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Obsessive Compulsive Disorder in Young People with Autism Spectrum Condition

Erika Lindstrom
July 27, 2018


Obsessive Compulsive Disorder (OCD) is defined by the WHO and American Psychiatric

Association as, “unwanted intrusive thoughts, images or urges (termed obsessions) and associated

repetitive or ritualistic behaviours (termed compulsions)” (Murray, Jassi, Mataix-Cols, Barrow & Krebs,

2015, p. 8). Obsessive thoughts create anxiety and compulsive actions alleviate that anxiety by acting on

the initial thoughts. Some individuals have the insight to understand the unreasonable nature of their

thoughts, and many can articulate this. People with Autism Spectrum Condition (ASC) and OCD with

limited insight and language may not be able to express how they feel about their obsessive thoughts (Neil

& Sturmey, 2013, p. 63). These symptoms must by time consuming, cause “clinically significant distress,

impair daily functions, they are not the cause or can be explained by another medical condition, or are

caused by an substance (American Psychiatric Association, 2013).

The common age of onset is in late childhood, and the recommended course of treatment for

individuals without autism is Cognitive Behaviour Therapy (CBT) with Exposure and Response

Prevention (ERP). Research has shown inconsistencies in symptom profiles for individuals with ASC and

OCD. While two studies found no statistical difference in profiles between individuals with an OCD/ASC

co-morbid diagnosis and those with OCD but no ASC, other studies found less sexual obsessions,

washing, checking and repeating compulsions (p.8-9). An important consideration for research is the ego-

dystonic nature of OCD symptoms of individuals without ASC, whereas repetitive and restrictive

behaviours in individuals with ASC seem to bring the person pleasure. While challenges with diagnosis

exist, this clear distinction can help with assessment and diagnosis (Murray, Jassi, Mataix-Cols, Barrow

& Krebs, 2015, p. 9).

Repetitive and restrictive behaviours are defined in the DSM-V by the American Psychological

Association as:

“1) Stereotyped or repetitive motor movements, use of objects, or speech.2) Insistence on

sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior. 3)
Highly restricted, fixated interests that are abnormal in intensity or focus. 4)Hyper- or
hyporeactivity to sensory input or unusual interests in sensory aspects of the environment. (Autism
Speaks, 2017)

Nadeau and colleagues (2014) summarize the following observable symptoms of comorbid ASC and

anxiety (including OCD) from various studies as, “social avoidance, sleep problems, and externalizing

behavior problems, as well as disruptions in family functioning and interpersonal relationships” (p. 22).

Due to repetitive behaviours being a part of ASC and OCD symptomology, differential diagnosis can be

challenging (Elliott, 2014, p. 156). The two main ways to distinguish ASC and OCD are to identify if the

person experiences obsessions, or to measure the level of distress they experience from their symptoms

(Neil & Sturmey, 2013, p. 65). However, as shown the literature, this differentiation can be challenging

to assess.

The Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and Yale-Brown Obsessive

Compulsive Scale (YBOCS) measures 50 behaviours that are common OCD symptoms, and included is

a severity scale. This is a measure commonly used to assess OCD in young people (Ruzzano, 2015, p.

200), and has been utilized in many relevant research studies in the field. Generally, a score greater than

16 is required for inclusion in a study (Russel & Jassi, 2013, p. 698). However, this assessment is not

psychometrically designed as a diagnostic tool to assess youth with ASC per se (Murray, Jassi, Mataix-

Cols, Barrow & Krebs, 2015, p. 11).

Other instruments used to assess OCD include the Diagnostic and Statistics Manual (DSM), Child

& Adolescent Psychiatric Assessment (CAPA-Parent Version), Kiddie Schedule of Affective Disorders

and Schizophrenia (K-SADS), DISC-Anxiety Disorders and Diagnostic Interview Schedule for Children

(DISC-IV-P) (Neil& Sturmey, 2013, p. 65), the Social Responsiveness Scale (SRS-2), the Child OCD

Impact Scale: Parent Report (COIS‑P), and the Family Accommodation Scale (FAS) (Griffiths, White

and Farrell, 2017, p. 3-4).



While the research is still growing in this area, and much is left to learn, an initial body of literature

has laid the foundation for a deeper understanding of ASC and OCD, in addition to the treatment of this

co-morbid diagnosis (see Appendix B for additional studies).

Van Steensel, Bögels, & Perrin (2011) conducted a meta-analysis and found a 17% prevalence of

OCD amongst youth with ASC. This could have been because the diagnostic tools used were not intended

for use with the ASC population. This begs the question if diagnostic tools are picking up on ASC traits

or actually components of the anxiety disorder. There is diagnostic overlap between OCD and ASC so the

authors suggest determining the target of special interests and repetitive behaviours and then comparing

these with targets of compulsive behaviours in children with OCD (p. 310). There were many limitations

with this study, beginning with significant heterogeneity across studies in the meta-analysis (p. 312). Very

few of the studies included individuals with an IQ lower than 70. This would impact generalization to the

larger ASC population (p. 313). Only some of the studies used measures that were designed or modified

for use with individuals with ASC and mostly importantly, their validity and reliability for use with this

population has not yet been established (p. 313).

A study by Arlindskov et al. (2016) sought to understand subclinical levels of ASC

symptomatology in the OCD population without an existing ASC diagnosis, examine age and sex

relationships within this group, and look at the severity of OCD behaviours and ASC symptoms (p. 712).

Baseline data from the Nordic Long Term OCD Treatment Study was used for this research study.

Participants included youth ages 7-17 with a primary diagnosis of OCD, as assessed by the CY-BOCS

and DSM-IV. Parents of the subjects completed the Autism Spectrum Screening Questionnaire (ASSQ)

(p. 713). This study found that subclinical rates of ASC traits co-occurred in 10-17% of individuals with

an OCD diagnosis, this occurred at a ratio of 2.6:1 of males to females, and ASC symptoms did not affect

the severity of OCD traits. The authors suggest a higher cut off for ASC scores on the ASSQ if an

individual already has an OCD diagnosis (p. 719). A limitation was that there was no control group,

however, normative ASSQ data was used from another study to address this. Finally, there might be poor

generalizability because the rate of comorbidity was lower than other large studies of the OCD population

(p. 721).

Recently, Griffiths, Farrell, Waters & White (2017) conducted a study that showed mixed results

in the prevalence of OCD amongst the ASC population. They found a range of 1.5-81% co-occurrence of

OCD in the ASC population (Griffiths, Farrell, Waters & White, 2017, p. 2). Prevalence of ASC traits in

the OCD population range from 8.26% to 26 .2%, measured by the Social Responsiveness Scale (SRS)

(p. 1). This study used the SRS to assess the prevalence of ASC traits in the OCD population, finding a

rate of 32.5%. Most relevant to the question of the comorbidity of ASC and OCD, is that the presence of

ASC traits in an individual with OCD did not indicate increased symptom severity, but did show increased

functional impairment. Furthermore, family accommodation was shown to mediate the higher level of

functional impairment (p. 9). Only assessment tools such as the SRS-2 and CY-BOCS were used, instead

of diagnostic tools that are psychometrically validated. Furthermore, they found the SRS-2 to rate 57.5%

of the sample with OCD above the cut off for ASC, and therefore might have been overly sensitive and

therefore less effective in distinguishing OCD from ASC. Finally, the researchers recognize their sample

population included families with a higher education and socio-economic status than the general

population so it brings into question generalizability. This study underscores the importance of preventing

diagnostic overshadowing by carefully screening for both OCD and ASC, as this will affect treatment

decisions (p. 9).

Conceptualization Approach (See Appendix B for framework table)

The biopsychosocial case conceptualization framework (Winters, Hanson & Stoyanova, 2007, p.

122) is a useful tool for understanding the layers of complexity in comorbid OCD and ASC diagnoses.

Predisposing Factors

Biological: It has been found that there is no clinically significant difference between males and females

with OCD exhibiting ASC characteristics, and the same is true of age groups within paediatric OCD

(Arildskov et al. 2015, p. 712). Three biological factors that connect OCD and ASC include: a possible

genetic link between the two diagnoses, both have disruptions in the frontostriatal system in the brain, and

in the 5-HT transporter gene (Lehmkuhl, Storch, Bodfish &Geffkin, 2008, p. 9780). Other common

factors that increase risk for both include older paternal age, and obstetrical complications & infections

increase risk (Meier, 2015 p. 9).

Psychological: No significant relationship between high scores of ASC traits in individuals with OCD and

symptom severity but the level of functional impairment was greater (Griffiths et al. 2017, p. 8). A

significant challenge in understanding the comorbidity of ASC and OCD is that individuals with ASC

have challenges with recognizing and reporting thoughts, feelings and behaviours, generalizing, rigidity,

impaired executive functioning, planning & organization (Krebs, Murray & Jassi, 2016, p.1162).

Social- Relationships: Parents may be unaware about the possible comorbidity of OCD and ASC (Nadeau.

Arnold, Storch & Lewin, 2014, p. 32).

Social- Environmental, Systemic: As the body of literature and research grows, dissemination of up to

date information is limited (Nadeau. Arnold, Storch & Lewin, 2014, p. 32).

Precipitating Factors

Biological: No significant relationship has been found between high scores of ASC traits in individuals

with OCD and symptom severity but the level of functional impairment is greater (Griffiths et al. 2017,

p. 8).

Psychological: Neil & Sturmey (2013) wrote a seminal systematic review that was the first to examine all

aspects of the OCD and ASC body of literature (p. 63). The disruptive and all-consuming nature of OCD

behaviours can impede education and therefore the authors of this study recognize the importance of

effective, early treatment (p. 64). One way to consider repetitive and restrictive behaviours is on a

continuum from lower order to higher order behaviours. Many higher order repetitive and restrictive

behaviours share topography with behaviours common in OCD (e.g. Ordering, washing, cleaning). The

authors raise the suggestion that lower order behaviours (e.g. stereotypy, self-injury) serve the function of

self-regulation (p. 62). The rationale for this perspective is that the DSM criteria excludes many

topographies that are common to people with ASC, that are similar to OCD symptoms. Fischer-Terworth

and Proust (2009) put forward the idea of Autism-Related Obsessive Compulsive Phenomena (AOCP)

which may look like OCD behaviours in that they include, “repetitive motor movements, rituals, ordering

and arranging, the need for completeness, as well as sameness and symmetry” (p. 64). They differ in that

AOCPs bring about a sense of pleasure, or even euphoria as suggested within this study.

For someone with ASC to be prevented from completing a behaviour might cause the same level

of distress as someone with OCD being blocked from a compulsive behaviour, which can make it difficult

to determine the function when someone is not able to articulate their obsessions of lack there of (p. 64).

The authors suggest that a functional analysis may be a useful way to test the function of rigid and

repetitive behaviours for those who are not able to articulate their level of distress (p. 66). Of all the

treatments evaluated, the following were rated the highest in the study as probably efficacious: behaviour

analysis & modification, Risperidone, Fluvoxamine for adults and Fluoxetine. All other behavioural and

pharmaceutical treatments were considered experimental at the time of this review (p. 76). Limitations

found in the body of research from this study included inconsistent OCD diagnoses, a preference to focus

on the topography rather than the function of behaviours, and a lack of well controlled experiments. None

of the 14 treatments were considered well-established in their research base (p. 76).

Social- Relationships: In children with ASC, family accommodation of rigidity can lead to a greater risk

of anxiety disorders (Griffiths et al., 2017, p. 2).


Social- Environmental, Systemic: Families often have limited resources to access specialized treatment,

after they are already involved with various other therapists for the treatment of ASC symptoms (Nadeau.

Arnold, Storch & Lewin, 2014, p. 32).

Perpetuating Factors

Biological: In youth with comorbid ASC and OCD compared to group of age and gender matched youth

with OCD only, there were high rates for comorbidity with other diagnoses and greater functional

impairment (Griffiths et al. 2017, p. 2).

Psychological: In youth with comorbid ASC and OCD compared to group of age and gender matched

youth with OCD only, there were high rates of ADHD comorbidity, more symptoms of depression

(Griffiths et al. 2017, p. 2). ASC characteristics might impact treatment delivery, making it more

challenging to delivery effect treatment (Arildskov et al. 2015, p. 712).

Using a network approach, Ruzzano, Borsboom & Geurts (2015) analyze the causality between

various repetitive behaviours in ASC and OCD symptoms (p. 192). This study points out that while

research has shown a connection between internal obsessions and compulsive behaviours in people with

OCD, evidence of obsessions within individuals with ASC does not yet exist. Rather, it is has been

hypothesized that the function of repetitive behaviours within ASC is sensory processing. Evidence to

prove this is limited, but there is evidence that shows a link between sensory processing difficulties and

repetitive behaviours (p. 193). A sample of 213 children and youth with one or more diagnoses were

assessed with the ADI-R and P-DISC-IV (p.194). Data from these measures were used to construct

networks showing causality between symptoms, which emerged as two separate clusters. This study found

that the network approach might be an effective way to conceptualize OCD and ASC because these two

clusters show that OCD and ASC symptoms are different (p.200). Traditionally, there is thought to be

symptom overlap, or they are conceptualized as two distinct issues (p. 199). This study discovered that

OCD and ASC symptoms interact differently depending on the pair of symptoms or how simply OCD

symptoms might interact with each other. It also confirmed that there is no connection between the

obsessions seen in OCD and ASC symptoms. They also found that some behaviours that are typical in

OCD, vary in strength in their connection to symptoms in an individual with ASC. Another important

finding included the centrality of the symptom ‘unusual sensory interests’ to the Correlation Data

Network. The authors of this study suggest that using the symptom ‘unusual sensory interests’ could lead

to a deeper understanding of the comorbidity of ASC and OCD. A significant limitation is that the

symptoms listed in the study ranged in their specificity so there could have been perceived overlap in the

rating of behaviours (p. 201).

Social-Relationships: In youth with comorbid ASC and OCD compared to a group of age and gender

matched youth with OCD only, impaired interpersonal skills were evident. Family accommodation of

OCD behaviours is an indicator for weaker treatment response, greater emotional dysreguation (Griffiths

et al. 2017, p.2), and a mediating factor leading to greater functional impairment. Family accommodation

might also affect the child’s ability to problem solve, and result in putting stress on family dynamics (p.


Social- Environment, Systemic Issues: Primary care physicians might not recognize the symptoms of

OCD in the ASC population, nor may they be aware of specialized treatment options available (Nadeau.

Arnold, Storch & Lewin, 2014, p. 32), and there is a lack of specialized treatment providers available (p.


Protective Factors

Biological: Research is being done on glutamatergic activity in the frontostriatal area of the brain as

possible treatment (Hage et al., 2016, p. 2). Regarding pharmaceutical treatment, Meier et al. (2015)

point out that most often, anti-depressants such as SSRIs are used to treat OCD (p.2). Neil and Sturmey

(2013) found Risperidone, Fluvoxamine for adults and Fluoxetine to be “probably efficacious” (p. 76).

Psychological: Those with a nonverbal IQ higher than 97 were found to be less likely to engage in

compulsive behaviours, specifically, the insistence on sameness (Neil & Sturmey, 2014, p.65).

Social-Relationships: Parental involvement in treatment is an important factor in the maintenance and

generalization of skills (Krebs, Murray & Jassi, 2016, p. 1168).

Social- Environment, Systemic Issues: A collaborative school environment that can work with a therapist

can yield generalized treatment skills to the school setting (Krebs, Murray & Jassi, p. 1178).

Evidence-Based Treatment Approaches

In a 2013 systematic review, behaviour analysis & modification was found to be ‘probably

efficacious’ to treat OCD and ASC (p. 76). Since then, more research has been seen around CBT as a

treatment for OCD and ASC. While modified CBT with ERP has not yet met the requirements to be

considered an Evidence-Based Treatment, a growing number of case studies, one Randomized Control

Trial and a few meta-analyses have established a trend in research towards EBP status. CBT involves

cognitive therapy (CT) and behaviour therapy (BT) components. The CT component includes addressing

ways of thinking that might perpetuate obsessions, leading to compulsive behaviours. Behaviour therapy

helps address anxiety by teaching relaxation techniques (Elliott, 2014, p. 156). ERP is a BT element of

CBT that is defined as, “gradually increasing exposure to feelings of anxiety engendered by the

obsessional thoughts. This is achieved by reducing and then eliminating the use of compulsive acts, which

are used by the client to neutralize anxiety engendered by the obsessional thoughts” (p. 156).

Modifying CBT with the purpose of discovering a meaningful way to use CBT principles while

accommodating for ASC characteristics has been successful in a number of case studies. Standard CBT

was shown to have limited effects for individuals with ASC (Krebs, Murray & Jassi, 2016, p.1162).

Successful modifications of CBT have included leveraging special interests to increase motivation, the

use of literal language, visual supports, rewards (i.e. Positive reinforcement), routine and a predictable

and structured format (p.1163).


In response to initial pilot studies using CBT for individuals with ASC and OCD, Russell, et al.

(2013) carried out the first randomized control trial to study the efficacy of this treatment with adolescents

and adults. All participants had a comorbid diagnosis of OCD and ASC, as diagnosed by the ADOS and

ADI-R. Baseline levels of OCD symptoms were assessed using the YBOCS, (p.698). The treatment group

received CBT that specifically was to treat OCD, and the control group received anxiety management

sessions (p. 698-699). Symptom severity was identified as a moderating factor in the response to treatment

(p. 703). The effect size of CBT was slightly greater than that of AM, which also showed to have a positive

effect on the reduction of OCD symptoms. At the point of a twelve-month follow-up, the CBT group had

sustained their gains (p. 705). A limitation of this study is that there were not enough participants to

statistically detect a significant difference in effect between the two treatment options. Furthermore, there

was a very wide range of ages and symptom severity represented in this study, and this could have

potentially impacted the outcome of the treatment. Finally, there was no follow-up data for the AM group,

and some participants in both groups scored minimal improvement or much worse at post-treatment (p.

706). Despite its many limitations, the authors of this study call it a, “proof of concept trial” (p.706) that

has overall contributed to the body of literature as the first controlled trial testing modified CBT for

individuals with ASC and OCD, and showed that such a treatment can be effective (p.707).

A seven-year-old boy with ASC was the subject of Elliott & Fitzsimmons’ 2014 case study, and

underwent modified CBT treatment for his OCD. It was established that his compulsive behaviours were

not pleasurable, and his obsessions were ego-dystonic (p. 157). This study contributes to the body of

literature by raising new ideas about how to modify CBT to make it relevant and accessible to children

with ASC. For example, there was a focus on very practical aspects of behaviour training, versus abstract

discussion of emotions. Twelve specific modifications were made an are described in the article in greater

detail (p. 158-159). While the child did demonstrate the ability to manage his obsessions and compulsions,

and generalized these skills to school (p.158), there were some limitations with generalization from this

case study to other young people with ASC and OCD. This child had an IQ over 70, was socially

motivated, was verbal, could understand his obsessions from an external perspective, and his parents were

willing and able to participate as co-therapists in his treatment (p. 159).

With the purpose of building on the literature regarding modified CBT as treatment for young

people with ASC and OCD, Nadeau. Arnold, Storch & Lewin (2014) conducted a case study of a nine-

year-old boy with both diagnoses (p.23). Treatment included modifications to the traditional course of

CBT, which included high levels of parental involvement. At the time of post-treatment, he was

determined to be in ‘remission’ and had decreased from a score of 27 on the CY-BOCS to 0 (p. 30). After

four months, follow up measures showed he remained in remission for OCD behaviours, but his social

anxiety had gone up (p. 32). This study is limited in generalizability as it is a case study of only one subject

(p.33). Nadeau and colleagues contribute to the growing body of literature to support the efficacy of

modified CBT as treatment for individuals with ASC. An important factor was combining exposure and

response prevention activities with parental training and involvement in treatment (p. 32). Finally, this

study calls for further research into the use of modified CBT to treat youth with more severe OCD and/or

ASC symptoms than the subject of this case study (p. 33).

A study by Murray, Jassi, Mataix-Cols, Barrow & Krebs (2015) clearly outlines the research on

the treatment of OCD in individuals with ASC up to the date of publication, highlighting the fact that

while research is growing, there is a need for more to test the efficacy of CBT and ERP for treatment of

OCD in the ASC population of young people. This study sought to find evidence to prove the hypothesis

that CBT needed to be modified for youth with ASC and OCD in order for it to be effective. A group of

adolescents with ASC and OCD were compared to a group of adolescents with OCD and without ASC as

both groups went through group CBT treatment for OCD (p. 9). The study found a response rate of 46%

and a remission in the ASC+OCD group, which demonstrates that CBT could be an effective treatment

but might need modifications to increase efficacy. Possible reasons for the lower remission and response

rates outlined include compromised executive functioning, challenges with assessing, recognizing and

expressing their own emotions, and issues with problem solving, imagining of new ways of functioning

and generalization of skills. This study also suggests practical modifications to typical CBT delivery to

account for these ASC-related traits. Most importantly, this study sets up future research to create a CBT

protocol that is designed to implement with young people with ASC (as such a protocol is being developed

for adults with ASC). Limitations included the potential bias of the therapists completing the CY-BOCS,

as they were not blind to the study, the absence of a third control group, only 68% of participants had a

legitimate ADS diagnosis with a valid diagnostic tool, additional comorbidities in the OCD group were

not accounted for, parental involvement was not standardized, and multiple informants were not used (p.


After discovering more research was needed on how to modify CBT for an individual with ASC,

Krebs, Murray & Jassi (2016) carried out a case study with a 12-year-old boy who had previously failed

to respond to CBT treatment for his severe OCD. The purpose of this study was also to examine the

maintenance of skills up to 12 months after the completion of treatment (p.1163). In line with previous

research, this case study found that modifying CBT can indeed be an effective treatment for young people

with a co-morbid diagnosis ASC and OCD, and skills can be maintained at least up to twelve months post-

treatment (p. 1172). Until this case study, previous work had used modified CBT as the first attempt for

treatment. This made it unclear as to whether modifications were necessary or not. The subject of this

study had previously undergone treatment and it was not effective, so the efficacy of the modifications

could be tested (p.1163). Parents were present for all sessions. Psychoeducation was the initial focus of

the treatment sessions. An anxiety rating scale was created in relation to his special interest area, Dr. Who.

Each level on the rating scale was associated with how scared he would be of a specific character (p.


The subject’s parents were coached to use the same strategies and language as “co-therapists” (p.

1167). Sessions began in the clinic, but then shifted to the student’s home. Tasks were broken down into

very concrete steps, and lots of opportunity for repetition was implemented. The therapist also took a more

directive approach by encouraging the subject to “pause and notice” throughout the sessions. ERP tasks

were ecologically valid and directly connected to the treatment goals so the subject would meet with

reinforcement in the natural environment (e.g. go to park without hood on, got to play in the park (p.1167).

An agenda for family meetings was set with the focus of reviewing progress, looking at the reward chart,

and setting new goals. Finally, a detailed and concrete relapse prevention plan was designed for the family

to have more ERP tasks to work on should the subject relapse. This empowered the family by giving them

the tools needed to help their son and promoted generalization to the home from the clinic and into the

greater environment (p.1168).

Another significant component of this study was the involvement of the school. The therapist

communicated with the subject’s school support worker every two weeks, (p. 1168) and attended school

meetings. The purpose was to set realistic expectations, parse out OCD and ASC behaviours with the

school team, collaboratively decide how behaviours could best be addressed in the school context, provide

education about OCD and ASC, coordinate therapy goals and expectations (p. 1169), provide ASC-related

strategies (e.g. schedules, warning of changes etc.), and OCD/ASC combined strategies (e.g. enter and

exit room 5 minutes before and after other students (avoid touching, AND noise desensitization) (p. 1168).

This level of collaboration lead to success at school by reducing his anxiety about school and thereby

positively affecting his behaviours outside of school that were related to this anxiety. Scores on the

ChOCI-C and ChOCI-P decreased from severe to moderate, and severe to mild on the CY-BOCS. Gains

were maintained over twelve months, parents reported no significant accommodation occurring at home

(FAS report), the subject regularly attended school, and his family reported improved social functioning

and family life (p.1170). A limitation of this study includes the fact that his modified treatment happened

years after his initial treatment round. Therefore, it was not determined if he simply had matured, so was

more receptive to treatment, or if the changes were actually because of the modifications to treatment



OCD in ASC is a complex comborbid diagnosis, but research is building towards gaining a deeper

understanding of the factors at play between these two conditions. Furthermore, treatment options are

growing as more research into modified CBT is conducted.


APPENDIX A: Extended Summary of Literature

Study Reference Summary of Contribution Limitations

Sze & Wood, 2007 As one of the first studies to use modified The use of one subject limits
CBT for someone with ASC and OCD generalization to the general
(no intellectual disability), the findings of population.
this study opened the door to further
research on modifications of CBT for
individuals with this dual diagnosis, as it
was found to be effective (p. 133).
Lehmkuhl, 2008 A case study of a 12 year old boy with Single subject, child received early
autism was done to determine the if there intervention so ASC symptoms might
was any potential in CBT for treating be muted compared to those who have
young people with ASC and OCD/ not received early intervention to the
Positive results were found and the same extent, insufficient modifications
authors call for great studies (p. 977). were made to the CBT treatment plan
(p. 980-981).
Lang, et al. 2010 This systematic review looked at studies The studies used did not have treatment
that had modified CBT to treat fidelity, a control subject/group, and
individuals with ASC and anxiety inter-observer agreement (p. 61).
disorders. They found positive effects
from implementing behaviour analysis
strategies to meet the ASC-related needs
Rooney, Alfano, This case study used ERP and medication The parents of the child were strong
Walsh & Parr, to treat a 7-year-old boy with ASC and advocates with the school system and
2011 OCD. He was also treated for sleep also very keen to implement the
problems. They found his anxiety and strategies from treatment into their
compulsive behaviours were reduced and daily lives. This level of enthusiasm
his sleep challenges were mitigated (p. and means to advocate might not
133). generalize to the wider parent
population (p. 142).
Lewin, Wood, Comorbidity rates and patterns were A control group with ASC was not
Gunderson, studied between a group of youth with used, functional impairment was not
Murphy & Storch, OCD and ASC, and a control group of measured in great detail, and the
2011 youth with OCD only. Severity of sample size was small (70) (p.550).
symptoms was not higher in the
OCD+ASC group, however, other
commonalities with comorbidity with
other conditions was found (p. 543).
Vause, Hoekstra & This single-case experimental design There were only two subjects, the
Fedlman, 2014 study is quite significant to the body of clinician rating pre-and post-treatment
literature as it used modified CBT was not blind to the study, some
treatment and the only treatment for baseline data was missing, one
OCD, that is rated as probably behaviour showed variable rates from
efficacious (ABA, i.e. function-based baseline throughout the study.
strategies). The two subjects had ASC

and OCD, and it was found that their

OCD symptoms decreased after
treatment by clinically significant levels
(p. 30).
Wu, McGuire, This study sought to determine the The sample population was mostly
Arnold, Lewin, validity of the CY-BOCS. They found white and male, no self-report was
Murphy & Storch that, “overall, the CY-BOCS included for the youth, and not all
2014 demonstrated adequate psychometric psychometric properties of the test
properties and utility in assessing were assessed (p. 209).
obsessive-compulsive symptoms in
youth with ASC and clinically
significant obsessive-compulsive
symptoms” (Wu, McGuire, Arnold,
Lewin, Murphy & Storch, 2014, p. 1).

Meier, Peterson, This longitudinal study used census data Limitations of this study include a lack
Schendel, from two national registries in Denmark of generalization to milder forms of
Mattheisen, (p.2). The study included individuals OCD as these cases are under reported
Mortensen & born in Denmark between January 1, in the national registry (p. 9).
Mors, 2015 1955 and November 31, 2006, and their Furthermore, the lack of generalization
parents, which included 3,380,170 might also apply to those receiving a
individuals (p. 3). This group was diagnosis in adolescence or adulthood
followed from 1994 to 2012 (p.4). Their as some in this older population may
findings confirmed previous research, have been misdiagnosed earlier in life
and built on it by discovering a high (p.10).
correlation between the diagnosis of
OCD and ASC. Having a history of ASC
doubled one’s chance of a later OCD
diagnosis. The reverse is true in that those
with an OCD diagnosis were four times
more likely to later receive an ASC
diagnosis (p. 7). This study found
“considerable familial links between
these disorders” (p. 7). Overall, the
findings in this study were “suggestive of
partially shared etiological mechanisms
between these severe mental disorders”
(p.9). The authors also mention that
evidence from neuroimaging and
neurochemical studies are also pointing
at a shared pathophysiology of OCD and
ASC (p.9).
Colasanto 2016 This dissertation comes out of the This paper is a dissertation and would
(Dissertation) University of Toronto Medical Sciences lack the review and research rigour of a
Department. The author uses a wide controlled study. The author mentions
variety of assessment and diagnostic limitations included a lack of
tools to determine the scope of ASC and information on comorbidity, diagnoses,
OCD subtypes. Their findings included the use of a cross-sectional design

many subtypes found within OCD, ASC versus a longitudinal format, and the
and ASC/OCD comorbidity. (Colasanto, superficial nature of information on
2015, p. ii). repetitive behaviours (p. 72).
Nonetheless, this dissertation is an
important building block for future

APPENDIX B: Biopsychosocial Case Conceptualization (Winters, Hanson & Stoyanova, 2007, p.



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Winters, N. C., Hanson, G., & Stoyanova, V. (2007). The case formulation in child and adolescent
psychiatry. Child and Adolescent Psychiatric Clinics of North America, 16, 111-132.

Wu, M. S., McGuire, J. F., Arnold, E. B., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2014).
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