Children and adolescents with obsessive-compulsive disorder: A primer for teachers

Childhood Education, Fall 1999 by Adams, Gail B, Burke, Robert W

In the United States, it is estimated that one in every 40 persons suffers from obsessive-compulsive disorder (OCD) (Penzel, 1995), an anxiety disorder characterized by the presence of obsessions or compulsions (American Psychiatric Association [APA], 1994). Once regarded as rare and untreatable, OCD is now considered to be the fourth most common psychiatric disorder among Americans (Rasmussen & Eisen, 1992). Indeed, OCD is so prevalent, yet so secretive, that it has been referred to as a "hidden epidemic" (Jenike, 1989).

OCD is also far more common among children than previously thought. Research indicates that one third to one half of adults with OCD report onset of the disorder during childhood (March & Leonard, 1996). When OCD begins in childhood, it frequently appears between 5 and 8 years of age or during adolescence (Swedo, Leonard, & Rapoport,1990). Although prevalence rates in the OCD literature vary, it has been estimated that 1 in 200 young persons suffers from obsessive-compulsive disorder-3 or 4 students in an average-size elementary school, or up to 20 in a large urban high school (March, Leonard, & Swedo, 1995). Prevalence rates may be even higher, however, since childhood OCD is frequently unrecognized or misdiagnosed (Clarizio, 1991; Rasmussen & Eisen, 1992). Thus, teachers have a critical role to play in the identification, treatment, and management of OCD (Adams & Torchia, 1998).

Over the past decade, a flurry of research in the psychological and medical communities has resulted in rapid and dramatic advances in understanding and treating childhood OCD. This article is essentially a "primer" for classroom practitioners, designed to promote an understanding of OCD and to better equip teachers to assist children who struggle daily with their "OCD monster."

What Is OCD?

Obsessions

The clinical definition of "obsession" refers specifically to thoughts, impulses, urges, or images that seem to force their way into a person's thinking (APA, 1994). Young children may try to explain obsessions in particular ways. They may say, for example, that someone on the outside (e.g., "Jiminy Cricket," "friendly martians") is telling them to do things or is putting thoughts in their heads (Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989). Most people with OCD, however, are aware that the source of these thoughts is their own minds. Nevertheless, they experience great discomfort, anxiety, and/or fear, because the content of the obsessions often is distressing (APA, 1994).

Common childhood obsessions include fear of contamination; fear of harm, illness, or death; fear of making mistakes that will have disastrous results; magical thinking (i.e., that engaging in certain behavior can prevent something bad from happening); fear of thinking or acting in a way that breaches morality or offends God (commonly called "scrupulosity"); and obsessive thinking related to numbers, symmetry, or sex (Francis & Gragg, 1996; Hanna, 1995; Swedo, Rapoport et al., 1989). Thus, a child may be overwhelmed by worries about germ-infested door handles at school, a house fire that may harm family members, or going to hell because of a sacrilegious thought. Obsessions also may take the form of pathological doubting. Indeed, doubting among OCD sufferers can be so strong that the French have called it "the doubting disease"; individuals doubt their memories or senses to the point that they do not trust their perceptions (Rapoport, 1991).

Most children attempt to ignore or suppress obsessions (March & Leonard, 1996). Without treatment, however, youngsters may be powerless to stop these intrusive thoughts. Having such uncontrollable, disturbing thoughts leads many sufferers to fear that they are going crazy. Individuals with OCD are not crazy, however. In fact, most children have insight into their disorder: They realize that what they are thinking is irrational or, in children's terms, "silly" or "stupid" (Johnston & March, 1992; March & Leonard, 1996).

Compulsions

Whereas obsessions occur only in the mind, compulsions manifest as ritualized behavior that can be either covert (internal, or mental) or overt (outward, or physical). Compulsions are behaviors that are performed intentionally to reduce the anxiety or discomfort brought on by obsessions (APA, 1994). Although a small percentage of sufferers experience only obsessions or only compulsions, the large majority of people with OCD have both obsessions and compulsions (March & Leonard, 1996). Indeed, children frequently experience multiple obsessions and compulsions concurrently. Furthermore, the specific content of their obsessions and compulsions tends to change over time (American Academy of Child and Adolescent Psychiatry [AACAP], 1998).

Compulsions frequently are shaped by the content of the obsession. For children who obsess about germs on a door handle, for example, the corresponding compulsion may take the form of covering their hands before touching the handle, washing their hands immediately after contact with it, or avoiding touching it entirely (Adams & Torchia, 1998). In some cases, however, obsessions and compulsions are paired in a way that cannot be explained. For example, a child may read and reread a sentence over and over again because he believes that doing so will somehow prevent his parents' deaths. The child may not understand his own behavior and may be embarrassed if asked to explain how his repeated actions can influence events (Johnston & March, 1992). It is important to note that some children, particularly younger children, are not aware of, or have difficulty verbalizing, obsessions. In these cases, ritualistic or compulsive behavior may be a more prominent index of OCD (Grados, Labuda, Riddle, & Walkup, 1997).