An Exploration of Perseverative Behaviors in Young Children with Autism

Discussion

Several linkages were found between the research done prior to this study and the results of this study. The findings from this study that apply to those studies will be discussed in detail. The researcher also found results that were not anticipated, and therefore not previously discussed in literature.

Links to the Field

Response interruption/redirection

Interventionists implement response interruption/redirection (RIR) in order to interrupt the response from the reinforcer that follows it (Wong et al., 2014). By this definition, RIR was observed at the Summer Social Skills Clinic through what the researcher defined as the interventionists redirecting Caleb and blocking Caleb’s behaviors. In one study examined in the literature review, RIR first increased the SRB and then decreased it to almost complete elimination upon extending the time of the redirection. The RIR procedure was effective for two of the three participants, but it resulted in aggression in one of the participants (Rodriquez et al., 2012).

The present study reflected these same results. In the example of June 9, one participant was banging a toy on the wall, and an interventionist redirected him to the floor. RIR was effective in this instance; the participant stopped banging the toy on the wall and transitioned to the floor without protest. However, when an interventionist used RIR during one of Caleb’s behavioral patterns, he did not comply as easily and became more aggressive. The same session (June 9), Caleb was upset that his brother had left the room. The interventionists blocked Caleb twice and redirected him six times, resulting in Caleb’s behavior escalating from crying and screaming to hitting Meg with his nametag. This shows that RIR works for some participants more effectively than it does for others, and aggression is a possible outcome when implementing this intervention. This finding is important because aggressive behavior is threatening to both the individual and those around that individual. Interventionists must be aware that RIR is found to result in aggressive behavior in some individuals so that an alternate intervention can immediately replace RIR should the individual exhibit aggressive behavior.

Positive reinforcement

The researcher identified two studies in the literature review in which automatic reinforcement was found to be the reinforcer maintaining the stereotypical repetitive behavior (SRB) (Wilke et al., 2012, Rodriguez, Thompson, Schlichenmeyer, & Stocco, 2012). One of these studies conducted a behavioral function survey on 53 participants, 9 of which exhibited a verbal stereotypy. The study resulted in automatic reinforcement being the factor that maintained the behavior. In terms of vocal stereotypies in particular, automatic, multiple, and tangible reinforcements were found to maintain the SRB in at least one occasion. Attention was not found to maintain any of the vocal stereotypies (Wilke et al., 2012).

These findings are inconclusive with those found in the present study. Mary perseverated on “rawr” more frequently than any other perseveration that she formed at the clinic. This perseveration was reinforced through the attention and verbal responses of Erik. The second most perseverated response that Mary formed at the clinic was asking if she could go home, which Meg reinforced through responding with when Mary could go home. These two findings within the theme of perseverations formed outside of the probes at the clinic show that the verbal stereotypies were strongest and most frequent when maintained by positive reinforcement. This contrasts with the findings of Wilke in that these stereotypies were not maintained by automatic reinforcement, but attention. In fact, none of the vocal stereotypies studied by Wilke et al. were maintained by an attention component (2012).

The contrast of the findings of this study and the study discussed are important because it highlights the differences in maintaining reinforcers for each individual. As defined in the literature review, behavior can serve a different function for different individuals. Interventionists should first conduct a functional behavior assessment (FBA) to determine what function the SRB serves for the individual being studied so that the intervention can be most effective for them (Scheuermann & Hall, 2012).. These two studies suggest that the type of maintaining reinforcer cannot be assumed for an individual based on a previous study; an FBA is necessary when using reinforcement as an intervention (Scheuermann & Hall, 2012).

Prompting

The interventionists used prompting at the social skills clinic primarily through the use of visual cue cards for the responses of each skill intervened upon. Similarly, a study discussed in the literature review used cue cards and simultaneous prompting to teach three participants with autism to say the numeral on each of the cue cards. The trainer would sit down with the participant, show them the cue card, prompt them through task direction (“show me three”), wait for a response within four seconds, and verbally praise correct responses (Akmanoglu & Batu, 2004). The procedure at the Summer Social Skills Clinic paralleled this. The interventionist would pull the participant aside, probe the participant while holding up the three blank cue cards, wait five seconds for a response, and reinforce correct responses with praise and a token reinforcer. Both of the studies involved the interventionists training the participants’ responses cue cards prior to probing the participant.

Both similarities and differences exist between the results of Mary’s success with the prompting intervention and the success found in the study by Akmanoglu and Baku (2004). Akmanoglu and Baku found success with this prompting procedure during the training of the participants saying the numerals. Similarly, Mary had great success with the prompting involving cue cards as she was being trained for each of the four skills. As depicted in the results, the only time she gave a varied response for the probe “what do you like to do for fun” was when the prompting cue cards were presented to the probes. However, the Akmanoglu and Baku study also had success in maintaining the trained behavior over time; the first participant maintained the 94.6% of the behaviors, the second participant maintained 85.7% of the behaviors, and the third maintained 100% of the behaviors (2004). Contrastingly, Mary reverted back to her original stereotypical response of “playing outside” immediately upon the removal of the cue cards. This finding is important because it suggests that the cue cards seem to be effective for the training of the skill, but they will not necessarily maintain the behavior over time. One factor that could contribute to this is the age of the participants, as Mary was only five and the participants in the Akmanoglu and Baku study ranged from six to seventeen years (2004).

Perseverations

In the review of the literature, the researcher did not anticipate the need to distinguish between stereotypical behaviors and perseverations. The stereotypies that Mary exhibited are more characteristic verbal perseverations, which are words, phrases, or topics that the individual repeats, often out of context (Arora, 2012). Perseverations can be described as “non-person oriented speech,” as they are an attempt at communication for individuals with autism, but are not meant by the individual as speech that desires a response (Arora, 2012). Three types of verbal perseverations can be identified: phrasal (repetition of phrases), sentential (repetition of sentences), and topical (fixating on a topic). In the case of Mary, phrasal and sentential verbal perseverations constitute all of the perseverations observed in the clinic; Mary did not exemplify perseveration on a topic on which she was fixated.

Arora’s article identifies two different interventions that are used to reduce verbal perseverations (2012). The first of these is telling the individual to stop saying the phrase or sentence. The use of this intervention was not seen in the clinic. The second intervention identified in Arora’s study is ignoring the perseveration. The researcher did observe this as an interventionist response to Mary’s perseverations at the social skills clinic. For example, when Mary would say “good job” to herself when doing something, the interventionists would ignore this since it was out of context; she would not be doing an activity that elicited a “good job.” However, the observations do not show the perseveration decreasing as a result of the interventionists ignoring the perseveration. In fact, the only change of frequency occurred as the perseverations increased when the perseveration was positively reinforced through attention and response (“rawr,” “can I go home,” saying names, etc.).

This finding is important because it highlights the need for an intervention that successfully reduces verbal perseverations. As mentioned in the introduction, SRBs (including perseverations) are a defining factor of autism (American Psychiatric Association, 2013). Perseverations can interrupt social acceptance, daily functioning, and learning. Researchers should identify a focused intervention for the replacement and reduction of verbal perseverations in order that programs such as the social skills clinic can effectively reduce them in participants.

Implications for Future Research

Further research would be needed to determine if RIR is an effective intervention with the majority of individuals with an SRB, or if it causes aggression in more individuals with an SRB. This study found that it was effective for one participant but onset aggression in another. This makes it difficult to say that it is effective for the overwhelming majority. Future studies should implement RIR at the onset of the SRB and observe its effect on the SRB over time to determine whether it is an effective intervention for replacing SRBs.

Researchers should further study reinforcement to determine what kind of reinforcers typically maintain SRBs for individuals with autism. This study found positive reinforcement to maintain and even increase the SRBs exhibited by one participant, which is not consistent with the literature. Future studies should determine whether a general reinforcer can be identified for most individuals with SRBs or if each individual displays behaviors maintained by very different reinforcers. If the latter is the case, interventionists should first begin with an FBA before each and every intervention. An FBA is an assessment of challenging behaviors based on the environmental, social, and cognitive conditions and the supposed function of the behavior (Scheuermann & Hall, 2012). A replacement behavior must serve the same function as the SRB for the individual, so identifying this function is vital for an effective intervention.

Researchers would need to further study prompting to determine if it is effective for maintaining the replacement behavior (or in the case of this study the replacement speech). The researcher would implement a study much like this one and then collect data after the clinic had ended. This would help the field by proving whether or not prompting is an effective intervention for teaching behaviors that are maintained over time or whether it is only effective for replacing behaviors in the presence of the intervention.

Future research into the interventions implemented to reduce verbal and behavioral perseverations should involve having set interventions in place with specific procedures set. This study relied heavily on interventions that were observed as the perseverations came up in the setting; there were no formal interventions in place for reducing perseverative speech or behavior. Because of this, the interventions could not adequately be evaluated for effectiveness. This study focused on observing the events of a summer social skills clinic, but specific studies would need to be done regarding single intervention implementation to determine which is most effective for each type of perseveration.

Another opportunity for future research exists in the nature of perseverations. Mary came to the clinic with ten observed perseverations and formed nine perseverations at the clinic. Investigating the causes of Mary’s perseverations and how they function for her may have helped develop an intervention to reduce them. Similarly, future studies should conduct a formal FBA to identify the behaviors that will be present ahead of time. The researchers should then identify replacement behaviors that serve the same function as the SRB and implement the replacement of the SRB. Doing this would have helped the interventionists develop an intervention to reduce Caleb’s behavioral pattern of trying to run out of the clinic room.

Limitations

There are several limitations to this study. The first limitation is that, like most qualitative study, the findings of this study are not intended to be generalized (Brantlinger, E., Jimenez, J., Pugach, M., & Richardson, V., 2005). This case is specific to the time, place, context, and participants involved. While the findings may apply to other, similar cases, an exact generalization should not be expected.

The second limitation is that the researcher was not able to observe the clinic from outside the room. By sitting in the same room as the interventionists and participants, the researcher was approached by participants, involved in recording the probes, and a part of the intervention by being another person in the small room. Had the researcher observed the clinic from an outside location, the researcher would have been less involved in the process and would have had to rely solely on direct observations of the events.

A third limitation is that there were no procedures in place for reducing the perseverations that existed. The interventionists dealt with the perseverations using their individual judgment, as there was not a set policy of whether they should ignore or respond to the perseverations. Similarly, there was not a behavioral plan in place for challenging behaviors such as the ones exhibited by Caleb. The interventionists tried different strategies to managing behavior each time a challenging behavior arose, so it is difficult to evaluate the effectiveness of different interventions when they were not used consistently throughout the clinic.

Finally, a fourth limitation is the amount of sessions at the clinic. If the clinic had met three or four times a week, the researcher would have been able to observe speech and behavioral patterns that were developing in the participants. Since the clinic only met twice a week, the researcher was not able to observe whether the different perseverations (Mary) and behavioral patterns (Caleb) multiplied or reduced. It also would have been beneficial to see whether Mary continued developing new perseverations on words or phrases.

Conclusion

Stereotypical and repetitive behaviors (SRBs) are a characteristic component of autism spectrum disorders (American Psychiatric Association, 2013). SRBs include stereotypies, rituals, compulsions, obsessions, perseverations, and repetitive speech (Watt, Wetherby, Barber, & Morgan, 2008). SRBs can cause an individual with autism to experience difficulty in carrying out everyday behaviors and activities. Effective interventions for SRBs are necessary to implement in order for individuals with autism carry out daily functional behaviors. This case study observed both behavioral and verbal SRBs in two participants in a summer social skills clinic for individuals with autism. Several intervening practices were identified and evaluated for their effectiveness in reducing the occurrence of the observed SRBs; these interventions include response interruption/redirection, positive reinforcement, and prompting. Although this study identified SRBs that developed at a social skills clinic and interventions that occurred at the clinic, additional studies are recommended which focus on more clearly defining the process of shaping perseverations into functional communication by developing pre-planned interventions geared specifically to the SRB of the individual.

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Appendix

Table 1. Coding System
Theme	Example
Theme 1 (pink): Mary’s verbal perseverations directly resulting from a probe	“Can I play outside?”
	“Can you have a toy?”
	“Playing outside.”
Theme 2 (orange): Mary’s verbal perseverations existing outside of probe Subtheme 1 (grey): Developed at the clinic	Can I go home? OR Can I go home after _____?
	Can I tap?
	Go to USM?
	_____ isn’t coming? ______ sick?
	Asks to play tickle
	Says “rawr!” or asks to play scare
	“Help please.”
	“When the big hand gets to the 12?”
Theme 2 (orange): Mary’s verbal perseverations existing outside of probe Subtheme 2 (purple): Developed before the clinic	Talks about sharing
	Repeats names. Ex: “Hello, ________.”
	Talks about playing outside (NOT in context of a probe)
	Asks to play with/fix hair. Comments on eye color
	Talks about anyone’s “mama”
	“I’m crying on the bus.”
	Talks about “having fun.” Usually, “I’m having fun with ________.”
	Tells herself “good job”
	“It’s okay?” OR “He’s crying?”
	Talks about relationships. Ex: married or with kids “Mr. John married to Ms. Katie?”
	“I’m talking” OR “I’m laughing at school.”
	“It was an accident?”
Theme 3 (green and yellow):	Any instance where Caleb yelled and tried to run out of the room
	“Good asking.”
	Redirection
	Blocking
	Positive reinforcement
	Interventionist pulling a participant aside
	Prompting
	Other behavioral management strategy (ex. Ignoring)

Table 2. Mary’s perseverations outside of the probes- frequency
Perseveration	Frequency	Time of Development
Names	81	Before clinic
Commenting on hair or eyes	53	Before clinic
Sharing	25	Before clinic
Mama	11	Before clinic
Having fun	11	Before clinic
It’s ok? I’m crying	11	Before clinic
Playing outside	10	Before clinic
Good job	9	Before clinic
Married/kids	6	Before clinic
Talking/laughing at school	3	Before clinic
Rawr!/scare	37	At clinic
Home	33	At clinic
When the big hand gets to the 12?	12	At clinic
Tap	11	At clinic
After ______?	10	At clinic
Tickle	9	At clinic
______ isn’t here/not coming?	8	At clinic
Help please	8	At clinic
Go to USM	6	At clinic