Felt but not seen: Observed restricted repetitive behaviors are associated with self-report—but not parent-report—obsessive-compulsive disorder symptoms in youth with autism spectrum disorder
Authors: Santore Lee A , Gerber Alan , Gioia Ayla N , Bianchi Rebecca , Talledo Fanny , Peris Tara S , Lerner Matthew D 
Published: March 2020

Repetitive behaviors are observed in autism spectrum disorder and obsessive-compulsive disorder. Clinically, obsessive-compulsive disorder obsessions are thought to drive repetitive or ritualistic behavior designed to neutralize subjective distress, while restricted and repetitive behaviors are theorized to be reward- or sensory-driven. Both behaviors are notably heterogeneous and often assessed with parent- or clinician-report, highlighting the need for multi-informant, multi-method approaches. We evaluated the relationship between parent- and child self-reported obsessive-compulsive disorder symptoms with parent-reported and clinician-indexed restricted and repetitive behaviors among 92 youth with autism spectrum disorder (ages 7–17 years). Regression analyses controlling for the social communication and interaction component of parent-reported autism spectrum disorder symptoms indicated child self-reported, but not parent-reported, symptoms of obsessive-compulsive disorder were associated with clinician-observed restricted and repetitive behaviors. Although both parent- and child self-reported obsessive-compulsive disorder symptoms were associated with parent-reported restricted and repetitive behaviors, the overlap between parent-reports of obsessive-compulsive disorder symptoms and restricted and repetitive behaviors were likely driven by their shared method of parent-reported measurement. Results suggest that children experience restricted and repetitive behaviors in ways that more closely resemble traditional obsessive-compulsive disorder-like compulsions, whereas their parents view such behaviors as symptoms of autism spectrum disorder. These findings provide guidance for better understanding, distinguishing, and ultimately treating obsessive-compulsive disorder behavior in youth with autism spectrum disorder and introduce new conceptualizations of the phenotypic overlap between these conditions. Lay abstract Youth with autism spectrum disorder often exhibit symptoms of obsessive-compulsive disorder; however, it can be difficult for parents and clinicians to tell the difference between the restricted and repetitive behaviors often seen in autism spectrum disorder and symptoms of obsessive-compulsive disorder. This difficulty in distinguishing symptoms may arise from the fact that these symptoms appear the same to observers but are typically differentiated based on whether the motivation for the behavior is to reduce stress (restricted and repetitive behaviors) or whether the behavior itself is stressful (obsessive-compulsive disorder). It is important to know the difference between these two symptoms as it may impact the treatment prescribed. The goal of this study was to better determine the difference between restricted and repetitive behaviors and symptoms of obsessive-compulsive disorder in youth with autism spectrum disorder. It was found that although parents and clinicians had trouble differentiating between the two, the children were able to provide insight as to their own motivations for behavior, and thus whether they were restricted and repetitive behaviors or symptoms of obsessive-compulsive disorder. It was also found that children may actually have subjective negative experiences when engaging in restricted and repetitive behaviors, which complicates their classification. These results provide guidance for better understanding, distinguishing, and ultimately treating obsessive-compulsive disorder behavior in youth with autism spectrum disorder.