This article is for parents raising a child who struggles with OCD. I begin by suggesting ways to explain OCD to your child and outlining some ineffective and often counterproductive methods that children typically use in trying to manage their worries. Then, I present six creative strategies that you can teach to your child to help him or her manage the problem.
Although I offer suggestions to assist parents in helping their children, all of these ideas are applicable to adults as well.
What Is OCD?
Obsessive-compulsive disorder (OCD) is the medical term for a disorder, or malfunction in thinking, in which a person suffers from obsessions, which are often linked to compulsions. Obsessions are intense and obstinate worries that something awful has happened or will happen. Compulsions are repetitious acts that the person performs to try to manage their intense worries. Examples of compulsions include repetitious checking, cleaning, ordering, and superstitious rituals.
OCD affects an estimated two percent of the population. It is slightly more common in females than in males, and often starts in childhood — typically at around seven to ten years old.
Obsessions and Compulsions
An obsession is an apprehension, or a distressful fear that something dreadful may have already happened or will soon happen because of something the person has done or failed to do. An obsession is an obstinate worry that preoccupies the mind of the person and haunts them even if they try their best to overcome it.
Compulsion is the term used for the ineffective methods that people suffering from OCD use to try to overcome their obstinate worries. Imagine that this thought pops up in your mind: “My hands are dirty” (even though you already washed them a moment ago). You can try to get rid of that worry-thought by washing your hands again. If you find yourself washing your hands repeatedly, the washing is a compulsion that you are using to overcome your persistent and overstated worry that your hands are dirty.
Another example: An intense worry occurs in a child’s mind that something bad may have happened to his mother while he is in school and his mother is at home. The child can try to get rid of his worry-thought is by calling his mother to make sure Mom is alive and well. If the worry reappears soon, and the child feels he needs to repeat the checking, we can say that the checking is the compulsion by which the child tries to control the worry “Something bad may have happened to my mother.”
Standard OCD Treatments
The two most commonly used treatments for OCD are medication and cognitive behavioral therapy (CBT).
Psychiatrists readily prescribe psychotropic drugs–even to children–but its effectiveness is very marginal. At best, medication may reduce or mask some OCD symptoms by reducing anxiety, but more often than not the side effects of the psychiatric drugs outweigh their possible benefits.
Cognitive behavior therapy (CBT) is considered the gold standard for treating OCD in children as well as adults. Although good results have been reported in clinical research studies, in real life, the effectiveness of CBT seems to be overrated. A large percentage of people who have undergone CBT are still suffering from OCD symptoms after having completed their treatment.
In this article, I propose a way of thinking about OCD and an approach to helping children struggling with the condition that are grounded in the basic principles of CBT. However, this approach adds a creative layer that makes it more fun and engaging for the child. My inspiration derives mainly from the traditions of brief, narrative, and solution-focused therapies.
Explaining OCD to Children
It’s not surprising that it’s difficult to explain OCD to a child, because even experts haven’t got a clue as to why some people suffer from this condition while most don’t.
One possible way for you to help your child make sense of her problem is to use “externalization,” an explanation commonly used in narrative therapy with children. It means that you tell your child that there is an imaginary creature, perhaps sitting on our left shoulder, whose job is to generate worries for us. Children usually respond well to this metaphor. You can then help your child come up with a name for the creature and ask her to draw a picture of it. In this article I will call this creature the “worry gremlin.”
An alternative way of using externalization is to explain that there is a special region in the human brain that is responsible for generating worries. You can call that area our “worry generator” or “nucleus worrius.” The very same methods that I describe in this article for coping with the worry gremlin can be applied to coping with nucleus worrius just as well.
Of course, there are no gremlins sitting on our left shoulder bombarding us with obstinate worries, nor are there any specific brain regions responsible for generating worries. Yet, metaphor can be very helpful to children, not only because it allows them make sense of their distressing experience, but also because it assists them in becoming more creative and astute in inventing ways to cope with their worries.
You can explain to your child that we all have a worry gremlin and we all need to learn to come to terms with or to live in harmony with it. Sometimes, if the worry gremlin becomes excited and goes into overdrive, we need to find ways to calm it down. It is also important to explain to the child that some ways to try to calm down the overexcited worry-gremlin work better than others.
Ineffective Ways to Calm Down the Gremlin
It may be useful for you as the parent to understand some of the ineffective ways in which children often try to come to terms with their worries. These methods include reasoning, reassurance, checking, cleaning, ordering, repeating, superstitious rituals, avoidance, and distraction. (If you are familiar with these strategies, feel free to skip this section and to proceed to the next, in which I describe six creative ways to help your child become better at coping with an overexcited worry gremlin.)
Children sometimes try to overcome their worries by starting an internal dialogue with their worry gremlin. The problem with this method is that it’s next to impossible to outsmart the gremlin. Consider this “conversation”:
“Are your hands perhaps dirty?” says the worry gremlin.
“No, they are not. I just washed them a minute ago,” the child replies.
“But they might still be dirty,” the worry gremlin insists.
“Why would they be if I just washed them?” the child tries to say.
“You did wash them, but not properly. You didn’t wash in between your fingers, did you?” the worry gremlin points out.
“I did wash between my fingers,” the child protests.
“Did you? Are you sure? You could have been careless. I bet your hands are still dirty,” the worry gremlin now says.
“My mother says that it’s impossible to have 100% clean hands. There will always be some germs on the skin,” the child tries to reason.
“That’s right, and by touching things that other people may eat, you can cause someone to become sick. Who knows, they may even die because of you,” the worry gremlin replies, and begins to scare the child.
“OK, I’ll wash them one more time just to make sure,” says the child, giving in to the obstinate worry gremlin.
Reasoning, or logical argumentation, means debating with the worry gremlin. It’s meant to silence the gremlin, but it does the exact opposite by triggering it to come up with endless counterarguments. The more the child tries to disprove the worry, the more intensely his or her worry gremlin will defend it. It is next to impossible to beat the worry gremlin by debating with it.
It is not uncommon for children who suffer from OCD to ask their parents to convince them that their worry is unnecessary. Parental reassurance can offer a temporary break from anxiety for the child, but the relief is often short-lived. By reassuring a child with OCD that there is nothing to be afraid of, the parents are doing a disservice to him. Instead of calming him down, this well-meant comforting ends up stimulating the child’s worry gremlin, simultaneously increasing the child’s dependency on his parents’ reassurances.
Child: Will someone in our family die during the night while we are sleeping?
Parent: No, nobody will die during the night. I have told you that many times already.
Child: Are you sure nobody will die? How can you be so sure?
Parent: We will all sleep well and wake up fresh in the morning.
Child: But what if someone dies in the night? Please tell me one more time that nobody will die. Say it again, please!
Checking, Cleaning, Ordering, and Repeating
Some worries can be overcome by checking. If you are taking to your child to school and she suddenly begins to worry that you left the door to your house unlocked, you can go back and make sure the door is, in fact, locked. Or if your child starts to worry that you may have left the stove on, you can go together to the stove to make sure it’s off.
Checking more than once is not a good way to overcome worries. Like reassurance, it only provides the child with temporary relief while paving the way for renewed doubt and a need to check again. “Yes, it’s true that you already checked, but did you check properly?” the worry gremlin taunts, forcing the child to check again and again. Rather than helping the child to conquer her worries, checking tends to make the worry more obstinate.
If the child’s worry is related to the dirt, it makes sense that she will try to overcome her worry by cleaning. Likewise, if the child is worried that something bad will happen if things are not placed in exactly the right way, or activities are not carried out in perfectly correct order, then it is understandable that the child will try to overcome the worry by spending time placing things just so, or repeating an activity again and again until she can feel that the sequence was done in the perfectly correct way. As we all know, these kinds of compulsions can consume huge amounts of time and do little in terms of helping the child to overcome the underlying worries.
Human beings are a superstitious lot. We knock on wood after we say something has been going well. We know this action has no effect, but we still do it. Just in case.
It is therefore no surprise that children who suffer from irrational worries come up with the idea that they might beat their worry by performing a superstitious ritual of some sort.
For example, a child who worries that something bad will happen because he has had a “sinful” thought might come up with the idea of preventing that bad thing by performing a ritual. That ritual could be reciting a prayer, repeating certain words in his mind, or even shaking his hands in a certain way X number of times.
By performing a superstitious ritual, the child may be able to conquer his worry for a brief moment, but the method is treacherous because it reinforces the child’s tendency to develop worries. When children try to ward off their worries with rituals, they are practicing superstitious thinking and thereby reinforcing the foundation on which their problem rests.
Many people who suffer from phobias (extreme, irrational fears) manage their anxiety by avoiding, at all costs, any situations that provoke their fear. For example, those who suffer from fear of heights often cope with their problem by avoiding high places, and those afraid of social situations often avoid going anywhere they would have to talk to strangers. Similarly, children who suffer from excessive worries can try to manage their anxiety by avoiding situations that they know will trigger their obsessions.
For example, if a child suffers from the worry that something bad may happen to her mother while she is at school, the child may “solve” the problem by staying at home to make sure that her mother is safe. The “solution” eliminates the worry, but the price is high, as the child misses out on school and being with her friends.
Some children are able to get a temporary break from their worry gremlin by redirecting their attention away from the worries toward something different. A child may, for example, distract himself by listening to music or by playing a video game.
Redirecting one’s attention to something else is useful inasmuch as it gives a temporary respite from anxious worries, but the relief can be short-lived if the worries become reactivated as soon as the distraction stops.
6 Creative Ways to Calm Down the Worry Gremlin
Now that you know about the ineffective strategies that children use to stifle their overexcited worry gremlin, it’s time to solutions. These strategies are more effective methods that you can teach your child to cope with her worry gremlin (or overactive nucleus worrius).
Worry-time is a method often recommended to people suffering from insomnia caused by excessive worrying. It means that you reserve a designated time for thinking about your worries during the day or evening before going to bed. During this timeslot, which may last from 10 minutes to a half an hour, you sit down with a pen and a paper and deliberately focus on thinking about your worries. The method is based on the observation that it is easier for people to rid themselves of bedtime worries if they have already dealt with them in advance. When a worry pops up in their mind in bed, they can then say to themselves: “I won’t think about it now. I already thought about it during my worry-time,” or “I won’t think about that now, I will think about it during my next worry-time.”
You can suggest this method to your child. Help your child set a timer and use a pen and a notepad and write down each worry that comes to her mind. Encourage the child to deliberately worry as much as she can during this period. What is the worst thing that could happen? What else (bad) can happen? What more are you worried about? When the timer signals that the worry-time is over, help your child put away the notepad and encourage her to start doing other things. Say to her, “You have given your full attention to your worries so you can now give yourself a break and let go of your worries until the next worry-time.”
You may enhance the effect of the method by asking your child to revisit her worry notes and to read her worries aloud to you. When children revisit their worries in this way, they often find that the worries have lost their grip on them and no longer trigger the kind of anxiety they used to.
Putting Worries on Hold
Guatemalan worry dolls are miniature dolls made of pieces of colorful thread that usually come in small bags of four or five. Guatemalans have used worry dolls for centuries to help children to free themselves of worries that keep them awake and prevent them from falling asleep at bedtime. The child’s mother, father, or grandparent takes one of the tiny dolls from the purse and asks the child to tell the worry to the doll. The doll takes on the worry, thus releasing the child for having to think about it. The doll is then placed under the child’s pillow and when the child wakes up in the morning the doll is gone. It has defeated the worry and returned to the purse. There are several dolls in the purse so that if a child has more than one worry, each of the dolls can take on a different one.
The idea of worry dolls is based on the observation that worries tend to vaporize, fade, or lose their intensity if the worrier does not even try to get rid of the worries, but instead puts them on hold, to be attended to later. When a worry is on hold in a safe and secure place, but not preoccupying the mind, time starts to do its miracles and the worry starts to diminish until it loses its and power.
You don’t necessarily need worry dolls to teach this method to your child. Instead, you can have her write his worries on slips of paper and to put them on hold (remove it temporarily from his mind) by placing the slips in a worry box or some other special place the child has reserved for them. When an hour later — or maybe even next day — the child opens the worry box and reads what is written on the slips, he is likely to find that the worries no longer bother him nearly as much as they did at the time he wrote them down.
To help your child make sense of this method, you can explain to him that the worry gremlin does not like you to ignore its worries, but it doesn’t mind you putting its worries on hold. By writing your worries down and promising the worry gremlin to give them attention later, you can calm down the overactive worry gremlin and learn to live in harmony with it.
Amending Worries with a Happy Ending
I have written an illustrated story for children about how to overcome recurring nightmares. You can find it at the Kids’Skills website (www.kidsskills.org). In the story, a boy named Nigel tells his grandmother that he has a recurring nightmare where big scary trucks are chasing him.
“Didn’t you know, Nigel, that there are no nightmares?” responds his grandma.
“Why do you say so? I have the same nightmare almost every night,” answers Nigel.
“There are no nightmares because all dreams have a happy ending,” explains Grandma.
“But mine doesn’t!” Nigel sobs.
“Of course not, if you wake up in the middle!” says Grandma.
The story continues with Nigel and his grandma imagining together a happy ending to Nigel’s dream. In their mutual fantasy, the trucks stop and drivers come out to tell Nigel that they are there to bring him presents. Nigel gets to enter the trucks, which are filled with interesting stuff, and to pick his favorite gift. When Nigel is in bed, Grandma says to him: “Remember to see the ending of your dream tonight.” That night Nigel sleeps through the night without any dreams and his nightmare never reappears.
One way to understand worries is to regard as them as waking nightmares, or nightmares occurring in a conscious state. The child’s mind generates scary fantasies during the day in the same way as during the night. This way of understanding worries makes it possible for you to teach your child to do to her worries what Nigel’s grandmother taught him to do with his nightmare: to revise the waking nightmare by amending it with a happy ending.
For example, if the child worries that something bad will happen to her parents because she didn’t put his clothes on in exactly the right order, ask the child to tell you the details of her waking nightmare. “What is your awake-nightmare like? What scary things do you imagine could happen to us?” Suppose your child now reports to a having a waking nightmare where one or both of you are run over by a car and die. You can now tell her that not only all dreams but also all waking nightmares have happy endings and proceed to help her amend his fantasy. Maybe in this happy ending, the ambulance comes to the scene of the accident and the paramedics find that her parents have survived the accident without a scratch and can return home without further ado. Or maybe an angel appears and heals their wounds and makes them happy again.
Children troubled by OCD are masters of using their ability to fantasize. If a child is good at creating scary fantasies, she can help herself by learning to create happy fantasies instead.
Imagine that when you were a child you had a big brother who took pleasure in teasing you. He teased you, for example, by saying things like “Watch out, there are monsters under your bed!” The more afraid you got, the more he enjoyed what he was doing.
As you grew up, you began to understand that there are no monsters under beds, and you learned to fight back against your brother. When he started to speak about monsters, you responded, “Stop it. There are no monsters under my bed. You are being stupid.” He stopped teasing you when he realized that he couldn’t trick you anymore. You defeated him by ignoring his ludicrous fearmongering.
Children often deliberately scare each other in this way. They project various scary images — “Tomorrow will be the end of the world!” or claim that the family’s pet dog has been hit and killed by a car — and then take pleasure in observing the other’s emotional reactions. From an outsider’s perspective, what they are doing appears to serve no other purpose but bullying, but we can also think of such interactions as a way of rehearsing an important life skill. When children play by deliberately scaring each other, they help train one another in the skill of handling and dealing with scary images and fantasies. The scaring game ends when the target learns to respond to the scaring in a way that indicates that he refuses to take the scenario seriously and instead shows an ability to ignore it by responding to the fearmonger by saying, for example, “BS!” “I don’t believe you,” or “Give me a break!”
It might be helpful for you to think about your child’s worry gremlin in much the same way you think about your imaginary big brother. Your child’s worry gremlin actively launches diverse images of danger and threats — not to pester him, but to teach and train him to become stronger; to help him develop a skin thick enough to protect him from all kinds of scary images and fantasies that threaten to ruin his happiness. Seen in this light, your child’s worry gremlin has good intentions. Its job is to teach him to respond to his worries by not taking them too seriously or simply ignoring them.
Turning the Worry Gremlin into a Teacher
If you can think of your child’s worry gremlin not as a bully, but as a teacher, it becomes possible for you to take this concept up a notch.
A father told me the following story of how he helped his then seven-year-old daughter to overcome a persistent worry. The girl’s worry appeared at bedtime. When her father was putting her to sleep, she would start to doubt that the door to the house was locked, allowing burglars to break into their home at night. When she was already in bed, she demanded, multiple times, to go with her father to check and to secure that the door was indeed locked. The worry persisted no matter how adamantly the father reassured her that the door was locked and even if they had already checked the door together many times.
The father was desperate. He did not want to aggravate the daughter’s problem by reassuring her again and again that the door was indeed locked. Nor did he want to give in to his daughter’s demands to check the door one more time. He decided to try something out of the ordinary. Next evening at bedtime when the girl started to worry about the door not being locked, the father agreed to check the door with her once. When the girl was back in bed the father surprised her by asking her: “I know we just checked the door but what do you think? Is it locked, or might there be a chance that it is still unlocked?”
“It is locked,” the girl said, reassuring her father that there was no reason to think that the door would not be locked.
Instead of becoming convinced by his daughter’s reassurance, he continued doubting. “Are you sure it is locked? Maybe we didn’t check properly?” he said and continued until the girl started to become annoyed at him and demanded him to stop. The strategy worked. The girl quickly overcame her worry by having to reassure her father that he didn’t need to worry about the door not being properly locked. The father initiated a game to play where he assumed the role of her worry gremlin to allow her to practice and to learn a better way to respond to her worries.
The Anti-Worry Muscle and the Worry-Tackle Game
If you can help your child imagine that her worries are generated by a worry gremlin, you can probably also help him to imagine that there is a skill he needs to be able to calm down her worry gremlin when it becomes overexcited and bombards her with unnecessary worries. You can call this skill-building the “anti-worry muscle” to help your child understand that it is a skill that can be strengthened with practice in the same way that you can strengthen muscles with workouts.
One possibility for doing this, which may seem weird at first, is to play a game with the child that helps him become better at discarding, ignoring, or laughing at silly worries. You can let your child give a name to this game, but for now I will call it simply the “worry-tackle game.” In this game, you take turns with your child to propose worries to each other and to demonstrate that you are each able to tackle these worries.
You should start playing the game by proposing silly worries that are easy to tackle and progress gradually towards worries that are more difficult for the child to overcome. You might start by proposing an absurd worry such as “your nose is going to fall off” or “the sky is going to fall.” When you are confident that your child is able to tackle such silly and easy worries, you can take the game up a notch and start suggesting each other more difficult worries.
For example, you might suggest “if you don’t touch the table three times, your bicycle will have a flat tire tomorrow,” “during the night, a storm will break out and our house will be hit by a lightning unless you turn around three times,” or even “you will get sick unless you wash your hands two times.”
The idea of the game is to ensure that your child learns, by emulating you, to tackle worries with creativity and humor. Possible responses include, among others, saying nothing and just shrugging one’s shoulders or rolling one’s eyes to indicate that one is unaffected by the worry. Another option is to say something along the lines of “Who cares?” “I cannot be bothered,” “Whatever!,” “In your dreams!” or “Give me a break!” The game should be fun for both you and your child. It should be infused with laughter, and every victory — even a small one — should be greeted with a high-five or another similar gesture.
Playing the worry-tackle game with you offers your child an amusing and non-threatening learning experience. It gives him a chance to work out his anti-worry muscle, to develop smarter strategies to respond to worries, and to learn to come to terms with his worry gremlin or her overactive nucleus worrius.
OCD is a common nuisance that countless people all over the world struggle with. It can take many forms, but it always consists of an imaginary fear, which the person tries to defend against using strategies that are not only unhelpful but actually make the problem worse.
Recovering from this ailment requires staying away from unhelpful strategies involving logic, reason, and sensibility and replacing them with creativity, inventiveness and playfulness.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.