The Anxiety Zone

The evils of hand sanitizers and other quirks of OCD

Why Would a Child Suddenly Need for Everything to Be "Just Right"?

Sometimes children change overnight.

Ever feel like you are being taken over by alien forces? Many people who have anxiety disorders feel like they (or their bodies) are being unwillingly transported to a kind of Twilight Zone where they lose control and the familiar becomes a frightening caricature of past reality.

This blog will present a series of composite case studies (no real client's confidentiality will be compromised). The case studies are of typical, yet less well known, anxiety symptoms. First, the reader can try to determine the diagnosis of the anxiety disorder and then I will suggest self-help and professional treatment strategies.

 

CASE STUDY: Chandra was a happy six year old who was learning to read rapidly, had lots of friends, and was a joy to her parents. One morning, she would not get out of bed. She sat on the edge of the bed and tried over and over and over to put both of her feet on the floor simultaneously.  After trying for over 30 minutes, she called for her mother to come to watch and check if she had done it just right. Mystified and anxious to help, her mother reassured her but Chandra continued for over an hour crying and trying to be sure her feet were hitting the ground just right. Soon the list of "just rights" got longer: her clothes had to feel just right, every letter she printed had to be perfect, even erasures had to be perfectly erased. She became increasingly clingy and agitated. She would throw tantrums if her mother wouldn't repeat her reassurances with exactly the same words. She feared that any mistake might make her mother die.

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DIAGNOSIS: If you guessed Obsessive Compulsive Disorder (OCD), you got it! Did you also guess PANDAS? "Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptoccocal  Infections" is a somewhat controversial diagnosis that is used when a child seems to have a sudden onset of OCD symptoms. The cause is thought to be an untreated strep infection in which the body's own immune system attacks some part of the body. Many people have heard about how strep throat can lead to rheumatic fever which can in turn cause permanent heart damage. Now there is some evidence that the same process may occur with the body attacking the basal ganglia in the brain and causing OCD. A major difference is that with appropriate treatment, the brain may be able to repair itself and the OCD can be reversed permanently.

In terms of the OCD, Chandra's symptoms were very typical for a child: clingy and cranky. OCD always tends to wrap itself around what is salient to the person. For a child, if they can articulate what is happening at all, it is often about the safety of mom and dad. "Just so" or "just right" is a common type of OCD for children and in Chandra's case it focused on kid world issues: getting out of bed, her clothes, her schoolwork, etc. 

OCD doesn't just affect the person who has it; the whole family becomes involved. Sometimes parents or siblings get angry and say, "Just stop it!" This makes the child more anxious and exacerbates the OCD. Almost always, children beg for reassurance as a way to try make the anxiety stop. But soon the reassurance becomes a compulsive ritual and despite the parents' best intentions, makes the OCD worse. Siblings may ridicule or resent the child with OCD. Parents may fight over how to best handle the OCD and that makes it worse too. 

TREATMENT: The first stop is the pediatrician. S/he should ask about sore throats and test for strep and possibly antibodies. If there is an active strep infection, antibiotics will be given. Some pediatricians will give antibiotics even if the acute phase of the infection is passed (this is controversial).

Next up, seeing a psychotherapist trained to treat OCD. Even a good therapist without specific training in OCD will not be enough because the treatment defies common sense. The current gold standard is a form of cognitive behavioral therapy called Exposure and Response Prevention (ERP). With ERP the brain is retrained to stop over-reacting by experiencing the fearful event (For example, having Chandra write a letter wrong on purpose and then making her wait it out to see if her mother dies.) This sounds a little counter-intuitive and also needs to be done carefully, firmly, and compassionately. This kind of treatment is best handled by a trained professional. A good place to find a specialist is http://www.ocfoundation.org/.

Family involvement is hugely important. At first, it may sound like parents can't do anything right, but research shows that children improve better and faster when the family is involved. Parents can be taught to coach the child at home. Parents can learn to gradually stop accommodating the compulsive rituals and stop playing the "reassurance game." Two really helpful books to read are: Tamar Chansky's Freeing  Your Child from Obsessive Compulsive Disorder and J. Schwartz's Brainlock.

 

 

Katherine Yost, Ph.D., LMFT is a former professor at Rutgers University. She is now a full-time private practitioner.

 

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