Repetitive and restrictive behaviors (RRBs) are a type of behavior that can include stereotyped or repetitive motor movements or speech. They are further defined as being inappropriate to the situation or context (Jiujias, Kelley, & Hall, 2017). Such behaviors are common in autism spectrum disorders (ASD), obsessive-compulsive disorder (OCD), and other neurological disorders (Jiujias et al., 2017; Rizzo, 2016). RRBs can have a significant negative impact on one’s life as they can interfere with one’s activities or social relationships, or involve directly self-injurious actions (Wolff, Boyd, & Elison, 2016; Jiujias et al., 2017). As such, they have been associated with factors such as anxiety, issues with executive functioning, and sensory phenomena (Jiujias et al., 2017). Thus, understanding the diagnostic and potential treatment methodologies for RRBs plays a significant part in managing these behaviors in applied behavior analysis (ABA).
RRBs are one of the diagnostic criteria for ASD, according to DSM-V. There, they are defined as “of restricted, repetitive patterns of behavior including motor stereotypies and […] resistance to change in routine” (Rizzo, 2016, p. 293). (Furthermore, RRBs can be differentiated into lower-level ones, such as motor stereotypies or self-injury, and higher-level ones, which include arranging or ordering items (Vause et al., 2018). Such behaviors can include motor tics (e. g. hand flapping, finger-snapping), repetitive use or arrangement of objects, or repetitive speech (Looney, DeQuinzio, & Taylor, 2018). The following subtypes of RRB are identified: akathisia, compulsions, dyskinesia, echolalia, obsessions, preservation, restricted behavior, ritualistic behavior, sameness, self-injury, stereotypy, and tics (Ritvo et al., 2013). Often, more than one behavior is present in a case.
As behavioral patterns with a wide variety of manifestations, RRBs are challenging to measure quantitatively. However, multiple methodologies exist that can aid in evaluating their severity and impact. Since most conditions involving RRBs are detected in infancy and childhood, diagnostic instruments for measuring RRBs are aimed at the same age group. However, non-pathologic repetitive behaviors are also a part of normative development (Wolff et al., 2016). Therefore, distinguishing between typical and atypical repetitive behaviors presents a particular challenge (Wolff et al., 2016). Methodologies to measure the severity of RRBs need to account for these issues to be effective.
Most methodologies for measuring RRBs rely on self-reports or, in the case of children, parent reports. Such instruments include the Repetitive Behavior Questionnaire (RBQ-2), Childhood Routines Inventory (CRI), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), and Repetitive Behavior Scale-Revised (RBS-R); generally they are aimed at RBRs associated with specific disorders (Evans, Uljarević, Lusk, Loth, & Frazier, 2017). Additionally, methodologies can be based on direct or recorded observation of subjects (Wolff et al., 2016). Developing methodologies attempt to improve on existing ones by introducing additional variables to measure, refine existing ones, or placing the measurements in a more developmentally appropriate context (Evans et al., 2017; Wolff et al., 2016). As RRBs are associated with neurological and developmental disorders, an additional issue with administering them is the possibility that a subject may lack the reading fluency and comprehension required to complete self-report questionnaires (Barrett, Uljarević, Jones, & Leekam, 2018). This is a significant limitation of current RRB measurement methodologies.
Within ABA, interventions aimed at RRBs can be described using the person, environment, occupation (PEO) model, aimed at improving at least one of the three aspects of this model. Most evidence-based interventions, however, target the environmental aspect of the model (Patriquin, MacKenzie, & Versnel, 2019). The general principles of operant conditioning — antecedent, behavior, consequence — are applied in most cases (Grigorenko, Torres, Lebedeva, & Bondar, 2018). Similar to measurement methodologies, treatment interventions are generally aimed at the associated disorder rather than RRBs directly (Grigorenko et al., 2018). Such interventions attempt to cause behavioral modification, reduce the frequency, duration, or intensity of RRBs, or reduce issues associated with RRBs, such as anxiety or difficulty with social integration.
One of the commonly used approaches to combating RRBs in children with ASD is occupational therapy. Other methods of the intervention included altering the subject’s environment in ways that reduce the likelihood of RRBs being triggered, offering the child a wider selection of activities, or educating parents and daycare workers (Patriquin et al., 2019). The use of a visual schedule has been shown to have a significant beneficial effect on reducing RRBs (Patriquin et al., 2019). If an object within the environment triggers the behavior, it is possible to modify the environment in a way that reduces one’s exposure to the triggering object (Patriquin et al, 2019). Methods targeting the occupation and person aspects of the PEO model include teaching the child new skills to cope and self-regulate, or to create alternative behaviors (Patriquin et al., 2019). This approach seeks to replace RRBs with similar, but more functional behaviors (Patriquin et al., 2019; Ritvo et al., 2013). Alternatively, if the repetitive behavior is inappropriate to a particular situation, interventions aim at moving it to a situation where it is appropriate.
As there is currently no definitive treatment for RRBs or their underlying neurological or neurodevelopmental conditions, new methodologies are emerging. Medication can be a part of treatment for RRB in both current and experimental methodologies (Ritvo et al., 2013; Rizzo, 2016). Behavioral treatments include cognitive-behavioral therapy (CBT) aimed at particular underlying conditions or particular types of RRBs, such as echolalia, compulsive or ritualistic behaviors (Vause et al., 2018). Another type of therapy is acceptance and commitment therapy, seeking to alter a person’s rules for non-optimal and inflexible behaviors (Szabo, 2019). Still more methodologies attempt to teach self-monitoring and differential reinforcement interventions to teach subjects to control their RRBs (Looney et al., 2018). Overall, experimental behavioral treatments represent improvements and developments to existing behavioral interventions. These improvements can be motivated by either refining the techniques used in current treatment methods or combining different approaches into a compound intervention program.
RRBs are atypical behaviors characterized by repetition or motor stereotypy. They are common in neurological and neurodevelopmental disorders such as ASD and OCD. These disorders and RRBs are commonly identified in children, however, they can affect adults, as well. Such behaviors can be harmful, either as direct self-injurious actions or as significant detractors from one’s normal functioning or social interaction. A multitude of subtypes of RRBs are commonly identified, and several methodologies exist to measure their impact, generally associated with a specific disorder. Treatment strategies for RRBs are similarly generally associated with specific disorders and generally involve CBT. The ultimate goal of treatment is to either alter the subject’s environment in a way that makes the RRB less likely to manifest, improve self-control, or replace the RRB with a more functional behavior. Experimental and developing treatment methodologies generally improve on current ones or combine them to achieve a compound, synergistic effect.
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