Obsessive-compulsive disorder in children and adolescents ... Fischer.pdf · lomania (compulsive hair pulling), body dysmorphic disorder, and impulse control disorders like compulsive

Abstract

Introduction: Obsessive-compulsive disorder with onset in childhood or ado-lescence causes considerable distress and functional impairment. While thereis a growing body of research focusing pediatric OCD, the presentation of thedisorder in school settings has not been subject of systematic research so far.Since children and adolescents spend one-third of their time at school, the issuewarrants further research. This article aims to provide a review of the existingliterature on the topic. Method: MEDLINE, PSYNDEX and PsycINFO werescreened for data about pediatric OCD putting special emphasis on the schoolcontext. Results: Results from 9 publications suggest that many OCD-symptomsoccur in school settings with evidence for a subgroup of typical compulsionsassociated with learning activities. Obviously, OCD often leads to substantialimpairment of academic and psychosocial functioning. Discussion: An increa-sing awareness of OCD among teachers, school psychologists and school socialworkers can facilitate assessment and treatment of children with the disorder.Given the many kinds of impairments evoked by OCD, future studies shouldinvestigate typical school-related OCD-symptoms and their impact in the aca-demic and social context. The results could then serve as a basis for the deve-lopment of subsequent psychological and educational interventions.

Keywords: Pediatric; OCD–academic/psychosocial; Functioning–school;

Personnel-identification-interventions.

Received: August 18, 2013, Revised: December 1, 2013, Accepted: December 1, 2013.© 2013 Associazione Oasi Maria SS. - IRCCS

1 University of Hamburg: Psychology Department. E-mail: [email protected]

Correspondence to: Christian Fischer-Terworth, Medicusstr. 27 - 67665 Kaiserslautern, Germany

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Life Span and Disability XVI, 2 (2013), 127-155

Obsessive-compulsive disorder in children and

adolescents: Impact on academic and psychosocial

functioning in the school setting

Christian Fischer-Terworth1

1. Introduction

1.1 BackgroundAccording to information from the Department of Health and Human Services

of the United States of America, every year 20% of children or adolescents

between ages of 9 and 17 experience symptoms of mental disorders leading

to functional impairment. If left undiagnosed and untreated, psychiatric disor-

ders tend to become chronic, and can lead to serious problems like school dro-

pout, unemployment, substance abuse or even suicide. Anxiety disorders like

generalized anxiety disorder, separation anxiety disorder and obsessive-com-

pulsive disorder (OCD) are the most common psychiatric disorders in chil-

dhood and adolescence (Helbing & Ficca, 2009).

According to DSM-IV-tr, OCD is a complex neuropsychiatric condition

classified as an anxiety disorder. The symptoms of OCD are time-consuming,

cause marked distress and/or interfere with daily living. They often lead to sub-

stantial impairment of occupational or academic functioning, social activities

and relationships with others (APA, 2000). Although the amount of scientific li-

terature on OCD in childhood and adolescence has been increasing in the recent

years, the impact of symptoms in the school setting has not been subject of sy-

stematic investigation so far.

Several publications, however, point to serious academic and psychosocial

impairment of children and adolescents with OCD, including distress from the

emergence of symptoms, academic difficulties and peer victimization (Adams,

Waas, March, & Smith, 1994; Helbing & Ficca, 2009; Dyches, Leininger, Heath,

& Prater, 2010). School-related stress can play a role in the onset, exacerbation

and maintenance of OCD symptoms (Honjo, Hirano, Murase, Kaneko, Su-

giyama, Ohtaka et al., 1989). As some parents become aware of their children’s

problems even years after the onset of the disorder, school personnel may repre-

sent “a first line of defense” (Adams, 2004) in identifying symptoms in students.

Educators may be able to recognize problem areas because they are familiar with

the behavior of students at a certain level of development. Teachers, school psy-

chologists and school social workers should play a crucial role in the process of

diagnosing and even treating students with OCD (Adams et al., 1994; Adams &

Burke, 1999; Adams, 2003, 2004). To be able to do so, acquiring basic kno-

wledge about the condition is paramount. As efficient treatment of OCD impro-

ves symptoms and overall quality of life, it should also affect academic

performance and psychosocial functioning in patients positively. This review ar-

ticle aims to delineate the presentation of OCD across school settings and to pro-

vide an overview on pediatric OCD with relevant information for educators.

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Life Span and Disability Fischer-Terworth C.

This knowledge should help them to identify symptoms and to participate in in-

terventions.

1.2 Obsessive-compulsive disorder: an overview

1.2.1 SymptomsThe core symptoms of OCD (Rasmussen & Eisen, 1992; Jenike, 2004; Steketee

& Pigott, 2006) are obsessions and/or compulsions. Obsessions are recurrent

thoughts, images, fears or impulses intruding into consciousness which cause in-

tense anxiety or other distressing emotions. The obsessions are difficult or im-

possible to resist, although they are usually experienced as inappropriate by the

sufferer. Although the core features of OCD with onset in childhood and adole-

scence (March & Leonhard, 1996; Walitza, Melfsen, Jans, Zellmann, Wewetzer,

& Warnke, 2011) resemble the adult form strongly, symptom profiles in the pe-

diatric population sometimes differ in presentation (Kalra & Swedo, 2009). Com-

pulsions are excessive and/or unreasonable repetitive behaviors, rituals or mental

acts which patients have to perform to (a) neutralize obsessive thoughts, (b) to

produce relief from the anxiety or discomfort caused by obsessions, (c) to prevent

some possible catastrophic event being very unlikely to occur, (d) to prevent or

avoid a situation where obsessions might occur or (e) to seek reassurance.

The most frequent obsessions occurring in children and adolescents are related

to contamination, illness, death or harm coming to loved ones (Swedo, Rapoport,

Leonard, Lenane, & Cheslow, 1989; Swedo, Leonard, & Rapoport, 1990). In con-

trast to psychotic patients, OCD patients usually have at least some insight into

the irrationality of their obsessions. As the degree of insight is generally lower in

children (Helbing & Ficca, 2009), especially in young children ritualistic behavior

is a better indicator for OCD. Young children are often unaware of their obsessions

thus not being able to verbalize them (March, Leonard, & Swedo, 1995).

Even in the presence of insight, obsessions lead to high anxiety, disgust,

feelings of guilt or other discomforts. Although their nature is irrational or at

least exaggerated, it is often nearly impossible for the individual to exert vo-

litional control about obsessions which are often accompanied by intense fear

and doubt. Individuals try to ignore or suppress their obsessions and often neu-

tralize them with compulsive rituals (APA, 2000).

Common compulsions include washing, checking, repeating, counting, tou-

ching, hoarding, questioning, magical rituals and mental acts (Swedo et al., 1989;

Swedo et al., 1990). Some compulsive rituals correspond to preceding obsessive

thoughts which determine the ritual’s content. A patient with an obsession about

harm coming to a loved one e.g., may compulsively check the stove or door locks

to ensure his/her safety.

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Obsessive-compulsive disorder in children and adolescents

Other rituals are not logically connected to the obsessions they should neutra-

lize, especially when the relationship between obsession and compulsion is of

a magic nature. This is, for instance, the case when a 8-year-old boy feels com-

pelled always to touch a radiator three times before going to bed “to prevent

his parents from becoming ill”. Many patients simultaneously exhibit more

than one symptom (March & Leonard, 1996), meaning they suffer from several

obsessions and/or compulsions.


Table 1 - Obsessions and compulsions (adapted from APA, 2000)

1.2.2 comorbiditiesMany children or adolescents with OCD have one or more other comorbid

psychiatric disorders (Honjo, 1989), which also can cause additional distress in

school settings (Fischer-Terworth, 2010). The most frequent comorbid conditions

in pediatric OCD are other anxiety disorders, depressive disorders and tic disorders.

School-aged children with OCD often have comorbid generalized anxiety disorder,

separation anxiety disorder or childhood-onset social phobia (Geller, Biedermann,

Jones, Shapiro, Schwartz, & Park, 1998). Other concomitant conditions are di-

sruptive behavior disorders like Attention Deficit Hyperactivity Disorder (ADHD),

eating disorders, schizotypal disorders (Wewetzer & Klampfl, 2004), substance

130

abuse (Adams, 2004), learning disorders (March et al., 1995) or autistic spectrum

disorders (Fischer-Terworth & Probst, 2009). The presence of ADHD, in addition

to OCD, is linked to further impairment in both academic performance and psy-

chosocial functioning, and requires separate treatment for both conditions (Geller,

2006). Furthermore, suicidal behaviors may be related to OCD (Adams, 2004). In

50-75% of adult patients, comorbid personality disorders ,develop in the course

of OCD, whereas obsessive-compulsive personality disorder (OCPD) is found in

16-30% of cases (Wewetzer & Klampfl, 2004). Some patients may be diagnosed

with comorbid obsessive-compulsive spectrum disorders (OCSD), being defined

as conditions exhibiting thoughts and repetitive behaviors similar to OCD (Jenike,

1990b; Hollander & Chapman, 1997). OCSD include substance abuse, trichotil-

lomania (compulsive hair pulling), body dysmorphic disorder, and impulse control

disorders like compulsive buying, gambling, stealing, internet or cellphone use.


Table 2 - Comorbid disorders in pediatric OCD in the samples of two epidemiologic studies by Swedo et al. (1989) and Wewetzer (2001; see Wewetzer & Klampfl, 2004)

1.2.3 Epidemiology and course of pediatric OCDThe estimated prevalence of pediatric OCD varies from 0.4 to 4% (Swedo

et al. 1989; also see Wewetzer, 2004a; Geller, 2006). Around 50-70% of OCD

cases begin in childhood, although the disorder is more likely to be diagnosed

in late adolescence or in early adulthood (Rasmussen & Eisen, 1992). OCD is

equally common in males and females, whereas onset between age 6 and 15

is more common in males. Some thoughts, fears and ritualized behaviors, such

as bedtime rituals or ritualized games, have to be considered as normal in dif-

ferent stages of childhood development (Wewetzer, 2004a). Unlike these phe-

nomena, OCD-related rituals consume much more time and are associated with

anxiety or other discomfort.

131

Initially, such thoughts and behaviors may be difficult to identify for parents

and even patients because they present similarily exaggerated variants of nor-

mal behaviors (Dyches et al., 2010).

Typically, the onset of symptoms is gradual. In cases of successful treatment,

nearly 50% of patients show remissions or subclinical symptoms over the long

term. Around 25% develop an episodic course with periods of increasing and

decreasing intensity, another 25% move towards a chronic course with mode-

rate to severe symptoms (Jans & Wewetzer, 2004). Obsessions and compul-

sions tend to change in severity which means that intensity and frequency of

symptoms vary over time. A patient can feel compelled, for example, to check

a light switch 10, 30 or 60 times a day, he can perform a washing ritual 30 or

120 minutes a day, or he may experience aggressive obsessions occasionally

or permanently. Symptom profiles often change, so a child having contamina-

tion fears and a washing compulsion may later engage in e.g. compulsive coun-

ting (March & Leonhard, 1996).

1.2.4 Diagnosis and differential diagnosisPsychiatric diagnosis of OCD is based on DSM-IV-TR criteria (APA, 2000),

and includes the following components: (a) neurological assessment, (b) cli-

nical interviews with patients and parents, (c) behavioral observation, (d) the

administration of self-report questionnaires, and (e) neuropsychological tests

in some cases. The gold standard instrument for diagnosing OCD is the Chil-

dren's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Goodman, Price,

Rasmussen, Riddle, & Rapoport, 1991), a modification of the YBOCS, a re-

liable and widely used adult measure. The CY-BOCS has been designed to as-

sess content and severity of OCD symptoms in children and adolescents aged

from 6 to 17. OCD warrants an exact differential diagnosis (Montgomery, Fi-

neberg, & Montgomery, 1992), as symptoms may mimic other disorders. Pa-

tients with obsessive compulsive personality disorder (OCPD) generally have

a personality pattern involving rigidity, perfectionism and preoccupation with

rules, order and/or cleanliness. In contrast to OCD-patients, they do not expe-

rience distressing obsessions and compulsions (Rasmussen & Eisen, 1992).

Although rituals related to autistic spectrum disorders (ASD) can resemble

the compulsions of OCD, they are mostly associated with special interests,

have the character of stereotypies or provide some structure and safety for the

individual (Fischer-Terworth & Probst, 2009). Furthermore, students with ASD

normally experience significantly more difficulties with communication and

relating to others than individuals with OCD (APA, 2000). In school, OCD-

related concentration deficits and distractability are caused by the interference

132



of obsessions and may be confused with symptoms of ADHD. OCD in chil-

dhood may also be associated with learning disorders such as dysgraphia, dy-

slexia, deficiencies in arithmetic and expressive written language, slow

processing and inefficiency (March et al., 1995) which have to be separated

from e.g. compulsions related to writing.

1.2.5 Etiology and pathogenesisAs concordance is greater among monozygotic (80-87%) than among di-

zygotic twins (47-50%), and as there is an increased prevalence among first-

degree relatives of patients, research points to a genetic basis of OCD (Nestadt,

Grados, & Samuels, 2010). Especially in the childhood onset of OCD, the ge-

netic component seems to be crucial (Walitza et al., 2010). Cases of OCD

which are directly preceded by infections like encephalitis or head injury (Ste-

ketee & Pigott, 2006) point to a neurological origin of the disorder.

Neuroimaging studies of the 1990s have contributed much to understand

OCD’s underlying neurobiology (Saxena, Brody, Schwartz, & Baxter, 1998).

They demonstrate differences in regional brain activity, especially in loops

between the orbital-frontal cortex, the striatum and the thalamus, which also

applies to children and adolescents (Huyser, Veltman, de Haan, & de Boer,

2008). This abnormal activity can shift toward normal after either successful

treatment with medication or cognitive-behavioral therapy (Schwartz, Martin,

& Baxter, 1992). OCD patients’ response to medications acting on serotonin

also demonstrate an important role of the serotonergic neurotransmitter system

in the pathophysiology of OCD.

According to the theory of Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), OCD may be associated

with an autoimmune reaction in response to a streptococcus infection in some

children. Antibodies could then trigger an inflammatory reaction in striatal areals

which may cause OCD symptoms (Swedo et al., 1990). The PANDAS condition

has been described by some typical features like e.g. sudden onset of symptoms

following a strep infection, an episodic course, separation anxiety, fine motor

changes and joint pain (Helbing & Ficca, 2009).

In children and adolescents vulnerable to OCD, the onset or symptom exa-

cerbations can be linked to critical life events like e.g. divorce of the parents.

Honjo et al. (1989) found that incidents related to school frequently precede

OCD symptoms. Such triggers can be revealed as distress with peers and tea-

chers, changing schools or pressure to perform (Adams, 2003). Psychological

stress caused by life events goes along with an excess production of stress hor-

mones like cortisol which can precipitate rewiring of OCD-related neuronal cir-

cuitry (Moll, Hüther, & Rothenberger, 1999) in persons predisposed for OCD.

133


As OCD clearly has a neurobiological origin, it is the basis of the individual’s

vulnerability to OCD and not the parents’ misdirected education which deter-

mines the response to stressful events with obsessions and compulsions.

1.2.6 Treatment

(a) Cognitive-behavioral therapy. Effective treatment of pediatric OCD includes

cognitive-behavioral therapy (CBT; March, Franklin, & Foa, 2005) and medica-

tion with Serotonin Reuptake Inhibitors (SRIs; Gentile, 2011). CBT is based on

the behavioral method of exposure and response prevention (ERP), and further

includes components like cognitive therapy and psychoeducation (Kircanski,

Peris, & Piacentini, 2011). ERP means gradual exposure to fear-provoking situa-

tions and the prevention of compulsive rituals. Working up from less to more an-

xiety provoking symptoms, the therapist encourages the patient not to engage in

compulsive rituals for increasing periods of time, although the obsessive thought

or the compulsive urge is present. A child with a washing compulsion triggered

by fear of poisoning herself by touching garden plants, will be encouraged to touch

the contaminated object, in that case the potentially poisonous plant, and then to

refrain from washing, for example, for 15 or 30 minutes. After repeating the exer-

cise, typically the anxiety associated with the triggering stimulus lessens, as does

the urge to perform the compulsive ritual. Consequently, the period of exposure

time can be extended e.g. to 45, 60 or 120 minutes. ERP should be part of a mul-

timodal psychotherapeutic approach, and include management of emerging emo-

tions, cognitive relabeling of symptoms and/or refocusing on adaptive behaviors.

The cognitive part of CBT helps children to increase their ability to do an realistic

appraisal of the sítuation despite the fact that an obsession is present. It also makes

sense that children learn to relabel obsessions and compulsive urges as symptoms

of OCD, a disorder of brain chemistry (see Schwartz et al., 1992).

Further cognitive strategies are: identifying irrational beliefs, dysfunctional

thought patterns and minimizing thought suppression (March et al., 2005).

OCD-related cognitions to be challenged are an exaggerated sense of risk, a

feeling of excessive personal responsibility for events or persistent doubt. Te-

chniques have to be adjusted to the developmental stage, as young children

may not understand the sense of exposure or challenging distorted thoughts.

Therefore, relabeling thoughts by using age-appropriate metaphors like a littledevil ( a monster or a figure in a cartoon) in the head is telling you wrongthings like “This plant will contaminate you, cause an illness or kill you, you

have to wash your hands“) can be effective methods for younger children (also

see March & Mulle, 1998; Helbing & Ficca, 2009).

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In the psychoeducational part of CBT, the therapist provides information to

patients and their parents, for instance, about the nature of OCD as a brain di-

sorder. Psychoeducation can also help to free parents from feelings of guilt or

shame and include explaining the rationale for a chosen treatment strategy.

(b) Medication. For most OCD patients the combination of CBT with the

use of medication is the most effective approach (Jenike, 2004). Treatment of

pediatric OCD is preferably focused on CBT and medication doses are chosen

generally lower (Wewetzer, 2004b). Children and adolescents successfully trea-

ted with CBT can stay in good health over the long term. Patients additionally

treated with medication are generally able to maintain improvement after tape-

ring medications (March, 1995). Medication with serotonin reuptake inhibitors

(SRI) has proved to be successful in children and adolescents with OCD (see

Table 3). SRIs block the reuptake pumps for serotonin thus increasing extra-

cellular serotonin levels and enhancing serotonergic neurotransmission. The

tricyclic antidepressant clomipramine, also a potent SRI, was the first medica-

tion shown to be effective in pediatric OCD, the action on serotonin being cru-

cial for clomipramine‘s antiobsessional effects (Wewetzer, 2004b). Today the

selective serotonin reuptake inhibitors (SSRIs) are often prefered. SSRIs selec-

tively act by selectively increasing serotonin levels and generally have fewer

side effects than clomipramine. SSRI’s side effects like nausea, sweating or diz-

ziness disappear after 4-7 days after starting the medication in most patients.


Table 3 - Medication for pediatric OCD: Serotonin reuptake inhibitors (SRI) incl. dosages; possible augmenting agents in cases of insufficient SRI-response and/or comorbidities

135

Legend: TCA = Tricyclical Antidepressant; SSRI = Selective Serotonin Reuptake Inhibitor

However, recent research suggests that especially sertraline and, again, clo-

mipramine should be considered as first-choice medication for pediatric OCD

(Gentile, 2011). The fact that clomipramine additionally acts on other neuro-

transmitters like, for instance, noradrenaline, may account for a slight supe-

riority in efficiency over SSRIs in some patients. When SRIs work, they can

reduce on average 30-70% of symptoms. Increased levels of serotonin help to

reduce anxiety levels and the intrusiveness of obsessions, allowing the indivi-

dual to respond to compulsive urges in a more controlled fashion. Moreover,

the medications facilitate CBT making it easier to relabel OCD symptoms and

to engage in exposure exercises. It may take from 6-12 weeks until patients

respond to clomipramine or an SSRI. Increasing the dose may be necessary to

achieve optimal results. Any medication used to treat OCD should not be di-

scontinued abruptly, but tapered slowly. When first-line medications fail, swit-

ching from an SSRI to clomipramine is indicated. There are currently no

controlled data examining the use of medications in SRI-nonresponders (We-

wetzer, 2004b), but there are several options the clinician may consider. If SRI

monotherapy is insufficient, augmentation with atypical neuroleptics like ri-

speridone or tiapride may be effective (McDougle, 1992), the latter especially

in the presence of concomitant tic disorders. When OCD and ADHD symptoms

co-occur, combining an SSRI with methylphenidate is possible (Jenike,

1990a). In cases of severe anxiety, augmenting SSRIs with the serotonin-re-

ceptor-agonist buspirone (Wewetzer, 2004b) can more helpful than anxiolytic

agents like as clonazepam, which should only play a role in the short term ma-

nagement of anxiety or panic in severe OCD (Knölker, 1987).

2. Method

To review literature on pediatric OCD with special emphasis on the school

context, MEDLINE, PSYNDEX and PsycINFO as well as data bases for e-

books, diploma and doctoral theses and google were screened. The search

terms, ‘obsessive compulsive disorder’, ‘OCD’, ‘obsessions’, and ‘compul-sions’ were combined with ‘children/childhood’, ‘adolescents/adolescence’as well as with ‘school’, ‘academic’ and ‘psychosocial’. Information was also

searched for in textbooks on pediatric OCD. The data found was extracted

from reviews, studies and textbooks and a complete set of 9 papers on OCD

in the school setting. The papers include 6 journal papers, 1 monography, 1

diploma thesis and 1 online article. As the revealed literature has to be regarded

as preliminary, all the papers contain unsystematic literature reviews, 3 of them

136


including non-controlled studies with small sample sizes.

Sabunguoclu and Berkem (2006) interviewed n = 26 patients with pediatric

OCD about the distribution of symptoms across home and school settings using

standardized diagnostic instruments. Boekhoff (2000) conducted retrospective

interviews with n = 14 patients with onset in childhood or adolescence, Fi-

scher-Terworth (2010) administered a semi-structured, email-sent question-

naire answered by n = 17 patients, both authors using frequency analysis and

qualitative content analysis (Mayring, 2008). All the papers reviewed provide

general information about pediatric OCD, and discuss typical manifestations

of symptoms in school, the impact on academic performance and peer rela-

tions. Furthermore, they focus identification of OCD symptoms in the school

setting and discuss possible educational interventions.

3. Results: Obsessive-compulsive disorder in the school setting

According to a review of 67 articles on pediatric OCD by Geller et al. (1998),

school avoidance, school refusal and academic difficulties are common in the

population. Often children and adolescents with OCD have to repeat a year,

change schools or even drop out of school (Knölker, 1987). Many of them

have to tolerate general major psychosocial impairments (Probst, Asam, &

Otto, 1979) and show low levels of social competence (Hanna, 1995). In later

life, many patients are discontented with their job situation with unemployment

rates between 40 and 50% (Hohagen, Rasche-Räuchle, Winkelmann, König,

Münchau, Geiger-Kabisch et al., 1997). As OCD is a chronic condition, it is

associated with social isolation, the development of comorbid psychiatric di-

sorders and an increased prevalence of suicide (Jans & Wewetzer, 2004).

The impact of OCD on psychosocial functioning was studied by Piacentini,

Bergman, Keller and McCracken (2003) in n = 151 patients with pediatric OCD.

Nearly 50% had substantial OCD-related problems in the school setting, at home

and in social contexts. The two most common problem areas were concentrating

on work in class and problems with completing homework. Furthermore, the se-

verity of impairments was significantly correlated with symptom severity (Pia-

centini et al. 2003). Although children and adolescents with OCD seem to

experience the highest levels of distress and impairment at home (McGough,

Speier, & Cantwell, 1993; Valderhaug & Ivarsson, 2005; Sabunguoclu & Ber-

kem, 2006), and mild OCD may not interfere with academic or social functio-

ning, many distressing symptoms are experienced in school-related settings. Of

a total of 57 patients with pediatric OCD from three small samples (Boekhoff,

137


2000; Fischer-Terworth, 2010; Subanguoclu & Berkem, 2011), 37 patients (65%)

reported to have at least moderate symptoms in the school context.

3.1 Manifestations of classical OCD symptoms in the school setting In literature, some descriptions of characteristic manifestations of school-

related OCD-symptoms can be found (Boekhoff, 2000; Adams, 2004; Dyches

et al., 2010; Fischer-Terworth, 2010). Compulsive washing is commonly as-

sociated with fear of contamination with dirt, germs or poisons. Also frequen-

tly, disgust associated with sticky substances or bodily secretions can trigger

washing compulsions. In school, children and adolescents may be driven to

leave the classroom to wash their hands. They may excuse themselves to go

to the lavatory or perform the compulsion during the breaks (Adams, 2004).

Furthermore, they may avoid touching e.g. doorknobs, tables or lunch trays or

refrain from sharing items used by other students (Dyches et al., 2010).

In the case of checking compulsions, patients repeatedly check door locks,

electrical appliances or water taps. They also tend to reassure themselves that

nothing terrible has happened. A student interviewed by Boekhoff (2000) had

repeatedly to check a window to make sure that no student could fall out of

the window. Another student (sample of Fischer-Terworth, 2010) felt compel-

led to phone his mother compulsively every break to reassure himself that she

was OK. When nobody answered the call, he felt the urge to rush home to

check that nothing terrible had happened.

Through compulsive questioning students may check and reassure themselves

if they have learned enough or if they have done everything the right way.

School-related obsessive fears can be associated with the constant doubt that a

school task hasn’t been accomplished perfectly. The obsessions may be followed

by repeated checking, questioning or ruminating. The obsessive fear of loss can

also trigger compulsive hoarding of personal items. In these cases, students may

make sure that personal items are secure by hoarding things that seem useless to

others (e.g. old magazines, books, notes or lists; Fischer-Terworth, 2010).

Students with ordering compulsions may arrange and rearrange e.g. books,

pencils or other items on their desk in an exact symmetrical order. Adams (2004)

states that in school they may be compelled to pronounce a word just right on

each syllable, draw lines and tables in a painstakingly exact way, carefully mea-

sure each footstep or tie shoelaces with exact equal length. Such compulsions can

be associated with feelings of incompleteness or obsessions about terrible things

that might happen (Rasmussen & Eisen, 1992). Many patients with pediatric OCD

have to carry out magical rituals like repeatedly counting up to a particular magic

number, touching certain items, repeating something else to prevent a potentially

138


threatening event or to neutralize inacceptable obsessive thoughts. Repeating com-

pulsions occurring in class can manifest themselves as the repeated sharpening of

pencils, repronouncing sentences endlessly (Adams, 2004), avoiding bad numbers

in mathematics lessons or saying mental prayers (Fischer-Terworth, 2010).


Table 4 - Frequent obsessions and compulsions in the school setting (Fischer-Terworth, 2010; n = 17)

Aggressive, religious or sexual obsessions are almost always kept in secret.

A religious obsession may be associated with the fear to call out blasphemic

thoughts in class or to be punished for thinking them. An aggressive obsession

may push a patient always to think he might injure other students. Sexual obses-

sions in adolescence involve, for instance, the fear to have some hidden homose-

xuality or the experience of intrusive images with sexual or perverse content.

Mental compulsions following those obsessions can be (a) ruminating about the

fact if one might be a bad or guilty person, (b) seeking for reassurance that ag-

gressive impulses (e.g. to stab a teacher with a knife) cannot be performed in rea-

lity, (c) doing rituals to protect others, (d) thinking good thoughts or (e) doing

praying rituals. Obsessions with dysmorphophobic content manifest themselves

in ruminating about aspects of one’s outer appearance like hair dressing, skin,

clothes or body weight. Adolescents with OCD may be prone to sense an unrea-

listic deformity of their body or their outer appearance. Corresponding compul-

sions may include repeated skin picking, hair combing or checking by compulsive

looking in a mirror (see Jenike, 1990b).

3.2 Compulsions related to reading, calculating and writingDescriptions in the literature point to the existence of a subgroup of OCD

symptoms, including checking and repeating compulsions which predominantly

139

occur in the school or learning context (Knölker, 1987; Boekhoff, 2000;

Adams, 2004; Danserau & Bouchard, 2005; Fischer-Terworth, 2010). Affecting

the basic learning activities reading, writing and calculating, they seem to cause

impairment in many patients. As disorder-related impairments and problems with

finishing homework is a major problem area in 90% of school-aged OCD patients

(Piacentini et al., 2003), it can be concluded that many difficulties refer to types

of compulsions described above. Children and adolescents with OCD may feel

compelled to reread text passages or sentences, to rewrite words or sentences or

to check calculating tasks again and again. The related compulsions can be asso-

ciated with substantial time loss and impairment of performance in tests. In the

following passage some presentations of these symptoms are described (see Knöl-

ker, 1987; Boekhoff, 2000; Fischer-Terworth, 2010).

(a) Reading. One 12-year-old girl feared obsessively about changing herself

completely (Knölker, 1987) and to become like her classmates. This fear was

linked to a repeating compulsion in the shape of a magic ritual: When she was

reading a text passage in class, she often had to read it again several times,

especially when other students were talking. She had to do the rereading toprevent the feared change of her person. In another case the obsessive fear of

making mistakes precipitated a checking compulsion performed to make sure

that everything was read. An 18-year-old student had to read one single word

repeatedly when he hadn’t read it without a mistake for the first time. He then

had to reread until he felt sure to have read every single letter (Fischer-Ter-

worth, 2010). This checking compulsion was connected to a repeating com-

pulsion revealing the OCD-typical feelings of insecurity and incompleteness

(see Rasmussen & Eisen 1992).

(b) Calculating. In compulsions related to calculating, patients can be compelled

to check and recheck the correctness of their result because they have obsessive

fears about mistakes which may lead to bad grades. Interfering thoughts linked

to magical thinking can compel a patient to repeat the calculating procedure till

he has a good thought. One student had to calculate until he had a good thoughtor till he was absolutely sure that the result was right. A 17-year-old girl had to

recalculate the same task several times, when she heard voices of other students(no hallucinations) or when she thought of something terrible (Fischer-Terworth,

2010). In that case the interference of an unwanted thought interrupted the calcu-

lating procedure by eliciting a feeling of incompleteness. As a consequence, the

thought seemed to warrant neutralization through repeating the task.

3.3 Situations and localizations associated with symptoms Obsessive-compulsive symptoms may be present in different places and si-

tuations of a typical school day. Symptoms may emerge during the lessons and

140


the breaks, on the way to or home from school as well as during homework

and exams. As symptoms often evoke feelings of shame, many patients tend

to hide their compulsions, delay them up to a later point in time or rationalize

them (Boekhoff, 2000; Fischer-Terworth, 2010). When rationalizing a com-

pulsion, patients pretend to perform them, for instance for the sake of cleanli-

ness, order or perfection disguising them as purposeful behaviors. as a result

of of such hiding behavior, parents are more likely to report significant im-

pairments concerning home and school functioning than patients (Piacentini

et al., 2003). Hiding compulsions generally leads to substantial inner tension

and feelings of shame evoked by the fear of being noticed by peers. It is not

uncommon that children and adolescents make exhausting efforts to suppress

compulsions which they must perform at home afterwards (Adams, 2004).

3.4 The identification of OCD symptoms in the school settingBefore school personel can be involved into identifying OCD symptoms,

they must acquire knowledge about the disorder, for instance, by reading literature

and attending lectures (Adams, 2004). Interventions have to be based upon the abi-

lity to recognize and react to OCD symptoms. Having extensive interaction with

students, classroom teachers and other school personel like school psychologists

or social workers can play a crucial role in identifying symptoms. Teachers may

be the first ones to become aware of compulsive behaviors. By doing unsystematic

behavior analysis, teachers can help to identify typical signs of possible symptoms

in the classroom. They can use verbal reports from classmates or keep written re-

cords to document academic, behavioral and social problems (Boekhoff, 2000;

Adams, 2004). Such typical signs are listed by Danserau and Bouchard (2005):

(a) Avoiding touching door knobs; use of tissues or handkerchiefs when

opening doors

(b) Repeated questioning for permission to leave the classroom to go to

the lavatory

(c) Repeated checking of doors, windows, light switches or written material

(d) Repeated and/or stereotypical reading of words, text passages or pages

in books

(e) Repeated writing, erasing and overwriting of letters, numbers or words

(f) Excessive and repeated questioning for reassurance

(g) Repeated and/or symmetric circling of items in multiple-choice-tasks

(h) Repeated ordering and arranging items (in an exact symmetrical way)

(i) Repeated and/or ritualized touching of items

(j) Avoidance of contact with sticky substances

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When a student’s behavior gives hints of possible OCD symptoms, school

staff can play an important role in gathering information (Adams, 2004). When

teachers witness obsessive-compulsive symptoms in a student, they can initiate

a trustful conversation with him integrating certain screening questions. In

such conversations, students tend to be surprised and relieved at the same time

because they do not assume that teachers can understand their compulsive be-

haviors (Boekhoff, 2000), which the students themselves mostly consider ab-

surd or even crazy.

If a student is exhibiting OCD symptoms, school personnel and parents should

share the names of psychiatrists and psychologists who are familiar with dia-

gnosing and treating pediatric OCD (Adams, 2004). School psychologists and

teachers should collaborate to identify the most crucial problem behaviors.

The psychologist can do systematic behavioral analysis serving as a basis for

possible interventions. Parents can be an important resource of information

because they may be able to tell relate experiences about symptoms which are

hidden in school and/or occur at home (Adams et al., 1994).

School social workers can play a key role in educating school personnel about

OCD, particularly in its effects on the danger of rejection and victimization of

students by peers. By staying in contact with parents, they can encourage them

to take part in the treatment process. The latter is crucial in most of the cases,

as OCD behaviors add stress to the family system (Livingston-van Noppen,

Eisen, Rasmussen, & McCarntey, 1990), and often exacerbate disturbances.

When involved into in treatment, family members will gain increased insight

into the nature of OCD, lose some feelings of guilt and build interaction pat-

terns which cause a diminishing of stress (Dyches et al., 2010). School psy-

chologists and social workers also can serve as an important link to therapists.

3.5 The impact of OCD in the school setting

3.5.1 Academic performanceWhile subclinical obsessive-compulsive personality traits like business or

precision may contribute to good academic performance, while obsessions and

compulsions definitely do not. Repeated controls, time-consuming ordering of

items or the repeated reading of texts can lead to a great amount of undone tasks

(Boekhoff, 2000). In fact, the ramifications of OCD can be enormous (Adams,

2003) as many compulsions negatively affect academic performance, especially

compulsions associated with reading, writing and calculating impair core acade-

mic tasks leading to major time loss in school exercises, homework and exams.

Compulsive repeating and checking often make it difficult or even impossible to

terminate tasks in an adequate time. Substantial deficits also arise through poor

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concentration (Piacentini et al., 2003) and dysfunctional perfectionism. The

avoidance of situations which trigger obsessions and compulsions in school

can result in a total inability to go to school. The fear of being “detected” by

peers or negative comments of teachers can lead to secondary school anxiety.

Children and adolescents, who perform rituals before going to bed, can be phy-

sically and mentally exhausted due to a constant lack of sleep. When compulsions

such as checking are performed in the morning before school, delayed arrival in

class may be a problem (Adams, 2004). Although children and adolescents with

OCD have intelligence levels above the average, strengths often cannot unfold

because information processing is blocked by obsessions and compulsions (Knöl-

ker, 1987). Obsessions also affect normal cognition and interfere with regular in-

formation processing results. When obsessive thoughts intrude into consciousness

during the lessons, selective attention focusing on academic tasks can be impaired.

Consequently, they interfere with the ability to progress through a task or to shift

from one task to another. Fixation on a thought may delay completing school as-

signments and lead to decreased performance and poor grades. To the uninformed

observer, an obsessional thought might appear as inattention or distractibility

which may be interpreted as a lack of motivation, “daydreaming“ or noncom-

pliance. Compulsions also can be distracting, as when symmetrical ordering of

pencils repeatedly interrupts learning activities (Boekhoff, 2000).

According to neuropsychological research, OCD patients may have impair-

ments in visuo-spatial and visuo-constructive abilities, executive functions,

nonverbal memory and motor skills like coordination of hand and fingers (Wa-

litza & Wewetzer, 2004). In a PET study with n = 14 OCD patients (Kwon,

Kim, Lee, Lee, Lee, Kim, et al., 2003), cognitive deficits were positively cor-

related with symptom severity and excess metabolic activity in critical pre-

frontal and striatal areals. Additionally, children and adolescents with OCD

tend to respond anxiously to situations where impaired motor skills, often ap-

pearing as clumsiness, are visible to the teacher and peers (Boekhoff, 2000).

3.5.2 Psychosocial consequences of OCD in school-ageThe 151 patients in the sample of Piacentini et al. (2003) exhibited many

specific impairments in psychosocial functioning related to different aspects of

OCD. 90% of patients reported at least one significant OCD-related dysfunction

and nearly 50% had substantial problems. Hanna (1995) could show substantial

impairment in social competence in a sample of children and adolescents with

OCD, measured by parent ratings of the Child Behavior Checklist (CBC).

School-aged children with OCD often endure negative psychosocial con-

sequences having their origin in OCD symptoms. Being ridiculed or mistreated

by classmates frequently arises from others‘ perception that OCD symptoms

143


are crazy (Helbing & Ficca, 2009). This notion often makes OCD patients wi-

thdraw from peers. OCD patients tend to have negative relationships to peers,

while low self-esteem and feelings of anxiety and shame make it difficult for

them to make friends. In the sample of Storch et al. (2006), 27% of OCD patients

reported peer victimization like physical attacks and social assaults like the ex-

clusion from a group. A correlation was found between peer victimization, lone-

liness and depression. Furthermore, being caught in obsessions and compulsive

rituals can take away time which normally could be spent with friends and hob-

bies. Symptoms like the fear of being touched as well as the fear that such rituals

might become visible for others, can be a hint for establishing good peer-rela-

tionships and friendships (Adams, 2004).

Consequently, social relationships are often restricted to the family. Patients’

relationships to their children are mostly described as good, but, however, in many

cases they seem to be ambivalent. Most of the parents are strongly involved re-

garding OCD symptoms. This may be the case through feeling guilt or responsi-

bility for childrens’ problems. As family members frequently restrict and adapt

their lives around a child’s OCD symptoms, they tend to become emotionally ove-

rinvolved or may criticize and resent the child. Such reactions can create feelings

of isolation and embarrassment, increase stress, exacerbate symptoms and trigger

family conflicts. Parents of children with OCD often have decreased confidence

in their children, and show increased levels of incendiary emotions. In families,

visibly escalated emotional expression, so called high-expressed emotions, can

maintain maladaptive functioning and contribute to relapse or exacerbations of

the child’s OCD (see Livingston-van Noppen et al., 1990; Dyches et al., 2010).

3.6 The role of teachersThe patients interviewed by Boekhoff (2000) and Fischer-Terworth (2010)

were also asked about teachers’ behaviors in the context of OCD. According to

the results, teachers did not recognize obsessions and compulsions in most of the

cases, and - as a logical consequence - didn’t react on them. The major reason for

that is the fact that patients make relevant efforts to hide symptoms which are perse difficult to recognize. Furthermore, hiding and rationalizing can be so “effi-

cient” that OCD-behaviors often resemble normal behaviors. As teachers may

have insufficient knowledge about psychiatric disorders like OCD, symptoms are

not easy to detect. When being told about the OCD-related problems by their stu-

dents or parents, many teachers made an effort to help. Several children and ado-

lescents with OCD wanted their teachers to acquire knowledge to be able to

recognize symptoms and to initiate help. But, however, for the vast majority of

patients it was crucial to take action themselves and to tell their teachers about

their OCD (Boekhoff, 2000; Fischer-Terworth, 2010).

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3.7 The effects of treatment on academic functioningTreatment with serotonin reuptake inhibitors (SRIs) and cognitive-behavioral

therapy (CBT) may also target academic performance. Antidepressant medi-

cation is likely to affect cognitive performance helping to redirect attention

away from symptoms to academic tasks. According to the neuropsychological

study of Kang, Kwon, Kim, Youn, Park, Kim et al. (2003), cognitive deficits

related to OCD can improve with SRI treatment. According to the results, the

improvement also correlates with a reduction of symptoms and normalization

of previously altered metabolic activity in the striatal area. CBT can help to

refocus behavior away from compulsions towards adaptive behaviors like

school tasks (see Schwartz et al., 1992).

3.8 Educational interventions As the Individuals with Disabilities Education Act of 1997 (IDEA‘97) em-

phasizes the importance of positive behavioral interventions and supports for

students with disabilities, Adams (2004) suggests that school personnel should

refer children or adolescents with at least moderate OCD to the so called referralor instructional assistance team (PIAT). PIAT can consider strategies to support

the student or initiate a detailed assessment for potential special education ser-

vices. Students with severe school-related impairment may require intensive ser-

vices like adaptations in the classroom environment provided under section 504of the Rehabilitation Act of 1973. Psychiatrists and clinical psychologists with

appropriate training have to be responsible for providing CBT and/or medication

for patients with pediatric OCD. School psychologists or social workers should

maintain in contact with the student, his parents and the clinicians. It is their task

to support the student and his family, (e.g. by providing information for diagnosis

and treatment). Communication among all parties will be essential to evaluate

and adjust treatment when necessary (Adams, 2003).

(a) General suggestions. Boekhoff (2000) describes disorder-unspecific

educational interventions generally decreasing students‘ distress and pressure to

perform. Such interventions can be helpful for all students contributing to the

prevention of stress and psychiatric disorders. For students with a tendency to-

wards perfectionism, encouragement to put less emphasis on grades may be hel-

pful (Boekhoff, 2000). Furthermore, it is important to focus on students‘

strengths and talents. The latter contributes to stabilize self- esteem in school-

aged psychiatric patients including those with OCD. It also makes sense to teach

social skills and to help children to develop coping strategies to deal with di-

stressing social situations (Adams, 2003). Talking about topics like anxiety and

psychiatric disorders in class and/or implementing anxiety prevention programs

can help to reduce peer victimization and to increase acceptance of patients by

145


peers. Additionally, the organization of presentations on OCD and other psy-

chiatric disorders in school can promote psychoeducation of students, teachers

and parents (Boekhoff, 2000; Adams, 2004).

(b) Transient modifications. Before patients have access to treatment, Adams

(2004) as well as Danserau and Bouchard (2005) suggest considering educa-

tional supports to decrease distress and to facilitate functioning in school, espe-

cially in the case of school-related compulsions. In this approach, the student

and his therapist may be involved in designing an individual modification plan.

In CBT, however, symptoms have to be treated at the same time with the aim

to enable the student to learn under normal conditions again. With successful

treatment, school-based OCD symptoms may lessen to the extent that at least

some supports can be reduced or eliminated step by step (Adams, 2004).

When compulsions associated with writing are a problem, a student with

OCD may transiently be allowed to write in italics or to use a laptop. To reduce

the functional importance of writing compulsions, only the content, rather than

the appearance of the written material should be graded. In the case of repea-

ting compulsions associated with reading, the amount of reading tasks may be

reduced. In cases of social anxiety associated with reading, tasks involving

reading aloud before class should be cancelled. When OCD leads to problems

in exams because of time loss, students may be given more time to do written

exams which they may be allowed to do in a separate room. Furthermore, oral

exams or multiple-choice-tests could replace written ones. If multiple-choice-

tests elicit symmetry compulsions like the urge to circle items painstakingly

exact or to delete non-symmetrical circles, it could be permitted to write an-

swers on the paper. When students are given additional time to do exams, a

date to hand in the exam at a designated point in time should be fixed in order

to structure the working process (Adams, 2004; Danserau & Bouchard, 2005).

(c) Educational interventions supporting CBT. Only through sustained beha-

vior modification at home and at school, can OCD patients can maintain their

therapeutic progress gained in CBT. When being supervised by a clinician, school

psychologists, social workers or even teachers may be involved into CBT exer-

cises (Boekhoff, 2000). For instance, they may encourage students to refrain from

performing compulsions and to refocus on adaptive behaviors. Educational in-

terventions, however, can also include facilitate exposure and response preven-

tion. In some cases of reading compulsions, reading aloud before class may serve

as a successful response prevention exercise as the compulsion to repeat passages

may be overridden. PC programs like Microsoft PowerPoint which present text

passages on the screen continuously and without interruption, can be an effective

tool to facilitate response prevention for that type of compulsion.

146


The process of getting stuck which leads to repetitive reading may then be pre-

vented (Danserau & Bouchard, 2005). According to the suggestions for ac-

commodating students with OCD of Packer, Challenging Kids, Inc. (2004),

Helbing and Ficca (2009) suggests that teachers may ask students if they would

like to have some redirection of their attention focus when they appear to be

distracted by obsessions.

4. Discussion

The Obsessive-compulsive disorder is a complex and severe anxiety disorder

frequently having its onset in childhood or adolescence. The disorder is now

being recognized as more prevalent than once believed. If undiagnosed and un-

treated, pediatric OCD tends to take a chronic course and to persist until adul-

thood. As children and adolescents spend much of their time at school, the

presence of OCD in the school setting should be regarded as an important subject

of scientific investigation.

Sabuncuoglu and Berkem (2006) state that children with the obsessive-

compulsive disorder experience the major part of their symptoms at home,

moreover they consider that some OCD symptoms even decrease at school.

Several OCD symptoms, of course, are not present at school, other ones may

be overridden by school-related activities. When school work serves to refocus

thoughts and behaviors away from symptoms, it may help patients to regain a

certain amount of control over them. In these cases, encouraging students to

engage in school-related activities, especially those associated with individual

talents, can serve as a therapeutic tool.

However, Sabuncuoglu and Berkem (2006) miss several important aspects.

Many OCD symptoms occur in school settings, some of them are clearly linked

to typical school-related activities. Even if symptoms in school lessen through

distraction, in most of the cases this kind of distraction is not an outcome of the-

rapeutic refocusing, attentional redirection or response prevention. The major rea-

son for students not to exhibit or report of school-related symptoms is the tendency

to hide, suppress, disguise or rationalize them. The latter consumes much energy

and can lead to mental and physical exhaustion. Once at home, children frequently

“engage in a ritualizing frenzy” (Boekhoff, 2000; Adams, 2004).

OCD is associated with many specific impairments deriving from the hete-

rogeneous nature of the disorder. Difficulties with finishing homework (Piacentini

et al., 2003) are undoubtedly one of the major school-related issues, independent

of the fact if homework is done at home or at school. Furthermore, concentration

147


deficits resulting from neuropsychological impairment have much relevance for

academic performance.

Obviously, symptoms of obsessive-compulsive disorder can be present in

several situations and localizations of a typical school day. If a teacher suspects

OCD in a student, he first should talk to the student confidentially. In the next step,

he should convince the student that it makes sense to inform his parents and to in-

volve the school psychologist. The student then can be referred to a child psychia-

trist for assessment and be provided with support and adequate educational

interventions. Once diagnosed, school-aged children and adolescents can be treated

effectively. If untreated, affected children and adolescents are at severe risk of sym-

ptom exacerbation, a chronic, unremitting course, and the development of comorbid

disorders. Furthermore, academic impairment and peer victimization can precipitate

social withdrawal, loneliness and comorbidities like depression or social phobia.

By increasing awareness of OCD symptoms among teachers, school psy-

chologists and school social workers can make a major contribution to the

identification of children with OCD. In conjunction with clinicians, they can

make a major contribution to behavioral assessment and treatment. Early dia-

gnosis and treatment, along with the support of the family and members of the

school community, will result in a positive outcome for the child (Helbing &

Ficca, 2009). Future studies need to investigate typical school-related OCD

symptoms and their impact in the academic and social context in systematic

controlled trials. Results then can serve as a basis for the development of sub-

sequent psychological and educational interventions.

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