Breaking the ritual
The child who is always last back from lunch, the child writing and re-writing a piece of work, or the teenager who seems to spend an inordinate amount of time in the toilets. All of these pupils may have obsessive compulsive disorder (OCD). OCD is an anxiety problem that affects up to 1 per cent of under-18s, so a large secondary school might have 10 to 20 affected pupils. Although it can start in children as young as six or seven, it is more common in teenagers.
The characteristic symptoms are obsessions and compulsions. Obsessions are unwanted, repetitive, unpleasant thoughts. Typically they may be unrealistic worries about things being contaminated or fears of bad things happening to loved ones. Compulsions are repetitive, unnecessary and unwanted behaviours. Sometimes they are clearly associated with particular obsessions, such as repeated and excessive hand washing, which is linked to fears of contamination; but they can be more "magical", such as tapping objects or walking in a particular way, which the child may feel protects their mother from an accident.
If teachers see a pupil with symptoms, they should gently ask about them. Depending on their age, the teacher should find out if the parents are aware of the problem and perhaps advise seeking help from a GP.
Once a diagnosis of OCD has been made it is very treatable, but unfortunately it often goes undiagnosed for years. One reason for this is that those with OCD are embarrassed about their symptoms, and they are the ones with full insight into the unnecessary and time consuming nature of the unwanted thoughts or rituals. If a child approaches the teacher about their problems, the teacher should treat the disclosure sensitively; make it clear they should not be ashamed, and with help they will recover.
The UK National Institute for Health and Clinical Excellence has published guidelines on the assessment and treatment of OCD throughout the lifespan (www.nice.org.uk). Treatment of mild cases may be possible with self-help books, or via a GP, but most children will need to be referred to child mental health services. The treatment includes cognitive behavioural therapy. A specific technique is recommended called "exposure with response prevention", where the child works closely with their therapist and family to gradually face their fears, to cut back and eventually stop rituals.
Occasionally, schools might be invited to help with this programme. For example, if a child has a fear of chemicals and has dropped out of science, their treatment might include gradually building confidence to step inside the science lab, touch a bench or pick up a bottle of chemicals. It helps if a school understands and co-operates with this type of intervention.
Some children with OCD are helped by specific medication. However, it does not usually need to be dispensed in school time and is unlikely to affect the child's ability in school.
The impact on school can be variable: from no impact to complete school refusal. Even if attendance is not a problem, OCD can sometimes make it hard for young people to concentrate, particularly if obsessions trouble them at school, or if they are tired from carrying out rituals, such as washing, through the night. Rituals may also make it hard to complete certain pieces of work. For instance, if sufferers have an urge to re-read or re-write. The need for reassurance can mean that they repeatedly ask the teacher questions.
Dr Isobel Heyman is consultant child and adolescent psychiatrist and Chloe Volz clinical psychologist in the service for young people with OCD at the Maudsley Hospital, London. Their website, www.ocdyouth.iop.kcl.ac.uk, lists books, information and other resources about OCD for children, parents, teachers and other professionals.
What schools can do for pupils with OCD
- Temporarily arrange alternative rooms to use if particular rooms are triggers for obsessions or rituals.
- Provide a safe place for a child to go to calm down if they are feeling particularly upset or stressed.
- Arrange for special consideration or extra time to be given during exams.
- Make special arrangements for homework, such as giving less work or more time.
- Assign a particular mentor.
- Agree on a sign so that teachers know when the pupil needs extra help or support.
- Show extra patience and understanding if rituals are performed at school.
View all special arrangements as temporary. The pupil should try to minimise the impact that OCD has upon their work and school life as part of their treatment.
A new self-help guide Jo Derisley, Isobel Heyman, Sarah Robinson and Cynthia Turner, Breaking Free From OCD: A CBT guide for young people and their families (Jessica Kingsley, 2008).