What are compulsions?
Compulsions are the visible behaviours of OCD. They are repetitive or ‘ritualised’ behaviours or mental acts that your child feels they must do as a response to their obsessive thoughts. These ritualistic behaviours are performed to prevent an objectively unlikely event resulting in harm, which otherwise might happen, and thus reduce the anxiety or distress that results from the intrusive thoughts. However, the relief gained is only temporary.
Compulsions may be visible actions or behaviours, or invisible within the mind or thoughts.
Common visible compulsions in children and teenagers include:
- Repetitive hand washing
- Checking switches
- Walking through doorways multiple times
- Having to touch certain objects a specific number of times or in a specific way
- Constantly seeking reassurance
- Putting clothes on in a specific order
- Going through very set routines that cannot be changed.
Common invisible compulsions include:
- Counting in the head, counting steps
- Repeating phrases or words
The compulsions your child may experience are often excessive or not logically linked to preventing the obsessive thought. They may be time-consuming and cause your child to struggle with school and family life. They will be neither enjoyable nor useful.
If your child or teenager is not able or allowed to perform the compulsion, they might experience high levels of anxiety and distress. In young children this may be exhibited as tantrum behaviour.
OCD can be extremely distressing for your child. They may be able to recognise that the compulsive behaviour is not rational, or they may enlist family members in the compulsion or through reassurance. They may try to conceal these behaviours in public, which can make it worse at home. This doesn’t mean that these behaviours are voluntary or not indicative of OCD.
Anxiety
The anxiety associated with obsessions and compulsive rituals may result in physical symptoms such as:
- Racing heart
- Nausea
- Dizziness
Symptoms and patterns of OCD may fluctuate and change depending on what’s occurring in your child's life. It’s common for the content of the obsessions to change with time.
When to seek more urgent help
If your child is demonstrating any of the following, it may be a sign that you need to seek help more urgently:
- Thoughts about suicide or harming themselves.
- If your child’s compulsions take up more than one hour per day or significantly interfere with their home or school life, or social functioning.
- Health issues, such as contact dermatitis from excessive handwashing.
You must seek immediate care if you believe your child is in danger. This may involve getting an emergency appointment with your GP, phoning 111 or 999, or taking them to the nearest emergency department. For more information and advice from the NHS go to their website - Where to get urgent help for mental health1.
Seeking help early can make a real difference, so do reach out if you believe your child struggles with any of the above symptoms.
How can I help my child or teenager with OCD?
As a parent, Obsessive Compulsive Disorder (OCD) can be a distressing thing to watch your child or teenager experience. The good news is there are evidence-based, modern and effective counselling and therapy methods for OCD.
There is strong evidence that Cognitive Behavioural Therapy (CBT) is successful in treating OCD. CBT can be accessed through children services2, who would then advise accordingly to the child’s needs, alternatively a GP can also direct a child to this service.
With children and teenagers, CBT can be more successful with family involvement. Your child will learn about what OCD is and will work with a technique called Exposure with Response Prevention (E/RP). In brief, ERP is where your child will gently expose themselves to the situations that trigger obsessive and unwanted thoughts but without performing their compulsions. There is evidence that doing this with a trained professional is a successful treatment for OCD3. As a parent, you will be able to follow your child's progress and help them with their anxiety management.
There are also things that you can do with your child at home:
Education
• Educating your child about OCD will help them understand what they are experiencing. Describe what obsessions and compulsions are, explain the causes of OCD and describe the OCD vicious cycle. Try using diagrams and concrete examples. You could try to create a chart with your child to explore their own OCD cycle, using their own real-life examples. In your diagram write down the intrusive thoughts (obsessions) and note the feelings that arise from these thoughts. Then write down what your child does to get rid of these thoughts or stop the bad thing from happening (compulsions). Note how your child feels after completing their compulsion (usually relief) but ask them how long their relief lasts for before the obsession returns.
• Your child may be embarrassed about their distressing thoughts and routines. They may be ashamed about their obsessions, or worried that their rituals may not be socially acceptable. This might mean they hide them or could be reluctant to seek help. Be patient, warm and compassionate. It might take a while for your child to feel comfortable enough to open up to you.
• Explain that OCD is an anxiety disorder. Giving a name to the fears, worries and physical feelings can help as a first step to understanding anxiety. Explaining what anxiety is and how it feels in the body may help your child better understand their experience. Explain to your child that anxiety is a normal, useful system in the body that tells us when we’re in danger. It’s important for them to understand that we’re not trying to eliminate anxiety, but rather looking for ways to manage it. Find out more about childhood anxiety.
• Begin by letting them know the OCD is not who they are, and is distinct from them. OCD is responsible for the rituals and routines. The OCD is the enemy to be defeated. It might help to locate the OCD outside of them when you talk about it. Try saying ‘what is the OCD telling you to do?’ or ‘how do you feel about not doing what the OCD wants?’ or ‘we’re going to boss back OCD off our land’. This can help your child to think of you as a team, joining forces against the enemy OCD.
Encourage your child to feel that OCD is normal. The aim is to make them feel less embarrassed or ashamed about their OCD so they’re more likely to open up. It’s more common than previously thought, occurring in 1-2% of the population (1-2 in every 100 people will experience OCD). Explain that everyone has unwanted or unpleasant thoughts sometimes, it’s normal. Educate them that thinking a bad thought doesn’t mean they’re a bad person, and it doesn’t mean that they want to do anything bad. Educate your child that thinking something doesn’t make it happen on its own. Children are more likely to engage in this kind of ‘magical thinking’. For example, if you think about winning the lottery, it doesn’t make it happen.
Understanding your child’s OCD (Mapping and Hierarchy)
One way to develop a deeper understanding of your child’s OCD thinking and behaviour is keeping an OCD diary. Over a week, try keeping track of the thinking, triggers and compulsions.
• Together with your child, write down 3 triggers per day (specific situations, objects, people, or thoughts that provoke the obsessive fears). Ask your child to rate the ‘fear’ from 0-10, where 0 means ‘no fear’ and 10 means ‘extreme fear’.
• Finally, write down what the compulsions or coping strategies they use to manage the obsession and fear are (make sure to include both physical and mental strategies).
• Next, create a hierarchy. With your child, write a list of all of their compulsions. Ask your child to imagine they have an unwanted thought and then are not allowed to perform their compulsions. In order of difficulty, list the compulsions from easiest to resist to hardest.
Small exposure exercise
This will be something you and your child will do alongside their therapist, but it is a good idea to understand how exposure will work. The idea is to show your child that they can tolerate a controlled amount of anxiety and it will be OK.
In other words, they can ‘face their fears’ and let the obsessive thoughts occur without ‘putting them right’ with their compulsions. You can say to your child, you are going to learn to ‘boss the OCD back’.
• This should be a very gentle process that’s broken down into stages, based on the hierarchy that you created earlier. Your child and their therapist might start with something very small so they can learn how to do it, and to build confidence.
• Begin with the habit that causes your child the least distress and slowly stop it. For example, if your child has to wash their hands five times when they arrive home, help them to wash their hands only once - or even better not at all. The aim of this is to show them that anxiety reduces on its own, the thoughts are just thoughts and that your child does not need to do the compulsion to bring down their anxiety. This is called ‘habituation’. You can help your child see this by asking them to rate their anxiety and seeing this get less over time.
• You might be tempted to reassure your child, but this is unhelpful; it’s important that they learn that their anxiety will lessen without reassurance or distraction. Remember the aim of the exercise is for them to see that they are able to tolerate the anxiety themselves. Eventually your child will feel empowered by their own strength and courage.
• Ask them to rate how they feel after 5 minutes, 10 minutes, 15 minutes, then after 30 minutes. Try to keep going until their anxiety drops to at least half of the initial rating (e.g. if they started at 8, continue until they reach 4).
• Encourage your child by giving lots of praise, or even a special treat as they beat their habits.
• Practicing positive self-talk with your child can be helpful. Show them how to do it by saying it out loud yourself. Show them that by repeating encouraging and positive messages to themselves they can feel empowered. For example, try getting them to say ‘I am going to beat my habits’ or ‘I have managed not to do this for 5 minutes so I can do another 5’.
• Your child might be helped by finding some ‘absorbing activities’ (things that you really get into and that take over your mind, making you forget about everything else), for example, computer games, Lego building, drawing, reading, listening to music or an audiobook.
