Functional Behavior-Based Cognitive-Behavioral Therapy for Obsessive Compulsive Behavior in Children with Autism Spectrum Disorder: A Randomized Controlled Trial

Abstract

Children with autism spectrum disorder (ASD) experience obsessions and compulsions similar to those specified in DSM-5 for obsessive compulsive disorder yet little controlled research exists on treating these behaviours. Thirty-seven children (7–13 years old) were randomly assigned to a 9-week functional behavior-based cognitive behavior therapy (Fb-CBT) or Treatment As Usual. Independent assessors administered measures pre- and post-treatment and at 6-months. Two primary outcome measures indicated statistically significant differences between groups, with large corrected effect sizes (Hedge’s g = 1.00 and 1.15, respectively). This is the first known RCT to exclusively treat obsessive compulsive behaviors (OCBs) in children and youth with high functioning (IQ ≥ 70) ASD, and suggests that Fb-CBT treatment shows promise in decreasing these behaviors and improving quality of life. Trial Registration This trial was registered with ClinicalTrials.gov (ID: NCT03123146).

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th edn.). Washington, DC: American Psychiatric Association.

  2. Barrett, P. M., Farrell, L., Pina, A. A., Peris, T. S., & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 37, 131–155. https://doi.org/10.1080/15374410701817956.

    Article  PubMed  Google Scholar 

  3. Bishop, S. L., Hus, V., Duncan, A., Huerta, M., Gotham, K., Pickles, A., et al. (2013). Subcategories of restricted and repetitive behaviors in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43, 1287–1297. https://doi.org/10.1007/s10803-012-1671-0.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Bodfish, J. W., Symons, F. J., & Lewis, M. H. (1999). The Repetitive Behavior Scale: Test Manual. Morganton: Western Carolina Center Research Reports.

    Google Scholar 

  5. Chok, J. T., & Harper, J. M. (2016). Heart rate assessment and use of a multiple schedule treatment for an individual with obsessive compulsive-like behavior. Journal of Developmental and Physical Disabilities, 28, 821–834. https://doi.org/10.1007/s10882-016-9511-3.

    Article  Google Scholar 

  6. Christensen, L., & Mendoza, J. L. (1986). A method of assessing change in a single subject: An alteration of the RC index. Behavior Therapy, 17(3), 305–308.

    Article  Google Scholar 

  7. Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd edn.). New Jersey: Pearson Education Inc.

    Google Scholar 

  8. Farrell, L., Waters, A., Milliner, E., & Ollendick, T. (2012). Comorbidity and treatment response in pediatric obsessive-compulsive disorder: A pilot study of group cognitive-behavioral treatment. Psychiatry Research, 199(2), 115–123. https://doi.org/10.1016/j.psychres.2012.04.035.

    Article  PubMed  Google Scholar 

  9. Goodman, W. K., Price, L. H., Rasmussen, S. A., Riddle, M. A., & Rapoport, J. L. (1986). Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). National Institutes of Mental Health (public domain).

  10. Hedges, L. V., & Olkin, I. (2014). Statistical Methods for Meta-analysis. Cambridge: Academic Press.

  11. Iovannone, R., Dunlap, G., Huber, H., & Kincaid, D. (2003). Effective educational practices or students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 18(3), 150–165. https://doi.org/10.1177/10883576030180030301.

    Article  Google Scholar 

  12. Jacobson, N. S., Follette, W. C., & Revenstorf, D. (1984). Psychotherapy outcome research: Methods for reporting variability and evaluating clinical significance. Behavior Therapy, 15(4), 336–352. https://doi.org/10.1016/S0005-7894(84)80002-7.

    Article  Google Scholar 

  13. Kose, L. K., Fox, L., & Storch, E. A. (2018). Effectiveness of cognitive behavioral therapy for individuals with autism spectrum disorders and comorbid obsessive-compulsive disorder: A review of the research. Journal of Developmental and Physical Disabilities, 30(1), 1–19. https://doi.org/10.1007/s10882-017-9559-8.

    Article  Google Scholar 

  14. Lafasakis, M., & Sturmey, P. (2007). Training parent implementation of discrete-trial teaching: effects on generalization of parent teaching and child correct responding. Journal of Applied Behavior Analysis, 40, 685–689. https://doi.org/10.1901/jaba.2007.685-689.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Lehmkuhl, H. D., Storch, E. A., Bodfish, J. W., & Geffken, G. R. (2008). Brief report: Exposure and response prevention for obsessive compulsive disorder in a 12-year-old with autism. Journal of Autism and Developmental Disorders, 38(5), 977–981. https://doi.org/10.1007/s10803-007-0457-2.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lord, C., Rutter, M., & Couteur, A. L. (1994). Autism diagnostic interview-revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24(5), 659–685. https://doi.org/10.1007/BF02172145.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Lord, C., Rutter, M., DiLavore, P. C., & Risi, S. (1999). Autism Diagnostic Observation Schedule. Los Angeles: Western Psychological Services.

    Google Scholar 

  18. March, J. S., & Mulle, K. (1998). OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. New York: The Guilford Press.

    Google Scholar 

  19. Matson, J. L., Tureck, K., & Rieske, R. (2012). The Questions About Behavioral Function (QABF): Current status as a method of functional assessment. Research in Developmental Disabilities, 33(2), 630–634. https://doi.org/10.1016/j.ridd.2011.11.006.

    Article  PubMed  Google Scholar 

  20. Matson, J. L., & Vollmer, T. R. (1995). User’s Guide: Questions About Behavioral Function (QABF). Baton Rouge. LA: Scientific Publishers, Inc.

    Google Scholar 

  21. Matson, J. L., & Williams, L. W. (2014). Functional assessment of challenging behavior. Current Developmental Disorders Reports, 1(2), 58–66.

    Article  Google Scholar 

  22. McPheeters, M. L., Warren, Z., Sathe, N., Bruzek, J. L., Krishnaswami, S., Jerome, R. N., et al. (2011). A systematic review of medical treatments for children with autism spectrum disorders. Pediatrics, 127(5), 1312–1321. https://doi.org/10.1542/peds.2011-0427.

    Article  Google Scholar 

  23. Mirenda, P., Smith, I. M., Vaillancourt, T., Georgiades, S., Duku, E., Szatmari, P., et al. (2010). Validating the repetitive behavior scale- revised in young children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 40(12), 1521–1530. https://doi.org/10.1007/s10803-010-1012-0.

    Article  Google Scholar 

  24. Mulligan, S., Healy, O., Lydon, S., Maron, L., & Foody, C. (2014). An analysis of treatment efficacy for stereotyped and repetitive behaviors in autism. Review Journal of Autism and Developmental Disorders, 1(2), 143–164. https://doi.org/10.1007/s40489-014-0015-8.

    Article  Google Scholar 

  25. Murray, K., Jassi, A., Mataix-Cols, D., Barrow, F., & Krebs, G. (2015). Outcomes of cognitive behaviour therapy for obsessive–compulsive disorder in young people with and without autism spectrum disorders: A case controlled study. Psychiatry Research, 228(1), 8–13. https://doi.org/10.1016/j.psychres.2015.03.012

    Article  PubMed  Google Scholar 

  26. Nauta, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H., & Waters, A. (2004). A parent-report measure of children’s anxiety: Psychometric properties and comparison with child-report in a clinical and normal sample. Behavior Research and Therapy, 42(7), 813–839. https://doi.org/10.1016/S0005-7967(03)00200-6.

    Article  Google Scholar 

  27. Neil, N., & Sturmey, P. (2014). Assessment and treatment of obsessions and compulsions in individuals with autism spectrum disorders: A systematic review. Review Journal of Autism and Developmental Disorders, 1, 62–79. https://doi.org/10.1007/s40489-013-0006-1.

    Article  Google Scholar 

  28. Öst, L. G., Riise, E. N., Wergeland, G. J., Hansen, B., & Kvale, G. (2016). Cognitive behavioral and pharmacological treatments of OCD in children: A systematic review and meta- analysis. Journal of Anxiety Disorders, 43, 58–69.

    Article  Google Scholar 

  29. Piacentini, J., Langley, A., & Roblek, T. (2007). Overcoming Childhood OCD: A Cognitive Behavioral Treatment Program. Oxford: Oxford University Press.

  30. Piacentini, J., Peris, T. S., Bergman, R. L., Chang, S., & Jaffer, M. (2007). Brief report: Functional impairment in childhood OCD: development and psychometrics properties of the child obsessive-compulsive impact scale—revisded (COIS-R). Journal of Clinical Chiild and Adolescent Psychology, 36(4), 645–653. https://doi.org/10.1080/15374410701662790.

    Article  Google Scholar 

  31. Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: A randomized trial. Journal of Child Psychology and Psychiatry, 53(4), 410–419. https://doi.org/10.1111/j.1469-7610.2011.02486.x.

    Article  PubMed  Google Scholar 

  32. Reaven, J., & Hepburn, S. (2003). Cognitive-behavioral treatment of obsessive-compulsive disorder in a child with asperger syndrome: A case report. Autism, 7(2), 145–164. https://doi.org/10.1177/1362361303007002003.

    Article  PubMed  Google Scholar 

  33. Rispoli, M., Camargo, S., Machalicek, W., Lang, R., & Sigafoos, J. (2014). Functional communication training in the treatment of problem behavior maintained by access to rituals. Journal of Applied Behavior Analysis, 47(3), 1–14. https://doi.org/10.1002/jaba.130.

    Article  Google Scholar 

  34. Rodriguez, N. M., Thompson, R. H., Schlichenmeyer, K., & Stocco, C. S. (2012). Functional analysis and treatment of arranging and ordering by individuals with an autism spectrum disorder. Journal of Applied Behavior Analysis, 45(1), 1–22. https://doi.org/10.1901/jaba.2012.45-1.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Rosa-Alcázar, A. I., Sánchez-Meca, J., Rosa-Alcázar, Á, Iniesta-Sepúlveda, M., Olivares- Rodríguez, J., & Parada-Navas, J. L. (2015). Psychological treatment of obsessive- compulsive disorder in children and adolescents: A meta-analysis. The Spanish Journal of Psychology, 18(20), 1–22. https://doi.org/10.1017/sjp.2015.22.

    Article  Google Scholar 

  36. Ruzzano, L., Borsboom, D., & Geurts, H. M. (2015). Repetitive behaviors in autism and obsessive–compulsive disorder: New perspectives from a network analysis. Journal of autism and developmental disorders, 45(1), 192–202. https://doi.org/10.1007/s10803-014-2204-9.

    Article  PubMed  Google Scholar 

  37. Sattler, J. M. (2008). Assessment of children: Cognitive foundations (5th edn.). La Mesa: Jerome M. Sattler Inc.

    Google Scholar 

  38. Sofronoff, K., Attwood, T., & Hinton, S. (2005). A randomised controlled trial of a CBT intervention for anxiety in children with asperger syndrome. Journal of Child Psychology and Psychiatry, 46(11), 1152–1160. https://doi.org/10.1111/j.1469-7610.2005.00411.x.

    Article  PubMed  Google Scholar 

  39. Stone, W. S., & Chen, G. (2016). Comorbidity of autism spectrum and obsessive-compulsive disorders. North American Journal of Medicine and Science, 8(3), 109–112. https://doi.org/10.7156/najms.2015.0803109.

    Article  Google Scholar 

  40. Storch, E. A., Arnold, E. B., Lewin, A. B., Nadeau, J. M., Jones, A. M., De Nadai, A. S., et al. (2013). The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 52(2), 132–142. https://doi.org/10.1016/j.jaac.2012.11.007.

    Article  PubMed  Google Scholar 

  41. Storch, E. A., Murphy, T. K., Geffken, G. R., Soto, O., Sajid, M., Allen, P., et al. (2004). Psychometric evaluation of the children’s yale-brown obsessive–compulsive scale. Psychiatry Research, 129(1), 91–98. https://doi.org/10.1016/j.psychres.2004.06.009.

    Article  PubMed  Google Scholar 

  42. Sukhodolsky, D. G., Bloch, M. H., Panza, K. E., & Reichow, B. (2013). Cognitive behavioral therapy for anxiety in children with high-functioning autism: A metaanalysis. Pediatrics, 132(5), 1341–1350. https://doi.org/10.1542/peds.2013-1193.

    Article  Google Scholar 

  43. Uher, R., Heyman, I., Turner, C. M., & Shafran, R. (2008). Self-, parent-report and interview measures of obsessive–compulsive disorder in children and adolescents. Journal of Anxiety Disorders, 22(6), 979–990.

    Article  Google Scholar 

  44. van Steensel, F. J., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review, 14(3), 302–317. https://doi.org/10.1007/s10567-011-0097-0.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Vause, T., Hoekstra, S., & Feldman, M. (2014). Evaluation of individual function-based cognitive-behavioural therapy for obsessive compulsive behaviour in children with autism spectrum disorder. Journal on Developmental Disabilities, 20(3), 30–41.

    Google Scholar 

  46. Vause, T., Neil, N., Jaksic, H., & Feldman, M. (2013a). I Believe in Me Not OCB!: Clinician’s Manual. St. Catharines, ON: Brock University (Unpublished manuscript).

    Google Scholar 

  47. Vause, T., Neil, N., Jaksic, H., & Feldman, M. (2013b). I Believe in Me Not OCB!: Workbook. St. Catharines, ON: Brock University (Unpublished manuscript).

    Google Scholar 

  48. Vause, T., Neil, N., Jaksic, H., Jackiewicz, G., & Feldman, M. (2015). Preliminary randomized trial of function-based cognitive-behavioral therapy to treat obsessive compulsive behavior in children with autism spectrum disorder. Focus on Autism and Other Developmental Disabilities, 32(3), 218–228.

    Article  Google Scholar 

  49. Watson, H. J., & Rees, C. S. (2008). Meta-analysis of randomized, controlled treatment trials for pediatric obsessive-compulsive disorder. Journal of Child Psychology and Psychiatry, 49(5), 489–498. https://doi.org/10.1111/j.1469-7610.2007.01875.x.

    Article  PubMed  Google Scholar 

  50. Wechsler, D. (2004). Wechsler Intelligence Scale for Children – Fourth Edition (WISC-IV). San Antonio: The Psychological Corporation.

  51. Wood, J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50, 224–234.

    Article  Google Scholar 

  52. Wu, M. S., McGuire, J. F., Arnold, E. B., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2014). Psychometric properties of the children’s yale-brown obsessive compulsive scale in youth with autism spectrum disorders and obsessive–compulsive symptoms. Child Psychiatry and Human Development, 45(2), 201–211. https://doi.org/10.1007/s10578-013-0392-8.

    Article  PubMed  Google Scholar 

  53. Wu, M. S., Rudy, B. M., & Storch, E. A. (2014). Obsessions, compulsions, and repetitive behavior: Autism and/or OCD. In T. E. Davis III, S. W. White, & T. H. Ollendick (Eds.) Handbook of Autism and Anxiety (pp. 107–120). New York: Springer.

Download references

Acknowledgments

We sincerely thank the participants, their families, and agencies for their support of this project. This research was funded by the Ontario Mental Health Foundation and the Ministry of Health and Long-Term Care. Funding sources did not have a specific role in the study itself, or in decision to submit this paper for publication.

Author information

Affiliations

Authors

Contributions

TV conceived of the project, oversaw clinical and methodological aspects, data analysis, and was the primary writer of the paper. HJ contributed to clinical aspects of the project, data collection and data analysis. NN contributed to clinical aspects of the project, data collection and analysis, and writing of the paper. JCF performed data analysis, contributed to methodological aspects of the paper and the writing of the results section. GJ contributed to participant recruitment, conceptualization of the clinical population, and expertise concerning participant characteristics and medication. MF contributed to research design, methodological aspects of the paper, and critical review of the paper.

Corresponding author

Correspondence to Tricia Vause.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Vause, T., Jaksic, H., Neil, N. et al. Functional Behavior-Based Cognitive-Behavioral Therapy for Obsessive Compulsive Behavior in Children with Autism Spectrum Disorder: A Randomized Controlled Trial. J Autism Dev Disord 50, 2375–2388 (2020). https://doi.org/10.1007/s10803-018-3772-x

Download citation

Keywords

  • Autism spectrum disorder
  • Obsessive compulsive behavior
  • Cognitive-behavioral therapy
  • Treatment
  • Function-based assessment