Research in Autism Spectrum Disorders 6 (2012) 422–430

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Research in Autism Spectrum Disorders

Journal homepage: http://ees.elsevier.com/RASD/default.asp

Review

Assessment and treatment of stereotypic behavior in children with

autism and other developmental disabilities: A thirty year review
Florence D. DiGennaro Reed *, Jason M. Hirst, Sarah R. Hyman
Department of Applied Behavioral Science, University of Kansas, Lawrence, KS, United States

A R T I C L E I N F O A B S T R A C T

Article history: A defining feature of children with autism includes stereotypy, characterized as restrictive
Received 1 July 2011 and repetitive vocal and motor behavior. The current literature review seeks to (a)
Accepted 4 July 2011 determine the number of empirical studies using behavioral interventions to treat
Available online 28 July 2011
stereotypy exhibited by children with autism or other pervasive development disorder, (b)
identify the assessment techniques used to determine the function of stereotypy, (c)
Keywords:
broadly categorize the treatment procedures, (d) summarize findings of other relevant
Autism
variables (e.g., participant demographics, experimental setting, change agents used, and
Stereotypy
Self-stimulatory behavior topography of stereotypy), and (e) determine the number of studies reporting reliability of
the independent variables. Results indicate that a wide variety of stereotypies are
represented in the published literature. A majority of studies do not rely on a functional
assessment to guide intervention planning and consequence-based approaches are the
most common treatment technique. Similar to previous research, measurement of
reliability of the independent variables is uncommon.
ß 2011 Elsevier Ltd. All rights reserved.

Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
2 Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
2.1 Overview of literature search procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
2.2 Coding procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
2.3 Rater training and interobserver agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
4.1 Implications for practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
4.2 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428

1. Introduction

Autism spectrum disorder (ASD) is an urgent concern in both public health and public expense. Recent prevalence reports
estimate that 1 in 110 eight-year-old children have ASD (Centers for Disease Control and Prevention [CDC], 2009) and the
annual direct and indirect per capita costs over the lifespan have reached $3.2 million in the United States (Ganz, 2007).

* Corresponding author at: Department of Applied Behavioral Science, University of Kansas, 4001 Dole Human Development Center, 1000 Sunnyside
Avenue, Lawrence, KS 66045-7555, United States. Tel.: +1 785 864 0521.
E-mail address: fdreed@ku.edu (F.D. DiGennaro Reed).

1750-9467/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2011.07.003
 F.D. DiGennaro Reed et al. / Research in Autism Spectrum Disorders 6 (2012) 422–430 423

Children with ASD show marked impairments in three core areas of functioning including social interaction,
communication, and repetitive or stereotyped behaviors (American Psychiatric Association [DSM-IV-TR], 2000). The latter
feature – stereotypy – refers to restricted and repetitive motor and vocal behaviors of no apparent adaptive function (LaGrow &
Repp, 1984; Matson, Kiely, & Bamburg, 1997; Smith & Van Houten, 1996). In addition to vocal and motor responses, stereotypy
may also include non-functional manipulation of objects (Falcomata, Roane, Feeney, & Stephenson, 2010). The importance of
researching and understanding stereotypy is underscored by evidence suggesting that these behaviors are related to a variety of
negative outcomes including, possibly not limited to, slowed skill acquisition (e.g., Dunlap, Dyer, & Koegel, 1983),
stigmatization (e.g., Jones, Wint, & Ellis, 1990), and impaired social interaction (e.g., Wolery, Kirk, & Gast, 1985).
While earlier definitions describe stereotypy as having no apparent function, more recent research supports the notion
that stereotypy is an operant behavior maintained by the consequences that follow it (e.g., automatic positive
reinforcement; Rapp & Vollmer, 2005a). Research has also documented that stereotypy can be socially mediated (i.e.,
maintained by attention from others or escape from task demands; e.g., Roantree & Kennedy, 2006). Identifying the function
of stereotypy through a functional behavioral assessment is an important condition for developing an effective intervention.
Functional assessment procedures consist of a variety of techniques along a continuum including informant report
(questionnaires and behavior rating scales; e.g., Durand & Crimmins, 1988), direct assessment (observation and data
recording; e.g., Lalli, Browder, Mace, & Brown, 1993), and experimental analyses (functional analysis, brief experimental
analysis; e.g., Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994). Presently, we do not know the extent to which
functional assessment precedes intervention design to address stereotypy in the published literature.
Although typically developing children may exhibit stereotypy at young ages (e.g., Foster, 1998), it tends to become less
frequent over time. Using direct observation techniques, MacDonald et al. (2007) found differences between the duration of
vocal and motor stereotypy in 2- to 4-year old children with ASD or pervasive developmental disorder not otherwise specified
(PDD-NOS) compared to typically developing children. At younger ages (i.e., 2 years) children with ASD or PDD-NOS exhibited
only somewhat higher levels of stereotypy than their typically developing peers. However, these differences were greater at
older ages (i.e., 3 and 4 years). Their findings documented higher durations of motor and vocal stereotypy for older preschool
children with ASD or PDD-NOS, but lower levels of motor stereotypy for same-aged typically developing children.
Significant differences in the prevalence of motor stereotypy between children with autism and children with other
developmental disorders have also been documented (e.g., Bodfish, Symons, Parker, & Lewis, 2000; Goldman et al., 2008).
Goldman et al. (2008) reviewed archived video footage of children with autism and children with other developmental
disorders and reported lower levels of stereotypy for the latter group. They noted that children with ASD exhibited increased
occurrence, frequency, and varieties of stereotypy compared to their peers with other developmental disorders.
Collectively, these findings suggest that identifying effective techniques to assess and treat stereotypy is a worthwhile
area of study to improve the lives of individuals with ASD. Fortunately, a body of literature exists to serve as a resource to
practitioners (MacDonald et al., 2007). For example, Ahearn, Clark, MacDonald, and Chung (2007) evaluated the impact of
response interruption and redirection (RIRD) on vocal stereotypy maintained by sensory consequences for four children with
ASD. During RIRD, occurrences of vocal stereotypy were interrupted (participants names were stated) and redirected
(delivery of vocal demands to which participants would likely comply). Prompts for appropriate vocalizations continued
until participants responded correctly without stereotypy for three consecutive trials, at which time praise for appropriate
use of language was provided. Results included reductions in stereotypy for all participants and increases in appropriate
vocalizations for 3 of 4 participants during RIRD. Several studies also support the effectiveness of access to matched
stimulation to reduce stereotypy (e.g., Rapp, 2007; Taylor, Hoch, & Weissman, 2005). Rapp (2007) examined the impact of
stimulation on vocal stereotypy exhibited by two boys with ASD and mental retardation. In the first study, a free-operant
preference assessment identified items that matched (i.e., generated sounds) or were not matched to the sensory
consequences of engaging in vocal stereotypy. Findings demonstrated that vocal stereotypy was lower only when access to
alternative auditory stimulation was made available (i.e., matched items were present).
Although several reviews have summarized stereotypy interventions for individuals with ASD, they either sample a
subset of representative studies (Rapp & Vollmer, 2005a), review neurobiological interpretations (Rapp & Vollmer, 2005b) or
may be considered dated (LaGrow & Repp, 1984). In an era of increased accountability and evidence-based practice,
practitioners would benefit from an up-to-date synthesis of stereotypy research to guide their assessment and intervention
efforts. Thus, the current review sought to: (a) determine the number of empirical studies using behavioral interventions to
treat stereotypy exhibited by children with ASD, (b) identify the assessment techniques used to determine the function of
stereotypy, (c) broadly categorize the treatment procedures, (d) summarize findings of other relevant variables (e.g.,
participant demographics, experimental setting, change agents used, and topography of stereotypy), and (e) determine the
number of studies reporting reliability of the independent variables.

2. Method

2.1. Overview of literature search procedures

We conducted computerized bibliographic searches in peer-reviewed journals from PsycINFO in June and September
2010 in order to identify potential studies. In addition, hand searches of the reference lists of all studies meeting inclusionary
criteria were also completed. A combination of the following keyword descriptors was used: autism, self-stimulatory,
424 F.D. DiGennaro Reed et al. / Research in Autism Spectrum Disorders 6 (2012) 422–430

stereotypy, stereotypic behavior, and stereotyped behavior. To be included in the review, studies were required to meet five
criteria. First, we excluded articles published in non-refereed journals and required that articles be at least four pages in
length. This requirement was established in order to ensure adequate descriptions of procedural details for our coding
procedures. Second, we required the identification of an effective treatment to address stereotypy as the main focus of
included studies. Third, we required that treatment effectiveness be assessed using rigorous experimental methodology. As a
result, treatment-control and treatment-comparison groups as well as single case experimental designs (excluding AB case
study designs) were appropriate for inclusion. Fourth, participants had to have a diagnosis of autism or other pervasive
developmental disorder (i.e., Asperger’s Syndrome, PDD-NOS) and be 18 years of age or younger. Finally, the article had to be
written in English and published in or after 1980. For articles containing multiple studies, we coded each study separately.
These selection procedures yielded 62 studies which were retained for additional coding and analysis.

2.2. Coding procedures

For this review, the articles were coded as follows: (1) participant demographics (age, gender, and disability), (2)
experimental setting, (3) topography of stereotypy, (4) type of assessment used, (5) function of stereotypy, (6) type of change
agent, (7) treatment used, (8) presence of an operational definition of the independent variable, and (9) whether or not
treatment integrity was monitored.
The experimental setting was coded as one of the seven of the following categories: (1) school, (2) hospital, (3) residence,
(4) university, (5) other, (6) does not specify, or (7) multiple.
The topography of participants’ stereotypy was coded into one of six broad categories adapted from MacDonald et al. (2007):
(1) movement of any or all body parts, (2) hand movements, (3) manipulation of objects (inconsistent with intended function or
manipulation of object), (4) vocal stereotypy, (5) other, and (6) multiple. Each category consisted of five–eight specific
topographies that were coded to provide more precise information about the form of stereotypy. For example, the first category
listed above – movement of any or all body parts – included the following topographies: (1) rocking, (2) non-functional closing
or squinting of the eyes, (3) jumping, (4) heel and toe walking, (5) pressing, rubbing, or tapping fingers or whole hand against
surface or body parts, (6) tapping objects with own body, finger, or open hand repeatedly, (7) spinning or rotation of entire body,
or (8) non-functional body tensing or posturing. The hand movement category included: (1) hand flapping/waving, (2) hand or
finger posturing, (3) non-contextual pointing/gestures, (4) fanning or spreading of fingers, (5) putting fingers/hands in ears or
mouth, (6) non-functional rotation of hand (more than 908) with or without materials, (7) positioning hands in front of face or
over ears, and (8) finger flicking. Stereotypy captured within the manipulation of objects category was further coded as: (1)
spinning, flipping, or waving objects, (2) addition of objects to a line (two or more), (3) licking, mouthing, or smelling objects,
people, or surfaces in a manner not appropriate to materials, (4) banging or tapping objects together, or (5) not otherwise
specified or other topographies. Any vocal stereotypy reported by authors was coded as: (1) vocalizations unrecognizable as
words and are not in direct response to another’s initiation, (2) non-contextual laughing or giggling, (3) non-contextual words
or phrases, (4) repetition of phrase, or (5) not otherwise specified or other vocalizations.
The type of functional assessment was coded as: (1) indirect (interviews, questionnaires, rating scales), (2) descriptive
(direct observation), (3) experimental, (4) combined, or (5) no FBA. In addition, the function identified by the researchers was
also recorded as one of the following categories: (1) attention, (2) escape, (3) tangible, (4) sensory/automatic, (5) multiple, or
(6) no function identified.
The type of change agent delivering the treatment was coded as either: (1) teacher, (2) professional, (3) paraprofessional,
(4) parent/sibling, (5) researcher, (6) does not specify, or (7) multiple.
Treatment designed to address stereotypy was coded as either: (1) proactive only (manipulation of antecedents); (2)
reactive only, including treatments that were (a) reinforcement based (procedures designed to increase behavior), (b)
punishment based (procedures designed to decrease behavior), or (c) combined (both reinforcement and punishment were
used); or (3) multicomponent (reactive and proactive).
Reliability of the independent variable was also coded to determine if an operational definition of the independent
variable was provided sufficient for replication (yes, no, or footnote) and if treatment integrity was monitored (yes, no,
monitored but did not report data). We replicated the coding procedures of McIntyre, Gresham, DiGennaro, and Reed (2007)
and DiGennaro Reed, Hyman, and Hirst (2011) for this part of the review.

2.3. Rater training and interobserver agreement

A doctoral-level behavior analyst (faculty member) and 2 doctoral students in behavioral psychology served as raters. The
doctoral students received individual training on the coding procedures and independently coded three articles until at least
100% agreement (by consensus) was obtained. Additionally, we calculated interobserver agreement for a random sample of
32.3% of included studies. Eight categories were coded: (a) experimental setting (7 categories), (b) topography of stereotypy
(28 categories), (c) functional assessment technique (5 categories), (d) function of behavior (6 categories), (e) type of
behavior change agent (7 categories), (f) treatment (5 categories), (g) operational definition of independent variable (3
categories), and (h) treatment integrity assessment (3 categories). Percentage agreement was calculated by dividing the
number of agreements by the number of agreements plus disagreements and multiplying by 100. Percentage agreement
averaged 94.1% (range, 62.5–100% across the eight category codes [100% experimental setting; 87.9% topography; 92.5%
 F.D. DiGennaro Reed et al. / Research in Autism Spectrum Disorders 6 (2012) 422–430 425

Table 1
Diagnosis of participants.

Diagnosis Frequency Percentage (%)

Autism 83 53.5
Mental retardation 41 26.5
No formal diagnosis 7 4.5
Down syndrome 6 3.9
ADHD 4 2.6
Childhood disintegrative disorder 3 1.9
PDD 3 1.9
Intellectual disability 2 1.3
Fragile-X syndrome 2 1.3
PDD-NOS 1 0.65
High-functioning autism 1 0.65
Cerebral palsy 1 0.65
Traumatic brain injury 1 0.65
Total 155 100.0

functional assessment technique; 90.0% function; 95.0% behavior change agent; 92.5% treatment; 95.0% operational
definition of the independent variable, and 100% treatment integrity assessment]).

3. Results

A total of 128 children received intervention to address stereotypy across the included studies. The sample was primarily
male (64.1%, n = 82) with a mean age of 9.05 years (range, 3–18 years, SD = 3.71). Autism (53.5%, n = 83) and mental
retardation (26.5%, n = 41) were the most commonly reported diagnoses; these numbers reflect children with multiple
diagnoses and, as a result, the data in Table 1 sum to more than 128 children. Numerous topographies of stereotypy were
represented in the studies we coded. A majority of studies included multiple topographies of stereotypy (69.4%, n = 43). As a
result, we coded each form of stereotypy for every child participant. Table 2 depicts all topographies described in the
included studies. The most frequently reported include: (1) rocking/swaying of body or head (10.6%, n = 19); (2) vocalizations
not recognizable as words (10.0%, n = 18), (3) other topographies not captured in the 24 categories we coded (9.4%, n = 17),
and (4) hand flapping/waving (8.3%, n = 15).
A main focus of this review was to determine the degree to which functional assessment techniques were used. Table 3
shows that a clear majority of studies did not use functional assessment procedures (56.5%, n = 35). Of the remaining studies
that relied on functional assessment, nearly all used experimental methodology (i.e., functional analysis) to attempt to

Table 2
Stereotypy topography addressed.

Topography Frequency Percentage

Rocking/swaying of body or head 19 10.6

Vocalizations, not recognizable as words 18 10.0
Other 17 9.4
Hand flapping/waving 15 8.3
Non-contextual words or phrases 13 7.2
Tapping objects with body, finger, or hand 12 6.7
Spinning, flipping, or waving objects 11 6.1
Putting fingers/hands in ears or mouth 10 5.6
Pressing, rubbing, or tapping fingers on surface or body parts 8 4.4
Licking, mouthing, or smelling objects 8 4.4
Positioning hands over face or ears 7 3.9
Hand or finger posturing 6 3.3
Repetition of phrase 5 2.8
Banging or tapping objects together 5 2.8
Vocal stereotypy, other/not otherwise specified 5 2.8
Finger flicking 4 2.2
Object manipulation, other/not otherwise specified 4 2.2
Non-functional body tensing/posturing 3 1.7
Non-functional closing or squinting eyes 2 1.1
Addition of objects to a line 2 1.1
Non-contextual laughing/giggling 2 1.1
Jumping 1 0.6
Spinning of entire body 1 0.6
Non-functional rotation of hand 1 0.6
Stereotypy, not otherwise specified 1 0.6
Total 180 100.0
426 F.D. DiGennaro Reed et al. / Research in Autism Spectrum Disorders 6 (2012) 422–430

Table 3
Functional assessment procedures used.

Type of assessment Number of studies Percentage (%)

No assessment 35 56.5
Experimental 25 40.3
Descriptive 1 1.6
Combined 1 1.6
Indirect 0 0.0
Total 62 100.0

Table 4
Intervention used to address stereotypy.

Intervention type Number of studies Percentage (%)

Multi-component (antecedent 17 27.4

and consequence)
Antecedent only 14 22.6
Reinforcement 11 17.75
Punishment/extinction 11 17.75
Combined reinforcement 9 14.5
and punishment
Total 62 100.0

identify the function of behavior (40.3%, n = 25) and one study used descriptive assessment techniques (1.6%). A majority of
studies did not identify the function of stereotypy (62.9%, n = 39). Of these, 89.79% (n = 35) did not include a functional
behavioral assessment of any type. Three of the studies using experimental methodology and one of the studies using
descriptive assessment procedures did not identify the function of stereotypy. Overall, the most commonly reported
function was sensory/automatic (35.5%, n = 22). One study reported multiple functions (1.6%).
Another focus of this review was to broadly categorize the intervention techniques used to treat stereotypy. Table 4
summarizes these main findings. A majority of studies used consequence-based approaches exclusively (50%, n = 31) with
approximately equal numbers of these using reinforcement only (n = 11), punishment/extinction only (n = 11), or combined
reinforcement and punishment (n = 9). Fourteen studies (22.6%) relied on antecedent strategies only (e.g., abolishing
operations, stimulus control, and antecedent exercise). Seventeen studies (27.4%) included multi-component interventions
(i.e., antecedent- and consequence-based procedures).
Table 5 depicts the settings reported in the 62 studies that met inclusionary criteria, a majority of which were conducted in
schools (40.3%, n = 25). Additionally, 12 studies (19.4%) were conducted in a residential setting, six studies (9.7%) were conducted
in university settings, and seven (11.3%) in multiple settings. Two studies (3.2%) did not report the experimental setting.

Table 5
Experimental setting.

Experimental setting Number of studies Percentage (%)

School 25 40.3
Residence 12 19.4
Multiple 7 11.3
University 6 9.7
Hospital 6 9.7
Other 4 6.4
Not specified 2 3.2
Total 62 100.0

Table 6
Type of change agent.

Type of change agent Number of studies Percentage (%)

Paraprofessional 23 37.1
Researcher 14 22.6
Not specified 11 17.75
Teacher 11 17.75
Professional 2 3.2
Multiple 1 1.6
Total 62 100.0
 F.D. DiGennaro Reed et al. / Research in Autism Spectrum Disorders 6 (2012) 422–430 427

Table 6 shows that the most commonly reported interventionist (i.e., change agent) was paraprofessionals (37.1%, n = 23).
Fourteen studies included researchers (22.6%) and 11 included teachers (17.75%). Eleven studies (17.75%) did not describe
who delivered the intervention.
We were also interested in assessing the percentage of articles reporting reliability of the independent variables (i.e.,
treatment integrity). All but four studies provided an operational definition of the independent variable (93.5%); three of
these four provided a reference of the treatment procedure in a footnote. Very few studies monitored and reported reliability
of the independent variable (9.7%, n = 6). The remaining studies did not measure treatment integrity.

4. Discussion

The goals of this review were to provide an up-to-date synthesis of the experimental literature on the assessment and
behavioral treatment of stereotypy in children with ASD or other pervasive developmental disorder. We were also interested in
summarizing relevant study features, such as participant demographics, experimental setting, and topographies of stereotypy.
Finally, this review determined the number of studies reporting independent variable reliability (i.e., treatment integrity).
Although commonly reported forms of stereotypy include body/head rocking/swaying, unrecognizable vocalizations, and
hand flapping/waving, 25 unique categories of stereotypy were coded across the studies we reviewed. Nearly 10% of the
topographies were coded into an ‘‘other’’ category. These findings suggest that a wide variety of repetitive vocal and motor
behaviors (i.e., stereotypies) are represented in the literature.
Functional (i.e., experimental) analyses were the most frequently reported assessment technique when one was used;
however, a clear majority of studies did not rely on a functional assessment to determine the purpose of stereotypy. We were
surprised to discover that most studies did not include functional assessment techniques of any type. This finding may reflect
the widely held, but inaccurate, assumption that stereotypy serves no obvious function for an individual (LaGrow & Repp,
1984; Matson et al., 1997; Smith & Van Houten, 1996). The articles that used descriptive or experimental functional
assessment techniques provide overwhelming evidence for the automatically maintained function of stereotypic behavior.
Interestingly, few studies documented other maintaining functions (e.g., access to attention or tangible items, escape from
task demands, etc.) despite recent research supporting the notion that individuals are motivated to engage in stereotypic
behavior for a variety of reasons (e.g., Roantree & Kennedy, 2006).
Findings suggest that interventions primarily consisted of consequence-based strategies (either alone or as part of a
treatment package) and were commonly delivered by paraprofessionals within school settings. The latter finding may be
expected given that our inclusionary criteria restricted participants to 18 years of age or younger. Common reinforcement-
based protocols included variations of differential reinforcement, such as differential reinforcement of other behavior,
alternative behavior, or incompatible behavior. A number of studies introduced intervention procedures designed to decrease
the frequency of behavior, including punishment and extinction procedures. Treatments using punishment primarily involved
brief restraint or response cost while common extinction procedures involved blocking or sensory extinction techniques.
Nearly one-quarter of the studies exclusively manipulated antecedents to prevent stereotypy occurrence. Of these studies, a
vast majority employed abolishing operations (e.g., noncontingent access to stereotypy and noncontingent access to
functionally matched stimulation). Antecedent exercise and stimulus control procedures were also represented.
Similar to other studies (e.g., DiGennaro Reed et al., 2011; McIntyre et al., 2007) the present results report an alarming
deficiency in the monitoring and reporting of treatment integrity (i.e., independent variable reliability). Given that one focus
of the current review was to synthesize the current literature for practitioners, the lack of treatment integrity data does not
contribute to confidence that the results of the studies can be replicated. Thus, any failure to replicate the success of these
treatments by consumers of the literature may be due to variations in the procedure that were not reported or extraneous
variables that were not monitored.

4.1. Implications for practitioners

These results suggest several implications for practitioners, particularly with respect to assessment and treatment
practices. Despite the glaring lack of functional assessment procedures in the literature we reviewed, we do not advocate
a similar approach in applied settings. Development of interventions based on findings of a functional assessment benefit
individuals with problem behavior (Hanley, Iwata, & McCord, 2003) and are considered an important component of
evidence-based practice (LaRue, 2010). In school settings, for example, functional assessment procedures are required
under certain circumstances (P.L. 108-446; Individuals with Disabilities Education Improvement Act of 2004). We were
surprised to discover that descriptive functional assessment techniques were uncommon, especially in the school setting.
Our findings suggest there is little research to guide practitioners who want to complete a functional assessment to
inform stereotypy interventions but who might not have the space, expertise, or resources to complete experimental
analyses. In these instances, we encourage practitioners to seek professional consultation with a licensed or certified
professional (e.g., certified school psychologist, licensed clinical psychologist, or board certified behavior analyst) with
documented training and experience in functional analysis. In the absence of such consultation, practitioners might
consider completing a brief treatment analysis of two or three potential interventions based on the results of a descriptive
functional assessment that includes direct observation and analysis of environmental events surrounding stereotypy. A
brief treatment analysis involves the rapid comparison of two or more interventions using single case experimental
428 F.D. DiGennaro Reed et al. / Research in Autism Spectrum Disorders 6 (2012) 422–430

design elements (e.g., mini-reversals or multi-element designs). An effective intervention can often be identified within a
few sessions before full-scale implementation, which requires training of paraprofessionals and other educators and
expenditure of limited resources.
There appears to be a fairly rich literature of intervention strategies to inform practices in applied settings. Our findings
suggest that consequence-based strategies are most frequently used; however, antecedent strategies (i.e., preventive) are
also common. Several of the empirical studies reviewed are available from free online access journals such as Journal of
Applied Behavior Analysis. Practitioners are also encouraged to consult with recently published reviews of stereotypy (e.g.,
Rapp & Vollmer, 2005a) for additional details about intervention practices they may find helpful.Treatment integrity
measurement is a particularly challenging issue for most practitioners working in applied settings with limited resources. If
treatment integrity data are not collected, practitioners are unable to draw valid conclusions that the intervention
procedures are responsible for child outcomes. If desired outcomes are not observed and treatment integrity data are not
assessed, practitioners are unable to determine if a different intervention is necessary or if the designed intervention was
poorly implemented. Despite these clinical reasons for measuring treatment integrity, federal law now mandates that
treatment integrity data be measured and monitored under certain circumstances in school settings (Martens and McIntyre,
2009). Fortunately, a number of resources are available for practitioners to help them consistently measure these important
data (e.g., DiGennaro Reed & Codding, 2011; Vollmer, Sloman, & St. Peter Pipkin, 2008).

4.2. Limitations

The current review has several limitations. First, the treatments described were not quantitatively compared for efficacy
but rather articles were included if they used a sound experimental design. Thus, recommendations for one treatment over
another cannot be made. Future research could focus on meta-analyses of the literature to compare efficacy of the
treatments identified. It may be the case that variables such as the setting, topography, or individual-specific characteristics
indicate or contra-indicate the use of certain treatment procedures. Research on these topics might prove to be valuable to
practitioners and other consumers of research. Second, lengthy descriptions of the procedures for assessment and treatment
were not provided and were outside the scope of this review. Interested readers are directed to the references of articles
reviewed as well as intervention-specific reviews (e.g., Rapp & Vollmer, 2005a) for further information. Finally, published
articles meeting our inclusionary criteria might not have been captured in our bibliographic search because of the particular
search term combinations we adopted. We attempted to address this issue by completing a hand search; however, it may be
the case that, despite our attempts, the present review is not exhaustive.

References

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Further reading (studies included in the review)

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reinforced stereotypy. Behavioral Interventions, 17, 93–103.
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Clark, J. C., & Thomason, S. (1984). The use of an aversive smell to eliminate autistic self-stimulatory behavior. Child & Family Behavior Therapy,
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Falcomata, T. S., Roane, H. S., Hovanetz, A. N., Kettering, T. L., & Keeney, K. M. (2004). An evaluation of response cost in the treatment of
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Hagopian, L. P., & Toole, L. M. (2009). Effects of response blocking and competing stimuli on stereotypic behavior. Behavioral Interventions, 24,
117–125.
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stereotypy. Behavioral Interventions, 20, 177–184.
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in autistic children. Journal of Autism and Developmental Disorders, 12, 399–419.
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Lang, R., O’Reilly, M., Sigafoos, J., Machalicek, W., Rispoli, M., Lancioni, G. E., et al. (2010). The effects of an abolishing operation intervention
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Lanovaz, M. J., Fletcher, S. E., & Rapp, J. T. (2009). Identifying stimuli that alter immediate and subsequent levels of vocal stereotypy: A further
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