Restricted,Repetitive Behaviors in Autism Spectrum Disorder and Obsessive–Compulsive Disorder: A Comparative Review

This review paper critically examines literature regarding restricted and repetitive behaviors (RRBs) in Autism Spectrum Disorder (ASD) and Obsessive–Compulsive Disorder (OCD). The similar behavioral profiles of these disorders presents the potential for confusion regarding diagnoses and intervention efforts. As such, this review highlights the similarities and differences between RRBs in ASD and OCD. The developmental trajectories of RRBs are presented, followed by an exploration of three constructs implicated in RRB manifestation: anxiety, executive functioning, and sensory phenomena. While RRBs tend to develop with some similarity in both disorders, the differing role of anxiety highlights important distinctions between ASD and OCD. We urge researchers and clinicians to think critically about the dimensions that affect RRB presentation. Future research should use this review as a starting point to further elucidate the differences between RRBs in these two populations.     

Subclinical autism spectrum symptoms in pediatric obsessive–compulsive disorder

The literature on subclinical autism spectrum (ASD) symptoms in pediatric obsessive–compulsive disorder (OCD) is scarce, and it remains unclear whether ASD symptoms are related to OCD severity. The aims of the present study were to assess the prevalence of ASD symptoms and age and sex differences in children and adolescents with OCD, and to explore the relation between ASD symptoms and OCD severity. This is the largest study of ASD symptoms in an OCD population to date, and the first directly aimed at elucidating sex and age differences in this matter. The study used baseline data from the Nordic Long-term OCD Treatment Study in which parents of 257 children and adolescents with OCD aged 7–17 completed the Autism Spectrum Screening Questionnaire. OCD severity was assessed with the Children’s Yale–Brown Obsessive Compulsive Scale. Pediatric OCD patients were found to exhibit elevated rates of ASD symptoms compared to a norm group of school-age children. ASD symptoms were concentrated in a subgroup with a prevalence of 10–17 %. This subgroup was characterized by a male preponderance with a sex ratio of approximately 2.6:1, while children versus adolescents with OCD exhibited similar rates. Autism-specific social and communication difficulties were not related to OCD severity, while restricted repetitive behavior was positively related to OCD severity. The results indicate that clinicians need to be aware of ASD symptoms in children and adolescents with OCD since one out of ten exhibits such symptoms at a clinical sub-threshold.     

Repetitive Behaviour in Children with High Functioning Autism and Obsessive Compulsive Disorder

Children with Autism Spectrum Disorders (ASD) and children with Obsessive Compulsive Disorder (OCD) were compared on a range of repetitive behaviours. Parents reported similar levels of sameness behaviour and repetitive movements in the clinical groups, although children with OCD engaged in more repetitive behaviour focussed around routines and rituals. Children with OCD reported more compulsions and obsessions than children with ASD; both groups reported more compulsions and obsessions than a typically developing comparison group. Types of compulsions and obsessions tended to be less sophisticated in children with ASD than those with OCD. Sameness behaviour was more prevalent in younger children with OCD, but for children with ASD, age was not significantly related to sameness behaviour, repetitive movements, compulsions, or obsessions.     

Differentiating between Autism Spectrum Disorders and Other Developmental Disabilities in Children Who Failed a Screening Instrument for ASD

This study compared behavioral presentation of toddlers with autistic spectrum disorders (ASD) and toddlers with global developmental delay (DD) or developmental language disorder (DLD) who display some characteristics of ASD using the diagnostic algorithm items from the Autism Diagnostic Observation Schedule, Generic (ADOS), the Childhood Autism Rating Scale (CARS), and Modified Checklist for Autism in Toddlers (M-CHAT). To date, 195 children have failed the M-CHAT and have been diagnosed with ASD, DD or DLD. Children with ASD had prominent and consistent impairments in socialization skills, especially joint attention skills and were more impaired in some aspects of communication, play, and sensory processing. Children with ASD and children with DD/DLD shared common features, but certain behavioral markers differentiated the two groups.     

Long-term post-intensive behavioral intervention outcomes for five children with Autism Spectrum Disorder

Research clearly indicates that early intensive behavioral intervention is an effective intervention for young children with Autism Spectrum Disorder (ASD). However little is known about the longitudinal development of these children. The purpose of this study was to examine the outcomes for a number of children with ASD following intensive behavioral interventions (IBI) prior to full-time integration in a mainstream setting having made significant gains following IBI. IQ, Adaptive Behavior Composites, Autism Index Scores, emotional and behavioral profiles and measures of parental perceived stress were obtained. Findings were mixed with some participants maintaining the gains they had made following IBI and others not. Results are presented and discussed with implications for future research outlined.     

Does Parent Report of Behavior Differ Across ADOS-G Classifications: Analysis of Scores from the CBCL and GARS

Behavior checklists are often utilized to screen for Autism Spectrum Disorders (ASDs) when comprehensive evaluations are unfeasible. The usefulness of two behavioral checklists, the Gilliam Autism Rating Scale (GARS) and Child Behavior Checklist (CBCL), in identifying ASDs was investigated among 109 children with Autism, 32 children with ASD, and 51 Non-Spectrum children based on Autism Diagnostic Observation Schedule-Generic classifications. The GARS did not distinguish children with ASDs from those without. The Withdrawn and Pervasive Developmental Problems subscales of the CBCL were higher among children with Autism than among Non-Spectrum children. These CBCL subscales also had better sensitivity and specificity in identifying children with Autism than the GARS. Results suggest that the CBCL is a useful behavioral checklist for screening ASDs.     

High concordance of parent and teacher attention-deficit/hyperactivity disorder ratings in medicated and unmedicated children with autism spectrum disorders

Abstract Objective: Parent and teacher ratings of core attention-deficit/hyperactivity disorder (ADHD) symptoms, as well as behavioral and emotional problems commonly comorbid with ADHD, were compared in children with autism spectrum disorders (ASD). Method: Participants were 86 children (66 boys; mean: age=9.3 years, intelligence quotient [IQ]=84) who met American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for an ASD on the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS). Parent and teacher behavioral ratings were compared on the Conners' Parent and Teacher Rating Scales (CPRS-R; CTRS-R). The degree to which age, ASD subtype, severity of autistic symptomatology, and medication status mediated this relationship was also examined. Results: Significant positive correlations between parent and teacher ratings suggest that a child's core ADHD symptoms-as well as closely related externalizing symptoms-are perceived similarly by parents and teachers. With the exception of oppositional behavior, there was no significant effect of age, gender, ASD subtype, or autism severity on the relationship between parent and teacher ratings. In general, parents rated children as having more severe symptomatology than did teachers. Patterns of parent and teacher ratings were highly correlated, both for children who were receiving medication, and for children who were not. Conclusions: Parents and teachers perceived core symptoms of ADHD and closely-related externalizing problems in a similar manner, but there is less agreement on ratings of internalizing problems (e.g., anxiety). The clinical implication of these findings is that both parents and teachers provide important behavioral information about children with ASD. However, when a clinician is unable to access teacher ratings (e.g., during school vacations), parent ratings can provide a reasonable estimate of the child's functioning in these domains in school. As such, parent ratings can be reliably used to make initial diagnostic and treatment decisions (e.g., medication treatment) regarding ADHD symptoms in children with ASDs.     

An Initial Case Series of Intensive Cognitive–Behavioral Therapy for Obsessive–Compulsive Disorder in Adolescents with Autism Spectrum Disorder

Obsessive–compulsive disorder (OCD) is prevalent among youth with autism spectrum disorder (ASD). Cognitive–behavioral therapy (CBT) with ASD-specific modifications has support for treating OCD in this population; however, use of intensive CBT in youth with ASD and severe OCD has not been tested. The current study examined the preliminary effectiveness of an individualized intensive CBT protocol for OCD in adolescents with ASD. Nine adolescents (aged 11–17 years) completed a regimen of intensive CBT (range 24–80 daily sessions) incorporating exposure with response prevention (ERP). Treatment materials, language and techniques were modified in accordance with evidence-based findings for this population. Seven of nine participants (78%) were treatment responders, and large treatment effects (d?=?1.35–2.58) were obtained on primary outcomes (e.g., obsessive–compulsive symptom severity). Preliminary findings suggest that an intensive CBT approach for OCD is effective among adolescents with ASD.     

Télémédecine et troubles du spectre de l’autisme de l’enfant et de l’adolescent : guide théorique et pratique

ObjectivesThe development of telemedicine for children and adolescents is a real need because of difficult accessibility of mental health and the paucity of childhood psychiatrists. Thus the American Academy for Child and Adolescent Psychiatry (AACAP) published in 2008 good practice recommendations for telepsychiatry in children and adolescents based on clinical consensus and scientific evidence. In France the legal framework defines four practical modalities according to the presence or not of a health professional or a psychologist with the practitioner accomplishing the teleconsultation act. Data exist about the outcome of children and adolescents who benefited from therapeutic interventions with technological media. Effect size is modest but it doesn’t justify ruling out these techniques. Children who present with a developmental disorder or who cannot cooperate are evaluated with a certain degree of uncertainty. By contrast, some children with severe Attention Deficit with or without Hyperactivity (ADHD), social anxiety or Autism Spectrum Disorders (ASD) can be more easily engaged within a teleconsultation model. Teleconsultations in autism spectrum disorders (ASD) are feasible because of the nature of diagnosis and the type of care recommended in this disorder. The behavioral nature of the disorder and the behavioral therapeutic approaches recommended in North America culture highlight the potential interest of telemedicine because these disorders are easily observable. Literature suggests new opportunities in order to facilitate the care process for the ASD person and his family: the first one is diagnosis with use of validated instruments such as the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview (ADI). Parental accompaniment is the second opportunity. Development of telemedicine for ASD could be a complementary approach for diagnosis and medical care.MethodSince 2015, a program called PROMETTED (PROgramme MEdical de Télépsychiatrie pour enfants et adolescents présentant un Trouble Envahissant du Développement) was supported by Regional Health Agency of Île-de-France. It was developed and managed by the team of a Diagnosis Center Evaluation for Autism (DCEA) of Paris area in collaboration with a DCEA of Île-de-France region. Five medico-social structures for children and adolescents with autistic disorders and the two diagnosis centers of evaluation for autism co-elaborated a scheme of intervention with telemedicine. The remote evaluation is a 4-step process: a first teleconsultation structured around the medical history of the subject in order to complete his medical file and the observation of the young subject; a second teleconsultation structured around the ADI-R interview with parents; the third teleconsultation is a mixed teleconsultation associating the medical expert of the DCEA and a psychologist trained in the use of the Childhood Autism Rating Scale (CARS) and the Vineland Adaptive Behavior Scales (VABS). The fourth teleconsultation consists of the psychiatrist giving feed-back to parents about the results of the observations of the DCEA team.ResultsThe four-step program is well-accepted and the use of validated instruments for diagnosis or functional evaluation appears feasible. Medical data were completed for 44% of cases; complementary genetic or medical investigations were prescribed for 50% of cases; medical advice about psychotropic or vitaminic medication was given for 31% of cases. Mean duration of evaluation was 11.1 weeks ± 9.4.ConclusionsThe PROMETTED program empirically validates the concept of remote evaluation for children and adolescents with ASD. The need to extend the use of telemedicine to tele-expertise for medicine monitoring or behavioral disorder management has been noted.     

Elevated Autism Spectrum Disorder Traits in Young Children with OCD

Studies have shown a high prevalence of autistic spectrum traits in both children and adults with psychiatric disorders; however the prevalence rate has not yet been investigated in young children with OCD. The aim of the current study was to (1) determine whether ASD traits indicated by the Social Communication Questionnaire (SCQ) and the Social Responsiveness Scale (SRS) were elevated in young children with OCD who do not have a specific ASD diagnosis and (2) determine if ASD traits were associated with OCD severity. Participants (N = 127) were children ages 5–8 years enrolled in the pediatric obsessive–compulsive disorder treatment study for young children (POTS Jr.). Results indicated that the SRS showed elevated autistic traits in the sample and was associated with OCD severity whereas the SCQ did not indicate heightened ASD symptoms. Implications of these results are discussed.     

Psychological adjustment and sibling relationships in siblings of children with Autism Spectrum Disorders: Environmental stressors and the Broad Autism Phenotype

Research with siblings of children with Autism Spectrum Disorders (ASD) suggests that they may be at increased risk for behavioural and emotional problems and relatively poor sibling relationships. This study investigated a diathesis-stress model, whereby the presence of Broad Autism Phenotype features in the typically developing siblings might interact with family-environmental risk variables to predict sibling functioning (5-17 years of age) of children with an Autism Spectrum Disorder (ASD), their child with an ASD, and their own psychological well-being. Sibling adjustment was associated with the extent of behaviour problems in the child with an ASD and with the extent of the sibling's Broad Autism Phenotype (BAP) features. Sibling relationships were more negative when the child with an ASD had more behaviour problems and when there was evidence of critical expressed emotion in the family environment. Siblings with more BAP features, who had brothers/sisters with an ASD and a greater number of behaviour problems, had more behaviour problems themselves. Siblings with more BAP features who had parents with mental health problems reported more sibling relationship conflict.     

Pilot randomized controlled trial of a Functional Behavior Skills Training program for young children with Autism Spectrum Disorder who have significant early learning skill impairments and their families

Many children with Autism Spectrum Disorder (ASD) possess early learning skill deficits and, do not achieve significant cognitive and adaptive gains following intensive behavioral intervention. This pilot randomized controlled trial investigated the effectiveness of a Functional Behavior Skills Training (FBST) program in improving children's performance on functional skills and communication, mitigating children's problem behaviors, and improving parents’ strain, sense of competence, and, knowledge of Applied Behavior Analysis (ABA). Fifteen children with ASD who demonstrated early, learning skill impairments (ages between 38 and 82 months) were recruited from a community-based, IBI program or its waitlist. Children and their parents were randomized to a treatment group who, received FBST for four months or a control group who received their treatment as usual. Children who, received FBST improved on targeted functional skills and communication and demonstrated lower, levels of disruptive behavior. Meanwhile, parents who received FBST improved in their knowledge of, ABA. Overall, preliminary findings suggest that FBST is a feasible and promising behavioral, intervention for children with ASD who have early learning skill impairments. FBST promotes the, development of functional behavior and communication which can direct children onto a path of, appropriate skill development and meaningful interactions in the real world.     

Behavioral avoidance test for childhood obsessive-compulsive disorder: a home-based observation

Obsessive-compulsive disorder (OCD) is one of the most debilitating of the anxiety disorders. As our knowledge about this childhood condition continues to grow, there is a need for controlled treatment-outcome trials with precise assessments that are sensitive to treatment change, to guide the development of effective interventions. To evaluate the efficacy of a treatment protocol, it is necessary to have reliable and sensitive measures of OCD symptoms, including measures of obsessions, compulsions, and related levels of distress and avoidance. Whilst structured diagnostic interviews, semistructured clinical interviews, and self-report measures have been widely used in the assessment of childhood OCD, related levels of behavioral distress and avoidance have not been measured in treatment-outcome trials. This study investigated the sensitivity of a behavioral avoidance test (BAT), conducted in the home environment, in assessing treatment-outcome effects for children and adolescents with OCD following a 14-week cognitive-behavioral therapy (CBT) family intervention, in comparison to children in an 8-week "waitlist" control group. The results of the current study strongly support the sensitivity of a standardized BAT in assessing treatment-related changes in children and adolescents with OCD. Implications and future directions for research are discussed.     

Distrust and retaliatory deception in children with Autism Spectrum Disorder

This study examined trust and retaliatory deception in children with Autism Spectrum Disorder (ASD). In Experiment 1, school-aged children with ASD and ability-matched typically developing (TD) children participated in a game to find a hidden prize. An adult repeatedly misinformed children about the whereabouts of the prize. Although children with ASD did not blindly trust all information provided by the informant, they were significantly more trusting of the deceptive adult than TD children. Further, children with ASD were less likely to retaliate by deceiving the adult than TD children. Experiment 2 showed that children with ASD who distrusted a deceptive adult were less flexible and therefore less able to generalize their distrust to different situations compared to TD children.     

Neurocognitive and Behavioral Outcomes of Younger Siblings of Children with Autism Spectrum Disorder at Age Five

Later-born siblings of children with Autism Spectrum Disorders (ASD) are at increased risk for ASD as well as qualitatively similar traits not meeting clinical cutoffs for the disorder. This study examined age five neurocognitive and behavioral outcomes of 39 younger siblings of children with ASD (Sibs-ASD) and 22 younger siblings of typically developing children (Sibs-TD) previously assessed in a longitudinal investigation starting in the second year of life. There were few group differences between Sibs-TD and Sibs-ASD on global measures of IQ, language, or behavior problems. Sibs-ASD did show vulnerabilities on measures of executive functioning, social cognition, and repetitive behaviors. These results highlight the importance of following sibling risk groups over an extended time period and employing measures targeting broader aspects of development.     

Indirect functional assessment of stereotypy in children with autism spectrum disorders

Autism spectrum disorders (ASD) are characterized by the presence of repetitive behavior and stereotyped patterns of interest and activities. It is common for clinicians to assume that repetitive behaviors are maintained by automatic reinforcement but, as with any challenging behavior, the function of stereotypy should not be assumed based on its topography. Previous research on the functional assessment of stereotypy has produced mixed results, and most previous studies on the functional assessment of stereotypy in children with ASD have included small sample sizes, so more research in this area is warranted. In the current study, indirect functional assessments consisting of the questions about behavioral function (QABF) were conducted across 53 children and adolescents with ASD. The QABF produced interpretable results in a high percentage of cases and 90% of the stereotypic behavior appeared to be maintained by automatic reinforcement.     

Co-occurring behavioral difficulties in children with severe feeding problems: A descriptive study

BackgroundRecent literature highlights the association between behavioral difficulties and the presence of feeding problems in children with an Autism Spectrum Disorder (ASD) relative to children with ASD without feeding problems. However, it is not clear to what extent behavior problems (outside of the meal setting) occur in children with feeding problems without comorbid ASD.AimsThe purpose is to describe co-occurring behavioral difficulties of a sample of children with severe food refusal/selectivity and examine potential predictors of behavioral difficulties outside of the meal context.Method and proceduresThe medical charts of fifty-four patients were reviewed and data were collected on the frequency of caregiver coaching and/or behavioral intervention outside of the meal context. Age, presence of developmental delay/autism, and type of feeding problem were examined as potential predictors of behavioral support.Outcome and resultsApproximately half of the sample received coaching or individualized intervention. The percentage of caregivers who received individualize coaching were similar across groups. Younger age at admission was a predictor of individual caregiver coaching. Presence of delay/ASD, age, and type of feeding problems were not significant predictors for individualized treatment programing.Conclusion and implicationsThese data provide evidence of difficult caregiver-child interactions that occurs outside of the meal context for some children with severe feeding difficulties and suggest that this association may not be exclusive to children with ASD.     

Cost comparison of early intensive behavioral intervention and treatment as usual for children with autism spectrum disorder in the Netherlands

Early intensive behavioral intervention (EIBI) may result in improved cognitive, adaptive and social functioning and reductions in autism severity and behavioral problems in children with Autism Spectrum Disorder (ASD). For a subset of children, normal functioning may be the result. However, due to the intensity (20-40h per week for 3 years with a low child staff ratio) implementation costs are high and can be controversial. Estimated costs for education, (supported) work and (sheltered) living for individuals with ASD in the Netherlands are applied in a cost-offset model. A compelling argument for the provision of EIBI is long term savings which are approximately € 1,103,067 from age 3 to 65 years per individual with ASD. Extending these costs to the whole Dutch ASD population, cost savings of € 109.2-€ 182 billion have been estimated, excluding costs associated with inflation.     

Handwriting Difficulties in Children with Autism Spectrum Disorders: A Scoping Review

Functional handwriting involves complex interactions among physical, cognitive and sensory systems. Impairments in many aspects of these systems are associated with Autism spectrum disorders (ASD), suggesting a heightened risk of handwriting difficulties in children with ASD. This scoping review aimed to: (1) survey the existing evidence about potential contributions to compromised handwriting function in children with ASD, and (2) map out the existing studies documenting handwriting difficulties in children with ASD. The current evidence implicates impairments in fine motor control and visual-motor integration as likely contributors to handwriting difficulties in children with ASD, though the role of the latter is not well-understood. Moreover, diminished overall legibility and compromised letter formation are emerging points of convergence among existing studies of handwriting quality in children with ASD.