Obsessive Compulsive Disorder (OCD) is characterised by intrusive thoughts, impulses and images that regularly play on the child’s mind, where they feel the urge to do certain actions to ease the distress caused by them.
For example, if the thought or fear is:
“I’ll get germs and become ill because I touched the trash can’ the corresponding action will be displayed openly (e.g. repeated hand-washing).
Further, if the thought or fear is:
“I’m filthy and if I’m not able to get a wipe and clean my clothes by 2pm, my mother will be harmed” the corresponding action will be to mentally neutralise the thought, e.g. by saying a silent prayer to ‘ward off danger’ and to ease distress momentarily.
Children might be teary at the start of a school day. This is natural and most likely related to separation anxiety in which teachers reassure parents that their child is fine once they’ve left the school gates.
However, be aware of signs that indicate a child is suffering acute distress.
For example, Clare, aged 8, has contamination fears that she keeps to herself because she doesn’t have the necessary skills to express what these fears mean to her. She dreads the day ahead and consequently uses avoidance behaviours (resists entering the school gates). Eventually her distress eases and she is able to join her class, but she suffers constant floating anxiety throughout the day.
Working in Groups
Pupils with contamination fears often find being too close to other children difficult. For example, Clare has an aversion to being touched and so finds it distressing during school assemblies, playing touch games during break and teaming up in sports. Certain classroom activities, such as Art and Crafts, are an additional challenge for her because the thought of touching sticky materials increases her anxiety.
In these situations be aware of the child who repeatedly uses avoidance behaviours; for example, regularly finding excuses not to take part.
Note – an aversion to being touched or participating in arts and crafts could also be a tactile sensitivity. A referral to the guidance counselor who can consult with the school occupational therapist can help determine the root cause.
Smells in the canteen (cafeteria) are often a trial because children with contamination fears frequently believe that food odours are able to transfer germs onto their food. Seeing other kids eat is also a lunchtime ordeal for these children.
Predictably, Clare guards her food, not only from smells but also from the possibility of saliva landing on her sandwich. She does this because she is terrified of swallowing germs and becoming ill. She usually leaves most of her food in her lunchbox uneaten, or surreptitiously empties the whole of the contents in the trash can to avoid questions when she gets home. Once lunch is over, and especially after using the trash can, her anxiety raises to such an extent that she disappears to the washroom where she gives in to a lengthy hand-washing ritual.
In this instance, consider the anxious child who is habitually late for afternoon class.
A child with contamination fears doesn’t always fear illness; sometimes they think being touched by others will make them unclean, or that using art and crafts materials will dirty their clothes and spoil their appearance.
As a guide:
- fearing illness is usually associated with health anxiety;
- fearing uncleanliness is linked to an overdeveloped responsibility for maintaining cleanliness.
The latter suggests the child attributes perfection with acceptance.
Clare, whose fears are associated with health anxiety and also uncleanliness, asks to visit the washroom more frequently than would be expected. Her hands are noticeably sore but this doesn’t stop the constant urge to wash them.
Watch for children, who, like Clare, hide hand-gel in their pocket if they are refused the washroom. They may also carry a supply of wet-wipes which they use to secretly wipe ‘dirty marks’ from their clothes.
Also be aware of children who avoid using the toilet all day. In contrast to the child who has an obsessive urge to repeatedly visit the bathroom, the child who keeps away from the bathroom may well be holding in their urine or feces for fear of contaminating their clothes. Parents might comment that their child, who ‘holds it in’ all day in school, undresses before going to the toilet at home. The child does this in an attempt to prevent becoming infected with germs; or to escape the horrors of feeling unclean.
Children who suffer one or more of these symptoms for an hour or more each day may have obsessive compulsive disorder.
Exposure Response Prevention
In challenging OCD, the child is often referred to a cognitive behavioural therapist who helps them conquer their fears with a strategy called Exposure Response Prevention (ERP).
What happens during ERP?
The exposure part means the child agrees to confront the triggers that initiate their obsessional fears.
The response prevention part means the child makes a determined effort to resist doing the corresponding action (compulsion), e.g. reducing hand-washing or not giving in to a neutralising affirmation.
ERP helps the child measure and tolerate anxiety in graded steps. In doing so, they begin to gradually habituate to their fears.
Cognitive therapy mentally prepares the child for the exposure process. As such, the child becomes more confident about testing out new beliefs. Put plainly, the therapist and child brainstorm ideas for generating and replacing irrational thoughts with more realistic ones.
For example: ‘I’ll catch germs and fall ill after touching the trash can’ to ‘there may be a tiny risk that I could catch germs in which case I can choose to either live with the small risk, or worry forever about my fear.’
How Can Teacher’s Support These Kids?
Parent and teacher collaboration is a good way to discuss a child’s therapy intervention. This helps the teacher learn about the child’s anxiety; they are then in a better position to foster self-reliance in which the child learns to manage anxiety within the school environment, rather than seek constant reassurance, or suffer in silence to the extent their obsessions get in the way of their learning.
Clare for example has learned to give a relevant signal that she is:
- Going for a 10-15 minute walk around the playground to simmer down
- Taking a 10-15 minute break in the school library to quietly read a list of realistic self-statements. For example: ‘My anxiety is horrible, but I have stuck it out before, and I can do it again; or ‘I know my anxiety will subside naturally and without asking for reassurance or giving into a compulsion
- Stepping outside the classroom for a few minutes to do breathing exercises to lower anxiety
In extreme cases, it may be that further intervention is necessary. Teachers and parents may need to get together to discuss whether outside healthcare professionals should become involved in assessing and providing school-based support.
OCD is a sub-class of anxiety disorders with two essential characteristics: recurring thoughts, feelings and ideas; and repeated ritualised behaviours. If a compulsion is left undone the child’s anxiety increases and is only relieved once they give into it, and this is cyclic. Contamination fears is one example of OCD; others include checking, symmetry, ordering, pure-obsessive thoughts (images, urges), and more. Students with obsessive compulsive behaviours are often faced with multiple problem situations which can be reduced in intensity and frequency using CBT with ERP. When teachers are aware that a child faces daily battles in school, they are more able to effectively support and monitor the child’s behaviours by fostering self-reliance, and recognising if and when further assessment/intervention is needed.
Disclaimer: Since this article is information-based only – it is advised that any concerns are discussed with the child’s parents who then can discuss with their doctor.