A concerned mother shares, “My 12 year old son thinks something bad will happen to me if he doesn’t do what OCD (Obsessive Compulsive Disorder) wants. For example, this morning he knelt down to tie his shoelaces but then untied them and repeated doing this a number of times. I asked him why felt the need to do this over and over again.” My son replied, “I have to check they’re double-knotted five times or OCD makes me think something bad will happen to you.” How can I support him with this? This is referred to as magical thinking.
First, the type of OCD your son is experiencing involves “magical thinking”.
Magical thinking is an illogical thought pattern in which a child believes a thought links with an action. Children (and adults) with magical thinking OCD become preoccupied with lucky or unlucky numbers, colours, words, actions, sayings or superstitions and attach them to a particular catastrophe.
Obsessions and Compulsions
Obsessive compulsive disorder (OCD) has two essential components: obsessions and compulsions. The compulsions are the repeated self-reinforcing behaviours that correspond with the obsession.
In this instance, the obsession for your son is that a bad thing will occur unless he ties his laces five times. By double-checking that his laces are double-knotted, he is giving into a compulsion that corresponds to his obsession.
In doing so he gains anxiety relief, since he believes this “saves” you from perceived harm. However, the relief is only temporary. This is because the compulsion to check strengthens the obsession by instilling doubts.
The OCD Cycle
The above example clearly demonstrates the OCD Cycle.
obsession > anxiety > compulsion > momentary relief > back to obsession
Obsessions are Involuntary
It’s important at this stage to recognise that obsessions are involuntary and cannot be controlled.
While this is the case, compulsions on the other hand are voluntary and can be controlled.
Since compulsions are the behaviours that keep OCD going, you can support your child by first explaining how the OCD cycle works. Then encourage him to tackle his magical thinking by having him agree to resist checking his shoelaces (or other compulsion).
This process is known as “exposure response prevention”.
Agree to Prepare for Exposures
When preparing for exposures, it is important that your child is in agreement before going ahead. A child must feel comfortable about agreeing to face his obsessional fears. He has to agree to altering the usual responses that reduce anxiety momentarily.
It is useful to have your child make a list of fears. Sit down with him and help him rate his anxiety level for each fear. Rate these fears using a number scale. 0 is no distress and 10 is the highest distress. If numbers don’t work for your child, consider using a distress thermometer to help your child rate his anxiety level.
The Fear Ladder
With all the fears written out and rated, you can then begin the exposures. Always start with the least distressing fear on the list. Then work your way up to the fear with the highest rating.
The Stepladder Approach to Help Anxiety in Children explains how this plan can be implemented.
Explain How Anxiety Works
Explaining how anxiety works is helpful before starting exposures.
An anxiety graph can help you explain to your child how his anxiety will reach quite high levels when he first does an exposure.
Explain that the anxiety level won’t remain high since anxiety can only reach a peak before reducing naturally. Anxiety levels usually reduce within 15-30 minutes and at most, no longer than an hour.
It’s also a good thing to gauge anxiety before, during and after an exposure to help with monitoring progress and set-backs. Make adjustments for your child where needed. For example, if an exposure on his fear list seems too high, you can come down one on the list. Or if the fear is too low, you can go up one.
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Step Back – Give Personal Space
It’s important to stand back and give your child leg room. Keeping a few paces back can help a child manage anxiety within their own personal space.
During this time, you only give occasional comments such as telling him to breathe easy or offering calm praise.
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Keep him in the moment. Let him know that the more he practices not giving into his double-checking compulsion (or other compulsion), the less high his anxiety will reach on the distress scale overtime.
Squash the Doubt
Further, explain that doing exposures and resisting compulsions will disprove his harm fears too.
What if your child questions this process? What if he says, “but what if you’re wrong and something bad does happen?” Then explain that while it can’t ever be certain that nothing bad will happen in life, research has established a truth or fact.
The truth or fact is that in all the hundreds of years that people have suffered from OCD intrusive thoughts or “magical thinking” there has never been any proof of a bad thing happening because a person had those thoughts.
Break it Down: Minimize the Goals
Finally, exposures work best when these are broken down into mini-practice goals.
For example, have your son agree to tie his shoe laces in the usual manner four times. Then encourage him to delay tying his shoelaces during the fifth time. For instance, wait 10 minutes before being allowed to check that his shoe-laces are double-knotted.
When he can go 10 minutes with much less distress, then have him delay tying his shoelaces for 20 minutes. Gradually increase the time allotment until the magical thinking is no longer is an issue for him. At the very least, until the magical thinking is a much less anxiety provoking problem.
When he can delay tying his shoelaces for an hour and his anxiety level has dropped to a 2 on a scale of 0 to 10, this is a pretty good indication. Once the level has dropped to 2/10, he will then be ready to practice delaying the compulsion during the fourth time he ties his laces. The same process will apply for the third time, and will continue like this, and until he is able tie his shoe laces only once.
Following this process, go up the ladder and tackle the next fear on the list. Continue to ensure that your child continues to tie his shoelaces once only. Continue up the ladder in the same fashion until each fear is reduced to 2/10 on the anxiety distress thermometer.
Obsessive compulsive disorder involves obsessions and compulsions. Exposure response prevention helps reduce the intensity and frequency of obsessions, which leads ultimately towards habituation, or becoming less sensitised to the obsessional fears. While the above article focuses on magical thinking and double-checking as a compulsion to “prevent” a disaster occurring, the same principles apply to any obsession and related compulsion, such as reducing handwashing due to a fear of germs, or feeling unclean.
Of special note, do prepare for extra time for doing exposures. Plan accordingly when your child’s OCD interferes with school times or other important activities.
Disclaimer: This article is information-based only. Please consult with your child’s doctor or mental health provider before carrying out the suggested exposures.