Treatment Challenges

A student must get appropriate treatment for OCD in order to get better.  Cognitive Behavior Therapy, or CBT, is the most recommended treatment (sometimes supported with medication).  In some cases, even when OCD has been correctly diagnosed and the young person is receiving treatment, challenges may arise.

In addition to proper diagnosis, treatment success requires that the parents and the student commit to the treatment plan.  And despite all good intentions, some children and teens do not go along with the treatment they are receiving for their OCD, so treatment fails.

Knowledge is a powerful tool that is linked to success in treating OCD.  It is important to understand some of the challenges to appropriately identifying, diagnosing and treating OCD.

Factors Contributing to Underdiagnosis and Misdiagnosis

Even though OCD is a relatively common illness and effective treatment is available, OCD is sometimes undiagnosed or misdiagnosed. There are a number of reasons why:

• Hiding symptoms.   Children or teens with OCD can be very secretive and hide their symptoms.  At first, you may not notice the symptoms, and only become aware of the problem when the parents alert you.  Or, you may observe symptoms in school, but learn that the student hides symptoms at home, making for some uncomfortable dialogue with parents (who don’t suspect there is a problem).  In some cases, students hide symptoms at school and have serious symptoms at home, setting the stage for potential conflict between school personnel and parents; teachers do not observe the OCD symptoms parents describe.  It is very important to take parents at their word when they explain what they are experiencing at home with their child.
• Avoidance.   In many cases, children and teens try to prevent their OCD symptoms from occurring by avoiding the people, places or things that trigger their anxiety, fears and/or urges. For example, a child who has an extreme fear of germs may not want to drink from school water fountains, touch shared classroom supplies, computers, lab equipment, etc., or eat in the cafeteria.  Unfortunately, it may not be obvious to you (and even parents) that the student is avoiding certain places, activities or people.  It’s natural for children to form opinions and preferences, so they may gravitate toward some places, activities and people more than others.  As a result, avoidance behavior may be missed as a sign of possible OCD.
• Physician Misses a Diagnosis.  Not all physicians know how to diagnose and treat OCD, especially in children and adolescents.  At routine check-ups, some doctors do not ask questions about a child’s mental health.  Even some mental health professionals are unfamiliar with how to diagnose and appropriately treat OCD in young people.
• Symptoms of OCD Not Recognized.  OCD can take many forms and is not limited to the more familiar or obvious types such as compulsive washing or checking door locks.  Less familiar symptoms of OCD in children may not be easily recognized.  Examples of OCD symptoms that may go unrecognized as such include:
  • Procrastination
  • Difficulty making decisions or inability to make a decision
  • Asking repetitive questions
  • Continual reassurance-seeking
• Misdiagnosis.  Certain factors may make it more difficult to correctly diagnose OCD. For example, OCD symptoms frequently wax and wane over time, or there may be a shift from one set of obsessions and compulsions to another.  Moreover, symptoms of OCD may look like symptoms of other mental disorders.  For example, although other anxiety disorders are different from OCD, they may look like OCD on the surface.  OCD may also be misdiagnosed as AD/HD.  When a child is experiencing intrusive obsessions and mental rituals, it is difficult for him or her to pay attention.

Other Treatment Challenges

• Lack of Treatment Provider Education.  Some psychologists and psychiatrists still rely on unproven, ineffective methods for treating OCD. Supportive psychotherapy may be extremely beneficial with regard to helping young people with OCD manage difficulties that arise as a result of the disorder (e.g., problems in school, with peers). However, there is currently no evidence to suggest that various "talk therapies" are effective in directly treating OCD. Psychoanalytic therapy and therapies that focus on family dynamics, early childhood trauma or issues of self esteem are ineffective treatments for OCD, as are relaxation and play therapies. Moreover, some therapists who are unaware of the effectiveness of Cognitive Behavior Therapy prescribe medication only.
• Lack of Access to Mental Health Services.  Access to mental health services is affected by factors such as location (e.g., individuals in rural areas frequently have less access to services), socioeconomic status (e.g., individuals from lower socioeconomic levels often do not have the means to seek help), and stigma (some cultures associate mental illness with shame and therefore do not seek services).
• Treatment Resistant/Treatment Refractory OCD.  A small percentage of cases of OCD do not respond to more traditional forms of therapy.  These situations may call for additional or more intensive forms of treatment.
   

Student Resistance to OCD Treatment

Even with the right diagnosis and parental enthusiasm for effective treatment, children sometimes have a difficult time committing to treatment. A number of variables may be involved, but some of the most common barriers to success are:

• Fear of Change.  Change is hard.  It takes courage to make changes and face fears, particularly if the obsessions and compulsions have existed for many years.  Some children and teens with OCD are afraid to begin treatment.  And the stress associated with change can sometimes make existing OCD symptoms worse.
• Demands of CBT.  Some children and teens with OCD who are undergoing Cognitive Behavior Therapy find the treatment sessions to be very difficult and may also find the ERP homework exercises to be stressful -- or even overwhelming.  In some cases, they may hide their symptoms to avoid going to therapy or doing ERP homework exercises.  Successful treatment depends on the therapist being able to plan and construct a program that is challenging but not impossibly difficult and design a schedule that is manageable for the child’s particular situation and tolerance level. 
• Embarrassment. You may see that some older children or teens feel upset or embarrassed about “having to go to therapy” or “having to go to the doctor” weekly (or more often, depending on the schedule determined by the therapist).  Or they may feel embarrassed about having to take medication.  Peer pressure to “fit in” may already be causing stress for the student, and being perceived as “different” or “mentally ill” can make the stress worse.

If a student confides in you about any of these barriers, or you believe any of these situations is taking place (and causing the student to falter in treatment), having a discussion about your concerns with the parents can be helpful.

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