TABLE OF CONTENTS:
1. Introduction and definitions
2. Myths and misconceptions
3. Manifestations of obsessive-compulsive disorder
4. Categories of obsessions and compulsions
5. Causes of OCD and triggers
6. Identifying OCD behaviour in the child, a parent’s guide
7. Formal diagnosis
9. Treatment options
10. Identifying and dealing with OCD in the classroom, the educator’s role
11. Support for parents
12. Final thoughts
14. Appendix: Further reading and websites
Mark worried that he’d get sick from dirt or germs.
He washed his hands for hours a day so he wouldn’t get sick or contaminated.
He refused to allow visitors into his home, and whenever he, his wife,
or his children entered the house
he made them change their clothes and take a shower.
(Phillips, K.A – 2009)
Introduction: Obsessive Compulsive Disorder…
Mark suffers with Obsessive-Compulsive Disorder (OCD), “characterized by obsessions or compulsions (usually both) that cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with functioning.”(Phillips 2009:282). An obsession is defined as a recurrent, persistent, and intrusive thought, impulse or image that is difficult to dismiss despite its disturbing nature. A compulsion is often known as a ritual. It is excessive repetitive behaviour (such as hand washing as in Mark’s case above) or mental acts (such as counting) that are performed to try to decrease the anxiety caused by an obsession. These compulsions are usually difficult to resist or control. (p. 279)
Myths and misconceptions…
Obsessive compulsive disorder initially was thought to be a relatively rare disorder, but is now recognized as a common psychiatric issue with an estimated lifetime prevalence of 1.9 to 3.3%. (Lochner & Stein: 19) According to Lochner and Stein (2001), there is a relative shortage of literature that addresses OCD and specifically focuses on gender comparisons; the interesting factor of this anxiety disorder is that it has approximately equal ratios of occurrence in males and females. The focus of this essay will be on children enslaved to OCD, outlining the types of obsessions and compulsions that manifest in children. The causes of OCD and signs to identify this disorder in your child will be covered, with indications for both the parent and the educator of a child with obsessive-compulsive disorder. Attention will be given to the treatment regime for children, and the assistance available for parents.
The United States has a prevalence rate for this anxiety disorder of one in every one hundred children. Research among the five to six million U.S. adults living with OCD discovered that 50 percent said that their symptoms began in childhood. A statistic like this drives home the need for both parents and educators to have a thorough understanding of the signs and symptoms of OCD in children in an attempt to identify and address the disorder as early as possible in the child’s life. One of the greatest stumbling blocks to seeking professional attention for a child is the myths and misconceptions attached to the behaviour of a child suffering with this disorder. In ‘The Everything Parent’s guide to Children with OCD”, Martin and Costello identify seven basic myths; they are just eccentric, they can stop it if they want to, it’s a self-esteem problem, they just need to relax, stress causes OCD, childhood trauma causes OCD, and they’ll never get better. The truth of the matter is that children often do not have the appropriate strategies at his/her disposal to be able to redirect attention. In addition, up to 75% of children with OCD are in remission by their teens. (Martin: xiv). If OCD in children is managed correctly the prognosis is promising.
The vast majority of fears and rituals that are observed in children are quite normal and have nothing to do with OCD, and the rituals can be changed without causing adverse trauma to the child. If a change in routine causes severe distress for a child, or if the routine takes up longer than an hour of the child’s day or causes him to become dysfunctional, then the behaviour could be an indication of OCD.
Manifestations of obsessive-compulsive disorder…
Obsessive Compulsive Disorder can manifest itself in a number of different ways in children as demonstrated in the examples below: (Martin & Costello: 2008)
- Jason is three and he’s already very picky about everything! When he puts his toys away, he has to do it in a very particular way. Like holding one round toy and one square edged one in each hand, always the same, and it has to be done in a very specific order. If I help him and it’s ‘out of order’, he’ll throw a tantrum, dump everything out, and start all over again.
- Josh, age six, performs an elaborate ritual every night, saying the words, “Mommy, one, two, three, four, five” as he touches each truck, game and stuffed animal lined up on his toy shelves.
- Stacy, at ten, counts every word on each page as she reads her book.
- Sixteen-year-old Sandra has developed a fear that germs in public restrooms, including the girls’ bathroom in her high school, will give her AIDS. Because she can’t leave the school building to go home midday, she washes up so often and harshly in the morning and afternoon that her hands and arms routinely are red and chafed.
- A seven-year-old shows signs of OCD, by asking the same questions over and over. Questions like, “Are you sure?”, “Is there going to be a tornado?”, “Am I going to throw up?” She gets a thought stuck in her head and she can’t get it out.
- Timmy showers four times a day. He insists that I wash his clothes separately from his brother and sister’s. When I wouldn’t wash his sheets separately, too, he insisted on sleeping in his clothes.
- Daniel, age eight, explained how he turned his need for certainty into a morning ritual. After he’d lined up and arranged his things just so, he would open his bedroom door, turn back around to face his furniture and belongings, and speak out loud the words, “Now everything is exactly as I want it”. Only then could he go to school.
- Michael can’t go outside on sunny days because he’s afraid that if his shadow falls on something or someone, like a bush or a small child on the playground, the plant or child will die.
- Steve struggles to let go of our trash. Last week, I got him to let go of two bags of trash, and that was a small victory. This week, though, it was like I had to pay a price for it.
- Brian says there’s a voice in his head telling him to do ‘bad’ things to others. He told me he was trying hard to fight back against it, but that it was hard. He admitted he was having ‘killing thoughts’, and they were about me.
The typical age of onset of OCD is 10.2 years, but occurs most commonly at around seven years of age for boys and again at adolescence for girls, although children can develop OCD from around three or four years of age. Boys with OCD outnumber girls by 3:2. A study by Bogetto et al (1999), found that male gender was a significant predictor of earlier onset, more insidious onset, and greater chronicity of course. (Lochner & Stein 2001). Males tend to have a greater contamination obsession than girls and obsessive slowness, symmetry and exactness, numbers, touching rituals and sexual symptoms are more prevalent.
Your child’s attempts to relieve anxiety caused by recurring thoughts leads to faulty thinking called obsessions. Compulsions result from repeated actions to try to relieve emotional discomfort. Compulsive behaviour is usually but not always connected to an obsession. “The most common OCD obsession is fear of contamination, and the most common compulsion is checking”. (Phillips 2009:244) It is quite normal for us to have doubts and fears and to worry about situations, but when these become overwhelming they have crossed into the realm of obsessions. According to Pope et al (2000), a child suffering with obsessive-compulsive disorder may develop an obsession with dirt; the child is tortured with recurrent thoughts that there might be germs or dirt on his hands. In response to these intrusive thoughts, he develops a compulsion to wash his hands two hundred times a day. The underlying cause of OCD is the combination of genetics and brain chemistry. This chemical imbalance in the brain is currently incurable but treatment is available for the child, which will be discussed later.
Categories of obsessions and compulsions…
The obsessive thoughts that your child may experience can be broadly grouped in to four categories as outlined by Martin & Costello (2008). The categories of obsessions include the following:
- contamination fears
- need for order
- aggressive thoughts
- superstitious thoughts
Jenike, Baer and Minichiello (1986) noted that the most common obsessions in a sample of 100 patients were contamination (55%), aggressive impulses (50%), sexual content (32%), somatic concerns (35%) and the need for symmetry (37%), with 60% of the sample group displaying multiple obsessions.
The obsessive need to be clean or make an area clean is the response to the overwhelming fear of dirt or germs. The child will clean obsessively in order to prevent infection or harm but this cleaning ritual will never be sufficient for the child to overcome the fear.
The need for order is driven in the child by anxiety, the ordering of the environment around the child is his attempt to gain control over his anxiety. This need for order can manifest in physical ordering of objects in the immediate environment, it can manifest as a need to check that the light switch in his room has indeed been switched off. The repeated asking of the same question or a constant need to apologize for a believed error are also examples of the need for order in the child.
When a child is bombarded with aggressive thoughts, the aggression obsession occurs from a fear of actually acting out the thought. The mere fact that these aggressive thoughts are usually seldom acted out, causes the obsession to become even more powerful. These intrusive thoughts about aggressing can and do cause social isolation.
Superstitious thoughts - this category could easily be referred to as ‘magical thinking’; the child believes they have super-human strength or powers; they have the power to control the fate of others. The belief that they can control another’s fate can be extremely disturbing for a child.
The mirroring or manifesting of the obsessive thoughts causes compulsions, the excessive or repetitive behaviours. These compulsions or actions “may be repeated over and over again until the person feels comfortable or certain that nothing bad will happen”. (Veale D et al 2009: 36). The compulsion is usually associated with a particular obsession that causes anxiety for the child. Martin & Costello (2008) outline five categories of compulsions:
- cleaning compulsions
- ordering compulsions
- hoarding compulsions
- avoidance compulsions
- ritualizing compulsions
The compulsion for cleaning can take many forms, such as repeated washing, reluctance or refusal to use public conveniences, excessive cleaning of an area, a need to throw things away, a reluctance to touch communal items, a fear of touching others or of being touched by others or a refusal to share food or drinks.
Ordering compulsions take the form of counting, hoarding things, sorting things, and lining up objects to create perfect symmetry. Children with ordering compulsions often have a preference for even rather than odd numbers which can have adverse affects on schooling.
Hoarding of objects, ‘is one of the more perplexing’ behaviours. (Martin & Costello 2008:34). The need to balance a fear of deprivation leads to hoarding and as such the child gains a sense of control over their environment. This compulsion ranges from toys and books, to food and even fingernail cuttings.
When a child is obsessed with intrusive thoughts of a violent nature it can cause avoidance behaviour to manifest in the child. The child will actively try to avoid being in the company of the person that is the object of the obsession or the situation in which the violent act might take place. Avoiding the situation helps to assure the child that he will not act out the obsession.