Treating Obsessive and Ritualistic Behaviors

In a previous blog post (Understanding Obsessive and Ritualistic Behaviors, August 6, 2019) we discussed why rituals and obsessive behaviors are detrimental to both the child’s life and the life and well-being of his/her family. We discussed how important it is that behavior technicians (BTs) play a role in recognizing, defining and communicating the child’s rituals and obsessive behaviors with the team. Next, we will discuss the kinds of treatment that work best for children with these challenging behaviors.

Managing rituals and obsessive behavior is particularly difficult because when children are blocked from engaging in these behaviors, they often engage in equally challenging behaviors such as aggression, tantrums, yelling, crying, or “shutting down.” The goal is to reduce these challenging behaviors, as well as the rituals and obsessive behaviors.

The first step is to ensure that the child has the proper replacement behaviors. If a child does not have the proper replacement behaviors in place, then those must be taught first. The BCBA will determine if the needed replacement behaviors are in place; however, BTs can aid in communicating to the BCBA if replacement behaviors are seen during sessions. Common replacement behaviors for the reaction to being blocked include emotional coping strategies. For example, you could ask yourself the following questions: Is your child able to take deep breaths rather than cry and scream? Does your child recognize when s/he may need to walk away from a situation to avoid having a meltdown?

Although we may not be able to change the child’s mind regarding why the ritual is absolutely necessary, we can teach him/her to react to changes as they occur. For example, you could teach replacement behaviors, such as taking deep breaths, counting backwards from 10, taking some time alone, or getting some water. BTs can assist in testing the various strategies and seeing which works best for the specific child --We all have different ways of calming ourselves down. Since BTs spend a lot of time with the children, the BCBAs will likely rely on observations and data from them regarding which coping strategies work the best for each child. The bottom line is that having coping skills helps children be more flexible with changes in their rituals or when they are blocked from performing their obsessive behavior.

Another important skill is called “Social Perspective Taking.” Let me paint a picture for you: I have an obsession with coasters. I really love to have a coaster under any drink whether it is at my home, my office, or someone else’s home. I have many coasters in my home to make this happen; however, other people often put their drinks down on my wood table. Social perspective taking allows me to know what another person might think or feel if I get overly upset about them not using a coaster. If I yell at them, they might feel mad. They might think: What is her problem? It’s not that big of a deal. I am able to identify this because I have the skill of Social Perspective Taking. When children are not flexible with changes in their environment, then BTs can point out how others might feel. Many children may not yet have this skill, so prompting them through a situation can help them learn to understand others’ emotions and thoughts.

Additionally, it may be difficult to find a strong enough reinforcer for the replacement behavior to successfully change the obsessive behavior. Oftentimes, the most preferred reinforcer for rituals is engaging in the ritual itself. You may consider reinforcing the child’s use of replacement behaviors with the chance for the child to engage in one ritual behavior. This often works well with children who have multiple obsessions but it can also be used for children who have only one obsession. For example, if your child really only likes talking about cars, you could reinforce engaging in novel topics of conversation with the opportunity to talk about cars.

Ritualistic and obsessive behaviors can be difficult to treat. Working together to create an individualized treatment plan can assist in increasing flexibility and overall use of replacement behaviors. You may not be able to change the child’s mind regarding the importance of the ritual; but you can teach the child replacement behaviors to help him/her be more flexible. Flexibility typically leads to better social relationships and greater independence in children’s lives. It can also be hugely helpful in the life of the entire family. Make sure to notify your BCBA if you see any signs of ritualistic and obsessive behaviors so they can be properly addressed during your child’s ABA sessions.

Allyson Kroneberger, M.S., BCBA, LABA
Associate Clinical Director, Boston, MA
September 10, 2019