student services

Obsessive-Compulsive Disorder

Characterized by repeated behaviors intended to control recurring anxieties, obsessive-compulsive disorder probably affects at least one of your students.

By Leslie Z. Paige arcus’s parents became concerned Performing rituals provides temporary when he asked the same question every relief from the anxiety created by the obsessive Mnight: “How do people get AIDS?” thoughts. Sometimes there is a clear connec- They also noticed that Marcus frequently tion between the obsession and the compul- washed his hands, which had become red and sion (e.g., contamination and washing), but chapped, and often kept them tucked into his this may not always be the case (e.g., counting armpits. behaviors may be used to prevent harm to oth- Similar concerns surfaced at school—­ ers). Often the urge to perform the compulsive Marcus frequently asked permission to leave behaviors becomes stronger over time. If the the classroom to go wash his hands, kept original compulsion becomes less effective them in his pockets, and often stopped by the in reducing anxiety, then other behaviors or nurse’s office with questions about contagious more elaborate rituals are added to provide ailments, particularly AIDS. He avoided inter- relief. The compulsive behaviors can become acting with other students—to the point that extremely time-consuming and interfere with he now ate lunch at a corner table by himself. normal functioning. Some people can delay During a session with the school psychologist, the behaviors, but this is very difficult and they Marcus indicated that he was overwhelmed will nearly always need to perform the ritual with fear that he would contract AIDS al- later. Students who are able to delay their though he never engaged in risky behavior. compulsions while in class, for example, may Marcus’ story is an example of obsessive- need a private place to go to perform rituals at compulsive disorder (OCD), an anxiety disor- a later time during the school day. der that can interfere with normal life People who have OCD are not delusional. and cause serious social and academic diffi- They usually recognize that these thoughts and culty in school. Although OCD is a psychiatric behaviors are unreasonable but feel unable disorder that requires professional diagnosis to control them. Symptoms tend to wax and and treatment, there are several ways that wane, and they may worsen as a result of ill- school personnel can help students who ness or stress. Washing; checking rituals; and have OCD. preoccupation with disease, danger, and doubt Leslie Z. Paige is are among the most common symptoms in a nationally certified Understanding OCD childhood-onset OCD (Swedo, Rapoport, school psychologist and a Once thought a rare psychiatric illness, OCD Leonard, Lenane, & Cheslow, 1989). grants facilitator at Fort Hays State University is now known to be a more common disor- Approximately 2%–3% of people (in- in Hays, KS. der characterized by a cycle of obsessions and cluding adolescents) have OCD, although compulsions that cause extreme distress, dys- this may be an underestimate because many Student Services is function, and fear. It is not simply meticulous- symptoms are kept secret. OCD can emerge produced in collaboration ness or worrying. Obsessions are involuntary, as early as preschool. The number of children with the National Association of School recurring, and unwanted thoughts that cause who develop the disorder peaks at puberty and Psychologists (NASP). feelings of anxiety or dread. They are irrational then again during early adulthood (National Articles and related and interfere with normal thinking. Compul- Institutes of Mental Health, Pediatric Obses- handouts can be downloaded from www sive behaviors are repeated to try to control the sive-Compulsive Disorder Research, 2006). .naspcenter.org/principals. obsessive thoughts. One-third of adults who have OCD developed

12 Principal Leadership September 2007 symptoms as children. Although OCD oc- Treatment curs equally in both sexes, there is an earlier Treatment success and effective strategies de- onset in boys than girls (National Institutes of pend on the age of the student and the severity Mental Health, 2006; Obsessive-Compulsive of the behavior. Common treatments include Foundation [OCF], 2006). medication and cognitive behavioral therapy OCD is related to tic disorders, such as (CBT). Medications help decrease anxiety and Tourette’s syndrome, and some adolescents reduce the intensity of the symptoms so the have both. OCD can also exacerbate other student is better able to ignore the obsessive disorders, such as Attention Deficit Hyperactiv- thoughts. CBT helps the student cope with ob- ity Disorder (ADHD), depression, and panic sessive thoughts and reduce his or her need to common compulsions disorder (OCF, 2006). Relatively persistent in perform compulsive behaviors. Many adoles- include: adults, child-onset OCD has a complete remis- cents who have OCD fear that they are going • excessive washing sion rate of 10%–50% by late adolescence crazy. CBT helps them understand the disorder, and cleaning (Zohar, 1999). Without treatment, OCD may helps decrease their symptoms, explains their • repetitive checking become chronic and result in severely de- behaviors, and teaches them coping strategies and rechecking creased functioning. The effects on adolescents that can be reinforced by parents and school • Counting or repeat- can be considerable, including depression, staff members. ing words (usually agitation, poor attention and concentration, silently) feelings of shame, slow performance, and Effects on School Performance • redoing, such as other problems associated with poor academic OCD can have a significant negative effect on opening and closing, functioning and difficulties with relationships learning, particularly if left untreated. Complex erasing and rewriting (Paige, 2004). rituals may cause attendance problems that • Hoarding useless appear similar to school avoidance. In school, items Cause and Diagnosis students may avoid situations or places that • praying (continuous The cause of OCD is unknown, but research increase their obsessive thoughts or may spend or excessive) suggests that it may relate to a biochemical im- time performing rituals in secret, which can • Symmetry (move- balance that interferes with the way the brain result in missed learning time and increased ments or objects need processes information and causes the brain to social isolation. Obsessive thinking may mimic to match or be ordered send false messages of danger. OCD may be a the symptoms associated with Attention Deficit in a certain way) learned response to reduce anxiety or may be Disorder because students are distracted by triggered by a stressful event. their obsessive thoughts or are trying to delay common obsessions Children and adolescents may hide their performing a compulsive behavior. Teachers include: symptoms for fear of being regarded as crazy should understand that a student who has • Contamination or weird. Adolescents may be particularly OCD and appears to be inattentive or agitated • Harm to self or others conscious of the stigma associated with OCD actually may be focused on distressing obses- • Sexual thoughts symptoms and may be adept at devising sive thoughts or trying hard to not tap a pencil • Death explanations for their behaviors or ways to a certain number of times. The compulsive • Doubting avoid places or situations that trigger them. behaviors may result in bullying or victimizing • Sin or guilt Compulsive rituals often begin gradually, and the student who has OCD. Obsessive thoughts • belief that things parents may unintentionally compensate for may create agitation or social problems. need to be done in a the behaviors. If children and adolescents have certain way or number rituals that are developmentally appropriate Helping Students With OCD of times to avoid harm (e.g., lining up stuffed animals in a certain Raise awareness. Early identification and way or wearing a lucky shirt for a ballgame) or appropriate treatment are very important appear healthy (e.g., washing hands after using to managing—and recovering from—OCD. the bathroom), parents may not initially be School personnel should be alert to the concerned by OCD symptoms. As a result, they symptoms of OCD and seek appropriate may not seek treatment for their child until advice from the school psychologist or school the behaviors become significantly disruptive counselor. Prolonged or frequent absences (Snider & Swedo, 2000). from class, unexplained agitation, repetitive,

September 2007 PrinciPal Leadership 13 student services

Identification and regimented behaviors might all be signs of a sionals communicate with the student’s health Treatment of OCD problem. Some behaviors may not be directly care provider regarding treatment plans and • 2%–3% of high school observed (e.g., hand washing) but can be behavior limits. The school psychologist may students—nearly inferred from indirect observations (e.g., raw, be able to suggest strategies to decrease anxiety, 500,000 individuals— bleeding hands). Reduce stigma by educat- reinforce coping skills, and enhance academic have OCD.* ing staff members and students about OCD performance. The school nurse may need to • OCD is highly man- and explaining the fact that symptoms of the administer medication during the school day. ageable, even curable disorder are not in the adolescent’s control and These school-based supports should be coordi- in 10%–50% of cases, are no more his or her fault than shortness of nated with the student’s health care providers. but early diagnosis breath is for a student with asthma. Provide appropriate support. Teachers and treatment are Partner with parents. Parent involvement should know how OCD affects learning and at- important. is essential to helping a student cope with tention in general terms and how they affect a • Adolescents may OCD. Some parents may require education particular student. They should also know how hide their symptoms about the disorder and how the school can to respond appropriately to a student who is for fear of being labeled support their child. Some parents will seek col- distressed or disturbed by unwanted thoughts. crazy. laborative support from school, but others may Telling adolescents who have OCD to stop • A combination be concerned with privacy and resist school worrying or that nothing bad will happen is of medication and involvement in treatment plans. Parents and not sufficient, and punishing or embarrass- cognitive-behavior adolescents feel more confident and hope- ing them is ineffective and may worsen the therapy can help ful and interventions are implemented more symptoms. diminish symptoms. effectively when parents are informed and are Well-structured classroom environments embraced as partners in decisions about how with clear expectations, smooth transitions, *Based on 2007 enrollment to help their child cope—and succeed—at and a calm climate are helpful for all students, estimates from the U.S. Department of Education, school. but especially for students who have OCD, National Center for Education Collaborate with community providers. whose symptoms may be exacerbated by stress. Statistics (2006). Ideally, school-based mental health profes- Some accommodations may be needed, such as allowing extra time to take a test because of a student’s compulsion to check and recheck. The school should ensure that there is at least one staff member (e.g., a school psychologist or a counselor) to whom a student can turn when struggling with symptoms. The school may also need to arrange for a safe spot for a student who is feeling overwhelmed with intense thoughts or feelings. Some students may qualify for special education services if the disorder impairs learning or behavior to a ADVERTISEMENT significant degree. Summary OCD can cause extreme disruption and distress for adolescents at a time when both self-actualization and socialization are vital and disrupted learning can have serious conse- quences. Fortunately, OCD is also manageable when identified and treated early and consis- tently. School administrators can help students with OCD by ensuring that staff members understand the disorder, recognize symptoms, and are prepared to provide the appropriate

14 Principal Leadership September 2007 support. Equally important, principals should n National Institutes of Mental Health, Pedi- Resources atric Obsessive-Compulsive Disorder Research. work to eliminate the stigma against those Freeing your child from who have OCD and other mental illnesses so (2006). FAQs about OCD. Retreived May 31, 2007, from http://intramural.nimh.nih.gov/pocd/ obsessive-compulsive that all students feel safe, valued, and sup- pocd-faqs.htm#FAQ-1 disorder. T. E. Chansky. ported by their school community. n Paige, L. Z. (2004). Obsessive-compulsive (2000). New York: Treatment for Marcus included medica- disorder: Information for parents and educators. Three Rivers Press. tion and CBT in addition to special education In Canter, A. S., Paige, L. Z., Roth, M. D., Romero, services for ADHD. The IEP team determined I., & Carroll, S. A. (Eds.), Helping children at home National Institutes of and school II: Handouts for families and educators. that Marcus’s obsessive thinking had interfered Mental Health Bethesda, MD: National Association of School with his ability to concentrate and perform Psychologists. www.nimh.nih.gov/ academically. In consultation with his thera- n Obsessive-Compulsive Foundation. (2006). HealthInformation/ pist and the school psychologist, the IEP team What is OCD? Retreived June 1, 2007, from www. ocdmenu.cfm added goals to address his OCD symptoms to ocfoundation.org/what-is-ocd.html his IEP. He is better able to control his fears of n Snider, L. A., & Swedo, S. E. (2000). Pediatric Teens Health obsessive-compulsive disorder. The Journal of the contamination, and his hand-washing behav- http://kidshealth.org/ American Medical Association, 284, 3104–3106. teen/your_mind/ ior has decreased to near normal. By monitor- n Swedo, S. E., Rapoport, J. L., Leonard, H. L., ing the condition of his hands, his parents and Lenane, M., & Cheslow, D. (1989). Obsessive- mental_health/ teachers can intervene as needed. PL compulsive disorder in children and adolescents: ocd.html Clinical phenomenology of 70 consecutive cases. Archives of General Psychiatry, 46, 335–341. OCD Foundation References n Zohar, A. H. (1999). The epidemiology of www.ocfoundation.org n National Institutes of Mental Health. (2006). obsessive-compulsive disorder in children and Anxiety disorders. Retrieved May 31, 2007, from adolescents. Child and Adolescent Psychiatry, 8, www.nimh.nih.gov/HealthInformation/ocd 445–460. menu.cfm

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