Treatment Challenges

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

In addition to receiving a 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 about their symptoms and may try and hide them.  When students hide symptoms at school but have serious symptoms at home, the stage may be set 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, and provide as much support as possible.  Or symptoms may be obvious at school, but the student hides them at home, making for some uncomfortable dialogue with parents (who don't suspect there is a problem).                   
• Avoidance.  In many cases, young people 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 intense 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, because it's natural for children to gravitate toward certain places, activities and people more than others, it may not be obvious that the student is avoiding certain places, activities or people.  As a result, avoidance behavior may be missed as a possible sign of 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 (they get better or worse, frequently for no apparent reason), 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, individuals with OCD and a number of other anxiety disorders may experience physical symptoms such as restlessness, irritability, shakiness, and difficulties with sleep or concentration.  OCD may also be misdiagnosed as AD/HD.  Because intrusive obsessions and rituals (especially mental rituals) are distracting and interfere with attention and concentration, OCD may be mistaken for AD/HD.

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 when a child with OCD has received the correct diagnosis and parents are ery enthusiastic about getting proper treatment, children sometimes have a difficult time committing to treatment.  A number of factors 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 young people with OCD who are undergoing Cognitive Behavior Therapy find treatment sessions very difficult and ERP homework exercises 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 overly 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 a teacher about any of these barriers, or if a school staff member believes any of these situations is taking place (and causing the student to falter in treatment), these concerns should be discussed with the child's parents.

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