"Johnny" is 13 years old, and his parents bring him in to our practice for a psychological evaluation. His parents are concerned that he might have Autism Spectrum Disorder (ASD). They report he engages in repetitive behaviors (washing hands) and is very rigid about things such as having his own set of dishes and eating utensils that no one else is allowed to use. Johnny does not have many friends and is viewed as “weird” by his classmates. He also shows an obsessive interest in germs, talking about them at length whether another person is interested or not.
Clearly ASD, right? Not necessarily.
Is it Autism or Obsessive-Compulsive Disorder?
While repetitive behaviors, rigidity (e.g. not being able to adapt to changes and insisting upon doing things a certain way), and impairments in social skills are features of ASD, they can also suggest Obsessive-Compulsive Disorder (OCD). OCD is characterized by obsessions (recurrent thoughts), compulsions (irresistible urge to do certain behaviors), or both that stem from a fear. For example, Johnny might be afraid of germs. He has obsessive thoughts that “germs will make me sick” or “if I use someone else’s plate or fork, I will get sick.” As a result, he engages in compulsive behaviors such as washing his hands multiple times a day and insisting upon using his own dishes.
In contrast, the repetitive behaviors, rigidity, and obsessive interests in Autism Spectrum Disorders are not a result of fear. No link has been established that indicates that the obsessive interests & compulsive behaviors of individuals with ASD are rooted in the reaction to an anxiety or a fear. For example, when we delve further into Johnny's behaviors he may show an intense interest in different types of bacteria and viruses, but does not wash his hands as result of fear of contamination. He is very rigid about using his own dishes, but it is not because he worries about getting someone else’s germs.
Which is it? It's all about Social Perspective
Social difficulties in ASD are a result of poor perspective-taking; meaning a person with ASD is unable to understand someone else’s point of view, and a poor understanding of social rules/routines. Although many children with ASD desire friends, they do not understand how to appropriately approach another child or how their behavior affects others. For example, due to poor perspective-taking, the child with ASD may not understand that it’s not appropriate to grab a toy from another child’s hands. They are unable to understand and predict how the other child will respond because they can only see their point of view. Children with ASD sometimes are rejected by peers because they don’t understand the social rules about how to play with others and how to treat a friend.
In contrast, individuals with OCD have difficulty with friendships and social interaction because their obsessions and compulsions interfere with normal activities. For example, Johnny may have a hard time establishing and maintaining friendships because he becomes very upset if someone accidentally touches him. He is unable to attend sleepovers or birthday parties because he would not be allowed to use his special dishes and spends more time washing his hands than actually playing with other children. Children with OCD understand social rules and how to treat friends, but become so overwhelmed by intrusive thoughts and the intense need to perform compulsions that they are unable to participate in many social activities... and thus become socially isolated.
Play is Serious Business
It's important to note that children with OCD enjoy playing with a variety of toys, use toys in a normal fashion, and engage in imaginative and interactive play. In contrast, a child with ASD may play with only one type of toy (e.g. Thomas the train) and be more interested in how toys work than how they can be used imaginatively. A common behavior seen in ASD is taking toys apart or a fascination with watching what happens when you drop various items.
Children with OCD enjoy playing with others and are very imaginative, whereas the individual with ASD often prefers to play alone and does not engage in any pretend play.
Seeing Eye to Eye
Another feature that distinguishes ASD from OCD is impairments in eye contact and nonverbal behavior. The child with OCD looks at people when conversing, responds with eye contact when someone says his/her name, can “read” facial expressions, and both uses and understands nonverbal gestures. Contrast that with someone with ASD in which eye contact is very poor, use of nonverbal gestures (e.g. shaking head yes/no, holding out hand to request something, shrugging shoulders) is very limited, and the child has difficulty recognizing facial expressions conveying certain emotions.
Many children with ASD also exhibit sensory sensitivities or unusual interests in sensory stimulation. For example, the child may be extraordinarily sensitive to noise and show a fascination with visually inspecting things or staring at spinning objects.
While the child with OCD may also be sensitive to these things; what appear to be sensory issues may be actually driven by obsessions/compulsions. For example, he may insist upon wearing a certain type of clothing or wearing particular shoes, but these behaviors could be related to an obsessive thought such as “if I wear jeans, the dye might seep into my skin and poison me” or “if I don’t wear X brand of athletic shoes, I will have bad luck.”
Stereotypical Behaviors are Not Always Stereotypical
Finally, in regard to stereotypical behaviors, children with OCD usually follow a particular ritual/sequence such as rocking forward and backwards seven times or clapping their hands in a particular rhythm when they see something red. The child may have to touch something with his right side first and then touch it with his left side. In comparison, stereotypical behaviors in ASD do not usually follow a particular pattern and are more notable when the child is excited or upset.
Although both ASD and OCD can be characterized by rigid behavior, stereotypical behaviors, restricted areas of interest, and impaired social skills, the two also have important differences. By paying close attention to other behaviors your child exhibits (particularly his/her use of toys, use of imagination, eye contact, nonverbal behaviors, and whether stereotypical behaviors follow a pattern), you can help your doctor or clinician with important information that leads to a more accurate diagnosis and appropriate treatment.