Chapter 3

The Impact of OCD

The impact of OCD is experienced by the child herself, but also by the family. It can interfere with family dynamics, creating tension in the home and between family members. The OCD can create obstacles to attending school, focusing on schoolwork, completing assignments, and participating socially. Depending on the age at which OCD begins during childhood, it can have a different impact on development. Erik Erikson (1963), a famous developmental psychologist, formulated a theory of lifespan development, divided into eight stages. At each stage, there is a “crisis,” or challenge, and how one navigates the crisis of one stage will affect the ones in the future. During adulthood, for example, the crisis is “generativity versus stagnation.” If resolved well and you have a sense of “generativity” from accomplishing (generating) your goals, whether that is in a particular career, getting married, or becoming a parent, you will be better able to resolve the next stage (“old age: ego integrity versus despair”) successfully. So, if you have generativity in adulthood, it will help you have a better chance of having a sense of integrity for how you lived your life. The following are the three stages primarily affected by OCD during childhood:

School age (5–12 years): Industry vs. inferiority

Industry refers to a sense of capability (think about an industry that produces something) and a belief that they can succeed in the world. Inferiority represents a sense of self-doubt and feeling of inadequacy, especially in comparison to others. The overarching goal of this phase is competence.

Adolescence (13–19 years): Identity vs. role confusion

Identity describes who you are, what you are about, and attempts to answer the question of “What can I be?” It builds on the previous stage of having a feeling of competence (based on industry). The opposite of being clear about who you are is role confusion; when a teenager doesn’t have clarity about who he is and doubts his decisions, he may have trouble forming a consistent self. This may interfere with developing meaningful relationships. The overarching goal of this phase is fidelity.

Young adulthood (20–35 years): Intimacy vs. isolation

Intimacy refers mostly to emotional intimacy (but physical as well), or the ability to be close to and vulnerable with another person. Can the person make a commitment to another and engage in a close, mutual relationship? Isolation is the opposite, and may be due to rejection or complicated by a lack of identity from the previous stage (e.g., when you are romantically rejected and you don’t have a strong sense of self, the rejection can define you and then you become afraid of being vulnerable in the future, thus the isolation). The overarching goal of this phase is love.

It is important to consider your child’s developmental stage in order to promote and encourage successful growth during the different stages, despite the OCD. This knowledge also helps you assess how the OCD is impacting him, and further highlights the importance of getting treatment. You want your child or teen to know himself outside of the OCD. He is a person first, and has a condition called OCD, which is second to who he is. It might be important to make extra effort to support his stage; for example, for the school-age child, you should help him identify hobbies or interests that he can work to succeed at, which allows him to experience his abilities and worth. Given that OCD (and anxiety in general) breeds self-doubt, it must be treated to prevent a sense of inferiority and, ultimately, poor self-esteem. Self-esteem is the greatest predictor of satisfaction in life and in relationships. For the child with OCD, it is important that the treatment process include working on positive self-esteem.

In addition to a developmental impact, children with OCD can often feel embarrassed or ashamed of their symptoms, may feel that something is “wrong” with them, and so on. It is of utmost importance that you do not support these beliefs and rather help them to understand that it’s not their fault that they have OCD. It is important for you to help them define OCD as something to be treated and overcome. Emphasize that many other children have OCD (they just might not talk about it) and that having OCD doesn’t make them “less” of anything (less normal, less likeable, less capable). You can also explain that, in fact, when you work through the obstacle of OCD, you learn what you are capable of and that you can handle anything that comes your way. This is how one develops resilience.

Your child’s social life can also be impacted; in addition to worries about what other children may think if they see her symptoms, she may miss social events or not fully participate when she has the opportunity. On the flipside, many children with whom I work have very supportive friendships; they have been open about their OCD and have found friends to be incredibly understanding, loving, and respectful. Most of the time, the child’s fears about being rejected or teased for having OCD are completely unfounded. This is particularly the case in adolescents, when most teens can have very strong empathy for their friends with psychological difficulties.

OCD can interfere in your child’s academic life. Stress worsens the OCD symptoms, and when there is stress about schoolwork, it can be a double-edged sword (the academic stress plus the increase in OCD symptoms can make it very hard for work to get done). We will discuss how to support your child in school in Chapter 6.

When it comes to how families are affected, the conversation is mostly one about accommodations. As stated earlier, when it comes to childhood OCD, accommodations are the rule, not the exception; up to 90% of families report at least some accommodation (Benito & Freeman, 2011). Accommodations are associated with a worsening of OCD symptoms for the child, and they create more family stress, specifically more functional impairment as viewed by parents (Storch et al., 2007). In fact, the degree of accommodations made by family members is associated with symptom severity and also with how well the child or teen will do in treatment (both CBT and pharmacological interventions like SSRIs). Reducing the amount of family accommodation results in better treatment outcomes (Benito & Freeman, 2011; Lebowitz, Panza, Su, & Bloch, 2012). One study showed that patients with OCD who did not benefit from CBT treatment had the highest levels of family accommodation compared with other participants (Ferrao et al., 2006). Essentially, family accommodation is an obstacle to the child’s prognosis in treatment (Amir, Freshman, & Foa, 2000).

Family accommodation refers to how the family members participate in the child’s OCD, whether they are also engaging in or performing the rituals with or for the child, supporting avoidance behaviors including avoiding anxiety-provoking situations, being willing to change the daily routine, or providing reassurance (Benito & Freeman, 2011; Lebowitz et al., 2012). The most common forms of family accommodation include providing reassurance, a family member’s participation in performing rituals, and supporting the child in avoiding. For example, family members may directly participate in rituals: They may agree to wash their hands multiple times, may be the first to drink milk to make sure it is not spoiled, or may repeat a goodnight “I love you” in several different inflections until it “feels right” to the child. Parents and siblings can be viewed by the child as more trusted sources of “checking” and can do the checking behavior and report back that it is all okay (this behavior reflects both participating directly in the rituals and providing reassurance). I worked with a child with OCD who had refused to allow his family members to kill any bugs found in the home (out of fear of punishment by God), so his parents and sibling would “rescue” silverfish and other bugs, even though this went against their preferred practice of flushing the bug down the toilet or using bug spray. Basically, when you find yourself doing something that you normally wouldn’t do on your own (for yourself) and that is in the service of the OCD, specifically for alleviating anxiety for your child, then you are accommodating! Although parents and other family members make accommodations out of love, warmth, and compassion (and usually a bit of desperation), it makes the OCD stronger and results in a worsening of symptoms.

Marital conflict can also result, as you may have one parent who gives in to the rituals and makes the accommodations and another who refuses to do so and blames the other for giving in. This dynamic (where you have one parent who is more permissive and one who is more authoritarian) is common whether OCD is involved or not, yet it can be exacerbated by the presence of OCD or another anxiety disorder. We will discuss how all family members need to adopt the same approach to dealing with the OCD and how family accommodation can be eliminated (see Chapter 6).

One study showed that the contamination type of OCD (e.g., washing symptoms) or a family history of an anxiety disorder were two factors that were related to more frequent family accommodation (Albert et al., 2010). Accommodations end up validating the OCD; after all, why are you rewashing your hands if there wasn’t any contamination risk, or why are you saving bugs if there wasn’t any risk of punishment? What families do to relieve the child’s distress is only relieving it temporarily, in the moment, while it strengthens the OCD in the long run. It simply doesn’t work. In the next chapters, you will learn that the goal is the opposite: Short-term relief is traded in for long-term relief. When your child or teen learns how to handle the short-term anxiety, stress, and discomfort that come from not performing the compulsions, she will learn how to become free from OCD in the long run.

Finally, extended family members may have a hard time understanding your child’s OCD and its symptoms, or if they are not aware of the diagnosis, they may personalize or become upset in response. For example, if the OCD interferes with arriving on time to a family event or results in multiple trips to the bathroom to wash hands, without an understanding (based on OCD) of the conditions, they may be upset about the late arrival. This can, in turn, cause more stress for your child. Similarly, other caregivers (extended family, babysitters) can be frustrated and show lack empathy for your child, which can make him unwilling to be without you. This is why it is essential for extended family and other caregivers to be educated not only about OCD, but also about how they can best respond in the moment.