Comorbid Autism Spectrum Disorder and OCD: Challenges in Diagnosis and Treatment

by PsychiatryAdvisor.com

 

Interventions shown to be highly effective in treating symptoms of autism are already limited, but the options shrink even further in the presence of anxiety comorbidities, particularly obsessive compulsive disorder (OCD). Research has been focused not only on identifying a specific anxiety disorder in children and adolescents with autism, but also in distinguishing between the symptoms of each disorder and how to treat each disorder. Although cognitive behavioral therapy (CBT) with various modifications has been shown to be beneficial, the research evaluating CBT includes small populations and a variety of nonstandard modifications.

Prevalence and Symptom Differentiation

Estimates of the prevalence of anxiety, specifically of OCD, among children and adolescents with autism spectrum disorder (ASD) vary widely, from 11% to 84% for any anxiety disorder and from 2.6% to 37.2% for OCD, reported Valentina Postorino, PhD, of Emory University Department of Pediatrics and of the Marcus Autism Center in Atlanta and colleagues.1 They draw particular attention to one meta-analysis of 31 studies, which found a 39.6% prevalence of “clinically elevated levels of anxiety or at least one anxiety disorder” in young individuals with autism.2

Interventions shown to be highly effective in treating symptoms of autism are already limited, but the options shrink even further in the presence of anxiety comorbidities, particularly obsessive compulsive disorder (OCD). Research has been focused not only on identifying a specific anxiety disorder in children and adolescents with autism, but also in distinguishing between the symptoms of each disorder and how to treat each disorder. Although cognitive behavioral therapy (CBT) with various modifications has been shown to be beneficial, the research evaluating CBT includes small populations and a variety of nonstandard modifications.

Prevalence and Symptom Differentiation

Estimates of the prevalence of anxiety, specifically of OCD, among children and adolescents with autism spectrum disorder (ASD) vary widely, from 11% to 84% for any anxiety disorder and from 2.6% to 37.2% for OCD, reported Valentina Postorino, PhD, of Emory University Department of Pediatrics and of the Marcus Autism Center in Atlanta and colleagues.1 They draw particular attention to one meta-analysis of 31 studies, which found a 39.6% prevalence of “clinically elevated levels of anxiety or at least one anxiety disorder” in young individuals with autism.2

Results from all of the studies showed at least some treatment gains, but they included only 170 participants total with substantial variation in age and severity of conditions. All participants with autism had “high-functioning” autism and an IQ above 69. Further, the studies were very heterogenous in terms of procedures, therapy modifications, and outcome measures.

“In all studies, a multicomponent CBT treatment was implemented,” the authors wrote. “The components of CBT typically involved mapping, cognitive restructuring, fear hierarchy development, [exposure and response prevention], and relapse prevention.” There were also 2 studies with emotional literacy education. The number of CBT sessions ranged from 6 to 17.4 sessions over 9 to 21 weeks, with each session lasting from 35 minutes to 2 hours.4

Further, all of the studies used at least 1 and up to 8 of the following 10 modifications, starting with the 5 most common:

  • Parental involvement
  • Increased use of visuals
  • Incorporation of child interests
  • Personalized treatment metaphors and coping statements
  • Self-monitoring
  • Nonverbal and concrete examples
  • Positive reinforcement
  • Use of clear language and instructions
  • Functional Behavioral Assessment & Intervention (FBAI)
  • Narratives

Glen Elliott, PhD, MD, chief psychiatrist and medical director of Children's Health Council in Palo Alto, California, was not persuaded by the review that CBT is very effective for comorbid autism and OCD, given the small population in this review, its substantial limitations, his own limited clinical success with CBT, and the need for the patient's willing participation in therapy.

“One of the requirements for diagnosis [of] OCD in non-autistic individuals is that the behavior they engage in [is] behavior they don't want to engage in,” Dr Elliott told Psychiatry Advisor. “They [are] compelled to do it even though they don't want to do it.”

Autistic repetitive behaviors are different, however. Children and adolescents with autism who have verbal skills often say they feel content with their repetitive behaviors and have no interest in stopping them.

“What they get upset about is when those behaviors are disrupted,” Dr Elliot said. He noted that their responses can range from annoyance to complete meltdowns.

“I think the motivation to do CBT would be much lower with autistic than [with] non-autistic individuals,” he said. “Most of them think, ‘Why should I give this up? It's fun, it's who I am, it's what I do.' CBT would be a hard sell since all therapy requires some agreement of ‘I have a problem I'd like to see changed.'”

If they do have repetitive behaviors they don't enjoy, however, CBT may help them reduce those behaviors, Dr Elliott told Psychiatry Advisor. He described the case of a boy who had such elaborate rituals that it took 3 hours to get through a meal and 20 minutes simply to enter his office. After treatment with fluoxetine and haloperidol, those behaviors decreased, freeing up 6 to 8 hours a day for him to be more socially engaged and participate in behavior he actually enjoyed.

In addition, neither of these reports address the distinction between obsessive and perseverative behaviors, Dr Elliott said.

“With perseverative behaviors, it's not the behavior that's important but the fact that they started doing it and can't stop,” he told Psychiatry Advisor. “Both occur, and they both can be responsive to medications, but they're different.” Perseverative behaviors typically respond better to antipsychotics while [selective serotonin reuptake inhibitors] more effectively treat obsessive behaviors, he said.

Dr Elliott agreed, however, that there is a strong need for evidence-based interventions for comorbid ASD and OCD.

Currently, CBT is at least somewhat effective, Kose et al noted, when “enhanced with modifications such as increased structure in the sessions, visual aids and cues, and considerable parental involvement.”

References

  1. Postorino V, Kerns CM, Vivanti G, Bradshaw J, Siracusano M, Mazzone L. Anxiety disorders and obsessive-compulsive disorder in individuals with autism spectrum disorderCurr Psychiatry Rep. 2017;19:92.
  2. van Steensel FJ, Bögels SM, Perrin S. Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysisClin Child Fam Psychol Rev. 2011;14(3):302-317.
  3. Bearss K, Taylor CA, Aman MG, et al. Using qualitative methods to guide scale development for anxiety in youth with autism spectrum disorderAutism. 2016;20:663-672.
  4. Kose LK, Fox L, Storch EA. Effectiveness of cognitive behavioral therapy for individuals with autism spectrum disorders and comorbid obsessive-compulsive disorder: a review of the researchJ Dev Phys Disabil. 2018;30:69-87.

Children With Autism, ADHD at Increased Risk for Anxiety, Mood Disorders

According to findings published in Pediatrics, children with both autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD)have an increased risk for anxiety and mood disorders.

Researchers performed a cross-sectional study of 3319 children aged 6 to 17 years with ASD, of whom 1503 (45.3%) reported a diagnosis of or treatment for ADHD. Primary outcome measures were professional diagnoses or treatment of anxiety disorder or mood disorder by parent report; secondary measures were population demographics, report of intellectual disability, and ASD severity score by standardized questionnaire. The cohort was largely boys (82.9%), white (87.2%), and non-Hispanic (92.4%), with a mean age of 10.3 years.

Of the children, 1025 (30.8%) were reported to have an anxiety disorder, 532 (16.0%) were reported to have a mood disorder, and 649 (19.5%) were reported to have intellectual disability. Comorbid ADHD increased with age (P <.001) and was associated with increased ASD severity (<.001). Per a generalized linear model, children with ASD and ADHD had an increased risk for both anxiety disorders (adjusted relative risk 2.20; 95% CI, 1.97-2.46) and mood disorders (adjusted relative risk 2.72; 95% CI, 2.28-3.24) compared with children with ASD alone. Increasing age was the most significant contributor for anxiety and mood disorders (both P <.001) for all children in the cohort, with a higher risk for both in the adolescent group compared with the grade school-aged group. 

The absence of report of intellectual disability was a significant contributor for mood disorder in both grade school-aged children (P =.041) and adolescents (P =.001), although not for anxiety disorder. Sex, race, and ethnicity were not found to be significant predictive factors in any analysis.

That the study questionnaires required internet access may have biased the cohort toward participants of higher socioeconomic status; as such, findings should be extrapolated with care. However, recognizing the increased risk for mood disorders in children with ASD and ADHD may be useful for clinicians and parents in developing proper screening and treatment strategies. 

Reference

Gordon-Lipkin E, Marvin AR, Law JK, Lipkin PH. Anxiety and mood disorder in children with autism spectrum disorder and ADHDPediatrics. 2018;141(4):e20171377.