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A Teacher’s Guide to OCD in the Classroom

How to recognize the disorder in a struggling child 

Jerry Bubrick, PhD

Senior Director, Anxiety & Mood Disorders Center; Director, Intensive Pediatric Obsessive-Compulsive Spectrum Disorders Program
Child Mind Institute

For children who have obsessive-compulsive disorder, functioning in school can be complicated and very difficult. And for a teacher, it can be easy to misread the symptoms of OCD as oppositional behavior on the child's part, or as ADHD.

If we can help teachers recognize the behaviors associated with OCD, especially when a child is embarrassed and trying to hide his anxiety, we can save children unnecessary struggle, and clear the way for them to learn successfully. Kids spend nearly a thousand hours per year in school, which means that teachers are often spending more time with kids than parents are, so it's especially important for them to be clued in to how to help a child with OCD function better.

OCD is an anxiety disorder characterized by having obsessions and/or compulsions. Obsessions are unwanted, intrusive thoughts, images, impulses, that cause anxiety. And the things you do to get rid of them are the compulsions. They're designed to relieve the anxiety that comes from the obsessions. We use the analogy of a mosquito bite. When you get bitten by a mosquito, it itches, so to make it feel better you scratch, and while you're scratching it feels great, but as soon as you stop scratching, the itching gets worse. That's exactly how OCD plays out. You have this source of discomfort. You do something to fix it temporarily, but that process, performing the ritual, makes it worse over time.

The most common obsessions we see in children are contamination—these kids are sometimes referred to as germophobes. In schools, this plays out with kids worrying about other kids sneezing and coughing, worrying about touching things that might be dirty, getting sick in many different ways.

We also see kids who do what we call catastrophizing—that is, they are worried that their thoughts will cause someone to get hurt, or get sick, and it's going to be their responsibility, their fault. Some kids' OCD takes the form of what we call magical thinking—which is like superstitious thinking taken to extremes—"step on a crack, break your mother's back" kind of thing. So kids might have a thought that, "Unless my things are lined up in a certain way, mom will get in a car accident."

There's also something we call scrupulosity, or having obsessive worries about offending God or being blasphemous in some way. Kids may be plagued by a lot of different kinds of thoughts about bad things they could do. "What if I hurt someone? What if I stab someone? What if I kill someone?"

And we see kids who just have to keep doing something until they get what we call the "right feeling." When OCD first develops, from about six to nine, kids may not know why they are doing something, but just that they need to do it until they get the right feeling. So: "I'll line these things up until it just kind of feels right, and then I'll stop." And then over time—nine, 10, 11, 12 range—it evolves into more of the magical thinking. It becomes more superstitious in nature.

What are the compulsions we see in kids with OCD?

Washing is a big one. Not just washing of hands and bodies, but also of items—of their pens, their pencils, their backpacks, their books. I once worked with a kid who needed, after his mother went to the grocery store, to wipe down the cans they brought home, because they were contaminated. Contamination is a big word in OCD.

We see a lot of checking—checking of doors, windows, lockers, desks - again, with that kind of need for certainty. "What if I left something behind?" And we see a lot of counting—counting steps, doing things in multiples of fours and eights. We see a lot of ordering and arranging of things. Capping and touching symmetrically. When I sit down at my desk, if I accidentally kick the chair of the kid next to me with my right foot, I'm going to have to then kick it with my left foot. That might look like somebody who's being oppositional, or somebody who's got too much energy, but it could very well be OCD.

Here are the kinds of behaviors you might typically see in kids with OCD at school:

Frequent requests to go to the bathroom: This could be to wash hands, if someone near them was coughing or sneezing, or if they touched something that they perceive as contaminated. It could also be an excuse to get out the classroom and just be away from everyone, and just have some respite.

Constant reassurance-seeking. This takes the form of repetitive questions. "Are you sure that's the answer? Could you tell me again? Did you hear what I said?" But over and over and over again.

Getting stuck on tasks. Sometimes kids with OCD will need to finish something to completion, or understand it to completion, before they're able to move on. So if I'm working out what I did wrong on a math test, and the teacher says, "Now let's open the textbook and start a new chapter," I'm not going to be able to shift gears.

Retracing: If I leave the classroom and I worry that maybe I left a pencil behind, I'll go back into the classroom and go to my desk and check. If I had a bad thought as I went through the doorway, I might have to go back and fix it by going through the doorway again saying a good word. Sometimes a kid who's had a bad thought when he went down a flight of stairs on the way to class needs to go back up that same stairway at the end of the period, even if it means being late to his next class.

Obsessive erasing: Sometimes it's because letters have to look perfect. Or because a child has used a word that disturbs him. If I have a fear of vomiting and I've written the word vomit, I can't stand see that word. I'll have to erase it so it's really gone. You start to see holes in the paper. You start having erasers worn down to the metal. A lot of times you'll see words drawn over on the back of the page. A lot of different areas of writing become problematic.

Distraction: If I am having an obsession that if I don't turn the cap and count to four the right way, then Mom's going to get sick, and then the teacher calls on me to answer a question, I'm not going to be paying attention. It may look like I have ADHD, but really I don't.

Slowness on exams and papers and tasks. Sometimes that's the perfectionism of needing to do things the right way.

Avoidance: We might see a child who doesn't want to sit on the floor, or pick things up that touched the floor, or get his hands dirty in art class. A child may avoid a lot of playground activities—kids with germ fears will look at the playground the way some adults look at the subway—it's gross. Why touch anything there?

Complaints of anxiety and fatigue. There's one interesting theory that kids with OCD are smarter than other kids. And if you think about how much thinking they're doing, they're really using their brain more frequently than a lot of other kids are. But when that's coupled with a lot of anxiety, you can have a lot of fatigue. So it's common for kids with OCD to want to come home and take a nap after school.

For a guide to what can be done in the classroom to help kids with OCD function better—both for themselves and other kids in the class—check out A Teacher's Guide to Helping Kids With OCD.

Updated: November 28, 2011

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