Category Archives: Anxiety
Parents often ask me whether their child’s behavior is typical or something more significant such as Obsessive Compulsive Disorder (OCD). In my clinical experience, OCD is a term that is often misused in ‘pop’ culture. For example, I often work with parents who describe themselves as “OCD” because they are organized or meticulous in their everyday lives. These behaviors may be orderly or repetitive, but they do not necessarily indicate obsessions or compulsions. Another example is the junior high school or high school perfectionist I counsel who wants to have straight A’s and becomes upset if this does not occur. Again, this is not OCD although many individuals with OCD tend to have some tendencies toward perfection. Just because you have obsessive thoughts or perform compulsive behaviors does NOT mean that you or your child have obsessive-compulsive disorder. Many people have mild obsessions or compulsions that are strange or irrational, but are still able to lead their lives without much disruption. In the case of obsessive-compulsive disorder, these thoughts and behaviors cause tremendous distress, take up a lot of time, and interfere with friendships, school functioning, employment, or relationships. Thus, the amount of disruption that occurs and the amount of settings (at least two) that are affected in one’s life help to define true OCD from someone who is orderly, ‘anal,’ or a perfectionist.
When it comes to determining the presence of OCD in children, the following need to be considered:
Children and adolescents with obsessive-compulsive disorder (OCD) suffer intensely from recurrent, unwanted thoughts (obsessions) or rituals (compulsions), which they feel they cannot control. Rituals such as hand washing, counting, checking, or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these rituals, however, provides only temporary relief, and not performing them markedly increases anxiety. Left untreated, obsessions and the need to perform rituals can take over a person’s life.
It looks like this:
The Sequence of OCD Symptoms:
1) Evoking Event
2) Obsessing Begins
3) Distress & Anxiety
4) Urge to Ritualize
6) Relief and Self-Criticism
While the onset of obsessive-compulsive disorder usually occurs during adolescence or young adulthood, younger children sometimes have symptoms that look like OCD. However, the symptoms of other disorders, such as ADD, autism, and Tourette’s syndrome can also look like obsessive-compulsive disorder, so a thorough medical and psychological exam is essential before any diagnosis is made. It is also important to note that OCD is an anxiety disorder, and in children, the symptoms of anxiety usually change over time. So a child with OCD symptoms will not necessarily have OCD as an adult. What is most important is to make environmental and behavioral changes to help reduce your child’s anxiety and provide support, yet do not give in to the anxiety or change your routine significantly in response to it. Remember, some anxiety is good..it tells us when we need to fight or flee. Making too many accommodations for your child’s anxieties will only serve to reinforce the fears. As the old saying goes: If you see a ghost in a graveyard, you should run toward it. This is the essence of exposure and response prevention treatment for OCD, which will be detailed in future blog postings.
Dr. Mark Bowers is a Licensed Pediatric Psychologist at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.
Autism Spectrum Disorders (ASDs) and Obsessive-Compulsive Disorder (OCD) can and do occur at the same time. OCD is a specific diagnosis under a larger umbrella of anxiety. Children with OCD experience unwanted and intrusive thoughts that they can’t seem to get out of their heads (obsessions), often compelling them to repeatedly perform ritualistic behaviors and routines (compulsions) to try and ease their anxiety. Children with ASD generally have repetitive, perseverative thoughts that are intense in nature, much like children with purely OCD symptoms. The big difference is that children with OCD do not like the experience of having repetitive thoughts and would do anything to get rid of the thoughts (such as washing one’s hands 25 times). Children with Autism Spectrum diagnoses are not bothered by their repetitive behaviors and thoughts, and instead are usually comforted by them (such as playing with a train in a repetitive fashion for hours at a time).
Anxiety is highly prevalent among children with Autism Spectrum diagnoses (greater than 35% of children experience both). This is due to a combination of genetics, brain development, and higher levels of stress. The error that many schools and therapists often make is attributing a child’s anxiety symptoms to his or her Autism diagnosis (i.e., “The only way to really reduce anxiety and aggression is to treat the Autism.”) For example, many children are referred into social skills groups when what they really need is help with anxiety that is interfering with their social functioning. Highly anxious children with OCD may begin to act out behaviorally in school prompting teachers to encourage (some might say ‘coerce’ or ‘force’) parents to begin medicating the behavior. The concerns here is twofold: 1) the behavior is numbed with medication and the root anxiety is never truly addressed (i.e., stop the medication and everything returns to the way it was), and 2) the school may begin to implement safety nets such as increased para support to keep the behaviors from occurring while again failing to adequately address the underlying anxiety symptoms.
The question often asked is, “Can you really treat a child who has both an autism spectrum diagnosis and OCD?” The answer is “yes” and new research is beginning to show that there are some exciting recent behavioral treatments out there for these children. Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for anxiety that has been established by the American Psychological Association as effective for children. A recent study of CBT for neurotypical children with anxiety (Wood et al., found):
- Childrens’ school performance improved & they attended school more regularly
- Children had more friends & better quality friendships
- Children got along better with family members
- Children had higher self-esteem
The authors of that study have adapted the neurotypical CBT protocol for children with autism spectrum and are finding some promising results. In general the results suggest that the authors’ adaptations of the pre-existing CBT manual can be effective for treating anxiety such as OCD in children with autism (research article link). This treatment manual is available to practitioners and families, a sample of which can be viewed here. Thus, there is hope for effective anxiety treatment for your child who also has an autism spectrum diagnosis. It is highly recommended that you seek out services from a pediatric specialist who has training and experience treating children with co-occurring anxiety and autism spectrum diagnoses.
On a personal note and aside, I will be spending tomorrow with noted Asperger’s guru Dr. Tony Attwood so stay tuned for a blog later this week where I hope to share some new ‘nuggets’ of information.
Dr. Mark Bowers is a Licensed Pediatric Psychologist and Autism/Anxiety expert at the Ann Arbor Center for Developmental & Behavioral Pediatrics in Ann Arbor, Michigan.
© 2009 Mark Bowers, Ph.D.
A paper presented at the International Conference on Violence, Abuse and Trauma on Sept. 25 by sociologist Murray Straus has caught my attention this week. Straus and his colleague Mallie Paschall followed children over the course of four years and determined that those who were spanked had up to a 5-point lower IQ than their peers who were not spanked. Further, the more the children were spanked, the lower their IQs.
This debate is not new. In fact, I find myself in this debate at least a few times each month with some of the families I see. The age old question is whether or not spanking is an effective form of discipline. My professional stance (in conjunction with the science that supports it) is that spanking is actually punishment (not discipline) and is only effective in the short-term. Try telling that to the ‘old school’ father who swears, “It worked on me when my father spanked me!” With a little more investigation in my office, I am often able to reveal that while it may have garnered attention in the short-term, it fueled resentment toward the parent over the long-term.
I truly believe that the majority of spanking occurs in the form of a parental temper tantrum in which the parent has lost control and is at a loss for an effective discipline strategy. There are a number of problems with punishment that I encourage parents to consider when deciding if they really want to employ spanking as a method of punishment.
- Spanking focuses anger on the parent doing the spanking. When we resort to punishment it gives children someone else to be mad at or something else (the spanking) to blame.
- Spanking causes the behavior to stop quickly, but in the absence of spanking, the negative behavior returns.
- Spanking does not teach accountability. The “punisher” (parent) is responsible to see that the child’s behavior changes. The child learns nothing on their own as a result of the spanking.
- Punishment denies a child the right to experience the real consequence of their actions. If your child hurts someone else, for example, the other child may not want to play with your child anymore. Your child quickly forgets this possibility when spanking is introduced.
- A big error comes when we think that the punishment has taught the child what to do the next time a similar situation occurs. It has taught the child NOT to do something… but it has not taught them what they should do!
In case those reasons were not enough, we also know that spanking makes children anxious (especially toward the parent using this method) and spanking can lower self-esteem. A report endorsed by the American Academy of Pediatrics in 2008 looked at 100 years of research and concluded, “There is substantial research evidence that physical punishment makes it more, not less, likely that children will be defiant and aggressive in the future.”
The full report can be read at www.phoenixchildrens.com/discipline