Asperger's and OCD - a 10-Step Guide

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 Asperger's Syndrome and OCD

A 10-step guide for teachers, caregivers and relevant others


  • Below is a non-medical guideline to help recognise obsessive compulsive behaviours associated with OCD; behaviours associated with Asperger syndrome; or a combination of both.
  • While Carol Edward's is not in a position to make a diagnosis for medical conditions, the information provided is based on her relevant studies and continuing professional development; and also lived experiences.
  • For easier reading, the term ASD is used to describe autism and Asperger's interchangeably. 
Cognitive Behavioural Therapy

Cognitive behavioural therapy (CBT) looks at thoughts, feelings and behaviours and how these interact with each other. 

Autism/asperger's considers the triad of impairments which are social communication, social interaction and social imagination. The view is that some children on the autism spectrum do not understand or don't fully grasp that other people have their own plans, thoughts and points of view. This refers to a theory of mind.  

Because children on the autism spectrum usually have difficulty understanding other people’s beliefs, attitudes and emotions means cognitive therapy wouldn't generally be effective for treating co-occurring OCD. However, adjustments with emotion-management can help a child prepare and cope with challenging situations. 

There are other times when a child on the autism spectrum has good insight into their obsessions and compulsions which means CBT can be used or modified to treat this disorder.

1. Obsessions and collecting – My child appears obsessed with a particular type of teddy and cannot resist adding these to her collection - she saves her pocket money to buy these. While she seems happy with her purchases (as any child would) she also feels highly distressed about how the compulsion to buy the teddies makes her feel. She says she feels she has to collect them, or something bad will happen or that she'll feel horrible and guilty for leaving the other teddies behind. In this sense, apprehension associated with obsessive collecting is likely attributed to OCD. In comparison my child's steady interest (e.g., collecting dinosaur information) is usually done without distress, unless interrupted. The point is that when a child who has both OCD and an ASD then teasing out one set of symptoms from the other helps with suitable treatment intervention for OCD - for example, CBT/ERP for OCD with adjustments to address ASD depending on insight, pathological doubt and assessment reliability.  

2. Idiosyncrasy – This is a behavioural quirk attributed to the person only, thus a distinguishing trait of a child with ASD might be to smell or sniff a particular object which is a self-stimulatory behaviour. These also include hand-flapping, rocking, staring at hands, sniffing hair or clothes etc - these self-stimulatory actions are calming for the child on the autism spectrum; and as it goes don't need to be over-analysed. However, a child who has OCD might do the same behaviour to gain temporary anxiety relief only, and this is cyclic. You might for example see a child sniffing a pencil repeatedly and become highly distressed if prevented from doing this. On the topic of OCD this would be seen as a ritual to ward off perceived danger, in which case it's important for teachers to take special care and discuss with parents for bringing into school CBT stragegies. 

3. Rituals – A child who has an ASD might prefer to follow a ritual. For example, Harry dresses in the same way every morning and will follow through with the sequence usually without distress. He follows a ritual because he prefers regularity. On the other hand, Sam, who has OCD, dresses in the same way every day but feels troubled by having to follow this pattern because it isn't what he really wants to do – he has a compulsion to do the ritual and unless he carries it out, his anxiety increases. This type of compulsive behaviour is usually to 'prevent' something bad happening or 'to feel right'. When changing for sports, care is needed, usually because while a child on either spectrum might take longer to change, it isn't necessarily because they want to get out of doing sports, they're seriously struggling with internal challenges. Some kids who have OCD often have problems choosing which colour clothes to wear too, for example, when dressing for a play, if they choose a white garment OCD might say choose the blue one or something bad will happen. Their distress might come across as being stubborn or simply not wanting to join in. Similarly, some children on the autism spectrum cannot tolerate the feel of certain materials and their distress might be seen as making a fuss.

4. Routine – Children with an ASD usually follow a routine when getting ready for school. Doing/using things in a particular order makes them feel grounded and secure. This is really just typical of ordinary behaviour in terms of any person preferring familiarity. That said, a neuro-typical person will usually feel little anxiety if a routine is broken, but a person with an ASD may feel intense distress. 

OCD rituals

In contrast, a child who has OCD may look like they're following a routine such as doing things in a certain order before leaving for school, but this is more in keeping with doing what the OCD wants, not what the child wants. For example, a child's 'routine' that actually involves a symmetry and ordering ritual or a checking ritual is not indicative of an ASD. Observing behaviours such as the child saying they've forgotten something or they need to go to the toilet just as they are about to leave the house might be a sign to say this could be OCD; and not a preferred routine. In other words, they might be nipping upstairs to double check on something, e.g., that all toys are 'perfectly' aligned, or that all windows are locked. Quite often this repeated behaviour makes the child late for school, so it's worth a parent mentioning the problem to teaching staff to lessen the impact when the child enters a full classroom with the register already done.

5. Tics – For a child who has an ASD, this would usually be attributed to a mannerism belonging to that child only. Or a child who has OCD with autism, tics can also occur. In this case, the child will usually make involuntary movements and sounds that serve no purpose. Children who suffer from involuntary tics may need time in a safe room (accompanied by support staff) to release their tics, since it's very difficult for them to suppress these for too long. On the other hand when a child who has OCD gets the urge to make sounds and movements that appear to mimic Tourette's, they are actually doing a compulsion - here the child may do forced blinking, spit, shrug, or shout out a single word or phrase. The difference is that this is done to neutralise unwanted thoughts, images or frightening urges. As such, the 'tics' (also known as compultics) are voluntary with the purpose that the compulsive behaviour temporarily reduces anxiety.  For the child who has OCD, strategies for intrusive thoughts that involve tics to 'prevent' something bad happening may already be set in place with a cognitive behavioural therapist outside of school hours. For better clarification for either tics associated with Tourette's, ASD's, OCD or a co-morbidity, connecting with the child's parents can help. Generating strategies for the child during class-times can then be agreed upon.

6. Intrusive thoughts, images, impulses and irrational fears – These are attributed to OCD and can overlap with ASDs. Unless children are able to express what they are thinking it's not easy to know the content of their unwanted thoughts, but certain behaviours can help to reveal when the intrusions are likely to be happening. For example, if Sarah hears an ambulance siren while in school (trigger), she gets the thought that her mother has been involved in an accident (obsession), which leads to ruminations in which she imagines her mother in hospital and starts going over what-ifs. When the teacher inadvertently snaps Sarah out of her thoughts, Sarah continues to experience internal distress. Intrusive thoughts often terrify children because they believe that getting a sudden thought about something bad happening can actually make it happen, so a regular habit of a child seemingly in a world of their own could be a clue to take special care.

Noise sensitivity in children with an ASD 

Bear in mind that the sound of a siren can trigger a reaction in children with an ASD because they are often noise sensitive; therefore they might cover their ears or flap their hands (stimming). Unfortunately they may still get told off for being 'silly' or 'disruptive', especially if the teacher is unfamiliar with the characteristics of autism, and especially if the child has no formal diagnosis or 504 plan put in place. Again, if the behaviours are ongoing, talking with parents and caregivers can help throw light on what the child's triggers are and ways to address these.

More OCD examples

The above OCD example is only one instance, and there are many more, including: 

  • Children living with contamination fears have an aversion to being touched. In this case they might be seen to 'shake off' the 'dirty feeling' from someone brushing against them. This may cause class or playground squabbles in which the child might get in to trouble for appearing 'naughty' or 'unfriendly'. It may be that their behaviour needs differentiating from an ASD since a child with autism may present similarly but this is often due to tactile response, not contamination fears; on the other hand it could be both.
  • Some children are urged to repeatedly straighten their pencils before they start writing, usually to ward off perceived danger and to reduce anxiety.   
  • Some repeatedly rub out 'mistakes' because they have an urge to make their work look 'perfect'. These children are often afraid of criticism; therefore, tact is needed.
  • Other children are seen to repeatedly tap a part of their body (e.g., leg, arm, opposite hand) or the edge of a table to reduce anxiety. If the taps follow a repeated number sequence then this again is usually to prevent something bad happening; or if a child is seen to repeatedly tap one side of their body then taps the other side, it's because he or she probably has a need for symmetry. 
  • There are other times when children experience sudden intrusive impulses or disturbing images that go against their beliefs; for example, getting the urge to poke another child in the eye with a pencil or 'seeing' their teacher naked etc. Here you might see a 'compul-tic' or the child may seem 'absent' - these are an indication that they are likely trying to mentally counter the impulse or image. Other times they may feel the sudden urge to escape the classroom (avoidance/escape compulsion).
  • A child may appear not to 'hear' a teacher trying go get their attention, but it could be that the child is performing a mental ritual to neutralise an intrusion. It's only when they've finished the neutralising affirmation that they respond; or they may respond when interrupted and then repeat from the beginning the mental counter as soon as the teacher (or someone else) has stopped talking to them. It's important to address this carefully if it's a regular pattern instead of assuming the child is ignoring you.
  • Some children get the urge to use the toilet at a particular time each day and fear that something bad will happen if they are not able to go.
  • There are also times when children experience defecation fears and will withhold faeces until they get home, because the only way they feel able to use the toilet is to take off all their clothes to avoid contaminating them. Some children also feel the urge to pee more than normal and will repeatedly ask to go to the toilet. The problem is not class avoidance, it's to reduce continuous angst about the fear of not being able to get to the toilet.

Containing distress

Children feel so exhausted at containing their distress caused by their unwanted thoughts and behaviours that they may well have a meltdown when they get home. Also, on arriving to school the next day, they may present with separation anxiety, knowing they are going to have to face another day with their fears alone. 

7. Socialising and sensory issues or contamination fears? – One of the reasons children with an ASD find mixing with other children difficult is due to touch sensitivity, which can be seen when they for example opt-out of game playing that involves touching. Other times they may decide not to join in after-school clubs involving noisy activities. Being sensitive to sensory input such as noise, touch, smells, light and  sights is challenging for children on the autism spectrum, which, to dispel the myth, is not related to bad manners or sulking about joining in or mixing with others. Instead, this is related to disordered neurological processing. A further example associated with social and interaction issues is sharing a meal in the canteen. On top of this, sights and sounds of other children eating exacerbate typical canteen noises, smells and kids brushing against each other. Children experience distress because they want to mix and socialise like other kids do and if they could do so without sensory difficulties (coupled with interaction and communication difficulties) they would. Allowing the child to sit by the door is one option. This gives them the choice to stand outside for a few minutes to take a few deep breaths (emotion management), and before rejoining the other children at the table. 

Contamination fears

Children with contamination fears present very similarly to the description above. For example, they may opt-out of game playing or decide not to join after-school clubs but not because they're touch sensitive but because they fear that touching one another will spread germs, or make them filthy. At lunch time a child with contamination OCD may worry about catching germs from someone else's hands touching their food or other children's food touching their food. Some children think the smells of foods in the air can transfer to their food and contaminate it too. Subsequently, they will try to sit away from other children to eat, or may leave their food untouched. These problems are unrelated to sensory sensitivities; however, when children on the autism spectrum have an overlap of contamination fears, then recognising and separating each behaviour is important for generating appropriate solutions.  

8. Change of plan – A teenager with Asperger's said it takes at least 24 hours to get the scene in her head when plans to do something have been put to her. She said she is 'thrown off balance' when the plans suddenly change because she doesn't have time to re-arrange the scene in her mind. I asked her how this felt and she said, 'This would be like someone planning your day, you have the scene in your head, then the person with you says, "Come on, we're going to catch a flight to Australia."' This is interesting because it helps to grasp that what typically might be classed as a minor change of plan is in fact quite a major event for a child with Asperger's, even if that means a change of classroom or teacher for just one lesson. In comparison, when a change of plan occurs for the child with OCD, such as taking another route to school, they may get distressed because it might take them away from a certain ritual such as touching a particular lamppost three times on the usual route to school to ward off perceived danger. Prior notice of any change is often helpful for children with an ASD or OCD. Discussing with parents ways to manage compulsions for the child with OCD and rituals seen in kids with Asperger's when these affect class times is also worthwhile. This can help with ideas and suggestions, such as having parents agree to get their child up half-an-hour earlier and to put into practice effective ways to get ready with less distress so their children are less likely to be late for school. 

 9. Morbid rumination – It's not uncommon to see children with an ASD seemingly in their own world, or distracted; however, when this is seen repeatedly in children with OCD, take care because they could be suffering a cyclic rumination in which hidden fears will be causing them to feel a constant floating anxiety. The content of their rumination is usually morbid but non-subjective, e.g., death, volcanic eruption or the world ending. If they are suddenly snapped out of their obsessive thinking they will be startled when the teacher inadvertently 'propels' them back into the classroom (or other person/place). All children daydream from time to time, usually about nice things, but because the content of the rumination is disturbing and repetitive for children who have OCD, it causes great distress; often mindful distraction can help. Much care is needed here, and can be handled similarly to what's described in Step 6 above on intrusive thoughts, images, impulses and irrational fears.  

10. Meltdowns - The image below took me back to an incident of a young couple with a little boy who were spending time by the sea. The mother seemed to be in control as she saw to her crying child's needs while the father held back, closely monitoring the situation. A man and woman, probably in their 50s, commented to the father that what the child needed for his temper tantrum was a spanked backside and that a good smack did them no harm when they were kids. The father replied calmly that their child was autistic and was in meltdown. The accompanying quote in the image below makes reference to this type of situation and reads: 'My child is not giving me a hard time; my child is HAVING a hard time.' This made me realise how identifying that a child with an ASD, who appears to be having a temper tantrum in public (including my own child), is actually going through the symptoms of what typically might be experienced as a panic attack - likely brought on by being overwhelmed with sensory input.  Autism awareness can help during shopping trips and outings. Nursery assistants and teachers can also take autism awareness cards with them when they accompany a child on a school outing for example. These (and other awareness material) can be purchased online here: autism awareness cards

Autism awareness cards can be carried by a parent or carer of a child or adult dependent and handed out in difficult situations where they may find communication difficult. Suitable for all age groups.

Autism awareness cards help others learn that:

> Autism is a lifelong disability that affects social and communication skills.

> Children and adults who have an ASD may behave in unpredictable ways as a result of their difficulty in understanding language and social situations.

> Children and adults are likely to be extremely anxious in unfamiliar situations.

> Being understanding, patient and tolerant is the best way to handle a child or adult who is experiencing distress.



Seeing Beyond a Parent's Anxiety

Teachers, caregivers and relevant others who see beyond a parent's anxiety make a huge difference. Being prepared to discuss any concerns for the benefit of the child is more than helpful because anxiety can overwhelm children on the autism and/or OCD spectrum (with or without diagnosis). Overtime a child may go on to develop associated mental health problems such as depression, especially if they are left to cope alone for too long. Supporting a parent with appropriate intervention fosters self-efficacy for their child, eases tensions in the home and thus helps the child better manage separation anxiety, and can reduce the chances of further problems developing.

Note: Carol Edwards is aware that some teachers, carers and other professionals are familiar with the conditions described in this 10-step guide and therefore wishes to say that her intention is not to insult those who already have this knowledge; instead, this guide is to help raise awareness and to also support uninformed teaching staff and relevant others. Please see the disclaimer at the end of this page.

Support   

Please leave a message on Carol Edward's contact page for further advice.

Disclaimer

Carol Edward's 10-step guide is information-based only. While the contents are based largely on her own observations whilst living and working with children on the OCD and ASD spectrum (together with lived experience), it is still advised that after reading this information that teachers and other professionals discuss any concerns with the child's parents/carers. This is with the understanding that a parent visit their child's general health practitioner for further assessment or to discuss intervention such as doing a 504 plan. While the points raised are from Carol Edward's own evaluations, she respects that her readers' ideas and opinions may differ. 

Thank you for reading  

Autism and OCD

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Copyright © 2013 Carol Edwards. Images: stock and advanced search. Updated 2016, 2018.