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. Author manuscript; available in PMC: 2024 Dec 1.
Published in final edited form as: Autism Res. 2023 Sep 21;16(12):2326–2335. doi: 10.1002/aur.3033

Characterizing Subdomains of Insistence on Sameness in Autistic Youth

Emily Spackman 1, Luke D Smillie 1, Thomas W Frazier 2, Antonio Y Hardan 3, Mirko Uljarević 1,3
PMCID: PMC10843390  NIHMSID: NIHMS1938150  PMID: 37735979

Abstract

Insistence on Sameness (IS) encompasses a range of behavioral patterns, including resistance to change, routines, and ritualized behaviors, that can be present across social and non-social contexts. Given the breadth of behaviors encompassed by IS, it is important to determine whether this domain is best conceptualized and measured as uni- or a multi-dimensional construct. Therefore, the current study aimed to characterize the structure of IS and explore potentially distinct of patterns of associations between identified IS factors and relevant correlates, including age, sex, IQ, anxiety, social abilities, emotional and behavioral dysregulation, and sensory hypersensitivity. Exploratory graph analysis was conducted using the Dimensional Assessment of Restricted and Repetitive Behaviors to examine the structure of IS in a sample 1892 autistic youth (Mage = 10.82, SDage = 4.14; range: 3–18 years; 420 females) recruited from the Simons Foundation Powering Autism Research for Knowledge cohort. Three distinct IS subdomains labeled as IS-Ritualistic/Sameness, IS-Routines, and IS-Individuals were identified. Generalized Additive Models demonstrated that each of the IS subdomains showed a unique pattern of association with key variables. More specifically, while sensory hypersensitivity was significantly associated with IS-Ritualistic/Sameness and IS-Routines, it was not associated with IS-Individuals. Further, while emotional dysregulation was a unique predictor of IS-Ritualistic/Sameness (but not IS-Routines or IS-Individuals), social interaction abilities were a unique predictor of IS-Routines (but not IS-Ritualistic/Sameness or IS-Individuals). Current findings provide preliminary evidence that the IS may encompass several distinct subdomains.

Lay Summary:

Insistence on Sameness (IS) refers to a range of behaviors and traits, including, but not limited to, routines, doing things in the same way each time, needing your environment to stay the same, and not liking change. This study separates IS behaviors into three different subdomains: IS-Routines, IS-Ritualistic/Sameness, and IS-Individuals (meaning IS in the context of interactions with others). Further, we demonstrate that each of these subdomains show different patterns of relationships with age, IQ, sex, anxiety, social characteristics, sensory features, and self-regulation. Identifying subdomains of IS is an important step towards more precise assessment and individualized support.

Insistence on Sameness (IS) is a complex and heterogenous subdomain of restricted and repetitive behaviors (RRB) that encompasses a diverse range of behavioral and cognitive patterns exhibited across social and non-social contexts, including, but not limited to, inflexible adherence to routines, ritualized patterns of behaviors, and resistance to change (American Psychological Association, 2013). IS has consistently emerged as a unitary factor across factor analytic studies of general autism assessment measures and dedicated RRB instruments (Bishop et al., 2013; Honey et al., 2012; Lidstone te al., 2014; Tao et al., 2016). Given the breadth and diversity of behaviors within this domain, it has been suggested that existing measures might undersample IS complexity and that, rather than being a unidimensional construct, IS may be multifaceted, encompassing several distinct subdomains (Lecavalier et al., 2020; Leekam et al., 2011; Uljarević et al., 2022b). Thus, further work is needed to characterize the structure of the IS domain.

IS factors identified across different studies and instruments have encompassed behaviors as diverse as rituals, routines, resistance to change, and sometimes even compulsions and/or circumscribed interests. Some measures have attempted to draw conceptual distinctions between potentially specific subdomains. For instance, the Repetitive Behavior Scale-Revised (RBS-R; Bodfish et al., 2000) originally aimed to differentiate between ritualistic behaviors, defined as the tendency to perform activities in a specific manner, and sameness behaviors, defined as a preference for environments to remain the same. However, majority of subsequent factor analytic studies failed to support the noted distinction and found that items across these two hypothesized constructs load onto a single factor (Bishop et al., 2013; Uljarević et al., 2022b; Russell et al., 2019). Additionally, some previous studies have attempted to distinguish between rituals and routines, whereby routines are defined as behaviors performed in the same sequence each time to achieve an instrumental goal, and rituals are behaviors with a more symbolic meaning or affective component (Boyce et al., 1983). However, empirical support for this noted distinction is currently lacking. Finally, although IS is traditionally conceptualized within non-social contexts, recent work has emphasized that it also occurs in the context of social interactions (Manor-Binyamini et al., 2019; Strang et al., 2017; Lecavalier et al., 2020), an aspect that is not captured by most current measures of IS.

Characterizing the structure of the IS domain is important for advancing our understanding of correlates and mechanisms. For instance, although IS has been theorized to serve as means for reducing anxiety by constraining unpredictability (Leekam et al., 2011; Uljarević et al., 2017; Laing et al., 2009), recent small scale studies have suggested that autistic individuals often report elevated anxiety in response to certain IS behaviors, especially when these behaviors are interrupted or not completed, and that levels of distress significantly vary between individuals and contexts (Rodgers et al., 2016; Jaffey & Ashwin, 2022). Thus, it is important to clarify whether the association between IS and anxiety is unform across different manifestations of IS, or if specific behaviors may be more strongly linked to anxiety than others. Further, if IS is multidimensional, collapsing potentially distinct subdomains within a single total score may obscure specific patterns of association with other clinical, demographic, and cognitive correlates and result in findings that are inconsistent and lack generalizability. Indeed, literature exploring IS association with age, sex, IQ, social functioning, self-regulation, and sensory features has reported largely inconsistent findings (Baribeau et al., 2021; Black et al., 2017; Richler et al., 2010; Evans et al., 1997; 2017; Factor et al., 2016; Frazier et al., 2014; Gotham et al., 2013; Lam et al., 2008; Lidstone et al., 2014; Uljarević et al., 2021a; 2021b; 2022a).

In summary, despite tentative evidence for the multifaceted nature of IS, factor analytical investigations utilizing comprehensive measures of IS are still lacking. Therefore, the current study employed a novel, comprehensive measure of RRB to characterize the structure of IS. Further, we aimed to explore patterns of associations between potential IS factors and demographic, cognitive and clinical correlates previously suggested to play an important role in the expression of IS. These included age, sex, IQ, anxiety, social difficulties, and different aspects of self-regulation, and sensory hypersensitivity. Given the lack of previous factor analytic studies that explore the factor structure of IS, it was not possible to form specific hypotheses. Nevertheless, it was expected that IS within social contexts would form a distinct factor.

Methods

Participants

Parents of autistic youth were recruited through Simons Foundation Powering Autism Research for Knowledge (SPARK) cohort. In line with previous SPARK studies (Fombonne et al., 2020; Uljarević et al., 2022a), only individuals with a parent-reported professional autism diagnosis scoring above the Social Communication Questionnaire (SCQ, Rutter et al., 2003) cut-off were included. Total sample included 1,892 youth with autism (Mage = 10.82, SDage = 4.14; range: 3–18 years; 420 females; Table S1). This research study was approved by the Stanford University Institutional Review Board (IRB #53669).

Measures

IS was assessed using Insistence on Sameness items from the Dimensional Assessment of Repetitive Behaviors (DARB; Uljarević et al., 2022a), a comprehensive informant-rated RRB questionnaire. For a full list of IS items see Table S2. In addition, parents also completed a battery of online parent-report questionnaires summarized in Table 1. As standard measures of self-regulation were not available, the SDQ dysregulation profile score was used to index emotion dysregulation (Deutz et al., 2019), whereas the SDQ hyperactivity subscale served as an indirect indicator of behavioral dysregulation. Parent-reported cognitive ability scores were available for 958 children and was coded on 10 levels (IQ = ≤24, 25−39, 40−54, 55−69, 70−79, 80−89, 90−109, 110−119, 120−129, and ≥130). Validity studies of the SPARK dataset have shown this to be a strong proxy estimate of IQ (Shu et al., 2022).

Table 1.

Parent-Report Measures Administered Online

Measure Reference Construct/s Scale Score Interpretation
DARB Uljarević, 2022a Insistence on sameness 5-point (from 0=Not a problem to
4= Very serious/extreme problem)		 Higher score= higher severity/frequency
SCQ Rutter, 2003 Social interaction
Communication		 2-point (0= No, 1= Yes) Higher score= higher severity/frequency
PRAS-ASD Scahill, 2019 Anxiety 4-point (from 0=None to 3=Severe) Higher score= higher severity/frequency
SEQ-3 Ausderau, 2009 Hypersensitivity 5-point (from 0=Never/almost never to 5=Always/almost always) Higher score= higher severity/frequency
SDQ Goodman, 2001 Emotion dysregulation
Behavioural dysregulation		 3-point (from 0=Not true to 2=Certainly true) Higher score= higher severity/frequency
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Note. DARB = Dimensional Assessment of Restricted and Repetitive Behaviours, SCQ = Social Communication Questionnaire, PRAS-ASD = Parent Rated Anxiety Scale – ASD, SDQ = Strengths and Difficulties Questionnaire, SEQ-3 = Sensory Experiences Questionnaire

Statistical Analysis

Prior to exploring the structure of IS, the dataset was randomly divided into an exploratory (n=971) and confirmatory (n=921) subsample. Exploratory graph analysis (EGA; Golino et al., 2020) using the graphical least absolute shrinkage and selection operator [(GLASSO; Friedman et al., 2008]) and the Walktrap community detection algorithm was conducted on the exploratory subsample in R using the EGAnet package. Reliability and item stability were investigated using bootstrapped EGA with 2,000 bootstrap samples (Christensen & Golino, 2019).

Following the EGA, the fit of the derived IS model was tested in confirmatory subsample using the confirmatory application of Exploratory Structural Equation Modeling (ESEM; Asparouhov & Muthén, 2009) with target rotation and weighted least squares means estimator. Model fit was evaluated using the Comparative Fit Index (CFI); the Tucker-Lewis Index (TLI); the Root Mean Square Error of Approximation (RMSEA) and the Standardized Root Mean Square Residual (SRMR). CFI and TLI values ≥ .90 and RMSEA and SRMR values of < .08 indicated adequate fit (Bentler, 1990). An additional bi-factor model was run to model the potential presence of a general underlying IS factor and further evaluate the distinctiveness of separate, correlated IS factors. Finally, generalized additive models (GAMs) were used to assess non-linear relationships between IS subdomains and key variables.

Results

Of the 1,892 autistic youth, 98% presented with at least one IS behavior. The most commonly endorsed items were bedtime routines (66%) and gets stuck on an idea (65%). Endorsement frequency across all items can be seen in Figure 1.

Figure 1.

Figure 1

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Percentage Response Distribution for all IS Items

Note: For ease of interpretation, items in this figure are divided into the subdomains identified below using EGA.

EGA suggested the three-factor model as optimal (Figure S1). Identified factors were interpreted as IS-Ritualistic/Sameness (10 items), IS-Routines (6 items), and IS-Individuals (7 items). The IS-Ritualistic/Sameness factor included items related to insistence that objects in one’s environment are arranged in the “correct” manner or following certain rules, as well as items related to repeating certain activities or “rituals” over and over until an intrinsic sense of things being “just right” is achieved. The factor labelled IS-Routines captured behaviors performed in the same order or sequence each time, typically to achieve an instrumental goal. Finally, the IS-Individuals factor captured behaviors in one’s interactions with others, including insistence that other people also follow specific routines or rituals (See Table S2 for item list). Bootstrapped EGA showed strong structural consistency, with the three-factor solution identified in 71% of replications and a mean item stability of .97 (Figure S2). Twenty-nine percent of replications favored a four-factor solution with two strongly correlated items (items 20 and 21) sometimes forming their own factor. However, as these two items showed acceptable weighted topological overlap (wTO = .280) and were conceptually distinct, both were retained in the final solution. Confirmatory ESEM confirmed the three-factor structure showed good fit (CFI= .96; TLI=.95; RMSEA=.06; SRMR=.03). Each subdomain showed strong reliability (IS-Ritualistic/Sameness: ω=.89; IS-Routines: ω=.87; IS-Individuals: ω=.83). As identified factors were significantly inter-related (IS-Ritualistic/Sameness-IS-Routines =.76; IS-Ritualistic/Sameness-IS-Individuals =.57; IS-Routines-IS-Individuals =.62), the presence of the general IS factor was modeled. The bi-factor model showed a slightly better fit (CFI= .98; TLI=.96; RMSEA=.05; SRMR=.03), however, all items continued to load significantly onto their individual factor after accounting for the presence of the general IS factor, providing further support for the validity of the described correlated, three-factor structure (Table S2).

Total scores for each IS subdomain were calculated by summing individual item scores for items loading onto the respective EGA factor. For each of the IS subdomains, GAMs were fitted with age, IQ, sex, social and communication abilities, anxiety, emotional and behavioral dysregulation, and hypersensitivity as predictor variables. Full model parameters are presented in Table 3 and significant relationships are depicted graphically in Figure 2. Anxiety was the strongest unique predictor of all three IS subdomains. While hypersensitivity was significantly associated with IS-Ritualistic/Sameness and IS-Routines, it was not associated with IS-Individuals. Social interaction difficulties were a unique predictor of IS-Routines (but not IS-Ritualistic/Sameness or IS-Individuals). Being male was a significant predictor of higher IS-Routines and IS-Individuals, but not of IS-Ritualistic/Sameness. Higher emotional dysregulation was a unique predictor of lower IS-Ritualistic/Sameness, but not IS-Routines or IS-Individuals. Supplemental analysis exploring the direction of this association revealed that emotional dysregulation was a positive predictor of IS-Ritualistic/Sameness prior to anxiety being included in the model, at which point this association became negative (see supplementary material).

Table 3.

Summary of GAM Models

Smooth Terms Estimated df Reference df F p-value
IS-Ritualistic/Sameness
 Age 2.92 3.66 3.33 .020
 IQ 1.63 2.04 5.87 .003
 Anxiety 3.42 4.26 18.45 <.001
 Hypersensitivity 2.42 3.07 15.39 <.001
IS-Routines
 IQ 1.31 1.56 14.78 <.001
 Emotional Dys. 1.55 1.93 3.16 .069
 Behavioral Dys. 1.73 2.17 2.91 .058
 Hypersensitivity 1.65 2.07 16.42 <.001
IS-Individuals
 Age 2.75 3.45 4.39 .004
 IQ 3.35 4.17 4.45 .001
 Emotional Dys. 1.66 2.08 0.64 .526
 Hypersensitivity 1.84 2.33 0.75 .426
Parametric Terms F p-value
IS-Ritualistic/Sameness
 Sex 0.07 .788
 Social Interaction 1.31 .253
 Communication 1.79 .181
 Emotional Dys. 11.76 .001
 Behavioral Dys. 0.35 .554
IS-Routines
 Age 18.05 <.001
 Sex 10.97 <.001
 Social Interaction 9.71 .002
 Communication 0.39 .535
 Anxiety 52.99 <.001
IS-Individuals
 Sex 6.30 .012
 Social Interaction 1.35 .247
 Communication 0.45 .505
 Anxiety 127.58 <.001
 Behavioral Dys. 2.41 .123
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Note. Dys. = Dysregulation; df= degrees of freedom.

Figure 2. Effects of significant predictors on IS subdomains.

Figure 2

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Note. Y-axis values reflect predicted IS scores for each x-axis value, when holding all other variables constant. The range of each y-axis has been chosen to improve readability and may not necessarily start at 0.

Discussion

The primary aim of this paper was to characterize the structure of the IS domain. A three-factor structure encompassing IS-Ritualistic/Sameness, IS-Routines, and IS in interactions with others (IS-Individuals) emerged in the exploratory and demonstrated excellent fit in the confirmatory subsamples. This study is the first large-scale, quantitative study to identify routines as a unique subdomain of IS which is most likely due to DARB having more comprehensive item coverage than previous measures. The ritualistic/sameness factor encompassed (i) items related to needing things in one’s environment to be in the “right” place, and (ii) items capturing actions that are repeated over and over to achieve an intrinsic sense of things being “just right”. On the other hand, the routines factor encompassed items capturing actions performed in the same way each time to achieve an instrumental goal. Interestingly, the item “Does your child insist that particular activities have to take place at the exact same time of the day regardless of the situation or context?” loaded onto the routines. It is possible that despite routines initially developing to achieve an instrumental goal, these behaviors may sometimes be overgeneralized and performed in the absence of an instrumental goal to satisfy an intrinsic feeling or need. Therefore, it will be important for future research to further clarify and characterize the distinction between rituals and routines. Finally, although recent work has emphasized that IS occurs in social interactions (Manor-Binyamini et al., 2019; Strang et al., 2017; Lecavalier et al., 2020), our study and a study by Strang et al., (2017) are the first to identify IS in the social context as distinct a subdomain. Whilst it is important to note that the IS-Individuals subdomain has some conceptual overlap with stereotyped language identified in the literature, items in this subdomain have a strong ritualistic/IS component. Therefore, it will be important for future studies to further address potential overlaps and distinctions between IS and other RRB subdomains.

The secondary aim of the study was to further examine the validity of the identified subdomains by exploring their associations with several theoretically driven correlates. Although several of the associations trended in the same direction for each of the subdomains, in particular for IS-Ritualistic/Sameness and IS-Routines, no two subdomains had the same pattern of significant predictors. Anxiety was uniformly the strongest predictor of all three subdomains, with higher anxiety predicting higher IS. This finding is in line with previous studies that have consistently demonstrated a strong relationship between IS and anxiety (Baribeau et al., 2021; Black et al., 2017; Gotham et al., 2013). It has been theorized that IS behaviors may serve as a means of anxiety reduction, either by constraining unpredictability, preventing exposure to adverse stimuli, or as means of self-regulation (Evans et al., 1997; Hwang et al., 2020; Uljarević et al., 2017). Although more research is needed to examine this, it is possible that different IS-subdomains may reduce anxiety through different pathways or mechanisms. For example, sensory hypersensitivity was the second strongest predictor of IS-Ritualistic/Sameness and the third strongest predictor (after anxiety and age) of IS-Routines, but did not predict IS-Individuals. One possible explanation is that while rituals and routines may function to constrain or limit adverse sensory experiences (Leekam et al., 2007; Black et al., 2017), IS in social interactions may reduce anxiety through a different pathway or serve another function altogether. However, despite correlational findings reported in this study and elsewhere (e.g., Uljarević et al., 2017), it is important to note that evidence more directly speaking to the causative nature and directionality of these effects are currently missing; thus, it will be crucial for future research to utilize specific methods, including treatment-oriented research targeting different mechanisms, to address these gaps.

While higher emotional dysregulation was a significant predictor of lower IS-Ritualistic/Sameness, it was not significantly associated with IS-Routines or IS-Individuals. Behavioral dysregulation did not predict any IS subdomains, although it’s relationship with routines was approaching significance. Although preliminary, these findings may suggest that specific aspects of self-regulation might play different roles in the expression of specific IS subdomains. Furthermore, although the direction of this association was negative, such that higher emotional dysregulation predicted lower IS behaviors, further analyses revealed that this association was positive prior to anxiety being introduced into the model, at which point emotional dysregulation instead became a negative predictor of IS-Ritualistic/Sameness. One possible explanation for this finding might be that, for autistic individuals with high anxiety, IS behaviours may be an important method of self-regulation, meaning individuals who do not use these behaviours to self-regulate may be more likely to show higher levels of emotional dysregulation. However, it is crucial to emphasize the preliminary nature of these findings and highlight the need to replicate and extend current findings by using more comprehensive measures of different aspects of self-regulation, including different facets of executive functioning and emotion regulation strategies. Finally, social interaction difficulties indexed by the SCQ predicted IS-Routines, but not IS-Ritualistic/Sameness or IS-Individuals. The SCQ is a broad index of social difficulties that does not capture fine-grained individual differences across specific facets of social functioning such as social motivation and social cognition. Thus, further research using more comprehensive measures of social functioning is needed to provide a better characterization of the nature of associations between distinct aspects of social processing and IS subdomains.

The findings reported here should be considered in light of several limitations. First, the study relied on parent-reports of diagnosis and IQ. As such, it was not possible to independently confirm diagnoses and it will be important for future research to replicate findings reported here by utilizing gold standard diagnostic instruments and dedicated cognitive assessments. Second, this study also relied on informant-report measures of IS and other clinical variables which has been shown to be an efficient means of measuring autism characteristics in samples including non-verbal participants (Irwin et al., 2012), but may be subject to parent bias. Further, we acknowledge the importance of incorporating self-report measures into autism research. Finally, SDQ dysregulation and hyperactivity scores were used as proxies of emotional and behavioral dysregulation. Even though this approach has been used previously (e.g., Deutz et al., 2018) and hyperactivity and behavioral dysregulation constructs are strongly linked (Barkley et al., 1997, Granziera et al., 2021), scores used in this study nevertheless provide a limited index of emotional and behavioral dysregulation. Thus, future studies will need to replicate and extend findings reported here using dedicated parent-report (e.g. Behavioral Rating Inventory of Executive Functioning [Gioia et al., 2000]) and experimental (e.g., Go/No-Go Task [Verbruggen & Logan, 2008]) measures self-regulation and executive functioning.

Whilst significantly more research is needed to support the validity and utility of IS subdomains identified here, this study represents an important step towards better characterizing specific manifestations of IS across different settings. Identified IS subdomains, IS-Ritualistic/Sameness, IS-Routines, and IS-Individuals, each showed unique patterns of association with key demographic, cognitive and clinical correlates. These findings offer preliminary evidence that these subdomains represent distinct but related constructs, potentially underpinned by distinct mechanisms, and highlights the importance of improving our characterization and measurement of the heterogenous IS domain. It will be important for future to replicate subdomains identified here and to further characterize their clinical correlates and continuities and discontinues in underpinning mechanisms.

Supplementary Material

Supinfo

Table 2.

Descriptive Statistics

Present (%) # of items N Mean (SD) Range
Insistence on Sameness
 IS Total 1858 (98.2%) 23 1892 21.02 (16.37) 0–89
 IS-Ritualistic/Sameness 1630 (86.2%) 10 1892 7.16 (7.39) 0–40
 IS-Routines 1639 (86.6%) 6 1892 6.01 (5.41) 0–24
 IS-Individuals 1676 (88.6%) 7 1892 7.85 (6.25) 0–28
Clinical Variables
 Age 1892 10.82 (4.14) 3–18
 IQ 958 6.30 (2.53) 1–10
 Social Interaction 1843 11.44 (4.56) 0–20
 Communication 1883 2.55 (1.41) 0–5
 Anxiety 1269 25.99 (16.3) 0–73
 Hypersensitivity 1666 21.60 (7.31) 9–44
 Emotional Dysregulation 1345 5.80 (3.68) 0–18
 Behavioral Dysregulation 1355 7.14 (2.31) 0–10
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Acknowledgments:

Authors are grateful to all the families in SPARK, the SPARK clinical sites, and SPARK staff. We appreciate obtaining access to recruit participants through SPARK research match on SFARI Base.

Funding:

The study was supported by grant R21MH121876-01 (Hardan & Jo) by the National Institute of Mental Health.

Footnotes

Conflict of Interest: None.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supinfo
NIHMS1938150-supplement-Supinfo.docx (883.2KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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