OCD: Obsessive-Compulsive Disorder in Youth
Obsessive-compulsive disorder (OCD) is characterized by repetitive, ritualisitc behaviors and thought patterns.
The obsessional thoughts and compulsive behaviors are often difficult to stop. The compulsive behavior is often carried out to reduce the likelihood of adverse consequences.
OCD runs a long-term and impairing course in many children and teenagers and affects 1.5 to 2.2 million children in the United States.
Early-onset obsessive-compulsive disorder (OCD) is one of the more common mental illnesses of children and adolescents, with prevalence of 1% to 3%. In the United States the mean age of onset is 19.5 years and 25% of cases start before age 14 years with nearly 25% of males having an onset before age 10 years (DSM-5). Its manifestations often lead to severe impairment and to serious conflicts in the family. Comorbid mental disturbances are present in as many as 70% of patients.
While Cognitive Behavioral Therapy is the treatment of first choice (March & Mulle, K. (1998) , followed by CBT with an SSRI, the disease takes a chronic course in more than 40% of patients (Walitza,et al., 2011.) Forgiveness therapy (FT) can be effective in diminishing the excessively angry obsessional thoughts and disruptive behaviors and that are highly comorbid with OCD. FT not only diminishes anger; it also decreases anxiety.
Fear and Anger
Obsessive-compulsive symptoms are often a defense against strong feelings of fear and anger which the child is unable to face. Betrayal experiences that damage trust leads to the development of anger and fear that are often unrecognized. Also, very sensitive children are often predisposed by their temperament to the development of anxiety. Unconscious fear and anger can lead to obsessional thinking and to compulsive behaviors which are an unconscious attempt to diminish their influence.
Please go to the mistrust checklist to evaluate your child's symptoms of mistrust and the possible origins of this conflict. If many symptoms of mistrust are identified, please write a list of fears you believe your child may have struggled with at different ages. Next, please go to the anger checklist in the angry child chapter on this website and rate your child's anger.
A 2012 study of rage attacks in pediatric OCD demonstrated that rage attacks are relatively common, have a negative impact on illness presentation, and contribute to functional impairment above and beyond obsessive-compulsive symptom severity. Rage may contribute to family accommodation of symptoms, which may further affect obsessive-compulsive symptom severity and impairment (Storch, EA, et al, 2012).
Forgiveness therapy helps to resolve the anger and associated aggressive obsessions in these youngsters and thereby assists in their recovery from OCD. It also helps to purify the memory by diminishing the anxiety from the past.
Most children with OCD meet the criteria for at least one other psychiatric disorder (e.g., 75% to 84%). In a major study of adolescents with OCD there was a high co-morbidity (association) with disruptive disorders and tic (Tourette's Disorder), mood, and anxiety disorders (Geller D, 1996). Many children whom we have treated with rapid, involuntary, sudden movements have very strong fears of a catastrophic event occurring in their lives such as the loss of a parent. Catastrophic obsessional thinking can also be manifested as a fear of suicide in a child who is not hopeless and who does not want to die.
The most frequently reported obsessions were:
- fearful thoughts of catastrophic events, often involving a loved one or oneself
- violent thoughts of hurting someone which are often the result of unresolved anger.
In a 2008 study of 236 children (149 boys and 87 girls) with OCD (Mataix-Cols, D., et al.), the most common obsessions were aggressive (81%), contamination (79%), symmetry (41.9%) and religious (40.7%), Girls had significantly more aggressive obsessions, while boys had significantly more religious and sexual obsessions. The most common compulsions were checking (80%), cleaning (79%), repeating (75%), ordering (59%) and counting (49%). Girls had significantly more hoarding compulsions while boys had significantly more counting compulsions.
This research which demonstrates that the most frequent obsession in boys and girls is that of aggressive thoughts clearly points to the need to evaluate anger and have a treatment protocol for anger in all youth with OCD.
The religious obsessions often relate to a fear of sinning. Weaknesses in confidence can result of in fear of making mistakes in one's spiritual life and to obsessional thinking. Also, loneliness in peer relationships can lead to strong sexual temptations and/or masturbation with resultant obsessional thoughts about offending God. The establishment of health peer relationships is effective in diminishing such OCD conflicts.
The other disorders seen in association with OCD in one major study were
- 53% had a disruptive disorder
- 43% had oppositional defiant disorder
- 73% had major depression
- 33% had ADHD (Geller D, 1996).
The common emotional conflicts of OCD in youth we have treated include:
- unresolved anger with peers, siblings or parents
- a strong fear of rejection as result of harsh, insensitive treatment by peers
- fears of parental loss or divorce
- fear of being hurt by others
- unresolved anger
- weaknesses in confidence
- catastrophic thinking
- modeling parental fears/ OCD
- excessive parental anger
- strong perfectionistic thinking
- traumatic family events with serious illnesses/early deaths
- fear of illness, death
- loss of trust due to insensitive caretakers when young.
This case study from Helping Clients Forgive demonstrates the value of forgiveness therapy in resolving symptoms in an obsessive-compulsive disorder.
Van, a seven-year-old first grader, developed a severe germ phobia and extremely compulsive behaviors. After going to the bathroom he would regularly spend twenty minutes to a half an hour cleaning himself. At school he would not open or close any doors without first covering his hand with his sweater to protect himself from germs. He limited his play with his friends because of his fear of being contaminated by germs. His compulsive behaviors increased and required larger amounts of time. The only anger Van manifested was when his parents tried to shorten the time he spent in compulsive behaviors.
Initially, Van had no awareness of any difficulties which preceded the development of his symptoms. However, when his parents were seen alone, they related numerous stresses in their relationship. His mother had been sick over the previous two years with severe chronic fatigue and numerous vague health problems which resulted in prolonged bed rest. She had had a very stressful relationship with her mother as a child and had difficulty in trusting her husband. Also, even though Van's parents rarely quarreled, there was very little affection in the marital relationship. Although each was dissatisfied with the marriage, they were not considering separation or divorce; neither were they working to improve their marital relationship.
Van denied having any fear that his parents might separate or divorce although he had been informed by them that there was considerable stress in the marriage. He, in fact, called their relationship good. When asked about his mother who had been in bed for almost two years, he insisted, I'm not worried about her. She'll be fine. It was suggested to Van that he might have developed a fear of something bad happening to him as a result of his mothers illness and of the stress in his parents marriage. It was explained to him that these fears might have been too frightening to face, so instead of addressing them, he acquired the fear that he might contract a serious illness from germs.
Van's parents made a commitment to work toward a resolution of their difficulties so that their relationship would improve. The therapist then told Van that he thought he had also denied angry feelings toward his parents and validated those feelings as being normal. Then he was asked to think daily that he wanted to forgive his parents. He reluctantly agreed to think of forgiving his parents for those times when they were not kind or loving to one another even though he was not consciously aware of being angry with them. After several months of therapy Van was able to admit having angry feelings toward his parents. Also, Van was encouraged to trust that his parents marriage would become a happier one. Work on forgiveness and trust over a period of six months, in addition to participation in marital therapy by the parents, resulted in a significant improvement of Van's obsessive-compulsive symptoms.
Other helpful interventions for OCD include:
- growing in trust
- strengthening healthy friendships
- building confidence
- forgiving those who have been insensitive in the past
- identifying and correcting errors in thinking, such as catastropic thinking
- letting go of a need to control
- treating parental fears, perfectionistic thinking and anger
- protecting children from school bullies including a school change or home bound education
- encouraging educators to take more direct action to protect children from bullying
- teaching forgiveness in the classroom
- cogntive-behavioral therapy for the excessive fears and the excessive anger in many children
- trying to make acts of trust before giving into compulsive behaviors such as hand washing and checking
- using serotonin reuptake inhibitors (SSRIs) for children with severe symptoms
- employing, when appropriate, the role of faith by encouraging the child to ask the Lord or Our Lady to help the child feel safe and by trusting the Lord with one's fears
- suggesting the child ask the Lord to protect his/her confidence and friendships
- consulting with a Catholic priest for Catholic children whose OCD is the result of severe fears of illness and death.
We encourage parents to help their children with OCD understand the origins of their fears and their anger and the growth in virtues that can be helpful. Also, empirical research has suggested that challenging compulsive behaviors and not accommodating or giving into them has been beneficial.
Some parents come to recognize that their insensitive behaviors in the home have harmed their child's basic ability to feel safe and to trust. In such families, they ask the child for forgiveness. Also, teaching children how to forgive those who have hurt them is effective diminishing OCD symptoms in our clinical experience. When the uncovered anger is strong, Catholic children benefit from taking this anger into the sacrament of reconciliation. Since youth with OCD can develop strong tendencies to try to control their environment and others, this needs to be challenged. Specifically, parents can encourage youth to trust them more and to give up the desire to control.
Since some children with OCD model after highly anxious parents, growth in self-mastery over anxiety in parents and over excessive anger is essential.
Obstacles in the treatment of OCD include:
- unconscious fears of one's intense, denied inner agner
- a compulsive need to control
- withdrawal into the sick or victim role as a way to avoid or control others
- a desire to punish others or seek revenge with a refusal to give up anger
- unwillingness of parents to address their anxiety, perfectionistic thinking and anger
- permissive parenting
- lack of confidence or courage in teachers and principals in addressing bullying in schools.
The Role of Faith
Research studies have demonstrated the benefits of faith in coping with anxiety disorders. In Catholic youth we have in particular that working with a priest on growth in trust and in faith to be beneficial. Priests often counsel such youth to daily entrust all their fears and anger to the Lord and to reflect that He is protecting them.
Parents can assist their children who struggle with this challenging anxiety disorder by encouraging them to try to trust more, not give into needless worries and fears and to resolve their anger with anyone who has hurt them. The new and promising field of positive psychology has a great deal to offer children with OCD and their families.