Stereotypy vs. Stimming: Restricted & Repetitive Behaviors in Autism (ASD) | Occupational Therapy Interventions

This article will use identity-first language based on the community’s preference for such language in accordance with the APA’s recommendations.

Introduction

Restricted and repetitive behaviors (RRBs) are one of the core symptoms of autism spectrum disorder (ASD). The other core symptoms of autism include deficits in communication and social interaction.

RRBs include stereotyped behaviors such as movements, postures, or utterances, which are often referred to as “stereotypy” or “stereotypies”. An example of motor stereotypy is hand flapping or body rocking. Stereotypies are often associated with autistic people, or those who are neurodiverse.

In people who are neurotypical, this behavior is often called “fidgeting”. Are stereotypies voluntary or involuntary? Stereotypies are believed to be semi-voluntary repetitive behaviors. To start, stimming typically begins involuntarily and is even unconscious. However, there is a degree of intentionality because stimming is reported to increase one’s self of control and comfort.

What about “stimming”? Stimming is short for self-stimulatory behavior (SSB). Stimming is the colloquial term for Autistic people who engage in these stereotypy behaviors. Lovaas (who pioneered ABA) and colleagues classified stimming as a sub-type or sub-category of stereotypy.

For this article, I will use the term stimming as it is used more than sterotypy in my experience, and also this often has positive connotations amongst the Autistic community.

Mechanism of Action

Stereotypy such as stimming produces sensory input such as vestibular, auditory (verbal stereotypy), tactile, and vestibular. This self-produced sensory input can be self-regulating and is one of the underlying approaches of Ayres Sensory Integration theory.

More technically, one theory attempts to explain this occurrence due to brain rhythms. A prominent hypothesis is that Autistic people have a disorder of sensory and motor brain oscillations within the auditory, motor, and visual regions. Researchers hypothesize that self-generated behaviors such as stimming causes the brain to produce electrical signals to regulate and normalize these abnormal brain rhythms and improve sensory processing.

An analogy is like a musician who is playing off beat, but with another signal or stimuli such as a metronome, the musician is now playing perfectly in sync.

Everyone Fidgets

“Neurotypical individuals also engage in repetitive movements, which are typically referred to as fidgeting. Examples include doodling, clicking a pen, rocking in a chair, playing with ones’ hair, humming, chewing gum, or bouncing one’s leg. These movements are often repetitive or patterned, and are self-initiated. Fidgeting may appear purposeless, but it can have positive effects on attention, concentration, and stress.”

Is stimming bad?

The answer to this question is who do you consider when you say bad.

Some research suggests that repetitive behaviors can be negative as they can negatively impact learning and socialization. Other research suggests that they may affect family functioning and well-being. This is all true, but only from the perspective of those who are not Autistic, or those who are neurotypical. Family members, peers, co-workers, and society. Some believe that stereotypes interfere with normal activity and that those who are stimming are not attending to their environment. To others students, this behavior may be distracting to learning. So in a setting like a school, it is understandable that educators and therapists would want to minimize, or even eliminate this behavior such as with ABA. In the home, parents probably would want the same decrease in stemming. Repetitive behaviors such as stemming among children have been found to be highly correlated with parental and family stress.10 11  So should this behavior be completely extinguished? And is seeing this behavior eliminated a sign of improvement or effectiveness of such a treatment? This is very controversial and we really have not known much of its effects until now, as Autistic children grew up into adults and are now speaking out about their experiences from parenting, their education, and therapy such as ABA.12 

So what if we ask the Autistic person? Researchers have proposed that stimming may not be a behavior that results in not paying attention, but instead used in order to pay attention. In other words, stimming can help the brain to process information. The behavior of Autistic people stimming has been found to have a correlation with stress and anxiety.13  Autistic people report that stimming helps them to self-regulate to help with anxiety and nervousness. However, Autistic people may also stim when regulated as well such as when they are relaxed or happy. The general consensus among Autistic people then is that stimming is a positive behavior that promotes calm, comfort, organization of thoughts, attention, and getting rid of excess energy.14 15  So then in an environment like a school, at home, or in public where there may be a lot of sensory stimulation that can then cause increasing stress, stimming can help the Autistic person to be better regulated.

Client-centered Practice

One value of occupational therapy is that it is client-centered. There are many textbooks and journal articles even with this in the title.16  Client being the Autistic child, or teenager, or adult, or older adult. While a family-centered approach is also a consideration, in the case of ASD, it is not so black and white.

ABA Controversies

Examples of some ABA approaches include:

  • Forced compliance: emphasis on compliance and obedience.17 18 
  • Physically or verbally blocking the individual from engaging in the behavior.19 
  • Removal of a positive consequence when a problematic behavior occurs.20 
  • Aversives: unpleasant stimuli or events to discourage behavior (although less commonly practiced).21 22 
  • Possible lack of consent and dehumanizing.23 
  • May not be culturally sensitive.24 

Evidence now shows that Autistic people experience increased trauma, PTSD, and suicidality compared to their neurotypical counterparts.25  Research even shows a direct correlation from approaches such as ABA being responsible for increased PTSD symptoms, with those exposed to ABA being 86% more likely to meet PTSD criteria than those who were not exposed.26 

Acceptance and Stigma

  • Autistic people report in research and on social media that they don’t want to be changed for who they are.
  • Neurotypical people such as parents, peers, educators, co-workers, and society typically want Autistic people to change.
  • This change such as Autsitic people suppressing stemming or masking their true identity results in harm, such as PTSD.

So maybe, neurotypical (“normal”) people should be more accepting of these less than “normal” behaviors.

Occupational Therapy Approach & Intervention

Interviews and accounts from Autistic adults often have the same message: stemming should not be suppressed. Research from Autistic adults revealed one theme that those with ASD should be accepted instead of fixed.27  One popular theoretical model for occupational therapy practice is P-E-O, or considering interventions to address the person, environment, and/or occupation. Many Autistic adults advocate for changing not the Autistic person, but instead the environment or task/activity/occupation with these behavioral strategies. Approaches that attempt to change behavior such as stemming may take away the Autistic’s feeling of safety and security in their environment. Instead, occupational therapy practitioners should foster trust, safety, and support with their clients. With this established, the child is likely to be more willing to co-operate, collaborate, or change their behavior. It is still important to be client-centered and allow the Autistic person to be autonomous. Overall, occupational therapy should support intrinsic motivation such as via child-led or play-based therapy, e.g., Sensory Integration.27 


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