Repetitive Behaviors and Anxiety in Children with Autism Spectrum Disorder

Background: There has been limited research on repetitive behaviors in ASD and the relation between repetitive behaviors, anxiety, and social impairments in ASD. Baron-Cohen (1989) suggested that social impairments in ASD lead to increased anxiety, which in turn leads to increased repetitive behaviors, but this theory has not yet been tested. An alternate model drawn from the OCD literature predicts that anxiety leads to repetitive behaviors which lead to social impairments. Additionally, there has been only one study directly comparing repetitive behaviors in children with ASD and children with OCD (Zandt, 2007).

Objectives: This study examined the relation between repetitive behaviors, anxiety, and social problems in ASD. Specifically, two models of repetitive behaviors in ASD were tested: Baron-Cohen’s model suggesting that anxiety mediates the relation between social impairments and repetitive behaviors, and an OCD model suggesting that repetitive behaviors mediate the relation between anxiety and social impairments. Further, this study directly compared the pattern of repetitive behaviors in children with ASD and children with OCD. 

Methods: Parents of 49 children with high-functioning ASD and 12 children with OCD, ages 7-17, completed interviews and surveys regarding their children’s repetitive behaviors (Children’s Yale-Brown Obsessive Compulsive Scale; Repetitive Behavior Scale – Revised), anxiety (Spence Children’s Anxiety Scale for Parents), and social impairment (Social Responsiveness Scale). 

Results: Within the ASD group, approximately half of participants were reported to have clinically significant levels of anxiety. Mediation analyses (i.e., Sobel tests) provided some support for Baron-Cohen’s (1989) model suggesting that social difficulties lead to anxiety, producing repetitive behaviors in individuals with ASD (indirect effect = .01). However, there was more support for the model based on theories of repetitive behaviors in OCD, suggesting that anxiety leads to repetitive behaviors, creating social problems (indirect effect = .40). Both models support theories suggesting that anxiety leads to repetitive behaviors in ASD. Multivariate analysis of covariance and qualitative descriptions were used to compare children with ASD and children with OCD. Results indicated that the severity and frequency of most types of repetitive behaviors are similar in children with ASD and children with OCD. However, differences were evident between groups on the number of obsessions (more in OCD) and stereotyped and restricted behavior (more in ASD). The distinction between groups on these symptoms suggests that they may be useful in differentiating ASD from other disorders. A significant number (74%) of children with ASD met criteria for OCD.

Conclusions: The current study provides converging evidence that anxiety is a significant clinical issue for many children with ASD and is related to core social and repetitive behavior symptoms. Further, the relation between anxiety, repetitive behaviors, and social impairments in this ASD sample was similar to the relation suggested in the OCD literature. This research suggests that it may be beneficial to examine the assessment and treatment of OCD when developing appropriate treatments for individuals with high-functioning ASD. The significant number of children with ASD who met criteria for OCD suggests that it may be appropriate to use both diagnoses in the same individual.