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Understanding obsessive compulsive disorder.

Article  in  The Journal of School Nursing · October 2009

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Mental Health

Understanding obsessive
compulsive disorder
Obsessive compulsive disorder (OCD) can severely impair children and young people’s
academic performance as well as their social life. School nurses can help identify
suspected cases of OCD as well as support those suffering from the condition.

O
bsessive compulsive disorder (OCD) is a common
and potentially debilitating anxiety disorder.
Although it has been considered to be rare in
children and adolescents, recent studies have reported
prevalence rates of 1–3% in children and young people
aged 5–15 years (Heyman et al, 2003). OCD has an equal
incidence in both males and females and can occur in
children as young as 5 years old (Heyman et al, 2003).
OCD is characterized by the presence of obsessions
and/or compulsions. Obsessions are intrusive thoughts,
images or impulses that are experienced as repetitive
(occur over and over again) and unwanted. Young
people can often (but not always) recognize that their
obsessions originate from their own mind, but they are
experienced as out of character, and are distressing or
anxiety-provoking. The content of obsessions can be
about normal preoccupations (e.g. germs, personal safety)
but the frequency and intensity of the intrusive thoughts
are significantly elevated, therefore leading to distress
(Rachman and de Silva, 1978). Alternatively, obsessions
can sometimes be bizarre, senseless or magical (Volz and Common compulsions in children and young people
Heyman, 2007). Common obsessions in children and include excessive or ritualized washing or cleaning.
young people include fears of contamination, illness or
dirt, fears of harm coming to themselves or loved ones, perfection, symmetry or order.
worry or fears about hurting other people, distressing Compulsions are repetitive or stereotyped (ritualistic)
sexual thoughts (especially in adolescents), or a need for behaviours, performed in order to neutralize an obsessional
fear, and therefore relieve anxiety. Compulsions are often
Katie Lang is an Assistant Psychologist at the National and time consuming and distressing for the child to carry
Specialist Clinic for Young People with Obsessive Compulsive out. They can be normal everyday behaviours (e.g. hand
Disorder, Maudsley Hospital washing) that are performed in excess (e.g. excessive
Georgina Krebs is a Clinical Psychologist at the National and frequency and intensity) or performed in a ritualized
Specialist Clinic for Young People with Obsessive Compulsive way. They may be clearly and logically related to the
Disorder, Maudsley Hospital fear (e.g. hand washing in order to alleviate fear of dirt
Caroline Stokes is a Clinical Psychologist at the National and or germs). On the other hand, compulsions can be
Specialist Clinic for Young People with Obsessive Compulsive behaviours that are ‘superstitious’ or ‘magical’, have no
Disorder, Maudsley Hospital everyday function, and may not be logically related to a
Cynthia Turner is a Clinical Psychologist at the National and feared outcome (e.g. tapping the table 18 times in order
Specialist Clinic for Young People with Obsessive Compulsive to stop something bad from happening to a loved one).
Disorder, Maudsley Hospital, South London and Maudsley In addition to observable compulsions, rituals may also
NHS Foundation Trust, and a Clinical Lecturer at Kings College be covert mental actions or behaviours, such as prayer
London, Institute of Psychiatry rituals or neutralizing ‘bad thoughts’ by purposefully
Email: Cynthia.Turner@slam.nhs.uk thinking ‘good thoughts’.
Key words A young person may become highly upset or angry if
■ Obsessive compulsive disorder ■ Anxiety ■ OCD his/her compulsions are interrupted or if they are unable
■ Cognitive behavioural therapy to perform or complete a compulsion for any reason.
Typically, the young person does not want to perform

390 British Journal of School Nursing October 2009 Vol 4 No 8

 Mental Health

their compulsion but finds it extremely difficult to resist

for fear that a dreaded event will occur if the ritual is not Table 1. Case study 1
completed. Common compulsions in children and young
Rebecca, a 12-year-old girl, first showed signs of OCD when she
people include (Table 1 and 2):
moved from primary to secondary school. She started to become
■ Excessive or ritualized washing or cleaning
concerned with germs and illnesses such as AIDS and cancer. She
■ Checking things repeatedly
also started to become fearful of being contaminated by chemical
■ Re-writing or erasing, or repeating tasks over and again
substances such as detergents. Rebecca worried that if she came
■ Arranging or ordering items
into contact with any of these substances they would ‘infect’ her and
■ Touching, tapping or rubbing
she would die. As a consequence, she would wash her hands up
■ Counting
to 40 times a day, so much so that they became raw and chapped.
■ Doing something until it feels ‘just right’.
Rebecca found it very difficult to concentrate in class because
she was so preoccupied with whether she might have touched
The effects of OCD on school and something that was contaminated. She would frequently leave the
home life class to wash her hands, but was too embarrassed to explain to her
OCD can have a profound effect on schooling, and
teacher why and so would often get into trouble. Science lessons
academic functioning is significantly and severely
were particularly difficult due to her fear of chemicals, and eventually
impaired in approximately 50% of young people with
Rebecca became so worried that she would avoid school on days
OCD (Piacentini et al, 2003). Poor concentration
when she had science lessons.
is common, usually as a result of being distracted
by upsetting and intrusive thoughts (obsessions). Comment: This is a fairly typical presentation of OCD, with fears
Compulsive behaviours can also interfere with school of contamination, handwashing and avoidance of ‘germy’ or
work. For example, a child with contamination fears contaminated places. It is also common for the onset of OCD to be
may feel compelled to leave the classroom to perform triggered by a stressful life event, such as transition to
washing rituals if he/she has dropped his/her pen on secondary school.
the floor. Repeating rituals, such as re-reading and
re-writing can be particularly impairing as the young
person may spend a long time going over his/her
work, slowing him/her down dramatically and, in Table 2. Case study 2
the case of rewriting, it can lead to illegible work.
Joe was 15 years old. He was extremely worried and upset about
OCD can also cause the child to become avoidant
intrusive thoughts that he was experiencing about sexual acts
of situations at school that may provoke intrusive
with children. He did not want to have these thoughts and found
thoughts, for example, avoiding areas that they believe
them abhorrent and distressing, but he worried that he might be
to be contaminated (e.g. school toilets) or lessons
a paedophile and that one day he might act on these thoughts.
that they may perceive as ‘dangerous’. A child with
Consequently, he avoided situations involving young children,
obsessional worries about being punished by ‘God’ may
including his younger sister’s birthday party. When he was around
find religious education lessons particularly anxiety
younger children he would avoid looking at them and avoid any
provoking and may therefore attempt to avoid them.
physical contact. When Joe experienced sexual thoughts about
Similarly, a young person who fears being poisoned
children, he would try to push them out of his head or ‘cancel them
may avoid any contact with science laboratories given
out’ by deliberately thinking of ‘good thoughts’. These mental rituals
the potential for chemicals to be nearby. In severe cases,
would take up hours every day. After several months, Joe disclosed
a young person with OCD may struggle to leave the
his worries to his parents. They became very concerned and wondered
house and may be unable to attend school altogether.
if it was safe to leave him alone with younger children.
Social interaction at school can also suffer due
to OCD. A child with contamination fears may feel Comment: It is common for a young person with OCD, particularly an
reluctant to be physically near others, and therefore adolescent, to report intrusive and unwanted sexual thoughts. Children
unable to participate in many typical activities of experiencing sexual obsessions can be wrongly viewed as a ‘risk’ or
school life; for example, group games such as football ‘dangerous’. It is important for professionals to realize that the young
or even eating in the school cafeteria. Many children person experiencing these thoughts finds them extremely distressing
with OCD are embarrassed by their rituals and may and would never act on any of these unwanted impulses.
refrain from social situations that may provoke them.
When children do engage in rituals in the company
of others, they may come across as socially odd and completed their compulsions to their satisfaction. If
be teased by their peers. Indeed, studies that have this is the case, they are likely to be exhausted at school,
examined bullying among children with OCD have and may be consistently late attenders or even become
found higher rates than in non-clinical groups (Storch increasingly socially withdrawn.
et al, 2006). Young people with OCD frequently engage At home, upsetting and intrusive thoughts can cause
in long and complicated rituals, and this may mean children to become irritable, often leading to increased
that they are awake late into the night until they have arguments with family members. Children are frequently

October 2009 Vol 4 No 8 British Journal of School Nursing 391

Mental Health
A young person who fears being poisoned may avoid any contact with
science laboratories given the potential for chemicals to be nearby.
observed to repeatedly seek reassurance from family
members. They may repeatedly ask questions such as:
‘Are my clothes clean?’
‘Did I lock the door properly?’
Once reassurance has been received, the child’s anxiety
may temporarily decrease. However, the relief gained
from the reassurance is only short lived and the
same reassurance is needed again and again, much to
the annoyance of the family member. This repetitive
reassurance seeking can lead to tension and disagreement
among the family. Family members may also find
themselves becoming increasingly involved in some
of these rituals. For example, they may do excessive
amounts of washing and cleaning, or repeatedly check
Table 3. Screening questions
for OCD recommended by NICE
■ Do you wash or clean a lot?
■ Do you check things a lot?
■ Is there any thought that keeps bothering you that
you would like to get rid of but cannot?
■ Do your daily activities take a long time to finish?
(e.g. getting ready for school)
■ Are you concerned with putting things in a special
order or are you very upset by mess?
■ Do these problems trouble you?
From: National Collaborating Centre for Mental Health, 2005
392
things for their child, in an effort to try and help them
to feel less distressed. Parental and sibling involvement
in rituals has been shown to be associated with distress
among family members as well as family dysfunction
(Calvocoressi et al, 1995).
Recognizing and detecting OCD
In most cases OCD is associated with a characteristic set
of symptoms. Nevertheless, it may be difficult to detect
for a number of reasons:
■ It is common for young children to engage in repetitive
routines such as bedtime rituals, and most often this
is a normal part of development. However, in some
cases, the repetitive behaviour may be due to OCD yet
adults might dismiss true OCD symptoms believing
that they are a phase the child will outgrow. Ordinary
childhood rituals or routines can be disentangled from
compulsions by considering whether they are likely
to take up a large amount of time, cause distress
(particularly if interrupted) and interfere with the
child’s functioning in day-to-day life (World Health
Organization, 2002)
■ Younger children can find it difficult to articulate
the obsessions that are driving them to perform
rituals. For example, a child with ‘fussy’ eating
habits may have an underlying fear of food
poisoning, yet because they cannot explain these
fears, parents may not recognize that it could in fact
be OCD
■ Children with OCD are often very embarrassed
about their symptoms and therefore attempt to
conceal them. They may feel as though they are ‘mad’
or ‘weird’, and may therefore be reluctant to disclose
information about their obsessions or compulsions.
This is particularly the case for sexual obsessions,
in which the young person experiences distressing
sexual thoughts (e.g. about sexual acts with children
or family members), and may worry that others
would think (incorrectly) that they are dangerous
or perverted.
To aid detection of OCD, the National Institute for
Health and Clinical Excellence (National Collaborating
Centre for Mental Health, 2005) has suggested six
screening questions (Table 3). Answers to these questions
do not provide a diagnosis of OCD on their own, but if
a child answers yes to more than one of these questions
it may indicate symptoms of OCD, and he/she should
be assessed by his/her GP or local child and adolescent
mental health service (CAMHS).
Treatment
In 2005, the National Institute for Health and Clinical
Excellence published a guideline for the treatment of
OCD, based on existing research and expert consensus
(National Collaborating Centre for Mental Health,
2005). They concluded that the first-line treatment
for OCD in young people should be a particular type
of psychological therapy called cognitive behaviour
British Journal of School Nursing October 2009 Vol 4 No 8

therapy (CBT). CBT helps young people feel better by
making changes to unhelpful thoughts and behaviour.
For OCD, this involves helping a young person to
gradually face their OCD fear while at the same
time refraining from performing any compulsions. For
example, a young person with a fear of contamination
may be encouraged to touch the floor and refrain from
washing their hands. With practice, as the child learns
that there is nothing to be afraid of, the tasks become
less anxiety-provoking until their fear disappears. CBT
for OCD is highly effective, and the majority of young
people respond well and are OCD-free at the end of
treatment (Turner, 2006).
CBT is typically carried out face-to-face in a clinic
setting. However, many young people are required to
travel long distances in order to access appropriately
trained and qualified professionals, and for this reason,
current research is focusing on developing alternative
ways of delivering effective treatment to young people.
The Obsessive-Compulsive and Related Disorders Service
for Young People at the Maudsley Hospital are currently
running a large research project comparing face-to-
face CBT with CBT conducted over the telephone. This
research is very important because being able to offer
effective therapy over the telephone will help to make
therapy for OCD more accessible to young people all
over the country.
The role of schools
In addition to showing patience and understanding
towards children and young people with OCD, there are
a number of practical ways in which schools can offer
help to a young person. First and foremost, schools can
assist a young person to obtain accurate information
about OCD, for example, what OCD is and how it
can be treated (Table 4). School staff can reinforce the
message that OCD is a known and treatable problem,
thereby helping the young person to realise that they
are not alone and instilling optimism about recovery.
In addition, schools can encourage a young person with
suspected OCD to seek an assessment (and treatment)
from appropriately trained and qualified mental health
professionals. This would usually involve going to their
GP in the first instance, who may then refer the child
on to their local CAMHS or to the Maudsley Hospital
Obsessive-Compulsive and Related Disorders Service
for Young People, although qualified school nurses can
make direct referrals.
Once a young person has been diagnosed with OCD
and is accessing treatment, schools can play a key role
in the recovery process. Therapists may liaise closely
with school personnel to establish ways in which they
can support the young person in implementing CBT
strategies in the classroom. For example, a young person
with obsessional worries about chemicals may be set
the task of going into the chemistry lab and touching
surfaces and objects that they fear may be contaminated,
as part of their treatment and with the permission of
October 2009 Vol 4 No 8 British Journal of School Nursing
Mental Health
Table 4. Further information
For children
■ Wagner AP (2004) Up and Down the Worry Hill: A Children’s Book
About Obsessive Compulsive Disorder and its Treatment. Lighthouse
Press, Deerfield Beach, FL
An illustrated book designed to help parents and professionals
explain OCD to younger children through the story of ‘Casey’, a
young boy with OCD
■ Wever C, Phillips N (1994) The Secret Problem. Shrink-Rap Press,
West Concord, NSW
An illustrated book that describes OCD in clear and simple language
to help children, teenagers and their parents understand OCD and
its treatment
For adolescents
■ Derisley J, Heyman I, Robinson S, Turner C (2008) Breaking free
from OCD: A CBT Guide for Young People and Their Families.
Jessica Kingsley Publishers, London
A step-by-step guide to overcoming OCD using cognitive
behavioural techniques. This book is written for older children
and teenagers, but can also be a helpful source of information for
parents and professionals
■ March JS, Benton M (2007) Talking Back to OCD: The Program That
Helps Kids and Teens Say “No Way”- and Parents Say “Way to Go”.
Guildford Press, New York, NY
Dr March tackles the bewilderment and isolation felt by many
families, highlighting the fact that OCD is nobody’s fault and
emphasizing that recovery is possible
For parents
■ Chansky TE (2001) Freeing Your Child from Obsessive-Compulsive
Disorder. Three Rivers Press, New York, NY
Proven techniques parents can use to help their children break
the debilitating cycles of obsessive compulsive disorder and take
control of their own lives. In this book, Dr Chansky offers step-by-
step ways to guide children put of OCD and help parents cope every
step of the way
For Professionals
■ Storch EA, Geffken GR, Murphy TK (2007) Handbook of Child and
Adolescent Obsessive-Compulsive Disorder. Lawrence Erlbaum
Associates, Publisher, Mahwah, NJ
This book provides a comprehensive overview of the assessment
and treatment of paediatric OCD. It includes a useful chapter
devoted to school issues
Useful websites
■ Factsheet for young people, parents and teachers
www.ocdyouth.info
■ OCD action
Helpline: 0845 390 6232, Tel: 020 7253 2664
Email: support@ocdaction.org.uk
www.ocdaction.org.uk
■ OCD-UK
PO Box 8955, Nottingham, NG10 9AU
www.ocduk.org
393
Mental Health
their teacher. Therapists may also discuss with teachers
actions which may inadvertently be serving to maintain
the child’s OCD symptoms (e.g. by providing reassurance
when the child ask repeated questions) and work with
them to find alternative ways of responding to the child
that will promote recovery. For young people with severe
OCD who have been unable to attend school, therapists
may work with teachers and the families to establish a
‘back to school plan’ for gradually reintegrating them
back into full time education.
There are also a number of pragmatic ways in which
schools can help to minimize the impact of OCD on
a young person’s education. It can be helpful to allow
extra time in examinations and for the completion of
homework assignments, as it is well established that
intrusive thoughts and/or compulsions can slow students
down or impair concentration. Alternative rooms in
which to study or take lessons could be temporarily
arranged if particular classrooms trigger obsessions or
rituals. A ‘safe haven’ could be provided for students to
go to when they need to calm down if they are feeling
particularly upset or stressed. Some students find it
helpful to agree on a sign to use with their teachers so
that teachers know when the student needs extra help,
support or some time out. A young person with OCD
may also find it useful to have a mentor assigned to
them, who can offer them support when needed. It is
important to note, however, that such measures should
be established as temporary adjustments, and they
should not viewed as a permanent solution. Ultimately a
young person needs to overcome their OCD by working
towards facing up to situations that they find stressful, as
outlined above.
Conclusions
OCD is a relatively common anxiety disorder,
experienced by as many as 3% of young people at
any one point in time. The disorder is characterized
Key Points
■ OCD is a common disorder characterized by unwanted thoughts,
impulses or images (obsessions) and/or repetitive, stereotyped
behaviours (compulsions)
■ To fulfill the diagnostic criteria for OCD, obsessions and/or
compulsions must be time-consuming, cause significant distress or
interfere significantly with daily functioning
■ OCD can have a profound effect on a child’s functioning at school by
impairing concentration, leading to avoidance of certain situations
that may trigger symptoms, and interfering with social interactions
■ Once recognized and diagnosed, OCD can be treated using a
psychological therapy called cognitive behavioural therapy (CBT)
■ Schools can help young people with OCD by encouraging them to
access treatment, working with therapists to implement treatment
programmes, and putting in place temporary, practical measures to
minimize the impact of OCD on academic functioning
394
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by obsessions and compulsions, which are time-
consuming and cause signifi cant distress and/or
marked interference to the young person’s day-to-day
functioning. OCD often goes undetected, as young
people are typically highly embarrassed about and/or
distressed by their symptoms. However, recognition
and diagnosis of OCD is of paramount importance,
not least so that young people can access effective
treatments as early as possible. If left untreated, OCD
typically persists and can seriously disrupt a young
person’s social and academic functioning, their family
life, and negatively impact upon peer relationships
and future development. School personnel can play an
important role in a young person’s recovery from OCD.
They can provide information about OCD to the young
person and their parents, and encourage them to access
assessment and evidence-based treatment through
appropriate professionals. For children with a known
diagnosis of OCD, schools can work with the young
person’s therapist and provide support in implementing
elements of their treatment. Furthermore, schools can
help to minimize the impact of OCD on education by
putting in place various practical, temporary measures
while the child accesses treatment. Treatment is most
likely to be effective when a young person, his/her
family, health professionals and education professionals
all work together to promote recovery. BJSN
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McDougle CJ (1995) Family accommodation of obsessive-com-
pulsive disorder. Am J Psychiatry 152: 441–3
Heyman I, Fombonne E, Simmons H, Ford T, Meltzer H, Goodman
R (2003) Prevalence of obsessive-compulsive disorder in the
British nationwide survey of child mental health. IInt Rev
Psychiatry 15: 178–84
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compulsive disorder: Core interventions in the treatment of
obsessive-compulsive disorder and body dysmorphic disorder.
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Behav Res Ther 16: 233–8
Storch EA, Ledley DR, Lewin AB, Murphy TK, Johns NB, Goodman
WK, Geffken GR (2006) Peer victimization in children with
obsessive-compulsive disorder: Relations with social-psychologi-
cal adjustment. J Clin Child Adolesc Psychol 35: 446–55
Turner CM (2006) Cognitive-behavioural theory and therapy for
obsessive-compulsive disorder in children and adolescents:
Current status and future directions. Clin Psychol Rev 26: 912–38
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Diseases. 10th revision. World Health Organization, Geneva,
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British Journal of School Nursing October 2009 Vol 4 No 8