Understanding Obsessive-Compulsive Disorder in Neurodivergent Individuals

Obsessive-Compulsive Disorder (OCD) is a mental health condition marked by persistent, intrusive thoughts (obsessions) and repetitive behaviours (compulsions) performed to alleviate the distress caused by these thoughts. While OCD affects approximately 1-2% of the general population, its prevalence is notably higher among neurodivergent individuals, particularly those with Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD).

Prevalence of OCD in Neurodivergent Populations

Research indicates a significant overlap between OCD and other neurodevelopmental conditions. Studies suggest that up to 36% of individuals with ASD also experience OCD symptoms. Similarly, there is a notable co-occurrence of OCD and ADHD, with some studies reporting that individuals with ADHD are more likely to develop OCD than the general population. This intersection underscores the importance of recognizing and addressing OCD within neurodivergent communities.

Presentation of OCD in Neurodivergent Individuals

OCD manifests uniquely in neurodivergent individuals, often intertwining with characteristics of their primary neurodevelopmental conditions.

• In Autism Spectrum Disorder (ASD): Both ASD and OCD involve repetitive behaviours; however, the motivations differ. In OCD, repetitive actions are performed to mitigate anxiety from intrusive thoughts, whereas, in ASD, such behaviours may provide comfort or stem from intense interests. Distinguishing between OCD compulsions and autistic routines is crucial for accurate diagnosis and intervention.

• In Attention-Deficit/Hyperactivity Disorder (ADHD): Individuals with ADHD may exhibit behaviours that superficially resemble OCD compulsions, such as repeated checking due to inattentiveness. However, these actions in ADHD are typically linked to distractibility rather than anxiety relief. Recognizing these nuances is essential for effective treatment planning.

Challenges in Diagnosing OCD in Neurodivergent Individuals

The overlapping symptoms between OCD and other neurodevelopmental disorders can complicate diagnosis. For instance, distinguishing between an autistic individual's adherence to routines and an OCD-related compulsion requires careful assessment. Misinterpretation can lead to inadequate or even counterproductive interventions. Therefore, clinicians must employ comprehensive evaluations that consider the individual's neurodivergent profile.

The Positive Systems Approach: An Overview

Developed by Dr. Bob Carey and Terry Kirkpatrick, the Positive Systems Approach (PSA) is a framework designed to manage disruptive behaviours by integrating principles from applied behaviour analysis, systems theory, and strength-based practices. PSA emphasizes understanding the underlying causes of behaviours and implementing proactive strategies to foster positive change. It has been widely used for over 30 years in community agencies throughout Southwestern Ontario, providing formal training workshops and courses in PSA and Applied Behaviour Analysis to thousands of staff working in community settings as well as college students (see drbobcarey.com and book “Managing Disruptive Behaviours through a Positive Systems Approach” on Amazon). 

Applying PSA to Treat OCD in Neurodivergent Individuals

1. Functional Behaviour Assessment (FBA)

A Functional Behaviour Assessment (FBA) is a structured approach used to analyze and understand the root causes of an individual’s behaviours. In the context of OCD in neurodivergent individuals, FBA plays a crucial role in distinguishing compulsive behaviours from other repetitive behaviours commonly seen in conditions like Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD).

Steps in Conducting an FBA for OCD

1. Identify the Target Behaviour

   • Clearly define the compulsions (e.g., excessive hand-washing, checking locks, repeating phrases).

   • Observe the frequency, duration, and intensity of the behaviour.

2. Gather Data through Direct Observation

   • Observe the individual in different settings (home, school, community).

   • Identify patterns in compulsive behaviours—when they occur, how often, and in response to what triggers.

3. Conduct Interviews with Key Individuals

   • Speak with caregivers, teachers, therapists, and the individual (if possible) to understand their experiences.

   • Look for factors that might reinforce or maintain the compulsive behaviour.

4. Analyze Antecedents and Consequences

   • Identify what happens before (antecedents) and after (consequences) the compulsive behaviour.

   • Determine whether compulsions are reinforced (e.g., do they temporarily reduce anxiety? Do caregivers unknowingly enable them?).

5. Develop a Functional Hypothesis

   • Answer key questions:

     • What function does the compulsion serve for the individual?

     • Is it anxiety-driven, sensory-seeking, or related to rigid thinking patterns?

By understanding why the compulsion occurs, PSA can create more effective interventions that address the underlying cause rather than just suppressing behaviours.

2. Individualized Support Plans

Once the FBA has identified the function of the OCD-related behaviours, an Individualized Support Plan (ISP) is developed. This plan aligns interventions with the individual’s unique neurodevelopmental profile, strengths, and challenges.

Key Components of an ISP for OCD Treatment

1. Customization to the Individual's Strengths

   • If the individual is highly verbal, Cognitive Behavioural Therapy (CBT)-based self-talk strategies may be helpful.

   • If they rely on visual learning, visual schedules and social stories can be used to reinforce coping skills.

2. Personalized Coping Mechanisms

   • Develop alternative coping strategies to replace compulsions (e.g., if a child compulsively washes hands due to contamination fears, they might learn to use a sensory object to reduce anxiety instead).

   • Use gradual exposure therapy tailored to the person’s comfort level.

3. Structured Routine Adjustments

   • People with ASD often thrive on routine, which can make sudden changes distressing.

   • The ISP ensures that new interventions are integrated gradually into their daily life.

4. Flexibility & Ongoing Adjustments

   • The support plan is not static—it evolves based on what works and what doesn’t.

   • Regular check-ins with caregivers, teachers, and therapists ensure continuous optimization.

3. Environmental Modifications

OCD behaviours are often triggered or reinforced by environmental factors. Adjusting the individual's surroundings can reduce the likelihood of compulsions and create a supportive setting for new behaviours.

Types of Environmental Modifications

1. Reducing Anxiety Triggers

   • If an individual’s OCD involves contamination fears, modifications might include:

     • Using unscented or hypoallergenic soap to reduce distress.

     • Gradually introducing mild messiness to build tolerance.

2. Creating a Predictable, Supportive Environment

   • Using visual schedules and clear expectations helps neurodivergent individuals feel more in control, reducing anxiety-driven compulsions.

3. Sensory Considerations

   • Many autistic individuals have sensory sensitivities that influence OCD behaviours.

   • If compulsions are sensory-driven (e.g., hand-washing for the feel of water):

     • Replace the compulsion with a sensory-friendly alternative, like a stress ball or textured object.

4. Minimizing Reinforcement of Compulsions

   • Caregivers and educators need to avoid inadvertently reinforcing compulsions.

   • Example: If a child insists that a teacher repeat instructions exactly five times to feel “right,” the teacher might respond by:

     • Acknowledging the discomfort.

     • Encouraging coping strategies rather than complying with the compulsion.

4. Skill Development

Since OCD behaviours often serve a function (reducing anxiety, providing sensory stimulation, reinforcing a need for symmetry/control), simply removing them without teaching alternative skills can lead to distress or new compulsions. PSA focuses on teaching replacement behaviours that serve the same function but in a more adaptive way.

Key Skill-Building Strategies

1. Cognitive Restructuring

   • Teaching self-talk techniques to challenge obsessive thoughts.

   • Example: If a person believes, “If I don’t tap my desk three times, something bad will happen,” they learn to reframe this as, “This is my OCD making me think that, but I am safe.”

2. Gradual Exposure Therapy (GET)

   • Breaking down feared situations into small, manageable steps.

   • Example: If an individual compulsively washes hands:

     • Step 1: Touching a clean object and waiting five seconds before washing.

     • Step 2: Increasing the waiting period to ten seconds.

     • Step 3: Touching something slightly outside their comfort zone (e.g., a doorknob).

     • Final goal: Reducing excessive hand-washing without distress.

3. Mindfulness and Sensory Strategies

   • Breathing exercises, progressive muscle relaxation, and fidget tools can help reduce anxiety and sensory discomfort.

   • Example: If a child taps objects repeatedly for sensory input, they might use a textured worry stone instead.

4. Social-Emotional Learning (SEL) and Emotional Regulation

   • Teaching emotional literacy helps individuals identify, express, and manage anxiety without compulsions.

   • Example: Instead of using a repetitive behaviour to cope, they might:

     • Express how they’re feeling through a visual emotion chart.

     • Use a coping card with reminders like “Take a deep breath,” “Count to five,” or “Ask for help.”

5. Collaborative Team Approach

PSA emphasizes a team-based approach, ensuring that interventions are consistent across home, school, therapy, and social settings.

Key Team Members & Their Roles

1. Family & Caregivers

   • Provide emotional support and reinforce intervention strategies at home.

   • Ensure consistency in responses to compulsive behaviours.

2. Educators & School Support Staff

   • Adapt classroom environments to minimize OCD triggers.

   • Use visual supports and structured routines to reduce anxiety.

   • Implement accommodations such as extra transition time or quiet spaces.

3. Therapists & Behavioural Specialists

   • Guide exposure therapy and cognitive restructuring techniques.

   • Train caregivers and educators on how to respond to OCD behaviours effectively.

4. Peers & Social Supports

   • Teaching neurodivergent individuals how to communicate their needs.

   • Encouraging inclusion and reducing stigma around OCD behaviours.

5. Medical & Psychiatric Professionals

   • In some cases, medication (SSRIs) may be needed in combination with behavioural interventions.

   • Regular check-ins ensure the right balance between therapy and medical support.

Case Study: Applying the Positive Systems Approach (PSA) to Treat OCD in a Neurodivergent Individual

Background: Emma is a 16-year-old diagnosed with Autism Spectrum Disorder (ASD) and Obsessive-Compulsive Disorder (OCD). She exhibits compulsive hand-washing rituals, often washing her hands for up to 30 minutes at a time, repeating the process multiple times a day. Emma’s anxiety spikes if she cannot wash her hands after touching objects she perceives as ‘contaminated,’ such as door handles or books that others have touched. Her compulsions have led to skin damage, avoidance of school activities, and significant distress for both her and her family.

Her family has attempted multiple interventions, including asking her to stop, providing gloves, and implementing a strict hand-washing schedule. However, these strategies have either increased her distress or reinforced her compulsive behaviour.

Step 1: Functional Behaviour Assessment (FBA)

A comprehensive Functional Behaviour Assessment (FBA) was conducted to determine the root cause of Emma’s compulsive behaviour.

• Triggers (Antecedents):

  • Touching objects perceived as ‘unclean’ (e.g., books, desks, doorknobs).

  • Eating food prepared by someone else.

  • Feeling an increase in general anxiety, unrelated to contamination.

• Behaviour:

  • Immediate compulsion to wash hands, sometimes multiple times in a row.

  • Verbal distress (“I feel dirty,” “I have germs on me”).

• Consequences:

  • Temporary relief after washing hands.

  • Avoidance of certain situations (e.g., refusing to participate in group activities involving shared materials).

  • Family members inadvertently reinforcing the behaviour by allowing her to wash repeatedly to prevent distress.

The FBA determined that Emma’s compulsions were driven by anxiety reduction and sensory sensitivities rather than a need for control or perfection.

Step 2: Developing an Individualized Support Plan (ISP)

Based on the findings of the FBA, a tailored Individualized Support Plan (ISP) was created. The plan focused on:

1. Gradual exposure therapy to reduce anxiety around ‘contaminated’ objects.

2. Replacing compulsions with alternative coping strategies to manage anxiety.

3. Incorporating sensory-friendly solutions to address tactile discomfort.

4. Providing structured support from caregivers and educators to maintain consistency.

Step 3: Environmental Modifications

Emma’s environment was adjusted to minimize unnecessary distress while encouraging gradual exposure to triggers:

• Modified Classroom Setup:

  • Teachers provided Emma with a personal desk and designated hand-washing times to reduce excessive interruptions.

  • She was given a visual schedule with hand-washing as a structured part of the day rather than an impulsive reaction.

• Home Adjustments:

  • Family members were trained to respond consistently to Emma’s distress without reinforcing compulsive washing (e.g., by offering reassurance instead of allowing immediate washing).

  • A small comfort kit was introduced, including sanitizing wipes and a sensory-friendly fidget tool to replace compulsive behaviours.

Step 4: Skill Development

Emma was taught alternative strategies to manage anxiety and reduce compulsive behaviours:

1. Cognitive Restructuring:

   • Emma practiced identifying and challenging irrational thoughts (e.g., “Not all germs are harmful”).

   • A therapist guided her through thought reframing exercises (e.g., “Even if my hands feel dirty, I am still safe”).

2. Gradual Exposure Therapy:

   • Week 1: Touching a ‘clean’ object (e.g., a book from home) and delaying hand-washing for 1 minute.

   • Week 2: Touching a schoolbook and delaying washing for 3 minutes.

   • Week 3: Using a public doorknob and waiting 5 minutes before washing.

   • Final Goal: Participating in activities without immediate compulsion to wash hands.

3. Mindfulness and Sensory Strategies:

   • Practiced deep breathing and progressive muscle relaxation to reduce anxiety.

   • Used alternative sensory experiences (e.g., textured stress ball) to provide comfort when resisting compulsions.

Step 5: Collaborative Team Approach

A collaborative approach ensured that interventions remained consistent across different settings:

• Family Role:

  • Emma’s parents participated in training sessions on how to reinforce coping strategies at home.

  • They used praise and reinforcement when Emma successfully delayed or reduced hand-washing.

• School Support:

  • Teachers provided predictable routines and reinforced coping skills in class.

  • A school counselor worked with Emma on a weekly progress plan, adjusting goals as needed.

• Therapist Involvement:

  • A behaviour specialist monitored Emma’s progress and adjusted exposure therapy levels accordingly.

  • Regular therapy sessions focused on anxiety management techniques.

Outcome: Measurable Progress Over Six Months

• Emma successfully reduced her hand-washing time from 30 minutes to 5 minutes per instance.

• She was able to delay washing after touching an object from immediate response to a 10-minute delay.

• Anxiety levels decreased significantly, as measured by self-reports and therapist assessments.

• She participated in classroom activities without distress, engaging more socially with peers.

• Her family reported lower stress levels and improved interactions at home.

Conclusion

Emma’s case demonstrates how the Positive Systems Approach (PSA) provides a structured, individualized, and compassionate way to address OCD in neurodivergent individuals. By combining functional assessment, environmental modifications, skill development, and collaborative support, PSA not only reduced compulsive behaviours but also empowered Emma to develop long-term coping skills for managing anxiety.

This case highlights the importance of holistic, strength-based approaches in treating OCD within neurodivergent populations, ensuring that interventions are effective, sustainable, and respectful of the individual’s needs.

Final Thoughts

The Positive Systems Approach (PSA) provides a comprehensive, individualized, and strength-based framework for treating OCD in neurodivergent individuals. Unlike traditional interventions that focus solely on reducing compulsions, PSA empowers individuals by addressing the root causes, building coping skills, modifying environments, and ensuring a collaborative support system.

By understanding the function of OCD behaviours and introducing adaptive strategies, PSA helps neurodivergent individuals achieve meaningful, lasting improvements in their quality of life—while respecting their unique strengths and challenges.