COVER SHEET

Woolcock, Elizabeth and Campbell, Marilyn Anne (2005) The Role of Teachers in the Support of Students with Obsessive-Compulsive Disorder. The Australian Educational and Developmental Psychologist 22(1):pp. 54-64. Copyright 2005 Australian Psychological Society Accessed from: http://eprints.qut.edu.au/secure/00004707/01/OCD_journal_article.The_Role_of_Teac hers.doc

Childhood OCD in school

The Role of Teachers in the Support of Students with ObsessiveCompulsive Disorder

Elizabeth Woolcock and Marilyn Anne Campbell

Queensland University of Technology

Dr Marilyn Campbell School of Learning and Professional Studies Faculty of Education Queensland University of Technology Victoria Park Rd Kelvin Grove Q 4059 3864 3806 [email protected]

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Childhood OCD in school

Abstract

The early identification and referral of students with obsessivecompulsive disorder (OCD) is crucial for the implementation of timely intervention and therapy. Classroom teachers could be well positioned to identify and refer students with OCD to the school counsellor or support services team due to their extensive interaction with these students. However, teachers need to become more knowledgeable about OCD to successfully identify and thus be able to refer students with OCD (Purcell, 1999). These students also need to be managed differently within the classroom. However, there is limited support to guide teacher practice in this area. This paper provides a general overview of childhood OCD and explores the role of teachers in the identification, referral and management of students with OCD.

Keywords Children Adolescents Obsessive-Compulsive Disorder Teachers

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Childhood OCD in school

Anxiety disorders are one of the most common forms of childhood and adolescent psychopathology and are estimated to affect up to 18% percent of 6 to 17-year-olds (Costello & Angold, 1995; Labellarte, Ginsburg, Walkup, & Riddle, 1999). These disorders may present in a variety of forms, such as separation anxiety, social phobia, generalized anxiety, panic disorder with and without agoraphobia, and specific phobias (Spence, 1998). Childhood obsessive-compulsive disorder (OCD) however, is considered to be one of the most chronic and debilitating anxiety disorders.

Over the past decade, childhood OCD has received greater attention than any of the other childhood anxiety disorders (Rapoport & InoffGermain, 2000). The burgeoning interest and research in the field has been accompanied by an increase in the diagnoses of child and adolescent OCD (Henin & Kendall, 1997) which has implications both for specialist and generalist teachers. This paper examines teachers’ ability to identify and refer students with OCD and the difficulties associated with the management of their learning and behaviour in the school setting. As much of the literature on OCD does not distinguish

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between children (5-12 years) and adolescents (13-18 years), the term childhood OCD will be used to describe both these age ranges.

Definition OCD is characterised by recurring, unwanted thoughts (obsessions) and repetitive actions (compulsions). ‘Obsessions’ are recurrent and intrusive thoughts, impulses, urges or images that are distressing and which interfere with daily functioning. These thoughts are evoked by fears that relate to threat, contamination, harm, illness, death, numbers and evil (Adams, Waas, March, & Smith, 1994; Black, 1999). ‘Compulsions’ are intentional urges or responses to obsessions that are repeated overtly (behaviours) or covertly (mental acts) intended to warn off such fears. Compulsions include washing and cleaning rituals (exhibited by up to 80% of children and adolescents with OCD), excessive avoidance, checking, repeating, symmetrical arranging and need for reassurance (Adams & Torchia, 1998). Although the specific content of a child’s obsessions and compulsions tends to change over time, the overall number of symptoms usually remains constant, while a minority of children may experience obsessions but not compulsions (Barrett, Healy-Farrell, Piacentini, & March, 2004).

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Onset and Prevalence

Between one-third and two-thirds of adults with OCD have reported that their symptoms first manifested during childhood (Barrett & Healy, 2003; Henin & Kendall, 1997; Shafran, 2000). Research has indicated that boys are more likely to experience onset in prepubescence whereas in girls, onset is more common in adolescence (Barrett et al., 2004; March & Mulle, 1998). A recent review of 11 clinical studies found that the mean age of onset was 10.3 years while the mean age at assessment was 13 years, which indicated a long lag between onset and referral (Geller & Spencer, 2003).

Some of the triggers linked with the onset of childhood OCD have included infections, personality or temperament, environmental factors, functional or contextual stressors and stressful life events. Some researchers have argued that neurobiological (Purcell, 1999), neurochemical (Waters & Barrett, 2000) and neurobehavioural (March & Mulle, 1998) dysfunctions are more influential than environmental factors, although most have agreed that there is no single cause. The consequences of childhood (as opposed to adult) onset have been

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reported as poorer treatment response, higher familial risk, and a high rate of tic and developmental disorders (Murphy, Voeller, & Blier, 2003).

Recent community estimates have indicated that OCD is more prevalent than once believed, affecting 0.25% to 4% of children and adolescents (Heyman, Fombonne, Simmons, Ford, Meltzer, et al., 2001). Childhood OCD tends to be more prevalent in community populations than in clinical populations (Douglass et al., 1995; Heyman et al., 2001; ValleniBasille, Garrison, Waller, Addy, McKeown, et al., 1996) which may be attributable to the under diagnosis of OCD by health care professionals or to the fact that young people with OCD or their parents, often do not realise that support is available. In addition, few students, especially under fifteen years of age, are self-referred (Rapoport & Ismond, 1996).

Up to seventy percent of children with OCD are diagnosed with at least one comorbid disorder (Reavin & Hepburn, 2003). The most common comorbid diagnoses associated with childhood OCD are other internalising disorders, such as anxiety disorders and depression (Barrett et al., 2004). OCD is also comorbid with externalising disorders, such as Attention-Deficit Hyperactivity Disorder, Autism, Tourette’s

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Syndrome and Asperger Syndrome (Kovacs & Devlin, 1998; Reavin & Hepburn, 2003). This significantly complicates (differential) diagnosis, the course of therapeutic interventions, research outcomes and school management (Strock, 1996; Waters & Barrett, 2000).

Identification of Students with OCD

The role of school personnel is particularly important in the identification of students with OCD. In a British survey, children and adolescents with OCD were found to seek help primarily from general practitioners and school staff (Heyman, et al., 2001). Similarly, an Australian survey found that family doctors/pediatricians as well as school-based counsellors provided the most frequently used services by young people (Sawyer, Arney, Baghurst, Clark, Graetz, et al., 2000). Given the limited numbers of support personnel within schools, teachers are therefore often relied upon to identify students with OCD. However, teachers have received little, if any, support to identify or to manage students with OCD.

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In an Australian study by Nicholson, Oldenburg, and McFarland (1999), teachers expressed concern about their ability to accurately detect children with internalising problems, such as depression, bereavement or elective mutism. Teachers also reported uncertainty about how or when to make referrals, which could exclude children from receiving appropriate services. The researchers suggested that school personnel were more attentive to students with externalising disorders because established mechanisms were already in place for the referral of these students and because their disruptive behaviour was more likely to create challenges for management in the classroom.

One of the reasons for the difficulty in identification of obsessive compulsive disorder could be that many teachers are not aware of OCD (Purcell, 1999). One possible reason for this is that most, if not all, children exhibit age-dependent behaviours that resemble obsessivecompulsive symptoms, such as stepping on cracks or arranging favourite objects (Evans, Leckman, Carter, Reznick, Henshaw, et al., 1997; March & Leonard, 1996). Recurrent worries, and perfectionistic and repetitive behaviours are common at various stages of

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development. However, the content, intensity, and unpleasantness of obsessions and compulsions make them distinct from ordinary childhood rituals or superstitious beliefs. Students with OCD are often so mentally and physically exhausted from ritualising that their ability to concentrate is impaired (Tomb & Hunter, 2004).

The fact that students are much less likely to perform rituals at school than at home, so that they can appear to ‘blend in’ with their classmates (Black, 1999), might further contribute to the difficulty in identification. Indeed, many symptoms may not be apparent at school unless they are self-disclosed because of their ‘hidden’ nature (Adams & Burke, 1999; Black, 1999). Even if students are correctly identified, many deny or minimise the significance of their symptoms and assessment is restricted to the child’s verbal descriptions of these symptoms (Detweiler & Albano, 2001; King, Leonard, & March, 1998). Furthermore, children often find it difficult to describe their obsessions and compulsions. This is because many children and adolescents feel shame and embarrassment, self-loathing and reluctance when disclosing the nature of their obsessions and compulsions (Adams et al., 1994; Fong & Silien, 1999).

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A third possible reason for the difficulty in identification is that few educational publications have focused on childhood OCD, and even fewer have been written by or for teachers. Some publications have attempted to raise the level of awareness amongst educators by describing OCD in terms of medical and psychological knowledge (see Alberta Learning, 2000; Purcell, 1999; Strock, 1996). Invariably, these publications have outlined the ‘warning signs’ of OCD, and provided case illustrations or clinical reports of children with the disorder. It is noteworthy that, with rare exception, most educational publications on childhood OCD have been authored by clinicians. Indeed, teachers might be reluctant to take these suggestions on board if they are “told what to do”, particularly by non-teachers (Everton, Gatton, & Pell, 2002).

Referral of Students with OCD

Given the amount of time spent with students, teachers often serve as the primary referrer for specialist school personnel and mental health professionals. However, some teachers may ignore problems because they feel that they lack the necessary skills to make a referral, are

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emotionally worn out or choose to remain disengaged with the situation (Nicholson, et al., 1999a; Nicholson, Oldenburg, McFarland, & Dwyer, 1999b). Problems might also be ignored because of the limited availability of guidance counsellors in Queensland schools, with their focus necessarily on the most severe cases (Nicholson et al., 1999b). Even when students are referred, obsessive-compulsive traits are not usually the identified problem at the time of referral to a school counsellor or psychologist. Most students with OCD are referred to school counsellors or psychologists because of academic, social or learning difficulties (Adams, et al., 1994; Parker & Stewart, 1994). The “acting out” behaviours of some students with OCD may be mistaken for externalising disorders, such as Attention-Deficit Disorder (Goranson, 1999). Alternatively, the perfectionist tendencies of an OCD child might be interpreted as giftedness (Webb, 2000). Therefore, a lack of awareness of potential differential hypotheses may contribute to the mislabelling of students.

In addition, many referrals are made to specialists after a disorder has had a significantly negative effect on school performance and peer relationships, thus making it more difficult to provide appropriate

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intervention support (Donovan & Spence, 2000). Nonetheless, the referral of students with OCD is crucial to minimising the detrimental effects of OCD between the time of onset and the provision of specialist support services.

Management of OCD in the School Setting

Teachers are often not aware of anxious students due to their compliant and non-disruptive behaviour (Donovan & Spence, 2000). Indeed, many obsessions and compulsions are germane to, and even lauded by, the educational system such as perfectionism, neatness and correctness (Parker & Stewart, 1994). However, when taken to excess, some forms of behaviour are more evident than others and can become significant classroom issues, such as excessive self-criticism and the need to retain control.

Students experiencing obsessions may get “stuck” or fixated on a thought, which causes an inability to complete set tasks. This obsessive slowness can lead to a decrease in work production and poor grades and drastic changes in academic performances may occur (March &

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Mulle, 1998). Students with compulsions may repetitiously cross out, trace or rewrite letters, excessively rub out or check/recheck answers, symmetrically arrange books and equipment and frequently need to leave the classroom (Adams et al., 1994). Students with OCD might also experience difficulty in establishing and maintaining peer relationships (Adams & Burke, 1999; Goranson, 1999). Depending on the severity of social pressures and related symptomatology, students with OCD might avoid or refuse to attend school.

In fact, an American study by Goranson (1999) highlighted the competitive, stressful nature of the school setting in activating and exacerbating obsessive-compulsive symptoms in students. The mothers of children with OCD reported that the pressure to perform academically and the transition to high school were particularly stressful. Furthermore, they expressed concern over the loss of “valuable learning time” because obsessive-compulsive symptoms had not been identified. Despite the establishment of multidisciplinary teams (consisting of class teachers, support staff and parents) to support students with OCD once they were identified, regular meetings occurred infrequently and parentschool communication was limited.

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However, research has shown that effective therapeutic strategies can be translated into the classroom setting. Indeed, these may already be a part of a teacher’s practice. Teachers may be included in a behavioural program (such as exposure and response therapy- ERP) whereby they are encouraged not to provide reassurance (Shafran, 2000) or participate in ritualistic behaviours as this may lead to poor treatment outcomes (Amir, Freshman, & Foa, 2000). Teachers might also assist in the monitoring of (ERP) homework tasks, particularly when parents are unable or overwhelmed by the situation (Francis & Gragg, 1996). A classroom climate in which students do not feel threatened by their peers or teachers is most conducive to the completion of these tasks.

Indeed, the classroom climate may determine the degree to which a child is prepared to face anxiety-provoking experiences (King & Ollendick, 1989). Keeping stress levels low is important, and teachers are encouraged not to threaten or punish a child with OCD because of tardiness, forgetfulness or procrastination (Black, 1999; March & Mulle, 1998). Teachers are also encouraged to organise classroom activities

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so that the child has a partner, for example, ensuring that the child has a few ‘safe friends’ to accompany them on field excursions.

Modifications to the classroom setting can be an effective way of reducing student anxiety. Many children with OCD have feelings of claustrophobia, so it is important that these students are placed in larger classrooms (Ottinger, 1998). Teachers are encouraged to decide where students with OCD are to be seated, namely away from windows or doorways to avoid distractions, and in seats that provide an unobstructed view of the board or teacher. The room should provide opportunities for the ‘easy’ movement of students, particularly if they need to leave the room to ritualise (Ottinger, 1998).

Sometimes whole-class interventions are an effective means of addressing student anxiety, including OCD (Barrett & Turner, 2001). Incorporating emotional learning into the curriculum can encourage students to express their emotions positively and ask for help when required (Campbell, 2004). Indeed, enabling all students to identify and name fearful emotions can help to gain control over them (Alberta Learning, 2000). Teachers might emphasise the fact that everyone is

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fearful and anxious at times, thus helping students with OCD feel less ‘abnormal’. The use of readily-available and cost-effective resources such as stories (for example ‘Dig the Fearful Pig’ by Campbell, 2005), television advertisement/shows and movie clippings within the mainstream curriculum might also help students to critique the influence of fear on their everyday lives. All students could help by collecting such ‘conversation starters’. It is important to remember that effective classroom interventions can complement, not necessarily compete with, the mainstream curriculum (Nicholson et al., 1999b).

It is also important to remember that while some children might use OCD as an excuse to avoid schoolwork, most prefer to do their work as best they can (March & Mulle, 1998). Therefore, it is important to maintain the same expectations of all students, whilst appreciating the idiosyncratic nature of obsessions and compulsions. In the main, teachers can help students with OCD by ignoring student behaviour that is not seriously disruptive (Ottinger, 1998). Teachers can also help by setting clear limits and establishing consequences for behaviour. An agreed-upon cue, or signal, might alert teachers to the more difficult situations. Teachers might also accommodate students who have

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difficulty completing tests or assignments by allowing breaks during testing, providing extra time or allowing students to submit tests or assignments orally (Adams & Torchia, 1998). For students with note taking difficulties, the teacher might provide outlines of class lessons and use audiotapes of texts for those with reading compulsions (Adams & Torchia, 1994). It is important that teachers maintain a learning environment in which students with OCD feel comfortable in contributing to the life of the class.

Indeed, the relationship between the student and the teacher plays a critical role in the life of students with OCD, as with all pupils. Students need to have time to verbalise their worries if teachers are to gain a ‘real’ perspective and understanding (Alberta Learning, 2000). Patience and persistence is needed to deal with the often entrenched thinking, feelings and behaviours of students with OCD. As with all teaching, helping these students feel more at ease with themselves is one of the most significant contributions that a teacher can provide (Scholzman, 2002). It is also important to remember that most students with OCD are not intentionally deviant and should not be punished for behaviours or

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situations over which they have limited or no control (March & Mulle, 1998).

Future Research

Research is an important source of knowledge on childhood OCD, which teachers can incorporate into their practice on the basis of their professional judgment. However, current knowledge of OCD is predominately based on medical and psychological research conducted in clinical settings. Future studies on childhood OCD might be more applicable for teachers if they accounted for the ‘real-life’ contingencies in the school setting, particularly in the classroom. Greater attention could be placed on teacher-generated issues, such as the need for educational publications written by and for teachers. Research might assess the best way to provide professional development on OCD and the use of effective whole-school and classroom strategies. In this way, future research could contribute to developing an understanding of the practical issues related to the identification, referral and management of students with OCD in schools.

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Summary

The early identification and referral of students with OCD is crucial if both students and teachers are to effectively manage the disorder within the classroom. However, the identification process may be complicated by the fact that many OCD symptoms resemble normal childhood games or superstitions and are hidden from school personnel and classmates. Furthermore, few educational publications have focused on childhood OCD, and most of them have not been written for teachers. A lack of awareness might also contribute to the non-identification or mislabeling of students with OCD, thus preventing them from receiving the support they require. Even if these students are identified, teachers might perceive that they lack the necessary skills to refer students with OCD. The limited availability of guidance counsellors might also prevent teachers from referring these students. In order to manage students with OCD, teachers might reinforce some of the strategies used in therapy. Indeed, many of these strategies might already be a part of the teacher’s practice. The establishment of a flexible working environment is important in reducing a students’ level of anxiety. Whole-class intervention also plays an important role in raising the level of

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awareness about anxiety, and can encourage all students to develop effective coping skills.

Effective school-based interventions for students with OCD should be designed in accordance with the guidelines for mental health interventions proposed by Nicholson et al. (1999b). Expectations placed on teachers concerning the identification, referral and management of students with OCD should be consistent with teachers’ existing skills and knowledge and professional development should be provided. Moreover, teachers should not be expected to take on the role of, and compensate for the lack of, mental health specialists in schools. Indeed, the classroom is only one of many environments affecting students with OCD. Effective intervention for students with OCD occurs across a range of settings, thus becoming the responsibility of all professionals and families.

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