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Self-Injurious Behaviors with Increased Likelihood of Injury in Autistic Youth: The Role of Distress Linked to a Strong Preference for Sameness

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Title: Self-Injurious Behaviors with Increased Likelihood of Injury in Autistic Youth: The Role of Distress Linked to a Strong Preference for Sameness
Language: English
Authors: Emily F. Ferguson (ORCID 0000-0002-2771-6346), Emily Spackman (ORCID 0000-0003-2300-439X), Antonio Y. Hardan, Mirko Uljarević (ORCID 0000-0002-7481-3923)
Source: Autism: The International Journal of Research and Practice. 2026 30(6):1620-1631.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 12
Publication Date: 2026
Sponsoring Agency: National Institute of Mental Health (NIMH) (DHHS/NIH)
Contract Number: R21MH121876
Document Type: Journal Articles
Reports - Research
Descriptors: Autism Spectrum Disorders, Youth, Self Destructive Behavior, Prediction, Sensory Experience, Repetition, Speech Skills, Student Characteristics, Behavior
DOI: 10.1177/13623613251396036
ISSN: 1362-3613
1461-7005
Abstract: Self-injurious behaviors in autistic youth vary widely in their form, intensity, and potential for physical injury. This study explored predictors of two categories of self-injurious behaviors that were delineated based on their potential for physical injury (self-injurious behavior--High Likelihood and self-injurious behavior--Low Likelihood), with a focus on the role of distress linked to a strong preference for routines (otherwise known as insistence on sameness). The sample included 1892 autistic youth (M[subscript age] = 10.82, SD[subscript age] = 4.14; 22% females) across the United States. Distress associated with insistence on sameness was the strongest predictor of total self-injurious behavior scores, self-injurious behavior--Low Likelihood, and self-injurious behavior--High Likelihood, after controlling for demographic factors and speech level, and remained a unique predictor after accounting for variance explained by other restricted and repetitive behaviors. Sensory hypersensitivity and sensory-seeking were strong unique predictors of all self-injurious behaviors, while hyposensitivity was a weaker predictor of self-injurious behavior total and self-injurious behavior--Low Likelihood, and a non-significant predictor of self-injurious behavior--High Likelihood. Among demographic factors, lower household income was the strongest predictor of all self-injurious behaviors. Higher speech level was a positive predictor of self-injurious behavior--Low Likelihood but a negative predictor of self-injurious behavior--High Likelihood. These findings demonstrate the role of distress associated with insistence on sameness in manifestations of self-injurious behaviors and highlight the importance of exploring predictors at a more granular level to inform targeted interventions and support.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1506441
Database: ERIC
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  Value: <anid>AN0193858182;f9d01jun.26;2026May21.02:15;v2.2.500</anid> <title id="AN0193858182-1">Self-injurious behaviors with increased likelihood of injury in autistic youth: The role of distress linked to a strong preference for sameness </title> <p>Self-injurious behaviors in autistic youth vary widely in their form, intensity, and potential for physical injury. This study explored predictors of two categories of self-injurious behaviors that were delineated based on their potential for physical injury (self-injurious behavior-High Likelihood and self-injurious behavior-Low Likelihood), with a focus on the role of distress linked to a strong preference for routines (otherwise known as insistence on sameness). The sample included 1892 autistic youth (M<sub>age</sub> = 10.82, SD<sub>age</sub> = 4.14; 22% females) across the United States. Distress associated with insistence on sameness was the strongest predictor of total self-injurious behavior scores, self-injurious behavior-Low Likelihood, and self-injurious behavior-High Likelihood, after controlling for demographic factors and speech level, and remained a unique predictor after accounting for variance explained by other restricted and repetitive behaviors. Sensory hypersensitivity and sensory-seeking were strong unique predictors of all self-injurious behaviors, while hyposensitivity was a weaker predictor of self-injurious behavior total and self-injurious behavior-Low Likelihood, and a non-significant predictor of self-injurious behavior-High Likelihood. Among demographic factors, lower household income was the strongest predictor of all self-injurious behaviors. Higher speech level was a positive predictor of self-injurious behavior-Low Likelihood but a negative predictor of self-injurious behavior-High Likelihood. These findings demonstrate the role of distress associated with insistence on sameness in manifestations of self-injurious behaviors and highlight the importance of exploring predictors at a more granular level to inform targeted interventions and support. This study explored factors associated with repetitive self-injurious behaviors in autistic youth, focusing on emotional distress linked to a strong preference for routines (often referred to as insistence on sameness), a category of behaviors that includes difficulties with change and a strong preference for routines and/or rituals. We examined two categories of self-injurious behaviors: lower likelihood of physical injury (self-injurious behavior-Low Likelihood) and higher likelihood of physical injury (self-injurious behavior-High Likelihood). The study included 1892 autistic youth of varying ages and cognitive abilities. The main finding was that distress associated with disruptions to routines was the strongest predictor of all types of self-injurious behavior. Youth with greater sensitivity to sensory input or sensory-seeking behaviors were more likely to engage in self-injurious behaviors that could increase risk of physical injury. In contrast, those with reduced sensitivity to sensory input were less likely to engage in self-injurious behaviors. Demographic factors also played a role in the manifestation and severity of self-injurious behaviors. Lower household income was strongly associated with greater self-injurious behavior severity. In addition, higher speech production (e.g. speaking in full sentences) was associated with greater severity of self-injurious behavior-Low Likelihood and self-injurious behavior-High Likelihood. These findings highlight the complexity of self-injurious behaviors in autistic youth and the importance of understanding the different factors that contribute to these behaviors. This study may help to contribute to the development of more responsive, tailored interventions for self-injurious behaviors among autistic youth.</p> <p>Keywords: adolescents; autism spectrum disorders; emotion regulation; insistence on sameness; repetitive behaviors and interests; self-injury</p> <p>Manifestations of repetitive self-injurious behaviors (SIBs) vary widely among autistic individuals, with some behaviors increasing the likelihood of immediate physical injury or hospitalization ([<reflink idref="bib5" id="ref1">5</reflink>]; [<reflink idref="bib26" id="ref2">26</reflink>]; [<reflink idref="bib56" id="ref3">56</reflink>]). Accumulating evidence suggests that clinical and demographic features such as dysregulation, sensory features, communication abilities, age, sex, and socioeconomic status (SES) might be associated with the presence of SIB in autism ([<reflink idref="bib16" id="ref4">16</reflink>]; [<reflink idref="bib22" id="ref5">22</reflink>]; [<reflink idref="bib52" id="ref6">52</reflink>]; [<reflink idref="bib65" id="ref7">65</reflink>]). However, it is crucial to identify factors associated with SIB manifestations that increase the likelihood of immediate physical injury to provide targeted and effective support.</p> <p>SIBs are often operationalized as a subdomain of restricted and repetitive behaviors (RRBs) in autism when they present in a repetitive manner ([<reflink idref="bib8" id="ref8">8</reflink>]; [<reflink idref="bib53" id="ref9">53</reflink>]; [<reflink idref="bib64" id="ref10">64</reflink>]). Repetitive SIBs include behaviors such as skin-picking, self-scratching, and forceful head-banging that vary in their intensity and potential for immediate injury. Existing SIB research has primarily utilized measures that provide aggregate information on the presence, absence, or overall severity of SIB. Consequently, it remains unclear whether SIBs that pose lower likelihood of physical injury (SIB-LL) and SIBs that pose higher likelihood of physical injury (SIB-HL) have distinct underlying mechanisms or risk factors. This study looks at these categories within the SIB subscale of the Dimensional Assessment of Restricted and Repetitive Behaviors (DARB; [<reflink idref="bib61" id="ref11">61</reflink>]), which includes specific examples of SIB with a corresponding example that results in physical injury, for instance, "repetitively twirl their hair?" (SIB-LL) and "pull or twists their hair forcefully so that it results in loss of hair?" (SIB-HL).</p> <p>Understanding the predictors and mechanisms underpinning SIB in autism is essential for improving intervention efficacy. SIBs are theorized to serve as a means of responding to extreme arousal or distress ([<reflink idref="bib24" id="ref12">24</reflink>]; [<reflink idref="bib39" id="ref13">39</reflink>]; [<reflink idref="bib65" id="ref14">65</reflink>]), particularly among autistic individuals who struggle with more adaptive forms of self-regulation ([<reflink idref="bib14" id="ref15">14</reflink>]; [<reflink idref="bib40" id="ref16">40</reflink>]; [<reflink idref="bib47" id="ref17">47</reflink>]). Notably, this link between SIB and self-regulation bears many similarities to the theorized functions of having a strong preference for routine. This preference for routine is otherwise known as "insistence on sameness (IS)" and falls within the RRB domain in autism.[<reflink idref="bib9" id="ref18">9</reflink>] IS encompasses complex patterns of routinized and ritualistic behaviors that may serve a regulatory function by constraining uncertainty and reducing exposure to adverse stimuli ([<reflink idref="bib34" id="ref19">34</reflink>]; [<reflink idref="bib54" id="ref20">54</reflink>]). Over time, persistent IS behaviors may limit the development of adaptive self-regulation skills to manage uncertainty and changes in routine, thereby increasing distress when routines are disrupted ([<reflink idref="bib34" id="ref21">34</reflink>]; [<reflink idref="bib36" id="ref22">36</reflink>]; [<reflink idref="bib63" id="ref23">63</reflink>]). Indeed, higher IS has been consistently linked to difficulties with self-regulation and anxiety ([<reflink idref="bib4" id="ref24">4</reflink>]; [<reflink idref="bib25" id="ref25">25</reflink>]; [<reflink idref="bib43" id="ref26">43</reflink>]; [<reflink idref="bib55" id="ref27">55</reflink>]). Furthermore, IS behaviors themselves are complex and heterogeneous in presentation. Although most current quantitative measures of IS capture either the frequency of specific behaviors, such as routines, or a general severity metric, preliminary qualitative evidence suggests that the level of distress children experience in response to interruptions to routines may vary independent of the frequency of these routines ([<reflink idref="bib54" id="ref28">54</reflink>]). Thus, the level of distress caused by interruptions to IS routines (IS-distress) might serve as an index of dysregulation in autistic youth that helps to predict SIB. However, this construct has not yet been operationalized in SIB research.</p> <p>In addition, SIB may serve as a response to unmet or overwhelming sensory needs in autistic youth ([<reflink idref="bib13" id="ref29">13</reflink>], [<reflink idref="bib12" id="ref30">12</reflink>]; [<reflink idref="bib16" id="ref31">16</reflink>]; [<reflink idref="bib21" id="ref32">21</reflink>]). Consistent with this observation, sensory hypersensitivity ([<reflink idref="bib26" id="ref33">26</reflink>]; [<reflink idref="bib37" id="ref34">37</reflink>]), hyposensitivity ([<reflink idref="bib61" id="ref35">61</reflink>]), and sensory-seeking behaviors ([<reflink idref="bib19" id="ref36">19</reflink>]; [<reflink idref="bib22" id="ref37">22</reflink>]) have each been linked to the presence of the broad SIB domain in autistic youth. Sensory hypersensitivity may also mediate the association between IS and anxiety ([<reflink idref="bib9" id="ref38">9</reflink>]). However, more research is needed to piece apart the relative contributions of the noted sensory subdomains in specific manifestations of SIB that vary in the likelihood of physical injury.</p> <p>Finally, SIB may serve as a mode of communication for some autistic individuals ([<reflink idref="bib17" id="ref39">17</reflink>]; [<reflink idref="bib18" id="ref40">18</reflink>]; [<reflink idref="bib39" id="ref41">39</reflink>]). Indeed, findings generally indicate that individuals with lower speech production have a higher incidence of the broad SIB domain ([<reflink idref="bib3" id="ref42">3</reflink>]; [<reflink idref="bib20" id="ref43">20</reflink>]; [<reflink idref="bib42" id="ref44">42</reflink>]). However, these findings are variable, with some research reporting non-significant associations ([<reflink idref="bib67" id="ref45">67</reflink>]), and other research suggesting that lower speech production is more strongly associated with certain SIB topographies such as head-banging ([<reflink idref="bib26" id="ref46">26</reflink>]). The possibility that lower speech production may be more strongly associated with SIB-HL than SIB-LL requires further investigation.</p> <p>Thus, this study sought to explore the relative contributions of the noted psychological features and demographic factors in the severity of total SIB scores and in the context of two categories of SIB that were delineated based on their likelihood of physical injury (SIB-LL and SIB-HL).</p> <hd id="AN0193858182-2">Method</hd> <p></p> <hd id="AN0193858182-3">Participants</hd> <p>Parents of 1892 autistic children and adolescents aged 3–19 years residing in the United States (M<subs>age</subs> = 10.82, SD<subs>age</subs> = 4.14; 22% females) were recruited through the Simons Foundation Powering Autism Research for Knowledge cohort (SPARK Consortium; [<reflink idref="bib23" id="ref47">23</reflink>]) to complete an online battery of questionnaires ([<reflink idref="bib61" id="ref48">61</reflink>]). Only youth with a parent-reported professional diagnosis of autism who scored above the cut-off on the Social Communication Questionnaire (SCQ; [<reflink idref="bib45" id="ref49">45</reflink>]) were included. The design of the study from which these data were drawn included community involvement. The Stanford University institutional review board approved this research study.</p> <hd id="AN0193858182-4">Measures</hd> <p>SIB and IS-distress were measured using relevant subscales of the DARB ([<reflink idref="bib61" id="ref50">61</reflink>]). When completing the DARB, informants rate items on 5-point Likert-type scale (from 1 = "Not at all a problem" to 5 = "Very serious/extreme problem"). To explore associations with distinct SIB composites, six SIB items were summed for SIB-Low Likelihood of physical injury, and five items were summed for SIB-High Likelihood of physical injury. Six of the SIB items describe the same behavior at different levels of severity; for instance, "Repetitively and gently scratch herself/himself for longer periods of time?" was designated SIB-LL and "Forcefully scratch herself/himself so that it results in significant scratches, tissue damage or bleeding?" was designated SIB-HL. In addition, items capturing self-hitting and head-banging were designated SIB-HL given the higher likelihood of physical injury, while items capturing pulling eyebrows and picking skin were designated SIB-LL given the lower likelihood of physical injury (see supplementary materials S1 for a complete list of items within each category).</p> <p>The IS-distress subscale is complementary to the primary, 17-item IS subscale of the DARB that was included to provide an additional characterization of the level of distress a child experiences related to a given IS behavior. For instance, informants that scored >0 indicating "a slight problem" or higher on the item, "Does your child have particular routines during play or leisure time?" were prompted to complete the follow-up question, "Does she or he get upset if this routine is not followed?" The follow-up items pertaining to <emph>level of distress</emph> were summed to create an IS-distress composite (Table 1). Finally, sensory hypersensitivity, hyposensitivity, and sensory-seeking behaviors were measured using the informant-report Sensory Experiences Questionnaire Version 3.0 (SEQ-3.0; [<reflink idref="bib2" id="ref51">2</reflink>]). In addition, parents reported on demographic characteristics and estimated cognitive ability (Table 1).</p> <p>Table 1. Descriptive statistics.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th /><th align="left"><italic>N</italic></th><th align="left">M (SD)/%</th><th align="left">Range</th><th align="left">ω</th></tr></thead><tbody><tr><td>Age</td><td /><td>1892</td><td>10.82 (4.14)</td><td>3–19</td><td>–</td></tr><tr><td>SIB total score</td><td /><td>1892</td><td>4.99 (5.02)</td><td>0–35</td><td>.73</td></tr><tr><td>SIB-LL</td><td /><td>1892</td><td>3.12 (3.21)</td><td>0–24</td><td>.64</td></tr><tr><td>SIB-HL</td><td /><td>1892</td><td>1.87 (2.57)</td><td>0–18</td><td>.66</td></tr><tr><td>IS-distress</td><td /><td>1829</td><td>17.56 (16.29)</td><td>0–83</td><td>.95</td></tr><tr><td>Hypersensitivity</td><td /><td>1671</td><td>21.60 (7.31)</td><td>9–44</td><td>.85</td></tr><tr><td>Hyposensitivity</td><td /><td>1672</td><td>12.54 (4.19)</td><td>6–29</td><td>.72</td></tr><tr><td>Sensory-seeking</td><td /><td>1642</td><td>13.68 (4.82)</td><td>6–30</td><td>.76</td></tr><tr><td>Total RRB<xref ref-type="table-fn" rid="tfn2">a</xref></td><td /><td>1892</td><td>55.13 (31.51)</td><td>0–221</td><td>.93</td></tr><tr><td>Sex</td><td>Males</td><td>1455</td><td>76.9</td><td>–</td><td>–</td></tr><tr><td /><td>Females</td><td>420</td><td>22.2</td><td>–</td><td>–</td></tr><tr><td /><td>Other</td><td>6</td><td>0.3</td><td>–</td><td>–</td></tr><tr><td /><td>N/R</td><td>11</td><td>0.6</td><td>–</td><td>–</td></tr><tr><td>Speech level</td><td>No words/does not speak</td><td>146</td><td>7.7</td><td>–</td><td>–</td></tr><tr><td /><td>Uses single words</td><td>144</td><td>7.6</td><td>–</td><td>–</td></tr><tr><td /><td>Combines three words</td><td>256</td><td>13.5</td><td>–</td><td>–</td></tr><tr><td /><td>Uses longer sentences</td><td>1343</td><td>71.0</td><td>–</td><td>–</td></tr><tr><td /><td>N/A</td><td>3</td><td>0.2</td><td>–</td><td>–</td></tr><tr><td>IQ</td><td>⩽24</td><td>42</td><td>2.2</td><td>–</td><td>–</td></tr><tr><td /><td>25–39</td><td>46</td><td>2.4</td><td>–</td><td>–</td></tr><tr><td /><td>40–54</td><td>58</td><td>3.1</td><td>–</td><td>–</td></tr><tr><td /><td>55–69</td><td>92</td><td>4.9</td><td>–</td><td>–</td></tr><tr><td /><td>70–79</td><td>128</td><td>6.8</td><td>–</td><td>–</td></tr><tr><td /><td>80–89</td><td>105</td><td>5.5</td><td>–</td><td>–</td></tr><tr><td /><td>90–109</td><td>143</td><td>7.6</td><td>–</td><td>–</td></tr><tr><td /><td>110–119</td><td>123</td><td>6.5</td><td>–</td><td>–</td></tr><tr><td /><td>120–129</td><td>107</td><td>5.7</td><td>–</td><td>–</td></tr><tr><td /><td>⩾130</td><td>114</td><td>6.0</td><td>–</td><td>–</td></tr><tr><td /><td>Have not had testing</td><td>921</td><td>48.7</td><td>–</td><td>–</td></tr><tr><td /><td>N/R</td><td>13</td><td>0.7</td><td>–</td><td>–</td></tr><tr><td>Household income</td><td>Less than $9,999</td><td>112</td><td>5.9</td><td>–</td><td>–</td></tr><tr><td /><td>$10,000–$20,999</td><td>144</td><td>7.6</td><td>–</td><td>–</td></tr><tr><td /><td>$21,000–$30,999</td><td>176</td><td>9.3</td><td>–</td><td>–</td></tr><tr><td /><td>$31,000–$50,999</td><td>299</td><td>15.8</td><td>–</td><td>–</td></tr><tr><td /><td>$51,000–$75,999</td><td>327</td><td>17.3</td><td>–</td><td>–</td></tr><tr><td /><td>$76,000–$100,999</td><td>263</td><td>13.9</td><td>–</td><td>–</td></tr><tr><td /><td>$101,000–$125,999</td><td>190</td><td>10.0</td><td>–</td><td>–</td></tr><tr><td /><td>$126,000–$150,999</td><td>130</td><td>6.9</td><td>–</td><td>–</td></tr><tr><td /><td>$151,000–$200,999</td><td>121</td><td>6.4</td><td>–</td><td>–</td></tr><tr><td /><td>Over $201,000</td><td>119</td><td>6.3</td><td>–</td><td>–</td></tr><tr><td /><td>N/R</td><td>11</td><td>0.6</td><td>–</td><td>–</td></tr></tbody></table> </ephtml> </p> <p>1 SIB total score: Self-Injurious Behavior Total Subscale Score from the Dimensional Assessment of Restricted and Repetitive Behaviors (DARB); SIB-LL: Self-Injurious Behavior-Low Likelihood of Physical Injury Category from the DARB (<emph>n</emph> = six items); SIB-HL: Self-Injurious Behavior High Likelihood of Physical Injury Category from the DARB (<emph>n</emph> = five items); IS-distress: Total Score of Level of Distress linked to Disruptions to IS Routines from the DARB; Sensory Experiences Questionnaire Version 3.0 for Sensory Hypersensitivity, Sensory Hyposensitivity, and Sensory-Seeking Behavior; Parent-reported speech level; Parent-reported estimated IQ level; Macdonald's ω: internal consistency of subscales in present sample; Total RRB: Total Restricted and Repetitive Behavior Score from the DARB.</p> <ulist> <item>2 Excluding SIB, IS, and sensory sensitivity.</item> <item>3 <emph>p</emph> <.001.</item> </ulist> <hd id="AN0193858182-5">Statistical analysis</hd> <p>The associations between SIB and key demographic and psychological correlates were assessed using Pearson's correlation (and Spearman's where relevant) with Bonferroni correction applied. Sex differences in SIB were assessed using a <emph>t</emph>-test. Correlations between variables of interest are presented in the supplementary materials (S2). Variables were then entered into three hierarchical multiple linear regressions to examine unique associations with SIB Total, SIB-LL, and SIB-HL scores. To account for skewness in data, bootstrapping using 5000 resamples was conducted and bias-corrected 95% confidence intervals were used to determine significance ([<reflink idref="bib58" id="ref52">58</reflink>]).</p> <hd id="AN0193858182-6">Results</hd> <p></p> <hd id="AN0193858182-7">SIB total score</hd> <p>Age, sex, speech level, and household income accounted for 6.2% of the variance in SIB total scores (<emph>F</emph>(<reflink idref="bib4" id="ref53">4</reflink>, 1552) = 25.51, <emph>p</emph> < 0.001). IS-distress accounted for an additional 16.6% of the variance (<emph>F</emph>Δ = 334.54, <emph>p</emph> < 0.001). Sensory hypersensitivity, sensory hyposensitivity, and sensory-seeking accounted for an additional 4.6% of variance (<emph>F</emph>Δ = 32.76, <emph>p</emph> < 0.001), while total RRB scores from the DARB (excluding IS, SIB, and sensory sensitivity) explained an additional 3.6% (<emph>F</emph>Δ = 80.01, <emph>p</emph> < 0.001). Although total RRB was the strongest predictor of SIB total in the full model, IS-distress and all sensory variables remained unique predictors of SIB total after accounting for the shared variance explained by RRBs (Table 2).</p> <p>Table 2. Hierarchical regression with SIB total scores as dependent variable.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left" rowspan="2"><italic>R</italic><sup>2</sup></th><th align="left" rowspan="2"><italic>R</italic><sup>2</sup> Δ</th><th align="left" rowspan="2"><italic>B</italic></th><th align="left" rowspan="2">SEB</th><th align="left" rowspan="2">β</th><th align="left" rowspan="2"><italic>t</italic></th><th align="left" colspan="2">BCa 95% CI</th></tr><tr><th /><th align="left">Lower</th><th align="left">Upper</th></tr></thead><tbody><tr><td><italic>Step 1</italic></td><td>0.062<xref ref-type="table-fn" rid="tfn6">**</xref></td><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.01</td><td>0.00</td><td>0.11</td><td>4.26</td><td>0.01</td><td>0.02</td></tr><tr><td>Sex</td><td /><td /><td>1.01</td><td>0.29</td><td>0.09</td><td>3.47</td><td>0.39</td><td>1.65</td></tr><tr><td>Language</td><td /><td /><td>−0.10</td><td>0.14</td><td>−0.02</td><td>−0.74</td><td>−0.38</td><td>0.17</td></tr><tr><td>SES</td><td /><td /><td>−0.42</td><td>0.05</td><td>−0.20</td><td>−8.22</td><td>−0.52</td><td>−0.32</td></tr><tr><td><italic>Step 2</italic></td><td>0.228<xref ref-type="table-fn" rid="tfn6">**</xref></td><td>0.166<xref ref-type="table-fn" rid="tfn6">**</xref></td><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.01</td><td>0.00</td><td>0.14</td><td>6.00</td><td>0.01</td><td>0.02</td></tr><tr><td>Sex</td><td /><td /><td>1.04</td><td>0.26</td><td>0.09</td><td>3.93</td><td>0.48</td><td>1.61</td></tr><tr><td>Language</td><td /><td /><td>−0.25</td><td>0.13</td><td>−0.05</td><td>−2.02</td><td>−0.51</td><td>0.00</td></tr><tr><td>SES</td><td /><td /><td>−0.27</td><td>0.05</td><td>−0.13</td><td>−5.82</td><td>−0.36</td><td>−0.18</td></tr><tr><td>IS-distress</td><td /><td /><td>0.13</td><td>0.01</td><td>0.42</td><td>18.29</td><td>0.11</td><td>0.15</td></tr><tr><td><italic>Step 3</italic></td><td>0.274<xref ref-type="table-fn" rid="tfn6">**</xref></td><td>0.046<xref ref-type="table-fn" rid="tfn6">**</xref></td><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.02</td><td>0.00</td><td>0.15</td><td>6.28</td><td>0.01</td><td>0.02</td></tr><tr><td>Sex</td><td /><td /><td>0.96</td><td>0.26</td><td>0.08</td><td>3.72</td><td>0.41</td><td>1.52</td></tr><tr><td>Language</td><td /><td /><td>−0.08</td><td>0.13</td><td>−0.02</td><td>−0.60</td><td>−0.34</td><td>0.18</td></tr><tr><td>SES</td><td /><td /><td>−0.22</td><td>0.05</td><td>−0.11</td><td>−4.72</td><td>−0.31</td><td>−0.13</td></tr><tr><td>IS-distress</td><td /><td /><td>0.08</td><td>0.01</td><td>0.26</td><td>9.38</td><td>0.06</td><td>0.10</td></tr><tr><td>Hypersensitivity</td><td /><td /><td>0.10</td><td>0.02</td><td>0.14</td><td>4.89</td><td>0.06</td><td>0.14</td></tr><tr><td>Hyposensitivity</td><td /><td /><td>0.08</td><td>0.03</td><td>0.07</td><td>2.64</td><td>0.02</td><td>0.14</td></tr><tr><td>Seeking</td><td /><td /><td>0.16</td><td>0.03</td><td>0.16</td><td>5.90</td><td>0.11</td><td>0.21</td></tr><tr><td><italic>Step 4</italic></td><td>0.310<xref ref-type="table-fn" rid="tfn6">**</xref></td><td>0.036<xref ref-type="table-fn" rid="tfn6">**</xref></td><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.02</td><td>0.00</td><td>0.15</td><td>6.31</td><td>0.01</td><td>0.02</td></tr><tr><td>Sex</td><td /><td /><td>1.07</td><td>0.25</td><td>0.09</td><td>4.26</td><td>0.53</td><td>1.62</td></tr><tr><td>Language</td><td /><td /><td>−0.35</td><td>0.13</td><td>−0.07</td><td>−2.67</td><td>−0.61</td><td>−0.10</td></tr><tr><td>SES</td><td /><td /><td>−0.13</td><td>0.05</td><td>−0.07</td><td>−2.94</td><td>−0.22</td><td>−0.05</td></tr><tr><td>IS-distress</td><td /><td /><td>0.04</td><td>0.01</td><td>0.13</td><td>4.13</td><td>0.02</td><td>0.06</td></tr><tr><td>Hypersensitivity</td><td /><td /><td>0.07</td><td>0.02</td><td>0.10</td><td>3.56</td><td>0.03</td><td>0.11</td></tr><tr><td>Hyposensitivity</td><td /><td /><td>0.06</td><td>0.03</td><td>0.05</td><td>1.91</td><td>0.00</td><td>0.11</td></tr><tr><td>Seeking</td><td /><td /><td>0.05</td><td>0.03</td><td>0.05</td><td>1.80</td><td>0.00</td><td>0.11</td></tr><tr><td>Total RRB<xref ref-type="table-fn" rid="tfn5">a</xref></td><td /><td /><td>0.05</td><td>0.01</td><td>0.31</td><td>8.95</td><td>0.04</td><td>0.06</td></tr></tbody></table> </ephtml> </p> <ulist> <item>4 Bootstrapping using 5000 resamples. Language: parent-reported current spoken language level; SES: total household annual income; IS-distress: level of distress related to insistence on sameness from the DARB. Sensory hypersensitivity, hyposensitivity, sensory-seeking behavior. Total RRB: total restricted and repetitive behavior (RRB) score from the DARB.</item> <item>5 Excluding SIB, IS, and sensory sensitivity.</item> <item>6 <emph>p</emph> <.001.</item> </ulist> <hd id="AN0193858182-8">SIB-LL</hd> <p>Age, sex, speech level, and household income accounted for 8.0% of the variance in SIB-LL (<emph>F</emph>(<reflink idref="bib4" id="ref54">4</reflink>, 1552) = 33.70, <emph>p</emph> < 0.001). IS-distress accounted for an additional 11.6% of the variance (<emph>F</emph>Δ = 224.66, <emph>p</emph> < 0.001). Sensory hypersensitivity, sensory hyposensitivity, and sensory-seeking accounted for an additional 3.9% of the variance (<emph>F</emph>Δ = 26.19, <emph>p</emph> < 0.001), while total RRB explained an additional 3.2% (<emph>F</emph>Δ = 62.60, <emph>p</emph> < 0.001). After accounting for shared variance explained by other RRBs, IS-distress was no longer a significant predictor of SIB-LL (Table 3).</p> <p>Table 3. Hierarchical regression with SIB-LL scores as dependent variable.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left" rowspan="2"><italic>R</italic><sup>2</sup></th><th align="left" rowspan="2"><italic>R</italic><sup>2</sup> Δ</th><th align="left" rowspan="2"><italic>B</italic></th><th align="left" rowspan="2">SEB</th><th align="left" rowspan="2">β</th><th align="left" rowspan="2"><italic>t</italic></th><th align="left" colspan="2">BCa 95% CI</th></tr><tr><th /><th align="left">Lower</th><th align="left">Upper</th></tr></thead><tbody><tr><td><italic>Step 1</italic></td><td>0.080<xref ref-type="table-fn" rid="tfn9">**</xref></td><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.01</td><td>0.00</td><td>0.17</td><td>6.44</td><td>0.01</td><td>0.01</td></tr><tr><td>Sex</td><td /><td /><td>0.92</td><td>0.19</td><td>0.12</td><td>4.95</td><td>0.51</td><td>1.35</td></tr><tr><td>Language</td><td /><td /><td>0.24</td><td>0.09</td><td>0.07</td><td>2.74</td><td>0.07</td><td>0.41</td></tr><tr><td>SES</td><td /><td /><td>−0.21</td><td>0.03</td><td>−0.16</td><td>−6.45</td><td>−0.28</td><td>−0.14</td></tr><tr><td><italic>Step 2</italic></td><td>0.196<xref ref-type="table-fn" rid="tfn9">**</xref></td><td>0.116<xref ref-type="table-fn" rid="tfn9">**</xref></td><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.01</td><td>0.00</td><td>0.19</td><td>7.95</td><td>0.01</td><td>0.02</td></tr><tr><td>Sex</td><td /><td /><td>0.94</td><td>0.17</td><td>0.12</td><td>5.38</td><td>0.56</td><td>1.33</td></tr><tr><td>Language</td><td /><td /><td>0.16</td><td>0.08</td><td>0.05</td><td>1.93</td><td>0.00</td><td>0.32</td></tr><tr><td>SES</td><td /><td /><td>−0.13</td><td>0.03</td><td>−0.10</td><td>−4.24</td><td>−0.19</td><td>−0.07</td></tr><tr><td>IS-distress</td><td /><td /><td>0.07</td><td>0.01</td><td>0.35</td><td>14.99</td><td>0.06</td><td>0.08</td></tr><tr><td><italic>Step 3</italic></td><td>0.235<xref ref-type="table-fn" rid="tfn9">**</xref></td><td>0.039<xref ref-type="table-fn" rid="tfn9">**</xref></td><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.01</td><td>0.00</td><td>0.19</td><td>7.97</td><td>0.01</td><td>0.02</td></tr><tr><td>Sex</td><td /><td /><td>0.88</td><td>0.17</td><td>0.12</td><td>5.19</td><td>0.52</td><td>1.26</td></tr><tr><td>Language</td><td /><td /><td>0.24</td><td>0.09</td><td>0.07</td><td>2.80</td><td>0.08</td><td>0.40</td></tr><tr><td>SES</td><td /><td /><td>−0.10</td><td>0.03</td><td>−0.07</td><td>−3.17</td><td>−0.16</td><td>−0.04</td></tr><tr><td>IS-distress</td><td /><td /><td>0.04</td><td>0.01</td><td>0.20</td><td>7.07</td><td>0.03</td><td>0.05</td></tr><tr><td>Hypersensitivity</td><td /><td /><td>0.06</td><td>0.01</td><td>0.14</td><td>4.89</td><td>0.04</td><td>0.09</td></tr><tr><td>Hyposensitivity</td><td /><td /><td>0.05</td><td>0.02</td><td>0.06</td><td>2.38</td><td>0.01</td><td>0.09</td></tr><tr><td>Seeking</td><td /><td /><td>0.09</td><td>0.02</td><td>0.13</td><td>4.77</td><td>0.05</td><td>0.12</td></tr><tr><td><italic>Step 4</italic></td><td>0.267<xref ref-type="table-fn" rid="tfn9">**</xref></td><td>0.032<xref ref-type="table-fn" rid="tfn9">**</xref></td><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.01</td><td>0.00</td><td>0.19</td><td>8.02</td><td>0.01</td><td>0.02</td></tr><tr><td>Sex</td><td /><td /><td>0.95</td><td>0.17</td><td>0.13</td><td>5.71</td><td>0.59</td><td>1.31</td></tr><tr><td>Language</td><td /><td /><td>0.08</td><td>0.09</td><td>0.02</td><td>0.88</td><td>−0.09</td><td>0.24</td></tr><tr><td>SES</td><td /><td /><td>−0.05</td><td>0.03</td><td>−0.04</td><td>−1.52</td><td>−0.10</td><td>0.01</td></tr><tr><td>IS-distress</td><td /><td /><td>0.02</td><td>0.01</td><td>0.08</td><td>2.39</td><td>0.00</td><td>0.03</td></tr><tr><td>Hypersensitivity</td><td /><td /><td>0.05</td><td>0.01</td><td>0.11</td><td>3.66</td><td>0.02</td><td>0.07</td></tr><tr><td>Hyposensitivity</td><td /><td /><td>0.03</td><td>0.02</td><td>0.04</td><td>1.71</td><td>−0.01</td><td>0.07</td></tr><tr><td>Seeking</td><td /><td /><td>0.02</td><td>0.02</td><td>0.03</td><td>1.04</td><td>−0.02</td><td>0.06</td></tr><tr><td>Total RRB<xref ref-type="table-fn" rid="tfn8">a</xref></td><td /><td /><td>0.03</td><td>0.00</td><td>0.29</td><td>8.20</td><td>0.02</td><td>0.04</td></tr></tbody></table> </ephtml> </p> <ulist> <item>7 Bootstrapping using 5000 resamples. Language: parent-reported current spoken language level; SES: total household annual income; IS-distress: level of distress related to insistence on sameness from the DARB. Sensory hypersensitivity, hyposensitivity, sensory-seeking behavior. Total RRB: total restricted and repetitive behavior (RRB) score from the DARB.</item> <item>8 Excluding SIB, IS, and sensory sensitivity.</item> <item>9 <emph>p</emph> <.001.</item> </ulist> <hd id="AN0193858182-9">SIB-HL</hd> <p>Age, sex, speech level, and household income accounted for 5.6% of the variance in SIB-HL scores (<emph>F</emph>(<reflink idref="bib4" id="ref55">4</reflink>,1552) = 23.02, <emph>p</emph> < 0.001). IS-distress accounted for an additional 13.2% of the variance (<emph>F</emph>Δ = 251.82, <emph>p</emph> < 0.001). Sensory hypersensitivity, sensory hyposensitivity, and sensory-seeking accounted for an additional 2.9% of the variance (<emph>F</emph>Δ = 19.26, <emph>p</emph> < 0.001), while total RRB explained an additional 2.0% (<emph>F</emph>Δ = 19.26, <emph>p</emph> < 0.001). After accounting for shared variance explained by other RRBs, IS-distress remained a strong, unique predictor of SIB-HL (Table 4).</p> <p>Table 4. Hierarchical regression with SIB-HL scores as dependent variable.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left" rowspan="2"><italic>R</italic><sup>2</sup></th><th align="left" rowspan="2"><italic>R</italic><sup>2</sup> Δ</th><th align="left" rowspan="2"><italic>B</italic></th><th align="left" rowspan="2">SEB</th><th align="left" rowspan="2">β</th><th align="left" rowspan="2"><italic>t</italic></th><th align="left" colspan="2">BCa 95% CI</th></tr><tr><th /><th align="left">Lower</th><th align="left">Upper</th></tr></thead><tbody><tr><td><italic>Step 1</italic></td><td>0.056<xref ref-type="table-fn" rid="tfn12">**</xref></td><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.00</td><td>0.00</td><td>0.01</td><td>0.28</td><td>0.00</td><td>0.00</td></tr><tr><td>Sex</td><td /><td /><td>0.09</td><td>0.15</td><td>0.02</td><td>0.59</td><td>−0.20</td><td>0.41</td></tr><tr><td>Language</td><td /><td /><td>−0.34</td><td>0.07</td><td>−0.13</td><td>−4.79</td><td>−0.51</td><td>−0.18</td></tr><tr><td>SES</td><td /><td /><td>−0.21</td><td>0.03</td><td>−0.20</td><td>−7.90</td><td>−0.27</td><td>−0.15</td></tr><tr><td><italic>Step 2</italic></td><td>0.188<xref ref-type="table-fn" rid="tfn12">**</xref></td><td>0.132<xref ref-type="table-fn" rid="tfn12">**</xref></td><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.00</td><td>0.00</td><td>0.04</td><td>1.44</td><td>0.00</td><td>0.00</td></tr><tr><td>Sex</td><td /><td /><td>0.10</td><td>0.14</td><td>0.02</td><td>0.73</td><td>−0.18</td><td>0.40</td></tr><tr><td>Language</td><td /><td /><td>−0.41</td><td>0.07</td><td>−0.15</td><td>−6.20</td><td>−0.57</td><td>−0.26</td></tr><tr><td>SES</td><td /><td /><td>−0.14</td><td>0.03</td><td>−0.13</td><td>−5.69</td><td>−0.19</td><td>−0.09</td></tr><tr><td>IS-distress</td><td /><td /><td>0.06</td><td>0.00</td><td>0.37</td><td>15.87</td><td>0.05</td><td>0.07</td></tr><tr><td><italic>Step 3</italic></td><td>0.217<xref ref-type="table-fn" rid="tfn12">**</xref></td><td>0.029<xref ref-type="table-fn" rid="tfn12">**</xref></td><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.00</td><td>0.00</td><td>0.05</td><td>1.86</td><td>0.00</td><td>0.01</td></tr><tr><td>Sex</td><td /><td /><td>0.07</td><td>0.14</td><td>0.01</td><td>0.53</td><td>−0.21</td><td>0.37</td></tr><tr><td>Language</td><td /><td /><td>−0.32</td><td>0.07</td><td>−0.12</td><td>−4.56</td><td>−0.49</td><td>−0.16</td></tr><tr><td>SES</td><td /><td /><td>−0.12</td><td>0.03</td><td>−0.11</td><td>−4.88</td><td>−0.17</td><td>−0.07</td></tr><tr><td>IS-distress</td><td /><td /><td>0.04</td><td>0.01</td><td>0.25</td><td>8.75</td><td>0.03</td><td>0.05</td></tr><tr><td>Hypersensitivity</td><td /><td /><td>0.03</td><td>0.01</td><td>0.09</td><td>3.08</td><td>0.01</td><td>0.05</td></tr><tr><td>Hyposensitivity</td><td /><td /><td>0.03</td><td>0.02</td><td>0.05</td><td>1.96</td><td>0.00</td><td>0.06</td></tr><tr><td>Seeking</td><td /><td /><td>0.07</td><td>0.01</td><td>0.14</td><td>5.09</td><td>0.05</td><td>0.10</td></tr><tr><td><italic>Step 4</italic></td><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Age</td><td /><td /><td>0.00</td><td>0.00</td><td>0.04</td><td>1.80</td><td>0.00</td><td>0.01</td></tr><tr><td>Sex</td><td /><td /><td>0.12</td><td>0.14</td><td>0.02</td><td>0.86</td><td>−0.16</td><td>0.42</td></tr><tr><td>Language</td><td /><td /><td>−0.43</td><td>0.07</td><td>−0.16</td><td>−5.98</td><td>−0.60</td><td>−0.27</td></tr><tr><td>SES</td><td /><td /><td>−0.09</td><td>0.03</td><td>−0.08</td><td>−3.55</td><td>−0.14</td><td>−0.04</td></tr><tr><td>IS-distress</td><td /><td /><td>0.02</td><td>0.01</td><td>0.15</td><td>4.68</td><td>0.01</td><td>0.04</td></tr><tr><td>Hypersensitivity</td><td /><td /><td>0.02</td><td>0.01</td><td>0.06</td><td>2.08</td><td>0.00</td><td>0.04</td></tr><tr><td>Hyposensitivity</td><td /><td /><td>0.02</td><td>0.02</td><td>0.04</td><td>1.42</td><td>−0.01</td><td>0.05</td></tr><tr><td>Seeking</td><td /><td /><td>0.03</td><td>0.02</td><td>0.06</td><td>2.03</td><td>0.00</td><td>0.06</td></tr><tr><td>Total RRB<xref ref-type="table-fn" rid="tfn11">a</xref></td><td /><td /><td>0.02</td><td>0.00</td><td>0.23</td><td>6.43</td><td>0.01</td><td>0.03</td></tr></tbody></table> </ephtml> </p> <ulist> <item>10 Bootstrapping using 5000 resamples. Language: parent-reported current spoken language level; SES: total household annual income; IS-distress: level of distress related to insistence on sameness from the DARB. Sensory hypersensitivity, hyposensitivity, sensory-seeking behavior. Total RRB: total restricted and repetitive behavior (RRB) score from the DARB.</item> <item>11 Excluding SIB, IS, and sensory sensitivity.</item> <item>12 <emph>p</emph> <.001.</item> </ulist> <hd id="AN0193858182-10">Discussion</hd> <p>This study explored the relative contributions of psychological and demographic predictors of SIB and further examined differences in their predictive power across unique subclasses of SIB delineated based on their potential for physical injury (SIB-HL and SIB-LL). Distress related to disruptions to IS routines (IS-distress) was a stronger predictor of all SIB types than demographic or sensory variables. After accounting for shared variance explained by other RRBs, IS-distress remained a strong predictor of SIB total and SIB-HL, but not SIB-LL. Among sensory features, sensory-seeking and hypersensitivity were stronger unique predictors of all SIB categories than hyposensitivity. Among demographic factors, lower household income was the strongest predictor of all SIBs. Older age and being female were significant predictors of total SIB and SIB-LL, but not SIB-HL. Notably, although speech was not a significant predictor of total SIB scores, speech level was a positive predictor of SIB-LL and a negative predictor of SIB-HL. Findings highlight the importance of exploring correlates of SIB manifestations at a more granular level to improve understanding and individualized supports.</p> <p>SIBs have been proposed to serve as a means of regulating distress, a communication tool, and/or a form of sensory-seeking behaviors in autism ([<reflink idref="bib65" id="ref56">65</reflink>]). Findings from this study support each of these theories, likely reflecting the complex and heterogeneous etiological nature of SIB. First, the level of distress in response to interruptions to IS behaviors, a possibly autism-specific index of distress dysregulation, was a strong predictor of SIB total and SIB-HL, even after accounting for shared variance explained by other RRBs. This finding is in line with theoretical understandings of SIB as a response to emotional distress and previous empirical evidence that dysregulation is strongly associated with SIB in autistic and non-autistic samples ([<reflink idref="bib11" id="ref57">11</reflink>]; [<reflink idref="bib46" id="ref58">46</reflink>]; [<reflink idref="bib48" id="ref59">48</reflink>]). Interestingly, after accounting for the shared variance of other RRBs, IS-distress was no longer a significant predictor of SIB-LL, possibly suggesting that distress dysregulation plays a different role in more severe versus less severe manifestations of repetitive SIB. Given the developmental links between IS and dysregulation in autism ([<reflink idref="bib15" id="ref60">15</reflink>]; [<reflink idref="bib43" id="ref61">43</reflink>]; [<reflink idref="bib54" id="ref62">54</reflink>]), it is possible that early emerging IS-distress levels may be a useful marker of physically harmful SIB or a target for SIB interventions ([<reflink idref="bib44" id="ref63">44</reflink>]; [<reflink idref="bib66" id="ref64">66</reflink>]).</p> <p>Second, sensory-seeking behaviors and sensory hypersensitivity demonstrated stronger associations with SIB-LL and SIB-HL than sensory hyposensitivity. Sensory hypersensitivity has been consistently linked to dysregulation, both directly and indirectly through well-established links to anxiety ([<reflink idref="bib33" id="ref65">33</reflink>]; [<reflink idref="bib34" id="ref66">34</reflink>]; [<reflink idref="bib62" id="ref67">62</reflink>]). The link with sensory-seeking behaviors underscores the importance of assessing sensory needs in autistic youth to develop tailored intervention plans that provide modulated sensory input throughout the day ([<reflink idref="bib12" id="ref68">12</reflink>]; [<reflink idref="bib35" id="ref69">35</reflink>]). Regarding sensory hyposensitivity, further research is needed to explore the role of altered pain experience and expression that may contribute to SIB ([<reflink idref="bib21" id="ref70">21</reflink>]; [<reflink idref="bib41" id="ref71">41</reflink>]; [<reflink idref="bib57" id="ref72">57</reflink>]).</p> <p>Third, lower speech production was associated with greater severity of SIB-HL, such as head-banging and self-hitting, but lower severity of SIB-LL, such as self-scratching or skin-picking without bleeding or tissue damage. SIB-HL behaviors may develop and persist as a means of communicating one's needs and garnering quick attention from others in the absence of functional communication strategies ([<reflink idref="bib18" id="ref73">18</reflink>]; [<reflink idref="bib27" id="ref74">27</reflink>]; [<reflink idref="bib29" id="ref75">29</reflink>]; [<reflink idref="bib32" id="ref76">32</reflink>]). Thus, interventions such as functional communication training (FCT) might help to reduce physically harmful SIB in autistic youth by promoting the use of alternative communication strategies (e.g. requesting "break" verbally, on a communication device, or using a visual) rather than SIB ([<reflink idref="bib1" id="ref77">1</reflink>]; [<reflink idref="bib59" id="ref78">59</reflink>]).</p> <p>In addition to clinical characteristics, understanding demographic predictors of SIB is essential to providing more targeted care and support. For example, indices of SES such as parental education and household income have been associated with the presence and severity of SIB among autistic youth, youth with intellectual disability, and in clinical samples more broadly ([<reflink idref="bib6" id="ref79">6</reflink>]; [<reflink idref="bib11" id="ref80">11</reflink>]; [<reflink idref="bib38" id="ref81">38</reflink>]). In this study, lower household income was more strongly associated with SIB-HL than SIB-LL. Autistic youth from low-income families often have delayed or limited access to acute care, specialized services, educational services, and community services in the United States ([<reflink idref="bib7" id="ref82">7</reflink>]; [<reflink idref="bib49" id="ref83">49</reflink>]; [<reflink idref="bib51" id="ref84">51</reflink>]), which may contribute to greater severity of SIB topographies that have the potential to cause serious physical harm ([<reflink idref="bib38" id="ref85">38</reflink>]). In addition, parents from lower income households may have fewer resources to implement behavioral supports or parent-mediated interventions that could reduce dysregulation and SIB among autistic youth ([<reflink idref="bib31" id="ref86">31</reflink>]). In turn, youth may exhibit greater emotional and behavioral dysregulation related to disruptions to routines as a means of managing inconsistency and uncertainty in their environments. Finally, age and sex differences were observed in SIB-LL, such that younger age and female (sex) were associated with greater severity of SIB-LL, while these differences were not observed in the severity of SIB-HL. Understanding the role of demographic features in SIB prediction is crucial for providing more effective support.</p> <p>The findings reported here should be considered in light of several limitations. First, this study did not include a full diagnostic battery to capture autism symptomatology and cognitive functioning. However, previous studies with the SPARK cohort have found a high validity of parent-reported autism diagnoses ([<reflink idref="bib28" id="ref87">28</reflink>]) and high agreement between parent-reported IQ levels and standardized IQ assessments ([<reflink idref="bib50" id="ref88">50</reflink>]). Furthermore, parents reported on their child's speech level (no words—uses longer sentences), but we did not inquire about alternative modes of communication, such as gestures, sign language, or alternative and augmentative communication devices (AAC). Such information would provide more nuanced information about associations between communication and SIB. Second, this study relied on informant-report measures of the impact of SIB, IS-distress, and sensory processing differences. Further research is needed to characterize the frequency and impact of SIB topographies utilizing multimodal assessment batteries that incorporate self-report, behavioral observations, physiological measures, and exploration of neurobiological mechanisms underpinning SIB episodes (e.g. [<reflink idref="bib10" id="ref89">10</reflink>]; [<reflink idref="bib30" id="ref90">30</reflink>]; [<reflink idref="bib60" id="ref91">60</reflink>]). In addition, the IS-distress variable was extracted from the same questionnaire measure as the SIB dependent variables, and for this reason may have a stronger predictive relationship than the sensory variables, which were extracted from a different questionnaire measure. Third, as this study did not specifically recruit autistic youth with SIB, more research is needed to inform understanding of topographies that have resulted in severe injury or hospitalization and mechanisms underpinning dangerous, potentially life-threatening forms of SIB. Thus, future research would benefit from including questions that directly assess the nature and severity of injuries related to specific topographies of SIB.</p> <p>In summary, findings from this preliminary investigation provide more nuanced information regarding key correlates of repetitive SIB of varying intensity to inform individualized understanding and support. Findings highlight the role of distress related to disruptions to IS routines, sensory features, lower speech production, and lower household income in the severity of SIB manifestations. Future research is needed to replicate the current fundings and to identify factors that predict more immediately harmful manifestations of SIB.</p> <hd id="AN0193858182-11">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-aut-10.1177_13623613251396036 for Self-injurious behaviors with increased likelihood of injury in autistic youth: The role of distress linked to a strong preference for sameness by Emily F Ferguson, Emily Spackman, Antonio Y Hardan and Mirko Uljarević in Autism</p> <p>The authors are grateful to all the families in SPARK, the SPARK clinical sites, and SPARK staff. They appreciate obtaining access to recruit participants through SPARK research match on SFARI Base.</p> <ref id="AN0193858182-12"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref77" type="bt">1</bibl> <bibtext> Emily F Ferguson</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibl id="bib2" idref="ref51" type="bt"></bibl> <bibtext>https://orcid.org/0000-0002-2771-6346 Emily Spackman</bibtext> </blist> <blist> <bibl id="bib3" idref="ref42" type="bt"></bibl> <bibtext>Graph</bibtext> </blist> <blist> <bibl id="bib4" idref="ref24" type="bt"></bibl> <bibtext>https://orcid.org/0000-0003-2300-439X Mirko Uljarević</bibtext> </blist> <blist> <bibl id="bib5" idref="ref1" type="bt"></bibl> <bibtext>Graph https://orcid.org/0000-0002-7481-3923</bibtext> </blist> <blist> <bibtext> All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.</bibtext> </blist> <blist> <bibtext> Informed consent was obtained from all individual participants included in the study.</bibtext> </blist> <blist> <bibtext> Emily F Ferguson: Conceptualization, Investigation, Methodology, Project administration, Writing—original draft, Writing—review & editing.Emily Spackman: Conceptualization, Formal analysis, Methodology, Project administration, Writing—original draft, Writing—review & editing.Antonio Y Hardan: Funding acquisition, Investigation, Resources, Writing—review & editing.Mirko Uljarević: Data curation, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing—review & editing.</bibtext> </blist> <blist> <bibtext> The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was supported by grant R21MH121876 (Hardan & Jo) by the National Institute of Mental Health.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref79" type="bt">6</bibl> <bibtext> The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref82" type="bt">7</bibl> <bibtext> Access to these data may be available upon reasonable request. 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  Data: Self-Injurious Behaviors with Increased Likelihood of Injury in Autistic Youth: The Role of Distress Linked to a Strong Preference for Sameness
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  Data: <searchLink fieldCode="AR" term="%22Emily+F%2E+Ferguson%22">Emily F. Ferguson</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-2771-6346">0000-0002-2771-6346</externalLink>)<br /><searchLink fieldCode="AR" term="%22Emily+Spackman%22">Emily Spackman</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-2300-439X">0000-0003-2300-439X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Antonio+Y%2E+Hardan%22">Antonio Y. Hardan</searchLink><br /><searchLink fieldCode="AR" term="%22Mirko+Uljarević%22">Mirko Uljarević</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-7481-3923">0000-0002-7481-3923</externalLink>)
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  Label: Abstract
  Group: Ab
  Data: Self-injurious behaviors in autistic youth vary widely in their form, intensity, and potential for physical injury. This study explored predictors of two categories of self-injurious behaviors that were delineated based on their potential for physical injury (self-injurious behavior--High Likelihood and self-injurious behavior--Low Likelihood), with a focus on the role of distress linked to a strong preference for routines (otherwise known as insistence on sameness). The sample included 1892 autistic youth (M[subscript age] = 10.82, SD[subscript age] = 4.14; 22% females) across the United States. Distress associated with insistence on sameness was the strongest predictor of total self-injurious behavior scores, self-injurious behavior--Low Likelihood, and self-injurious behavior--High Likelihood, after controlling for demographic factors and speech level, and remained a unique predictor after accounting for variance explained by other restricted and repetitive behaviors. Sensory hypersensitivity and sensory-seeking were strong unique predictors of all self-injurious behaviors, while hyposensitivity was a weaker predictor of self-injurious behavior total and self-injurious behavior--Low Likelihood, and a non-significant predictor of self-injurious behavior--High Likelihood. Among demographic factors, lower household income was the strongest predictor of all self-injurious behaviors. Higher speech level was a positive predictor of self-injurious behavior--Low Likelihood but a negative predictor of self-injurious behavior--High Likelihood. These findings demonstrate the role of distress associated with insistence on sameness in manifestations of self-injurious behaviors and highlight the importance of exploring predictors at a more granular level to inform targeted interventions and support.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2026
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1506441
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1506441
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/13623613251396036
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 12
        StartPage: 1620
    Subjects:
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Youth
        Type: general
      – SubjectFull: Self Destructive Behavior
        Type: general
      – SubjectFull: Prediction
        Type: general
      – SubjectFull: Sensory Experience
        Type: general
      – SubjectFull: Repetition
        Type: general
      – SubjectFull: Speech Skills
        Type: general
      – SubjectFull: Student Characteristics
        Type: general
      – SubjectFull: Behavior
        Type: general
    Titles:
      – TitleFull: Self-Injurious Behaviors with Increased Likelihood of Injury in Autistic Youth: The Role of Distress Linked to a Strong Preference for Sameness
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Emily F. Ferguson
      – PersonEntity:
          Name:
            NameFull: Emily Spackman
      – PersonEntity:
          Name:
            NameFull: Antonio Y. Hardan
      – PersonEntity:
          Name:
            NameFull: Mirko Uljarević
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 06
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-print
              Value: 1362-3613
            – Type: issn-electronic
              Value: 1461-7005
          Numbering:
            – Type: volume
              Value: 30
            – Type: issue
              Value: 6
          Titles:
            – TitleFull: Autism: The International Journal of Research and Practice
              Type: main
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