Understanding obsessions, routines and repetitive behaviours

These may include arm or hand flapping, finger flicking, rocking, jumping, spinning or twirling, head banging and complex body movements. They may also include a preoccupation with parts of objects (such as the spinning wheels of toy cars), repetitive use of a particular object, such as the flicking of a rubber band or the twirling of string, or repetitive activities involving the senses (such as repetitive smelling, feeling of particular textures, and listening to different noises). Repetitive behaviours such as these are often observed in people at the lower functioning end of the autistic spectrum and in children rather than adults. However, some adolescents or adults may revert to old repetitive behaviours such as hand flapping or rocking in response to anxiety or stress (Howlin, 1998).

The exact nature and function of repetitive behaviours will vary according to the individual; however several reasons for these behaviours have been suggested including:

An attempt to gain sensory input (eg rocking may be the individual's attempt to gain necessary stimulation for the vestibular (balance) system, hand flapping or finger flicking may provide visual stimulation).

An attempt to reduce sensory input and environmental stimulation (eg focusing on a particular sound may reduce the impact of a loud and distressing environment, particularly if this is in a social situation).

A coping strategy for dealing with stress and anxiety and to block out uncertainty.

A source of enjoyment and occupation.

Obsessions

"Jed cannot think about anything but bath plugs and plumbing fixtures because bath plugs and plumbing fixtures make personal sense and feel personally significant. For Jed, bath plugs are like floodgates that he has control over in sending water away in such a consistent, predictable and clearly purposeful and seemingly intentional direction. Because of this, Jed has no interest in anyone or anything else because they don't have the same clear meaning and significance and they can't compete with bath plugs and plumbing fixtures. He cannot control the direction of people and they never act in any clearly defined, consistently predictable, intentional and purposeful direction." (Williams, 1996, p. 29).

Obsessions can cover a diverse range of topics dependent on the individual's particular areas of interest and level of ability. Thomas the Tank Engine, dinosaurs or cartoon characters can be common obsessions for younger children with autistic spectrum disorders. Other topics may include computers, trains, historical dates or events, pop or movie stars, the military, sports or science. Sometimes an individual may develop obsessions in unusual subject areas such as car registration numbers, bus or train timetables, postal codes, traffic lights, numbers, shapes or particular body parts such as feet or elbows.

Some people will remain interested in one area for their entire lives; others develop interests in new areas after particular time periods. Obsessions generally differ from other interests in their intensity (ie how much an individual will learn about a particular area and how strongly they feel about it) and their frequency and duration (ie how long a person will spend on their area of interest). Obsessions can be very intrusive in an individual's life and limit the person's involvement in other activities.

Another common characteristic of autistic spectrum disorders is an attachment to particular objects. These may be particular toys such as figurines or model cars, or more unusual objects such as milk bottle tops, stones, shoes or bath plugs as described in the above example. Other individuals develop an interest in collecting items. These may vary from Star Trek videos and travel brochures to insects, leaves or bus tickets. As with other obsessions it is the intensity, frequency and duration of an individual's interest in a particular object or collection that distinguishes it.

Again there may be several reasons why an individual with an autistic spectrum disorder may develop particular obsessions. The following are some possible reasons:

Particular subjects or objects may provide structure, order and predictability to a person with an autistic spectrum disorder, which can assist the individual to cope with the changes and uncertainties of daily life.

A person who experiences difficulties engaging with other people socially may refer to their area of special interest to facilitate conversation and to regain a sense of assurance in these situations.

Obsessions may assist the individual to relax.

The individual may gain extreme enjoyment from learning about a particular subject or gathering together items of interest.

Routines and resistance to change

"Reality to an autistic person is a confusing, interacting mass of events, people, places, sounds and sights. There seem to be no clear boundaries, order or meaning to anything. A large part of my life is spent trying to work out the pattern behind everything. Set routines, times, particular routes and rituals all help to get order into an unbearably chaotic life. Trying to keep everything the same reduces some of the terrible fear." (Jolliffe, 1992 in Howlin, 1998, pp. 201-202)

Many people with an autistic spectrum disorder, of all ages and levels of ability, have a strong preference for routines and sameness. The individual may have a need for routine around particular daily activities such as mealtimes or bedtime, and may experience great distress if the routine is disrupted. Routines can become almost ritualistic in nature needing to be followed very precisely, with attention paid to the tiniest details. There may be a need to engage in a series of behaviours in an exact and almost compulsive way and the individual may become extremely distressed if interrupted before the completion of the ritualistic routine. Some individuals may develop compulsive behaviours such as constantly washing their hands or checking locks; others may have obsessional thoughts regarding distressing topics such as death, illness or making mistakes (Howlin, 1998). Rituals may also be verbal in nature, and may involve the individual repeatedly asking the same question and requiring a specific answer.

The individual may find changes to their physical environment (such as the layout of furniture in a room) or the presence of new people/absence of familiar ones very difficult to manage. Even those changes to routine that others may enjoy such as holidays or birthdays can cause anxiety for a person with an autistic spectrum disorder. Sometimes minor changes such as transitions between two activities can be distressing, for others unexpected changes are the most difficult to manage. Some individuals can have very specific and rigid preferences when it comes to the food they eat (such as only eating foods of a particular colour), the clothes they wear (eg only wearing clothes made from specific fabrics) or objects used on a day-to-day basis (such as the type of soap or brand of toilet paper they will use).

An individual's dependence on particular routines can increase during times of change, stress or illness and may even become more dominant or elaborate at these times (Attwood, 1998). Attwood (1998) also suggests that an individual's dependence on routines may increase or re-emerge during adolescence in particular as a result of the personal, physical and environmental changes that the individual will be exposed to. Routines can be highly intrusive in the lives of the individual, their family and carers. They can also cause extreme distress and limit the individual's experience and opportunities. However, it is important to remember that these behaviours often serve a very important function for the individual - to introduce order, structure and predictability and to assist the person to manage anxiety levels.

Responding to obsessions, routines and repetitive behaviours

Before looking at how we might respond to obsessions, repetitive behaviours and routines it is important to ask ourselves a number of questions:

Does the person appear distressed when engaging in the behaviour or does the person give signs that they are trying to resist the behaviour? (eg someone who flaps their hands may try to sit on their hands to prevent the behaviour).

Can the individual stop the behaviour independently?

Is the repetitive behaviour, obsession or routine impacting on the individual's learning?

Is the behaviour limiting the individual's social opportunities?

Is the behaviour causing significant disruption to other people in the individual's life?

Clements and Zarkowska (2000) discuss the importance of distinguishing between hobbies and obsessive behaviours, by considering whether the behaviour poses a real issue for the individual or whether others in the individual's life may be uncomfortable with the behaviour. We all have hobbies and special interests and people generally have a strong preference for routine and can experience stress if this is disrupted. It is therefore important to consider whether it is really to the individual's advantage for limits to be set around a particular behaviour. If the answer is yes to any of the above questions, then it may be appropriate to look at ways of assisting the person to reduce obsessive and repetitive behaviours.

Research into appropriate responses to these particular behaviours has indicated that a graded approach to change appears to be most effective (Howlin, 1998). This means that a reduction in repetitive behaviours is achieved by making small changes and moving slowly. As discussed earlier, obsessions, repetitive behaviours and routines frequently play a very important and meaningful role in the life of the individual with an autistic spectrum disorder, often assisting the person to manage anxiety levels and to gain control over a confusing and chaotic world. The focus should therefore always be on the development of alternative skills to assist the individual to self-regulate stress levels and to better deal with their environment. Gradual but sustainable reduction in these behaviours is best achieved by understanding the role the behaviour may have for the individual and developing an intervention which addresses this. However, some general strategies for intervention are as follows:

Functional analysis

Develop a clear understanding of underlying factors or functions of the behaviour for the individual. For some individuals, the behaviour will assist them in self-regulating anxiety levels or in coping with unfamiliar or stressful situations (such as social situations), for others the behaviour may serve a sensory function (ie by increasing or reducing stimulation). The function for the behaviour will vary according to the individual, so it is very important to gather information about possible causes for the behaviour and to develop a hypothesis or theory as to why the behaviour might be occurring.

Intervene early

Repetitive behaviours, obsessions and routines generally become more resistant to change the longer they continue. For this reason, it is important to set limits around repetitive behaviours from an early age and remain vigilant to any new behaviours that may arise as the individual gets older. Also, a behaviour that may be quite acceptable in a two or three year-old child may not be appropriate as the child gets older and may, by this time, be very difficult to change (eg a child who repeatedly removes his clothes may not present a huge problem, however this is not the case with adolescents or adults who engage in the same behaviour).

Environmental structure

Increasing structure in the physical and social environments can assist an individual to feel more in control of their world and may reduce anxiety. Reduced anxiety levels may consequently minimize the need to engage in repetitive behaviours and reduce reliance on routines. Increased environmental structure may also reduce boredom thereby further limiting opportunities for participation in repetitive behaviours. Some strategies to increase environmental structure include:

Visual cues such as objects, photos, symbols or written lists can help reduce some of the anxiety related to difficulties in predicting what will happen next in a sequence of activities and can support an individual who has a strong preference for routines. Visual supports to assist an individual's understanding of abstract concepts such as time (ie an egg timer or specially designed 'time timer' which visually represents the passage of time) can be particularly helpful, as can visual timetables or daily planners. Visual supports can also be of assistance when an individual asks the same question repeatedly, as described in the following example:

"Our 14-year-old son, Willie, liked to ask the same question over and over again. He seemed to come up with a new question every few weeks. Since this was very tiresome for me, I learned to put the answer on a paper and paste it on the refrigerator. When he asked me the question, I told him to go to the refrigerator and find the answer. Since he was able to read, I could write out the answers. For children who can't read, pictures can be used instead of words." (Schopler, Ed., 1995, p. 40)

Further information regarding visual cues can be found at the Do 2 Learn website, which also includes a number of picture symbols which can be downloaded for free: www.do2learn.com

Preplanning strategies can assist the individual to prepare for stressful activities or events or for any upcoming changes that we might be aware of. Present information to the individual about the event at a time when everyone is relaxed and happy. Presenting information visually can assist the individual's understanding and provides a physical reminder for the individual to refer back to during times of stress or anxiety. Hilde de Clerq as quoted in Peeters, 1997 (p.3) describes the benefits of preplanning for a stressful event (Christmas in this case) with her son:

"... I show him all the advertising brochures with the toy that Santa can bring, what he can do with the toy, how he can use it. We cut out all the pictures and stick them on pieces of paper. I make him a calendar with white pages so he can tear them off himself, one every day. He can see exactly how long it will be. We stick the picture with the surprise on a sheet of red paper. We then go to the shop to look at the real present because it doesn't look exactly the same as one in the advertisement ... The night before Christmas I tell him where he can find the 'surprise' and in what kind of paper it will be wrapped. His brothers and sisters think half the fun is lost if they know about things beforehand. But when the big day comes and the red sheet turns up on his calendar, it is a real party for ALL the children. Even for Thomas because now he doesn't fling the paper on the ground, doesn't scream or cry. He has found what he expected. It was predictable. HIS SURPRISE ... And then I just melt because I see he is really happy."

Social Stories (Gray, 1993) may be appropriate for some people as they provide information regarding what to expect in a variety of situations and can be adapted to meet the individual's needs. For further information regarding Social Stories, please contact the Autism Helpline or visit the following website: www.thegraycenter.org

Preplanning may also involve structuring the environment to minimize anxiety and to reduce boredom. An example of this may be to arrange for a student to use a computer in the library during lunchtimes, which may reduce the stress associated with this time of day. Another example would be to have a range of enjoyable or calming activities prepared which the individual can be redirected to if they appear bored or stressed.

Minimizing the impact of sensory input such as noises (eg school bells) or smells (eg perfumes or soaps) can also assist the person to better cope with their environment.

Skill development

Development of self-regulation skills

Self-regulation skills include any activities which assist the person to manage their own behaviours and emotional states. Learning how to identify stress or anxiety from bodily reactions and developing a range of appropriate alternative responses (such as using relaxation strategies, or asking for help) to the repetitive or ritualistic behaviours can reduce the occurrence of these behaviours. Also, research has shown that increasing an individual's insight into the obsession or repetitive behaviour can significantly reduce the behaviour, even for individuals with quite severe learning disabilities (Koegel et al, 1995 in Howlin, 1998).

Social skills training

Teaching an individual social skills such as how to start and end a conversation, appropriate topics for discussion and how to read the non-verbal cues of others may reduce the person's reliance on a particular subject area in social situations.

Coping with changes

Changes are an unavoidable and important part of life which can present significant difficulties for many people with an autistic spectrum disorder. While it may not always be possible to prepare for changes to routines or circumstances, it is important to provide the individual with as much warning and preparation as possible. Gradually exposing the new object, place, person or circumstance to the individual in small, manageable chunks can help the individual to cope with the change. Reinforcement (such as praise or other rewards) can be provided to the individual for coping with these minor changes to encourage increased tolerance. Presenting information visually (ie through visual symbols, timetables, or calendars) can assist in reducing the impact of a change in routine or circumstance. Using Social Stories to explain why changes to a particular situation or routine may sometimes occur can also assist the individual's understanding. Redirecting the individual's attention to a calming activity and encouraging them to use simple relaxation strategies such as breathing exercises when unexpected changes occur can also assist the person to cope.

Increase opportunities for the person

Clements and Zarkowska (2000) comment on the importance of thinking about what the individual will do instead of engaging in the repetitive behaviour or obsession. This means thinking about the alternative activities available to the person if limits are placed around an obsession or repetitive behaviour. Increasing the range of activities available to the individual and facilitating the individual's skill development to enable participation in a broader range of activities are important components of any intervention. For some people this may mean providing social skills training, and increasing social opportunities for the individual by joining a group or club. For others this may be looking at what recreational (ie sport and leisure) or vocational (ie further education, job readiness training or employment) opportunities could be introduced into the person's life.

Set clear and consistent boundaries for the behaviour

Setting limits around repetitive behaviours, routines and obsessions is an important and often essential strategy to minimize the impact of these behaviours on the individual's life. There are several steps to be followed when setting limits around a particular behaviour:

Clearly identify the repetitive behaviour, obsession or routine of concern (eg Jane likes to talk about train engines during most social interactions. Jane currently starts talking about train engines after approximately ten seconds of conversation for up to 15 minutes).

Think about reasonable and achievable limits that can be placed around the behaviour. You will need to decide on a starting point which is manageable for the person. If the starting point is not attainable for the person, then it is important to reduce the limit to a more achievable level. Remember behavioural change is most likely to be successful and the individual is less likely to experience distress if you start small and go slowly (eg In addition to social skills training to assist Jane to learn about appropriate, alternative topics of conversation, Jane is allowed to talk about train engines initially after 20 seconds of conversation for five minutes only. Dependent on how Jane copes with this, the time restriction will gradually increase and limits will be introduced around the number of times per day that Jane is allowed to talk about train engines and then around who Jane is allowed to talk about train engines with. The eventual goal may be for Jane to speak about train engines to family members only for one minute two times per day).

Limits can be set in a range of ways dependent on the behaviour of concern. Following are some other examples:

- Ration object (eg can carry five pebbles only at a time in pocket).

- Ration time (eg can watch Thomas the Tank engine video for 20 minutes at a time twice per day).

- Ration place (eg spinning only allowed inside own home).

It is important that a consistent approach to limit setting be adopted across environments to assist the individual's learning.

Limits need to be set using clear and transparent rules which state where, when, with whom or for how long the behaviour is allowed to occur. Present this information visually (with a focus on when the individual is able to engage in the behaviour as well as when the individual is not able to engage in the behaviour) to assist the individual's understanding and to help them to cope with anxiety that restricted access to the obsession or activity may create.

Explore alternative more appropriate options

Interrupt repetitive behaviours by redirecting the person to another enjoyable and appropriate activity that is incompatible with, but has the same function as the repetitive behaviour. Some examples are provided below:

Redirect child who is rocking for sensory input to a swing.

Provide the individual who flicks his or her fingers for visual stimulation with a kaleidoscope or bubble gun/blower.

Provide the individual who puts rocks and other inedible objects in his or her mouth with a bum bag containing a variety of edible alternatives (that provide similar sensory experiences) such as raw pasta or spaghetti, or seeds and nuts.

Use a bum bag containing play dough for individuals who smear their poo.

Make use of obsessions

"Angela loved to rummage in the dustbins. Rather than stop the behaviour, she was given the regular job of sorting the rubbish for recycling (bottles/paper/plastic) and ensuring rubbish was placed in the appropriate bins. Regular time was scheduled every day for this activity. A condition of this job was that she wears disposable gloves whilst sorting the rubbish and always wash her hands afterwards." (Clements & Zarkowska, 2000, p. 162)

Obsessions can be positively channelled to increase skills and areas of interest, promote self-esteem, and expand an individual's social group. Looking creatively at a particular obsession and thinking of ways of developing it into something more functional for the individual can be a very effective way of managing the behaviour. In her book 'Autism: An Inside-Out Approach' (1996), Donna Williams talks about using obsessions as 'bridges' to develop skills and interests in other areas:

"One of the benefits of tolerance of so called 'bizarre' behaviour is the expansion of repertoires - sometimes in very constructive ways. My interest in fabrics was expanded into collection and then crafts and sewing and I later became a machinist." (p.227)

Some further examples of using obsessions to develop skills, self-esteem and social involvement are listed below:

An obsession with computers could be developed into a vocation in IT.

A person with a special interest in historical dates could join a history group and meet people with similar interests.

A person with knowledge of sport or music would be a valuable member on a pub quiz team.

An interest in particular sounds could be channelled into learning a musical instrument.

An obsession tearing paper could be used to develop skills in making recycled paper.

A strong preference for ordering or lining up objects could be developed into housework skills.

Obsessions can also be used to motivate and reward by following a less desired activity (such as homework) by a period of access to an obsession (such as extra time on the computer).

In summary

Does the obsession, routine or repetitive behaviour restrict the person's opportunities, cause distress or discomfort or impact on the individual's learning? If not, is it really necessary to intervene?

What function does the repetitive behaviour, routine or obsession have for the individual? (ie what does the person get out of the behaviour?).

Intervene early by setting boundaries around repetitive behaviours and obsessions from a young age and as they emerge.

Increase environmental structure by using visual cues (eg timetables, daily planners), social stories, and pre-planning strategies to prepare for stressful events or change.

Provide skill development opportunities including social skills training, relaxation and emotions identification training and skills to assist the individual better cope with change.

Increase social, recreational and vocational opportunities for the person.

Set clear and consistent boundaries around the behaviour by rationing the object, the time or the place - remember to start small and go slowly.

Explore alternative, more appropriate activities that have the same function as the repetitive behaviour.

Use obsessions to motivate and reward, develop skills, increase social opportunities and improve self-esteem.

When and where to get extra help

Sometimes an individual's repetitive behaviour, routine or obsession can present significant risks to the person or those around them. In these instances it is important to get specialist help to deal with the behaviour.

Some children with autism have challenging behaviour. This is a huge area and we would advise consulting books in the recommended reading section. Most behaviour problems are as a result of the communication difficulties experienced by those with autism, and therefore it is important to consider what the function of the behaviour is and look at ways to enable the child to communicate this appropriately through words or signs as an alternative to the behaviour. Below are some very general guidelines.

Try to incorporate some sort of routine and structure in to your child's day. Make sure your child understands what is happening next. The use of photographs or picture symbols can be particularly effective for this.

Keep to your word. Once you have agreed to something with your child it is important to try to keep to it. Extreme anxiety can occur when something they expect to happen does not.

Try preventative measures. For example think of things to distract the child from whatever may be upsetting them.

Encourage your child to go out in to the garden or somewhere safe when they are becoming angry or upset. Make sure that they can get there easily without encountering too many obstacles on the way.

Channel behaviour positively. If your child goes in to the kitchen and smashes the crockery when they are anxious, think of ways to channel this. For example keep cheap crockery from car boot sales in a marked box and set some rules such as 'you can smash this crockery at the bottom of the garden' or may be a visit to the bottle bank could provide a similar output for this energy.

Listen to your child. More able children with autism may be able to express in some way to you what is upsetting them. This may occur at the time or in many cases hours or even days later. Observe your child's behaviour and see if you can notice any patterns. What are they trying to tell you?

Consider the iceberg effect. You may see a particular behaviour, but the underlying reason may not be clear. When a child starts behaving differently assess if there have been any changes in the child's routine or environment at all. Also consider whether there may be a medical reason underlying their distress. Head banging for example can sometimes occur when a child has an ear infection and similarly biting can sometimes be due to toothache.

Choose the right incentives. Think of things to motivate your child to behave. What things do they enjoy? What will they find rewarding? For some children using whatever their obsessional interest is can be particularly rewarding. So for example if your child really enjoys watching Thomas the Tank Engine videos allow him or her to watch this after they have done something good or behaved well.

Be consistent. Whatever strategy you choose to use with your child it is essential that you are consistent. To be successful, all those involved with your child should use the same strategy and language in response to your child's behaviour. It is very important that children with autism have clear boundaries.

Useful reading

Clements, J. and Zarkowska, E. (2000). Behavioural concerns and autistic spectrum disorders: explanations and strategies for change. Jessica Kingsley Publishers: London*

Clements, J. (2005). People with autism behaving badly: helping people with autism move on from behavioural and emotional challenges. Jessica Kingsley Publishers: London *

May, F. (2005). Understanding behaviour. NAS: London*

(This is also available as free information sheet from the Autism Helpline.)

Schopler, E. (1995). The parent survival manual. Plenum Press: London

Whitaker, P. (2001). Challenging behaviour and autism: making sense - making progress. NAS: London

See the behaviour section on the NAS website: www.autism.org.uk/nas/jsp/polopoly.jsp?d=1070

Disciplining the child with autism

Children with autism need guidance on appropriate behaviour.

Does your child understand what they have done wrong? Make sure they know what they have done wrong and why. So for example instead of saying 'You have been naughty today' say 'You took your sister's sweets, they are not yours'.

Focus on behaviour not the child. Tell your child if you are unhappy with what they have done, not what they are. So for example don't say 'You are naughty' but make it clear that what they did was wrong.

Be aware that your child with autism may not learn from experience. They often have great difficulty applying what they have learnt in one situation to another. Your child may require very clear and consistent instructions.

Reinforce good behaviour. Try to reward good behaviour and where possible ignore the bad behaviour. Any attention, even being told off can be rewarding for a child.

Special circumstances. There may well be times, no matter how well behaved your child is, when they misbehave. A deterioration in behaviour may well be seen in times of anxiety, for example if there is a change in routine or in the environment no matter how small.