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):
- Childrens’ school performance improved & they attended school more regularly
- Children had more friends & better quality friendships
- Children got along better with family members
- Children had higher self-esteem
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 Inner Child 
Thanks on the insights on the way to descibe the difference between the feelings of having OCD alone (wanting to get rid of the feeling)and how it differs from how a child with OCD and also on the spectrum. And for the link for hopeful treatment! My sons school has been starting to tally his “OCD behavior” which they have defined as repitition of 3 times or more, but I haven’t really understood the valid reason for them to be doing this. Maybe now I can have a discussion so they can better understand my son.
Kathleen–
Thanks for the comment! I am not sure what tallying your son’s behavior would accomplish other than establishing a baseline of how much the particular behavior occurs. I would be curious to hear what they accomplish with that methodology.
Readers should note that the best source of information for prevention, diagnosis, and treatment is their psychologist, pediatrician, or other appropriately-trained and credentialed members of their healthcare team. For additional information or to schedule an appointment with Dr. Bowers, please visit http://www.aacenter.org.
Reading about how easily the symptoms of OCD and autism intersect, and how often these behaviors are misdiagnosed in children as “acting out” or “ADD” — and then masked, rather than treated with medication — sent chills up my spine. As the mother of a 23 year old who suffers increasing intensity of anxiety which antidepressants can’t calm, I’m gaining an understanding of the whys. Wishing we had this information 20 years ago, but I’m hoping some of the exercises that you’ve developed for children can be retrofitted for the young adult.
You’ve described my kid exactly!
Joanna–
I am always happy to hear that I am on target with my assessment of symptom patterns and how they are addressed. Many of the strategies designed for children are being modified and can be used successfully among young adults as well, especially if there are differences between the individual’s chronological and developmental ages. I don’t buy any argument that there is a certain age in which it is “too late” for intervention. There may be some hurdles to jump through if the individual is resistant to intervention (after all treating a 23 -year-old requires their consent rather than treating a 4-year-old whose parents make the decision), but once you get through those and find a connection then everything else tends to begin to fall into place. All the best to you and your child as you continue to seek out answers and solutions.
Readers should note that the best source of information for prevention, diagnosis, and treatment is their psychologist, pediatrician, or other appropriately-trained and credentialed members of their healthcare team. For additional information or to schedule an appointment with Dr. Bowers, please visit http://www.aacenter.org.
Hi,
My son goes through, phases on how things should be done. First, it was that his clothes be hand washed and not put in the machine, then he got over it. Then it was driving by a certain place to see a certain bridge, whenever we were intersected with the road that it was on. etc. Lately, it’s closing the car door by himself and was the toaster (toasting bread by himself). If we did it for him, he would get very upset. If we did not comply to any of these, he would get really upset. My question is, would this type of behavior be considered OCD or would it be considered routine?
I’ve been telling people these were ocd issues, but from reading your blog, it seems it’s not.
Thanks
Christine–
I would be happy to try and answer your question although I would need more information about your son and his age, diagnosis, history to give you an accurate response.
Readers should note that the best source of information for prevention, diagnosis, and treatment is their psychologist, pediatrician, or other appropriately-trained and credentialed members of their healthcare team. For additional information or to schedule an appointment with Dr. Bowers, please visit http://www.aacenter.org.
Dr. Bowers,
I am SO grateful to have come across your blog, particularly this post. My cousin is 16 and autistic. He suffers from severe OCD as well, which causes him to, amongst other things, wash his hands until they bleed. He has yet to receive effective treatment for his OCD and it is truly destroying his family and his life. He is paralyzed by fears of every kind — even of words and abstract concepts — which cause him to act out in his OCD behaviors. We, as his family, are at a loss. Would you be willing to speak to his parents over the phone, and/or answer some more specific questions in order to help us take the next step to find him some help? Please email me or post response if possible. Thanks so much,
Jaime
Jaime–
I would be happy to speak with his parents. Have them call my office at their earliest convenience.
Readers should note that the best source of information for prevention, diagnosis, and treatment is their psychologist, pediatrician, or other appropriately-trained and credentialed members of their healthcare team. For additional information or to schedule an appointment with Dr. Bowers, please visit http://www.aacenter.org.
The link to the article on treatment of OCD IN PDD is borken for me can you send me the citation. thank you.
Thanks for bringing it to my attention. I t looks like the old link is shut down. I have repaired it with a new link or you can go directly here: link
My 5 year old son has autism but is super smart as he has been reading, adding, spelling, &s ubtracting since age 3 & now at age 5 can multiply. He has major issues with not being first, things have to be perfect, & rules can not be broken. Things have to be (like blocks) in a specific order (by color, size or shape) before he can begin to play with them. At night things have to be the same (blanket, stuff toy and amount of kisses). At the playground we can not play if other children are going up the slide instead of down because his focus is on that they are “not following the rules of sliding)Thank you for this article as it gives me hope that there is help for him.
This really helped me understand the difference of OCD and Autism with OCD. My 12 yr. old has autism with severe OCD. He is experiencing severe behavioral problems especially at school. He has an appt. with a therapist to possibly start CBT. I love this little guy and I am hoping this will help.
Hello Dr. Bowers,
My daughter to is in the Autism spectrum and also suffers from what I think is OCD. She repeats herself over and over again and then does these rituals with touching her shoulders with her hand back and forth from side to side. She continues to babble to herself during class and is now becoming a great disruption to all the other children in the class. We live in Houston Texas is there any Dr. down here that does what you do that you could recommend to us to take our daughter to?
Have you checked the Houston OCD Center?
It’s hard to come by knowledgeable people about this subject, however, you sound like you know what you’re talking about! Thanks