Does Your "Obsessive" Child on the Autism Spectrum Have OCD?

"My child (with HFA) does obsess about certain things, but how can I tell if he has full-blown obsessive compulsive disorder?"

Obsessive compulsive disorder (OCD) is described as a condition characterized by recurring, obsessive thoughts and compulsive actions. Obsessive thoughts are ideas, pictures of thoughts or impulses that repeatedly enter the mind, while compulsive actions and rituals are behaviors that are repeated over and over again.

The obsessions seen in kids with Asperger’s (AS) and High-Functioning Autism (HFA) differ from the youngster with obsessive compulsive disorder. The youngster with AS or HFA does not have the ability to put things into perspective. Although terminology implies that certain behaviors in AS and HFA are similar to those seen in obsessive compulsive disorder, these behaviors fail to meet the definition of either obsessions or compulsions.

They are not invasive, undesired or annoying, which is a prerequisite for a diagnosis of obsessive compulsive disorder. The reason for this is that children with severe autism are unable to contemplate or talk about their own mental states. However, obsessive compulsive disorder does appear to coincide with AS and HFA.



Szatmari et al (1989) studied a group of 24 kids. He discovered that 8% of the kids with AS and 10% of the kids with HFA were diagnosed with obsessive compulsive disorder. This compared to 5% of the control group of kids without autism, but with social problems. Thomsen el at (1994) found that in the kids he studied, obsessive compulsive disorder continued into adulthood.

==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism

AS and HFA kids with obsessive compulsive disorder:

• become preoccupied with whether something could be harmful, dangerous, wrong, or dirty
• experience a need for symmetry, order and precision
• experience intrusive sounds or thoughts
• feel like they must perform the task or dwell on the thought
• feel strong urges to do certain things repeatedly (i.e., rituals or compulsions) in order to banish the scary thoughts or ward off something dreaded
• have a difficult time explaining a reason for their rituals
• have a fear of contamination
• have a fear of illness or harm coming to oneself or relatives
• have a strong belief in lucky and unlucky numbers
• have an "overactive alarm system" 
• have upsetting or scary thoughts or images that pop into their minds that are hard to shake
• may have preoccupation with body wastes
• may have religious obsessions
• may have sexual or aggressive thoughts
• realize that they really don't have to repeat the behaviors, but the anxiety can be so great that they feel that repetition is "required" to neutralize uncomfortable emotions
• try to relieve anxiety via the use of obsessions and compulsions
• want to feel absolutely certain that something bad won't happen 
• worry about losing things, sometimes feeling the need to collect these items, even though the items may seem useless to others
• worry about things not being "in order" or "just right"

Compulsions that are most common include: 

• cleaning rituals
• counting rituals
• grooming rituals
• hoarding and collecting things of no apparent value
• ordering or arranging objects
• repeatedly checking homework
• repeating rituals (e.g., going in and out of doorways, needing to move through spaces in a special way, rereading, erasing, rewriting, etc.)
• rituals to prevent harming self or others
• rituals to undo contact with a "contaminated" person or object
• touching rituals

Moms and dads can look for the following possible signs of obsessive compulsive disorder in their AS or HFA child: 

• a continual fear that something terrible will happen to someone
• a dramatic increase in laundry
• a persistent fear of illness
• a sudden drop in test grades
• an exceptionally long amount of time spent getting ready for bed
• constant checks of the health of family members
•  high, unexplained utility bills
• holes erased through test papers and homework
• raw, chapped hands from constant washing
• reluctance to leave the house
• requests for family members to repeat strange phrases or keep answering the same question
• unproductive hours spent doing homework
• unusually high rate of soap or paper towel usage

 ==> "OCD: What To Look For" - Excerpt from Mark Hutten's Lectures

If your AS or HFA youngster shows signs of obsessive compulsive disorder, talk to your physician. In screening for obsessive compulsive disorder, the physician will ask your youngster about obsessions and compulsions in language that he or she will understand, for example:

• Are there things you have to do before you go to bed?
• Do things have to be "just so"?
• Do you collect things that others might throw away (e.g., hair, fingernail clippings, dead batteries, etc.)?
• Do you count to a certain number or do things a certain number of times?
• Do you have to check things over and over again?
• Do you have to wash your hands a lot?
• Do you have worries, thoughts, images, feelings, or ideas that bother you?

Treatment—

The most successful treatments for AS and HFA children with obsessive compulsive disorder are cognitive-behavioral therapy (CBT) and medication. CBT helps these “special needs” children learn to change thoughts and feelings by first changing behavior. The therapy involves gradually exposing children to their fears, with the agreement that they will not perform rituals in order to help them recognize that their anxiety will eventually decrease and that no disastrous outcome will occur.

Just talking about the rituals and fears have not been shown to help obsessive compulsive disorder, and may actually make it worse by reinforcing the fears and prompting extra rituals. Thus, for CBT to be successful, it must be combined with “response prevention,” in which the youngster's rituals or avoidance behaviors are blocked (e.g., a youngster who fears dirt must not only stay in contact with the dirty object, but also must not be allowed to wash repeatedly).

Many children can do well with CBT alone, while others will need therapy and medication. Selective serotonin reuptake inhibitors (SSRIs) often can reduce the impulse to perform rituals. Once a youngster is in treatment, it's important for moms and dads to participate, to learn more about obsessive compulsive disorder, and to modify expectations and be supportive.

AS and HFA kids with obsessive compulsive disorder get better at different rates, so parents should try to avoid any day-to-day comparisons and recognize and praise any small improvements. Also, try to keep family routines as normal as possible.

More resources for parents of children and teens with High-Functioning Autism and Asperger's:

==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's

==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism

==> Launching Adult Children with Asperger's and High-Functioning Autism: Guide for Parents Who Want to Promote Self-Reliance

==> Teaching Social Skills and Emotion Management to Children and Teens with Asperger's and High-Functioning Autism

==> Parenting Children and Teens with High-Functioning Autism: Comprehensive Handbook

==> Unraveling The Mystery Behind Asperger's and High-Functioning Autism: Audio Book

==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism

Part 3: Teaching Strategies for Students with Asperger’s and High-Functioning Autism – The “Hidden Curriculum”

Curriculum education is not the only education an Asperger’s (AS) or High-Functioning Autistic ((HFA) student encounters in the public school system. Social behaviors are not only necessary for successful playground interaction, they are necessary for successful acquisition of educational curriculum.

The “hidden curriculum” consists of important social skills that everyone knows, but no one is taught. This includes assumed rules, student expectations, idioms and metaphors. Understanding the hidden curriculum is difficult for all kids, but it is especially so for young people with AS and HFA who have deficits in social interactions.

The following example illustrates the difficulty children on the autism spectrum have understanding the hidden curriculum:

Michael was a popular ninth-grader, despite his social awkwardness. His classmates accepted him and were understanding of his disorder. One day Michael was hanging out with his peers in the hallway before class when his friend Jamie began swearing in disappointment about his D in math. Michael picked up on the swearing and associated it with disappointment. The bell rang and Michael went on to his next class. As he sat down, Michael realized that he left his history book in his locker. His teacher, Mr. Williams, would not let him go back to his locker, and immediately Michael got mad and began using cuss words. Mr. Williams sent Michael to the dean’s office, leaving Michael mystified about what he did wrong. He thought it was acceptable to cuss when he was disappointed at school. Michael did not understand the hidden curriculum – swearing may be acceptable around peers, but you should never curse when a teacher is present.

The hidden curriculum suggests an aspect of learning that is not obvious to students with AS and HFA. This aspect of learning includes the basic how-to's of daily functioning. These are things that other students seem to just know. The social know-how that tells “typical” students what is inappropriate subject matter may be foreign to an AS or HFA student. Thus, teachers should instruct students struggling in this realm through the use of acting lessons, direct instruction, scope and sequence, self-esteem building, and social stories. Social stories and acting lessons give examples of proper behaviors in various public settings.

More information on creating social stories can be found here: How To Write Social Stories

==> Teaching Students with Aspergers and HFA

Catatonia in Children and Teens on the Autism Spectrum

Catatonia is a complex disorder covering a range of abnormalities of movement, posture, speech and behavior associated with under-activity as well as over-activity. Research and clinical evidence reveals that some children with Autism Spectrum Disorders (ASD), including Asperger’s and High Functioning Autism, develop a complication characterized by catatonic and Parkinsonian features.

In children with ASD, catatonia is shown by the onset of any of the following traits:

• increased slowness affecting movements and/or verbal responses
• increased reliance on physical or verbal prompting by others
• increased passivity and apparent lack of motivation
• Parkinsonian features (e.g., freezing, excitement and agitation, a marked increase in repetitive and ritualistic behavior)
• difficulty in initiating, completing, and inhibiting actions

Behavioral and functional deterioration in the teenage years is common among young people with ASD. When parents notice a deterioration or an onset of new behaviors, it is important to consider the possibility of catatonia as an underlying cause. Early recognition of problems and accurate diagnosis are important, because it is easiest to manage and reverse the condition in the early stages.

Catatonia is a serious condition that can become more severe. This risk increases the longer the condition is left untreated, and it becomes more difficult to reverse the more severe it becomes. Catatonia is distressing for the ASD child, which can cause additional behavioral disturbances.

Autism-related catatonia looks quite different from classic catatonia. It occurs across a spectrum from mild to severe. In mild and moderate cases, moms and dads often describe their ASD teenagers as “slowing down” or appearing depressed. Sometimes, these teens become stuck when trying to initiate a movement (e.g., he or she may walk up to a doorway and then freeze before stepping over the threshold). Severe cases of autism-related catatonia look a lot like classic catatonia, with the youngster almost completely shutting down.

Autism-related catatonia also produces changes in movement patterns, which can include a brief “freeze” during actions, bursts of hyperactivity, difficulty coming to a stop, incontinence, marked reduction in speech, odd gait, and stiff posture.

One of the reasons autism-related catatonia went unrecognized for so long is because many of its symptoms overlap with those of autism. Thus, the “red flag” for moms and dads is a “marked change in behavior.” What’s lost is the ability to turn intentions into action.

There is little information on the cause or effective treatment of catatonia. In one study of referrals who had ASD, it was found that 17% of all those aged 15 and over had catatonic and Parkinsonian characteristics of sufficient degree to severely limit their mobility, use of speech, and ability to carrying out daily activities. It was more common in those with mild or severe learning disabilities, but did occur in some who were high-functioning.

Autism-related catatonia appears to result from a depression in the GABA neurotransmitter system. GABA is a brain neurotransmitter (i.e., it enables nerves in the brain to send messages to one another). One medication used to treat autism-related catatonia is the GABA-stimulating medicine called lorazepam (trade name Ativan).

With true autism-related catatonia, positive response to such treatment are often seen within an hour or so. This lasts for up to several hours. Thus, a positive response (with the ASD child showing improved spontaneous movement) helps confirm the diagnosis. For many of these kids, this type of medicine is also an effective long-term treatment. For severe cases, treatment options include electroconvulsive therapy, which seems to act like a “brain reboot” that helps get the child moving and eating again.

Given the scarcity of information in the literature, as well as the potential adverse side effects of medical treatments, it is important to recognize and diagnose catatonia as early as possible so that environmental, cognitive and behavioral methods of the management of symptoms and underlying causes can be implemented. Detailed psychological assessment of ASD children, their lifestyle, environment, circumstances, pattern of deterioration and catatonia are needed to design an individual program of management.

When evaluating for catatonia, the doctor needs to understand what the child was like before concerns arose. How smooth were his movements? What were his interests and abilities? How did they change?

More resources for parents of children and teens with High-Functioning Autism and Asperger's:

==> How To Prevent Meltdowns and Tantrums In Children With High-Functioning Autism and Asperger's

==> Parenting System that Significantly Reduces Defiant Behavior in Teens with Aspergers and High-Functioning Autism

==> Launching Adult Children with Asperger's and High-Functioning Autism: Guide for Parents Who Want to Promote Self-Reliance

==> Teaching Social Skills and Emotion Management to Children and Teens with Asperger's and High-Functioning Autism

==> Parenting Children and Teens with High-Functioning Autism: Comprehensive Handbook

==> Unraveling The Mystery Behind Asperger's and High-Functioning Autism: Audio Book

==> Parenting System that Reduces Problematic Behavior in Children with Asperger's and High-Functioning Autism