Restricted and Repetitive Behaviors in Toddlers with ASD: The Impact of Caregiver-Mediated Jasper on Child Behaviors and Caregiver Strategies

Background:   Restricted and repetitive behaviors (RRBs) are a core feature of autism spectrum disorder (ASD). While research into this symptom domain has increased, considerably less is known about the function, treatment and etiology of RRBs relative to the social-communication impairments characteristic of ASD. As a result, social-communication deficits are often viewed as a more tangible target within early intervention. 

Objectives:   We know of no study that has explored the potential impact of a caregiver-mediated early intervention focused on social-communication behaviors on the core deficit of RRBs. The purpose of this study was to operationalize child RRBs and the strategies caregivers use in response to these behaviors within a free play session following a caregiver-mediated joint attention and symbolic play (JASPER) intervention which found beneficial effects on social-communication behaviors (Kasari et al., 2014). 

Methods:  86 toddlers (means age = 31m) with a diagnosis of ASD and their caregivers were recruited. Caregivers were randomized to receive a caregiver psychoeducation intervention based on Brereton & Tonge’s (2006) model (n=43) or JASPER (n=43) which involved hands on one-to-one coaching of the caregiver with their toddler with ASD. Child RRBs (object, motor, visual, verbal) were coded from a caregiver-child play interaction (CCX) at entry and following treatment, 10 weeks later. A caregiver behavior was selected for each child behavior (ignore, did not notice, physical, verbal and redirection). 

Results:  Using a mixed effects ordinal logistic model controlling for total number of RRBs, overall frequency of child RRBs reduced over the course of the intervention (F (3, 1399)= 9.14, p <0.001). Children in the psychoeducation group were more likely to reduce in their expression of motor RRBs compared to children receiving JASPER (F (3, 1399)= 4.80, p = 0.0025). All caregivers employed more active strategies to child RRBs over the course of the intervention (F (1, 1569)= 36.88, p <0.001); however, this was greater for caregivers in the JASPER group than caregivers receiving the psychoeducation model (F (1, 1569) = 13.09, p <0.001). This was specific to object RRBs (F (3, 1569) = 40.75, p <0.001). 

Conclusions:   Despite increases in child engagement and social-communication variables in the JASPER condition (Kasari et al., 2014), reductions in RRBs were not observed. Still caregivers in the JASPER group employed more active strategies in response to object RRBs within the free play session – most likely a consequence of the strategies implemented within JASPER and the potential interference these behaviors may have on play-based routines.  In comparison, there was a reduction of motor mannerisms in the psychoeducation group, suggesting that child and caregiver behaviors may vary as a result of intervention content and focus. While RRBs represent a concrete behavior in early childhood these may be harder to change within intervention than social-communication. Given the social-communication gains observed in the JASPER group (Kasari et al., 2014), our results suggest that these core deficits can “co-exist” and improvement in one domain may not be dependent upon improvement in the other. The relationship between these core deficits warrants further investigation.