The Role of School Personnel: Healthful Support Strategies
Healthful Support Strategies
OCD can have a negative effect on many aspects of school functioning. Like other neurobiological disorders, OCD can cause a student to have extreme anxiety, and OCD symptoms can interfere with a student’s normal capabilities. Some of the areas affected are learning, memory, problem solving, and focus. Because of OCD's potentially harmful impact on the capacity to concentrate, understand what is read, comprehend problems, make deductions, devise strategies or remember, a student can experience serious difficulties with the learning process.
General Classroom Support Strategies
Some effective strategies for supporting students with OCD include:
- Learn about OCD - School personnel should review this web site and take advantage of the additional resources listed in the Tools and Resources and OCD Guides sections. A variety of information is available including the names of books, web sites, tapes, DVDs and other OCD-related material. It may be helpful to establish, within a school's library or learning/resource center, an area where information on OCD (and other disorders) is placed and easily accessed by faculty.
In the Chicago area, speakers may be requested from Beyond OCD for large groups. In-person presentations with accompanying question-and-answer sessions provide important learning opportunities for teachers and other school staff. They can gain insight about the disorder, learn tips for better classroom management and discover new strategies for helping students who have OCD. If an OCD organization doesn't exist in a particular geographic area, school personnel may ask local health care providers or other individuals with expertise on OCD to provide professional development workshops. School personnel can also stay informed about the newest research on OCD by attending lectures, seminars and conferences that feature information on the disorder, many of which offer continuing education credits.
- Bring awareness to the classroom - Conducting classroom discussions to educate peers about OCD, whenever appropriate, can be a positive step toward building understanding and tolerance. If the parents and student are willing to disclose the OCD, it's possible that the student may want to take part in a presentation about OCD, depending on the student's age, self-esteem and comfort level. Due to privacy concerns or the fear of the stigma of mental illness, however, some parents will not want their children to be identified as having OCD. Even if the parents don’t mind, children can be very sensitive to this issue and may not want to be singled out as having a problem. If this is the case, the discussion about OCD can be incorporated into the health or biology curriculum. OCD, of course, is not the only disorder that could be included in mental health discussions. Most organizations that focus on a particular disorder have information available for classroom use. In fact, a number of organizations provide curricula on disability awareness free of charge (e.g., Easter Seals).
Other approaches to peer education include using educational curricula designed for disability awareness (e.g., Kids on the Block), having assemblies or guest speakers, showing documentaries and other films, and providing students with appropriate books and other print (e.g., newspapers) on the topic. When choosing an approach for providing peer education, the age and maturity level of the students will be important considerations. Regardless of the approach used, great care must be taken to protect the student's confidentiality.
Strategies for Managing the Student and the Situation
Some of the following strategies can help both the student who has OCD and the teacher who manages the classroom.
- Focus on self-esteem issues - Building or maintaining the self-esteem of the student with OCD is extremely important. Students can be very cruel to one another and students with OCD may need some extra help realizing that they have value, talent and capabilities. They need to hear that OCD is not who they are, but just something they happen to have, just as asthma and diabetes do not define who a student is but, rather, are illnesses a young person may have. School personnel should look for the student's strengths -- perhaps creativity, artistic capabilities or athletic prowess. Educators should help them focus on their strengths, which can relieve some of the self-esteem issues that may arise from feeling “different.”
It may also be helpful to provide opportunities for students with OCD to demonstrate their talents. Such opportunities may help the student with OCD realize that he or she is not defined by OCD. They may also help peers see the student in a different light. Of note is that student talents should never be misused as a "carrot" that is given and taken away in a behavior plan. An activity the student loves or one in which he or she excels should not be considered something to be taken away as a punishment or allowed only as a privilege to be earned.
- Create a “safe” environment - A student who has OCD may get “stuck” trying to solve a problem or may falter and be unable to read aloud or present to the class. He or she may do poorly on an in-class assignment or a test. The student needs to know that the teacher will not become angry about these difficulties or lecture or punish the student for something over which he or she has no control. If school personnel treat students who have OCD with respect and understanding rather than anger and punishment (which can be difficult, given the challenges these students sometimes present), they will provide peers a positive model. Treating students who have OCD with respect and understanding can also boost their self-esteem.
There are many reasons why a student may do poorly in school. But when it's known that the student has OCD (or it is strongly suspected), his or her patterns of problems may become more obvious and predictable. It’s unrealistic to expect disciplinary action to change what the student is unable to change (and is already upset about). In fact, punishment may actually create more stress for the already distressed student and therefore exacerbate OCD symptoms.
- Allow a “break” to defuse anxiety - Sometimes the pressure of the anxiety, worry, doubt, and urges associated with OCD builds to a point where students feel as if they could explode. If an outburst occurs in the classroom, it has the potential to be very disruptive. Students can sometimes avoid an outburst when they experience mounting stress by taking a kind of “time out” to relieve the pressure. It's important to note that this is not the traditional time out in which a student is asked to leave the classroom or go to a designated area as a result of inappropriate behavior. When a child has OCD, he or she may be allowed to leave a situation in order to calm down, or regroup.
Some teachers have reported good success allowing students to leave the classroom for a few minutes before things get out of control, or before they cannot control their emotions. Surprisingly, this privilege generally is not abused by the student who has OCD –- he or she realizes it is a coping strategy. The child may just need to stand outside the classroom or walk down the hallway and back to feel better. Or the student may be allowed to leave the room briefly to get a drink of water, run an errand, etc. to help clear his or her mind of obsessive thoughts.
Sometimes the office of a staff member (such as the school nurse or counselor) can be designated as a “safe” place where the student can go for a few minutes or talk with the staff member for a short time. To avoid classroom disruption, a small card can be developed with wording such as “GO” or “BREAK” on it. The student can lay the card on his or her desk and quietly leave the room without disturbing the class and drawing classmates' attention to the exit (it may help these students if they sit near the classroom door). Teachers should make every effort possible to help students with OCD "save face" in front of their peers.
Another suggestion is to have the teacher and student develop a private signal (e.g., a hand signal such as raising the hand with a closed fist) that the student can use to indicate he or she needs to leave the room. A time limit should be established in advance for breaks, and, should a student be found to be using this privilege inappropriately, usual behavior management strategies should be implemented. Of note is that this is not a good strategy for a student who experiences contamination fears and wishes to go to the bathroom repeatedly to carry out washing rituals.
- Watch for side effects of medication - Some problems students experience may be caused by a reaction to medication. While Cognitive Behavior Therapy (CBT) is frequently the first line of treatment for OCD, it’s possible that the student may also be taking medication. And in some cases, a student may be taking medication only. All medications, including those used for OCD, have potential side effects. Side effects such as nausea, increased anxiety, jitteriness, and insomnia are relatively common, especially during the initial phase of treatment. Any side effects -- even those that are minor and hardly noticeable -- should be documented. If side effects are frequent, unusual, or severe, however, parents should be contacted immediately. Some of the more serious side effects are listed below, but more information about reactions to medication can be found in books listed in the Tools and Resources section of this web site.
- Tremors, difficulty speaking, slurring of speech
- Extreme restlessness or motor activity
- Extreme jumpiness
- Slowed thought processes
- Rigid muscles or uncontrollable spasms; any seizures
- Excessive sleepiness
- Extreme stomach upset
- Contortions of muscles or the face
- Unusual or extreme eye movements
One potential side effect of antidepressants, which are frequently used to treat OCD in children and adolescents, is something known as behavioral activation. Behavioral activation includes a variety of symptoms, including agitation, aggression, irritability, impulsivity, hyperactivity, increased depression or anxiety and, among a small fraction of youth, an increased risk for suicidality -- suicidal thinking and behavior. In fact, in October of 2004, the Federal Drug Administration issued a black box warning (a warning that appears on the package insert of prescription drugs) alerting health care providers to the potential risk of increased suicidality among young people taking antidepressants. Studies have indicated that this risk applies not only to children and adolescents with depression but also to those with OCD and other anxiety disorders. Numerous treatment studies have provided evidence that the benefits of using antidepressants to treat childhood OCD generally outweigh the risks. Whenever a child or adolescent is taking an antidepressant, however, the prescribing physician should closely monitor the student for the presence of suicidal ideation, suicidal behavior, and other troubling behaviors. Potential safety concerns related to medication lend support to the idea of using cognitive behavior therapy prior to medication as a treatment for childhood OCD.
If parents share information about OCD medication with school personnel (and, hopefully, whenever a child is on medication, school personnel will be alerted), it’s appropriate to ask them to provide a list of possible side effects of the medications their child is taking (which parents may obtain from their physician) so teachers and other staff members can be aware of what to watch for. And school personnel should always share any behavioral changes with parents, so parents have a complete picture of their child’s behavior while he or she is in school. In addition, although teachers are frequently overwhelmed with what feels like mountains of paperwork and other responsibilities, it is extremely important that they take the time to complete checklists or questionnaires when asked by various professionals (e.g., psychiatrist). Feedback from school personnel can be crucial in terms of determining the appropriateness or effectiveness of a student's medication.
- Try to recognize tough spots for the student and respond appropriately. Teachers can improve the student's chances for success by recognizing a particular difficulty a student may be experiencing and responding in a constructive way. For example, many children who have OCD are paying attention to the OCD worries instead of the teacher during class. Before explaining an assignment, the teacher may need to capture the attention of the class by announcing that directions are about to be given. A change in one's tone of voice or modulating one's speech may also help to break through the OCD thoughts. A child who has OCD may be better able to understand the instructions with these simple strategies. The good news is that these techniques may be very beneficial for other students in the class, as well -- not just the student with OCD.
- Be positive and reward even small successes - Because students may be anxious or uncomfortable about their OCD, it’s important to help them see that even small gains or achievements matter. Therefore, it's essential that school personnel watch for and praise small improvements. The student who previously was unable to touch a door knob without first covering his hand with his short sleeve, for example, should be commended when he has touched the door knob with his hand. Moreover, a student should be praised for making an effort to fight the OCD -- even if it is unsuccessful.
- Create ways to reduce stress for the student with OCD - Showing respect for the student who has OCD may seem obvious but, when a child or teen presents teachers and other school personnel with challenging behaviors, it can be easy to forget that the student has little or no control over the OCD behavior. When school personnel create a positive relationship with the student, the student is more likely to believe that he or she has allies and will trust that teachers and other school staff are motivated to try to help. School staff who respond to the student with OCD in a positive manner also serve as excellent role models for the other students. In addition, structuring educational environments to keep stress levels at a minimum can go a long way toward managing the behavior of students with OCD. Well-structured classroom settings in which there are clear expectations, smooth transitions, and a calm climate can be helpful not only for students with OCD but for all students.
- A “buddy” system - With this system, the teacher designates (or the student who has OCD selects) a fellow classmate to share notes taken during class to help with studying. This plan must ensure that the student selected to act as a "buddy" is willing to and has the time to participate. Moreover, participation should not affect the buddy's ability to complete assignments or study for tests. it is also extremely important that the student with OCD be comfortable with this arrangement.
The buddy system can help the student who has OCD access information missed either because the OCD interrupted concentration or the student was unable to take notes due to excessive slowness or writing compulsions. Having a buddy to work with on homework assignments can help the student who has OCD focus on studying, and concentrate on the most important points for the assignment or for an upcoming test. A buddy system can also be helpful during recess, breaks or cafeteria time. The benefits of this practice include helping to reduce anxiety and relieve the isolation and loneliness students who have OCD often feel, improving the academic performance of the student with OCD (and possibly, the student who is helping), and increasing empathy among students without disabilities.
- Seating accommodations - Seating students who have OCD closer to the door can make it less awkward for them to make an exit if they need to leave the room to relieve an anxiety build-up. It may also be helpful to seat students with OCD close to the teacher, so the teacher can get their attention when they start to lose focus and help them stay on track with the lesson or discussion. Teachers must recognize that it’s not realistic to expect students with OCD just to set aside their worries, obsessive thoughts and rituals in school. Because OCD is a neurobiological disorder, students are frequently unable to suspend disturbing thoughts, fears and compulsions on command. It is important for school personnel to be patient.
- Create different expectations - Some students who have OCD will not be able to finish an in-class or homework assignment in what is considered to be a “normal” length of time. The teacher can reduce the amount of work required of the student, and can also set limits on the amount of time the student has to spend on homework. The teacher should be sensitive to the student’s feelings and refrain from giving negative feedback if he or she has not completed the assigned work.
The book Students with OCD: A Handbook for School Personnel by Gail Adams, Ed.D., includes hundreds of accommodations and support strategies for helping students who have OCD with academic, social, behavioral, and emotional functioning. Three additional resources that contain numerous suggestions for working with students who have OCD are (1) Tigers, Too: Executive Functions/Speed of Processing/Memory by Marilyn P. Dornbush, Ph.D. and Sheryl K. Pruitt, M.Ed., ET/P; (2) The Tourette Syndrome and OCD Checklist: A Practical Reference for Parents and Teachers by Susan Conners, M.Ed.; and (3) Challenging Kids, Challenged Teachers by Leslie E. Packer, Ph.D. and Sheryl K. Pruitt, M.Ed. These books are available in the Tools and Resources section of this web site.
An Important Note About Using Traditional Behavior Modification Principles with Students Who Have OCD
It is very important to note that symptoms of OCD frequently do NOT respond to traditional behavior modification principles. Many educators believe that when a student has a behavioral problem -- a need for attention, for example -- it is linked to student motivation. And if behavior is directed by motivation, then using traditional behavior modification principles (e.g., positive and negative consequences) to alter motivation is likely to resolve behavioral difficulties. Applied to students with OCD, this would mean that reducing or eliminating obsessions or compulsions should be a simple matter of finding the appropriate reward or punishment. Obsessions and compulsions are a function of the OCD, however, and may not respond to positive and negative consequences. As a parallel, it would be ludicrous to try to control a student's asthma attack by telling him that he will receive a candy bar if he stops his asthma attack or lose recess for a week if he doesn't stop wheezing. It is understood that an asthma attack is not within the student's control -- it is not a willful behavior that can be stopped simply by altering motivation. And yet, when students with OCD receive consequences for behavior that occurs in the throes of an "OCD attack," the same principle is being applied. Trying to use positive or negative consequences to alter the motivation of a student who is extremely anxious because he is "stuck" in a checking ritual at his locker not only may be ineffective but very possibly could increase his anxiety and worsen symptoms.
Another concern about using traditional behavior modification plans with students who have OCD (and other neurobiological problems) is that these plans usually don't take into consideration whether the student can suppress a behavior consistently, even if he or she is highly motivated to do so. It is true that students sometimes can control/suppress their symptoms (e.g., rituals, tics) for a period of time (although symptom suppression may result in high levels of anxiety or stress). If the student can't suppress them continuously, however, applying positive or negative contingencies is likely to increase stress, make symptoms worse, and even create new behavioral problems.
Still another concern about using traditional behavior modification for students with neurobiological problems is that these children -- like all children -- are motivated to earn rewards and avoid punishment. If an attempt is made to alter a truly involuntary symptom, however, these students may try to modify their behavior, but potentially at great cost to the student. For instance, the student with OCD who spends a tremendous amount of time and energy trying to suppress a ritual to avoid punishment or earn a reward may experience high levels of stress and fatigue and have difficulty concentrating on school-related tasks.
Before using positive and negative consequences with students who have OCD, it may be helpful to talk with the student and his or her parents to discuss whether they believe these techniques would help or hinder progress. Also, if consequences are used, school personnel should carefully monitor the student's behavior to be sure that the OCD symptoms aren't getting any worse.
It is important to note that, despite the concerns associated with positive and negative consequences, positive reinforcement may be effective for students with OCD in certain situations. Rewards may be effective, for example, when trying to teach a student to use and maintain a behavior that replaces an inappropriate or interfering OCD behavior (e.g., teaching a student to use hand sanitizer at her desk instead of constantly going to the school bathroom to wash her hands). As previously noted, it is also helpful to reinforce students for making progress on improving their OCD symptoms or even for putting forth effort to fight their OCD.
Academic and Social Strategies
In addition to the general classroom support strategies and techniques for managing the student and situations described above, there are many other specific strategies for helping students who have OCD succeed academically and socially. This OCD Education Station web site includes separate sections for academic and social support strategies. Follow the links below to access those sections.