OCD: Obsessive-Compulsive Disorder in Youth
Obsessive-compulsive disorder (OCD) is characterized by repetitive, ritualistic behaviors and obsessional thinking.
The compulsive behaviors are often carried out to attempt in an unconscious attempt to reduce the in tens anxiety, irritability and other emotional conflicts.
OCD 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 (CBT) 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 present in OCD. FT not only diminishes anger; it also decreases the anxiety that contributes to OCD.
Fear and Anger
Obsessive-compulsive symptoms are often a defense against strong feelings of fear, anger and sadness which the child is unable to face. Betrayal experiences that damage trust lead to the development of these emotional conflicts that are often unconscious. 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 the intensity of the fears and anger..
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. Also, please review the possible origins of fears and, if your child is older, consider reviewing them with him/her. 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 decrease the influence of past hurts 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 (ODD, etc.) 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 that a catastrophic event may occur in their lives such as the loss of a parent. We often see this in families in which a child fears that his/her parents may divorce. 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 common obsessions and compulsions
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 in youth with OCD and have a treatment protocol for uncovered anger. From our clinical experience with youth with OCD we believe forgiveness therapy should be part of the treatment plan, but as of this time no research studies have empirically proven its effectiveness.
The religious obsessions in youth often relate to a fear of sinning and offending God. This conflict often arises from a weaknesses in confidence which can then lead to fears 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.
Other disorders present
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 in youth that can lead to the development of OCD include:
- betrayal experiences in the family or with peers
- fear of one's unconscious anger with a parent, sibling or peer
- fears of parental loss or divorce
- a strong fear of rejection as result of harsh, insensitive treatment by peers
- fears of losing a loved one through death
- fears of acquiring a severe illness
- fear of being hurt by others
- weaknesses in confidence
- catastrophic thinking
- modeling parental fears/ OCD
- significant guilt
- strong perfectionistic thinking
- traumatic family events with serious illnesses/early deaths
- loss of trust due to insensitive caretakers when young.
Can you identify any of these struggles in your child with OCD?
The challenge of uncovering the cause of anxiety, fear and lack of confidence
Many youth are unaware of the real cause of their fears and associated anger and insecurity. For example, some youth experience intense fears when their parents have serious marital conflicts or after parental divorce and can identify fears about the future. Only later does it emerge that the fear that drives their OCD is that of a losing a sense of family or losing a parents. Also, the child's OCD can be influenced by intense unconscious anger with the parent who is seen as the major cause of marital stress of divorce.
Other youth can have religious obsessions about worrying about sinning, when the actual powerful fear that emerges is that of a family member dying as the result of the death of a close family member in the past. One youth who had been badly bullied in ninth grade, developed intense fears of acquiring a medical illness in the facial area that interfered with his speaking and eating. The actual problem identified later was his fears of being betrayed by his peers and his fears of his anger toward them.
Parents can help their children with OCD by asking them to record all the fears that they can recognize. Cognitive distortions or errors in thinking can be identified and attempts to correct them can be initiated. Also, when hurts have been uncovered, forgiveness therapy can be recommended in which youth with faith are advised that there are three ways they can forgive those who have hurt them - cognitively with their mind, emotionally with their heart or spiritually in prayer. Forgiveness therapy can compliment cognitive-behavioral therapy in the treatment of this disorder.
This case study from Forgiveness Therapy 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 catastrophic thinking
- letting go of a need to control
- treating parental anger, fears and perfectionistic thinking
- 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
- cognitive-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
- at times using a second generation antipsychotic which is approved by the FDA for severe anxiety
- consulting with a Catholic priest for Catholic children whose OCD is the result of severe fears of illness, death or hell.
Cognitive Behavioral Therapy for Cognitive Distortions
Cognitive distortions are thinking errors strongly influence anxiety, as well as depressive disorders. In regard to OCD they include many types of catastrophic thoughts such as –
-I am always sinning and will go to hell.
-I will be contaminated and become sick if I touch objects.
-I am contaminated and need to clean myself frequently.
-I am giving into evil thoughts and will be punished for doing so..
The actual fears and unconscious anger that some of these children have can be too overwhelming to face. They can develop as a result of serious illness of death in the family some children have an intense unconscious fear that a loved one may die. After divorce, a unconscious fear that can drive OCD is that the loss of the mother. In families with strong conflicts between the parents, another unrecognized fear is that may separate or divorce. In youth who have been bullied by an older sibling or by peers at school or in the neighborhood, other sources of fear are of being betrayed by others and a fear of one’s own unconscious aggressive impulses toward the bully.
The thinking errors need to be corrected and the child/teenager reassured that nothing catastrophic is going to occur in his/her life.
In those who have been badly betrayed through divorce or bullying trauma, the intense inner, unconscious anger needs to be validated as being appropriate as a way to break through denial and enter into the forgiveness therapy process. Often, youth will only stop denying anger related to severe trauma when they are told that they may not be able to forgive from the mind or the heart but can forgive spiritually, that is, give their deep resentment over to God with those who have betrayed them.
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.
When marital conflicts, marital separation or divorce are identfied as a major source of the child's OCD, parents should consider their responsibility to their child and make a commitment to uncover and address their weaknesses, particularly the primary family of origin emotional conflict that was brought into the marriage. We recommend parents complete the family evaluation form on the home page at www.maritalhealing.com which can assist in this process.
Obstacles in the treatment of OCD include:
- unconscious fears of one's intense, denied inner anger
- a compulsive need to control
- withdrawal into the sick or victim role as a way to avoid peers or control others
- a desire to punish others or seek revenge with a refusal to give up control
- unwillingness of a parent to address his/her psychological conflicts which include a tendency to control, excessive anger, perfectionistic thinking or intense anxiety
- permissive parenting and the failure to correct
- ongoing rejection by peers at school with a subsequent severe fear of betrayal
- lack of confidence or courage in teachers and principals in addressing bullying in schools.
PANDAS and OCD
Streptoccal infections have been identified as triggering sudden-onset obsessive-compulsive disorders in some youth. Quikc treatment with antbiotics has been shown to be helpful to some of these youth. This pediatric autoimmune neuropsychiatric disorder assoicated with streptococcal infections is referred to as PANDAS for short. This controversial and seemingly rare diagnosis was given to children who aburptly developed obsessive-compulsive disorder or tic disorders such as Tourette's syndrome after contracting infections caused by group A streptococcus bacteria, such as strep throat or scarlet fever.
The first case of PANDAS was described in 1998. Since then, experts have recognized that other infectious organisms besides group A streptococcus bacteria can cause sudden-onset OCD and tics in youth.
Our recommendation is that these youth should also be evaluated for any trauma to their ability to trust that could result in anxiety, insecurity and excessive anger that strongly influences many youth with OCD.
In some youth with severe OCD symptoms, SSRIs can be helpful by reducing obsessions and compulsive behaviors and the anxiety, anger, insecurity and sadness that often drive them. We describe the use of medications as a chemical crutch to be used while addressing the conflicts in the child. In some youth with severe OCD it may be necessary to add a stronger tranquilizing medication that is approved by the FDA, a second generation antipsychotic for brief periods. Parents often demonstrate an initial resistance to medication, but many youth and parents are pleased by its benefits in reducing OCD symptoms.
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 by working on forgiving. The new and promising field of forgiveness therapy has a great deal to offer children with OCD and their families.