VISTAS articles are made available for historical reference only and are presented "as is." ACA does not guarantee or represent that the information is current, accurate or indicative of the original or intended quality. These materials are not maintained or updated and may contain outdated or incomplete information. Readers should exercise discretion and verify information independently before relying on it. We assume no responsibility for the use or interpretation of this content.

Article 17

Suffering in Silence: Examining Obsessive Compulsive Behaviors in the School Setting

Terry L. Pertuit, Jerry Trusty, & Mary Ballard

Download PDF

According to the National Alliance on Mental Illness (2010), 4 million children and adolescents in the United States experience a significant mental health problem during their school years, but only about 20% receive appropriate services. Failure to address students’ mental health needs is linked to poor academic performance, behavior problems, school violence, dropping out, substance abuse, special education referral, criminal activity, and suicide (National Association of School Psychologists, 2002; Van Ameringen, Mancini, & Farvolden, 2003).

Once considered rare and untreatable in the early 1980s, obsessive compulsive disorder (OCD) is now considered common among children and adolescents, with an estimated prevalence rate between 1-3% (Teixeira, Carbalho, & Pires, 2013). This percentage may be an underestimation given the secrecy of the disorder that, for a large majority of adults, has its origins in adolescence, with the onset of OC behaviors before the age of 15 (Besiroglu, Cilli, & Askin, 2004).

Yet, in spite of the growing clinical literature related to OCD across the life span, only a few studies have systematically examined the impact of OC behaviors on school success (i.e., Placentini, Bergman, Keller, & McCracken, 2003; Valderhaug & Ivarsson, 2005). Even this sparse research has focused predominately on children and pre- adolescents in elementary and middle school as opposed to youth in high school. High school rules, procedures, and expectations can be a challenging environment for any adolescent. Students with OC behavioral tendencies must overcome extra hurdles in order to succeed academically and socially in school. Implementing an effective school counseling program requires an awareness of these hurdles (ASCA, 2012).

Many youth who suffer from obsessions and compulsions go undiagnosed or misdiagnosed and do not attain appropriate services or treatment in a timely manner. However, we now know that in many cases, early detection can play a vital role in recovery (Sloman, Gallant, & Storch, 2007). Unfortunately, many students attempt to hide their symptoms and are embarrassed to seek help, thinking that they are the only ones who experience these obsessions and compulsions or fearing that others will think of them as “crazy” (NAMI, 2010). Therefore, the ability of the professional school counselor (PSC) to recognize, monitor, and intervene with those students exhibiting OC behaviors is critical to their personal, social, and academic success (ASCA, 2012).

Adolescents with OCD typically attempt to ignore, suppress, or neutralize obsessive thoughts and associated feelings by performing compulsions. Oftentimes obsessions pair with compulsions in ways that defy explanation (Adams, 2004). For this reason, thoughts and behaviors associated with OCD are often perplexing to parents, teachers, and peers. For example, a student who experiences an obsession regarding the death of a loved one, such as a parent, may feel compelled to trace the number “8” a prescribed number of times on a sheet of paper in order to prevent the death. When inquiring how tracing the number “8” would prevent the loved one from dying, the adolescent might be unable to provide a reason and is often embarrassed as a result. Often, an observer only sees the result of the symptom, (e.g., darkened numbers or letters on writing assignments, hours in the bathroom, extended time alone in a bedroom turning the light switch on and off, or peevishness when the student cannot do something his or her way), and not the agonizing thought processes behind them.

Considering children and adolescents spend, on average, one-third to one-half of their day either in school or going to and from school (Sabuncuoglu & Berkem, 2006), the prevalence, presentation, and consequences of OCD and OC behaviors in school settings is worthy of further investigation by the professional school counseling community. PSCs and other school personnel can make a profound difference in the lives of those exhibiting OC behaviors by taking the appropriate steps to ensure that they get the services they need. Armed with this information, PSCs may be better equipped to identify, intervene, and advocate for those students who, for the most part, are suffering in silence. The purpose of this paper is: (a) to define OCD and raise awareness concerning the prevalence of OC behaviors in the school setting, (b) to identify the subtypes of OC behaviors and provide examples of how these behaviors can manifest in observable behaviors in the school environment, (c) to discuss the implications for schools, and (d) to present ideas for much needed future research.

Obsessive Compulsive Disorder Defined and OC Behaviors Identified

OCD is an anxiety disorder characterized by recurrent, unwanted, disturbing thoughts (obsessions) and/or repetitive, ritualized behaviors, mental acts, or avoidance (compulsions) that lead to significant distress or impairment (American Psychiatric Association [APA], 2013). Some common childhood obsessions are fear of contamination, fear of some dreaded event (e.g., fire, death, illness), and a need for symmetry or exactness (Sloman et al., 2007). Common compulsions include repetitive hand washing, ordering, checking or mental acts such as praying, counting, or repeating words silently in hopes of alleviating feelings of anxiety (APA, 2013).

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013), obsessions or compulsions cause pronounced stress, can be time consuming or significantly interfere with normal routines, and interfere with occupational and academic functioning or normal social activities or relationships. Youth who are plagued by obsessive thoughts and ritualized behaviors are at risk for significant disruptions in normative social and educational functioning due to distress and frequent ritual engagement (Van Ameringen, Mancini, & Farvolden, 2003). For academic performance, obsessions can be extremely intrusive and interfere with concentration or information processing (Adams, 2003; Muller & Roberts, 2005). Attention that students should allocate to academic tasks is frequently redirected to obsessive thoughts or mental compulsions, and interference with completing academic tasks may lead to decreased work production and poor grades.

Also impairing school performance is tardiness, if morning rituals result in students being late to school, and absenteeism, if students skip school because they fear that school-based stimuli will trigger obsession or compulsion, or because of overwhelming peer ridicule (Adams, 2003). Students’ preoccupation with ceaseless ruminations and compulsions leaves little time or energy for friends or family. Many are withdrawn and isolated from peers and have few friendships, if any. In addition, because of the shame and embarrassment surrounding their OC behaviors, many adolescents attempt to hide their condition from family and friends and live secret lives. Many fear that they cannot verbalize or explain what they are experiencing (Chansky, 2011).

Recognizing OC behaviors in the school setting may be challenging, as the behaviors can easily be misinterpreted as willful disregard, opposition, or meaningless worry. For self-conscious adolescents who see their own behavior as odd and distinctly different from their peers, many will more than likely be reluctant to divulge their symptoms unless asked directly, and many PSCs often fail to ask. Additionally, many teens are skilled at keeping compulsions hidden and rituals may remain undetected (Chansky, 2011). This accentuates the need for sensitive and direct interviewing of students by the PSC about obsessive-compulsive behaviors and assessment of how varying degrees of these behaviors affect psychosocial functioning in school (i.e., academic and social functioning). Once those behaviors are identified, the PSC can then facilitate the appropriate course of action, which may involve consultation and referral (ASCA, 2012).

Subtypes and Manifestations of OC Behavior in School Settings

For students, OC behavior can manifest itself in various ways. Typically, the types of behaviors that are observed are: (a) compulsive behavior, (b) neutralizing/avoidance behavior, and (c) obsessions (Abramowitz, Lackey, & Wheaton, 2008). Logically, students who experience obsessions in the context of school functioning also utilize such behaviors. What follows is an overview of some of the more commonly observed subtypes of OC behaviors and examples of how they may manifest themselves in the school setting.

Washing/Cleaning

Many children and adolescents with OCD experience washing or cleaning rituals. These rituals are typically driven by fear of contamination obsessions, a fear that is frequently reported by children and adolescents (Adams, 2004; March & Benton, 2007). These fears typically center on a concern with germs, dirt, or other substances such as ink, glue, excrements, and chemicals for example. The most common ritual among this population is hand washing. These individuals may feel compelled to wash extensively (e.g., until their hands bleed) or to clean their environment excessively (e.g., for minutes to hours at a time). Some may even engage in unusual cleansing rituals besides washing or cleaning, including baking their schoolbooks in the oven each day after school to remove contaminants.

Adams (2003) hypothesizeds that students with fear of contamination obsessions paired with washing compulsions may result in excessively excusing oneself from class to go to the restroom to carry out washing rituals. Also, these students may be observed as excessively late to school or appear fatigued in class as a result of extensive grooming rituals before school or at bedtime. They may appear anxious or frustrated, even angered, if permission for restroom visits is refused.

Doubting and Checking

Checking and doubting compulsions have been shown to be connected (March & Benton 2007). Studies report (van den Hout & Kindt, 2003) that checking compulsions are often triggered by an obsessive fear of harm to self or others. As a result, individuals will engage in behaviors designed to prevent some dreaded event and to create a safe environment. These individuals may incessantly check doors, windows, electrical outlets, appliances, and other items. Individuals fraught with doubt (e.g., obsessively doubting that the door was actually locked), will compulsively check their environment.

Adams (2004) hypothesizes that students’ fear of harm, illness, death or pathological doubting obsessions paired with checking compulsions manifest in frequently checking books in a backpack, a compelling urge to return home to check something, checking and rechecking an assignment or homework, or checking a school locker to verify that it is locked. A student who engages in compulsive checking might be observed as consistently late to school or appear tired in class as a result of excessively engaging in checking behaviors before school or at bedtime. Compulsive checking can also cause a student to work late into the night on assignments that, on average, should take 2 to 3 hours to complete. Some students may even turn in assignments late or not complete tests because of checking behaviors. Or, they may have doubting obsessions (e.g. doubting that an assignment was actually carried out as instructed) which may be particularly alarming to the student. Some checkers may express a lack of confidence in their ability to remember or are unable to recall performing an activity (Cuttler & Taylor, 2012). Some students may also become fixated on self-doubt and engage in compulsive reassurance seeking such as checking in with others.

Repeating

Repeating rituals are regularly connected to counting rituals and may assume various forms in the school setting. Fear of harm, illness, and death are obsessions also associated with repeating rituals (Baer, 2012). The repetitive actions are generally the result of the experienced anxiety. Individuals with repeating compulsions are either compelled to repeat an action a certain number of times or may experience a strong feeling that an action has to be completed “enough” or “just so.” They may repeatedly walk in and out of a doorway, may walk forward and backward, or get up and down from a chair several times in a particular fashion until it “feels right.”

Likewise, number or counting obsessions are exhibited in repeatedly counting up to a particular (“magic”) number or a multiple of that number, touching or counting an object a certain number of times, or repeating an action a certain number of times. With counting, some numbers are considered “lucky” or “safe” and will prevent harm, while others are considered “unlucky” or “unsafe” and will bring about harm (Baer, 2012).

In school settings, repeating rituals may include endless streams of different questions, or one question repeated in a variety of ways, reading or repeating sentences, paragraphs, or pages in a book, or repeatedly sharpening pencils (Sloman, Gallant, & Storch, 2007). Hand-written assignments may reveal holes that were worn from excessive erasing, crossing out words, or rewriting or tracing letters or numbers. In some cases, students’ may be observed as being tardy to class due to an inability to execute locker combinations in a timely manner. Interestingly, Rapoport (1989a) presented a case where a young boy was referred to a psychiatrist because his obsession with the number 4 dominated his life, causing problems in school and with friends. Rapoport (1989b) also noted a case in which an adolescent reported an attack of certain numbers into his thoughts and, as a result, the teen and was unable to play his clarinet and keep step in the school marching band.

Ordering/Arranging

Radomsky and Rachman (2004) discussed obsessions that develop around a need for symmetry that also results in compulsive arranging. Ordering and arranging rituals can also be associated with feared consequences or with unacceptable thought such as sexual or violent obsessions (Wheaton, Abramowitz, Berman, Riemann, & Hale, 2010). Sexual obsessions might result in difficulties in relating to the opposite sex and in social skills. In class, students might appear stuck, fixated on a particular task, or appear to be anxious or frustrated. In actuality, the student might be struggling with trying to neutralize feelings of guilt brought on by illicit thoughts.

Individuals with symmetry obsessions, paired with ordering or arranging compulsions can display observable behaviors such as repeatedly tying shoelaces until both shoes look identical. For some individuals, common movements may have to be symmetrical or balanced. For example, Swedo and Rapoport (1989) observed children and adolescents taking steps of identical length or speaking with equal stress on each syllable. In general, these individuals may appear to have an abnormal concern about the neatness of their personal appearance or environment.

In the school setting an obsessive need for order or symmetry may be noted by large blocks of unexplained time, such as unproductive hours spent doing homework or an in class assignment. Students may spend an excessive amount of time arranging books on a shelf or items on a page so they appear symmetrical even at the risk of failing an exam (Obsessive-Compulsive Foundation [OCF], 2006). For example, an overwhelming need to align objects "just so" or symmetrically may override students’ better judgment to put the right answer on the test. Therefore, the OCF advises that a sudden drop in test grades may be an indication of a student struggling with obsessions and compulsions.

Hoarding

The practice of hoarding is described by researchers (Pertusa et al., 2008) as the repetitive collection of excessive quantities of items that have little or no value with failure to discard these items over time. As evident in the DSM-V (APA, 2013), hoarding behaviors occur in many clinical syndromes (e.g. Obsessive Compulsive Personality Disorder (OCPD), Impulsive Control Disorder, Schizophrenia, depression, eating disorders, dementia). In relation to OC behavior, however, fixations are not focused on perfectionism as in the presence of OCPD, for example, or on paranoia as in the presence of schizophrenia. Many individuals acquire or save indiscriminately to avoid emotional upset and/or to prevent negative outcomes. That is, the possessions provide a sense of safety, used to cope with actual or perceived danger (Pertusa et al.).

March and Benton (2007) suggested that hoarding is the least common subtype in children and adolescents. In contrast, Seedat and Stein (2001) reported that 11-42% of children and adolescents diagnosed with OCD display hoarding tendencies. Researchers (McKay et al., 2004; Samuels et al., 2002) proposed that when hoarding is present, it is the most disabling and most treatment resistant form of OC behavior. Hoarding has also been shown to be more prevalent in males than females (Samuels et al., 2002) and is often considered one of the more severe OC behaviors.

Rapoport (1989a) described a 15-year-old girl who collected a variety of trash, including soiled sanitary napkins, pieces of paper, and empty juice cans. She saved partially chewed food in napkins and stored them in various places throughout her parents’ house. Despite humiliation and teasing from peers including ridicule for climbing into a garbage can, she was unable to stop her compulsive hoarding even though she had complete insight into the uselessness of these items.

According to the OCF (2006), the surplus of hoarding items is such that they form piles and disrupt workspaces. To reduce the discomfort associated with the anxiety of throwing things away, students may hold onto used notebooks, graded assignments from years past, school newspaper clippings, letters from friends, or seemingly useless items such as scraps of paper, even used household products such as used egg cartons intended for future art projects. Logically, in school, these students may appear unorganized with school bags, lockers, and desks cluttered with saved items.

Avoidance

In addition to the compulsive behaviors previously described, students may engage in avoidance behaviors to access relief from obsessions (Baer, 2012). Compulsive avoidance is sometimes part of a broader OC phenomenon and shares some characteristics of other forms of compulsive behavior, such as those presented above (i.e., ritualized washing/cleaning, doubting/checking, ordering/arranging, hoarding, and scrupulosity). What follows are some brief examples of the manifestations of avoidance as it may occur in the school setting.

While contamination fears often lead to excessive washing, they may also cause some students to arrange their lives around avoiding contaminants or to engage in bizarre rituals besides washing or cleaning. In these cases, students may appear to have dirty hair, untied shoes, or to be slovenly clothed for example. Adams (2004) explained that this opposite effect (i.e. cleanliness) is instigated by the student refusing to touch certain objects or body parts for fear of being infected. Students may be noticed as using objects such as tissue or sleeve of shirt as a barrier to touch things.

Rapoport (1989b) noted compulsive avoidance behaviors associated with an obsessive fear of objects such as paint in art class, animals or chemicals in science class, or fear of contact with other people such as in sports played in physical education class. Also referencing avoidance, March and Benton (2007) pointed out that indecisiveness is strongly associated with hoarding and checking behaviors, and both appear to be driven by a strong tendency to avoid making mistakes. Moreover, students with scrupulosity symptoms may create elaborate schemes to avoid certain thoughts, memories, or actions (Greenberg & Huppert, 2010). In any of these cases, compulsive avoidance can result in activity refusal or school refusal.

Neutralizing

Just as with avoidance, neutralization is part of a broader OC phenomenon and shares some characteristics of other forms of compulsive behavior. Neutralizing is a compulsion aimed at reducing anxiety caused by obsessive thinking (Obsessive- Compulsive Disorder and Tic Disorder Studies Centre, 2013). Thus, although functionally equivalent to overt or physical compulsions, the purpose of neutralizing activities, which are usually mental or covert, is focused on undoing or reversing the obsessive thoughts.

To reference March and Benton (2007), obsessions associated with scrupulosity may be one example of thought content that may trigger mental neutralizing tactics for children or adolescents. Rapoport (1989a) noted a case in which a teenaged boy was plagued with evil thoughts and images. Ultimately, he was afraid he would decapitate his younger brother. He struggled with this impulse by avoiding letters of the alphabet with his brother’s name. Each time he would encounter the word “death,” he went through an extensive “counter-ritual” to undo the image of decapitation. For example, he would search for the word “life” in what he was reading to offset “death” before he could continue his reading (Rapoport, 1989a).

In a related vein, Adams (2004) suggested students might circumvent the use of particular objects in the classroom (e.g., scissors, sharp objects), reading certain assigned books, or working with certain numbers, because they may trigger feelings of distress. In some cases, students may feel compelled to count while they are engaged in an activity to neutralize a thought. Nonetheless, manifestations of neutralizing activities would be difficult to detect in a school setting. From the examples above, one can concluded that in school, this student might appear distracted or stuck on one task (Sabuncuoglu & Berkem, 2006).

As shown by these examples, youth with OCD are at risk for significant disruptions in normative social and educational functioning due to distress and frequent ritual engagement. For example, those who engage in extensive bedtime or morning rituals may be exhausted in school due to not getting enough sleep. On academic performance, obsessions can be extremely intrusive and interfere with concentration or information processing. Attention that students should allocate to academic tasks is frequently redirected to obsessive thoughts or mental compulsions. Adams (2003) suggested that students with OCD “often appeared stuck or fixated on certain points and lost the need or ability to continue” (p. 50). As a result, teachers may mistakenly believe that the student is experiencing difficulties with attention task compliance, daydreaming, or motivation. Or, they may label the child as lazy.

Also impairing school performance is tardiness if morning rituals result in students being late to school or absenteeism, if students skip school because they fear that school-based stimuli will trigger obsession or compulsion or because of overwhelming peer ridicule (March & Benton, 2007). Students’ preoccupation with ceaseless ruminations and compulsions leaves little time or energy for friends or family. Many are withdrawn and isolated from peers and have few friendships, if any (Chansky, 2011). For some students, OCD symptoms are mild to moderate and may not interfere with academic or social functioning in school. Other students require adaptations in the general classroom and school environment.

Implications for the Professional School Counselor

Professional school counselors and other school personnel can make a profound difference in the lives of students exhibiting OC behaviors if they can identify them and provide the help they need through comprehensive school counseling programs (ASCA, 2012). One such intervention would be to advocate for these students. The ASCA National Model states that, “Advocating for the academic achievement of every student is a key role of school counselors and places them at the forefront of efforts to promote school reform” (2012, p. 4).

Working with teachers to understand how OC behaviors influence academic, personal, and social success could be beneficial in arranging for classroom accommodations. As Wertlieb (2008) pointed out, accommodations can help students “bypass their obstacles so that learning can take place” (p. 15). For example, a child who compulsively must trace the all written capital letters three times before moving to the next sentence could be permitted to take an exam using a computer. Likewise, a student who must circle his or her desk twice before sitting could be permitted to sit in the back of the room to avoid embarrassment. And a student who has trouble with written assignments due to writing compulsions may need to do assignments orally or record responses on audiotape.

Such accommodations may be provided within the context of Section 504 of the Rehabilitation Act of 1973, “a civil rights law under which a child qualifies for special services if he or she exhibits a physical or mental impairment that substantially limits one or more major life activities, such as learning” (Adams, 2004, p. 47). With a greater understanding of this disorder, PSCs will be prepared to take the appropriate steps to assist students who experience obsessions and compulsions and their related effects. Because of the extensive interaction counselors and teachers have with students they are most likely to represent the first line of defense in identifying the children and adolescents who experience OC behaviors. Therefore, it is also the job of PSCs to advocate for these students by educating classroom teachers and other school personnel about this under diagnosed condition (ASCA, 2012).

Collaborating with community mental health professionals to provide vital referral services to assist students and their families with OC behaviors is another critical role of the PSC (ASCA, 2012). Parents and caregivers are often frustrated, confused and angry as they struggle to understand the nature of OC behaviors (Chansky, 2011). Families need a tremendous amount of support just to understand how to relate to their children. Through education and counseling, families can begin to address and cope with the complex challenges of OC behaviors.

Lastly, PSCs can also address the personal, social and emotional needs of these students by providing individual and group counseling services to help them cope with OC-related symptoms (ASCA, 2012). The feelings of embarrassment, shame, self-doubt, and fear that often accompany OC behaviors can find a safe place for expression in the counselor’s office. A genuine, trusting, warm, and empathic relationship between the counselor and student can promote healing and provide a refuge for the student in what can otherwise feel like a hostile environment (Sloman et al., 2007). Clearly, the PSC is a necessary liaison between families, school, and community mental health professionals.

Implications for Future Research

With the void of empirical studies addressing the prevalence and influence of OC behaviors in the school setting, especially in the school counseling literature, researchers face significant and exciting challenges. More work is needed to identify and evaluate the independent and collective effects of socio-demographic characteristics and OC behaviors on school functioning and the help-seeking practices of students. Studies that compare and describe the range and frequency of OC-related problems and symptom sub- type and severity on school functioning would be extremely valuable. The impact of race, religion, socioeconomic status, age, sex, and grade level on the prevalence of specific OC behaviors and help-seeking behaviors should also be examined. Further investigations such as these could allow PSCs, teachers, and other school personnel to help normalize life for children and adolescents who experience OC behaviors. By understanding the influence of OC behaviors, school functioning, and help-seeking practices of students, PSCs can assist in the facilitation of school-based programming and early intervention (ASCA, 2012).

Conclusion

We now know that the prevalence of Obsessive Compulsive Disorder among children and adolescents is greater than once believed (Teixeira, Carbalho, & Pires, 2013). And, we know that OC behaviors can negatively influence academic, personal and social growth (Van Ameringen, Mancini, & Farvolden, 2003). Yet, so many students who suffer from obsessions and compulsions go undiagnosed or misdiagnosed and fail to receive the services or treatment they need. Making the situation worse is the fact that so many students attempt to hide their symptoms due to shame and embarrassment. Therefore, the ability of the PSC to recognize, monitor, and intervene with those students exhibiting OC behaviors is critical to their personal, social and academic success (ASCA, 2012).

Darren Fleeger (1995) wishes that his teachers had taken a closer look at his idiosyncrasies:

As a child who experienced obsessions and compulsions, I was very sensitive, moody, depressed, and introverted. Much of my time was spent seeking refuge in some solitary activity…. Teachers saw me as a bright, thoughtful, and emotional student. Now I wish that my character was more problematic in school. This was such a secretive and embarrassing experience. It would have been nice if someone had picked up on my strange behavior and suggested something. Maybe that would have saved me years of suffering. (pp. 27-28)

Through education and school-based programming, PSCs, parents, school personnel, and community mental health professionals can help to stabilize life for adolescents who experience OC behaviors, such as Darren Fleeger (1995). Educating others about OC behaviors and OC-related problems can bring the much needed awareness that is so necessary to the healing process. Students should not have to live secret lives veiled in shame.