Especially for Educators

Recognizing Signs Obsessive-Compulsive Disorder in Children and Teens

This article is an expanded and revised version of an article that first appeared in Teachers in Focus magazine in February 1999 – Ministering to Students with Obsessive-Compulsive Disorder, by Cherlene Pedrick (Cherry)

(Names of the people in this article have been changed to protect their privacy)

As an adult with Obsessive-Compulsive Disorder (OCD), I feel a special empathy for children and teenagers with OCD. Most people develop OCD in young adulthood, adolescence, or childhood. Suspecting something is wrong, that we are different, we have a tendency to keep our symptoms secret because of shame and fear. It must be much worse for teenagers and children who want to be like everyone else.

Peter was diagnosed with OCD in sixth grade, and although he exhibited symptoms at school even with treatment, his teachers did not recognize signs of OCD in his behavior. His papers had many eraser marks because he could not let any of his letters touch each other. Even the tails of letters couldn’t touch the letters on the line below. His pencil and books had to be placed in certain places on his desk. His mother stapled his lunch bag closed so no one could poison his lunch. When he went to a religious school, they had daily prayer. He repeated the prayers softly to himself. Most recognizable were the constant questions; he asked questions about almost every assignment to make sure he got it right.

Obsessive-compulsive disorder is characterized by recurrent obsessions or compulsions severe enough to be time consuming (more than one hour a day), cause marked distress or significantly interfere with normal routine, occupational functioning, relationships with others, or usual social activities. The adult recognizes that the obsessions or compulsions are excessive or unreasonable at some point. Due to their limited development, children don’t always recognize this. Even adults may not realize their fears are unreasonable when they are anxious and obsessing.

Obsessions are persistent impulses, ideas, images, or thoughts that are experienced as intrusive and inappropriate and cause marked anxiety. The person has the sense that the thought is not the kind of thought that he would expect to have and not within his control. However, he is able to understand the obsessions are the product of his own mind and are not imposed from without.

Compulsions are mental acts, such as counting, praying, repeating words silently, or repetitive behaviors such as hand washing, ordering, or checking, with the goal of reducing or preventing anxiety, not to provide gratification or pleasure. The person usually feels driven to perform the compulsion to reduce the distress accompanying an obsession or to prevent some dreaded situation. Compulsions are either clearly excessive or not connected in a realistic way with what they are designed to prevent or neutralize.

As we can see from the account of Peter’s battle with OCD, even classic signs of OCD are not always noticed. Perhaps this is because these children are usually not disruptive in class. Jeremy was a well behaved, quiet child in Mrs. Miller’s first grade class. He answered questions in class, drew the typical pictures of houses, trees, and cars, learned to add, and played well with the other children. But he would not write in his journal.

"I can’t think of anything to write," he would tell Mrs. Miller, staring down at the empty paper.

For weeks Mrs. Miller struggled with Jeremy and his journal. She noticed that he didn’t finish assignments. As she watched him, she realized he had a vague fear of writing something wrong. Spelling and grammar had to be perfect before he handed in a paper. When she urged him too strongly to finish an assignment or write in his blank journal, he often cried.

At the first open house the children’s paperwork was displayed on each desk and colorful pictures decorated the walls. Although Jeremy’s pictures hung on the wall, and his math papers were on his desk, his journal remained empty.

When Jeremy’s parents came to the open house, Mrs. Miller was anxious to talk to them about his school work. As she extended her hand to greet Mr. Stevens, he drew back his hand and stuffed it in his pocket. She talked with Mr. and Mrs. Stevens about Jeremy’s work and encouraged them to have him seen by his pediatrician.

Mrs. Stevens sought treatment for Jeremy. He was diagnosed with OCD and improved greatly with behavior therapy and medication. He is in fourth grade now and functioning well. It is no surprise to the family that Jeremy has OCD, for his father has OCD also. OCD seems to run in families but is not thought to be a learned behavior; as with the Stevens’ family, each family member’s symptoms are usually quite different. Mr. Stevens’ symptoms involve contamination which explained his reluctance to shake hands.

Most children go through developmental stages characterized by rituals which are quite normal. These include bedtime rituals, not stepping on sidewalk cracks, counting, having lucky and unlucky numbers, ordering or arranging objects, and collecting things. These rituals begin in toddlers and become more intense in four to eight-year-old children. OCD rituals persist into adolescence. Normal childhood rituals enhance socialization, advance their development, and help them deal with anxiety. However, OCD rituals promote social isolation and are painful and incapacitating.

Children and teenagers with OCD may have a tendency toward perfectionism, have a more adult-like moral code, appear to be stubborn, have a more active fantasy life, have more anger and guilt, be disruptive, have difficulty making up their minds, or be overly neat and clean. I have compiled a list of signs of OCD to look for. Keep in mind, when reviewing the list, that having these symptoms does not necessarily mean a person has OCD. By definition of the disorder, OCD symptoms must be time consuming, cause marked distress, or significantly interfere with one’s life. These are simply signs that there may be a problem.

Some children may only have one symptom manifested by a seemingly insignificant behavior. Ashley was a fifth grade student earning straight A’s. But she developed an irritating habit. She began tapping her desk frequently. At first she tapped quietly. Then her tapping became louder. Soon she was tapping her chair and the floor. The rest of the class noticed the tapping and began to mimic her. As her teacher, Mr. Johnson, heard the tapping from every corner of the room and saw the embarrassed look on Ashley’s face, he knew he needed to talk to her parents.

He had no idea what was wrong, but he sensed that Ashley needed help. He could see that she was trying not to tap and just couldn’t seem to stop.

Mr. Johnson spoke with Ashley’s parents and they sought treatment for her. She was diagnosed with OCD and with therapy and medication, has now been able to stop tapping.

It is believed that OCD is associated with a chemical imbalance in the brain involving the neurotransmitter, serotonin. Medications are now available to help correct this imbalance. Behavior therapy and medication are the most commonly used treatments

Children may be afraid to tell a parent or authority figure about their obsessions or rituals and try to hide the symptoms out of fear that people will think they are "crazy." They are less aware of available treatment and may think they are the only ones in the world with these behaviors. Some children may not be aware that they have a problem.

If you suspect OCD symptoms in a child or teenager, talk to the school counselor, psychologist, social worker, nurse, or others in the student services team. Speak with the child’s parents about your concerns and suggest that they try to discuss the rituals or obsessive behavior with the child in a nonjudgmental manner. Encourage the parents to have the child seen by his or her pediatrician.

How Educators Can Help the Child with OCD

• Ask the parent how you can help. Behavior therapy comes in many forms and you may be able to play a part in recovery. However, it also may be better to treat the child like any other to discourage him or her from "using" the illness for special privileges, which may adversely affect his recovery
• While he or she is recovering, accommodate behaviors of which the child has no control. Punishment may increase stress and exacerbate OCD symptoms. Mrs. Miller waited until Jeremy was ready to write in a journal, then encouraged creativity, rather than perfect grammar and spelling.
• Never tolerate teasing by other children. Mr. Johnson recognized the pain teasing caused Ashley and would not allow it in his class.
• Designate a school employee to be the child’s "safe" person he or she can turn to when struggling with OCD symptoms. Assign the child to a teacher who is sensitive to the child’s needs. Jeremy was assigned to a teacher who was very familiar with OCD in second grade
• Educate the child’s peers about various disorders, such as asthma, ADD, epilepsy and OCD. Do not discuss the child’s OCD and his symptoms without obtaining the child’s and his or her parents’ permission.
• Watch for side effects of medications.
• Document changes in the child’s behavior that may be a result of intervention and share this information with the parents and health providers as needed.
• Assess the child for special education needs.
• Assure parents that they did not cause the OCD.

The booklet, School Personnel: A Critical Link, (available through the OC Foundation) is an excellent resource for school personnel on identification, treatment, and management of OCD in children and adolescents.

Jeremy and Ashley are functioning well in school with the help of behavior therapy, medication, and the support of their families and school personnel. Ashley no longer gets straight A’s. Now she gets A’s and B’s, but this is much preferable to a life struggling with OCD. With treatment, Peter has improved but none of his teachers or friends have become aware of his illness.

Signs of Obsessive-Compulsive Disorder:

• being overly concerned with dirt and germs
• frequent hand washing or grooming, often in a ritualistic manner; red, chapped hands from excessive washin
• untied shoes, since they may be "contaminated"
• avoiding touching certain "unclean" things
• excessive concern with bodily wastes or secretions
• insistence on having things in a certain order
• having to count or repeat things a certain number of times, having "safe" or "bad" numbers
• repeating rituals such as going in and out of doors a certain way, getting in and out of chairs in a certain way, or touching certain things a fixed number of times; this may be disguised as forgetfulness or boredom
• excessive checking of such things as doors, lights, locks, windows, and homework
• taking a lot of time to perform tasks; you may find a lot of eraser marks on school work
• going over and over letters and numbers with a pencil or pen
• excessive fear of harm to self or others, especially parents
• fear of doing wrong or having done wrong
• excessive hoarding or collecting
• staying home from school to complete assignments, checking work over and over
• withdrawal from usual activities and friends
• excessive anxiety if usual routines are interrupted

Dornbush, Marilyn P. Ph.D and Sheryl K. Pruitt, M.Ed. Teaching the Tiger. Hope Press. 1995

Foa, Edna, Ph.D. and Reid Wilson, Ph.D. Stop Obsessing! How to Overcome Your Obsessions and Compulsions. Bantam Books, 1991

Gravitz, Herbert, Ph.D. Obsessive Compulsive Disorder, New Help for the Family. Healing Visions Press, 1998 (Also from Healing Visions Press, the following booklets: When the Person with OCD is Your Child, When the Person with OCD is Your Parent, When the Person with OCD is Your Brother or Sister, A Note to Therapists and Other Educators)

Osborn, Ian, MD. Tormenting Thoughts and Secret Rituals, The Hidden Epidemic of Obsessive-Compulsive Disorder. Pantheon Books, 1998

Rapoport, Judith L. MD, editor. Obsessive-Compulsive Disorder in Children & Adolescents.

American Psychiatric Press, Inc.,1989

Rapoport, Judith L. MD. The Boy Who Couldn’t Stop Washing: the Experience and Treatment of Obsessive-Compulsive Disorder. E.P. Dutton,1989

Steketee, Gail, Ph.D. and Kerrin White, MD. When Once is Not Enough. New Harbinger Publications, Inc.,1990

The Obsessive-Compulsive Foundation publishes a newsletter offering information about living with OCD, new research, and treatment advances. They also publish a newsletter for children and teenagers called Kidscope. The booklet, School Personnel: a Critical Link, by Gail B. Adams, Ed.D. and Marcia Torchia, R.N. can be obtained through the Obsessive-Compulsive Foundation. Other information can also be ordered through the foundation. Their address is:

The OC Foundation, Inc.
P.O. Box 70
Milford, CT 06460-0070
(203)878-5669

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