Insistence on Sameness and Routine – Understanding a Hallmark Autism Trait

The DSM-V lists restricted and repetitive behaviors as one of its diagnostic criteria for autism. These behaviors can look like repetitive movements, restricted interests, insistence on sameness, and atypical responses to sensory stimuli. Mirko Uljarević, clinical assistant professor of psychiatry and behavioral sciences at Stanford University in California, says these four types of repetitive behavior described in the DSM-V may erroneously lump together distinct characteristics. In his study of 1,892 autistic children, Uljarević’s team found the insistence on sameness is comprised of three distinct types of behavior: routines, rituals, and insistence on sameness in others’ behavior.

While this study found that all three types correlate with anxiety, there is also distinct relationships with the individuals’ other traits, sex, and age. One finding was autistic boys tend to have routines and insist on sameness in others’ behavior but lack rituals.

Uljarević says, “Most existing measures don’t really contain enough items to assess the full range of behaviors that autistic people show. For instance, a measure that provides only a total repetitive behavior score cannot distinguish between someone who has very intense special interests but does not visibly stim — meaning they do not exhibit repetitive movements — and someone who mainly has stims but does not have special interests.”

To conduct this study, Uljarević and his colleagues devised the Dimensional Assessment of Repetitive Behavior (DARB) that has at least 10 items for each of the eight subdomains of repetitive behavior. (You can read more about the validation of this new parent-report measure here.)

The 3 subdomains from this study are:

1. Ritualistic – the need for objects in one’s environment to be arranged in a particular or “correct” manner, according to the person. For example, food must be arranged in a certain way or the person asks the same questions and needs specific answers.
2. Routines –  behaviors that are performed in the same order each time, typically to achieve a goal such as always going to bed or taking a bath in exactly the same way.
3. Sameness – insisting that other people follow specific routines or rituals. This third subdomain is less commonly seen outside of autism. Ex. At bedtime, my son needs me to say 3 specific sentences before he can go to sleep.

Mirko Uljarević’s concern about the DSM-V grouping all of these behaviors together under one category is that they might have different mechanisms behind the behavior and if that isn’t understood, then the interpretation and interventions or supports used may be incorrect.

To illustrate this point, Uljarević found that people who showed more sensitivity to sensory stimuli showed high levels of ritualistic sameness and routines, whereas sensory sensitivity was not linked to sameness behaviors that are focused on others. One explanation for this may be that people who are sensitive to sensory experiences may unconsciously use routines and organizing their environment in a particular way as a strategy to avoid distressing sensory experiences, such as loud noises or crowds.

Regarding the insistence on sameness, Uljarević’s colleague Emily Spackman thought perhaps that sameness behaviors involving others may have more to do with limiting unpredictability and feeling in control. Because social interactions are unpredictable, they can cause anxiety in autistic people. But – social functioning is very broad and there are many different types of social difficulty. This research team also developed the Stanford Social Dimensions Scale (SSDS) and plan to use this scale and the DARB together in future.

Emily Spackman has found a method to track and assess behaviors in real time using smartphones. By using this tracking method, certain questions could be answered such as:

1. Are certain repetitive behaviors commonly preceded by specific events?
2. How does engaging in repetitive behaviors affect autistic people’s mood?

Wendi Powers’ blog post My Autistic DNA Is Etched In Sameness And Routine provides autistic insight and experience on the insistence of sameness. Wendi says:

Insistence on sameness (IS) is a hallmark of the autistic brain. There are studies which attempt to understand this phenomenon. While it will be interesting to know what the researchers discover along the way, I can tell them one thing for a fact: IS dramatically dictates the life of a person with ASD. For a group of people who love to have a sense of control, it is ironic that IS is usually something we can’t control.

So what does IS have to do with motivation? In my case, it is everything. Even at such a young age, my biological drive for food was surpassed by my insistence that my mother’s appearance remained unaltered. I was not even motivated by the promise of my favorite dinner… apparently mac and cheese with cut up hotdogs.

We know that the insistence of sameness behavior (IS) is a core feature of autism that appears correlated with anxiety severity, but even with research on this topic (Uljarević completed an earlier study in 2017 on sameness, control and anxiety), we are learning that there may be other reasons for this behavior.

This also illustrates the point in my blog post How can we develop a better understanding of behaviors of concern? that we have to understand that the behavior we observe is just like the tip of an iceberg; below the surface of the waterline lies the cause of behavior and it might not be what we initially think it is. We need to delve below the waterline and address the root cause, not just the behavior itself. While routines and rituals can help an autistic person’s life feel more structured and predictable, there may be more reasons for this need that we haven’t discovered yet.

As we learn more about this topic, continue supporting the reduction of anxiety with ideas and tools that work best for the autistic person.

References

Powers, W. (November 10, 2018). My Autistic DNA Is Etched In Sameness And Routine. The Art of Autism

Schenkman, L. (October 30, 2023). Teasing apart insistence on sameness with Mirko Uljarević, The Transmitter