The signs of autism and obsessive-compulsive disorder (OCD) may sometimes look similar. Both can involve repetitive behaviors and routines, along with a strong need for things to happen a certain way. The difference comes down to the reason behind those behaviors.
My autistic daughter has to take a shower every night at the same time. If a change in routine interferes, she becomes stressed and emotional. A child with OCD may also have similar rituals.
As parents, their similarities may make it difficult for us to tell whether behavior is part of our child's autism or a possible sign of OCD. It's further complicated when autistic people are also diagnosed with OCD.
Knowing what's driving repetitive behavior helps you figure out when your child may need additional support. Here's what parents should know about the connection between autism and OCD, how to recognize possible compulsions, and what treatment can look like when a child has both conditions.
Key Takeaways
- Autism and OCD can both involve repetitive behaviors, but understanding what drives the behavior can help distinguish between them.
- Autistic children can also have OCD, and symptoms may be harder to recognize because the two conditions can overlap.
- OCD-specific treatment, particularly exposure and response prevention (ERP), can be adapted to meet the needs of autistic children. If your autistic child needs ABA therapy, you can get started with Alpaca Health.
What is the connection between OCD and autism?
Autism and OCD are different conditions, but they can share certain features in the same child. Children can be diagnosed with both or either one.
Restricted and repetitive behaviors are a core feature of autism. An autistic child may repeat movements, follow the same routines, have highly focused interests or prefer things always to happen in predictable ways. These behaviors serve different purposes, like providing enjoyment, predictability, or sensory regulation.
OCD can involve obsessions, compulsions, or both. Obsessions are recurring unwanted thoughts or images that can cause distress. Compulsions are repetitive behaviors or thoughts that a person feels driven to perform often in response to an obsession or according to rigid rules.
At this point, the conditions can become difficult to distinguish. A child who repeatedly checks the door, follows an exact bedtime routine, arranges objects in a particular order, or becomes upset when something changes can appear to have similar behaviors. But what drives a behavior and how the child experiences it provides key clues.
The distinction matters. An autistic repetitive behavior isn’t automatically an OCD compulsion. When OCD is also present in a child, they may need treatment specifically targeting OCD in addition to the support they receive for autism.
If you're concerned about your child's behaviors or development, Alpaca Health offers free autism screeners and insurance-covered evaluations, as well as ABA therapy.
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How often OCD and autism occur together
OCD is more commonly seen among autistic children and adolescents than among children overall. A 2024 systematic review and meta-analysis found that about 11.6% of autistic children and adolescents also had a diagnosis of OCD. Researchers also found the relationship went both ways, with about 9.5% of children and adolescents with OCD also having autism.
Both conditions may affect how symptoms appear and how much they interfere with daily life. Some research suggested children with both autism and OCD can experience greater functional impairment than children with OCD alone.
These numbers don't mean that repetitive behaviors in an autistic child are likely to be OCD. Repetitive behaviors are already a core characteristic of autism. Instead, the data tells us why it's important to consider the possibility of a separate OCD diagnosis when new behaviors are accompanied by significant distress or begin interfering with your child's everyday life.
Compulsions or repetitive behaviors: how to tell them apart
An OCD compulsion and an autistic repetitive behavior can look almost identical. A child can arrange toys in a particular order, repeat the same phrase or follow an exact routine a number of times.
But the behavior doesn't always tell us what's causing it. Understanding the reason for the behavior and your child's experience of it may provide more useful clues.
What drives the behavior
OCD compulsions are a response to an unwanted thought, fear, urge, or feeling. A child may feel that they have to perform the behavior to reduce distress or prevent something bad from happening.
For example, a child who is scared of germs may repeatedly wash their hands. Another child may repeatedly check something because they fear something bad will happen if they don't.
Autistic repetitive behaviors serve different functions. A familiar movement or routine may provide predictability, enjoyment, sensory input, or help with self-regulation. It doesn't necessarily occur because a child believes they must perform the behavior to prevent a feared outcome.
Unfortunately, this distinction isn't always obvious. Autistic children may have difficulty identifying or explaining why they're doing something. Anxiety and sensory experiences also play a role, and repetitive behaviors occur in both autism and OCD.
How your child feels during and afterward
Another hint may be how your child experiences the behavior.
OCD compulsions are often associated with anxiety or distress. Performing the compulsion may temporarily reduce the distress, but the relief doesn't last. The obsession or urge often returns, leading the child to perform the compulsion again.
On the other hand, some autistic repetitive behaviors are enjoyable, calming, or regulating. Your child may actively want to engage in the behavior rather than feeling forced to do it by an unwanted thought or fear.
But this isn't a perfect test. Autistic children can become distressed around the routines, while a child with OCD may not be able to describe the thoughts or feelings behind a compulsion. Clinicians therefore look at the overall pattern rather than rely on whether a behavior is enjoyable or upsetting.
What happens when the behavior is interrupted
Observe what happens when your child can't complete the behavior or routine.
A child with OCD may experience significant anxiety or fear if they're unable to complete a compulsion. They may feel that something bad is going to happen or that something is incomplete or “not right.”
An autistic child can also become very upset when a repetitive behavior or routine is interrupted. That distress can come from unexpected change, sensory dysregulation, loss of predictability or being unable to complete something that helps them regulate.
Both situations can cause distress. So your child's reaction alone can't diagnose OCD. The bigger question is what appears to be driving the behavior and what function it serves.
What OCD looks like in an autistic child
OCD may look different from one child to another. Recognizing OCD in an autistic child is especially challenging because some symptoms may resemble repetitive behaviors or routines that are actually part of their autism.
OCD may involve fears about contamination, harm, mistakes, or something bad happening. A child may check doors or objects, ask the same reassurance-seeking questions, count or arrange things until they feel just right. Compulsions can also be mental, such as silently counting, repeating words or reviewing something over and over in their mind.
Instead of focusing on what the behavior looks like, pay more attention to whether something has changed. A new repetitive behavior, increasing anxiety, rituals that take up a significant amount of time, or behaviors that interfere with school, sleep, family activities, or other parts of daily life may be worth discussing with your child's healthcare provider.
Why OCD gets missed in autistic children
OCD can be overlooked in autistic children because the two conditions have overlapping features. A new compulsion may initially look like another repetitive behavior, special interest or preference for sameness associated with autism. Research has found considerable overlap in the expression and content of repetitive behaviors between autism and OCD.
A child may also find it difficult to explain what's happening internally. For example, a parent may see repeated checking but not know that the child is doing it because of an intrusive fear. So some children may also have difficulty identifying or even describing the distress associated with the behavior.
This is one reason changes from your child's usual patterns are important. If a behavior becomes increasingly time-consuming or distressing or begins interfering with everyday activities, it may deserve a closer look rather than automatically being attributed to autism.
How OCD is diagnosed alongside autism
Healthcare professionals don't look for one behavior or test to tell them whether an autistic child has OCD. The diagnosis involves looking at the overall pattern of symptoms and trying to understand what's driving the behaviors.
A clinician may ask you about your child's obsessions, compulsions, anxiety, routines, and how much the behaviors interfere with everyday life. They may also want to know when you first saw the behaviors and what happens when your child tries to resist or is prevented from completing them.
Standardized tools may also be a part of an OCD assessment. One commonly used clinician-rated tool for children is the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). The tool helps assess OCD symptom severity.
Clinicians also need to consider whether behavior is better explained by autism, OCD, or a combination of both. That may require looking beyond the behavior itself to understand its function and your child's experience of it.
If you're concerned about OCD, look for a clinician who's experienced in evaluating OCD in children and understands how symptoms can overlap with autism.
What treatment looks like when a child has both
Treatment must be tailored to your child's OCD while also taking their autism-related needs into account. Cognitive behavioral therapy (CBT), which includes exposure and response prevention (ERP), is the leading treatment for pediatric OCD.
Exposure and response prevention
During ERP, a child gradually faces situations, thoughts or triggers that may bring on OCD-related distress while learning not to perform the compulsion they would normally use to reduce that distress. Treatment is gradual and guided by a trained therapist, instead of forcing a child to stop a behavior.
Adapting therapy for an autistic child
A therapist may need to adapt therapy to meet the needs of an autistic child. It should be based on their communication, sensory, developmental, and learning needs. It's also important for the therapist to distinguish OCD compulsions from autism-related behaviors. That allows treatment to target the OCD instead of trying to eliminate behavior simply because it's repetitive.
When medication is considered
Medication may also be recommended for some children, particularly when OCD symptoms are moderate to severe or significantly interfering with everyday life.
Serotonin reuptake inhibitors, including SSRIs, are commonly used to treat pediatric OCD and are often combined with ERP. Any medication decision should be individualized and discussed with a clinician experienced in treating OCD in children.
How ABA therapy and OCD treatment fit together
ABA therapy and OCD treatment may both be a part of an autistic child's care. The difference is that they don't serve the same purpose. ABA may address skills and behaviors related to your child's individual autism-related needs, while OCD requires treatment specifically designed to address obsessions and compulsions.
ERP is an established treatment for OCD. If your child receives both ABA and OCD treatment, communication among providers can help ensure everyone understands which behaviors are being addressed and why.
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What parents can do at home
At home, start observing patterns rather than trying to diagnose a behavior yourself. Notice when it happens, what occurred beforehand and how your child reacts if they can't complete it. You also want to see whether the behavior is becoming more distressing or time-consuming.
If your child is receiving OCD treatment, ask their therapist how you can support the treatment plan at home. Avoid abruptly stopping rituals or forcing exposures on your own. Plan ERP with a qualified professional.
When to ask for an OCD evaluation
Consider speaking with your child's healthcare provider if you notice repetitive behaviors are new, increasingly distressing, time-consuming, or interfering with school, sleep, relationships and everyday activities.
You may also ask for an evaluation if your child describes unwanted thoughts or fears or seems to be driven to perform rituals to prevent something bad from happening. A clinician experienced with both autism and OCD can help determine what's behind the behavior.
How Alpaca Health helps families with autism and OCD
Alpaca Health provides individualized ABA therapy for autistic children through independent BCBAs in Texas, Colorado, North Carolina, Hawaii, and Michigan. Alpaca Health does not provide OCD treatment. If your child also has OCD, their care may involve additional mental health professionals who can provide OCD-specific treatment.
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Frequently asked questions about autism and OCD
Can a child have both autism and OCD?
Yes. Autism and OCD are separate conditions, but a child can have both. Research suggests OCD occurs more frequently among autistic children and adolescents than among children overall.
How do you tell OCD apart from autistic repetitive behaviors?
The behaviors of OCD and autism can look similar. Consider what seems to drive the behavior, how your child experiences it, and what happens when it's interrupted. There can be significant overlap. An experienced clinician with autism and OCD can help determine what's behind the behavior.
Does ABA therapy treat OCD?
ABA therapy and OCD treatment serve different purposes. The primary treatment for OCD is cognitive behavioral therapy that includes exposure and response prevention. An autistic child with OCD may need OCD-specific treatment in addition to support for their autism.
What kind of therapist treats OCD in autistic children?
Look for a licensed mental health professional with experience treating pediatric OCD using ERP who also understands autism. This can help ensure the OCD compulsions are appropriately identified without automatically treating autism-related repetitive behaviors as OCD.
If your child also needs ABA therapy, Alpaca Health can help by verifying your insurance and matching your family with a BCBA.
