“During any moment of any given day, I’m either obsessed with what I’m doing or bored with what I’m doing.”
–Student with Asperger’s explaining the difficulty navigating everyday activities.
Autism Spectrum Disorders (ASDs) and Obsessive-Compulsive Disorder (OCD) can and do occur at the same time. OCD is a specific diagnosis under a larger umbrella of anxiety. Children with OCD experience unwanted and intrusive thoughts that they can’t seem to get out of their heads (obsessions), often compelling them to repeatedly perform ritualistic behaviors and routines (compulsions) to try and ease their anxiety. Children with ASD generally have repetitive, perseverative thoughts that are intense in nature, much like children with purely OCD symptoms. The big difference is that children with OCD do not like the experience of having repetitive thoughts and would do anything to get rid of the thoughts (such as washing one’s hands 25 times). Children with Autism Spectrum diagnoses are not bothered by their repetitive behaviors and thoughts, and instead are usually comforted by them (such as playing with a train in a repetitive fashion for hours at a time).
Anxiety is highly prevalent among children with Autism Spectrum diagnoses (greater than 35% of children experience both). This is due to a combination of genetics, brain development, and higher levels of stress. The error that many schools and therapists often make is attributing a child’s anxiety symptoms to his or her Autism diagnosis (i.e., “The only way to really reduce anxiety and aggression is to treat the Autism.”) For example, many children are referred into social skills groups when what they really need is help with anxiety that is interfering with their social functioning. Highly anxious children with OCD may begin to act out behaviorally in school prompting teachers to encourage (some might say ‘coerce’ or ‘force’) parents to begin medicating the behavior. The concerns here is twofold: 1) the behavior is numbed with medication and the root anxiety is never truly addressed (i.e., stop the medication and everything returns to the way it was), and 2) the school may begin to implement safety nets such as increased para support to keep the behaviors from occurring while again failing to adequately address the underlying anxiety symptoms.
The question often asked is, “Can you really treat a child who has both an autism spectrum diagnosis and OCD?” The answer is “yes” and new research is beginning to show that there are some exciting recent behavioral treatments out there for these children. Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for anxiety that has been established by the American Psychological Association as effective for children. A recent study of CBT for neurotypical children with anxiety (Wood et al., found):
The authors of that study have adapted the neurotypical CBT protocol for children with autism spectrum and are finding some promising results. In general the results suggest that the authors’ adaptations of the pre-existing CBT manual can be effective for treating anxiety such as OCD in children with autism (research article link). This treatment manual is available to practitioners and families, a sample of which can be viewed here. Thus, there is hope for effective anxiety treatment for your child who also has an autism spectrum diagnosis. It is highly recommended that you seek out services from a pediatric specialist who has training and experience treating children with co-occurring anxiety and autism spectrum diagnoses.
On a personal note and aside, I will be spending tomorrow with noted Asperger’s guru Dr. Tony Attwood so stay tuned for a blog later this week where I hope to share some new ‘nuggets’ of information.
Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.
© 2009 Mark Bowers, Ph.D.
The nature of Autism is the brain’s desire to keep the world the same. This is why one of the hallmark diagnostic features of Autism is repetitive, perseverative, and stereotypical behaviors. One of the most common is scripting in which the child takes dialogue that he or she heard someone else say (usually a favorite cartoon or television character) and applies it in a repetitive and often nonfunctional fashion. Scripting is often referred to as a Comfort Zone behavior. This posting attempts to provide some strategies for how to deal with scripting as well as some reflections on the nature of Comfort Zone behaviors.
For children with Autism, the Comfort Zone is what the child will do when you let them do whatever they want to do. Examples include: playing with/lining up cars, watching portions of the same video, flipping through familiar books, scripting, opening/closing doors/drawers, visually stimulating on an object (e.g., spinning), and staring off in the distance as if in a trance or daydream. By the way, ever wonder why the fascination with trains? The answer is that there is not likely anything much more linear and repetitive than a train going from one place to another and then back again. I digress, so in this comfort zone, children are not connected or engaged with the world. In fact, by the time kindergarten starts, one measure of school readiness is that the children are connected with the social environment most of the time and turn consistently to their names. You probably notice that your child does not turn to his or her name being called consistently if they are absorbed in a particular activity. If your child is ‘stuck’ inside their comfort zone and not paying attention to the environment, not easily engaged, not able to interact in a back-and-forth fashion; then they are going to need help leaving this comfort behavior for longer periods of time (i.e., you will need to engage them more and not allow them to be off on their own in a perseverative or repetitive behavior). The key to remember here is that as engagement with others increases, perseverative/repetitive behaviors such as scripting decreases. Thus, we must be aware of when the child is in his or her comfort zone and not allow them to remain there for too long.
I do want to take a moment to acknowledge, however, how it must feel for a parent to see the Autistic ‘veil’ drop in front of the child’s eyes as they check out from the real world for a moment and become absorbed in a repetitive behavior. Especially for parents who have been working with their child for a number of months or years and have begun to see progress; the child’s return into scripting and other stereotypical behaviors is a glaring reminder that the child has Autism. It also serves as a reminder to the world that something is not quite connecting in the child’s brain. I often conceptualize this as a neurological tug-of-war that is taking place inside the child’s brain. The hardwiring of the Autistic brain is determined to keep the world simple and the same, with little (if any) interest in relationships or social connections. However, as the child makes progress and begins to learn how much fun can be had with others and the value of having play partners, another part of the brain begins to compete for dominance.
I see a similar phenomenon take place among children with OCD that I treat. They experience what I refer to as “brain hiccups” that play tricks in one’s mind, often convincing the child that unless he washes his hands 15 times in a specific fashion, for example, something awful will certainly happen. This thought will not go away (hence the ‘hiccup’) until the child engages in the ritual of the brain’s liking. What these children describe to me, however, is the rational part of their brain telling them that they don’t really want to have to wash their hands that many times (or at all for that matter) to make the thoughts go away. There are often strong similarities between the brains of children with OCD and brains of children with Autism. However, one critical difference is that the OCD brain ultimately wants the repetitive thought to go away while the Autistic brain is comforted by the repetitive and familiar nature of the thought.
For more information on this topic, visit the work of Dr. Rick Solomon and the PLAY Project.
Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.
Mark Bowers, Ph.D. © 2009
A paper presented at the International Conference on Violence, Abuse and Trauma on Sept. 25 by sociologist Murray Straus has caught my attention this week. Straus and his colleague Mallie Paschall followed children over the course of four years and determined that those who were spanked had up to a 5-point lower IQ than their peers who were not spanked. Further, the more the children were spanked, the lower their IQs.
This debate is not new. In fact, I find myself in this debate at least a few times each month with some of the families I see. The age old question is whether or not spanking is an effective form of discipline. My professional stance (in conjunction with the science that supports it) is that spanking is actually punishment (not discipline) and is only effective in the short-term. Try telling that to the ‘old school’ father who swears, “It worked on me when my father spanked me!” With a little more investigation in my office, I am often able to reveal that while it may have garnered attention in the short-term, it fueled resentment toward the parent over the long-term.
I truly believe that the majority of spanking occurs in the form of a parental temper tantrum in which the parent has lost control and is at a loss for an effective discipline strategy. There are a number of problems with punishment that I encourage parents to consider when deciding if they really want to employ spanking as a method of punishment.
In case those reasons were not enough, we also know that spanking makes children anxious (especially toward the parent using this method) and spanking can lower self-esteem. A report endorsed by the American Academy of Pediatrics in 2008 looked at 100 years of research and concluded, “There is substantial research evidence that physical punishment makes it more, not less, likely that children will be defiant and aggressive in the future.”
The full report can be read at www.phoenixchildrens.com/discipline