Stereotypy in Children and Adults: When to Intervene and Some New Directions

Rebecca K. Schulman, Psy.D., BCBA-D | Behavior Therapy Associates | Somerset, New Jersey

What Is Stereotypy?

Restricted and repetitive patterns of motor or vocal behavior, often referred to as stereotypy, are one of the core diagnostic categories for autism spectrum disorder (ASD; American Psychiatric Association, 2013). Stereotypy or “stimming” is not inherently problematic and may serve important functions for individuals, including helping them to adapt and self-soothe in certain environments (Manor-Binyamini & Schreiber-Divon, 2019). However, stereotypic behavior may interfere with an individual’s participation and engagement in social and academic contexts (e.g., Cook & Rapp, 2020) and lead to less independence and ultimately more restrictive placements long-term. Specifically, individuals may engage in such high levels of stereotypy that they do not communicate with others, respond to instructions, or engage with other potentially reinforcing activities. Vocal stereotypy, which consists of repetitive and non-contextual vocal utterances, can be disruptive to the environment if it occurs at high volumes and may result in additional negative social impacts. For example, stereotypic screaming may evoke dangerous forms of challenging behavior by other individuals in the environment who are sensitive to loud noises.

How Practitioners Should Assess Stereotypy?

Practitioners should carefully assess if and in what contexts to intervene and ensure agreement on the social importance and acceptability in doing so with all stakeholders (e.g., parents, educators, etc.). In all cases, practitioners should only target stereotypy if the detrimental consequences of the behavior outweigh the positive aspects. If it is agreed that intervention is needed, it is important that individuals still have identified times and places to engage in stereotypy to continue to experience the positive effects. For example, “stereotypy breaks” can be added to a student’s schedule, during which they have a separate location to engage in stereotypy. A visual can be used to help individuals learn when they are permitted to engage and when they are expected to refrain from engaging in stereotypy. Individuals can also be taught to request these types of breaks when more are needed. Furthermore, less intrusive reinforcement-based interventions should be evaluated first (BACB 2020), such as providing scheduled access to preferred auditory stimuli (e.g., Lanovaz et al., 2012) or access to reinforcers for the absence of stereotypy (Taylor et al., 2005). If those approaches are not successful and the occurrence of stereotypy continues to lead to undesirable outcomes for the individual, reinforcement-based interventions may need to be combined with additional approaches, such as response interruption and redirection (RIRD), which is a procedure that interrupts stereotypy.

What is RIRD (Response Interruption and Redirection)?

RIRD has been shown to be an effective behavioral treatment for stereotypy (e.g., Ahearn et al., 2007; Athens et al., 2008; Cassella et al., 2011), though the majority of evaluations have targeted vocal stereotypy (Ryan et al., 2022). This procedure involves the interruption of stereotypy by presenting instructions that prompt the individual to say or do different things. Some studies of RIRD have focused on determining why this procedure is effective.

• Some researchers have suggested that RIRD is an extinction-based treatment, which means the individual no longer receives reinforcement after engaging in the behavior. This is the case when stereotypy is interrupted through RIRD, as the person does not get the usual reward (e.g., it sounds or feels good) from doing it. Studies that support this theory are ones that effectively used vocal tasks to treat vocal stereotypy and tasks requiring a motor response to reduce motor stereotypy (i.e., matched tasks) (e.g., Ahearn et al., 2007, Athens et al., 2008; Colón et al., 2012; Love et al., 2012; Miguel et al., 2009).
• Others have posited that it involves positive and negative punishment components.
  • More specifically, the demands in RIRD may function as positive punishment (i.e., adding a negative consequence to reduce behavior) because studies have shown that RIRD can continue to be effective even if individuals can do both the demand and the stereotypy at the same time. Researchers who have used
    unmatched tasks (e.g., motor tasks to treat vocal stereotypy) have observed behavioral reduction in vocal stereotypy.
  • Another possible mechanism explored has been negative punishment, such as response cost (i.e., the loss of rewards to reduce behavior). The majority of evaluations of RIRD take place when the participant has free access to preferred toys and items (e.g., Martinez & Betz, 2013). When RIRD is implemented, the experimenter will typically block access to preferred items to deliver instructions.

There have been many studies conducted with RIRD exploring the type of instruction used in the procedure. Recently, several of my colleagues and I had our study evaluating the role of task preference on the efficacy of RIRD published in the Journal of Applied Behavior Analysis (Sloman et al., 2024). For three of the four participants, results showed that RIRD using higher preference tasks to interrupt the stereotypy was not effective at reducing vocal stereotypy, whereas RIRD using lower preference tasks to interrupt the stereotypy was effective for all participants. To learn more about RIRD and our study, you can visit: https://onlinelibrary.wiley.com/doi/10.1002/jaba.1064

If you need more individualized assistance, feel free to contact Behavior Therapy Associates.

Rebecca K. Schulman, Psy.D., BCBA-D is a Licensed Psychologist in New Jersey and a Board
Certified Behavior Analyst at the Doctoral Level. She works at Behavior Therapy Associates in
Somerset, New Jersey. Dr. Schulman has the authority to practice interjurisdictional
telepsychology (APIT) from the PSYPACT commission, allowing her to provide telepsychology to
clients in many states. She can be reached at rschulman@BehaviorTherapyAssociates.com and
at www.BehaviorTherapyAssociates.com.