RESTRICTED AND REPETITIVE BEHAVIOURS AND …

How do restricted and repetitive behaviours influence theparticipation of children with autism in school contexts?

Author

Ryan, Sally Victoria

Published

2018-07-23

Thesis Type

Thesis (Masters)

School

School Educ & Professional St

DOI

https://doi.org/10.25904/1912/1760

Copyright Statement

The author owns the copyright in this thesis, unless stated otherwise.

Downloaded from

http://hdl.handle.net/10072/380676

Griffith Research Online

https://research-repository.griffith.edu.au

RESTRICTED AND REPETITIVE BEHAVIOURS AND PARTICIPATION AT SCHOOL

1

How do restricted and repetitive behaviours influence the participation of children with

autism in school contexts?

Sally Ryan

Graduate Certificate in Autism Studies

Graduate Certificate in Teaching and Learning

Bachelor of the Built Environment

Professor Jacqueline Roberts

Dr Kate Simpson

Submitted in fulfilment of the requirements of the degree of Master of Education and

Professional Studies Research

School of Education and Professional Studies

Griffith University

23rd July 2018


2

Keywords

attendance, autism, behaviours, children, context, education, involvement, participation,

RRB, restricted and repetitive behaviours and interests, school


3

Abstract

Background: Restricted and repetitive behaviours and interests are one of the two core

diagnostic features of autism. Frequent, severe restricted and repetitive behaviours and

interests can cause significant difficulties for individuals with autism. These behaviours can

impede participation in activities at home and in the community and affect social interaction.

To date, there is little research into the effects of restricted and repetitive behaviours and

interests in the school environment. This study aimed to document the effects of restricted

and repetitive behaviours on participation for children with autism.

Method and Results: The data used in this study has been collected through the Cooperative

Research Centre for Living with Autism’s (Autism CRC) Longitudinal Study of Australian

children with Autism (LASA). Caregivers of children on the spectrum aged 9–10 years (n =

131) completed the Participation and Environment Measure for Children and Youth school

section and the Developmental Behavioural Checklist- Parent Version. Caregivers reported

on frequency of child's participation and level of involvement in school activities and the

amount and frequency of restricted and repetitive behaviours. Analysis was performed using

a series of Mann-Whitney U tests at PEM-CY item‐level which revealed that children with

elevated lower order restricted and repetitive behaviours participate less in getting together

with peers outside of class.

Conclusion: Lower order restricted and repetitive behaviours affect participation in

socialising with peers. This is concerning as limited or absent peer relationships can

negatively influence health and mental health. Further investigation is warranted through

multi informant designs that seek the perspectives of the child and education specialists.


4

Acknowledgements

I would like to thank my thesis supervisors Professor Jacqueline Roberts and Dr Kate

Simpson of the Autism Centre of Excellence at Griffith University for their continuing

support and advice over the last two years. I would like to acknowledge Dr Lorraine McKay

of the School of Education and Professional Studies at Griffith University as the reader of the

original confirmation statement. I am thankful for her valuable comments on the statement. I

acknowledge the financial support of the Cooperative Research Centre for Living with

Autism (Autism CRC), established and supported under the Australian Government's

Cooperative Research Centres Program.


5

Statement of Originality

This work has not previously been submitted for a degree or diploma in any university. To the

best of my knowledge and belief, the thesis contains no material previously published or

written by another person except where due reference is made in the thesis itself.

Sally Ryan


6

Table of Contents

Title page ……………………………………………………………………………………. 1

Keywords ……………………………………………………………………………………. 2

Abstract ……………………………………………………………………………………… 3

Acknowledgements……………………………………………………………………………4

Statement of Originality……………………………………………………………………….5

Table of Contents ……………………………………………………………………………. 6

List of Figures………………………………………………………………………………... 8

List of Tables……………………………………………………………………………...…. 9

List of Abbreviations ………………………………………………………………………...10

1. Introduction………………………………………………………………………………. 11

1.1 Background …………………………………………………………………...............11

1.2 Significance...………………………………………………………………................ 12

1.2.1 Inclusion……….…………………………………………………………………….12

1.3 Context………………………………………………………………………………...14

1.3.1 Participation ………………………………………………………………………...14

1.4 Purpose and Research Question…………………………………………………….... 16

2 Literature Review ………………………………………………………………………… 17

2.1 Research on Autism and Restricted and Repetitive Behaviours………………………18

2.2 Definition……………………………………………………………………………...21

2.3 Higher and Lower Order Restricted and Repetitive Behaviours………….…………. 23

2.4 Change………………………………………………………………………………. 25

2.5 Cause…………………………………………………………………………………. 28

2.5.1 Theoretical explanation of restricted and repetitive behaviours…………………… 28

2.5.2 Restricted and repetitive behaviours and anxiety…………………………………. 29

2.6 Context ………………………………………………………………………………. 31

2.7 Autism and School Participation……………………………………………………. 34

2.8 Conceptual Framework………………………………………………………………. 38


7

Table of Contents Continued

3 Method……………………………………………………………………………………. 41

3.1 Participants…………………………………………………………………………….42

3.2 Sample Participants……………………………………………………………………43

3.3 Measures………………………………………………………………………………46

3.3.1 Developmental Behaviour Checklist- Parent Version………………………………47

3.3.2 Participation and Environment Measure- Children and Youth……………………. .53

3.3.3 Vineland Adaptive Behaviour Scales Second Edition ………………………….… 54

3.4 Data Analysis………………………………………………………... ……………….55

3.4.1 Stage 1 analysis……………………………………………………………………. 58

3.5 Stage 2 Analysis……………………………………………………………………….58

3.5.1 Stage 2a analysis…………………………………………………………………….58

3.5.2 Stage 2b analysis………………………………………………………………….... 59

3.6 Results….…………………………………………………………….......................... 59

3.6.1 Stage 1 analyses of higher and lower than mean restricted and repetitive behaviours

at PEM-CY item level …………………………………………………………………….59

3.6.2 Stage 2a analyses of elevated and non-elevated lower order restricted and repetitive

behaviours at PEM-CY item level ………………………………………………………. 60

3.6.3 Stage 2b analyses of elevated and non-elevated higher order restricted and repetitive

behaviours at PEM-CY item level………………………………………………………...65

4 Discussion……………………………………………………….........................................67

4.1 Results Compared to Literature……………………………………………………….70

4.2 Receptive Language…………………………………………………………………...72

4.3 Comparison to Other Participation Literature………………………………………...74

4.4 Limitations ……………………………………………………………………………75

4.5 Significance of the Study……………………………………………………………...76

4.6 Future Directions ……………………………………………………………………. 77

References…………………………………………………………………………………... 79


8

List of Figures

Figure 1 Higher and lower order restricted and repetitive behaviours and interests……….24

Figure 2 Participation as a multidimensional construct…………………………………....39

Figure 3 Bidirectional restricted and repetitive behaviours and participation construct…...40

Figure 4 Boxplot graph of elevated and non-elevated restricted and repetitive behaviour

scores for PEM-CY item frequency of ‘getting together with peers outside of

class.’……………………………………………………………………………...64


9

List of Tables

Table 1. Classification of Severity Levels of Restricted and Repetitive Behaviours……20

Table 2. Child and Caregiver Characteristics……………………………………………45

Table 3. Measurement Instruments………………………………………………………46

Table 4. Repetitive Motor Movements in the RBQ-2 and the DBC-P…………………..49

Table 5. Rigidity and/ or Adherence to Routine in the RBQ-2 and the DBC-P…………50

Table 6. Preoccupation with Restricted Patterns of Interests in the RBQ-2 and the

DBC-P…………………………………………………………………………..52

Table 7. Data Analysis per Stage…………………………………………………………57

Table 8. Results of analyses of higher and lower than mean restricted and repetitive

behaviours at PEM-CY item level………………………………………………61

Table 9. Results of analyses of elevated and non-elevated lower order restricted and

repetitive behaviours at PEM-CY item level……………………………………..63

Table 10. Results of analyses of elevated and non-elevated higher order restricted and

repetitive behaviours at PEM-CY item level……………………………………..66


10

List of Abbreviations

ADHD Attention Deficit and Hyperactivity Disorder

APA American Psychiatric Association

ASD- ENA Autism Spectrum Disorder Educational Needs Analysis

Autism CRC Cooperative Research Centre for Living with Autism

DBC-P Developmental Behaviour Checklist- Parent Report

fPRC Family of Participation-related Constructs

ICF International Classification of Functioning, Disability and Health

IQ Intelligence Quotient

LASA Longitudinal study for Australian Students with Autism

NCCD National Consistent Collection of Data

OCD Obsessive Compulsive Disorder

PEM-CY Participation and Environment Measure- Children and Youth

RBQ-2 Repetitive Behaviour Questionnaire-2

SPSS 23 Statistical Package for the Social Sciences 23


11

1. Introduction

1.1 Background

Autism spectrum disorder (ASD), herein referred to as autism, is a

neurodevelopmental disorder that is defined by the Diagnostic Statistical Manual of Mental

Disorders- Fifth edition (DSM-5; American Psychiatric Association, 2013) as a dyad of

restricted and repetitive behaviours and interests, and social and communication difficulties

as the core impairments (Harrop et al., 2014). Restricted and repetitive behaviours (RRBs)

and interests were among the first characteristics of autism described by Kanner (1943).

These behaviours are not specific to this developmental disorder, as they are also observed in

children and adults with other developmental disorders (Langen, Durston, Kas, van Engeland,

& Staal, 2011; Uljarevic et al., 2017) and in typically developing young children (Arnott et

al., 2010; Barber, Wetherby, & Chambers, 2012). However, in individuals with autism the

behaviours are frequent, and always combined with characteristic social communication

difficulties (Joseph, Thurm, Farmer, & Shumway, 2013; Mandy, Charman, Gilmour, &

Skuse, 2011).

Restricted and repetitive behaviours have been commonly grouped into two distinct,

but not mutually exclusive categories (Georgiades, Papageorgiou, & Anagnostou, 2010;

Papageorgiou, Georgiades, & Mavreas, 2008; Szatmari, Georgiades, & Bryson, 2006; Turner,

1999). These groups are lower order behaviours related to repetitive sensory movement; and

higher order behaviours related to insistence on sameness (Bishop et al., 2013; Georgiades et

al., 2010; Mooney, Gray, & Tonge, 2006; Papageorgiou et al., 2008; Richler, Bishop,

Kleinke, & Lord, 2007; Richler, Huerta, Bishop, & Lord, 2010; Szatmari, Bryson, Boyle,

Streiner, & Duku, 2003). An additional study by Lam, Bodfish, and Piven (2008) found

evidence for a third subgroup called circumscribed interests that also feature alongside

insistence on sameness as higher order behaviours.


12

The lower order behaviour group contains repetitive sensory motor behaviours. These

behaviours can present as rocking and hand flapping (Boyd et al., 2010), spinning around,

and self-injurious behaviour such as skin picking and head banging (Soke et al., 2018). These

behaviours are thought to become less severe over the lifetime of an individual (Esbensen,

Seltzer, Lam, & Bodfish, 2009). This particular category of lower order behaviours has been

found to be more prevalent and severe in children with lower cognitive ability (Bishop et al.,

2013; Boyd, McBee, Holtzclaw, Baranek, & Bodfish, 2009; Lam & Aman, 2007).

Insistence on sameness behaviours, part of the higher order behaviour group, are

described as behaviours that are exhibited when individuals have difficulties with change to

routine (Kim & Lord, 2010). People with autism may sometimes create rituals in order to

cope with the unpredictability of their surroundings (Dewrang & Sandberg, 2011).

Circumscribed interests, also higher order behaviours, are defined as behaviours such as

object attachment and repetitive language (Cho et al., 2017; Watt, Wetherby, Barber, &

Morgan, 2008). These interests can also be intense preoccupations (Boyd, Conroy, Mancil,

Nakao, & Alter, 2007; Lam et al., 2008) such as amassing large amounts of information on

unusual topics (Klin, Danovitch, Merz, & Volkmar, 2007). Higher order behaviours like

these are more likely to be observed in individuals with higher cognitive abilities (Bishop,

Lord, & Richler, 2006; Joseph et al., 2013; Watt et al., 2008).

1.2 Significance

1.2.1 Inclusion. Autism is a spectrum and individuals have varied profiles and

severities of different restricted and repetitive behaviours (Boyd, McDonough, & Bodfish,

2012). Understanding these behaviours is important because of their adverse impact on

adaptive behaviour (Baker, Lane, Angley, & Young, 2008; Kirby, Boyd, Williams,

Faldowski, & Baranek, 2016; Lane, Young, Baker, & Angley, 2010), and the negative

association with frequency and quality of participation in activities (Dickie, Baranek, Schultz,


13

Watson, & McComish, 2009; Hochhauser & Engel-Yeger, 2010). The effect of restricted and

repetitive behaviours on school participation is not well understood and requires

investigation.

There is growing evidence of the difficulties that students with autism are facing in

school settings. In 2015, the National Consistent Collection of Data (NCCD) identified 18 per

cent (674,323 students) of all Australian school students as receiving an educational

adjustment due to disability (Education Services Australia, 2016). According to the

Australian Bureau of Statistics (Australian Bureau of Statistics [ABS], 2017) of the children

diagnosed with autism attending mainstream schools, it was found that 83.7 per cent

experienced difficulties in their place of learning. Students reported that their main areas of

difficulty were fitting in socially (63.0%), learning difficulties (60.2%) and communication

difficulties (51.1%) (ABS, 2017). It is reported that educational outcomes for children with

autism at school (Ashburner, Ziviani, & Rodger, 2010; Roberts & Simpson, 2016) and after

they leave (Howlin, Savage, Moss, Tempier, & Rutter, 2014; St. John, Dawson, & Estes,

2018) are poor compared to their typically developing peers and those with other disabilities.

Outcomes are also poor in relation to the cognitive ability of students with autism, that is they

underachieve in relation to their cognitive ability (Keen, Webster, & Ridley, 2016).

While inclusion of children with autism in mainstream classrooms is generally

supported by educators, they find it difficult to successfully include students with autism in

their classrooms (Lindsay, Proulx, Thomson, & Scott, 2013), most likely because inclusion of

children with disabilities remains one of the least understood areas of education (Symes &

Humphrey, 2010). A lack of provision of autism specific adaptations and autism specific

training for teachers (Roberts & Simpson, 2016) can result in limited effective inclusive

practice. An ASD educational needs analysis (ASD-ENA) conducted in 2015 obtained

information about the educational needs of students with autism in Australia (Saggers et al.,


14

2015). The study used perspectives from 1468 respondents from four key stakeholder groups;

educators, parents, specialists and students with autism aged 11-18 years. The ASD-ENA

study found that social emotional needs had the most impact followed by behavioural needs

in educational settings. They also discovered that after funding, the key barriers to supporting

the challenging and complex needs of students with autism were lack of time, lack of

education and training, and lack of specialist support.

The characteristics of autism present unique difficulties for successful participation

and need to be examined (Simpson, Keen, Adams, Alston‐Knox, & Roberts, 2017). It is

noted that students with autism have difficulties with self-control and hyperactivity, assertion

and cooperation (Macintosh & Dissanayake, 2006). Active participation in educational

settings is difficult because they are less likely to answer questions out loud or work

collaboratively with peers (Vakil, Welton, O’Connor, & Kline, 2009).

Children who display high levels of restricted and repetitive behaviours and interests

fail to learn simple discrimination tasks whilst engaging in this behaviour (Koegel & Covert,

1972). Additionally, when individuals are engaged in restricted and repetitive behaviours and

interests they have been found to be less able to physically participate in leisure activities in

the home and in the community (Hilton, Graver, & LaVesser, 2007; Hochhauser & Engel-

Yeger, 2010; LaVesser & Berg, 2011). Information about how restricted and repetitive

behaviours impact on school participation is needed to enable adjustments to be made to the

learning environment and the delivery of curriculum, to assist children and young people and

their families in achieving success during their schooling career.

1.3 Context

1.3.1 Participation. The publication of the International Classification of

Functioning, Disability and Health for Children and Youth (ICF-CY) by the World Health

Organisation in 2001 has increased global interest in participation for children with


15

disabilities (World Health Organisation [WHO], 2001, 2007). Participation is considered to

have a positive influence on an individual’s health and wellbeing and plays a role in learning

new skills and developing relationships (Anaby et al., 2014; Khetani et al., 2014). It is

recognised that children with disabilities can form close friendships, acquire life skills,

competencies and creativity, and achieve mental and physical health by participating in

different activities (Anaby et al., 2014; Jeong, Law, Stratford, DeMatteo, & Kim, 2016). Full

participation in day to day activities and routines is considered to be the ultimate indicator of

health and functioning (WHO, 2007). In addition, occupational engagement is understood to

lead to the achievement of intellectual, health, communicative, and social potential (King et

al., 2003; Tanner, Hand, O'Toole, & Lane, 2015).

Research investigating children with autism who engage in restricted and repetitive

behaviours in terms of participation in the school context requires an understanding of the

constructs of both restricted and repetitive behaviours and participation. Whilst restricted and

repetitive behaviours and interests are well defined, there has been confusion about the

definition of participation in studies, which has led to varied descriptions of the concept

(Granlund et al., 2012) and therefore mixed approaches to measurement. This has caused

misinterpretation of results found and reported (Imms et al., 2016).

Imms et al. (2016) reviewed the language, definitions and intervention research

around the construct of participation with the aim of understanding how participation is

viewed by other researchers. Attendance and involvement were found to be the two themes

that were explicitly linked with the experience of participation, with attendance a prerequisite

for involvement (Imms et al., 2016). However, participation is a multidimensional construct

(Granlund et al., 2012; Imms et al., 2017) that also includes related concepts of preference,

activity competence and sense participation. Additionally, all participation occurs within a


16

contextualised setting (Anaby et al., 2014; Hammel et al., 2008; Mallinson & Hammel,

2010).

There is growing evidence to show that there are intricate links between participation,

restricted and repetitive behaviours and context. It is becoming clear that the effect of context

in general on restricted and repetitive behaviours and interests is a complex combination of

intrinsic factors, such as level of anxiety, and environmental factors such as what is

happening, or who is involved (Joosten et al., 2009, 2012). Therefore, the focus for

successful participation in school for children who engage in restricted and repetitive

behaviours and interests needs to be considered from a bioecological and holistic viewpoint,

with a shift from fixing the behaviours through intervention, without discounting this

approach altogether, to the consideration of environmental adjustments to reduce the

chances of occurrence (Ashburner et al., 2008; Brown & Dunn, 2010; Joosten et al., 2012;

Kirby et al., 2016).

1.4 Purpose and Research Question

To date there has been limited research on the impact restricted and repetitive

behaviours and interests can have on daily functioning, compared to the research conducted

into social and communication difficulties (Berry, Russell, & Frost, 2018). Studies have

predominantly focused on definition, change and cause (Leekam, Prior, & Uljarevic, 2011)

and consists of clinical observations, or anecdotal reports with very few being in natural

contexts (Kirby et al., 2016). No studies of restricted and repetitive behaviours focus on the

effects of participation in education. Exploration of literature focusing specifically on

participation for children with autism also confirms that these two subject areas have not

been researched together. Further research is required to identify the way restricted and

repetitive behaviours affect participation in order to create effective treatments for students


17

with autism that promote active engagement within educational settings (Sparapani, Morgan,

Reinhardt, Schatschneider, & Wetherby, 2016).

The Family of Participation-related Constructs (fPRC; Imms et al., 2016) provides a

conceptual framework for this study, from which to examine the interaction between the

factors of restricted and repetitive behaviours and participation within the context of school.

The fPRC also provides a classification of participation that gives clarity and uniformity.

This enables comparisons between the proposed study and other studies using the same

definition.

The main purpose of this study is to develop a specific understanding of the effect of

restricted and repetitive behaviours on school participation for children with autism through

data collection and analysis. This potentially will assist to identify ways to remove the

barriers restricting attendance and involvement for students with autism in mainstream

schooling. Therefore, the following research questions were formulated for this study:



This will be addressed by two sub-questions:

Research sub-question 1: How do differing levels of restricted and repetitive behaviours

influence attendance and involvement of children with autism in school activities?

Research sub-question 2: How do differing types of restricted and repetitive behaviours


2. Literature Review

A systematic approach was required when examining the relevant research in the

areas of school participation and restricted and repetitive behaviours in children with autism,


18

due to the volume of literature available. After an initial search of the literature through data

bases such as CINAHL®, ERIC®, PsychINFO®, PubMed®, SAGE Journals Online®,

ScienceDirect® and SpringerLink® it was apparent that there is considerable research into

participation and also research into restricted and repetitive behaviours. However, it became

clear that there was no literature that addressed the relationship between restricted and

repetitive behaviours and school participation for students with autism. The two main

categories observed were restricted and repetitive behaviours in autism, and participation for

individuals with autism. Therefore, the exploration of the research was divided into these two

areas. Links, relationships and overlaps were discovered between the two categories, along

with clear gaps in the research. This extensive search then led to the identification of the

aforementioned research questions.

2.1 Research on Autism and Restricted and Repetitive Behaviours

Autism is a neurodevelopmental disorder that is estimated to affect between one to

two and a half percent of children globally (Kim et al., 2011; Randall et al., 2016). The

increase in reported prevalence is worldwide. Possible explanations include under diagnosis

in the adult population, causing previous rates of prevalence to be underestimated. It is also

possible that the increase in diagnosis is due to the rising awareness of the disorder by health

care professionals and the general public (Duchan & Patel, 2012). Additionally, the increase

in prevalence could be explained by the changing diagnostic criteria of autism as knowledge

evolves (Mahjouri & Lord, 2012). This increase has placed a huge demand on services such

as early intervention programs (Wise, Little, Holliman, Wise, & Wang, 2010) and presents

great challenges to the educational system (Crosland & Dunlap, 2012).

The Diagnostic Statistical Manual of Mental Disorders 5th edition (DSM-5; APA,

2013) consolidated the classifications of autistic disorder, Asperger’s disorder, childhood

disintegrative disorder and pervasive neurodevelopment disorder not otherwise specified into


19

the category of autism spectrum disorder. This supports the structure of a continuum of

expression from mild to severe (Lauritsen, 2013; Young & Rodi, 2014) rather than distinct

disorders. The previous triad of symptomology: impairments in social interaction,

impairments in communication and restricted repetitive and stereotyped patterns of

behaviour, interests, and activities was reclassified as a dyad: impairments in social and

communication, and restricted and repetitive patterns of behaviour, interests, or activities

(Young & Rodi, 2014). The diagnostic section of social and communication impairments is

divided into three areas; deficits in social-emotional reciprocity, deficits in nonverbal

communicative behaviours used for social interaction and deficits in developing, maintaining,

and understanding relationships (APA, 2013). Under the core diagnostic criteria of restricted

and repetitive patterns of behaviour, interests, or activities there are four subcategories:

stereotyped or repetitive motor movements, use of objects or speech; insistence on sameness,

inflexible adherence to routines, or ritualised patterns of verbal or non-verbal behaviour; and

highly restricted, fixated interests that are abnormal in intensity or focus. A new category of

atypical sensory behaviours was also introduced. To receive a diagnosis, a person needs to

demonstrate at least 2 of these 4 behaviours. The DSM-5 further classifies both core

diagnostic areas by levels of severity based on the impact they have on an individual’s ability

to function in daily living (Table 1).


20

Table 1.

Classification of Severity Levels of Restricted and Repetitive Behaviours

Severity Level Description

Level 3- Requiring very substantial

support

A level three severity rating indicates that due to their

debilitating restricted and repetitive behaviours and

interests, individuals require very substantial support to

function on a daily basis. They display marked distress

when rituals or routines are interrupted, and it is very

difficult to redirect from a fixated interest or return to it

quickly.

Level 2- Requiring substantial support People with level two severity of restricted and

repetitive behaviours and interests have more frequent

displays of behaviours that are noticeable to others.

These behaviours cause difficulties in functioning over

multiple contexts. Distress or frustration is apparent

when RRB’s are interrupted; difficult to redirect from

fixated interest.

Level 1- Requiring support Individuals require some support in their day to day

functioning and engage in inflexible behaviours that

interfere in one of more contexts. This includes having

trouble with transitions, planning and organisation and

resisting attempts by others to interrupt RRB’s or to be

redirected from fixated interest.


21

Children with autism engage in restricted and repetitive behaviours on a daily basis

and these behaviours are a part of everyday experiences of the individuals and their families

(Baranek, David, Poe, Stone, & Watson, 2006; Dunn, 2007; Leekam, Prior, & Uljarevic,

2011). However, restricted and repetitive behaviours are far less researched, and less is

known about their aetiology and development (Harrop et al., 2014). The majority of research

to date has focused on the types and frequencies of restricted and repetitive behaviours with

minimal exploration of these behaviours in context (Kirby, Boyd, Williams, Faldowski, &

Baranek, 2016). There has been some research regarding atypical sensory responses, now

under the umbrella of restricted and repetitive behaviours in the DSM-5. Therefore, in this

research the three other subcategories of stereotyped or repetitive motor movements,

insistence on sameness, and circumscribed interests, will be considered.

2.2 Definition

Restricted and repetitive behaviours can be divided into three subcategories: repetitive

sensory motor movements, insistence on sameness and circumscribed interests. Repetitive

sensory motor movements, also referred to as stereotypy (Chebli, Martin, & Lanovaz, 2016;

Cunningham & Schreibman, 2008; Lanovaz, Robertson, Soerono, & Watkins, 2013) can

comprise of behaviours such as hand, finger and whole-body movements, (e.g. hand flapping,

stereotyped body movements, spinning, jumping, rocking) (Szatmari et al., 2006). Hand and

finger flapping can be an expression of excitement in younger children, whereas complex

whole-body movements such as rocking may also be associated with agitation and function

as self-calming. Repetitive sensory motor behaviours can also include repetitive use of

objects, or parts of objects such as flicking elastic bands or twirling a stick, repetitive

activities involving the senses such as touching or smelling (Joyce, Honey, Leekam, Barrett,

& Rodgers, 2017) and repetitive vocalisations (Bodfish, Symons, Parker, & Lewis, 2000;

MacDonald et al., 2007). Self-injurious behaviours also fall under this category and can


22

present as hitting, self-biting (Buono, Scannella, & Palmigiano, 2010; Richards, Oliver,

Nelson, & Moss, 2012), head banging, skin picking and eye gouging (Rice et al., 2016). All

of these repetitive sensory motor behaviours have the potential to prevent children from

physically engaging in school activities.

Insistence on sameness behaviours can often present as compulsions and/or rituals

and difficulties with changes in routines (Factor, Condy, Farley, & Scarpa, 2016). Frequent

changes of schedule can cause challenging behaviours due to preference for sameness in

many individuals with autism (Richler et al., 2007). With a typical school day being full of

changes in schedule or activities, this could make it difficult for children with autism, who

prefer rigid routines, to participate. Insistence on sameness can also mean that individuals

with autism find it hard to manage changes to their physical environment, including the

presence or absence of particular people. This could cause difficulties in the classroom

setting when a relief teacher has to take the class, or a familiar teacher aide or support teacher

are not available. In particular, the marked distress people with autism show when routines

are changed is unusual and can be disruptive and detrimental to everyday activities.

The presence of restricted and repetitive behaviours and interests, particularly

insistence on sameness, may limit home, leisure and classroom participation (Richler et al.,

2010) and changes in schedules or activities may also cause involvement in problematic

behaviours (Richler et al., 2007; Sparapani, Morgan, Reinhardt, Schatschneider, & Wetherby,

2016). Children may also have difficulty shifting attentional focus, which has implications

for individuals with autism in the classroom when facing daily transitions from one activity

to another (Sparapani et al., 2016). People with autism may also demonstrate a rigid

preference for particular types of food (e.g. certain colours only) and types of clothing (e.g.

particular brand, fabric). Routines may be required to be carried out with precise detail. Some


23

people with autism can also have verbal rituals where they require the same answer to the

same question repeatedly (Factor et al., 2016).

Circumscribed (also known as restricted) interests are abnormal in intensity and/or

focus (APA, 2013). They can develop as early as two to three years of age (Bashe & Kirby,

2001) and are seen in 75-95% of children with autism (South, Ozonoff, & McMahon, 2005;

Turner-Brown, Lam, Holtzclaw, Dichter, & Bodfish, 2011). Circumscribed interests fall into

two categories: acquisition of knowledge, and collections. The subjects of interest in both

groups can range from common topics such as trains (Winter-Messiers, 2007) to unusual

topics, such as fans or lawnmowers. The amount of time dedicated to special interests can

cause considerable disruption to the daily life of a person with autism and their family (South

et al., 2005). Children who are only interested in their topics of choice can be difficult to

engage in other activities, which can cause challenges in the classroom. Additionally,

individuals with autism may only want to converse with others about their specific topics of

interest, which can lead to challenges with reciprocal social interactions (Boyd et al., 2007).

However, these special interests can also provide intellectual enjoyment and be used

constructively to facilitate learning and friendships (Mottron, 2017).

2.3 Higher and Lower Order Restricted and Repetitive Behaviours

Restricted and repetitive behaviours and interests have been further categorised into

two separate, but not mutually exclusive, groups (Szatmari et al., 2006; Turner, 1999) of

lower and higher order behaviours (see Figure 1). Lower order behaviours are considered to

be unusual sensory interests and repetitive motor behaviours such as hand and finger

mannerisms, stereotyped body movements and repetitive use of objects (Szatmari et al.,

2006). Higher order behaviours were initially identified and were grouped into two clusters;

insistence on sameness and circumscribed interests (Spiker et al., 1994). Further to this, using

exploratory factor analysis, (Lam et al., 2008) found evidence for another higher order


24

behaviour, a third distinct category of behaviours called circumscribed interests, shown in

figure 1, which present as abnormal preoccupations and unusual/ intense attachments to

subjects and objects (Lam et al., 2008).

Figure 1. Higher and lower order restricted and repetitive behaviours.

Lower order behaviours have been found to be associated with lower nonverbal and

verbal IQ (Bishop et al., 2006; Kim & Lord, 2010; Lam et al., 2008) and lower chronological

age (Leekam et al., 2007). Stereotypy, or repetitive motor and vocal behaviours, can be

defined as involuntary, patterned, rhythmic and non-reflexive behaviours that are not caused

by social stimuli (Freeman, Soltanifar, & Baer, 2010; Rapp & Vollmer, 2005). Some

repetitive motor behaviours provide strong sensory feedback and are sometimes referred to as

Restricted and repetitive behaviours and interests

Lower order behaviours Higher order behaviours

Circumscribed interests

Insistence on sameness

Intense fascinations with objects or subjects

Collections of unusual objects

Rituals

Adherence to routines

Extreme reactions to changes of environment

Repetitive sensory movements and

behaviours

Hand flapping

Repetitive verbal behaviours e.g. echolalia

Spinning Rocking


25

repetitive sensory and motor behaviours (Richler et al., 2007). It is important to note that not

all repetitive motor behaviours provide this sensory experience and should not be confused

with atypical sensory reactions. Overwhelming sensory experiences may trigger restricted

and repetitive behaviours and interests, and it is known that sensory features and restricted

and repetitive behaviours and interests co-occur (Leekam et al., 2011) however there is a

clear conceptual difference.

Higher order behaviours include insistence on sameness; for example, the need to

maintain routines and rituals, wear the same clothing, or insist on particular foods.

Circumscribed interests are described as intense and unusual preoccupation with particular

objects or topics and are often pursued to the exclusion of other activities. They are also

considered to be more complex, higher order behaviours and are usually associated with

individuals with higher cognitive ability (Bishop et al., 2006; Joseph et al., 2013; Watt et al.,

2008), although Turner-Brown et al. (2011) found in their study that circumscribed interests

were not associated with intelligence. Circumscribed interests also seem to increase in

intensity over an individual’s lifespan (South et al., 2005).

This research gives us clear definitions and begins to explore the difficulties that

restricted and repetitive behaviours can create in daily living for individuals with autism.

However, studies in this area of definition do not discuss in detail how these behaviours

affect individuals. The research does not measure the number of restricted and repetitive

behaviours, and these behaviours are not considered in context.

2.4 Change

As previously stated, research into the domain of restricted and repetitive behaviours

has been historically underrepresented. Whilst there has been an increase in studies over the

past decade, these developments have taken place in a number of different fields, resulting in

a lack of integration in the research (Berry et al., 2018; Leekam et al., 2011). Nevertheless,


26

advances in the understanding of developmental trajectories of restricted and repetitive

behaviours have been made, primarily through studies of young children and adolescents

(Berry et al., 2018). As these studies are mostly concentrated on children of school age, it is

worth exploring this literature to look for information that may help to understand restricted

and repetitive behaviours and the effects these behaviours have on daily life for school age

children with autism.

Research into trajectories commonly addresses the relationships between restricted

and repetitive behaviours and age, cognitive ability and time. The findings regarding the

connection between age and higher order restricted and repetitive behaviours have generally

been in agreeance. It has been reported that insistence on sameness behaviours and

circumscribed interests become more prevalent among older children (South, Ozonoff, &

McMahon, 2005), perhaps due to the increase in cognitive ability necessary to engage in

these behaviours (Richler et al., 2010).

Repetitive motor behaviours, considered to be lower order behaviours appear to be

more common in younger children (Berry, Russell, & Frost, 2018; Harrop et al., 2014;

Honey, McConachie, Randle, Shearer, & Couteur, 2008; Richler, Huerta, Bishop, & Lord,

2010). These behaviours become less frequent over time but do not disappear (Harrop et al.,

2014). However, Richler et al. (2010) found that repetitive sensory motor behaviours

remained high over a period of 9 years in a group of children who were aged 2 at the start of

the study, and then reassessed at ages 3, 5, and 9 years old. Similarly, a meta-analysis of

change in autism symptoms found that in general, restricted and repetitive behaviours did not

change over time across studies (Bieleninik et al., 2017). This indicates that caution must be

used in comparing findings across studies, as many variables such as measures used, age and

IQ may also be factors that influence outcomes.


27

The research on the relationship between cognitive ability and restricted and repetitive

behaviours differs. One study found that there is no relationship between nonverbal

intelligence quotient (NVIQ) and restricted and repetitive behaviours in children under three

years of age (Bishop, Lord, & Richler, 2006). In addition, Kim and Lord (2010) found no

relationship between NVIQ and restricted and repetitive behaviours in toddlers under two

years old.

Conversely, other studies (e.g. Gabriels, Cuccaro, Hill, Ivers, & Goldson, 2005; Lam,

Bodfish, & Piven, 2008; Militerni, Bravaccio, Falco, Fico, & Palermo, 2002; Rao & Landa,

2014) found that lower order restricted and repetitive behaviours are more persistent and

severe in children with lower verbal and non-verbal IQ. The study by Militerni et al. (2002)

consisted of participants aged 2-4 and 8-11 years old. It was found that simple repetitive

sensory motor behaviours were more frequent in children with an IQ of less than 35. The

participants in the study by Rao and Landa (2014) were aged between 4 and 8 years old. This

study reported that children with lower cognitive ability displayed more stereotypic and

restricted behaviours than children with a higher cognitive ability. Another study (Gabriels et

al., 2005) found that children (mean age 10 years 7 months) with a low NVIQ showed

significantly greater restricted, repetitive, and stereotyped behaviours than those with a high

NVIQ. Additionally, a study by Harrop et al. (2014) found greater rates of restricted and

repetitive behaviours in children with lower language abilities.

This indicates that school age children display a range of restricted and repetitive

behaviours and some of these studies suggest that these behaviours can create barriers to

social engagement and learning (Berry et al., 2018) and can hamper development (Honey,

McConachie, Randle, Shearer, & Couteur, 2008). It is also suggested that different types of

restricted and repetitive behaviours may have differing underlying causes and maintaining

factors (Honey et al., 2008). Nonetheless, these studies did not focus on restricted and


28

repetitive behaviours in a school context and add nothing significant to the knowledge about

the way these behaviours affect school participation.

2.5 Cause

2.5.1 Theoretical explanations of restricted and repetitive behaviours. The

reviewed literature about the cause of restricted and repetitive behaviours falls into several

categories. There is a substantial amount of research on the theoretical causes of restricted

and repetitive behaviours. Neurobiological research (e.g. Rothwell et al., 2014; Wolff et al.,

2017) focuses on explanations of restricted and repetitive behaviours based on gene-

environment neuroadaptation and has received support from research based on animal models

(Ray-Subramanian & Weismer, 2012). Support for genetic involvement is also indicated

through familial aggregation in factor analytic studies of restricted and repetitive behaviours

(Szatmari et al., 2006).

Neuropsychological perspectives have highlighted the role of executive functioning in

restricted and repetitive behaviours. Results for the findings of executive dysfunction are

mixed possibly due to the types of assessment (Leekam et al., 2011). From a developmental

perspective, it is unlikely that executive functioning could have a direct causal link to

restricted and repetitive behaviours as they appear so early in typical development. Lack of

specificity is a problem as executive functioning impairments are common across a range of

childhood disorders including obsessive compulsive disorder (OCD) and attention deficit and

hyperactivity disorder (ADHD) (Clark, Prior, & Kinsella, 2002).

The developmental psychological approach to restricted and repetitive behaviours is

best represented by work by Thelen (1981). This approach frames restricted and repetitive

behaviours as having adaptive functions that are maintained past typical infant development

in children with autism. It could be that rhythmical behaviour patterns of repetition have a

systemic effect on development that transcends the behaviours themselves and may be related


29

to other areas of development such as communication and social interaction (Iverson &

Wozniak, 2007).

Although these approaches to the cause of restricted and repetitive behaviours are

important fields of research they are all theoretical or clinical explanations. This literature is

not focused on the effects of restricted and repetitive behaviours in any context. However,

there are two further areas of research regarding the cause of restricted and repetitive

behaviours which are relevant to the current study. These areas are the link between restricted

and repetitive behaviours and anxiety, and the relationship between restricted and repetitive

behaviours and context.

2.5.2 Restricted and repetitive behaviours and anxiety. The number of studies of

anxiety, sensory responses and restricted and repetitive behaviours in people with autism has

been growing in recent years. The relationship between these three constructs is complicated,

but it is clear there are links between anxiety and particular types of restricted and repetitive

behaviours.

Individuals with autism often present with co-occurring anxiety which is reported to

be a significant source of distress (White, Oswald, Ollendick, & Scahill, 2009; Wood &

Gadow, 2010). Anxiety has long term associations with depression, hyperactivity and self-

injurious behaviour (Mazzone et al., 2013). To date, there has been little agreement about the

prevalence rate of anxiety in individuals with autism, with proposed rates ranging from 11 to

87 per cent (White & Roberson-Nay, 2009). However, there is general consensus that 40 to

50 per cent of people with autism meet criteria for at least one anxiety disorder (MacNeil,

Lopes, & Minnes, 2009; Steensel, Bögels, & Perrin, 2011; White et al., 2009), whereas

estimates in typically developing children are thought to be between three and 24 per cent

(Cartwright-Hatton, McNicol, & Doubleday, 2006). Anxiety in individuals with autism has

been linked to sensory over responsiveness (e.g. Green & Ben-Sasson, 2010) and restricted


30

and repetitive behaviours and interests (Factor et al., 2016; Gotham et al., 2013; Joosten &

Bundy, 2010; Joosten et al., 2009; Lidstone et al., 2014; Rodgers et al., 2012; Spiker et al.,

2012; Wigham et al., 2015) but there are differing views on the exact nature of the

relationships between these three constructs.

Some investigators have examined the link between restricted and repetitive

behaviours and interests and anxiety, and found that higher levels of anxiety are

accompanied by a greater incidence of restricted and repetitive behaviours and interests

(e.g. Rodgers et al., 2012). However, it is still not fully understood why this relationship

occurs. A number of studies (e.g. Joosten & Bundy, 2010; Joosten et al., 2009; Lidstone et

al., 2014; Rodgers et al., 2012) investigated this connection and found evidence to suggest

there is a correlation between anxiety and insistence on sameness behaviours, but not

between anxiety and repetitive motor behaviours. It has also been suggested that the

relationship between sensory processing abilities, restricted and repetitive behaviours and

anxiety may be due to intolerance of uncertainty (Wigham, Rodgers, South, McConachie, &

Freeston, 2015).

Restricted and repetitive behaviours and interests may also function as a way to

reduce anxiety (Factor et al., 2016). However, social motivation may also be a mediator

between restricted and repetitive behaviours and interests and anxiety. It is thought that

individuals with autism do not derive satisfaction from social interactions often (Kohls et al.,

2013), and therefore do not seek these experiences. This social disconnection causes

individuals to seek non-social behaviours for intrinsic pleasure resulting in the engagement of

restricted and repetitive behaviours and interests. This theory is further supported with a

study by Loftin, Odom, and Lantz (2008) that has shown that social skills training leads to

higher incidents of social interaction and lower rates of restricted and repetitive behaviours

and interests.


31

When viewing restricted and repetitive behaviours and interests contextually, it is

clear that there is a strong link with anxiety and it is important to be aware of the complexity

of this relationship. All of the studies mentioned above however, do not directly address the

topic of the effects of restricted and repetitive behaviours on participation. Moreover, whilst a

holistic view provides a better understanding of restricted and repetitive behaviours and

interests and the way these behaviours affect other areas of an individual’s life, it does not

explain what effects restricted and repetitive behaviours and interests have on school

participation.

2.6 Context

There is a number of published studies that suggest that context may be a cause of

some types of restricted and repetitive behaviours. For the purpose of this study, the literature

merits further investigation as some of the studies are school context based. This research

may provide some insight into the effects of restricted and repetitive behaviours on

participation.

Additionally, understanding the context in which restricted and repetitive behaviours

occur can inform decisions regarding intervention. If the belief is that context does indeed

affect these behaviours, then intervention needs to change from simply suppressing

behaviours to adjusting the environment (Matson & Nebel-Schwalm, 2007). Understanding

the effect of context can also help determine whether the restricted and repetitive behaviours

are of concern. For example, a repetitive motor behaviour such as hand flapping or rocking

may not be considered a problem at home whist watching a television show but may be more

problematic in class (Joosten, Bundy, & Einfeld, 2012).

Assessment of the motivation for restricted and repetitive behaviours in the past has

led to interventions that alter the environment, social demands and schedules, and improve

communication, rather than treating the behaviours (Horner, Carr, Strain, Todd, & Reed,


32

2002). Researchers Joosten, Bundy and Enfield determined that further investigation of the

variables that drive restricted and repetitive behaviours was required so that modifiable

aspects of the behaviour could be understood. Three studies were conducted by these

researchers between 2008 and 2012 examining the effect of context on motivating students to

engage in restricted and repetitive behaviours. The participants for all three studies were a

group of students attending a specialist day school.

Joosten and Bundy (2008) initially investigated motivation for restricted and

repetitive behaviours in a group of 67 children aged 5-18 years with a diagnosis of either

intellectual disability or autism and intellectual disability. The Motivation Assessment Scale

(MAS; Durand & Crimmins, 1988) was used as a measurement tool, which grouped 16 items

into four sources of motivation; to gain social attention, both negative and positive; to gain

access to tangible objects or in response to object being removed; to escape from people or

activities and to experience sensory feedback. The results of the study found that diagnosis

was a factor in explaining the motivation for restricted and repetitive behaviours. Children

with intellectual disability were more likely to be motivated by the desire to gain an object,

whilst children with both intellectual disability and autism were more likely to be motivated

by sensory stimulation or escape when engaging in restricted and repetitive behaviors.

Further to this study, Joosten, Bundy, and Einfeld (2009) studied the motivation for

stereotypic and repetitive behaviours in the same group of participants from the 2008 study,

using a revised MAS. For the study the MAS was divided into intrinsic and extrinsic

measures and anxiety was added in as an intrinsic motivator. The study found that stereotypic

and repetitive behaviours are impelled by multiple motivators and can be both intrinsically

and extrinsically driven.

Building on the two prior studies, the later study by Joosten et al. (2012) broadened

their research on the influences of context on stereotypic and repetitive behaviour in the same


33

group of participants from the 2008 and 2009 studies discussed above. This study used the

revised MAS observation measure that was developed in the 2009 study which was named

the Motivation Assessment Scale (MAS: R; Joosten et al., 2009). This measure assesses five

common motivators: enhanced sensation and anxiety alleviation, (intrinsic motivators);

seeking attention, objects or escape (extrinsic motivators) (Joosten et al., 2012). The study

also defined three contexts across the school day; during tasks; at times of transition, and in

free time, to determine if restricted and repetitive behaviours are different in each context.

The research found that the effect of context on restricted and repetitive behaviours

and interests is a complex combination of intrinsic factors, such as level of anxiety, and

environmental factors such as what is happening, or who is involved. The study also revealed

that restricted and repetitive behaviours occur more frequently during transition time,

possibly because the individual is uncertain of what is about to happen next, and during free

time when trying to gain attention or a tangible object. It is also thought that these behaviours

may also be present during free time due to reduced stimulation and are used as a sensory

enhancing tool. In agreement with other studies, Joosten et al. (2012) also refer to the

relationship between anxiety, sensory responsiveness and restricted and repetitive behaviours

as further complications in determining the cause of restricted and repetitive behaviours.

Nonetheless, whilst restricted and repetitive behaviours were measured, these studies

were observational, and each child was only rated by one rater. Due to the requirement of the

rater to have close contact with the child, bias was possible. The construct of participation

was not discussed in these studies, as the intention was not to find out if restricted and

repetitive behaviours affected participation, but to find out if context motivated the

behaviours. Further research is required to understand the potential impacts of restricted and

repetitive behaviours in a school setting, with a clear focus on participation.


34

2.7 Autism and school participation

Inclusive education is a movement of substantial proportions (Evans & Lunt, 2002;

Rodriguez & Garro-Gil, 2015). The Salamanca Statement indicates that schools must respond

to the needs of the diverse learner by adjusting curricula and teaching strategies to

accommodate all students, including those with physical and learning disabilities (Hunt,

2011; Unesco, 1994). It is reported that more than half of students with autism spend a

significant part of their day in mainstream schooling, with a large group spending at least

80% of their day in class (Adams, Taylor, Duncan, & Bishop, 2016). While inclusive

education can lead to increased social engagement and advanced education goals for students

with disabilities compared to those who are educated in special schools, inclusion is still

challenging for mainstream schools and teachers (Eldar, Talmor, & Wolf-Zukerman, 2010;

Vakil et al., 2009).

Educational outcomes for students with autism in mainstream schooling are poor

compared to other disability groups and to typically developing students. Outcomes are also

poor in relation to the cognitive ability of students with autism, that is, they underachieve in

relation to their cognitive ability (Keen, Webster, & Ridley, 2016). There is an increasing

need for special education resources for children with autism (Kim, Bal, & Lord, 2018) with

many educators finding it difficult to successfully include students with autism in their

classrooms (Lindsay, Proulx, Thomson, & Scott, 2013). This is most likely because inclusion

of children with disabilities, and in particular, children with autism (Roberts & Simpson,

2016) remains one of the least understood areas of education (Symes & Humphrey, 2010).

The search for studies about participation of children with autism in schools

uncovered a considerable amount of literature addressing the subject of inclusion in

mainstream schooling. A review of the literature into attitudes of key stakeholders for

students with autism was conducted by Roberts and Simpson (2016), which highlighted the


35

diverse attitudes to inclusion among stakeholders. One of the concerns that teachers had was

the behaviours of students with autism in the classroom (Johansson, 2014). Behaviours such

as stereotypic utterances, movement around the classroom and task refusal were considered

disruptive and inappropriate (Hay & Winn, 2005; Sansosti & Sansosti, 2012; Soto-

Chodiman, Pooley, Cohen, & Taylor, 2012), and teachers raised concerns about the effects of

these behaviours on other students in the classroom (Sansosti & Sansosti, 2012).

However, it was found that most of the behaviours described by teachers in these

studies were the result of the interaction between the student and the environment rather than

being a primary characteristic of autism (Roberts & Simpson, 2016). This highlights a gap in

understanding how the school context can affect the behaviour of children with autism,

including restricted interests and repetitive behaviours, which could prevent learners with

autism from successfully participating and learning in the classroom (Ravet, 2011).

Participation as a construct has gained much scrutiny in recent times being considered

a positive influence on an individual’s health and wellbeing that also plays a role in learning

new skills and developing relationships (Anaby et al., 2014; Khetani et al., 2014). A clear

definition of participation is required when researching the effects of restricted and repetitive

behaviours in the school context. There have been varied descriptions of participation

(Granlund et al., 2012) leading to multiple approaches to measurement, resulting in

misinterpretation of findings and an inability to compare studies (Imms et al., 2016). Whilst

participation is a multidimensional construct it can be defined as attendance and involvement.

The Participation and Environment Measure for Children and Youth (PEM-CY; (Coster et

al., 2012), which is being more widely used in the measurement of participation uses this

definition of participation.

Using the PEM-CY as a measurement tool, Coster et al. (2013) compared the

participation patterns of children between 5 and 17 years old, with and without disabilities by


36

looking at school features as a barrier or support for participation. The study found that

overall school participation was higher for students without disabilities across the three

domains of frequency, involvement and satisfaction. Parents of children with disabilities

stated that their children participated less in important school related activities. They reported

that features of the environment such as physical, cognitive and social demands of activities

and the sensory qualities of the environment were barriers to the participation of their

children. This study adds to the understanding of the difficulties children with disabilities

face in the mainstream schooling context. However, only a small percentage of the children

included in this study were listed as having autism as their sole disability. Additionally, the

sole focus of the study was features of the physical and social environment that create

barriers to learning, not child characteristics.

Another recent study used the PEM-CY to explore the participation of children with

autism at home, in the community and at school (Simpson et al., 2017). In the school section

of the PEM-CY, it was noted that even when participating in school activities, children with

autism scored lower on involvement than their typically developing peers. This included

children as young as five years old and suggests that patterns of difference may be

established from the very start of school. Again, this information builds evidence that

children with autism are not participating at school as fully as others. Nonetheless, as the

focus for this study was measuring levels of participation, the reasons for lower levels of

participation involvement levels for these students are not considered.

There are further studies that investigate classroom engagement for children with

autism (e.g. Nicholson, Kehle, Bray, & Heest, 2011; Ruble & Robson, 2007; Sparapani,

Morgan, Reinhardt, Schatschneider, & Wetherby, 2016). As with the previous research

mentioned, the focus is not about how restricted and repetitive behaviours contribute to or


37

create barriers to classroom participation. This further highlights the gap in the literature

regarding the effects of child characteristics on participation.

Only one study was found at this time that specifically discussed how restricted and

repetitive behaviours affected the participation of an individual student with autism in a

school setting. A study by Sigafoos, Green, Payne, O'Reilly, and Lancioni (2009) looked into

an intervention strategy to prevent a student from missing out on learning time due to a

fixation on having items on his school desk arranged in a particular way. Whilst it was

acknowledged that this particular behaviour was affecting participation during classroom

teaching time, the study did not explore any other areas of school participation to determine if

this particular behaviour affected other activities. The purpose of the study was to measure

the effects of an intervention, so participation was not defined or measured. Data collection

for this research was observational and was subject to human bias (Kawulich, 2005). Lastly,

this study used only one participant, limiting the replication of the findings to the population

of individuals with autism.

The literature covered in this section considers inclusion challenges and teacher

perspectives. There is consensus that children with disabilities, and children with autism

participate less in school compared to their typically developing peers. Whilst these studies

have enormous benefit in understanding how students with autism can achieve success in the

classroom, they tended to be school, teacher or environment centered and have not

considered the child characteristics and how these affect inclusion and participation.

In studies of participation (Coster et al., 2013; Simpson et al., 2017) the term was

clearly defined. However, there has been little research on the impact of restricted and

repetitive behaviours on participation. No study was found which used standardised measures

to determine the effect of restricted and repetitive behaviours on school or classroom

participation in children with autism. The aim of this research proposal therefore, is to


38

address the identified research gaps and establish whether restricted and repetitive behaviours

have an effect on participation in school for children with autism. Participation will be clearly

defined as attendance and involvement and will be measured. Restricted and repetitive

behaviours will also be measured. The data collected will be analysed to determine if these

behaviours affect participation. This study will advance our understanding of restricted and

repetitive behaviours in the school context and enhance effective education for children with

autism in mainstream schooling.

2.8 Conceptual framework

Whilst restricted and repetitive behaviours and interests are well defined, there has

been confusion about the definition of participation in studies, which has led to varied

descriptions of the concept (Granlund et al., 2012) and therefore mixed approaches to

measurement. This has caused misinterpretation of results found and reported (Imms et al.,

2016). Researching children with autism who engage in restricted and repetitive behaviours

in terms of participation in the school context requires an understanding of the constructs of

both restricted and repetitive behaviours and participation.

Imms et al. (2016) reviewed the language, definitions and intervention research

around the construct of participation with the aim of understanding how participation is

viewed by other researchers. It has been found that participation is a multidimensional

construct that includes individual and environmental factors as an influence on participation.

Attendance and involvement were found to be the two themes that were explicitly linked with

the experience of participation, with attendance a prerequisite for involvement (Imms et al.,

2016). Participation is a multidimensional construct (Granlund et al., 2012; Imms et al.,

2017) that also includes related concepts of preference, activity competence and sense

participation. Additionally, all participation occurs within a contextualised setting (Anaby et

al., 2014; Hammel et al., 2008; Mallinson & Hammel, 2010) (see Figure 2).


39

Figure 2. Participation as a multidimensional construct.

Note. Adapted from Imms et al. 2016 p. 58 “‘Participation’: A systematic review of

language, definitions, and constructs used in intervention research with children with

disabilities,” by C. Imms, B. Adair, D. Keen, A. Ullenhag, P. Rosenbaum and M. Granlund,

2016, Developmental Medicine & Child Neurology, 58, p. 36. Copyright 2015, Mac Keith

Press.

The Family of Participation-related constructs (fPRC; Imms et al., 2016) is a

conceptual framework that considers participation as an entry point and a primary outcome of

intervention. It also identifies the transactional processes by which participation is expressed.

This framework was designed to provide conceptual and terminological consistency and to

support education research and practice for children and adults living with long term

impairments. Research designed using this framework aims to understand the influences that

affect an individual’s daily functioning by addressing their developmental, mental, physical,

psychosocial and environmental challenges. This framework supports research of both


40

immediate and long-term outcomes on lives impacted by impairment by examining the

interacting forces on the individual child and the family within the contexts in which they

live.

Figure 3. Bidirectional restricted and repetitive behaviours and participation construct

Note. Adapted from Imms et al. 2016 p. 58 “Participation, both a means and an end: A

conceptual analysis of processes and outcomes in childhood disability” by C. Imms, M.

Granlund, P.H. Wilson, B. Steenbergen, P.L. Rosenbaum and A.M. Gordon, 2017,

Developmental Medicine & Child Neurology, 59, p.19. Copyright 2017 by Mac Keith Press.

The fPRC provides a conceptual framework for this study, from which to examine the

interaction between the factors of restricted and repetitive behaviours and participation

within the context of school. The framework specifies clear and consistent terminology for

participation, which will enable comparison of this study with others that employ the same


41

definition. The research resulting from the framework is designed to increase understanding

of child characteristics that affect the daily functioning of an individual, in this case,

restricted and repetitive behaviours, and their effect on participation. The study also

acknowledges that the relationship between the two factors is bidirectional (as illustrated in

figure 3). This relationship is supported by the bioecological model of development

(Bronfenbrenner & Ceci, 1994), which states that biological and environmental factors

interact to influence a child’s development (Cunningham & Rosenbaum, 2015). Within the

microsystem it is explained that proximal processes, disposition, personal resources and

demand characteristics, context and time all interact with each other reciprocally to influence

development (Bronfenbrenner & Ceci, 1994). The intended outcome of this study is to

examine the effect of restricted and repetitive behaviours and interests on participation for

children with autism at school. The implications of these findings could be to inform

interventions and modifications to address these barriers to learning. It is not intended that

child focused interventions only will be suggested, nor that only environmental adjustments

be made, but a combination of both approaches should be considered.

3. Method

Data were collected using online surveys. Online surveys are an efficient, cost

effective and convenient way to gather information (Lefever, Dal, & Matthiasdottir, 2007;

Scott et al., 2011). Surveys collect information at a point in time from a pre-determined

population specific to the research study. Data collected from standardised surveys can be

used to explore the effects of one set of variables on another which suits the purpose of this

study and allows the data to be compared to other studies using the same measures (Creswell

& Plano Clark, 2018).

Online data collection has the benefit of reaching larger populations. This potentially


42

enables a wider spread of respondents (Evans & Mathur, 2005) allowing for inclusion of

diversity. Additionally, the ability to collect data from many people means that the data is

more likely to be based on a representative sample and can then be generalisable to a

population (Kelley, Clark, Brown, & Sitzia, 2003).

Furthermore, response rates can vary so being able to reach a larger population

ensures a better opportunity to get a sufficient number of responses. Additionally,

participants have the flexibility of completing online surveys at their own convenience, with

respondents having the option of saving the survey and returning to complete the survey at a

convenient time (Jones, Murphy, Edwards, & James, 2008)

3.1 Participants

The participants were accessed through the Cooperative Research Centre for Living

with Autism’s (Autism CRC) Longitudinal study for Australian Students with Autism

(LASA) research project. The Autism CRCs LASA project was designed to investigate

educational and participation trajectories and outcomes for Australian students with autism

over a six-year period. Participants were recruited across Australia, where there are an

estimated 35 000 or more school aged children with autism. The primary participants sought

were caregivers of children aged four to five, and nine to 10 years old who have received a

clinical diagnosis of autism from a health care provider. Parent/ caregiver participants were

recruited from state autism organisations, child development and early intervention units,

parent support and autism advocacy groups, websites, mailing lists and internet groups. The

parent/ caregiver participants were initially asked to register through an internet link, after

which a research team member contacted them to ascertain eligibility and interest in

participating. Once this was completed the parent/ caregiver was sent an online questionnaire

(Roberts et al., 2018).


43

Ethical approval for the Autism CRCs LASA study was obtained from all recruiting

sites and universities involved in the project. Consent was obtained from all parents whose

child joined the study. There was no risk to the participants associated with the study.

However, there was some possibility that parents may become distressed when discussing

their child’s autism traits and difficulties. Therefore, the study was designed to finish with

questions about the strengths and interests to end on a positive note. The parents were all

provided with the project administrator’s contact details so that they could discuss the

questionnaire if needed. Participant information was securely stored electronically. Once

downloaded from the database it was anonymised by allocating an identification number for

each participant. De-identified data was made available only to members of the research

team. Ethics approval for this particular study was gained from Griffith University. Approval

was also given by the LASA team and the Autism CRC. The data released was de-identified

and was used in an ethical manner in accordance to the guidelines of the LASA study.

3.2 Sample participants

The participants for this study were parents/ caregivers of a group of children aged -

nine- 10 years old who have a diagnosis of autism. This age group were in upper primary

school at the data collection point in time. This group of students was chosen as they were in

their last 1 or 2 years of primary schooling. Therefore, their participation and behaviour

scores should be representative of their experience through primary school.

Demographic information for this sample is provided in Table 2. There were 131

participants in this cohort in Time 1 who provided data for both of the questionnaires used for

data analysis. The ratio of male to female in this cohort is 4:1 which compares to previous

statistics (Fombonne, Quirke, & Hagen, 2011) but is slightly higher than the current statistic

of 3.5:1 according to a study by Loomes, Hull, and Mandy (2017). In addition to autism,


44

nearly 44% of participants have another medical condition or disability e.g. attention deficit

and hyperactivity disorder (ADHD), anxiety, asthma and epilepsy.

For this study the mother was predominantly the person who filled out the

questionnaires. The most common occupation for caregivers was part time employment and

74.3% of caregivers stated that they completed tertiary education. The average family income

was $80 001 - $180 000. Caregivers also completed the Social Communication Questionnaire

(SCQ; Rutter, Bailey, & Lord, 2003) to identify the level of autism severity. The SCQ

provides a cut-off score of 15 with scores above this indicating more severity (M = 22.09, SD

= 6.61).


45

Table 2.

Child and Caregiver Characteristics

Categorical variables Participants (n = 131)

N (%)

Categorical variables Participants (n= 131)

N (%)

Child gender Caregiver’s highest level of

education

Male 111 (79.3) No formal/ primary school 2 (1.4)

Female 29 (20.7) Secondary school 32 (22.9)

Other medical condition or disability

Caregiver’s relationship to the child

61 (43.6) Tertiary education

Missing

104 (74.3)

2 (1.4)

Mother 122 (87.8) Annual family income

Father 14 (10.1) < $18 200 5 (3.6)

Other 3 (0.21) $18 201- $37 000 15 (10.7)

Caregiver’s occupation

Unemployed

Full time employment

Part time employment

Caring responsibilities

Full time study

Part time study

4 (2.9)

34 (24.3)

57 (40.7)

36 (25.7)

3 (2.1)

5 (3.6)

$37 001- $80 000

$80 001- $180 000

> $180 000

26 (18.6)

65 (46.4)

13 (9.3)


46

3.3 Measures

Table 3.

Measurement Instruments

Measurements Purpose

Developmental Behaviour

Checklist-Parent Version

(DBC-P; Einfeld & Tonge,

1995).

The DBC-P is a parent/ caregiver 96 item checklist that

assesses the behavioural and emotional disturbances in

young people between four and 18 years with

developmental or intellectual disabilities.

Participation and

Environment Measure-

Children and Youth (PEM-

CY; Coster et al., 2011).

The PEM-CY is a parent-report instrument that reports on

the number of activities, frequency of attendance, the level

of involvement, and parent’s desire for change in

participation in typical activities at home, in school and in

the community.

Repetitive Behaviour

Questionnaire- 2 (RBQ-2;

Leekam et al., 2007).

The RBQ-2 has 20 questions based on the two-factor

grouping of high and low order behaviours further divided

into four factors: repetitive motor movements, rigidity/

adherence to routine, preoccupation with restricted patterns

of interest and unusual sensory interests.

Vineland Adaptive

Behaviour Scales Second

Edition (VABS-II; Sparrow,

Cicchetti, & Balla, 2005).

The VABS-II is a clinician-administered, semi-structured

parent interview that is used to obtain parent ratings of

children’s adaptive functioning across three domains:

communication, socialisation, and daily living skills.


47

Table 3 summarises the measurement tools used in this study. The DBC-P was used

to measure the amount of restricted and repetitive behaviours that each participant displayed.

The PEM-CY was used to measure frequency of participation, and involvement of each child

in school activities. The RBQ-2 was used for comparison to validate the use of the BDC-P as

a restricted and repetitive behaviour measurement. The VABS-II was used in this study as an

indicator of adaptive functioning of participants. This was included as a measure to control

developmental differences. These measures are described in further detail below.

3.3.1 Developmental Behaviour Checklist-Parent Version (DBC-P; Einfeld &

Tonge, 1995). The DBC-P was used in the Autism CRCs LASA longitudinal study. The

DBC-P is a parent/ caregiver 96 item checklist that assesses the behavioural and emotional

disturbances in young people between four and 18 years with developmental or intellectual

disabilities (Brereton, Tonge, Mackinnon, & Einfeld, 2002). It is completed by the primary

caregiver. The DBC-P was developed in response to the limitations of available instruments

to evaluate the psychopathology of children, adolescents and adults with developmental

disabilities (Aman & Singh, 1988; Fraser & Rao, 1991). To address these limitations, Einfeld

& Tonge (1995) developed a standardised instrument to broadly assess the emotions and

behaviours of individuals from four to 18 years old with intellectual disability. The DBC-P

was revised in 2002, and currently provides a total behaviour score (range 0 - 192;

Cronbach’s coefficient = 0.94), which can reflect a level of disturbance which would be

considered clinically significant by a trained physician. It provides six subscale scores:

disruptive, antisocial, self-absorbed, communication disturbance, anxiety and social relating

(Brereton et al., 2002) and also individual behaviour symptom scores.

At the same time, the Developmental Behaviour Checklist- Autism Screening

Algorithm (DBC-ASA) was created (Brereton et al., 2002) which was modified in 2016,

applying DSM-5 autism criteria. Further to this, the Developmental Behavioural Checklist-


48

Adult Version (DBC-A; Mohr, Tonge, & Einfeld, 2005) was created in order to allow

continuous assessment of psychopathology over a lifespan for individuals with ID. The

DCB-P has strong psychometric properties and is reliable and valid in discriminating

between individuals with ID with and without autism using a factor analysis derived 29-item

score, the DBC-Autism Screening Algorithm (DBC-ASA; score range 0–58; cut-off score

14) (Brereton et al., 2002; Steinhausen & Winkler Metzke, 2004; Teh, Chan, Tan, & Magiati,

2017).

The DBC-P has been used in a variety of research areas such as anxiety, and

continuity and change in anxiety in young people with autism (Gotham, Brunwasser, & Lord,

2015; Teh et al., 2017) and to compare psychopathology in children and adolescents with

autism and young people with ID (Brereton, Tonge, & Einfeld, 2006). The DBC-P was also

used in a study by Chandler et al., (2016) to assess the frequency and pervasiveness of

emotional and behavioural problems in young children with autism. It was picked out of a

selection of tools by parents who considered it easy to fill in and highly relevant to their child

and is considered to be an effective tool to measure emotional and behavioural difficulties in

children with autism (Brereton et al., 2006).

Items in the DBC-P survey relate to restricted and repetitive behaviours. An

investigation was conducted to determine if it was comprehensive enough for this study. To

validate the use of the DBC-P in measuring restricted and repetitive behaviours, DBC-P

items were compared with the Repetitive Behaviour Questionnaire- 2 (RBQ-2; Leekam et al.,

2007) items. The RBQ-2 has 20 questions based on the two-factor grouping of high and low

order behaviours further divided into four factors: repetitive motor movements, rigidity/

adherence to routine, preoccupation with restricted patterns of interest and unusual sensory

interests. In this study, the sensory interests section was not included as these behaviours are

not being researched.


49

In the repetitive motor movement category there are five items from the RBQ-2 that

match questions from the DBC-P (Table 4). Items 25 in the DBC-P and 72 corresponded

with item 2 in the RBQ-2. Item 90 in the DBC-P related to items 3, 4 and 5 of the RBQ-2.

Additionally, item 59 in the DCB-P correlated to item 6 in the RBQ-2.

Table 4.

Repetitive Motor Movements in the RBQ-2 and the DBC-P

RBQ-2 DBC-P

2. Repetitively fiddle with toys or other

items? (e.g. spin, twiddle, bang, tap,

twist, or flick anything repeatedly?)

25. Flicks, taps, twirls objects repeatedly

72. Switches lights on and off, pours water over

and over; or similar repetitive activity

3. Spin himself around and around?

4. Rock backwards and forwards, or side

to side, either when sitting or when

standing?

5. Pace or move around repetitively?

(e.g. walk to and from across a room or

around the same path in the garden?)

90. Unusual body movements, posture, or way

of walking

6. Make repetitive hand and/or finger

movements? (e.g. flap, wave, or flick,

his/her hands or fingers repetitively?)

59. Repeated movements of hands, body, head

or face e.g. hand flapping or rocking

A comparison between the measures identifies items in the rigidity/ adherence to

routine category in the RBQ-2 that match with items in the DBC-P (Table 5). Item 91 in the


50

DCB-P corresponded to items 13, 15 and 16 in the RBQ-2 regarding insistence on things at

home, and aspects of daily routines staying the same. Item 11 in the DBC-P corresponded

with item 14 in the RBQ-2. Additionally, there is a parallel with DCB-P item 26 and RBQ-2

question 19.

Table 5.

Rigidity and/ or Adherence to Routine in the RBQ-2 and the DBC-P

RBQ-2 DBC-P

13. Insist on things at home remaining the

same? (e.g. furniture staying in the same

place, things being kept in certain places,

or arranged in certain ways?)

15. Insist that aspects of daily routine must

remain the same?

16. Insist on doing things in a certain way

or redoing things until they are “just

right”?

91. Upset and distressed over small changes in

routine or environment

14. Get upset about minor changes to

objects (e.g. flecks of dirt on his clothes,

minor scratches on toys)

11. Cries easily for no reason, or over small upsets

19. Insist on eating the same foods, or a

very small range of foods, at every meal?

26. Fussy eater or has food fads


51

The items addressing preoccupation with restricted patterns of interest from the RBQ-

2 and the matching items in the DBC-P shown in Table 6. Item 5 from the DBC-P matched

with item 1 in the RBQ-2. Items 28, 44 and 54 in the DBC-P corresponded with item 7 on

the RBQ-2. Item 68 in the DBC-P matched with item 8 from the RBQ-2, as did item 44 in

the DBC-P and item 11 in the RBQ-2. Finally, item 58 from the DBC-P correlated with item

17 in the RBQ-2.


52

Table 6.

Preoccupation with Restricted Patterns of Interests in the RBQ-2 and the DBC-P

RBQ-2 DBC-P

1. Arrange toys or other items in rows

or patterns?

5. Arranges objects or routine in strict order

7. Have a fascination with specific

objects? (e.g. trains, road signs or other

things?)

28. Gets obsessed with an idea or activity

44. Likes to hold or play with an unusual object

e.g. string, twigs; overly fascinated by

something e.g. water

54. Overly interested in looking at, listening to

or dismantling mechanical things e.g.

lawnmower or vacuum cleaner

8. Like to look at objects from particular

or unusual angles?

68. Stares at lights or spinning objects

11. Have any special objects he/she

likes to carry around? (e.g. a teddy, a

blanket, a book, or a stick?)

44. Likes to hold or play with an unusual object

e.g. string, twigs; overly fascinated by

something e.g. water

17. Play the same music, game or video,

or read the same book repeatedly?

58. Preoccupied with only one or two particular

interests

Sensory interest items are not included in the restricted and repetitive behaviours that

this study is investigating. Once these were removed from the RBQ-2, 17 items were left.

There was no equivalent question in the DCB-P to question 20: What sort of activity will

your child choose if they are left to occupy themselves? so this was also disregarded.


53

Therefore, 14 DBC-P items correlated with 15 of the remaining 16 RBQ-2 items. The DBC-

P items matched 100% of the repetitive motor movement items, 100% of the rigidity/

adherence to routine items (disregarding the sensory item in this section) and 83% of the

preoccupation with restricted patterns of interest items (also disregarding the sensory item in

this section). The only RBQ-2 item that could not be matched was ‘collect or hoard any items

of any sort?’ It was therefore decided that the data from the DCB-P was appropriate for the

purpose of this study because of its extremely high correlation to the RBQ-2.

Additionally, parents of children with autism encounter more stress than other parents

(Jones, Bremer, & Lloyd, 2017; Pozo, Sarriá, & Brioso, 2014; Zaidman-Zait et al., 2017),

The desire to minimise the burden on the participating parents played a significant part in the

decision not to administer another survey (Sullins, 2003).

3.3.2 Participation and Environment Measure- Children and Youth (PEM-CY;

Coster et al., 2011). The PEM-CY is a parent-report instrument that reports on the number

of activities, frequency of attendance, the level of involvement, and parent’s desire for

change in participation in typical activities at home, in school and in the community.

Perceived supports or barriers to participation in the environment are also examined (Coster

et al., 2011). An 8-point Likert scale is used to score frequency of child participation from

never (0) to daily (7), and how involved the individual is measured on a 5-point Likert scale

ranging from minimally involved (1) to very involved (5). The parent/ caregiver also

identifies whether they would like to see a change in the participation levels in the activities

(no or yes) (Coster et al., 2013). In addition, the parent is asked whether certain features of

each environment are barriers or assist in participation (response options: not an issue,

usually helps, sometimes helps/ sometimes makes harder, usually makes harder). As the

focus of this study is the school environment, data were only used from the school

participation component of this report, focusing on the attendance and involvement scales.


54

The school participation items include classroom activities, (e.g. group work,

classroom discussions and tests), field trips, and school events (e.g. going to the museum,

school fete or school disco). Activities such as school-sponsored teams, clubs and

organisations (e.g. sports teams or student’s councils), getting together with peers outside of

class, and other special roles at school (e.g. peer mentor or tuckshop duties) are also

included.

The psychometric evaluation of the PEM-CY confirmed its validity as a measure of

participation and environment for children and youth with and without disabilities (Coster et

al., 2011). The International Classification of Functioning, Disability and Health

(ICF) framework refers to the PEM-CY as an ICF- compatible assessment instrument for

measuring participation. The PEM-CY has also been used in a variety of research areas

including school participation for children with and without disabilities (Anaby et al., 2014;

Coster et al., 2013) to assess participation within the home environment (Law et al., 2013),

for health impact assessment (Khetani et al., 2014) to assess participation of children needing

or using power mobility (Field, Miller, Ryan, Jarus, & Roxborough, 2015) and has been

translated into Korean and validated (Jeong, Law, Stratford, DeMatteo, & Kim, 2016) among

other studies. Recent research has used the PEM-CY to measure participation of children

with autism at school, home and in the community (Egilson, Jakobsdóttir, & Ólafsdóttir,

2017; Egilson, Jakobsdottir, Olafsson, & Leosdottir, 2017; Simpson et al., 2017).

3.3.3 Vineland Adaptive Behaviour Scales Second Edition (Vineland-II). The

Vineland Adaptive Behaviour Scales (VABS; Sparrow, Balla, & Cicchetti, 1984) and has

been used frequently over the past three decades as an assessment for adaptive behaviour in

individuals with autism as well as other populations (Gillham, Carter, Volkmar, & Sparrow,

2000; Perry, Flanagan, Dunn Geier, & Freeman, 2009). The VABS evaluates adaptive

functioning in four domains: Communication, Daily Living Skills, Socialisation, and Motor


55

Skills. Age equivalent scores and standard scores (M = 100; SD = 15) are given for each of

the four domains and can be combined to create an overall Adaptive Behaviour Composite

score (ABC).

The second edition of the VABS was published in 2005 (Vineland-II; Sparrow,

Cicchetti, & Balla, 2005) and measures adaptive functioning in a similar way to the original

tool. The VABS-II is a clinician-administered, semi-structured parent interview that is used

to obtain parent ratings of children’s adaptive functioning across three domains:

communication, socialisation, and daily living skills. The VABS-II provides an indicator of

the degree to which daily adaptive skills are impacted, over and above what would be

expected given IQ level in children with developmental disabilities. The VABS-II standard

scores have a mean of 100 and standard deviation of 15. The VABS-II provides the

following categorical levels of adaptive functioning: high (≥130), moderately high (115–

129), adequate (86–114), moderately low (71–85), and low (≤70).

This measure has been widely used in clinical, educational and research settings for a

variety of populations such as autism (e.g. Pugliese et al., 2015; Szatmari et al., 2015) Down

syndrome (Hahn, Fidler, & Hepburn, 2014) and other neurodevelopmental disorders

(Chatham et al., 2018). It has been found that cognitive and adaptive composite scores are

highly correlated (e.g. Kenworthy, Case, Harms, Martin, & Wallace, 2010; Liss et al., 2001;

Vig & Jedrysek, 1995). The Vineland-II is used in this study as an indicator of adaptive

functioning of participants. This was included as a measure to control developmental

differences.

3.4 Data analysis

Data analysis was conducted using the Statistical Package for the Social Sciences 25

(SPSS 25). A series of Mann-Whitney U Tests were used to analyse the data in each of the

three stages. Additionally, an independent t-test was conducted to compare the Vineland-II


56

receptive language scores between the different groups in each of the three stages. This was

included as a measure to control developmental differences. Preliminary analyses identified

non-normed data distribution. In addition, data were ordinal, therefore non-parametric

measures were used with significance determined by p < .05. The effect size for each

comparison was calculated using Cohen’s d (Cohen, 1988) with a value of 0.1 considered a

small effect, 0.3 a medium effect and 0.5 a large effect.


57

Table 7.

Data Analysis per Stage

Stage Data Analysis Used

Stage 1- comparison of

higher than mean (group 1)

and lower than mean (group

2) restricted and repetitive

behaviours

A series of Mann-Whitney U Tests were used to analyse and

compare group 1 and 2 against each item of the PEM-CY

school section for attendance and involvement.

An independent t-test was conducted to compare the

Vineland-II receptive language scores for higher and lower

than mean restricted and repetitive behaviours.

Stage 2a- comparison of two

groups of participants that

gained non-elevated (group 1)

or elevated (group 2) scores

of lower order restricted and

repetitive behaviours





Vineland-II receptive language scores for group 1 or group 2

scores of lower order restricted and repetitive behaviours

Stage 2b- comparison of two

groups of participants that

gained non-elevated (group 1)

or elevated (group 2) scores

of higher order restricted and

repetitive behaviours.





Vineland-II receptive language scores for group 1 or group 2

scores of higher order restricted and repetitive behaviours


58

3.4.1 Stage 1 Analysis. In Stage 1 participants were divided into two groups based on

the mean score of restricted and repetitive behaviours. Participants were classified based on

whether they were above or below the mean score. To determine above and below mean

restricted and repetitive behaviour scores the total scores of 12 items were calculated with

scores ranging from 0 (never) to 2 (often). The mean score was calculated as 1.5, SD =

0.502. Participants who scored 1.5 and over were assigned as group 1- higher than mean

score. Participants who score below 1.5 were assigned as group 2- lower than mean score.

An independent t-test was conducted for group 1 and 2 to identify any significant differences

in receptive language scores using data from the Vineland Adaptive Behaviour Scale

(Sparrow, Balla, Cicchetti, Harrison, & Doll, 1984). Group 1 and 2 were then compared

against each item of the PEM-CY school section for attendance and involvement. A Mann-

Whitney U test was used as the data were ordinal, and initial analyses identified the data

were violating assumptions for the use of parametric tests.

3.5 Stage 2 Analysis

3.5.1 Stage 2a analysis. In Stage 2a data analysis compared two groups of

participants that gained elevated or non-elevated scores of lower order restricted and

repetitive behaviours. Participants were classified as having elevated or non-elevated lower

order restricted and repetitive behaviour scores based on whether their score was above or

below the mean. The mean scores for total lower order restricted and repetitive behaviours

were calculated for each participant and then compared to the whole group mean score. The

whole group mean score was 1.34, SD = 0.474, so individual scores under this mean were

ranked as non-elevated and assigned as group 1 and scores above this mean were ranked as

elevated and assigned as group 2. An independent t-test was conducted for group 1 and 2 to

identify any significant differences in receptive language scores. As with data analysis in


59

stage 1, group 1 and 2 were compared against each item of the PEM-CY school section for

attendance and involvement using Mann-Whitney U tests.

3.5.2 Stage 2b analysis. In Stage 2b data analysis compared two groups of

participants that gained elevated or non-elevated scores of higher order restricted and

repetitive behaviours. Participants were classified as having elevated or non-elevated higher

order restricted and repetitive behaviour scores based on whether their score was above or

below the mean. The mean scores for total higher order restricted and repetitive behaviours

were calculated for each participant and then compared to the whole group mean score. The

whole group mean score was 1.42 SD = 0.496, so individual scores under this mean were

ranked as non-elevated and assigned as group 1 and scores above this were ranked as

elevated and assigned as group 2. As with data analysis in stage 1 and 2a, group 1 and 2 were

compared against each item of the PEM-CY school section for attendance and involvement

using Mann-U Whitney tests. An independent t-test was conducted for group 1 and 2 to

identify any significant differences between groups based on receptive language scores.

3.6 Results

3.6.1 Stage 1 analyses of higher and lower than mean restricted and repetitive

behaviours at PEM-CY item level. Results from Stage 1 analysis are shown in Table 8. A

Mann-Whitney U Test revealed no significant differences between the group of participants

that show higher than mean restricted and repetitive behaviours and the group that show

lower than mean restricted and repetitive behaviours in either frequency or involvement in

each of the five participation areas.

Caregivers reported that children in both groups (higher than mean restricted and

repetitive behaviours and lower than mean restricted and repetitive behaviours) attended

classroom activities at least several times a week on average (mean 6.51 and 6.64

respectively). However, both groups were less likely to attend field trips or participate in


60

school sponsored teams, clubs or organisations. Special roles at school (e.g. lunch room

supervisor, student mentor) were the least attended activities, with children participating less

than once in the last four months. Caregivers stated that children in both groups were

somewhat involved in any activities that they attended.

An independent t-test was conducted to compare the Vineland-II receptive language

scores for higher and lower than mean restricted and repetitive behaviours. There was no

significant difference in scores for higher than mean restricted and repetitive behaviour

scores (M = 9.12, SD = 2.96) and lower than mean restricted and repetitive behaviour scores

(M = 9.57, SD = 2.78; t (138) = 0.942, p = 0.38, two-tailed). The magnitude of the

differences in the means (mean difference = 0.46, 95% CI: -0.5 to 1.42) was very small (eta

squared = 0.006). This indicated that there were no group differences due to other factors

assessed.


61

Table 8. Results of Analyses of Higher and Lower than Mean Restricted and Repetitive Behaviours at PEM-CY Item Level

Participation items Frequency, mean (SD) range Involvement, mean (SD) range

Children with at

or higher than

mean restricted

and repetitive

behaviour score

Children with

lower than mean

restricted and

repetitive

behaviour score

p-value r Children with at

or higher than

mean restricted

and repetitive

behaviour score

Children with

lower than mean

restricted and

repetitive

behaviour score

p-

value

r

1. Classroom activities

(e.g. group work, classroom

discussions, tests, in-class

assignments)

6.51 (1.52) 7 6.64 (1.21) 7 .793 .02 3.17 (0.97) 4 3.17 (1.02) 4 .973 .003

2. Field trips and school events (e.g.

going to the museum, the school

fair, spring concert or play,

dances, fundraisers)

2.18 (1.27) 5 1.97 (1.33) 5 .328 .08 3.57 (1.05) 4 3.69 (0.96) 4 .560 .05

3. School sponsored teams, clubs

and organisations

(e.g. groups, clubs teams, student

council)

2.48 (2.56) 6 2.66 (2.39) 6 .779 .02 3.36 (1.22) 4 3.33 (1.31) 4 .981 .003

4. Getting together with peers

outside of class

(e.g. hanging out during lunch, at

recess, or other breaks during the

school day)

5.46 (2.31) 7 5.64 (2.31) 7 .307 .09 3.42 (1.38) 4 3.40 (1.18) 4 .732 .03

5. Special roles at school

(e.g. lunch room supervisor,

student mentor)

0.89 (1.95) 7 0.65 (1.39) 7 .800 .02 2.95 (1.34) 4 2.60 (1.47) 4 .449 .11

p = Mann-Whitney U Test

r = Cohen’s d


62

3.6.2 Stage 2a analysis of elevated and non-elevated lower order restricted and

repetitive behaviours at PEM-CY item level. Table 9 shows the results of Stage 2a

analyses. Mann-Whitney U Tests revealed a significant difference in one area. This

difference related to the question ‘getting together with peers outside of class’, between

participants that showed elevated lower order restricted and repetitive behaviours (Md = 6.0,

n = 44) and participants that showed non-elevated lower order restricted and repetitive

behaviours (Md = 7.0, n = 87), U = 1525.5, z = -2.076, p = 0.038, r = .181, reflecting a small

to medium size effect according to Cohen’s d (Cohen, 1988).


63

Table 9. Results of Analyses of Elevated and non-Elevated Lower Order Restricted and Repetitive Behaviours at PEM-CY Item Level


Children with

elevated lower

order restricted

and repetitive

behaviour score

Children with

non-elevated

lower order

restricted and

repetitive

behaviour score

p-value r Children with

elevated lower

order restricted

and repetitive

behaviour score

Children with non-

elevated lower

order restricted and

repetitive

behaviour score

p-

value r


(e.g. group work, classroom

discussions, tests, in-class

assignments)

6.42 (1.29) 7 6.65 (1.29) 7 .063 .16 3.02 (1.08) 4 3.24 (0.95) 4 .314 .09

2. Field trips and school events

(e.g. going to the museum, the

school fair, spring concert or

play, dances, fundraisers)

2.22 (1.40) 5 2.00 (1.24) 5 .432 .07 3.64 (1.06) 4 3.62 (0.98) 4 .878 .01

3. School sponsored teams, clubs

and organisations

(e.g. groups, clubs teams,

student council)

2.39 (2.54) 6 2.66 (2.44) 6 .701 .03 3.12 (1.40) 4 3.45 (1.20) 4 .269 .12

4. Getting together with peers

outside of class

(e.g. hanging out during lunch,

at recess, or other breaks during

the school day)

5.07 (2.56) 7 5.79 (2.14) 7 .038 .18 3.42 (1.48) 4 3.40 (1.18) 4 .751 .03


(e.g. lunch room supervisor,

student mentor)

1.00 (2.06) 7 0.66 (1.48) 7 .799 .02 2.38 (1.36) 4 2.96 (1.45) 4 .174 .02


r = Cohen’s d


64

To further analyse these results and explore the pattern of behaviour, the frequency of

results was displayed using a box plot (Fig 4). In Figure 4 the non-elevated group had a small

number of outliers and extreme points, with the remaining members of this group reporting

to get together with peers at least a few times a week. The participants in the elevated group

showed that around 50% reported that they get together with peers outside of class at least a

few times a week, 25% a few times a month to once a month, and a further 25 % not at all to

monthly.

Figure 4. Boxplot graph of elevated and non-elevated restricted and repetitive behaviour

scores for PEM-CY item frequency of ‘getting together with peers outside of class.’

An independent t-test was conducted to compare the receptive language scores for

elevated and non-elevated low order restricted and repetitive behaviours. There was no

significant difference in scores for elevated low order restricted and repetitive behaviour

scores (M = 8.91, SD = 2.77) and non-elevated low order restricted and repetitive behaviour

scores (M = 9.56, SD = 2.91; t (138) = 1.26, p =0.21, two-tailed). The magnitude of the


65

differences in the means (mean difference = 0.64, 95% CI: -0.37 to 1.66) was small (eta

squared = 0.011). This indicated that there were no group differences assessed.

3.6.3 Stage 2b analyses of elevated and non-elevated higher order restricted and

repetitive behaviours at PEM-CY item level. The results of Stage 2b analyses are

displayed in Table 10. The results in the area of elevated and non-elevated higher order

restricted and repetitive behaviours indicate that children get together with peers outside of

class at least once a week (mean 5.42 and 5.65 respectively). In concurrence with results in

the previous two analyses, caregivers reported that their children attended classroom

activities at least a few times a week and did not participate often in special roles at school.

On average, all children were somewhat involved in all activities attended.


66

Table 10. Results of Analyses of Elevated and Non-Elevated Higher Order Restricted and Repetitive Behaviours at PEM-CY Item Level


Children with

elevated higher

order restricted

and repetitive

behaviour score

Children with

non-elevated

higher order

restricted and

repetitive

behaviour

score

p-

value

r Children with

elevated

higher order

restricted and

repetitive

behaviour

score

Children with

non-elevated

higher order

restricted and

repetitive

behaviour

score

p-

value

r


(e.g. group work, classroom discussions,

tests, in-class assignments)

6.63 (1.26) 7 6.53 (1.46) 7 .626 .04 3.14 (0.94) 4 3.19 (1.04) 4 .558 .05

2. Field trips and school events (e.g. going to

the museum, the school fair, spring concert

or play, dances, fundraisers)

2.12 (1.23) 5 2.04 (1.35) 5 .667 .04 3.57 (1.09) 4 3.67 (0.93) 4 .666 .04

3. School sponsored teams, clubs and

organisations

(e.g. groups, clubs teams, student council)

2.65(2.61) 6 2.51 (2.38) 6 .607 .05 3.47 (1.24) 4 3.26(1.29) 4 .514 .07

4. Getting together with peers outside of class

(e.g. hanging out during lunch, at recess, or

other breaks during the school day)

5.42 (2.38) 7 5.65 (2.25) 7 .451 .07 3.34 (1.33) 4 3.45 (1.24) 4 .715 .03


(e.g. lunch room supervisor, student

mentor)

0.68 (1.70) 7 0.85 (1.71) 7 .244 .10 2.86 (1.29) 4 2.70 (1.52) 4 .726 .05


r = Cohen’s d


67

An independent t-test was conducted to compare the receptive language scores for

elevated and non-elevated high order restricted and repetitive behaviours. There was no

significant difference in scores for elevated high order restricted and repetitive behaviour

scores (M = 9.32, SD = 2.81) and non-elevated high order restricted and repetitive behaviour

scores (M = 9.36, SD = 2.93; t (138) = 0.73, p = 0.94, two-tailed). The magnitude of the

differences in the means (mean difference = 0.036, 95% CI: -0.94 to 1.01) was very small

(eta squared = 0.003). This indicated that there were no group differences due to other factors

assessed.

4. Discussion

Research to date investigating restricted and repetitive behaviours has been limited

compared to the research conducted about social and communication difficulties (Berry et al.,

2018). Studies have predominantly focused on definition, change and cause (Leekam et al.,

2011). Research consists mainly of clinical observations with very few being in natural

contexts (Kirby et al., 2016). No studies of restricted and repetitive behaviours to date have

focused on the effects of participation in education.

The main purpose of this study is to develop a specific understanding of the effect of

restricted and repetitive behaviours on school participation for children with autism through

data collection and analysis. This potentially will assist to identify ways to remove the

barriers restricting attendance and involvement for students with autism in mainstream

schooling. The following research questions specify the type of data collected in the study:



This will be addressed by two sub-questions:


68

Research sub-question 1: How do differing levels of restricted and repetitive behaviours


Research sub-question 2: How do differing types of restricted and repetitive behaviours


In Stage 1 participants were divided into two groups based on the mean score of

restricted and repetitive behaviours. Participants were classified based on whether they were

above or below the mean score of 1.5, SD = 0.502. Participants that scored 1.5 and over were

assigned as group 1- higher than mean score. Participants that score below 1.5 were assigned

as group 2- lower than mean score.

In Stage 2a data analysis compared two groups of participants that gained elevated or

non-elevated scores of lower order restricted and repetitive behaviours. Participants were

classified as having elevated or non-elevated lower order restricted and repetitive behaviour

scores based on whether their score was above or below the mean. The whole group mean

score was 1.34, SD = 0.474, so individual scores under this mean were ranked as non-

elevated and assigned as group 1 and scores above this mean were ranked as elevated and

assigned as group 2.

In Stage 2b data analysis compared two groups of participants who gained elevated or

non-elevated scores of higher order restricted and repetitive behaviours. Participants were

classified as having elevated or non-elevated higher order restricted and repetitive behaviour

scores based on whether their score was above or below the mean. The whole group mean

score was 1.42 SD = 0.496, so individual scores under this mean were ranked as non-elevated

and assigned as group 1 and scores above this were ranked as elevated and assigned as group

2.


69

There was a significant result in stage 2 a data analysis. In the participation item

getting together with peers outside of classroom based on lower order restricted and repetitive

behaviours. Children who were reported to demonstrate elevated scores on lower order

restricted and repetitive behaviours were found to get together with peers outside the

classroom less frequently than children with non-elevated scores.

The receptive language analysis for each of the three groups showed that there was no

difference in scores for the two groups of participants displaying higher than mean restricted

and repetitive behaviours and those displaying lower than mean restricted and repetitive

behaviours. Additionally, there was no receptive language score difference between the

groups of participants who displayed elevated/ non-elevated lower order restricted and

repetitive behaviours, or with the groups of participants who displayed elevated/ non-elevated

higher order behaviours. This is contrary to other studies.

The results from the research sub-question 1, which investigated whether higher than

or lower than mean restricted and repetitive behaviour scores impact on attendance and

involvement of children with autism in school activities, showed no significant differences.

In all participation items in the PEM-CY, both groups scored very similarly. However, it was

shown that students in both groups attended classroom activities most frequently, followed by

getting together with peers outside of class. Irrespective of type of restricted and repetitive

behaviours, children with autism spend less time attending school sponsored teams, clubs and

organisations, and field trips and school events. The least attended activity was special roles,

such as lunch room supervisor.

Research sub-question 2 was organised into two parts. Part A related to the difference

between effect of elevated and non-elevated lower order behaviours on participation. Part B

related to the difference between elevated and non-elevated higher order behaviours. The

research conducted in the second research sub-question, part A found no significant


70

difference between groups in participation in classroom activities, field trips, school

sponsored teams and special roles at school.

The outcome for the second research sub-question, part B observing the difference

between elevated and non-elevated higher order behaviours on participation also revealed no

significant results. The results in this area were similar to the results in sub-question 1.

Children in both groups attended classroom activities the most frequently with getting

together with peers being the next most attended activity. They attended school sponsored

teams and field trips less often and had the lowest attendance score in special roles in class.

4.1 Results Compared to Restricted and Repetitive Literature

The purpose of this study was to determine whether differing levels and types of

restricted and repetitive behaviours have an effect on participation in the school context. The

results show that neither levels of, or type of restricted and repetitive behaviours had an effect

on participation in classroom activities, field trips, team activities or special roles at school

for this group of children. This appears to contradict some of the research regarding restricted

and repetitive behaviours.

The APA explains that restricted and repetitive behaviours range from low severity;

having trouble with transitions, planning and organisation, to high severity; having frequent

displays of restricted/ repetitive behaviours that are noticeable to others, in multiple contexts,

where individuals require substantial support to function (American Psychiatric Association,

2013). As part of the diagnostic criteria, all children with autism display some level of

restricted and repetitive behaviours.

Even at a low severity level, it is understood that individuals have difficulty with

transitions, planning and organisation. It has been observed that students with autism have

difficulty shifting attentional focus, due to insistence on sameness behaviours (higher order

behaviours). Changes in schedules or activities during school time is a common occurrence


71

and this has implications for students in the classroom when facing daily transitions from one

activity to another (Joosten et al., 2012; Richler et al., 2007; Sparapani et al., 2016).

Insistence on sameness behaviours have also been linked to intolerance of

uncertainty, causing individuals to regard any unfamiliar events as situations to be avoided

(Boulter, Freeston, South, & Rodgers, 2014; Buhr & Dugas, 2009). This would cause

difficulties for children going on field trips or attending a school fete for example. Moreover,

unknown places, people or events can contribute to anxiety, whereupon individuals may

engage in restricted and repetitive behaviours in order to exert control (Lidstone et al., 2014;

Rodgers et al., 2012; Wigham et al., 2015). This could potentially affect many aspects of a

school day such as the arrival of a relief teacher, or a fire drill or lockdown. The results from

the study did not show any difference in participation between participants with elevated and

non-elevated higher order behaviours, despite the literature suggesting otherwise.

Additionally, it was thought that the study may indicate that repetitive motor

behaviours (lower order behaviours) interfere with engagement in classroom-based activities.

Research states that individuals who are engaged in repetitive motor behaviours are less able

to physically participate in leisure activities in the home and in the community (Hilton et al.,

2007; Hochhauser & Engel-Yeger, 2010). It is expected that this would also be the case in the

school context. Moreover, a person who is occupied with repetitive motor behaviours may

miss out on critical information that prevents them from participating in activities (Richler et

al., 2010) potentially affecting the ability to work in class and join in team activities.

This study shows that children with elevated lower order restricted and repetitive

behaviours participate less in getting together with peers outside of the classroom. This result

is concurrent with previous research on the effect of restricted and repetitive behaviours on

socialisation. Literature indicates that restricted and repetitive behaviours and interests can

affect socialisation by diminishing the likelihood of engaging in positive peer interaction.


72

Repetitive behaviours and interests can be socially stigmatising (Szatmari et al., 2006),

interfering with the opportunity to make friends (Rodgers, Glod, Connolly, & McConachie,

2012). Rotheram‐Fuller, Kasari, Chamberlain, and Locke (2010) identified a dramatic drop in

peer relationships in late primary school for individuals with autism. It is suggested that this

is because peers become more aware of differences between themselves and children with

autism and worry about the stigma associated with playing with a child that no-one else

wants to play with. In addition, typically developing peers become less tolerant of differences

and peculiar behaviour (Rotheram‐Fuller et al., 2010).

Furthermore, it has been found that circumscribed interests can influence conversation

(Nadig, Lee, Singh, Bosshart, & Ozonoff, 2010). Individuals with autism often have a topic

that interests them in particular. However, the compulsion to talk about one topic can result in

one-sided stereotyped conversations and does not facilitate reciprocal interaction. These

intense preoccupations may hinder the development of relationships and limit social

participation (Boyd et al., 2010; Reynolds, Bendixen, Lawrence, & Lane, 2011). Although

circumscribed interests are categorised as higher order behaviours, the combination of these

behaviours and repetitive motor behaviours could contribute to the lower score in socialising

with peers outside of class. Nevertheless, it is likely that there is a combination of many

factors, both internal and external to the individuals who have produced this result.

4.2 Receptive Language

Interestingly, the receptive language analysis for each of the three groups, used in this

study as an indicator of adaptive functioning of participants, yielded results contrary to

research (e.g Bishop et al., 2013; Boyd et al., 2009; Harrop et al., 2014; Lam & Aman, 2007;

Ray-Subramanian & Weismer, 2012). In the study, there was no difference in levels of

receptive language scores for the two groups of participants displaying higher than mean

restricted and repetitive behaviours and those displaying lower than mean restricted and


73

repetitive behaviours. Additionally, there was no receptive language score difference between

the groups of participants who displayed elevated/ non-elevated lower order restricted and

repetitive behaviours, or with the groups of participants that displayed elevated/ non-elevated

higher order behaviours.

These results contradict research that states that higher levels of restricted and

repetitive behaviours are associated with children with lower receptive language skills and

non-verbal cognitive skills (Bishop et al., 2013; Boyd et al., 2009; Harrop et al., 2014; Lam

& Aman, 2007; Ray-Subramanian & Weismer, 2012). The results also contradict literature

that reports that higher order behaviours are more likely to be observed in individuals with

higher cognitive abilities (Bishop et al., 2006; Joseph et al., 2013; Watt et al., 2008) or that

lower order restricted and repetitive behaviours are more persistent and severe in children

with lower IQ (Bishop et al., 2006; Esbensen et al., 2009; Rao & Landa, 2014).

The lack of significant results could be attributed to a number of factors. Some

research suggests that restricted and repetitive behaviours, particularly lower order

behaviours, decrease over time. It could also be that there are a number of supports that have

been put in place for the students in this study to manage their restricted and repetitive

behaviours at school. The participants of this study are 9-10 years old and would be in year 4

or 5 at primary school. It is possible that they have adjustments such as visual timetables,

mufflers for noise management, and adjusted curriculum, to help reduce the likelihood of

engaging in restricted and repetitive behaviours. The students in this cohort would also be

familiar with the routines and schedules of a typical school day, and possibly the staff and

other students in the classroom and around the school. Students may also have the benefits of

medication or external therapies to help them manage their restricted and repetitive

behaviours.


74

4.3 Comparison to other Participation Literature

The results from the PEM-CY section in this study were contrasted with previously

published results from a study conducted by Coster et al. (2013) comparing school

participation patterns of students aged 5- 17 years old with and without disabilities. Some

frequency scores were comparable between studies. The study by Coster and colleagues

revealed that primary school aged children with disability attended classroom activities with

a mean frequency of 6.63 (SD 1.01). The scores for frequency of attendance in classroom

activities for children in this study were very similar. Students who displayed above mean

restricted and repetitive behaviours had a mean attendance frequency of 6.51 (SD 1.52) and

those that displayed below mean restricted and repetitive behaviours had a mean attendance

frequency of 6.64 (SD 1.21).

Additionally, students with disability from the Coster et al. study had a mean

attendance frequency of 2.31 (SD 1.29) for field trips and school events. Correspondingly,

children from this study with above mean restricted and repetitive behaviours had a mean

frequency of attendance of 2.18 (SD 1.27). The final close correlation was in the frequency of

getting together with peers outside of class. The students with disability in the study by

Coster et al. had a mean frequency of 5.29 (SD 1.16) and the students with higher than mean

restricted and repetitive behaviours in this study had a mean frequency of 5.46 (SD 2.31).

Lastly, the students with disability in the study by Coster et al. had a markedly higher

mean frequency of attendance in special roles at school (4.09 SD 1.65) than students in this

study (0.89 SD 1.95). This may in part be due to the difference in special roles assigned for

students in Australian class rooms, where this study was conducted, compared to those in

Canadian and American schools, where the study by Coster et al. was conducted. Indeed,

caution should be used in the comparison between these two studies due to the cultural

differences. However, it is clear that students in primary school with disability participate less


75

in all school activities compared to their non-disabled peers. These results highlight the

continuing challenges in facilitating meaningful inclusion for students with disability in the

full range of activities taking place in mainstream schools.

4.4 Limitations

The non-significant results from this research do not necessarily mean that restricted

and repetitive behaviours do not affect participation in school for children with autism. There

are limitations to the study that may have had an effect on the results. The responses for this

study were collected via online surveys, and it is possible that different results could have

been obtained if the survey was delivered face to face or in a paper format. Additionally,

parents and caregivers, mostly mothers, were the primary responders to both surveys used. It

is difficult for parents to report on what happens at school, particularly when asked about

involvement in a specific activity. The information gathered from parent report measures is

also subjective, which can be problematic (Richler et al., 2010). There might also be a

difference in opinion between the child and their parents if the child were to be given the

opportunity to self-rate their behaviours and their attendance/ degree of involvement in

school activities (Egilson, Ólafsdóttir, Leósdóttir, & Saemundsen, 2017; Hemmingsson,

Ólafsdóttir, & Egilson, 2017; Law et al., 2013). Using multiple raters including teachers or

other school-based staff able to observe the child may be more effective.

These findings should also be considered in the context of the study. Respondents on

average reported higher levels of household income and higher levels of education than that

of the general Australian population (ABS, 2017) meaning that that the sample may not be

representative of the entire population. The study design did not allow for direct observation

of participation at school or of cognitive ability. The sample is also Australian and the level

of inclusion in mainstream schooling may not reflect the levels in other schools around the

world.


76

4.5 Significance of the Study

There is growing evidence to show that children with autism learning in mainstream

educational environments are facing substantial challenges. Of the children diagnosed with

autism attending mainstream schools, 83.7 per cent experienced difficulties in their place of

learning. Students reported that their main areas of difficulty were fitting in socially (63.0%),

learning difficulties (60.2%) and communication difficulties (51.1%) (ABS, 2017). The long-

term impact of ineffectual educational supports is becoming more apparent. Many adults with

autism are unemployed and experience limited independence (Moss, Howlin, Savage, Bolton,

& Rutter, 2015). Additionally, a recent systematic review classed outcomes in social

integration and independence as ‘poor’ or ‘very poor’ with adults with autism being largely

dependent on parents or carers for support for living arrangements and employment (Magiati,

Tay, & Howlin, 2014).

While there is some understanding of the long-term outcomes for adults with autism

(Howlin et al., 2014; Magiati et al., 2014) it is necessary to understand the experiences during

the school years that influence these outcomes. Despite the documented difficulties of

children with autism in mainstream schooling, there is limited information about participation

in school, and how the characteristics of autism affect their education. It is necessary to

understand the experiences of children with autism in the educational setting, and to explore

the impacts of social and communication difficulties, and restricted and repetitive behaviours

on those experiences.

Whilst the results of this study were largely non-significant, it has identified areas of

low participation for students with autism. The results showed children with elevated lower

order behaviours participated less in socialising with peers outside of the classroom. This is

concerning as limited or absent peer relationships can negatively influence health and mental

health (Bukowski, Laursen, & Hoza, 2010). In addition, the results indicate that special roles


77

in school was the least represented activity for all students with autism, with the area of field

trips and school events following closely behind.

Participation in school sponsored teams, clubs and organisations such as sports teams

rated lower than participation in classroom activities and getting together with peers outside

of the class overall. This is also important, as the benefits of physical activity are universal

for all children. In particular, the participation of children with disabilities in sports and

leisure activities is found to reduce symptoms of anxiety and depression (Jin, Yun, &

Agiovlasitis, 2017), promote inclusion, improve physical functioning, and improve overall

well-being (Murphy & Carbone, 2008).

This information is significant as it begins to highlight the impact of non-participation

in school activities. It is also necessary to understand and promote that participation includes

all areas of a school day, not just classroom activities. The Disability Standards for Education

(2005) state that children with disabilities in Australia have the right to participate in all

activities of a school day on the same basis as their non-disabled peers and this needs to be

addressed in mainstream educational settings.

4.6 Future Directions

The strength of this study has been that it measured both restricted and repetitive

behaviours and participation at school. This is the first study to do so at this point in time.

Use of the PEM-CY as a participation measure has also allowed for comparison with other

literature. Future studies could begin to investigate student perspectives on school

participation in order to get a fuller picture of how participation is affected by the

characteristics of autism. Additionally, it is important to obtain ratings from professionals in

the school environment who are familiar with the students and can directly observe the

frequency of participation and levels of involvement. Further investigation also needs to be

conducted with more diverse samples to further increase understanding how child


78

characteristics of autism, such as restricted and repetitive behaviours affect participation in

other geographical, economic and cultural contexts. Finally, it will be valuable to follow up

with the students in this cohort after their transition to high school to monitor the way

restricted and repetitive behaviours potentially affect participation in an unfamiliar

environment.


79

References

Adams, R., Taylor, J., Duncan, A., & Bishop, S. (2016). Peer victimization and educational

outcomes in mainstreamed adolescents with autism spectrum disorder (ASD). Journal

of Autism and Developmental Disorders, 46, 3557-3566. doi:10.1007/s10803-016-

2893-3

Aman, M. G., & Singh, N. N. (1988). Patterns of drug use, methodological considerations,

measurement techniques, and future trends. Psychopharmacology of the

Developmental Disabilities, 1–28. doi:10.1007/978-1-4613-8774-9_1

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders: DSM-5 (Vol. Fifth). Arlington, Virginia; Washington, DC: American

Psychiatric Association.

Anaby, D., Law, M., Coster, W., Bedell, G., Khetani, M., Avery, L., & Teplicky, R. (2014).

The mediating role of the environment in explaining participation of children and

youth with and without disabilities across home, school, and community. Archives of

Physical Medicine and Rehabilitation, 95, 908-917. doi:10.1016/j.apmr.2014.01.005

Arnott, B., McConachie, H., Meins, E., Fernyhough, C., Couteur, A. L., Turner, M., . . .

Leekam, S. (2010). The frequency of restricted and repetitive behaviors in a

community sample of 15-month-old infants. Journal of Developmental and

Behavioral Pediatrics, 31, 223-229. doi:10.1097/DBP.0b013e3181d5a2ad

Ashburner, J., Ziviani, J., & Rodger, S. (2010). Surviving in the mainstream: Capacity of

children with autism spectrum disorders to perform academically and regulate their

emotions and behavior at school. Research in Autism Spectrum Disorders, 4, 18-27.

doi:10.1016/j.rasd.2009.07.002

Australian Bureau of Statistics. (2017). Autism in education, Australia, 2017, (Catalogue No.


80

4428.0). Retrieved from

http://www.abs.gov.au/ausstats/[email protected]/Latestproducts/4430.0Main%20Features752

015

Baker, A. E. Z., Lane, A., Angley, M. T., & Young, R. L. (2008). The relationship between

sensory processing patterns and behavioural responsiveness in autistic disorder: A

pilot study. Journal of Autism and Developmental Disorders, 38, 867-875.

doi:10.1007/s10803-007-0459-0

Baranek, G. T., David, F. J., Poe, M. D., Stone, W. L., & Watson, L. R. (2006). Sensory

Experiences Questionnaire: Discriminating sensory features in young children with

autism, developmental delays, and typical development. Journal of Child Psychology

and Psychiatry, 47, 591-601. doi:10.1111/j.1469-7610.2005.01546.x

Barber, A. B., Wetherby, A. M., & Chambers, N. W. (2012). Brief Report: Repetitive

behaviors in young children with autism spectrum disorder and developmentally

similar peers: A follow up to Watt et al. (2008). Journal of Autism and Developmental

Disorders, 42, 2006-2012. doi:10.1007/s10803-011-1434-3

Bashe, P. R., & Kirby, B. L. (2001). The oasis guide to Asperger Syndrome: Advice, support,

insights, and inspiration. New York: Crown Publishers.

Berry, K., Russell, K., & Frost, K. (2018). Restricted and repetitive behaviors in autism

spectrum disorder: A review of associated features and presentation across clinical

populations. Current Developmental Disorders Reports, 5, 108-115.

doi:10.1007/s40474-018-0139-0

Bieleninik, U., Posserud, M. B., Geretsegger, M., Thompson, G., Elefant, C., & Gold, C.

(2017). Tracing the temporal stability of autism spectrum diagnosis and severity as

measured by the Autism Diagnostic Observation Schedule: A systematic review and

meta-analysis. PloS one, 12, e0183160. doi:10.1371/journal.pone.0183160


81

Bishop, S., Hus, V., Duncan, A., Huerta, M., Gotham, K., Pickles, A., . . . Lord, C. (2013).

Subcategories of restricted and repetitive behaviors in children with autism spectrum

disorders. Journal of Autism and Developmental Disorders, 43, 1287-1297.

doi:10.1007/s10803-012-1671-0

Bishop, S., Lord, C., & Richler, J. (2006). Association between restricted and repetitive

behaviors and nonverbal IQ in children with autism spectrum disorders. Child

Neuropsychology, 12, 247-267. doi:10.1080/09297040600630288

Bodfish, J. W., Symons, F. J., Parker, D. E., & Lewis, M. H. (2000). Varieties of repetitive

behavior in autism: Comparisons to mental retardation. Journal of Autism and

Developmental Disorders, 30, 237-243. doi:10.1023/A:1005596502855

Boulter, C., Freeston, M., South, M., & Rodgers, J. (2014). Intolerance of uncertainty as a

framework for understanding anxiety in children and adolescents with autism

spectrum disorders. Journal of Autism and Developmental Disorders, 44, 1391-1402.

doi:10.1007/s10803-013-2001-x

Boyd, B. A., Baranek, G. T., Sideris, J., Poe, M. D., Watson, L. R., Patten, E., & Miller, H.

(2010). Sensory features and repetitive behaviors in children with autism and

developmental delays. Autism Research, 3, 78. doi:10.1002/aur.124

Boyd, B. A., Conroy, M. A., Mancil, G. R., Nakao, T., & Alter, P. J. (2007). Effects of

circumscribed interests on the social behaviors of children with autism spectrum


doi:10.1007/s10803-006-0286-8

Boyd, B. A., McBee, M., Holtzclaw, T., Baranek, G. T., & Bodfish, J. W. (2009).

Relationships among repetitive behaviors, sensory features, and executive functions in

high functioning autism. Research in Autism Spectrum Disorders, 3, 959-966.

doi:10.1016/j.rasd.2009.05.003


82

Boyd, B. A., McDonough, S. G., & Bodfish, J. W. (2012). Evidence-based behavioral

interventions for repetitive behaviors in autism. Journal of Autism and Developmental

Disorders, 42, 1236-1248. doi:10.1007/s10803-011-1284-z

Brereton, A. V., Tonge, B. J., & Einfeld, S. L. (2006). Psychopathology in children and

adolescents with autism compared to young people with intellectual disability.

Journal of Autism and Developmental Disorders, 36, 863-870. doi:10.1007/s10803-

006-0125-y

Brereton, A. V., Tonge, B. J., Mackinnon, A. J., & Einfeld, S. L. (2002). Screening young

people for autism with the Developmental Behavior Checklist. Journal of the

American Academy of Child & Adolescent Psychiatry, 41, 1369-1375.

doi:10.1097/00004583-200211000-00019

Bronfenbrenner, U., & Ceci, S. J. (1994). Nature-nurture reconceptualized in developmental

perspective: A bioecological model. Psychological Review, 101, 568-586.

doi:10.1037/0033-295X.101.4.568

Buhr, K., & Dugas, M. J. (2009). The role of fear of anxiety and intolerance of uncertainty in

worry: An experimental manipulation. Behaviour Research and Therapy, 47, 215-

223. doi:10.1016/j.brat.2008.12.004

Bukowski, W. M., Laursen, B., & Hoza, B. (2010). The snowball effect: Friendship

moderates escalations in depressed affect among avoidant and excluded children.

Development and Psychopathology, 22, 749-757. doi:10.1017/S095457941000043X

Buono, S., Scannella, F., & Palmigiano, M. B. (2010). Self-injurious behavior: A comparison

between Prader-Willi syndrome, Down syndrome and autism. Life Span and

Disability, 2, 187-201. doi:10.1111/j.1741-1130.2005.00038.x


83

Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected

population: Prevalence of anxiety disorders in pre-adolescent children. Clinical

Psychology Review, 26, 817-833. doi:10.1016/j.cpr.2005.12.002

Chandler, S., Howlin, P., Simonoff, E., O'Sullivan, T., Tseng, E., Kennedy, J., . . . Baird, G.

(2016). Emotional and behavioural problems in young children with autism spectrum

disorder. Developmental Medicine & Child Neurology, 58, 202-208.

doi:10.1111/dmcn.12830

Chatham, C. H., Taylor, K. I., Charman, T., Liogier D'ardhuy, X., Eule, E., Fedele, A., . . .

Bolognani, F. (2018). Adaptive behavior in autism: Minimal clinically important

differences on the Vineland‐II. Autism Research, 11, 270-283. doi:10.1002/aur.1874

Chebli, S. S., Martin, V., & Lanovaz, M. J. (2016). Prevalence of stereotypy in individuals

with developmental disabilities: A systematic review. Review Journal of Autism and

Developmental Disorders, 3, 107-118. doi:10.1007/s40489-016-0069-x

Cho, I. Y. K., Jelinkova, K., Schuetze, M., Vinette, S. A., Rahman, S., McCrimmon, A., . . .

Bray, S. (2017). Circumscribed interests in adolescents with Autism Spectrum

Disorder: A look beyond trains, planes, and clocks. PloS one, 12, e0187414.

doi:10.1371/journal.pone.0187414

Clark, C., Prior, M., & Kinsella, G. (2002). The relationship between executive function

abilities, adaptive behaviour, and academic achievement in children with externalising

behaviour problems. Journal of Child Psychology and Psychiatry, 43, 785-796.

doi:10.1111/1469-7610.00084

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale,

N.J: L. Erlbaum Associates.

Coster, W., Bedell, G., Law, M., Khetani, M. A., Teplicky, R., Liljenquist, K., . . . Kao, Y. C.

(2011). Psychometric evaluation of the Participation and Environment Measure for


84

Children and Youth. Developmental Medicine & Child Neurology, 53, 1030-1037.

doi:10.1111/j.1469-8749.2011.04094.x

Coster, W., Law, M., Bedell, G., Khetani, M., Cousins, M., & Teplicky, R. (2012).

Development of the participation and environment measure for children and youth:

Conceptual basis. Disability and Rehabilitation, 34, 238-246.

doi:10.3109/09638288.2011.603017

Coster, W., Law, M., Bedell, G., Liljenquist, K., Kao, Y. C., Khetani, M., & Teplicky, R.

(2013). School participation, supports and barriers of students with and without

disabilities. Child: Care, Health and Development, 39, 535-543.

doi:10.1111/cch.12046

Creswell, J. W., & Plano Clark, V. L. (2018). Designing and conducting mixed methods

research (Third ed.). Thousand Oaks, California: SAGE.

Cunningham, A. B., & Schreibman, L. (2008). Stereotypy in autism: The importance of

function. Research in Autism Spectrum Disorders, 2, 469-479.

doi:10.1016/j.rasd.2007.09.006

Cunningham, B. J., & Rosenbaum, P. L. (2015). A bioecological framework to evaluate

communicative participation outcomes for preschoolers receiving speech–language

therapy interventions in Ontario, Canada. International Journal of Language &

Communication Disorders, 50, 405-415. doi:10.1111/1460-6984.12145

Dewrang, P., & Sandberg, A. D. (2011). Repetitive behaviour and obsessive–compulsive

features in Asperger syndrome: Parental and self-reports. Research in Autism

Spectrum Disorders, 5, 1176-1186. doi:10.1016/j.rasd.2011.01.003

Dickie, V. A., Baranek, G. T., Schultz, B., Watson, L. R., & McComish, C. S. (2009). Parent

reports of sensory experiences of preschool children with and without autism: A


85

qualitative study. The American Journal of Occupational Therapy, 63, 172-181.

doi:10.5014/ajot.63.2.172

Disability standards for education 2005. (2005). PsycEXTRA Dataset.

doi:10.1037/e669532010-001

Dunn, W. (2007). Supporting children to participate successfully in everyday life by using

sensory processing knowledge. Infants & Young Children, 20, 84-101.

doi:10.1097/01.IYC.0000264477.05076.5d

Durand, V. M., & Crimmins, D. (1988). The Motivation Assessment Scale. Topeka: Monaco

& Associates.

Egilson, S. T., Jakobsdóttir, G., & Ólafsdóttir, L. B. (2017). Parent perspectives on home

participation of high-functioning children with autism spectrum disorder compared

with a matched group of children without autism spectrum disorder. Autism,

1362361316685555. doi:10.1177/1362361316685555

Egilson, S. T., Jakobsdottir, G., Olafsson, K., & Leosdottir, T. (2017). Community

participation and environment of children with and without autism spectrum disorder:

Parent perspectives. Scandinavian Journal of Occupational Therapy, 24, 187-196.

doi:10.1080/11038128.2016.1198419

Egilson, S. T., Ólafsdóttir, L. B., Leósdóttir, T., & Saemundsen, E. (2017). Quality of life of

high-functioning children and youth with autism spectrum disorder and typically

developing peers: Self- and proxy-reports. Autism, 21, 133-141.

doi:10.1177/1362361316630881

Einfeld, S. L., & Tonge, B. J. (1995). The Developmental Behavior Checklist: The

development and validation of an instrument to assess behavioral and emotional

disturbance in children and adolescents with mental retardation. Journal of Autism

and Developmental Disorders, 25, 81-104. doi:10.1007/BF02178498


86

Eldar, E., Talmor, R., & Wolf-Zukerman, T. (2010). Successes and difficulties in the

individual inclusion of children with autism spectrum disorder (ASD) in the eyes of

their coordinators. International Journal of Inclusive Education, 14, 97-114.

doi:10.1080/13603110802504150

Esbensen, A. J., Seltzer, M. M., Lam, K. S. L., & Bodfish, J. W. (2009). Age-related

differences in restricted repetitive behaviors in autism spectrum disorders. Journal of

Autism and Developmental Disorders, 39, 57-66. doi:10.1007/s10803-008-0599-x

Evans, J., & Lunt, I. (2002). Inclusive education: Are there limits? European Journal of

Special Needs Education, 17, 1-14. doi:10.1080/08856250110098980

Evans, J., & Mathur, A. (2005). The value of online surveys. Internet Research, 15, 195-219.

doi:10.1108/10662204510590360

Factor, R. S., Condy, E. E., Farley, J. P., & Scarpa, A. (2016). Brief report: Insistence on

sameness, anxiety, and social motivation in children with autism spectrum disorder.

Journal of Autism and Developmental Disorders, 46, 2548-2554.

doi:10.1007/s10803-016-2781-x

Field, D. A., Miller, W. C., Ryan, S. E., Jarus, T., & Roxborough, L. (2015). Exploring

suitable participation tools for children who need or use power mobility: A modified

Delphi survey. Developmental Neurorehabilitation, 1-15.

doi:10.3109/17518423.2015.1004763

Fombonne, E., Quirke, S., & Hagen, A. (2011). Epidemiology of pervasive developmental

disorders. In D. G. Amaral, G. Dawson, & D. H. Geschwind (Eds.), Autism spectrum

disorders (pp. 90–111). New York, NY: Oxford University Press.

Fraser, W. I., & Rao, J. M. (1991). Recent studies of mentally handicapped young people's

behaviour. Journal of Child Psychology and Psychiatry, 32, 79-108.

doi:10.1111/j.1469-7610.1991.tb00004.x


87

Freeman, R. D., Soltanifar, A., & Baer, S. (2010). Stereotypic movement disorder: Easily

missed. Developmental Medicine and Child Neurology, 52, 733-738.

doi:10.1111/j.1469-8749.2010.03627.x

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, 169-181. doi:10.1016/j.ridd.2004.05.003

Georgiades, S., Papageorgiou, V., & Anagnostou, E. (2010). Brief report: Repetitive

behaviours in greek individuals with autism spectrum disorder. Journal of Autism and

Developmental Disorders, 40, 903-906. doi:10.1007/s10803-009-0927-9

Gillham, J. E., Carter, A. S., Volkmar, F. R., & Sparrow, S. S. (2000). Toward a

developmental operational definition of autism. Journal of Autism and Developmental

Disorders, 30, 269-278. doi:10.1023/A:1005571115268

Gotham, K., Brunwasser, S. M., & Lord, C. (2015). Depressive and anxiety symptom

trajectories from school age through young adulthood in samples with autism

spectrum disorder and developmental delay. Journal of the American Academy of

Child and Adolescent Psychiatry, 54, 369-376.e363. doi:10.1016/j.jaac.2015.02.005

Granlund, M., Arvidsson, P., Niia, A., Björck-Åkesson, E., Simeonsson, R., Maxwell, G., . . .

Pless, M. (2012). Differentiating activity and participation of children and youth with

disability in Sweden: A third qualifier in the International Classification of

Functioning, Disability, and Health for Children and Youth? American Journal of

Physical Medicine & Rehabilitation, 91, S84-S96. doi:

10.1097/phm.0b013e31823d5376

Green, S. A., & Ben-Sasson, A. (2010). Anxiety disorders and sensory over-responsivity in

children with autism spectrum disorders: Is there a causal relationship? Journal of


88

Autism and Developmental Disorders, 40, 1495-1504. doi:10.1007/s10803-010-1007-

x

Hahn, L. J., Fidler, D. J., & Hepburn, S. L. (2014). Adaptive behavior and problem behavior

in young children with Williams syndrome. American Journal on Intellectual and

Developmental Disabilities, 119, 49-63. doi:10.1352/1944-7558-119.1.49

Hammel, J., Jones, R., Smith, J., Sanford, J., Bodine, C., & Johnson, M. (2008).

Environmental barriers and supports to the health, function, and participation of

people with developmental and intellectual disabilities: Report from the State of the

Science in Aging with Developmental Disabilities Conference. Disability and Health

Journal, 1, 143-149. doi:10.1016/j.dhjo.2008.05.001

Harrop, C., McConachie, H., Emsley, R., Leadbitter, K., Green, J., & Pact Consortium.

(2014). Restricted and repetitive behaviors in autism spectrum disorders and typical

development: Cross-sectional and longitudinal comparisons. Journal of Autism and


Hay, I., & Winn, S. (2005). Students with Asperger's syndrome in an inclusive secondary

school environment: Teachers', parents', and students' perspectives. Australasian

Journal of Special Education, 29, 140. doi:10.2260/1030-0112.29.2.0265

Hemmingsson, H., Ólafsdóttir, L. B., & Egilson, S. T. (2017). Agreements and disagreements

between children and their parents in health-related assessments. Disability and

Rehabilitation, 39, 1059-1072. doi:10.1080/09638288.2016.1189603

Hilton, C., Graver, K., & LaVesser, P. (2007). Relationship between social competence and

sensory processing in children with high functioning autism spectrum disorders.

Research in Autism Spectrum Disorders, 1, 164-173. doi:10.1016/j.rasd.2006.10.002

Hochhauser, M., & Engel-Yeger, B. (2010). Sensory processing abilities and their relation to

participation in leisure activities among children with high-functioning autism


89

spectrum disorder (HFASD). Research in Autism Spectrum Disorders, 4, 746-754.

doi:10.1016/j.rasd.2010.01.015

Honey, E., McConachie, H., Randle, V., Shearer, H., & Couteur, A. S. L. (2008). One-year

change in repetitive behaviours in young children with communication disorders

including autism. Journal of Autism and Developmental Disorders, 38, 1439-1450.

doi:10.1007/s10803-006-0191-1

Horner, R. H., Carr, E. G., Strain, P. S., Todd, A. W., & Reed, H. K. (2002). Problem

behavior interventions for young children with autism: A research synthesis. Journal

of Autism and Developmental Disorders, 32, 423-446. doi:10.1023/A:1020593922901

Howlin, P., Savage, S., Moss, P., Tempier, A., & Rutter, M. (2014). Cognitive and language

skills in adults with autism: A 40‐year follow‐up. Journal of Child Psychology and

Psychiatry, 55, 49-58. doi:10.1111/jcpp.12115

Hunt, P. F. (2011). Salamanca Statement and IDEA 2004: Possibilities of practice for

inclusive education. International Journal of Inclusive Education, 15, 461-416.

doi:10.1080/13603110903131713

Imms, C., Adair, B., Keen, D., Ullenhag, A., Rosenbaum, P., & Granlund, M. (2016).

‘Participation’: A systematic review of language, definitions, and constructs used in

intervention research with children with disabilities. Developmental Medicine &

Child Neurology, 58, 29-38. doi:10.1111/dmcn.12932

Imms, C., Granlund, M., Wilson, P. H., Steenbergen, B., Rosenbaum, P. L., & Gordon, A. M.

(2017). Participation, both a means and an end: A conceptual analysis of processes

and outcomes in childhood disability. Developmental Medicine & Child Neurology,

59, 16-25. doi:10.1111/dmcn.13237


90

Iverson, J. M., & Wozniak, R. H. (2007). Variation in vocal-motor development in infant

siblings of children with autism. Journal of Autism and Developmental Disorders, 37,

158-170. doi:10.1007/s10803-006-0339-z

Jeong, Y., Law, M., Stratford, P., DeMatteo, C., & Kim, H. (2016). Cross-cultural validation

and psychometric evaluation of the Participation and Environment Measure for

Children and Youth in Korea. Disability and Rehabilitation, 38, 2217-2228.

doi:10.3109/09638288.2015.1123302

Jin, J. P. D., Yun, J. P. D., & Agiovlasitis, S. P. D. (2017). Impact of enjoyment on physical

activity and health among children with disabilities in schools. Disability and Health

Journal, 11, 14-19. doi:10.1016/j.dhjo.2017.04.004

Johansson, S. (2014). "He is intelligent but different": Stakeholders' perspectives on children

on the autism spectrum in an urban indian school context. International Journal of

Disability, Development and Education, 61, 416-433.

doi:10.1080/1034912X.2014.955786

Jones, S., Bremer, E., & Lloyd, M. (2017). Autism spectrum disorder: Family quality of life

while waiting for intervention services. Quality of Life Research, 26, 331-342.

doi:10.1007/s11136-016-1382-7

Jones, S., Murphy, F., Edwards, M., & James, J. (2008). Doing things differently:

Advantages and disadvantages of Web questionnaires. Nurse Researcher, 15, 15-26.

doi: 10.7748/nr2008.07.15.4.15.c6658

Joosten, A., & Bundy, A. (2008). The motivation of stereotypic and repetitive behavior:

Examination of construct validity of the Motivation Assessment Scale. Journal of

Autism and Developmental Disorders, 38, 1341-1348. 10.1007/s10803-007-0523-9


91

Joosten, A., Bundy, A., & Einfeld, S. L. (2009). Intrinsic and extrinsic motivation for

stereotypic and repetitive behavior. Journal of Autism and Developmental Disorders,

39, 521-531. doi:10.1007/s10803-008-0654-7

Joosten, A., Bundy, A., & Einfeld, S. L. (2012). Context influences the motivation for

stereotypic and repetitive behaviour in children diagnosed with intellectual disability

with and without autism. Journal of Applied Research in Intellectual Disabilities, 25,

262-271. doi:10.1111/j.1468-3148.2011.00663.x

Joseph, L., Thurm, A., Farmer, C., & Shumway, S. (2013). Repetitive behavior and restricted

interests in young children with autism: Comparisons with controls and stability over

2 years. Autism Research, 6, 584-595. doi:10.1002/aur.1316

Joyce, C., Honey, E., Leekam, S. R., Barrett, S. L., & Rodgers, J. (2017). Anxiety,

intolerance of uncertainty and restricted and repetitive behaviour: Insights directly

from young people with ASD. Journal of Autism and Developmental Disorders, 47,

3789-3802. doi:10.1007/s10803-017-3027-2

Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217-250.

King, G., Law, M., King, S., Rosenbaum, P., Kertoy, M. K., & Young, N. L. (2003). A

conceptual model of the factors affecting the recreation and leisure participation of

children with disabilities. Physical and Occupational Therapy in Pediatrics, 23, 63-

90. doi:10.1300/J006v23n01_05

Kawulich, B. B. (2005). Participant observation as a data collection method. Qualitative

Social Research, 6, 71-92. doi:10.1057/9781403980564_5

Keen, D., Webster, A., & Ridley, G. (2016). How well are children with autism spectrum

disorder doing academically at school? An overview of the literature. Autism. 20,

276–294. doi:10.1177/1362361315580962


92

Kelley, K., Clark, B., Brown, V., & Sitzia, J. (2003). Good practice in the conduct and

reporting of survey research. International Journal for Quality in Health Care, 15,

261-266. doi:10.1093/intqhc/mzg031

Kenworthy, L., Case, L., Harms, M. B., Martin, A., & Wallace, G. L. (2010). Adaptive

behavior ratings correlate with symptomatology and IQ among individuals with high-

functioning autism spectrum disorders. Journal of Autism and Developmental

Disorders, 40, 416-423. doi:10.1007/s10803-009-0911-4

Khetani, M., Marley, J., Baker, M., Albrecht, E., Bedell, G., Coster, W., . . . Law, M. (2014).

Validity of the Participation and Environment Measure for Children and Youth

(PEM-CY) for Health Impact Assessment (HIA) in sustainable development projects.

Disability and Health Journal, 7, 226-235. doi:10.1016/j.dhjo.2013.11.003

Kim, S. H., Bal, V. H., & Lord, C. (2018). Longitudinal follow‐up of academic achievement

in children with autism from age 2 to 18. Journal of Child Psychology and

Psychiatry, 59, 258-267. doi:10.1111/jcpp.12808

Kim, S. H., & Lord, C. (2010). Restricted and repetitive behaviors in toddlers and

preschoolers with autism spectrum disorders based on the Autism Diagnostic

Observation Schedule (ADOS). Autism Research, 3, 162. doi:10.1002/aur.142

Kirby, A. V., Boyd, B. A., Williams, K. L., Faldowski, R. A., & Baranek, G. T. (2016).

Sensory and repetitive behaviors among children with autism spectrum disorder at

home. Autism, 21, 142–154. doi:10.1177/1362361316632710

Klin, A., Danovitch, J. H., Merz, A. B., & Volkmar, F. R. (2007). Circumscribed interests in

higher functioning individuals with autism spectrum disorders: An exploratory study.

Research and Practice for Persons with Severe Disabilities, 32, 89-100.

doi:10.2511/rpsd.32.2.89


93

Kohls, G., Schulte-Rüther, M., Nehrkorn, B., Müller, K., Fink, G. R., Kamp-Becker, I., . . .

Konrad, K. (2013). Reward system dysfunction in autism spectrum disorders. Social

Cognitive and Affective Neuroscience, 8, 565-572. doi:10.1093/scan/nss033

Lam, K. S. L., & Aman, M. G. (2007). The Repetitive Behavior Scale-Revised: Independent

validation in individuals with autism spectrum disorders. Journal of Autism and

Developmental Disorders, 37, 855-866. doi:10.1007/s10803-006-0213-z

Lam, K. S. L., Bodfish, J. W., & Piven, J. (2008). Evidence for three subtypes of repetitive

behavior in autism that differ in familiality and association with other symptoms.

Journal of Child Psychology and Psychiatry, 49, 1193-1200. doi:10.1111/j.1469-

7610.2008.01944.x

Lane, A. E., Young, R. L., Baker, A. E. Z., & Angley, M. T. (2010). Sensory processing

subtypes in autism: Association with adaptive behavior. Journal of Autism and


Langen, M., Durston, S., Kas, M. J. H., van Engeland, H., & Staal, W. G. (2011). The

neurobiology of repetitive behavior. Neuroscience and Biobehavioral Reviews, 35,

356-365. doi:10.1016/j.neubiorev.2010.02.005

Lanovaz, M. J., Robertson, K. M., Soerono, K., & Watkins, N. (2013). Effects of reducing

stereotypy on other behaviors: A systematic review. Research in Autism Spectrum

Disorders, 7, 1234-1243. doi:10.1016/j.rasd.2013.07.009

Lauritsen, M. B. (2013). Autism spectrum disorders. European Child & Adolescent

Psychiatry, 22, 37-42. doi:10.1007/s00787-012-0359-5

LaVesser, P., & Berg, C. (2011). Participation patterns in preschool children with an autism

spectrum disorder. OTJR: Occupation, Participation and Health, 31, 33-39.

doi:10.3928/15394492-20100823-01


94

Law, M., Anaby, D., Teplicky, R., Khetani, M. A., Coster, W., & Bedell, G. (2013).

Participation in the home environment among children and youth with and without

disabilities. The British Journal of Occupational Therapy, 76, 58-66.

doi:10.4276/030802213X13603244419112

Leekam, S., Prior, M. R., & Uljarevic, M. (2011). Restricted and repetitive behaviors in

autism spectrum disorders: A review of research in the last decade. Psychological

Bulletin, 137, 562-593. doi:10.1037/a0023341

Leekam, S., Tandos, J., McConachie, H., Meins, E., Parkinson, K., Wright, C., . . . Couteur,

A. L. (2007). Repetitive behaviours in typically developing 2‐year‐olds. Journal of

Child Psychology and Psychiatry, 48, 1131-1138. doi:10.1111/j.1469-

7610.2007.01778.x

Lefever, S., Dal, M., & Matthiasdottir, A. (2007). Online data collection in academic

research: Advantages and limitations. British Journal of Educational Technology, 38,

574-582. doi:10.1111/j.1467-8535.2006.00638.x

Lidstone, J., Uljarević, M., Sullivan, J., Rodgers, J., McConachie, H., Freeston, M., . . .

Leekam, S. (2014). Relations among restricted and repetitive behaviors, anxiety and

sensory features in children with autism spectrum disorders. Research in Autism

Spectrum Disorders, 8, 82-92. doi:10.1016/j.rasd.2013.10.001

Lindsay, S., Proulx, M., Thomson, N., & Scott, H. (2013). Educators’ challenges of including

children with autism spectrum disorder in mainstream classrooms. International

Journal of Disability, Development and Education, 60, 347-362.

doi:10.1080/1034912X.2013.846470

Liss, M., Harel, B., Fein, D., Allen, D., Dunn, M., Feinstein, C., . . . Rapin, I. (2001).

Predictors and correlates of adaptive functioning in children with developmental


95


doi:10.1023/A:1010707417274

Loftin, R. L., Odom, S. L., & Lantz, J. F. (2008). Social interaction and repetitive motor

behaviors. Journal of Autism and Developmental Disorders, 38, 1124-1135.

doi:10.1007/s10803-007-0499-5

Loomes, R., Hull, L., & Mandy, W. (2017). What is the male-to-female ratio in autism

spectrum disorder? A systematic review and meta-analysis. Journal of the American

Academy of Child & Adolescent Psychiatry, 56, 466-474.

doi:10.1016/j.jaac.2017.03.013

MacDonald, R., Green, G., Mansfield, R., Geckeler, A., Gardenier, N., Anderson, J., . . .

Sanchez, J. (2007). Stereotypy in young children with autism and typically

developing children. Research in Developmental Disabilities, 28, 266-277.

doi:10.1016/j.ridd.2006.01.004

MacNeil, B. M., Lopes, V. A., & Minnes, P. M. (2009). Anxiety in children and adolescents

with autism spectrum disorders. Research in Autism Spectrum Disorders, 3, 1-21.

doi:10.1016/j.rasd.2008.06.001

Magiati, I., Tay, X. W., & Howlin, P. (2014). Cognitive, language, social and behavioural

outcomes in adults with autism spectrum disorders: A systematic review of

longitudinal follow-up studies in adulthood. Clinical Psychology Review, 34, 73-86.

doi:10.1016/j.cpr.2013.11.002

Mallinson, T., & Hammel, J. (2010). Measurement of participation: Intersecting person, task,

and environment. Archives of Physical Medicine and Rehabilitation, 91, S29-S33.

doi:10.1016/j.apmr.2010.04.027


96

Mandy, W., Charman, T., Gilmour, J., & Skuse, D. (2011). Toward specifying pervasive

developmental disorder—not otherwise specified. Autism Research, 4, 121-131.

doi:10.1002/aur.178

Matson, J. L., & Nebel-Schwalm, M. (2007). Assessing challenging behaviors in children

with autism spectrum disorders: A review. Research in Developmental Disabilities,

28, 567-579. doi:10.1016/j.ridd.2006.08.001

Mazzone, L., Postorino, V., De Peppo, L., Fatta, L., Lucarelli, V., Reale, L., . . . Vicari, S.

(2013). Mood symptoms in children and adolescents with autism spectrum disorders.

Research in Developmental Disabilities, 34, 3699-3708.

doi:10.1016/j.ridd.2013.07.034

Militerni, R., Bravaccio, C., Falco, C., Fico, C., & Palermo, M. T. (2002). Repetitive

behaviors in autistic disorder. European Child & Adolescent Psychiatry, 11, 210-218.

doi:10.1007/s00787-002-0279-x

Mohr, C., Tonge, B. J., & Einfeld, S. L. (2005). The development of a new measure for the

assessment of psychopathology in adults with intellectual disability. Journal of

Intellectual Disability Research, 49, 469-480. doi:10.1111/j.1365-2788.2005.00701.x

Mooney, E. L., Gray, K. M., & Tonge, B. J. (2006). Early features of autism: Repetitive

behaviours in young children. European Child and Adolescent Psychiatry, 15, 12-18.

doi:10.1007/s00787-006-0499-6

Moss, P., Howlin, P., Savage, S., Bolton, P., & Rutter, M. (2015). Self and informant reports

of mental health difficulties among adults with autism findings from a long-term

follow-up study. Autism, 19, 832-841. doi:10.1177/1362361315585916

Mottron, L. (2017). Should we change targets and methods of early intervention in autism, in

favor of a strengths-based education? European Child and Adolescent Psychiatry, 26,

1-11. doi:10.1007/s00787-017-0955-5


97

Murphy, N. A., & Carbone, P. S. (2008). Promoting the participation of children with

disabilities in sports, recreation, and physical activities. Pediatrics, 121, 1057-1061.

doi:10.1542/peds.2008-0566

Nadig, A., Lee, I., Singh, L., Bosshart, K., & Ozonoff, S. (2010). How does the topic of

conversation affect verbal exchange and eye gaze? A comparison between typical

development and high-functioning autism. Neuropsychologia, 48, 2730-2739.

doi:10.1016/j.neuropsychologia.2010.05.020

Nicholson, H., Kehle, T. J., Bray, M. A., & Heest, J. V. (2011). The effects of antecedent

physical activity on the academic engagement of children with autism spectrum

disorder. Psychology in the Schools, 48, 198-213. doi:10.1002/pits.20537

Papageorgiou, V., Georgiades, S., & Mavreas, V. (2008). Brief report: Cross-cultural

evidence for the heterogeneity of the restricted, repetitive behaviours and interests

domain of autism: A Greek study. Journal of Autism and Developmental Disorders,

38, 558-561. doi:10.1007/s10803-007-0409-x

Perry, A., Flanagan, H. E., Dunn Geier, J., & Freeman, N. L. (2009). Brief report: The

Vineland Adaptive Behavior Scales in young children with autism spectrum disorders

at different cognitive levels. Journal of Autism and Developmental Disorders, 39,

1066-1078. doi:10.1007/s10803-009-0704-9

Pozo, P., Sarriá, E., & Brioso, A. (2014). Family quality of life and psychological well‐being

in parents of children with autism spectrum disorders: A double ABCX model.

Journal of Intellectual Disability Research, 58, 442-458. doi:10.1111/jir.12042

Pugliese, C. E., Anthony, L., Strang, J. F., Dudley, K., Wallace, G. L., & Kenworthy, L.

(2015). Increasing adaptive behavior skill deficits from childhood to adolescence in

autism spectrum disorder: Role of executive function. Journal of Autism and



98

Rao, P. A., & Landa, R. J. (2014). Association between severity of behavioral phenotype and

comorbid attention deficit hyperactivity disorder symptoms in children with autism

spectrum disorders. Autism, 18, 272-280. doi:10.1177/1362361312470494

Rapp, J. T., & Vollmer, T. R. (2005). Stereotypy I: A review of behavioral assessment and

treatment. Research in Developmental Disabilities, 26, 527-547.

doi:10.1016/j.ridd.2004.11.005

Ravet, J. (2011). Inclusive/exclusive? Contradictory perspectives on autism and inclusion:

The case for an integrative position. International Journal of Inclusive Education, 15,

667-682. doi:10.1080/13603110903294347

Ray-Subramanian, C. E., & Weismer, S. E. (2012). Receptive and expressive language as

predictors of restricted and repetitive behaviors in young children with autism

spectrum disorders. Journal of Autism and Developmental Disorders, 42, 2113-2120.

doi:10.1007/s10803-012-1463-6

Reynolds, S., Bendixen, R. M., Lawrence, T., & Lane, S. J. (2011). A pilot study examining

activity participation, sensory responsiveness, and competence in children with high

functioning autism spectrum disorder. Journal of Autism and Developmental

Disorders, 41, 1496-1506. doi:10.1007/s10803-010-1173-x

Rice, L. J., Gray, K. M., Howlin, P., Taffe, J., Tonge, B. J., & Einfeld, S. L. (2016). The

developmental trajectory of self-injurious behaviours in individuals with Prader Willi

syndrome, autism spectrum disorder and intellectual disability. Diseases, 4, 9.

doi:10.3390/diseases4010009

Richards, C., Oliver, C., Nelson, L., & Moss, J. (2012). Self‐injurious behaviour in

individuals with autism spectrum disorder and intellectual disability. Journal of

Intellectual Disability Research, 56, 476-489. doi:10.1111/j.1365-2788.2012.01537.x


99

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


Richler, J., Huerta, M., Bishop, S. L., & Lord, C. (2010). Developmental trajectories of

restricted and repetitive behaviors and interests in children with autism spectrum

disorders. Development and Psychopathology, 22, 55-69.

doi:10.1017/S0954579409990265

Roberts, J., Adams, D., Heussler, H., Keen, D., Paynter, J., Trembath, D., . . . Williams, K.

(2018). Protocol for a prospective longitudinal study investigating the participation

and educational trajectories of Australian students with Autism. BMJ Open, 8,

e017082. doi:10.1136/bmjopen-2017-017082

Roberts, J., & Simpson, K. (2016). A review of research into stakeholder perspectives on

inclusion of students with autism in mainstream schools. International Journal of

Inclusive Education, 20, 1084-1096. doi:10.1080/13603116.2016.1145267

Rodgers, J., Glod, M., Connolly, B., & McConachie, H. (2012). The relationship between

anxiety and repetitive behaviours in autism spectrum disorder. Journal of Autism and

Developmental Disorders, 42, 2404-2409. doi:10.1007/s10803-012-1531-y

Rodriguez, C. C., & Garro-Gil, N. (2015). Inclusion and integration on special education.

Procedia - Social and Behavioral Sciences, 191, 1323-1327.

doi:10.1016/j.sbspro.2015.04.488

Rotheram‐Fuller, E., Kasari, C., Chamberlain, B., & Locke, J. (2010). Social involvement of

children with autism spectrum disorders in elementary school classrooms. Journal of

Child Psychology and Psychiatry, 51, 1227-1234. doi:10.1111/j.1469-

7610.2010.02289.x


100

Rothwell, P. E., Fuccillo, M. V., Maxeiner, S., Hayton, S. J., Gokce, O., Lim, B. K., . . .

Südhof, T. C. (2014). Autism-associated neuroligin-3 mutations commonly impair

striatal circuits to boost repetitive behaviors. Cell, 158, 198-212.

doi:10.1016/j.cell.2014.04.045

Ruble, L. A., & Robson, D. M. (2007). Individual and environmental determinants of

engagement in autism. Journal of Autism and Developmental Disorders, 37, 1457-

1468. doi:10.1007/s10803-006-0222-y

Rutter, M., Bailey, A., & Lord, C. (2003). The Social Communication Questionnaire:

Manual: Western Psychological Services.

Saggers, B., Klug, D., Harper-Hill, K., Ashburner, J., Costley, D., Clark, T., . . . Carrington,

S. (2015). Australian autism educational needs analysis – What are the needs of

schools, parents and students on the autism spectrum? Full report. Cooperative

Research Centre for Living with Autism, Brisbane.

Sansosti, J. M., & Sansosti, F. J. (2012). Inclusion for students with high‐functioning autism

spectrum disorders: Definitions and decision making. Psychology in the Schools, 49,

917-931. doi:10.1002/pits.21652

Scott, A., Jeon, S.-H., Joyce, C. M., Humphreys, J. S., Kalb, G., Witt, J., & Leahy, A. (2011).

A randomised trial and economic evaluation of the effect of response mode on

response rate, response bias, and item non-response in a survey of doctors. BMC

Medical Research Methodology, 11, 126-126. doi:10.1186/1471-2288-11-126

Sigafoos, J., Green, V. A., Payne, D., O'Reilly, M. F., & Lancioni, G. E. (2009). A

classroom-based antecedent intervention reduces obsessive-repetitive behavior in an

adolescent with autism. Clinical Case Studies, 8, 3-13.

doi:10.1177/1534650108327475


101

Simpson, K., Keen, D., Adams, D., Alston‐Knox, C., & Roberts, J. (2017). Participation of

children on the autism spectrum in home, school, and community. Child: Care,

Health and Development, 44, 99-107. doi:10.1111/cch.12483

Soke, G. N., Rosenberg, S. A., Rosenberg, C. R., Vasa, R. A., Lee, L.-C., & DiGuiseppi, C.

(2018). Brief report: Self-injurious behaviors in preschool children with autism

spectrum disorder compared to other developmental delays and disorders. Journal of

Autism and Developmental Disorders, 48, 2558–2566. doi:10.1007/s10803-018-3490-

4

Soto-Chodiman, R., Pooley, J. A., Cohen, L., & Taylor, M. F. (2012). Students with ASD in

mainstream primary education settings: Teachers' experiences in Western Australian

classrooms. Australasian Journal of Special Education, 36, 97-111.

doi:10.1017/jse.2012.10

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, 145-158. doi:10.1007/s10803-004-1992-8

Sparapani, N., Morgan, L., Reinhardt, V. P., Schatschneider, C., & Wetherby, A. M. (2016).

Evaluation of classroom active engagement in elementary students with autism

spectrum disorder. Journal of Autism and Developmental Disorders, 46, 782-796.

doi:10.1007/s10803-015-2615-2

Sparrow, S., Balla, D., & Cicchetti, D. (1984). Vineland Adaptive Behaviour Scales. Circle

Pines, MN: American Guidance Service.

Sparrow, S., Cicchetti, D., & Balla, D. (2005). Vineland Adaptive Behaviour Scales (2nd ed.).

Circle Pines, MN: American Guidance Service.

Spiker, D., Lotspeich, L., Kraemer, H. C., Hallmayer, J., McMahon, W., Petersen, P. B., . . .

Chiotti, C. (1994). Genetics of autism: Characteristics of affected and unaffected


102

children from 37 multiplex families. American Journal of Medical Genetics Part A,

54, 27-35. doi: 10.1002/ajmg.1320540107

St. John, T., Dawson, G., & Estes, A. (2018). Brief report: Executive function as a predictor

of academic achievement in school-aged children with ASD. Journal of Autism and


Steensel, v. F. J. A., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders in children and

adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and

Family Psychology Review, 14, 302-317. doi:10.1007/s10567-011-0097-0

Steinhausen, H.-C., & Winkler Metzke, C. (2004). Differentiating the behavioural profile in

autism and mental retardation and testing of a screener. European Child & Adolescent

Psychiatry, 13, 214-220. doi:10.1007/s00787-004-0400-4

Sullins, C. D. (2003). Adapting the empowerment evaluation model: A mental health drop-in

center case example. American Journal of Evaluation, 24, 387-398.

doi:10.1016/j.ameval.2003.08.002

Symes, W., & Humphrey, N. (2010). Peer-group indicators of social inclusion among pupils

with autistic spectrum disorders (ASD) in mainstream secondary schools: A

comparative study. School Psychology International, 31, 478-494.

doi:10.1177/0143034310382496

Szatmari, P., Bryson, S. E., Boyle, M. H., Streiner, D. L., & Duku, E. (2003). Predictors of

outcome among high functioning children with autism and Asperger syndrome.

Journal of Child Psychology and Psychiatry, 44, 520-528. doi:10.1111/1469-

7610.00141

Szatmari, P., Georgiades, S., & Bryson, S. (2006). Investigating the structure of the restricted,

repetitive behaviours and interests domain of autism. The Journal of Child


103

Psychology and Psychiatry and Allied Disciplines, 47, 582. doi:10.1111/j.1469-

7610.2005.01537.x

Szatmari, P., Georgiades, S., Duku, E., Bennett, T. A., Bryson, S., Fombonne, E., . . .

Thompson, A. (2015). Developmental trajectories of symptom severity and adaptive

functioning in an inception cohort of preschool children with autism spectrum

disorder. JAMA Psychiatry, 72, 276-283. doi:10.1001/jamapsychiatry.2014.2463

Teh, E. J., Chan, D. M.-E., Tan, G. K. J., & Magiati, I. (2017). Continuity and change in, and

child predictors of, caregiver reported anxiety symptoms in young people with autism

spectrum disorder: A follow-up study. Journal of Autism and Developmental

Disorders, 47, 3857–3871. doi:10.1007/s10803-017-3136-y

Thelen, E. (1981). Rhythmical behavior in infancy: An ethological perspective.

Developmental Psychology, 17, 237- 257. doi:10.1037/0012-1649.17.3.237

Turner, M. (1999). Annotation: Repetitive behaviour in autism: A review of psychological

research. Journal of Child Psychology and Psychiatry, 40, 839-849.

doi:10.1111/1469-7610.00502

Turner-Brown, L. M., 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, 437-456. doi:10.1177/1362361310386507

Uljarevic, M., Carrington, S. J., Fernyhough, C., Arnott, B., Meins, E., McConachie, H., . . .

Leekam, S. R. (2017). Development of restricted and repetitive behaviors from 15 to

77 months: Stability of two distinct subtypes? Developmental Psychology, 53, 1859-

1868. doi:10.1037/dev0000324

Unesco. (1994). The Salamanca Statement and Framework for action on special needs

education: Adopted by the World Conference on Special Needs Education; Access

and Quality. Salamanca, Spain, 7-10 June 1994: Unesco.


104

Vakil, S., Welton, E., O’Connor, B., & Kline, L. S. (2009). Inclusion means everyone! The

role of the early childhood educator when including young children with autism in the

classroom. Early Childhood Education Journal, 36, 321-326. doi:10.1007/s10643-

008-0289-5

Vig, S., & Jedrysek, E. (1995). Adaptive behavior of young urban children with

developmental disabilities. Mental Retardation, 33, 90.

Watt, N., Wetherby, A. M., Barber, A., & Morgan, L. (2008). Repetitive and stereotyped

behaviors in children with autism spectrum disorders in the second year of life.

Journal of Autism and Developmental Disorders, 38, 1518-1533.

doi:10.1007/s10803-007-0532-8

White, S. W., Oswald, D., Ollendick, T., & Scahill, L. (2009). Anxiety in children and

adolescents with autism spectrum disorders. Clinical Psychology Review, 29, 216-

229. doi:10.1016/j.cpr.2009.01.003

White, S. W., & Roberson-Nay, R. (2009). Anxiety, social deficits, and loneliness in youth

with autism spectrum disorders. Journal of Autism and Developmental Disorders, 39,

1006-1013. doi:10.1007/s10803-009-0713-8

Wigham, S., Rodgers, J., South, M., McConachie, H., & Freeston, M. (2015). The interplay

between sensory processing abnormalities, intolerance of uncertainty, anxiety and

restricted and repetitive behaviours in autism spectrum disorder. Journal of Autism

and Developmental Disorders, 45, 943-952. doi:10.1007/s10803-014-2248-x

Winter-Messiers, M. A. (2007). From tarantulas to toilet brushes: Understanding the special

interest areas of children and youth with Asperger syndrome. Remedial and Special

Education, 28, 140-152. doi:10.1177/07419325070280030301

Wolff, J. J., Swanson, M. R., Elison, J. T., Gerig, G., Pruett, J. R., Styner, M. A., . . . Gu, H.

(2017). Neural circuitry at age 6 months associated with later repetitive behavior and


105

sensory responsiveness in autism. Molecular Autism, 8. doi:10.1186/s13229-017-

0126-z

Wood, J. J., & Gadow, K. D. (2010). Exploring the nature and function of anxiety in youth

with autism spectrum disorders. Clinical Psychology: Science and Practice, 17, 281.

doi:10.1111/j.1468-2850.2010.01220.x

World Health Organisation. (2001). International Classification of Functioning, Disability

and Health (ICF). Switzerland: World Health Organisation Geneva.

World Health Organisation. (2007). International Classification of Functioning, Disability

and Health: Children and Youth version (ICF-CY). Switzerland: World Health

Organisation Geneva.

Young, R. L., & Rodi, M. L. (2014). Redefining autism spectrum disorder using DSM-5: The

implications of the proposed DSM-5 criteria for autism spectrum disorders. Journal of

Autism and Developmental Disorders, 44, 758-765. doi:10.1007/s10803-013-1927-3

Zaidman-Zait, A., Mirenda, P., Duku, E., Vaillancourt, T., Smith, I. M., Szatmari, P., . . .

Thompson, A. (2017). Impact of personal and social resources on parenting stress in

mothers of children with autism spectrum disorder. Autism, 21, 155-166.

doi:10.1177/13623613


106

RESTRICTED AND REPETITIVE BEHAVIOURS AND …

Documents

Transcript of RESTRICTED AND REPETITIVE BEHAVIOURS AND …