Obsessive-Compulsive Disorder (OCD)

Introduction to OCD

Symptoms of mental illnesses such as OCD can lead to functional impairment. Children with disorders such as OCD are likely to have no health insurance, be underinsured, have difficulty seeking care and services, and have comorbid health conditions with adverse effects on ADLs. As a result, children may miss more days of school. Left untreated, conditions such as OCD can lead to school dropout, violence, substance abuse, injuries, incarceration, and suicide.¹  OCD can interfere with the ability to play, socialize, attend school, and function in daily life with family outside of school. OCD is a type of anxiety disorder, along with generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and separation anxiety disorder (SAD).² 

OCD is characterized by disturbing thoughts or impulses (obsessions) and repetitive or ritualistic behaviors (compulsions). Compulsions in children include excessive hand washing, preventing bad things from happening, counting things, and repeating actions.³ 

Examples of Obsessions

• Contamination: fear of being contaminated, e.g., bugs or other people.
• Repetitive doubts: e.g., if their locker was locked.
• Need for order: anxiety if something is out of order or cluttered.
• Aggressive, horrific, fearful impulses: to hurt themselves or others, to shout, break, or steal something.

Examples of Compulsions

• Repetitive behaviors: handwashing, bathing, tooth brushing, checking doors, checking supplies, need to touch certain objects, rewriting assignments, ordering or organizing behaviors, asking the same question over and over (reassurance).
• Repetitive mental acts: praying, counting
• Repeating words or numbers silently³ 

Prevalence

• OCD is seen in 1-3% of children and adolescents.⁴ 

Causes and Risk Factors

• Factors that may increase the risk for OCD include genetics, family history, enabling behaviors by family members, complications of pregnancy, tic disorders, and autoimmune diseases.
• OCD does run in families and can be passed down through genes.⁴ 
• Evidence indicates that OCD is an anxiety disorder caused by a chemical imbalance in the brain.⁵ 

Impact on Occupations

School

• Tardiness, absence
• Reading out loud
• Being prepared for class
• Writing and handwriting
• Taking tests and completing assignments
• Getting good grades
• Participating in gym
• Leisure and play during recess
• Concentrating on schoolwork
• Eating lunch with peers
• Going on fieldtrips

Self Care and Home

• Dressing
• Bathing
• Doing chores
• Eating meals
• Watching TV or listening to music
• Reading for fun
• ‘Getting ready for bed; sleeping
• Going to the bathroom
• Getting along with family
• Going on vacation or church

Social

• Making new friends and keeping new friends
• Leaving the house
• Being with a group of strangers
• Going to a friend’s house
• Being touched (sports, grooming)
• Going to movies, shopping
• Having a partner
• Eating out in public places⁶ 

Outcome Measures

• Children’s Yale – Brown Obsessive Compulsive Scale⁷  – Gold standard and most widely used for measuring OCD for children and adults.
• Child Obsessive Compulsive Impact Scale⁸ 
• Sensory Profile (Dunn, 1997)
• Anxiety Disorders Interview Schedules for Children and for Parents
• Brief Symptom Inventory
• McMaster Family Assessment Device
• Coping Responses Inventory⁹ 

Treatment and Occupational Therapy

• Obtain detailed evaluation including symptoms.
• Educate family members about reducing critical emotions and how to be supportive.
• Establish short-term and long-term goals to manage symptoms, achieve recovery, restore functioning, enhance the quality of life, and prevent relapses.
• Educate the client and family members about expectations for quick recovery vs. what to expect, including the lag of medications reaching therapeutic levels.
• Improve chances of success with motivation, homework compliance, and tolerance for symptoms with graded activities.¹⁰ 
• OCD is treated with therapy, psychoeducational, and/or medication.
• The most effective therapy is Cognitive Behavioral Therapy (CBT) with Exposure Response Prevention (ERP).
  • ERP exposes the child to something that may make them anxious.
  • The child is encouraged to resist the urge to do the ritual.
  • The child then becomes used to the anxious feeling and learn to get slowly better with time for changing their rituals.⁴ 
  • Educate child and parent on OCD conceptualization, maintenance, and treatment.
  • Provide symptom reduction through exposure, response prevention, and habituation to feared stimuli.
  • Train parents to plan and coach children through exposures.¹¹ 
• Use a family-centered approach with collaboration as parents of children with OCD may feel burdened and struggle with the child’s symptoms.¹² 
• The child can potentially view their tendencies as a strength and be interpreted as giftedness.¹³ )
• Promote or modify the environment for students with OCD to feel comfortable and be able to contribute to the classroom.
  • (Sensory Processing) Strong reactions to sensory stimuli was found to be highly correlated with ritualism in children and adolescents.¹⁴ 
  • Minimize oral and tactile hypersensitivity to reduce ritualism with activities, the environment, e.g., certain foods, smells, textures, or social situations.¹⁵ 
• Keep stress levels low and never threaten or punish a child with OCD for their tardiness, forgetfulness, or procrastination.
• Provide the child with a partner to ensure the child has peers to accompany them.
• Reduce factors that may contribute to feelings of claustrophobia – away from windows and doorways (distractions) and provide an unobstructed view of the teacher or board.
• Allow the child to take breaks to ritualize.
• Whole-class interventions can be effective for addressing student anxiety.
• Incorporate emotional learning to encourage emotional expression.
• Maintain a level of expectation, set clear limits, and establish consequences of behavior.¹⁶ 
• Children and adolescents may experience functional impairment at home due to OCD symptoms.¹⁷ 
• Children with OCD who do better at school should be encouraged to spend more time in school-related activities.¹⁸ 
• (COVID-19) Encourage children and parents to maintain social contact virtually.¹⁹ 

Strategies for Students with OCD

• Address and prevent anxiety-provoking situations.
• Reduce the chances or impact of failure during learning in school.
• Model how to accept making mistakes.
• Provide social support for who to talk to when feeling anxious.
• Praise on-task behaviors in the classroom.
• Ignore reassurance requests that bring attention to what the student is doing (OCD symptoms).
• Allow the student to determine why worrying is unnecessary.
• Provide alternative tasks to complete with encouragement to stay on-task.
• Allow students to take short breaks when they feel overwhelmed or anxious.
• Provide students with structure, e.g., outline.
• Allow students to type their responses on a computer.
• Give clear and simple directions and break down complex tasks.
• Teach strategies for effective learning.
• Create social contracts for longer-term assignments with time expectations and estimations.
• Provide extra time or alternative locations as accommodations.
• Allow the student to demonstrate knowledge of subjects with alternative assignments.²⁰ 

Obsessive Compulsive Personality Disorder (OCPD)

“Obsessive Compulsive Personality Disorder is different from OCD. It is not diagnosed until adulthood. It is based on a pattern of behaviors and personality traits that get in the way of a balanced life and getting things done efficiently, like perfectionism, extreme orderliness, working way too hard, overthinking things, and being really controlling.”⁴ 

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