One of the most common reasons a child diagnosed with autism spectrum disorder comes to see me in my clinic is because of problems related to attention, focus and concentration. I spend time talking with the family and the child about the difficulties the child is experiencing. These difficulties are almost always related to performance at school. It is not uncommon for us to discover that the problem the child is experiencing is not that he or she can't focus, attend or concentrate. Indeed, we often find the child is focused, attentive and concerned - just not focused where others expect him to be focused.
The ability to be singularly focused is a core feature of ASD. Perseveration, rigidity, and routine are the hallmarks of ASD. Max's focus in this episode is the vending machine, but his fixation is Skittles and candy in general. Now a lot of kids really like candy, but for Max candy is a fixation. Eating candy, thinking about candy, planning on getting candy are some of the ways he organizes his life. His fixation is an odd, often maladaptive way to help him make sense of his life.
In lay terms we would say that Max is "obsessed" with candy, but that isn't how we would frame it clinically. An obsession clinically is usually an unwanted intrusion into someone's mind that may or may not require a certain action called a compulsion. For someone diagnosed with ASD, fixations and perseverations are favorite activities that have a function in giving a frame of reference or purpose. Clinical obsessions or obsessions and compulsions, on the other hand, don't provide a desired frame for people suffering with OCD (obsessive compulsive disorder) but instead impair them.
Sometimes people diagnosed with ASD are also at times diagnosed with OCD, but the usual fixations and rigidity a person diagnosed with ASD exhibits are not the same thing as OCD. A teenager I see clinically has been diagnosed with Asperger's Disorder. He is a great kid and I enjoy seeing him and talking with him. His most enduring fixation has been Broadway musicals and lyrics. He is able to tell you just about anything you would ever want to know about any Broadway musical. In fact, he will tell you a lot more than what you might want to know about any particular Broadway musical. And while this might create social problems for him, this isn't his clinical obsession. He is also diagnosed with OCD, and his obsession is that his feet are not clean and need to be washed. As you can imagine this obsession leads him to worry and suffer significantly. He isn't able to make this obsession go away without engaging in a compulsion to wash his feet. This means taking off his shoes and socks and washing his feet in whatever way may be handy - for example, a wet wipe, or a sink, or even a water fountain at school. Try as he might, he can't get the obsession that his feet aren't clean out of his head. He tries his best, often failing, to resist the compulsion to clean them. He certainly doesn't have the same desire to curb his Broadway musical interests.
The fixations and perseverance of a person diagnosed with ASD can be a problem, as I noted above, in the case of mistaking that singularity of focus for, paradoxically, problems with attention or focus. ASD can be misdiagnosed as OCD, which leads to inappropriate treatment and intervention.
Fixations can cause social problems, as Max experiences during his interactions with Micah in this episode. However, fixations can also lead to great achievements and provide focus and meaning to the life of a person diagnosed with ASD. A great example is the fixation and perseverance that Temple Grandin, PhD, brought to her work in animal husbandry. Perhaps Max will achieve a similar focus and meaning for his life in middle school.
The exercise for us as parents and clinicians associated with these fixations is not to completely curb or eliminate the fixations - as we would try to accomplish with an obsession and compulsion in someone diagnosed with OCD - but to help the person diagnosed with ASD to learn to guide and manage their fixations so that there are more positive results associated with their interests than negative consequences.
Written by Roy Q. Sanders, MD
Kristina learns in this week's Parenthood how she may be treated for breast cancer, which her doctors discovered when she got a routine mammogram in a previous episode. Mammograms are the best way to find breast cancer early. Learn more about breast cancer from the CDC.
