Case Study: Manifestations of Obsessive-Compulsive Disorder in Young Children

Colleen Kapsch ED 142: Education of the Exceptional Child Summer 2013

I. Student Profile: ! A is an eight-year-old boy who is going into third grade. For the past three years, he has

attended - School, a private school with a progressive early childhood focus. A attended The - Preschool from the time he was two years old until he entered kindergarten at -. In preschool, he received interventions from an SOS team that consisted of a social worker, occupational therapist, and speech pathologist. In addition to specific interventions provided by his SOS team, A benefitted from the small class sizes and shorter school day that offered. A applied to attend - for his pre-kindergarten year, but the admissions committee recommended that he remain at and reapply to for kindergarten. His application to kindergarten was accepted after his final year at -, and he was placed in my class. The observations that follow are based on my work with him in kindergarten. A was an athletic child who loved to play team sports. He had a special love of soccer and played on a community team outside of school. A almost always chose to play soccer or basketball during outdoor play times. His gross motor skills were very strong: he could kick and dribble a soccer ball at an advanced level compared to his peers, and he excelled in physical education classes. The PE teachers reported that A could walk on a balance beam, skip using alternating feet, and climb high towers. He had good upper-body strength and could cross the monkey bars independently.

In the classroom, A enjoyed building in the block center and participating in math workshop. He particularly liked trying to create the tallest building possible with wooden blocks, and he loved designing detailed spaceships and skyscrapers with Legos. In math workshop, A had strong number sense skills, which allowed him to calculate the answers for many problems mentally, and by mid-year he had surpassed all of the math benchmarks for Kindergarten. He was one of the first students in the class to calculate change in money problems, and he could explain his thinking using numbers and manipulatives like Unifix cubes. Because he was a very active student, A found it difficult to perform tasks that required him to sit still for more than three to five minutes. He especially struggled during morning meeting and during whole-group stories, when he often rolled around on the floor behind the other students. When he took a mid-year literacy assessment, the school reading specialist wrote on his report: A has strong early literacy skills, but he did not sit in a chair for the entirety of the assessment. He crawled, jumped up and down, and even lay on the table as I asked him questions. However, A correctly answered almost every question I asked him. During times when it was important for A to sit with the group, he often sat on a rocking chair. Occasionally, he rocked so forcefully that he tipped himself backward. Throughout the year, A had extreme shame reactions to minor events. One such reaction occurred after he ate at least six dessert puddings during lunchtime. One of the other students in the class approached me and said she saw A throwing away several pudding cups, and I noticed that we were indeed short many desserts. I quietly took A aside to speak with him, but he dashed into the bathroom before I could say anything. While inside the bathroom, he wailed and hid behind the toilet, refusing to speak. When he finally came out of the bathroom, he began

to wash his mouth with soap. My co-teacher picked him up and took him out of the classroom to calm him down. Just weeks later, a similar event occurred. A was convinced that he had kissed another student while walking back to the classroom from Science. Once again, he ran to the bathroom and attempted to lock himself inside, after which he washed his hands several times. A was able to calm down in the hallway with teacher help, but he perseverated on this episode hours and even days after it occurred, asking us if we remembered what had happened. When we asked the other student if A had kissed him, the other child said that nothing had happened. We had several meetings throughout the year with As parents to discuss his progress in kindergarten. We paid particular attention to As extreme emotional responses to certain behaviors and his self-soothing techniques (washing, clearing his throat). As parents had noticed similar outbursts but had not found effective coping strategies at home. They noted that A had not behaved this way at , and they were concerned about whether the behaviors would continue. We suggested possible evaluation by a psychologist, and his parents were open to this idea. Ultimately, they decided to wait until first grade to pursue testing. II. Diagnosis: In first grade, A was evaluated by a neuropsychologist who diagnosed him with ADHD. In Massachusetts, ADHD is classified as a health impairment, which is defined as, A chronic or acute health problem such that the physiological capacity to function is significantly limited or impaired and results in one or more of the following: limited strength, vitality or alertness including a heightened alertness to environmental stimuli resulting in limited alertness with respect to the educational environment (Special Education - Mass Dept. of Ed., 2000). According to As father, the evaluating neuropsychologist said that A was in the top 2% of

hyperactive children I have ever seen. Though I was not able to see the final report of As testing, his behavior in my classroom and anecdotal evidence from specialist teachers supported the diagnosis. After being diagnosed with ADHD, A began taking medication to help him participate fully in his first grade classroom. His teachers described the medication as successful, and A continued to take it during second grade. What the diagnosis of ADHD did not take into account were the extreme emotional reactions and perseveration that my co-teacher and I observed throughout Kindergarten. As first and second grade teachers echoed this concern: while he was now able to sit through lessons, certain events continued to cause outbursts, as his parents had called them. Over time, many of his teachers noticed patterns in these episodes that were consistent with descriptions of obsessive-compulsive disorder in children. Obsessive-compulsive disorder is categorized by the Massachusetts Department of Education as an emotional impairment. Children with emotional impairments may exhibit, among other criteria, inappropriate types of behavior or feelings under normal circumstances and/or a tendency to develop physical symptoms or fears associated with personal or school problems (Categories of Disabilities Under IDEA, 2012). These criteria were particularly relevant in As case. A became very upset if his actions toward another child could be viewed as sexual (kissing, touching), and he frequently used washing to self-sooth or alleviate his feelings of shame. We also noticed that these situations were accompanied by throat clearing, hand rubbing, and the need for reassurance through checking rituals. I believe As ADHD is comorbid with obsessive-compulsive disorder, and I am concerned that a diagnosis of ADHD could preclude recognition and/or treatment of his OCD symptoms.

III. Research Question: How Does Obsessive-Compulsive Disorder Manifest in Children? Early understandings of obsessive-compulsive disorder revolved around religious fanaticism and melancholia. Robert Burton, an Oxford Don, described obsessions in a religious context in his Anatomy of Melancholy in 1621. He wrote, If he be in a silent auditory, as at a sermon, he is afraid he shall speak aloud and unaware, something indecent, unfit to be said (Stanford, 2013). Later writers described people who seemed unable to control their naughty or blasphemous thoughts despite their worship of God. Such people were believed to be possessed by the devil and, indeed, the term obsession came to mean hostile action of the devil or an evil spirit in the fifteenth and sixteenth centuries (Aardema & OConnor, 2007, p. 185). A more modern understanding of OCD evolved throughout the nineteenth and twentieth centuries. The German neurologist and psychiatrist Wilhelm Griesinger described three cases of OCD in 1868 and called the disorder "Grubelnsucht," from the Old German word Grubelen, to rack one's brains (Stanford, 2013). Less than ten years later, in 1877, Carl Friedrich Otto Westphal used the term Zwangsvorstellung, compelled presentation or idea, to describe a patients behaviors. The modern term obsessive-compulsive disorder arose in an attempt to translate Zwangsvorstellung into English. In Great Britain, the word was translated to obsession, but in the United States, it was understood as compulsion. Thus, the term obsessive-compulsive disorder was a compromise between these two translations. In the twentieth century, Pierre Janet and Sigmund Freud tried to understand the causes of OCD in terms of nervous energy and the ego and the id, respectively (Stanford, 2013). Janet was the

first psychologist to describe a case of pediatric OCD in his Obsessions and Psychasthenia (Boileau, 2011). Despite the disorders long history, cases of OCD in children remain relatively rare. Boileau (2011) cites a study of 2800 children at the Bellevue Hospital in New York conducted between 1935 and 1939 in which the prevalence rate of OCD was as low as 0.02% (p. 402). Today, prevalence rates range from 1% of children and adolescents affected (Tolin, 2001) to up to 4% (Futh, Simonds, & Micali, 2012). Age of symptom onset varies from 7 years old to 18 years old, with studies differing on mean age of onset. Hanna (1995) cites a mean onset age of 12.8 years while Boileau (2011) references a study of 58 children in which mean onset age was 5 years. While boys are overrepresented in studies of OCD (typically in a 3:2 male-female ratio), Hanna (1995) notes that there are approximately equal numbers of adult men and women with this disorder. There is some evidence that boys have an earlier onset of OCD and exhibit more severe symptoms in childhood, which may explain their disproportionate referral to psychiatric studies (Hanna, 1995). In children as in adults, OCD is marked by the occurrence of persistent negative intrusive thoughts (obsessions) and overt or covert neutralizing strategies (compulsions) aimed at reducing distress or nullifying threats (Futh et. al., 2012). The nature of obsessions and compulsions tend to be different for people of different ages. Obsessions typically fall under broad categories such as contamination obsessions, aggressive obsessions, catastrophic or harm obsessions, and somatic obsessions, among others (Flessner, Berman, Garcia, Freeman, & Leonard, 2009). There are also obsessions that do not fall into any particular category; these are usually referred to as miscellaneous obsessions. In young children, particularly those who

present symptoms between the ages of six and seven, aggressive, contamination, and catastrophic obsessions are most common (Boileau, 2011). Boileau (2011) describes the manifestation of catastrophic obsessions in children as fear of catastrophic events or fears of death or illness in self or parent (p. 402). Catastrophic obsessions can sometimes be coupled with or mistaken for separation anxiety in young children. In fact, up to 56% of children with OCD also suffering from separation anxiety (Boileau, 2011). For those suffering with OCD, obsessive thoughts are relieved by compulsions that take the form of repetitive behaviors or mental acts. Tolin (2001) writes, They [compulsions] are subsequently reinforced by fear reduction, and they prevent normal habituation and realistic appraisal of the threat value of feared stimuli (p. 1111). Like obsessions, compulsions fall into broad categories, and some compulsions are more common among children than adults. In his study of 31 children with OCD, Hanna notes that 84% of children had washing or cleaning compulsions. Checking and repeating rituals, such as asking a parent for reassurance, were also prevalent, with 64% of children in the study exhibiting these compulsions (Hanna, 1995). Many children exhibited more than one compulsion, and this compulsion could change based on the obsession. Boileau (2011) writes, Young children with OCD often heard an inner voice ordering ritualization [...] and felt greatly relieved by completion of compulsions (p. 402). This so-called inner voice tends to be understood in adulthood as a symptom of OCD. Boileau notes that OCD is frequently comorbid with depression, Tourettes disorder, generalized anxiety disorder, and ADHD in children. Disruptive behaviors are particularly common in children with OCD: Disruptive disorders are prevalent in youth [with OCD] (51% in children and 36% in adolescents for ADHD, 51% and 47% for oppositional defiance

disorder) (p. 404). The older a child is when he is diagnosed with OCD, the more likely he is to experience co-occurring depression rather than ADHD. Cognitive behavioral therapy (CBT) has been shown to be effective in treating OCD in children and adults. Tolin (2001) describes CBT intervention as exposure to feared situations in order to reduce compulsive behavior. One method that is frequently used with young children is extinction, where parents and caregivers stop providing the reassurance that reinforces compulsions (Tolin, 2001). In his study, Tolin describes a novel implementation of CBT where he pairs extinction with what he calls bibliotherapy. In this model, parents and teachers were instructed not to reassure Howard, a five-year-old boy with severe OCD, about cleanliness and germs. Howards parents also read him the book Blink, Blink, Clop, Clop: Why Do We Do Things We Cant Stop: An OCD Storybook. In the story, a character named OC Flea tells his friends that activities are dangerous and that they must perform strange rituals. Howards parents read him this book many times, and he was encouraged to make fun of OC Fleas silly ideas. Tolin reported success with this method of therapy, noting that Howards reassurance-seeking behavior rapidly decreased. Howards mother reported improvements in his academic performance and ability to pay attention at school (Tolin, 2001). Due OCDs comorbidity with other psychiatric disorders, effective treatment must take into account the range of behaviors and symptoms exhibited by a child. Hanna (1995) writes, A clinical implication of this finding [that OCD is comorbid with other psychiatric disorders] is that these other disorders must be addressed in a comprehensive treatment plan for substantial improvement to occur in the overall level of functioning of most patients (p. 25). A child with a dual diagnosis of OCD and depression will have a very different treatment course from a child

diagnosed with OCD and ADHD. For a child with OCD and ADHD, a combination of CBT and interventions for ADHD like those described by Mather and Goldstein could be helpful. Providing a consistent routine and preparing for change, for example, are strategies that could support a child with a dual OCD/ADHD diagnosis (Mather & Goldstein, 2008). IV. Reflection The research on manifestations of pediatric OCD supports my belief that A likely has a dual diagnosis of OCD and ADHD. The descriptions of OCD in children mirrored many of the behaviors he exhibited in the classroom, and I saw definite connections between five-year-old Howard from Tolins study and five-year-old A. Dual diagnoses like these remind me that teachers must be sensitive to the complex causes of behavior. A child might have ADHD, but treating attention problems without addressing the emotional component of behavior is unlikely to yield satisfying results. As an elementary school teacher, I must work to see not only a chids actions but also the feelings behind them. Working with As OCD and ADHD was a challenge during my first year of teaching. I made certain accommodations that worked well, like the rocking chair. There were other times, however, when I felt utterly overwhelmed. Should I allow A to wash his hands repetitively? Was it okay for him to hide in the bathroom? Even after reviewing the literature, I am still wrestling to understand when accommodations hinder a child with OCD and when they help. Though I dont yet know how to strike this balance, writing this case study has given me many valuable opinions to consider. If I teach a child with OCD in the future, I think it would be highly beneficial to collaborate with a school psychologist to ensure that the student receives the necessary support.

I have also been able to reflect on my own experience with OCD while writing this case study. I was diagnosed with generalized anxiety disorder at 22, and my psychiatrist and psychologist first noticed my OCD symptoms about one year into my treatment. As I reviewed the research on pediatric OCD, I realized that I exhibited symptoms of the disorder as a child. I struggled with catastrophic obsessions, and I performed checking rituals to self-soothe. I often drove my parents and teachers crazy by asking the same question repeatedly. One good thing did come out of my diagnosis, however: I am much more sensitive to the emotional needs of all of my students, and for that I am thankful.

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References

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Aardema, F., & O'Connor, K. (2007). The menace within: obsessions and the self. Journal Of Cognitive Psychotherapy, 21(3), 182-197. Retrieved July 26, 2013, from the ProQuest database. Boileau, B. (2011). A review of obsessive-compulsive disorder in children and adolescents. Dialogues in Clinical Neuroscience, 13(4), 401-411. Retrieved July 26, 2013, from the ProQuest database. Categories of Disability Under IDEA. National Dissemination Center for Children with Disabilities. (2012, March 1). National Dissemination Center for Children with Disabilities. Retrieved July 30, 2013, from http://nichcy.org/disability/categories#ed Flessner, C. A., Berman, N., Garcia, A., Freeman, J. B., & Leonard, H. L. (2009). Symptom profiles in pediatric obsessive-compulsive disorder (OCD): The effects of comorbid grooming conditions. Journal of Anxiety Disorders, 23(6), 753-759. Retrieved July 26, 2013, from the ProQuest database. Futh, A., Simonds, L., & Micali, N. (2012). Obsessive-compulsive disorder in children and adolescents: Parental understanding, accommodation, coping, and distress. Journal of Anxiety Disorders, 26, 624-632. Retrieved July 27, 2013, from the ProQuest database. Hanna, G. L. (1995). Demographic and clinical features of obsessive-compulsive disorder in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 34(1), 19-27. Retrieved July 26, 2013, from the ProQuest database.

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History of Treatment of OCD - OCD Research - Stanford University School of Medicine. (n.d.). OCD Research - Stanford University School of Medicine. Retrieved July 30, 2013, from http://ocd.stanford.edu/treatment/history. Mather, N., & Goldstein, S. (2008). Attention and self-regulation. Learning disabilities and challenging behaviors: a guide to intervention and classroom management (pp. 101-109). Baltimore, Md.: P.H. Brookes Pub. Co. (Original work published 2001) Special Education - Massachusetts Department of Elementary and Secondary Education. (2012, July 19). Massachusetts Department of Elementary and Secondary Education. Retrieved July 30, 2013, from http://www.doe.mass.edu/sped/ Tolin, D. F. (2001). Case study: bibliotherapy and extinction treatment of obsessive-compulsive disorder in a 5-year-old boy. Journal of the American Academy of Child & Adolescent Psychiatry, 40(9), 1111-1114. Retrieved July 26, 2013, from the ProQuest database.

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