PFA Tips: What About Those Obsessive-Compulsive Behaviors?
By Melanie DuBard, Ph.D., BCBA-D, Kennedy Krieger Schools
Maybe you are thinking about Jack Nicholson in As Good As It Gets when I mention OCD (locking and re-locking his door, washing his hands with scalding water and a new bar of soap each time, not stepping on lines in the sidewalk, bringing his own silverware to a restaurant, etc.). Well, that is what it can look like, but many children with autism exhibit obsessive and compulsive behaviors which may or may not fit into the categories of cleaning or germ phobias. Many children diagnosed with autism have other behaviors which seem to be obsessive (in the sense that they are hyper-focused on preferred topics or items) or compulsive (the need to have things look a certain way, the need to have things happen a certain way, etc.). However, that does not mean they need an OCD diagnosis; it is sometimes just the best way to describe the behaviors they are engaging in. Getting an OCD diagnosis can be complicated and should only be given by someone with experience with children with autism and OCD.
Many children with autism have ritualized behaviors and interests
These behaviors are often just accepted as part of life; however, there are occasions when the behaviors pose a problem. This most often occurs when it interferes with a child being able to leave their home, go into public, or participate in typical school activities. The problem typically arises when a ritual or compulsive behavior is interrupted or prevented or when the child is not allowed to engage in discussing/searching the internet for their preferred topics/interests because someone does not want to talk about what they want to talk about, their access to the computer is restricted, or they are redirected to a different task. At these times, it is not uncommon to see the emergence of problem behaviors such as aggression, disruptive behaviors, etc. Most often your child is exhibiting these behaviors to try and regain control, reduce anxiety associated with not being able to engage in their obsessions and rituals, or in an attempt to have others allow them to have their way (for example, they may have learned that engaging in problem behaviors typically results in you letting them have their way so they will try to see if that works).
What purpose do these behaviors serve?
In children diagnosed with autism, obsessions and compulsions have been reported to function as a way of coping when the environment is unpredictable and as a means of helping to control the unpredictability. Anxiety often develops because of the unpredictability, and it is reduced when an individual engages in repetitive behaviors.
Who do I ask for help if my child begins having these behaviors?
Finding a provider can be tricky because not everyone with experience with OCD will have experience with children with autism and vice versa. So, you need someone who has experience working with children with autism who also has a behavioral background. They would need to be creative in coming up with interventions and possibly consulting the cognitive-behavioral literature on OCD treatment. For an example see the article by Reaven and Hepburn, 2003*.
It is also possible that your child’s anxiety may be so great that behavioral intervention alone is not effective. If that becomes an issue, it may be necessary to consult your pediatrician, a psychiatrist, or a neurologist to discuss using a combination of medication and behavioral treatment to address the anxiety and behavior difficulties.
What are some of the interventions used to treatment these OCD behaviors?
Behavioral treatments work because they are individualized to the child and the particular function(s) that the behaviors serve for a child. Your child may exhibit tantrumming or aggression for a completely different reason than another child with autism, and part of assessment and treatment is figuring out why and under what situations your child is more likely to have the behaviors. Once that information is obtained, (typically through a functional behavior assessment) it is possible to identify an appropriate treatment. Treatments for OCD behaviors can be as simple as a reinforcement system, a competing items treatment (where you find other items/activities that are more socially appropriate and can be used as a replacement for the inappropriate behaviors), or a modified version of a cognitive behavioral treatment (this means a treatment that involves both cognitive and behavioral components; these are most often used with children who are verbal but can be modified for non-verbal children in some instances).
Cognitive-behavioral interventions focus on changing how an individual thinks about and responds to emotions. The theory behind these interventions states that an individual’s responses to the environment are mediated by cognitions (meaning that how a child thinks about things and how they process affects their behavior). Cognitive-behavioral treatment use techniques to try and change an individual’s thought process therefore changing the behavior. Some children with autism are non-verbal or have significant difficulty communicating their thoughts and emotions; in these cases, it may be possible to take the ideas and interventions identified in cognitive behavioral therapies and modify them to obtain the same or similar information in alternative ways. As stated previously, consultation with a therapist/doctor who has experience with both OCD and autism would be helpful if these behaviors arise and are problematic for your child.
*Reaven, J. & Hepburn, S. (2003). Cognitive behavioral treatment of obsessive compulsive disorder in a child with Asperger syndrome: A case report. Autism, 7(2), 145-164.
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