Teaching Students With Obsessive-Compulsive Disorder

Teaching Students With Obsessive-Compulsive Disorder MELISSA LEININGER, TINA TAYLOR DYCHES, MARY ANNE PRATER AND MELISSA ALLEN HEATH Obsessive-compulsive disorder (OCD) is a neurobiological condition affecting 1 of every 200 school-age children. OCD greatly affects students’ academic, behavioral, and social functioning, and it can lead to additional problem such as depression. To effectively collaborate with other individuals providing appropriate support to students with OCD, teachers need to understand this disorder, particularly its manifestations in school settings. This article addresses typical manifestations of OCD in school settings and provides general and specific accommodations for teachers to implement in their classrooms. Keywords: obsessive-compulsive disorder; disabilities; classroom techniques; academic accommodations O bsessive-compulsive disorder (OCD) is a neurobiological condition that typically emerges during adolescence or young adulthood, although younger children may also manifest symptoms (Adams, 2004; American Psychiatric Association [APA], 2000; Piacentini & Bergman, 2000). It is the fourth most common pediatric psychiatric disorder in the United States (Adams & Burke, 1999), and one third to one half of adults with OCD report childhood onset (Rasmussen & Eisen, 1990). Frequently cited studies indicate that OCD affects 1 in 200 school-age students (Flament, 1990; Flament et al., 1988), which is approximately three to four students in an average-size elementary school or up to 20 students in a large high school (March, Leonard, & Swedo, 1995). Although some research has cited OCD prevalence rates ranging from 1% to 4% for children and adolescents (Zohar, 1999), more recent epidemiological research has indicated that it affects .25% of children ages 5 to 15 (Heyman et al., 2001). Some of the difference in cited prevalence rates may be due to (a) significant increases in prevalence as children reach adolescence (Heyman et al., 2001), (b) differences between clinic-referred and nonreferred populations Intervention in School and Clinic, Volume 45 Number 4, March 2010 221-231 DOI: 10.1177/1053451209353447 • © 2010 Hammill Institute on Disabilities http://isc.sagepub.com hosted at http://online.sagepub.com Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 221 222 Intervention in School and Clinic (Zohar, 1999), (c) incorrect diagnosis (March et al., 1995), (d) differences between self-report and clinicianadministered measures (Stewart, Ceranoglu, O’Hanley, & Geller, 2005), and (e) disguising of symptoms by children and adolescents (Leonard, Ale, Freeman, Garcia, & Ng, 2005; Penn & Leonard, 2001). If teachers are to effectively support students affected by OCD, they need to be informed about this complex disorder (Adams, 2004). However, students with OCD often attempt to keep people, including peers and teachers, unaware of the disability by trying to hide their symptoms (APA, 2000; Purcell, 1999). Yet, these students must deal with their OCD symptoms daily, including the impact on their schoolwork. In fact, a recent study of 5- to 17-year-olds indicated that the two most common problems resulting from OCD in this age group were school related: (a) concentrating on schoolwork and (b) completing homework (Piacentini, Bergman, Keller, & McCracken, 2003). Obsessive compulsive disorder is characterized by obsessions and compulsions that are time consuming (taking more than 1 hr per day) and cause marked distress, anxiety, or impairment in functioning (APA, 2000). Obsessions are intrusive, repetitive, and distressing thoughts. In an attempt to ignore, suppress, or neutralize these thoughts, the individual develops coping behaviors, referred to as compulsions. Though not well understood by others and thus seemingly illogical, compulsions are repetitive ritualistic behaviors, such as repeatedly washing hands or erasing written work (APA, 2000). Obsessive compulsive disorder is a chronic condition with symptoms that wax and wane (APA, 2000; Franklin & Foa, 1998; Leonard et al., 2005; Penn & Leonard, 2001), meaning that an individual’s symptoms are inconsistent across time. For instance, a student typically obsessed with hand washing, as evidenced by cracked and raw skin, may have several weeks of only washing hands occasionally. This period of reprieve is then followed by a reemergence of excessive hand washing. Obsessive behaviors are affected by stress, which exacerbates symptoms (APA, 2000; Penn & Leonard, 2001). Rettew, Swedo, Leonard, Lenane, and Rapoport (1992) studied 79 children and adolescents with OCD and provided illustrative case examples. One of these case studies described a 14-year old boy who, after moving to a new neighborhood at age 4, began washing his hands repeatedly. The hand washing subsided and disappeared after 6 to 8 months. No obsessive behaviors were observed until he started junior high school. At age 12, the boy exhibited multiple obsessive fears; specifically, he compulsively checked the light, TV, and radio switches and repeatedly erased and corrected his handwriting. In addition to his new compulsive behaviors, his washing compulsion surfaced. With prescribed medication, the boy’s washing compulsions subsided but increased in severity during high school. At the study’s conclusion, the young man was enrolled in college, only mildly troubled by aggressive obsessions and compulsions. The study concluded that his numerous OCD symptoms changed in content and severity over time. Although the exact causes of OCD are unknown, most evidence indicates that it is an anxiety disorder caused by a chemical imbalance in the brain (Adams, 2004; APA, 2000; March, Frances, Carpenter, & Kahn, 1997; Paige, 2007; Piacentini & Bergman, 2000; Wagner, 2002). Other factors that may influence the development of OCD include genetics (Cameron & Region, 2007), viral infections (National Institute of Mental Health, 2008), and stressful life events (Piacentini & Bergman, 2000). And although there is no known cure for OCD, existing treatments help control its symptoms (Wagner, 2002). In particular, cognitive behavior therapy (CBT) and medication have demonstrated effectiveness in reducing OCD symptoms in children and adolescents (Cameron & Region, 2007; Carter & Pollock, 2000; Piacentini & Bergman, 2000). With CBT, individuals are gradually exposed to their fears and anxieties while being instructed to refrain from compulsive behavior. They are taught to identify and correct dysfunctional beliefs and evaluate the likelihood of feared consequences (Cameron & Region, 2007; Piacentini & Langley, 2004). Selective serotonin reuptake inhibitors (SSRIs) such as Zoloft, Prozac, and Luvox are often the pharmacological treatment for OCD in children (Cameron & Region, 2007; Wagner, 2002) because they help reduce anxiety. Within the past few years, Riluzole has proven effective in reducing glutamate production, which essentially turns down the brain’s warning sensors (Pittenger et al., 2008); however, pharmacological studies for Riluzole have not included children. The Pediatric Obsessive Compulsive Disorder Treatment Study Team (2004) and the OCD Expert Consensus Guidelines (March et al., 1997) recommend beginning treatment for OCD with CBT alone or in conjunction with an SSRI. The sole treatment of CBT is preferred for children and adults with milder OCD symptoms (March et al., 1997). Other researchers have suggested that SSRIs should not be administered to children or adolescents unless they have co-morbid disorders or when CBT has not been effective (Sloman, Gallant, & Storch, 2007). Although evidence exists for the efficacy of these SSRIs in older children and adolescents, less is known about their effectiveness in preschoolers and younger children (Cameron & Region, 2007; Carter & Pollock, 2000). Also, CBT for OCD in children and adolescents has only recently received empirical support (March, Franklin, & Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 Leininger et al. / Teaching Students with OCD Foa, 2005). Freeman et al. (2007) conducted a qualitative review of child CBT research and found no treatment studies examining OCD in children younger than 7 years old. Most of the studies also examined the efficacy of CBT in conjunction with medication. Therefore, findings from many studies may not generalize to younger children, who are less likely to be prescribed medication. Understanding Students With OCD Because OCD behaviors can be easily misunderstood, teachers should learn to recognize when a student may have OCD tendencies. An increased awareness of symptoms can lead to early interventions, decreasing the negative impact of OCD on learning (Cameron & Region, 2007; Freeman et al., 2007). Students with OCD typically perform well below their potential in areas of academic achievement (Parker & Stewart, 1994). This decline in schoolwork often occurs because symptoms of OCD are interfering with concentration and productivity (APA, 2000). For example, some students may have trouble getting to school on time because of countless morning rituals they perform to get ready for school. Some students may not be able to finish their homework because they are frequently erasing, redoing, and perfecting their work. Some students may have anxiety attacks during tests or become too depressed to attend school (Purcell, 1999). Students with OCD tend to have more learning disorders—specifically, nonverbal learning disabilities (Adams, 2004)—than those without OCD. This means that although some students with OCD may have adequate verbal skills in language, reading, and spelling, they may struggle with tasks that require visual-spatial skills, such as mathematics and handwriting. Also, OCD can exacerbate a preexisting learning disorder and cause problems with attention and concentration (APA, 2000; March et al., 1997). In the classroom, OCD may resemble attention-deficit-hyperactivity disorder (ADHD) or oppositional behavior (Carter et al., 1999; Schlozman, 2002). Students with OCD may have trouble paying attention in class because they have a hard time disengaging from their own thoughts or are involved in mental rituals in response to their obsessions. They may also try to avoid or delay carrying out a compulsive behavior (Adams & Burke, 1999; Paige, 2007). When students stare out a window or hover over a worksheet in a daze, the teacher could interpret these behaviors as “inattentive, lazy, or even defiant” (Adams & Burke, 1999, p. 5). In some cases, these off-task behaviors are related to a student’s OCD, and if they are properly treated, may subside (March et al., 1997). 223 Obsessive compulsive disorder also affects the social functioning of students (Adams & Burke, 1999). They may struggle with processing social-emotional information, which negatively affects friendships and interpersonal skills (Adams, 2004; Adams & Burke, 1999). As students with OCD are often bullied or victimized because of their compulsive behaviors, they take great measures to hide their compulsions from peers, which may increase their social isolation (Adams & Burke, 1999; Adams, Waas, March, & Smith, 1994; Paige, 2007). Additionally, rituals are time consuming and mentally exhausting, leaving children and adolescents little time or energy for friends (Adams & Burke, 1999). Character traits of individuals with OCD that interfere with performance include incessant worry, excessive expectations, dissatisfaction with results, competitiveness, procrastination, need for control, and self-criticism (Parker & Stewart, 1994). Teachers must carefully note when such behaviors significantly interfere with students’ functioning because misunderstanding students with OCD often leads to their discouragement, frustration, and depression. It also leads to nonidentification of the disorder or mistaken labeling of students with OCD, as well as ineffective academic and behavioral interventions (Parker & Stewart, 1994). Teachers should not assume, however, that any student engaging in the behaviors described earlier in this article has OCD. Many children exhibit developmentally appropriate, typical behaviors that are somewhat similar to OCD behaviors (Adams & Burke, 1999), such as bedtime rituals (e.g., getting tucked in or hearing a story), childhood ritual games (e.g., “step on a crack and break your mother’s back”), or having things done “just so” (Adams, 2004; Boucher, 1999). These can be comforting and help children overcome separation anxiety and deal with the developmental issues of mastery and control (Adams, 2004; Boucher, 1999; March & Leonard, 1998). These OCD-like behaviors usually disappear by middle childhood and tend to be replaced by collections, hobbies, and focused interests (March & Leonard, 1998). One way teachers can distinguish OCD from similar but more developmentally appropriate behaviors is to remember that OCD “occurs somewhat later in development, appears bizarre to adults and other children (if not to the affected child) and produces dysfunction, rather than mastery” (Adams & Burke, 1999, p. 4). For example, it is appropriate for 2- to 3-year-old children to follow typical developmental routines for eating, bathing, and bedtime (Francis & Gragg, 1996), whereas strict adherence and insistence in following such routines and rituals at later ages may be cause for concern. Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 224 Intervention in School and Clinic Obsessive-compulsive behaviors are distinctly different from typical developmental behaviors (Francis & Gragg, 1996). Unlike students with typical ritual behaviors, students with OCD have obsessions and compulsions that are all-consuming and fears that they may never outgrow (Black, 1999; Schlozman, 2002). These obsessions are not simply excessive worries about reallife problems (APA, 2000). Teachers should realize that “neatness and correctness are virtues; unnecessary erasing, redoing, and the inability to accept mistakes are concerns” (Parker & Stewart, 1994, p. 570). Teaching Children and Adolescents With OCD positive and negative effects of medications (Adams & Burke, 1999; Adams et al., 1994; Carter et al., 1999; Dornbush & Pruitt, 1995; Purcell, 1999). Teachers should be aware of side effects of medications. Negative side effects include sedation, insomnia, stomach and intestinal upsets, increased or decreased appetite, and restlessness. More serious side effects include elevated heart rate, dizziness, blackouts, psychiatric symptoms, and seizures (Adams & Burke, 1999). Teachers are cautioned to report accurate information so the students’ health care providers can make medication adjustments as necessary; it is not the teacher’s responsibility to suggest changes in medication or health care services. Teachers’ attitudes are critical to the success of students with OCD. Teachers will be more successful when they understand that students who manifest obsessivecompulsive behaviors are often trying to do their best and that coping with their symptoms is not simply a matter of willpower (Carter et al., 1999; Parker & Stewart, 1994). Teachers should recognize that these students often have low self-esteem and need additional positive attention (Adams, 2004). One of the most important ways teachers can help students who exhibit obsessive-compulsive behaviors is to recognize symptoms of the disorder. If students’ compulsions are impeding their academic or social skills, the teacher needs to seek help from specialists to identify the problem as well as find solutions to promote academic and social success. Students who are diagnosed with OCD may qualify for services under General Classroom Strategies Section 504 of the Rehabilitation Act or special education services under the Individuals with Disabilities Although students with moderate to severe OCD may Education Act ([IDEA]; Adams, 2004; Adams & need services beyond what teachers can provide, such as Burke, 1999; Black, 1999). In the past, students with CBT or medical treatments (Heyman, Mataix-Cols, & OCD have been classified under IDEA’s emotional Fineberg, 2006), teachers can implement many simple disturbance category. OCD is now most often classified strategies to help students with OCD. The following under other health impairment as a neurobiological strategies are not only applicable to students with OCD disorder (Adams, 2004). General and special education but helpful for other students in the classroom (Parker & teachers should be familiar with state and federal regu- Stewart, 1994). Before determining which strategies to lations to provide evidence-based instruction, adapta- use, teachers should consider each student’s unique tions, and accommodations. characteristics (Carter et al., 1999) and collaborate freAnother important way teachers can help students quently with parents to exchange observations, progress with obsessive-compulsive symptoms is by collaborating reports, and advice (Black, 1999). with parents and professionals (Paige, 2007). Teachers Establish rules and expectations. Rules and expectamay be asked to provide information from classroom observations of students’ academic and behavioral func- tions for all students should be consistent and stated tioning to their parents, school psychologist, or school positively rather than negatively (Dornbush & Pruitt, counselor (Purcell, 1999). School personnel should edu- 1995). Because students with OCD frequently worry cate parents about OCD and provide information regard- about doing something wrong, a nonpunitive, positive ing services offered by the school and community approach to discipline can provide needed security and (Paige, 2007). If a student with OCD qualifies for ser- comfort (Boucher, 1999). For example, a teacher should vices under IDEA, the special education team would not threaten or severely punish a student with OCD for also become involved (Adams et al., 1994; Black, being tardy or for forgetting a homework assignment 1999). Teachers should consult with the school psy- (Black, 1999) but instead should recognize such behavchologist or school counselor to develop interventions, iors as related to the student’s OCD (Adams, 2004; monitor progress, and evaluate interventions (Adams Black, 1999). In a nonpunitive, positive approach, the teacher would not call attention to students’ tardiness et al., 1994; Carter et al., 1999). Teachers also may be asked by parents or health care but welcome them to school. The teacher could also professionals to monitor, document, and report both allow students to submit their homework after school or Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 Leininger et al. / Teaching Students with OCD the next day. However, students with OCD should still experience natural consequences for problem behaviors not related to their OCD (Adams, 2004). Help students transition from one task to another. Transitions can be challenging for students with OCD because they may want to keep working on a task until it is completed to their satisfaction. Teachers may begin teaching the rest of the class and let students with OCD join when they are ready, or they may set a specific time when they can return to the task (Carter et al., 1999; Purcell, 1999). Teachers can also assign the student with OCD less time-consuming tasks that can be confidently accomplished within the given time frame (Boucher, 1999; Dornbush & Pruitt, 1995). Stress can be reduced by providing students with OCD additional structure and guidance during transitional periods (Boucher, 1999; Dornbush & Pruitt, 1995). Students with OCD like predictable routines so they know what to expect in every situation. Having consistent routines, posting the daily schedule, and informing children in advance of changes can help to prevent or alleviate possible stress and provide security for anxious students (Boucher, 1999; Dornbush & Pruitt, 1995). Help students set goals. Many teachers help their students set short-term goals and chart their progress. This is particularly important for students with OCD (Boucher, 1999) because they may have a distorted view of their degree of success. They may also feel threatened when their performance does not meet their expectations or the expectations of others (Parker & Stewart, 1994). Helping students achieve their goals can increase students’ satisfaction with themselves and enhance their sense of control (Boucher, 1999; Parker & Stewart, 1994). Initial success can be used to encourage and facilitate future success, with specific goals that students can reach in 3 to 5 days. Teachers should not expect their students to confront their “worst nightmare” but help them to move toward a reasonable goal in small, nonthreatening steps (Boucher, 1999, p. 216). Promote self-awareness and self-regulation. Selfawareness and self-regulation are skills that teachers of young children in particular regularly teach. It is especially pertinent to students with OCD, particularly when their symptoms reemerge or wane. Teachers can help students with OCD become self-aware by having them record the number of times they feel a need to perform a ritual and the number of times they do not perform that ritual (Boucher, 1999). Students with OCD can keep a daily journal of thoughts and worries and then discuss them with the teacher at the end of the day. Teachers can 225 ask questions such as, “Did things go O.K., even though you were worried about them?” or “Did you need to write the item down more than once?” (Boucher, 1999, p. 214). Teachers can help students notice their positive thoughts and accomplishments and use these to build their self-esteem and work toward goals (Boucher, 1999). Teachers can also help students with OCD develop internal control by teaching them to talk themselves through difficult situations and by helping them recognize what they attend to, how they evaluate different events, and how they identify expectations about their capacity to handle stress (Boucher, 1999). Teachers can also help students identify antecedents to anxious behavior (i.e., recognize triggering situations) and teach them coping strategies to manage anxiety and foster selfregulation. For example, if a student tends to become anxious during testing situations, a teacher can show the student how to set aside time to prepare for the test and coach him or her in strategies for answering true/false, multiple choice, and essay questions (Boucher, 1999). Teach decision-making skills. Although many professionals encourage giving children choices, teachers have to consider carefully the choices given to students who manifest obsessive-compulsive behaviors, as they may have trouble making decisions (Carter et al., 1999). Teachers should limit the number of options available and not force students to make decisions with which they are not comfortable (Boucher, 1999; Carter et al., 1999). Teachers can foster students’ skills and confidence in decision making by teaching positive steps (e.g., ask questions, gather information, list benefits/consequences) and by role-playing effective decision making. They can then reinforce students’ positive choices (Boucher, 1999). Specific Strategies for the Classroom Students with OCD often have trouble with the following specific issues related to school. By using appropriate strategies, teachers may reduce the stress and anxiety that accompany these difficult situations for students who display obsessive-compulsive behaviors. See Table 1 for examples of specific strategies to facilitate student success in the classroom. Help alleviate stress during anxiety-provoking situations. Learning experiences should be structured to reduce the chance of failure, particularly for students with OCD, who can become overwhelmed by excessive demands they place on themselves or by their fears or anxieties in certain situations. Teaching individual or class relaxation exercises (involving techniques for breathing control or muscle relaxation) and modeling ways to accept and deal Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 226 Intervention in School and Clinic Table 1 Specific Teaching Strategies for Students With OCD Area of Concern Sample Strategies Anxiety-provoking situations Reduce chance of failure on learning tasks. Model acceptance of mistakes. Make a list of people the student can talk to when he or she feels overwhelmed or anxious. Praise on-task behavior. Ignore reassurance requests or bring attention to what the student is doing and have him or her determine why the worry is unnecessary. Give students another task to complete. Provide encouragement to keep them working on a task. Allow students to take a short break. Provide the student with an outline of the class lecture. Allow the student to complete his or her work orally or on tape, tell his or her responses to an adult or peer writer, or type his or her responses on a computer. Give simple directions and break down complex tasks. Teach strategies for effective learning and have the student create a strategy notebook. Create contracts for long-term assignments and homework, including time estimates. Provide extra time or alternate locations for testing. Allow the student to demonstrate knowledge with alternative assessments. Reassurance seeking Getting stuck Written assignments Completion of assignments Testing Note: OCD = obsessive-compulsive disorder. with mistakes are strategies teachers can use to alleviate students’ anxiety and stress (Adams et al., 1994; Parker & Stewart, 1994; Purcell, 1999). Students can also be taught how to talk themselves through difficult situations. Another helpful activity is to make a list of people students with OCD may talk with about their fears and concerns. Safe people may include the school counselor or psychologist, school nurse, principal, or another teacher with students can check in whom for 5 to 10 min when feeling overwhelmed or anxious (Boucher, 1999; Dornbush & Pruitt, 1995). Because students with OCD may have low self-esteem (Adams, 2004), teachers should remind them of their strengths and talents and call attention to their accomplishments (Black, 1999; Boucher, 1999). For example, teachers can mark correct, rather than incorrect, answers (Dornbush & Pruitt, 1995). Classroom activities should be monitored so teachers can prevent peers from teasing a student with OCD (Boucher, 1999). Teachers should be caring, empathic, and supportive—developing close relationships with students with OCD so they feel comfortable coming to school (Black, 1999; Boucher, 1999). Teachers can help students with OCD who isolate themselves from their peers become socially involved in the classroom. They can facilitate friendships by providing structured social activities (Wagner, 2005). They can also set up cooperative learning groups and assign group projects that focus on effective communication and group goals rather than on individual performance (Parker & Stewart, 1994; Purcell, 1999). Rather than consistently letting children choose their own groups, teachers should form groups by counting off or by structuring and assigning them (Adams, 2004). Ignore reassurance requests. Students with OCD often request verbal reassurance about their fears (APA, 2000; Heyman et al., 2006). Teachers should not provide this reassurance because doing so reinforces students’ compulsive reassurance seeking. Teachers should praise on-task behavior and either ignore reassurance requests (Adams et al., 1994; Boucher, 1999) or bring attention to what the student is doing and have him or her determine why the worry is unnecessary. Teachers could keep track of how many times a student asks for reassurance to make him or her more aware of its frequency (Boucher, 1999). Help students get unstuck. When students with OCD get trapped in their obsessions and compulsions, teachers can help them switch to another task or provide encouragement to them to keep working on a task despite obsessive-compulsive symptoms (Carter et al., 1999). For example, if a teacher notices a student is erasing his or her answers excessively, the teacher can provide assistance by attending to the task rather than the compulsive behavior. The teacher can redirect the stuck behavior by reminding the student of the learning goal and, if needed, giving alternate options to reach that goal (Boucher, 1999). Students with OCD may need to take short breaks because pressures can build quickly and overwhelm them. Having their desk close to the door will allow students with OCD to leave the classroom without others noticing (Carter et al., 1999; Dornbush & Pruitt, 1995), and so they can clear their head quickly. Teachers can also set up a signaling system by which students use a green hand signal when they are hopelessly stuck in a ritual and need the teacher’s help and use a red signal when they are trying to handle the problem on their own (Purcell, 1999). Help students with written assignments. Students with OCD may spend so much of their time erasing and Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 Leininger et al. / Teaching Students with OCD rewriting their assignments or checking and rechecking to have everything exactly right that they may not complete their school work (Parker & Stewart, 1994). They may also miss large amounts of information because they try to write down everything the teacher says. This issue of missed information is of particular concern for students in junior high and high school, for whom there is an increased expectation regarding taking notes in class. Teachers can provide students who have difficulty taking notes with an outline of class lectures (Adams et al., 1994; Parker & Stewart, 1994; Purcell, 1999). They can also teach specific note-taking techniques. The SQ3R (Survey, Question, Read, Recite, Review) and the Cornell system of note taking (Record, Reduce, Recite, Reflect, Review) are effective strategies that may benefit all students (Parker & Stewart; Purcell, 1999). Teachers can allow students to complete their work orally, put their responses on tape, tell their answers to a peer or adult writer, or type their assignments on the computer (Adams & Burke, 1999; Carter et al., 1999; Dornbush & Pruitt, 1995). For some types of assignments, students can be given options such as creating a poster, making a model, or giving an oral presentation instead of writing a paper (Dornbush & Pruitt, 1995). Some students may feel anxious about presenting or speaking in front of the class, and teachers should not require a student with OCD to do so (Boucher, 1999). Assignments can be graded on content instead of handwriting, punctuation, or spelling, reducing students’ anxiety about having everything written perfectly (Dornbush & Pruitt, 1995). Help students stay focused and complete assignments. Students with OCD have trouble completing tasks that require concentration because their obsessions are intrusive, distracting, and very disruptive to their overall functioning (APA, 2000). Providing simple directions and breaking down complicated tasks into smaller steps can help students focus on important parts of assignments (Boucher, 1999). Creating a signal to alert students that instructions are going to be given and writing directions and assignments on the board are helpful as well (Dornbush & Pruitt, 1995). For students with reading compulsions, audiotapes or digitized recordings of chapters in texts may be made available, a peer or adult can read out loud to the student, or shorter reading passages may be assigned (Adams, 2004; Adams et al., 1994). Teachers can teach students to keep a strategy notebook, where the students record strategies for success when they are completing a difficult task or dealing with a recurring problem. These strategies should be methods 227 that help students independently solve problems. Students may write down the steps to complete a task or term paper, a solution they found for organizing their notebook, or a trick they have discovered for recognizing when to ask for help (Dornbrush & Pruitt, 1995). Teachers should frequently check for students’ understanding to make sure they are paying attention and listening during lessons. Teachers can check every 10 to 15 min by asking questions or having students share with a partner what they have learned so far (Boucher, 1999). Teachers can provide a peer tutor or even set a timer to help students focus and stay on target for in-class assignments (Boucher, 1999; Purcell, 1999). Children with OCD may be fearful of getting in trouble, so teachers should try to seat them away from disruptive children to enable them to concentrate (Dornbush & Pruitt, 1995). Long-term assignments or take-home work should be avoided at first because students may be overwhelmed or spend an excessive amount of time completing assignments. Teachers should monitor students’ in-class work first to help students stay on task, avoid obsessing over details, and stick to a time limit (Parker & Stewart, 1994; Purcell, 1999). When the teacher determines students are ready, contracts for long-term assignments and homework can be created to help them complete assignments on time (Parker & Stewart, 1994). Providing time estimates for each assignment can also help students with OCD stay on target (Wagner, 2005). Teachers can provide structure guides for longer assignments or essay assignments to guide students’ studying and writing (Parker & Stewart, 1994; Purcell, 1999). Setting specific deadlines also provides focus and necessary time limitations for students with OCD (Purcell, 1999). Provide adequate support for testing. Students with OCD may experience anxiety in testing situations. They may spend more time on tests than other students because of their compulsive behaviors or perfectionist tendencies, or they may work quickly through a test to guard against these OCD behaviors. Thus, their test scores may not accurately represent their true abilities and accomplishments (Purcell, 1999). Before making testing accommodations, teachers should check what is allowable under state and test guidelines for standardized and nonstandardized testing situations. Any accommodations made should be included on the student’s individualized education program (if applicable) and used consistently in the classroom prior to the testing situation. Students with OCD may need extra time on tests or alternative locations for testing that are free of distractions (Adams et al., 1994; Carter et al., 1999; Purcell, Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 228 Intervention in School and Clinic Table 2 Recommended Web Site Web Sites Anxiety Disorders Association of America www.adaa.org/GettingHelp/ AnxietyDisorders/ OCD.asp National Alliance on Mental Illness www.nami.org/Content/ ContentGroups/Helpline1/ Obsessive_Compulsive_ Disorder_(OCD).htm National Institute of Mental Health www.nimh.nih.gov/health/ topics/obsessivecompulsive-disorder-ocd/ index.shtml National Mental Health Association www.nmha.org/go/ocd Obsessive Compulsive Foundation www.ocfoundation.org OCD Education Station www.ocdeducationstation .org including those with OCD, will experience greater success in school. Description General information about OCD and anxiety disorders in children and adolescents, treatment options, and criteria for choosing a therapist. Free downloadable brochure about OCD and self-screen for OCD. Information on manifestations and causes of OCD, medication, and behavior therapy. Hotline telephone number and free downloadable guide. General information about OCD and instructions for locating services. Information also available in Spanish. Description of characteristics, causes, and treatment of OCD. Crisis center hotline telephone number. OCD questions and answers, free downloadable brochure, online database of OCD therapists, instructions for finding a local support group. Facts about OCD, recognizing OCD at school, role of school personnel, tools and resources, and success stories. Free downloadable OCD guides. Note: OCD = obsessive-compulsive disorder. 1999). Teachers can be supportive of students who have excessively high expectations by using alternate forms of evaluation, as well as emphasizing the importance of knowledge over grades (Parker & Stewart, 1994; Purcell, 1999). Some alternate forms of assessment include administering tests orally, having students respond orally, or designing a shorter form of the test (Boucher, 1999). Because students’ OCD symptoms fluctuate, educators must be flexible and adjust their expectations accordingly (Dornbush & Pruitt, 1995; Purcell, 1999). Some weeks and months may be better than others, but teachers should understand that they may have to implement these classroom strategies indefinitely because OCD is chronic, and some students may never fully manage or overcome its symptoms (Purcell, 1999). Resources for teachers and students are available on many Web sites (see Table 2). However, even with the outside support and available resources, teachers’ attitudes are a key element in helping students with OCD. When teachers are compassionate, positive, understanding, and willing to implement individual strategies, all students, Case Study The following case study is presented as an illustration of what an elementary school teacher may do throughout the school day to facilitate the academic and social success of a student with OCD. All names are pseudonyms. Zachary is a 10-year-old boy in fourth grade. Classmates and teachers note that he likes everything to be just right. This is most noticeable with his writing because he frequently erases and rewrites. His teacher, Mrs. Vera, meets frequently with the school psychologist and his parents to discuss Zachary’s needs and to develop and evaluate academic and social interventions. This morning, Mrs. Vera welcomes her students and reviews the class schedule posted on the whiteboard. Yesterday she talked with Zachary and his parents about a change in the usual schedule—an afternoon assembly. Advance preparation for change helps reduce Zachary’s anxiety. Afterward, the students gather in their reading groups to work on poster presentations based on the book they have recently finished reading. Mrs. Vera places Zachary with an understanding and patient group of students. Artistic Zachary prefers to draw illustrations with a compatible classmate; the two other students in the group are assigned to write information on the poster. Before transitioning to social studies, Mrs. Vera gives the class a 10-min warning to clean up and prepare for their next activity. Zachary is permitted to take longer if he needs to and join the class as soon as he is ready. As he joins the class, Mrs. Vera gives Zachary a copy of the brief outline given to all students regarding what they will be learning in social studies and encourages the students to highlight important points. After the lesson, the students begin writing their reports on counties in their state. Each student is given a paper with step-by-step instructions on how to begin the report. Mrs. Vera goes over the instructions with the whole class, giving an estimated time frame for completing the in-class report. As the students begin their work, Mrs. Vera checks with Zachary to make sure he understands the instructions. Zachary begins to feel anxious and distressed as he works on his assignment. He puts a card on his desk, signaling Mrs. Vera that he needs a break. He then leaves the classroom, talks with the school psychologist for a few minutes to calm down, and then returns to class. At lunch time, Mrs. Vera reminds Zachary’s lunch group that it is their turn to eat with her in the classroom. Zachary has formed friendships with the students in his Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 Leininger et al. / Teaching Students with OCD lunch group, and they often play together at recess. Mrs. Vera reminds the recess monitor to keep an eye on Zachary and to check in with her before picking up the class from lunch recess. After lunch, the students begin their math lesson, starting their first day of long division. Because this is a complicated computation, Mrs. Vera has broken down the division process into simple steps. She has written these on a poster, and as she teaches each step, she has the students write the steps in their notebooks for future reference. Zachary has been assigned a peer tutor who sits next to him. Initially, the tutor checks in with Zachary to make sure he understands what to do. While working, Zachary repeatedly goes to Mrs. Vera, checking to see if his numbers look right and are lined up correctly. Mrs. Vera ignores these attention-seeking requests but praises his on-task behavior when she sees him working at his desk. After the class completes their math work and takes a short break, it is time for a science test. Zachary is given time to refer to his strategy notebook, where he has written down test-taking strategies that Mrs. Vera has coached him to use. He no longer needs to be tested in a separate room with a parent volunteer serving as his scribe for questions that require more writing than he can comfortably complete. He is given more time to finish his test and joins his class in the auditorium for the assembly. Mrs. Vera explains the homework assignment at the end of the school day. Each student has a homework sheet, and Mrs. Vera asks her students to write how much time they should spend on each assignment. As the students clean up, Mrs. Vera pulls Zachary aside to review his goal for the week. He has set the goal of staying within 10 min of the time limit for his homework assignment. Because he successfully met his goal for last night’s homework, he is allowed to place a check mark on his goal chart. Mrs. Vera comments on Zachary’s hard work and writes a quick progress note for Zachary to take home and share with his parents. Summary The mental health of students is an essential part of their well-being and affects physical health, social relationships, and academic achievement. School professionals encounter children’s mental health issues on a regular basis. For instance, over the past year, the parents of 15% of children ages 4 to 17 discussed their 229 child’s behavioral or emotional difficulties with a health care provider or school staff, and 5% of students received medication for these difficulties (Simpson, Cohen, Pastor, & Reuben, 2008). Although ADHD is most frequently a topic of concern for teachers, students with OCD are also at high risk for academic and social failure because of the debilitating nature of their symptoms. These obsessions and compulsions can interfere significantly with their academic and social success in school. In a school setting, students with OCD are educated with various levels of support. School-based interventions may include individual or group counseling, CBT coordinated with community-based services, special education services, or accommodations and adaptations provided by general education teachers. Working collaboratively with other professionals, teachers play a critical role in promoting and facilitating the academic achievement and adaptive social functioning of students with OCD. Some strategies that are effective with most students (e.g., teaching decision-making skills, goal setting) are also effective with students with OCD. Teachers can use these strategies as well as other strategies more specifically designed to address issues and concerns of students with OCD (e.g., helping students get unstuck, ignoring reassurance requests). With compassion, understanding, and a willingness to make individualized adaptations, teachers can create safe, positive classroom environments that will decrease anxiety and increase the academic and social success of students with OCD. About the Authors Melissa leininger, BS, is a graduate student in the School Psychology Education Specialist program at Brigham Young University. Her current interests include bibliotherapy and working with families raising children with disabilities. Tina Taylor Dyches, EdD, is an associate professor of special education at Brigham Young University. Her research interests include family adaptation to disability, children’s literature, and multicultural issues in autism. Mary anne Prater, PhD, is a professor and chair of counseling psychology and special education at Brigham Young University. Her current interests include children’s literature, multicultural special education, and teacher preparation in special education. Melissa allen Heath, PhD, is an associate professor in the Department of Counseling Psychology and Special Education at Brigham Young University. Her current interests include school-based crisis intervention, grief, and bibliotherapy. References Adams, G. B. (2004). Identifying, assessing, and treating ObsessiveCompulsive Disorder in school-aged children: The role of school personnel. Teaching Exceptional Children, 37(2), 46–53. Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 230 Intervention in School and Clinic Adams, G. B., & Burke, R. B. (1999). Children and adolescents with Obsessive-Compulsive Disorder. Childhood Education, 76(1), 2–7. Adams, G. B., Waas, G. A., March, J. S., & Smith, M. C. (1994). Obsessive Compulsive Disorder in children and adolescents: The role of the school psychologist in identification, assessment, and treatment. School Psychology Quarterly, 9, 274–294. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Black, S. (1999). Overcome by fear. The American School Board Journal, 186(3), 31–34. Boucher, C. R. (1999). Students in discord: Adolescents with emotional and behavioral disorders. Westport, CT: Greenwood. Cameron, D. L., & Region, C. H. (2007). Obsessive-Compulsive Disorder in children and adolescents. Journal of Psychiatric and Mental Health Nursing, 14, 696–704. Carter, A. S., Fredine, N. J., Findley, D., Scahill, L., Zimmerman, L., & Sparrow, S. S. (1999). Recommendations for teachers. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome—Tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 360–369). New York: Wiley. Carter, A. S., & Pollock, R. A. (2000). Obsessive-compulsive disorder in childhood. Current Opinion in Pediatrics, 12, 325–330. Dornbush, M. P., & Pruitt, S. K. (1995). Teaching the tiger: A handbook for individuals involved in the education of students with attention deficit disorders, Tourette syndrome or obsessivecompulsive disorder. Duarte, CA: Hope Press. Flament, M. (1990). Epidemiology of obsessive-compulsive disorder in children and adolescents [French]. Encephale, 16, 311–316. Flament, M. F., Whitaker, A., Rapoport, J. L., Davies, M., Berg, C. Z. Kalikow, K., et al. (1988). Obsessive compulsive disorder in adolescence: An epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 764–771. Francis, G., & Gragg, R. A. (1996). Childhood obsessive-compulsive disorder. Developmental Clinical Psychology and Psychiatry, 35, 1–107. Franklin, M. E., & Foa, E. B. (1998). Cognitive-behavioral treatments for obsessive-compulsive disorder. In E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (pp. 339–356). New York: Oxford University Press. Freeman, J. B., Choate-Summers, M. L., Moore, P. S., Garcia, A. M., Sapyta, J. J., Leonard, H. L., et al. (2007). Cognitive behavioral treatment for young children with Obsessive-Compulsive Disorder. Biological Psychiatry, 61, 337–343. Heyman, I., Fombonne, E., Simmons, H., Ford, T., Meltzer, H., & Goodman, R (2001). Prevalence of Obsessive-Compulsive disorder in the British nationwide survey of child mental health. The British Journal of Psychiatry, 179, 324–329. Heyman, I., Mataix-Cols, D., & Fineberg, N. A. (2006). ObsessiveCompulsive Disorder. British Medical Journal, 333, 424–429. Leonard, H. L., Ale, C. M., Freeman, J. B., Garcia, A. M., & Ng, J. S. (2005). Obsessive-Compulsive disorder. Child and Adolescent Psychiatric Clinics of North America, 14, 727–743. March, J. S., Frances, A., Carpenter, D., & Kahn, D. A. (1997). The expert consensus guideline series: Treatment of ObsessiveCompulsive disorder. The Journal of Clinical Psychiatry, 58 (Suppl. 4), 1–72. March, J. S., Franklin, M., & Foa, E. (2005). Cognitive-behavioral psychotherapy for pediatric Obsessive-Compulsive disorder. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 121–142). Washington, DC: American Psychological Association. March, J. S., & Leonard, H. L. (1998). Obsessive-Compulsive Disorder in children and adolescents. In R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive-Compulsive disorder: Theory, research, and treatment (pp. 367–394). New York: Guilford. March, J. S., Leonard, H. L., & Swedo, S. E. (1995). Pharmacotherapy of obsessive-compulsive disorder. Child and Adolescent Psychiatric Clinics of North America, 4, 217–236. National Institute of Mental Health. (2008, April 9). P.A.N.D.A.S. Retrieved September 29, 2008, from http://intramural.nimh.nih .gov/pdn/web.htm Paige, L. Z. (2007). Obsessive-Compulsive disorder. Principal Leadership, 8(1), 12–15. Parker, Z., & Stewart, E. (1994). School consultation and the management of Obsessive-Compulsive personality in the classroom. Adolescence, 29, 563–574. Pediatric Obsessive Compulsive disorder Treatment Study Team. (2004). Cognitive-behavioral therapy, sertraline, and their combination for children and adolescents with Obsessive-Compulsive disorder: The pediatric OCD treatment study (POTS) randomized controlled trial. Journal of the American Medical Association, 292, 1969–1976. Penn, J. V., & Leonard, H. L. (2001). Diagnosis and treatment in children and adolescents. In M. T. Pato & J. Zohar (Eds.), Current treatments of Obsessive-Compulsive disorder (pp. 109–132). Washington, DC: American Psychiatric Publishing. Piacentini, J., & Bergman, R. L. (2000). Obsessive-Compulsive disorder in children. The Psychiatric Clinics of North America, 23, 519–533. Piacentini, J., Bergman, R. L., Keller, M., & McCracken, J. (2003). Functional impairment in children and adolescents with Obsessive-Compulsive disorder. Journal of Child and Adolescent Psychopharmacology, 13(Suppl. 1), S61–S69. Piacentini, J., & Langley, A. K. (2004). Cognitive-behavioral therapy for children who have Obsessive-Compulsive disorder. JCLP/In Session, 60, 1181–1194. Pittenger, C., Coric, V., Banasr, M., Bloch, M., Krystal, J., & Sanacora, G. (2008). Riluzole in the treatment of mood and anxiety disorders. CNS Drugs, 22(9), 761–786. Purcell, J. (1999). Children, adolescents, and Obsessive-Compulsive disorder in the classroom (Report No. EC 308043). Washington, DC: Office of Educational Research and Improvement. (ERIC Document Reproduction Service No. ED445439) Rasmussen, S. A., & Eisen, J. L. (1990). Epidemiology of obsessivecompulsive disorder. Journal of Clinical Psychiatry, 53(Suppl.), 10–13, Discussion 14. Rettew, D. C., Swedo, S. E., Leonard, H. L., Lenane, M. C., & Rapoport, J. L. (1992). Obsessions and compulsions across time in 79 children and adolescents with Obsessive-Compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1050–1056. Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015 Leininger et al. / Teaching Students with OCD Schlozman, S. C. (2002). Quit obsessing! Educational Leadership, 59(5), 95–97. Simpson, G. A., Cohen, R. A., Pastor, P. N., & Reuben, C. A. (2008). Use of mental health services in the past 12 months by children aged 4–17 years: United States, 2005–2006. NCHS Data Brief, No. 8. Retrieved October 24, 2008, from http://www.cdc.gov/ nchs/data/databriefs/db08.pdf Sloman, G. M., Gallant, J., & Storch, E. A. (2007). A school-based treatment model for pediatric Obsessive-Compulsive disorder. Child Psychiatry and Human Development, 38, 303–319. Stewart, S. E., Ceranoglu, T. A., O’Hanley, T., & Geller, D. A. (2005). Performance of clinician versus self-report measures to 231 identify obsessive-compulsive disorder in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 15, 956–963. Wagner, A. P. (2002). What to do when your child has ObsessiveCompulsive Disorder: Strategies and solutions. Rochester, NY: Lighthouse Press. Wagner, A. P. (2005). Worried no more: Help and hope for anxious children (2nd ed.). Rochester, NY: Lighthouse Press. Zohar, A. H. (1999). The epidemiology of obsessive-compulsive disorder in children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 8, 445–460. Downloaded from isc.sagepub.com at BRIGHAM YOUNG UNIV on October 1, 2015