How To Help a Child With OCD and Autism

If you have an Autistic child, they might exhibit some behaviors that look similar to compulsions in obsessive-compulsive disorder (OCD), like having to wear certain clothes, lining up toys in a certain way, or engaging in specific routines and rituals.

OCD rituals, aka compulsions, can look similar to the repetitive behaviors common in Autism, as a 2011 study found that about 17% of people with an Autism Spectrum Disorder (ASD) also meet criteria for OCD. However, the difference between repetitive behaviors in Autism and those in OCD is that Autistic children often engage in the behaviors to feel more secure, to self-soothe, or because of sensory issues. With OCD, compulsions are done consciously from feared thoughts to relieve anxiety or prevent something bad from happening.

In an Autistic child with OCD, sometimes the reasons for these repetitive behaviors can overlap. If you interrupt either, your Autistic child might become very upset, just for different reasons for if it’s ASD or OCD.

Exposure and response prevention (ERP) therapy is the best treatment for OCD. It decreases the need for an Autistic child to use compulsions as a way to self-soothe. The treatment is more gradual and specific and progresses slowly for more success with someone on the spectrum versus a child who is more neurotypical. This is because of differences in the brain, and the fact that generally, it can take longer for an Autistic child (or adult) to habituate to their anxiety and distress, as well as for those learnings to generalize from the therapy session out into the rest of their world. An Autistic child might really like the relief that compulsions bring and may not want to stop them at first. To be very clear, ERP is used only to address OCD symptoms and not for the Autism itself. 

Here are several key points to consider when helping an autistic child with OCD.

1. Parents’ involvement

Parents should be involved in therapy sessions and ERP practice at home. Team up with your child’s therapist to understand how to structure exposure practice at home. As parents, you might be asked to make some adjustments to any OCD accommodations that might have developed at home. The school team also needs to be aware of your child’s treatment for OCD. Frequent and thorough communication between team members is essential.

2. Use visuals

Many autistic children do well with visual cues. Having charts or pictures to show the agenda for practice, exposures and reinforcers is beneficial. Some children will love drawing pictures illustrating how they can defeat OCD. It can be extra effective if some of the explanation visuals reflect your child’s special interests. Coping cards describing how kids can work through being stuck can also be helpful.

Using social stories can help explain the reasons for exposures and how to do them, and the benefit of reducing compulsions. A good source for learning about how to implement social stories is Carol Gray’s work.

3. Communication tips

Ask fewer questions. Talk less. Do not force eye contact. Give time to process information. Let them set the pace. Give praise for effort. Modify language if the child has communication challenges by using pictures, communication boards. Autistic individuals struggle to process much of anything if they’re experiencing sensory overload, so also be aware of the sensory stimuli in their environment during ERP. 

4. Structure

Autistic children with OCD can be resistant to a change in schedule or routine because those are things that help make the world more manageable for them. Create a structured, consistent visual schedule for ERP as routines/rules help children learn what to expect for practice sessions. Work on one ERP task at a time which helps to reduce stress and prevent refusals.

However, be flexible around time as autistic kids have their own timeline and ability to manage sensory overload. Be proactive and talk through exposures, or role-play exposures before actual ERP practice can be helpful. Helping children to develop psychological flexibility is key to tolerating change. As a parent, being flexible when working with an autistic child is also key.

5. Rewards

Rewards or reinforcers for participation in ERP work best if centered around the child’s favorite interests. For example, you may need to take away privileges for compulsions that they refuse to give up, like limiting screen time.

However, try a constructive approach using a positive reward first. As another example, if a child really loves playing video games, they can earn a reward of increased video game time for practicing ERP. 

Reference: Anxiety disorders in children and adolescents with Autism spectrum disorders: a meta-analysis. Clin.Child.Fam.Rev. 2011,Sp; 14(3): 302-17.