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«Obsessive Compulsive Disorder and the School Counselor Ellen C. Wertlieb University of Pittsburgh School of Medicine Obsessive Compulsive Disorder 2 ...»

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Obsessive Compulsive Disorder and the School Counselor

Ellen C. Wertlieb

University of Pittsburgh School of Medicine

Obsessive Compulsive Disorder 2

Abstract

The current article is designed to provide school counselors an understanding of

obsessive-compulsive disorder (OCD). The causes, characteristics, and treatment

approaches are presented with examples focusing on school-related issues. The article

concludes with a discussion about the role that the school counselor can take in helping the child with OCD to have a successful school experience.

Obsessive Compulsive Disorder 3 Obsessive Compulsive Disorder and the School Counselor School counselors play a very important role in the educational process. While specific duties may vary from school to school depending upon student age level and population need, their overall function in all settings is to facilitate the optimal growth of each child (U. S. Department of Education, 1991). Unfortunately, history has demonstrated that population-specific barriers have sometimes restricted the achievement of this goal for students. In fact, it was not until the passage of the Education for All Handicapped Children Act in 1975 that children with disabilities were insured access to appropriate education (Individuals with Disabilities Education Improvement Act of 2004). Federal laws have been written with regulations that not only describe the obligations that teachers have in making reasonable accommodations for these children, but also provide implicit and explicit counselor responsibilities for helping to establish and maintain equal access in the educational system. For example, the regulations of Section 504 of the Rehabilitation Act of 1973 indicate that students with disabilities are “not [to be] counseled toward more restrictive career objectives than are nonhandicapped students with similar interests and abilities” (U.S. Office for Civil Rights, 2007, 34 C.F.R. Part 104.37).

It is easy to see how this mandate can be implicitly expanded to include an advocacy role within the school system to help insure that students with disabilities are neither foreclosed from opportunities for which they are capable nor restricted from appropriate participation in the classroom. With these goals in mind, counselors might serve as consultants to teachers, support personnel for students, and sources of referral for parents. As members of child study teams, they might also find themselves in key Obsessive Compulsive Disorder 4 positions to give input about the directions to pursue with children in the general student body who are exhibiting difficulties.

Informal classroom adaptations might be a sufficient way to handle a variety of challenges students and teachers confront. However, students with obsessivecompulsive disorder (OCD) would qualify for a legally protected educational plan under either Section 504 or the Individuals with Disabilities Education Act (IDEA) when the OCD interferes with learning. The 504 plan is designed to provide reasonable accommodations for those students who do not need special education services (U.S.

Office for Civil Rights, 2007). When OCD is so disabling as to necessitate special education and related services, a more detailed individualized education plan (IEP) would be developed through IDEA (Department of Education, 2006). Counselors might find themselves serving as members of multidisciplinary teams that create and implement either of these educational plans. In addition, they might be included in the IEP itself as providers of related services designed to assist the student in benefiting from special education. It is, consequently, clear that the counselors’ input within the school life of children and adolescents with disabilities can be wide-ranging. However, carrying out some of these responsibilities may be quite challenging for some counselors given the inconsistent level of disability-related training that exists across school counselor preparation programs (Milsom, 2002; Wood Dunn & Baker, 2002).

The dearth of articles concerning obsessive-compulsive disorder in education and school counseling journals is, perhaps, reflective of the paucity of such training for school personnel, in general. A survey of representatives from all Obsessive

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(Wertlieb, 2006). Once considered to be very rare, researchers have recently found that the prevalence of OCD is quite significant, that being 1% among prepubescent children and up to 4% among adolescents (Carter & Pollock, 2000). The purpose of the current article is to provide the school counselor with a general overview of obsessivecompulsive disorder as well as its potential causes. There will be a discussion of the common characteristics with examples of how this disorder may manifest itself in relation to school. Treatment approaches will be discussed along with suggestions for the role that the school counselor can take in addressing the needs of the student with OCD.

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The person who is clinically diagnosed with OCD is characterized as having obsessions, compulsions or a combination of both. Nearly all children with OCD demonstrate the combination (McCracken, 2005). Obsessions involve intrusive thoughts, impulses, or images that persist to the degree of causing anxiety or distress.





In contrast, compulsions are the repetitive behaviors (e.g., hand washing) or mental acts (e.g., counting to oneself, praying, silently repeating words) that are done to prevent or reduce anxiety or distress. Compulsions are generally impelled by the person’s obsessions since the compulsive actions or thoughts ameliorate the intense anxiety. While adults typically realize that their obsessions and compulsions are not rational, children often do not have the same degree of insight (American Psychiatric Association, 1994), especially prior to adolescence (Geller et al., 2001).

It is important to differentiate between developmentally normal rituals and those

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changes in such routines are difficult, especially in relation to bedtime, mealtime, and bathtime. In fact, it may not be until about age eight or nine that bedtime rituals disappear. Playtime is also characterized by rituals during the early years. It is not unusual, for example, for a preschooler to repeatedly line up trains or other toys in a specific manner. Such solitary play eventually transitions into a significant amount of ritually-based collective play. The elaborate rules and rhymes that young elementaryschool-aged children use as they engage in such games as jump rope and hopscotch resemble the behaviors that might be observed in someone with OCD. While the outward appearance is similar, their processes are quite distinct. Normal rituals are thought to help children learn to master anxiety and develop social skills. They do not create anxiety themselves. In contrast, rituals associated with OCD are distressing, time consuming, and interfere with normal functioning (Leonard, Goldberger, Rapoport, Cheslow, & Swedo, 1990). An individual with OCD might attempt the same ritual over and over again, getting more and more frustrated and distressed if he or she feels that it has not been done exactly as it should. Sometimes the person with OCD brings other people into the ritual to confirm that the acts were done ‘just so.’

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OCD has been reported in children as young as two years of age (Carter & Pollock, 2000). However, the most likely time of onset is either between the ages of 8 and 11 or approximately age 21. There is a clear gender difference in incidence during the prepubescent years with boys outnumbering girls two to one. The distribution becomes approximately equal across gender after puberty (Farrell, Barrett, & Piacentini,

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Most researchers have concluded that youths who are diagnosed with OCD can expect their disorder to be chronic in nature. However, a recent meta-analysis of 22 longitudinal studies raises questions about this generalization. The researchers concluded that long-term persistence of OCD may be lower than initially believed. They found that less than half of the individuals taking part in the studies had fully symptomatic OCD upon follow-up. Age of onset was one of the factors found to be a good predictor of persistence level with earlier onset being more typical of greater OCD persistence. As might be expected, poorer initial treatment response was also found to be a predictor. The same effects seemed to be evident for both males and females. The authors caution, however, that additional studies need to be done to replicate these findings since ongoing treatment was not taken into account in the results and the time period for patient follow-up ranged from one to 15.6 years (Stewart et al., 2004).

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OCD was once considered solely psychogenic in origin. However, there is increasing evidence that it is a neurobiological dysfunction with genetic underpinnings (Hemmings & Stein, 2006; Hudziak et al., 2004). Studies focusing on the inheritability of OCD have revealed that up to 18% of individuals affected have relatives with clinical or subclinical symptoms (Towbin & Riddle, 2002). Despite the recognition of this strong genetic component, the actual means of genetic transmission is complicated and has not yet been determined (Hemmings & Stein, 2006). In fact, the genetic mechanism behind OCD seems to vary between subgroups of individuals. Unlike the majority of children, there is a subset of youngsters who are thought to acquire OCD as a

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& Rapoport, 2004; Towbin & Riddle, 2002). It is thought that this autoimmune response occurs due to a genetic predisposition (Arnold & Richter, 2001; Dale & Heyman, 2002).

A genetic vulnerability may also relate to why OCD may manifest itself in some individuals after suffering a trauma (Lochner et al., 2002). Storch and his colleagues (2005) depict how school bullying can be one of OCD’s potential catalysts as they vividly describe the case of a 14 year old boy whose symptoms began after being subjected to a pattern of peer victimization in his school.

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OCD typically does not present itself alone. Social phobia, panic disorder, and/or generalized anxiety disorder have often been found to accompany this condition (Tukel et al., 2002). Depression, the most frequently cited coexisting condition, has been described by some researchers as being present for one third to two-thirds of this population at some point during the course of the disorder (Fineberg, Fourie, Gale, & Sivakumaran, 2005). Researchers have posited that it may sometimes be a consequence of the negative impact OCD has on one’s life. However, a clear cause/effect relationship between depression and OCD does not exist (Carter & Pollock, 2000). Attention-deficit hyperactivity disorder also seems to be overrepresented within this population, having a comorbid rate estimated to be as much as 30% among boys with early onset of OCD (Geller et al., 2007).

Eating disorders and OCD have been described as having especially close ties with one another. Some researchers have even posited eating disorders to be a form of OCD since the rituals in both conditions are fueled by a fear that disastrous

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relationship between eating disorders and OCD does not disappear when symptoms surrounding eating behaviors are removed from diagnostic assessments. Those with eating disorders often display a disproportionate amount of other OCD symptoms as well (Lavender, Shubert, deSilva, & Treasure, 2006). Researchers have, in fact, found OCD to be a common childhood predecessor to anorexia and bulimia nervosa (Kaye et al., 2004). The high comorbidity rate has led Serpell and her colleagues (2006) to emphasize the importance of assessing for OCD among those young people who present with eating disorders in order to insure appropriate treatment.

Knowledge of the additional conditions that a child with OCD is likely to manifest provides the school counselor with information crucial for understanding the child’s behavior and providing the appropriate help. It is also important for the counselor to be aware that sometimes the diagnosis of OCD might have been overlooked in a child with another more prominently appearing condition. Tourette syndrome is a good example of such a disorder. Some researchers have approximated that up to 50% of individuals with this syndrome manifest obsessive-compulsive symptoms or clear-cut OCD. In contrast, less than 20% of individuals with OCD have chronic multiple tics.

Developmentally, children with Tourette syndrome seem to develop tics before obsessions and compulsions. However, by adulthood, obsessive-compulsive symptoms often become the predominant difficulty, even after the tics from Tourette syndrome might have dissipated (Goodman, Storch, Geffken, & Murphy, 2006).

There are also a disproportionate number of individuals with Pervasive Developmental Disorders, such as autism and Asperger syndrome, who have OCD

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to identify the specific OCD symptoms amid the various characteristics evident in these other disorders (Russell et al., 2005). For example, individuals with autism have sometimes been characterized as engaging in repetitive movements that are selfstimulatory in nature (Lewis & Bodfish, 1998). Therefore, the child who demonstrates repetitive finger movements might be manifesting this behavior for visual and/or tactile stimulation so as to obtain automatic reinforcement (Rapp & Vollmer, 2005). However, the child whose finger movements represent an OCD compulsion may be engaging in this behavior to decrease anxiety brought about by something such as a contamination obsession.

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The specific obsessions and compulsions that can exist for people with OCD are unlimited and typically change over time (Towbin & Riddle, 2002). It is for this reason that Section 504 agreements and IEPs must be regarded as quite fluid, adapting to the changing needs of the student involved. Despite the heterogeneity of specific symptomatology, there are some overall themes that are commonly seen.



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