The diagnosis of Obsessive-Compulsive Disorder (OCD) is usually quite straightforward in adults. However, symptoms of OCD in children often manifest in different ways, which can lead to detrimental misdiagnoses. The key is to understand the underlying cause of each child’s behavioral manifestations. Let’s take a look into Nick’s symptomology and how it was approached.
Nick was 10 years old at the time he began treatment with me. He had already been to several psychologists intermittently for talk and play therapy. He had begun seeing a psychiatrist and was placed on a medication regimen of Luvox and Risperdal. Nick had been given various diagnoses since preschool, including Separation Anxiety, ADHD, Oppositional Defiant Disorder, Panic Disorder, and OCD. Due to his emotional outbursts and issues with anger, his family sought family therapy unsuccessfully and was considering residential treatment at the family therapist’s suggestion. Nick also had difficulty paying attention in his classes and always declined play dates with friends after school, although he was socially interested and active during school.
When I first met Nick, he appeared to be a gentle boy with excessive fear and anxiety. He often smiled and nodded nervously in agreement with little much else to say. He expressed that his biggest fears were about being alone and “something bad happening” to him or his parents. He often worried about getting kidnapped or his parents getting into a car accident. He also had fears of contamination, and avoided any potentially contaminated items. To ensure that nothing “bad” would happen, Nick developed a set of behavioral and mental compulsions, including: tapping a certain way, checking door locks, windows, stove, etc for safety measures, repeating “just kidding” to himself when he had an intrusive image of harm befalling his family, wearing the same two outfits over and over again, because they felt safe.
Nick’s parents described their days as chaotic and debilitating. Getting Nick to school every morning was a struggle because of his emotional crying and pleading to let him stay home, which usually resulted in angry outbursts of threats. A detailed bedtime ritual of specific behaviors and words such as hugs, “goodnight” and “I love you” had to be performed in a particular way every night by each family member. If any part of the ritual was done incorrectly, it had to be repeated or Nick would have an emotional meltdown. These outbursts worsened over time, and became so severe that the neighbors called the police at one time when they saw Nick jumping on the roof of his father’s car shouting “I hate you,” “I’m going to kill you,” “I want to shoot your head off.” Nick’s parents expressed waking up every morning in dread, because they felt helpless to help their child, and yet, frustrated by his unexplained behaviors.
At the outset of treatment at our program, Nick decided to call his OCD, “Mr. Worry.” Although he reported being very motivated to improve his behavior and relationship with his family, he appeared hesitant and uncertain. We developed a hierarchical list of all of the rules given by Mr. Worry. I educated Nick and his family on how Mr. Worry thrives when these rules are followed and how Mr. Worry weakens when these rules are broken. I explained how we do not have direct control over our emotions, such as fears and anxiety and can only redirect them through our defenses. I described how we do not have direct control over the specific thoughts going through our minds. Using his thought of being kidnapped as an example, I explained that at any given time, we have a million tiny stimuli entering and exiting our minds. Helping him to understand that what we do have is “selective attention,” which allows us to focus on any one whole thought at any given time. This clarified how when we try not to think of something (i.e., getting kidnapped), we are actually selectively attending to that thought. Nick tested this theory when I said, “Now don’t think of the yellow duck.” He couldn’t, and his eyes lit up with more interest, which indicated our first breakthrough. I continued to explain that what we do have control over is our behaviors, including our actions and reactions to our thoughts and emotions. This means that we only have control over those behaviors that Mr. Worry instructs us to perform, such as checking and tapping.
From this very first psychoeducation of how OCD functions, Nick’s initial hesitation began to subside. We developed a strategy to beat Mr. Worry by selecting those rules (compulsions) to break that were at the bottom of the difficulty scale and worked our way up. Nick began acquiring tools to beat Mr. Worry by following this model:
We cannot control our emotions.
We cannot control our thoughts.
To beat Mr. Worry, we can only control our behaviors by not following his rules.
As for Nick’s behavioral outbursts, I explained to his parents how Nick himself did not comprehend what he felt. The anxiety from the obsessive fears of harm for a 10-year-old can be extreme and debilitating. Rather than feeling protected by his parents, Nick felt resentment toward them for making him go to school and experience his anxiety even more. I discouraged their consideration of residential treatment, which would only increase Nick’s resentment, and instructed them to audiotape his behavioral outbursts.
This was used during sessions to increase Nick’s awareness of his emotional meltdowns. Additionally, we practiced graded exposures to his fears of being alone, such as separating from his parents for brief moments by stepping just outside the front door for two minutes and taking 10-minute walks around the neighborhood.
To increase Nick’s motivation, we used a behavioral modification program for the Exposure and Response Prevention (ERP) part of treatment. This involved exposing Nick to his obsessive fears in a hierarchical level of difficulty without engaging in the compulsive behaviors. Nick was rewarded with his chosen privileges each time he was able to beat Mr. Worry and not give into the rules.
By that summer, five months from starting our treatment program, Nick was able to ride the school bus daily without anxiety, enjoy sleepovers at friends, participate in a week-long camp away from home, and fly on a plane by himself. His mother even got into a minor car accident, which he stated, “was a good exposure.”
Although Nick’s behavioral symptomology may have initially appeared as ADHD or Oppositional Defiant Disorder, the underlying cause for his behaviors were clearly triggered by obsessive fears of harm to self and others, accompanied by the compulsive rituals to ensure safety. Had we entertained the other diagnoses, his symptoms would have been aggravated by the medications for ADHD, his anger would have worsened by his perception of his parents lack of understanding, and his overall functioning would have decreased by his inability to manage Mr. Worry.