View in EDS HTML Full Text PDF Full Text

Understanding the Influence of Social and Motor Context on the Co-Occurring Frequency of Restricted and Repetitive Behaviors in Autism

Saved in:
Bibliographic Details
Title: Understanding the Influence of Social and Motor Context on the Co-Occurring Frequency of Restricted and Repetitive Behaviors in Autism
Language: English
Authors: Lampi, Andrew, Fitzpatrick, Paula (ORCID 0000-0002-4231-6500), Romero, Veronica, Amaral, Joseph, Schmidt, R. C.
Source: Journal of Autism and Developmental Disorders. May 2020 50(5):1479-1496.
Availability: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 18
Publication Date: 2020
Sponsoring Agency: National Institute of Mental Health (DHHS/NIH)
Contract Number: R21MH094659
Document Type: Journal Articles
Reports - Research
Descriptors: Children, Autism, Pervasive Developmental Disorders, Behavior Patterns, Repetition, Social Behavior, Severity (of Disability), Mental Age
DOI: 10.1007/s10803-018-3698-3
ISSN: 0162-3257
Abstract: The social and motor context in which restricted and repetitive behaviors (RRBs) occur in autism and their relationship to social traits are not well-understood. Participants with and without autism completed tasks that varied in social and motor engagement and RRB frequency was measured. Motor and verbal RRBs were most common, RRBs varied based on motor and social context for participants with autism, and social engagement was associated with lower motor and verbal RRBs. Significant correlations between RRBs and autism severity, social synchrony, and nonverbal mental age were also found. This research confirms the importance of context for understanding RRBs during on-going tasks and raises questions about whether the factors that elicit vocal and motor RRBs are unique for individual children.
Abstractor: As Provided
Entry Date: 2020
Accession Number: EJ1252836
Database: ERIC
Full text is not displayed to guests.
FullText Links:
  – Type: pdflink
    Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwE2PDDFMnsDrtbbWEm6dheWAAAA4zCB4AYJKoZIhvcNAQcGoIHSMIHPAgEAMIHJBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDE-dwRntu7kw60gxDQIBEICBm092a6lloJXsXYX-wV5P3ugJbYqWGIiEdh5YdcDHY4bUl7g7_KTHuCQeGqawLPyQa7qPEH7JVFQI3JWMSmRVVrKPz0luG4EnJgz-fPY40TeGxWuKi5I_xBcdJIZ1q1-o4UySy7h9n2U3Yhs5FLxJyTGM_23VkpVlvp0i3-0kCNSHu2wm1YKR0m0EdXFTfuY6PeNgUxqetKgl05rZ
Text:
  Availability: 1
  Value: <anid>AN0143136307;aut01may.20;2020May12.02:23;v2.2.500</anid> <title id="AN0143136307-1">Understanding the Influence of Social and Motor Context on the Co-occurring Frequency of Restricted and Repetitive Behaviors in Autism </title> <p>The social and motor context in which restricted and repetitive behaviors (RRBs) occur in autism and their relationship to social traits are not well-understood. Participants with and without autism completed tasks that varied in social and motor engagement and RRB frequency was measured. Motor and verbal RRBs were most common, RRBs varied based on motor and social context for participants with autism, and social engagement was associated with lower motor and verbal RRBs. Significant correlations between RRBs and autism severity, social synchrony, and nonverbal mental age were also found. This research confirms the importance of context for understanding RRBs during on-going tasks and raises questions about whether the factors that elicit vocal and motor RRBs are unique for individual children.</p> <p>Keywords: Autism Spectrum Disorder; Theory of mind; Joint attention; Social engagement; Repetitive behavior; Social synchrony; Motor engagement</p> <hd id="AN0143136307-2">Introduction</hd> <p>The two main diagnostic criteria for Autism Spectrum Disorder (ASD) are the co-occurrence of difficulties in social communication and interaction and the presence of restricted and repetitive behaviors (RRBs; American Psychiatric Association, APA [<reflink idref="bib3" id="ref1">3</reflink>]). Social interaction, broadly defined, refers to the act of social engagement, which involves communicating with other people both verbally and nonverbally in a meaningful manner. People with ASD experience difficulties in social functioning, which may be evident in both social and motor interactions with others. RRBs include behaviors such as repeated motor actions and sensory manipulation of objects and adherence to routines and rituals. Various factors have been proposed as motivation to engage in RRBs (e.g., Factor et al. [<reflink idref="bib27" id="ref2">27</reflink>]; Joosten et al. [<reflink idref="bib43" id="ref3">43</reflink>]) and treatment decisions are complex and must take function and developmental and social context into account (Cunningham and Schreibman [<reflink idref="bib20" id="ref4">20</reflink>]; Harrop and Kasari [<reflink idref="bib36" id="ref5">36</reflink>]). However, a deep understanding of the underlying causes of RRBs, mechanisms that maintain them, and best ways for managing them remains elusive (Leekam et al. [<reflink idref="bib52" id="ref6">52</reflink>]). While individuals with ASD experience difficulties in both social and motor engagement, there have been few studies that have examined the social and motor context of behavior to understand how they are related to the presentation of RRBs. Identifying the contextual factors that influence the expression of RRBs is therefore a useful endeavor. In addition, as Leekam et al. ([<reflink idref="bib52" id="ref7">52</reflink>]) argued recently, there is a need for additional research to clarify the relationship between RRBs and social and communication impairments because the co-occurrence of these behaviors is what distinguishes individuals with ASD from other diagnostic groups.</p> <hd id="AN0143136307-3">Research on Restricted and Repetitive Behavior (RRBs)</hd> <p>One framework for classifying RRBs focuses on the primary systems involved—vocal/verbal (repetitious words and phrases), non-verbal oral (repetitious noises that are not words or phrases), oral-motor (motor based stimulation of mouth and facial area), and motor-based (motions of extremities and body; Lee et al. [<reflink idref="bib50" id="ref8">50</reflink>]; Enloe and Rapp [<reflink idref="bib25" id="ref9">25</reflink>]). Another framework classifies RRBs as "higher order" (cognitive-based, focus on sameness, routines, etc.) an example of which may be reading the same three books before bedtime every night, and "lower order" (physically-based motoric and sensory manipulation of objects/bodies) RRBs, an example of which may be clapping or hand-flapping (i.e. Harrop et al. [<reflink idref="bib37" id="ref10">37</reflink>]). Motor-based RRBs and lower-order RRBs contain many of the same behaviors, while higher-order RRBs are more complex behaviors that rely on more cognitive processes, much the same as verbal-based RRBs.</p> <p>Some researchers have proposed that RRBs in individuals with ASD may be due to problems in selective attention (Ozonoff et al. [<reflink idref="bib66" id="ref11">66</reflink>]) or motor control (Ravizza et al. [<reflink idref="bib75" id="ref12">75</reflink>]). Other researchers have found that RRBs in ASD may function to provide stimulation (Factor et al. [<reflink idref="bib27" id="ref13">27</reflink>]), or create rhythmicity, which allows one to tune and adapt to the environment and is sometimes disrupted in individuals with ASD (Tordjman et al. [<reflink idref="bib86" id="ref14">86</reflink>]). Research on individuals with ASD and other developmental disabilities have further found that RRBs may be motivated by an effort to reduce anxiety (Joosten et al. [<reflink idref="bib43" id="ref15">43</reflink>]) or to obtain attention, attain an object, or escape an undesirable situation (Joosten et al. [<reflink idref="bib43" id="ref16">43</reflink>], [<reflink idref="bib44" id="ref17">44</reflink>]).</p> <p>As a consequence, understanding the functions of RRBs for the individual with ASD is essential in developing treatment plans (Cunningham and Schreibman [<reflink idref="bib20" id="ref18">20</reflink>]). There are some in the autism community who believe that RRBs should be seen as simply another form of communication, much the same as other types of nonverbal communication (Kim [<reflink idref="bib46" id="ref19">46</reflink>]). However, as a core diagnostic feature of ASD, it is widely recognized that RRBs can be problematic because they can interfere with learning and social interactions (Leekam et al. [<reflink idref="bib52" id="ref20">52</reflink>]). Rather than focusing on simply suppressing RRBs, awareness is growing that more nuanced approaches to individualized treatment which alter the environmental conditions that elicit or maintain RRBs may be a more effective means of decreasing RRBs (Joosten et al. [<reflink idref="bib44" id="ref21">44</reflink>]; Matson and Nebel-Schwalm [<reflink idref="bib58" id="ref22">58</reflink>]).</p> <p>The clinical significance of RRBs in ASD is reinforced by research that has found high rates of RRBs are associated with poor outcomes in the development of language, play, and imagination (Honey et al. [<reflink idref="bib38" id="ref23">38</reflink>]). Research has also found a relationship between RRBs and parental stress (Gabriels et al. [<reflink idref="bib33" id="ref24">33</reflink>]). Furthermore, the combination of RRBs with social and communication problems can lead to stigmatization by peers in both childhood and adulthood (Campbell [<reflink idref="bib16" id="ref25">16</reflink>]; Butler and Gillis [<reflink idref="bib15" id="ref26">15</reflink>]).</p> <p>Interestingly, some research emphasizes the importance of observable behavior on stigmatization. For example, Grossman ([<reflink idref="bib35" id="ref27">35</reflink>]) found that children with ASD were rated as significantly more socially awkward on the basis of brief, subtle nonverbal cues and Butler and Gillis ([<reflink idref="bib15" id="ref28">15</reflink>]) found that the social behaviors associated with ASD corresponded with significantly higher stigmatization. RRBs are one such type of observable social behavior that can contribute to stigmatization.</p> <p>One of the difficulties in fully understanding the role RRBs play in ASD lies in the fact that RRBs are not unique to ASD. RRBs appear in several other neurodevelopmental, psychiatric, and neurological disorders, such as Fragile X syndrome, obsessive compulsive disorder, and Tourette's disorder (Darrow et al. [<reflink idref="bib21" id="ref29">21</reflink>]; Jiujias et al. [<reflink idref="bib42" id="ref30">42</reflink>]; Lewis and Kim [<reflink idref="bib53" id="ref31">53</reflink>]) as well as in typical early development (Bishop et al. [<reflink idref="bib9" id="ref32">9</reflink>]; Joseph et al. [<reflink idref="bib45" id="ref33">45</reflink>]; Thelen [<reflink idref="bib83" id="ref34">83</reflink>], [<reflink idref="bib84" id="ref35">84</reflink>]). Complicating matters further, the RRBs often appear to be similar in presentation, making it difficult to distinguish between disorders, and even between young children with and without ASD (Bishop et al. [<reflink idref="bib10" id="ref36">10</reflink>]; Darrow et al. [<reflink idref="bib21" id="ref37">21</reflink>]; Harrop et al. [<reflink idref="bib37" id="ref38">37</reflink>]). In addition, there is a great deal of heterogeneity in the presentation of RRBs in ASD (Boyd et al. [<reflink idref="bib13" id="ref39">13</reflink>]). However, one distinguishing feature of RRBs for ASD is that both the frequency and severity of RRBs has been found to be elevated in ASD compared to other developmental disorders (Bodfish et al. [<reflink idref="bib12" id="ref40">12</reflink>]).</p> <hd id="AN0143136307-4">Social Communication and Interaction Skills in ASD</hd> <p>Two widely measured skills related to the social communication and interaction diagnostic criteria for ASD are theory of mind (ToM) and joint attention (JA). ToM is best described as the ability to understand that others may have concepts of reality that differ from our own (Baron-Cohen [<reflink idref="bib5" id="ref41">5</reflink>]), while JA is directing attention to an object or event with another person with the intention of sharing attention to the object in question (Tomasello [<reflink idref="bib85" id="ref42">85</reflink>]) and can be demonstrated, for example, by looking at another, or through pointing and other gestures indicating interest (Sodian and Kristen-Antonow [<reflink idref="bib80" id="ref43">80</reflink>]).</p> <p>A large number of studies indicate that the development of ToM is disrupted in individuals with ASD (Hoogenhout and Malcolm-Smith [<reflink idref="bib39" id="ref44">39</reflink>]; Colle et al. [<reflink idref="bib18" id="ref45">18</reflink>]; Peterson et al. [<reflink idref="bib70" id="ref46">70</reflink>]; Ronald et al. [<reflink idref="bib76" id="ref47">76</reflink>]; Senju et al. [<reflink idref="bib79" id="ref48">79</reflink>]). While some research questions whether performance on ToM tasks may be influenced by experimental context (e.g., Chevallier et al. [<reflink idref="bib17" id="ref49">17</reflink>]), performance in ToM tasks is a widely used social cognitive assessment to demonstrate difficulties in understanding the intentions of others.</p> <p>Similarly, research on joint attention, another skill assessed related to the social communication and interaction diagnostic criteria for ASD, has indicated that children with ASD perform poorly on joint attention tasks (Dawson et al. [<reflink idref="bib22" id="ref50">22</reflink>]; Mundy et al. [<reflink idref="bib63" id="ref51">63</reflink>]). Presently, most researchers agree with the findings of Krstovska-Guerrero and Jones ([<reflink idref="bib48" id="ref52">48</reflink>]), which indicate that the development of JA is disrupted in ASD, but disagree on the underlying mechanisms or developmental trajectory (Hurwitz and Watson [<reflink idref="bib41" id="ref53">41</reflink>]; Paparella et al. [<reflink idref="bib67" id="ref54">67</reflink>]).</p> <p>ToM and JA are widely used as outcome measures to test the effectiveness of interventions designed to increase social skill. For example, social skills training has been found to improve targeted social interaction skills from baseline in children with ASD (Malmberg et al. [<reflink idref="bib56" id="ref55">56</reflink>]), with some indicating improved pre-posttest measures on ToM (Bauminger-Zviely et al. [<reflink idref="bib8" id="ref56">8</reflink>]), and others specifically including JA in the skills package delivered (Radley et al. [<reflink idref="bib72" id="ref57">72</reflink>]). However, the skills tend not generalize to improving social interaction on the whole (Bauminger-Zviely et al. [<reflink idref="bib8" id="ref58">8</reflink>]; Radley et al. [<reflink idref="bib72" id="ref59">72</reflink>]).</p> <p>importance of social actions is also underscored by a noteworthy, if largely overlooked, characteristic of most social interactions—the coordination of people and their movements that occurs in social situations such as walking together. Often times, when two or more people interact with one another, their movements become synchronized with each other such that the timing of their movements is simultaneous or complementary. This phenomenon is called interpersonal or social synchrony (Schmidt and Fitzpatrick [<reflink idref="bib78" id="ref60">78</reflink>]). High levels of social synchrony have been shown to increase feelings of rapport (Miles et al. [<reflink idref="bib61" id="ref61">61</reflink>]) and affiliation (Hove and Risen [<reflink idref="bib40" id="ref62">40</reflink>]) between individuals, as well as increase group cooperation (Wiltermuth and Heath [<reflink idref="bib93" id="ref63">93</reflink>]). Interestingly, social synchrony has been found to be a marker of social competence, the ability to act appropriately and understand the mechanisms of a social interaction, and is suggested to develop in children between the ages of 9 and 12 months (Tunçgenç et al. [<reflink idref="bib88" id="ref64">88</reflink>]). Research also suggests that social synchrony breaks down in ASD. For example, synchronization of speech and gesture was found to be disrupted in ASD (de Marchena and Eigsti [<reflink idref="bib23" id="ref65">23</reflink>]), as was the timing of facial mimicry (Oberman et al. [<reflink idref="bib65" id="ref66">65</reflink>]). In addition, research has found that preschoolers (Marsh et al. [<reflink idref="bib57" id="ref67">57</reflink>]), school-age children (Fitzpatrick et al. [<reflink idref="bib29" id="ref68">29</reflink>], [<reflink idref="bib31" id="ref69">31</reflink>]), and adolescents (Fitzpatrick et al. [<reflink idref="bib30" id="ref70">30</reflink>]) with ASD had lower social motor synchronization abilities than controls. Furthermore, social synchrony was found to be related to ASD traits (Fitzpatrick et al. [<reflink idref="bib32" id="ref71">32</reflink>]; in press), suggesting these processes are not independent.</p> <hd id="AN0143136307-5">Relationship Between RRBs and Social, Motor, and Clinical Variables</hd> <p>While RRBs are thought to interfere with social interactions, the relationship between RRBs and social interaction is poorly understood. In fact, while a sizeable number of studies (Bahrami et al. [<reflink idref="bib4" id="ref72">4</reflink>]; Enloe and Rapp [<reflink idref="bib25" id="ref73">25</reflink>]; Joosten et al. [<reflink idref="bib44" id="ref74">44</reflink>]; Lee et al. [<reflink idref="bib50" id="ref75">50</reflink>]; Prupas and Reid [<reflink idref="bib71" id="ref76">71</reflink>]; Rosenthal-Malek and Mitchell [<reflink idref="bib77" id="ref77">77</reflink>], Tse et al. [<reflink idref="bib87" id="ref78">87</reflink>]), have focused on the need for understanding the motivations and contexts for behaviors before deciding whether to attempt to reduce or eliminate RRBs, very few studies simultaneously assessed social skill. A deeper focus on the conditions that influence and maintain the presentation of RRBs is needed to more fully understand the relationship of RRBs to social interaction in ASD.</p> <p>While there is little empirical evidence that the reduction of RRBs indirectly improves social interactions, both passive and active social engagement have been found to reduce RRB presentation (Enloe and Rapp [<reflink idref="bib25" id="ref79">25</reflink>]; Lee et al. [<reflink idref="bib50" id="ref80">50</reflink>]). However, results are largely limited to immediate engagement and rely on small samples. Likewise, gross motor interventions reduced subsequent RRB presentation in children with mild to moderate ASD (Bahrami et al. [<reflink idref="bib4" id="ref81">4</reflink>]; Prupas and Reid [<reflink idref="bib71" id="ref82">71</reflink>]; Rosenthal-Malek and Mitchell [<reflink idref="bib77" id="ref83">77</reflink>], Tse et al. [<reflink idref="bib87" id="ref84">87</reflink>]). Physical activity has also been found to reduce the prevalence of specific RRB subtypes, namely motor and self-injurious RRBs (Lang et al. [<reflink idref="bib49" id="ref85">49</reflink>]; Murray and Healy [<reflink idref="bib64" id="ref86">64</reflink>]). The importance of matching the physical activity to the biomechanics of the repetitive behavior has been suggested by Tse et al. ([<reflink idref="bib87" id="ref87">87</reflink>]), who provided evidence that physical activity that matched the biomechanics of a repetitive motor behavior was more effective at reducing that repetitive behavior but physical activity that did not match the biomechanics of the repetitive motor behavior did not. However, many of the studies regarding physical activity relied on small samples, had short-lived effects, and did not simultaneously measure social interaction abilities. In addition, the findings have been criticized due to potential positive bias (Sowa and Meulenbroek [<reflink idref="bib81" id="ref88">81</reflink>]) and selection, detection, and confound biases (Bremer et al. [<reflink idref="bib14" id="ref89">14</reflink>]).</p> <p>Research assessing the relationship between RRBs and other co-occurring clinical features suggests the relationship between RRBs and other behaviors characteristic of ASD is complex (Gabriels et al. [<reflink idref="bib33" id="ref90">33</reflink>]). For example, Memari et al. ([<reflink idref="bib60" id="ref91">60</reflink>]) reported lower levels of physical activity was associated with decreased cognitive flexibility and social skill and social skill was related to the ability to maintain a continuous bout of physical activity. Similarly, Ravizza et al. ([<reflink idref="bib75" id="ref92">75</reflink>]) reported a significant positive relationship between RRB prevalence and motor error in a rhythmic tapping task however found no relationship between RRB prevalence and measures of attention. Other research has found that nonverbal intelligence is related to RRBs in young children (Boyd et al. [<reflink idref="bib13" id="ref93">13</reflink>]) and school-age children (Gabriels et al. [<reflink idref="bib33" id="ref94">33</reflink>]), and lower-order RRBs were also negatively correlated with intelligence (Militerni et al. [<reflink idref="bib62" id="ref95">62</reflink>]; Turner [<reflink idref="bib89" id="ref96">89</reflink>]). In contrast, no relationship between RRBs and nonverbal mental age has been found in toddlers and preschoolers (Kim and Lord [<reflink idref="bib47" id="ref97">47</reflink>]) or school-age children (Joseph et al. [<reflink idref="bib45" id="ref98">45</reflink>]).</p> <hd id="AN0143136307-6">Research Questions</hd> <p>While the importance of the understanding the context of RRBs has been clearly articulated (Joosten et al. [<reflink idref="bib43" id="ref99">43</reflink>], [<reflink idref="bib44" id="ref100">44</reflink>]; Matson and Nebel-Schwalm [<reflink idref="bib58" id="ref101">58</reflink>]), a fuller consideration of the context in which RRBs are elicited and maintained is still needed. In addition, RRBs very often occur during social and motor interactions with other people but RRBs displayed in public during such interactions have not been systematically evaluated. Futhermore, these exchanges are dynamic, as they unfold over time and require on-going adjustment of behavior in real time. Research, such as functional behavior assessment has illustrated the importance of evaluating what happens immediately before and after RRBs are displayed (McGill et al. [<reflink idref="bib59" id="ref102">59</reflink>]), but little research has focused on the dynamic unfolding of RRBs during structured interactions. Here, we take a unique approach by studying the production of RRBs in an ongoing social and motor context rather than applying a social or motor intervention and subsequently evaluating its effect on RRB production. In addition to a focus on the environmental context, this study also evaluated the relationship between RRBs and a variety of ASD traits, some of which have been the subject of very little research.</p> <p>In particular, we explored whether the level of social and motor engagement corresponded to the frequency of RRBs during structured tasks. That is, do low levels of engagement co-occur with higher levels of RRBs, does one form of engagement have a greater correspondence with RRB frequency than another, and is there a relationship between RRB frequency and social traits? A conceptual understanding of repetitive behaviors outlined by Rapp et al. ([<reflink idref="bib73" id="ref103">73</reflink>]) would predict a reduction in motor RRBs when motor engagement is high and a reduction in verbal RRBs when social engagement is high. They propose that RRBs change as a result of either a direct effect (performing an alternate behavior with a similar sensory consequence) or an indirect effect (performing a behavior that competes with performing the RRB). In contrast, one could alternatively predict that tasks that involve high task demands of motor or social activity may increase anxiety and be associated with increased RRBs. This research tests these alternative explanations.</p> <p>Furthermore, we evaluated the relationship between presentation of RRBs and measures of ASD traits (cognitive ability, social cognition, social action, social synchrony, and ASD severity). As Leekam et al. ([<reflink idref="bib52" id="ref104">52</reflink>]) argued, more research is needed to better understand the relationship between repetitive behaviors and social traits and our research adds to that literature. A lack of significant relationships between RRBs and social and cognitive measures would be predicted if RRBs and social and cognitive functions have independent underlying processes and significant relationships between measures would be predicted if RRBs and social communication and interaction skill either share underlying processes or if a disruption in one leads to a disruption in another. This research will evaluate these contrasting predictions. Due to the possible mediating role of nonverbal intelligence, we also explored the relationship between RRB prevalence and ASD traits after controlling for nonverbal intelligence.</p> <hd id="AN0143136307-7">Method</hd> <p></p> <hd id="AN0143136307-8">Participants</hd> <p>Videos of 103 participants engaging in a series of tasks were collected as part of a larger study and six were excluded from the analysis because of technical problems recording the session. Thus, data from 97 children (77 males, 20 females) are reported here. There were 50 children in the ASD group (43 males, 7 females) and 47 children in the control group (34 males, 13 females). The mean age of all participants was 7.94 years, the mean age of the ASD group was 8.02 years, and the mean age of the control group was 7.85 years. Seventy-six participants were white, 12 black or African-American, 2 Asian, and 7 multiracial. A breakdown of numbers of participants by age, gender, and diagnosis can be found in Table 1.</p> <p>Age and gender distribution of participants</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" colspan="2"><p>Gender</p></th><th align="left" colspan="5"><p>Age (in years)</p></th></tr><tr><th align="left"><p>Male</p></th><th align="left"><p>Female</p></th><th align="left"><p>6</p></th><th align="left"><p>7</p></th><th align="left"><p>8</p></th><th align="left"><p>9</p></th><th align="left"><p>10</p></th></tr></thead><tbody><tr><td align="left"><p>ASD</p></td><td align="left"><p>43</p></td><td align="left"><p>7</p></td><td align="left"><p>10</p></td><td align="left"><p>10</p></td><td align="left"><p>9</p></td><td align="left"><p>11</p></td><td align="left"><p>10</p></td></tr><tr><td align="left" colspan="8"><p>Ethnicity</p></td></tr><tr><td align="left"><p> White</p></td><td align="left"><p>37</p></td><td align="left"><p>5</p></td><td align="left"><p>10</p></td><td align="left"><p>8</p></td><td align="left"><p>6</p></td><td align="left"><p>9</p></td><td align="left"><p>9</p></td></tr><tr><td align="left"><p> African American</p></td><td align="left"><p>3</p></td><td align="left"><p>1</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>0</p></td><td align="left"><p>2</p></td><td align="left"><p>1</p></td></tr><tr><td align="left"><p> Multi-racial</p></td><td align="left"><p>3</p></td><td align="left"><p>0</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>2</p></td><td align="left"><p>0</p></td><td align="left"><p>0</p></td></tr><tr><td align="left"><p> Asian</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>0</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>0</p></td><td align="left"><p>0</p></td></tr><tr><td align="left"><p> Control</p></td><td align="left"><p>34</p></td><td align="left"><p>13</p></td><td align="left"><p>12</p></td><td align="left"><p>10</p></td><td align="left"><p>7</p></td><td align="left"><p>8</p></td><td align="left"><p>10</p></td></tr><tr><td align="left" colspan="8"><p>Ethnicity</p></td></tr><tr><td align="left"><p> White</p></td><td align="left"><p>24</p></td><td align="left"><p>10</p></td><td align="left"><p>8</p></td><td align="left"><p>7</p></td><td align="left"><p>6</p></td><td align="left"><p>4</p></td><td align="left"><p>9</p></td></tr><tr><td align="left"><p> African American</p></td><td align="left"><p>6</p></td><td align="left"><p>2</p></td><td align="left"><p>3</p></td><td align="left"><p>2</p></td><td align="left"><p>0</p></td><td align="left"><p>2</p></td><td align="left"><p>1</p></td></tr><tr><td align="left"><p> Multi-racial</p></td><td align="left"><p>4</p></td><td align="left"><p>0</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>1</p></td><td align="left"><p>2</p></td><td align="left"><p>0</p></td></tr><tr><td align="left"><p> Asian</p></td><td align="left"><p>0</p></td><td align="left"><p>1</p></td><td align="left"><p>1</p></td><td align="left"><p>0</p></td><td align="left"><p>0</p></td><td align="left"><p>0</p></td><td align="left"><p>0</p></td></tr></tbody></table> </ephtml> </p> <p>The participants with ASD had previously been diagnosed by a licensed clinical psychologist or medical doctor based on DSM-IV_TR criteria (APA [<reflink idref="bib2" id="ref105">2</reflink>]) and diagnosis was confirmed using the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2, Lord et al. [<reflink idref="bib54" id="ref106">54</reflink>]). The ADOS scores are reported in Table 2.</p> <p>Mean clinical and social measures</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" colspan="2"><p>ASD (n = 50)</p></th><th align="left" colspan="2"><p>Typical (n = 47)</p></th></tr><tr><th align="left"><p>Mean</p></th><th align="left"><p>SD</p></th><th align="left"><p>Mean</p></th><th align="left"><p>SD</p></th></tr></thead><tbody><tr><td align="left"><p>CA (years)</p></td><td char="." align="char"><p>8.02</p></td><td char="." align="char"><p>1.44</p></td><td char="." align="char"><p>7.85</p></td><td char="." align="char"><p>1.49</p></td></tr><tr><td align="left"><p>CA (months)</p></td><td char="." align="char"><p>102.02</p></td><td char="." align="char"><p>17.17</p></td><td char="." align="char"><p>99.85</p></td><td char="." align="char"><p>17.83</p></td></tr><tr><td align="left"><p>DAS nonverbal mental age<sup>a</sup></p></td><td char="." align="char"><p>100.26</p></td><td char="." align="char"><p>25.79</p></td><td char="." align="char"><p>114.39</p></td><td char="." align="char"><p>30.95</p></td></tr><tr><td align="left"><p>DAS verbal mental age<sup>a</sup></p></td><td char="." align="char"><p>96.72</p></td><td char="." align="char"><p>25.22</p></td><td char="." align="char"><p>107.66</p></td><td char="." align="char"><p>30.00</p></td></tr><tr><td align="left" colspan="5"><p>ADOS</p></td></tr><tr><td align="left"><p> SA</p></td><td char="." align="char"><p>8.90</p></td><td char="." align="char"><p>4.04</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> RRB</p></td><td char="." align="char"><p>2.77</p></td><td char="." align="char"><p>1.82</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Overall</p></td><td char="." align="char"><p>11.67</p></td><td char="." align="char"><p>4.90</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Autism severity (composite)</p></td><td char="." align="char"><p>6.60</p></td><td char="." align="char"><p>2.20</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>RRB Parent Report (RBS-R)<sup>a</sup></p></td><td char="." align="char"><p>32.06</p></td><td char="." align="char"><p>22.55</p></td><td char="." align="char"><p>2.98</p></td><td char="." align="char"><p>5.16</p></td></tr><tr><td align="left"><p>Social problems (SRS)<sup>a</sup></p></td><td char="." align="char"><p>80.80</p></td><td char="." align="char"><p>20.95</p></td><td char="." align="char"><p>45.77</p></td><td char="." align="char"><p>7.09</p></td></tr><tr><td align="left"><p>Attention problems (CBCL_ADHD)<sup>a</sup></p></td><td char="." align="char"><p>63.82</p></td><td char="." align="char"><p>8.66</p></td><td char="." align="char"><p>51.64</p></td><td char="." align="char"><p>3.26</p></td></tr><tr><td align="left"><p>ToM<sup>a</sup></p></td><td char="." align="char"><p>3.01</p></td><td char="." align="char"><p>0.88</p></td><td char="." align="char"><p>3.54</p></td><td char="." align="char"><p>0.67</p></td></tr><tr><td align="left"><p>IJA</p></td><td char="." align="char"><p>0.92</p></td><td char="." align="char"><p>0.14</p></td><td char="." align="char"><p>0.96</p></td><td char="." align="char"><p>0.10</p></td></tr><tr><td align="left"><p>RJA<sup>a</sup></p></td><td char="." align="char"><p>0.67</p></td><td char="." align="char"><p>0.28</p></td><td char="." align="char"><p>0.89</p></td><td char="." align="char"><p>0.22</p></td></tr><tr><td align="left"><p>Imitation/synchrony coherence<sup>a</sup></p></td><td char="." align="char"><p>0.56</p></td><td char="." align="char"><p>0.18</p></td><td char="." align="char"><p>0.71</p></td><td char="." align="char"><p>0.16</p></td></tr><tr><td align="left"><p>Handclapping coherence<sup>a</sup></p></td><td char="." align="char"><p>0.85</p></td><td char="." align="char"><p>0.13</p></td><td char="." align="char"><p>0.93</p></td><td char="." align="char"><p>0.05</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>CBCL-ADHD</emph> Achenbach Child Behavior Checklist ADHD subscale, <emph>SRS</emph> Social Responsiveness Scale, <emph>RBS-R</emph> Repetitive Behavior Scale-Revised, <emph>ADOS</emph> Autism Diagnostic Observation Schedule <sups>a</sups>A significant group difference has previously been reported for this measure (Fitzpatrick et al. 2017[<reflink idref="bib31" id="ref107">31</reflink>], [<reflink idref="bib32" id="ref108">32</reflink>])</p> <p>As this study included completing simple motor tasks for a short period of time (10–15 min) a number of exclusion criteria utilized in the larger study (Fitzpatrick et al. [<reflink idref="bib31" id="ref109">31</reflink>], [<reflink idref="bib32" id="ref110">32</reflink>]) applied to participants of this study as well. These criteria excluded children lacking the ability to complete such motor tasks without impairment, as well as children who had a verbal age of less than 24 months. Additionally, participants were excluded if they had a medical condition that prohibited valid administration of tasks, or if they were unable to walk independently. Participants were screened for additional disorders and medical diagnoses, and those with genetic (e.g. Fragile X, Down syndrome), non-ASD developmental disorders (e.g. intellectual disability disorder) or clinical diagnoses (e.g. specific learning disorders) were excluded. Finally, participants who did not identify English as a primary language or with primary caregivers who were unaware of the developmental history of the participants (e.g. foster or some adopted children) were also excluded from the study.</p> <p>The project was approved by the Cincinnati Children's Hospital Medical Center's (CCHMC) Institutional Review Board. Participants were recruited from CCHMC and local communities through print advertising, a recruitment brochure, email, social media, and community events.</p> <hd id="AN0143136307-9">Experimental Tasks</hd> <p>The dataset used here was part of a larger project, in which participants performed a large range of motor, social, and cognitive tasks. Here, we selected four tasks from that dataset that best represented all combinations of high and low levels of social and motor engagement. We conducted data coding of RRBs during these tasks. These tasks occurred in the same order for all participants and different tasks had inherently different timescales for their natural unfolding and completion, with some requiring a longer timescale to complete and others requiring a shorter timescale. Since the tasks were not time limited, participants began new tasks after varying times of having been in the experimental session.</p> <hd id="AN0143136307-10">Low Social/Low Motor Engagement: Box Sorting Affordance Task</hd> <p>As seen in Fig. 1a, participants were instructed to pick up a box with either one or two hands, depending on what was most comfortable, and place the box on a large X on a wooden turntable. Each box was presented to the participant from behind a small black curtain, and once each box was placed on the turntable, it was spun until it went behind another black curtain. Since the experimenters were instructed to say as little as possible to each participant, this task had low social engagement. Additionally, as the task required little movement except for small back and forth motions picking up blocks, it had low motor engagement. This task lasted between 10 and 15 min.</p> <p>Graph: Fig. 1 a Low social/ low motor-box sorting affordance task. b High social/ high motor-interpersonal handclapping task. c High social/ low motor-interactive cooperation task. d Low social/ high motor-social imitation and synchrony task</p> <hd id="AN0143136307-11">High Social/High Motor Engagement: Interpersonal Hand Clapping Task</hd> <p>In this task, depicted in Fig. 1b, participants completed a hand clapping task with the experimenter. In this version of the children's game patacake, the participants and experimenter sat facing each other and both clapped their own hands together and then clapped hands with each other in rhythm with the experimenter's singing. This task was chosen because it involved high levels of social engagement as the experimenter and child were looking at each other throughout the task, and high motor engagement since they were physically moving their hands and arms to perform the clapping during the entire task. This task was performed twice and the total time spent lasted between 1.5 and 2 min.</p> <hd id="AN0143136307-12">High Social/Low Motor Engagement: Interactive Cooperation Task</hd> <p>This task, as seen in Fig. 1c, consisted of the experimenter and the participant engaging in a cooperation task where they played the double-tube task (Warneken et al. [<reflink idref="bib90" id="ref111">90</reflink>]). In the first part of the task, the experimenter dropped plastic pieces down the tubes for the participant to catch in a cup, and in the second part, they switched roles and the participant dropped the pieces while the experimenter caught them. This task was chosen for its high levels of social engagement but lower levels of motor engagement. Since the experimenter kept the participant engaged throughout the task with phrases such as "Got it!" or "Nice catch!" and it was a joint, turn-taking task, the levels of social engagement were high. However, since the motor requirements only consisted of holding a cup at the bottom of a tube or letting go of a plastic piece at the top of one, motor engagement was low. This task lasted between 4 and 5 min.</p> <hd id="AN0143136307-13">Low Social/High Motor Engagement: Social Imitation/Synchrony Task</hd> <p>This task, as seen in Fig. 1d, consisted of the experimenter and participant engaging in a series of tapping tasks (Fitzpatrick et al. [<reflink idref="bib31" id="ref112">31</reflink>]). In the imitation version, the experimenter tapped a pattern with both a small hammer and his finger on the drums and then motioned for the participant to follow suit. In the synchrony version, the experimenter demonstrated the pattern and then the child completed it with the experimenter. The participant and experimenter were not facing each other, so the participant did not maintain eye contact with the experimenter during the task, indicating low levels of social engagement. However, motor engagement was high as participant and experimenter spent a great deal of time completing tapping tasks, which involved motor-based behavior. This task lasted between 5 and 10 min.</p> <hd id="AN0143136307-14">Social and Clinical Measures</hd> <p>We used five measures of social development (theory of mind (ToM), initiating joint attention (IJA), responding to joint attention (RA), and synchrony of interpersonal clapping, synchrony of imitation/synchrony task) and five clinical measures to (confirm diagnosis and assess symptoms) from the larger study. The purpose of these measures is to evaluate how they relate to RRB presentation. Group differences for these variables have been previously reported (Fitzpatrick et al. [<reflink idref="bib31" id="ref113">31</reflink>], [<reflink idref="bib32" id="ref114">32</reflink>]) and those measures with significant group differences are noted in Table 2.</p> <hd id="AN0143136307-15">Theory of Mind (ToM)</hd> <p>The four theory of mind (ToM) tasks from the larger study were used as a measure of understanding intentionality (see Fitzpatrick et al. ([<reflink idref="bib31" id="ref115">31</reflink>], [<reflink idref="bib32" id="ref116">32</reflink>]) for a complete description of the tasks). There were three verbal and one non-verbal task. The three verbal tasks were as follows. In the "Sally Ann" Verbal Task (Baron-Cohen et al. [<reflink idref="bib7" id="ref117">7</reflink>]), participants watched a scene acted out with puppets in which one puppet moved an object, unbeknownst to the other. The participant was asked a false belief, memory, and reality question to assess understanding of the perspective of each puppet. In the "Smarties" task (Perner et al. [<reflink idref="bib68" id="ref118">68</reflink>]; Luckett et al. [<reflink idref="bib55" id="ref119">55</reflink>]) participants were shown a familiar candy box containing an unexpected item. The participant was then asked a false belief, reality, memory, and justification question. In the Contents False Belief task (Wellman and Liu [<reflink idref="bib92" id="ref120">92</reflink>]) participants were presented a labeled box with an unexpected item inside, and were then asked what they thought was inside the box and what others would think was inside the box once they view the contents. The nonverbal task was the choose-a-drawing task (Peterson [<reflink idref="bib69" id="ref121">69</reflink>]) where participants indicated what he/she believed to be in a box, as well as what others would believe to be in it by pointing to a picture. The fourth author completed the tasks with the child during the experimental session and undergraduate research assistants blind to the study coded the data. The child received one point for each correct answer (out of a possible 11 points). Due to the lengthy experimental procedure in the original study, the experimenter did not always ask each child all 11 questions. Therefore, a mean was calculated for each of the four tasks (number correct/total number of questions for each task) and the sum of the mean for each ToM task was calculated and used as the ToM total score (out of a possible 4 points) in the data analysis. Mean ToM scores are reported in Table 2.</p> <hd id="AN0143136307-16">Joint Attention</hd> <p>The gaze-monitoring task (Leekam et al. [<reflink idref="bib51" id="ref122">51</reflink>]; Warreyn et al. [<reflink idref="bib91" id="ref123">91</reflink>]) from the larger study was used as a measure of responding to joint attention (RJA). The fourth author completed the tasks with the child during the experimental session and undergraduate research assistants blind to the study coded the data. The child received one point for each correct fixation on the picture or object the examiner looked at, for a total of four possible points. Initiating joint attention (IJA) was assessed using the active joint attention task (eye contact in ambiguous situations) developed by Warreyn et al. ([<reflink idref="bib91" id="ref124">91</reflink>]), in which the experimenter covers the child's hands while he/she is playing with a toy (blocking task), or offers the child a toy but withdraws before the child can take it (teasing task), to see if the child will make eye contact with the experimenter. There were two trials of the blocking task and two trials of the teasing task. The child received 1 point for each trial in which eye contact was made, for a maximum of 4 points. Mean RJA and IJA scores are reported in Table 2.</p> <hd id="AN0143136307-17">Social Synchrony</hd> <p>In the original study, social synchronization was measured during the interpersonal handclapping task and the social imitation and synchrony task. Small, light-weight wireless motion tracking sensors (Polhemus Liberty Latus, Polhemus Corporation, Colchester, VT) were attached to the wrists of the child and experimenter using comfortable nylon sleeves in order to obtain high resolution time series recordings of the child and experimenter's movements during the tasks. The fourth author completed the tasks with the child during the experimental session and the third author calculated the synchronization measures. Weighted coherence was calculated from the time series movements. Weighted coherence is a measure of the coordination that occurred between the child and experimenter by estimating the correlation between their movements. A coherence of 1 reflects perfect correlation of the movements (absolute synchrony) and 0 reflects no correlation (no synchrony). Interpersonal hand-clapping and imitation/synchrony task coherence scores are reported in Table 2.</p> <hd id="AN0143136307-18">Clinical Measures</hd> <p>In the original study, participants were also assessed with a battery of clinical measures to confirm diagnosis and assess symptoms (see Fitzpatrick et al. ([<reflink idref="bib31" id="ref125">31</reflink>], [<reflink idref="bib32" id="ref126">32</reflink>]) for more details). Two clinical psychologists who were part of the larger study conducted the assessments. Here, we used the Autism Diagnostic and Observation Schedule-Composite score (ADOS-Composite; Lord et al. [<reflink idref="bib54" id="ref127">54</reflink>]) to confirm diagnosis. In addition, the CBCL-ADHD score (Achenbach and Edelbrock [<reflink idref="bib1" id="ref128">1</reflink>]) was used as a measure of attention problems, the SRS score (Constantino and Gruber [<reflink idref="bib19" id="ref129">19</reflink>]) was used as a measure of social problems in natural social settings, and Repetitive Behaviors Scale-Revised (RBS-R; Bodfish et al. [<reflink idref="bib11" id="ref130">11</reflink>]) was used as a parent-report measure of repetitive behaviors, and the Differential Abilities Scales, 2nd Edition (DAS-II; Elliot [<reflink idref="bib24" id="ref131">24</reflink>]) was used as a measure of cognitive ability. The general conceptual ability score (GCA) measured verbal ability and the special nonverbal composite score (SNC) measured nonverbal ability. Mean scores for all measures are reported in Table 2.</p> <hd id="AN0143136307-19">Data Coding and Analysis</hd> <p>The video segments from the four engagement tasks (low social/low motor, low social/high motor, high social/low motor, high social/high motor) were coded using Interact software (Mangold International) to record the duration of each task and the observed frequency of RRBs was coded. The first author conducted the primary coding of the videos and was blind to diagnostic group during coding. A behavior was coded as an RRB only if it was repeated more than once out of context. Four different types of RRBs were coded: vocal/verbal, non-verbal oral, oral-motor, and motor-based. The operational definitions of these four RRB types were adapted from Lee et al. ([<reflink idref="bib50" id="ref132">50</reflink>]) and Enloe and Rapp ([<reflink idref="bib25" id="ref133">25</reflink>]) and are explained in Table 3.</p> <p>RRB types measured for frequency</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>RRB type</p></th><th align="left"><p>Description</p></th><th align="left"><p>Examples of behavior</p></th></tr></thead><tbody><tr><td align="left"><p>Motor based</p></td><td align="left"><p>Any movement of the body or extremities</p></td><td align="left"><p>Rocking, hand flapping, standing up frequently, finger twisting, laying head on table, manipulating objects walking around room</p></td></tr><tr><td align="left"><p>Non-verbal oral</p></td><td align="left"><p>Noises from throat and/or mouth that are not spoken words or utterances</p></td><td align="left"><p>Teeth chattering, laughing, giggling with no apparent cause, tongue clicking, undecipherable whispering, meaningless sounds</p></td></tr><tr><td align="left"><p>Oral-motor</p></td><td align="left"><p>Motor activity focusing on mouth, cheeks, chin, facial region</p></td><td align="left"><p>Touching any part of face repetitively, licking body parts, biting nails, putting objects against mouth/face</p></td></tr><tr><td align="left"><p>Vocal/verbal</p></td><td align="left"><p>Words or utterances that were frequently repeated</p></td><td align="left"><p>Discussing topics out of context, repeating words or phrases</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0143136307-20">Inter-Rater Reliability</hd> <p>A second rater, blind to diagnostic group while coding, independently coded 30 randomly selected videos (30% of the sample). Several training videos were used to teach the second coder to recognize and label the RRBs. After demonstrating competency with the training videos, the second rater coded the 30 reliability videos. Inter-rater reliability for frequency coding was very high [<emph>r</emph> = 0.98 (<emph>p</emph> <.001)].</p> <hd id="AN0143136307-21">Analysis</hd> <p>Since not all experimental tasks were identical in length, the total number of RRBs was divided by the task length and RRBs per second served as one of the primary dependent measures. In addition, the number of RRBs performed during the first 60 s of each task was also calculated as an additional dependent measure. Sixty seconds was chosen to equate task length and because all participants performed each task for at least that long.</p> <p>Both RRBs per second and number of RRBs in the first 60 s were analyzed using 2 × 4 × 4 mixed ANOVAs in order to compare the number of RRBs displayed in the various social and motor engagement conditions. Diagnosis (ASD or control) was a between-subjects variable and type of social and motor engagement (high–low, high–high, low–low, or low–high) and RRB type (motor-based, non-verbal oral, oral-motor, and vocal/verbal) were within subject variables. Additionally, Pearson correlations were conducted to explore the relationship between RRBs per second and RRBs during the first 60 s and nonverbal intelligence, verbal intelligence, ToM, IJA, RJA, attention problems (CBCL-ADHD), social problems (SRS), self-report RRBs (RBS-R), autism severity (ADOS) and social synchrony (imitation/synchrony coherence, handclapping coherence). Correlations were calculated separately for participants with ASD and controls and follow-up partial correlations were calculated for the ASD group to control for nonverbal intelligence.</p> <hd id="AN0143136307-22">Results</hd> <p></p> <hd id="AN0143136307-23">RRBs per Second</hd> <p>A mixed 2 × 4 × 4 ANOVA with the RRBs per second as the dependent variable, and the diagnosis of participants, type of social and motor engagement, and the type of RRB as the independent variables revealed a statistically significant main effect for diagnosis, [<emph>F</emph> (<reflink idref="bib1" id="ref134">1</reflink>,<reflink idref="bib89" id="ref135">89</reflink>) = 49.36, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.36, <emph>M</emph> = 0.017 and 0.003 for ASD and control, respectively] with a large effect size. The main effects for engagement condition, [<emph>F</emph> (<reflink idref="bib3" id="ref136">3</reflink>,<reflink idref="bib267" id="ref137">267</reflink>) = 44.24, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.33, <emph>M</emph><subs>low−social–low−motor</subs> = 0.018, <emph>M</emph><subs>low−social–high−motor</subs> = 0.006, <emph>M</emph><subs>high−social–low−motor</subs> = 0.011, <emph>M</emph><subs>high-social–high−motor</subs> =.0.005] and type of RRB, [<emph>F</emph> (<reflink idref="bib3" id="ref138">3</reflink>,<reflink idref="bib267" id="ref139">267</reflink>) = 29.83, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.25, <emph>M</emph><subs>motor</subs> = 0.019, <emph>M</emph><subs>non−verbal</subs> = 0.006, <emph>M</emph><subs>oral−motor</subs> = 0.003, and <emph>M</emph><subs>vocal/verbal</subs> = 0.012] were also statistically significant, with large effect sizes. The two way interactions between engagement condition and diagnosis [<emph>F</emph> (<reflink idref="bib3" id="ref140">3</reflink>,<reflink idref="bib267" id="ref141">267</reflink>) = 14.66, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.14)], RRB type and diagnosis [<emph>F</emph> (<reflink idref="bib3" id="ref142">3</reflink>,<reflink idref="bib267" id="ref143">267</reflink>) = 10.00, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.10], and engagement condition and RRB type [<emph>F</emph> (<reflink idref="bib9" id="ref144">9</reflink>,<reflink idref="bib801" id="ref145">801</reflink>) = 7.85, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.08], were all statistically significant with moderate and small effect sizes, respectively. Finally, the three way interaction between engagement condition, RRB type, and diagnosis [<emph>F</emph> (<reflink idref="bib9" id="ref146">9</reflink>,<reflink idref="bib801" id="ref147">801</reflink>) = 2.24, <emph>p</emph> =.02, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.03], was also statistically significant, with a small effect size. As seen in Fig. 2, participants with ASD had significantly more RRBs per second (top panel) than control participants (bottom panel), motor and verbal RRBs were the most common, and RRBs varied based on engagement condition for participants with ASD but not controls. For participants with ASD, motor and verbal RRBs were highest when both social and motor engagement were low; motor and verbal RRBs were lowest for the two high motor conditions.</p> <p>Graph: Fig. 2 Participants with ASD had significantly more RRBs per second (top panel) than control participants (bottom panel), motor and verbal RRBs were the most common, and RRBs varied based on engagement condition for participants with ASD but not controls. For participants with ASD, motor and verbal RRBs were highest when both social and motor engagement were low and motor and verbal RRBs were lowest for the two high motor conditions</p> <hd id="AN0143136307-24">RRBs During First 60 s</hd> <p>A mixed 2 × 4 × 4 ANOVA with the RRBs during the first 60 s as the dependent variable, and the diagnosis of participants, type of social and motor engagement, and the type of RRB as the independent variables revealed a statistically significant main effect for diagnosis, [<emph>F</emph> (<reflink idref="bib1" id="ref148">1</reflink>,<reflink idref="bib90" id="ref149">90</reflink>) = 43.01, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.32, <emph>M</emph> = 0.78] and 0.11 for ASD and control, respectively) with a large effect size. The main effects for engagement condition, [<emph>F</emph> (<reflink idref="bib3" id="ref150">3</reflink>,<reflink idref="bib270" id="ref151">270</reflink>) = 2.61, <emph>p</emph> =.05, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.03, <emph>M</emph><subs>low-social–low-motor</subs> = 0.47, <emph>M</emph><subs>low-social–high-motor</subs> = 0.51, <emph>M</emph><subs>high-social–low-motor</subs> = 0.48, <emph>M</emph><subs>high-social–high-motor</subs> =.0.31] and type of RRB, [<emph>F</emph> (<reflink idref="bib3" id="ref152">3</reflink>,<reflink idref="bib270" id="ref153">270</reflink>) = 20.20, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.28, <emph>M</emph><subs>motor</subs> = 0.019, <emph>M</emph><subs>non-verbal</subs> = 0.006, <emph>M</emph><subs>oral-motor</subs> = 0.003, and <emph>M</emph><subs>vocal/verbal</subs> = 0.012] were also statistically significant, with small and large effect sizes, respectively. The two way interactions between RRB type and diagnosis [<emph>F</emph> (<reflink idref="bib3" id="ref154">3</reflink>,<reflink idref="bib270" id="ref155">270</reflink>) = 10.09, <emph>p</emph> <.001, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.10] and engagement condition and RRB type [<emph>F</emph> (<reflink idref="bib9" id="ref156">9</reflink>,<reflink idref="bib810" id="ref157">810</reflink>) = 2.96, <emph>p</emph> =.002, <emph>η</emph><subs><emph>p</emph></subs><sups><emph>2</emph></sups> =.03], were statistically significant with small effect sizes. Finally, neither the two-way interaction between engagement condition and diagnosis nor the three-way interaction between engagement condition, behavior, and diagnosis were statistically significant. As seen in Fig. 3, participants with ASD had significantly more RRBs during the first 60 s (top panel) than control participants (bottom panel), motor and verbal RRBs were the most common, and RRBs varied based on engagement condition for participants with ASD but not controls. For participants with ASD, motor and verbal RRBs were highest when both social and motor engagement were low and motor and verbal RRBs were lowest for the two high social conditions.</p> <p>Graph: Fig. 3 Participants with ASD engaged in more RRBs during the first 60 s of the task (top panel) than control participants (bottom panel) and RRBs varied based on engagement condition for participants with ASD but not controls. For participants with ASD, motor and vocal RRBs were highest for the two low social conditions and lowest for the two high social conditions</p> <hd id="AN0143136307-25">Correlations Between Clinical and Social Measures and RRBs</hd> <p>To examine the correlation between RRBs and social and clinical measures, we calculated two composite scores for all four types of RRBs combined that consisted of (a) the mean RRB per second; and (b) mean RRBs during the first 60 s. Correlations were calculated separately for the ASD and control groups to evaluate whether the relationship between RRBs and social traits was different for the two groups. The correlations for participants with ASD are found in Table 4. For both dependent measures (RRB per second and RRBs during the first 60 s) there were statistically significant positive correlations with social problems (SRS) and autism severity (ADOS-Composite) and statistically significant negative correlations with social synchrony as measured in both the imitation/synchrony battery and interpersonal hand-clapping. In addition, there were statistically significant negative correlations between RRB per second and age, nonverbal mental age, verbal mental age, and ToM. Significant positive correlations were found between RRB during the first 60 s and attention problems (CBCL-ADHD) and RRB self-report (RBS-R). There were no statistically significant correlations between the RRB per second or RRB during the first 60 s and initiating joint attention or responding to joint attention. For the control group, as seen in Table 5, only one significant correlation was found, and that was between RRB frequency during first 60 s and RJA (<emph>r</emph> = −.3, <emph>p</emph> =.04).</p> <p>Correlations between RRB frequency and clinical and social cognitive measures for participants with ASD</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2"><p>Variable</p></th><th align="left" colspan="2"><p>RRB frequency ratio</p></th><th align="left" colspan="2"><p>RRB first 60 s</p></th></tr><tr><th align="left"><p><italic>r</italic></p></th><th align="left"><p><italic>p</italic></p></th><th align="left"><p><italic>r</italic></p></th><th align="left"><p><italic>p</italic></p></th></tr></thead><tbody><tr><td align="left"><p>Age</p></td><td char="." align="char"><p>− 0.33*</p></td><td char="." align="char"><p>0.03</p></td><td char="." align="char"><p>− 0.04</p></td><td align="left"><p>0.78</p></td></tr><tr><td align="left"><p>Nonverbal mental age</p></td><td char="." align="char"><p>− 0.33*</p></td><td char="." align="char"><p>0.03</p></td><td char="." align="char"><p>− 0.25</p></td><td align="left"><p>0.08</p></td></tr><tr><td align="left"><p>Verbal mental age</p></td><td char="." align="char"><p>− 0.34*</p></td><td char="." align="char"><p>0.02</p></td><td char="." align="char"><p>− 0.14</p></td><td align="left"><p>0.35</p></td></tr><tr><td align="left"><p>Attention problems (CBCL-ADHD)</p></td><td char="." align="char"><p>0.23</p></td><td char="." align="char"><p>0.14</p></td><td char="." align="char"><p>0.31*</p></td><td align="left"><p>0.03</p></td></tr><tr><td align="left"><p>Social problems (SRS)</p></td><td char="." align="char"><p>0.31*</p></td><td char="." align="char"><p>0.04</p></td><td char="." align="char"><p>0.28*</p></td><td align="left"><p>0.05</p></td></tr><tr><td align="left"><p>RRB Self Report (RBS-R)</p></td><td char="." align="char"><p>0.28</p></td><td char="." align="char"><p>0.07</p></td><td char="." align="char"><p>0.34*</p></td><td align="left"><p>0.02</p></td></tr><tr><td align="left"><p>Autism Severity (ADOS Composite)</p></td><td char="." align="char"><p>0.36*</p></td><td char="." align="char"><p>0.02</p></td><td char="." align="char"><p>0.35*</p></td><td align="left"><p>0.02</p></td></tr><tr><td align="left"><p>ToM</p></td><td char="." align="char"><p>− 0.37*</p></td><td char="." align="char"><p>0.02</p></td><td char="." align="char"><p>− 0.26</p></td><td align="left"><p>0.08</p></td></tr><tr><td align="left"><p>IJA</p></td><td char="." align="char"><p>− 0.17</p></td><td char="." align="char"><p>0.28</p></td><td char="." align="char"><p>0.00</p></td><td align="left"><p>0.99</p></td></tr><tr><td align="left"><p>RJA</p></td><td char="." align="char"><p>− 0.25</p></td><td char="." align="char"><p>0.10</p></td><td char="." align="char"><p>− 0.27</p></td><td align="left"><p>0.06</p></td></tr><tr><td align="left"><p>Imitation/synchrony coherence</p></td><td char="." align="char"><p>− 0.47**</p></td><td char="." align="char"><p>0.002</p></td><td char="." align="char"><p>− 0.30*</p></td><td align="left"><p>0.05</p></td></tr><tr><td align="left"><p>Handclapping Coherence</p></td><td char="." align="char"><p>− 0.47***</p></td><td char="." align="char"><p><.001</p></td><td char="." align="char"><p>− 0.30*</p></td><td align="left"><p>0.02</p></td></tr></tbody></table> </ephtml> </p> <p>*<.05 **<.01 ***<.001 <emph>CBCL-ADHD</emph> Achenbach Child Behavior Checklist ADHD subscale, <emph>SRS</emph> Social Responsiveness Scale, <emph>RBS-R</emph> Repetitive Behavior Scale-Revised, <emph>ADOS</emph> Autism Diagnostic Observation Schedule</p> <p>Correlations between RRB frequency and Clinical and Social Cognitive Measures for control group (participants without ASD)</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2"><p>Variable</p></th><th align="left" colspan="2"><p>RRB frequency ratio</p></th><th align="left" colspan="2"><p>RRB first 60 s</p></th></tr><tr><th align="left"><p><italic>r</italic></p></th><th align="left"><p><italic>p</italic></p></th><th align="left"><p><italic>r</italic></p></th><th align="left"><p><italic>p</italic></p></th></tr></thead><tbody><tr><td align="left"><p>Age</p></td><td char="." align="char"><p>− 0.21</p></td><td char="." align="char"><p>0.16</p></td><td char="." align="char"><p>− 0.18</p></td><td align="left"><p>0.24</p></td></tr><tr><td align="left"><p>Nonverbal Mental Age</p></td><td char="." align="char"><p>− 0.26</p></td><td char="." align="char"><p>0.08</p></td><td char="." align="char"><p>− 0.11</p></td><td align="left"><p>0.46</p></td></tr><tr><td align="left"><p>Verbal Mental Age</p></td><td char="." align="char"><p>− 0.28</p></td><td char="." align="char"><p>0.06</p></td><td char="." align="char"><p>− 0.14</p></td><td align="left"><p>0.36</p></td></tr><tr><td align="left"><p>Attention Problems (CBCL-ADHD)</p></td><td char="." align="char"><p>0.14</p></td><td char="." align="char"><p>0.35</p></td><td char="." align="char"><p>− 0.11</p></td><td align="left"><p>0.46</p></td></tr><tr><td align="left"><p>Social Problems (SRS)</p></td><td char="." align="char"><p>0.11</p></td><td char="." align="char"><p>0.48</p></td><td char="." align="char"><p>− 0.10</p></td><td align="left"><p>0.48</p></td></tr><tr><td align="left"><p>RRB Self Report (RBS-R)</p></td><td char="." align="char"><p>0.08</p></td><td char="." align="char"><p>0.60</p></td><td char="." align="char"><p>− 0.11</p></td><td align="left"><p>0.48</p></td></tr><tr><td align="left"><p>ToM</p></td><td char="." align="char"><p>− 0.004</p></td><td char="." align="char"><p>0.98</p></td><td char="." align="char"><p>0.003</p></td><td align="left"><p>0.99</p></td></tr><tr><td align="left"><p>IJA</p></td><td char="." align="char"><p>0.22</p></td><td char="." align="char"><p>0.15</p></td><td char="." align="char"><p>0.23</p></td><td align="left"><p>0.13</p></td></tr><tr><td align="left"><p>RJA</p></td><td char="." align="char"><p>− 0.08</p></td><td char="." align="char"><p>0.60</p></td><td char="." align="char"><p>− 0.3*</p></td><td align="left"><p>0.04</p></td></tr><tr><td align="left"><p>Imitation/Synchrony Coherence</p></td><td char="." align="char"><p>− 0.09</p></td><td char="." align="char"><p>0.58</p></td><td char="." align="char"><p>− 0.05</p></td><td align="left"><p>0.74</p></td></tr><tr><td align="left"><p>Handclapping Coherence</p></td><td char="." align="char"><p>0.01</p></td><td char="." align="char"><p>0.93</p></td><td char="." align="char"><p>0.03</p></td><td align="left"><p>0.85</p></td></tr></tbody></table> </ephtml> </p> <p>*<.05 <emph>CBCL-ADHD</emph> Achenbach Child Behavior Checklist ADHD subscale, <emph>SRS</emph> Social Responsiveness Scale, <emph>RBS-R</emph> Repetitive Behavior Scale-Revised</p> <p>Given the mediating role that nonverbal mental ability may have on RRBs (Evans and Gray [<reflink idref="bib26" id="ref158">26</reflink>]; Gabriels et al. [<reflink idref="bib33" id="ref159">33</reflink>]), we performed partial correlations between the RRB frequency measures and the clinical and social measures for the participants with ASD only, after controlling for nonverbal mental age. As seen in Table 6, statistically significant positive correlations were still found between RRB frequency and autism severity (ADOS composite) and statistically significant negative correlations with the two social synchrony measures.</p> <p>Correlations between RRB frequency and Clinical and Social Cognitive Measures after partialing out nonverbal mental age (data from participants with ASD only)</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2"><p>Variable</p></th><th align="left" colspan="2"><p>RRB frequency ratio</p></th><th align="left" colspan="2"><p>RRB first 60 s</p></th></tr><tr><th align="left"><p><italic>r</italic></p></th><th align="left"><p><italic>p</italic></p></th><th align="left"><p><italic>r</italic></p></th><th align="left"><p><italic>p</italic></p></th></tr></thead><tbody><tr><td align="left"><p>Age</p></td><td char="." align="char"><p>− 0.08</p></td><td char="." align="char"><p>0.63</p></td><td char="." align="char"><p>− 0.27</p></td><td align="left"><p>0.11</p></td></tr><tr><td align="left"><p>Attention problems (CBCL-ADHD)</p></td><td char="." align="char"><p>0.26</p></td><td char="." align="char"><p>0.12</p></td><td char="." align="char"><p>0.20</p></td><td align="left"><p>0.24</p></td></tr><tr><td align="left"><p>Social problems (SRS)</p></td><td char="." align="char"><p>0.21</p></td><td char="." align="char"><p>0.22</p></td><td char="." align="char"><p>0.25</p></td><td align="left"><p>0.14</p></td></tr><tr><td align="left"><p>RRB Self Report (RBS-R)</p></td><td char="." align="char"><p>0.15</p></td><td char="." align="char"><p>0.37</p></td><td char="." align="char"><p>0.07</p></td><td align="left"><p>0.66</p></td></tr><tr><td align="left"><p>Autism severity (ADOS Composite)</p></td><td char="." align="char"><p>0.32</p></td><td char="." align="char"><p>0.06</p></td><td char="." align="char"><p>0.39*</p></td><td align="left"><p>0.02</p></td></tr><tr><td align="left"><p>ToM</p></td><td char="." align="char"><p>− 0.05</p></td><td char="." align="char"><p>0.78</p></td><td char="." align="char"><p>− 0.20</p></td><td align="left"><p>0.25</p></td></tr><tr><td align="left"><p>IJA</p></td><td char="." align="char"><p>− 0.05</p></td><td char="." align="char"><p>0.76</p></td><td char="." align="char"><p>− 0.18</p></td><td align="left"><p>0.26</p></td></tr><tr><td align="left"><p>RJA</p></td><td char="." align="char"><p>− 0.27</p></td><td char="." align="char"><p>0.09</p></td><td char="." align="char"><p>− 0.30</p></td><td align="left"><p>0.06</p></td></tr><tr><td align="left"><p>Imitation/synchrony coherence</p></td><td char="." align="char"><p>− 0.30</p></td><td char="." align="char"><p>0.07</p></td><td char="." align="char"><p>− 0.44**</p></td><td align="left"><p>0.01</p></td></tr><tr><td align="left"><p>Handclapping coherence</p></td><td char="." align="char"><p>− 0.41</p></td><td char="." align="char"><p>0.01**</p></td><td char="." align="char"><p>− 0.56***</p></td><td align="left"><p><.001</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>CBCL-ADHD</emph> Achenbach Child Behavior Checklist ADHD subscale, <emph>SRS</emph> Social Responsiveness Scale, <emph> RBS-R</emph> Repetitive Behavior Scale-Revised , <emph>ADOS</emph> Autism diagnostic observation schedule * <.05; ** <.01; ***<.001</p> <hd id="AN0143136307-26">Discussion</hd> <p>The main purpose of this study was to explore the presentation of RRBs in an ongoing social and motor context and understand how RRBs are related to social and cognitive traits. The data presented here provides evidence that motor and verbal RRBs were the most common type of RRB for both groups (not surprisingly, RRBs were performed at a much lower rate in the control group) and RRBs were least frequent in an environmental context when both social and motor engagement were high. Importantly, RRBs varied based on motor and social context for participants with ASD but not controls. In addition, the influence of context was different when we examined behavior during the first 60 s of a task compared to the number of RRBs performed throughout the task. Lastly, results support the hypothesis that presentation of RRBs is related to clinical, social cognitive, and experimental measures of social skill and cognitive ability.</p> <p>As mentioned above, our results demonstrated that when both social and motor engagement were high, the frequency of RRBs in children with ASD was lowest. This was true for both measurements of RRBs—during the first 60 s of the trial and RRBs per second for the entire trial. Our results are similar to those of both Lee et al. ([<reflink idref="bib50" id="ref160">50</reflink>]) and Enloe and Rapp ([<reflink idref="bib25" id="ref161">25</reflink>]) who also found that social engagement (in the forms of peer interactions and being read to from an e-reader, respectively) significantly reduced RRBs in children with moderate to severe ASD. Similarly previous research on motor engagement (Bahrami et al. [<reflink idref="bib4" id="ref162">4</reflink>]; Prupas and Reid [<reflink idref="bib71" id="ref163">71</reflink>]; Rosenthal-Malek and Mitchell [<reflink idref="bib77" id="ref164">77</reflink>], Tse et al. [<reflink idref="bib87" id="ref165">87</reflink>]) found that interventions that involved engaging in gross motor activities resulted in reduction in RRBs following the intervention. Our research differs from these previous findings in that we were investigating fine motor engagement rather than gross motor engagement and we were measuring RRB presentation during social and motor engagement activities rather than measuring RRB presentation following the intervention.</p> <p>It is worth highlighting several noteworthy ways in which our findings extend the previous literature. First, as mentioned above, we were evaluating the way in which the contextual features of a task (namely, whether it actively engaged the child socially and/or physically) impacted RRB production during a structured task rather than testing the impact of a social or motor intervention on subsequent RRB production. In addition, the fine motor engagement and the social engagement utilized were highly structured and took place in the context of a one-on-one interaction. Our findings indicate that the contextual features of a task have an important impact on RRB production. This impact could be the consequence of the motor and social engagement required from the task competing with the ability to perform RRBs (an indirect effect as proposed by Enloe and Rapp [<reflink idref="bib25" id="ref166">25</reflink>]). Alternatively, it could be that because the task required multiple types of engagement, attention to task demands was very high and left few cognitive resources for engaging in RRBs. In either case, our results emphasize the need for carefully structuring the environment to promote on-task behavior and reduce possibilities for engaging in RRBs. While this may sound simplistic on the face of it, the difficulties inherent in managing RRBs points to the need for a deeper exploration of the role of attention and task demands on RRB presentation. In fact, Stasolla et al. ([<reflink idref="bib82" id="ref167">82</reflink>]) found that on-task engagement was effective at both increasing participants' academic performance as well as reducing their presentation of RRBs. While the change in RRBs was not a causal factor in the increase in academic performance in that study, both results were desirable outcomes, and both were higher during on-task engagement.</p> <p>This research adds to our understanding of the importance of context and engagement in additional ways. For instance, our tasks with low levels of engagement resulted in higher RRB presentation, pointing to the need to more fully understand the impact of periods of non-activity in influencing RRB presentation. Of interest is how periods of non-activity compare to times of transitions, which have been found to result in heightened RRBs (e.g., Joosten et al. [<reflink idref="bib44" id="ref168">44</reflink>]). That is, what roles do the motivators underlying the RRBs and presence of other people play in these different contexts? And, are these factors unique for each child, perhaps even being different in different contexts for the same child? Our findings point to the importance of structured activity and allocation of attention as useful avenues of future research that could have potential impacts for educators and therapists in determining how engagement might be customized to what the child may best tolerate and/or what is most appropriate in the situation's context. In addition, our fine-motor and social engagement were integrated parts of the activities and relevant for task completion, unlike the research that employed physical activity or social engagement as an intervention. Rather than designing explicit interventions our research suggests focusing on environmental enrichment may be a more effective pathway for managing RRBs. Such "environmental enrichment", as suggested by Rapp and Vollmer ([<reflink idref="bib74" id="ref169">74</reflink>]) may serve to replace the positive reinforcement stereotypic behavior sometimes provides or could enhance task attention. Importantly, such environmental enrichment needs to take the individual child into account to ensure that the environmental supports are actually reinforcing for that child. Our findings also add to the literature in that we demonstrated that fine motor activity impacted RRB production. Previous research has focused exclusively on gross motor activity.</p> <p>Interestingly, RRBs during the first 60 s of the task were higher in the two low social conditions and lower in the two high social conditions, while RRB presentation did not vary as a consequence of motor engagement. This is rather interesting as social engagement was associated with lower <emph>motor</emph> RRBs as well as vocal RRBs. That is, social engagement was not linked exclusively with reduced verbal RRBs. This is a surprising finding because Tse et al. ([<reflink idref="bib87" id="ref170">87</reflink>]) recently found that physical activity that was matched with a biomechanically similar repetitive motor behavior had the biggest impact on subsequent RRB production. They concluded that matching the biomechanics of physical movement and motor RRBs might be a useful clinical intervention. The fact that we did not confirm this finding for vocal RRBs provides evidence that the factors that elicit and maintain vocal RRBs may be different for vocal RRBs than motor RRBs. Since reduction in vocal RRBs was not matched to social engagement, it is more likely that RRBs varied due to differences in the degree of attention required rather than the task demands being incompatible with RRB production. It is also worth noting that this finding underscores the importance of understanding RRB presentation at the level of the individual child, rather than the group level. The same RRB may serve different functions for the same child in different contexts and different functions for different children in the same context. The factors that influence heightened attention are unique for each child. For some children, high social tasks may heighten attention for performance and that allocation of attention interferes with RRB production. For other children, it is possible engaging in RRBs may reduce anxiety and hence enhance engagement or heighten attention to task performance. In this case, RRBs might facilitate desirable behavior rather than interfere with it. While additional research is needed to disentangle the influence of social engagement and attention on the production of RRBs for individual children, our preliminary findings indicate attention may play a bigger role than incompatibility of behavior, at least in the case of vocal RRBs.</p> <p>In contrast, when looking at the number of RRBs performed per second during the entire task, RRBs were lowest during the two high motor conditions and highest in the low motor/low social engagement condition. As seen when examining behavior during the first 60 s of task initiation, both verbal and motor RRBs were lower, which may indicate that task behavior competing with the production of the RRBs is not a complete explanation. However, this finding is different from what we found when we examined behavior during the first 60 s of a task, wherein RRBs were <emph>lowest</emph> in the two high social conditions. This is a potentially important finding because it raises the possibility that the influence of the environmental context (in this case, social and motor engagement) may change over the course of task execution. It could be the case that attention to the task may decrease as a simple consequence of task length. That seems unlikely, however, because (a) not all tasks had equivalent number of RRBs during the first 60 s; and (b) the two high motor tasks were not equivalent in length even though number of RRBs was not different from each other in those two conditions. These findings point to the need for research that compares findings across different sorts of measurement methodologies. Our findings suggest the prevalence of RRBs as behavior unfolds over a more extended period of time may be influenced by different contextual factors than during the initiation of a behavior. Such a methodological approach evaluates on how the behavior of an individual child changes over time and moves away from methodologies focused on common explanations for all children.</p> <p>Another consideration is that different tasks have a different timescale for their unfolding, which was certainly the case in the tasks we examined. Our research suggests it would be worthwhile to compare fast-paced tasks versus slow-paced tasks to understand if task pace is related to RRB presentation. It could be that the allocation of attention changes over the timescale of the task. Our findings highlight the need for research to systematically explore the role of pace of task and task length while examining the performance of RRBs as behavior unfolds dynamically over time. We would argue that understanding the time unfolding of the behavior may provide insights into understanding environmental contextual influences on RRB presentation that summary scores of behavior overlook (Fitzpatrick [<reflink idref="bib28" id="ref171">28</reflink>]). Technology that allows for automated and continuous detection of RRBs over long time scales (Gilchrist et al. [<reflink idref="bib34" id="ref172">34</reflink>]) is a promising avenue for furthering our understanding of the dynamics of RRBs at the level of the individual child.</p> <p>While our primary interest was in the ways different forms of engagement correspond with the presentation of RRBs, we also sought to understand more fully how RRBs are related to social and cognitive skill in children with ASD. The largest correlations we found were between RRB frequency and the two measures of social synchrony—high levels of RRBs were associated with poorer synchronization ability. Furthermore, this relationship remained significant even after controlling for nonverbal ability. This is a potentially interesting relationship because it suggests that engaging in synchronization tasks (which tend to be rhythmical in nature) requires the production of a behavior that competes with the production if the RRBs (an indirect effect according to Rapp et al. ([<reflink idref="bib73" id="ref173">73</reflink>])). Alternatively, it could be the case that the production of rhythmical and synchronous behavior provides a substitute reinforcer (a direct effect, Rapp et al. ([<reflink idref="bib73" id="ref174">73</reflink>])) and as a consequence results in lower levels of RRBs. The latter would be consistent with Tordjman et al.'s ([<reflink idref="bib86" id="ref175">86</reflink>]) proposal that RRBs function to create rhythmicity. Therefore, engagement in a rhythmical task may fulfill the internal need for creating rhythmicity and hence result in fewer RRBs. Another possibility is that the relationship between RRB presentation and social synchrony could be the consequence of underlying motor control problems (Ravizza et al. [<reflink idref="bib75" id="ref176">75</reflink>]). Certainly, our correlational results do not allow us to draw any conclusions about causal relationships but the strong association between these factors raises interesting questions about the nature of these relationships and can contribute to the conceptualization of future research.</p> <p>We also found that RRBs were related to social problems and autism severity, with only the relationship with severity remaining after controlling for nonverbal ability. Interestingly, these findings contradict those of Harrop et al. ([<reflink idref="bib37" id="ref177">37</reflink>]) who found no significant correlations between the frequency of RRBs and the social impairment (as assessed by the ADOS) of children with ASD. However, while both our study and theirs utilized observation of RRBs, the participants of Harrop et al.'s, ([<reflink idref="bib37" id="ref178">37</reflink>]) study ranged in age from 2 years to 4 years 11 months. Since we had an older sample in our study, it suggests these relationships may be different at different points in development. Indeed, Kim and Lord ([<reflink idref="bib47" id="ref179">47</reflink>]) found that RRBs decreased developmentally in children without autism but increased developmentally or remained stable in children with autism. Our findings raise the possibility that the differentiation between the groups in terms of RRB prevalence and its relationship to social skill happens later developmentally. This interpretation is consistent with a developmental psychology approach to RRBs proposed by Thelen ([<reflink idref="bib84" id="ref180">84</reflink>]) and recently highlighted by Leekam and colleagues ([<reflink idref="bib52" id="ref181">52</reflink>]). Additional research should focus on finding the extent to which RRBs and social behavior are linked and whether and how the relationship changes developmentally.</p> <p>Interestingly, we found that, after controlling for nonverbal ability, RRBs were not related to other measures of autistic traits—initiating joint attention, responding to joint attention, theory of mind, or parental reports of social problems. RRBs were, however, related to autism severity (as measured by the ADOS composite score) and measures of social synchrony. This is a valuable contribution to the literature because very little research has focused evaluating the relationship between RRBs and a wide range of autistic traits. Our findings may suggest that certain aspects of social communication and interaction may be independent from RRB production. However, other aspects of social communication and interaction may share mechanisms that also contribute to RRBs or a core deficit in one process may give rise to the other. Another alternative is that the lack of a relationship between RRB production and many autistic traits highlights the need to understand the multi-functional and individual nature of RRB production.</p> <p>Furthermore, we found that RRBs (as measured over the entire trial) were negatively correlated with both nonverbal and verbal mental age and the relationship between RRBs during the first 60 s and nonverbal mental age approached significance. These findings are consistent with other research that has found that nonverbal intelligence is related to RRBs in young children (Boyd et al. [<reflink idref="bib13" id="ref182">13</reflink>]) and lower-order RRBs were negatively correlated with intelligence (Militerni et al. [<reflink idref="bib62" id="ref183">62</reflink>]; Turner [<reflink idref="bib89" id="ref184">89</reflink>]). In contrast, Kim and Lord ([<reflink idref="bib47" id="ref185">47</reflink>]) did not find a relationship between RRBs and nonverbal intelligence in toddlers and preschoolers, although there was a significant relationship between nonverbal intelligence and RRBs for non-spectrum and control groups for older children (37–56 months). Similarly, Joseph et al. ([<reflink idref="bib45" id="ref186">45</reflink>]) did not find a relationship between RRBs and nonverbal mental age in children ranging from 2 to 11 years. Some of these differences could be due to the reliance on different measurement instruments for RRBs (parent-report versus observation) and different ages of the children tested. While research that systematically evaluates how these relationships change over the course of development, using a consistent measurement tool, is recommended for future research our findings support the conclusion that nonverbal mental age may be a mediating factor during later childhood.</p> <hd id="AN0143136307-27">Limitations and Conclusions</hd> <p>Due to the post-hoc nature of this study, participants' motivations for engaging in RRBs were unable to be considered. This is something that deserves attention in future research, as determining motivation can both determine if an RRB ought to be targeted for redirection, and if so, what means of engagement may be most effective (i.e. social engagement for attention-driven actions, motor-engagement for anxiety-driven actions, etc.)</p> <p>Another limitation of this study is that the experimental tasks were selected for their levels of social and motor engagement subsequent to the study's completion. In other words, the videos that were selected for their differing levels of social and motor engagement were not created for the sole purpose of observing their effects on the presentation of RRBs. This means that in some cases, there were instances where social engagement was momentarily higher in a low social engagement condition, such as when a participant said something that made the experimenter laugh. Future research should design conditions with the idea of administering high or low levels of social and motor engagement in order to more directly test these effects.</p> <p>Additionally, tasks were not the same length for every participant and varied in length between tasks as well. Given our findings that the presentation of RRBs during the different social and motor contexts was different when measured during the first 60 s versus measured throughout the trial, future research should aim to develop rigorous engagement conditions, standardize the amount of time for each task, as well as systematically vary task length.</p> <p>Overall, our results indicate that the environmental circumstances, here, motor and social engagement, were related to RRB expression. In particular, we found that motor and verbal RRBs were the most common and RRBs varied based on motor and social context for participants with ASD but not controls. In addition, the influence of context was different when we examined behavior during the first 60 s of a task compared to the number of RRBs performed throughout the task, and social engagement was associated with lower motor RRBs as well as lower verbal RRBs. We also found significant correlations between RRBs and autism severity, social synchrony ability, and nonverbal mental age. This adds to our understanding of the relationship between RRBs and a wider range of other co-occurring features of ASD than previously investigated in a single study. These findings highlight the important role that attention, task complexity and length, and rhythmicity and motor control have on RRB production. Importantly, these factors can influence different children in different ways as well as influence the same child in different ways at different times. This research confirms the importance of understanding how context influences RRB prevalence for an individual child during on-going tasks and raises questions about whether the factors that elicit and maintain RRBs are unique for vocal and motor RRBs and individual children.</p> <hd id="AN0143136307-28">Acknowledgments</hd> <p>Research reported in this article was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R21MH094659. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Health.</p> <hd id="AN0143136307-29">Author Contributions</hd> <p>AL and PF contributed to study design, data analysis, data interpretation, and writing. VR contributed to data collection, and data analysis. JA contributed to data collection. RCS contributed to study design, data analysis, and data interpretation.</p> <hd id="AN0143136307-30">Compliance with Ethical Standards</hd> <p></p> <hd id="AN0143136307-31">Conflict of interest</hd> <p>Andrew Lampi, Paula Fitzpatrick, Veronica Romero, Joseph Amaral, and R. C. Schmidt declares that they have no conflict of interest.</p> <ref id="AN0143136307-32"> <title> References </title> <blist> <bibl id="bib1" idref="ref128" type="bt">1</bibl> <bibtext> Achenbach TM, Edelbrock C. Manual for the Child Behavior Checklist and revised child behavior profile. 1983: Burlington; University of Vermont</bibtext> </blist> <blist> <bibl id="bib2" idref="ref105" type="bt">2</bibl> <bibtext> Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 2000: Washington, DC; American Psychiatric Association</bibtext> </blist> <blist> <bibl id="bib3" idref="ref1" type="bt">3</bibl> <bibtext> Diagnostic and statistical manual of mental disorders: DSM-5. 2013: Washington, D.C.; American Psychiatric Association</bibtext> </blist> <blist> <bibl id="bib4" idref="ref72" type="bt">4</bibl> <bibtext> Bahrami F, Movahedi A, Marandi SM, Abedi A. Kata techniques training consistently decreases stereotypy in children with autism spectrum disorder. Research in Developmental Disabilities. 2012; 33; 4: 1183-1193</bibtext> </blist> <blist> <bibl id="bib5" idref="ref41" type="bt">5</bibl> <bibtext> Baron-Cohen S. Perceptual role-taking and proto-joint attention pointing in autism. British Journal of Developmental Psychology. 1989; 7: 113-127</bibtext> </blist> <blist> <bibl id="bib6" type="bt">6</bibl> <bibtext> Baron-Cohen S. The autistic child's theory of mind: A case of specific developmental delay. Journal of Child Psychology and Psychiatry and Allied Disciplines. 1989; 30; 2: 285-297</bibtext> </blist> <blist> <bibl id="bib7" idref="ref117" type="bt">7</bibl> <bibtext> Baron-Cohen S, Leslie AM, Frith U. Does the autistic child have a "theory of mind"?. Cognition. 1985; 21: 37-46</bibtext> </blist> <blist> <bibl id="bib8" idref="ref56" type="bt">8</bibl> <bibtext> Bauminger-Zviely N, Eden S, Zancanaro M, Weiss PL, Gal E. Increasing social engagement in children with high-functioning autism spectrum disorder using collaborative technologies in the school environment. Autism. 2013; 17; 3: 317-339. 10.1177/1362361312472989</bibtext> </blist> <blist> <bibl id="bib9" idref="ref32" type="bt">9</bibl> <bibtext> Bishop SL, Luyster R, Richler J, Lord CKatarzyna C, Klin A, Volkmar FR. Diagnostic assessment. Autism spectrum disorders in infants and toddlers: Diagnosis, assessment, and treatment. 2008: New York; The Guilford Press: 23-49</bibtext> </blist> <blist> <bibtext> Bishop SL, Richler J, Lord C. Association between restricted and repetitive behaviors and nonverbal IQ in children with autism spectrum disorders. Child Neuropsychology. 2006; 12; 4–5: 247-267. 10.1080/09297040600630288</bibtext> </blist> <blist> <bibtext> Bodfish JW, Symons F, Lewis M. The Repetitive Behavior Scale: Test Manual. 1999: Morganton; Western Carolina Center Research Reports</bibtext> </blist> <blist> <bibtext> Bodfish JW, Symons FJ, Parker DE, Lewis MH. Varieties of repetitive behavior in autism: Comparisons to mental retardation. Journal of Autism and Developmental Disorders. 2000; 30; 3: 237-243. 10.1023/A:1005596502855</bibtext> </blist> <blist> <bibtext> Boyd BA, McDonough SG, Bodfish JW. Evidence-based behavioral interventions for repetitive behaviors in autism. Journal of Autism and Developmental Disorders. 2012; 42; 6: 1236-12483709868</bibtext> </blist> <blist> <bibtext> Bremer E, Crozier M, Lloyd M. A systematic review of the behavioural outcomes following exercise interventions for children and youth with autism spectrum disorder. Autism. 2016; 20; 8: 899-915. 10.1177/1362361315616002</bibtext> </blist> <blist> <bibtext> Butler RC, Gillis JM. The impact of labels and behaviors on the stigmatization of adults with Asperger's disorder. Journal of Autism and Developmental Disorders. 2011; 41; 6: 741-749. 10.1007/s10803-010-1093-9</bibtext> </blist> <blist> <bibtext> Campbell JM. Middle school students' response to the self-introduction of a student with autism: Effects of perceived similarity, prior awareness, and educational message. Remedial and Special Education. 2007; 28; 3: 163-173. 10.1177/07419325070280030501</bibtext> </blist> <blist> <bibtext> Chevallier C, Tonge N, Le L, Miller J, Parish-Morris J, Schultz RT. Susceptibility to the audience effect explains performance gap between children with and without autism in a theory of mind task. Journal of Experimental Psychology: General. 2014; 143; 3: 972-979</bibtext> </blist> <blist> <bibtext> Colle L, Baron-Cohen S, Hill J. Do children with autism have a theory of mind? A non-verbal test of autism vs. specific language impairment. Journal of Autism and Developmental Disorders. 2006; 37; 4: 716-723. 10.1007/s10803-006-0198-7</bibtext> </blist> <blist> <bibtext> Constantino JN, Gruber CP. Social Responsiveness Scale. 2005: Los Angeles; Western Psychological Services</bibtext> </blist> <blist> <bibtext> Cunningham AB, Schreibman L. Stereotypy in autism: The importance of function. Research in Autism Spectrum Disorders. 2008; 2: 469-4792598746</bibtext> </blist> <blist> <bibtext> Darrow SM, Grados M, Sandor P, Hirschtritt ME, Illmann C, Osiecki L. Autism spectrum symptoms in a Tourette's disorder sample. Journal of the American Academy of Child & Adolescent Psychiatry. 2017; 56; 7: 610-617. 10.1016/j.jaac.2017.05.002</bibtext> </blist> <blist> <bibtext> Dawson G, Toth K, Abbott R, Osterling J, Munson J, Estes A, Liaw J. Early social attention impairments in autism: Social orienting, joint attention and attention to distress. Developmental Psychology. 2004; 40: 271-283</bibtext> </blist> <blist> <bibtext> de Marchena A, Eigsti IM. Conversational gestures in autism spectrum disorder: Asynchrony but not decreased frequency. Autism Research. 2010; 3: 311-322</bibtext> </blist> <blist> <bibtext> Elliot CD. Differential Ability Scales II. 2007: New York; Pearson Education, Inc.</bibtext> </blist> <blist> <bibtext> Enloe KA, Rapp JT. Effects of noncontingent social interaction on immediate and subsequent engagement in vocal and motor stereotypy in children with autism. Behavior Modification. 2014; 38; 3: 374-391. 10.1177/0145445513514081</bibtext> </blist> <blist> <bibtext> Evans DW, Gray FL. Compulsive-like behavior in individuals with Down syndrome: Its relation to MA level, adaptive and maladaptive behavior. Child Development. 2000; 71: 288-300</bibtext> </blist> <blist> <bibtext> Factor RS, Condy EE, Farley JP, Scarpa A. Brief report: Insistence on sameness, anxiety, and social motivation in children with autism spectrum disorder. Journal of Autism and Developmental Disorders. 2016; 46; 7: 2548-2554. 10.1007/s10803-016-2781-x</bibtext> </blist> <blist> <bibtext> Fitzpatrick P. The future of autism research: Dynamic and process-oriented approaches. Journal of the American Academy of Child & Adolescent Psychiatry. 2018; 57; 1: 16-17</bibtext> </blist> <blist> <bibtext> Fitzpatrick P, Diorio R, Richardson MJ, Schmidt RC. Dynamical methods for evaluating the time-dependent unfolding of social coordination in children with autism. Frontiers in Integrative Neuroscience. 2013; 7; 21: 1-13. 10.3389/fnint.2013.00021</bibtext> </blist> <blist> <bibtext> Fitzpatrick P, Frazier JA, Cochran DM, Mitchell T, Coleman C, Schmidt RC. Impairments of social motor synchrony evident in autism spectrum disorder. Frontiers in Psychology. 2016; 7: 1323. 10.3389/psyg2016.013235005316</bibtext> </blist> <blist> <bibtext> Fitzpatrick P, Romero V, Amaral JL, Duncan A, Barnard H, Richardson MJ, Schmidt RC. Evaluating the importance of social motor synchronization and motor skill for understanding autism. Autism Research. 2017; 10; 10: 1687-16995648610</bibtext> </blist> <blist> <bibtext> Fitzpatrick P, Romero V, Amaral JL, Duncan A, Barnard H, Richardson MJ, Schmidt RC. Social motor synchronization: Insights for understanding social behavior in autism. Journal of Autism and Developmental Disorders. 2017; 47: 2092-2107</bibtext> </blist> <blist> <bibtext> Gabriels RL, Cuccaro ML, Hill DE, Ivers BJ, Goldson E. Repetitive behaviors in autism: Relationships with associated clinical features. Research in Developmental Disabilities. 2005; 26: 169-181</bibtext> </blist> <blist> <bibtext> Gilchrist KH, Hegarty-Craver M, Christian RB, Grego S, Kies AC, Wheeler AC. Automated detection of repetitive motor behaviors as an outcome measurement in intellectual and developmental disabilities. Journal of Autism and Developmental Disorders. 2018; 48: 1458-14665889956</bibtext> </blist> <blist> <bibtext> Grossman RB. Judgments of social awkwardness from brief exposure to children with and without high functioning autism. Autism. 2015; 19; 5: 580-587. 10.1177/132361314536937</bibtext> </blist> <blist> <bibtext> Harrop, C, & Kasari, C. (2015). Learning when to treat repetitive behaviors in autism. Spectrum News. Retrieved from https://spectrumnews.org/opinion/viewpoint/learning-when-to-treat-repetitive-behaviors-in-autism/.</bibtext> </blist> <blist> <bibtext> Harrop C, McConachie H, Emsley R, Leadbitter K, Green J. Restricted and repetitive behaviors in autism spectrum disorders and typical development: Cross-sectional and longitudinal comparisons. Journal of Autism and Developmental Disorders. 2014; 44; 5: 1207-1219. 10.1007/s10803-013-1986-5</bibtext> </blist> <blist> <bibtext> Honey E, Leekam S, Turner M, McConachie H. Repetitive behaviour and play in typically developing children and children with autism spectrum disorders. Journal of Autism and Developmental Disorders. 2007; 37; 6: 1107-1115</bibtext> </blist> <blist> <bibtext> Hoogenhout M, Malcolm-Smith S. Theory of mind in autism spectrum disorder: Does DSM classification predict development?. Research in Autism Spectrum Disorders. 2014; 8; 14: 597-607</bibtext> </blist> <blist> <bibtext> Hove MJ, Risen JL. It's all in the timing: Interpersonal synchrony increases affiliation. Social Cognition. 2009; 27; 6: 949-960. 10.1521/soco.2009.27.6.949</bibtext> </blist> <blist> <bibtext> Hurwitz S, Watson LR. Joint attention revisited: Finding strengths among children with autism. Autism. 2016; 20; 5: 538-550</bibtext> </blist> <blist> <bibtext> Jiujias M, Kelley E, Hall L. Restricted, repetitive behaviors in autism spectrum disorder and obsessive–compulsive disorder: A comparative review. Child Psychiatry and Human Development. 2017; 48; 6: 944-959. 10.1007/s10578-017-0717-0</bibtext> </blist> <blist> <bibtext> Joosten AV, Bundy AC, Einfeld SL. Intrinsic and extrinsic motivation for stereotypic and repetitive behavior. Journal of Autism and Developmental Disorders. 2009; 39; 3: 521-531. 10.1007/s10803-008-0654-7</bibtext> </blist> <blist> <bibtext> Joosten AV, Bundy AC, Einfeld SL. 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. 2012; 25; 3: 262-270. 10.1111/j.1468-3148.2011.00663.x</bibtext> </blist> <blist> <bibtext> Joseph L, Thurm A, Farmer C, Shumway S. Repetitive behavior and restricted interests in young children with autism: Comparisons with controls and stability over two years. Autism Research. 2013; 6; 6: 584-595</bibtext> </blist> <blist> <bibtext> Kim, C. (2014). Behavior is communication: Are you listening? Retrieved December 29, 2017, from https://musingsofanaspie.com/2014/04/30/why-behavior-is-communication-is-no-longer-good-enough.</bibtext> </blist> <blist> <bibtext> Kim SH, Lord C. Restricted and repetitive behaviors in toddlers and preschoolrs with autism spectrum disorders based on the autism diagnostic observation schedule (ADOS). Autism Research. 2010; 3: 162-1733005305</bibtext> </blist> <blist> <bibtext> Krstovska-Guerrero I, Jones EA. Joint attention in autism: Teaching smiling coordinated with gaze to respond to joint attention bids. Research in Autism Spectrum Disorders. 2013; 7; 1: 93-108. 10.1016/j.rasd.2012.07.007</bibtext> </blist> <blist> <bibtext> Lang R, Koegel LK, Ashbaugh K, Regester A, Ence W, Smith W. Physical exercise and individuals with autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders. 2010; 4: 565-576</bibtext> </blist> <blist> <bibtext> Lee S, Odom SL, Loftin R. Social engagement with peers and stereotypic behavior of children with autism. Journal of Positive Behavior Interventions. 2007; 9; 2: 67-79. 10.1177/10983007070090020401</bibtext> </blist> <blist> <bibtext> Leekam S, Baron-Cohen S, Perrett D, Milders M, Brown S. Eye-direction detection: A dissociation between geometric and joint attention skills in autism. British Journal of Developmental Psychology. 1997; 15; Pt 1: 77-95</bibtext> </blist> <blist> <bibtext> Leekam SR, Prior MR, Uljarevic M. Restricted and repetitive behaviors in autism spectrum disorders: A review of research in the last decade. Psychological Bulletin. 2011; 137; 4: 562-593</bibtext> </blist> <blist> <bibtext> Lewis M, Kim S-J. The pathophysiology of restricted repetitive behavior. Journal of Neurodevelopmental Disorders. 2009; 1: 114-1323090677</bibtext> </blist> <blist> <bibtext> Lord C, Rutter M, DiLavore PC, Risi S, Gotham K, Bishop SL. ADOS-2: Autism Diagnostic Observation Schedule. 2012: Los Angeles; Western Psychological Services</bibtext> </blist> <blist> <bibtext> Luckett T, Powell S, Messer D, Thornton M, Schulz J. Do children with autism who pass false belief tasks understand the mind as active interpreter?. Journal of Autism and Developmental Disorders. 2002; 32; 2: 127-140</bibtext> </blist> <blist> <bibtext> Malmberg DB, Charlop MH, Gershfeld SJ. A two experiment treatment comparison study: Teaching social skills to children with autism spectrum disorder. Journal of Developmental and Physical Disabilities. 2015; 27: 375-392. 10.1007/s10882-015-9420-x</bibtext> </blist> <blist> <bibtext> Marsh KL, Isenhower RW, Richardson MJ, Helt M, Verbalis AD, Schmidt RC, Fein D. Autism and social disconnection in interpersonal rocking. Frontiers in Integrative Neuroscience. 2013; 7; 4: 1-8</bibtext> </blist> <blist> <bibtext> Matson JL, Nebel-Schwalm M. Assessing challenging behaviors in children with autism spectrum disorders: A review. Research in Developmental Disabilities. 2007; 28; 6: 567-579. 10.1016/j.ridd.2006.08.001</bibtext> </blist> <blist> <bibtext> McGill P, Teer K, Rye L, Hughes D. Staff reports of setting events associated with challenging behavior. Behavior Modification. 2005; 29: 599-615</bibtext> </blist> <blist> <bibtext> Memari AH, Mirfazeli FS, Kordi R, Shayestehfar M, Moshayedi P, Mansournia MA. Cognitive and social functioning are connected to physical behavior in children with autism spectrum disorder. Research in Autism Spectrum Disorders. 2017; 33: 21-28</bibtext> </blist> <blist> <bibtext> Miles LK, Nind LK, Macrae CN. The rhythm of rapport: Interpersonal synchrony and social perception. Journal of Experimental Social Psychology. 2009; 45; 3: 585-589. 10.1016/j.jesp.2009.02.002</bibtext> </blist> <blist> <bibtext> Militerni R, Bravaccio C, Falco C, Fico C, Palermo MT. Repetitive behaviors in autistic disorder. European Child & Adolescent Psychiatry. 2002; 11: 210-218</bibtext> </blist> <blist> <bibtext> Mundy P, Sigman M, Kasari C. A longitudinal study of joint attention and language development in autistic children. Journal of Autism and Developmental Disorders. 1990; 20; 1: 115-128</bibtext> </blist> <blist> <bibtext> Murray C, Healy O. An examination of response variability in children with autism and the relationship to restricted repetitive behavior subtypes. Research in Autism Spectrum Disorders. 2015; 11: 13-19</bibtext> </blist> <blist> <bibtext> Oberman LM, Winkielman P, Ramachandran VS. Slow echo: Facial EMG evidence for the delay of spontaneous, but not voluntary, emotion in children with autism spectrum disorders. Developmental Science. 2009; 12: 510-520</bibtext> </blist> <blist> <bibtext> Ozonoff S, Cook I, Coon H, Dawson G, Joseph RM, Klin A. Performance on Cambridge Neuropsychological Test Automated Battery subtests sensitive to frontal lobe function in people with autistic disorder: Evidence from the Collaborative Programs of Excellence in Autism Network. Journal of Autism and Developmental Disorders. 2004; 34: 139-150</bibtext> </blist> <blist> <bibtext> Paparella T, Goods KS, Freeman S, Kasari C. The emergence of nonverbal joint attention and requesting skills in young children with autism. Journal of Communication Disorders. 2011; 44; 6: 569-583. 10.1016/j.jcomdis.2011.08.002</bibtext> </blist> <blist> <bibtext> Perner J, Leekam SR, Wimmer H. Three-year-olds' difficulty with false belief: The case for a conceptual deficit. British Journal of Developmental Psychology. 1987; 5; 2: 125-137. 10.1111/j.2044-835X.1987.tb01048</bibtext> </blist> <blist> <bibtext> Peterson CC. Drawing insight from pictures: The development of concepts of false drawing and false belief in children with deafness, normal hearing, and autism. Child Development. 2002; 73; 5: 1442-1459. 10.1111/1467-8624.00482</bibtext> </blist> <blist> <bibtext> Peterson CC, Wellman HM, Liu D. Steps in theory-of-mind development for children with deafness or autism. Child Development. 2005; 76; 2: 502-517. 10.1111/j.1467-8624.2005.00859.x</bibtext> </blist> <blist> <bibtext> Prupas A, Reid G. Effects of exercise frequency on stereotypic behaviors of children with developmental disabilities. Education and Training in Mental Retardation and Developmental Disabilities. 2001; 36; 2: 196-206</bibtext> </blist> <blist> <bibtext> Radley KC, Ford WB, Battaglia AA, Mchugh MB. The effects of a social skills training package on social engagement of children with autism spectrum disorders in a generalized recess setting. Focus on Autism and Other Developmental Disabilities. 2014; 29; 4: 216-229. 10.1177/1088357614525660</bibtext> </blist> <blist> <bibtext> Rapp JT, Swanson GS, Sheridan S, Enloe K, Maltese D, Sennott L. Immediate and subsequent effects of matched and unmatched stimuli on targeted vocal stereotypy and untargeted motor stereotypy. Behavior Modification. 2013; 37: 543-567</bibtext> </blist> <blist> <bibtext> Rapp JT, Vollmer TR. Stereotypy I: A review of behavioral assessment and treatment. Research in Developmental Disabilities. 2005; 26; 6: 527-547. 10.1016/j.ridd.2004.11.005</bibtext> </blist> <blist> <bibtext> Ravizza SM, Solomon M, Ivry RB, Carter CS. Restricted and repetitive behaviors in autism spectrum disorders: The relationship of attention and motor deficits. Developmental Psychopathology. 2013; 25; 3: 773-784</bibtext> </blist> <blist> <bibtext> Ronald A, Viding E, Happe F, Plomin R. Individual differences in theory of mind ability in middle childhood and links with verbal ability and autistic traits: A twin study. Social Neuroscience. 2006; 1: 1412-1425</bibtext> </blist> <blist> <bibtext> Rosenthal-Malek A, Mitchell S. Brief report: The effects of exercise on the self-stimulatory behaviors and positive responding of adolescents with autism. Journal of Autism and Developmental Disorders. 1997; 27; 2: 193-202</bibtext> </blist> <blist> <bibtext> Schmidt RC, Fitzpatrick PAPassos P, Davids K, Yi CJ. The origin of the ideas of interpersonal synchrony and synergies. Interpersonal coordination and performance in social systems. 2016: London; Routledge: 17-31</bibtext> </blist> <blist> <bibtext> Senju A, Southgate V, White S, Frith U. Mindblind eyes: An absence of spontaneous theory of mind in Asperger syndrome. Science. 2009; 325; 5942: 883-885. 10.1126/science.1176170</bibtext> </blist> <blist> <bibtext> Sodian B, Kristen-Antonow S. Declarative joint attention as a foundation of theory of mind. Developmental Psychology. 2015; 51; 9: 1190-1200. 10.1037/dev0000039</bibtext> </blist> <blist> <bibtext> Sowa M, Meulenbroek R. Effects of physical exercise on autism spectrum disorders: A meta-analysis. Research in Autism Spectrum Disorders. 2012; 6; 1: 46-57. 10.1016/j.rasd.2011.09.001</bibtext> </blist> <blist> <bibtext> Stasolla F, Perilli V, Boccasini A, Caffò AO, Damiani R, Albano V. Enhancing academic performance of three boys with autism spectrum disorders and intellectual disabilities through a computer-based program. Life Span and Disability. 2016; 19; 2: 153-183</bibtext> </blist> <blist> <bibtext> Thelen E. Rhythmical stereotypies in normal human infants. Animal Behavior. 1979; 27: 699-715</bibtext> </blist> <blist> <bibtext> Thelen E. Rhythmical behavior in infancy: An ethological perspective. Developmental Psychology. 1981; 17: 237-257</bibtext> </blist> <blist> <bibtext> Tomasello MMoore C, Dunham PJ. Joint attention as social cognition. Joint attention: Its origins and role in development. 1995: Hillsdale; Erlbaum: 103-130</bibtext> </blist> <blist> <bibtext> Tordjman S, Davlantis KS, Georgieff N, Geoffray M, Speranza M, Anderson GM. Autism as a disorder of biological and behavioral rhythms: Toward new therapeutic perspectives. Frontiers in Pediatrics. 2015; 3: 56-70. 10.3389/fped.2015.00001</bibtext> </blist> <blist> <bibtext> Tse CA, Pang CL, Lee PH. Choosing an appropriate physical exercise to reduce stereotypic behavior in children with autism spectrum disorders: A non-randomized crossover study. Journal of Autism and Developmental Disorders. 2018; 48: 1666-1672. 10.1007/s10803-017-3419-3</bibtext> </blist> <blist> <bibtext> Tunçgenç B, Cohen E, Fawcett C. Rock with me: The role of movement synchrony in infants' social and nonsocial choices. Child Development. 2015; 86; 3: 976-984. 10.1111/cdev.12354</bibtext> </blist> <blist> <bibtext> Turner M. Annotation: Repetitive behavior in autism: A review of psychological research. Journal of Child Psychology and Psychiatry. 1999; 40; 6: 839-849</bibtext> </blist> <blist> <bibtext> Warneken F, Chen F, Tomasello M. Cooperative activities in young children and chimpanzees. Child Development. 2006; 77; 3: 640-663</bibtext> </blist> <blist> <bibtext> Warreyn P, Roeyers H, Oelbrandt T, de Groote I. What are you looking at: Joint attention and visual perspective taking in young children with autism spectrum disorder. Journal of Developmental and Physical Disabilities. 2005; 17; 1: 55-73</bibtext> </blist> <blist> <bibtext> Wellman HM, Liu D. Scaling of theory-of-mind tasks. Child Development. 2004; 75; 2: 523-541. 10.1111/j.1467-8624.2004.00691.x</bibtext> </blist> <blist> <bibtext> Wiltermuth SS, Heath C. Synchrony and cooperation. Psychological Science. 2009; 20; 1: 1-5. 10.1111/j.1467-9280.2008.02253.x</bibtext> </blist> </ref> <aug> <p>By Andrew Lampi; Paula Fitzpatrick; Veronica Romero; Joseph Amaral and R. C. Schmidt</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib27" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib43" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib20" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib36" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib52" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib50" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib25" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib37" firstref="ref10"></nolink> <nolink nlid="nl9" bibid="bib66" firstref="ref11"></nolink> <nolink nlid="nl10" bibid="bib75" firstref="ref12"></nolink> <nolink nlid="nl11" bibid="bib86" firstref="ref14"></nolink> <nolink nlid="nl12" bibid="bib44" firstref="ref17"></nolink> <nolink nlid="nl13" bibid="bib46" firstref="ref19"></nolink> <nolink nlid="nl14" bibid="bib58" firstref="ref22"></nolink> <nolink nlid="nl15" bibid="bib38" firstref="ref23"></nolink> <nolink nlid="nl16" bibid="bib33" firstref="ref24"></nolink> <nolink nlid="nl17" bibid="bib16" firstref="ref25"></nolink> <nolink nlid="nl18" bibid="bib15" firstref="ref26"></nolink> <nolink nlid="nl19" bibid="bib35" firstref="ref27"></nolink> <nolink nlid="nl20" bibid="bib21" firstref="ref29"></nolink> <nolink nlid="nl21" bibid="bib42" firstref="ref30"></nolink> <nolink nlid="nl22" bibid="bib53" firstref="ref31"></nolink> <nolink nlid="nl23" bibid="bib45" firstref="ref33"></nolink> <nolink nlid="nl24" bibid="bib83" firstref="ref34"></nolink> <nolink nlid="nl25" bibid="bib84" firstref="ref35"></nolink> <nolink nlid="nl26" bibid="bib10" firstref="ref36"></nolink> <nolink nlid="nl27" bibid="bib13" firstref="ref39"></nolink> <nolink nlid="nl28" bibid="bib12" firstref="ref40"></nolink> <nolink nlid="nl29" bibid="bib85" firstref="ref42"></nolink> <nolink nlid="nl30" bibid="bib80" firstref="ref43"></nolink> <nolink nlid="nl31" bibid="bib39" firstref="ref44"></nolink> <nolink nlid="nl32" bibid="bib18" firstref="ref45"></nolink> <nolink nlid="nl33" bibid="bib70" firstref="ref46"></nolink> <nolink nlid="nl34" bibid="bib76" firstref="ref47"></nolink> <nolink nlid="nl35" bibid="bib79" firstref="ref48"></nolink> <nolink nlid="nl36" bibid="bib17" firstref="ref49"></nolink> <nolink nlid="nl37" bibid="bib22" firstref="ref50"></nolink> <nolink nlid="nl38" bibid="bib63" firstref="ref51"></nolink> <nolink nlid="nl39" bibid="bib48" firstref="ref52"></nolink> <nolink nlid="nl40" bibid="bib41" firstref="ref53"></nolink> <nolink nlid="nl41" bibid="bib67" firstref="ref54"></nolink> <nolink nlid="nl42" bibid="bib56" firstref="ref55"></nolink> <nolink nlid="nl43" bibid="bib72" firstref="ref57"></nolink> <nolink nlid="nl44" bibid="bib78" firstref="ref60"></nolink> <nolink nlid="nl45" bibid="bib61" firstref="ref61"></nolink> <nolink nlid="nl46" bibid="bib40" firstref="ref62"></nolink> <nolink nlid="nl47" bibid="bib93" firstref="ref63"></nolink> <nolink nlid="nl48" bibid="bib88" firstref="ref64"></nolink> <nolink nlid="nl49" bibid="bib23" firstref="ref65"></nolink> <nolink nlid="nl50" bibid="bib65" firstref="ref66"></nolink> <nolink nlid="nl51" bibid="bib57" firstref="ref67"></nolink> <nolink nlid="nl52" bibid="bib29" firstref="ref68"></nolink> <nolink nlid="nl53" bibid="bib31" firstref="ref69"></nolink> <nolink nlid="nl54" bibid="bib30" firstref="ref70"></nolink> <nolink nlid="nl55" bibid="bib32" firstref="ref71"></nolink> <nolink nlid="nl56" bibid="bib71" firstref="ref76"></nolink> <nolink nlid="nl57" bibid="bib77" firstref="ref77"></nolink> <nolink nlid="nl58" bibid="bib87" firstref="ref78"></nolink> <nolink nlid="nl59" bibid="bib49" firstref="ref85"></nolink> <nolink nlid="nl60" bibid="bib64" firstref="ref86"></nolink> <nolink nlid="nl61" bibid="bib81" firstref="ref88"></nolink> <nolink nlid="nl62" bibid="bib14" firstref="ref89"></nolink> <nolink nlid="nl63" bibid="bib60" firstref="ref91"></nolink> <nolink nlid="nl64" bibid="bib62" firstref="ref95"></nolink> <nolink nlid="nl65" bibid="bib89" firstref="ref96"></nolink> <nolink nlid="nl66" bibid="bib47" firstref="ref97"></nolink> <nolink nlid="nl67" bibid="bib59" firstref="ref102"></nolink> <nolink nlid="nl68" bibid="bib73" firstref="ref103"></nolink> <nolink nlid="nl69" bibid="bib54" firstref="ref106"></nolink> <nolink nlid="nl70" bibid="bib90" firstref="ref111"></nolink> <nolink nlid="nl71" bibid="bib68" firstref="ref118"></nolink> <nolink nlid="nl72" bibid="bib55" firstref="ref119"></nolink> <nolink nlid="nl73" bibid="bib92" firstref="ref120"></nolink> <nolink nlid="nl74" bibid="bib69" firstref="ref121"></nolink> <nolink nlid="nl75" bibid="bib51" firstref="ref122"></nolink> <nolink nlid="nl76" bibid="bib91" firstref="ref123"></nolink> <nolink nlid="nl77" bibid="bib19" firstref="ref129"></nolink> <nolink nlid="nl78" bibid="bib11" firstref="ref130"></nolink> <nolink nlid="nl79" bibid="bib24" firstref="ref131"></nolink> <nolink nlid="nl80" bibid="bib267" firstref="ref137"></nolink> <nolink nlid="nl81" bibid="bib801" firstref="ref145"></nolink> <nolink nlid="nl82" bibid="bib270" firstref="ref151"></nolink> <nolink nlid="nl83" bibid="bib810" firstref="ref157"></nolink> <nolink nlid="nl84" bibid="bib26" firstref="ref158"></nolink> <nolink nlid="nl85" bibid="bib82" firstref="ref167"></nolink> <nolink nlid="nl86" bibid="bib74" firstref="ref169"></nolink> <nolink nlid="nl87" bibid="bib28" firstref="ref171"></nolink> <nolink nlid="nl88" bibid="bib34" firstref="ref172"></nolink>
Header DbId: eric
DbLabel: ERIC
An: EJ1252836
AccessLevel: 3
PubType: Academic Journal
PubTypeId: academicJournal
PreciseRelevancyScore: 0
IllustrationInfo
Items – Name: Title
  Label: Title
  Group: Ti
  Data: Understanding the Influence of Social and Motor Context on the Co-Occurring Frequency of Restricted and Repetitive Behaviors in Autism
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Lampi%2C+Andrew%22">Lampi, Andrew</searchLink><br /><searchLink fieldCode="AR" term="%22Fitzpatrick%2C+Paula%22">Fitzpatrick, Paula</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-4231-6500">0000-0002-4231-6500</externalLink>)<br /><searchLink fieldCode="AR" term="%22Romero%2C+Veronica%22">Romero, Veronica</searchLink><br /><searchLink fieldCode="AR" term="%22Amaral%2C+Joseph%22">Amaral, Joseph</searchLink><br /><searchLink fieldCode="AR" term="%22Schmidt%2C+R%2E+C%2E%22">Schmidt, R. C.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. May 2020 50(5):1479-1496.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 18
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2020
– Name: SourceSuprt
  Label: Sponsoring Agency
  Group: SrcSuprt
  Data: National Institute of Mental Health (DHHS/NIH)
– Name: NumberContract
  Label: Contract Number
  Group: NumCntrct
  Data: R21MH094659
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Patterns%22">Behavior Patterns</searchLink><br /><searchLink fieldCode="DE" term="%22Repetition%22">Repetition</searchLink><br /><searchLink fieldCode="DE" term="%22Social+Behavior%22">Social Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Severity+%28of+Disability%29%22">Severity (of Disability)</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Age%22">Mental Age</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10803-018-3698-3
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0162-3257
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The social and motor context in which restricted and repetitive behaviors (RRBs) occur in autism and their relationship to social traits are not well-understood. Participants with and without autism completed tasks that varied in social and motor engagement and RRB frequency was measured. Motor and verbal RRBs were most common, RRBs varied based on motor and social context for participants with autism, and social engagement was associated with lower motor and verbal RRBs. Significant correlations between RRBs and autism severity, social synchrony, and nonverbal mental age were also found. This research confirms the importance of context for understanding RRBs during on-going tasks and raises questions about whether the factors that elicit vocal and motor RRBs are unique for individual children.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2020
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1252836
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1252836
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1007/s10803-018-3698-3
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 18
        StartPage: 1479
    Subjects:
      – SubjectFull: Children
        Type: general
      – SubjectFull: Autism
        Type: general
      – SubjectFull: Pervasive Developmental Disorders
        Type: general
      – SubjectFull: Behavior Patterns
        Type: general
      – SubjectFull: Repetition
        Type: general
      – SubjectFull: Social Behavior
        Type: general
      – SubjectFull: Severity (of Disability)
        Type: general
      – SubjectFull: Mental Age
        Type: general
    Titles:
      – TitleFull: Understanding the Influence of Social and Motor Context on the Co-Occurring Frequency of Restricted and Repetitive Behaviors in Autism
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Lampi, Andrew
      – PersonEntity:
          Name:
            NameFull: Fitzpatrick, Paula
      – PersonEntity:
          Name:
            NameFull: Romero, Veronica
      – PersonEntity:
          Name:
            NameFull: Amaral, Joseph
      – PersonEntity:
          Name:
            NameFull: Schmidt, R. C.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 05
              Type: published
              Y: 2020
          Identifiers:
            – Type: issn-print
              Value: 0162-3257
          Numbering:
            – Type: volume
              Value: 50
            – Type: issue
              Value: 5
          Titles:
            – TitleFull: Journal of Autism and Developmental Disorders
              Type: main
ResultId 1