Self-Monitoring for Students With Obsessive-Compulsive Disorder and Autism Spectrum Disorder

Abstract

Obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD) are neuropsychological disorders that can be challenging to students both academically and social-emotionally, especially when they occur together. Students with ASD can have co-occurring OCD, which can complicate social-emotional and academic outcomes. Teachers are in an ideal situation to provide classroom-based strategies, such as self-monitoring, that can help facilitate students’ social and academic success. With self-monitoring, students observe and measure their behavior and compare it against a goal, which can promote greater self-awareness and behavior change. This column provides a step-by-step guide on how to implement self-monitoring with students who have OCD and ASD.

Keywords

obsessive-compulsive disorder autism spectrum disorder self-monitoring

Obsessive-compulsive disorder (OCD) occurs in 1.2% of the U.S. population (American Psychiatric Association, 2013), and about 33% of people with OCD are diagnosed before 15 years old (Pérez-Vigil et al., 2018). The essential clinical features of OCD include obsessions and compulsions. Obsessions are “uninvited,” “unwelcome” intrusive thoughts that appear with or without an external trigger. Common obsessions include germs, death, unwanted thoughts about hurting others, and a fear of doing something wrong (Abramowitz & Reuman, 2020). When the obsession occurs in a child’s mind, it triggers anxiety and fear. The child, afraid, tries to avoid the thought and engages in compulsions that help to decrease their fear at the moment (Abramowitz & Reuman, 2020). Compulsions are behavioral or mental responses that a child feels that they “need” to do to make the fear go away. This can include checking, washing and re-washing, mental reviewing, saying a lucky number, or seeking a significant amount of reassurance (Abramowitz & Reuman, 2020). Although the compulsions provide temporary respite from fear, they reinforce the obsession-compulsion cycle, ultimately strengthening their symptoms.

The presence of another disability along with OCD can further complicate outcomes for students. One of the most common comorbid disorders in students with OCD is autism spectrum disorder (ASD). When looking at students with a primary ASD diagnosis, some research has shown that approximately 17% of people with ASD also have a diagnosis of OCD (Meier et al., 2015). Other researchers suggest that in students with OCD, approximately 36.2% have ASD or ASD traits (Stewart, 2016). This higher percentage of comorbidity has been reflected in past research as well, with Lewin et al. (2011) finding the prevalence of students with comorbid ASD and OCD at 37%. Because the comorbidity is so high, it is difficult to disentangle these diagnoses, as they share a significant amount of similarities in symptomatology (e.g., need for routine, repetitive behaviors, sameness, inflexibility, and persistent thoughts or urges; Stewart, 2016).

Both OCD and ASD can have negative implications for social and academic success. Findings suggest that individuals diagnosed with OCD or ASD are at a greater risk of academic underachievement (Chen et al., 2019). Obsessive-compulsive disorder and ASD may also negatively affect a student’s ability to form and maintain peer relationships, as they both tend to display significantly worse social functioning and less prosocial behavior than their peers (Borda et al., 2013; Zeedyk et al., 2016). Teachers are in a prime position to offer supports and interventions to help buffer these potentially negative outcomes for students with ASD and OCD.

One such intervention is self-monitoring, which is the act of bringing awareness to a particular behavior by noting when the behavior occurs. For example, a student may make a tally each time they “blurt out.” The tallying acts as a way for the student to bring awareness to the blurting behavior and therefore control the behavior over time. In another example, an individual who taps their desk three times before writing is much more likely to be able to stop that behavior after they are made aware of the tapping. Moreover, the tallying of the behavior can also create an opportunity to monitor progress and intervention effectiveness and adjust the intervention as needed. Research suggests that self-monitoring has the potential to aid overall learning outcomes for students across settings, including general education (Willis & Mason, 2014) (Bruhn et al., 2015; Fishley & Bedesem, 2014) and developmental disabilities (Fishley & Bedesem, 2014).

Self-monitoring has a strong evidence base for an array of developmental disabilities and psychiatric disorders, including OCD and ASD (McDougall et al., 2017). It has been used with children with ASD, highlighting its efficacy in increasing independence (Bouck et al., 2014), task completion, and decreasing disruptive behavior (Rosenbloom et al., 2019). Self-monitoring has also been used with children with OCD and has been related to an increase in independence and a decrease in disruptive behaviors (Abramowitz & Arch, 2014; Reinecke et al., 2018). Given the overlap of symptoms and the efficacy of self-monitoring for both ASD and OCD separately, an argument can be made for its effectiveness for students with both diagnoses. Although there is a significant dearth of literature on students with comorbid ASD and OCD, some research has highlighted that self-monitoring can be particularly beneficial for these students as it can reduce rituals, and facilitate social skills, decision making, and cognitive flexibility (Jiujias et al., 2017).

The following section outlines a step-by-step guide on how teachers can implement self-monitoring for students with OCD and ASD in a way that promotes school success. The intervention is described broadly so teachers can implement it across different behavioral targets, such as on-task behavior, completing academic work, or following instructions. Although the intervention is directed toward teachers, it is recognized that support staff, such as paraprofessionals, often play a crucial role in implementing these types of interventions.

Self-Monitoring Intervention

Step 1: Define the Behavior

The first step to implementing a self-monitoring intervention for students who have OCD with comorbid ASD is to identify a target behavior (e.g., problem behavior) and describe the behavior in a way that is specific, observable, and measurable. The behavioral definition should state what the behavior includes and excludes. An example of an appropriate operationalized behavior is: “the student should monitor the number of verbal requests for reassurance related to their OCD.” This can be further specified with examples specific to the child, such as the child asking the teacher if the desk has been cleaned, if they tracked in dirt, or if they are dirty. For students with OCD and ASD, other targeted behavior often involves social skills, behavioral regulation, checking compulsions, or perseverations (Jiujias et al., 2017).

Although the student will ultimately implement self-monitoring, teachers should help the student identify the most appropriate behavior to target. Behavioral targets should be functionally impairing but also consider student input. For example, if a student is having contamination obsessions about food poisoning during lunch, and the student is engaging in excessive checking around their food being “safe” to consume, this could be an appropriate intervention target. The amount of student involvement in choosing the behavioral target will vary by student age and cognitive ability. However, autonomy is a key factor in student motivation (Deci & Ryan, 2000), and student involvement at this step of the process is encouraged. Teachers can involve students by asking them what behaviors they may want to improve and then helping the student operationalize that behavior. For example, if a student is using self-monitoring to track mental compulsions, such as mental reviewing, the child can be told to mark a tally each time they think “I’m pretty sure I washed my hands. I remember going to the bathroom after lunch, going to the sink, washing my hands.” Visual prompts can also be used to help cue students to self-monitor as a way to scaffold students into independent implementation (Bouck et al., 2014; McDougall et al., 2017). For instance, teachers can provide visual prompts of the thoughts or behaviors that constitute compulsions so the child can accurately track them, as the use of visuals is particularly effective for students with ASD (Knight et al., 2015).

Next, the setting of the behavior should be identified. Although the ultimate goal may be to reduce a non-preferred behavior and increase the use of coping skills throughout the entire day, research suggests that focusing on a specific time and setting can greatly increase the success of the intervention (Greenwood & Kim, 2012). Some specific settings may include math work, journal time, independent seatwork, or explicit instruction time.

Step 2: Goals and Behavior Tracking

Choosing a goal

After defining the behavior, the second step of self-monitoring is choosing a behavioral goal and how the behavior should be measured. The goal should be predetermined, realistic, and based on the severity of the target behavior. It may be prudent to start with an easily achievable goal to facilitate self-efficacy and buy-in. Teachers should consider the following questions when constructing a goal. How long will this intervention take place? At the end of the time allotted for the intervention, how much reduction in behavior should be expected? How will progress be tracked? Teachers should aim to construct a goal that is (a) specific to the target behavior, (b) measurable, (c) attainable, (d) realistic, and (e) time-based. For example, “John will reduce his checking compulsions during lunch by half (from 30 times a period to 15 times a period) in 6 weeks. A frequency count will be used to measure behavior change and progress will be charted daily.” Teachers can also set predetermined smaller goals to reach a larger goal; this can include generating hourly, daily, or weekly goals.

Choosing a tracking system

To determine the appropriate tracking system, teachers should first determine whether the target behavior is discrete or continuous. Students with OCD and ASD can exhibit discrete behaviors (i.e., behaviors with a distinct starting and stopping point) such as asking for reassurance, checking, washing hands, or “blurting out.” They can also exhibit continuous behaviors, which do not have a clear beginning or end. This can include eye contact, tapping, rubbing, and vocalizing (Kirby et al., 2015). Although some behaviors may fall in either category, teachers should use their best judgment. For example, a single tap on the desk every few minutes would be considered discrete, while multiple taps happening every minute would be considered continuous. After determining whether a behavior is discrete or continuous, teachers should choose a self-monitoring schedule that outlines when students should engage in recording the target behavior. While there are various tracking schedules, discussing all of them is beyond the scope of this column. The two most relevant tracking schedules follow.

Fixed intervals

For students who engage in more discrete behaviors, a fixed interval tracking schedule is preferable. A fixed interval tracking schedule is when the student tracks the frequency of the behavior through simple tally marks during the specified time interval (e.g., marking the number of times handwashing occurs during 20 min of indoor recess). A frequency count may be the best fit when tracking compulsions using a fixed interval schedule as it may be more sensitive to change in behavior, easy to implement, and objective (Cunningham, 2012). To implement a frequency count, the student tallies the number of times compulsive behavior occurs. For instance, if a student’s compulsions include checking to make sure school materials are arranged “just right,” then the student would be encouraged to mark the number of times they engaged in these checking behaviors. The length of the recording interval is dependent on the baseline frequency of the target behavior and may change over time. For a target behavior that occurs very frequently (e.g., several times per minute), the tracking interval might initially be very short, such as 5 min. As the student’s awareness of the behavior increases and the frequency of the compulsions decreases, the tracking interval can be extended and applied in other settings to generalize the student’s learning and behavior change.

Partial interval

For students who engage in continuous behavior, such as tapping the table many times, frequency counts may be tedious and time-consuming. In these cases, it may be more prudent to use a partial-interval tracking approach, in which the student simply marks if the behavior occurred during the predetermined interval. To do this, a teacher can give a student a sheet that asks the student to mark “yes” or “no” as to whether the behavior occurred during the interval, regardless of how many times it occurred. For example, after 5 min a student may be prompted to mark “yes” or “no” if within those 5 min they engaged in any tapping. An unobtrusive alarm or timer (whether it is through a beep, a flashing light, or a vibration) can be used to cue the student to mark their behavior at the specified interval (Wright, 2013). Prompts should always be as least intrusive as possible while still effectively cueing the student.

Step 3: Ensuring Success Through Reinforcers

Providing reinforcers can help motivate students to engage in an intervention (Wright, 2013) and also increase intervention fidelity (Davis et al., 2014). Reinforcers (e.g., rewards) are commonly overlaid with self-monitoring; both are critical components of self-regulation, and thus combining the two into a multicomponent intervention is effective in promoting behavior change (Bruhn et al., 2015; McDougall et al., 2017). Rewards can include sensory toys (e.g., fidgets), use of technology (e.g., use of a tablet, phone, or a video game), and puzzles. Rewards should be specific to the child: a video game for one student may not be as reinforcing as a puzzle is for another student, so student input at this step is essential. It is important to note that sometimes rewards can reinforce compulsions or perseverations. Avoiding this pitfall and choosing a reward that is not related to a student’s OCD or ASD can prevent any accidental reinforcement of problem behavior. For example, an unhelpful reward for a student with contamination fears would be getting extra hand-washing time. Teachers should base the frequency of rewards on the frequency or duration of the target behavior. Students should earn a reward after one interval of self-monitoring. For example, if a student self-monitors the target behavior for 10 min during recess, they should earn the reward at the end of this interval. The reward system should be explained to the student, and it may be helpful if a reminder is taped to their desk. Rewards can then be gradually phased out as the student builds success. Natural transitions, such as a semester change, long holiday weekends, or summer break, can be useful times to remove rewards if the student is continuously successful with the strategy.

Step 4: Monitoring the Accuracy of Instruction and Implementation of Self-Monitoring

The fourth step of a self-monitoring intervention is trifold: monitoring the teacher’s instructions to students, monitoring the students’ implementation of self-monitoring, and fading. The teacher should follow Steps 1 through 3 outlined above to instruct the student on implementation. Specifically, after identifying the target behavior, the teacher can discuss with the student the behavior that they would like to see changed. The teacher should operationalize the behavior to the child. For instance, if the goal is to reduce seeking reassurance, the teacher can list all the ways a student can seek reassurance, such as “I’d like for us to keep track of when you ask me if you brought in dirt from recess or when you ask me whether or not you are dirty.” The teacher should discuss the behavior in a firm but empathetic way to show support and instill confidence in their ability for success (Lebowitz et al., 2014).

The teacher should then outline the goals and how they will be measured to the student. Using the previous example outlined in Step 2, a teacher can tell the student:

Demi, I would like for us to work on cutting your worry questions in half. Right now, you are asking me 30 worry questions a day. I would like for us to work on cutting it down to 15 worry questions a day. Let us aim to do that in 6 weeks, how does that sound? Every day you will be given a notecard where you will tally every time you ask me a worry question.

The teacher should then model how to record the behavior on the notecard or tracking sheet.

If appropriate, the teacher should discuss with the student that a timer can be used to help the student engage in self-monitoring. The teacher can show the student how to use the timer in conjunction with recording the behavior. In addition, the teacher should discuss any reinforcers or rewards that will be provided to the student and when they will be provided. When possible, this discussion should be collaborative, where the teacher and student agree upon a reinforcer. For instance, the teacher can say, “If at the end of the day you meet your goal of 15 questions or fewer, you will get your choice of a puzzle to play with for 15 minutes.” To aid in a teacher’s monitoring of instruction on self-monitoring, the teacher can use the checklist shown in Table 1, which outlines teaching the steps to students.

Table 1.

Checklist for Teaching Self-Monitoring.

Steps	Completed the Step?
Step 1: Pick a behavior and operationalize it to the student and discuss preferred behavior using firm but empathic terms	Yes	No
Step 2: Discuss goal and appropriate measurement system with the student (e.g., frequency, check marks)	Yes	No
Step 3: Discuss the length of recording interval with student (e.g., monitoring every 5 min)	Yes	No
Step 4: Model to the student how to record the desired behavior	Yes	No
Step 5: Provide materials necessary for the student to record their behavior (e.g., a table or notecard to tally, a timer, pencils)	Yes	No
Step 6: Discuss the reinforcement system with the student (e.g., If compulsions are decreased by half, then the student would get an appropriate reward). Ask the student their preferred rewards/reinforcers	Yes	No
Step 7: Conduct random checks to ensure accurate implementation of self-monitoring by student	Yes	No

Teachers should also engage in random checks to ensure accurate implementation by the student and provide corrective feedback if necessary (Wright, 2013). Teachers can use the guiding questions from Table 2 to facilitate their monitoring of the students’ implementation of self-monitoring. To do this, teachers can randomly choose a time to look at the student’s self-monitoring sheet and analyze whether the child is consistently marking according to the schedule. If the student has not followed the expectations, the teacher should ensure that the student is not engaging in avoidance or escape-related behavior. The more a child resists compulsions, the greater the discomfort and appeal of avoidance/escape. Teachers should check to make sure the students are aware of and understand the expectations of the intervention. Students with ASD tend to excel when something is explained in a clear and structured way, such as a list of “rules” (i.e., teachers write down the steps of self-monitoring and talk about them as “rules”). If the child has significant difficulties implementing self-monitoring, the teacher may implement it on behalf of the student with the expectation that the intervention will transition to being student-led. Over time, the hope is to fade out self-monitoring as the child gains more awareness and decreases compulsive behaviors.

Table 2.

General Guide for Implementing Self-Monitoring in Students With OCD and ASD.

Define the Behavior	Identify the Goal	Measuring the Goal	Checking for Accurate Implementation
What does the behavior look like? What does it not look like?	On a scale of 1 to 10 (10 being highly disruptive) how disruptive is the behavior?	If the student is engaging in discrete behaviors, did you use a fixed interval observation measurement schedule?	Did I randomly analyze the student’s self-monitoring sheet?
Is it a compulsion (does the student engage in repetitive behavior, such as checking, washing, repeating, counting? Does the student engage in rigid ordering or arranging of items)?	What is the easiest goal you think the student can achieve?	If the student is engaging in continuous behaviors, did you use a partial-interval observation measurement schedule?	Did the student consistently mark in accordance to the appropriate schedule and interval length?
Is it a perseveration (Does the student have a hard time shifting attention, shifting to another task, shifting to another topic)?	What are some smaller goals the student can aim for to help them reach a larger goal?	How frequent are the student’s compulsions?	Have you or the student engaged in progress monitoring?
Is it an ASD-related repetitive behavior (does the student engage in behaviors such as rocking, tapping, pacing, etc.)?	How long will this intervention take place?	How long will the recording interval be?
Is it discrete or continuous behavior?	At the end of the time allotted for the intervention, how much reduction in behavior should be expected?	Will a visual prompt be required to help the student remember?
	How will you be progress monitoring? (e.g., frequency count? Check lists?)

Note. OCD = obsessive-compulsive disorder; ASD = autism spectrum disorder.

Self-monitoring may be difficult for the student to implement if the student is not invested in the intervention. One important part of ensuring successful implementation is to maintain motivation and engagement with the intervention. To do this, teachers could create a self-monitoring sheet that is individualized based on the unique interests of the child. For example, if the student has a strong interest in cars, the sheet could be titled “Race to Success,” and images of cars and a racetrack border could be included on the page. This can help promote a sense of agency and ownership. Figures 1 and 2 provide examples of self-monitoring recording sheets that students could use to self-monitor their behaviors. Finally, it is important to mention that self-monitoring may be more difficult for students with very low insight into their obsessions or compulsions. In this case, it may be more beneficial if the teacher mediated this intervention by highlighting when a compulsion occurs to the student and recorded the data for the student (Bruhn et al., 2015). The degree of scaffolding and teacher involvement will vary by the student; students with lower insight into their obsessions and compulsions will need more teacher involvement on the front end than those who have some or high insight. When the student increases their self-awareness around their behavior, the teacher can then shift control of the intervention over to the student (Bruhn et al., 2015).

Figure 1.

Self-monitoring Daily and Weekly Recording Sheet examples.

Figure 2.

Self-monitoring Hourly Recording Sheet example.

Step 5: Formative and Summative Evaluation

Throughout the use of self-monitoring, the teacher should focus on engaging in formative evaluations (i.e., progress monitoring) to determine if the student is making progress. To do this, the teacher should first set subgoals (daily or weekly) that provide information on the student’s response to intervention. For instance, if the goal at the end of 6 weeks is to cut compulsions in half (e.g., to 15 compulsions a day), then the teacher can set a goal that the frequency of compulsions will decrease by a rate of about 2.5 each week. The teacher can graph this progress or encourage the student to monitor their progress, which is crucial in self-regulatory behavior (McDougall, 2017). The teacher can engage in a visual analysis to determine if the intervention is decreasing at an appropriate rate and make adjustments as necessary (McDougall, 2017).

At the end of the intervention, the teacher should engage in an outcome evaluation (i.e., summative evaluation) to help determine if the intervention should continue, discontinue, or be faded out. The teacher should use the agreed-upon long-term goal as a decision point for an outcome evaluation. For instance, after 6 weeks of consistent intervention, a teacher can engage in an outcome evaluation to determine if the goal has been met. The teacher can then make data-based decisions about the intervention moving forward. Factors to consider during an outcome evaluation include, if original goals were met, the frequency of the target behavior at the time of the outcome evaluation and the effectiveness of the reward system.

Conclusion

This article provides a step-by-step guide on how to implement self-monitoring in students with OCD and ASD. While the general steps are consistent across students, it is important to note that the examples provided in this article are not exhaustive. Implementing self-monitoring should be specific to each child and their target behaviors. For some students, this may be all they need to help them be successful in the classroom. For other students, this may be a supplemental strategy. Regardless, promoting self-awareness of their behaviors in students with ASD and OCD may help facilitate prosocial behaviors (e.g., social skills, cognitive flexibility, decision making; Jiujias et al., 2017) and set a student up to be socially and academically successful.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Danielle Balaghi

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