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Restricted and Repetitive Behaviours, Sensory Processing and Cognitive Style

in Children with Autism Spectrum Disorders

Article in Journal of Autism and Developmental Disorders · December 2008

DOI: 10.1007/s10803-008-0663-6 · Source: PubMed

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J Autism Dev Disord (2009) 39:635–642
DOI 10.1007/s10803-008-0663-6

ORIGINAL PAPER

Restricted and Repetitive Behaviours, Sensory Processing

and Cognitive Style in Children with Autism Spectrum Disorders
Yu-Han Chen Æ Jacqui Rodgers Æ Helen McConachie

Published online: 18 November 2008

Ó Springer Science+Business Media, LLC 2008

Abstract Many individuals with autism tend to focus on rote memory skills or visuospatial processing. In order to
details. It has been suggested that this cognitive style may try to account for the strengths as well as the weaknesses
underlie the presence of stereotyped routines, repetitive in autism, cognitive theories have emerged which link
interests and behaviours, and both relate in some way to behavioural characteristics to an underlying cognitive style
sensory abnormalities. Twenty-nine children with diagno- typified by a style of information processing known as
sis of high functioning autism or Asperger syndrome weak central coherence (WCC) (Frith 1989). Frith postu-
completed the Embedded Figures Test (EFT), and their lated that a cognitive style indicative of WCC will result in
parents the Short Sensory Profile and Childhood Routines a reduction of the usual tendency to strive for coherence
Inventory. Significant correlations were found between and integrate sensory stimuli into a ‘gestalt’ or ‘perceptual
degree of sensory abnormalities and amount of restricted whole’ whilst the ability to focus on detail is preserved or
and repetitive behaviours reported. Repetitive behaviours, in some instances even enhanced. Since then the theory has
age and IQ significantly predicted completion time on the been proposed to account for superior performance by
EFT. The results suggest a cognitive link between an individuals with ASD on a range of measures. One
individual’s detail-focused cognitive style and their repet- example is the Embedded Figures Test (EFT) which
itiveness. No such relationship was found with sensory requires the individual to identify a smaller shape that is
processing abnormalities, which may arise at a more ‘camouflaged’ by integration into a wider pattern or pic-
peripheral level of functioning. ture. Individuals with ASD have been found to display
superior performance to controls on this task (Jolliffe and
Keywords Embedded Figures Test
Sensory processing
Baron-Cohen 1997; Shah and Frith 1983) supporting the
Restricted and repetitive behaviours
theory. However recently evidence has emerged which has
Weak central coherence
Cognitive style resulted in the refinement of the construct of WCC. In
some studies, the predicted superior performance by indi-
viduals with ASD on tasks which require detailed focusing
Introduction has not been found (Brian and Bryson 1996; Norbury
2005); in others, inferior performance on tasks which
Some individuals with autism spectrum disorder (ASD) require gestalt or holistic processing has not been detected
present with islets of superior performance, for example in (Mottron et al. 2003). The consensus appears to be that
‘central coherence’ is not the issue, but rather the need to
explain the superior performance of many children with
Y.-H. Chen
J. Rodgers
H. McConachie ASD on visuospatial tasks which require detailed or local
Newcastle University, Newcastle, UK processing.
Furthermore, the question has been raised of whether
H. McConachie (&)
there may be relationships between a detail-focused cog-
Sir James Spence Institute, Royal Victoria Infirmary,
Newcastle upon Tyne NE1 4LP, UK nitive style and some of the behavioural characteristics of
e-mail: [email protected] ASD, such as abnormal responses to sensory input and

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636 J Autism Dev Disord (2009) 39:635–642

the presence of restricted or repetitive behaviours and of restricted and repetitive behaviours (e.g. staring at lights,
thoughts. or avoidance of certain environments), and furthermore
Studies of sensory processing in individuals with ASD that a detail-focused cognitive style may be involved.
find high rates of reported abnormalities (over 90% in some However to date no research has examined the potential
studies) including hyper- and hypo-sensitivity, and sensory inter-relationships between sensory processing abnormali-
overload (Leekam et al. 2007; Rogers et al. 2003; Rogers ties, restricted and repetitive behaviours, and cognitive
and Ozonoff 2005; Tomchek and Dunn 2007). It is sug- style.
gested that, because of a detail-focused style of processing, We hypothesise that: (a) children with ASD with sen-
individuals with ASD may have great difficulty in filtering sory processing abnormalities will show a greater degree of
out sensory information from the environment. For exam- restricted and repetitive behaviours; (b) children with ASD
ple, heightened sensitivity to novel elements in the with a greater degree of repetitive behaviour and sensory
environment may underlie preference for sameness (Baron- symptoms will show a detail-focused cognitive style.
Cohen and Belmonte 2005; Happé 1999). However, there
is as yet little empirical evidence for a link between per-
ceptual or cognitive processing and sensory abnormalities. Methods
Minshew and Hobson (2008) did not find a correspondence
between the one-third of individuals with high functioning Participants
autism in their sample who reported high levels of sensory
responsiveness, and the one-third who showed high rates of Inclusion criteria for the study were: child aged between 8
complex sensory processing errors on testing. and 16 years, with a diagnosis of Asperger syndrome or
In relation to repetitive behaviours, Evans et al. (2001) ASD. Children under the age of 8 years were not included
investigated the connection with certain visuo-spatial due to task demands of the EFT. Seventy-seven potential
abilities in typically developing young children. They participants were identified by child and adolescent mental
found that higher levels of restricted and repetitive health clinicians, who had previously conducted the diag-
behaviours were associated with superior performance on nostic assessment for the child. They sent an invitation
the EFT, indicating a potential association between cog- letter to each family with information about the study.
nitive style and repetitiveness. However, South et al. Forty-one (53%) consented to take part in assessments.
(2007) did not find evidence of a link between measures of Exclusion of children’s data from analysis: age 7 years
WCC and repetitive behaviours in school-age children with (1 child); IQ below 70 (2 children); screening score less
ASD and in matched typically developing children. The than 9 on the Social Communication Questionnaire (SCQ)
inclusion of differing measures of repetitive behaviours (see below) (1 child). Further, 8 children were unable to
and children of very different ages makes it difficult to complete more than the first item of EFT, so their data are
interpret these contradictory findings. As the association not included (see Table 1).
between cognitive style and repetitiveness is found early in Data from 29 children (26 male, 3 female) were there-
typical development, further exploration is warranted in fore analysed. All had been diagnosed through assessment
ASD. by a multidisciplinary team including as a minimum child
An association between sensory processing abnormali- and adolescent psychiatrist and clinical psychologist. The
ties seen in ASD and the presence of restricted and assessment procedures used by the teams follow the
repetitive behaviours has been described by a number of guidelines suggested in the UK National Autism Plan for
authors (Lovaas et al. 1987; Minshew and Goldstein 1998; Children (Le Couteur 2003) and include a detailed devel-
Turner 1999). Preoccupations with non-functional ele- opmental history, observation in several settings, and the
ments of materials (odour, texture, vibration, etc.) are Autism Diagnostic Observation Schedule (Lord et al.
included in one of the categories of ‘restricted, repetitive 2000). Participants had no known concomitant neurologi-
and stereotyped patterns of behaviour, interests and activ- cal disorder or physical disability. Mean age was 11 years
ities’ in the International Classification of Diseases (ICD- 11 months (range 8 years 2 months to 16 years 2 months).
10, WHO 1992). It is suggested that some restricted and
repetitive behaviours may be undertaken by individuals Screening Measures
with autism in order to manage their unusual sensory
processing (Baker et al. 2008). Social Communication Questionnaire (SCQ)
Thus, in summary, it has been suggested that there are
relationships between some sensory processing abnormal- This is a 40 item screening questionnaire completed by
ities seen in ASD (e.g. hyporesponsiveness to visual caregivers. In this study it was used to confirm a history of
stimuli, or hyperresponsiveness to sound) and the presence significant autism behavioural characteristics. The

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J Autism Dev Disord (2009) 39:635–642 637

Table 1 Characteristics of participants

EFT analysis Gender M:F Mean age (SD) Mean SCQ score (SD) Mean IQ (SD)

Participants included (n = 29) 26:3 11 years 11 months (25.6 months) 21.3 (7.1) 114.4 (16.8)
Participants excluded (n = 8) 6:2 9 years 1 month (11.9 months) 22.7 (5.5) 80.4 (9.3)
EFT = Embedded Figures Test; SCQ = Social Communication Questionnaire; IQ = WISC estimated full scale IQ

suggested cut-off score of SCQ for autism is a score of 15 was chosen for the study as it emphasises adherence to
or above (Berument et al. 1999). However, this cut-off can routines and desire for sameness, more than repetitive
be adapted for individual studies. Eaves et al. (2006) found sensori-motor behaviours which have been shown to be
that sensitivity and specificity were lower for children with less prominent in individuals with higher ability (Cuccaro
high verbal IQs, and it has been suggested that a lower cut- et al. 2003). The reported internal consistency is .89. Two
off may be appropriate (Corsello et al. 2007). Thirty-one scores are produced, the total number of behaviours
children were at cut-off point of 15 or above; six had scores endorsed and the mean intensity (between 1 and 5). Factor
from 9 to 13. As mentioned above, one child with a SCQ scores (‘Just Right’ and Repetitive Behaviours) were not
score of 2 was excluded from analysis. used in analysis because of uncertainty about their repro-
ducibility (Zohar and Felz 2001).
Wechsler Intelligence Scale for Children (WISC) The Embedded Figures Test (EFT) (Witkin et al. 1971)
is a perceptual task which is widely used to assess visual-
A short form version of WISC-III-UK (Weschler 1991), spatial cognitive style. Participants are required to locate a
suggested by Kaufman et al. (1996) as being a good previously seen simple hidden figure (e.g. triangle or house
compromise between psychometric and clinical accept- shape) within a larger complex abstract design. The time
ability and practical utility, was used to estimate taken to correctly spot the simple shape in the 12 complex
participants’ IQ. Four subtests were included (Picture pictures is recorded, and has been shown to distinguish
Completion, Similarities, Arithmetic, and Block Design). individuals with autism from controls (De Jonge et al.
2006; Keehn et al. 2008). Following the modified proce-
Dependent Measures dure of Shah and Frith (1983) and Ropar and Mitchell
(2001), the children were allowed to indicate the hidden
The Short Sensory Profile (SSP) (Dunn 1999) is a parental figure by using their finger or a stylus pen without ink to
report of children’s sensory symptoms, and one of the most trace the simple shape. The target shape was visible when
frequently used methods for studying sensory responsivity the participant was searching for it in the complex figure.
in autism (Rogers et al. 2003). Parents rate the frequency The children were told to work as quickly as they could.
with which their child responds to various sensory expe- The researcher recorded completion time on a stopwatch
riences in everyday situations for 38 items on a 5-point once the child had pointed out the correct solution. The
Likert scale, with a lower score indicating more impair- mean solution time (seconds/items) for items identified
ment. The Total score range is 38–190, with cut-off points correctly within 3 min was recorded. Where children did
for probable and definite difference from typical perfor- not succeed on an item, a solution time of 180 s was
mance. Seven subscales are identified: tactile sensitivity, attributed to that item.
taste/smell sensitivity, movement sensitivity, visual/audi- Eight children scored either 0 or only 1 item correct on
tory sensitivity, underresponsive/seeks sensation, auditory the EFT and their data were therefore excluded from fur-
filtering, and low energy/weak. ther analysis. As can be seen from Table 1, these children
The SSP Total score has internal consistency of a = .95. were younger, had lower IQ and higher SCQ scores indi-
Tomchek and Dunn (2007) have found that 95% of young cating that the EFT may have been too difficult for them.
children with ASD are reported to have some degree of
sensory processing dysfunction on the SSP Total score, and Procedure
that they perform significantly differently (p \ .001) on
92% of items from age-matched typically developing A positive opinion for the research was granted by the
children. Sunderland Research Ethics Committee. Children were
The Childhood Routines Inventory (CRI) (Evans et al. seen either at home, at school or at a University office as
1997) is a 19-item parent-report questionnaire developed to convenient to the family. The WISC-III subtests were
assess ‘compulsive-like behaviours’ in young children, administered first, followed by two visual tasks: the EFT
recorded according to frequency and intensity. The CRI and the Planning Drawing Task (Booth et al. 2003). (The

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Planning Drawing Task data are not reported here, as the Table 3 Profile of subscale scores on the Short Sensory Profile
task appeared easy for many of the children, so the error Proportion of sample Definite Probable Typical
analysis was uninformative.) All the assessments were difference difference
completed within approximately 60–90 min. Children were
SSP Factor 1 (tactile sensitivity) 52 17 31
given a 5 min break after the WISC.
The three questionnaires were sent to parents if their SSP Factor 2 (taste/smell sensitivity) 45 14 41
child was assessed in school. Where the child was seen at SSP Factor 3 (movement sensitivity) 38 14 48
home or in the university department, parents were asked SSP Factor 4 (under responsive/ 66 7 28
seeks sensation)
to complete the questionnaires while their child was being
SSP Factor 5 (auditory filtering) 90 7 3
assessed. It took approximately 40 min for parents to
SSP Factor 6 (low energy/weak) 52 3 45
complete the questionnaires.
SSP Factor 7 (visual/auditory 38 24 38
sensitivity)
Analysis

Prior to statistical analysis, the distribution of the data was the SSP. For the SSP Total score, 7% were reported as
examined for normality using the Kolmogorov–Smirnov ‘typical’, 17% as having a ‘probable difference’ [from the
test. The total score of the Short Sensory Profile was not norm], and 76% a ‘definite difference’. The proportions for
normally distributed. Data transformation (square root) was the SSP subscales are presented in Table 3. Auditory fil-
therefore applied. tering was the sub-scale for which most children were rated
SPSS (Statistical Package for Social Science software, as presenting with a definite difference from the norm
version 11.0) was used for all statistical analyses. Pearson (including difficulties such as ‘can’t work with background
correlations and multiple regression analyses were used to noise’, and ‘appears to not hear what you say’), i.e.
examine the hypotheses. including both hyper- and hypo-responsivity. Underre-
sponsive/seeks sensation and tactile sensitivity were the
next most frequently abnormal categories, as was also
Results found by Tomchek and Dunn (2007).
Hypothesis 1 It was predicted that children with more
The Childhood Routines Inventory (CRI), Short Sensory
severe sensory processing abnormalities would show more
Profile (SSP) and the EFT mean scores, with standard
restricted and repetitive behaviours. This hypothesis was
deviations and ranges, are given in Table 2. Even for
supported. Significant correlations were found between the
typically developing children at their most repetitive (age
total score on SSP and the CRI total number of items
2 years) Evans et al. (1997) reported CRI mean number of
endorsed (r = -.42, p = .02), as well as the total fre-
items endorsed as 9.53 (SD 4.93). Therefore this group of
quency and intensity score (r = -.61, p = .00) (see
able young people with ASD are reported to show signif-
Table 4).
icant numbers of types of restricted and repetitive
Further exploration of the relationship between types of
behaviours. The three most frequently endorsed items of
sensory processing and repetitive behaviours was under-
the CRI were ‘prefer to have things done in a particular
taken. Correlations between the seven individual subscales
order or in a certain way’ (endorsed for 97% of the sam-
of the SSP and the CRI total number of items endorsed and
ple), ‘prefer the same household schedule or routine
the frequency and intensity score are reported in Table 4.
everyday’ (97%) and ‘strongly prefer to stick to one game
Significant relationships were found between the total
or activity rather than change to a new one’ (93%).
number, and the frequency and intensity, of behaviours and
The level of reported sensory abnormalities can be
both tactile sensitivity and visual/auditory sensitivity. This
compared to the norm-referenced classification system for
suggests restricted and repetitive behaviours may be more
related to forms of hyperresponsiveness than to under-
Table 2 Total scores on the Childhood Routines Inventory, Short
Sensory Profile and Embedded Figures Test responsiveness and low energy/weakness.

Mean (SD) Range Hypothesis 2 It was predicted that there would be a

relationship between the sensory abnormalities and com-
CRI (total number of items endorsed) 15.48 (3.70) 6–19
pletion time on the EFT. However no significant
CRI (frequency/intensity per item) 3.28 (.93) 1.42–4.89 correlations were found between completion time on the
Short Sensory Profile total 122.24 (23.54) 82–168 EFT and the SSP (Table 4).
Embedded Figures Test mean 54.43 (33.30) 15.56–129.35 It was predicted that children exhibiting more restricted
solution time (sec/item)
and repetitive behaviours would have faster completion

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J Autism Dev Disord (2009) 39:635–642 639

Table 4 Correlations between Childhood Routines Inventory, Short Sensory Profile and the Embedded Figures Test
SSP total CRI items endorsed CRI frequency/intensity EFT speed

CRI items endorsed 2.42*

CRI frequency/intensity 2.61** .85**
Tactile sensitivity .77** 2.72* 2.73* -.01
Taste/smell sensitivity .42** .22 -.05 .15
Movement sensitivity .31 -.11 -.4 -.20
Under responsive .75** -.33 .36 -.08
Auditory filtering .70** -.55 -.43 -.03
Low energy/weak .43* -.31 -.31 .07
Visual/auditory sensitivity .67** 2.74* 2.78* -.03
EFT speed -.02 2.39* -.26
* Significant at p \ .05 (2 tailed)
** Significant at p \ .01 (2 tailed)
Significant correlations in bold

Table 5 Predictors of performance on the Embedded Figures Test

Dependent variable Independent variables R square Adjusted R square Beta t p Value

EFT (mean solution time) n = 29 Age .546 .470 -.504 -3.552 .002
IQ -.467 -3.169 .004
SSP (total) -.233 -1.532 .139
CRI (no. items) -.360 -2.280 .032
IQ = WISC estimated full scale IQ; CRI (no. items) = total number of items endorsed in CRI; SSP (total) = total score of Short Sensory Profile
Significant predictors in bold

times for the EFT. A significant correlation was found style in able young people with ASD. We found that sensory
between mean solution time on the EFT and total number processing abnormalities did not predict performance on the
of CRI items endorsed (r = -.39, p \ .05), though the cognitive task measuring the extent of detail focus (the
correlation with frequency and intensity of behaviours was EFT). However, the degree of restricted and repetitive
not significant. The findings suggest that high functioning behaviours (as measured by the CRI) was found to be a
children with ASD who demonstrate a detail-focussed significant predictor of the speed with which children with
cognitive style tend to have a considerable number of ASD completed the EFT.
different restricted and repetitive behaviours. We found a significant relationship between the presence
of sensory abnormalities and restricted and repetitive behav-
Predictors of Cognitive Style iours. This is in accordance with the ICD10 classification
system for the repetitive domain in autism. That a significant
Multiple regression analysis was used to determine the association was detected between sensory symptoms and
strongest predictors of speed of completion on the EFT. repetitive behaviours supports previous work (Rogers et al.
Age, IQ, the number of items endorsed by parents on the 2003; Turner 1999; Minshew and Goldstein 1998; Lovaas
CRI and SSP total score were entered into the analyses as et al. 1987). The detailed findings suggested particular
the independent variables. Age, IQ and the number of items relationships with tactile, visual and auditory hyperrespon-
endorsed on the CRI were found to be unique and signif- siveness. A review of the evidence on sensory dysfunction by
icant predictors of solution time on the EFT (Table 5). Rogers and Ozonoff (2005) suggested stronger evidence for
hyporesponsiveness in autism than hyperresponsiveness, but
there may be differing findings in groups at different ages and
Discussion level of ability. In combination with previous findings of the
high prevalence of sensory abnormalities, this study suggests
The main purpose of this study was to investigate whether that there is much yet to be learned about how sensory pro-
restricted and repetitive behaviours and sensory processing cessing may relate to the characteristic restricted and
abnormalities are associated with a detail-focused cognitive repetitive behavioural features in autism.

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Why do restricted and repetitive behaviours, but not Our study has a number of limitations. Almost half of
sensory processing abnormalities, predict performance on the children and/or parents approached did not reply or
the EFT? Sensory processing is by its very nature a lower- declined participation. Recruitment bias is possible there-
level activity induced by peripheral sensory input and is fore. Those children who were willing to take part in this
thus not comparable to the type of processing required for study might have been more cooperative or accepting of
more complex tasks (Minshew and Hobson 2008). In other changes in their daily routines, and less impaired in terms
words, lower-level sensory processing might not be of their autism symptoms. This might be the reason why
directly related to performance of higher-level cognitive some of the children in our study did not reach the original
functions required to complete tasks such as the EFT. The suggested cut-off point on the SCQ (Berument et al. 1999).
restricted and repetitive behaviours reported in the CRI Whilst this may have reduced the likelihood of a type 1
focus on rituals and routines more than on repetitive sen- error because those children recruited may not have been as
sori-motor behaviours such as hand flapping, etc. They are restricted or repetitive as the wider ASD population and
more complex acts, involving cortical processing, and thus therefore strengthens the findings, it remains important to
perhaps more likely to be related to cognitive style. Thus determine whether the associations found can be replicated
although sensory processing abnormalities are significantly across the autism spectrum.
correlated with restricted and repetitive behaviours, it is not In addition we were not able to address whether the
surprising that sensory abnormalities did not predict which relationship between restricted and repetitive behaviours and
individuals evidenced a detail-focused cognitive style as cognitive style is specific to individuals with autism. Our
measured in this study. More research is required to findings support Evans et al. (2001) who found that increased
explore the potential associations between sensory abnor- repetitive behaviours were associated with better perfor-
malities, perceptual and cognitive functioning in autism mance on the EFT in a group of younger, typically
and the role that developmental change may potentially developing children, suggesting the relationship between
have (Leekam et al. 2007; Minshew and Hobson 2008; cognitive style in the visual domain and restricted and
Rogers and Ozonoff 2005). repetitive behaviours may be a feature of early typical
Frith (1989) proposed that WCC could explain autistic development. It would be important in a future study to
individuals’ focus on visual and auditory details, their dif- explore whether the strength of the relationship between
ficulties in processing information in context, stereotyped these two areas is stronger in children with autism than in
movements and thought, language and communication typically developing children, and whether within a young
impairments, and impairments in the perception of emotion. typically developing group the findings in relation to sensory
Our findings suggest that restricted and repetitive behav- processing and repetitiveness could be replicated. Finally,
iours are associated with a detail-focused processing style in there is the issue of change with age. The young people in this
the visual domain. This finding requires replication, and study were at least 8 years old and were high functioning. It
extension to other domains of functioning, such as the would be important to examine further the natural history of
auditory and linguistic domains. It seems likely that a the relationship between cognitive style and restricted and
cognitive style typified by a detail-focused approach might repetitive behaviours. Glenn and Cunningham (2007) have
underlie the presence of restricted and repetitive behaviours suggested that the presence of routinised behaviours in
such as a preference for sameness in household routines and children (both those with typical development and those with
environments, carrying out a ritual in a precise way, an Down syndrome) appears to have some positive functions
obsession with details of a circumscribed interest, or using and to support developmental progress.
the same repetitive actions and words whilst playing with In summary, this study found that amongst a high
objects. functioning group of school-age children with autism the
The nature of potential links between repetitiveness and number of restricted and repetitive behaviours, but not the
sensory abnormalities is only beginning to be explored. amount of sensory processing abnormalities, was associ-
Restricted and repetitive behaviours in ASD are manifest in ated with a cognitive style characterised as focusing on
many ways from simple sensori-motor actions to complex details. Children with more restricted and repetitive
circumscribed interests. In addition the sensory symptoms behaviours also exhibited more sensory processing abnor-
seen in ASD can be related to a range of different types of malities, particularly in relation to tactile, visual and
sensory processing systems, with hypo- and hyper- auditory hyperresponsiveness.
responsiveness co-existing in the same individual (Leekam
et al. 2007). A programme of research will be required to Acknowledgments We are grateful to all the young people and
parents who gave time to the study. The results were presented at the
develop a range of appropriate direct and indirect mea- British Psychological Society conference, Manchester, April 2005,
sures, with samples of young people of different ages and and formed part of the MPhil thesis of Yu-Han Chen.
abilities (Rogers and Ozonoff 2005).

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