Applied Behavior Analysis (ABA) has long been recognized as an evidence-based approach for supporting children with autism and developmental disabilities. However, ABA’s principles extend far beyond autism treatment. Increasingly, ABA strategies are being adapted to help children with comorbid conditions—meaning additional diagnoses such as anxiety disorders, obsessive-compulsive disorder (OCD), or oppositional defiant disorder (ODD)—that frequently occur alongside developmental challenges or independently.
Children with multiple diagnoses often present complex profiles. For example, a child may have autism and anxiety, or ADHD with ODD. In these cases, behaviors may serve multiple functions at once, and intervention requires careful analysis and tailoring. This article explores how ABA can support children with comorbidities, reviewing the principles behind interventions and providing strategies for parents, teachers, and clinicians.
Understanding Comorbidity in Children
Comorbidity is common in childhood mental health and developmental conditions. Studies show that children with autism spectrum disorder (ASD) experience higher rates of anxiety (Van Steensel & Heeman, 2017), while obsessive-compulsive traits are often present in both neurotypical and neurodivergent children. Similarly, ODD frequently co-occurs with ADHD, autism, and mood disorders (Beesdo-Baum et al., 2020).
These overlapping conditions can make assessment and treatment challenging. For example:
A child refusing to complete work may be motivated by escape from difficult tasks (ABA perspective), but also influenced by anxiety about making mistakes (clinical psychology perspective).
Ritualistic behaviors could serve an automatic reinforcement function (sensory soothing), while also aligning with OCD compulsions.
Defiance in ODD may reflect a history of reinforcement for oppositional behavior, as well as difficulties with emotion regulation.
Recognizing that behaviors are multifaceted allows ABA practitioners to design interventions that are sensitive to the child’s needs while addressing the environmental and functional components of behavior.
ABA Principles Applied to Comorbidities
At its core, ABA is about understanding why behavior occurs and teaching more adaptive skills. The following principles are especially relevant to children with comorbidities:
Functional Behavior Assessment (FBA): Determines the underlying function(s) of problem behavior, critical when symptoms overlap across diagnoses.
Reinforcement: Builds replacement skills and encourages adaptive behaviors.
Differential Reinforcement: Reduces problem behavior by rewarding appropriate alternatives.
Functional Communication Training (FCT): Helps children express needs safely instead of through maladaptive behaviors.
Exposure with Response Prevention (ERP): Though rooted in cognitive-behavioral therapy, ERP techniques can be blended with ABA strategies for OCD and anxiety.
ABA and Anxiety
Anxiety can present as avoidance, crying, somatic complaints, or disruptive behavior. In classrooms, anxious children may refuse tasks, withdraw socially, or over-rely on teacher reassurance.
ABA Strategies for Anxiety
Graduated Exposure (Systematic Desensitization): Slowly exposing a child to anxiety-provoking situations while reinforcing calm coping responses. For example, if a child fears group presentations, start with answering one question aloud, then build up.
Shaping: Reinforcing successive approximations toward brave behavior, such as praising a child for entering the cafeteria even if they don’t yet eat there.
Differential Reinforcement of Incompatible Behavior (DRI): Reinforcing behaviors like raising a hand to ask for help instead of engaging in avoidance.
Teaching Coping Skills: ABA can reinforce self-management strategies (deep breathing, using a break card) so children rely less on avoidance.
Research supports ABA-based exposure approaches for reducing anxiety in children with ASD (Leyfer et al., 2018). Teachers and parents can collaborate with behavior analysts to integrate coping practice into daily routines.
ABA and Obsessive-Compulsive Disorder (OCD)
OCD often involves repetitive rituals, compulsive checking, or rigid routines. These behaviors can overlap with autism’s restricted and repetitive behaviors but may serve different functions.
ABA Strategies for OCD-like Behaviors
Functional Assessment: Determine if rituals are maintained by automatic reinforcement (self-soothing), escape from demands, or attention.
Response Blocking with Reinforcement: Prevent compulsive behavior when possible and reinforce alternative coping strategies.
Differential Reinforcement of Other Behavior (DRO): Reinforce periods of time without ritualistic behaviors.
ERP-Informed ABA: ABA can incorporate exposure by reinforcing tolerance when the child resists rituals (e.g., touching a “contaminated” object without washing hands immediately).
A 2019 study by Storch et al. showed that blending ABA reinforcement with ERP techniques led to improved outcomes for youth with OCD, especially when families were involved in the process.
ABA and Oppositional Defiant Disorder (ODD)
ODD is characterized by persistent patterns of defiance, arguing, and hostility toward authority figures. Traditional discipline often escalates conflict with these children. ABA offers a non-confrontational, skill-building approach.
ABA Strategies for ODD
Identify Reinforcement Histories: Many oppositional behaviors are maintained because children gain attention or escape demands by arguing.
Differential Reinforcement of Alternative Behaviors (DRA): Reinforce compliance, calm requests, or problem-solving instead of arguing.
Token Economies: Effective for increasing compliance and reducing defiance when paired with clear expectations.
Functional Communication Training: Teach children to express frustration (“I’m upset, can I take a break?”) instead of shouting.
Antecedent Interventions: Give clear, positively stated instructions, provide choices, and use pre-corrections (“Remember, first we finish math, then we can talk about soccer”).
Research supports ABA-informed parent and teacher training as highly effective for ODD (Fabiano et al., 2020). Consistency across environments is critical: if one adult gives in to defiance, behaviors are more likely to persist.
The Role of Families and Teachers
When comorbidities are present, children need consistent support across home and school. Collaboration ensures strategies are applied uniformly.
At Home: Parents can reinforce coping strategies, establish routines, and use differential reinforcement for compliance.
At School: Teachers can integrate ABA strategies into classroom management systems, support exposure practice, and reinforce functional communication.
Clinician Collaboration: ABA providers often coordinate with psychologists, psychiatrists, and school staff to ensure interventions address both behavioral and emotional needs.
Ethical Considerations
Working with comorbidities requires careful attention to ethics. ABA providers must:
Respect the child’s autonomy by using assent-based practices (Ferguson et al., 2019).
Ensure interventions are individualized, not “one-size-fits-all.”
Collaborate with other professionals to address biological or emotional needs beyond ABA’s scope.
The goal is not simply to eliminate behaviors, but to build adaptive skills, independence, and quality of life.
Case Examples
Case 1: Anxiety in the Classroom
Profile: An 8-year-old with ADHD and anxiety refuses to attend gym class.
ABA Approach: Conduct FBA—function is escape due to anxiety about peer judgment. Intervention: gradual exposure (start with attending the gym without participation), reinforce brave behaviors, teach coping strategies like deep breathing, and use token reinforcement for attendance.
Case 2: OCD Rituals at Home
Profile: A 12-year-old with autism and OCD washes hands 20+ times before meals.
ABA Approach: Use ERP-inspired ABA—limit handwashing to 2 minutes, reinforce compliance with this limit, and gradually increase tolerance for eating without rituals. Family implements DRO by rewarding periods free of compulsive handwashing.
Case 3: Defiance in ODD
Profile: A 10-year-old refuses homework nightly, yelling at parents.
ABA Approach: FBA reveals escape from non-preferred tasks. Intervention: break homework into smaller chunks, reinforce completion with preferred activities, teach child to request breaks appropriately, and use a token system to track compliance across the week.
Limitations and Future Directions
While ABA provides powerful tools, it is not a stand-alone treatment for all comorbidities. For example, severe anxiety or OCD may also require cognitive-behavioral therapy (CBT) or medication. The best outcomes occur when ABA is part of a multidisciplinary approach. Recent research emphasizes the need for integrated models combining behavioral strategies with cognitive, emotional, and medical interventions (Wood & Kendall, 2017).
Conclusion
Comorbidities like anxiety, OCD, and ODD complicate behavior management, but ABA provides a framework for understanding and addressing them. Through functional assessments, reinforcement, differential reinforcement, and functional communication training, children can learn more adaptive ways of coping and interacting. When ABA strategies are paired with exposure methods, consistent reinforcement, and collaboration across environments, children with comorbidities show meaningful improvements in both behavior and quality of life.
The key is consistency, compassion, and creativity. By meeting children where they are and reinforcing their strengths, ABA helps unlock potential even in the face of complex diagnoses.
References
Beesdo-Baum, K., Knappe, S., Fehm, L., Hofler, M., Lieb, R., & Wittchen, H. U. (2020). The structure of oppositional defiant disorder symptoms in the general population. Journal of Child Psychology and Psychiatry, 61(6), 653–661.
Fabiano, G. A., Schatz, N. K., Aloe, A. M., Chacko, A., & Chronis-Tuscano, A. (2020). A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder. Clinical Psychology Review, 78, 101853.
Ferguson, J., Tarbox, J., & Najdowski, A. C. (2019). Assent-based interventions in applied behavior analysis. Behavior Analysis in Practice, 12(3), 654–664.
Leyfer, O. T., Folstein, S. E., Bacalman, S., Davis, N. O., Dinh, E., Morgan, J., & Lainhart, J. E. (2018). Comorbid psychiatric disorders in children with autism: Interview development and rates of disorders. Journal of Autism and Developmental Disorders, 48(4), 924–933.
Storch, E. A., Schneider, S. C., & Guzick, A. G. (2019). Behavior therapy for pediatric obsessive-compulsive disorder: Current evidence and future directions. Behavior Therapy, 50(1), 180–192.
Van Steensel, F. J., & Heeman, E. J. (2017). Anxiety levels in children with autism spectrum disorder: A meta-analysis. Journal of Child and Family Studies, 26(7), 1753–1767.
Wood, J. J., & Kendall, P. C. (2017). Integrated CBT for anxiety and autism spectrum disorder: A transdiagnostic approach. Journal of Consulting and Clinical Psychology, 85(6), 543–555.
