If ever there was an event that made obsessive compulsive disorder (OCD) behavior seem “normal,” the COVID-19 pandemic, with its calls for extra vigilant sanitary and social-distancing measures is it. Jennifer Keluskar, PhD, a Stony Brook child and adolescent psychologist explains why validating your child’s anxiety emotional state during this time is helpful — whether they’ve been diagnosed with OCD or not — and offers advice to guide you and your family through this challenging time.
Obsessive Compulsive Disorder (OCD) is a psychiatric condition that impacts about half a million (or 1 in 200) children and adolescents in the U.S. (source: International OCD Foundation.)
It’s also a term we throw around to describe behaviors in people who don’t actually have OCD but are exceptionally particular about who is allowed to touch valued personal possessions.
Given the recent attention drawn to sanitary and social-distancing measures to prevent spread of COVID-19, many of us have become extra vigilant about our behavior, as well as anxious about the consequences of not following these measures. People have been ordered to stay home from work and school, restaurants have closed, and play dates and holidays have become restricted to virtual platforms.
These behaviors would be considered unusual during “normal” times. But these are not normal times. Validating your child’s anxiety emotional state is the new normal. This means that it’s okay to remind your children that it’s okay to feel anxious (validation) and that many are feeling anxious at this time (normalization). Note, though, that this is different than saying they should or must feel this way all the time.
In the face of this unprecedented event, it’s important to consider the potential impact of the COVID-19 pandemic on children and adolescents with OCD or features of OCD.
First, let’s consider the criteria for OCD:
- Obsessions, or thoughts, pictures, or ideas that keep coming to mind even though the person doesn’t want them to and may try to resist the thoughts.
- Compulsions, or behaviors that the individual thinks they MUST complete to avoid feelings of distress. Often, the distress caused by obsessive thoughts makes people try to get the thoughts to stop. They also come to believe that they can make the thoughts less scary by completing compulsions, such as repeating a specific phrase to protect against the feared thought from making bad things happen to them.
- The obsessions and/or rituals cause noticeable distress, take up more than one hour of a person’s day, or interfere with their ability to function (i.e. social activities, daily life activities, self-care, school, and relationships). Often, a person with OCD feels like they have little control over their symptoms.
Obsessions and compulsions tend to surround certain themes
The Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS) is a measure that behavioral health specialists use to assess OCD symptoms in children.
Obsessions outlined in the CYBOCS include (but are not limited to):
- Fear of contamination
- Fear of harming self or others
- Magical/superstitious thoughts, such as lucky numbers
- Fear of offending religious objects
- Fear of illness
- Other themes include fear of not knowing the right thing to say; needing to know or remember; and intrusive sounds, music, or words
Compulsions may include (but are not limited to):
- Excessive washing
- Frequent, repetitive checking (for mistakes, things left behind or undone, etc.)
- Repeating the same sequence of actions over and over (such as erasing and writing the same words
- Touching items a certain number of times.
Will the COVID-19 pandemic and measures taken as a result cause children to get OCD?
There is strong research support for a neuro-biological and genetic basis of OCD. (Click here for a good article on this topic.) This means that parents and life situations don’t cause OCD. However, in people who biologically and genetically are more likely to have OCD, the symptoms can be heightened or triggered by life events, particularly stressful ones.
What about kids whose obsessions and/or compulsions aren’t focused on contamination and compulsive washing?
The way that OCD symptoms present themselves can change over time. This means that symptoms can shift from one focus to another (and possibly towards a focus on contamination and washing even if this was not previously a concern). Stress and lifestyle changes can also impact the severity of any OCD symptoms, even if the symptoms don’t relate to contamination fears and washing compulsions.
What’s the effect of the COVID-19 pandemic on children with OCD?
Due to the unprecedented and evolving nature of this pandemic, there’s insufficient research highlighting the effects of COVID-19 on children with OCD. We do know that OCD symptoms can re-emerge or be made worse by stress. We also know that giving in to or encouraging compulsions will make the OCD worse, making it harder to overcome. Given our current situation however, this doesn’t mean that OCD-prone kids are doomed. Parents’ response to children’s fears and behaviors can play a critical role in lessening any negative impact of the pandemic. Here are some suggestions that may help:
- Use this situation as an opportunity for sharing and validation. Many kids with OCD have insight into the lack of rationality underlying their fears and behaviors. They think they are "weird" because of their condition, and for this reason, they may be reluctant to talk about it. With anxiety being the "new normal" in current COVID-19 times, it presents an opportunity to welcome a discussion of OCD symptoms with your child. Because the symptoms are unique to every individual, cannot be seen, and don't make sense, encouraging your child to share the details of their obsessions and compulsions is the first step toward helping them manage their symptoms. As a parent, you should focus on the goal of preventing OCD symptoms from worsening, rather than expecting your child to be cured of it during this unprecedented time. The evidenced-based, best practice approach for this is known as Exposure with Response Prevention (ERP). The "Exposure" part simply means helping your child to face or confront their own fears repeatedly until the fear subsides. "Response Prevention" means helping your child refrain from compulsions, avoidance or escape behaviors.
- At the same time, try not to condone OCD symptoms. When a person is diagnosed with OCD, the diagnosis is based on the excessive nature of their symptoms. For instance, we’ve been told that it’s important for good health to wash our hands before eating or preparing food, after using the bathroom, and after having obvious contact with germs from coughing or sneezing on ourselves or from when others cough or sneeze on us. On the other hand, washing our hands every time we touch anything would be viewed as excessive. While heightened sanitary measures have now been normalized for good reason, it’s still possible to help your child better understand the difference between what’s currently being recommended for their given situation, and what behaviors are excessive, unhelpful, and potentially unhealthy. For example, washing hands to the point that they bleed will invite rather than protect against germs.
- Remember that kids with OCD tend to be overly stuck on rules. People who don’t have OCD may not realize how often they slightly (or more than slightly) break rules, even under threatening circumstances. While rule following is a highly desirable trait for achievement, health, and remaining within good standing in society, too much of a good thing can, ironically, be self-defeating. One reason for this is that people tend to get worn down by excessively harsh rules. And because the pandemic may last for several more months, being able to maintain an excessively rigid approach over the long haul is not realistic. Another reason these efforts are self-defeating is that they prevent social connection with others. Although the way we interact now with social distancing and virtual meet ups, feeling connected with others continues to be essential for health and wellbeing. Another example of being overly stuck on rules is when someone has trouble putting information in context appropriately. For example, someone who is sheltering in place likely doesn’t need to change their clothes after taking a walk around the block, but a hospital worker is more likely to be advised to follow these guidelines. Individuals with OCD may feel that they need to go over the top to “make sure” they follow the rules and stay safe. Try validating your child’s anxiety while gently challenging them by highlighting the cons of their instinct to be “extra safe.” It’s often helpful to have your child imagine the OCD voice in their mind as a villain or an annoying character that is bullying them and encourage them to “stand up to” the “OCD bully” in their mind.
- Remember that kids with OCD make connections between their fears and events that others may not make. People with OCD easily connect their fears to irrelevant events in an effort to control what in fact cannot be controlled. They may think that if they don’t wear their lucky socks every day, they “might” get infected with COVID-19. Their rationale may be that given the potentially deadly nature of this disease, “Is it really worth taking the risk to not wear the socks? Nope!” As a parent, you’ll need to approach situations like this with care. Given the heightened anxiety understandably surrounding COVID-19, it won’t be helpful to be overly harsh or critical. Instead, try to make it a meaningful moment with a cheerleading attitude. You can bond by creating a family funny sock night and emphasizing that it’s OK to tweak the rules sometimes. Also emphasize that the extreme measures being taken are essential but don’t necessarily pertain to your child’s situation and explain why it’s still important for essential healthcare workers and others in the community to take these measures.
- Try to maintain a healthy lifestyle, including routine and structure in the day; good sleep hygiene; healthy meals; and exercise. These lifestyle factors will help lessen the severity of OCD symptoms.
- Take time to learn and practice meditation with your child. Meditation is all about encouraging the individual to focus on what’s happening at the present moment. The more we focus on what’s right in front of us, the less attention we’re able to give to the “What if’s” festering within the mind.
- Schedule a family meeting time for talking about COVID-19. With families homebound, and media and talk related to COVID-19 likely to be overheard by children, make a deal to limit talk and sharing updates about the pandemic to a specific time regularly. Find a private time to talk about anything you don’t feel your child is ready to hear.
- Be mindful of your own reactions. Children with OCD will often try to get their parents to reassure them or participate in their compulsions. This isn’t meant to be a manipulative behavior, but rather the child’s desperate attempt to get rid of their anxiety and feel safe. Validate how difficult your child’s distress is, but don’t give in to pressures to relieve it, by, for example, providing reassurance excessively. Doing so will only fuel the OCD.
- Show compassion but also set boundaries and limits and enforce them. This is a good time to be especially compassionate toward your kids to help them feel safe and loved. At the same time, this can be accomplished while maintaining the same expectations and limits for behavior that you had before the crisis. For example, understand that your child is acting out due to anxiety and try to talk to them about this. At the same time, enforce consequences for negative behaviors, such as harmful physical or verbal fighting with their siblings or cursing at you. If your sense that your child is reacting to your behavior, (i.e. treating you like an outcast if you’re working outside the home), validate their anxiety, but firmly state what your expectations are for their appropriate behavior toward you.
Goodman, W.K., Scahill, L., Price, L. Rasmussen, S., Riddle, M. & Rapoport, J. Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS), last revised 10/4/2007.
Ruscio, A.M, Stein, D.J., Chiu, W.T., & Kessler, R.C. (2010). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication. Molecular Psychiatry, 15 (1) 53-63. doi: 10.1038/mp.2008.94. Epub 2008 Aug 26.
[BL1]I changed this from the “normalization of anxiety” language that was there previously – is that ok? I figured since we mention that phase earlier on on the article it made sense to mention it again)