A friend approached me recently to discuss her worries about the behavior of her partner's nine-year-old daughter, whom she had noticed counting things "rather obsessively." For as long as my friend had known her, Libby had always had a number of rituals -- laying out clothes in a certain way, following a strict routine before going to bed -- but this was something new. Were her habits related, she wondered, and if so, was she right to be concerned?
I was reminded of a conversation I'd had with another friend, in which we had confessed to the various tics and habits we'd each had as children.
For years she'd been very fussy about the order in which she ate her food, she admitted, while I used to rock myself to sleep at night. Talking to other friends on the subject, a whole raft of unusual childhood behavior was exposed: everything from avoiding the cracks in the pavement (all that "break your mother's back" malarkey can have serious repercussions on the childhood mind, apparently) to the brief period during which my sister pulled out some of her eyelashes and hair. We had all grown out of these rituals with no apparent consequences, but did that mean that my friend wasn't right to be concerned? Was there a link between behavior like this and obsessive-compulsive disorder (OCD)?
ILLUSTRATION: YU SHA
"Many children have stages where they have a rigidity about their behavior, and they simply grow out of the phase," said Allan Norris, consultant clinical psychologist at Birmingham's Nuffield Hospital in central England, when I questioned him about possible parallels. "It doesn't mean that a child who insists on things being a certain way, or has certain rituals, has OCD or is going to develop it."
However, Mitzi Waltz, author of Obsessive-Compulsive Disorder -- Help for Children and Adolescents, and an OCD sufferer herself, believes that children displaying even apparently harmless tics and habits should be monitored. "You can do things to help children who are on that borderline to be more flexible," she says. "Then it's the kids who can't manage to be flexible despite their best efforts who may be getting into problem territory."
Waltz was five when she first fell under the influence of her OCD. She had always been a "picky child." Foods, for example, could not touch on the plate. But whereas such things made sense to her childhood mind, aged five or six she embarked upon "nonsensical" behavior that she now knows was the onset of OCD. "I was making lists of all the dogs in the neighborhood and I had to know every single one. On the way to school I would pass several fences and I would have to count the fence posts. If I missed out, if my attention wandered, I'd have to go back to the beginning."
How a child feels about their ritualizing can be a good indicator of whether or not their behavior is a problem, says Isobel Heyman, consultant child psychiatrist and head of Maudsley Hospital's OCD Clinic for Young People in London. "What is very different with the child with OCD is not only does [a ritual] become more intrusive and more frequent, but often they recognize that what they're doing doesn't really make sense, and it annoys and upsets them," she says.
Of course, not all children can articulate this feeling. Waltz's only explanation of her childhood rituals (they suddenly stopped when she was about 11) was that she "had to." It wasn't until her OCD reappeared in adulthood that she recognized it, understood what it was and was able to seek medical help.
Both Waltz and Heyman stress that it is important for parents not to indulge a child in their rituals, no matter how harmless they might initially seem. Heyman tells the story of a mother whose son had started checking the contents of his bag before school, unpacking and repacking it each time. As this was taking longer and longer to do -- another sign that ritualizing is becoming problematic -- the mother began to do a couple of the checks herself, while her son was getting ready, so that they'd get through it more quickly. Because OCD often sets in gradually, many parents, notes Waltz, "become really enmeshed in the rituals." This can "give meaning to and reinforce them," agrees Heyman, articulating the child's mindset: "If a parent is helping me then it must be important that I do this."
Statistics reveal that one per cent of young people will suffer from OCD; while over half the adults who seek help for it had it (often undiagnosed) as children. In general, OCD responds well to treatment -- usually a course of cognitive behavioral therapy (CBT), which helps patients to understand that their anxieties about what might happen if they fail to complete their rituals are unfounded, and/or anti-anxiety medication. The earlier it is "caught," argues specialist charity OCD Action, the less those who have it will suffer in later life. It's a theory that's hard to argue with.
Chloe Upcraft, 13, has just completed treatment for OCD. The condition is often exacerbated by stress. ("I wouldn't ever say it was the cause," advises Heyman, "but I think it can be a factor that can make OCD emerge, or make it worse.") Chloe's symptoms coincided with her being bullied at school.
The shift in her behavior was sudden and extreme -- she felt impelled to do things in fours, from checking the lock on the front door and opening and closing the curtains, to locking her four dogs in separate rooms -- and her mother promptly took her to see their family doctor, who assessed and referred Chloe to Heyman's clinic.
Swift diagnosis and treatment have meant that Chloe has been successfully treated within about six months of her OCD first occurring. She feels "like a completely new child. My mum says she's got back the Chloe she knew. Before, I would just sit in my bedroom, shaking. I couldn't let anybody in."
Chloe's brush with OCD clearly required expert treatment, but it's less easy to know how to deal with "borderline" ritualizing behavior. Heyman advises parents to "try ordinary measures to help them stop by just gently moving them on, or encouraging them to do something else instead. It's worth considering how much a child's actions interfere with the rest of their life -- the more it gets in the way, the more there may be something to worry about." If in doubt, she advises, consult a doctor.
My parents had been worried about my sister's hair-pulling (which, I remember, she was less than thrilled about herself), but they didn't visit the doctor. Rather, they gently discouraged her from her absent-minded plucking (she wasn't, she said, even aware that she was doing it) and gave her a necklace with a large pendant to rub, as a way of diverting her attention.
The combination seemed to work -- she stopped and never did it again. As for my pre-slumber habit, I don't think they were ever really concerned by it at all.
One of my aunts, my mother told me, had rocked herself to sleep; she grew out of it and they suspected (correctly) that I would, too.
For similar reasons, my friend's partner currently prefers to monitor rather than act on the change in his daughter's behavior, for he used to count when he was a boy, just as she is doing now.
Such knowledge can, in fact, be reassuring for parents, as Heyman notes: "Something that adults in the family have had in childhood and that they've grown out of is, in a sense, very positive. The chances are that if it's the same in your child they're going to grow out of it as well."
It is also good to remember, notes Heyman, that a certain degree of "obsessionality" is typical in young children: "The last thing one wants people to get worried about is a perfectly normal phase of development."
NOTE: Some names have been changed. For further information, contact OCD Action at: www.ocdaction.org.uk
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