Associations between Repetitive Behaviors and Play Diversity in Toddlers with Autism Spectrum Disorder

Background: Research investigating the relationship between repetitive behaviors and play skills in children with autism spectrum disorder is limited. Restricted and repetitive behaviors (RRBs) are a core symptom of ASD. RRBs encompass a broad range of heterogeneous behaviors, including repetitive motor mannerisms, overriding preoccupations with object parts, preoccupation with restricted patterns of interests, and adherence to nonfunctional routines (Richter et al. 2007). Currently, it is unclear how RRBs relate to other core areas of ASD. For example, children with ASD demonstrate less frequent, diverse, elaborate, and integrated symbolic and non-symbolic functional play than their typically-developing peers (Kasari et al., 2005; Jarrold, Boucher, & Smith, 1996; Williams, Reddy, & Costell, 2001). Research indicates that frequency of play acts is inversely related to the frequency of RRBs (Honey et al., 2006). However, this research relied upon caregiver report through questionnaires. Thus, the purpose of this study is to determine how behaviorally-coded RRBs within the context of a free play session associate with play acts within a standardized assessment of play.

Objectives: This study aims to examine the relationship between the frequency of behaviorally-coded repetitive behaviors during a free play session and the diversity of play acts demonstrated by toddlers with ASD.

Methods: 85 toddlers (69 male: 16 female; mean age = 31 months, SD = 3 months) with a diagnosis of ASD were included in the study. The ADOS-2 and ADI-R were completed by independent research-reliable testers to confirm the diagnoses of ASD. Child RRBs were coded from the 10-minute caregiver-child free play session. Observational coding focusing on lower-order RRBs was based on the coding scheme developed by Harrop et al. (2014). Higher-order RRBs were excluded for the purpose of this study to account for the young population age and time-limited observation. RRBs were coded into four categories: (a) motor/body behaviors, (b) visual behaviors, (c) repetitive object use, and (d) repetitive vocalizations/language. The frequency, type, and level of spontaneous play behaviors were coded from a 15-minute structured play assessment (SPA; Ungerer & Sigman, 1981). Children were presented with a variety of related toy sets to assess play skills.

Results: Two children who didn’t display any RRBs during the interaction were excluded from the analysis. On average, toddlers had 10.8 instances of RRBs during the 10-minute interaction (SD = 7.10), and had an average of 17.5 total types of play (SD = 10.4). Repetitive object use constituted the majority of repetitive behavior displayed (55%). There was a significant negative correlation between the number of RRBs and total play diversity (r = -0.26, p-value = 0.02).

Conclusions: These results suggest that the presence of repetitive behaviors is associated with impairments in the diversity of play demonstrated by toddlers with ASD. This highlights the pervasive effects of repetitive behaviors and suggests that the extent of their intrusiveness may preclude a child’s ability to play. Our results suggest that improving play within intervention may yield spillover effects in reducing the frequency of observed RRBs, emphasizing the need for targeted early interventions that specifically address repetitive behaviors.