitive behaviors and nonverbal IQ in children with autism spectrum disorders
Child Neuropsychology
(2006) - et al.
The repetitive behavior scale: Test manual
(1998) - et al.
Repetitive and stereotyped behaviours in pervasive developmental disorders
Journal of Child Psychology and Psychiatry
(2006)