Sameness Behaviors, Anxiety in ASD May Indicate of Future Behavioral Trajectories

sad child
sad child, anxiety
In children with ASD, sameness behaviors and anxiety may be indicative of future behavioral trajectories.

The assessment of insistence on sameness and anxiety behaviors among children with autism spectrum disorder (ASD) may aid understanding and serve as markers for future behavioral trajectories, according to research results published in The British Journal of Psychiatry.

Data were collected from the longitudinal inception cohort Pathways in ASD study (n=421). Children between 2 and 5 years of age were recruited from 5 community and academic sites across Canada within 5 months of ASD diagnosis. Children were assessed for anxiety and sameness (rigid, repetitive, and routinized patterns) behavior at 8 time points between 3 and 11 years of age. The assessments were in the form of a parental report using the Child Behavior Checklist (CBCL).

At baseline, median participant age was 37.5 months (interquartile range [IQR], 31.5-44). Participants were majority boys and had a median CBCL anxiety T-score of 54.0 (IQR, 50-63).

Among study participants, 3 patterns of sameness behavior over time were identified. The participants with the most adaptive behavior were grouped in the low-stable cohort (41.7%); most participants were in the moderate-increasing group (52%), and a minority of children, with the most difficulty in variation, were grouped in the high-peaking cohort (6.3%).

The investigators identified 4 trends in anxiety over time. Most children had low levels of anxiety and were grouped in the low-increasing cohort (51.0%), while children with some level of anxiety were split between moderate-decreasing (16.2%) and moderate-increasing (19.6%). Those with the highest level of anxiety were grouped in the high-stable cohort (13.1%).

In a joint trajectory analysis, the most common profile among children (34.8%) was a combination of low-stable sameness with low-increasing anxiety. These children were categorized as low-risk. The children with this low-risk profile had higher adaptability, higher family income, and lower parenting stress than other groups.

A second group of children (13.8%) was determined to have an incongruent profile, as it included a combination of moderate-increasing sameness and moderate-decreasing anxiety. Children with a congruent profile (10.6%) exhibited a combination of moderate-increasing symptoms for both sameness and anxiety.

The rest of the children (10.1%) were considered persistently anxious. Observed symptoms included moderate-increasing sameness behavior and persistently elevated anxiety. These children had parents with the highest level of stress and include a higher proportion of girls than other groups (27.9% vs <18% among all other profiles).

Study investigators noted several limitations of this research. The major limitation of this study was that it was solely based on parent perspectives; neither the teachers of the children nor the children themselves were asked for their opinions. Other limitations include the use of the statistical approach, assuming no variation between patients in trajectory groups, and the assignment of trajectory groups not absolutely reflecting individual symptom patterns.

The study authors concluded that rigid behavior and anxiety among children with ASD may aid in the understanding of current symptoms and allow parents and clinicians to anticipate future behavioral trajectories.

“Given the high and impairing rate of anxiety disorders in this population, prevention studies recruiting preschool-aged or early school-aged children are needed,” they concluded.

Disclosure: One author declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of disclosures.


Baribeau D A, Vigod S, Pullenayegum E, et al. Co-occurring trajectories of anxiety and insistence on sameness behaviour in autism spectrum disorder [published online July 9, 2020]. Br J Psychiatry. doi: 10.1192/bjp.2020.127