Self-injurious behaviors with increased likelihood of injury in autistic youth: The role of distress linked to a strong preference for sameness.
Distress when routines change, not the preference for sameness itself, most strongly predicts self-injury in autistic youth.
01Research in Context
What this study did
Ferguson et al. (2025) asked parents of 1,892 autistic youth to fill out an online survey.
They wanted to know which traits make self-injury more likely or more severe.
The team looked at insistence on sameness, sensory issues, speech level, and family income.
What they found
Distress when routines change was the strongest predictor of both mild and severe self-injury.
Sensory seeking and hypersensitivity also raised risk.
Lower income and limited speech added extra risk, but the distress piece mattered most.
How this fits with other research
Spackman et al. (2023) used the same 1,892 families to show insistence on sameness is not one thing.
They split it into rituals, routines, and social sameness. F et al. built on that by showing it is distress over change, not just liking sameness, that fuels injury.
Carson et al. (2017) found half of autistic adults also self-injure. F et al. extend that downward, mapping the youth warning signs that may start the cycle early.
Park-Cardoso et al. (2023) heard adults call sameness habits helpful self-regulation. F et al. agree sameness can soothe, but add that when change still happens, the resulting distress can turn harmful.
Why it matters
You can now screen for injury risk without extra tools. Ask parents how their child reacts when a routine breaks. If the answer is "melts down," plan proactive visual schedules, priming, and distress-tolerance lessons. Target the distress, not the preference for sameness itself.
Want CEUs on This Topic?
The ABA Clubhouse has 60+ free CEUs — live every Wednesday. Ethics, supervision & clinical topics.
Join Free →Add one question to your intake: "What happens when a daily routine changes?" Use the answer to flag high-risk cases and front-load schedule priming.
02At a glance
03Original 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 (Mage = 10.82, SDage = 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.Lay AbstractThis 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.
Autism : the international journal of research and practice, 2025 · doi:10.1177/13623613251396036