School-aged children and adolescents often experience anxieties (see December 2001/January 2002, “The Jitters”). Anxious feelings themselves are not necessarily a problem. In their healthiest expressions, anxious feelings alert those experiencing them to the possibility of seriously threatening situations and help them avoid traumatic, direct confrontations. Anxiety becomes problematic and potentially damaging for young people, however, when they become so pre-occupied with worry that they miss many of the subtle elements of normal development.
One anxiety-related disorder that is particularly complex and often misdiagnosed in children and adolescents is Obsessive-Compulsive Disorder. Educators who recognize what constitutes normal and abnormal kinds of obsessive behavior among young people can help sufferers cope and create a less stressful classroom environment for all students.
What Is Obsessive-Compulsive Disorder?
Obsessive-Compulsive Disorder is a neuropsychiatric disorder characterized, as the name suggests, by intense obsessions and sometimes corresponding compulsions. The exact number of young people with this disorder is difficult to estimate, but some studies suggest that approximately 1 in 200 children suffer from it. Although almost half adults with the disorder experienced their symptoms as children, very few had the disorder recognized—a fact indicating that many young people with this disorder may not receive treatment until much later in life.
The Diagnostic and Statistical Manual for Mental Disorders (American Psychiatric Association, 1994) lists the formal criteria for the disorder. In general, obsessions are powerfully intrusive thoughts that are unwelcome, extremely anxiety-provoking, and to a large extent uncontrollable by those who experience them. In both young people and adults, obsessive thoughts disrupt their lives even as they realize the outlandishness of their worries. Typical concerns include a morbid fear of contamination by germs, sexual or aggressive images and themes, so-called “forbidden thoughts,” religious preoccupations, and urges to create symmetry in body movement or in the environment.
An important difference between adults and children with the disorder is the extent to which younger individuals may not understand that their thoughts are unreasonable. For example, an adult might realize that he is unlikely to catch a fatal disease simply by touching the floor, but a child might not have the experience to recognize the reality that contrasts with this particular fear. Younger children with this disorder might therefore be mistakenly considered psychotic or out of touch with reality (March & Leonard, 1996).
In many cases, those who suffer from this disorder try to ameliorate their intense anxiety by engaging in rituals or compulsions. Those with contamination fears might compulsively wash their hands, for example, briefly feeling relief that the serious risk has momentarily passed. In other instances, the accompanying compulsion might seem completely unrelated to the sufferer's fear, as when a child experiences an intense fear that his mother will be harmed if he does not count to 10 every morning upon wakening. A person need not demonstrate both obsessions and compulsions; serious problems with one set of symptoms are enough to meet the criteria for this disorder.
We are beginning to understand Obsessive-Compulsive Disorder from a neuropsychiatric perspective. Neuro-imaging studies demonstrate abnormalities in specific regions of the brain, including the frontal lobes of the cerebral cortex, a more primitive region of the brain called the basal ganglia, and various circuits connecting these regions. The disorder is transmitted to some extent genetically, but it is also possible that some individuals may develop the syndrome as a result of certain infections. Individuals with this disorder are more likely to suffer with such problems as tics—sudden, repetitive, nonrhythmic movements—or attention deficits. Treatment is often helpful, involving such medications as selective serotonin reuptake inhibitors—including Prozac, Paxil, Celexa, Zoloft, and Luvox—typically in higher doses than those used for treating depression and other conditions. Cognitive and behavioral therapies are also effective. Neuroimaging studies suggest that successful treatment with medications and certain talk therapies can normalize brain activity.
Normal and Abnormal Obsessions
Although this disorder is clearly maladaptive, careful organization and scrupulous attention to detail are skills that we teach young people to help them learn to organize the growing complexity of their lives. We should not confuse this disorder with normal levels of obsessive behavior that characterize specific developmental stages or with the behavior of a particularly scrupulous and compulsive—yet relatively happy—individual.
Younger school-aged children are often quite obsessive, focusing intently on baseball batting averages, Pokémon cards, Harry Potter trivia, or other collectible items of popular culture. They may devote many hours and enormous energy to thinking about, arranging, and cataloging their collections. Seen in virtually all elementary students, this behavior is normal. Similarly, normal variations in temperament and personality include the careful, excessively neat, but otherwise unbothered individual. In contrast, people with this disorder describe their concerns as powerfully uncomfortable and at times all-consuming.
Although Obsessive-Compulsive Disorder is relatively uncommon, keeping it in mind is important because treatment providers often fail to consider its diagnosis. Many childhood problems appear superficially similar to this disorder, and, more important, it often mimics numerous, more common, and completely different childhood difficulties. Consider the following hypothetical example: A 9-year-old girl fidgets often in class, appears to lose focus many times throughout the day, and has to be told over and over to come back to her desk from the classroom window. Because her behavior is noticeably interfering with her schoolwork and social activities, the teacher refers the child to a clinician, who suggests Attention Deficit Hyperactivity Disorder (ADHD) and begins appropriate treatment. The girl's condition worsens, however, leaving the girl, her family, and her teachers frustrated and confused.The clinician then questions the girl more carefully about her behavior. The girl is embarrassed by her actions and reluctantly admits that she can't stop thinking that locusts are about to attack her town and, even more frightening, her home. A few months ago, she read about locust plagues in Sunday School, and although she knows that locusts are really not a concern in this part of the world, she can't seem to quell these concerns. As a result, she is constantly scanning the skies for the start of the locust attack. When she sees that no locusts are present, she relaxes briefly. Her worries soon return, however, and she again finds that she is unable to focus on much else.
This example emphasizes the importance of not mistaking Obsessive-Compulsive Disorder for other common problems. In the classroom, this disorder can look like ADHD or simply oppositional and unruly behavior. Misunderstanding students with real anxiety states can leave them feeling further demoralized.
How Teachers Can Help
Once a clinician diagnoses a student with this disorder, teachers might try to accommodate the student's compulsions as much as possible. These efforts require communicating with the student's family and with those who are providing treatment. For example, a teacher might allow a student who needs to wash his hands many times a few special bathroom breaks each day to help him discharge this anxiety. The goal of treatment is ultimately to extinguish these behaviors, but the student in the early stages of treatment will probably not be able to focus on academic material or social concerns. Careful teachers can understand and help their students while preserving the normal routines of the classroom. In this fashion, the student feels less ostracized and uncomfortable, and the teacher feels less frustrated.
Obsessive-Compulsive Disorder is almost always treatable, a fact that contrasts with how rarely it is recognized. Students spend a great deal of their lives in classrooms. Because this disorder clearly interferes with academic and social success, teachers are an important part of the student's defenses against this potentially devastating problem.
