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Restricted Repetitive Behaviors in Autism Spectrum and Obsessive-Compulsive Disorders
Abstract
The prevalence of neurodevelopmental disorders has been on the increase in the United States and the world as a whole. Autism Spectrum Disorder (ASD) and Obsessive-Compulsive Disorder (OSD) are examples of such neurodevelopmental disorders. ASD and OCD are similar in that they share some of their common characteristics. Restricted Repetitive Behaviors (RRBs) refer to a broad category of behaviors observed across many neurodevelopmental disorders. These behaviors fall into various categories. Some of these categories include sensory-motor movements, rituals, and stereotypic constrained interests. In other words, RRBs refer to the responses whose main characteristics include recurrence and inflexibility in their normal routine. In line with RRBs in ASD and OCD, this paper intends to review the article “Similarities and differences between children and adolescents with autism spectrum disorder and those with obsessive-compulsive disorder: executive functioning and repetitive behavior.” The main purpose of the article is to examine the differences between the Repetitive Behaviors in Autism Spectrum Disorder and Obsessive-Compulsive Disorder and their implications on the treatment of the conditions.
Article Summary
The article “Similarities and differences between children and adolescents with autism spectrum disorder and those with the obsessive-compulsive disorder: executive functioning and repetitive behavior” was written by Zandt et al.

, and was published by the Autism journal in 2009. The article studies the neurocognitive process in repetitive behavior observed in children, adolescents, and adults. The study achieves this by examining a comparison of a range of executive functions (EF) measures on clinically diagnosed individuals with Autism Spectrum Disorder (ASD) and Obsessive-Compulsive Disorder (OCD).
According to Zandt et al., Restricted Repetitive Behaviors (RRBs) are the core characteristics common to both ASD and OCD (43). However, the authors also affirm that these behaviors may be apparent in normally developing individuals and can also signify other neurodevelopmental disorders (Zandt et al. 43). Nevertheless, the study described in the article primarily focuses on comparing RRBs as observed in ASD and OCD patients.
The study was conducted on 54 children and teenagers who were divided into various groups. One group included the children with OCD, the other group consisted of children with ASD, and the third group had normally developing children to serve as a control group. The participants were aged between seven and sixteen years. To gain a complete understanding of these children, their parents were asked to complete an information sheet that contained details such as the child’s diagnosis, current medication for the diagnosis, comorbid psychological and neuropsychological status and the family mental health history (Zandt et al. 47).
Further, the children’s intelligence was measured as Verbal and Performance Intelligence. The use of WISC-II covered other aspects of intelligence I model (Mayes et al. 330) to test for vocabularies, block design and coding-subtests (Zandt et al. 47). Other measurements included the executive function measures which were conducted through a number of tests such as the Walk, Don’t Walk Task, the Verbal Fluency and the child version of the concept-generation task. Finally, the repetitive behavior measurements were conducted with the help of the Repetitive Behavior Questionnaire (Zandt et al. 48).
After conducting these studies, the authors observed a number of points. First, that the participants belonging to the ASD and OCD groups did not differ with the normally developing group of corresponding age intelligence on most of the tasks involving executive functioning (Zandt et al. 53). Secondly, children with ASD tended to demonstrated difficulties when they attempted to complete those tasks that required the generation of multiple responses (Zandt et al. 53). Similarly, a different study showed that adults with ASD demonstrated an impaired response to questions that needed multiple responses (Ambery 551). Another observation showed a connection between executive functioning and repetitive behavior (Zandt et al. 53).
Moreover, the authors observed that children with Autism Spectrum Disorders showed poor performance in Verbal Fluency and the child version of the Concept Generation Task (53) in comparison with children with OCD. It should be noted that both of these tasks require intensive thinking and the generation of multiple concepts. This is consistent with Ambery’s observation concerning multiple answer generation in adults with ASD. According to the authors, they attempted to establish a link between the parent’s rating of the participants’ executive functioning. The authors were able to relate greater functional impairment with the parents’ rating of the children’s executive functioning for ASD and normally developing children groups and not the OCD group. The reports by the participants’ parents also showed greater variance in restricted, repetitive behavior for the children with Autism Spectrum Disorders in compared with the children with Obsessive Compulsive Disorder.
Epidemiology of Restricted Repetitive Behaviors
Restricted, Repetitive Behaviors refer to a broad category of characteristics observed across many neurodevelopmental disorders. However, RRBs are primarily present in Autism Spectrum Disorder (ASD) and Obsessive-Compulsive Disorder (OCD) patients (Zandt et al. 43). These behaviors fall into various categories. Some of these categories include sensory-motor movements, rituals and stereotypic constrained interests (Kim and Lord 163). In other words, RRBs refer to the responses whose main characteristics include recurrence and inflexibility in their normal routine.
RRBs in Autism Spectrum Disorder
RRBs are among the core characteristics used in the diagnosis of ASD. There are a number of common RRBs observed in ASD. They include repetitive manipulation of objects, repetitive motor movements and extreme preference for the status quo (Lewis and Kim 114). Children with ASD are uncomfortable with the changes to their normal routine (Reaven et al. 39). However, RRBs have been linked to other brain development disorders. Some of these disorders include Fragile X and Prader-Willie Syndromes (Lewis and Kim 115). However, Zandt et al. note that RRBs are most commonly found in ASD and OCD (43). They further claim that doctors and therapists sometimes make mistakes in the diagnosis of the two disorders because of the similarity of these Restrictive Repetitive Behaviors (Zandt et al. 44).
RRBs in Obsessive Compulsive Disorder
Obsessive Compulsive Disorder (OCD) refers to a condition whereby an individual has obsessions particularly in the form of disturbing thoughts or pictures which lead to increased anxiety and uneasiness (Stein 397). Consequently, the individual responds in a certain repetitive or ritual manner so as to decrease his or her anxiety (Stein 397). These responses are referred to as compulsions. According to the American Psychiatric Association’s DSM-IV, these compulsive behaviors include physically observable responses to these thoughts or unobservable mental rituals. These obsessions and compulsions consume significant amounts of time, thus leading to functional impairment in the individuals.
Essentially, OCD obsessions are in the form of unwanted thoughts that make the individual afraid, uncomfortable or uneasy. Consequently, the individuals have constant heightened anxiety which they relieve by the aforementioned compulsive responses. Some of these obsessions include fear of germs, losing favorite belongings or insecurity about completing a given task (Stein 397). As a result, OCD patients resort to compulsive activities such as excessively washing of the hands and cleaning surfaces.
According to Markarian et al., research has shown that OCD is number four among common mental disorders in children and adults (79). Topping the list include phobias, substance abuse, and depressions. Despite this, relatively little information about OCD is available. The heterogeneity of the obsessions and compulsions is among the main reasons for the insufficient and inconsistent information concerning this disorder (Zandt et al. 50).
Comparison of RRBs in ASD and OCD
According to Zandt et al., the main purpose of the article is to highlight some of the differences in the RRBs as exhibited by ASD and OCD patients (43). Other researchers have also made progress in their studies with an aim to understand these differences and better ways to differentiate the two. People with ASD and OCD exhibit restricted interests, obsessions and repetitive compulsions, which may appear similar at first. The intrusive nature of RRBs in both OCD and ASD results in a social and communication impairment, which is a reason behind the similarities. Initially, this brought confusion in the diagnosis of the two until the American Psychiatric Association (APA) gave a clear definition to differentiate OCD from ASD.
From a detailed perspective, however, the executive function capability of ASD and OCD patients becomes apparent. For instance, Zandt et al. study individuals aged between seven and sixteen years to compare their executive function (EF) measures determined that children with ASD experience more difficulty in solving problems upon set-shifting in comparison with the children in the control group (43). Further, children with ASD performed poorly on tasks that required verbal fluency and the concept of the Generation Task (Zandt et al. 53). The study further revealed that children with ASD performed poorly in tasks that required multiple responses (Zandt et al. 53).
Conversely, the study revealed that children with OCD had impaired inhibition as a comparison with their ASD counterparts (Zandt et al. 53). However, compared with adults who have OCD, the children were reported to be less notably impaired than the adults (Zandt et al. 54). However, Zandt et al. observe that in the study, parents reported developmental dysfunctions in both ASD and OCD children in comparison with other typically developing children. However, Cath et al. argue that the phenomenological overlap observed across ASD and OCD could, in fact, signify a symptomatic overlap (108). In the study, Cath et al., determine that although there are fundamental differences between the two conditions, subsequent should put more emphasis on a more collective understanding of the neuropsychological and neurobiological aspects of these conditions in an intention of determining the best treatment approach (109).
Drug-Induced RRBs
Most of the available information about the neurobiological aspect of RRBs is as a result of experiments that use drugs to induce stereotyped behavior in animals (Langen et al. 341). Animals have been used for the study of repetitive behavior since the early 20th Century. Originally, these studies were based on the basal ganglia, which was the main candidate for studying these behaviors (Langen et al. 341). In 1920, studies determined that the striatum was directly linked to studies based on drug-induced repetitive behavior on guinea pigs (Langen et al. 341; Singer 78). Subsequent studies have determined that damage to the basal ganglia is directly responsible for the recurrent responses (Langen et al. 341).
The most commonly used drugs to induce repetitive behaviors include amphetamine and apomorphine (Bechard and Lewis 3). Further, the bi-directional approach by using selective pharmacological drugs showed that the cortical-basal ganglia makes significant contribution in repetitive behavior (Schmidt 71). Another experiment has determined that stereotypy induced by amphetamine can be increased through the intracortical introduction of the D2 or GABA antagonists. Conversely, the stereotype can be weakened by the administration of DA or GABAergic agonists.
Cognitive Aspect of RRBs
For years, research conducted on the neurocognitive impact of RRBs in ASD has determined that their general executive dysfunction, relatively little information is available concerning the exact impact of these changes on specific executive functions. some studies have been conducted with the intention of acquiring sufficient knowledge on the cognitive aspects of RRBs. According to Lewis and Kim, much of these studies suggest that RRBs cause significant impairment in an individual’s cognitive flexibility (116). Other effects include set-shifting and the inhibition of prepotent responses to various environmental and behavioral factors (Lewis and Kim 116).
Additionally, studies have shown that ASD patients and exhibiting RRBs have the capability of learning new rules and responding appropriately in relation to these rules. Nevertheless, these individuals are extremely uncomfortable in the application of new rules or responses as it is way out of the comfort zone to which they were used (Lewis and Kim 116). For this reason, they insisted on sameness in the conditions around them or behavior as opposed to shifts in negative sensory motor responses. It is worth noting that studies have linked these deficits to the RRBs aspect of ASD and not the social or communication difficulties.
Further, another study showed that tasks of executive functions such as set-shifting and the inhibition or suppression of motor response are directly linked to the frequency of compulsive behaviours characteristically in growing children with ASD (Lewis and Kim 114). Similarly, Evans et al., have associated a wide range of cognitive deficits with adult-onset OCD (223). Moreover, just like in ASD, RRBs in OCD have been associated with dysfunctional executive capabilities (223). In these patients, executive functions such as impulse control, planning, sustained attention and working memory are affected by these conditions (Evans et al. 223).
RRBs as an Attempt to Reduce Stress
Numerous studies attempting to explain the psychological aspect of RRBs have hypothesised that RRBs are a form of stress relieving mechanism (Leekam et al. 563). For instance, individuals with Obsessive Compulsive Disorders engage themselves in repetitive behaviours in an attempt to reduce the high anxiety built by the obsessions (Stein 397). Similarly, people with ASD tend to relieve their anxiety through motor movements such as twirling of hair, flapping in hand or rocking. The success of these behaviours in calming down the patients contributes to their reinforcement until they become RRBs (Buffer et al. 18).
Explanation Models of RRBs
Neurobiology Aspect of RRBs
A number of neurobiological systems have been linked with repetitive behaviours in studies involving animals and humans (Amaral et al. 137). Originally, scientists had suspected the basal ganglia as the main cause for repetitive behaviour (Estes et al. 214). Further studies determined linked the striatum directly to the drug-induced repetitive behaviour observed in (Langen et al. 341; Singer 78). Subsequent studies have determined that damage to the basal ganglia is directly responsible for the recurrent responses (Langen et al. 341). Volmer et al. also suggest that underdeveloped connections of the thalamus to the cortical and subcortical brain regions are another cause for repetitive behaviour in ASD (498).
Neuro-Imaging Research
Recent studies on Restricted Repetitive Behaviors have incorporated the use of brain imaging to understand the activities of various regions in relation with the occurrence of RRBs. These studies have made a significant contribution to the understanding the correlation between various neural networks and RRBs, the discrepancies of the results in each study have made it difficult to integrate (Traynor and Hall 21).
According to Oberman et al., many researchers are conducting studies intended to understand the activities in given regions of the brain and repetitive behaviours (526). Transcranial Magnetic Stimulation refers to the application of a non-invasive device to induce a fast and fluctuating magnetic field to the brain in the shortest time possible (Oberman et al. 526). Consequently, the fluctuating magnetic field induces an electric current in the whole neural network in a short time. The stimulation of electrical current in the brain is useful in the imaging of brain activity for ASD patients (Oberman et al. 526) and stimulating various parts of the brain that show signs of low development rates (527).
Treatment of RRBs
Some of the Restricted Repetitive Behaviors may get worse with age as the ASD or OCD progresses. For instance, in OCD, some compulsives may comprise of self-harming tendencies such as pulling one’s hair or banging on the head against certain objects. For these reasons, treatment of the RRBs become necessary. Although the article by Zandt et al. are meant to understand the differences in RRBs between ASD and OCD, they do not cover the treatment options for either condition.
a Medications used in for treating RRBs
Numerous medication approaches have been experimented in the treatment of RRBs in both ASD and OCD. For instance, McArthur advocates for the use of Selective Serotonin Reuptake Inhibitors (SSRIs) such as fluoxetine and fluvoxamine for treating ASD RRBs because of the success it has had in OSD treatment (361). However, Williams et al. point out the safety guidelines put forth by the Food and Drug Administration about the rise in risk of suicide-related behaviours that have been associated with the use of these drugs (3). Despite the possible side effects, Reaven and Hepburn state that the use of SSRIs has shown promising results (147).
Electrical Stimulation
Electrical stimulations (Neuro-stimulation) refers to the application of controlled amounts of electric current to the brain matter for the treatment of neurodevelopmental disorders such as ASD and OCD. This method of treatment is applicable when patients continue to be symptomatic even after pharmacological treatment. Zandt et al. do not mention some of these treatment approaches and the ones suited for each of the disorders depending on their findings.
The oldest method of neuro-stimulation is Electroconvulsive therapy. It was used to produce seizures in the brain by stimulating it with an electric current. The therapeutic effects of this method were proven to be successful at the time of its invention (Kar and Sarkar 330). Today, the technological advancement has made it possible for this method of treatment to be made more effective, efficient and safe (Kar and Sarkar 330).
Behavioral Therapy
According to Neil and Sturmey, studies intended to systematically treat restricted repetitive behaviours such as hoarding, repetitive questioning and constant checking of structures such as doors have been successful in the past (67). Among the main approaches to cognitive behaviour therapy, psychoeducation, teaching management, and exposure and response prevention are the most commonly applied (Neil and Sturmey 67). Storch et al. state that these approaches have registered success in past tests (134). In light of the differences as outlined in the article by Zandt et al., behaviour therapy approaches appropriate for each RRB according to the identified disorder can be achieved (Drahota et al. 263).
Conclusion
Restricted Repetitive Disorders are commonly exhibited in both ASD and OCD patients. Before taking scrutiny, these behaviours may seem similar in both ASD and OCD patients. However, the research discussed in this review has shown that that is not the case. There are many fundamental differences of the RRBs in patients who have been diagnosed with ASD and OCD. Further, studies indicate that there are differences between the motor action behaviour children and adults. The findings of the studies by Zandt et al. are a major step towards the advancement of available knowledge of Restricted Repetitive Behavior. Future research on the topic should cover other aspects of RRBs such as the best diagnosis and treatment methods and the effectiveness of the available treatment options.

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