Individuals with autism exhibit a wide variety of repetitive and ritualistic behaviors. Such patterns of behavior are a defining characteristic of autism spectrum disorders, and are generally expected as part of the behavioral profile of individuals with autism. While often conceptualized as stereotypy, these behaviors are similar to those which characterize obsessive compulsive disorder, leading to the question of how to differentiate between the two in those with an autism spectrum disorder.
Stereotypy is defined as nonfunctional, repetitive behaviors that may be verbal or nonverbal and can present very differently in form and complexity across individuals, contexts, and time (e.g. Rapp & Vollmer, 2005; Cunningham & Schreibman, 2008). Examples of vocal stereotypy include repeating portions of previous conversations or imitating voices and sounds heard in videos or on television. Motor-oriented stereotypy examples include hand waving, eye gazing, rocking, and twirling objects. More complex forms of stereotypy may manifest in individuals with autism as engaging in very specific, yet nonfunctional rituals or routines or exhibiting a rigid demand for sameness.
A significant body of research examining the function of stereotypic behaviors in individuals with autism suggests it may serve a sensory (i.e., self-stimulatory) function that is maintained by automatic reinforcement (e.g. Lovaas, Newsom, & Hickman, 1987; Rapp & Vollmer, 2005). Consistent with this function, individuals with autism may engage in such behaviors for prolonged periods of time, when alone, or when bored or in distress. Although these behaviors may sometimes serve automatic functions, they may also be maintained or mediated by social consequences or tangible reinforcement (Durand & Carr, 1987; Cunningham & Schreibman, 2008). In educational settings, stereotypy can interfere with a child’s ability to learn, and may slow down the rate of instruction or lead a teacher to change tasks. Similarly, stereotypy may increase teacher attention or redirection. Outside of school, such behaviors can be socially stigmatizing, making community outings difficult for parents and restricting opportunities for peer interactions.
The examination of the functions of stereotypic behaviors in these instances is consistent with a behavior analytic frame of reference. Behavior analysts may seek to determine if a stereotypic behavior is serving multiple functions (e.g. sensory, social, tangible). For an automatically reinforcing function, they may seek to limit the contexts in which such behaviors are emitted. Additionally, they may endeavor to find alternate, more appropriate sources of the sensory input that could serve as replacement sources. These interventions are commonly part of a comprehensive ABA approach to reducing stereotypy.
At times, however, such behaviors are described as something more than stereotypy. They may be labeled as obsessive and/or compulsive and as indicative of a dual diagnosis of OCD. It seems (anecdotally) that the use of such terminology to describe the repetitive behaviors of individuals with autism is increasing. To what extent is the extension of OCD appropriate to the population of individuals with autism?
Obsessions are defined in psychiatric literature as persistent ideas, thoughts, and impulses that are intrusive and inappropriate, and which cause marked distress or anxiety in the individual. Compulsions are defined as repetitive behaviors (or mental acts) that are engaged in to prevent or reduce anxiety and distress (American Psychiatric Association [DSM-IV-TR], 2000). The definitional nature of these symptoms requires that the individual be able to describe their subjective experience and emotional state. In children, self-report as to the intrusiveness of the compulsions or obsessions is not a requirement for an OCD diagnosis due to the recognition that they “may lack sufficient cognitive awareness to make this judgment” (DSM-IV-TR, 2000, p. 457). Instead, physicians rely on parental report and clinical observations to confirm whether the child’s behaviors are excessive and severely restricting their general and social functioning. Therefore, diagnosing OCD in any child is challenging. This is even more difficult if the child has autism, given their inherent difficulties in self-report and often limited insight into their behavior.
Furthermore, it is not clear whether the diagnosis of OCD is appropriate for the population of individuals with autism. The link between compulsive acts and obsessive thoughts rests on the assumption of anxiety reduction. While there may be some individuals with autism whose repetitive acts serve this function, it is very difficult to reliably and confidently determine this information with this population.
From a definitional perspective, stereotypy is often viewed as less complex. In addition, it is generally assumed that it does NOT serve an anxiety reducing function. There are individuals with autism that do seem to engage in behaviors that generally correlate with those seen in people with OCD. For example, they may engage in ritualistic cleaning or fixing, or they may engage in movement sequences that are linked to certain mathematical rules (e.g., 16 repetitions of a motor action, closing and opening each cabinet 5 times, etc.). It could be that such behaviors are best described as compulsive, and that they would respond to treatments linked to that presumption. However, as noted earlier, research shows that some stereotypy is in fact socially mediated, which would argue against the hypothesis of anxiety reduction.
A better model for diagnosing OCD may be functional assessment (Iwata, et al., 1982). Functional assessment is a systematic evaluation of the variables in the social and physical environment that may both “trigger” and reinforce the obsessions and compulsions. Functional assessment has evolved out of the scientific study of human behavior, which posits that the variables influencing behavior can be found in the external environment (e.g, Skinner, 1953). The paradigm asserts that behavior is influenced by stimuli occurring prior to the behavior, and any behavior that persists must be reinforced (strengthened) by variables following the behavior. Functional assessment is the state of the art assessment strategy for a wide range of inappropriate and challenging behaviors, ranging from noncompliance to severe aggression, with a significant amount of research on self-stimulatory, stereotypic behaviors (e.g., Mace & Belfiore, 1990).
Research has shown that there are four functions that maintain behaviors – attention, escape/avoidance, tangible reinforcement, and automatic reinforcement (e.g., Lang, O’Reilly, Lancioni, Rispoli, MacHalicek, Chan, et al., 2009; Mueller, Sterling-Turner, & Moore, 2005). Various functional assessment strategies have been developed to determine which of these functions appear to apply to a particular problem behavior. The research base clearly shows that by conducting functional assessments of problem behaviors and hypothesizing which function may be in play for a particular behavior, treatments based on that function are more successful than treatments based on a different function not selected. Therefore, functional assessment has become a powerful tool in the assessment and treatment of maladaptive behaviors (e.g., Kodak, Northup, & Kelley, 2007;Vollmer, Marcus, Ringdahl, & Roane, 1995).
The application of functional assessment to traditional OCD may provide information regarding the function of the OCD from a behavior-analytic perspective. This information, in turn, may result in treatments that are not only more effective, but also do not rely solely on pharmacological interventions (i.e. medication) as is often the case today.
Of all the functional assessment strategies in existence, functional analysis is the most powerful in that it provides the best determination of function (Iwata, et al., 1987). A functional analysis involves a systematic manipulation of antecedent and consequent events to determine covariation of the target OCD behaviors. Typically, there are five conditions, one testing each of the four functions (i.e., attention, tangible, escape/avoidance, and automatic reinforcement), and one “control” condition, consisting of a typical play or recreational activity.
A functional analysis of an OCD behavior may proceed as follows. The target behavior for this example is repetitive wiping of dark smudges from floors, walls, and tables. To test whether this behavior is motivated by attention, the clinician would set up a room with dozens of smudge marks on the table and floor. The client would sit at a table and be instructed to play with preferred materials, while the clinician sat nearby and ignored the client by pretending to work. If the client began wiping off a smudge mark, the clinician would physically stop the behavior and give several seconds of undivided attention to the client, after which the clinician would go back to ignoring the client. This process would be repeated for a set amount of time (e.g., 10 minutes) and across multiple sessions. The number of smudge attempts would then be recorded for each of the sessions.
To assess whether the behavior was reinforced by escape/avoidance, the clinician would put the client in a nonstop work context, using work materials/activities that, through interview or experience, were known to be difficult or unpleasant to the client. Identical to the previous setting, the work environment would contain numerous smudges throughout. The clinician would present work demands continuously to the client; if at any time, the client attempted to wipe off a smudge mark, the clinician would remove all work demands and materials for a brief period of time (e.g., 30 seconds). This session would continue for a set amount of time and the number of smudges would be recorded.
To determine the influence of tangible consequences on the occurrence of compulsive smudge wiping, the clinician would provide a preferred object for the client to engage with for a brief period of time (e.g., 1 minute). The clinician would then remove the object while ignoring the client. If at any time after that the client attempted to wipe off a smudge, the clinician would return the preferred item for a brief period of time (e.g., one minute). This process would be repeated throughout the session and the number of attempts at wiping off smudges would be recorded.
To assess the influence of “automatic” reinforcement (which is the closest explanation to the current theory of OCD), the clinician would place the client in a room with numerous smudges within arm’s reach, and then ignore the client for the entire session. The number of attempts at the target behavior would again be recorded.
Numerous sessions of each condition would be conducted and data would be analyzed to see if the behavior occurs more consistently in one condition than another. If so, this is known as “differentiated results” and the identified condition can be said to be serving the function that is maintaining the target behavior. On the other hand, if there is no differentiation in the data from one condition compared to the others (that is, in all conditions the rates of the OCD target behavior were consistent), then these would be labeled as “undifferentiated results” and the assumption would be that the OCD is, indeed, automatically reinforced, possibly by the reduction of anxiety.
The ability to distinguish truly compulsive behaviors from stereotypy in individuals with autism could increase the efficiency and effectiveness of our attempts to treat such behaviors. In addition, a new perspective on OCD, one that does not rely primarily on the self-report of the patient, but rather on a scientific analysis of human behavior, may produce gains in the assessment and diagnosis of the disorder. This, in turn, could lead to more effective and varied treatment options beyond the use of medication which is most commonly used today. Considering a different perspective in which the function (cause) of behavior could drive the development of interventions for OCD might allow for a variety of currently unanswered or unclear treatment questions to be answered. The first step toward this goal is the development of a functional analysis protocol that would explain this behavior from a behavior analytic perspective.
Mary Jane Weiss, PhD, BCBA is the Director of Research and Training at the McCarton School. Thomas Zane, PhD, BCBA consults to the McCarton School. Nicole Pearson, MA is a Research Associate with the McCarton School. Cecelia M. McCarton, MD is the founder and CEO of The McCarton Foundation.
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